color-by-number

A new patient walked into my psychopharmacology clinic last week. She seemed reasonably typical at first. A line in the chart noted that she was somewhat wary of psychotropic medications, but then many patients are, and I don't tend to mind that attitude myself since I also subscribe to the less-is-more theory of psychiatric meds.

She was on a fraction of the normal dose of a common antidepressant, which, she reported, was her only medication. It seemed unlikely that this small dose was having any effect, positive or negative, on her mental health; but her mood was stable and she was sleeping and eating well. Things looked good. The main points covered, I asked if she had any other concerns.

"Well, I had my brain imaged," she offered. Brain imaging? Did she have a neurological disorder I hadn't known of? I asked which physician had ordered the tests.

"Oh, I did it myself. I saw it on TV and thought it would be a good idea."

Brain imaging advertised on TV, direct-to-consumer?

She handed me a sheaf of papers, of which the first few pages read like Baby's First Book of Neuroanatomy crossed with the New Age Guide to Herbal Remedies. "Prefrontal cortex: Planning ! Attention!... L-tyrosine!... Anterior cingulate: Cooperation! Flexibility!... St John's Wort!" There was then a list of "hyperactive" and "hypoactive" regions in this patient’s brain.

She'd paid out of pocket to have her brain SPECTed at a clinic that advertises on late-night TV.

Where to begin.

Let me just state up front that there is no established role for brain imaging in psychiatry at this time. None. You can't look at a picture of blood flow (or any other parameter) in the brain and make a diagnosis. (SPECT has some utility in distinguishing Alzheimer's from vascular dementia, but that's more neurology than psychiatry.)

To start out with, despite the existence of a number of studies looking at blood flow in depression, there is not a clear consensus on which areas of the brain are most involved.

Then, let me point out that we have no standard against which to judge baseline levels of regional activity. Blood demand fluctuates on a moment-to-moment basis depending on what the brain is doing at any particular time. The variation in demand between individuals and times is not very well described. So my patient's brain regions were over- or underactive compared to what? Somebody else's brain thinking sad thoughts? Her own brain thinking happy thoughts? The average of ten other people's brains doing a crossword puzzle? Any way you slice it, it doesn't sound informative.

Even when looking at more stable and reliable imaging correlates of clinical depression, in which a clear average population difference exists between depressed individuals and normal controls, there is so much overlap between the two groups that you can't usually infer a person's mood from his brain scan alone. Check out this graph from a review by J.H. Meyer, showing MAO-A density in different brain regions.






While there are clear differences between the populations on the whole, it's also just as clear that an isolated brain scan likely won't tell you much about whether that individual is depressed or not. There are just too many people in the overlap region.

As you can tell from these links, science is still in the phase where we use clinical data as the gold standard against which to judge the validity of imaging results. Going the other way round - starting with the scan and inferring the diagnosis - is something that's far away from our current level of understanding.

Consonant with this, the 'interpretation' of this woman's SPECT scan was nothing you couldn't have figured out from talking to her for a few minutes. After citing a number of areas in which 'dysfunction' was discovered by the SPECT scan, it described some related problems she might have, such as "negativity, guilt, blame, irritability." The kinds of things you could diagnose more easily from a cheap interview than from an expensive brain scan.

The recommendations included a number of OTC supplements (without indication of dosage, of course, since these supplements are largely unregulated, little is known about optimal dosing and in any case actual content may vary wildly from what's written on the label). Some of them were items that have some evidence for their utility (e.g., omega-3 fatty acids); others seemed relatively benign (e.g. Coenzyme Q10) but with little available evidence regarding their use in depression; and others (e.g., St John's Wort - see this FDA advisory) can be positively harmful under the wrong circumstances.

My patient was on all of the recommended supplements - some six or seven different pills - despite having declared the Lexapro as her only medication. This is an incredibly frequent error made by patients, who are soothed by the 'supplement' label into thinking the items are somehow safer or less likely to produce side effects than chemically prepared medications. In fact, there are a number of supplements that have produced significant health problems in their users (e.g., ma huang, which was ultimately banned by the FDA), and since their preparation is poorly regulated, both the dose of the medication and the number and identity of the compounds present are pretty much up for grabs. These facts make supplements a rather riskier bet than prescription preparations.

There were some other very general recommendations of the type that any mainstream psychiatric practitioner would typically make: cognitive behavioral psychotherapy, good social and emotional support, exercise, self-relaxation, and a balanced diet without excess use of nicotine and caffeine. All useful advice, none of it requiring the service of gamma ray scans.

