Good morning, Dr. Malzberg. How are you?
I'm all right. I think, you know, just a little bit of a cold, a little bit of pressure in the head. Brain's not going to be going too fast today.
Yeah, same here, which is, I think, unfortunate because we have an interesting topic to talk about today that does involve brain processing. What are we talking about today?
I know I think today it would be helpful to have our neurons firing fast, but today we're talking about psychosis, and we did do another podcast on psychosis a little while ago. This one stemmed from... There's a question that I see come up a lot in terms of a patient comes in with psychosis, and then how do you know what the diagnosis is and the differential? And then...
I asked you if we want to do a podcast on that. And I think you have a lot of other really important clinical psychosis things you want to touch on. And I feel like you've been teasing us for the how to suss out the subtle signs of psychosis. So I'm feeling this is going to be a few parter.
Yeah, sounds right to me. I would say that. The how to tease out subtle signs of psychosis issue is not one you can talk a very long time about because the concept of it is less important than execution. You know, frankly, to be able to do that, you just have to evaluate a lot of subtle psychosis, right? It's a clinical skill, but it's something we can talk about.
And I think there's a lot of surrounding issues that are important. So yeah, it's a good topic.
Yeah, and I think there can just be little pearls on things you picked up because it's not very satisfactory to hear the way to get good at it is to do it a lot.
Unfortunately, that's true of most of the psychiatry things, so we'll just keep that in mind.
Yeah, either be good at it or do it a lot. So I guess maybe to just get started. Why don't we talk a little bit about the simple, simple question of what is psychosis?
Yeah, I think this may sound a little basic for a lot of people, but it's an important thing to get into. Psychosis, what is it? Is it one thing? Well, let's start with the DSM. We have delusions. hallucinations, most people know those. In fact, I think most people jump straight to those, and sometimes some people don't think about the other aspects of psychosis until they're prompted, okay?
But that's not all there is to DSM psychosis. What else do we have? On top of delusions and hallucinations, we have disorganized speech, disorganized behavior, and negative symptoms. then there's catatonia which is actually not uh only seen in psychosis even though we sort of put it in there conceptually and it's in the psychosis chapter keep in mind that catatonia can theoretically appear with any condition but really we expect it the most in a mood disorder and also uh with delirium but we'll leave that aside so what is psychosis actually is it these symptoms I would like people generally to think of psychosis differently.
Psychosis is not one thing. It's simply syndrome. And like many things in psychiatry, it probably reflects a wide, wide range of different entities that tend to present syndrome. more or less similarly or often less similar. So don't get too stuck in an idea of what psychosis is or is not, especially if you're early in training. I see this a lot with people who are going through residency because in the first couple of years of residency, you're only really seeing acute emergency level cases, inpatient cases, and you're not seeing a lot of outpatients or subtle psychosis.
So don't... get drawn into a very stereotyped idea of what this is. There is no single psychosis or schizophrenia.
Yeah. And the first thing that comes to mind when you say that, I think the word psychosis suffers from the same difficulties that the word depression does. And that you said psychosis is a syndrome, but it depends on like what psychosis you're referring to as to whether or not it's a syndrome. In the same way that depression, like I can say that person's depressed and I could mean a bunch of different things.
Like the super basic definition of psychosis is is just the inability to tell what's real and not real. But the psychosis, as we're talking about in psychiatry, is that syndrome that we're kind of going to go into. And it's funny because even in the beginning, you defined it as delusions and hallucinations, but even delusions is not a perfectly clear thing as to what it is. I think hallucinations is a little bit more clear, but I hope we kind of paint out what we mean by it's a syndrome and then what we mean by each of those different things.
Yeah, part of the difficulty here is that the words schizophrenia and psychosis have taken on many different meanings across the last hundred years right and i don't even know if we still agree about it at least we have a dsm now that we can refer to and define under so i do want to stick to that definition and in that sort of backwards fashion then personally i recommend that we as a field we stop using terms delusions, hallucinations, negative symptoms, disorganized behaviors or speech.
I think we should stop using those unless we can attribute them to a primary quote-unquote psychotic disorder. The schizophrenia has severe mood disorders with psychotic features. and other schizophrenia spectrum disorders like schizoaffective. If it's a manifestation of another condition, we should not call it psychosis or one of those specific terms. We should call it something else.
Yeah, and that's where things get so darn confusing, especially when you go back. The definition of schizophrenia has changed. If you look at early literature, schizophrenia is clearly not referring to the schizophrenia today. So, And then we refer to, you know, the borderline is defined as on the border of neurosis and psychosis. And you do see patients who have psychosis in a personality disorder. So I guess we, from the onset, we should say that we're using our definitions according to the DSM here.
And the psychosis we're referring to is the psychotic disorder psychosis.
Yeah. Yeah. I think maybe we could review a little history. I actually should have been prepared and pulled it up in front of me. But generally speaking, never trust.
I have a DSM too, if you want me to pull, if you want to read that one out.
