Unusual Behaviour

SPEAKER_00 0:12

Hello and welcome to the Home of Medicine Podcast, a podcast in association with the Royal College of Physicians of Edinburgh. I'm Dr. Amy Burbridge.

SPEAKER_01 0:21

Hi, I'm Dr. Ben Lovell. Nice to be back.

SPEAKER_00 0:24

So, Ben, I have a case for you. Are you ready?

SPEAKER_01 0:28

Yep, go for it.

SPEAKER_00 0:29

Okay, so this is a 26-year-old female with no past medical history of note. She presented to hospital with what her friend describes as a collapse. Now I saw this patient on day four of hospital admission. But I'm gonna take you back to day one. So the friend says that they were out for lunch and they were having a really nice time. They had a really nice dinner. There wasn't any alcohol drank during the lunch. And the patient stood up, said she was going to the toilet, and didn't come back for quite a long time. And they were like, Oh, this is a bit unusual. Where is she? They went to the toilet and they found her collapsed on the floor. She was rousable, she woke up, she was not confused, but just very, very sleepy. There was no obvious cause of the collapse. The friends just say it didn't really make sense. They found her on the floor, they picked her up and they went home because they didn't know what was going on, and they put her to bed. So she lived in a household with how you know housemates, and there was four of them in total, and they put her to bed. And she woke up about seven hours later and was acting a little bit peculiar. And she took her clothes off, went out into the street. It was raining, ran up and down the street a few times. Wasn't really making any sense at all. They caught her, caught her or found her, took her into the house and called 999. Any thoughts?

SPEAKER_01 2:27

Okay. I always go to with collapses head versus heart.

SPEAKER_00 2:31

Yes.

SPEAKER_01 2:32

So let's work out if it's head or heart.

SPEAKER_00 2:34

Okay.

SPEAKER_01 2:35

Um, so found on floor. I mean it's easily revisible. What I mean by heart is arrhythmias or structural heart diseases which cause transient losses of consciousness, such as Hokum if it's uh something done on exertion. So you said that she was found on the floor and she was unconscious when they came into the toilet.

SPEAKER_00 2:53

So I tried to pin down exactly what happened, but it was really difficult to trying to it was whether it was my poor questioning or but they found her on the floor, but she was easily rousable. It was almost like she was asleep.

SPEAKER_01 3:06

Okay. So let's think of it as arithmogenic or or or postural or or structural. Um, these people pass out normally for a few seconds and they come around looking deathly pale, um, but uh are oriented and don't know what's happened. And they often describe they're being woken up from sleep, and that's how it feels to them. Um, sometimes palpitations are associated with it, sometimes chest pain is associated with it. Um, and on examination, you may find things like uh abnormal um rhythms on the ECG uh or murmurs on on a cardiac exam. So that's not only by hearts. By heads, I mean, is this epileptic? So she uh collapsed because she had a seizure and she lost consciousness. Now, these people tend to go down quickly, they tend to go, they can go down any position, standing, lying, sitting. Um, they can be unconscious for longer, they can be associated with epileptiform movements such as jerking or shaking. Um, they're difficult to rouse and they're post-ictal afterwards. Um, and colour-wise, they can go pale, they can go quite purple or sort of almost cynotic when they're having an attack. So that's what I was asked about in uh in the history from the bystanders. And the other thing it's worth thinking about with heads, just coming down the line is sort of functional things like non-epileptic attack disorder, but I I don't go there yet. Um and of course, I guess heads could also involve things like encephalitis, so a viral infection which has caused encephalitis, because that can cause um seizures or uh any kind of neurological impairment and and strange behaviours as well. So I'd be interested if there's any fevers um associated with this. Now, at the moment, I can't quite commit. She was roused easily. It happened while she was walking, um, and that sort of points towards um a cardiac issue, and she was fine, but she goes home and then she behaves strangely afterwards, and that sort of could be post-dictal, but that's after a seven hour sleep. So I'm feeling this is neurological. Um, so I'm gonna go down that road for now because there shouldn't be a cardiac cause that would make her take her clothes off, walk down the streets in the rain, and all that sort of behavior. So is she is she having temporal lobe epilepsy? Is she having did she have an epileptic um event? Do we need to scan her brain and do an EEG? Um, or has she got a central nervous system infection? Do we need to start thinking about whether MRI and a lumbar puncture are necessary? So, based on the scant information you've given me, that that's my immediate jump. And I've made I've I've done a very long lecture there, but I I normally can get there in about 15 seconds or of um of you telling me that information. That's where I immediately went to, but I it sounds slow because I'm explaining my laborious thought processes.