I fully expect that brain imaging will one day have a place in psychiatric practice. However, that day is not today, and I find it upsetting when my patients are conned into paying good money for a useless procedure, a dose of radiation, and some occasionally inappropriate advice.

I do find it curious that so many people place deeper trust in the uncharted waters of alternative medicine than they do in the well-documented, frequently evidence-based recommendations of the standard medical establishment. Things aren't always peachy in the world of traditional medicine; doctors have done a lot of harm as well as a lot of good. But I like to think that as a profession we ultimately learn from our mistakes, and I'd submit as evidence the enormous strides modern medicine has made in extending the productive lifespan, reducing infant mortality, etc etc etc. And in a plug for my own specialty of psychiatry, although there are many patients who are beyond our present capacity to help, I know many others who have unquestionably been saved from suicide or from personal and social destruction.

When someone shows me a randomized controlled trial that demonstrates the utility of a supplement, I'll be happy to use it and recommend it. (I already do recommend both fish oil and melatonin under the appropriate circumstances.) Until then, it's just a black box; and that's not something I'm comfortable giving to a patient.

mind control II: yours

I wrote last week about how surprisingly simple it can be to turn around an angry patient. Two small words hold the key to taming the beast: "You're right." Those words are like a magic tonic, a soothing balm. The patient drops his offensive posture, loses his hostile glare. His hackles soften. His ears are open, receptive. Magic.

But it's not enough merely to mouth the two magic words. You need to believe them, to find the grain of truth in the patient's angry accusations and hold it up to the light. Typically that grain of truth contains a failing of your own. That's hard to admit.

In the CBT group I attend we use role-plays as learning tools. We mimic angry patients, throwing harsh words at our colleagues as a challenge to their empathetic skills.
It's curious that even when you are merely acting a role, pretending to be upset, you can feel in yourself the good or bad reaction to the 'therapist's' words. Defensiveness from the therapist provokes further heights of anger. But the crucial initial words "you're right" produce a rush of surprise and disarmament, a shock of pleasure at being understood, a hint of gleeful righteousness, and an intense curiosity and complete willingness to listen to what's coming next.

Rookies never get the task right the first time, or even the first ten times, even after having the strategy thoroughly explained and seeing more experienced members employ it. They simply can't get themselves to say, "You're right; I've failed; you're understandably angry; but tell me more so I can try to fix it." Instead they mouth platitudes like "I hear that you're frustrated," or "Why don't you calm down so we can discuss this," or they get defensive and explain why the patient is wrong to be angry. These strategies are all, of course, bound to escalate the situation.

Never, never on the first try do they plainly acknowledge the patient's anger and the faults of the therapist. I sure didn't, and I've yet to see any other rookies manage it either. It's suspiciously simple, yet incredibly difficult to do.

As I mentioned last week, I've been using this strategy on belligerent colleagues and other assorted meanies as well as on patients. It's been absolutely foolproof so far. But interestingly, when I shared the strategy with some of the psych residents who are not in the seminar, I met stubborn disbelief.

"I don't think it's appropriate to just subdue yourself to the demands of the patient. You have to maintain your own integrity," one woman said.

She'd verbalized the gut resistance to this strategy that comes from your own ego. That's exactly why it's so hard to implement, despite being so simple. Because you have to lose in order to win. You have to cave in order to prevail. You have to drop your ego in the dust and squish it with your toe in order to have any hope of success.

Even in the false environment of the role-play, where your partner flings made-up accusations at you, it's hard to accept and apologize for these acts you didn't commit. In that setting it's really just a script you could recite with no personal involvement whatsoever. "You're right, I did [fall asleep during your session/give you the wrong drug/insert horrific therapeutic sin of your choice], I bet you're feeling really angry right now." That's it, and with minor variations it's pretty much always the same. Yet it takes a long time to be able to do, even under laboratory conditions. How much harder is it when it's truly your own actions that are being assaulted.

Seeing the patient's anger as a threat to your ego integrity is losing sight of the goal of the therapy, which is to help the patient. The goal is not to maintain your own sense of dignity and self-worth; presumably you've already got a healthy dose of those or you haven't any business trying to therapize others. And if you consistently put the goal of preserving your dignity ahead of the goal of helping the patient, you'll have a lot of frustrated patients and that won't be good for your ego as a therapist in the long run anyway.

