Hi, good morning, everybody. I would like to welcome you to today's PepNet SMI Advisor webinar. Our topic today is Cross-Cutting Hallucinatory Experiences Across Diagnostic Spectrums in Early Psychosis Clients with Dr. Ryan Melton. I am Judith Dauberman, the Program Manager for PepNet at Stanford University School of Medicine. And with us today is Dr. Stephen Adelsheim, who is a Clinical Professor at the Stanford Department of Psychiatry and Behavioral Sciences, the Associate Chair for Community Partnerships, and the Director of the Stanford Center for Youth Mental Health and Well-Being. Dr. Adelsheim will be co-facilitating with your presenter today your questions. So today's webinar is brought to you, against the slides here, through a partnership with SMI Advisor, which is a SAMHSA-funded initiative implemented by the American Psychiatric Association. And we will be offering CEUs for physicians and psychologists for the live presentation for today's webinar, and we'll share information with you on how to claim CEU credits at the end of the webinar. So I'd also like to cover a couple of logistics items. You will see that you should have a floating panel on your Zoom screen that shows you how to, and you can click on chat, and that's how we'll take your questions for today's webinar. And Dr. Adelsheim and Dr. Melton will also be sort of monitoring the chat as well. We all will be. So please make sure that if you want to introduce yourself, that would be great, and put your questions in the chat box. You will see there it says to everyone in a little box there in chat. So please make sure that you select to everyone so that it goes to both the presenters and to the attendees. Fabulous. Thank you. And now to give you an introduction to Dr. Melton. So Dr. Ryan Melton is the Acting Dean of the School of Psychology and Counseling at Bushnell University and is the Clinical Director of the ESA Center for Excellence at Oregon Health Sciences University, where he provides clinical consultation and training on early intervention with mental illness to programs nationwide. Dr. Melton's research focus is on the impact of interventions with individuals experiencing early psychosis, engagement strategies, effective treatment, and reducing the duration of untreated psychosis. Dr. Melton is certified in providing training for cognitive behavioral therapy, feedback-informed treatment, using the structured interview for DSM-5 disorders of the SCID, and is one of seven in the world certified to train clinicians in the use of the structured interview for psychosis risk syndromes or the SIPs is what we call it. Dr. Melton also has a private practice in which he supervises mental health conditions for licensure and provides training on diagnosis and evidence-based mental health practices. And here's Dr. Melton. So many people that I know popping up on the chat there. It's kind of exciting to see. So some of you that I do know, you probably heard, you're going to hear some of this feel before. So hopefully I will try not to bore you that much. I'm excited to do this talk. My little disclaimer on this particular topic is that it's a combination of literature, what I've gleaned from the research of some of my heroes in the field, as well as a little bit of theory. So I hope that the topic really facilitates a strong discussion as we kind of think about the psychotic experiences that the young people that we serve, at least in coordinated specialty care, early psychosis programs, experience and kind of the heterogeneity of those experiences and what those might mean diagnostically. And I'll stress the word might, because I don't think we don't have, as you all are aware, perfect diagnostic systems to clearly identify what diagnosis per se the individual may be experiencing. So what I really hope today is to kind of meet these learning objectives. Thank you, Judith, for popping those up. Timing is spot on. Really to think about the types of hallucinations and all the topic is on hallucinations. I'm certainly going to touch on delusions as well. I don't think you really can talk about one without the other when we're talking about psychosis and really try to help us understand what an attenuated hallucination looks like, what a fully psychotic hallucination looks like, and then what are these other types of hallucinatory and psychotic experiences that don't seem to fit either, that don't seem to be kind of attenuated as if they're kind of developing schizophrenia, and then clearly don't seem fully psychotic, as in the type of psychosis we see in schizophrenia, but there is something going on. They're psychotic-like in nature. And what are those about? And what do they mean diagnostically? And maybe even more importantly, what do these experiences mean from a treatment standpoint? So we're going to try to describe appropriate diagnostic impressions given the hallucinatory experience. Really, I mean, one thing I really stress in my consultation work and in my classes is to not have a one-size-fits-all with a psychotic experience, you know, that, you know, if they have this psychotic experience to not certainly jump on the title or the label of schizophrenia or one of the schizophrenia-related disorders, you know, and maybe even avoiding the kind of catch-all diagnosis of unspecified psychosis or other specified psychosis, and really try to get to some more detail on what the person is experiencing. And again, my goal in that is to really inform appropriate treatment. And again, not that I fully want to say that a diagnosis in and of itself informs, I mean, that is specifically tied to a treatment, but it's a starting place. And that's really what I want to talk about. And then, yeah, maybe we'll hit on some of the guidelines around treatment approaches based on the kind of quality content of hallucinatory and other psychotic experiences. Yeah. Go ahead, Judith. All right. This is a slide that I've been actually working on for somewhat of a decade, really. Started out with a colleague of mine several, several years ago, when we were really trying to just help people understand that symptoms of psychosis, whether they're hallucinations, delusions, and to an extent, disorganized behavior and speech, don't always imply a diagnosis of schizophrenia or schizophrenia-related disorders. A wide range of mental health symptoms that have psychosis as part of it. And then there is another set of mental health disorders that have psychosis-like experiences as part of them. And then there's other mental health experiences that people diagnostically confuse as psychosis. And that's what makes our work really challenging as diagnosticians, is we need to try to tease all of these items out. And then we have some other confounding situations that people experience, which are not necessarily mental health disorders, but illicit drug use, prescribed medications, medical illnesses that all potentially cause or influence psychotic experiences. And our goal really is to try to tease these out to the best that we can, again, to ultimately inform treatment, recognizing that somebody with a schizophrenia-related psychosis or psychotic disorder like schizophrenia, their treatment may be different than somebody who is using methamphetamines, for example, and causing psychosis or somebody that has a medical condition that's resulting in psychotic symptoms. We probably need to do that work to the best of our ability to understand that. And then there's this broader idea of cultural experiences. I get asked a lot about how do we differentiate somebody's cultural beliefs that we don't understand that can feel psychotic to us, and how do we not diagnose them, or do we diagnose them? Oftentimes a question I get. So as you think about this slide, let me explain it to you. If you try to, the direct lines, the straight lines, tend to be conditions where we see psychosis as part of them. So illicit substances, drugs, we certainly see psychosis as part of it. Schizophrenia. Schizophrenia is a psychotic disorder. Medical illnesses, a wide range of medical illnesses can have psychosis as part of it. Speaking to our public health director locally, and he was consulting with me on COVID-related psychosis, and what he's starting to see in his practice around COVID-causing psychosis. So we know that there's a wide range of medical conditions that can cause psychosis. Certainly autism spectrum disorder has psychosis as part of it, as well as elements of the autism spectrum disorder in and of itself that look psychotic, that we sometimes need to differentiate out. And then we have these conditions that are a little more wavy, and so where you see the lines that are a little more wavy with trauma, stress, depression, these are all mental health symptoms that where psychosis maybe is there, but at least they're experiencing symptoms that look like psychosis. We see this in obviously major depression. We