S03_E13 - Focus on Psychosis - A Conversation with a Clinical Psychologist

05/12/2024

The Healthy Matters Podcast

S03_E13 - Focus on Psychosis - A Conversation with a Clinical Psychologist

Schizophrenia, Delusional Disorder, Hallucinations, Bipolar Disorder...  These are some of the many conditions that fall under the category of Psycosis.  But did you know that 1 in every 30 people in the U.S. will experience a psychotic event at some point in their life?  But who is most at risk?  What are some of the early signs?  How is psychosis diagnosed and what treatments do we have?

It's safe to say psychosis has been given an imperfect definition in the media and in entertainment over the years.  Psychotic episodes typically occur when someone has difficulty telling the difference between what's real and what's not.  These conditions can take many forms and they are treated in a variety of ways, but thankfully it's been a long time since the era of asylums.  But what's the current state of affairs around these conditions?   Joining us on Episode 13 is Dr. Marielle Demarais, PhD, LP, who will help us better define psychosis and walk us through the current diagnoses, treatments and supports available to patients and their loved ones.  We'll also field a few listener questions on the subject as well!  

Although psychosis might be more common than you think, it might not be exactly what you've been lead to believe.  We hope you'll join us to find out more!

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Transcript

Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:19

Hey everybody, it's Dr. David Hilden , your host of the Healthy Matters podcast. And welcome to episode 13. Today we are gonna cover the topic of psychosis, what it is, what it means, and what it looks like. The human mind is an incredible mystery at times. And to help us better understand the causes effects , treatment, and the human experience behind psychosis, I've invited clinical psychologists and director of the Hope Program at Hennepin Healthcare, Dr. Marielle DeMare . Marielle , welcome to the podcast.

Speaker 3: 0:47

Thank you for having me. Help

Speaker 2: 0:48

Our listeners right off the bat, understand what psychosis means, if you would.

Speaker 3: 0:53

Sure. So psychosis is a description of clinical symptoms. There's a number of different symptoms that make up what we call psychosis. Uh , the ones that people commonly think of are hallucinations and delusions. So hallucinations are any kind of sensory experience that is not actually occurring in reality as other people experience it. So hearing voices, seeing things that other people aren't able to see can also be smells, tastes, sensations on the body that aren't actually occurring. Delusions are beliefs that someone holds despite there not being any evidence that that belief is true. So commonly people might feel that somebody is out to get them wanting to harm them. They might believe that they're a very important or famous person, even though there's no evidence that would really support that belief to be true.

Speaker 2: 1:45

Do we know why this occurs?

Speaker 3: 1:47

So we know some of why it occurs. So there seems to be a pattern that's happening in the brain where the dopaminergic activity, kind of some brain chemistry at the front of the brain is misfiring and causing information to seem maybe more important than it actually is. And so people start to misperceive information around them and it causes them to stop being able to tell the difference between what's real and what isn't real. It

Speaker 2: 2:16

Must be scary.

Speaker 3: 2:17

It's really scary for people that are having that experience.

Speaker 2: 2:20

How common is it and is it more common in men, women, or any particular demographics?

Speaker 3: 2:25

Psychosis occurs in about 3% of people, and it occurs across all genders, all socioeconomic classes, all races and ethnicities. It really broadly occurs in the general population.

Speaker 2: 2:41

So is there an age when it most commonly sets in?

Speaker 3: 2:44

Psychosis typically occurs during adolescence or young adulthood. That's a time when there is a lot of brain change that's happening, that's when it's occurring.

Speaker 2: 2:55

Were there warning signs or any clues prior to when people are diagnosed? Are there typically signs that precede that

Speaker 3: 3:04

Often? There are though, not always. And it can be really hard to know that that's what it's leading toward. So there's a period of time that we call this prodromal period ahead of somebody developing those acute symptoms of psychosis. Oftentimes people become more withdrawn and isolated. They may not be communicating as fluidly as they had before. They might start to feel more anxious or paranoid, and other times it may just seem like adolescent behavior or it might appear like anxiety or like depression. And frequently families, schools, they don't realize that what's happening is somebody developing psychosis because it, it really does look like so many other more common things. So

Speaker 2: 3:52

You're talking about young adults, even teenagers. Um, as a common time, we also got a question from a listener , uh, who asks, what, what can schools do to support students experiencing psychosis? Could you address that?

