Sara

Alex Porthukaran is psychologist at the Center for Addiction and Mental Health, autism, wellness and flourish health services. He works with autism or neurodevelopmental conditions, with CO occurring mental health conditions. And as part of his role at CAMH, he provides consultation to inpatient teams on cases where clients have complex or severe mental health conditions. So today we've invited Dr Porthukaran to talk about youth mental health, a closer look at complex diagnoses, and at this point I will hand it over to him, and we're excited to have you, Dr Porthukaran, thank you so much for joining us.

Dr. Porthukaran

Yeah, thanks, Sarah. It's I'm glad to be here. Excited to see so many people. I see some people. Even from CAMH that I work with, like Louisa. But yeah, so I'm gonna talk about some of these complex mental health conditions that we see. If you have any questions, feel free to interrupt or throw in the chat. I don't know, Marie, if you have a different way of doing it, but that's.

Marie

That's great. Megan will be monitoring the chat, so if there are any questions, that's Megan, Will, Megan will let you know. Awesome.

Dr. Porthukaran

Yeah, so we can get started. And Marie will be doing my slides for me, so sometimes I'll just tell her to go to the next slide. So like Sarah was saying, I'm a psychologist. I work at autism wellness, I work at CAMH and at flourish. And I work primarily with autism, but I see a lot of co occurring conditions, and then especially some of these differential diagnoses when I'm trying to separate what might be autistic characteristics from things like some of the disorders that we're going to talk about today. So just to give you a quick outline on the next slide, I want to talk about three things in particular. So we're going to talk a little bit about bipolar disorder, about psychosis, about DMDD, and what that is even and then we'll talk a little bit about how we maybe think about differential diagnosis, of how we understand that in relation to some other things that maybe you more commonly work with. And then finally, I'll have just a couple of comments on treatment and considerations as well. Okay, so first of all, maybe you're thinking that you don't work with complex mental health conditions. You probably refer out if you see people with bipolar disorder or schizophrenia or psychosis, and I'm not trying to tell you to not do that, but I think that very often these conditions are misunderstood or misdiagnosed, and when that happens, that can cause a lot of issues for some of the clients that you and I work with. And so keeping that in mind, I think it's very important to have an understanding of what these more complex mental health disorders look like, so that when we see it with the people that we're working with, we know to refer or you know what to do with that. Okay, so let's with that. I'm going to talk a lot more about that later, especially like about what kinds of issues it can cause, or what kinds of problems we see when we don't understand these conditions properly. But we can come back to that near the end of the presentation. So let's talk a little bit about what Bipolar disorder is, and we'll go through each of them. And so, I mean, I do have, like, the list of symptoms at some point on these slides, but I really want people to understand more of like, what, what is the main character that we're seeing when we're when we're seeing someone with bipolar disorder? So, so first of all, I'll just say Bipolar disorder is the presence of both manic episodes and depression that even that's already a little bit a little bit wrong. But you know, one reason why this is important is that the typical age of onset is adulthood, but about 30% of people that develop bipolar disorder have the onset in adolescence and sometimes even in childhood, so about 5% of the time, and the people that develop it more early are more likely to have negative outcomes. So that makes it, you know, especially important for us to be, for us to be thinking about it with children and with you when we're seeing these, you know, more severe mood concerns. And so I'm not going to get into the last little bit on the slide too much, but I just want you to know that there are different considerations when we're diagnosing bipolar disorder. So there's bipolar one versus bipolar two, and I'm not going to again, talk too much about that, but bipolar two is a hypomanic state that's defined rather than a manic state. And then sometimes you don't always see the depressive state, and then sometimes there's something called a mixed episode, which is something you probably haven't heard of. But again, I'm not we're not going to spend too much time on that, because we're not here trying to figure out what each of those things look like, but rather, what you know bipolar as a whole looks like. So if you go to the next slide, yeah. So I just. To talk for a second about what's going on in the brain when we're talking about bipolar disorder. So every day, you and I engage in, you know, what we call interoception and exteroception. So we are paying attention to, you know, what's happening physiologically within us. You might notice that your heart rate gets elevated. You might notice that you're feeling anxious or nervous, and those are pretty standard things for you to be experiencing. And then there's extra reception, so perceiving the world around you. And so sometimes people talk about bipolar as a priority of EXO reception, or even that the interoceptive brain are impaired. And so what that means is that this can affect your ability to, you know, regulate your emotions, to consider consequences, to think, to experience fear, and so, you know, one quote that I have from an article that I'll just read is that I thought was very interesting. Is effective dysregulation of bipolar disorder arises from Dynamic instabilities and interoceptive circuits, which subsequently impact on fear circuitry and cognitive control systems. And so this group of researchers and I have their reference later described the resulting disturbance as a psychosis of interoception, so loss of contact with interoception. So you probably haven't thought of bipolar disorder in that way. And I thought that was a very interesting way of framing it in that when we see people with bipolar disorder, sorry,

