Thanks everybody for coming. So this, I'm David Hellerstein. I'll give myself a little more introduction in a few minutes. I was just remembering in coming to this year's APA, I heard the protesters out front. It was pretty loud and well organized this year. It reminded me of my first time at APA, which was in 1985. It was in Dallas, Texas. And I remember going past the Texas Book Depository where Lee Harvey Oswald had shot JFK. I remember there were tours of the South Fork Ranch where Dallas was filmed. The Smothers Brothers were presenting. And also, a very strange thing for a psychiatric convention. The great writer, Louis Borges, from South America actually had been invited to present. He was elderly. He died like two years afterwards. And he presented a standing room talk to an audience of psychiatrists. And he was blind. And his talk was about Helen of Troy. And I just remember at the end of the talk how she disappeared and all that was left was her gleaming eyes. So I just finished residency at that time. And I was trained psychoanalytically. And we're going to be talking about that today, some of the models of psychiatry. And I was like, wow, what did Borges mean? We tried to get his autograph later. But his protector, this very gray lady, sort of pushed us away. We couldn't get his autograph. I don't know how you get an autograph from a blind person anyway. But it was quite a moment because I thought, oh, maybe the eyes are all that's left. Maybe that is symbolic of psychoanalysis, which was sort of disappearing at that time and was being replaced by DSM. And in fact, 1985 was a sort of remarkable time. DSM-III had just come out in 1980 when I started residency. And also there were, I think there was fluvoxamine. There were some presentations on the industry part of the exhibition about this new drug that nobody could talk about that was going to revolutionize psychiatry that had something to do with the serotonin system. So flash forward a couple of years. We had Prozac. And life has never been the same. So now 38 years later, psychiatry is again under a process of massive change, still being challenged. I don't know if those are Scientologists or who it is outside, but that hasn't changed. But we're in the midst of a new revolution. We were in the DSM revolution at that point. Now we're in the midst of a neuroscience revolution. And also we're very excited about psychedelics, which is my new area of research. And there's a host of new treatments that we see that are really largely untested. Ketamine, web-based mills are being set up everywhere. People are getting lozenges sent to their home. Lots of people have IV ketamine centers in their locales. There's TMS being done wildly, rampantly. Hard to tell what kind of coils people use, where they dose people, how they do it. And we actually need a new STAR-D study to test these new treatments. Is it going to happen? I don't know. With NIMH's current policies, I would say don't hold your breath. But we're in the midst of this interesting revolution. And we're eager for a next phase, a next consensus. And so what I want to talk about today is my book, which is sort of a different kind of book than the usual psychiatric book. Just came out a couple of weeks ago from Columbia University Press. There's my disclosure slide and a picture of the book cover. But I've gotten grant funding from various industry and foundation sources. I'm on a couple of NIH grants. I'm on an advisory panel for a small startup, and so on. In terms of my background about myself, I'm a professor of clinical psychiatry at Columbia. I conduct research on treatments of mood and anxiety disorders. And as I mentioned, most recently have been investigating psychedelic compounds. And also, I've done a lot of studies that have combined neuroimaging with randomized clinical trials, which kind of bridges the eras from DSM psychiatry to neuroscience. Now, this is really kind of the core of my talk and my kind of approach for my book. For a couple of decades, besides my academic work and my practice, I've taught a course to Columbia P&S medical students, preclinical medical students, on writing creative nonfiction. The title of the course is The City of the Hospital. And it teaches narrative medicine methods as a way of exploring the ever-changing worlds of becoming a doctor and practicing medicine. And in teaching this course, I became aware of a paradox, which is that the folks in internal medicine, surgery, other branches of medical professions have become very interested in narrative. And in fact, personal narratives have become very popular among the general public. And there's a lot of doctor writers. And people, the public is, I would say, rightly fascinated by personal narrative, both written by patients, families, but also health care providers, including physicians, as ways of exploring the world of health care. And the New England Journal of Medicine, Analysts of Internal Medicine, JAMA, Lancet, they all run substantial sections of essays, personal narratives, and even poetry. And paradoxically, psychiatry has moved away from narrative. And this is a huge change. If you go back to psychiatric journals in the 1930s, 40s, 50s, but even 1970s, 80s, you'll see that the journals of those days had a lot of articles about doctor-patient relationships, processes of psychotherapy, interesting cases. And now, if you