16.3 Encephalitis: Interview with Jaime Shoup, MD

[00:00:00] [SPEAKER_01]: All right, so I have back today for the first time on video, Jaime Shoup, trained with Jaime in medical school.

[00:00:12] [SPEAKER_01]: He went into neurology, I went into psychiatry, but Jaime is one of the most intelligent and best critical thinkers that I know.

[00:00:21] [SPEAKER_01]: He is able to synthesize so much information, but he's also extremely nuanced and has a great appreciation for the massive swath of unknown out there.

[00:00:38] [SPEAKER_03]: Somebody get this guy some help!

[00:00:48] [SPEAKER_01]: You're super inquisitive and you really just have a passion for learning and understanding whatever it is that we're treating.

[00:00:58] [SPEAKER_01]: You know, and trying to just uncover more and more pieces of the puzzle over time.

[00:01:05] [SPEAKER_01]: I'd very much appreciate the warm introduction.

[00:01:11] [SPEAKER_03]: Yeah, that's fantastic. I'm happy to be back. We're going to be talking about some stuff light us today.

[00:01:17] [SPEAKER_01]: Yeah, so when I actually had my probable future brother-in-law, Jolly, I had him on the other day to give his kind of patient perspective.

[00:01:29] [SPEAKER_01]: And just so you all know, when this all went down at the end of May, Jaime was one of the first people that I called.

[00:01:36] [SPEAKER_01]: And so Jaime helped me through it, but before we get all to that, catch us up on where you're at and what you're doing.

[00:01:44] [SPEAKER_03]: Yeah, so I finished my epilepsy training going to be starting at the autism center here next month.

[00:01:53] [SPEAKER_03]: And also practicing pediatric epilepsy, focusing more so on the refractory cases, the more challenging epilepsy cases in combination with autism.

[00:02:05] [SPEAKER_03]: So really excited and then get to kind of springboard my research career in that regard. So there's a lot of exciting things happening.

[00:02:17] [SPEAKER_01]: Yeah, absolutely. And you've had for the first time in several years, you've had a couple of months off of work, right?

[00:02:25] [SPEAKER_03]: Yeah, I don't know what to do with myself. The house is really clean.

[00:02:30] [SPEAKER_03]: I've grown a garden, have nice herbs growing, a bunch of basil and got some hobbies.

[00:02:39] [SPEAKER_03]: I got to fill my time with something still researching a lot. Kind of just read for fun.

[00:02:45] [SPEAKER_03]: It's amazing that we have them right at our fingertips. Any question you have, you can, you know, really feed into.

[00:02:52] [SPEAKER_03]: So it's been a good time. Been able to hang out with my kids.

[00:02:57] [SPEAKER_03]: Yeah, there are now eight, five and one and a half. And it's yeah, amazing being able to see them grow and get this time to spend with them, you know?

[00:03:10] [SPEAKER_01]: I know it's like, it's like kind of sad even, you know, my mother not even won and just turned two and I'm already thinking about, you know, the future and how they're not going to be babies in.

[00:03:22] [SPEAKER_01]: And it's like, I know my son the other morning came running into the bathroom. I was in the shower and he just rips his clothes off. I'm getting in the shower with that.

[00:03:33] [SPEAKER_01]: I'm like, man, he's sitting on my lap and they're like, man, it's just going to be a few years before he's like, yeah, I don't want to do that anymore.

[00:03:41] [SPEAKER_01]: No, it's really like, when he comes in there and gives me a big kiss and he just like, you know, it really softens your heart.

[00:03:49] [SPEAKER_01]: But of course, the human mind loves to look at the all the problems that are coming in the future, including the inevitable and unyielding problem that your children will grow up.

[00:04:04] [SPEAKER_03]: And it's, it's very quick and each stage to think you have all the time in the world but they've got this gone and you look back here like, oh my gosh, you're a little kid now. Oh my gosh, you're a teenager.

[00:04:17] [SPEAKER_03]: You hate me all the sudden.

[00:04:19] [SPEAKER_01]: I remember when he used to sit on my lap in the shower.

[00:04:26] [SPEAKER_01]: It's like, Dad, you're so weird.

[00:04:30] [SPEAKER_01]: Oh, man. Well, anyway, yeah, no, it is exciting. I'm excited for you. We are here to talk a little bit more about in Sepulitis.

[00:04:41] [SPEAKER_01]: Just as a background, so you are in the know I have talked to Jolly who experienced it. I've also talked to a guy named Philip Briton. He is an Australian encephalitis researcher and is pretty widely known in that circle around the world.

[00:05:02] [SPEAKER_01]: He focuses more on pediatric encephalitis. So we've talked a little bit, he's given some overview.

[00:05:11] [SPEAKER_01]: So we're not coming in totally blind but I wanted to have a sit down with, you know, my local neurology expert.

[00:05:19] [SPEAKER_03]: Yeah, and I've seen patients, several patients with, you know, encephalitis, encephalitis is pretty broad, right?

[00:05:27] [SPEAKER_03]: It basically breaks down into your brain as inflamed. It's a catch-all for a lot of different conditions, whether it be infectious, autoimmune, whether it be, you know, through other mechanisms that seizures can lead to you having a kind of encephalopathy, but there probably is some type of encephalitis that occurs with a good fraction of seizures.

[00:05:56] [SPEAKER_01]: And because you have toxic byproducts and then the immune system, the neuro immune system is trying to clean up those toxic byproducts, right?

[00:06:07] [SPEAKER_03]: And so how the astroglyl network gets remodeled, following acute symptomatic seizures is a big part of this.

[00:06:28] [SPEAKER_03]: Yeah.

[00:06:29] [SPEAKER_03]: And so there's a lot of doctors that kind of lead towards the cooling off of the immune system once the job's done, that it doesn't occur the same in every person.

[00:06:40] [SPEAKER_03]: And some people, it stays on longer and it leads towards more hyper synchronized networks that leads towards more epilepsy.

[00:06:49] [SPEAKER_03]: You're now having seizures without the provoking cause of the initial injury.

[00:06:53] [SPEAKER_03]: Yeah. Whereas there are, you know, immune responses that can occur based off of how we live after we have an acute symptomatic seizure.

[00:07:06] [SPEAKER_03]: And so, fascinating experiment in this was is from a doctor in Nebraska.

[00:07:15] [SPEAKER_03]: She looked at mice and used kinate, which is a seizure inducer to induce these symptomatic seizures.

[00:07:23] [SPEAKER_03]: And then they checked information markers in the brain immediately after and then also, you know, sometime later kind of seeer early over a week to two weeks up to three months afterwards.

[00:07:36] [SPEAKER_03]: And what they did is they took some of those mice, put them in a cage by themselves.