SPEAKER_00 5:53

Okay, so what are you gonna do?

SPEAKER_01 5:56

I want to take a full history.

unknown 5:58

Okay.

SPEAKER_01 5:58

You said no, no, you said no past medical history, but let's do a proper history, a proper med school history. Uh presenting complaint, I'm gonna get a friend either on the phone or face to face, and I'm gonna say, I want a beat-by-beat account of everything that transpired when you entered that toilet. In fact, when you arrived at the restaurant, um, I like to ask the patient, Were you fitting well when you woke up this morning? Were you all right? Or were you feeling a bit funny? Do you remember getting up, going to loo? What's the last thing you remember? What's the next thing you remember? How do you feel when you wake up? How did you bit your tongue? Did you have a headache? How do you wet yourself? I want to ask the friend, what did she look like on the floor? Eyes open, eyes closed? Did she respond to her name? What colour was she? Any weird movements? Did she get up straight away or did she sit on the floor saying, Where am I? Does she look irritable and have a headache? Sound post-ictal? So I need to interrogate both the patient and the witness so I can sort of pin down what I think's going on. And then, of course, I want to know things like drug history, um, uh uh, social history, alcohol, um, smoking, recreational drugs. And then I'm gonna do a proper head-to-toe examination, which will be a very focused examination looking at the cardiac and the neurological systems.

SPEAKER_00 7:10

Okay. So basically, you're gonna do a timeline, a very clear timeline of the history, and then you're gonna do a full systematic examination.

SPEAKER_01 7:19

Mm-hmm. Yeah.

SPEAKER_00 7:20

Okay, so I'm gonna give you some more information then. So to be fair, when I was looking at the notes, that was really where we ended from the history perspective before I saw her. And the diagnosis, and you've already mentioned it, was given of encephalitis. And she was started on intravenous acy career and hef triexone.

SPEAKER_01 7:41

Oh, okay. I have I have thoughts about that, but keep going.

SPEAKER_00 7:44

So, as I've already mentioned, a past medical history where there's nothing of note, medications, she there was nothing, nothing over the counter. She did live with some friends, and she occasionally drank herbal teas that she bought from um a Chinese herbalist, but nothing else of note, wasn't allergic to anything. Social history, as I said, she lived with housemates, she never smoked, didn't drink any alcohol, didn't take any recreational drugs at all. Um, she was working in sort of like a setup company for the internet. So I'm not entirely sure what was what it was, but I never, to be fair, really know what people do outside of medicine. Um but she enjoyed her work. Um, and that was really a slide from that. There were a few questions, so she denied fever, there was no headache, no shortness of breath, no chest pain, no palpitations, no bowel, no bladder problems. She wasn't pregnant. She'd had no carhizal symptoms previously, there was no recent infection of note, her periods were completely normal.

SPEAKER_01 8:52

Okay. I find in kephilitis a very, very reasonable diagnosis. Yeah. And starting acyclovia, I had a little wobble on keftriaxone. Me too. You know, keftriaxone is a treatment for bacterial meningitis. Yeah. Uh and she you said she's got no headache, no meningism, no photophobia. Um, um so the kefriaxone is a bit weird for me. That it that doesn't make any sense. Acyclovia, fair enough. I you can start it pending further investigations. The only thing to watch out for acyclopia, from my point of view, is that sometimes it can cause a nasty AKI in patients to keep an eye on their renal function. Yeah. But um, I think it's reasonable. However, if you're going to treat encephalitis, that then you've committed yourself to an MRI and a lumbar puncture.

SPEAKER_00 9:33

Absolutely, yeah. Um, so MRI and the lumbar puncture um weren't done.

SPEAKER_01 9:40

Um, and and also I'd like some blood tests, please.

SPEAKER_00 9:43

Oh, okay. So um MRI lumbar puncture hadn't been done by the time I'd seen the patient. Um and she was on acytic library and as I've mentioned, keft triaxone. And blood tests that had been done originally. What if I actually I'm gonna ask you, what bloods would you like?

