The Hardest Part About Diagnoses (And How To Avoid Biases)

Hey there, everybody, and welcome to today's presentation on differential diagnosis and the framing bias. I'm your host, Dr. Donnelly Snipes. In this presentation, we're going to review differential diagnosis for symptoms of common mental health issues such as add, adhd, anxiety, autism and depression, and actually schizophrenia. I should have had that one on there too. And talk about what we might be missing, like a runny nose. Most symptoms are common to a variety of problems you're going to learn shortly. If you don't already know that fatigue can be caused by low testosterone, low estrogen, low thyroid. It can be caused by withdrawal or intoxication from substances. It can be caused by medication side effects. It can be caused by nutrient imbalances and blood sugar problems and even cardiovascular disease. And that's just a few. So we don't want to rule in or out anything right away. We want to actually do a comprehensive biopsychosocial diagnosis in order to make sure that we understand all the causes. If somebody is feeling fatigued because they've got atrial fibrillation, no amount of talk therapy is going to fix that. Now we can fix the cognitions associated with that potentially we can help them develop tools to cope with having atrial fibrillation. But talk therapy ain't going to reset the heart. And that's really where I what I harp on in supervision and even when doing my own diagnoses, when I talk with clients about the importance of looking at the big picture in order to reach maximal gains and improve, reach your highest quality of life. We don't want people to come to counseling and feel 10% better and then stop there because they're just, they're not making any further progress because the other 90% of the causes of their symptoms are physiological. We need to bear that in mind. Now, the framing bias is a cognitive bias that influences decision making based on how information is presented and what is expected affected. So think about when you go to the doctor versus the a therapist or an addiction counselor. If you're having, let's just say, symptoms of depression, how are you going to describe it differently to the doctor versus the therapist? And since y' all are therapists, you may be like, well, I'm not going to describe it differently. The non therapist would tend to describe to the doctor the physical symptoms and to the therapist and the cognitive and emotional symptoms and really not necessarily discuss overlap it. So it's important if you are in primary care, if you're a nurse practitioner, etc. That you're aware of this and but it's also important to recognize as you've been trained, there are a lot of physiological causes. For the clinician, we need to recognize the signs of depression and help the person develop a plan to deal with whatever symptoms they're facing, which include ruling out any underlying physiological causes that no amount of talk therapy is really probably going to address that they need to take care of. So they can rebalance their nervous system, rebalance their neurotransmitters. Now the confirmation bias, they kind of go hand in hand. All three of these do. The confirmation bias is when professionals are more likely to diagnose based on what's expected, which can lead to misdiagnosis or under diagnosis. When I see people in counseling, they're coming to me for counseling, I'm assuming, often wrongly, so that all they've got, quote unquote, is a mental health issue. Now mental health issues depress depression, anxiety, stress, all of those things can cause changes in body physiology. And body physiology changes can cause all of those symptoms that we're going to talk about. So it's important that I don't just say, okay, you've got major depressive disorder without also referring to any a medical practitioner to evaluate the physiological side. The availability heuristic is sort of related to confirmation because we see when upsurgens in diagnoses of certain disorders when they suddenly start getting a lot of media attention and it could be because more people are aware so now they're seeking help and that's possible. It could be because the therapist is now aware so they are fine tuning their diagnosis. Or it could be that we are diagnosing because that's what we expect to see. Just like people who are afraid of airplanes, when they get on an airplane, they are assuming it's going to crash because what do we hear about with airplanes? We don't hear about the 20, 40,000 flights every day that go just fine. We hear about the one every six months or so or less that crashes. So that is what's most available in their mind. That's what they think about. They don't think about the stuff they didn't hear about. Paying attention to those things in your diagnosed in your diagnostic rubric, if you will, is really important to make sure that you're not being swayed by things. There was an upsurgence in with my supervisees for a while in diagnosis of personality disorders, particularly narcissistic personality disorder. And a lot of that stemmed from was around the time that it started becoming very popular in social media and they Started self diagnosing and diagnosing everybody else with personality disorders. And it was important for me to say, okay, let's step back and look and say what else might be causing these symptoms, such as, hey, ptsd. We'll get there. Assuming that someone has major depressive disorder when they feel. Feel depressed is a very dangerous assumption. It's important to evaluate the entire picture, including all other pieces of their life. Remember, that's my favorite mnemonic. Physical, interpersonal, emotional, cognitive, environmental, and spiritual. We want to look at what things in those areas might be contributing. Their depression may be because they just had a baby and they're having some hormone changes and they've got