Key moments, in order
Pay attention to what you feel inside with a patient and you will find your own trends with certain subtypes of patients.
A countertransference reaction is not a diagnosis. It is a sign that you should question or get more history on that slice of possible psychopathology.
Whichever side you lean toward, practice the one you are more uncomfortable with, because we do have both.
With paranoid patients, externalize the feared object and sit together with the patient, harnessing at least a little feeling of you and me against the world.
Being in their world is assessment. Then you come back to yourself and use your expertise, pattern recognition and experience of how patients report symptoms to formulate a diagnosis.
Clarification is any question or move that gets the patient to go into more depth or detail about what they are talking about. It may redirect the narrative, but it does not challenge or change it; once you challenge it, it is no longer a clarification.
It is very easy to take the position of interrogator, expert or master who is going to do something to the patient and get something from them.
Use OLD CARTS, even for voice hearing: onset, location, duration, character, aggravating and alleviating factors, radiation, timing.
Then ask why, again and again: who are the voices, why do they think they have them. Patients rightfully expect to be judged for these experiences.
Always start with what the patient can see as a problem, find common ground there, and pick the medications with the fewest side effects you have access to. If they see no mental health problem at all, externalize it.
You can recommend a medication the patient disagrees with: I know we do not agree, but as your doctor I am recommending it and it will be waiting at the pharmacy. Keep seeing them.
Unless you detect an emergency, psychosis is technically not an emergency. If the patient is unsure about treatment or you are unsure of the diagnosis, forge the alliance and gather information before starting a medication; random medications cause side effects, and without an alliance they will not be taken.
With a refusing patient: "I know you disagree, but we've talked about the risks and benefits, and I think it's indicated. It'll be at the pharmacy waiting for you."
Pick weight-sparing medications when possible, knowing the trade is often akathisia. Lurasidone is number one for akathisia and aripiprazole is up there; newer drugs that help mood and spare weight still cause a lot of it, and it is a big reason people cannot take them.
Outpatient akathisia is largely subjective, something the patient feels, and they can suppress it, especially in the visit with you.
Most patients respond below 8 mg, just like risperidone, and it is much better tolerated dosed that way. Some people do need high doses: do not be afraid of 10 to 15 mg in very rare cases.
The FDA took away the REMS, not the recommendation. People still get severe neutropenia, so ANC monitoring continues on the exact same schedule; you just no longer report to a central registry. Skip the classic monitoring and you are outside the standard of care, with your license on the line.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.