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When Psychiatry Meets the Immune System with Dr. Tom Pollak
132 Plays12 days ago
In this episode of Doorknob Comments, Grant and Fara chat with Dr. Tom Pollak about the complex relationship between the immune system, the brain, and mental illness. Dr. Pollak is a NIHR Clinical Lecturer at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London and a specialty trainee general adult psychiatrist at South London and Maudsley NHS Foundation Trust with a specialist interest in neuropsychiatry. Listeners will learn how doctors distinguish true autoimmune brain disorders from primary psychiatric conditions, why tests like spinal fluid analysis are complicated but sometimes crucial, and how both “it’s all psychological” and “it’s all biological” explanations can miss the bigger picture. Their conversation offers a nuanced look at how mind, brain, body, and environment interact, and why good psychiatric care requires holding all of those pieces together.
We hope you enjoy.
Resources and Links
Doorknob Comments
https://www.doorknobcomments.com/
Dr. Tom Pollak
https://www.kcl.ac.uk/people/thomas-pollak
https://drtompollak.substack.com/
Dr. Fara White
Dr. Grant Brenner
Recommended
Transcript
Debating Psychiatry: Psychological vs Biological Explanations
00:00:00
Speaker
And then there's this sort of this recent emergence of this other strain, which is saying, well, no, no, quite the opposite. Psychiatry is not medical enough. It's not, you know, we are psychologizing these people too much. There's no way that the psychological formulation of my problems could have any kind of truth at all. And in fact, the answer is some sort of biological factor and and usually it's only one, right? And of course, a lot of the work that our group does shows that there is this hugely dynamic interaction between the biology and the psychology. And in fact, then they're not separate things.
00:00:32
Speaker
hello I'm Dr. Farrah White. And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment.
00:00:45
Speaker
Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.
Introducing Dr. Thomas A. Pollock and His Research
00:00:52
Speaker
Doorknob comments happen not only during therapy, but also in everyday life.
00:00:56
Speaker
The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them.
00:01:09
Speaker
Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Today on Doorknob Comments, we're delighted to welcome Dr. Thomas A. Pollock.
00:01:22
Speaker
Dr. Pollock is a reader in immunopsychiatry the Institute of Psychiatry, Psychology, and Neuroscience at King's College London, and a general adult psychiatrist at South London and Maudsley NHS Foundation Trust.
00:01:34
Speaker
His specialist clinical interest is in neuropsychiatry, and Tom has more recently been applying his considerable talents to address emerging Psychopathologies of the Technologically Extended Mind, sometimes referred to as AI psychosis.
00:01:48
Speaker
Tom's research focuses on neuropsychiatry, psychotic disorders, encephalitis, neuroimmunology, and an immunopsychiatry. And he's a consultant neuropsychiatrist with a special interest in autoimmune encephalitis.
00:02:02
Speaker
He leads an immunopsychiatry research group at King's College London, oriented towards understanding the role of autoimmunity and infection in psychiatric disorders.
Holistic Approaches in Psychiatry: Beyond Inflammation
00:02:12
Speaker
His recent piece in Brain Journal, Why Inflammatory Reductionism is a Threat to Psychiatry, explores the emergence of a new worldview which attempts to explain all manner of ills as the result of inflammation or immune dysfunction.
00:02:26
Speaker
He argues that while this view is rooted in science, it neglects the true complexity of most health conditions and risks undermining the more holistic concepts of illness favored by psychiatry.
00:02:38
Speaker
Tom is co-investigator and clinical lead for the Wellcome Trust-funded Immune Mechanisms of Antipsychotic Treatment Response Study. He has a developing research interest in the neuroscience phenomenology, neuropsychiatry benefits, and adverse effects of meditation and other contemplative practices.
00:02:58
Speaker
Sounds like you're very busy. Welcome to Doorknob Comments, Tom. Thank you. Thank you. It's a very extensive introduction. I i appreciate it. It's all accurate. Very good. So, you know, we thought our focus today could be on helping people understand the concept of autoimmune disease as it relates to psychiatry and psychosis, though you have many other things we may touch upon.
00:03:22
Speaker
I think there is a lot of misinformation about this, and it's always the case in psychiatry that whatever is... most present in the news cycle, you'll see people coming in and kind of wondering about that specific thing. As well-trained clinicians, we know we want to approach the patient as a whole person though, and not get channeled in too quickly.
00:03:45
Speaker
So that's what we would like to start with today. could Could you tell us a little bit about how you see the state of the art when it comes to this concern? Yeah, thank you. um I mean, i've i've I've been sort of interested in the immune system and and and mental illness in the mind for, I've sort of been working it for around 15 years or so now. And there've been sort of two discernible hype cycles that have been kind of right the way through. It's like it's like my Birkenstocks. I've had them for about the same amount of time. They've been fashionable at least twice in that in that period. um But i think we the that the I think we're in a second time, actually, a second sort of period where
00:04:25
Speaker
but for various reasons, there's a lot more interest ah in the immune basis or of psychiatric illness, psychosis in
Understanding Autoimmune Encephalitis and Diagnosis Challenges
00:04:33
Speaker
particular. um There was a wonderful article last year and in the New Yorker, which really um helped sort of shine um a lot of attention on it again by Rachel Leviev, who writes so so beautifully about about mental health and in a really nuanced way.
