Welcome to the Psychopharm Podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice diagnosis for treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality. Good morning, Dr. Malzberg. Good morning, Dr. Fu. How are we doing? I'm okay. I have a good quote for you. Okay. It's from Henry Stack Sullivan. Psychiatry studies interpersonal relations, which occur only in interpersonal situations. Such situations imply something more than the presence of two people somewhere. They concern two people who are involved with each other, and that we call integration.
Oh, lovely. He's a great writer. I highly recommend reading him. Well, let's continue on with the content from the last time.
And for context, integration used to be the thesis of our podcast. I think it still is.
I think it still is.
It's just less explicit.
We've been talking about how to define things and understand certain concepts, but how do you figure out subtle psychosis? You asked that earlier. I would say that you have to be watchful and open to subtle signs, and I do find that using the countertransference is useful. I don't mean your negative countertransference necessarily. What I mean is that if you pay attention to what it's like to be with a patient, what do you the clinician feel inside emotionally, you're going to find trends for yourself with certain subtypes of patients.
The psychotic patient, the narcissistic patient, the depressed patient, the anxious patient. Everybody has their own unique or not so unique reaction emotionally, interpersonally to types of patients. And for me... My reaction to psychotic disorders, delusions and paranoia is sort of a feeling of the uncanny. It's the same feeling that I got when I was younger reading P. Lovecraft for the first time. It's a little frightened, a little I don't know what I'm dealing with kind of feeling.
I don't know if you get anything similar or what do you usually tend to feel when somebody begins to discuss delusions or psychotic disorders.
Well, talk to me a little bit. So explain, because uncanny, not everyone kind of knows what that means. Can you maybe give us a little bit more of a feel of what you mean by that?
Well, it's qualia. And I don't know if it matters for me to explain more than that. What's more important is that people reflect on how they tend to feel as a clinician in response to specific types of patients. And it may be any variety of feelings. There's no wrong feelings here. It's your automatic response. What's important is detecting your own automatic response. It's like trying to describe to you what red looks like.
I don't think it's really.
Well, uncanny, though, is not everyone knows even what that means.
I know, but again, I can't describe what Red looks like. I can't describe what Uncanny looks like. I suppose I can tell you the body feelings. The body runs a bit cold and, you know, there's a sense of danger maybe or attack coming. That's how I feel in the countertransference, not from the patient. It's that there's danger. It's like being told a scary story, because often it is a scary story.
If you believe that those experiences are real, and of course, for a psychotic patient, they feel what has happened to them as very, very, very real. That's terrifying most of the time to be monitored, tracked, harassed. Otherwise, attacked. It's an awful place to be.
When you're saying the uncanny feeling, are you talking about patients who are very explicitly and it's very obvious that they're psychotic or the more subtle, quiet ones that are talking to you against their will? Not against their will, but they're in the ED and you happen to get consulted.
I mean, both is what I'm saying. I'm saying that the obvious ones, you get a big feeling, and then for the subtle ones, it may be a small feeling, but it's a sign. It's not a diagnosis. It's just a sign that you can reflect within yourself that says, perhaps I should question or get more history on this particular slice of possible psychopathology.
I'm trying to... I have a difference between the subtle and the more overt ones. For the more overt ones, I get, I think, more frustrated and confused. If I feel like I'm hitting a wall and every thread I pull... I get a ton more threads that make less sense. And I just keep pulling threads. And I get confused in that. There's like an inability. There's something that I can't understand.
And the more I try to understand it, the more confused I get. Now, I'm less of a... I'm very cognitive. So feelings for me aren't as helpful. It's just different cognitive feelings that I experience. As you said, quality is hard to describe. Now, for the subtle ones, that's when I get that uncanny feeling. So when there's just some... It's more than confusion. It's like a, I guess this one is more of a feeling.
It's like a pit in the stomach. It's this feeling that something's not quite right and I can't put my finger on it. It's like, I don't know.