Speaker 3: 4:05

Mm-Hmm, <affirmative> , I love that question. I love that question because oftentimes schools may be the place where their first noticing people developing psychosis because of the age. When people typically do develop psychotic symptoms, high schools are frequently that space. So there's several things. One is schools can make sure that teachers and social workers faculty are aware of kind of psychiatric symptoms to look out for in the student body. And then how to connect those students with resources very quickly, as quickly as possible. The other recommendation I would have is making sure to educate the student body themselves. I think that these are topics that are not talked about frequently enough, and when a person is starting to hear voices or they're starting to experience paranoia, it is a frightening experience. It's also something that, because societally we do not feel like that's something we trust or that is necessarily very safe, people tend not to share the experience that they're having until it's progressed rather far. And so if we are talking about mental health more in schools and we're really breaking down the stigma that persists, I think it will increase the likelihood that people themselves who might be starting to have some of these experiences will feel more comfortable coming forward and saying, you know, I'm sometimes like hearing things that I can't find the source for. And that's a beautiful opportunity to then connect them with services because if we can come in at that point in time before they've even had to miss a day of school, that's so much better than it being two, three months down the road or two years down the road. Yeah.

Speaker 2: 5:57

What great advice, and thank you to the listener who sent in that question about school supports. We've had somebody ask us about psychosis versus dementia or Alzheimer's disease. Now these are different conditions, but could you comment on the difference between psychosis and dementia? So

Speaker 3: 6:14

Dementia typically occurring later in life. Certainly there are some kinds of dementia where people do develop symptoms of psychosis. An example would be like Lewy body dementia. However, a big distinction between dementia and other kinds of psychotic illnesses like schizophrenia or a bipolar disorder with psychosis would be that age of onset that with a psychotic illness, we're gonna see that at age 17, 19 22 versus dementia that's going to occur middle aged or older.

Speaker 2: 6:46

Yeah, different age groups is one of the first clues right there. Absolutely. Uh , another listener on social media has asked us this question, is it likely that everyone experiences a psychotic episode during their lifetime?

Speaker 3: 6:58

No. So again, that prevalence rate's about 3% of people. We know that there are different risk factors for people to develop symptoms of psychosis. So for example, if you have family history of psychosis, you have a greater likelihood of developing those symptoms yourself. Other risk factors include things like having adverse childhood experiences, a history of abuse or trauma growing up in an urban environment, being a part of group that experiences a lot of discrimination, racism, having a lot of those stressful life experiences put you at a heightened risk of developing psychotic symptoms as well as some substance use, particularly things like cannabinoids,

Speaker 2: 7:43

Marijuana, cannabis,

Speaker 3: 7:44

Exactly . Yep . Marijuana. It's still a relatively low prevalence though of just three out of a hundred people.

Speaker 2: 7:50

Okay. That's helpful. Thank you for that. And thank you listener. Let's talk about some of the specific diagnoses that fall under psychosis because you've described kind of the general condition of having a psychotic episode. What are some of the psychotic type of diagnoses?

Speaker 3: 8:05

Psychosis occurs in a lot of different clinical diagnoses. Most commonly we think of schizophrenia because the main characteristic of that illness is psychosis. Psychosis can also occur in major depression, bipolar disorder, schizoaffective disorder, which is a combination between schizophrenia and either major depression or bipolar disorder. It can occur in a postpartum period after pregnancy. There's delusional disorder that people can develop where it's only characterized by having those false beliefs. And psychosis can also happen in response to substance use, where it can just be during that more acute period of intoxication or following substance use for a period of time, but not sustained past a period of substance use to become a more chronic mental illness.