know that individuals with major depression can have a psychotic element as part of it. People who experience high levels of stress and anxiety can start to believe in things that aren't completely in touch with reality or hearing voices that are negative in nature. Then trauma, and I'm really talking about psychological trauma here and other forms of physical trauma that can have these really what I describe as psychotic like, and what the literature is really picking up on is it's causing psychotic like experiences where the person's experiencing something that isn't real, and then they can recognize that it's not real, but it doesn't have that flair. It doesn't have that kind of quality what we see in psychosis related to schizophrenia. And then we have disorders like attention deficit hyperactivity disorder, factitious disorder, malingering personality disorders, oppositional defiance disorders that some diagnosticians confuse as psychosis, but in fact aren't really connected at all, at least in a direct way. And then obviously we need to pay attention to one's kind of cultural beliefs that are completely different than our own that may indicate, which we may perceive as psychosis, believing where that's kind of believing in the day of the dead or spirit quests or other forms of cultural beliefs that I clearly don't understand, but don't want to necessarily, of course, we want to diagnose as psychotic. And I've certainly had many colleagues who treat individuals from cultures different than my own and their own who've kind of complained of or have experienced psychiatric diagnosis, diagnoses based on their cultural beliefs. So I want to throw that out there too as something you need to also pay attention to. In this slide, I did a few other techniques in which I kind of increased the font of symptoms or situations that tend to be more tied to psychosis. You can see like the largest font is drugs. So really not referring to illicit drugs here. They can really kind of one more prevalent causes for psychosis where schizophrenia is kind of tiny, small font. It's where schizophrenia is a psychotic illness, but it may not be one of the big disorders that causes psychosis, at least of what we see getting referred to coordinated specialty care, you know, particularly with younger people. So again, we have to do a really tricky job of a really tricky, really unique kind of job to determine what is going on when somebody shows up at our clinics or gets referred to our programs and they're hearing voices. And that's the primary complaint. They're hearing voices or believing something that's may not be real. We have to then sort through all of these when mental health conditions, potentially medical conditions, even medical conditions where we're not at all trained in. I'm certainly not trained in a wide range of medical conditions and certainly have to trust the medical providers in our community to help us with that. Illicit substances. And then of course, this kind of cultural piece and there's a little teaser for my SCID trainings in that, you know, we've kind of tell a story of a subculture of an individual from a subculture that the referent believed was absolutely psychotic. And then when I completed my assessment, I had to call the referent and say, this is not a individual who's psychotic at all. This is someone from a subculture we don't understand and had to work through how I made that determination. But that is a fear. It's a fear that, you know, and then we're much more aware of that when I started in the field of paying attention to different cultural, spiritual beliefs that are not predominant in kind of a westernized medical culture that we need to really pay close attention to that are really not psychotic at all, that are really outside that spectrum. So that's the work. And so I'm not going to explain all of this today. We're certainly not going to go through all of these conditions. I think my job today in the short amount of time that I have is to one, get us thinking about this, get us thinking about the broad based experiences that people have with psychosis, psychotic life experiences and potentially attenuated psychosis. So I'll hit on a few of those. Hopefully we'll have some time to ask some questions. And I always try to make myself available following these webinars to discuss this. I'm happy to discuss cases. And it really is kind of a discussion. And when we work in this world of diagnosis, so much of it really is theoretical. So again, I'm going to be very clear in my disclaimer that I cannot give you, I'm sorry, I got distracted by the chat there. I can't give you a definitive tool to say, oh, if you use this tool, you'll be able to determine that this is autism spectrum disorder, that this is ADHD, that this is a cultural belief. I mean, we have to kind of think about that and really kind of work through it. And I oftentimes encourage people to not do that alone, to really consult with your colleagues, consult with me, consult with others in the field that really are doing this work on a kind of a day-to-day basis. Okay. Judith, yeah, you can go to the next slide. Thank you. All right. So I'm going to start with things that confuse us quite a bit in this field in terms of who gets referred to coordinated specialty care programs in early psychosis programs. And one thing we wanted to try to distinguish is psychosis, and I'm going to say the capital P psychosis there. And when I refer to that, I'm really referring to schizophrenia-related psychosis. So it's the psychosis that may come with diagnoses like schizophrenia, schizophrenia form disorder, maybe a brief psychotic episode, schizoaffective disorder, those type of disorders. And then we have these psychotic-like experiences. So it's usually a young person and adolescents, sometimes a child, but mostly adolescents who are experiencing these unusual and disturbing sensory experiences, but they just don't fit kind of the quality of how the DSM-5 describes a schizophrenia disorder. But given that we tell people in our community education around referring, we tell people to, you know, if you have a young person that's hearing voices, if they talk about hearing voices, refer them to our coordinated specialty care programs, and we'll figure it out. But that bit, because the experience of, say, hearing voices in particular, is so common that we get a ton of these referrals, and we end up trying to determine whether or not these hallucinatory experiences are due to what primarily coordinated specialty care and early psychosis programs take, which is schizophrenia-related disorders, versus these other types of experiences. And that takes some effort, and it's oftentimes met with frustration from referents who say, well, why did you turn this 16-year-old down? They're clearly hearing voices. And we say, well, they're not the type of voices that we work with in coordinated specialty care. They're not the type of hallucinatory experiences that we see in schizophrenia. There's something different. And so that's, and we do that, at least why I want us to do that is because I want to inform appropriate treatment. We don't want individuals who are having hallucinatory-like experiences that may be due to a traumatic event or complex PTSD or even complex trauma that diagnosed with schizophrenia and ultimately labeled in that way, or maybe even use inappropriate treatment. We certainly don't want to cause unintended harm in that way. And I think this is really important because who are we working with here in these coordinated specialty care early psychosis programs? We're working with young people who are kind of an average age, 16 to 19 years old, who are really at the crux of identity development. And we really don't want to kind of label schizophrenia at that age and try to, again, the unintended consequences, they kind of own that label. And I'd really like us to spend more time and be careful with that. So let's just kind of go through briefly, some of these, what we kind of see as psychotic experiences and psychotic-like experiences. And so these psychotic-like experiences tend to be more egotistonic with less role impairment. So meaning that they're disturbing. So there's certainly disturbing symptoms, but they kind of feel like they're part of the oneself, you know, that there's something kind of related. There's something related. There's a relatedness quality of the psychosis, you know, to them. So this could mean, this example of this might be somebody who's seeing a dark, scary figure with a bloody head that floats by them at night. You know, we've had many referrals of this type of symptoms. So scary and disturbing and in need of treatment, all of those things are likely true. But what we oftentimes see with those type of experiences is that the child is already scared. They're scared of something. And this bloody head represents maybe a trauma in their