Yeah. Look at a mannequin that would fall within uncanny valley and see how you feel. I would give that as a general instruction to other people. You may not have this reaction to psychotic disorder patients. Everyone has unique reactions. I've run this exercise with lots of trainees. Everyone's different. It doesn't matter what your reaction is. As long as you have a pattern reaction, you can use it as a clinical signal.
Again, not diagnostic, something that tells you maybe I should look into this direction. And by the way, some people are fundamentally more thoughts based. Some people are fundamentally more feelings based. That's just maybe your temperament or personality. But regardless of which one you are, I would recommend that you try to go left a little bit. You try to go into your weakness a bit and practice for whichever one you're more uncomfortable with, because we do have both.
Every single one of us try looking into reflecting upon your thoughts and If you're more of a feelings type person and reflect and look into your feelings, if you're more a thoughts.
Absolutely. And the same goes not just for patient encounters, but in your individual therapy. Not that I'm prescribing anything, but as someone who does get cognitive, like it's been super helpful for me to focus on things I feel in day to day life, pay more attention to, you know, heart beating, tightness of hands, little things like that, that like don't come natural to me because I'm In terms of how I pick up on how I'm feeling, it's like, oh, this thought pattern, whenever I think these sort of things, that usually means that I'm upset.
And that's how I naturally work. And it was helpful for me to add that extra component, which felt very unnatural. And as you're saying, depending on which blueprint you are, the other one will feel less natural.
Yeah. So that's kind of a starter or screener almost, right? That's just like getting a positive of PHQ-9. It's non-diagnostic, just tells you the interview in a certain way. Another thing I would recommend to suss out subtle psychosis. There was something I read from Harry Stack Sullivan. I don't remember if he was writing about working with primary psychotic disorders or not. But he made a recommendation, I think, for the paranoid patient that you shouldn't sit facing them.
that instead you should sit alongside them so that you're both sort of facing out at an angle towards the same point in space, as if you're both sitting together and looking out at a third party. OK, I did this literally when I was doing more in person stuff and you can do it figuratively in how you feel and interact with the patient. But I think this helps.
It's sort of using triangulation. Maybe you could argue that's a defense to help the interview. But you want to externalize the bad object or the feared object. You want to sit together with the patient and try to harness at least a little bit of a feeling of you and me against the world. Because for somebody who is being biologically or personality primed to feel that way, to think that way, if you don't do that, then you're going to become the persecutor, at least in that moment.
So it's important that you sit with the patient, not next to the patient literally, but like with the patient in your heart, in your thinking as you interview. Otherwise, I think the patients will detect your separation from them psychologically. and the interview will not flow as well.
Yeah, now I haven't read any of his writing specifically on psychosis, but my understanding of the general gist of his work, the core of a psychiatric appointment is two people meeting together, and the explicit kind of thing is, The one person is an expert in terms of, you know, he was dealing with therapy, so like interpersonal relations, but here we're talking about psychiatric conditions. And then the other person is expected to derive some sort of benefit through the encounter with that person.
Now, in that process, there's a lot of hindrances, things that come up. So there's things that are coming up from the provider in regards to the provider is going to feel emotions like anger or boredom or responses that are not appropriate that they need to deal with in order to best control. deal with that situation. And then the patient's going to have things that come up that are getting in their way to getting better, whether it's defenses, anger.
And if I'm going to put into words what you're saying is it's working with the pathology of psychosis, of your siding with them and looking outward because, you know, in some sense, a big defense mechanism of psychosis or paranoia in general is projection. So you're working together rather than joining in with the persecutor. You're, like you said, combining in some sense psychologically with them and looking out and trying to figure out this problem together.
Yeah. And that's where I also say a lot. Try to live in the world of the patient's belief, especially. Well, always, but especially when interviewing for a psychotic disorder, you need that suspension of disbelief. not total credulousness, but you need the same suspension of disbelief that you might have watching the new Avatar movie, you know, Blue Aliens. You're not sitting there skeptical. How could this be? I bet there are people who do that and they don't like those movies.