postpartum depression. Their depression may be because they're grieving, because. Because somebody in their life just died or maybe died three years ago. So we need to explore disorders can co occur. There's no doubt about that. You can have addiction and major depression and even PTSD on top of that. But it's important not to throw the kitchen sink at people, because when people end up with five, six, seven different diagnoses, how does that make them feel? I mean, in most cases, it makes them feel completely broken and powerless and overwhelmed. So we want to make sure that we are not including diagnoses that are better accounted for by something else. PTSD and CPTSD account for a lot. Underscore, bold, italicize. Same thing with anxiety and depression. But people with CPTSD often have, guess what, anxiety and depressive symptoms. But that's accounted for in that diagnosis. Can you give them multiple diagnoses? Well, yeah, I mean, you could, but it's important not to get lost in all of the acronyms. Mdd, bpd, ptsd, all that stuff, and really focus on the symptoms. What are you presenting with today? What symptoms are causing you problems? And let's figure out what the root cause of those symptoms is. Ultimately, it comes down to physiology. We know that emotions are caused by alterations in hormones and neurotransmitters. And those hormones and neurotransmitters are. Can be altered by the hypothalamic pituitary adrenal axis or the hpt. Hypothalamic pituitary adrenal HPA axis, the hypothalamic pituitary thyroid axis, hpt, and the hypothalamic pituitary gonadal axis, horizontal hpg. All three of them work together. They are inseparable, even though we have them listed differently. When one's triggered, the other's triggered. When one becomes miscalibrated, the others typically become miscalibrated and it affects the balance, the very delicate balance of hormones and neurotransmitters. So let's talk about the symptom of depressed mood. I know you're looking at all this going whoa, in your classroom at all ceus when you log in, There is a PDF of this PowerPoint. You can click on all these different articles and studies, most of them are in PubMed and read more about it if you want to do a deep dive. But just suffice it to say the high level overview. There are a lot of physiological causes of diagnosis depressed mood. Now, one of the challenges I have when I diagnose people and when people are talking to me is a lot of times they kind of lump in fatigue, low motivation and apathy and look into depressed mood. So we kind of have to ferret that out. But depressed mood is, is sadness and inability to find joy in things. Physiological changes can cause that. Why is that? Because stress on the body due to these changes can cause alterations in the nervous system and make certain neurotransmitters like your pleasure neurotransmitters, serotonin, dopamine, endorphins, more difficult to access. Vitamin D. We know that vitamin D, low vitamin D is associated with depression. We see it in seasonal affective disorder. But we also have seen in research that in the same place where the receptors for serotonin are in the brain, there are a lot of vitamin D receptors and they know that low vitamin D is associated with depression. Easy to test for iron deficiency. We've all probably heard of iron deficiency anemia. When we don't have enough iron, our blood can't carry oxygen throughout our body as efficiently, which leaves us feeling tired. When we are poorly oxygenated, we can feel depressed. Hydration can also contribute to depressed mood. When we are dehydrated, it makes it harder for those neurochemicals to actually do their job. It makes it harder for the synapses to connect and converse, if you will, because that is done in a fluid state. And if the fluid is kind of lacking, then it's going to be hard to transmit. Anorexia is another issue that can cause depressed mood. And part of that is because of the loss of water. But part of that is also due to other nutritional imbalances. In order to make serotonin, for example, the body needs tryptophan. Tryptophan is broken down into a component part and then it's broken down again. And it's important to understand that in that process to break tryptophan down, we need to have calcium, we need to have iron, we need to have a whole host of vitamins and minerals that someone with anorexia may not have. And I should have also included on here bariatric surgery. This is not true for everybody who has bariatric surgery, but there are some people with bariatric who have bariatric surgery that be, have difficulty actually absorbing nutrients anymore because they had that bypass. And that can also contribute to depressed mood for the same reason as anorexia. And when I say anorexia, that can mean anorexia nervosa or it can mean the general term anorexia that doctors use to describe just a complete loss of appetite, which we see sometimes in older people and sometimes as a side effect of medications. Hormonal imbalances, hypothyroid. I didn't even bother finding a study for that because I feel that it is pretty common knowledge that hypothyroid can produce depressive symptoms. Depressed mood, cortisol imbalances. Now remember, cortisol goes up first thing in the morning to help get you energy and motivated to get up out of bed. And it decreases throughout the day, being lowest in the evening, which triggers your body to create melatonin. People who have undergone chronic stress or complex post traumatic stress may have what we call glucocorticoid resistance, which is very similar to tolerance that we talk about in addiction. The brain has started to sort of ignore the cortisol when it comes a knocking because it just, it doesn't have the energy anymore. And in other videos on the HPA axis, I've talked a lot about flat to furious. And people with cortisol imbalances with glucocorticoid resistance often will emotionally dysregulate