SPEAKER_01 10:00

FBC. Normal. Um okay. I was gonna say you can see a lymphocytosis, a lymphopenia with viral infection, CRP?

SPEAKER_00 10:08

Less than three, normal.

SPEAKER_01 10:09

Uh okay. All right. Um usenese?

SPEAKER_00 10:14

Normal.

SPEAKER_01 10:15

Okay. Now, I've seen encephalitis, viral encephalitis with a normal CRP before, but it's it's not as likely. Um and you also think about um autoimmune encephalitis and uh encephalitis, which um which wouldn't cause an inflammatory response. Yeah. Um, all right then. The blood can't take us any further. Uh I'm intrigued she got to day four of both antiviral and antibacterial therapy met you, and no further tests to confirm the hypothesis of encephalitis had been done, but it's not our place to criticize because we weren't there. But I think we ought to press on and really sort of test our diagnosis now.

SPEAKER_00 10:56

Mm-hmm. Okay. So when I saw her, um, this the information that I've just given you is the information that I had. So when I see encephalitis as a diagnosis, this is a cognitive bias of mine, which I am fully aware of. The first thing I say is it's not encephalitis.

SPEAKER_01 11:16

Without I know why you say that. Because you don't want to do the lumbar puncture.

SPEAKER_00 11:21

I love a lumbar puncture, actually. But yeah, it's like I think again, that's challenging my own biases, is that I've seen one case of herpes encephalitis, herpes within my 20-year career. I've seen cases of viral meningitis, viral meningitis and viral encephalitis, and I've seen um cases of bacterial meningitis, but very few herpes associators. So I always think, oh gosh, you know, the chances of this being encephalitis are so slim, you know. Oh gosh, why was this diagnosis even given? And then I have to like check in with myself and say, Amy, this is your bias. Stop it. This could be encephalitis. So I have to be fully aware of that, of that in me. And I don't know why I do that.

SPEAKER_01 12:12

Um maybe Oh, it's because you don't see it. So you don't see it, therefore it can't really exist. I've often reassured myself when I thought to us, oh, it could be X. And I've gone, well, X is incredibly rare, Ben. It's like uh one of the rare So it really, it really won't be. And and I've used it in my own clinical reasoning before.

SPEAKER_00 12:31

I mean, could it be unavailability bias? So we talk about availability bias, where we see lots of cases, and therefore the next case we see with a similar presentation must be the same. But because I never see encephalitis, could this therefore be unavailability? It's never available, definitely can't be. Well, that's not true, is it, Amy? So I need to check in with myself. So I walked into the, she was in a side room, and I walked in to see her, and a friend was with her. And the first thing that I noticed was she was lying in bed. Let's do it about 11 o'clock in the morning. She looked very well, incredibly well. And was chatting away completely normal. She was orientated in time and place. She was able to describe what had happened perfectly to me. She knew that she was eating dinner in a restaurant, she knew that she'd gone to the bathroom, she knew that she'd collapsed, she knew that her friend had found her, she knew that she'd gone home and slept, woke up, went into the road, didn't know why, but just felt like it, and ended up in AE. She'd been told she'd gotten kephalitis and was receiving antibiotics and antivirals as we've talked, and she was able to recount all of this to me. There was something about the way that she was talking to me that was odd. Not what she was saying, but the way that she was talking. Almost a bit robotic. I know that sounds bizarre.

SPEAKER_01 14:01

Was it her affect? Was she flat?

SPEAKER_00 14:03

Yeah. Her affect was she was not like I'd say it was euthymic. You know, it was a little bit flat, actually. Yeah. So there was certainly no, she wasn't like very happy or very sad. It was just something felt odd. And you know, sometimes you see a patient and it's your gut instinct. Something doesn't fit. And the diagnosis of encapshitis, one number one, never fit for me, so I have to check in on that. But also in this case, didn't fit at all. So I started to talk to her and said, What's happened? And she said, Well, last Wednesday, um I'd been told that a close relative had died, and I booked a flight to see them. I was like, Okay, this is a bit odd. Um, and the friend said, No, there's no close relative who's who's died. It's like, okay. And I said to the patient, I said, Well, how did you find that out? And she said, Well, um the thought was put into my head.

