I'm glad to see the APA recognizing the importance of your work! To take you up on the AMA, do you have any thoughts on mind-body syndromes and the recent momentum of Pain Reprocessing Therapy, Emotional Awareness and Expression Therapy, and the broader movement inspired by John Sarno--which gained academic credibility with the 2022 JAMA Psychiatry trial of PRT for lower back pain. Or put differently, any thoughts on somatization of distress and somatoform disorders? I can't wait to read your book. I find pretty much every one of your blog posts indispensable in my understanding of mental disorders.
Thank you Thomas! So far I have been a rather peripheral observer of these developments, viewing them with a mix of curiosity and hesitation. So I don't really have anything meaningful to say about it for now, but this is a good reminder for me to dig deeper into this literature. A good topic for a blog post!
I am only surprised that you've received that award because I wouldn't have imagined that the association would be as so open to your work. But I'm also delighted! Your success bodes well for the field and for our patients. And please don't believe the post-literate hype! I'm happy to report from the publishing trenches, we're still writing and reading :)
Hello, Mr Aftab! I’m a high school student here interested in pursuing the field of medicine and psychiatry. I greatly admire your work, especially your commentaries on the social impacts of mental illness. I have a question that's a little more conceptual in nature, and I'd love your thoughts if you have a moment.
From what I’ve been reading in classical presentations of psychosis, delusions tend to borrow heavily from cultural content — aliens, religious figures, government surveillance etc etc. But this implies that the content of a delusion is shaped by the patient's existing conceptual framework of what is 'real' versus 'unreal’, which is largely built through cultural upbringing and social interaction.
So, what would delusions (delusions specifically, not hallucinations) look like in someone with schizophrenia who had no cultural scaffolding to draw from, say, a child raised in complete isolation? Since delusions are defined by their departure from shared reality, and recognising something as a delusion requires knowing what the person believes reality to be, I'm wondering whether psychosis would still produce fixed false beliefs in the absence of any shared symbolic system. Basically, no concepts of God, aliens, authority or anything of that sort to borrow from. If so, what form would this content take? Would it be as severe and impairing?
Wow, what a creative question! So aside from content of delusions, we also have to keep the “form” in mind and delusional mood/atmosphere in mind. Delusional mood is a sense that the world has shifted, that everything is saturated with a strange significance, something enormous is happening but you can’t yet say what. This mood then crystallizes into a specific conviction expressed linguistically as a proposition. In the feral child scenario, we’d still get the delusional mood and a pre-linguistic sense of danger, or threat, or invincibility, etc, but it likely wouldn’t progress to a specific narrative belief (like CIA put a chip in my brain). In some ways that might be worse!
Thank you so much for your detailed response! I was thinking along those lines but you expressed it so articulately. When you say that these types of pre-linguistic delusions would be worse, i’m guessing that because there’s no narrative it’s just an unresolvable, persistent dread. And consequently it would be much harder to seek therapeutic help without the linguistic tools.
I was also thinking of what a treatment plan would look like for such an individual — but if a group of psychiatrists somehow stumbled into them, would they even be able to observe that psychosis is present given that much of psychiatric evaluations rely on self reporting? I feel like a feral child without psychosis would exhibit many behaviours associated with it like hypervigilance, simply from severe deprivation and absent socialisation. The biggest challenge then would be disentangling psychosis from the effects of isolation right?
Congrats! Can't wait to read the book. In your opinion, how much could we reduce psychiatric hospitalization by providing more affordable and accessible housing? How about alternatives to hospitalization like peer-run respite centers? What, if anything, should mental health professionals and professional associations be doing to help secure "upstream" solutions?
My impression is that accessible housing would have a fairly marginal effect on psychiatric hospitalization in the US. From what I have seen, inpatient admissions that would have been prevented had the person had stable housing tend to constitute a small percentage of cases. Peer-run respite centers can likely have a bigger impact, if they are well-known enough and accessible enough that patients can go there directly instead of going to the emergency room. In US, that would also mean that peer-run respite center would have to assume some degree of legal liability of care, which makes things tricky.
I think we need to create genuinely voluntary, open-door inpatient psychiatric units and we need to ensure that the care provided there is covered by insurance. Right now insurance would typically only cover inpatient admission if you meet criteria for involuntary care (i,e, demonstrate significant risk to self/others or grave disability). That is, even if you are voluntary, you should still be committable in theory. We need to move beyond this restriction.
