Episode 31: Neuropsychiatry, Connecting the Brain to Behavior with Dr. Julia Ridgeway-Diaz

Once a psychiatrist understands what is happening in their patient’s brain, who gives insight on why this is happening? Join this episode of The Menninger Clinic’s Mind Dive Podcast as hosts Dr. Bob Boland and Dr. Kerry Horrell explore the world of behavioral neurology with Dr. Julia Ridgeway-Diaz, psychiatrist, neurologist and neuropsychiatrist at Menninger. 

As they dive into the neuropsychiatrist’s role in physical and mental health, explore the important relationship between medical ailments and resulting behavioral changes. Also discussed is the importance of a neuropsychiatric perspective in complex cases, including a real-life example of treatment failure with antipsychotic medication in a comorbid patient experiencing obsessive-compulsive disorder (OCD) and schizophrenia. 

Julia Ridgeway-Diaz, MD, MS, is a staff psychiatrist in outpatient therapy at the Menninger Clinic. With special expertise in neurocognitive disorders, movement disorders, autism spectrum disorder, sleep disorders, epilepsy, multiple sclerosis and traumatic brain injury, she is also an assistant professor in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. 

“I like getting to the bottom of why things are happening. In psychiatry, we do a really good job of describing what is happening, but we’re not always able to explain the neurologic processes that are causing what we’re seeing,” said Dr. Ridgeway-Diaz. “When what a clinician is seeing doesn’t make sense, that is where a neuropsychiatrist can make an impactful difference.” 

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Visit www.menningerclinic.org to learn more about The Menninger Clinic’s research and leadership role in mental health. 

Listen to Episode 30: The Troubled Teen Industry with Meg Appelgate, CEO of UnSilenced

Resources mentioned in this episode: 

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Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.

Transcript

00:02

Welcome to the Mind Dive Podcast brought to you by the Menninger Clinic, a national leader in mental health care where your host, Dr. Bob Boland,

00:11

and Dr. Kerry Horrell. Twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives in the minds of distinguished colleagues near and far. Let's dive in.

00:43

We are thrilled to have with us today our very own Dr. Julia Ridgeway-Diaz. Dr. Julia Ridgeway-Diaz is a staff psychiatrist and outpatient therapy here at the Menninger Clinic. She's also a behavioral neurologist and a neuropsychiatrist, as well as an assistant professor at Baylor College of Medicine. Her specialties include neurocognitive disorders, movement disorders, autism spectrum disorder, and much more. I personally have known Dr. Ridgeway-Diaz since I was a trainee we were on we were on a similar team together when I was training you one

01:16

of my favorites, the feeling is mutual. So

01:19

we're excited to have you here today to talk about neuropsychiatry, and specifically about your work here at the clinic as kind of leading the charge in having a neuropsychiatry consultation service.

01:30

Yeah, I mean, we, I mean, we've, I mean, just start simple like what what is neuropsychiatry? I mean, this neurology, the psychiatry--How's it different?

01:39

Well, first of all, thank you so much for having me. I'm really honored. You guys have had some incredible guests. So I'm really honored to to be invited today. And thank

01:47

you. You're amongst them.

01:51

flattering me. Thank you. So neuropsychiatry, there's kind of two answers to that question. There's the really practical question of what does it actually look like in the clinic? And then there's the bigger kind of philosophical question of what is psychiatry what we want both. All right, you're, I'm excited to talk about it as much as possible. So thank you. The practical answer is that neuropsychiatry is kind of a subfield of either neurology or psychiatry, neurologists tend to identify as behavioral neurologists and people with a psychiatry background tend to say, neuropsychiatrist, the two terms are basically the same thing. It kind of just speaks to your training background. Okay? So if you do a neurology residency, you can do a behavioral neurology and neuropsychiatry fellowship, and you will call yourself a behavioral neurologist. And if you do a psychiatry residency, you do the same fellowship and you call yourself a neuropsychiatrist.

02:47

Oh, that's good to know, I

02:49

would have never known that. So you might hear them both. You might hear both terms. Neuropsychiatry in the clinic, it is typically you know, what I see is often patients who are primarily psychiatric patients, so they're coming in and their main their chief complaint, their main issue is a psychiatric issue. But they may also have a concurrent neurological issue. For example, a patient who has depression and multiple sclerosis, or depression and epilepsy, or patients who are kind of more pure neuropsychiatry patients in that maybe the primary issue is a neurodegenerative disorder like an Alzheimer's or Parkinson's, which is a condition that will bring with it both kind of classically neurologic and classically psychiatric symptoms, and they're both being caused by the same process.

