Really smart way to engage people. I am not in medicine but nonetheless I often use a lot of socratic reasoning, starting with asking people "What is your goal here?", and working from that. People can end up coming to the same conclusions that you would have suggested at the start, or even new and better ideas, but they come to it through their own process and so it's internalized and egosyntonic, where they might have been very resistant to the idea if you just said "Yeah I think you should X". This is especially true for cases where you have no evidence that would be subjectively compelling to them, or that they lack the capacity to understand the evidence. Obviously I'm dealing with technology but the same principles apply when talking to non-experts about a technical domain.
I wish you talked more about how to interact with these type of patients in the crisis center setting. I have a lot of people come in off the street with a lot going on and I want some tips on better ways to interact. I'm an ER Trauma nurse but we do crisis as well and a lot of it
I work in the security department at a hospital with an inpatient psych ward that does involuntary holds. Having more of these videos would be invaluable, we aren't taught any of this as part of the de-escalation training, and it gets really old seeing what we are taught fail repeatedly. Only reason I know so much about mental illness now is a combination of experience, and studying pre-med psychology.
As a former ED psych nurse, listening is underrated. The problem is that most environments are so restrictive and risk-bound that you aren't given the freedom to actually listen. So bend the rules, make it work, the systems aren't made for humans, they're made for business. Do what is right for people and listen, rather than restrict.
This is actually so helpful. Would you mind sharing more of your approaches when it comes to psychosis? I work at a mental health occupational therapist at a psychotic disorders clinic and I love getting to hear your perspective so I can modify and improve my own practice. Personally I would love to hear about whether or not insight can be built with some clients and whether anosognosia can be improved/treated beyond medication, motivational interviewing and building therapeutic rapport. Thank you for your content. 😊
Thank you for your collaborative approach with your patients. So many providers forget their patients are human beings with unique experiences and concerns not dogs that are being given commands on an agility course. There is nothing more lonely that having to take medications that cause horrible side effects or simply don't work and being told to just endure it, end of discussion. I appreciate your kindness for us psych patients and willingness to see us with dignity.
The only problem with that reasoning is that a lot of times anti-psychotics don't get rid of delusions, so then the patient could take it as further evidence that they are real -- but then again, maybe not a big risk, because otherwise the patient would continue to believe the delusions anyway
@@ArloKnudsenFit not always true at all, in fact this allopathic compulsion is likely the root of the very oppressive practices in psychiatry and mental health.
This is amazing and so helpful to me. I am a medical student but I have also been an emergency RN for a number of years and where I'm from we have very poor mental health training. A lot of us struggle to communicate with psych patients, one of our most vulnerable groups. This is awesome stuff!
i love this, there is so much stigma around people experiencing psychosis when in reality many of them have great insight on their condition and their various life factors. more content like this please
Great video. So often do people think it's just a simple method of taking meds. But, the patient has to be willing to accept treatment and stick to the treatment.
You know what I would always say? Something along the lines of: “Imagine your heart was failing, and it was making you extremely ill, but I said to you you can take this medication and it would bring your heart under control and make your life so much easier; you’d take it right? Well these beliefs and visions/voices etc that you’re experiencing are one and the same: there is this medication that can make everything a lot easier and you can just start to make sense of it all again.”
Our solution in the ED is something more like 4 point restraints+enough meds to put down a horse. But all jokes aside, I have interacted with patients like the one you have described who realize what they are seeing is not real and are more than willing to take meds and get help.
Unfortunately your comment about what is done in the ED is true. Not even in the inpatient unit are situations handled correctly more than half the time. I just finished my psych rotation. Handling the situation correctly is truly a matter of MUCH skill and MUCH experience. Unfortunately it's rare.
@@user-bv7jc It's the case when we don't have a psychiatrist managing these patients. We just have ER physicians who are dealing with over a dozen other patients, including STEMIs, strokes, respiratory arrests, etc. meanwhile a patient is in acute psychosis while 5-6 staff members are trying to manage the situation trying to avoid being physically assaulted. Usually the doctor will just do his best to stabilize the situation and move on to other emergencies.