look at our journals, they look like radiology journals, public health journals, psychometric journals, lab science journals. They don't really impress you as about doctor-patient relationships in the field of psychiatry. And I actually wrote a piece about the disappearing patient in our profession. So now, I think that's a mistake, and that the literary narrative method is a very powerful one. And again, our brothers and sisters in medicine have discovered this. And if you just read what the surgeon Atul Gawande writes, or the oncologist Siddhartha Mukherjee, they illuminate the worlds of heart disease and the mysteries of cancer. And then, of course, the late neurologist Oliver Sacks, the immunologist Louis Thomas, the internist, more recently, Suzanne Coven at Mass General Hospital, and out west, the infectious disease physician Abraham Verghese, have all written really compelling medical narratives. So why did I write this book? So when I thought of writing a book, and why to write this book, and a book of this kind, as opposed to a sort of dispassionate history of psychiatry, I thought writing a personal history of psychiatry, a history of lived experience, so to speak, would be potentially engaging and could illuminate things that are more objective kind of history, would do in different ways, but wouldn't necessarily show the same things. And also, I thought it might be a way to illuminate shared experiences, both of colleagues and students and co-workers, and also to engage people who are entering the field as well. So my book is at once a personal history of my own doubts, missteps, discoveries, breakthroughs, and my evolving approaches as psychiatry has remade itself over the last few decades, not once, but actually twice. And also, it's a history of our professions and our society's evolving understanding of the mind and its maladies. Now, the changes in psychiatry over recent decades, has anybody read Thomas Kuhn about scientific revolutions? It's really a classic book. And what he calls paradigm shifts in science, where the ground sort of shifts underneath a field and a new set of ruling paradigms takes over. I would say we've experienced a form of that in psychiatry with our changes from psychoanalytic to DSM, now to neuroscience. And they've been disruptive changes, controversial, and I would say in many ways, non-linear. And the, it's, I would say for many of us who practice, it's also been a pretty bumpy, bumpy road. When I began medical school in the 1970s, late 1970s, a psychoanalytic model that had dominated American psychiatry since the 1950s still held sway. And then in 1980, the DSM-based model, DSM-3, kicked in and DSM psychiatry began to become the default method of treatment. And now, starting around the turn of the millennium, neuroscience began to sweep through research and medical education. And it now is having a profound impact on clinical care for the first time. It's been, one of the readers of my book said it was a wild ride to read it. And I think for our profession, for a lot of us, it indeed has been a wild ride. And why? Well, again, the ride has been, the changes have been, as I mentioned, non-linear. Each of these models has radically different explanations for causes and cures of psychiatric illnesses, and each prescribes different treatment approaches with very different goals. For psychiatrists, psychologists, and patients as well, I would say this has been a pretty disorienting and baffling kind of change. So, stories. So again, why are stories important? Medicine's always been centered around stories, and both in medical education and practice. Now we're very aware of HIPAA, so we don't tell stories in the elevators and public hallways. But that's what medicine traditionally has been about. I saw a patient who, last night, the wife called or the husband called. This morning, I went into the operating room. And what happened, what happened, what happened. So, and when I was a kid, both of my parents were physicians, there were six kids in my family, and my dad was a cardiologist, my mom was a pediatrician, and innumerable other relatives who were doctors, nurses, other healthcare workers. And dad would take us down to the hospital at night, and we would, he would go into his exercise physiology lab, put us on treadmills and bicycle ergometers, tell us, take us on rounds on nights and weekends, and we would often really learn how medicine was practiced and the dilemmas and problems from both being there as kids in our white coats that were trailing on the floor as we went down the hall, but also what, how medicine worked and didn't work. And mom would also take us to the urban clinic where she worked, which was subject to the riots, inner-city riots in the 1960s. And the stories, again, that we grew up with were elegant ways and eloquent ways to connect these disparate kinds of experiences. And today, stories are important as doctors that go through training, because even as it gets more and more science-based, and when I talk to the young medical students, it's amazing the kinds of stuff they just absorb that we, you know, older people didn't have to learn, but they still learn through stories, in rounds, in classes, at the bedside. And narratives really integrate scientific and personal, social, biological, genetic realities as they affect the mind and body of an individual patient and