How many patients suffer from bipolar disorder? Or ADHD or any other well-defined psychiatric condition. Do they also suffer from comorbidity? How are your patients doing, and how does treatment work? How often are you completely sure of the diagnosis and that the treatment is the right one? Or do you sometimes wonder if it might be entirely different factors causing and perpetuating the suffering?
Well, even if you yourself, experienced as you are, surely do most things right and correctly, there always remains some uncertainty in the assessment. It is not unlikely that your patient will feel worse in a while and then present a symptom picture that is no longer entirely consistent with the previous one. As a clinician, you need to deal with the situation, evaluate your previous assessment to find a way forward that helps your patient feel as good as possible.
Uncertainty is, regardless of what we think about it, one of the basic foundations of life. Some of us accept this without a problem, while for others, it causes more headaches. With death as the only entirely predictable thing, even this is subject to uncertainty. For some, it may be about the process itself, for others more about the time after the inevitable.
We all have to deal with a multitude of conditions related to uncertainty on a daily basis. It concerns our jobs, future illness, climate change, conflicts, economic issues, and much more. It is easy to be overwhelmed by this, but one must deal with it. But how? Some accept the situation and live with it. Others create apparent certainty in various ways, while others are overwhelmed by feelings of discomfort. Fear of the unknown contributes to both the onset and perpetuation of anxiety, to the extent that it affects quality of life. Does the increased flow of information and increased experience of uncertainty about the future contribute to the presumably increased mental ill-health of our days? What does uncertainty mean for the conditions we as psychiatrists treat? And how does it affect us personally?
What defines science, really? Certainty about the existence of things? No, rather the opposite: certainty about the uncertainty and transience of described results, which must constantly be subject to reassessment. This is a given for every researcher. The same approach should apply to our psychiatric diagnoses, which at best somewhat describe an individual's suffering but nothing more. It is both easy and tempting to place too much trust in psychiatric diagnostic instruments, which can result in a number of diagnoses. This mechanistic approach easily creates apparent certainty for both patient and doctor. One has found a constellation of symptoms that describe a condition, which is perceived as really existing because it has allowed itself to be described. Then there is the second piece of the puzzle: the evidence-based treatment intervention. Both doctor and patient may experience a sense of insight and security. Unfortunately, the same usually breaks down after a while.
As psychiatrists, we must come to terms with the fact that we actually do not know much for sure about our patients' conditions and how they should be treated. When assessing, for example, the risk of relapse into criminal behavior in forensic psychiatry or future suicidal behavior, we must accept the fact that we actually do not know how it will turn out in the individual case. We have to deal with statistical risk factors and then our gut feeling, and make our choices based on that.
Whether it concerns data or other potentially ominous circumstances, we need to relate, both to ourselves and to our surroundings, with the knowledge that life is actually an uncertain project.
Life is and remains an uncertain project on all levels. Both the individual and the group must deal with this and make the wisest possible choices. This is, as is well known, not a given. In this issue of The Nordic Psychiatrist, we have chosen to shed light on the concept of uncertainty from different perspectives - and not least its significance in psychiatry. It is my hope that you as a reader will find this stimulating and reflect on your own uncertainty, but after reading, from a new perspective. □
Best regards!
Hans-Peter Mofors Chief editor
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