when they are not terrified or infuriated. They're flat, they're just, they're blah. They have difficulty getting excited about anything. When they are not upset. Sorry, heard a cat. When they are not upset, they don't, can't feel happy. When they do get upset, their body just sends a tsunami of stress hormones. And so this can cause emotional dysregulation. Estrogen, low estrogen is associated with depressed mood. And as people age, whether you like to hear it or not, as people age, Starting about age 35, our gonadal hormones slowly, hopefully start to decline. And that decline in some of your gonadal hormones can contribute in some people to increased symptoms of depression, especially in people who already had Depression who already had a serotonin or norepinephrine or dopamine imbalance, those symptoms can be exacerbated. Same thing with testosterone. Men produce less testosterone as they get older and that can in some cases contribute to depressed mood. The research out there does indicate that that's not true for everybody. But just bear that in mind because it's easy to test when you do the blood work for the vitamin D and the iron and the B12, you can also do it for gonadal hormones and thyroid hormones. Let's just do a full blood panel. Microbiome alterations are another cause of depressed mood. When you eat food. Well, that's wonderful. It's great. Goes into your gut and is broken into its component parts that are going to be used to make the hormones and neurotransmitters. Now, the staff in your gut microbiome that's on duty is the staff that correlates to your mood. So if you are feeling flat, if you are feeling stressed out, you've got a whole different crew working in your gut than you do when you're feeling happy. And your gut microbiome actually changes pretty quickly. But they have found that improving the health of the gut microbiome is associated with improvements in depression and overall, what they perceive as neurotransmitter functioning. Sleep dysfunction. Well, there are reasons for sleep dysfunction. Sometimes it is because of sleep apnea. And sleep apnea is when you basically stop breathing multiple times at night. Well, I just said oxygenation is important for us to feel happy. When we regularly experience episodes where we're stopping breathing, then the, then the body perceives it as a stressor. When the body perceives it as a stressor, you trigger the HPA axis. When that's happening throughout the night, every single night, guess what? You're going to start to develop glucocorticoid resistance and you're going to start developing some associated mood symptoms due to alterations in neurotransmitters. There is a strong correlation between sleep apnea, the development of sleep apnea and ptsd, which I thought was interesting. Irrespective of the person's weight or body type, people with PTSD are a lot more likely to have sleep apnea. So not saying that apnea causes ptsd, but it. There's a strong correlation that it all almost might be the other way around. I don't know the mechanics behind that HPA axis dysregulation. I already talked about the flat to the furious. That is so important because when your HPA axis gets dysregulated, throws off the hpt, the thyroid axis, and the hpg, the gonadal axis. And without those things working well, your hormones are going to get out of balance. I didn't even mention oxytocin here, but oxytocin is huge for promotion of mood and pleasurable feelings. Inflammation has been shown to have a strong direct correlation, not causation. We can't say causation, but a strong direct correlation with. With depressed mood, and that is chronic inflammation. We see more of it in people with autoimmune disorders, people with ongoing inflammation for some reason, people with ongoing illnesses like cancer or even an abscessed tooth or something that is contributing to physiological inflammation associated with increased depression. Now, we can argue that people who have inflammation are in pain. And when people are in pain, they don't sleep as well. When you don't sleep as well, you tend to have more fatigue and tend to have more. More difficulty getting excited about things. Sure. But let's figure out what is the underlying cause of all of this. If somebody has an abscessed tooth and that's causing systemic inflammation and they aren't getting good sleep as a result, and we're treating them for depression and trying to teach them skills to reset their HPA axis, well, that's great. But until that inflammation's handled, you know, medication side effects, particularly opioids, benzodiazepines, and barbiturates, tend to be sedating. And that can contribute to people feeling depressed. When we're sedated it, there is an alteration in our brain neurochemicals, and so some people experience depression on those things. Addiction is associated with depressed mood. Addiction is hard on the body. When the person uses it is a stressor. So that HPA axis gets set off, and then when the person's detoxing, it's a stressor. So the person's HPA axis gets set off. And this is true for substances, which pretty obvious how that happens, as well as behavioral addictions. Behavioral addictions over tax or over stress, the neuroceruitry with dopamine and endorphins and everything else. And then when the person's not using, whether it's gambling or sex or gaming or whatever, then they have a deficit because their body, just like in substance addictions, their body adapts to that excess. So they're always in a state of stress, either too much or too little. Cardiovascular dysfunction. As I mentioned, if your body is not able to effectively circulate oxygen. Oxygen, then it's going to be a stressor. It's going to dysregulate those axes and it's going to typically contribute to low mood and fatigue. Pain. Well, think about it. When you're in chronic pain, are you in the best mood? Or even when you're in acute pain, are you in the