But when you watch a piece, when you watch or read or consume some fiction, you're living in that world. You know, it feels real to you, at least, even if you don't fundamentally believe it. It's that same process. Live in the world of the patient's belief as you ask the questions, even with skepticism, because I do think that internal experience matters. It changes something, probably micro expressions, you know, different ways of phrasing or intonation i i think something gets detected if you're more separated psychologically from somebody in an interview and you're just not going to be able to get a good interview if you can't manage that aspect i want to i want to go into
a little bit more detail here and i think you feel free to correct what i'm saying When you're first getting to know a patient, you're really focusing on the alliance. And when you side with them, when you get in their world, when you live through their eyes, then you're building the alliance in a way that they can work with you. Now, I don't want to take it too far in that treatment doesn't consist of you living exclusively in their world how they see things.
And I actually see...
Correct. This is assessment.
This is assessment. Because I do worry, there's so many patients I see now where they're presenting complaints are taken to be what the problem is. You know, Doc, I have depression and everyone's out to get me. So then when I see so many providers, they try to treat the depression, the depression, the depression, the depression. No one's doing the assessment to look at other underlying things. Is this bipolar?
Is this personality disorder that's kind of going untreated? And Now I see providers go too far in that we fully trust their perspective on how things occur. It's a process of assessment, of being in their world to understand their world, and then coming back to yourself and using your expertise and your pattern recognition and your experience with how patients report symptoms to formulate a diagnosis that will actually in the end help the person.
The person's perspective on what's going on and their view of the solution, What they might not understand is that their idea of the solution might not be the correct step or might be the problem.
Yeah, that's a great general summary, global summary of how to approach that across all patients. It makes me think of actually some... Maybe diverging advice or at least something that on the surface can seem a similar advice that is that is often said about dealing with delusions. Don't argue with the delusions, but also don't agree with the delusions. Right. You have to keep in mind that when you live in the world of the patient, you're not.
agreeing with the delusions necessarily. When you are working with patients more treatment-wise, you're also not totally disagreeing with the delusions. It's a stance that's frankly more neutral. How do you do that? Well, I think that what you do is that you should always acknowledge and make apparent that you have an understanding of the patient's reactions, especially emotional reactions to the delusional network and its effects. OK, that's not the same as saying, yes, your neighbor is implanting devices all throughout your apartment that irradiate your urgesis.
It is saying, boy, that sounds terrifying and awful for that to be happening all the time. And I'm also worried that this is going to make you so mad you're going to do something. I don't want you going to jail. So can you make sure that if you get really angry about that, you call 911 or you go to a hospital? That's an aside. But this process, you could...
put that under the umbrella of empathic mirroring. So that is a very important technique, I think, both in the assessment and treatment phase, especially when you talk about delusions, especially when you talk about psychotic experiences that many people can feel are foreign to them. You still need to use your empathic mirroring technique and skills. This can also arguably have been referred to as mirroring statements, you know, reflective statements, or in some definitions, containment.
What are you doing when you do empathic mirroring? You're basically demonstrating to the patient that you have some kind of a experience emotionally based on the things that they're telling you and based on their internal experience. So the simplest way is to actually comment on an emotion that you suppose or that you perceive the patient is going through. Wow. Going through that, you must have been so angry and sad.
Right. You can say it with more or less certainty. You can even make it part of a question. You can say. And what do you suppose you felt because of all that going on? Was it a lot of stress? Was there a lot of fear? Right. There's lots of ways you can do this. And you can also do it simply by not saying words, but even nonverbal interventions.
So you can say hmm. Hmm. Right. You're conveying some kind of motion and you're conveying it through your face, too. Right. So empathic marrying is really important. I would use a lot in the dysregulated patient and in the guarded and paranoid patient. Not too much. I'm not asking you to be super effusive, to lean in real close and go like, tell me, tell me, I'm such an empathic and caring doctor.
