What we’ve said about Psychosis

“Psychosis is not one thing. It's simply syndrome. And like many things in psychiatry, it probably reflects a wide, wide range of different entities that tend to present syndrome. more or less similarly or often less similar”

“When you get psychosis secondary to a mood disorder, a depressive disorder or bipolar disorder, then the psychosis is quite different. You generally don't see disorganization”

“On top of delusions and hallucinations, we have disorganized speech, disorganized behavior, and negative symptoms. then there's catatonia which is actually not uh only seen in psychosis”

“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”

“if you use the term psychotic in the way that it was originally meant, namely... there's a problem with joining with consensual notions of reality. Then you see a number of people who aren't diagnosably schizophrenic but who are struggling to stay in reality or who have some really crazy ideas”

“I really feel that for psychotic and bipolar disorders, as a society, we've been incorrectly conceptualizing these conditions as psychological. They're not psychological. These are brain disorders”

“The delusions, hallucinations, disorganized behaviors of the psychotic syndromes and the psychotic features of a bipolar disorder respond simply to medication. You don't have to do psychoanalysis”

“with psychosis, there's dysfunction here and your brain is attributing salience. So it's attributing important events to mundane things. I think of it as like it's the attribution of surprisal, of what's important, of things that you need to focus on is totally random”

“what Dr. Fu is mentioning is what's called duration of untreated psychosis. And the core concept there is that psychosis, the process of psychosis can be thought of as almost toxic to the brain. And the longer time that someone is in psychosis, the more damage, potentially irreversible damage that it can do”

“I think these discrete categories blind us to the ways in which we all have the And we could all go mad in one way or another”

“you need the same suspension of disbelief that you might have watching the new Avatar movie, you know, Blue Aliens. You're not sitting there skeptical”

“It's a process of assessment, of being in their world to understand their world, and then coming back to yourself and using your expertise and your pattern recognition and your experience with how patients report symptoms to formulate a diagnosis”

“it's very, very, very easy to instead take the position of the interrogator. the expert, the master, the person who's saying, I'm going to do something to you and I'm going to get something from you”

“I would say for any intake or any time that you're assessing for a specific diagnosis, don't ask your structured interview questions or the DSM criteria. for at least the first 20% of your interview”

“Simply asking questions to get more information about something without challenging or changing the narrative. That's a little bit tricky because if you challenge or change the narrative, that's not really a clarification anymore”

“Be real. Simply perceive what's going on. And if you can demonstrate to a patient that you have an understanding of their internal experience and their past experiences, that's the important part. That's the empathy”

“you want to externalize the bad object or the feared object. You want to sit together with the patient and try to harness at least a little bit of a feeling of you and me against the world”

“Rather than looking directly at the patient, imagine that you two are two people looking at a third party. You should try to arrange the dynamic of the encounter instead of two people looking at each other as to two people looking at a third party”

“Ask why, ask why, ask why, why? Because, again, these are experiences that lots of patients rightfully feel and expect that they're going to be judged negatively for, right”

“I not only measure frequency of being bothered by or perceiving delusional beliefs, I also will ask, how much do you really believe that? Could it be something else that shows you sometimes the nature, the source of the apparently delusional belief”

“the best way to detect any kind of issues with someone who's dissimulating is to try to hold a prolonged conversation that has nothing or very little to do with evaluating for specific symptoms”

“when we're reasonably sure that we have evidence to support a primary psychotic disorder of some kind, you know. And for me, it's when you see clear disorganized behaviors or speech. thought disorganization, right, and if you also see negative symptoms”

“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”

“Don't look at the internal logic. And say, that's not logical. Of course, it's not logical. It's psychosis. Compare the reported or recorded internal logic to the surrounding circumstances in the history”

“You can't simply ask, are you having this? And you can trust the answer. Because these are the two conditions that come with memory deficits about impairments and also lack of insight into impairments”

“It actually doesn't matter if it was a voice or not, because people with psychotic disorders can experience foreign thoughts or they can even experience their own thinking, but in a manner that is quite intrusive and different than their normal selves”

“the way you solve that is first off time and seeing them progress and see how those symptoms progress. And second, collateral”

“Number two, bipolar 2 disorder technically allows you to have psychosis without upgrading the bipolar 1”

“if you pay attention to what it's like to be with a patient, what do you the clinician feel inside emotionally, you're going to find trends for yourself with certain subtypes of patients”

“even if your individual response can be unique or outsized in terms of your internal emotional feelings, those feelings, the countertransference, are being provoked by something objectively identifiable”

“I would encourage that clinicians carefully observe different types of patients and compare them to each other”

“the biggest ones that I saw is definitely substance use, chronic substance use, or patients who come in with a substance-induced psychosis and they get tacked on with schizophrenia. Other big ones are PTSD is another big one. Patients with borderline personality disorder”

“a lot of people who might be identified by some clinicians as having some kind of an odd psychotic disorder are actually experiencing dissociative reactions. A lot of voice hearing is not the product of a schizophrenia spectrum disorder”