best mood? And that's important to remember that pain itself is going to represents inflammation and it's going to trigger certain hormone and neurotransmitter changes. Emotional and cognitive people who have a lot of anger when, if they're angry at the world, if they have a lot of resentments, that's exhausting. Same thing with anxiety. Remember, anger and anxiety are threat responses. So people who constantly feel or frequently feel angry or anxious, they are revving that engine. They don't feel safe, they can't relax, which is exhausting. And that can that number one, it triggers the hp, axes, all of them. And it can impair sleep, which can contribute to depressed mood. Now remember depressed mood. The two key features hallmarks are hopelessness and hopelessness. Well, if you're in chronic pain or if you're feeling angry or anxious all the time, yeah, guess what, you're probably going to have a little bit of depression. We can help people address the sense of hopelessness and helplessness in, in their cognitions as well as in their behaviors. Once we help them identify what's causing this obviously depressed mood. You're going to see it in depression. You're going to see depression in people who are grieving. And we don't want to pathologize grief by saying, oh my gosh, you know, you're grieving and you're displaying these symptoms of depression. We need to slap a diagnosis on it. No, grief is a very normal process. Depression in terms of grief is the person recognizing that I can't change this. This loss is for real and forever, and I don't like it. Doesn't mean they aren't going to move through the grieving process. Now, we do have prolonged grief disorder in the DSM 5 TR now which. Okay, fine. If the person has had these grief symptoms for a long time and you need to find a diagnosis, but. And then schizophrenia. Schizophrenia, especially in the prodromal periods, the periods right before a. An acute episode, the person with schizophrenia may have anhedonia. They just, they can't feel much of anything. It's just blah all the time. And actually, when they're on antipsychotic medications, a lot of people with schizophrenia complain that they can't feel much in the way of happiness. Low energy, fatigue physically. And we already talked about a lot of this, but same principles apply. Nutritional imbalances. We need sugar, not table sugar, but we need blood sugar in order to have energy. We need fatty acids in our body in order to have energy. We need certain nutrients in order to break down the food we eat to convert it to energy. So if we don't have the right nutrients, we can feel fatigued. Dehydration, another one that. And I'm going to actually do an entire video on the importance of hydration and water in the coming weeks. But dehydration is associated with fatigue because your neuro nervous system can't communicate effectively when it's in a drought, if you will. The gut microbiome, that's where everything's broken down. So if the gut microbiome is not working, if everybody called out sick because they were too tired, then you're not going to effectively break down the foods. Hormonal imbalances, including estrogen, testosterone and cortisol for the same reasons that they can lead to depressed mood, alterations in neurotransmitters and inability to trigger certain physiological reactions. We see the same thing with low energy. Different neurotransmitters, same principle. Sleep dysfunction in self or other. When somebody is not sleeping well, for whatever reason, whether it's allergies or a, a cat that won't be quiet or something else, then sleep dysfunction can contribute to low energy. If you have a new baby in the house or a new puppy in the house, you may not be getting good sleep. And when your sleep becomes dysfunctional disrupted, it can also start altering your circadian rhythms. Remember, circadian rhythms set when your body releases cortisol and when your body releases melatonin. And if your circadian rhythms get out of whack, not only does that change, but the release of pretty much all your other hormones changes and addictions again. Intoxication or withdrawal. Typically, withdrawal symptoms are roughly the opposite of intoxication. So people who use stimulants tend to feel exhausted when they are withdrawing. People who use opioids and benzos and other depressants tend to feel anxious and restless and irritable when they are detoxing. And medication side effects, especially in older people. As we age, not only do we produce less gonadal hormones, but our liver becomes less effective, less efficient. And older people, and when I say older, depending on their health of their liver, anywhere from 55 to 65 pe, older people tend to take longer to clear substances from their body. So certain medications, especially sedating medications, what is adequate for somebody else to take every four hours may need to be taken every six or eight hours or not at all by somebody who is older. Medications that are sedating, antihistamines. I think we've all taken Benadryl or something like it at one point in in time. So we know this. Some of your other an over the counter antihistamines also do have some sedation with them. Statins. These are your cholesterol medications. Yeah. They can cause low energy, they can cause fatigue. Proton pump inhibitors, these are your gastric reflux medications. They too can cause low energy. Benzodiazepines, opioids. Those are both in that depressant category. And then guess what? Antidepressants, if you've been working in the field for a while, you're familiar, there are certain medications like Paxil for example, very well respected antidepressant. But it is also extremely sedating. And most people that I know that take Paxil take it at night because of the sedating side effects. But we want to look and say when did your symptoms start? In relation to what? When you started taking this medication or changed your