"Those who create "author's methods" should be avoided": an interview with psychiatrist Alexander Chomsky

Alexander Chomsky sees 1,500–1,700 people with various mental problems per year. He notes that the number of minor patients has recently increased. For example, once he had to treat a 7-year-old boy for anorexia.

People generally became more anxious, but at the same time they began to take better care of their mental health. We asked Alexander what are the reasons for such changes. We also talked about crosswalk diagnoses, anime, and googling symptoms.

About psychiatry

- Let's immediately draw a line: what is the difference between psychiatrists, psychotherapists, psychoanalysts and psychologists?

- Let's go in order. Psychologist not a doctor. Its functions may include psycho-correction, which is achieved through conversation, clarification of problems and search for solutions. But he does not prescribe treatment and does not prescribe medicines.

Psychotherapist is a specialist who works with the help of one or more psychotherapeutic approaches: psychoanalytic (hence - psychoanalyst), cognitive, narrative and so on. He provides individual and group counseling. But he can't prescribe medicines either.

At the same time, the psychotherapist may or may not be a doctor. The client for him is not a patient, but rather a customer who acts with him on a relatively equal footing. Their work is based on a certain alliance.

But psychiatrist is always a doctor. He received a medical education and knows what a person consists of - from cells to the bone. And he uses in his approach both psychotherapeutic, and psychopharmacological, and non-drug methods for improving the mental state.

At the same time, its work is strictly regulated: there is lawLaw of the Russian Federation of July 2, 1992 No. No. 3185-1 "On psychiatric care and guarantees of the rights of citizens in its provision" "On psychiatric care and guarantees of the rights of citizens in its provision." For example, it includes Article 29, which describes cases of involuntary hospitalization. The main motive here is the patient's condition, which may be dangerous for himself or for others.

In general, the psychiatrist is the most hardcore. He can take you to the hospital even when you don't think it's necessary.

- And to whom is it better to go first of all - to a psychotherapist or a psychiatrist?

- Better - a psychiatrist. If he says that your problem is not medical, he will direct you further - to psychologist or a psychotherapist.

- What is the most difficult thing in the profession of a psychiatrist?

- I think the most difficult thing for a Russian psychiatrist is not to burn out. And also to maintain a humane attitude towards patients and a desire to improve their professionalism.

Unfortunately, today the healthcare system does not properly stimulate the independent development and professional development of specialists working in this field.

Stories like "Psychiatrist in HDPEPsychoneurological dispensary. didn't even look at me. He prescribed an ancient drug and released it” – this is more the rule than the exception.

The system is designed in such a way that, while working in a dispensary, people receive the same salary for the same load, regardless of whether they improve their professional level or not. So many take the path of least resistance.

But there is another problem. Suppose a person improved his qualifications, realized that it was no longer possible to treat the way he used to. But he has no opportunity to change anything. The system does not give him new tools.

- It seems that the psychiatrist's own mental disorder can also become a problem. Is it ethical to continue the practice in this case?

— Absolutely. Is it ethical surgeon, suffering from cancer, but remaining capable, continue to operate on patients? He is on his feet. He is holding a scalpel. He has been doing this for 20 years. Before going to see a patient, he spent 6 years at the institute, a year in an internship, and 2 years in residency. If he is also a candidate of sciences, then he has 3 years of postgraduate study behind him. He's been slacking all his life. And then he is diagnosed with cancer, and what - you can’t operate further?

Yes, but it seems to be a little different. It is difficult to shift this metaphor to the mental realm.

- You seem right. There are professions that are subject to mandatory psychiatric examination. For example, a high-altitude climber, when applying for a job, is periodically examined by a psychiatrist for his own adequacy.

Doctors, including psychiatrists, also undergo such an examination. And in the acute phase of some kind of mental illness, they will never be allowed to see the patient. But if a doctor, for example, drank a course antidepressants with depression and went into remission, then you can return to practice.