You know, you can trust me. No, don't do that. Okay. Be real. Simply perceive what's going on. And if you can demonstrate to a patient that you have an understanding of their internal experience and their past experiences, that's the important part. That's the empathy. On top of that, important in sussing out, assessing, and reading is clarification.
We should have a full episode on the subtleties of Dr. Fu's nonverbal grunts.
Well, I mean, we could have an episode on psychodynamic technique.
I'm just making a joke. Keep going.
Keep going. Okay. Clarification is also a pretty important technique. This is obvious. This is the one that most people are the most familiar with. And this is one that probably is almost 90% of psychiatric interviewing today for a lot of people. Simply asking questions to get more information about something without challenging or changing the narrative. That's a little bit tricky because if you challenge or change the narrative, that's not really a clarification anymore.
You're not just getting more information. You're starting to diverge the narrative and you want to try to prevent divergence from the narrative as much as possible. That includes the patient's own diversions, actually, unless you're trying to observe thought form disorganization. If a patient is talking about, let's say, some kind of delusional process, you don't want to start asking questions that that process stimulates in you, that you're curious about the patient.
You don't want to go like, oh, you know, actually, you mentioned your mother. Can you tell me about your mother? Oh, that brings you off of the narrative of the delusion, for example. You want to stick with the narrative of the delusion. But if the patient becomes distracted in the same way, you might just say, Oh, actually, just a moment. I hear what you're telling me about your mother and how she was so stressful for you when you were growing up.
That must have been pretty challenging for you all those years. But you were saying something quite interesting there, and I wanted to know more. What's happening with your neighbor again? Tell me about that. Okay. These kinds of open-ended techniques... Empathic marrying the clarification, living in the world of patient's belief and occupying the same space as the patient psychologically, interpersonally. I think that simply by doing that and eliciting narrative, that is the most effective way to get out subtle psychosis, because it's very, very, very easy to instead take the position of the interrogator.
the expert, the master, the person who's saying, I'm going to do something to you and I'm going to get something from you. That's not a very facilitating environment to get information that someone is scared about and scared about being judged for. So these are my tips in terms of getting to subtle psychosis.
Oh, and for the topic... of history taking, I want to remind people that there is also sort of a unique approach to history taking when it comes to voice hearing. And I'm saying voice hearing again because I want to use nonspecific terminology until we get more history and get closer to a diagnosis. Like many things in medical histories and psychiatric history, history of present illness, you can use the old school mnemonics like old carts, but modify them a little bit to take a history on hearing voices.
What's old carts? Onset, location, duration, character, aggravating and alleviating factors, radiation, timing. So don't forget to apply these wherever possible, even to voice hearing. Onset is important. When did the voices start? When was the first time you can recognize hearing voices or notice hearing voices? Location. Where do you hear the voices? Do they sound like your own thoughts? Do they sound like they're coming from inside your head?
Do they sound like they're coming from outside the head, left or right side? No particular direction, far away or close. Duration is important too. This one helps also for tracking the efficacy of your treatment. How often and how long do you hear the voices? Is it 24 hours a day? Is it mostly at night before bedtime? Is it just for a few hours a week? Everyone's going to vary on that one.
For character, specifically for voice hearing, I like to think of characters. Who are the voices? Are they always the same people? Can you recognize or describe the voices to me? Are they young, old? Are they children, adults, men, women? Are they people you recognize? Are they old? Are they young? Are the people you know? Or are they strangers? Is it always the same people or not? These are all things that I would consider characters.
And on top of that, I would always ask, even if you can't, well, even if they do recognize who the voices are or they don't, you can ask, who do you think they really are? And what do you think these voices are? Why do you think you're getting these voices? These are all important questions that can help you build data, gather data to get to a diagnosis.
