Fall Color

My wife and I just returned from a 3-day trip to visit friends and take in the fall color.  The trip took us north to US Hwy 2 from Duluth, MN to Wakefield, MI and then south to Winchester, WI.  My home town is on that route and I have driven HWY 2 both ways to Minnesota and Michigan hundreds of times.  When you are an old man like me with a personality like mine – that means a lot of associations along the way.

The overriding themes seemed to be feeling grateful, being lucky and particle spirituality.  I have posted about my blue-collar origins in the past.  Much of that comes down to railroads, mines, relatives I never met, and the thousands of people I have interacted with.  The railroaders include a grandfather and a great-grandfather and three more recent railroad employees - my father, brother, and uncle.  My earliest introduction to Hwy 2 was driving with my family to Ironwood, MI 30 miles away to pick up my father. He would drive a freight train down to the Fox River Valley, sleep on a locker room bench overnight, and then return to Ironwood rather than our home town.  I never found out why he was never delivered to his starting point.  I was always focused on the image of that hard wooden bench he was sleeping on - especially as he got older and started to look more fatigued.

Railroad jobs were highly valued.  The pay was good if you could work, but there was a seniority system that strung a lot of people along.  It seemed like a prolonged residency program – all of the work and inconvenience and none of the rewards.  There was plenty of work in the local switch yards that my father could rarely get because of that system.  Instead, he worked 40 hours in 4 days and slept on a bench 2 nights per week.  Six decades later that still raises a lot of questions for me and there is nobody around for the answers. 

Apart from the work-related trips, we would drive over to the Upper Peninsula of Michigan (UP) to buy margarine.  Until 1967, Wisconsin had a law that banned adding yellow food coloring to margarine.  Without it - the sticks of margarine were an aesthetically unappealing white in color.  We drove over to Michigan to get the yellow stuff.  Wisconsin became the last state to repeal that law in 1967.           

Hwy 2 starts as an exit off US35N in Duluth. The freeway drops quickly down a long hill to that exit.  From that hill you can see the Richard I Bong Memorial Bridge.  It is an impressive piece of engineering and it seems to be aging well.  We lived there my first three years out of residency training as part of a National Health Service Scholarship arrangement.  I really liked that city even though the lake kept it cold.  When I lived in Duluth, I was a member of the Duluth Speedskating team.  Before we had ice we would do dry land training out to the middle of the Bong Bridge.  Rhythmic side to side motions from an extreme flexed position at the waist.  It was done at night in darkness, in the gales of November, uphill to the middle of the bridge – the highest point -  and back down again.  There were about a dozen of us following a coach who was my age at the time.  By the end of the month, we were on a 400m oval of ice that we flooded ourselves.  

In the summer, I would cycle to my office across the Bong.  That involved 5 miles on the Skyline Drive in Duluth until I could drop down a steep avenue to the bridge.  There were days when I imagined myself in a movie – cycling over Lake Superior to and from work.  It was that unreal.

I am reminded of my cycling escapades along this route. On my first attempt I thought it was going to be an easy romp down an old railroad right of way right 60 miles into my home town.  The trail was about 100 yards north of Hwy 2.  Railroads are built on a bed of gravel called ballast that is tightly packed to support the immense weight of trains.  The ballast is about 18-24” deep.  There are about 3,240 wooden ties per mile and each tie is about 9” x 9” x 96” or 4 cubic feet.  The rails rest on those ties.  That means when the rails and ties are removed about 6 inches of loose gravel covers the surface.  When I took an undersized mountain bike down that trail it was quite a mess.  It is impossible to move forward when your wheels are buried in gravel.  You can go about 6 feet and eventually collapse to one side or spin out and fall over.  I made it about 27 miles and got picked up in Maple by my wife.  My second attempt was on a road bike that involved cycling over the Bong on my usual route but taking Hwy 53 south from Superior to Pattison Park and then county roads east and north to Poplar, WI.  From there is was all Hwy 2 and battling heavy traffic for the next 47 miles into my home town. Looking back both of those cycling adventures were foolish.  That is affirmed by the loss of two of my friends.  Both were experienced cyclists.  Both killed while cycling. I will never put myself in high traffic areas again.

