A Forthright Conversation about Psychosis with Dr. Mahesh Menon

Dan is joined by Dr. Mahesh Menon, clinical associate professor in the Department of Psychiatry at the University of British Columbia (UBC) and a psychologist with Vancouver Coastal Health.

Dr. Menon shares his journey into psychology and mental health advocacy, discussing his early experiences with an NGO that supported homeless women with mental illness. Dr. Menon then explains the complexities of psychosis, including its symptoms, classifications, and the role of dopamine in the brain. Then, Dan and Dr. Menon discuss differences between delusions and hallucinations, the impact of substance use on mental health, and the age of onset for psychosis. 

Special Guest: Dr. Mahesh Menon

Cognitive Remediation Resources

The North American CBT for psychosis Network page

Links to a lot of helpful resources (video, books etc) related to psychotherapy for psychosis

Online Training Portal for Metacognitive Training (MCT) for Psychosis

Brain Fitness Games

Dr. Nicola Wright: Resources for treating psychosis

🎞️ Video version of the show@PsychotherapyAppliedPsychology on YouTube
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Connect with Dan
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Chapters

• 0:00 Introduction
• 3:08 What psychosis is
• 7:12 Early Signs and Misconceptions
• 11:46 The Lived Experience of Psychosis
• 16:25 Triggers and Underlying Factors
• 21:02 Delusions and Hallucinations Explained
• 26:00 Understanding the Psychotic Process
• 30:48 Therapeutic Approaches and Challenges
• 36:05 Working with Clients in Psychotic States
• 41:30 Clinician Self-Awareness and Boundaries

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain and hopefully have some fun along the way. If you find this show interesting, it'd be much appreciated if you shared it with someone you know, who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on psychosis. Now, I've never been someone who's particularly interested in psychosis, but when I had a conversation with my guest and I learned about how he was thinking about treating psychosis, I was immediately engaged and wanted to have him on the podcast. In part one of our conversation, we discussed what psychosis is and why people experience it. And again, conversations about the mechanisms involved in psychosis are usually not something that I'm not interested in, but I found this conversation extremely engaging and I learned quite a bit. This episode starts with my guest responding to my question about how he got into studying and practicing with psychosis. Oh, and I should let you know that for the first couple of minutes, you might hear what I think is a power saw on the background, but that goes away quickly. So, without further ado, it is my pleasure to welcome my very special guest, Dr. Mahesh Menon. When I was in my teens in undergrad, I was interested in psychology, but actually I was looking for experience in the field. And there's a wonderful... I was doing my bachelor's degree in India and there's a wonderful NGO that was started by two women who were just a few years older than me, where they had started a home for women who were homeless, who had been experiencing severe mental illness. And they were of course, such a vulnerable group. And so these two inspiring women had started a home where they would take people and give them a safe place and start to work with them around medications and so on. And then that really led to a whole incredible system of care eventually, kind of many years later. But when I was working with them, it was just like working. They had just started a small place and they needed volunteers to help out. So basically I was doing my undergrad and I was looking for volunteer opportunities to work in the field of psychology. And I ended up working with this incredible NGO that started this home for homeless women with mental illness. And so when I was volunteering because it was just a new NGO, you know, it was everything like kind of writing fundraising letters, many things out, helping to kind of cook the food, serve, help out around the office, all of that stuff. But I kind of became really interested in like, you know, as a kind of naive undergrad, like you understand at an intuitive level depression and anxiety. But what I didn't get was how can whatever changes happen in the brain kind of lead people to having these beliefs about the word that other people don't have or have hallucinations, you know, you're hearing voices that other people don't. And to me it was like this real unknown and that kind of peaked my interest in the field. And so when I was doing my psychology undergrad research project, I got to work with a neuropsychologist who then agreed to be my PhD supervisor as well. And so we started to look at like, you know, what are the sort of cognitive factors that lead to the development of delusions. So in some ways it was this question of like, how can something that changes in the brain lead to, you know, abnormal beliefs. And it was sort of like this question that I came to at first just kind of from like a just understanding it kind of causally. And then later on, after getting my clinical licensure, also just looking at kind of interventions for that aspect of it. So when you were working with the NGO, was that the first time that you were exposed to psychosis? Yeah, yeah. So I was just, and like, you know, just kind of like talking to the people that were at the NGO about what was going on for them. And just kind of like, wow, you know, they think that someone's trying to harm them or hurt them. And at that point, you know, my thinking was not sophisticated about any of these pieces. I was just kind of like curious