PsychEd Episode 30: Anti-black Racism and Mental Health with Dr. Kwame McKenzie

• PsychEd Episode 30: Anti-black Racism and Mental Health with Dr. Kwame McKenzie

  Dr. Alex Raben: [00:00:19] Okay. Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. We have a very interesting episode for you today, listeners. We are here to discuss racism and mental health, the interrelations between those two things, and specifically with a focus on anti-Black racism and mental health. I'm Alex Raben. I'll be your host today. I'm a new staff at CAMH, working on an assertive community team here, and I'm joined by my co-hosts, Anita.

  Anita Corsini: [00:00:56] Thanks, Alex. So my name is Anita Corsini. I'm a social worker and I currently work in knowledge translation and exchange at the Centre for Addiction and Mental Health in Toronto. And previous to that, the majority of my frontline experience was working as a counsellor with youth and young adults.

  Dr. Alex Raben: [00:01:15] Great. Thanks, Anita, and we're very pleased to be joined by Rebecca Marsh, who is a fourth year medical student.

  Rebecca Marsh: [00:01:22] Hi everyone. Yeah, my name is Rebecca and I'm a fourth year medical student here at the University of Toronto.

  Dr. Alex Raben: [00:01:28] Thanks, Rebecca. And we should also say that Randi was part of this episode as well, but she wasn't able to join us this morning. But we are joined by the esteemed Dr. Kwame McKenzie, who is the CEO of the Wellesley Institute and is an international expert on the social causes of mental illness, suicide, and the development of effective, equitable health systems. Dr. McKenzie is also the Director of Health Equity at the Centre for Addiction and Mental Health and a full professor in the Department of Psychiatry here at the University of Toronto. And I'll let Dr. McKenzie introduce himself as well to add to that. Welcome to the show.

  Dr. Kwame McKenzie: [00:02:12] Well, thanks very much and congratulations, Alex, on your new position at the Centre for Addiction and Mental Health. You know, not that I'm biased, but I am biased. A wonderful, wonderful place to work. And, you know, I'm really glad to be here. As you know, I'm a psychiatrist, although my books have tended to be about the social determinants of health or about anxiety and depression. And most of my work at CAMH was in schizophrenia, running the schizophrenia department before doing other things, as in old age and children and dual diagnosis. But most of the work I did in the UK was also in serious mental health problems. So I've done loads of different things and I'm really glad to be here and love this idea of this podcast. Making myself sound old, right?

  Dr. Alex Raben: [00:03:19] Well, we're so glad to have you. We really appreciate you coming on and bringing your wealth of expertise, both clinically and in the research world. Alright. Well, let's start with the learning objectives. So, by the end of today's episode, you should be able to understand the history and legacy of racism and mental health in the Black community in Canada. Number two, understand the current state of racism towards Black people and the impacts on their mental health. And number three, explore how health care workers can be anti-racist in providing mental health care and how the system can change to improve the mental health of Black people. To start out. We wanted to go from the basics because we don't want to take things for granted. So this may seem like a question that has an obvious answer, but I'll ask it anyways. What is racism? How do we define that? And outside of the abstract, what does that look like practically speaking for people who deal with it?

  Dr. Kwame McKenzie: [00:04:41] I think that is a really great question because one of the things that always happens with this is everybody has their own ideas about what we're talking about. And racism, one way of thinking about it, is discrimination plus power. So it's not that you discriminate, just discriminate against people because of their race, but there's a power structure that is set up so that that discrimination actually means something and it changes the lives of those other people. And it's built on the idea that one race is superior to the other. And therefore there's a hierarchy of races, where there's a privileged race and there's a less privileged race, and it permeates all areas of society. It permeates how we think about other people, how we interact with other people, people's chances in life. So it's an idea, it's an abstract idea. It's not based on anything that could be considered in any way scientific, but it has very, very real consequences to the lives of people. And so I think it's a great question because there's loads of confusion about what we're talking about.

  Dr. Kwame McKenzie: [00:06:05] And when we're talking about anti-Black racism, it's actually a Canadian phrase that was coined at Ryerson University. And the idea of anti-Black racism is it tries to explain how racism is actually different for Black populations, how the systemic nature of racism — not just what we see with regards to stereotypes in the media, not what we see with regards to the way the Children's Aid Society or the prison justice system works with people — but how it permeates every part of society to produce a toxic environment for Black people in Canada that's different than the racism that other groups in Canada feel. You know, obviously there's anti-Indigenous racism, which has a similarly toxic air. But, you know, when you're thinking about Black and Indigenous, the levels of racism and the impacts of racism are very different to other groups.

  Dr. Alex Raben: [00:07:14] That makes a lot of sense to me. I guess, in terms of examples of racism, I think that it can be kind of easy to think about examples of an extreme case or a historical case where racism took on violent and overt forms. And not that I'm presuming that doesn't happen now, but I'm wondering what is the range of things that qualify as racist in terms of examples that we could talk about or we could bring alive for the listener?

  Dr. Kwame McKenzie: [00:07:53] So, it's one of these things that when you have a complex society and you have social divisions and you have ideas that create social divisions, they get everywhere. So, no, the question isn't where IS racism — the question is where ISN'T racism. So, you know, when people talk about perceived racism, so I can see that I'm getting differential treatment or, you know, our interaction is different, or I've got racist abuse or attack, or microaggressions happen, right. And I'll talk about microaggressions second. So those are perceived racism. I can actually see it. Right. But then lots of racism is NOT perceived. You may not know why you didn't get an interview. You don't know what happened. It's just, you didn't get an interview, so you never see it. But actually, it changes your life. Then there are loads of other forms of structural racism. The way the police react to people, what happens in education, educational outcomes, children's services, the prison justice system, not just the police, whether you can get a loan or not. Then there are other forms of racism, again, which we're seeing during COVID. Where we can see that there are these huge disparities in risk of COVID for some groups compared to the others. And we do nothing about it.

  Dr. Kwame McKenzie: [00:09:39] And that form of racism by neglect is some of the most pernicious types of racism in Canada, where people just don't do stuff. They see that there are incredibly high differences in colon cancer screening or cervical cancer screening for Black women, but they just don't do anything about it. And so at the Wellesley Institute, when we were thinking, how do you think of this sort of systemic racism? Is systemic racism an intent? So, I tend to treat people differently? Is it that I have no knowledge about, you know, what is it? You're a system, like the mental health system, and you can see big disparities in access, outcomes, deaths, and you do nothing about it... then, that is systemic racism. It's not that you cause the problem, it's that you're not part of the solution and you just allow it to happen. And there are all sorts of reasons why we convince ourselves that we shouldn't be part of the solution. But in a connected world, where you're a human being, when you see other people suffering, you are supposed to be part of the solution. And so it's complex. But the thing is, you look at the effects and you can see the differential effects.

  Dr. Alex Raben: [00:11:15] Wow. Yeah. So it's, I mean, quite a range. As you say, it's almost the better question is, where ISN'T it? It's actually at so many different levels. It can be at so many different levels. It can be visible or relatively invisible. And even inaction can be a form of racism, as you point out. Now, I know, Anita, you had done some looking into in terms of the history of racism in Canada, or maybe I'm misclassifying that, but I know you had dug in a little bit into the history because I was hoping we could present the listeners, because we have an international audience, with a bit of the Canadian context. Now, I know, Kwame, you're from the UK originally, I believe.

  Dr. Kwame McKenzie: [00:12:09] Yeah, that's right. I mean, you couldn't tell from my voice? From somewhere, not Canada!

  Dr. Alex Raben: [00:12:22] Yes, our listeners were ahead of me on that, I think! But I guess what I'm saying is we often in Canada talk about racism in the US context. We don't as often talk about it in the Canadian context. And so I'm wondering, what are the differences there? Are they meaningful and what do they mean to people living in Canada? Maybe, Anita, I can hand it to you, because I know you had done some digging into that question.

  Anita Corsini: [00:12:50] For me what stands out is, and it's something I've kind of been mindful of for a while, is just like the tendency, the Canadian tendency, to understand ourselves as good and benign. And I think that erases a lot of our history. And if we're talking about the experience of Black Canadians or Black people in Canada, we often think of, like you mentioned, Alex, like the histories of slavery in America, but we don't recall or talk about the history of slavery in Canada and all the ramifications of that in terms of systemic racism and oppression and the legacies of that and how that, sort of, is part of our institutions today. I think that it's kind of that if we're thinking about neglect, like the historical neglect of acknowledging those histories and the fact that there is intergenerational, I think, implications for that in terms of people who are living today, who, you know, their histories, their personal histories, sort of extend back to those experiences. But also just that the fact that those histories sort of shape our institutions today.

  Dr. Kwame McKenzie: [00:14:21] Well, fabulous question. I mean, I think that one of the things we take for granted is our understanding of our history and our heritage. So every time we have an interaction with somebody who has a very similar heritage to us, we have a whole bunch of cultural assumptions that allow us to interact with people at a certain level. And that's the foundation of the way we interrelate as humans, and that's the foundation of the way we understand what's happening in our consultations and our interactions. So what if somebody has got a completely different heritage? What if that heritage is a heritage that could produce a certain different discourse in the interrelationship? What if, you know, and it's relatively easy for people to think about it when they're thinking about the proximity to residential schools and the way that, you know, that colonial aspect of residential schools and the trauma that has been wrought on the Indigenous population through that violence. And you can understand how there is a different relationship between some Indigenous populations in the interaction with White European settlers and colonists and Black European settlers and colonists like we are. I mean, and you know, there's a dialogue and a dialectic that you have to think about.

  Dr. Kwame McKenzie: [00:16:11] But we discount the impact of racism, the impact of the transatlantic slave trade, and the impact of the legacy of the transatlantic slave trade, and also the impacts of the lies. And so Canada, like everybody else at at that time, was in North America, was part of the slave trade. There were fewer slaves in Canada. Canada didn't have big plantations, but it was part of that whole trade. And it was part of that whole trade, but made laws in the 1780s and 1790s, which were sort of earlier than other people with regards to. And first of all, I think it was Upper Canada, so it would have been Ontario, was one of the first places to outlaw the slave trade, though they didn't free slaves, but they outlawed the slave trade. And that was how the sort of the underground railway started. And I think Canada plays on that, sort of, 30 to 50 years when there was a difference between what was happening south of the border and what was happening north of the border. And we produce this narrative that slavery wasn't here and slavery was different in Canada. And it probably was, for about one eighth of the whole time, you know, between the 16th and 19th century, there's 350 years of slavery. There may be 30 to 50 years where it was a bit different. But apart from that, it was the same thing. And that sort of continual retelling of history is a bit problematic.

  Dr. Kwame McKenzie: [00:18:20] And then, of course, we don't think about the fact that there were whole structures that were set up to keep slaves in their places. So, one parent families and things like that were organised in that way and people were moved around so that there wasn't tight family units that would be strong. And then there's been a reaction to all of those. There's been a reaction to all of that, which plays itself out in Black communities, but also in the reaction of White communities to Black communities. And so that interaction between Black patients and White staff is a sensitive interaction. And understanding, you know, understanding a bit of what might be going on at various levels, at deep psychological levels, as well as present day issues that are coming up with regards to disparities, is quite important. And it's difficult, because the easiest thing and what everybody wants is a cookbook. Tell me what I need to know in order to, you know, work with Black patients, you know, and that's not how things work, because in every other part of medicine, you have to take in information, you have to understand it, and then you have to be a humble human being that's trying to work out what's going on in that particular interaction, which can be anything from somebody for whom Blackness isn't a particular issue to somebody who it's a real issue.

  Dr. Kwame McKenzie: [00:20:22] And you have to have that in the back of your mind. But it can't then become a dominant stereotype that produces inauthentic interaction with your patients, because that's like, you know, that would be a mess. It would be like me deciding that I'm going to be "down with the youth" and wear a baseball cap. And everybody would laugh at me. But back to your question. There is no excuse for me not knowing anything about Indigenous populations. I'm here, in Canada. There is no excuse for a doctor who works in Canada not to know about the history of different Canadian people. That is the basic, whether you're a doctor, whether a human being, you relate to other people, people are part of your community, so know about them. It's just respect, right?

  Dr. Alex Raben: [00:21:25] Yeah. I like your last point there about just having it being an issue of basic respect, not even talking about medicine, but as a citizen of the country. But then, you know, as professionals, as clinicians, we're in the business of people. And just like we're expected as physicians to, you know, know how to take a blood pressure and know what the ranges are on that... what you're saying is that we should have a similar expectation to know something about the people we're treating and the histories there.

  Dr. Kwame McKenzie: [00:22:04] And, like, oh, sorry, Alex. I'm doing exactly what I said I wouldn't do, I'm talking over you!

  Dr. Alex Raben: [00:22:11] That's okay. Go ahead!

  Dr. Kwame McKenzie: [00:22:12] So, you know, there are always tools and structures that help you with these sorts of things. And one of the things, you know, when you're looking in DSM-5, they've got the cultural formulation interview. And the cultural formulation interview basically says, let's start an interview by trying to work out what your location is with regards to how you think of an illness, how you know, what the culture is around the illness, who you think should be treating the illness, whether you think you'll get better, and whether you think I'm the right person who should be here. And the reason why people go into that sort of conversation isn't because you get these concrete answers that tell you everything you need to know, but it gives you a structure to start an interview from a different place, that starts saying, you know, I actually want to know who you are and how you think and what's important to you. And, you know, the cultural formulation, plus a good social history, gives you an idea of what's going on and how an interview can run and what the sensitivities are in the interview. You're not going to get, in the first interview, anywhere near somebody taking down their guide about racism. But it starts an interview in a way that allows for a better balance to a discussion, and more humility in the interview, which then allows you to get to different places. And you've got to open the door to be able to ever hear about people's trauma. Because everybody is going to protect themselves, right?

  Dr. Alex Raben: [00:24:04] Yeah. I mean, I was going to save this point for a little bit later in the interview, but since you've brought it up, I'll bring it up now, because we're talking now a bit more about how, as individual practitioners, we can be with people in a way that's culturally sensitive, competent, safe — to use some of the the buzzwords that we use in terms of the language around that. And to your point about people letting their guard down. So, I've become more intentional, I think, as I've gotten more experienced about asking about racism directly, that's been my strategy recently. But I've noticed that actually, frequently I get fairly neutral answers to that question, or patients I'm speaking to want to move on from that topic. And I'm wondering, and I'm guessing now it's maybe because of this guard. Maybe, Kwame, you could speak more to that. What advice would you give me, in terms of, and for our listeners, in terms of broaching this topic? Because I guess in my mind, I see it as something we could be more proactive about, and that's why I was using that strategy.

  Dr. Kwame McKenzie: [00:25:28] The question I would ask is, to what end? To what end are you asking that question? So, is it that you are trying to look at people's socioeconomic situation and you're trying to find ways of decreasing barriers? Is it that you're trying to work out where the traumas are? Is it that you're trying to develop a rapport? And it depends what you're trying to do, as to how you broach the subject. And that then gives you an indication about whether they're ever going to answer that question to you. Because most people do not let their guard down unless it's going to help them in some ways. You know, and if you're not the person who's actually going to help them, then what is the point of going through the trauma of having to explain X, Y, and Z to this person? You know, to what end am I doing this? Is this just, are they just curious? And they're just asking? Are they just going to put it down in a chart? To what end am I doing this? So I think it's like anything, it's like any other problem or trauma or whatever. If you're just collecting the information to be able to say, I've got the information, then I think you'd expect a relatively low yield of that question, right?

  [00:27:10] If, say, for instance, you've got somebody who you, you know, you're going to send for CBT, and you're saying to them, listen, I'm going to send you to CBT, and we've got different sorts of therapists who specialise in different things, and we have some people who — if you have, and there are those people in Toronto, at least, and I know there are the same people in Nova Scotia and there are people in Quebec — who specialise in CBT, taking an anti-racism approach. You know, you might say, well listen, I'm trying to work out who I'm referring you to. You know, I know this is difficult, but is this an issue for you with regards to where you're being referred? And then you might get a whole bunch of stuff that comes out because there's actually some utility to that for somebody. Similarly, if you're going to have that question and you're asking about police interactions, the question is, what's the utility? And it may be that you're talking about trying to set up a safer community response that tries to keep the police out of the way. And, you know, if you know that somebody has got experience of bad interactions with the police, you'd have to think really twice about a community treatment order because, you know, you're setting them up to have interactions with the police because that's the whole point of it.

  Dr. Kwame McKenzie: [00:28:49] So I think, if it's gratuitous and you're just asking the question because you want to know, then expect low yield. If there's actually a reason for knowing about this and you're saying, say, for instance, you're saying, well, you know, I really don't understand what's going on. I'm trying to make a diagnosis. I don't know whether this is depression, anxiety, or whether this is an adjustment reaction because there are specific traumas and there are traumas, like blah, blah, blah that are happening. You know, I'm trying to work out what's going on, because that's going to change how we treat you. Then I think you'll find that people will start talking. But if it's gratuitous...

  Dr. Kwame McKenzie: [00:29:35] One of the things I used to, when I was in the emergency department and you're looking over the notes that people write, you know, they'd start off with a description of the, of the patient and the patient would say, you know, a middle aged Black man who looks younger than his age or whatever. And I'd say to them, why did you write that? And they say, well, we describe the patient. And I say, okay. So you think the fact that the person's middle aged is important? Yes, because that changes what we might decide with regards to diagnoses and risk and blah, blah, blah. Do you think the fact that he looks younger than his age is important? Well, that's sort of descriptive, and blah, blah, blah, and it's helpful. And, so you think the fact that the person is Black is important? And they say, what do you mean? I said, well, you put it there, so it must be a very important thing. And, surprisingly, most people don't could not answer why they wrote it, apart from the fact that it is written, and then it's part of the notes, and then it's always part of the notes. But what it also does is it gives a signal. And the question is, what signal is it trying to portray in psychiatry? Not saying that it shouldn't be there... but the question I ask people is, what is that communication? Now, is the fact that this person is Black really important in this situation, yes or no? I mean, and it was interesting, just having that discussion, actually starts people thinking, yeah, it was important that he was Black. And you say, why? And often, we couldn't answer it, apart from race is so important that when somebody is walking down the road towards you, the first thing you notice is, you know, psychologically, is whether they're a man or a woman. The second thing is their race. And the third thing is whether they're a child or not.

  Dr. Kwame McKenzie: [00:31:59] And that's how important it is. But why? And actually, when you start asking yourself why, is when you get into some self discovery. And that self discovery, I think, is important for producing equitable care. And people always think that it's the dialectic that's important, or it's the race of the other person that's important. But, actually, it's our own biases that are incredibly important. Did you see the paper in, I think it was in the New England Journal this year? They did a simple paper on the survival of children in ICU, of high risk children. So ICU type children in born to Black women in the States. And they simply said, we're just looking at survival rates. And the survival rates varied. If the doctor looking after the child was Black, the survival rates were much higher than if they were white. Much higher. And when you look to the actual, it's not clear that the white doctors were not following the protocol. Look, it looks like they were following protocols, but somehow the care that they were getting from the Black doctors was better and the outcomes were better. And it was a it was life or death. And that is not that is about that extra thing that we all do when we identify with people and we think it's important and we go that extra mile to take a better history and to better tests and we're on top of things and blah, blah, blah.

  Dr. Kwame McKenzie: [00:34:06] It's that extra bit on top of the protocol. Yes, there are places where you see that people are getting worse care because there's neglect, but often they're getting worse care because one of the worst things that can happen in an hospital. Is if everybody works only to their contract. If the whole of the hospital and I mean, you'll know this Anita is a social worker if you just did the hours you were given to do. The whole thing grinds to a halt as a resident. You know that. Alex And unfortunately, Rebecca, you'll see this more and more as you get out of med school, that if you just did the job you were supposed to be doing, the whole system stops working and the quality of care is hugely different if you you are dependent on that extra you give. So if you study after study in the states in emergency departments, mental health and emergency departments have looked at Black patients and white patients and emergency doctors spend more time with white patients and Black patients, the interviews are longer. There's more information. Outcomes are better. Protocols followed the same with both people. And that's about. Sort of what we care about and the internalised disparities, the internalised racism and that we have.

  Dr. Alex Raben: [00:35:45] Right. And jumping off of that last point you make, it sounds like there are the discrepancies within the system. The health system can be rather subtle, right? The protocols can seem like they're being followed in an equal way, but there can still be quite a lot of room there for disparities that happen. Maybe more. Interpersonally and what have you. I'm wondering if maybe now's a good time to turn more towards the mental health question specifically and explore that landscape a bit more. What does the mental health of the Black population in Canada look like? What are the outcomes? What are the disparities there? And Rebecca, I know you had looked into this question, so maybe I'll hand it over to you.

  Anita Corsini: [00:36:36] Yeah, I did. I did see in my reading some disparities, particularly in the prevalence of some mental illnesses such as schizophrenia, as well as the burden of disease for those who are Black compared to those who are white in terms of the chronicity, the severity response to treatment. And interestingly, these weren't necessarily reported in the countries of origin of these groups, but rather where where white people are the majority. So I think reading about this, I guess my question to you, Kwame, would be what's what's the relationship between racism and mental health?

  Dr. Kwame McKenzie: [00:37:30] Last time I looked. And there were about. 500 peer reviewed good studies that were looking at the relationship between perceived racism. And health and mental health outcomes. And a lot of them were mental health outcomes. And they were split into mental health. So you're looking at stress and depression scores and the others, and then you're looking at mental illness and you're looking at diagnosed schizophrenia, diagnosed depression, diagnosed anxiety. And the groups have done various meta analyses. And the meta analyses are complex, but they essentially show that if that perceived racism increases your risk of mental health problems and also mental disorders and. Even the mental disorders that people have sort of talked about as being more biological. And increasingly, everybody realises that your biology is in an interaction with your environment and and therefore you can increase your risk of sort of a more biological illness from what happens in the social space. And racism increases the rates of physical, biological, as well as psychological problems. Think of if you were thinking just of the normal sort of thing of anxiety and allostatic load, you'd be thinking, well, okay, you don't get a job that makes you upset and increases your stress and therefore increases your risk of a number of different types of mental health problems. Because we know there are a lot of things that are linked to stress. Then if you think, okay, well, you've got that first stress, which is I didn't get the job.

  Dr. Kwame McKenzie: [00:39:43] And then on top of that, you start thinking, hey, well, just a second, that was unfair. But we've got a model in our mind that fairness is really important and that unfairness increases the level of stress now. So you don't go and get the I didn't get the job. You then get more stress because I didn't get the job and this was unfair. And then if you can't do anything about it, you get higher stress still. So this is unfair. You know, I didn't get the job. It's unfair and I can't do anything about it. And that multiplier effect on stress is what makes sort of racism stress sort of so pernicious. But on top of that, in Canada and in a lot of high income countries, it happens on a backdrop of. An increased likelihood of socio economic issues such as financial insecurity, the Black population or the one of the most food insecure populations in Canada, 28%. Increased rates of children being in care, increased rates of of of precarious housing and then sort of poorer housing in sometimes more dangerous areas. And when people talk about dangerous areas, they always think about gun violence. They forget police violence and they forgot they forget racist violence. Right. So. All of these stresses are happening on top of existing sociodemographic issues and social stresses, which means that that racism stress.

  Dr. Kwame McKenzie: [00:41:43] That multiplies even more. And the truth about the Black population and its mental health. These. If you just went with the numbers, there should be many more mental health problems than there are. But that history of having to deal with adversity has made the population much more resilient than other populations. But still, we've still got in Ontario 60% increase with regards to. With regards to psychosis, we have increased rates of depression. We have increased rates of anxiety both here and also in the in erm in the US for the Black population and a lot of trauma and chronic trauma, so complex PTSD. So we see this whole gamut of mental health problems that are happening in the Black populate Black populations. Not every Black person. Mental health problems are a minority issue, not a majority issue, but significant. But here's one thing that most people don't know. We have increased risk of illness, but in Ontario we spend 30% less per head of per head of population on mental health services for the Black population compared to the white population. And you know, what I was saying before is this idea of. When you see disparities and you do nothing about them. So this is so high risk, high risk, low service. And then we get surprised that we see a whole bunch of people end up in the prison justice system.

  Dr. Alex Raben: [00:43:42] I was just going to say what I really liked about that answer is because we often talk about in psychiatry, education, formulating patients and the importance of the bio psycho social cultural model. And I think we touched on actually aspects of that of all of those things. You touched on it, Kwame, in your answer, because there is the biology, you know, the illnesses we think of as biological that aren't completely biological, of course, like schizophrenia being one of them that has a biological component. But then you also have the psychological impacts of racism in whatever form it's taking. And then the social piece, right. The social determinants of health, which we know on a population level that the Black population has more struggles with respect to that, more potential social determinants of health that impact on them. And then of course, that cultural is wrapped around all of that. But where am I going with this is the better question. I guess what I'm what?

  Dr. Kwame McKenzie: [00:44:46] Alex One of the things that I just wanted to say from that, if find out where you're going with it, the we always forget. That the social and the biological are linked. So when we're talking about stress, stress has a psychological, social and biological substrate. So, yes, you can get high blood pressure. Yes. Your kidneys may not work as well. But, yes, on top of that, your immune system isn't going to work so well. Okay. So your immune system changes and there are t cell changes and various other changes that happen because of chronic stress. And they also are more likely because of chronic stress, because of socio socioeconomic issues. Right. So these things that happen in society can change our biology. And when we're looking at things like inflammation, neurogenesis, things that we think are important increasingly in the aetiology of disease, we can see how the social can end up being biological, how the biological can then inform the social, and that we can, unless we break the cycle and see what we can do socially, we can set populations up for disparities, that we can then turn back on them and say, well, it was just genetic. But most of the things we think of genetic are actually epigenetic and they are influenced by society and the response to them isn't genetic. The response is to go upstream and to be social.

  Dr. Alex Raben: [00:46:42] Right. Right. And you actually, you've brought me back to where I was hoping to go with that piece there, which is I mean, first of all, I think that makes a lot of sense that we think about the biopsychosocial model often separately. I think for learners, it's helpful to make those arbitrary distinctions in terms of categories, but we need to be careful that actually they're all interrelated and something that's actually social can be mimic or seem biological, and we need to be aware and mindful of that. Speaking of the social, this is where I was hoping to go is where how do we tackle things upstream? What what work is left for us to do in Canada and in the mental health care system to start to close these gaps? These disparities have a more equitable system.

  Dr. Kwame McKenzie: [00:47:36] So I think there are a few things that are say, let's just think about the mental health system and how you'd produce equity of care. So equity of care is partly and when I'm talking about equity, I'm talking about differences and disparities that can be changed. And if we're thinking and that's where we're going to inequity, some things, maybe you're not going to be able to change, but a lot a lot of things you can and some of them are down to the social determinants of health. And so, you know, it's housing, it's income disparities, it's education, it's a prison justice system. It's laws around racism and cultural safety. It's all of those things that you've got to think about. And those are things that if we want our treatments to work, we need to have a some thought about. So often mental health systems start thinking about supportive housing. They used to think about supportive jobs and income, and we all think about getting people on DSP, but we don't think about advocating so that our benefit systems are Rdsp is the the Ontario benefit, but it's the same. All you know, there are benefits for every province, but we don't advocate for that to actually be at a level where people can thrive. We actually just allow it to be for our most seriously ill people to live in poverty. And that's okay. Actually, there's a responsibility to be doing that, to be actually saying, well, actually we need to do something about the social determinants of health because you don't get recovery without dealing with that.

  Dr. Kwame McKenzie: [00:49:28] And disproportionately. Black patients have negative social determinants of health. So the generally looking at social determinants of health and focusing on the social determinants of health for Black patients will increase our will improve our outcomes. But we have to do that. And that doesn't mean every doctor necessarily has to do that. But as a system, we need to use our lever as doctors to make sure that we give people the best opportunity for access to care and outcome. On the mental health system side. Usually when we're thinking about health equity for racialized populations and definitely for the Black population, we're talking about having culturally capable or culturally competent practitioners with culturally capable and equity in outcomes because of having interventions that work equitably for different populations and then nested within a system of care that allows equal access to care and supports people so that they have equal opportunities for recovery. And we tend not to do any of that. We might do something like this to try and upskill people, to be able to offer culturally appropriate, culturally capable care at an individual level. We tend not to culturally adapt our interventions to make sure they work equally for different populations. And we know things like CBT. If you culturally adapt them, you get better care.

  Dr. Kwame McKenzie: [00:51:29] If you don't, then there are populations that don't do so well. But it's the same for child services. It's the same for it's the same for old age services. And we tend not to go to the next stage, even if we do those things is to say, how can we ensure that people have equity of access to services and how can we make sure that we do the work to make sure that the system supports them in recovery? It's all of that stuff. This idea of vertical equity and horizontal equity. Horizontal equity is people with the same problems and the same needs get the same treatment. We don't do that. And vertical equity is that people with different levels of need get different levels of treatment. We don't do that for the Black population. And so we've got to structure social determinants, improve and also improve psychiatry. We've got an equity issue with regards to identifying need and giving services to people most need, and we don't do it. And then we're surprised that we get differential outcomes. All of the information on how to do this is all available. There are Canadian studies. The Mental Health Commission have lots on its website, but the true problem we have is that as a profession, we choose not to do it. And that's why communities will turn around and say that as a profession we have a racist profession because they'll say the information there.

  Dr. Kwame McKenzie: [00:53:14] But we choose not to do it. And that's that is increasingly with Black Lives Matter and with all of the other things that are happening in society, that's increasingly the problem. I'll tell you a joke. There is a joke that goes around policy circles, which is why did the Canadian policy adviser cross the road? And the answer is to get to the middle. Right. And the truth is, in the past, that was a really completely fine and decent, pretty Canadian outcome. Yeah. But we've now reached a position in society. Where if you sit in the middle. It's not good enough for a lot of people. So if you sit on the fence around me, too, you're part of the problem. If you sit on the fence about reconciliation, you are part of the problem. And if you sit on the fence around anti-Black racism, you are considered part of the problem. Your people are increasingly saying if you are not with us, you are definitely against us. And I think it's a pivotal moment for psychiatry to start thinking about these things because we will be viewed through that lens. And if we are not clearly thinking about anti-Black racism and what that means for changes and significant changes in psychiatry, we will be considered to be part of the problem and that we we can't cross the road to be in the middle anymore. It's not possible.

  Dr. Alex Raben: [00:55:15] Right. And it goes back to, I think what we were talking about earlier, where racism can take the form of inaction or neglect. Especially when faced with the stark data that we've been discussing around the disparities. I wonder, can we come? Can you help us in our listeners understand that? In a concrete example, you've talked about adapting CBT for different cultures and that being an important step that practitioners can take. You also pointed out that it's not readily readily available, and I've actually had no experience with that in my training. So I'm wondering, can you help us understand what that looks like and can we take lessons from that and apply it to our other areas of clinical work?

  Dr. Kwame McKenzie: [00:56:05] There are very few things in psychiatry that have such a evidence base and are just neglected. And so last time I looked and this was a few years ago, there are about 400,000 people who've been in studies of culturally adapted CBT places like the London School of Hygiene and Tropical Medicine in the UK have even produced manuals of how you culturally adapt CBT. About ten years ago, something like that may be a little less and it can produced manuals of culturally adapted CBT for the Caribbean origin population, for the African origin population, and for the Spanish speaking populations of Toronto and the Caribbean and Africa. African one was picked up by women's health in women's hands, and they have seen hundreds of people and women's health in women's hands as a community health centre, and they've seen hundreds of people. Not only have they seen hundreds of people if you were a resident. Working in the emergency department at the Centre for Addiction and Mental Health. You used to see lots of Black women coming in with trauma, history histories, anxiety and depression from the Women's Health and Women's Community Health Centre. Once they started training, everybody in culturally adapted CBT, they managed to get those numbers down to a trickle, literally a trickle and all culturally adapted.

  Dr. Kwame McKenzie: [00:57:52] Cbt does, it says that spine of CBT of how we do treatment and how treatment works, that stays the same. You don't have to adapt that. You don't have to take away the fact that you are doing cognitive work and behavioural work and you don't have to take away the fact that you're going to do it over a certain number of sessions. That's straightforward. The question is, are there things about that that will make it more accessible? And the things that you tend to look at is the illness models that use the words that you use around the illness models. The examples are there Black people in the examples? Are you talking about somebody who who works in a bank or an office when most of the people you're going to come across are not going to do that? Are you going to start calling things home? Work in the Black communities that we work with in Toronto really hated the idea of it being called home work, journaling, Fine homework. No way. Right. And then are you when you're doing your CBT, going to ask people who you know Black and are hard pressed to do homework? Are you going to have to think about your model? The other thing was we for that culture that CBT for the Black population, there was an extra introductory meeting.

  Dr. Kwame McKenzie: [00:59:30] And that meeting was about CBT. It was about worries about CBT. It was about trying to introduce yourself as a therapist and getting people on the right page and all of those other things rather than just expecting everybody to to, to know you and like sort of give everything to you. And it was going back to some of the things we said before, Alex, about what you're trying to do in the first interview and what that first interview was actually about making the space. And it was about making the space for people to be able to ask all of the questions and allaying the fears. And it was also about demonstrating that, you know, there was a level of humility. You understood where they were coming from and that you were open to doing things differently if need be. And so it's all of the stuff around therapy doing it during the day. They're doing it right. Is it individual? Is it group? What do people like? You know, and all of these things when you put them together? You can change your outcomes by ten 15%.

  Dr. Alex Raben: [01:00:47] So many common themes throughout this this talk we're having, it's very helpful to hear how the CBT has adapted, that it's not necessarily changing the core therapeutic principles, but it's about making things more accessible, understanding the person in front of you, which are kind of hallmarks of psychiatry in general. And yet, as you point out, we're still not doing this stuff. There's still that gap. Things being hardwired in that aren't helpful, that aren't equitable. Those are just some of the things that popped up.

  Dr. Kwame McKenzie: [01:01:25] Yeah, no, I agree. And I think part of the part of the issue you have with the commodification of therapy and CBT is an evidence based commodification of therapy. We get a structure, we keep people structure, and because we keep we have that structure, we can replicate it. And that is the model of the Industrial Revolution. That's how it works, right? You get it, you work out how it works. You produce something that is your package and that's your widget and you produce something that everybody else can use and that is the model. Okay, fine. The problem is that if you bake in rigidity to that model, you bake in differential outcomes for people. And so cultural adaptation is just about saying we can understand why we have this model and we can understand that that increases the opportunity for different people to do therapy and for it to reach more people and for it to be demystified and for people who are not psychiatrists to do it. But we do actually have to try and say that that industrial model needs to be changed if we actually want it to work for the population.

  Dr. Alex Raben: [01:02:47] Well well, we did go into some theories there, but I you know, what I really took away from that was a call to action that there's so much we have left to do, both in terms of personal reflection and as reflect and reflecting as a profession as well and as a society. And and that inaction, as we've talked about, is not not acceptable, frankly. I'm just being mindful of the time. We want to respect your time. And so maybe we will end on that note. But we would really like to thank you again for being on the show and providing us with such a rich discussion and stretching our brains today. Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Anita Corsini, Randy Wang, Rebecca marsh and myself, Alex Rabin. This episode was hosted by Anita Corsini, Rebecca marsh and myself. The audio editing was done by Rebecca Marsh. Our theme song is Working Solution by All of Music. A special thanks to the incredible Dr. Kwame McKenzie for serving as our guest expert on this episode. As always, you can contact us at Psych podcast at gmail.com or visit us at Psych podcast. Org. Thanks so much for listening.

PsychEd Episode 28: Newcomer Mental Health with Dr. Lisa Andermann, Dr. Clare Pain, and Norma Hannant

• PsychEd Episode 28: Newcomer Mental Health with Dr. Lisa Andermann, Dr. Clare Pain, and Norma Hannant

  Sarah Hanafi: [00:00:05] Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. In this episode, we're going to be exploring the mental health of immigrants and refugees. I'm Sarah Hanafi. I'm a third-year resident in psychiatry at McGill University and today I'm joined by a lovely group of experts, Doctors Andermann, Pain, as well as Norma Hannant, to teach us about this topic. And I'll maybe give everyone a chance to introduce themselves.

  Dr Lisa Andermann: [00:00:37] Hi, I'm Lisa Andermann. I'm a psychiatrist at University of Toronto and working with immigrants and refugees in two settings: the New Beginnings Clinic at CAMH and also at the Canadian Centre for Victims of Torture. And I also work at Mount Sinai Hospital, where I'm with the Psychological Trauma Clinic, as well as the Ethnocultural Assertive Community Treatment team.

  Dr Claire Pain: [00:01:04] My name is Dr. Clare Pain. I'm a psychiatrist. I work at Mount Sinai with Lisa Andermann, and I work in two settings or perhaps even three settings. Most of the week are Canadian patients who suffer from traumatic disorders. But on Thursdays I work at CCVT and our New Beginnings clinic at CAMH, exclusively with refugees, and I'm also part of the Ethiopian project where we, it's different now with Covid, but we used to send about 100 volunteers a year to partner with Ethiopians to teach into their graduate programs. The first program was psychiatry.

  Norma Hannant: [00:01:49] And I am Norma Hannant. I'm a social worker in the New Beginnings Refugee Clinic at the Centre for Addiction and Mental Health.

  Wiem Sieffien: [00:01:59] Hi. And I'm Wiem Sieffien. I'm a third-year medical student at the University of Toronto.

  Randy Wang: [00:02:05] Hi, I'm Randy and I am also a third year medical student at Uoft.

  Sarah Hanafi: [00:02:10] So we're very excited to be joined by the team today and over the course of this episode we'll be covering a number of learning objectives. So first, to explore the social, political and legal context of refugees and immigrants presenting with mental health concerns. Second, to appreciate the specific mental health needs of refugee and immigrant populations in Canada. And third, to describe the clinical approach to providing mental health care for this population. Maybe I'll hand it off to to Randy to get us started.

  Randy Wang: [00:02:44] Sure, Sarah. So just a bit of a very quick and dirty primer on immigration patterns in Canada. So immigration first started in the 1600s by British and French settlers, and immigration was really predominantly from Europe until the latter half of the 20th century. And nowadays, approximately 20% of the Canadian population are comprised of immigrants and also more recently, we have more visible minorities who come from China and South Asia. So I am curious to know from our expert panel, how have the changing trends in immigration been reflected in psychiatry practice, and how have healthcare professionals adapted to treating more diverse populations?

  Dr Claire Pain: [00:03:43] I don't know that I personally see a huge difference in the number of people from different countries. For as long as I've been working in the field, which is about 20 years, CCVT Canadian Centre for Victims of Torture have always seen about refugees from about 150 countries.

  Dr Lisa Andermann: [00:04:03] Maybe I'll jump in. I guess it also depends what immigration categories those immigrants or refugees are coming from, because we tend to see in our clinics people who require psychiatric assessments to assist with their refugee process, things that their immigration or refugee lawyer needs to help them prepare for their hearing. So in that case, as Dr. Pain said, we are seeing people from many, many different parts of the world. And as world news and frontline headlines change over time, we tend to see different populations kind of even over the last 10 or 15 years where, you know, now these days we're seeing a lot of people from East Africa, from Nigeria, and in previous years we might have been seeing more people from Colombia or other parts of South America or Mexico. So those are kind of smaller changes that we can see, that doesn't reflect on on a lot of the immigrant population who are coming by choice to Canada and setting up their lives here to go to school, to work and to do all of those other things who may not come under psychiatric observation in any way. So we're seeing a kind of very limited slice of the population. Norma, do you want to add anything?

  Norma Hannant: [00:05:28] Well, I think in terms of, you know, just adapting to like any adaptations to diverse populations, I think also just having, you know, the added benefit within, you know, the New Beginnings clinic as well, to have interpretation services, which I know that that's something that is not readily available in a lot of rural settings. And I know as well, you know, with having IFH coverage and so forth, that can also be a big challenge with a lot of the populations that we see.

  Randy Wang: [00:06:07] Okay, great thank you. And Dr. Andermann, I'm really glad that you brought up the different classes of immigrants, because that's actually the next thing we wanted to ask about. So a bit of background for those who are not familiar with the system. In Canada, we have a few different classes of newcomers, so we have economic immigrants, so those who come to work and then we have immigrants who are sponsored by family and then finally refugees. And these people are defined as those who have suffered from persecution for reasons of race, religion, nationality, membership in particular social groups or political opinion in their home country and the process is actually quite complicated. So in order to qualify for refugee status, they have to make a claim at either port of entry or in IRCC office and then later attend a hearing before the government in the end makes a decision as to whether or not they actually get refugee status. And I know this has been touched on already in some of the answers, but I just really want to hone in on any specific challenges that our experts here have identified in providing care to different classes of newcomers.

  Dr Lisa Andermann: [00:07:37] Well, maybe I'll just start by saying that refugee claimants, the people who arrive here and then make their claim for refugee protection are under an enormous amount of stress. So in in one sense, they may feel a little bit safer than they did when they were back home because they're now in a safe country, but they don't know if they're going to be allowed to remain in that safe country and that waiting period while they get their paperwork in order and find a shelter or rent an apartment and get a lawyer and start to figure out the process of how they're going to be staying here can sometimes take many, many months or even years to wait for that hearing date that we've mentioned, which sometimes gets postponed or there's not enough information the first time or the wrong interpreter came on that day. I mean, they're, you know, very rare people get their answer that they can stay on the actual day of the hearing itself. And so when people are in limbo, that can definitely add to their mental distress and sometimes even worsening of symptoms the longer that people are here waiting for, for the answer about whether they're allowed to stay. In contrast, government assisted refugees, like many of the Syrian refugees that were brought to Canada in 2016/17 and are some are still continuing to come now are brought from refugee camps either in the country where the problems are happening or somewhere next door where they've sought refuge, to Canada. So when they arrive, they have OHIP, they have funding for their first year and so they have a lot easier time seeking health care, finding a family doctor who's going to accept them. Any family doctor technically should be able to accept the IFH or Interim Federal Health funding, but you'd be surprised how many people are reluctant to do that because they're not familiar with it or because they just don't want to do the extra steps it takes to get that paperwork.

  Dr Lisa Andermann: [00:09:39] But these people are entitled to, I mean the refugee claimants with IFH, are entitled to the same health care as as most people who come as government assisted refugees. So for things like obstetrical care, prenatal care, all of those things are are covered. And some mental health care is also very easily covered if you just familiarise yourself with with that system. And then once people become permanent residents, you know, in some ways they know they're here to stay so some of that stress may have dissipated, but then there may be other stresses of adjustment, of acculturation, of worrying about family members who are left behind and maybe are not able to join their families here in a timely way if and sometimes not at all for various reasons. So there are many other kinds of post-migration stressors that come into play for all three categories of these populations and for immigrants, as well as a fourth category, the people even who choose to come here or even who choose to move from one part of Canada to another and settle in a new province, as some of our learners might do when they graduate from medical school, you know, there are still adjustments. You miss friends, you miss home, you miss the food, you miss, you know, a lot of different things. And there can be a lot of nostalgia and sort of feeling torn between two places, um, that can affect people's mood and mental health as well.

  Randy Wang: [00:11:09] Okay. Thank you, Dr. Andermann. And you just keep reading my mind here, because when you mentioned that, you know, the stress doesn't really end after a specific period of time and even after years, you know, people still experience stressors and different kinds of stressors. That brings me to the next thing I wanted to discuss, which is the healthy migrant effect. So the healthy migrant effect is an observed phenomenon where the health of immigrants starts off as better than that of the average Canadian born person, but it slowly declines with years spent in Canada and after 20 years it actually becomes equivalent to the health of Canadians. And this has typically been explained by the social determinants of health and how they really negatively affect immigrants and refugees. A study by Robert and colleagues in 2012 on 7700 immigrants found that upon four years of arrival, 29% of respondents reported what they called emotional problems such as loneliness, sadness and depression. Such issues were found more commonly in females. They also found that refugees were more likely than other classes of newcomers to suffer from emotional problems. And finally, they found that 16% of respondents reported high levels of stress, mainly due to employment and financial concerns. So my question to our experts would be how have you seen the social determinants of health affect newcomers in your psychiatry practice? And what are some ways we as health care workers can mitigate the negative effects?

  Norma Hannant: [00:13:04] So, you know, I think advocacy is something that can really help many refugees who are experiencing a lot of distress. I know within our work, like even saying something simply as talking about their rights, particularly around legal aid, for example, we have had a lot of clients that have been really terribly misinformed around their rights to have legal aid if they do have limited income. So oftentimes they might be going with someone that they believe they have to pay, which is, you know, spending thousands of dollars and creating so much more financial stress for them. Also, in terms of their right for housing oftentimes we have stepped in to provide some advocacy for clients that are living in refugee shelters and are being pushed into maybe some rural settings where they won't have access to the mental health supports that they truly need that may not be available there or the limited interpretation services that might be that may not be available in more rural settings. And also in terms of being able to find different forms of employment services that can assist them with those barriers of accessing jobs, which is extraordinarily challenging if you don't have any Canadian experience.

  Dr Claire Pain: [00:14:34] You started talking about the healthy migrant effect. It's hard to know, but certainly with the refugee population, it seems that really in order to get to Canada, to work your way through the bureaucracy, the complexity, the danger, the language barrier, you have to be a remarkable person or family, and that may be a kind of bias. So we see refugees anyway who are healthier than the normal population. They may have had hard lives, but they are future directed, hardworking people. I think I'm going to bring my bias in here, what I've learned. So all my population from when I graduated in 1992 were always trauma patients who were Canadians, who weren't immigrants or refugees. And then I started working with refugees and what I realised is, and the literature bears this out, that if you have a childhood where your family respected you and cherished you, whatever happens later as an adult is far less difficult than if you've had a very compromised childhood. I'm not saying that things that happen to adults from good families or well loved children don't struggle and suffer. But there's quite a difference. And I think that the people who come here often are people who have that confidence and that daring to jump into an unknown future. We're always talking about refugee pathology and really the most important thing is to see these people as the true, remarkable new Canadians, if we can help them stay that they are and they enormously contribute to our country. I'm not sure it's pills, therapy and programs. It's more like the individual encounter matters more than one can possibly imagine.

  Sarah Hanafi: [00:16:33] I thought that was a really refreshing perspective Dr Pain. I know you know myself, the few patients that I've had the privilege of working with and who are coming from these sorts of experiences, I've certainly been struck by the resilience that they show and I think it maybe challenges us. You know, as you say, we're so stuck on finding pathology, but maybe it challenges us to to work on being promoters of resilience and really looking to to highlight and support individuals and allowing them to kind of reconstitute in the face of what's really remarkable adversity that they face when they are coming to Canada and having to go through this arduous process of, in the case of at least refugee claimants can be a very long period of uncertainty. I think also the point you make regarding the hearing and the challenges around that and the the value sometimes that even having a report from a psychiatrist, I think that'll be an interesting point to touch on maybe later around what's the role that professionals can play in being more of an advocate, whether it's other kind of multidisciplinary team members like a social worker or a psychiatrist in terms of recommendations surrounding their hearing. But it certainly challenges us to work, I think, in different ways.

  Dr Lisa Andermann: [00:17:58] Yeah. I have another example I can add to that and I agree with everything that Clare and Norma have shared already. You know, it's very hard to separate the topic of social determinants of health from this healthy immigrant effect because, you know, when people come and their expectations are high that the future is going to be bright here and then they may find themselves unemployed, their credentials unrecognised, unable to achieve the kind of things that they did back home or having to retrain or work overnight factory shifts and PSW jobs exposed to Covid and all these other things. The unhealthy diet that comes with that, the poverty, the the housing stresses, you know, make it very difficult to achieve a sense of wellness, even if the goal of being now established in Canada is met. And there are also a lot of pressures to maybe support family members back home and send money back even from, you know, the pittance of OW or even ODSP to scrape together children's tuition fees when single parents are here on their own and supporting family members can be very, very difficult. So the one example I wanted to share was of a woman who had been in detention in her country. She had had some experiences in jail that were very traumatising and then here in Toronto, the only place she could afford to live in was a basement apartment with no windows, which was hugely re-traumatising for her. And she's referred to me as a psychiatrist, of course she has PTSD symptoms, of course she has nightmares and re-experiencing when really we have to work with social workers to get her into a second-floor apartment with a window. You know, it's very important to have this kind of teamwork because she doesn't need Prazosin for nightmares, she needs, you know, a balcony and and fresh air from a window. It's not a medical solution to these kinds of problems.

  Sarah Hanafi: [00:20:04] Maybe on that note, I think it'd be helpful to hear a little bit more about how these patients are typically presenting and the clinical realm. I think Wiem had some questions on that regard.

  Wiem Sieffien: [00:20:15] Yeah. Thank you, Sarah. So I think I wanted to kind of I was a question I asked was kind of what kind of presentations do people from immigrants and refugees and newcomers present with? And I did a little search on that, and I found that the most common mental illnesses in this population are depression, anxiety and PTSD. And what I found actually, that they experience very similar distress to Canadian born individuals but what struck me is that despite having similar levels of distress, they're a lot less likely to seek or be referred to mental health services and that was was very surprising for me. And then I wanted to kind of look more into that. And it seemed to be there's a lot of barriers that this population face that are unique to this population, including some cultural and linguistic barriers as well, and stigma, obviously. So I wanted to ask our panellists here, what type of barriers do you see in your line of practice that prevents people from seeking care?

  Dr Claire Pain: [00:21:15] So this is where we get all muddled up, I think, because people have distress and suffering and then suddenly they're diagnosed with depression, which means pills, admission, therapy in our in our culture. But I think that feelings of depression and as Lisa said, the awful feeling of, for everyone refugee or immigrant, the huge deal is you've lost everything you've ever known and valued, maybe because you have to. But there are enormous amounts of emotions around that and uncertainty about the future. But I think sometimes we over-diagnose, those are legitimate feelings but the treatment may absolutely not be psychiatric as Lisa just said, good settlement services, proper housing, ESL. So again, the great, great privilege of working at the two clinics that we work in is that we have wonderful social workers and settlement counsellors and a huge amount of treatment is not psychiatric. We get the referrals because we're psychiatrists, but the treatment is within the social determinants of health. A non-psychiatric treatment to manage a psychological presentation.

  Dr Lisa Andermann: [00:22:46] Maybe to follow up on on Wiem's barriers to seeking mental health care. You know, I think many of the patients that we see from many parts of the world have no experience of the formal mental health care system, of a psychiatrist, of knowing what a psychiatrist does. And in many parts of the world, you know, where there is psychiatry, it's kind of reserved for the most severely psychotic and maybe behaviourally disturbed kinds of of patients that do exist all around the world in the same percentages as they do, because these are universal diagnoses like schizophrenia, bipolar disorder. We can find them all around the world. Um, but those aren't the kinds of patients that were mostly seeing here. We're seeing regular people who had normal lives and families and got caught up in some kind of, you know, war or terrorist problem or family problem or they're LGBT in a country that doesn't allow LGBT. They're just normal folks who were in the wrong place at the wrong time and had to leave and find safety here. So not people that were ever really going for counselling or knowing what that is. So psychoeducation and explanations about who all of our different roles and what we do is very important and when lawyers send referrals for psychiatric assessments, most of the time the person we're seeing has no idea really why they're coming to see a psychiatrist at all. And so explaining to people a biopsychosocial model of assessment and treatment and including cultural elements to try to understand how people are connected here, what are the stressors and supports that people are connected with or not, you know, making sure everybody has a settlement agency, community support, inquiring about family supports both here and far away, those religious supports are also hugely important to people. And if they're not connected to those things, it's our it's our job to try to help them connect to to some of those things, because that will go a long way to improving their mental health.

  Sarah Hanafi: [00:25:08] It's been very helpful to learn from all of our experts about the unique approach to caring for newcomers with mental health concerns and trying to take more of a resilience-based approach and to think much more broadly in terms of the social context and to work within teams to try and support patients in having access to to necessary services and try to address many of the adversities that they're facing as they're adjusting to their new life in Canada. Now, one thing that we were actually hoping to touch on within the clinical approach is maybe some more practical concerns. So, you know, as as I think, Norma, you mentioned interpretation services is definitely something that can be very hard to come by for some of these patients. For many of them, it can make a huge difference if they're able to express themselves in their mother tongue. And I was wondering if you could all give some a few practical tips for working with interpreters, because I know, at least in my experience, I've seen some huge variation in how people approach this.

  Norma Hannant: [00:26:14] Well, I think one that we try to do within the clinic is always having a professional interpreter and again, we do have the luxury and the funds to be able to provide that. Whether it is I mean, obviously right now regarding Covid, we're not doing any in-person appointments unless it's an emergency situation. But to be able to provide as much, you know, in-person, also asking someone in terms of who they would feel more comfortable with oftentimes as well is to, you know, there have been times where family members will also want to interpret, so really discouraging that letting them know that, you know, they can be part of maybe the the end of an appointment if the client consents to that to be able to add some feedback. But that can add a lot of discomfort for someone who's coming in to tell really personal information about their lives. And also maybe, you know, letting clients know about what it entails to have an interpreter confidentiality, because oftentimes there is a fear that someone is within their community and will be spreading this information to other people. And again, that is a luxury that we have. I know that that is not often the case in smaller settings. And one thing that we've also been able to provide for a lot of clients as well is with Ontario Works, for example. So they will be given an interpreter for the first the initial assessment and then after that, they have to actually find someone. So there has been some pretty difficult circumstances where someone might be isolated and they'll be using their neighbour as their interpreter to find out about very personal financial information about them or someone in their family who they really don't get along with, and they really don't want them to know this specific information but have no one else. So often times we've been able to organise that through our clinic to have an interpreter available for them and coordinate that in our services.

  Sarah Hanafi: [00:28:08] Okay. And I'm wondering actually, you know, because as you mentioned, ideally you want a trained interpreter, but one might not always have access to that and certainly an interpreter that's used to facilitating mental health assessments. I'm wondering what kinds of instructions you might give to interpreters who are participating in an assessment.

  Dr Lisa Andermann: [00:28:31] Well, I think a mental health assessment requires a very careful translation of what the patient's words are, because we pay attention to cadence, rate and rhythm of speech. We want to know about thought process, disorganised thoughts and so we do want to make sure that the interpreter is not inadvertently or trying to help us by cleaning up the way that the patient is speaking, by editing or making things sound more organised than they are. This is especially important when we're trying to rule out a diagnosis of psychosis and then being able to get at the exact words that we're trying to use to find out about perceptions, paranoia, delusions, hallucinations, you know, asking someone, are you hearing voices? You know, can be a very confusing kind of question if it's not translated properly and then translated back to you in English. There's a lot of room for confusion. And on top of that, there are also the whole cultural overlay of what these things mean to that person. If it's part of a religious understanding or if it's part of a kind of cultural understanding of how things work, maybe after a person's died that you may hear their voice, something that could be very normal, but that we could misconstrue as a symptom of mental illness. And so there's another kind of of interpreter, not just the language interpreter, but also getting the advice sometimes of a cultural interpreter who can give us a sense of whether some of these beliefs or behaviours are actually making sense in the person's culture. And so the typical language interpreter may not be comfortable to share their opinion on that. They're there to kind of simply translate what's going on in the session. But it can be very helpful maybe to contact a community agency or a worker from a settlement agency who may know something about where the person's background is from, and to be able to give some idea. I mean, the family can also provide some of that background of whether this person's behaviour or presentation would make sense in their culture and how they would understand it.

  Sarah Hanafi: [00:30:42] So it sounds like, you know, beyond actual interpreters, there's also utility around having cultural brokers to help understand more of that cultural context and the information that's being provided. Um, I think it's really helpful to hear that piece and I'm sure there's also a lot of advocacy that's done by health care workers surrounding access to interpretation services. Um, I've also kind of wondered and had some experiences myself when it comes to advocacy around legal status and immigration status. I know this past year with some of the patients I was working with who were refugee claimants, um, there were requests by, by lawyers to write letters and support for their hearing, as well as recommendations surrounding accommodations to the refugee hearing in light of their symptoms. I was actually hoping to maybe explore some of your experiences around this. Are there any practical tips for how our listeners can effectively advocate for their patients in these circumstances?

  Dr Claire Pain: [00:31:51] All the time one wants to write in a report, "this is the most remarkable person who's been through terrible times, but who's clearly on top of things or who's struggling a bit, but who has every we have no reason to expect they won't find their feet and do well". But you can never write that in a refugee report. If you advocate in any way for a refugee, any good lawyer knows that that's death to the any kind of psychiatric report that will be taken seriously by the system. So it's important to know when not to write down the kinds of things that we might want to. I mean, I think it was mentioned earlier about advocating for housing, advocating for for a bunch of other things. But certainly in a report, it's very important people know that. Sorry there were just two little things I wanted to add to the interpreter thing. One is if you don't have the luxury, as we do of professional volunteers, when you have to work with volunteer interpreters who aren't family, you're often dealing with the same group of people who've suffered torture or imprisonment or. And I think it's worthwhile to always be quite respectful that you may be dealing with somebody whose own family members may have gone through the same thing or they may have. So I think that kind of appropriate checking that they're okay and if they're not, that we can guide them to services or debrief with us. The other thing I mean, Lisa's completely right, cultural brokers are so useful. But sometimes I hope this sounds all right. I found I had a complex woman from the islands and one of my colleagues, dear friend and colleague at work, you know, within the bounds of confidentiality. I said, what does this mean? And he immediately knew. So people who come from a similar culture or community, we all come from somewhere, right? Most of us have roots elsewhere.

  Sarah Hanafi: [00:34:07] No, I think it's helpful to hear how how we also bring in our own lens and our own understanding from our from our personal backgrounds as well as like how do we ensure the safety of all who are involved in the assessment. I wonder, though, like specifically, say, around a hearing and those who might have a trauma history, how like the way in which the hearing is conducted affect like the reliability of the report, if they have certain symptoms related to PTSD, how do you maybe prepare patients for that?

  Dr Lisa Andermann: [00:34:43] I think that kind of gently with reviewing the basis of claim narrative and going through it with people will give you a sense of how they will be able to speak about those events at the hearing. And so it gives you a chance to notice if there are any gaps in the story, if there are times when people need to pause and maybe need extra time to collect themselves, to have a break, to have a glass of water, to to kind of have a support person coming with them to the hearing. Those kinds of things are the sorts of accommodations that you can advocate for and you can also do some psychoeducation to the the hearing to explain that people who've been through trauma and many people have been through more than one event and they may be recounting events, let's say, in the case of somebody who's escaped a situation of domestic violence. There have just been so many incidents like dozens or hundreds of incidents over, you know, the 5 or 10 or 15 years that they've been married and kept in a home, you know, where so many things happened. You can't possibly remember each event, what day it happened, which time you went to the police station to report it and which time you just, you know cleaned yourself up at home like there are just so many. And to translate that into like a sequential narrative with dates and times is very difficult. So being able to explain that, you know, the way our memory works when there's been a trauma may be, you know, to go into a flashback, when you're talking about a piece of the story that you're not there to remember, Oh, it was two men in a green car, it might have been five men in a black car. Like your life was in danger, it wasn't about taking in those details and being able to tell them back in the same way, you know, 5 or 10 years later, every time you tell the story, you may tell it a little bit differently depending on the setting, how stressed you are, who's listening, what the information is going to be used for, and and so on. So Doctor Pain had already mentioned something about reliability, and that piece is is very important that people can still have been through lots of difficulties, even if they may not remember exactly specific details. And avoidance is also a big part of coping with trauma. And many people may want to push away or not go to certain places from their past because it's just too too difficult and brings up too much emotion for them. And so they may robotically talk their way through their narrative without showing any emotion, which is also not what you want at the hearing when you're talking about these kinds of things. And on the opposite side, you don't want somebody to be so flooded with with feelings that they can't tell their story at all. So I think the more times people practice and have a bit of exposure, not in the way of exposure therapy, but in the way of just being able to tell their story from beginning to end and kind of get through it and kind of be able to go on from there is is kind of helpful in preparing people for their hearing.

  Dr Claire Pain: [00:37:58] I think that the actual experience of interviewing a patient and and doing the report or working with them is an opportunity to coach the patient. Insofar as I find myself saying, "you're doing a very nice job with me, you're so respectful, you have great eye contact. If you can just focus on the question I ask you because it's like practice for the judge. I know you want to tell your story, which is great. You can tell me anything, but right now, practice". So you kind of work with a patient and let them know, the judge may ask you about your assault, they may ask you, "do you feel able to say it?" Because if you don't just say, I'm so sorry, I can't. It's like coaching people to be not advocates for themselves but feel empowered to not let the hearing get away on them. That they can pause, have a sip of water and focus on the questions. But knowing what's in store is enormously helpful.

  Sarah Hanafi: [00:39:05] Sounds like a lot of that anticipatory guidance can really be a huge support to patients as they prepare for undergoing this process.

  Dr Lisa Andermann: [00:39:14] There are opportunities to visit the hearing venue when when we're not in Covid and hearings are taking place in real time and a lot of claimants don't know about that. So there are community agencies that will take you for a tour and you get to see the room while it's empty and figure out where you're going to sit and where the judge sits. And that can be very helpful in reducing some people's anxiety.

  Wiem Sieffien: [00:39:37] Thank you so much. These were very great tips. And I think for me as a medical student, I learned a lot during this time. I think, although I thought I prepared for the episode, but I learned so much from all the experts. And I want to thank you all. I think just to kind of just summarise or to wrap up, what are some take home messages or final words that you want to make sure our audience leave this episode with.

  Norma Hannant: [00:40:02] For me as a social worker, when I started working at New Beginnings, I assumed that a big portion of my job was going to be involving processing people's traumas, and I was nicely surprised to learn that that was actually something that people really didn't feel that they needed at the beginning of their process of settling into a new country. Right. That might be something that they're interested in doing years from now, but there's also different forms of doing it and the having connection to their communities, finding spiritual and religious communities that they're connected with, being able to find housing, getting a good lawyer, going to ESL classes. Those are the things that, for me, I really learned in terms of being able to help them to reduce the distress of all of these huge shifts coming to a new country.

  Dr Lisa Andermann: [00:41:04] I would add that this work is very, very rewarding. It might sound challenging, it might sound intimidating writing reports for lawyers, but refugees are an amazing population to to work with. We learn new things every day about every corner of the world and people's resilience and what's important to them and what keeps them going. It's just very rewarding. And when people come back with good news that they've passed their hearing or you're able to do an assessment and write a letter that prevents somebody from being deported and they're allowed to stay after ten years of limbo, you know, nothing beats that.

  Dr Claire Pain: [00:41:44] Yeah, I agree. I think I actually think this is advice for all of us with patients, but in particular with refugees. It's like they're, as Lisa said, they're ordinary people, they're ordinary folk caught up in bad situations who've managed to flee for their lives successfully to find safety in Canada and then cross the next hurdle, which is to be accepted here. So I think that one of the reasons I love working with refugees is I'm a learner. Like, how did you do that? Well, what was the worst thing about? How did you overcome it? Where did you find support or guidance? You know, it's like I will never, thank God, have to do what they've done. So I'm in this wonderful situation where I can actually respectfully understand more from someone who has first-hand experience about resilience, about and it helps me understand what about human beings we need to focus on and support.

  Sarah Hanafi: [00:42:48] Thank you all so much. We're very privileged to have had your time for you to be able to share this this expertise with our audience. So once again, we wanted to thank Norma Hannant, Dr. Lisa Andermann and Dr. Claire Pain. You've been wonderful and we're really excited to share this episode with our audience. We also want to thank you all for listening to PsychEd. Feel free to contact us on Twitter @Psychedpodcast or check us out on psychedpodcast.org. We love hearing from you and your feedback and your questions are vital to the podcast. Take care.

  Sarah Hanafi: [00:43:23] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. The episode was hosted by Wiem Sieffien, Randy Wang and Dr. Sarah Hanafi. Audio Editing by Randy Wang. Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible guests Dr. Lisa Andermann, Dr. Claire Pain and Norma Hammant for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at Psychedpodcast.org. Thank you so much for listening.

  Wiem Sieffien: [00:44:19] I was always interested in immigrant and refugee mental health, and I had the opportunity to take the Immigrant and Refugee Mental Health Project's online course, which is a free self-directed training course that is offered by the Centre for Addiction and Mental Health. It was a great learning experience. It provided me with a comprehensive overview of immigrant and refugee mental health, some of the key principles, and I learned a lot about the influence of cultural on mental health and mental illness. I also learned some great tools and resources to help me in my clinical training, which I really found helpful during my clerkship. I would highly recommend this course and the link will be posted in the show notes, so I recommend checking it out.

Episode 56: Understanding Trauma and Addictions with Dr. Gabor Mate

• Episode 56: Understanding Trauma and Addictions with Dr. Gabor Mate

  Nikhita Singhal: [00:00:14] Welcome to Site the Psychiatry Podcast for Medical Learners Biomedical Learners. This episode covers trauma and addictions. My name is Nikhita and I'm a fourth year psychiatry resident here at the University of Toronto. I'll be one of the co-hosts for this episode. I'm joined by my colleagues who I'll let introduce themselves.

  Angad Singh: [00:00:35] Hi, my name is Angad. I'm a second year medical student at McMaster.

  Sena Gok: [00:00:39] Hi, I'm Sena. I'm an international medical graduate from Turkey.

  Rhys Linthorst: [00:00:43] And I'm Reece Linthorst, a fourth year psychiatry resident at the University of Manitoba.

  Nikhita Singhal: [00:00:47] We're thrilled to be welcoming our guest for this episode, Dr. Gabor Mate, a retired physician who, after 20 years of family practice and palliative care experience, worked for over a decade in Vancouver's downtown east Side, with patients challenged by drug addiction and mental illness. The bestselling author of five books published in 30 languages, including the award Winning in the Realm of Hungry Ghosts Close Encounters With Addiction. Dr. Mat is an internationally renowned speaker, highly sought after for his expertise on addiction, trauma, childhood development and the relationship of stress and illness. For his ground breaking medical work and writing, he has been awarded the Order of Canada, our country's highest civilian distinction, and the Civic Merit Award from his hometown, Vancouver. His fifth book, The Myth of Normal Trauma, Illness and Healing in a Toxic Culture, was released on September 13th, 2022.

  Rhys Linthorst: [00:01:43] Maybe when. Next? We'll talk a little bit about our learning objectives. So the learning objectives today are as follows. By the end of this episode, the listener will be able to, number one, understand the connection between trauma and the development of addictions and other mental illnesses. Number two, critically reflect on current diagnostic and treatment paradigms. And number three, apply principles of trauma, informed care to psychiatric assessment and provision of mental health services. Next, we'll maybe turn things over to Sienna to get our discussion started.

  Sena Gok: [00:02:11] Thank you so much, Chris. Doctor Matt, could we start off with how would you define trauma?

  Dr Gabor Maté: [00:02:17] Sure. So trauma is one of these words that like the word God, everybody uses, it has a different meaning for it. So it is important to begin with the definition. So the way I'll be using it in this context, trauma means a wound. In fact, wound is the Greek origin of the word trauma. It literally means a wound or a wounding. It's a psychological wound that we sustain at some point in our lives, in my view, most frequently in childhood. And unless it's healed, it has all kinds of consequences for physical and mental health, including what we call mental health diagnoses and addictions. But in my view, it's also shows up in its manifestations in autoimmune disease and malignancy even. That's not a matter of just my opinion. It's scientific research. To give you an example of the latter, who would you say would be the most traumatised segment of the Canadian population? You'd probably agree it's Indigenous women. Indigenous women has six times the rate of rheumatoid arthritis than that of the average population. This is amongst a population that used to have no autoimmune disease prior to colonisation. So I'm saying there's a huge link between trauma and all manner of illness. Um, I'll also say that. Trauma is not what happened to you. Trauma is what happened inside you.

  Dr Gabor Maté: [00:03:45] Trauma is not the blow on the head. It's the concussion that you sustain. Two people can sustain a blow on the head. One of them might not have a concussion at all. They're not wounded. But the other one is. So it's not what happens to you. It's what happens inside you as a result of what happens to you. Number one. And number two, traumatic events can take many forms. Most famously, the adverse childhood experiences ACE studies which, if anybody listening has not heard about that should be your first task tonight is to look them up because they've been published in major medical and psychological journals since the 1990s. They show that the more childhood adversity occurs to an individual, the greater the risk for addiction exponentially, the greater the risk of addiction for mental health problems, for autoimmune disease, malignancy, behavioural problems, sexually transmitted disease and so on. These ACE studies, again, are not in the least controversial. They don't show a causal relationship. They certainly show a statistical relationship. Causation has been shown in many other studies, but adverse childhood experiences include ten categories that originally listed physical, sexual or emotional abuse. That's three. The death of a parent, A parent being jailed. A parent being addicted. A parent being mentally ill. Violence in a family, a rancorous divorce and neglect, to which we have to add some social factors poverty and racism, which are also being shown to have traumatic impacts.

  Dr Gabor Maté: [00:05:29] And those are what we call the big T traumas, the big T traumatic events. What physicians, physicians barely learn about these, at least not until very recently. What they don't learn about at all is that people can be wounded not by these big T traumatic events, not by just the bad things that happen to you, but also by the good things that don't happen to you. So human infants in utero onwards have certain needs. On birth and after birth in early childhood. They have certain emotional needs. If those needs are not met, the child can also be wounded without anything terrible having happened. Which also means that in this culture. Which is so out of alignment with the needs of children. Many kids are wounded in homes where there's nothing but love, nothing but good intention, no abuse, no big T traumas. But children are still wounded because they innate human needs are not being met. So trauma then, is a wound sustained through either through overt misfortune or through. Essential needs not being met. And then for purposes of this conversation, trauma then shows up. In addictions, all addictions and in mental health conditions, in my view, all mental health conditions.

  Angad Singh: [00:06:56] Yeah. Thanks for that definition, Dr. Mate. So I was wondering, beyond the ACE studies, could you speak to the relationship between trauma and addiction and the many ways that they're connected?

  Dr Gabor Maté: [00:07:04] Sure. Now, one of the learning objectives that you outlined was critique of the current model. Let me begin with that. Okay. And then I'll revert back to answering your question directly. Because the because looking at the inadequacies of the current medical model of addiction is essential to then leading into the actual nature of addiction. So in this society, there are two dominant views of addiction. By far the most dominant view, the one that is infused into the legal system, is that addictions and some kind of a choice that somebody makes just through ethical lapse, moral weakness, failure of will. And so people then choose to do drugs. And addiction, by the way, is very much in a social mind associated with drugs. And it's a culpable, conscious, deliberate act. Now, I won't spend any time on it because it's complete nonsense. I've never met anybody who ever chose woke up one morning and decided to become an addict. But that's a dominant view. And that's why, by the way, largely why if you look at the jails of Canada, 50% of the women in jail in this country are indigenous. They make up 5% or 6% of the female population, 50% of the jail population. Because addictions are so widespread in the native communities. A lot of. Actions flow from that and then the people are punished. So that's the legal view. Now, the medical view, which is what concerns us here today, is a step forward.

  Dr Gabor Maté: [00:08:46] The medical view sees addiction as a disease of the brain, primarily a disease of the brain, which affects behaviour and the sources of it, according to the medical view, is largely genetic. So the US Surgeon General, Dr. Vivek Murthy, published the overview of addiction is maybe six years ago now where 50 to 70% or 40 to 70% of addictions are ascribed to genetic tendencies. Now the medical view is a step forward. Markedly so from the popular choice model, because, number one, if somebody is a disease, at least you, you don't blame them for it. And furthermore, especially if the disease is genetically determined or influenced, who can you blame for inheriting certain genes? So it removes blame and shame, at least ideally, ideally, but not in practice, because a lot of physicians still practice shame based medicine when it comes to working with addicts. Just visit any emergency ward when an addict addicted person comes in and how they're treated by the nurses and the doctors. So theoretically, the medical model. Obviates shame and blame in practice. Not like that. But at least theoretically. Secondly, it provides treatment. So if somebody comes to you with rheumatoid arthritis, you'll treat them. That's good. Number three. When somebody relapses with cancer or multiple sclerosis or rheumatoid arthritis, you don't punish them for it. You don't judge them for it. You accept that that's the part of the so-called disease. So you just treat it.

  Dr Gabor Maté: [00:10:33] So these are all steps forward that the medical model offers and they're valuable. But does that mean that they're accurate? No, doesn't mean they're accurate at all. So I'm going to assert for you that addiction is not genetic and it's not a disease. What is it? So we'll do a little test here with our four panellists. I'll ask for your but your honest participation. Maybe I'll draw a blank, but maybe I won't. I'll give you a definition of addiction that I don't think is controversial. And it's the one. Okay. Conflict of interest here, folks. I'm going to mention my books. Okay. So in this book, The Myth of Normal, which is the most recent book that I've written, I gave a definition of addiction. An addiction is a complex, biological, psychological process that is manifested in any behaviour in which a person finds temporary relief or pleasure and therefore craves. But then suffers negative consequences as a result of and cannot give up despite negative consequences or does not give up. So craving pleasure relief in the short term. Harm in the long term. Knack of giving it up. That's what an addiction is. Now, notice something I haven't said. I think about drugs. It could include drugs, certainly cocaine, crystal meth, heroin and caffeine, alcohol, nicotine, opiates, of course. But it could also include sex. Gambling. Pornography. Shopping. Eating. Bulimia. Gaming. The Internet. Cell phones. Extreme sports. Work. I could go on forever.

  Dr Gabor Maté: [00:12:34] The point is not the behaviour as such. You can actually take heroin not addictively. Not that I recommend it, but you can or you can take it addictively. You can work not effectively or you can work addictively. You can eat. Not addictively. Or you can eat addictively. So the issue is not the behaviour per se. It's the internal relationship to the behaviour. Does it provide pleasure relief in the short term? Therefore, you crave it causes harm. You can't give it up. You got an addiction. So I'm going to ask my four brave panellists here if, according to that definition, you will acknowledge that any time in your life you had any kind of addictive pattern, just raise your hand and I'm not going to ask you what it was or when. I just I just ask you in general, did you ever have anything like that? Yes or no? Yes. Yes. Okay. Here's what I'm going to ask you. No, I'm not going to ask you what you're addicted to. What substance or behaviour. Nor am I going to ask you when or how long. I'm just going to ask you, each of you tell me what was right about it for you and what was wrong with it. You know what was wrong with it. What did it give you in the short term that you wanted? What did it give you that you craved, actually? So anybody would like to start.

  Sena Gok: [00:13:56] I can start with idea of pleasure and distraction.

  Dr Gabor Maté: [00:14:00] Pleasure and distraction. Thank you. What else.

  Nikhita Singhal: [00:14:05] Made me feel safe? It was predictable.

  Dr Gabor Maté: [00:14:08] So the sense of safety. Yeah. Okay. Sense of security. Go on. Thank you. Next. Anybody else? Yeah.

  Angad Singh: [00:14:16] I can follow up with a sense of approval.

  Dr Gabor Maté: [00:14:18] A sense of approval From whom?

  Angad Singh: [00:14:21] From the outside world. Okay.

  Dr Gabor Maté: [00:14:23] Thank you. And one more person.

  Rhys Linthorst: [00:14:27] Really just sort of a relief from distress, like almost just finally being able to let go.

  Dr Gabor Maté: [00:14:32] Distress. Okay. Very good. So pleasure was the first thing that a good thing or a bad thing in itself? Distraction from unpleasant. When do we need to be distracted? When we're in uncomfortable? So it's a sense of comfort. Is that a good thing or a bad thing in itself? Safety, security. Is that a good thing or a bad thing in itself being accepted or approved of by others? Sense of I'm okay. Is that a good thing or a bad thing? We all want it. It's a good thing. Distraction again from distress. Stress relief. Is that a good thing or a bad thing? Clearly in itself, it's a good thing. The lack of pleasure, the stress, the lack of safety, the fear of not being approved of, and the feeling of distress. These are all forms of emotional pain. Hence, addiction is not a disease. It's not genetic, but it actually is is an attempt to resolve the problem of human pain. So the addiction wasn't your primary problem. It was your attempt to solve a problem. The problem of some form of emotional psychological distress. Therefore, if you want to understand the addiction and here's my mentor and if you remember nothing from this conversation, try to keep this phrase in mind. The question is not why the addiction, but why the pain? Now, if we understand why the pain and the question was the relationship between trauma and addiction, the pain is an imprint of trauma.

  Dr Gabor Maté: [00:16:21] The pain that you're still carrying. An adult life is an imprint of trauma that you sustained at one point in your life. It's the wound that hasn't healed yet. No. You want this proven? Statistically, if you look at the adverse childhood experiences studies, if a male child had six of those, his risk of becoming an injection using substance dependent person as an adult is not six times greater than the average is 46 times greater. They multiply each other. And I like also to talk about it from the point of view of the human brain. And I wonder if this would be a good time to do that, because certainly it's a manifestation of brain dynamics. But the big mistake made by neuroscientists and psychiatrists is they think the brain is the origin of things. So I would like to discuss the question of it's a brain disease. Let's look at why do addictive substances even work in the human brain? We're talking about substances now for the moment. So let's take the opiates. So I think it was mentioned in the introduction, or if it wasn't for seven years, I was the medical coordinator of the palliative care unit at Vancouver Hospital looking after terminally ill people. So I dealt with a lot of death and a lot of pain. Thank God for the opiates. The opiates are the strongest pain relievers that we have.

  Dr Gabor Maté: [00:17:47] We know that. But why do they work in a human brain? The opiates come from opium papaver somniferum the poppy that puts you to sleep. That's the Latin word for it. And it goes in Afghanistan. Why do we find relief from a plant that grows in Afghanistan? Because we have receptors in our brain for opiates. But why do we have receptors from a plant that grows in Afghanistan? We don't. As you will probably all know, we have receptors for opiates because we have our own internal opiate system. And our internal opiates are called endorphins, which simply means endogenous morphine like substance. S. So our bodies are full of endorphin receptors in our guts, in our immune system, in our mucous membranes, in our brains. And in each of these areas, they play different roles. So I'm here now concerned with the role they play in addiction and specifically in the brain. The endorphins. Played three major roles in the brain now. If you want to understand why people crave opiates, you gotta understand endorphins. What do endorphins do? Well, the first thing they do, I've already mentioned this. They provide pain relief. Pain is an essential part of human life. As you know, if it wasn't for pain, we would not be able to protect ourselves. But there has to be pain relief as well. The endorphins help provide that. So in a placebo effect where you give 100 people an inert pill for pain and 25 have complete pain relief, it's their own internal endorphins that are being released that.

  Dr Gabor Maté: [00:19:25] So, you know, this is not a it's a real effect. It's actually an opiate that's helping them when they think they're getting an opioid. They're getting their substance, but they won't. Endorphins kick in. So that's the first job. But not only physical pain relief, the emotional pain relief as well, because the part of the brain that experiences the suffering of physical pain is also the part that experiences the suffering of emotional pain, and that's the anterior cingulate cortex. Now pain is felt different areas of the brain, but the suffering is felt largely in the ACC, which is heavily endowed with endorphin receptors so that the first job of the endorphins then is emotional and physical pain relief. Number one. Number two. They help. Experience. They help us experience. Moments of pleasure and reward and elation. So when people go bungee jumping, the higher their resultant endorphin level, the more exalted they are, the more exaltation there is. That's important in human life because human life is full of suffering. We have to have pleasure and reward. Endorphins help to do that. That's the second important role. The third one is the most important, which is a word we never even talk about in medical school. The third rule of the endorphins is to help potentiate a little thing called love.

  Dr Gabor Maté: [00:20:53] My love. I mean, the attachment between two human beings for the purpose of caretaking, which is an essential dynamic between mother or parent and infant. So both the infant and the mother have endorphin surges when they're looking into each other's eyes. That's why parents get so addicted to their kids. It's that endorphin high, which is a good thing because otherwise parenting would be a very difficult business. If you take infant mice and genetically you knock out their endorphin receptors, they will not cry on separation from their mother. What would that mean in the wild? Their death. That's how important detachment is. That's how important the endorphins are. And if you ask heroin addicts, what does the heroin do for you? You know what they'll tell you? They'll say, it makes me feel like a warm, soft hug. It makes me feel like. One person told me this in. In a detox facility. I said, What does it do for you? He said, You know, Doc, it's like when you're three years old and you're shivering with a fever. And your mother puts you on her lap, wrapped in a warm blanket and gives you a warm chicken soup. That's what the heroine feels like. Love. That's the endorphin circuitry. That's where the opiates are so powerful. No. Then is dopamine. Dopamine is another little mouse experiment where you put a little mouse in front of a plate of food.

  Dr Gabor Maté: [00:22:30] He is hungry, he hasn't eaten, and he will not budge two inches to eat. Why? Because genetically they knocked out his dopamine receptors. Dopamine is essential for motivation, for seeking, for curiosity, for vitality. Dopamine flows were seeking a novel object, were exploring a novel object or a novel environment. Dopamine flows when we are seeking food or seeking a sexual partner. I got news for you. Sex addicts are not addicted to sex. If they were. And it's a serious condition, even though the DSM doesn't recognise it. But that's a whole other picture. But sex addiction is a serious problem for a lot of people. What they're looking for is not sex because it was sex. They just had to marry another sex addict. It'd be okay for the rest of their lives. It's the dopamine hit of seeking that they're looking for and all the behaviour addicts. And I've had my own. Believe me, we're not seeking the object. What you're shopping for or the gambler is not after winning money. Because if they want a big. Role, they'd quit, but they don't get back the next morning and they lose it thereafter. The seeking the dopamine hit the excitement. So all behaviour addicts are actually substance addicts, but the substance is their internal dopamine apparatus. So that's the second circuitry. Of the brain that's implicated in addiction. The third one is stress regulation.

  Dr Gabor Maté: [00:24:12] If you talk to addicted people who were clean for a while, then they relapsed. You ask them what happened. Usually something stressful happened. They couldn't handle it. They used the addiction behaviour, whether it's gambling or sex or pornography or shopping or drugs to soothe the stress. Now, our brains, as you know, is medical students, medical people. We do have a stress apparatus and, you know, the hypothalamic pituitary adrenal axis, but we also have the stress regulation. Addicts don't have good stress regulation. They use the addiction to soothe their stresses. As a couple of you have already told me. And finally, there's the impulse regulation circuitry. I'm pointing at it. The right orbitofrontal cortex. And his job is to tell you you may want to do this thing, but it's not good for you. Don't do it. No, babies don't have good impulse regulation or any impulse regulation. But a baby wants they'll reach for it right away. Addicted people are the same thing. What should that tell us? It should tell us that addiction is not an inherited disease but a developmental problem. Certain circuits in the brain did not develop properly. So what we're looking at in addicted people is that these various brain circuits, the endorphin apparatus, the dopamine apparatus, the special litigation circuitry, the impulse regulation circuitry did not develop properly. And I'm going to just spend two more minutes to talk to you about brain development and then I'll stop.

  Dr Gabor Maté: [00:25:47] So how does the human brain actually develop? And here's another one of these little secrets that I would wager to say most of you in medical school have never heard about. And I am not critical here of individual physicians, but I'm telling you, your education is bereft of some of the most important dynamics in human life, including normal psychological development, which you probably never heard a lecture about. We just learn about pathology or including healthy brain development. So I'm going to read you an article that's not in the least controversial. It's from the Journal of Paediatrics, February 2012. That's the Journal of the American Paediatric Academy. The article is from the most prestigious centre on Child development in the world, the Harvard Centre on Child Development. Again, it was published 11 years ago now in February. And. I'm going to read you two sentences on brain development. This article, when it was published in 2012, was no longer in use. I'd known about this stuff since the 90s. You know, there was by the 90s there was not news anymore. It was just, you know, being established in the literature. Here's an article from 2012 summarising all that knowledge. The architecture of the brain is constructed through an ongoing process that begins before birth, continues into adulthood, and establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow.

  Dr Gabor Maté: [00:27:27] I'm going to parse that sentence for you. The architecture of the brain is constructed through an ongoing process that begins before birth. You know what that means. It means that the emotional states of the mother are already promoting and influencing the physiological development of the child's brain. Now I could cite for you X number of studies if you want the references on which I rely. You're welcome to find them in my books, most recently The Myth of Normal. Previous to that, my book on addiction in the Realm of Hungry Ghosts. Previous to that, published 24 years ago, my book on ADHD called Scattered Minds. So the architecture being is constructed through an ongoing process begins before, which also means that the prevention of addiction needs to begin at the first prenatal visit. We have to pay attention to the emotional states of the mother when she's carrying the child. Because stress is depression. Anxiety on the part of the mother will have a physiological impact on the child's brain, including on a number of dopamine receptors, for example. So because before birth continues into adulthood, so goes on throughout childhood. So childhood is a period of being development. And establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow. Not some of the health learning and behaviour that follow all the health learning and behaviour that follow. The base of it is established early on.

  Dr Gabor Maté: [00:29:04] Okay. Second sentence The interactions of genes and experiences literally shapes the circuitry of the developing brain. So it's experience is acting on the genes. This is called epigenetics. How the genes are turned on or on off by the environment based on methylation and a whole lot of other biological mechanisms, which I'm not smart enough to understand or not patient enough to memorise. But it's genes being affected by the environment. That's why you can have people with the same genes, two animals with the same genes, totally different behaviours if you put them in different environments. So the addiction is not genetic. It may run in families, but so what? Those All four of you here are medical doctors or medical doctors to be. If any, future children you might have go into medicine. Does that prove that the passage of medicine is a genetic disorder? I mean, maybe it is, right? So it's critical. So so these experiences shaped the circuit of developing brain and is critically influenced by the mutual responsiveness of adult child relationships, particularly in the early childhood years. In other words, the biggest influence on the physiological development of the brain, the circuitry, the systems, the neurotransmitters is the quality of emotional relationship with the early environment. Now what happens to a traumatised brain? Guess what? These circuits don't develop. Now you got the template for addiction. That's it in a nutshell.

  Angad Singh: [00:30:47] Thanks, Dr. Matt for outlining those normal physiological mechanisms ranging from the brain circuits you outlined that underlie sort of the normal motivation and and attachment mechanisms to the HPA axis and the Neuroendocrinology as well as the genetics and epigenetics. And you sort of hinted at this at the end of what you were saying. But I'm wondering what are the ways that trauma gets encoded into those systems? And then how does that lay the groundwork for addiction and other problems?

  Dr Gabor Maté: [00:31:14] Well, first of all, if we look at any development, so look at the development of a plant. If you're growing a plant in your garden, what questions would you have to ask yourself? I'm asking you.

  Angad Singh: [00:31:25] Whether the soil is fertile.

  Dr Gabor Maté: [00:31:27] Good. That's an important one. What's another one?

  Angad Singh: [00:31:30] Whether there's enough sunlight.

  Dr Gabor Maté: [00:31:32] Very good. That's 2 or 3. There's one more.

  Angad Singh: [00:31:35] Whether you're watering enough.

  Dr Gabor Maté: [00:31:36] Very good. In other words, you would take care of the conditions that the plant needed for the development. Same with human beings. Human beings have certain needs, a certain expectations into which they are brought into this world. They include safe, secure attachment relationships. Where the child is absolutely can rest in the awareness that they're accepted and seen and loved for exactly who they are. That's a human need. They have a need not to have to work inside that relationship. In other words, the child shouldn't have to be pretty compliant. Presentable. Good. Corroborative shouldn't have to try to make the parents feel better in their own miseries. Judges rest. Because growth happens during rest. Not doing struggle. That's the second need of the child. The child is a third need. And again, this is a chapter on this and the myth of normal, the irreducible needs of children. The third need is now the great neuroscientist. His name is Jacques Jaak Panksepp PR and SCP. Unfortunately, he died a few years ago before his time of cancer. But he distinguished seven number of brain circuits that we share with other mammals. They include caring love. That's the endorphin circuitry seeking curiosity. That's the dopamine circuitry. Fear. Grief. Anger. These are all essential for human functioning. Now. We asked you about what does a plant need? Irrigation, sunlight and minerals in the soil. Yeah.

  Dr Gabor Maté: [00:33:35] Well, the human child needs these conditions. Do you mean the child? Also, by the way, needs free play out in nature. Spontaneous play. Play plays a huge role in brain development, much more important than academic learning. We have a huge circuit in our brain dedicated to play. Cats play. Lions play. Bear Cubs play. Everybody plays because the brain promotes healthy brain development. You know, society free spontaneous play is barely available for kids anymore. They don't play anymore. They play with cell phones. That's not play. So these are the four irreducible needs of children. When they're not met. These circles don't develop properly. The receptors don't develop stress mothers. The kids dopamine circuitry won't develop properly. You know, so. Because don't forget what this article from Harvard said, that the brain develops under the influence of the mutual responsiveness, responsiveness of adult child relationships, particularly in the early childhood years. Now, come to the downtown east side with me in Vancouver, North America's most concentrated area of drug use, where I worked for 12 years. In 12 years of work in the downtown east Side, I didn't have a single female patient out of hundreds who had not been sexually abused as a child. Not one. And what was amazing is that until I asked them, nobody had asked him that before. In most cases. What does sexual abuse do to your child's brain? The stress of it, the activation of the HPA axis, the release of cortisol which interferes with brain development.

  Dr Gabor Maté: [00:35:12] Which undermines the availability of dopamine receptors. Which interferes with healthy stress responses. Because the child who is being. Abused. Take an extreme case. Can't generate the healthy stress response because the healthy stress responses to fight or to escape. Can a four year old being abused fight or escape? They actually they have to gut their own stress responses. No wonder. Then later on, they don't know how to handle stress. It's a wonderful volume by my colleague and friend Bessel Van der Kolk called the body keeps the score. On, on on stress. If you want to really know the traumatic impact of severe trauma, read that book. But as I said to you earlier, you don't need those big T traumas. And this is where genetics do come in. Here's what I'm going to tell you. This is true for mental health conditions in general. There's no gene for depression. There's no gene for schizophrenia. There's no gene for bipolar. There's no gene for addiction. There's no gene for ADHD. There's no gene for nothing. Nobody's ever found a single gene. That if you have it, you will have this disease. And if you don't, you won't. Don't believe me, by the way. Look it up for yourselves. Nobody's ever found a group of genes that if you have them, you'll have this or that condition.

  Dr Gabor Maté: [00:36:41] And if you don't, you won't. What they have found. As best I could tell, when I did the research last time, a year and a half ago, in preparation for my most recent book, A Large Group of Genes, that the more of them you have, the more likely you are to have any number of mental health conditions. But no specific one. So those jeans are not for diseases. You know what they're for. Susceptibility sensitivity. So the more of these sensitivity genes you inherit, the less it takes to make you suffer, the less it takes to have an impact on you. Now that is inherited, but that in itself does not lead to disease. It's the action of the environment. On sensitivity genes that makes some people much more prone for addiction. Now, you don't have to have those genes to become addicted, but the more you have, the more likely to have any number of mental health conditions. And that's one more thing I want to say. When I was working in the Downtown Eastside, it wouldn't be unusual for somebody to say to me, Hey, doc, I don't get it. But most people, they do cocaine. They go all hairy. But me, I calm down and I cleaned my room. What do you think they were telling me?

  Nikhita Singhal: [00:37:57] Self-medicating in a way, I guess.

  Dr Gabor Maté: [00:37:59] They were self-medicating ADHD because Hobby Medicate, ADHD is with dopaminergic drugs. You know, Dexedrine, Adderall, Ritalin, methylphenidate. These people were using the stimulus to medicate themselves. People also use these people also tend to use. And so but in the study, statistically, about 30% of of amphetamine addicts or stimulant addicts, nicotine, caffeine, crystal meth, they're actually self-medicating ADHD. And most doctors don't even realise that. And in general, very often the drugs are self. Heroin is a wonderful self-medication for PTSD. Do. Cocaine elevates serotonin levels. Not as long as Prozac does, but it does. People self-medicate depression with cocaine. So very often people medicate. I mentioned maybe marijuana. People sued the ADHD brain with marijuana. I was talking to Prince Harry a few weeks ago. Some of you may have heard that. And I kind of controversially, but diagnosed him with Add because it's in his book. He couldn't pay attention. It was distractable, you know, And and marijuana really helped him because it helps the hyperactive brain calm down. So very often addictions to substance are self medications.

  Nikhita Singhal: [00:39:19] So mean so much of what you've talked about. You know, things start in childhood. There's there's something that happens. And it's not necessarily what happened is, you know, how how we respond. There's certain maybe genes that make us more susceptible to respond certain ways. And then thinking about how the addictions are serving some purpose, some function. And we don't maybe take on more adaptive ways of coping with things as we grow up. Bring that. Then maybe to our third learning objective thinking about how can we use this pen to provide better care for people?

  Dr Gabor Maté: [00:39:52] Sure, if you believe that what you have in front of you is a person afflicted by some genetic disease which manifests in a certain behaviour. Well, what can you do about anybody's genes? All you can do is manage the behaviour. So to an opiate addict, you might provide some medically assisted help. You know, give them Suboxone or methadone. That's useful. You might put them into a group where they learn better behaviours that can be useful. But you're forgetting or not knowing. Not that you forget it because you never knew it. You're ignoring the fact you're not aware of the fact that underlying those behaviours is trauma. So we need to have a trauma informed view. Of treatment. Now, trauma informed view of treatment doesn't mean that all you talk about is trauma. It means trauma informed. It means that you're informed by the fact that this person of any gender, of any age, when they come to you with an addiction, and I would argue with any mental health condition, if there's time, we can talk about that. If not, we just talk about addiction. Actually, there's a traumatic wound inside them so that any healing program needs to address not just their behaviour, like with cognitive behaviour therapy and dialectical behaviour therapy. You need to address the underlying pain. Now why the addiction, but why the pain? And that pain shows up in self-loathing. in self-blame. In aggression. In. Mistrust in a skewed view of the world, in constant behaviours designed to soothe the pain or to numb the pain.

  Dr Gabor Maté: [00:41:43] So let's deal with. And. The ultimate pain is. When you're suffering as a child. Whether it's emotional suffering or physical or both. And you're alone with that suffering. You almost are forced to disconnect from yourself because the pain is too much. And that disconnection from yourself no longer knowing your gut feelings, not trusting yourself, not even liking yourself. That's the ultimate wound. So that trauma informed care would help lead people back to themselves. And let's face it, pain is a part of life. You can't escape pain if you're a human being. You don't have to inflict on inflicted on people. Which incidentally, the medical system often does unwittingly, but it does just by how it treats them. But you have to help them cope with pain. So part of the trauma informed care is how can we help you develop ways of being with the genuine pain of being alive without having to resort to escape from it all the time? So it's healing that traumatic wound. That's the ultimate goal here, which doesn't obviate or invalidate other approaches. And I'm all in favour of, you know, Suboxone and methadone when it's required. I'm not against psychiatric medications. I've taken them with benefit but taken antidepressants and I've taken stimulants for my ADHD. But they're not the answer. They only deal with symptoms.

  Rhys Linthorst: [00:43:27] Think that's a really helpful kind of approach to the treatment of addictions and trauma. Dr. Mate And actually noticed in your latest book, The Myth of Normal, there was like a chapter on kind of Steps towards healing, which kind of elaborates on strategies that individuals can use to move toward more adaptive ways of thinking was actually sort of curious, kind of on a broader scale how you see the role of the medical doctor, whether it's the family doctor, the psychiatrist or addiction specialist in regards to the provision of the psychological work versus the prescribing, and if there's any upside or pitfalls to having the same person do both.

  Dr Gabor Maté: [00:43:59] Well, I certainly did both. In fact, I couldn't have imagined not doing both. And it's not as complicated as you might think. You know, I'll tell you, for myself and I teach a therapeutic program internationally. We've had over 3000 students now in over 80 countries. It's called Compassion Inquiry. I've never had a day's training in psychotherapy. I'm not saying you shouldn't. I'm just saying. The formal training is not the essence of it. Something else is the essence of it. I'm not saying it's just like that. And I've learned a lot from others and from my clients and so on. But the most important thing is, is what you have to keep in mind. This makes all the difference in the world. Even if you have no factual knowledge. People were hurt in relationship. They were hurt unwittingly. We're not blaming parents here, by the way. Parents do their best. Your parents did their best. My parents did their best. I did my best as a parent. And I'm telling you, I hurt my kids. Not because I meant to, because I didn't know any better. There were stuff I hadn't worked out yet that I invented. And trauma is multigenerational that way. You can see that especially in the Aboriginal community in Canada, just a multigenerational it is, but it's multigenerational. But it means that we were hurt originally in relationship. It also means that we need to heal in relationship. So the therapeutic relationship is the most important thing you bring to your client. I don't care what training you had and I don't care what training you didn't have. Can you see them as human beings? Can you accept them? Can you look at them without judgement? When they come in your office having relapsed yet again.

  Dr Gabor Maté: [00:45:55] We feel resentment and frustration and judging. Because if you are. And you're saying to yourself, I got this difficult client. There are no difficult clients. Who's got the difficulty? You've got the difficulty. Look at where that judgement, where that resentment comes from. You don't look at your rheumatoid arthritis patient that way, do you? Where is your judgement coming from? So if we can strive to provide an accepting, unconditionally accepting. I'm not saying to put up with bad behaviour. I'm not saying somebody wields a knife at you. I'm not saying sit there, accept it. You know, I'm not talking that nonsense. I'm talking about their behaviour in their own lives. If you cannot judge them, if you can see the pain behind it, if you can accept them and not only accept them, but see the possibility of wholeness in them. The to that relationship. That's a huge healing influence. And many of you who are listening to this, at some point, I hope you experience this, that somebody will say to you. Dark many years ago or some years ago. I came to your office and you listened and you didn't judge me and you accepted me. And that made all the difference in the world. And it does. So trauma informed doesn't mean like a huge load of training necessarily. It doesn't mean that you show up seeing that person as carrying a wound that can heal and you look at them with compassion and acceptance and you take responsibility for your own reactions. That's the biggest part of it.

  Sena Gok: [00:47:41] Thank you, Dr. Mate. You mentioned the impact of multigenerational trauma and that we see within the indigenous population, and especially in women in Canada, highly this impact. And also there are societal barriers that are impact addiction population. Could we maybe speak to these? And I've also read that you mentioned trauma informed care can be applied from our society. Could we could you speak to that as well?

  Dr Gabor Maté: [00:48:11] So what are the societal barriers?

  Sena Gok: [00:48:13] Yeah.

  Dr Gabor Maté: [00:48:16] Well, so let's just own the fact that we live in a society of high inequality. So these barriers are not general. They're specific. Some barriers affect everybody, but some barriers affect some people much more than others. So poverty is a huge barrier. Lack of drinking water. A lot of our native communities until very recently and some even now don't have potable water. We make societal choices as to where we're going to spend our money. We spend our money on sports stadiums, millions of dollars on certain celebrations. We don't spend it on drinking water for our indigenous communities. That's a barrier. But it's an arbitrary one. Which speaks to the values of this particular society. Race is a barrier. Not in itself. In itself, race doesn't even exist. There's no race. Skin colour and shape of lips or nose does not create a new race. Race is a function of a society that in its evolution, dependent on making some people inferior for the sake of enslaving them or of depriving them of their goods and lands. Race is a concept arose only with the rise of capitalism. But that's a huge barrier. Article yesterday or two days ago. The Toronto police are much more likely to be violent with black people than with Caucasians.