Yes, yes, if you have that. But I want to make a point that you should never trust a pre-1980 schizophrenia diagnosis. and frankly i don't even know if you can trust a schizophrenia diagnosis today because don't trust any schizophrenia well don't trust any diagnoses uh unless you verify them for yourself we've talked about that before but especially before the 1980s before the dsm-3 there wasn't a uniform definition of schizophrenia and they even did some research to show that for example american psychiatrists pre-dsm-3 were calling all kinds of different conditions schizophrenia that we would not call schizophrenia today whereas uk psychiatrists were a little bit more specific in their use of the term but to give an idea of how confusing this has been let's just start with dsm uh two which is not that long ago i believe it's the 70s right uh can you tell us what the dsm2 defined as schizophrenia
Yeah, so I'll just read it out. So this large category includes a group of disorders manifest by characteristic disturbances of thinking, mood, and behavior. That's nice and vague. Disturbances in thinking are marked by alterations of concept formation, which may lead to misinterpretation of reality and sometimes to delusions and hallucinations, 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 schizophrenias, in which the mental status is attributable primarily to a thought disorder, are to be distinguished from the major affective illnesses, which are dominated by mood disorder. And so there they're thinking bipolar or depression. Okay. The paranoid states are distinguished from schizophrenia by the narrowness of their distortions of reality and by the absence of other psychotic symptoms. And then it walks through the different subtypes.
You want me to go through those?
Not quite yet. A little commentary on that. If you're very particular about your conceptualization of schizophrenia, you can see that a lot of the legs are there. But I would say that for someone who has insufficient training or rigor in their diagnostic categorization, that description of schizophrenia really allows for a wide range of non-psychotic disorders that uh to be identified because it's pretty vague right this is before the diagnostic criteria revolution of the 1980s uh so again don't trust old diagnoses um and understand that it was an umbrella term in the past and it still is today uh Another thing I wanted to go over was schizophrenia subtypes.
We had subtypes in the DSM up until DSM-IV. And they got rid of them because there wasn't enough empirical support to talk about subtypes. But I do think there was an educational loss when we stopped talking about subtypes of schizophrenia because it made everyone think that schizophrenia was one thing, when really schizophrenia is, again, an umbrella term referring to a wide range of presentations. I wouldn't use the DSM-II for that, though.
Do we have the DSM-IV handy?
If not, I should follow that. I have the different subtypes. The different subtypes are paranoid, disorganized, catatonic, undifferentiated, and residual. And I agree, there's a huge loss in losing these different subtypes because it kind of became this... The umbrella became almost too big. And that grouping together these... the disorganized people who are saying word salad and then the paranoid people who thought the CIA was hacking their brain.
It was really hard to see what kind of unified those things. Do you want to actually read out the...
Maybe I could at least highlight paranoid because I think that at least for my trainees, the paranoid type, as it was previously defined, often makes people question things because they're used to very, very acute schizophrenia, being the only schizophrenia that they're familiar with when they hit PGY3. because it's i think much more likely in today's era many decades past the institutionalization for someone that has primarily paranoid features to escape hospitalization and treatment uh but let's go ahead and hear how did they define paranoid schizophrenia before
So yeah, going through the different DSM-IV criterias, for the paranoid type, it's a type of schizophrenia in which the following criteria met. Preoccupations with one or more delusions or frequent auditory hallucinations. And B, none of the following is prominent. Disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. Yeah. disorganized is all the following a prominent disorganized speech disorganized behavior flat or inappropriate affect and not catatonic type catatonic type um is motor immobility, excessive motor activity, extreme negativism, peculiarities of voluntary movement, and echolalia or echopraxia.
The undifferentiated type is the person meets criterion A, but the criteria is not met for paranoid, disorganized, or catatonic. And then the residual type is absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. There is a continuing evidence of the disturbance as indicated by the presence of negative symptoms or two of the more following symptoms, for criterion A, present in an attenuated form, for example, odd beliefs, unusual perceptual experiences.
Right, and again, we don't have empirical support that these are separate categories, right? But I think what we can say is that clinically these are separate presentations and you don't have to have all four core psychotic symptoms, right? You can have just delusions and hallucinations. And by the way, for people who have primarily delusions and hallucinations without negative symptoms or disorganization, Many of them will not tell you about the hallucinations or they don't perceive the hallucinations to be hallucinations.
So all you're left with is delusions. And then you get into the difficult situation of trying to suss out what is or is not a delusion, right? Which I don't know if there's a good broad understanding of in the field. And there's also weird ones where you don't seem to see any delusions or hallucinations or even disorganized behavior, and that it's predominantly negative symptoms, right? And how are you going to declare that?
You won't be able to achieve modern DSM criteria without adequate patient report. You'll have to infer it, which many people are going to be uncomfortable with. You know, as early as the DSM-2, you'll see a subtype called simple schizophrenia, which was... Just people that were described to have severe negative symptoms lying down for hours or days under an overpass or something, just not really doing anything. Right.
Which was considered under the umbrella of schizophrenia. And there's a final type that I don't think ever really made it by name, at least I could be wrong. into the DSM system. And I'm probably mispronouncing it, but it's propfoschizophrenia. This is a subtype proposed for schizophrenia where it occurs essentially in the context of a neurodevelopmental disorder. I think traditionally intellectual disability, right? So why are we talking about all this stuff?
It's that you don't need anything more than two out of four of these schizophrenia criteria today to have schizophrenia. Only one of them has to be delusions or hallucinations or disorganized behavior or speech. And so don't box yourself into one conceptualization. What would I recommend that you think globally a schizophrenia or a psychotic syndrome is? I would say that it is a degenerative condition. It is a neurodegenerative condition.
