How Psychiatric "Background Noise" Interferes with Optimal Functioning
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In practice for almost 40 years, Francis Mas, MD, has become a “psychiatrist’s psychiatrist” because of his mastery in treating treatment-resistant and complex cases, working with patients who often feel depleted by multiple previous treatment failures. One reason for his success is his ability to quickly form a positive therapeutic working alliance with patients by framing their psychiatric symptoms as “background noise” that is interfering with their access to inner resources of their core self. This paradigm allows him to operate with a shared language that patients and consulting psychotherapists can use to communicate about the vicissitudes of the patient’s clinical presentation and ability to do deeper work on the essential psychic issues. Working like a detective in search of clues as to the nature of diagnosis, exploring the difficult niches found between categorical DSM approaches, Dr. Mas’s goal is to help his patients gain access to their authentic natures. Here, he explains the origins of his approach and highlights its application in his work with a patient with an unusual clinical presentation…Richard Juman, PsyD
You have a unique way of framing the general concept of psychopharmacology as "Turning Down the Noise" in the patient's head. Can you explain to our readers what you mean by that and how you came to arrive at this way of thinking about your work?
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As a psychiatrist who specializes in psychopharmacology, I usually stand at the end of the therapeutic line to see complex or treatment resistant cases sent to me by psychiatrist colleagues or by psychotherapists. Treatment compliance is extremely crucial in such situations, and yet there are significant obstacles to compliance. For example, many patients have already come to resent “needing a pill,” especially since none of the medications they’ve been prescribed have provided sufficient relief. In addition, some patients will stop treatment as soon as they become less symptomatic. Others who come in are greatly afraid of losing their identity on a “mind-altering drug.”
So the first order of business must be to establish a trusting therapeutic alliance by conveying a clear and understandable plan of care. Executing such a plan, however, is not easy! I find that using a lot of biological jargon is confusing to patients, while browbeating them to follow a regimen without first helping them understand your approach is simply counterproductive: you’ve got to get the patient to understand that you and he are working collaboratively to solve a well-understood problem.
Over the years, I tried a number of approaches designed to establish this working relationship, but I was never satisfied with any of them until I found a very simple metaphor that has resonated well with all of the various populations, demographics and psychopathologies in my practice.
I am referring now to the metaphor in your question—thinking of a patient’s presenting symptoms as a distracting “background noise“ that is interfering with her consciousness and ultimately her life itself. The goal of treatment, therefore, is that I work collaboratively with my patients to arrive at a psychopharmacology regimen that eliminates the “background noise” and allows them to be their best selves. Everyone can understand this idea, and through that understanding comes the therapeutic alliance, compliance with treatment, a greater willingness to stay in treatment for the long haul, even when obstacles present themselves.
Every human being can be distracted by a very noisy environment, either external or internal, and this establishes a commonality of experience with any patient. Seen in this light, a patient’s symptoms can then be construed as unwanted noise that interferes with a person’s ability to utilize all of his resources—which I envision as largely intact but only reached intermittently as a result of the “noise” getting in the way. So the goal of a successful treatment—of any kind, by the way—should therefore be to quiet that noise allowing for better use of these resources. This principle holds for all of us and should be presented that way. Noise distraction is not a weakness, and free and unobstructed access to our inner core is what makes us whole.
I like to work closely with psychotherapists to help them gauge the optimal intensity of the therapy with our shared patients. When the “noise” is powerful the patient benefits from a supportive approach on all sides, but as that quiets down, the work can go deeper and become more productive as the patient is able to connect to and take advantage of their inner resources on a steady basis. Although simplistic at first glance, in my experience this shared metaphor allows for better acceptance and enhanced effectiveness of an integrated treatment. I think that it is simply intuitively grasped by all parties and becomes a shared language that facilitates an early, positive and strong therapeutic alliance.
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The "noise" is a wonderfully intuitive metaphor for describing the ways that psychiatric symptoms can interfere with consciousness, as well as a patient's general level of functioning in the world. I would also imagine that it would be received as very destigmatizing by patients, because it posits the symptoms as extraneous, as opposed to an intrinsic part of the self. Do you think that your patients receive the "noise" analogy as destigmatizing?