  Dr Gabor Maté: [00:49:56] What a surprise. That's a barrier. Gender is a barrier. Um, in that there are certain acculturated tasks that devolve onto women more than onto men, particularly being the stress absorbers of everybody. Women have much more risk of of being on psychiatric medications, antidepressants, anxiolytics, and so on. Women have more PTSD. Obviously not exclusively, but there are more prone for sexual abuse in childhood. These are barriers. Class is a barrier to receiving treatment. The Canadian health care system does not cover psychotherapy. One of the reasons I developed my own psychotherapy therapeutic skills such as they are, because as a general practitioner, once I began to recognise the connections between people's emotional states and their mental health or their physical health. I thought, well, okay, I can I can give them the antidepressant or I can give them the anti-inflammatory or the immunosuppressant or whatever they need, but who's going to talk to them about their emotional needs? In the medical system, only psychiatrists are paid to spend money and only in Toronto with their GP psychotherapists. But in B.C. there aren't. Most provinces do not. Emojis are not trained in that way. So then I'd have to send people to psychiatrists. But I hate to tell you. Most doctors are not trained in decent therapy.

  Dr Gabor Maté: [00:51:36] That is not even part of their training. They at least wasn't. They mostly deal with hospitalised patients with severe mental health conditions. Therapy barely comes into it. So therefore I had to start talking to my patients myself. So money is a barrier because here in Vancouver, to see a private therapist. You know what? $100 an hour, $150 an hour, maybe more. Well, in a in the East Vancouver family practice I used to have before I worked in the Downtown Eastside, my people were working class immigrants. They couldn't afford $150 an hour for psychotherapy. So these are all barriers. But the biggest barrier is an ideological one. Which is that the medical profession itself doesn't recognise the connections that have been trying to draw for you. You can go to medical school and I hope you'll tell me otherwise today. I hope you'll tell me right now that I'm wrong. But my assertion is that the average medical student doesn't hear a single lecture on trauma. In a way that I talked about it today, the significance of it now. In, at least in the undergraduate years. Tell me if I'm wrong. Okay. I'd like to know that I'm wrong on that one. Yes or no?

  Angad Singh: [00:52:57] No, you're not wrong.

  Dr Gabor Maté: [00:52:58] Okay. Which means that the biggest dynamic in causing addictions and mental health problems is not even mentioned in medical school. Now, talk about barriers. That's a barrier. All the more. I'm appreciative that you guys are giving me this opportunity to address some doctors in training. I mean, I, you know, am I an evangelist? Yes, I am. I'd really like people to know about this stuff. And you know what frustrates me here? When I allow myself to be frustrated. It's not that the medical practice is scientific, it's that it's not scientific enough. Because what I'm talking about, you know, when I wrote this book, The Myth of Normal, I collected 25,000 articles. Multiple hundreds on trauma and its impact on the brain and the body and unity of mind and body and the connection between addictions and ADHD and everything else. You guys don't even learn the science. And you would call yourself a scientific discipline. So that's the biggest barrier is our ideological blinders Imho.

  Dr. Alex Raben: [00:54:02] Thanks so much, Dr. Mate. I haven't introduced myself, but I'm Alex Raben. I'm a psychiatrist from here in Toronto. Great. Um, and I have to say, yes, in my own medical training, I would agree with what Angad was saying there and many of our panellists here today, thankfully, I think in psychiatry training is a bit different and we certainly have had some episodes on trauma, thankfully before, not not the same lens as today. I just wanted to jump in with a question as well that came to me to do with harm reduction because we've talked a lot and in your book you talk a lot about the biological, psychological, developmental, multifactorial aspects of addiction and, and the way trauma layers on top of that. Yeah. But there's also, I guess, this element of the substance or whatever the target of the addiction is. And it strikes me that some of those behaviours may lead to bigger harms than others. And I'm thinking about, for instance, the opioid crisis which is rampant in the country, has been getting worse and particularly in BC. How do, how do we view, how do we make sense of that from this model, right where we see this substance being taken up in greater quantities and causing greater and greater harm? Is there a role here to do something in that realm as well? Or how how does that fit into all this?

  Dr Gabor Maté: [00:55:32] Sure. So in this in my previous book, which is in the realm of Hungry Ghosts, Close Encounters addiction, there's a chapter on harm reduction. Um, so I was the physician at North America's at that time only and first supervised injection site which is called Insite or here in Vancouver on Hastings Street, where people could bring their substances of abuse or use and get clean needles and sterile water and a tourniquet and inject under supervision. And if they're overdosed. They'll be resuscitated. The Canadian government In its wisdom at the time, the Harper Conservative government tried to shut it down. Under the principle that we're aiding and abetting addiction. From their point of view, it would have been better to what I'm saying now. The Supreme Court of Canada ruled. Unanimously against them. So now there are other injection sites throughout the country. Not nearly enough. So that's a harm reduction measure. Harm reduction says basically harm reduction says it's not just a practice. Harm reduction is an attitude. And it says, we know that right now you find yourself incapable of not using. So let's. Can we help you use in a way that reduces the harm so that you don't infect yourself or somebody else with HIV or hepatitis C so that you don't develop a brain abscess from a dirty needle? or abscess in joints. Um, so that we can talk to you and you can start to trust us and maybe accept treatment from us because we're not judging you. Harm reduction also includes provision of safer forms of opiates like Suboxone or methadone. But basically it says that while sobriety or abstinence is a legitimate and ultimately the hoped for goal, it's not the only goal.

  Dr Gabor Maté: [00:57:44] By the way, there's nothing so unusual about that in medicine. I mean, if you come if you come if you come here as a type one diabetic. Nobody's hoping to cure you. But they are hoping to reduce the harm. By maintaining your sugar levels, insulin levels at an optimal range. By dealing with foot injuries so they don't get infected. But make sure that your kidney functioning stays within normal parameters. These are all harm reduction measures. So it's the same principle. And sometimes people say this is controversial. Well, we shouldn't have harm reduction. I mean, these people brought it on themselves. Let them suffer. There's that attitude which I say I go along with as long as we're consistent. Which means that the next time a workaholic, cigarette smoking businessman shows up in the emergency room with a heart attack, we don't give them a bypass. We kick them out. You're saying you brought this on yourself, not deal with it. You know, but no, we go in there and and we reduce the harm. You know, we give them the medications and if needed, the stent or whatever they need. Well, harm reduction is in the same range. And by the way, nobody stays in addict because of harm reduction and nobody becomes an addict because of harm reduction. So it's just a part of the to me, it's totally irrational. Hopefully it'll lead to abstinence if people trust enough and they enter the treatment system. But unfortunately, there's not a good enough treatment system to enter. So I think. Once you understand trauma, harm reduction becomes a self explanatory dynamic.

  Dr. Alex Raben: [00:59:36] Right. Sounds very complimentary. Going back to what you were saying earlier about being able to be a doctor while also providing trauma informed care in that combination being essential. Right. It's not just one or the other.

  Dr Gabor Maté: [00:59:49] But listen, Alex, why why also like it's like it was somewhat extraneous, you know, not while also that ought to be part of your work as a physician.

  Dr. Alex Raben: [01:00:01] Right? They're there. They're inextricably linked and linked in a sense. And the even the language you use around it can kind of make these false dichotomies. Yeah. Yeah.

  Dr Gabor Maté: [01:00:12] Yeah.

  Dr. Alex Raben: [01:00:14] Nikita. Maybe I'll hand it back to you to wrap us up.

  Nikhita Singhal: [01:00:17] Yeah, I think we could go on for ages talking about it. And thank you so much for, you know, providing us with this perspective, because as as you alluded to, it's not one that we are often, you know, exposed to, although increasingly, I think it's becoming. Know, thanks to your work and others more more in the general awareness. But really, I think, you know, just a quick recap. You covered, you know, trauma and how we can really think about trauma in a broad sense and how that is really linked to not only addictions, all kinds of health conditions, and that the current approaches, the way we think about things doesn't really do the people we serve justice in allowing us to understand and and then to best be able to help help empower them to move past what they're struggling with. And you gave us some really great considerations for ways that we can be trauma informed. And that is our job is to be trauma informed and provide that care. So really, we we thank you so much for for your time and speaking to us. And we think this will be a really helpful for all those future providers out there.

  Dr Gabor Maté: [01:01:31] Well, my pleasure. Thanks for the opportunity and the great questions and I'll talk to you again sometime. You take care.

  Nikhita Singhal: [01:01:39] This concludes our episode on understanding. Trauma and Addictions featuring Dr. Gabor Mate. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Sena Gok. The episode was hosted by Sena Gok, Rhys Linthorst, Angad Singh, Nikhita Singhal, and Alex Raben. The audio editing was done by Sena Gok. Our theme song is Working Solutions by Olive Musique. A special thanks to our incredible guest, Dr. Gabor Mate, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org, Thank you so much for listening.

Episode 47: Understanding the DSM-V-TR with Dr. Michael First

• Episode 47: Understanding the DSM-V-TR with Dr. Michael First

  Alex: [00:00:10] Welcome to PsychED, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers all you need to know about the new DSM five TR. I'm Alex Raben. I'm a staff psychiatrist at the Centre for Addiction and Mental Health in Toronto, and I'm also a lecturer at the University of Toronto. I'm joined today by my co-host Saja Jabri. She is a international medical graduate and a psychiatry enthusiast and this is her first episode. So welcome, Saja.

  Saja: [00:00:44] Thank you. I'm very happy to be here.

  Alex: [00:00:48] This was also such as brainchild. I should say so. Thank you, Saja, for picking a wonderful topic. We're also very pleased to be joined by our esteemed expert, Dr. Michael B first, and he is a professor of clinical psychiatry at Columbia University. Dr. First is also a internationally recognised expert on psychiatric diagnosis and assessment issues as a private practice in New York City and also conducts expert forensic psychiatric evaluations in both civil and criminal matters, including the 2026 trial of Zacharias Moussaoui.

  Dr. First: [00:01:29] Sorry. Moussaoui.

  Alex: [00:01:31] Moussaoui. Thanks, Doctor. First. And then especially important to this episode, Dr. First is the editor and co-chair of the DSM five Text Revision Project, the editorial and coding consultant for DSM five, the chief technical and editorial consultant of the World Health Organization ICD 11 Revision Project and was an external consultant to the NIMH Research Domain Criteria Project or RDOC. Dr. First is also the lead author of the Structural Structured Clinical Interview for DSM five, known as the SCID. More broadly, and this is a widely used or the most widely used structural diagnostic instrument for DSM five diagnoses and in research and in the clinical setting. He has also authored and co-edited a number of books, including a research agenda for DSM five, the DSM four TR Guidebook, the DSM five Handbook for Differential Diagnosis and Learning, DSM five by Case Example. So we could not be more pleased to have you here, Dr. First on the show to talk about this topic, which you are clearly a leading expert on. Welcome to the show.

  Dr. First: [00:02:42] Thank you. A pleasure to be here.

  Alex: [00:02:45] Now I'm going to just quickly talk about our learning objectives today, and then I'm going to hand it over to Saja, ask the first question. So by the end of the episode, the listener will be able to, number one, understand the rationale for undertaking a DSM five TR revision, as well as how that revision process looks. Number two, become familiar with disorders, the text and the symptom code additions and modifications to the DSM five TR. And number three, understand the purpose and function of the DSM generally and be able to contemplate what future directions are going to look like in this area. All right, Saja, I'm going to hand it over to you to take it away.

  Saja: [00:03:33] Okay. So without further do, I'll jump into things to start with, Dr. First. Could you briefly describe to our listeners in simple words, what is the DSM and where did it come from and how did we get to the present edition?

  Dr. First: [00:03:48] Okay, so the DSM that stands for the Diagnostic and Statistical Manual of Mental Disorders and the version that the subject of today's presentation is the DSM five. Tr So that means it's the fifth edition of the DSM, and the TR is the latest version, which is a version that focuses primarily on revising the text. So the DSM is basically a dictionary, so to speak, of all of the psychiatric diagnoses which are accepted as valid by the American Psychiatric Association. The fifth edition when the first edition came out in 1958 and the second 62 and DSM three, which is the one that is it's the first one to have diagnostic criteria for every disorder. That was the 1980, and then DSM four was in 1994, and now we're up to DSM five, which is in 2013. So we're now 11, eight years past the release of DSM five. So we felt that a revision was needed and that's what the DSM five text revision is.

  Alex: [00:04:53] That's terrific. Thanks so much, Dr. First. No, we live in Canada. You live in America, but we have listeners from all over the world, certainly in North America. We turn to the DSM quite frequently in our clinical practice, as you said, as a dictionary for diagnosing. But our international listeners, I'm guessing they might use some other sources. So there's the ICD. So how do we differentiate the ICD from the DSM five? And could you take us through that?

  Dr. First: [00:05:24] Sure. So the it's a little complicated. So the the version, the DSM, the ICD 11, which is the 11th revision, just got finished a couple of years ago, but no country is yet implemented yet. Eventually, every country in the world will have to use ICD 11 codes in the same way. Right now, the United States, Canada and all the countries of the world are using ICD ten codes. The DSM uses the ICD code. So when you open up the DSM and make a diagnosis and write down the code, you're actually fulfilling the obligation to use the ICD codes. But the definitions in ICD and DSM are very, very similar, but they're different. There's been attempts over the years to harmonies them, and I've been involved in that process. So they're pretty close. But there are still differences that have to do with some different historical traditions between the United States and other parts of the world and different levels of detail, different types of disorders. So they're pretty much the same, but not identical. It really depends upon where you live. Even though the DSM is produced by the American Psychiatric Association, there are a number of countries around the world which also use the DSM. It's been translated into different languages, and that got started basically after DSM three came out in 1980. DSM three had introduced diagnostic criteria for every disorder. The basically the rules you need what needs to be present in the patient duration and symptom wise in order to make the diagnosis at the time. The system which is affected in the rest of the world was ICD nine, which did not have those kinds of definitions. So a lot of countries decided to use the DSM three as their main system, mainly because of the sense that the diagnostic criteria were so useful. It was they preferred using the DSM. Since then, ICD has caught up. The ICD 11 does have something called clinical descriptions of diagnostic requirements, which are like criteria. So both systems now have criteria. So I think the usage of the ICD 11 has greatly increased over the years, and in many countries that's the only system that's used.

  Alex: [00:07:31] Interesting. I didn't realise there was that sort of practical difference between the manuals historically and caused a lot of uptake of the DSM three. For that reason. It's quite interesting.

  Saja: [00:07:43] Okay. So, Dr. First, thank you so much for that. Could you tell could you briefly describe to our listeners and tell us more about why was the DSM five are needed? What was the rationale behind it?

  Dr. First: [00:07:56] Okay. So the as you can imagine, the DSMB is an amalgam of what we currently know about the mental disorders. And we luckily live in a world where what we know keeps changing as we learn more things. So know, like any textbook, you would not use a textbook of medicine from ten years ago. You would assume that a lot of things there would be out of date. So the same thing is kind of true too. There are two components to the DSM. There's the criteria which defined the disorders, but actually 95% of the words in the DSM are the text. That's the information about the disorders. It includes things like prevalence, sex ratio, familial pattern, all those aspects about the disorder, which are very important. And in more recent years we include things like risk factors and diagnostic markers. So this information, it's really become an authoritative source of information so that information could get out of date. As we know things happen. So the the version, the DSM five from 2013, all the texts there was based upon what we knew about mental disorders in 2012. So in the intervening eight or nine or ten years, a lot of the information in the DSM is really no longer up to date. So this is an attempt, since we don't know when the next big DSM six will be. We wanted to take the opportunity to revise the text to make it up to date. Now, one thing that's a little new this time around is in the previous DSM's, in between DSM editions, there were no changes, so you had to wait till the next big DSM to make changes.

  Dr. First: [00:09:28] We finally got rid of that way of doing it, which is kind of bad to have to wait for some artificial period of time and changes can be made on a rolling basis. There's a process by which people could submit proposals for changes to the DSM five website, and then there's a whole process by which the proposals are evaluated. They have to be empirically based. You can't just write in and say, I think it would be a good idea to have this kind of disorder. You would say, I think we'll give you an example. A disorder that is becoming more and more popular around the world is Internet gaming disorder. People who have basically kind of like a gaming addiction. ICD 11, when they came out, has actually a disorder called gaming disorder, and DSM five doesn't yet. It's in the appendix. But it's very possible that in maybe the next ten years there's more and more data is collected. They'll feel that there's enough data to justify going into the DSM five. So new disorders could be added when there's enough data. There was one new disorder since DSM five came out that has been added, and that's prolonged grief disorder, which that's been much discussed already also in ICD 11. But the DSM group finally felt that there was enough data to justify being added to the DSM. So it is now in the text revision.

  Alex: [00:10:46] I see. So a lot of years have passed. There's progress in science taking place all the time. And so there was this need to update the the DSM clearly, but it needs to be data driven. You can't just make an arbitrary change, as you were saying. You mentioned one of those changes, prolonged grief disorder. We are going to get into the meat of what these changes are very shortly. But I did want to talk about the process because you've been directly involved in that. So I was hoping with your personal perspective on that, what does that look like? How do these changes get approved? Who's sitting on these committees, how many committees, that kind of thing.

  Dr. First: [00:11:27] So when the DSM five came out, that was the preparation for the DSM five was about seven or eight years. So that was a big process with different work groups working over that period of time to make all of the proposals. And once we've changed over to DSM five, post DSM five, this new ongoing revision model, we now have a different process. Now, for the first time, we have a website open up for proposals, and when a proposal comes in to the website, the website is very specific about what a proposal has to include. So for example, if you want to add a new disorder, which is probably the hardest thing to do, you have to show a lot of data about things like its validity and different kinds of validity. It's clinical utility, it's reliability, all the kinds of things you would want to know about before you make the decision to add a disorder. So a lot of data has to be collected, and it's pretty clear on the website what kind of data it needs to be. So this website has been open since 2013 and proposals have come in and some of the proposals are for tiny changes, but there have been a number of proposals that have been evaluated and have gotten through the process and that prolonged grief disorder is one of them.

  Dr. First: [00:12:39] So now for that process, there's a steering committee that is the first line of when when a proposal comes in, they evaluate and see whether it looks like there's enough data in the proposal to even spend time considering it. If somebody just writes it, this should be this and. My data is I did a study of five people or whatever that would clearly not not immediately get sent back and say we need a lot more data. But so you would outline the proposal, kind of say what kind of data they're planning to give in. And then the committee would decide, okay, if they're in the ballpark of getting in, they would actually send it to a special committee that had expertise in whatever area it is that somebody had a proposal for a new mood disorder, the Mood disorder group would look at it and they would review a proposal and decide whether the data was sufficient, and if not, they would send it back to the submitter and say, you know, this is really good, but we still need more about this kind of validity, and then would go back to them and then it would be up to the person who submitted the proposal to provide that data.

  Dr. First: [00:13:39] Then it would go back to the committee again. And if the committee feels like there's sufficient data, then the next step gets posted on the website for public comment for 45 days and then know notices are sent out to organisations saying there's a new proposal for such and such on the website. And then after 45 days we look at what comes in and then they get analysed and then that goes back to the steering committee to see whether or not any of the concerns that were raised by the public comments need to be addressed. And if everything's sort of taken care of and everybody's satisfied with how it looks, then it goes through the APA approval process. The APA has a board of trustees and an assembly. They also get to look at it and give a thumbs up or thumbs down on it. So by the time it's in there, it's got going through many, many layers of approval and the not so easy gets up at the end basically.

  Alex: [00:14:31] Doesn't sound like it. So just to summarise that for our listeners, because it's harder to do visually, this would be, I think, a little bit easier, but it sounds like it goes to the steering committee first. If it passes a threshold, then it goes on to the individual committees that are experts in those areas or review committee. And then from there there's a public appraisal.

  Dr. First: [00:14:55] Let's say it goes back to the steering committee first, because the steering committee has to approve. So the review committee would say, we think it's good. Then the steering committee debates whether to put it in. And when they're satisfied, like, okay, we really think it's solid and then it goes for public review and then then we'll see what the public has to say. And and hopefully it happened. It's been you know, the big one was the prolonged grief disorder. We got lots of very helpful comments. And the criteria that were proposed actually were changed after the public comments came in to address some of the problems that they pointed out.

  Alex: [00:15:28] Interesting. And I think that's something. Yeah, Really? No, because I don't think a lot of people, myself included, realised there's this public component to it and and then after that back to the steering committee and then ultimately kind of APA for the final signoff. Okay.

  Dr. First: [00:15:42] And that's what this is the first time we ever did that. There was never such an all the previous DSM's while people would write things into the APA and whenever there was never a formal process by which the public could make a proposal, that's that's new since DSM five.

  Alex: [00:15:59] Gotcha. Okay. Very cool.

  Saja: [00:16:01] Wonderful. Dr. First. Can I submit a proposal, let's say? Or who can submit these proposal for changes to the DSM? Is it open to the public?

  Dr. First: [00:16:11] Well, the the hard part is fulfilling the requirements for the data. I mean, a regular person, a psychiatrist in practice might think there's a good idea for new disorder, but to get it in, a lot of data would be collected. And that's what that's what's laid out on the website, what that data is needed. So generally most of the people are either organizations or researchers or groups of researchers who can present all the data that is required to at least submit the proposal. But you're right. Theoretically, if an enterprising clinician collateral that data available, then then sure, you know that absolutely would be appropriate.

  Alex: [00:16:53] Great. So I wonder if maybe we should go to the case now as a entryway into some of the changes in the DSM five, if you want to read that out.

  Saja: [00:17:04] So for today's episode, we have a case presentation. Mariyam, she's a 56 year old female, married her daughter, completed suicide more than two years ago. She often feels depressed but does not think that she feels depressed most of the time, and she's unsure whether she feels depressed most of the day. Her appetite is normal. She sleeps very well. She often experiences fatigue and anhedonia. She experiences recurrent involuntary dreams and memories associated with her daughter's suicide. She used to avoid places and things that reminded her of her daughter outside the home rather than inside the home. But this is no longer the case. Her beliefs about the world have become negative and very pessimistic, and she struggles with substantial guilt associated with her daughter's suicide. She has invested. A great deal of time and effort to investigate and try to find answers and reasons for her daughter's suicide. She's not particularly angry, or hypervigilant, and she does not engage in reckless, self-destructive behaviours. She thinks about her daughter very frequently and longs for her daily. Since her daughter's death, she feels as though a part of herself has died. She has struggled to engage with friends or interest and experiences life as meaningless and feels intensely lonely and emotionally numb. So I don't know. Should we take a minute to think about the possible diagnoses?

  Dr. First: [00:18:44] Yeah, I mean, you want me to comment on it.

  Alex: [00:18:46] That'd be Great.

  Dr. First: [00:18:47] So if you if her mother, Miriam, if you saw her mother one month after her daughter's suicide and she gave that story, you would say to her, you're going through a normal grieving process. It's painful, but there's then maybe counselling to help you get through the grief. But you would not consider her having a disorder because, you know, that's normal for people to grieve the loss of especially a child. The fact that it's two years later is what suggests that might be pathological. Another thing that's in the differential there. So normally when when there's a death like that, the two most common besides this, a grieving and abnormal grieving process could be depression. Major depression can be triggered by grief reaction, like any life stressor. But certainly if you're predisposed, have a family history of depression, you have a past history of depression that could trigger a depressive episode. But as was described in the case, she doesn't have the symptoms that would justify a diagnosis of major depression. The depression wasn't every day didn't include many of the required symptoms. So that was sort of ruled out. The only other diagnosis that sounds possible could be PTSD, avoiding things, you know, feeling nightmares that that's a symptom. So one of the questions which wasn't in the case was what was the nature of the suicide that the mother let's say the the she found her daughter had killed herself with a shotgun and the mother finds the body in the bedroom.

  Dr. First: [00:20:19] That exposure to that traumatic experience could actually be enough to go for PTSD. But it doesn't sound like from the description that the typical symptoms of PTSD were, they're like things like re-experiencing the trauma. The only one that was a little bit like that were the dreams. But the doesn't sound like a picture of PTSD, but that would be in the differential. So and all three of these could happen together. So the three diagnoses I've mentioned in the differential would be major depression, PTSD, And then this new diagnosis, which has recently been added, which is called prolonged grief disorder. And the concept is simple. There's certain a certain amount of grieving. And some people, when they're grieving, become non-functional for a month or two after the death of a loved one. They really can't do anything but the normal grieving process. People at different paces slowly get over it. At a certain point in time, most people will have gotten pretty much back to normal, at least somewhat, and for that reason. So this the idea here, this is a diagnosis reserved for that subgroup of people who experience a loss, who never get over it. Now, that's a tricky state. When I use phrases like get over, a lot of people would say, Nobody, you never get over the death of your child, which is true.

  Dr. First: [00:21:36] That's why getting over it is not the right word. But there's the way you get. If your grief is stuck at such a high level two years later, where it's preoccupying your life and it's interfering with your functioning, then we could say that that's not a normal grief reaction. When this diagnosis was put on the website for comment, there was a contingent of people who are very upset about the idea of labelling grief of any kind as disorder. And we're very we're very sensitive to that. We want to make it very clear that there's a normal grief and then there's abnormal prolonged grief disorder. And what made it even more compelling to add this diagnosis to the DSM is there's a treatment that has been shown to work. It's a cognitive therapy type treatment. There's no medication for this condition. It's a therapeutic therapeutic edition. And theoretically, you're supposed to wait a year until the death has occurred to be able to say you have prolonged grief disorder. So, I mean, I'm sure you could start the therapy earlier if you wanted. But as far as getting the label, you really need to wait a full year before you can conclude that the reaction to the grief and the person's life change is beyond what we would consider normal.

  Alex: [00:22:50] That's really interesting to me that the way the public commentary kind of played into thinking about this as a disorder. And thank you for outlining your differential in the case. I couldn't agree more. And then you also let us nicely into this prolonged grief disorder discussion. You kind of outlined a bit of it for us, including even treatment. But I'm wondering, can we get a bit more specific? Like what are these criteria that clinicians will be looking out for? What's the sort of DSM version of this?

  Dr. First: [00:23:24] As with the many DSM diagnoses, is symptoms which are core that are required for all cases. So for a manic episode, you must have elevated or expansive mood the rest of the symptoms, whether or not you don't need sleep, that's optional, that's variable. But you must have the elevated or irritable mood to have mania in the same way. Prolonged Grief disorder has two symptoms in particular, one of which must be present in all cases. The two cardinal symptoms. Either of them have to be present, usually both, or it's a yearning for the person and preoccupation with thoughts or memories of the person you can't get, Everything you think about has to do with the death of the person. So you have to have those. And as with many DSM definitions, you have to have it's not just every once in a while. It's got to be nearly every day for 12 months, very long period of time. That's the first part of it. So if you don't have either of those, you're not even in the ballpark. But once you have either the yearning or the preoccupation, then there's a bunch of other symptoms that you need. At least I believe it's three. There's a list of eight symptoms and three out of the eight are required. And let me tell you what the first is called identity disruption, which means that you feel like as though a part of yourself has died.

  Dr. First: [00:24:48] A lot of people in right after the death of a level. And they feel that. But again, months later and again, that's why that itself would not be enough to make the diagnosis. That's why it's you need a whole cluster. It's a combination of the symptoms together. So that's one of them. Some one another one is a more sense of disbelief about the death. You really can't believe the person has died. Avoidance of reminders that the person is dead. Intense emotional pain, which includes anger or bitterness, difficulty reintegrating into one's relationship. So it's very common to kind of withdraw into yourself when you're grieving. But the part of the normal grieving process, you get back to your old life, you reconnect with your friends. In this condition, you really have a real hard time integrating with the way your life used to be. Some people are emotionally numb. They feel like they don't have any emotions at all. People will feel life is meaningless and there's an intense loneliness as a result of the death. So any one of these on their own may not be pathological. It's the three together, plus the yearning or preoccupation. All of that together is required. And like most DSM diagnoses, there's a requirement that that all of these symptoms together have to be severe enough to cause distress or impairment in occupational or social functioning. All that together is what makes it a disorder.

  Alex: [00:26:14] Thank you so much for taking us through that doctor. First and looking at the list. I'm also kind of struck by, as you were mentioning before, like the overlap with PTSD, for instance, or some other conditions. Right. Identity disruption. You can think of that in other conditions, emotional numbness, avoidance. But to me, it seems like it's very oriented around the person you're grieving. That seems to be a very distinct difference here. And then the timing, as you were saying as well.

  Dr. First: [00:26:41] That all of the symptoms, the identity disruption is as a result of the death. So, you know, people can have these symptoms chronically before the death happened. So you couldn't count that as part of prolonged grief disorder unless you could attribute it to as a result of the death of the loved one.

  Alex: [00:26:59] It makes sense. Makes sense. Great. Thank you for taking us through that. I think now we'd like to turn to the other changes because prolonged grief disorder, that's the only new disorder added to DSM five TR. But there have been a number of other changes. Could we maybe go through?

  Dr. First: [00:27:18] Well, actually, there are a couple of other new new in quotes. They're not completely I mean, this is the major one. There's no question. This is the one of the most clinical interest. It's three other disorders or conditions which have been added. One is something called unspecified mood disorder, which sounds it's a technical thing of sorts, but it's for real. When DSM five got rid of, you know, all of the categories in the DSM have an unspecified sort of a wastebasket for individuals who have presentations that don't meet the criteria for any of the disorders. And that actually is fairly common. A decent percentage of people who come for treatment don't actually meet the full criteria. So you really can't give them a diagnosis of one of the disorders in there because you don't meet the criteria. So you have to use one of these unspecified categories. So for someone who has like a subthreshold depression or subthreshold bipolar disorder, they would get a in the DSM five, bipolar, unspecified bipolar disorder or unspecified depressive disorder. But what is the mood category like something like irritability? Is that a depressive thing or is that a bipolar thing or agitation? Those certain mood symptoms aren't specific to either depression or mania. So one of the questions was what if somebody comes in and their main problem is irritability and agitation, but they don't meet the criteria for any of the disorders? What do you call that in the DSM five, you'd have to pick between decide whether is it really depressive or is it really bipolar.

  Dr. First: [00:28:49] But the arbitrator, if you don't know anything, you have to pick like flipping a coin. The problem with that is then the person ends up having that wrong diagnosis stuck on their chart. So the solution is to take a step back and and reintroduce something which used to be in the DSM, which is an unspecified mood disorder. So we're now allowing the clinician to just say, hey, this is a mood problem. I'm not going to commit myself to whether it's bipolar or unipolar as of yet. So it's mood. So as you know, with all of these unspecified, there's more information comes in. You hope to be able to rewrite the diagnosis based upon new information. So you have to start somewhere. So this is sort of like a place to start for some unspecified general mood problem without committing yourself to bipolar versus unipolar. So that was one. There's a category called No Diagnosis. Believe it or not. So what? You know, when you work in a hospital, you have to write down a diagnosis or your practice. So sometimes you're going to get somebody who comes in, says, you know, I need to have a doctor's note saying I'm ready to go back to work.

  Dr. First: [00:29:55] I've been on disability, everything's gotten better. So what would the diagnosis be for that person? There was really nothing in it. So we reintroduced another category that used to be in the DSM called No Diagnosis or Condition. So for somebody getting a wellness exam or sort of a duty to work thing that's been reintroduced for that reason. So these two are a little bit administrative, but they have real world implications. Another new thing was in the in the neurocognitive section, substance induced neurocognitive disorder. So that's a section of conditions that could cause dementia. Mostly dementia Drugs like alcohol, inhalants and sedatives can lead to a dementia that is very, very severe. The DSM five got rid of dementia, interestingly, and replaced it with a category called neurocognitive disorder. That comes in two levels of severity major, which is really the same as dementia. And this new thing that was added to DSM five, which is mild neurocognitive disorder. So it turns out the three drugs which cause dementia, which is inhalants, sedatives and alcohol, also cause mild neurocognitive to, I mean, the severity of the symptoms. If it's going to cause dementia, it should also cause less severe cognition.

  Dr. First: [00:31:16] But it turns out there's one substance which only causes milder neurocognitive care, but not severe, and that's amphetamines. So amphetamines can present with a prolonged cognitive impairment that's not severe enough to call it a major neurocognitive disorder that was by accident, left out of the DSM five. So that's been now a new diagnosis, which is basically stimulant induced mild neurocognitive disorder. And the other new addition, which is a new thing for the DSM, which is to have codes for symptoms that are not disorders. And you can now add and the two that were added to DSM five was a code for suicidal behavior and non suicidal self injury. If suicidal behavior can occur in a wide variety of conditions that it's clearly very, very often it's going to be a focus of attention. It's something you really want to know. It's present and be able when you're referring the person to another clinician, know that that's on the table. So there was no way to indicate that suicide was part of the picture before. Now there's a special code that you can now write down the chart, which basically is for either current suicidal behaviour or past history of suicidal behaviour, and the same thing for non suicidal self injury, current and history. So those are all, those are new to.

  Alex: [00:32:31] So is that diagnostically sort of agnostic in terms of the suicide behaviour and non suicidal self-harm behaviour, You could apply that to anything.

  Dr. First: [00:32:43] You can apply to any diagnosis. You can also apply with no diagnosis. I mean there are people who make suicide attempts and you can't find any diagnosis at all. So you could write, you could use the code for that. But so there's so basically this categories for two uses. One, when those behaviours occur in the absence of a condition, but we expect that most cases of suicide or non suicidal self-injury will have a co-mental disorder diagnosis like depression, schizophrenia substitutes or whatever, they're usually going to use the codes that are code with an actual diagnosis.

  Alex: [00:33:15] Right, Right. Makes sense.

  Dr. First: [00:33:17] So that's those are the big changes with respect to new things. Some of that we've corrected some definitional problems or things that were unclear. Probably the biggest one is persistent depressive disorder. So persistent depressive disorder, which used to be known as Dysthymia in DSM five, is now any depression which lasts more days than not for at least two years, is now called persistent depressive disorder. So that includes the old dysthymia, which was. But if you have a major depressive episode every day for two years, that's also a persistent depressive disorder. If you have what used to be called double depression, there are chronic mild depression with occasional intermittent, serious depressive episodes. That's also if it's last at least two years. That's also called persistent depressive disorder. So you can indicate what waiver it is by using one of the subtypes. But the question was, do you also write down a diagnosis of major depressive disorder and persistent depressive disorder? So somebody, the double depression, get two diagnoses or just the the persistent depressive disorder. And the problem was that depending the two different spots of the DSM, which had the exact opposite thing, so it was really unclear what to do.

  Dr. First: [00:34:30] It turns out that the actual it was supposed to be that you're supposed to use both diagnoses. You're supposed to use major depressive disorder and persistent depressive disorder. And the reason that's important, it's a little bit of a technical thing. It's a coding. So, for example, the coding for major depressive disorder allows you to see if the person's psychotic or mild, moderate, severe and psychotic are available in the diagnostic code. So if you write if that shows up in the chart, you could see immediately this person had a psychotic depression. The persistent depressive disorder, the code is is has nothing, nothing of severity, no anything. So if we only use the persistent depressive disorder code, you would have lost the information of the person had a psychotic depression. You need to use a code for major depression to get the psychosis in there, not plus the severity, which could also be relevant. So kind of technical reasons. We really want both codes there. And in a sense, the persistent depressive code really is used to say this is a chronic type of depression. And then the major depressive disorder codes indicate what the episode looks like.

  Alex: [00:35:29] Makes sense.

  Saja: [00:35:32] Okay. Shall we move on to the next question? So, Dr. first, as everybody knows, there are changes in regards to the terminology as well that's used in the manual. Could you briefly highlight the most important ones our listeners should be aware of?

  Dr. First: [00:35:47] Sure. Some of them are extremely technical, which I won't even go into. It has to do with the most has to do with the people may have noticed that some of the diagnoses have parentheses next to them, which gets their alternate name. We kind of change some of the alternate names. The two most important ones are the use of the word neuroleptic. So Neuroleptic is a word from the fifties. I believe that's how the antipsychotics were referred to, and that word is still around. Neuroleptic malignant syndrome is still there. But through the DSM it appears in a number of different places that were term is really going out of disfavour and neuroleptic. If you look at the history of the word, basically focusing on the side effects of antipsychotics, that's what a neuroleptic is. So we decided to change it and get rid of it. Accepted in one spot. Neuroleptic malignant syndrome has been entrenched so much we sort of allow it there. But whenever we refer to the class of drugs, we call them antipsychotics and other dopamine blocking agents. Now, if in the text we refer to it as this is a drug for schizophrenia, we would call antipsychotic. The problem is that class of drugs is sometimes used for other medical uses, like nausea. You know, some of the dopamine blocking agents neuroleptic could be used to treat nausea. So we don't want to call them antipsychotic when they're not being used for that purpose. So we basically made the terminology throughout the whole book consistent. And we also got rid of the word neuroleptic wherever we could. The other area where there's significant changes of terminology was, perhaps not surprisingly in the gender dysphoria section, terminology about gender.

  Dr. First: [00:37:22] If there's one area of the terminology, it's changing very, very rapidly. That's one of the a lot of terms become both. I don't say old fashion exactly, but they're just I guess they're let's let me tell you. So the key ones in in the gender dysphoria section, we used to say that the person you had your gender and the desired gender was the terminology that was original use. That's been changed now to the experienced gender, which is much more accurate. It's not just that you want it, you experience yourself as being that gender. Another the word phrase cross-sex as in the terms of a cross-sex medical procedure. That's another term, which is you can understand why the term was there. But that term is also going out of favour and it's been replaced by gender affirming medical procedure. And the other big one is the issue of being assigned Natal. So if you're considered a natal male, that means you were born male. That's, that's, that's also replaced because it's been replaced by assigned male at birth. It's really emphasizing the gender is what you were assigned with the doctor and the family thought you look like at birth. That's what gets you started. It's not that you're actually a male at birth, so it's really kind of highlighting the fact that gender is a social construct. And so the words have been changed to reflect that gender is not just a biological phenomenon. So they're basically basically bringing the text in line with current usage of these concepts.

  Saja: [00:38:59] That's great. So just to summarise it, we've changed. Instead of saying desired gender to experienced gender and instead of saying cross-sex medical procedures, we use gender affirming medical procedures. And the third one would be instead of saying natal at birth, natal male at birth or natal female at birth, we say an individual assigned male at birth, and the fourth one us retiring the term neuroleptic and using antipsychotic. Amazing. Should we move on to the next question?

  Alex: [00:39:34] I'm really curious to get your thoughts on this one Dr. First, for the DSM, as we've been talking about, used very widely, very highly regarded, and especially in North America. But I guess we're also wondering from your opinion, what does it do well, clinically and where where there's still some blind spots or weaknesses in your opinion, either from your own experience clinically or from what you've heard from other clinicians? And also you could speak to the research world if you feel there are pros and cons there to.

  Dr. First: [00:40:06] Well, absolutely. The DSM has gotten an immense amount of criticism over the last 30, 40 years. There are very high hopes when the DSM in 1980, when DSM three came out, that these conditions actually were like diseases and that they were closer to medicine than they turned out to be. So it's turned out, for example, that it would have been nice if all if you had a diagnosis of depression, that drug that antidepressants would be the drugs to use and only they would work. But it's turned out that the relationship between a diagnosis and treatment is many to many. So many treatments work for the same diagnoses like SSRIs, work for like anxiety disorders, a compulsive disorder, and given a disorder that's many, many different treatments. So we were hoping it would be a better fit between making the diagnosis and knowing what the treatment is. And that didn't quite work out. So that in that sense the utility has been a problem. So when some people say, well, why use, you know, what's the point of using the DSM if it's not going to help me practice? Certainly one use of the DSM that I think everybody would agree on as a as a getting back to the dictionary term, that's the way we communicate with everyone, coalitions, family members, newspapers, everybody uses this terminology. And if you use the word major depression, the person hearing you, if they know how depression is defined, well, understand that I'm giving you I'm going to refer you a patient with major depression. If the person is using it correctly, you can expect when that person walks into your office what that person you'd expect to look like.

  Dr. First: [00:41:40] You'd expect them not to have manic episodes, because if they had manic episodes, you would have said they were bipolar. So the terms both indicate what they have and what they don't have. So the terms are powerful as a communication. Beyond that, that's where it gets more controversy. The fact is that all of the treatments that have been developed in the past 50 years have been geared to some DSM diagnosis, like all of the medications on the market. To get approved for use in patients, you have to pick a drug indication to say this drug is indicated for depression. All that means is the studies have been done on patients with that diagnosis and it's been demonstrated that the medicine works better than placebo for that diagnosis. So as a clinician, if you're looking if your patient that you're seeing has a presentation that meets the criteria for social anxiety disorder, then if a drug is indicated for social anxiety disorder, you would expect it to work for that patient because that's where they date. So that all the treatment data and all the studies have been geared to the DSM system. So that's another. So it does tell you something, if we didn't have it, any system at all, you really be hard to get to get started about how how to think about how to plan the treatment. So it's been the framework for psychiatry for the past 50 years.

  Dr. First: [00:42:56] It's far from perfect and people point that out all the time. You have this lack of specificity. The the other hope was, I think when DSM three came out that once we defined when we really didn't know the causes of any disorders and I'm I was in practice back then and I and I the belief was that now that we have a system of criteria that makes it clear what the patient's conditions look like and we do the work and the studies will find out what the causes are now that we at least have a language we all agree on. You know, here we are 50 years later, we still don't know what the cause of virtually any of the mental disorders are. That's been a really big disappointment. In fact, some researchers have blamed the DSM for our not being able to find the cause. I think that's a little over, but I could see they make some points. It's the DSM drives research funding and drives drug development, and the system itself is has no validity. Then you're really in a hole. I think there's some problems with validity, but I still think it does. Have a considerable amount of validity, enough validity to make it useful, but it's far from what we would have liked it to be. So I think that I'm I'm the first to admit that it's an imperfect system. But when people start harping on I said, Well, what should we replace it with? And then nobody has an answer.

  Alex: [00:44:15] All right. An imperfect system is better than no system. As you were saying. Okay. So I think that that leads us in nicely, though, to Saja's, I think our last question for today. And so I'll hand it over to Sasha.

  Saja: [00:44:30] Yeah. So when thinking about the DSM and this whole system, if we are to replace it, what can we replace it with? And there has been increasing, increasing evidence about the Rdoc framework that the APA is working on. Could you tell us if it's going to replace the DSM and what are the differences between those two systems?

  Dr. First: [00:44:55] If Rdoc is not really a replacement. I mean, the ICD ICD is the only system in existence which is trying to do the same thing the DSM does. So, I mean, you know, you could argue maybe they really should only be one system, but I think it's safe to say that the ICD and the DSM will continue to co-exist indefinitely. But the other newer hopes, like Rdoc is basically a framework for doing research. That was an attempt. It kind of got started with the idea you should you shouldn't be doing a study looking recruiting patients for major depression because there's no doubt and schizophrenia is the same way that the people who have major depression probably have many different things going on biologically. It's a huge amount of heterogeneity. That's the big problem you have to people who meet the criteria for major depression, they're completely different, nothing in common other. Then you even have depressed mood in common necessarily because either depressed mood or loss of interest. So there's a huge variability for all of these diagnostic categories, which is a real problem. So Rdoc partly said, you know, if we're going to try to find the cause, the underlying biological cause of mental disorder, we should be recruiting patients based on whether they meet the criteria for a DSM disorder. We should be recruiting patients because they have some biological factor or pathway in common.

  Dr. First: [00:46:08] And that's what Rdoc. Rdoc has broken things down into domains of functioning. And so and they they break them down into they're based on known neurocircuitry. For example, there's a whole group of domains which are called negative valence systems, and they correspond to symptoms that people have that are negative like fear, anxiety, loss. These correspond to actual brain circuitry. So the idea is if we recruit somebody, a group of patients that all share in common the same domain, which is linked to the biology, we're much more likely to be able to have a homogeneous group of patients to be studied. So that's another one called Positive Valence, which is where mania and stuff comes in and substance use disorders as a cognitive one. And so so these are broken down, not diagnostic. And that's the whole idea that Rdoc it's cross diagnostic. It kind of ignores the entire DSM system and recruits patients based upon these common symptom factors which are connected to the neurobiology. It's a sensible approach. So it's almost like, say, the the DSM, we know we're not going to find the cause of mental disorders if we just use the DSM. I think everybody would agree very strongly. The question is what would help us find the cause? And Ladakh was a proposal by the NIMH for a completely different approach, much more tied to the biology.

  Dr. First: [00:47:36] And since a lot of the treatments they were looking for a biological and since we all know there is a biological basis for most mental disorders, that was very promising and continues to be a very promising approach. It's you can see it's not ready to replace anything. I mean, I think the reality is it will help us improve the DSM and the ICD as information comes in, we maybe will be grouping the categories differently. For example, once we determine that OCD and anxiety disorders have the same neuro circuitry. So we would reorganise maybe the disorders by the neuro circuitry, That approach is very appealing, but we're still far from getting there. So I don't think we see the Rdoc as a very, very useful replacement for basing science on a system, but it's also completely not practical for clinicians. That's the other thing. I mean, the DSM having a system which is symptom base that corresponds to the symptoms you see, that's very valuable. And also the Rdoc approach doesn't do well with things like delusions. What, what neurobiological is a delusion. I mean, the circuits, it's way too complicated. So it really works really well for anxiety, depression, addiction, not so well for a lot of the psychotic disorders.

  Alex: [00:48:51] That's super interesting. And I know I said that was our last question, but that discussion that just now raised one more for me, if that's okay with you Dr. First, which is that you said and I think nice line why Rdoc is not a DSM replacement. I know you don't have a crystal ball, but where do you see the future of the DSM going, like in DSM six, for instance, and beyond?

  Dr. First: [00:49:15] That's I think there's been a push on the DSM five. When they started work on DSM five, there was this hope for a paradigm shift, partly because of the frustration with the DSM. And that was not very I think it was very clear during the DSM process that we weren't ready to get rid of the current approach. One thing that another criticism of the DSM is the fact that it's a categorical system. You either have a diagnosis or you don't know which is not the world. Everything is not. Yes, no, it's like the shades of things. So everything's dementia, like blood pressure. One of the best examples of hypertension is a category. You either have hypertension or you don't. But in fact is it's a continuous measure of blood pressure. So any place you cut it, that's where you could call hypertension. So the same idea could work for mental disorders where you could have different possible cut points across the spectrum. And then and there's some reflection of that in the DSM five itself. So, substance, in fact, what I mentioned earlier, they got rid of dementia that was replaced by this neurocognitive impairment spectrum and autism. They got rid of Asperger's and autistic disorder, and that's now been replaced by an autistic spectrum disorder. And they did that with substance use and dependence. Now it's substance use disorder. So they're trying to move towards having some broader dimensions with cut points within them to define. So that's certainly a very, very important direction and that's already been started. And I think it will continue as we move forward. I'm not sure if this what the next big paradigm shift is, because if I knew that, I would have to know what's going on. I mean, I have a really amazing crystal ball to know that.

  Alex: [00:50:59] Or what proposals might come through that. The new website.

  Dr. First: [00:51:02] Yeah, right.

  Alex: [00:51:03] Well, thank you so much, Dr. First, for joining us today. We really appreciate it. I know I learned a lot. And so thanks for being here. And Saja, thanks so much for the great first episode and this idea. And I hope you come back for another. Take care, everyone, and we'll see you next time.

  Dr. First: [00:51:24] Okay. Thank you.

  Saja: [00:51:25] Thank you.

  Alex: [00:51:29] Psyched is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Saja Jabari and myself, Alex Raben. The audio editing was done by Alex Raben. Our theme song is Working Solutions by all live music. Special thanks to our incredible guest, Dr. Michael B, first for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at PsychED Podcas.org Thank you so much for listening.

Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam

• Episode 46: Antisocial Personality Disorder and Psychopathy with Dr. Donald Lynam

  Dr. Chase Thompson: [00:00:12] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers the development of antisocial or psychopathic personalities and features our guest expert, Dr. Donald Lynam. Dr. Lynam is a clinical psychologist by training and professor at Purdue University, where he heads the Purdue's Developmental Psychopathology, Psychopathy and Personality Lab. He has written extensively on the topic of antisocial and psychopathic personalities. The learning objectives for this episode are as follows one Develop a basic understanding of what is meant by antisocial or psychopathic personalities two be aware of some of the core characteristics and traits of these personalities. Three Describe the theoretical basis for the development of these personalities, as well as their clinical trajectory over time. I just want to make a note to our listeners that we will be referring to the DSM five criteria for antisocial personality, as well as a psychopathy checklist or PCL. Dr. Lynam, is there anything you would add to that or anything you want to clarify?

  Dr. Lynam: [00:01:21] No, that sounds about right. I mean, I also work on sort of just personality disorders more generally and personality more generally, but that's a pretty good description.

  Dr. Chase Thompson: [00:01:31] Dr. Lyneham Since is kind of an interesting area, we don't always ask our expert this, but I'm just curious how you how did you get interested in this area of personality and psychopathy more in general?

  Dr. Lynam: [00:01:43] Sure. Well, I started my graduate training with Terrie Moffitt at University of Wisconsin, and her her main interest was kind of the longitudinal study of antisocial behaviour and folks who would become kind of severely antisocial later in adult. I mean, that's a huge issue kind of in that sort of research is that all adults who were antisocial were antisocial as kids, but not all antisocial kids grew up to be antisocial adults. So a lot of her work was about how can you identify kids who are at greatest risk for continuing kind of their delinquent or their antisocial behaviour into adulthood. So I kind of started there looking at early risk factors like IQ and neuropsychological deficits and problems. And while there, her husband, Aslam Caspi, also worked some with him, and he was more interested kind of in personality. So I added this kind of personality layer. And then I took several classes with Joe Newman, who's a psychopathy researcher. So I became very interested in psychopathy at that point. And so those those kind of interests began to merge. And my earlier work was sort of on trying to identify can you identify in early adolescence kids who look psychopathic and who might go on to become to be psychopathic in adulthood? So that was kind of my my earliest work. But then I was at University of Kentucky, and I began working or hanging out more with Tom Whitaker, who was a big five factor model of personality fan. And it's sort of at that point that I began thinking of psychopathy the way I do now as sort of this collection of personality traits that that if you're extreme enough and you have enough of these, you're going to be psychopathic. And so that's kind of the history of how I got involved in this. And ever since about whatever late nineties, I've been pursuing that line of research.

  Dr. Chase Thompson: [00:03:35] I see. And I think we'll get into some of those points that you brought up a little bit later on. But I think maybe a good place for us to start would be sort of some definitions of the terminologies, because I think that's a source of confusion for myself at least. And I know some other learners in the areas of psychiatry and psychology. So maybe I'll just put it out to you. Like how would you sort of define the terms an antisocial personality, or how is that different or similar to a psychopathic personality?

  Dr. Lynam: [00:04:12] Well, I think ultimately that they are referring to the same things. I mean, there's been a distinction. So there are three terms that get used. Psychopath, sociopath and antisocial personality disorder. And I think ultimately they're all referring to the same people, which typically is sort of folks who are seriously, consistently chronically antisocial. It's sort of what it's meant to capture. The distinction between APD and psychopathy was really about how they were operationalized. So so in DSM three, this distinction really began to emerge. DSM three adopted these very behavioural criteria that came out of Leigh Robins work. And so it was really just a series. It was like a behavioural checklist, right? And you just sum those up and check the things they had done and that was how the diagnosis of of APD or antisocial personality disorder was arrived at. Psychopathy was about was a bit different. It kind of grew out of work. It was more closely aligned with kind of beckley's clinical description. And it had a direct line through Bob Hare who was trying to take collect these description. He had this in-depth, in-depth descriptions of 16 folks that he thought were psychopathic, and he had a set of criteria. And Bob Hare was interested in using those criteria in prison settings, maybe to identify this this kind of very chronically and consistent antisocial group of folks.

  Dr. Lynam: [00:05:45] And so he built the psychopathy checklist in that kind of forensic setting or that prison setting. And it was a bit more focused on sort of traits. Right. So callousness, lack of remorse, lack of guilt, irresponsibility. So it wasn't just this behavioural checklist. And so that was the initial big distinction between antisocial personality disorder and psychopathy across time, like DSM four DSM, four TR, the criteria for APD have moved much more much closer to psychopathy criteria, where now they're really just traits that are being assessed and rather than the close. So so APD and DSM three are used very close criteria. Right. Did they do this act? Did they do that act? Did they do this other act? The criteria now in the current DSM are much more open, like, does he does things? Do they do things that look like they lack remorse? So it's not just this like checklist of things that you had to check. And so those diagnoses are becoming much more closely aligned. And I think a big deal was made about how different they were early on, I think in part Bob Hare and colleagues, to try to highlight how good the psychopathy diagnosis was and why you might want to use that. Their big line was like virtually 90% of people in prisons will receive antisocial personality disorder diagnoses.

  Dr. Lynam: [00:07:16] But but only a subset of those 20% will get diagnoses of psychopathy. So but but all psychopaths, also all individuals with psychopathy, will get diagnoses of APD. And that, I think, was mostly about threshold. I mean, so on the psychopathy checklist, to get a diagnosis of psychopathy, you need 30 out of a possible 40 points. And that's a pretty strict cut-off. But for APD, you needed three out of nine criteria. So so there's a huge difference in the threshold that led to that sort of subset finding or that sort of subgroup finding. And the other thing that gets used is a sociopath, and it's often contrasted with psychopath. And the idea there is that sort of there's a difference between why people got the way they did. And so there was an assumption that if you were for people who were psychopathic, they were sort of born that way or as innate or something internal to them. But the sociopath was created by his or her environment. They they grew up in a really poor environment which pushed them down that path. So they're still meant to refer to the same type of people. But there's a difference in the assumption about where it came from.

  Dr. Chase Thompson: [00:08:32] And correct me if I'm misconstrued misconstruing what you're saying a little bit, but it sounds a little bit like the DSM version of antisocial personality is sort of a an outward checklist that tries to capture the person's outwardly manifesting behaviours. Sorry for listeners who don't have the DSM criteria in front of them, but basically they're mostly outward behaviours, except for, I believe, one which is lack of remorse for, for such behaviours. But I guess there's been concerns raised by some people that one could enact those certain antisocial behaviours. Say you're, you're experiencing poverty and you need to commit a certain amount of crimes to feed yourself and or you have a substance use disorder and you're sort of caught in this horrible cycle of trying to, to obtain substances for yourself that basically an individual without sort of a core of psychopathy could, could still end up meeting criteria for an antisocial personality disorder, but may have a different underlying subjective experiences. Is that a concern in terms of differences between those two constructs or.

  Dr. Lynam: [00:09:54] I mean, it's possible. I mean, I think I think the DSM criteria have more kind of trait like things. So I'm staring at them now. So I can tell you, I mean, one is very behavioural failure to conform to social norms and so indicated by repeatedly performing acts that are grounds for arrest. Lots of reasons for for committing crimes, as you just outlined. I mean, deprivation need sort of know growing up in a culture where that's in a place where that's the only available way to get, get the things you want. But there are some others deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility, lack of remorse. So, I mean, those are a little more less behaviorally tied or less less specifically tied to the antisocial stuff. But but it is still a concern. But but it's also a concern for psychopathy. I mean, if you look at how the psychopathy checklist is scored, it's based on a semi-structured interview and a file review. Right. And there's a lot of emphasis placed on crimes committed. So so in fact, a lot of what they call factor two psychopathy is based kind of on criminal history. How much have you done? When did you start? Do you show remorse about those crimes? I mean, so so so those crimes sort of suffuse the psychopathy checklist as well. So so I do think that's a possible concern. I mean, I think it would be very hard to hit the tops of these scales just on the basis of having come from a really rough and deprived environment or disadvantaged environment. But but certainly sort of low to mid-level elevations would certainly be possible, I think, for reasons that didn't have to do with sort of the underlying personality that this person possesses.

  Dr. Chase Thompson: [00:11:48] Got you. You know, in terms of when we think about, say, psychopathic individuals, maybe I'll draw a similarity to, say, borderline personality disorder, where we think of affective dysregulation. Is this core one of the core defining features of the disorder and some of the other aspects of the disorder kind of flow out from that core. Is there a sort of core characteristic or defining features of psychopathic individuals?

  Dr. Lynam: [00:12:24] Sure. I mean, I think I think there's one big one and then sort of a fairly large secondary one. And the first is sort of this this interpersonal dimension that that if you want to talk about the negative pole, you call it antagonism. If you want to talk about the positive poll, you call it agreeableness. But this is sort of a basic measure of personality shows up in everybody's personality model. It shows up in these models of disordered personality and it's an interpersonal dimension and it's really about how you feel about other people. So it's separate from extroversion, which is like, how much do you like them, how warm you are, This is your orientation to them and you kind of at a very basic level, it's a nice versus mean dimension. Antagonistic folks are egocentric, they're lying and manipulative. They're callous. I mean, they really just don't care much about other people. And I think that accounts for almost all of the most of the symptoms that we that we use to define psychopathy. And in fact, if you take these sort of self-report measures of psychopathic personality. It's the glue that holds them together, both within an inventory and across inventory. So this is a feature that that is really shared across all various ways of assessing psychopathy.

  Dr. Lynam: [00:13:45] There's another important part which which is sort of this low conscientiousness or lack of constraint or disinhibition that also seems to be in there. And so this is that poor impulse control, this lack of self discipline, this lack of this irresponsibility bit that sort of has. And when you put those two things together, I mean, you just have a person, I think, who is free to do whatever pops into their head because they're not constrained by by what the effect their actions have on others or what other people expect. So boom, they can do whatever they want there. And and they're probably not constrained by consideration of future consequences either. And so. Yeah, they just they lack these internal constraints that most of the rest of us have. If an antisocial impulse pops into our head, we think, well, I could get in trouble. That might hurt that other person. They might be really hurt. What would that do to my social? I mean, there are all these things that we think about that kind of keep us in line. But if you start peeling those off, you get a person who's pretty much capable of doing almost whatever they please.

  Dr. Chase Thompson: [00:14:58] And along those lines, like lack of remorse is sort of one of the criteria as well. And I think, you know, when you you hear about psychopaths talked about in the media or or among just in general conversation, it commonly comes up that they don't they lack empathy. I mean, part of the reason I bring this up is because lack of empathy is a feature that occurs across numerous different disorders in psychology and psychiatry, including it's like a schizoid personality or pathological narcissism or. So on, but you don't necessarily see these like very antisocial acts among in these other sort of diagnostic entities. So are you sort of suggesting that it's this antagonism and lack of restraint that is sort of the the thing that separates them and sort of drives the antisocial behaviours?

  Dr. Lynam: [00:16:02] Or in part, I mean, I think I think I mean, narcissism and psychopathy are pretty closely related. I mean, we we do research on narcissist, I do research on narcissism as well with my collaborators. And the core feature to lots of narcissism is this very similar antagonism dimension. I mean, that seems to be what's what, why these two things are so highly correlated with each other. If you look at kind of relations between psychopathy and narcissism is they both share this sort of antagonistic core of I'm better than others. And I'm I don't really care what my what what effect my actions have on you because frankly, you're not important. Right. And so so that is a common theme there. I mean, I think what you get for psychopathy is maybe it's a little more broad. You add that deceptive Ms.. And that willingness to manipulate other people and and use them, there may be a little bit absent in narcissism. But the other big part is narcissism is not associated with this control or disinhibition. Right? I mean, it doesn't have that sort of poor impulse control piece to it. So I do think that's important for separating out psychopathy from narcissism.

  Dr. Lynam: [00:17:15] The other role it serves, too, is you'll hear people sort of talk about successful psychopaths often. And what I think people mean when they say that is they mean people who are antagonistic but can still hold it all together. Right. So they've got impulse control. I think they have enough impulse control to contain to to get advanced degrees. They have enough impulse control not to punch somebody when they feel like it. Right. And so but but that kind of callousness and that coldness and that lack of concern for other people lets them do lots of stuff that is not very nice. Right? Cheating, manipulating, using. I mean, this is where all the financial or some of the financial crimes come from, right? They don't care about the people whose money they're taking. Right. It's all about sort of them. And so those folks get called successful because they haven't been arrested. They don't have a long rap sheet. But but but they're really just sort of these incomplete manifestations of psychopathy because they've got some of the some of the traits, but not the others.

  Dr. Chase Thompson: [00:18:20] This is sort of touch on what you talking about is psychopathy being sort of a cluster of specific traits. I'll just put it to you. Like, what are the traits? Is it you mentioned antagonism and impulsivity.

  Dr. Lynam: [00:18:32] Right. So I work from this this big five model, A personality, which is sort of the current coin of the realm. And it suggests there are these five broad traits that you can use to describe everybody that are relatively universal and extroversion. So one's orientation to others, whether you really like being around others or you prefer to be alone neuroticism, which should be very familiar to anybody working with psychopathology, right. Sort of high levels of negative affect that are experienced easily, often, and take longer to subside versus kind of an emotional stability. There's this openness to experience idea that people are open or close to new experiences. And then you've got the two that I'm most interested in, which is the one is that antagonism dimension or that agreeableness dimension, which is really that other interpersonal dimension about how you are oriented to others or whether you care about them or you don't, whether you're nice or whether you're a jerk. And then the last one is this conscientiousness domain, which has a couple of pieces to it, but it's like organisation and impulse control and that's sort of what it gets at. And so I work with them. I work with a slightly bigger model because the specific five factor model that I work with has six subscales for each one of those. And you can get this very kind of well articulated profile of psychopathy across them. One of the things that comes out is they are low on every aspect of agreeableness. So they are they are distrustful, They are lying and manipulative, They are selfish, they are noncompliant, they are immodest and they are callous.

  Dr. Lynam: [00:20:11] And so across the board, that's true. And so that's a huge feature. And the other bit is you get within conscientiousness like it order doesn't matter, right? So one of the aspects of order is like, how neat is your room? That doesn't seem to be very psychopathy, but the things that are like dude awfulness like I do, what I'm supposed to do is self discipline. I finish stuff, I start and then sort of deliberation, I think things through. So those are the big pieces. And then there's this little mix of stuff on extroversion and neuroticism, the kind of up and down. So within neuroticism, they have a lot of hostility, but they don't have much self-consciousness, they're not depressed, they're not anxious. And then in extroversion, they are not warm, but they are sort of gregarious and assertive. So it's kind of this little mix profile. And that extroversion neuroticism piece gets clumped together in some inventories and it gets called boldness or fearless dominance. So those are the big three pieces of psychopathy. And I know there's debate about how important that boldness piece is. I mean, I think it's window dressing, right? I don't think it does anything really for for the kinds of stuff we care about in psychopathy. But but those are, I would say, the big three pieces. And so the more of those pieces you have, the more psychopathic you are kind of in my model because it's nothing more than just this collection of extreme traits.

  Dr. Chase Thompson: [00:21:47] Yeah. And I think going back to the impulsivity thing and talking about the high functioning psychopath versus the lower functioning or someone we might imagine is in a lower socioeconomic status group and maybe more involved with the criminal justice system. It almost seems that the the ones who do have some restraints on their impulsivity and who are of more ability to carry out their goals is maybe as aligned as they are, almost seem to be more harmful in some sense. Like, I don't know, I guess I'm thinking of people like Bernie Madoff. I think he was assessed and not actually found to have psychopathic personality by whoever assessed him because he didn't meet sort of the other external behaviours. But I guess it seems like there's like this problem of maybe overdiagnosis in people who are more, more actively involved in in criminal acts versus those who are sort of high functioning and sitting in, in a high up office downtown somewhere.

  Dr. Lynam: [00:22:59] I mean, I think that's definitely a risk. I mean, but, you know, that's an issue with white color crime anyway, right? I mean, people regarded differently than kind of non white color crime, right? It gets overlooked a lot or that's not real crime or I don't know how people feel about it, but but that's just my kind of my general sense is that people don't think of white color. Crime quite in the same way they think of other types of crime. And so, I mean, but I mean, Bernie Madoff defrauded. Tons of people out of lots of money. But I mean. But but, but, but he but he wasn't violent, right? And he didn't have a huge, you know, a long, long rap sheet, which will elevate your psychopathy checklist scores because that's a huge focus of of of what they're assessing in prison settings. So, yeah, I mean, but the other thing that happens to I mean is that people want to call Bernie Madoff psychopathic. Right? And they want to call the person who's called psychopathic because it's like a curse word, you know? You know, and it's like we don't like that person. That person's not good. But but you have to be a little careful about how you throw the label around, because it is more than just that callousness. It does include these other pieces. And sometimes people will shrink the entire idea down to just one trait, coldness or lack of empathy or fearlessness or whatever it is. But these are all just kind of sub manifestations of the much bigger construct.

  Dr. Chase Thompson: [00:24:35] Right. As in people who are not necessarily psychopaths can still do some pretty bad things.

  Dr. Lynam: [00:24:41] Right. Exactly. I mean, you know, the the the individuals of psychopathy don't have sort of the corner on the market of antisocial behaviour. Right.

  Dr. Chase Thompson: [00:24:55] Maybe just changing gears a bit. Can we talk a bit a little bit about how common is the problem of psychopathy? How how many people in broader society or kind of experiencing what we're talking about here?

  Dr. Lynam: [00:25:13] It's funny, I've had a back and forth for three weeks now with one individual wanting me to try to tie me down to, well, exactly how many are there. And I think that's I think that's hard to do, because I really do think this is something that is continuously distributed in lots of ways. So my response to this person was, well, how many tall people are there in the world? Right. And that's the problem you run into. At what point do we decide to call somebody tall? And at what point do you decide to call somebody psychopathic or give them a diagnosis of psychopathy? I mean, the psychopathy checklist has a pretty explicit criteria. It's 30 out of 40 on their scale. That'll probably identify less than 1% of the population is my guess. If you could assess everybody on the psychopathy checklist, which you probably can't because you need to file a review and it takes forever. But but they have a pretty strict criteria. So kind of if you use that criteria, it's about 1%. If you do something like I think APD criteria is 3 to 5%, something like that. But again, if you change the threshold, how many do you need? How many? What's the score on the psychopathy checklist? Well, instead of 30, let's make it 25, because those guys are pretty bad, too. Then all of a sudden your prevalence rate increases. And with APD, we'll just require a set of three of three of them or four of them require five or six, and then your prevalence will decrease dramatically.

  Dr. Lynam: [00:26:43] Mine is always about sort of I think this is this is you can you can see this as not relatively normally distributed in the population. You have some people who are basically anti psychopathic, right. They are they have great impulse control and they're really agreeable. So they're like negative, psychopathic. And then you've got most of us who are somewhere in the middle and then you've got a bunch of folks out on the far end. And how far out do you want to draw that? I mean, two standard deviations above the mean prevalence rate of two and a half percent. So something along those lines. So that's how I think about it. I mean, the really, really extreme folks are relatively rare, but it depends on what criteria and what what threshold you're going to use. So it's sort of hard to put a number on that. But if you went with the psychopathy checklist, you're going to tell you about less than 1% at the very, very, very extreme end. And that's comforting unless you think that, you know, the person with a 29 is basically as bad as the person with a 30, and so is the person with 28, that it is continuous, that there's no point at which this seems to become qualitatively different. And so that's the issue you face anytime you're dealing with something that's continuously distributed like that is prevalence depends on where you want to draw your cut point.

  Dr. Chase Thompson: [00:28:05] Right. Right.

  Dr. Lynam: [00:28:06] That may not be what you wanted, but that's all I got.

  Dr. Chase Thompson: [00:28:08] Sorry. No, fair enough. I don't know if this is known, but is it is it expected that the prevalence is sort of the same across different populations?

  Dr. Lynam: [00:28:22] I think there's been some research suggesting well, some research suggesting that say the items on the PCLR don't function the same in certain groups. And so so that's a bit problematic. And that gets back to your idea about are these scores going to be elevated for people from disadvantaged backgrounds? And so there's some evidence that at least on some of the symptoms that are used in the psychopathy checklist, that that is problematic. And I think it's probably around most of the antisocial items because there are a lot there are multiple pushes to making people antisocial. And so if you grow up in an environment where you're experiencing a lot of those, you're you're going to elevate a little bit on the antisocial related facets. But but in terms of I mean, mostly men score higher than women, as you might imagine. And that's actually you can actually predict that just from the basis of what we know about the traits that are involved and the gender differences there. So that's one thing that you could certainly say with, I think, some authority, although there are some folks who disagree a bit saying, well, we should change the criteria. If you change the criteria and had different criteria, they would be more equal. That's that's possibly true. But but but in general, actually, it's interesting. Among all the personality disorders so kind of attend DSM, PDS and psychopathy if you sort of calculate gender differences on the basis of gender differences in the traits that they contribute to them, psychopathy by far has the largest sort of male to female ratio, but it should be the most male disorder of them all.

  Dr. Chase Thompson: [00:30:09] What do we know about the development of psychopathic personalities in terms of like, is it genetic, environmental and.

  Dr. Lynam: [00:30:20] Well, I think like most things, I mean, it's, you know, what is it, 40 to 40 and 50% of the variance seems to be heritable, you know, or 40 or 50% of the variation in the population seems to be due to genetic variation. And that's that's true for for lots of lots of these sorts of things. What we do know is, is that that that this adult manifestation has kind of adolescent and childhood precursors. I mean, if you look at if you look at kind of conduct disorder diagnosis in the DSM, there's a specify that is called callous unemotional traits. And that's basically Paul Frick's version of psychopathy in a lot of ways. And I had a version, too. We called it the childhood psychopathy scale, but it was much the same as kind of what what Paul's done, which is that sort of you can identify early on folks who are callous and impulsive and don't seem to care about other people and and all these traits. And there is some stability across time. And so it's not surprising that the kind of the child who's going to grow up to receive a diagnosis of psychopathy, of psychopathy, or who's going to look psychopathic in adulthood is also looking psychopathic in childhood and adolescence.

  Dr. Lynam: [00:31:33] Do we know how that comes about? Not really. Really? Well, I mean, I think Paul has done some work sort of on on on on parenting. And there seem to be some parenting styles that are associated with with those sorts of traits in kids in adolescence. But the problem with those studies, it's awfully hard to know. I mean, parents are also reactive to kids, and that's been shown again and again, right? Difficult kids who are difficult end up with parents who have certain parenting styles. And it may not be the parenting styles that come first. So it's really kind of a thorny thing to try to figure out about how does this develop. We do know there's a genetic component. We also know that 50% of the at least 50% of the variation is not genetic. And that's the hardest piece to get on. And, you know, and again, we didn't know what the genes what the what the genetics of it are at all. Anyway, These are global estimates, and our ability to identify any specific genes is really lousy. So I'm not sure that those numbers ever help us a whole lot.

  Dr. Chase Thompson: [00:32:39] Sometimes you commonly hear that, for example, an individual who has severe a personality disorder, that there tends to be some sort of contribution of early life trauma. Is that something that's relevant in psychopathic personality disorders?

  Dr. Lynam: [00:33:01] I'm not I'm not sure. I'm not sure about that. I'm not sure that's been as strongly demonstrated for psychopathy as, say it has been for some some other sort of disorders. So I would I'm not going to go out on a limb and say anything about that. Sorry, I just I just don't know.

  Dr. Chase Thompson: [00:33:17] Yeah, no worries. And you mentioned something about children showing some there being some stability of psychopathic traits over time, even from early childhood. What are some of the early signs that you tend to see in children?

  Dr. Lynam: [00:33:38] A lot of them are just sort of just the similar manifestations as what you find in in adults. So my earliest work was taking the psychopathy checklist and trying to operationalise it in a group of 13 year old boys using sort of archive data. And so so you could find things like they lie a lot, right? They're aggressive, they're in trouble a lot, but they don't seem to feel bad after misbehaving. They've got impulse control problems, you know, they steal. So it's a lot of the same sorts of traits. I mean, they're not stealing cars, right? But they are stealing food or things like that that are a little more developmentally normative. But sort of those same traits seem to be present earlier on as well, that they look slightly different, but they seem to mean the same thing. Yeah. So, you know, they seem to be they seem to be callous, they seem to be selfish. And one of the concerns was some of that stuff is, well, aren't all kids callous and selfish and and things like that. But but it's really a matter of degree, you know, like these folks are these these kind of kids who will grow up to show more psychopathic features are even more callous and even more self-centred and lie even more.

  Dr. Lynam: [00:34:55] And so it's about sort of elevations across all of those things that seems to predict higher levels of psychopathy. I mean, we did one study where we had those 13 year old boys that we had that we had assessed using this kind of childhood psychopathy scale, and we followed them up 11 years later in the young adulthood and gave them the the PCLSB, which is a psychopathy checklist screening version. And across those 11 years, I mean, the stability wasn't high, but it was a correlation of about 0.35, which is not awful when you consider it's 11 years. And these are different instruments being used. And there's mother ratings at time one and it was interviewer ratings at time, too. So there's definitely some degree of stability in all of that. And again, it's sort of like predicting like it's, it's the same sorts of behaviours, early predicting the same sorts of behaviours later on.

  Dr. Chase Thompson: [00:35:50] So what about in the DSM for antisocial personality? One of the criteria is that there's some evidence of conduct disorder behaviour in the past, and at the beginning we were talking about the concept of a sociopath or someone who might be like a it's an acquired antisocial personality. I guess I'm wondering how do you reconcile those things or is acquired sort of antisocial personality, not really a thing or or what's going on there?

  Dr. Lynam: [00:36:25] I mean, are you thinking that sort of those who acquire this antisocial personality won't show that sort of early evidence of conduct disorder? I'm not sure quite what you're.

  Dr. Chase Thompson: [00:36:34] Yeah. I mean, I guess I'm wondering, like if you have an adult who has what seems to be really antisocial behaviours, but as far as you can tell, there isn't clear evidence from, from the parents or on review of their development that there was clear conduct disorder behaviour.

  Dr. Lynam: [00:36:55] There have been a couple attempts to look at that. I mean there have been a couple this was years ago that I read on it, but there have been some people arguing that you can have kind of antisocial personality disorder in the absence of evidence of of earlier conduct disorder that you can sort of meet these other criteria and that it's still sort of meaningful and important. So I do think that's possible. I mean, I think there's a whole issue of sort of a lot of times like psychopathy checklist is used to predict future violence or it's used to predict recidivism, things along those lines. But there is an issue about the assessment being saturated with the behaviour you want to predict later on. So one of the reasons that the psychopathy checklist might serve so well as a predictor of future antisocial behaviour is because, boy, it's certainly built on past antisocial behaviour in a lot of ways because that file review just just bleeds into lots of those criteria. And so if you have lots of anti sociality in your background, in your file, you're going to elevate that psychopathy checklist purely on the basis of the past behaviour. So of course that's going to predict future behaviour very well.

  Dr. Lynam: [00:38:12] One of the ways we've tried to move away from that is trying to move to a much more pure personality assessment. And there have been some other folks too in the adult military who are working around the psychopathy checklist saying we should try to exclude antisocial behaviour so we eliminate that kind of contamination and we're getting more at sort of pure personality. There's something that's a little bit separate from the behaviour that we're interested in and care about, and that's almost what you'd be doing with the APD if you eliminated childhood conduct problems because that's the most antisocial or the most, frankly, anti-social criteria in that set. But I mean, I think it's I think it's meaningful to to have these characteristics in the absence of I mean, I think they I think a lot of times antisocial behaviour will follow from having this collection of traits because again, I think it's about the removal of of internal controls that let you do almost anything. And so I think anti-social behaviour is a pretty probable outcome if you have these traits. But, but again, doing away with previous childhood conduct problems is probably might not be a bad idea for for the APD criteria. Mm hmm.

  Dr. Chase Thompson: [00:39:28] What can we say about the prognosis or long term clinical trajectory of individuals with psychopathic personalities?

  Dr. Lynam: [00:39:38] Years ago, they thought they would talk about them being untreatable, right? You couldn't do anything with psychopathy, with individuals, with psychopathy. And they pointed to a couple treatment studies that looked just like things went terribly. There was no help at all. But but more recent scholars have looked at those and said those were crazy treatments you were trying. And sort of more recent stuff suggests that they're about as treatable as anybody with a personality disorder, which is so you can treat some, but it's not great, right? I mean, I think psychopathy may be a particularly difficult disorder to treat because there's not a lot of distress. I mean, like borderline right, individuals, borderline PD. I mean, they are remarkably distressed, right? I mean, they are not happy with how stuff's going. Right. But I think I think for folks with who are high in psychopathy or anybody who's high in antagonism generally, like they don't feel a lot of distress. They're like they're not anxious and worried and really, really sad. I mean, the pissed off and it's not their fault either. Right. I mean, it's your fault for for being so soft or it's it's the cop's fault for coming along at an inopportune time or it's the victim's fault for falling and hitting your head more severely.

  Dr. Lynam: [00:41:05] I never intended for her to get hurt that bad, You know, this sort of things like that. And so I think it may be harder to get a lever. What do you grab to try to convince somebody to change? And Reed Molloy years ago was talking about kind of what he tried to do and was try to make them understand that you are not happy now. Jail sucks. Jail is not fucking right. What can we do to keep you out of ending up here again? And so it kind of it's an appeal to a certain amount of selfishness that sort of you might be happier if you could avoid prison or if you could sustain a relationship or. And so I think I think that's an issue for for psychopathy is sort of where do you grab on to? What kind of handle can you get? Because that big handle of subjective distress and you feel terrible, let's figure our way out of this just is not as available as it is in other places.

  Dr. Chase Thompson: [00:42:06] Right. Right. I think there's also been some areas I've read around kind of like a burnout effect of antisocial behaviour as as individuals hit their midlife. Is that a phenomenon that that you recognize?

  Dr. Lynam: [00:42:23] Well, one of the things that seems to happen a lot I mean, is this sort of crime decreases, our crime changes at least. So if you chart sort of the changes in levels of the psychopathy checklist factors, they break them into two factors. One, they I think erroneously call personality and the other they call antisocial behaviour. And it's more about for me, it's more about pure antagonism and then a mix of antagonism and conscientiousness. But what you see is that that factor one stuff changes a little bit, maybe decreases a little bit, but it's really the factor two stuff that drops off. And that's probably due to the kind of the way in which it's assessed and the reliance on crime. I mean, at 50, you just can't fight as much. You can't you can't break stuff and climbing windows anymore. I mean, it's sort of I think the burnout is more about the sort of crimes that are being committed. And so so those are definitely dropping off because I think they're hard to sustain as you get older. So I do I do think that that part's definitely a real thing. We're about to start looking at, at least in an older age cohort, just sort of psychopathy assess purely on the basis of personality. So not including the really antisocial stuff to look and see what does happen across 15 year old, 15 year span from, say, 60 to 75. Are the traits themselves changing very much at that point, or is it reasonable to believe that all the change people are reporting on is really this this drop off in antisocial stuff?

  Dr. Chase Thompson: [00:44:03] So if I can try and paraphrase you it's it's it's that the outward behaviours decline, but maybe the inner subjective world remains the same.

  Dr. Lynam: [00:44:15] Yeah, I think that's fair.

  Dr. Chase Thompson: [00:44:17] Okay. Psychiatry and psychology. We always see a lot of comorbidity. And what are the common comorbid issues that people with psychopathic personalities run into?

  Dr. Lynam: [00:44:34] I mean, you know, one is, is it really a kind of a close cousin personality disorder, which is narcissism. So you end up with narcissism is highly correlated with psychopathy. Substance abuse and substance use problems are highly correlated with psychopathy as well. I mean, there are diagnoses, but but aggression is a problem. Relationships are a problem. But but again, because they tend to lack this subjective distress, it's not as comorbid with other forms of psychopathology as, say, borderline personality disorder is right, which is co morbid with almost everything, because they all have this big piece of of emotional reactivity and subjective distress. And you don't really find that in psychopathy, but it is co morbid with all the externalising behaviours. So various sorts of substance use alcohol problems, I mean all, all that sort of what gets called externalising stuff, psychopathy sits right in the middle of that.

  Dr. Chase Thompson: [00:45:38] So is it kind of protective against the internalising depressive depressive anxiety disorders?

  Dr. Lynam: [00:45:45] It is, especially if you allow that boldness component in. I mean, in fact, if you allow boldness in psychopaths, psychologically speaking, you really want to be psychopathic because you are relatively immune to those sorts of those sorts of problems. If you don't have that in there, then you can get some of the kind of depressive sorts of stuff going on. But but if you allow boldness as a piece of psychopathy, it definitely protects against against kind of internalising disorders because frankly, it's it's virtually the opposite of internalising disorders.

  Dr. Chase Thompson: [00:46:25] Right, Right. So I think we're getting closer to the end of our time together. One maybe question I have is sort of more theoretical, broader question, but sometimes thinking about personality, I wonder why is psychopathy a something that's developed in people as opposed to any other disorder? And does it we've talked about it being sort of on the spectrum.

  Dr. Lynam: [00:46:53] I see.

  Dr. Chase Thompson: [00:46:54] Is there some sort of benefit that antagonism maybe has a in a more milder sense or what is is there any sort of function of psychopathic orientation?

  Dr. Lynam: [00:47:05] Sure. So I'd say a couple of things. One, one thing I would say I think is that I'm not sure psychopathy is a natural category in the sense that sort of I think what it is, is it's a it's a presentation that is really kind of bothersome and people notice it. Right. And so you can't help but see it. These folks are like this. But but I'm not sure that it coheres like a syndrome does. So I'm not sure it's a natural category. But but the question is interesting, like, why does high antagonism exist at all? But why are we not all just kind of flat, bare and all nice to each other and stuff? And, and I do think there's some advantage to being a bit of a jerk. I mean, quite quite frankly, I think I think this is a way of pushing and getting what you want. It's a way of stepping ahead of others while stepping on others, which can be to kind of your individual advantage. I mean, these are sometimes I think of these if you think of these in evolutionary terms, different reproductive strategies, these are the cheaters. These are the folks who aren't following kind of our rules as long as there are too many of them.

  Dr. Lynam: [00:48:13] It's a very successful strategy. And so I think that sort of these folks are probably I mean, if you want to talk purely evolutionarily, these folks are having more babies, right? At least at least the men are right. If you're if you're sort of can't have committed relationships, then any relation you have is sort of uncommitted. And so you have lots of them. And and just that'll propagate your genes just quite simply. And I do think just from a subjective feeling, I mean, some of these folks are decently successful because they're the first in line and they will find their way up front if they're not there already. And so this is a manipulative they don't care what they do to you. They don't think you're particularly important. And this this this allows them to get some of what they need at the expense of others. And so so that's why I think probably, you know, there is high antagonism out in the world. But not everybody could be like that. Right. Because living in community becomes really very difficult, is my thought on it. I mean, I'm not an evolutionary psychologist, but that's me pretending to be one.

  Dr. Chase Thompson: [00:49:28] Fair enough. I know you spoke a little bit about treatment, just in the sense that there's not a lot a ton of intersubjective distress that drives someone towards treatment. But say you did have someone who is, for some reason, very motivated to get treatment. Is there any sort of modality that's been shown to help at all? Or.

  Dr. Lynam: [00:49:52] Not really

  Dr. Lynam: [00:49:53] I mean, I don't think I mean, I don't think people have studied treatment for psychopathy in the same way they have, say, for for borderline or for depression. I mean, not what works best. I mean, so you certainly don't have these sort of cross treatments and people trying to figure out what will work. I think people have thought for a while that these folks are probably relatively untreatable. So and frankly, they don't come in a lot. I mean, you know, in your clinical practice, let's say, how many grandiose narcissists do you see rolling in of their own accord? I think the answer is very few. They get there because the spouse brings them in or court orders them there. I mean, this is what kind of brings them in. So there's not a huge population to work with. And I think a lot of a lot of clinicians find that group a difficult group to work with. And I think individuals with psychopathy are much the same because they've got that same core of I don't know why I'm here, I don't have a problem. You guys have a problem. This kind of shifting of blame. And again, what do you do? I mean, I think Reed Molloy was probably right. If I find a lover in there, that's a selfish leaver. Look, you don't like coming in to see me. You don't like being in trouble with everybody? What's something we could maybe figure out that you could do differently that would keep you from ending up in jail or would allow you to resume a decent marriage with with your spouse. Right. I mean, that's kind of the only thing I can think of. I mean, I do think I mean, I'd love to see somebody develop. There's a unified protocol for negative affects in the world today. I mean, boy, if you could come up with something like that for antagonism, that'd be great. You know, maybe it starts with this kind of motivational interviewing approach about sort of just getting them to think about change because the way they're doing stuff now is is less than optimal for them.

  Dr. Chase Thompson: [00:51:55] Hmm. Mm hmm.

  Dr. Lynam: [00:51:57] But but I mean, appeals to look at. Look at how you hurt this person are probably not going to work very well. Wow. Yeah.

  Dr. Chase Thompson: [00:52:06] Hmm. Well, is there anything that you think that we haven't touched on in terms of psychopathy that you think is important to say at this point?

  Dr. Lynam: [00:52:17] No, I think I think I've got to say pretty much everything I wanted to say. I appreciate your questions and I hope I was somewhat clear, at least.

  Dr. Chase Thompson: [00:52:24] Yeah, I think you're. Yeah, absolutely. Well, thank you very much for being on our podcast. We really appreciate it.

  Dr. Lynam: [00:52:33] Thanks for the invitation.

  Dr. Chase Thompson: [00:52:34] Okay.

  Dr. Chase Thompson: [00:52:43] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by myself, Chase Thompson. Theme song is Working Solutions by all Live music, especially thanks to our incredible guest, Dr. Donald Lynam, for serving as our expert for this episode. If you want to get in touch with us, you can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.Org. Thank you for listening bye.

Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

• Episode 45: Reproductive Psychiatry with Dr. Tuong Vi Nguyen

  Nima Nahiddi: [00:00:10] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll be exploring the psychiatric aspects of reproductive mental health. I'm Dr. Nima Nahiddi, a fourth year resident at McGill University. And I'm joined by Arielle Geist, a second year resident at the University of Toronto, and Audrey Le, a first year resident at McGill University.

  Arielle Geist: [00:00:34] Hi, everyone.

  Audrey Le: [00:00:37] Hi, everyone.

  Nima Nahiddi: [00:00:39] We're really grateful to have our guests, Dr. Nguyen, this week to share her expertise. Dr. Nguyen, if you could, please introduce yourself.

  Dr. Nguyen: [00:00:48] Sure. So I'm a reproductive psychiatrist at McGill University Health Centre.

  Nima Nahiddi: [00:00:54] For this episode. Our learning objectives are the following to define the field of reproductive psychiatry to discuss the possible neurobiological pathways impacting mood and cognition during the reproductive cycle of women, to discuss the influence of sociocultural gender roles on psychopathology, to list the DSM five diagnostic criteria of Premenstrual Dysphoric Disorder. To recall the Epidemiology of Premenstrual Dysphoric Disorder. To describe the steps in the diagnostic evaluation of Premenstrual Dysphoric Disorder. To list lifestyle and psycho pharmacological interventions for Premenstrual Dysphoric disorder and to discuss common mental health concerns during the perimenopausal period.

  Arielle Geist: [00:01:42] So I'll start with the first question today. So before diving in today's discussion, could you briefly explain the clinical scope of reproductive psychiatry and what your work entails? Exactly.

  Dr. Nguyen: [00:01:55] So reproductive psychiatry is really about all of the mental health changes that occur in a woman's lifetime during reproductive periods, typically around puberty. You start to see changes related to hormones and you can see a significant proportion of women who start to have premenstrual syndrome, 70 to 80% with a smaller proportion that go on to the premenstrual dysphoric disorder. Another stage of life when you have these hormonal fluctuations is, of course, the pregnancy and postpartum period. And then finally you have the perimenopausal period. And there has been talk amongst us, reproductive psychiatrist that psychiatry should also include hormonal changes for men. But we'll see maybe in in ten years. For now, it's pretty focused on women's mental health.

  Arielle Geist: [00:02:46] Mm hmm. Since you mentioned hormones, my next question was, how do these hormones, especially in the field of reproductive psychiatry, where the focus is on mostly estrogen and progesterone, how do those hormones modulate mood and the neurobiological pathways that are involved in regulating mood?

  Dr. Nguyen: [00:03:06] There's no simple answer for that. I think that when you think about hormones and women hormones, you have to think about the fact that there are classes rather than just thinking about estradiol and progesterone. It's really all of the steroid hormones are linked together. And you can have up to 54 metabolites, maybe more, maybe more metabolites could be discovered. And then you have these three or even four classes. I don't know if you're aware, but it all starts with cholesterol. And then you have one branch that go on to be corticosteroids. You have one branch that go on to be the estrogens, but then you have tons of different types of estrogens, including 17 beta estradiol, the most famous one. And then you have the progesterone progestogen basically progesterone alone and all of these related hormones. And then you also have the androgens like DHEA and testosterone. So all of these hormones change cyclically throughout the menstrual cycle and then very drastically during pregnancy and the postpartum period and of course the perimenopausal period in terms of how they affect neurotransmitters, I would say again, no easy answer, but just in a very broad way, in simplified way, the estrogens tend to regulate serotonin. Well, all of the all of the neurotransmitters, it's really like they're really almost like dirty medications. So they will affect serotonin and norepinephrine, dopamine in different ways. Progestogen also and estrogen suppression tend to have opposite effects. So for example, estrogen tends to be more stimulating to, for example, up the serotonin, serotonin tone and also androgenetic tone. And then progestogen tend to act again, not all of them, but most of them act through the GABA receptor and then they will lead to inhibition or kind of downregulation of the HPA axis, for example. So the kind so more a bit more like benzos androgens, there's a lot of research that remains to be done on androgens, which are really not well studied. But the typical effect is really in terms of activity, mood, lability, competitiveness, things like that.

  Arielle Geist: [00:05:23] Thank you. I think you really were able to simplify something that that seems very complicated to. I think many trainees. Next, because of the way that we formulate things in psychiatry, going with the biopsychosocial model, I wanted.

  Arielle Geist: [00:05:38] To step away.

  Arielle Geist: [00:05:39] From the biological aspects of reproductive mental health for a second and take some time to explore its social aspect. So my next question was about how do you feel that social and cultural type of gender norms affect clinical presentations of this field? For example, how the way that it might affect the experience that mothers who have postpartum depression have?

  Dr. Nguyen: [00:06:05] I think there are still many unanswered questions regarding that. And one of the key aspects of the literature is that we still don't know enough about the social determinants of health for perinatal depression. I hope that beyond post-partum depression, we'll start to talk about perinatal mental health disorders. I think PPD has become very famous. Postpartum depression has been recognized by and large by the mainstream media. But then oftentimes we miss the anxiety disorders that present during the period of period the post-traumatic stress disorders, OCD, which is its own different beast as well. And so I think that, yes, there's a lot of advantages to to have more recognition and awareness, awareness of depression. But we must I think it would be more helpful for women if we use a broader term, perinatal mental health disorders. And I think that in the past decade or so, more and more women are delaying fertility or delaying reproduction to further career or other interests that they may have. And so more and more women will have unfortunately, more and more couples will have infertility and fertility problems. And then that kind of opens the door to a whole other area of mental challenges, which is all of the mood fluctuations related to hormonal treatments, IVF IUI, and in addition to the psychological issues of repeated miscarriages and pregnancy complications. So I think in terms of in terms of that social aspects of mainstream recognition and awareness, we've done a lot, but there's still there's still a lot of work to do because some women will still come to me and say, well, I have suffered for two years because I had no idea.

  Dr. Nguyen: [00:07:54] I thought they were suffering from postpartum anxiety, let's say, and then not want to present to not want to discuss it with their doctor because it's they felt they were obviously not depressed. So I think that's that's one aspect. I think the other aspect socially that is that is important to mention is that unfortunately, we're still, despite the fact that Hillary Clinton said several years ago that women's rights are human rights or human rights or women's rights, something like that. I don't know if I'm quoting her properly, but I still think that we are struggling to we are struggling to kind of have the political recognition that we that we need. And this is at all levels. Just to give you an example, all of the reproductive psychiatrists currently working in Quebec have really struggled to implement to have even a prenatal clinic. This in the in face of the fact that we know now that maybe one in three women around the period may have a significant period of mental health disorder with all of the uncertainties surrounding COVID, with the fact that most of the child care burden and house chore burden still falls on the woman at home, and that several of them have out of work because of that. Even so, we're still really struggling to establish these these clinics. And there's actually just one, I would say, clinic in the Quebec province that offers psychological help, an experienced nurse and a psychiatrist. Then the rest of us are basically perinatal and reproductive psychiatrists that are working with little support.

  Arielle Geist: [00:09:32] Mm hmm. Thank you for all of that wise insight. I have one last question about the social aspect that I think you kind of touched on to. So when I was reading on the literature leading up to doing this episode, some of it suggested that premenstrual syndrome and postpartum depression and such are quite seem to be a bit more culture bound because there is some literature out there that suggests that it's less prevalent outside of Western countries. So I was just wondering if you had any comments to make in terms of how those differences might be explained by cultural norms or whether that even is true, whether or not we do see it pretty prevalent in in all cultures?

  Dr. Nguyen: [00:10:13] Yeah, No, no, absolutely. I wanted to mention that too. So it's again, an example of of perhaps some of the biases that are in some of the controversy that always surround women's mental health in terms of of how long it took for the premenstrual dysphoric disorder to make it into the official category of the diagnosis instead of being relegated to the culture bound syndromes. I would say all of the evidence up to now point towards the fact that there are similar percentages, proportions of women suffering from PMDD across all across all cultures, across all ethnicities. And so I would say if you have a multiple choice question, I would say that PMDD is not the culturally bound syndrome. And it it really does seem that there is an overlap between the women who suffer from PMDD and the women who may have bad reactions like disinhibition and aggression with alcohol. So there seems to be something surrounding maybe men alone and the GABA receptor, but there's several biological and particular genetic contributions to this to this illness.

  Audrey Le: [00:11:16] Thank you for answering all of those questions. We're going to move a little bit now into premenstrual dysphoric disorder. So this is a depressive disorder that's linked to the menstrual cycle with symptoms presenting in the week before the onset of menses. Before we dive into this further, it might be helpful for our listeners to briefly talk about the DSM criteria for premenstrual dysphoric disorder to get a better understanding of what this looks like. So before asking further questions, I'm just going to run through the DSM criteria for premenstrual dysphoric disorder. So A, in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses start to improve within a few days after the onset of menses and become minimal or absent in the week post menses, criteria B one or more of the following symptoms must be present, and these include effective lability, irritability or anger or increased interpersonal conflicts, depressed mood, feelings of hopelessness or self deprecating thoughts and anxiety, tension and or feelings of being keyed up or on edge. Criteria C, one or more of the following symptoms must additionally be present to reach a total of five symptoms when combined with the symptoms and criteria B above.

  Audrey Le: [00:12:32] These include decreased interest and interest in usual activities, subjective difficulty in concentration, lethargy, easy fatiguability or marked lack of energy, marked change in appetite, overeating or specific food cravings, hypersomnia or insomnia, a sense of being overwhelmed or out of control. And lastly, physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of being bloated or weight gain. Of note, the symptoms I mentioned must have been met for most menstrual cycles that occurred in the preceding years. And the rest of the criteria after this include D causes significant distress or interference with daily activities or relationships. E The disturbance is not an exacerbation of the symptoms of another disorder such as MDD, panic disorder, PDD, or personality disorder. F Criterion A should be confirmed by prospective daily readings during at least two symptomatic cycles, which we'll talk about more detail later in the episode and G. The symptoms are not attributable to a substance medication or another medical condition. So now that I've gone through the diagnostic criteria of premenstrual dysphoric disorder, let's talk about the epidemiology. How prevalent is this disorder and how does it evolve across the lifespan?

  Dr. Nguyen: [00:13:53] So in terms of the last estimates, they go between two, it's 2 to 8%. I think if you define it very rigorously with a two month perspective ratings, which not all women are willing or able to complete, then it maybe is 2 to 5% and that is compared to the 70 to 80% of women who have premenstrual syndrome.

  Audrey Le: [00:14:16] Thank you. And and how does this tend to evolve across the lifespan?

  Dr. Nguyen: [00:14:21] So typically, PMDD, unfortunately, tends to get worse with the years, particularly after having had children, that we we still don't know what exactly in terms of hormonal mechanisms that's due to. But that has definitely been documented in terms of it's getting worse over time.

  Arielle Geist: [00:14:40] And again, thinking about premenstrual dysphoric disorder, what's the differential diagnosis that you think about when you're seeing a patient?

  Dr. Nguyen: [00:14:48] Oh, you have to think about all of the gynaecological endometriosis, for example, PID (pelvic inflammatory disease), ovarian cysts or ovarian torsions. There's a lot of different gynaecological conditions that you have to think about. I am actually of the school of thought that I don't. I think that disorders can be co-morbid. And so even though I know that in the DSM, it says it cannot be the exacerbation of another condition. We know from family studies that, for example, MDD and PMDD coexist in these families. And so you will have several women who suffer from both. And so then it's really difficult to disentangle. Is it just an exacerbation of MDD or PMDD and MD together? So for me, it's not kind of hard exclusion criteria per se.

  Nima Nahiddi: [00:15:37] I was just wondering how realistic or easy do you find it is for people to do the prospective charts for the two months? Is that something that if you will have resources or with your smartphone, that is very doable.

  Dr. Nguyen: [00:15:54] It is doable. I just find that this is this goes back to the social determinants of health, I guess, but it's just very special to me that it's the only disorder which you require. Two months perspective ratings for all of the other disorders are not it's not that hard to to meet the criteria, basically. And I think that for some of our some of our population it is quite difficult. You know, like you have three children, you're trying to get diagnosed with PMDD, you just don't have the time. So it can be challenging for some people. So at least we have the option of being of giving a PMDD provisional diagnosis until the person kind of hands in the two months perspective readings. But typically I really try to encourage them to do it either like you said, on the smartphone or some people just like hard paper copy. So it's it's doable. But I think maybe in ten years there may be changes again to that specific criteria.

  Audrey Le: [00:16:55] And thinking of those rating scales. What are some rating scales that are typically used in diagnosing premenstrual dysphoric disorder that you use?

  Dr. Nguyen: [00:17:05] They're quite widely available now, particularly given that a lot of women are trying to track their fertility. So you just there are several apps like Overview and several other new apps as well. It's called Fertility. I don't remember, but there are several for both iPhones and Google Samsung phones now. And even if you just do, you don't even have to download an app. You can just do a Google search and you'll see like all of these paper forms, you just have to make sure that the big categories, like the effect of symptoms, cognitive symptoms, physical symptoms are all properly listed, but they're widely available and free.

  Nima Nahiddi: [00:17:42] Now that we've reviewed the diagnosis of premenstrual dysphoric disorder, what is your approach to the treatment once you've diagnosed someone?