the society at large, and they illuminate the course of illness and healing. Now, what about psychiatry? Are stories still central to psychiatry? So this is one of the paradoxes, I think, about psychiatry, that psychoanalytic psychiatry was all about stories. And so, going back to Freud, everybody who still reads his case histories is reading stories. He won the Nobel Prize for Literature, not for medicine. And he was a great writer. But, and that's been the basis of psychotherapy, is telling and retelling narratives of suffering and healing. And in our offices, we hear the stories of patients. They're suffering, they're at a dead end, they're miserable, maybe they're suicidal. And we work collaboratively with them over time to recast and retell their story. So actually, it's a narrative, creative process to tell and retell the story, so that the person had a, was at a dead end, and you're trying to allow them to have more hope and more possibilities. Then with the DSM-III, and I think this accounts for a lot of the switch and the, I'd say, discarding and even despising of narrative, DSM-III came in with objective, measurable, reliable criteria, and stories, I think, were perceived as deceptive, and potentially, anybody could tell a story with any beginning, middle, and end. And so, they've been kind of dumped. But I would say, even in DSM psychiatry and neuroscience-influenced psychiatry, they still are central. They're just very different types of stories. So let me just give some examples, and I'm gonna read a couple of excerpts, some excerpts that I, just short excerpts, I promise, that will give a very brief sense of how the stories are very different in the different ages of psychiatry. So, um, so the first excerpt is from the age of the psychoanalytic, of psychoanalytic psychiatry. And this is when I was just learning how to do psychodynamic psychotherapy, and I had the horribly disruptive and difficult experience of a patient falling in love with me. So, I don't know if this has happened to anybody else in their practice, but this is how the story went. And we're talking to my, my supervisor was named Dr. Banks. And she had mentioned that there were transference issues, counter-transference issues with this patient. There's, I admit to Dr. Banks at our next supervisory session, there's an element of truth to it. A counter-transference issue, transference, it turns out, is only one half of the therapeutic relationship. As transference describes the patient's feelings for the therapist, so counter-transference reflects the therapist's feelings for the patient. It could reflect unresolved issues from the therapist's own life, or give clues to issues that the patient is struggling with. Do you think that's relevant here? Maybe, I say, then sink into silence. Either way, understanding these is crucial for the progression of their work. Unresolved issues, these days, besides unwelcome feelings for my patient, egotistonic feelings, I'm painfully aware of all the unresolved issues in my life. Now in the frenzy of learning psychodynamic therapy, it's like a ripping away of bandages, having no choice but to jump into the morass. It's very scary, hence my uncertainty is whether I can do the work, regardless of whether I believe in it or not, a whole other issue. Anyhow, who is training who? To a great degree, it feels like my patient is training me, or trying to, since I don't seem like a very quick learner. The great mystery of training programs, medical or psychiatric, is how raw young doctors are thrown into situations they can't be prepared for and somehow come out the other end as well-trained professionals. Order emerging from chaos. My supervisor is watching me with what looks like amusement. Okay, so my supervisor led me through a very painful learning experience and enabled me to come out on the other side of what seemed like an unresolvable problem. But then I talked to my classmates and it turned out having patients fall in love with them was almost universal among my psychoanalytically trained colleagues. And in fact, it seemed like it was essential to learning how to do psychoanalytic psychotherapy. Now, in the age of neuroscience, do people have the same experiences, feel the same way? I don't know. So later in the book, I talk about the clinic. And the age of the clinic is the age of DSM-III. Now, the reason I talk about the age of the clinic is that with DSM-III, we had reliable diagnoses. We could make them two psychiatrists or two trained mental health professionals could make the diagnoses, agree with each other whether they were valid or not, different issue, but at least you could agree this is what I was looking at. Not only that, we got the development very quickly of evidence-based treatments. And I think for people who have grown up in the last couple decades, that doesn't seem like a big deal. It's a huge deal because psychoanalysis was not evidence-based and still largely is not. Okay. So this excerpt is from a patient who accidentally got better. And the reason this patient accidentally got better is because she had been banned from our clinic. This is in a very busy urban setting. And she had been, I talk about the red box. I don't know if people have worked at hospital facilities. There's often a list of patients who shouldn't be readmitted. And in my place, it was the red box. So if someone was red boxed, it