lives, a negative experience. And usually inside is intact. They know that the bloody head, you know, isn't real, but it's really, really scary. And it doesn't impact them. I mean, these are usually young people that are struggling and been struggling for a while. So if I kind of look at, you know, how their functioning level, their functioning level may not be great, but it hasn't been great for a long time. Whereas you look at something like schizophrenia, where there's more of kind of a gradual deterioration in functioning. So we kind of describe these symptoms as the difference between kind of longstanding and stable symptoms. So in stable, of course, I don't mean good, but longstanding symptoms versus kind of new and unraveling symptoms. So the latter, the new and unraveling symptoms can be more related to kind of the schizophrenia related disorder, whereas symptoms that, you know, tend to be kind of around for a long time. But they tend to be, and again, these are all qualities that I saw a chap kind of pop up. So I kind of was asking about bizarre symptoms in adults. So I want to stress again, these are all qualities that none of this is absolute, but they tend to be more non-bizarre symptoms. And when I say the word non-bizarre, I'm referring to kind of the psychiatric or DSM definition of bizarre, meaning that not in touch, couldn't possibly be real. So an example of a bizarre delusion would be that, and speak to a client that I supported, where he believed that half of his brain had been stolen by the government. And, you know, so he was then protecting the rest of his brain by wearing really tight, tight caps. That's a bizarre delusion. It's not possible, not possible the government could have come in and stolen half of his brain. You know, whereas these type of experiences tend to be more non-bizarre that, you know, believing that people are out to hurt them, you know, so that's potential may not be in touch with reality, but certainly not bizarre. These psychotic like experiences tend to be more episodic, kind of happening once a day, brief, oftentimes when there's stress levels or at night, many, many of these experiences are described late at night, hearing, seeing a shadowy figure, a skeleton, a bloody head. And these themes are just quite common with this particular group. Sometimes the experience is described as inside of oneself. So they recognize again, that particularly when it comes to hallucination, sorry, that they're, they tend to be inside of oneself. So they have a hard time distinguishing whether or not what they're hearing is a negative thought or intrusive thought versus an illusory experience. And sometimes they can identify the voice as their own voice, sometimes another voice, but they recognize the voice. So again, these all start to get somewhat explainable if we start to dig into their histories. And the other quality of things that are psychotic alike that we see as we talk about hallucinations, they tend to be visual, you know, and so we know in schizophrenia that visual hallucinations tend to be a little more rare, but in kind of younger people with these psychotic like experiences, they tend to be more presence. We see these in kind of children and adolescents more so than we're going to see them in adults. And oftentimes they've been around for a long time. They're very graphic in nature. And I'm going to use this theme of kind of scary, bloody, terrifying, that theme tends to predominate this particular group. Again, they know it's not real and it's been around for a while, but still very scary. So, and we don't see changes on the MSE. I saw some cat pop up. I should spell these out. It's good feedback for me. I mean, mental status exams. So we don't see a lot of changes in the mental status exams, you know, with this particular group. It's been pretty stable and not that it's great, but stable. And then as I've already mentioned that these experiences have some alternative meaning or value that they can oftentimes, not always, but oftentimes can identify if we probe a little bit, what might be going on? Why are you thinking this scary demon figure is, scary demon figure is, who could that represent? What does it represent? And they might be able to, might be able to identify that, you know, so it kind of fits that thematic, thematic representation of their trauma, you know, which we see as like kind of more of a PTSD symptom versus a psychotic disorder symptom. Judith, is it possible, can you hide the questions from me? Cause I get so distracted by them. Cause they're so cool. And I want to answer them immediately, but they're a little distracted. I don't know if I could be hidden from you or not, but they pop up quite a bit. They pop up right on my screen, so sometimes it causes me a little bit of a pause. If you can't, it's okay. All right, then let's kind of talk about these qualities of true psychosis. And when I say true psychosis, I'm talking about schizophrenia-related psychosis. They're almost the opposite of PLEs in a lot of ways. They're egocentronic, yet there's role impairment. So that's more so with delusions and hallucinations, where they actually believe that the experience is real, at least at some point. An insight is lost, and that's really that definition of psychosis, right? If we read the DSM-5, it clearly states that psychosis is defined as kind of losing touch with reality or some verbiage along those lines. So that's one thing that's different with a kind of true psychosis, but then functioning is change. That's the difference. Whereas PLEs, this might be young people who've been struggling in school, but they've been struggling in school for a long time or have behavior problems. Those behavior challenges have been present for a long time. Whereas schizophrenia-related psychosis, particularly in younger people and new-onset psychosis, has that gradual decline, this kind of slow and insidious changes that we see in schizophrenia that we don't see in kind of this PLE-like experience, where grades have been dropping socially, they're struggling cognitively, they're struggling. There's just a difference. When we have qualitative interviews with family members or close supporters, those who are family members of individuals with people with burgeoning psychotic disorders or new-onset psychotic disorders, they'll say, this is not my child. Something is really different. Whereas some of these PLEs, they say, oh, my child. And I ask them about voices, and the family say, oh, they've been hearing those since they're four years old, which, again, that would be really atypical of schizophrenia. In the qualities of true psychosis, more frequently psychosis, true psychosis doesn't seem to distinguish from night and day. They'll have these experiences throughout the day. Certainly, people, when they're stressed or they're stressing their system, psychosis happens more frequently, but it doesn't seem to distinguish. It doesn't seem to be a specific time or specific mood where the psychosis is happening. In terms of hallucinatory experiences, they're oftentimes described as outside of one's self. I'm moving away from the term outside of one's head, and I think what we have recognized, particularly when we're talking to adolescents about hallucinations, they have a hard time localizing where the experience is coming from, whether it's inside of their head or outside of their head, but those with developing true psychosis, it feels like it's some type of alien quality, and it's outside of at least one's self, and that the voices tend to be much more outside of oneself and very different. The voices aren't matching one's mood, for example, whereas somebody who has a depressed mood may hear a voice saying, you should die, you're worthless, those type of things, whereas somebody who's developing kind of a schizophrenia-like hallucination, it's more of, look at you walking around, look at you thinking about people, watch out for that person, look at you talking on this webinar, kind of third-person type of, sorry, look at him, kind of third-person-like kind of quality. Sometimes two voices talking to each other, generally the gender can be identified, but not the person, whereas in PLEs, sometimes they can identify the voice, it might be the voice of a parent, it might be a voice of someone that's harmed them, or at least representative of someone that's harmed them. And then kind of the big change is these objective findings on the mental status exam, where there is changes, I've already said that, but that's just key with schizophrenia, you know, new and uncharacteristic versus long-standing and stable, and I think those are kind of the terms that we want to pay attention to as we kind of distinguish these experiences. And then, you know, with schizophrenia-related psychosis, we're much more likely to see disorganized speech, disorganized behavior, which we don't see as many in