  Dr. Nguyen: [00:17:51] It really depends on the patient. I think most of I think most of reproductive psychiatry is. There's a lot of joint decision because it's such a it's such a personal decision. For example, for PMDD, it depends whether the woman is willing to consider contraception, in which case you could try something like Yasmin for three cycles with four days off. It's important to mention, though, because I see this very commonly, is that you cannot just throw any oral contraceptive pill at PMDD and hope that it works. Several pills, particularly the ones that have more androgen potency, actually can make PMDD worse. One common culprit is alesse, for example, which is quite commonly prescribed. So even though if alesse has very low levels of hormones and so some GP's or some other health care practitioners may think that this is going to be helpful for someone who's suffering from PMDD. It actually is not about the levels of hormones but about the potency and which direction, which of the different classes of the steroid hormones that I mentioned earlier, which the oral contraceptive is offering. And the other thing that people often forget is that you have to prescribe it really three cycles and four days off, which is not the typical regimen for oral contraceptive pills. Usually it's like three weeks on and then you have like a week of sugar pills or placebo pills. But you need to do this to disrupt the cycle and to help in terms of the PMDD symptoms. Another aspect I would say is some women actually come to me already on SSRI, And then I think in that case, it's easy to consider, okay, why don't you try to increase your SSRI during your luteal period? And so the week before menses, this is depending on their perspective tracking this.

  Dr. Nguyen: [00:19:39] This can be useful in terms of knowing. Does the woman start to have symptoms right after ovulation, which some women do, unfortunately. So they have like a full two weeks of symptoms that then only start to improve slightly when menses start. Some women only have like three days of symptoms before their period occurs. And so depending on the timing that you can tell them to increase, bump it up a little bit. For example, if the person is on escitalopram, they could go up to 25 or 30 just for that period. What's important to remember is that the mechanism through which the SSRI work for PMDD is not the same as how it works for depression, for depression and anxiety. You have all of these changes at the synapse or occurring the changes in auto receptors 5HT1A But for PMDD, it's really thought to occur through a disruption in the way that the hormones are being metabolized. So again, because there's this communication between the serotonin and just overall neurotransmitter systems and the hormones, basically the if you administer SSRIs or an increased dose of SSRI during this period of time, perhaps it's changing how fast the hormones are being self-rated or converted to different metabolites in a way that then helps women. So there's still a lot of research, kind of more fundamental research that needs to be done in terms of how that occurs. Exactly. But there are now several studies showing that the SSRI are quite effective for PMDD when administered in this fashion.

  Nima Nahiddi: [00:21:11] So to clarify for pharmacological treatments, there's oral contraceptive pill and SSRI. And so can you explain in which situation would you choose one or the other or would you recommend one or the other?

  Dr. Nguyen: [00:21:27] I think I've touched a bit on that in terms of, you know, depending on the on the patient perspective and what they what they want to priorities. Some women may be in the midst of trying to conceive and so the Yasmin wouldn't be the right choice for them. Some women might have a family or personal history of stroke, pulmonary embolism, deep vein thrombosis and other and have other risk factors such as being over 35 years old and smoking, etc. And in that case, Yasmin and Yaz, that whole category of oral contraceptives actually are associated with an increased risk of stroke and deep vein thrombosis, etc. So there are some exclusions in some cases where I tend to shy away from the Yasmin or Yaz, oftentimes. Also, it may be easier for women who are already on SSRI to just continue on and just change their dosages that way. And then it's less stressful for them in terms of changing medications. I just want to mention also that if SSRI and oral contraceptives don't work, then you can help. GNRH agonist or antagonists are kind of like basically surgical or medical menopause. So this is really a last resort, though. And I would say 70 to 90% of women actually respond to Yasmin or SSRI. And in terms of the study. It does seem that the contraceptives have a slightly higher rate of success. It may be 80 to 90% versus the SSRIs, which are more like 70 to 80%. So like a highly treatable condition.

  Nima Nahiddi: [00:23:03] You had mentioned that we should avoid certain contraceptives like Alesse, What is the specific reason why you would avoid that? Just to clarify.

  Dr. Nguyen: [00:23:15] So some contraceptives have more androgen activity like you remember, Like the difference, like there's androgen activity, progestogen activity and estrogen activity. So each pill actually has different balances or mixes of of that similar to, I guess, the antidepressants in the different neurotransmitters. So if you have one that acts more on androgen and not so much on the drospirenone or basically it's the metabolite that is in the progesterone category that is part of Yasmin and Yaz, then it's not going to be effective. So some some contraceptives will just be neutral. It will neither help nor worsen the PMDD and then some others will make it worse if they have the wrong mix, if they have too much androgen activity, for example. And then that's why we think that it's Yasmin or Yaz, that has that is efficacious because of that drospirenone metabolite specific to those medications.

  Nima Nahiddi: [00:24:12] Thank you so much for clarifying that. Are there any lifestyle interventions that can help with the treatment of PMDD?

  Dr. Nguyen: [00:24:19] Unfortunately, there's very weak evidence to support that. Some women will say, I've tried calcium, I've tried B vitamins, I've tried exercise. And I'm not saying like in lots of cases, add on CBT, add on light therapy even could help. There's a lot of different conditions, but it's just that the the evidence behind those complementary therapies is still quite weak.

  Nima Nahiddi: [00:24:46] So I'd like to finish our discussion by going to another topic. Mental health concerns during the perimenopausal period. Can you clarify? First, the definition of perimenopausal?

  Dr. Nguyen: [00:24:58] Perimenopausal is again, difficult to define because you have so you have menopause, which is one year after the cessation of the complete cessation of menses. So you can basically only define menopause retrospectively because you never know if you're going to have another period at perimenopause. In most of the studies are is thought to represent the whole period of when the ovaries or the follicles are starting to decline up until menopause, which is one year after the last period. And then you have early perimenopause and you have late perimenopause. I feel like for your learning, you don't need to know all the details of that, but just know that the changes of hormones are different in early versus late perimenopause. Menopause in early perimenopause, you can see a lot of erratic changes in estradiol and other hormones, too. I don't want to get too much into the complexities of that. And in the late period menopause, that's when you start to see a profile that is more similar to menopause. So a lot of ups and downs and fluctuations throughout that whole period. And just to mention that some women can start to enter the early menopause around age 40, 45 years old. So it can be quite much earlier than than some of us would expect.

  Nima Nahiddi: [00:26:20] And what are some mental health concerns that arise during this time period?

  Dr. Nguyen: [00:26:25] It's typically anxiety and depression, but you will also see exacerbations of schizophrenia and exacerbations of bipolar disorder, for example. So again, if you have a patient with bipolar disorder or schizophrenia and suddenly you have treatment resistance, you have to think about asking those questions about the menstrual, the menstrual history and reproductive history in terms of the more common disorders like anxiety and depression. And so what we see is that these perimenopausal mental disorders tend to be more persistent and more comorbid. So instead of just seeing a classical picture of depression, you will see a lot of anxiety, kind of depression with anxious features, difficult to treat, a lot of insomnia. And sometimes the women will describe it as the worst, the worst mental breakdown that she's had during her entire life and accompanied accompanying these mental symptoms. You have, of course, the physical symptoms also. So the hot flashes, the vaginal dryness, there's a lot of discomfort physically that occurred during this time as well.

  Nima Nahiddi: [00:27:27] Can you speak about the incidence of depression specifically in the perimenopausal period and perhaps what effect estrogen has in the treatment of depression?

  Dr. Nguyen: [00:27:38] I think other than the fact that the depression is often comorbid with anxiety in terms of presentation, I don't see any remarkable features of the depressive symptoms that are different from an MDD at another period of life. It's possible, though, that in terms of psychological and social contexts it's even harder because it's like a woman ageing, her children leaving. There's a lot of life changes also that are different from other periods of life in terms of the hormonal treatment. So I mean, we do consider transdermal estradiol as one of the useful add ons to antidepressant treatment. I don't tend because I'm not a gynaecologist, I don't tend to start with the transdermal estradiol, Some gynaecologists will, and I guess it's for them to comment on how the how they think, how they consider it first line versus second line. For me, I consider it more second line because there are several antidepressants. All of the antidepressant categories have been shown to be effective for perimenopausal depression and anxiety. Maybe with the SNRIs being a little bit more effective, we think because of all of the hypothalamic changes and dysfunction in the noradrenergic nucleus in the hypothalamus that happened with hot flashes. And that may also be may also cause some of the mood fluctuations that occurred during this period. So perhaps a SNRI a little bit more effective, but SSRI is also effective. Mirtazapine is also effective. I wouldn't go so much with bupropion though, because it's too activating and it can increase the anxiety that is often comorbid with perimenopausal depression.

  Dr. Nguyen: [00:29:21] And then if that doesn't work, then you can consider something like transdermal estradiol. I think Raloxifene at some point was also discussed. It tends not to be very effective, maybe mildly effective sometimes a bit like how we use Pregabalin for for GAD like it can be effective, but oftentimes more like an ad as an add on. It actually has been studied in schizophrenia. I don't know if you're aware, but in terms of schizophrenia for cognitive and effective symptoms of schizophrenia and Raloxifene, which is a selective receptor modulator, seems to be effective for those symptoms in schizophrenia. And so that's why sometimes we also use it for perimenopausal depression. If someone, for example, has contraindications to transdermal estradiol, I always make sure to have a family doctor or a gynaecologist who is my partner in prescribing these medications. Typically, I've had no issues with people kind of collaborating and getting back to me quickly. And usually it's like at least it takes six weeks of transdermal estradiol and sometimes a bit more six weeks to six months. I would say after that I would be reluctant to continue to prescribe unless I have like an ultrasound or a really good follow up by the the other either family doctor or gynaecologist to make sure that endometrial thickness is not has not change, etc..

  Nima Nahiddi: [00:30:46] And these other side effects that you've spoken about, like hot flashes that occur during menopause, do you find that these contribute to having increased mental health concerns?

  Dr. Nguyen: [00:30:59] So just like the co-morbidity between PMDD and MDD, sometimes it's hard to disentangle. However, all of the prospective studies have shown that even when you control for hot flashes and all of the physical symptoms of menopause, you still have a peak. So the mental health symptoms do seem to be independent, although of course, the worse, the more anxious you are, the more you can suffer from hot flashes also. So so so there's a bidirectional kind of exacerbation that can occur. But even in a woman who would have very little physical symptoms of perimenopause, you can still have an increased risk of perimenopausal depression, anxiety, as well as exacerbations of bipolar disorder and schizophrenia.

  Nima Nahiddi: [00:31:41] Thank you so much for that overview of reproductive mental health. Before we leave, do you have any specific clinical pearls you'd like to leave our listeners with?

  Dr. Nguyen: [00:31:52] Oh, I would say I mean, I hope that everyone who listens to this podcast will remember to ask about menstrual history, because that's what I kept repeating throughout the podcast and then strong sexual history. I think these are really key and this is something that we often as psychiatrists feel uncomfortable to talk about and at any life stage, as you can see. So even a woman who comes to you 55 years old. So I have to ask about reproductive history, sexual history as well.

  Nima Nahiddi: [00:32:18] Thank you so much, Dr. Nguyen.

  Dr. Nguyen: [00:32:20] You're welcome.

  Arielle Geist: [00:32:27] Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode is produced by Dr. Nima Nahiddi, Dr. Arielle Geist, Dr. Audrey Le and Dr. Rebecca Marsh. The episode was hosted by Dr. Nima Nahiddi, Dr. Arielle Geist and Dr. Audrey Le. The audio editing was done by Dr. Audrey Le and the show notes were done by Dr. Arielle Geist. Our theme song is Working Solutions by All Live Music, and a special thanks to the incredible guests we had today, Dr. Nguyen, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 42: Interpersonal Psychotherapy (IPT) with Dr. Paula Ravitz

• Episode 42: Interpersonal Psychotherapy (IPT) with Dr. Paula Ravitz

  Jake Johnston: [00:00:15] Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. This episode covers Interpersonal Psychotherapy or IPT for short. I'm Jake Johnston, a fourth-year medical student at UBC, and I'll be hosting this episode. I'm joined by my colleague Sena, who will be co-hosting. Sena why don't you introduce yourself?

  Sena Gok: [00:00:36] Hi. I'm Sena Gok, a doctor with international training and huge passion for pscyhiatry. I'm really excited to be here!

  Jake Johnston: [00:00:44] Awesome! Thanks. And last but not least, we have the privilege of hosting Dr. Paula Ravitz as our guest expert for this episode. Dr. Ravitz is an associate professor of psychiatry at the University of Toronto and senior clinician scientist at the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital. She was the director of Psychotherapy, Humanities and Education Scholarship Division, the University of Toronto Department of Psychiatry. Dr. Ravitz is also one of three authors on the latest Canadian Psychiatric Association position Statement on Psychotherapy in Psychiatry, just published in November 2021. The last position statement was published in 2003. Dr. Ravitz, would you like to introduce yourself?

  Dr. Paula Ravitz: [00:01:27] Sure. First of all, thank you so much, Jake and Sena, for inviting me to participate in this. And it's my pleasure to be able to share some ideas about Interpersonal Psychotherapy. IPT I have been involved in teaching and practising and also researching IPT for the last 20 years or so, and I'm delighted to be able to share some of the ideas about the core principles of IPT in this episode for interested learners.

  Jake Johnston: [00:02:09] Thank you so much for coming on to this episode, Dr. Ravitz. We are truly lucky to have you. Without further ado, I will launch into our learning objectives. By the end of this episode, you should be able to one define Interpersonal Psychotherapy to describe the core principles and phases of IPT. Three become familiarized with some psychological theories underpinning IPT. Four, List some patient selection considerations for IPT. Five, describe the efficacy and evidence base for IPT. Six, understand how IPT is practically carried out. Seven, briefly compare and contrast IPT to other common psychotherapies. Now the learning objectives are out of the way, Dr. Ravitz will take us away. We'll start off with the question; what is IPT?

  Dr. Paula Ravitz: [00:03:05] Well, first of all, I think IPT is predicated on the centrality of relationships in our lives. Relationships matter in health and disease and resilience, in coping with stress and in recovery from illness. So this is the rationale for IPT, which is a time limited psychotherapy model that focuses on relational aspects of experience and mental health. And there's a strong evidentiary base. I know we're going to get into that a little bit later, but there are both phase and focus specific tasks of IPT. So there's a beginning, middle and end phase. Generally it is anywhere from 4 to 16 sessions. In my clinical practice and teaching, I use a 12 session model of IPT and in many low and middle income countries we use a briefer version of IPT. So for example in an implementation project we did a number of years ago in Ethiopia, we used a 4 to 8 session model of IPT. Generally. I know there are a number of questions, but the beginning phase of IPT is similar to what we do in psychiatry and an assessment. So we begin to establish an alliance with the patient. We learn about what they're struggling with. So that's what we do in the diagnostic assessment and in the history of presenting illness. So we learn both about symptoms about, but as well in the story of the context of what's going on in their lives right now.

  Dr. Paula Ravitz: [00:05:05] And IPT focuses on these universal life events of loss of change and of conflict and relationships that are often associated with the onset or worsening of symptoms. And so there are therapeutic guidelines for the middle phase, for grief, for what we call role transitions, which has to do with large life changes. And that happened to us all. We all have multiple social roles which kind of determine what we expect from one another, depending on kind of the social roles. And social roles change inevitably in a lifetime, and sometimes the changes are planned and wished for and sometimes they're unplanned and I've wished for. And these can be associated with distress or symptom onset or worsening. And then of course there are conflicts or non-shared expectations that can unfold in relationships and that are often kind of the salt in the wound and IPT is predicated on this idea that what happens in our relationships and what might unfold in terms of symptoms or distress are bi-directionally linked. So it's when people are in a state of depression, it's often more difficult to engage or utilize social supports. And similarly, when there are difficulties in relationships or people are more disengaged or in conflict or they've experienced losses in their social network, that can also exacerbate or contribute to symptoms.

  Jake Johnston: [00:07:00] Thank you so much for that eloquent overview of IPT. It sounds like it's somewhat of a feedback loop where relationships feed into mood and mood feeds into relationships. With that, I'll pass the mic over to Sena for our next learning objective.

  Sena Gok: [00:07:19] Thank you, Jake. So, Dr. Ravitz, could you please tell us further about the core elements of IPT?

  Dr. Paula Ravitz: [00:07:28] So in terms of the core elements, first of all, I want to emphasize common factors in psychotherapy that I think apply to every therapeutic engagement session, whether we're providing follow-up psychiatric care, doing a psychiatric assessment or delivering any of these evidence supported psychotherapy models. So these are included in the core elements. So first and foremost, it's really important to establish a therapeutic alliance in which there is a trusting bond. And we need to earn our patient's trust and we need to actively listen, use empathy, engage with our patients with positive regard, seeing them for their strengths, for their healthy wishes to recover and to find their way to feeling and doing better and for receiving care and help in a time of need. The core elements as I mentioned, there are three phases of IPT. So in the beginning phase of IPT, in addition to conducting an assessment of symptoms, getting agreement on the patient's goals and at a very high level, the goals of IPT are the same as we have for all medical care to help our patients feel and do better. And the way we do that is by helping them to connect with support of others. We try to identify one of four interpersonal problem areas or focal areas of IPT. The four focal areas have to do with what I've already alluded to. Grief is one of them related to loss of a significant other.

  Dr. Paula Ravitz: [00:09:39] Role transitions, which has to do with life changes, for example, becoming coupled or becoming separated, becoming a new parent, moving, migrating, whether it's chosen migration or forced migration, graduating from a training program and starting your new role as a practising professional. So starting a new job. Losing a job. So life changes, as I say, are kind of very common. There's lots of literature of IPT in perinatal depression for people who are becoming new parents and a very strong evidentiary base as well. There's lots of evidence for IPT, for different age groups. So in adolescence there's lots of life changes as as young people begin to affiliate more with peers and get a sense of their identity separate from their families of origin. And in adjusting to a medical illness that might be disabling or life shortening or disfiguring and in in late life, right. Adjusting to retirement or the loss of some of a functioning or certain social roles. There's also role disputes where there's non shared expectations and then there's a default focus that in earlier manuals of IPT was called interpersonal deficits. I think many of us see that term is somewhat pejorative. And so what I tend to use is the more 21st-century term of interpersonal sensitivities, and that's for individuals where there doesn't seem to be any clear life event associated with onset or worsening. But oftentimes as we dive into the work, we will learn of smaller life events.

  Dr. Paula Ravitz: [00:11:43] But it's for individuals who have difficulties with forming or sustaining relationships and as I said, in the middle phase, we are guided by those focal areas which each have a set of therapeutic guidelines. For example, with social world transitions, we will explore the change. What do people miss and what are they grappling with? There's a sense of grieving, if you will, over positive aspects of what was and struggling with some of the challenges or negative aspects of the new role. And I like to divide the middle phase into two parts. Early middle is about deepening understanding. In the late middle phase, patients often become more emboldened, regain a sense of agency, begin to connect with support of others as they problem, solve and find ways to manage the new role. We focus very much on what happens in communication. So communication analysis is something that we do a lot of in the middle phase where we understand I like to think of it as way more than fact finding. We understand problems with understanding, with empathy, with non-reciprocity. We might brainstorm and do role plays or marginal role plays in order to help our patients clarify what their expectations are, how they might express them. And in the process of doing communication analysis, we often use principles of mental sizing, right? This idea of that, we all have thoughts and feelings and expectations of one another. These thoughts and feelings are not necessarily known. They're sometimes opaque. And sometimes what we assume in terms of what's happening in others may or may not be true. Right? So this is where I might intersect with some of the principles of cognitive therapy. Excuse me, in the early phase, I forgot to mention we really focus on what we call the interpersonal inventory. Getting a sense of who are supportive, others and which relationships and which focal area we want to work on. We try to limit the focus to two areas. Even though all there might be salience in all four areas because it is brief and it is structured so we mark time. I like to use validated measures such as the PHQ-9 and the GAD-7 and of course in research studies we'll monitor those symptoms week to week. But in usual clinical care you want to have repeat measures, so you want to do it at least three times beginning, middle and end. Or if you're doing a 12 session model, you might want to do it at least monthly or every few sessions. Remembering that there's a whole literature on self-report versus clinician rated symptoms, there's going to be a subset of patients who continue to endorse high. And you might notice as the clinician that they seem to be getting better, in which case you might want to do a HAM-D on them, a clinician rated, and see if there is a mismatch. There's also a subset of patients that seem to under-report, but you get a sense that they're suffering in functional.

  Dr. Paula Ravitz: [00:15:41] Their struggles with functioning are more profound. So, we use measurement-based care, but we also want to use our clinical judgement. And then in the final phase of IPT, again similar to the beginning phase, which I think can be used in any therapeutic episode of care, right? It's about kind of doing an assessment, getting a sense of what's going on, where the problems are, where we might help our patients to find resolution to those problems. In the ending phase. I find that the termination phase tasks of IPT are very much generalizable to any episode of care, such as discharging someone from an inpatient stay or from a course of treatment in a day hospital program and in the termination phase we try to consolidate gains. So we look back and we'll ask patients thinking back to when we first started and now what are you taking away and what's your sense of kind of how you're feeling or doing differently or how things have changed? And so if I was a fly on the wall and I was doing competence ratings with my IPT hat, I could tell whether you were in a beginning, middle or ending phase. The ending phase is we need to be very deliberate in our practice in order to consolidate gains. There's going to be a subset of patients who struggle more chronically. Treatment works for 100% of patients, but there's still value in marking efforts and gains that might not result in full recovery or significant reduction in symptoms. So the other thing that we do in the end is we think about what next, what more, what else might make sense. In terms of sequencing care episodes it's very important to be able to have a good goodbye. So Winnicott wrote about how we have to navigate a gazillion separations in a lifetime and how you don't want to leave things unsaid. Right? The ending phase can be evocative of the termination phase of of any treatment. When we say goodbye, we might feel some emotions, some sadness in parting. And again, we it's helpful to differentiate what is normative sadness from full on clinical depression. So sometimes people might feel alarmed that they're feeling depressed again or feelings of sadness and IPT is focussed. And it's not that we want to make sadness go away. Sadness is an important, useful marker in the face of loss, right? That's the core emotion. So we want to help our patients for those who have recovered to be able to differentiate, tease apart normative sadness, who they might talk to, who else they might connect with and get support from, and when to recognize if depression is returning and have a contingency plan, for example, of connecting with their family physician or seeking reassessment.

  Jake Johnston: [00:19:30] Thanks Dr. Ravitz, for walking us through the core principles and phases of IPT. We're curious to learn more about some of the psychological theories that underpin IPT. Our preliminary reading indicated that attachment theory is one of them.

  Dr. Paula Ravitz: [00:19:48] Yeah. I mentioned earlier that at the time of Bowlby's work on attachment theory was very much kind of in academic discourse. And I think it has remained very central a relationships. This is based on Bowlby's work are critically important for survival and for thriving and that we need to have a secure base in order to explore, in order to manage now. Early relationships might shape these attachment patterns of relating because it's about survival. So for example, in individuals where attachment figures are generally unavailable, it's adaptive for individuals to become more self sufficient. Right? Remember that attachment patterns are only evident in times of stress. Otherwise, they might not be so evident when patients come in with symptoms of mental illnesses. They're in a state of distress, I mean this is true of medical illnesses. Right? And so that's when we might see these attachment patterns of relating, whether it's someone being somewhat kind of avoidant or dismissive of care or the other insecure attachment pattern is anxious, preoccupied. And again, if you think back, it might have been adaptive for someone to be signalling their attachment needs very loud and frequently in the face of others being inconsistently available. So the other theory that I draw from is contemporary interpersonal theory by the late Don Kiesler and Timothy Leary that talks about these universal needs that we have for affiliation or connection in our relationships, along with a sense of agency or power or influence in our interactions. They have developed what they call the interpersonal complex, where individuals can be mapped based on kind of our patterns of expectations of others.

  Dr. Paula Ravitz: [00:22:30] And again, this intersects with attachment theory, right? Bowlby talked about these internal working models based on early life experiences of what we tend to expect from others. And contemporary interpersonal theory is interesting because there are some predictions about the polls that we have that might be distancing or might be silencing of others and lead to individuals being kind of inadvertently authoring distance or perpetuating this sense of being disconnected or disempowered in their relationships. And we did some process research at a number of years ago. I'm happy to share the article where we looked at both attachment, self reported attachment and mapping on the interpersonal complex and looking at changes with treatment. And we found that in IPT patients with depression and this is patients with depression tend to be disempowered and with chronic forms of depression tend to be disconnected. And so one way of conceptualising recovery and IPT is that we help patients regain their sense of agency and to become less disconnected in their relationships. And we found that patients who recovered fully from depression in a course of IPT, whether or not they were on medication or not, tended to regain their sense of agency and become less disconnected as well. They moved away from dimensions of attachment insecurity towards security. So we did find some validity to these models. However, in terms of movement towards attachment security, we only found that in patients who fully recovered from depression. So you might wonder about how the state of depression also might interact with these self reported experiences of attachment in relationships.

  Jake Johnston: [00:24:41] Thanks, Dr. Ravitz, for touching on and contextualising some of the psychological theories that are important in IPT. One thing you had mentioned was that no treatment works in 100% of patients, which is something we all know is true in medicine. With that in mind, are there any characteristics that make people better or worse candidates for IPT? Specifically, we're curious if there are any indications or contraindications for IPT and some patient selection considerations.

  Dr. Paula Ravitz: [00:25:10] So based on this idea that IPT has these therapeutic guidelines for grief, for social transitions and parole disputes, it makes sense that especially for depression, where there's the strongest evidentiary base and the most IPT studies, that if an individual is presenting with depression and in the timeline in the history of present illness, it's clear that the depression, the onset of worsening depression seems very much linked to the death of a loved one, to disagreements in important close relationships, or to big life changes. Then for sure, IPT is likely to be a good model. Right? And then I started doing clinical research where the inclusion criteria was depression in not acutely suicidal because of course, then we need to move to kind of acute crisis care or higher level in order to ensure safety. It might require admission for patients who are not psychotic. So there really haven't been a lot of studies showing that. There's only one study that I know of that shows that IPT can be helpful for patients with affective psychosis. This was done at CAMH years ago and there was a poster presentation with Janice Harris who used to work at the Effect of Psychosis Clinic at CAMH. So depression, not acutely substance abusing or functionally impairing substance abusing, I should say. Not acutely psychotic and not acutely suicidal. So I started in the context of doing research studies with inclusion and exclusion criteria, found that patients who intuitively I wasn't so sure that IPT was going to help, that I started discovering that the IPT model actually helped patients who even in this fourth category of interpersonal sensitivities or whether there was no clear precipitating or triggering life events.

  Dr. Paula Ravitz: [00:27:51] So I would say for your first training cases to try IPT because the middle phase therapeutic guidelines are so useful and can be applied. However, I think that IPT is really a good depression treatment. It's very powerful and it has sustained effects, sustained improvements. For a depression treatment, Ellen Frank and Holly Swartz. Ellen is a professor emeritus from University of Pittsburgh, has done a lot of the landmark IPT studies, including for patients with more chronic and recurrent forms of depression, and has adapted IPT for individuals with bipolar disorder. Holly Swartz is doing an NIH study looking at comparing IPT and Quetiapine IPT as a monotherapy for patients with bipolar disorder. It includes kind of a behavioural element with what they call "using a social rhythm tracking" where they find that if they can stabilize social rhythms, it actually significantly extends the period of wellness. Like not only does it aid recovery, but it delays relapse. Originally, it was in combination with mood stabilizing medications for Bipolar 1 Disorder for sure. As well, IPT has been researched for eating disorders, particularly for Bulimia in a group format.

  Dr. Paula Ravitz: [00:29:27] Earlier studies were done by Chris Fairburn and Denise Wolf showing that compared to IPT, compared to CBT. That. Actually, it's interesting. It's kind of the turtle and the hare, the horse race that if you look long-term that IPT actually surpassed CBT. But in the short-term there were CBT seemed to work better in the kind of short-term follow up, but they're both powerful models. IPT has been extensively researched in adolescence for adolescent depression. This has been led by Laura Mufson and Jami Young has looked at group IPT as a preventative treatment and is doing work in high schools in the US. Using her model, a family-based IPT model has also been shown to be helpful by Laura Dietz. And again, for people who are interested in learning more about these models, there are many publications. We did a 40-plus year scoping review of IPT, looking at trends and themes over time and looking at all the different clinical populations including in low and middle-income countries. IPT for PTSD, I suspect, will be in future guidelines. As you know, in these guideline panels you have to have a minimum of two randomised controlled trials conducted by different groups of researchers in order to control for kind of allegiance or bias of the research group and the original gold standard study conducted by John Markowitz compared to the prior gold standard which is exposure based CBT and shown this was the first non-exposure based structured treatment to be as effective as exposure based CBT. Since that time, others are kind of have done studies in other settings, including in Brazil. What's interesting about the adaptations of IPT is that the model is generally the same in contrast to some other models of therapy that have been adapted for specific patient populations that differ quite a bit like exposure-based or exposure and response prevention for PTSD or OCD in CBT. Whereas with IPT, the model is essentially kind of preserved. So there's a bit less variation in the adaptations of IPT. As I mentioned, there's very strong evidentiary base of IPT for postpartum and perinatal depression, and many of us have been numerous studies, including one that was led by Cindy-Lee Dennis and Sophie Grigoriadis and myself were the clinical leads where we supported nurse therapists in the delivery of telephone IPT. This was published back in 2020 and found that 85% of our patients who started out meeting full criteria based on skid with 12 sessions of telephone IPT remitted. Again, there were no differences in patients who were on medication versus not on medication and with sustained improvements over time.

  Jake Johnston: [00:33:17] Thank you very much for that thorough answer. Dr. Ravitz. So just to sort of summarise and reiterate, you're saying that IPT has the best evidence for major depressive disorder. According to the CANMED guidelines, IPT is a first line treatment for acute depression, second-line maintenance treatment for depression. And as you were saying, according to the can guidelines is a first-line treatment for depression in several special populations, including children and youth, mild to moderate, major depressive disorder in pregnancy and mild to moderate postpartum depression during breastfeeding. It's such a strong treatment that it is recommended before medications even in these populations. Dr. Everts, you had also mentioned that there's evidence for use in some other disorders, including Bipolar Disorder, Bulimia Nervosa and PTSD. One clarifying question I wanted to ask was if you could comment on IPT's use in anxiety disorders.

  Dr. Paula Ravitz: [00:34:19] Yeah. John Markowitz and the late Joshua Lipsitz did a review looking at the evidentiary base for IPT and anxiety disorder. At present we don't really have sufficient evidence for it to make it into guidelines. But what I can tell you is that depression and anxiety are often comorbid. As mentioned in all of the depression studies that I've participated in, we monitor both GAD- and PHQ-9 and in our perinatal in our postpartum IPT telephone IPT study, we found that the patients who had comorbid levels of depression and anxiety seemed to benefit even more. In all the clinical trials that I've participated in, including a current clinical trial that I'm a clinical lead on using behavioural activation for women with perinatal depression the SUMMIT Trial. Interestingly, in the back channels I'm noticing that the anxiety scores are also going down significantly. So I think for patients who have comorbid depression and anxiety, both symptoms often decrease significantly. And perhaps surprisingly, because we're not directly targeting anxiety. But IPT is not only interpersonally focussed, it's affect focussed.

  Jake Johnston: [00:35:56] Okay. Thank you for the information on the indications for IPT. Are there any contraindications?

  Dr. Paula Ravitz: [00:36:08] I think if patients are kind of acutely suicidal, we need to provide kind of crisis support and we need to assess safety. So I think that clinically you need to just shift your focus and not necessarily proceed regardless of what their therapeutic model you might have in mind to be rendering. There really isn't evidence for a patients with psychosis. There's been some really important and helpful modifications of CBT for psychosis, and there is some evidence of the adaptations of that model. That work hasn't been done in IPT. It might be eventually over time, but in our thus far, over these last 40 years, there haven't really. There really isn't evidence for it. So I don't think it's indicated. And for patients who are struggling with functionally impairing substance misuse, it's really important to address the Concurrent Disorders and see if we can kind of help our patients with that. It doesn't mean that you can't still integrate some of the principles of these other useful evidence supported therapeutic models such as CBT or MI or IPT. I think they can still be integrated, but there really isn't research showing that it's helpful.

  Jake Johnston: [00:38:09] Thanks, Dr. Ravitz, for walking us through some of the patient selection considerations for IPT. You've already touched on the some of the evidence base behind IPT. I'm wondering if you would be able to take us and our listeners through a brief history of sort of how IPT was developed and maybe a deeper dive into the evidence base behind IPT.

  Dr. Paula Ravitz: [00:38:35] The first controlled study for depression was published over 40 years ago and originally there was a study conducted by Gerald Klerman and Myrna Weissman and others that compared IPT to medication. So this was, as I said, over 40 years ago, and what they tried to do was operationalize what effective, well-respected community-based therapists were doing. So in a way, it was a descriptive study of kind of good psychotherapy where they discovered that patients were coming in with these universal relational life events. So it was kind of a life events based model. At the time of IPT's genesis, Bowlby seminal work on Attachment Theory was kind of in in academic discourse as well. Brown and Harris studies on the associations between bereavement and depression were being published, and the etiological links between biological and psychosocial factors were becoming influential in discourse on illness and recovery. Since that time, the importance of relationships for health, coping and resilience has been well established. And in the very first study, to Gerald Klerman surprise and he was a pragmatist, he found that patients who received this structured psychotherapy and at that point in time it was a 16 session model. And partly the reason for the dose was because they also wanted to compare it to pharmacotherapy over time, they found that IPT worked as well as medication as pharmacotherapy. Now remember back then it was the tricyclic antidepressants, but that led to IPT being included in what still stands as a landmark study, the TDCRP study with Irene Elkin that was published long ago in which IPT-CBT pharmacotherapy and a kind of comparative, just supportive response to when patients requested it was conducted.

  Dr. Paula Ravitz: [00:41:12] It was the first multi-site RCT that compared IPT and CBT. And in that study Lester Luborsky wrote a paper that quoted the Dodo bird from Alice in Wonderland that said "all must have prizes and all have won". So in the initial analysis, they found that everyone seemed to improve even the low-contact patients. There have since been multiple analyses of that study looking at process factors, looking at moderating factors, and they looked at baseline patient severity and when they examined that, the patients and pharmacotherapy did best, followed by IPT, then CBT and then the kind of low contact model. And subsequent to that study, there have been many studies of both IPT and CBT in particular showing that both models are highly effective, thus included in many international consensus guidelines as a depression treatment, especially including the World Health Organization here in Canada, the Canadian Association of Mood and Anxiety Treatments. It's amongst a very short list of three first-line treatments for depression based on many effectiveness and efficacy studies. And for people who are interested, there's Pim Cuijpers in the Netherlands has done many well conducted meta-analyses and the most recent one published in 2016 was a transdiagnostic meta-analysis of IPT showing that IPT is is helpful in the horse races. Comparing IPT and CBT in particular, they're both shown to be highly effective treatments, thus both recommended in consensus treatment guidelines here in Canada, in the US and in other parts of the world, including the World Health Organisation. So it's long been included in the mental health gap and guidelines of the World Health Organisation.

  Jake Johnston: [00:43:32] Thank you, Dr. Ravitz for that comprehensive answer. You mentioned the IPT being cited as one of the three most effective psychotherapies in the CANMED guidelines. And I'd just like to point out that I noticed your name on the author list for that paper and just for our listeners, all of the papers that Dr. Ravitz has mentioned, we'll make sure to include in the show notes. So Dr. Ravitz, you've sort of gone through and given us a really good idea of what IPT is. The principles behind it are some of the patient selection considerations and some of the evidence behind it. And I'm curious, can you go through some of the more practical elements of going through a course of IPT? You know, you mentioned that it's usually sort of 12 ish sessions. There's a beginning, middle and end phase. And I'm curious if you could sort of paint a picture for our listeners what it's like to actually go through and maybe experience each of those phases and what type of things happen in each of those phases.

  Dr. Paula Ravitz: [00:44:39] So, first of all I think that the provider needs to be aware of the structure. So a number of sessions. So when I first meet with a patient, if I'm doing IPT, I will orient them to the different phases and explain to them the rationale. I might say, "thank you for coming. Today is our first session of 12" and I explain the phases. So, "in these first few sessions, I am going to learn more about you as a person, about what's been going on in your life that's associated with you feeling worse. I am also going to ask you about important relationships so that we together can decide on which relationships and which focus we want to pursue in the middle phase of our work together. I'm going to be monitoring your symptoms as we go along using these two questionnaires, the the physician health questionnaire, which is nine items, which asks you about the last two weeks, how you have been feeling and to what extent it's affecting you, along with another short questionnaire about anxiety symptoms. The reason I do this is because the goal of our work together is to help you feel and do better. So this is one way I can track how you're feeling and doing in order to lessen the symptoms of depression and anxiety. And in the middle phase of our work together, once we decide which relationships in which focus I, we will go through a process of, first of all, deepening our understanding of what's been going on with respect to changes or losses or conflicts in your relationships that are linked to the moments when you're feeling worse or better. Then in the final 1 to 2 sessions, we'll try to consolidate our gains and what you've taken away if necessary. Think about next steps. Again, as I mentioned, I'm going to be tracking your symptoms over time so that if you're feeling worse or not feeling better, we're not going to wait for 12 sessions to think about what next. I might, depending on your symptoms, make recommendations".

  Dr. Paula Ravitz: [00:47:40] In my mind, I'm also monitoring for the need for medication and safety monitoring. So then I proceed similar to what we do in psychiatric assessments to getting their identifying data. Chief Complaint History of present illness and a symptom review along with family, psychiatric and medical history, their past psychiatric history, medications, they are on. And then in the psychosocial history, the interpersonal inventory is kind of it happens in the beginning session and I usually begin with a genogram, but I ask them using the interpersonal inventory to tell me more about the important relationships where I learn about kind of maybe 6 to 10 closest relationships. I like to use questions from the adult attachment inventory, some of them. So I'll ask "Who raised you?". I love that question because it doesn't assume that it was biological parents. Sometimes people will say, "I raised myself or it was my big sibling or my neighbour or a teacher or a religious leader". It gives me, again, similar to doing communication analysis, data about their back story about whether there might be unresolved developmental trauma. I also watch and listen very carefully. If there are lapses in narrative coherence and I watch for affect, when do they become flushed with emotion or when do they tear up? Because again, this is data for me to revisit most important relationships in the middle phase. That's how I might introduce IPT. I track time. And at three points at the beginning when I'm kind of contracting and this is again, there might be times when you are post call or a crisis comes up and you have to reschedule or it could be just a word conflict or a personal conflict, and the same might be true for them. So you want to kind of set some ground rules. "I will let you know ahead of time but I understand that emergencies come up and you can let me know". I try to reschedule in the same week, where possible. And again, "I don't think we have time today, but there's going to be a subset of patients that it's it's hard for them to come within a period of time". Or they keep cancelling that they there's this might signal problems in the alliance of a tendency to kind of withdraw or be reluctant to trust or to engage. And that's a topic for another conversation. But I then in the middle so it's session six, say "we're halfway through".

  Dr. Paula Ravitz: [00:50:51] People are often surprised, but do you want to mark time and you also want to get a sense I will sometimes work it as a middle session, but I'll also ask like what more else? Like thinking back to kind of where we are right now and that we have six more sessions including today. "What more else do you think would be helpful and important for us to focus on that seems to be linked to your distress?" and as I mentioned, the homework that I assigned in IPT has to do with paying attention to their emotions, to their affect both times when they feel more upset or distressed or annoyed or disconnected or sad or angry or scared. So any negative emotions but also positive emotions are really important for us to mark and track the times when they feel better, because hopefully it's linked to times when they feel more connected or understood or a sense of belonging or a sense of having begun to master some of the interpersonal problems that brought them in. Then in the last 10 minutes of the third from last session, so if I'm doing 12 sessions last 10 minutes of the 10th session, I'll say something like, "We have two more sessions after today". Again, that's a very different homework assignment. I'll say "Between now and when we meet, I'd like you to give some thought, and I will as well give some thought to this thinking back to when we first started and now what are you taking away? And also thinking back and this is again of a bit of a pre-post, what's changed? How you feeling different or what's changed in terms of your life or your relationships?" So one has to do with kind of of all the things that we've done and talked about.

  Dr. Paula Ravitz: [00:52:55] This is such great data for learners and for therapists because sometimes the things that we think are the most salient or most important in terms of kind of supporting change and recovery are not necessarily what our patients report. So I think it's iterative discovery, joint discovery, and you want to also give some thought to that such that if I was a fly on the wall or I was doing a competency rating in the final two sessions, the first, maybe third of the session, 15, 20 minutes, you want to unpack whatever they bring again? I often I ask from session two onwards, How have you been since we last met? If they report events, I'll ask. And how did that affect your mood or symptoms? If they affect if they report motor symptoms? I want to ask and how did that and what's been going on? So again, we begin to socialise our patients to making those bidirectional links. Over time, patients just spontaneously report both right and so. You want to give some thoughts to those same questions that we ask our patients? And when you begin to ask those questions to say, okay, this is our second from last session, as I mentioned last week, we want to take some time today.

  Dr. Paula Ravitz: [00:54:24] So it's similar to agenda setting that we might do in more highly structured therapy like CBT. "Thinking back to when we first started what are you taking away or thinking back to when you first started? What's changed?" You want to use therapeutic communication 101. So open-ended questions, empathic, paraphrasing or summarising what your patient tells you and not parroting, but paraphrasing. So this is part of the skill set that I think in all therapies our clinicians can improve over time and that will help them in all their clinical interactions, regardless of what kind of medicine you're going to practice. Actually, sometimes questions pop up in your mind that are like, yes, no questions that I often invite trainees. It's a good question. So how can you rephrase that to be more open-ended questions such as or prompts such as "Can you say more about that?" or to paraphrase. So, "You had an argument with your partner last week and it was really upsetting to you". Full stop. Don't even ask the question. Just paraphrase. Nine times out of ten, when our patients feel like we're really with them in that moment, they'll just elaborate spontaneously. There will be a subset of patients where it's like pulling teeth. And you actually have to ask, "Can you say more?" or "I'm not sure I quite understand."

  Dr. Paula Ravitz: [00:56:08] And I want to just go back to communication analysis, because oftentimes when patients come in, they'll just give us the tip of the iceberg, the most heated moment of the argument or the way that they were feeling or the resentment that they experience from feeling kind of misunderstood or mis misinterpreted or responded to in ways that felt just kind of really empathic or miss a tune. And you want to roll the tape back. You get "Hang on, so this is what happened at the end and how you were feeling." So. "Where were you" and "What time of day" and "What day of the week" and "How did this start", "What was going on just before the interaction started?" And you want to get what words did you use or what did you say and how did they respond and how will you feel and what do you think they were thinking and what do you think they were feeling or what do you think they thought you thought. So you begin to draw kind of this figure eight linking of kind of two people in an interaction. And again, that gives us data about misunderstandings, about difficulties with empathy or with mental sizing and whether expectations or wishes are both reasonable and realistic. Sometimes we need to lower expectations, considering limitations of others. Sometimes we need to be more clear in our communication, right? In being in the way we give voice to things.

  Jake Johnston: [00:57:57] Thanks. I'm sure of it. So that communication analysis sounds a lot like chain analysis, DBT for Borderline Personality Disorder which is actually a good segue way into our last learning objective. But all parking lot that for now, that was a beautiful way you took us through sort of how IPT is practically carried out in the focus of the various phases. A couple of more pointed questions. You mentioned it's about usually about 12 sessions in total. How long does each session last?

  Dr. Paula Ravitz: [00:58:31] There's variability. Generally, I think the shortest sessions are 30 minutes and depending on kind of whether what practice setting you're in and also patients, they may or may not have time ideally, I think 45 to 60 minutes. So psychologists tend to do 60 minute sessions and psychiatrists do, like 45, 46 minute sessions. I think this is partly been driven by funding plans, but that's been my practice and that seems to be a good amount of time to really kind of cover a good amount of material using the IPT model, both phase and focus specific guidelines. Generally, it's once weekly, but for example, 12 sessions can take as long as four months because of holidays or interruptions. But you want to probably complete it. You want to complete it with them, 4 to 5 months or 4 to 6 months, I would say if it's 16 sessions within six months.

  Jake Johnston: [00:59:53] And could you comment on maintenance IPT? Is that something that you practice?

  Sena Gok: [00:59:59] Yeah, so I do. I was very much influenced by Dr. Alan Franks studies, I've showed that what gets you well, keeps you well. IPT alone can be very helpful. So if our patients, we have a more a history of chronic depression have gotten well with IPT rather than just kind of concluding with no follow up at the end of 12 or 16 sessions, what I do instead is the last few sessions I increase the time frame between. So it's a tapering, right? So let's say they've recovered by session ten or 12. I might then schedule sessions every other week for the next few sessions, then every third week and then offer monthly follow up for because they're at higher risk of relapse as well in the event that they become ill or severely symptomatic. We have a good alliance, so they're more likely to accept medication if I think it's indicated based on severity, functional impairment. So, they may have said no to pharmacotherapy in the past, but agreed to it in the future. And I find that there's a subset of patients who actually recover and then they just naturally taper off because they enter into their lives and no longer feel the need for mental health care and support. I usually keep my door open in the event that they're in crisis or feeling unwell that they can call. And I'm happy to reassess or sometimes I'll do some booster sessions with them. And again, having already had a relationship and know a little bit about their back story and their relationships, we can move into kind of therapeutic action pretty quickly. Right? In just a few sessions I can help to stabilise them. So that's in my clinical practice how I tend to work and with the residents that I provide supervision to the guidance that we give for patients who recover but who have a history of more longstanding struggles with depression. I suggest you kind of extend those 12 to 16 sessions over a longer time period, especially.

  Jake Johnston: [01:02:30] Towards the end. I love that you call them booster sessions. It's like extending our immunity on the assaults on our mental health.

  Sena Gok: [01:02:39] Yeah, that's a that's a beautiful metaphor.

  Jake Johnston: [01:02:41] Yeah, absolutely. Thank you, Dr. Ravitzt. So that was a really helpful overview of the practical aspects of IPT. Just wrapping up now with our last learning objective, I'll pass the mic over to Sena.

  Sena Gok: [01:02:58] Thank you, Jake. So Dr. Ravitzs, you mentioned earlier that IPT might have some advantages when compared to CBT. Could you explain these further, and are there also other advantages to other common psychotherapy methods?

  Dr. Paula Ravitz: [01:03:13] So I think that we as clinicians need to have a repertoire of approaches because no one treatment works for everyone. I think as well that clinicians have models that just feel like a better fit, right? And so I think that just like is as medical students, you will kind of have preferences or things, areas, clinical populations or therapeutic tasks that are more appealing and feel like a better fit in terms of your motivation to gain expertise. The same is true in these different psychotherapy models, but what is also true about these psychotherapy models is that there are factors that are common to them. All right. And that are included right in the teaching of them and I think if you only learn one, you might not know that. Right? You might think this is IPT or this is CBT, when in fact it is an important common element for people who are interested in that. John Norcross and Bruce Wampold have done some wonderful work and looking at common factors and in fact in the most recent can that guidelines, we include a list of the common factors. We got permission from John Norcross who vetted it to include that run across such as the therapeutic alliance, use of empathy, positive regard, presence. These are very important having agreement on the goals and the tasks of whatever treatment you're doing.

  Dr. Paula Ravitz: [01:04:58] So being explicit, being collaborative, being authentic and being non-judgmental, using open-ended questions and empathy and using paraphrasing and summative comments really go a long ways. No matter what you're doing, no matter which brand or guilt of practice you identify with, CBT is highly effective. And I think CBT has been shown to be effective diagnostically more. So there's been more studies but IPT the evidence is that the jury is out. It's the effect size is like compared to a cholinesterase inhibitor that has an effect size of over 30. The effect size of in terms of number needed to treat in IPT is over 30 for cholinesterase inhibitors and it's three for IPT and something like seven or eight for for CBT. But again, it depends on the practitioner, your preference, your style. As I mentioned, I think IPT is particularly helpful in the context of existential life events, right, in which one's appraisal might have, you know, a degree of accuracy. S,o I also think that it's helpful to actually have more than one model in your therapeutic repertoire. You don't want to be to have kind of a one size does not fit all. Procrustes was a famous innkeeper in Greek mythology that used to the idea of a one size fits all, because he used to cut the legs of long-legged people or stretch the legs of short-legged people in order to fit the one-size bed.

  Dr. Paula Ravitz: [01:07:01] So one size does not fit all. And so that's why I really encourage people interested in having kind of these powerful psychotherapeutic approaches. And again, we've used we've trained nurses, we've trained family medicine residents and family physicians and into professional providers of social workers. It's not just for mental health specialists, because we know from the work of Martin Prince and Vikram Patel and those landmark articles that were published in the Lancet that there is no health without mental health, and it's incumbent on us all to be alive to struggles with mental health, which can help our patients in their recovery and in their functioning. So IPT focuses on clinician, on thoughts, CBT focuses on relationships, they are both affect focused, they're both structured, they're both time limited, they're both evidence supported. Jake, you mentioned comparing communication analysis to chain analysis in DBT. DBT has strong evidence base for our patients with Borderline Personality dDisorder. A handful of studies of IPT would be PD, but I think that right now, mentalising based therapy and DBT have the strongest evidentiary base for our patients with Borderline Personality Disorder. But communication analysis and chain analysis are not dissimilar and in behavioural activation, we look at helping our patients in a more kind of concise and simple way with communication of feelings or asking for help or being assertive, you know, by kind of starting with facts, feelings, a request or expression, but also thinking about impact which is important in thinking about sometimes we say things that aren't understood or aren't clear or don't land well with others for all kinds of reasons.

  Dr. Paula Ravitz: [01:09:15] And so I think that there's lots of intersection and some of the things that we describe in these different models. It's a matter of semantics. And if you train and I have trained and taught and edited books on kind of multiple models of therapy, including through one series that learners might be interested, it might be in the library collections of the different schools where you go called Psychotherapy Essentials to Go that have both videotapes, and they're kind of learner's guides for some of the key principles of IPT for depression, CBT for depression, CBT for anxiety, affect regulation, skills from DBT and Motivational Interviewing along with a book on Common Factors and Improving Alliances and Outcomes. So I encourage learners to peruse these different models and make sense of them. You know that sometimes it's a matter of semantics and there's lots of similarities. But I also think that these different models of therapy give us different frameworks that are really useful to make sense of patients experiences and to give us kind of a roadmap for fostering reflection and exploration that will then lead to patients kind of finding their way in problem solving and adjusting to new roles or resolving disputes or processing grief through bereavement.

  Jake Johnston: [01:11:01] That was a beautiful comparison, Dr. Ravitz, and a great way to sort of wrap up the learning objective part of this episode. I think we better let our listeners off the hook here pretty soon. It's been a ton of information and you've shared a lot of your expertise with us. Do you have any closing thoughts before we wrap up?

  Dr. Paula Ravitz: [01:11:20] First of all, I think that psychotherapy has a role in the armamentarium of especially mental health specialists in both the training and provision of care. A group of us, Gary ChaimoWitz, Weerasekera and myself, recently published a position paper on psychotherapy in psychiatry with the Canadian Psychiatric Association, reaffirming the role. And I think that as mental health specialists, we are the ones who see patients who are at higher risk, who have higher levels of severity, chronicity, comorbidity, functional impairment. So it's really important that we have a full armamentarium of therapeutics, both to establish alliances, to understand, to monitor and to provide care and treatment to people who maybe have failed treatment from multiple first trials of either therapeutics or self-help or pharmacotherapy. I think the good news is our Mental Health Commission of Canada has done a really wonderful job of decreasing stigma and raising awareness of how common struggles are and with mental health and how we really need to scale access and treatment to mental health care. And there are apps and online treatments and lower intensity treatments that are being studied and offered. But when those aren't sufficient, I think that we as for those of you who want to become mental health specialists, I really encourage you to get training in a number of these evidence supported psychotherapies. They're powerful treatments. And for those of you who are going to become other kinds of specialists, I think it will really serve you and your patients and the teams that you work on well to. It's easily accessible to get more training and learning, including through these terrific podcasts that your group is hosting on these evidence-supported psychotherapy models.

  Jake Johnston: [01:14:07] Thanks, Dr. Ravitz. Those are some beautiful closing thoughts and I really like the way how you framed it within the broader context of psychotherapy and within the broader context of our healthcare system. Before we wrap up the episode, Dr. Ravitz, you had mentioned a website that you're currently developing that could be useful for learning more about IPT.

  Sena Gok: [01:14:30] Thank you Jake, for reminding me of that. So with IPt experts and instructional designers and learning management system programmers, we've developed what I think is a really exciting learning resource for people interested in kind of taking a deeper dive into learning about IPT. It's called www.learnipt.com. At present we're just at the tail end of completing an educational research study and we're in conversations about extending access to medical learners at different levels across the educational lifespan. So for people who are interested in doing the course, where we have all kinds of videotaped demonstrations that are captioned and transcribed so it can be translated into different languages, interactive case based learning exercises and brief segments of different experts talking about therapeutic aspects of IPT, including a welcome message from Myrna Weissman, who is the founder of IPT and John Markowitz, who has done more IPT studies than anyone I know. They're both at Columbia University. A brief segment from Holly Swartz, from Ellen Frank. So I've mentioned some of these and from Wanda McGinn along with psychologist Giorgio Tasca, talking about kind of colonic common elements and the therapeutic alliance. So I know I'm biased, but I think it's terrific learning resource. We've gotten wonderful feedback from learners and people can email me directly. So it's not open access at this point, but we hope there will be. We will find ways to open access over time. So I'm at Paula Ravitz at Sinai Healthcare and you can probably kind of put that in the resources for people who want to contact me or who want for the readings as well.

  Jake Johnston: [01:16:50] Sounds great. We'll do. Well, Dr. Ravitz, on behalf of the entire team, we thank you very much for coming to speak about IPT on this episode. And we would also like to thank our listeners for your continued support and dedication to our podcast. Until next time!

  Dr. Paula Ravitz: [01:17:06] Thank you so much, Jake and Sena for your interest and for this really enjoyable conversation about IPT.

  Jake Johnston: [01:17:21] PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Jake Johnston. The episode was hosted by Jake Johnston and Sena Gok. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music. A special thanks to the incredible guest, Dr. Paula Ravitz for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer

• Episode 40: Suicide Epidemiology and Prevention with Dr. Juveria Zaheer

  Chase: [00:00:06] Welcome to PsychEd the Psychiatry podcast for Medical Learners by Medical Learners. Today, we'll be taking a deeper dive into talking a bit more about suicide. It will cover additional topics relating to suicide risk assessment, suicide prevention and suicide epidemiology. Today, our guest expert is Dr. Juveria Zaheer. Dr. Zaheer is a clinician scientist with the Institute for Mental Health Policy Research, and she is also the medical head of the CAMH emergency department in Toronto, Ontario. She's also a assistant professor in the Department of Psychiatry at the University of Toronto. Her research integrates both population level investigations with qualitative research on an individual level to better understand mental health service delivery and service outcomes as it relates to suicide and psychiatric care. My name is Chase Thompson. I'm a fourth-year psychiatry resident at the University of Toronto, and I'll be hosting this episode. The learning objectives for this episode are as follows: One, develop an awareness of suicide risk and suicide prevalence as it pertains to the general population as well as psychiatric populations. Two, incorporate additional contextual information into suicide risk assessment that goes beyond SAD PERSONS or other list-based approaches. And three, develop a deeper understanding of how to approach and help individuals with suicidal thoughts and behaviours. Hope you enjoy the conversation.

  Chase: [00:01:44] Thank you so much, Dr. Zahir, for joining us today and talking a little bit more about suicide. Just for our listeners, this episode is meant to build on some of the previous topics we've had in suicide, assessing suicide risk, as well as how to manage suicidal patients. But I think that it's important for us to have a little bit more of an in-depth conversation on this topic, given how often it comes up and how important it is to psychiatric practice. So thank you so much for joining us, and I'll just let you introduce yourself. I know you've been a frequent podcast guest at this point. I think this is your third interview, as we discussed earlier.

  Dr. Juveria Zaheer: [00:02:28] Yeah. Thanks so much, Chase. My name is Juveria Zaheer, please call me Juveria. I am a psychiatrist at the Centre for Addiction and Mental Health in Toronto, Ontario. I am the emergency department medical head at CAMH. So we are the only standalone emergency department in Ontario and our goal is to provide ethical, evidence-based and dignified care to the people who walk through our doors. And I am also a clinician scientist and my program of research is focussed on suicide and suicide prevention, trying to understand the epidemiology of suicide, the lived experience of people with suicidal behaviour and to bring them together to co-create interventions that work.

  Chase: [00:03:05] So I think one of the things that I wanted to touch on, you know, in this conversation is something that you spoke about in the previous conversation you had with us about: we tend to stratify individuals as low, medium or high suicide risk. But, you know, as trainees and residents working in the emergency department, sometimes it's hard, I think, for us to kind of have a more concrete idea of what that means. And we often don't really get taught about some of the statistics around suicide and the numbers or how often this actually happens. So I'm wondering if we could go through that a bit and kind of talk about suicide risk as it pertains to different populations in psychiatry.

  Dr. Juveria Zaheer: [00:03:46] Yeah, I think that's a really important question because it's sort of like zooming out to see what the lay of the land is and then we can zoom in to make sure we understand a person's individual risk. So I think if you if you meet 100 people, probably 100 of them have been affected by suicide in some way. Suicide is the leading cause of death for young people and it is a top ten cause of death here in Canada. So when we think about what our rates of suicide, we often put them in person-years. So in Canada, we have 11 suicide deaths per 100,000 person-years, and person-years can feel a little bit tricky. But basically what it means is it's using, it's trying to account for the number of people that you're following and the length of time that you're following them. So I could follow a thousand people for one year and that would be 10,000 person-years. Or I could follow 100 people for ten years and it's the same amount of person-years. So we're looking at about 11 per 100,000 in Canada across the general population. And I know that one of the first things that medical students and residents are taught is that men die by suicide three times more often than women do, about 3.2 times more often in Canada, which is very consistent with other sort of white majority countries, European, North American countries. I think it's really important to point out, though, that women engage in non-fatal suicidal behaviour at a rate about 3 to 4 to 1, and that in itself is a really important treatment target and this gender ratio is quite culturally mediated. So in other parts of the world, that gender gap is much lower and up until about 15 years ago in China, women actually died by suicide more than men do and the rates there are about 50/50.

  Dr. Juveria Zaheer: [00:05:24] And I think it's really important when we think about how we stratify risk or how we understand risk, to understand that there are certain things that are going to be more important than others. If you're a clinician and if you have a man or a woman sitting in front of you, the most important thing isn't their gender on an individual level, the most important thing is their history of suicidal behaviour or their current suicidal ideation, or whether they've been recently discharged from hospital. So, for example, in a in a psychiatric population and we consider that to be like anyone who has been admitted, say in the last year, you're looking at 500 suicide deaths per 100 000 person-years. And if we look at like closer discharge, so if you look at people who are discharged within the past week, it's close to 3000 per 100 000 person-years. So the closer you are to a discharge, the higher your risk is. And then I think an area that we don't talk about too much that can be quite frightening and dramatic for folks, for families and for patients and for care providers is that people do die by suicide in hospital. And so one out of every 600 or so psychiatric admissions can end in a suicide death in hospital but it's really important to point out that environmental factors, programmatic factors are so important and this is a really important area where we could reduce suicide risk and there's a lot of variability within institutions based on the kind of care that's provided and the kind of environment that you're looking at.

  Chase: [00:06:46] Right. And I know you had mentioned that the gender gap in suicide rate is actually quite culturally mediated. I know you've done some work in this area, and I'm wondering if you could speak to the kind of anomaly that China represented where they didn't have that same gender gap that we see in North American culture?

  Dr. Juveria Zaheer: [00:07:05] Yeah absolutely.

  Chase: [00:07:06] Do you know what's going on there?

  Dr. Juveria Zaheer: [00:07:07] Yeah, I think it's a really big and a really important question, especially when we live in a place like Canada that's so diverse and we know that, for example, my background is Indian Muslim, and although I was born in Canada, my risk is actually more similar to an Indian woman living in India for at least 2 or 3 generations and so understanding suicide risk in different cultures can be really important in prevention. And so, you know, classically when we formulate suicide, so people like Durkheim, Emile Durkheim, who was a sociologist, talked about how only men have the sort of the strength and the decision-making ability to die by suicide. And so it's the idea that non-fatal suicidal behaviour then culturally becomes something that a woman does and death by suicide is something that a man does. And these cultural scripts are so important because for a man who's suffering, who may be socially isolated or who may be not engaging in mental health care, it becomes a script that that makes sense to them and that's really important in suicide prevention. In China, though, up until, you know, the 90s and the 2000s, like psychiatry, is a relatively new discipline and suicide often didn't show up in psychiatry or neurology textbooks. It was more of a behaviour, it was an act of a powerless person in a very difficult situation. And the other thing to to point out around Chinese women in particular is the gender gap where women are dying more often than men is often seen in rural areas because women often engage in the consumption of poison, so rat poison, agricultural poison. And when you, those can be very fatal and so there's if you have an impulsive overdose attempt, for example, the risk of death is quite high. And there's a beautiful quote from some sociological work in China that said, 'when somebody dies of suicide, we don't ask why, we ask who is to blame'. And so we sort of start to see how important culture, gender construction of suicide is in suicide prevention.

  Chase: [00:08:58] And the other thing that stood out to me about what you said, you know, when we're talking about the population of individuals who's recently discharged from hospital, the number I think was 3000 suicide deaths per 100,000 person-years, which, you know, is almost 300 times population-based rate. You know, I guess that kind of brings up other issues. Like one might look at that number and think, are we discharging patients too early or what is, is there some sort of lack of risk assessment going on at the discharge period? Or how do you understand that sort of really high risk period right after discharge?

  Dr. Juveria Zaheer: [00:09:41] For sure, and I think what you're speaking to is can we develop a sense of therapeutic nihilism that our interventions don't work or our hospitalisation, which is often like the biggest card in your deck for acute care psychiatrist, doesn't work. I think another way of framing it is is a way of trying to be optimistic about the fact that we have a population of people that we know are high risk that we can identify. Often we don't know who's at risk and, you know, in the general community. So is this a place where we can act? And, you know, epidemiological data tells us what's happening. It often doesn't tell us why. And so the other half of my work is qualitative, where we interview people about their lived experiences. And one of the things we've just done, we're doing a study right now where we've interviewed all told 70 people, people who have lived experience of suicidal behaviour, who've been admitted, their family members, care providers. And what keeps coming up in that study is that you're in so much distress, you're in so much pain, you go into a hospital, you get support, you get the right treatment, and when you're discharged, your level of care goes from 100 often to zero. There's a really important paper authored by Paul Kurdyak, who's one of my colleagues, that says in Ontario 68% of people who have a suicide attempt don't have follow up within a month. And so I think as a system, we really need to think about intensive access to care in that post discharge period. So there are things that can work like close-contact follow up, so calling or following up with a person within 24 hours of discharge, higher intensity things than just offering an appointment. So can we meet someone on the inpatient unit, even start psychotherapy with them, have them discharged to the same provider? So I don't necessarily think that it's because hospitalisation doesn't work or that we're necessarily doing something wrong in that piece. I think in all of health care, transitions are so important and cardiac care, if you have an MI, then you go to cardiac rehab and trying to figure out in mental health care, how we can sort of honour the suffering of the people that we're serving and make sure that we don't go from 100 to 0.

  Chase: [00:11:37] Right. Makes sense.

  Dr. Juveria Zaheer: [00:11:38] And I think and I think the other piece is that, you know, epidemiologically, we're selecting for a very, very sick population. And I think anyone who has you know, it's an honour often to sit with someone on the worst day of their life and they tell you their story and they're in so much pain and you bring them into the hospital to help them. There's you see ten people you may admit two, and they are people who are very, very unwell and they're deserving of sort of very good in-patient care and then transitional care thereafter. And I think that's another piece of it.

  Chase: [00:12:09] There's I guess, been some conjecture that potentially with the sort of deinstitutionalisation of psychiatry, the burden of suicide risk has actually kind of moved from, you know, the institution in the past, as we would call it, and now sort of exists more in the community. Do you think that's also plays into that part of the elevated risk in the post-discharge period or.

  Dr. Juveria Zaheer: [00:12:35] Yeah, it's a it's a great question. We know that length of stay is a little bit shorter now, much shorter than it was back in the day and we know that very intensive services are less available. I do think, though, that one of the really important pieces around framing suicide prevention is it's not just a psychiatric issue. I think it's more about it's a public health issue and it has public health components, and that's food security, housing security, financial security and freedom from trauma and oppression. And I think as we see a bit of an unravelling of the social net where we see, you know, people who can't get a job out of high school and buy a house and, you know, have supports in that sense, I think that these broader social factors are really important as well. And so I think it's difficult to sort of understand deinstitutionalisation in context versus kind of the broader picture. And I think to a lot of people who are suffering from suicidal thoughts don't necessarily have the kind of mental illness that is severe enough for long term hospitalisation. So I think we always there's always that stuff that gets thrown around that 90% of people who die by suicide have major mental illness. That psychological autopsy studies are fairly flawed. And there's been some interesting work by the CDC and a nice paper in the New England Journal of Medicine that sort of talks about how the intensity of psychiatric symptoms are only one piece in risk prediction and things like relationship breakdown and conflict, things like housing insecurity, things like financial distress or trauma all play a huge role.

  Chase: [00:14:06] So I kind of want to switch gears a little bit. So we have this sort of idea as residents and psychiatrists that, you know, one of our primary tasks is to assess suicide risk and to really kind of quantify the risk when we're presenting the case and charting that risk. But I think one of the things that I've learned from you in part, is that there's a lot of other factors about, you know the patient's wishes. What would be best for them in their certain scenario, whether that means hospitalisation or actually returning home and whether they're able to kind of participate in an outpatient plan that you put together for them. And I think you've also spoken about this on previous podcasts, but, you know, sometimes that means that patients who may have a higher, you know, quantitative risk, if we can say that would end up being discharged versus someone who might be lower risk being hospitalised. I just wanted to ask you, like, are there certain cases where, you know, even when an individual seems sort of reasonable, doesn't seem to have overt symptoms on the face of it, but the, you know, the plan you're sort of putting together seems good, but for whatever reason, you kind of have a bad feeling about the case, either from information you've gotten from family or from collateral, and in those cases, you're considering certification. I'm just wondering, like, how do you sort of approach those cases where the patient is actually presenting very well, but the family is very concerned and sort of saying, you know, well, if they go home, then I'm really worried what's going to happen to them, but there may not be like any sort of material evidence so far that the person is at risk.

  Dr. Juveria Zaheer: [00:15:58] Yeah, I think that's a really excellent question, Chase. As an emergency department psychiatrist, I think one of the hardest sort of sets of cases you deal with is when there's conflict. In a perfect world, everybody is on the same page that I say to the patient, I think you're deserving of hope and help. The patient understands that and is hoping to come into hospital for initiation of treatment, and the family is on board as well. And as you say, when there's there's lack of consistency in that triangulation, it can feel very difficult. One of the things that I tell myself and I often share with patients and families, in obviously more appropriate language, is that admission to hospital in and of itself is not an evidence-based strategy for suicide prevention. There are things that we can do in hospital that can prevent suicide. For example, if someone's experiencing depression with psychosis, we can treat that psychosis, which would reduce someone's suicide risk considerably if that's what's driving the risk. If someone is intoxicated and having suicidal ideation in the context of that intoxication, holding and being able to sort of understand the person in context and safety plan thereafter would reduce their risk. And so I think that helps me sort of move beyond admission versus discharge. The question of and the other thing I say and I think I said this in our last podcast together as well, is if I'm working with someone and they want to be admitted, I should have a really compelling reason that I don't think that they should be admitted. And if I'm working with someone and they don't want to be admitted, I should have a really compelling reason for bringing them into hospital and engaging in what is trauma and what is quite carceral.

  Dr. Juveria Zaheer: [00:17:28] And so the things that I sort of think about in terms of involuntary hospitalisation is trying to hold on to a thread of hope, if someone can hold on to a thread of hope and they want to be alive and they want to engage in care, then there's a lot that we can do to support them. So, for example, safety planning is an evidence-based intervention in suicide prevention. There's a lovely paper in JAMA Psychiatry that shows that we show a 50% reduction in suicidal behaviour post discharge if a safety plan is completed. So a red flag for me is if someone can't safety plan, if they say I have nothing to live for, I don't really I have no hope, I have no one to connect with, that makes me a little bit concerned. Things that can really affect someone's ability to plan or to not be impulsive make me really nervous. We did a study that showed that of people who die by suicide between the ages of 25 and 34 in Ontario, something like a fifth or a quarter of them have a diagnosis of schizophrenia. So for younger folks, having a psychotic disorder is a really big risk factor for suicide, and it's really treatable. Psychosis is treatable and psychosis hurts and bringing someone to hospital to manage that, if someone has psychosis, whether it's an affective psychosis, whether it's a primary psychotic disorder, postpartum psychosis is very high risk. These are people I tend to bring into the hospital because if you're not able, if you think about keeping yourself safe, the psychosis can really interfere with that. Around family work, I think one of the biggest principles in working with families is is radical genuineness and radical transparency. So to be honest and open about what we're thinking, I'll often say to a patient, I'm really worried about you. I'll say to a family, you know, I would really love to keep your loved one in hospital. I'm worried too, and not but, and, here are the limitations of the Mental Health Act. And so I think if somebody I think one of the dangers in risk assessment is say, if I see somebody and they had a very serious suicide attempt. They engaged in preparatory behaviour, so they wrote notes to their loved ones, they've been giving away their belongings, they have a very deep depression that is sort of characterised by decreased problem solving ability, a lot of pain and potentially even some psychotic symptoms and that person has an overdose attempt. They made efforts to seclude themselves, they happen to be found and they come in and they're sitting in front of you and they say, oh, everything's fine, I'm not suicidal anymore. One of the really important things to think about is like, what has changed between now and then? And for this person, not much has changed and there's very much that could be modified. And if you can come up with a way to keep that person safe, in hospital, can someone stay with them 24 over seven? Can we start treatment? Can they come to day hospital and be seen every day? Then you can kind of modify that risk. But if the person says, no, I'm done here, and you know that three months ago they were going to work every day and they were really active in parenting their children. And, you know, they have a family history where someone died by suicide in the same circumstances. That's a situation in which I would certainly certify. If you meet someone who, you know, brings themselves in, I have a very difficult time when someone brings themselves in for care and they're really honest about what they're going through, you know, that's a really good sign that they're able to engage and they're able to share with you what they need. And that's a it's kind of like the the door is open. There's a crack, there's a light where you can kind of connect with them and support them in that sense.

  Chase: [00:20:48] For sure. Even sort of talking about, you know, the individual who's brought in by family, who's kind of concerned about suicidality. It sort of, even reminds me of when you see patients who are suffering with addictions and the family brings them in similarly and the person isn't kind of really ready to engage in that sort of care. And, you know, I think we understand that they need help at some level. And but at the same time, in terms of addiction and sometimes suicidality, the person is still kind of in that stage where they're not ready to engage with care or that can make it really hard too when you and the family are sort of on the opposite page as the patient.

  Dr. Juveria Zaheer: [00:21:33] For sure, one of my colleagues, Gina Nicoll, who has dual expertise, she has lived experience with suicidal behaviour and is also does research with me, she says something really beautiful. She said, 'it's really important, not like not to just try to understand the plan, but to understand the pain behind the plan'. And so I think sometimes when people are feeling really ambivalent about living or dying or getting care or not getting care to try to focus maybe less on the plan and less on keeping someone safe and more on what's going on in your life that is so painful and what is driving it. Yvonne Bergman often says, one of her lines that is so moving, is when people want to die by suicide and you ask them what they want to end, they don't often say my life, they often say I'm exhausted or I'm a burden or I'm terrified. And sometimes connecting with that emotion and that feeling, it's almost like a motivational interviewing approach, as if we can connect with that person as a person, then it can help us understand how we can get at that underlying piece behind the work. And so I think there's some really interesting parallels with addictions as well. And I think any kind of tools that families have are really useful. In our work with families, so we've interviewed people who who've lost loved ones to suicide and who've supported loved ones in navigating the health care system. People don't necessarily often complain about like, I brought them to the hospital and they weren't admitted. They are really distressed about lack of communication, lack of open communication. They are really distressed about the differences between like confidentiality and safety, like that kind of space there. They get really distressed that the follow up plan makes no sense. Like, oh, you want me to follow up in three months? That doesn't make a lot of sense. And so I think there's instead of getting stuck on admission versus discharge, even with families, to sort of try to understand their concerns and context and try to do whatever we can to make sure that we have a safe discharge plan for someone and that we can help them engage in the supports they need. And if the person isn't ready, then that we have a plan in place that if they're ready, like can we like harness that moment and bring them into the hospital and do what we need to do at that point?

  Chase: [00:23:37] Yeah. One thing you stressed is evidence-based care for patients with suicidality. And one of those things is completing a safety plan for that patient. I'm just wondering, is there any sort of particular, you know, diagnostic category that you might consider completing a safety plan, or are they really good for most patients who are having suicidal thoughts or behaviours?

  Dr. Juveria Zaheer: [00:23:59] Yeah, I love that question. I talk about safety planning all day. So I think the old term that people often use to use is like contracting for safety. So like if I say like, you promise you're not going to do anything right, there's no evidence for that because you're not actually giving the person any support or skills in that moment. The cool thing about safety planning, you know, you talk about reasons for living. How do I distract myself? Who do I call to distract myself? Who do I call for support, resources that I can talk, I can contact and keeping my environment safe. So a little bit of means restriction in there. Every time you use the safety plan effectively, it's positively reinforcing, which is really, really cool. Although like safety plans aren't a panacea, like there's certain times where it's not going to work and timing is really important. So you mentioned around, I'll come back to the timing piece, but around diagnosis. Suicide safety planning is a pan diagnostic intervention, but there are certain people who may struggle with safety planning. So, for example, someone who's experiencing mania or psychosis, this may not be the right moment or the right time to engage in safety planning, although you can still engage in kind of a modified form of safety planning. We just had a meeting yesterday with our colleagues at the Adult Neurodevelopmental Service, and we talked about how do we adapt a safety plan for people with intellectual disabilities or people with autism. We're doing some research right now where we interview people about their views on safety plans. And so I think that's a really great place to start, is ask someone what do you think about this process? And if someone is like all in on it, then absolutely do it. If someone is kind of ambivalent, sit with them and show them. If someone is like, No, I've done it, this doesn't help me, find an alternative.

  Dr. Juveria Zaheer: [00:25:32] The other piece that I mentioned earlier is around timing and safety planning. My colleague Gina often talks about waiting until the emotional bleeding has stopped. It can be extraordinarily invalidating, if I came to you in crisis and you were seeing me and I was saying that my relationship has broken down and I have been staring at a bottle of pills and I feel so alone and I'm not working, and you hand me a safety plan, you haven't even assessed me yet. A safety plan should be something that we come to collaboratively and we talk about the sort of striking while the iron is cold rather than trying to do the safety plan in the midst of crisis. I really like the idea of talking to folks about what works for them, and people are really good about about telling you. And I didn't realise until we started to do the research, but some people say to me, I prefer visual safety planning. Someone said to me once, I prefer a safety plan that's like a circle, so there's not an end to it. Some people say, like, I've been through this enough times that I can do it all in my head, and having a piece of paper isn't helpful. There's something at CAMH called the Hope App, which is really excellent. And for people who are like really good at the Internet, the app might feel a lot better. Often we ask who's important to you and we can photocopy the safety plan and give it to people that they love or give it to their care team too, which is really useful. One of the things I say is if you have like an iPhone, take a picture of it and then do the heart so it goes into your favourites so you can always find it easily. So I think that safety plans, again, they're not going to solve everybody's problems for sure, but they're sort of a tool in your arsenal that can be very helpful. And also it gives us kind of a shared language. So if my outpatient, for example, is struggling, they can say, you know, I've worked all the way through my safety plan and I know I need to come to hospital, and that's very useful and effective to know.

  Chase: [00:27:15] I've definitely had the experience of being sort of an earlier trainee and bringing a safety plan to, I believe it was an older gentleman who was having suicidal thoughts, and he did find it to be quite invalidating to actually receive the plan and sort of fill it out with me. So I think I have sort of learned to ask as well if people find that helpful or appropriate or if they've done one in the past before, sort of jumping into completing one at this point.

  Dr. Juveria Zaheer: [00:27:43] Yeah, absolutely. Like any time like it's we always talk about how like we always try to find the perfect question or the perfect thing to do, but it's not about the perfect thing to do, the perfect questions but the relationship. And so figuring out what the relationship, that's another Gina-ism. So figuring out what the relationship is is really, really useful and and reading the room before you start with one intervention or the other. And I think in in suicide-safe mental health care, choice is so important. Treating someone with dignity is really important. Not jumping to conclusions is important. Like if someone has been on Mirtazapine in the past and they hated it, then you probably would offer other choices. And so in the same in suicide safe care, if someone doesn't like doing a safety plan, is there something else that we could do that could be helpful?

  Chase: [00:28:29] And just on the lines of evidence-based care for patients with suicidality. Are there other sort of treatments that we should be looking towards when a patient is having a high degree of suicidality, maybe across some diagnoses? We could talk about those a bit.

  Dr. Juveria Zaheer: [00:28:46] Absolutely. I sort of think about suicide prevention strategies in four large buckets. So the first is how do we create a world where every life is worth living? And that means things like housing interventions, universal basic income, making sure that people are free from trauma and oppression, sort of like one bucket. How do we make the world a better and safer place? The second bucket is around understanding the treatment of underlying mental health issues. So we if somebody has depression, if somebody has schizophrenia, engaging in treatment for those for those illnesses. So we know that lithium, for example, is an evidence-based suicide prevention strategy for folks with mood disorders. We know that Clozapine is an evidence-based suicide prevention strategy for folks with psychotic disorders. So making sure that we know what the diagnosis is and then treating it. DBT, CBT, other types of psychotherapeutic interventions and antidepressants, not individually, they're not like lithium or clozapine, but as a class has level one evidence. Young people are really, really, really responsive to any kind of suicide prevention strategy. So any kind of sort of psychotherapy or higher term support for those young folks. And then the third bucket I think of is like public health interventions that are maybe more specific than the first bucket we talked about. So that's things like means restrictions. So gun control, lock boxes for poisons, bridge barriers that that kind of group of interventions, and then things like positive messaging around suicide and suicide safety in the media. So we think about the Werther effect where suicide can have a contagion effect. The opposite is the propaganda effect where we can talk about suicide in a safe way, show that there is care available and hope exists and help exists, that can be really important. Other types of interventions in that kind of bucket are things like gatekeeper education. So, for example, in the armed forces, if you can train like the generals and the corporals and the people who are kind of higher up to understand mental illness and to be open about it, it might make it easier for other people to get care. This works very well in schools as well, and religious institutions. And then primary physician knowledge and engagement, so like upscaling family docs and other care providers to be able to pick up on the signs of depression and suicidality. And then there's like this last bucket, which is kind of one that I'm really interested in, which is like specific interventions for suicide, often pan diagnostic. So the safety plan is one of them for sure. Another one of them that we're sort of trying to build evidence for is something called close contact follow up. So it's a little bit what we talked about earlier. So if you're getting discharged from an emerge or you're getting discharged from an inpatient unit, like someone will call you or reach out to you or you'll have like more intensive care in that period.

  Dr. Juveria Zaheer: [00:31:26] There's also psychotherapies that are specifically designed for suicide prevention. So things like CAMS is a really effective treatment, DBT, CBT for suicidality, these sorts of interventions can be very useful. Family and patient psychoeducation can be very useful as well. And then individual means restriction, so like talking to people about safe prescribing. If someone is, a risk factor for someone for engaging in suicidal behaviour is alcohol, like getting the alcohol out of the house. If somebody is like feeling really unsafe around subways, like avoidance of those things. So it's kind of like safety plan adjacent, like trying to make your environment safe. And then we also, I think in the biological treatments we mentioned things like ECT, rTMS, ketamine, lots of new things with evidence building. So I think basically the principles are how do we create a world that's safe for folks both in terms of like both broadly and more narrowly? How do we make sure we treat the underlying illnesses that are raising suicide risk and reminding ourselves that mental illness is only one part of suicide prevention. And then the third, the last bucket is how do we engage in suicide safe care in terms of suicide specific interventions?

  Chase: [00:32:39] And on the note of providing evidence-based care for patients with suicidality. I think sometimes, you know, we hear this sort of comment that like, oh, it's impossible to prevent or or we don't know that this particular intervention, including like SSRIs, even, is known to prevent suicide. And I think sometimes that can make one feel a little bit disenfranchised with some of the treatments we have. And are we even, you know, this patient's coming to me with suicidal thoughts and am I even helping them because I have this supervisor who told me this is this particular intervention has no evidence for reducing suicide. So I guess my question is like, you know, why is it so notoriously difficult to prove that our interventions are effective for reducing suicide? And and why do we have limited evidence on these?

  Dr. Juveria Zaheer: [00:33:36] Yeah, absolutely. And as for like the Zaltzman paper that came out in 2016, it's a review in Lancet psychiatry and suicide prevention, SSRIs as a class do have level one evidence in preventing suicide. But you're absolutely right. It's not like I can link this prescription for Prozac with reduction in suicide deaths, because doing an RCT around suicide is very, very difficult because suicide is an extraordinarily rare outcome. So we often use proxy measures like suicidal ideation or suicide related behaviour. The other piece is that but even those aren't necessarily common, especially suicide related behaviour. The other thing is often in studies like people with suicidality are often excluded and so people think we're there too. Even for me, someone who does qualitative work, you know, you have to struggle with IRB to get approved, to even talk to folks who are experiencing suicidal ideation. And I think, too, like suicide is so multifactorial that one of the challenges in working with folks with suicidal ideation is that it's a complex problem that requires complex solutions. But there are interventions that work and hope and help exist. And I think to your initial point, I loved kind of hearing you describe that feeling as a trainee when you're sort of trying to navigate these two messages. So one message is that we can't prevent suicide. We get that in training. We have a terrible outcome and we reassure each other with this statement and it has its benefit in that it can help us feel better when something awful happens. It can be reassuring for families too, who did everything they could for their loved one. But it has, it's problematic in the sense like how do you, it can cause therapeutic nihilism. It can make us like not think as seriously about treating people who are really, really suffering. And then the second one is like, every suicide is preventable and that's lovely because we want to make sure that nobody dies of any kind of illness. And the goal of zero suicide and suicide, perfect care for people with suicidal ideation is so, so important. The problem with that, though, is that it can lead to a lot of distress in care providers and families. It can also lead to really bad outcomes like, are we just not going to see people who we think we can't help? Are we going to put everybody on a form one? It can be, it's really a tough kind of dichotomy to navigate. So like swinging between like therapeutic nihilism to like feeling awful about ourselves and our system.

  Dr. Juveria Zaheer: [00:35:47] So for me, the way that I kind of the story that I tell myself is that like every suicide death is an extraordinary tragedy that affects families and care providers and the person whose life is cut short. And at the same time, suicidal ideation is a really important treatment target and people who are experiencing suicidal thoughts are deserving of hope and help, and we do have treatments and therapies that work. And so if it takes all of us to prevent suicide, I individually can't change the way the world is. We can advocate and we can be activists, but we can't change the whole world, but we can do our part. And that makes me feel better. And when I think when I do a suicide risk assessment, my goal is to make the person feel comfortable and safe. To say, I'm so glad you came, and like these these thoughts can often feel really shameful, but to say, like a lot of people have been through what you've been through and they've come through the other side. So stories of hope and recovery can be very useful for people, not in a toxic positivity kind of way, but in a natural and genuine way. And then once the person is feeling safe or more comfortable with you, then how can we understand their risk in context? How do we get all the answers to all the questions, understand their narrative of suicide, understand their risk factors, understand their protective factors, and work systematically to manage the risk factors and to strengthen the protective factors. And that's kind of the approach that I take. So it's less about prediction and most more about like best practices and providing good care. So if I see someone who has alcohol use disorder and when they use alcohol, it makes them at higher risk for suicide, we can do things like taking the alcohol out of the house. We can also help them enrol in addiction services, we can start them on naltrexone, we can introduce them to to other psychosocial rehabilitation models. And so if we can kind of link everything that the person is going through to their suicide risk as like making it higher or lower, and we can both address their suicide risk, but we can also decrease their suffering, which is ultimately the goal and have them live a life with meaning.

  Chase: [00:37:41] Right. And I think one of the things, too, that I also came to understand is that, you know, saying that something doesn't have any evidence in preventing suicide doesn't mean that it has been proven not to have any benefit in preventing suicide. It's just that also that we don't have possibly the power of or powerful enough studies to kind of show the effects that we're looking for as well.

  Dr. Juveria Zaheer: [00:38:07] Absolutely. And that's the challenge. So we know, if we can understand what the risk factors are across a broader population, then I think it makes sense that treating those individual risk factors can help. And I think the other really important piece is and this is like a plug for for qualitative research, is that understanding. There's no there's no like with like for us without us, right? Like there's no way of understanding someone's lived experience of suicidality and what helps and what doesn't unless we actually talk to folks and have them help us understand what's meaningful or not. So I think like engagement and co-creation is really, really valuable too in this population.

  Chase: [00:38:45] So one thing that I think comes up in the emergency department quite often, and we have touched on this topic briefly in our borderline personality disorder episodes, but, you know, there's this, I guess, constant balance that we're trying to strike with some of our patients who have borderline personality. On the one hand, we are concerned about their safety and on the other hand, we're also told that we don't want to create sort of this situation where, you know, the individual comes to hospital and we make them feel safe in hospital and we sort of become a de facto coping mechanism for that individual. And I'm just kind of wondering, how do you balance that care for someone's safety and wanting to be validating, but at the same time sort of taking on the cruel to be kind sort of mantra that others have advocated for in terms of treating borderline personality.

  Dr. Juveria Zaheer: [00:39:41] For sure. And the first thing I'll say around BPD is it's a diagnosis that does not have a ton of like construct validity in a sense. Like it's not a it's supposed to be a diagnosis that indicates like a lifetime, pervasive pattern of dysfunction. But we do know that a lot of people who are experiencing other types of major mental illness, particularly people who have a trauma history, can look like they have BPD, but that might not be the most appropriate diagnosis or it may be a comorbid diagnosis. So I think for me, one of the things that helps me is to move beyond like how do I treat someone with BPD to like, how do I use universal precautions from trauma at all times? And so many people who come to psychiatric emergency departments have a trauma history. Many people with BPD have trauma. Almost everyone with BPD has trauma, and the system and having suicidal ideation and behaviour is traumatic in and of itself. It's like threatened loss of life and threatened loss of integrity. And so for us at CAMH, and I think for me personally, it's like, well, how can I understand someone's story? How do I make them feel comfortable? How do I make them feel safe? How do I work with them to build safety and autonomy? I think one of the things that we do is if we have someone who is coming into hospital a lot, it's really important to look at their narrative arc of suicide risk. So, for example, if you have someone who is has come in eight times in the last month but hadn't come in in the three years before that, you know, a diagnosis of BPD or a formulation of 'we don't want to reinforce this behaviour' might not be the most accurate one because it could be that there's an episode of severe mental illness that we're just not treating all the way. If we know that someone is not doesn't get better in hospital or gets worse in hospital, I think it's really worth striking while the iron is cold again, having conversations with this person in the context of safety planning outside of the moments of crisis. There's a lovely paper by Von Bergmans and two of her former patients who have BPD that talk about how different I look when I'm not in crisis. And so if we can engage with people and we do this in the CAMH Emerge often as they engage with people when they're not in crisis with their care teams to figure out what exactly is most helpful in the moment. Sometimes what we do is we want to sort of it's kind of a I'm not a DBT expert by any means, but sort of taking we we live and work in a system where, like there's sometimes suicidality can be seen as a ticket to admission and if you don't endorse suicidality, then you can't get admitted. And so then it ends up that people have to up the ante to get the care that they need.

  Dr. Juveria Zaheer: [00:42:15] And I often reflect on the word manipulative, right? Like we often use this. It's a very gendered word, first of all. And for someone like me, if I if I had like a loved one or if I myself was struggling, I could call like 100 people and they would help me, like get the care that I need. But that's an incredible privilege. And if you don't have that privilege, all you may have is the emergency department. And so I think, like we see somebody who has increased service utilisation, one of the strategies we use is to try to strike while the iron is cold. It is very difficult to safety plan or to identify one's feelings or needs when one is in distress. And so if we can work with a patient and their care team outside of crisis, then it can really help us understand what they may need when they are in crisis. For some of our patients, we try to get rid of that ticket to admission kind of construct. And so often in mental health care, it's you're admitted if you're suicidal, you're not admitted if you're not. And then the ante keeps getting upped. Well, you're only going to get admitted if you self-harm in the department, you're only going to get admitted if you have a serious suicide attempt. And so what we try to do is disentangle the reinforcement from the behaviour and to say things that we sometimes we do something called a green card strategy where someone can come into hospital for a set number of days, a set number of times in a six-month period. And we really validate and reassure and support people for coming in before their crisis. I think it's really important to remember that people with BPD do die by suicide and they often die by suicide after periods of intense service utilisation. And so coming into hospital to break that cycle can be very useful. We work when we when we bring people in, I think it's really important to identify goals of admission and so that can be really tough when someone is like really activated and struggling. But to say, you know, we'd like to bring you in, we'd like to review your medications, help you connect with family, try to arrange good follow up, which is part of the problem, right? Like if you go from everything to nothing, that's a huge problem. And I think trying to be open and transparent and honest about, here are our behavioural expectations, what are your expectations of us? What do we think this length of stay is going to be? When people have a lot of trauma, they can't predict their environment and even neutral stimuli can feel very frightening and threatening. So should try to be as as as reassuring and supportive and open as possible, I think is a nice approach. And again, like if I if I'm working with someone and I know that when they come into hospital, things don't get better and they probably know that too, I try to be really honest about it and try to problem solve. And I think the other thing I know you and I have talked about this even on call, where it's a lot easier to be empathic and kind when it's 11 a.m. on a Tuesday and you're just back from vacation than it is at 3 a.m. where there's a full waiting room with 15 people waiting and you haven't slept and you haven't eaten. And so I think for us, it's really important to reflect on our own ambivalence and our own distress and what we're bringing to the encounter, because it can it's a it's a bidirectional process, assessment. And so to be kind to ourselves as well and to check in with ourselves, before we work with folks who are also in crisis and struggling, can be very useful.

  Chase: [00:45:20] Yeah. And you know, it also brings to mind sometimes I feel a bit disingenuous telling people, well, you know, the treatment for this is DBT and that's ideally what you should get on an outpatient basis. But in reality, you know, the person may not have any funds to access it and the wait times for publicly available DBT, you know, this is an Ontario based podcast, but I'm sure it's very similar no matter where you are, accessing DBT can be quite difficult. And so admission also becomes the fastest way to speak to someone who may be like first in DBT or able to kind of work with you on your distress tolerance in a really immediate sense.

  Dr. Juveria Zaheer: [00:46:03] Yeah, absolutely. And I think that's not a bad indication for admission. I think we need to think about the failures in our system and to be really open and genuine about those failures and then thinking about ways that we can advocate for better access to trauma therapies and better access to DBT and we definitely can't do it alone for sure. And I think I really like what you said about like picking up on those moments of feeling disingenuous and to sort of say like, does the plan I'm giving this person actually make sense? Like in talking to patients in our studies, like I think they would rather hear from us like, look, here's the treatment and the waitlist is going to take a really long time. And I'm so sorry about that. And what can we do in the meantime to help you feel supported, whether that's, you know, an urgent care clinic or other types of support rather than DBT is the way to go, here's a list and then when they call everybody, they realise that nothing is open or available. So I think that that kind of that feeling that you have, that empathy for the person you're working with is so important.

  Chase: [00:47:01] Wanted to get your thoughts on another topic that I think is becoming maybe more relevant as we move towards legislation for made for people with psychiatric illness. And this sort of revolves around the topic of involuntary hospitalisation for people who have suicidality or who have had suicide attempts. I guess I'm wondering how you sort of frame that or how you think about the ethics of involuntary hospitalisation for people who have suicidal thoughts or behaviours.

  Dr. Juveria Zaheer: [00:47:37] Then starting with the involuntary hospitalisation piece, I think psychiatry is facing a reckoning of sorts where we have to come to terms with our own history of oppression. We need to come to terms with our own systemic racism and anti-black and anti-indigenous racism specifically. We also need to come to terms with the fact that we are how we are the third arm of the law in many ways. We are carceral and so part of this sort of process needs to be understanding the power that we have and needing to understand the experience that people who are being held involuntarily are having. So for me, I think it's really important. There's a few things that I do to help myself understand the ethics of this. I think, as I said earlier, if I'm going to bring someone into hospital involuntarily, I better have a very good reason for it and I better be able to describe that rationale to the person I'm working with. Here's what I'm worried about. And for someone with suicidality to be very clear that it's not a punishment, that these are the goals for you coming in, whether it's collecting more information or providing support or whatever it is. I think that's really, really important.

  Dr. Juveria Zaheer: [00:48:46] And I think one of the things that is really helpful around forms and certification is to actually speak with the person about it, asking about past experiences of certification, asking about what it means to them. Like I have people who I say, I'll say, I'm so worried about you and I'm worried that if you were to leave here, you would continue to suffer and your life would be at risk and I think that we can help you here in the hospital. But I also know that being held involuntarily is really traumatic. What are your thoughts? And then people, you have these really interesting discussions about some people will say, you know what, I'd like to come in voluntarily and being formed would be really awful. Other people have said to me, the act of being put on the form is reassuring to me because it shows me that people care about me and I don't, sometimes when the thoughts get really dark, I don't trust myself and so I understand. Other people say, I don't like this, but I know it'll make my family feel better. And so actually having that conversation can be very useful. And I think like owning what we're doing is really, really important.

  Chase: [00:49:56] So I know we've taken up a lot of your time already, but I just wanted to get your thoughts on what do you think the future holds for suicide prevention and suicide treatment?

  Dr. Juveria Zaheer: [00:50:08] I was reflecting. I was doing teaching for our first year residents yesterday, Gina and I were. And we often ask people like, when was the first time you ever heard about suicide? Like when you were a kid? Like, what was what were those conversations like in your family? And the answers are so thoughtful and meaningful and so sad in some cases. And I feel badly, I'm the kind of person who never thought they would always talk about their kids, but I always talk about my kids. And I have an eight-year-old and a three-year-old and, you know, in my family, we were a muslim family, you know, suicide was haram. We never talked about suicide. We didn't even kind of understand it. And if it happened to someone else it was 'how could they do that to their family?' There wasn't an understanding of the mental health piece. And with my daughters, you know, we talk about how we're so happy that they feel well now and there's going to be things in their life that make them feel worried or scared or happy or sad. And sometimes sadness or worries can stick around even when good things are happening and they can make us not feel like ourselves and they can make us feel so sad and scared. And sometimes for some people they can even make us not want to be alive anymore and if that ever happens to you, we're always here and we'll figure it out together and people get better from this. And so I know it's like a long-winded way of saying, you know, when we think about the future of suicide prevention, it's not my eight-and three-year-old for sure, but I think it's like these conversations that's striking while the iron is cold. It's the work that's done by people like Jack.org. It's like changing the way we talk about suicide and making it easier for people to understand that there is hope and there is help and there are treatments that work.

  Dr. Juveria Zaheer: [00:51:39] I think, when I think about the future of suicide prevention in terms of research, I really do think that the future of suicide research is in co-creation and working with people to develop interventions for communities that work and then to test those interventions. And the future of suicide prevention is around accessibility and availability of evidence-based treatment. As you say, we have really good treatments that work, and universal health care means universal access and equitable access. And I'm really interested again in these kind of like suicide specific interventions that that we might not think of because we always think about like diagnostic silos, but I think that's really exciting. And I think the last piece is, is how do we go back to creating a world where every life feels worth living and how do we invest in social cohesion and a social net and freedom from the stressors that make us feel really scared and worried. And I think a lot about gender and race and how we, like the cultural scripts of how we act. So how do we encourage white middle-aged men in rural communities to get care? How do we make sure that people from indigenous communities have clean water and freedom from trauma and have ways to tell their stories in ways that matter? And I think that's what suicide prevention looks like to me.

  Chase: [00:52:54] Thank you so much Juveria for joining us today. We really appreciate having you on the podcast. Your answers were incredibly insightful and always helpful in guiding how we think about suicide as trainees and helping us move forward beyond risk assessments. So thank you so much. Did you have any final comments or any words of advice for our listeners?

  Dr. Juveria Zaheer: [00:53:17] I think what I would say is that we're you guys are really good at this, like you're good at talking to people about suicide. The more you do it, the better that you get and don't ever think that the checklist is more important than your humanity. You need to learn the checklist; you need to make sure that you're thorough and you create a plan that works for people but the thing that people are going to remember about you is your humanity and your kindness and your openness.

  Chase: [00:53:42] Thanks for listening. We hope you found our conversation informative and enjoyable. PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and recorded by myself, Chase Thompson and our theme song is Working Solutions by Olive Musique. You can contact us at Psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thanks again for listening. Bye.

Episode 33: Treating Borderline Personality Disorder with Dr. Robert Baskin and Dr. Ronald Fraser

• Episode 33: Treating Borderline Personality Disorder with Dr. Robert Baskin and Dr. Ronald Fraser

  Dr. Sarah Hanafi (PGY3): [00:00:09] Welcome back to Psyched, the psychiatry podcast for medical Learners By medical learners.In this episode will actually continue exploring a topic that I'm certain remains of interest to many of our listeners. Borderline Personality Disorder. In the first part of this episode, we reviewed the diagnostic considerations of the gist of this disorder, and the second part of this episode will touch on management of borderline personality disorder.

  Audrey Le (CC4): [00:00:34] During today's episode, we'll touch on several learning objectives. One understand the frame and principles of care for the treatment of individuals with borderline personality disorder or BPD. Two, to explore the approach to the treatment of individuals with BPD, including the presentation in crisis to the emergency department, the inpatient psychiatric admission, and finally the context of psychiatric outpatient care. Three understand the use of psychotherapy in the treatment of individuals with BPD, and four understand the use of pharmacotherapy in the treatment of individuals with BPD. Now let's get started.

  Dr. Nima Nahiddi: [00:01:17] I think it would be a good idea to start off with describing the general principles of care for treatment of individuals with borderline personality disorder.

