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Okay, good morning everybody. Thank you for coming. Uh No, you all have busy days. I've got the video off just at the moment. I don't have my own home. I'm living in a hotel and um the wifi is not great. So you don't have a picture of me just to, to try to help the stream. Okay, today we're talking about psychosis and as with all other psychiatric presentations and discussion's, it can be triggering for some people if you find that, that it is triggering that it is distressing. You. Please feel free to leave and um contact me if you would like. So further help and support via Facebook. Don't send me Facebook friend request. I never look at them. Send me a direct message. I'm on Facebook under my name Phyllida Row. That's row R O E. I'm pretty easy to find. I have a bright yellow flower as my icon. Okay. So what have we got? We got a nice, nice selection of people. Welcome to you all psychosis. The important thing to remember about psychosis is that it's a symptom. It's not a diagnosis in itself. Okay. So you might comment, for example, that somebody has pyrexia, but you wouldn't give that as their diagnosis. You would say they're pyrexia or they've got a race temperature because they are septic. Okay. So on messages, you can see a very simple spider outline of what we're going to be talking about during this session and the next session. And towards the end of the next session, I'll share with you a much more detailed map that summarizes the sorts of things that we're going to be talking about. Okay. So can anybody here please join in? The great thing about psychiatry is that there are very rarely wrong answers, but there might be answers that perhaps, maybe because things slightly differently might make us debate, things like that. So it's so be brave. I know you're all quite shy. Um And let's see how far we got we get today. Okay. So somebody tell me if you can, what is psychosis or say something about psychosis? They won't be brave. A Nilla just because I can see your name on my screen. A Nilla. Tell us something about psychosis. Uh Hello. Hello, doctor. Hello. I've been tell you about psychosis. What is it? One, hello? One sentence telling us what psychosis is or isn't? Yeah. Okay. That's fine. Um So um psychosis um is um is when you have hallucinations and you believe things that may not be true or really? So you have kind of delusions. Um And then what else? Um you have three stages in psychosis from what I remember, uh prodroma acute and I think recovery. Okay. So you, you've picked up the key point that it's some kind of combination of somebody who's having hallucinations and somebody who has what we call fixed delusions. Okay. So what has happened to these people is that for some reason, they can no longer distinguish experiences that are being generated inside themselves from experiences that are being generated outside. And the term real or not really, it's a bit of a tricky one because by definition to the patient, this is very real indeed. They believe absolutely that what they're seeing, Israel, that they're interacting with what they're seeing and hearing and they believe absolutely in their delusions. So I saw an interesting paper the other day, I didn't read it in great detail but a study done in the USA that uh was investigating what proportion of the population generally. So not selected for mental health problems, experienced delusions. Salman, do you want to guess what percentage of people who for what again, want of a better term are completely normal experience delusions. You there, Salman? Okay. How about Natasha Rough? Guess how many people, what percentage do you think? Probably experienced delusions or delusional beliefs? 1% 1% Shereen, do you want to go up on 1%? Yeah. So 25% 25% Dr Addy. Do you want to go up on 25%? Ok. Anoushka up or down from 25% down, I think 2021. Okay. Would it? Well, it clearly would surprise you all. 80 Anila, you said 80 80 to 90 Anila, your closest um estimated levels of fixed delusions round about 75%. So the chances are that most of us sitting here have fixed delusions about ourselves or about the world we live in because they're fixed, we believe them. Absolutely. So, I'm sure I have some delusional beliefs, but I can't tell you what they are because I can't tell the difference between that delusional belief and a rational belief because they all seem rational to me because that kind of makes sense. Yeah. Thank you. Yeah, it's quite, it's quite a tricky thing to get your head around that too. Except that you experience delusions, but you have no idea what they are. So, for example, I've got lovely friend. We've been friends for, well, since school, very long standing. She has a delusional belief that she loves going on holidays to, to quite exotic, challenging places. She doesn't, she absolutely hates it even in something as basic in terms of western travel as going to a bizarre in Egypt. She gets so anxious, she gets ratty. She can't cope with all the people and the noise and the different stimulus. But she holds firm to this belief that she loves travel. Okay. Yeah. She likes the idea of it. She, like we all have things that we like to think of ourselves in certain ways. Yeah. And quite a lot of the time we're right. But some of the time other people will just love themselves stupid