I really like this content. I like the honest analysis, commentary and opinions. Don’t get me wrong, the skits are insanely good! But diving into serious issues with this level of honesty is refreshing.
Thank you! I’ll be doing more skits when I have more time and people to do them with. I’d rather do them not at all than do them poorly. So while I’m working 6 days a week it’s gonna be serious videos in my car when I have time lol
Actually the most important thing is , that there is no radiological or any other medical findings that are present in all patients ( or findings that are present in many patients )with any mental illness. There are theories and hypotheses that suggest etiology but there are no findings that are persistently present in large group of psychiatric patients with same mental illness.
I'll also add that the way you interpret images is extremely tightly tied to what a person is experiencing. Every radiologist in the world will tell you that an image without a good clinical history is generally meaningless. So when you put those two things together, you realize that you're not going to be skipping a history anyway.
Same with EKGs generally speaking. Obvious Vfib is obviously vfib But the same is true of like, obvious epidural hemorrhages, they are kinda hard to NOT notice 😂😂
I'm glad to hear about the non-specificity of brain imaging. I feel that overall in medicine sometimes patients are too hung up on imaging. The history and the clinical evidence are an essential part that combines with the results of imaging to form many diagnoses. I think so many people would poop themselves over how many incidental findings there would be if they got a CT scan. It's the whole workup that makes imaging helpful in diagnosis (and yes, in some cases imaging alone is probably good enough).
I’d love to learn more about what the first symptoms are of schizophrenia & how that changes in each onset stage, how to get help and the diagnosis process. Both of my grandmas had it so I’m interested to hear more.
Another thing is, you took schizophrenia as your example. Schizophrenia, if I am not mistaken, is actually one of the most easy mental disorders to actually spot, and it is still not easy. As far as I know though, most other types of mental illness don't show clear brain 'pathology'. Even if altered brain activity can be measured, the question remains, is the activity altered because of the mental illness, or is it the opposite. And are we even able to distinguish different types of brain activation to different mental disorders?
That’s a great point. To look at it from another angle I think the issue at hand is your spatial resolution/unit of analysis. MRI can only look at lobes and cortices, but most psychiatric illnesses involve aberrant neural pathways and circuits. (for example the hypoactive mesocortical pathway in schizophrenia) The relevant unit of analysis of is smaller than what can be made out by an MRI. You lack the spatial resolution to see how discrete clusters of neurons are wired together.
I feel like this discussion gets to the heart of why some people maybe “dismiss” mental health as there’s often nothing concrete we can test for to say whether or not someone has disease and often times these diagnoses are ones of EXCLUSION rather than “inclusion” For example, if im having lower stomach pain and my hcg is negative, you can confidently tell me im not pregnant. But if someone has all the symptoms of SIG E CAPS for example, you sort of have to go “well I’ll test thyroid, b12 etc. and if that’s all negative, I guess it’s really a psych issue”. It just seems less “definitive”
One of my theories is that our diagnostic system is built around clinical observations and history rather than any other kind of analysis (factorial, biomarkers, etc.). As a result, the classifications are kind of like Carl Linnaeus' taxonomy. The classifications seem sensible and intuitive and we even find "support" for them, but they're fundamentally wrong if you use other methods (molecular, genomic, etc. in taxonomy). We're classifying unrelated things together, the same things separately and whole categories are just missing. That's why it comes back all weird and nonspecific when we try to use other methods besides the ones we used to create the system in the first place. We're trying to find biomarkers for social constructs. We find nothing definitive because our constructs don't physically exist. I'd bet money if we actually built a diagnostic system from the ground up using data while ignoring previous "wisdom" it would look very different and a lot of stuff would make more sense.
We’re trying to find biomarkers for social constructs. That is very well said . My oppinion is that there are people that have biological root of their mentall illness, but there are people experiencing same symptoms with no biological root . As we can see the diagnostic criteria is weakening ( meaning that it is a lot easier to diagnose mental illness because criteria for it is common in all people not just psychiatric patients) we are going away from fininding true biological cause of any mental illness.
That's kind of sort of true, but the catch is that the categories being used for mental illness work for targeting treatment, because the goal is to treat the illness, not the biomarkers (and in cases where possible, testable organic causes have been found, a lot of the time there's dozens to hundreds of different ones where only a minority of patients have any given one, even in syndromes where most people reliably respond to the same treatment). A big part of the problem here is that mental illness is kind of a software problem, to use an analogy with computers - trying to diagnose it by poking around your motherboard isn't going to get you anywhere when the problem is in the code so to speak.
Hey brother, do you wanna do a skit or video on the topic of psychiatric care in the prehospital environment. I’m lucky that my paramedic program is actually one of the first to implement mandatory psychiatric exams during clinical rotations and I think it’s one of the, if not the most under trained and misunderstood aspects of prehospital medicine.