But we're accustomed to working hard to maintain our dignity and self-worth, because people without them are racked with doubts and insecurities and generally have a difficult time in life. So we're pretty well programmed to protect our egos, which we do in different ways depending on our basic characters, stages in life, and how we frame ourselves to ourselves. But we all do it. When faced with a blow to our egos, we're socialized to parry it, swiftly and surely.

However, it's all too easy to forget that an interaction between a therapist and a patient is not the same as a typical social situation. Your goal is to help the patient support and develop his ego, not to prop up your own. But when faced with a threat, it's instinctive to forget that, and to fall back on the strategies that have always been helpful (defending or rationalizing or denying your actions, deflecting the blame, etc.).

Hence my colleague's assertion that it was important to maintain one's own integrity. But important for what, I'd ask? Important for the patient, I suspect she'd say - to set limits, to teach the patient how to behave calmly and fairly. But the key point here is that there is always a reason for the anger. Truly isolated, reasonless, purely biological anger is a rare thing that occurs with specific brain lesions, typically affecting the hypothalamus. Real humans in the real world have triggers, and if the patient is lashing out at you it's likely that you're at least part of the trigger. It's your job to be the level head and figure out what that part is and what you can do about it. Otherwise your chances of getting the patient to a state where he can be calm and fair are going to be on the slim side of nonexistent.

mind control I: theirs

I'm in a seminar that meets once a week to educate ourselves in the technique of CBT (cognitive-behavioral therapy). This is only one of a plethora of available therapeutic modalities (dialectical behavioral therapy, psychodynamic, psychoanalytic, etc etc etc).

We're learning specific, codified techniques for making our interactions with patients productive. Some of them are very simple; but the results are absolutely amazing.

One of the things that attracted me about psychiatry was how smooth the attendings were about dealing with difficult patients. You'd have an obnoxious patient on the medicine or surgery floors who would have all the docs chewing their stethoscopes with utter frustration. Then the psychiatry consult would walk in and in three minutes he'd have the patient eating out of his hand. Unbelievable. I wondered whether this was a talent they were born with or a result of their education. (Ultimately, as with most things, it's probably a little bit of both.)

It's a bit of a chess game, as one has to think a few moves ahead. If I say this, he'll likely say this. If I don't say this, another chance may not come. If I say it in this particular way, will he react well or badly?

It's perhaps funny to imagine that human interactions could be condensed down into a set of algorithms. One would like to think that individuals are so very different from each other that one size could never fit all. And it's true that one needs to apply one's interpersonal intuition to an extent. But only to an extent. There are definite ways to bring angry or frustrated patients back to a state in which they can engage in rational conversation.

And it doesn't only work in the controlled environment of a hospital or clinic. I've used some of the basic techniques we're learning with other angry, irrational people in my life (mainly frustrated residents from other services) with excellent results. Secret weapons! Psychiatry is incredible.

Next entry: Getting people to be rational is both easier and harder than it seems.

biology vs psychology: false dichotomy?

I was speaking with a very intelligent and insightful patient today who mentioned that he'd felt his problems (depression, some obsessional traits, a mild eating disorder) were all 'psychological' until he found a drug that significantly improved them. From that point on he was convinced they were 'biological,' and embarked upon a quest for the Magic Pill that would solve all his neuroses at a single swallow.

I see references to this sort of split all the time, and not just from patients but also from highly educated physicians and scientists. Somehow they consider that our behavior* arises from two distinct sources: one composed of neurons, synapses, and neurotransmitters, and another composed of experiences, drives, and willpower.

If you buy the biological theory of behavior at all, then it makes little sense to imagine a dividing line between 'biological' and 'non-biological' causes of behavior. Experience alters neurochemistry just as surely as medications do.

Here's a nice (but somewhat technical) piece of work discussing some of the cellular-level changes that have been observed to be triggered by real-world experience (Takahashi, Svoboda and Malinow).

Evidence abounds for the utility of 'talk therapy' in psychiatry. In order to separate the 'biological' from the 'psychological,' one would have to believe that there exists an entirely separate underpinning of human behavior that operates on some ethereal plane, unrelated to the biomechanical world of synapses and neurotransmitters.

If you're going to accept that neurobiology underlies behavior, then there is no clear point at all where you can divide the biological from the psychological. If you accept that experience exerts its effects through alteration of our neuronal activity, and you accept that hearing your therapist is an experience, then there is no room for some nebulous 'non-biological' effect. Your therapist's words tickle your ear neurons, which tickle your brain neurons, which make subtle changes - sticking themselves to some of their neighbor cells, unsticking themselves from other neighbors, changing the rate at which they spit neurotransmitters at each other - and voila! You change your behavior.

