Sex Differences in Aging Cognition with Dr. Sullivan

A. Campbell Sullivan: [00:00:00] I was having so much irritability, and there were times where I would get so angry, and I just had this, like, rage. And I was like, "This is weird, and I can't explain it." Like, like yeah, like, you know, it was Iggy couldn't figure out which nightgown she wanted to wear, and I would get so angry, and it just, like, it was really this distinct change.

And I'm like, "I've done this twice before. Like, what is going on now?" It's not just because there's two of them, and it's sort of, you know, amplified. But something felt distinctly different. And then there was a moment where... Not a moment, but I essentially called one of the senior research staff, I called this person a liar.

Preston: Welcome back to How to Be Patient. I am joined today by Dr. Campbell Sullivan, PsyD, who is an exciting [00:01:00] guest because I have been a guest on her show for the last couple years, the show being, the Neuropsychological Mind Patient Eval. So I, I met Dr. Sullivan when I was a, I guess, an intern on an elective, and I was kinda learning about behavioral neurology and neuropsychology, and that's, that's when we first kind of crossed paths.

But now it's your chance to, to come onto How to Be Patient. 

A. Campbell Sullivan: Yeah. Thanks for having me. I'm excited, I'm excited to do this. 

Preston: So we always start out with an icebreaker, and the icebreaker that I have for you today is- 

A. Campbell Sullivan: Ooh ... 

Preston: what would you say your favorite neurocognitive assessment word is? 

A. Campbell Sullivan: My w- the favorite word or test?

Preston: Yeah, any word 

A. Campbell Sullivan: From all of 

Preston: them? Yeah, so, so like any kind of word you would use in the neuropsychological eval or, any of your cognitive tests. Oh, 

A. Campbell Sullivan: I think my, I think ... Well, okay, so I, I mean, I'm gonna give you a [00:02:00] little bit of both because- Okay. Okay ... I mean, as a neuropsychologist, like what I love are the tests, you know?

So like- It's true ... it's always ... And that's a, that's a good way to ... a witness test for me to sort of see like, are you a keeper or are we sort of, you know, not keeping you. So one of my favorite tests, and one that's really easy to do at the bedside too, is, is assessment for simultagnosia. So I really, I do, I love simultagnosia.

We had a little bit today in clinic. and the first time it was explained to me, I, oh, I was just a wee babe, and I was at the, the Memory and Aging Clinic at UCSF, and I'd never heard of simultagnosia. I had no idea what it meant. And we had a patient, and I think, ah, I forget who it was. It may have been Bruce Miller.

But he held up like a pen and a stopwatch, and he was like, to a patient, he was like, "Tell me what you see." And, [00:03:00] and the person like could not do it. And I was like, "What is happening here?" Like, I'd, I'd never really like been exposed to that before, and I was just like, my mind was blown. I was like, this is fascinating.

and so- So from the 

Preston: foreground, they can't differentiate the different silhouettes of the objects. 

A. Campbell Sullivan: Exactly. Like, their eyes aren't seeing everything. So the, the way I, I explain it to patients is essentially the eyes are fine, but it's the way the brain is processing what the eyes are seeing. Like, it cannot put all the figures together.

And so you might be able to, to see sort of one item on its own, but when you have two items sort of overlapping, it's, it's almost like too much information. It's, it's sort of the sensory overload, and they can't really tease apart the two figures. And so the brain is just not processing what the eyes are seeing accurately.

Preston: Mm ... 

A. Campbell Sullivan: and so it can lead to a lot of problems at home, so, you know, misplacing items, getting lost in the house, getting lost when driving, so it can lead to a lot of safety concerns. But sort of like [00:04:00] seeing that live firsthand and sort of learning this, you know, fancy neurology term has really, I think, stuck with me.

Preston: Yeah. 

A. Campbell Sullivan: That- that's a really fun one. Yeah. I would say that's my favorite. 

Preston: Okay. That's a good one. And- 

A. Campbell Sullivan: Yeah ... 

Preston: where does that ... I- I'm trying to, I'm, I guess quizzing myself here. where does that localize to, i- if, if anywhere? It's in the parietal lobes. Parietal lobes. So, so it's- Yeah ... it's an extension- Parietal lobes

or it, it falls under your visual spatial function or processing. 

A. Campbell Sullivan: Very much so. Yeah. 

Preston: Okay. 

A. Campbell Sullivan: Yeah, yeah, 

Preston: yeah. My favorite word is in the parietal lobes too. What is it? I think we just, we're both just parietal lobe stans. So mine is ideomotor apraxia. Oh, yeah. 

A. Campbell Sullivan: And I, and I 

Preston: think that- Alicia loves that ... it kind of has some similar vibes.

It's, it's right next to dressing apraxia. So, 

A. Campbell Sullivan: Mm-hmm 

Preston: This, I had a similar moment with, Dr. Parker where we were assessing a patient, and she asked them to imitate her hand sign. I think she [00:05:00] just kind of went like this. So for those- Mm-hmm ... who are listening, like by audio sign, it's essentially like the Spider-Man, like, web symbol or, like, the rock on kind of thing.

And the patient couldn't figure out which fingers to align to imitate the position in front of them. And it also, like, instead of differentiating the silhouettes of the objects in front of them, like, and identifying and naming them, it was, how do I take what's in front of me and then reposition my body and then execute my motor system to then recreate that?

So I guess it's, it's a dem- different breakdown in the pathway, but also, like, really fascinating 'cause it has a lot to do with, I think your, like, social-emotional processing, too. Like, so much of conversing with someone is imitating their body language and, Mm-hmm ... you know, like understanding- Mm-hmm

like, kind of the nuances of them moving around. So it can affect that. But I think primarily we're concerned with it affecting, like, fine motor skills, dressing yourself and driving, things like that. So I, [00:06:00] first of all, I think it was a, I think just ideomotor is a fun word. 