I often focus on concentration issues, sleep issues, and the restlessness and anxiety that come with paranoia. These are usually things that the patients themselves are bothered by, even during psychosis
ER Nurse here. Yeah, sometimes I just go to them "Man, just take your meds, ok? It makes the voices go away and helps you feel better.". It really works in some cases. But it really depends on the patient. Most patients never get ask straight to take them. Either someone tries to go the full empathetic round and it backfires for them beeing "too soft", or the staff just runs into the room and restrains them.
Humble med student here. I thought the effect of antipsychotics on delusions was not to actually eliminate them, but rather to dampen the response the patient has towards them and to dampen the effect they have on the patient? E.g. to make them less aggressive/angry and more indifferent to the delusions? Because if so doesn't that sort of contradict the idea of "the pill will make the FBI go away if they're not real?" Sorry if I'm misunderstanding
yo! I'm also a med student. You raise a great point as I thought similarly. It was my understanding that antipsychotics mainly help the patients more with auditory and visual hallucinations rather than paranoid delusions,and that they make the patients more docile and easier to handle. Paranoid delusions, based on my limited experience, seem to be rooted in the patient's logic, which we may think is illogical because they are drawing strong conclusions with insufficient evidence. I think Preston is using motivational interviewing techniques to get the patient to take the med on their own accord based on their logic, and this may involve some simplification of how the medication works to get the patient to do something that is beneficial for them. -------- .... unrelated to my above comment, antipsychotics seem potent and with risky side effect profile for what, by my subjective standard, is unsatisfactory medical management. One of my med student/newly minted-resident friend has a sister who presented in her teens with major emotional lability, disorganized behavior, and paranoia which lead to a diagnosis of schizoaffective disorder. She was started on a medication regimen with multiple psychiatric drugs, which according to my friend, they made her "easier to handle" by their parents, which I understood as making more "stable" aka docile/controllable without major ups and downs like before. This was done at the expense of major weight gain by the patient who was supposedly a "beautiful cheerleader" in her teenage years prior to her symptom onset, and after her medical management, she became quite overweight. When I saw her, I could endorse these things, and notably, her affect was rather muted. There has to be better ways of helping these patients because if I were the patient, I would be quite unsatisfied by this solution.
@@bosstowndynamics5488 respectfully I'm not sure what precisely you mean by mitigate? As in my question do you mean eradicate/erase or simply cause apathy towards?
@@youtubeusername1239 Improve would be a better term, as in directly decrease those symptoms. I hesitate to use absolute terms like eradicate or erase because no treatment is perfect and antipsychotics are no different, some people get a complete response but relapses happen, and some people only get a partial response even in the best case.
Hi! I was wondering what happens is the antipsychotic only mutes or doesn’t fully resolve the psychosis, in this strategy wouldnt that then validate and reinforce their belief? Even with the muting what’s to stop them seeing it as a sedative effect as opposed to a real antipsychotic effect?
Could you do a video on “excited delirium” and the mistakes that law enforcement and Fire/EMS make regarding it and it’s treatment. Primarily how we have killed these patients far more often than is acceptable and how “excited delirium” is a BS word
psych it seems demands very high level of thinking and reasoning skills to really make a dent in patients diseases...distortions in the ground truth of experienced everyday human reality...
@@itspresroI do find in my experience that most of my conversations with patients in psychosis become extremely philosophical very quickly. It’s good to have that confirmed by someone who has a better grasp on the subject than myself.
@@itspresro woah, presro reacted to ME!...I am just reading about classical education of olden times and that seems to also fit the bill...grammar, logic, rhetoric etc.
I tried to convince a man who came in with chest pain (and history of LAD PCI) to go for a cath and he really didn't want to. I asked him what he expected the result would be when he came into ER with the exact same kind of chest pain that his first MI presented with and he just flat out said "idk i thought i would be able to go home" 😅 sometimes reason ain't the best choice
@@itspresro Acknowledge that they feel unwell (which they usually do) or that they’re going through a stressful situation and that the medication might help them cope better with it. Ie. Patient worried family are CIA - acknowledge the stressful experience and say the medication helps to reduce stress and frightening experiences, but do not confront the delusions per se.