about it and understanding their experience as best I could or listening to them about that. There was no therapy in any kind of structured way. But just like listening and being fascinated by their narratives. So what is psychosis broadly speaking? Yeah, so I think when we are thinking about psychosis, like the way we kind of classify symptoms, we often kind of talk about it as like positive symptoms, negative symptoms, disorganized and cognitive symptoms itself. So the positive symptoms not because they're good, but really because it's more of something. So the positive symptoms would be like the delusions and hallucinations. So delusions of a false belief and hallucination is a false perceptual experience. And then the negative symptoms will be a reduction of some of the things. So a reduction in motivation. So a motivation or reduction in speech or reduction in expressed emotion. So kind of active platinum, and Adonia, those all would be part of the negative symptoms. A lot of times people who have psychosis also show a disorganization that to varying levels, that's not seen with everyone, but you know you can have what's called a thought formed disorder. So their speech tends to be a little bit more disorganized. There might might be jumping from one to another. And another very common symptom, which is actually quite strongly associated with the outcome, the art and cognitive symptoms of that are associated with psychosis. Again, they're not specific to psychosis, but across the board, we see impairments in a number of cognitive domains. So memory, exactive functioning, processing speed. There is it, you know, as a result of those when we look at kind of cumulative indices like IQ, you know, there is like kind of maybe a half a standard deviation difference in the samples as a whole. Those cognitive impairments are actually predictive of how someone functions in the real world with psychosis as well. Right. I think we're going to probably get into those cognitive functions a little more deeply when we get into one of the treatments you've been a part of. Okay. So by one to just because the audience is going to be a pretty broad audience. Could we just double click for a moment on sort of delusions, hallucinations, and how you differentiate them? So with delusions, I mean, we can think about essentially like when people are sort of developing a belief, there was a wonderful paper that had come out actually when I was doing my PhD by strategic rapport. And this was kind of 2003 was when this paper came out and the paper was, you know, inspired me to kind of go and try to do a postdoc with him, which I was fortunate to do. But it was a great description of this idea of like how can kind of changes in biology kind of lead to changes in belief. And, you know, that link that I have been kind of wondering about but didn't really have a sense of it. So the Kapoor hypothesis is basically called the Aberanthesalian model now of psychosis. And essentially the idea is that what dopamine does in the brain is it is not like people think of it as sort of the reward neurotransmitter. So there are those dopamine neurons maybe firing in response to a reward, but it turns out that when you're learning associations, those neurons actually tend to fire when you have a cue which predicts their reward itself. And similarly, it's possible that there might be other clusters of those dopamine neurons which fire in response to the cue which predicts something a negative outcome as well. And so the idea was that the firing of those neurons might be encoding the prediction error, but in some ways basically when those neurons fire, it's saying that there is a cue. There's something in the environment which is unexpected or has positive or negative consequences. So something to pay attention to basically. Exactly. So it's like pay attention to this. This is important. This is meaningful. And so the idea was that that depending on kind of which which clusters of those what is the kind of emotional tone that is connected to that signal itself because that the mid-rain the neurons are quite heavily connected to like our limbic regions, the amygdala and kind of you know. So it's possible that when those neurons are firing, they're saying this is important and it's potentially positive or potentially negative itself. So when we see people kind of quite early on in the sort of pro-dromal phase or in early psychosis, they will often be sort of saying, you know, I feel like there's something big and meaningful that's happening in the world and I'm trying to put a finger on it. Like people have used a phrase like, I feel like I'm in the matrix. You know, I want to know there's something going on like the world has changed or there's a message that I'm meant to get. And it is, it's up to me to try to figure that out. And so within that framework, the delusion that the person actually comes to is the narrative, the explanation for these experiences of significance that is happening in their life to help them make sense of the world. And once we have that system, that explanation, then we fit other things into like reinforce that belief so to speak. So what we really see when people are developing delusions are two key experiences. One is like the feeling of paranoia itself and the other is what we call ideas of reference, which then become kind of delusions of reference. So the paranoia is this really strong sort of almost feeling of self-consciousness. I feel like I'm being watched or observed or people kind of know what is going on in my world or in my life. And sometimes they make sense of that experience by saying someone must be following me or there must be a camera hidden away somewhere inside, which is why I'm still