Not every person with mental disease has findings on brain image. Not every mental disease has a single, consistent finding on brain image. Not every finding on brain image has a single disease or disorder that explain it. Not every brain imaging modality has the same sensitivity for a pathological finding. Regression of brain lesions is not necessarily correlated with improvement of illness. Pathophysiology rarely tell us whether a brain lesion detected in brain imaging is the cause or the consequence of a psychiatric illness.
I don’t think the issue is that we’re not 100% relying on these scans I think the issue is that we’re throwing darts at patient with regards to medications instead of maybe using these scans as way to guide treatment decisions. I know it sounds like a wild idea 🙄🤷🏻♂️😬 The key word was “guide.” I get that the qualitative approach to diagnosis is important since we’re treating patients with difficulties managing their symptoms and so person A with condition X may be struggling while person B with condition X might not be. Again the criticism isn’t that weren’t not 100% relying on these scans it’s that we’re not using them at all in the diagnostic process. Psychiatry is the only branch of medicine that doesn’t haven’t some sort of machine/tool to aid in that process… and so the critique that the process of a psychiatrist’s diagnosis and treatment of a patient feels like you’re just throwing a dart 🎯 at a wall is still unfortunately valid… Edit: I didn’t know about the existence of Radiologically Isolation Syndrome though, so it is definitely interesting to add that into the discussion. And thanks you so much for putting out this content! You’ve really helped me understand what this specialty is all about. 😁
Preston, you seem wracked with insecurity over choosing psychiatry as a career and seem to feel the need to prove yourself by pushing psychiatry pseudoscience to assure everyone that you’re working in a reputable field. No psychiatrist has ever used head imaging to diagnose schizophrenia ever and there is no prospect of that occurring any time soon. That’s why psychiatrists distinguish between organic and functional illness. Schizophrenia is diagnosed as a syndrome when the head imaging and CSF are normal. If there’s an abnormality on MRI that needs referred to a neurologist and if causing the patient’s symptoms it would never be referred to as schizophrenia, which is, by definition, a functional psychiatric disorder and not a disease. Please get therapy so you feel worthy and don’t keep trying to prove you’re as smart as all the other doctors out there. Just be happy!
![Eminem - Like My Shit [Official Audio]](http://i.ytimg.com/vi/vx_IMvFkrfA/mqdefault.jpg)
I really like this content. I like the honest analysis, commentary and opinions. Don’t get me wrong, the skits are insanely good! But diving into serious issues with this level of honesty is refreshing.
Thank you! I’ll be doing more skits when I have more time and people to do them with. I’d rather do them not at all than do them poorly.
So while I’m working 6 days a week it’s gonna be serious videos in my car when I have time lol
@@itspresro could you do a skit about people justifying and blaming their actions on astrology and signs.
@@itspresro man, I’m impressed you have time for even the car vids. Idk how you’re a full time Doctor and a full time content creator.
Actually the most important thing is , that there is no radiological or any other medical findings that are present in all patients ( or findings that are present in many patients )with any mental illness. There are theories and hypotheses that suggest etiology but there are no findings that are persistently present in large group of psychiatric patients with same mental illness.
I'll also add that the way you interpret images is extremely tightly tied to what a person is experiencing. Every radiologist in the world will tell you that an image without a good clinical history is generally meaningless. So when you put those two things together, you realize that you're not going to be skipping a history anyway.
Same with EKGs generally speaking.
Obvious Vfib is obviously vfib
But the same is true of like, obvious epidural hemorrhages, they are kinda hard to NOT notice 😂😂
I'm glad to hear about the non-specificity of brain imaging. I feel that overall in medicine sometimes patients are too hung up on imaging. The history and the clinical evidence are an essential part that combines with the results of imaging to form many diagnoses. I think so many people would poop themselves over how many incidental findings there would be if they got a CT scan. It's the whole workup that makes imaging helpful in diagnosis (and yes, in some cases imaging alone is probably good enough).
I’d love to learn more about what the first symptoms are of schizophrenia & how that changes in each onset stage, how to get help and the diagnosis process. Both of my grandmas had it so I’m interested to hear more.
Another thing is, you took schizophrenia as your example. Schizophrenia, if I am not mistaken, is actually one of the most easy mental disorders to actually spot, and it is still not easy. As far as I know though, most other types of mental illness don't show clear brain 'pathology'. Even if altered brain activity can be measured, the question remains, is the activity altered because of the mental illness, or is it the opposite. And are we even able to distinguish different types of brain activation to different mental disorders?
Indeed. Very well said.
That’s a great point. To look at it from another angle I think the issue at hand is your spatial resolution/unit of analysis. MRI can only look at lobes and cortices, but most psychiatric illnesses involve aberrant neural pathways and circuits. (for example the hypoactive mesocortical pathway in schizophrenia) The relevant unit of analysis of is smaller than what can be made out by an MRI. You lack the spatial resolution to see how discrete clusters of neurons are wired together.
I just want to say how much I appreciate these educational videos! Short but very effective communication of complex ideas!