[00:07:44] [SPEAKER_03]: Had their necessary resources but didn't have a way to exercise, didn't have other mice.

[00:07:50] [SPEAKER_03]: Yeah.

[00:07:50] [SPEAKER_03]: And then took mice, put them in a great environment, had socialization, had, you know, everything that they needed spiritually in a sense.

[00:08:01] [SPEAKER_03]: Yeah.

[00:08:02] [SPEAKER_03]: And what they showed is that the inflammatory markers in the isolated mice persisted for weeks and weeks and weeks afterwards, and those same mice developed epilepsy.

[00:08:16] [SPEAKER_03]: And so, we're as the other mice didn't.

[00:08:21] [SPEAKER_03]: There's went quickly down and that's with the same diet and same diet, same, the only changes what they were doing with them.

[00:08:30] [SPEAKER_03]: They were gentling them also.

[00:08:32] [SPEAKER_03]: So you take a mouse out and you pet it.

[00:08:34] [SPEAKER_03]: Release is oxytocin for the mouse, right?

[00:08:37] [SPEAKER_03]: Same with just, but they're similar to us and so it shows that what we do after acute injuries, right, has a huge effect on how our brain kind of rewires afterwards and how chronic states of dysfunction can occur following acute and cephalitis.

[00:09:00] [SPEAKER_03]: Yeah.

[00:09:00] [SPEAKER_03]: So, what are the other types of cells that are in the brain?

[00:09:02] [SPEAKER_01]: It reminds me a little bit of the rat park studies in addiction.

[00:09:07] [SPEAKER_01]: How, you know, rats in this isolated environment which was how we study addiction for a long time and we've talked to another podcast about how the rat park experiments were hard to replicate and they there may have been problems within that research by itself.

[00:09:23] [SPEAKER_01]: But it showed that the mice or the rats who were surrounded in like an amusement park with other rats and things to do and social encounter, they didn't rely nearly as much on the drug as much as the rat that's sitting in isolation.

[00:09:43] [SPEAKER_03]: Exactly.

[00:09:44] [SPEAKER_01]: I thought that mind blowing is up.

[00:09:45] [SPEAKER_03]: And it, and it, I think it speaks a lot to kind of a neurobiologic facet of being epilepsy. You know, that's almost the furthest extent of a brain hypersynchronization.

[00:09:59] [SPEAKER_03]: Right. That's the complete breakdown of the kind of individual networks that allow for the diversity of behavior, right?

[00:10:08] [SPEAKER_03]: And so that's very damaging, but in a kind of similar type of way the throughput of that energy.

[00:10:18] [SPEAKER_03]: If it's only focused in specific pathways leads a lot of times towards a disease state over time and it's, you know, behavior plays a role in that right?

[00:10:29] [SPEAKER_03]: And how we interact with our environment afterwards plays a role in that.

[00:10:33] [SPEAKER_01]: That is a fascinating study because I mean, it makes a lot of sense when you talk about addiction.

[00:10:39] [SPEAKER_01]: But I wouldn't intuitively think, I mean, I wouldn't think the opposite, but I wouldn't intuitively think, oh, like I need to make sure that I have appropriate social engagement as a form or as a part of my recovery.

[00:10:55] [SPEAKER_03]: Yeah. And what's interesting is our drives change with the inflammatory systemic state.

[00:11:04] [SPEAKER_03]: So in a systemic and flamed state, our oxytocin systems don't work as well.

[00:11:11] [SPEAKER_03]: They don't go to the brain as much the oxytocin doesn't.

[00:11:15] [SPEAKER_03]: So you aren't motivated by socialization because in a kind of primitive sense, that's how you walk down if you're infected, right?

[00:11:23] [SPEAKER_03]: Yeah. And so what happens though is that system is sensing a lot more than just tissue breakdown, right?

[00:11:33] [SPEAKER_03]: If your brain gets inflamed, the aster sites start breaking down sometimes and start releasing S100 beats.

[00:11:42] [SPEAKER_03]: And that causes this pro-inflammatory effect that leads to NFK beta.

[00:11:48] [SPEAKER_03]: And so the NFK B is kind of this linchpin, a part of that and it starts changing the genetic signaling towards producing Iol 1 beta and Iol 6 and TNF Alpha.

[00:12:02] [SPEAKER_03]: And you don't need to explain the story markers.

[00:12:03] [SPEAKER_03]: But exactly. It's just inflammation and it's telling your system that hey, we got to fix things. We got to fight against it.

[00:12:12] [SPEAKER_03]: And the thing is our brains rely on these cells in a normal sense for other things, right?

[00:12:19] [SPEAKER_03]: We need to have our microglia and our aster sites working just for normal functioning, just to learn appropriately, to remodel the network so that it's energetically

[00:12:32] [SPEAKER_03]: Optimized. That's the important part is it our brain takes a ton of energy. So it really does have to couple with our immune system and our understanding of our environment, how much food we have,

[00:12:47] [SPEAKER_03]: How much resource we have in our body, the stores like it's interfacing so many signals to try to figure out this is what this person's supposed to do right now.

[00:12:57] [SPEAKER_03]: Yeah, right? That this person, oh, this person's actually good to have babies now. Oh, this person is not in a place to have babies now like that's going on in our neuro immune kind of system.

[00:13:11] [SPEAKER_03]: Yeah, I don't know. I think it's it's fascinating how you can find different signals or different kind of shapes forms different markers.

[00:13:27] [SPEAKER_03]: Yeah, different markers, biological markers of of how the systemic diseases of endocrine dysfunction kind of trace back to hypothalamic dysfunction.

[00:13:39] [SPEAKER_03]: Yeah, right? How PCOS for instance is part of that.

[00:13:44] [SPEAKER_03]: I think it's a really holistic and holistic, really holistic, really holistic.

[00:13:45] [SPEAKER_03]: Yeah, we are so much more integrated with our system than I think we realize and how much is kind of out of our control to in that inner facing.

[00:13:57] [SPEAKER_01]: Yeah, absolutely. I told you he was smart. So in terms of that kind of post acute recovery from something like encephalitis.

[00:14:08] [SPEAKER_01]: If you got it, what kind of treatment plan would you develop for yourself?

[00:14:15] [SPEAKER_03]: Yeah, that's a great. I think willfully putting yourself back into normal routine things that you do is really important surrounding yourself with people who

[00:14:30] [SPEAKER_03]: Maybe you don't have the drive to socialize, but just being around other people now granted you're not infectious at this time. You're not in a place where it's a problem, but just once you get to that recovery phase

[00:14:45] [SPEAKER_03]: really working with other people as part of that network, you know, they can help rebuild your body because the sense is that, hey, I'm in a stabilized network.

