Barbara Schildkrout, MD

Reviewed by Barbara Schildkrout, MD, and Karen Greenberg, MD

Amy Bloom does not waste any time. Within 3 pages, readers learn the arc of her story—that Brian, the author’s husband, has developed Alzheimer disease; that he is charming, spirited, and vital; that Amy and Brian love to travel, sharing gum and water on their airplane trips, including one to Switzerland; that they are in love; and that Brian has decided to end his life by “accompanied suicide” at Dignitas in Zurich.

Then, the epigraph: “‘Please write about this,’ my husband said.”

Sunday, January 26, 2020, Zurich, Switzerland

Why read such a book? The whole story is foretold at the outset. There are no surprises. The subject is terribly controversial and downright depressing. But 

 is not about death. It is about life—an ode to Amy and Brian’s deep and touching intimacy that endures to the end. The book is creatively crafted, shifting back-and-forth in time, the way associative memory moves from past to present and from inner thoughts to outer realities. Along the way, there is a lot for psychiatrists to learn.

Alzheimer disease moves in with a family, quietly at first. Even once a patient or family member finds the courage to seek medical consultation, they likely will still have doubts about whether something is really the matter. If they enter a psychiatrist’s office—for the first time or the hundredth time—they might be thinking that cognitive changes are due to depression, anxiety, stress (of which there is no shortage), transient postanesthesia memory impairment, sleepless nights, or normal aging. They might describe increasing tension with a spouse, a boss, or adult children. Would you recognize the early signs of this degenerative disease in such presentations?

Approximately 6.5 million Americans are living with Alzheimer disease today, and that number is projected to rise to about 13 million by 2050.

 Whatever your practice may be, you will surely see patients with Alzheimer disease or their family members. We now know that brain changes that characterize the disease begin to appear approximately 10 years before clinical symptoms—long before mild cognitive impairment and very long before mild dementia. Brain MRI, neuropsychological testing, and amyloid and tau PET scans are useful diagnostic tools, and in most cases, it is possible to make a definitive diagnosis based on cerebrospinal fluid biomarkers. Numerous blood assays have already been developed and are being studied to determine which are the best predictors of cognitive decline.

The US Food and Drug Administration (FDA) recently approved Aduhelm (aducanumab) for the treatment of early Alzheimer disease. Aduhelm is a monoclonal antibody that targets beta-amyloid plaques in the brain. Approval of the drug has been controversial, largely because of its small effect size in combination with a high incidence of serious side effects, as well as its $28,000/year price tag: Medicare will only cover Aduhelm for patients in clinical trials. Nonetheless, the indications for this medication are a wake-up call to clinicians: It is prescribed only for the treatment of mild cognitive impairment or early dementia caused by Alzheimer disease. Early identification is crucial. And while we do not yet have an altogether safe and effective pharmacologic treatment that is widely available, we do know that early diagnosis of Alzheimer disease will be even more essential once such a medication is developed.

Bloom paints a word picture—as only a gifted writer can—of the early signs of Alzheimer disease and her emerging realization that there really was something wrong with Brian. Or was she just imagining it? Why was she so irritable with him? Why were they fighting so much? Why had his boss asked her accomplished architect husband with such a high IQ to take an early retirement? Why did her gregarious soulmate not want to see friends? Why was he only talking about the past? As psychiatrists, we get to peer into the very beginnings of Brian’s disintegration and the widening ripples, then tidal waves, that his disintegration caused in Amy and Brian’s life together:

I could feel him through a glass, and I was banging on it, screaming at him: Why is there a glass between us? Where did it come from? Take it down! And Brian looked at me with puzzled, irritated concern and said, in effect, What glass? And, Please please stop complaining about this thing that isn’t even there.

I called the neurologist and made an appointment.

 revolves around the pivotal decision that followed Brian’s Alzheimer disease diagnosis: “It took Brian less than a week to decide that the ‘long goodbye’ of Alzheimer’s was not for him.” Brian was a lover of life—a “big, handsome man with a big laugh” who thrived on good food and good conversation. When he joined his men’s book club, he announced the reason: “I love a good read, and I love intimacy.” Only 66 years old, he was unwavering in his plan: “I’d rather die on my feet than live on my knees….” He did not want the onslaught of his disease to steal his ability to end it all.

Given Brian’s slipping cognition, he asked Amy to find an effective way for him to end his own life without implicating her in a murder. He wanted Amy at his side, and he wanted the method to be peaceful and 100% foolproof in order to avoid catastrophic disability. Amy’s painstaking research uncovered a truth that most Americans do not know: It is simply not possible to end one’s life on one’s own terms in the United States if you have a dementing illness.

