Is Behavior Finally Catching Up?

We used to look at behavior as an entirely separate entity and at one point in time, not even as an entity in terms of health. In other words, 1000 years ago, 100 years ago and to some degree, quite possibly 50 years ago behavior (or emotional status) was a "concern” almost totally independent of any other aspect of health. When the patient came in with the sniffles; or with a sore shoulder; or complaining of week long constipation; or trouble seeing; or chest pains…the patient got involved with a family practitioner; and probably either directly or via referral, a specialist. Many years ago if someone came into the ER, the acute presentation was diagnosed and then dealt with. The point being, the patient’s behavior was of less concern and in many cases, no concern. The primary focus was on the more tangible, physical problem

Outside of the world of medicine, if someone’s sales quotas started to fall the concern revolved around the stability or quality of the product, the presentation by the salesperson, or the economic atmosphere. If the athlete or entertainer started to show diminished performance, the concern might have been the aging of the individual, or lack of interest or belief in "job”, or ill health, or lessening physical skills.

In any walk of life, when performance or physical condition started to suffer, the approach was usually to look at the visible presentation and then come up with a solution to alleviate the visible presentation: be it a medication, a surgical procedure, a retraining process, a rest, a retake (or repeat performance)….and if we could not devise some sort of immediate solution, there was a good chance that the condition was written off to, "well, there isn’t anything we can do to improve matters except ‘take it graciously’, or make you comfortable”, or "why don’t you take a few days off”.

The point is, in our western approach to medicine, or thinking in general, about the only consideration we gave to "behavior” was if a person "went berserk” we would be concerned with his/her behavior and relegate dealing with it to some special conduit. 1000 years ago it might have been banishing someone, 200 years ago it might have been creating a space / facility for "people like that” and then maintaining them "there”…and 50-100 years ago it probably meant assigning the person to a "highly trained”, very specific "specialist” whose only objective was dealing with "that type” of behavior.

While this evolution was going on in western society, the ancients, meaning Traditional Chinese Medicine, or the older Indian Medicines were looking at behavior as a totally integral element in one’s total makeup, meaning physical and physiological presence as well. Looking to improve one’s emotional / behavioral stability was as important as taking out the diseased structure, getting the proper chemical into the body, counseling the proper dietary habit. If the original Greek Olympic athlete, or the Roman carpenter, or the Egyptian engineer, or the medieval hunter, or the pioneer wagon master started to falter on the job, the concern was with whatever was visible. When Van Gogh cut off his ear, he was advised to rest. To many, then, his behavior was considered to be the behavior of someone who was "cursed”. Today, when reviewing recorded accounts of his behavior many would consider him to be some degree of manic-depressive or bipolar with psychotic features, or perhaps some form of schizoaffective disorder possibly with anti-social personality features.

It is only quite recent (50-100 years), in western thinking that we have recognized that our behavior and behavioral drives are so important to, and influencing on, whatever we do in our daily routine. It is in this later time frame that we have come to accept that there are behavior patterns that are distinguishable, diagnosable, and treatable. As a result of this recognition, we accept that frequently by turning our attention to and accepting the need to treating behavior, we can improve the status of the person, no matter what the presenting physical problem was.

Matter of fact, don’t we now accept athletic coaches, frequently, as part-time psychologists as well as teachers of Xs and Os and other related skills. Isn’t industrial psychology (the behavior of the people involved in the plants and not just the psychology of marketing) as integral in successful sales and production as much as the quality and efficiency of the product itself and the process of its manufacturing? Haven’t we started to accept that we can get more compliance out of a patient when we show appropriate interest and understanding in their psyche, as well as their developing fetus, or the deterioration of their tissue when cancer as been diagnosed, or the cause of their nasal congestion, or the significance of their chest pain?

It was not that long ago when the teacher’s responsibility, at any level of education, was to come into the classroom and spew out required information and then somehow evaluate whether or not someone was listening to him/her. The student’s responsibility was to come into the same room and sit and "learn” without question, whatever the teacher told them to learn. A student with what we would now see as a Cluster B Personality Disorder, or an AD-DBD, or MDD-R and therefore not conforming, was then labeled as having poor conduct and being disobedient and when attaining a certain age was merely dismissd out of school. In the traditional Patient-Practitioner relationship, which was severely paternalistic, if the patient questioned the physician or wasn’t compliant, the patient faced being asked to "go to someone else”. The possibility that the patient might have had OCD or an Avoidant Personality Disorder (Cluster C) or some degree of depression (unipolar or bipolar) was of less concern to, let alone recognized by, the clinician.

Years ago there was no thought given to the possibility that one’s behavior might have an effect (negative, at that) on the immune system. Or that someone constantly having mechanical problems like falling or car accidents, might not just be suffering from some physical problem but that a behavioral problem might be so distracting as to create the conditions for the mechanical problems.

In the older, certainly the more historic, medical training, if there was attention being given to "the mind” it probably was more in terms of the specific training as a psychiatrist as opposed to the general training of the physician to be alert to also devoting some examination time and effort to the emotional stability of the patient, regardless of what the initial presentation was. The conception in the 1950s, of the Mental Status Exam with its variations, was a broad instrument developed for use by psychiatrists. Even the Mini-Mental Status Exam, conceived in the 1970s, was designed for use in the office of the psychiatrist. It’s only in the recent couple of decades that we have taken a different view of the importance of being more aggressive in incorporating an evaluation of the patient’s emotional stability. We have become more sensitive, for example, to looking for behavior suggestive of depression or anxiety, or symptoms and risks of suicidal ideation. At the same time we have also become more aggressive in the medical education of clinicians in teaching them to be more sensitive to the patient’s behavior regardless of their subspecialty. More and more studies are showing the importance of being able to detect depression or anxiety disorders as early as possible. As we move from a traditional paternalistic patient-practitioner relationship to a more sharing relationship, we see the importance of showing the patient a broader interest in him/her, beyond the aching knee, the pain in the left arm, or the sinus headache. We see it in the improved compliance of a patient; we see it in a patient who is more open and relaxed; but most of all, while recognizing that there is a rise in depression and anxiety, the desire and ability to spot them earlier and thus start treatment early, not only may be of physical value such as improving immune capability, but also reinforces both the need and ability to treat their behavioral disorders. By being more sensitive and alert, no matter what the office specialty is, we can reach out to a broader population, and not have to wait for just those specific patients to finally go into the office of a psychiatrist or psychologist.

The internal medical practitioner, the primary care physician, the EENT specialist, the orthopedist, etc., all should now have the mindset to look for these early signs of such behaviors and then have a range of options to consider. The ObGyn, or the ophthalmologist, or the nephrologist who sees an arrhythmia and then decides that a medication might be of immediate necessity in addition to referring to the cardiologist should feel the same if seeing indications of high anxiety or depression.

There still exists a stigma of going to a "shrink”. However if recommended by the trusted physician who shows care beyond the presenting physical problem, more patients are apt to follow through. In addition, as the population ages, and lives longer, we are bound to see increases in certain behavioral disorders. We certainly are seeing these increases at the other end of the age spectrum.

Are concerns with behavior finally catching up to concerns of the heart, joints, kidneys, etc?


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