  Dr. Ronald Fraser: [00:01:26] As Dr. Biskin mentioned sort of in the first podcast, there's a lot of different frames, a lot of different theoretical perspectives on the treatment of borderline personality disorder. I think the one thing that most have in common is that they're psychotherapies. So the most robust evidence for treatment of borderline personality disorders is psychotherapeutic rather than pharmacological and. You know, obviously they have other commonalities. But personally, Dr. Baskin may disagree about this. Personally, I think the thing that's most important is just having a frame, like just having a conceptual framework that that you have confidence in as a therapist. And from my perspective, it's always been important to me to be part of a team and that the team share the same basic conceptual framework. I think that provides a grounding which is particularly useful when situations get challenging or if there are clinical situations that are difficult for the team or for the individual or for the patient. I think having that framework to structure the work is very grounding for everybody involved. And for me, I think that's the the essential ingredient. I have no doubt that the various disciplines of various schools of thought would disagree with that, and they would say that, no, no, no, it's super important that you do X, Y, and Z. I'm not so convinced that that's true. Now, I'm biased because when I put together, along with a team, a framework for our program, we consciously decided to go with a trans theoretical approach where we basically stole components of all kinds of different schools of thought that we thought would best serve our patients. And and I think that has served us and served our patient population well.

  Dr. Robert Biskin : [00:03:54] I would I would actually completely agree with what what Dr. Fraser said, that the framework and the structure is probably the most important part of treatment for people with BPD. It highlights one of the challenges in terms of treating people with BPD in an outpatient setting versus other settings. There's a lot more variability in teams and structures in both the emergency room and the inpatient units. So having a consistent team with the same theoretical framework, the same approach to treatment is is extremely important. There was an interesting paper actually a number of years ago that looked at many of the different specialised types of psychotherapy for people with BPD, and it highlighted that the use of a team, the use of a consistent theoretical model, consistent frame force for treatment, the use of psychotherapy and particularly obviously looked at psychotherapies and particularly the use of multiple different types of psychotherapies, often with different treaters providing different parts of the therapy are some of the elements that are really essential or consistent across many different many of these different theoretical models, many of these different specialised treatment programs, which again kind of highlights what Dr. Fraser was saying about how no matter what type of psychotherapy that you choose to employ, there's many different tools from different approaches that can kind of be brought in and are probably very useful for treatment of people with BPD so that those structural elements are probably extremely important. So that would be what I would focus on as primary principles.

  Dr. Nima Nahiddi: [00:05:40] Can you discuss what you both mean by the idea of the therapeutic frame?

  Dr. Robert Biskin : [00:05:45] So the the idea of the therapeutic frame incorporates a few different components, but it's often a very structured approach to the therapy with very clear therapeutic goals, therapeutic steps and therapeutic outcomes or consequences for different sorts of actions. So a lot of the types of treatment will have very specific types of therapy every week. So you'll have a number of different individual sessions or group therapy sessions every week. And oftentimes attendance at these sessions, at these appointments is very, very important. There's often a lot of specific rules that people might have about attendance, about showing up on time, about communicating with the treating team or indoor therapists in between sessions. But in addition to that, there's a more global framework as well in terms of identifying early on specific targets for the treatment. So this is, in my opinion, an area where focusing on functional outcomes actually becomes very important. Having that as an overarching goal, not necessarily the only goal, but one of the goals for for treatment, for example, being able to find a job or look into or be able to develop new friends or relationships as kind of overarching functional goals for therapy is another part of the framework. And finally, another essential component of framework is that therapy must end. And I do believe that having an endpoint that the patient is aware of from the beginning of therapy is one of the important steps for having this consistent approach, not only because it gives patients the chance to recognise when therapy is going to end and they must take those steps to work on their own and learn to trust themselves in the skills that they've developed on their own. But it's also necessary because otherwise we won't be able to continue providing treatment for new people if we're continuing with the same groups of people indefinitely.

  Dr. Ronald Fraser: [00:07:49] Yeah, I think all of that is really, really key. I think the only other thing I would add is that there's also a secondary frame for the team itself. And, you know, both the teams that both Dr. Biskin and I belong to meet on a weekly basis that provides our own internal structure. And one of the things that we do is obviously we provide support, peer supervision, guidance. But also, you know, we have a place where we all feel safe enough to ask difficult questions and ask ourselves, what are we doing and why? But also, what are we not doing? And why. And those are really important questions for us to step back and reflect on, because we have to be accountable to the patient. We have to be accountable to the system. We have to be accountable to each other, and we have to be accountable to ourselves. And so there are two frameworks one, the clinical framework for the patient. And then secondarily, but equally important is a clinical team framework that we work with in.

  Dr. Sarah Hanafi (PGY3): [00:09:11] So you've both touched on the emergency department as one of these areas where maintaining that frame is perhaps a little more challenging. And I know in the previous episode we talked about how patients can sometimes present in crisis in the emergency department. I'm wondering, can you walk us through an approach to the management of someone who's presenting with BPD in the emergency department and is in crisis.

  Dr. Ronald Fraser: [00:09:38] So that can be. Theoretically easy and. Extremely difficult in reality. So one of the advantages that our teams have is team consistency. Emergency rooms sometimes have that where they have consistency of staffing, but most often they don't. So most often there are different psychiatrists on different shifts, different days with different ideas, which is all fine, but different nursing staff and different patient attendants and just different everything. And you can imagine that that doesn't necessarily lend itself to consistent messaging. And that can be problematic because the one thing that these patients do, all patients do well with is consistent messaging and not mixed messaging. So wherever possible. It's important to try to really communicate amongst ourselves within the emergency room of what the plan is. Why that's the plan, What's the rationale? What are the goals with complex patients that may present more often to the emergency room? Often we'll have case conferences with various stakeholders in terms of their outpatient care, their inpatient care, their emergency care, and try to put together treatment plans. So when a patient presents under such circumstances, this is going to be the consistent response. And obviously the patient is involved in that treatment plan so that there's no there's no surprises. And so they understand what the plan is and they understand what the rationale is. The rationale is to do no harm and to hopefully improve the situation. You know, ideally emergency room team sort of come up with consistent approaches of how they're going to manage these patients and how they're not going to manage these patients. So, you know, not using things that are punitive, not we don't have control over what other people do. So we don't have control over what patients do when they're in crisis. But we do have control over how we choose to respond. And that's what we need to focus on is our choices. And our reactions. I think that's really the key starting starting point for any patient that we see in the emergency room in crisis.

  Dr. Robert Biskin : [00:12:35] I'll add a few other points as well. It's interesting because for my experience, the way that I work with patients who are in my clinic at the Jewish General Hospital, it's I have the I have the ability to provide care for them in whatever setting they come in. So if they're in active treatment with us, I will be the one who will go down and see them in the emergency room. I will see them when they're admitted on the inpatient unit and I'll follow them as well when they're discharged into the outpatient clinic. So it provides a lot of consistency in that context, but that's not feasible for people who don't have my job. So in general, the approach that I take for for patients the first time that they're coming or one of the first times that they're coming and presenting to the emergency room is I tend to take approach that gives people more time. So the assessments of the work often does end up taking a little bit longer. And I actually have a rather particular approach that I will use with these patients, oftentimes beginning with the interview similar to what Dr. Fraser described before, more emphasis on people's or in the previous podcast, more emphasis on people's personal history, understanding their context or situation. I'll give people a lot more time to talk and share a lot about their story. And during those times, I'll be looking for clues as to what's the stressor, what are the triggers for why they're presenting to the emergency room that particular day? Because sometimes it's very obvious there was a particular stressor problems at work, relationships, school, etc.. But sometimes people will come in and say that they've just been feeling unwell for a very long time and being able to identify what it is that was making today that much more difficult than the day before is is very useful and it's a source that are the ones that I identify that particular topic. I spend a fair bit of time validating and validating that the person is having a lot of difficulty, that they're doing their best to cope with the situation. They might not necessarily have the best coping skills at work over the long term, but again, to come back to that idea that they're trying their best. So a fair bit of time validating and oftentimes patients who are coming in to the emergency room have not had the opportunity to have these sorts of specialised types of therapies that Dr. Fraser and I are both able to provide. So I'll also talk to them about the the hope for change and see how motivated they are for something like a specialised type of psychotherapy that might be different than other treatments they've received before. I don't try to do psychotherapy in the emergency room. I'm not going to be trying to teach them skills because it's not the best time to do that. But emphasising that there is hope and there are things that can be done. I take a model that's similar to a school that you never had the chance to learn this before in the past, so you kind of need to sit down with the books and have a chance to learn it in a structured way to kind of catch up for the things that you've missed. It often, again, destigmatize a bit about the illness and. Helps people feel more comfortable with the idea of going for a therapy if they're not so comfortable with it before. So, yes, that's kind of the approach that I take. Again, it does take a little bit longer, but most of the time patients again, it often ends with disclosing and discussing the diagnosis. Most of the time patients are quite satisfied with that. They feel like they've been heard, they've been understood, and they're interested in treatment when they're eventually able to get it.

  Dr. Sarah Hanafi (PGY3): [00:16:16] Thank you for that. So it sounds like in the emergency department, the stance is very supportive. I'm wondering, outside of the emergency department, can you touch more on these different specialised psychotherapies? It sounds like psychotherapy really is the mainstay of of treatment.

  Dr. Robert Biskin : [00:16:43] it's worth mentioning at the very beginning that there's not really any evidence of superiority from one to another. So they're all probably equivalent in many ways. And it's possible that certain elements from one or slightly better than another, but it's minimal. As we talked about before, the frame is kind of a central component of these these specialised psychotherapies. But one of the ones that probably are the one that does have the most research behind it is specialised treatment called dialectical behaviour therapy, which is a variant or it developed out of cognitive behavioural therapy, specifically designed for people who have intense or chronic recurrent suicidality and a lot of self harm. So like many of the cognitive behavioural therapies, it emphasises a toolbox approach. So in DBT it's again a combination of individual and group therapy. In DBT, there's many, many different skills that are taught to patients depending on how you might read the book. There's about 30 or so core skills with a few hundred variants of all of those different skills. So it can often be overwhelming for people at the beginning, but emphasising that there's just a few core skills that people need to work on and develop is part of the treatment and the four main areas that the skills come in is mindfulness, which overlaps a lot with mentalization or sorry, mindfulness based CBT. I mean the ability to just be aware of what's going on inside you and ideally do so non-judgmentally. The second main area is emotion regulation, which kind of steals a lot of the ideas from cognitive behavioural therapy, such as thought records. In DBT, we would call it checking the facts. Opposite action often incorporates a lot of elements of exposure therapy from cognitive behavioural therapy, and there's a lot of activity or a lot of emphasis on kind of having pleasurable activities and developing skills and mastery and things in different parts of life. The third component in DBT is interpersonal effectiveness, which is a lot of skills about managing relationships. So both being assertive but also trying to learn how to validate other people when it's appropriate to or to set boundaries and establish or self respect, as well as managing conflicts and building new relationships as well. And the final component of DBT is what we call distress tolerance, which is a lot of crisis management skills. So distraction techniques, breathing exercises. And a huge component of this section is also radical acceptance, which is accepting things that cannot be changed, accepting things the way they are. And that's often a very challenging part for people in therapy. But the very core idea of DBT. So DBT is typically a therapy that's given over about a year and has been shown to be very effective, particularly for suicidality, self harm. And depending on how you read the literature, certain other elements of BPD as well. So that's the most common type of psychotherapy. But there's a number of others. So mentalization based treatment focuses on the capacity that somebody has to recognise the internal states of other people as well as themselves. So be it. Emotions, thoughts, impulses and the work in that sort of therapy is focused on practicing and developing that is built. It's kind of emphasise as a muscle that you continue to develop, to develop with treatment and it also includes individual and group therapy, other types of therapies such as transference, focus therapy, take a more psychoanalytic approach and focus on the relationship between the therapist and the patient and the expectations that the patient might have of the therapist. But this is just a few of the psychotherapies, and there's a good dozen more that I probably can't talk about in much detail because I don't know them enough.

  Dr. Ronald Fraser: [00:21:07] I actually wanted to share a clinical point that has absolutely nothing to do with your question, but popped into my head as I was listening to Dr. Biskin, and it's related to actually to diagnosis. So oftentimes one of the reasons I see people who have never been diagnosed with BPD that have BPD is because they lack one of the nine criteria. And if they happen to be an individual that has never had a past suicide attempt, does not engage in self harm. For some people, for some reason, clinicians feel that this is an essential component of BPD, and if you don't have that, then it's like exclusion criteria. But there's up to 20% of patients with BPD actually don't don't have that criteria. So often these patients will not get picked up and not get identified as having borderline personality or even if maybe they have eight, all eight of the other criteria. So I think that's actually an important point for learners and for trainees to realise that just just because of the absence of suicidality and self harm, that doesn't necessarily mean that this individual may not have borderline personality disorder.

  Dr. Sarah Hanafi (PGY3): [00:22:35] Thanks for that clinical pearl, Dr. Fraser. So I wanted to go back to the topic of therapy after that. So bouncing off of the discussion that we've just had about psychotherapy. Could you maybe discuss the role of pharmacotherapy in treatment for these patients, for example, in in terms of how different medications can be used to target the different symptoms that we may commonly see them present with?

  Dr. Ronald Fraser: [00:23:00] So this is actually. Probably one of the areas of greater controversy. If you look at the treatment guidelines that come out of, say, the U.K. and compare and contrast treatment guidelines that come out of North America with the APA, there's tremendous differences of opinion on the role of medications. There certainly can be a role. I think everybody agrees that there could be a role for medications. There's no medication that has an indication or treatment of any personality disorder. So they're all used off label. Often the approach is symptom focused. So for example, there are certain medications that one might use for impulsivity. Other medications that people or the exact same medications that people might use for mood stabilization or for anxiety or for insomnia. There's another whole set of medications, obviously, that might be indicated for comorbid conditions, and those have much more robust evidence. One of the things that's always sort of of concern and, you know, I've seen hundreds of patients and so I've seen patients on zero medications and I've seen patients on 12 different medications. And there isn't necessarily much in the way of clinical differences in terms of their outcome. And there's other patients know, you give them one medication and they really find that it makes an a profound impact on one domain. So perhaps there's a diminishing of their anxiety, and that really makes a significant difference in their quality of life. But the main concern that we often have as clinicians is that we see polypharmacy where there's one medication added and maybe there's a little bit of benefit, but it's not certain. And so then another one is added maybe targeting a different symptom or trying to augment the first medication. Very seldom medications are taken away and then gradually over time, you get you find a situation where you're on a 10 to 12 different medications, including medications to treat the side effects of the original medications. You're not entirely sure how the heck we got here, and you're certainly not sure how are we going to get out of here? So you don't like today? I had a follow up appointment with patients, which of course was done virtually because we're in the middle of a pandemic. She joined our program in January, and since she arrived in January, we've been gradually trying to clean up her pharmacotherapy. She's been since let's we're September, so that's nine months. So in nine months we've taken away one at a time. And so she's been taken off lithium. Let's see. So when she started, she was on three mood stabilisers. One of which was lithium, two antipsychotics, two antidepressants, two sleep aids. And so we've removed lithium. Epival, Emmavain, regular Seroquel, Seroquel, XR and Zoloft and Wellbutrin. And her clinical condition is no different, except she has a lot less side effects. So it's complicated and every patient is different. Some patients have a significant response. Very rarely is there like symptom remission. So if you're treating anxiety, it's very rare that they're going to describe, you know what, I'm no longer anxious. I don't have any anxiety. But their anxiety might go from 10 to 8 or 8 to 6, and that may be clinically significant. Even though you don't have remission of the particular symptom, you may have taken enough of the edge off that it makes a difference in their quality of life and perhaps allows greater functioning.

  Dr. Robert Biskin : [00:27:21] My opinions about pharmacotherapy are probably a little stronger than Dr. Fraser's. I'm not particularly fond of pharmacotherapy for patients with BPD, and there's evidence that the medications themselves are of generally limited value. And when you look at the literature, the research, the better quality of the study is, the less likely it is to show any benefit over placebo. And this has been shown now with a number of different agents, Zyprexa, Lamotrigine or two that come to mind with recent examples. So I'm skeptical of most of the medications because again, these are most of the medications we use in psychiatry do have a substantial side effect burden. And as well, one of the things that I'm always concerned about is toxicity. So I'm highly concerned about people who are, for example, on mood stabilizers and things like that where the risk, if they overdose on it is quite profound. So I'm very reluctant to prescribe these medications and will often do prescribe medications as well. I tend to if in situations where, for example, anxiety or things like that Are Significant, depressive symptoms are really getting in the way. I occasionally do prescribe medications more than occasionally. Sometimes we'll prescribe medications, but often it is ones that are lower risk, less side effect burden as well. And interestingly, there's been one study that showed that when you prescribe medications for depressive symptoms with people who are actually in the program, the people who receive medications actually did worse. Which is fascinating. And it interestingly fits with my clinical opinion perspective as well in that sometimes people wish or hope for the medications to be the solution because it seems easier to take a pill than it does to do therapy because therapy involves a lot of hard work, whereas the pill, the side effects are not immediate. You're not going to feel anything immediately after taking it. So they might prioritise taking medications as solutions as opposed to therapy. So sometimes emphasising medications too much or people focusing on medications too much lessens their focus on actually making the necessary therapeutic changes and committing themselves to the to the process of psychotherapy. So again, I do use medications on occasion, again, lower typically lower risk medications and again, always monotherapy stopping the medications if they're not effective, sometimes medications for sleep as well, but more or less, less frequently.

  Dr. Ronald Fraser: [00:30:05] Yeah, I wanted to actually emphasise this point because I think it's really key in Western society. We have a real love affair with medications and we have this sort of belief that we should never feel any physical or psychological discomfort and if we do, there should be a pill for that. And. As Dr. Biskin points out, it can actually prevent people from engaging fully in the therapy because of their never ending quest for just the right medication or just the right combination of medications. People's belief that there's got to be some medication or combination of medications, and we just haven't hit it yet. And that's going to resolve. All my distress can can really be quite remarkable and it can be very difficult, despite providing tremendous psychoeducation, that that's unlikely to happen. We know from the literature that medication is not likely to be that beneficial. And we know from the literature what is likely to be beneficial is psychotherapy, which sadly is a heck of a lot of hard work. And I think that it can't be emphasised enough but dynamic.

  Dr. Robert Biskin : [00:31:35] In my opinion, it often comes back to this idea about trying to the self and validation that people have learned that they're not supposed to feel things, so they will seek out whatever it might be, including prescribed medications, if they're feeling sadness, if they're feeling anxiety, to do whatever they can to make those feelings go away. Many of the patients that I've worked with have said that they wish that they could turn off their feelings if possible, but that's not actually possible in psychotherapy. It's a very clear point that you have to live with your feelings. You have to learn how to cope with them and how to be with them instead of trying to make them go away.

  Dr. Ronald Fraser: [00:32:14] Which, of course, is what leads so many patients with borderline personality disorder to develop substance use disorders because there's no more effective short term solution to negative affective straights than intoxication. Unfortunately, it's a spectacularly poor long term solution, but it's the same principles.

  Dr. Sarah Hanafi (PGY3): [00:32:37] I actually wanted to address something that you had briefly mentioned earlier, Dr. Fraser, in regards to comorbid disorders. How do you approach treating comorbid disorders in this patient population?

  Dr. Ronald Fraser: [00:32:50] So my perspective on this has actually changed over the. Decade and a half. And so this is more personal opinion than anything else. So I think we should have that caveat early on in my career. Saw tons and tons and tons of co-morbidities. Now more and more I conceptualise things as really it's part and parcel of the personality disorder and that really is what needs the focus of attention. There are some exceptions to that. So occasionally I have that conceptualization and then I see them, a year into treatment and they're fluidly manic. And I say, okay, we missed that. That's what's pretty clear that they have bipolar disorder, and that happens about once every 75 patients or something like that. I think the most prevalent comorbidity that I see is substance use disorders. And despite being an addiction psychiatrist, we don't do a great job of treating that. We're not even though we recognise it, we see it. I really wish we did a better job of that. I think the next most prevalent thing that I see is probably things in the eating disorder spectrum. A lot, a lot of very clear comorbidities there. Oftentimes patients we struggle with, we'll refer to the eating disorders program, patients that they struggle with, they'll send to us. And sometimes we have success with theirs and they have success with ours. Different interventions and perspectives resonate with different patients. Anxiety and mood disorders are described as very prevalent comorbidities, but I'm less and less convinced of that as as my career goes on, to be perfectly honest, that I don't think I see it. And I may be seeing a bias sample. And then, of course, trauma related disorders are quite common because unfortunately, many of these patients have had very difficult backgrounds, some of which are just literally horrific. And and often it would be shocking if they didn't have a trauma related disorder, given their experiences. So I think those are the sorts of things you see. The good news is, is that many of the treatments for borderline personality disorders, many of the psychotherapies, also have a certain amount of effectiveness for other things. So if you are suffering from a substance use disorder or trauma related disorder, distress tolerance is a super useful skill, right? If you're suffering from different disorders, usually they're impacting on your interpersonal functioning. So improving that is tremendously helpful. So you don't necessarily have to change the interventions regardless of the comorbidities. But I do think you need to be aware of them. You need to be cognisant of them, and that may sometimes inform your pharmacotherapy in particular.

  Dr. Robert Biskin : [00:36:15] I would. I definitely agree with what everything that Dr. Fraser has said and I'm also of the mindset and perhaps slightly controversially so that a lot of the mood disorder symptoms, the depressive symptoms, the anxiety symptoms are often manifestations or components of the person of BPD as part of those difficult or dysphoric states. The comorbidities that are the ones that are most concerning and will lead to changes of treatment really are the substance use disorders, particularly if more severe. And it's that point that I'll refer people to Dr. Fraser, but as well the people with the severe eating disorders and I've seen quite a number of cases of people who once, for example, when they have an anorexia and once the anorexia becomes quite impairing and consuming of somebody's life, it's very hard to pull back from that without the structure and specialised support that eating disorder programs are able to provide. Other disorders. I've had patients in my clinics who often younger patients who at a certain point will have psychotic episodes that will persist for time. And at that point, clearly we have to revise the diagnosis to a psychotic disorder or something like schizophrenia, which dramatically changes the treatment approach. But for many of the more garden variety mood or anxiety disorders, I completely agree that treatment for BPD, whatever that treatment might be, is shown to be efficacious. People's symptoms of depression, anxiety with specialised psychotherapies will reduce will improve as well.

  Dr. Ronald Fraser: [00:37:58] I just want to add one last point, because I think this is actually Dr. Biskin touched on an important point, that it's important to contextualize for learners about the controversial aspect of these things and that I think you figured out by now that what we say is not necessarily gospel. So you can have the same patients who Dr. Biskin and I might clearly conceptualise as having borderline personality disorder. And you could have one of our very respected and revered colleagues in a mood disorder clinic who would say, Look, Fraser doesn't know what he's talking about. This is clearly bipolar spectrum disorder. And you know, it's not clear that I'm right and they're wrong or vice versa. And I think that's where it's really important for learners to decide for themselves what makes sense for them, what they think is going on, and recognising that everything you hear from me and Dr. Baskin consciously or unconsciously, has a certain bias based on our training, our background, our experience, all of those factors. And if you had two other people here with different background training and experience, you might get very different answers that might be equally or even more valid than what we're sharing.

  Dr. Sarah Hanafi (PGY3): [00:39:31] I'm really enjoying this this discussion. I think it's bringing up some really interesting points. I actually wanted to circle back to something you had mentioned, Dr. Biskin, about safety risk. Briefly, I was wondering, can you just talk about how you approach managing safety in this patient population?

  Dr. Robert Biskin : [00:39:51] Boy, that's not an easy question. Much like Dr. Fraser is mentioning about different diagnostic approaches and different diagnostic thresholds. I would say the same applies for thresholds, for accepting risk, because you'll get many different answers for many different people. I would most clearly say that I accept a higher threshold of risk, fortunately or unfortunately, than many of my colleagues who don't work with this population. And it's something that is a particularly tricky question to answer. And I guess, as I pointed out before, for learners, it's something that you would be very careful to discuss with whoever it is that you're working with as time goes on, because you'll get very different perspectives. My particular approach or understanding is that people with BPD, they suffer a lot. And the idea of suicide, because I'm assuming that's mostly what we're talking about. The idea of suicide is something that's pretty much constantly present because it's the escape hatch. If there's a lot of pain in their life and they're doing everything they can to control it and it's just not working, it's sometimes reassuring. Your comforting to know that suicide is there as a backup option, which is very both comforting for patients sometimes when they're thinking about that and also terrifying for them as well, because many times that's not the path that they want to take unless it's absolutely necessary. So accepting the risk that there might be, which is a chronic risk, but people working with this population or in general mental health problems, that accepting that suicide might be a risk is part of the treatment. And it's one of the challenges with when you're deciding what to do with somebody who's presenting in the emergency room. It makes it very challenging because what we know that reduces that suicidality is specialised therapies that exist as on the outside. We don't really have evidence that hospitalization and the treatments provided in a general psychiatric inpatient unit are able to reduce suicide in the same way or suicidality in the same way that the outpatient psychotherapies are. So it's a very difficult question to answer.

  Dr. Ronald Fraser: [00:42:18] So one of the things I would add is that, you know, if you don't want to have a patient die, you probably shouldn't go into health care because it's unfortunately an occupational hazard. Our job is, wherever possible to minimize the prevalence of that. But certain populations have higher risks than others. At certain populations are more unpredictable than others not. You have to have a certain tolerance of uncertainty and a certain tolerance of risk to work with this particular population. And not everybody has the temperament or disposition for that, which is fine. I don't have the temperament or disposition to work with other patient populations. I think it's super important to try to differentiate between chronic risk and acute risk. So, you know, I have patients that are, you know, are thinking about suicide every single day. And and as Dr. Biscuit points out. That can be perversely comforting because it actually gives them a sense of one thing in their life that they have control over. I can choose to kill myself or I can choose to not kill myself. I have control over that. I may not have to feel like I have control over anything else. And one of the rewarding things is that as people respond to therapy, you know, often with tears in their eyes, they'll say, you know, I haven't thought about end of my life in months. It used to be my daily companion. So that actually does respond to therapy, as he pointed out. But then there can be acute risk on top of the chronic. And that's where you sort of have to be cognisant of picking that up. And so particularly in acute crises, often if there's a loss of a significant relationship because relationships are so important to people in general and this population in particular. So the the loss of a therapist, whether it's through the end of therapy or if they've had the misfortune them, I've had patients with their therapists have died. So that's difficult or they've been kicked out of the therapy for whatever reason, or there's been a loss of a loved one or a relationship or a pet if there's been some other acute stressor. If you see in your patient that there's a profound clinical change, it helps if you know the patient really well. It's like, okay, this is like they're really disorganised or they're really struggling or they're really like severely dissociating or severely regressed. There's something acute going on here that's that is alarming. Then you're concerned that their chronic risk of suicide may have escalated acutely and you may need to make significant differences in your treatment plan in terms of brief containment and a brief intervention unit or a very short admission until that acute situation stabilises itself. And you may still discharge them with suicidality, but it will be back to their chronic state, not the acute state.

  Dr. Nima Nahiddi: [00:46:09] And so to finish off and building on our discussion, which we started in the diagnostic episode. Can you both speak on stigma and Treatment of patients with borderline personality disorder?

  Dr. Ronald Fraser: [00:46:19] So that's a big thing and it's less of a thing than when I started. So we're making headway. We've got a long way to go. But when I started the idea that there would be groups for loved ones and concerned others, for people suffering from a borderline personality disorder, like there's a whole network in Ontario of these things. We have Quebec here in Montreal, like the fact that there would that these would even exist was like unheard of. So we're still making headway. There's been a lot of education in the media that didn't use to exist. There's still a lot of bad information out there, as Dr. Biskin touched on in the last session. So the Internet transformed the world. But it's not all positive. And there's a lot of really. Misinformation. Know, I think that's sort of a buzz word for 2020 is misinformation. And so it's really important to try to direct our patients to reliable sources of information. For me, the National Education Alliance for Borderline Personality Disorder is a web resource that I often direct patients and families to. There's a lot of Biblio therapy that I direct people to. So you try to explain that there's just like everything else, the world is good and bad information. But the biggest challenge is, I think, still. Is stigmatization within the health care network. So the reception these patients get when they go to the emergency room. Is often far less than ideal. And many of my patients are smart people and they started to figure out I get a much better perception or reception story if I tell them I have schizophrenia or bipolar disorder, or I tell them I'm having auditory hallucinations. They sort of learn because it's aversive. To present with borderline personality disorder. And I've had patients that have engaged in self-injurious behaviour and they need sutures like that's the medically indicated treatment. And and the emergency room physician will say, you know, if you like pain so much, maybe I shouldn't give you any lidocaine or any anaesthetic or The emergency room physician who have a very difficult job, don't get me wrong, but it's very frustrated and says, you know, I should teach you to try sutures so that you can just suture yourself. How you can do one handed sutures, I'm not sure. But anyway, so they get abysmal Treatment Often when when they interact with the health care system, that really wouldn't be acceptable for any other human being, let alone any other diagnosis. So where we need to make the most progress is around reducing stigmatization within our own health care networks. And one of the ways we do that, which has also been quite fruitful, is through conferences and education and podcasts like this. You know, there's probably, I don't know, 86 people other than my father that are going to watch this podcast, but they will learn something from it. And these things make a difference over time. Maybe underestimated the numbers.

  Dr. Sarah Hanafi (PGY3): [00:50:09] We we have more listeners than that, but.

  Dr. Robert Biskin : [00:50:14] So to add to to what Dr. Fraser was saying. I do agree that the health care system is one of the sources of a lot of stigma. And I do think that one of the things that has changed and has helped improve the amount of stigma, particularly within mental health care, is greater accessibility to these specialised treatments. So the programs that Dr. Fraser have established and that Dr. Paris have established here in Montreal has helped people change their perspective and seeing that the beliefs that they have about these these disorders are not necessarily accurate. And unfortunately, not every region, not every city has access to programs like we do. Obviously, I think they should. And I think that both education information and advocating for increasing services and increasing recognition of the disorder is something that will help. And this is where I get concerned about people who might label BPD as another psychiatric disorder, such as the comment that Dr. Fraser made last time about the overlap between criteria with complex PTSD and borderline personality disorder, that one of the potential outcomes of that is that it might further stigmatise borderline personality disorder that might think of it as the unwanted illness, even though the symptoms are almost exactly the same. So further awareness and access to the disorder and to the treatments for it, I think is something that over time will help improve the perception within the health care system as well.

  Dr. Nima Nahiddi: [00:51:58] A huge thank you to both of you, Dr. Biskin and Dr. Fraser. I certainly learned a lot myself. Do you have any closing remarks for our listeners?

  Dr. Ronald Fraser: [00:52:07] Well, I think we both are really appreciative that you invited us. Obviously, hopefully it came through that this is a topic that we're both pretty passionate about. We've chosen to devote our careers to this and any opportunity we get to sort of share the gospel, we're really tremendously appreciative to have the opportunity. So thank you for expressing an interest in it and having it as a topic in your podcast series. And thank you for inviting us. We really appreciate it.

  Dr. Robert Biskin : [00:52:40] Thank you very much for inviting us. Definitely something that is not just passionate for us, but something that we genuinely enjoy as well. So any chance that we get to talk about it and to kind of share some of that, that enjoyment that we have with working with these sorts of problems and people with these sorts of problems, we're thrilled to do it.

  Dr. Nima Nahiddi: [00:53:01] Thank you both once again.

  Dr. Sarah Hanafi (PGY3): [00:53:03] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi and Audrey Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Ronald Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org Thank you so much for listening.

Episode 32: Diagnosing Borderline Personality Disorder with Dr. Robert Baskin and Dr. Ronald Fraser

• Episode 32: Diagnosing Borderline Personality Disorder with Dr. Robert Baskin and Dr. Ronald Fraser

  Dr. Hanafi: [00:00:09] Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll explore a topic that I'm certain will be of interest to many of you. Borderline Personality disorder or BPD. In the first part of this episode will touch on diagnosing borderline personality disorder and in part two will review treatment. I'm Sarah Hanafi, a PGY 3 at McGill University, and I'm joined by Nima Nahiddi (PGY3), a fellow PGY 3 McGill.

  Nima: [00:00:40] Hi, I'm Nima.

  Dr. Hanafi: [00:00:41] We're also joined by Audrey Le, a fourth year medical student at McGill. Everyone, we're very grateful today to have our guests, Dr. Robert Biskin and Dr. Ronald Fraser, to share their expertise. Dr. Biskin, why don't you introduce yourself?

  Dr. Biskin: [00:00:59] Hello. My name is Rob Biskin. I'm a psychiatrist. I work mostly at the Jewish General Hospital, as well as at the McGill University Health Centre. I'm an associate professor at McGill, and I work mostly in personality disorders, as well as the general inpatient setting.

  Dr. Hanafi: [00:01:18] And Dr. Fraser, why don't you introduce yourself to our listeners?

  Dr. Fraser: [00:01:22] Thank you for the kind of invitation. I'm Ronald Fraser. I'm also a psychiatrist like my colleague, Dr. Biskin. I split my time, half time work as an addiction psychiatrist, running the withdrawal management unit at the Montreal General Hospital. And the other half of my time is leading a team that treats severe and persistent treatment resistant borderline personality disorder. And I'm an associate professor here at McGill and adjunct professor at Dalhousie University in Halifax.

  Dr. Hanafi: [00:02:04] During today's episode will touch on several learning objectives. One list the DSM five diagnostic criteria of Borderline personality disorder or BPD, two recall the epidemiology of BPD, Three Consider the risk factors and posited causal mechanisms for BPD, including developmental and neurobiological mechanisms. Four discuss the clinical presentation of BPD in different clinical settings, including the emergency and outpatient settings. Five Recognize the differential diagnoses for patients presenting with BPD. Six, List the common comorbid psychiatric and general medical conditions with BPD. Seven, Discuss the common diagnostic challenges and pitfalls. And finally. Eight, Explore the stigma surrounding the diagnosis of BPD and discuss a therapeutic approach to providing psychoeducation to patients with this diagnosis. Now let's get started.

  Dr. Le: [00:03:02] Before we dive into things. I thought it may be helpful for our listeners if we first defined what a personality disorder is per DSM five or the Diagnostic Statisticians Manual. A personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture and is inflexible and pervasive across a range of social situations. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. Now, in the DSM five, Borderline Personality disorder specifically is described with nine diagnostic criteria, of which at least five must be met to make the diagnosis. These criteria include frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, identity disturbance, including a persistently unstable self image, impulsivity, and two or more areas such as spending, substance use and sex, recurrent suicidal behaviour, gestures, threats or self mutilating behaviours, affective instability, chronic feelings of emptiness, inappropriate and intense anger, and finally transient stress related paranoid ideation or severe dissociative symptoms. So with that, I think it would be helpful for our listeners to understand whether in practice there are other associated features that are typically found. Maybe, Dr. Biskin, if you could speak to this.

  Dr. Biskin: [00:04:49] Sure. The DSM obviously gives a good presentation of the main symptoms. And we have a lot of research that's developed over the years to kind of that really gives a clear picture that it is a unitary construct, BPD and all the symptoms really kind of go together. But one of the things that it really doesn't capture adequately is to some extent the the just negative affective states how unwell people with BPD often feel. So if you look in the appendix of the DSM five, you'll see that they include an alternate model for personality disorders. And one of the nice features about that alternate model that's not captured in the current model that we use now is to some extent the amount of just angst, anxious mood, depressed mood and those sorts of components that are just really prevalent for people with BPD, they just feel unpleasantly bad a great deal of the time. There are moments when they feel better, but I think that those dysphoric states are really one of the associated features that's not fully captured.

  Dr. Hanafi: [00:05:56] So I think that one thing that many learners, including myself, struggle with, is trying to distinguish BPD from other conditions, such as primary mood disorders, post-traumatic stress disorder, or other personality disorders. Could you perhaps share with our listeners how you approach making this diagnosis and how you differentiate between BPD and other conditions with overlapping features?

  Dr. Fraser: [00:06:20] So maybe I'll tackle that one. It's an excellent question, Audrey, And it's not just about differentiating it from other conditions, but also trying to determine what, if any, co-morbidities they may have. And it's not unusual for people to have comorbid conditions. So. So, for instance, you might see somebody in the emergency room and either withdrawing from substances or intoxicated on substances, and their presentation may resemble a great deal of personality disorder. But you have to try and tease out and determine, is that a state feature of of either the withdrawal or the intoxication or is it a trait? And it's a more persistent thing. So it can be difficult to tease out all these things. And that's where it's really important to try to resist looking at things. Cross sectional, see what's happening in the moment and try to have, if at all possible, a more longitudinal perspective. And that can be certainly easier said than done in many instances. If it's the first time you've ever met an individual or assessed an individual. But if you've had the opportunity to follow people over time, often that will certainly clarify itself. Oftentimes what I see people for the first time, I may have a lot of uncertainty as to what the exact diagnosis is. Human beings are fairly complex systems and creatures. Sometimes collateral history can be tremendously informative if that's available. But often what you want to try to do is get from the patient themselves sort of what's happening in the here and now, but also try and contextualize that by having a sense as to the more longitudinal history, which often sort of goes back to adolescence and getting a sense as to are these isolated issues or have these been really quite longstanding. And I think that can be tremendously helpful because many of the symptomatology can be somewhat non-specific. So, for example, if you look, the DSM five doesn't actually have complex PTSD as a formal diagnosis. But if you look at the proposed criteria for complex PTSD, it's pretty much the same criteria as borderline personality disorder. It's problematic when you have two conditions with the exact same criteria. So it can be really difficult to determine how you're going to conceptualize something. But I think if you take a careful history, if you have some humility about the fact that you may not have all the answers in the here and now and work collaboratively with the patient to try and tease out what is going on. And often my experience has been if you review the diagnostic criteria of borderline personality with an individual, a lot of it will often profoundly resonate with them and be in fact extremely validating. And they'll say, Wow, you know, is my picture in there or something to that effect? And sometimes they're right, and sometimes it may resonate with them, and it still may in fact not be the correct diagnosis. So you have to be prudent about that. But I think those is sort of the general approach as to how we try to tease these things out.

  Dr. Biskin: [00:10:17] If I can, I would just add to what Dr. Fraser says, that I completely agree with his points and working on an inpatient unit. One of the things that that I'll often see is that when you take that cross sectional approach, you'll often see patients that look like they have a lot of symptoms of personality disorders, be it narcissism, borderline personality disorder, antisocial. And just based on that cross sectional presentation, you might be misconstruing a manic episode or a psychotic episode. Sometimes people have worked with people who have very severe depressive episodes and they look quite dependent. But again, that longitudinal history and kind of exploring how people change over time really with those symptoms that go back to adolescence is is really very crucial. I would also add that there's a few little tidbits that are sometimes a bit helpful in distinguishing some of the disorders. So, for example, sometimes I would find that people with bipolar disorder, they often report a lot of. Manic episodes. There's a great deal of elation for people with BPD. It's tends to be less likely. Elation does occur, but it's not as present. It's not present for as long. And when the mood shifts happen, that is characteristic for both disorders. The mood shifts in BPD tend to alternate between a lot of sadness, anxiety, anger. Again, much more of those dysphoric states in terms of, I guess, even some of the elements of PTSD, the chronicity and the timeline of the symptoms is something that's quite important as well. And it becomes much more this is true for all personality disorders, that it's global across multiple domains. So having symptoms with just one particular type of situation or one particular environment is less likely to be associated with a personality disorder, whereas people with personality disorders do have problems in many areas of their life that cause them difficulty. So that chronicity and the kind of global nature disorders, this is one thing that I find distinguishes it from some other disorders.

  Dr. Fraser: [00:12:28] Sort of to to add on that. One of the things you noticed, particularly in my line of work in addiction psychiatry, is you'll see somebody that meets all the diagnostic criteria for personality disorder. But if you treat the underlying condition effectively, the the other psychiatric conditions, suddenly those features will all disappear. So you may have somebody who has a severe opioid use disorder who engaged in all sorts of anti-social behaviours because they have a four or $500 a day habit. You put them on methadone or Suboxone or some appropriate treatment for their opioid use disorder, and they no longer have to support that habit and all those antisocial behaviours go away. And then there's other individuals, you treat them with methadone and they continue to engage in all those antisocial behaviours. And so that can really be essential in trying to determine what you're observing and whether it's an underlying personality disorder that requires treatment or this other condition. If it's effectively treated, then those other features effectively resolve.

  Dr. Hanafi: [00:13:49] Thank you for both of your very thorough answers regarding my question. My next question was, you know, who typically suffers from this disorder? Or in other words, what is the typical epidemiology of BPD?

  Dr. Biskin: [00:14:05] So typically the epidemiology for BPD, it's common. It's about 1 to 2% of the population. And there is some variation between different parts of the world. So certain areas, for example, East Asia might have a slightly lower rates than certain parts of Europe and North America. But in general, North America, it is about 1 to 2% of the population, North America and most of Europe. It despite what we see in clinical practice, where in general women present for treatment more frequently than men in the population, the prevalence is approximately equal. And in terms of other aspects of life, socioeconomic status and things like that. People with BPD, it's across the spectrum. So anybody can have BPD.

  Dr. Fraser: [00:15:01] I think it's to touch on the point that Dr. Biskin had. The vast majority of patients that we see are women. And to some extent, that's because depending on gender, these patients tend to have different trajectories. So female patients with BPD often are in the health care system, male patients with BPD who may have the exact same behaviours or struggles often end up in the legal system. And often the women are in hospital and the men are in prison. A given behaviour society reacts very differently based on what your gender happens to be. It's also important to realise the vast majority of people with BPD we never see. So if it's 1%, let's say it's 1% of the population. That means in Montreal there are 30,000 people with borderline personality disorder. We see a tiny fraction of that. So basically it has the same prevalence as as individuals with schizophrenia. And certainly we we don't see anywhere near those sorts of numbers. So the vast majority of people don't seek treatment. And I don't know about Dr. Baskin's experience, but my experience is unfortunately, the clinical population that we treat. Does not represent the diversity of the city. So we're not seeing the sort of diversity of different cultures and ethnicities that we would anticipate when we look at the demographics of a city like Montreal. And I think that is worrisome. And that's something that where we need to make greater inroads.

  Dr. Biskin: [00:17:00] I don't have I don't have the numbers to say exactly about the diversity in terms of the clinical population that we see. But I can say that there is a fair degree of diversity, probably not fully representing the the the full diversity accurately of the city. But I would say that there is a fair degree of diversity. One other thing that I would probably add as well is that BPD, although it is occurs across all ethnicities and socioeconomic backgrounds, it is more likely because of family history and genetic risk to be more commonly associated with people in lower socioeconomic statuses as well. And it is quite likely that people with BPD or it is known that people with BPD do tend to have kind of that same downward drift that we see with other psychiatric disorders that they tend to have more difficulty with occupational functioning, be more likely to require financial assistance and things like that. But yes, I'll completely agree with Dr. Fraser that more inroads with communities is always a good thing.

  Dr. Hanafi: [00:18:08] Going further with that. How would you say the epidemiology evolves over a patient's life span? Or in other words, how does it change as they age?

  Dr. Fraser: [00:18:18] So maybe I'll tackle that one first. So. In general. This is a disorder that has a relatively good prognosis in that it tends to improve with age, which is not necessarily the case for the vast majority of DSM five diagnoses. So it tends to have onset in adolescence or early adulthood. Many people seem to begin to develop the disorder around puberty, and as you age, many of the symptoms actually diminish and improve. And often by the time you're sort of in your thirties, you often no longer meet the diagnostic criteria. Now, the problem can be, however, you may not meet the diagnostic criteria, but you may still have residual symptoms that are subthreshold but still contribute to quite significant disability. Also, something that's problematic for many of my patients that no longer meet the criteria during the more acute phase of their illness, when they are much more symptomatic, often as a result of a variety of things. They've burnt many social bridges and are often unfortunately estranged from either their children or their extended family, have really have significant academic sequelae and have not been able to complete their educations. They've had significant occupational consequences. And so there can be significant disability even with remission. The other good news is, though, once you remit, you tend not to relapse. So it tends to be quite consistent. Once your symptomology has improved, it tends to stay improved.

  Dr. Biskin: [00:20:27] I have very little to add. I completely agree with Dr. Fraser, of course, again. And just to provide some numbers to that. If you look at like 20 year data sets of longitudinal follow ups, over 95% of people will have periods of remission from the diagnosis where they don't meet criteria anymore. But again, as pointed out, the functional problems remain notable and only about 60 or well, frame it positively, 60% of people do have good functioning. When you look at follow up 20 years later, so that's more than half. But there's still a large amount of people who do have functional problems. And trying to find ways to continue helping those people and improving their functioning is, in my opinion, a very important area for treatment.

  Dr. Hanafi: [00:21:20] I guess looking more at early in life, what are some explanatory models for why someone develops borderline personality disorder?

  Dr. Biskin: [00:21:29] So there's a lot of different models, and it's a difficult question to answer because to some extent the models for the development of BPD depend on your theoretical framework for treatment of BPD. Given that I am more comfortable with dialectical behaviour therapy, I'll give the answer for how BPD develops. So the idea behind how BPD develops is that people are born with a genetic risk for emotional instability or liability. What Linehan would call affective dysregulation so that as a child you might be a bit more difficult to sue, you might be more likely to cry as a baby and. Be more unpredictable in your response. Now, normally parents would be able to adjust or caregivers would be able to adjust and provide a bit more support and reassurance and security in the situation where there is a combination of a child who's difficult to soothe and the parent figures who aren't, who don't have the capacity to provide that support and soothing to help the child learn to manage their emotions. The parents might respond by. Saying that the emotion is not okay, the emotion is not appropriate. In other words, they'll say you're not really sad to the baby or it's not to the child. It's not a big deal what you experience. Don't worry about it. Just keep going. Push through or that often will take much more serious forms where the child would be neglected and completely ignored. They're having emotional difficulties. They could be responded to with physical abuse. If the child is crying too much, they might be hit and this would lead to the child learning that their emotional states are not worth listening to. They're not valid, they're not appropriate. And as the child continues to grow up within the same environment, the emotions continue to be present because there is that genetic risk or genetic component of the unstable emotions. But they they learn that they have to use whatever tools are available to them to help them control how they're feeling. And because the feelings are very intense, you often have to use very intense tools to cope with it. And this is what often leads to some of the impulsive behaviours, like using a lot of substances or alcohol or using very intense emotional tools like self harm, which are meant to kind of often use to help people feel or focus on their feelings or numb their feelings. So a lot of these behaviours arise as a way to control the emotions and this subsequently furthers that sense of invalidation that the patient has that my feelings are not worth listening to. My feelings are not valid. I have to do everything I can to make them go away. So that is often the pattern from a DBT perspective that leads to the development of BPD. To add a little bit more to it, there are neurobiological models or neurobiological findings that are associated with BPD that lends some support to the emotional dysregulation component. So the usual genetic findings of the long arm or the serotonin transporter gene, which is associated with almost every psychiatric disorder, it's also associated with BPD. Certain studies have found dopamine receptor associated or specific subtypes of dopamine receptors associated with impulsivity and BPD. And there's also findings on your imaging that suggest a heightened amygdala activity which might be interpreted as a stronger emotional response or threat response. So certain biological findings, although there's obviously no very consistent single pathway and as mentioned before, a lot of the different psychotherapies have different etiological models for the development of BPD. So for example, mentalization based therapy has a similar style, but uses a language that comes from attachment theory, which basically says that the way that the parents react to the child is often unpredictable. So the child doesn't learn how to predict the responses of the caregiver. And this has a whole series of sequelae for the child as well. So again, there's like a dozen or 20 or so different models for treatment of BPD, and each has their own variation on the similar theme that emphasizes intense emotions and impulsivity, often as core, but not always.

  Nima: [00:26:00] Thank you so much for that answer, Dr. Biskin. Going back to something Dr. Fraser had said about how different people may be presenting to the health care system, I was wondering whether there are different presentations for BPD, for example. Have you noticed differences in presentation when people come to the emergency department or whether they may be on the inpatient setting?

  Dr. Fraser: [00:26:21] Maybe I'll tell a story. I like to tell stories what I'm famous for. So when I came on staff, I had a number of jobs. One was working with the short term, borderline percentage sort of program led by Dr. Paris was international expert that both Dr. Biskin and I have had the fortune of learning from. And my other job was working in the mood disorder clinic. And each Monday we would have mood disorder assessments with the medical students and the residents. And the first ten weeks, you know, ten assessments and nine of them. Came with the same picture treatment resistant depression. They had failed like 12 different trials of different antidepressants. And you can imagine how discouraging that is as a patient where you've tried X number of medications, none of which have had any real, sustained, significant benefit. As Dr. Biskin mentioned earlier, you're still suffering tremendously. You know, you're not comfortable in your own skin, You're dysphoric, you're anxious, you're distressed. Nothing seems to help even though you're reaching out for help. And nine of the ten all had borderline personality disorder that had that had not been recognized, had it not been diagnosed and it not been treated, and they were all being treated for disorders that they did not in fact have and understandably weren't having great results. It's a little bit like, you know, you go in with appendicitis to the emergency room and all the emergency room physician offers you ventolin puffer, you know, you're not going to have a great outcome. So I think that things are better. But oftentimes you're seeing people by the time they get to us still, when you look at their trajectory through the health care system, they've often been diagnosed with a wide variety of different things, failed a wide variety of treatments from very well intended health care professionals. But it's very discouraging for patients and for their families. It's a bit of a marathon, and that's why it's often so validating for them when you go through the criteria with them and they say, Oh my gosh, and they feel understood, you know, for often the first time in their health care trajectory. So that's certainly one of the ways that you see people is in a variety of outpatient clinics. The emergency room is is another place where you see people I think when you're seeing people in the emergency room, you know, if you're seeing me as a patient in the emergency room, I guarantee you you're not seeing me at my best. So I think it's important to remember that when you're seeing anyone in the emergency room, they're they're struggling, they're in crisis. They're not presenting their best foot forward and it's not representative of who they are. 24/7. And you need to contextualize that. So pass it over to Dr. Biskin as well.

  Dr. Biskin: [00:29:53] I completely agree with that point. And I think that's one of the the advantages that Dr. Fraser and I have working in a clinic for people with BPD is that we get to see these patients on a regular basis over a longer period of time because many people will present for treatment when they're in by presenting to the emergency room for suicidality or self-harm, and they might not get immediately directed to treatment, which can be quite frustrating. As Dr. Fraser pointed out, it takes an average of about six or so years until people receive a diagnosis of BPD despite symptoms starting earlier. But when we're in providing therapy and treatment for these people, we're able to see them in a different context, which is often a much more, much more stable and easier or much more enjoyable experience to work with these people in a treatment context where we're able to provide a treatment that's designed for them, designed for their disorder and able to help. Because the bias that we might have just relying on people, the presentations in the emergency room is quite striking. So when we see people in treatment, it's a much more positive thing.

  Nima: [00:31:05] Both of you have spoken about the necessity. For that longitudinal. Approach. When we speak of borderline. Personality disorder and when we're interviewing patients. As a learner. I see a variety of different practices where some psychiatrists feel that BPD diagnoses cannot be made in the emergency Department when patients. Are in crisis. What do you think about that type of approach? Do you believe that the emergency department is an adequate place to make the diagnosis?

  Dr. Fraser: [00:31:45] Well, to take it even one step further, some of my colleagues don't even believe borderline personality disorder is a valid diagnosis, period. So there's. There's some controversy about these things, which is a bit remarkable because it's fairly validated diagnosis. But anyways, I think I think you have to be cautious. Particularly if you're seeing someone in the emergency room for the first time. If you're seeing someone in the emergency room for the 10th time, then you would have ten assessments. And so you have a little bit more context. I think often when we see people in crisis in the emergency room, we many, many people simply defer the diagnosis of what used to be called access to. I think there's also problems with that. I think ideally, if this is in your differential and if you are thinking that this is one possibility, I think it's important to put it as a rule out, right, that it's on your differential that you may not have enough evidence, you may not have as much clinical confidence in the diagnosis as you might ideally want to have, but it's somewhere on your range of clinical suspicions. And I think it's important to reflect that in your consultation. So you may not be able and it may not be prudent to make a definitive diagnosis, but I think it should be mentioned somewhere that, you know, at this point in time, these are the criteria that they meet in this cross-sectional, and we may not be able to comment on whether that is an acute situation or if it's an exacerbation of a more chronic situation, which would be more suggestive that they, in fact, do have the condition.

  Dr. Hanafi: [00:33:50] Maybe it's a good time to to touch on the topic of stigma and a misunderstanding surrounding this disorder. You talked about making the diagnosis. Why is it important to disclose this diagnosis to patients? And any practical tips on how to do it effectively and compassionately?

  Dr. Biskin: [00:34:11] I would like to just go back for a second because I want to expand on Dr. Fraser's comment. I have a slightly different perspective on it, and I'm much more comfortable making the diagnosis of BPD in the emergency room, assuming that the patient is able to provide adequate history or there's sufficient collateral that I'm able to trust. The real shift, in my opinion, comes in making sure that you're changing and adapting the questions to really get accurate information about the longitudinal history and not just the cross sectional. If you are able to get that accurate history, I think that your diagnosis from an emergency room setting, again, assuming good information is just as accurate as it would be for most other diagnoses. And I guess to touch on your point about stigma. The thought that comes to my mind is that we often assume that when we're making a diagnosis of BPD, it has to be a very firm, stable diagnosis, whereas we often are in the emergency room and will make diagnoses of psychosis and or psychosis unspecified, often for first episode psychosis patients to where we're not making a firm diagnosis about whether they have schizophrenia, bipolar induced or bipolar with a psychotic mania with psychosis. And assuming that we have to have a very, very firm convincing, absolutely correct diagnosis for BPD, whereas we don't require that same level of certainty for other diagnoses. I think that's part of the stigma that is inherent about BPD, that people are much more reluctant to make. The diagnosis of BPD, which is associated with poorer outcomes for our patients, is one of the reasons why it takes so long for patients to receive care for diagnosis of BPD. So I think that in general we should be cautious about any diagnosis that's made in an emergency room, whatever the diagnosis might be. But we should make those diagnoses if the symptoms are consistent with that. I forget the other part of your question.

  Dr. Hanafi: [00:36:09] So the other part was just how do you approach it effectively and compassionately when you're speaking with a patient about the diagnosis?

  Dr. Biskin: [00:36:19] As Dr. Fraser mentioned, emphasising that the diagnosis of BPD, although it is stigmatised within society. One of the things that most people don't realise, and this includes many health care providers, is that the prognosis is quite good actually. So I will often encourage people not to look on Google, not to look on YouTube because a lot of the images associated with BPD are again based on that cross sectional image of what people imagine, kind of like the worst case scenario would be like. Whereas the reality is much more complicated and there's a lot more fluctuations that you're able to see. And and people are not just identified by one specific difficult moment. So I think providing a lot of information, providing a lot of information that people don't choose this disorder, they don't choose to have the problems that they have. But it developed out of a reason or developed for a reason. And it's often meant internally to kind of cope with the intense, unpleasant experiences they have. And this is the best that they can do, because again, a lot of the difficulties are ways to avoid the one remaining alternative, which is often suicide. So people I often frame it that people are trying everything they can to keep themselves alive and to make their lives as bearable as possible.

  Dr. Fraser: [00:37:41] I think the other issue that comes from your point is clinicians, typically, because of the systemic stigmatisation of these patients, have a hesitancy to disclose the diagnosis because there's this either conscious or unconscious fear that there's going to be a bad reaction because the system views the these patients as problematic, troublesome, undesirable. So there's this systemic. The stigmatisation that gets internalised by the clinician that the patient is oblivious of. Like they they have no idea. At this point in their career. Unfortunately, they may become very aware of it moving forward as they have more contact with the health care system. But so we have this fear that they're going to react badly because we're telling them something that's really bad news and it's that internalised systemic stigmatisation. You know, I've had the opportunity to disclose the diagnosis to hundreds of patients, and most people are really relieved to finally have an answer. That makes sense. And their families are relieved to finally have an answer that makes sense. I can only actually think of one person to react badly. And she said Borderline. So you're telling me I barely have a personality? No, no, that's not what I'm communicating here. I didn't do a good job. Let me try again. So. For the most part, it's very well received because these patients have been suffering. For often years looking for answers that make sense, often for years. And finally, you've given them something. So that actually gives them hope. And one of the earlier parts of your question is why is it important to disclose the diagnosis? Because what often happens with teams is teams make the diagnosis, but they never tell the patient. And that's sort of the epitome of internalised stigmatisation. It's important to disclose the diagnosis because that diagnosis informs treatment. So we're not going to continue. To give you a pharmacotherapy for conditions that you don't have. And we're going to try our damnedest to connect you with an evidence based treatment that's demonstrated effectiveness for treating your condition. And, you know, when I started my career, that was not the situation. Right. And when I started my career, these patients were viewed largely as untreatable. And the change. In the clinical circumstances, you know, even in the last 20 years. It's remarkable. We have something to offer people. And when I was a resident, we didn't have that.

  Nima: [00:40:58] Thank you for speaking on the piece of internalised stigma. I think it's very important and refreshing to hear, and it's also nice to hear as a learner that there's hope for our patients and there's something that we can do. Do you have any tips or clinical pearls for clinicians who would like to screen for borderline personality disorder?

  Dr. Biskin: [00:41:19] I think in terms of the the comments, the tips that I would say really is that emphasis on longitudinal symptoms and don't get stuck with the cross sectional and don't get stuck with just necessarily what's going on right in this moment, but taking that chance to kind of understand the person's life. Where where are they not functioning? Where are they having problems with their emotions, their impulsivity, etc.? One of the other interesting things I've always been particularly interested in the symptom of emptiness in BPD, and I always find it fascinating how people with BPD with that particular symptom, you'll ask people, Are you empty? And that term will resonate with them very clearly. You ask somebody what it means or what it's like for them to experience emptiness and you'll get a whole variety of different answers. But the term that specific word is just so consistent. And if somebody doesn't understand that word when they say, Oh, what do you mean by emptiness? Is there anything else like it? You just move right on to the next question. They definitely do not have that criteria. And anecdotally, I'd say that the chances of them having BPD go down quite a bit at that point. A couple other tips that I would say is looking at how long the symptoms and the problems have been present. And when you ask people, when do they start having difficulties in their life. The earlier the problem started, the more likely it is to be BPD so or any personality disorder. Two weeks ago, very unlikely if it was since they were like early adolescent or childhood, then the chances are much, much higher. Those would be a little bit of the suggestions I would make.

  Dr. Fraser: [00:43:00] Yeah, I would agree with all of that, and particularly emptiness is is one of the most unique diagnostic criteria for BPD that is not very commonly seen in other conditions. Maybe a couple other personality disorders, but it's really unlike, like, impulsivity. Are you impulsive? That's like spectacularly non-specific. Almost everything in DSM five can have impulsivity as a feature. I don't do this in the emergency room because you sort of have to focus on the crisis and what brought them here. And if you don't, people get upset about that. But when I'm just doing a general assessment, seeing somebody for the first time and they're not in crisis. I often start with the personal history before anything else. And this. This is helpful for a couple of things. So I'm finding out the longitudinal history without them necessarily being aware. I'm looking at the longitudinal history and I'm going to be able to learn a lot about their childhood, their adolescence, their relationships within their family, within peers. I'm going to get that developmental history. So it's super useful for me clinically, but it's also, in my experience, very helpful therapeutically because you give you give the patient the correct impression that you're interested in them as something more than a collection of symptomatology, because eventually I am going to get to sort of a checklist of symptomatology. But by doing that personal, developmental, social history at the outset, you get that context right at the get go and it helps you have a better sense as to when you do get to the FBI and what's been happening more recently. It gives you some some contextualisation of where that fits into the larger picture. And I really do think it helps with the therapeutic alliance. It's not so effective in the emergency room. However, people tend to get frustrated with you because they want to get right to the chase and that's okay.

  Dr. Biskin: [00:45:14] Sorry, just to go back, I do need to add, even though I made that comment about emptiness from a very technical perspective, it's not the most reliable or useful diagnostic criteria. It is that the positive predictive value is a little low. If you want to be specific in terms of which criteria is the most useful to screen for, it varies by study that you look at, but the one that's probably the most useful is to look at the chaotic interpersonal relationships in multiple domains. And this kind of touches on the point that Dr. Fraser made about kind of getting that longitudinal history of their relationships. And to kind of add to that one other thing that I particularly find interesting to understand for patients is how they spend their time. Like, what does a typical day look like for them? This is more useful when initiating therapy, but it's it's quite fascinating to some extent how how people spend their time and how much of their time can be consumed by the challenges that they're experiencing or how how much empty time there might be for them to fill.

  Nima: [00:46:20] Thank you for those clinical pearls. I'm sure they'll be very useful. Lastly, I'm wondering if there are any evidence based screening tools or skills that you know of or use that could help learners who would like to diagnose BPD.

  Dr. Biskin: [00:46:37] I guess I'll answer this one. There's a number of self-report questionnaires that can be used, and depending on which expert you will ask, you'll get different opinions about which ones are the most useful. So one of the ones that I am fond of is called the Borderline Personality Questionnaire. It's a bunch of yes, no questions about 70 or 80. So it's not the fastest questionnaire, but it gives you a with good psychometric properties, it gives you a good chance to make an accurate diagnosis. Obviously, you'll still need an interview. One of the shorter ones is the McClean's, the MSI-BPD. The McClean screening instrument for Borderline Personality disorder, which is nine items that basically takes the DSM questionnaire or the DSM and puts it into questionnaire form, which has okay psychometric properties, but it's much shorter than 70 something questions. One of the tools that we use a lot and sadly seems to have fallen out of favour in the research literature is the diagnostic interview for borderlines where the DIB-Ab are revised version, which is now about 30 years old or so, 25 years old, I think. And it is a semi-structured interview that can take typically about an hour or so to do it. That really covers a wide range of symptomatology. And when you're using the the this diagnostic interview for borderlines, it will kind of select for a more homogenous group of people who have problems, not the standard five out of nine, which creates a rather diverse group of presentations, but you're going to end up with a more homogenous group of people who have a greater degree of symptomatology. But it's good if you want to get very accurate diagnoses. Having said that, most of those are used for research, clinical research and in clinical practice I rely primarily on the interview. The other ones are sometimes used for symptom tracking with so-so data about whether or not they're useful for that.

  Dr. Fraser: [00:48:48] I just talked to people.

  Dr. Hanafi: [00:48:50] Well, thank you so much, Dr. Biskin and Dr. Fraser, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had this opportunity. And I think we learned a lot about an important topic in psychiatry. We're looking forward to speaking with you again for part two. So listeners, please stay tuned for the next episode on the management of BPD. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi, and Audry Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live Music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Roland Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org, Thank you so much for listening.

Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay

• Episode 31: Understanding Psychodynamic Therapy with Dr. Rex Kay

  Jordan Bawks: [00:00:12] Welcome to PsychEd, the Educational Psychiatry podcast by Medical Learners for Medical Learners. If you're a return listener, welcome back. If it's your first time, thanks for checking us out. Today's episode is an introduction to psychodynamic psychotherapy. Your host today are yours truly Jordan Bawks, a fifth year psychiatry resident at the University of Toronto. And I'm also joined by Anita Corsini, a social worker who works in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. She's a new member of our team and I'm excited to have her co-hosting with me today. She's been working behind the scenes for a number of months now. Our guest expert today is Dr. Rex Kay, a staff psychiatrist at Mount Sinai Hospital and an assistant professor at the University of Toronto. He is the U of T Psychiatry Department modality lead for dynamic psychotherapy and a graduate member and faculty member of the Toronto Institute for Contemporary Psychoanalysis. He's an award-winning teacher of both undergraduate medical students and psychiatric residents. And on top of all that, he's a pretty nice guy who has a stunning book collection, which is a way to win affection in my heart. So I'll let our two colleagues introduce themselves. We'll start off with you, Anita.

  Anita Corsini: [00:01:38] Yeah, I'm really excited to be here. I think you might have mentioned this, but I am a social worker and I work in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. My official job title is education specialist, and what that means is I develop online training curriculum for therapists and other mental health professionals. Previous to that, the majority of my frontline experience has been working as a counsellor with adolescents and young adults in the field of mental health.

  Jordan Bawks: [00:02:11] That's awesome. We're super happy to have you. Knowledge translation is the name of the game in podcasts, so welcome to your first episode. And Dr. Rex Kay. Why don't you tell us a little bit about yourself, your clinical interests, a bit of your kind of training history and your, I guess, your relationship and interest in psychodynamic.

  Dr. Rex Kay: [00:02:38] So first of all, Jordan, Anita, thank you so much for inviting me to be a part of this Knowledge Translation indeed, the project is so important that it feels like it should have been around for a lot longer than it has been, and I'm really delighted to be a part of this. So thank you for inviting me and I'm looking forward to talking to you. I am a psychiatrist, I trained at the University of Toronto and psychoanalyst, I trained at the Toronto Institute for Contemporary Psychoanalysis. And as Jordan noted, I'm modality lead for dynamic psychotherapy. What's a little misleading about that is that what I fundamentally am is a general psychiatrist. I trained as a child psychiatrist while I trained as a child psychiatrist. I was told that the definition of a child psychiatrist is somebody who used to treat children. And I'm guilty of that. I used to treat children. Now I work with transitional age, older adolescents, young adults as much as I can. But I've got a general practice ranging from mid teens to mid 80s, and I treat a wide, wide, wide range of psychiatric illnesses. Um, quite happily using whatever comes to hand that's going to help somebody.

  Dr. Rex Kay: [00:03:57] Prominently among that for me is dynamic psychotherapy. But I see myself and I would hope that I am seen as fundamentally a general psychiatrist who uses dynamic psychotherapy a lot, along with whatever else I can. My interests are, I'd have to say, first and foremost, education. I spend a lot of my time teaching. In any given month, it can be up to a quarter of my time is spent teaching in one capacity or another, and I love it. I have a long standing interest in creativity, both in terms of the standard creative arts output, but creativity in living and in work and a strong interest in the arts. I am co-founder of a literary journal devoted to issues of medicine and health Ars Medica. I encourage all of you, here comes the shameless plug. Ars Medica do a search for it. We're very proud of it. It's been going for about 15 years now, and I am proud to also be a co-developer. Along with two colleagues at Mount Sinai of Narrative Competence Group Psychotherapy, a program that uses the writing of narratives in treatment. That's my background.

  Jordan Bawks: [00:05:17] Fantastic. We'll expect some royalties if you get any extra subscribers to Ars Medica, but we'll work out those details later.

  Dr. Rex Kay: [00:05:26] I'll take it up with my co-editors.

  Jordan Bawks: [00:05:28] All right. So I'll quickly go over our objectives for the episode today. Psychodynamic psychotherapy is an enormous topic that you can only do so much with in 60 minutes. And so I would encourage listeners to take this as a kind of teaser. We want you to be familiar, you know, when after listening to this episode, when psychodynamic psychotherapy comes to mind, we want you to be able to sort of have a recognition of what that is, what that means, the kinds of patients that you're going to be that are going to be treated in psychodynamic therapy. So here's our explicit kind of objectives. So first off, listeners should have a sense of what psychodynamic therapy is and a bit of an idea of how it works. Number two, we want you to have an idea of who it's for, what kind of problems it's for, and a bit of a sense of the evidence that supports its use. And third, I hope that by the end of the episode you can compare and contrast psychodynamic therapy to other psychotherapies because there's a large degree of overlap. And that's something that we'll talk about towards the end of our time together today. So let's start at a pretty high level. Rex, why don't you walk us through what is psychodynamic psychotherapy?

  Dr. Rex Kay: [00:07:03] You're starting not only at a high level, you're starting at probably the hardest level you possibly could have. And I just want to note that, you know, you're starting at the hardest level you can and I will remember that because apparently I'm only a pretty nice guy. Let me answer that, Jordan, by actually moving up one level, because whenever I start talking about psychodynamic psychotherapy, I always find I'm starting a little bit too late in some ways. I want to talk about psychotherapy because it's very easy to lose how audacious the idea of psychotherapy actually is in and of itself. Uh, if we, if we go back historically, people probably since language developed. Have gone to other people with problems that we would broadly put in the emotional range. Typically what we expect are people giving advice, what we would call counselling, maybe doing teaching something educational. Often religious leaders would provide a moral slant on it. All of those factors are to some extent or another part of all psychotherapy. We haven't abandoned that, but the notion of all psychotherapies is that in some way we can help people with mental illness and mental anguish and suffering. Just by helping them talk through their problems, feel more deeply. Understand more deeply. And change. And that's audacious. And and it's remarkable.

  Dr. Rex Kay: [00:08:47] And it's only a century and a third old in formal sense. Uh. And it is still, to me, a remarkable human endeavour. And that applies to all psychotherapies, short term, long term, very brief, performed by psychiatrists, psychoanalysts, social workers, psychologists and anybody else that I think we have to start by appreciating that what the attempt here is to use language, relationship, experience together to effect change in the horrible, horrible toll of mental illness and mental suffering. So bringing down from there what is psychodynamic psychotherapy, a lot of what psychodynamic psychotherapy is overlaps with other forms of psychotherapy. But here's my best way of trying to summarise it for you at a basic level. It's about pattern recognition. That people will suffer. And suffer not just anguish, but suffer diagnosable mental illnesses as a result of their patterns of behaviour. Their patterns of being able to process inner experience, emotions, outer experience, process their thoughts and the characteristic patterns at times leads to tremendous suffering, which at times leads to maladaptive behaviour and attempts to cope. So what psychodynamic psychotherapy is about at its most fundamental level is helping somebody gradually elaborate these patterns, collaborate with them in exploring where the patterns come from, to give somebody the chance to alter those patterns and reduce the suffering and illness.

  Jordan Bawks: [00:10:47] Well said. And somehow you didn't even mention Freud.

  Dr. Rex Kay: [00:10:56] That was an error, but the sentry was the reference.

  Jordan Bawks: [00:11:02] That's wonderful. So what I'm hearing in that is that, you know, before we begin even to talk about psychodynamic psychotherapy, it's important to to really root ourselves in the psychotherapeutic endeavour, which is to help people with suffering and including when that suffering reaches the point and fits the sort of pattern of a diagnosable mental illness is to through relationship with another, through talking with another try and. Transform that suffering or alleviate the symptoms associated with the disorder. I mean, I'm not doing justice to your explanation, but talking to the key points that I heard there. If you could speak even more to like what's unique to, as you see it, psychodynamic psychotherapy, like what are the aspects of a therapy that are the hallmarks of, of psychodynamic? How would I know that I was watching somebody doing psychodynamic therapy as opposed to watching somebody do CBT?

  Anita Corsini: [00:12:08] Can I just kump in there?

  Jordan Bawks: [00:12:09] Absolutely.

  Dr. Rex Kay: [00:12:10] Please do, because I really don't want to answer that question.

  Anita Corsini: [00:12:14] You're not off the hook, Rex, But I had a quote that I wrote down and it's kind of speaking to Jordan's two questions, right? And it is I read in chapter one of this book, it was maybe the first line. "The dynamic treatment is hard to describe but easy to understand when you watch it unfold". So not only Rex, did you do a superb job of explaining what it is you were actually did an incredible job at describing it. But now I think that Jordan is asking you to help us imagine how it unfolds in the therapy room and wonder if you can.

  Dr. Rex Kay: [00:12:54] So I have a feeling that we're going to elaborate on the answer to that question throughout the duration of our conversation. Um, so let me give you just 2 or 3 initial ideas. One. Psychodynamic psychotherapy takes place in four different time frames or spaces. We attend to. The early experience that somebody had. It's a developmental model. It says that early experience shapes those patterns we were talking about. Shapes the characteristic ways that people process experience, internal and external. So we talk about the early experience. We talk about the lived life experience from those early days until the person walks into the office. Again, looking for the patterns, the characteristic development and how that life altered those patterns or reinforced those patterns. We talk about the current lived life, What has happened to the person in between the last session and this session? And explore those And then and this is probably the chief hallmark of dynamic therapy. We spend a lot of time also looking at the relationship in the room. We look at what's unfolding between the for generic purposes. I'll refer to patient and psychiatrist. We can talk about patient and therapist, client and therapist, but we look at what's happening between the two people in the room as a source of understanding pattern. We do that. We refer to this as the transference and countertransference the therapeutic matrix. We do that not because Freud said it was important. Freud said a lot of things were important, some were, some were not. We do it because all of experience and as increasing studies have emerged from a wide range of fields, we know that he was right in supposing that early experience shaped the relationship in the room. But that in and of itself isn't enough to justify it. We do it for two other reasons.

  Dr. Rex Kay: [00:15:18] We talk about what's happening in the room because it's happening live in our patients. They're having the experience now. There's no filter. There's no time to reflect. There's no time to revise. It also live for us. We are participants in the process. We are experiencing something. We are observing something. Because it's live between the two of us. Something else is going on that's really important. And for that, I turn to the neuroscience. That's when something is experienced emotionally and intellectually simultaneously. Then the brain is most open. The the the limbic lobe on the right side wherein rides the affect the sense of self, a sense of empathy is engaged. The frontal cortices of the brain. The rational, logical thinking in the upper left is engaged. And what we know from the neuroscientists is that when multiple parts of the brain are engaged, is the time when rewiring has the best chance of happening. But it's also the time when we can explore the patterns most clearly. So we're looking at those four times early childhood lived life current life relationship in the room as a way of seeing how they play into one another and form one another and can help us and the patient together elaborate on those patterns. So if you see a conversation that is focused on affect and experience and looking at those four different timeframes in emotionally charged, meaningful relationship. You were looking at what I would call a dynamic process. I will quickly add that that can unfold in cognitive behavioural therapy, in interpersonal therapy, in acceptance and commitment therapy, in group therapy, in couples therapy. There's no exclusiveness. But in psychodynamic psychotherapy, we are deliberately setting out to court that kind of process.

  Jordan Bawks: [00:17:29] Yeah, I think that's. Uh, that's lovely. I mean, looking at those different kind of spaces that we work in. And I'd say it's a pet peeve of mine when I hear people have described psychodynamic therapy to a patient of mine or a patient who is referred to me for psychodynamic therapy as a then in their therapy as a therapy where you're exclusively going to talk about the past. Now, there's no doubt that that's important, right? Like people are shaped fundamentally by their life experiences. So we need to get a sense of that, to get a sense of who they are now and the way in which they respond to things. But. My sense of the literature and my experience is that the therapeutic change happens most in the relationship, in the live relationship and the examination of that experience in that relationship.

  Dr. Rex Kay: [00:18:30] Jordan let me add to what you just said, because another of the misunderstandings of psychoanalysis, psychodynamic psychotherapy, is that it is mother bashing, it's parent bashing and or blaming. If we tone the word down a little bit and think I'd like to clarify that while we absolutely see those early years and early experiences as profoundly shaping and all of the evidence supports that, the purpose of understanding that. Is not to wash our hands of the affair because we have discovered that it was Dad's fault. Mom's fault. The only purpose of looking back like that is to help somebody transcend. We are looking at the ways in which an individual made sense of their early experience. We believe with some evidence that there is a rough approximation between what people remember and what happened. There's enough corroboration, but it's only a rough approximation. What matters most is the way you made sense of your childhood, the way you made sense of those experiences, the way they shaped you, given your temperament, your other experiences. And we're doing that to help you transcend the patterns, not so that you can simply lay blame.

  Anita Corsini: [00:19:58] Yeah, I kind of feel like it's emerging. For me, that part of what I'm hoping for this episode and I feel like it's already happening, is that we are going to debunk, I think, some of the misconceptions. And for me, I don't think I mentioned this at the top, but I'm really new to psychodynamic therapy. I was aware that it was existing, that it was in the aether, that it was foundational. But in terms of really understanding it, this working on this episode has really sort of like, um, illuminated a lot of things for me. And I feel like even debunking my own misconceptions like through this conversation. And I think that's, that's one of the big ones that then and their idea that sometimes people bring the assumption that we're only going to talk about the past and it's everything that you've said has kind of challenged that notion.

  Jordan Bawks: [00:20:54] I'm going to put you on the spot. Anita, What are some of the other misconceptions that you either came to this episode with or things that you really wanted to understand? What's the dirty rumours about psychodynamic psychotherapy on the street?

  Anita Corsini: [00:21:12] Mm Um, no disrespect, Rex.

  Dr. Rex Kay: [00:21:17] None. None taken!

  Anita Corsini: [00:21:18] Some of the things that came to come to mind for me are, like, outdated, out of fashion. These are these are all words I'm using that have negative connotations. Like inefficient.

  Dr. Rex Kay: [00:21:44] Those are good. I'm glad Jordan put you on the spot. Feel free to come up with more. But but I want to I want to address a couple of those ideas quickly and in a way that might surprise you. Uh. There was a time not all that long ago. When think the early claim that you just made from the street was becoming true. Psychoanalysis had succeeded a little bit too well. And by the late 70s, early 80s had become a bit of an out of step dinosaur. And if it had not evolved, I would not be an analyst today. There was a. An attack on psychoanalysis for multiple directions from the Psychopharmacologists a term I don't love, but the people using medication and the rise of medication from cognitive behavioural therapists, from the neuroscientists, from the philosophers, from the psychologists, from the feminists, from queer theorists, and from the memory researchers, from the from all of these sources, there was an attack. I would love to say that the field dealt with that in a very open non-defensive way, but the initial response wasn't. There was actually a double initial response, though the outward facing response was, you know, it's the standard Vietnam line.

  Dr. Rex Kay: [00:23:38] You know, you weren't there, man. You don't get psychoanalysis. And if you did, you'd know that you're wrong, which is a horrible argument and fundamentally not true. The second line of response, though, was to stimulate a period of creativity within the field. Between the late 70s and early 90s, that was astonishing. And psychoanalysis revamped itself without abandoning its core principles. It recreated itself. Taking in the input from all of those fields. Neuropsychoanalysis over the last 20 years has been a really hot topic of research influencing treatment, attachment theory, serious research coming out of the psychologists. It is incorporated Feminist theory, queer theory, Post-structural theory. There is a wide range of responses to these very legitimate attacks that has produced. A different version of psychoanalysis and psychodynamic theory. That still holds onto for me a lot of the gold that goes all the way back to Freud. But made it a much more vibrant and meaningful field. So fair criticism. But I like to think that it's the criticism itself is now largely out of date.

  Jordan Bawks: [00:25:25] And I'll jump in to talk a little bit about the evidence base, because I think this is also a misconception about psychodynamic psychotherapy, including psychoanalysis, is that it's not evidence-based or that it doesn't have a robust evidence base. And I think this will also bleed into answering your question about efficiency, which I think is a very valid question to be asking in, you know, from a systems perspective. Um, uh, so I'll briefly, um, there are a couple of pretty comprehensive and high level reviews that I'm going to link in the show notes. Um, Leichsenring I'm going to butcher their name, unfortunately, but it's a giant in the field of psychodynamic psychotherapy, and there have been a number of high quality studies published in The Lancet. There was a Cochrane Review. There was a pretty rigorous meta analysis in the American Journal of Psychiatry, all within the last 5 to 7 years that have shown that psychodynamic therapy is equal, in effect, size to most other standard interventions and may be superior in some situations. One situation where it actually looks like it's superior to other kinds of treatments is in the treatment of what they call complex mental health disorders. So these are personality disorders, people with chronic mood anxiety conditions or people with multiple disorders and in comparison to treatment as usual, to medications, to shorter-term psychotherapies, a variety of modalities, long term psychodynamic psychotherapy as defined by more than a year of weekly treatment, shows superiority in outcomes for those kinds of situations.

  Jordan Bawks: [00:27:34] Um, and then the other kind of piece of this is that I, I think one of the things that happened as well is that a lot of psychodynamic psychotherapies were semi-manualized and so made themselves a bit more amenable to treatment. So there's also a pretty robust evidence base for those short-term psychodynamic therapies as well. And you know, a debate around the manualization of therapy is beyond the scope of our talk. And I think there is something that's lost in that setting, but it's also something that was necessary for psychodynamic psychotherapy to sort of prove itself on the same playground as something like CBT, which I think at this point in time it's done extremely convincingly. And I think for me as a, you know, a psychiatry resident who's about to graduate, who is a real, I'd like to think a student of psychotherapy, like I train in CBT, mindfulness, acceptance, commitment, etcetera.

  Jordan Bawks: [00:28:30] I think the place where Psychodynamics kind of separates is in some of these situations where people have failed multiple other therapies, you know, they end up in this complex category. They failed sometimes like 10 to 15 medications. I'm talking about chronic conditions and people who've had neurostimulation treatments who haven't gotten better. And, you know, this is an evidence-based intervention for these people where there are almost no evidence-based interventions. And so when we talk about efficiency in the health care system, there's a lot of talk right now about a stepped-care model that we sort of start at the lowest level of intervention. And to me, just based on the evidence, psychodynamic therapy has a place either in the sort of early steps when you're looking at it like you can short-term psychodynamic therapy as being a non-inferior treatment to CBT, and we can look at patient preference and go from that. And once we get to the higher steps, the higher complexity and chronicity, then I think psychodynamic therapy has a robust evidence base to deserve to stand on those treatment steps when there really is not a lot of other stuff that has that kind of evidence base.

  Dr. Rex Kay: [00:29:49] Jordan that was really well summarised and nothing in there that I don't agree with. I'd like to provide a slightly different perspective and this addresses the efficiency question too, and it does address the stepped treatment model. But I want you to start by imagining what people come out of childhood with. That's a temperament, a fit between a child and parent or parents. An early experience. Produces. A character, a personality, a way of being, characteristic ways of being in the world. And what we know is, you know, the biography of Jim Morrison, No one gets out of here alive. No one gets out of childhood unscathed. But what we can say is that some people are more damaged by that combination of temperament, fit and early experience than others. The patterns that we talk about can be luxuries for people who suffered sufficient trauma and sufficient adverse childhood experience that the damage done to their capacity to process inner and outer experience, to manage the complexities of just living can be extreme. Now those people go through life and life happens to them. Life can be physical illness. Life can be life events. And life can actually be the onset of a psychiatric illness that isn't directly related to the features we just talked about that are more genetically or biologically driven.

  Dr. Rex Kay: [00:31:37] For those people who came out of childhood relatively unscathed. When life happens, they can often get back on track with nothing but themselves or a close friend or partner. Maybe a little bit of advice from a family doctor. Maybe a single visit to an emergency room or a single visit or a few visits to a psychiatrist. They may require a short-term treatment. They may require medication, but they're likely to do well. For those people. For whom early life was damaging. When life happens, it can be astonishingly difficult. And what we what I think of and what evidence suggests psychodynamic psychotherapy is at its best dealing with is helping those people. The complex problems that the desperately suffering damaged individual who may have a psychiatric diagnosis, who may have a physical illness or who lost a job or a partner. And for those people. We can move through the steps, but very often there is nothing else other than long-term intensive psychotherapy, which I think of typically as being based in dynamic principles, but drawing on everything that the practitioner is capable of drawing on to help from all schools of thought to try to help these people get through.

  Jordan Bawks: [00:33:19] So you've hinted I mean, both of us have hinted at this already. Who are the kinds of patients that when you see you think this person needs or deserves psychodynamic therapy?

  Dr. Rex Kay: [00:33:38] So part of the answer to that question is contained in what I just said, which is usually somebody who's tried other things. Very few of the patients who come to me come to me without having tried other treatments, medication, shorter term therapies, other approaches. There has to be a level of suffering. Uh, not just of. But of suffering in order to justify a longer term treatment. Psychodynamic psychotherapy itself typically lasts 2 to 3 years. Psychoanalysis itself, a fuller, longer version still only typically lasts four and a half years. We talk a lot about the commitment of time of the psychiatrist. Efficiency comes in there, Anita. We talk about the expenditure of the health care dollar of Doug Ford's taxpayers of Ontario, which is a perfectly legitimate standard. What often isn't talked about, but is very much in my mind is the commitment we're asking of our patients. If somebody is going to come and see me once or twice a week for three years, two years, four years, that is an enormous commitment of time and it's a commitment of emotion. Though the therapy is often useful and often enjoyable, it's also often very hard. We're asking a lot of our patients in order to justify that there has to be a level of suffering. And by and large, there should be an attempt at other solutions that hasn't worked. That's not quite the spirit of what you're asking, Jordan, But that's the background to what I think is really important is a consideration.

  Dr. Rex Kay: [00:35:29] A patient who shows little or no curiosity about their own past life and the possible connection to current issues does not scream psychodynamic psychotherapy. A patient doesn't want to do that, but yet wants help is still fully entitled to help. Should probably try other things. Before, if at all, trying a commitment to psychodynamic psychotherapy. Uh, somebody equally. Who? Uh. Has little or no proven capacity to form a relationship. Little image in their mind. That a relationship can benefit them. Should probably try a shorter term psychotherapy or medication or other treatment. Before trying psychodynamic psychotherapy, because the one thing I can promise you is that that therapy is going to be very difficult for them and probably for the practitioner. But if nothing else is working, I deeply believe that for those most unfortunate of people, psychodynamic psychotherapy is rapidly going to become the only game in town, the only treatment that can provide an experience in which a first beneficial relationship can occur. Providing a vantage point for those patients to start exploring their life and their responses and their patterns and begin to change. So ironically, the most difficult patients are also often the ones who scream psychodynamic psychotherapy most, whether they've experienced physical trauma, sexual trauma, relational trauma. They often end up screaming once other treatments still have been tried and failed. Anybody have a thought?

  Anita Corsini: [00:37:34] Think Yeah, I was totally reacting to the word trauma because that was like the question that was on the tip of my tongue as you were talking. Just about like complex almost seems sometimes like a euphemism for having like a trauma history. And I just know that, you know, often, you know, adults who have had like adverse adverse childhood experiences, trauma histories and, you know, can have the most difficulty just, you know, dealing with day to day life, as you were saying. And then so then my question was, you know, I haven't come across that in any of the reading I've done so far. But in terms of thinking about patients who might be most appropriate and, you know, having had that early trauma history or, you know, significant series of traumatic events that processing, I wonder if that's possible in dynamic therapy. It seems to be beneficial.

  Dr. Rex Kay: [00:38:36] The evidence would tell us there are some really valuable and really helpful, trauma centric therapeutic approaches that are creative and thoughtful and very moving, even to read about when they don't work or when they only get somebody so far is really when dynamic therapy should kick in because they tend to be shorter term and very nicely focussed and often are very helpful. When that hasn't worked is when you ask for the commitment to a longer term therapy if you can get.

  Anita Corsini: [00:39:16] So transference and countertransference are sort of key concepts in psychodynamic therapy. And I'm wondering, Rex, if you could talk a little bit about what they are and if you could offer some examples of how they play out within the therapeutic relationship.

  Dr. Rex Kay: [00:39:34] Yeah, absolutely. They are central ideas and they've evolved. Transference began as Freud's concept that people make false connections between people in their past and people in their present, which is a perfectly fair way of thinking about it. But to Freud, it seemed to imply that the transference, feelings, the feelings that a patient has for their therapist are in some way not real to the relationship with the therapist. They are simply transferred from their past. Uh, this is a case where I'm going to give him his due. He fought hard trying to argue that a transference feeling was false because it was just a recreation of the past and it didn't apply in the present. And as hard as he tried, he ended up shooting down his own argument. And I just want to make this point because I think that it's it's it's so underappreciated even today. Uh, for Freud in the end. The important point about transference is ethical. Freud noted that we as practitioners, as psychiatrists, can anticipate that for many of our patients, as they work with us, the patients will experience strong emotions about us. Not all, but many. Some of them might be unpleasant for us to experience. What Freud argues. Is that as somebody experiences these feelings, we have an ethical obligation. To use that experience of our patient for their benefit, no matter truly how unpleasant it may be up to limits of personal safety, but that the idea is that an individual based on their past is, we hope, going to experience us as an emotionally significant person in their life.

  Dr. Rex Kay: [00:41:42] And as such, their old patterns will be reactivated and as the emotional significance of this other person who is in the room with you. Listening struggling as that intensifies, often the feelings will intensify. And that it is our job to not make that go away. But to use that to help our patient. Similarly countertransference which Freud did not develop at all well. Countertransference initially referred to the feelings that the therapist has about the patient. And usually to the early gang, indicated that the therapist hadn't been properly analysed or therapist that went away a long time ago. And now what we see is countertransference. Is the experience of being the other person in relationship with our patient. And it's a source of information. So transference are the patterns that the patient brings into the room intensified by the gradually increasing meaning and importance of the relationship with the therapist. Countertransference can be. My bringing my issues into the room. If that's the case, I need to address that myself and do something about it. But very often counter-transference is me experiencing something that I can use to help me understand my patient. And again, the ethical obligation. Is to use that to benefit the patient.

  Jordan Bawks: [00:43:33] I'm glad we're talking about Transference Countertransference because to me this is one of the most useful contributions of psychodynamic thinking that applies in almost all clinical settings, even outside of psychiatry, because it's natural that we're going to have feelings that are arising when we see patients and patients are going to have feelings that are arising as they see us and about us in particular, and having an understanding of the dynamics of transference and countertransference allows us to use those, as you said, to the patient's benefit. I'm wondering, Rex, do you have a clinical example to bring this to life for us?

  Dr. Rex Kay: [00:44:15] Okay. Let me preface my comment by saying that I'm going to tell you a rather sketched out clinical story. Mm. But I have the permission of the individual involved to tell this story, even though it's very sketchy and there's no identifying features. I want to reassure your listeners that I have explicit permission from the original to tell this story in teaching. Um, here's a common experience for a lot of people in the healthcare world, whether they're in any area of healthcare world. I'm working with somebody who. Rejects every single idea I propose. Uh, practical idea. Uh, perspective. Interpretation, whatever it is I have to offer. Is rejected. So we can see a characteristic pattern, perhaps. But what matters here, I'm going to talk about the Countertransference at this point. What matters is that I become aware that I'm not simply frustrated. That either I'm not good enough, I'm not putting forth useful ideas or frustrated that this person is shooting down all of my ideas. I begin to feel. Like. My university made a mistake in admitting me to a medical program, let alone a psychiatric or psychoanalytic that I should never have engaged in this work because I'm utterly incompetent, that anybody would be able to do a better job than I am doing. And I'm feeling quite worthless. Fortunately, that's not an experience I have all that often.

  Dr. Rex Kay: [00:46:15] And I begin to feel like that's an interesting response on my part. It takes a little while to gain control of my own emotional state, but as I do, I start saying it's interesting that I'm experiencing this so intensely. So I start attending to the way the patient is rejecting my ideas, suffering, individual. And yet they're rejecting my ideas. Not with a sense of sadness. I wish my doctor could come up with good ideas. Not with a sense of despair. Oh, no, he can't help me. He's not coming up with anything useful. Not even quite with the sense of frustration. He's rejecting my ideas with what I can only describe as a sense of glee. And malice, and I start reflecting on what I know about him. And the way he had described and I've known this person for a little bit of time and the way he described. His parents as being really quite supportive and very encouraging and. Having high standards for their children and for him always wanting him to do his best and always encouraging him to be the best person he could possibly be. Which sounded to me like pretty good parents and that he experienced them as pretty good parents. But I'm starting to wonder about somebody who is rejecting my ideas with this intensity and begin to generate an hypothesis based on my countertransference of feeling so belittled.

  Dr. Rex Kay: [00:48:11] And so incredibly incompetent. And I start thinking about two things. One is, I think is there evidence that this is how this person feels as he goes through life? I generate an hypothesis that my countertransference may capture his lived experience. It's not the way he narrated his life. But over the time that I've known him, as I reflected on it, I start to think. He's got a narrative of his life, but it could easily be connected to this kind of feeling that he's avoiding and warding off. And then go back and think about the parents and look at other authority figures in his life. And I look for parallels there as well. How has he described bosses? How has he described teachers? And I begin to generate some hypotheses. Don't say anything because they're just hypotheses. But over time, I'm listening in a slightly different way. I'm exploring his rejecting feelings towards me in a different way. And I'm asking different questions. Over time these things don't happen quickly. Over time, together, working together, it's such a fundamentally collaborative process. We gradually come to recognise that the way he experiences me is a way that he's experienced bosses and teachers in the past.

  Dr. Rex Kay: [00:49:48] That he did experience his parents exacting standards as standards that he could never live up to. He did not see his parents particularly as attacking, he said, but they were impossible to live up to and it made him feel horrible. But then we so we've done really good work. We're laying out a pattern that he is now talking about benefiting him. In his lived experience that he is slower to anger. Slower to ascribe malice to others. But then we take one more step. And this is more transferential. That we start looking at the moment when he becomes attacking. And we start looking at the moment that came just before. And how he heard me and how he experienced my suggestions. And what emerges is that. He didn't experience my suggestions as possibly helpful ideas that would benefit him in life. He experienced my suggestions as evidence of his failure to have thought of those ideas himself and enact them. He experienced me not as saying, Hey, why don't you try X? But he experienced me as saying, Well, aren't you stupid for not trying x? Why the hell haven't you tried X? And as he experienced that repetition of the childhood experience of not living up to even though my tone was mild, as his parents were, he knew what I meant. He turned the tables on me. And he stopped being himself in the presence of what he experienced as a judgemental other. And he became the judgemental figure and I became the attacked other. Now that unfolded over months. But that can give you hope. And again, I recognise it's an inadequate summary, but I hope that gives you a little bit of a feel for how transference and countertransference can play out in effect change.

  Jordan Bawks: [00:52:05] I mean, if you could summarise months and months and months of dynamic work in only five minutes, I know that you were short changing us and leaving out the richness of the work, but I think there's first off, that was a helpful illustration of transference and countertransference, you know, looking at the way in which the patient was transference, being the way in which the patient was experiencing you, the countertransference, and how you were able to use that experience of you as a way into his world, into his life, in a way that was helpful for the both of you working together and also how you were able to use your own experience with him also as a way into his life that wasn't immediately apparent. And along the way, I think you've kind of hinted at, um, you know, a question that's implicitly throughout this whole podcast is how does psychodynamic therapy work? And when I when I listen to that story, I hear it come through. Like there's that sort of almost relentless attention to the patient's experience. Their thoughts, their emotions, their inner world. Um, that is so important for the work that you do together.

  Dr. Rex Kay: [00:53:35] Let me step back in, because for time's sake, I left out the last piece, but. But I think that for your listeners, it's important to hear this as well. Uh, he experienced me as being attacking. My professional identity, of course, is someone who would never be sharply critical or attacking of a patient who is suffering and coming to me for help. But doing my job and taking my job seriously involved really looking hard at myself and wondering if when I said, Why don't you try X? At least some of the time. My frustration with his typical rejecting behaviour wasn't creeping into my voice and I decided that it was, and I talked to him about that. Uh, because I think it did. And I think that his response was based on his transference. But it was also responding to a level of frustration. That he heard in me accurately. Now, that's hard. That's hard as a therapist to own. But jerking with a patient's reality and denying that piece is counter-therapeutic. So at some point it was necessary for me. I felt. To explore his response, to explore mine, and to own up to the possibility that at times he was hearing frustration, which was very meaningful to him. So that's the last chapter. And think think it's necessary to round it out in that way.

  Anita Corsini: [00:55:16] Like Jordan, you were just pointing out that sort of very close and sensitive attention to the patient's inner world or what the patient is bringing into the room. And it sounds like, Rex, you're also drawing attention to paying close attention to what's happening in that relationship, What's happening between the both of you? In terms of affect, in terms of emotionally, but also sort of cognitively as well.

  Jordan Bawks: [00:55:50] All right. So I want to just take a step back and kind of summarise where we've been and check in on our learning objectives. So number one, we wanted people to have a sense of what psychodynamic therapy is and how it works. And I think Rex, through that example, through our kind of discussion throughout, I hope that we've given our listeners a taste of that. I'll make an aside here to say that psychodynamic therapy and writing is extremely diverse. There's a sort of an enormous richness to psychodynamic thinking. And so this is really a taste. This is like a flight and it's like a flight in comparison to a beer hall. And so my hope is that you like what you've had so far and you want more. Secondly, we talked about who it's for. We talked about the evidence base. Our third objective was around contrast and comparing psychodynamic psychotherapy to other therapies. And I think we've done a decent job of that. I mean, just to make it explicit, I mean, I think the things that are common to all therapies is that we're attending to the therapeutic relationship, the working alliance. I think what psychotherapy psychodynamic therapy adds to that. It is a sort of explicitly looking at investigating, talking about the therapeutic relationship rather than just sort of relying on a warm, supportive stance that's going to facilitate a good therapeutic bond. Um, I think we've talked about the ways in which psychodynamic therapy pays attention to patterns. Patterns from the past to the present, from outside relationships to the therapy relationships looking at these kinds of patterns, um, looking at patterns of emotions, thoughts, and in relationship to other people and relationship to the therapist. Um, and you know, it's funny actually, the more I get into all psychotherapies, the more I see tons of commonalities that I think many psychotherapists do these things in very similar ways. Like in cognitive therapy, there's maybe just people are a bit more explicit, like they're actively talking about it with the patient, someone's core schemas, their core beliefs, the assumptions that they have. But I think psychodynamic therapists do that anyway. You're looking at the way in which people interpret the world think about themselves. It's just a sort of slightly different language and a slightly different frame. Um, so now I want to kind of take a step back. This wasn't explicitly in our objectives at the very beginning, but I think this is something that we want our listeners to leave with. I want our listeners to leave with. This is why I fell in love with psychodynamic therapy. Um, that psychodynamic therapy, something about psychodynamic theory, psychodynamic thinking feels really relevant to general clinical work. Like there's always some aspect of a clinical encounter where I kind of lean on what I think of as my own psychodynamic training and principles. And Rex, you're a few years further down the road than me in this path, and I'm wondering if you can talk about the ways in which psychodynamic thinking influences your general psychiatric care.

  Dr. Rex Kay: [00:59:22] Yeah, a few years down the road. Jordan, way back in my childhood when I was about your level, I decided that I wanted to train as a psychoanalyst, not because at that time I envisioned doing psychoanalysis at all. Uh, but because I felt that I needed to understand these principles in order to be the kind of psychiatrist that I wanted to be. That's what pulled me into the Analytic Institute initially. Along the way, I discovered that very long term intensive treatment is useful for some patients, and I still believe that and my experience goes with that. But I wanted to be a really good psychiatrist who used psychotherapeutic principles. You could be a tremendous psychiatrist without studying in an analytic institute, but the way I envisioned the work and what I felt drawn to do this seemed to be the route for me. What I feel all good psychiatrists have learned are the basic principles that we've been talking about today. They may not explicitly think of them as psychodynamic, but a lot of them do. Most every psychiatrist that anybody works with today has been trained at least somewhat in these principles and uses them. But if they weren't trained in their residencies, they were trained by their patients. That in order to do the work well, you simply have to learn to attend to the meaning that a patient is drawing from what their life is affording them. The meaning that a patient draws from handing over a prescription for an antidepressant. The way in which a patient is experiencing affective states. And when they learn to and enhances the work. If you can attend to what's happening in the room. As even a consultation progresses. And it is my strong belief that every good psychiatrist.