Medical aid in dying (MAID) is legal in 10 states and the District of Columbia—areas comprising 22% of the US population—under statutes using language such as “death with dignity” as opposed to the more provocative physician-assisted suicide (PAS). However, all MAID laws in the United States require that a patient have a prognosis of 6 months or less to live and 

 be competent to make an informed life-and-death decision. Individuals with neurodegenerative diseases are effectively excluded.

Here is where Dignitas (“To live with dignity—to die with dignity”) comes in. Brian said, “I don’t want to end my life… but I’d rather end it while I am still myself, rather than become less and less of a person.” Switzerland is one of the many countries that do not require individuals to be terminally ill to access MAID, but it is the only country in the world where foreigners are eligible—hence Amy and Brian’s trip to Zurich, where Dignitas, a nonprofit organization, is headquartered.

The Dignitas admissions process is arduous and includes extensive paperwork, doctors’ letters, multiple telephone interviews, and dental records for identification after death. Once in Zurich, Brian still had to meet twice with a Dignitas physician to get final approval. At each point, Brian was in charge of the choices. After he and Amy took a car to the Dignitas apartment on the outskirts of town, Brian chose to swallow the prescribed antiemetic followed by sodium pentobarbital. With Amy holding his hand, Brian ended his life, as 3000 others had done before him. For Amy and Brian, access to Dignitas was at once a gift and a tragedy.

How would you have worked with Brian and Amy? Are all suicides the same? Is a thoughtfully planned, accompanied suicide different from a suicide motivated by mental illness and excruciating psychic pain? 

 leaves us with much to contemplate and reflect upon.

The book describes Amy and Brian’s encounters with numerous physicians, 2 of whom Amy says, “are for me the villains of this story”: Brian’s neurologist and psychiatrist, who, along with his internist, “failed him.” For Amy, there is also a hero: her psychiatrist, who interviewed Brian and wrote a decisive letter to Dignitas describing Brian’s life story and mental status. Would you have written such a letter, participating in the Dignitas process and potentially facilitating Brian’s accompanied suicide?

 has been hosting a spirited debate on this topic since 2018, which is summarized in “

Physician-Assisted Suicide: A Pressing Question of Ethics and Humanity

 is a short but compelling read that is likely to elicit strong feelings on both sides of the debate.

is an assistant professor of psychiatry, part-time, at Harvard Medical School in the Department of Psychiatry at Brigham and Women’s Hospital. She is the author of several books and a blog. 

is an affiliated physician, Beth Israel Deaconess Medical Center; part-time instructor, Harvard Medical School; and fellowship alumna, HMS Center for Bioethics.

1. Alzheimer’s disease facts and figures. Alzheimer’s Association. Accessed April 15, 2022. 

https://www.alz.org/alzheimers-dementia/facts-figures

2. Leuzy A, Mattsson-Carlgren N, Palmqvist S, et al. (2022). 

Blood-based biomarkers for Alzheimer's disease

3. Kuntz L. Physician-assisted suicide: a pressing question of ethics and humanity. 

. January 29, 2022. Accessed April 15, 2022. 

https://www.psychiatrictimes.com/view/physician-assisted-suicide-a-pressing-question-of-ethics-and-humanity

Articles

Compelling new book discusses love, Alzheimer disease, and medical aid in dying.

In Love: A Memoir of Love and Loss

by Karl Deisseroth, MD, PhD; Random House, 2021

, the newest book by Karl Deisseroth, MD, PhD, is a beautifully written memoir about this gifted psychiatrist’s work with patients, focusing on those who pierced his professional armor and shook him to the core. But we have all read books like this—books that are wonderfully evocative of the profound experiences we have had with patients. This book is like that. It is also more.

Ever since George L. Engel, MD, introduced the biopsychosocial model in 1977,

 physicians have been challenged with the difficult task of conceptualizing a patient’s psychological dynamics, life situation, and biology as entirely intertwined and virtually inseparable. Deisseroth achieves that integration in his thinking. His sophisticated formulations incorporate multiple dimensions and the influence of each on the others. His narrative moves effortlessly from thoughtful, personally revealing descriptions of patients to insights about behavior that are infused with an understanding of cultural context, brain functioning, and the long process of genetic evolution.

From a young age, Deisseroth was absorbed with narrative—the creative use of words through poetry, literature, and writing. Later, in college and medical school, he also found himself interested in scientific approaches that looked at how single units assembled into complex systems—neural networks, for example (although language also comes to mind). Deisseroth had not been interested in psychiatry.

But, on Deisseroth’s first day of his psychiatric rotation, a patient burst into the nurses’ station and focused an emotional outpouring on Deisseroth.