[music]: It is. Second 

Preston: is- A good one

it's like a fun test to do. Mm-hmm ... so, so I, I enjoy that one. I, I like to do, like, kind of the okay sign, and then sometimes we'll do, like, interlocking, 

A. Campbell Sullivan: So tricky. So tricky. 

Preston: Yeah. Yeah. I need to find, like, higher levels. 

A. Campbell Sullivan: I had a supervisor who would always talk about, he was like, "We need to really talk about this syndrome, the parietal lobe dementia."

and it's, like, individuals who are having, you know, these kind of difficulties. They're having the trouble with the visuospatial pathways. And then a lot of times there's just, like, the heightened anxiety. and you can see these really, like, huge, like, expressions or, you know, bursts of anger. Like, the only time I've ever had anyone throw testing materials at me was, an individual who was in sort of the, the moderate stages of a posterior cortical atrophy, and just, like, really heightened emotions.

and she just, like, you know, [00:07:00] picked up, picked up the blocks, and it was a hard test for her. She picked up the blocks- Yeah. ... and, like, threw them at my head, and I was like, "Ah." So, yeah, I think that

there's something, there's something to the parietal lobes and emotion and just sort of reciprocity, but also knowing where you are in space and, and yeah, it was, it's a really interesting area of the brain. 

Preston: You know what? It's, it's so funny for me because I feel like when I'm, was learning about the brain in college and then again in med school and again in residency, when, when you look at emotion, when you ask, like, where is emotion located in the brain, like, people will give you different answers.

They'll say like, "Oh, the amygdala, the anterior cingulate, the temporal lobes." Yeah. But then anytime you look at a lobe, it actually does have a huge role in emotion. Like, even, even the cerebellum, Yeah ... I had a talk the other day where they were talking about how the, the cerebellum is, like, so important for essentially, like- coordinating which emotions to use at which times, like appropriately and inappropriately, just like how you coordinate your movements and balance with like your motor system.

It like kind of [00:08:00] helps do the same thing for like timing of like emotional discharges. And I was like, oh my gosh, like who would've thought? So, so I think, it is impossible to, to remove emotion from any part of the lobe, any, any one lobe 

A. Campbell Sullivan: or- Yeah. It's all, it's all one system. 

Preston: Yeah. It's all connected together.

It's all just, it's all just feelings- So ... at the end of the day. So, 

A. Campbell Sullivan: Big feelings 

Preston: Big, and blocks getting thrown- Yes ... as, as we've learned. So we're, we're gonna take a quick break, and when we come back, I just wanna learn more about your story as a PsyD and, and kind of what a day in the life looks like as a neuropsychologist.

A. Campbell Sullivan: Happily.

Preston: And we are back to talk about Dr. Campbell Sullivan's childhood. Just kidding. We're

A. Campbell Sullivan: talk- we're talking [00:09:00] about your journey. I think it, it And unless it starts with your childhood It was probably influential, right? Yeah. No, it doesn't. But there's always this, this joke. They say, like, it takes five generations to, to make a psychologist, and I always used to joke to my family, I'm like, "I feel like we got there in one."

so yeah. Yes, speed run. No, we're not gonna go into my childhood. Yeah. 

Preston: Your, your parents are like, "Okay, let's... Like, they do it in five, we'll do it... We can, we can crank it up" 

A. Campbell Sullivan: But, I mean, probably, c- and we'll get into it later. But yeah, I, I came to this a very, like, circuitous way. Like, it was, it was not a direct path for me.

and I, I think a lot of that is, you know, I didn't really know what to do. I didn't know what, what I really wanted to do. I knew I liked psychology, and so I started, you know, after college, I was in LA and I was working at, like, a locked mental hospital for seriously mental ill offenders. and so that was sort of interesting.

And then, you know, transitioned to working with individuals who had just been s- you know, [00:10:00] they're sort of hospitalized or institutionalized their entire adult lives, again, for sort of this refractory, you know, psychiatric syndrome. Some of them had schizophrenia, some of them had, like, you know, bipolar disorder.

But I really... I... It was... I was in my early 20s. I was a, I was a baby, but I really found that I could develop rapport pretty quickly with these guys and, you know, and I enjoyed them. Like, I liked people. I like spending time with people. I had, like, one of my, my favorite guys, his name is Fast Eddie, and we would just, like, take walks, you know?

And, like, he'd smoke cigarettes and we would just take walks, laps around, around the facility. and I just, I, I liked it. and so I thought, well, maybe I wanna, like, pursue psychology. And so I got a master's degree in counseling, and that was in Austin. And I, I realized pretty quickly, like, counseling is not my forte, as you can probably attest to.

Like, sometimes I'm a little bit Too [00:11:00] candid, maybe too direct. and sometimes if I'm not interested, my attention will sort of- Mm-hmm ... shift and and I don't, I don't 

Preston: follow. In, in counseling, you have to be on it the entire time. 

A. Campbell Sullivan: Yes. A- 

Preston: and- 

A. Campbell Sullivan: Yes, 

Preston: and I- ... very controlled with your emotions. 

A. Campbell Sullivan: Yes, and I just cannot do it.

I also, you know, I found that if, if the person I was talking to was really anxious, like I would also get anxious and they'd be like, "This is hopeless." I'm like, "It is hopeless. I don't know what to do." And I was like, "This is not good. This is not- Yeah ... my forte." 

Preston: They're, they're like, "Tell me I'm crazy," right?

And you're like, "No, I think you're onto something here." 

A. Campbell Sullivan: You might be. Like this isn't gonna be a good, a viable career path for me. so then I, I started looking around at doctorate programs. And while I was doing that, I was working as a psychometrist. So that- Hmm ... is somebody who is trained to administer neuropsychological tests, and it was for a private [00:12:00] practice in Austin, and we saw kids and adults, and we would give these huge long test batteries.

