🧵1/6 The ‘ADHD brain’ 🧠

"I get bored easily."

"I’m easily distracted."

Why do stimuli grab the brain’s attention so easily in ADHD? 👇

Let’s explore the neuroscientific principles 👇 1/ This is tied to the salience network, which mediates arousal and reward.

In ADHD, this network struggles to regulate what’s salient (important).

Reward and arousal become key players. Here's how 👇

🧵1/5 What do we know about the Neuroscience of Love? ❤️

Let’s explore 👇

https://twitter.com/drmarkhyman/status/1870503496551715064

1/ Love and Immune System Regulation ❤️

Study:
Over 2 years, researchers profiled immune cell gene expression in 47 women in romantic relationships.

Key findings:

👉Up-regulation of Type I interferon genes (enhancing antiviral immune responses via dendritic cells).

👉Down-regulation of neutrophil-related α-defensin genes (modulating innate immunity).

These effects occurred independently of illness, social isolation, or sexual activity.

Clinical Relevance:

👉Understanding how emotions modulate immune responses opens new avenues for psychosomatic medicine. - Affective Immunology

👉 Social relationships are associated with beneficial outcomes in inflammatory conditions

“People who have supportive close relationships have lower levels of systemic inflammation compared to people who have cold, unsupportive, conflict-ridden relationships.”

🧵1/14 Is C-PTSD replacing BPD ?

Why is BPD having to look over its shoulder ? 🚨

Let’s explore this shift 👇 2/ The growing recognition of complex PTSD (C-PTSD) highlights the longstanding limitations in how borderline personality disorder (BPD) has been conceptualised-particularly its neglect of :

1.Biological

2.Neurodevelopmental factors.

Predicting Parkinson's Disease : Early Clues That Matter 🚨🚨

Key messages :

1. Men with constipation, REM sleep behaviour disorder (RBD), and hyposmia have a 23x higher risk of developing Parkinson’s Disease (PD) within 3 years.

2. A probability of prodromal PD ≥0.8 predicts a 21x higher risk of PD diagnosis. ( probability of prodromal PD based on the Movement Disorders Society (MDS) research criteria)

3. Combining key non-motor symptoms provides stronger predictive power than individual symptoms.

4. Screening these signs may help identify individuals for early intervention and PD prevention trials. Study 👉 onlinelibrary.wiley.com/doi/10.1002/an…

🧵1/ Amygdala Functioning in ASD 🚨
The amygdala in patients with ASD has been associated with abnormal face processing. 2/ Although not yet fully understood, it is postulated that the failure of the amygdala to develop during the early stages of neurodevelopment may mediate amygdala habituation in ASD (i.e., amygdala responsiveness to repeated presentation of stimuli). [Tam et al., 2017]

Three important phenomena are linked to social communication difficulties: 👇

🧵1/ Is ADHD Management Missing the Bigger Picture?

A new study sheds light on the benefits and limitations of current treatments for ADHD 👇 2/ A systematic review and network meta-analysis (NMA) evaluated the comparative benefits and harms of pharmacological and non-pharmacological interventions for adults with ADHD.

This phenomenon is one component of Abnormal Reward Prediction Processing that forms the basis of Borderline Personality Disorder (BPD) symptoms.

I use this in psychoeducation with patients 🧵1/ 👇

https://twitter.com/marklruffalo/status/1866959116712755602

2/ Prediction errors (PEs) are mismatches between predictions and outcomes.

Accurate prediction of rewarding or aversive stimuli is crucial for adaptive functioning.

Prediction error signals are crucial for directing attention, assigning meaning, and integrating internal and external information, which helps in developing and updating the brain's "internal model" of the environment.

This process is known as predictive processing.

ADHD and Anxiety - Why? Because 🧵1/ 👇

1. ADHD is not just about cognition:

👉It involves the emotional world, mediated by the salience network, which governs arousal and emotional response.

👉Dysregulation of this network leads to heightened arousal and sensitivity to uncertainty, increasing the likelihood of anxiety.

👉Dysregualtion here can also interfere with day to day activities via excessive arousal and ⬇️PFC fxn 2/ ADHD as a neurodevelopmental disorder:

👉Treatment often focuses on improving cognitive and activity dimensions.

👉Once these are managed, the emotional dimensions (e.g., flight-or-fight response) emerge.

👉For some, this unmasking leads to a constellation of symptoms that meet criteria for an anxiety disorder.

“I can focus better now but I also notice my emotions more! It make me nervous.”

Being a neurodevelopmental condition, this is more ‘anxiety provoking’ in adolescents / children who have to navigate this uncertainty along with the other demands of development

🧵 This is the iron molecule.

As a psychiatrist, an iron infusion is one of the most common interventions I implement!