We also need to find ways to reduce the liability culture in the US, especially around suicide risk. If we can do that, we can significantly reduce unnecessary involuntary inpatient admissions.
I’ve enjoyed the thoughtful way you question established knowledge. Also the quality writing still matters in a post-literate world. 1. Since you will be headed to the Netherlands, what are your thoughts on psychiatrists in that country offering euthanasia for mental illness, even in teens? 2. Many states in the US allow LCSWs to perform evaluations and diagnoses of any condition in the DSM. How has this affected your practice or patients?
Thank you! I am quite conflicted on the issue of physician aid in dying. While I believe the option should be available in theory in highly restricted situations, we don't have any clear idea of how to draw the appropriate lines in the case of psychiatry given our clinical mission to prevent suicide and given the subjective nature of suffering and we have no idea how to implement appropriate safeguards. Until we figure that out, I don't think we should extend physician aid in dying to mental illness.
In the setting where I work, patients first undergo an evaluation with LCSW who offers a preliminary diagnosis and formulation, which is then used to initiate psychological treatment, and when I see them, I finalize my own diagnosis, and use that for medical management, medical billing, and other paperwork (like medical leave or disability). A similar process is used in many community mental health centers as well. Generally it works well. Have you noticed any concerns in this regard?
Thinking of HiTOP... How would that account for someone like Prof Kay Jamison? As I understand it, it's a snapshot of current psychopathology with no capacity to log currently well and stable, no psychopathology or personality dysfunction of note, high functioning, past history of severe mania and depression... At least a DSM diagnosis of BP1 gives you the relevant information (vulnerability to mania and depression) which something that tells me my patient is in excellent psych health when assessed euthymic completely ignores
“Bipolar Disorder” is one of the areas where HiTOP is weakest compared to traditional nosology, precisely because bipolar disorder conveys information about a cyclical course of mood episodes, whereas HiTOP is a symptom profile in the current moment. I also don’t think HiTOP is ready to replace DSM/ICD yet. That said, in HiTOP terms, you’ll have an evolving symptom profile over time, a high on mania dimension (plus other clinical features) at one time and high on Distress at others. Degree of impairment /disability is noted alongside symptom profile. When the person is doing well, their symptom ratings will be low, within population typical range, along with low impairment.
Very excited for the book. It's one I will certainly promote on my own Substack :)
Has anyone challenged HiTOP on the grounds that psychopathology is nowhere close to being ergodic? I'm not a statistician, and so may not fully appreciate the nuances here. But Big Five's ergodocity assumption is controversial enough that I find it pretty shocking someone would try to apply a similar methodology to deviations from normalcy.
Awais - finally came up with a question to ask. What do you think happens to the psychotherapist profession if/when AI becomes as effective “on average”? (One prediction: we will see some goalpost shifting away from the current emphasis on evidence-based care/average effects, towards rationales like “it’s the human relationship that counts”)
My suspicion is that a lot of psychotherapy modalities that fundamental focus on skill building, behavioral activation, cognitive restructuring, etc will get replaced by effectively replaced by AI, and the focus of in person therapy will shift more towards therapies that require a human relationship, ie, depth psychotherapies.
Congratulations on your book, and all the engagements coming up, I have a feeling you’re just going to get busier!
As a new social work graduate working in DFV in Australia, I do not diagnose, but I have seen a trend of pathologisation of women and children’s responses to interpersonal traumas and systemic barriers. I tend to lean on the side that often these adaptive symptoms are circumstantial, and if safety & recovery is emphasised, the symptoms will subside. But we live in a society that would rather blame the individual rather than provide secure housing, or trauma therapy, or welfare above the poverty line, so the symptoms persist. I’m not sure where I will end up, maybe in the macro policy advocacy space after my time in frontline work. But in the meantime, I thank you for keeping my mind open and questioning of the DSM status quo.
Thank you Viviane. Over time I have gotten less confident that we can easily disentangle the personal from the environmental when it comes to mental health challenges, including sequelae of trauma. Sometimes symptoms persist because of lack of social or clinical support of the right kind, and sometimes they persist because of temperamental vulnerabilities (e.g. high neuroticism or high antagonism) and sometimes because the symptoms have acquired a self-sustaining character, among other possibilities. So I'd encourage you to think more deeply about the temperament-environment-behavior entanglements. But you are very right that we are not doing what we can to support people experiencing traumas and adversities.