PLE, as much in PLEs, and again, when I talk about disorganized speech or disorganized behavior, I really want us to make sure we understand the definition of disorganized speech and disorganized behavior. It's a really high threshold. I think people, when they diagnose, I oftentimes read reports and there's a description of disorganized speech, and it's, the speech is really related more to some mild tangentiality or occasionally going off topic as related to what we might see in an ADHD, but not this kind of gross disorganization that we see with schizophrenia-related disorders, which is complete loose associations, logisms, you know, word salad type of disorganization. So the DSM actually sets a pretty high threshold for the definitions for disorganized speech and disorganized behavior that I think many clinicians don't quite reach. So, but that's, that more, that type of quality is more consistent, obviously, in a psychotic-related disorder or psychotic disorder related to something like schizophrenia. Oh, sorry, Judith, you can move to the next slide. Thank you. But yeah, let's talk about trauma, though, right? We actually know that, you know, these aren't mutually exclusive, that people who experience traumatic experiences also go on to develop psychosis. Many studies suggest that people, they're more likely who've experienced early trauma, particularly people with higher ACEs scores tend to have, are more likely to be later, sorry, more likely to later be diagnosed with a psychotic disorder. So that's, that's true. So they're not necessarily mutually exclusive either. So we have to really think through that. Oftentimes I'll hear, gosh, Ryan, I wish there was a PTSD or trauma-related disorder with psychosis, you know, some kind of specifier, you know, a psychotic features specifier, like there is with depression or bipolar disorder. Why isn't there one with PTSD? Because so many of these young people who have experienced trauma have these hallucinatory-like experiences, but we know they're not psychotic. And I say, well, it doesn't have a psychotic specifier because it's not psychotic, you know, it's something else. So I mean, diagnostically, I've encouraged clinicians to consider a diagnosis of other specified trauma-related disorder, and then maybe make a note about with unusual or disturbing sensory experiences, almost leave the psychosis out of it. So that's, that would be a, just kind of another way to describe it. Because then I think we, when we, when we label something like that, I think it tells us that we really need to be focusing on the trauma and that type of treatment, because I think, I think the treatment is different. I think I see these young people that have these PLEs that didn't get diagnosed with something like schizophrenia or a schizoaffective disorder, and then they go on medicines and those medicines don't seem to be helping that much. And then they go on more medicines and they're labeling, and then they, then the kids, the young person's talking about having schizophrenia. And I just don't think that's what it is. So I really do think we want to focus on kind of the trauma element of, of the experience. And then we, yeah, and I think there was a comment also having untreated psychosis increases, yeah, there's a opposite effect of if your psychosis goes untreated, you're also more likely to be traumatized, which has been actually experienced more common in this kind of schizophrenia-related stuff. Yeah. So even we have to think about, you know, people with trauma-related disorders, are they hallucinating or are they kind of re-experiencing their trauma? You know, that's, or are they dissociating? Is, is that going on? So we have to do kind of, and our questions aren't great all the time because we'll ask, our diagnostic questions sometimes lead us to ask, are you hearing things that other people don't hear? And I see that that particular question is endorsed by a wide range of adolescents at a much higher rate than what we would see in an incident rate of schizophrenia. So they, I think they really can kind of, that question of itself can really kind of confuse them. I mean, that question is looking for true hallucinations, but somebody who's experiencing negative intrusive thoughts or kind of hearing the voice of an abuser is of course going to endorse it. So we kind of have to pull it. We can't just leave it at, oh yes, check, check that box or experiencing hallucinations. We need to probe, we need to follow up. We need to really understand the quality, context, severity, frequency, you know, of, of the experiences. And then if there are delusions, what are those themes of delusion? People with, that have experienced trauma, not unusual of course for them to avoid reminders of, of the trauma. That's a diagnostic criteria in PTSD, even know, or even, even avoid reminders of, of the traumatic experience, which can be misperceived as delusional because they're, because they might get a sense that they believe that that place or that reminder is going to cause them harm, even though in reality it isn't, but it's a reminder of that. So that can be confusing. And then I mentioned this earlier, but when, when it comes down to hallucinatory experiences, they tend for people with PLEs and trauma-related disorders, they tend to be very, very graphic and very visual and visual, visual in quality. Seeing again, that was bloody heads, skeletons, shadow figures. Those are common graphic kind of experiences that people with PLEs and trauma-related experiences oftentimes describe. Okay. Now let's look at kind of affective psychosis or mood-related psychosis. You know, that's another, another form of psychosis that we're, we need to assess for, particularly in coordinated specialty care, early psychosis programs. And I also fully recognize that some coordinated specialty care programs and early psychosis actually accept these individuals, accept individuals with say major depression with psychosis. The program that I work for in Oregon, the ESA program will accept individuals with say a bipolar disorder with, with psychosis. But we have not accepted major depressive disorder with psychosis. So I fully recognize that the different programs have different acceptance rates, but just are different acceptance criteria. That being said, we still want to differentiate diagnostically because an affective psychosis is an affective disorder. It's a mood disorder. It's not necessarily a psychotic disorder, although there's a psychotic element as part of it. And these types of psychosis are some of the more common psychotic conditions of childhood. And they tend to have a higher rate of psychotic experiences than their adult counterparts with major, say major depression disorder, or even maybe a bipolar disorder. We know with affective psychosis, some of the qualities there that the psychosis is often related to the mood disorder, certainly not always, but I've done a lot of assessments over my, over my many years in the field. And I probably can count on one hand, how many times that the psychosis was, if it wasn't an affective psychosis or mood related psychosis, how many times the mood was not, or sorry, the psychosis was not related to the mood disorder, maybe a few times, but generally if somebody's experiencing a depressive episode or depressive symptoms, the hallucinations, and they're usually auditory, are, fit that current mood. You're worthless. You should die. You're not worth living. People don't like you. You know, those, those type of, of experiences, or if they're angry, you should hurt people, those type, very much kind of fitting, fitting the mood. If they're experiencing, say a bipolar disorder or a manic episode, the, the symptoms tend to, if there's voices that you're great, you are powerful, something that's kind of thematic in that, in that nature. So oftentimes that's, that's what's going on there. So we can, it's really important to look at when the psychosis is occurring, the mood at the time of the psychosis, did they meet criteria for a major depressive episode or a manic episode? And was, was those symptoms occurring within the timeframe of the mood episode, not far out of it, far as it moves out of the mood episode, then, you know, we might be looking at it more of a psychotic disorder, primary psychotic disorder, but we see hallucinations observed about one third, one half of depressed children, or at least reported hallucinations. I'm not sure if they're clearly real hallucinations, but reported hallucinations. Again, I believe that question of do you hear things that other people don't hear is over endorsed, particularly in children and adolescents. And then certainly we want to pay, delusions tend tend to be more common in adolescence, where we see hallucinations more common in children with affective psychosis, delusions more common in adolescence. And then mania in general, I know I