[00:14:58] [SPEAKER_03]: It is a good time for me to recover or still and it's amazing how biologically we have signals to say that.

[00:15:06] [SPEAKER_01]: Yeah.

[00:15:07] [SPEAKER_03]: Diet is a huge part.

[00:15:09] [SPEAKER_01]: A huge part of recovery for anybody.

[00:15:11] [SPEAKER_01]: Would you recommend like with pretty much every other condition in medicine and psychiatry? The Mediterranean diet?

[00:15:18] [SPEAKER_03]: Yeah. And I think the Mediterranean diet has a big, big upside because it minimizes the kind of carbohydrate load in a way that allows for less inflammatory signaling from our micro biome.

[00:15:35] [SPEAKER_01]: Yeah. And you had mentioned that earlier before we started recording how we have so much added sugar in so much of our food that that sugar attaches onto our proteins where it really is not supposed to be in that high quantity or frequency and then it creates a more of a vicious inflammatory cycle exactly.

[00:16:00] [SPEAKER_03]: And so we see this specifically with diabetes which you can use as a model of excessive glucose, right?

[00:16:09] [SPEAKER_03]: Glucose just by virtue of being around things can react with our proteins, particularly lysine likes to do this one of our amino acids.

[00:16:19] [SPEAKER_03]: And when it does that, that protein no longer works like it's supposed to. And our bodies have to figure out how much of that is occurring in order to kind of repair the things that are going on, right?

[00:16:34] [SPEAKER_03]: Yeah. And so if there's too much though and there's too much backup in your metabolic pathways, then you end up getting basically this inflammation that occurs at different levels in the body.

[00:16:48] [SPEAKER_03]: The microbiome are gut being a big component of this right? And signaling there then can kind of everything that gets broken down there becomes a chemical that gets taken up and ultimately changes the substrate for our brain and for our system, right?

[00:17:08] [SPEAKER_03]: Yeah. And so our fats for instance, they get broken down into these short chain fatty acids, buterate, propryinate and acetate, okay?

[00:17:21] [SPEAKER_03]: And these go to the brain and they have real effects on our astrosights in our power, microglia function. They change how our liver expresses genes.

[00:17:39] [SPEAKER_03]: And the thing is there are other markers that we use too, but this is just the fat component of our diet.

[00:17:46] [SPEAKER_03]: And different bacteria in our gut break down fats differently. So you are not just one type of bacteria in your gut.

[00:17:58] [SPEAKER_03]: There's lactobacillus, there's bifidobacterium, there's clastridiums, there's all these different species and they all break things down differently.

[00:18:09] [SPEAKER_03]: So what you feed them determines the community that you have.

[00:18:14] [SPEAKER_01]: You got my brain going with, and it's such a simple idea that all of our systems are interconnected.

[00:18:22] [SPEAKER_01]: Even though we do an autopsy or we are in the the cadaver lab in medical school and we dissect one part at a time.

[00:18:31] [SPEAKER_01]: But you had me thinking about all the way back to organic chemistry and I had a professor who would talk about how and why diet coke and these essentially fake sugar can be so harmful to us.

[00:18:48] [SPEAKER_01]: But he focused his conversation on the increased risk of colon cancer because these huge bulky, you know, 14, 16, 18 sugar molecule compounds are a disaster for the body to break down.

[00:19:05] [SPEAKER_01]: Whereas to give a comparison for the viewers listeners, something like fruit which comes from the term fruit dose, which is two sugar molecules connected together that is so easily cleaved early in its digestion, creating energy that is readily accessible.

[00:19:24] [SPEAKER_01]: And you're not going to have to do a lot of work after that to access it. You just got me thinking about these fake sugars or things that, you know, don't ever get into the brain but they instigate.

[00:19:40] [SPEAKER_01]: The information that does not just stay specifically in the gut.

[00:19:45] [SPEAKER_03]: No, and it has downstream consequences to how the brain functions.

[00:19:50] [SPEAKER_03]: Different species are much better at breaking those things down than others, right?

[00:19:56] [SPEAKER_03]: And what ends up happening is you feed them.

[00:19:59] [SPEAKER_03]: And if you're eating just that source, that population takes over and you get a bacterial overgrowth within a specific type.

[00:20:09] [SPEAKER_03]: Now what's interesting is each biomolecule that we have kind of ties to specific bacterias and clostridium is, or sorry, not clostridium, candid.

[00:20:23] [SPEAKER_03]: So fungal spores as well, fungues also plays a role in this as well.

[00:20:30] [SPEAKER_03]: But lactobacillus is one that is found organically in breast milk.

[00:20:37] [SPEAKER_03]: It's a very important kind of initial colonizer, right?

[00:20:42] [SPEAKER_03]: The first bacteria that we get from our mom come through the vaginal canal and then our diet and the milk microbiome that is kind of being produced.

[00:20:53] [SPEAKER_03]: So even the establishment of the microbiome after that will shape that person's relationship to their kind of environment for the rest of their life.

[00:21:04] [SPEAKER_03]: Yeah, which is fascinating.

[00:21:07] [SPEAKER_03]: Yeah, that something as simple as breastfeeding which all mammals do, right?

[00:21:12] [SPEAKER_03]: Something very important to our evolutionary tree and kind of makes us different than the rest of the animal kingdom, right?

[00:21:23] [SPEAKER_03]: It starts with the microbiome getting established and then lactobacillus actually tells the end parasites to produce oxytocin.

[00:21:36] [SPEAKER_03]: The small intestine cells.

[00:21:38] [SPEAKER_03]: Yeah, the small intestine cells.

[00:21:40] [SPEAKER_03]: Sorry, I got you.

[00:21:42] [SPEAKER_03]: The small intestine cells start releasing oxytocin.

[00:21:47] [SPEAKER_03]: And that process changes behavior.

[00:21:51] [SPEAKER_03]: So even something on the level of changing your gut is having a huge effect on your brain and how you learn how to interface with your environment for the rest of your life.

[00:22:01] [SPEAKER_01]: Yeah, that's incredible and it's just I have fun talking to you because you know you send me down those roads of thought of things that I'd never kind of put together before.

[00:22:15] [SPEAKER_01]: That that downstream inflammation in the gut can also create inflammation in the brain because we're all connected and you're responding to markers and exactly exactly.

[00:22:29] [SPEAKER_03]: And we have mechanisms to try to kind of compartmentalize things, right?

[00:22:35] [SPEAKER_03]: We have in a healthy system are got tries to have tight junctions tries to make it so that hey,

[00:22:43] [SPEAKER_03]: you're a lot of the bacterial products LPS being one of those like popolosaccharide, which is found mostly on E colis and gram negative type of bacteria but it was evolved to once that gets into our system.

