[Music]
let me tell you a story an
all-too-common story in all two tragic
story that someone who might come to
Austin Riggs or end up in any the
offices of psychiatrists and
psychotherapists around the world
imagine a boy 3rd or 4th grade who has
trouble sitting still fidgeting maybe
he’s like some of you in the audience
right now get sent to the principal and
then to the counselor’s office
turns out this boy’s got some difficult
things going on at home his parents are
fighting there’s an illness in one of
his siblings but the teachers have to do
their job they have to get him to sit
still and listen to the lesson so he
gets sent to a therapist maybe a
psychiatrist to diagnose him with
something we all know about called ADHD
attention deficit hyperactivity disorder
he may improve somewhat get put on a
medication get some therapy for that
flash-forward several years now for that
same young man now a teenager he’s in
high school gets into the wrong crowd
starts using alcohol and drugs again
gets sent to a counselor he’s lucky
actually to a therapist or a
psychiatrist who gives him another
diagnosis the diagnosis of substance
abuse disorder may be alcoholism or
maybe something else boy get some help
goes back to high school but now it’s
time for graduation his classmates are
moving out going off to college getting
jobs he struggles he has a job briefly
sleeps later on more than one occasion
loses his job ends up staying in bed for
much longer than his good friend plays
video games during the day rather than
going out and socializing his friends
aren’t in town anyway again he gets sent
to some kind of counselor for therapist
and this time the diagnosis may be
depression or maybe gets referred to as
having an anxiety disorder a few more
years go on and his life doesn’t improve
he starts to self-injure he cuts himself
and after one particularly bad breakup
with a girlfriend he threatens to commit
suicide and again luckily ends up in the
hospital
rather than young through he gets yet
another set of diagnosis is told that he
has bipolar disorder or borderline
personality disorder now this is not the
exception that I’m describing
unfortunately this is how the diagnosis
in our field have developed over time
that it’s surprisingly easy to end up
with five or even six diagnoses that I
just described in one individual with
one set of problems a quarter of
Americans will get diagnosed with a
psychiatric disorder at some time in
their lives and the majority of those
will get more than one diagnosis so what
does this mean about our field what does
it mean that someone can have so many
different labels associated with them
I’m not here to criticize those label in
fact each and every one of them is given
by someone caring in order to facilitate
in their minds some kind of treatment
but there’s a truth in there that I
think we speak to all too infrequently
in the field and that is where we are in
the fields of psychiatry and psychology
is that we’re describing symptoms we’re
describing how somebody feels how
somebody presents whether they’re
depressed whether they’re anxious
whether they’re abusing substances what
we haven’t been able to describe yet is
what the underlying causes are let me
make an analogy to medical illnesses to
make this clear imagine that instead of
describing someone who’s having an
appendicitis we describe someone as
having abdominal pain fever nausea all
very real all very important symptoms
but each one doesn’t specify the foil
note in fact there’s multiple reasons
one could have fever nausea or abdominal
pain but put together in a certain way
with a certain type of dominant pain and
you have appendicitis so that diagnosis
is not just a symptom in fact it gets to
something that in medicine we refer to
as pathos
physiology a word that means we
understand what the underlying problem
is we know that the appendix is inflamed
infected and in also in most cases
refers to a potential treatment we know
that the way to treat an appendicitis is
to remove the appendix in appendectomy
so by identifying the underlying cause
that not referring to it as a series of
symptoms as important as those are we
set ourselves up to treat and to heal
another example this would be pneumonia
pneumonia involves a cause but we don’t
refer to it as a call we refer to it by
its underlying name pneumonia what you
might not know is the history of
medicine is filled with examples where
we refer to things initially by their
symptoms because that’s what we knew
famous example of this is a disorder
that used to be known called dropsy or
hydrops II was the full name and what it
meant was an accumulation of fluid but
in the limbs or the abdomen what today
we usually refer to as a demon now you
may know there’s many reasons one can
have an accumulation of fluid for
example one very important reason would
be heart failure but another could be a
problem with the kidneys or even another
could be some kind of a cancer that’s
impairing the body’s ability to resort
water but we don’t refer to it as dropsy
anymore because we have those other
names and we understand the underlying
pathophysiology and therefore we can
call it heart disease or kidney disease
or cancer this is where we are in
psychiatry today in psychology we are on
the brink of being able to describe
disorders by their pathophysiology not
merely by their symptoms now that’s not
an easy task and in order to get there
we have tough things to understand so
let me start with one this is a normal
distribution curve or bell curve many of
you may have learned about this in high
school or college what does the bell
curve tell us what it tells us is that
average things happen more frequently
than things at the extreme so if we
imagine that to be higher on
Merve means more people have that
particular trait or symptom and to be
off to the right side or to the left
side is to suggest that fewer people
lower have more extremes many many
natural phenomena are described in this
way height weight for example most
people are somewhere in the middle and
then some people fewer are higher and