I mean, I was spending hours with these people, and you know, we I think it was 9:00 to noon, we'd take a break, and it was like 1:00 to 4:00 every single day. So I got really good at 

Preston: testing. And, and these testing batteries, these are like anything from the MOCA to like the Benson Copy, Hopkins Verbal Learning, to like, it's, it's the whole shebang.

A. Campbell Sullivan: Yeah, it was like a full... Like, we would do like, you know, a full, IQ test called the WAIS, and then we would do like a full achievement battery, so looking at like spelling, their, like their academic achievement. Mm-hmm. Then we would like go into memory. And so we would hit all the domains, but we would- So it's like

Preston: the SAT- We would test a lot ... on steroids, just- Very 

A. Campbell Sullivan: much so ... for your brain. Okay. Yeah. People were exhausted. and so I, I did that, and I liked the testing, and I, I was starting to sort of understand like what it meant and, I was looking at programs, and I found a PsyD [00:13:00] program In California. Mm-hmm. And I didn't think I was, you 

Preston: know- So what, what made you drawn to PsyD over PhD or MD?

Like, I feel like that's kind of like a pathway that people have to pick. 

A. Campbell Sullivan: Yeah. And I think it's one that, honestly, I don't know that I, I did that much research. I was like, "This seems good." I knew I didn't wanna be a medical doctor. Like, I, I, I don't love to touch people. I don't... It seemed like a lot of touching, seemed like a lot of body fluids.

Sure is a lot of touching. Right? and seems like you don't get to sleep very much, and so I was like, "Polite pass on that." and as far as, like, the PhD route, I didn't think that research was really my thing. I, I was very focused on, you know, being a clinician and working with patients and working in a clinic, maybe an academic medical setting.

But, like, doing just, like, hardcore research was really never a draw for me. but again, do... For anyone listening out there, [00:14:00] do, do more research than I did. Don't follow me. and so I just happened to fall, you know, into this program. It's a joint program. At the time it was called Pacific Graduate School of Psychology, and then a joint program with Stanford.

And so I think it has since... The, the school name has changed to Palo Alto University, but my diploma says PGSP/Stanford. So all of our classes were at Stanford with Stanford professors. we had a few of the, the PGSP faculty, but majority of it was, was at Stanford. And just being in the Bay Area, I really had a lot of access to a lot of really amazing faculty and opportunities and clinical opportunities.

So I started working at the Palo Alto VA, and I was working sort of one of the early, the pioneers of, like, polytrauma and working with a lot of, veterans returning, from Afghanistan and Iraq. And so they had concussions, and then they might have PTSD and, sort of really [00:15:00] focusing on that and then long-term head injuries and recovery.

And that was interesting. And then sort of delved into working with older adults at the VA. But at that time, there was a, a diagnosis called cognitive disorder NOS, which meant not otherwise specified. And I realized a lot of our patients were coming in with all these complaints and these concerns, and we would just sort of give this very bland, generic diagnosis, "Oh, you have, you have cognitive disorder NOS."

And I was like, "Well, that seems kind of boring. Like, can't we do a little bit more testing?" And so then I, I found my way, to UCSF, and I was there for several years, and I worked with a lovely neuropsychologist named Joel Kramer. And that's where I just kind of fell in love, and I was like- Mm ... "This is what I want 

Preston: to do."

So that's where you discovered sun lieutenant nosia 

A. Campbell Sullivan: Yes. Okay. And that was where I discovered- It's all making sense now ... frontotemporal dementia. Yeah. And that's where I discovered, hey, there's [00:16:00] a lot more to differential diagnosis of dementia. Like, w- it doesn't have to be cognitive disorder NOS. We can say not only is it a dementia, but what type of dementia it is, and then that can help guide treatment and give a lot of answers for families.

And so it was really, it was just, you know, sort of a, a life-altering moment for me. And I just loved it. And so I sort of structured the remainder of my training to really focus on these challenging dementia cases, atypical dementias, young onset dementias. And so then I was in Maryland at the University of Maryland and the Baltimore VA, and then I went to Hopkins.

And at Hopkins I worked a lot with, their FTD and young onset dementia center. and just really I tried to get to work with like the most challenging patients, see the, the, the rarest of the rarest unicorns, so that when I was practicing, I felt comfortable with anyone who walks through that door.

Like I, I was like, "Okay, I've seen [00:17:00] this, and I, I can do this now." and so that, that was always my goal was clinical care, education, making sure I c- I'm the best diagnostician I could possibly be. Mm-hmm. so that was sort of the reason I went to PsyD. Now, now that I'm more mid-career, senior career, I'm doing a lot more research than I ever thought I would be doing.

so that, that is, was not on my bingo card, but I'm enjoying it. so- I, 

Preston: I think you teased it earlier because at, at its core, research is a desire to excavate more knowledge, and I think your frustration with cognitive sort of not otherwise specified, that, that, that probably foreshadowed research to come.

'Cause you're saying, "This status quo is not good enough for me, and I want to differentiate these things." 

A. Campbell Sullivan: But I also... Yeah, I mean, I think so. But I also be- through my m- my clinical work and through my, where I work with families and individuals who might have a familial form of dementia, like I'm seeing gaps, gaps in the research- Mm-hmm

gaps in [00:18:00] programming, and I'm seeing like we need to be doing more. and that is sort of like drives me and, you know, it's- Hmm ... it's, it's easy to, to build these programs and create these things when we have amazing resources, so. I 

Preston: see. Yeah. So it... The other part was just you felt like you have a responsibility to fill those gaps because you can.

