Key moments, in order
In the DSM, psychosis is more than delusions and hallucinations: it includes disorganized speech, disorganized behavior and negative symptoms. Catatonia sits nearby but is not only seen in psychosis.
Psychosis is not one thing. It is a syndrome that probably reflects a wide range of different entities presenting more or less similarly.
Never trust a pre-1980 schizophrenia diagnosis, and do not trust any diagnosis until you verify it yourself. Older definitions were too loose, sweeping in anyone with disturbances of thinking, mood and behavior, so schizophrenia in older texts is not the same group of patients we mean today.
Psychosis is not one thing; it is a syndrome that probably reflects a wide range of different entities. Dropping the schizophrenia subtypes was an educational loss, because it made everyone think schizophrenia is one thing when it is an umbrella term for a wide range of presentations.
Today, decades after deinstitutionalization, someone with primarily paranoid features is much more likely to escape hospitalization and treatment, so do not picture only the acute inpatient case.
Patients with mainly delusions and hallucinations, without negative symptoms or disorganization, often will not tell you about the hallucinations or do not see them as hallucinations, so all you are left with is delusions.
You need only two of the four core criteria today, and only one of them has to be delusions, hallucinations or disorganized behavior or speech.
Look at the long-term trajectory. You should be able to identify a point where functioning, especially mental functioning, begins to decline and stays down, and can be partially rescued with antipsychotics.
One view is that schizophrenia is a neurodevelopmental disorder that may or may not involve progressive neurodegeneration; calling it neurodegenerative is more controversial.
We do not think those writing about schizophrenogenic mothers and other developmental contributors demonstrated that they are actually causal.
The biggest mimics are chronic substance use or substance-induced psychosis, PTSD and borderline personality disorder, which get tacked on with a schizophrenia label.
Do not write off the possibility of a primary psychotic disorder co-occurring with a substance use disorder.
Heavy methamphetamine use can cause so much disorganization and delusion that, even after stopping, the person looks exactly like someone with schizophrenia. A paranoid delusional belief system that began on methamphetamine can persist after the perceptions that fed it stop.
In our clinical, non-scientific experience, long-term substance-induced psychosis has more positive than negative symptoms. In the end, the question is less what caused it than what will help treat it.
Reserve 'delusions', 'hallucinations', 'negative symptoms' and 'disorganization' for primary psychotic disorders. For trauma and personality syndromes say reported voices, fear or hypervigilance, and overvalued idea or inflexible belief.
Clear disorganized behavior or speech, thought disorganization and negative symptoms are what make you reasonably sure of a primary psychotic disorder.
Clinicians underestimate the risks because antipsychotics are so easy: no labs, and they work fast, especially inpatient. And tardive dyskinesia risk is higher in people without a primary psychotic disorder.
When the picture is likely trauma or personality and still undifferentiated, start with smaller things like gabapentin, hydroxyzine, buspirone or propranolol rather than serotonin-based drugs, because of the risk of agitating an unrecognized bipolar disorder.
Do not chase the voice. Getting rid of it often takes an antipsychotic dose high enough to cause intolerable side effects or drug-induced negative symptoms. Aim for function.
Those voices are parts of the self that have been split off and experienced as separate from the core self. In our experience, and we think in the research, they do not respond to dopamine blockade.
Treating the positive symptoms does not fix the rest, so address negative and cognitive symptoms separately. Do not keep raising the antipsychotic hoping they improve; use psychosocial interventions aimed directly at them.
The antipsychotic evidence in autism is for controlling unwanted or disruptive behaviors, not for quasi-psychotic symptoms or general functioning. Do not give them to high-functioning people without severe disruptive behaviors.
Culture, religion, spiritual ideas and unusual overvalued ideas from society are not in themselves psychosis.
When something is off but unclear, the answer is first time, watching how the symptoms progress, and second, collateral.
Even when you are quite sure there is no primary mood or psychotic disorder and you want to stop medication, say that you do not know for certain what happened before or what will happen in the future.
When you truly do not know, say so: you may or may not have something, there are things in your history that suggest something, but I cannot tell you what it is yet.
Patients often come off the inpatient unit with a completely definite diagnosis, such as schizophrenia, that was never discussed with them. Ask about it at intake: many genuinely did not know.
When the case is uncertain, your priority is keeping the patient in treatment and monitoring. In treatment does not necessarily mean on a medication; it means engaged with monitoring and follow-ups.
Regardless of the cause of psychosis, continue antipsychotic treatment for six months to a year.
Better a patient who tapers safely and stays monitored than one told they must stay on a medication who never follows up. Autonomy is a guiding principle.
Explain psychotic disorders as something that happens to the brain, like epilepsy, not a matter of personality or development.
Psychotic features of a severe mood episode do warrant an antipsychotic, but do not neglect the primary mood treatment with an SSRI or mood stabilizer. Whether those patients can later come off the antipsychotic varies; many can. Psychosis is like a fire in the brain: after treatment some kindling remains that can catch again.
At very high doses most people can get a little psychotic on cannabis; at lower doses most do not, but some do. In our opinion, people more prone to these experiences may be more likely to develop a long-term primary psychotic disorder.
BPD resembles psychotic illness in some ways: on unstructured psychological testing these patients show much of the same thought disorder. The most severe BPD may be a crossover of a severe personality syndrome and a genetic vulnerability to psychosis.
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.
Trust and a strong alliance can be as big a factor as the underlying diagnosis, or bigger.
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.