The most rewarding part of that trip was pulling into my grandmother's driveway and walking in to see her with my three young cousins.  My grandmother was always worried that I cycled too much.  I did not want to add to that by describing any of the close calls.  I made a joke instead and my youngest cousin laughed the loudest and the longest.  It was an infectious laugh that made the rest of us laugh. I think about that every time I see her - 30 years later.  

There was always plenty of sports related travel both ways on Hwy 2.  Football, baseball, basketball, track, canoeing, and kayaking.  We drove over two rivers that I had canoed and kayaked multiple times, including one where I was almost killed twice in one day.  The Montreal River was not very visible from the road.  I was guessing it is fairly tame this time of the year.  In the spring it moves 1800+ cubic feet per second down a steep gradient through a narrow canyon with steep rock walls.  In some stretches the gradient looks like you are going down a staircase.  If you go down in that water, there is no way out. The day I tried it with the friend I was driving to see and 4 novices in 3 aluminum canoes I was trapped against the bottom by a canoe full of water and then an aluminum canoe wrapped around a boulder holding me down. I was lucky to get loose – twice.  

I think about the games played not so much about the scores or seasons. I was quarter miler in high school and think about a qualifying heat I ran in Ironwood. I was trying to run a sub 50 second quarter mile and failed. I really knew nothing about running or training.  When I finally started learning about the biomechanics of running and realized I could train indefinitely – I beat that time at age 45 on the high school track in my hometown. 

I thought about football practice and weight lifting back in those days. How much more or less am I lifting now as an old man? In high school we used homemade weights fashioned out of concrete set in coffee cans at the ends of an iron bar.  I think they were estimated to weigh 60-80 pounds.  Our weight-lifting area was behind the spectator bleachers on the football field.  I still get a mental image of all of my teammates and the expressions on their faces going through practice.  I remember who went on to college and where they ended up.  I remembered who is no longer with us and the last time I talked to them.   I remember how hot it could get and how bad all of the equipment smelled.  At times I think about what I would have changed over 50 years ago on those fields.

And then it is on to other friends.  I drive past a courthouse and think of my friend who took care of it for decades. He never owned a car and would either walk or cycle to this building to makes sure it was running right – even on the bleakest winter night.  As we were driving up Birch Hill - headed east outside of Odanah I had thoughts about coming down that hill in the opposite direction in a 1963 Plymouth Valiant.  My friend Bob – had his father’s car and decided to see how far it could coast from the top.   It was a standard transmission.  He reasoned it would coast a long way.  It’s the kind of thing that teenage boys did before there was an Internet and Smartphones.  I tell my wife the story about a guy from my hometown who was coming down this hill one night on his new Norton Interceptor when he decided to put the kickstand down and crashed.  But the hill is most famous as a line of demarcation between the mild to moderate snowfalls of Wisconsin and the epic ones of the UP.

All the while music is playing in the background.  Rock music by the decade from a streaming service.  No more cassettes or CDs. Just tell the phone what you want.  In the past - we had to carry separate briefcases just for the media. I used to be able to sing along to the falsetto parts but no more.  I can strain to hit "Goin' Up the Country" on a good day but no more Steve Perry or old time Robert Plant. I start talking about vocal ranges of rock singers.  I know Grace Slick is a contralto.  I think Jim Morrison was an alto – but might be wrong.  Lately I have been playing his tracks over and over again. I have seen many videos of his band mates praising his lyrical ability. His song Soul Kitchen started playing spontaneously at home as we were leaving.  The music cuts out several times as we go off the grid reminding me that we are streaming and not listening to downloads.