 “In arm’s reach, standing above me, he fixed his gaze to mine—his eyes wide in fear and rage… [T]he hurt was bright in his eyes; the terror was real.”

 What most struck Deisseroth as a medical student was the patient’s speech:

[I]t was creative in its agony, full of phrases used not for traditional meaning, but seemingly for their own sake, as communicative effects, with their own grammar and aesthetic, self-contained. …He spoke a novel word that sounded like one in a phrase of Joyce’s I had read long ago. …He evoked in me science and art together, not in parallel, but as the same idea, fused…

Deisseroth, who is now the D.H. Chen Professor and a professor of bioengineering, psychiatry, and behavioral sciences at Stanford University and a Howard Hughes Medical Institute investigator, had always been interested in words. Here, in this encounter, it became clear to him that psychiatric illness was manifested through a patient’s emotional communication. Everything came together for Deisseroth and reset the course of his career. He writes, “[W]hat, in fact, are those feelings, in a physical sense, down to the level of cells and their connections? This struck me as perhaps the most profound mystery in the universe—rivaled only by the question of the universe’s origin, its reason for being.”

Deisseroth’s encounters with patients become opportunities for self-reflection, curiosity, and keen observation; they also provide the grounding for discussions about the neural underpinnings of behavior. Deisseroth’s descriptions of neuronal functioning are lucid and vivid; they have narrative life. Far from the dry, rote lessons about neuroscience to which we have become accustomed, Deisseroth’s deep understanding makes his explanations of brain function entirely lively and memorable.

Throughout, Deisseroth appreciates and captures the full breadth of psychiatry—from the astonishment he felt upon hearing a thought disorder (a first glimpse at the multitude of extraordinary ways that mental functioning can go awry), to the counterintuitive behaviors of someone afflicted with an eating disorder, to the power of human connection and the magic of creativity. Deisseroth reminds us of the profound mysteries of human behavior that called many of us to pursue careers in psychiatry.

On September 27, 2021, the prestigious Lasker Award was presented to Deisseroth for his work with colleagues in pioneering a revolutionary approach to studying individual neurons in living mammals—a technique known as 

. Deisseroth’s book makes the fundamental concepts of optogenetics easy to understand.

Algae contain proteins that transform light into energy; this is how these organisms produce energy for survival. Optogenetics takes the genes that code for these proteins and transfers them into mouse neuronal DNA. This makes it possible for a researcher to turn individual mouse neurons “on” or “off” by exposing them to light delivered through fiber optics that have been inserted into the mouse brain. Switch “on” the light—switch “on” a neuron. This can be used, for example, while simultaneously observing the animal’s behavior and thereby discerning the specific neuron’s function.

This methodology has proven to be extraordinarily powerful as an investigative tool. In 2009, 25 papers were listed in PubMed under the search term 

; by 2016, there were more than 900, and more than 1000 have appeared thus far in 2021.

In his book, Deisseroth shows us how his work with patients and his curiosity led to important scientific questions. These questions, in turn, fueled his prolific neuroscience research and have influenced scientific work around the world.

, the book’s title, refers to a defense mechanism, well known to psychiatrists, in which aspects of the self are experienced by the individual as residing outside the self. But 

 also are the ultimate destination of a neuron—the anatomical site to which a neuron extends its axon and exercises its synaptic influence.

Deisseroth is a model and an inspiration for all of us in the field of psychiatry, and 

 is a work of true biopsychosocial integration. The book is not only a joy to read, but also a compelling, educational experience. I recommend it to every 21st-century psychiatrist.


is an assistant professor of psychiatry, part-time, at Harvard Medical School in the Department of Psychiatry at Brigham and Women’s Hospital. She is the author of several books and a blog.

The need for a new medical model: a challenge for biomedicine

. Random House Publishing Group; 2021:8-10. ❒

Karl Deisseroth's new book is a compelling, educational experience for readers.

Optogenetics and Piercing the Professional Armor

On September 27, 2021, the prestigious Lasker Award was presented to a psychiatrist: Karl Deisseroth, MD, PhD, of Stanford University. Deisseroth’s recently published book, 

 is not only a joy to read; it is also a compelling, educational experience. I recommend it to every 21st-century psychiatrist. Here’s why.

Deisseroth’s book is a beautifully written memoir about this gifted psychiatrist’s work with patients, focusing on those who pierced his professional armor and shook him to the core. But we have all read books like this—books that are wonderfully evocative of the profound experiences we have had with patients. This book is like that. It is also more.

