Hello, it's Dr. Malsberg. When I was listening back, it really kind of sounded like I have no idea what we're talking about often in this episode. And I just feel the need to say, oftentimes I'll ask questions because I want Dr. Fu to paint the rest of the picture, and I think those questions will help do that. Not necessarily because I have that question. I don't know if that makes sense.
Enjoy the episode.
Good morning, Dr. Malsberg.
How are we doing?
We don't have a cold open. You know, instead of the cold open, I think you told me not to spend too much time on this, but I do feel that I should clarify some things from the last episode in case there was some misunderstanding.
Before we jump into that. Maybe to give some context on the Reddit. Do we need to give the context?
I don't know if we need to give the context.
We have to. The most voted comment was like, I disagree with Dr. Fu. And I don't think anyone actually read the post. I'm actually sure a bunch of people read the post.
I'd be fine if it just said I disagree. I want people to disagree with me. I like discussion. But it said that I made several errors throughout while also saying something like the DSM doesn't define psychosis, which is not true. But anyway, it's not about that exactly, but I did listen back due to the criticism, and I wonder if there are some things I should clarify. So without belaboring that, let's just talk about a few things.
Unrelated to any kind of discussion about last week's episode, I think our tail end might have overly implied that tapers should be attempted almost all the time. If you can reasonably identify a classical primary psychotic disorder or a serious bipolar disorder, tapering is actually quite dangerous. Generally speaking, in my opinion, those conditions do require lifetime medications. They just often are not necessarily the lifetime medications that they leave the inpatient unit with.
That being said, I have seen decompensation even from down titration from there. So it's individualized treatment. Secondly, how should we define psychosis? Again, I think if you try to define anything in psychiatry with a single line, you're going to run into problems because you're not going to be able to capture all of the differences between different patients. But I might say that it's a acquired neurodegenerative disease with also initial traits or differences in development that has heterogeneous brain dysfunction manifesting as any of hallucinations, delusions, paranoia, disorganized speech, thinking behavior and negative symptoms.
That's probably the best I can do anyway. This conceptualization is syndromic, but a syndrome or a disease itself is not an arbitrary collection of symptoms that a patient reports. Our diagnosis relies more than on plain reported symptoms. We have to look at how the patient relates to and describes the symptoms themselves. We will be talking about that today. You have to look at time force, function, your mental status, exam findings, and treatment response.
So when I make recommendations last episode and today about how we document and use terminology, it's a practical clinical matter, not making statements on overall nosology or what something really is fundamentally. We don't have the data for that. I'm saying that you should use neutral descriptive language until you have a more reasonable degree of medical certainty and that to prevent confusion, we should reserve certain terminology for certain groups of diagnoses, certain syndromes.
So this is practical advice, regardless of any kinds of fundamental disagreements.
Now, I want to take a bit of a microscope to how you defined a psychosis and kind of just hear... So, you know, the big things I hear you say, neurodegenerative, heterogeneous... conditions, brain dysfunctions that are causing the psychosis. And then the, essentially the core symptoms that we include, you know, positive symptoms, negative symptoms, uh, disorganized speech thinking behavior. Um, one thing I, I guess if you could help me understand now, I think that's a definition of schizophrenia, not psychosis.
And the reason why this, I want to make that distinction is because I can say someone with bipolar, with psychotic features has psychosis. And I don't think that the definition you provide fits at all.
That's true. Uh, let me be clear. That was supposed to be a definition of, uh, primary schizophrenia spectrum, psychotic disorders. Uh, are there psychotic states beyond that? Uh, Yes, but the only ones that I would say have a true resemblance to the schizophrenia spectrum and psychotic disorder primaries is mood disorders with psychotic features. That's my clinical experience. I would also argue that there's probably some data to support that.
