Long-acting depots wear off towards the end, so they might need to be given more frequently.

Administering a medication with food means something like 10 minutes on either side of actual meal ingestion.

A particular breed of falsified collegiality is siding with the foe of a foe. This has a convenient name: pseudo-altruism.

Pseudo-altruism is a pattern of behavior used by people who have a problem in coping satisfactorily with repressed rage. Observed in both individual and group psychotherapy, it allows the discharge of unacceptable impulses through professed concern about others. This model involves the interaction of at least three people. One individual, A, unable to acknowledge his rage toward a second person, B, comes to the assistance of a third party, C, whom he is convinced has been injured by B. A attacks B or encourages C to do so. In this way A, who experiences difficulty in discharging aggression directly, finds an acceptable means of doing so. He convinces himself that his aggression is warranted by B’s behavior and that he acted solely out of concern for C’s welfare. The pseudo-altruistic pattern thus includes denial, rationalization, and at times projective identification.

Edelson SR. Pseudo-altruism. Psychiatr Q. 1981 Summer;53(2):106-9. doi: 10.1007/BF01064894. PMID: 7330125.

References

1. Edelson SR. Pseudo-altruism. Psychiatr Q. 1981 Summer;53(2):106-9. doi: 10.1007/BF01064894. PMID: 7330125.

To form proper memories, a few steps must be followed.

Firstly, the event must be experienced. The sheer imagination of things that aren’t really true might represent psychosis. That’s a whole other matter.

Secondly, a memory must be created.

Thirdly, the memory must be consolidated. That is, placed into long-term storage in an organised way. In other words, the internal librarian of your brain grabs the recollection and shoves it into a mental shelf with some kind of labelling and retrieval system. That way, you can access it again when needed, providing you don’t have any overdue fines. That could be a metaphor for brain injury or anything that disrupting usual functioning.

In PTSD, the consolidation phase is messed up. Because the memory isn’t stored away properly, it involuntarily, inconveniently and semi-randomly replays. And since it’s not actually linked to a shelf place, it’s experienced in fragments that appear to be current. This explains the re-experiencing phenomenon.

In case of traumatic memory as in PTSD, the process of memory consolidation seems to fail. The traumatic memory trace stays primarily located in subcortical and primary perceptual areas, leaving it tightly coupled to its autonomic and perceptual markers, and lacking the appropriate integration in autobiographical, cortical memory networks. Exposure to a trauma trigger subsequently results in a solely involuntarily retrieved memory trace (intrusion), that is very hard to verbalize, often fragmented in time, and consisting for the most part of primary sensory information (images, smell, sounds) that is linked to physiological fear symptoms (Brewin, 2011). Due to the lack of autobiographical context, the memory is relived as happening in the present. Thus a failure to properly consolidate and thus emotionally depotentiate potentially traumatic memories may form the neural basis of key PTSD symptoms like unwanted memories, intrusive flashbacks, nightmares, hyperarousal, and dissociation. Reduction of PTSD symptoms is accomplished by successful transfer to pre-existent, cortical memory circuits.

This might explain why journalling is thought to be so helpful for processing emotional trauma. The explicit step-through of event recollection places it in the realm of a more logical part of the brain, for a grounding effect. Elaborating on the details of the event helps give it labels and keywords, allowing it to ultimately earn a place of belonging on the memory shelf.

Bibliography

1. van Marle H. (2015). PTSD as a memory disorder. European Journal of Psychotraumatology, 6, 10.3402/ejpt.v6.27633. https://doi.org/10.3402/ejpt.v6.27633

I wrote this piece for a competition entitled ‘The psychiatrist’s role in responding to global disasters’. It was run by a society of psychiatrists. I don’t think they liked it much.

The ludicrous proposition

Psychiatrists have no role in global disasters.

“Wait, wait!” you cry in outrage.

Hear me out.