meant they had burned every possible bridge. Okay. So this is a patient called Viv. I first became aware of Viv when I was appointed director of the outpatient division of my hospital in the early 90s, overseeing the day treatment program, the clinic, and the psychiatric emergency room. For years, Viv has haunted our emergency room. For years, dozens of doctors, psychologists, and social workers have tried to help before finally reluctantly red boxing her. She has a pale face and crooked teeth. And when you talk to her, she stares toward a corner of the room, never making eye contact. She's always accompanied by her father. She wears a hat no matter what the weather. He sports a grimy raincoat no matter what the weather. She is the one with the labels, innumerable grim DSM diagnoses. He is the chorus, the escort, the relentless and tireless advocate. Remarkably belligerent, always cursing, complaining, raising a ruckus, Viv has never responded to treatment of any kind. She has evolved a routine, however. Once admitted to the hospital, she immediately submits a sign-out letter and refuses everything. I want to leave this hellhole immediately. I refuse to take any medications. You have no right to give me Haldol. Let me go home now. So now what happened was there's a medical new year every year. Every June and July, there's a turnover of residents, new residents come in. They don't know the rules, and things tend to fall between the cracks, never get sick in June or July. Everybody knows that. Okay. So a new doctor came in, and somehow in the chaos that we were experiencing, Viv got readmitted to the clinic. And so this is her new doctor, Dr. Lamkovich, describing that Viv has become a member of his clozapine group. Now clozapine required, everybody come twice a week, wants to get the blood test, wants to get the result, get a week of medicine at a time, may have changed by now, but because it causes a granulocytosis, very closely monitored. She was the world's worst candidate for clozapine. I never would have allowed her to get it because she was a guaranteed failure. So Dr. Lamkovich says, yeah, she comes to clozapine group. He explained patiently as though to a small child. Clearly, he doesn't see what the fuss was about. One meeting each week is for the blood drawing and to talk about medicine effects and side effects. The second meeting is to get the prescription and to talk about their lives. Viv is one of the best members of the group. She's also a very good student in her classes. And she had been in college, had to drop out. She'd been on back boards of hospitals and so on. She's thinking of going back for her bachelor's degree. So long story short, she did. To the amazement of all the doctors who worked for her and her family and everybody else, she was able to eventually live independently, return to college, and even, last I heard, graduate school. And this was a really interesting story because it showed really a triumph of DSM psychiatry. Somebody made a good diagnosis. There was a treatment that seemed reasonable to try. We just didn't want to give it to her because she was so impossible. And it actually then connects to the era of precision psychiatry because what we're seeing now in psychiatry is there's some of my colleagues at Columbia are looking at back boards patients in search of targets for precision psychiatry, rare copper number variations, and other kinds. So it's actually like a boiled down distillate of failed cases actually may be the source of a lot of potential progress in psychiatry with very, very sophisticated techniques. And then in the third section of my book, I call it the scanner. Now the reason I call the couch of the clinic in the scanner is because obviously in the age of neuroscience, scanners are essential to our work. So we're doing PET scans, MRI scans, but also different kinds of neuropsychological testing and other kinds of gene scans and so on. But also we are scanners. So I just went to a class or a meeting just before this about nutrition and psychiatry. It's connecting to neuroscience in really interesting ways. And everybody in that room is probably a devotee of nutritional aspects of psychiatry related to neuroscience. So we're scanners as well. So when I was at Columbia, when I first came to Columbia in the year 2000, I heard our Nobel Laureate Eric Handel, a neuroscientist who investigated molecular basis of memory, and he was talking about some research in his lab. And one of his junior faculty was doing a study on what he called safety centers. And so we think PTSD is a disorder of fear. You can't turn off your fear responses. The fight or flight mechanism is constantly turned on. Your amygdala is out of control. And what Handel and his colleagues had uncovered is that PTSD is not just a disorder of fear. It's also a disorder of safety. So there's two different processes. And safety is, if you don't have a sense of safety, then you're always liable to having fear. Okay. So when I was in this Grand Rounds, a light went off because I'd just seen a patient with very severe PTSD who had repeated traumas and who had actually described to me never feeling safe. So the victim of two rapes during her college years, nearly losing her life, Aileen struggled with PTSD and major depression for a decade afterward. She became dependent on alcohol and marijuana and lost several jobs. She