Have you observed professional deformation? Conditionally, did you communicate with a person and suspected that he had a mental illness?

- That's a very difficult question. First, I have no desire to do this. Especially for free.

Secondly, I consider the diagnosis “in a pedestrian crossing” to be a wrong practice. If another specialist does this, then he is most likely unqualified and does not understand what a psychiatric examination and a qualitative conclusion are. It is impossible to make a diagnosis without this.

On the other hand, there is life experience. For many years I have been in contact with unhealthy people. Three-quarters of those who open the door to my office came because "something is wrong." And, of course, the knowledge and experience gained in dealing with them give me the opportunity to suspect certain problems in others. But this is my intimate experience.

I will never go up to a person and tell him: "Listen, I see you have a problem, let's solve it." There is also ethics.

For example, a dermatologist looks at the faces of others and perfectly understands: here is acne, and here is the beginning of melanoma. And on the beach, he probably generally has fun. But this does not mean that he runs around with his business cards and distributes them.

Your question is quite popular. It stems from a common fear: "There are people among us who see through everyone." And this is very uncomfortable.

But I will reassure you: there is no tool that would allow you to make an accurate diagnosis without a comprehensive review of the case.

- Thanks! The question is: how did you get into psychiatry? Was there any personal backstory?

“Initially, I wanted to be a surgeon. But in the third year I realized that it was boring. Typical tasks. All your life you stand at the table and without an operating room you cannot realize your skills. You need good equipment. You can’t say that you are a god-like surgeon when you work on the equipment of the 1970s.

When I realized this, I began to study psychotropics, psychopathology and realized: “This is fucking interesting!” It's about a person. About the quality of life. About the real ways of influencing the mental state. And then it went and went, it sucked... And now - I have been working as a psychiatrist for 17 years.

Has anything changed in this time? Have people become more aware, have they become less afraid of psychiatrists?

Yes, a lot has happened in this short period of time. People know more about mental pathology. Services of psychological and psychotherapeutic counseling appeared. Everything connected with the prefix "crazy" has practically ceased to be a stigma.

People have become more anxious and began to care more about the quality of their lives. They no longer brush aside: “Yes, I have not slept for years.” It worries them. They understand that insomnia reduces their productivity.

The general level of well-being has slightly increased. People have come to think that their family budget can be spent on such non-obvious things as mental health.

About patients

Who comes to you most often? With what diagnoses?

— Recently, a lot of young patients come: girls 12–18 years old in anxiety-depressive states, with debuts of brutal mental disorders, self-harm, eating disorders, panic attacks, experience bullying, insomnia, thought disorders.

If we look at the records for the last 10 years, we will notice that there are much more such patients. Perhaps this is due to the fact that the world is rapidly changing - in many aspects that are not even obvious to us.

The most vulnerable categories of people are the victims of progress or the victims of change.

The social role for them is either not spelled out, or it does not suit them. For example, in matters of gender identity.

The growth of mental illness in young people is also influenced by the inflexibility of the social environment, the problems of "fathers and sons" - a deep misunderstanding of the child by parents. Whatever they say, anime has nothing to do with it.

Yes, I remember that at one of the conferences you talked about a 7-year-old boy suffering from anorexia. How did this story end?

The boy is now in remission. What happens next is hard to judge. There is no smoke without fire. If a child describes such a brutal psychopathology at an early age, keep your pocket wider - there will be more berries.

- Can this case be called the most memorable in your practice?

“You can’t remember all the patients, of course. Each of my colleagues and I host 1,500–1,700 people a year. Recently, at one of the working meetings, I asked my colleagues the following question: “Which case in your practice do you remember the most? Was it your therapeutic success or failure? How do you think they answered?

I think failures are more memorable.

- Yes. Colleagues remembered the most terrible cases where one could only shrug. That happens. We are not gods. If a patient comes already deeply transformed by his disease, if irreversible changes occur at the organ level, what can we do? Almost nothing.