00:04:46
Speaker
And it's actually that kind of nuanced approach that I think is missing a lot of the time. I i went into neuropsychiatry rather than going into psychiatry. i So it's ah it's a branch of psychiatry, but I knew from the start that there were at least two languages that I wanted to to be able to speak. And sort of the the the immunology bit came along for the ride of eventually and and and and some other sort languages as well. And and And that took a lot i mean it it it took a lot of ah it took a lot of learning, it took it took a lot of a lot of study, and I think it's it allows a perspective that I feel really passionate about, which is in mental health in general, in psychiatry in particular, we are so often sucked towards one kind of reductionism or another.
00:05:35
Speaker
and I don't think historically any of these reductionisms have have ever ended well. um And I found myself super passionate about about the immune system and the brain, engaging in research in it. And then I suppose it was... it was about five years in that I realised that the enthusiasm that I was obviously exuding was obviously felt by a lot of other people. And then I started to sort of see things in clinical practice that suggested that maybe the enthusiasm was getting ahead of the evidence. um And so I've tried since then to sort of take a little bit more of a more, a more measurable or cautious stance. I'm not sure everyone ah would agree, but I think
00:06:15
Speaker
the nice thing about these kinds of opportunities is, is, is to be able to dispel some of the myths around actually what is the relationship between the immune system and and and the brain? What is the relationship between the immune system and psychosis? So I'm, yeah, it's a, it's a pleasure to be able to do that.
00:06:31
Speaker
Yeah. I am curious. I don't know if you're able to talk about it, but what were the things that you were seeing where you thought people were getting ahead Was it really making treatment decisions?
Historical and Modern Treatments in Psychiatry
00:06:43
Speaker
guided by the idea of an autoimmune process?
00:06:48
Speaker
yeah Yeah. So, I mean, to put it in context a little bit, um I mean, these ideas that the that sort of psychiatric illness might be immune in nature i've gone back a a long way. You know, there are some amazing stories from the 1950s about people who were convinced it was all to do with infections in the teeth or in the gut. And you know they would They would remove the teeth of all their patients with schizophrenia. If that didn't work, they'd do a colectomy. They'd cut out large portions of their their colon. And of course, wow you know not that that lots of patients didn't didn't do very well after that. and these people have been rightly sort of and rejected. The current wave of enthusiasm, I suppose,
00:07:25
Speaker
came about in sort of mid 2000s with this discovery of um this very exciting ah new neurological disorder called anti-NMDA receptor autoimmune encephalitis.
00:07:40
Speaker
it's ah It's a subtype of autoimmune encephalitis, right? So just just to pause a little bit for listeners who may not know the medical lingo. So encephalitis or encephalitis is an inflammation of parts of the brain. Yeah. um And NMDA receptors are an important receptor class that that is involved with learning and glutamate receptors.
00:08:04
Speaker
And if we have antibodies to these very, very common and NMDA receptors in the brain, it can seriously affect psychiatric and neuropsychiatric illness, correct? That's exactly right. The encephalitis is an itis, it means inflammation. and And traditionally encephalitis was understood many to occur from infection of the brain, but this sort of immune mediated encephalitis has in the last decades really taken a bit more of a kind of center stage, although the two the two are related. And ah autoimmune encephalitis is it's an all kind of autoimmune disease. So the body creates antibodies and another other parts of the immune response against its own proteins ah for various reasons we could we could go into.
00:08:46
Speaker
And among those are proteins in the brain. So you have a bunch of antibodies that are being produced by the body. They circulate into the central nervous system and then they attack these NMDA receptors, which is, as you say, a really important protein in the brain that is responsible for it's It's totally ubiquitous. It's all over the brain. it's It's responsible for sort of memory, learning, emotion. And we know from other bits of medicine that if you mess with the NMDA receptors, you get really interesting results. So we have a couple of drugs, things like ketamine or PCP, that are NMDA receptor antagonists. And so if you take these, either because you're having fun in a club or you've you've gone a bit too wild and
00:09:34
Speaker
some sort of therapy or or something like that, you can develop sort of dissociation. ah You can develop um a sense of unreality. Sometimes if you if you take too much, a kind of catatonic type sort of psychomotor presentation, ah some people will have ah hallucinations and some people will get into a sort of delusional state, which sounds a bit familiar, right? I mean, this is these are many of the kind of cardinal symptoms of of psychosis, of a psychotic disorder like schizophrenia.
Misdiagnosis and the Quest for Biomarkers
00:10:00
Speaker
In parallel, there's this now decades-old strain of research showing that schizophrenia is likely to be caused by dysfunction of the and NMDA receptor alongside the other problems with dopamine that we kind of all know about. So what we're seeing in this newly discovered form of of encephalitis is yet another way of getting those and NMDA yeah receptors to to not do their job properly. It's not caused by neurodevelopment or genetic problem or or environmental, as as appears to be the problem in in schizophrenia. It's not caused by ingesting a substance immediately. It's it's caused by a sort of ah internally produced agent, as it were, ah which stops those NMDA receptors functioning. So there's this kind of
00:10:44
Speaker
ah similarity between the symptoms of acute intoxication with ketamine or PCP, schizophrenia, and on the other hand, NMDA receptor antibody encephalitis, which is why when these people come down with it, and typically they are of the same sort of age range in demographics as people who experience the first episode of psychosis,
00:11:05
Speaker
very often they are initially thought to have a first episode of psychosis. And so they get, they get, uh, um, seen by mental health services. They get assessed by psychiatrists. Often they get detained against their will in, uh,
00:11:21
Speaker
in a psychiatric setting. and and And that can be for a long time. um And in some cases, the disorder makes itself known because after the initial psychotic period, there's the development of seizures, of autonomic instabilities, like blood pressure and heart rate are all over the place.
