Psychosis: History, Delusions, Diagnosis, Theories, and Modern Care

Dr. Food, do you like paradoxes?

Uh, only when I dislike them.

Do you want me to... Um, the liar says something about a rule concerning when they lie. Isn't that correct? It's... This sentence is false. Right. Yeah. Um... Or, I'm a pathological liar, as a statement, right?

It's pretty interesting. It reminds me of, I believe it's a Lacanian concept, that essentially language cannot capture everything. There's always some element of truth that has to be left out. The real, basically. We try to describe reality itself using language, symbolization, but there's always something that's going to drop out and not be captured. Similar to this, of course we have to take on faith because I'm not terribly good at math and I can't confirm that guy's work.

Well, I see where you're going. So, you know, step ahead of you there. I'm not going to argue with that. Let's explore it. Tell me more about what made that come to mind and where that came from.

That must be quite invalidating to feel that when you're talking to me. You know, just not getting a sense of agreement and wanting it. Must be frustrating. I would expect that anyway. So for the listener. This is not a therapy session for you.

Do you think I disagree with everything? I don't know if I disagree with everything. And there's probably the first answer.

I do hope that it can be more of a yes and kind of thing, but I will say I'm probably high on disagreeableness. I don't know if they call it that, but agreeableness is one of our big five personality traits, and I'm not very agreeable.

Any agreeableness that you see I would say, has been a learned quality in order to get on in the world in a way that's relatively peaceful.

I think it's psychosis. I was hoping it's psychosis. You didn't seem too jazzed on psychosis.

dialectics very important I gotta tell you, for a guy who trots out the word dialectic pretty frequently, I'm describing myself right now, I don't know if I can define it to you so accurately. But, you know, that's one of those things. And at least for dialogue, I do think that's quite important in reaching truth, coming to some kind of consensus reality.

Yeah, definitely. Well, you know, that is one of the theories of psychosis, right? That it's a breakdown or an alteration or some kind of a deficit problem. in somebody's ability to form dialogue, speak language in a way that is transmittable to someone else, right? To speak the same language as you. And I don't know, some people might say, what are you talking about? We're just talking about speaking English to each other, but you know, we may all speak the same language on the face of it, but the way we use those words and symbols are going to be pretty different from person to person.

And in the primary psychotic disorders, we do see language and thought disruption to the extent that they begin to use language in a wholly dissimilar way than other people.

Yeah, I mean, I agree with that. I think that's where we were at the beginning there in terms of there's always going to be some truth that's let out. Sorry, left out. Let out, maybe. Yeah, I guess.

What else do you see then? Did you say psychopathy?

Yeah, I mean, that's one way of, I guess that's a more complete way of thinking of language. When I think about symbols and language, the way I'm talking about, I'm restricting it to semantic meaning. And yes, it's true that some people with certain types of psychopathy or personality problems will lack the integration of the affect, the emotional content with the words. The words don't necessarily echo that emotional experience for them.

But I don't see that as a breakdown of the language functioning of the brain. Or the mind. Mind is probably better here. I see that as a breakdown of the emotional processing aspect. Which, of course, comes automatically for most language users because emotions and affect are all ever-present for the regular person. So at least for me, I just don't consider it a language, but that's why truth falls out, I think, because we all have our own private way of using language.

And so if we're going to have a coherent discussion about anything, it really requires us to sit down and lay out what do we mean by certain words? What do we mean when we say this and that? Same thing that we do with our patients.

So, I mean, that particular theory... Is that Lacanian? Well, I don't know if it's original to Lacan, But I think it's certainly a major feature of how Lacan describes psychotics, what you call psychotics. And I guess let's then start from the beginning and just say that the word psychosis and the understanding of what schizophrenia is and the schizophrenia-type disorders has changed quite a lot over the last 100 years.

We don't necessarily still have a ton of agreement or concordance. in the field about what these conditions are but certainly i think it's a lot more uniform than what used to happen um are you familiar with the uk us diagnostic project that they did i think it was pre-dsm-3 right before it do tell us basically they had a group of S. psychiatrists and K. psychiatrists interviewing and then reaching diagnosis for the same group of patients.