someone muted me, I think they're very much concerned with what they're doing, rather than, you know how they're feeling or what they imagine will happen to them in the future. And so one of the reasons so lithium actually has a very interesting history with bipolar disorder. And if you're very if you're interested in this, I definitely encourage you to kind of look that up, and, you know, learn more about that. But lithium can be protective of these circuits. Stop that, you know, that shift from happening, and so allow people to have that contact with interoception, as well as their, you know, the exteroceptive circuits. So again, that's all I'll say about that. That's not really my area or anything, but I just wanted to kind of look into that a little bit and share that with you. So what, what the manic episode, which is, again, bipolar, is having both mania and depression. What a manic episode really is, is a period of abnormally and persistently elevated, expansive or irritable mood. Okay? And you know, you're also supposed to have three out of four of the symptoms that you see in that in that checklist on the bottom. So what, what that typically presents as is people that feel like they can't make any mistakes, like they have as much energy as they need and they're able to do, you know, these really grand and, you know, sweeping kinds of projects. So for example, you might hear about, people who feel like they can write a whole book or they can't, you know, they can go write some tests and not make any mistakes when they're doing that. And, you know, one kind of very key component of this is, this is very goal directed. They're, you know, focused on accomplishing tasks. They might not, they might not have the follow through to finish the task, but they're trying to go from task to task to task to task, task task, to get something really big or really impressive done often. And so alongside of that, they might feel like they're, you know, grandiose, as in, like they can't make a mistake, or they can't do anything wrong. They might not need to sleep when that's happening. They you might hear them talking in this way where they're talking about one idea and they go to another idea, and they go to another idea, and their speech is just, it's spilling over itself. And that's what we call pressured speech, and the and the idea from one to the next is called, is the flight of ideas. They could be distractible. So they're working on something, but then they, you know, see something else, and then they go off to that. So it's, it's a much different kind of distractibility than we see with ADHD, where, you know, you're working on homework or something, and then you get distracted, and then you try to come back to your homework. And you get distracted, you come back to the homework. This is more. You go from one thing to the next thing to the next thing to the next thing. And again, a key feature is goal directed activity. I'll tell you why I'm making a big deal out of that in a second. And so often that leads to people feeling impulsive as well. So when we're understanding mania, again, here's another quote that I thought was interesting. So there's this radical acceleration, and you people are really kind of out of touch with time. They are, you know, doing everything in the moment. There's this instantaneous existence that people are focused on. And, you know, there's not none of those, like normal boundaries. So one of the things that we often ask when we do things is, if I do this, and you might not ask this consciously, but you're thinking about this. How is this going to affect me in the future? What is the downstream consequence of this action? But when they're in this manic state, often people are really focused on what's happening right now. They feel like they can do anything. They're capable, and then they also have the energy that they need to do whatever it is that comes to mind. So you can imagine how that leads to people, you know, doing a lot of things that they might not normally do. Okay? So we can go to the next slide. So that's, that's what I'm going to say about bipolar. We're going to talk a little bit more about, you know, similarities and, you know, differential diagnosis and things like that. But hopefully you have a little bit of a flavor of what bipolar disorder can look like. So maybe we can shift now to talking a little bit more about psychosis. And sorry, I'm just trying to switch my slides as well. And so when we're talking about psychosis, we are talking about that lack of contact again, but this time with reality, the things that we know to be real. And so again, the age of onset is relevant for people who work with with youth, and especially people that work in that early adulthood state. So the age of onset is typically late adolescence or early adulthood, but we know that there are certain factors that exacerbate this or cause an earlier onset. For example, cannabis use has been something that's been, you know, indicated in the literature. And so there's, there's main, there's four main kind of symptoms that are associated with what's, what is psychosis, and you really just need one to have some kind of a psychotic disorder. And so those are hallucinations, delusions, disorganized speech and disorganized behaviour. And again, we'll talk a little bit more about what those are. But in schizophrenia, which is just one kind of psychosis, you also tend to see negative symptoms, so that's the loss of normal functioning. So, you know, just because I've just read the words and, you know, probably people don't really know too much about what disorganized speech or disorganized behaviour looks like. Really, what we're trying to understand is an internal state, and we're trying to kind of guess at that internal state based on their external behaviour. So what we find actually, is that a lot of people that are experiencing a psychosis, have you know, they're not organizing their ideas in their brain in the same way that they typically do, but you can't really see that. What you can see is the speech and the behaviour. So you might find that in their speech, again, they're going from topic to topic, but it's not goal directed anymore, like it was in bipolar. It's not this idea of like, I can do this and I can do this, then I can do this. The ideas might be random. They might be disconnected. They might not even make sense. It might sound a little word salady, and the behaviour has that idea has that kind of quality as well. So again, differentiating this from a manic state, it's not that they're going from one activity to the next activity, they might be engaging in behaviour that's random. So for example, they might be walking somewhere. They stop turn around, but it's not because something else got their attention. It's because the behaviour was disorganized and so again, and sorry, Marie, one more comment on this slide. So this is not the focus, but there are different kinds of psychosis as well. So a lot of people will just experience one psychotic episode. So we call that a brief psychotic episode, and that's the only time they have, you know, these significant symptoms. Some people will experience that for a prolonged period of time, and then we give, we give a diagnosis schizophrenia. Some people will have that in conjunction with a mood disorder, with a severe mood disorder, and then we'll, you know, talk about schizoaffective disorder. And so there's other other considerations as well, but, but again, the important thing to keep