Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian Psychiatry. My name is Ed Miller and I'm the trainee editor of Australasian Psychiatry. And joining me today are Deputy Editor of Australasian Psychiatry, Dr. Andrew Amos, Editorial Committee member Michael Waitman, and psychoanalyst Stephen Yates. Welcome everyone. So this is the second part of our podcast, which is called Integrating Neuropsychoanalytic and Neuropsychiatric Perspectives into Psychiatric Clinical Neuroscience Curricula. The first part we recorded at Congress 2025 at the Gold Coast. So today we're going to be discussing some clinical vignettes and sort of trying to highlight some of the principles and concepts that we've talked about in the first podcast. So if you haven't listened to the first podcast, we'd recommend just checking that out. So we've got seven cases which are all fictional and they've just been created for illustrative purposes only. And the point is to try to demonstrate the key neuropsychiatric and neuropsychoanalytic concepts that we've talked about in the first podcast. And we're really going to try to show how these can be useful for understanding different psychiatric presentations. Furthermore, these examples can be integrated in psychiatry training. So if you're a clinical educator or a tutor, you might want to use some of these cases in your tutorials or in your bedside teaching to try to illustrate these points, and you'd be most welcome to do so. So the first scenario is about Jack, who's a seven-year-old boy. And Jack's presented to clinic because he's been disruptive and misbehaving at school and at home. He's prone to having explosive outbursts of anger, and Jane, who is his mother, feels threatened by him when she tries to engage him in limit and boundary setting. Jane and Jack's father have been separated for some time, and Jane, who is now a single mother to Jack and a younger sibling, is his only caregiver, and she feels overwhelmed. So Jane says to you that she thinks that Jack has a conduct disorder just like his father, and says that most of their weekly activities are in response to Jack's behaviour in order to placate him. So there's not a lot of structure and they basically just do whatever Jack kind of wants. So within your service, they've been seeing a child psychotherapist for parent-child interaction therapy, which is focused on things like attachment style, parenting sort of techniques and advice and communication skills. But after doing 12 months of this, the same problems are persisting. So Jack and Jane are referred to a child psychiatrist within the team for an assessment, and the child psychiatrist diagnoses Jack with ADHD. So the question is really how could this child psychiatrist integrate clinical, neuroscience, and psychoanalytic principles to help better formulate and understand Jack and Jane and the dynamics between Jack and Jane? Yeah, also help to explain what's going on. And this is how we might approach this situation. So the psychiatrist could formulate ADHD with Jane and Jack in terms of dysfunctional neural networks. And this is essentially what causes Jack to struggle with controlling his emotions and make impulsive decisions without thinking them through. And so because of that, you can then explain that it's not Jane's fault. So it's not necessarily just a parenting problem or a communication problem. And then that takes a lot of the blame and burden off of Jane. But it's also helpful to explore some of the dynamics that might be existing between Jack and Jane. So you can explore the reasons for the separation between Jane and Jack's father, and particularly the feelings that Jane holds around the breakup. And then you can read into some deeper levels and think, well, is Jane displacing some of this blame onto Jack? So there's an element of blame that she's putting onto him. You could also talk with Jack about the feelings that he has towards the breakup, how he feels about not seeing his father, whether he has any resentment and internal conflict such as love or hate towards his mother. You can explain that the treatment for ADHD is both pharmacological and psychological and behaviour. And so that both of these things together are usually more effective than either than doing either of those things alone. And that simple things like enforcing a regular routine and having structure in the home will augment the effect of the medication. And finally, you can validate Jane's experiences of how difficult parenting has been. So that's the end of the first case example.