because it's so obvious to them that we're believing complete nonsense. So, what you have to be careful of, about delusions? Have any of you ever heard the expression, one man's faith is another man's delusion. Probably not. It's, um, so, so what that means is if you have a religious belief, so I'm now an atheist. So it's nothing personal but I do not believe in God at all. When I was younger, I was brought up in a Roman Catholic family. And we believe as Roman Catholics that at the Eucharist, at the community, at the communion service that the Wafer and the wine actually turn into the body and blood of Jesus. So in that context, if I tell you that this is true at the communion, I am eating and drinking the body and blood of Jesus because I was brought up in a Roman Catholic family. This is, would not count as a delusion even though I no longer believe it because it's appropriate to the culture, it's appropriate to the society, it's appropriate to the family environment that I brought up in. Okay. So just because somebody has a belief that you disagree with and religion is, is the easiest one to give an example of this. Yeah. So you do have to be a little bit careful when you're dealing with people's delusions and ask yourself, are they appropriate to that person's culture? Okay. So we've got Anila here who is living in the Ukraine for her. Pardon me? For picking on your Neela. But I still got your photo on the screen. Just the, this, the way it works for Anila. If you're in the Ukraine, you're in a country at war and it is not delusional to believe that you're about to be attacked by Russian snipers. I'm sitting in a hotel in London and if I believe that I'm at risk from Russian snipers, then I'm either not the really rather dull psychiatrist. I actually am or I am delusional. Okay. So when you're working through delusions with people, that's something really important to think about. Yeah, I sometimes work with gang members. Yeah. They have a fixed belief that they are at risk of being murdered wherever they go. But I've actually got someone on my ward at the moment who's been stabbed in the head twice, two different occasions because of gang affiliation. It is not delusional for him to believe that he's at serious risk of being stabbed and murdered. Whereas for me, that would be a delusional belief. Okay. So that's the first thing to think about with delusions. Yeah, I remember going on to award elsewhere when I was a trainee and the nurse is saying to me, oh, you're gonna love it this morning. We've got the oldest son of an African chief named a country. We've got a Spanish princess and we've got George Best's niece, George Best for those of you are not British, very famous footballer. Um, in the sixties, seventies. Okay. And the girl is only in her early twenties. So the ages don't fit very well. When I spoke to those people, the oldest son of the African prints was indeed an African prints and was expecting to take over responsibility from his for his country. When his father passed on George, best niece, really was George. Best niece. The Spanish princess' wasn't a princess but did live in a castle in Spain normally and was in Britain on holiday. So that's a real life example of where things that sound completely delusional actually turned out to, to be basically true. Okay. So what sorts of delusions are common particularly but not exclusively for people who have mental health problems? Any ideas? Miracle are you there? What kind of delusion might somebody have? Ok. Miracles a bit shy. He burr. It's a problem. So if you don't volunteer, I'm going to pick on you. No, my captain with these. With the question Huber. What? Yeah. Could you speak up please? I'm a bit deaf. Okay. I said, can you please repeat the question? What kinds of delusions are common? Give us an example of a common delusions, delusions of persecution. Absolutely. Paranoia. Very, very common. We actually have a disease named after it. We have paranoid schizophrenia. Yeah. Where the main symptom is a delusion, a fixed delusion of paranoia. Well done. Ok. Somebody else, somebody I haven't picked on yet or somebody I picked on and didn't answer Natasha. Thank you. Oh, here we go. Yeah. Very rudely. Can't pronounce your name. Go. Zika is iphone. A delusion that they've been. Yeah. I think fetish belief could be delusion, fetish beliefs. I don't know if I'm right. Uh There, there are some delusions that are associated with sex and sexuality. So, but they're, they're quite specialist or perhaps thinking of declaring bows syndrome where somebody believes, usually somebody very famous is actually wildly in love with them and is sending them messages and you know, messages through the TV and, and, and things like that. Um So religiously dictated things that, you know, are impossible. For example, the R E exam in a Catholic school where the teachers are, none. People might believe themselves to have superpowers. Very dangerous. That one if people believe that they can fly because they will test it out unless you find a way to prevent them from doing. So. Delusions of grandeur. Yeah. You often find delusions of grandeur, especially in mania, Arata mania folia do. Yes. So lots. I think it boils down to the common ones are paranoia all through the pandemic. Um I worked without PPE um because so many of my patient's were paranoid and