in mind is that this is something that can just be a one off thing, like someone has a psychotic episode caused by stress or trauma. We'll talk about that in a second, or it could be a lifelong condition as well. Okay, so now we can go to the next slide. One of the most important things for people who work with youth to keep in mind is that psychosis isn't just, you know, the acute phase when we're seeing hallucinations, delusions and the disorganized speech and behaviour, but there's also often what we call a prodrome. So a prodromal phase is what precedes the psychosis, and you see some characteristics that you know you can see kind of a logical connection with psychosis. So you see things like reduced concentration, people losing motivation. And so what that often results in is a withdrawal from social activities. So you might find that this was, you know, a youth that you're working with that has has friends and, you know, goes out and things like that, and then they start to withdraw from that. And, and the cause isn't really clear. You might start to see sleep issues and suspiciousness that, you know, starts to border on paranoia. So you might see that they're, they're, you know, they're talking about their parents, and they used to trust their parents and have good relationships, but now they're worried that their parents are not going to understand them or believe them, or something like that, and then they might start developing this focus on odd or disturbing ideas. So these are obviously not diagnostic. These are things that you see with a lot of people in a lot of different conditions. But it's this change that goes from, you know, not having a lot of these things going on to then start having them that that that starts to trigger these warnings for us. And so one thing to keep in mind is that so vulnerability, plus the change, is a key consideration for the clinician. So if you're if you're working with people, and you know, there's a history of psychosis, there's a history of of severe mental health conditions, and then you start to notice this change that's especially important. So, and then we're going to talk about something, just for a moment, called the stress bucket model, which people talk about sometimes. So, so we can go to the next slide, and I I'll explain a little bit more about what that is. So, you know, I'm not actually getting into the biology or the genetics of psychosis much, but we know that there's a link in terms of psychosis and genetic and biological factors. And so what a lot of people have been hypothesizing is that the way that psychosis, or a psychotic state, manifests is that everyone has what people are using like a metaphor, metaphorically a bucket. You know that that is your mental health and stress can flow into this bucket, and our vulnerability, our biological disposition to schizophrenia, are genetic are, you know, family history, things like that, are the size of the buckets. Some people have larger buckets if there's no family history, if there's no genetic vulnerabilities, and then as stress comes, we're able to cope with that, or you let out some of that stress in healthy ways, and it kind of reduces in a natural way. But for other people, if there is that vulnerability, that as stressful life events accumulate, the bucket overflows, and mental health problems like psychosis, can develop. And so already, you can kind of see the need for psychological interventions here as well, in that reducing that you know, or being able to cope with stress, or having good strategies for coping with stress, becomes a very important factor in preventing and preventing, you know, even an initial episode of psychosis, but also in terms of preventing relapse and things like that. So I hope that makes sense this. This is a little bit of a confusing graph, and I don't really want to get into too much the you know, on the left side, you're going to see CNS activity. We're not, we're not really going to get into that too much. But I think people are really curious about what psychosis looks like. So when it develops, you know what, what starts to happen. And so what we often start to see is that there is this programmable phase, and that there is kind of this, this pattern of, you know, slight disruptions from kind of normal, from that person's typical, and then suddenly we see this spike in in in these differences. So this is, again, talk about CNS activity, but we see that as well in terms of their observed behaviour, where they're now experiencing one or more of those symptoms, including hallucinations, or, you know, disorganized behaviour, or something like that. And then there's a lot of disruptions. And then, typically, you know, after medications been started, after there's been some sort of treatment, there is this recovery phase, but there's kind of a decreased activity for a while, and it takes a while for that to recover, and that typically is when we start to see the negative symptoms, when we start to see things like, oh and sorry, I didn't describe negative symptoms earlier, but things like flat affect, where we're not seeing a lot of emotion In that person. And then the other thing that happens is, you know, this could be what a first episode looks like, but over time, if someone is diagnosed with schizophrenia, and now this is a more long lasting thing, these the acute psychotic episode, the positive symptoms of schizophrenia, the hallucinations, delusions, the disorganized behaviour and speech and the negative symptoms start to blend together. You start to see them together at the same time more and more often. Obviously, these are just examples. Every there are so many there's so much variability in what this actually presents as, and we see so many different kinds of presentations with this. So you shouldn't assume that this is kind of the only way that that happens. Okay, so before we go on to the next slide, I just wanted to see you know if there's any questions or thoughts on on bipolar and psychosis? Well, again, we're going to talk a little bit more about considerations about these disorders in a few moments. But you know, sometimes I just want to make sure that these things are clear before we do that. Maybe there's too many people to ask that question for so maybe we can just keep going, and if people have questions, they can just ask in the chat. Okay, so then I wanted to talk about DMDD, so disruptive mood dysregulation disorder. This may be something that you've heard of, or may not be, because it's a new DSM, a new diagnosis in the DSM five, so it wasn't around, you know, if you were trained before the DSM five came out, maybe, maybe you haven't heard too much about it. And then I think that sometimes when people hear it, people think of having, like, a lot of tantrums or outbursts. And they probably think of that because that's one of the criteria, is that is having, I think so the DSM describes it as outbursts and tantrums that have been ongoing for at least 12 months. That's one of the criteria. But actually, it's actually a much more severe condition where, you know, it's meant to actually be more severe than oppositional defiant disorder. And the underlying feature, the main characteristic of it is this mood condition. That is, you know that that's the character of this order so, and the mood condition looks like being persistently irritable or angry almost all of the time. So this is not something where you know you're having some outbursts with your child. You're seeing some tantrums. This