spoke about bipolar disorder, certainly after the manic episode to be diagnosed with bipolar disorder, that, that those symptoms in and of themselves are incredibly rare in children. We really don't see mania until the earliest kind of adolescence on average. And certainly there's some rare cases where we might see mania in children, but we're not going to generally see it until late, it was late adolescence. And I think even on average, more likely in adulthood but we, we do get children diagnosed with this. And so that's, that is something that we as diagnosticians and our coordinated specialty care team need to pay attention to. I oftentimes referred to the program in EISA as the undiagnosing program. So we would get so many, particularly children diagnosed with schizoaffective disorder, bipolar type. We, we then think, so then we end up doing kind of full assessments and determine that they really never even had a manic episode. So bipolar disorder or that particular type of schizoaffective disorder couldn't have been diagnosed. And it was really probably extreme mood irritability with PLEs. So it's, yeah, I think that schizoaffective disorder is a big diagnosis. And so we really do want to pay attention to that. And if that's the diagnosis, that's the diagnosis, but I really want us to be very careful. And basically when that diagnosis is coming to us in individuals, particularly with, with that label already on children and adolescents. Okay. I pulled this slide from Kingdon and Turkington's Cognitive Therapy in Psychosis and how Kingdon and Turkington were kind of thinking about this is they want us to really kind of get down to the kind of the quality of psychosis in terms of how we then start applying formulations in cognitive behavioral therapy. And I'll save all of that for my CBT with psychosis lecture, but I think this is an important slide or I think maybe a useful slide. And here's some, a little bit of the theoretical components of my talk is like, I think, I think they're really onto something and it may be just a kind of the type of psychosis that the quality of the psychosis that people experience are different based on diagnosis. And these are some of the qualities that we might see with these specific diagnoses. You know, for example, what they call, what they're referring to is sensitivity psychosis. I think that's, that's really schizophrenia or your type, your very more traditional psychotic disorders are probably a true psychotic disorders. You know, let's look at kind of the descriptions there. Gradual onset. Yes. You know, new and unraveling in starting in teens and early twenties. Yep. That's what about schizophrenia tends to tend to start, you know, the clients tend to be more kind of isolative, you know, ideas, the type of psychosis experience or like ideas of reference that then transitions delusions of reference thought broadcasting is common, especially when there's stress, there's negative symptoms, you know, so which we don't see in PLEs. If you don't people with psychotic, like experiences, less likely to see negative symptoms. This is true for drug induced psychosis. Also less likely to see negative symptoms, unless it's part of a potential misdiagnosis as part of a withdrawal or something. So yeah, so I think, see that, that first box or that top left box is really kind of the characteristics of kind of true psychosis, schizophrenia related psychosis. And then you have these other forms of psychosis or psychosis like to drug related psychosis. I mean, I believe that drug related psychosis are true psychosis inside is oftentimes lost, but it tends to happen after we use substances, right? Or well, even by definition, it happens after we use substances. However, the symptoms can reoccur or continue without drugs. We actually see this in methamphetamine induced psychosis that people who've had methamphetamine induced psychotic disorders, even when they've been off methamphetamines for some time, they're more likely to have a reoccurrence of psychosis under high levels of stress. You know, there's more kind of visual hallucinations. And if there is a kind of delusion, it tends to be more paranoid. So paranoia tends to predominate drug induced, you know, psychosis, you know, so this is, I mean, one thing that's similar is onset in teens or twenties and what we see the onset of substance use disorders, unfortunately for us diagnosticians trying to sort all this out is that it also happens around the same time as schizophrenia starts to develop. And then there's trauma related psychosis, you know, when, if we look at the types of whole auditory hallucinations, abusive, violent, sexual content, second person, you're a, a whole, you know, try not to custom these webinars. You should know more like command in nature, you should kill yourself. You know, they, our experience is kind of shocking. They're just, they're disturbing. They then more fluctuating insight at times, they really struggle with what it's real or not, but when really probed, you know, the clients oftentimes can say that these experiences aren't real, you know, and then, and there's this kind of anxiety, like psychosis, which later onset, you know, after late twenties tends to be stress related and say a whole lot of work pressure or family pressure. The anxiety is relieved by making meaningful explanations of distressing feelings, you know, you know, that the neighbors are potentially responsible and, you know, for your, your stress, they tend to be kind of more non-bizarre, like, like psychosis isolation still is common. And then it usually begins with a strong belief that then transitions to a delusional system such as the, the neighbors don't like me and they're terrible people. They're, they're always trying to make life harder on me. And then it turns into the neighbors are now planning cameras into my, in my house and something like that. So I really do think Kingdon and Turkington were onto something here in their kind of early CBT work with psychosis. And I think we can kind of use these, these kind of qualifications of psychosis as potentially diagnostic guides on the type of experiences that different psychotic related disorders have. And I hope then much like Kingdon and Turkington wanted us to do, they wanted these to kind of guide treatment. They wanted, of course, specific to cognitive behavioral therapy, but we could use it then for other forms of treatment interventions as well. And then this is kind of worked by one of my favorite persons in the world, Barbara Kornblatt, and she kind of just talked about the kind of progression of psychosis. And I bring this up, not because I want to go into great detail on it, but just to remind us that true psychosis tends to be changing. It's an insidious course that, and there's a wide range of associated symptoms that tend to happen with true psychosis that we don't see with psychotic-like experiences. We don't see with drug-induced psychosis. We don't see with medical related psychosis or other, or other medical conditions, non-mental health condition psychosis that, you know, that there probably is, although there probably is a biological element to schizophrenia, I think we mostly agree that, agree with that. But the first things we don't see in the development of schizophrenia is these positive symptoms, these hallucinations, these illusions. We don't usually see that first. What we see kind of progressing over time is something that Barbara describes as a CASIS model, where early on we'll start to see cognitive deficits, kind of these changes in cognition, which the phenotype of that is that they're struggling in school, if they're of school age, which in most cases they are. And then those symptoms transition to more affective symptoms, depressive-like symptoms transition into social isolation, then ultimately school, and if they're of work age, work failure. And the positive symptoms don't start until later. They don't really start picking up until there's all these social and environmental triggers, stressors from families, stressors from the school system that are saying, hey, if you don't come back to school, we're going to fail you. And those things ultimately start to progress to increasing positive symptoms. Why is the school after me? And then the school is out to get me, then it turns into more of the teachers are reading my mind. So it progresses over time, whereas something like a PLE, we don't see some of these other symptoms, at least not progressing in this way, but we will see it with a pattern like this with schizophrenia. And when you interview family members of individuals who've developed schizophrenia, they'll talk about this pattern. It's not perfect, but they'll talk about that early on that they thought that their child was depressed and they referred to a counselor, they referred to a doctor to go on antidepressants, but that didn't seem to help. And