A. Campbell Sullivan: Yeah, and I, and I think it's, it's needed. It's necessary. I'm a, I'm a bit of a fixer. it also, like, I mean, there's a really gnarly gene in my family that I never knew about, but I did know a lot of my family members are a little odd. and then my aunt was diagnosed with, ALS with FTD, so Lou Gehrig's disease with a frontotemporal dementia, and that was caused by a gene.

It's, a, a variant in TAR DDP, and so that causes accumulation of TDP-43, that bad protein that builds up in your brain. and so I knew [00:19:00] like all her life she'd been a little bit different, and same with my dad. He'd been a little bit different, but you know, I got along with him. I could have these relationships.

And then only in their-- you know, as they got older did I start to recognize, hey, think this is, this isn't right. we could explain it away. We could say she's always been like this and this is just personality, but, but you know, like when we start to see the motor changes, that was really what helped convince the family like, oh, we need to get a workup and treatment.

And then we sort of found this. and so through my work with that and work with my cousins and other family members, I'm realizing like, we're testing these 26-year-olds for these really sort of deterministic, terrible pathologic genes, and like we have really nothing to offer them. Like, what if it is positive?

and my family's just one of many. And so like when we have these these gaps, like I'm like, we need, we need to do something. 'Cause, you know, in this case it happens to be my family, but in a, you [00:20:00] know, sometimes it's not my family, but there's still, there's a need there. And so we need to, we need to work to make it better because it's only as we get better with the precision medicine, as we get better identifying these dementias and these syndromes earlier in the disease course, we're going to identify people who are at risk or, increased risk for a neurodegenerative process, and we're gonna get them way before symptoms start.

And so we need to have counseling, we need to have services, we need to have lifestyle interventions so that hopefully, you know, we get to a point where they don't ever become symptomatic. 

Preston: Yeah. 

A. Campbell Sullivan: So sorry, I kind of went off on a tangent there. 

Preston: No, I, I think it's just such a testament to how prolific and life-altering these, both the genes and the neurodegenerative illnesses are.

The, you know, seeing that it affects your family, but that, that's a sign of how many families it does affect that they don't know. There's, there's- Yes ... you know, millions of families out there who are just a little odd, and- 

A. Campbell Sullivan: Yeah ... 

Preston: you know, they don't have a, a niece or a [00:21:00] granddaughter who's a neuropsychologist who can help guide them.

So I, I- 

A. Campbell Sullivan: Yeah ... 

Preston: I'm, I'm glad that your family has you, and also I, you know, I wish that that didn't even need to be necessary. 

A. Campbell Sullivan: Yeah. But I think that's, you know, I think it's, it's amazing that we've gotten to a place now that we can test for these genes and we have these answers, and we can give families these answers.

Because otherwise you're just left with this, like, person that you love who's always been a little, a little quirky- Mm-hmm ... but just completely disintegrate, and you have no reason, you have no understanding as to why. And so I think giving- Yeah ... families those answers can be really powerful. 

[music]: So- 

A. Campbell Sullivan: So 

Preston: now- Yeah

coming to Texas, 

A. Campbell Sullivan: Oh, yeah ... 

Preston: what, what is like a normal day in your life look like at this point? I, I think you've kind of described all the different hats you've worn at the, the various universities, but now kind of working as a PsyD neuropsychologist, what does your life look like? 

A. Campbell Sullivan: I mean, I will... [00:22:00] It's pretty awesome.

Like, I'm really, I'm really happy with the way things are going. so I was recruited down sort of on the promise of, of this Biggs Institute, and I'd been at Hopkins, and honestly, like I, we had no interest in coming back to Texas. I was, I was headed to Seattle. I had a, I had a job there, and we had a whole, all the things we were gonna be doing.

And I applied here sort of on a whim as a backup, and just really fell in love with it and fell in love with the idea of, of The Biggs. And so- Over the last 10 years, I've really done everything. and so I've worked in epilepsy and pre-surgical interventions for our patients who, who are considering undergoing surgery to help alleviate their, their epilepsy symptoms, sort of, you know, a temporal lobectomy.

and so-- And then I've also worked with our patients who have Parkinson's disease, who are, [00:23:00] considering, deep brain stimulation to help, control some of those symptoms. So a neuropsychologist is really helpful there where you do these, these pre-surgical evaluations to see if they're gonna be a good candidate for surgery.

Preston: Mm-hmm. 

A. Campbell Sullivan: it's, it's been a minute since I've done that, so I haven't really kept up on that research. But I helped sort of build those programs to where they are now. And now we have great faculty who's-- have sort of taken the lead and sort of, you know, gone off and done amazing things with that. and then I really-- When, when Dr.

Parker came, it was like I, I met my partner in crime. And so it was really nice 'cause we, we built this Mind Clinic 'cause what was happening is, like, she'd see a patient and refer to me, and they'd wait six months, and then I'd see a patient and refer to her and wait six months. I'm like, "Let's just see.

Let's see patients together," and I love a group project. so we created this, this Mind Clinic, and we call it Management in Neurodegenerative Diseases. So patients come in, they have two hours with me where I do an interview, and then I try to do as much [00:24:00] testing as possible. So what that private practice neuropsychologist was doing in a whole day, I try to condense into 90 minutes.

and we're pretty good at it. And then I-- we score it up really fast, and then I go talk to, Dr. Parker, and we kind of go over, you know, everything I've learned. She usually has found the imaging, and we go over that, and we kind of-- we debrief, and we have our, our discussion, like our case consensus, and then she has her appointment with them.

And then over the years, as we've grown, we've tacked on, like, all the different resources we've had. So we have social work now. We have a genetic counselor. We have RAs for any research that they might be interested in. Back in the day, it was just myself and Dr. Parker, and it was really we had no resources.