getting that feeling even when I'm by myself in my house for instance. And it is connected to a sense oftentimes of harm so it can be physical harm like there are people who are watching me and they mean to hurt me or tell me or it can be social harm like they are talking about me somewhere. And so it used to be like I think that there are people gossiping about me or now it's become like I think that there are people talking about me online and I think that there might be a website. So these are like these common ways that that fear kind of manifests. And because there is sometimes a sense of powerlessness that is connected to that feeling, people often then think that there is a powerful entity or people or organization that kind of is perpetrating this harm towards them. So you know they might say like I think the CIA is watching me and they mean to harm me and then there is an explanation for that right. So it's like we're trying to make sense of why we have this really strong feeling of being watched. And then that sense of paranoia often develops into what we call the persecution delusions themselves. And then the other component which is very common especially in early psychosis and kind of purses for many people are what are called ideas of reference. So it is basically where something happens in the world outside and I get the feeling that that is a message to me. So the classic experience that you know shows up is like where people say like I was walking and I saw these like license plates and it was a message to me that you know I have do X, Y or Z. And it's like I see that and it's kind of maybe kind of triggering that meaning making machinery and it feels like that was really personally a message to me specifically. And so again that is then those experiences we're trying to make sense of why am I getting that message or what is the tone of that message often times they might be negative messages. And so you know that kind of we're coming up with an explanation for it and that explanation then becomes the solution. So the specifics of the explanation can be culturally impacted. It can be impacted by things that are happening in my life at that point in time. How religious I am or not how technologically inclined I am or not how socially connected I am. And and you know the types of traumas that we may have experienced in our life growing up that kind of dictate how we make sense of those experiences. And so just to make sure I understand so this all sort of starts because normally when we see certain cues to pay attention to dopamine fires in our brain which but for certain folks somehow that'll get that firing will start to happen when it's sort of a misfiring when the cues aren't present the cues that we should and so that sets this cascade. Yeah of experiences this thing is happening so I'm so my brain saying my body is saying pay attention to something but there actually is no there's no car speeding down the road you need to get out of the way up there's no there's no social threat there's no social any there's no there's nothing right but like some so your body so your whole self is saying pay attention to the thing but there's no thing so but because of how we're set up you create a thing. Yeah or it's basically like it's that you know it's a neutral thing that has nothing to do with me right and and when I'm seeing it that car. That car. That car which has nothing to do with you but it just happens to be parked there but because this is firing you then yes almost because of how we're built you almost have to make an explanation for what that has to do with me why it's a threat or why it's a concern or whatever. Yes and and because we're social creatures we those even kind of neutral things that are there are oftentimes connected to social agents as masters to me right that that car has been left there by someone like you know yeah right okay so we when I was doing my my postdoc I we were looking at kind of like brain imaging kind of FMRI correlates of some of these things and we tried to develop a study where we tried to induce that experience for people when they were in the scanner so we told people you know I'm going to show you some sentences folks with psychosis or without folks with psychosis and folks without psychosis to kind of see what was happening in the brain when they have that experience and so they'd be in the scanner and we would kind of show them up just a bunch of sentences and brought be accepted and was. When you see this I want you to tell me whether you think that this was written specifically about you so you wouldn't say yes if that's true of me like you know if the sentence was I have like he has black hair and you have like hair you wouldn't say yes but it's when you read that you're like whoa they put that just specifically about me and we said like that's a really uncommon experience we don't expect you to have it but if you do get it when you're in the scanner say yes if not say no and what we actually did was we kind of. We kind of met with people before we did kind of an intake assessment and we snuck in the sentences which were actually about them things from their life and we kind of put that in there and so everyone would have some things which are about them and we were looking at like do people recognize the specificity of that as well as what's happening in the brain when they are kind of seeing that and so there's a lot of like mid brain structures which do a lot of self reference show information processing right as well as like the parts of the brain like the. Those dopamine regions of the mid brain the stride them and what we found is that when people were making those judgments those cortical and sub cortical structures all