Here’s why psychiatrists should know it better. Let's journey into ADHD and RLS for this thread: 👇

image: Iron complex (From Puglisi et al , 2011) 1/ Iron & Dopamine Production

Iron is critical for dopamine synthesis as a cofactor for tyrosine hydroxylase, the enzyme controlling the first step in dopamine production.

Dopamine pathways are essential for cognitive function, attention, and motor control, all areas impacted in ADHD and RLS.

🧵1/ Cyclothymia or Bipolar? ADHD or BPD? ADHD or BPAD? – Look Beyond the Labels

Formulation Time 🚀

Grab a cup of coffee, as this is going to be long. ☕️Here’s How 👇 2/ Why Formulation?:

When differentiating conditions like cyclothymic disorder, borderline personality disorder, and ADHD, clinicians often get caught in a binary mindset.

This tendency to "split" doesn’t just affect our perspective-it impacts patient treatment.

For example, with a BPD diagnosis, we may lean towards psychotherapy, often placing pharmacology on the back burner.

Conversely, with cyclothymia or BPAD 2, we might prioritise a biological treatment approach, allowing psychotherapy to take a backseat.

To truly address our patients' needs, we need a biopsychosocial approach.

This requires going back to first principles and developing a thorough formulation.

So here’s the formulation for patient X - this is what I include in my letters as well. (not all exhaustive - the art is to be able to use multiple languages to help understand the patient's issues)

🧵1/ This is the Striatal Dopaminergic Synapse

Dopamine plays a crucial role in ADHD - But it's not as simple as 'boosting" dopamine (DA) ❌

Let's explore the intricate nature of DA in ADHD management. 👇

Diagram (Wallert et al., 2022) 🧬 2/ Dopamine’s Evolutionary Role:

Dopamine is one of the oldest neurotransmitters, evolving to support movement in primitive organisms and playing a foundational role in the brain’s development across species.

Its functions have expanded from basic movement to complex cognition, making it central to our behaviour today. #Evolution #Neurobiology

🧵 1/ This is the mu-opioid receptor 🧵
It plays a crucial role in attachment, reward, social bonding and pain.
🚀Understanding Borderline Personality Disorder (BPD) as an Interpersonal Pain Syndrome 👇 1/ BPD and Pain Sensitivity: Evidence shows that individuals with BPD often present atypical pain responses, with up to 80% displaying reduced pain perception during non-suicidal self-injury (NSSI) episodes.
This phenomenon may stem from opioidergic system dysregulation, where neurobiological shifts alter pain processing in the brain.

1/ 🧵 This is your amygdala! It’s tiny-about the size of a shelled peanut at 1.24 cubic cm.

It’s the central hub of stress and trauma responses.
PTSD is one expression of the amygdala’s influence over cognitive, emotional, and behavioural domains
BUT
there’s more to it: the amygdala connects to the autonomic nervous system, hormonal systems inflammatory and even pain pathways.

So, let's explore some key aspects of PTSD 👇 2/ PTSD is diagnosed by symptoms across 4 clusters:

1. Intrusion phenomenon
2. Avoidance
3. Alterations in Cognition and mood
4. Alterations in Arousal and reactivity

The Gut-Brain Axis in Play: When Psychiatrists Treat Constipation 💩🚀 🧵1/

How I use Constipation as a Clinical Diagnostic and Management Marker ✅👇

One of the most fascinating aspects of treating depression is the intricate link between mood and the bowels.

Constipation is a very common symptom in severe melancholic and psychotic depression! ( >association with psychotic depression)

So, two things happen

1. Constipation

2. ‘Worry about constipation’ - this phenomenologically is not anxiety but is often misdiagnosed as such.

Note I am not referring to cases where addressing constipation improves mental state, treats confusion.

I’m talking about cases where long standing treatment of constipation has not shifted the bowels.

Phenomenology 👉As part of phenomenological evaluation -

I ask, "What proportion of your day do you think about this?" the answers are often 70%, 80%, even 90% of the day.

This ‘all consuming’ nature is not just anxious preoccupation BUT rather moving toward overvalued ideation. 🔥

But as clinicians, we must dig deeper-
financial ruminations, obsessional guilt, or pervasive feelings of doom are often present as well. ✅

How do we conceptualise this presentation in clinical practice and can it guide treatment? Absolutely! 1/ 👇 The answer lies in the gut-brain axis, a key player in this clinical scenario.

So what are the links between the Gut and the Brain in this scenario?

1️⃣Dopaminergic Dysfunction:
Did you know that dopamine, plays a crucial role in bowel motility?

In fact, guess which symptom often occurs early in Parkinson’s disease? That’s right-constipation.

Dopamine plays an important role in intestinal homeostasis.