dose of this medication or even added another medication, Maybe a completely unrelated medication. But if you were in my class the other day when we Talked about Cytochrome P450, if you're taking one of these medications which are all cleared with cytochrome P450 enzymes and you start taking another medication that that is Cleared with cytochrome P450 enzymes, your body may not be able to efficiently clear both medications. So you may start feeling more sedated. Emotional and cognitive anger, anxiety, depression, as I mentioned, it's exhausting. Now the low energy, the exhaustion from it is different from the sense of hopelessness and helplessness. But we feel emotionally hopeless and helpless when we've been fighting a fight and not getting anywhere. So they kind of go hand in hand. But they're not the same. People who are grieving are trying to quote, find a new normal, if you will. And that is, that takes a lot of energy. Processing what happened takes a lot of energy and it can be exhausting. And people with PTSD and CPTSD are also often plagued by low energy because they can't relax, they're hypervigilant, they don't feel safe. Core features of trauma being feeling unsafe and disempowered. Core features of PTSD and CPTSD continuing to feel unsafe and disempowered which makes it hard to relax and will drain your energy. Sleep disturbances, again, nutritional imbalances. We need tryptophan to make serotonin to be broken down into melatonin to help us get to sleep. So if we're not eating a good diet, then our body may not be able to make the, if you will, hormones and neurotransmitters necessary for sleep. And you need more hormones, hormones and neurotransmitters than just melatonin to get to sleep. But, you know, we only have so much time to talk today. Hormonal imbalances, including night sweats, can also cause sleep disturbances. So in addition to feeling either irritable sometimes or just flat and like heavy and everything is just exhausting, hormonal imbalances can also directly impact the quality of your sleep. Hyper vigilance, not being able to calm down, sleep dysfunction in self or other. Oh, I didn't talk about other on the last slide. We'll talk about it now. So sleep dysfunction in yourself can be apnea, it can be night terrors, it can be circadian rhythm dysfunction. Maybe if you're a shift worker and it's keeping you from getting adequate sleep. Overactive bladder, which can be a thing in and of itself or due to an enlarged prostate in men, we need to be aware of these things especially, well, just being aware of these things, asking people, how many times a night do you get up? That's important. Now, why do I say or other? Because if you're sleeping in the room with somebody and they've got apnea, you're probably waking up every time they snort themselves awake. If you're sleeping in a room with somebody who has night terrors, you're not going to sleep through that. If you're sleeping in a room with somebody who's getting up every two hours to go to the bathroom, you're not going to sleep very well. If you have a young child at home that's waking up throughout the night for some reason when you get up, it's disturbing your sleep, or if your partner gets up to go tend to the child, it's probably going to disturb your sleep. No matter how quiet they try to be. Our body registers a lot of this. Some of these things. We're not, obviously not going to get rid of our kids and our pets and our children and whatever, that's not going to happen. But recognizing this and taking steps to minimize it, treating sleep apnea, treating night terrors, addressing the circadian rhythms. And there's stuff to medical Interventions for overactive bladder enlarged plot, prostate finishing up your water or whatever you're drinking at night within X number of hours before you go to bed. There are things that we can help people do to reduce their sleep disruption. Pain. We know that when we're in pain, we don't sleep well. Allergies when you're not breathing well at night, it makes it harder to sleep. And some people have allergies. I know I have allergies to my pets. I make the conscious choice, not the best choice, but the conscious choice to still allow them in the room. They've done studies that have found that people with post nasal drip because of allergies do tend to have more sleep disturbances and sleep difficulties than people who don't have post nasal drip. Addiction Again, intoxication or withdrawal. And this includes behavioral. People who are intoxicated may, if they're taking a depressant, they may get, they may pass out, get a lot of sleep, but it's not quality sleep and that's dangerous anyway. When they are withdrawing from medications and from substances, it impacts the quality of their sleep and they may have difficulty getting to sleep if they're feeling irritable, agitated, et cetera. If somebody's withdrawing from opioids, for example, that is a rough withdrawal because there is so much, so many flu like symptoms. We'll say we need to understand that people are not getting good rest when they're withdrawing. If they are withdrawing from a behavioral addiction, then obviously if they're intoxicated with a behavioral addiction, they're actively engaged in it. And if they're doing it all night long, ain't sleeping well. If they are withdrawing from a behavioral addiction, like we'll say gambling, they're laying in bed and they're thinking about all the money they're not making or all the chances that they're not able to take because they're sleeping and they can be obsessing about that addiction. Medication side effects. Antipsychotics are extremely sedating for most people. And they found that people with schizophrenia do tend to have sleep disturbances, medicated or unmedicated. Because the anti psychotics are so sedating. A lot of people who are on them tend to sleep on and off throughout the day, which messes up their circadian