Menu Icon Search
Close Search

About the ads

  1. If you prefer the SDN Blue style, go to the bottom left of the page and select "SDN Blue"

Anosognosia and Schizophrenia. A figment of the imagination?

Discussion in 'Psychiatry' started by Ibid, 05.04.12.

  1. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member

    SDN Members don't see this ad. (About Ads)
    https://www.ncbi.nlm.nih.gov/pubmed/16958934

    If this is true then it's true but i'm skeptical. Apart from picking this apart my concern is that anyone labeled with schizophrenia who appears non compliant is automatically assumed to have this condition or are at least treated as if they do.

    Certainly anosognosia will a handy get out for any Doctor who may not inclined to listen to patients who genuinely want to discuss options that fall outside their own recommendations.

    Any thoughts or dare I say it.... insights?
  2. F0nzie

    F0nzie

    Joined:
    08.22.11
    Messages:
    821
    Status:
    Attending Physician
    Physician SDN 2+ Year Member
    I just looked up the word anosognosia. I plan on reading the article once I get off work. ;)
  3. PETRAN

    PETRAN

    Joined:
    12.28.10
    Messages:
    187
    Status:
    Psychology Student
    SDN 2+ Year Member
    Also these ones


    http://scan.oxfordjournals.org/content/early/2012/03/09/scan.nss016.abstract

    http://www.schres-journal.com/article/S0920-9964(11)00141-1/abstract

    and two very good reviews


    http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1819.2012.02325.x/pdf


    http://www.gjpsy.uni-goettingen.de/gjp-article-chakraborty-insight.pdf


    There is a lot of research in the cog. neuroscience of insight/metacognition of psychotic disorders, very interesting from both the basic and applied perspective IMO



    p.s. I thought anosognosia was pretty common as a word in psychopathology. Heh, maybe is more common in neuropsychology and behavioral neurology (usually occuring after right-hemisphere posterior strokes together with hemi-neglect, hemi-paresis etc. patient feeling like "there is no problem" and vastly over-estimating his/her abilities. Very problematic for any clinician)
  4. F0nzie

    F0nzie

    Joined:
    08.22.11
    Messages:
    821
    Status:
    Attending Physician
    Physician SDN 2+ Year Member
    Thanks for posting. That was an interesting read. Reminds me I need to brush up on my neurology as I keep forgetting the neuro deficits after every PRITE.
  5. BobA

    BobA Member

    Joined:
    08.23.04
    Messages:
    937
    SDN 7+ Year Member
  6. kugel

    kugel

    Joined:
    02.06.07
    Messages:
    827
    Status:
    Attending Physician
    SDN 7+ Year Member
    When dealing with a pt who does not recognize the existence or severity of psychiatric illness, you have to help the patient identify stop focusing on things he can't control (others' belief he has a problem) and focus on the things he can control, i.e. how to get the things he wants out of life. This does, indeed, take active and careful listening to the patient.
    Does he want to get out of the hospital?
    Focus on how to get the "fool doctors" to let him out. What behaviors does he have to stop and which does he have to start in order to convince the doc and the family to let him go home? If needed, review the chart notes and summarize for him which behaviors seem to be blocking the doc from discharging (if that's you, then focus it on "hospital policy won't let me discharge you until you..."). Let the pt stumble onto the idea that taking the pills (despite the fact that pt believes there's no illness) might get people to d/c him.
    Does he want to get his own apt?
    Show him that his family/payee is stubborn and he will not succeed by simply demanding. He will need to prove he can handle increasing personal responsibility by first adhering to the rules at home (taking meds, going to appts, not threatening to kill people, etc) in order to convince family to let him go to a "board and care" setting where he is living outside family home, but still has meds provided at correct times, etc. Then graduate to a "room and board," then to his own apt., and then to becoming his own payee.
    Does he want a job?
    Show him that volunteering at the library, VA hospital, etc. for 4 hrs per week will prove that his family is wrong and he can handle responsibility, and will provide the beginning of a resume with real supervisors. Then graduate to volunteering 8 hrs per week, and so on. If needed, the pt may have to start with going to a day-program, then move on to volunteering.


