The Other Brain Doctors

I'm starting to think that I need to get back to traveling frequently. Not because I'm getting wanderlust, but because that's what makes me want to write. It's a lot easier to decide to write something when you're stuck in an airport with half an hour to kill and not enough brain cycles for real work.

June was more forays into the world of "real doctoring", i.e. neurology. I got a little lucky -- it was a slow month for them, which left me time to actually think and talk to patients as opposed to scurrying around doing paperwork at breakneck pace. As some of you know, I seriously considered neurology as a specialty choice before settling on psychiatry, since they both treat the same organ. This second neurology month only confirmed my choice. It was interesting, I learned a lot, I had a pretty good team, and I got some good cases. That said, it's sort of like a city you enjoy visiting but could never live in. I'm quite happy to be back to shrinking heads.

The reason I like to visit neurology but not live there has to do with the nature of their patients and the overlap between our two disciplines. Part of neurology is dealing with patients who are Really Sick -- strokes, brain tumors, autoimmune diseases that can leave someone temporarily on a ventilator or permanently disabled, seizures that aren't quite controlled by medication, and degenerative diseases like Parkinsons. That's about half their patients. The other half are Really Not Sick. They have headaches. They have pain syndromes. They have odd weakness or paralysis that doesn't fit the anatomic pathways, which implies there's not actually something wrong with the structure of their nervous system. All of these people have what we politely and semi-euphemistically call "functional neurological syndromes".

There are two important things to know about functional syndromes. First, they tend to occur more in people who have chaotic, unfulfilling, or emotionally stressful lives, complicated and not-always-supportive family dynamics, and diagnoses of depression or anxiety. Second, they get worse when the stress gets worse. Imagine yourself for a moment as a neurology resident. The evening is dragging on, but instead of going home, you're paged to the ER for the third time that day, because there's a patient here with headache and she's unwilling to go home. She's had headaches every day for years, but in the context of recent job troubles, they're getting worse, and she feels nauseous and in constant pain. Over the years, she's taken migraine meds, every over-the-counter known, narcotics both oral and IV, and even herbal supplements. She tells you she's in "eleven out of ten" pain, but yet is able to sit there, keep her eyes open, talk on her cell phone when not talking with you, and generally not act like someone who's in truly excruciating pain. The physician response is not universal, but pretty common -- frustration and anger (of the "You think you're stressed? Try doing MY job!" variety), plus a general feeling that this patient is simply exaggerating, failing to Suck It Up And Deal, and a healthy dose of insecurity given that there's no easy way to make her symptoms better.

From one perspective, there really is nothing "medically wrong" with these patients. They don't have any traceable anatomic or chemical problem, nothing that any objective or quantitative measure can diagnose. There's another perspective, and it's the point at which the border between neurology and psychiatry gets fuzzy. Your nervous system consists of many paths and circuits, and they're interlinked in ways that no human can truly understand. Some of those pathways deal with pain. Some deal with emotion. Some deal with motor function. Some appear to spend all their time just keeping the others in line and balanced, and those tend to be up in the "higher" parts of your brain that theoretically separate us from the "lower animals". Ultimately, what's wrong in patients with functional neurological syndromes is exactly what the name says -- their functioning is off. Pain is much more than just nerve endings going from your skin to your spine to your brain. The bits of your brain that perceive physical and emotional pain are right on top of each other, so close that some speculate they might actually be one entity. In these patients, those high-order "executive" circuits that are supposed to be regulating their pain system aren't doing their job. It's no surprise that no modern medication can control their pain -- the systems at the heart of that control are broken!

How does a circuit in the brain, or the connection between two circuits, go haywire? What kinds of life experiences cause the "program" to venture into "diseased" territory? More importantly, what the heck do you do to fix it? All of those questions are squarely in the domain of psychiatry. When we tweak your neurotransmitters with drugs, the goal is to boost up some brain areas and let them reassert control. It's the same with talk therapy, except that we're trying to modify brain activity by pushing in various inputs through the language system. If you can gently nudge the system in just the right way, the patient's natural capacity for self-control can take over, and they can get at least some mastery of their pain (usually not total, especially when you're only seeing them in the hospital, but some).

That's why I like visiting neurology. Functional-syndrome patients drive most neurologists nuts, because they don't have the right tools. I am still far from having a complete psychiatric toolbox, but I've been trained from a perspective that helps me reframe the patient's problem. I've also been trained in the delicate art of being frustrated and annoyed at a patient without showing it too much. (I'm not always good at it, and particularly not outside of work, but at least I've had practice.) Most importantly, there are actually evidence-based therapeutic techniques for working with these patients, and while I'm no expert, I've at least had some exposure to them this year. In the usual case, that means that I at least can be calm about a patient while the rest of the team is developing headaches of their own. In the best case, when I'm lucky enough to have actually used the techniques correctly, I can get the "difficult patient" to agree to leave the hospital, take a particular med, get a follow-up appointment, or do whatever else they've been resisting doing. It only happens about once in a one-month rotation, but when it does, it makes you feel like a magician. Psychiatrists on a neurology service tend to get a little bit of short shrift -- we don't have the detailed physical exam skills or knowledge of anatomy that our colleagues do, and there's sometimes a sense that they consider us mildly mentally defective. (Not actually true, it just feels that way sometimes.) It's nice, once in a while, to be able to do something that makes your colleagues from other specialties jealous.

It'd be nicer if I could actually "fix" some of these patients and make their pain disappear more permanently, but that's a bit more advanced; maybe in another couple years I'll have at least a one-in-ten chance of that.