  Dr. Rex Kay: [01:01:41] It does use dynamic principles, but we also all use including the analyst cognitive behavioural principles, dialectic behavioural principles. Systems thinking developmental thinking that mental illness is a vicious, multi-headed beast. And those of us who work with mental suffering and mental illness need to be able to use everything that we possibly can to help and that these principles, I find, achieve their greatest value not in the hands of people treating patients directly with psychodynamic psychotherapy. But in the hands of people using the principles in their general psychiatric work and their general therapeutic work, whatever mental health profession they come from.

  Jordan Bawks: [01:02:38] Yeah, I'm. You're preaching to the converted here and I guess you literally you are because you converted me over my residency training that and now I take this work on for myself as one of the reasons I was eager to take this on is that for me, you know, again, not that this is entirely unique to Psychodynamics, but that the things that psychodynamic thinking emphasise, which is seeing the individual, seeing the person as an individual, paying attention to their past experiences, the value of attending to their relationship with you, the value of attending to their emotion. And the you know, this is, I think, one of the late developments of psychoanalysis relatively, that you hinted at that sort of transformation in the 80s and self psychology is how valuable it is to just to empathise to enter the patient, to make a really concerted effort to understand the patient's world and their experience and how healing that is, how stabilising that is, that those are things that I have gained from my psychodynamic training and things that have really greatly enriched my psychiatric work.

  Dr. Rex Kay: [01:03:57] Let me pick up on one thing you just said, Jordan, And this will illuminate the cross-fertilisation between psychotherapies. There was a time, and I can still slip into the language of saying that there's a tension in psychiatry. There was a sociologist who wrote a book about psychiatry called of Two Minds that American psychiatry is of two minds, and the minds are along a kind of biological orientation, a psychological orientation. We can talk about a tension between the desire and the need to see people in categories to make psychiatric diagnoses. And that's an extraordinary, valuable pursuit. Starting in 1980, Bob Spitzer and the DSM proposal was incredibly important and remains incredibly important because it's trying to establish categories that we can compare. So we need to make diagnoses and put people in categories, and that's crucial. The other pool that can be called attention is in seeing every individual as an individual. And focusing on their individuality as a person with a unique history and a unique way of experiencing the world. And we can call that attention. But my colleagues in the dialectic behavioural therapy world have helped me recognise that that's not attention. It's a dialectic that the two live together and they actually benefit one another at their best. And that it's actually our job to not choose between the two, but to constantly be integrating and seeing from the two perspectives and integrating what we see to the betterment of the patient.

  Jordan Bawks: [01:05:51] Yeah, I totally agree with that. Rex, I'm going to ask you an annoying question, which I've been doing all episode, putting you on the spot with these hard, monolithic questions. But we like to ask at the end of our episodes, our experts if they have any recommendations for interested listeners who want to learn more. If you were to recommend a resource, a website, a book, or even just kind of a general idea to our listeners if they wanted to learn more about second and psychodynamic thinking or therapy, where would you direct them?

  Speaker4: [01:06:26] Oh, that's such a hard question.

  Jordan Bawks: [01:06:27] I know.

  Dr. Rex Kay: [01:06:28] The literature is, as you noted, a complex literature, but it's also an enormous literature. So it's rather difficult to recommend general texts. Probably the best single volume. And Jordan, you could put this up on the website is Jeremy Safran's introductory book. Uh, as a single volume describing the therapy in about 150 pages. The best introduction to theory is probably Stephen Mitchell and Margaret Black's Freud and Beyond are a fascinating introduction to attachment theory, which also helps understand from an evidentiary base. The role of early experience is Robert Karen's Becoming Attached, which looks at the history of attachment theory, but in the process of doing so and it's a fascinating story and he tells it very well, but in the process of doing so, he helps review the literature of just how early experience shapes later. So there are three places that people could start, but I would also encourage people, especially in the field, who are interested. In any given Non-covid year there are six or 8 or 10 people coming in to speak on broadly psychodynamic themes to various groups. Through the Toronto Institute of Psychoanalysis, the Toronto Institute for Contemporary Psychoanalysis, the Child Psychotherapy Institute, the Ontario Psychiatric Association. There are multiple websites that people can keep an eye on. What I would encourage people to do, if they're interested, is grab and follow in exactly the same way that we try to do as therapists. Follow your curiosity. Don't try to start with Freud and work your way up or study the classics. My strong encouragement is to read what is interesting to you and read it until it's no longer interesting and see if that leads you somewhere else and follow your curiosity.

  Jordan Bawks: [01:08:52] Wonderful. I'll make my own plug to add to those resources, which I would generally agree with is to try and find your own Rex Kay wherever you live. Look up your local Rex Kay. Can you tell Rex that I'm trying to get you back for another episode?

  Dr. Rex Kay: [01:09:18] Where you're going about it the entirely wrong way.

  Jordan Bawks: [01:09:21] But truthfully and I'll chop this up with audio. Um, I would also encourage people to look up their whatever your local institution is and try and find a mentor. A mentor if you can so like if you do clinical work asking around in your local clinical department for people who have psychodynamic training or they do psychodynamic therapy is the best way to learn. As much as I love books and podcasts is to is through real relationships. And so I strongly encourage you to ask around for your local psychodynamic expert or trainee or whoever's keen and go through that exploration together. So I want to thank you guys both. Anita, well done your first episode. Rex, thanks so much for joining us and tolerating all my questions and admiration.

  Dr. Rex Kay: [01:10:26] No disrespect, Jordan, but Anita, coming at this from the outside, uh, stimulated my questioning mind and I think really facilitated this discussion. So thank you. And Jordan, as always, thank you just for being Jordan.

  Jordan Bawks: [01:10:47] Can't be anybody else. Thank you for listening to PsychEd the Psychiatry Education Podcast, by medical Learners for Medical Learners. Our theme song is by Olive Musique. I want a special thank you to our guest expert today, Dr. Rex Kay. Post-production was done for this episode by Jordan Bawks and Anita Corsini, and we hope to have you back on our podcast sometime soon. Take care!

Episode 29: Cultural Psychiatry with Dr. Eric Jarvis

• Episode 29: Cultural Psychiatry with Dr. Eric Jarvis

  Sarah Hanafi: [00:00:08] Welcome to PsychEd, the psychiatry podcast for Medical Learners by Medical Learners. In this episode, we want to build off of some concepts that were touched on in a previous episode about newcomer mental health and explore more broadly the field of cultural psychiatry and the value this work can bring to communities that are increasingly diverse. I'm Sarah Hanafi, a PGY3 at McGill University, and I'm joined by Audrey Lee, a fourth year medical student at McGill.

  Audrey Lee: [00:00:36] Hi, everyone. Thanks for having me here today.

  Sarah Hanafi: [00:00:40] And we're really grateful to have our guest, Dr. Eric Jarvis, this week to share his expertise. Dr. Jarvis is an associate professor of psychiatry at McGill University, and he's the director of the Cultural Consultation Service at the first episode psychosis program at the Jewish General Hospital here in Montreal. Welcome, Dr. Jarvis, and thanks for joining us. I was hoping you can tell us a bit about your current clinical work and your research interests.

  Dr. Eric Jarvis: [00:01:08] Yeah. I'd be happy to. Thank you for having me on this program. Right now, I am the director of the Cultural Consultation Service at the Jewish General Hospital. So that's a speciality team that evaluates newcomers, immigrants, and refugees, as well as other people where there may be questions of cultural understanding or religious issues or problems in their lives. And so we will do consultations to the community, to clinicians in the hospital or in the greater Montreal area, even sometimes other places, just to try to help people understand the diagnosis or the treatment planning better. And I also run a first episode psychosis program, which is really becoming more and more a culture and early psychosis program, as we have more projects that are kind of linking the cultural consultation service to what we do in first episode psychosis as well. So that's kind of what I do clinically. Research wise, I've been very interested in how culture and psychosis interact and how culture and psychosis influenced each other. And the most recent grant we have received from Health Canada is looking exactly at some of these problems. How do we adapt culturally some of the interventions that we do in the first episode psychosis program? So most specifically, how do we adapt culturally, family psychoeducation, for example, to the many diverse members of our community? So those are some of the things I'm doing.

  Sarah Hanafi: [00:02:45] Excellent. Now I'm excited to hear more and I'm certain kind of later on in the episode you'll be able to draw from this clinical and academic work to illustrate some of the points in this episode. So in terms of today's episode, we're going to touch on several learning objectives. One, define culture. Two, describe how culture affects psychiatric care. Three, outline the goal in the structure of a cultural formulation interview. Four, evaluate clinical scenarios to determine whether to employ the cultural formulation interview or to seek a cultural consultation. Five, define the three types of cultural concepts of distress and compare these with DSM five and psychology. Six, discuss the concept of cultural competency. Seven, explore the role of advocacy in psychiatric practice. So for many of our listeners, this may be the first time they've heard of the concept of cultural psychiatry. Dr. Jarvis, I'm wondering, can you explain what this field entails and how does it differ from the field of social psychiatry?

  Dr. Eric Jarvis: [00:04:00] Sure that's a good question. I think a lot of people lump together social and cultural or social and transcultural psychiatry, and in many ways they are the same and they do overlap, at least in many ways. But there are distinctions and I think if you're in the field of cultural psychiatry, it's important to maybe think about some of those differences. So social psychiatry has more to do with examining how the power structures are aligned in society and how they may give or deny resources or access to care, for example, to certain groups of people. And so social psychiatry is interested in determining the determinants of mental health and is closely aligned maybe with psychiatric epidemiology, say, whereas cultural psychiatry is a little bit different. It's not ignorant of those kinds of issues. I mean, certainly cultural psychiatrists know that that's very important. But cultural psychiatry borrows heavily from medical anthropology, and so it's interested really in how people construct their identity or their identities. It's interested maybe in other topics like how people believe that they become ill or how people understand the illness process or the illness experience. And then how do people react? Or how do communities organise to alleviate suffering and maybe even define suffering itself? So these are kinds of the questions, more of cultural psychiatry, and I think it's important to kind of take stock that there are some subtle variations or maybe not so subtle differences between the two fields.

  Sarah Hanafi: [00:05:45] And how did you yourself come to be involved in work in cultural psychiatry?

  Dr. Eric Jarvis: [00:05:52] Well, for me, it was a real choice. I mean, I did a non-science undergrad degree in history and I enjoyed the humanities immensely as well. And when I went to medical school, I was looking through all the different, different programs around the country. And I saw there was a transcultural psychiatry program at McGill, and I just was immediately taken with the idea of applying to McGill and going and doing a residency there and learning more about what that might be. And when I came to McGill, I immediately started to work in that field. I got to know Lawrence Kirmayer and others of his colleagues, and from there it was such a great natural fit. I've always been fascinated with the field ever since, and I've structured my clinical and research and writing interests around those kinds of topics. So it's been a really wonderful journey.

  Audrey Lee: [00:06:54] Thank you for sharing with the listeners the journey that you took into getting involved within this field. Dr. Jarvis. So we've talked a little bit already about what cultural psychiatry is, and evidently culture is an important and central concept in this field. In the DSM-5, culture is defined as systems of knowledge, concepts and rules and practices that are learned and transmitted across generations. Could you elaborate more on what we really mean when we're talking about culture? And furthermore, how does culture differ from race and ethnicity?

  Dr. Eric Jarvis: [00:07:30] Yeah, I mean, the definitions of culture abound. There are so many different definitions. Every book that you read on the topic will have a slightly different take on what it means. A few ideas that I always think about culture is it's kind of a legacy that we receive from those who came before us. So many of the things that we take for granted in our lives, the patterns that we follow throughout our lifetimes, maybe the beliefs that we think are spontaneously coming up from our own psyches are actually bequeathed to us by the people that we've known in our lives, people that are parents or our families and people in our communities all around us. And so for me, this culture is not something that necessarily just comes into being through our own wills and our own ways of living that we choose. It's something that comes to us from long ago, and I think we can remember that and recognise that we'll see why it's so critical to take account of the cultures of the peoples around us, professional cultures as well as ethnic and religious cultures that we might participate in. So important to remember that culture is a legacy, but it's also something that is often taken for granted. It may be things we're dimly aware of, practices and beliefs that we're dimly aware of until we encounter somebody that's different from ourselves.

  Dr. Eric Jarvis: [00:09:01] And that's an important opportunity and important moment when we encounter somebody who believes or behaves very differently from how we think is what we would consider to be normal or acceptable. We have to step back, descend ourselves, and begin to ask some very important soul searching questions and try to reach out to people and form commonalities or bridges that can help us to not just communicate, but to maybe be helpful if they're in distress. So final point on culture I wanted to mention has to do with the fact that we often put culture into other people. We might say that patients or families or other people from other places have culture. But to remember that we as observers in medicine and psychiatry, we also have a culture of our profession. We have cultures that we've grown up learning and understanding and believing. And part of cultural psychiatry is to seriously consider what those core beliefs are that we have that may or may not be shared by other people. What are the things? What are the ideas and the values that we might put out there that other people may not understand or may not accept, but that we think are maybe right or valuable just in and of themselves. So this is something that I think cultural psychiatry can really bring to medicine in general, in psychiatry more particularly.

  Sarah Hanafi: [00:10:39] I really appreciate that. Dr. Jarvis, that reminder that we, you know, take a step back and consider the culture that we bring, whether as an individual clinician or as a professional body. I wonder, you know, with these differences culturally or these different legacies, how do you find that this impacts care in psychiatry?

  Dr. Eric Jarvis: [00:11:05] Well, for me, as I've kind of come along over the years, I've come to realise that culture is at the root of what makes meaning and value to people. So if I'm going to try to understand other people and try to offer some help to them, then I think for me, I need to take account of this aspect of their lives. To pretend that people are all the same, or to pretend that culture isn't really present or maybe isn't that important if it is, I think, is really missing a lot of what we need to take account of as clinicians. I think ignoring culture means we may be misled in our diagnostic practices or what disorders we think are present in people. We may completely miss the boat on proper and acceptable treatments for our patients. And if we don't take account of people's cultural backgrounds and what's at stake for them in the clinical encounter, we may not ever see them again after the first visit. I mean, they may not want to come see us again. They may not adhere to the kinds of medications or other interventions we think may be important to alleviate their distress. So to me, a cultural evaluation is just part of a routine and comprehensive psychiatric or mental health evaluation.

  Sarah Hanafi: [00:12:39] I mean, it sounds like culture or taking culture into account can affect all facets of psychiatric care. I wonder going further with that: Do you find that certain cultural communities experience disparities in our mental health system in terms of their outcomes?

  Dr. Eric Jarvis: [00:13:00] Yeah, definitely. I think that that's part of the interest, but also the challenge of cultural psychiatry, is to try to find ways to reach out to people who may, because of various problems, it may not be anything to do with them, it may be the way that society is structured, because of social structures and structural issues, maybe systemic racism or other problems. But certain people from different communities, different backgrounds, may find they can't or aren't willing to access care or may feel very mistrustful of what we think are such basic notions like psychotherapy or maybe taking medications. So yeah, I think that some communities are more adversely affected than others by this. I hesitate to make stereotypes sort of by drawing attention to particular issues. I know in the news right now, a lot of people are very upset, rightly so, about mistreatment of African Americans, African Canadians, black Britons, people of African origin in different countries and societies who have very difficult and historical legacies of oppression through the police, for example. But some of those kinds of problems exist in psychiatry as well, and Summer Knight, she's a student with us on our team, has recently done her master's thesis on this very topic and finds that people of African origin here in Montreal suffer a greater degree, greater amounts of coercive treatment measures, for example, than members of other communities. So what does that mean in psychiatry? It might mean outcomes like forced treatment orders, it might be being forced or compulsorily admitted. It might be having police contact prior to presentation at the emergency department. These kinds of outcomes she found in her master's thesis to be present. So I think these kinds of things are very real and they negatively impact the way that we can help other people. So cultural psychiatry is trying to take stock of these issues and trying to modify the way we approach members of indigenous or African communities who may feel very deeply wounded and have been deeply wounded for decades or even centuries.

  Audrey Lee: [00:15:44] I really appreciate your perspective on the impact that culture can have on the psychiatric care of certain marginalised populations within society. And I think that this is an extremely important topic to address within the current social climate that we're living in. Now that you've provided some insight into why culture is important and into its relevance in psychiatry, I think that listeners would benefit from learning about some tools that they can use to tackle cultural issues within their clinical work. So I understand that the cultural formulation interview or the CFI is one such tool that exists and that it's a framework. Can you perhaps elaborate a little bit more about the CFI and its goal?

  Dr. Eric Jarvis: [00:16:28] Yeah, for sure. So in the DSM-IV, there was something called the outline for cultural formulation and it was really a broad general framework trying to help people who are interested in in considering culture in the clinical encounter. It gave five kind of general categories of topics to cover that a clinician could use. The cultural formulation interview arose because people found the outline for cultural formulation a little bit too vague and maybe not very specific in its direction as to how to inquire about these basic ideas. So the outline for the culture formulation interview is comprised of 16 questions, and the questions come out of the basic categories of the outline for cultural formulation, like cultural identity, for example, or examining explanatory models. These are sort of general categories from the outline of culture formulation. The culture formulation interview takes these basic building blocks and then makes concrete questions that fit into each of these larger categories. And so a clinician can use these really in any clinical setting, usually at the beginning of the interview, to make sure that at least some facets of culture are covered in the evaluation or clinical interview.

  Dr. Eric Jarvis: [00:18:04] It takes about 20 minutes to do a cultural formulation interview. And, I mean, these 16 questions really are quite basic. They're certainly not a comprehensive cultural evaluation or psychiatric or mental health evaluation. If people discover that there's more to discover or more to uncover, I guess, in the evaluation, there are 12 supplementary modules as well that a person can turn to, a clinician can turn to, and find much more guidance on how to pursue, say, issues of religion and spirituality, or if they want to go deeper into immigration or migration. They could find a supplementary module to complement what they've already tried to do in the interview. There's also a version of the CFI for families or for third parties. It's called the informant version of the interview. So it could be for family members, it could be for community members or other people who are participating in the interview. And the informant version of the CFI has one more question than the usual 16, and it just asks the person at the beginning what their relationship is to the patient that you're interviewing. So that's kind of a general overview of the CFI.

  Audrey Lee: [00:19:32] So now that the listeners have a bit of a better idea of what the cultural formulation interview consists of. When exactly do you decide to introduce the CFI when you're evaluating a patient, and what are the indications that you look for that warrant, this kind of assessment?

  Dr. Eric Jarvis: [00:19:48] Yeah, that's a good question. People wonder maybe when should I introduce it or when should I do it really? The CFI was made for everyone, every clinician to use and the idea is for people to use it all the time. When you wouldn't use it? Maybe if you're already kind of doing a more in-depth cultural assessment of a person, you may kind of surpass what the cultural formulation interview is able to give you. If you already know a person well or if you're doing a more in-depth cultural evaluation at the beginning, you may not do the CFI for various reasons, which I'll talk about. But for most clinicians, the CFI is really made for you to use. And so I would encourage the listeners to check out the CFI and the DSMV and look it over. It's not too intimidating. I hope the 16 questions are fairly simple and easy to use, I think, and you can look it over and begin to consider how they could use it in their practice. So that's what I would recommend and hope. I mean, the CFI is studied fairly widely around the world in different settings, mostly academic settings, but it's been shown to be feasible, it's been shown to be useful, and it's been shown to be pretty well tolerated by clinicians and patients alike from a wide variety of backgrounds. So I think it's something really to consider using more routinely in our clinical work.

  Sarah Hanafi: [00:21:27] So you kind of touched on something. I was hoping, you know, we would get to the the evidence around the CFI. So it sounds like it's something that's been demonstrated as as valid and feasible. I guess, just for clarification, has this been solely in Canada or the States or has this also been looked at in other practice populations?

  Dr. Eric Jarvis: [00:21:54] Yeah, the CFI, it was initially pilot tested in various centres around the world, not just in mostly the US and Canada I guess, but it was pilot tested in other settings as well. Since that time there have been a number of studies from different places that have used the CFI in the work that they're doing. One of the problems is most of these settings are academic settings, so it hasn't really been culturally validated, so to speak. It's been shown more to be feasible and useful in clinical settings. So cultural validation would be a much longer, more complicated issue. So that's something that hasn't yet been achieved. The CFI hasn't been shown to be culturally valid necessarily. It also is kind of lacking in effectiveness studies. So does use of the CFI really improve clinical outcomes? This is a question that remains still. It's something that can be, as I say, that's useful and that can be implemented well in clinical settings. And we feel like it's helpful and it brings a lot of good things into the clinical evaluation. But effectiveness studies need to still be done. It's really kind of a work in progress. The CFI, it's still the subject of a lot of ongoing investigations and it appears in the DSMV, but it'll keep growing as the research database grows. And I think you'll get more and more attention as it does so.

  Audrey Lee: [00:23:39] I think that it could also be helpful for our listeners to get a sense of how to use the cultural formulation interview through examples. So would you be able to share with us perhaps a typical case that you might see in either the Cultural Consultation Service or the first episode psychosis program and how you go about implementing the CFI.

  Dr. Eric Jarvis: [00:24:04] Well, the CFI is something, as I mentioned, that really depends on the individual clinician. Do they want to make its implementation a priority or not in their clinical practice? So it's really an open tool that we can use. It doesn't have to be used in just speciality or subspecialty services, like in a general psychiatric practice. I would really encourage its use there. For example, I think that it's best to use the CFI at the beginning of the evaluation because it, as I mentioned, after practice, takes maybe about 20 minutes to use the CFI, but it really opens up some general information about the client or the patient, their identity, what they feel is important about themselves and their presenting problem. So it's kind of a new way to introduce the patient to the mental health evaluation. You know, there are some limitations of the CFI, though it's not been very well studied in patients that need a linguistic interpreter or culture broker. Also, if you're doing evaluations with family members present, it might be a little complicated to use the CFI if there's referring clinicians as well present or members of the cultural community.

  Dr. Eric Jarvis: [00:25:30] For this reason, in the Cultural Consultation Service at McGill, we don't use the CFI very often because most of our evaluations are with other people present. So it's not sort of a one-on-one kind of an interaction. Also, if people are acutely ill with psychosis, maybe, or acutely suicidal, if they're aggressive or if they have cognitive problems, cognitive neurocognitive disorder, for example, and they may not be able to actually finish a questionnaire like the CFI, you may have to radically adapt your interview to suit their needs. So those are some of the thoughts I have on the CFI. Personally, I think the CFI there's one question in the CFI that has to do with the clinician patient relationship, which I don't think is enough. I think the clinician patient relationship is so important. As I as I was mentioning before, psychiatry itself is a culture and all psychiatrists, all mental health professionals come to clinical encounters with their own cultural backgrounds. So I think the CFI needs to pay more attention to that, to the culture of the observer.

  Sarah Hanafi: [00:26:47] I think those are really thoughtful points and ones that maybe we don't often consider. Kind of coming from that, you've talked a little bit about the Cultural Consultation Service. Can you share with us, you know, maybe a typical case you might see on the on the CCS? And how do you approach that, especially if the team maybe isn't necessarily using the CFI?

  Dr. Eric Jarvis: [00:27:14] Yeah, well, most of the people referred to the culture consultation service are either immigrants or refugees. I guess refugees are a kind of immigrant. So it's more than 90% of the people referred come from those two kinds of groups. We've had a few indigenous patients referred over the years, about 30 total maybe, and they might make up the bulk of the non-immigrant, non-refugee referrals to the service. So what we do is we work with the referring team and we invite the referring team to come to the consultation. And we also spend quite a bit of time before the consultation learning about the client and his or her family. So we'll ask if they need an interpreter and we ask if a culture broker would be beneficial, we try to determine if that would be the case. How do we know if an interpreter is necessary, if somebody has a mother language other than French or English? In Montreal, we would at least offer an interpreter. Some people might take that to be a little bit offensive, maybe like if they've been to school in France, in French, in another country or English, another country, and they feel they're very proficient in that language, they might feel a little bit miffed.

  Dr. Eric Jarvis: [00:28:39] But we take the risk because so many people are never offered an interpreter during the time of their psychiatry evaluation or the time of their psychiatric treatment. So we take that risk. And many, many people are extremely grateful to have an interpreter present. When do we need a culture broker? We would try to have a culture broker present for every client, but sometimes we don't have a person we've identified as a culture broker. We have a network of culture brokers that we work with fairly regularly. But sometimes we don't have a person that we could pair up with a client from a particular background. So in those cases, it's up to me and the resident or the interpreter and other people who are present in the evaluation to do the best that we can. And we have to use our cultural competency skills to the best of our abilities. You know, they're strained sometimes, but it's it's always a very challenging a kind of a career, a challenging kind of an interaction. You're trying to really reach out to people. You're trying to help people feel comfortable, people who have been horribly traumatised or may have a terrible mistrust of anything official, especially anything official in Canada.

  Dr. Eric Jarvis: [00:30:04] I mean, especially if they've been brutalised by police in the past or they're seeking refugee status, they may worry that anything they say could and will be used against them. So much of the cultural consultation at the beginning stages anyway is trying to help people feel culturally safe and comfortable in the evaluation at least enough that they can have a meaningful interaction. So the culture of consultation is usually maybe one or two evaluative sessions. And then from there we try to gain a decent sort of overview of the person's life, and we then meet with the clinicians in a separate meeting. We call it a clinical case conference, and there we present the case to the referring clinician and we have the culture broker present, if there has been one, and we present the report and we try to definitively - well, I won't say definitively - but we'll try to settle on a most appropriate diagnosis, and then we'll try also to work out some helpful recommendations. Some of them are biologic, meaning using medication or other interventions, but a lot of what we try to do is modify the social world or recruit resources from the social world, maybe from religious communities or other other community organisations to try to help individuals.

  Sarah Hanafi: [00:31:34] I think one thing I wanted to almost circle back to that you mentioned was this idea of the families involvement in the process of evaluation. I know often when we think of child and adolescent psychiatry, when we're talking about family systems and including that in the clinical evaluation, particularly in the work of cultural psychiatry. Can you elaborate a bit more on the role of the family system and how it might differ from what we typically see in psychiatric clinical interviewing?

  Dr. Eric Jarvis: [00:32:13] Absolutely. I mean, in cultural consultation and cultural psychiatry, I should broaden out a little bit. I mean, family and family interviewing and family interventions are key, very, very critical because you're trying to establish the context of a person's behaviours. So we do see people who are individualised, I mean people that come without their families, they're maybe in Canada alone or something, or in rare cases they might refuse to have family involvement. But the majority of cases we see with family members, I'd say, and that's because I guess like in child and adolescent psychiatry, we realise so, so much the role of the family not only in supporting, helping or sometimes harming individuals even, but also in structuring what the distress is really all about and the form the distress takes. So we want to see that interaction. So we do see people without their family members. We might if we come into an interview, we begin to suspect a problem of abuse or other issues. We will ask the family members to leave for a time and interview the individual alone, especially if it's a woman or a younger person. But oftentimes, we almost always start off the evaluation with the family together in the consultation. And that may be a little bit different than most psychiatric evaluations, because, like I say, we really are searching and seeking for the context. And we look at the interactions, we see who speaks the most often, what languages are used. Sometimes people might speak English to the interpreter and then maybe French to some people in the family, and then maybe another third language to the grandparents. And so this is all of great importance to us as we're doing our evaluation, trying to see how the system, the family system was set up and how it may or may not be a microcosm of something larger, a larger cultural construct.

  Audrey Lee: [00:34:23] Thank you for that detailed explanation of the CFI and its usage. Dr. Jarvis. In the DSMV, there's also this mention of cultural concepts of distress. Could you describe what these are in further detail?

  Dr. Eric Jarvis: [00:34:38] Yeah. So cultural concepts of distress are ways that people from different backgrounds might describe their suffering. So we have our own cultural concepts of distress in North America. So some of them are lay, some of them are professional. So we have a whole DSM full of diagnoses that you could argue to some degree are cultural concepts of distress that have kind of emerged over the last century or so of psychiatric practice and wisdom, you know. So it's kind of a new way of understanding. DSMV, the diagnoses, the nosology that we all take for granted. But I think it's good to step back and look and see how these kinds of concepts affect psychiatry and medicine as well as other people and other peoples. I don't know. There's three different kinds of cultural concepts of distress that people talk about. So I don't know if that's of interest to you guys, but I could talk about a little bit here maybe. So there are cultural syndromes that have been identified, in DSM IV, there was a glossary of these culture bound syndromes which has been abandoned. And the reason that it was abandoned is that cultural behaviours and forms of cultural distress aren't usually limited to one group. People from all different backgrounds can experience anxiety, depression, anger, irritability and psychosis, for example. So these syndromes aren't really culture bound. They're more emphasised maybe in one place, more than another. So one place may emphasise sad feelings or sorrow as part of depression.

  Dr. Eric Jarvis: [00:36:34] Another place may emphasise maybe backache or headache when they're feeling discouraged. So they may nonetheless experience the full gamut of depression symptoms at different times, and maybe they just won't focus on the same degree. So the new term is cultural syndromes, and these are really like clusters of symptoms that may be specific to certain cultural groups and that form a pattern of recognisable symptoms of distress. So there are some examples listed in DSMV and there's many we could talk about. One of them is an entity called taijin kyofusho, which may be related to a form of social anxiety disorder, say, in Japanese people, where people from that particular background might feel that their body odour is offensive to other people, or maybe they have offensive breath to sort of an extreme degree. But this problem of being sensitive to how your body odour is affecting other people might be relatively present in Japanese society. It might be more of an issue for Japanese people in general. It's always hard to stereotype. Individual people, of course, have great variation in every context, every society. But so this this kind of cultural syndrome taijin kyofusho might be a representation of an extreme form of this concern about offending other people. So that's sort of an example of a cultural syndrome, and how it might overlap in some ways with an entity or a diagnostic category from the DSM. But these overlaps aren't perfect. And so it's rare that you can have a 1 to 1 equation between what would be called a culture bound syndrome and something from the DSM. There's also some other ideas about cultural concepts of distress.

  Dr. Eric Jarvis: [00:38:40] One of them is a cultural idiom of distress. And this is not quite a cultural syndrome, it's a manner of expressing distress that is recognisable in a group of people but it's not on the way to becoming syndromic. It's something that's more kind of colloquial or in the common language of things. So a person might say, for example, focus on, as I mentioned earlier, pain or discomfort in their body as opposed to feeling sad or melancholic about a life situation. And we have it in North America as well. People might get backaches or frequent headaches or stomach upset in distressing situations. So if more people, more and more people take these kinds of use these ways to express their distress, that it might become an idiom of distress. A cultural explanation is a third kind of concept, a cultural concept of distress. And it's kind of a cultural explanation or perceived cause that has more to do with how somebody explains what's happening to them as part of their explanatory model. So somebody might say, you might ask them what their problem is and they might say, my problem is jinn possession. Say they might say spirit possession. It's not in any part of a syndrome. It's not necessarily an idiom of distress. It might be something, an explanation of what they're going through. So these are some of the ways that people might might categorise cultural concepts of distress. They differ by degree of organisation into discrete illness or syndromic categories.

  Audrey Lee: [00:40:45] You know, I think that the topics that we've touched on throughout this episode, such as the CFI and these cultural concepts of distress, just speak to this growing need for cultural competency, humility and safety and and that these calls are growing within medicine and certainly within psychiatry. However, I can understand and see that there are many variations and nuances to these different concepts. So I was hoping that you could explain the role of cultural competency within mental health care and how it differs from cultural safety.

  Dr. Eric Jarvis: [00:41:20] Okay. No problem. Cultural competency refers to the idea of skills that clinicians can acquire, that can help them to work with diverse clientele or diverse populations of patients and their clinics. So one of the problems of the cultural competency idea is it may foster a false sense of security. I mean, if you sort of pass a certain level of competency, if you're checked off as being competent culturally in a certain situation or with a certain group of people, you might kind of think, oh, now I know it all kind of. But really part of cultural competency is a concept called cultural humility, where clinicians recognise the tremendous diversity of beliefs and of health beliefs, I guess, and of values among their clients. And so we recognise and we strive to recognise that we don't have all the answers, even if we have mastered some aspects of cultural competency and we sort of recognise as kind of a lifelong process of learning more and more about the people that we're trying to help and allowing them to speak up and and teach us about what is helpful to them. And for me in my practice, and I learn a tremendous amount from my patients, about what can be helpful and what may not be. So this is just a caveat when it comes to ideas of cultural competency.

  Dr. Eric Jarvis: [00:43:02] There's also the issue of cultural safety, which I think I touched on before. Cultural safety is another component of cultural competency. And what that means is that as clinicians we recognise that people from various backgrounds, various cultural communities may have important histories of oppression where they don't feel safe coming to meet professionals like us and to them we represent the oppressor of the past. We might represent power or authority or various problems, and that to them, coming to see a psychiatrist or any kind of mental health practitioner might be a very daunting task. So for us, it's incumbent upon us as the people with the power to recognise that. And then we try, as I mentioned before, in cultural consultations, we spend time to help all of our clients feel comfortable to the degree that we can. I mean, nobody's perfect to the degree that we can. We may help people to feel comfortable and give them some space and time and then acknowledge these differences and these historical legacies that can many, many times be very harmful. So if we can do that, I think we are able to reach a lot more people and people will be more likely to come to us and take note of what we're trying to tell them, because we do have important treatments and important ideas to share with people about their health and their mental health.

  Dr. Eric Jarvis: [00:44:38] So we don't want to kind of squelch it off at the beginning by being a little too, I guess I'll say, arrogant about what we've come to understand or I mean, this is part of the problem. So cultural competency includes these kinds of ideas. Culture competency also includes a number of other skills. Some of them are more generic, some of them are more specific that clinicians can try to - I shouldn't say try to learn - every clinician can improve, I think, some of the general skills have to do with active listening skills in a non-judgmental manner and a patient manner. Even when people are not behaving the way you anticipated, they might behave in a clinical context. There's an idea called scientific mindedness. Stanley Sue and his group in California came up with some of these ideas about some elements of cultural competency. Scientific mindedness has to do with keeping an open mind and not forming a hard and fast conclusion about the people that you're meeting too quickly, letting people have some room to move around in the evaluation or maybe in a few evaluations or in a few meetings and not locking in, say, a diagnosis or a treatment plan too quickly. There's another kind of a concept called dynamic sizing, which means that we can kind of modulate the interventions and the perspective that we're taking ourselves.

  Dr. Eric Jarvis: [00:46:15] Sometimes we might pull back and adopt a psychiatric perspective with the people that were interacting with. Other times you might want to take a little more of a on the ground level view of what's going on. We might try to enter the worldview of our clients and see if we can. Maybe they need that to establish a relationship of trust with us, for example, and so we can work on these kinds of skills preventing premature closure, trying to adapt the perspective that we come into the evaluation with. There are specific skills for cultural competency as well. We might become very knowledgeable about one or two communities over the time of our professional lives, and maybe because of our birth or where we come from, we might know third or fourth languages, and this can be very helpful. It just takes a long time to acquire the in-depth knowledge of some of these specific cultural skills. And we have to be, again, humble. And if we recognise we're a little bit outside of our comfort zone, we can reach out to linguistic interpreters and culture brokers who can come to help us to give extra input so that we can understand the patient and his or her context better. So those are some ideas of cultural competency.

  Sarah Hanafi: [00:47:53] Thank you. I think that's very helpful. I really like the way that that you explain those different concepts and compare them to one another. Building a little bit off of that, we've talked a lot about how this practice of cultural psychiatry is also related to social context and how it can be very much rooted in social systems. And therefore, social inequities can impact on what patients are experiencing in terms of health disparities. I'm wondering in your practice, how do you view the role of advocacy as a psychiatrist?

  Dr. Eric Jarvis: [00:48:36] The advocacy is, I think in cultural psychiatry, especially cultural consultation, also in culture and early psychosis. I mean, I think we are advocates most of the time for our clients because many of the people that we see are truly on the margins of society. Some of them come to us from very difficult backgrounds. They may be new to Canada as well because they have a mental disorder often, or at least they're suffering mental distress. There's a heavy stigma from families, from cultures of origins. So we as mental health professionals are poised and should be ready to advocate for people in these circumstances. I think that's a core aspect of our role as mental health professionals. When you're working with refugees in particular, I mean, as refugees are in a terribly precarious state. So they're waiting on other people to make decisions about their future lives. They're leaving very difficult circumstances. They're having a very hard time often understanding Canadian society and how to negotiate it. So as a mental health practitioner, we can help that quite a bit. We can guide them in the proper path to take. We can write letters for them. We can volunteer to speak to their lawyers, to their referring clinicians, and we can try to smooth over misunderstandings and the letters that we can write. Placing the person's individual's behaviour in a cultural context can be very, very eye opening to the judges on the immigration board and the lawyers as well who are helping to represent the clients. And so these are just some of the things we can do. I mean, we can also, in some cases, we might recognise that a refugee applicant may not be able to effectively represent him or herself for whatever reason. And so we can advocate for a designated representative that can accompany them to court and can serve some of the functions that a person regularly would do for him or herself. So, I can't stress enough the importance of the advocacy role for psychiatrists and mental health professionals, especially working with these populations.

  Sarah Hanafi: [00:51:08] You know, it seems like I mean, there's so many ways in which a psychiatrist can impact on a patient's well-being and advocate for them beyond the clinical encounter. We're starting to near the end of our episode, so I'm hoping we could end more on the topic of training in cultural psychiatry. And one thing certainly that strikes me in this clinical work is that it seems more process oriented. I'm wondering, how do you approach educating trainees about this field?

  Dr. Eric Jarvis: [00:51:40] Yeah, the training in cultural psychiatry is very experiential and there's a tremendous amount of literature as well on the topic. And in fact, it can be a little bit daunting to beginners in the field of cultural psychiatry. It's so multidisciplinary that people sometimes don't know where to begin. I mean, do you start with the social science literature, with the psychiatric literature, the anthropology, literature, history of peoples current events? They all are really important in cultural psychiatry and they help the culture, cultural psychiatrists and make or build a cultural formulation. So when you're building a cultural formulation, you're drawing in from these different, different perspectives that come to bear on the individuals and the families that you're seeing. So I tell beginners I meet with not to give up. Don't be discouraged, follow your interests. So if you have an interest in helping people in these kinds of situations as a clinician, or if you have research questions that you want to answer, follow through on those, and gradually you'll enter into this world, this larger world of cultural psychiatry and with all of its many bridges to different fields. There are some things you can do to help with this. You can watch for certain kinds of events that are going on during your training. Some people in residency training programs, for example, may not have a lot of access to cultural psychiatry training.

  Dr. Eric Jarvis: [00:53:11] Some places have more in Canada or in the United States. But if if you're a resident, for example, you can watch for something called Cultural Psychiatry Day, which is put on annually, usually in April of every year, and it's open to all residency training programs across Canada. There's also cultural psychiatry events at the CPA. Usually there are some there you can attend. You can watch for some international conferences. There's one called the Society for the Study of Psychiatry and Culture, which takes place usually in the spring as well. In April or May this year, it's because of COVID. It was moved to October. Well, I think it's September 25th and October 9th and 10th of this year. It's entirely virtual this year. There's still time for people to join that conference that they want to. There's other opportunities that come up for training for people. There is a McGill Summer program in Social and Transcultural Psychiatry, which takes place every year around May. And there's an event study institute usually in June that people can attend. This is where you network. If you come to some of these events, you'll meet a lot of the cultural psychiatry people from around the world. And before you know it, you'll be part of the group and you'll have really a great experience and some of that confusion will disappear a little bit as you realise everybody is doing different things and it's okay.

  Dr. Eric Jarvis: [00:54:43] Part of the great thing about cultural psychiatry is diversity and so people in the profession also appreciate diversity and the people that come to participate and they like to see diverse interests as well. You can do a rotation at McGill and the Cultural Consultation Service, if you like, to get kind of practical on the ground feeling about what cultural assessments might mean during all this process. It's important to choose a mentor. You might hear of somebody or hear someone speak, or you might read an article or paper, or you might see a podcast or hear a podcast or see some other thing where somebody really speaks to you, you know? And then you can choose to write or contact that person, write them and see what they have to offer. And they'll usually be very happy to talk to you and start to guide you in ways you can foster your own interests in the field. So this is kind of the informal way I think the training takes place. I think it's very important because I think it's really the way that I learned cultural psychiatry and the readings that I do and did are part of it, but it's a vast kind of pool.

  Dr. Eric Jarvis: [00:55:59] And you need to have some personal, I think, one-on-one help in doing that, more formal ways to to engage in training and cultural psychiatry. I mentioned some things like cultural consultation, service or formal teaching structures that you can attend. A summer school, for example, can give a very good kind of overview of the field. And then gradually you begin to learn how to use interpreters and culture brokers in clinical work. And I think that when you learn those kinds of things, when you start to have an appreciation for that, I think that it really takes off. You can learn how to use the CFI, the cultural formulation interview. And to structure your thinking along the outline for cultural formulation to really make it maybe not too lengthy, hopefully, but helpful cultural formulations that can benefit the people that you're seeing. So these are some of the training problems and some of the benefits. To me, it's very wide open and cultural psychiatry, very exciting, a little daunting for the diversity and sometimes lack of structure. But if you enter in and start to look around, you'll impose your own structure and you'll start to make a unique contribution, which is, I think, what all of us want in cultural psychiatry.

  Audrey Lee: [00:57:16] I had one last question for you, Dr. Jarvis, which is a bit of a follow up to what you just talked about. So along the same lines of tips and advice that you might have for trainees, what additional insight might you offer to trainees who are interested in cultural psychiatry but can feel overwhelmed by all the cultures that they might encounter or need to navigate?

  Dr. Eric Jarvis: [00:57:39] Well, nobody is an expert in all the cultures. So I mean, I certainly am not. And when I was a new staff at the Jewish General Hospital in Montreal, I was the director of the Cultural Consultation Service. And people would come up to me and ask me what to do for this person from this country or that person from here or there. And I didn't know, I had to say, I'm so sorry. I know I'm the director of the service, but I'm going to have to get back to you on that one. So that's okay. It's okay to feel that way. And over time, what I found is if I kind of stuck to it and persisted and I found that there are some general kind of trends you can follow with people in general kind of approaches you can follow that I mentioned already some of those kind of general cultural competency skills that you can learn and you can. Those are helpful not just with our clients, with our colleagues as well, because our colleagues are also people coming with their own agendas, their own interests and their own needs. And when they ask you questions, when they submit a consultation. So this is the way that I've kind of negotiated that problem. And I think some patience is with yourself as it is a major step. You can't be expected to learn it all right away, and you can't be expected to know everything about every culture, every group. You're kind of forced into a culturally humble position. I think when you're working with a big group, with greatly diverse groups, you have to sort of be humble that way. And then gradually over time you'll learn about how you can reach out to people to help you.

  Audrey Lee: [00:59:25] Thank you so much, Dr. Jarvis, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had the opportunity to learn about this fascinating and important approach to mental health care. Do you have any closing remarks for the listeners today?

  Dr. Eric Jarvis: [00:59:42] Yeah, I mean, to me, a lot of people look at cultural psychiatry and they just give up a little bit. They think, Well, I'm not going to get into all that stuff. It's just a little bit too much, you know? And I'm going to just stick to what I know and I'm going to try to do the work I do the best I can. And I think that's understandable. I think, though, that as psychiatrists, psychologists, mental health professionals, we have a responsibility to to watch out for ways we can improve ourselves. And I think that we need to watch out for the well being, too, of everybody that we see. So I would try to be a little daring. I would crack open the DSMV and go to the cultural formulation interview as a starting point, look through the questions and ask yourself, you know, how can I implement this in the evaluations that I'm doing? Is there a way I could put this in at the beginning of what I do, try it for two or three clients and see if it isn't something that opens up some new angles you hadn't seen before and if it doesn't create a better treatment alliance with your patients. So I guess I'm asking people to be a little bit daring and try something a little bit new and see if this can really make a difference or not for themselves.

  Sarah Hanafi: [01:01:11] Well, thank you once again, Dr. Jarvis, for sharing your expertise and your time with us today. PsychEd is a resident driven initiative led by the residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Drs. Sarah Hanafi and Audrey Lee. Audio Editing and Show Notes by Dr. Sarah Hanafi. Our theme song is "Working Solutions" by All of Music, a special thanks to the incredible guest, Dr. Eric Jarvis, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening and take care.

Episode 27: Serotonin Pharmacology: From SSRIs to Psychedelics with Dr. Robin Carhart-Harris

• Episode 27: Serotonin Pharmacology: From SSRIs to Psychedelics with Dr. Robin Carhart-Harris

  Lucy Chen: [00:00:17] Hi guys. Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. I'm your co-host, Dr. Lucy Chen. I've recently graduated from the University of Toronto Psychiatry Residency program, but definitely most definitely still considering myself a medical learner. I'm currently working at the Centre of Addiction and Mental Health, doing a combination of women's inpatient and general adult psychiatry work. I'm joined today by Dr. Chase Thompson, a PGY3 resident.

  Chase Thompson: [00:00:48] Hi, Lucy. Happy to be here.

  Lucy Chen: [00:00:50] And Dr. Nikhita Singhal, a PGY2 resident from the University of Toronto.

  Nikhita Singhal: [00:00:56] Thanks, Lucy. Also very excited to be here and it's my first interview, so really excited.

  Lucy Chen: [00:01:03] Great. So we have a really brilliant, like, exciting episode. I'm really excited to introduce our guest and dive in. We're covering a topic that touches on the foundational psychopharmacological principles in addition to the fringes of the unknown with respect to psycho-pharm treatments for depression and exactly how they work. We are zooming in. We're on Zoom, so we are also focusing and zooming in into serotonin function and pharmacology with a focus on an excellent review article called Serotonin and Brain Function: A Tale of Two Receptors, written by our guest expert Dr. Robin Carhart-Harris. Dr. Carhart-Harris is a psychologist and neuroscientist who heads the Centre of Psychedelic Research at Imperial College London, where he conducts leading research in the field. We're really lucky to have you on the show, Dr. Carhart-Harris. Anything else you'd like to share about yourself or your work?

  Dr Carhart-Harris: [00:01:58] No, but very happy to to be here and yeah, honoured to be, that people are interested in this article, so I'll be delighted to go through it with you all.

  Chase Thompson: [00:02:10] Yeah. So as Lucy mentioned, we're discussing Dr. Robin Carhart-Harris's review. We chose to discuss this review on our podcast because we believe it provides a resonance in psychiatry and medical students a scaffold of knowledge about the serotonin system to further build upon throughout residency training. Our experience of learning about serotonin transmission involved a broad range of different receptors with different functional profiles and a variety of different medications that act on these receptors, all of which can be a bit confusing and dizzying to us as learners. With this discussion, we really hope to provide a slightly different and distilled way to think about these receptors. In addition, as psychedelics and MDMA enter contemporary psychiatry, some of the topics discussed today will become increasingly relevant.

  Nikhita Singhal: [00:02:57] The learning objectives for this episode are as follows. By the end of the episode, the listener will be able to: understand the general anatomy and function of the serotonin system with a focus on the purported activity of the more common serotonin receptors and transporters as well as serotonin's basic mechanism of action. To describe the effects of serotonin reuptake inhibitors and how they lead to symptom improvement in mood and anxiety disorders in addition to the mechanism of action of other serotonergic medications and to consider the two-pronged serotonin system conceptualised by Dr. Carhart-Harris and understand how serotonergic agents, including SSRIs and classic psychedelics and the concepts of active and passive coping, fit within this theory.

  Lucy Chen: [00:03:40] So that's a mouthful, guys. I know we're going to explore some in depth concepts and topics, but just follow along, we'll do the best that we can to condense this material for you. So I think we should just start, Dr. Carhart-Harris, before we delve into the main content of your review, it might be helpful for us and our listeners to just go over the basics of serotonin anatomy and physiology, anything that you think would be helpful for our foundational understanding.

  Dr Carhart-Harris: [00:04:10] Um, well, serotonin, um, you know, it's an old evolutionarily evolutionarily old neuromodulator. So let's start by, by, I guess, clarifying what a neuromodulator is. Um, neurotransmitters are chemicals in our brains that alter the activity of neurons, um, in different ways. But, but neuromodulators, like serotonin are more about kind of tweaking the system rather than a sort of direct excitatory or inhibitory action. And so I think of these neuromodulators like serotonin as kind of, um, you know, tuning the function of the brain rather than exciting the brain or inhibiting the brain. It's a more subtle but no less sort of profound, in effect, action of these particular particular neurotransmitters. And you have, you know, similar neuromodulators in terms of tweaking the system like dopamine and acetylcholine and noradrenaline um, but serotonin is, is particularly interesting, um, for a few reasons, implicated in lots of psychiatric disorders in different ways. Um, and interesting drugs, you know, like the psychedelics work on the serotonin system, MDMA, you know, the Prozac-like drugs, the selective serotonin reuptake inhibitors, I think probably the most prescribed drugs in, in psychiatry, maybe benzodiazepines could compete with that um and so, you know, very, very important. And what surprises people sometimes is that most of the body's serotonin is actually outside of the brain, it's in our in our gut.

  Dr Carhart-Harris: [00:06:19] Um, but, you know, the serotonin that is produced and released in our brains plays a very crucial function in how our brains and minds work modulating states of consciousness, so modulating sleep, plays a big role in modulating sleep architecture um, and mood classically. You know I guess to the layman people, they may have heard of serotonin as the happy hormone, they might think of the general rule that high serotonin levels equals better mood and the flip of that low serotonin levels equals maybe depression or low mood. Um, I mean, in the broadest sense, there's some truth to that, but the reality is much more complex. And speaking to complexity, the serotonin system, what arguably sets it apart from the other neuromodulators is its complexity. So these neuromodulators have a number of different receptors, which are the proteins that sit in the membrane of neurons and when they're bound to by by the chemical itself, the neurotransmitter neuromodulator itself, they'll initiate a different response. They're kind of locks that sit in the membrane of neurons and the key is the neuromodulator, the chemical, the serotonin, so that docks into this complex protein, the receptor, lots of these different receptors, and in the serotonin system there are truly lots of these receptors, I think something like 14 different receptors have been identified. And what struck me when I was studying the serotonin system, this is this was my introduction to neuroscience, really, I started my PhD in psychopharmacology, and I studied the serotonin system for four years and then I was lucky to segue into studying psychedelic drugs that work on the serotonin system in a more direct way. But yes, just the sheer number of different receptors, serotonin receptors, and then to to see that different receptors were associated with such different responses I thought was really remarkable and actually that sowed the seed for this paper. You know, I started studying psychopharmacology, um, in 2005, I think it was and this paper published in 2017, serotonin brain function. I guess the seeds were sown early on in my PhD for thinking, you know, trying to kind of, I guess, make some effort to solve the riddle of the serotonin system. I don't think I've done that at all. But, you know, I guess speaking to some of the things that puzzled me about the serotonin system, that certain receptors can do such different things and certain serotonin acting drugs like, say, a Prozac or LSD, both work on the serotonin system, but they couldn't be more different. And so I thought that was that was just incredible and process of trying to get to grips with this and, you know, writing things on on the whiteboard in my office for what different functions and behaviours are associated with, with certain serotonin receptors and what are associated with others, kind of led to the to the creation of this particular paper.

  Chase Thompson: [00:10:14] Great. So that's a perfect segue into what you mainly discuss in your paper, which seems to be the 1A and 2A receptors. So maybe you could tell us a bit more specifically about these receptors and why your paper focuses on it.

  Dr Carhart-Harris: [00:10:30] Yeah, sure. I suppose what was coming through the literature, I mean, I studied MDMA for my PTSD, for my PTSD, for my PhD. That's an interesting Freudian slip. I think there was any PTSD there, and what was coming through there was that certain behaviours that were associated with the post MDMA period seemed to be of a certain category. So there were things like impulsivity and aggression, um, and so, you know, I started, I started jotting these things on the board and with a view to, to, to writing this paper and, within the paper for those who have it in front of them, Table One is, is kind of the product of, of this, this process. And so you know certain, I guess, symptom clusters like impulsivity and aggression,anxiety, depression, low mood that seemed to be a fair bit of work on on you could say MDMA abuse you know um sort of a lot of use of MDMA, regular and high doses, there were reports of these behaviours afterwards. And so for me, this was, I think, you know, suggesting a clue as to what serotonin does, broad brush if you want. And then, um, you know, so, so these could be, you know, examples of behaviours and symptoms associated with low serotonin functioning. Um, but the inverse of them seemed to be things that were, um, promoted by stimulation of the serotonin system.

  Dr Carhart-Harris: [00:12:40] So a reduction in things like impulsivity and aggression, the kind of things that you see when you yeah, stimulate the serotonin system, like with, with, with MDMA, uh, probably the most potent serotonin releaser that we, we know of. Um, and people often say, oh, MDMA, well, it releases other monoamines, but you know, the next highest monoamine that's, that's released noradrenaline, I think you get five times as much release of serotonin than you do to noradrenaline. So while people say that, you know, MDMA really is a serotonin drug, it is, you know, really hitting the serotonin system hard, spitting out serotonin into the synapse um, and, and, you know, people report this profound pro pro-social quality to the experience, you know, things like impulsivity and aggression dropping away. They describe MDMA as the kind of hug hug drug or, you know, love drug. I think hug drug is probably better and empathogen. Um, and so for me, all of this was, was kind of clue to serotonin functioning generally. But then, um, looking more into the literature, it seemed as though, uh, there was one particular serotonin receptor that arguably encapsulated these effects better than any other, and that was the serotonin 1A receptor. Now the picture is complex as it always is, um, in relation to the serotonin 1A receptor, because they are expressed in, in two key areas.

  Dr Carhart-Harris: [00:14:42] So the serotonin system has its cell bodies in the midbrain, in the raphe nuclei that they're called um, and that's where the nuclei of these serotonin cells, uh, serotonin-synthesising cells are found deep down in the old brain and the fibres innervate all the way up into the cortex, really long fibres. It's remarkable how long, you know, these neurons are, individual neurons stretch all the way, their axons all the way from the old brain, the midbrain, all the way to the furthest reaches of the of the cortex. And so if we trace down to those cell bodies in the raphe nuclei where 1A receptors are expressed on on the cell bodies themselves, when they're stimulated by serotonin or a 1A-agonist, meaning stimulating, drug um then that serves to inhibit the firing of those cells and this is a feedback inhibition. It's serving a function like a kind of regulatory brake to slow things down. If there was excessive spill-over of serotonin into the synapse, this system would shut that off because it would stop the spitting out of serotonin from from the axon terminals. Um, so that's what the 1A receptors do in those cell bodies but then what we call postsynaptically, so this is presynaptically in the cell bodies, but postsynaptically on the receiving end of the synapse the effect is of 1A stimulation is, is somewhat different.

  Dr Carhart-Harris: [00:16:35] It's going to it's going to inhibit the activity of those receiving cells, so it has a kind of quelling inhibitory action elsewhere in the brain. Sure, you can inhibit the cell bodies themselves in the raphe nuclei, but that's going to stop the spitting out of serotonin and that'll have lots of, you know, repercussions. Um, but what I was seeing in the literature is that postsynaptic stimulation of 1A receptors in regions like the stress circuitry, the limbic system, was associated with this inhibition and reductions in, in, in functions that you associate to associate with those stress circuitry like anxiety and stress, of course, impulsivity, aggression, you know, so for me, it started to make sense that MDMA was, you know, to a large extent and also the antidepressant Prozac-like SSRIs are to a large extent working on stress circuitry to, um, kind of smooth things out. And while it would be too simplistic to put all of that on the serotonin 1A receptor, um, it is highly characteristic of the, at least the postsynaptic serotonin receptor. Um, and for me that, that, yeah, that, that kind of got things sorted in my head to some extent about what the serotonin system is, at least in one dimension of the serotonin system. Now there's another one, the one that the psychedelics work on. But perhaps I'll pause because I covered quite a lot in relation to the to the 1A system there.

  Chase Thompson: [00:18:35] Yeah. So maybe I'll just make an attempt at summarising what you said, just so we understand here. So we have these serotonergic neurons with the and their cell bodies are in the raphe nuclei and they have an axon which kind of loops back and acts on itself at an autoreceptor which acts as sort of a brake or a self inhibiting mechanism. But then it also extends and acts on the stress circuitry to provide an overall overall inhibitory action on the stress circuitry. Is that sort of.

  Dr Carhart-Harris: [00:19:13] Oh, broadly So. So I mean, you have the cell bodies, the the nuclei deep down in the old brain and they'll express these 1A receptors. When serotonin or a 1A-agonist drug, whenever anyone hears the term agonist, think, oh, that's a drug that's going to stimulate those receptors and they're kind of mimicking the endogenous ligand or, you know, the serotonin itself, the serotonin imposters and they'll so the 1A receptors sit on the cell bodies there. There isn't, the axon shoots off into the rest of the brain, but it's the 1A receptors on these cell bodies and when that's hit, stimulated, it inhibits now this this cell, it's going to release less serotonin. So that's the kind of inhibitory brake on on serotonin release. Is this mechanism is very relevant to how the SSRIs work, because in time this break gets sort of desensitised, it stops working so that the cell bodies continue to to spit out serotonin. Early on when you take an SSRI, activating these cell bodies and stopping serotonin release might relate to some of the irritability and worsening of symptoms that sometimes is seen early on in the in treatment with SSRIs.

  Dr Carhart-Harris: [00:20:45] Now, just to to finish this thread, so here's the cell bodies with their inhibitory 1A receptors on serving as kind of brakes on the activity of these serotonin spitting cells that shoot their axons out to the rest of the brain, into the cortex and into the limbic system. So let's follow an axon now, and it's going all the way up into the brain, maybe into the stress circuitry, into like the hippocampus or something and the serotonin is going to be released from this this axonal terminal. Now, that's going to hit a receiving neuron, also in the hippocampus, because these synapses are, you know, just tiny, tiny little gaps. So here's the the cell body from the from the from the raphe nuclei spitting out its serotonin and here's the receiver and on the receiver you have 1A receptors, the serotonin is released potential you know to bind to 1A receptor here binds, inhibits this receiving cell and the activity in this region drops because the action of 1A stimulation is to inhibit the host cell. So I know it's complex, but that's it.

  Lucy Chen: [00:22:04] Yeah. For sure. And like, I always, my understanding around the impact of serotonin reuptake inhibitors in treatment of depression is this idea that we're, we're down regulating 1A receptors presynaptically so that the cell can release more serotonin in the future, like it's it's not as inhibited. And that's basically like that was my kind of really that's how I grappled on to my understanding was that that's the that's the antidepressant effect of a of an antidepressant.

  Dr Carhart-Harris: [00:22:39] Right. I would say that half of the picture. So you're you're desensitising these breaks, these inhibitory breaks on on the serotonin spitting out neurons so that it can start spitting out more freely. There's nothing inhibiting it spitting out a serotonin so in time that should lead to the cell spitting out more serotonin. And generally speaking, that seems to be good for mood in a sense. So that's part of the picture. The other part is that general increase in serotonin in the synapse is going to lead to more of it hitting these these post-synaptic 1A receptors. So in a sense, you're you're ramping up the serotonin system a little bit with an SSRI, dialling up a little bit the serotonin system but if you were to introduce a drug that worked directly on these inhibitory 1A receptors, you would essentially do the same thing. And that's one thing that people have tried to develop in in, you know, I guess biological psychiatry drug development, is the combination of a 1A agonist, just mimic serotonin and also reuptake inhibition to get that kind of sort of double whammy effect. So yeah.

  Lucy Chen: [00:24:08] Yeah so I think this is a good transition to talk about the 2A receptors um, and more specifically, you know, I'm not sure if this is a good place to start, but there's differential expression of these receptors in different parts of the brain. They seem to be located on higher cortical areas of the brain and so we're kind of curious about that and how that sort of manifests its effect when it's stimulated or blocked.

  Dr Carhart-Harris: [00:24:34] Yeah. Yeah. Well, I'm I'm really curious about that as well, because, I mean, if the listeners have the paper open and they look at Figure One, this for me was really stark, you know, and this, this tells a story. Sometimes a picture says a thousand words, for me that says a lot because we have two maps on the left. You have the in blue or at least the, you know, highlighted frame is blue, is the 1A receptor and where it is in the brain and it's hard to see the raphe nuclei, they're labelled, but you can see the the postsynaptic receptors labelled in kind of the limbic circuitry there. Um, and then look at the 2A receptor on the right and it's very much a cortical receptor. There's not much going on subcortically there, there's not much in the hippocampus really in the amygdala, not much. And yet in the cortex and particularly in association cortex, there's loads of it, loads of this this receptor and this receptor is in my mind, really interesting because of psychedelics and because psychedelics are so interesting. You know, how is it possible to to pin the the action of these drugs that can yield, you know, the most profound experiences of a person's life that leaves them just, you know, struggling to find words to describe what they've experienced. And ad yet we can pin all of that to a large extent on at least, you know, the 2A receptors, stimulating this 2A receptor is the start of all that.

  Dr Carhart-Harris: [00:26:23] I mean, if you block this receptor, you don't trip. It's as simple as that. And so for me, that just screams there is something really important about this receptor because if you want to profoundly alter the quality of conscious experience, you can stimulate, you can stimulate this receptor. So we don't know why and what and you know why it's so critical, but we just know that it is, um, and a lot of a lot of, you know, little clues make sense. Like, you know, if you're going to profoundly alter consciousness, maybe it does make sense that you're perturbing receptors that are expressed in aspects of the brain that are the most developed in our lifetime as the brain develops from infancy into adulthood as well as in phylogeny or the evolution of of the human brain, Um, the expression is particularly high in aspects of, of the brain that are particularly evolutionarily expanded. I find that intriguing. There are some wacky theories about psychedelics being involved in the evolution of, of the human brain and human consciousness. Um, I don't quite buy that, but I'm intrigued by the possibility that the serotonin 2A receptor has played a role. Um, and you know, and then, you know, questions like what does it, what does it do? I mean it's again, there's wacky theories that it's there for psychedelics, maybe endogenous psychedelics like DMT, psychedelics that you can find occurring naturally in the body.

  Dr Carhart-Harris: [00:28:11] But the evidence there is pretty slim. The concentrations of DMT in the body and in the cerebrospinal fluid are really, really low. They spike up during actually during induced death in, in, in rodent studies, but so does so much else, you know, so there's no specificity there. Serotonin spikes right up if you essentially induce a heart attack in a in a in a mouse. Um, and you have the complication of cells dying and spilling out their content anyway, which sort of makes for a murky picture. Um, so I don't think that's necessarily compelling evidence for, you know, endogenous psychedelics being the key ligands for these 2A receptors. I think it's a simple, you know, kind of Occam's razor go with the simplest explanation, I do think they're there for serotonin. But then, you know, what did they do? Well, increasingly, we're discovering that they promote plasticity. They promote synaptogenesis, so the generation of new synaptic connections, functional components of the synapse, the key bit where the communication is, is done in the brain. Um, uh, and, uh, yeah, so it's the especially especially fascinating receptors associated with plasticity and particularly high-level cortex and I suppose high-level aspects of of cognition and consciousness. Yes. Yeah.

  Nikhita Singhal: [00:30:06] Okay. Yeah, it's very interesting just how there are these two different receptors with very different effects. Could you tell us a bit about under normal conditions, what determines where most of the serotonergic activity in our brain is going? Is it mostly involving the 1A receptors or the 2A receptors? And are there different factors?

  Dr Carhart-Harris: [00:30:30] Yeah, I'm glad you asked that question, Nikki, because that's a key component here. If you were to look at where the serotonin transporters are, in fact, this this paper that I got, these maps from Beliveau et al 2016 is worth looking up because it's a kind of nice atlas of of different aspects of the serotonin system are the receptors and also the serotonin transporters. And what you find when you look at the transporter map is that a lot of the transporters, which are kind of like hoovers, you know, hoovering up serotonin from the synapse to kind of recycle it, essentially. Um, uh, these transporters are heavily expressed in the stress circuitry and in the sort of older brain, quite, quite high subcortically and they overlap to a fair extent with, with the distribution of the 1A receptors. Now there's a so for me this is a bit of a clue that the serotonin 1A receptor might sort of dominate the serotonin picture, so to speak, broadly. You know, this question, what does serotonin do in the brain is more dominated by what the 1A receptor does than the 2A receptor. Otherwise, if we tweaked serotonin levels with Prozac or MDMA, we would trip out, you know, and you might a little bit with MDMA, but not really to the same extent as what you do with a drug like LSD. So for for me, you know, it is it's this this sort of stress related, um, um, you know, mollifying, taking the edge off thing, action of serotonin that seems to be mediated by these 1A receptors. Another key consideration here, and I'd love to find more literature on this, we cite something in our paper, but I was really on a quest to find more because it seems like such a critical question.

  Dr Carhart-Harris: [00:32:37] And the question is this what is the what is the relative affinity of serotonin itself for its different receptors? I mean, you might just think it has a uniform affinity. First of all, what's affinity? Well, it's stickiness. It's the binding potential of serotonin for its different receptors. You might just think, well, you know, these are all proteins that recognise serotonin. It's just going to be a uniform thing. Serotonin sticks to them all equally well, but that there's some suggestions that that's not the case. And actually serotonin has a higher affinity for its 1A receptor than its 2A and its natural affinity for the 2A receptor is quite low. And for me that's kind of intriguing because that could suggest that, again, if you're going to modulate serotonin levels with a drug like, you know, Prozac or another SSRI Citalopram, um, uh, you're not really going to have a big impact on the 2A receptor in its, its functioning because if you did, you might feel something more akin to a psychedelic experience with, with those, with those SSRIs and you don't. So that seems to be a key question. And, and there seems to be some evidence that, yes, the affinity of seratonin itself is higher for the 1A receptor than the 2A.The 1A receptor is also very heavily expressed and expressed in regions that have a very dense innervation from those serotonin fibres coming up from the from the, the cell bodies. Um, so again, that that might be suggestive to this principle of the 1A receptor kind of dominating the serotonin picture in a, in a general sense.

  Chase Thompson: [00:34:35] We just want to take a moment here to pause to provide some context for the upcoming discussion. We are about to discuss some theoretical positives and negatives of taking serotonin reuptake inhibitors, as well as classic psychedelics for the treatment of depression. It is important to note that this discussion is purely academic and no clinical decision should be made based upon it. Further to this, we are also not recommending that anyone pursue or undergo psychedelic therapy outside of a rigorously controlled medical setting. One should be aware that there are medical and psychiatric risks from taking these drugs in uncontrolled environments.

  Lucy Chen: [00:35:08] And, you know, you've talked about in your paper that, you know, 1A seems to be a mechanism for passive coping and sort of this degree of like a degree of kind of like release under stress or punishment. And then the 2A receptor having a differential like mechanism by which it causes plasticity or kind of improves the depressed state. So can you kind of talk about, I guess, the bipartite model?

  Dr Carhart-Harris: [00:35:39] And yeah, so, you know, the principle here would be there's multiple roads to Rome. Is that how the saying goes? Or more than one way to swing a cat? You know, you can you can get to the same sort of, you know, end goal by different by different means and and here so you know, what's the end goal? Well, it's an antidepressant effect. You can either take your Prozac for two, three, six months, years, whatever, and it's going to just take the edge off things, help you get through less of the intense anguish that you can see in all sorts of disorders. Or you can undergo a psychedelic experience, maybe just one and first of all, think about how different that that is, the model there, you know, years, I don't know, maybe a thousand administrations ofof your SSRI daily administrations or one versus one potentially one or a small number anyway of a of psychedelic administrations. And so this must be radically different. I mean, if psychedelic therapy, and I'll unpack that in a moment, works for depression then it works in a radically different way. It's got to yet it's working on the serotonin system but the serotonin system is is a chimaera. You know, it's a it's a at least, you know, certainly has more than one face and these faces are radically different to each other.

  Dr Carhart-Harris: [00:37:26] Um, and so and so for me, you know, tackling that in a sense, the less exciting side of serotonin, the one related to taking the edge off things, was something I felt I needed to do to properly understand the system, or at least get a bit of a handle on it. Whereas the other one was more naturally exciting and interesting, the psychedelic side and the 2A side. Um, and for me, you know, I came across these terms active and passive coping and I just found that a really useful phrase, active and passive coping. Here it is, Puglisi-Allegra and Andolina. Yeah and so for me, I was like, well, this is kind of speaking to the principle here. You know, if you're on your SSRI for six months, a year, years, and it's taking the edge off things, you've gone to kind of doctor and said, I'm struggling, I need some help and the prescription comes and in a sense it's quite a classic medical model. It's quite passive: Doctor, fix me, give me, give me medicine, I just need to take medicine, medicine makes me better kind of thing. Sorry for being sort of so kind of simplistic about it, but you get what I mean. Whereas the psychedelic model is quite different.

  Dr Carhart-Harris: [00:38:54] It's, um. You know, Doctor, what have you got for me? Well, let's talk. And I guess that's how it starts. It's like, let's talk, you know, tell me about yourself. You build a relationship of rapport and trust. You get to know the kind of nooks and crannies of the individual in front of you on a much more intimate and personal level to build that rapport and trust. And then you're going to have this huge, I would say, hugely destabilising experience potentially um, that's in a sense the, it speaks to the complexity and maybe the limitation of psychedelic therapy is that the experience can be damn hard, you know, really, really tough and weird, weirdest experience that you might ever have um, at least you're conscious of, um, and can remember, because birth's got to be pretty weird. Um, and, um, yeah, and you're in a state of vulnerability and so, you know, how do we, how does your clinician, your supporter, your guide, your sitter, whatever, therapist, how do they look after you? And so that critical role of the therapist or guide in Classic Model, it's two individuals that are doing the prep work, then the facilitation or support during the session itself and then the integration, the landing afterwards, talking through the experience. Um, you know, as you land, if you follow the arc of the experience from, from prep and then the intense experience itself, then trust the arc, you know, you always come down and then the, the work that's done afterwards to kind of to allow for space to talk through insights that might have arisen during the experience, moments, periods of perhaps cathartic release, crying, sometimes floods of tears, um, sometimes serious anguish, sometimes serious confusion as well.

  Dr Carhart-Harris: [00:41:16] But to allow space for talking through all of that weirdness and wonderfulness and, you know, the richness of the experience is so critically important. And that's why earlier on I intentionally put some emphasis on therapy. So one is a classic medical model. Doctor, what have you got for me? Medication, you know, take your pills and off you go. And the other one is this engagement where, okay, there's some work to be done here. It's drug doing something in my mind and brain, opening it up and now this is ripe, ripe conditions for some deep therapeutic work. So for me, when I came across these terms of active and passive coping, which I think were outside of the context of the serotonin system I think, I have to remind myself, they resonated with this, these different properties of the serotonin system and serotonin drugs, antidepressants.

  Lucy Chen: [00:42:25] So I'm wondering because it's interesting that you're kind of talking about the 2A receptor also in this psychotherapeutic process where there may be like a profound realisation or working through of some past traumatic content. So is that sort of the mechanism of action of certain types of therapeutic processes that are more sort of expressive or they're more sort of exploratory?

  Dr Carhart-Harris: [00:42:51] Yes, there is some evidence that processes like destabilisation can actually paradoxically be a good thing in in psychotherapy. So there's empirical evidence to back that up. So but but this, you know, intrinsically is a more complex model than the much simpler, and this is the merit of the of the classic medical model, you know it's simple. You don't, you know the complexity of human beings and interactions and relationships areare not so much involved. Uh, whereas here you, with psychedelic therapy, you have a model that depends on the therapeutic work that is combined with the drug action. You can't pull these things apart because if you try to you, you can get adverse events and you know, even iatrogenesis meaning things get worse rather than better. So it's the point I always emphasise, you know, not through any sentiment as such, only that sentiment in the sense that it just follows from the science and everything about what these drugs seem to do in my mind is saying they are um, sensitising the, the individual to experience to environment. Um, and therefore, you know, logically, scientifically, one needs to pay very careful attention to environment. And while you can't change the past, you can, you can, um, you can engineer the present and the future to some extent and so you have a therapeutic duty, based on the science and the logic, to do that when you're making someone exceptionally sensitive to environment. And another little qualifier that's important, environment doesn't, in my mind at least, doesn't just mean external environment. There's an internal environment that often we're not aware of, and it runs so deep, you know, because there's aspects of our minds that we are remarkably unaware of, and yet they're revealed under psychedelics. And the psychedelic therapy model is typically lying with your eyes closed. So there's not much, you know, visual input from the environment at all. Yet the experience is so experientially rich and content rich. So where is that material coming from? Well, it's coming from our minds, of course. And so that's just evidence for the the depth and the richness of our minds that we're unaware of ordinarily.

  Chase Thompson: [00:46:01] So it sounds like with action at 1A, we're kind of talking about, you know, an individual learning to tolerate their current circumstances or at least experience less stress in their in whatever they're already doing. But with action at 2A we're talking about kind of like an expansive or neuroplastic type changes or someone really learning to cope with their environment rather than just tolerate it. I guess I'm just wondering because, you know, when we're talking about the action of psychedelics at 2A, do we know that the new beliefs or the plastic changes are always in a more positive direction, or are there cases where it's really not a good idea for someone to undergo that type of experience?

  Dr Carhart-Harris: [00:46:54] Uh, yeah. So. So first of all, um, you know, we can look at the aggregate data, whether from control studies or population studies or observational survey type studies and say, well, at the aggregate level, at the average level, the psychedelic experiences, even actually outside of an obvious context of therapeutic care and support, the outcomes appear to be positive. Now, there might be some, some there may well be some biases in in in data from certain sources, but generally that is a very, very clear picture, you know, large effect sizes in the direction of positive. But that's not to say this is an absolute rule and that somebody could come to have a psychedelic experience and be negatively affected by it. And this is a really critical point that, you know, again, speaks to this principle that psychedelics are not intrinsically healing, in my view. Now, some would even challenge that, but I would sort of challenge them back and say, maybe you're being slightly naive here. Um, you know, most of the time the large majority of uses of psychedelics, people are taking them, especially these days, with some forethought and planning and so, you know, the outcomes are skewed in this positive direction.

  Dr Carhart-Harris: [00:48:30] But I do still emphasise that, um and sometimes I oscillate on it because I could see how this process of breakdown and reconfiguration could could be healthy, you know, or it could be intrinsically healthy, speaking to, you know, a mechanism of a recalibration. You know, you take someone who has, um, crystallised, set into a pathological mode of being, you may well think, well, this isn't working or this, this isn't right so we're going to destabilise and the, the hope I suppose is that you return recalibrating into a healthier state. And, you know, maybe there maybe there is something to be said for for that model but I just think it's a bit of a dangerous model to to have too much faith in that psychedelics are intrinsically healing and sort of work in this sort of resetting way because most of the time and most of the evidence is is backing up, you know, careful intention for the experience and, um, and, you know, directing it in a particular, in a particular way with therapeutic support.

  Lucy Chen: [00:50:10] I'm curious about sort of the longitudinal impacts of like the 2A stimulation treatment model. Like, is it the neurogenesis? Like what is it? What is sort of what is a longitudinal impact of that treatment model?

  Dr Carhart-Harris: [00:50:26] Yes, I'm curious about it, too and I would say we're yet to really have the answers. There hasn't been that much done in the way of brain imaging work, for example, on the longer term changes in brain anatomy and function from from psychedelic use. We have some data that we're processing currently and I suppose the principal, if there is a principal that's coming through, it's that the kind of changes that you see during the experience itself, you will see in the opposite direction afterwards into the longer term. And so for example, if you were to look at our, um, I mean this is limited data to extrapolate from to an extent, but in our depression trial, this is a paper published in scientific reports, we scan people a day after their second treatment session with psilocybin and, whereas, we know now with a high degree of confidence that during a psychedelic experience itself, brain networks break down, they kind of disintegrate. But it's a transient disintegration as the drug effects wear off, they spring back and reconfigure. And we saw this in the default mode network, a network associated with, um, well, actually it's a network that's the regions that make up the default mode network have very high expression of serotonin 2A receptors and it's a network associated with high level cognition, self-reflection, imagination, daydreaming, theory of mind, thinking about the future and the past, mental time travel. So these really high level, arguably species specific, at least to the extent that we do these things, functions, um, is associated with the default mode network.

  Dr Carhart-Harris: [00:52:22] We see it break down under psychedelics and this correlates with the intensity of the psychedelic experience but then a day afterwards, at least, the network seems to spring back and actually the magnitude of this springing back and, and there was a we're not sure how salient this is, but we noticed it, there was a slight expansion in the spatial extent of the default mode network um, one day after the treatment in our depressed patients who weren't depressed when we rescan them, a good majority of them were feeling well. Um, and that actually predicted, that was prognostically predictive meaning that those who were responders out at five weeks later were those who showed this slight expansion in the spatial extent of the default mode network. That's a bit arguably a bit too much detail I would say. But generally the rule is that disorder during the trip and a return to order afterwards and maybe there is a kind of um at least a lot of this is sort of theoretical, but maybe there is a kind of, um, uh, kind of, um, sort of spring cleaning of the system. It, it springs back simpler. Um, there's some of the redundancy has been, has been lost, uh, into the longer term maybe, which might make for a kind of cleaner, crisper style of, of, of being, dare I say.

  Chase Thompson: [00:54:07] It kind of sounds what you're talking about with the psychedelic experience of being broken down and then rebuilding back up, a little bit like the model of therapeutic action that some people talk about, where the goal is kind of integrating a bunch of diverse experiences into sort of one unified whole person. Do you think that that maps on in this case?

  Dr Carhart-Harris: [00:54:35] Well, there's suggestive evidence that that it does. I mean, you know, to many people, this might feel almost, I don't know, it might speak to to the way sometimes people push back about the reductionism of science, where if you were to say, look, you know, these these profound mystical type experiences, these this sense of, you know, mystical union or spiritual union sense of interconnectedness relates to some, uh, you know, alteration in brain function during the experience itself, where, for example, the brain is operating more as a, you know, coherent whole unit. It's more globally interconnected, and you see correlations with that effect and ratings of things like ego, dissolution. Um, it's quite easy to say, ah, you know, those are the neural correlates of ego dissolution and those are the neural correlates of the unitive experience, that sense of profound interconnectedness. Now, if I was really pressed on it, I would say I do actually think that that's, that's the way things are um, but I also acknowledge that that's just one piece of the puzzle um, and there's, there's so, so much more to the story that we've yet to really flesh out um, I would say and you know, part of it is that in a sense we're, you know, inching our way forwards with a model of, um, in a sense, what's lost under a psychedelic experience in terms of the, the usual sense of stability and familiarity of one's self and the world that's lost, um, and that relates to a breakdown in familiar systems that are usually stable in their functioning.

  Dr Carhart-Harris: [00:56:57] But the thing that we haven't yet cracked and for me is the most tantalising sort of next frontier for psychedelic research is how do we explain the more, the stuff that comes in when something is lost? You know, the emergent order, how can we explain these visions of of, you know, seemingly timeless motifs that, um, you know, enter enter our minds um, and so, you know, stark um, or memories that flood back that are felt you know, as if one is re-experiencing something and um how do we explain the order amidst the disorder or the emergent order from, from the disorder. And we're not there yet. And, you know, we've got ideas about how to try and do it. It's going to be how to be a kind of, um, oh gosh, a sort of, we're going to have to capture these things as they play out in real time, and that's a challenge. But yeah, that's the kind of next frontier, I would say. Yeah.

  Chase Thompson: [00:58:23] So maybe I'll just bring us back a little bit to the original model you discussed related to 1A and 2A. Earlier on, you had talked about MDMA being a potent serotonin releaser and with the potential to act on both of these receptors. But I guess the kind of phenomenon you're talking about under a classical to a experience is quite different than what one might experience with just MDMA. Is there a way to explain that or.

  Dr Carhart-Harris: [00:58:57] Yeah. Yeah. Sorry. In the sense that, you know, why doesn't MDMA produce these psychedelic-like experiences?

  Chase Thompson: [00:59:06] Right.

  Dr Carhart-Harris: [00:59:08] Yeah. And I think part of that is that MDMA isn't a direct agonist of the serotonin 2A receptor. It doesn't really have any appreciable affinity stickiness for the 2A receptor. So any action at the 2A receptor that's being caused by MDMA is being caused through its increase in the endogenous ligand, serotonin. So you might think, well, you know, if you're if you're whacking up the the serotonin levels in the synapse profoundly with MDMA and and as I said earlier, you know, MDMA, maybe mephedrone could compete and not much more else, all these things are dose dependent, of course. But, you know, for sheer big release of serotonin, it's hard to beat MDMA, really. Um, and so why doesn't it produce, you know, trippy psychedelic effects? And I think part of the explanation for that is that, well, there's a lot of serotonin receptors and some of them counteract each other um, and you're not just increasing activity at one receptor, you're increasing activity at 1A receptor and the 1A receptor in particular has a counteracting effect to the 2A receptor. And 1A receptors are found in, even though they're heavily expressed in the limbic circuitry, they are expressed in the cortex and they're often co-expressed with 2A receptors. And so the assumption, and there's a little bit of evidence to back this up, Rick Strassman did some related work, um, there's a bit of evidence that the 1A activation, 1A activation say with uh MDMA-induced serotonin release might counteract the the effect of any 2A agonism through the serotonin release. So it's kind of like a diluting, you know, having a diluting effect on what otherwise would be a big trippy effect through the release of serotonin.

  Chase Thompson: [01:01:27] Just in follow up to that, you know, when we are prescribing these medications that promote passive coping, namely, you know, SSRIs, do you think that that limits the individual's capabilities to actively cope in some sense?

  Dr Carhart-Harris: [01:01:44] Maybe. And, you know, it's a dangerous question because of the implications of it, given that millions of people are prescribed SSRIs. You know, you might think on a sort of policy level like, you know, what are we doing? Are we doing a good thing here? And I mean, that's a very complex question because you you know, you have people on the cusp of just complete breakdown and and just turmoil and often suicide and so, you know, if you can get through the initial rough ride of going on an SSRI, this can really smooth things out for a period and help you get through a crisis that otherwise might have led you to do something drastic, like, you know, attempt on your own life. Um, and so, uh, it's a complex one.

  Dr Carhart-Harris: [01:02:44] You know, so but, but, but let's be honest in our opinions, in my opinion um, yes, I think probably that would be the implication that instead of, you know, really getting to the nitty gritty of of, often there's not a clear, obvious solution to why one is suffering, you know, very, very complex, but, um I'm not sure it's helping to, to in terms of insight and self-development, I'm not really sure it's helping to, to actively cope, to, to, to be just smoothing things out with an SSRI. Might help you engage and be willing to go and talk to someone, a therapist and the evidence of the combo SSRI-time-psychotherapy suggests a bit of an additive effect, but not much. It's quite modest. Um, and so, you know, might just get you out of the house and, and so it might just be helping in that respect.

  Chase Thompson: [01:03:51] Yeah, absolutely. And definitely don't mean to suggest to anyone that one way or the other is better that they should seek out one style of treatment. I think it it's a selection issue or who should really pursue each type of treatment at this point.

  Dr Carhart-Harris: [01:04:07] Yeah. Who and when. You know.

  Chase Thompson: [01:04:09] Right.

  Dr Carhart-Harris: [01:04:10] In the throes of, you know, period of real serious turmoil in your life. Is it right to go and have a big, you know, dose of ayahuasca? I'm not sure. Um, so yeah, who and when I think.

  Lucy Chen: [01:04:28] I'm actually really curious about whether people have thought about like developing guidelines for approaching treatment, like in a staged model or stage approach to care, you know, is there a way to determine sort of readiness for, you know, a psychedelic treatment-based modality, and how is that determined? And I wonder about your kind of your study criteria, too, and who you decide to recruit?

  Dr Carhart-Harris: [01:04:54] Yeah. Um. Well, that's something that we're trying to crack. We've been doing these surveys for a long time, collecting data prospectively from people taking psychedelics in the wild, so to speak, you know, whether they're microdosing or LSD in the bedroom or, you know, uh, mushrooms at Burning Man or whatever, or ayahuasca at a retreat. Um, and so for us, there's an advantage in doing that naturalistic work because people are taking the psychedelics in all sorts of novel contexts. So we can look at, you know, set and setting, we can look at, um, how ready people feel simply by asking them, um, and if you do this with a tracker, you know, that's going to capture data before the event as well as afterwards, then you can do that and, and grab more useful data you know. If you try and do it in retrospect, it's always just in retrospect so you're, you're not really predicting things. You need to make your prediction ahead of time or collect the data ahead of time to really predict. But we've made a stab at that. We've got a couple of publications that have tried to predict or do predict response and a lot of our assumptions about set and setting were consolidated by that work. Um, but we're still getting to grips with it and getting to grips with the relative weighting of different factors like for example, emotional support and trust appears to be particularly heavily weighted as a predictor of the kind of experience that you have, which is the mediator of the longer-term outcomes.

  Dr Carhart-Harris: [01:06:48] And so, for example, let's, let's do a quick sort of back of the envelope algorithm here. If you feel, uh, you report feeling ready, there aren't distractions in your life you're ready to do this, you're willing to let go to this experience, surrender to the experience, you're in the company of people who you trust and you feel emotionally supported then these are all, you know, green lights, meaning the these are good signs. These are good signs. Um, uh, now ahead of time, there's not much else, I said a back of the envelope algorithm here, so what what's this going to predict? Well, it's going to predict a stronger chance, not a done deal, but a stronger chance of a of a mystical-type experience, a peak experience if you want to put a more sort of obviously humanistic spin on it, you know, sense of bliss, a sense of interconnectedness, sense of timelessness um, and if you have this, this is another kind of green light or good sign that the longer-term outcomes are going to be favourable. And, and then things can come in, and I would say it's a bit too early to put any empirical data on this, but again, there are strong assumptions about integration, you know, to help sustain the positive effects that you got from the experience. And you know, this great phrase from Jack Kornfield, "After the Ecstasy, the laundry", you know, after the big experience comes the work, you know, the work never stops. Uh, doesn't have to be painful, but it's the work needs to continue.

  Dr Carhart-Harris: [01:08:39] And so I think, you know, very, very simply that's a kind of back of the envelope algorithm that at least, you know, helps us put a lot of emphasis early on, which is critical and that helps me address, I could try and do it briefly, the other part of your question, which is the screening, you know, how do we screen? And I suppose in a sense, you know, in our clinical studies there is a bit of selection bias because we are looking for people where we feel that we've developed some rapport. There is a sense of trust. We're picking that up from, from from the people that we're talking to um, and those are kind of ideal for psychedelic therapy it seems. Uh, but so, you know, people see the results of these small studies and they get very, very excited and think psychedelics are the big breakthrough treatment in mental health and while they may well be, um, also it's healthy to have some critical acumen and think, well, there may be a selection bias in the patients that come into those trials. Um, maybe a bit of confirmation bias. The patients really want to get the psilocybin and believe it's going to work, you know, so well that doesn't mean that, you know, that will never be part of the treatment effect and always is, you know, that positive expectation at least just be conscious that that's part of the vehicle that can that can be producing these really impressive outcomes.

  Nikhita Singhal: [01:10:15] Thank you for that. I think it's really exciting to hear about some of these benefits of possible future therapies coming out and I guess just one more question, coming back to this idea of the receptors. So the 2A agonism seems to be able to induce these very positive changes. I just wonder about some of the medications that we prescribe people for depression that are actually 2A antagonists such as Mirtazapine. How like how can we reconcile the the fact that they may both, 2A agonism and antagonism, have positive effects on depression.

  Dr Carhart-Harris: [01:10:52] Yeah. Again really key question. And that brings us back to the you know many roads to Rome analogy that what 2A antagonism might do. So now we're blocking these these receptors rather than stimulating them um, what that might do is to work more in the direction of passive coping. You know, again, it's sort of maybe anxiolytic, flattening people out, less, less scope for any extremes in emotion. Um, and you know, Mirtazapine is kind of a bit of a sedating medication often I think taken just before sleep and it's it's probably that that that mechanism it also promotes sleep as well so you have deeper sleep so less awakenings and that can be a problem in depression, poor sleep, you know, waking up hyper aroused. Um, and so it's a it's a, yeah a different road to ideally a similar effect, but more just passive coping, taking the edge off things rather than, you know, getting to the, to the root, um, maybe the root cause of the suffering and promoting insight and therapeutic development.

  Lucy Chen: [01:12:18] Um, well, thank you so much, Dr. Carhart-Harris. You know, a goal of our podcast is to not only cover like fundamental key concepts in psychiatry, but also to stimulate curiosity and to create opportunities for depth of understanding and to allow for expansive thinking when it comes to learning about treatments and treatment options in psychiatry. Your article and your ideas most definitely facilitate these values and goals for us, um we truly appreciate your time and your your valuable expertise. Um, I just wanted to know if you have any parting thoughts or ideas to leave our audience who are comprised from a variety of learners, um they're mostly sort of senior medical students and junior residents in psychiatry.

  Dr Carhart-Harris: [01:13:03] Oh uh no, just to say that I appreciate your appreciation. I guess that's why, you know, people like me, write these things and do this work is that hopefully it should inspire others. And so I suppose one passing thought might be improve on this. You know, this isn't by any means the end of the story. It's just everything's iterative in science. So I'd love to see some bright young people come along and take this on to the next the next stage and develop our understanding.

  Lucy Chen: [01:13:35] All right. Thank you so much.

  Chase Thompson: [01:13:40] PsychEd is a resident driven initiative at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Drs Nikhita Singhal, Lucy Chen and Chase Thompson. This episode was audio edited by Chase Thompson. Our theme song is Working Solutions by Olive Musique, and a huge thank you to our incredible guest expert, Dr. Robin Carhart-Harris. You can contact us at psychedpodcast@gmail.com or psychedpodcast.org. Thank you very much for listening. Bye.

Episode 26: Nutritional Psychiatry with Dr. Laura Lachance

• Episode 26: Nutritional Psychiatry with Dr. Laura Lachance

  Alex Raben: [00:00:00] Hey, listeners, it's Alex here. I just wanted to say how excited we are to have our very first episode coming out of Montreal. This episode on nutritional psychiatry was led by Sarah Hanafi. Sarah works tirelessly behind the scenes as our head of research, and we really appreciate all she does for PsychEd. I hope you'll learn as much about this important and often neglected topic in psychiatry as I did. Enjoy.

  Sarah Hanafi: [00:00:36] Welcome to PsychEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. In today's episode, we're going to be covering the topic of nutritional psychiatry. My name is Sarah Hanafi and I'm a PGY2 in psychiatry at McGill University. We're very happy to be joined today by Dr. Laura LaChance, who is a psychiatrist at Saint Mary's Hospital here in Montreal.

  Nima Nahiddi: [00:00:59] My name is Nima Nahiddi, and I'm also a Pgy2 psychiatry resident at McGill University.

  Gray Meckling: [00:01:06] And my name is Gray Meckling, and I'm a third-year medical student at University of Toronto.

  Sarah Hanafi: [00:01:11] By the end of this episode, we're hoping that you'll be able to have a better understanding of how we define nutritional psychiatry, that you also develop an understanding of the mechanisms, common misconceptions, challenges and current evidence supporting the role for nutrition in mental health and finally, that you'll be able to apply this understanding to clinical cases in psychiatry.

  Nima Nahiddi: [00:01:44] So to start off, Dr. LaChance, we're so happy you can be here with us, although here is virtually. Can you let us know a bit about your professional background before we start?

  Dr Laura LaChance: [00:02:00] Sure. So thanks so much, guys, for having me on the podcast today. And you know, I know we were having some scheduling difficulties and Covid obviously didn't help and at a certain point you just need to get on with learning activities, so I'm glad we're able to make this happen. So I'm a psychiatrist. I work at Saint Mary's Hospital, which is a McGill affiliated hospital in Montreal, and my clinical practice right now is in general psychiatry, so I work with patients in the emergency room and the outpatient clinic. I'm also newly the director of outpatient psychiatry here at Saint Mary's and the my focus right now is actually on working in the Mental Health Crisis Clinic so I work with a lot of transitional aged youth in particular through that clinic. So that's kind of what I'm doing now clinically. Um, you know, where does that place me in relation to nutritional psychiatry? So this is my research interest. I graduated from the University of Toronto in 2017 residency program in psychiatry and, as part of my residency I did a fellowship, a research fellowship in the social determinants of mental health and there I focused on nutrition and food insecurity as determinants of mental health. And so that kind of, you know, early on informed my research interest in the field. And I've been doing research in this field since about 2012, I would say. Um, so yeah, I guess we'll get more into specifics. Um, but I'll just add, I'm also doing my Masters in psychiatry right now, so I kind of have a few different hats that I'm wearing.

  Gray Meckling: [00:03:33] Okay. Thank you so much, Dr. LaChance, for sharing some of your background. So I think to jump things off in the episode, we're going to just ask if you could define nutritional psychiatry for our listeners.

  Dr Laura LaChance: [00:03:47] Yeah, it's a good question and there are a bunch of different definitions floating around if you Google it. So what I choose, the definition that I choose to stick with is nutritional psychiatry is basically integrating nutritional approaches into both the prevention and the treatment of mental disorders and their comorbidities.

  Gray Meckling: [00:04:08] Okay. And so that's one question that I had starting this episode, was whether or not the nutritional interventions are really just looking at the mental health disorders or if they're also addressing things like metabolic syndrome that can happen to people who have mental health diagnoses.

  Dr Laura LaChance: [00:04:29] I mean, I think it's both because, you know, you're obviously going to have some side effects, quote unquote, of your nutritional interventions, which are going to be impacts on physical health as well. And we know that our patient population has high rates of metabolic illness, cardiovascular illness, so you can't really separate the two.

  Gray Meckling: [00:04:47] Yeah. And so being a medical student, this was definitely a new field of psychiatry that I've just been exposed to. Could you maybe walk us through sort of the origin or the history of nutritional psychiatry as a field?

  Dr Laura LaChance: [00:05:02] Um, well, I mean, it's interesting because we think that nutritional psychiatry is this new field and, you know, the whole kind of concept of food as medicine is getting a lot of attention and, you know, all the health blogs in the general population and obviously in scientific research as well. And um, when you look at the scientific literature, there are actually a ton, there's been a ton of research in nutritional psychiatry kind of even predating our medications. So I did a meta-analysis of, um, biomarkers of gluten sensitivity in individuals with schizophrenia in 2014 and the reason I mentioned that is because there were research papers where psychiatrists were looking at biomarkers of gluten sensitivity in that patient population schizophrenia back in the 1960s. And so like, you know, they had randomised controlled trials in the, in the standards that were, you know, typical of research at the time where they randomised one psychiatry inpatient unit to a gluten free and a casein free, which is the milk protein, one of the milk proteins that's most likely to cause an allergic reaction. So they had milk free, wheat free, um, wards versus wards that got just like the regular control diet and then they measured psychiatric symptoms and time to discharge, yeah and this is the 60s. And you know, another example would be like Orthomolecular psychiatry, which I couldn't actually put a date on that but the person who most closely comes to mind is Linus Pauling and high doses of vitamin C to treat a number of conditions, including psychiatric conditions. And this is all, you know, really, these are all really old ideas. And so I think nutritional psychiatry was actually popular, um, you know, more than 50 years ago, but is now seeing a resurgence really in the last ten years or so I would say.

  Sarah Hanafi: [00:06:55] It's really helpful to hear that background and get a better sense of what, where or where this field has kind of come from in the past few decades. Um, you know, I know for myself, I've heard of terms like inflammation and the immune system is, is possibly explaining some of the link between mental health and nutrition as well as concepts like oxidative stress and the microbiome gut brain axis. I'm wondering if maybe you could touch briefly on some of the mechanisms we're starting to think are involved in the relationship between nutrition and mental health.

  Dr Laura LaChance: [00:07:37] For sure, and I'll try my best to be brief on these because each one could be, you know, a podcast in and of itself. So when we think about the different mechanisms that underlie the links between nutrition and mental health, before we get into it, I just want to emphasise that it's a bidirectional relationship. So, you know, we're talking today about how nutrition can impact mental health, but obviously the reverse is also a very important relationship to consider, so how having a mental disorder or your mental health can impact your nutrition. And so kind of taking a step back, like thinking about things like food insecurity, how mental health disorders can impact, you know, appetite, how our psychiatric medications can impact appetite and how that impacts eating behaviour. You know, obviously eating disorders is kind of a separate entity that's beyond the scope of today but so just kind of before we get into the science, looking at, you know, nutrition impacting mental health, just recognising that this is obviously complex and bidirectional.

  Dr Laura LaChance: [00:08:37] Um, but so with that, so thinking about mechanisms, so inflammation is certainly one of the, one of the important mechanisms, explaining how nutrition can impact mental health and inflammation is an area of research in psychiatry that's gaining a lot of traction recently. So, you know, a number of meta-analyses have found that there are heightened number, heightened levels of peripheral biomarkers of inflammation, so things like inflammatory cytokines, um, interleukins, TNFs, CRP, you know, those types of molecules in bipolar disorder, in depression unipolar in schizophrenia and we also know that, you know, when we think about the comorbidities that our patients often are diagnosed with like metabolic disorders, cardiovascular disorders, we know that inflammation plays a role there, too. So this is a really important topic and I think for today we're interested in understanding what does diet have to do with this. So try to kind of break it down. So we know there are certain foods or dietary factors that tend to promote inflammation, so those are things like refined carbohydrates, ultra processed foods and also sugar. There are also dietary factors that tend to reduce inflammation so things like vegetables, fruits, fibre, so legumes are examples of sorts of sources of fibre, whole grains, healthy fats like omega-3s or monounsaturated fats and also fermented foods. And so when I'm describing kind of the factors that tend to either promote inflammation or reduce inflammation, I'm describing a dietary pattern that maps pretty closely onto the Mediterranean diet. And, you know, it hasn't been shown yet in psychiatric populations. But if looking at other clinical populations, there's a recent meta-analysis of 50 experimental studies that found that Mediterranean diet can reduce biomarkers of inflammation. So, you know, that's kind of one way of thinking about it as from like a dietary pattern perspective.

  Dr Laura LaChance: [00:10:45] We can also break it down so we can look at, for instance, the balance of omega-6 and omega-3 in the diet. So those are two types of fatty acids that are they make up a minority of the amount of total fat that we eat. But in recent years with, you know, how agriculture and the food processing industry has changed, we've seen really major shifts in the amount of relative omega-6 and omega-3 that we consume today relative to 100 years ago. And omega-6 fatty acids tend to be pro-inflammatory, whereas omega-3s are anti-inflammatory. So that kind of imbalance that we see in the diet is another way that diet ties to inflammation. And then the microbiome is implicated there too but I think I'll save that for a bit later.

  Sarah Hanafi: [00:11:32] Fair enough.

  Dr Laura LaChance: [00:11:33] So yeah, because we'll get to that. There's a lot of overlap.

  Nima Nahiddi: [00:11:38] It's really fascinating, this idea of the bidirectionality between, you know, nutrition and then some of, you know, implications of mental health. Do you think that there's common misconceptions about things that are happening in, you know, mental health and the role that nutrition can have? Maybe things that are in the media or things that physicians might think of that could be common misconceptions?