Why? Because... The use of the word psychosis as loss of contact with reality, I think, is nonspecific. It's too broad. I know that's what's been done historically, but I think we need to become more precise over time with language. And when we talk about delusions today, I think we'll begin to see why it's not enough to do that. And there's a lot of ways we can seem to lose contact with reality because reality is co-constructed.
It's the product of at least two people in dialogue.
So the definition you provided, to clarify, that is primary psychotic disorders, specifically schizophrenia, not psychosis generally.
I would like psychosis generally, this is my preference. I know it's not what's happening out there. I would like psychosis generally to refer to states that we can reasonably connect to that process, even if it's a temporary state, even if it's a state that will resolve without standard psychotic disorder treatments. But I don't want it to refer to mimics.
But I guess, and maybe you clarify this, bipolar psychotic features isn't a mimic. To me, the patient is experiencing psychosis.
uh undoubtedly yes that's why i said the mood disorders with psychotic features i would are the ones that i would connect to it even if i wouldn't put it under the same umbrella right that being said even bipolar mania can mimic psychotic features uh the speed of distractible thoughts, rushing thoughts and speech can appear and has been defined in the literature as thought disorientation. But I'm not convinced it's the same kind of thought disorientation outside of more severe cases.
Similarly, the grandiosity sometimes can begin to reach a level that seems like it's a delusion, a loss of connection with reality and often is unrealistic. But there is some kind of a broad dividing line where if you interview these patients, some of them still have contact with reality. If you challenge the belief, some of them will have a delusional quality. to their thinking. So it's a fuzzy area.
I'm not saying these are hard and fast rules. I'm speaking in general.
Yeah. Yeah, there's a few things I'm still struggling with. But let's, let's get to our topic. Let's, let's, let's, let's move on. The big things we want to talk about today. I know we want to go into the tall. We want to talk, talk about delusions. Do you have somewhere you want to start off with?
yeah i mean we just talked about varieties of disorganization right and i mean you can argue that even someone with adhd is disorganized in their speech when you converse with them but this is the problem i'm kind of highlighting we can rightfully When we use output-based definitions, phenomenological definitions, we can assign certain clinical terms to a variety of outputs that come from fundamentally different disorders or at least reasonably different disorders.
But is it disorganization of a psychotic disorder? It's so clunky to have to say of a psychotic disorder, of a primary psychotic disorder every single time. I would prefer to use terminology specific to disorder or syndrome clusters because I believe in different underlying conditions rather than some kind of a mess of buffet where you can pick symptoms and everyone's about the same underneath. And that's because the differences of treatment effects, among other things.
So it's hard to get a working understanding of thought disorganization. Did we mention this last episode? I don't know. But the TALT, the thought and language disorder scale, TALD, which I believe you can find online, at least can give you a text sort of research grade description and definition of a variety of different things that are thought disorganization. I think that in modern day training, a lot of residents are basically taught three levels of disorganization, or maybe four.
You have linear, non-disorganized, you have circumstantial, disorganized, and then you have tangential, fairly disorganized. That's really not sufficient. And if you have that prior in your head for what to look for in terms of level of organization versus disorganization, you're going to miss certain types of thought rupture or thought disorganization because the fact is you're not going to get to level four word salad all that often in your clinical practice.
Even if you're working almost exclusively SMI, it's not going to be majority of the cases. True word salad.
And to talk a little bit. So the tall, to get to the helpful part of the tall, it's actually in the supplementary materials of the paper. I can link to this specific thing that you're referring to in the show notes. But the gist is, when we're talking about these things... because a lot of times you bring up rating scales, it's not the sort of thing that you have to actually apply to understand it.
What we're recommending is to read through it because it contains a lot of really, really helpful information. So the tall goes through objective phenomena that are positive. So positive things there, it goes through like derailment, tangentiality, circumstantiality, cross talk, logeria, pressured speech, paraphages, neologisms, perseveration, poverty of content. It goes through the subjective negative type symptoms, poverty of thought, inhibited thinking, dysfunction of thought, blocking and Rumination, receptive slash expressive speech dysfunction.