is like your child is persistently angry, persistently irritable. And then additionally, there are these regular, again, what they call tantrums and outbursts. And those have to go on for a long period of time, I think for 12 months in the DSM, and happen very frequently. They're happening, you know, more than three times a week. So this is something that's diagnosed only in children. It's not meant to be diagnosed in adulthood. So if you go to the next slide, like many of you probably are thinking that we diagnose, you know, too many things and and you're probably right about that. So you're wondering, like, what is the use for having even more of these diagnoses, for having something like DMDD in the DSM. And so a little bit of understanding the history of where DMDD comes from is maybe important in in knowing about that. And so the diagnosis of paediatric bipolar disorder, so bipolar disorder that was given to children in the 2000s increased 40, 40 fold, so 40 times what it was being diagnosed in the 1990s and so obviously, that's a staggering increase, right? That's an incredible amount of people children to be getting that diagnosis. And the reason for this, it actually makes a little bit of sense if you, if you kind of understand the reason that psychiatrists were kind of thinking about when they when they were doing this, is that there were kind of two main hypothesis for people that would later go on to develop bipolar disorder. And so you're going to see BD a lot. I'm referring to bipolar disorder when I do that. And the two main hypotheses were that, so Okay, so if you're going to develop bipolar disorder later on in that initial state before, before that happens, what you're seeing is maybe a rapid cycling of mood states. So you're going from irritable, not irritable, irritable, not irritable, irritable, depressed, maybe irritable, depressed. And you're kind of seeing that change very frequently and very regularly. And then there's another hypothesis, another kind of hypothesis state for those who eventually develop bipolar, and that's that they're just irritable. So this is what scientists and psychiatrists were thinking would lead to later bipolar disorder. And so when they saw either of these conditions, they were diagnosed in bipolar disorder. They were diagnosed in paediatric bipolar disorder. And so, you know, the kids that now maybe fit under the DMDD criteria of being persistently irritable were being given bipolar disorder diagnoses and and so the question is, does that make sense? Like, will those kids eventually develop bipolar disorder? Does it make sense to give them that diagnosis, you know, and then get treatment that that aligns with bipolar disorder early. So what the NIMH? The NIMH did a really large study that looked at what they then called severe mental or sorry, severe mood disruption, and identified high rates of like, you know, later psychiatric disorders. So they they found this, they, you know, they identified this condition of like, being persistently irritable. And they looked at what these kids would develop later in the in the future. And again, there's more information about that soon. So what they found was that actually, these kids would be diagnosed with ADHD, with ODD and anxiety and all of these were, you know, highly likely. So they're more than 50% of the time, these kids were being diagnosed with those three conditions and with depression. But actually, these kids with a persistently irritable mood state didn't develop bipolar. More than more so than, you know, other other kids without this persistently irritable mood state. So if you go to the next slide, so they, you know, they looked at this 20 year community based study, and what they were finding is that if you have this chronic irritability picture, you're almost, you know, certainly going to develop some sort of psychiatric condition, depression, ADHD anxiety, or something else, but not bipolar. But if you're experiencing this cycling or episodic irritability, where you'd be irritable than not irritable, than not irritable than not then you were much more at risk for developing mania. So based on that, and they concluded that, you know, we really don't want these kids that have this chronic irritability that leads the depression to be on mood stabilizers, which is the most common medication for bipolar disorder. And so therefore, they wanted to add in a new diagnosis, DMDD, which would lead to those kids not being put on mood stabilizers. So I think actually, in this case, it's an example of a time where it made a lot of sense to add a new disorder to the DSMs, just so we're not over medicating these kids or giving them something that's not actually going to help them in the long term. So hopefully that makes sense. I think we can go on to the next slide. And so now what I want to do for a little bit is I want to talk more about differential diagnoses. So again, those disorders are maybe not something that you see regularly, or you work with regularly. Maybe they are for you, I'm not sure, but you are much more likely if you work with youth mental health to deal with at least borderline personality symptoms or characteristics, or autistic characteristics and so, and that'll be the next slide. So I wanted to talk a little bit about differential diagnoses with both of them, and I'm hoping that I leave about 15 minutes at the end so that we can have a conversation more about, you know, about topics that people are interested in. So borderline personality disorder can also be characterized by these fluctuations in affect, right? So you are also seeing maybe a lot of energy, a lot of anger or irritability, and then a lot of depression, or, you know, withdrawal, things like that. And so I've just kind of pulled two of the criteria from the DSM for Borderline Personality here. So a pattern of unstable, intense interpersonal relationships alternating between extremes of idealization and devaluation. So one moment they might see you as, you know, the best person that they've ever worked with, or, you know, the their hero, or something like that. And then, you know, in the next moment, they might devalue you, or say that you're the worst therapist that they've ever worked with, or or something like that. And then also there was this, this instability and affect, right? So their mood is very reactive, described as very reactive. But the key difference between borderline personality, BPD and and and bipolar disorder is that this instability and mood is something that happens on the scale, the time scale of hours and sometimes minutes, very rarely for days, whereas in bipolar disorder, you're seeing a distinct period of really elevated mood, and sometimes irritable mood. So that could be for seven days, and that's what's required for a diagnosis of a mania, a manic episode, seven days of that elevated mood, or maybe a little bit less, maybe around four days for a hypomatic episode. But it's not this kind of moment to moment change and shift that we see in borderline personality. And then another kind of key difference. Sorry, one more thing on that slide. One Another key difference is that borderline personality should be understood in a relational framework, so when they see you as someone that's, you know, as the best therapist that they've ever worked with and then the worst therapist that they've ever worked with, that shift isn't happening always because of a, you know, internal mood state. It's happening because they're responding to you relationally. You