Yes, it can have such an effect. Many patients feel ashamed and defeated by their condition by the point that they are sent to me. And many of them tend also to perceive their symptomatic self as the “real” one, so a crucial aspect of early treatment is to help them understand that there is a truer self waiting underneath the symptoms, and that an unimpeded access to all of their resources will make them freer and more authentic. As I mentioned earlier, the initial presentation of a clear and accessible treatment plan becomes fundamentally important in that context.
This reconceptualization of the presenting clinical picture provides a much-needed reassurance to the patient about the basic integrity of her “true self,” which is essentially sound but only being reached intermittently due to the intensity of the background noise which is the target of the biological treatment. This requires a reframing of the role of the patient’s willpower, which permeates most therapeutic environments but is, in my opinion, often ill-used. In my framework, I present the patient with a different challenge, understood as a dyad:
Background noise: You are NOT responsible for it, but you ARE responsible for helping me ameliorate it by allowing me to understand it and by following my proposed treatment.
Resources: You are FULLY responsible for their development and for the development of your authentic self as they become more available to you on a steady basis. Always, psychotherapy is strongly suggested as a mean to accelerate and consolidate the process.
The basic purpose of this working metaphor is to give back a sense of mastery to the patients, which has often become confused by the multiple dimensions of their condition and past treatment failures. It does not pretend to explain biological or psychodynamic issues, but is rather an operational tool to facilitate an integrated treatment.
With respect to the tools that are available to you as a psychiatrist now, as opposed to at the beginning of your career, how dramatic has the change been? Do you feel that the assessment tools and psychotropics that you're using now are a dramatic improvement over those from 20 or 30 years ago?
It may come as a surprise to you, but the most dramatic change for me has been more conceptual than tool-based. Some of the best medications we currently have are over 60 years old. Using them along with the more recently developed medications in a different context is what I have progressively learned to do over the years. What prompted me, as well as a number of colleagues, to evolve in that direction was the brain mapping findings showing that:
Similar brain states often produce different symptoms.
Different brain states often produce similar symptoms.
In other words, a given psychiatric clinical picture can have many possible biological correlates that are not easily defined phenomenologically. By analogy, think about the experience of an internist trying to determine the possible etiology of a fever. In that domain, one is reminded of the state of medicine in the middle of the 19th century: the physical characteristics and evolution of a number of fevers allowed them to be classified as well-defined “diseases” grouped in a “Catalog of the Fevers.” A paradigm shift only occured later on, following the discovery of the possible bacterial, viral or various other etiologies, thus exploding the long-lived prior conceptualization.
It follows then that entities such as “anxiety,” “depression,” or even “psychosis” can be conceptualized as symptoms of various brain states as opposed to categorical diseases per se. One observes an application of this concept when a ”treatment-resistant depression” not responding to a series of regular antidepressants improves on a anticonvulsant mood stabilizer such as lamotrigine, or when a cyclical, well-defined unipolar depression only responds to lithium treatment. The current classifications of psychiatric illnesses such as those in the DSM-5 and ICD-10 are very useful in that they establish a common language that is shared among clinicians as well as between various bureaucratic entities. But they are not as useful insofar as treatment is concerned, and even less so in difficult cases.
As a result, the NIMH Research Domain Criteria (RDoC) initiative, which is designed to look at psychiatric illness from a completely different vantage point, has recently been launched. But it’s hard to say how long it will be before it begins to produce reliable and practical tools. The task at hand is indeed gigantic and will require resources similar to the ones used in the deciphering of the human genome!
Meanwhile, we will need to use a “low tech” approach, which can still be quite effective. It involves merging the combined information provided by the patient’s personal and medical history, his personality type and genetic background, his presenting symptomatology, as well as a longitudinal and detailed history of the responses to his current and past psychotropic medications. Once that work is done, then and only then can we establish a probable therapeutic “statistical space” and reach for the psychotropic “tool box,” as well as for non-psychotropic interventions which includes all the various psychotherapies and the recent emergence of electrical brain stimulation.
The way that you describe your approach to diagnosis and treatment, especially in "treatment-resistant" cases, might remind our readers of the way a seasoned detective looks at all possible factors and variables in looking for clues as to the best way to "solve a case." Is that an apt way of describing your approach?