    When you have a pt that understands the existence of the illness/disability, but wants to proceed with treatment in a very different way than the doc, you have to first find out what the patient wants, and why. He will likely need help figuring out how to negotiate one change after another, to show his provider that each change can work and progress to bigger and bigger changes, and that doing one change at a time is likely much safer than abandoning the current treatment plan altogether in favor of something else.

    WAIT!! How are those two processes different?!
  7. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    Yes, but a lot of it is terrible. This guy is a misguided weirdo. imo Never going to see the light this guy. Perhaps every scrap of information he has come into contact with at Janssen-cilag seminars has resulted in some sort of neurological deficit so his point of view is now a hard wired delusional framework. Tough one.
    http://greatdanefilm.dk/web/Janssen-cilag/npa2011_13012011/npa_09.html

    The way uses his dead brother who had schizophrenia as an example is particularily distasteful. He uses it to say it gives him more credibility. He fails to see that his role as a brother prevents him from viewing his brothers circumstance dispassionately.

    eg "my brother said I don't want to go to the day centre with all those ill people". This is his own brother telling him that he wants more out of his life than drugs and a drop in circle of companions, not because he is not like them, rather because he dosen't want to become like them. Not a denial of his "illness". Sad bugger probably never really listened to his brother and what he was really trying to tell him.
    Last edited: 05.05.12
  8. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    Thanks. What you say about finding out what the person wants seems to be the key concept.

    imo the two groups you posit are usually confused to the extent that everyone with schizophrenia is considered to fall into the first group.

    I do wonder if an ability to effectively "rage against the machine" is part of some peoples ability to recover without medication.
    http://www.ncbi.nlm.nih.gov/pubmed/22340278
    Last edited: 05.05.12
  9. kugel

    kugel

    Joined:
    02.06.07
    Messages:
    827
    Status:
    Attending Physician
    SDN 7+ Year Member
    For me it always has been. But I tend to take a salesman's approach:
    - Start by asking questions to which the only possible answer is "yes."
    - Identify what they want, what they are buying.
    - Show how my product (service, therapy, medication, etc.) fits perfectly well into what they want.
    - Show that the cost of my product (treatment) is less expensive (in the long run) than the competition (whatever the other treatment plan is).
    - If Plan A is not selling, then try to sell part of Plan A, to at least keep the customer coming back so I can try again to sell.
    - If I can't sell anything, then ask what the customer will do if Plan A doesn't work out, what is Plan B? Will you come back in two weeks and let us know how it's working out?
    I know that seems crass to some people, but the process of getting someone to agree with your treatment plan (for HTN, or Hypothyroid, or Diabetes, etc) is essentially the same process as selling a car. It's just that the reason I'm selling, and the goals I have for the sale, are different from those of a car salesman.

    I lump everyone (illness or not) into the same group. My process is the same. It's just that the abstractness of my arguments, of my sales pitches, is different - tailored to the abstractness of the worries, arguments against my treatment plan. Doesn't matter to me whether the reluctance is due to the effects of the illness or not.

    I think a sense of ability to control something about one's life is important to battling most any disease, or any challenge. And helping people find some way to "rage against the machine" in a way that doesn't compromise the basic treatment is often extremely helpful. I often suggest getting involved in NAMI, Patients' Rights, Peer Support, etc.

    And. . . I'm back to, "start by volunteering just an hour or two a week for (whatever agency or charity fits his need to rebel), and show all those people who doubt you that you can indeed do things for yourself."
  10. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

    Joined:
    12.02.04
    Messages:
    4,656
    Location:
    Left of Center
    Status:
    Attending Physician
    Physician SDN 7+ Year Member
    Hint: Motivational Interviewing isn't just for chemical dependency.
  11. BobA

    BobA Member

    Joined:
    08.23.04
    Messages:
    937
    SDN 7+ Year Member
    You're entitled to your opinion, but he essentially dedicated his life's work to his brother. See his famous book: " I'm not sick, I don't need help."