And then it goes through objective negative type symptoms. So poverty of speech, slow thinking, concretism, and then subjective positive type. So pressure slash rush thoughts and thought interference. And when you read through it, it's really helpful because it gives explicit definitions because I know I remember when I was in residency, these thoughts were relatively loosely defined and we wouldn't use them very rigorously. It kind of just got slapped into the mental status exam without much forethought most of the time.
So it is super helpful to kind of go through these things and learn like these specific definitions.
Yeah, and if you believe at all in Bayesian theory or the theory of predictive coding, you're really not going to be able to recognize something until you know that it's there to be recognized. So I guess what I'm advocating for is just simply to read through it. I don't even necessarily say that you have to agree with their definitions. To be frank, I don't use the terminology the same way they do in my documentation.
It's not uniform, right? These things aren't really discussed in the DSM. But just seeing what's out there and seeing their written clinical examples, I think is quite helpful.
Absolutely. Is there anything in particular you want to highlight about the TALT?
Not exactly. It's simply that remember that disorganization of thought and speech is broader than the three or four stage model that kind of a lot of people are taught these days. It's not enough to think about it just as how the thoughts connect. There are other ways that thoughts can rupture or can become jumbled.
Awesome. Should we use this as a springboard to the subtle signs of psychosis or do you want to talk about delusions first?
I want to talk about delusions because it's kind of still definitions, and this is kind of the big one. I think the best way to understand delusions is to work with them. Find people who have delusions, things that almost every physician and clinician will agree is a delusion, and explore it with them. It's not necessarily a challenge, but you can't not ever challenge. The way you should challenge in a clinical interview is not a true challenge.
I think it should be with the air of disbelief of someone who really does want to understand more and believe. That's the kind of challenge, like, wow, that is quite a lot to hear. I can hardly believe it, and I'd like to know more. That is the basic vibe. Let that switch to whatever you are like as a person in order to communicate that and learn more about the belief system.
That's the best way to really understand delusions, but it also helps to know theory. There is a paper that I always recommend. I believe it's called Understanding Delusions. We'll link that. I would certainly read that. I'm sure there are conceptualizations of delusions that disagree with it. But the short version is this. We're going to annoy some people again because I'm going to advocate for tautology here. But in my opinion, if you really think about it, we can't truly understand delusions from a primary psychotic disorder without defining it tautologically.
We really only know delusions from what they are not. And delusions, clinically, psychotic disorder delusions are not religious beliefs. They are not cultural beliefs. They are not overvalued, genuine beliefs derived from some life experience or any other variety of belief other than a belief that originates from a primary psychotic disorder or psychotic process that persists Despite reasoning, evidence, in a manner that is different than somebody without a psychotic process.
So there can be a delusion. There can be delusional type thinking. uh and the truth quality of the delusion is not enough to let us know whether it's true or false uh is or not a delusion i mean uh it's not enough to say fixed false belief and by the way it's not even a uh doesn't have to be false and doesn't have to be fixed it just has to be relatively impervious to reasoning so now
Yeah, for some reason, you define a delusion as something that has to be the result of a primary psychotic disorder. There's something that rubs me the wrong way about that. I don't have the words to articulate it right now, but there's something that doesn't quite feel right about that.
Well, I'll let you cook on that. I think probably because some personality types and personality syndromes will take on beliefs that seem basically delusional in quality. But those beliefs are usually interpersonal.
No, I guess I can think— That's not it? Let me keep painting it out. I've seen delusions—and you mentioned it's not a part of a religious thing, but I've watched many cult documentaries, or not even cult documentaries, but abuser-victim documentaries that the person develops a ton of different delusions that are slowly— I mean, it's very possible that they go away after therapy or after time or that don't go away and they're talking and what they're saying is explicitly delusional content and not religious in the sense of like...
what I think of as religious, but might have religious undertones. I've seen delusions with substance use disorders where, you know, we talked a little bit before with, with meth, a patient will develop a delusional belief system. They'll, they'll stop the meth. And then that delusional belief system breaks down over time. So it's not like it converts into a primary psychotic disorder. I've seen delusions. Obviously with, we were talking about bipolar with psychotic features, but I think we kind of,
Yeah, I think that's a psychotic process.