might have done something that they don't like or that they perceive as a as something that a slight or an insult, or something like that. And so often that's better understood in the context of developmental trauma, though I think that's a little bit controversial. Not everybody with BPD has developmental trauma, but many people do and and the other difference is that you know when, when you're seeing people with bipolar disorder. Sometimes they're completely uninterested in, you know, in dealing with other people. Sometimes their mood when they're when it's elevated, is really focused on writing that book that you know is going to be a national bestseller, or they're really focused on completing some art or, you know, like or solving a crisis or something like that. And they're not really interested in how you respond to that. They're going from idea to idea. They're going from activity to activity so quickly that it's not really about how you perceive that idea. And so, you know, whereas BPD people are very concerned with how you perceive things, and they might be reacting very strongly to how you're interacting with them. Okay? And so we can go to the next slide. And so the other thing to consider is that maybe a lot of people, and I know a lot of people that flourish work with autism. And so we also want to understand how autism looks different from these conditions as well. And so autism is characterized by, you know, these long, life long differences in social communication and the presence of what we call repetitive behaviours. And sometimes that's actually quite difficult to differentiate from the negative symptoms of schizophrenia. So a lot of the time in with the negative symptoms of schizophrenia, or even in that prodromal phase, you'll see that normal phase, you'll see that social withdrawal. You'll see that people don't show a lot of their affect. They're not, you know, responding emotionally the way that they would have otherwise, and they're engaged in behaviours that that maybe you don't understand, right? And so that becomes a very difficult thing to separate from what autism is and so, and this can also happen with severe mood conditions, right? So if people are in a very low depressive state, they're probably also withdrawn, withdrawn socially. They're probably also not showing a lot of emotion on their face. They're probably also, you know, engaging in behaviours that don't that don't make sense to you. And so the key difference here, and you know, one of the reasons why any diagnosis of autism in youth or adults should really have a very thorough developmental history is that the prodromal phase of psychosis and psychosis really don't begin before age five, and I'm sure, you know, maybe there's an exception to there. There's probably case studies out there that show exceptions, but generally that's not the case, and autism does, so when, when I'm getting a developmental history for autism, I'm really focused in on that two to five period, and really looking for the social differences in that period, or, you know, the strong interests in that in that period, the repetitive behaviours that serve a regulating function in that period. And then the other thing to keep in mind that last point on this slide is that the repetitive behaviours that we see in autistic people are a goal directed so again, people with disorganized behaviour like you see, in psychosis, they might be going from behaviour to behaviour, and there's no kind of risk that it serves. They're not really thinking of something very quickly. But in autism, people are engaging in these behaviours too often to calm themselves, to make the environment more predictable, to find something that that has a regulatory function for them, so we can go to the next side. And so, you know, again, bringing this back to regular practice in therapy or assessment, whatever you're doing, I kind of insistent that this is a very important these conditions are very important to consider, because they impact things. So we've already talked a lot about the diagnosis of autism and how difficult that can be when you're trying to understand what's autism versus what's a prodrome or psychosis, or, you know, if you're seeing someone in that negative symptom stage after a psychotic episode, is that person autistic? Well, then they should have been their whole life, and that you should see that early evidence for it. So it can be very important in that case, but even in understanding mood, right? So when you're trying to understand someone's mood, and you're seeing someone that's depressed, and you know, they started to get depressed all of a sudden, and we know that happens in adolescence, right? People have good friendships, and then they something happens, and they start to become depressed. And, you know, we kind of lean towards diagnosing depression in that case, if it's prolonged and severe and everything like that, but we have to make sure that we're kind of considering these more severe mental health condition, even if we're not diagnosing even if we're referring them somewhere to better understand them. And so and we might be providing psychotherapy for people that are experiencing some prodromal symptoms or having these fluctuations in mood. And so it's also important for us to to consider what's. Happening when that's when we see that, okay? And so to kind of drive that home further, I'm sure many of you have heard but you know so, for example, one thing that might happen is that you might diagnose depression in someone. They go to their family doctor and they're prescribed an SSRI or an antidepressant or something like that, and SSRIs can often actually trigger a manic state if the person is, you know, vulnerable to bipolar disorder, or if the person has bipolar disorder. And so again, I don't want to make people hesitant to diagnose things like depression, but I just want to make sure that this is a consideration when you're asking about mood, when you're asking about how things have been for the last two weeks or months or whatever. We're also trying to notice if there's a period where that mood was up and then it went down, and then it went up again, or something like that, even if it wasn't a full manic episode. And then we want to understand again, the reason for these differences that we're seeing in affect, in their emotions, in their reciprocity or behaviour, is this something that's long standing, they just understand the world a little bit differently, like autistic people do, and they have they they show their reciprocity in different ways, like autistic people do. Or is this like a sudden change in their motivation for for social interaction? And then I just kind of starred disorganized speech here, and because I'm just going to read you the F criteria of schizophrenia. So Schizophrenia has criteria. We went through some of them, but I didn't go through all of it. But the F criteria is that if there's a history of autism spectrum disorder or communication disorder, childhood onset, the the additional diagnosis of schizophrenia is only made if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia are also present. So I don't know if you caught that, but you might see someone with disorganized speech, or a psychiatrist might see someone with disorganized speech, and they might be tempted to make a diagnosis of schizophrenia. But if they know that they're autistic, that they have a diagnosis of autism or some other communication disorder, some autistic people engage in speech that