03:33

Can I ask a quick question? Because I don't think I really understand neurology if you're not a behavioral neurology. Did you say nerves? Yeah. Okay, so when so neurologists are into nerves. Look, we gotta get real simple. Okay. All right. And if you're not a behavioral neurologist, what would be like the thing you do? So general

03:54

neurologists can see all types of patients, including patients with Parkinson's or other movement disorders. And then within neurology, you can have all kinds of different sub specialties, like there's movement disorders, there's epileptologist, there's new people who deal with autoimmune issues like multiple sclerosis, so they will see those patients and they're often the patient's primary doctor that was often the one kind of driving, driving the bus, so to speak, when those patients get referred to somebody like me is typically when they're having behavioral issues as a result of it. Okay, depression, other things like that.

04:31

Yeah, I actually presented America presenting once with a neurologist and a student asked, Where does Psychiatry and Neurology begin? And he said about here and he put his hand around his neck. I don't think it says something.

04:46

I am appreciating that. Oh, that makes sense. Well, no, they care about the brain as well. Yeah. Right. So how did you get interested in this? How did you decide like this was kind of the specialty path I was going to take.

04:58

I was first interested in it. in medical school, when I started medical school, I wasn't really sure what I wanted to do. And I kind of was most interested in stuff that had to do with the brain. So I was interested in neurology and psychiatry, and I had always been interested in things like consciousness and sleep. And you know, even before medical school was just kind of interested in brain related topics. And when I was kind of having to decide between psychiatry, and neurology, the kind of embarrassing answer is that psychiatry seemed to kind of come a little more naturally to me, or it was a bit easier. So it just seemed like, well, if I'm going to work really hard in residency, maybe I should do the thing that comes a little bit more naturally, to me, that makes a lot of trying to make residency livable. But I always maintained an interest in neurology. And I think that what I love the most about neuropsychiatry is that I really like getting to the bottom of why things are happening. And I think in psychiatry, we, we do a really good job of describing what is happening, but we're not always able to explain the neurologic processes that are that are causing what we're seeing. And, you know, psychiatric conditions are really, by definition, kind of descriptive. You know, rather than talking about the etiology, we talk about what we're seeing, and that's wonderful. And that has a place and we've come very, very far with that approach. But I'm really curious always to try to understand what's going on under the surface. And why is this happening?

06:23

We're gonna get more to this, I think in a bit, but that is exactly why you were one of my favorite people at the clinic is because you know, of course, like we work with really complicated patients. And the times in which, as a team, we get so lost as we're like this person's had that's very complicated picture. Maybe they have some psychosis. Maybe they have like a history of some sort of like genetic condition or like, some underlying kind of neurocognitive condition, and we're just lost on like, what is driving these symptoms, which, of course, is then going to impact where do we go with treatment, and you are so skilled at helping us think about that, like and piecing it apart and trying to make sense of like, which parts are coming from what and again, I think that that is like a huge asset to especially working with complicated patient.

07:10

Yeah. So how do you get there? So you're not specialty board in neurology and psychiatry right now?

07:16

No, I'm board certified in psychiatry. So if after at the end of psychiatry residency, got that board certification, and then I did the behavioral neurology and neuropsychiatry fellowship here at Baylor, and then I took the board certification exam for behavioral neurology and neuropsychiatry, and that's the same exam that you take, regardless of whether your backgrounds in neurology or psychiatry, so I'm not a board certified neurologist, but I am a board certified neuropsychiatrist.

07:45

Right. Okay, so subspecialty Exactly. of Psychiatry in your case.

07:49

Yes. Yeah.

07:50

How many years? Were you like a trainee? College,

07:54

starting with college? Well, I also did two years of grad school because I did a master's degree in an unrelated, that's radios

08:01

public health.

08:02

Anthropology. Oh, my God. Yeah. So that it actually does not do any of it. It's more related to psychiatry than you might think. Oh, that makes sense to me. Yeah. Cultural influences. So see four years of college, two years of grad school, four years of med school, five years of training, I thought, 15

08:21

years. This is why especially psychiatrists who go on to do like a specialty fellowship, to get like a specialty board certification. I'm always like, my goodness, the dedication, you must just be a lifelong learner. 15 years?