  Dr Laura LaChance: [00:12:19] Yeah. So the first misconception that comes to mind is the idea that mental health and nutrition are not related, or that somehow nutrition is not important for mental health. And I'm obviously an early career psychiatrist, but I would say earlier in my career, that's the one that I was really pushing up against. And so every time I would give talks or presentations or whatever, it was always kind of like, you know, newsflash, nutrition is important for mental health, whereas now I find that's already become, um, you know, sort of accepted, at least relative to where things were about five years ago. Um, so I'm happy that there's a growing recognition now that food is medicine and that psychiatry is part of medicine, so that one is a little bit less relevant. What I'm seeing a lot now in terms of misconceptions is this idea around helping psychiatric patients to change their diet is not feasible, in some way, or that it's futile. You know, there's always something else that's higher priority than talking about diet and so I have some thoughts about about that if you guys are interested.

  Nima Nahiddi: [00:13:30] Yeah. What is it that that you think is the greatest barrier?

  Dr Laura LaChance: [00:13:34] Well, I mean, we know that nutrition is not a huge part of medical training. So there's definitely a piece around lack of knowledge, um, for like perceived lack of knowledge for health care providers. But I don't think you need to have a graduate degree in nutrition to be able to counsel your patients on diet because, you know, we all prepare food for ourselves and eat every day. Um, so, you know, I think it, I think it's more like some kind of barrier that, that we've put up based on, um, you know, what our comfort level is or what like we learned from observing other clinicians. So, you know, other clinicians aren't talking about food, so, so we shouldn't like, I don't, I don't think that there's, um, I don't think it's anything really more complicated than that. And, you know, I see that we talk to our patients about all kinds of stuff. We talk about substance use, we talk about, you know, finances, their innermost private thoughts, past trauma, their sexuality, you know, everything. And so why why would it not be appropriate to also talk about food?

  Dr Laura LaChance: [00:14:42] And then, you know, when you think about who is best suited to help psychiatric patients to make these often basic changes in their diet, I think we actually, as mental health professionals, have a lot of tools at our disposal to help our patients make behaviour change because, you know, that's what we do, whether it's sleep hygiene, taking medication, you know, engaging in psychotherapy. Um, so I mean, I think we're actually well suited and, you know, often patients are coming to us with like, okay, well what can I do to take care of myself at this early stage while I'm waiting for the medication to take effect? Or families are asking us, what can I do to support my loved one who's struggling with depression? Well, I think actually preparing healthy food for yourself or your family member is something tangible that we can do that gives some direction to families and patients. And I think we have to remember that these interventions are also very safe. So, you know, I talked earlier about side effects of dietary interventions being possibly improved physical health. And so, yeah, I think we need to kind of take that into consideration as well as we're like, you know, waiting for the perfect research to to guide us in terms of making recommendations for our patients.

  Nima Nahiddi: [00:15:52] And being mental health professionals, do you have or can you discuss a bit about some of the research and some of the evidence supporting the role of nutrition in the management of psychiatric illnesses?

  Dr Laura LaChance: [00:16:08] Yeah. So, um so I think it makes sense to probably focus a little bit here just because it's hard to give like a broad overview of everything. But if I take depression for an example, which is a condition that like anyone's going to treat, and it's also the condition that has the most advanced literature in terms of nutritional psychiatry. So depression, so there's at least three randomised controlled trials now of dietary interventions in depression, like clinically significant major depressive disorder, and they're all a little bit different. So one was an individual intervention of a mediterranean diet. One was a group intervention of a mediterranean diet with supplemental omega-3, and the other was basically a video with two five-minute follow up phone calls and some information on FAQs and like tips and recipes. And all three of those studies found that the Mediterranean diet, as compared to a control intervention, significantly reduced depressive symptoms. And so these are these are add-on treatments, I think that's an important point that you know nobody's recommending that you don't offer you know the gold standard treatments that we have but it's just like something benefit something additionally that's beneficial because we don't like you know we don't have 100% remission rate for depression with our current treatments.

  Nima Nahiddi: [00:17:40] And as you said, the side effects, the side effects are or can be safe when it comes to nutritional interventions.

  Dr Laura LaChance: [00:17:51] Yeah, exactly and another sort of piece of literature, so there's, there's been a shift in the field where initially there was a lot more emphasis on studying individual nutrients or individual foods. And then in recent years, to say the last ten years or so, people have been talking a lot more in the literature about dietary patterns and understanding which dietary patterns can either increase risk or decrease risk of depression or be used as treatment. And so a couple of years ago, probably for I don't know, honestly, I think was in PGY2 when I first came up with this idea, um I was wondering okay, so there are these dietary patterns which seem to be helpful for depression, but what are the actual active ingredients here? Like, if somebody wanted to actually design a diet that was going to promote recovery from depression, what foods would be included in that? So I partnered with Dr. Drew Ramsey, who's a nutritional psychiatrist in New York and runs the brain food clinic there, and we conducted a literature review to identify what are the, what are the, we call them "antidepressant nutrients", so which nutrients have the highest level of evidence to support their role in either prevention or treatment of depression? And then we took this list of antidepressant nutrients, and we applied a nutrient density formula and then tried to identify what are the foods that actually have the highest nutrient density of these antidepressant nutrients. And we looked at individual foods, we looked at food categories and the findings were super interesting to me because the foods that came up on top were, you know, leafy greens, seafood, organ meats, other vegetables, fruits and it was really foods that are highly prevalent in traditional diets from a number of different cultures, but certainly foods that are not common in the Western diet. So it was like another, you know, kind of coming at it from coming at the question from a completely different angle and then finding the same answer.

  Nima Nahiddi: [00:20:00] And so do you think with the dietary patterns, you know, we should be looking into making new diets with these types of foods in them?

  Dr Laura LaChance: [00:20:11] Well, not necessarily. I mean, I think what's interesting about the findings is that I think that they could be like the foods that came up on top could be integrated into any dietary pattern that that's fitting with your culture and preferences. So, you know, like seafood came up on top, for instance and like, depending on what your culture is and what your preference is, you could choose different kinds of seafood. I mean, you know within reason, I think it's I think it's reasonable to sort of shift towards, you know, maybe a certain food that may have a higher nutrient density than another, but I don't think anybody, you know, I think compliance would be a problem if you if you try to be too prescriptive with any diet.

  Nima Nahiddi: [00:20:55] Yeah, I can imagine that that would be it would be difficult. Compliance would be difficult with any diet and I think we see that in with a lot of different people. Um, do you have any, any evidence about you talked about omega-3 versus omega-6. Have there been any, any evidence or any studies about those and their roles in the management of mental health disorders?

  Dr Laura LaChance: [00:21:26] Mhm. So, um Omega-3s so again, there's probably the most literature in, in depression, although there's a decent smattering of literature in schizophrenia as well, although probably a bit more controversial. So in depression, if you look to the most recent CANMAT guidelines,so C-A-N-M-A-T, which are the guidelines that we typically refer to in Canada to um, you know, guide us in terms of treating depression, omega-3s are listed there as second line evidence, as either monotherapy or as adjunctive therapy. Um, and the International Society for Nutrition and Psychiatry Researchers published in September 2019 a series of specific guidelines for using omega-3s in depression. So basically what's been shown is that for both bipolar depression and unipolar depression, there's there's multiple, you know, 15 plus RCTs to support use of omega-3s as adjunctive treatment. If you have mild depression, you can start with just omega-3s as monotherapy, so by themselves and it's more important that the omega-3s contain a higher dose of EPA relative to DHA, and those are the two long chain fatty acids that are the most bioavailable and usable by the brain. So you want to look for a dose of EPA somewhere between 1 and 2g, so 1000 to 2000mg and depending on which supplement you're taking, that might actually involve taking more than one of those little gels, so you have to read carefully on the label, but that's the dose for acute treatment. And then if you're more in like a maintenance kind of brain health, then you can then it's okay to use to use lower doses, similar as with medication. We have doses for acute treatment and then doses that we would use for maintenance.

  Nima Nahiddi: [00:23:18] Similar to any other type of medication.

  Dr Laura LaChance: [00:23:21] Yeah. So I treat it as such. And it's the same kind of thing, right? I'll start the omega-3s, you know, assess tolerability at two weeks, think about maximising the dose based on tolerability, wait 4 to 6 weeks to see an effect. You know, same same kind of principles.

  Gray Meckling: [00:23:35] So we've been discussing some of the research around nutritional psychiatry. I think the next section we wanted to touch on was really tie things back to clinical practice. And so I'm wondering if you can take us through maybe a common clinical case that might demonstrate some of these principles. For example, one that I saw in the literature and I'm sure there are many others, would be something like iron deficiency and how that may relate to depression.

  Dr Laura LaChance: [00:24:02] Sure. So so I mean, I can think of a number of cases. So what I'll share with you is probably just like a bit of a fusion of several individuals. But I tend to think of iron deficiency when I see somebody who's presenting with depression, who has decreased food intake for whatever reason, it may be due to their depression itself as a symptom or there may be other reasons like, you know, food insecurity, dietary preferences, they're restricting a bunch of different kinds of foods and as part of our usual workup for depression, we should be doing a CBC. But I think that in certain, if you have certain risk factors, like somebody who's vegetarian, a woman who's of in their reproductive years, you know, decreased intake for another any other reason I always add on a ferritin with that first CBC that I order because you can see early signs of iron deficiency even before the person becomes frankly anaemic. And often when you think about symptoms, often the person's presenting with cognitive difficulties and low energy, right? A lot of fatigue in in context of their depression. And then I'll basically include adjunctive treatment with an iron supplement as part of the treatment. And I'll also counsel my patients around iron rich foods to increase into their diet.

  Gray Meckling: [00:25:34] Right, and so have you seen this play out in any of your patients where prescribing the iron or the ferrous sulphate as an adjunctive treatment has really shown an improvement in their symptoms beyond maybe the standard of care?

  Dr Laura LaChance: [00:25:49] Yeah, I mean, I've seen I've seen it a few times. I've presented a few cases at our clinical rounds, which feels like an eternity ago, which was in April. But one person stands out in particular. She's the young woman with bipolar depression and she she looked kind of iron deficient to me. She just looked so tired all of a sudden and she was complaining a lot of low energy, and it was really a change from her mental status before. And she had been following a diet that was, um, like it wasn't vegetarian per se, but she was really focused on weight loss and so her main protein source was chicken breast and a lot of just like basic salads and stuff like that. So her actual intake of iron is down and she's a menstruating woman and she was iron deficient. And so I added that to her treatment for depression. Um, you know, I would never, like if somebody has symptoms of depression, I would never deprive them from the normal, you know, standard of care treatment. So it's challenging in nutritional psychiatry because you never have the situation where you're just treating somebody with a dietary intervention. Um, but, you know, she responded really well and I could see the improvements in her mental status track with, with her ferritin levels normalising. So I mean it's, it's challenging because you don't really have you know, you can't say what did what with 100% certainty. Um but I have been seeing definitely a pattern in my clinical practice.

  Gray Meckling: [00:27:26] Yeah, that's great. And it sounds like it can be really important to watch out for these nutritional deficiencies or other dietary factors that may be contributing to people's mental health challenges. One question related to this is I'm wondering if you think most psychiatrists are comfortable prescribing these types of dietary or supplemental interventions.

  Dr Laura LaChance: [00:27:53] I think the supplements are a little bit trickier. They're also higher risk. For instance, you wouldn't want to indefinitely prescribe somebody an iron supplement because, you know, you can have toxicity from having too much iron. You know, similarly, if you took four grams of EPA, you know, every day for the rest of your life, maybe you'd be at increased risk of bleeding, for instance. So the supplements are a little bit trickier. So I think we do need to, you know, lean on guidelines, for instance, like the guidelines I mentioned for the omega-3 supplements in depression or looking to clinical, you know, point of care resources like UpToDate to understand how to prescribe iron supplementation for iron deficiency. But I think that the food interventions, I think the beauty of the actual nutritional interventions is that they have such a better safety profile. So really, I think that any doctor, you know, can feel comfortable and I can get into kind of more specifics of how do I assess diet and what do I recommend if that's of interest?

  Gray Meckling: [00:28:54] I think maybe for now we can just put a flag in that point, because I wanted to quickly ask you also about psychotic disorders and if there's any evidence or any clinical cases that you can think of that might relate to diet and any of the psychotic disorders.

  Dr Laura LaChance: [00:29:12] Yeah. So I published a scoping review on that topic about a year ago and so there is there is a very, you know, plentiful body of research on this topic and I think it speaks to the fact that we still don't really understand schizophrenia very well. The treatments we currently have are limited so it's one of those disorders where, you know, pick a theory and somebody studied it 50 years ago because it's just like, you know, we just really don't, we have more questions than answered than answers. But so for for psychotic disorders, I mean, where to start? So certainly we know from observational literature that individuals who have schizophrenia spectrum disorders follow a lower quality diet than the general population and kind of just summarise it at that. There's a large body of research on omega-3s as adjunctive treatment for psychotic symptoms themselves, but also for metabolic comorbidities in schizophrenia. And there are a couple of RCTs that have found that you can prevent weight gain or triglyceride abnormalities in in individuals with schizophrenia treated with antipsychotics by using omega-3 supplements, so that's kind of interesting. In terms of the effect on psychotic symptoms, it's more heterogeneous. So there seems to be more of a signal in early disease that omega-3s can potentially have an effect as opposed to chronic illness that's less clear.

  Dr Laura LaChance: [00:30:46] Um, there are no so there's, there's some, you know, people have looked at probiotics, people have looked at different micronutrients like a bunch of the B vitamins, for instance. In terms of whole diet interventions, so I'm involved in a randomised controlled trial of a virtual care intervention to target diet, exercise and smoking in youth with first episode psychosis. So again, the intervention is, is like it's a compound intervention, it's complex, it has, you know, those three elements. It's not just diet, but, you know, it's an intervention where we follow participants over 12 weeks and we help them make changes in their health behaviours and so I have experience with participants from that research study of just like, you know, experiencing huge changes in not necessarily psychotic symptoms, but mood, energy within a diagnosis of schizophrenia after making dietary changes. Concentration is another big one that comes up, motivation, and so you know we can think about also the comorbidity of depression or of even negative symptoms in schizophrenia as targets for dietary interventions aside from the psychotic symptoms themselves.

  Gray Meckling: [00:31:59] Yeah, that's all fascinating and I think I'll just point out to our listeners that we'll link to the scoping review that you mentioned, and I did flip through some of it, it was very fascinating. So that's, the paper is titled Diet and Psychosis: a Scoping Review, and you can find that in the show notes beneath the episode if you want to learn more about that. There's a lot of great information there. So I didn't have any other questions. I wanted to see if Sarah and Nima wanted to jump in with anything.

  Sarah Hanafi: [00:32:27] Yeah. Um, so I was, you know, I was hoping to maybe tease out a little bit more of your experience in trying to capitalise on this mode of intervention and what might have been maybe some of the challenges you've encountered. I know you've alluded to, to how perhaps the tide is shifting in terms of the interest in the field, but certainly I can imagine that there's still kind of some progress to be made. And the first one that certainly comes to mind is even just obtaining like the necessary workup, is that something that sometimes you face some resistance when you're ordering certain bloodwork or other investigations for your patients or even, you know, consulting, nutrition?

  Dr Laura LaChance: [00:33:13] Yeah. I mean consulting nutrition as a psychiatrist is certainly a challenge. Um, but the, I mean, yeah, I really haven't had very much luck with that at all actually in the hospital setting that I work in. So I do feel like I'm kind of on my own a little bit, which is unfortunate. Um, in terms of the workup, I mean, the workup is the dietary history at this point because there's not so much that you can actually order in terms of blood tests. So like I mentioned, ferritin and along with CBC is something that I order for anyone with depression or anyone who has risk factors for decreased intake of iron. Um, and then, you know, if they're anaemic, we can order B12 but, and or folate, but that's like pretty much it, or you can order B12 if there are other risk factors for B12 deficiency. But we're very limited in terms of what actual lab tests that we can do. So the workup at this point is, is the dietary history. Um, and you know, I'd love to see, um, you know, in Ontario for instance, it was really easy to get what's called an Omega-3 index, which is basically a blood test that measures the amount of, so it gives you the percentage of EPA and DHA that's been incorporated into red blood cell membranes and you can use that as an indicator for people, you know, to identify people who would be preferential responders to supplementation with omega-3. You can use that to target the dose because we have, you know, ranges for what the omega-3 index should be between 8 to 12%. But we can't order that here, I haven't been able to find a private lab that can do it and so that would be really that would be really wonderful.

  Nima Nahiddi: [00:34:54] For you, what would be some of the questions you would ask your patients in order to get key elements of the dietary history?

  Dr Laura LaChance: [00:35:00] Yeah. So it's like really bare bones. So the first thing I do is give people some psychoeducation about the role of nutrition and mental health. So I'll say something like, you know, your brain is an organ just like every other organ and it needs the proper fuels to function and if your brain isn't supplied with the right nutrients, it can't function in the way that it that it needs to. So, for instance, doing things like making neurotransmitters, having your neurones communicate with each other, all of those processes require nutrients to function properly. So then I'll ask people, is it okay if we talk about your diet a little bit in relation to your mental health? Because sometimes people are, you know, they're a bit confused, right? Or they're not used to having mental health professionals ask them about diet.

  Nima Nahiddi: [00:35:38] Yeah.

  Dr Laura LaChance: [00:35:38] So ask permission, give some psychoeducation and then I'll ask people to start about the number and timing of meals and snacks. So how many meals do you eat a day? How many snacks do eat a day? Do you generally eat food at home or are you picking up food or going to eat at restaurants? So just have like a little bit of a landscape, right? So the person who, you know, doesn't eat anything at all until 5 p.m. and then snacks all night is very different from the person who eats three meals and two snacks a day. So that's the first question. Then I go through, I go for like, biggest bang for your buck. So how many servings of vegetables do you eat in a day? How many servings of fish and seafood do you eat in a week? And how many servings of sugar sweetened beverages do you eat in a day? And like that is, you know, I mean, you can often get find targets for intervention right there. You know, lots of people have many vegetables do you eat? One. How much seafood do you eat? No, none. How many sugar sweetened beverages do you have? Oh, just two, you know, so that's kind of a really easy place to start. And then the next question kind of if I have time and people are actually cooking at home, I'll ask them about what kinds of cooking fats do they use in the house and to try to shift them towards olive, avocado or coconut oil if that's something that's of interest to them. And so that's kind of where my assessment. And then as we've been kind of talking about this, you know, people have like even, you know, the somebody with the most basic food literacy, they usually have some idea of something that they could do better with their diet. So even just from talking about it, I'll ask them, you know, is there is changing your diet something that you feel that you could do? You know, what's your motivation? What's your confidence that you could make a change? And then do you have an idea of something that you could change about your diet? And like that, you know, you don't need a nutrition degree to do any of that.

  Sarah Hanafi: [00:37:38] So it sounds like you take almost a bit of a motivational interviewing approach to coax behavioural change.

  Dr Laura LaChance: [00:37:47] Certainly, yeah. Yeah. If it's their idea, they're much, much more likely to do it.

  Sarah Hanafi: [00:37:53] And you know, you mentioned a little bit how your interest in the social determinants of health is part of what led towards nutritional psychiatry. A lot of the patients that we work with in psychiatry are vulnerable and might have limited access to financial resources or other kind of economic resources. I'm wondering if that's a challenge that you've encountered sometimes for patients who may be interested in adopting diet-based interventions or other kind of physical activity changes, but are limited.

  Dr Laura LaChance: [00:38:34] Certainly. So, I mean, one thing is, you know, work with, so collaborate, so, you know, working with our social work colleagues to ask them about resources in the community for nutritious food. There are a lot of different options out there, and we can't possibly know about everything that exists in our environment. So that's one thing is collaborate. Another thought that I have about that is that restaurant food is often much more expensive than food that you prepare at home. So, you know, shifting toward preparing more food at home can often identify a way where you can make an intervention that's cost neutral. Um, I'm currently in the process of evaluating a handout that I created based on the scoping review with one of my colleagues, Dr. Monique Aucoin, about and it's actually Aucoin, not Oakley, I'm not mispronouncing it. And it's a handout that's specifically made for individuals with severe mental illness and there's a section on there about, um, about eating well on a budget. And so certain items like, you know, frozen vegetables or very inexpensive, buying like dried beans and legumes, very inexpensive, um, eggs, another source of complete protein, healthy fats that can be added to many different kinds of meals, many different types of cuisines. So like, obviously there, you know, it's more challenging for sure, but everything else is more challenging also with an individual who is, you know, facing barriers like insecure housing and, you know, substance use and, you know, everything that we see of patients poverty really in general. So, um, I think you just you meet the patient where they're at and you try to make an improvement, you know, in one step. And just because you can't have them, you know, eating a $20 salad from pick a restaurant, um, it doesn't mean that it's not worth trying to make some gradual changes with them.

  Sarah Hanafi: [00:40:35] No and I think I think you make a really good point, too, about those opportunities to collaborate and lean on other members within the team or other resources to support our patients and in making these changes within their life.

  Nima Nahiddi: [00:40:50] All of, all of this has been really fascinating with the discussion on some of these really basic questions we can ask the patients in order to get really important information about their everyday habits and move forward with these dietary patterns and, you know, really get them interacting with us and becoming better clinicians ourselves. Do you see future directions for nutritional psychiatry? Do you have anything in mind as to what's going to be next steps in the field or what's going to be things to come?

  Dr Laura LaChance: [00:41:35] Um, yeah. I mean, so I think this podcast is a really nice next step and examples like it so thank you for giving the topic some attention. Um, you know, I look forward to opportunities for more nutrition education and as part of medical education in general so that we can have nutrition be on our radar as doctors. Um, I think, you know, there's obviously a ton of research to do. We didn't even touch on gut microbiome today, which is a huge, you know, diet is one of the major and most modifiable determinants of the gut microbiome. And I think we're just we're in like we're just in the dark. We don't even understand what a healthy microbiome looks like versus an unhealthy microbiome or what a healthy microbiome is even supposed to produce or how to influence that. So I think that's really going to be a major future direction for the field.

  Nima Nahiddi: [00:42:35] So my my knowledge about gut microbiome is quite limited. Do you mind giving us a quick update on like what's when you say that or like what is the current knowledge on the gut microbiome? Because it is something, you know, you read about in newspapers, magazines and I would think it's something that, you know, we would be interested in developing more knowledge about. But do we have current evidence or what's the current knowledge about the gut microbiome?

  Dr Laura LaChance: [00:43:06] So, so you know, microbiome as it relates to mental health has a number of important functions. Um, mostly so the microbiome is, is crucial in maintaining that barrier between outside of the body and inside of the body at the level of the gut, right? So we have this gut epithelium or intestinal lining which protects the inside of our body from what's in the lumen of our intestines. And if that barrier is not functioning normally, then, you know, toxins from food, bacteria can translocate, bacterial antigens can translocate across the gut lining and get into our circulation, and there they can cause an immune response. And that, you know, when we talked about inflammation earlier and inflammation being an important mechanism in mental illness, the question of where does this inflammation coming from? Well, a lot of people think that it's coming from the gut for exactly this reason, because the gut lining is not intact. So the microbiome plays a massive role in terms of maintaining that gut barrier integrity. It also produces a number of important molecules like short chain fatty acids, but also neurotransmitters directly, so, you know, of obvious relevance. Um, and it modulates the HPA axis, which is our stress system, which is of also crucial relevance to mental health.

  Dr Laura LaChance: [00:44:30] And the gut and the brain are talking to each other. So Sarah mentioned earlier the microbiota-gut-brain axis, and that's a bidirectional means of communication between the gut and the brain, where the vagus nerve is one of the channels of communication but also there are endocrine and cytokine signaling molecules that communicate between gut and brain. So, um, I think like, you know, there's, there's a lot of overlap when you start to dig into these mechanisms but I think what's super important and I think exciting about the gut microbiome is how modifiable it is. And so, you know, you can modify the gut microbiome with, with probiotics, with synbiotics, with postbiotics, with, um, faecal microbial transplant, but also diet is actually coming out as the most potent way of changing your microbiome. So if you change your diet for a couple of days, you can see dramatic shifts in the composition of the gut microbiome. And so I think that's going to, you know, I hope as that field develops, we start to see, um, a lot more attention to, to diet there.

  Nima Nahiddi: [00:45:35] It's really fascinating.

  Dr Laura LaChance: [00:45:37] I mean, it is and it's just like it's a whole other, you know, like layer of complexity to apply to the physiology that we already understand about our bodies. So it's hard to even wrap your head around it. But we have now we've got at least five randomised controlled trials in depression of probiotic interventions. We've got one in anxiety, we've got two in schizophrenia and like I said, it's early days because I don't think we know what a healthy gut microbiome even looks like, so I don't think we know which kind of probiotic to prescribe. So my response to that clinically right now is we know that you can support a healthy gut microbiome by avoiding things that damage the microbiome, like ultra processed foods and sugar. We can support a healthy microbiome by providing our gut microbiome gut microbiota with lots of healthy food, which is fibre, right, another another word for it.

  Nima Nahiddi: [00:46:29] Yeah.

  Dr Laura LaChance: [00:46:30] Um, and then we also know that we can consume fermented foods directly so we can eat things like yoghurt, kimchi, sauerkraut, whatever, kombucha, if you will. Um, and, you know, those are all sort of safer things that, you know, are actually probably more cost effective than probiotic supplements anyways.

  Nima Nahiddi: [00:46:52] And it's nice that even though, you know, it seems that we're at the tip of the iceberg for, you know, what we know about the microbiome, there's still a lot of things clinically that we can recommend to the patients.

  Dr Laura LaChance: [00:47:05] Yeah. And I mean, there's a lot of convergence, right? We've been talking about anti-inflammatory diets. We've been talking about supporting a healthy microbiome and, you know, having lots of fruits and vegetables like, the Mediterranean diet is essentially a template that everything kind of converges in that direction. And I realise that not everybody on the planet is going to consume a mediterranean diet for various reasons. But you know, it's rich in fruits, rich in vegetables like beans, legumes, whole grains, you know, fermented foods, healthy fats, not refined carbohydrates, not sugar. And those are really just like, I think, take home points at this point.

  Gray Meckling: [00:47:43] Well, that was great to touch on all those future directions. And I for one, I'm grateful that we've had such an expert on the topic to to chat with, and we can count on you to sort out all of these research questions. The last topic we wanted to touch on was just if you had any tips or advice for for someone who's maybe in medical school or early on in their residency who is interested in nutritional psychiatry, where they can learn more or how they can get involved.

  Dr Laura LaChance: [00:48:12] So there is a society that I alluded to that's called the International Society for Nutrition and Psychiatry Researchers, and it's actually probably 50% researchers, 50% clinicians. But they have an absolutely fascinating conference every two years and it just happened in 2019, so it'll be 2021 in Vancouver, actually. Um, and if anyone's interested in learning more about the field, that is where the experts are. It's a group of about, the last conference was about 200 people and it was like, you know, I felt like I was, you know, in Hollywood, like seeing all the stars. And, you know, it was so that's something that I would strongly recommend to anyone who's interested in the field because you'll get the the most kind of cutting edge knowledge. Um, I mean, if anyone, like anyone at McGill who's interested, please reach out to me, I'd love to chat with you and like, you know, we can definitely talk about it. So you're welcome to share my contact info in the show notes also. There's a Food and Mood Centre at Deakin University that was created by Dr. Felice Jacka, who's probably the, um, she's probably the most, I guess, famous researcher in the field. She's the person who actually started the society and she's like kind of the mother of modern nutritional psychiatry, I guess. Um, and so it's called the Food and Mood Centre at Deakin University in Australia and they have a course on food and mood that's free on, through FutureLearn and so if you're wanting to learn more as a clinician or just as a person who is interested in making healthy changes to your life, that's a good place to get really high-quality information. Um, and you know what I would say if anyone's interested, I mean, read broadly and start talking to your patients about their diets. I don't, you know, I don't think we need to wait for that.

  Gray Meckling: [00:50:06] Yeah, that sounds like great advice and we'll definitely link to some of those resources in the show notes so thank you for sharing all of that with us. I think I'll hand things off to Sarah now.

  Sarah Hanafi: [00:50:17] Yeah. Thank you so much, Dr. LaChance, for joining us for this episode. You know, I think I can speak for our listeners in saying that maybe the takeaway, the takeaway from all of this is that nutritional psychiatry is something that's actually quite accessible. It's something that, you know, in speaking with our patients, we can quickly ascertain opportunities for intervention by not only trying to to work with our patients and meet them where they're at, but also work with our colleagues and finding and facilitating access to to resources. So I think that that gives me a lot of hope as a trainee that I feel like a little better equipped to address some of this when I'm caring for my patients. So we really thank you for your time and for our listeners, keep an eye out for the show notes. We'll make a point of linking many of the the useful resources that Dr. LaChance mentioned today. Thank you.

  Dr Laura LaChance: [00:51:16] Thank you.

  Alex Raben: [00:51:26] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sara Hanafi, Dr. Nima Nahiddi and Gray Meckling. The audio editing was done by Dr. Alex Raben. Our theme song is Working Solutions by Olive Musique. A very special thanks to our incredible guest, Dr. Laura LaChance, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org. As always, thank you for listening.

Episode 25: Understanding Attachment with Dr. Diane Philipp

• Episode 25: Understanding Attachment with Dr. Diane Philipp

  Lucy: [00:00:10] Hey there, podcast listeners. It's Lucy here. I hope everyone's well today. I'm excited to be remote co-hosting this episode on Attachment theory. Hopefully this audio quality is sufficient despite this remote recording. We have two new guests with us today. Firstly, I will introduce Chase Thompson, a PGY2 psychiatry resident who will be co-hosting with me. Fun fact I actually met Chase on an emergency psych call shift at CAMH. And basically we plan to collaborate on the episode and and here we are. So, Chase, can you just tell us a little bit about yourself and any of your interests?

  Chase: [00:00:54] Hi, my name is Chase. I'm a PGY2 in psychiatry here at the University of Toronto. I'm originally from Calgary and moved to Toronto for psychiatry residency. Recently, I became interested in attachment theory after doing some work with our guest, Dr. Diane Phillip, and I'm excited to explore that a little bit further today.

  Lucy: [00:01:16] Thanks for that Chase. And our expert today is Dr. Diane Phillip, who is a child and adolescent psychiatrist at the SickKids Centre for Community Mental Health in Toronto. And she's also assistant professor at the University of Toronto. So she's developed a family therapy method called Reflective Family Play, which is a model of therapy which aims to improve parent child dynamics and more specifically, attachment. She currently practices reflective family play and also teaches this method locally and internationally.

  Dr. Diane: [00:01:49] I'm really excited to be here today talking with you guys about attachment theory.

  Lucy: [00:01:53] All right. Awesome. So today we will be exploring a key foundational concept in psychiatry, which really informs a great deal of what we do in the scope of formulation and psychotherapy. This is such a backbone framework in theory, and I think having this understanding will also set us up well for future episodes on different psychotherapeutic modalities and other areas of psychiatry. So I hope I mean, our hope is to sort of cover the following learning objectives. It's kind of loaded, but we will do our best. So firstly, we will define attachment and attachment theory. I think that this would be a great place to start. Then we will review some of the history of attachment theory and how the field developed. We'll touch on the evolutionary basis and the functional role of attachment in infants. We will also review some of the neurobiological perspectives of attachment. Well, of course, look at the different types of attachment and attachment disorders and how infant attachment is assessed. And hopefully we'll will also have a little bit of time to also explore how adult attachment is assessed and how attachment disorders impact adult relationships and child rearing. So that's a lot. So I think we should get started. So why don't we explore this first question. So what is attachment? Is it a noun? Is it a verb? What is attachment? What does attachment theory?

  Dr. Diane: [00:03:32] Sure. And it is confusing because there's the English language that uses the word attachment to mean a whole bunch of things. And there's pop culture that has come to adopt attachment theory and kind of morph it in ways that it never was intended for. So in its purest sense, when we talk about attachment, we're talking about a specific bond that an infant or child has towards their primary care giver or primary care givers. And so I should also specify that this particular bond has to do with when the child is feeling insecure, threatened, unwell in distress, and they seek security or they seek comfort or protection. So it's a drive to seek comfort or protection with a primary care giver.

  Chase: [00:04:24] Thank you, Diane. And attachment, it's it seems to be kind of this specific phenomenon that has been observed. And I'm just wondering where the first observations of this behaviour in infants came about and how it became a recognizable phenomenon with within psychiatry and psychology.

  Dr. Diane: [00:04:45] So there. In the history that we tend to talk about. And the first is john bowlby, who was trained in psychology. He was and went on into medicine and became a psychiatrist and a psychoanalyst. And he observed children and observed. Okay children who were in more challenging and marginalized situations and started to develop this theory also influenced by mythologist Konrad Lorenz, who was observing other species actually. And so he came up with this idea of attachment and that this idea of infants and children seeking security from a primary caregiver. And he saw this really as a primary human drive, just like the drive for food and sustenance or the drive for sex and procreation. And his theory was also that which we often forget, is that infants and children seek security from their attachment figures in times of distress. They're then free to explore their environment. And so there actually he talked about two poles for attachment, the pull of security and comfort seeking when the attachment system is what we call activated. And so they're activated to try to find a secure base. And then they are able to explore when they're on the other pole, the other end of the continuum, they're able to then explore their environment. And so that's that's Bowlby stuff in a nutshell. And then we flip over to somebody else, a colleague of his, Mary Ainsworth, who is actually studying mothers and babies in Uganda and getting some of her own ideas around attachment behaviour and attachment security seeking in infants in that setting. And she came back and created this laboratory setting called The Strange Situation, where she actually created a model or a paradigm where we have been able to measure or define or categories infants and toddlers into categories of attachment. And we can talk, I'm sure we will more about those categories as we go forward in this discussion.

  Lucy: [00:07:09] Yeah, thank you for that. I mean, it's so interesting. I mean, that's why I kind of asked about is attachment sort of like a verb. I mean, it kind of seems like an impulse, like a basic instinct for survival. And that's where I kind of see this strong sort of evolutionary basis for attachment.

  Dr. Diane: [00:07:27] Absolutely. And it makes sense from an evolutionary perspective. And certainly Bowlby spoke about this and others have, too, that it makes evolutionary sense that we're not the largest or the strongest, but perhaps we're the smartest species on the planet. And these kind of prosocial behaviours that we have our ability to communicate and our ability to signal our distress and get comfort from our parents is a key thing that perhaps put us at a survival advantage from an evolutionary perspective. And so, yeah, it's this biological drive within us that may have been selected for as something that increase the probability of the infant surviving infancy because infants, infant mortality rates historically have been extremely high. So if you are an infant that is able to let your caregiver know, hey, there's a problem, I'm not well and there's something threatening happening to me, this is scary. And then your caregiver picks you up and you are soothed and comforted by that. Well, that's also rewarding for the caregiver. It's a really clear communication pattern that has a nice cycle to it for the for the parent and the child.

  Lucy: [00:08:46] Yeah, for sure. Like, I feel like a lot of this overlaps with what I've been learning through the trauma therapy program and women's college, where I'm doing an elective. You know, I think everyone knows about, you know, fight or flight as, you know, survival responses. But I've also learned about attach, cry and also freezing. But like attach cry. I forgot that that's sort of like it's definitely a protective measure as a means for survival. So that kind of maps on to what you've been saying. I guess next, what I'm kind of wondering about is exactly like when does attachment develop? Like does it begin in the womb? I guess more so curious about how attachment develops?

  Dr. Diane: [00:09:29] We believe it develops sort of over the course of the first six months of life. It's starting to develop. And then by when it became measurable in this this laboratory setting that Mary Ainsworth developed was around 12 to 18 months when she created this thing called the Strange Situation. But we believe it's developing all along through the first year of life. And there have been others who have actually done modified strange situations with much younger infants and seen kind of the precursors of some of the attachment behaviours. But it isn't until a child is 12 to 18 months old that they're able to either crawl or even walk and so give a really clear indication of their attachment behaviours. So I don't know if it's okay for me to digress a little bit and talk about the strange situation.

  Lucy: [00:10:20] Yeah, please digress.

  Dr. Diane: [00:10:23] So this is the thing that Mary Ainsworth developed, which was in the lab with infants and their mothers at that time who and the infants were 12 to 18 months old, and it's this increasingly stressful situation. So these were just community volunteers, mother baby dyads, and they brought them into the lab and they came in and they played with some toys. It was a new playroom situation for the infant. And then at a certain point, this friendly but unknown other woman comes into the room and at first she's not interacting with the baby. She then starts to interact with the baby and then they get the mother to leave and the baby is left alone with the stranger. Then a stranger leaves and the mother comes back. And with these increasing levels of stress, the baby obviously reacts to, or most babies react to the stressful situation. And then what ends up happening in the classic strange situation is everybody's left him or her. And then the mother returns and the behaviour of the baby on the return of the mother is then coded by independent coders in a way that can then categorise the baby. So a majority of the babies, somewhere around 65%, let's say, will do this thing where they they make a beeline to the mother. And that's why, as I mentioned before, you kind of want a baby that can crawl or walk so that they can make this beeline towards the mother and sort of letting the mother know I'm in distress, pick me up. Mom scoops the baby up, and within a relatively short period of time, the baby settles to the point that they are able to return to play, although there's usually this sort of guarded play for the next couple of minutes and then full rapprochement of the relationship to more back to baseline and those that what I just described that sort of distress beeline soothing bit guarded and then back to baseline is what we describe as. As a secure pattern in an infant or preschooler. And then there are these two different insecure patterns that we see, which is still considered attachment behaviour, but it's considered insecure, avoidant or insecure, ambivalent, resistant. And about 15 to 25% of babies will be insecure avoidant. And what their behaviour looks like is Mom comes back in the room after we've had lots of comings and goings of the stranger and the mom and the baby's now been left alone and mom comes back in the room and baby kind of sees them. First of all, baby doesn't show as much distress.

  Dr. Diane: [00:13:07] Outwardly Baby sees mom and seems pretty calm when Mom returns and we don't have that same distress kind of pattern with these insecure, avoidant babies that are still attached. But in this kind of avoidant of big dramatic displays of distress and then the insecure, ambivalent resistant babies, which is about 10 to 15% of babies in these studies, have more of a pick me up, put me down, stay distressed much longer kind of pattern compared to the secure babies. And then there was this fourth category called Insecure, Disorganised, and these babies were categorised as disorganised because their behaviours looked disorganised. We now recognise their behaviours as quite organised, but not they're more atypical and they are more not in the service. They don't seem to be as coherent with the idea of getting proximity. They the child may freeze the some of them may crawl backwards. They do bizarre things that don't seem to have that same goal of trying to get closer. So I should come back to the kids that are insecure but attached. Sorry, they're all attached but insecure attachment styles of avoidant and ambivalent resistant. Those babies have learned a strategy. All of the babies have learned strategies for maintaining proximity to the caregiver.

  Dr. Diane: [00:14:39] In particular, these these first three categories that I described, the secure ones and the two insecure ones, these are strategies that they have learned through the course of that first year of life to maintain proximity to their caregiver. Because, remember, the goal here is to stay safe and this biological drive, to stay safe, to stay close to the caregiver so that the caregiver can protect me and comfort me and deal with any distress that I might have. So if I've learned that my caregiver kind of the best way to keep my caregiver near me is to be is is to signal I'm in distress, I'm unhappy. I've developed what we call this internal working model that my caregiver is going to be there for me to comfort me when I'm in distress. But I may have a different internal working model that my caregiver kind of doesn't want me to make such a big fuss. So I'm not going to make such a big fuss because that's the best way to keep my caregiver around. That's the avoidant strategy, and the ambivalent resistant one is more sort of a push pull kind of relationship with the caregiver. But I'm going to pause there because I think I've talked a lot and maybe have some questions.

  Chase: [00:15:53] Yeah. So that's an interesting point about the infant wanting to keep their caregiver around as much as possible. I guess that sort of implies that parents respond differently to their infant's distress cues. And I'm wondering. Parental style that would lead to an infant developing an avoidant attachment style, and then also maybe an ambivalent or preoccupied style. And maybe you could describe what types of behaviours would lead to that.

  Dr. Diane: [00:16:22] Absolutely. So we know from research that actually the parents attachment style and that's a whole different discussion that you may or may not have already had with somebody else on this podcast. But parents attachment style or adult attachment style can be categorised into very similar categories. And so parents who have a secure attachment style tend to have what we call good reflective capacity. So they have a good sense of how they're feeling, but they also have a good sense of how their infant is feeling as distinct from them. And they can flexibly consider a number of hypotheses about what might be going on for this infant. Oh, maybe he's not feeling well. Maybe she's cutting a new tooth. Maybe they are feeling scared because we're in a new situation. Maybe they've got gas. So they come up with a they have what we call cognitive flexibility around what might be going on for their infant. And that cognitive flexibility allows them to really pay attention to the infant's cues and respond in a sensitive and attuned manner. The parents who are who have insecure infants typically are parents who have an insecure attachment style themselves, and they have less of that good reflective capacity and less of that cognitive flexibility. So for them, the infant cries and they might think, why is he doing this again to to bother me or and that's the only only understanding they have of their child's behaviour is that they're just doing this to bug me or, you know, she's just she doesn't actually have a problem. She's just a drama queen. And that's the only explanation that parent has of what's going on for the child. They're not able to come up with a bunch of different hypotheses and so they respond insensitively or in a less attuned manner. And that comes from their own inheritance of of an attachment pattern that they have perhaps with their own primary caregivers.

  Chase: [00:18:35] Yeah. So it sounds like what you're talking about, in a sense, it's the attachment style of the parent is kind of passed down from parent to child in the way that they're able to discern what's going on in their own infant and Attune provide some sense of attunement to their own infant's needs. I guess I'm wondering in that in the disorganised infant, it sounds like the infant doesn't really have an organiser consistent approach to the caregiver and what kind of behaviours from the caregiver would lead to that sort of style?

  Dr. Diane: [00:19:11] Yeah, they're a very interesting group and probably a group that is way overrepresented in my clinical population and what we know from work of folks like Dr. Karlen Lyons Ruth, who actually took the same strange situation and looked at parental behaviours on that reunion moment and in particular looked at these, these disorganised infants, is that those parents were frightened or frightening. So you can imagine that you're in distress, you're an infant and you're in distress and you look to your parent to help you with your distress and your parent either appears frightened by your behaviour or frightening. Neither of those responses from your caregiver are going to help you feel contained in your distress. And so those infants are the ones that have a more disorganised pattern. There. Typically in these dyads, there's a history of some sort of unresolved trauma or loss in the in the parent or the caregiver who who gets distressed by their child's distress.

  Lucy: [00:20:34] So thank you for taking us through each of these different types of attachment styles. And I guess I wonder about like, you know, do these attachment styles, are they sort of like fixed? Or is it possible to learn a new attachment style? And I guess I'm thinking about orphans or or children who are who go from one foster home to another. I guess is it possible to learn a new attachment style? And I guess when is it best to kind of learn a new attachment style during childhood? Or is there a specific age range in which it's it's sort of optimal to teach a child a new attachment style?

  Dr. Diane: [00:21:19] So obviously we're very interested in this because we have this population often of infants who have gone through pretty, pretty high risk situations when they were quite young and supposed to be forming these attachment relationships and. I guess there are two. The good news is all hope is not lost. And the bad news is, yeah, these it can profoundly impact you and set you up for a higher likelihood of psychopathology and just poor outcomes in general, both in terms of health, academic and mental health outcomes if you've had this rough start to life. So the earlier a child is the adoption studies where the kids were in, particularly in deprived orphanages back in the nineties, there was a lot of research on those those kids. The earlier the child is adopted, the better, the better the orphanage situation was, i.e. that there were primary care givers instead of a rotating random array of caregivers, the better the outcome. But there's actually been more recent research on adoption and that you looking at particularly actually doing these adult attachment interviews with adoptive parents around the time of adoption and looking at outcomes in the kids and securely attached adoptive parents have a much higher likelihood of having even later adoption kids end up with a secure attachment and better outcomes than parents, where in particular the mother has an insecure attachment. And the worst case scenario is when both parents have an insecure attachment. So yeah, all hope is not lost in a good foster home or a good adoption. There is some very promising, not a ton of data, but some promising data that you can shift the attachment relationship or the attachment outcome for the child. So that's that's one area of data. And the other area of data is treatment. So you can also do work with kids who are in problematic attachment dyads but have not been removed from their home or adopted out. And treatment can also shift an infant or a child towards greater security.

  Chase: [00:23:51] So it sounds like, you know, even infants who are in a more marginalised home at the beginning can shift their attachment style to from maybe insecure to secure what do parents, adoptive parents or even just parents in general, what do they actually do with their infants to create a secure attachment? And how is that actually what does specifically that look like in terms of the parent child interaction?

  Dr. Diane: [00:24:23] Right. So in the adoption population, if you've got a parent who's already got a secure attachment, they have these models of internal working models in their mind of what relationships should look like. They have good reflective capacity, meaning they have a good sense of this is what I'm feeling, this is how I'm reacting and this is how I imagine my child is feeling and how my child is reacting to me in this moment. And maybe I'm going to. And they're able to adjust and sensitively attune their behaviour not 100% of the time, because that'd be just weird to be 100% of the time attuned to what somebody else needs because we're not psychic. It's more that they have a sense and they're able to keep doing that. That dance of attunement, where they're, they're shifting their behaviour to meet the needs of their child. And through that relationship, this child who's come from a more high risk background, who's been adopted into this family with securely attached parents, is going to to shift their internal working model of what relationships should look like so that rather than adults being frightening or frightened all the time and unpredictable and erratic or withdrawn and unavailable, they they now have multiple instances where these securely attached parents are responding in this much more predictable, much more sensitive and much more attuned way.

  Dr. Diane: [00:25:53] So that that would be the the good enough foster home or the the good enough adoptive parents. And the data is looking like part of it is a securely attached parent can can help shift that child in treatment. It looks a little bit different because you're taking the parent who perhaps has their own insecure attachment and you're working with them in in in the relationship with their child and trying to help them to shift from what I was describing earlier, this cognitive rigidity. So the work with those kind of parents is to help them broaden their understanding of why else might your child be having a tantrum when you. Make him stop playing his video game and come to the table, or when you move too quickly and decide to transition him to a new activity that has nothing to do with devices and you start helping them. Then consider what else might be going on for their child as opposed to this one hypothesis that they have.

  Lucy: [00:27:00] You've been speaking a lot about, you know, I guess, how you would respond to a patient or to a parent maybe in the scope of the work that you do. So I'm kind of wondering about the type of therapy that you specialise in and how attachment informs the way that you do that form of therapy. And how might you respond to parents with with approaches that might be informed from their own attachment styles?

  Dr. Diane: [00:27:29] So at our centre we do a therapy called Watch, Wave and Wonder, which there was an RCT that looked at attachment security actually pre and post treatment, and it was found to shift the infant and preschoolers attachment towards greater security. But there are lots of attachment based therapies that do similar work. So Areal Slate has this program called Minding the Baby and the folks in some folks in the UK, Anthony Bateman and Peter Fonagy have mentalization based therapy and all of these therapies are sort of geared towards helping people who struggle with being able to view to people who struggle with being being able to keep the mind of somebody else in mind with being attuned and sensitive with that people who struggle with that cognitive flexibility and have very rigid ideas about why others behave the way they behave, or or no interest or curiosity about why others behave the way behave. So people with more avoidant attachment styles who tend to have infants, who have avoidant attachment styles, they're less curious about the minds of others and don't really take them into consideration. And that can be problematic too. So when you're working with the parents, it's actually all of these different types of therapies. We we think about the parents attachment style quite a bit because that tells us how they're going to approach their child. And so if they have cognitive rigidity or no curiosity about what's going on in the mind of others or no ability to even imagine, imagine what might be going on or motivating their infant going on in the mind of their infant or motivating their infant to behave the way they behave.

  Dr. Diane: [00:29:24] The work is in trying to help them consider other possibilities. And in the infant and pre-school population, we really use play quite a bit, whether we're more directive and behavioural in our approach or whether we're more exploratory. An insight oriented play actually usually forms a significant portion of each session in the infant pre-school population and the idea is through play, you're able to help the parent become more sensitive and attuned and thinking about what might be going on for their infant as somebody separate and different than themselves. Who who's impacted by your behaviour and plays a very non-threatening way to work with parents. But they're often able to generalise from these play moments to other moments in their life that are not so non-threatening. And the other thing that happens typically we do watch wait and wonder interaction guidance, some mentalization based work and reflective family play, all of which have this play component and then discussion about the play. And while it's supposed to be play most of the time, some of the time kids have tantrums, kids have challenging moments with their parents. Kids refuse to play with their parents. Well, what do you think might be going on for your child right now and start getting them to exercise that reflective capacity muscle that there isn't just one thing or nothing that motivates us. There are lots of things that could be going on that that can explain a child's behaviour.

  Lucy: [00:31:04] You know, I guess you've already talked about, you know, parents with different attachment styles themselves, and this makes me kind of wonder about the trajectory from each of these attachment styles. What does it look like when there is no intervention? And, you know, they these types of attachment styles persist into adulthood. How does it affect their interpersonal relationships or how do they how does it affect their work? And I'm wondering, without intervention, how these attachment styles manifest in adulthood.

  Dr. Diane: [00:31:35] So there's a lot of evidence that children who have a secure attachment when they're infants or preschoolers are going to go on to have much more positive social and emotional competence. I think I mentioned they're just it's kind of a win win situation when you have a a good working model of what relationships could look like, that people can be trusted that when you're in distress, somebody is going to comfort you. You it has a good outcome for lots of different measures that have been looked at from cognitive functioning, physical health and mental health. And the inverse is the case for children with insecure attachments. They're more at risk for negative outcomes. It doesn't mean you're actually going to have a negative outcome, but they are more at risk for those negative outcomes. And then those who have the disorganised attachment style are at much greater risk for psychopathology.

  Chase: [00:32:35] I guess going back to what you've talked about briefly in terms of adults who have a secure attachment style, are able to foster that sort of secure attachment with their infant who may go on to become securely attached in general. Is there any sort of other psychopathology which would get in the way of a parent developing that attachment with their child outside of their own attachment style?

  Dr. Diane: [00:33:08] Sure, absolutely. If the parent is psychotic or abusing drugs, then their ability to be sensitive and attuned is going to be problematic, even if they're super stressed. And I do actually worry about parental use of devices and its impact on attachment, because parents who are on their devices when they're with their children are can't be attuned and sensitively responding. And there's actually a lot of very concerning data coming out of a number of sites, looking at parental use of devices and increase likelihood of children acting out, increased likelihood of the child actually getting a device to use to but increased likelihood of problematic interactions as parental device use just in naturalistic studies. Actually one coming out of Ann Arbour, where they were just observing parents and kids and the children were more likely to get into trouble if they were if the parents were using devices more. So I do worry about that too. But coming back to your question, Chase, about psychopathology for sure, substance abuse, psychosis, severe depression, where the parent can't really pull it together to be attuned and might actually appear frightening to the child is going to have an impact. There's also a goodness of fit. So there has been a lot of research on temperament, which is kind of the wiring of the child and how easily they can be soothed and how calm they are and how easily they adjust to a schedule and new situations which seems to be biologically driven.

  Dr. Diane: [00:34:57] The problem with the with temperament research is it's it's questionnaire based and where you're giving the questionnaire to the parents to describe their child. So it's a bit relational. So you have to take that with a grain of salt. But what I take from it is this idea of goodness of fit. So if you have a child who is temperamentally really challenging, not sleeping well, not settling easily, not easy to soothe and you're secure, but maybe not the most secure because secure attachment, again, is on a continuum. You might not be the best fit for that child, and you may respond in such a way that is not as sensitive or attuned because it's not a great fit because the child is a little bit more challenging. That being said, you can have a child who's temperamentally really easygoing and you put them in the wrong situation. They're going to end up insecurely attached because they're not getting their needs met because all infants and children are going to have needs, even the most easygoing ones.

  Lucy: [00:35:57] And that's great. I mean, I think we've talked a lot about different, different types of attachment. And I guess in an extreme sort of case, I'm also curious about detachment or what happens to a child that does not attach to an attachment figure.

  Dr. Diane: [00:36:12] It's extremely rare and it's in these rare situations. So most children attach because it's a survival thing, right? It's just whether they attach securely or insecurely and even the disorganised ones, one can construe them as having an attachment, a bond as well with the caregiver. Despite the maltreatment or bizarre behaviour of the caregiver, children who are removed from the situation, if if they had a good enough attachment with the primary caregiver that they lost, they may suffer, they will suffer and they may be more prone to things like depression and they may show lots of signs of distress, but they have a template for what an attachment relationship should look like. And they have a work internal working model that adults can be trusted and lost, but they can be trusted. And so they're much more likely to be able to form a new attachment with a good enough attachment figure. The ones that have had, you know, very deprived situations, either from the children that were studied from the 1990s where they were in in orphanages that were overpopulated with rotating roster of caregivers and no sense of primary caregiver or children who are in and out of problematic foster homes and high risk situations. Those children are very disorganised and they would be that that small subset of the population. And those are the ones where we know from some limited data, but promising that good enough foster placement as opposed to bad foster placement or good enough attachment. Adoption, adoption. Adoptive families where the parents have secure attachment and it's a stable environment, can have a corrective influence and shift the child towards something that's approximating security or even to security.

  Chase: [00:38:17] It sounds like attachment in a broad sense is an individual's first sort of internal working model of someone else. I'm wondering, like, does this map onto what we think of as like empathy or even just the way we think about others? It almost sounds as if if you can't sort of develop that first primary attachment with a caregiver, that it sort of impedes you the rest of your life in terms of creating an attachment with other people. Is that fair to say, or is that a little bit too abstract?

  Dr. Diane: [00:38:55] Well, it's fair to say that, like your earliest attachment relationships do set the template for what your expectation is in relationships. And I know there's Mickalene and Florian have looked at romantic relationships. I believe that's the folks that have done that and and correlating it with your attachment style as well. So yeah, it has a profound impact and it can be you can have corrective experiences through adoption, through an important relationship with a loved one or a teacher or through psychotherapy where you can shift, shift that template and get a new, more corrective experience. But yeah, it has this profound impact. But there was something else that you said that made me think of something else which has now slipped my mind about attachment.

  Chase: [00:39:53] I was just commenting whether it might does it map onto what we think of as a sort of cognitive empathy or empathy?

  Dr. Diane: [00:39:59] Right. Right. So empathy and empathy is in there. But to me, empathy and correct me if you disagree, but to me, empathy is sort of feeling for somebody else. And I think that in the. Attachment literature. We're talking about something even bigger than that, which is it's feeling like having a sense of what somebody else is feeling. But it's also in the context of my relationship with that person. So knowing that my behaviour, how I'm feeling affects my behaviour, which then affects how somebody else feels, which then affects how they behave. So yeah, like empathy to me is wow, I really get how so-and-so is feeling. But mentalization, which is another term that we use in the attachment literature, or my reflective capacity or my ability to internalise what somebody else is feeling or what I'm feeling is about also the relationship. I'm not sure if that makes sense, but it goes beyond empathy. Not only can I empathise or figure out what that person is feeling, but I also am aware that I maybe created some of that and that if I change how I'm behaving, which may mean me needing to figure out how I'm feeling, then I can shift the whole relationship.

  Chase: [00:41:19] Right? And that whole process seems to kind of necessitate a really high level of emotional intelligence. And I wonder if. I'm not sure if this is known, but is there some sort of component of emotional intelligence or sort of social intelligence that plays into whether people are good at developing attachments with their infant? Because it seems like sort of a complicated process that could be quite difficult if you if you aren't able to really pick up what your infant is needing and being able to develop all these models. It sounds like a complicated process.

  Dr. Diane: [00:42:02] It sounds complicated, but I'm not a I don't know how to. I'm not a psychologist, so I don't want to speak to stuff that is out of my area of expertise in terms of measuring emotional intelligence. But it is something that has been studied with people of varying intelligence. And it's it's not something that's necessarily so I'm making it sound much more conscious and explicit, but it's more on an implicit level that the parent can consider, Oh, maybe his diapers wet or maybe she's cutting a tooth or maybe she's cranky because she didn't get enough sleep or it's a new situation. Like, you don't have to be that super smart to take those things into consideration. You have to be curious, open to the possibility that there might be multiple reasons why the child why a child is in distress. But I don't know that you have to be super clever or anything like that.

  Chase: [00:43:07] I think that that is clarified because I think the laying it out is something that's sort of implicit or something that kind of naturally happens in human child rearing makes it, I think, a bit more understandable because, you know, when we do kind of talk about it in an intellectualised sense, it does sound like a very complicated process, but it is something that every Parents is kind of capable of in a natural sense, like they can learn to do these things without being a highly emotionally intelligent individual is kind of the sense that I'm getting from you.

  Dr. Diane: [00:43:44] Right. And like, you can get people who are very intelligent, who have no curiosity, and I'll have parents will say, well, why do you think he chose to do X, Y or Z? And the parents, like, I have no idea. And that sort of that an avoidant kind of lack of curiosity about the mind of somebody else and a shutting down of of feelings around in particular distressful behaviour, distressing behaviours, and then the more preoccupied ambivalent attachment system the parent might is more likely to say, well he, you know, he's they'll have this very rigid idea of the my child did this to just piss me off and can't I mean I said this earlier just they can't entertain the possibility that there are multiple, multiple, multiple options and often more than one thing that might be going on. And again, it doesn't have to be that complicated and you don't have to be that smart to think it could be one of a few things that might be causing the child to be in distress.

  Lucy: [00:44:53] I'm just kind of also curious about what you mentioned around the implications of attachment in romantic relationships. And I'm wondering if you work with couples and parents and you're kind of noticing two different attachment styles between the parents and and how you manage that or or how you explore that within the scope of therapy.

  Dr. Diane: [00:45:12] Right. So reflective family play, this approach that we developed at our centre where we took some of the mentalization based therapy and said, Hey, we don't have something for this for a whole family and to work on couples stuff. It was explicitly developed in order to try to work on couple co-parenting issues and some of these differences in parenting styles. And for sure you can have parents who have different attachment styles and children will actually attach differently to the two different parents based on that. And that can create some of the conflict in our relationship around co-parenting. And so, I mean, often in co-parenting, a lot of the work we do is just sort of identifying and labelling these differences and then looking for ways to find complementarity. And instead of saying this is this is a problem and it's a difference that's insurmountable to rather say, hey, let's capitalise on each of your strengths and your differences to find some sort of complementary way of co-parenting this child or these children. But I'm not sure I answered your question. Lucy.

  Lucy: [00:46:22] No, that's great. I mean, I guess I was just thinking about my couples therapy case right now and how I could apply some of this theory into kind of managing these two with the couple that I'm working with two vastly different ways forms of attachment and ways of relating to each other. And I guess I was just curious about that and how it would help me with my specific situation.

  Dr. Diane: [00:46:48] For sure. And I sometimes call talk about the match made in hell, which is typically the kind of preoccupied, maybe borderline mom or wife and the female part of the partnership, if it's a heterosexual couple. And then the dismissing avoidant or maybe even slightly autistic male in the partnership. And I think of that as a match made in hell where she just keeps up regulating and upping the ante in her pre-occupied way to try to keep him engaged. And he keeps avoiding and dismissing and escaping. And it can be very frustrating to see. And again, naming that as a difference is half the work and getting them to recognise that they have this difference. And at our site we do adult attachment interviews with both parents and so that helps us understand where that behaviour, that attachment style comes from. And then we can talk about whether you have this template of X, Y and Z and you have this alternate template of showers and, and that can be challenging for the two of you. Let's talk about that.

  Lucy: [00:48:00] Thanks, Diane Chase, do you do you have a final question?

  Chase: [00:48:03] I do. I just just wanted to put it out there because I know at the beginning, Diane, you mentioned that attachment is really become kind of the purview of popular culture. And in some sense, like I've seen multiple books about it, podcasts mainly out of California about it. I'm wondering like, what do you think are the most common misconceptions you see out there regarding attachment? And is there anything you'd like to kind of dispel for us before we close here?

  Dr. Diane: [00:48:35] I think my top peeves are that when people sort of use attachment and bond or relationship interchangeably and say things like they've got a great attachment because they were playing so nicely together in the waiting room, attachment. The attachment relationship is not about facilitative behaviour, so it's not about their ability to play. They might be able to play really well together and then the child gets distressed and the parent freaks out or is unavailable to the child. So attachment is again, that thing that you do when you're in distress and it's not the same as loving and playing and feeding and all those other great things and teaching great things that parents need to do to help their children survive and thrive. But they're different. And then I the other issue is like confusing attachment to literally needing to be inseparable from the child and having the child attach to at all times and not being able to kind of set clear limits and boundaries. One of the things children need to learn how to do is how to manage their own distress. And one of the ways parents help children learn to manage their own distress is by responding in an attuned and sensitive way. But I said earlier that you wouldn't want a parent who is 100% attuned because that doesn't really leave the child any breathing room to to actually live with some distress and learn how to manage their distress for themselves. And I have one colleague who talks about benign neglect and that that children sometimes need a little bit of benign neglect. They need to learn how to self-soothe a little bit. Obviously, this is not something we recommend in situations where there's a history of trauma or disorganised attachment or even avoidant attachment. But this idea that children need to always be sensitively dealt with and be literally with their parents constantly and attached to them constantly is is a misuse of the terminology. Attachment theory is really about what is what do you do when a child is distressed. So if a child and that whole thing coming back full circle to what Bowlby said, which was there's two poles to the whole thing. So if the child's attachment system is activated, they need to seek that primary care giver. But if the attachment system is not activated, then they should be free to explore their environment. And being able to explore your environment is the other pole of attach the attachment continuum.

  Chase: [00:51:10] It sounds like what you just spoke about kind of maps onto the concept of being a good enough parent, one who is attuned to their child sufficiently, but also gives them that space where there might be periods of distress that the child does have to learn to deal with in some sense.

  Dr. Diane: [00:51:27] Yeah, you were really paying attention, Chasee When we were talking about this stuff.

  Chase: [00:51:33] That's right.

  Lucy: [00:51:35] This is excellent. I mean, I think we've all definitely expanded. I mean, at least Chase and I am speaking for me specifically around expanding on some of these concepts of around attachment that we sort of, at least for me, have kind of always thought of it in a very sort of solid, specific way and now have a much more sort of elaborate way of thinking about it. And thank you for also dispelling some of those misconceptions about attachment. And I think this also will kind of better inform the way that we approach patients with different attachment styles, and it may alter the way that we were able to engage with them in therapy, but also sort of in a clinical and sort of assessment sort of context. I guess just to wrap things up. Dr. Philip, I always sort of ask the expert if there's any sort of words of wisdom or any advice or any thoughts about attachment or psychiatry in general that you'd like to share with our audience, which composed of young learners.

  Dr. Diane: [00:52:34] I think I love attachment theory. I think it's this profound piece of psychological theory that has influenced the last 30 odd years of mental health thinking. And so I recommend that trainees in psychiatry consider learning more about it and maybe even learning about the adult attachment interview if you're more of an adult psychiatry person, because I think it's it's a great clinical tool and there are folks who've written about using the adult attachment interview clinically because it's a laboratory thing to and so it's not something you need to go and get training in because that's like an 18 month conversion process and religious conversion process to learn how to to become a coder for the AEI, but rather there's lots of stuff now, lots of people writing about how to use the adult attachment interview, the A.I. clinically. So I think it's just so useful to have that lens when you're thinking about shifting people, people's. Psychosocial experience through psychotherapy. And I, I really love the work of the group in the UK that does mentalization based treatment, and I think I would recommend reading some of phonics and dating and stuff.

  Lucy: [00:54:23] Thanks. So thanks, Diane, for your expertise and Chase for joining me. And stay tuned, guys. We'll have another episode for you shortly. Bye.

  Chase: [00:54:44] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Lucy Chen and Chase Thompson. This episode was audio edited by Alex Raben. Our theme song is Working Solutions by All of Music. A very special thanks to our incredible guest, Dr. Diane Philip, for serving as our expert on this episode. You can contact us at the psychedpodcast@gmail.com or visit us at psychedpodcast.org, As always, thank you so much for listening.

Episode 23: Autism Spectrum Disorder with Dr. Melanie Penner, Dr. Yona Lunsky and Dr. Mitesh Patel

• Episode 23: Autism Spectrum Disorder with Dr. Melanie Penner, Dr. Yona Lunsky and Dr. Mitesh Patel

  Alex Raben: [00:00:00] Hi, listeners, this is Alex. This episode on Autism was recorded prior to the COVID-19 crisis. Before we jump into the episode, we wanted to take a moment to recognise the extraordinary efforts of the global community, which has come together to face this pandemic. This includes the tireless work of medical learners like you from around the world. Thank you, guys. Not just for listening, but for the service you're providing people in need. Stay safe and keep well. We plan to continue to make episodes to the best of our ability in this trying time, and we hope you will continue to listen. In addition, we've added to this episode's show notes an additional resource for how to help people with autism during the COVID-19 crisis. In less serious news, this episode had some technical difficulties and so you will notice a drop in the audio quality in the last 10 minutes or so. We apologise for this, but felt it was more important to release the episode blemishes at all than to not release it. As always, we hope this episode will enrich your learning.

  Alex Raben: [00:01:18] Welcome to PsychEd, the psychiatry podcast for Medical Learners by medical Learners. I'm Alex Raben. I'm a PGY-five in psychiatry at the University of Toronto, and I'll be the host of this episode. And today, we're going to be learning all about Autism Spectrum Disorder from an understanding of what it is to how we can help people with this condition. I'd like to introduce the panel to you, the people joining me in the room today. I'll start with my co-host, Sabrina Agnihotri, who is a PGY one.

  Sabrina Agnihotri: [00:01:50] Yes.

  Alex Raben: [00:01:52] Excellent. And but Sabrina also has a PhD where she studied Fetal Alcohol Syndrome and so has some background in neurodevelopmental disorders. And she'll be bringing that expertise to this episode today as well. And then to Sabrina's right, we have Dr. Mitesh Patel, who is a child, as well as a forensic psychiatrist at Camh, and he works with young offenders, homeless youth, as well as people with neurodevelopmental disorders. Do I have that correct, Dr. Patel?

  Dr. Mitesh Patel: [00:02:28] Yes. And also in the adult forensic system as well.

  Alex Raben: [00:02:31] Oh, great. And then to his right, we have Dr. Yona Lunsky, who is a psychologist who works also at Camh, and she is a Professor of Psychiatry and actually has done a number of teaching sessions for my cohort of residents. And we've certainly appreciated those and wanted to get her on the show. She also does research into various neurodevelopmental disorders, including Autism Spectrum Disorder. So welcome, Dr. Lunsky.

  Dr.Yona Lunsky: [00:03:03] Thanks. Happy to be here.

  Alex Raben: [00:03:05] And last but not least, we have Dr. Melanie Penner, who is a developmental paediatrician from the Holland Bloorview Hospital, also here in Toronto. And she is a clinician educator, so she wears a clinician as well as a research hat. And in both those worlds, she works with people with autism. And in her research she works specifically looking at the services and program evaluation around Autism Spectrum Disorder. Welcome, Dr. Penner.

  Dr. Melanie Penner: [00:03:35] It's great to be here.

  Alex Raben: [00:03:37] All right. So it's wonderful that we have such a panel of experts this episode. I don't think we've ever had so many in one room. Just just to give everyone an idea of the scope of this episode. I think it's important that we go through today's learning objectives. So for this episode, by the end of the episode, the listener will be able to, number one, have an understanding of the neurobiology and epidemiology of autism. Number two, be able to tailor their diagnostic interview for autism spectrum disorder in a way that improves the accuracy of their diagnostic assessment, as well as being empathic and aware of issues in this condition. Number three have a familiarity of the impact of autism spectrum disorder on the people with this condition, as well as their families and the interdisciplinary and bio-psychosocial approaches involved in caring for people with autism spectrum disorder. So with that in mind, I'd like to start off first by getting a sense of this condition. And my first question for all of you is what is autism spectrum disorder? What does that mean? I know it's a DSM diagnosis that's in the Neurodevelopmental chapter, but if we can, without going into diagnostic criteria, is there an easy way for people to understand this condition? Is it one thing? Is it multiple things? I'll leave it there and maybe we can start with you, Dr. Patel.

  Dr. Mitesh Patel: [00:05:10] Yes. Autism spectrum disorders is really an umbrella term. What that means is that it captures a lot of different kinds of presentations or ways of thinking. And the way that I like to think about autism and explain it to parents, for instance, is that autism is really a different way of thinking, a different way of seeing the world. And sometimes that way of seeing the world can lead to incredible strengths and talents and abilities that no one else could even ever have or fathom having. And at other times, it can lead to difficulties both in interacting with others. So some of that social communication stuff, but also sometimes there's some behaviours like repeating certain sets of behaviours or really being really focussed on certain things. And at times individuals who are diagnosed with autism can face incredible challenges.

  Alex Raben: [00:06:03] Right. I'm wondering if other people on the panel wanted to add to that definition.

  Dr. Melanie Penner: [00:06:08] It's so interesting. I had kind of jotted down some notes that said so many of those same things. So just a different way of. Interacting with the world. Thinking about both inputs and outputs in that different interaction. So inputs can be difficulty with the sensory environment that can cause a great deal of distress for autistic people and then outputs that may look a bit different than what we may be used to seeing. So different ways of expressing things like joy by, say, flapping your hands and jumping up and down different types of outputs in terms of how autistic people engage with other people.

  Alex Raben: [00:06:51] Is there a preferred way of talking about this condition.

  Sabrina Agnihotri: [00:06:56] Even referring it to a condition like like do you guys have any feedback for us and our listeners in terms of how that language comes across to you, too?

  Dr. Mitesh Patel: [00:07:08] Yes. Yeah. I think it's immensely important that we stay away from labelling people according to their diagnosis. And something that I've often pushed for and tried to do within my own practice is not label individuals as like this is a schizophrenic individual. For instance, we might say this is an individual who has been diagnosed with schizophrenia in the same way when it comes to autism. I think it's really important for families and patients in particular to hear that, that there's a difference in learning. We term this autism. There can be a difference in terms of how they interact with the world. And I tend to try to stick to an individual who has been diagnosed with autism or has met criteria for autism versus saying the autistic individual.

  Dr. Melanie Penner: [00:07:48] So I'm going to kind of jump in with some some things that I've learned from listening to the autistic community. And you'll notice that I'm tending to use identity first language a little bit more. And that's something that I actually picked up from actually Twitter, from listening to more autistic self advocates who at least for some of them really find something important in claiming that autistic identity for themselves and to acknowledge that it kind of it impacts their whole state of being. I think the approach I'm taking in a clinical environment, particularly when now I'm dealing with youth or young adults, is to actually ask them what their preference is for me to refer to their autism. And so some don't seem to have a preference. And then those who seem to be a little bit more kind of in that savvy community of thinking about disability and how autism kind of interplays with their life and society. A lot of them are kind of requesting identity, first language.

  Dr.Yona Lunsky: [00:09:07] It's so interesting, right, because we really do hear different things from different people. So I would agree with this idea of, you know, talking with people to see what they're comfortable with. But even how we talk about it outside is going to make a difference to people. And I know I've also made a shift because I work primarily with adults to use identity first language around autism. So to talk about autistic people and then, you know, families would be like, well, why? Why do you do that? You know, or like clinicians, what do you doing? Like, don't you realise like and it's like actually I do and I'm now going and so so educating people say you may notice, right? So sometimes I'm going to say autistic people. And that's because some people have said they really have a lot of pride in their autism. They're really excited about that and they've asked us to speak in that way. We don't feel kind of, but that's okay. Whatever works for you, I will do that. But that's why I sometimes use that language. So kind of helping people to understand different perspectives. And I think with families too, even if their families have younger kids, just encouraging them. There's so much interesting literature now to read about that people are writing from their own voice. People who identify as being autistic write about what these things mean and why they're using that kind of language. So some nice things, I think that residents are clerks could just be reading to sort of get more aware of because it's changing. It's I think it's even different from two or three years ago. Certainly is different than six years ago. And it may be that in two years we're having a different conversation again.

  Alex Raben: [00:10:28] So right. So much nuance there I'm hearing and a couple of different types of terminology that may be preferred by different people. And so it's really just important to be aware of these issues, check in with people and keep up with this as well, because as you say, it can change over time. With all of that said, there is this standard definition that we do have in the DSM five, and I'm wondering if we can work through that, because although as we've clearly spelled out here, this is not just about a DSM five diagnosis like with any of these diagnoses, we're talking about people who are very multidimensional. But we also use the DSM five as an important tool in our practices. And so I think it is important for us to unpack that for our listeners who are going through this large diagnostic manual in their clinical rotations. So can we talk a little bit about that? What is the DSM five criteria? How does one meet that? And then I think we can also get into how we actually ask around that and make the diagnosis.

  Dr. Mitesh Patel: [00:11:40] In my work in forensics, it's actually really important that we know these criteria quite well because they do end up coming up. And I think for all of us they come up quite a bit and just knowing. But I think what's really important to remember is that when we're talking about developmental disabilities or neurodevelopmental conditions, in this particular case, autism, it's important to remember that this stuff starts in childhood. Early childhood, there has to be evidence of symptoms or concerns that come from the early childhood period. So some may come to their family doctors later in life or to their paediatricians or even to nurse practitioners or whoever else they might be meeting and say, Oh, I think I might be autistic. That often takes a long assessment. And really going back to interview biological family members, for instance, to find out what could potentially be going on there. So I believe that that's criterion C is that the symptoms are present from early childhood. Criterion D is that there is this impairment to functioning on an everyday basis. And so that is important as well, that this is not something that just simply goes by and it doesn't cause any impairments. I think the other two criterion I believe are much more important being criterion A and B, and I imagine others can speak to this much more.

  Dr. Mitesh Patel: [00:13:02] But just in brief, the first criterion or criterion A is difficulties with reciprocal social communication and social interaction. What that means is that there's this general difficulty with understanding other people's emotions, having difficulties expressing their emotions, or being able to communicate in that context. And the second criterion or criterion B is that there's a restricted or repetitive patterns of behaviours, interests or activities. And so that could involve stereotypical or repetitive behaviours, highly restricted or fixated interests. And this is really why a lot of children come to clinical attention for us, I would say, is that that's one of the main challenges, at least in my practice, that I see a lot of. But also just in terms of the social reciprocity and understanding what's going on there, I would also point out that in autism, there's a lot of advancements that have been made in terms of identifying the severity of the illness or if we call it an illness or the condition. And I think that's really important is that things have changed so that now we're actually identifying them by how impaired the individual mate might be.

  Dr. Melanie Penner: [00:14:17] Yeah. So. So I think within those kind of big A and B criteria. So, so there are two main domains of symptoms. So the first one is that social communication. So within those there, there is the sort of social emotional reciprocity. And like Natasha was saying, that's a lot of like the back and forth interaction piece. So kind of reading the situation appropriately and responding in the way that is generally expected. There is difficulties with nonverbal communication. And it's interesting because when I'm seeing young children, it's often the verbal communication that is presenting as the main reason for concern. But then as we look into it there, it's a broader difficulty with communication. So not only is perhaps the child not using their words to communicate yet, but they may not be using other strategies as well. And I see a lot of parents who are sort of doing a lot of guesswork about what it is their kids are trying to ask for. So within that nonverbal category, we're looking for things like eye contact pointing, use of gestures like nodding or shaking your head, you know, your use of facial expressions. Are you expressing how you're feeling on your face and beyond that? Are you also directing that to another person? And then the third criterion within that kind of social communication group is the development of relationships.

  Dr. Melanie Penner: [00:15:55] So there we're looking at the earliest relationships being the caregiver relationship. So how is the child pulling the caregiver sort of into play, their siblings perhaps into play, whether they're doing that rich, you know, back and forth, imaginative play. And then as they are getting older, how they're developing peer relationships. So I think it's important to note as well within those social communication criteria, there are lots of things that can give you social difficulties. So autism is not the only one, but it is certainly one of the the ones you should be thinking about if you have a child who's presenting with those difficulties and then, yes, the restricted repetitive criteria. So that's where we see the some of the what we call stereotyped behaviours. So that's where we see things like lining up of toys, flapping of hands, repeating speech. We can see insistence on sameness. So kids who really want things to be like the same way every time, difficulty with transitioning from one thing to another. We can see intense or unusual interests. And so kids who get really obsessed with something and then those sensory difficulties that we've already sort of alluded to. So those can be both things that are extra alluring from a sensory perspective or things that are really aversive from a sensory perspective.

  Alex Raben: [00:17:28] What I've heard and I'll just summarise sort of the criteria that I heard, which were these two big domains of what we might call a criteria, social deficits or difficulty with social communication or a difference in social communication. And then B was, which was restricted in repetitive behaviours that it had to be impairing and that it had to start in childhood, that this is a neurodevelopmental disorder, it starts young. How do we conduct ourselves in the interview that allows us to make this diagnosis? Does that involve collateral? Does it? What are the components of an actual diagnostic assessment?

  Dr. Melanie Penner: [00:18:08] So to me the it you definitely need input from various sources so your history with the people who know that person best including perhaps that person depending on how you know what their age and developmental level is and and how they are able to contribute. I think collateral information is almost always helpful. Some of my really young ones who aren't in Day-care yet, it's, it's hard to get collateral information but once they're in Day-care or school, that's really, really helpful information because that is for children and youth, their sort of main occupation. So we definitely care about how they're doing in that environment. And then there should be some form of observation and interaction. And to me, that's so, you know, watching the child or youth is not really enough. They're you. You do need to be able to interact with them, whether that is with a standardised tool or otherwise and to to see what that interaction feels like. I think it's interesting though, sometimes you can have the effect of being a very good playmate. And I'm thinking of one case that I had where, you know, very bright boy who loved the idea of talking to an adult for an hour, like just loved it, and then afterward asked if I did birthday parties. So. So sometimes we can. We can accidentally select for making things. Things seem a bit rosier than they might in the real world. But those are generally the main components that I would think about.

  Alex Raben: [00:20:11] And you also mentioned Scales. We had a listener write in with some questions. And actually, Connie Lutton, I hope I'm pronouncing that correctly. She's a social worker who works here at CAM in the Slate Centre. And one of her questions for us today was whether there were brief scales people could administer as a way of screening for for autism.

  Dr. Melanie Penner: [00:20:34] So there are definitely, I think, of the tools in a few different buckets. So there are screening tools. There are screening tools that are based on questionnaires and then there are a few for really young kids that are based on a short interaction. And then there are diagnostic tools and again there are diagnostic tools that are more based on a questionnaire or interview, and there are some that are based on an interaction in terms of the diagnostic tools we are often thinking about. So in the interview sort of category, there's the autism diagnostic interview revised, which is fairly lengthy takes, you know, and does take a lot of training. But if you are looking at something that's that's sort of considered among the most reliable tools, that's what you would be looking at. And then for the observation and interaction sort of part of diagnostic tools and that the sort of main one that people often think of is called the AIDS or autism diagnostic observation schedule. And that one definitely takes a lot of training. You need very specific materials for it. It's important to know that depending on where you are making your diagnosis, you may or may not need specific tools to make that diagnosis. So where we are right now in Ontario, you do not need a specific tool to make a diagnosis that differs quite a bit if you go to a province like B.C. so it's important to know where you are and what the eligibility requirements are for diagnosis so that kids and families can access services based on how you've done the diagnosis.

  Dr. Melanie Penner: [00:22:20] Probably the most important point here is that you're not going to find a score or a number that's going to make or break this diagnosis. It's a clinical diagnosis. And though I think the temptation is to find these ways to put to attach scores and numbers to it at the end, it's still based on clinical best judgement. And, you know, different types of cases may require different levels of kind of testing and kind of semi-structured interactions and things like that to come to that diagnostic conclusion. But at the end of the day, it's not based on a number, it's based on really rich information of that child, their context and support. Sorted by what you've seen in your clinical environment with the caveat, I would say that, you know, we do these clinical assessments in a strange place, like we make people come to a clinical place. They have to play with a strange adult. And so and I think we need to be aware of, of that limitation, particularly when we're kind of coding and scoring these types of interactions as well. That context is really important. And so I always try to really prioritise the descriptions of that child in the real world, recognising that my ability to kind of mimic that in my clinic is going to be limited even though I am a good playmate.

  Alex Raben: [00:23:58] So what I'm hearing is that there's no replacing an actual clinical assessment and if there's a suspicion, there are tools available to you. But ultimately, someone probably needs to assess in person, get an A, get a fulsome assessment. I think part of why Connie was asking this question is she works at Slate, which is a centre here at CMS that works with people who have early signs of schizophrenia. And she was explaining that oftentimes it's not clear to her whether the person in front of her has actual schizophrenia or may be developing schizophrenia, or if this is more of an autism spectrum disorder. I'm wondering, are there other things that mimic ASD and what are they what do we have to look out for when we're trying to narrow down the diagnosis?

  Dr. Mitesh Patel: [00:24:47] There are many other, many other conditions that can sometimes be confused for aspects of autism or presentations that they might have. Going back to what was mentioned about schizophrenia, autism can be comorbid with schizophrenia. That is incredibly important to remember. And when that happens, the presentation is can be very complex and it can be a bit more difficult to tease out what is psychosis versus what is an underlying interest that an individual may perceive it upon. Does that meet criteria for a delusion? Is there an aspect of paranoia tied into that? Are these things then connected? And oftentimes they are all connected, so it's really difficult to put people into these neat boxes.

  Dr.Yona Lunsky: [00:25:37] Are there certain symptoms that you guys can think of from your practice that jump out to you as the most distressing to a patient?

  Dr. Mitesh Patel: [00:25:45] Absolutely. I think one of the most difficult challenges for many youth, at least with autism, is bullying. And as soon as you start mentioning that question or raising aspects of it, the first thing that comes to mind is youth who are bullied for being different or not understanding what other people are trying to communicate and being subject to extreme amounts of bullying. But that's something that comes to mind. I'm not sure if that was your question, but yeah, no, that's what I that's what comes to mind for me is that that's one of the most distressing things. And OCD is very comorbid in terms of autism. And so there can be a lot of distress with having to keep that sameness, as was mentioned. And also a lot of the anxiety symptoms that come along with that.

  Dr. Melanie Penner: [00:26:35] Yeah, I agree with all of those. The only other thing I would add, I think, is that the sensory symptoms can be very impairing. So for people with a lot of sound sensitivity, going out in public can be hard. Using a public washroom can be really hard between the like automatic flushing toilets and the like blasting hand dryers. There are lots of parts of the environment that are just not built with the needs of autistic people in mind.

  Dr.Yona Lunsky: [00:27:09] Yeah. Even just, you know, your regular kid's birthday party with all the screaming, the happy birthday and the terrible thing that happens at the end of the happy birthday singing, which is the applause, you know, with the blowing out the candles and kind of that sudden like that is very jarring. So then you don't want to be at a birthday party, right? Or then you don't want to go to a sports event or all kinds of things that are really, really difficult.

  Alex Raben: [00:27:31] Right. So quite a number of aspects of the illness can have can evoke distress. And part of it also seems to be at times the mismatch between people who we might call neurotypical versus people who have autism spectrum disorder, focusing on this sort of neurotypical word. I'm wondering if we can take a step in the direction of understanding the etiology of autism spectrum disorder. And I imagine this is there's a lot of question marks out there still. But what do we know about the differences in their brains and and how this and how this condition comes to be?

  Dr. Melanie Penner: [00:28:14] Lots of looks around the table.

  Dr.Yona Lunsky: [00:28:16] This one was the one cause of autism.

  Dr. Mitesh Patel: [00:28:20] I think if we knew that, we wouldn't be here.

  Dr.Yona Lunsky: [00:28:23] I was just going to say, I mean, I think it's really a cluster of symptoms or characteristics with so many different aetiologies. So we're learning more about those things. We no longer think, for example, that it's caused by how mothers raise their infants or their children. Right. So the refrigerator mother kind of phenomenon, we recognise that's not true and we know there's a certain biological sort of component to it, but it's not, it's not as clean cut as maybe we were hoping as we sort of advanced all of our, you know, expertise around understanding things like genetics and, you know, the sort of the actual anatomy, what's going on in the brain itself. It doesn't always look quite so different from some other neurodevelopmental condition.

  Dr. Melanie Penner: [00:29:08] Yeah. So, I know some of the people who are doing the kind of cutting edge biological exploration in this area are starting to say things like the autism's so is autism as we know it really at a biological level, more a collection of rare disorders that present in a similar way from a from a behavioural perspective. And then the concept as well of neurodevelopmental disorders. I mean there are very fuzzy boundaries between our diagnostic buckets as we've already discussed. Right. Kids don't fit neatly into one bucket or often even two buckets. And so there's also a lot of work going on right now to re-examine these diagnostic categories that we've created and say, well, do these actually really hold up if we put them under scrutiny? And so I think of my colleague of TYCHE and agnostics work with the Province of Ontario Neurodevelopmental Disorders Network platform where they are. This is exactly the question they're taking on. They're saying if we take if we enrol a whole bunch of kids with various neurodevelopmental disorders, run them all through the same sort of phenotyping platform and look at their underlying biology, what would this tell us about the integrity of our diagnostic constructs? And so far, the results are showing that there is that the borders that we've constructed are quite hazy between these conditions.

  Alex Raben: [00:30:50] Right. So there's I think although we're in the early stages of understanding the ideology, it seems like it's really ideologies at this. From what we understand at this point and a lot of that understanding comes from genetic testing and things of that nature. Is there a role for that kind of testing diagnostically today? Is there a role for other types of testing in our assessment of someone with potential ASD?

  Dr. Melanie Penner: [00:31:22] So right now genetic testing in the form of chromosomal, microarray and fragile x testing is offered to families post diagnosis. And so we're not using it at this point to detect autism. It will be interesting to see, I guess, how the field develops that way. Right now, though, it's used, is more to see if we can find an underlying genetic condition that is that we think is associated with the autism. And there are various results we can get along those lines and a lot of grey areas. So. So I counsel families that it's generally about a one in ten chance that we're going to find something associated with the autism. When we do that testing, sometimes we get a genetic mutation back and it's a variant of uncertain clinical significance. So we don't know what that means. It hasn't been described in the literature as being associated with autism. And then sometimes we get a normal result, which may mean that there's not anything that we can detect that is that is a mutation. But it also may mean that just the type of testing we're doing right now, which is microarray testing as opposed to like a whole genome or whole exome sequencing, is not picking up things that a granular level that we would be able to find otherwise. So it's going to evolve and it will be interesting to see where we move as a field.

  Dr.Yona Lunsky: [00:33:07] Yeah, I was going to just say it's still, I think, a really important message, you know, for clinicians that it is good practice to figure out, I think, if there is a cause, what it is because with certain things like for example, let's say it's fragile X and we didn't pick that up before. Well, we know a lot of things about people with Fragile X. We know about different medical things to look for, stuff that's going to happen over the course of development. We also know what that means in terms of other people in the family. Right. So there are conditions. I mean, Fragile X is hereditary. That's a particular one. There's other conditions as well where it's going to give us ideas of things that we want to be watching, whether it's about how that person's going to communicate best stuff we know about people's language with that kind of condition, medical stuff that's going to come into play, psychiatric things that may involve repair likely over time. So it does help us, but it's helpful, I think, to talk with families about why genetics is important and what we might find and what we might not.

  Dr. Melanie Penner: [00:34:00] Yes, exactly what to expect.

  Dr.Yona Lunsky: [00:34:03] There's one other again, thinking about adults and thinking about what people are talking about these days. It is important we can talk about what we're doing with our young children and our families when we think about genetics and autism, certainly things that I've read or that I've learned from autistic adults talking about this, there's a real fear around that. So if we look at, for example, how we understand genetic screening in another disability, so in Down's syndrome, we can actually test that prenatally. And what that's done, and especially in terms of how we counsel people when we notice that prenatally is sometimes there's an option or even sometimes in how we explain it and encouragement, you know, to abort that fetus. Right. So there can be fears or concerns around why are we doing genetic testing in autism? So people don't understand that it might be to help understand if this is the underlying cause. Here's some good things we could do to help address some of the things that might happen with that underlying cause. So it can feel like, well, we are doing that screening or we want to understand more about genetics because we're trying to not have autism or autism is wrong or autism is bad or this is something we want to get rid of. So it sends a certain messaging for people who are working really hard to take pride in who they are, about what we think of that condition. So with everything we talk about, I sort of hear this sort of perspective around working in the child area. And then I think, well, how is that perspective different when we're working with adults? And I think as people who may work both with children and adults, to have that recognition that something that makes so much sense for one group may have different sort of implications or meanings for another group and to be sensitive to that.

  Dr. Melanie Penner: [00:35:33] Mm hmm.

  Alex Raben: [00:35:35] Yeah, for sure. And just I mean, even in this room, we don't have all groups represented at the table in terms of this discussion. I think we should acknowledge that as well. But we are doing our best to keep that in mind with all of this. And it's a perspective I didn't think of with respect to the genetic testing and how that could be interpreted by someone who identifies as autistic. At this stage, though, it sounds like from what you're saying, the genetic testing is not diagnostic. However, it can be helpful in terms of treatment decisions down the line for people with autism spectrum disorder. Using that as a launching pad. Perhaps now we should turn to treatment and how we can help people who are suffering with autism. We talked a little bit about comorbidities. We've talked a little bit about some of the particularly distressing symptoms. And so we have a starting place, I imagine, of targets for treatment. But if we think broadly, what are the general considerations here when we're trying to help people with this condition?

  Dr. Mitesh Patel: [00:36:49] I think one of the the main challenges in working with individuals who meet criteria for autism is that it can be immensely difficult for them to navigate the world. And as they enter adulthood and something I see a lot in adults, is there social determinants of health are so much poorer than others potentially. And there's a large prison population that may meet criteria for ASD or autism spectrum disorder and just haven't undertaken the diagnostic testing because they didn't come from a family that could have questioned that diagnosis. I see a lot of children at the Children's Aid Society of Toronto that may meet criteria, but again, until they've come into care, haven't had that opportunity to potentially undertake assessment. There's lots of homeless youth who meet criteria for this diagnosis and they face incredible challenges trying to figure out applications for housing money. Many of them are targeted and preyed upon by predators who are either after their money most often. And there's also a sexual predation upon this population. And so it can be immensely difficult for these individuals. And so when we think about treatment, I think it's also important to think about what we can do to help intervene and assist individuals. And many of these individuals are our highest-risk populations. And so when we think of high-risk youth, when we think of high-risk adults, this neurodevelopmental community in particular comes to the forefront in many instances because they are facing very unique challenges, and they they can often become targeted by others, something we haven't really talked about much. And maybe I'll start the treatment discussion. There is what we see a lot of in clinical practice, especially if you're a child psychiatrist.

  Dr. Mitesh Patel: [00:38:38] One of the main things you see is conduct disorder amongst youth. And so when you have an autistic child who comes in with some conduct sort of behaviours, it's often because of what we call poor frustration, tolerance, which is having difficulties understanding all the frustrations that they might have or understanding what's going on around them. And so if you don't have the same kind of perspective on the world around you as others might expect you to have, obviously that's going to be super frustrating. Right. And for some of these children, it can be difficult to let out that kind of frustration. And other people might get hurt when they try to let out their frustrations. So some might behave in an aggressive manner or a hostile manner to let out some of that pent-up energy or pent-up frustration. And so oftentimes that's the focus of treatment, is how do we target these behaviours that are of major concern. Potentially others might be getting hurt in the home or that child might be hurting themselves. Did what we call self-injurious behaviours or SEB that happens predominantly in this community in terms of Seb in general and there are treatments for that. A lot of it is behavioural therapy. There are some medications that can be tried as well that have been shown to have some benefit. But I think it's really important to focus first and foremost on what we can do to help assist that individual navigate the complex social array that we have before them, depending on their age of development.

  Dr. Melanie Penner: [00:40:03] Yeah. Some of my sort of first principles around thinking about treatment goals are thinking about what gets in the way of everyday life. So what that question of function and I think in the past a lot of autism treatment was focussed a bit more on the idea of removing autism or making the autistic person look normal. And so treatment could be focussed on things like getting rid of hand flapping, even though that hand flapping in and of itself may not be harming another person or harming that person. And so I think increasingly the goals of various types of treatment are starting to move towards an idea more of improving function. And with that, I think there's also an emphasis on goal setting. So what is what are that family's goals at this moment as they get older? What are the child and youth goals? And then what are the the young adult, the adult schools to work on? Because I think if you're starting from that place of what does the family really want to work on what's going to or that does the autistic person want to work on? That's going to make the most difference in their day to day life. I think that's where that's where we're going to do the most good.

  Sabrina Agnihotri: [00:41:35] And what does family involvement look like in the paediatric world versus the adult world in terms of treatment goal setting?

  Dr. Melanie Penner: [00:41:44] I think ideally, it's it's a continuum of change as according to the autistic person's sort of developmental, you know, level at that period of time. So we would want to see, you know, some degree of things of enhancing and encouraging as much independence as is sort of reasonable in that situation. Certainly when they're really young, obviously it's a lot of talking to parents. When I'm seeing adolescents, I am trying to do more of that. You know, let's kick your parents out for a bit if that's if that is kind of developmentally appropriate. And I'm going to ask you to tell me what your medications are. I'm going to, you know, ask you about how school is going. And the disclosures that I get during those times are really, really important. And so I think sometimes we think about it in kind of a stepwise fashion, but ideally it's more of a continuum.

  Dr.Yona Lunsky: [00:42:56] Yeah, I think one of the big differences is that when we're doing our adult based work, we sort of forget all that stuff around more family-centred care. That's so obvious in terms of our training when we're working with children. So kind of finding that balance in adulthood is really important. And certainly from a family perspective, you know, whether it's an adult sibling or parents, they will talk about how it feels to not be included in care decisions. So if I am not the best person at articulating, you know, a full context of a situation and people are only listening to my story or I'm not very good at remembering something that happened in my therapy session, for example, or just reflecting on memory of when certain behaviours or symptoms were going on. When I'm giving a history, then the clinician doesn't have all the information, but sometimes I think families are kind of left out of that because we have a sort of model of how we work with adults. So we have to figure out how we blend those two models in a respectful way as possible, sort of promoting autonomy and independence, but also a little bit of interdependence and sort of seeing where that is.

  Dr.Yona Lunsky: [00:43:54] I think it's easy for us to do that with kids. It's harder for us to figure that out with adults, and sometimes people don't share the same perspective. So like, I don't want you to talk to my parents because actually I'm really mad at my parents right now and they don't understand me. I understand me. So how do we respect that with a young adult or an adult, but is there something kind of to learn from that? And sometimes I think therapeutically, if you can sort of help that person potentially appreciate or better understand why they don't want the conversation to happen with family, that could be really informative and there could be something they can learn as a family together if you can sort of bring people together around some of that stuff. So don't shy away from it. I think just because it seems like you're supposed to work in a certain way based on that person's age.

  Dr. Mitesh Patel: [00:44:36] So I tend to work primarily with children who have lost their families or there's been a there's been so, so many challenges within the family that it's fallen apart or their supports have fallen apart. And I think there's three main issues that that come up with that. So the first is a lack of support for those family members that it can be immensely challenging to have a child with special needs that requires so much more attention than other children in the home, for instance, it can lead to immense amounts of frustration, substance abuse challenges, involvement by external agencies, investigations, etc., etc. And it can be immensely challenging, particularly if the child engages in externalising behaviours or ends up getting into trouble with others or there's legal involvement. The second thing is around Psychoeducation, so really understanding what the needs of their child are, and that is do I understand what kinds of resources this child will need as they move forward? And the third is a lack of infrastructure, actually, and I don't say that lightly. When I see a homeless youth, for instance, it is immensely difficult to identify what kind of dedicated services are actually going to be available for that individual. Many of the services we have, they're dedicated and designed for people who can interact well with that system, who can actually advocate for themselves or say, Hey, this is what I want.

  Dr. Mitesh Patel: [00:46:04] You know, I've got this odious application. I need to get it filled out. I'm going to go find the doctor to get this done. You give a form to an autistic individual has no understanding of what that involves or how they would go about booking an appointment or try to get someone on board to maybe assess them and fill out a form that is so challenging. And our system just isn't really well designed for that. And so I see a lot of youth in shelter where we're scrambling to get as many workers on board to help them. Some of these frontline workers do amazing amounts of extra work just to help these kids out and these youth out. And you. I think it's it's always surprising to me when I bring other people into a shelter setting just to see how many of these youth have developmental challenges or meet criteria for autism and are now homeless and have lost all their family supports. And you just see this look of complete concern on almost every worker's face because we don't know what to do and people are trying to get them as much assistance as possible. And it is difficult.

  Alex Raben: [00:47:12] It's it strikes me that we often talk about the biopsychosocial model in terms and approach to treatment of various kinds of conditions in psychiatry and in medicine in general. And I think almost everything we've mentioned so far has been in that social category. So it's almost in reverse, the social psycho-bio approach, perhaps. And, you know, in terms of that social bucket, what I've heard from you guys is understanding the goals, both from the family's perspective and the individual's perspective, working with families to ensure that they are involved in care, but also that the system surrounding them is supporting them in order so that they understand what's going on, so that they don't feel overburdened, which could lead to the ultimate outcome of that individual becoming homeless or not really having that family support and further social determinants of health worsening from their. So that really stuck out to me. I'm wondering if there's anything else in that bucket we should be discussing in terms of what a learner might want to know in terms of helping people with this condition, or if that or if it's a bit too hard to know the specifics around that, because I often find that with social with the social bucket is you need to know very minute services in your area. So I'll just leave it there if there's anything else in social we should cover. But then I was thinking we could move in more specifically to psychological and biological interventions as well.

  Dr.Yona Lunsky: [00:48:49] I think just to mention on the social side that there are a lot of we talked about a lot of the problems and a lot of the challenges, but it also means there's a lot of things we can do. So we can if we can set up infrastructure that makes a big difference. If we can give either that autistic person social supports, that match what they're looking for or their families, that's really important. There's again, we've talked about the sort of movement for, I think, both youth and adults in terms of feeling like they belong somewhere and connecting with other people who see things the same way they do. So there can be a lot of power in terms of peer-based kinds of supports and connections, and sometimes that's in person, but sometimes that's virtual. So there's a lot of support that people connect with through technology. So understanding, for example, a young person who's spending a lot of time gaming and thinking about how problematic that is, but if there's a whole community of people playing that game with them that they can only connect with through that game, that's actually a really important social support for them. So we have to think about that. Or there might be for adults a way of sort of communicating, reading, talking about their experience, and they might be doing that through Twitter, for example, or through Reddit or so, kind of recognising that there are things we can do socially and also in terms of meaning poverty. You talked about housing, which is obvious, so huge, so important, but also having something meaningful that you do during the day. So some of our treatments are really trying to figure out how we can give things for people to do that, make them feel good about themselves, and that gives them meaning. So it's a really important part of intervention.