I really appreciate that. I am in no way saying that victim survivors of DFV do not concurrently have aspects of disorders, or that their reactions to trauma are 100% angelic.
Especially in cases escalating to High Risk Teams, sharing information among agencies, we have had women withdraw often due to re-experiencing or ‘self-fulfilling’ lived knowledge of their world view. Not necessarily accurate.
I’m fresh and still learning. I appreciate your work, and look forward to future Substack notices, your book, and keeping an eye on your keynote speeches, I hope they will be published?
Oh, yes, many times. It has gotten less frequent over time as I have acquired a better understanding of various conceptualizations available, but it is still common for me to meet with a patient and leave with a sense that we are missing some important concept from our toolkit.
Recently, i've been trying to think deeper regarding the moral concerns surrounding suicide. Oftentimes, people regard suicide as a "selfish" act, so a big accusatory question many people ask is, "Why are those dying to a physical illness (e.g. cancer) not regarded as selfish but those dying to a mental one are?"
I think this question is quite valid. However, come to think of it, I don't think many would call, say, a schizophrenic or autistic person committing suicide selfish, as compared to someone with MDD or BPD. Why do you think this is the case? At the core of it I think it might be something linked to choice (as in - many still have the misguided albeit subconscious notion that MDD or BPD is just a mindset). I'd love to hear your thoughts on this!
I am a US medical student entering my final year currently getting ready to apply for psychiatry residency. In the first episode of Mark Mullen's excellent podcast Psychiatry Bootcamp, you said that "the biggest issue we have had in psychiatric education is that there has been no systematic way in which trainees have explored the conceptual, theoretical, and philosophical side of psychiatry." Well, I am about to start my journey as a psychiatric trainee, and I very much wish to explore these things! Are there any excellent books that jump to mind as "required reading" for someone who is about to start their psychiatric training? I am open to almost anything be it philosophical, political, historical, or even personal accounts. (I will of course be reading Remaking Psychiatry whenever it becomes available)
I'm glad to see the APA recognizing the importance of your work! To take you up on the AMA, do you have any thoughts on mind-body syndromes and the recent momentum of Pain Reprocessing Therapy, Emotional Awareness and Expression Therapy, and the broader movement inspired by John Sarno--which gained academic credibility with the 2022 JAMA Psychiatry trial of PRT for lower back pain. Or put differently, any thoughts on somatization of distress and somatoform disorders? I can't wait to read your book. I find pretty much every one of your blog posts indispensable in my understanding of mental disorders.
Thank you Thomas! So far I have been a rather peripheral observer of these developments, viewing them with a mix of curiosity and hesitation. So I don't really have anything meaningful to say about it for now, but this is a good reminder for me to dig deeper into this literature. A good topic for a blog post!
I am only surprised that you've received that award because I wouldn't have imagined that the association would be as so open to your work. But I'm also delighted! Your success bodes well for the field and for our patients. And please don't believe the post-literate hype! I'm happy to report from the publishing trenches, we're still writing and reading :)
Thanks Bethany! :)
The mood is definitely changing! And you are a big part of that! Congratulations on the APA honor and looking forward to reading your book!
Thank you Trysa
Congrats! That book is gonna be great.
Thanks Sofia!
Hello, Mr Aftab! I’m a high school student here interested in pursuing the field of medicine and psychiatry. I greatly admire your work, especially your commentaries on the social impacts of mental illness. I have a question that's a little more conceptual in nature, and I'd love your thoughts if you have a moment.
From what I’ve been reading in classical presentations of psychosis, delusions tend to borrow heavily from cultural content — aliens, religious figures, government surveillance etc etc. But this implies that the content of a delusion is shaped by the patient's existing conceptual framework of what is 'real' versus 'unreal’, which is largely built through cultural upbringing and social interaction.
So, what would delusions (delusions specifically, not hallucinations) look like in someone with schizophrenia who had no cultural scaffolding to draw from, say, a child raised in complete isolation? Since delusions are defined by their departure from shared reality, and recognising something as a delusion requires knowing what the person believes reality to be, I'm wondering whether psychosis would still produce fixed false beliefs in the absence of any shared symbolic system. Basically, no concepts of God, aliens, authority or anything of that sort to borrow from. If so, what form would this content take? Would it be as severe and impairing?
Thank you!