Thanks, Ed. So for our second vignette, we have David, who's a 25-year-old man who is attending an outpatient appointment with his uh psychiatrist for the first time. David has been having abnormal perceptual experiences, including auditory hallucinations, for more than six months. These are distressing to him and causing him to isolate himself at home. He is certain of their basis in reality. David lives with his mother and father who often fight. His mother displays a high degree of expressed emotion, and his father is mostly passive and avoids conflict. The psychiatrist diagnoses David with schizophrenia and wants to talk with him and his parents about the diagnosis and to explain the rationale for taking medications to help. So the question for this vignette from a neuropsychoanalysis lens could be: how could the psychiatrist incorporate clinical neuroscience and psychoanalytic principles into this discussion? So, again, an approach that we have suggested for this patient could be that the psychiatrist initially could formulate schizophrenia with David and his parents in terms of dysfunctional neural networks, and that this results in problems in the way that David's brain and mind interprets and predicts sensory data. So in this way, we're talking about things in a non-dual or monistic explanation, following on from what we described in the first episode of this podcast. The psychiatrist could also explain that the brain and mind are connected to one another and that both work together to filter and predict sensory data from the world, including external perception and internal proprioception, as well as to differentiate between inner and outer reality. The psychiatrist could further explain that in David's case, his brain and mind are having trouble with representing this data in an accurate way. So David is therefore experiencing these as perceptual disturbances, including in ipseity or basic self-experience. The psychiatrist could explain that medication may help to correct the way that the mind and brain interpret this information. It would also be important to explore the conflict between David's parents and the ways in which the family experience and discuss emotions, including if any blame is directed towards David. The psychiatrist could discuss how high levels of family conflict may cause worse outcomes or relapses for people with schizophrenia, and that better outcomes, including for medication adherence, come from more transparent family communication. Mentalising the family system through circular and reflexive questioning may be quite helpful in this regard as well.

I was just thinking, it sounds quite technical, but I've explained to people with autism and their parents around how the brain and the mind, you know, interpret this sensory data. And we've got sensory data coming from the world around us and from inside our own bodies. And when our brain struggles to interpret that data in people with autism, for example, and simil similarly with psychosis, it just gets o overloaded. Um, and in autism, I found that's really helpful because it it makes sense that, for example, new sexual feelings in a teenage boy or going through puberty and having new smells or new sensations is new sensory data that that they they just can't cope with. And I actually find that's a really helpful sort of technical explanation. And for me, I guess schizophrenia or psychosis is kind of the next step of an extreme of that sort of situation.

I was also thinking, Ed, just because you're a neuropsychoanalyst doesn't mean you stop being a psychoanalyst, and you would always, before you did this sort of explanation, do some sort of assessment of what level you would need to provide this sort of information at, and whether or not the people involved can tolerate it. So just thinking about the mother of a schizophrenic patient with uh a high level of expressed emotion, I suspect there might be some level of volatility. Some of these explanations either might be beyond their level of comprehension or extremely upsetting to them. So you would obviously not throw all of this at them at once. You'd be thinking about the most simple level of an explanation and then building on those. And probably in the extreme, there are going to be some patients where taking a neuropsychoanalytic frame to this would be for your own understanding rather than as a way of explaining to the patient and their family. Yep.

I completely agree. And I think with everything we we're sort of translating it across, so it's like a translational science, you know, in some ways. Uh Stephen's going to do the next um case.

Okay. Felicity is an 18-year-old woman who engages in superficial self-harm by cutting and whose emotions can rapidly change from feeling well to feeling deep despair and emptiness. She fears abandonment by others and is very emotionally intense. She lives at home with her mother, with whom she has a fractious relationship, especially since her violent father left without warning. She's had no further contact with him. Felicity comes to an emergency department and is seen by a psychiatrist whom she asks for a diagnosis of bipolar disorder, as she says that all my friends say I have it. She threatens to hurt herself if she's not diagnosed properly. So what does clinical neuroscience and neuropsychoanalytic principles bring to our understanding of felicity? Well, it'd be helpful for the psychiatrist to be aware of the transference when working with felicity. If male, the psychiatrist may represent Felicity's abusive and violent father, causing her to threaten him as getting in the way of her meeting her needs, or as a reaction formation against feeling threatened. If she's female, the psychiatrist may trigger Felicity's feelings of blame and anger toward her mother, which may also be partially displaced from her father. Her emotional instability at a later stage could be conceptualized in terms of brain network dysfunction after rapport has been established. Keeping in mind that Felicity may experience any diagnosis or description as an invalidating label rather than as a potentially helpful explanation if that explanation isn't formulated sensitively.

I guess that and that's coming back to what to what Andrew's saying around it's one thing to know an explanation in our minds and it's another to consider the way that we're explaining it or whether a certain degree of information is relevant or not. How that will be heard. Yeah, which is where the psychoanalytic stuff comes in, as Andrew said as well.