SPEAKER_01 15:04

Uh yeah, okay.

SPEAKER_00 15:06

And I was like, Okay, what do you mean the thought was put into your head? She says, there was it was placed into my head. And I was like, Okay, what's going on here? I'm not sure. So an hour later, I was still in there trying to really figure out what was going on.

SPEAKER_01 15:21

Oh my word.

SPEAKER_00 15:22

Yeah, you know me though.

SPEAKER_01 15:23

I'm your poor resident doctors.

SPEAKER_00 15:27

You know, I could see him. The resident doctor I was with him standing, and then slowly at the end of it was sat on the floor.

SPEAKER_01 15:35

He had his own collapse, Amy. That'll be the case for next next week's episode, the collapsing resident.

SPEAKER_00 15:40

I was like, should we get you a chair? Anyway, so anyway, let's um moving on swiftly. Um, so taking a further history, it appears that actually things had started to go wrong about six months ago.

SPEAKER_01 15:54

Yeah.

SPEAKER_00 15:55

When the housemate said something was a little bit peculiar, something was odd, but they couldn't put the finger on it. And she'd been to visit the GP, and the GP had diagnosed anxiety and suggested antidepressants and referral to um a counsellor, but the individual hadn't taken up on that. And I looked at the notes and it had got documented. The individual was very concerned that people were out to get her. Which was interesting. And when I explored this a little bit more, when she was talking to me, it was like a completely normal conversation, but what she was saying was so strange, if that makes sense. So she was very lucid, very intelligent, but what she was saying made no sense at all to me. It was all very peculiar. So I thought, okay, I need to do a mental state examination here. Is this enkerphalitis or is something else going on? So what's what's going through your head now, Ben?

SPEAKER_01 17:03

Um, she's she's thrown up two features of psychosis. One is thought insertion, um, which is a sort of thought uh uh and the other one's ideas of paranoia or paranoid ideation. It is really, really tricky to differentiate a first presentation of psychosis from an organic uh CNS disorder. Yep. Um and sometimes it can be a point of a little bit of tension between the medical and the psychiatric teams. If somebody, even if somebody comes in and we look, we see them, we go, oh look, this is florid first presentation of psychosis. They've got all the psychiatric team will still say, no, you still have to do that lumbar puncture, you still have to do that EEG. And sometimes that can be a source of friction. I remember at a conference I was talking to a colleague from Germany, and he was saying, Oh, this is just routine psychiatric practice in Germany. All new psychosists that get an LP and an MRI. That's standard workup, because we don't want to be treating someone with temporal lobe epilepsy with antipsychotic medications. We don't want to be treating somebody with a CNS infection with sedating drugs. And I said, Oh, that's definitely not the practice here in the UK, but it we we do have the same fears as you. And I think we rely on, oh gosh, I suppose much more subtle, as maybe more fallible ways of differentiating organic from psychiatric disease, which is very, very careful history taking and examination and calling on the expertise of both mental health and um general physicians or neurologists to try and tease them apart. So at the moment, she she could have a new diagnosis of psychosis, and sometimes it sounds like there is this prodrome of behavioral change, which sort of leading up to it, which which uh makes you lean towards it a little bit. However, I suspect from my own experience, if I were to call the mental health team, the liaison psychiatry, and say, I think this is psychosis, they'd say, Well, hang on, get a few tests first. Where's the EEG? Where's the lumbar puncture? We're making a few bold steps here towards the diagnosis. However, I still think it's reasonable to ask them to come and assess the patient. Yeah. Because we've discussed it so many times before. A lumbar puncture is not a straightforward thing to do. It has risk, it's an invasive test. And if they come and they say, Do you know what? This pattern that she presents matches perfectly. And I can say with a lot of certainty, this is a psychiatric presentation, it means she gets out of painful invasive testing. You know? So at this point I'm thinking, yeah, CNS uh organic versus psychiatric, and I would be calling on the health team for their expertise in this situation. Uh otherwise I feel I feel she's still heading towards some more tests.

SPEAKER_00 19:37

You have just described exactly what happened in my head. I know. Um, so that exact thought process of this could still be organic or it could be psychiatric.

