Diverse Patients, Common Ground

December 29, 2020
Horacio A. Capote, MD

Psychiatric Times, Psychiatric Times Vol 37, Issue 12, Volume 37, Issue 12

In psychiatry, 2 patients with the same condition are never the same.

SPECIAL REPORT: COGNITION

As psychiatrists, we are constantly challenged by complex patients with a wide variety of clinical presentations. In fact, 2 patients with the same condition are never the same. Yet for all this diversity, there may be some common features. I propose that cognition is paramount in this respect.

Cognition is a word that we use frequently, perhaps without pondering all that it entails. It is an important human attribute that has played a crucial part in our evolution. Yet the concept is so broad as to span many fields, from philosophy to psychology and the neurosciences. At the end of the day, we can all agree that cognition is essential for human fuctioning and flourishing.

Cognition involves many processes, both conscious and unconscious. Different aspects include introspection, memory, learning, reasoning, perception, attention, problem solving, and the use of language. In some ways, this sounds so abstract that it is difficult to make practical sense of it. This is why I often reflect on my interactions with patients and what they have taught me.

On any given day, I see patients who are asymptomatic for their condition, yet they are certainly not enjoying a robust quality of life. For instance, one gentleman is without a doubt brilliant. He reads constantly and voraciously, and he can engage in a detailed discussion of various topics. After deciding that he wanted to read scripture in the original language, he learned several languages.

This patient is in remission from bipolar disorder. His scores are extremely low to nonexistent on the Patient Health Questionnaire (PHQ) 9, General Anxiety Disorder (GAD) 7, and Young Mania Rating Scale. Yet, he lacks significant organizational skills and has great difficulty in prioritizing tasks. This manifests in an extremely cluttered house, which is in shambles since his last manic episode approximately 2 years prior. Furthermore, this patient is obese and has increased inflammatory markers.

Another patient, a mechanical engineer who has been through extensive schooling and is given to preciseness, was seen by a neurologist who focuses on neurodegenerative disorders. His quantitative magnetic resonance imaging (MRI) showed no degeneration in his hippocampus. In addition, psychometric testing showed no evidence of any memory disorder. He presented complaining of “adult-onset/attention deficit disorder.” Yet, on further exam, we realized his cognitive difficulties were due to depression.

Earlier I saw a woman who was morbidly obese. She very much wanted bariatric surgery and knee surgery for the immense pain. Her other physicians were in agreement with this plan. In the processes of her workup, she saw a sheet of labels with her name—the ones that are commonly used to identify information on documents or containers with biological specimens. The patient incorrectly deduced that each sticker was meant for a different test tube of blood. She thought the staff was going to draw at least 12 tubes; she began to think that she was going to be admitted against her will. It became clear that this patient was delusional; she was drawing incorrect cognitive conclusions that were negatively affecting her progress.

In addressing cognition, it is important to remember that psychotherapy, in addition to medications, can be an effective tool. Studies have demonstrated physical changes in the brain that occur as a result of effective psychotherapy. The work of Eric Kandel, MD, for instance, elucidated the synaptic changes related to memory and learning. (This won him, along with 2 others, the Nobel Prize for medicine in 2000.)

It is hard to overstate the importance of cognition in our day-to-day lives, especially as it relates to our work as psychiatrists. It is my hope that you will enjoy this Special Report on cognition and that it serves as an appetizer to awaken a deeper hunger and curiosity.

Dr Capote is the medical director, Division of Neuropsychiatry, at Dent Neurologic Institute, and the medical director, Addiction Services, at Brylin Hospital in Buffalo, NY. The author(s) report no conflicts of interest concerning the subject matter of this article. ❒

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