    Also, he was co-chair of the DSM IV section on schizophrenia.
  12. Iwillheal

    Iwillheal

    Joined:
    04.11.12
    Messages:
    254
    Speaking of schizophrenia, I was reading an article that made reference to the "emotional paradox" of schizophrenia. Anybody know what that means or where that expression comes from?
  13. whopper

    whopper Former jolly good fellow

    Joined:
    02.08.04
    Messages:
    5,845
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    http://www.ncbi.nlm.nih.gov/pubmed/20801135

  14. Iwillheal

    Iwillheal

    Joined:
    04.11.12
    Messages:
    254
    Thank you
  15. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    http://www.xavieramador.com/

    Ok. I'll say it again. His view is clouded by his disposition towards his brother. He is incapable of being dispassionate. As I am sure you know carers (usually parents but also other family members) can be critically supportive but they can also be very disabling as well.

    It's not a surprise that family members want their relations locked up rather than supported in the least restrictive enviroment possible. It's not a surprise they just want them medicated to the maximum extent whatever the cost. It's not a surprise that they are going to be extremely risk averse. So its not a surprise they often disable their relative. This guy wants to disable EVERYONE.

    He says this LEAP method is good for any relationship with an element of conflict. The critical thing is that this man is NOT A PSYCHIATRIST. He has NEVER had to form a theraputic relationship with someone that he has detained, are detaining and could if they wished enforce just about any treatment plan. This complex dynamic is something he is totally ignorant of and unaware of.

    Listening to him talk about the patient psychiatrist relationship is like listening to a sex therapist who happens to be a virgin.

    The usual critism (from people who like to be critical) of the psychiatrist / patient relationship is that it is a relationship between the powerful, knowledgeable, superior vs. the disempowered, ignorant, inferior. Now thats a terribly helpful or accurate, but this method just feeds that impression.

    The whole method is about pretense. It's not honest. He can never level with the patient and say truthfully "I don't know" but we can work on it this way and come to some agreement (or other form of words). He can't do that because he believes he knows. He purposely puts himself in the position of the powerfull, knowledgeable superior because he also believes the "other" is ignorant and inferior.

    Critically he can't say to a patient "I will be using the LEAP method and here are the principles". Because no body would want to work with him after that because it exposes him as a cheap manipulative con artist.

    There are other holes in what he says particularily about social workers potentially not being team players and sabotaging his plans "by being on the patients side" (FFS everyone is supposed to be on the patients side) anyway the point is in the UK the role of the social worker in the detention process is mandated in law to take a look at the patients circumstances from another perspective. THATS THE WHOLE POINT. Becasue the patient is vulnerable to just the sort of group think that he wants to subject the patient to.

    He has a nasty little line of patter about people with schizophrenia first declining medication and this leads inevitable to petty crime and then more serious crime and then prison. NOTHING about the tricky fact that many many people recover with and without taking medication long term and the difficulty of knowing who will manage this and who wont. Of course in his world who cares about that anyway. He has ALL the answers, at least in his own head.

    Anyway thanks for pointing out the link. I "enjoyed" taking a look at it. Very helpful. To go along with anti-psychiatrist and critical psychiatrists I now have a whole new class of wannabe nobody/somebodies with psychiatry envy to pick the bones out of.

    The way he brought the unabomber into one of his talks was salacious and nauseating as well.

    I think I'll stop there. I must be pretty clear I think the guy is a misguided ignorant selfpublist with a nasty little belief system. He should stick to relationship counseling.
    Last edited: 05.07.12
  16. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    Thanks, Ive spent some of today looking more closely at Motivational Interviewing and I can't find anything I don't like. I need to keep reading.
  17. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,281
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Practice. Don't just read.
  18. loveoforganic

    loveoforganic -Account Deactivated-

    Joined:
    01.30.09
    Messages:
    4,229
    SDN 2+ Year Member
    How do you recommend? I've been through MI 2nd, the workbook, etc., along with some of the primary lit during the course of last year, but haven't been able to identify ways to really practice. I see a limited number of patients (avg of 4/mo?), but I haven't come across a situation that lends itself to it. I've tried reflective listening with the gf but have stopped - I found it too hard to remain neutral and not try to steer it one way or another. In day-to-day conversation with friends, the subject matter seems too shallow.
  19. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,281
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Any situation where you're asking for a lifestyle/behavioral change that the person isn't 100% invested in doing is an opportunity to do MI. You shouldn't be trying to change the behavior of friends, IMO. But you can play with structuring the language of your interactions with any person, such as how you ask questions to guide the interaction - having them open up more or less, establishing rapport with the way you ask a question, getting some level of introspection from the structure, how to reflect back what they're saying, etc etc
  20. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    I havn't got to the chapter on appropriate use of pithy phrases delivered with a hint of sarcasm yet.
    :)
  21. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,281
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Well get on that ;)
  22. aphenomenon