So, you know, and there's also, you know, we kind of talked about strongly held beliefs by some people aren't, I've seen self-protective beliefs, I guess that would be personality, that border on a delusional quality.
Yeah. So let's address those briefly. I would say that category two and three, the substance induced and the mood induced, I would still consider those within the psychotic realm. It's simply that they're from a non-permanent or non-chronic is the better word, from a non-chronic perspective. Psychotic process. I figure that the underlying process the underlying experience is like that of the psychotic disorders fourth category Sounds like it's defensive qualities, right?
That's similar to what I was referring to in terms of the personality syndromes I in my opinion that is Fundamentally going to be likely a different category than the primary psychotic disorders Those That's why you pretty much only see them within the interpersonal realm, unless this is somebody with some comorbidities that can be hotly debated. The first category is, I think, why I came to this conclusion, because if you have to evaluate And frequently, whether cultural beliefs and religious beliefs are or are not psychotic in origin and should or should not be treated with an antipsychotic in a court of law, I think this is where you run into this problem.
And like I said, reality is co-created. And things that seem completely delusional to one party can seem basically true to another party. And there is no realm of human experience, I think, that you're more likely to run into this than religion and politics. Two people can be looking at the exact same thing and think that the other person is completely out of touch with reality. And without a true objective measure of reality, if you...
think that human perception is flawed to some extent and biased, which I do inevitably, then you can't rely on truth quality. OK, and so when you see that happening as a result of religious process, interpersonal process or, you know, some kind of learning process, I don't think that should be categorized. in the same area because it comes from a different fundamental experience. The idea here is that delusion should come from the more aberrant perceptions and experiences of a psychotic disorder where you get insight from a internal experience that is perceived as external.
Think of the first rank symptoms.
Now, what you were saying about the religious content, I almost want to make a distinction in that there's some religious content that I agree... as you said, context matters so much. From a Western Christian perspective, the idea of Vishnu having four arms and being a god of the Hindu philosophy sounds delusional in regards to how ridiculous it sounds. But of course, we know that within that culture, that is...
Their culture will have the same feelings about our culture in regards to a bearded man in the sky. That'll sound completely bizarre and ridiculous. But then there's... When I was thinking of the religious cult-type things, there was that one documentary that I think I talked about earlier where they thought Robin Williams came down from the sky to bless us all. They just needed to talk to Robin Williams.
Now, to me... I don't think religious, cultural things, like I was mentioning of how certain aspects of different religions that are far away from our culture seem implausible. To me, that doesn't sound delusional. But then this one quality of, you know, it's still a religious belief that Robin Williams is going to come save humanity. I would categorize that as delusional.
Why? Why would you categorize it as delusion? Because of its truth quality? Because of how distant it is from your experience? Or because of how few people subscribe to it? You see what I mean? I don't think... Rating it based on how many people believe it is objective enough. I agree. That becomes democratic, right? I don't think that's appropriate. I don't think rating it based on how bizarre it is is good either because truly psychotic people can have ordinary non-bizarre delusions.
So what's left? I think what's left is how did this belief come up? How did this person come to the belief? And why are they so sure? Why is it fixed or relatively fixed? Why is it resilient? And if the reason is because of the social and emotional process of religious belief, then I don't think that's enough to call it a delusion. Now, here's the caveat. If you look at the research, people who subscribe to new religions and cults tend to have more psychosis.
They tend to have more mental illness. They tend to be more cluster A, okay? And so I think that when you get to the small religions, the new religions, you probably are seeing people of comorbidity, that the delusions or religious beliefs, whatever you want to call them, may come from a social process, but they're building upon a diathesis, right? A tendency towards delusional thinking. But how will you know until you evaluate?