And they found that in the S. use of the term schizophrenia, it referred to such a large group of different patients and conditions as compared to the K. group. So I think that's the thing that we have to at least put at the outset when we talk about psychosis. It's that psychosis is at least partially a breakdown in language. And our language has historically been broken down, unclear, fuzzy, strange when we talk about schizophrenia and schizophrenia type disorders.

I think it was like, it had to be the 70s. It was pre-DSM3. And DSM3 with the nosological revolution of the, oh, geez, I can't believe we're forgetting their names right now. But basically, the WashU group and the people who spearheaded the DSM3 system that we use still today in using a form of diagnosis where we rely on externally verifiable observations and reports, that is what brought, I think, the field into a more tight understanding of psychosis, even though it's still an area that's pretty fuzzy.

Absolutely. Yeah, so valuable and so important both for clinicians and patients, right? So that is something, though, that people need to keep in mind, especially lay people when they do any reading in the area. I would say that tons of literature pre-1980 and certainly post-1980, especially about theories around psychosis and schizophrenia, may not be talking about the same patients as other people writing and publishing on the same word schizophrenia.

they can be and have been historically referring to totally different groups of patients.

Yeah. And at least from my impression, I would say that what people were willing to call schizophrenia before included at minimum personality disorders of all stripes, trauma disorders, certainly certain forms of manic depressive illness. Just tons of things got captured. Many, many things got captured under the term schizophrenia. And it should come as no surprise if you actually read the DSM-2 definition of schizophrenia. Have we done that before on this podcast?

I don't believe we have. Okay. Schizophrenia. Okay, everybody. This large category includes a group of disorders manifested by characteristic disturbances of thinking, mood, and behavior. Disturbances in thinking are marked by alterations of concept formation, which may lead to misinterpretation of reality, and sometimes to delusions and hallucinations, only sometimes, which frequently appear psychologically self-protective. Corollary mood changes include ambivalent, constricted, and inappropriate emotional responsiveness and loss of empathy with others.

Behavior may be withdrawn, regressive, and bizarre. The schizophrenia in which the mental status is attributable primarily to a thought disorder, a thought disorder, thinking, which requires language, that's my own addition, sorry, are to be distinguished from the major affective illnesses which are dominated by a mood disorder. The paranoid states are distinguished from schizophrenia by the narrowness of their distortions of reality and by the absence of other psychotic symptoms.

You can see there that they're trying to differentiate schizophrenia, which they consider a thought disorder from the mood disorder group, and also kind of carving out a paranoid states, which we would probably call the delusional disorders today.

Wow, was that mocking? I'm sorry. I didn't mean to mock. Well, you can see here that this is before they came up with diagnostic criteria. They're just giving you a narrative description of the illness. It's more similar to what the ICD used to do before. Nothing that is being said in this paragraph is wrong, actually. what it is is that it's insufficiently tight in its definition and if you just call this characteristic disturbances of thinking mood and behavior then anyone with any disturbances or alterations in their concept formation thinking mood and behavior can potentially be misidentified as schizophrenia when there was already older concepts around schizophrenia dementia praecox that were published and i'm really shocked didn't make it into the dsm2 i've never looked into why that's the case but you'd think that they'd at least mention some of the uh first rank symptoms of schizophrenia in the first paragraph on schizophrenia.

But instead, it's actually a description that reflects more psychoanalytic bent in DSM-II, where they talk about, at least they put in the line where the delusions of hallucinations frequently appear psychologically self-protective, UCD. The idea that it could be a defense, which, by the way, is I think can be true that if you analyze psychotic symptoms, you may find that there is method to the madness, that there is reasoning behind how and why certain symptoms manifest for a patient.

At the same time, I strongly and uniformly believe that the proper psychotic disorders are not psychological in their origin. They're more biological in their origin. It's a disruption in the reasoning network of the brain, the perceptive network of the brain, but the way the symptoms manifest are still psychologically rooted, even if the cause is not psychological.