    aphenomenon

    Joined:
    04.23.12
    Messages:
    114
    Status:
    Resident [Any Field]
    In med school, we had to "practice" on our classmates (required of everyone). But it wasn't role playing like in most similar scenarios, we would practice as ourselves in sessions to get classmates to exercise or study or whatever. Kind of weird/interesting.
  23. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,281
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    1. Don't feel like you have to rush everything and over-practice in med school. Make sure you're learning your med school basics.
    2. Practice building rapport with everyone. Mirroring physical posture, movement, volume of speech, inflection, rate, energy, etc. Reflective listening with anyone you interact with.
    3. Build on interventions from there (build rapport, then see where it leads).
    4. Practice with the most difficult people (psychotic, annoying, abrasive, those you hate). See what comes up for you about yourself, learn about your own biases, and see what getting into rapport with them gives you as insight about what they're experiencing.
  24. Mattchiavelli

    Mattchiavelli

    Joined:
    05.22.10
    Messages:
    499
    Status:
    Resident [Any Field]
    SDN 2+ Year Member
    This is easy to do- try to get friendly with people of all levels at the hospital including nurses, secretaries, custodial and kitchen staff etc. You will not be able to approach all of them in the same way. It can be considered part of "people skills" which are very useful in medicine, you will have to sell people on therapies which do have a lot of unattractive qualities (chemotherapy, antipsychotics, metformin, etc..)but are overall good.

    EDIT- I forgot why I originally was reading this :D

    Schizophrenia with the "lack of insight" is in a way like anosognosia in classic neurologic illness in some cases where people cannot render their deficit due to the deficit its self (I think that's really the crux of the descriptive term)

    Really IMO anosognosia is not
    -willful ignorance
    -denial, which is a psychological defense mechanism
    -being unable to understand abstract concepts well like "responsibility" because of functional level

    I think that as investigative tools for neuroanatomy and functional neuroimaging get better we will start to see more heterogeneity within the schizophrenia diagnosis. Just look at what the diagnosis was 50 years ago compared to now
    Last edited: 05.13.12
  25. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    Interesting. Just to clarify. Are you saying that anosognosia should be considered a core trait or just that some people with schizophrenia might have it and other people with schizophrenia might not?
  26. robmcc1

    robmcc1

    Joined:
    10.02.09
    Messages:
    8
    Status:
    Medical Student
    Hi,

    I only watched a bit of the video - the bit where he runs through the LEAP method, I didn't quite understand why you found it so distasteful: the method in fact seemed to be something along the lines of: "I don't know" but we can work on it this way and come to some agreement".

    I agree that you don't want a blanket approach of everyone showing any psychotic symptoms needs lifelong medication, but there are often patients who you want to encourage to take their meds and I didn't think his method seemed so awful.

    Like I said I don't know much about it but was wondering if you had any criticisms of the method itself (rather than the guy promoting it)?
  27. aphenomenon

    aphenomenon

    Joined:
    04.23.12
    Messages:
    114
    Status:
    Resident [Any Field]
    I think this is quite relevant and interesting

    Self and narrative in schizophrenia: time to author a new story
    http://mh.bmj.com/content/31/2/89.full
    (bold added)
  28. Mattchiavelli

    Mattchiavelli

    Joined:
    05.22.10
    Messages:
    499
    Status:
    Resident [Any Field]
    SDN 2+ Year Member
    The second one, in my opinion
  29. loveoforganic

    loveoforganic -Account Deactivated-

    Joined:
    01.30.09
    Messages:
    4,229
    SDN 2+ Year Member
    I just realized I'd forgotten to reply here - I have read and noted the advice in response to my q's, thank you for that. I'll have to look again into the relationship-developing chapter(s) as I honestly don't really recall this specifically, although I may have just blended the techniques described in with others. In retrospect, I had also somewhat stopped looking for opportunities after running into difficulty finding them initially - so vigilance hopefully restored. Thanks again, sorry to seem neglectful!
  30. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    What if they want a different car to the one you are selling? They probably agree they need transport. If you are selling Audi thats all very well but with that approach you will never "find out" that what they really want and actually best meets their needs is a BMW.
  31. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    It's more along the lines of "I know what is best but I will tell a platonic lie and pretend that I don't know."