“It is possible for someone with a primary psychotic disorder to have a substance use disorder too, and we can't write off the possibility of a primary psychotic disorder co-occurring with a substance use disorder”

“if you have a substance-induced psychosis from a drug that does not cause psychosis in most people most people like cannabis yes at a very very high dose Most people can get a little psychotic on cannabis, but most people do not on a lower dose, but some people do”

“we also have general culture. Religion, spiritual ideas, overvalued ideas from society itself. Anyone can have an idea that is unusual or different off the beaten path. That is not in itself psychosis”

“while autism and general personality oddness is a mimic for true psychosis, we should also note that those conditions are risk factors for true psychosis as well”

“Psychosis itself can look or sound like mania when it's mostly agitation and insomnia without the manic features. This can get confusing with the schizoaffective spectrum”

“I'm open to the possibility that the very severe borderline personality disorder is comorbidity, that it's some kind of a crossover of both a severe personality syndrome and some kind of genetic vulnerability”

“I think, again, we are touching upon our inability as a field to correctly capture the crossover genetic risk between psychotic disorders, bipolar disorders, OCD and autism. I would just do a careful eval on those”

“it was a high level of achievement and persistence in achievement that did not match the kind of apparently psychopathic assaultive behavior that is usually the product of a personality disorder or a personality problem. So that was a mismatch there”

“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”

“We can call it voice hearing, right? Reported voices instead of hallucinations. We can call it fear or hypervigilance instead of paranoia. And we should call it an overvalued idea or inflexible belief instead of delusion”

“unless you're sure, reasonably sure of what you're treating, I don't think you should throw on random medications. You're going to cause side effects. You're going to cause problems”

“the biggest difficulty in treating psychotic disorder, the meds work. The meds work really well. The problem is that they're not fun and they have really bad side effects. And the challenge in treating psychotic illness is to develop a relationship with the patient that they trust you and that they trust your recommendations”

“trust in a provider and having a good, strong therapeutic alliance is such an enormous factor and is as big if not, is bigger than what the actual underlying, can be bigger than what the underlying diagnosis is”

“One of the reasons that the neuroleptics help psychotic people is that they are huge anti-anxiety drugs. They reduce terror and sometimes allow for more clear-headedness”

“Often you have to go to a high enough dose of antipsychotic that there's intolerable side effects or serious neurolepsis, basically drug-induced negative symptoms. So don't just go, here's the symptom of the voice, I need to get rid of it, right”

“clinicians are underestimating the risk of antipsychotic treatment because antipsychotic treatment is so easy. You don't have to draw labs and it works really fast, especially inpatient. So everyone gets antipsychotic. But they have side effects. And the risk of tardive dyskinesia is higher in people who don't have a primary psychotic disorder”

“if you take an example of people with a lot less experience with rare psychotic disorders and severe psychotic disorders, and you tell them to use the same rules, they might end up prescribing a lot of unnecessary antipsychotics to people”

“if you see something that looks like MDV with psychotic features alongside the PTSD, don't be afraid to consider the agents for bipolar depression efficacy as well”

“the astounding data, which didn't replicate, but that doesn't matter because it's now one against one, in adolescents who were psychosis prone. You know those studies. It's just jaw-dropping the difference”

“I think you always have to start with what's the problem for the patient. What is the patient able to see as a problem? And sometimes they see zero mental health problems. So then you'll have to externalize”

“i don't think i would ever say um not purposefully to one particular patient that's not real or that isn't reality i might suggest it even strongly uh most of the time it would be to ask them if they're willing to consider an alternative interpretation as reality”

“I know we don't disagree. I know we don't agree that it's an appropriate treatment for you. But medically, as your doctor, I am recommending it. I think you should continue it because I think it is going to help you”

“I strongly believe that psychotic disorders are not a matter of personality or development and are a matter of just something that happens to the brain, like epilepsy”

“just because you're more likely to be a victim doesn't mean that you're also not more likely to be a perpetrator, too. Right? That doesn't make any sense”

“when a parent kills their own child, if you look at the studies, pretty much a majority of them did have psychosis. But what are some other reasons why someone might kill their own children”

“the moderate grade severity psychosis often goes unnoticed. but it can impact people's decision-making, thinking, and beliefs about the world”

“a large chunk of people basically got moved from what were the insane asylums and state hospitals of the past to jail and prison of today. This has had an effect on, in my opinion, psychiatrists, the majority of psychiatrists, their ability to detect and understand psychotic disorders”

“in the emergency room, the definition of getting inpatient hospitalization involuntarily is acute danger to themselves or others”

“If you encounter it because of a delusion, right? A hallucination. It's technically not objectively threatening. But I would say that that's a situation where most people encountering that and unable to tell it apart from reality would be objectively threatened”

“tons of literature pre-1980 and certainly post-1980, especially about theories around psychosis and schizophrenia, may not be talking about the same patients as other people writing and publishing on the same word schizophrenia”

“I don't think that the people writing about the, quote, schizophrenia, schizophrenogenic mothers, et cetera, et cetera, developmental contributors to schizophrenia, I don't think, A, they demonstrated that that's actually causal”