rhythms, which causes ineffective sleep at night. Antidepressants and benzodiazepines, your antianxiety medications can cause sleep disturbances. Now there is some research that antidepressants in some people can improve sleep quality, but they've shown repeatedly that the effectiveness of antidepressants for people with depressive symptoms is anywhere from 35 to 60%. So that leaves a big portion of people that it doesn't help at all. So sometimes it even works against them. And then obviously, if you're taking stimulants, whether that is caffeine or decongestants or some other medication that has stimulant effects associated with it, for example, you wouldn't take ADHD medication right before you went to bed. What emotional or cognitive things might cause sleep disturbances that we need to consider? Adhd, very common for people with ADHD and ADD to have difficulty quieting their mind in order to get to sleep. There's a lot of research that indicates people with autism tend to have sleep disturbances. We want to recognize this and if a person's presenting as depressed, okay? But we also want to make sure that we screen for adhd, autism, and maybe early onset or prodromal schizophrenia symptoms. Chance. Chances that you're going to find it may not be good, but we need to screen for it so we can catch the ones that, quote, fall through the cracks. I've had a lot of people that I worked with in addiction treatment centers that had adult adhd. They were adults with ADHD and had never been diagnosed. They'd been called oppositional or problematic or some other even more derogatory word. And once we figured out that, hey, you're using to self medicate your adhd, huh? Light bulbs went off and things rapidly got better for most of them. Anger, anxiety. When you're laying in your bed and you're, you know, revved up because you're angry or you're stressed out, I ain't going to sleep very well. Depression. Well, when you're depressed, many times your serotonin is low, your norepinephrine may be low. Many times when you're depressed, you're not doing your, quote, normal activities, which means your circadian rhythms are getting out of whack, which will make it harder to get to sleep and get good quality sleep. Obsessive compulsive disorder keeps a lot of people from getting to sleep. Ptsd, cptsd, because they're hypervigilant, may cause disrupted sleep. And because people with PTSD or CPTSD may have night terrors that may also contribute. And schizophrenia research has shown medicated or unmedicated, a lot of people with schizophrenia have sleep disturbances. So we need to pay attention to those things. Restlessness can be due to having too much caffeine, hormonal imbalances particularly hyperthyroid gut microbiome dysregulation medication side effects. Dopamine agonists are medications that are used for a variety of things, not the least of which is restless legs. But dopamine agonists can cause people to feel restless. Antipsychotics are dopamine antagonists and they cause people to feel unmotivated and flat and, you know, blah. Dopamine agonists go the other way. It's activating or hyperactivating those dopamine receptors. Antidepressants, some of them. Pax, not Paxil, Prozac is one that I'm super familiar with because, you know, they've been prescribing it since I've had my license. People who take Prozac tend to report more restlessness and irritability, especially in the first week that they're taking it. And again, stimulants. If people are taking stimulant medications like ADHD meds, it can cause restlessness. Now, if they've truly got adhd, it doesn't tend to do that. It tends to help them focus. But people who are taking dexmethylphenidate when they don't need it tend to have more restlessness addictions. Again, people are obsessing about thinking about their substance of choice, their addiction of choice. If they can't get it, they tend to be frustrated. They tend to not know what to do with that energy. They feel like they need to go get it and that contributes to restlessness. We do see restlessness in people with Alzheimer's and dementia. So if somebody starts becoming suddenly more restless and there's not some other cause that you can find, and they're displaying other cognitive symptoms, definitely want to rule out any sort of dementia or even early onset dementia. Emotional and cognitive causes of restlessness. Well, adhd, it's in the diagnosis. Anger and anxiety. Remember, those are your fight or flight emotions. So of course you're going to feel restless. When you feel like you need to fight or flee. Your body is not going to say, let's just sit on our butt and relax for a bit. It's not how it works. We need to figure out where's this restlessness coming from. And people with schizophrenia tend to have more restlessness in the prodromal phase and even at night when they're trying to get to sleep. Because when they try to go to sleep, if they're having any breakthrough symptoms, a lot of times that's when those symptoms are most problematic. They hear the voices, they see the things. So if you're working with somebody with schizophrenia, we do need to ask about potential sleep problems and potential restlessness that's keeping them from getting good sleep, social isolation or withdrawal. Now this isn't caused by a whole lot of physiological things with the exception of possibly oxytocin. Now the interesting thing is that oxytocin actually is made more available with based on the levels of other gonadal hormones. So if your testosterone or your estrogen or your progesterone are not in the right balance to promote social interactions, then guess what, your oxytocin is probably going to be low too. Oxytocin is responsible for helping us derive pleasure from interacting with other people. It's our bonding hormone. People with schizophrenia, they've shown, have deficits in their oxytocin system. They may have the same levels of oxytocin as someone