Speaker 2: 8:58

Let's get into how listeners would recognize psychosis, because it's is obviously when you hear what you're saying, it's like people have false beliefs, they have delusions, they're hearing things, seeing things that sounds like some significant mental illness that many people might be sort of familiar with, but how would I know how to recognize that? So start us out kind of early. What are the most common initial signs and symptoms, and then what does that first episode typically look like?

Speaker 3: 9:26

It can be difficult sometimes to know if a person's having these experiences, especially early on, because these are internal experiences. Only the person themself knows if they're hearing voices or if they are having some of these false beliefs or delusional beliefs.

Speaker 2: 9:41

So let me before you even go on from that, does the person experiencing those delusions or those hallucinations know that this is not a normal thing or are, are people fully convinced that these voices represent something real?

Speaker 3: 9:56

That's an excellent question for psychosis. The person has lost that ability to tell the difference between what they're experiencing as being not a real experience prior to those symptoms becoming that acute psychosis. Oftentimes people may start to hear whispers or other kinds of sounds or noises that they may still be able to hold some awareness of, maybe my mind is playing tricks on me. Or they can use what we call reality testing where they might check out a sound that they've heard and then see that there was no one actually there calling their name. As those diseases progress, the ability to recognize that those symptoms are symptoms, that they're not actually occurring lessens , and the person starts to lose more and more contact with reality.

Speaker 2: 10:50

So I know people experience this differently, but but when people are experiencing hallucinations, are they hearing specific messages that are directed to them or is it more just kind of general nonsensical voices?

Speaker 3: 11:01

It's a good question, and it does vary person to person, though. There are some commonalities that a lot of people have. So sometimes people will hear kind of a running commentary of what they're doing, just a voice that's constantly narrating. Now you are talking on a podcast, now you're picking up your pencil, now you are looking at your phone. Other time people experience what we call command hallucinations, where they are being told to do something, leave this room, it's not safe. Sometimes people experience command hallucinations that tell them to harm themselves, and unfortunately we know that self harm and suicide rates are really quite high in people experiencing psychosis because oftentimes the content of hallucinations , um, can be just so negative and dark. I'd

Speaker 2: 11:48

Like to delve into that a little bit more because a lot of the general perception is that we ought to be fearful of people who, who are living with schizophrenia or having psychosis. You just said that they're at risk for self-harm. Mm-Hmm. <affirmative> is that general perception that people who are having psychosis are dangerous to others? Is that true?

Speaker 3: 12:07

Unfortunately, the media has really shifted the perception that many people with psychosis are dangerous. What we know is that people experiencing psychosis are actually less dangerous than the general population. So what I mean by that is a person with schizophrenia has a lower likelihood of harming another person than you or I do. Just people living in the general population, people living with psychosis are at a much higher rate of being victimized or harmed by other people because of vulnerabilities that they have, and they're at a much higher rate of being harmed due to actions toward themselves.

Speaker 2: 12:48

Are there specific triggers that bring on a psychosis episode, or are people kind of always having psychosis or, or is it triggered by certain things more episodically?

Speaker 3: 13:00

Most of the psychotic illnesses are episodic, and we know that there are common triggers. So when we are providing treatment, we tend to educate people how to be aware of different triggers and, and certainly how to avoid them. So for example, avoiding alcohol and other substances is a recommendation because we're wanting to help people not alter their brain chemistry in a way that would enhance the likelihood that symptoms of psychosis return. We also want people to better manage their levels of stress because having really high levels of stress can exacerbate symptoms or it can bring symptoms back on. And the role of medications is frequently quite important in treating psychosis. And when people stop taking their medications or when they are taking them inconsistently, that's another time that can frequently trigger symptoms to return or to worsen.

Speaker 2: 13:56

Is there any link between panic attacks, anxieties and psychosis?