lit up and then for our healthy controls people without psychosis when they thought something wasn't about them they said no it's not and then that those networks kind of shut down but for the people who had delusions of reference those parts of the brain kind of were hyperactive and they also tended to make more false positive. So you know like our controls were pretty good at saying oh yeah I think that is actually about me whereas like the people who had delusions of reference tended to have many more things that they were like yes I think that's about me and yes I think that's about me and really intriguingly in the brain even when they thought something was not about them those parts of the brain were still hyperactive especially the sub cortical regions like the the ventral stride and and and some bits of the insula and the ametula and the ametula and the brain. And the intensity of that activity was actually correlated to the intensity of the delusions of reference that the person was experiencing so it's kind of cool like just to see like what's happening in the scanner there and more both groups able to like equally is pick up on the sentences that were about them yeah so so you know we talked in like 20 sentences that were about them in the kind of large stimulus set for everyone and then the controls kind of identified like 18 out of the 20 is being about them and I think you know some of that was really the quirk of me how specific I was to make it or not but then the people who had the delusions of reference they on average kind of like endorsed about I want to say like maybe 25 sentences or something like that so there were a number of like false positive things which is which were pretty generic statements that for whatever reason they were like it feels like that's written about me as well. Okay so that's delusions now let's jump to hallucinations yeah so hallucinations essentially are like a false perception so those can be in any of our sensory modalities so it can be the most common in psychosis dance to be auditory hallucinations so this is where you hear people talking and it can sometimes be one person talking or it can be more than one person talking and less commonly but actually much more so that we we used to initially think our visual hallucinations as well what you might kind of see either shapes or people they tend to be kind of bearing levels of like acuity and clarity if you will so it's it's rare that you would kind of see someone standing in front of you as real as you know I might be seeing you on the screen but but you might see kind of shadows people at the periphery and sometimes you may actually see kind of figures themselves and sometimes you would have kind of multi-modal hallucinations so you might see the shape that is speaking but that that tends to be rare despite you know what you see in films and things like a beautiful mind and so on. That was exactly what I was thinking of was like so the popular cultural reference where you see like it's like they're it's like their world has changed right their environment the people that are there the person like it's like they could reach out and touch them yeah where it's like no it's much more vague than that yeah and there are people have that but that is less frequent it's much more common that people would hear voices with the same level of clarity that they might with someone as if someone was kind of talking to them. And that can kind of vary in frequency and intensity and of course how much it occupies your mind that tends to be a lot more common and then about a quarter to a third of the people will see some kinds of visual hallucinations that could be the occasional kind of like bigger it could be shadows could be you know other things that that our brains kind of filling in the gap in terms of uncertainty but but not often. So how often do delusions and hallucinations co occur like how very frequently yeah okay so so I probably should know the exact numbers right but because we need the diagnosis of delusions or hallucinations for the diagnosis of psychosis 100% of the people who would have a diagnosis of psychosis have one or four. One or both of those experiences I would say about two thirds of the people would have both and again it may kind of wax and wane at different points in time so you may have periods where the delusion is quite prominent and the hallucinations are less so periods with a hallucinations are quite frequent and prominent but but people are less feeling paranoid and other times when they are feeding into each other a lot because again like it's it's important to recognize that you know that the now we certainly kind of think about it as has been much more on a continuum in a way that we didn't previously right so we can all experience hallucinations and in all of our senses some tend to be a little bit more frequent with with certain conditions you know like so for instance you know tactile hallucinations are a little bit more common say in like drug withdrawal for instance or factory hallucinations can be quite common in some like neurological conditions but even when we're just thinking about like the common experience of or hallucinations if you ask or have you ever had the experience where you thought someone called your name and then you turn around and then there was you know what there are no one I called your name you've probably had that that is so so common have you many people have probably had that where they think they hear something when they're kind of falling asleep or waking up from sleep so those are called hypnogogic and hypnopompic hallucinations that those are really quite frequent as well and then when people have done studies in the general population