without schizophrenia, but their receptors don't respond to it in the same way in the expected way. But they have found that intranasal oxytocin actually does reduce a lot of the social withdrawal in people with schizophrenia. So that thought that was interesting. Autism. People with autism often crave interaction with other people, but they may get easily overwhelmed because of their sensory gating issues and their neuro atypicality. We need to ask some people with autism prefer isolation because it feels safer. We need to ask them what is it they want and how can we help them feel safe. And then anger and anxiety. If you don't feel safe, then do you really want to hang out with a bunch of people? Not probably where you're thinking about spending your energy. And depression when you're feeling depressed, when you're feeling exhausted, when nothing's making you happy. A lot of times thinking about trying to go out and put on a happy face is the furthest thing from your mind. So again, just considering, what are these symptoms communicating anxiety or worry. See how often these nutritional balances come up or imbalances come up as well as gut microbiome dysfunction. Magnesium, vitamin D, vitamin B6, iron, omega 3 and zinc have all been associated with anxiety when they are in the wrong balance. Vitamin B6, iron omegas and zinc, when you're taking too much of it actually causes anxiety. But you need those things in order to not feel anxiety. So it's that Goldilocks principle. You don't want it too too cold, you don't want it too hot, has to be just right. But too many people think more is always better and that's just not it. Hormonal imbalances, thyroid hormone imbalances can contribute to anxiety and worry. And estrogen imbalances, especially high levels of estrogen, can contribute to anxiety and worry. Sleep dysfunctions. Because of ruminations or distress intolerance, people who are anxious may have sleep dysfunction. But when we don't get enough sleep, again, studies have shown that when we don't get enough sleep, we have more difficulty tolerating distress, more difficulty engaging our wise mind and disengaging our default mode, and more difficulty coping with ruminations. We tend to have more intrusive thoughts and negative intrusive thoughts at that when we are sleep deprived. And I go over a lot of that in the video that I, that I did on sleep medication. Side effects benzos, they're your anti anxiety medications, but when they are leaving your system, you can have rebound anxiety. Antidepressants. Sometimes they're used to treat anxiety, but some antidepressants actually increase anxiety, which is why it's important to communicate with your doctor or advocate with the patient's doctor if the patient's having difficulty advocating for themselves if the medication they're on, especially after a few days, is still making them feel not good. Decongestants like Sudafed are stimulants that can increase anxiety in people. If nothing else we know it increases the stress response, it increases heart rate, it increases blood pressure. And some people will associate that with anxiety, which will spin up their perception of anxiety. And interestingly enough, antihistamines, I know we talked about them under depression, but some antihistamines, and I'll tell you brand name Allegra, but it's, I believe fexofenadine was supposed to be a non drowsy antihistamine. The most non drowsy antihistamine. And I get drowsy real easy. So I tried it. Oh my gosh, I felt like I was going to crawl out of my freaking skin. Now I'm sensitive to medications, but we do want to always talk with people about, you know, what changed right before you started having these symptoms in your nutrition, in your sleep, in your life, in your environment, in your habits. And addictions can contribute to anxiety and worry. Somebody who has an addiction worries about other people finding out about it. They worry about, you know, how to hide any problems that they're having. There's a lot of stress that goes along with addictions in terms of emotional or cognitive issues that can cause anxiety and worry. People who are angry a lot may worry that other people don't understand them. That they're going to be rejected. People who are anxious have anxiety. People who are depressed, similar to anger, some people who are depressed may worry that people aren't going to understand that they're never going to feel any better, that this is all there is. There's a lot of things they worry about, which is exhausting and contributes to their feelings of hopelessness and helplessness. And people with depression sometimes develop depressive like symptoms as a result of anxiety because of that glucocorticoid resistance. Because the HPA axis finally says, this ain't working, Fighting this fight is not. There's no point. So I'm not going to pay attention to the cortisol unless you really, really, really tell me it's a really big emergency. And in schizophrenia, we tend to see rapid mood shifts and stark increases in anxiety in people in the prodromal period. And this can be before the first acute episode or any episode. Further episodes, if they're in remission and they start getting ready to have another episode, we'll see those prodromal signs physically for low motivation. Now, this is not low energy. Low energy is, oh, I'm tired. Low motivation, I've got all the energy in the world, but I don't feel like it. So hyperthyroid, interestingly enough, is associated with low motivation. Sleep dysfunction is associated with low motivation. Now what is our main motivation chemical? Dopamine. Everybody say dopamine? Sorry. Anything that disrupts the HPA axis is going to alter the levels of dopamine. So sleep dysfunction can also alter levels of dopamine. Medication side effects like antipsychotics, which by their very nature reduce dopamine, are going to contribute to low do. Low motivation and benzodiazepines may