Yeah as a psych resident my experience exactly. It is very complicated though because I get very torn apart. On the one had I do want to be honest and repeat "this is psychosis"; on the other it just gets me nowhere with 60% of patients. In the end I just have to do some circles, confront them with the consequences of not taking the meds (like losing the apartmenta) and so on.
@@citomica1469 I find if you build a sufficiently trusting rapport and focus on connecting with the patient, they will usually be amenable to taking medications. I validate their version of reality but gently challenge their delusions to see if they’re shiftable. If it’s done in a confrontational way they’ll just get defensive, as anyone in their position would. I sell the medication as helping to reduce stress and help them cope better with the frightening experiences.
As a schizophrenic who tends to go into 1-2 psychotic episodes a year, I love being in psychosis and the best way to get me to take antipsychotics is to not make me at all. What ends up happening every time is I get involuntarily admitted because I speak in odd ways and they physically force them into me As in, I refuse, they call security to pin me down while they inject it. Makes me wish I was more violent.
They make me wanna die, lol. I was on them as a teenager and I hated life and everytime they force me to take them they put me in a super apathetic state for months.
If he’s thinking of this stuff as a resident he’s gonna be an incredible psychiatrist
Really smart way to engage people. I am not in medicine but nonetheless I often use a lot of socratic reasoning, starting with asking people "What is your goal here?", and working from that.
People can end up coming to the same conclusions that you would have suggested at the start, or even new and better ideas, but they come to it through their own process and so it's internalized and egosyntonic, where they might have been very resistant to the idea if you just said "Yeah I think you should X".
This is especially true for cases where you have no evidence that would be subjectively compelling to them, or that they lack the capacity to understand the evidence. Obviously I'm dealing with technology but the same principles apply when talking to non-experts about a technical domain.
Excellent vid! Can we have more “educational” formats such as these? They’re fantastic!
Also, any books in particular you recommend for psychopharmacology? Something that helped you “understand” it. Thanks!
Katzung Basic and Clinical Pharmacology &
Goodman and Gilman Pharmacological basis of therapeutics 14th edition
I agree! I really like him walking through his reasoning & why he makes the decisions he does.
I wish you talked more about how to interact with these type of patients in the crisis center setting. I have a lot of people come in off the street with a lot going on and I want some tips on better ways to interact. I'm an ER Trauma nurse but we do crisis as well and a lot of it
I work in the security department at a hospital with an inpatient psych ward that does involuntary holds. Having more of these videos would be invaluable, we aren't taught any of this as part of the de-escalation training, and it gets really old seeing what we are taught fail repeatedly. Only reason I know so much about mental illness now is a combination of experience, and studying pre-med psychology.
As a former ED psych nurse, listening is underrated. The problem is that most environments are so restrictive and risk-bound that you aren't given the freedom to actually listen.
So bend the rules, make it work, the systems aren't made for humans, they're made for business. Do what is right for people and listen, rather than restrict.
This is actually so helpful. Would you mind sharing more of your approaches when it comes to psychosis? I work at a mental health occupational therapist at a psychotic disorders clinic and I love getting to hear your perspective so I can modify and improve my own practice. Personally I would love to hear about whether or not insight can be built with some clients and whether anosognosia can be improved/treated beyond medication, motivational interviewing and building therapeutic rapport.
Thank you for your content. 😊
Thank you for your collaborative approach with your patients. So many providers forget their patients are human beings with unique experiences and concerns not dogs that are being given commands on an agility course. There is nothing more lonely that having to take medications that cause horrible side effects or simply don't work and being told to just endure it, end of discussion. I appreciate your kindness for us psych patients and willingness to see us with dignity.
The only problem with that reasoning is that a lot of times anti-psychotics don't get rid of delusions, so then the patient could take it as further evidence that they are real -- but then again, maybe not a big risk, because otherwise the patient would continue to believe the delusions anyway
The risk is really that you are back where you started
But doing something is better than doing nothing.
