Psychiatrists Don’t Care About “Why”

psychiatrists don't care about whyPsychiatrists tend to be surprisingly uninterested in discussions about why people are experiencing mood symptoms or anxiety symptoms or terrible stress. Let me try and explain this stance, which often seems bizarre to my patients.

A young man who was recently married and had been living at home, and hadn’t been working for the last six months because of anxiety and fear that work stress would overwhelm him again, came in to my first visit in a few months and told me that he was in a good mood today. He said he had little anxiety. And since it was hard to get him to talk about what was going on, I decided to go through my favorite anxiety check list with him.

He reported that he had none of any of the symptoms of anxiety on that check list. For example, he was noticeably fidgety and agitated, but when I asked him if he had any feelings of tension, he said, “No, none at all.” I was perplexed by this until he told me, when I pointed out another apparently impossible answer (namely that he was not at all uncomfortable being out in the crowds, which contrasted with a statement that he made at the beginning of our session about how stressful it was to be traveling in busy airports), that the reason he was answering this way was because “for him” he was not feeling anxious. He also said that any anxiety he was experiencing was “just normal anxiety, anyone would have it.”

Another young man, who I’ve been seeing for a number of years, and who recently broke up with his fiance, and has been drinking and partying more and having trouble getting to sleep at night, said that his parents had wondered if he might be hypomanic. Together, we went through the HCL 32 hypomania check list, and he endorsed 20 of the 32 items. I reflected on this and suggested that the check list suggested that he was indeed at least somewhat hypomanic. He told me that was flat out not the case, because this mood he was in was due to the fact that he was finally out of the “prison” of his relationship.

This is why psychiatrists tend to be uninterested in explanations, about “why” someone is in a certain mood. We know that people are extraordinarily good at coming up with explanations for changes in mood and rarely think that the change in mood is the primary driver of their changes in experience.

The number of times that someone will tell me that their energized feeling is because of a mood shift rather than due to the fact that life is going better is very small. Most people ascribe changes in mood to changes in environment. I’ve written about this phenomenon elsewhere in this blog.

For that reason, the discussion about “why” takes a strong second place to focusing on exactly what has changed and during what time frame.

The time frame is especially important because the brain’s explanation generator is often willing to make some leaps of logic about what caused what. Many times, someone will tell me that their mood change is because of some positive event, and yet careful exploration reveals that the mood change preceded that positive event.

Since this happens often, it’s not because the people I talk to are dumb, it’s just that the brains ability to find reasons sometimes is. The brain’s need to find reasons is sometimes greater than its capacity to analyze the data. So psychiatrists like to know what happened, what were the symptoms, what were the moods, and when and how did it happen.

After that, it is sometimes useful to speculate about why. Although in many cases, it isn’t necessary to know why in order to know what to do.

For example, the young man who was so insistent he wasn’t hypomanic, nevertheless agreed that he needed to increase his dose of Seroquel so that he was sleeping more. In other words, why was not as important as clarity about what was happening and how long it had been going on. And with clarity about that we could agree about what to do even if we still didn’t agree on “why” things were happening.