Aggravating and alleviating factors is pretty straightforward. That's anything in particular that they've noticed that made things better or worse, sleep deprivation, level of stress, fear, drugs, anything. For radiation, I would think of that more as associated symptoms. Do you notice anything else happening in your body or in your feelings or your thoughts when you get these voices? What happens when you get these voices? And it can be associated symptoms and behaviors.
And of course, timing, which I think I might have already touched on, actually. But, you know, what time of the day do you hear the voices the most? Is there timing to it? Once you've gotten a thorough history of voices, I would ask again, even if you've asked before, the whys. So what do you really think is causing this? Do you think the voices are real? Why or why not?
And you can ask multiple times, well, are you sure this is just random voices? Maybe there's a reason for it. Or do you think it's just from a mental health condition? Is it your head, your brain? Is it something else? Ask why, ask why, ask why, why? Because, again, these are experiences that lots of patients rightfully feel and expect that they're going to be judged negatively for, right?
There's stigma. And in the untreated psychotic disorders and in the treated psychotic disorders, there's a lot of paranoia. So we're already working with somebody who's primed to not really trust the process. And so the likelihood of giving inaccurate answers is elevated because of rational fears.
Okay. Now, everything you're saying is so important for, as you mentioned, assessment, building rapport, building alliance. I now want to take it to the next step, which is, okay, so now... There's going to be a gap at some point with what you think is the best next steps for the patient and what the patient's going to think is the best next steps. How do you bridge that gap?
You mentioned some techniques in regards to seeing things through the patient's world and in regards to discussing treatment. And I can think of one easy example I had. which I'll discuss and then I'll turn the question over to you. There was a patient who was discharged on the ACT team. And ACT means they've been hospitalized more than four times and they have pretty much the highest level of care, but they needed a bridge for like three months before they were on that ACT team.
And the patient was refusing to take the clozapine. And The way that I worked with the patient was I said, listen, I don't know what happened in the hospital. I'm making this case up. She was talking about all these crazy things that happened in the hospital in terms of radios and all these other things and being persecuted and the CIA was coming on. And I said, listen, I can't say for sure what happened in the hospital.
I do know that a lot of patients come out and it's a terrible experience and that they were around. They didn't feel safe. I see that all the time. Now, I can't speak for your diagnosis because we don't know each other well enough and we haven't worked for long enough. What I can say is if you don't take your medications, you're going to end up back in the hospital.
And if you do take your medications, then we have a case keeping out of the hospital. Now, that one was an easy one because I had the system on my side. And normally I have to use a little bit more tact because I can't just make stuff up. I can't say like, I don't think you have schizophrenia, but take your medications. I wouldn't go that far. So that was a little bit of an easier one to build rapport and figure out mutual goals.
But yeah, I do want to hear you talk about narrowing that gap for when, you know, so now you have your assessment, you have ideas of what's going to be helpful for the patient. How do you bridge the gap?
I think you always have to start with what's the problem for the patient. What is the patient able to see as a problem? And sometimes they see zero mental health problems. So then you'll have to externalize. You'll have to find out what they see as a problem in their lives and find ones that you can reasonably connect to some kind of mental health condition or treatment process.
And I'm not saying that you'll always be able to find that. You may not always be able to find that. You gave a good example, right? Being hospitalized is a problem. That's an easy one. Most people do not want to be in the hospital. It's not a good experience. So you can come to an agreement. Even if we disagree about what's going to help you stay out of the hospital, it seems like the system will probably try to hospitalize you if you don't take the medications.
And on my end, I am worried that there is some kind of an underlying issue medical process that makes it more likely for you to go to the hospital if you don't take the medications. So I know we don't disagree. I know we don't agree that it's an appropriate treatment for you. But medically, as your doctor, I am recommending it. I think you should continue it because I think it is going to help you.
And if you have side effects of problems, we should talk about that. That's one example. Right. Other popular ones, at least for the psychotic disorders that people can agree on are things like thought disorganization. Sleep quality. and paranoia, fear, and if they can perceive them as hallucinations, hallucinations. And failing those topics, if you can't agree on those, most people can agree on stress. And I can say in a true primary psychotic disorder, your stress levels are going to be a lot higher off the medication.