They said, I mean, there's a the principle in that clinically they call listening to listening. So we've heard people talk about this is that you you can you listen to the next story or the next utterance that a patient gives you as to be a symbol of how what you've said has been received. So I'm always interested if I say something to a patient, I mean these are making these up, but they say, last night I was on the way home from work and I stopped at the supermarket and I bought milk and it fell out the bottom of a bag. This is going to be symbolically very different to somebody who says, last night I watched a movie and there was a violent rape in it. So each of those will give you some symbolic representation of how some aspect of what you've intervened with might be heard. In the first, there's something about dropped milk, maybe something that you know what you've the intervention you've made has been heard in a particular way, as opposed to in the in the latter example, it's been heard violently. Or you might also get, I was visiting my cousin and she's just had a new baby and they're deeply in love. And then you might hear that there's what you've said has been heard in a very different way again. So principle, which I think is popularized by a guy called Antonino Ferro, he calls it listening to listening. But there's it's been around as a principle for a long time. I hope that digression wasn't.

No, that's really helpful, Stephen. And I'm I'm also thinking that part of that communication would also be through the transference as well, and that sort of special type of psychoanalytic listening. So it's hearing unconsciously how they're responding as well, as well as the kind of their words.

So it is a transference communication. That's the assumption is that the next thing the patient says is a transference communication. So how they're hearing what's going on in the transference right now. This took me an enormous amount of time to actually do it, because it's very hard to listen in real time in that way. But if you in a psychoanalytic encounter, in an analysis within a frame, you can hear each utterance that the patient makes through the potential lens of being transference interpretation. Now, of course, this can become absurd, like if it's 40 degrees and the air conditioning isn't working, and the patient says, I'm hot, and you make some uh transference interpretation about that, that can be kind of silly. But there's a lot of a lot of get uttered in an analysis is a transference communication. The assumption is in these other settings, like in the vignette that I just just gave, is that there is there is a transference. You know, there's always a transference in every setting. You're just not specifically setting up the conditions to observe it in a concentrated way, which is the only difference in an analysis is that you're really trying to distill it so that you can see it and talk to the patient about it.

I suppose the other key difference there is in analysis you're seeing people deeply over a long period of time, whereas in an emergency department, there's only a very narrow perspective of the patient and in that relationship between the two people as well.

Yeah, and and one of the primary reasons why in analysis you see people intensely for a long period is to develop the transference. They're not unconnected. It's not the absolute only reason that you do it, but the analogy I use is that I need lots of sessions, and I joke because I'm so stupid, but you know, I need lots of sessions because you need lots of telescope time. You know, you need lots of time at the instrument so that you can start to observe the patterns of interacting, the way that the patient relates to you. Because those things are not they're not easy things to see. They take a long time to develop uh that type of lens. The risk, of course, and the joke, I think it was Antonio Ferro's joke as well. He said that the risk is you start to take that way of being outside of your analytic work. So if a friend comes over for dinner and they say they went to the worst restaurant that last night, you hear that as being that they don't like what you've just served them. So we have to be s relatively circumscribed within our frames.