[00:22:59] [SPEAKER_03]: Inflammation like we need to fight that off. That is not in the right place, right?

[00:23:04] [SPEAKER_03]: Yeah, which also has effects on the microglial activation and LPS has a huge effect you get sepsis.

[00:23:14] [SPEAKER_03]: That's going to change your behavioral pattern simply by that inflammatory response.

[00:23:19] [SPEAKER_03]: Gaba, which is our kind of main inhibitory neurotransmitter.

[00:23:24] [SPEAKER_03]: Yeah, it breaks on the brain. Yeah, the breaks on the brain. It comes from a very specific bacteria.

[00:23:31] [SPEAKER_03]: There are very specific bacteria that are involved with that in the production of gamma things like that.

[00:23:39] [SPEAKER_03]: Dopamine. Same thing. You break down the molecules in your food and it produces these phenol groups, one of which I'm trying to remember the name.

[00:23:54] [SPEAKER_03]: P crustal. P crustal and that gets transported and made into brain dopamine and seems to correlate.

[00:24:03] [SPEAKER_03]: Yeah, and how very specific types of bacteria again are involved in the metabolism to make this p crustal.

[00:24:10] [SPEAKER_03]: So it I don't know to me it is beautiful that we are these like diverse communities that if our behaviors and how we eat and what we eat play a role in how our brain

[00:24:24] [SPEAKER_03]: develops and how it ends up learning what is available to it. What is going on out there.

[00:24:32] [SPEAKER_01]: Right. If he lost you there in the last five to ten minutes, the bottom one is you are what you eat.

[00:24:41] [SPEAKER_01]: Yes. That is 100% what it is.

[00:24:43] [SPEAKER_01]: Well, to jump back to in cephalopathy. So or in cephalitis. So again, imagining that you were the person who contracted it and you had your acute recovery.

[00:24:58] [SPEAKER_01]: What would you expect in terms of when do you think would be reasonable for you to be followed up with by your neurologist or by really ideally your neurologist?

[00:25:11] [SPEAKER_03]: Yeah. So it really one depends on your acute complications. Right.

[00:25:20] [SPEAKER_03]: If you had acute symptomatic seizures in that first time, how difficult they were to control.

[00:25:26] [SPEAKER_03]: Right. Someone comes in with super refractory acute symptomatic seizures meaning we try to conventional anti seizure medicines still going on.

[00:25:39] [SPEAKER_03]: We tried benzodiazepine still going on. We put you on a drip.

[00:25:44] [SPEAKER_03]: After 24 hours, seizures are still going on. We tie trade stops. Well, that person is at a much different position than somebody who has one seizure doesn't have another one. Right.

[00:25:57] [SPEAKER_03]: So when to follow up is going to me have to do with what happened to them in that time.

[00:26:04] [SPEAKER_03]: The seizure is being a big part of that because HSV and cephalitis for instance tends to have a high temporal lobe epilepsy risk.

[00:26:14] [SPEAKER_03]: So following up within what I would say a month to a month and a half two months at least checking in.

[00:26:22] [SPEAKER_03]: Yeah, right. What about three and a half months? That's pushing it. That's a little long.

[00:26:28] [SPEAKER_01]: That's the earliest that Jolly was able to get in with the neurologist. Now he has been able to see his primary care who actually a new primary care because he didn't have one before.

[00:26:37] [SPEAKER_01]: Yeah, who is pretty knowledgeable about it all, honestly.

[00:26:41] [SPEAKER_03]: That's that's good. And that's very helpful to have in the medical infrastructure shout out to primary care who can kind of fill that gap.

[00:26:50] [SPEAKER_03]: Yeah, which we certainly need with specialists. There is unfortunately not as many specialists and so you are at the mercy of you know how much resources available and where they're at ideally I think sooner really just to kind of see health and it probably won't change much.

[00:27:12] [SPEAKER_03]: It doesn't even have to be a full visit. You know, you can see I'm in just make sure hey you're not having seizures.

[00:27:18] [SPEAKER_03]: You're not having peer-scenalty changes or getting back like just making sure and asking the questions and just kind of checking in.

[00:27:27] [SPEAKER_03]: I think is important but we also are in an age of technology where interfacing through text messaging just text through the EMR right.

[00:27:38] [SPEAKER_03]: Yeah, I encourage my patients to check in much more frequently than my followers.

[00:27:45] [SPEAKER_03]: Yeah, and I think it's important to one give the good counseling of what is the possibility of bad things that can happen after acute you know in cephalitis.

[00:27:55] [SPEAKER_03]: Yeah, you know as far as HSV and cephalitis the rate of serial conversion for NMDA afterwards in some studies is upwards of 30%.

[00:28:07] [SPEAKER_03]: So a post infectious autoimmune response following an acute and cephalitis.

[00:28:15] [SPEAKER_03]: I need to be known and people need to know exactly and that's why I think at least for that case you know it's really important to have sooner follow up.

[00:28:24] [SPEAKER_01]: So how long would you managing a patient or if you had it yourself? How long would you remain on a essentially a prophylactic and I epileptic?

[00:28:35] [SPEAKER_03]: Again, it is so if it's prophylactic and I don't know exactly which one was a keprah was it.

[00:28:43] [SPEAKER_03]: Keprah yeah.

[00:28:45] [SPEAKER_03]: You know there's not great evidence to suggest even in acute injury acute and cephalitis that using a prophylactic like that is going to have much of a difference in terms of epileptic genesis.

[00:29:00] [SPEAKER_03]: Yeah, my general feeling is that if you didn't have a acute symptomatic seizure.

[00:29:07] [SPEAKER_03]: Okay, that taking it is not going to make a big difference but if there is signs of irritability on EEG keeping it on you know it's not going to make a big a big negative it's low risk.

[00:29:22] [SPEAKER_03]: So I think keeping it on probably for you know three months is reasonable and then afterwards taking off.

[00:29:29] [SPEAKER_01]: So remember he had the interectal ittle continuum show and it's kind of an on specific finding that could be related to the infection itself.

[00:29:39] [SPEAKER_01]: Yeah, it could be related to an epilepsy but you tell me more about.

[00:29:44] [SPEAKER_03]: So interectal ittle continuum it's hard to say whether it's a seizure or not and at that point it's it's you can kind of consider it status I would consider it status epilepticus because if he's and it depends on his clinical symptoms right if he's.

[00:30:00] [SPEAKER_03]: Not speaking he's completely in cephalopathic and he has that pattern and that's a huge departure from normal yeah that's probably seizure going on right wasn't a huge departure it wasn't enough of a departure to immediately be like something wrong but it was immediately like.

