What Came First?

This time of year, for some reason, I think a lot about eggs.  Some years, I think about the boiling water and iron skillet physics of the perfect poached egg.  Other years, I contemplate whether or not it is true that “real men don’t eat quiche”.  I disagree with that quote, by the way.  A real man will eat quiche because he likes it and doesn’t worry what others think about what he eats.

This year’s thoughts are not about how diet defines one’s man-hood.  This year the thoughts are cooped up with the question, “What came first, the chicken or the egg?”   It is at this point that I trade my chef’s hat for my tweed jacket.  I try to crack this question in relation to what causes psychiatric disorders.

Psychiatric patients and their families understandably want to have a specific reason for what caused their particular problem.  It naturally feels better that, having suffered, there is closure, or at least an answer to “why?”  This helps in healing and moving forward.   In most psychiatric or psychological problems, however, there is not a definitive answer to that question.  Applying this to the age old dilemma of chicken versus egg, the first thought is that we are all eggs (genetics); however, we are also all chickens (products of our environment).

In the field of psychiatry, we don’t have any bio-markers to make a diagnosis. There are no blood tests or radiographic tests of what causes mood, anxiety, focus or other central nervous system problems.  We understand that there are genetic and environmental risks that have complex interactions. Psychiatric evaluations, explanations and discussions are rife with theories, vague time frames on prognosis, no specific “cures”, and a bunch of “we will just have to see.”

Adding to the frustration of this is that historically the general population believes that psychiatrists attribute all issues to a “chemical imbalance”.   This would suggest that we should have a way to directly and efficiently diagnose and treat mental illness; that we just need to “fix the imbalance”.  This is not true.  The American Psychiatric Association released a statement that reads, “The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers.  We can say that certain inherited dispositions interact with triggering environmental factors.  Poverty and stress are well-known to be bad for your health…Like physical illnesses, mental disorders can have a biological nature.  Many physical illnesses can also have a strong emotional component.”   This could be called the “bio-psycho-social model” and is how most psychiatrists are trained to conceptualize a patient.

The diagnosis and treatment of mental illness is as much art as it is science.  It is nice, but not expected to have direct explanations to a person’s psychiatric problems.  This is, however, where a psychiatrist can be so valuable in treatment.  A psychiatrist can incorporate usual medical models of “cause and effect”, can understand medical issues, and thoughtfully incorporate the study of nature and nurture in a disorder to help understand it and to help apply solutions.

Psychiatrists include in the focus of treatment “why?” but also help shift to “what to do”.  The emphasis is on strength and what a person can do and what can be controlled.

This is done through many types of therapy and sometimes with medications.  It depends on the assessment of what best fits a patient and family.  There is trial and error to this and no guarantees to outcomes.  Healing of the central nervous system can be a slow process.

The key to success is for the provider to take more time to listen, validate, understand, support and educate people with mental illness.   The patient must be comfortable enough to tell the truth and to provide as much information as possible.

Neuroscience will advance and biomarkers will be available to make specific diagnoses in psychiatry.   There are plenty of studies in action that show promise.  They include research in genetics, inflammatory illness, environment, even testing saliva and urine (gross!).  These may all prove to be clinically important and relevant.  Perhaps they will make contemporary psychiatrists look like chickens with heads cut off in terms of how care is delivered.  (Relationship, good communication and trust will always be crucial in psychiatric diagnosis and care.)

For now, replacing my tweed jacket for my chef’s hat, I cook up the belief that we should accept that there is no perfect egg dish.  This is partly because so many different ingredients go into it.  There are no omelets without eggs, no eggs without chickens, no chickens without eggs and each chicken and egg is different.

The chicken or the egg may never individually be implicated in a dish that does not meet expectations.  Success depends on the acceptance that the current recipe may not work.  Instead of animatedly waving the spatula in the direction of the chicken or the egg, flicking food hither and yon like a crazed chef,  consider adding a bit of pepper or cutting back on the salt.

A psychiatrist, whose name escapes me, once wrote, “We are creatures in nature but we create our own nature.”  I interpret this to mean that we are all born with a different quality and type of egg and chicken that we can work with.  Because of this, we should be willing to try new things and work on better recipes if the ones we are using aren’t working.

Ironically, the path to this solution starts by admitting there is no clear solution.  We have lots of ingredients to work with that come from many different places.  Thus, there are an infinite number of dishes to create.