00:11:38
Speaker
um The catatonia du looks a little bit you know more intense than what you might see in in in in sort of normal psychiatric presentations. And so in the majority of cases, you know they get spotted eventually, but sometimes it can be quite a long period of time.
00:11:51
Speaker
And part of what motivated our work was to ask the question, well, okay, there are these really obvious cases where, you know, even the, you know a psychiatrist who really wasn't paying much attention would be able to say, okay, something is not quite right here. Let's let's send them to the neurologist for a checkup. We were interested in in in the cases that might appear more subtly and and you know how how sort of big is the the base of that iceberg, as it were, which turned out to be a very difficult question to answer. but There's no simple test for this, right? And we're talking about like a psychiatric presentation that's analogous just for listeners to like rheumatoid arthritis.
00:12:30
Speaker
There's autoantibodies and rheumatoid arthritis that attack the joints. In this case, it's attacking some protein in the brain, the the more common one being anti-NMDA receptors, yes.
00:12:42
Speaker
Yeah, exactly. And so, I mean, it' it's it's ah an amazing story of medicine and to how they found the these antibodies. And it was clear that that a new disease subtype had been found, right? And these antibodies were were often...
00:12:56
Speaker
i mean, they were found in the the CSF, the spinal fluid of these patients, but the tests in these neurological patients would be done with blood. And so when we had this idea that maybe there were site psychiatric patients who also had this disorder, but went undiagnosed, the initial feeling was, let's just do blood tests, see if we can find these and these antibodies. And if they have those antibodies, then we just call up our friendly neurologist, get them to give them some immunotherapy.
00:13:20
Speaker
And we've changed the course of this person's life. As with everything in the history of psychiatry, and particularly when it comes to these kind of new biological approaches, it turns out that it's not that simple, because it turns out that the antibodies that we have in our blood, in our periphery, aren't necessarily a good guide to what's going on in the brain. And in fact, one of us three, for example, may well have those antibodies in our periphery, but it's not getting to our brain and it's not causing us to become ence it's It's like not a good test. It's not a good... What we want are biomarkers, right, that are sensitive and specific, meaning that if you have them, you have the disease. If you don't, you don't. But it's very gray. That's exactly right. And we actually do have a really, really good biomarker of this disorder.
00:14:04
Speaker
And it is this antibody, but we need to find it in the CSF, in the spinal fluid. Now, you're both psychiatrists, and I think you both worked in sort of public ah psychiatry at one point or another, right? And it's not easy on a busy psychiatric ward, particularly if you're in a kind of inner city setting or a resource poor area where the ward is full of very, very ill, often chaotically behaving people,
00:14:28
Speaker
yeah you're You're not going to be able to do a full neurological examination and an m MRI and an EEG and a lumbar puncture on every patient who's ah presenting acutely with psychosis. So that is is the problem, really.
00:14:40
Speaker
It's pragmatically very difficult. And yeah, Farrah, you look like you want to say something. I did general surgery for two years and i'm i'm remembering all the lumbar punctures and doing a lumbar puncture on someone who's acutely agitated is not so easy and could be dangerous. But Farrah, what were you going to say? so I was just going to say that, that, you know, we, we do have a process here that involve for sort of first time psychotic symptoms that involves a lot of imaging and blood tests. But right now it does not include a lumbar
Integrating Medical Diagnostics in Psychiatry
00:15:11
Speaker
puncture. And I think it's because there's so many like logistical and ethical issues to try to get that work up.
00:15:18
Speaker
Some of it is like cultural too. if If someone comes in and they're like not feeling well, um as a psychiatrist in New York anyway, if I say get an MRI, that's hard enough to do. And then if you say, well, you need to get a lumbar puncture, what does that mean? Well, you know, someone is going to do a procedure. They're going to take this very long needle. They're going to insert it. into your back. They're going to withdraw fluid.
00:15:41
Speaker
um It's a little bit like when you get anesthesia for an epidural giving birth. It's a very safe procedure. Usually you need neuroimaging first because there's a risk that if you do a lumbar puncture, you can cause serious problems. It's called a herniation if the intracranial pressure is high. It's a tough cell, as they say.
00:16:00
Speaker
you You would think that, and and I think you're you're right, but I sometimes wonder, I guess to put it a bit more psychotherapeutically, where the resistance is coming from here. And actually all the studies that have looked at the acceptability and take up of the offer of a lumbar puncture when it's systematically offered to people with the first episodes of psychosis, the take up is in the 70 to 80% region.
00:16:20
Speaker
In an inpatient setting, I assume, right? No, in an outpatient setting. Outpatient, interesting. In a mixed setting, actually. um Interesting. There have been a few different studies looking at this. I mean, we we have an ongoing study where this is exactly what we're doing. It's the early days yet, but we we're we're We're quietly hopeful ah that we'll we'll get a reasonable acceptance rate. But what we what we don't get is frequently the the clinicians and the nursing staff agreeing that this is a good idea. And and often there's a lot of reasons that come up for you know why why it's difficult, why it can't be done on this site.