Ever since George Engel introduced the biopsychosocial model in 1977,

From a young age, Deisseroth was absorbed with narrative—the creative use of words through poetry, literature, and writing. Later, in college and medical school, he also found himself interested in scientific approaches that looked at how single units assembled into complex systems—neural networks, for example (though language also comes to mind). Deisseroth had 

Addressing Challenging Moments in Psychotherapy: Clinical Wisdom for Working with Individuals, Groups and Couples

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

Science Over Stigma: Education and Advocacy for Mental Health

But, on Deisseroth’s first day of his psychiatric rotation, a patient burst into the nurses’ station and focused an emotional out-pouring on Deisseroth. “In arm’s reach, standing above me, he fixed his gaze to mine—his eyes wide in fear and rage… [T]he hurt was bright in his eyes; the terror was real.”

 What most struck Deisseroth, the medical student, was the patient’s speech. “…[I]t was creative in its agony, full of phrases used not for traditional meaning, but seemingly for their own sake, as communicative effects, with their own grammar and aesthetic, self-contained. …He spoke a novel word that sounded like one in a phrase of Joyce’s I had read long ago. …He evoked in me science and art together, not in parallel, but as the same idea, fused…”

Deisseroth had always been interested in words, and here, in this encounter, it became clear to him that psychiatric illness was manifested through a patient’s emotional communication. Everything came together for Deisseroth and reset the course of his career. He writes, “…[W]hat, in fact, are those feelings, in a physical sense, down to the level of cells and their connections? This struck me as perhaps the most profound mystery in the universe—rivaled only by the question of the universe’s origin, its reason for being.”

Deisseroth’s encounters with patients become opportunities for self-reflection, curiosity, and keen observation; they also provide the grounding for discussions about the neural underpinnings of behavior. Deisseroth’s descriptions of neuronal functioning are lucid and vivid; they have narrative life. Far from the dry, rote, lessons about neuroscience to which we have become accustomed, Deisseroth’s deep understanding makes his explanations of brain function entirely lively and memorable.

But Deisseroth did not win the Lasker Award for any of this. The award was given to him for his work with colleagues in pioneering a revolutionary approach to studying individual neurons in living mammals—a technique known as optogenetics. Deisseroth’s book makes the fundamental concepts of optogenetics easy to understand.

This methodology has proven to be extraordinarily powerful as an investigative tool. In 2009, there were 25 papers listed in PubMed under the search term, “optogenetics;” by 2016, there were over 900, and so far in 2021, there have been well over 1,000.

, the book’s title, refers to a defense mechanism, well-known to psychiatrists, in which aspects of the self are experienced by the individual as residing outside the self. But 

 is a work of true biopsychosocial integration. Karl Deisseroth is a model and an inspiration for all of us in the field of psychiatry.

is an assistant professor of psychiatry, part-time at Harvard Medical School in the Department of Psychiatry at Brigham and Women’s Hospital. She is the author of several books and a blog.

The need for a new medical model: a challenge for biomedicine.

. Random House Publishing Group; 2021:8-10.

Karl Deisseroth's new book is a compelling, educational experience.





Projections: A Story of Human Emotions

Loss of the sense of smell—anosmia—can be devastating. Without smell, patients describe feelings of emptiness, isolation, and emotional distress. Given that anosmia is a common first symptom of COVID-19 and a long-term sequela for as many as 10% of patients who have had COVID-19– related anosmia, psychiatrists need to be familiar with this symptom in order to identify and manage the associated psychological effects.

Prior to the current pandemic, anosmia and hyposmia (decreased sense of smell) received little attention in the popular press or in the non–ear, nose, and throat (ENT) medical literature.However, disturbances in the sense of smell have become a widespread focus of concern now that anosmia has emerged as a possible first symptom—and sometimes the only symptom—of infection with the SARS-CoV-2 virus. 

For most individuals who have a COVID-19–related loss of smell, the deficits are short-lived. But for those individuals who do not fully recover, the neuropsychiatric consequences can bedebilitating. Pleasures of eating are lost when one cannot detect the complex scents of food. Atmospheric odors disappear: the smells of the kitchen and garden, the gym, the sea. 

 may ensue without the ability to detect signals of danger (eg, smoke, gas, spoiled food). It is not uncommon for 

The pandemic-related increase in the prevalence of anosmia has thrown its debilitating effects on mood and quality of life into sharp relief and presents an opportunity for psychiatrists to help. 

The SARS-CoV-2 virus was first reported in December 2019, although the association between anosmia and this viral infection initially was not made. Then, in late March 2020, 

Hopkins and Kumar sent a bulletin to Public Health England

, noting high rates of COVID-19 infection “amongst ENT surgeons compared [with] other health care workers.”