- Was it such that the patient could not be diagnosed, although it was clear that he was unwell? What did you do in such cases?

- Of course. In such situations, I can make a preliminary diagnosis - syndromic. For example, if I understand that a patient has depression, but right now I can’t give him either recurrent depressive disorder or major depressive disorder. And I don’t want to endure some kind of vague diagnosis like an anxiety-depressive disorder.

This diagnosis is garbage, it can include anything.

After that, I will go to the consultation of doctors, where I will describe the case of this patient. Together we will form a survey plan. For example, we will appoint an MRI of the brain, an experimental psychological examination, electroencephalography. Perhaps we will involve specialists from other areas.

For example, if a patient has a movement disorder, they may have Parkinson's disease. To do this, you will need to consult a neurologist so that he can help verify this diagnosis. So the whole world - give birth.

If a psychiatrist does not know something, this does not mean that he is not qualified. He is not qualified if he does not want to understand the situation and takes the simplest decision, stretching the diagnostic heading under the patient's condition.

At the same time, do not forget that we have the opportunity to make several diagnoses. If I see that the patient's condition matches both an eating disorder like anorexia nervosa and includes panic disorder, I supply both.

— How often do you gather such a council of doctors?

“We can collect it almost anytime. Everything is limited only by the work schedule. But the real need does not arise very often.

“They say that genius and madness are two extremes of the same essence. What do you think about this? What is genius, in your opinion?

- Medicine does not operate with such terms. These are socio-philosophical categories. It is indirectly clear that under genius, and by insanity we mean properties other than the population average. But the doctor has nothing to do with that.

A doctor begins to be a doctor when a patient sits in front of him and says: “Doctor, I am so brilliant. Do something about it." If the patient is not sick and is not going to therapy, we will not treat him - neither from genius, nor from madness.

— That is, geniuses and madmen are just neuro-atypical people?

- Yes. A person who is brilliant, insane or talented is just a set of characteristics. But that doesn't make him sick.

About diagnoses

- What diseases are the easiest and most difficult to treat, if it is possible to distinguish in this way?

- There is no such definition. It does not depend on the disease. Often other factors influence recovery. I will give two examples.

Light case. A patient:

• seeks psychiatric help in time, with the onset of the first symptoms;
• gets to a specialist who really tries to understand his situation;
• receives the correct treatment;
• follows the recommendations of the doctor and withstands the necessary period of drug treatment;
• is sensitive to therapy.

Such a patient goes into clinical remission - from six months to a year. The therapy is canceled, and he does not disappear from the field of view of the psychiatrist.

Difficult case. A patient:

• turns when the situation is already running - sometimes there are several suicides, he is burnt out and he does not have the resources even to follow the recommendations given by the doctor;
• gets to an unqualified specialist;
• receives incorrectly prescribed therapy;
• does not follow the recommendations of the doctor;
• is resistant to therapy.

If we notice that during the passage of two courses the patient's condition does not improve even by a quarter of severity, then we are forced to conclude that this is a pharmacologically resistant case. Then you need to use regimens that are suitable for patients with drug resistance.

- Could you tell us about the most characteristic mental disorders that are detected at different times depending on age?

Most often, up to 10 years, patients are diagnosed with problems associated with neurodevelopmental disorders, autism spectrum diseases, ADHD, epilepsy, neurotic disorders.

After 10 years - hyperactivity syndromes, tics, problems associated with the inability to realize physiological functions - enuresis, encopresis. In addition, affective disorders, such as childhood depression and eating disorders, begin to develop at this age.

But by the age of 20, schizophrenia appears - the queen of the fields. This is the most favorable age for her. There is also a flourishing of depression, schizotypal and bipolar affective disorders.

And then there is the broad psychopathology of middle age: substance-associated disorders, major depressive disorders, exacerbations schizophrenia and other states.