if you will ask people like have you actually had voices kind of speaking to you when you were awake between like different studies kind of find numbers between like six and 13 or 15% of the population but even if we take a low-end estimate and say it's 6% of the population it's about 1% to 1.5% of the population that has psychosis diagnosis with with oratory hallucinations so that means for every one person we're seeing in the hospital there's between 5 and 10 people in the community who have similar experiences but they're not either distressed fight or it's not causing the same level of impairment in their in their life so when I'm working with clients I'm explaining to them it's not that you don't it's not the presence of the absence of the voices but it's just inherently pathological hearing voices is a part of the human experience it's the distress and the impairment that it's causing you which is actually what makes something pathological right all of us would hear voices if some of us can be just more prone to hearing it more easily but but anyone you know you go a few days without sleep you'll start to hallucinate lots of people hear voices in times of grief and bereavement right like the voice of the loved one might be kind of comforting or like might be a way of processing some of those experiences as well right so there are many lots of people who have PTSD experience traumatic flashbacks but when we think about kind of the components of a trauma flashback there is a very strong hallucinatory piece as well that can be part of it we've just kind of passed that out differently within kind of our no-sology but really like there's a lot of phenomenological overlaps between those experiences as well so it is a part of the human experience it is just how we make sense of it and how much it's impacting our life that we need to you know address and figure out as you were talking I was thinking there are two sort of public service announcement kind of questions I should probably ask you one age of onset yeah so typically it's a bit of a bimodal curve so for men the age of onset dance to be a little bit earlier it's kind of from like the late teens to kind of the early 20s dance to be the peak of that curve is between kind of 18 and 24 or so for women it's a little bit later it's between about maybe say 22 and 28 but again it's a curve so you can have kind of on sets anywhere for some people are kind of a much earlier onset is usually kind of associated with more illness severity so you know people who had the symptoms start off you know 10 12 14 that can be associated with with greater severity and sometimes it can be also associated with kind of earlier substance use for instance which is a big risk for psychosis that was another question I was going to those in my next question but just for to put a pin in this or put a bow on this one so so you talk to it's a distribution right so it's sort of these are the typical ages of onset that doesn't mean it can't happen outside of that but it would be this is a question it would be very unusual to have a 42 year old man who was at initial onset of psychosis when he was 42 yeah it would be rare it's not impossible that be possible but very very unlikely yes and it is oftentimes kind of indicated perhaps of like a particularly stressful period that might be happening something which is kind of like we can talk a little bit about the stress vulnerability model you know we were talking about the biology part earlier on but like this this idea right the biopsychosocial model there what is pushing someone towards developing some of those experiences at that age now I should also point out for women we do think that there might be some hormonal things which are protective and so it turns out that for women there is actually a smaller second lip that happens around menopause so there are some women who will develop it act around menopause when there are some of those hormonal changes and for the same reason you know those hormonal changes might also be why women do sometimes have postpartum repression postpartum anxiety and postpartum psychosis because there are such profound hormonal changes that are happening there bones as well huh so in some cases you get sort of a short term psychosis so follow up on what you were saying before I feel like in sort of popular culture right there's this I guess the question is can drugs start off you know get somebody going down the path of psychosis yeah okay and so I guess when we think about like the stress vulnerability model of you like we can think about there is no one gene that causes psychosis or that kind of predisposes us towards psychosis but so we can think about kind of multiple genes with additive effects right so we can think about like we have some wonderful genetic counseling colleagues and they use a good metaphor like so imagine a glass and you put a bunch of models in it and the number of models is your genetic load and the water that you're pouring in is the stress and the point at which the glass overflows with water and it spills over is maybe when that stress kind of becomes the psychosis right so if you had a low genetic load you could have a lot of stressors like psychosocial and biochemical stressors that you could take on before that kind of tips over into psychosis if you are a higher genetic load or a higher kind of stress it might not take a lot of kind of tip over into psychosis if that makes sense right so we can have that the sort of water the stressors that we see could be biological stressors like substances for instance which in the vulnerable brain can tip us towards psychosis they could also be psychosocial stressors so trauma bullying isolation sleep disturbance and all