08:34

Well, I think that anybody in mental health and certainly everyone I know, here at mendengar is a lifelong learner, because everyone I work with is always wanting to continue to learn and grow. And that's one of the things I love about working here. Hmm,

08:46

fantastic. Well, can you tell us about some of the patients who might prefer to you like what, what kind of what kind of patients might you see and be able to be helpful with

08:54

some background, you lead our neuropsychiatry consultation service, so patients referred to you here are going to be referred by a team, right? So that doesn't necessarily like that's not what it's gonna look like, always in like the field, like, sometimes you're gonna be referred to neuropsychologist, excuse me, neuropsychiatrists, for lots of reasons. But here, it's like, our patients are working with a primary team of psychiatrists, social workers, psychologists, and they're gonna say we need we need more, and then they're gonna for you are like the leader of our consultation

09:23

service. Yes, exactly. I see a few different kinds of consults. And one is exactly what you described, which is we have a patient who's admitted a manager and their primary team is wanting another perspective, or nurse psychiatric assessment. And so I'll see that patient and then I also have gotten patients referred from our Pathfinder program from Minister 360. And then a few that have just found us, you know, through the community through marketing and other things like that. And so I love seeing patients regardless of kind of where they're coming from. And it means that I get to see a really wide variety of patients and including patients who are younger. So I can see patients as young as 12 years old, all the way up to, you know, end of life, the types of patients that get referred, it's a really wide variety. And the kind of catchphrase or short way to describe it is when what you're seeing doesn't make sense, then maybe I can help. And what that means is, if it's been well, that could be a lot of things. Yeah. So for example, if the age of onset isn't right, if it's if they're too young for what's going on, or they're too old for what's going on, or if the way that the symptoms are presenting is atypical, if the way that they're reacting to medications is unusual, or if there's a personality change that is, is difficult to explain, for example, someone in their 40s and 50s. And suddenly they have a personality change. Let's say that someone is in there, I had a patient who was in his 50s. And he had what was being described as his first lifetime manic episode. Well, that's really unusual, unusual. So maybe there's actually something neurologic going on. In general, you know, what I see is neurodevelopmental disorders like ADHD, autism spectrum disorder, OCD, first break psychosis, making sure that this isn't being caused by something that's, you know, preventable or treatable, I guess I should say, treatable, and then we kind of go to the other end of the lifespan where I'm seeing patients with dementia and other neurocognitive disorders.

11:28

Because I could imagine not people who've been listening to us for a while know, I work with young adults, and I haven't worked with the general adult population in a while. But I could imagine, especially in that population, like if you're seeing like, significant, like, yeah, personality or mood shifts. And it's like, their first time really experiencing that later in life, like I'm sure, like, questions would be like, what's going on with the brain rather than like, oh, did you just suddenly develop a personality disorder? Yes,

11:53

yes, exactly. And so that would be one of those cases where what you're looking at doesn't make sense. It doesn't fit what you've typically seen. And then there'll be a case of hopefully, it can be helpful.

12:02

Yeah. So but it strikes me that you know, you're not talking about very unusual disorders, these are very common actually return at from anything from ADHD to some Alzheimer's dementia imagine.

12:13

Yes. So it's not it's not necessarily only rare or unusual disorders. It's often something that's very common, but maybe it's just showing up in an unusual way.

12:23

You're you make such a good point, though, that one of the like, double edged shorts, or like stressful things about psychiatry is that it compared to maybe other disciplines, or medical specialties, like, we're just we look at symptoms, we look at, like clusters of symptoms that come together. And most of our disorders kind of barring PTSD, you don't get diagnosed based on the etiology you diagnosed based on the symptoms present. And again, I think that that, for me and the way my brain works, that's always been a little bit bothersome. And especially because our patients, I would say, this is an oversimplification. But a typical Menninger patient might come in with some personality functioning difficulties with some mood difficulties, and then maybe like something eating disorder or substance use trauma, like and so they're this complex experience, where it's like, Yes, you are feeling depressed, you are struggling socially, you are struggling with your relationships, and then you like are just having some random psychosis. And it's like, it's just it does, it turns into this complicated mess of like, you do fit the criteria for things. But is that really, like schizophrenia is a great example. It's like, you might fit the criteria for schizophrenia to really capture what's going on. And again, that's why as someone who works on kind of some primary teams, I'm like, You are, this is an incredible service to to help us think through like, the timelines, I'm like, Does this make sense? And should we look at more? And you know, the complexity of it?