  Alex Raben: [00:50:16] Right? So not forgetting those sort of low-barrier ways we can improve, potentially improve people's social lives by acknowledging the groups that they can find and connect with online or in person in addition to broader social programs to help with housing and poverty. I think that's very important. That said, I'm wondering in terms of psychological treatments, what is available for people with ASD.

  Dr. Melanie Penner: [00:50:39] So yeah, so I think the most commonly discussed form of therapy is ABA or Applied Behaviour Analysis. And ABA I guess similar to autism is a very broad term that covers a lot of stuff. And so I would say some of the core elements of ABA are that it sort of works with the idea of motivation and how you keep people motivated to learn skills that might be more challenging for them. But there is a lot of breaking things down into very small component parts and then teaching them sort of one piece at a time and a lot of repetition built into that. And it's done. It's supposed to be done in a in a somewhat systematic way, often involving some data collection to sort of track progress. And the evidence base is interesting. So there was a recent meta-analysis that was published of different early interventions for autism, and they actually found that the quality of evidence for many of these ABA programs is not that great. So very little in the way of randomised controlled trials. And this is it's hard to study these types of interventions in a very, very rigorous way in the types of study designs we see when we're doing, you know, double-blind, placebo-controlled drug trials, for instance. But I do think that that it is it does pose a challenge to the research community to think about how we can generate the best possible evidence, control for bias as much as possible to generate the type of evidentiary support that we ideally would like to have for these interventions.

  Dr. Melanie Penner: [00:52:45] In that meta-analysis, the sort of standout that had the best evidence supporting it was something called naturalistic developmental behavioural interventions or NDB models. And we have so many abbreviations in our world, as you can probably tell, and this is sort of the newest sort of iteration I think, of where ABA is and is going where so. Naturalistic refers to applying the intervention in the child's natural environment. So taking it out of a very clinical space, because when it's done in a clinical space, then you have to the child has to then make the leap to applying those skills than in their regular environment. So the idea is by applying the teaching in their regular environment, you eliminate that step developmental. So the RD in MTBI refers just to the fact that we're thinking about the developmental domains and the developmental skills that were kind of wanting to focus on at that age. And so again, previous models were maybe a bit more focussed on kind of table-based tasks, academic type tasks. And these NDB models are starting to move a little bit more into saying, okay, like what are the domains in terms of social interaction, in terms of communication that we want to work on? The behavioural reflects that this is still like a behaviourally based model. So that's that is the kind of I would say where the field is sort of going with those types of interventions.

  Dr.Yona Lunsky: [00:54:37] Just to add from psychological thinking and about adults that we would be thinking about different things for adults, we wouldn't be thinking so much. What are the interventions for autism psychologically? But we might be thinking, what are the interventions for depression or for anxiety? And, you know, it's we're in an earlier stage because most of the research done on autism is done on kids. So it's much less done on adults. But we are learning that many of the things that we do in the general population might also have some use in terms of psychological interventions, especially if that person, for example, has speech and is able to do a more psychological kind of therapy. But there are certain things we might want to shift or change. So and again, Autism's, not everybody does well with the same thing. So one person might really appreciate the sort of scientific inquiry or approach that you use sometimes in CBT, where you take a thought and you think about it and you look at the evidence, but someone else might find it incredibly impossible to capture what an automatic thought is.

  Sabrina Agnihotri: [00:55:36] Can you give us a few examples of the more biological treatments?

  Dr. Mitesh Patel: [00:55:39] Yes, in a lot of the work that I do focussed around youth who are facing some challenges, some of that can be externalising behaviours and so we may treat that with low dose third generation antipsychotic medications. Abilify has shown some evidence in that regard.

  Alex Raben: [00:55:57] And by externalising behaviours you mean things like aggression.

  Dr. Mitesh Patel: [00:56:01] Yes. Or even self-injurious behaviours. Yeah. There is some evidence as well for using some other agents related to opioids for self-injurious behaviours. That evidence is somewhat limited. It's a difficult area to treat, but as I've indicated, as has come up here before, many of the symptom concerns that come forward are related to mood and anxiety. And so when we've exhausted psychological approaches and social approaches to treat these underlying issues, we may turn potentially to biological agents. And in that case, we are looking at typical agents that we would use in others, including SSRI medications or other antidepressants. This is in my practice, it's not a population that I typically use benzodiazepines, and I have a very not good experience. And I wouldn't do that anyhow with youth. But even in adults, I find that it's just it's not it doesn't have the same effect even in short-term cases. There's a lot of looking at what the comorbid symptoms are. Is there a poor sleep? Is melatonin going to work, for instance, just to facilitate some improved sleep? And if that happens, is there improved mood and anxiety symptoms? Usually that's the case even when it comes to aggression and hostility. We look at those things as well. There is a specific population that may have certain focussed sets of interests and even engages in some sexualised behaviours which isn't overly common, but it can happen. And so sometimes we look at some medications to help with that too. But I don't want that to be the focus of this and I don't want people to walk away thinking that that's what we're treating for and that's what we have to do. These are very specific cases and I think the rare cases, but I think for some of us that practice in certain areas, we end up seeing so much of one thing that we start to think like, Oh, maybe this is more prevalent than we thought. But no it's not.

  Dr. Melanie Penner: [00:57:45] Yeah, I would say the one well a couple I would add , ADHD commonly occurs with autism. And so we have a lot of kids who are and teens and probably adults who are started on ADHD medications, so stimulants. Alpha agonists. At a max teen. And the other thing to think about from the biological sort of component is co-occurring medical conditions. And so there I think we have to be thinking about. Seizures, which we know frequently occur in autism. Sometimes side effects of seizure medications have a big impact on the presentation that we're seeing. Constipation. I don't think I'd be allowed to be a paediatrician and be interviewed here without mentioning constipation. So but, you know. That's something that you can make you very irritable thinking. Thinking about, particularly for autistic people who don't have the best ways of communicating with us. I think we need to be extra careful that we're not missing things. And so one of the one of the toughest cases in our clinic was a dental abscess that that had been missed. And that was a big source Of pain. And so those are the things that you just don't want to miss. Right. So it's important not to just chalk up the behaviour to autism. But to make sure that you're, you're doing a good review of systems as well to make sure that those medical co-occurring conditions are considered too.

  Dr. Mitesh Patel: [00:59:36] That's immensely important, particularly in autistic clients, especially those that don't have the ability to communicate. In fact, they can't tell you if they're experiencing pain. And so oftentimes in psychiatry or child psychiatry, we're working very closely with paediatricians to have the child undertake a fulsome assessment. Even the dentists will get involved to look for this kind of thing, which is why it's so important to have these multidisciplinary teams working together for these clients, which also presents infrastructure challenges because it can be difficult to get all these players around the table in the same place for some of these youth.

  Dr. Melanie Penner: [01:00:16] And I think often it's a virtual table that we're talking about. Right? And it does. I think the issue comes. In sort of who's running point on this, who's coordinating all of this information, synthesising it, making sure that all of the boxes are checked off? Because you're right, it's we don't have infrastructure such that everyone sort of sits around the same table to discuss these cases. So there's a lot of behind the scenes work, I think, that probably all of us are doing to coordinate things for our patients.

  Alex Raben: [01:00:55] So there's a lot there. I'm going to because we've come closer to the end of our time together. I'm going to try my best to summarise the treatment, but there's a lot to summarise. But I think, as I was saying in the beginning, it sounds like it's an almost reverse social psycho-bio approach with social considering factors of social determinants of health, large issues like poverty and homelessness, but also considering the person's social circle, their family supports and ensuring those are as healthy as they can be to support this person in the psychological pathway. We have ABA applied behavioural analysis and this is a behavioural type of therapy that works with positive reinforcement to help with the core deficits that relate to ASD, such as social reciprocity and things of that nature. And then the last section is biological interventions, which from what I was hearing, really don't target the core symptoms if you will, of ASD.

  Alex Raben: [01:02:04] But rather target the comorbid psychiatric conditions and medical conditions. And it's important to recognise both and recognise that there could be overlap that a biological or a medical condition may be causing a psychiatric or mimicking a psychiatric reaction. Leading that person to be aggressive, for instance, and that we do have some medications that help, such as atypical antipsychotics that can help with externalising behaviours and then SSRIs if there's a comorbid depression. I also heard the subtext was that no one does this alone. This is a team working around this individual, ideally a team of professionals, and that's not necessarily an easy team to coordinate all the time in our current health system, but one that is paramount to the treatment of people with this condition.

  Alex Raben: [01:02:59] As sort of a last hurrah, I'm wondering if you guys have any resources you would recommend for clerks or early residents that would allow them to delve a bit deeper into this topic.

  Dr. Mitesh Patel: [01:03:14] Autism Canada.org has a ton of information. I think that's a good place to go but also just I think reading from Journals and seeing some of the newest information that comes out, it's also very helpful and getting a lot of clinical exposure. I think that's the main thing is if you can shadow or do an elective or do a rotation in some of these areas, we haven't talked too much about dual diagnoses, but that's a big area to do this in. And I think you'll find across psychiatry, many practices end up working with individuals who have autism or diagnosed with it.

  Dr. Melanie Penner: [01:03:52] I think my advice is to actually seek out first-person accounts of autism. I think that's where some of my best sort of hidden curriculum learning has happened. So, you know, there is a very rich, nuanced discussion of autism happening every day on Twitter. There are lots of books written. So Yonas mentioned Temple Grandin. One of my favourites is Look Me in the Eye by John Elder Robison. And then for a really nice sort of overview of the history and kind of politics and sociology of autism. The book Neuro Tribes by Steve Silverman is excellent. Great.

  Dr.Yona Lunsky: [01:04:46] I would actually echo a lot of I think recognising different people are looking for things at different times, but so important, I think, to understand people's experiences themselves. And also if you're interested in supporting families, understanding also families experiences and being familiar with the different stories because there isn't just one. And so it's helpful to understand the perspective of autistic adults, the perspective of parents or siblings, of people who are autistic at different ages from different times. The more you can read, the more you can learn, right? And the more you see people and interact with people, I think is also I mean, there's even a huge difference that people who are listening to this right. Now, who are clerks or early residents, were brought up at a different time than I was in terms of who was in your school and who was in your neighbourhood, right? So that's already making a difference is probably people, you know, that you can talk to. I think that could be really helpful as well.

  Dr. Mitesh Patel: [01:05:36] I just want to echo that Look Me in the Eye book that was actually required reading for me during my residency by one of my supervisors, and I'm so glad he pushed for that. That was at the Maples Institute in Vancouver, which is a Child Custody Centre and Youth Forensic Centre. But it definitely helped to, I think, educate me a lot about the perspectives. And yeah, I think there's so many things to do. There's movies to watch as well. Yeah. So I think there's lots of ways about learning about this, right.

  Alex Raben: [01:06:06] And now a podcast episode. Thank you guys so much for being here. We really appreciate it and for taking us through various aspects of autism spectrum disorder and for giving us some resources to move forward with. So I just want to thank you all again and thank you guys for listening. And we will. Talk to you next time. Bye bye.

  Alex Raben: [01:06:35] PscyhEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Weam Sieffien, Gurnaam Kasbia, Sabrina Agnihotri and Alex Raben. This episode was hosted by Alex Raben and Sabrina Agnihotri. Audio editing by Jordan Bawks and Alex Raben. The accompanying infographic for this episode was created by Weam Sieffien and Nikhita Singhal. Our theme song is Working Solutions by Olive Music. A special thanks to the incredible guests Dr. Melanie Penner, Dr. Yona Lunsky and Dr. Mitesh Patel for serving as our experts for this episode and providing us resources for our show notes. You can contact us at podcast at gmail.com or visit us at Psych podcast dot org. Thank you so much for listening!

Episode 22: Psycho-Oncology Assessments with Dr. Elie Isenberg-Grzeda

• Episode 22: Psycho-Oncology Assessments with Dr. Elie Isenberg-Grzeda

  Jordan Bawks: [00:00:05] Welcome to Psych, the psychiatry podcast for Medical Learners by Medical Learners. This episode is an introduction to the subspecialty of psychosocial oncology. It's a big topic, and today we will focus mostly on how to approach assessment in patients with cancer. I'm your host today, Jordan Box, a fourth year resident in psychiatry at the University of Toronto, working at Sunnybrook Hospital. And that's where I've met my guest today, Dr. Elie Isenberg-Grzeda. So why don't you introduce yourself and tell us a little bit about yourself and your training background and how you came to be interested in psychosocial oncology?

  Dr. Elie Isenberg-Grzeda: [00:00:44] Sure. So first of all, thanks for for having me and for setting this up. So, as you know, I'm a psychiatrist here at Sunnybrook. My subspecialty training is in psychosocial oncology or psycho oncology, depending on which jurisdiction you're in. And, you know, essentially, I trained as a psychiatrist in residency at Albert Einstein College of Medicine in in the Bronx in New York, having really no idea what I wanted to do afterwards, other than maybe something HCL related. And one of my supervisors at the time, CL psychiatrist at my hospital, had suggested that I check out a program at Memorial Sloan-Kettering Cancer Centre. It's like a freestanding cancer hospital in New York City that they have a great CL fellowship program there. And even if I didn't want to work in cancer, it's a great training and the sort of thing that's generalizable to to other areas. So I said, sure, I went to check it out and I absolutely fell in love with it. I fell in love with the place and with the work and with the people and just really felt like a rich, interesting, stimulating area to to work in. So so that's where I trained for for psycho oncology. And for anybody who doesn't know what that is. I mean, essentially what we're doing is we're looking at the really the interface between mental health and cancer. You know, we treat patients, we treat their families, sometimes treat or support the oncologists. Yeah. And so that's the work that I do here at Sunnybrook at the Odette Cancer Centre.

  Jordan Bawks: [00:02:30] Cool. And before I guess we go any further, I'll just make sure that we outline our objectives for today, which are really pretty self-explanatory, which is that we want our listeners to become more comfortable with the sort of unique aspects of a history assessment formulation related to patients who have history of cancer. And our hope through this episode is that after listening to it, you'll feel more comfortable both doing consults and follow ups because we're going to cover a lot of different unique areas. Ever since I've done kind of some electives in psychosocial oncology, it actually opened up areas to talk about my other patients, like when I talk to people about meaning and about impact of illness, like although we'll sort of talk about this as though this is stuff that's specific to cancer, I think kind of like you hinted at with your fellowship at Sloan-Kettering. You know, the sort of the mindset that we bring to doing a psychiatric assessment in patients who have cancer is one that we can apply in multiple settings. So moral story is we want people to learn a little bit about that kind of mindset. So this the outline for today is that we're going to cover some of these unique areas of the assessment. We have about ten of them. And then we're also going to spend some time towards the end talking about diagnostic issues in psychosocial oncology. But before we kick into that, I wanted to let Dr. Elie Isenberg-Grzeda to talk about a little bit about the history of psycho oncology, because it's an interesting one.

  Dr. Elie Isenberg-Grzeda: [00:04:15] Yeah, for sure. And so, as you know, I find this area, the history of psycho oncology or psychosocial oncology very interesting. It's I mean, the history of medicine in general is is really interesting. And this is no exception to that rule. Cancer care in the 20th century is very was very different than than cancer care the way it looks right now in the 20th century. I mean, basically at the start of 20th century, you know, essentially cancer care was in its infancy. It was a very kind of rudimentary surgery based. A type of way of of treating people. And, you know, the surgeries were really not very well refined. Anaesthesia really was not very well refined. And so people kind of had these. You know, these tumours that were taken out and what felt like kind of barbaric procedures that, you know, would send us running if we were kind of given the option for those today. And so cancer itself was seen as something really, really scary and generally really, really untreatable. It was the sort of thing that came with connotations of. Of nihilism. Basically, cancer was synonymous with death. And if you could somehow avoid that fate from the cancer, then at the very least you'd be and you'd be left off with, again, some really disfiguring, barbaric, pretty awful surgical treatments and eventually maybe radiation. And then chemotherapies came about and. And anaesthesia techniques got a bit better and combined treatments came about. So chemo and radiation or surgery followed by chemotherapy or. And so slowly what happened probably around maybe mid 20th century is that there started to be a little bit more of a window of possibility when somebody was diagnosed with cancer beyond just death or suffering this inevitably barbaric, awful, torturous treatment.

  Dr. Elie Isenberg-Grzeda: [00:06:47] And. And so then cancer went from this thing that represented. Death and basically really awful potential outcomes to something that that maybe had a bit more breadth in terms of possible outcomes and people could start to talk about it a little bit more. Certainly there was still a lot of stigma, but maybe a little bit less so. And eventually maybe around 1960s, 1970s, there was this kind of confluence of factors where you had better treatments. People were starting to survive a little bit more than they had been. Breast cancer, of course, one of the most common cancers, and that coincided with the time of women's liberation movements. Sexual revolution. You know, the idea of things that were taboo coming out of the woodwork. And so even the word cancer, which wouldn't have been allowed to be published in many newspapers up until well into the 1970s, slowly started kind of making its way into more lay media. And so people started hearing the word more. Again, less and less stigma associated with it over time. And what happened when you had more people surviving, more people talking about it? People becoming very interested in advocacy and awareness and sort of social responsibility. It is as a field. We started seeing patients going through this type of diagnosis and treatment. And. Starting to need more care beyond purely the the actual cancer treatment. The surgery, the radiation, the chemotherapy. And in the way that this had happened in other areas of health care as well, is we started seeing psychiatrists, psychologists, social workers, nurses and even some oncologists start to take more of an interest in.

  Dr. Elie Isenberg-Grzeda: [00:09:13] Really the whole person. Beyond, let's say, the cancer itself. And what that meant was trying to understand what the impact was on people on their lives and. In as much as cancer caused distress. How we can actually help those people. And so that area of really the interface between health care, medical care and psychiatric care, body and mind essentially started to get looked at by more clinicians and researchers. And oncology was by no means the only area. I mean, certainly well into the 1980s, you know, there were many HIV psychiatrists, for example. But something about cancer psych oncology probably had to do with funding models. And again, just advocacy about cancer in general at the time really did help build a psycho oncology into what's probably the biggest of these subspecialty areas that that kind of rest at the interface of of medicine and and psychiatry. And so. You know, the field grew again. Cancer treatments got even better. Patients started living even longer. Many patients ended up surviving from their cancer. The cancer treatments issues of survivorship started to get looked at and again, the field continued to grow. There are professional associations. There's the American and the Canadian associations of psychosocial oncology. There's the international association. These are anywhere between maybe ten and 30 years old, depending on the associations. So, you know, not new, new, but certainly not associations that have been around for hundreds of years, like in some other areas of medicine.

  Jordan Bawks: [00:11:21] So what I'm hearing is that as cancer treatments progressed. Longevity increased. Also, morbidity increased as people lived with kinds of consequences of treatment. Some of the stigma softened to the point where people were kind of allowed and encouraged to start talking about it. Advocacy groups sprung up to sort of advocate for the well-being of people living with illness or diagnosed with illness. I always like to have that kind of context. Where is where is the field at now? Like what? What are the current things that psych oncology are grappling with? Where does it see itself?

  Dr. Elie Isenberg-Grzeda: [00:12:11] Yeah, that's a good question. So right now, and I'd say this is probably true for me the last ten or 15 years or so is we really seem to be in the era of distress and distress screening. And, you know, there's very good data out there to show that that we continue to really not pick up on people's distress all that well, generally speaking, in the oncology setting. And so there's been a lot of work done by research groups into creating distress screening tools that looks at not only psychological distress, the things that, you know, in psychiatry we tend to talk about and think about all the time depression, anxiety, but also physical distress, spiritual or existential distress, distress around social or practical concerns. And so really, where we are right now is in the era of distress screening. And and we're sort of veering into the era of how best do we then help people who screen high on their distress, on their distress screeners, for example.

  Jordan Bawks: [00:13:21] And like what role psychiatry would have in that? Because I imagine that I mean, this is certainly a bigger conversation than we're able to have just on this podcast today. But, you know, a certain degree of distress, I imagine, is a sign of actually psychological health in the face of certain diagnoses.

  Dr. Elie Isenberg-Grzeda: [00:13:39] Yeah, Yeah, that's absolutely true. I mean, the overwhelming majority of people will experience distress around the time of diagnosis and it's completely normative and the overwhelming majority of them will have their distress levels decrease right back down to baseline can take weeks sometimes, but that's the general pattern. And so you're absolutely right. Do we need to call psychiatry? Do we need to call anybody, frankly?

  Jordan Bawks: [00:14:03] And I imagine that that's one of the things that's on your mind when you're seeing people is to what degree is this sort of transient, expected healthy reaction and to what degree may this distress be, for lack of a better word, pathological or stock?

  Dr. Elie Isenberg-Grzeda: [00:14:20] Yeah, exactly.

  Jordan Bawks: [00:14:22] So maybe that's a good Segway to talk about the different areas to consider when interviewing somebody in a psycho oncology kind of setting the sort of unique aspects of the history. And just to be clear, if this is the first time that you're joining us or you're new to a psychiatry rotation, you probably want to go back to some of our earlier episodes on some of our basic diagnoses to to get familiar with the basic kind of aspects of a psychiatric history and a symptom screen. We've done episodes on the psychiatric interview. That would be a great place to start. So the areas that we're going to cover, I'm just going to quickly list them off. So we're going to talk about cancer history, beliefs about illness, physical symptom, burden, body image and sexual identity. Coping /mental health. Family and supports work and life disruption, disclosure of illness, religion, spirituality and death and dying. And in our show notes, I'll try and earmark the times that we are touching on each of these unique areas. But for now we can just go into them one at a time and spend a couple of minutes on each. And what are the kinds of questions you ask about and why they're important to you? So starting with cancer history, what are your typical openers? What are you really trying to find out?

  Dr. Elie Isenberg-Grzeda: [00:15:49] Yeah, so cancer history and this is an interesting one because this is basically also very generalisable to other areas of these kind of like medical surgical areas that overlap with psychiatry. We want to have a good understanding of what the medical situation is, plain and simple. And what's interesting about this is sometimes when I'm reviewing a case with a resident, we could be sort of well into the history before I actually hear about what type of cancer the patient has, why they're in hospital, what sort of cancer treatments they're receiving currently and. You know, of course, when we think about a psycho oncology consultation, when we think about it, psycho oncology assessment, the cancer piece is really front and centre. You sort of can't extricate that from the sort of overall situation. And so usually that's the sort of thing that we'll want to find out about basically right away what type of cancer the patient actually has. Many most patients have one type of cancer. Some people have the unfortunate reality of having two completely unrelated. So the type of cancer they have when they were diagnosed, what sort of treatments they've received, treatments come like a variety of different shapes and sizes and flavours, and there's chemotherapy, radiation surgery. And nowadays you hear people talk about targeted therapies and essentially having a good understanding of what treatments the patient has had, what those treatments have been like for them. Some of these are extremely onerous, some of them are painful.

  Jordan Bawks: [00:17:38] And what the treatments mean is also sometimes interesting to to get a sense of as well, like is this something that people are understanding is going to cure them? Is it something that they're understanding is to improve their quality of life and or whether they even know that at all? Like I encountered patients who like, yeah, they don't know. And that's distressing in itself. And I guess kind of like what you're saying is that the cancer history is almost like the skeleton by which we drape everything on. And I often that's advice that I give to junior residents when I often try to keep in mind as well when I'm interviewing any patient is to get if you can try and get a clear sense of what's been going on in someone's life and the most stressful thing that's been going on in someone's life, then it gives you an opportunity to both really understand that person and create timelines for things. So when you're hearing about something like Low Mood, it's like, well, in a setting of psycho oncology, did you know, was the low mood there before? You know, right at the beginning, Is it thereafter? Was it thereafter the chemo? Was it there after the surgery? Was it, you know, and by having those different time points, that gives you that kind of structure to jump around?

  Dr. Elie Isenberg-Grzeda: [00:18:58] Yeah, totally.

  Jordan Bawks: [00:18:59] Do you have like do you have a typical go to line? Is there any magic to this? Or like, how do you usually open this up?

  Dr. Elie Isenberg-Grzeda: [00:19:06] Well, so in reality, just by nature, by virtue of of the work that I do here as a consultant at the cancer centre, I always have access to the patient's chart. I've already seen the diagnosis. I have some sense of that kind of skeleton framework. I will usually tell the patient that, you know, that I received the referral from Doctor So-and-so and that I have some understanding of their cancer, their cancer journey thus far, and that I've read through the chart and I've read through their paperwork that they've done for me and but that I want to hear in their own words what the cancer journey has been like for them up until this point. If that's too vague, sometimes I'll ask people. So take me back to when you were diagnosed, and I can definitely say my experience. I don't even have to say diagnosed with cancer, Right? If you say to somebody, take you back to when you were diagnosed in this type of setting in the psycho oncology world, they they know what you're talking about.

  Jordan Bawks: [00:20:10] Our next area here is beliefs about illness.

  Dr. Elie Isenberg-Grzeda: [00:20:15] Yeah. So when we were talking about beliefs about illness, I mean, you know, this can sort of go two ways. Some people interpret this as illness understanding, which I think you were alluding to before. You're talking about does the patient know whether or not the treatments are curative, intent or not? And so there's an illness understanding or an understanding of treatments that are being offered sort of illness, understanding or awareness or health literacy. It kind of all lumps together. But I think what we're getting at more with this idea of beliefs of illness are how does somebody actually think they got cancer? And ultimately. I won't say always, but maybe almost always people have some sense, some belief. Sometimes it's completely rational. Sometimes they'll even tell you, I know this is irrational, but. But everybody, or almost everybody has some. Belief about where or how or why they got cancer. In my experience, it's often not rooted in scientific evidence. Many people are are well aware of that and they'll say, I know this sounds like garbage, and everybody tells me this isn't even possible, but I know it's because of that trip we took that time and and there was that that sort of like chemical smell in the hotel room. And and I know it had something to do with.

  Jordan Bawks: [00:21:43] And why why do you find that important to hear about or know about?

  Dr. Elie Isenberg-Grzeda: [00:21:48] Well, so sometimes it gives a sense of who the patient actually is, kind of what their own just sort of background is, what their relationship is with science, what their relationship is with their doctors or their treatment team, the extent to which they might require some. Myth busting, the extent to which they may or may not even be open to myth busting. And for some people and I tend to see this more. With people who have a real. Sense of control. Sometimes delusionally. So. A sense of control in their lives in the world and how things work. That consequences follow actions. Those types of folks that that sometimes there can be a sense of guilt that goes along with it. I know this. This has to do with that year that I had in that, like that really stressful job. Had it not been for that, then I wouldn't have. And so sometimes that can also be an area of of focus. Something worth exploring to see if you can try to help alleviate the person of that guilt, or at least of the distress that comes with it.

  Jordan Bawks: [00:23:06] Yeah, that I know you've we've talked about this in other kinds of settings when you've given this talk. It also follows with a kind of moralistic like Western attitude that we kind of grow up with. Good things happen to good people, bad things happen to bad people. So if I have a bad disease, it must be because I was a bad person. Yeah. And I've seen people really grapple with that, either believing that they were a bad person or trying to understand it, sort of like people with strong, certain spiritual faiths. I don't understand how this could have happened to me in this with the beliefs that I have.

  Dr. Elie Isenberg-Grzeda: [00:23:50] Yeah, that's exactly right.

  Jordan Bawks: [00:23:52] Moving on into physical symptom burden. You know, it's funny. This is actually one that overlaps also with some of our depression and anxiety screening symptoms. So this is always a tricky one. I've found and I've had junior residents or medical students sort of ask like, I don't even know why I'm asking about their energy. Like, of course they're fatigued, they have cancer. Like, of course they're nauseous, they're getting chemo. But at the same time, it's important to know, like just because we can't know the validity of the sort of symptom for depressive diagnosis may be in question. Does it mean that we still not important to know about what the kind of symptoms that that person is living with and to what degree they're bothered by those things?

  Dr. Elie Isenberg-Grzeda: [00:24:38] Yeah, exactly. So all of that is an extremely important reason to ask. I mean, these are all important reasons to ask and might get information that, like you said, will really help you understand the person and understand their experience. Another reason to ask these questions is because not everybody actually gets optimal symptom management, and we happen to be extremely lucky at this hospital. I think my colleagues in palliative care and parenthetically the palliative care docs are really the ones who who treat people's symptoms. They're really the experts in symptom management here and elsewhere. But at this hospital, they're really excellent. And and I think the oncologists are also really good at picking up on people's physical symptoms and knowing when to refer. But even with that, not everybody has optimal symptom management, not everybody who's been seen by the symptom management experts when they need to. And sometimes even in psychiatry and psycho oncology, we might be picking up on something that nobody's really asked about yet. And it's not that uncommon that I actually end up making a referral to palliative care.

  Jordan Bawks: [00:25:59] Because you're picking up on pain or nausea or something like that. And that's something we can do something about, right? Pretty quickly, Yeah. Next up, we have the area of body image and sexual identity.

  Dr. Elie Isenberg-Grzeda: [00:26:15] Yeah. So these areas are are really huge in the in cancer care and the cancer world and. I mean, let's face it, human beings are sexual beings and we all have body image. You know, these sort of internal representations of what our bodies are like and how they appear and how we feel sort of in our bodies. Sexual health is like a really big part of that, and sexual identity is a really big part of that as well. And so breast cancer, prostate cancer, colorectal cancers, right. Are three certainly on top five most prevalent cancers, maybe even top four lung is in there somewhere. Right. So breast, prostate, colorectal, these are cancer areas that really cause huge, huge impact on people's identity, on their sort of integrity of their of their body and in a way that really affects sexual organ, sexual functioning as well. We also happen to live in a world or in a society at least that sometimes a little sexually averse and stigmatising. And people don't always ask their doctors and they don't always share symptoms that they're experiencing. The oncologists don't always ask their patients. And so sometimes what happens when people are experiencing sexual sort of body image or issues related to sexual identity or sexual functioning during or following cancer is that they can, a, be experiencing these really unpleasant symptoms or experiences and then be actually kind of left with it alone in a very isolating, unnecessarily isolating way. And so issues related to body image, identity, sexual health, sexual functioning are critical. They're like a core part of the human experience. They're a part of the experience of cancer care. And so we really need to. Be better about, you know, asking.

  Jordan Bawks: [00:28:32] Yeah. Leaning into those kind of questions because I think it is, you know, people are it's already hard to open up to somebody that you've never met before who's kind of a stranger to you. And so to expect the majority of our patients to volunteer that kind of like aspect of their lives that's often so private, it's unlikely. I think it's a good reminder for us to that we should be the ones to open up these conversations and can play a role in kind of normalising these conversations and identifying these areas. At least just so someone else can hear about it and understand it and empathise with them. And they're pretty common experiences to.

  Dr. Elie Isenberg-Grzeda: [00:29:18] Well, that's it. And so not feel so alone. And patients will often say that is they didn't realise that this happens to everybody or this is so common. Or one thing I would definitely suggest to to trainees is really just to practice asking, even if it means starting like just practising in front of the mirror or, you know, in like a study group kind of thing, throwing around different questions, different ways of asking and literally getting comfortable with the words coming out of your mouth. Mm hmm. I mean, the last thing the last thing a patient wants is for their doctor to ask a really important question in the most awkward sounding way.

  Jordan Bawks: [00:30:02] Do you have any problems with, you know, that thing that people sometimes do? Yeah. Yeah.

  Dr. Elie Isenberg-Grzeda: [00:30:10] So don't do that. Yeah.

  Jordan Bawks: [00:30:12] Yeah.

  Dr. Elie Isenberg-Grzeda: [00:30:13] I'll usually actually start off just by asking about intimacy, you know, And I'll sort of normalise by saying that, like cancer and maybe certain cancers have a way of really, you know, negatively impacting on people's intimacy and, you know, has that been an issue for you? And, and usually people know what we're getting at with that. Sometimes they don't. And then I'll make it a bit more explicit and literally just use the words sexual functioning. Mm hmm. You know, might ask about intercourse and penetrative sex and and sort of the list goes on and on. But ultimately, what I'm trying to do is sort of start by something that's maybe less stigmatising, that's normalising for people, and eventually sort of building up to questions that that might feel a little bit more uncomfortable, but that are important nonetheless. Mm hmm.

  Jordan Bawks: [00:31:05] And this I'm just going following along in your slides and was cued to something sexual intimacy versus relationship intimacy. And I believe we had a talk this year by a couples therapist that you had brought in, and she was sort of mentioning that for many couples, they sort of rely on their sexual intimacy as a way of sort of being close and supportive in the relationship and getting through rocky patches. And when that is vulnerable or disrupted because of a treatment, then you don't have that thing to go to and rely on to stabilise the relationship. It's important to find other ways to navigate around that. So this is something that kind of is, for lack of a better word, intimately related to attachment and relationships and social functioning between partners.

  Dr. Elie Isenberg-Grzeda: [00:32:03] So yeah, and you know. We could sort of talk about this issue at length. But, you know, suffice it to say that that even when sexual intimacy takes a real hit because of cancer or cancer treatments or anything in between, there is still a degree of physical intimacy that isn't. You know, truly sexual, something like hand-holding, hand-holding or cuddling or a sort of physical closeness with one's partner that. You know, I often hear patients say seems to get something about the hand-holding, feels stronger, more loving, more tender, special or different than it did before. And so there is a. Really an ability to actually kind of further grow one's intimacy in a in a couple, even if true sexual functioning is impaired or sort of sexual closeness is kind of prohibitive, that there's still a way to to actually really kind of build upon and improve physical intimacy and closeness among partners.

  Jordan Bawks: [00:33:34] Mm hmm. And that's also another opportunity for a pretty early work. Like, that's not something that requires weeks and weeks of intensive psychotherapy, right? Like, that's stuff like basic psychoeducation and encouragement, normalisation that you can make an impact on. Yeah, on a pretty short basis. This is another good general area of assessment asking about coping.

  Dr. Elie Isenberg-Grzeda: [00:33:59] This is where we try to get a sense of how somebody is actually managing. And usually what I'll do is I'll ask sort of up until this point, what I would have been asking about was about the illness, about aspects of function or dysfunction that have come from the illness. So sexual functioning, for example. But now what we're doing is we're talking about coping and adjustment and how somebody is actually managing with the diagnosis or the treatments and the sort of emotional distress that that comes with it. And I usually yeah, I usually just ask in a very kind of open ended way and almost always that's enough to sort of spark enough conversation around these issues that, you know, that I can get a good sense of how somebody is coping. We can then sort of whittle it down all the way through the most kind of checklist we review of systems if if needed, but we often don't really need to to get there.

  Jordan Bawks: [00:35:04] Mm hmm. And when you say open ended, you're not I take it you're not sort of saying, how are you coping with that? You're rather than that you're saying how are you coping with your symptoms? How are you coping with your sexual functioning? How are you coping with that diagnosis? So it's tying it to those kinds of concrete things that the person's already told you that they're struggling with.

  Dr. Elie Isenberg-Grzeda: [00:35:26] Exactly. So relating it back to what they've told me exactly. You know, in the cancer world, generally, if I had to go for kind of one thing and one thing alone, what I would ask is how are they coping with the diagnosis? Yeah, that's usually just in my experience, sort of where where the money's at.

  Jordan Bawks: [00:35:43] Yeah, I find this question. You know, it's funny because, you know, we reference this as like a bread and butter thing we could do in our sleep as psychiatry trainees. And, you know, this is, this isn't actually something that I felt like I was good at until recently, like how useful this question is. You know, you can kind of use it to try and get symptoms like or are people withdrawing or are they not eating or are they? But I find this really helpful to to also look at people's kind of attachment styles, like, you know, is this the kind of person that's going to be talking to their partner like late into the night about this or just the kind of person who's going to pretend like nothing's happening? Is this the kind of person who is going to be looking up on the Internet like over and over and over? Are they going to be going to reach for natural health products or supplements or really, are they trying to rigidly control their diet or their medications? I find these kind of coping questions to be like really rich from a formula, like a formulation kind of perspective, just even in the way people kind of answer them sometimes. Like, what do you mean, coping? Like.

  Dr. Elie Isenberg-Grzeda: [00:36:51] Yeah, no, totally. These are like really, really like high yield questions and whether we think long attachment lines or personality inventory lines. I mean, either way, this question and the way people approach illness coping style really tells us a lot about who they are and actually about how they're going to manage moving forward as well.

  Jordan Bawks: [00:37:15] Yeah, Yeah. And then how we can adapt ourselves to perhaps like kind of meet them where they're at. Right. But like when you see kind of a particular coping style, you might want to adapt. Like if this is someone who kind of downplays their distress a little bit, then you're going to want to maximise their sort of sense of autonomy in this process and not go to too quickly for the emotions. And the other thing I find coping really helpful for is to normalise stigmatised areas like areas of coping, like people cope through being angry, they cope through drinking, they cope through withdrawing and avoiding and some of those things can be shameful. And so I find sometimes the coping language as a helpful way to get into that. You know, it's this sounds so hard. I am I, I imagine that you must get really desperate to deal with these kinds of feelings. And no wonder you've been drinking more.

  Dr. Elie Isenberg-Grzeda: [00:38:20] Mm hmm.

  Jordan Bawks: [00:38:20] No wonder you've been getting so angry. No wonder you've been pulling away from your friends. It takes away the shame. If we can connect that behaviour to their underlying pain or distress.

  Dr. Elie Isenberg-Grzeda: [00:38:31] Yeah, totally.

  Jordan Bawks: [00:38:32] So the next couple of sections, you may most naturally fit into a personal history asking about. So the first one is asking about family and supports.

  Dr. Elie Isenberg-Grzeda: [00:38:45] Yeah. So family and supports are always important, but they are particularly important I think in psycho oncology when people are often. Been getting treatments that they. Almost just can't do without some sort of support in their life. You know, a lot of radiation treatments require five or six weeks of coming to the hospital every day for 30 or 35 treatments in a row. Even if you can actually make it to the hospital on your own, like who's at home taking care of the kids and. Right. And often people can't make it to the hospital on their own. They really do need help. So it's not to say that people are doomed if they have no family or other supports, but it really makes things more challenging for them. And so having a good understanding of who this person's family is, if we're going to support people, where do we add kind of that extra cushioning, that extra padding?

  Jordan Bawks: [00:39:53] So how do you usually phrase questions like who? Who are your supports or who's supporting you through your cancer? Who's in your life? Yeah.

  Dr. Elie Isenberg-Grzeda: [00:40:02] So sometimes I'll, I'll say, yeah, any of those I mean often I'll ask people, I'll say, who do you have in your life to help support you through times like these? Usually once they've identified people that that they see as supports, I'll kind of ask them, you know, in what ways these people help. So what is the actual support that they give? You know, is this somebody who drives you to appointments? Is it somebody that you can call to vent to if needed? You know, is it somebody who will keep their phone on and let you call them if they if you get a fever and have to come into hospital? Is it you know, this also gives people the opportunity to talk about family members that might actually create more stress or distress in their lives that, for better or for worse, are very much part of their families. And as far as kind of doing an inventory of what the current context is, it's still really helpful to know who are the players in somebody's life that might sort of add to the stress rather than help alleviate some of that. Mm hmm. So it's really getting an inventory, I would say, of who's around, who's around and what they're capable of.

  Jordan Bawks: [00:41:15] Yeah, it reminds me a little bit of interpersonal therapy, the sort of interpersonal inventory where you're like, who is the closest? Who is. Who do you talk to when things are really bad? Like, who can you go to? Yeah. What are the people that you've told and maybe bring in meals or babysit or, you know, and this also, I think this is an area that also lends naturally to a big topic that I have found really interesting and challenging and working with this population around disclosure. So who knows exactly and why if people don't know, why not? And what's that like? And that's a very intense area for some people.

  Dr. Elie Isenberg-Grzeda: [00:42:03] Yeah, So that's a really, really good way to put it. It's intense. And, you know, the idea of disclosing the illness, who have you told and what have you told them is such a critical one? When when we work with folks going through this type of thing, because, number one, by not telling. Right, by not always disclosing, it's basically the equivalent of really having to keep a secret of putting pieces in place so that nobody spills the beans, so to speak. And that's incredibly stressful for people. On the other hand, if one is to disclose to their friends, their family, their kids, their parents, whomever, that's equally stressful. And so I think no matter how you slice it, there's this is a it's a very intense kind of stress laden topic that in most cases that I've been involved with tends to need some handholding, some support, some guidance, some education. It's not rocket science. I mean, essentially what we want to do is we want to be as open and transparent as possible, certainly with the people who are closest to us, people who will otherwise know and find out. You know, I think a big piece of this conversation involves what do we tell kids? Mm hmm. And so in a hospital like this, we don't it's an adult hospital. We don't treat kids here, but we treat a heck of a lot of patients who have their own kids and who often present with a lot of stress around this very topic of do I tell my kids and and what do I tell them? And the general rule is openness, transparency, honesty.

  Dr. Elie Isenberg-Grzeda: [00:43:57] Better to explain to them now why you're telling them something then? To have to explain to them later why you didn't tell them. And that includes using adult language, even for young kids. You know, a lot of parents want to protect their kids. All well-meaning parents want to protect their kids. And sometimes parents have a misunderstanding of of how best to protect them. And so they think by kind of hiding information from them or not telling them or sort of sparing them until they really have to know. And, you know, usually comes from the way they were taught implicitly or explicitly and how to deal with these situations. But invariably, what ends up happening is kids will find out from maybe an oldest sibling or a cousin or an aunt or opening the mail. We're seeing an email or picking up a phone call or sometimes from the backseat when mom or dad drives the other parent to the cancer centre. And if a kid is old enough to read, they can read the sign that says Cancer Centre.

  Jordan Bawks: [00:45:13] And also that kids are exquisitely sent. I mean kids are wired to. Breed their parents. Most cancers. Cancer treatments are going to have a visible impact. It doesn't matter how hard we try. You know, there's like infant literature that, you know, pre-verbal kids can pick up on moms who have been experimentally stressed or not stressed before they walk into a room. So that's you know, that's the kind of language I sometimes use, is, you know, how do you know that they know something's going on, Right? And so bringing bringing your children into that. To me. I know it's a sign of kind of respect, transparency, of collaboration, of openness, because kids have really active imaginations.

  Dr. Elie Isenberg-Grzeda: [00:46:09] Yeah. I mean, so at the end of the day, really what we know is that kids just do better when the parents are open with them. And I think it's for exactly the reason that you're alluding to is that kids have. Incredibly wild and creative imaginations. Even when they know that a parent has cancer, there's a way for them to imagine or fear that the cancer is worse than it is. Even if a parent's dying, there's a way for a kid to imagine that it's worse than it is. Maybe they're dying in pain, maybe they're dying and there's an afterlife and something bad is going to happen to them after. Or maybe they're dying and the kid is. And I'm next. Yeah, exactly. Yeah. So openness.

  Jordan Bawks: [00:46:54] And that's that. Ever since I learned this, it's really stuck with me is like the language as well is so important, right? To say like mommy or daddy is sick, like really loads sickness for someone who doesn't really understand it. All of a sudden, you know, the same word you're using for someone with the sniffles is the same word that's related to this horrible thing that you're witnessing that's stealing your parent from you. And so that the use of that language is so important to create a different category that allows the child to still be sick, just to interact with others who are sick and know that it's a different thing. Yeah, and there's an evidence base for this, right?

  Dr. Elie Isenberg-Grzeda: [00:47:38] Certainly there's a lot of literature out there, including different sort of age categories and kind of developmentally, typically at a given age category, what kids are able to comprehend and sort of what language to use with them. And usually as a general rule, from about the age of five onwards, we'd recommend just open, honest adult language, not euphemisms like sick or booboo.

  Jordan Bawks: [00:48:05] Or yeah, it's important for me to keep in mind when I, you know, sometimes I'll hear this and or I'll be thinking about this and think, okay, well, the right thing to do is for them to disclose. And I always have to be careful to hold that as well, because people go they go through their own process at their own pace. And, you know, obviously, if somebody hasn't told their child, they're doing that with the best of intentions. And if you're going to be able to work with somebody, they need to be able to know that you respect them, where they're. At Where they're coming from, and not to be judgemental about what they're doing or not doing or saying or not saying.

  Dr. Elie Isenberg-Grzeda: [00:48:38] So that's a really excellent point, is that so I will always praise a parent and reflect to the parent that they are trying their best to be a good parent and I'll usually ask them if they're interested in hearing what the experts say. And I tell them, Look, I'm not a child psychologist, I'm really not. But, you know, certainly I have lots of patients and I've studied this. And and there is a sort of commonly accepted sort of best approach. Are they interested in. Hearing what that is and sort of the aspects of what they've done already that that are really in line with that. Do they want to wait for another time or is this a conversation they don't want to have at all? Like, you know, really trying to to respect where they're at rather.

  Jordan Bawks: [00:49:27] Than just sort of dropping your exclusive knowledge? Well, you know, what's best is Yeah, yeah, yeah. Meeting people where they're at. So important in our field, the next area is work and life disruption.

  Dr. Elie Isenberg-Grzeda: [00:49:43] Yeah. So this is also a big area. I mean, this comes up a lot during active cancer treatment. So somebody diagnosed and they go in for whether it's surgery, chemo or radiation and and their bodies recovering and there's a period of time. Maybe a month, maybe six months, maybe a year, depending on the type of treatments, the type of cancer, where they might just simply not be able to go to work either because they've too many appointments and they're coming in for treatments too often, or the treatments really make them feel quite sick with side effects or get rid of their energy and they just can't sort of peel themselves from from bed. And and so that's one big area. And the other big area is this idea of returning to work after the cancer has resolved. Right. So somebody is done with their cancer treatments. They're in a phase of the journey that we most people would probably call survivorship. And the question of when to return to work, will I be able to return to work? Am I going to have the mental Energy and capacity to to really do the job that I used to do. Am I going to feel as alert? Am I going to be able to multitask? Will people be able to rely on me the way that they used to? These are questions that that almost invariably people have at some point. They become stickier for certain people. There are some people where the question is sort of resonates more with them and they have trouble kind of shaking it and where the issue of returning to work becomes the focus of the treatment, it becomes the focus of the pathology, if you want to call it that, although that might be a strong loaded term, but certainly the focus of the treatment.

  Jordan Bawks: [00:51:32] So this might be a big focus of distress for certain patients.

  Dr. Elie Isenberg-Grzeda: [00:51:36] Yeah, so focus of distress and there are actual sort of treatment interventions, programs that that are geared towards helping people get back to work.

  Jordan Bawks: [00:51:46] Well, I can't help but think of Freud's old saying right, that like, like his definition of mental health was to be able to work to love. So that's a fitting.

  Dr. Elie Isenberg-Grzeda: [00:51:58] Yeah.

  Jordan Bawks: [00:51:59] Then we're our last two kind of areas of assessment are ones that I think are somewhat unique to psycho oncology, or at least where you access the most kind of readily. One of them is the first one is religion and spirituality. How do you usually open this up in your assessments?

  Dr. Elie Isenberg-Grzeda: [00:52:22] Yeah. So, I mean, as far as religion is concerned, usually I'll, I'll start by normalising and actually this is probably something I do for, you know, for, for everything that I ask about is I'll, I'll try to normalise it and so I'll say, you know, for some people religion is a way that kind of helps them get through tough times, including through illness and, and through cancer and. So what role does religion play in your life? Something like that. Usually that's a good opener to let me know if religion is something that is important and the extent to which, you know, plays a role in the patient's life. Many people cope through tough times in life by drawing support from their religion, whether it's the people that they interface with. So, you know, parishioners or congregants, people in their religious community, or whether it's drawing on support from God, whatever God means to them. And for people who do do that, for people for whom religion does play that role, it is a big enough role that we'd be missing an aspect of who this person is if we don't ask about it. And so I'll be the first person to admit that sometimes even that question can kind of turn people off a little bit. There are people who are very anti religion and who are sort of, you know, turned off or at least quickly dismissive of that word and sort of all the connotations that it brings up for them.

  Dr. Elie Isenberg-Grzeda: [00:54:11] But again, in normalising it, usually even those people understand kind of where the question comes from, why we're asking about it. And I think appreciate the opportunity to appreciate the fact that we're sort of thinking about people as whole people. And so religion and spirituality, I mean, first of all, you'll find tons of different definitions on these. But the definitions that I tend to subscribe to are the following is that religion essentially is the stuff of divinity. Right. There's usually we're talking about something that's related to God, that there's often an organised aspect to it. Spirituality. It deals with the the essence of something bigger and greater than us. Not necessarily God based, right? It's not necessarily in the realm of divinity, but it looks at and thinks about something bigger than us as individual human beings. And so there are people who many people who will say, well, I'm a very spiritual person, but I'm not religious. I don't subscribe to a certain religion, I don't have a God, but I'm a very spiritual person. I feel like there's something sort of bigger than than me. There's. The idea of purpose. And purposefulness. And that's often associated with religion and the idea of a purposeful world. So a sort of God driven or higher power driven world, that there was a purpose and intention, usually as a concept that. That people think about when they think about religion. And it was sort of God based religion.

  Jordan Bawks: [00:56:23] And so I guess that kind of circles back to that earlier phenomenon I was referencing where people can sometimes sort of in if they have a belief structure in which there's a purpose to life and life's events, then they can be kind of sometimes put in a spin of what is the purpose of me having cancer?

  Dr. Elie Isenberg-Grzeda: [00:56:42] Yeah, yeah, why did I get cancer? Or for the really religious folks, Why did God give me cancer? This is the true essence of the phrase. Why did this happen to me? Right. Has a real flavour of purposefulness, as though there was some reason that this happened, that it. That there's a purposefulness to me having cancer. So whether or not people realise it or rather not, people mean it in this way, there's, you know, those, those questions are the stuff of religion.

  Jordan Bawks: [00:57:13] And I think this, you know, I've also encountered patients who have become more interested in spirituality and religion when faced with like a cancer diagnosis. People have said, you know, I never really thought about it until now. And my take on that is that it's related to our last area of assessment, which is around death and dying.

  Dr. Elie Isenberg-Grzeda: [00:57:37] What cancer almost invariably does, as you've pointed out, is it really makes people think about death and dying and thinks makes people think about their own mortality and love it or hate it. We are mortal beings, right? We are animals, and we are doomed to suffer the same fate as all animals, which is that we are going to die, all of us at some point, and human beings. You know, the sort of cruel irony is that we have the the the cognitive capacity to really understand our own awareness, right? To have an awareness of our own existence, the fact that we're alive now, that we won't always be so we have this cognitive capacity, but in the bodies of animals, right, the same animals that will end up dying if we get hit by a car, if we get cancer, if our heart stop at the ripe old age of whatever, if we get the wrong infection. Right. So we we are animal species that happen to have this really complex, high level brain functioning that allows us to be aware of our own existence. So there is a sort of almost cruel irony joke to it. Death, of course, is inherently scary. It's a scary concept almost universally so. And as a society, we've done a really good job at trying to avoid death as much as possible. So it's no wonder that we have you know, we're we're a culture of heroes, basically have the, again, very understandable need to sort of to sort of dismiss death from the realm of possibilities until we can't. And so sometimes, whether it's, as you said, some sort of cardiac event or in this case, cancer. All right. Sometimes that's just enough to really trigger people's sense of their own mortality and gets people questioning sometimes things that they have never questioned before.

  Jordan Bawks: [00:59:50] Before we move on to sort of distress as a diagnosis versus depression, how do you ask how do you ask your patients about this?

  Dr. Elie Isenberg-Grzeda: [00:59:58] So when it comes to working with cancer patients, in my experience, almost always people have thought about death and dying. They've almost always asked their doctors, or at least thought about asking their doctors. And so it's usually not the first time. If I were to ask about it. It's not usually not the first time that somebody has thought about this. And so in some ways, it's not as high pressured of a question or high risk of a question. And so usually I'll just ask people point blank if this is the type of disease where they've had to start thinking about death and dying, or is the type of cancer where they've had to start thinking about death and dying. There are times when it's the answer is obvious, right? And if it's obvious enough, I might not ask that question. There may have been other questions that come up. Usually I'll ask people if they've thought about asking their oncologist about prognosis, because again, it's on many people's minds. And oncologists don't always have the skill set to talk about prognosis in the way that's most effective and most meaningful for patients.

  Jordan Bawks: [01:01:22] What what would that look like, an effective and meaningful conversation?

  Dr. Elie Isenberg-Grzeda: [01:01:25] Yeah. So, you know, generally speaking, what patients what we've what we've all learned to ask is how long do I have? Right. It's what we hear people say in movies and TV. And maybe we've heard parents say or it is how long do I have? It's probably the worst question for somebody to ask, because essentially what that implies is that you have to have a crystal ball and that doesn't exist. And so it's sort of a meaningless question that can only get a sort of meaningless. Unhelpful answer. And inasmuch as that's the case, generally speaking, all that's going to do is sort of push the oncologist into a corner and they're going to usually say, well, you know, I can't answer that. You know, I can't answer that crystal ball. And so maybe, you know, when the time comes, I'll let you know. Don't worry. I'll let you know when we start talking about that. And so what's much more effective than that is, is actually asking what a best case scenario looks like and what a worst case scenario looks like. And, you know, with generally speaking, the oncologist should be able to quote sort of a median. Right. So 50% of people will be alive at this point. Let's call it ten years. And based on that, there are some calculations that they can do to essentially capture probably 95% of people kind of under what looks maybe like a bell curve.

  Dr. Elie Isenberg-Grzeda: [01:02:54] And to the right, there are some patients who will be these miracle cases, and maybe to the left, there will be some unfortunate people who died because they got hit by a car or for whatever reason, that was just completely unanticipated. But most people will fall between these two. Best case and worst case scenario. And there's the likeliest scenario as well, which is going to be something hovering around the median. But the reason patients find this this information more meaningful is because it allows them to have something to hope for. That's realistic if they're hopeful people and it also allows them to prepare for the worst if needed. And at the end of the day, knowing that knowing that we don't have crystal balls and that we only live in a world with as good information as the information that we've got, then what people really want is they want to be able to retain hope for something and also to prepare for worst case scenario so that they know that they're as ready as they can be. And then my job becomes or any of our jobs becomes about figuring out, well, how do we help support somebody? How do we help get them as ready as they need to be if that were to happen? And so ultimately, as far as kind of meaningful, applicable, useful information is concerned, that's generally speaking, what patients will find to be most useful. Yeah.

  Jordan Bawks: [01:04:22] And so you can also even kind of guide them in that process if they're not.

  Dr. Elie Isenberg-Grzeda: [01:04:26] Sure that's exactly it. And that's usually what I'll do is I'll tell them if they haven't yet had the conversations about prognosis or or if they haven't been satisfying and kind of gotten them the information that they're looking for, go back to your oncologist and ask it in this way. Best case scenario. Worst case scenario, Likeliest scenario. And then what do we have to do to get me ready for the worst case scenario?

  Jordan Bawks: [01:04:50] Yeah. Yeah. We've we've talked about a lot of different aspects of the assessment when we interview patients with a cancer history. How does all of this trickle down into questions of diagnosis? How do you synthesise a diagnosis? What's the use of the diagnosis? What are the relative pros and cons to having one, not having one?

  Dr. Elie Isenberg-Grzeda: [01:05:16] Yeah. And so you're talking about a DSM diagnosis. And so I think the overwhelming majority of patients that we end up seeing, if we were to sort of map their symptoms onto a diagnosis, it would be adjustment disorder, right? I mean, that's going to be the probably the most common and understandably so. There's a small percentage of people who will have a pre-existing psychiatric diagnosis, and in some cases the cancer then becomes something that might tip them over the edge, might mitigate their sustained remission, and or it might be something that seems almost inconsequential that the stress and trauma and burden of the psychiatric diagnoses that they've had throughout their lives just kind of dwarfs the cancer diagnosis. But generally speaking, it's actually that's kind of a small slice of the pie. What we tend to see a lot more is people who come in with what almost seems like normative distress. And it's a word that really, over the last maybe 20 years or so, has been a real push to try to use that term distress rather than the more pathologizing DSM diagnoses actually is a way of trying to get more people, more help. There was a thought that perhaps if we use diagnoses, if we say you're suffering from major depressive disorder and there's something more stigmatising about it, people might be less likely to to look for help, oncologists might be less likely to to sort of buy into that. And so distress was also kind of this user friendly word.

  Dr. Elie Isenberg-Grzeda: [01:06:59] But I think it also is a really great word to use. And as much as it sort of sums up the experience, I think for a lot of people, which is that there's this unpleasant emotional experience that they're that they're experiencing that can be mapped on to either psychiatric symptoms, physical symptoms, concrete kind of social, practical concerns, existential or religious concerns. And thinking about it that way then allows us to formulate and to then come up with a treatment plan that sure might include antidepressants or but it might actually be more tailored to some of the sources or foci of distress that the person's experiencing. And so, for example, if the emotional distress, psychological distress that they're experiencing is because they don't have any close family members to help take care of them as they're recovering from chemotherapy and well, So then the answer isn't going to be antidepressants. It's going to be maybe trying to see if we can hook them up with some home visiting nurse services, if their distress is about the finances, financial burden that they're going to have to incur by coming for radiation every day over the course of six weeks and the cost of parking that they have to pay and the fact that they're going to be missing work while they're coming here. Then again, antidepressants might not be the answer. The answer might be. And helping them with whatever sort of resources are out there to allow for compassionate, you know, funding finances.

  Jordan Bawks: [01:08:43] So I guess that ties back to these kind of specific areas that we're including in our histories is, you know, we're seeing people with a high degree of distress. And that distress may be in areas that we're not always tuned to as psychiatrists. Like I can imagine, you know, seeing somebody in doing an Capps depression screen and a gad screen and a panic disorder screen and a bipolar screen and a psychosis screen, and, you know, you could do a 45 minute assessment and miss like so much like you miss the core areas of distress. And, you know, maybe that person doesn't meet criteria for DSM five diagnoses, but that doesn't mean they're not in distress. And also that by doing a good history that covers these kinds of areas, we find places to intervene with them.

  Dr. Elie Isenberg-Grzeda: [01:09:35] Yeah, and that's really what we want to always, right, is, is the whole purpose of formulating period is to know how to actually have that effect. Are management or.

  Jordan Bawks: [01:09:45] Are you sure that it was just to impress supervisors.

  Dr. Elie Isenberg-Grzeda: [01:09:48] Well, there's that too. Yeah.

  Jordan Bawks: [01:09:52] So, you know, this is such a huge area and I hope that we can come back and talk about it more. I think one of the things that I'd like to be able to revisit is treatment. You know, like, how do we take all this information and how do we make decisions about medications? And I know that there are some kind of relatively unique medication decisions and in psycho oncology and also some unique psychotherapies. Absolutely, psycho oncology. So I do hope that we take the time to come back and take a look at those.

  Dr. Elie Isenberg-Grzeda: [01:10:29] Yeah, I'd love that.

  Jordan Bawks: [01:10:30] All right. Super. Any closing thoughts or comments? One of the things I'm actually wondering is you want to make an argument for why psychiatrists should do some training in this area. Like what? Why this has been meaningful to you? Why you think it's helpful for the general psychiatrists?

  Dr. Elie Isenberg-Grzeda: [01:10:53] Yeah. I mean, so so it's an interesting point about the training, because on the one hand, we can say that, you know, the recent stats about what do they say one in two people will end up getting cancer at some point in their lifetime. And I mean, this is like huge. And so you can argue that, well, every psychiatrist should be trained in how to do this. On the other hand, you could also say, well, this is becoming so common that psycho oncology won't even really need to be a thing, meaning it's own subspecialty area, because frankly, cancer is just going to be so darn common. Personally, I think that this is one of the most, again, enriching, stimulating areas that I could ever imagine working in. You really. Connect with people in a way that, you know, that really kind of enhances the human experience. Like my human experience. What people want at the end of the day is to feel understood, to feel like they matter. Sickness and illness really get in the way of that. And, you know, I think the work that we do in psycho oncology is on the one hand so skilled and sub specialised and niche in so many ways. But on the other hand is also just plain, plain old good work, just connecting with people in a human way, trying to understand their experience, helping them understand ways in which they do matter. And you know, there's never a day that goes by that I'm not stimulated. It's, I think, just part of what happens when you work in this in this type of setting.

  Dr. Elie Isenberg-Grzeda: [01:12:41] And, you know, we work with patients and their families, we work with the oncologists. It's just really there's so much breadth to it. I think the one very sort of kind of expert you almost just can't really get good at if you're not trained is the existential piece. And it could be that if we do connect again and talk about treatments and and all that, maybe we'll take a look at that as well, is, you know, understanding people in the human experience and the type of existential distress that people can experience when they're faced with something like this, like cancer, knowing what to ask, how to ask it, how to address it, and how to sort of help re ground people when they're so they're in such existential crisis, I think is a very kind of skilled process without being trained in it. You really just can't do it all that well, all that skilfully. So that would be one my one pitch in terms of whether everybody should be trained in this or not, I'd say everybody should be trained in that. And I think that is part of the work that is also then generalisable to other areas of of psychiatry, other areas of consultation liaison psychiatry, other areas of medicine in general. And it's rich. It's really like one of my favourite parts of my day is when I'm doing that type of existential work.

  Jordan Bawks: [01:14:08] Well, I, I hope we do find the time to do that and trust that we will. I'll be around Stony Brook for another six months, even though I'm leaving the service. Try and come back and do more of that.

  Dr. Elie Isenberg-Grzeda: [01:14:20] You're going to be missed.

  Jordan Bawks: [01:14:21] Yeah, I'll miss you guys too, but I'll see you around. And now our voices will live forever in the internet.

  Dr. Elie Isenberg-Grzeda: [01:14:28] Awesome.

  Jordan Bawks: [01:14:30] So thanks so much for giving me your time this afternoon.

  Dr. Elie Isenberg-Grzeda: [01:14:33] Yeah, you're very welcome.

  Jordan Bawks: [01:14:35] Look forward to hopefully having you back.

  Dr. Elie Isenberg-Grzeda: [01:14:37] Great. Thanks, Jordan.

  Jordan Bawks: [01:14:38] You're welcome.

  Jordan Bawks: [01:14:41] PsychEd is a resident driven initiative led by residents at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced, hosted and edited by Jordan Bawks. He therefore takes credit for any and all imperfections and errors. Our theme song is Working Solutions by all Means. Special thanks to the generous Dr. Elie Isenberg-Grzeda for serving as our expert for this episode. You can contact us at PsychedPodcast@gmail.com or visit us at PsychedPodcast.org Thank you so much for listening. Catch you next time.

Episode 21: Motivational Interviewing with Dr. Wiplove Lamba

• Episode 21: Motivational Interviewing with Dr. Wiplove Lamba

  Dr. Lucy Chan: [00:00:05] Okay. Hey, listeners, this is Lucy Chan speaking for this month's episode. We're excited to travel to Quebec City to be at the Canadian Psychiatric Association's annual conference. Alex and our experts were able to find a small meeting room in the Hilton Hotel to discuss the ins and outs of Motivational Interviewing, otherwise known as MI. Alex also volunteered to undergo some MI himself, and we're hoping to get a sense of his experience, and we hope that it will also benefit you in your understanding of Motivational Interviewing. So let's get started!

  Dr. Alex Raben: [00:00:50] Welcome to PsychED, the Psychiatry podcast for medical learners by medical learners. Today we're going to be doing an introduction to Motivational Interviewing or MI. This is a special episode because we are actually at the 69th annual conference for the Canadian Psychiatric Association or the CPA in beautiful Quebec City, Quebec. And I'm joined today by three experts who presented at the conference on MI for over how long? It was a number of hours, and I joined for some of it and it was wonderful. I'm going to get them to introduce themselves to you now and we'll start.

  Dr. Wiplove Lamba: [00:01:32] So my name is Wiplove Lamba. I'm a psychiatrist who works primarily in addiction in Toronto, and I've been in practice for now about five, six years after finishing actually probably closer to seven since finishing my fellowship. I was first exposed to MI in residency and then in my later years, that's where I actually learned the skills. I was lucky enough to have a mentor, Tim Guimond, who was running the MI clinic and we had about six observed interviews using the MITI Scale and it was after that I really felt I could bring in that language because in psychiatry, I thought were so good at the diagnostic assessment and MI is a slightly different skill. And around that time, I also realised that a lot of people don't have this training and so how do I learn to guide others and picking it up? And so there were some great people at Camh that Carolyn Cooper and Stephanie and Tim Gordon who really helped me pick up those skills there through running workshops.

  Dr. Alex Raben: [00:02:35] Great, and Marlon.

  Dr. Marlon Danilewitz: [00:02:37] Hey there. My name is Marlon Danilewitz, and I'm a PGY-5 psychiatry resident at the University of British Columbia, and I'm also an Addiction Medicine fellow. For me, my experience with MI came through in that context of the Addiction Medicine Fellowship and having taken a few courses there. And it was really a fundamental part of my training that helped me to work with populations in Vancouver and the Downtown Eastside who really struggle with drug addiction. So that gave me a tool to engage them and also provide for me a way of resilience in working with some really challenging groups. And it's been a fundamental part of my training and it's something that's inspired me to continue working with that population. And it's been a tremendous experience now to present at this conference with such a great team of other collaborators and so awesome to be here today.

  Dr. Alex Raben: [00:03:34] Great. And last but not least Anees.

  Dr. Anees Bahji: [00:03:37] Now, my name is Anees Bahji. I'm a fifth year psychiatry resident at Queen's University, and most of my experience with me has actually come from working with Wiplove. But I was lucky enough to get to do concurrent disorders work in PGY-2 with Nadeem Mazhar. He was our former program director and he was an addiction psychiatrist and he really emphasized how important MI is as a core skill to being a good psychiatrist, even if you don't do addictions. And I also heard about this book "Getting to Yes"aAnd it actually turned out to be more or less about motivational interviewing. So I realised if I could learn that skill, I might be helpful in getting to yes outside of psychiatry. So, over the past couple of years I've done a few workshops and seminars and I've been able to get a little bit more experience with learning about MI and also being able to teach it to other people across the training spectrum.

  Dr. Alex Raben: [00:04:37] That's great. So we have a wealth of experience between all of you and from different areas of the country as well. So that's great to have all of you here today. So thanks once again. And as you know, I'm Alex Raben and I'll be hosting today's show. Before we dive right in, I'm going to start with the learning objectives. So by the end of this episode, you should, number one, be able to define MI or Motivational Interviewing and describe its utility number to appreciate some of the techniques that are used in MI to increase motivation. And number three, be able to use in the real world some of these techniques or start to use them with your patients. Okay. So now that we've done introductions and done the learning objectives, let's jump into the questions and anyone can feel free to jump in. But my first question is essentially, what is MI? How do we define it? And how is it separate from other types of psychotherapy? What defines it?

  Dr. Wiplove Lamba: [00:05:46] This is a great question and makes me wish that I had my slide deck. I mean, there's a lot of different definitions that are out there and I don't know the current most recent one. For me, motivational interviewing is really about the language of change, how we work with someone to bring out in them, evoke in them the reasons to make those changes where they're in the driver's seat and we're a bit more of a guide in some kind of way. Luckily, Merlyn has the definition here in front of us, and I'm just going to read that out so our learners actually get that. So this one is motivational interviewing is a collaborative, goal oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual's motivation for and movement toward a specific goal by eliciting and exploring the person's own argument for change. So it was similar to what I said, sort of that I think for medical school you definitely need a clear definition, especially if you're asked a question on a test of some kind.

  Dr. Alex Raben: [00:06:57] Yes, exactly. So as you said, it sounds like it has to do with contributing to that person's change, but they're the change that they already have in mind for themselves, is what I was hearing in that definition. But I wonder, I'm going to push a little bit, because I wonder how that differs from other types of psychotherapy, where a lot of the time we are saying or we are doing that for some degree of change in the person. What makes MI unique or what is different about it? Do you guys think compared to something like psychodynamic therapy or CBT?

  Dr. Anees Bahji: [00:07:34] So the really cool thing about MI is that its theoretical foundations are a bit different than other forms of psychotherapy and I'm not sure if even calling it MI psychotherapy is fully appropriate because it's probably more of a conversational style. That is then also similar to psychotherapy because it's a therapeutic style. So one of the things about MI is this idea of ambivalence and it also has to do with the Festinger's theory of cognitive dissonance. So where it strikes a chord in difference from other psychotherapies is that you're not using that theory or that principle outside of MI. It's sort of unique to me where you're trying to help the person work with their inner ambivalence to promote change. The other is that you're also thinking about the stages of change models. So that's the Prochaska & DiClemente transtheoretical model. So those two elements are really at the heart of of the foundation of MI. And that's unique to MI from other forms of psychotherapy.

  Dr. Alex Raben: [00:08:45] Right. So it's, as you say, a more of a perhaps conversational or a style of conversation in some ways, but has some commonalities. But the theoretical underpinnings are different in that it works really with the ambivalence and the stage of change. Is that correct?

  Dr. Anees Bahji: [00:09:07] I think it's a pretty good way of putting it.

  Dr. Alex Raben: [00:09:11] Maybe this also gets at some of the same thing, but what do you think motivated the creation of MI? What was the niche it was filling that other therapies or ways of being in the room with people were not accomplishing?

  Dr. Wiplove Lamba: [00:09:31] For Motivational Interviewing, it was really heavily influenced by Bill Miller and he was trained in psychoanalytic psychodynamic psychotherapy. But most of his work was done using Rogerian therapy from Carl Rogers was a very humanistic approach. In the eighties, he wrote a paper and then Steven Rollnick and I can't remember if he's from New Zealand or Australia read that paper in the early nineties and started doing that therapy on his own. And then randomly he was at a conference and he saw Bill Miller and he's like, "Hey, I'm doing your therapy". And he's like "What therapy?" And then it's like, "Oh, that paper you wrote a while back." And then it started to get a little bit of momentum in that context. Bill Miller's style really came from New Mexico, where in the addiction world AA has taken over, and AA is phenomenal. For some people. It's very top down, higher power and there are certain people and I suspect some of the people that we see with some maybe some oppositional trades people that need to have their own reasons for sort of doing things where it wasn't working. And so it really was something that developed in I don't want to say opposition maybe in parallel to AA that was separate but I think was really shaped by the psychodynamic psychoanalytic with a huge emphasis on Carl Rogers. And whenever I've seen Bill Miller speak, he has like ten slides just talking about Rogerian therapy.

  Dr. Alex Raben: [00:10:51] So was it born out of addictions management and treatment then?

  Dr. Wiplove Lamba: [00:10:56] Yeah, so both Miller and Rollnick were using it for alcohol use disorder when they started using it and then it slowly evolved to other areas as well. And Anees and Marlon, feel free to add anything at any point because I'm sure both of you have unique things to contribute for any of these questions.

  Dr. Anees Bahji: [00:11:15] There's some early videos where you can see Carl Rogers interviewing a patient named Gloria, and those old videos are on YouTube. And really, it was sort of as I was saying, it's really born out of this Rogerian skilful, reflectful listening and there's very little advice giving in that style. So it's a very interesting style. And I think a lot of psychiatry residents, we watch those videos just to get a sense of where it came from. And you can see how it was shaped further with Miller and Rollnick's applications.

  Dr. Alex Raben: [00:11:50] Right. And this makes me think of the idea of the spirit of MI which I know is a very central concept to the essence of motivational interviewing. Can we talk about that? What does that mean, the spirit of MI?

  Dr. Marlon Danilewitz: [00:12:07] I think there's like a number of ways to talk about like the spirit of MI. And one of the ways we work in MI is using different mnemonics. So perhaps in this context to share one of those. So the mnemonic for the spirit of MI is "PACE". P stands for Partnership, A stands for Autonomy, C for Compassion and E for Evocation. And it's a great acronym because it gets across the context of what MI and what it's not, and that it's a partnership, a collaborative experience between the client and the therapist, and not a hierarchical form of communication where we're pushing one particular message and the autonomy gets at that really what's happening here is in the control of the individual and that we're working with them, their strengths to help get to towards the answers that lie within them. See, the compassion aspect deals with the fact that this is really an empathic therapy where a lot of genuineness and reflection and validation affirmations come and help to provide such an important aspect. And the last part, the E for Evocation reflects that the core answers lie within the individual themselves, that it's not about providing for them external information, that the message is within you. And that's really, I think, what the heart of MI and the spirit. And I think what would be most useful for learners is getting the spirit.

  Dr. Alex Raben: [00:13:48] And thank you for unpacking that, Marlon. And I think that's quite helpful in terms of understanding a little bit beyond the definition, what MI is actually about. And so as you were alluding to, there's lots of acronyms in MI and this is the first "PACE". So Partnership, Autonomy, Compassion and Evocation. I think I got that right? Okay. I'm getting the thumbs up. So that's something that can be helpful to to keep in mind. And later on, we're going to be doing a demonstration of MI. So keep these the spirit in mind while we go through that. Okay. So Wip, something you mentioned was that, the origins of MI was really around the treatment of alcohol use disorder. So I'm imagining that you use MI in that disorder? But are there other patient populations we use MI for? Like if I have someone who's in front of me who's depressed, is that an appropriate therapy? Who is MI tailored for in terms of patient population?

  Dr. Wiplove Lamba: [00:14:54] For me I believe it can be used in any clinical encounter. And every year, if you look at the number of publications in PubMed, they just keep going up and up. And so it includes medical management adherence and other disorders as well. There was a great study out of a group from York where they did an RCT comparing CBT alone versus MI plus CBT for Generalized Anxiety Disorder. And the group with both did phenomenal compared to the ones who just had the CBT piece for it. For me, it's sort of what Anees was saying earlier, where it's more of a tool for engagement. It's a way to have that dialogue and it's a way to potentially set the stage for some structured kind of treatment. It's almost a special way of gift wrapping it in some kind of way. And even when you talk to Bill Miller around it, he'll usually just do two or three MI sessions with someone and then they'll move on to whatever else it is that they plan on doing. So it's almost like this complement thing as opposed to a separate thing for some people.

  Dr. Alex Raben: [00:16:05] So if I'm understanding correctly, rather than other types of psychotherapy where you have a course and it may for CBT for instance, be like 12 to 20 weeks, you meet once weekly for an hour. It sounds like MI is a little bit less structured and is actually more of a style of talking to people that you can incorporate in your day to day and perhaps do a couple of sessions.

  Dr. Wiplove Lamba: [00:16:31] Yeah, absolutely. It's a bit of a starting point for engagement to get them on to board to other kinds of treatments.

  Dr. Alex Raben: [00:16:41] Is there a recommended length for a session if you can even have kind of a session in MI or what would the literature generally do in that instance?

  Dr. Wiplove Lamba: [00:16:54] So I'm not really sure about the answer for the ideal time frame for MI. Once you go through the training, you almost incorporate that spirit and sprinkle it in for a lot of different things. There is clear evidence for MI for HIV risk, diet, exercise. There's stuff for groups and stuff as well. That's there. I just remember hearing Bill Miller speak maybe he'll do three sessions for about 30 minutes to an hour and then have the person move on to whatever the next treatment is for them.

  Dr. Anees Bahji: [00:17:35] Maybe one thing I could add, I've noticed in the literature is that there's MI and then sometimes it gets operationalised into this Motivational Enhancement Therapy and then that can be turned into a module or I've seen it incorporate into some randomized controlled trials. So even some of the research out of Toronto where they're doing treatments for Cannabis Use Disorder, where they're testing a pharmacotherapy and they might have adjunctive motivational enhancement therapy which is actually it's still MI based. So it can be used in that way quite well but it's based on MI.

  Dr. Alex Raben: [00:18:11] Right, so MI seems to be quite flexible in terms of time frame and how you incorporate it. And then some people will take that a step in a different direction and they'll formalize it a little bit and call it something slightly different. That makes sense to me, and I think that's quite different than other psychotherapies. So it's interesting. If we now turn to how we actually do MI, I'm wondering like, what does it look like when you're doing it on someone? What are the techniques you're actually using in that encounter that make this conversational style, so to speak, different?

  Dr. Wiplove Lamba: [00:18:56] The key ingredients for Motivational interviewing is for basic interview skills, and they love acronyms and motivational interviewing, and so they use the "OARS" acronym for this. So when you're watching an interviewer, the things that'll be coming out of their mouth, if they're doing MI or Open-Ended Questions, Affirmations, Reflections and Summaries, and it's almost like a recipe where you can pick the dose and the amount of each one's those to use and the ways to use them as well. When you hear these words, they're really straightforward, considering the complexity that we're used to doing as health care providers. It's also something that doesn't always come naturally because in medicine we're so good at getting a focused history, figuring out what the problem is. We're not used to having this dance and dialogue to elicit more things.

  Dr. Alex Raben: [00:19:50] So that's helpful to have another acronym "OARS" Open-Ended Questions, Affirmations, Reflections and Summaries. Can we unpack what each of those words mean? I know they sound somewhat self-explanatory, but I think there's probably a bit of meat to each of those.

  Dr. Wiplove Lamba: [00:20:07] So closed-ended questions would have one or two answers: What is your age? When did you start school? To make them open-ended would be more like: Can you tell me a bit about yourself? Tell me a bit about how school was like for you? Things like that. There will come points where you will need to direct them more, but that's just sort of a way to start. For me, affirmations are one of the key skills for Motivational Interviewing, and when I'm doing a psychiatric assessment, I'll sprinkle those in throughout any time. Someone talks about a skill, something they've worked for all affirm it in some kind of way with the statement that was really important to you. "You really care about your mother", "Your health is something that you really want to work on". And then I stop and then I wait and I see what comes up then. It's surprising how many of our patients get such little encouragement and how many of them that it's hard for them to see their accomplishments at their values, and sometimes they'll even say stories. I see a lot of people with depression and for some of them certain days, it's a huge accomplishment to get out of bed. And when they hear that, it can sometimes hit them because it is a huge accomplishment on some days to get out of bed. Reflections are probably the most challenging skill, at least for me they were to pick up. And these are statements that we use and there's various different kinds, simple and complex. Simple have to do with repeating what the person is saying, paraphrasing, getting the gist and the complex are where we're sometimes strategic on the statements we take and give back. Sometimes we can add emotion to it, sometimes we can add extra meaning to it as well. Summaries are almost like a bouquet of reflection, so it's almost like you hear the full interview and then you selectively pick the points that you want to share and bring out and repeat for them to hear as well. And it's also a way that people can really feel heard.

  Dr. Alex Raben: [00:22:11] Thank you. That makes a lot of sense. The one that sometimes gets me is affirmations. But if I understand what you're saying, it's rather than just reflecting, you're actually putting a positive you're emphasizing the positive of what that person is doing with the statement you're making. Is that what differentiates an affirmation from just simply reflection?

  Dr. Wiplove Lamba: [00:22:31] I mean, affirmation. People do say it's a type of reflection. I see it's commenting on something positive in them. And the key thing about that is because, I mean, you could praise anything someone does, you can say, "Oh, I like your hair" or "I like your jacket", "I like" whatever it might be. You want to find something that's a genuine praise and feels authentic from within when you when you do it. There are certain people where it's not hard to get out of bed. And if you don't believe it's you think it's really easy for them to talk about and you say, "Oh, it's so great that you came in saying you go to bed", people are really good at picking up the nonverbal and the inauthenticity that sometimes comes with it as well. Usually we really try to affirm the strengths and values, especially when the person's less ready for change as well.

  Dr. Alex Raben: [00:23:14] Gotcha! And I understand there's two kinds of reflections broadly anyways, simple and complex. What are what's the difference between those two things?

  Dr. Marlon Danilewitz: [00:23:29] Yeah. So I think that really gets to an important aspect. So I think simple reflections have to do with just repeating back kind of the virtual statements kind of parroting back, whereas more complex reflections get beyond just what was said in the content and get to perhaps some of the underlying emotion values it brings together more than just what was at the surface level.

  Dr. Alex Raben: [00:23:57] Can you give an example of those, like what would be an example of a simple reflection versus a more complex?

  Dr. Marlon Danilewitz: [00:24:06] So if someone said "I had a rough day" and yet said back to them "it sounds like your day was pretty lousy". That might be more in keeping with a simple reflection, whereas taking into account what they were saying before, you might respond back with a complex reflection saying "It sounds like you've had a really challenging day and it's really had an impact on your relationship with your wife at home, and it's really seeming to be overwhelming for you".

  Dr. Alex Raben: [00:24:41] So you take it one step beyond. You make some inferences when you're doing a complex reflection.

  Dr. Marlon Danilewitz: [00:24:46] Yeah, you kind of have to take a little bit of a leap with a complex reflection, and sometimes you're right on the money and sometimes you may be a little bit off. But it also helps to, if you're able to follow with that, develop a stronger rapport with the individual.

  Dr. Alex Raben: [00:25:03] So to kind of summarize what we have so far, we've defined what MI is we talked about the spirit which is "PACE" Partnership, Autonomy, Compassion and Evocation, evoking what the person already has inside of them to help them with change. And then we talked about the "OARS" acronym, which is how one actually talks in the room with the person using Open-Ended Questions, Affirmations, Reflections and Summaries. But how do we know we're accomplishing what we're setting out to accomplish, and what are we trying to set out to accomplish with MI if that makes sense? How do we measure our our success? How do we know where we're going?

  Dr. Wiplove Lamba: [00:25:49] What a fantastic question! So when we're doing workshops on MI, I mean, we can cover the didactic within an hour. It's all done through experiential exercises. And once people learn the skills. But what the therapist says, eventually they start picking up what they're listening for in the conversation. And the thing that we listen for is something called "Change Talk". And there's different kinds of change talk; there's Preparatory Change Talk, there's the Action Change Talk and there's also an acronym as well. I feel weird sharing all these acronyms because the learning happens through the experiential exercises when you're training, it doesn't happen for memorizing the acronyms. And I know that from my own learning, I memorized the acronyms I wasn't doing it by and then I go through the experiential I get it. So, Preparatory Change Talk is about desire to change, ability to change, reasons to change and need to change. And so whenever you hear somebody say something like "I want to", "I can" "if this then that", "I need to", "I have to". These are the things that you want to try to encourage. And you can even go further for the Action Change Talk, which is commitment, activation and taking steps. One thing to remember is that Change Talk is that there's opposite end of it as well, which is Sustained Talk. And they're two sides of the same coin. And the whole goal that you have when you're working with someone is you listen very carefully what they say. You're very strategic and the reflections and things that you respond with and you really want to soften the Sustained Talk. So Sustained Talk could be like "I need to smoke", "I have to smoke to sleep at night" whatever it might be. So soften the intensity of that and then amplify the other side of it where it's like "I really care about my health", "I can't be coughing every night", "I want to play soccer with my kids".

  Dr. Alex Raben: [00:27:42] That makes sense to me. So there's with ambivalence, we haven't really talked about ambivalence too much, but my understanding is that it's kind of a conflict in a way or there's two sides to the coin, as you're saying. So one side of yourself may want to continue doing the thing you're doing, and then another side of yourself does not. And the Change Talk would be heading in one direction, the Sustained Talk would be heading in the opposite direction, and they can be at different levels of intensity. So sort of preparatory, I'm thinking about that versus action like "tomorrow I will do this".

  Dr. Wiplove Lamba: [00:28:19] Yeah. And there's also this thing in Motivational Interviewing where it's like I believe as I hear myself speak. And so there's something that happens when people start to verbalise those things inside. We have all that stuff. I mean, I'm sitting right here. We got some of this hotel dessert in front of us and I'm going in both directions the entire time. Part of me is like "Oh, I'd love how it tastes right now. I'm really tired. I need some energy". And then I'm thinking about, like, how I've started some cardio. I've convinced my wife to let me pay for a trainer short term. Every time I eat this stuff, it shows on the scale. And both those sides are going very well. And it's almost like by verbalising the part that's important to me, I'm more likely to do it. And the great thing about Motivational Interviewing is that a lot of the research they've done, they actually have psychotherapy researchers where they code the words that are being said. And they find that at the end of the interviews, if you have more Change Talk, the person is more likely to make the behaviour change as well and there is some literature in that regard to.

  Dr. Alex Raben: [00:29:16] So that does seem to be part of the driving force of MI is getting some of that Change Talk, I see.

  Dr. Wiplove Lamba: [00:29:22] And preferably around the end of your interview as opposed to having that Sustained Talk at the end. So say if we're talking about this dessert thing and we finish off and the last thing I'm saying is that, "Oh, it looks really good" and I walk out, I'm going to be more likely to have it. But if as you walk out, I'm thinking more about my health, how I don't want that sugar crash afterwards, I'm going to be more likely to not eat something when I leave.

  Dr. Alex Raben: [00:29:45] Right. I know we talked about the process of MI already but how do we get more change talk? What are some specific techniques that allow us to drive that Change Talk? It sounds like ensuring we get it at the end of an interview is helpful, but are there other ways to support that?

  Dr. Wiplove Lamba: [00:30:06] When we go through workshops, there's all these questions that we typically do that try to evoke things in people in some kind of way. There's one question where they it's like this imagination question, a dream question for the future "What would you like that to be in some kind of a way?". Maybe I'll let Marlon or Anees share a little bit because I know they've talked about this recently.

  Dr. Marlon Danilewitz: [00:30:34] So, I think that's a great question. And there's like a whole variety of ways you can do it and I think it depends on the individual. Things that I've tried before that are perhaps helpful is one like what's called like an Importance Ruler. So speaking with the person and helping to put on a scale, so to speak, where they might say their motivation is on a scale between like 0 to 10, their confidence with changing on a scale of 0 to 10 and then engaging them in a conversation around where they might fall on that scale in terms of eliciting the reasons why it wasn't lower or higher to create some kind of curiosity with where they actually lie. And that oftentimes elicits new reasons for wanting to change and helps to generate more insights into what's going on internally. Other things that are helpful or kind of considering where things might be in a few years from now, or looking back of where things were before and helping people to kind of get a better sense of what their internal values are and their goals are. That also helps to sharpen people's motivation.

  Dr. Alex Raben: [00:31:47] Gotcha! And just going back to your ruler question, Marlon, because I learned this just recently from you guys. It kind of matters which direction you say that question, right? So you ask them to rate themselves on a scale of how important it is to them. And if I say a five, then it's better to ask why not a four than it is to say why not an eight, isn't it? Or am I maybe I'm missing that up?

  Dr. Marlon Danilewitz: [00:32:16] Yeah. So I think you're right on the money. So sometimes it's helpful to ask people why not a lower score in particular, because that often helps them to consider what is actually motivating them to get back to their core values. Whereas if you were to ask people why not a higher number, so to speak, in my attempt to kind of occupy the conversation over obstacles or barriers or reasons why it's not the most salient value for them at that particular moment.

  Dr. Alex Raben: [00:32:50] More ustained talk too potentially.

  Dr. Marlon Danilewitz: [00:32:53] Right. Well, I'm glad you took away something from our show.

  Dr. Alex Raben: [00:32:58] No, it was very helpful. And I think you guys summarised nicely at the end. You had all of us take away something. But I guess I've taken away two things now. We've spoken a lot about what MI is in the abstract and we've tried to use examples here, but what I'm thinking might be most helpful for our listeners is to actually do what we call a real play and demonstrate live or I guess this is recorded, but we'll try to do one take, we'll see how it goes. How this actually works in reality, what it sounds like. So I am volunteering myself to do the real play. So I'm going to bring something that I'm ambivalent about to the group and then Wip is going to be doing the actual MI and a Anees and Marlon are going to be evaluating and listening in to allow for a more fulsome debrief at the end. So we can point out some of the techniques to you guys. Are you guys ready?

  Dr. Wiplove Lamba: [00:34:13] Sure. Let's try this out. And Anees and Marlon, are you going to be using the "EARS" Exercise or the MITI? Okay, perfect.

  Dr. Alex Raben: [00:34:22] So, we're referring to some scales here that we have on a piece of paper that can allow us to get a better assessment of all the times, reflections we're used or affirmations and that kind of thing. And my understanding is this is actually used in the training for MI as well.

  Dr. Wiplove Lamba: [00:34:38] So the MITI Scale is used in the research. So there's this motivational interviewing, a treatment integrity that was developed by Moyers in New Mexico. And for all research studies, they use those scales, they're available online. But the ones we're doing are they're basically going to be tracking the stuff that I say, the open-ended questions, affirmations, reflection, summaries. And this is something we'll do in workshops so people can practice those things.

  Dr. Alex Raben: [00:35:05] And I guess we should also mention "frequency" there. Is there an ideal frequency to how many reflections versus questions?

  Dr. Wiplove Lamba: [00:35:15] Yeah, so they say a good Motivational Interviewing is about 2 to 1 reflections to questions. And if you're Bill Miller or I guess Carl Rogers, it's like 4 to 1. I still remember some interviews I've watched with Bill Miller and the patient says everything and he's not asked a single question. And I'm like, his ratio might even be higher than that 4 to 1 that we sometimes say.

  Dr. Alex Raben: [00:35:37] Right. And for the listeners, we will link to some of these assessment sheets so that if you want, you can pause the episode right now, download them and kind of mark along with us. Or you can just listen in and see if you can pick up reflections and affirmations and summary statements and open-ended questions on your own. All right!

  Dr. Wiplove Lamba: [00:35:57] Alex, thank you for meeting with me today. And this is an opportunity for you to talk about something that you want to change in your life. It could be something that you used to do and want to do again, or it could be something that you sort of imagine yourself doing down the road, right?

  Dr. Alex Raben: [00:36:15] So for me, the thing I would like to change is my use of caffeine.

  Dr. Wiplove Lamba: [00:36:22] Your caffeine use?

  Dr. Alex Raben: [00:36:23] Yeah, I'm quite addicted, I think to caffeine. I drink quite a bit of Diet Cokes, Coke Zero throughout the day, some coffee as well. And previously I went a year without caffeine and then I've kind of relapsed in the last year. And I'd like to go back to the old way, but it's difficult.

  Dr. Wiplove Lamba: [00:36:46] Yeah. So you keep drinking it for the taste.

  Dr. Alex Raben: [00:36:49] Not just the taste. I do enjoy the taste, but I think it's more the caffeine and avoiding the withdrawal of the of stopping. It's kind of both.

  Dr. Wiplove Lamba: [00:36:59] You actually get withdrawal when you don't have it.

  Dr. Alex Raben: [00:37:02] Yeah, pretty significant. Like I know some people don't quite understand that because I don't know, maybe genetics, but I do get quite substantial withdrawal. And so it does make me quite irritable for a number of days, quite tired, lethargic, headaches, the whole kind of nine yards. And so I really can't function very well. So in the past when I've quit, I've actually quit on vacations because I don't need to function at a high level, obviously.

  Dr. Wiplove Lamba: [00:37:34] So when you're like a nice resort or you can sleep in, irritability doesn't affect you or your family.

  Dr. Alex Raben: [00:37:39] Well, it may affect them slightly, but it's not going to be like irritable at work where I need to be cool and collected.

  Dr. Wiplove Lamba: [00:37:45] You like to be on when you're at work, you want to be sharp and on and productive.

  Dr. Alex Raben: [00:37:48] Exactly. Yeah.

  Dr. Wiplove Lamba: [00:37:52] What are the things that make you really want to stop using it?

  Dr. Alex Raben: [00:37:59] Well, cost is one thing. I know that individual cans of coke or coffee is not that expensive, but in the long run, it does certainly add up. I also just don't like the idea of being kind of under the thumb of a substance. I'd rather, because I know when I've quit in the past, I actually feel better. So it's really not a great feeling to know you're just kind of staving off withdrawal in some ways. I guess I do get some pleasure from drinking it, but those are the reasons I would want to stop.

  Dr. Wiplove Lamba: [00:38:38] Yeah, you really want to be able to control your day, choose what you do and when and you don't like having to count the hours before your next caffeine hit, so to speak.

  Dr. Alex Raben: [00:38:48] Like before coming here today to record this, for instance, I had to have a Coke Zero because I knew I would be too low energy if I didn't, which is kind of a bit of a, I don't know, ball and chain or something like this.

  Dr. Wiplove Lamba: [00:38:59] So when you have no caffeine at all, you can't actually function at all at work.

  Dr. Alex Raben: [00:39:06] Not function at all. But it's difficult. And if I were to go like days, like if I were to go a day without it, I would be pretty miserable and irritable. Then, my work might suffer and I don't want that to happen.

  Dr. Wiplove Lamba: [00:39:22] What did it take you to get to the point where you had those moments where you're caffeine free and you actually feel like you're functioning better?

  Dr. Alex Raben: [00:39:33] I think it was like an opportunity. The other thing was that it was around New Year's, and so it was a resolution.

  Dr. Wiplove Lamba: [00:39:40] And you had to follow through and finish it.

  Dr. Alex Raben: [00:39:42] It was a symbolic time of year. And because it was the vacation over that period and I didn't have any like I wasn't even going on a trip. It was a staycation. So I knew I could just kind of stay in and have some lazy days and just get through it. And then once you're once I was through it, then it was immediately much better. I still had some cravings, but I could kind of deal with that for the most part.

  Dr. Wiplove Lamba: [00:40:08] And you're able to stay away from caffeine for a full year?

  Dr. Alex Raben: [00:40:12] Yes. And then I'm trying to remember why I relapsed. I think it was probably being on-call and not getting a lot of sleep and then, you know, allowing myself that one drink of caffeine to feel a little better and then it just kind of snowballs from there.

  Dr. Wiplove Lamba: [00:40:32] I'm really interested in hearing about what it's like for you when you're off caffeine, maybe like the second or third month when you talk about your overall life being different.

  Dr. Alex Raben: [00:40:44] Well. I mean, I'm saving money. I'm not going to Starbucks every day, which, again, adds up. I'm. My energy is actually higher, sleep is better.

  Dr. Wiplove Lamba: [00:40:57] You sleep better without caffeine?

  Dr. Alex Raben: [00:40:58] I think so.

  Dr. Wiplove Lamba: [00:41:00] Just not for the first week. But once it's clear, you sleep better.

  Dr. Alex Raben: [00:41:04] Yeah, exactly. And then I just don't have to have it. So if I'm in a rush to get somewhere, I don't have to plan my day around ensuring that I can get some Coca Cola or I can get a coffee or something like this.

  Dr. Wiplove Lamba: [00:41:22] So, you have more freedom when you're caffeine-free about where you go and when you're not really forced to take certain routes in certain places, you can explore a little bit more.

  Dr. Alex Raben: [00:41:33] That's true.

  Dr. Wiplove Lamba: [00:41:38] How exactly did you work through that withdrawal? It sounds like you're at home. You didn't have work. How did you get through that?

  Dr. Alex Raben: [00:41:49] I was literally on the couch writhing and sweating. And not quite so bad. But it was a lot of Netflix, a lot of just like lying on the couch. Some just naps during the day. It was not very productive and it was kind of miserable. But because I had no obligations, it was helpful. Also, my girlfriend at the time was supporting me in this endeavour. And so team effort.

  Dr. Wiplove Lamba: [00:42:24] So on a scale of 1 to 10 where ten is like the most and one is at least, how important is it for you to get through that withdrawal and be caffeine-free?

  Dr. Alex Raben: [00:42:35] It's funny because I think I would have put it as a lower number prior to this conversation we're having. And actually I did the same real play at the session yesterday. We didn't get very far because we didn't have much time, but I put the number then at three out of ten and now I'd probably say about a 5.

  Dr. Wiplove Lamba: [00:42:56] And why is it a five and not like a three? Where to?

  Dr. Alex Raben: [00:43:01] Well, it was helpful to hear myself and kind of reflect back to me the things I like about it, particularly the freedom piece. I don't think I think about that very often that I am kind of shackled in a way by it.

  Dr. Wiplove Lamba: [00:43:15] Not having to go here and there at certain times and plan your whole day around it.

  Dr. Alex Raben: [00:43:18] I don't like to have that extra thinking on board. It's distracting.

  Dr. Wiplove Lamba: [00:43:25] And what do you think it would take for you to get up to six or seven in terms of the importance?

  Dr. Alex Raben: [00:43:30] It's interesting because it's almost like dependent on time of year or like if I had vacation coming up shortly, I would feel, I think, more confident or more I would prioritize it more. But I think because I know I still have a few months before a vacation that I'm prioritizing it less.

  Dr. Wiplove Lamba: [00:43:49] It's almost like your last hurrah. And then when vacation comes, you're going to stop.

  Dr. Alex Raben: [00:43:53] I guess so. I mean, like I said, I do enjoy aspects of it. I do like the taste.

  Dr. Wiplove Lamba: [00:43:59] On a scale of 1 to 10, how confident are you that you can cut back on your caffeine use for 10 is unbelievably confident and 1 is like not at all.

  [00:44:09] Now it would probably be about three or four. But again, it kind of depends on the timing. If I was coming up to a vacation and I knew it wasn't going to be a busy vacation where I was doing a lot of things or going somewhere where there's really good coffee or something. Then I would be much more confident, maybe like an eight or nine, even because I've quit the one time I've talked about already, and then I've also quit in the past.

  Dr. Wiplove Lamba: [00:44:36] So the number would jump up if you were in an environment that made it easier to do.

  Dr. Alex Raben: [00:44:40] Yeah, exactly.

  Dr. Wiplove Lamba: [00:44:42] And you can't think of any ways to bring some of those principles in now.

  Dr. Alex Raben: [00:44:47] No, I guess I can like I guess there's like long weekends coming up. So that would be one possibility. Thanksgiving weekend is coming up. So here in Canada, Thanksgiving is in October for our international listeners. I could see that being possible opportunity and I will be going home with family and whatnot. So I could perhaps enlist their help as well. And then I guess another thing that you kind of made me think of is like because work is such a driver of this, if I can find work at the moment, I'm sort of getting a bit more used to my rotation and if I have no call for a little bit, perhaps that would also be helpful, if I planned around that.

  Dr. Wiplove Lamba: [00:45:37] Right. So you've talked about a lot of things today. You talked about briefly what you like about caffeine, the way it's almost like this ball and chain. It sort of captures you. You don't like the withdrawal you go through and you don't have it. And it's tough to have to think almost every few hours when you're going to get your next caffeine piece. You've been through this before, right? You made a decision. You picked a date. You were able to do it for a full year with a little bit of support. And part of you wants to go back to it. You just haven't figured out when and how. Yes. And there's clear things about this current pattern that bothered you and upset you to the point that this was the one thing that you're like "This has got to change".

  Dr. Alex Raben: [00:46:16] Oh, it's a really good point. I think that this was the thing I chose and I chose it twice in a row, technically. So clearly it's one of the things on my mind and one of the things I'm quite ambivalent about. And I think the when in the "how piece" you just said makes a lot of sense. I think I am still figuring out "the when and the how", and that's the big piece I have to work on.

  Dr. Wiplove Lamba: [00:46:38] What do you see as the next steps in this?

  Dr. Alex Raben: [00:46:42] I well, I can see myself, at the very least looking at my calendar and seeing what are my next call shifts. When are there longer weekends or opportunities where I have slightly less work or I might be able to chart out a period of time where I can just go through the irritability and the withdrawal and all of that.

  Dr. Wiplove Lamba: [00:47:06] I want to thank you a lot for sharing these kinds of things. And from a personal standpoint, I love to hear how it goes down the road at any point that's there. Thank you for putting this on the air.

  Dr. Alex Raben: [00:47:20] Well, same to you. Thank you. All right. So why don't we debrief that?