fewer or lower well it turns out that
virtually every one of the psychiatric
symptoms that we talk about depression
anxiety substance abuse when measured
lie along bell curve and what that tells
you is that rather than falling neatly
into groups of those who have the
problem and those who don’t
we’re actually describing something very
human that we all are depressed
sometimes that we all are anxious
sometimes that there are fewer of us who
have more and fewer who have less so
what we are doing in most of
contemporary psychiatry nowadays is
drawing the vertical line on this chart
and saying well we have more than a
certain amount we’re going to refer to
that as a diagnosis depression anxiety
and so on and if you have less than that
we’re going to refer to you as not
having a diagnosis we’re dichotomizing
something that is not intrinsically
dichotomies and we do that for an
important reason we have to make
decisions about who to give treatments
to and who to fund for other treatments
but we can’t lose sight of the fact that
right now that is what we’re describing
by the way this is true of attentional
disorders as well as much as it may seem
that there are children who fit neatly
into the category of ADHD or not in fact
attentional disorders lie along this
continuum so where do we need to go we
need to move to a graph like this we
need to be able to identify different
aspects again pathophysiology of the
mind the brain that allow us to as Plato
said carved nature up by its joints to
separate things out in a way that
actually makes intrinsic
since let me give you the medical
example if we asked a group of people to
describe some aspect of abdominal pain
most people have some abdominal pain
they fall somewhere in the middle much
greater pain would be off to one side
and lucky people who have no abdominal
pain ever at all would be off to the
other side and that would look like a
normal distribution and if we will find
our question though and instead of just
asking about abdominal pain we did an
x-ray or cat scan of the appendix and we
saw in how many people is the appendix
inflamed it would look more like this
that is we would see a smaller sub group
that had two inflamed appendices and we
know what the treatment is for that and
a larger group that doesn’t this is
where we need to go in psychology and
psychiatry but getting there is pretty
tricky there are three parts that we
have to accomplish and I’m happy to say
that I think these are happening in the
coming decade or two first we have to
understand something about underlying
vulnerabilities as much as we would like
it to be true that we are all born
exactly the same and everybody has the
opportunity to be as healthy as the next
we also know from many genetic analyses
that this is not true we each come into
the world with vulnerabilities that we
inherit from our genome amazingly we now
have the capacity to read out that
genome for a relatively reasonable
amount of money we can spend about a
thousand dollars now to read out the
totality of someone’s genome a project
that only 20 years ago would cost
billions the famous Human Genome Project
which set the stage for current
technologies that means that we have the
ability to read this code we don’t yet
know what the code means but gives us
the opportunity to understand that
within that code where are the
vulnerabilities that will make certain
individuals more likely to develop
certain disorders in certain
environmental contexts so that’s number
one
number two we need to understand the
pathophysiology of
the mind and the brain that’s the organ
it’s the most complicated organ in the
body and it’s the one we know the least
about
but we’re developing technologies that
allow us to understand how the brain
works in health and in illness the most
important of those new technologies is
something you’re probably familiar with
MRI or magnetic resonance imaging that
same technology that can be used to get
those incredibly beautiful pictures of
ones need when children can also be used
to get a picture of the brain and this
is relatively new technology been around
for about 20 years and we’re making
rapid progress just in the last couple
years a major government effort that was
inspired by the human human genome
project this project called the human
connectome project gathered data on over
a thousand individuals healthy
individuals to understand the way the
brain is structured the way it functions
and even the way different parts of the
brain are connected the image I have
above me is something called diffusion
tensor imaging or DTI what it looks at
is the pathways the wires that connect
different parts of the brain that can
process it and colors are used to
illustrate the direction of those wires
so really for the first time we’re able
to apply technologies like this in an
experimental research oriented way to
individuals and look at the differences
and the similarities between them that’s
truly revolutionary and will give us I
believe the opportunity to start to
identify which regions of the brain and
how they’re connected affect individuals
we’re not there yet we can’t use MRIs
today to diagnose or to treat mental
illness but we’re getting there we can’t
get too distracted by these technologies
the excitement of the human genome
project the excitement of the human
connectome project to forget that where
we are now and still need to understand
the stories of our patients just like
that boy and young man I described to
you at the beginning of
stalk it’s not enough to say that he’s
depressed he’s anxious he has a
substance abuse problem we need the full
story would we at Austin Riggs often
refer to as the deep story what’s
happening the symptoms for sure also
what the symptoms mean to him what did
it mean that he was left behind when his
friends went off to college or had jobs
what does it mean that he’s depressed or
using substances or even later on
cutting himself these meanings are key
we must match them up to those things
that we learn in neuroscience as well as
in genetics if we do that the future is
bright
[Applause]
you
let me tell you a story an