13:50

Yeah, I definitely agree. And it's one of the things i i like about our patient population is that they are complex, and that we are looking not just at, you know, what boxes, do they check, but actually looking at the whole person, and how does their childhood experience fit into this and their personality, their personality patterns? And then also, did they have a traumatic brain injury? You know, do they have a history of autoimmune disorder in their family? Could this be some sort of autoimmune process, you know, and that's where the primary team is at work, where I can come into play, and also our internal medicine team, which is an incredible team, you know, they are all I work closely with them to make sure that we're not missing anything.

14:29

Any examples of patients that you want to give us? I love it. Well, you brought up some elements of you know, yeah, of course, confidentiality, but some general points,

14:39

you brought up schizophrenia. And I think that's such a good disorder to focus on because it is exactly this very descriptive disorder where we're kind of saying, you get this label when we can't figure out what else it is, you know, this this isn't. This isn't a neurologic process that we can identify this isn't substance induced. Psychosis, for example, this isn't autism. And so it becomes sort of this diagnosis of exclusion. But I think a lot, sometimes the common practice is that you have a young person, particularly a man, and often, particularly if it's a person of color, where a lot of that kind of workup isn't done, and they kind of show up and they're acting different. And maybe they're hearing voices or having other experiences where they're not in touch with reality. And then very quickly, they get that label of schizophrenia. I recently did a consult on a patient, very complicated patient, very, very wonderful young young man who does have Autism Spectrum Disorder, also has obsessive compulsive disorder, and also was coming in with a label of primary psychotic disorder. They were thinking either schizophrenic or excuse me,

15:48

not super complicated. Yes, I'm just retweet retweet.

15:52

Yeah. But he wasn't responding to antipsychotic medication, it really wasn't doing anything for him. And it was really difficult to understand what is an intrusive thought, coming from OCD? And what is the voice? Oh, my God, yes. And the this young man, he's, he's very smart. And he was really able to try to articulate to us, you know, this is an intrusive worrying, worrying kind of OCD type thought. And this is a voice that sounds like it's coming from outside of my head. And it's not necessarily an obsession, like we would say, with OCD. But he was coming in, and he was on every medication under the sun. And it was a really complicated picture. So I worked with the primary doctor, we got it, we got him off of a lot of medications, a lot of what nursing you just do is get people off of medications. They don't need to be on tried to clear up the picture. And then my primary, the primary question that was asked of me was, Does this kid have a primary psychotic disorder? Do they even have Schizophrenia or Schizoaffective disorder, and it was an interesting case, because he did hear voices. So he had auditory hallucinations, which are part of the criteria for schizophrenia. But he had no other symptoms that were indicative of a primary psychotic disorder. So he didn't have negative symptoms. He didn't have catatonia, he didn't have anything really other than voices. And so what we ended up figuring out, was that No, he doesn't have schizophrenia, that instead actually we diagnosed him with schizotypal personality disorder. So needing so meaning that typically

17:25

doesn't have voices, no typically

17:27

does not. But they can have some kind of period psychotic experiences, particularly when they're under stress. And he does, yes, exactly. As his stress level went down, the burden of the voices really went down. And so what that ended up happening, what ended up happening was, you know, we were able to get him off of the antipsychotic medications. By and large, he stayed on a little bit of one medication, which was really more for the OCD. And he came in not on any medications for OCD. And the primary doctor was able to get him on an SSRI to actually treat the OCD symptoms, which the patient had been saying from the very beginning was the by far the most bothersome symptoms for him. So it was an interesting case where, you know, I think he could make an argument for different diagnoses for this patient. And we we ended up going with schizotypal, because in part because, you know, diagnoses, they rarely fit a patient perfectly. And often, the purpose of a diagnosis is to communicate a lot of information to their next doctor quickly, right? Yes. And so my fear and our fear was with this patient is this, this young kid is, you know, socially awkward, he's got other reasons to be socially, you know, to be oddly related, or, you know, to just look or act different from other people. And I hated the idea of him getting labeled with schizophrenia, when it didn't really quite fit, and which because that would mean that I can guarantee you that every doctor taking care of him going forward is going to be giving him high doses of antipsychotics, which he didn't respond to, and which caused terrible side effects in him. So you know, part of it is really just to try to think what labels are actually going to serve this patient and think really, really carefully about what criteria do they really fit? And what do they just kind of look like they fit?