And you'll have to be able to detect and reference both causes. I guess I'm just much more willing to speculate on and operate on presumed etiology than many psychiatrists.
Yeah, and you made a good point. And I'm thinking of, you know, Charlie Manson's religious beliefs that he passed on to his family cult, which, as you mentioned, they were... He had big appeal, and he got a lot of people because he was drawing on New Age religions, Western interpretations of Eastern religions. And then they started doing a ton of acid, and they threw in there, oh, yeah, by the way, the Beatles are sparking a race war, and we're getting the messages.
Mm-hmm. As you're saying, the high amount of LSD is really the identifier there, not the milieu that they had of New Age religions.
Yeah. So we're talking too much philosophy, I think. So I'm just going to wrap it up with delusions. Because of this, I recommend that you ask at least some of these following questions when you're not sure if it's a delusion or not. Ask them, how is it that you came to understand this to be true? What experiences and when did you start to believe this, or suspect it at least?
Ask, what evidence or experiences, not in these words, you know, in plain language, what evidence or experiences have you had more recently that make you sure or more certain that it is true? What could convince you otherwise? If this happened, would you begin to think something else? If that happened, would you begin to think something else? How do other people think and feel about your belief? Have you talked to them about it and have they reacted and what do you make of that?
And finally, how much do you really believe this? Are you really, really sure? Are you 100% sure? Are you 0% sure? Is there anything that could change that again? And then some kind of funny phenomenon, you don't always have to do this, I've noticed in true psychotic disorders, is that sometimes in this discussion, somebody with schizophrenia will actually start to deny that they believe the delusion. Uh, because they, their ability to detect your social judgment is not impaired.
Okay. Uh, they can be aware in some cases that they're being judged or they think they are right. Or they can be guarded and paranoid and that can contribute to it. So they might go like, Oh, you know what? Actually, no, I don't really believe that. Uh, you know, that's, that's just kind of crazy. Um, And then if you let that rest for a second and move on to something else, then you come back later and go like, you know, you said you didn't really believe this.
Are you sure? Because it's OK. Do you think that's true or not? A lot of them will be like, oh, yeah, it's true. That's true. So the strength of the delusion will change the output of this process. But talking, using these questions in patients with delusion, primary psychotic disorder delusions and patients that have only religious beliefs, political beliefs or ideologies or overvalued ideas, you will see a clinical difference.
OK, so it's not enough to give you some kind of a set of answers to these questions. That's not how this works. You have to get your clinical experience applying these kinds of detailed questions about belief to different patient populations.
And you mentioned I feel like the most experience I got actually was in medical school. So I remember, and I'm actually going to give a little bit of advice in medical school. A lot of times there'll be nothing for you to do during your psychiatric rotations, or there'll be like eight hours where like you have 15 minutes of work that you need to get done. And then it's like, Oh, go talk to the patients.
Um, and a lot of the kids will go and study for, you know, their, their, whatever they're called, the boards, whatever. Um, I would sit down and like talk to someone who was delusional. And at that time, I was naive enough to... Or not naive enough, but I would try to get them to see how I was seeing things. And you learn a lot in terms of how rigid these beliefs are.
You can see them fill in, in real time, different logical inconsistencies. And you mentioned if someone's aware enough to say, no, I don't believe in that delusion. If you ask later, you usually don't have to ask later. And that something... slightly associated will hit on it, and then it'll bring up that topic again for them. Now, you brought up a lot of things in regards to asking the questions to figure out the delusions, but what sort of things are you looking for that make you feel like it is a delusion?
Again, it's the origin. If the origin is overtly unreasonable, not from a social experience, not from learning it from somebody else or from some source, even if you think it's a very disreputable source, The more sudden religious insight, basically, you have into a strange idea or a very valued idea, the more likely it is to be from a psychotic disorder. Of course, tracing back the origins of those experiences and beliefs to the onset of some kind of a schizophrenia syndrome is also another sign.