of those things often feed into each other right so if we kind of think about say a kid in his early teens who's being bullied they if they're dealing with that they tend to isolate themselves they might cope with using substances as a sort of self medication part they might be much more stressed out and anxious hyper vigilant right and if they had the vulnerability to hearing voices of getting paranoid it might take a little bit or a lot to kind of cause that to manifest at some point in that in that trajectory but now it's worth pointing out that I think it doesn't like the risk for developing psychosis not all substances are equal there is a lot of data that suggests that cannabis use particularly the THC part of it particularly early in in your teens increases the risk of developing psychosis so high dose THC early teens is like the riskiest window for it early I think some of the dopaminergic drugs methamphetamine particularly those are really high risk again because they are really messing with your dopamine system and so you know the no-volum methamphetamine induced psychosis is such a common thing as well so not so much psychedelics not so like I mean I think so there is a fantastic researcher at the University of Ottawa and in Microsoft me and they tracked like use of different substances at lead to kind of hospitalization and emergency room visits for it and they did find that psychedelics were associated with an increased risk also but I wonder if a part of it is just like like people tend to use psychedelics much more sporadically you know you don't see people kind of like right you're not doing so in an early basis yeah yeah where you might be smoking part of it yeah but but but I do think that there is there is a risk from psychedelics as well however people are also looking at psychedelics as a sort of potential treatment for a whole range of interventions right the psychosis species is really really in its early days but you know the idea of psychedelics as a kind of therapeutic is also you know something which is available but that's in a very kind of controlled supportive therapeutic environment I think the risk with psychedelics for people who don't really know what they're getting into or kind of the set and setting part of it is that it does cause you to have experiences of it hallucinations it does cause you to have you know like a fraction of your word view and I think for some people they can like there are a lot of like case reports of people who you know don't ask it and their word who is kind of permanently altered I think in some ways but I don't really know kind of how systematic it is but the reviews that have come out more recently do suggest that yes there is an increased risk for it but I think it's a little less because we tend to use it a little bit more sporadically that's sort of my reading of it I could be wrong on that so you know over the last couple years ago I'm not sure which has probably been three four years ago that marijuana became legalized in Canada just federally and in the US it's sort of it's a state by state thing but it's sort of increasing I don't know if it's plateaued or not at this point so I guess when that was happening knowing what you know and working with whom you work with did you have a oh no kind of a what's your reaction to that or thoughts about legalization now that what you say is like that this is this is a risk factor it's a right for some time for probably a small number but you know for people who's lives get you know forever altered you know still very important number of folks I mean I think the data is showing that there were increases that the increased availability to cannabis did kind of increase the numbers of folks that we were seeing with it so I think about a public health yes that has been a risk I think the people who were probably at risk who were finding we smoke a 13 and 14 they probably weren't getting it from the legal places anyway right so I think that that risk was probably present even before but I think at a population level we are certainly seeing a little bit more of an increased risk now so and this might so this this might be beyond what the data that we have now say but would it be reasonable I guess to say like that you know habitually doing drugs or these sorts of things that increases risk that that's going to be more more likely to lead to psychosis if it's happening around when those windows are for onset then when outside of those when I'm sort of in our case after those windows okay it's it's certainly if you had a family history of psychosis or bipolar disorder and and you were curious about smoking weed maybe hold off till after your risk window to two experiment with it I think would be a good you know take away so and I think also like what is happening in your in our teen years is that is a lot of like brain changes that are happening right and there's a lot of like neuro pruning there's a lot of kind of network level changes my elimination so not messing with brain development is probably just a good thing right and then once your brain is developed probably able to better tolerate some of those biological stresses better yeah I mean just thinking about the public health messaging theoretically that is like that's really useful you know for people who have a family history in particular to sort of say like you know we're not saying that this we're not making a big statement or political statement this shouldn't be legal or you shouldn't do the all we're saying is that in these what four five six year in these in the in these in this window it's going to be more likely to lead you into trouble yeah yeah I then you know there are people who recognize like you know what smoking