@@ArloKnudsenFit not always true at all, in fact this allopathic compulsion is likely the root of the very oppressive practices in psychiatry and mental health.
The example at the end is so simply wonderful.
This is amazing and so helpful to me. I am a medical student but I have also been an emergency RN for a number of years and where I'm from we have very poor mental health training. A lot of us struggle to communicate with psych patients, one of our most vulnerable groups. This is awesome stuff!
i love this, there is so much stigma around people experiencing psychosis when in reality many of them have great insight on their condition and their various life factors. more content like this please
Great video. So often do people think it's just a simple method of taking meds. But, the patient has to be willing to accept treatment and stick to the treatment.
You are a good doctor!
You know what I would always say? Something along the lines of:
“Imagine your heart was failing, and it was making you extremely ill, but I said to you you can take this medication and it would bring your heart under control and make your life so much easier; you’d take it right? Well these beliefs and visions/voices etc that you’re experiencing are one and the same: there is this medication that can make everything a lot easier and you can just start to make sense of it all again.”
This is the content I like
Our solution in the ED is something more like 4 point restraints+enough meds to put down a horse.
But all jokes aside, I have interacted with patients like the one you have described who realize what they are seeing is not real and are more than willing to take meds and get help.
Unfortunately your comment about what is done in the ED is true. Not even in the inpatient unit are situations handled correctly more than half the time. I just finished my psych rotation. Handling the situation correctly is truly a matter of MUCH skill and MUCH experience. Unfortunately it's rare.
@@user-bv7jc It's the case when we don't have a psychiatrist managing these patients. We just have ER physicians who are dealing with over a dozen other patients, including STEMIs, strokes, respiratory arrests, etc. meanwhile a patient is in acute psychosis while 5-6 staff members are trying to manage the situation trying to avoid being physically assaulted. Usually the doctor will just do his best to stabilize the situation and move on to other emergencies.
But the scenarios you've mentioned are best case scenarios right..? Its not that easy to reason with all..? Also, Beautiful green eyes..!
Make more of these educational vids! Some longer format, maybe with more visuals would be cool too!
I often focus on concentration issues, sleep issues, and the restlessness and anxiety that come with paranoia. These are usually things that the patients themselves are bothered by, even during psychosis
ER Nurse here. Yeah, sometimes I just go to them "Man, just take your meds, ok? It makes the voices go away and helps you feel better.".
It really works in some cases. But it really depends on the patient. Most patients never get ask straight to take them. Either someone tries to go the full empathetic round and it backfires for them beeing "too soft", or the staff just runs into the room and restrains them.
Good video
Humble med student here. I thought the effect of antipsychotics on delusions was not to actually eliminate them, but rather to dampen the response the patient has towards them and to dampen the effect they have on the patient? E.g. to make them less aggressive/angry and more indifferent to the delusions? Because if so doesn't that sort of contradict the idea of "the pill will make the FBI go away if they're not real?" Sorry if I'm misunderstanding
yo! I'm also a med student. You raise a great point as I thought similarly. It was my understanding that antipsychotics mainly help the patients more with auditory and visual hallucinations rather than paranoid delusions,and that they make the patients more docile and easier to handle.
Paranoid delusions, based on my limited experience, seem to be rooted in the patient's logic, which we may think is illogical because they are drawing strong conclusions with insufficient evidence.
I think Preston is using motivational interviewing techniques to get the patient to take the med on their own accord based on their logic, and this may involve some simplification of how the medication works to get the patient to do something that is beneficial for them.
--------
.... unrelated to my above comment, antipsychotics seem potent and with risky side effect profile for what, by my subjective standard, is unsatisfactory medical management.
One of my med student/newly minted-resident friend has a sister who presented in her teens with major emotional lability, disorganized behavior, and paranoia which lead to a diagnosis of schizoaffective disorder. She was started on a medication regimen with multiple psychiatric drugs, which according to my friend, they made her "easier to handle" by their parents, which I understood as making more "stable" aka docile/controllable without major ups and downs like before.
This was done at the expense of major weight gain by the patient who was supposedly a "beautiful cheerleader" in her teenage years prior to her symptom onset, and after her medical management, she became quite overweight. When I saw her, I could endorse these things, and notably, her affect was rather muted.