What it is, is a condition where somebody was more or less on one trajectory growing up, and then something happens, and they're neuropsychological functioning starts going down a different path okay usually with a downtrend an impairment typically permanent even if it's mile of cognition reality testing volition something along those lines you have to look at the long-term trajectory And you should be able to identify a point where functioning, especially mental functioning, begins to decline and stays declined, can be rescued partially with antipsychotic treatment.
But it's essentially a neurobiological disorder.
I do want to challenge you on one thing, and you might have just misspoke. I don't think the consensus now is that it's neurodegenerative as much as it's neurodevelopmental. I think of schizophrenia as a neurodevelopmental disorder that may or may not have progressive neurodegeneration. But the fact that it's a neurodegenerative disease is a little bit more controversial.
I don't think there's a consensus that it's neurodevelopmental because neurodevelopmental means that it's present from an early age, right?
No.
So I mean that... What do you mean by neurodevelopmental?
That at some point in development, something went awry that occurred before the person or during while they started experiencing symptoms and that... there are patients who have whatever symptoms they have at a certain level, it actually stays that level of symptoms. And then there are patients who do get progressively worse as their delusions or symptoms get worse.
Yeah. So I was very deliberate about this and I don't agree with that. And I think we have the consensus on that. And I think that's one area that people think that it is, but it doesn't only occur in development. There are late onset schizophrenia. And you can argue that, yes, there's something rooted in development, There's something rooted in early biology that you can detect very early on, typically seen as cluster A personality, which we probably shouldn't call personality.
We should probably just call it pre-psychosis or psychotic vulnerability. But yeah, I wouldn't call it neurodevelopmental just because I think that's too confusing.
I wouldn't call it neurodegenerative. What's that? It's funny. I feel the same way. I wouldn't call it neurodegenerative because I think that's confusing. Yeah.
i do think it's more close to a dementia just like how a dementia occurs in a setting of previous functioning and then now you have a decline of that functioning uh i think that these syndromes are much more neuro uh degenerative than now
historic now historically that absolutely so the initial term was dementia praecox which is like early early dementia um My opinion is that we've kind of moved away of thinking of it as a neuro-progressive disease. But yeah.
Yeah, I think that's an error. And I think that they tried to make this into a disease of development all the way through maybe in the 1990s even, especially in the psychoanalytic circle. I think that's a huge mistake. And I don't think that the people writing about the, quote, schizophrenia, schizophrenogenic mothers, et cetera, et cetera, developmental contributors to schizophrenia, I don't think, A, they demonstrated that that's actually causal.
And B, I don't think they even had the clinical experience with the schizophrenia to be able to talk about this. I would not trust people's opinions on this unless they're state hospital severe mental illness primary treaters.
Yeah, I think the thing I'm pushing back on is there are so many cases that don't get progressively worse. They can have a stable set of symptoms without brain degeneration that occurs. But let's put it let's let's let's keep pushing on.
Okay. Yeah. That would depend on whether you do specific neurological testing, I would say.
Okay.
So that's kind of a bad attempt, I would say, to talk about what schizophrenia is. And it's hard to define it because it's, again, an umbrella term. I think maybe it can help clarify things if we talk about what psychosis, what the schizophrenia is, are not. What are the common mimics? Anything that you run into yourself? What do you see commonly that people mistake for a schizophrenia spectrum disorder?
You know, the biggest ones that I saw is definitely substance use, chronic substance use, or patients who come in with a substance-induced psychosis and they get tacked on with schizophrenia. Other big ones are PTSD is another big one. Patients with borderline personality disorder. I feel like in the hospital, those are the big ones that you kind of see people incorrectly get labeled and sometimes they keep that diagnosis for over time.
Yeah. You know, for the substance one, I have seen it's entirely possible for people to have a purely substance induced psychotic episode. It's absolutely the case, you know, and should be higher in differential whenever you see psychosis. That being said, I've also seen the mistake of people wholly attributing a syndrome to substance use. It is possible for someone with a primary psychotic disorder to have a substance use disorder too, and we can't write off the possibility of a primary psychotic disorder co-occurring with a substance use disorder.
And I've seen that happen. And that's pretty bad because it can get people to go untreated for the psychotic disorder. Of course, I've seen people who were labeled for primary psychotic disorder and maybe didn't quite have that. A prominent example comes to mind where it was a guy who had chronic meth use disorder and also what I think was post TBI disorder. neurocognitive disorder that kind of gave them a little vulnerability to the substance-induced psychosis too.
But ultimately, I didn't necessarily see evidence for a primary psychotic disorder. So I'm just saying with substance-induced, don't be so sure one direction or the other. And if you do have a serious psychotic episode due to substance use, even the ones that are well known to cause psychotic episodes, it probably does reflect some underlying vulnerability to psychosis.
Yeah, and the way I think about that is we all have a capability of getting psychotic with enough stressors. If I didn't sleep for seven days and then did meth and blah, blah, blah, blah, blah, like I'm going to have a psychotic experience. So I almost think of it as like how – Likely is that particular substance to cause psychosis? And then think about how they were using it with regards to how likely I think it is related to that one thing.