eventually became abstinent thanks to regular attendance at AA and started psychotherapy. While SSRIs could have helped her depression and PTSD, she refused to take them and instead started intensive practice of yoga, often two or three hours per day. She practiced deep breathing, intensive muscle relaxation, and switched from junk food to a Mediterranean diet and the like. After about a year, she was able to go back to work, to finish college. She began dating soon afterwards, moved in with her partner who was later her wife. She became a yoga teacher and then eventually went back to school to become a therapist. So this to me was an interesting jump between the lab essentially and the clinic, not easily verifiable that her safety center individually was disturbed or whatever, but actually today there's a whole line of research about enhancing safety conditioning, safety strengthening brain safety mechanisms and so on. So our period of neuroscience. So it's very different, one has to agree, from the psychoanalytic era and it's also very different from the DSM era because the DSM era we had focus on specific diagnoses. Here we're looking at underlying circuits that involve many, many different, underlying many different disorders and are not neatly cut by diagnostic criteria. And then now we're sort of, which I talk about at the end of my book, in this strange period of psychedelics. So now we're in a strange moment which is the reemergence of psychedelics after a pretty much 50-year ban. And so one of the questions that I think is really interesting is how are psychedelics going to fit into the three previous models? So with the importance of mystical experiences, psychological experiences, early life experiences, does it somehow reify the psychodynamic approaches to psychiatry? What about DSM diagnoses because there's so many DSM diagnoses that are being studied with psychedelic treatments. But then on the other hand, neuroscience, there's clear effects that psychedelics have of potentially restructuring neural networks. So this is one of I think the kind of interesting questions that we're facing now. So let me just say some things about how stories differ between the three models of psychiatry and how profoundly they are different. So in the psychoanalytic model, the method is exploring early trauma issues, attachment issues using free association analysis of dreams. In DSM psychiatry, we use reliable diagnostic criteria. You provide evidence-based therapies and we would say you have these five diagnoses and you need these three evidence-based treatments. But these days, neuroscience-based psychiatrists are trying, I would say, in a bit of a state of chaos because there's no guidelines. So whereas psychoanalytic therapy was very structured, DSM training and therapy were very, very structured, what we see in the age of neuroscience, there's no guiding rubric to define how we should, how should we approach neuroscience and tell our stories. So one of the things about neuroscience is that we're starting to use treatments that would have been really unthought of just a few years ago. So we're thinking of the brain as having dysfunctional brain networks and we're providing treatments in addition to conventional medicine and therapy. We're doing meditation, exercise, brain stimulation treatments, and the idea is to try to enhance brain health and neuroplasticity and to modulate circuits and to really essentially help people out of broken record circuitry situations of ruminations, compulsive behaviors that they can't stop despite them not being rewarding or even dangerous. But it's a very mysterious thing because the same circuits seem to be affected with different disorders. And again, the circuits don't respect the DSM boundaries. So I think if people want more information about my book and then just wanted to have some room for discussion. So I actually had questions for the audience. So because we're in a time of such, I would say, tumult and chaos, how many people here would say that they follow a mostly psychodynamic approach to treatment? Okay, 1, 2, 3, 4. How many follow mostly a DSM approach? Okay. And how many follow a neuroscience influenced approach? Okay. So if we had three corners of the room, you know, we could have the teams. I did see a few people. How many put up their hands for more than one? Okay. How many put up their hands for all three? Okay. So we have sort of a triple vision. So this is actually one of the interesting questions, like how do people incorporate or synthesize those three models? So is your approach primarily psychodynamic? Is it primarily DSM? Is it primarily neuroscience? How do you decide which patient is going to get what sort of approach? And is that patient-based or do you have an integrated way of providing care kind of for most of your caseload? If you can come up to the, if anybody wants to comment, please come up to the, don't be shy. Go ahead. Thank you for a very interesting discussion. I put my hand up for all three questions that you asked because I shift between these different paradigms sometimes in one session with a patient, thinking about them psychoanalytically, which is I've been trained as a psychoanalyst. I'm also an addiction therapist and will sometimes think about the addiction components to what is being presented very much along the lines of a DSM understanding of