00:16:56
Speaker
I mean, I think these, I don't know what what the situation is in the States, but um if you're a mental health nurse in the UK, you have had a totally different training scheme to if if you're you're working in ah in a general hospital, looking after physical health conditions. And so for... for for quite good reason, the nursing staff might not feel comfortable looking after people that have complex kind of physical health needs, who might need drips, who might, you know, will need lumbar punctures.
00:17:22
Speaker
And, and so, I mean, i I sometimes say, you know, these, these dualisms pill. and And actually, you know, there's so many ways where I think, I think that is true, that the kind of knockdown effects of these artificial separations we have, have real clinical impact on on our patients. Right. Psychiatry is less medicalized. I have to say I don't have that many folks, but when I recommend imaging, even though I i believe that I'm not anxious or sending the wrong messages, it's still very hard to get people to do it.
00:17:51
Speaker
I find the same thing comes up with things like i I treat people with transcranial magnetic stimulation, and I don't have much of a problem getting people to get an MRI to do neuro-navigated TMS imaging. And the recommendation, and and I think you're also alluding to the training, um really needs to happen so that the rest of the staff is on board. I'm curious what your experience has been, Farah, because, you know, without getting into too much detail, you see a lot more people with a presentation like this.
00:18:18
Speaker
And it's relatively unusual for someone with psychosis to have, Tom, those other symptoms you mentioned, like having had an illness beforehand or having seizures or blood pressure changes that are indicative of a more traditional biological process. But Faram, I'm curious how you find it and what you would want listeners to understand as to why it's important to sort of follow these recommendations. Yeah.
00:18:41
Speaker
Well, when I was in residency, we had someone, a journalist, Susanna Callahan, who wrote a book about her experience with anti-NMDA receptor encephalitis.
00:18:54
Speaker
And she gave a grand rounds and it was really interesting. And i think my work treating women in their 20s, 30s, 40s has really well prepared me in some way to transition into looking at sort of inflammatory factors as as part of treatment.
00:19:16
Speaker
So we're seeing a lot of things from like a post-COVID POTS type picture where people are just not really feeling great. And um anything that we can do right to bring down that inflammation is a good thing.
00:19:32
Speaker
I feel really lucky because most of my patients are very motivated and they want to get better. So they will do things that are not super convenient towards that goal.
00:19:43
Speaker
But usually when people come to my practice, they have already gone through the process of being stabilized, usually, yeah not always. And so sometimes I do wonder, like, did we miss the moment for that sort of workup? And then do we need to wait until we get to a place where they're motivated to figure out more about the cause of some of their symptoms.
Guidelines for Recognizing Autoimmune Disorders in Psychiatry
00:20:08
Speaker
Yeah, I i mean, i think it's so interesting the way that this plays out in different contexts. So, um one of the reasons that we ended up deciding that we had to write a bunch of very specific clinical criteria and guidelines aimed at psychiatrists for how to recognise these conditions, because some great guidelines existed for neurologists, but they kind of let they they existed on the assumption that all these investigations had already been done, which as think we said it's is very difficult.
00:20:39
Speaker
And it was precisely what you're saying is that that people come at different stages, But also in in in the settings that I work, have a very demographically diverse population. and we were beginning to see signs that there are clinical biases that are at work, that certain segments of the population are far less likely to be systematically investigated for ah secondary causes of psychosis. And these, you can exactly imagine what these what these factors are. They're they're they're they're ethnic, they they relate to sort of a whole bunch of different sort of sociodemographic So one of the main motivations for us as well was, if we have some guidelines out there, then at least we can try and apply them um across the board. Because, yeah, we have a ah a lot of sort of um well-resourced, well-to-do families who come in, they've read Susanna's book and and I've met Susanna many times and I think she's done an amazing job at at at sort of getting over the, you know, just educating people about this.
00:21:47
Speaker
But there are plenty of people out there who haven't ah read the book because they don't read those kind of books, et cetera, and who it's quite possible that when these symptoms come on, it would it just would not occur to sort of them or their or their or their family that that this is an issue.
00:22:02
Speaker
I mean, incidentally, if you... I think Susanna writes around about this very beautifully, but if you see the way that, for example, in the film, the the different characters are portrayed, you have the the psychiatrist who's making this kind of slightly bumbling diagnosis. of She sees her once, oh, you've got schizoaffective disorder and it's alcohol's got something to do with it and And then, you know, it doesn't paint a very flattering portrait of a psychiatrist, right? And then, of course, she get any better. She takes the antipsychotics or whatever. And then a few weeks later, she she has the catatonia or the seizures. I can't remember quite which one it is.
00:22:34
Speaker
She gets admitted to ah what is strongly suggested to be a kind of proper hospital. And, you know, and then comes the the the doctor in the white coat who, who you know, gets her to draw the clock face and and and in a sort of Dr. House style, you know, makes the deduction and it and everything gets sorted. and And while that may well have been a good representation of how things were, I think what it also does is it it it underlies a kind of caricature about the different worldviews and approaches of psychiatry versus neurology. And that's it kind of hurts a little bit as ah as a neuropsychiatrist to see that.