I've heard stories of people I know who have gone psychotic on Adderall after long streaks of not sleeping. Um, and then return to normal pretty much the next day once they kind of re rebalance their sleep. Um, so I, I do factor in sort of like how they use those substances in terms of how likely I think it is that it's a primary psychotic disorder or, and I guess we kind of get to talk about this, like the life histories and so important to understanding what we think that the diagnosis is.
And I think one thing that's helpful, I think, I think maybe you talked about this, um, Whenever you're in the emergency room and something doesn't make sense and you're like, what the heck is this? The classic thing is it's meth. Whenever there's some weird cluster of symptoms or timeline that doesn't – it's just really confusing – almost like meth is that thing oh it's meth and like everything kind of clicks into place but i think one time you you described someone who used meth so much when psychotic so much that it converted to a schizophrenia and i think that that was helpful in that like it's not like you're trying to figure out the true underlying thing someone can can cause so much disorganization and delusions and odd belief systems in their brain that now there's no different there's no if this person were to stop using meth they'll look the exact same as someone who has schizophrenia
Yeah. And there has been some research done to try to differentiate those kinds of syndromes, the long-term substance-induced from a primary psychosis. In my clinical, non-scientific experience, they seem to have more positive symptoms than negative. But in the end, what we're trying to determine most of the time as a clinician is not what caused this, but what's going to help treat this. Now, what caused it can help us think of what to treat and how to treat but it gets a little murky and that's a little related to one of the other common mimics you mentioned right uh you mentioned ptsd quote psychosis and borderline um pseudo psychosis right uh so that's personality and trauma an important consideration.
I've seen people with either condition get mislabeled with a psychotic disorder and treated with high dose antipsychotics, you know, sometimes causing tardive dyskinesia. And it's tricky because both of those conditions, personality and, uh, trauma can respond to a second generation or even the first generation antipsychotic these are dirty drugs they hit a lot of receptors at the same time there can be some comorbidity too and this ties back to what i mentioned earlier about trying to save our uh psychotic disorder chapter terminology for primary psychotic disorders i would hope that as a field we stop calling these experiences reported by people of ptsd and personality syndromes and dissociative disorders as uh hallucinations delusions, paranoia.
Let's not call it that anymore. We can call it voice hearing, right? Reported voices instead of hallucinations. We can call it fear or hypervigilance instead of paranoia. And we should call it an overvalued idea or inflexible belief instead of delusion. I'd prefer to save the very specific terminology for psychotic disorders.
It's very interesting because I guess, how do you then change the approach of someone who you don't have the diagnosis? Because I do hear what you're saying, but on the surface, it can be very, very difficult to distinguish when you first meet someone, if it's psychosis, if it's personality deregulation, if it's a PTSD flashback. So I'm curious, for patients that you don't know, What's going on underneath?
I guess you're saying that essentially you refer to it as the symptom, which is voice hearing. And then only after you know the diagnosis should you then look back and call it what it is, which is hallucinations. Is that...
More or less, but I suppose it's not only when we know the diagnosis. It's that when we're reasonably sure that we have evidence to support a primary psychotic disorder of some kind, you know. And for me, it's when you see clear disorganized behaviors or speech. thought disorganization, right, and if you also see negative symptoms. Those are more pathonomic for a primary psychotic disorder. Again, life isn't so easy.
You're not going to have this kind of certainty with many cases, but it's because I think especially today, clinicians are underestimating the risk of antipsychotic treatment because antipsychotic treatment is so easy. You don't have to draw labs and it works really fast, especially inpatient. So everyone gets antipsychotic. But they have side effects. And the risk of tardive dyskinesia is higher in people who don't have a primary psychotic disorder.
It's probable, in my opinion, that there is some kind of receptor or brain difference in the primary psychotic disorders that changes the risk-benefit ratio for the use of an antipsychotic. absolutely so um unless there's a genuine emergency emergency this person cannot uh go on without antipsychotic uh you probably should take more time to evaluate and watch and if there is a reasonable belief that it is a trauma or personality condition i would recommend the use of uh prns or scheduled medications that are not antipsychotics Not SSRIs, you know, not necessarily serotonin-based medications primary because of the risk of agitating bipolar disorders because in undifferentiated patient, we don't know which is which, but just smaller things, you know.
your gabapentin hydroxyzine your uh buspirone uh propranolol anything that you could use more generally for the uh over activated person with trauma type issues i would reach for those long before antipsychotic so i think if i'm hearing you
correctly when you're assessing things like voice hearing um what you're assessing is not the whether they have it, don't have it, how much they have, but the impact on functionality. And I think what you're saying, and tell me, that you hold the risks of antipsychotics as very serious. So it's not something that you can just kind of use thoughtlessly on any sort of patient population, because if it's not a primary psychotic disorder, it really just tips the scale on risks.
Yeah. So... For patients that have these things, assessing the voice hearing on itself is not something that you need to get rid of. I feel like it's similar to like OCD symptoms where some patients think it's like OCD symptoms bad, get rid of it, where the goal is functionality. The goal is not to just remove those symptoms. So hearing how those voices, what it plays in that person's life, what it means and how it impacts them is important for dictating how you're going to be dealing with them.