I think about my relatives along the way – the ones with the greatest impact on my life. My life story is one of many tragedies and I start to think about life being tragic.  I have the recurrent thought – “You did not really plan anything – you were just lucky.”  As usual I can’t disprove it.  At no point in my early life along this highway did I say to myself: “You need a plan to (go to college, get a job, join the Peace Corps, avoid the draft. etc).”  My early life was a series of desperate last-minute decisions.  I had to do something.  In some cases, the decisions were failure based. In some cases like a high lottery number when I was 1A during the Vietnam War draft - luck was clearly a factor.  In some cases, I was just moving along to the next failure.  I think about those failures and what I was like at the time. I think about how everything seemed to fall in place after those desperate decisions.  My life seemed out of control until I was in my thirties. 

And whenever I think about that random walk through life, I always end up thinking about my undergraduate professors.  They were people who believed in me and they were not shy about saying it.   They were people who had clear life plans and philosophies and knew how to live life.  They were people very comfortable about living life outside of a blue-collar world. They were people who the friends we were visiting and I later agreed were the best people you could ever meet.  It is still a mystery to me how I thrived at a small, now defunct college by identifying with those professors and realizing I had a genuine knack for academics.  We did summer projects along Hwy 2.  The focus was water chemistry leading us to remote rivers and creeks – in some cases driving down logging roads.  As we drove down those roads we talked about the Watergate scandal.  We took hundreds of water samples and then ran all of the analyses ourselves back in the chem lab - in triplicate.  In biology classes we sampled the insects and plankton living in streams and rivers and did all of the taxonomy.  It opened up a whole new level of thinking in the place where I grew up.

At some point in the trip my mind wanders to composite particles and elementary particles.  A few years ago, I discovered that protons and neutrons lasted a trillion trillion years (10⁵⁰ to 10⁵² years).  Almost all of the protons were formed when the universe formed.  The protons in my body are 13.8 billion years old and they have plenty of life left in them.  If I am cremated 96% to 98% of my body is oxidized or vaporized as carbon dioxide, water, and nitrogen gas.  My protons are back out into the universe to live again - for billions of years.  If I am buried it takes slightly longer but the same process prevails in the end. That seems like a spiritual process to me, but I am trying to get opinions from experts.  From my own reading it seems consistent with what Spinoza called a single unified and infinite substance identical with God.  He saw individual humans as temporary perturbations in the infinite substance.  I am part way through 2 books on particle physics and the origins of the atoms in the human body from the cosmos.  During a recent phone call with one of my undergrad classmates, he thought my reading and connections to protons over 50 years after our last chemistry class together was quite humorous. 

As we drive through Ironwood, Hurley, and Bessemer – the last time I was here Hwy 2 was just 2 lanes wide.  Now it is 4 lanes wide with a lot of traffic.  Just to the north is Copper Peak – a ski flying hill.  It has been out of business for 20 years but it is being rebuilt with a large grant.  My wife and I watched a ski flying competition there back in the 1980s.  There were three guys from my hometown standing behind us that day. One of them was the funniest guy I ever knew. He was killed in a car accident a few years later.  One of the other guys was the nicest guy I ever knew.  He died in an industrial accident about 10 years later.  The third guy is still alive. He was responsible for my first dental crown when he elbowed me in the mouth playing basketball and broke tooth number 24 in half.  I get an image of all of us standing there, talking, and joking.

When we get to Wakefield, I think of the first time I was there as a kid to visit my aunt and uncle.  My uncle worked in a copper mine setting explosive charges.  As we drove around Sunday Lake to find their house, I remembered a spillway on the opposite side of the lake but did not look for it this time.  We still had 22 miles to go down S. County Hwy 519.   The fall color along that route was spectacular and I don’t know why.  The weather there is probably subject to what is happening on both Lake Superior and Lake Michigan.  At some point big lakes bring the baseline temperatures down, especially in low lying inland areas.       