That the line between biological and psychological is fuzzy to the point of nonexistence is indeed starting to permeate the general consciousness, at least to a degree. This usually arises in discussions of ethics, where the whole edifice of crime-and-punishment rests on an assumption of free will. This assumption is being radically challenged by evidence that our behavior is heavily determined by factors not under our direct control (genetics and medication in particular).

This opens up another can of worms, because we frequently associate 'biological' with 'beyond our control' and 'psychological' with 'within our control.'  Hence my patient (and many like him) and his Magic Pill search.

But I think the educated world at large is not yet ready to join Steven Pinker in declaring us will-less playthings of our genes and environment. Fine for now, but I'm curious to see what we'll make of coming scientific advances that will no doubt push us even closer to the will-free wall.

*I'm using "behavior" intentionally to encompass all of the workings of the human brain that are manifest to others. I'm doing this very deliberately because the question of whether mind is biological at all is a very sticky wicket and not something I can afford to get into in this limited space.

free will and eating disorders

We've a number of eating-disordered patients on the unit at the moment.  Eating disorders have never been a particular interest of mine; yet as I work more closely with eating-disordered patients, I've come to realize their problems raise a number of interesting philosophical questions.

We've all had the experience of being of two minds.  We want something, yet we do not want it. One experiences this on a regular basis, yet it rarely disturbs the view of oneself as a single, integrated ego, a unified mind.  However, the problem is very severe in the eating-disordered.

How to want to be well but also not want to eat?  How to want one's life back, to know that the eating disorder has wrecked it, to understand that one flirts with death, yet be so petrified of food?  Even my patient Ms. G., weighing just 35 kilos and desperate to regain a normal life, was yet utterly unable to prevent herself from binging, vomiting, and binging again.  "Obviously I have free will," she wailed unprompted, "but somehow I can't stop doing it."

Our medical student was surprised at her intelligence, unable to credit her self-destructive behavior because "but she's so smart!"  But 'smart' has nothing at all to do with it; in fact, quite the opposite: anorexics may have higher than average IQs.

(This may be tied to the well-documented association between anorexia and the need for control.  Besides body weight, academic achievement is another area where due diligence generally yields the desired results, and thus appeals to the controlling anorexic personality.  In fact, Dura et al. note that 'perfectionistic striving' actually yields better academic results for anorexics than would be predicted by their IQs alone.)

 

This makes a degree of sense when one considers that a certain level of complexity is required in order to deny one's own basic drives so severely.  At the most straightforward level of functioning, one merely obeys one's basic drives - hunger, thirst, fear, desire - pursuing the most immediate means of gratification.  At a somewhat more sophisticated level, one may delay instant gratification for a bigger payoff later on, forgoing one candy now for two candies later.  Ultimately, one may come to value successively loftier intangibles above the basics: staying up late to finish that big paper; starving for one's art; giving one's life for one's country.

Well then, how to be cognitively impaired, like our patient Ms. S., and yet have an eating disorder?  Ms. S. had been impaired since birth, and she behaved for all the world like a sweet and coquettish child, grinning impishly at the team, asking for hugs, requesting praise for her accomplishments.

At first I could not believe someone functioning at this simple level was sophisticated enough to have an eating disorder.  I thought she must have an organic illness, a food sensitivity or irritable bowel.  And yet as we weaned her down to the most elemental and gastroenterically benign food supplements it became clear that the problem was not in her bowel, but in her head.  She played all of the typical eating-disorder games: saving food, dumping food, vomiting food, mixing and freezing and thawing and refusing it, drinking gallons of black coffee and diet soda, and on and on and on.  

Ultimately it became clear that at least one of the reasons for Ms. S.' eating patterns had, unsurprisingly, to do with control - a common theme among eating disordered patients.  In Ms. S'. case, though, it was more to do with control over her family than over her body.  Still living with her mother in her forties, Ms. S. yearned to go out and build her own life.  She found that refusing to eat allowed her to exert a measure of control over her large, loving, yet stifling family, all of whom rallied round her and raised a ruckus of attention over her malnourished status.  Which was, evidently, far preferable for Ms. S. than sitting quietly on the couch watching TV all day and being ignored by those with lives of their own.

I hadn't given Ms. S. nearly enough credit for the complex, multilayered psyche she evidently possessed.  Humans are deep creatures, even the simplest of us.  