addiction, trying to diagnose a psychiatric addiction disorder. And may at the same time think about getting some neuroimaging or at least referring to a colleague who is better equipped to understand neuroimaging techniques to ascertain what could, what may be going on with a specific individual. So I think that your talk has really shed light on a fascinating field where we're able to shift using these different paradigms. It's eclectic and lends itself to dilution, but I think that we still don't know enough about the brain to be able to say this is the path that we should be taking. And I think humility in the face of an enormously complex organ and an enormously complex topic is what I think you bring to this talk, so thank you. Thanks. And yeah, another comment? Yeah, Dan. So I think that you, in my view, I know there's an important element in your history that I like. I think you, I don't know if you overlooked it or you put the focus differently, but in the 1970s, there was a very intense debate in the journals about whether psychiatry was legitimately a branch of medicine. And there were articles written about this, even books. There was also a debate about whether schizophrenia was really a disease of the brain. And I think that the rise of the DSM and psychopharm was in some ways psychiatry's attempt to legitimize itself in the eyes of other branches of medicine. And I wonder if, to some extent, we're still kind of struggling with those kinds of questions of identity. And if that doesn't also inform your book and your work. Right. And I think, thank you, thanks, David. It's a very, I think that's a very excellent question that certainly, notwithstanding the protesters outside, I think most people in general society, most people in medicine accept that schizophrenia and bipolar disorder have biological basis, depression as well, although it's much more heterogeneous. And so I think that may be sort of mostly a battle from the past that DSM played probably a role in helping make progress on. But I think the interesting thing to me about the neuroscience component is that we're all very eager to figure out what components can be applied to our treatment approaches. And any one study, any one lab, any one finding, I think can be very susceptible to not being replicated. And so, you know, there's issues of the serotonin transporter gene. There was a, I actually, one of the stories I tell in my book was a four generation family where everybody in the family had the same disorder, including the spouse of one of the family members married into the family. And that husband had the same disorder, sort of like a selective mating. And they were exquisitely responsive to a single drug. It turned out it was an SSRI because that was the drug of the time. And the whole family's trajectory was radically changed as a result of a simple intervention. So then I was reading, like, Absalom Caspi, he had these findings about, I think it was a serotonin transporter. And it's like, oh, these people have this homogeneous, homozygous, you know, two short arms and their serotonin transporter is abnormal. Then that whole line of research was kind of discredited. And now there's a third round where people say, no, no, actually, it looks like that transporter polymorphism is, it's related to vulnerability. So in enriched environments, those people do very well. And in adverse environments, they do very badly. So you see in one, you know, one very short time, like 15 year period, that the hypotheses of very, you know, well done science labs and investigators go back and forth. And it may be eventually move in a kind of coherent, single explanatory direction. That said, that family was remarkably changed. I don't know if they had a serotonin deficiency or transporter problem or they all placebo responded to the same drug. I don't know. But it was four generations. But the one thing that was very humbling was the couple, the marriage, which had started out as the two members of the couple had gotten together in, I think it was in high school or college, because they were both very shy and fearful, they sort of selectively made it in a sense. And then once they both were not having the disorder anymore, they decided they didn't really like each other that much and they broke up. So one of the, it was very humbling because I could help the family, but I couldn't save the marriage. But it was, so I would, so the one thing that I've tried to do is, I consider myself very, I trained in psychodynamics, I kind of rejected it, I became big into DSM, I participated in the differential therapeutics revolution and et cetera, et cetera. And now I'm like, well, what can we do with neuroscience? And I see it as principles. So I see like, okay, what kinds of principles that could be applicable across many different disorders, many different conditions. So brain health. And it's really interesting to me that cardiology, my dad was a cardiologist, my grandfather also, brain health was so, cardiac health has been an issue for a hundred years. Brain health, psychoanalysis didn't have anything to do with brain health. The brain didn't really exist, it was just the mind. DSM-III didn't have a mind, it just had symptoms, it didn't even really have a brain. And so neuroscience is trying to have a brain, a body, and a mind. And so brain health seems like one logical thing that makes