Speaker 3: 14:02

So those are different kinds of psychiatric conditions during panic attacks, which are typically characterized by sort of a sudden over consuming fear that a person might be losing their mind or going crazy or might be dying. That can feel extreme. It typically lasts about 20 minutes and then dissipates psychosis is going to have a much longer duration, and it may have periods of greater intensity than others, but that sensation of I'm going crazy, isn't going to have such a, a short timeframe. Anxiety is a really common experience. There's common levels of of worry that I would argue most people can relate to, and then there's certainly clinical levels of anxiety , uh, with conditions like generalized anxiety disorder, social anxiety disorder, and others. A differentiation between that and psychosis is with anxiety disorders, people are typically aware that their worries are irrational. The difference with psychosis is that there isn't that same ability to know that the worry that you're having is not based in reality. So paranoia with psychosis feels absolutely true. There isn't that ability to say, I'm worried this might be the case. Instead it is. I know that this is what's happening.

Speaker 2: 15:27

It's really helpful . Wow . So much to know about psychosis in the human mind. We've been speaking with Dr. Marielle DeMare . She is a clinical psychologist from Hennepin Healthcare here in downtown Minneapolis, and the director of the Hope Program. I'm gonna ask her about that after a short break. In addition to that, we're gonna talk about supports that are available to people living with psychosis and supports to their family and their communities, and what treatment options are available. So stick around. We'll be right back

Speaker 4: 15:55

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Speaker 2: 16:31

And we're back with Dr. Mario DeMare talking about psychosis. I'd like to talk to you if we could, about the impacts on people's lives and what types of societal or community supports that are available to people living with psychosis. Many of us remember the era of asylums. We don't do that anymore. That was not an effective intervention. What is the current state of cares in our society? So

Speaker 3: 16:56

Fortunately we've moved away from institutionalization. We focus a lot more on mental health recovery and really wanting our treatments to help people live lives that are meaningful, enjoyable in the community, and to be contributing members of society. Psychosis is a really frightening experience for people to have, and it has huge functional impacts on people's lives. So when people are developing symptoms of psychosis, oftentimes it does affect their functioning in school, in work, it affects relationships. So having a lot of treatment interventions is a pretty critical component of helping people get back to having those meaningful, rewarding lives. We have a lot of really great interventions that we can use to help people get there. And I think from a societal standpoint, one of of the things that's critical is just knowing that psychosis is something we can treat. We want to be able to treat it as quickly as we possibly can before people are experiencing too many of those functional losses. And in order to do that, we need to be able to recognize it early and we need to be able to destigmatize psychosis so that people feel like they can come in and get the help and the care that they need.

Speaker 2: 18:15

I haven't heard that so much , um, in my profession about treating early, but we talk about that all the time in everything else I do in internal medicine. You know, we talk about treating diabetes and heart disease and all that. The same is true for some of these more significant mental health illnesses, and I really appreciate that you said that starting early and not waiting until a person is not able to function as much in the community. But what you're saying, what I'm gathering from that is that it's entirely possible for people to lead happy, functional, productive lives in the community,

Speaker 3: 18:46

Right? So people are able to treat their symptoms through medications, through engaging in therapy where they can learn coping strategies. I had mentioned earlier that reality testing, so finding ways where people can learn to check out some of these internal experiences that they're having and determine is this something that their brain is creating or is this something that is genuinely happening? And then they can use that information in order to determine what do they want to do next. So having those right supports in place absolutely translates to people being able to live in the community and live their lives. If people aren't able to get those supports, though the capacity to do that is really difficult. And unfortunately, that's where we see a lot of people in our society who experience things like homelessness because a lot of people who aren't able to get the mental health treatment that they need aren't able to function the way that we want people to be able to do.

Speaker 2: 19:45

You've touched on something I wanted to ask you. What are the consequences of untreated or undertreated psychosis? You mentioned homelessness because

Speaker 3: 19:52

Of the multifaceted ways that psychosis affects a person, it significantly impairs someone's ability to live their lives independently. So we, we talked about some of those specific symptoms, the inability for somebody to tell what is real and and what isn't. There are a number of other components of psychosis that occur. There are a lot of cognitive deficits that can happen with psychosis. So having a difficult time being able to engage in what we call like working memory effectively, engage in different kinds of problem solving tasks, thinking through things with effective amounts of attention, and all of these different important abilities that translate directly to functioning at work, functioning in school, being able to remember when to pay bills on time in order to sustain housing. A lot of social skills are impacted by psychosis. Communication is something that gets impacted. And so relationships can become much harder when somebody isn't getting the treatment that they need. And so there are so many different parts of a person's life that fray if they're not getting the treatment they need that cause them being unable or having great difficulty living that high functioning life that they would want to be living.