    This approach always assumes the patient is more stupid than the doctor. That's not always going to be the case. So its only going to work when it's true and be a disaster when its not. (and by not I include the circustance of relative proximity regarding intelligence)

    If your patient is smarter than you and that will be true sometimes I would say that you should try and avoid looking like a total idiot. No?

    When the solution is to just admit you don't know EVERYTHING and just work on a problem together that would seem a far superior idea.

    There is some evidence that the amount of further education a person diagnosed with schizophrenia has the more likely they are to not want to take medication. I'll try and find it. (I'm not saying its going to be great evidence btw, just a note)

    Motivational Interviewing looks a lot better as it seems to have a more honest edge to it.
  32. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
  33. kugel

    kugel

    Joined:
    02.06.07
    Messages:
    827
    Status:
    Attending Physician
    SDN 7+ Year Member
    Originally Posted by kugel
    For me it always has been. But I tend to take a salesman's approach:

    I know that seems crass to some people, but the process of getting someone to agree with your treatment plan (for HTN, or Hypothyroid, or Diabetes, etc) is essentially the same process as selling a car. It's just that the reason I'm selling, and the goals I have for the sale, are different from those of a car salesman.

    Sorry for the delay. I've been away for a while.

    Audi vs BMW: that's where the analogy breaks down (as they all must do), because I'm not selling what makes ME profit. Initially, I'm simply selling "treatment." Once I get an agreement to treatment, then we can work out the details of what kind of treatment makes sense, and try to put together a plan that will fit his needs. And part of my goal is to arrange for a useful treatment plan that costs LESS (because treatment he can't afford/get is useless, and dollars "wasted" on Abilify are dollars I don't have to spend on the next guy through the door). I can actually worry much more about his needs than the Audi dealer can ("what you really need is a car that seats four and has high gas mileage and low cost of ownership over 10 yrs - maybe that's a 4 yr old Honda with some cosmetic damage").

    Right diagnosis and treatment are useless if I can't "sell" him into doing it. And that's not about psychiatry. It's true in most every field of medicine. I'm sorry if this sounds manipulative, but it sort of IS. Please remember that I'm not selling him in order to make profit for me. Even if we look at it in a purely selfish manner, I'm trying to get him to pursue the treatment plan that I think will reduce My workload - because he gets better and doesn't need to see me as often. The confluence of his interests and mine is part of why I like public mental health over private.
  34. Ibid

    Ibid

    Joined:
    06.21.10
    Messages:
    658
    SDN 2+ Year Member
    Same here. Me too.:)

    Thats a nice way of putting it as it denotes and recognises the intersection rather than a complete concordence.
  35. Ceke2002

    Ceke2002 Patient Zero

    Joined:
    09.26.09
    Messages:
    450
    Location:
    South Australia
    Status:
    Non-Student
    SDN 5+ Year Member
    Speaking of insight in psychosis, would anyone be able to settle an argument for me?

    If a person experiencing psychosis develops insight, say through therapeutic techniques, learning to reality check, and so on, to the point that they are able to tell when a hallucination or delusional thought is just that, and implement coping measures, is that person still considered to be experiencing a) true hallucinations and b) are they still considered to be experiencing psychosis when symptomatic?

    From my own experience, and what I've read on the subject, I say yes, but a friend of mine on a discussion forum is saying a very adamant no, once someone has insight, they cease to experience true hallucinations, and cannot be considered psychotic.