Biological Psychiatry: Risks of Oversimplification
00:23:06
Speaker
No doubt. It is Sherlock House. I mean, you know, you mention um you mentioned in your article and in Brain why inflammatory reductionism is a threat to psychiatry and the rest of the of medicine, um you know, some of these problems. And, you know, it is there is always an element of truth to the caricatures, right? So it is often the case that community-based psychiatrists who are stressed out and overworked don't do a fastidious job and and can't, and it often pains them. And if someone comes in, they treat symptomatically and it's very hard to do a proper job.
00:23:44
Speaker
um It's also the case that sometimes at proper hospitals, people... get the same kind of care that's not so great, ah you know, depending where you are. I've certainly seen that.
00:23:54
Speaker
So you you talk about in in this article, kind of the pendulum swinging the ah the other way back. So I want to come back to your work and what are the what are the actual diagnostic criteria that that both psychiatry and lay people listening to our podcast can really learn from you. So you talk about kind of, well, first, there was this increase in awareness that And that's very helpful because maybe we catch people we would have missed who really deserve to recognize, certainly if they have obvious symptoms, that they need a different workup. But now you're talking about what what is called monocausotaxophilia.
00:24:32
Speaker
Like everyone, as Farah was saying, is coming in saying, hey, I have an immune problem. um And there's plenty of that with depression too, the you know the inflammation. And of course, there's a very understandable human wish to find one thing that kind of fixes everything.
00:24:48
Speaker
So could you talk a little bit about the way the pendulum has swung in the other direction in what you're seeing and particularly what what listeners really should be thinking about when they're thinking about their own best wellbeing or their family members? Yeah.
00:25:02
Speaker
Yeah, thank you. It's such a question that's really close to my heart. ah And I think I wrote that article maybe so two or three years ago. And since then, things have only got worse, ah to to be honest. And and i think what we started seeing in clinic eventually would be often families coming in with a loved one who Sometimes it was psychosis, more often it was something along the anxiety or depressive kind of ah spectrum or a kind of complicated sort of what we might call a kind of interface type presentation or what other people might refer to as some psychosomatic with a bunch of so different somatic symptoms, kind of i ill-defined
00:25:40
Speaker
And occasionally there might be a story of a preceding infection or something like that, as as it turns out, if you ask systematically to almost any psychiatric patient, there's often that that sort of story there, which I think is interesting. But you would have families coming in.
00:25:55
Speaker
Sometimes they'd have Brain on Fire by Susanna Cahill, and sometimes they'd have articles that I'd written sort of in their hands saying, you know, I... we i I think that my loved one's brain is on fire. um Can they have um immunotherapy? And my ah concern, and this was happening sort of during COVID, was that giving people immunotherapy ah in the context of, at the time, a sort of pandemic illness is not not a great idea.
00:26:25
Speaker
so not Not a great idea because it might make them more susceptible to infection. susceptible to to infection. And it became more and more common. And it became clear that at the sort of level of the public understanding, the idea of inflammation and the immune system turning on itself and these kind of notions, which are all good scientific notions, had a kind of sway. And and it was resulting in...
00:26:54
Speaker
people being diagnosed on the basis of inadequate evidence with sort of inflammatory disorders, and in turn being treated with often extremely potent and powerful immunosuppressive medications, often in by sort of clinicians at the fringes of sort of mainstream medicine.
00:27:14
Speaker
Now, in the UK, that is a very easy demarcation to make. I've become aware that in the States,
Healthcare Systems and Ethical Implications of Treatment Access
00:27:21
Speaker
it's... it's There is a ah difference in regulation has profound effects on the way that this plays out, right?
00:27:30
Speaker
So I've had at least 10 and probably close to 15 patients who've been to the States to get immunotherapy, whether it's intravenous immunoglobulins, rituximab. sometimes therapies that don't even really count as immunotherapy, like sort of ozone therapy or or hyperbaric oxygen, you know, these sorts of things, often at huge personal cost. ah You know, people people are remortgaging houses and and the like, right? For treatments that have no evidence base or no significant evidence base, right? It's hugely, let's just, I'll be blunt. It's hugely unethical.
00:28:05
Speaker
And it's easier to happen in probably in the US than in the UK because of the NHS. Though I think you have private consultants, it's a lot harder to access, you know, sort of whatever you want, right?
00:28:17
Speaker
that That's right. That's right. And i and it it it's had some really tragic consequences then in in the families I've met. Because of course, in the vast majority of these cases, they don't respond. And in in in in the the more upsetting cases, then that's the opportunity for the clinician involved to say, well, you need to be on these things long term. And that has its own sort of set of of consequences, financial and and kind of health related ah consequences. But I... i where's this coming from is is the thing that that interested me. and And, you know, this all came up for me at a time where skepticism around vaccines was ah sort of exploding over the world, particularly in in communities that you wouldn't have expected, you know, the you know sort of wellness communities and the like, which you would have thought would be interested in staying well throughout a pandemic, as ah as an example, where that turned out not not to be the case. And, you know, things that things have gone even further with
00:29:15
Speaker
you know, some sort of high profile government appointees, ah you know, who who very well. Yeah, we're all thinking the same thing, which is methylene blue, right? Well, um amongst other things, right? um And so, but you know, where does that come from? And I think that word you you mentioned, monocausto taxophilia, and it is a ah word that's coined a little humorously, but it's the search for a single silver bullet that explains everything.
00:29:40
Speaker
That's never gonna be the case and in psychiatry, except for a few kind of rare causes. But more than that, it it it really, it it's based on two other things. One, i think is a ah failure to understand what inflammation even is.