Late age psychiatry is already involutionary processes, where we see, basically, the debuts of dementia, Parkinson's disease, Alzheimer's, and so on.

- Is it true that mental illness can be divided into endogenous - due to nature, genes, and exogenous - acquired as a result of some life circumstances? How to distinguish one from the other?

- The division of diseases into endogenous and exogenous is very convenient in the educational process. Life is full of mixes. Soviet psychiatrists, for example, singled out endoreactive types of response - cases when an external, exogenous factor acts as a provocateur, and then everything develops according to the endogenous type. It turns out that the patient would not have become ill if the environment had not given a reason.

But more often psychiatrists do not have a strict definition of endogenous and exogenous diseases. We always work with the customer's material. And it is he, his reactions to external stimuli that determine the clinical picture of the disease.

So, one person, having returned from the war, goes to parades and shines with medals, and the other, faced with post-traumatic stress disorder, becomes an inveterate drunkard.

And in this sense it is easiest to talk about the biopsychosocial paradigm. It includes the causes of the development of a mental disorder, and biological, and social, and psychological factors.

So, the features of the metabolism of monoamines in the central nervous system are a biological factor. BUT narcissism - a psychological feature.

And if we take, for example, a concentration camp prisoner, then he has his own psychopathology. Both biologically and psychologically, he could be an absolutely typical person, but after seven years of hard labor, of course, he fell ill. Where is the endogeny, where is the exogeny - go figure it out.

— Is it true that the mental state and cognitive functions of people who have had COVID‑19 change? How exactly?

- For some part of those who have undergone this infectious disease, it is true. This mainly affects cognitive abilities: the amount of RAM decreases, attention and perseverance suffer. But, according to our observation, these are reversible processes. Often you just need time or timely prescribed therapy.

Important, that covid, like any virus, is just an unfavorable environmental factor. It can become provocative if a person has already formed a certain basis for the development of certain diseases.

Practical advice from a psychiatrist

— How to choose a good specialist? By regalia, by reviews?

- I do not know. Now everyone can write that he is a super-duper specialist, a member of the multi-star staff of some clinic that he created author's technique… By the way, it is better to bypass those who create “author's methods” altogether. The description of a specialist is not an indicator.

Feedback in psychiatry is also an interesting phenomenon. On the Internet, for example, there are sites where people describe their impressions of visiting doctors. But neither their creators nor their users often understand that an adequate qualified a psychiatrist in the emergency room who handles involuntary hospitalizations will not have five stars.

Patients come into contact with him once, and subsequently see him as the author of all troubles. And leave him negative reviews.

Even a doctor who works in a hospital and conscientiously does his job can face this. People leave him angry comments because, for example, they do not agree with the diagnosis of schizophrenia and consider him a personal insult. Or if they decide that the typical neuroleptics that they are shown are “old”, and they definitely need the “new”, 3rd generation. Means what? The doctor is bad.

It is very difficult to use such ratings. Probably, today word of mouth, with all its subjectivity, is the most reliable tool. If you are looking for a doctor, you can ask your friends about it - who and where received help.

The easiest way to understand what kind of doctor is in front of you is at the very reception. If he seeks to help, establishes normal contact with you, does not pull the blanket over himself, and you feel comfortable, this is a good sign.

Is it possible to conduct a mental health check-up on your own? How to do it?

- One simple criterion: if you notice that your mental sphere reduces the quality of your life, contact a specialist. No one is interested in making diagnoses left and right. It will be easier for the doctor to conduct an initial appointment, say: “Do physical education” and give the most general recommendations if there is no need to interfere in this situation. No one is interested in treating healthy people.

In addition, there self-questionnaires, which can answer only one simple question: “Is it time for me to seek professional qualified help?” Diagnosing and prescribing treatment with the help of them will not work.

- Can you recommend a couple of them?

- Scale depression and scale anxiety Beck. But I don't really want to promote it.

Why don't people self-diagnose?

- Yes. Never google your symptoms.