 They reported that physicians and surgeons from around the world had noticed a significant increase in the number of otherwise asymptomatic individuals who were presenting with an abrupt onset of anosmia. They hypothesized that these patients could be unsuspected carriers of the SARS-CoV-2 virus and advised the use of full personal protective equipment for clinicians examining any patient withanosmia.

During this early stage of the pandemic, individuals across the globe did not qualify for COVID-19 testing if their only symptom was anosmia; however, in countries where testing waswidespread, patients who tested positive for COVID-19 often had anosmia, and frequently anosmia was their first symptom. By April 2020, the Centers for Disease Control and Prevention had added sudden loss of smell and/or taste to the diagnostic criteria for COVID-19. Both subjective and objective evidence for 

 have now been documented in up to 80% of patients with COVID-19.

It is now known that abrupt loss of smell may be an early, and possibly the only, symptom of SARS-CoV-2 virus infection. While anecdotal reports of anosmia abound, scientific studies of outcome are limited. Published research to date indicates that approximately 25% of individuals continue to have disturbances in their sense of smell for 

; fewer than 15% of individuals have disturbances in their sense of smell by 2 months; and up to 10% of individuals have a protracted course of recovery or 

may not fully recover their sense of smell

 Given that confirmed SARS-CoV-2 infections have reached more than 33 million cases in the United States and more than 

 more than 3 million individuals could be left with some deficit in this sensory modality in the United States.

pathophysiological theories to explain COVID-19 anosmia

. The most plausible explanation is viral infiltration of support cells of the olfactory epithelium (sustentacular cells), inflammation, and 

 The sustentacular cells of the olfactory epithelium are especially vulnerable to viral damage due to having a high density of ACE2 cell surface receptors. The ACE2 receptor is a known entry point for the COVID-19 virus. 

, the pathway to regaining olfaction may be marked by experiences of unpleasant, distorted, and often repugnant smells (parosmia). In somecases, individuals may have hallucinatory smells (phantosmias). The mechanisms that underlie these phenomena are still unclear but may be related to imbalanced rewiring of regenerating olfactory neurons or immaturity of neuronal networks when stem cells have been recruited to replace damaged olfactory neurons.

The sense of smell is neurologically a function of cranial nerve I and distinct from the neurological basis of taste, which is a function of cranial nerves VII, IX, and X. The subjective experience of taste, however, is extremely complex and may be altered with changes in sense of smell. Taste involves the basic sensations of sweet, sour, salty, bitter, and umami in addition to the somatosensory experiences of temperature, touch, pressure, and pain (spiciness) (

). The experience of taste also includes sensations from odorants that are presented through the nostrilsand/or via the nasopharynx. 

 Factors Contributing to the Experience of Flavor

Before the current pandemic, about 3% of the adult population aged 40 years or older and up to 22% of adults aged more than 60 years were 

 Patients with neurodegenerative diseases such as Alzheimer disease, Parkinson disease, and dementia with Lewy bodies exhibit a gradual loss of the sense of smell; often these individuals are only minimally aware of their deficit. The abrupt loss of a sense of smell can occur with head trauma or with any of numerous viral infections, including infection with SARS-CoV-2 (

When there is a sudden loss of the ability to smell, patients are startled by how important scents are to their daily life experience. This sudden alteration in one’s experience of the environment is unsettling and often deeply emotionally distressing. Even before this pandemic, researchers had documented the negative effects that anosmia has on mood, 

Possible Psychological Consequences of Anosmia

Since the pandemic, newspapers and magazines have published essays by individuals who have 

personally experienced COVID-19 anosmia and parosmia

. The authors widely report a loss of pleasure in eating. For example: “It was first apparent that something was wrong when I took a bite of a falafel sandwich that morning and it hung like tasteless cardboard in my mouth.”

 These writers also comment on changes in weight and disruption to patterns of social engagement that center around sharing a meal. 

Some of the articles focused on individuals who depended on the sense of smell for work: chefs, firefighters, and perfumers. 

Sommeliers commented on their experiences

: “It was absolute terror. The thought of no longer being able to do so much of my job was just terrifying. And then there’s everything else in your life. I love to cook, I love more than just wine, and all of that would be gone.”

The loss of smell sensations also affected individuals in ways that are difficult to define: “I feel alien from myself... It’s also kind of a loneliness in the world. Like a part of me is missing, as I can no longer smell and experience the emotions of everyday basic living”

—like I don’t exist. I can’t smell my house and feel at home. I can’t smell fresh air or grass when I go out. I can’t smell the rain.”

. He quotes a patient as saying, “This strange, empty feeling makes me feel weird about my body.”

 The other patient was aware of feeling “distant from the world, without atmospheric cues deriving from environmental triggers.”