also reduce motivation less about reducing dopamine, but more about significantly increasing, increasing the levels of GABA in the system. Now, GABA is our natural valium. It's our natural anti anxiety medication. It's our natural chill pill. So people tend to be less motivated when they're feeling all relaxed and stuff. Addictions by their very nature, screw up the dopaminergic system. Therefore, we may see low motivation in a lot of different areas, with the exception of acquiring that addiction. It's really important to recognize that once somebody becomes physically tolerant to a substance or an activity when they're not using, they're actually not getting enough dopamine and other neurochemicals into their system because the receptors have become unreceptive. Therefore, the only thing that's really motivating is the thing that is going to give them more dopamine, and that is the addiction. Chronic fatigue syndrome. Low motivation is a common symptom. Now they also have chronic fatigue, so low energy. But people with chronic fatigue syndrome also have differences in their dopaminergic system. So says the research. Emotional cognitive causes of low motivation. It could be anger if you feel threatened, if you feel angry about everything all the time, hear those cognitive distortions, then it's going to be hard to get motivated because it may seem like there's nothing you can do to change, which takes me down to depression, that sense of hopelessness and helplessness. But when people are anxious, a lot of the time, they may not have a lot of motivation to do things they used to do because they're too worried about preparing for the sky to fall. And schizophrenia, because of the changes or problems in the dopaminergic system, we may see low motivation. Now, typically, people with schizophrenia have too much dope activity in their dopamine system, which is why the antipsychotics slow that down. But definitely when they're medicated, there's a lot of low motivation. It's not resistance, it's not them trying to be difficult. We're actually turning down the amount of dopamine, amount of motivating chemical they've got in their system. So then we have to figure out, okay, what can we do to help this person be more motivated. Difficulty with attention or concentration. Nutritional imbalances. Blood sugar issues. When your blood sugar is too low, it's really difficult to focus. They found that children with ADHD because the brain uses so much glucose, children with ADHD often have more behavioral problems mid morning because they've already burned through all of the glucose they had to from breakfast, so to speak. Providing them snacks throughout the day helped manage their behavioral issues. Interestingly enough, gut, gut microbiome changes can make it difficult to concentrate. Dehydration, 1% dehydration. Your reactions are a little bit slower. You may be just kind of. But you're not even feeling thirsty yet. By the time you're feeling thirsty, you're 3% dehydrated. And it has started to have significant impairment on your cognitive functioning and your reaction time. Cardiovascular diseases that keep us from getting enough oxygen make the brain so it's, you know, oxygen starved and makes it harder to concentrate. Hyper, hyperthyroidism and estrogen. Too much estrogen can contribute to difficulty in concentration and attention. Sleep dysfunction. If you're exhausted, gonna be hard to focus. Hepatic encephalopathy this is when a lot of times it's seen in people with cirrhosis, but it's when the liver is so ineffective that the toxins are backing up into the brain and the brain's becoming inflamed and that's obviously going to affect your ability to function cognitively. Medication side effects We've all read the warning signs on sedatives and antihistamines that say probably not to use this while driving because it impairs your concentration. Addictions. People with addictions are focused on their addictions. Emotional and cognitive reasons for this can be ADD or adhd, which is diagnosable and treatable. It can be anger or anxiety. You feel unsafe. You're like that squirrel in the middle of the road just trying to figure out what's going to come next and you're not really focused on the big old car that's headed towards you. Depression. Well, when you're depressed you feel hopeless, you feel helpless, you feel lethargic, you're unmotivated. Yeah, it's going to be hard to focus on anything if you're not motivated to focus. And schizophrenia. Resources, great resources for you here. Medication side effects database drugs.com SFX side effects drugs and supplement interactions drugs.com drug underscore interactions and the symptom checker. If a patient is presenting with symptoms, you can throw it into the symptom checker and get an idea because I didn't cover all of the possible physiological causes of symptoms. So you can toss this stuff in in there and say is there any underlying physiological issue that, that this person may need to be screened for it? Really? I, I ran, ran it a few times on different things yesterday and it seemed to be a really useful resource. All of these are free, all of them online. Being alert to the variety of issues that can be contributing to certain symptoms is essential for effective treatment. Many physical causes of symptoms can ultimately lead to complications in all pieces of life. So we need to address the whole person. Clinicians must recognize the interactions between the HPA axis and stress in any of a pieces of a person's life. So stress in any of those pieces and how those interactions impact the balance of hormones and neurotransmitters. Thank you for being with me today. Thank you for bearing with me as I ran a couple minutes over. Everybody have an absolutely amazing, wonderful rest of your week and wonderful weekend. I'm with you there Babs. My, my cats get the zoomies at about one o' clock in the morning usually.