19:17

Yes. Okay. I have two follow up questions, if that's okay. You asked me Well, yeah, I will. Okay. One is you brought up autism. And I feel like that has been a shift over the last few years that I've noticed, where we're having a lot of patients coming in with a history of autism spectrum disorder, or even maybe not having had the diagnosis, but they are coming in thinking they have autism. There's I've never been tested. I think this is part of the picture, or their family is saying we think that is part of the picture. And then a myriad of other psychiatric illnesses that that it feels like the autism complicates it like agitation and irritability. Is this coming from autism? Or is this coming from like a a mood dish? Order, and it's been really complicated. Okay, so here's my question. Have you noticed this trend? I'm referring back to one of the episodes we Bob and I did recently where we were talking about the uprise of like, tick tock and people self diagnosing autism? Do we think that's part of it? And?

20:16

That's a tough question. Yeah,

20:18

I'm just gonna end it there. I had other facts, but talks

20:21

about what you said, yeah.

20:23

Yeah, I have a lot of thoughts, I have a lot of thoughts about what's going on with autism spectrum disorder right now. It's an area of particular interest to me, reasonable people can disagree about the value of kind of self diagnosing autism, I can see both sides. So on the one hand, as someone who's you know, dedicated my life to professional evaluation and diagnosis of things, I think there's certainly a lot of value in see in getting the diagnosis from somebody with clinical expertise. And particularly, because autism tends to have does tend to have psychiatric comorbidities, and neurologic comorbidities. And so like you said, it can be really complicated. And so if you're coming in with, if this person has a complicated picture, you really want to parse it out, you want to understand, like, what is autism? What isn't, you know, what is depression? What is social anxiety, you know, and, and because those things have different treatments, that's really why it matters, right? Because you treat them differently. On the other hand, you know, we have a real problem with access to care, and particularly mental health care in this country. So there are going to be people based on their background or insurance coverage are where they live geographically, where it's really not practical for them to get that diagnosis in a timely manner from an expert. And there are people who are on the spectrum who can do of course, do their own research and look at it and say, Hey, this really fits me. And I think actually, I do have autism. And that can be incredibly validating for them, it can be freeing, and it can also help their family understand why do they behave this way, and it can be life changing, right? And they never, they never see an MD or a PhD for that diagnosis. So I see, I can understand both perspectives, right? You don't want to have someone self diagnose, they get it wrong. And then they're missing out on a treatment for something else, right, that they could be having. But also I have to kind of live in reality and see that not everyone has access to that, or maybe they don't have access to it as a kid. But then they have access to it as an adult. And then that would be someone who would be considered a late diagnosed autistic person.

22:27

That's an again, that's a very gentle, balanced answer for a relatively controversial topic. The one part I'm thinking about too, and I've been having more conversations about this, because we're seeing it more is and again, I know that because this your second question are actually or, unfortunately, but this was the thing we I feel like I've been seeing more and more of is comorbid, autism and psychosis, and it feels complicated. Like, I feel like we you know, parsing that out, especially when the Autism is a bit more severe. Feels really complicated. And I wonder like, is there some this is too big of a question, but like, is there some like, underlying, what's the word I'm looking for?

23:11

brain stem mechanism? Yeah.

23:14

There we go. Brains. Yeah. Between those between psychosis and autism,

23:19

I recently gave a talk on the overlap between autism and psychosis at Harris health, I knew we're gonna I play I had planted that.

23:28

Many years ago, I think I learned that they were not quite but almost mutually incompatible. So it's amazing how that's changed.

23:34

It has changed so much. Yeah. I mean, just the history of autism, the history of psychosis, and all of that could be its own separate podcast. It's such an interesting history. And

23:45

great, we're marking that down. Yes.

23:47

We can be our project for for next year. Excellent. So I mean, you know, originally, autism was thought to be sort of this childhood onset schizophrenia, right?

23:56

That's right. That's right. Yeah. That's like what it used to be called. Exactly. It's right.