believed the government was out to get them turning up in PPE would have guaranteed they wouldn't talk to me. And I'm happy to say touch wood. I didn't get COVID. Okay. What's the difference between psychosis and schizophrenia? Now, remember, psychosis is a symptom. Yeah. Schizophrenia is a disease which includes psychosis as one of its core symptoms. All right. The one about being abducted by aliens. That's a really interesting point to raise about illusions. We don't really understand very much about how delusions and hallucinations are generated. What we do know is that delusions tend to focus on whatever the current most advancing technology is. So back in the sixties, seventies, eighties with the space race and things like that was when we started to see delusions about alien abduction coming up these days with intense surveillance cameras everywhere. Um A friend of mine mentioned they wanted to go to Samarkand when I was talking to them on the phone the other day. And suddenly my Facebook feed is full of advertisements for travel companies going to Samarkand. Um Is that a delusion? Is it by chance? Is my telephone listening to me? Yeah. So these days, we get lots of people with the paranoid style delusions where they're being watched. Okay. And sometimes these delusions can be really bizarre. So lovely gentlemen, years ago when I was working near the coast who became absolutely convinced that the government had a trained seagulls to spy on him, just him in person. So, if you're only half a mile from the coast, this is absolutely terrifying. Yeah, because seagulls are all over the place is the source of delusions, extreme fear and anxiety. Um What I would say is that in my experience, delusions and hallucinations, if you dig down, no matter how bizarre they are, you can find a grain of truth. You're quite right. There's, there's a start point there which somehow grows out of control. Delusions seem to start with something called delusional atmosphere. So, just a general feeling that something isn't quite right. Yeah, that's something somewhere is weird and strange and you're not understanding it and that delusional atmosphere can actually be caused by some medications. So I get migraine years ago, they decided to try me on a beta blocker as prophylaxis for migraine. And I realized that I was experiencing something abnormal because of the tablets and I stopped taking it and it was only as a psychiatrist looking back that I realized that it had triggered delusional atmosphere. Had I continue taking it. I would almost certainly have developed obvious, um, delusions or at least delusions that would be obvious to other people, if not to me. And a lovely lady that I met many years ago who was detained under section, her mother had flown her in from South Africa where she's been living because she wasn't well and at the airport she tried to murder somebody. You know how crowd id airports are arrivals hall. She spotted someone and for no reason that anybody could, could identify at that time, made a really, really good attempt to murder them. It turned out that she believed that she had a voice, an auditory hallucination that she believed was God telling her that certain people have been possessed by the devil and that she had been sent by God to drive the devil out by destroying the body. The devil was in pretty florid and she did cause quite significant injury. When I was exploring her background in much more detail. Getting a proper detailed history which in psychiatry can take weeks. It transpired that this lady hand and her family had moved to South Africa when she was quite a small child. They were reasonably affluent, they, they had a small staff and so on. She had a bad marriage. She had a couple of episodes of depression and then her mom, her father died. Her mom moved back to, to the UK and she stayed in South Africa. She, she had a job, she had friends at that time. She was married and so on. As her mental health deteriorated, her husband left her and her brother, um and his side of the family decided that she was possessed by the devil and kept her chained to a bed and he and his church tried to beat the devil out of her. This only came to light because one of the old family servants heard that she was staying with her brother and came to visit her. And that servant realized what was going on and helped her escape. And that lady then lived rough in uh one of the less desirable black areas uh of the region. And we think was definitely sexually assaulted on at least three and probably more occasions that she lived rough in one of the townships probably for about 2, 2.5 years. And then this servant managed to, to track down her mum and that was why her mum had flown her to Britain. So once you know that story where she has been tortured, because people around her believe that she is possessed by a devil, you can see the grains of the beginnings of her own delusions and hallucinations and finding that kind of information out is why psychiatrists appointments for so long and are often repeated appointments to try to uncover that kind of detail. So she's a lady who um uh stays with me a lot. Um So case of attempted murder, how would you testify in court? It as an expert? It was very, very clear that this lady was not fit plead, that she was not responsible for her actions and that when she