SPEAKER_01 19:52

Yeah.

SPEAKER_00 19:53

And there's that whole, I think as physicians, and we are so separate from the mental health team. But a lot of the things we see in acute medicine, there are mental health conditions. I would see a lot of mental health conditions in acute medicine. And I I would love it if we worked together more closely. And our mental health team and a lot of places that I've worked are often not in the same site. Um and you know, I think there's a big call, not you know, in England or however, should we all work together more closely?

SPEAKER_01 20:33

Well, this is where liaison psych was invented to try to try and bridge these silos. It's a whole self-speciative psychiatry designed to in reach to medical wards uh and and and support this. Um, I suppose it's not as available in every every hospital as as it is in others.

SPEAKER_00 20:52

Yeah, absolutely. So, on further questioning, the patient said that she saw visions within the room, and the visions were trying to tell her something. And they were telling her all sorts of things about family members, about people, about herself. She was also seeing parts of Greek mythology within the room that were talking to her and telling her things and inserting thoughts and feelings into her head. So I automatically jumped to this is psychiatric. I've never known this happening, keephalitis, ever. Again, another mistake that I made there. Or not necessarily a mistake, but a bias of mine that I was like, I anchored onto the first piece of information, thought, no, this cannot be organic. So I examined her, her observations were normal. So blood pressure 120 over 70, heart rate 96, temperature 36.9, respiratory rate 16, saturations 96% on room air. Her ECG was composed. Completely normal. CT head was normal as well. Mental state examination. Mood-wise, a little bit flat. She was dressed appropriately. She was lying in bed. She was describing thought insertion and paranoid delusions. There was also some auditory hallucinations. She said that she some possible visual hallucinations. And that was really where I got with my mental state examination. And she wasn't delirious. She was orientated in time and place.

SPEAKER_01 22:45

I mean, the other thing worth remembering is that psychosis is so much more common than autoimmune encephalitis. So, in terms of pretest probability, I think what I'd what I'd actually do, I might get an MRI as a non-invasive test and similar simultaneously speak to mental health. If the MRI shows, you know, inflammation of the temporal lobes in keeping with viral encephalitis, that would be very telling. An MRI would be normal in an autoimmune encaphytic process. But I think I'd speak to Leas on psych and think about MRIs at the same time. However, I I think we're going to struggle not to LP her.

SPEAKER_00 23:23

What's on your differential list at the moment?

SPEAKER_01 23:26

Encathalitis, virally autoimmune versus first presentation of a psychiatric disease such as schizophrenia.

SPEAKER_00 23:33

Okay.

SPEAKER_01 23:33

Have I missed anything else? I suppose temporal lobe epilepsy is floating in there as well. And EEG, that's relatively non-invasive. Yeah. Okay. EEG, MRI, uh and a cycliaison review, I think, is a reasonable list of things to do.

SPEAKER_00 23:48

How easy is it for you to get an EEG?

SPEAKER_01 23:52

And I've got to say, in my trust, relatively painless. Um, usually we get them within one working day, a bedside EEG. Only Monday to Friday night, 9 to 5, but um, depending on the busyness. I think um our ITU uses them a lot for um various ITU reasons. Um, you know, check check for patients who are unconscious and ventilated. So there is a service.

SPEAKER_00 24:18

Okay, so I you don't. Yeah, yeah, absolutely. And I think it depends where you work, but um, I'm gonna be entirely honest here. Um my diagnostic momentum at this point was psychosis. And I'd written in the notes this is not encephalitis, stop antibiotics, um, no need for LP, refer to nuclears and psychiatry. I don't know whether that was right or wrong. Um so it's a really difficult one. I mean, I think I was thinking about the differences between encephalitis. How does encephalitis present and how does psychosis present? So with encephalitis, you often can have a delirium, fever, you might have autonomic dysfunction, blood pressure changes, heart rate changes, seizures, there may be a rash, there may be a headache, there might be a fever. Um and she had none of those. And somnolence is often a problem as well, and sleepiness. Again, she had none of those, whereas psychosis, the delusions, the hallucinations seem to fit a little bit more with that. So I boldly, whether right or wrong, said stop everything.

SPEAKER_01 25:39

Yeah.

SPEAKER_00 25:40

Speak to the Ase on psych. Section 5.2.

