Psychiatry Stress Tests

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COMMENTARY

Recently, I was asked to appear on an internet broadcast focused on the diagnosis of myocardial infarctions, which includes the role of the well-known cardiac physical stress tests.¹ Did we have any comparable helpful stress tests in psychiatry?

That sounded intriguing, so I readily agreed, even if I thought the answer was no. But I had been retired from clinical practice for 5 years, so maybe I had missed a new development like this.

Stress tests for schizophrenia

Very quickly, a long-forgotten memory emerged. It must have been traumatic.

When I began my medical career some 50 years ago, we tried such a stress test. I believe I was on my clinical rotation in psychiatry at Yale Medical School and we had a patient that exhibited some sort of psychosis. Was the diagnosis schizophrenia, manic-depression, or something else? The team couldn’t seem to agree. Treatment would depend on the answer.

The argument for the recommended action was this. If you gave such a patient in question a stimulant drug like an amphetamine, it would increase the release of dopamine in the brain, thereby increasing any symptoms of schizophrenia and, voila, that would confirm the diagnosis.² Remember that this was the time before improvements in ethically obtaining informed consent.

The theory was right and it did so in our patient, but in his and other cases, the increased symptoms of hallucinations or delusions intensified and persisted. It was as though we opened Pandora’s Box to full-blown schizophrenia, perhaps never to close again. That felt like an obvious violation of the Hippocratic Oath to do no harm. No wonder similar endeavors ceased for some time.

Nevertheless, the promise of correctly diagnosing what we thought was schizophrenia before any psychosis emerged was too important to ignore. Based on our current knowledge, we already knew correct diagnosis might take years. The longer we delayed treatment-social, psychotherapeutic, and/or medication-the worse the outcome would be.

Waiting for psychotic symptoms to emerge would be like diagnosing coronary artery disease after someone already had a myocardial infarction-helpful to some extent, but not nearly enough. What we needed was a suitable and safe stimulus with associated reliable outcome measures.

Researchers from Yale took up this challenge once again.³ After reviewing all the recent trials of biological and social stimuli that might compose a useful stress test for schizophrenia, they came up with a different proposal. They concluded that cannabis or, more specifically, the primary active component of THC, may offer unique advantages because:

. The recreational use of marijuana has been linked to transient psychosis

. Cannabis exposure in adolescence is associated with later psychosis in some vulnerable individuals

. Laboratory studies of THC (as limited as they are) show it is well-tolerated in healthy subjects, including that any detection of psychosis that usually remits after the test day

. For any rare prolongation of THC psychosis, antidotes (ie, lorazepam, extended observation) can help

Given that marijuana usage is being legalized in more states, we may have more naturalistic opportunities to understand this sort of psychiatric stress test. Like the recent solar eclipse in the United States-the moon covering the sun and then disappearing-so may marijuana stress.

Stress tests of life

I know of no other promising psychiatric stress tests. Conceivably, others could develop one. Could something only temporarily destabilize bipolar disorders? Could the use of identified mild triggers suggest PTSD? Could controlled cognitive stressors reveal dementias such as Alzheimer disease?

Meanwhile, there still is value to be found in assessing everyday stress. Stress alone is not harmful. Too little stress can be nearly as harmful as too much. With too little, personal growth comes to a halt and complacency set in. Extreme stress is overwhelming and mental paralysis sets in. Stress “somewhere in the middle” can be just right.

All of us have our own inevitable stress tests. No one escapes loss, trauma, and transitions to get through. The ability to move on and function well, if not better, after an adjustment period of some months is the goal.

Of course, people have their own ways of finding out how well they are coping with stress. Many patients look to “Dr. Google” as a source to see if they have a diagnosable mental disorder and what to do about it. The trouble with this is one’s source may be unreliable, or the reliable information will be misinterpreted.

A better solution is for doctors to include a mental health check as part of an annual physical. Here the well-versed physician uses brief questionnaires and talks in some depth about how the patient’s life is going. Like the cardiac stress test, often the patient doesn’t recognize their own psychiatric vulnerability. Feedback from physicians and loved ones is essential for proper assessment.

Value for clinicians

Of course, everyday clinicians are not going to administer marijuana or any other potential psychiatric stress tests without more research and safety controls. We should assess how the treatment we are providing affects the stress level of our patients. This is the art of our work.

. Psychotherapy: How and when to phrase your feedback is required for the patient to accept and use it

. Freudian psychodynamic psychotherapy: an ill-timed or ill-framed interpretation can cause more harm than good

. Behavioral or exposure therapy: careful escalation to stressors is necessary for success

. Pharmacotherapy: The way in which the patient views medication and the possibility of adverse effects may influence whether it is taken as directed and how fast it is titrated

. History-taking. Knowing what elicits transient psychosis may be useful in history-taking. Obtaining a general history how the patient has dealt with recent and current life stressors should suggest certain vulnerabilities or resilience

A final note

Given the epidemic of physician burnout and our tendency to deny or ignore its development in ourselves, we may even need a viable stress test for our mental well-being. At the very least, we should have a yearly assessment to measure the degree of burnout and come up with a strategy to prevent or reduce any significant degree of burnout. Would you like to take such a stress test if it were available?

References:

1. Khera A Kathireson S. Is coronary atheroschlerosis one disease or many? Circulation. 2017:135:1005-1007.

2 Angrist BM Gershon S. The phenomenology of experimentally induced amphetamine psychosis-preliminary observations. Biol Psychiatry. 1970:2:95-107.

3. Gupta A, Ranganathan M, D’Souza DC.: The early identification of psychosis: Can lessons be learnt from Cardiac Stress Testing? Psychopharmacology. 2016;233:19-37.