00:29:58
Speaker
ah And it's wild that inflammation, which is the body's way of getting rid of infections, is our body's defense system. I remember in the 1980s growing up and watching kind of early morning cartoons where you had the white blood cells wearing hats, um you know, sort of going off defending you.
00:30:15
Speaker
These days, that's not how how people think about things. This kind of martial metaphor, this warlike metaphor has kind of mutated into inflammation being this damaging fire that if you don't put out is going to kind of burn burn the house down. Now that that may be true, but actually inflammation is far more complex than that. For a start, the idea of there being high inflammation and low inflammation is an utter myth.
00:30:39
Speaker
you know there is that it just isn't the correct way of thinking about things. The immune system has many different arms. It interacts extremely reciprocally. reciprocally and and And it's not just causing trouble. It's often ah ah part of the, that it's one of the ways that the ways that the body actually body actually regulates tissues and and and and responds to other sort of non-infectious challenges as well. Like it's a balance. Inflammation is not, it's not black and white, right? There's this tremendous oversimplification. It's somewhat understandable for human psychology because you really do have to be very smart and dedicated to understand the complexities. And, you know, you talk about the difficulty tolerating ambiguity, right?
00:31:22
Speaker
Yeah, I mean, i think, again, i think people have ah often say to me it's nuanced and it's it's difficult to to to understand the complexity. That's true, but actually you don't you can go back a few thousand years and find early kind of you know models of medicine, you know in Chinese medicine, for example, in new medicine, where the the notion isn't one of, if it's too high, make it low, if it's too low, make make it high. it's It's actually one of but of dynamic balance. right And there's this notion of harmony, which actually I think is far closer to the way that the the body actually works. So I think that inflammation is deeply relevant to to to psychiatry and deeply relevant to to almost all the presentations in medicine in the same way that, for example, genetics is or or life experiences. But it's never, at least not in in most situations, going to be the only cause.
Integrating Psychological and Biological Approaches
00:32:11
Speaker
I would just say the other sort of, I'm sad to say that the other maybe motivating sort of stream of thought that I think sometimes leads to this is is a kind of anti-psychiatry.
00:32:24
Speaker
um And, you know, i guess when we were all training, we knew what anti-psychiatry was. It was people who'd read R.D. Lange and Satz and and and and and there was this notion that psychiatrists are the thought police. we are we're We're pathologizing normal sadness. We're psychologizing or medicalizing things that don't need to be medicalized.
00:32:46
Speaker
though Those people still exist and and and their criticisms are are nuanced and sometimes it's true. And then there's this sort of, the this recent emergence of this other strain, which is saying, well, no, no, quite the opposite. Psychiatry is not medical enough. It's not, you know, we are psychologizing these people too much. There's no way that the psychological formulation of my problems could have any kind of truth at all.
00:33:08
Speaker
and And in fact, the answer is some sort of biological explanation. factor and not and usually it's only one, right? And of course, a lot of the work that our group does shows that there is this hugely dynamic interaction between the biology and the psychology. And in fact, then they're not they're not separate things.
00:33:26
Speaker
I mean, i mean ah just yesterday, a but beautiful study looking at, I think from Israel, showing um that ah the the antibody response to a vaccine can be modulated by essentially neurofeedback, by by by changing the sort of the the the the psychological, the the the reward-based response to ah to stimuli. so So these things are so dynamic. and It's only when we realize that Dividing things into sort of inflammatory versus psychological or biological versus something else, it's just a non-starter.
00:34:03
Speaker
Yeah, I mean, i this is very much, you know, i I think that is a false dichotomy in a sense between psychology, neurobiological. i'm I'm very much a fan of dynamic systems theories. i like Glenn Sachs' work on causal diagnostic modeling using Markov dynamics, which is very congruent with Carl Fristen's work.
00:34:24
Speaker
um You know, a psychological process must have a correlate with what's happening in the brain. And as someone who does interventional psychiatry, I've seen, you know, remarkable changes in people who have been making progress in therapy.
00:34:39
Speaker
And I've seen some less remarkable changes, but it really shifts the way their whole physiology and and brain functions. And, you know, you also see that in things like dissociative identity disorder, where people have different physiological presentations because of their brain state. I would imagine that that math and artificial intelligence holds a lot of promise for creating models that account for the complexity and can also identify what are the multiple causal factors um so that we're not overwhelmed by um what researchers sometimes call the curse of dimensionality.
00:35:11
Speaker
um There's so many different factors. You have to have like a lower... a more simple but not too simple model that actually allows you to get stuff done.
Challenges of Disconnected Care in Psychiatry
00:35:21
Speaker
But with respect to time, we have about 10 more minutes. I want to sort of call Farah in and see, because I would love to just talk for hours, how we can kind of come back.
00:35:32
Speaker
I don't want to digress into AI psychosis and your specialization. We won't have time. um But what ah sort of what do you think, Farah? What do you think listeners want to know? What what would you want to know as a psychiatrist?
00:35:47
Speaker
Well, I think that this really highlights an issue ah that I come up against every single day, which is that I feel like my work with patients is really siloed off.
00:36:00
Speaker
from whatever other work they're doing, from whatever hormones they're taking, from whatever their primary care doc is says, um whatever their, you know ah acupuncturist is doing. And I think that that really limits the success. Whatever they're, so I would jump in and say, whatever they're doing, but also whatever they're telling them.