sense, it's consistent with animal studies, human studies, it's consistent with medicine, neurology, et cetera, et cetera. Neuroplasticity is another thing. Neuroplasticity exists throughout life, it looks like the stress response that occurs in psychiatric disorders causes decreased neuroplasticity, causes neuronal shrinkage. So that seems an applicable kind of principle from neuroscience that makes a lot of sense in clinical practice, because you could say, well, what kinds of behaviors can you do that would enhance brain health, neuroplasticity, decrease your stress response systems? A lot of fear response systems are chronically turned on in many different disorders, and people have trouble modulating their fear response system, so trying to help people to modulate their fear and stress response systems better. And resilience, I think, is a neuroscience consistent model of investigation, and it's in animal studies and human studies and so on, and makes sense as a principle. So to my mind, those are things that one can apply that are neuroscience-based, oh, trying to also, importance of exercise, diet, and so on. So trying to enhance positive neuroplasticity, trying to decrease inflammation, trying to decrease systemic inflammation. So those are all things that I think go beyond the findings of an individual lab or investigator or study, and make sense as principles that can be implemented in psychiatric practice. For instance, it's been really interesting to me in talking to my psychoanalyst friends that a lot of them seem to be very into mindfulness and meditation and yoga, even though back when we were training at Payne Whitney Clinic in the mid-'80s, people were smoking in their offices. Every office had two ashtrays, and I think a lot of psychiatrists died young because they were surrounded by a haze of smoke all the time. So the zeitgeist has kind of changed, and I think that's a way in which we're searching for models. But that said, I think there's some psychiatrists who are more circuit psychiatrists, like Josh Gordon, the head of NMH, describes himself as a circuit psychiatrist. So those folks are thinking about the default mode network is overactive in different kinds of psychiatric disorders. How can you modulate the default mode network? Well, therapy, meditation, medication, mindfulness, exercise, a bunch of things can allow people to modulate that network. Even though in the individual person, do I know that this depressed person actually has an abnormal default mode network? No. But is that a logical model that we could derive from neuroscience that would be applicable across our field? A couple of comments and questions. Yeah. Well, it's not a question, it's rather a commentary. I'm a child psychiatrist from Belgium, Mechelen. I started after medical graduation with general practice, went into systemic and family therapy. And then I took a training in child and adolescent psychiatry, psychoanalytic psychotherapy, other therapy forms. I appreciate your talk, because you've shed a light on personal development as a psychiatrist. You didn't stick to one model, what is the source of friction among colleagues, I think. In child and adolescent psychiatry, it's all about development. And if you put me to question, what do you choose as an approach in practice? From my analytic experience, I know that each patient wants to be listened to. That's particularly true for young people, for adolescents. And then they expect sometimes practical solutions, guidings. My opinion about diagnosis is that diagnosis is important for a psychiatrist, not for the patient. Diagnosis is important for the patient. So in order to get to prognosis, I tell them, I want to know who you are, and I'm not interested in your disorder. Because many times, these youngsters come up and they say, I've seen on the internet, and I think I have a phobia. I have a tick disorder. I think I have ADHD. I'm afraid that I have a personality disorder. Because you can't imagine where my thoughts go, what my dreams are telling me. And that's my practical approach. You just have to adjust to your patient. Particularly if you work in a first-line psychiatric approach, as I do. I think this is quite different from colleagues working in an academic environment, such as you do. I think it's particularly interesting that you still keep that particular view on different branches in psychiatry. So you make me curious to read your book. Thank you. Thank you. Hi, I'm Jason Gardner. I'm a private practice psychiatrist, also a child psychiatrist. I wanted to, I guess, pick up on one thing that you had said about psychodynamic psychiatry and that it's not largely evidence-based. I read lots of articles where they're trying to rectify that, and there have been some studies marrying psychoanalytics. I don't know how current you are on that piece of that, but that is something that's coming there. I was thinking, as I was listening to your talk, the idea of paradigms. You mentioned how they get washed away, but psychoanalytic therapy, which has now become psychodynamic, which now becomes interpersonal therapy and branches out into other areas of therapy, still has a pretty solid, I think, grasp in the field, and is a way of approaching healing. But I also wondered what your own lens or preferred lens was, and I guess my understanding is that it's more from the neuroscience. Well, I