There has to be better ways of helping these patients because if I were the patient, I would be quite unsatisfied by this solution.
Antipsychotics mitigate all of the positive symptoms of psychosis, including delusions, they just don't help the negative symptoms
@@bosstowndynamics5488 respectfully I'm not sure what precisely you mean by mitigate? As in my question do you mean eradicate/erase or simply cause apathy towards?
@@youtubeusername1239 Improve would be a better term, as in directly decrease those symptoms. I hesitate to use absolute terms like eradicate or erase because no treatment is perfect and antipsychotics are no different, some people get a complete response but relapses happen, and some people only get a partial response even in the best case.
They also can eliminate hallucinations and delusions. Which are caused by excessive or pathological dopamine signaling
Hi! I was wondering what happens is the antipsychotic only mutes or doesn’t fully resolve the psychosis, in this strategy wouldnt that then validate and reinforce their belief? Even with the muting what’s to stop them seeing it as a sedative effect as opposed to a real antipsychotic effect?
i was gonna make a joke about the first comment then i realized this wasn't a joke video
bro talk about derealization and dpdr from anxiety please!!!
and if he thinks you're the fbi?
Carry a badge that says CIA on it so at least they know you're not FBI
Could you do a video on “excited delirium” and the mistakes that law enforcement and Fire/EMS make regarding it and it’s treatment. Primarily how we have killed these patients far more often than is acceptable and how “excited delirium” is a BS word
psych it seems demands very high level of thinking and reasoning skills to really make a dent in patients diseases...distortions in the ground truth of experienced everyday human reality...
You need a grounded understanding of logic, truth and philosophy
@@itspresroI do find in my experience that most of my conversations with patients in psychosis become extremely philosophical very quickly. It’s good to have that confirmed by someone who has a better grasp on the subject than myself.
@@itspresro woah, presro reacted to ME!...I am just reading about classical education of olden times and that seems to also fit the bill...grammar, logic, rhetoric etc.
I tried to convince a man who came in with chest pain (and history of LAD PCI) to go for a cath and he really didn't want to. I asked him what he expected the result would be when he came into ER with the exact same kind of chest pain that his first MI presented with and he just flat out said "idk i thought i would be able to go home" 😅 sometimes reason ain't the best choice
holy FUCK. What a video.
Plus, many patients still have delusions after taking antipsychotics. So I’m not sure your strategy is valid.
Interesting, what strategy do you use when treating psychotic patients?
@@itspresro Acknowledge that they feel unwell (which they usually do) or that they’re going through a stressful situation and that the medication might help them cope better with it. Ie. Patient worried family are CIA - acknowledge the stressful experience and say the medication helps to reduce stress and frightening experiences, but do not confront the delusions per se.
Yeah as a psych resident my experience exactly. It is very complicated though because I get very torn apart. On the one had I do want to be honest and repeat "this is psychosis"; on the other it just gets me nowhere with 60% of patients. In the end I just have to do some circles, confront them with the consequences of not taking the meds (like losing the apartmenta) and so on.
@@citomica1469 I find if you build a sufficiently trusting rapport and focus on connecting with the patient, they will usually be amenable to taking medications. I validate their version of reality but gently challenge their delusions to see if they’re shiftable. If it’s done in a confrontational way they’ll just get defensive, as anyone in their position would. I sell the medication as helping to reduce stress and help them cope better with the frightening experiences.
As a schizophrenic who tends to go into 1-2 psychotic episodes a year, I love being in psychosis and the best way to get me to take antipsychotics is to not make me at all.
What ends up happening every time is I get involuntarily admitted because I speak in odd ways and they physically force them into me
As in, I refuse, they call security to pin me down while they inject it.
Makes me wish I was more violent.
They make me wanna die, lol.
I was on them as a teenager and I hated life and everytime they force me to take them they put me in a super apathetic state for months.
And I'm always aware I'm in "psychosis" but my delusions aren't even based in reality, they're religious, so nothing is certain in any aspect.
:/