And so a lot of this has grown, and so w-we, we have these Mind Clinics. We have a generalized Mind Clinic. We have our specialist Mind Clinics. and so for me, that is the We call it the FTD Mind Clinic, but a lot of times it's, it's just any individual who's having a lot of behavioral [00:25:00] changes. And so they come in, and so I do those assessments.

I work with those families. you know, today my clinical interview was two hours long, and so, like, I have the flexibility of really, like, sinking my teeth into a case when I want to, or if it's really simple and straightforward, we can, we can move it along. in the afternoons, I, I just started showing up to, Dr.

Jackson's ALS clinic, I don't know, six years ago. And she's like, "What are you doing here?" I was like, "I just-- I feel like, I feel like there's a place here for me, but I don't know what it is yet." And so just sort of like toyed around with it 'cause they have this huge multidisciplinary clinic where, ALS, patients are coming in, and they see everyone.

So they see, you know, Dr. Jackson, who's the neurologist who specializes in ALS, but they also see, like, the pulmonary doctors. They see, the, this, the-- We have a speech-language pathologist there. They see a dietician, occupational therapy, physical therapy. [00:26:00] there's some- usually someone from ALS Associat- Association is there.

The genetic counselor is there. I'm there. And so it's like, it's just, it's a, it's a great way to get ex- for the patient to see all of their providers in, like, a single afternoon. 

Preston: Mm-hmm. It's like, it's like a A NASCAR pit stop is kind of how it, it comes to mind. That's 

A. Campbell Sullivan: a really good- Like, 

Preston: like they're- That's a really good- They're pulling it off the track

A. Campbell Sullivan: analogy. Yes 

Preston: They've been scheduled, and then, and you come in with social work, with the behavioral neurologist, with the genetics counselor, and you're like and it's like we're gonna do- 

A. Campbell Sullivan: And everyone just 

Preston: like- Yeah. Like would've taken us- It's amazing ... six to nine months before, like we're, we're gonna knock it out in half a day.

A. Campbell Sullivan: And it's amazing. And it's, especially with that disease, 'cause, you know, it can affect people so differently, but a l- majority of the time there are huge problems with mobility. And so you have... Like, just getting someone ready for a single appointment is, like, moving heaven and earth. Mm-hmm. But to try and do that for nine different specialists, [00:27:00] like every three months, like it's just too much.

It's too much for caregivers. And, and 

Preston: so many of the patients are driving from all over Texas to like- Yes ... we, like a lot of patients that drive two and a half hours, three hours and 

A. Campbell Sullivan: All the time. 

Preston: And 

A. Campbell Sullivan: it, yeah- All the time ... it's so hard to make them come in- We have a huge 

Preston: catchment area ... for multiple appointments.

Yeah. 

A. Campbell Sullivan: Yeah. Yeah, and if you, other- they would, they would be professional patients at that point. So this, I think it gives them, you know, it really, it eases the burden, on the caregiver. It eases the burden on the patient. They have a little bit more of their life left to live with their family, not spend it waiting for a doctor.

so yeah. So that's, that's my main, those are my main clinics. It's mine clinics and ALS clinics, at this point in my career. And so that's my favorite. I love a multidisciplinary clinic. Like, I really... I think working alone in a silo, like in a private practice is like, would be the worst for me. some people thrive in that environment, but I just- I, I also don't thrive- I need to 

Preston: chitchat

in that. Yeah, I, I need to- No ... I need to work on a [00:28:00] team too. And- 

A. Campbell Sullivan: Yes ... 

Preston: it sounds like no matter- It's the best ... where you are as the neuropsychologist, you're able to be a part of the team as... Like, if the disease has to do with the brain and cognition anyway, like you have a niche there and a way to kind of support the goal 

A. Campbell Sullivan: Yeah, I love it.

And then I also, I help lead, we have a, a fellowship, like a neuropsychology fellowship. So we have fellows rotating in every two years. We have a match. and so I, I work with our fellows and I, I help them in clinic. and then I also, like, I lead... My research is really sort of managing these large observational studies.

So, like, I'm the site PI for something called All FTD, and this is a national study. I think there's 19 different sites. and so it's nice because a lot of our, our families, and patients come to FTD Mind Clinic and they're like, "Oh, you know, I am interested in research." I'm like, "Perfect. We'll just take everything you just [00:29:00] did, take your name off of it, and use that for the research part of it."

And so it's really, we're trying to be efficient with our time, 'cause again, it's probably, you know, some of my background in dealing with, you know, my dad and his, his illnesses is like I really am cognizant of how hard it is on caregivers. And so I'm always wanting to sort of reduce that burden. But allowing people to participate in research when there, when there's that interest, because it, goodness, it is so helpful.

So yeah, that's a, that's a day in the life of 

Preston: me. That's, that's a big day. So, well, thank you for, for sharing your, your whole journey and kind of like, I guess, a glimpse into all the different clinics you wear hats in. let's take a quick break and then when we come back, I, I want to hear more about kinda your takes on kind of the current field of neuropsychology.

And I think we've talked, I guess, off camera about this a couple times about, you know, your opinions on the, the aging female brain and, and where, we could see improvements or, [00:30:00] or, or maybe, maybe where we have some shortcomings right now. So, when we come back, we will get into that. 

A. Campbell Sullivan: Sounds good.

Preston: I know we've talked a lot about a- how great and fun neuropsychology is, all the different things you could do. And if I, I guess I wanna hear where are some, where are some gaps? Just like how you noticed with the gaps in the cognitive not otherwise specified disorder, where, where are some gaps that you think we could improve?

A. Campbell Sullivan: As a, as an aging woman, like, I've noticed that there, there's a lot of things that I was not prepared for, and no one had really talked, talked about. And, you know, I, I had some inklings. Like, when I first came to UT, I worked on a project, with the cancer center, and it was working with men who had prostate cancer and were being treated with androgen deprivation therapy.