  Dr. Anees Bahji: [00:47:34] So we kept track of the "EARS". So, a few elaborating, exploring questions were used. There was a few affirmations. But the thing that's really important here is that they're all interwoven with each other. So there was times when you can combine multiple different techniques. So, I think at the very end, one of the things that really stood out was when he said, you did this for a whole year. So there was a bit of affirmation built in there that you're really building on that previous success that you had had with that attempt and then building some confidence that you may be able to experience that again.But that was also partly a more complex reflection at the same time, because it was building on something you had said previously. There was a few things that were combined.

  Dr. Alex Raben: [00:48:30] Yeah. That made me feel really listened to as well because it seemed like you followed along the entire story you brought back, even the reference to the ball and chain that I had kind of thrown out there. You brought that back towards the end, and I think it was like little touches that made me feel quite listened to and supported.

  Dr. Marlon Danilewitz: [00:48:50] I'm also very happy to report that for Wip, the reflections definitely outnumbered the collaborations. And what I think was also quite interesting was that you really had a good base of engagement early on, and towards the end of the conversation, the questions that were posed really helped to move ground and to by asking the ruler question to assess your level of confidence, it really helped to evoke a sense of change talk there, which I think really shone through.

  Dr. Alex Raben: [00:49:27] And you brought up engagement, Marlon, so maybe we can elaborate on that a little bit because how does that play a role in MI? Because in this situation, we already know each other from before and the engagement was kind of good from the get go. But I could imagine scenarios where you don't have good rapport with someone and you're trying to use these techniques.

  Dr. Marlon Danilewitz: [00:49:54] So, I think that's a great question because oftentimes in our clinical interviews, we spend a lot of time on the questions and getting the content. But developing rapport and engagement is such a fundamental aspect of my in a successful interview. And it really sets the stage that only through having a solid foundation of engagement can you start to begin to move on to the next stages. And that's really an integral part of my is that knowing that where the person's at and their readiness for change and where they are at any particular moment.

  Dr. Alex Raben: [00:50:29] Right. And we've talked about this on past episodes. Just for the listeners reference, our episodes on the Psychiatric Interview really focussed on that because building rapport is so fundamental in psychiatry, all the things we do. And I guess the same is true in using me as well.

  Dr. Wiplove Lamba: [00:50:46] Yeah. And from what I remember about the evidence MI, it tends to work really well when people are bit more oppositional traits when they're quick to anger and it's quite effective at bringing you down that level of anger in our case, because we know each other, we've worked together before. I suspect if I took a non-MI approach, if I took it direct, it might even have an impact, especially because you know what's coming from a good place. MI is one tool of many and there are situations that do require us to be direct as well. And I don't want people to think that we're coming in and say "Oh, I use MI all the time". I have a suspicion that if we did a different interview that wasn't my based or was a bit more direct, you might have gotten something from it as well. It would have been a different experience for sure but just to think about that for the relationship. One thing I did want to comment on quickly is just that with these interviews, at least when I've been recorded and people have scored me on the MITI, I tend to do okay in terms of reflections, I do okay in terms of listening Change Talk. The thing I'm not that great with is a softening Sustained Talk piece. And there was a couple of times that you made a few sustained talk questions, and I just went over like that. The only reason I'm bringing this up is that just like any psychotherapy, there's levels of which people can improve. And with Motivation Interviewing because they're so careful about tracking the language when they review you, they're actually very specific about which things you could do differently and how.

  Dr. Alex Raben: [00:52:12] Right. Now that makes a lot of sense. We can all obviously continue to improve in these techniques. And I think you brought up the point that it's not the be all, end all. It has a time and place that there are other techniques that one can use with patients. And sometimes advice giving can be helpful. You know, thinking outside of the doctor-patient relationship, good friends are often in a position where they can give that hard advice because you've had years of building a relationship with that person. So that's just an analogy in a way. But to emphasize the point that advice giving is not a part of me, that's actually sort of counter in a way to the spirit.

  Dr. Wiplove Lamba: [00:53:01] Yeah, unless you ask for permission first. I have that little trick there so you can still be a doctor and ask for permission. A little twist in the MI book for health care.

  Dr. Alex Raben: [00:53:12] Right. And that would be sort of the autonomy, peace of the spirit, making sure they're okay with you, giving them some facts. I guess I'll just give a bit of my subjective experience in terms of a debrief. I mean, I found that to be quite helpful. And as you saw, my rating scale even had changed from yesterday to today. And particularly pinning me to thinking about next steps was helpful. And I didn't think I would get there. I thought I was too entrenched. I really do appreciate that because it is, I think something I will potentially do or consider, which was not something I expected coming into this today. I hope it shows the power that MI has to the listeners. Was there any other comments any of you had in terms of that interview before I ask sort of the final question?

  Dr. Marlon Danilewitz: [00:54:14] I'm just excited to see whether you come with a coffee to next academic day.

  Dr. Alex Raben: [00:54:20] Yeah, that'll be the true test, right? Maybe we'll do it. Update in the next episode. All right. Well, I have one final question for you guys, because I want to make sure we're bringing it back to the junior learners. What do you think a clerk or a junior resident ideally should take away from from this talk? Where can they start to use MI? Sorry, it's a double-barrelled question, but how can they access resources to learn more as well?

  Dr. Wiplove Lamba: [00:55:01] I think all of us have our favourite resources and you'll find MI is very individual in terms of how it's taught. There is a British Medical Journal article that's six things you can do in the medical interview that are MI adherent includes things like the Importance and Confidence Scales. It includes ways to give advice in my adherent way, and it covers the guiding principle and it's available for free online. And the British Medical Journal also has a two-hour free CME that covers some of the basics. This is something I would strongly recommend practising. You could do it at any point in the interview you could do when you give the treatment recommendations, you could do it to try to elicit more things. It's really important that people try it out and figure out for themselves if it works or not, because we tend to do things that we believe are effective, you know? And for me, I wasn't sure if it would work at first. Some of these skills, they seem so basic. It's only when you have those experience of responses that are there as well. So those are my thoughts. But usually what happens for people in medicine, it's usually when they're working for three or four years, they're seeing the same patients over and over again that aren't getting better. That's when the motivation comes, because in medical school and residency, you're just learning how to be a good doctor, right? And there's so much content, so much practice, all that kind of stuff. So those are my thoughts.

  Dr. Alex Raben: [00:56:31] And Marlon.

  Dr. Marlon Danilewitz: [00:56:33] There's always the book Motivational Interviewing by Miller and Rollnick. There's also a great opportunity in the community at large through training those who are extra keen to pursue excellence in MI.

  Dr. Alex Raben: [00:56:48] How do people access training? That's online?

  Dr. Marlon Danilewitz: [00:56:51] Yeah.

  Dr. Alex Raben: [00:56:53] We'll make sure to put these resources in the show notes as well.

  Dr. Wiplove Lamba: [00:56:57] Yeah. It's the Motivational Interviewing Network of Trainers. They have a national conference every year, one year it's in North America, the next year it's somewhere nice to visit. And it's really how to get to that next level of MI. A colleague of mine who taught me a bunch was actually three years below me, and he went there when he was a resident and he got really quite good at MI quick by attending those intensive workshops.

  Dr. Marlon Danilewitz: [00:57:25] I think the last thing is just practice.

  Dr. Alex Raben: [00:57:27] Yeah. Get the experience. That's terrific and I agree completely. Thank you guys so much for taking time out from the busy schedules here, your busy schedules at the CPA conference and I'm taking you away from dinner and the lovely day outside now, night outside in the beautiful city of Quebec City. I really appreciate that and hope to have you back at some point as well.

  Dr. Wiplove Lamba: [00:58:01] Thank you.

  Dr. Marlon Danilewitz: [00:58:03] Thank you so much.

  Dr. Anees Bahji: [00:58:05] Thank you.

  Dr. Alex Raben: [00:58:05] Take care. That's all for now. Listeners, we're going to sign off and we'll see you next time. Thank you all for listening. If you can, I suggest you stick around for some important announcements about our new email, our new infographic initiative, and to hear about my progress since the episode was recorded over a month ago, we first of all have a new email psychedpodcast@gmail.com. Our old email is no longer operational, so please send all your comments and questions to our new email. In terms of our next update.

  Dr. Alex Raben: [00:58:52] Thanks to our newest member, Nikhita Singhal, who is a first-year resident at the University of Toronto in Psychiatry. We now are making infographics to accompany our episodes. The first one being with this episode on Motivational Interviewing. These are meant to allow you to refer back to key concepts from the episode, using a quick one-page graphic available through our show notes for that episode or on our website Psychedpodcast.org. We hope that you'll find them useful. Finally, a bit of an update since I did the real play with Dr. Lamba on this episode. Although it sucks to admit I have yet to make a meaningful change in my caffeine use since the episode was recorded a little over a month ago. However, I did take some actions towards change. I did look at my calendar and I looked for opportunities to set a quit date.

  Dr. Alex Raben: [00:59:52] Also, since listening to the recording during the editing of this episode, I have noticed I've started to think about change again in this area. And so we'll see where that leads me and I may share some updates as we go. I think for me, this highlights how difficult change can be in general and for our patients. And it's given me a new renewed empathy for our patients that find themselves in similar situations, but with drugs and other behaviours that often have a far greater impact on their mental health than caffeine. I hope that you'll reflect on this as well. So that's all for updates.

  [01:00:36] Now let's go to the end credits. PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced, audio edited and hosted by Alex Raben. Lucy Chen provided our episode intro. Our theme song is Working Solutions by all of music. Nikhita Singal created the infographic to accompany this episode. A special thanks to our incredible guests, Dr. Wiplove Lamba, Dr. Anees Bahji and Dr. Marlon Danilewitz for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.

Episode 27: Serotonin Pharmacology: From SSRIs to Psychedelics with Dr. Robin Carhart-Harris

PsychEd Episode 27 - Serotonin Pharmacology From SSRIs to Psychedelics with Dr. Robin Carhart-Harris.mp3: Audio automatically transcribed by Sonix

PsychEd Episode 27 - Serotonin Pharmacology From SSRIs to Psychedelics with Dr. Robin Carhart-Harris.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Lucy Chen:
Hi guys. Welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners. I'm your co-host, Dr. Lucy Chen. I've recently graduated from the University of Toronto Psychiatry Residency program, but definitely most definitely still considering myself a medical learner. I'm currently working at the Centre of Addiction and Mental Health, doing a combination of women's inpatient and general adult psychiatry work. I'm joined today by Dr. Chase Thompson, a PGY3 resident.

Chase Thompson:
Hi, Lucy. Happy to be here.

Lucy Chen:
And Dr. Nikhita Singhal, a PGY2 resident from the University of Toronto.

Nikhita Singhal:
Thanks, Lucy. Also very excited to be here and it's my first interview, so really excited.

Lucy Chen:
Great. So we have a really brilliant, like, exciting episode. I'm really excited to introduce our guest and dive in. We're covering a topic that touches on the foundational psychopharmacological principles in addition to the fringes of the unknown with respect to psycho-pharm treatments for depression and exactly how they work. We are zooming in. We're on Zoom, so we are also focusing and zooming in into serotonin function and pharmacology with a focus on an excellent review article called Serotonin and Brain Function: A Tale of Two Receptors, written by our guest expert Dr. Robin Carhart-Harris. Dr. Carhart-Harris is a psychologist and neuroscientist who heads the Centre of Psychedelic Research at Imperial College London, where he conducts leading research in the field. We're really lucky to have you on the show, Dr. Carhart-Harris. Anything else you'd like to share about yourself or your work?

Dr Carhart-Harris:
No, but very happy to to be here and yeah, honoured to be, that people are interested in this article, so I'll be delighted to go through it with you all.

Chase Thompson:
Yeah. So as Lucy mentioned, we're discussing Dr. Robin Carhart-Harris's review. We chose to discuss this review on our podcast because we believe it provides a resonance in psychiatry and medical students a scaffold of knowledge about the serotonin system to further build upon throughout residency training. Our experience of learning about serotonin transmission involved a broad range of different receptors with different functional profiles and a variety of different medications that act on these receptors, all of which can be a bit confusing and dizzying to us as learners. With this discussion, we really hope to provide a slightly different and distilled way to think about these receptors. In addition, as psychedelics and MDMA enter contemporary psychiatry, some of the topics discussed today will become increasingly relevant.

Nikhita Singhal:
The learning objectives for this episode are as follows. By the end of the episode, the listener will be able to: understand the general anatomy and function of the serotonin system with a focus on the purported activity of the more common serotonin receptors and transporters as well as serotonin's basic mechanism of action. To describe the effects of serotonin reuptake inhibitors and how they lead to symptom improvement in mood and anxiety disorders in addition to the mechanism of action of other serotonergic medications and to consider the two-pronged serotonin system conceptualised by Dr. Carhart-Harris and understand how serotonergic agents, including SSRIs and classic psychedelics and the concepts of active and passive coping, fit within this theory.

Lucy Chen:
So that's a mouthful, guys. I know we're going to explore some in depth concepts and topics, but just follow along, we'll do the best that we can to condense this material for you. So I think we should just start, Dr. Carhart-Harris, before we delve into the main content of your review, it might be helpful for us and our listeners to just go over the basics of serotonin anatomy and physiology, anything that you think would be helpful for our foundational understanding.

Dr Carhart-Harris:
Um, well, serotonin, um, you know, it's an old evolutionarily evolutionarily old neuromodulator. So let's start by, by, I guess, clarifying what a neuromodulator is. Um, neurotransmitters are chemicals in our brains that alter the activity of neurons, um, in different ways. But, but neuromodulators, like serotonin are more about kind of tweaking the system rather than a sort of direct excitatory or inhibitory action. And so I think of these neuromodulators like serotonin as kind of, um, you know, tuning the function of the brain rather than exciting the brain or inhibiting the brain. It's a more subtle but no less sort of profound, in effect, action of these particular particular neurotransmitters. And you have, you know, similar neuromodulators in terms of tweaking the system like dopamine and acetylcholine and noradrenaline um, but serotonin is, is particularly interesting, um, for a few reasons, implicated in lots of psychiatric disorders in different ways. Um, and interesting drugs, you know, like the psychedelics work on the serotonin system, MDMA, you know, the Prozac-like drugs, the selective serotonin reuptake inhibitors, I think probably the most prescribed drugs in, in psychiatry, maybe benzodiazepines could compete with that um and so, you know, very, very important. And what surprises people sometimes is that most of the body's serotonin is actually outside of the brain, it's in our in our gut.

Dr Carhart-Harris:
Um, but, you know, the serotonin that is produced and released in our brains plays a very crucial function in how our brains and minds work modulating states of consciousness, so modulating sleep, plays a big role in modulating sleep architecture um, and mood classically. You know I guess to the layman people, they may have heard of serotonin as the happy hormone, they might think of the general rule that high serotonin levels equals better mood and the flip of that low serotonin levels equals maybe depression or low mood. Um, I mean, in the broadest sense, there's some truth to that, but the reality is much more complex. And speaking to complexity, the serotonin system, what arguably sets it apart from the other neuromodulators is its complexity. So these neuromodulators have a number of different receptors, which are the proteins that sit in the membrane of neurons and when they're bound to by by the chemical itself, the neurotransmitter neuromodulator itself, they'll initiate a different response. They're kind of locks that sit in the membrane of neurons and the key is the neuromodulator, the chemical, the serotonin, so that docks into this complex protein, the receptor, lots of these different receptors, and in the serotonin system there are truly lots of these receptors, I think something like 14 different receptors have been identified. And what struck me when I was studying the serotonin system, this is this was my introduction to neuroscience, really, I started my PhD in psychopharmacology, and I studied the serotonin system for four years and then I was lucky to segue into studying psychedelic drugs that work on the serotonin system in a more direct way. But yes, just the sheer number of different receptors, serotonin receptors, and then to to see that different receptors were associated with such different responses I thought was really remarkable and actually that sowed the seed for this paper. You know, I started studying psychopharmacology, um, in 2005, I think it was and this paper published in 2017, serotonin brain function. I guess the seeds were sown early on in my PhD for thinking, you know, trying to kind of, I guess, make some effort to solve the riddle of the serotonin system. I don't think I've done that at all. But, you know, I guess speaking to some of the things that puzzled me about the serotonin system, that certain receptors can do such different things and certain serotonin acting drugs like, say, a Prozac or LSD, both work on the serotonin system, but they couldn't be more different. And so I thought that was that was just incredible and process of trying to get to grips with this and, you know, writing things on on the whiteboard in my office for what different functions and behaviours are associated with, with certain serotonin receptors and what are associated with others, kind of led to the to the creation of this particular paper.

Chase Thompson:
Great. So that's a perfect segue into what you mainly discuss in your paper, which seems to be the 1A and 2A receptors. So maybe you could tell us a bit more specifically about these receptors and why your paper focuses on it.

Dr Carhart-Harris:
Yeah, sure. I suppose what was coming through the literature, I mean, I studied MDMA for my PTSD, for my PTSD, for my PhD. That's an interesting Freudian slip. I think there was any PTSD there, and what was coming through there was that certain behaviours that were associated with the post MDMA period seemed to be of a certain category. So there were things like impulsivity and aggression, um, and so, you know, I started, I started jotting these things on the board and with a view to, to, to writing this paper and, within the paper for those who have it in front of them, Table One is, is kind of the product of, of this, this process. And so you know certain, I guess, symptom clusters like impulsivity and aggression,anxiety, depression, low mood that seemed to be a fair bit of work on on you could say MDMA abuse you know um sort of a lot of use of MDMA, regular and high doses, there were reports of these behaviours afterwards. And so for me, this was, I think, you know, suggesting a clue as to what serotonin does, broad brush if you want. And then, um, you know, so, so these could be, you know, examples of behaviours and symptoms associated with low serotonin functioning. Um, but the inverse of them seemed to be things that were, um, promoted by stimulation of the serotonin system.

Dr Carhart-Harris:
So a reduction in things like impulsivity and aggression, the kind of things that you see when you yeah, stimulate the serotonin system, like with, with, with MDMA, uh, probably the most potent serotonin releaser that we, we know of. Um, and people often say, oh, MDMA, well, it releases other monoamines, but you know, the next highest monoamine that's, that's released noradrenaline, I think you get five times as much release of serotonin than you do to noradrenaline. So while people say that, you know, MDMA really is a serotonin drug, it is, you know, really hitting the serotonin system hard, spitting out serotonin into the synapse um, and, and, you know, people report this profound pro pro-social quality to the experience, you know, things like impulsivity and aggression dropping away. They describe MDMA as the kind of hug hug drug or, you know, love drug. I think hug drug is probably better and empathogen. Um, and so for me, all of this was, was kind of clue to serotonin functioning generally. But then, um, looking more into the literature, it seemed as though, uh, there was one particular serotonin receptor that arguably encapsulated these effects better than any other, and that was the serotonin 1A receptor. Now the picture is complex as it always is, um, in relation to the serotonin 1A receptor, because they are expressed in, in two key areas.

Dr Carhart-Harris:
So the serotonin system has its cell bodies in the midbrain, in the raphe nuclei that they're called um, and that's where the nuclei of these serotonin cells, uh, serotonin-synthesising cells are found deep down in the old brain and the fibres innervate all the way up into the cortex, really long fibres. It's remarkable how long, you know, these neurons are, individual neurons stretch all the way, their axons all the way from the old brain, the midbrain, all the way to the furthest reaches of the of the cortex. And so if we trace down to those cell bodies in the raphe nuclei where 1A receptors are expressed on on the cell bodies themselves, when they're stimulated by serotonin or a 1A-agonist, meaning stimulating, drug um then that serves to inhibit the firing of those cells and this is a feedback inhibition. It's serving a function like a kind of regulatory brake to slow things down. If there was excessive spill-over of serotonin into the synapse, this system would shut that off because it would stop the spitting out of serotonin from from the axon terminals. Um, so that's what the 1A receptors do in those cell bodies but then what we call postsynaptically, so this is presynaptically in the cell bodies, but postsynaptically on the receiving end of the synapse the effect is of 1A stimulation is, is somewhat different.

Dr Carhart-Harris:
It's going to it's going to inhibit the activity of those receiving cells, so it has a kind of quelling inhibitory action elsewhere in the brain. Sure, you can inhibit the cell bodies themselves in the raphe nuclei, but that's going to stop the spitting out of serotonin and that'll have lots of, you know, repercussions. Um, but what I was seeing in the literature is that postsynaptic stimulation of 1A receptors in regions like the stress circuitry, the limbic system, was associated with this inhibition and reductions in, in, in functions that you associate to associate with those stress circuitry like anxiety and stress, of course, impulsivity, aggression, you know, so for me, it started to make sense that MDMA was, you know, to a large extent and also the antidepressant Prozac-like SSRIs are to a large extent working on stress circuitry to, um, kind of smooth things out. And while it would be too simplistic to put all of that on the serotonin 1A receptor, um, it is highly characteristic of the, at least the postsynaptic serotonin receptor. Um, and for me that, that, yeah, that, that kind of got things sorted in my head to some extent about what the serotonin system is, at least in one dimension of the serotonin system. Now there's another one, the one that the psychedelics work on. But perhaps I'll pause because I covered quite a lot in relation to the to the 1A system there.

Chase Thompson:
Yeah. So maybe I'll just make an attempt at summarising what you said, just so we understand here. So we have these serotonergic neurons with the and their cell bodies are in the raphe nuclei and they have an axon which kind of loops back and acts on itself at an autoreceptor which acts as sort of a brake or a self inhibiting mechanism. But then it also extends and acts on the stress circuitry to provide an overall overall inhibitory action on the stress circuitry. Is that sort of.

Dr Carhart-Harris:
Oh, broadly So. So I mean, you have the cell bodies, the the nuclei deep down in the old brain and they'll express these 1A receptors. When serotonin or a 1A-agonist drug, whenever anyone hears the term agonist, think, oh, that's a drug that's going to stimulate those receptors and they're kind of mimicking the endogenous ligand or, you know, the serotonin itself, the serotonin imposters and they'll so the 1A receptors sit on the cell bodies there. There isn't, the axon shoots off into the rest of the brain, but it's the 1A receptors on these cell bodies and when that's hit, stimulated, it inhibits now this this cell, it's going to release less serotonin. So that's the kind of inhibitory brake on on serotonin release. Is this mechanism is very relevant to how the SSRIs work, because in time this break gets sort of desensitised, it stops working so that the cell bodies continue to to spit out serotonin. Early on when you take an SSRI, activating these cell bodies and stopping serotonin release might relate to some of the irritability and worsening of symptoms that sometimes is seen early on in the in treatment with SSRIs.

Dr Carhart-Harris:
Now, just to to finish this thread, so here's the cell bodies with their inhibitory 1A receptors on serving as kind of brakes on the activity of these serotonin spitting cells that shoot their axons out to the rest of the brain, into the cortex and into the limbic system. So let's follow an axon now, and it's going all the way up into the brain, maybe into the stress circuitry, into like the hippocampus or something and the serotonin is going to be released from this this axonal terminal. Now, that's going to hit a receiving neuron, also in the hippocampus, because these synapses are, you know, just tiny, tiny little gaps. So here's the the cell body from the from the from the raphe nuclei spitting out its serotonin and here's the receiver and on the receiver you have 1A receptors, the serotonin is released potential you know to bind to 1A receptor here binds, inhibits this receiving cell and the activity in this region drops because the action of 1A stimulation is to inhibit the host cell. So I know it's complex, but that's it.

Lucy Chen:
Yeah. For sure. And like, I always, my understanding around the impact of serotonin reuptake inhibitors in treatment of depression is this idea that we're, we're down regulating 1A receptors presynaptically so that the cell can release more serotonin in the future, like it's it's not as inhibited. And that's basically like that was my kind of really that's how I grappled on to my understanding was that that's the that's the antidepressant effect of a of an antidepressant.

Dr Carhart-Harris:
Right. I would say that half of the picture. So you're you're desensitising these breaks, these inhibitory breaks on on the serotonin spitting out neurons so that it can start spitting out more freely. There's nothing inhibiting it spitting out a serotonin so in time that should lead to the cell spitting out more serotonin. And generally speaking, that seems to be good for mood in a sense. So that's part of the picture. The other part is that general increase in serotonin in the synapse is going to lead to more of it hitting these these post-synaptic 1A receptors. So in a sense, you're you're ramping up the serotonin system a little bit with an SSRI, dialling up a little bit the serotonin system but if you were to introduce a drug that worked directly on these inhibitory 1A receptors, you would essentially do the same thing. And that's one thing that people have tried to develop in in, you know, I guess biological psychiatry drug development, is the combination of a 1A agonist, just mimic serotonin and also reuptake inhibition to get that kind of sort of double whammy effect. So yeah.

Lucy Chen:
Yeah so I think this is a good transition to talk about the 2A receptors um, and more specifically, you know, I'm not sure if this is a good place to start, but there's differential expression of these receptors in different parts of the brain. They seem to be located on higher cortical areas of the brain and so we're kind of curious about that and how that sort of manifests its effect when it's stimulated or blocked.

Dr Carhart-Harris:
Yeah. Yeah. Well, I'm I'm really curious about that as well, because, I mean, if the listeners have the paper open and they look at Figure One, this for me was really stark, you know, and this, this tells a story. Sometimes a picture says a thousand words, for me that says a lot because we have two maps on the left. You have the in blue or at least the, you know, highlighted frame is blue, is the 1A receptor and where it is in the brain and it's hard to see the raphe nuclei, they're labelled, but you can see the the postsynaptic receptors labelled in kind of the limbic circuitry there. Um, and then look at the 2A receptor on the right and it's very much a cortical receptor. There's not much going on subcortically there, there's not much in the hippocampus really in the amygdala, not much. And yet in the cortex and particularly in association cortex, there's loads of it, loads of this this receptor and this receptor is in my mind, really interesting because of psychedelics and because psychedelics are so interesting. You know, how is it possible to to pin the the action of these drugs that can yield, you know, the most profound experiences of a person's life that leaves them just, you know, struggling to find words to describe what they've experienced. And ad yet we can pin all of that to a large extent on at least, you know, the 2A receptors, stimulating this 2A receptor is the start of all that.

Dr Carhart-Harris:
I mean, if you block this receptor, you don't trip. It's as simple as that. And so for me, that just screams there is something really important about this receptor because if you want to profoundly alter the quality of conscious experience, you can stimulate, you can stimulate this receptor. So we don't know why and what and you know why it's so critical, but we just know that it is, um, and a lot of a lot of, you know, little clues make sense. Like, you know, if you're going to profoundly alter consciousness, maybe it does make sense that you're perturbing receptors that are expressed in aspects of the brain that are the most developed in our lifetime as the brain develops from infancy into adulthood as well as in phylogeny or the evolution of of the human brain, Um, the expression is particularly high in aspects of, of the brain that are particularly evolutionarily expanded. I find that intriguing. There are some wacky theories about psychedelics being involved in the evolution of, of the human brain and human consciousness. Um, I don't quite buy that, but I'm intrigued by the possibility that the serotonin 2A receptor has played a role. Um, and you know, and then, you know, questions like what does it, what does it do? I mean it's again, there's wacky theories that it's there for psychedelics, maybe endogenous psychedelics like DMT, psychedelics that you can find occurring naturally in the body.

Dr Carhart-Harris:
But the evidence there is pretty slim. The concentrations of DMT in the body and in the cerebrospinal fluid are really, really low. They spike up during actually during induced death in, in, in rodent studies, but so does so much else, you know, so there's no specificity there. Serotonin spikes right up if you essentially induce a heart attack in a in a in a mouse. Um, and you have the complication of cells dying and spilling out their content anyway, which sort of makes for a murky picture. Um, so I don't think that's necessarily compelling evidence for, you know, endogenous psychedelics being the key ligands for these 2A receptors. I think it's a simple, you know, kind of Occam's razor go with the simplest explanation, I do think they're there for serotonin. But then, you know, what did they do? Well, increasingly, we're discovering that they promote plasticity. They promote synaptogenesis, so the generation of new synaptic connections, functional components of the synapse, the key bit where the communication is, is done in the brain. Um, uh, and, uh, yeah, so it's the especially especially fascinating receptors associated with plasticity and particularly high-level cortex and I suppose high-level aspects of of cognition and consciousness. Yes. Yeah.

Nikhita Singhal:
Okay. Yeah, it's very interesting just how there are these two different receptors with very different effects. Could you tell us a bit about under normal conditions, what determines where most of the serotonergic activity in our brain is going? Is it mostly involving the 1A receptors or the 2A receptors? And are there different factors?

Dr Carhart-Harris:
Yeah, I'm glad you asked that question, Nikki, because that's a key component here. If you were to look at where the serotonin transporters are, in fact, this this paper that I got, these maps from Beliveau et al 2016 is worth looking up because it's a kind of nice atlas of of different aspects of the serotonin system are the receptors and also the serotonin transporters. And what you find when you look at the transporter map is that a lot of the transporters, which are kind of like hoovers, you know, hoovering up serotonin from the synapse to kind of recycle it, essentially. Um, uh, these transporters are heavily expressed in the stress circuitry and in the sort of older brain, quite, quite high subcortically and they overlap to a fair extent with, with the distribution of the 1A receptors. Now there's a so for me this is a bit of a clue that the serotonin 1A receptor might sort of dominate the serotonin picture, so to speak, broadly. You know, this question, what does serotonin do in the brain is more dominated by what the 1A receptor does than the 2A receptor. Otherwise, if we tweaked serotonin levels with Prozac or MDMA, we would trip out, you know, and you might a little bit with MDMA, but not really to the same extent as what you do with a drug like LSD. So for for me, you know, it is it's this this sort of stress related, um, um, you know, mollifying, taking the edge off thing, action of serotonin that seems to be mediated by these 1A receptors. Another key consideration here, and I'd love to find more literature on this, we cite something in our paper, but I was really on a quest to find more because it seems like such a critical question.

Dr Carhart-Harris:
And the question is this what is the what is the relative affinity of serotonin itself for its different receptors? I mean, you might just think it has a uniform affinity. First of all, what's affinity? Well, it's stickiness. It's the binding potential of serotonin for its different receptors. You might just think, well, you know, these are all proteins that recognise serotonin. It's just going to be a uniform thing. Serotonin sticks to them all equally well, but that there's some suggestions that that's not the case. And actually serotonin has a higher affinity for its 1A receptor than its 2A and its natural affinity for the 2A receptor is quite low. And for me that's kind of intriguing because that could suggest that, again, if you're going to modulate serotonin levels with a drug like, you know, Prozac or another SSRI Citalopram, um, uh, you're not really going to have a big impact on the 2A receptor in its, its functioning because if you did, you might feel something more akin to a psychedelic experience with, with those, with those SSRIs and you don't. So that seems to be a key question. And, and there seems to be some evidence that, yes, the affinity of seratonin itself is higher for the 1A receptor than the 2A.The 1A receptor is also very heavily expressed and expressed in regions that have a very dense innervation from those serotonin fibres coming up from the from the, the cell bodies. Um, so again, that that might be suggestive to this principle of the 1A receptor kind of dominating the serotonin picture in a, in a general sense.

Chase Thompson:
We just want to take a moment here to pause to provide some context for the upcoming discussion. We are about to discuss some theoretical positives and negatives of taking serotonin reuptake inhibitors, as well as classic psychedelics for the treatment of depression. It is important to note that this discussion is purely academic and no clinical decision should be made based upon it. Further to this, we are also not recommending that anyone pursue or undergo psychedelic therapy outside of a rigorously controlled medical setting. One should be aware that there are medical and psychiatric risks from taking these drugs in uncontrolled environments.

Lucy Chen:
And, you know, you've talked about in your paper that, you know, 1A seems to be a mechanism for passive coping and sort of this degree of like a degree of kind of like release under stress or punishment. And then the 2A receptor having a differential like mechanism by which it causes plasticity or kind of improves the depressed state. So can you kind of talk about, I guess, the bipartite model?

Dr Carhart-Harris:
And yeah, so, you know, the principle here would be there's multiple roads to Rome. Is that how the saying goes? Or more than one way to swing a cat? You know, you can you can get to the same sort of, you know, end goal by different by different means and and here so you know, what's the end goal? Well, it's an antidepressant effect. You can either take your Prozac for two, three, six months, years, whatever, and it's going to just take the edge off things, help you get through less of the intense anguish that you can see in all sorts of disorders. Or you can undergo a psychedelic experience, maybe just one and first of all, think about how different that that is, the model there, you know, years, I don't know, maybe a thousand administrations ofof your SSRI daily administrations or one versus one potentially one or a small number anyway of a of psychedelic administrations. And so this must be radically different. I mean, if psychedelic therapy, and I'll unpack that in a moment, works for depression then it works in a radically different way. It's got to yet it's working on the serotonin system but the serotonin system is is a chimaera. You know, it's a it's a at least, you know, certainly has more than one face and these faces are radically different to each other.

Dr Carhart-Harris:
Um, and so and so for me, you know, tackling that in a sense, the less exciting side of serotonin, the one related to taking the edge off things, was something I felt I needed to do to properly understand the system, or at least get a bit of a handle on it. Whereas the other one was more naturally exciting and interesting, the psychedelic side and the 2A side. Um, and for me, you know, I came across these terms active and passive coping and I just found that a really useful phrase, active and passive coping. Here it is, Puglisi-Allegra and Andolina. Yeah and so for me, I was like, well, this is kind of speaking to the principle here. You know, if you're on your SSRI for six months, a year, years, and it's taking the edge off things, you've gone to kind of doctor and said, I'm struggling, I need some help and the prescription comes and in a sense it's quite a classic medical model. It's quite passive: Doctor, fix me, give me, give me medicine, I just need to take medicine, medicine makes me better kind of thing. Sorry for being sort of so kind of simplistic about it, but you get what I mean. Whereas the psychedelic model is quite different.

Dr Carhart-Harris:
It's, um. You know, Doctor, what have you got for me? Well, let's talk. And I guess that's how it starts. It's like, let's talk, you know, tell me about yourself. You build a relationship of rapport and trust. You get to know the kind of nooks and crannies of the individual in front of you on a much more intimate and personal level to build that rapport and trust. And then you're going to have this huge, I would say, hugely destabilising experience potentially um, that's in a sense the, it speaks to the complexity and maybe the limitation of psychedelic therapy is that the experience can be damn hard, you know, really, really tough and weird, weirdest experience that you might ever have um, at least you're conscious of, um, and can remember, because birth's got to be pretty weird. Um, and, um, yeah, and you're in a state of vulnerability and so, you know, how do we, how does your clinician, your supporter, your guide, your sitter, whatever, therapist, how do they look after you? And so that critical role of the therapist or guide in Classic Model, it's two individuals that are doing the prep work, then the facilitation or support during the session itself and then the integration, the landing afterwards, talking through the experience. Um, you know, as you land, if you follow the arc of the experience from, from prep and then the intense experience itself, then trust the arc, you know, you always come down and then the, the work that's done afterwards to kind of to allow for space to talk through insights that might have arisen during the experience, moments, periods of perhaps cathartic release, crying, sometimes floods of tears, um, sometimes serious anguish, sometimes serious confusion as well.

Dr Carhart-Harris:
But to allow space for talking through all of that weirdness and wonderfulness and, you know, the richness of the experience is so critically important. And that's why earlier on I intentionally put some emphasis on therapy. So one is a classic medical model. Doctor, what have you got for me? Medication, you know, take your pills and off you go. And the other one is this engagement where, okay, there's some work to be done here. It's drug doing something in my mind and brain, opening it up and now this is ripe, ripe conditions for some deep therapeutic work. So for me, when I came across these terms of active and passive coping, which I think were outside of the context of the serotonin system I think, I have to remind myself, they resonated with this, these different properties of the serotonin system and serotonin drugs, antidepressants.

Lucy Chen:
So I'm wondering because it's interesting that you're kind of talking about the 2A receptor also in this psychotherapeutic process where there may be like a profound realisation or working through of some past traumatic content. So is that sort of the mechanism of action of certain types of therapeutic processes that are more sort of expressive or they're more sort of exploratory?

Dr Carhart-Harris:
Yes, there is some evidence that processes like destabilisation can actually paradoxically be a good thing in in psychotherapy. So there's empirical evidence to back that up. So but but this, you know, intrinsically is a more complex model than the much simpler, and this is the merit of the of the classic medical model, you know it's simple. You don't, you know the complexity of human beings and interactions and relationships areare not so much involved. Uh, whereas here you, with psychedelic therapy, you have a model that depends on the therapeutic work that is combined with the drug action. You can't pull these things apart because if you try to you, you can get adverse events and you know, even iatrogenesis meaning things get worse rather than better. So it's the point I always emphasise, you know, not through any sentiment as such, only that sentiment in the sense that it just follows from the science and everything about what these drugs seem to do in my mind is saying they are um, sensitising the, the individual to experience to environment. Um, and therefore, you know, logically, scientifically, one needs to pay very careful attention to environment. And while you can't change the past, you can, you can, um, you can engineer the present and the future to some extent and so you have a therapeutic duty, based on the science and the logic, to do that when you're making someone exceptionally sensitive to environment. And another little qualifier that's important, environment doesn't, in my mind at least, doesn't just mean external environment. There's an internal environment that often we're not aware of, and it runs so deep, you know, because there's aspects of our minds that we are remarkably unaware of, and yet they're revealed under psychedelics. And the psychedelic therapy model is typically lying with your eyes closed. So there's not much, you know, visual input from the environment at all. Yet the experience is so experientially rich and content rich. So where is that material coming from? Well, it's coming from our minds, of course. And so that's just evidence for the the depth and the richness of our minds that we're unaware of ordinarily.

Chase Thompson:
So it sounds like with action at 1A, we're kind of talking about, you know, an individual learning to tolerate their current circumstances or at least experience less stress in their in whatever they're already doing. But with action at 2A we're talking about kind of like an expansive or neuroplastic type changes or someone really learning to cope with their environment rather than just tolerate it. I guess I'm just wondering because, you know, when we're talking about the action of psychedelics at 2A, do we know that the new beliefs or the plastic changes are always in a more positive direction, or are there cases where it's really not a good idea for someone to undergo that type of experience?

Dr Carhart-Harris:
Uh, yeah. So. So first of all, um, you know, we can look at the aggregate data, whether from control studies or population studies or observational survey type studies and say, well, at the aggregate level, at the average level, the psychedelic experiences, even actually outside of an obvious context of therapeutic care and support, the outcomes appear to be positive. Now, there might be some, some there may well be some biases in in in data from certain sources, but generally that is a very, very clear picture, you know, large effect sizes in the direction of positive. But that's not to say this is an absolute rule and that somebody could come to have a psychedelic experience and be negatively affected by it. And this is a really critical point that, you know, again, speaks to this principle that psychedelics are not intrinsically healing, in my view. Now, some would even challenge that, but I would sort of challenge them back and say, maybe you're being slightly naive here. Um, you know, most of the time the large majority of uses of psychedelics, people are taking them, especially these days, with some forethought and planning and so, you know, the outcomes are skewed in this positive direction.

Dr Carhart-Harris:
But I do still emphasise that, um and sometimes I oscillate on it because I could see how this process of breakdown and reconfiguration could could be healthy, you know, or it could be intrinsically healthy, speaking to, you know, a mechanism of a recalibration. You know, you take someone who has, um, crystallised, set into a pathological mode of being, you may well think, well, this isn't working or this, this isn't right so we're going to destabilise and the, the hope I suppose is that you return recalibrating into a healthier state. And, you know, maybe there maybe there is something to be said for for that model but I just think it's a bit of a dangerous model to to have too much faith in that psychedelics are intrinsically healing and sort of work in this sort of resetting way because most of the time and most of the evidence is is backing up, you know, careful intention for the experience and, um, and, you know, directing it in a particular, in a particular way with therapeutic support.

Lucy Chen:
I'm curious about sort of the longitudinal impacts of like the 2A stimulation treatment model. Like, is it the neurogenesis? Like what is it? What is sort of what is a longitudinal impact of that treatment model?

Dr Carhart-Harris:
Yes, I'm curious about it, too and I would say we're yet to really have the answers. There hasn't been that much done in the way of brain imaging work, for example, on the longer term changes in brain anatomy and function from from psychedelic use. We have some data that we're processing currently and I suppose the principal, if there is a principal that's coming through, it's that the kind of changes that you see during the experience itself, you will see in the opposite direction afterwards into the longer term. And so for example, if you were to look at our, um, I mean this is limited data to extrapolate from to an extent, but in our depression trial, this is a paper published in scientific reports, we scan people a day after their second treatment session with psilocybin and, whereas, we know now with a high degree of confidence that during a psychedelic experience itself, brain networks break down, they kind of disintegrate. But it's a transient disintegration as the drug effects wear off, they spring back and reconfigure. And we saw this in the default mode network, a network associated with, um, well, actually it's a network that's the regions that make up the default mode network have very high expression of serotonin 2A receptors and it's a network associated with high level cognition, self-reflection, imagination, daydreaming, theory of mind, thinking about the future and the past, mental time travel. So these really high level, arguably species specific, at least to the extent that we do these things, functions, um, is associated with the default mode network.

Dr Carhart-Harris:
We see it break down under psychedelics and this correlates with the intensity of the psychedelic experience but then a day afterwards, at least, the network seems to spring back and actually the magnitude of this springing back and, and there was a we're not sure how salient this is, but we noticed it, there was a slight expansion in the spatial extent of the default mode network um, one day after the treatment in our depressed patients who weren't depressed when we rescan them, a good majority of them were feeling well. Um, and that actually predicted, that was prognostically predictive meaning that those who were responders out at five weeks later were those who showed this slight expansion in the spatial extent of the default mode network. That's a bit arguably a bit too much detail I would say. But generally the rule is that disorder during the trip and a return to order afterwards and maybe there is a kind of um at least a lot of this is sort of theoretical, but maybe there is a kind of, um, uh, kind of, um, sort of spring cleaning of the system. It, it springs back simpler. Um, there's some of the redundancy has been, has been lost, uh, into the longer term maybe, which might make for a kind of cleaner, crisper style of, of, of being, dare I say.

Chase Thompson:
It kind of sounds what you're talking about with the psychedelic experience of being broken down and then rebuilding back up, a little bit like the model of therapeutic action that some people talk about, where the goal is kind of integrating a bunch of diverse experiences into sort of one unified whole person. Do you think that that maps on in this case?

Dr Carhart-Harris:
Well, there's suggestive evidence that that it does. I mean, you know, to many people, this might feel almost, I don't know, it might speak to to the way sometimes people push back about the reductionism of science, where if you were to say, look, you know, these these profound mystical type experiences, these this sense of, you know, mystical union or spiritual union sense of interconnectedness relates to some, uh, you know, alteration in brain function during the experience itself, where, for example, the brain is operating more as a, you know, coherent whole unit. It's more globally interconnected, and you see correlations with that effect and ratings of things like ego, dissolution. Um, it's quite easy to say, ah, you know, those are the neural correlates of ego dissolution and those are the neural correlates of the unitive experience, that sense of profound interconnectedness. Now, if I was really pressed on it, I would say I do actually think that that's, that's the way things are um, but I also acknowledge that that's just one piece of the puzzle um, and there's, there's so, so much more to the story that we've yet to really flesh out um, I would say and you know, part of it is that in a sense we're, you know, inching our way forwards with a model of, um, in a sense, what's lost under a psychedelic experience in terms of the, the usual sense of stability and familiarity of one's self and the world that's lost, um, and that relates to a breakdown in familiar systems that are usually stable in their functioning.

Dr Carhart-Harris:
But the thing that we haven't yet cracked and for me is the most tantalising sort of next frontier for psychedelic research is how do we explain the more, the stuff that comes in when something is lost? You know, the emergent order, how can we explain these visions of of, you know, seemingly timeless motifs that, um, you know, enter enter our minds um, and so, you know, stark um, or memories that flood back that are felt you know, as if one is re-experiencing something and um how do we explain the order amidst the disorder or the emergent order from, from the disorder. And we're not there yet. And, you know, we've got ideas about how to try and do it. It's going to be how to be a kind of, um, oh gosh, a sort of, we're going to have to capture these things as they play out in real time, and that's a challenge. But yeah, that's the kind of next frontier, I would say. Yeah.

Chase Thompson:
So maybe I'll just bring us back a little bit to the original model you discussed related to 1A and 2A. Earlier on, you had talked about MDMA being a potent serotonin releaser and with the potential to act on both of these receptors. But I guess the kind of phenomenon you're talking about under a classical to a experience is quite different than what one might experience with just MDMA. Is there a way to explain that or.

Dr Carhart-Harris:
Yeah. Yeah. Sorry. In the sense that, you know, why doesn't MDMA produce these psychedelic-like experiences?

Chase Thompson:
Right.

Dr Carhart-Harris:
Yeah. And I think part of that is that MDMA isn't a direct agonist of the serotonin 2A receptor. It doesn't really have any appreciable affinity stickiness for the 2A receptor. So any action at the 2A receptor that's being caused by MDMA is being caused through its increase in the endogenous ligand, serotonin. So you might think, well, you know, if you're if you're whacking up the the serotonin levels in the synapse profoundly with MDMA and and as I said earlier, you know, MDMA, maybe mephedrone could compete and not much more else, all these things are dose dependent, of course. But, you know, for sheer big release of serotonin, it's hard to beat MDMA, really. Um, and so why doesn't it produce, you know, trippy psychedelic effects? And I think part of the explanation for that is that, well, there's a lot of serotonin receptors and some of them counteract each other um, and you're not just increasing activity at one receptor, you're increasing activity at 1A receptor and the 1A receptor in particular has a counteracting effect to the 2A receptor. And 1A receptors are found in, even though they're heavily expressed in the limbic circuitry, they are expressed in the cortex and they're often co-expressed with 2A receptors. And so the assumption, and there's a little bit of evidence to back this up, Rick Strassman did some related work, um, there's a bit of evidence that the 1A activation, 1A activation say with uh MDMA-induced serotonin release might counteract the the effect of any 2A agonism through the serotonin release. So it's kind of like a diluting, you know, having a diluting effect on what otherwise would be a big trippy effect through the release of serotonin.

Chase Thompson:
Just in follow up to that, you know, when we are prescribing these medications that promote passive coping, namely, you know, SSRIs, do you think that that limits the individual's capabilities to actively cope in some sense?

Dr Carhart-Harris:
Maybe. And, you know, it's a dangerous question because of the implications of it, given that millions of people are prescribed SSRIs. You know, you might think on a sort of policy level like, you know, what are we doing? Are we doing a good thing here? And I mean, that's a very complex question because you you know, you have people on the cusp of just complete breakdown and and just turmoil and often suicide and so, you know, if you can get through the initial rough ride of going on an SSRI, this can really smooth things out for a period and help you get through a crisis that otherwise might have led you to do something drastic, like, you know, attempt on your own life. Um, and so, uh, it's a complex one.

Dr Carhart-Harris:
You know, so but, but, but let's be honest in our opinions, in my opinion um, yes, I think probably that would be the implication that instead of, you know, really getting to the nitty gritty of of, often there's not a clear, obvious solution to why one is suffering, you know, very, very complex, but, um I'm not sure it's helping to, to in terms of insight and self-development, I'm not really sure it's helping to, to actively cope, to, to, to be just smoothing things out with an SSRI. Might help you engage and be willing to go and talk to someone, a therapist and the evidence of the combo SSRI-time-psychotherapy suggests a bit of an additive effect, but not much. It's quite modest. Um, and so, you know, might just get you out of the house and, and so it might just be helping in that respect.

Chase Thompson:
Yeah, absolutely. And definitely don't mean to suggest to anyone that one way or the other is better that they should seek out one style of treatment. I think it it's a selection issue or who should really pursue each type of treatment at this point.

Dr Carhart-Harris:
Yeah. Who and when. You know.

Chase Thompson:
Right.

Dr Carhart-Harris:
In the throes of, you know, period of real serious turmoil in your life. Is it right to go and have a big, you know, dose of ayahuasca? I'm not sure. Um, so yeah, who and when I think.

Lucy Chen:
I'm actually really curious about whether people have thought about like developing guidelines for approaching treatment, like in a staged model or stage approach to care, you know, is there a way to determine sort of readiness for, you know, a psychedelic treatment-based modality, and how is that determined? And I wonder about your kind of your study criteria, too, and who you decide to recruit?

Dr Carhart-Harris:
Yeah. Um. Well, that's something that we're trying to crack. We've been doing these surveys for a long time, collecting data prospectively from people taking psychedelics in the wild, so to speak, you know, whether they're microdosing or LSD in the bedroom or, you know, uh, mushrooms at Burning Man or whatever, or ayahuasca at a retreat. Um, and so for us, there's an advantage in doing that naturalistic work because people are taking the psychedelics in all sorts of novel contexts. So we can look at, you know, set and setting, we can look at, um, how ready people feel simply by asking them, um, and if you do this with a tracker, you know, that's going to capture data before the event as well as afterwards, then you can do that and, and grab more useful data you know. If you try and do it in retrospect, it's always just in retrospect so you're, you're not really predicting things. You need to make your prediction ahead of time or collect the data ahead of time to really predict. But we've made a stab at that. We've got a couple of publications that have tried to predict or do predict response and a lot of our assumptions about set and setting were consolidated by that work. Um, but we're still getting to grips with it and getting to grips with the relative weighting of different factors like for example, emotional support and trust appears to be particularly heavily weighted as a predictor of the kind of experience that you have, which is the mediator of the longer-term outcomes.

Dr Carhart-Harris:
And so, for example, let's, let's do a quick sort of back of the envelope algorithm here. If you feel, uh, you report feeling ready, there aren't distractions in your life you're ready to do this, you're willing to let go to this experience, surrender to the experience, you're in the company of people who you trust and you feel emotionally supported then these are all, you know, green lights, meaning the these are good signs. These are good signs. Um, uh, now ahead of time, there's not much else, I said a back of the envelope algorithm here, so what what's this going to predict? Well, it's going to predict a stronger chance, not a done deal, but a stronger chance of a of a mystical-type experience, a peak experience if you want to put a more sort of obviously humanistic spin on it, you know, sense of bliss, a sense of interconnectedness, sense of timelessness um, and if you have this, this is another kind of green light or good sign that the longer-term outcomes are going to be favourable. And, and then things can come in, and I would say it's a bit too early to put any empirical data on this, but again, there are strong assumptions about integration, you know, to help sustain the positive effects that you got from the experience. And you know, this great phrase from Jack Kornfield, "After the Ecstasy, the laundry", you know, after the big experience comes the work, you know, the work never stops. Uh, doesn't have to be painful, but it's the work needs to continue.

Dr Carhart-Harris:
And so I think, you know, very, very simply that's a kind of back of the envelope algorithm that at least, you know, helps us put a lot of emphasis early on, which is critical and that helps me address, I could try and do it briefly, the other part of your question, which is the screening, you know, how do we screen? And I suppose in a sense, you know, in our clinical studies there is a bit of selection bias because we are looking for people where we feel that we've developed some rapport. There is a sense of trust. We're picking that up from, from from the people that we're talking to um, and those are kind of ideal for psychedelic therapy it seems. Uh, but so, you know, people see the results of these small studies and they get very, very excited and think psychedelics are the big breakthrough treatment in mental health and while they may well be, um, also it's healthy to have some critical acumen and think, well, there may be a selection bias in the patients that come into those trials. Um, maybe a bit of confirmation bias. The patients really want to get the psilocybin and believe it's going to work, you know, so well that doesn't mean that, you know, that will never be part of the treatment effect and always is, you know, that positive expectation at least just be conscious that that's part of the vehicle that can that can be producing these really impressive outcomes.

Nikhita Singhal:
Thank you for that. I think it's really exciting to hear about some of these benefits of possible future therapies coming out and I guess just one more question, coming back to this idea of the receptors. So the 2A agonism seems to be able to induce these very positive changes. I just wonder about some of the medications that we prescribe people for depression that are actually 2A antagonists such as Mirtazapine. How like how can we reconcile the the fact that they may both, 2A agonism and antagonism, have positive effects on depression.

Dr Carhart-Harris:
Yeah. Again really key question. And that brings us back to the you know many roads to Rome analogy that what 2A antagonism might do. So now we're blocking these these receptors rather than stimulating them um, what that might do is to work more in the direction of passive coping. You know, again, it's sort of maybe anxiolytic, flattening people out, less, less scope for any extremes in emotion. Um, and you know, Mirtazapine is kind of a bit of a sedating medication often I think taken just before sleep and it's it's probably that that that mechanism it also promotes sleep as well so you have deeper sleep so less awakenings and that can be a problem in depression, poor sleep, you know, waking up hyper aroused. Um, and so it's a it's a, yeah a different road to ideally a similar effect, but more just passive coping, taking the edge off things rather than, you know, getting to the, to the root, um, maybe the root cause of the suffering and promoting insight and therapeutic development.

Lucy Chen:
Um, well, thank you so much, Dr. Carhart-Harris. You know, a goal of our podcast is to not only cover like fundamental key concepts in psychiatry, but also to stimulate curiosity and to create opportunities for depth of understanding and to allow for expansive thinking when it comes to learning about treatments and treatment options in psychiatry. Your article and your ideas most definitely facilitate these values and goals for us, um we truly appreciate your time and your your valuable expertise. Um, I just wanted to know if you have any parting thoughts or ideas to leave our audience who are comprised from a variety of learners, um they're mostly sort of senior medical students and junior residents in psychiatry.

Dr Carhart-Harris:
Oh uh no, just to say that I appreciate your appreciation. I guess that's why, you know, people like me, write these things and do this work is that hopefully it should inspire others. And so I suppose one passing thought might be improve on this. You know, this isn't by any means the end of the story. It's just everything's iterative in science. So I'd love to see some bright young people come along and take this on to the next the next stage and develop our understanding.

Lucy Chen:
All right. Thank you so much.

Chase Thompson:
PsychEd is a resident driven initiative at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Drs Nikhita Singhal, Lucy Chen and Chase Thompson. This episode was audio edited by Chase Thompson. Our theme song is Working Solutions by Olive Musique, and a huge thank you to our incredible guest expert, Dr. Robin Carhart-Harris. You can contact us at psychedpodcast@gmail.com or psychedpodcast.org. Thank you very much for listening. Bye.

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Episode 23: Autism Spectrum Disorder with Dr. Melanie Penner, Dr. Yona Lunsky and Dr. Mitesh Patel

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Alex Raben:
Hi, listeners, this is Alex. This episode on Autism was recorded prior to the COVID-19 crisis. Before we jump into the episode, we wanted to take a moment to recognise the extraordinary efforts of the global community, which has come together to face this pandemic. This includes the tireless work of medical learners like you from around the world. Thank you, guys. Not just for listening, but for the service you're providing people in need. Stay safe and keep well. We plan to continue to make episodes to the best of our ability in this trying time, and we hope you will continue to listen. In addition, we've added to this episode's show notes an additional resource for how to help people with autism during the COVID-19 crisis. In less serious news, this episode had some technical difficulties and so you will notice a drop in the audio quality in the last 10 minutes or so. We apologise for this, but felt it was more important to release the episode blemishes at all than to not release it. As always, we hope this episode will enrich your learning.

Alex Raben:
Welcome to PsychEd, the psychiatry podcast for Medical Learners by medical Learners. I'm Alex Raben. I'm a PGY-five in psychiatry at the University of Toronto, and I'll be the host of this episode. And today, we're going to be learning all about Autism Spectrum Disorder from an understanding of what it is to how we can help people with this condition. I'd like to introduce the panel to you, the people joining me in the room today. I'll start with my co-host, Sabrina Agnihotri, who is a PGY one.

Sabrina Agnihotri:
Yes.

Alex Raben:
Excellent. And but Sabrina also has a PhD where she studied Fetal Alcohol Syndrome and so has some background in neurodevelopmental disorders. And she'll be bringing that expertise to this episode today as well. And then to Sabrina's right, we have Dr. Mitesh Patel, who is a child, as well as a forensic psychiatrist at Camh, and he works with young offenders, homeless youth, as well as people with neurodevelopmental disorders. Do I have that correct, Dr. Patel?

Dr. Mitesh Patel:
Yes. And also in the adult forensic system as well.

Alex Raben:
Oh, great. And then to his right, we have Dr. Yona Lunsky, who is a psychologist who works also at Camh, and she is a Professor of Psychiatry and actually has done a number of teaching sessions for my cohort of residents. And we've certainly appreciated those and wanted to get her on the show. She also does research into various neurodevelopmental disorders, including Autism Spectrum Disorder. So welcome, Dr. Lunsky.

Dr.Yona Lunsky:
Thanks. Happy to be here.

Alex Raben:
And last but not least, we have Dr. Melanie Penner, who is a developmental paediatrician from the Holland Bloorview Hospital, also here in Toronto. And she is a clinician educator, so she wears a clinician as well as a research hat. And in both those worlds, she works with people with autism. And in her research she works specifically looking at the services and program evaluation around Autism Spectrum Disorder. Welcome, Dr. Penner.

Dr. Melanie Penner:
It's great to be here.

Alex Raben:
All right. So it's wonderful that we have such a panel of experts this episode. I don't think we've ever had so many in one room. Just just to give everyone an idea of the scope of this episode. I think it's important that we go through today's learning objectives. So for this episode, by the end of the episode, the listener will be able to, number one, have an understanding of the neurobiology and epidemiology of autism. Number two, be able to tailor their diagnostic interview for autism spectrum disorder in a way that improves the accuracy of their diagnostic assessment, as well as being empathic and aware of issues in this condition. Number three have a familiarity of the impact of autism spectrum disorder on the people with this condition, as well as their families and the interdisciplinary and bio-psychosocial approaches involved in caring for people with autism spectrum disorder. So with that in mind, I'd like to start off first by getting a sense of this condition. And my first question for all of you is what is autism spectrum disorder? What does that mean? I know it's a DSM diagnosis that's in the Neurodevelopmental chapter, but if we can, without going into diagnostic criteria, is there an easy way for people to understand this condition? Is it one thing? Is it multiple things? I'll leave it there and maybe we can start with you, Dr. Patel.

Dr. Mitesh Patel:
Yes. Autism spectrum disorders is really an umbrella term. What that means is that it captures a lot of different kinds of presentations or ways of thinking. And the way that I like to think about autism and explain it to parents, for instance, is that autism is really a different way of thinking, a different way of seeing the world. And sometimes that way of seeing the world can lead to incredible strengths and talents and abilities that no one else could even ever have or fathom having. And at other times, it can lead to difficulties both in interacting with others. So some of that social communication stuff, but also sometimes there's some behaviours like repeating certain sets of behaviours or really being really focussed on certain things. And at times individuals who are diagnosed with autism can face incredible challenges.

Alex Raben:
Right. I'm wondering if other people on the panel wanted to add to that definition.

Dr. Melanie Penner:
It's so interesting. I had kind of jotted down some notes that said so many of those same things. So just a different way of. Interacting with the world. Thinking about both inputs and outputs in that different interaction. So inputs can be difficulty with the sensory environment that can cause a great deal of distress for autistic people and then outputs that may look a bit different than what we may be used to seeing. So different ways of expressing things like joy by, say, flapping your hands and jumping up and down different types of outputs in terms of how autistic people engage with other people.

Alex Raben:
Is there a preferred way of talking about this condition.

Sabrina Agnihotri:
Even referring it to a condition like like do you guys have any feedback for us and our listeners in terms of how that language comes across to you, too?

Dr. Mitesh Patel:
Yes. Yeah. I think it's immensely important that we stay away from labelling people according to their diagnosis. And something that I've often pushed for and tried to do within my own practice is not label individuals as like this is a schizophrenic individual. For instance, we might say this is an individual who has been diagnosed with schizophrenia in the same way when it comes to autism. I think it's really important for families and patients in particular to hear that, that there's a difference in learning. We term this autism. There can be a difference in terms of how they interact with the world. And I tend to try to stick to an individual who has been diagnosed with autism or has met criteria for autism versus saying the autistic individual.

Dr. Melanie Penner:
So I'm going to kind of jump in with some some things that I've learned from listening to the autistic community. And you'll notice that I'm tending to use identity first language a little bit more. And that's something that I actually picked up from actually Twitter, from listening to more autistic self advocates who at least for some of them really find something important in claiming that autistic identity for themselves and to acknowledge that it kind of it impacts their whole state of being. I think the approach I'm taking in a clinical environment, particularly when now I'm dealing with youth or young adults, is to actually ask them what their preference is for me to refer to their autism. And so some don't seem to have a preference. And then those who seem to be a little bit more kind of in that savvy community of thinking about disability and how autism kind of interplays with their life and society. A lot of them are kind of requesting identity, first language.

Dr.Yona Lunsky:
It's so interesting, right, because we really do hear different things from different people. So I would agree with this idea of, you know, talking with people to see what they're comfortable with. But even how we talk about it outside is going to make a difference to people. And I know I've also made a shift because I work primarily with adults to use identity first language around autism. So to talk about autistic people and then, you know, families would be like, well, why? Why do you do that? You know, or like clinicians, what do you doing? Like, don't you realise like and it's like actually I do and I'm now going and so so educating people say you may notice, right? So sometimes I'm going to say autistic people. And that's because some people have said they really have a lot of pride in their autism. They're really excited about that and they've asked us to speak in that way. We don't feel kind of, but that's okay. Whatever works for you, I will do that. But that's why I sometimes use that language. So kind of helping people to understand different perspectives. And I think with families too, even if their families have younger kids, just encouraging them. There's so much interesting literature now to read about that people are writing from their own voice. People who identify as being autistic write about what these things mean and why they're using that kind of language. So some nice things, I think that residents are clerks could just be reading to sort of get more aware of because it's changing. It's I think it's even different from two or three years ago. Certainly is different than six years ago. And it may be that in two years we're having a different conversation again.

Alex Raben:
So right. So much nuance there I'm hearing and a couple of different types of terminology that may be preferred by different people. And so it's really just important to be aware of these issues, check in with people and keep up with this as well, because as you say, it can change over time. With all of that said, there is this standard definition that we do have in the DSM five, and I'm wondering if we can work through that, because although as we've clearly spelled out here, this is not just about a DSM five diagnosis like with any of these diagnoses, we're talking about people who are very multidimensional. But we also use the DSM five as an important tool in our practices. And so I think it is important for us to unpack that for our listeners who are going through this large diagnostic manual in their clinical rotations. So can we talk a little bit about that? What is the DSM five criteria? How does one meet that? And then I think we can also get into how we actually ask around that and make the diagnosis.

Dr. Mitesh Patel:
In my work in forensics, it's actually really important that we know these criteria quite well because they do end up coming up. And I think for all of us they come up quite a bit and just knowing. But I think what's really important to remember is that when we're talking about developmental disabilities or neurodevelopmental conditions, in this particular case, autism, it's important to remember that this stuff starts in childhood. Early childhood, there has to be evidence of symptoms or concerns that come from the early childhood period. So some may come to their family doctors later in life or to their paediatricians or even to nurse practitioners or whoever else they might be meeting and say, Oh, I think I might be autistic. That often takes a long assessment. And really going back to interview biological family members, for instance, to find out what could potentially be going on there. So I believe that that's criterion C is that the symptoms are present from early childhood. Criterion D is that there is this impairment to functioning on an everyday basis. And so that is important as well, that this is not something that just simply goes by and it doesn't cause any impairments. I think the other two criterion I believe are much more important being criterion A and B, and I imagine others can speak to this much more.

Dr. Mitesh Patel:
But just in brief, the first criterion or criterion A is difficulties with reciprocal social communication and social interaction. What that means is that there's this general difficulty with understanding other people's emotions, having difficulties expressing their emotions, or being able to communicate in that context. And the second criterion or criterion B is that there's a restricted or repetitive patterns of behaviours, interests or activities. And so that could involve stereotypical or repetitive behaviours, highly restricted or fixated interests. And this is really why a lot of children come to clinical attention for us, I would say, is that that's one of the main challenges, at least in my practice, that I see a lot of. But also just in terms of the social reciprocity and understanding what's going on there, I would also point out that in autism, there's a lot of advancements that have been made in terms of identifying the severity of the illness or if we call it an illness or the condition. And I think that's really important is that things have changed so that now we're actually identifying them by how impaired the individual mate might be.

Dr. Melanie Penner:
Yeah. So. So I think within those kind of big A and B criteria. So, so there are two main domains of symptoms. So the first one is that social communication. So within those there, there is the sort of social emotional reciprocity. And like Natasha was saying, that's a lot of like the back and forth interaction piece. So kind of reading the situation appropriately and responding in the way that is generally expected. There is difficulties with nonverbal communication. And it's interesting because when I'm seeing young children, it's often the verbal communication that is presenting as the main reason for concern. But then as we look into it there, it's a broader difficulty with communication. So not only is perhaps the child not using their words to communicate yet, but they may not be using other strategies as well. And I see a lot of parents who are sort of doing a lot of guesswork about what it is their kids are trying to ask for. So within that nonverbal category, we're looking for things like eye contact pointing, use of gestures like nodding or shaking your head, you know, your use of facial expressions. Are you expressing how you're feeling on your face and beyond that? Are you also directing that to another person? And then the third criterion within that kind of social communication group is the development of relationships.

Dr. Melanie Penner:
So there we're looking at the earliest relationships being the caregiver relationship. So how is the child pulling the caregiver sort of into play, their siblings perhaps into play, whether they're doing that rich, you know, back and forth, imaginative play. And then as they are getting older, how they're developing peer relationships. So I think it's important to note as well within those social communication criteria, there are lots of things that can give you social difficulties. So autism is not the only one, but it is certainly one of the the ones you should be thinking about if you have a child who's presenting with those difficulties and then, yes, the restricted repetitive criteria. So that's where we see the some of the what we call stereotyped behaviours. So that's where we see things like lining up of toys, flapping of hands, repeating speech. We can see insistence on sameness. So kids who really want things to be like the same way every time, difficulty with transitioning from one thing to another. We can see intense or unusual interests. And so kids who get really obsessed with something and then those sensory difficulties that we've already sort of alluded to. So those can be both things that are extra alluring from a sensory perspective or things that are really aversive from a sensory perspective.

Alex Raben:
What I've heard and I'll just summarise sort of the criteria that I heard, which were these two big domains of what we might call a criteria, social deficits or difficulty with social communication or a difference in social communication. And then B was, which was restricted in repetitive behaviours that it had to be impairing and that it had to start in childhood, that this is a neurodevelopmental disorder, it starts young. How do we conduct ourselves in the interview that allows us to make this diagnosis? Does that involve collateral? Does it? What are the components of an actual diagnostic assessment?

Dr. Melanie Penner:
So to me the it you definitely need input from various sources so your history with the people who know that person best including perhaps that person depending on how you know what their age and developmental level is and and how they are able to contribute. I think collateral information is almost always helpful. Some of my really young ones who aren't in Day-care yet, it's, it's hard to get collateral information but once they're in Day-care or school, that's really, really helpful information because that is for children and youth, their sort of main occupation. So we definitely care about how they're doing in that environment. And then there should be some form of observation and interaction. And to me, that's so, you know, watching the child or youth is not really enough. They're you. You do need to be able to interact with them, whether that is with a standardised tool or otherwise and to to see what that interaction feels like. I think it's interesting though, sometimes you can have the effect of being a very good playmate. And I'm thinking of one case that I had where, you know, very bright boy who loved the idea of talking to an adult for an hour, like just loved it, and then afterward asked if I did birthday parties. So. So sometimes we can. We can accidentally select for making things. Things seem a bit rosier than they might in the real world. But those are generally the main components that I would think about.

Alex Raben:
And you also mentioned Scales. We had a listener write in with some questions. And actually, Connie Lutton, I hope I'm pronouncing that correctly. She's a social worker who works here at CAM in the Slate Centre. And one of her questions for us today was whether there were brief scales people could administer as a way of screening for for autism.

Dr. Melanie Penner:
So there are definitely, I think, of the tools in a few different buckets. So there are screening tools. There are screening tools that are based on questionnaires and then there are a few for really young kids that are based on a short interaction. And then there are diagnostic tools and again there are diagnostic tools that are more based on a questionnaire or interview, and there are some that are based on an interaction in terms of the diagnostic tools we are often thinking about. So in the interview sort of category, there's the autism diagnostic interview revised, which is fairly lengthy takes, you know, and does take a lot of training. But if you are looking at something that's that's sort of considered among the most reliable tools, that's what you would be looking at. And then for the observation and interaction sort of part of diagnostic tools and that the sort of main one that people often think of is called the AIDS or autism diagnostic observation schedule. And that one definitely takes a lot of training. You need very specific materials for it. It's important to know that depending on where you are making your diagnosis, you may or may not need specific tools to make that diagnosis. So where we are right now in Ontario, you do not need a specific tool to make a diagnosis that differs quite a bit if you go to a province like B.C. so it's important to know where you are and what the eligibility requirements are for diagnosis so that kids and families can access services based on how you've done the diagnosis.

Dr. Melanie Penner:
Probably the most important point here is that you're not going to find a score or a number that's going to make or break this diagnosis. It's a clinical diagnosis. And though I think the temptation is to find these ways to put to attach scores and numbers to it at the end, it's still based on clinical best judgement. And, you know, different types of cases may require different levels of kind of testing and kind of semi-structured interactions and things like that to come to that diagnostic conclusion. But at the end of the day, it's not based on a number, it's based on really rich information of that child, their context and support. Sorted by what you've seen in your clinical environment with the caveat, I would say that, you know, we do these clinical assessments in a strange place, like we make people come to a clinical place. They have to play with a strange adult. And so and I think we need to be aware of, of that limitation, particularly when we're kind of coding and scoring these types of interactions as well. That context is really important. And so I always try to really prioritise the descriptions of that child in the real world, recognising that my ability to kind of mimic that in my clinic is going to be limited even though I am a good playmate.

Alex Raben:
So what I'm hearing is that there's no replacing an actual clinical assessment and if there's a suspicion, there are tools available to you. But ultimately, someone probably needs to assess in person, get an A, get a fulsome assessment. I think part of why Connie was asking this question is she works at Slate, which is a centre here at CMS that works with people who have early signs of schizophrenia. And she was explaining that oftentimes it's not clear to her whether the person in front of her has actual schizophrenia or may be developing schizophrenia, or if this is more of an autism spectrum disorder. I'm wondering, are there other things that mimic ASD and what are they what do we have to look out for when we're trying to narrow down the diagnosis?

Dr. Mitesh Patel:
There are many other, many other conditions that can sometimes be confused for aspects of autism or presentations that they might have. Going back to what was mentioned about schizophrenia, autism can be comorbid with schizophrenia. That is incredibly important to remember. And when that happens, the presentation is can be very complex and it can be a bit more difficult to tease out what is psychosis versus what is an underlying interest that an individual may perceive it upon. Does that meet criteria for a delusion? Is there an aspect of paranoia tied into that? Are these things then connected? And oftentimes they are all connected, so it's really difficult to put people into these neat boxes.

Dr.Yona Lunsky:
Are there certain symptoms that you guys can think of from your practice that jump out to you as the most distressing to a patient?

Dr. Mitesh Patel:
Absolutely. I think one of the most difficult challenges for many youth, at least with autism, is bullying. And as soon as you start mentioning that question or raising aspects of it, the first thing that comes to mind is youth who are bullied for being different or not understanding what other people are trying to communicate and being subject to extreme amounts of bullying. But that's something that comes to mind. I'm not sure if that was your question, but yeah, no, that's what I that's what comes to mind for me is that that's one of the most distressing things. And OCD is very comorbid in terms of autism. And so there can be a lot of distress with having to keep that sameness, as was mentioned. And also a lot of the anxiety symptoms that come along with that.

Dr. Melanie Penner:
Yeah, I agree with all of those. The only other thing I would add, I think, is that the sensory symptoms can be very impairing. So for people with a lot of sound sensitivity, going out in public can be hard. Using a public washroom can be really hard between the like automatic flushing toilets and the like blasting hand dryers. There are lots of parts of the environment that are just not built with the needs of autistic people in mind.

Dr.Yona Lunsky:
Yeah. Even just, you know, your regular kid's birthday party with all the screaming, the happy birthday and the terrible thing that happens at the end of the happy birthday singing, which is the applause, you know, with the blowing out the candles and kind of that sudden like that is very jarring. So then you don't want to be at a birthday party, right? Or then you don't want to go to a sports event or all kinds of things that are really, really difficult.

Alex Raben:
Right. So quite a number of aspects of the illness can have can evoke distress. And part of it also seems to be at times the mismatch between people who we might call neurotypical versus people who have autism spectrum disorder, focusing on this sort of neurotypical word. I'm wondering if we can take a step in the direction of understanding the etiology of autism spectrum disorder. And I imagine this is there's a lot of question marks out there still. But what do we know about the differences in their brains and and how this and how this condition comes to be?

Dr. Melanie Penner:
Lots of looks around the table.

Dr.Yona Lunsky:
This one was the one cause of autism.

Dr. Mitesh Patel:
I think if we knew that, we wouldn't be here.

Dr.Yona Lunsky:
I was just going to say, I mean, I think it's really a cluster of symptoms or characteristics with so many different aetiologies. So we're learning more about those things. We no longer think, for example, that it's caused by how mothers raise their infants or their children. Right. So the refrigerator mother kind of phenomenon, we recognise that's not true and we know there's a certain biological sort of component to it, but it's not, it's not as clean cut as maybe we were hoping as we sort of advanced all of our, you know, expertise around understanding things like genetics and, you know, the sort of the actual anatomy, what's going on in the brain itself. It doesn't always look quite so different from some other neurodevelopmental condition.

Dr. Melanie Penner:
Yeah. So, I know some of the people who are doing the kind of cutting edge biological exploration in this area are starting to say things like the autism's so is autism as we know it really at a biological level, more a collection of rare disorders that present in a similar way from a from a behavioural perspective. And then the concept as well of neurodevelopmental disorders. I mean there are very fuzzy boundaries between our diagnostic buckets as we've already discussed. Right. Kids don't fit neatly into one bucket or often even two buckets. And so there's also a lot of work going on right now to re-examine these diagnostic categories that we've created and say, well, do these actually really hold up if we put them under scrutiny? And so I think of my colleague of TYCHE and agnostics work with the Province of Ontario Neurodevelopmental Disorders Network platform where they are. This is exactly the question they're taking on. They're saying if we take if we enrol a whole bunch of kids with various neurodevelopmental disorders, run them all through the same sort of phenotyping platform and look at their underlying biology, what would this tell us about the integrity of our diagnostic constructs? And so far, the results are showing that there is that the borders that we've constructed are quite hazy between these conditions.

Alex Raben:
Right. So there's I think although we're in the early stages of understanding the ideology, it seems like it's really ideologies at this. From what we understand at this point and a lot of that understanding comes from genetic testing and things of that nature. Is there a role for that kind of testing diagnostically today? Is there a role for other types of testing in our assessment of someone with potential ASD?

Dr. Melanie Penner:
So right now genetic testing in the form of chromosomal, microarray and fragile x testing is offered to families post diagnosis. And so we're not using it at this point to detect autism. It will be interesting to see, I guess, how the field develops that way. Right now, though, it's used, is more to see if we can find an underlying genetic condition that is that we think is associated with the autism. And there are various results we can get along those lines and a lot of grey areas. So. So I counsel families that it's generally about a one in ten chance that we're going to find something associated with the autism. When we do that testing, sometimes we get a genetic mutation back and it's a variant of uncertain clinical significance. So we don't know what that means. It hasn't been described in the literature as being associated with autism. And then sometimes we get a normal result, which may mean that there's not anything that we can detect that is that is a mutation. But it also may mean that just the type of testing we're doing right now, which is microarray testing as opposed to like a whole genome or whole exome sequencing, is not picking up things that a granular level that we would be able to find otherwise. So it's going to evolve and it will be interesting to see where we move as a field.

Dr.Yona Lunsky:
Yeah, I was going to just say it's still, I think, a really important message, you know, for clinicians that it is good practice to figure out, I think, if there is a cause, what it is because with certain things like for example, let's say it's fragile X and we didn't pick that up before. Well, we know a lot of things about people with Fragile X. We know about different medical things to look for, stuff that's going to happen over the course of development. We also know what that means in terms of other people in the family. Right. So there are conditions. I mean, Fragile X is hereditary. That's a particular one. There's other conditions as well where it's going to give us ideas of things that we want to be watching, whether it's about how that person's going to communicate best stuff we know about people's language with that kind of condition, medical stuff that's going to come into play, psychiatric things that may involve repair likely over time. So it does help us, but it's helpful, I think, to talk with families about why genetics is important and what we might find and what we might not.

Dr. Melanie Penner:
Yes, exactly what to expect.

Dr.Yona Lunsky:
There's one other again, thinking about adults and thinking about what people are talking about these days. It is important we can talk about what we're doing with our young children and our families when we think about genetics and autism, certainly things that I've read or that I've learned from autistic adults talking about this, there's a real fear around that. So if we look at, for example, how we understand genetic screening in another disability, so in Down's syndrome, we can actually test that prenatally. And what that's done, and especially in terms of how we counsel people when we notice that prenatally is sometimes there's an option or even sometimes in how we explain it and encouragement, you know, to abort that fetus. Right. So there can be fears or concerns around why are we doing genetic testing in autism? So people don't understand that it might be to help understand if this is the underlying cause. Here's some good things we could do to help address some of the things that might happen with that underlying cause. So it can feel like, well, we are doing that screening or we want to understand more about genetics because we're trying to not have autism or autism is wrong or autism is bad or this is something we want to get rid of. So it sends a certain messaging for people who are working really hard to take pride in who they are, about what we think of that condition. So with everything we talk about, I sort of hear this sort of perspective around working in the child area. And then I think, well, how is that perspective different when we're working with adults? And I think as people who may work both with children and adults, to have that recognition that something that makes so much sense for one group may have different sort of implications or meanings for another group and to be sensitive to that.

Dr. Melanie Penner:
Mm hmm.

Alex Raben:
Yeah, for sure. And just I mean, even in this room, we don't have all groups represented at the table in terms of this discussion. I think we should acknowledge that as well. But we are doing our best to keep that in mind with all of this. And it's a perspective I didn't think of with respect to the genetic testing and how that could be interpreted by someone who identifies as autistic. At this stage, though, it sounds like from what you're saying, the genetic testing is not diagnostic. However, it can be helpful in terms of treatment decisions down the line for people with autism spectrum disorder. Using that as a launching pad. Perhaps now we should turn to treatment and how we can help people who are suffering with autism. We talked a little bit about comorbidities. We've talked a little bit about some of the particularly distressing symptoms. And so we have a starting place, I imagine, of targets for treatment. But if we think broadly, what are the general considerations here when we're trying to help people with this condition?

Dr. Mitesh Patel:
I think one of the the main challenges in working with individuals who meet criteria for autism is that it can be immensely difficult for them to navigate the world. And as they enter adulthood and something I see a lot in adults, is there social determinants of health are so much poorer than others potentially. And there's a large prison population that may meet criteria for ASD or autism spectrum disorder and just haven't undertaken the diagnostic testing because they didn't come from a family that could have questioned that diagnosis. I see a lot of children at the Children's Aid Society of Toronto that may meet criteria, but again, until they've come into care, haven't had that opportunity to potentially undertake assessment. There's lots of homeless youth who meet criteria for this diagnosis and they face incredible challenges trying to figure out applications for housing money. Many of them are targeted and preyed upon by predators who are either after their money most often. And there's also a sexual predation upon this population. And so it can be immensely difficult for these individuals. And so when we think about treatment, I think it's also important to think about what we can do to help intervene and assist individuals. And many of these individuals are our highest-risk populations. And so when we think of high-risk youth, when we think of high-risk adults, this neurodevelopmental community in particular comes to the forefront in many instances because they are facing very unique challenges, and they they can often become targeted by others, something we haven't really talked about much. And maybe I'll start the treatment discussion. There is what we see a lot of in clinical practice, especially if you're a child psychiatrist.

Dr. Mitesh Patel:
One of the main things you see is conduct disorder amongst youth. And so when you have an autistic child who comes in with some conduct sort of behaviours, it's often because of what we call poor frustration, tolerance, which is having difficulties understanding all the frustrations that they might have or understanding what's going on around them. And so if you don't have the same kind of perspective on the world around you as others might expect you to have, obviously that's going to be super frustrating. Right. And for some of these children, it can be difficult to let out that kind of frustration. And other people might get hurt when they try to let out their frustrations. So some might behave in an aggressive manner or a hostile manner to let out some of that pent-up energy or pent-up frustration. And so oftentimes that's the focus of treatment, is how do we target these behaviours that are of major concern. Potentially others might be getting hurt in the home or that child might be hurting themselves. Did what we call self-injurious behaviours or SEB that happens predominantly in this community in terms of Seb in general and there are treatments for that. A lot of it is behavioural therapy. There are some medications that can be tried as well that have been shown to have some benefit. But I think it's really important to focus first and foremost on what we can do to help assist that individual navigate the complex social array that we have before them, depending on their age of development.

Dr. Melanie Penner:
Yeah. Some of my sort of first principles around thinking about treatment goals are thinking about what gets in the way of everyday life. So what that question of function and I think in the past a lot of autism treatment was focussed a bit more on the idea of removing autism or making the autistic person look normal. And so treatment could be focussed on things like getting rid of hand flapping, even though that hand flapping in and of itself may not be harming another person or harming that person. And so I think increasingly the goals of various types of treatment are starting to move towards an idea more of improving function. And with that, I think there's also an emphasis on goal setting. So what is what are that family's goals at this moment as they get older? What are the child and youth goals? And then what are the the young adult, the adult schools to work on? Because I think if you're starting from that place of what does the family really want to work on what's going to or that does the autistic person want to work on? That's going to make the most difference in their day to day life. I think that's where that's where we're going to do the most good.

Sabrina Agnihotri:
And what does family involvement look like in the paediatric world versus the adult world in terms of treatment goal setting?

Dr. Melanie Penner:
I think ideally, it's it's a continuum of change as according to the autistic person's sort of developmental, you know, level at that period of time. So we would want to see, you know, some degree of things of enhancing and encouraging as much independence as is sort of reasonable in that situation. Certainly when they're really young, obviously it's a lot of talking to parents. When I'm seeing adolescents, I am trying to do more of that. You know, let's kick your parents out for a bit if that's if that is kind of developmentally appropriate. And I'm going to ask you to tell me what your medications are. I'm going to, you know, ask you about how school is going. And the disclosures that I get during those times are really, really important. And so I think sometimes we think about it in kind of a stepwise fashion, but ideally it's more of a continuum.

Dr.Yona Lunsky:
Yeah, I think one of the big differences is that when we're doing our adult based work, we sort of forget all that stuff around more family-centred care. That's so obvious in terms of our training when we're working with children. So kind of finding that balance in adulthood is really important. And certainly from a family perspective, you know, whether it's an adult sibling or parents, they will talk about how it feels to not be included in care decisions. So if I am not the best person at articulating, you know, a full context of a situation and people are only listening to my story or I'm not very good at remembering something that happened in my therapy session, for example, or just reflecting on memory of when certain behaviours or symptoms were going on. When I'm giving a history, then the clinician doesn't have all the information, but sometimes I think families are kind of left out of that because we have a sort of model of how we work with adults. So we have to figure out how we blend those two models in a respectful way as possible, sort of promoting autonomy and independence, but also a little bit of interdependence and sort of seeing where that is.

Dr.Yona Lunsky:
I think it's easy for us to do that with kids. It's harder for us to figure that out with adults, and sometimes people don't share the same perspective. So like, I don't want you to talk to my parents because actually I'm really mad at my parents right now and they don't understand me. I understand me. So how do we respect that with a young adult or an adult, but is there something kind of to learn from that? And sometimes I think therapeutically, if you can sort of help that person potentially appreciate or better understand why they don't want the conversation to happen with family, that could be really informative and there could be something they can learn as a family together if you can sort of bring people together around some of that stuff. So don't shy away from it. I think just because it seems like you're supposed to work in a certain way based on that person's age.

Dr. Mitesh Patel:
So I tend to work primarily with children who have lost their families or there's been a there's been so, so many challenges within the family that it's fallen apart or their supports have fallen apart. And I think there's three main issues that that come up with that. So the first is a lack of support for those family members that it can be immensely challenging to have a child with special needs that requires so much more attention than other children in the home, for instance, it can lead to immense amounts of frustration, substance abuse challenges, involvement by external agencies, investigations, etc., etc. And it can be immensely challenging, particularly if the child engages in externalising behaviours or ends up getting into trouble with others or there's legal involvement. The second thing is around Psychoeducation, so really understanding what the needs of their child are, and that is do I understand what kinds of resources this child will need as they move forward? And the third is a lack of infrastructure, actually, and I don't say that lightly. When I see a homeless youth, for instance, it is immensely difficult to identify what kind of dedicated services are actually going to be available for that individual. Many of the services we have, they're dedicated and designed for people who can interact well with that system, who can actually advocate for themselves or say, Hey, this is what I want.

Dr. Mitesh Patel:
You know, I've got this odious application. I need to get it filled out. I'm going to go find the doctor to get this done. You give a form to an autistic individual has no understanding of what that involves or how they would go about booking an appointment or try to get someone on board to maybe assess them and fill out a form that is so challenging. And our system just isn't really well designed for that. And so I see a lot of youth in shelter where we're scrambling to get as many workers on board to help them. Some of these frontline workers do amazing amounts of extra work just to help these kids out and these youth out. And you. I think it's it's always surprising to me when I bring other people into a shelter setting just to see how many of these youth have developmental challenges or meet criteria for autism and are now homeless and have lost all their family supports. And you just see this look of complete concern on almost every worker's face because we don't know what to do and people are trying to get them as much assistance as possible. And it is difficult.

Alex Raben:
It's it strikes me that we often talk about the biopsychosocial model in terms and approach to treatment of various kinds of conditions in psychiatry and in medicine in general. And I think almost everything we've mentioned so far has been in that social category. So it's almost in reverse, the social psycho-bio approach, perhaps. And, you know, in terms of that social bucket, what I've heard from you guys is understanding the goals, both from the family's perspective and the individual's perspective, working with families to ensure that they are involved in care, but also that the system surrounding them is supporting them in order so that they understand what's going on, so that they don't feel overburdened, which could lead to the ultimate outcome of that individual becoming homeless or not really having that family support and further social determinants of health worsening from their. So that really stuck out to me. I'm wondering if there's anything else in that bucket we should be discussing in terms of what a learner might want to know in terms of helping people with this condition, or if that or if it's a bit too hard to know the specifics around that, because I often find that with social with the social bucket is you need to know very minute services in your area. So I'll just leave it there if there's anything else in social we should cover. But then I was thinking we could move in more specifically to psychological and biological interventions as well.

Dr.Yona Lunsky:
I think just to mention on the social side that there are a lot of we talked about a lot of the problems and a lot of the challenges, but it also means there's a lot of things we can do. So we can if we can set up infrastructure that makes a big difference. If we can give either that autistic person social supports, that match what they're looking for or their families, that's really important. There's again, we've talked about the sort of movement for, I think, both youth and adults in terms of feeling like they belong somewhere and connecting with other people who see things the same way they do. So there can be a lot of power in terms of peer-based kinds of supports and connections, and sometimes that's in person, but sometimes that's virtual. So there's a lot of support that people connect with through technology. So understanding, for example, a young person who's spending a lot of time gaming and thinking about how problematic that is, but if there's a whole community of people playing that game with them that they can only connect with through that game, that's actually a really important social support for them. So we have to think about that. Or there might be for adults a way of sort of communicating, reading, talking about their experience, and they might be doing that through Twitter, for example, or through Reddit or so, kind of recognising that there are things we can do socially and also in terms of meaning poverty. You talked about housing, which is obvious, so huge, so important, but also having something meaningful that you do during the day. So some of our treatments are really trying to figure out how we can give things for people to do that, make them feel good about themselves, and that gives them meaning. So it's a really important part of intervention.

Alex Raben:
Right? So not forgetting those sort of low-barrier ways we can improve, potentially improve people's social lives by acknowledging the groups that they can find and connect with online or in person in addition to broader social programs to help with housing and poverty. I think that's very important. That said, I'm wondering in terms of psychological treatments, what is available for people with ASD.

Dr. Melanie Penner:
So yeah, so I think the most commonly discussed form of therapy is ABA or Applied Behaviour Analysis. And ABA I guess similar to autism is a very broad term that covers a lot of stuff. And so I would say some of the core elements of ABA are that it sort of works with the idea of motivation and how you keep people motivated to learn skills that might be more challenging for them. But there is a lot of breaking things down into very small component parts and then teaching them sort of one piece at a time and a lot of repetition built into that. And it's done. It's supposed to be done in a in a somewhat systematic way, often involving some data collection to sort of track progress. And the evidence base is interesting. So there was a recent meta-analysis that was published of different early interventions for autism, and they actually found that the quality of evidence for many of these ABA programs is not that great. So very little in the way of randomised controlled trials. And this is it's hard to study these types of interventions in a very, very rigorous way in the types of study designs we see when we're doing, you know, double-blind, placebo-controlled drug trials, for instance. But I do think that that it is it does pose a challenge to the research community to think about how we can generate the best possible evidence, control for bias as much as possible to generate the type of evidentiary support that we ideally would like to have for these interventions.

Dr. Melanie Penner:
In that meta-analysis, the sort of standout that had the best evidence supporting it was something called naturalistic developmental behavioural interventions or NDB models. And we have so many abbreviations in our world, as you can probably tell, and this is sort of the newest sort of iteration I think, of where ABA is and is going where so. Naturalistic refers to applying the intervention in the child's natural environment. So taking it out of a very clinical space, because when it's done in a clinical space, then you have to the child has to then make the leap to applying those skills than in their regular environment. So the idea is by applying the teaching in their regular environment, you eliminate that step developmental. So the RD in MTBI refers just to the fact that we're thinking about the developmental domains and the developmental skills that were kind of wanting to focus on at that age. And so again, previous models were maybe a bit more focussed on kind of table-based tasks, academic type tasks. And these NDB models are starting to move a little bit more into saying, okay, like what are the domains in terms of social interaction, in terms of communication that we want to work on? The behavioural reflects that this is still like a behaviourally based model. So that's that is the kind of I would say where the field is sort of going with those types of interventions.

Dr.Yona Lunsky:
Just to add from psychological thinking and about adults that we would be thinking about different things for adults, we wouldn't be thinking so much. What are the interventions for autism psychologically? But we might be thinking, what are the interventions for depression or for anxiety? And, you know, it's we're in an earlier stage because most of the research done on autism is done on kids. So it's much less done on adults. But we are learning that many of the things that we do in the general population might also have some use in terms of psychological interventions, especially if that person, for example, has speech and is able to do a more psychological kind of therapy. But there are certain things we might want to shift or change. So and again, Autism's, not everybody does well with the same thing. So one person might really appreciate the sort of scientific inquiry or approach that you use sometimes in CBT, where you take a thought and you think about it and you look at the evidence, but someone else might find it incredibly impossible to capture what an automatic thought is.

Sabrina Agnihotri:
Can you give us a few examples of the more biological treatments?

Dr. Mitesh Patel:
Yes, in a lot of the work that I do focussed around youth who are facing some challenges, some of that can be externalising behaviours and so we may treat that with low dose third generation antipsychotic medications. Abilify has shown some evidence in that regard.

Alex Raben:
And by externalising behaviours you mean things like aggression.

Dr. Mitesh Patel:
Yes. Or even self-injurious behaviours. Yeah. There is some evidence as well for using some other agents related to opioids for self-injurious behaviours. That evidence is somewhat limited. It's a difficult area to treat, but as I've indicated, as has come up here before, many of the symptom concerns that come forward are related to mood and anxiety. And so when we've exhausted psychological approaches and social approaches to treat these underlying issues, we may turn potentially to biological agents. And in that case, we are looking at typical agents that we would use in others, including SSRI medications or other antidepressants. This is in my practice, it's not a population that I typically use benzodiazepines, and I have a very not good experience. And I wouldn't do that anyhow with youth. But even in adults, I find that it's just it's not it doesn't have the same effect even in short-term cases. There's a lot of looking at what the comorbid symptoms are. Is there a poor sleep? Is melatonin going to work, for instance, just to facilitate some improved sleep? And if that happens, is there improved mood and anxiety symptoms? Usually that's the case even when it comes to aggression and hostility. We look at those things as well. There is a specific population that may have certain focussed sets of interests and even engages in some sexualised behaviours which isn't overly common, but it can happen. And so sometimes we look at some medications to help with that too. But I don't want that to be the focus of this and I don't want people to walk away thinking that that's what we're treating for and that's what we have to do. These are very specific cases and I think the rare cases, but I think for some of us that practice in certain areas, we end up seeing so much of one thing that we start to think like, Oh, maybe this is more prevalent than we thought. But no it's not.

Dr. Melanie Penner:
Yeah, I would say the one well a couple I would add , ADHD commonly occurs with autism. And so we have a lot of kids who are and teens and probably adults who are started on ADHD medications, so stimulants. Alpha agonists. At a max teen. And the other thing to think about from the biological sort of component is co-occurring medical conditions. And so there I think we have to be thinking about. Seizures, which we know frequently occur in autism. Sometimes side effects of seizure medications have a big impact on the presentation that we're seeing. Constipation. I don't think I'd be allowed to be a paediatrician and be interviewed here without mentioning constipation. So but, you know. That's something that you can make you very irritable thinking. Thinking about, particularly for autistic people who don't have the best ways of communicating with us. I think we need to be extra careful that we're not missing things. And so one of the one of the toughest cases in our clinic was a dental abscess that that had been missed. And that was a big source Of pain. And so those are the things that you just don't want to miss. Right. So it's important not to just chalk up the behaviour to autism. But to make sure that you're, you're doing a good review of systems as well to make sure that those medical co-occurring conditions are considered too.

Dr. Mitesh Patel:
That's immensely important, particularly in autistic clients, especially those that don't have the ability to communicate. In fact, they can't tell you if they're experiencing pain. And so oftentimes in psychiatry or child psychiatry, we're working very closely with paediatricians to have the child undertake a fulsome assessment. Even the dentists will get involved to look for this kind of thing, which is why it's so important to have these multidisciplinary teams working together for these clients, which also presents infrastructure challenges because it can be difficult to get all these players around the table in the same place for some of these youth.

Dr. Melanie Penner:
And I think often it's a virtual table that we're talking about. Right? And it does. I think the issue comes. In sort of who's running point on this, who's coordinating all of this information, synthesising it, making sure that all of the boxes are checked off? Because you're right, it's we don't have infrastructure such that everyone sort of sits around the same table to discuss these cases. So there's a lot of behind the scenes work, I think, that probably all of us are doing to coordinate things for our patients.

Alex Raben:
So there's a lot there. I'm going to because we've come closer to the end of our time together. I'm going to try my best to summarise the treatment, but there's a lot to summarise. But I think, as I was saying in the beginning, it sounds like it's an almost reverse social psycho-bio approach with social considering factors of social determinants of health, large issues like poverty and homelessness, but also considering the person's social circle, their family supports and ensuring those are as healthy as they can be to support this person in the psychological pathway. We have ABA applied behavioural analysis and this is a behavioural type of therapy that works with positive reinforcement to help with the core deficits that relate to ASD, such as social reciprocity and things of that nature. And then the last section is biological interventions, which from what I was hearing, really don't target the core symptoms if you will, of ASD.

Alex Raben:
But rather target the comorbid psychiatric conditions and medical conditions. And it's important to recognise both and recognise that there could be overlap that a biological or a medical condition may be causing a psychiatric or mimicking a psychiatric reaction. Leading that person to be aggressive, for instance, and that we do have some medications that help, such as atypical antipsychotics that can help with externalising behaviours and then SSRIs if there's a comorbid depression. I also heard the subtext was that no one does this alone. This is a team working around this individual, ideally a team of professionals, and that's not necessarily an easy team to coordinate all the time in our current health system, but one that is paramount to the treatment of people with this condition.

Alex Raben:
As sort of a last hurrah, I'm wondering if you guys have any resources you would recommend for clerks or early residents that would allow them to delve a bit deeper into this topic.

Dr. Mitesh Patel:
Autism Canada.org has a ton of information. I think that's a good place to go but also just I think reading from Journals and seeing some of the newest information that comes out, it's also very helpful and getting a lot of clinical exposure. I think that's the main thing is if you can shadow or do an elective or do a rotation in some of these areas, we haven't talked too much about dual diagnoses, but that's a big area to do this in. And I think you'll find across psychiatry, many practices end up working with individuals who have autism or diagnosed with it.

Dr. Melanie Penner:
I think my advice is to actually seek out first-person accounts of autism. I think that's where some of my best sort of hidden curriculum learning has happened. So, you know, there is a very rich, nuanced discussion of autism happening every day on Twitter. There are lots of books written. So Yonas mentioned Temple Grandin. One of my favourites is Look Me in the Eye by John Elder Robison. And then for a really nice sort of overview of the history and kind of politics and sociology of autism. The book Neuro Tribes by Steve Silverman is excellent. Great.

Dr.Yona Lunsky:
I would actually echo a lot of I think recognising different people are looking for things at different times, but so important, I think, to understand people's experiences themselves. And also if you're interested in supporting families, understanding also families experiences and being familiar with the different stories because there isn't just one. And so it's helpful to understand the perspective of autistic adults, the perspective of parents or siblings, of people who are autistic at different ages from different times. The more you can read, the more you can learn, right? And the more you see people and interact with people, I think is also I mean, there's even a huge difference that people who are listening to this right. Now, who are clerks or early residents, were brought up at a different time than I was in terms of who was in your school and who was in your neighbourhood, right? So that's already making a difference is probably people, you know, that you can talk to. I think that could be really helpful as well.

Dr. Mitesh Patel:
I just want to echo that Look Me in the Eye book that was actually required reading for me during my residency by one of my supervisors, and I'm so glad he pushed for that. That was at the Maples Institute in Vancouver, which is a Child Custody Centre and Youth Forensic Centre. But it definitely helped to, I think, educate me a lot about the perspectives. And yeah, I think there's so many things to do. There's movies to watch as well. Yeah. So I think there's lots of ways about learning about this, right.

Alex Raben:
And now a podcast episode. Thank you guys so much for being here. We really appreciate it and for taking us through various aspects of autism spectrum disorder and for giving us some resources to move forward with. So I just want to thank you all again and thank you guys for listening. And we will. Talk to you next time. Bye bye.

Alex Raben:
PscyhEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Weam Sieffien, Gurnaam Kasbia, Sabrina Agnihotri and Alex Raben. This episode was hosted by Alex Raben and Sabrina Agnihotri. Audio editing by Jordan Bawks and Alex Raben. The accompanying infographic for this episode was created by Weam Sieffien and Nikhita Singhal. Our theme song is Working Solutions by Olive Music. A special thanks to the incredible guests Dr. Melanie Penner, Dr. John Wolinsky and Dr. Mitesh Patel for serving as our experts for this episode and providing us resources for our show notes. You can contact us at podcast at gmail.com or visit us at Psych podcast dot org. Thank you so much for listening!

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