might not make sense to to the psychiatrist that's interviewing them, and so they have to additionally look for hallucinations or delusions in order to make that diagnosis. So it really matters, you know, when we're thinking about autism and how that looks compared to how schizophrenia looks. And then, you know, like I said, with the stress bucket model coping, and when we're working with people in teaching those coping strategies, when we're teaching things like emotional regulation, helping people with their affect, those things are really important as preventative preventative measures, things that protect people from developing more severe mental health. Okay, so we can go to the next slide. And so I just wanted to say that, you know, medications are almost always a part of the treatment of bipolar disorder and schizophrenia. And so we just briefly talked about mood stabilizers. People often use anticonvulsants, and a lot of people are prescribed antipsychotic medications. And these are really heavy duty medications that are laden with side effects. There are a lot of reasons why people don't want to take them, and so often there people are engaging in psychotherapy in addition to the medications, and I think that's a really important piece. And so if this is something that's kind of peaking your interest, and you're more interested in learning more about this or working with these conditions, I think it's really important that we have more people that provide psychotherapy to people with these conditions as well. So just kind of flag back and more on the next slide. Marie, go there. And so, you know, it also becomes really important to, you know, work through, for example, things like trauma, right? So we can, we can see how trauma can be a very big addition to that stress bucket can see, obviously, how people that have been through significant trauma or developmental trauma have much more stress as part of their daily life, and then become much more vulnerable to developing these conditions. And then, you know, if someone's developing one of these conditions, you might notice that they're becoming very mistrustful of you, or they're becoming very fearful of you, of of clinicians or of other people that they previously trusted. And so it's very important to recognize that their experience is their experience, even if it's you know, lot losing contact with reality and to provide validation of that experience, right? Imagine the fear of believing that everyone's out to get you, the paranoia that we often see in schizophrenia, or the idea that, like you have this grand idea you want to make the world better if someone's in a manic state, and you have all of these ideas, but no one else you know gives you the time of day, and no one else thinks that's worth it. So it's possible to validate those experiences and develop some of that rapport even without acknowledging something that's, you know, a delusion, as a delusion. So what I'm saying is you can separate their experience and validate that even if you can valid. Date, the actual thing that they're that they're concerned with. And then, of course, it's also important to consider that these people really do require a lot of psychological supports during those depressive states as well. And you know, there's good research that indicates that if people get good supports during the depressive state, they're less likely to go back to a manic state. And of course, if you think of the stress buckets, they're experiencing less stress as well during those times. Okay, no, that's good, Marie. We can go, go to the next slide. And I just wanted to talk a little bit about trajectories of both bipolar and schizophrenia or psychosis to to kind of show people like you might I think I was showing this to someone else earlier, and they were wondering, are these like lifelong conditions? Is is that you develop bipolar and then you have it for the rest of your life? And so I just wanted to comment on that a little bit. So these are for this slide is for adolescents who develop bipolar disorder. So specifically, again, focusing on people that I think we're more likely to see in this for the people that were are here in this presentation. So when psychiatrists say euthymic, they're indicating that, you know, they're in a good, good mood, in like, without any severe depressive or manic kind of states present. So there's a group of people that develop bipolar disorder, have a full manic episode and then are predominantly not experiencing severe mood state. So that's the class one. That blue line. Oh, you can't see my mouse, but I'm drawing a I'm moving my mouse over the blue line. So you know, these people in that blue line are, you know, mostly in sitting in that euthymic state, and then, you know, most of the time they're in that state in another group of people, they have significant, you know, illness, and then they have an improving course. So then they're kind of returning to that baseline, and they're able to kind of stay in that baseline. A third group of people are maybe not at that, not back to baseline. They have some alterations from having a normal mood or from having their normal mood, and that's probably most likely to be depression, more more so than mania. But you know, people do continue to experience depressive symptoms and maybe some mood symptoms or mania symptoms. And then the fourth class are people that are have more severe conditions, and they just kind of moderately improve. So this is with medication. So you know, a significant chunk of people, almost everyone, improves after that first identification and treatment of that bipolar episode, the manic episode. But you know, some people continue to experience significant symptoms, and some people experience only some symptoms. They're actually doing much better. So that's for, sorry, bipolar disorder, and this is for schizophrenia. And so you'll see actually pretty similar kinds of things. This graph is kind of reversed. So the on the X on the y axis, you'll see the number of months symptomatic, so experiencing symptoms of psychosis. And so you'll see that the first line, sorry, I'll start with the red line at the bottom the class one are people that experience less and less and less, you know, psychotic symptoms over time. So these are the people that are really improving after that follow up. And you know, this is a 10 year follow up, right? So after 10 years, they're experiencing very few psychotic symptoms. And then class two actually are people that seem to improve for a little bit, but then worsen significantly. That's a very small percentage of people. It's only about 5.6 percentage of people, percent of people, but they do exist. And then another group that you know for many years, they're experiencing psychotic symptoms, but over time, they start to get better and return kind of to that baseline. And the fourth class, which is actually about a third of people don't even with medication, experience kind of improvements from their psychotic symptoms. So a lot of variability in what's happening, and a lot of differences in terms of people's experiences once they have this diagnosis. Okay, so that's it. We can go to the last slide. Iris is my business partner at autism wellness, and she helped put together a lot of this presentation in terms of the slides and formatting and all of that. So I wanted to thank her. But that's it. We can stop now and maybe open it up to questions or comments or other thoughts. Oh, it looks like Megan has her hand up.