[00:30:17] [SPEAKER_03]: He's acting really funny and so he's not baseline and from a focal standpoint if you have those discharges going on and he's altered I would say he's clinically having symptoms.

[00:30:29] [SPEAKER_03]: And treating it with a benzoy or treating it usually it's a benzoy that we try first and if you give it to him and then he improves yeah that was a seizure he was happy.

[00:30:40] [SPEAKER_03]: And it is interesting how the it's the firing rate that makes it that so if you synchronize.

[00:30:46] [SPEAKER_01]: And I don't think the benzoy when they first gave it to him did not have that effect on how that.

[00:30:51] [SPEAKER_03]: Yeah so the thing is it's a it's a spectrum of hurts and it so it depends on how fast those bursts are coming and if it's one hurts to 2.5 hurts that's nice.

[00:31:04] [SPEAKER_03]: That's kind of more we don't know if it's having an effect on your brain or not you need to clinically correlate it right but if it is you see the person they're not acting normally.

[00:31:16] [SPEAKER_03]: Then you probably should err on the side of it's it's seizure going on right now it's ongoing seizure so in his case I would say depends on what you're doing right it's all a risk first benefit.

[00:31:29] [SPEAKER_03]: Um kind of analysis and if you're not working you're not driving you could try coming off worst case you have a seizure.

[00:31:37] [SPEAKER_01]: Right which everybody is terrified of but.

[00:31:41] [SPEAKER_01]: I try to reassure people that 99.9 plus person at the time having a seizure is not fatal.

[00:31:48] [SPEAKER_01]: Um it it it doesn't lead to a lot of this like downstream cute complication.

[00:31:54] [SPEAKER_03]: No and it depends on how long the seizure goes on and how frequently the seizures go on so having one seizure 95% of the time that seizure is going to stop within a minute.

[00:32:07] [SPEAKER_03]: It's not going to cause a significant damage to the brain that's not a hypoxic state.

[00:32:12] [SPEAKER_03]: Right as you can think of a relative hypoxic state which is a lack of oxygen your brain's not getting it but if it's firing like crazy over five minutes.

[00:32:21] [SPEAKER_03]: Uh we start to have more kind of an oxy occur.

[00:32:25] [SPEAKER_03]: We really don't from models see damage until about 20 minutes to 25 minutes after having to acute symptomatic seizure or a seizure just a seizure leading to pure a not sick damage that leads to long term effects.

[00:32:41] [SPEAKER_03]: Right um there are you know kind of phases that you can think of and if it's going on less than two minutes.

[00:32:51] [SPEAKER_03]: It's probably not going to have a long term effect on the functioning of the brain afterwards.

[00:32:58] [SPEAKER_03]: It is important for that small group who doesn't have it that they have in a board of agent or rescue agent.

[00:33:03] [SPEAKER_03]: Right and so for him if he's ever thinking of coming off of that medicine which I would encourage you given that right say that at the end on the side exactly you have diastat you have altoco you have you know these these things which they go right in the nose they're pretty easy to administer.

[00:33:19] [SPEAKER_03]: Um and it can stop that seizure if it were to go on so you're covered so you can feel comfortable at that point and his brain then tells you he's going to be on this medicine for two years now that we're not going to revisit this for a bit.

[00:33:34] [SPEAKER_03]: Right yeah.

[00:33:35] [SPEAKER_01]: And so it seizures are bad even if at the point there is still potential for long term recovery.

[00:33:43] [SPEAKER_03]: Yeah certainly and the age with which it happens makes a big difference right if you have an on-line.

[00:33:49] [SPEAKER_03]: I don't immune and cephalitis when you're 14 your brain may rewire differently than somebody who's in their 30s.

[00:33:58] [SPEAKER_03]: Yeah right or then somebody in their 60s.

[00:34:01] [SPEAKER_03]: Yeah exactly and so it makes a complete the complete difference of how much our genetics can change how much our brains trying to learn of what the environment is sometimes.

[00:34:12] [SPEAKER_03]: Being younger is better.

[00:34:14] [SPEAKER_03]: Yeah.

[00:34:15] [SPEAKER_03]: And recovery standpoint sometimes the network gets formed incorrectly after it has a huge hit like that.

[00:34:24] [SPEAKER_03]: I got it for him he has no further seizures after you know say he stops it three months six months he stops it they go on try it.

[00:34:39] [SPEAKER_03]: And then it's cautiously a year.

[00:34:41] [SPEAKER_03]: Yeah probably very cautiously I don't think you necessarily have to if he has no seat you know things the thing is it also has to do with who's around him if someone lives by himself and they have a subtle.

[00:34:56] [SPEAKER_03]: And then the actual ideal is that he's a little bit more like a little bit of a little bit of a little bit of a little bit of a little bit of an ideal temperal seizure which is most likely to happen for him.

[00:35:01] [SPEAKER_01]: You may not know he had it that that that that is so it is so important when questioning a patient about their seizure history.

[00:35:09] [SPEAKER_01]: You know ideal with more of the full blown tonic, chronic alcohol withdrawal.

[00:35:13] [SPEAKER_01]: Then so withdrawal seizures that are more obvious but even then somebody who's having a seizure you don't have the ability in that full tonic, chronic state to be aware of what's happening.

[00:35:27] [SPEAKER_01]: No you don't have insight now you may feel drastically different when you come out of it you wake up from it.

[00:35:33] [SPEAKER_03]: Yeah that post-tic will stay exactly and and so generalize seizures usually they do know afterwards because it affects their dominant hippocampus.

[00:35:43] [SPEAKER_03]: Their dominant memory centers are brain lateralizes in a lot of regards memory and it lateralizes language.

[00:35:52] [SPEAKER_03]: So following a seizure if it's on your dominant memory side you do usually not you don't know like that area is not encoding it didn't even even know that it was happening or your awareness may be not altered during a seizure if it's on your non-dominant but if it's your dominant your awareness is affected.

[00:36:12] [SPEAKER_03]: Like it plays a big role with focal seizures especially in these cases.

[00:36:20] [SPEAKER_03]: In Sepulitis for the most part HSV specifically it's more of a temporal type of seizures so knowing the focal nature of what could happen is important and usually with HSV I don't know with his image did he have both sides affected did he have anything on his image.

[00:36:45] [SPEAKER_01]: He was still in such an altered state going through the MRI machine he didn't really understand the importance of it and was kind of flailing thrashing about so there's a lot of artifact on the MRI of his brain.

[00:36:59] [SPEAKER_03]: I think if he were to have subsequent symptoms and wants answers seeing I would probably recommend getting an interval MRI at some point to see if he develops hippocampus chlorosis.