Not too much can go wrong with a simple machine like an abacus or a bacterium.  But as you add more bits and parts and cogs and circuits and cells and networks, the number of ways things can go wrong explodes.  Ultimately you end up with personal computers and human beings, both of which are endlessly surprising and infuriating in the sheer number of things that can go wrong with them.  Hence computer wizards, and psychiatrists.

chemical love

One of my more interesting recent patients had a problem straight out of a daytime talk show. This was a young gay man in love with his heterosexual roommate. The two of them had a very close relationship, eating dinner together, going to movies as a couple, and generally engaging in very couple-like domestic activities. They also had a surprisingly open relationship. The gay man had confessed his ardor to the roommate, and the roommate, while he did not return the sexual feelings, was mind-bogglingly relaxed about the whole issue and the two of them remained as close as before.



Matters took a turn for the worse when the roommate acquired a girlfriend. Naturally the gay man could not stand the girlfriend and resorted to drinking alone in his room or going for long drives whenever she was around. Ultimately he became so depressed and consumed by the situation that he was unable to work, could not sleep, lost interest in his hobbies, and finally sought psychiatric help.


At first nobody on the treatment team could understand the situation, and in particular the behavior of the roommate. We speculated that perhaps he was a closeted homosexual who unconsciously returned the feelings, or else that he simply couldn't bring himself to give up the incredibly cheap rent offered by his lovesick roommate (who owned the apartment).


The answer turned out to be a bit more complicated. I sat down with both men for a frank discussion of the situation, and found that, at least to casual observation, their relationship appeared as close and open as had been described to me by the gay patient. Together we dissected the timeline of their relationship. It turned out they had been ordinary good friends until they began to use the drug Ecstasy (MDMA). Over the course of a summer they had used the drug weekly together - rarely with anyone else - in the process cementing a bond that ultimately became more like a love relationship than anything else.


It is likely impossible to convey the emotional power of Ecstasy to anyone who has not tried the drug. Roughly, it works by reversing the direction of the reuptake transporter that vacuums leftover serotonin out of the synaptic cleft. This dumps enormous amounts of serotonin into the synaptic cleft - far more than would ever normally be present there at one time. Just as chocolate cake overstimulates the taste receptors that evolved to detect the more mild and nuanced sweetness of fruit, Ecstasy overstimulates circuits designed to underlie the natural pleasures of romantic attachment and sensory experience.


In a stark demonstration that love really is just chemistry, Ecstasy can make you feel a gush of deep affection for just about anyone sharing the experience with you. It's Cupid's Arrow in chemical form.


In this particular case, these two men overstimulated their 'love circuits' together over and over again for an entire summer. It's no wonder the gay one fell in love with his friend. As for the straight roommate, evidently Ecstasy can't alter sexuality (unsuprising, as anyone who's tried it will tell you Ecstasy has little to do with sexual feelings, and in fact often inhibits them). But it did seem to have triggered many of the other hallmarks of romantic love. The man gazed affectionately at his roommate, expressed all manner of deep and abiding emotion for him, was wracked with guilt for the suffering he'd caused. Everything was there but the sexual attraction.


The chemical basis for emotion is nothing new, and at this point carries little shock value. Yet it is still difficult to believe how easily we can manipulate our deepest emotions with a little diddle to the neuropharmacological machinery.


What was the cure for this young man? Fighting fire with fire, I prescribed him Prozac. Prozac works by paralyzing the same reuptake transporter that is reversed by Ecstasy. Instead of being vacuumed back out of the synaptic cleft when their job is done, the serotonin molecules loiter around in the cleft. The simple way to think about this is that more serotonin in the cleft equals more happiness, duh - though in fact the biological effects of SSRIs such as Prozac are somewhat more complicated than that (see Nutt et al for a useful summary).


As one might expect, then, Prozac blocks the effects of Ecstasy. With Prozac in your system paralyzing your reuptake transporters, a nice fat pill of E has no more effect than a sugar tab. That was one little-known side effect I thought might be useful in this particular patient's case.


A more well-documented side effect of SSRIs is inhibition of sexual function, including the ability to orgasm (see Rosen et al. for review). In addition to this, there are some anecdotal reports that SSRIs such as Prozac have adverse effects on romantic love. This is a much mushier and less well-documented realm. I found nothing about it on PubMed, though I did find a bit of schlock in Psychology Today that discusses the phenomenon. If this latter bit did turn out to be true, I would wonder whether the effect were secondary to inhibition of sexual desire or whether it involved a distinct group of neural circuits.