Megan

I do. I have a question here. Sorry, I'll turn my camera just. You Talked about trauma. Is it because we always talk about this, I feel like how trauma is such a differential for any diagnosis? Is it limited more so to that, like stress bucket model that like, if somebody experiences a traumatic event in their life, like it reduce it puts them at greater risk, or they're more vulnerable to their like, pre disposed, you know, factors for developing a certain disorder. Are there other ways that trauma might impact, like the ability to diagnose somebody with something?

Dr. Porthukaran

Yeah, I think trauma is, like, so important to think about. So for sure. That's one way for sure. So we know from a lot of big studies out there, like the Adverse Childhood Experiences Study, which is, you know, a huge cohort where people that have a lot of those early trauma experiences have, you know, everything, much more likely to develop later on. So depression, anxiety, severe mental health conditions, and we know that the stress bucket is a reason for that. But also I think trauma just leads to things like more social isolation, more social withdrawal, less being less trustful of people. Sometimes we see that, and so obviously we can see how those things can also mask or, you know, it might be hard to understand someone's paranoia in that context, or something like that. So there's a lot of ways in which trauma affects people and and so when we're working with people that have experienced a lot of trauma, especially early childhood trauma, developing that trusting relationship with them, being able to have that good rapport can can be so important, and being able to, you know, differentiate exactly what's happening for them later, any other questions or comments,

Megan

Yeah, and I think Chantal says too, like early childhood trauma can also disrupt development, and it's important for differentials, for autism as well as mental health. So kind of to your point, the Early Childhood Trauma impacting the course of someone's development

Dr. Porthukaran

for sure, yeah, and a lot of that happens actually, when I when we see adults here at CAMH and we're trying to diagnose autism, we're trying to understand that early trauma history that becomes, like, a really important piece, you know, like, often we see kids with trauma withdrawing from their peers. Their peers don't understand them. There might be a little bit more of that instability with their affect, and so that causes problems. And so really trying to understand the root of what's going on is can be so important.

Megan

And I think Laura is wondering if you could talk a little bit more about some other comobidities with mental health diagnoses and autism. I think you touched on it a little bit, just like in the how the like depression mood can present as autism sometimes, but could you speak to any Yeah,

Dr. Porthukaran

yeah, for sure. So I can't see the chat, by the way, so I don't know if there's other questions in the chat, but that's okay. I'm sure Megan, you can tell me about them, but yeah, yeah. So for example, a lot of CO occurring conditions, like can co occur with autism, but there can also be a lot of things that look like autism, but maybe aren't so often we see things like OCD, and sometimes when you know OCD severe, there's also a lot of social impairment as well. There's a lot, a lot of social withdrawal, or you can't be around other people because you're so concerned about, you know, getting sick or getting germs or or you're so focused on, you know, making sure that your things are just right, that you can interact with other people. And so we definitely see, you know, things like that. And actually, I had a case at CAMH where the OCD was so severe, it actually even looked like psychosis, because people were spending hours unable to move right, unable to do daily living tasks, because it had to feel right before they did it. And so at that point, it might look like catatonia, which we haven't really talked about, or it might look like they're just not moving, or, you know, things like that. And so, yeah, a lot of these conditions, I think it's really important to think of what's the root and that's really hard to do when someone's manic, for example, because they don't really want to talk to you, or they're talking so quickly they're going from one thing to the other. Or when they're experiencing psychosis because they're paranoid, or they're, you know, not interested in talking to you, or something like that. But whenever we can trying to understand their phenomenology, their experience of what's going on. I think it's so important, because you know what, when you talk to people that, for example, have OCD, and it's driven by the fear, right, if I don't do this in this way, it won't feel right. Or if I don't do this in this way, I'll get sick. Or if I don't engage in this behaviour, it won't make me better, like, I won't, my mom will get sick or something like that. I don't know if you if you understand that experience, that it's driven by fear rather than desire for regulation, wanting to be more calm or wanting to feel more comfortable in your environment, then you might mistake, you know that for repetitive behaviour like you might mistake it for even psychosis or something like that. So OCD, a lot of and other kind of personality issues definitely have a lot of overlap. I I'm going to say something kind of controversial. Maybe I shouldn't, because I think it's being recorded, but I don't know if I've ever seen someone with like schizoid personality that I actually believe has schizoid personality. I think it's often autism, but maybe that's not true, I don't know. So yeah, so there's a lot of overlap, I think, and a lot of I think there's a lot of ways in which the DSM kind of pushes us to deal with conditions as categories, rather than trying to understand the experience. And there's a lot of value in trying to understand people's experience, especially with these difficult to tease apart conditions.

Marie

It's interesting you say that, Alex, because in when we're doing the PAI for adults, or, you know, it's always that schizoid piece that comes up when we have autism as that query. That's really interesting, that you say that, yeah, I agree with that,

Dr. Porthukaran

yeah. And maybe people who work more with adult personality disorders would disagree with that. But really, when you look at, you know, the early developmental history, that's how they've always been, or that they've always had the social differences and and behaviours that you know other people find on but yeah,

Marie

Nikki, sorry, Nikki has a really good question, because we see this all the time. What's your thoughts on women being diagnosed with BPD prior and turning out to be diagnosed as autistic later on in life?

Dr. Porthukaran

Yeah, I think maybe I saw Louisa here, and I don't know. I think maybe Louisa were even to start doing some research on this or something like that. But this is probably, you know, the most common differential diagnosis that we're asked to make in inpatient teams when we go to consult. And so it's women that have come to the emergency. And I basically think if you go to an emergency and your woman two times, they're probably going to diagnose you with borderline personality, which is so unfortunate, because that might not be what's going on you might be experiencing, feeling overwhelmed or not being able to cope with what's going on around you, which are, you know, very often seen in autistic people and autistic women. And so, I think you know, it's sometimes there is this kind of CO occurring picture that happens where there's both BPD and autism, but often it's people mistake being overwhelmed for being unstable, or having the instability in your in your affect or mood, and so again, really understanding that early history, really understanding the social piece that you know it's not necessarily that you're idealizing then devaluing someone like you know the but the BPD symptom says it's more so that you don't understand the way that they're communicating. And if that communication was more clear, there'd be less overwhelmed. And because you're expected to do so often, and because women are, you know, much less likely to be diagnosed as children and your you know, world, your social world, is so much more chaotic because you don't understand that autism piece of yourself. You know, there might be much more of a likelihood of getting overwhelmed and having that kind of a response. Talk for hours about BPD and autism, the very important area for, you know, future work. I think, sorry, Megan, go ahead.