So it's essentially like, like a [00:31:00] chemical castration to sort of like, you know, reduce their cancer risk and help control their prostate cancer. And what they were noticing is that these guys were having cognitive impairment and a lot more emotionality. And so they... You know, we wanted to put together some, some ideas and to do some testing and sort of really look at, at cognition and, you know, I think we went through a few rounds of that.

But that was the first time where I was really doing a deep dive into sort of hormones and effects on the brain and, you know, realizing that estrogen is, like, very neuroprotective. And I was like, "Huh, that's interesting." But I was like... I was in my 30s. Like, I was like, "It's not... Doesn't really affect me now."

and then, like, as I got older, and I had-- I have a lot of children, so I-- my-- I had my first at 30, I had my second at 35, and then I had the twins at 41. And so, like, I raised a lot of [00:32:00] toddlers in my life. and I noticed that with the, the twins when they were around two, and again, it was sort of like COVID times and it was a little bit a lot going on, but I just realized, like, I was having so much irritability.

And there were times where I would get so angry and I just had this, like, rage. And I was like, "This is weird, and I can't explain it." Like, like, yeah, like, you know, it was... Iggy couldn't figure out which nightgown she wanted to wear, and I would get so angry and it just, like, it was really this distinct change.

And I'm like, "I've done this twice before. Like, what is going on now?" It's not just because there's two of them and it's sort of, you know, amplified, but something felt distinctly different. And then there was a moment where... Not a moment, but I essentially called one of the senior research staff, I called this person a [00:33:00] liar And I was so angry, and I was, like, having all these, like, email battles.

Have you ever engaged in that, where you're just like, like, you're just really angrily writing a letter? Oh, I usually s- 

Preston: I stick to Twitter or X for my battles. I haven't, I haven't ventured into email yet. It's like- But I, I can picture it, yeah. 

A. Campbell Sullivan: This is, like, just, just a battle, like, just with yourself, basically.

But it's like, it's on full display 'cause everyone's CC'd. and I was like, "What is going on with me?" Like, I'm having s- like, such these huge, like, emotional outbursts, and that's very unlike me. And, you know, that was the time I really-- I discovered TikTok, and I am such a TikTok fan. And I think around that time was when they started talking about perimenopausal and menopausal women and, like, I Do Not Care Club, and, like, there was all this, like, talk around it, which really had never, like, been on my radar, radar before.

And I started doing more r- research into this. And we'd aw- I had always known, not always known, but, like, there are sex differences in dementia, right? So, like, [00:34:00] women are, you know, diagnosed or the prevalence of women in Alzheimer's world is, you know, two times that, that of men. So women are at increased risk for dementia.

A lot of times they are diagnosed later in the disease process, so by the time they get the diagnosis, they essentially have more, amyloid and, tau in their brains, and it's because women are sort of better at a lot of these list learning tests. So it's like we can hold onto our abilities a little bit longer and test a little bit better.

and then finally, when you see the, changes in the testing, they start to do poorly on the testing, that, you know, they really sort of like, they've sort of crossed a, a, a moment in time. And so there's just more buildup of, of bad protein in the brain. And the, the differences in the prevalence rates, the fact that we're, we're, we're able to sort of like compensate early in the disease, but we're, we're getting diagnosed and we have more disease pathology, like, it just all sort of like started...[00:35:00] 

I don't know. It was just something I was, I was thinking about more, and then thinking about more with estrogen. And then, you know, I, I think was doing some research into it, and I-- it was back in the early aughts when they did the black box warning on hormone replacement therapy. And so- You know, around, prior to that, women were getting some degree of, of hormone replacement therapy as they were going through perimenopause, and menopause.

And then they, they had this big study, and they, they were using, I think, like equine. I had it, I looked it up earlier, but they were using sort of synthetic forms of, of estrogen and progesterone, and they're at very high rates. And so they're noticing that with that, with those levels, women were, were having a lot of trouble as they were.

They were having, you know, greater risk of, of stroke and, blood clots and cancer, and so all of these sort of terrible things. And of course, they, [00:36:00] like, stop the study, and they put this, this warning on it. So there's an entire generation of women who were sort of deprived of this hormone replacement therapy, deprived of this estrogen, and that we know that estrogen is really protective for the brain.

And so, you know, I'm not saying that entirely accounts for this, this huge difference and this increased risk in, in women, but I'm sure that it, it sort of, it, it contributes to it. And so I, when I was in my, like, early to mid-40s, was starting to realize, like, this is really problematic. Not only the emotions, but, like, I was having more trouble concentrating.

Like, I was having trouble coming up with the right word, and you know, I'm not alone in this. I was, like, seeing it sort of, like, all over my FYP. My friends were describing the same thing, and I was like, "I don't even know what to do." And it, just through circumstance, like, a friend of a friend's husband happened to be an endocrinologist, and he specializes in menopause.

And I was like, "I didn't even know that was a thing." [00:37:00] and like, I work in the medical field, and like, I, I'm in a hospital. I know a lot of doctors. I've never heard of anyone specializing, in menopause. And so You know, I, I went and saw him and, like, we started slow and, like, started to get the, this estrogen patch and, like, the progesterone and, like, my sleep got better, my moods got better, and it, like, at a certain point I was like, "I feel back to normal."

So now I'm, like, the biggest proponent. If you're a candidate for it, like, like, let's go and let's, let's start this journey, because I have so many, like, people on my teams, people, patients coming in where it's like they're reporting all this cognitive change and, you know, we start du- du- you know, digging into it and, like, they're having a lot of trouble with their sleep.

They're waking up two or three times a night, and it's not because they have obstructive sleep apnea. It's not because they have to go to the bathroom. They're just waking up and they're sort of wired, and they're having all this difficulty at work. And so, like, there are definitely changes, [00:38:00] happening that really aren't being addressed, and even now, like, they...