was well, she was not a danger to the public. And so that that wouldn't normally go to trial. Uh not in the UK anyway. Okay. So yes, iatrogenic causes medical and psychiatric. We're going to look at a little bit further down the line. Okay. So another common one is ideas of reference, okay. And then this is again, this is quite a tricky one to get your head round. But people will, um, make assumptions that will seem very bizarre to the rest of us about obvious things like somebody on the television in an interview is actually talking directly to them and sending them direct messages and sending them direct information and direct instructions. It can be really elaborate. So I had a gentleman who, when we were exploring his ideas of reference with him, there were, there was a floor fan in the room and he pointed at that and said, it's, it's good that I have God with me and we kind of, you know, with psychiatrists, we we didn't display any, any particular reaction to that. But exploring that, that was an idea of reference because a floor fan moves air which is like breath and it is God who provides the breath of life for all of us. So these ideas of reference can actually be quite complex. If you get a patient with ideas of reference in an exam, they will be straightforward ideas of reference. It will be the TV, talking to them or, or an electric point or something like that. Okay. But in the real world, most patient's haven't read the text books and may not give you those really obvious kinds of um pointers to what's going on for them. Now, delusions are very closely related to a subgroup of the thought disorders. Anybody like to try giving us a simple definition or a simple description of what a thought disorder is. Again, it's a tricky one and it covers a huge area. So I'll let you off. So, thought disorder is, again, it's a symptom and it's a common symptom in mania in um uh schizophrenia. Um And so, okay, the ones that are particularly associated with delusional beliefs are a group of four where your patient might believe that somebody is putting thoughts directly into their head or they might believe that somebody is removing thoughts directly from their head. Yes. Well done Masilela. I do apologize for not being able to pronounce your names properly. Um So insertion and withdrawal or somebody is blocking your thoughts. So you get halfway through a thought and you lose the thread, somebody is deliberately interfering with that. Um or that sometimes that your thoughts are not internal, that you are broadcasting them so that everybody knows exactly what you're thinking. Okay. So, thought disorders are about the, are not about the content of the thought there about how thoughts are communicated. And that includes simple things like pressure of speech, flight of ideas, things like that. But we're not going to talk about that today. So I don't want to get too derailed but just be aware that there is a bit of an overlap with those four specific thought disorders and delusional beliefs. Yeah. Sometimes people with mania in particular will actually give you what's called word salad and it's because their brain is running so fast. You're just, you're just getting odd words from them. They actually can't create a coherent sentence because their brain is running too fast and it can be very difficult to follow. Yeah. I think we've probably all got the relative um who will spend 10 minutes telling you a story that probably could have been told in two sentences. So tangential consequential discussion, but we're not, we're not going to go down that that path may perhaps we'll do something about thought disorders because they are quite interesting in, in a future session. Okay. Sun. That's a little bit to think about, about delusions, hallucinations. Actually, before we go on to hallucinations, what's the difference again? Keep it simple between an illusion, a delusion and a hallucination? Oh, you've all gone shy. Is a hallucination? Is it the type of illusion, isn't it or not? No, it's not there completely separate. And that's why I'm asking the question. It's an important distinction to be able to, we've all experienced delusions. Okay. Delusion is like a false belief of thing and hallucination is something that you're imagining. Um something is happening to you. Mhm What about an illusion? Uh You see. So, so it's important again, especially I know we shouldn't focus um on, on exams. But illusion is something maybe that you can see but you see it in a different way and hallucination is something that is not present but you still see or hear or smelly. Perfect. So an illusion, there's a really stimulus that you misinterpret a hallucination, there's no stimulus that would be experienced by other people. You're not misinterpreting it. It's really to you. So it's all about whether or not there's a stimulus. So I suspect that most of us maybe after dark walking along the street and we look along the street and we think is that someone behind that tree. Yeah, because we're in a state of anxiety. And so we're trying to over interpret what's going on. So there's a really stimulus and when you get to the tree, you discover it's just a tree that got a bit of funny, normally shape on it. A bit of IV, a bit of plant growth on it. So illusions can be uh mood, what we call mood congruent. So if you're a little bit