SPEAKER_01 25:43

Yeah.

SPEAKER_00 25:44

One-on-one, um, sort of observation. And at this point, I hadn't thought of autoimmune encephalitis.

SPEAKER_01 25:52

It's so rare. What is the prevalence? Like five in a hundred thousand or something autoimmune enfylitis. It's such a and you know, you can even get zero-negative autoimmune encephalitis. So even so you can work them up. Nothing comes back on the immunological testing, but there's something going on. It's such a um a nebulous diagnosis for us to make in a general medical ward or an acute medical unit. Really, really tough.

SPEAKER_00 26:18

It is. But when I hear about diagnoses of autoimmune encaphylitis that weren't made early enough, it's always because of the awful things that has that the patient has experienced because of that late diagnosis.

SPEAKER_01 26:32

Did you get her to draw a clock face?

SPEAKER_00 26:34

No.

SPEAKER_01 26:35

I remember reading a case report about how this might I have not looked this up, but um uh uh someone who went to system several times presenting to uh EDs with all sorts of what sounded like psychiatric problems, and it and then eventually they asked her to draw a clock face and draw the time at 10 to 2. And she drew it, and all the numbers were down once. It looked bizarre. And I remember seeing the how she drew it, and they're like, oh, your perception's gone screwy. You, you're you're you've you your neuroperception, and that's how they first thought, actually, maybe this is a neuropsychiatric problem. So I do ask them to draw clock face. I haven't seen it in my own personal uh experience, but I asked them to draw a clock face now with a time on it, um just in case that throws up anything interesting.

SPEAKER_00 27:17

Oh, well, that's I do know that's something in my brain is reminding me of that, but I don't, I've never done it. So autumn encephalitis is NMDAR encephalitis, isn't it? It's when you've got antibodies to N-methyl D aspartate receptors, and these are essential for learning and memory. So I guess what you're saying about the clock face would fit actually for not being able to remember how the clock face goes or or the memory changes or ability to learn new things. However, I didn't think of that, Ben. I'm gonna be completely honest, that wasn't in my thought process at the time. And I spoke to a lovely, fantastic liaison psychiatrist, and they did a Mental Health Act assessment on her that afternoon. And the diagnosis was acute psychosis, and um, they started her on some antipsychotic medication, and she was taken to the uh to be an inpatient. Now I guess this conversation that we've had and um my reflection that I've done over the last sort of few months has sort of led me to think should I have LP'd her? Should I have done an EEG? And you know, I should I have thought more about organic causes instead of being very rigid about this is not encephalitis, it is psychosis. Did I put my diagnostic anchor down too soon?

SPEAKER_01 28:49

I think people appreciate decisiveness. Um patients do, colleagues do, our resident doctor colleagues do, they want a clear direction, and I I often do sometimes feel the push to be decisive. Sometimes that push comes on us in the sense of, let me just say, for example, we've spoken to psycholiazo and they will not see until the medical team have ruled out organic problems, and that leads us to write very strong statements like this is not organic, this is clearly psychiatric, with all the best intentions. I think that I don't know how I feel about my German colleagues' perception that the general workup for psychosis is a lumper puncture, EEG and MI for everyone. I don't think we're built for that, we're not resourced for that. I don't know if that's patient focused. I don't know if that would provide us with more useful diagnoses with their left with few side effects, or or are we willing to give a few people, you know, epidural hematomas and post-LP headaches in the name of our total patient safety. I don't know the data on that. Um I remember a case of someone I saw in the psych area of our ED, where they put patients who are who need careful security presence and a one-to-one. And they said, psych of RC2C to rule out organic problems. And I met this young man who was, to me, floridly psychotic. He was saying, The security men are talking about me, they've got it in for me. Maybe they did, they've got it in for me. People are um, people are plotting against me, they're all after me, they're all out to get me. And he was sweating and looked really agitated and was pacing the room. And I came out and said to my SHO at the time that, oh, this is clearly, clearly psychiatric. And I wrote something similar to you. Um, this absolutely is not going to be um this is an index presentation of psychosis. This is not gonna be anyway. I can't remember how, but they ended up scanning his head and he had a spontaneous subdural hematoma. And I've never seen a subdural present a psychosis before, and that really threw me for a loop. Um, and maybe that's why my caution in this case today, and I'm doing some more tests, is based from that previous case, but yes, because I felt like a fool, to be honest with you. Um that was me saying, absolutely not, stop this, stop that, go to psych. This is this man does not come to the AMU because this is not organic. And it turns out he had a new neurosurgical problem. So that's maybe drawn this my view a little bit of how I work up new psychosis. What I'd be super interested in is what happens to the people who present de novo with psychotic illness who don't come to the medical take. Yes. What happens to them? Who where do they go and who makes the the call? I presume they're presenting their GPs with subtle personality changes and the GPs are referring to psychiatry. Are the GPs holding all that risk? Are the GPs the ones saying, oh, don't bother Ben down on the acute medical take because this patient doesn't need an LP and an A kind of imaging? I'll send him off to psych. And presumably that model works because I haven't heard anything to the contrary. But but I the ones who come to the medical take will get over-investigated, and there is harm associated with that. And I suppose we're trying to walk this sort of very imperfect balance of being as safe as possible whilst keeping an open mind.