That that's really helpful, Stephen. And I think it's important to sort of acknowledge the difference between you know long-form psychoanalytic psychotherapy and how a how a psychiatrist in a sort of clinical setting might be informed by some psychoanalytic principles, but how that might be different to how a psychoanalyst might also kind of use those principles as well. And I think the same similar principles but sort of used in different ways or to different degrees. So the next scenario. So an inpatient child and adolescent psychiatry unit is stu struggling with staff retention and satisfaction. The unit deals with severely unwell children and young people, many of whom are admitted under the Mental Health Act. They often come from dysfunctional families with high degrees of conflict and trauma. Some staff in the unit have gone on long-term sick leave or threaten to resign in recent months, and there are regular complaints from staff towards the consultant psychiatrist and other managers in the unit. Junior staff often disagree with suggested management plans or complain frequently about various aspects of the patient's care. So the question to consider is what clinical neuroscience and neuropsychoanalytic principles might help the consultant psychiatrist or any of the senior management team actually understand the roles and the current functioning of the unit. And so this comes back to sort of organizational psychodynamics and group sort of dynamics as well. So, and this is how we might sort of approach this question. So psychoanalytic principles can help understand the complexities of interactions between staff, parents, and young and young people in an inpatient unit, and not necessarily just a child and adolescent psychiatry inpatient unit, but probably most inpatient units. Because everyone brings their own perspectives and projections and interpretations within that kind of system. And so, due to inherent power balances within the system, so you've got managers, doctors, you've got the use of the Mental Health Act, you've got parents and children trying to recognize the transference and counter-transference sort of principles and reactions that are happening are actually an essential component of effective leadership and also for helping to prevent things like burnout in yourself. So for example, parents in an inpatient unit tend to attack the staff, so verb verbally. They often say things like, the unit is stupid, or you know, this service is stupid. You have you've done nothing to help my child. But if you can sort of read underneath the surface of that and see actually it's the parents feel often feel inadequate and they feel guilty that their child is actually engaging in itself and they feel like they failed as a parent. So then they project that sort of inadequacy onto the unit and they might project that onto junior staff who then project that onto senior staff. And so being able to actually recognise that um, like I say, is actually key to your own sort of mental health and and well-being. And similarly, the unit as an organization is a sort of body of which families and children can then interact with with particular attachment styles. So families and and children will interact with the unit in, say, an ambivalent or disorganized way. So that they might go on leave but then not return, or they might abscond. And so that's that's a manifestation of the attachment style within a family system, for example. And a lot of those behaviors can then become projectively identified by the staff. So the energies and the feelings get get physically put in staff who then those actions out unconsciously themselves. So they might go on sick leave all the time, they might constantly threaten to resign. So it's all about recognizing what's the actual emotions that are at play here? What are what are the real emotions like guilt, like fear, like blame, like anger that are underneath all of these things? And who do these emotions belong to? Do that do they belong to the unit or do they belong to the families and the young people? And being really clear in your boundaries with that, and particularly how the defenses that play out around these emotions and how they play out against existing power structures structures within the unit. So that's sort of the psychoanalytic side of things. But then having a clinical neuroscience perspective can also be really helpful. So the pattern that you can sort of see here in these examples is that clinical neuroscience really looks at severe psychiatric problems as neural network problems. So it tries to understand these severe manifestations of human sort of behaviour and illness in terms of the wiring in the brain and the networks in the brain just not connecting properly. That's a very simplistic way of putting it, and there's lots of reasons why that might be. But it's the best understanding we have for I guess severe sort of mental illness at the moment. So sometimes it's helpful to actually explain that. And because again, that takes blame away from parenting style, for example. And it might help the young people or any patient to actually have a have a better understanding of why they might actually be a certain way and why medications might be helpful. With the caveat, of course, that we can't actually show people that. So we can't actually scan someone's brain in a clinical setting and show that there's a particular, you know, wiring problem. So we're always guessing in the same way that um, you know, Stephen is saying we're kind of guessing around transference and symbolic interpretations in psychoanalysis. Even in clinical psychiatry, we're still we're still guessing with a lot of this stuff anyway. But it's it comes back to communication as well and trying to explain things as best as we can. So there was a lot in that scenario and lots of different layers and levels to thinking about problems.

There's two real challenges to face there. One is identifying those dynamics and factors, and then two is then finding ways to intervene effectively as well.

Yeah. So particularly in a child and adolescent inpatient unit, but I think a lot of units benefit from having staff reflective practice groups, um, you know, staff bailing groups, some units have an external sort of supervisor um come in and think with the group about a particularly complex patient or situation. So it's really similar to what Stephen's saying, it's turning the attention to deeper sort of things that are going on under the surface and moving past the resistance and the defences to actually think about feelings rather than react to the feelings, you know, all the time. And and then you've got you know things like family therapy, for example, might start to do some of that. Some units are lucky enough to have um, you know, dynamically trained therapists, which is amazing. But in an inpatient unit, that wouldn't be long term, obviously, that would be in a rel relatively short, short term. Okay, next scenarios. Um, and Andrew will present.