You often can tell that from first set of hospitalizations, first observations from collateral. about changes in functioning and symptoms and behaviors right so temporality and you also want to look at flexibility right how flexible or inflexible how certain or uncertain is this person and the context for my clinical experience is basically that uh you know i don't get this from doing clinical work in clinical work If you're reasonably medically sure, you don't have to explore the history too much, right?
You got a bunch of other history. You can start trial and treatment with antipsychotic if the patient agrees. Done. But when you're tasked to look at the edge cases in forensics for a competency to see in trial, when all the delusions for these edge cases are reasonable and non-bizarre, the police are corrupt. my attorney is not helping me. The evidence is very weak in my case. All non-bizarre, all plausible, and sometimes even true.
It can be extremely challenging to figure out whether the Differences in belief and behavior are the product of a medical condition, a psychotic disorder, or because of genuine belief, or because of cultural learning. For example, strange ideas about the law acquired from talking to other inmates. Okay, so you can take these principles. It can help you understand delusions a little bit more. Now, yes, this is only really relevant for people who work regularly with the SMI population.
Okay, but I think, well, this is the topic of the episode, so... But I think that's about what I've got in terms of talking about delusions. The rest should be done in clinical experience and reading primary tech.
I'm going to bring up a made up case and see kind of how you think through it as to what aspects are or don't fit into a delusion. Now let's say there's a 30-year-old guy, and he comes in saying that when he was 20, he had one dose of lion's mane. And since then, his sex drive just completely doesn't work. And now he's completely suicidal. And his life is over.
He doesn't have any purpose. He doesn't want to work anymore. Because his sex drive has been nuked by external forces um he doesn't he has no no purpose in life working is not worth it because of his sex drive is not worth it um then when you kind of talk with him more you find out he's actually been having sex once every two months um he masturbates but then when you talk to him he says i masturbate uh one four times a week but i i don't have fun doing it like it's just not worth it um And all of his problems in life are, no matter what you talk about, it's this one lion's mane dose he had when he was 20 years old.
Everything kind of goes back. He doesn't want to work because his sex drive is decreased from the lion's mane. His relationships don't work because of this lion. There's inconsistencies with the fact that he's saying he's having sex, you know, multiple times a year, but his sex drive is nuked from the lion's mane at 20. Is this a delusion?
Well, I don't even start thinking of it as a delusion, just hearing the premise, right? I'm not hearing of a belief that comes without a underlying experience. I'm not hearing anything overtly... Well, no, it is quite inflexible. But I would just say for global reasons that I can't immediately put into words, delusion is not the first thing that comes to mind. The first thing that comes to mind, top of the differential for me, is overvalued idea.
Why? It's a theory about... his illness. And people get all kinds of wild theories about their illnesses, and they can come into all kinds of ideas about what is or is not their illness. Are we going to say everyone with certain types of things that we suspect are somatoform, are delusional. I don't know about that. It's simply because the way of perceiving and experiencing illness and health is so emotional and so unreliable for the average person, even for the average person who has medical training, that it's murky.
So I'm not ready to call it. It is on the differential. It's just lower for me because it's overall kind of odd, right? There is some possible inflexibility. So I would ask, I would say this is in psychodynamic technique, a confrontation.
I will be patient.
Yeah. I don't quite understand. You mentioned that you don't have a sex drive and that sex isn't good, but you aren't masturbating and having sex even a few times a year. How is that possible?
And that's the thing. I just hate it. I don't enjoy it. When I was 18, I loved masturbating. It brought me so much gratification. I would feel great afterwards. I felt alive. I felt like a man. Now I do those things hoping to get those feelings and nothing. Just nothing.
So it's not a matter of your ability to have sex or your mental desire to have sex. Exactly. It's the feelings that you get along with sexual activity, how much you actually enjoy the activity and its outcome. Is that about right?