Wow, what a creative question! So aside from content of delusions, we also have to keep the “form” in mind and delusional mood/atmosphere in mind. Delusional mood is a sense that the world has shifted, that everything is saturated with a strange significance, something enormous is happening but you can’t yet say what. This mood then crystallizes into a specific conviction expressed linguistically as a proposition. In the feral child scenario, we’d still get the delusional mood and a pre-linguistic sense of danger, or threat, or invincibility, etc, but it likely wouldn’t progress to a specific narrative belief (like CIA put a chip in my brain). In some ways that might be worse!
Thank you so much for your detailed response! I was thinking along those lines but you expressed it so articulately. When you say that these types of pre-linguistic delusions would be worse, i’m guessing that because there’s no narrative it’s just an unresolvable, persistent dread. And consequently it would be much harder to seek therapeutic help without the linguistic tools.
I was also thinking of what a treatment plan would look like for such an individual — but if a group of psychiatrists somehow stumbled into them, would they even be able to observe that psychosis is present given that much of psychiatric evaluations rely on self reporting? I feel like a feral child without psychosis would exhibit many behaviours associated with it like hypervigilance, simply from severe deprivation and absent socialisation. The biggest challenge then would be disentangling psychosis from the effects of isolation right?
Congrats! Can't wait to read the book. In your opinion, how much could we reduce psychiatric hospitalization by providing more affordable and accessible housing? How about alternatives to hospitalization like peer-run respite centers? What, if anything, should mental health professionals and professional associations be doing to help secure "upstream" solutions?
My impression is that accessible housing would have a fairly marginal effect on psychiatric hospitalization in the US. From what I have seen, inpatient admissions that would have been prevented had the person had stable housing tend to constitute a small percentage of cases. Peer-run respite centers can likely have a bigger impact, if they are well-known enough and accessible enough that patients can go there directly instead of going to the emergency room. In US, that would also mean that peer-run respite center would have to assume some degree of legal liability of care, which makes things tricky.
I think we need to create genuinely voluntary, open-door inpatient psychiatric units and we need to ensure that the care provided there is covered by insurance. Right now insurance would typically only cover inpatient admission if you meet criteria for involuntary care (i,e, demonstrate significant risk to self/others or grave disability). That is, even if you are voluntary, you should still be committable in theory. We need to move beyond this restriction.
We also need to find ways to reduce the liability culture in the US, especially around suicide risk. If we can do that, we can significantly reduce unnecessary involuntary inpatient admissions.
I’ve enjoyed the thoughtful way you question established knowledge. Also the quality writing still matters in a post-literate world. 1. Since you will be headed to the Netherlands, what are your thoughts on psychiatrists in that country offering euthanasia for mental illness, even in teens? 2. Many states in the US allow LCSWs to perform evaluations and diagnoses of any condition in the DSM. How has this affected your practice or patients?
Thank you! I am quite conflicted on the issue of physician aid in dying. While I believe the option should be available in theory in highly restricted situations, we don't have any clear idea of how to draw the appropriate lines in the case of psychiatry given our clinical mission to prevent suicide and given the subjective nature of suffering and we have no idea how to implement appropriate safeguards. Until we figure that out, I don't think we should extend physician aid in dying to mental illness.
In the setting where I work, patients first undergo an evaluation with LCSW who offers a preliminary diagnosis and formulation, which is then used to initiate psychological treatment, and when I see them, I finalize my own diagnosis, and use that for medical management, medical billing, and other paperwork (like medical leave or disability). A similar process is used in many community mental health centers as well. Generally it works well. Have you noticed any concerns in this regard?
Thinking of HiTOP... How would that account for someone like Prof Kay Jamison? As I understand it, it's a snapshot of current psychopathology with no capacity to log currently well and stable, no psychopathology or personality dysfunction of note, high functioning, past history of severe mania and depression... At least a DSM diagnosis of BP1 gives you the relevant information (vulnerability to mania and depression) which something that tells me my patient is in excellent psych health when assessed euthymic completely ignores
“Bipolar Disorder” is one of the areas where HiTOP is weakest compared to traditional nosology, precisely because bipolar disorder conveys information about a cyclical course of mood episodes, whereas HiTOP is a symptom profile in the current moment. I also don’t think HiTOP is ready to replace DSM/ICD yet. That said, in HiTOP terms, you’ll have an evolving symptom profile over time, a high on mania dimension (plus other clinical features) at one time and high on Distress at others. Degree of impairment /disability is noted alongside symptom profile. When the person is doing well, their symptom ratings will be low, within population typical range, along with low impairment.
