精神科クリニックに行ったとき、精神科医の頭の中では何が起きているのか？

Good evening, I'm Takahiro Haga, a psychiatrist. Today, I'd like to talk as candidly as possible about what goes on in a psychiatrist's mind when you visit a psychiatric clinic. It's a bit long, but I'll summarize it briefly. Also, as always, I'd like to promote my book, "The Suicidal Thoughts Inside Me," which is now in its third printing and has been on the market for about three months. I wrote this book to be of some help to anyone truly experiencing "painful feelings so intense they make you want to die." I'd be thrilled if you picked it up in your favorite way, whether it's browsing at a bookstore, on Amazon, or on Mercari. ① What are you thinking during the first 30 minutes of your initial consultation? At most clinics and hospitals, initial consultations last about 30 minutes, and follow-up consultations last about 5-10 minutes. Even at the outpatient department of the general hospital where I was in charge, initial consultations were limited to 30 minutes. To be honest, I'd love to spend an hour on each consultation, but that's not realistic, so I have to simultaneously do two things: "Draw a diagnosis and formulate an initial treatment plan in these 30 minutes," and "Also ensure the patient leaves feeling reasonably satisfied." This is a crucial point for psychiatrists every time. ② Why ask so much about your upbringing? There are doctors who ask about your upbringing in detail, asking questions like, "Where were you born? How many siblings do you have? What were you like as a child in elementary school? How were your grades?" That has two meanings. One is simply when it helps with diagnosis. For example, Suggested developmental disorder → How the patient was during kindergarten and elementary school Presence or absence of intellectual disability → Elementary school grades and lifestyle Based on these, we can make some inferences. The other is to create a "systematic review." The idea is to provide a "complete medical history" when presenting the patient to other doctors or discussing them at a conference. Honestly, if you intend to examine the patient alone and complete the diagnosis, you can make a diagnosis even with more brief questions. However, doctors who think, "I hope to share this patient's case with another doctor someday," tend to carefully gather a patient's developmental history. You may feel annoyed by their in-depth questions, but you can generally trust that they are sincerely trying to understand you. ③ The "Bending Point" of Schizophrenia and Subjectivity vs. Objectivity When considering schizophrenia and other conditions, the "bending point" is important. This is the point at which a person's personality and lifestyle, which have developed in their own way up until that point, suddenly take a turn. Up until that point, they had been able to go to school or work normally. At a certain age (e.g., age 18, entering university, immediately after starting work), they suddenly become unable to do so, and their behavior begins to deteriorate. Looking for this "breaking point" is one of the processes that takes place in a psychiatrist's mind. At the same time, a unique feature of psychiatry is that there is often a mismatch between the patient's subjective symptoms and the problems experienced by those around them. For example, talking to oneself or yelling in the middle of the night often doesn't bother the patient, but it can be extremely troubling for their family. That's why we place as much importance on what is bothering those around them as on the patient's chief complaint (the patient's own problems). ④ "Guess the Problem" Using Pattern Recognition Since we only have 30 minutes, we'd really like to ask about everything, but we use pattern recognition to a certain extent to "guide the problem." At a glance, It looks like depression It looks like schizophrenia It looks like bipolar disorder It looks like developmental disorder (ASD/ADHD) It looks like addiction It looks like obsessive-compulsive disorder We first intuitively classify the condition, and then ask about the patient's medical history to support that hypothesis. For example, if you feel like you might be suffering from depression, we will monitor your perfectionism, the intensity of your feelings of guilt, stressful events, and whether your condition improves after a leave of absence. We will then determine whether your condition is an adjustment disorder or full-blown depression. A diagnosis isn't set in stone from the start; we start with a tentative hypothesis and fine-tune it over several months. ⑤ Prescribe Medication and Rapport Issues After making a diagnosis, a psychiatrist will consider how much medication to use. Schizophrenia → Antipsychotics are generally essential. Moderate to severe depression → Antidepressants (such as SSRIs) are almost always necessary. However, both antipsychotics and antidepressants often have a negative initial effect. Symptoms such as fati...