then they were kind of isolating or not being around people as much. And school was just plummeting again with PLEs, problems have been there all along or from a very early age. Drug-induced, we don't see this stuff, at least not related to the psychosis. And then the first symptoms are kind of more true psychotic experiences versus some of the other symptoms. Now, kind of talk, and what does that ultimately look like? We kind of conceptualize schizophrenia as being in phases. Yeah, someone's bringing up, Regina saw her post, so you can start to see why some of these, when I mentioned that ADHD is one of those disorders that can get misdiagnosed as psychosis. I mean, sometimes people get diagnosed with ADHD when it actually is kind of development of psychosis because there's these concentration and cognitive problems really early on. But yeah, there's phases of schizophrenia that I'm sure you're all aware of, kind of your premorbid phase, which is kind of a non-diagnostic phase of schizophrenia. There are no real positive symptoms. There's not even a lot of symptomology we can really identify here. There's some studies that are looking at old VHS tapes of children that later developed schizophrenia and prior to age of 10, there were some coordination difficulties and things like that that kind of just seemed to be more acute, but it isn't a lot. We don't have good diagnostic instruments to really identify schizophrenia in a premorbid stage of its condition. Where we can start to identify schizophrenia is when it starts to hit that at-risk phase where a few things are happening. Functioning is dropping, and there's these now new mild psychotic symptoms, and this is what we would call kind of attenuated psychosis, where the characteristics of these symptoms tend to be more of what we see in schizophrenia-related disorders as what we see in PLEs. So that's what's starting to happen here. Here, we can actually start diagnosing and end where treatment is recommended because functioning is dropping. That black line kind of represents functioning. And then ultimately, this particular group transitions to full-blown psychosis where insight is lost. Functioning continues to drop, and the treatment functioning tends to improve, but maybe not at baseline, at least not right away. It was mentioned earlier in the chat that duration of untreated psychosis or the longer treatment goes, that can certainly can be traumatizing. I couldn't agree more that someone who's actually experiencing now a psychotic episode, a true psychotic episode, where inside is lost, where the voices aren't potentially something that could be in my head to now, these are real voices, these are people talking to me, these are people either trying to get me or hurt me or tell me to do something or just really uncharacteristic of my behaviors. And then not getting treatment for that or not even recognize it's real. One of the problems with this particular group in terms of treatment is by definition, once you've kind of crossed over that psychotic threshold, insight's lost. So this is not a group now is help-seeking anymore. The at-risk phase is more likely to be help-seeking. Once they cross over to an active phase, it's not help-seeking anymore because they don't believe that they have a condition. And that's where, again, why we have assertive community treatment teams or why we have these coordinated early psychosis teams that really can go out and kind of engage these people, individuals in the community. Again, not quite what we see with PLEs. Their functioning was always low and insight remains intact. So yeah, it's just a different phenomenological experience with kind of the development of the true, true psychotic disorder. Yeah, so this clinical high risk, about 90% of individuals with schizophrenia do experience this prodromal or clinical high risk phase. About 35% or so different studies have different kind of findings on this, do kind of develop a psychotic disorder. And then kind of the diagnosis for clinical high risk for psychosis is very similar to the diagnosis schizophrenia, where you have to have one of these three symptoms of delusions, hallucinations, or disorganized speech, but in an attenuated form. So again, not everybody who certainly goes on, who has this kind of clinical high risk psychosis certainly goes on to develop schizophrenia. And we certainly have individuals with PLEs that get diagnosed in this category. I have some diagnostic tips to try to rule them out, but again, they fall in this category, can potentially fall in this category, but characteristically they're different. And again, this group didn't necessarily have a prodromal phase. They didn't have this kind of development of psychosis in the same way that we see with schizophrenia going through a little bit. So let's give an example of what an attenuated delusion versus an actual delusion looks like within what we might see with schizophrenia. You know, it might be the 15-year-old now sits in the back of the class because she's feeling really uncomfortable in an unusual way, not what we typically see with an adolescent that people are whispering and laughing about her. She knows that this isn't real, but it bothers her so much, she goes to the back of the room. And then a full-blown delusion is now people are reading her mind, making fun of her wherever she goes. She's sure it is happening. That's the key characteristic, insight lost. And she's isolating herself because now she's so uncomfortable to go into public. Then what kind of topic of this talk, hallucinations, what does kind of an attenuated hallucination look like that's kind of more characteristic of developing schizophrenia? Two to three time, 22-year-old cashier says he colors on the wall, the distorted textures and waves in the wall, starts hearing beeping sounds that can last for minutes. And last week heard a momentary, faint, unintelligible voice, not sure, but thinks his mind is likely playing tricks on him. So the qualities here are interesting in that if there is some type of visual experience, it tends to be more kind of fit that quality of an illusion or an anomalous experience where there's something in the visual field, but it becomes distorted. That's kind of what maybe an attenuated hallucination looks like as someone who's developing schizophrenia versus someone with psychotic-like experiences who sees a fully blown, something not in the visual field of a figure, an animal, usually again, more graphic and grotesque or scary in nature. So that's some of the kind of qualities that are different. And then I kind of, Judith jumped ahead there, but you all probably had a chance to read that last slide about what a full-blown hallucination looks like. And that qualities of that hallucination in that previous slide really are quite, yes, are qualities of what we see with schizophrenia, referring to the person in third person, saying something that just doesn't make sense, like pat the cat versus you're a terrible person and you're going to go to hell, who's kind of doesn't think very highly of themselves. That in some ways makes sense, but hearing something like pat the cat, that doesn't make much sense, the latter more characteristic of developing schizophrenia. Just with this, one thing to help us identify who kind of falls in this at-risk category, and there's a ton of terms. I've probably already used two of them to describe this group, ultra-high risk, clinical high risk, prodromal psychosis, attenuated psychosis, psychosis risk syndrome. As we've been kind of studying this phenomenon, we've had different terms kind of throughout the ages, starting with DSM-3, which is referred to as prodromal psychosis. I think the most current nomenclature for this group is clinical high risk for psychosis. Again, this group is usually a help-seeking group because something is changing, something is distressing, and then we have good tools to kind of help identify this. We have the prime screen, the prodromal questionnaire brief, the early psychosis screener, and these particular tools then can help us identify who goes on to get a full-blown assessment. There's two primary assessment tools out there, the CARMS and the SIPS. The SIPS tends to be the assessment tool that's most commonly used, the one that I train on, which really helps us try to identify those who are developing schizophrenia. That's what it's intended to do. Not perfect, and we're continuing to add other categories, really study the SIPS, understand which symptoms tend to be more predictive of conversion. So I think we're still working on that. That being said, what the SIPS does a good job of, it does a good job of saying kind of what the person is at risk of and what the person doesn't have. So it does a nice job of ruling out true psychotic disorders for people who, say, are presenting with autism spectrum or individuals who are presenting with