00:36:25
Speaker
Right, right. Which is often anti-psychiatry. Certainly. um i guess that part, when I hear the sort of anti-psychiatry, I just think, and um Tom Grant knows this, that, you know, my family has been in this business for a long time and I have embraced the fact that there is a dark history and,
00:36:48
Speaker
As a result, I practice in what I think is the most open-minded way. Like that's always my goal is to say, well, I don't think so, but maybe, and let's see. And there's so little that we can actually say for certain. So just getting comfortable with that ambiguity. yeah and i completely agree. We do have a dark history in the field that we need to own. um I'm also talking about you know someone who might say, you shouldn't take that Abilify. It's bad for you. And then the person crashes into depression or psychosis a week later. Right. And I think my job would be a lot easier if I didn't have to have those discussions, but I've just accepted it as
00:37:30
Speaker
part of my day to day. That's what this from like a vending machine. Right. um And I think we all want to be good clinicians and use our, use our minds, but how is that dangerous? Right. And I think about maybe siloing. Yeah. The siloing. I think about when I work with, let's say a new mom and the opportunity cost of being depressed, not bonding with their newborn. i mean, these days we get like a couple of chances at that. And so to not be able to be present or to not feel like oneself in that moment, like that's something that people regret. all Right. And so that's where I come from and what I'm thinking about how to treat someone.
Impact of Antipsychotics on Immune Response
00:38:14
Speaker
Yeah, I think i think that that's beautiful. and I think that's how we how we ought to approach our ah ah patients. I mean, i think there's a way to to to hold these different ways of seeing at the same time and do that with your patients. It's it's actually, you know, for all that I've been saying about the kind of the the sort of cultural aspect of it, it's actually when when you're face to face with an individual patient and you can really kind of talk about things, I think it's it's a lot less difficult than that sometimes.
00:38:43
Speaker
that you know Just coming to you know thinking about in inflammation, I mean, what this discourse has done is it's highlighted the importance of staying well, of avoiding things that are going to be bad for your body, essentially. And that's a good thing, right? you know If it's getting people exercising, that that that's great.
00:38:59
Speaker
and And I think there's a way to sort of encourage that while at the same time not allowing that way of thinking to foreclose other other ah sort of ways of working. And you know one of the major projects that we're working on at the moment is the immune mechanisms of antipsychotic treatment studies. So you know we have now ample evidence that antipsychotics modulate the immune response. and And if you think of something like Clozapine, which is the most effective antipsychotic that we have,
00:39:27
Speaker
It is a profound immunosuppressant that is comparable in some respects to something like rituximab. In some in patients, it can produce ah ah a reduction in in in antibody production and a reduction in in in some white cell subsets. So there's essentially like an immunosuppressant. so it's Very important work. Antidepressants also change the expression of a variety of inflammatory inflammatory meteors. Of course, if we didn't have inflammation, we'd probably all get sick and die.
00:39:55
Speaker
exactly that Exactly that. And actually, what the the thing that our group is is looking at is is this idea that it's not about the high versus low inflammation, it's about the shape of the the response. right So we we we have some data that should be published soon showing that People who, when they have a challenge, if it's a like whether it's a life event or or a natural sort of more biological challenge, they mount a kind of brisk immune response and then recover quickly, appears to be psychologically and in some other areas, the most healthy thing. People who don't respond at all,
00:40:32
Speaker
who have low inflammation, they do worse. People who who respond and stay at high inflammation, they do worse as well. And that makes sense, right? We are we are regulatory systems who are designed to rebound when we get out of joint. The whole point of having a homeostatic sort of body is that we come back to where we were. and And again, it's that dynamic systems kind of thinking grant, which I think is really important. And there are I think there are some ways that we can talk to our patients which which get that over in a way that doesn't sort of throw you know too much. It's not hard to follow. I do that all the time. We do it in disaster response. We developed a systems-oriented model. It's like stress regulation, you know shutting down versus being overactive. Exactly. we need We need to have that conceptual framework that that's how we think about things, and then we can deal with ambiguity and
Advice for Patients: Multidisciplinary Evaluation
00:41:22
Speaker
complexity. Again, I wish we had more time. I want to ask you to the point, though,
00:41:26
Speaker
What is your recommendation to patients who have... a clinical presentation like this, and what should they be having in their back pocket when they go to talk to their doctors?
00:41:41
Speaker
What is your best advice for patients? Yeah, so I've realized that probably it's important that I do this because otherwise I'm saying a lot about what isn't ah this problem. So i you know we we have a number of sort of papers specifically addressing this, including our autoimmune psychosis criteria, but really one of the major things is in in the vast majority of what we call primary psychiatric illness, it doesn't come on overnight, right? Most people have what's called a prodrome or they start to get sort of, you know, worse over over weeks, months, even years.
00:42:14
Speaker
If you're doing well one day and then the next day you're in a terrible terrible sort of state psychiatrically, whether it's psychosis, whether it's ah other sort of symptoms as well, that very acute onset might be a red flag.
00:42:28
Speaker
There are other red flags, confusion, suddenly not knowing where you are, what the date is, and who you're talking to. That's not meant to happen in in sort of primary psychiatric illness either.
00:42:40
Speaker
If you happen to also at the same time have a major, immune, an an illness that's likely to affect your immune system and in in some way, whether it's cancer or a kind of and an autoimmune disease like lupus or something like that. Well, of course, then it's reasonable to say, well, hey, what's the relationship between this disorder and what I'm experiencing at the moment?