[00:37:14] [SPEAKER_01]: Right right and we had talked about I talked to him about that going just outside of the typical medical system go get your MRI done and then we will find somebody to read it for you.

[00:37:26] [SPEAKER_03]: And really doing it later and not in the subacute phase so really doing it once everything's kind of settled then you can kind of prognosticate I think your epilepsy risk.

[00:37:41] [SPEAKER_03]: Yeah best and you may be able to have better understanding of maybe mood issues that are rising and things like that and now whether it changes what you do right now I think from a prognosis standpoint though.

[00:37:55] [SPEAKER_03]: Checking to see if the escalorosis is going to be the biggest.

[00:37:58] [SPEAKER_01]: Yeah you know this this whole topic of conversation kind of illuminates a bigger overarching issue and in my field of psychiatry you know civil issues to be a psychiatric condition then we figured out that there is a organism that causes that and it became a neurologic condition.

[00:38:19] [SPEAKER_01]: Things like this that lead to a very biologic thing that's happening in somebody's brain that lead to prominent behavioral abnormalities sometimes without any focal neurologic deficits.

[00:38:33] [SPEAKER_01]: How would you decipher this working in the ER especially if you encounter somebody that has pre existing severe mental illness.

[00:38:45] [SPEAKER_03]: Yeah that is at as a great question one thing that can really help tip you off to an organic disorder in these senses is autonomic dysfunction so.

[00:38:59] [SPEAKER_03]: What do you mean by autonomic heart rate breathing changes people airy dilation sweating things that aren't normally under the listional control right things that are kind of just happening our brains are interfacing with it with our autonomic nervous system.

[00:39:21] [SPEAKER_03]: And you do see more so in a cute and cephalitis changes in that regard now it makes a difference what type right if you're going to have an infectious and cephalitis.

[00:39:35] [SPEAKER_03]: You're probably going to be febral too are you're going to have other other inflammatory things going on whereas if you have an autoimmune and cephalitis.

[00:39:45] [SPEAKER_03]: The dis autonomic dysfunction can be really helpful for you.

[00:39:51] [SPEAKER_01]: We've had a couple of autonomic or we've had a couple of autoimmune in cephalitis on the psych unit one of them was a lupus serabritis where the patient unfortunately had onset of psychiatric major behavioral disturbances later in life.

[00:40:11] [SPEAKER_01]: In her late 40s early 50s bounced on and off of psych units.

[00:40:19] [SPEAKER_01]: And I think another thing to add to what you said especially maybe not in the acute setting but more in the subacuter or chronic treatment is people who are not responding to typical psychiatric medications that would help with some of those symptoms of psychosis is what that woman was dealing with.

[00:40:39] [SPEAKER_01]: And unfortunately at some point her brain herniated and swollen too much just too swollen herniated and you know that was that but it was only after the fact that.

[00:40:54] [SPEAKER_03]: You know through autopsy that it's discovered this was related to an autoimmune condition yeah I give another another example and this was more of an infectious.

[00:41:05] [SPEAKER_03]: It was an early 40s etiology but a man in his 40s late 40s came with seizures.

[00:41:16] [SPEAKER_03]: And behavior changes more more behavior changes than seizures but it did through history seem like he was having some focal seizures.

[00:41:25] [SPEAKER_03]: Was ultimately put on the stabilized because behavior became more of his issue and was discharged.

[00:41:35] [SPEAKER_03]: And he continued having these episodes that were probably seizures weren't getting treated but was mainly getting treated for psychiatric illnesses.

[00:41:44] [SPEAKER_01]: And so now he's giving him medicines that make him more likely to have seizures.

[00:41:50] [SPEAKER_03]: Exactly and well it gets worse he ended up having a psychiatric break got admitted to the psych unit and through this is three months later through some more history they were like, oh this is weird we're going to get neurology on board see you know.

[00:42:11] [SPEAKER_03]: First of all anyone having acute seizures in their 40s probably need to get a orthorovaluation but unfortunately took three months for this man.

[00:42:24] [SPEAKER_03]: He they did an image and he had.

[00:42:31] [SPEAKER_03]: He had a sinus infection that ate its way through and was in his frontal cortex so this man was having frontal lobes seizures.

[00:42:42] [SPEAKER_03]: And behavior changes was built as just a behavior change issue was more psychosis when it was really just an infection in his body.

[00:42:51] [SPEAKER_01]: And I worry about that with as I mean with anybody in general you know I think luckily for jolly he was 35 and it's not very it's not a very likely age to have the onset of something like bipolar mania or.

[00:43:06] [SPEAKER_01]: You know I had heard that he had slept in three days and then he had these major behavioral changes the lack of insight and the psychiatrist is thinking well is he is he manic.

[00:43:16] [SPEAKER_01]: He's laying in bed that doesn't really add up he's not making a whole lot of sense but it it it frightens me for how and it leads into my next question which is I don't expect like a legitimate or actual answer but.

[00:43:31] [SPEAKER_01]: How prevalent.

[00:43:34] [SPEAKER_01]: Do you think not just in cephalitis because that's probably still pretty rare on it in patients psychiatric unit but in general how prevalent or any other neurologic medical cause of the psychiatric illness and you could even argue that all of it.

[00:43:55] [SPEAKER_01]: Yeah that once we figure out what more about the cause then we would label it a medical problem but how prevalent do you think it is to have something that really requires a drastically different.

[00:44:07] [SPEAKER_03]: Treatment approach where people end up on a on a psychiatric unit that's a that's an.

[00:44:54] [SPEAKER_03]: In point the mechanism.

[00:44:56] [SPEAKER_03]: And the thing is a lot of those organic disorders, the longer they go untreated if the body doesn't fix itself.

[00:45:06] [SPEAKER_03]: Which a lot of times it doesn't they're going to start showing organic science meaning they're going to start ceasing right right and so they're going to have word finding difficulty.

[00:45:17] [SPEAKER_03]: Yeah, it's going to spread to other so the real question is how many patient how long does it take for someone to get literally read my mind that was going to be my next question on the auto immune in cephalitis.

[00:45:31] [SPEAKER_01]: A branch of things is you know how often are people able to recover from it without treatment which is again another loaded question that we probably don't have enough.

[00:45:41] [SPEAKER_03]: So that's our job because they didn't seek treatment and you never know.

[00:45:45] [SPEAKER_01]: It's something that could have been a cult the whole time and that fixes itself and you never ever knew about it exactly.

[00:45:53] [SPEAKER_03]: And and short of doing large scale studies antibody panels on healthy individuals which we don't really have.

[00:46:03] [SPEAKER_01]: And he's going to do that exactly not any any any profit to be had exactly but it is interesting and makes you wonder.