think that this is probably one of the reasons I wrote the book, was to try to figure it out. I think, and it was interesting because I went through the editorial process. It's my sixth book, so it's not like I'm new to writing books, but it was a particularly difficult book to write because I was pulling together essays that I'd written over many years and trying to see, well, this shouldn't be just a collection because it's too diverse and varied. So what are the underlying themes? How can I find emergent properties in a way? So I ended up using psychodynamic processes to figure out what the underlying themes were and so on. But to try to figure out, well, what do I actually do, or what do my colleagues actually do? And we go to all these different kinds of talks and lectures, and how do we actually put it together in our own practices? Because the three big baskets of type of information that we have, they're very like oil and water. They don't really mix particularly well. I think we do try to integrate them into our practices. So I think, and also one interesting thing was my editor, as I rewrote it, was like, well, what's your opinion of psychoanalytic psychotherapy? What did psychiatry get from psychoanalytic psychotherapy? Nobody's recommending that everybody go into four times a week lying on the couch and talking about their dreams and transference. So that's clearly not a model that's applicable to millions of people. It's not labor-intensive or practical. But well, deep listening, respect for patients, trying to make therapeutic alliances with people, trying to understand, as the gentleman was saying, in terms of connecting to people, what do they want from treatment? Who's the diagnosis for? Is it for the patient or the clinician? And so I think that's a profound component. I think that making, you know, diagnoses, decent diagnoses may not be valid, but they are reliable. And it's striking to me that even if they're not valid on a biological basis, why do so many people with a particular diagnosis respond to one treatment? So even if they're so diverse, why would one treatment work for more than half of people with depression? Is it all placebo? I don't think so. But, you know, is it, you know, why would, and also people tend to track over time. So children may go from anxiety to depression to whatever. But adults, if they have a mood disorder at year one, they're going to have a mood disorder at year 10, 20, and 50. So they may develop other comorbid diagnoses. But it's very useful because on a practical level, it helps you say, well, this is how this person is tracking through life. They may have the same circuits as a person with PTSD or OCD that have abnormalities, but there's, you know, the way it's manifesting in their phenotype seems fairly constant. And then the neuroscience piece, to me, it's a, so I guess I in a way integrate them all, but I'm trying to sort of put people in the broader picture of what do I think is happening from a mind, brain, body perspective. Because so often people have poor nutrition, poor exercise habits, impaired social functioning, some kind of evidence of recurrent negative thought loops and patterns. And so there's, I think, a way to say that the neuroscience can be sort of, neuroscience base can sort of integrate all these things. And then one can use kind of psychodynamics or DSM kind of as needed. But I think, again, we, one of the difficulties I have is, and I sort of said this before, but psychodynamic therapy is so focused in its training and approach. DSM, you have to learn how to be reliable on these instruments. Neuroscience, it's a wild west. And the, you know, the, are we ever going to have studies that compare ketamine to TMS to psilocybin to MDMA to exercise for treatment resistant depression? Are we going to have like a star D two or three? I don't think so. So we're kind of in, in sort of everybody's inventing their own kind of phase, which is to me a very disturbing situation because there's not a way to sort of help people to integrate and think these things through. Everybody's doing their own thing. Everybody's, if they are neuroscience focused, everybody seems to have a somewhat different way of kind of slicing the situation. Okay. Well, I think that's it unless there's any last questions or comments. Thanks very much. Oh, Dave. Yeah. Just very, very quickly. I just want to just following up on what you last said. So there was a fellow who had an office near me who said, asked if he did, he had a TMS device installed in his office and he was telling me about this great TMS and he wanted patients. He says, let me tell you how it works. He says, the patient comes in and we have this nice kind of couch that they lie on and they come in and they're like there four or five times a week and they lay on the couch for like 45 minutes and the nurse positions the device. But over the course, the nurse gets to know the patient, patient gets to know the nurse, and about six weeks later, the patient feels a lot better. So I thought that was just a great ... Thank you. I mean, yes, there's certainly room for other effects than what the device is providing. Well thanks very much.

psychiatry evolution

psychoanalytic psychiatry

DSM-based psychiatry

neuroscience

psychedelics treatments

narrative in psychiatry

storytelling in medicine

patient stories

David Hellerstein