    So who's right? Me, her, neither of us, both of us? :confused:
  36. billypilgrim37

    billypilgrim37 Unstuck in Time

    Joined:
    04.21.07
    Messages:
    2,400
    Status:
    Attending Physician
    Physician Faculty SDN 7+ Year Member
    You are.
  37. splik

    splik

    Joined:
    11.30.09
    Messages:
    1,438
    Status:
    Resident [Any Field]
    Physician SDN 2+ Year Member
    you're both wrong
  38. snarfer

    snarfer

    Joined:
    03.24.10
    Messages:
    132
    Status:
    Attending Physician
    SDN 2+ Year Member
    I agree with billipilgrim37. you are.
  39. Iwillheal

    Iwillheal

    Joined:
    04.11.12
    Messages:
    254
    I think this is a more complex question than it seems. It partly depends on the nature of the insight and also the framework used, whether you're talking about psychosis in general or a particular psychotic illness, etc.
  40. Ceke2002

    Ceke2002 Patient Zero

    Joined:
    09.26.09
    Messages:
    450
    Location:
    South Australia
    Status:
    Non-Student
    SDN 5+ Year Member
    ...(tmi)
    Last edited: 09.21.14
  41. billypilgrim37

    billypilgrim37 Unstuck in Time

    Joined:
    04.21.07
    Messages:
    2,400
    Status:
    Attending Physician
    Physician Faculty SDN 7+ Year Member
    The example I think of is a patient of mine with schizophrenia who had been doing very well for years. When she is on the bus, she hears people saying bad things about her. This can happen whether people are actually talking or if she is alone on the bus (point being, there are several versions, some hallucinations, some delusional, some IOR, all with similar content). It upsets her a lot. However, she can look right at you, tell her it is entirely her illness, that it is very likely that nothing is being said about her, and that she can't let it keep her from doing the things she needs to do. She has several strategies for distracting herself and avoiding conflicts about it. She has been working for the past ten years or so and is a very good aunt. She is chronically psychotic but has very good insight. This can be true as psychosis is a very heterogenous concept.
  42. splik

    splik

    Joined:
    11.30.09
    Messages:
    1,438
    Status:
    Resident [Any Field]
    Physician SDN 2+ Year Member
    Well this is complicated and there is no general consensus but I say you're both wrong because you have misunderstood the cognitive psychological approach to psychosis. A hallucination is simply a perception without a stimulus (that is not shared or experienced by others - until you get a bunch of psychotics together!). Whether the person believes the hallucinations to be real has nothing to do with whether it is a 'true' hallucination or not. Just that they have experienced it, and experienced it as external to the self (as opposed to a pseudohallucination which is in the 'mind's eye')

    As for the second point, about whether you are psychotic if you recognize your hallucinations are your mind playing tricks on you or whether you come up with another explanation...Psychiatrists tend to have a more diagnostic/biomedical conceptualization so they would tend to say, hallucinations are a symptom of psychosis and thus indicate the individual is psychotic even if the person recognizes their experience as a hallucination. The problem with this is that psychotic-like experiences (or anomalous experiences) such as hallucinations occur in about 8-10% of people in the general population, people who never ever present to a psychiatrist or mental health professional, who are never bothered by these experiences, and never trouble anyone with them. Are these people psychotic? Is it right to label them as psychotic (which implies to an extent they are medically ill) when they have no need for medical help and their functioning is completely normal? As such many psychologists do not see one as being 'psychotic' simply because they have anomalous experiences. It is how these experiences are interpreted that they deem as making an individual psychotic. They note that information processing errors like jumping to conclusions, and having an external attribution style differentiate the 'psychotic' patients who come to our clinics, from those in the community. They also note these individuals tend to have negative schemas and core beliefs about the self, that shape how these experiences are handled. Finally, they note that the most common sign of schizophrenia is 'lack of insight' into the nature of ones experiences. This is not seen in individuals who never come and see a doctor for their experiences. In BP's patient's case, her insight is presumably because she has had the illness so long she has recognized her hallucinations as intrinsic to the self, rather than external.

    The difference between me saying you are both wrong, and BP37 saying you are right, comes back to this idea of levels of explanation. If I understand psychosis primarily at the neurobiological level, as a product of the brain, then you are right. If on the other hand, I understand psychosis at the cognitive level, i.e. how we interpret and make sense of these experiences then you are both wrong, because it is how biases in the way we think about these experiences that make us psychotic, and not the experiences themselves. The problem with this cognitive model is it does not really explain why people develop these anomalous experiences in the first place.
  43. DrDrummer

    DrDrummer lulwhut?