Yeah, you know, when you treat a lot of primary psychosis and schizophrenia, you will begin to find that it's not the majority of the cases where you can get full remission of the hallucinations. And you'll also find that not every patient has that as a goal to have zero hallucinations, you know, because frankly, to get to zero hallucinations, Often you have to go to a high enough dose of antipsychotic that there's intolerable side effects or serious neurolepsis, basically drug-induced negative symptoms.
So don't just go, here's the symptom of the voice, I need to get rid of it, right? You do want to get a more thorough assessment of the patient's relationship to those voices and how long they've been around and how impairing they are in order to make a mutual decision on how to treat. And, you know, going back to I want to be more clear about voice hearing from other sources, those don't respond to antipsychotics, right?
If your voices are from what's essentially dissociative disorders or experiences, either from a dissociative disorder itself, trauma disorder, or personality syndrome. Those are really just parts of the self that have been split off in terms of an experience, experienced as different or at least separate from the core self. And that does not, in my experience, and I think in the research, actually respond to dopamine blockade.
Now, one thing I did want to talk about, and I think it might wrap around into this, is You know, it's easy to think of schizophrenia as just the symptoms that you see, as just the hallucinations and delusions. And one of the core things that we're kind of talking about is that there are different symptom domains for schizophrenia. So there's the positive symptoms, and those are the ones that we see.
We know that a core part of the disorder is negative symptoms and cognitive symptoms. And I recently read a study that said, like, essentially that you have to treat the symptom domains different and separately. It's not like the antipsychotics just treat schizophrenia and then everything's taken care of. And with schizophrenia, you need to address the cognitive and negative symptoms through other treatments. Yeah. And what I think the paper was saying is that like in bipolar with psychotic features, once the core problem is fixed, essentially all the other kind of things fall into place.
Whereas with schizophrenia, if you treat the positive symptoms, it's not like the other things kind of fix in themselves. So you really do address those things separately.
Yeah, that's true, though. I will say I don't think we're at a situation... We're not at a step here, a stage, where we can target a lot of the impairments in schizophrenia directly to pharmacology. So we hope to be able to get there someday, of course. But often all we can do is find the right antipsychotic and titrate it and then try to get some coping skills in there.
It would be nice if we can definitely target everything else.
And Ian, I bring that up in that... You don't expect – like let's say you do treat those positive symptoms. If you're seeing negative and cognitive symptoms, it's not like, oh, that's who that person is. With those, first of all, a lower threshold for going for clozapine or medications that have some help with the negative symptoms, which is a little bit. But also, you know, there is an emphasis on – psychosocial rehabilitation on getting the person into work, into socializing.
We have here, it's called like Fountain House, which is like an awesome program for connecting people to jobs and a network. So Yeah, I agree that we don't have great pharmacological treatments, but I think the helpful thing is, like, don't just keep increasing the antipsychotic, hoping that those things can improve. Instead, start thinking of psychosocial interventions to directly address those things.
Yeah, those are underrated, especially for early psychosis and early intervention, right? Yeah. um of course we have to from a science standpoint argue is that because we got an antipsychotic on board early is it because of selection bias in terms of that less severe cases are more likely to engage in psychosocial efforts uh who knows but in my experience it's helpful and yeah don't just pound the antipsychotic you try to get some lifestyle changes in there the best you can.
And often that does require encouragement and prompting from other parties, usually family members. But just, yeah, don't just increase the antipsychotic. A couple other things I wanted to mention in terms of common mimics, what isn't psychosis before talking about delusions more. neurodevelopmental disorders and generalized oddness, right? Cluster A, personality traits, and autism spectrum disorders. Unfortunately, can be easily mistaken for a primary psychotic disorder, but these are things that are present from earlier age throughout development and should not be simply treated with antipsychotic unless there's no other clear alternative.
Now, you might say, well, isn't there research evidence to support the use of risk for all unabilifying autism spectrum disorders? Yes, there is, but that is not for the treatment of quasi-psychotic symptoms, and it is not for general functional improvement so much as it is for the control of quote-unquote unwanted or disruptive behaviors. You should not Give those to high-functioning people who don't have severe disruptive behaviors.
There's a risk. I would, again, reach for other medications first if they are safe and appropriate. In addition to neurodevelopmental disorders potentially mimicking psychosis, we also have general culture. Religion, spiritual ideas, overvalued ideas from society itself. Anyone can have an idea that is unusual or different off the beaten path. That is not in itself psychosis. You need to find the core syndrome, which, again, I think is neurodegenerative and comes at a later date.
Yeah, and I like your, because I feel like the thing that you really focus on, which I love, is kind of getting to the diagnosis, not treating symptoms. And yeah, there's so many patients, you kind of mentioned like autism or just patients that I'm not quite sure what the diagnosis is, but I just get, they say odd things that I'm not quite sure of. And that's where We kind of talk about like hearing someone's life history, collateral is super helpful because there's so many patients where like something's not right, but I don't know what it is.
And for there, the way you solve that is first off time and seeing them progress and see how those symptoms progress. And second, collateral. Now, one thing that can be a challenge is sometimes – this is also helpful. You have a patient that has – something's really off, but you're not quite sure what it is. And then you call the parent and it's much more off. Like your attempt to get the history makes you even more confused, which is information in itself.