PLEs. It will rule this group out as developing psychosis. If done correctly and if you're really looking at the qualities of progressive attenuated symptoms, because those potential symptoms tend to be the ones that are more likely to convert to schizophrenia, and then it rules out those who have longstanding and stable symptoms that we see in ASD or autism spectrum disorders and individuals with psychotic-like experiences. This is important, because we actually, when kind of looking at attenuated psychosis, kind of serving mental health practitioners, we found that APS is attenuated psychosis. People that would score positively using the SIPS instrument were actually being diagnosed as a full-blown psychotic disorder, which they just don't have. But they were distressed, they were in distress, so treatment is indicated, but it's not necessarily anti-psychotic, you know, treatments. That was most oftentimes recommended treatment. However, you know, we know that the American Psychiatric Association has come out and said, eh, be cautious in prescribing anti-psychotics for this attenuated group. But clinicians were missing it. They were calling them fully psychotic and then giving them medications. So we need to continue to kind of educate ourselves and clinicians in terms of really doing this good distinction, because it could mislead diagnosis and then ultimately treatment. Here's just an example, and that's, sorry, that's not a very great screenshot there, but of the Prodromal Questionnaire Brief, that's a questionnaire I like to use in our program in Oregon to really determine who might be at risk of developing psychosis, true psychosis, and then who ultimately gets referred to the SIPs. It's a, having this 25 questions, some people complain that's a little long. So I've gone through and highlighted a couple of the items in reviewing the literature that tend to be more predictive of conversion. So I said, if you're going to, if you're a program that doesn't want a full 25 questionnaire to give to every adolescent that comes through your program, because I really do advise that any new person presenting to a clinical mental health program that's between the ages of 15 and 25-year-old that didn't have previous diagnoses maybe should get the PQB, just like we do the GAD-7 to check for anxiety, just like we do the PHQ-9 to check for depression. I'd love us to do the PQB to check for psychosis, but I get we don't want to over-assess people either. So I've highlighted a couple of the questions that tend to be more predictive of conversion to psychosis. If you were just going to pull out, say five questions or something, and if they say three, yes, then maybe you refer them to the SIPs. So when to refer to the SIPs, so in some of the questionnaires that use the prime screen, six on any items or five on any three items, PQB distress score of five to seven, and I'm not going to, I can, the instructions are pretty easy to understand. So if you want to use these assessments, then you can read the instructions. And I'm certainly happy to interpret them for you or help you with that. At ESA, the program that I support in Oregon, we have a link directly to a PQB where individuals can take themselves, again, as long as they're between those ages of 15 to 25 and they're having new experiences. And then the language actually is quite soft in that it doesn't say, oh, you're at risk of psychosis, call for help. It kind of says your score indicates that, you know, it may be helpful to talk to somebody. Would you like to be connected? And then we can do a direct referral to one of our programs or the person can reach out on their own if they choose to. And then the EPS, the early psychosis screener has a score of 33.5, should be a referral to full kind of a SIPs assessment to really get at that potentially attenuated psychosis. This is just kind of the content of the SIPs in terms of the symptoms that tend to be rated. We really mostly only diagnose on positive symptoms for attenuated psychosis, although there's good evidence that some of the negative symptoms are predictive of conversion as well, continuing to try to study that. The SIPs kind of can come up with one of three disorders, a brief intermittent psychosis syndrome, incredibly rare, but possible, and then attenuated psychosis syndrome, which is a much more common diagnosis of individuals that are potentially developing schizophrenia, and then genetic risk and deterioration syndrome. And this is individuals who have a first degree relative of psychosis, with psychosis, and who are experiencing a pretty significant drop in their functioning. So that can also be an attenuated state. It's really kind of characteristic of someone developing schizophrenia, which we don't see again in PLEs or other disorders. So with the SIPs, why I like this tool, because it can be helpful, and again, it won't diagnose whether someone has autism. It won't diagnose whether someone has a major depression with psychosis or a trauma-related psychosis or a PLE. But what it will do, particularly with disorders like autism, trauma-related disorders, is that it will rule them out of attenuated psychosis, rule them out of attenuated psychosis, because the symptoms, both in autism and the symptoms in PLEs, tend to be longstanding and stable, that there isn't a change. And the SIPs is really sensitive to pulling out when change occurs, meaning that change is more predictive of true psychosis. So again, it's not a tool that's going to say, oh, this individual has ASD, or this person has the trauma-related disorder. But what it will say is this person isn't at risk of developing true psychosis, meaning that there's probably something else. So it doesn't always do a great job saying what it is, but does a good job saying what it isn't. So that's what we can pay attention to when people don't, when they're having experiences that tend to be, that people perceive as psychosis, but they don't score on the SIPs. Then we can then start pulling out other assessment items, other assessment tools, maybe the SCID, the Structured Interview for the DSM-5 disorder, maybe the case ads for younger people to really try to get a clearer diagnosis. And just one thing, of course, with attenuated psychosis, we want to try to catch people early, or whatever the psychosis may be. We still want to catch people early. We still want to provide treatment. Here is a picture of a poster that we developed with ESA, in which we worked with a focus group of young people, 15 to 17-year-olds who didn't have a psychotic disorder, who reviewed the assessment tools, actually gave them copies of the PQB, and they were trying to pull out language that would be more comfortable to help other young people refer themselves. It was a really rewarding experience for me to engage in this focus group, because actually I felt almost in some ways hopeful for the next generation, because what I heard from these young people was, wow, if I had a friend experiencing this stuff, I'd really want to get them help, which was really cool. It wasn't, oh, they're weird, or I don't want to hang out with them anymore. It was, I want to help them. So they helped us kind of design this poster to really try to get referrals early. Again, whether or not these are individuals with PLEs, whether these are individuals with developing psychosis, or maybe even new onset psychosis, we at these coordinated specialty care early psychosis programs want to be clear diagnosticians, try to really understand what's happening, again, with the goal not to give a label, but to attempt to assure the most appropriate treatment. I think we're becoming pretty good at this. I mean, ESA stands for Early Assessment and Support Alliance, and I take the A in our name, that assessment, the first A anyways, as really critical, and we're trying to understand what's going on. And there's my references, and that's me. If you have follow-up questions, I do enjoy discussion. This is one of my favorite parts of my job, and I love talking about differential diagnoses and helping people find appropriate treatment. So feel free to reach out to me, and there's our website for a ton of resources that mostly are free that you can use. Thank you for your time. Dr. Milton, thank you. That was really terrific. So, Dr. Milton, you know, we have probably a little less than 10 minutes for questions, and there were many of them, and they were great. They're great. Yeah, there was a lot of really great questions. I wanted to just frame two general questions, and the first one really kept coming around sort of cultural interpretations of experiences as it relates to psychosis. And, you know, I know it's hard to really sort of define how one does that type of interpretation, but I think any additional thoughts you have around that I think would be really helpful, because it comes up in lots of ways. We have people participating