When we finally arrive at our destination – we are greeted by a couple I have known since 1970.  We stayed in touch through the lean times, the industrious times of medical careers, and now in retirement.  We caught up on families, common interests, activities, and the medical infirmities of aging or as my friend put it “an organ recital”.  Among the four of us we have 4 knee replacements, 1 shoulder replacement, 1 hip replacement, 3 ablations for arrhythmias, a pacemaker placement, and various other necessary surgeries.   Nobody is upset about it.  The general attitude is do what is necessary to keep going.  There is some reminiscing but not a lot.  I want them to do as well as they want us to do.  The two days we spend there flies by and we are back on Hwy 2 headed home – hoping to see them a lot sooner next time.  On the road again I think of how important this relationship has been.

In the past few years, I have touched on semantics on this blog and the increasingly well-worn phrase: “The map is not the territory.”  My territory as I have outlined it involves extended connections to people at almost every fork in a 274-mile stretch of road.  There are so many of these connections they can be overwhelming, especially considering the emotional aspects.  With a few exceptions it is impossible to estimate the impact of all of these people on my life.  I am always happy to see them and I miss them when I don’t.  Some people reading this might be surprised.  I am considered to be a loner and asocial on the surface but I don’t think many people really are.  Especially if they have an active memory and can recall the details of what happened to them on Hwy 2 or anywhere else. 

They are just quieter…

 

George Dawson, MD, DFAPA

 

Supplementary 1:

I tried to capture some of my personal experience - the way I think most of the time as I went along this trip.  It has a lot of room for improvement - but at the same time it covers a lot of ground.  I debated constructing a diagram of all the people I would think about along this route and probably will at some point laying it over the route on the map.  I also wanted to provide details of how semantic memory automatically created meaning from these relationships but will defer that to another time. I could not include everything and that may seem paradoxical for a guy with few apparent relationships.  

Supplementary 2:

Some people might argue that my associations and experiences in locations has nothing to do with a map.  The experience of the geography is also different.  The best example I can think of is the Blueberry Store.  With my hundreds of trips on Hwy 2,  I could always count on seeing the Blueberry Store on the west side of Maple, WI on the south side of the road.  Over the decades of my life it went from being a weathered appearing general store to a run down appearing store to an abandoned store.  It was eventually demolished in 2019.  Even though I never went inside - it was a familiar landmark and every time I drive by - I remember what it looked like.  Every time I drive past that empty lot - I see mental images of the Blueberry Store.  Not ghosts - real mental images.  So the territory for me is people, relationships, and memories - none of which are on the map.

Supplementary 3: 

If you think you have had an important interaction with me in the past - you are probably right.  I intentionally used few names in this essay.  But whether you played football with me every night for years, asked me for help when I was a lab assistant, or was the last person to see me before I left for the Peace Corps I remember you.  And if you were in the Peace Corps with me - my head is still full of those images and conversations from 50 years ago and I wish I was talking with you right now. 

References:

1:  Wenliang Li ,The proton’s next secret. Science 393,663-664(2026). DOI:10.1126/science.aek0574

2:  Spinoza, Benedictus de. "Ethica, ordine geometrico demonstrata." In Opera Posthuma. [Amsterdam: Jan Rieuwertsz], 1677.  (Grapevine Kindle edition and translation – Benedictus de Spinoza.  Ethics. 2023.

The Semantic Memory of Physicians - and More...

 

I have the somewhat grandiose plan to model psychiatric diagnosis based on the cognition of a physician rather than focusing on the externals.  By the externals I mean classification systems and critiques of classification systems.  At a later date – I might try to comment on how this approach compares with AI.  For now, I will try to keep it focused on human diagnosticians.  I have an interest in this is because I have made and witnessed incredible diagnoses and treatments by physicians and psychiatrists who I have been affiliated with. I don’t think there has been much of a focus on the process.  A secondary consideration is that cognitive neuroscience is a neglected subject in psychiatry and I hope to make the point that should change. I would go as far as suggesting that cognitive neuroscience should be taught to all psychiatrists more urgently than focusing on another DSM.    