I have no drive. I get no enjoyment. It's really so it's those two big things. I have no drive for it. Like I don't have. You know, I get home from work. It's not like I want to do it anymore. And then if I do force myself to do it, it just does it feels empty. It's like I'm twiddling my thumbs.
OK, tell me about the last time you masturbated. I want you to tell me how you got the idea to masturbate and what made you decide to do it. Because you say you don't enjoy it and you say that you don't have a drive for it. So how do you get there?
So it used to make me feel like a man, like it makes me feel alive. So I want to reget that feeling. So I do it hoping that I'll feel that thing. and then it's just completely empty.
And we're going to pause the simulated conversation for a second here. I wouldn't accept that as an answer. I would say, look, that's informative, but to help you, I really want something specific. I want you to imagine the exact last time you did this and I want you to rewind to the moment right before you got the idea for it and walk me through it step by step.
Hallucinatory level of detail. I would want something more concrete. A lot of patients will answer with a general explanation of what happens. That's often not good enough, especially for edge cases, but let's pretend that happened. That can give you some information or no information. Another thing I would want to know is... Why is it that, how are you, how do you know? You seem very certain that it was, I think, lion's mane that made this change for you.
How are you so sure that it's that and not something else?
So my entire life before then, I had this sex drive. It gave me purpose. I felt like a man. The second I had that lion's mane, like that day, From then on, like this switch turned off and it was obvious, you know, like I'm talking about like four years of this very clear thing. And then I had this one dose of high dose lion's mane and all of a sudden everything changes.
Everything goes offline.
And nothing has been. Oh, and then another thing we want clarifying the history is and has anything else in your life been enjoyable since then?
How can anything be enjoyable? Like once this this is like what gave me it made me feel like I'm like I'm just nothing anymore. Like I feel like nothing with. No, like I don't feel like a man at work. I don't feel like a man. No, I've pretty much been suicidal since.
You know, you're telling me that at one point. You began to feel like you didn't enjoy anything in life. And you begin to have a lot of negative thoughts and feelings about yourself, that you're not a man anymore. And that you can enjoy the things that you used to enjoy quite a lot, like sex and masturbation, and that you started to become suicidal. Are you aware that those are symptoms common to the depressive disorders?
And that's so, Doc, Doc, my mom sent me to a psychiatrist. I've been on every medication. I've been diagnosed with depression. I've been diagnosed with, I went inpatient. I did IOP. I've been on literally absolutely everything. They told me maybe it was OCD. Maybe it was, they've tried everything. Nothing's worked.
Even if the treatments haven't worked, is there any possibility that this could be some kind of a severe and non-responsive treatment depression instead of a sexual disorder?
If it is, I've tried every high dose of every class of medication.
So you agree there is some possibility, even though the treatments don't seem to be helping?
Absolutely. Yeah, I mean, sure. It's sure it's possible. If you were to tell me something would work, I would do it in a second.
So you can see here I'm already looking at you and I can see that you think, OK, you're able to receive information from me. You're able to turn it over in your head and you're able to consider possibilities. You often don't see that in severe psychosis. You often don't see that for the strongest delusions. There's almost a short circuit of reasoning. Any outside information doesn't get absorbed in and processed in the thinking.
If anything, it's as if another automatic explanation will come up to disqualify that new information. That's something that you can sometimes see. Anyway, the next step that I would go to is Well, from what I'm hearing anyway, we agree about what the problems are in your life. You can't enjoy anything. Sometimes you think about suicide. And in particular, you can't enjoy sex, even though you can do it and you force yourself.
Sometimes you can't enjoy it. What do you see as if you think that the lion's mane cost us? And if you're right about it, what do you think we should do about it? You know, I'm a psychiatrist. I'm not a sexual expert. We're here today together. Is there anything that you think I can do to help you?