The world needs more than psychiatrists

Many eons ago, dinosaurs decided to drop dead, and the way was paved for Homo sapiens to take over the earth. And that was exactly what humankind did. They put animals in zoos, traded financial instruments, made television shows, flew to other countries, and generally enjoyed their man-made creations – like sausage rolls and drive-in cinemas.

But with that luxury came an inevitable risk: the danger of losing everything. Because of the advent of civilisation, things which didn’t matter before started to become vitally important. The fragile entity of the economy, social fears, world politics, technological dependence – all of these became concepts that can be threatened by global disasters (World Economic Forum 2020).

Wealth can be protective against adverse outcomes, yes, but the strong risk of adverse outcome is still there (Brookings 2017; Scientific American 2017; The Guardian 2020). A severe enough disaster can affect basically everyone (United Nations 2020).

Thus, when a global disaster strikes, what the world needs isn’t psychiatrists; it’s resolution, co-operation, and community.

In emergencies, we can’t limit ourselves to a single role to achieve the most reparation. We need to be flexible and versatile. We need to revert to generalists to do the most good. We need to be ready to do whatever our training allows us to contribute, even if that doesn’t refer to the specialised skills trained many years for. We need to prepare for a step in humility, and we need to offer whatever basics the world most requires of us.

If the majority of the world is dying of an infectious disease, maybe you don’t need a psychiatrist right that second. But you do need a doctor generally when physical health is the most pressing issue.

Or maybe it’s something that can’t simply be cured that instant. Then perhaps you need a human, or a friend to help talk to you or bring you a hot meal, if emotional support is the thing required at the time (Purdue University 2018).

Neither of these situations calls singularly for a psychiatrist as the only prescription. They require a doctor – or simply a very helpful human.

That’s why psychiatrists specifically don’t have a role in global disasters. But doctors generally do. And especially in those times, doctors are human and need to be human first (PR Newswire 2011).

The burden of global disasters

Disasters are bad. Pretty bad. By definition, it’s in the name. And if something bad turns global, it’s sure to be even worse.

There are the pandemics – Black Death, Spanish flu, HIV/AIDS, and now COVID-19 (National Center for Biotechnology Information 2017). There are the natural disasters – of which there are around 400 annually (Brookings 2010), with the potential to leave people trapped in gruelling conditions for days (Direct Relief 2019). There are the human-created dilemmas – terrorism, war, and others.

Each of these seems different on the surface, but they all have some grave things in common: significant death and injury, world chaos, a huge burden on healthcare workers, and depletion of the workforce.

Negative consequences range from economic devaluation to social anxiety to illness and injury to death, for which the stories can be jarring. During the COVID-19 pandemic, one woman described her experience of tragic loss. She woke up to find that her fiancé, who tested positive for COVID-19, was not next to her. Logically, she fathomed he must have been downstairs. However, something was unsettling; they had a parrot that typically squawked in conversation whenever someone was near it. But the parrot that day was completely silent. That was how she realised that her fiancé was dead at home downstairs (CBS News 2020).

We haven’t yet figured out how to revive people from the dead – and there are many reasons why we probably wouldn’t want to – so what we need is prevention over cure. Simply put, people need more healthcare in these moments to prevent deterioration. However, a significant proportion of people can’t afford to pay for healthcare even in normal times (The New York Times 2020).

Yet, it would be naïve to think that a global disaster doesn’t involve a massive shake-up to every industry – and health is no exception.

Especially, especially, if the global disaster is of such proportions that it disrupts the healthcare workforce. Speaking historically, with pandemics such as influenza or COVID-19, that’s a huge concern and probably even an inevitability (National Center for Biotechnology Information 2007).

When the world is short on medical staff, there’s a clear solution: source more.

Why psychiatrists should be doctors and doctors should be humans

Remember that psychiatrists aren’t just psychiatrists; they’re doctors.