But that's why it's so helpful for patients to have providers that they're with long-term and kind of understand how they kind of formulate their symptoms. Because as you're saying, like if you just load these people to antipsychotic, you're not treating the underlying thing at all. You're just giving them, like the risk benefit profile is horrendously tipped towards risk.
Yeah. And I guess while autism and general personality oddness is a mimic for true psychosis, we should also note that those conditions are risk factors for true psychosis as well. And that in autism spectrum disorders, you can see brief episodic psychosis that doesn't look like schizophrenia exactly in the time force. can be more time-limited or stress-based. And you can also see higher risk of mood disorders that may look atypical because of the way that the patient presents or reports symptoms.
I'm thinking of a case I had where there was a woman who came in on Essentially, it was guanfacine. She came in on a non-stimulant ADHD treatment, primary diagnosis was ADHD. But the record was available, even though there was no collateral available for this patient. And you saw what was essentially a normal functioning person until about the age of 20 in college, and then a sort of decline.
And then there was also a lot of weird claims made by the patient, kind of grandiose in the record, including that they were once a college professor, which would be strange given what was known about the rest of the patient's life history. Yet when you interviewed the patient, the patient denied ever having made such claims. So I treated this patient for a little while and just watched.
And eventually... Patient came in and reported having essentially a hypomanic episode for about two weeks. And we put her on lithium. she stabilized and oh I forgot to mention the context is that the whole time when you interact with this patient autistic traits were pretty clear right so what was this patient once we had had the observed hypomania I interviewed the patient again about her history and then she told me that I You know what?
Now that we talk about it some more, I remember when I dropped out of college, I had gone to the hospital and they had put me on Zyprexa for six to eight months. But then my outpatient psychiatrist called me a liar eight months afterwards and took me off the Zyprexa. So you can't get too into diagnostic categories as well because you can start to miss conditions because you say, this is a strange presentation.
This person is telling me strange things. I'm just going to assume that this is a normal and healthy person. You may potentially deprive patients of necessary treatment. So I would say that even when I'm quite sure that a primary mood or psychotic disorder is not present and I want to take someone off of medication, I will still say, I don't know for certain what happened before or what's going to happen in the future.
Even if we have you off medications, I recommend that you get monitored long term, even if it's just four checkups a year to see how you're doing.
Yeah, you bring actually one of the I do want to I think we can almost do a longer podcast, but the patients that you don't have. You know there's something going on, but you're not quite sure what the diagnosis is. How to handle it with that patient, how to talk to them about your differential and what you're kind of observing for is a skill in itself where you're not making a diagnosis.
Instead, you're holding on to a placeholder diagnosis with the patient with the understanding that time will tell us what happens. what it is. Like for that patient, until you saw that hypomanic episode, you didn't have a way to talk with the patient about what you thought it was. And that's the... I think it would be helpful if we did a podcast on the differential for these patients and how to communicate with them and how to essentially treat them.
When you aren't sure and you have a very legitimate large differential, it's impossible to sort out and say, I think it's definitely this or it's more likely this.
um yeah and i recall with that particular patient i i said you know i don't know what you have i don't know if you have anything at all you could have something you might not there's definitely some stuff we are seeing here uh in the past from you that suggests there's something but i can't tell you what it is so for now what i suggested that we either continue the guanfacine or uh we can stop it but either way we should continue to meet and the patient uh after a couple business wanted to stop the guanfacine but agreed to continue to meet and lo and behold we uh we're able to detect something um so yeah you gotta see things longitudinally you know one assessment uh can be enough sometimes especially if you're a very good assessor often will not be in people who have episodic uh conditions You know, we're...
I guess this is a richer topic. This may even have to be a three-parter.
Yeah, and that's... Okay, so maybe we can take just a few minutes to dive into it. There is... I had this all the time in the outpatient clinic. Patients who essentially had their first psychotic episode with a few odd details that made it so you weren't 100% sure if it was schizophrenia or bipolar. They had this extremely big stressor that... they reported was a big stressor that they attribute almost all the problems to.
And what makes it challenging is you're actually not sure if it was bipolar or schizophrenia. So you can't say like, no, it's not just that you had this stressor, you're this. So the challenge is made bigger because you say like, I don't think it was just this stressor, but I actually don't know what it is. That was an extremely common patient. And to make it more confusing is I mean, I essentially categorize these patients.
These were patients who had a brief psychotic episode. Often they come off the inpatient floor with a completely definite diagnosis, which was never talked to with the patient. Like it'll say schizophrenia. And then on the intake, you'll go like, okay, so you were diagnosed with schizophrenia. And authentically they go, oh, I didn't know that. Or bipolar. And they'll go like, oh, no one told me. I don't know how you're...
psychiatric inpatient system was but it was incredibly common for patients to have a psychotic episode get an outpatient appointment and through their entire inpatient stay they were put on an antipsychotic got better and then no one talked to them about what was going on and that oh yeah i watched i saw firsthand it's not like uh it's not like patients you know conveniently forgot uh like i saw that happen um yeah yeah
I mean, it's a problem. I suspect that that happens because of insurance practices, right, that they require a specific diagnosis on inpatient. That's my understanding. I haven't really worked on inpatient past my training period. I've been almost exclusively outpatient or crisis. Yeah, I think they need a specific diagnosis for billing in some situations, so they're sandboxed into picking certain diagnoses, which is pretty unfortunate. That's a systems issue.