Since the early 1970s, memory functions are divided along various lines clinically and functionally. The first division is long term memory and working memory (also called short term memory).  On the long-term side there is a further division to declarative and procedural memory.  Declarative memory is divided into episodic and semantic memory.  Episodic memory is the ability to recall discrete events.  Semantic memory can have a number of graded definitions.  A minimalist definition is factual knowledge independent of the source (7). A definition more informed by recent research in cognitive psychology: “General (encyclopedic) knowledge as well as schematic representations of events distilled from lifelong experiences, retrieved independently from their original spatial or temporal context” (9).  The authors in that case give examples of knowing who wrote the book “1984” and what generally happens at a birthday party.  That naturally raises the question how does all of this freestanding knowledge occur in the first place?  And also – does that imply a connection to episodic memory? In other words, does semantic memory occur when the context surrounding episodic memory is forgotten?

In the case of physicians there is a very long list of formative experiences across the course of one’s career.  The ability to recall them often assists in making diagnoses and provides an advantage over a physician who has not experienced that event.  Semantic memory is about concepts, words, and their relationship independent of a specific event or experience.  It typically consists of a collection of general facts and word meanings.  For example, it would include facts that apples can be red, green, or yellow and what a mechanic does.

Anyone familiar with cognitive screening examinations has probably asked questions focused on semantic memory.  Naming, word similarities, verbal fluency by word generation, general knowledge questions, are all examples. 

The semantic memory of a physician will contain many unique concepts and they will vary based on experience and exposure to clinical scenarios.  The general categories can be described as the following:

1:  Meaningful prior experiences – even though episodic memory stores specific events at specific intervals, semantic memory contains the specific meaning.  In the case of psychiatry an example would be seeing the effects of CMV encephalitis in a major university transplant unit and a decade later seeing similar behavior and consulting on a case in a general community hospital for similar findings.  That similarity triggers non-analytic hypothesis generation.

2:  Prototypes - the patterns noted in the above example can be averaged over a group of patients and those averages can be consolidated into prototypes.  In the above case a psychiatrist may have seen many cases of encephalitis and many cases of meningitis resulting in encephalitis and meningitis prototypes.  Similar prototypes may exist for all major neurological, medical, and psychiatric condition that they have encountered.  Note that the prototype differs from diagnostic criteria (the typical focus) because it is recall of all of the relevant and in many cases unique clinical features that were experienced.

3:  Specific patient memories (exemplars) – all physicians recall specific patients.  These memories are important for non-analytical reasoning like pattern matching.

4:  Knowledge Encapsulation – medicine like most professions is based on a system of graduated learning.  Basic science transitions rapidly into clinical medicine and then into clinical practice and lifelong learning.  At each stage prior knowledge is reorganized in a more efficient way.  In this case – general biomedical knowledge from basic science is organized under higher level concepts. 

An example in one of the references is a person with an infection who is experiencing progressive physiological problems.  At the medical student/basic science level the analysis might proceed from the basic science level and pathophysiology first.  At the clinician level the relevant pathophysiology is organized as sepsis and that provides a more immediate pathway for intervention.  The encapsulation encompasses and efficiently organizes the lower-level information.  At the same time experts must retain a significant amount of that earlier information.  

5:  Illness Scripts – are mental representations of diseases containing three different dimensions.  The first is enabling conditions like risk factors, demographics, predisposition, and context.  The second is fault or underlying pathophysiology.  The third is consequences including signs, symptoms, lab findings, and course or natural history.  Experts have a significant collection of these features.   

One of the questions in this area is what kind of illness script do physicians have?  Should they all be from their particular specialty or should these scripts encompass the totality of their training?  Some authors suggest that the pathophysiological mechanisms from basic science needs to be retained for true expertise – so my conclusion is that the illness scripts from the entirety of a physicians training probably remain relevant.