All right, so Carly is a 30-year-old woman who was injured in a motor vehicle accident as a passenger in a car driven by her partner. Initial MRI brain showed diffuse axonal injury of the frontal lobes. And in the months following the accident, Carly exhibited good recovery, with the exception of frequent episodes of impulsive. Verbal anger directed at her partner. Six months after the accident, Carly's partner reported that she appeared depressed and was less interested in her usual activities. And furthermore, Carly was short-tempered and demonstrated occasional inappropriate rage towards the treating team, who she believed were incompetent. So the question we were looking at was what neurological, psychiatric, and psychoanalytic factors might be considered when formulating Carly's presentation. So in terms of neurological factors, traumatic brain injury has been associated with depression and apathy. Frontal lobe damage in particular is associated with a deterioration of executive functions, including attention and uh working memory. And damage to the orbitofrontal cortex is common with rapid deceleration injuries during car accidents and can result in failures of inhibitory control, including impulsive aggression and emotional liability. Now, in terms of psychiatric factors, the diagnosis of psychiatric illness following TBI requires careful assessment of the etiology of symptoms common to both, including emotional lability, irritability, apathy, loss of energy, difficulty concentrating, and sleep and appetite disturbances. So a differential diagnosis may warrant a consideration of the presence of an adjustment disorder, a depressive disorder due to another medical condition, or personality change due to another medical condition. And there are various other possibilities, of course. Now, in terms of psychoanalytic factors, Carly's frustration with her treating clinicians could be a manifestation of an omnipotent defense towards her own cognitive shortcomings. So when not enraged, she was noted to lapse into long blank silences, which felt enervating to those around her. With time, she could understand that her rage was self-directed, and she felt grief and sadness at the loss of her previous capacities. She also developed awareness that she had repressed a sense of blame toward her partner as the driver at the time of the accident. So, look a relatively uh complicated presentation with some very biological features, but the possibility of psychoanalytic factors contributing to psychiatric illness there. This is probably one of the more clear discussions where we're talking about specific symptoms of those different diagnoses and then considering how that plays into the patient's relationship and her feelings towards her partner. So nice example of the interaction of the biological, psychological, and social features and why neuropsychoanalysis might play an important part in explaining all three.

Yep.

I was going to say the very similar thing. Like to me, that that case illustrates how closely linked the mind and brain are. So an injury to the brain is going to, and particularly frontal lobes, is going to affect your mind and your personality and those softer kind of features as well.

It does remind me that there has been a truism in psychiatry. I'm not sure if it's taught to younger psychiatrists that in terms of the hierarchy of severity, the higher up you go, higher levels trump the lower levels essentially. So if you have an organic cause of disease, in olden times we used to almost dismiss, let's say, personality factors. I'm not sure that that that is any longer true.

Isn't that in the one of the DSM sort of diagnostic criteria? The pyramid. So you rule out organic first and then you rule out access one or something.

Well, the example in this case, of course, would be if if there is a frontal cortex cause for impulsive discontrol, if you like, how much can you make any assumptions then about the pre-existing personality features? Um and of course, what you would do would be to ask the partner or other secondary sources about the existence of those factors. How much use that would be when there is an organic cause for those things, of course, is another question. But it might give you a baseline beyond which you're you're never really going to be able to go. Is that something that's happened in your practice, Stephen?

Which particular aspect, Andrew? Give me another.

The superimposition of organic and personality features in someone's presentation.

Yeah, um the most common scenario where I've seen that if you want to subsume it under organic drug and alcohol disorders. So you I've certainly seen covert concomitant heavy alcohol use, which looks like borderline affect dysregulation. Uh and during periods of sobriety or after a rehabilitation stay, there's a huge debt change in the dynamic, essentially, the quality of the transference, counter transference, and the patient's level of disinhibition. That would be the one that comes to mind. Uh seen similarly with gamma hydroxybutyrate addiction or benzodiazepin misuse.

I was going to talk about Steve Irwin as a popular example of a chap that probably had a few impulse control issues beforehand, but started to accumulate brain injuries because of the dangerous behaviour that he'd had, and eventually got less and less uh control over his behaviours until, of course, he came to a bit of a tragic end. And and young males, of course, particularly who have been involved in car accidents, can sometimes demonstrate that sort of progression, which is a literally organic progression, but does have some origin and some personality features before they had their first brain injury.

I think we need to be very aware of people in the public eye who subsequently die by suicide, who also have a pre-existing history of head injury, you know, in sportsmen or performers or in actors who also have a concomitant brain injury or a condition such as Parkinson's disease or progressive supernical palsy or dementia with Lewy bodies. Yeah, absolutely. All right, on to the next vignette. A psychiatrist psychotherapist is seeing Bernard, a 55-year-old man, for weekly psychoanalytic psychotherapy following his marriage breakdown. During sessions, Bernard will occasionally begin hysterically laughing. The psychotherapist initially believes that the patient's laughing could be a manifestation of repressed eatable aggression or a defence against the sadness and guilt he feels secondary to the marriage breakup. The therapist tries to understand and interpret the laughing in order to help resolve the symptom. However, after a year of therapy, the laughing still persists. The therapist's getting frustrated because he believes that Burnham is in deep denial and that the frequent laughing is getting in the way of true therapeutic progress. So, what would neuropsychiatry or neuropsychoanalysis help with in this scenario? Well, laughing, of course, could be a manifestation of complex, deeply embedded emotion, but after a year of regular therapy, one might expect some progress. So it's helpful then to think more broadly. The psychiatrist, psychotherapist might consider other explanations like a pseudobulbar affect or a tick disorder. Other underlying causes such as early onset frontotemporal dementia or a stroke leading to focal or network dysfunction could also be considered. These other causes may be more likely if the patient had a sudden change in personality, such as becoming more irritable, which may have predisposed the marriage breakup. Interpreting changes to his dream phenomenology may also need to be considered in this regard.