That being said, it's also possible for people to appear floridly and convincingly psychotic on inpatient, but that it's episodic because in the prodromal period, People are not going to neatly fit into a box of a DSM diagnosis most of the time. And as we've already discussed a few times in the last 40 minutes or so, there are people who under stress will manifest a convincing psychotic episode, even if they don't have a pure schizophrenia.
These are usually people with some neurodevelopmental stuff, differences. So what do you do? Well, I would say that in that situation, your priority is keeping the patient in treatment and monitoring. And in treatment is not on a medication necessarily. In treatment means engaged with monitoring and follow-ups. And so that's what I try to emphasize for those patients who I suspect may be prodromal. I try to let them know about what I think possibly has happened and the risk of not being monitored long-term, but I leave it to them about whether they want to be on the medication.
I have some of these folks strongly resist coming off an antipsychotic years later because they had one episode, they stayed in the antipsychotic, and their life has essentially been fine. I can often see that there's a total lack of negative symptoms or disorganized behavior, speech in these patients. And you're on a baby dose of antipsychotic and perhaps don't need to be on one. For the ones that have agreed to come off, I have unmasked OCD before as a primary cause.
And then there are also people who immediately want to get off the antipsychotic. You have to warn them about the risk of doing that, but ultimately it's up to them. And you still monitor. And some, a lot of those people will show themselves to have a primary mood or psychotic disorder once off the antipsychotic. So again, what's more important than a particular medication is keeping them in monitoring and engaged with treatment.
Yeah, one thing I find helpful, and I don't know, regardless of the cause of psychosis, you should continue antipsychotic treatment for six months to a year. So with these patients, I say, you know, I talk to them about what I think the differential is. And if I have like, you know, oftentimes it'll be bipolar with psychotic features versus schizophrenia. And then I'll give them reasons why I'm thinking one more towards the other.
But then I'll say, but to be honest, there's no way for me to know for sure. The only thing that would let me know is if we came off the medications and you had another episode and I could see that episode for myself. But what I say is, regardless of the cause, psychosis causes, psychosis is actually in some form brain damage. So it's been known that one of the the best predictors of how much problems it causes is what's called duration of untreated psychosis.
So when your brain's in psychosis, it's sort of like, it's toxic to your brain. And I say, it's generally recommended to continue the antipsychotic for six months to a year, regardless of the cause. So even if we think it was, even if we were 100% sure that this was caused by the bad grades you got in that one class, I still would 100% recommend that we continue this medication.
Now, as you said, it's up to them if they want to continue. I'd rather a patient safely taper off and safely be monitored than tell a patient they need to be on a medication and have them not follow up. Autonomy is one of our guiding principles. But it's important that you talk to them once you're starting to taper off that medication, what the risks are, that you don't know exactly.
If this is schizophrenia, if this is bipolar, if this is just a brief psychotic episode, and even if it is a brief psychotic episode, there's still a 50% chance that it recurs and that there are risks with coming off that medication of unveiling things. And the best thing, if they're 100% sure they want to get off medications, is to continue follow-ups so that if something arises, we can catch it early and get you back on treatment.
Yeah. And unfortunately, you are going to see some tragic cases. You know, I'm thinking of a case I saw last few years of a young person who I just wasn't sure was prodromal versus purely stimulant induced. And this was not illegal stimulant this use. This was prescribed, quote, ADHD treatment, you know. And that patient wanted to be off the meds as, you know, as soon as possible.
I recommended nonetheless take a little bit of, you know, Abilify, they refused. And I recommend monitoring and they did stick with monitoring for a little bit. But unfortunately, as they became more acute off of treatment, the parents became concerned and started calling, but the patient became more and more unwilling to engage with treatment. So, you know, we need patient autonomy and it is going to cause some tragic outcomes.
You know, that's the balance that we strike as a society. And you're going to have to stomach that as a clinician. But we try our best. And for all those cases, there's also the cases where people stay in treatment and prevent a lot of bad outcomes for their brain functioning. And, you know, I do emphasize that this is about dysfunction in the brain. And at this point, I strongly believe that psychotic disorders are not a matter of personality or development and are a matter of just something that happens to the brain, like epilepsy.
So similar, schizophrenia, bipolar, epilepsy, I think we should really be conceptualizing them in the same medical category. And so I explain it to patients that way. And I will say that it does seem to make it a little easier to stomach the treatment. and the diagnosis so even if it's not fully scientifically supported uh even though i think that's the direction we're going to be going in the research i think it helps treatments so you can consider talking about it that way i don't think we have time to get into delusions i think we should save that for part two uh maybe we can just list a little bit about other things that We've talked about what is psychosis, roughly.
We've talked about what probably isn't psychosis. We can talk a little bit now about what may or may not be psychosis. We've already talked about the unusual episodic presentations of psychosis seen in neurodevelopmental disorders. You mentioned the mimic of PTSD, I would say that in severe PTSD plus a severe primary mood disorder, you can see psychotic features. And when there are psychotic features of a severe mood disorder, episode, that's probably closer to what we consider psychosis.