23:59

Yeah, go way back. Going way back back. Yeah. So and then there was this kind of evolution where eventually they were could actually consider to be separate. And then we got the pendulum swung, and we got to the other extreme, where they were mutually were considered mutually exclusive. And now Now hopefully, we're seeing things with a little bit more balance where someone can have both or either or just depending on that particular person's presentation. But the diagnosis of or the the approach to somebody with autism spectrum disorder, or a person who's autistic you can use there's, there's just an aside, there's identity, first language and there's person first language and people have different preferences on what they use, and I use both interchangeably, but a person with autism who has psychotic symptoms is going to it's a really tough diagnostic picture. Because for one, communication, so how does that person communicate is the first question right when you're going to be working with a patient like this, right? You got to know you got to know going into it. What's there For a method of communication, and how is that going to get in the way of kind of me being able to get the information I need? And then the other thing is an effect. So you know, one of the ways that we diagnose primary psychotic disorders is they tend to have a flat effect. Well, flat effect can also be seen in autism, and it doesn't have anything to do with psychosis. And then you have to think about their interpretation of your questions. Right. So if somebody an autistic person, you ask a question, they're not going to hear it in the way the neurotypical person hears it. They might be. I mean, I'm speaking in generalities. But you know, in general, you would expect them to be more concrete and literal in the way that they interpret your question. So you have to think about that. And you have to make sure you're asking it in a way that makes sense to that person. Is psychosis more common in people with autism, compared to the general population? That's kind of a question that's still up in the air? Yes, I think that, you know, people with autism are more likely to have kind of different or unusual sensory experiences. So that can be sometimes interpreted or misinterpreted as tactile hallucinations, for example, they also are going to be at increased likelihood of like anxiety, for example. So if what they're feeling or experiencing, are they is that really an anxious rumination, or is that a voice? It's really, really tough. But But basically, the answer is that autistic people are at higher risk of all kinds of psychiatric comorbidities. And it doesn't look as if schizophrenia in particular is a comorbidity that they are at higher risk of having compared to the general population is going to be much more likely to be anxiety or depression. But they are more likely to be misdiagnosed with a primary psychotic disorder for all the reasons that we just talked about.

26:46

So because it's making it easy to because they do share a lot genetics, but yes, that's a whole different thing. Yeah, I don't want to talk about that. But I want to turn it off, because I know we're running out of time, is can you say just a few words about functional disorders? Because that is, you know, an area that I think often we turn to behavioral neurologists and neuropsychiatrists.

27:03

Yes, I'm so glad you asked about functional neurological disorders. So functional neurological disorders are really kind of the prototypical neuropsychiatric condition. There's so much that we don't that we don't understand about functional neurological disorders. And the way that we talk about these disorders to our patients can often be really confusing, or I

27:25

think it's the most difficult diagnosis, we probably should define what it Yeah, I'm struggling, this is like, you just give an example. Sure.

27:32

So a functional neurological disorder is a disorder where a person has a neurological symptom, like for example, weakness, paralysis, a sensory experience, and or a seizure, for example, seizures are kind of the big the thing that everyone thinks of, but instead of being caused by something like a stroke, or an MS lesion, or an injury, it's actually caused by a miscommunication between different networks in the brain. It's not something that we can look at and see on an MRI, for example, and it's not something we could do a blood test for. So what it is, is, instead of a particular lesion or injury, it's a dysfunction of networks in the brain. And functional neurological disorders used to be considered a diagnosis of exclusion where we can't find anything, so let's just call it that. But actually, now there are physical exam maneuvers, and also elements of the history that can actually allow us to diagnose it without doing a lot of workup and a lot of tests that ended up being unnecessary. So it's no longer considered a diagnosis of exclusion.

28:34

It's a tough diagnosis to get right. Because I mean, at least one I've heard it given a lot of times patients here at that we're saying they're kind of making it up, or they're doing it.

28:43

This is a great news, because my second question was going to be about pnds. seizures. Yeah. And does that fall into this?

28:49

Yeah, we wanted to find what that means. Hold on. I

28:51

remember it's like, oh, no, hold on. Non epileptic seizures at the end. Yes. psychogenic?

28:57

Yes. Yeah, yeah. peonia, psychogenic non

29:02

should be called pseudo seizure. Exactly. Yeah.

29:05

Not very nice name.