There are certain times, such as global disasters, where it’s very important to be a doctor first and a specialist second. It’s only in this way that we can do what world healthcare needs holistically. It’s not about resorting to what we trained most recently in because that’s what we feel comfortable doing, as we can offer more by stepping out of that comfort zone – while remaining within the realm of our certified qualifications, of course. It’s not about choosing what we can charge the most for; the focus is what the patient needs the most.

Now, psychiatrists are important – it’s not much fun if your brain is running through depression or your mind is addled by psychosis – but we have to step back and remember what it’s all for. You train as a psychiatrist because you enjoy being a doctor and you have a specific interest in addressing pathologies of the mind. You take up that specialty because it’s the area you feel you have a knack for and can do the most good in.

But why do you become a doctor? Because you want to help people. Because you find health fascinating. Because you realise that a life lived with serious ailments and maladies is not really a life well lived at all – or at least one with a handicap better resolved as much as it can be.

So you become a psychiatrist because you want to be a mind doctor, and you became a doctor because you want to help people. You want to help people because you want to do some real good for the world, because you want to contribute to that idea of the greater good.

So really, if you can help the world a bit, that’s your mission accomplished. It isn’t about being a psychiatrist; it’s about doing good for others. Psychiatry is just the vessel you use to achieve that.

Which means, if some unprecedented situation arises like a huge pandemic or a massive tidal wave that demolishes half the city, you’re best to revert to your basic aims: helping people and doing the most good. If people around you are starving or succumbing to infection, maybe your priority doesn’t change – doing that good – but maybe your method does.

Emergency department doctors act as miniature specialists across many fields. If the patient enters with chest pain, they switch on cardiology mode. If it’s abdominal pain, they warp to gastroenterology thinking. In times of crisis, this is a model we need to emulate. It reflects the ability to be versatile and adapt to whatever the patient most pressingly needs.

Global disasters ruin life as we know it, which calls for adept generalists. That’s particularly when we need more than psychiatrists specifically; we need doctors generally.

Conclusion

Aesop wrote of a conversation between the Oak and the Reeds.

The Oak, haughty about its ability to stand upright and rigid no matter what, criticised the Reeds for unfailingly swaying with the breeze. Unruffled, the Reeds declared their intention to continue bending pliantly with the wind. Later that day, a hurricane struck and ripped the Oak out of the ground (Library of Congress n.d.).

Versatility is rewarded; inflexibility is destroyed.

Psychiatrists have no role in global disasters. Doctors do.