Yeah, it's related to precocious. It's different than the neurocognitive disorders, which are the traditional dementias.

Yeah. A couple of things I want to add to that excellent little explanation to encapsulate his work is that, yeah, he was a great scientist. He even looked into family history, right? He would see what the life and illness course would be like for family members of people with more severe conditions. Also that his manic depressive illness, today we would actually put both major depressive disorder recurrent and bipolar disorders under manic depressive illness, because for him, it was not the polarity of the episodes that mattered.

It was the chronicity and the recurrence. If you had 10 major episodes of any type, depressive or manic, you had manic depressive illness.

Yeah, and I think if you read primary Freud text, you'll see that he's pretty careful about that. He refers to dementia praecox as a separate area of illness, and he just mentions, he understands those illnesses, he mentions known aspects of them, and then uses it sort of to relate to other forms of paranoia or grandiosity that is better attributed to, let's say, personality. I'm thinking here on narcissism, the classic text.

So, you know, you mentioned that interesting thing. I don't know how many people out there necessarily know this, but yeah, there is actually kind of a traditional divide in psychiatry that kind of exists today. And you can say it's the biological versus psychological divide or the inpatient versus outpatient divide. But I like to say you have clinic docs and you have asylum docs. Asylum is not a very nice word, but let's face it, it's an accurate description.

And rather than two things branching up, it's almost two trees branching. that intertwine periodically from different routes. Because you had the people who were running the insane asylums early on, right, who were looking at very severe mental illness that was probably more biologically rooted. And then you had the people in the clinic, right, treating people who were much more functional generally, but still had symptoms, problems, inhibitions, anxiety.

And there's got to be some overlap, but there was probably less overlap in the past because society was perhaps overly aggressive in institutionalizing people with symptoms, right? Today, we're maybe going the other direction depending on where you are in the country or in the world where there are people who would have been institutionalized or even should be institutionalized but are not. And it's both political and personal about where you want the divide to fall.

But the fact is that we have to recognize that major thinkers and writers work with different patients so their experience base is different and so the theories are based on those patients and that's still the case today yeah and a lot

we're working with different populations yeah i'm lucky to have a nice crossover population i at least i think i get a good mix of severe mental illness and um more neurotic conditions. We want to use older language.

I honestly wonder how much study has been done on this because you're right about the push and pull in the West. But I would probably hypothesize that most societies throughout history have either unfortunately killed the mentally ill or incarcerated them in some fashion. I'll give you an example. From what I know about Vietnam, they are not exactly a resource country in terms of medical care. They're not exactly a very sophisticated country, as far as I can tell, with different psychiatric theories and policies.

They don't have involuntary commitment, as far as I'm aware. And what ends up happening is a lot of severely mentally ill people, this is what I've heard, I'm not an anthropologist, so I could be wrong, but many of them essentially get locked up at home. Their families are considered to be responsible and the conditions can be decent to extremely bad, right? It's almost that the individual family unit becomes the arbiter of what should be done with a person's mental illness.

And you can see how that's pretty bad. I also know of situations where in countries elsewhere in Asia that have a lot of family focus is that people can go for quite a long time without any treatment at all because they're being held together by a few threads of family doing a lot of social support. And for me as a psychiatrist, this is a problem. Why? Because when it comes to the proper psychotic disorders and the severe mental illnesses of bipolar disorders, every episode that you go untreated for without medication is burning brain.

It's, it's, causing more and more dysfunction, distress, and worsening the illness. I know we don't have the data for this yet, but I believe that if we can prevent the symptoms and the decompensation with medication, despite the side effects, with the modern medication that we have, we will see less and less disability. And I think that's what was being seen by the dementia praecox research back in the late 1800s, that It was, they didn't have medications.

We didn't have these medications until the sixties, 1960s. So every time someone would have an episode, they would work, they would worsen in their brain functioning. So it's not necessarily a good thing to allow people to go without any public attention for an illness.