    Joined:
    01.02.05
    Messages:
    271
    Location:
    Screwston, TX
    SDN 7+ Year Member
    I was going to start a new thread, but in a happy coincidence, this seems to be an appropriate place for this question.

    To contextualize the knowledge I'm bringing to this: I just finished my first year of medical school, and have an interest in psychiatry but haven't taken our school's behavioral science class or done my psych rotation. Today I was volunteering at our clinic for homeless patients and had an experience that I'm sure many students/residents encounter at some point. We had a patient whose chief complaint was recent weight loss, but over the course of the interview, with some prodding, turned out to harbor significant delusions/paranoia (I may or may not be using these terms appropriately) regarding plots to assassinate her, as well as a citywide network of protectors looking out for her and intervening before these assassinations could happen. According to EMRs and the patient, she had never been treated for psychiatric illness before, despite being a 50-something person with an advanced degree in science who had now been homeless for almost five years.

    My question is this: When something like this comes up in the history, what is the best way to address it with a patient so that they will be receptive to the idea of trying antipsychotics (or whatever meds are appropriate)? Obviously the reality that matters to them is the one they perceive-- if they believe in their gut that everyone is plotting against them, telling them otherwise will not convince them, and may even make them believe you're in on it, right? Simply giving them a drug and telling them it's to help them sleep at night without telling them it's an antipsychotic seems unethical (and if they're highly-educated/pharmaceutically-literate as this pt was, they'll just look it up and find out themselves what it's for), and confronting their delusions as being false or telling them you think they have schizophrenia/insert other disorder here seems like it risks them reacting badly to that label and maybe rejecting all the other medical treatment they need and came in for.

    Is there any literature out there on how to conduct a good psychiatric history and how to gently ease someone into accepting a psychiatric diagnosis based on a closely-held (but obviously false) delusion that's causing impairment and distress? This patient almost seemed prodromal-- again, don't know if that is the accurate word, but it seemed like she had insight into the belief-defying improbability of the plots she was describing. I felt uncomfortable addressing this stuff as just a pre-clinical student, but neither the senior student working in the clinic with me nor the attending brought it up with the patient. They ended up giving him a script for respiridone but never mentioning that it was an anti-psychotic or that he might have schizophrenia. Attached to it, of course, is the prescribing info that describes as it as an anti-psychotic indicated for the treatment of suchandsuch, which I'm sure she'll read. I just don't know whether she'll shrug and take it anyway, or be angry at her doctors for treating her for a psychiatric illness without being explicit with her that that's what they were doing.

    For what it's worth, in our city, the waitlist for uninsured patients to be seen by a psychiatrist is months long (probably true in a lot of places). In absence of SI/HI, it's really tough to get people seen. There aren't any psychiatrists on staff at the walk-in clinic, so a consult wasn't really an option here.

    Any advice/links/readings/etc. would be greatly appreciated. Thanks.
  44. Ceke2002

    Ceke2002 Patient Zero

    Joined:
    09.26.09
    Messages:
    450
    Location:
    South Australia
    Status:
    Non-Student
    SDN 5+ Year Member
    Thank you for both of these, this does make a lot of sense. :)
  45. billypilgrim37

    billypilgrim37 Unstuck in Time

    Joined:
    04.21.07
    Messages:
    2,400
    Status:
    Attending Physician
    Physician Faculty SDN 7+ Year Member
    Disagreeing w/ Splik is such a civil event! ;)
  46. splik

    splik

    Joined:
    11.30.09
    Messages:
    1,438
    Status:
    Resident [Any Field]
    Physician SDN 2+ Year Member
    heh i have a patient who describes his psychosis as a spiritual awakening. He would be fine most of the time if he didn't try and attack people occasionally as a result of such awakening. He said other people said he had a mental disorder. I asked him, is it possible that his interpretation of a spiritual awakeneing and the interpretation that his experiences suggest schizophrenia are both correct? He said, yes. So I wrote in the notes: 'pt is a postmodernist'.
  47. billypilgrim37

    billypilgrim37 Unstuck in Time

    Joined:
    04.21.07
    Messages:
    2,400
    Status:
    Attending Physician
    Physician Faculty SDN 7+ Year Member
    Very awesome.