Based on anecdotal reports from people who have used them, it sounds as if SSRIs may in fact dull the capacity for deep emotion. You don't feel sad anymore, you even feel kind of happy, but the happiness is a sort of pleasant zoning out rather than a meaningful joy. Indeed, by some reports the entire spectrum of emotion is flattened out (see, for example, comments posted by readers on this WebMD blog).


Much has been made of the possibility that we are depriving ourselves of essential human experiences by medicating away our emotions (see, for example, this review of Eric Wilson's book Against Happiness). Of course, many others more articulate than I have also argued the opposite side of the story (see this other review of Peter Kramer's Against Depression).


As is often true, I find myself taking a position somewhere in the middle. I don't want my patient to be zoned out forever, but I can't help but think that he's already had more than enough character-building for a while. A little Prozac in this case is probably a good thing.

it's all in your head

Psychiatrists - and doctors generally - see two kinds of symptoms.  There are the 'classic' symptoms that have meaning because they signify something we can treat, and the 'off-road' symptoms that don't seem related to any disease process we understand.

In psychiatry, the former are typified by people who are having frank hallucinations and delusions.  I know how to recognize them  - they look ill, odd, off - and how to treat them - antipsychotics, patience, consideration.

Then there are people who report experiences that are just... not what one normally talks about.  I do brief screenings for psychotic symptoms on all of the patients I see, many of whom may have, e.g.,  mood or anxiety issues, but certainly no evidence of a psychotic disorder.  They may be sad or nervous or emotionally disordered, but their reality testing is absolutely intact.  When asked if they've ever "seen things others don't see," or heard things others don't hear, they typically hesitate.  Then they preface with, "Well, I don't think it's relevant..." or "I'm not crazy, but..." and I know what I'm about to hear.

There was the twenty-two year old girl who said "My sister and I see ghosts.  It's accepted in my family, it's not a problem."  There was the sixty-four-year old Vietnam Vet who heard music when he saw mountains.  It was real music, heard aloud, and specific for each peak. 

Musical hallucinations seem to be an entirely different kettle of fish from the angry, insulting voices that are typically heard by psychotic patients.  (Oliver Sacks has written eloquently about music and the brain.)  

In my short time as a psychiatrist I've already heard many variations on these themes.  They seem a class apart from the psychotic symptoms that are familiar to doctors and treatable.

In fact, this sort of phenomenon is seen throughout medicine.  For doctors, there are two types of complaint: those that signify a known pathological process, and those that don't have a cause we understand.  Most doctors put the second type of complaint in the "all-in-your-head" category.  They may be more or less sympathetic to patients with these complaints (often less, and sympathy tends to correlate inversely with the doctor's workload), but they don't know the cause of the symptoms and there doesn't seem to be an underlying disease they can treat, so they're not really interested.

This gives rise to the common complaint among patients that "the doctor doesn't listen to me."  It's not that he isn't listening, it's that he's categorizing your problems as "meaningful" and "meaningless."  If you tell your doctor your skin is turning yellow, he'll be all ears and will likely order a battery of tests.  If you tell him you have a pain in your left elbow that only happens after you eat,  he'll say "uh-huh" and try to move on quickly.  That kind of pain isn't a symptom of any disease he knows of, so he'll file it under "random aches and pains" and turn his attention to more pressing matters.

Of course, patients rarely know the difference between the significant symptoms and the insignificant ones (that's what medical school is for), so they can get understandably upset at getting yes-deared by the doc.

In psychiatry, these sorts of off-road symptoms fall even further by the wayside than do the general medical aches and pains, because they tend not to bother people.  Few people come to psychiatrists complaining of seeing ghosts or hearing music; rather, they accept these things as part of their lives, and the experiences only come to light if they happen to come to a psychiatrist for another reason.

Symptoms can sometimes move from the all-in-your-head category to the now-I'm-listening category when we come up with an explanation or a treatment for them.  A lot of people with the fatigue and joint pains characteristic of chronic Lyme disease got the brush-off from doctors before the cause of the disease (a spirochaete transmitted by tick bites) and the appropriate treatment (antibiotics) were identified.

I doubt we will ever find a 'cure' for the off-road symptoms seen in psychiatry, for the simple reason that most people who have them don't particularly want to be cured.  I would, however, be extremely curious to see whether we might find an explanation.  Are these really psychiatric phenomena, or are they something else?