SPEAKER_00 32:17

Yeah, absolutely. And when you when you're saying all that, I'm like, oh God, I should have done an LP. Um, I don't know. We always see cases that will challenge us um and make us question and reflect on what we did well and what we can do better next time. And I think the important thing about cases like this is being a reflective practitioner. And I know that we're both very reflective, and I have reflected on this case a lot and gone, okay, if I was to see this individual tomorrow, what would I do differently? Would I do anything differently? Because I think I've talked before about how slow I am, but I spent about two hours thinking about this case. It's not like I just went, oh, stop everything, refer to psych. You know, I really did spend a huge amount of time with a patient and the friends, speaking to lots of different people, you know, gathering information from lots of different places. It wasn't like I just got nah, stop everything. So I it was, I think it was quite a thoughtful process that I went through rather than um very quick. Um I don't know.

SPEAKER_01 33:23

And it probably was the right diagnosis. You haven't heard anything to the contrary, have you?

SPEAKER_00 33:27

Not yet.

SPEAKER_01 33:28

No, no. So it probably was the right diagnosis. And I think it's important that distinction that you're making is that there's a big difference between misdiagnosis based on poor effort and not thinking it through arrogance, whatever, and and a misdiagnosis based on just miscalling something because it was a zebra, it was a rare thing, and uh you thought it was the right board. I mean, this is the deal with the devil that we make of being doctors, isn't it? We have to we have to take a little bit of risk. And diagnosis ultimately is hypothesis testing, and we have to create a hypothesis and then test it. And it sounds like you tested yours. You tested yours well, and you're saying, I've tested it differently. Yeah. But um, again, I think we need to be wary of that kind of previous case bias where we say, do you know what? All these patients now are getting lumber punctured, and that's the end of that. Because it's not fair to stick needles in every patient's back because you have um, not you, but because one has a risk aversion. That isn't fair on patients. That's on us.

SPEAKER_00 34:29

Yeah, you're absolutely right. And yeah, it'd be interesting to see um if I get an individual with exactly the same presenting complaint, would I do it anything differently? I don't know.

SPEAKER_01 34:42

Um Do you think that your colleague in the uh liaison psych team, what do you wonder they would have said if you'd said to them, I don't think this is organic. I'd appreciate your review and tell me whether you think this patient needs further testing to rule out organic disease. Or do you think that's an invitation for them to say, yes, they do, please, please do more tests.

SPEAKER_00 35:08

Yeah, that's I'm not entirely sure because when I spoke to them, I was very much of this is not organic. I have done this, this, this, this, this. I have ruled this out. I am happy this is not organic. I truly believe this is a non-organic cause of the presentation, and I'd really appreciate your help. Now, actually, I guess from their perspective, they could have come in and gone, what is she talking about? This is clearly organic and requesting more tests, potentially.

SPEAKER_01 35:37

Or they might have read your referral or whatever or received it, and as a team thought, it sounds like they haven't fully investigated this patient, medically speaking, yet. Please call us back when you're sure. They might have said that. And that would have pushed you, say, okay, now I'm sure. So so it's about it's a bit about the interaction and the interface between specialties which influence our behavior because we want to get what we think is the right thing to happen. Yeah.