It’s definitely not a bad way to construe how I operate. Let me give you a clinical example involving a treatment-resistant depression in which a variety of “clues” and “red herrings” needed to be deciphered. “Gary,” a very successful professional in his early thirties, was referred to me by his long-time psychotherapist. The presenting problems were an unrelenting form of depression with increasing anxiety, plus mounting obsessional as well as compulsive features such as compulsive checking. I first met him in April, and he expressed his puzzlement at not feeling better in spring time "as he always did in the past." In fact, he reported that he was “getting worse by the day.” He reported having experienced a major depressive episode the previous September: “my first one…it came out of the blue after a great summer…I lost all my energy, could not sleep, lost weight and could not concentrate.”
As a result of the depressive episode, he was given a standard SSRI. He reported that initially “It was like a miracle…I felt great within a few days and was very productive again…almost back to myself." The improvement lasted for a few months, until the end of the year, but “by January I started to feel very sluggish and depressed again.” Bupropion was then added, with some initial benefits, but pretty soon the presenting clinical picture of depression and anxiety with obsessive compulsive features emerged in spite of increasing both antidepressant dosages while adding a benzodiazepine at night.
At first glance, it seemed that the patient fit the well-established criteria for Major Depressive Disorder and Anxiety Disorder with Obsessive Compulsive features. He would then be a candidate for a different type of antidepressant such as a SNRI or clomipramine. Adding an atypical neuroleptic to ease the agitation could also be an option. But in these more complicated cases one must look at the whole biopsychosocial picture in order not to be swayed by the immediacy of the presenting symptoms.
Gary had an uncomplicated childhood. A very bright student, he attended and graduated from an Ivy League college and graduate program. He describes himself as a “high energy person,” but there is no evidence of manic or hypomanic episodes, nor had he ever demonstrated any significant impulsive or impulsive behavioral problems. His sleep has always been preserved. He always liked the spring and summer seasons but felt a little sluggish during the winter, particularly for the last several years. But the sluggishness never rose to the level of a formal Seasonal Affective Disorder.
He has a family history of isolated cases of alcoholism; currently, one of his siblings is in recovery for drug abuse and has been on an antidepressant for the past two years. Gary reports that his brother “seems OK…but he is struggling at work.”
So in looking at Gary I saw no evidence of a formal bipolar disorder, but it didn’t look quite like a unipolar depression either. It also didn’t reach the established criteria for a bipolar II condition. In thinking about the “clues” a few things stood out and suggested a pattern:
- An ultra-rapid response to an antidepressant is often seen in typical bipolar disorders.
- But the rapid improvement is not sustained over time, ultimately giving way to increased agitation.
- A seasonal pattern is also often seen in that group of disorders.
- In these instances, once an underlying medical condition has been ruled out, one is facing a situation that is unlikely to respond to a linear approach.
So my working hypothesis fell along the lines of an incipient atypical “bipolar” diathesis, for the lack of a better terminology. Please note here that it is apparent that the brain states producing such a clinical picture are only weakly captured by phenomenology alone. For still unknown reasons, these presentations tend to respond well to a mood stabilizer.
As a result, my first move, which was initially interpreted as counterintuitive, was to decrease and progressively phase out the antidepressants while introducing Lamotrigine. In Gary’s case, his agitation decreased while his mood improved. Euthymia was reached after two months and sustained over time. Many similar clinical situations are of course not as straightforward as this one, or as easily resolved, but I hope that this example captures the essence of the process required to solve them. Identifying patterns rather than chasing symptoms is the key element to be stressed. Gary had of course a lot of initial “background noise” that was severely interfering with his level of functioning but was then able to use psychotherapy very effectively as it quieted down leaving his self esteem intact.
Francis Mas, MD, is a graduate of the Montpellier University Medical School (France) and of the New York University Medical School Psychiatric Residency program. Currently a Clinical Professor of Psychiatry at NYU, he is a member of the Ordre des Médecins (Paris, France) as well as of the American Medical Association. He is a Distinguished Fellow of the American Psychiatric Association.