I mean, I'm only here because... So this is the problem. I go... I went to a sexual specialist. They did scans. They did everything. And they tell me nothing's wrong and I need to see a psychiatrist. I just keep getting bounced back and forth. So what do I want you to do? I don't know. Figure out something. Like, I've gone to the doctors. They tell me to go to the psychiatrist.
The psychiatrist put me on a medication. I don't feel better. I tried the doctors again. It's kind of just like this awful cycle.
Yeah. A lot of disappointment, a lot of efforts and nothing to pay off. I don't see why. I don't see how anyone could go through that and not feel at least a little cynical. Exactly. Yeah. It's an awful way to be. So let me tell you this. I do work with a lot of people that have chronic medical conditions, you know, all kinds. It doesn't matter what organ system.
And what I do see a lot is that stress and mental health play a role, even if it's not the fundamental cause. You know, psychiatric issues can definitely make body issues worse. And we definitely know that's true for sexual issues. OK, so if your issue is a sexual one. and it comes from some kind of medical thing that we don't really understand i still think it's going to be really important that we tackle everything else that could be making it worse and that's going to be my job so i'd like to work with you to figure out what symptoms or problems can we actually fix or not necessarily make go away make better at least and i want you to continue working on the other end you can do your own research uh you can run treatments by me we got to make sure there's no interactions i want you to keep working with the other doctors to figure out what's going on.
But there's also clearly a lot of emotions and thoughts. about what's happened to you. And I think that's getting your way. So not only with our medications here and my recommendations about what you do with your life, but I think you're going to process those difficult emotions. And that's also my recommendation. So this is a common spiel I give for somatoform people. Okay. And I think it's true.
There's not a single thing I said there that I don't genuinely believe. But there's a way to frame beliefs that will keep you from progressing. And there's a way to frame them that may give you a chance to progress. And that's why I frame it that way. So, you know, you've heard this before. Don't argue of overvalued beliefs or delusions.
There's no point.
Right. Find common ground and move forward. That's basically how I approach it.
Now, so that was great. And I want to make a distinction. So you mentioned assessing delusions, in which case you're asking all these questions. But there's a difference between assessing and then how you're actually supposed to interact with it once it's a part of the treatment. And that like you have the formulation of whether it's a delusion or an overvalued idea. Can you talk a little bit about navigating those things within treatment?
Yeah, I would say that whether it's a delusion or overvalued idea, once you're certain about its status, unless it's directly interfering with a very key or emergent part of the treatment plan, you shouldn't work too much on it. Acknowledge that it's there. If the patient is distressed by it, you can talk a little bit about that, but you want to focus on what you can actually work on together and that you can both agree are a problem that can change.
So don't get too hung up on trying to change or challenge overvalued ideas outside that assessment phase. And of course, be diplomatic when you're doing your assessment. And with a note on treatment, I wanted to reiterate from last time. Unless you've detected an emergency, something that you have to put someone on hold for, hospitalized for, or referred to an ER, no matter how concerned you are about patient psychosis, it's technically not an emergency, even if it's not good for them.
Because what we talked about before, if you don't get to an alliance with a patient and you prescribe medication, they just won't take it. Right. So nobody takes medication willingly that they don't believe in. And that's the most important part, getting to that alliance.
Absolutely. All right. I think we're we got to wrap things up.
Yeah. This will probably, I think, need to be split into a two-parter. So we'll probably look out for that. It's kind of a long one. That is a total of three parts.
You're saying, not that we have another one, that this one's going to be a two-parter.
I think so. But either way, I'll see you next time.
Thanks for listening. We'd really appreciate it if you would leave a review on Apple Podcasts or wherever you listen to. The only reimbursement Dr. Fu gets from these podcasts is you leaving reviews, so you have to go and do it. I did make an antidepressant course. You should check it out. Just go to farm. I also have a book out on Amazon, Psycho Farm's Guide to Treating Depression.
You can just go to Amazon and search my last name, Maldberg, and Psycho Farm.
Thank you.