Key moments, in order
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.
The question is not whether the person has a mental illness, or even whether they were psychotic. Depending on the jurisdiction, it is whether they understood the act was wrong or whether they could control their behavior.
Behavior far outside the norm does not by itself make someone mentally ill. A psychiatrist has to say in what particular way they are outside the norm.
When a parent kills their own child, the studies show that a majority had psychosis.
Evidence from the time of the incident is worth more than anyone's recollection after the fact, because memory is fallible.
Start with a pre-evaluation probability of what has been happening, and let the evaluation confirm or overturn it based on the evidence.
Connect your conclusion to what you are seeing, and the best way to do that is to consider the context.
A neutral, ethical expert will reach conclusions that do not help the side that hired them, and those conclusions never see the light of day.
Malingering is not as common as you would think, though exaggeration of symptoms is probably pretty common. People who are malingering tend to get filtered out by the legal system.
It is an umbrella term. Psychosis secondary to a depressive or bipolar disorder is quite different from schizophrenia: you generally do not see disorganization.
Delusions, hallucinations and disorganized behavior respond simply to medication. You do not have to do psychoanalysis.
Postpartum psychosis is rare enough that most psychiatrists have never seen it. It can be microepisodic: the patient can look rock solid normal most of the time, with husband unaware, then have brief episodes of delusion that pass within about 40 minutes.
The cleanest definition: you can locate a medical condition that responds to medical treatment, the belief is not part of the person's baseline belief system, and it was not acquired through normal rational, cultural or social avenues.
You cannot define a delusion by its truth value: you can be delusional about something and be right. If a man's jealous delusion is built on nothing, it does not matter whether his wife happens to be cheating.
Hearing a voice and following it is not enough. What the person believed at the time has to justify following the voice in a way that means they did not understand it was wrong.
Voices can come from many conditions, or from being an ordinary person: some people simply hear an internal monologue.
Try to stick with one therapist or psychiatrist over time, because gathering information about your case relies on time and repeated observation.
A patient's perception of a clinician as good or bad does not track well with clinical expertise and outcomes. A jerk can be a great doctor and a sweet listener can be a terrible one.
No doctor can talk to you for 45 minutes and know with 100% confidence what your diagnoses are, and you cannot rule conditions out that way either.
Never say never. Not "you absolutely don't have this" but "my working theory is this, and we will keep screening, monitoring and watching."
Tell patients that they are the only single person who can coordinate their care and report everything to everybody.
Clinicians rule bipolar disorder out too quickly, as if it cannot exist unless they see mania or hypomania in front of them. What someone does and says in front of you is output, not the underlying process.
Substantially worsening or physiologically improbable sleep, like three to five hours, especially without a trauma disorder, should make you start considering bipolar disorder.
Think of a mood spectrum rather than a bipolar-or-not split. There is no dividing line between the bipolar and unipolar parts: bipolarity is like pigment in white paint shifting it toward red, so the question is not whether the patient is bipolar but how bipolar they are.
Someone with bipolar disorder can become agitated or worse on an SSRI, and persisting with it in bipolarity is where it becomes harmful and dangerous. There are other options.
The DSM is not that limited; people's understanding of it is. Many have never read the section on other specified bipolar disorder, where it discusses subthreshold hypomania.
Draw a timeline of DSM-defined major depressive episodes with the patient: first onset, length, time between and recurrence. Early onset and recurrent episodes should raise your suspicion.
Advise patients about the risk of suicidal ideation and agitation. It is probably mainly a bipolarity problem, but it is a risk.
About 50 percent of postpartum major depression, not baby blues, ultimately proves to be bipolar disorder.
Lithium started postpartum has the strongest evidence for preventing postpartum psychosis, which is highly linked to bipolar disorders.
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.