29:07

And then probably not. And now they're

29:09

now they're heading toward just calling them non epileptic seizures and taking the psychogenic out of it. And the reason is exactly what you're saying is that it's a tough diagnosis to give because patients do experience it as a saying, well, there are two things, right. It's hard one is that they kind of feel like maybe we're just kind of giving up and like we don't want to do any more workup and we're kind of tired of it. So let's just call it this. And then the other reason is that they can feel blaming, and it can feel like we're saying you're doing this intentionally You're making it up. That's not the case. In functional neurological disorders. It's not volitional, it's not something the patient is doing on purpose by any means. It's not something that the patient has conscious control over PNAS, psychogenic seizures. psychogenic, non epileptic seizures are definitely part of the functional neurological disorder umbrella. They are also fortunately one of the ones that are easiest to actually diagnose because what You can do is do a prolonged EEG. And hopefully during that period, the patient has an episode. And so they're being monitored on EEG, they're being monitored by video, you get a video recording of the episode, and then you correlate that with what's going on in the EEG at the same time. And you see that there's not epileptic activity going on in the brain and what during the episode, and then that's actually considered the gold standard diagnosis for PNAS

30:25

is there? And again, I know we're kind of on a short on time, but like, is there then a treatment for that? Yes, yes. Like what happens at next? It's like the it's not epilepsy? Yes. Yeah. Well, one of

30:35

the biggest things that that you can actually do for these patients is get them off epilepsy medications, because often they've been put on these kind of heavy duty medications that have a lot of side effects. And then, of course, they're incredibly discouraged because they don't work, right. And then they're just on something that that's not helping and causing side effects. So one of the biggest life changing things you can do is actually get them off medication they don't need to be on and then there is effective treatment for non epileptic seizures. And it's, there's actually a CBT protocol, specifically for PNAS, and it's in the treatments that work. series of books. Very cool. Yeah.

31:08

So with cognitive therapy and behavioral therapy, I mean, what I'm, what are you focusing on?

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Your identifying, seeing if you could identify any kind of triggers for the episodes? And then you're identifying what is the patient? And sometimes more importantly, what do the people in the patient's lives do when they have an episode? How do they react? And then you're also trying to get at any underlying depression or anxiety that could be exacerbating what's going on?

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I so I did my final practicum of my PhD with a program at Loma Linda University called the Mend program. I am forgetting what men stands for. I'm so sorry, if any men to folks are listening right now. But it was, it was focusing on chronic illness. But specifically, like a specialty of usually you got referred to us were kind of functional, neurological disorders, particularly PNAS features. And one of the ways that we talked about it was like, this is the way your body's showing up for you, your your body, and that's how we would try to help them be like, this isn't a blaming situation or like now, it's that there's a way that your body has learned that you get your needs met through this and your body's showing up for you, and how can we help you get your needs met? And it did seem to also be pretty related to trauma. Like anecdotally, there was a lot of overlap between our PNAS folks and trauma and yeah, it's, it was complicated treat because it's like they're having functionally they're having seizures. Yes. And we're being like, let's talk about your trial.

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Right? It can be hard, it can be hard. So I'm glad you brought up trauma, I think so for the traditional teaching around functional neurological disorders, including PNAS is that these patients always have trauma, that it's a necessary part of kind of the genesis of this disorder, we're actually finding that's not the case. There are a lot of patients with functional neurological disorders who who do not have a trauma history, but PNAS actually more than other functional neurological disorders, those patients are more likely to have a history of from again, not everyone, but they are more likely.

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Well, I think we'll we'll get to you and your colleagues, because I think this is something that was kind of dismissed in the past are treated as being untreatable, or just Yes, or something, and you actually have real treatment for it now. So thank you,

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if it's not abundantly clear, already, I am so obsessed with you as a professional. But again, also this service like, um, you know, our podcast tends to be geared towards mental health professionals, and I just want to be like, get yourself a neuropsychiatrist, get yourself one of them, especially if you're working with complex patients, because it has been truly life saving for so many of our patients this, like being able to say like, A, you're not crazy. There's all these different pieces, and we're gonna try to help make sense of it, and we're gonna give you the time of day. We're not just going to slap a label on we're gonna say like, let's make sense of it. And I'm so grateful to you for your work with our patients. Thank you so much.

33:43

So we've been listening to Julia Ridgeway-Diaz, a doctor here at the Menninger Clinic, and we're your hosts.

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I'm Dr. Kerry Horrell and Dr. Bob Boland,

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and

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the Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

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For more episodes like this, visit www.MenningerClinic.org.

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To submit a topic for discussion, send us an email at podcast@menninger.edu