I think they reversed that black box warning in 2025, and so, you know, I, I think that's helpful and it- we're starting to see some changes, but that's like, that's an entire, like, almost 20 years. Over 20 years. 

Preston: Yeah. It, it's a really interesting timeline because I remember reading about how in, like, the '80s and '90s everyone got OCPs, everyone got hormone replacement therapy- Yeah

and then it kind of got vilified. You know, this, this- Mm-hmm ... has an increased risk of cancer, increased risk of- Mm-hmm ... blood clots, stroke, et cetera, and then it was like nobody gets it unless you have severe hot flashes, pain, symptoms. Yeah. And then as far as using it as a way to treat cognition or mental illness, that, like, that was, like, an aside.

for us in- Yeah ... psychiatry actually, there's a, a bimodal distribution of schizophrenia and, like, women can develop, like, almost, like, later in life [00:39:00] schizophrenia between the ages, like, 45 to 50, and it's usually around the, dip in estrogen. So- Hmm ... we do our own studies- Interesting ... about the, like, neuroprotective effects of estrogen almost, like, augmenting against things like psychosis.

A. Campbell Sullivan: Mm-hmm. 

Preston: S- but it's really fascinating that, like, you were experiencing these, Firsthand ... symptoms personally, and then instead of just being like, "Ah," you know- You know, that's, that's just me, hormones going crazy. You're like, wait, I'm a neuropsychologist. I can think about why my affect is changing, why my distress tolerance is affected, and like, let me actually like dig into this.

A. Campbell Sullivan: Fix it. Yeah. And that's what I think was so hard is like, you know, this, like none of the women, like, you know, my, my mother or anyone of, of her age or generation like really got hormone replacement therapy or knew about, you know, there are options other than just sort of like white-knuckling your way through it.

but it also explained like a lot of their behavior. It's like, oh, [00:40:00] okay. So they're not entirely cuckoo bananas. 

Preston: Do you know if hormone replacement therapy has any effect on your like future risk of developing dementia? 

A. Campbell Sullivan: It does. So, so taking it sort of within 10 years of menopause seems to be protective.

Taking it sort of after that window, it does, it might, sort of increase your risk or have r- little to n- to no effect. So there definitely seems to be some protective effects as long as you're sort of taking it in, in that window. But it's also, this is an area where we haven't really studied it, or, or, you know, our data's a little bit outdated, and I think this is an area that's ripe for investigation.

And so just last year, so we know we have, an Alzheimer's Disease Research Center, an ADRC here, and all, it's one of 34 in the country And every center who has an ADRC, we all use the [00:41:00] same test battery and questionnaires, and we call it the Uniform Data Set, or the UDS. And so last year they updated the UDS, and it now is starting to ask questions about when you went through menopause.

Are you now... Did you get hormone replacement therapy before? Are you getting it now? So this is something that's gonna be, I think, really helpful for researchers and scientists, is, like, we're gonna have this data all across the country on thousands of women, and not just, like, at one time point, 'cause the ADRCs are designed to have really strong follow-up.

So we're gonna have this data longitudinally, and we'll be able to sort of track this, as, you know, individuals start to become symptomatic or have more changes in their thinking. so I think it, it's a great time to really start focusing on women's health, focusing on, you know, what are the protective factors.

because there is something interesting ab- about, like, you know, we don't get diagnosed until we have a lot [00:42:00] of, of tau burden in the brain. and so there, there's something a little bit interesting in that regard. 

Preston: Yeah, even the, the ner- the psychometric testing focus is, like, biased towards screening for men with these problems.

Absolutely. And, and women fall under the radar. Like, you know, w- we, you learn till the cows come home about chest pain, shortness of breath being the, you know, the primary symptoms of a heart attack, and then, women come in, nausea is their, their primary symptom. 

A. Campbell Sullivan: Mm. 

Preston: But it, but it's- 

A. Campbell Sullivan: Interesting ... 

Preston: it's half the population, you know?

It's not like one is the standard- ... and the other one is, like, a man plus hormones. Like, so it sounds like, too, even within your, like, kind of psychometric batteries, there's probably a lot of work to be done about, like, adjusting it to, to better screen for, for women in the prodrome. 

A. Campbell Sullivan: I definitely think we can...

There's some, some latitude there, and we can sort of improve our precision and improve, like, how we're measuring things. I mean, we do our best with norms, and we try to control for sex so that we can [00:43:00] sort of reduce those differences, and we can compare, you know, me to other women like me. so, you know, we can identify those, those problems earlier.

But yeah, you're absolutely right. We need, you know, we, we need to update a lot of our tests. 

Preston: Absolutely. Or, or even if psychometric testing isn't, isn't the best one, then the fact that we're focusing on it, like we should be focusing on something else to, to better screen. So- 

A. Campbell Sullivan: Absolutely ... 

Preston: I mean, I d- I think It's honestly probably not on my radar, maybe should be to, you know, look into hormone replacement therapy for, you know, perimenopausal women who are, whose primary complaint is like cognitive difficulty or, or sleep problems.

Or sleep or- Yeah, 

A. Campbell Sullivan: and- ... or like the irritability. Yeah. 

Preston: Yeah. So, and, and it's really interesting even just like what you're saying about it being neuroprotective in the future or having like immediate like symptom relief rather than like putting this person on Trazodone, a bunch of SSRIs, like trying to stabilize it.

Otherwise, just [00:44:00] like, oh, you know, let's... We know that there are risks of hormone replacement therapy, but we, we're, we can't be dogmatic about the risks and not appreciate that there are benefits to it. 

A. Campbell Sullivan: But I think a lot of the risks are, you know, we're finding that they are reduced. So like, you know, the concern with like blood clots, is really high with, with oral estrogen, but the patch, you know, it sort of, it reduces that risk.