References

1. World Economic Forum 2020, COVID-19: What are the biggest risks to society in the next 18 months?, accessed 2 August 2020, <https://www.weforum.org/agenda/2020/07/covid19-future-economic-societal-geopolitical-risks/>.
2. Brookings 2017, Pandemics and the poor, accessed 2 August 2020, <https://www.brookings.edu/blog/future-development/2017/06/19/pandemics-and-the-poor/>.
3. Scientific American 2017, Natural Disasters by Location: Rich Leave and Poor Get Poorer, accessed 2 August 2020, <https://www.scientificamerican.com/article/natural-disasters-by-location-rich-leave-and-poor-get-poorer/>.
4. The Guardian 2020, We’re about to learn a terrible lesson from coronavirus: inequality kills, accessed 2 August 2020,<https://www.theguardian.com/commentisfree/2020/mar/14/coronavirus-outbreak-inequality-austerity-pandemic>.
5. United Nations 2020, The Social Impact of COVID-19, accessed 2 August 2020, <https://www.un.org/development/desa/dspd/2020/04/social-impact-of-covid-19/>.
6. Purdue University 2018, A little help from your friends is key to natural disaster recovery, study suggests, Science X Network, accessed 2 August 2020, <https://phys.org/news/2018-10-friends-key-natural-disaster-recovery.html>.
7. PR Newswire 2011, Loss: What to Say After the Flood, Earthquake, or Disaster from Grief Expert Aurora Winter, accessed 2 August 2020, <https://www.prnewswire.com/news-releases/loss-what-to-say-after-the-flood-earthquake-or-disaster-from-grief-expert-aurora-winter-121990828.html>.
8. National Center for Biotechnology Information 2017, Pandemics: Risks, Impacts, and Mitigation, U.S. National Library of Medicine, accessed 2 August 2020, <https://www.ncbi.nlm.nih.gov/books/NBK525302/>.
9. Brookings 2010, Natural Disasters, Conflict, and Human Rights: Tracing the Connections, accessed 2 August 2020, <https://www.brookings.edu/on-the-record/natural-disasters-conflict-and-human-rights-tracing-the-connections/>.
10. Direct Relief 2019, 10 Disasters That Changed the World, accessed 2 August 2020, <https://www.directrelief.org/2019/12/10-disasters-that-changed-the-world/>.
11. CBS News 2020, Coronavirus: The hidden pain and sorrow of dying at home, accessed 2 August 2020, <https://www.cbsnews.com/news/coronavirus-pain-and-sorrow-of-dying-at-home-60-minutes-2020-04-26/>.
12. The New York Times 2020, As Coronavirus Deepens Inequality, Inequality Worsens Its Spread, accessed 2 August 2020, <https://www.nytimes.com/2020/03/15/world/europe/coronavirus-inequality.html>.
13. National Center for Biotechnology Information 2007, Can the Health-Care System Meet the Challenge of Pandemic Flu? Planning, Ethical, and Workforce Considerations, U.S. National Library of Medicine, accessed 2 August 2020, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936949/>.
14. Library of Congress n.d., The Oak & the Reeds, accessed 2 August 2020, <http://www.read.gov/aesop/011.html>.

Schizophrenia is a thought disorder characterised by positive symptoms and negative symptoms.

Positive symptoms mean too much abnormal behaviour, like hallucinations and delusions. Psychosis! Disrupted perceptions of reality! That sort of thing.

Negative symptoms mean not enough normal behaviour, like flattened affect and alogia. Things starting with “a”! Amotivation! Avolition! Anhedonia! That sort of thing.

Like a massive tree of mental health, schizophrenia has partially related disorders and terms that branch out from it.

Behold! The many children of schizophrenia!

Here’s a simplified summary of it all.

Schizophrenia

Brief psychotic disorder is schizophrenia symptoms < 1 month.

Schizophreniform disorder is schizophrenia symptoms < 6 months.

Schizophrenia is schizophrenia symptoms > 6 months.

Mood Disorders

Schizoaffective disorder is schizophrenia symptoms with mood disorder. The psychosis is present without the mood component for > 2 weeks.

Mood disorder with psychotic features is what it says it is. Surprise!

Personality Disorders

A schizoid person avoids social interaction. Think limited emotional expression.

A schizotypal person is a weird type of person. Think oddness and magical thinking.

Save your paper bags for your lunches!

Panic attacks can involve people hyperventilating, which means they breathe too much and end up exhaling more carbon dioxide than normal. The low carbon dioxide level results in symptoms like dizziness and lightheadedness.

Breathe into a paper bag, they said. Let the recirculated carbon dioxide increase the carbon dioxide levels in the person’s body, they said.

Is this really effective?

Critics say this is not the case because hyperventilation doesn’t reliably induce panic attacks. They add that high carbon dioxide levels are more associated with impending suffocation, such as from situations of hypoxia or hypoventilation.

In fact, because panic attacks are fleeting by nature, it can be a sort of placebo effect that makes paper bags look like winners. The panic attack was going to pass anyway, so the panic fading just happened to coincide with the use of the paper bag.

References

1. Allstetter, W. (n.d.). Panic Attacks and “Suffocation Alarm Systems”. [online] The Journal of the College of Physicians and Surgeons of Columbia University. Available at: http://www.cumc.columbia.edu/psjournal/archive/archives/jour_v19no1/theories.html [Accessed 11 Nov. 2017].