Speaker 2: 21:09

I've heard that our country has untold numbers of people living with severe and persistent mental illness that are sort of estranged from their supports. Even their own families, they might not even be in touch with their folks or their siblings or their high school friends or whatever. Is that a real thing? And what, what would you say to families of people who have severe mental illness?

Speaker 3: 21:32

It is a real thing, and the work that I'm primarily do here in the Hope Program is working with families. And I have so much empathy and respect for families and for the individuals going through psychosis because this is a really difficult experience for everyone to have. What can happen when people aren't given good information and good support is that these symptoms are really difficult to understand and it creates an incredible amount of stress and conflict in families and relationships have a difficult time persevering through that. Another contributing factor is that oftentimes with psychosis, people have what we call anosognosia, which is just this term that means they're not able to actually know that they're experiencing any kind of illness. So that further complicates things by somebody not realizing that maybe they would benefit from taking medication or attending therapy. And so as time goes on, if the illness progresses, relationships get strained, people lose a lot of those supports, not because the family doesn't want to be a support, I I wanna be really clear about that. But because things just get so exceptionally hard, and so a big piece of my work and what we do in our program at In the Hope program is really helping to shore up families in understanding what they're going through, helping them learn effective ways to talk about experiences, to problem solve through things so that they can really withstand and be there for the long haul.

Speaker 2: 23:06

I really like that, that you deal with families who are going through , uh, a loved one or a family member , um, experiencing psychosis. Let's shift if we could to how it's diagnosed. Mm-Hmm, <affirmative> . So somebody gets to you, I assume you're a , a psychologist, you're a doctor of psychology. How do you diagnose it? It's

Speaker 3: 23:23

A clinical diagnosis. So what that means is it's a lot of asking questions. So asking the individual themself about these internal experiences. So asking somebody about their beliefs, the hallucinations that they may be experiencing. It's also really important that we're getting collateral information. So asking family members, friends, what kinds of observations they've had. Many people with psychosis engage in different kinds of disorganized behaviors. They may be doing things that are kind of strange or bizarre that don't seem to make sense to other people. That's all clinical information that's really important for us to know so that we can take that into our diagnostic formulation. And we're also using our own behavioral observations. So we are observing if somebody is seeming distracted by something in the room that I can't perceive in the room, maybe somebody isn't able to share with me that they are having voices or hallucinations, but if I can see that they're frequently turning their head or they're talking back to someone that I can't perceive, I can deduce that they might be hearing voices.

Speaker 2: 24:33

You just observe that and you can see that they're behaving, they're responding to something that isn't there. Right.

Speaker 3: 24:39

So

Speaker 2: 24:39

Let's shift to treatments. What treatments are available to people with psychosis?

Speaker 3: 24:44

So one of the first line treatments that we always think of are medications, because this is primarily a collection of symptoms that are happening because of brain chemistry that's dysregulated. The medications that we use are helping to correct that dysregulation. We have a number of different antipsychotic medications that are used. We also have a lot of really good psychotherapy interventions. Cognitive behavioral therapy can be used. We also have acceptance and commitment therapy that can be quite effective.

Speaker 2: 25:13

Acceptance and commitment therapy. Mm-Hmm. <affirmative> . Say more please. So acceptance

Speaker 3: 25:17

And commitment therapy really focuses on helping people learn that the kinds of thoughts that we have our brain is just creating. And so we can avoid getting into essentially a power struggle with our own brains by accepting thoughts are going to flow into our mind, and we can kind of let them pass by without attaching a lot of meaning or fact to those thoughts. And we can sort of pick and choose which of our thoughts are helpful ones.