00:43:03
Speaker
If you develop neurological symptoms, whether that's, you know, sort of jerks or difficulties moving or or or forgetting to an extent that, again, we wouldn't really see in most psychiatric disorders apart from the you know the dementias, um then then these are all sort of so-called red flags. But the point is that none of these red flags is absolute. you can't You can't see the ah the presence of one of these and say, oh, hey, this person has ah has has an immune problem. And the problem is is is, and we saw this recently in a UK newspaper, saying, you know do you get brain fog? Do you feel... um
00:43:38
Speaker
You feel anxious, you tired all the time. These are symptoms of of autoimmune encephalitis. And well, yeah, the brain fog is such that some people aren't able to speak. They're tired all the time, is sleeping 23 hours a day. um And so, you know, the idea that there are symptoms that are present in this disorder, but get sort of so diluted in the kind of retelling that people can read it and say, well, hey, that's me.
00:44:05
Speaker
And you know that's not even to mention what happens if you go on TikTok or Instagram or or something. And I think that's where that's where there's a responsibility and where these things are so unregulated, because people are going to be looking at these things and thinking, hey, that that is me.
00:44:18
Speaker
And what that also does is they turn away from the treatments that may well be exactly what they need, you know, whether that is a psychiatric treatment or a psychological treatment or or some other area of medicine that needs to be in inputting here.
00:44:31
Speaker
You know, the same type of messaging that you described that's kind of vague, nonspecific, could be almost anything, is also used by people who market um alternative medicine things. Do you have brain fog? Are you tired?
00:44:43
Speaker
um I'll use the same example. Take methylene blue because I saw it on Twitter. Yeah. And it does real harm. You know, these are not innocuous treatments. They can do real harm and they prevent people, as you're saying, from getting proper care. So I hope listeners will take what Dr. Pollack is saying to heart, that when when you are concerned about something, please you know go to your doctors, do the research, read his work.
00:45:07
Speaker
There are ways to be more specific, um but also keep an open mind that it's very hard to make these diagnoses properly. And and you really deserve to have ah a good evaluation. And to Farrah's point, a multidisciplinary evaluation.
Benefits of Combined Psychiatric and Neurological Assessments
00:45:22
Speaker
You know, it's very hard to do what what I do when people consult for TMS, because I really believe the TMS interacts with the psychotherapy over a much longer term than has been studied.
00:45:32
Speaker
You know, as a psychoanalyst who does interventional psychiatry, I have my team operationalize it so that we try to book a team meeting at the same time as the consult, often with the therapist and the outside psychiatrist.
00:45:45
Speaker
And that's very hard to do um unless you have the luxury of working in a hospital based setting and you have weekly case conferences. Yeah. Um, so, you know, let it, let us help you in the ways that we know how to, um and the other thing is right. There's been an erosion of trust in the professions that we need to kind of win back.
00:46:03
Speaker
Yeah. Yeah. A hundred percent. And we're, we're equally, you know, we are for a while now, we've been in these sort of bubbles, these echo chambers where we kind of can't really agree about what our sort of methods of, of confirming, uh, you know, a diagnosis or in fact, many, many other things, um,
00:46:20
Speaker
And that's a real problem. There's a problem of knowledge and one that's only going to get worse with with AI and and and the like. And actually, that was something that I was so aware of when I started working with immunologists and neurologists, because I found that we talk about a patient and then I'd hear the neurologist talk about it. I thought, is this the same patient that we're we're talking about? You're talking about about an expressive dysphagia. I'm pretty sure I thought I was seeing formal thought disorder. um You know, what what what is this? And so so we did something which I think is doesn't happen very often. We now see every single patient who comes to our clinic, sees the neurologist and me, the neuropsychiatrist at the same time. We're in at the same time. And, you know, people talk about, you know, finding the elephant in the dark. Well, if you've got two people at the same time saying, is this a leg? Is this ah a trunk? it It makes a little, a little ah easier. and and And it's remarkable.
00:47:09
Speaker
I think how that dynamic where In real time, you can say, yeah, you know what, this is really atypical for psychiatry, we really need to investigate this person. ah Or the for the neurologist to point out, you know, that person's got a tremor or or, you know, they've got slight facial weakness or something that perhaps I i i wasn't about to to notice if I was on my own. That's amazing. And and and I think we need more of that.
00:47:33
Speaker
That's brilliant. And I think for the patient and to have the communication skills between the psychiatrist and the neurologist, that the patient can hear that dialogue and and internalize that there's a real thought process going on um is also very valuable.
00:47:47
Speaker
Farah, would you like to read us out? Yeah. um So, Tom, thank you so much. This was really awesome to hear about your work. And I hope that you'll come back and join us later on. But in the meantime, where can people find you?
00:48:02
Speaker
So they ah they can find me on my King's College London webpage. I also have a Substack where I talk about much more speculative matters, but also a lot that pertains to to to this kind of thing.
00:48:17
Speaker
And media too. You have some pieces on movies and the media, and um that would be another conversation for another time. But definitely check out Tom's Substack. It's really smart and entertaining.
00:48:28
Speaker
I'm going to go subscribe and we'll link to it as well. So thank you very much. It's been a real pleasure. Thank you. Remember the doorknob comments podcast is not medical advice.
00:48:41
Speaker
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