Although smell is arguably the least appreciated of our senses, it is extraordinarily fundamental. The sense of smell is neurologically (and, therefore, experientially) involved in memoryformation, emotional processing, and social behavior. 

Smelling is inextricably entwined with breathing

, just as tasting is inextricably entwined with swallowing.

 Smell is a source of extraordinarily complex, often nonconscious, information about our environment, including our social environment. We smell our babies; we smell our partners; we know the smell of our ownbodies. Intimate relationships may be disrupted by disturbances in the sense of smell. 

. Although it followed a traumatic brain injury (TBI), the description could apply to post–COVID-19 anosmia

Sense of smell?...I never gave it a thought. … But when I lost it—it was like being struck blind. Life lost a lot of its savour—one doesn’t realize how much “savour” is smell. You smell people, you smell books, you smell the city, you smell spring—maybe not consciously, but as a rich unconscious background to everything else. My whole world was suddenly radically poorer.

Over time, as neurological functioning returns to normal, some individuals may experience distorted sensations of odorants (parosmia) or hallucinatory smells (phantosmias). Often these sensations are repellent and 

However, the most unbearable is tap water. Showering, rinsing dishes, brushing my teeth, washing my face, and many more daily encounters are now repulsive and unbearable. Living in a world where tap water smells putrid has been one of the hardest things I’ve ever gone through.

My sweat acquired an acrid rotting-veggie–like fetid smell—swamp-like, but acidic and sharp.

Of paramount importance is the psychiatrist’s role in listening to patients, gaining an understanding of anosmia’s effects on their quality of life. While anosmia may be an acute or chroniccondition, in either case, managing related health problems and maximizing quality of life are key goals of treatment. 

In addressing the patient’s health problems, psychiatrists should first clarify the anosmia etiology, then identify and treat any comorbid psychiatric conditions, such as anxiety and depression. Anosmia may exacerbate an already existing mental health disorder. It is also important to determine whether a patient has been able to maintain good nutrition, hydration, and stable weight.

Other health-related issues relate to personal hygiene and guarding against breath and body odor—with important social implications. Changes in relationships and intimacy can result from anosmia because of the complex relationship linking scents and social bonding. While a lack of awareness of one’s body odor can lead to poor hygiene and interfere with personal relationships, an inability to detect a partner’s scent can also negatively influence a feeling of attraction. 

Like our senses of vision and hearing, our sense of smell serves not only to bring pleasure from pleasant smells and taste, but also to protect us from danger. Anosmia can make one unaware of the presence of dangerous inhalants like smoke, natural gas, and harsh cleaning ingredients. Spoiled food can go undetected, be consumed, and lead to illness. Thus, part of counseling an individual about the management of anosmia should also include advice about prevention of injury and illness. Recommendations may include installing smoke and natural gas detectors, regular maintenance to gas appliances, and dating food when opened to anticipate spoilage. Also, asking others to smell for noxious odors of any kind can be helpful.

Psychiatrists might wish to refer patients for consultation for help in managing the consequences of anosmia. If an individual’s occupation is at risk due to loss of ability to detect scents, career counseling may be useful. Individual, couples, or family therapy might be helpful, with an emphasis on education regarding anosmia and its effect on close relationships. 

Smell training is the one treatment approach that directly addresses anosmia. Smell training aims to enhance the natural process of recovery by a program of consistently sniffing and concentrating on a small sample of scents multiple times a day over a period of months. The scents may be purchased as a kit, or a set of samples can be homemade.

Referrals to otolaryngologists who specialize in anosmia may be appropriate, especially for those with severe symptoms, or if there is uncertainty about the underlying cause. Many hospital-based otolaryngology departments have clinics that specialize in patient care for disturbances of smell, some of which offer smell training. 

The Global Consortium for Chemosensory Research was founded in response to the outbreak of COVID-19–related anosmia. Its website has become a hub for researchers and is an easy way for patients who are interested to participate in research.

, which was published in 2010 as part of the 

 Although it was written before the currentpandemic, this book is nonetheless useful for individuals with COVID-19–related disturbances in smell and taste. Written for a general audience, it includes numerous recipes that were developed to emphasize aspects of the food experience to enhance the pleasure of eating for those with disturbances in the experience of taste. Nutritionists also may be able to advise patients on how to modify food preparation and seasoning to emphasize aspects of taste that do not rely on smell.

Several websites by nonprofit organizations offer support to those suffering with anosmia. Fifth Sense and AbScent are charities in the United Kingdom aimed at helping those with anosmia. They have advice about smell training, as well as community forums and Facebook groups, ranging from general support groups to those with a more specific focus, such as COVID-19–related anosmia or parosmia/phantosmia. These online resources make it possible for patients to share their experience of loss with others while also obtaining advice on how to cope with symptoms.