Yeah, and I don't think this would be surprising to people who have really sat down and interviewed or watched or made contact with people who are in the throes of psychosis. It's an extremely stressful state. It is not fun. It is not a good time, you know, and Any kind of severe stress seems to play a significant role in worsening people's mental health outcomes. So at least for me, I'm a big advocate for treatment, but I know that there are many well-meaning people out there who feel like any kind of advocacy for treatment is a encroachment upon human rights.

But unfortunately, this is an area that we're going to have to hash out as a society over a long period of time, I think.

Yeah, this process, I believe, is referred to as delusional perceptions or delusional percepts as well, or ideas or reference. There's a lot of different ways you can describe the nuanced ways that someone can experience this. But yes, it's essentially attributing importance to some kind of an environmental stimulus that other people would not necessarily find as important. Now, the manner in which you do so varies a lot from person to person, right?

The ones you mentioned are good examples. It could also be for a depressed person who is quite paranoid. If a stranger glances at them in a certain way or takes an extra second to respond, it's because they can actually hear the patient's thoughts and they want them to die. For example, or in the case of relatively well known in our area case, a guy's on his way to shoot up a hospital and he's not exactly sure if he should do it, but he sees the light coming in through the clouds and he says, oh, oh, that's that's something that's communicating with me.

It's telling me that I'm doing the right thing. So there are a lot of different ways that the abnormal interpretation of an experience of reality can impact people. But that's probably just one small part of psychosis because psychosis is this big, wobbly, unclear thing that we just kind of know by seeing and we're gradually chipping away at with science. whatever it is that causes that process seems to be bad for the brain.

That would be my not very complicated way of summing it up.

I think that's a high-tier belief for me.

If I wake up in the morning, my wallet will be on my desk.

That's how I. Yeah, it's very interesting. And I will say when we talk about severe mental illnesses, it is definitely an area where most ordinary people have less access to the patient population and to the inner experience of it because it is more rare. than let's say the conditions that are related to personality disorders, which are more universal. It's not that it's impossible for people to feel these things.

If you give someone an IV injection of methamphetamine at the right dose, most people are going to have a psychotic experience. But it's still more rare, I think, than the things that we've been talking about before. Everyone knows what it's like to feel excited or sad and depressed or ill or scared. But having a biological disruption in your reality processing networks, not everyone gets that. Not everyone gets that.

Some people get it. Not everyone gets it. The thing you mentioned about duration of untreated psychosis, it makes me think of an interesting observation I've come across in my forensic work, and it's that people who are on really prolonged methamphetamine-induced psychosis from their voluntary use of meth over the course of a year or two at least, I've found that the ones that get paranoid on methamphetamine can develop a delusional belief system.

And even if they stop getting the perceptions that support that delusional belief system after they stop using the methamphetamine, that delusional system can persist as a belief. In jail, they're not using drugs. And by the DSM system, these people could be diagnosed with a delusional disorder, but I don't think that's appropriate because I think that even if they maintain that, in fact, there were many different Teslas following them around 24 hours a day as something that the FBI was tracking them for, for their criminal activities.

Even if they continue to believe that two years out, I don't think that's the same thing as a delusional disorder that develops in somebody that has never touched a drop of stimulants, right? And what's interesting is that if you rely on the DSM, which is etiology neutral, to make public policy about who should or should not face criminal responsibility, you get into some weird situations. Just a little side note.

Yeah, that's interesting because what you're describing there is important, in my opinion, to considering the treatment course of delusions. If you just take what people say as an accurate reflection of their inner state, you may detect that a delusional condition has remitted in some capacity, when really what a lot of people with chronic psychosis will do from any etiology, well, they'll just socially learn that you can't talk about certain things without people looking at you.

So in the situation where everyone else thinks that the sky is purple for two years, a lot of people just learn that when you start talking about the sky, just say it's purple, even though it's blue. Is that a remission of the delusional condition? No, it's not. But it's more of a social adaptation. So it's a very interesting area. to me anyway, the treatment and the observation of psychotic disorders, uh, because there's so much nuance that you can get into, but that we don't necessarily get into, uh, because of the settings where people are experiencing these conditions.