I feel like this discussion gets to the heart of why some people maybe “dismiss” mental health as there’s often nothing concrete we can test for to say whether or not someone has disease and often times these diagnoses are ones of EXCLUSION rather than “inclusion”
For example, if im having lower stomach pain and my hcg is negative, you can confidently tell me im not pregnant. But if someone has all the symptoms of SIG E CAPS for example, you sort of have to go “well I’ll test thyroid, b12 etc. and if that’s all negative, I guess it’s really a psych issue”. It just seems less “definitive”
One of my theories is that our diagnostic system is built around clinical observations and history rather than any other kind of analysis (factorial, biomarkers, etc.). As a result, the classifications are kind of like Carl Linnaeus' taxonomy. The classifications seem sensible and intuitive and we even find "support" for them, but they're fundamentally wrong if you use other methods (molecular, genomic, etc. in taxonomy). We're classifying unrelated things together, the same things separately and whole categories are just missing. That's why it comes back all weird and nonspecific when we try to use other methods besides the ones we used to create the system in the first place. We're trying to find biomarkers for social constructs. We find nothing definitive because our constructs don't physically exist. I'd bet money if we actually built a diagnostic system from the ground up using data while ignoring previous "wisdom" it would look very different and a lot of stuff would make more sense.
We’re trying to find biomarkers for social constructs. That is very well said . My oppinion is that there are people that have biological root of their mentall illness, but there are people experiencing same symptoms with no biological root . As we can see the diagnostic criteria is weakening ( meaning that it is a lot easier to diagnose mental illness because criteria for it is common in all people not just psychiatric patients) we are going away from fininding true biological cause of any mental illness.
That's kind of sort of true, but the catch is that the categories being used for mental illness work for targeting treatment, because the goal is to treat the illness, not the biomarkers (and in cases where possible, testable organic causes have been found, a lot of the time there's dozens to hundreds of different ones where only a minority of patients have any given one, even in syndromes where most people reliably respond to the same treatment). A big part of the problem here is that mental illness is kind of a software problem, to use an analogy with computers - trying to diagnose it by poking around your motherboard isn't going to get you anywhere when the problem is in the code so to speak.
Hey brother, do you wanna do a skit or video on the topic of psychiatric care in the prehospital environment. I’m lucky that my paramedic program is actually one of the first to implement mandatory psychiatric exams during clinical rotations and I think it’s one of the, if not the most under trained and misunderstood aspects of prehospital medicine.
Not every person with mental disease has findings on brain image.
Not every mental disease has a single, consistent finding on brain image.
Not every finding on brain image has a single disease or disorder that explain it.
Not every brain imaging modality has the same sensitivity for a pathological finding.
Regression of brain lesions is not necessarily correlated with improvement of illness.
Pathophysiology rarely tell us whether a brain lesion detected in brain imaging is the cause or the consequence of a psychiatric illness.
very interesting, that makes a lot of sense
I need professor Preston to start teaching classes!
I don't think it is an either/or issue; one is subjective and the other is objective so, ideally, both should be applied.
I don’t think the issue is that we’re not 100% relying on these scans I think the issue is that we’re throwing darts at patient with regards to medications instead of maybe using these scans as way to guide treatment decisions. I know it sounds like a wild idea 🙄🤷🏻♂️😬
The key word was “guide.” I get that the qualitative approach to diagnosis is important since we’re treating patients with difficulties managing their symptoms and so person A with condition X may be struggling while person B with condition X might not be.
Again the criticism isn’t that weren’t not 100% relying on these scans it’s that we’re not using them at all in the diagnostic process. Psychiatry is the only branch of medicine that doesn’t haven’t some sort of machine/tool to aid in that process… and so the critique that the process of a psychiatrist’s diagnosis and treatment of a patient feels like you’re just throwing a dart 🎯 at a wall is still unfortunately valid…
Edit: I didn’t know about the existence of Radiologically Isolation Syndrome though, so it is definitely interesting to add that into the discussion. And thanks you so much for putting out this content! You’ve really helped me understand what this specialty is all about. 😁
When are you going to do more skits?
Hay feelings bro
We need more skits
Bro like why even use brain imaging if mental health is just high test and mental illness is simply low test
Preston, you seem wracked with insecurity over choosing psychiatry as a career and seem to feel the need to prove yourself by pushing psychiatry pseudoscience to assure everyone that you’re working in a reputable field. No psychiatrist has ever used head imaging to diagnose schizophrenia ever and there is no prospect of that occurring any time soon. That’s why psychiatrists distinguish between organic and functional illness. Schizophrenia is diagnosed as a syndrome when the head imaging and CSF are normal. If there’s an abnormality on MRI that needs referred to a neurologist and if causing the patient’s symptoms it would never be referred to as schizophrenia, which is, by definition, a functional psychiatric disorder and not a disease. Please get therapy so you feel worthy and don’t keep trying to prove you’re as smart as all the other doctors out there. Just be happy!
🙄