This is important in psychiatry because the general pathophysiology important in today’s environment was probably not taught is any detail in medical school and most conditions that are not secondary to medical conditions or the effects of drugs do not easily lend themselves to physiological explanations.  I would suggest that medical stability, generalized seizures and seizure variants, increased intracranial pressure, meningitis, encephalitis, cerebral localization, cerebellar dysfunction, peripheral neuropathies, coma, confusion/stupor/delirium, intoxication, and cranial nerve deficits are some of the illness scripts that every psychiatrist must have.

6:  Semantic Qualifiers - every physician has a lexicon of semantic qualifiers acquired in both medical school and post graduate training. They include anatomic descriptions (areas, more specific locations), pathological descriptions, disease course descriptions, and many others. Framing clinical scenarios with these qualifiers is often all that is needed to acquire associations to the disease of interest.

7:   Base rates and Context – experts by way of their clinical practice have an intuitive grasp of the base rates of various clinical conditions and how they typically present in their practice.  These rates of presentations and findings are integrated with the other features of semantic memory (disease scripts, patterns, etc) for more analysis and hypothesis generation.

These features of semantic memory are of course models of brain function for the most part determined by experimental models in cognitive psychology. Examples include testing for specific functions and seeing how those modelled functions vary among trainees and experts at various stages of development. 

Apart from the descriptive approaches used in many studies on physicians at various levels of training are there any more general models that could apply?  Cognitive neuroscience and cognitive psychology offer a more complete model of memory and knowledge structures as well as the underlying biology.  The lead figure for this post is a case in point and has the potential to consolidate many of the descriptions under a more comprehensive model based on experimental validation.

At levels B and C in the diagram we see a perceptual episode being processed from the left to the right in the diagram.  The activated or instantiated schema is a template for extracting relevant features and repressing irrelevant features.  In the diagram circles represent general concepts and squares are action scripts. Gist in the case of the model is a representation of a single episode where much of the detailed information is removed.  The overall sequence at level B depicts how a schema serves to form semantic type memory (gists) and at the same time can be altered or accommodated by new information.

Level A in the diagram illustrates what is known about the localization of these processes largely from human fMRI and preclinical studies.  Memory schemas are stored in various sites including the retrosplenial cortex (RSPL), middle and superior temporal gyrus (MTG/STG), anterior temporal lobe (ATL), and temporoparietal junction (TPJ).  These sites are bound per the diagram to the ventromedial prefrontal cortex (vmPFC).    Solid lines are context sensitive associative pathways biased by the vmPFC. Broken lines in the diagram represent context irrelevant associations that are not activated or inhibited.

How might all of this model work for psychiatry?  In general physicians are seeing a lot of patients in their training and practice.  In the course of that work - schemas are developed for diagnoses, signs, symptoms, and situations.  Here is a comparison of two scenarios that all psychiatrists are trained to recognize acute encephalitis and bipolar disorder, manic with psychotic features. 

	Encephalitis	Bipolar disorder, manic with psychosis
Schema	Acute illness, acute altered mental status, fever, seizures, focal neurological deficits, CSF/MRI abnormalities	Acute illness, euphoria/irritability/anger, hyperactivity, functional impairment, psychosis, temporal pattern, exclusion features
Subschema	Predisposing factors, pathophysiology patterns, temporal pattern	Euphoric expansive Irritable dysphoric Spontaneous v. precipitated
Gist	Acute confusion + fever + temporal lobe MRI changes = treat as HSV until proven otherwise" "Young woman + new psychosis + movement disorder = think anti-NMDAR, look for teratoma" "Summer encephalitis + flaccid paralysis = arboviral, likely West Nile" “Immunocompromised man with acute agitation = think CMV encephalitis	Episodic psychosis +/- mood changes (diagnosis gist) Mood stabilizer + antipsychotic (treatment gist) Severe postpartum psychosis = think bipolar disorder, manic with psychotic features Catatonia – think bipolar disorder, manic/depressed/mixed with psychotic features.