Preston: Right. 

A. Campbell Sullivan: Right. and so like, there's, there's different, there's different, you know, ways to prescribe and to sort of like manage this so that we can sort of address the symptoms, and really give relief, and neuroprotective benefits to, to these women. So Yeah, I think, I think it, I think it's an important gap.

I'm, one that I'm, I'm focused on more and more as an aging woman, 'cause I do wanna protect my brain. 'Cause every time, every time I, I forget a word, I'm like, "Ugh, God, that's my logopenic aphasia," like- 

Preston: Yes ... 

A. Campbell Sullivan: just bursting through. 

Preston: It's just- So ... here it comes. [00:45:00] Wow. Yeah. Well, thank you. I, I really appreciate that take.

I think I'll probably fold it into, to my own practice, too, when I'm evaluating, kind of women in that range. Great ... I think that was- 

A. Campbell Sullivan: Yeah ... 

Preston: most of what I had for today. do you have any other kind of, like, last points, hot takes, maybe predictions about the World Cup? 

A. Campbell Sullivan: No, but I will say we were in Boston, with the Tartan Army, and that was, like, that was really fun.

Mm-hmm. And so- 

Preston: When, when they drank 

A. Campbell Sullivan: all the beer? My name is Campbell. Yeah, did you call them

your- Yeah. They- And, like, allegedly I come from- They drank all the beer at the 

Preston: Boston... 

A. Campbell Sullivan: It's just, like, they just... I mean, I've never seen so much- 

Preston: Oh ... 

A. Campbell Sullivan: like, support. It's, it was really good. Yeah, I, I haven't been following it since, since they, they got kicked out. 

Preston: Yeah, it's, it's too 

A. Campbell Sullivan: bad ... but yeah, I'm, I'm just gonna, I'm gonna go back and enjoy my TikTok hour before, before I go to sleep.

Yeah. 

Preston: So- I, I- Yeah ... you know what? I think that's a great plan. I think the [00:46:00] USA is playing tonight, so I'll probably be catching that. 

A. Campbell Sullivan: Okay. That sounds 

Preston: good ... if, if you are, like, hoping to have anyone reach out to you on socials, where... Or if people just wanna ask you more questions, where can they find you?

Oh, yeah. 

A. Campbell Sullivan: Yeah, that's a great, that's a great question. I don't technically have any of the socials. I should probably, I should probably 

Preston: work on that. Yeah. Well, maybe like your- your LinkedIn or your email. 

A. Campbell Sullivan: I do have a LinkedIn. Your Snapchat, 

Preston: any of those. 

A. Campbell Sullivan: Yeah. You can find me on LinkedIn. I don't know wh- It's probably just A.

Campbell Sullivan. so go, go from there, and 

Preston: we can- Okay ... we can go- Okay. And then we'll, we'll, we'll navigate it ... go forward. And then, to all those of you who, who are listening, if Dr. Sullivan, decides to get into the TikTok, posting game, we will I'll let you guys know. We'll post on the, the How to Be Patient story.

We'll, we'll help you find her 

A. Campbell Sullivan: I always ask people what they wanna do, like, their sort of alternative career, and, like, mine is slowly becoming, like, a, a TikTok influencer. I really... [00:47:00] I think that's gonna be- Well- ... that's gonna be my retirement plan ... 

Preston: I think you'd be great at it. There's, you know, if you're a fixer who likes plugging gaps, there's absolutely a gap on TikTok for well-educated neuropsychologists that aren't just using, therapy speak to, to to push pseudoscience.

So, 

A. Campbell Sullivan: like we would- I really just wanna talk about makeup, though. So it might be... We can talk about the brain and makeup. 

Preston: Here's the thing. 

A. Campbell Sullivan: So there you go. 

Preston: You could do get ready with me while I put on a- ... full beat of makeup while I tell you about my opinions on estrogen's neuroprotective, factors. I, I think that's, like- There you go

absolutely a video that would pop off. So th- Okay ... there's plenty to play with there. 

A. Campbell Sullivan: Perfect. 

Preston: and honestly, and that's why you lull, you, you lull the audience in, right? They're like, "Oh, I wanna learn about makeup," and then you're like, "Gotcha, you're actually gonna learn some neuroscience. Surprise." 

A. Campbell Sullivan: Let's talk about the behavioral variant of FTD.

So, 

Preston: yeah. 

A. Campbell Sullivan: All 

Preston: right. 

A. Campbell Sullivan: This 

Preston: was perfect. Well, thank you so much for being on here. This was a ton of fun. to our listeners, thanks so much for supporting through this [00:48:00] whole, season four thing, four seasons. It's, it's wild that we've made it to this point. It's impressive ... yeah. If you want to watch the full, video episodes, they're g- on, gonna be on Spotify or on YouTube @itspresro.

Thanks again to everyone leaving the comments. I think we had a, a comment this week that was, "Could you make an episode about studying for the board exam?" And that was from Tumul. Yes, Tumul, we can do that. That'd be pretty easy. Well, not the studying part. Stu- studying part's hard, but making the episode part, it's no problem at all.

anyways, we're your hosts, Preston Roche. Margaret Duncan will be joining us again next week, and Campbell Sullivan Saidi is our guest. Our executive producers are me, Preston Roche, Margaret Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portizo.

Our music is by Omer Ben-Zvi. To learn more about our program disclaimer and ethics policy, submission verification and licensing [00:49:00] terms, and our HIPAA release terms, go to howtobepatientpod.com, or reach out to us at howtobepatient@human-content.com with any questions or concerns. How to Be Patient is a Human Content Production.

Thank you for watching. If you wanna see more of us or if you wanna see... This is Lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They pr- they probably exist for real.

But in the meantime, I'm just gonna pet Lilac, and then I'm gonna go dance in the [00:50:00] background