all-too-common story in all two tragic
story that someone who might come to
Austin Riggs or end up in any the
offices of psychiatrists and
psychotherapists around the world
imagine a boy 3rd or 4th grade who has
trouble sitting still fidgeting maybe
he’s like some of you in the audience
right now get sent to the principal and
then to the counselor’s office
turns out this boy’s got some difficult
things going on at home his parents are
fighting there’s an illness in one of
his siblings but the teachers have to do
their job they have to get him to sit
still and listen to the lesson so he
gets sent to a therapist maybe a
psychiatrist to diagnose him with
something we all know about called ADHD
attention deficit hyperactivity disorder
he may improve somewhat get put on a
medication get some therapy for that
flash-forward several years now for that
same young man now a teenager he’s in
high school gets into the wrong crowd
starts using alcohol and drugs again
gets sent to a counselor he’s lucky
actually to a therapist or a
psychiatrist who gives him another
diagnosis the diagnosis of substance
abuse disorder may be alcoholism or
maybe something else boy get some help
goes back to high school but now it’s
time for graduation his classmates are
moving out going off to college getting
jobs he struggles he has a job briefly
sleeps later on more than one occasion
loses his job ends up staying in bed for
much longer than his good friend plays
video games during the day rather than
going out and socializing his friends
aren’t in town anyway again he gets sent
to some kind of counselor for therapist
and this time the diagnosis may be
depression or maybe gets referred to as
having an anxiety disorder a few more
years go on and his life doesn’t improve
he starts to self-injure he cuts himself
and after one particularly bad breakup
with a girlfriend he threatens to commit
suicide and again luckily ends up in the
hospital
rather than young through he gets yet
another set of diagnosis is told that he
has bipolar disorder or borderline
personality disorder now this is not the
exception that I’m describing
unfortunately this is how the diagnosis
in our field have developed over time
that it’s surprisingly easy to end up
with five or even six diagnoses that I
just described in one individual with
one set of problems a quarter of
Americans will get diagnosed with a
psychiatric disorder at some time in
their lives and the majority of those
will get more than one diagnosis so what
does this mean about our field what does
it mean that someone can have so many
different labels associated with them
I’m not here to criticize those label in
fact each and every one of them is given
by someone caring in order to facilitate
in their minds some kind of treatment
but there’s a truth in there that I
think we speak to all too infrequently
in the field and that is where we are in
the fields of psychiatry and psychology
is that we’re describing symptoms we’re
describing how somebody feels how
somebody presents whether they’re
depressed whether they’re anxious
whether they’re abusing substances what
we haven’t been able to describe yet is
what the underlying causes are let me
make an analogy to medical illnesses to
make this clear imagine that instead of
describing someone who’s having an
appendicitis we describe someone as
having abdominal pain fever nausea all
very real all very important symptoms
but each one doesn’t specify the foil
note in fact there’s multiple reasons
one could have fever nausea or abdominal
pain but put together in a certain way
with a certain type of dominant pain and
you have appendicitis so that diagnosis
is not just a symptom in fact it gets to
something that in medicine we refer to
as pathos
physiology a word that means we
understand what the underlying problem
is we know that the appendix is inflamed
infected and in also in most cases
refers to a potential treatment we know
that the way to treat an appendicitis is
to remove the appendix in appendectomy
so by identifying the underlying cause
that not referring to it as a series of
symptoms as important as those are we
set ourselves up to treat and to heal
another example this would be pneumonia
pneumonia involves a cause but we don’t
refer to it as a call we refer to it by
its underlying name pneumonia what you
might not know is the history of
medicine is filled with examples where
we refer to things initially by their
symptoms because that’s what we knew
famous example of this is a disorder
that used to be known called dropsy or
hydrops II was the full name and what it
meant was an accumulation of fluid but
in the limbs or the abdomen what today
we usually refer to as a demon now you
may know there’s many reasons one can
have an accumulation of fluid for
example one very important reason would
be heart failure but another could be a
problem with the kidneys or even another
could be some kind of a cancer that’s
impairing the body’s ability to resort
water but we don’t refer to it as dropsy
anymore because we have those other
names and we understand the underlying
pathophysiology and therefore we can
call it heart disease or kidney disease
or cancer this is where we are in
psychiatry today in psychology we are on
the brink of being able to describe
disorders by their pathophysiology not
merely by their symptoms now that’s not
an easy task and in order to get there
we have tough things to understand so
let me start with one this is a normal
distribution curve or bell curve many of
you may have learned about this in high
school or college what does the bell
curve tell us what it tells us is that
average things happen more frequently
than things at the extreme so if we
imagine that to be higher on
Merve means more people have that
particular trait or symptom and to be
off to the right side or to the left
side is to suggest that fewer people
lower have more extremes many many
natural phenomena are described in this
way height weight for example most
people are somewhere in the middle and
then some people fewer are higher and
fewer or lower well it turns out that