 

I came up with the following graphic (click to enlarge) based on the descriptive categories and the cognitive neuroscience model of Gilboa and Marlatte (12).  From left to right – the  “heterogenous construct supported by clinical utility” characterization is probably the most charitable one from philosophers.  Others like “this disorder does not exist” or “this disorder is not real” are two additional examples.  The central semantic memory category includes investigations and models of diagnostic reasoning conducted largely on medical students and physicians.  The cognitive neuroscience model contains schema and I have attempted to show how the concepts and actions map from the semantic memory to the schema model.  In both the semantic memory and cognitive neuroscience model, although the focus is memory the conceptualizations are really knowledge structures emphasizing a dynamic role for the schema in incorporating features of reality – in this case patient encounters. The cognitive neuroscience and semantic memory models also map on to brain anatomy – with a more comprehensive map for the cognitive neuroscience model as illustrated in the figure at the top.

What have I learned about this so far:

1:  The pattern matching of yesterday is more complicated today – I taught a course in diagnosis and diagnostic reasoning for 15 years into the early part of this century.  Pattern matching and pattern completion was a big part of that course.  The patterns were fairly simple and involved visual diagnoses (diabetic retinopathy, rashes) comparing physicians at various levels of training.  The most dynamic aspect was the implication that experts were better at matching incomplete patterns than novices.  Today’s conceptualizations of knowledge structures and schemas contain concepts, actions, and dynamically alter what is retained in memory and what is not. 

2:  There are clear implications for psychiatric diagnosis -   the DSM classification and all of the criteria do not capture the reality of medical and psychiatric diagnoses.  There is a qualifier in the manual that it is not a substitute for experience but that is never defined.  That reason becomes a lot clearer looking these cognitive models.  Classification systems attempt to operationalize the diagnostic reasoning of a physician by averaging a verbal description of those events.  I don’t think that is possible and I will cite a couple of examples.

Example 1:  A psychotherapist refers a 27-year-old woman to a psychiatrist because of concerns that she has histrionic personality disorder.  She has not been able to make progress in therapy.  The psychiatrist seeing the patient knows within minutes that she is manic.

Example 2:  An intern is presenting the history of a 68-year-old man to his psychiatric attending.  The patient is extremely depressed to the point that he believes that he is cursed based on a trivial event that occurred in his childhood. Within the first 5 minutes the attending realizes that the patient is delusional and communicates that to the intern. The intern acknowledges that this is true and wonders how he failed to make that diagnosis.

Both cases highlight that knowledge of a classification system is not enough.  The psychotherapist and the intern both know the DSM and use it regularly. They have both had didactics in classification of mental disorders.  The only difference is that the psychiatrist in both cases has experienced cases of the disorder and had knowledge structures and schema to make the diagnosis.  Written descriptions of schema and knowledge structures are an incomplete approach to diagnostic reasoning. 

3: Classifications artificially separate actions from concepts – any reading of the DSM gives the impression that “this is the universe of psychiatric disorders – in order to function as a psychiatrist, pick one and then come up with a treatment plan.”  This is problematic at two levels.  First, if the cognitive neuroscience model of memories and knowledge structures is correct – a classification system is operating at a sublevel that averages features.  It is blind to the overall gist that despite this averaging no two people are alike.  Second, it removes action features that are necessary to function as a physician.  That would include top level schemas like “This patient is medically unstable and requires medical or surgical care first” or “This is a life-threatening problem that requires a safe and closely monitored environment." Some will argue that is not the goal of classification.  I would argue that many consider classification to be a diagnosis and in order for it to function that way – it needs to include action items in addition to a general rule out of causative intoxication states and medical problems. The DSM as it exists is classification without diagnosis.

4:  Cognitive neuroscience models highlight the fact that the separation between diagnosis and treatment is artificial.  All physicians are taught to do exhaustive evaluations of medical problems.  That is the initial step in a career.  It is also critical to learn when that exhaustive process needs to be immediately interrupted to focus on a more acute problem. I can still recall seeing a 7-year-old boy who have been hit by a car while playing in the street. He was alert but had significant abdominal pain.  The car bumper struck him just below his left rib cage.  It took me less than 5 minutes to determine that he had an acute abdomen and call the trauma surgeons. That non-linear process happens frequently in acute care psychiatry and in outpatient psychiatry with patients in crisis who need verbal interventions to assist in the diagnostic and treatment process.  

