Key moments, in order
Do not confuse your moral reasoning with legal conclusions. A legal test is a statute applied to evidence; a moral judgment weighs blame, agency, intention, capacity and the effects of mental illness. They are very different things.
Burden of proof matters. At least one jurisdiction makes the prosecution prove the absence of mental illness and insanity beyond a reasonable doubt, which is a crazy standard.
A volitional prong is murky. There is no scientific test of who can or cannot control their behavior, and no uniform, accepted medical way to say whether someone could conform their conduct to the law. The cognitive test of knowing it was wrong is much cleaner.
Standards vary by state. Using moral wrongfulness is more permissive and lets more people plead insanity; legal wrongfulness alone admits a very small minority. California separated the two, so not understanding the moral wrong qualified even if the legal wrong was understood.
Whether it was a heard voice or an intrusive thought matters less than how and why it is happening. People with psychotic disorders can experience foreign thoughts, or their own thinking as intrusive and unlike their normal selves.
Do not judge the internal logic and say it is not logical; of course it is not, it is psychosis. Compare the reported internal logic to the surrounding circumstances and history.
Malingering is not a binary of fully genuine or fully malingering. That is all-or-nothing thinking; there are many varieties.
In clinic the outcome is simply getting the patient better, so you do not have to worry about this as much. In legal work you need to strike a balance.
Some symptoms are genuine and believed by the patient but do not come from the disorder they think. They come from the unconscious, from stress or from motivations.
Many emergency physicians assume non-epileptic seizure patients are faking. They are not, and brain activity on fMRI differs between those patients and people who are faking seizures.
Be careful with language: a fully feigned seizure is not a psychogenic seizure, it is a malingered seizure.
Any DSM diagnosis captures only one slice of a patient's pathology.
Bipolar II technically allows psychosis without upgrading the diagnosis to bipolar I.
Take the facts and use them to reach a diagnosis. Do not take a diagnosis and use it to extrapolate to the facts.
Postpartum psychosis can be argued to be a unique syndrome that interacts with a baseline bipolar II disorder: the postpartum psychosis lifts, and the bipolar II remains.
Learn a lot about psychopathology first, then fit it into the DSM's boxes. That is the healthiest way to use it.
Being more likely to be a victim does not mean a person with psychosis is not also more likely to be a perpetrator.
Having a psychotic disorder raises the risk of interpersonal violence about 4 to 10 times over the general population, but it is still very rare.
The main risk factors for interpersonal violence are substance use and what can be called the criminal personality.
Maybe the most common symptom is an almost, if not entirely, neurological inability to have insight into having an illness at all.
Many patients with schizophrenia simply learn to go along socially. Ask why they believe they have it, and the answer is often that the doctors told them.
It is rare: only about 1 percent of felony cases raise it at all. With long commitments and long hearings, most people would rather take a deal, and the outcome is often not favorable.
Release in most states requires the illness to be in total remission, full medication and treatment adherence, and a lack of dangerousness.
Incompetency to stand trial is far more common than not guilty by reason of insanity, which raises the hard question of what should happen to someone who can never be restored to competency.
The alliance is not just whether the patient likes you. It has three necessary parts: an emotional bond, including trust in the treatment process; a shared understanding of the problem and the goal; and a shared understanding of how to get there, meaning the treatment target and modality.
When a patient is not going along with the plan, ask what they see as the major problem, compare it to your conceptualization, and talk openly about whether you agree and why or why not.
Treatment should not be one medication and done. That works for about 4% of patients; the other 96% need something more.
With higher risk, actively request to communicate with family or trusted people so they can help coordinate care, encourage appropriate medication and watch for alarm symptoms and dangerousness.
When a patient has rejected several medications, the next step is often not another one: bring in family, talk through pros and cons, and hear what other people say.
Anosognosia, the inability to acknowledge the disorder, is part and parcel of bipolar disorder. Bipolar and psychotic disorders come with memory deficits and lack of insight into impairment, so you cannot simply ask and trust the answer.
Ask about sleep in detail, not just how it is or how much: when they go to bed, how long it takes to fall asleep, and so on.
Do not overcorrect either. When there is an increased risk of bipolarity but the patient understands the alternatives and still wants depression treatment, document that discussion and keep a very close eye on them.
Patients make the decisions, within parameters we provide. Think of the bumpers on a kids' bowling lane: the patient decides where the ball goes, and the lanes are our job.
Your job is to give your formulation and your treatment recommendations and to explain the benefits and the risks, and the risks include not taking the medication.
They are under-prescribed. Lithium in particular scares people and its prescription rate has gone down. Think of mood stabilizers more often.
A patient who repeatedly refuses your treatment recommendations is a liability bomb. And if you cannot reach an alliance and get them to go along with the plan, you are not helping anyway.
If you offer or agree to an ineffective treatment and do not warn the patient, you are liable if something bad happens.
For a clearly neurobiological condition that responds well to medication, offering an alternative in its place is like an oncologist suggesting fasting for a malignant cancer.
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.