, patients rarely discussed loss of smell with their psychiatrists. For patients with postviral anosmia, an ENT specialist was most often consulted, not apsychiatrist. For patients with loss of smell from neurodegenerative diseases, the onset of anosmia is insidious and generally not a major focus of concern for the patient. For patients with TBI, the loss of smell is abrupt, but often pales in comparison with other, more salient disabilities. Because of COVID-19, however, millions of individuals have been affected by anosmia from COVID-19, including patients who seek psychiatric consultation for other concerns.

It is important for practitioners to understand the full spectrum of smell-related disturbances so they can be maximally helpful to patients. In some cases, anosmia or parosmia might be contributing to the psychiatric presentation. Psychiatrists need to be familiar with what is known about the natural course of COVID-19–related anosmia, approaches to ensuring safety and facilitating recovery, and how to help patients to find resources.

Perhaps most importantly, psychiatrists need to appreciate the depth of emotional disturbance that a loss of smell brings and the destabilization that ensues when one’s world suddenly lacks an important dimension; this is especially true for patients who might already have eating disorders or difficulties with feeling safe in the world. Along with practical advice, psychiatrists might facilitate the articulation of this complex experience. We also can offer empathy and validation to patients.

(This article has been updated to correctly attribute the quotes from reference No. 16--Ed.) 

is an assistant professor of psychiatry at Harvard Medical School in the Department of Psychiatry at Brigham and Women’s Hospital; she is the author of several books and a blog.

is an adjunct assistant professor at the University of Maryland School of Medicine and is the director of The Concussion Clinic at Sheppard Pratt.

is an assistant professor at the University of Toronto and a staff psychiatrist at the University Health Network.

is a neuropsychiatrist in Wellesley, Massachusetts; she also serves on the Harvard Medical School faculty and on staff at Brigham and Women’s Hospital.

1. Coelho DH, Reiter ER, Budd SG, et al. 

Quality of life and safety impact of COVID-19 associated smell and taste disturbances.

Olfactory disorders and quality of life—an updated review.

3. Hopkins C, Kumar N. Loss of sense of smell as marker of COVID-19 infection. ENT UK/Royal College of Surgeons of England. 2020. Accessed June 1, 2021. 

https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%20smell%20as%20marker%20of%20COVID.pdf

Olfactory dysfunction: a highly prevalent symptom of COVID-19 with public health significance. 

5. Printza A, Katotomichelakis M, Valsamidis K, et al. 

Smell and taste loss recovery time in COVID-19 patients and disease severity. 

6. Parente-Arias P, Barreira-Fernandez P, Quintana-Sanjuas A, Patiño-Castiñeira B. 

Recovery rate and factors associated with smell and taste disruption in patients with coronavirus disease 2019. 

7. Johns Hopkins University & Medicine: Coronavirus Resource Center. Accessed June 1, 2021. 

Smell and taste disorders in COVID-19: from pathogenesis to clinical features and outcomes.

COVID-19 and anosmia: a review based on up-to-date knowledge.

COVID’s toll on smell and taste: what scientists do and don’t know.

11. Boesveldt S, Postma EM, Boak D, et al. 

12. Kollndorfer K, Reichert JL, Brückler B, et al. 

Self‐esteem as an important factor in quality of life and depressive symptoms in anosmia: a pilot study.

Assessing the impact of anosmia: review of a questionnaire’s findings.

. September 12, 2015. Accessed June 1, 2021. 

https://www.theatlantic.com/health/archive/2015/09/world-without-scent-smell-anosmia/404749/

15. Camuto R, Harans J. What’s a sommelier to do when they lose their sense of smell? 

https://www.winespectator.com/articles/what-s-a-sommelier-to-do-when-they-lose-their-sense-of-smell

16. Burges Watson DL; Campbell M, Hopkins C, Smith B, Kelly C,  Deary V. Altered Smell and Taste: anosmia, parosmia and the long impact of Covid-19. Accessed August 30, 2021. 

 (accepted for publication). Preprint available at 

https://www.medrxiv.org/content/10.1101/2020.11.26.20239152v1.full.pdf

Importance of SARs-CoV-2 anosmia: from phenomenology to neurobiology. 

19. Parosmia: “The smells and tastes we still miss, long after Covid.” BBC News. February 6, 2021. Accessed June 1, 2021. 

https://www.bbc.com/news/stories-55936729

Loss of smell can be devastating for patients. How can psychiatrists deal with the associated psychological effects? 