Yeah, I mean, I wasn't referring to it directly. I think you filled it in nicely. And yeah, I absolutely subscribe to that because you'll find that it just varies depending on the person. You know, some people, when you give them antipsychotics and they stop having that delusional perception anymore, they go like, well, I remember feeling that way about it, but that just seems strange now. You know, I don't think that's the case anymore if you give them enough time without the delusional percepts.

And then there are some people where even if they didn't have a primary psychotic disorder that we could detect to begin with, They had two years of it. They stopped having it for two years. They're still thinking, yeah, people were following me. It's very interesting. Of course, we have to open up the field of possibilities to consider that some of these people might be motivated to present themselves as mentally ill for purposes of evading legal responsibility.

But, you know, that's a different discussion. That's a whole other discussion.

No.

Yeah, I mean, that is the caveat here. If you want to become familiar with psychotic experiences, which I do not recommend you do, the psychedelics and some dopamine related drugs will definitely give you those psychotic experiences. Again, I highly recommend you do not do so. People who are more prone to these experiences, in my opinion, actually would be more likely to develop a long-term primary psychotic disorder, even with drugs that you might not necessarily expect to cause that, you know, now that cannabis has been used more popularly and more frequently in the population over the last couple of decades, we're starting to see there are bad effects, even from cannabis, you know, even brain volume changes in various areas.

Yeah. Yeah. It's interesting that there are some people who will have similar experiences, but will continue to use. And you'd really wonder about study to show what causes people to continue to use certain recreational substances, even when they have adverse effects from them. You run into that a lot doing forensics, but it's just a kind of a side note.

And I mean,

Yeah. I wonder if it has to do with just your, I guess we can call them preferences, your personal preferences about experiences. You know, two people can have the exact same experience externally in the environment and inside the body, let's say feeling a fast heart rate. And one person can think that was terrible. And one person can think that was exciting. Think about like bungee jumping, right.

Uh, as an example. Uh, something I wanted to also mention is that, um, there are some people where psychotic type experiences are apparently more normal. Uh, we referred to them in 2024 in using DSM criteria as the cluster A personalities, the schizoid, not schizoid, schizotypal personalities, right? which, um, as of today, I think we believe there's more genetic relationships with those compared to people with schizophrenia's full on.

Uh, but you can have quasi psychotic experiences without having a psychotic disorder. It could mean that you could have more vulnerability to certain drug use, uh, I certainly think so. But I'll say that having worked with enough psychosis and near psychosis, I don't really believe in the paranormal anymore. Because any paranormal story that I've run into can be adequately explained by a brief psychotic experience or a psychotic experience under stress of some kind.

And every spooky, scary thing, I've heard some variation of it. And I've treated some of it too.

Yeah, that's true. Yeah. So, you know, we can easily be that character that dismisses the reality of the paranormal experience. And then we walk and go, oh, you know, nothing's going to happen. And then we get killed in the first or second act.

And the psychoanalytic theory of paranoia, yeah.

Good points there. And I guess when I say the severe syndromes of psychosis are not that familiar to people, the milder forms of psychosis let's call it less reality-based thinking or less reality-based updating of preexisting belief. That's pretty common. I think almost everyone does that. And of course it's all a matter of degrees, right? And you got some of the population that doesn't do that very much.

And you got some of that population that does that probably a little too much, but that is very familiar to people. And this kind of touches on how do you conceptualize and diagnose psychosis delusions, let's say, um, in particular, if we don't have a common reference for truth or reality, and if everyone does this kind of thing, right? How do you tell the difference between a delusion, a religious belief, or ideological belief, um, or just a mistaken idea?

Well, um, I have an answer for that, but I don't think many people will find it satisfactory. Because I think that if we're going to properly define delusions, we have to be tautological. You can't define a delusion based on its truth value, first of all. Because you can be delusional about something even if you're right about it. I know that sounds very strange. This is an old Lacanian thing.