[00:46:12] [SPEAKER_03]: Do is there the potential for low low concentration and MDA antibodies that do alter behavior and we're just not aware right HSV for instance extremely common right.

[00:46:30] [SPEAKER_03]: We live with these viruses we have antibodies that mimic our own receptors and in a healthy sense we're supposed to get rid of the ones that are going to target us right supposed to get rid of them.

[00:46:43] [SPEAKER_03]: Those who have poor mechanisms end up having amounting response so then it ends up leading to these severe you know presentations.

[00:46:54] [SPEAKER_03]: But how tolerant is the system to low dose antibodies.

[00:47:00] [SPEAKER_03]: Okay, that's a good question.

[00:47:01] [SPEAKER_01]: I mean it's all it's all an ongoing balance playing out right it's not like your immune system sitting here right now or my immune system the amount of neuro inflammation that we're dealing with right now is not zero.

[00:47:14] [SPEAKER_01]: Absolutely it's not zero and how much do those fluctuations and it you know we can bounce right back to the beta amoloid theory of Alzheimer's and how long does beta amoloid.

[00:47:27] [SPEAKER_01]: Have to have to be there to disrupt the connection is that what we're seeing is the the information I actually don't think that beta amoloid is the primary destructive force that's leading to the issue it's a fallout.

[00:47:43] [SPEAKER_01]: It is a secondary it is sign of examinant that I think has already been done.

[00:47:50] [SPEAKER_03]: To an extent I think it's occurring concomonately and it is through this rage system that I talked about so APP.

[00:48:01] [SPEAKER_03]: Get's transported out of the brain using rage yeah and so if you were brain your brain is constantly inflamed with this you're not going to be able to clear these these things there's a lot of things that are problems with inflammation going on in the brain.

[00:48:18] [SPEAKER_03]: Yeah, not just that this is accumulating so it's accumulating because of a byproduct of the problem right which is why all the beta amoloid removal medicines don't actually really work.

[00:48:33] [SPEAKER_01]: Now because you didn't change the the functioning of the brain or if the the protein that's accumulating in there has already disrupted the matrix.

[00:48:44] [SPEAKER_01]: You can't just take it out and you know it's like if you have a intricate you know spider web that you dip your finger into.

[00:48:54] [SPEAKER_01]: And when your fingers in there you're already disrupted it but then the minute you take that finger out you're going to pull strands with it exactly and so functionally that those met I mean you know that's a big.

[00:49:06] [SPEAKER_01]: And so the main of my existence is all of these beta amoloid drugs that.

[00:49:14] [SPEAKER_01]: These these companies and these researchers are so behind the eight ball.

[00:49:17] [SPEAKER_01]: I think they have to know that they really don't work that well, but they've poured billions of dollars into the R&D the research and development side of it.

[00:49:26] [SPEAKER_01]: Yeah, so now they're in this stage of yeah we're going to try to say that it works and try to recoup some of our money.

[00:49:33] [SPEAKER_01]: But there's a new another one that just the oral one that just got FDA approved to but it doesn't end up.

[00:49:39] [SPEAKER_03]: It doesn't I think we will find that it doesn't end up changing what you really should be doing is putting money towards changing the system for in a chronic sense so that the energy doesn't get backed up like that.

[00:49:53] [SPEAKER_03]: Yeah, and in a way this is you know, Friedland's microbiome defense just stuff I think a big part of that is also the inflammation and the rage system is interfacing with it.

[00:50:06] [SPEAKER_03]: There's a lot of literature in Alzheimer's that that's the that's the big problem is you're basically.

[00:50:13] [SPEAKER_01]: Predisposing your metabolism towards this more inflamed state that over time causes just degradation in the neurons and which is why I think that the low doses of lithium are helpful because they feedback through that GSK three beta system to decrease overall inflammation.

[00:50:35] [SPEAKER_01]: Yeah, and in help as we were saying like Alzheimer you know your our brains right now are in a constant equilibrium of degeneration and regeneration or or accumulation of toxic metabolites and clean up of those toxic metabolites before they disrupt anything exactly and a big part of this is our sleep wake cycles.

[00:50:57] [SPEAKER_03]: Yeah, and a major problem that we face in today is is our sleep disruption because of the energy you talked about the technology and all of those things.

[00:51:09] [SPEAKER_03]: That is a constant load on the brain and then we're also not getting good sleep because of the amount of light and things that we're having.

[00:51:18] [SPEAKER_01]: We also distract ourselves from ourselves all day and then we lay down to go to sleep at night and we're like, why can't I sleep my mind won't stop taught it's because you've been trying to ignore it all.

[00:51:30] [SPEAKER_03]: And it becomes a new set point in a way and what's interesting about restorative sleep actually n3 and for restorative sleep you double the CSF look.

[00:51:44] [SPEAKER_03]: Yeah, you're getting rid of a lot of that stuff during the day that is accumulating and causing damage and and so it's all part of that balance and it really does harkin back to just like.

[00:51:56] [SPEAKER_01]: Good sleep and exercise like good diet and I remember with with especially some of my early bipolar patients you know I was hesitant to call them bipolar because they didn't have the classic sleep disturbance.

[00:52:13] [SPEAKER_01]: You know I'm getting more manic and I'm I'm sleeping to the point you know less and less to the point where I'm not sleeping at all.

[00:52:20] [SPEAKER_01]: But a lot of people don't have that they probably you know they're still getting six hours of sleep but sleep study wise they're not getting into the restorative phases of sleep and so.

[00:52:32] [SPEAKER_01]: Fascinating they may not be cleaning up their brain to the degree that they need in order to break out of that vicious cycle.

[00:52:40] [SPEAKER_03]: That's an interesting that's an interesting kind of phenotype to consider right that you're you're not quite you're not quite to the point of decoupled where you're bipolar, you know one two but that you are this kind of.

[00:52:54] [SPEAKER_03]: In a way just below.

[00:52:58] [SPEAKER_01]: I had a patient the other day who had never really had this you know any sleep disturbance beyond six hours tonight that was the worst but but he was clearly manic.

[00:53:10] [SPEAKER_01]: And only after talking to his sister who deals with the same condition who said yeah I never had insight into the fact that I wasn't sleeping but later on I found out that I wasn't getting any sort of restorative sleep.

[00:53:25] [SPEAKER_01]: Yeah I was sleeping you know I was getting the the initial stages of your.

[00:53:32] [SPEAKER_03]: So we call that.

[00:53:35] [SPEAKER_03]: Behaviorally sleeping biob behaviorally sleeping on us when we look at eg we can see someone but then the brain is doing things that it's like no yeah actually still pretty it's firing quite a bit and you know it is interesting these.