I can tell you that. I can guarantee it most of the time. So that may be an area where we can mutually agree on that is a problem and that should be treated.
Now, I think we also wanted to dive a little bit into first steps of treatment for psychosis. And we talked a little bit about how outpatient psychosis is not an emergency. Yeah. Walk me through your general principles for thinking about first steps of treatment. And when you say outpatient is not an emergency, what is it that you're encompassing there?
Well, what I mean is, again, what's more important is building the alliance and getting a good history. Because unless you're sure, reasonably sure of what you're treating, I don't think you should throw on random medications. You're going to cause side effects. You're going to cause problems. You want to make sure the risk and benefit is there. I'm not saying that a specific proportion of your patients should be given watchful waiting or not.
It very much depends on the patients that you're seeing. So it has to be individualized. But don't forget that you don't have to prescribe a medication every single time. On the same note, you can still prescribe a medication if it's totally medically indicated and the patient is refusing. Okay, you can say, listen, I know you disagree, but we've talked about the risks and benefits of this medication, and I think it's indicated.
It'll be there at the pharmacy waiting for you. And I'd like you to take it. I'd like you to think about it at least. But even if you don't take it, I still want to see you next time. Okay, I often do this with very high-risk patients where there's dangerousness. I think at least there's a chance. There's at least a chance that they may take the medication.
So remember your options. You don't have to act too quickly. Secondly, when you do pick the medications, just as Stahl's textbook recommends, I think it's super important to pick weight sparing medications when possible. Yes, that trades often for risk of akathisia. or maybe sometimes even risk of tardive dyskinesia if you're picking a first generation. But, you know, especially for young folks, try to spare your patients from long-term metabolic syndrome or worsening of metabolic syndrome.
But treat the akathisia too, right? You need to watch out for and carefully pick out for akathisia and tardive dyskinesia. These are real side effects and will happen to a lot of patients on long-term antipsychotics. Also, akathisia is not just something that you can see on the exam. That's the most severe akathisia possible. Largely, in my experience, outpatient akathisia is subjective. It's something that the patient feels.
They can suppress it, especially in the encounter with you, or there are times of the day that it feels worse than others, especially the mild versions where it kind of just feels like leg twitching or basically restless leg syndrome. symptoms in bedtime. So assess, watch and ask, especially with patients with primary psychotic disorders. When there's negative symptoms, often the symptoms will not be reported to you unless you explicitly ask about it.
So basically I'm saying don't use cerebral.
Yeah, and I can – when you say like the weight-sparing ones, the ones that tend to have the lowest average risk of weight gain, big ones, aripiprazole, ciprazidone, lurasidone, cariprazine, brexpiprazole. The biggest offenders that we know are the pines. Whoa, whoa, whoa. Hold on. Haldol. Don't forget Haldol. So I was going to throw Haldol in there, but we're talking generally first line. So Haldol absolutely is – It's a first gen, so you're much higher risk of EPS and tardive dyskinesia.
Oh, let me make a note. If you dose Haldol with his chloropromazine equivalents like Risperdal, it's a lot more better tolerated. That being said, some people do need high doses. Yeah, chances are when you get there, you're on a patient who needs a higher dose. Well, not for me. I reach for it pretty quick.
That's for another debate. The worst ones that we're talking about are the pines, olanzapine, quetiapine. uh clozapine obviously but that will not be your first line choice um well some
people argue it should be but frankly most people don't want to do the labs i wonder how many people out there are violating the labs do they know that uh with the absence of the rems the recommendation is still to follow the exact same lab
schedule just that there's no rems if you listen to the top 10 clozapine things with me and roxanne we did bring that up right Just because the REMS is gone doesn't mean that all the problems are gone. Well, I think that's everything we've got. Hopefully it was helpful. All right. Have a good one.