If a man is extremely paranoid that his wife is cheating on him, and she is... The paranoia is still pathological. This is generally true, that it's more about the process of the delusion than the fact that it's there. So whether or not you're right, it's more about where does the delusion come from and why is it maintained? But then on top of that, the fixed nature of the delusion is also insufficient to tell you whether or not it's a delusion.

It can help a little bit, but not necessarily, because you can find fixed and subjectively false beliefs all over the map in people without psychotic disorders. So what do you do? Ultimately, I say, what is a delusion? A delusion is a pathological belief that comes from a psychotic disorder. So you have to identify the psychotic disorder first. You have to identify the psychotic style of thinking first and also test it.

You have to get experience in interviewing people with overvalued ideas.

Yes, that is a problem, but I don't think we have any way out of it fundamentally until we can detect the delusion in a brain network, because let's put it this way. From a philosophical standpoint, unless we include the concept of mental illness, there is not really an objective measurement that can tell us the difference between a delusion from a psychotic disorder, a deeply held religious belief, a deeply held cultural belief, or a mistaken belief.

just based on one's experiences, right? You can't tell them apart. So what you have to do, you have to trace back and say, is this person fundamentally more a regular person, a religious person, an ideologue, or a psychotic person, right? And the only way we can do that clinically, again, not for ultimate truth value, the only way we can do that clinically is if you test and evaluate people's beliefs and how they think, across all those categories.

You can't just limit yourself to asking people about their delusions and testing them under delusions. You have to also test the deeply held beliefs, not in a mean way, but you should, you know, poke at and go into some death on the deeply held beliefs of people who are without psychotic disorders. So for the clinicians out there, that's what I recommend. You just need a lot of experience with people that have delusions and people that don't have delusions.

That's going to really ultimately help you decide what's a delusion or not.

I do recommend that because there is a reality where someone can come to you and say that and they don't have a psychotic disorder. Right. Just and then there's also a reality where someone comes to you and says, hi, my name is Bill and I'm an alcoholic. And that's delusional. Maybe they think they're actually Bill from AA, the original Bill.

Yeah. So you're going to have to, you can't take statements at face value. You really have to investigate where they come from, how they respond to alternative things, where it came from originally. How did you come to understand that you're Jesus Christ? How would you feel if I, or what would you say if I said, I didn't really believe you? What do you think other people think about this?

All these kinds of questions can...

No, I don't think so, right? That doesn't... Partially. No, no. I mean, how does a Messiah come to understand it or Messiah? Probably in the same way that someone who isn't a Messiah came to understand it. How do we know? Unless we can establish some religious... committee that form make their religious manual that says, this is how we're going to confirm or disconfirm religious experiences. It's a whole mess.

Of course, the discussion about the intersection between religious experience and psychotic experience and mental illness is a very interesting area too, where we have a lot of unsettled questions.

Yeah, it's better than the last one, I would say. I mean, how you define delusion is really about how sensitive or specific you want to be as a clinician in detecting these conditions, right? Personally, I think that it's a little bit more dangerous to not detect psychosis. But that's because I am pretty confident in my ability at this point to accurately detect psychosis and also to evaluate about whether someone's antipsychotic is helping them or harming them.

Now, if you take an example of people with a lot less experience with rare psychotic disorders and severe psychotic disorders, and you tell them to use the same rules, they might end up prescribing a lot of unnecessary antipsychotics to people. that don't get removed. Right. So it's all a matter of trying to balance risk and harm and benefit. And it depends on who you are too, and who you're working with.

Yeah. You know, that's a broader trend that you can say is good or bad and, but no one can disagree has resulted in changes. And I want to focus on the change that I've observed at least in psychiatric trainees and therefore psychiatrists. There is without a doubt in the United States, a historical trend that we initially had most people with mental illnesses that are moderate to severe in highly controlled settings, including involuntary long-term commitment, right?

Then there was a move towards moving everyone to outpatient because we thought that by using the medications people would be able to do fine without being monitored and if you don't know what happened after that what happened was a lot of those mentally ill people ended up in the carceral system they ended up in jail and prison long term okay So a large chunk of people basically got moved from what were the insane asylums and state hospitals of the past to jail and prison of today.