weed makes me paranoid and they sort of lay off it but unfortunately with cannabis that are these sort of like you shaped curves on things right so you can actually be actress smoke some weed your anxiety becomes less you think that this is kind of common you but it's actually you know causing your anxiety to kind of go back up a little bit later and so then you could be kind of stuck in a use factor and to like cope with it but in using something which is cumulatively kind of increasing your your your anxiety risk as well and that these huge differences I think interpersonal that we don't fully kind of know the ortho specific software but yeah in reading about psychosis one of the things that also came up was the that folks the psychos and psychosis often have impaired insight yeah can help us understand that a little bit yeah so you know the the when we were thinking about kind of what are the differences around these periods of hallucinations for instance right if you were hearing a voice and you were able to say oh yeah my brain does that sometimes right then all of a sudden it's not as terrifying is thinking like where is this voice coming from right and can we think of this as illness or a symptom of an illness itself and so I think like there is varying levels of acceptance around that and an understanding of it and so number of colleagues have suggested that like maybe understanding it through the lens like what we think of is like anisegnosia is a helpful construct so anisegnosia in sort of neurological illnesses is where someone might for instance have a stroke and their left side is paralyzed but they're like I'm fine I can walk and then if you follow me you're like why is someone can holding on to my foot because I can't reconcile that there's a part of me which which isn't working so it's an it's an unusual and interesting phenomenon you know the sort of like thing that Ollie Sacks talks about him in some of his books right but in psychosis it is to say like I'm hearing the voice or I'm feeling paranoid and someone saying to me that's a that's a symptom of an illness but my brain isn't somehow able to recognize that is a symptom that that experience is so real are kind of in-donal signal is so powerful and overwhelming what is the external feedback that is coming in so it we can't see kind of inside as not really denial or just like someone kind of refusing to accept something but you know could be partially kind of by what might be happening in the brain as well and so with by former fellow the Gerritzman who's now at damage we had done a few studies kind of looking at like brain network things which are associated with anisegnosia to look to see whether there's kind of a lairality differences or kind of like some potential things and you know the without getting too nerdy about it there is probably a brain reason for why someone might have difficulty accepting that something could be a symptom we are I think in therapy the need to find a way to work around like developing some alternative framework or inside I think that that is kind of a helpful piece and it's important to not see inside kind of as a unitary construct it's not like a binary like you either have it or you don't I think lots of times you know people are trying to make sense of these experiences like we were saying right I'm having this very strong internal experience of like the paranoia or the ideas of reference or I'm hearing the voice and I'm trying to make sense of that in a way that feels reasonable to me and so the narrative that comes from that but people will say to me sometimes well yes I have psychosis and the CIA is trying to kill me like it's like they're kind of trying to hold both these messages but certainly the the encodes delusion is so powerful as well I was also reading about I think it's called source monitoring bias which I think fits sort of fits in with what we're talking about right yeah a little bit and we were thinking about that a little bit in the construct of in the around when hallucinations so we were thinking that you know one of the possibilities is that that when we have internal experiences if we're uncertain of where that is coming from you know how likely every to think of that as internal versus external and and so some one of the hypotheses had been that maybe if we're in conditions of uncertainty have an internal experience but we think it's coming from the outside we experience that as a voice and we can look at that in terms of like more long term memory processes the sort of tagging that's happening we can also think about it more in a kind of moment to moment basis and one of the other similar hypotheses around that was what was called the sort of perceptualization threshold like when we have our internal thoughts our auditory context and our speech processing regions in our in our brain are all active so it's possible that if it's that activity is above a certain threshold we just kind of experience it as a voice and if it's below a threshold we experience that as our sort of in our thought so sometimes we may have that experience of like on this it's like a loud thought hammering in my head right like especially if it's something kind of stressful or you know maybe like if you were thinking of something like awkward that you said and and some huge social four part that you made in your brains are you playing that over and over it can just feel so loud in your head and maybe that it's that is a part of that continuum between like a silent thought sort of a loud thought to a soft sound to a loud noise might be kind of a sound noise might be kind of like how much might those those brain regions are active so it could be kind of related to our how we tag internal