By Alan Koenigsberg, M.D.

As a reminder, I depend on questions asked from the TJP reading audience, so I can respond appropriately to those questions you have always wanted to ask a psychiatrist, but were too afraid to ask…

Please email me directly at akoenigsberg@mac.com, or to Sharon Wisch-Ray (sharon@tjpnews.com) directly at the TJP and she can forward the emails to me. Thanks!

I have had patients ask me why we don’t use scanning techniques to help diagnose as well as monitor psychiatric conditions, the way we use them in neurology, cardiology and other areas of medicine. They cite various articles about some psychiatrists claiming to use them in their practices.

The answers are pretty straightforward. Despite some claims, the CT, MRI, PET and SPECT scans simply don’t have the resolution to reliably detect changes at the molecular level, especially at the synaptic levels, which is where we have found dysfunction in the various psychiatric ills.

Some of these scans are indeed used in research, and the research continues avidly to attempt to use these scans. However, it is all still in the research phase. As of now, February 2023, these scans are not ready for prime-time use in everyday practice.

Our understanding of depressive disorders, anxiety disorders, ADHD, eating disorders, bipolar disorder and addictive disorders is that they are the result of dysfunctions of circuitry in the brain. The foundational causes may be a combination of heredity; infections, especially during pregnancy; trauma; as well as life experiences.

All of the above, however, result in either physical changes to brain cells or changes in the functioning of those cells in various circuits in the brain.

Given that we can’t really do biopsies, can’t pinpoint the location of the dysfunction and can’t exactly target the areas needing help, we resort to the tools we have at our disposal.

Just as the CT scanner revolutionized the diagnosis of many diseases, I hope that one day, we will indeed have external, objective means of diagnosing these conditions as well as monitoring progress. In the meantime, we rely on old-fashioned clinical diagnosis, meaning that we listen to our patients, ask specific questions and look for recognizable patterns.

It’s still how we diagnose pain conditions such as migraine, fibromyalgia, diabetic peripheral neuropathy and other chronic illnesses.

On a more positive note, in spite of what people may have read about the modest benefit of many of the psychiatric medications, especially antidepressants, the reality is that when properly done, these medication treatments can be very effective.

Given that we are usually targeting symptoms, we do the best we can to treat the primary conditions, such as a major depressive disorder, and then continue to work to completely alleviate all residual symptoms.

In other words, if I have a patient who has improved on an antidepressant but still has residual insomnia, after we investigate the sleep hygiene and do a sleep study if appropriate, we may also prescribe a sleeping pill.

If, when treating a severe chronic anxiety disorder, there is improvement but residual anxiety, we may consider an antipsychotic medication, which has been shown to be quite effective as an adjunct treatment.

If, when treating panic disorder, there is noted improvement but residual panic attacks, we may prescribe a rescue medication such as a short-acting benzodiazepine.

The practice of medicine has always rested on the foundations of science, and the art of treating the patient in front of us, with the tools at our disposal. With proper care and enough time, many if not most people can attain substantial benefit.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas.

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