This has had an effect on, in my opinion, psychiatrists, the majority of psychiatrists, their ability to detect and understand psychotic disorders because most psychiatrists will therefore no longer ever work with that huge proportion of people with psychotic disorders because they're in jail and prison. So when do you encounter those people? If you're a forensic psychiatrist or if you're a jail or prison psychiatrist. And they present differently.

It's a special group of people who have psychosis, but often do not want to be identified as having psychosis. Not that these people don't exist outside the jail. They exist, but they don't come to clinic, right? And they're not severe enough to come to the emergency room or need the inpatient hospitalization. So they just live on their own being psychotic. And there's not necessarily anything wrong with that.

But I got to tell you, for at least the people who come to my clinic and I get them on medication, almost uniformly, they find that their life is better after the medication. So we don't know what's going on out there. But at least from a training standpoint, I think a lot of people are missing the more subtle psychosis in recent years because those people just don't come to voluntary treatment.

It's simply that they don't, they're not severe enough that they're a danger to themselves or others, or can't manage their own resources, right? And that they don't feel themselves as having a problem or having a problem bad enough to go through the entire hassle of going to a psychiatric outpatient clinic. And that is a hassle, no matter where you are, right? Trying to get an appointment, waiting for that appointment, showing up for the appointment.

That's a real hassle. Therefore, the moderate grade severity psychosis often goes unnoticed. but it can impact people's decision-making, thinking, and beliefs about the world. For example, you might think that actually you're not just some guy who worked in a factory for a couple of years and then became homeless. You might think that you're a world-famous record producer and that your PA booked a giant mansion in Malibu for you, so then you show up.

No one's in there, of course, because you booked it with your millions of dollars. And then you go down to the basement and you drink a bunch of the cognac, you know, very expensive cognac. Well, what is that now? Is it a simple mistake based on a mental illness? Sure. But under the law, that is also a burglary, right? A felony. So now you end up in jail.

That guy would have never came to a clinic, right? He thinks he doesn't have an illness.

Yeah, that's what I mean. They're not coming to the clinics at all. They're not coming to the inpatients or the emergency rooms at all. So you just don't get any experience with them because they're not showing up. But where they are showing up is jail and prison because by deinstitutionalizing people, we didn't necessarily improve their lives. We just stopped their treatment in many, many cases. And then the first time they can be seen or treated is because they, as a matter of chance or bad luck, got involved with the legal system.

That's right. I will say the newer ones, in my experience, are a little better. You know, the lorazodones, the Abilify's, The cariprazine seem a little better. Basically all the ones that seem to be okay for treating bipolar depression, that also work on schizophrenia but don't cause a lot of weight gain, people tend to tolerate those better. But they still cause tons of akathisia.

We'll save that for later. But I'm just going to say don't forget akathisia. Just because your medication is newer, helps with mood, and doesn't cause so much weight gain, well, watch out for akathisia. It's a big reason why people can't take the med well. It's very uncomfortable.

Yeah. And how do you do that, right? I think that people really need to go back to the concept of the therapeutic alliance, right? Something that's talked about a lot for psychotherapy, but is just as important in medication management, that you and the patient have to have some kind of a working agreement and understanding about what the problem is, what you're going to do with the problem, and how, right?

And that's really hard with schizophrenia and psychotic disorders, because if you don't know, The most common symptom of schizophrenia in certain frameworks or studies is the lack of insight, the lack of insight into having an illness at all. So if you see that a person's problem is, quote, schizophrenia or voices or problems with thinking, but you tell them this is for schizophrenia and they see their problem as the guy next door won't stop telling me to have gay sex with him.

He won't stop. Okay. And that's keeping me up at night. And no, it's not a mental illness. If his idea is that, and your idea is schizophrenia, and you say, here's a medication for schizophrenia, where are the chances that there's going to be a working alliance? Almost zero.

Yep, absolutely.

