Ahmad Gamal Saad-Eddin

The article was originally published in The Arabic Edition of Scientific American.

The first time Sarah visited a psychiatrist, he told her, “I don’t deal with ‘problems’, I only treat illnesses. I wouldn’t have a solution for your problems if you got one”. This sharp tone troubled her immensely and her experience was weighed down with guilt; she felt a need to apologize.

In the beginning, Sarah went to therapy feeling it wasn’t worth it at all; other people are probably suffering more than her and don’t go to therapy or even ask for any help. So her “problems” mustn’t be that big of a deal.

The symptoms that made her seek therapy weren’t severe at that time, just some mood swings. However, what turned thought into decisions was that these swings grew stronger and more intense with time. Back then, she was still a medical student; the academic pressure was one of many reasons that made her conclude that her situation was much simpler than she thought, that her symptoms were related to a particular reason and obviously would stop at its end.

Finally, the psychiatrist diagnosed her with a type of obsessive-compulsive disorder; a common disorder where a person suffers from the control of certain thoughts over her, or an urge to do certain behaviors frequently and continuously. The critical element here is the incapability of controlling these thoughts or resisting these behaviors; this is why it’s described as “obsessive”.

Though Sarah started taking her prescribed medicine, her symptoms didn’t improve. After a while, she decided not to take them anymore and not to go to the doctor, too. For two years, she refused to see any other specialist. She doubted a few things based on her experience, then concluded that she was perfectly well and it was all in her head, and must simply ignore it. However, with time, new symptoms appeared on the horizon with attacks of some physical unexplainable pains.

The scientific medical knowledge Sarah acquired, added to some reads throughout her treatment journey, made her, once in a while, gather some notes on her case while telling her story.

For instance, when she mentioned that the second psychiatrist diagnosed her differently, “chronic depression,” she adds, “the depression part in my case was so obvious for him that he preferred it to other diagnoses.” But there were other less severe and hard-to-notice symptoms, such as Hypomania.

Her second experience was disappointing as well so Sarah decided to visit another psychiatrist.

The third one didn’t diagnose her at all. When she had suicidal thoughts, he told her that these thoughts weren’t “real”, but actually she was just “obsessed” with them, nothing else. Confused, Sarah added, “what he said wasn’t what I was actually going through.”

Obsessive thoughts are usually denied by the person who’s having them, trying to resist them in vain. Suicidal thoughts are the exact opposite; those thoughts, in Sarah’s words, made her feel sort of relieved. That scared her, “Not just a relief, they made me feel happy! That, at some point, I might go for it.”

Later, Sarah went to two other doctors and got the same diagnosis: unipolar depression, which is a type of depression characterized by a constant bad temper with a lack of desire to do anything. What differentiates this diagnosis from ‘bipolar disorder’ is the absence of obsession waves but the person’s state of mind ranges primarily between two extremes: severe obsession or severe sadness.

However, all the treatments she took had no effect whatsoever; it was a huge disappointment for her as given her medical background and her confidence and trust in psychiatry, the failure seemed to trouble her even more.

How to recognize an illness?

Diagnosis is one of the medical practice foundations, it’s a path aimed to arrange the pathological symptoms in a certain context, treating them accordingly with suitable medications, then assessing their function.

When it comes to medical practice, psychiatry manages symptoms as all other specialties do, using experience-based treatment methods. Except that it’s not like any other field, as Talal Faisal, a psychiatrist at Philipps-University of Marburg in Germany, puts it. This field manages matters such as consciousness, decision-making, and motivations, building upon them the meaning of illness and health. It also extends its influence to other harder-to-define spaces, such as free will and self-precognition. The direct influence and concern of this field are involved with all different types of human relationships; it simply takes interest in all that makes humans “humans”. Measurement of such matters isn’t like measuring blood pressure or sugar level and exactly this makes diagnosing and treating the illness difficult.

Muhammad Al-Sheikh, an associate lecturer of psychiatry and addiction treatment at Al-Azhar University and consultant psychiatrist and psychotherapist at the Charité – Universitätsmedizin Berlin, approves this notion, noting that the structure of psychiatry has some characteristics that “open the door to speculation and assumption when it comes to diagnosis, which causes the confusion.”