COVID-19 Brings Anosmia to the Attention of Psychiatrists

A complete, accurate, and timely diagnosis is the cornerstone around which effective treatment is constructed. Yet, the complex skills involved in the art and science of diagnosing have only been the focus of investigation for less than a decade.

While the process of diagnosing is common to all fields of medicine, this article specifically addresses missed “medical” diagnoses in patients who present to or are being followed by psychiatrists and other mental health clinicians. It is hoped that by learning about vulnerabilities within the diagnostic process, readers will have the opportunities to reduce diagnostic error rates in their own practices and institutions.

Diagnostic errors and delays are so widespread that most individuals will experience a diagnostic error during their lifetime.

 And surely, every physician has had the experience of missing a diagnosis or coming to the correct diagnosis only after too long a delay. Memories of missed opportunities for earlier intervention weigh heavily upon us.

What Is the Correct Diagnostic Formulation In Neuropsychiatric Practice?

Recent studies have found that any individual with a “psychiatric history” or with “presenting symptoms in the sphere of mental functioning and behavior” is especially prone to experiencing a diagnostic error.

 This should alert all psychiatrists, since these are the very patients we are called upon to see. Rare diseases might be misdiagnosed, but, more often, common diseases are missed, especially if they present atypically.

In 2015, an Institute of Medicine report-

-concluded that, “. . . improving the diagnostic process is not only possible, but presents a moral, professional, and public health imperative.”

How do doctors make a diagnosis? As you read the following vignette of a referral, try to be aware of your diagnostic hypotheses.

According to his primary care physician (PCP) who referred him, Mr O has a long history of psychosomatic complaints. Mr O is a 63-year-old accountant who recently retired. He’s been sleeping restlessly and waking up depressed each morning. He jogs a few miles a day, most days, but says that lately he’s been feeling stiff and somewhat unsteady on his feet. Also, he says he’s “plagued by” constipation. The patient told the PCP that he can’t tell whether these physical problems are “all in my head” or whether there’s really something to worry about.

When you get a referral, you are presented with a great deal of information, and it isn’t clear which information will be relevant to your eventual understanding of the patient’s health problems. Some of the material that is contained in the referral will be explicit, some implied, details may be inaccurate, and surely, much will be left out.

Now consider that once you greet a patient in the waiting room, you will have even more information. You will notice how the patient is dressed and what he’s been doing while waiting; you will observe his facial expression, level of social comfort, his gestures and gait. And, before you even hear the patient’s voice or ask a single question, all of these experiences will affect you and have an influence on how you are inclined to think about the diagnosis.

Diagnostic problem solving is extremely engaging for physicians, but it is not the defined type of problem solving one encounters with something like a crossword or Sudoku puzzle in which there are 26 letters or 9 numbers that are manipulated to form one unique solution. Making a diagnosis is complex problem solving in an uncertain domain. Any particular information or observation might be relevant; and any particular information or observation might be irrelevant (noise). The patient might leave out crucial parts of the illness story, perhaps not realizing that they are important. Or the physician–problem-solver may have insufficient knowledge, perhaps never having heard of the diagnosis that actually explains the patient’s symptoms. There also could be more than one diagnosis; and these diagnoses might be interacting with one another.

The reigning theory about diagnostic problem solving is that it involves two interacting cognitive systems-system 1 and system 2.

System 1 cognition is illustrated by the experience of seeing a patient for the first time and “knowing” immediately that the patient has, for example, schizophrenia. System 1 is based on mental pattern-recognition; it is intuitive, but honed and refined by experience; it is fast, effortless, and operates outside of awareness. While this system is extraordinarily efficient, processing large amounts of information very rapidly, it is also highly error-prone and open to biases (predispositions to think and act a certain way) of which the clinician is generally not aware.

System 2 cognition is exemplified by the generation of a differential diagnosis list and examining the evidence for and against each diagnosis. System 2 utilizes explicit rules of logic; it is slow, effortful, entirely conscious, and analytical. Clinicians naturally favor the use of system 1 cognition because it is effortless. But the most effective clinical reasoning involves going back and forth iteratively between system 1 and system 2 cognition.

Now let’s return to the case vignette. The patient’s story is in your mind when you go into the waiting room. Depending upon your fund of knowledge and your experience, you might have what turns out to be an accurate diagnostic impression from the referral information. But perhaps you don’t. To get to the correct diagnosis, you might have to overcome the “framing effect” in which your cognition has been biased by the way the patient’s problem was first presented to you.

 In the case of Mr O, your intuition may have been biased toward thinking that the patient is depressed with somatic complaints precipitated by his recent retirement.

While the process of diagnosing is common to all fields of medicine, this article specifically addresses missed “medical” diagnoses in patients who present to or are being followed by psychiatrists and other mental health clinicians.