Yeah. Some patients can stomach it. Some patients can... come to some emotional understanding with that. But I find that if you try to pound that into the pavement, a lot of what happens is what we referenced earlier. They just learn to say that the sky is purple. They still think it's blue, right? You got to find common ground. And I try to find common ground in things like concentration, sleep, fear, or just stress levels.

And I am not lying when I tell them that the medication will help reduce those, because it does. OK, but trying to just emphasize an FDA indication for a medication, I think, is highly inappropriate in treating people with psychotic disorders. First of all, there is no point in communicating something that has no therapeutic benefit. There is no point in telling people that's gold. Say that again. There is no point in communicating something that has no therapeutic benefit.

Now, you could argue there is a liability issue. But at least for me, I'm not doing any involuntary treatment. I don't do involuntary treatment. I don't like it. And I want people to get better. So I try to get people better before I worry too much about liability. I know a lot of people will feel uncomfortable with that.

No, that's all right. I mean, the point is, I mean, this is the area I feel very passionate about. There's people out there that got brain condition. If you conceptualize it as a psychological condition, it's not going to help you. It's not going to help the patient. And, um, It's hard to even accept that you have a neurological or brain condition. Think of things like seizure disorders and how many people are not necessarily fully adherent to the medications.

So even if it's a brain condition, which is a little easier to stomach, and I still think quite realistic, true to life, that it is a brain condition, getting people to take unpleasant medications, it's a problem. So you just really need to find common ground in what patients find to be a problem. And you need to pick the medications that have the least side effects that you have access to.

Unfortunately, for cost reasons, the most commonly used medications by inpatient doctors are very effective but very unpleasant and cause a lot of weight.

Also the thinking. Don't forget the process of thinking is fundamentally disrupted. Many of these people, even if the thought disorganization is pretty subtle, and yes, they can organize their thoughts better and piece them together better and plan things better on medications. I don't lie. You know, I'm not going to tell them that it's not an antipsychotic. I tell them it's antipsychotic, but I also tell them the truth.

And the truth is that second generation and first generation antipsychotics are indicated and used in a variety of different conditions, right? They're used in not only psychotic disorders, they're used for depression, they're used for mania, they're used for hypomania. They're even used for trauma disorders sometimes by people. They're used for a lot of different things. They work on a lot of different things. And let's be frank, we don't really understand these medications so much.

We just call them antipsychotics because that's how they're discovered. They do a lot of different things, including make you, for some of them, not all of them, guys, some of them make you very fat.

Yes, the cholinergic, right? What was the name of it? Cobenphy? Cobenphy. Yeah. Fun fact, actually existed in the 90s, but they didn't have the extra add-on medication to cut down the rest of the body's side effects, so no one could tolerate it. But now that they've paired it with another medication, the Covenphe is a combo med, they're trying to restrict the cholinergic action to the brain only to help treat the symptoms of psychosis.

I am excited to use it in eight years or so because I'm a community psychiatrist.

I don't think the newer meds are more effective, but they're certainly better tolerated. I don't think that can be questioned. Why? They're not going to put a medication out that's new and do all the marketing and research if it's not better tolerated because no one will buy it and they won't get their money back. Now, the cobenphy might be a different story. I've read that the nausea can last very long in some patients.

I think regardless of side effects, they're going to try to get cobenphy out because it's a new mechanism. What does that mean? It could mean, we don't know. It could mean that patients who didn't respond to other medications in the past might begin to respond. It's promising. I'd like to see how it goes.

Well, we've got to wrap up if we're going to finish up. What's your takeaway here? What do you think?

My takeaway? Well, I think it's a neglected area. I think it's a very misunderstood area. I think the patients are very misunderstood. And I think that's a real shame. I love studying, working with, and treating psychosis. I think it's very rewarding. And if you're a clinician, I encourage you to continue to do so if you already are or do more if you haven't already. And if you're a patient, I hope that if you have any problems at all with your mental health, you keep an open mind.

Remember, treatment is supposed to get you better. Okay, forget about the labels.

Oh, that's tough.