Yes, I guess that relates back to what you were saying earlier, Stephen, about, you know, so a psychoanalyst might be always thinking symbolically about what something means, but a neuropsychoanalysis would also be thinking neurologically about what something potentially means as well. And I guess this is an example of that.

Well, a really good example of that that I can speak to from experience is that what do you know about the dream life of people with obstructive sleep apnea, untreated obstructive sleep apnea? Well, they have dreams of choking and being underwater and all these interesting imagery that gets thrown up as their brain turns inward during sleep and tries to make sense of their internal experience. And these dreams all go away when you put them on CPAP, of course, and it can also present with uh things like depression, and I think with some sort of quasi-psychotic uh phenomena and really badly untreated, I say the inner life, the neuropsychoanalytic principles of the inner life are that it is of course a reflection of what's going on uh in on the inner aspect of the brain or the mind, which is the inner aspect of the brain or the subjective experience of the brain, which means that we're when we think about what psychoanalysis typically treated, well, it's about brain diseases that are linkable to development. So it has to do with functional disorders that occur as a result of development, things like related to attachment or interpersonal interactions or things that psychoanalytic theory is is full of explanations for. But there are, of course, the inner life reflects all of the aspects of the brain uh in in its fullness and in its impoverishment, you know, in in a in a dementia, for example.

Are there any post-sea dream patterns like uh the feeling of an alien on the face or anything like that? That's terrific.

That's a great question. I became fascinated with this. The one that I found is that a REM rebound, because REM sleep is more implicated in obstructive sleep apnea because the soft palate loses tone during REM sleep. So supine position and REM sleep are the most probable to cause obstructions, and in bad you have obstruction in every position. But as you treat the condition with either the mandibular advancement devices or with CPAP, you have a of course the brain begins to recover and you have the sleep architecture starts to be restored, including a restoration of REM sleep. Now, having a REM rebound, which is you know extremely rich dreams and maybe nightmares and all of these other things, predicts adherence to the treatment, which I think is absolutely amazing. So the brain wants to dream. Actually, it's it's as soon as it gives you give it an opportunity by not having to be woken up every 15 seconds, uh it will do it like crazy. And for the punter, it feels good to have a REM rebound.

So I that that's the I think that's a really good point because uh you know what's happening in the body does get represented in our dreams, so sexual feelings and wanting to go to the toilet, for example.

Yep, the sound of the garbage man coming past in the truck.

Yeah. But your example of you know people with OSA having strangulation dreams, for example, if if you didn't know that, you would interpret that, you know, probably as repressed, you know, trauma or age or something like that. So so you would spend months and months and months trying to unpack that and analyse it and s and symbolize it properly, whereas y that would actually be incorrect because that wouldn't actually be the cause of it.

Well, according to a kind of a Bionian model of what the process is that's happening in psychoanalysis, which is completely congruent with neuropsychoanalytic discovery, is that the brain is in a constant process of representation of the of symbolization of the inner life, and this can be occurring to a sort of greater or lesser extent, and traumatic experiences are those that are unable to be symbolized. But from a neuropsychoanalytic perspective, they would be those that can't be consolidated in memory. You know, there's what is REM sleep for memory consolidation. It's not the only part of sleep that dreaming occurs in. You have dreams all through sleep, including in deep sleep, but preferential memory consolidation occurs in REM sleep. So when you have a lot of fracturing of REM sleep, you're not consolidating memories, which also is an interesting thing to consider when you think about whether somebody with untreated OSA should be having psychotherapy. Because are they consolidating new memories? Which is the mechanism by which some of the change occurs in the mind and in the brain. You just have to have a new experience as well as to explore others. Something to think about.