from all over the world, from multiple cultural groups as well. I know in working with the EISA team we've been talking about, and I know you've been working with many of the Native American communities in Oregon to start having more of these discussions. So any guidance you would have around this particular issue might be helpful. Yeah, I'll give a couple of tips. Nothing is perfect here. So, yeah, so I've got my tips here. One, I do like the cultural formulation interview. So the kind of the use of that particular assessment, which is a free assessment provided on the APA or the DSM-5 website, that really starts, it asks questions in a way that don't kind of make any necessarily assumption about one's culture or one's belief. It kind of simply just says do individuals who have a shared kind of, within your shared culture, explain the challenge that you're having or that you're potentially having. So it starts to kind of pull that out in that way. So I really like that instrument, and it's not, you know, it's not like your structured SCID or IQ assessment. It really is just kind of, it's a discussion assessment. It's really to have, it's what we might call consistent with like the cultural broaching approach in treatment of mental health, where we're acknowledging that there's cultural differences between us as providers and you as somebody who may be seeking help. It really kind of pulls out and opens that conversation, you know, as opposed to kind of these more structured medically-based, are you hearing things that other people don't hear? Someone from maybe Native American culture might say, yes, but that's within my culture. And then we check off the box and go, oh man, they're hallucinating. So I think adding that cultural formulation interview in helps quite a bit. The other areas to pay attention to are that I advise in kind of really differentiating between my cultural experience you're not familiar with and more of a mental health symptom is paying attention to the depth of clinical distress. You know, I mean, if you read the DSM, and I get the DSM is a Westernized book that was written by a bunch of white people, but there's one element in there that really kind of focuses on is it doesn't matter if someone met all the criteria for schizophrenia, at least from a simple standpoint, is it causing difficulties? Is it different than one would expect in their culture? And if it is, then maybe that is a potential symptom. Maybe it's an expansion of one's beliefs. So I've worked with many religious beliefs that I'm not familiar with where I've asked them about their belief system and it sounds delusional to me. But then when I talk to the family, they say, no, we do that. That's part of our practice. Okay. Then, although I was thinking, wow, this young person is experiencing mania or experiencing a delusion, it's not because it's better. It's explained by their culture. So I did have to interview the family to kind of get that, but I was cautious enough to not diagnose it because it was, you know, certainly a religious belief that I'm not at all, wasn't at all familiar with. So I, we want to pay attention to that criteria. Don't miss that criteria, that clinically significant distress criteria. Again, I tell a kind of a, which I think is an amusing story of, of a subcultural interview of, I actually interviewed someone who identified as a vampire a several years ago. And of course, everybody believed he was delusional and had all these odd beliefs. And when I was done, man, my final diagnosis was no diagnosis, given that there was no level of distress. There was no functional change. You know, others were a little disturbed by his appearance, but if we're going to diagnose people based on disturbed by appearance, then you would have diagnosed me with a mental illness at 16 when I had long hair and a pretty sweet mullet. I was wearing guy liner and had long earrings, you know? I mean, so it's, we can't just diagnose based on that. And then the final thing is really, really encouraged is when we look at the studies that kind of say, well, we really need to pay attention to diagnosis, particularly people of color, BIPOC populations tend to be overdiagnosed, particularly with psychotic disorders. And that's been, that's been a replicated finding in many kind of diagnostic reviews. But one thing that mitigates that, not perfectly, but does reduce the likelihood of overdiagnosing, particularly individuals of color is using a structured instrument. So using something like this, use some type of that, those type of instruments can help remove our biases, you know, from otherwise we're, we're kind of, if we use unstructured instruments, we're going off our own experiences, our own beliefs. Right. Although some people might argue that the, that the instruments really were never validated, right? With people from different groups. Yeah, absolutely. Remains one of the concerns about them. And let me just ask you one other question again, because I know we need to stop in just a few minutes, but in general terms, people were asking about sort of these different differential diagnosis questions and even a schizoaffective disorder versus bipolar disorder versus schizophrenia versus drug induced. I guess one of the questions that I think comes up for me is this issue around you know, clinical staging, which you hear a lot about. And many of our international colleagues talk quite a bit about it in terms of at what point and when does one really come to a diagnostic point and hold someone there when these processes often seem to be evolving over time. And, and, and as you were speaking, there's sort of functional issues and challenges that people are facing that may be even more diagnostic in a way than, than sort of the name we might come up with. And I just wonder if you could speak to that before we stop for today. Yeah. And again, I, and I hear the concern on diagnostic instruments can not be always validated with, with certain cultures. And I, absolutely a concern. I would also argue that unstructured interviews aren't validated on other cultures as well. Like I said, another benefit of using some structured instruments is that it really starts to pull out individual symptomology, which I think that's a lot of times, that's much more important than the diagnosis itself. You know, so if somebody's experiencing a, let's say a PLE, a trauma related diagnostically, we're like, oh, is this evolving into schizophrenia? Is this a trauma disorder? You know, we start to use, if we have to build something, if we have to do a diagnosis, we can put in another specified or unspecified diagnosis temporarily to kind of sort through that. But then that allows us to really kind of really target the symptom. I mean, again, I agree with you, Steve, that's, that's much more valuable. I mean, I tell my students, I go, once you start trying to treat schizophrenia, you're likely going to fail because there is that, that people, once you met one person with schizophrenia, you met one person with schizophrenia. These are heterogeneity, I mean, the heterogeneity in the diagnosing is, is across the board. Let's focus on symptomology. Let's focus on where the challenge really is and see if we can see improvement in that specific area. And then maybe if improvement occurs, then we were not as worried about the diagnosis anyway, particularly if it's not a lifelong diagnosis. But I, so I do that kind of thing. It's that, that staging like approach is people have these attenuated symptoms, maybe following a recommendation of now let's not go to antipsychotic medications right away. Let's see if we can use some cognitive behavioral therapy. I encourage everybody to listen to the next SMI webinar, listen to Dr. Hardy and kind of the work that she does around kind of working with attenuated psychosis. And that might be one of a more kind of appropriate approach, you know, as opposed to kind of jumping in with a, with a medicine. So really paying attention to severity of symptoms, onset of symptoms, quality of the symptoms, and then trying to match that. Well, that seems like a great summary and a great place given that we have to stop now. So let me just say thank you for a wonderful presentation and thank you to Judith for all of your support and guidance in this process as well. And the presentation will be available in two weeks or so on the PepNet website, along with a PDF of the presentation. And again, Dr. Melton, thank you so much for your wisdom and sharing it with us today. And thank you all for joining us. And hopefully we'll see you again in a few weeks for the CBT for psychosis presentation that you were just referencing. So thank you all and take care. Thank you.

hallucinatory experiences

early psychosis clients

accurate diagnosis

appropriate treatment

psychosis

schizophrenia

trauma

hallucinations

delusions

psychiatric disorders

diagnostic labels