Megan

I think we also just have some questions about that, like differentiating between, like repetitive behaviours versus compulsions, even specifically in individuals who are non speaking, and how you can, kind of, like, get to what the root of what's going on between those two?

Dr. Porthukaran

Yeah, actually, we have that come up quite a bit as well, especially again, for people with intellectual disability or for autistic people without ID that are not speaking. And, you know, a lot of people will see like scripting and autism, where someone's like saying something to themselves and or, you know, like mumbling something if they're not speaking, you might still hear like, see mouth motor movements. And you might think that that is a compulsion, or they're doing that compulsively, but there might not be any sort of trigger. They're not doing it when they're upset, right? They're not doing it. They don't, you know, show the ordinary signs of distress, unless you try to stop it. They're, you know, just living their life, having a good day, they're sitting on their favourite couch, and they might start scripting or or doing something repetitive to themselves. And if it doesn't have that, you know, at least at the beginning, that negative affect, if it's not trying to reduce a negative internal state, then they're probably doing it to regulate and that's probably more of a repetitive be. Behaviour. But if you notice that, you know, every time you talk about what this one thing, there's a trigger. They seem to get anxious, and then they start engaging in some sort of behaviour that looks repetitive, that might be more of a compulsion. They're trying to reduce that internal negative state with that compulsion. So again, trying to understand their experience, which obviously is very hard to do if they're non speaking. Is again, the really important piece at the beginning, other thoughts or questions, or are we out of time?

Megan

Yeah, just like any tools that you can suggest diagnostically for autism, maybe following a psychotic episode in childhood,

Dr. Porthukaran

yeah. And so I think this is one of my biggest problems, right, like so, for example, in at flourish, that we have maybe sometimes started to do is to give people the seq, because it specifically asked about childhood experiences. So I actually think a big problem in autism research is that we don't actually have very good tools for early developmental history. We have the ADIR, but most of you probably don't want to do the ADIR, because either you have to go do like a $2,000 training somewhere, and you can't even find it, or something like that, and then it takes, like, an hour and a half to deal with parents, and you're just going through everything, and it takes so long, or it's like the seq, and you're getting this kind of very bare seq, is the social communication portion, by the way, you're getting this very bare bones picture of their developmental history. So what we've actually done, actually, both at flourish and at CAMH, is we've kind of made our own list of questions to ask about the developmental history. And so that's obviously not the best either, because we don't know if, like, the research kind of supports that, but I think again, we're trying to establish a clear pattern of early social communication differences. So a lot of people that develop psychosis and after that, or even during that have social communication differences. That's not enough, right? You want to see that before their psychosis started. So if there's any sort of history you can get, if there's parents or caregivers or anything like that. But often, we'll even talk to siblings. We'll talk to just people that knew them in grade school. Again, we want to we ideally, we want to see people as early as possible, like we want to talk to a parent that knew them when they were like two, as opposed to a friend that met them when they were 12. But if you're trying to differentiate, did this start after a psychotic episode or not? Then even seeing like a high school friend would would still be helpful, right? Because you can still see, okay, yeah, that person was showing a lot of differences. Then they had a good friend group, but they were always focused on their interests. It was always about D and D or whatever, and so, you know, outside of that context, they didn't do well.

Marie

I have one more question, Alex, just because it's one of our our summer students that's asking a really good question. Is she says, Could you elaborate on the differences in motivations of repetitive behaviours in OCD versus autism?

Dr. Porthukaran

Yeah, so the DSM uses this language, right? That OCD is ego dystonic. So what that means is that like you experience a threat, and that could be a thought, it could be an image, could be whatever, so most commonly with OCD. So about half of people with OCD have contamination fears, right? And so they're thinking that they touch something or they, you know, you know, someone sneezed on them, or something like that. And then to reduce the anxiety that comes from that fear, they engage in a compulsion, okay, as opposed to you are feeling overwhelmed, or you're feeling stress or something like that, and just as a general dysregulation, like to regulate yourself, to regulate your experience, you're trying to engage in repetitive behaviour. So for people that are speaking, I don't want to say it's easy, but it is easier because you can ask them so like, when do you engage in your repetitive behaviours? And they can say, you know, something along the lines of, whenever I touch this thing, I I'm so anxious, I'm so scared, or feel so wrong that I have to do these behaviours. And that's probably a compulsive behaviour, as opposed to, you know, just anytime it gets stressed. I like to go and watch my favourite show, or I like to stim with my hands, or whatever it is that they're doing as a repetitive behaviour. So it's about that internal state that they're experiencing. So we really need to ask questions about that, and then so what the purpose of it is? So to either, you know, regulate or to remove an intrusive thought that you're having, and to remove an intrusive thought was obviously OCD, compulsive behaviour.

Marie

Awesome. Thank you. I think would you be willing to take any questions that get emailed to us? Alex, as well, yeah,

Dr. Porthukaran

of course, maybe you can, just, like, send me a list or something. I can, yeah,

Marie

go ahead. Were you gonna say something? Meg, sorry. Nope. Thank you so much, Alex, this was, this was awesome. Really, really good. I'm loving the turnout on these things. So you had close to 80 people here today hanging out with you on their lunch hour. And so that was really great. Alex, looking forward to seeing everyone next week. We have Dr, I'm gonna go back to the chat, because I've just closed it. Hang on. Dr Noor Sharif talking about no longer in the margins, an introduction to understanding anti oppressive practice and racial trauma. So thanks everyone. Alex, that was awesome. Thank you so much, Iris for helping with the slides, and we'll see everyone next week. Have a good have a good Tuesday. Everyone. Take care.

Megan

That was awesome. Thanks, everybody.

Sara

Thanks. Alex