Speaker 2: 25:47

What do you say to people about medications , um, who are reluctant? They say, you know, you don't know how these work, you don't know what's going on. You're just get , you're just medicating people. What do you say about that?

Speaker 3: 25:58

Well, there are a lot of health conditions for which medications are really quite effective. And so the first place that I start a conversation is talking about what are the goals that that person has in their life? Are they wanting to get back to school, go to work? Are they wanting to have romantic relationships? Medications are simply a tool that can help someone accomplish the goals that they have. And so to that end, if there is a medication that helps to quiet some of the voices that are happening inside of a person's brain so that they can better pay attention at work and they can perform better at work, and then they can earn an income and they can live independently than those medications may be an important part of their treatment picture.

Speaker 2: 26:47

That's a thoughtful response. There's, there's, it's just one tool in addition to therapy and support systems. Um, I really appreciate that answer. So there are effective treatments for the conditions, but do people grow out of psychosis?

Speaker 3: 27:00

It's a good question. Psychosis, again, it occurs for a lot of different reasons. And so there are some acute forms of psychosis. For example, if somebody develops psychosis in response to substance intoxication, for a lot of psychiatric illnesses like schizophrenia, where psychosis is the main symptom profile, those are chronic illnesses. We do not currently have any cures, but we have these effective treatments. And so what's really important for people to know is that while we cannot cure these illnesses, we can effectively treat them so that people can have productive and positive lives.

Speaker 2: 27:39

The world has a lot of conceptions about psychosis, and there's a lot out there in in public consciousness and in media and in entertainment. Are there any myths you'd like to dispel about psychosis?

Speaker 3: 27:51

One we talked a little bit about, which is that I think many people think individuals experiencing psychosis are dangerous, and that is an absolute misperception. The other myth that I would want to dispel is that psychosis is an untreatable condition that is going to always result in chronic homelessness, and that's also not true. We know that we have good treatments. We know that this is something that we can change what the trajectory of a person's life is, and we wanna be able to do that.

Speaker 2: 28:29

Wonderful. Those are great things to point out and they're also hopeful. Before we wrap up, I wanna talk about the HOPE Program, which you are the director of. Could you say a little bit more about what your program does?

Speaker 3: 28:39

Absolutely. The HOPE Program is an early intervention program for people who are just developing or have just been diagnosed with schizophrenia or schizoaffective disorder. We focus on just those two psychotic illnesses because they are mainly characterized by symptoms of psychosis and because they are chronic illnesses. We come in with an interdisciplinary team that provides comprehensive services that include medication management. With psychiatry, we include therapy, both individual therapy and family therapy, and we have a lot of other supports built into the program. We have employment and education specialists, people that are helping get folks back to work into school. They're working with the schools and employers in getting accommodations in place so that they can be successful. They're helping people explain why they've had a gap in employment while they were maybe hospitalized, and how to talk about that on a job interview so that people can be successful. We have peer support specialists on our team, so somebody who has had their own experience with mental illness, with having been hospitalized, taking medications. We have a caseworker on our team that can help connect people with different kinds of community-based supports that folks might need, making sure people have the insurance that they need so that they can afford the healthcare that's going to help them get back on track. There's so many different ways that we want to really be comprehensive in our approach to care, because we know that getting back on track and really focusing on that mental health recovery, it's more than just about treating symptoms. It's about how do we get people back into their lives?

Speaker 2: 30:24

What an incredible program. When people ask me what healthcare issues ought I to be advocating for, I always tell people, advocate for a more robust mental health system. So this is one area that's working more and more of that is needed. Thank you, Marielle . We've been talking with Dr. Marielle DeMare . She is the director of the Hope Program at Hennepin Healthcare in Minneapolis, and a clinical psychologist talking about psychosis. Thanks so much for being here. Thank you,

Speaker 3: 30:50

Listeners.

Speaker 2: 30:51

I hope you've picked up some great information, as have I, and I hope you'll join us for our next episode. And in the meantime, be healthy and be well.

Speaker 1: 31:00

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive Producers are Jonathan , CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.