And that does absolutely warrant treatment with an antipsychotic. But don't neglect the primary treatment of the mood with either SSRI or mood stabilizer. That's still the primary treatment over the antipsychotic, in my opinion. So don't forget that.
Yeah, and I think when it is connected to mood, tapering off the antipsychotic once the psychosis is treated for six months. I do see patients who have major depression with psychotic features, and then I saw a patient who was on Zyprexa for two years afterwards, and then they just were continued on it despite having no symptoms of psychosis. So I do think of... I don't know if this is helpful, but for schizophrenia, the antipsychotic is necessary for baseline.
For bipolar with psychotic features and for major depression with psychotic features, you can choose to pull off the antipsychotic once the acute phase and psychotic symptoms are done. Again, after six months, the thinking that I think of there is... The analogy I always like to say is that... psychosis is like a fire in your brain and once the initial treatment's done there's still some kindling and that like there's still a little bit of uh you know little tiny flames going on so if you were to stop treatment one of those little flames could catch fire and and restart the whole fire again so you're in this very susceptible period uh so you do want to continue the antipsychotic for six months so that you kind of fully put out that fire so that there isn't those little kindlings that could that could create a full fire
Yeah, in my experience, it's pretty variable in terms of the mood of psychotic features patient, whether or not they can go off the antipsychotic. Many can. I've done it even after 20 years. They say two years. Not that I treat them for 20 years, that they came to me with 20 years of risperidol at a high dose that they didn't ultimately need. But some people will have reemergence of some psychotic features or at least severe depression when you pull off of the antipsychotic because many of the second generation or even the first generation in psychotics can have an effect, augmenting effect on treatment of depression.
a couple other things that i wanted to mention as unclear categories for whether or not they are biologically related to primary psychotic disorders we already talked about severe substance associated psychosis i think especially if you have a substance-induced psychosis from a drug that does not cause psychosis in most people most people like cannabis yes at a very very high dose Most people can get a little psychotic on cannabis, but most people do not on a lower dose, but some people do.
That, again, I think is a sign of more vulnerability to psychosis. Final category of what's unclear to me whether or not it is or is not a primary psychotic disorder would be sort of the top 1% severity of borderline personality. And no, I don't mean top 1% of patients. I mean, top 1% of only the patients that have a diagnosable borderline personality disorder. You probably have run into this once or twice in your inpatient setting.
It's pretty rare. You probably know what I'm talking about. It's basically people who have maybe had at least... Minimum one hospitalization a year in the most acute phase of their treatment. They present as both borderline and psychotic or mood. And if they're stabilized, they come to you on a huge cocktail of multiple antipsychotics and mood stabilizers. For those patients, I often see a lot of discussion about across treatment teams about is this borderline only or is this psychotic only.
Personally, I'm open to the possibility that the very severe borderline personality disorder is comorbidity, that it's some kind of a crossover of both a severe personality syndrome and some kind of genetic vulnerability. So you get a lot of vulnerability distress from the personality syndrome, and that can activate the genetic neurodevelopmental vulnerability to episodic psychosis. So I'm more inclined to keep those people on some kind of a psychotic disorder regimen, but I also acknowledge that we could be over-medicating a personality syndrome, and they simply don't have access to good personality disorder psychotherapy.
Yeah. And more cases than not, you're throwing in a nice hefty dose of substance use to complicate the picture even more.
But I've seen it happen with zero substance use pretty reliably. And I still have no idea what I'm treating really.
Now, there's one other thing I wanted to touch on today. And it's that you mentioned outpatient psychosis is not an emergency.
Oh, I was hoping to keep that for the next one. Maybe we can reiterate on the next one. What do I mean when I say outpatient psychosis is not an emergency? I basically say don't get too heated about initiating treatment right away for two reasons. Now, it's weird to say that it's not an emergency after you've just talked about the whole kindling thing and that being in psychosis is bad for the brain, which I absolutely agree with.
Why is outpatient psychosis not an emergency? Well, simply because you cannot force people to take medications in outpatient 90% of the time, 99% of the time, right? People will not take a medication that they don't believe in. And you can harm somebody with a medication that's unnecessary. We already talked about that today. So try not to get too heated about treating psychosis right away if, A, the patient's not sure about the treatment, or B, you're not sure about the diagnosis.
Try to focus on forging the treatment alliance and getting more information rather than just starting a med. That's my main thing there.
trust in a provider and having a good, strong therapeutic alliance is such an enormous factor and is as big if not—is bigger than what the actual underlying—can be bigger than what the underlying diagnosis is. And that because so many of these conditions, the reasons why there's problems is because they don't have a good alliance and they don't take their medications or they're noncompliant or they're ambivalent about their treatment, so fall off.
That is a massive problem and a huge confounder in terms of like when people say they have a bad prognosis. That is often a big portion of it.
Yeah. Well, I think it was a pretty dense episode. I apologize for any quality issues, given that we're both, I think, at least a little sick. But I do like this topic and I hope people find it useful. There's a lot more to say about it, especially in terms of understanding delusions and the assessment of psychosis and the detection of psychosis, especially subtle psychosis. But I think we'll have to save that for next time.
Once again, you've tickled us.
All right. Well, until next time.
Thank you.