5:  Psychotherapy – there are recent perspectives on how cognitive psychology applies to the psychotherapeutic process at both the psychological and biological levels using these models.  Basically, maladaptive schemas are confronted and modified during the therapy.  There is some empirical evidence that this may happen particularly in the area of positive and negative self-schemas.  Much of this literature draws on existing cognitive behavioral therapy.  That leads to a question of what is the difference between a therapy focused on a cognition or an isolated memory compared with a schema focused therapy?

At the highest level of analysis memory focused therapies generally involve isolated autobiographical memories and schema focused therapies are about knowledge structures abstracted across multiple events that involve emotion, cognition, and behavior.  In theory the schema focused therapies may be useful in cases where the memory focused therapy is not effective, but a competing consideration is that schemas can be entrenched and difficult to change.  The memory focused therapy could be considered a bottom-up type of approach and the schema focused a top-down approach. 

6:  Criticisms – Criticizing the DSM as a diagnostic system is a cottage industry in the US and the UK.  As we approach a new version of the DSM expect most media sites to start months and even years of criticism. Practically everybody does it rarely discussing their motivations, understanding, and the limitations of their proposed system if they have one.  If diagnostic reasoning is a complex process consistent with the cognitive neuroscience models and requires direct experience, criticism of the manual rings hollow.  It is equivalent to reading about things that might exist and proclaiming you are an expert.  Psychiatrists with criticisms are also limited if they have insufficient experience in the areas they are criticizing.  Psychiatrists with the broadest experience will produce the best criticism. If you are criticizing a list of diagnostic criteria in a classification system in isolation – that is exactly what you are doing.  It is trivial compared with an actual diagnosis by a trained and experienced psychiatrist.        

This brief focus on the cognitive neuroscience of diagnosis should highlight that psychiatric education and practice is seriously lagging in this knowledge base.  If we are taking the “diagnosis” in DSM seriously it has to be modified to include this important brain science.  All of the current competing models face the same criticism.  A diagnosis by a physician is much more than typed criteria attempting to capture a dynamic process.  Secondly, psychiatry needs modern approaches to the mind. Approaches that correlate with neurobiology and have a clear empirical basis. Much of the DSM claims a sketchy atheoretical basis that should no longer be acceptable when powerful explanatory theories may exist.  Philosophy is no substitute.  Finally, we must find a way to implement these across all of our training programs and practitioners.  We should be devoting as many resources to integrating cognitive neuroscience into psychiatry as we do modifying the DSM.

And that should be the first step.  What does a DSM looked like with cognitive neuroscience baked in?  The answer goes a lot farther than “dimensions”.      

   

George Dawson, MD, DFAPA

 

 

References:

 

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12:  Gilboa A, Marlatte H. Neurobiology of Schemas and Schema-Mediated Memory. Trends Cogn Sci. 2017 Aug;21(8):618-631. doi: 10.1016/j.tics.2017.04.013. Epub 2017 May 24. PMID: 28551107.

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Graphics Credit:

1:  The lead graphic as noted is from Cell Press and reference #12.  It is reproduced here with permission from Elsevier and this is their acknowledgement:

Reprinted from Trends in Cognitive Sciences, August 21(8), Gilboa A, Marlatte H. Neurobiology of Schemas and Schema-Mediated Memory, p. 618., Copyright 2017, with permission from Elsevier.  License 6278000229455, May 29, 2026 

2:  Second graphic was made by me using Microsoft Visio.

Supplementary 1:  Nobel Laureate and Psychiatrist Eric Kandel noted the importance of cognitive neuroscience years ago and this was a quote from his book:  The Age of Insight.