Very excited for the book. It's one I will certainly promote on my own Substack :)
Has anyone challenged HiTOP on the grounds that psychopathology is nowhere close to being ergodic? I'm not a statistician, and so may not fully appreciate the nuances here. But Big Five's ergodocity assumption is controversial enough that I find it pretty shocking someone would try to apply a similar methodology to deviations from normalcy.
Awais - finally came up with a question to ask. What do you think happens to the psychotherapist profession if/when AI becomes as effective “on average”? (One prediction: we will see some goalpost shifting away from the current emphasis on evidence-based care/average effects, towards rationales like “it’s the human relationship that counts”)
My suspicion is that a lot of psychotherapy modalities that fundamental focus on skill building, behavioral activation, cognitive restructuring, etc will get replaced by effectively replaced by AI, and the focus of in person therapy will shift more towards therapies that require a human relationship, ie, depth psychotherapies.
That makes sense - that the more interpersonal/dynamic psychotherapies will retain a competitive advantage!
Congrats on so many fronts!
Congratulations on your book, and all the engagements coming up, I have a feeling you’re just going to get busier!
As a new social work graduate working in DFV in Australia, I do not diagnose, but I have seen a trend of pathologisation of women and children’s responses to interpersonal traumas and systemic barriers. I tend to lean on the side that often these adaptive symptoms are circumstantial, and if safety & recovery is emphasised, the symptoms will subside. But we live in a society that would rather blame the individual rather than provide secure housing, or trauma therapy, or welfare above the poverty line, so the symptoms persist. I’m not sure where I will end up, maybe in the macro policy advocacy space after my time in frontline work. But in the meantime, I thank you for keeping my mind open and questioning of the DSM status quo.
Thank you Viviane. Over time I have gotten less confident that we can easily disentangle the personal from the environmental when it comes to mental health challenges, including sequelae of trauma. Sometimes symptoms persist because of lack of social or clinical support of the right kind, and sometimes they persist because of temperamental vulnerabilities (e.g. high neuroticism or high antagonism) and sometimes because the symptoms have acquired a self-sustaining character, among other possibilities. So I'd encourage you to think more deeply about the temperament-environment-behavior entanglements. But you are very right that we are not doing what we can to support people experiencing traumas and adversities.
I really appreciate that. I am in no way saying that victim survivors of DFV do not concurrently have aspects of disorders, or that their reactions to trauma are 100% angelic.
Especially in cases escalating to High Risk Teams, sharing information among agencies, we have had women withdraw often due to re-experiencing or ‘self-fulfilling’ lived knowledge of their world view. Not necessarily accurate.
I’m fresh and still learning. I appreciate your work, and look forward to future Substack notices, your book, and keeping an eye on your keynote speeches, I hope they will be published?
Have you ever had a patient that made you doubt whether we ontologically get things right?
Oh, yes, many times. It has gotten less frequent over time as I have acquired a better understanding of various conceptualizations available, but it is still common for me to meet with a patient and leave with a sense that we are missing some important concept from our toolkit.
Congratulations!! Also very much looking forward to the book
Thank you Isaac!
Congrats Awais!
Thanks David!
Hello, Mr Aftab!
Recently, i've been trying to think deeper regarding the moral concerns surrounding suicide. Oftentimes, people regard suicide as a "selfish" act, so a big accusatory question many people ask is, "Why are those dying to a physical illness (e.g. cancer) not regarded as selfish but those dying to a mental one are?"
I think this question is quite valid. However, come to think of it, I don't think many would call, say, a schizophrenic or autistic person committing suicide selfish, as compared to someone with MDD or BPD. Why do you think this is the case? At the core of it I think it might be something linked to choice (as in - many still have the misguided albeit subconscious notion that MDD or BPD is just a mindset). I'd love to hear your thoughts on this!
Hello Dr. Aftab,
I am a US medical student entering my final year currently getting ready to apply for psychiatry residency. In the first episode of Mark Mullen's excellent podcast Psychiatry Bootcamp, you said that "the biggest issue we have had in psychiatric education is that there has been no systematic way in which trainees have explored the conceptual, theoretical, and philosophical side of psychiatry." Well, I am about to start my journey as a psychiatric trainee, and I very much wish to explore these things! Are there any excellent books that jump to mind as "required reading" for someone who is about to start their psychiatric training? I am open to almost anything be it philosophical, political, historical, or even personal accounts. (I will of course be reading Remaking Psychiatry whenever it becomes available)