    On a rainy Sunday night on consult call, I was called by a very incompetent PCP with an urgent consult to one of the hospitals we cover that I affectionately call "the bull**** factory". The reason for the consult? The patient was anxious that he might get constipated in the hospital because he has before (we have no authority to refuse consults). My assessment/plan: "Anal retentive. Miralax BID." Attending was pissed the next day, but I felt that was a good time to cash in some karma points.

    Not to derail the thread...
  48. Ceke2002

    Ceke2002 Patient Zero

    Joined:
    09.26.09
    Messages:
    450
    Location:
    South Australia
    Status:
    Non-Student
    SDN 5+ Year Member
    Yes I must admit it is interesting reading the different viewpoints on psychosis, the neurobiological vs the psychological cognitive ideas of what psychosis is (I think I have that right?) I'd say for me the experience of psychotic symptoms, for the most part, has always felt more biological than psychological. I don't quite know how to explain the difference exactly, just that it seems to have a different feel about it, compared to say some of my experiences and thought processes when I was being treated for BPD or Anorexia.
  49. kugel

    kugel

    Joined:
    02.06.07
    Messages:
    827
    Status:
    Attending Physician
    SDN 7+ Year Member
    Can't remember if I've told this story here before (so I probably have).

    A mentor of mine told me that the only time he saw an appropriate use of one particular old diagnosis was on a consult for, "Should we start an antidepressant?" for a patient still intubated and comatose.
    Dx: Inadequate Personality Disorder
  50. Ceke2002

    Ceke2002 Patient Zero

    Joined:
    09.26.09
    Messages:
    450
    Location:
    South Australia
    Status:
    Non-Student
    SDN 5+ Year Member
    I can only give advice from a patients point of view, but I hope a viewpoint from the otherside of the table, so to speak, might still be helpful.

    When I had my first episode/experience of psychotic symptoms, the way the Psychiatrist at the time responded, was not a way I'd personally recommend, unless you wanted to risk completely freaking your patient out. There was no gentle lead in, no calm explanation as to why a diagnosis of Schizophrenia was being considered, it was just straight out (paraphrased) 'I want you in hospital by tomorrow, we need to assess you for the possibility of Schizophrenia, and I want you started on Largactil immediately'. My response was basically 'Say what? :eek: Oh hell no, excuse me whilst I bolt out the door and never return. :scared:

    Compare that to how my latest Psychiatrist broached the subject of anti-psychotic medication with me.

    First of all he took the time to reassure me that the symptoms I was experiencing did not automatically mean I was either Schizophrenic, or 'Crazy'. He then went on to give a basic overview of how the brain, due to the misfiring of certain neurotransmitters, sometimes misinterpreted sensory input, which could result in someone experiencing both disturbances of thought and perception, and also how, because I had a family history of psychotic illness, I was more at risk for these types of disturbances occurring. Although the explanations that were given was still very much couched in lay man's terms, I was spoken to intelligently, and without being made to feel patronised at any stage.

    When it came time to present the possibility of medication, first of all we discussed a number of non medication treatments that could be used, including mindfulness training, and continuing CBT. It was also made clear that if I did decide not to give medication a go, my decision would be respected. The fact that my Psychiatrist was prepared to work with me on a non medication basis, rather than presenting it as if I didn't have any choice in the matter, actually made me for more willing to at least listen to what he had to say regarding medication (in this case, Seroquel) and how, in conjunction with other therapeutic techniques, it could really benefit me. Having had some prior bad experiences with Psychiatric medications he also took the time to assure me that he would start me off on a very low dose, and monitor me very carefully as the dosage was slowly raised up to therapeutic levels.

    Because of all of this, the fact that I felt respected, that my concerns and opinions were taken into consideration, I was spoken to intelligently, not made to feel patronised, and was also offered a number of reassurances, I did decide to give medication a go, and I'm happy to report with great success so far. :)
Similar Threads
  1. chaos
    Replies:
    5
    Views:
    919
  2. purplelife
    Replies:
    0
    Views:
    191
Loading...

// Share //

Style: SDN Universal