[00:53:51] [SPEAKER_03]: And the the oscillatory nature and how part of our day to day is the speeding up in the slowing down of the oscillations.

[00:54:00] [SPEAKER_03]: And we have to be able to appropriately do that at the right times to function and how people who have these these mood issues particularly the you know bipolar the more of those circadian type I think they're.

[00:54:19] [SPEAKER_03]: That's the problem it's their their oscillations are completely off there they're firing all at once for long periods of time and then they crash because of it.

[00:54:30] [SPEAKER_03]: Yeah like getting to that decoupled state and how.

[00:54:35] [SPEAKER_01]: And then we're going to be so why social rhythm therapy is an effective treatment for bipolar where you force yourself into routine yes and you have better control over those oscillations or the oscillations are more predictable exactly right exactly.

[00:54:52] [SPEAKER_03]: And I think there are things that we should be mindful of and of socialization that we should be not forcing ourselves but we we've gone away from the society where we have direct one on one contact or we have group contact with people as much.

[00:55:11] [SPEAKER_03]: And I do think that we've kind of disrupted our our biological mechanisms of energy expenditure because our network from a social standpoint has degraded.

[00:55:27] [SPEAKER_03]: And it's fast and you know but the oxytocin network and AVP this that that ends up breaking down as people age and traditionally.

[00:55:38] [SPEAKER_03]: You had families who had their elderly with them right they were still interacting with them they were still a part of it is completely different when you put them in a isolated situation where they don't know anybody.

[00:55:53] [SPEAKER_03]: And so the people are not familiar with the environment that they're in exactly and all of those oxytocin networks that they formed are useless for them now yeah.

[00:56:03] [SPEAKER_01]: And it's in a way it's kind of sad but dammit Jamie it's such a big market alright someone's making money to be made that you can then one day take to your grave and into the afterlife with you right.

[00:56:16] [SPEAKER_01]: I can't well maybe you could make a nice statue and people will remember you that way.

[00:56:22] [SPEAKER_01]: And then you can pay God an indulgence and get into get in through the heavenly gates fantastic.

[00:56:31] [SPEAKER_01]: All right let's let's call it all right well thank you for having me absolutely we'll do it again we'll do it again.

[00:56:38] [SPEAKER_01]: Hey just wanted to give you a quick message to wrap up the series on in semifillitis hope you enjoyed it it is a huge topic and could be expanded even further maybe in another series or episode if we talk about in semifillopathy's and include non infectious causes of brain swelling or change in behavior or change in any of our brains functions.

[00:57:05] [SPEAKER_01]: Some general takeaways so in semifillitis you know viral in semifillitis, bacterial autoimmune but especially the viral in the autoimmune in semifillities and semifillities they can be really scary and unpredictable.

[00:57:23] [SPEAKER_01]: You know jolly didn't see his coming at all and it really wasn't extremely obvious to those who knew him very well and worse arounding him.

[00:57:36] [SPEAKER_01]: We certainly don't want to miss these when we're looking at a patient in the ER or looking at a patient in the psyche are or even on the psyche at your unit and it's our job as mental health providers.

[00:57:52] [SPEAKER_01]: Specialists in psychiatry to ensure that our patients are not suffering from a medical cause of their altered behavior something we fall way short on doing in the current system as it is so we don't want to miss these and.

[00:58:12] [SPEAKER_01]: For as little as we know, we know a heck of a lot more than we used to and we can actually find ways to diagnose these and treat these.

[00:58:24] [SPEAKER_01]: And early recognition and aggressive treatment is extremely important so it's it's very reasonable for folks to cast a wide net and not to delay treatment because the complications can be so serious and severe.

[00:58:43] [SPEAKER_01]: In terms of recovery, you know like everything in America we got to get better at eating healthier.

[00:58:50] [SPEAKER_01]: We've got to stop be cognizant of how much added sugar is in our foods.

[00:58:56] [SPEAKER_01]: Be cognizant of what process food does to our bodies and I get it it's it's good it's delicious it satisfies that I want it now instant gratification it tastes good it's very sweet it's very salty.

[00:59:14] [SPEAKER_01]: But ultimately it's not leading us to the long term outcomes that we want also with recovery you know Jamie Schuper really emphasized the importance of returning to a sense of normalcy.

[00:59:28] [SPEAKER_01]: And also positive social interaction being aware of the risk of seizures and tackling that head on you know coming off of anti seizure medicines with the help of of a professional.

[00:59:43] [SPEAKER_01]: And being open to the possibility that that may be something that persists for months years or even a lifetime.

[00:59:56] [SPEAKER_01]: But on that note on a in a psychiatric sense, you know this is a situation where you're battling a lot of uncertainty there can be a fear of recurrence but for those reasons for you know if you do end up having to be on an an api-leptic for the rest of your life.

[01:00:13] [SPEAKER_01]: Also we have got to consciously insert our gratitude into our lives our minds are our survival centers in the center of our brains.

[01:00:26] [SPEAKER_01]: They don't care about the things that are going well they are there to let us know about all the things that we haven't done that would help our survival and all of the things that we may be need to look out for.

[01:00:39] [SPEAKER_01]: So consciously inserting our gratitude's consciously deciding the lives that we want to live and then using our minds as tools can be so important for posts and cephalitis recovery but also for life in general.

[01:00:55] [SPEAKER_01]: easier to say than to do but definitely the more practice we put in the better we can get at it and the more stable internal lives that we can live.

[01:01:07] [SPEAKER_01]: Anyway hope you enjoyed the series on encephalitis if you got an idea for a topic if you are a patient that has had.

[01:01:15] [SPEAKER_01]: a difficult time or a unique condition or case please reach out I would love to interview you and get more patient perspectives on these things that I talk about.

[01:01:28] [SPEAKER_01]: Thanks for listening thanks for watching like subscribe do all those things that I'm supposed to tell you to do and get our viewership you know maybe over a hundred folks in episode thanks.

[01:01:41] [SPEAKER_01]: Thanks again for watching and or listening if you're passionate about the subjects that I discuss on the channel do me a favor and like comment subscribe.

[01:01:53] [SPEAKER_01]: Do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[01:02:02] [SPEAKER_01]: If you have any questions comments or concerns I want to hear them.

[01:02:08] [SPEAKER_01]: Feel free to reach out on social media or email us at renegade site at gmail.com.

[01:02:14] [SPEAKER_01]: And if you'd like to be a guest of the show or you have a connection to some money that you think would be a good guest.

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[01:02:33] [SPEAKER_00]: Disclaimer this podcast is for informational purposes only the information provided in this podcast and related materials are only to educate this information is not intended as a substitute for professional medical advice while I am a medical doctor in many of my guests have extensive medical training and experience nothing stated in this podcast.

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