virtually every one of the psychiatric
symptoms that we talk about depression
anxiety substance abuse when measured
lie along bell curve and what that tells
you is that rather than falling neatly
into groups of those who have the
problem and those who don’t
we’re actually describing something very
human that we all are depressed
sometimes that we all are anxious
sometimes that there are fewer of us who
have more and fewer who have less so
what we are doing in most of
contemporary psychiatry nowadays is
drawing the vertical line on this chart
and saying well we have more than a
certain amount we’re going to refer to
that as a diagnosis depression anxiety
and so on and if you have less than that
we’re going to refer to you as not
having a diagnosis we’re dichotomizing
something that is not intrinsically
dichotomies and we do that for an
important reason we have to make
decisions about who to give treatments
to and who to fund for other treatments
but we can’t lose sight of the fact that
right now that is what we’re describing
by the way this is true of attentional
disorders as well as much as it may seem
that there are children who fit neatly
into the category of ADHD or not in fact
attentional disorders lie along this
continuum so where do we need to go we
need to move to a graph like this we
need to be able to identify different
aspects again pathophysiology of the
mind the brain that allow us to as Plato
said carved nature up by its joints to
separate things out in a way that
actually makes intrinsic
since let me give you the medical
example if we asked a group of people to
describe some aspect of abdominal pain
most people have some abdominal pain
they fall somewhere in the middle much
greater pain would be off to one side
and lucky people who have no abdominal
pain ever at all would be off to the
other side and that would look like a
normal distribution and if we will find
our question though and instead of just
asking about abdominal pain we did an
x-ray or cat scan of the appendix and we
saw in how many people is the appendix
inflamed it would look more like this
that is we would see a smaller sub group
that had two inflamed appendices and we
know what the treatment is for that and
a larger group that doesn’t this is
where we need to go in psychology and
psychiatry but getting there is pretty
tricky there are three parts that we
have to accomplish and I’m happy to say
that I think these are happening in the
coming decade or two first we have to
understand something about underlying
vulnerabilities as much as we would like
it to be true that we are all born
exactly the same and everybody has the
opportunity to be as healthy as the next
we also know from many genetic analyses
that this is not true we each come into
the world with vulnerabilities that we
inherit from our genome amazingly we now
have the capacity to read out that
genome for a relatively reasonable
amount of money we can spend about a
thousand dollars now to read out the
totality of someone’s genome a project
that only 20 years ago would cost
billions the famous Human Genome Project
which set the stage for current
technologies that means that we have the
ability to read this code we don’t yet
know what the code means but gives us
the opportunity to understand that
within that code where are the
vulnerabilities that will make certain
individuals more likely to develop
certain disorders in certain
environmental contexts so that’s number
one
number two we need to understand the
pathophysiology of
the mind and the brain that’s the organ
it’s the most complicated organ in the
body and it’s the one we know the least
about
but we’re developing technologies that
allow us to understand how the brain
works in health and in illness the most
important of those new technologies is
something you’re probably familiar with
MRI or magnetic resonance imaging that
same technology that can be used to get
those incredibly beautiful pictures of
ones need when children can also be used
to get a picture of the brain and this
is relatively new technology been around
for about 20 years and we’re making
rapid progress just in the last couple
years a major government effort that was
inspired by the human human genome
project this project called the human
connectome project gathered data on over
a thousand individuals healthy
individuals to understand the way the
brain is structured the way it functions
and even the way different parts of the
brain are connected the image I have
above me is something called diffusion
tensor imaging or DTI what it looks at
is the pathways the wires that connect
different parts of the brain that can
process it and colors are used to
illustrate the direction of those wires
so really for the first time we’re able
to apply technologies like this in an
experimental research oriented way to
individuals and look at the differences
and the similarities between them that’s
truly revolutionary and will give us I
believe the opportunity to start to
identify which regions of the brain and
how they’re connected affect individuals
we’re not there yet we can’t use MRIs
today to diagnose or to treat mental
illness but we’re getting there we can’t
get too distracted by these technologies
the excitement of the human genome
project the excitement of the human
connectome project to forget that where
we are now and still need to understand
the stories of our patients just like
that boy and young man I described to
you at the beginning of
stalk it’s not enough to say that he’s
depressed he’s anxious he has a
substance abuse problem we need the full
story would we at Austin Riggs often
refer to as the deep story what’s
happening the symptoms for sure also
what the symptoms mean to him what did
it mean that he was left behind when his
friends went off to college or had jobs
what does it mean that he’s depressed or
using substances or even later on
cutting himself these meanings are key
we must match them up to those things
that we learn in neuroscience as well as
in genetics if we do that the future is
bright
[Applause]
you
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