I'll just mention that there is a recently published article in Australasian psychiatry called The Clinical Use of Dream Content in Modern Psychiatry, which uh goes through some of these issues. They essentially take the it's by David Plevan and Virginia Munro, they take the position that while the dreams used to be thought to be the royal road to the unconscious, we've really fallen out in training of examining that that part of the people's uh unconscious experience.

We have to think about why it is the royal road to anything. It's the most inward-looking time of your existence. It happens in a quiet environment. You're lying down somewhere usually, you're able to focus inward, and the activity of the brain is essentially with the seeking system turned on, looking around for solutions to various problems and exploring your inner environment. So you'd have this massively decreased sensory environment, so you're not constantly bombarded with information from the external world, and you can perform a bit of housekeeping, which is what you need to update your predictive models and update and memory, consolidate new memories. And there's a very interesting analogue with that experience of sleeping and dreaming and how you set up the frame of a psychotherapy or a dynamic psychotherapy at least. It's a quiet place. Sometimes you're lying down, it's free from a lot of other sensory input. Usually the therapist doesn't talk and talk and talk and talk and talk. Of course, they engage in the interaction, but they they're not, you know, giving a lecture or or um quizzically asking question after question. So it shares quite a lot of the characteristics of an inward-looking kind of luxury experience where you get to explore what's going on in your inner life. There's there's a good argument to be made that what somebody like Beyon and his contemporaries were talking about is now able to be articulated in terms of what's going on in the brain. We just didn't have the language or the technology to observe it in the past.

Alright, so a final case for the episode today is about Sally, a 35-year-old woman who has had several previous operations due to recurrent abdominal pain, although there's never been any obvious underlying physical cause found. The surgeons continue to offer exploratory surgery as a means of ruling out underlying pathology. The clinical psychologists in the hospital are at odds with the surgeons, suggesting Sally in said suffers from a functional pain disorder, which they say is not physical, but rather in her mind. The psychiatrist in the hospital was asked to provide an opinion on what is contributing to her pain. So the question here might be: could neuropsychiatric or neuropsychoanalytic insights provide any help to the psychiatrist? So some of the things that we wondered about were that the psychiatrist could suggest that even a functional disorder may involve underlying network dysfunction in the patient's brain, and this could cause abnormalities in the way the patient perceives pain signals in her body. So, therefore, through this lens, the disorder does have a physical component. However, the patient may also suffer from a displacement or conversion of other complex underlying emotions, perhaps relating to events from her childhood, and that these have been displaced into a subjective experience of anxiety or somatized into abdominal pain. So exploration of her unconscious through psychoanalytic psychotherapy could provide useful insights into the nature of her complex underlying emotions. Also, the invasive nature of the surgeon's repeated actions could be understood in terms of the surgeon responding to strong levels of projective identification or a reaction to feelings of impotency at being unable to fix Sally's issue. The divide between the psychologists and the surgeons could also reflect a splitting defence against this anxiety.

Just to sort of add on to that, I I do find that, particularly when talking with other medical professionals, thinking about psychiatry problems as network problems is something which is quite new, I think, to them. Because I think a lot of my colleagues see psychiatry as being a mind thing and not a body thing, and neurology is the sort of the brain thing. Whereas explaining actually psychiatry is about the brain, it's just about the networks in the brain, it's not sort of focal problems like a stroke or a tumour that neurologists might deal with. It's actually about the way that the brain connects together. I think that it that's quite a helpful explanation and brings psychiatry back to a sort of medical thing for me anyway.

It's a great trick of subjectivity that you lose touch with the idea that you're an organ. It's terrific. I don't know how evolution did this. Gives you this fantastic feeling that you're you're you know, all of your intellectual content and your working memory and everything is somehow separate from the substrate that it's encoded in.

Well, that's that's all the time we have for today, so we'll need to bring this really, really fascinating discussion to a close. I'd like to thank Andrew, Michael, and Stephen for coming on today and having such a really rich and interesting discussion. Thanks. Thanks very much, Fred. We'd also like to acknowledge Nishitek Uma from the College, who gives us so much support in producing and editing the show. We are also thankful to Australasian Psychiatry for the opportunity to make these podcasts, as well as Sadoni Prentice for our artwork and Shady Day for our music. We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors. We always love getting feedback or suggestions for further episodes, including volunteers interested in being a guest. Please get in touch by email at thethoughtbroadcast.org. That's all for now. My name is Ed Miller. Thanks for listening, and we'll catch you next time.