SPEAKER_00 36:04

It does make me think, though, did I sell the case to them? The diagnosis that I wanted to get, you know, that framing effect, framing bias.

SPEAKER_01 36:13

Yeah, we're all in the business of selling. Just speak speak speak to the poor radiologist who's taking all these referrals. The way we the way we present data to get the scan we need or we think we want. I don't know. Uh, and I think everyone sort of knows it happens. Maybe that's another episode.

SPEAKER_00 36:29

Absolutely. So just one final thing. Um, yeah. The patients and and our friends did say that they regularly drank tea from um a local Chinese herbalist.

SPEAKER_01 36:39

I wondered why you mentioned that.

SPEAKER_00 36:41

Yeah, I was reading about this today. Um, and there is a frequent medicine that is included, not frequent medicine, a frequent sort of herbal or herb that is included in Chinese tea called Ma Huang. I've probably said that wrong. It's also known as ephedra sineca.

SPEAKER_01 37:00

Ephedra sounds like ephedrine to me.

SPEAKER_00 37:02

Yeah, absolutely. It's it's part of that family. Um because it's an ephedrine-containing product. Right. Um, and I don't know whether we can still get this, but uh whether it's still available um in shops. However, um it's usually it's native to Mongolia, northern China. It's a shrub. Um, and it contains alkaloids, including ephedrine. It has been banned. Ephedrine's been banned from the market in the EU, US, and lots of other countries. But I don't know. One of its side effects is psychosis.

SPEAKER_01 37:41

So it's available in Mongolia and Northern China. And I think that um it's not available in in India, but you know, people visit. Ephedrine, you can buy in the UK, can't you? It's in the superfed behind the counter. Yeah. And it's a drug of abuse, and it can be turned into other naughty drugs and things like that. And I see case, so I know it's not effigrene, but I've seen cases of people with undiagnosed um or pre-diagnosed psychiatric conditions who start taking um the medications you take for ADHD, um, like rental and etc. And that has unmasked psychosis. Um, I've seen that before. And they say he was struggling, he was struggling, he was strange, his personality was a bit different, he wasn't sleeping. He went to a private consultation, they diagnosed AHD, they gave him this, and then everything went wrong and he went psychotic. And I've seen it unmask or accelerate previously undiagnosed psychiatrists. I wondered if Ephedrin might have the same, same sort of effect. If taken in a I mean, how much tea she was drinking, I don't know. But if it was taken in uh in excess, and maybe it didn't help.

SPEAKER_00 38:44

Yeah. I mean it's got it's probably got nothing to do with that, but I just read about it and I thought, oh, that sounds interesting. It just made me think about other medications that can cause psychosis and think about steroids, St. John's wart, you know, some of the anticholinergic. So always when the St.

SPEAKER_01 38:57

John's Wart? Yeah.

SPEAKER_00 38:58

Is that quite yeah?

SPEAKER_01 38:59

Is it anticholinergic? I never knew that.

SPEAKER_00 39:01

No, no, it's not an anticholinergic, but St. John's Wart can also contribute towards psychosis.

SPEAKER_01 39:06

Blimey, they don't put that on the bottle, do they?

SPEAKER_00 39:08

Oh, exactly.

SPEAKER_01 39:09

Oh, we're gonna get sued now. Big farmer.

SPEAKER_00 39:12

Don't say that. Um, we've got no money. Um, okay. Loads of learning points here. Um, I still haven't quite got to get up to the case. Um, what I do want to say as well is obviously we discussed the case in huge detail. I have changed some of the patient identifiable factors and some of the story within that case to ensure that um it's non-recognizable.

unknown 39:37

Okay.

SPEAKER_01 39:37

Good.

SPEAKER_00 39:38

Yeah. Okay, so um, thank you very much, Ben.

SPEAKER_01 39:42

Thanks. I enjoyed that conversation. That was an interesting case.

SPEAKER_00 39:45

Interesting case, yes. Absolutely. Thank you to everybody at there who listens to the Home of Medicine podcast. Please rate, review, and subscribe to the podcast. And please, please, please leave us reviews because when we get a review, it increases the number of people who see our podcast on your podcast listening platforms, and we can get more listeners. Thank you for listening.

SPEAKER_01 40:08

Bye.