Dopamine receptors, including D1, D3, and D5, are distributed in the intestinal wall- not just in the mucosa but also in the nerve endings of the intestinal wall.

Dopamine D2 receptors, are located specifically in the nerve endings within the intestinal wall. Meanwhile, the D4 receptor is found only in the mucosal layer.

When dopamine deficit states occur as in severe depression ( or many neuroinflammatory states) this can lead to reduced gut motility, resulting in constipation.

Thus , by enhancing dopaminergic activity through specific treatments, we can often see improvements in both the depression construct and bowel function. ✅

2️⃣Noradrenergic pathways :

The autonomic nervous system (ANS), which controls involuntary bodily functions like digestion, also plays a role in this process.

The noradrenergic descending pathway from the brain influences gastrointestinal motility by acting on the lumbosacral spinal defecation center.

In severe depression, ANS dysfunction may contribute to constipation, and addressing this requires a delicate balance- reducing agitation while potentiating NA to promote ANS homeostasis. 2/

The Law of Rare Events: The Suicide Prediction Paradox
Prompted by the discussion around ADs and suicide prevention and predicting suicide in general- i.e. preventing suicide events and the misunderstanding of probability. 🧵 1/ 👇
#SuicidePrevention #Psychiatry #MentalHealth Imagine we had a nearly "perfect" test to predict suicide – with 99% sensitivity and 99% specificity. Perfect right?
Well....not really!

Let's look at the surprising reality of what such a test might actually do.

First, some definitions:

Sensitivity: The ability of a test to correctly identify individuals who will suicide (true positives TP).

Specificity: The ability of a test to correctly identify individuals who will not suicide (true negatives TN).2/

🌟A Neuroscientific Voyage from Learned Helplessness to Depression 🌟

Here's a summary of my talk as an invited speaker at the Sri Lanka Psychiatry Conference / SAARC, taking the audience on a journey from learned helplessness to the complex realms of depression. 1/ 🧵 1. The Voyage to the 1960s: Was Learned Helplessness Truly Learned?

Seligman and Maier’s experiments demonstrated in animals how uncontrollable stress leads to passivity/anxiety and a cascade towards hopelessness.

Dogs subjected to inescapable shocks showed behaviours mirroring human responses to chronic stress-reduced aggression, social dominance, and exploration, along with heightened anxiety.

Below is a 10-minute video that sets the foundation for the key principles and stages of the Default Mammalian Response to Stress!

🧠 Addiction Psychiatry: The Power of Salience 🚀 🧵

1/ In psychiatry, addiction isn't just about substances like alcohol or cannabis.

It's about the brain's response to what's most "salient." 2/ Salience is what the brain finds most attention-grabbing.

When one stimulus dominates, a cascade of addiction-related behaviors can follow.

A shift from liking to wanting to seeking .

🧵 Twitter Thread: #AKATHISIA Important Points on Akathisia
🧠
1. Akathisia, derived from the Greek word "akathemi," refers to a compelling urge to move, often accompanied by a sense of inner restlessness.

2. Objective restlessness often leads to identification however 1/ 3. Subjective restlessness is equally distressing & Clinicians must rule out subjective restlessness and promptly address it, as akathisia is linked to an increased risk of suicide.

Weighing into the the ongoing debate on the existence of ADHD. Strange to me. Labels can always be debated and disproven but the underlying neuroscience ( may be incomplete) but not so easily disproved. So let's get back to neuroscience to understand #ADHD. 🧵👇 In order to understand ADHD, we need to look at the three main brain functions
1. Cognition
2. Movement & action and
3. Reward sensitivity. 1/

Relevance to GPs & psychiatrists in 🇦🇺 [webinar open for all HPs]. Up to 1/2 of patients w #longCOVID could be described as meeting criteria for CFS. Approximately 10 million Australians have had confirmed SARS-CoV-2 infection with long-term sequelae only now being defined ...1/

https://twitter.com/sanilrege/status/1623266618167160839

"To prepare the next generation of health-care providers and researchers, medical schools must improve their education on infection-initiated illnesses such as long COVID and ME/CFS, and competency evaluations should include these illnesses. [Davis et al, 2023]

Amazing news this evening! The Neuropsychiatry of Chronic Fatigue Syndrome & #LongCovid - A Practical Guide is accredited for CPD by the RACGP (7.5 hrs) over 3 evenings. Self-accreditation for psychiatrists (7.5 hrs). Coming up in May! #ChronicFatigueSyndrome #LongCovid #meded Day 1
✅Neuropsychiatry of Chronic Fatigue Syndrome
✅Pathophysiology of Chronic Fatigue Syndrome
✅ Clinical Assessment of Chronic fatigue syndrome
✅Management principles in Chronic fatigue syndrome
✅Clinical Case Study part 1 – Diagnostic aspects