Why? Because the available diagnostic tools in this field aren’t evidence-based, according to Al-Sheikh. For instance, the process of diagnosing a patient with depression depends on a personal interview and what they would say during it, the psychiatrist takes their medical history, and then comes the Mental Status Examination (MSE). Al-Sheikh uses the same metaphor Faisel used earlier, “It is not a blood sample you would simply draw and send to the lab,” the latter also adds that the diagnostic process may include physical examinations or psychological tests to eliminate any potential physiological causes of mental disorder and, in some cases, Neuroimaging is needed for clarification, too.

Diagnosis, undoubtedly, isn’t an arbitrary process, even if it has some gaps as the entire process is undertaken based on the medical principles stated in diagnostic manuals such as The International Classification of Diseases (ICD), which was published and edited by the World Health Organization (WHO), (the eleventh version is the latest/ICD-11), also there is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), the fifth revision of manual was released in 2013.

Nowadays, a combination of psychiatric medication and verbal psychotherapy is the most popular form of treatment among many practitioners.

Furthermore, Al-Sheikh remarks that medical practice in some countries along with physicians traineeship imposes, by nature, a general context on doctors regardless of their specialty, stressing that “residency training programs in Egypt, in general, need more care, attention, and improvement.”

There are a lot of other interfering elements in the psychological treatment process along with psychiatrists themselves, as Al-Sheikh observes. Starting with physicians of other specialties and psychotherapists who have no medical background, meaning that diagnosis is carried out basically by non-medicals, which makes ambiguity take the lead.

What makes the experience unsuccessful?

In 2018, the Egyptian Ministry of Health published a local mental health survey to measure the prevalence of mental disorders rate in the country during 2017. The survey showed that 25% of Egyptians suffer from mental disorders and symptoms. This means that one in every four tested people has a symptom or mental disorder; this percentage requires psychiatry and mental illness to hold a central place in the spotlight.

Many issues still make going to a psychiatrist a fruitless and disappointing experience for those who already made the decision, whether because of professional errors or over-expectations. Or simply because of the different answers to the consequential questions: What is mental illness? Are treatment manuals the only way to diagnose? Not to mention: What does it mean to be cured of an illness at all? And how would patients know that they are really cured? All the answers to these questions must be addressed and answered in the treatment relationship between physician and patient along the treatment process. 

Defining the sequence that the field is moving inside, as Faisal says, is a crucial matter to maximize all possible benefits of expertise the field contains and offers to patients through physicians.

According to Al-Sheikh, psychiatry is still improving, growing, and succeeding every single day. Besides, it doesn’t stop there, he also sees that the physical functional aspect of the field is effective, too. As to the unsuccessful experiences, it simply means that we still have so much to learn, and acknowledging that will be reflected in the way psychiatrists manage their specialization and the expectations patients put on their doctors and treatment experiences.

However, there’s another essential point that should be addressed, as  Al-Sheikh states; psychiatry includes many schools that approach humans from multiple angles, not just the biological angle. Though it’s utterly true that the neurological side is one of the most crucial sides, some other factors, such as the social and cultural environment, are playing a major role, so the psychiatrist and the patient must consider all these factors. 

Al-Sheikh believes that there’s room for progress regarding diagnoses based on the biological factor, practically in research, along with the huge advances in psychotropic medications, now drugs grow to be more accurately oriented and with less severe side-effects. 

It’s getting better

When Sarah started her treatment with the doctor she’s seeing currently, things began to get better slowly; her psychiatrist concluded that the right diagnosis is mostly Bipolar II Disorder. Sarah describes the diagnosis in her doctor’s words as, “a very difficult one”, specifically that symptoms haven’t appeared traditionally, as her doctor adds. A wave of comfort came over Sarah after traveling to the United States and her psychiatrist there confirmed the same diagnosis.

Sarah’s journey took six doctors and three different diagnoses.

Al-Sheikh doesn’t deny that there are plenty of fruitless journeys that a lot of patients are going through, stressing that “the road is so long”, but he adds with confidence, “at least, there is a path to walk through.”

This article was produced as part of the “Scientific Storytelling” project, organized by the Goethe-Institut and the Deutscher Akademischer Austauschdienst (DAAD), with support from the German Foreign Ministry.