experiences it could be related to kind of the activity in some parts of the brain they're just like kind of different speculations about what makes something BXB is as an intro thought or an external speech sound it seems like in reading about this stuff preparing for this conversation one of things that did jump out to me is something that is perhaps somewhat unique about psychosis is that is sort of that lack of insight or awareness in terms of what's happening that a lot of times if you're working with somebody who's depressed that they're going to say I shouldn't feel this way you know and not those shoulds aren't really very helpful but that they have this awareness that what I'm experiencing is atypical yeah and often even atypical for them right I remember a time when I was functioning better that I was happier and so I aspire to get back to that and you know that sometimes people that are anxious will say like you know I shouldn't feel like this you know this is an actual threat or whatever but it does seem like with folks with psychosis something that comes along with the package is often just a lack of just self awareness or insight in terms of what is happening so that they can more effectively deal with it yeah and that could also be kind of related to the severity of those other experiences right so for instance like there are in depression you can have the depression where it is so severe that people will have like kind of delusions of guilt like you know I've done something so wrong that something catastrophic has happened from that or with OCD you can have it where people are recognizing that yes this is an obsession or this is an intrusive thought but if I don't act on this I really think something battle happened and they have a belief around it those lines the boundaries between these conditions does start to get a bit fuzzy in some of those conditions as well like you can have now OCD and the inside specifiers also change a little bit of the DSM vibe so you know you start to have this obsessive psychosis kind of blurry line like a schizophrenic disorder or you know delusions of guilt and depression with psychotic features also tends to be something where it is the same as the other person where it is starting to drift in there so just then and this is what we are going to have to this we are going to sort of jump into the intervention stuff does it like that some of the challenges with insight I would imagine would I mean it would make it harder to get folks engaged and motivated for treatment yeah and I think that is certainly one of the sort of interesting pieces of therapy where we are going from the interventions that we have to also thinking about how do we engage our clients in the therapeutic process as well like it is one thing to know like I can use thought, challenge or behavioral experiments but we need to get to a place where we are saying are we willing to work on something together and I think that is sort of a there is many steps in that process but certainly kind of early on in therapy we are thinking about how do we find common goals that we can work towards and so one of them is going to be to say like if let's say someone comes to me and they think that the CIA is trying to kill them and it is interesting as well like you know for me we live in Canada but the CIA features more prominently the intelligence that the ceases does I think so I think it is just in the zeit guest a little bit more let's say the person thinks like you know there is an entity that is trying to kind of harm them and so the goal isn't for me to try to convince my client that their belief is wrong like none of us wants to kind of have that and that is the same with any political debate that you have ever had with you know around the Christmas dinner table which may cause things to go right but really the goal there is you are feeling unsafe and anxious and it is getting the way of you doing the thing that you might want to do whether it is going back to school, getting a job, maybe getting a girlfriend or a boyfriend and how can we help you to feel safer so that you can kind of get these things that you would like in life which may be the same for all of us and so that can be the goal that we want to work towards, how can we help you to feel safer in the process of doing that we might allow you to think that maybe I am not in danger or it might be to say I am even though I might be in danger I am still able to do these things and that is something that is going to develop along the way so I think that first step is finding those common goals that we are willing to work towards and then in the process of therapy I think what we are trying to do is build out an alternative model for the client and the choices need to shift away from I am right versus I am wrong to I am unsafe versus I am safe so then it becomes easier for us to let go of a belief and consider a different belief without it being a challenge to my sense of self and my place in the world and then I think the stage after that is if they are willing to consider that idea that I am safe and that means that I have this belief maybe one of the sort of latest stages of therapy that we might work on for someone is how do we make peace with that experience with that lost time with that pain that they had to deal with and sometimes I think that the common threat for all of those is that longitudinal formulation that is the kind of thing that is going to happen in a different way so let's keep going with the treatment side of things that's a wrap on the first part of our conversation as I noted at the top it would be much appreciated if you spread the word to anyone else who you think might enjoy the show until next time[Music]