anxious, you might have a real stimulus that you might interpret as being much more threatening than it actually is. And illusions, of course, they use for entertainment. Yeah. Lots of magic tricks. Our illusions, you're given a really stimulus, but there's a distraction there that makes you misinterpret what you're seeing. Yeah. So illusion has a real stimulus, what the rest of us would believe is a real stimulus, like I said, real or not really, you get into deep water when you're talking about psychosis. Um hallucinations only the individual concerned will be receiving any kind of information stimulus, anything like that. Okay. So how are we doing? We've got a few minutes now to start thinking about hallucinations. Okay. What modalities can you experience hallucinations in? No trick questions? We've talked about voices, talked about seeing things. We're going to unpack those a little bit more in a minute. What are the modalities? Can people experience hallucinations? Also doc tell hallucinations, tactile very good. Anybody else factory or factory? Excellent. And there's one more very uncommon one gustatory. So um taste a sense of taste, okay. So all five sentences, all, all five senses. I beg your pardon. They're all potential sources of hallucinations. Okay. The most common are auditory and then visual. And we talked a little bit earlier about how there might be a kind of a you can identify like a starting grain. And one thing that I've noticed when I'm working with people with tactile sensation with tactile hallucinations, they often believe that they're infested with insects or worms or parasites and they will show you, you know, just the average little blemish or freckle and we'll try to make you understand that that's proof that they're being bitten by something. It's actually a really difficult hallucination to deal with it. It doesn't uh improve much with antipsychotics. Um And so management for that is much more psychological. And I've had a four or five patient's, it's not very common, but, but it's not vanishingly rare. And in each case, what was notable was that 4 to 6 months before the onset of the hallucinations, they had actually had some kind of insect infestation. Maybe the cat bought in fleas or um, maybe one of their kids picked up scabies or something like that. So there's a trigger event there which was really, that has now overwhelmed and now occupies all they're thinking and again, it's a hallucination. It is really to them, they feel like they are covered in little insects that are biting, nibbling. I mean, you know, anybody who's been anywhere with mosquitoes, um, and mages and things like that know how annoying it is. And if that's happening 24 hours a day for weeks on end, it becomes enormously distressing. Okay. Quick vote there for like bombs. Yep. Um, so auditory hallucinations by far the most common. Okay. So normally I'm in a classroom or a lecture theater to do this. So I'm not sure if this is going to work here. What I need is three volunteers. So let's have he because you seem very brave. Ok, Leanne. Leanne. Yeah. And one more. Anila do you want to? Yeah, of course. Yeah. Yeah, because you, because you've been chatting a bit. So. Okay. So a Nilla. Sorry if I'm not pronouncing your name. Right, by the way, um you are the patient, you are hearing voices. All right. And that's what the other two are going to do. The other two are going to be your voice is. So when they switched their microphones on, they're going to start providing hallucinatory voices for you and what I want you to do, I don't know exactly where you are, but I want you to, to think of a simple process like giving me directions to the nearest coffee shop or to a nice coffee shop nearby. Okay. So a fairly simple task most of the time. Okay. So voices, it's up to you whether you talk directly to Anila and tell her things like you see, they, they think you're really stupid. They can tell you don't really know the way they know you're an idiot. Look at the way you brush your hair this morning. Why haven't you done? Why haven't you said? So, the constant nagging directly at her or you can talk to each other giving a running commentary on what's going on and the rest of you in your own minds without your microphones, because I think the system might actually break down completely. Just think in your own head, see if you can generate a simple set of instructions or advice and then after two or three minutes we'll stop and we'll talk a little bit about what that felt like. Okay. So voices, could you make sure your microphone's are on, please. Anneal a make sure your microphone is on. So voices. Can you start being annoying, please? Okay. Sorry, that was another fake voice. That's okay. That's absolutely fine. Let them join in. Oh, okay. Voices please start start being unkind to uh you can take it. It's, it's Leann. Right. Okay. Yeah, Leanne. Are you there? Yeah. Yeah, I don't want to make up your really quiet. Okay. There you go. Right. Start nagging at Anila and then we'll ask Neela how to get to the coffee shop. Okay. So you guys need to just start being auditory. Hallucinations for her. Mhm You're not very good. Hallucinations. I don't know a person. You do a third person. One. Yeah, that would work good for it. Um So talk to each other about Camilla but nice and loudly say the rest of us can hear. Yeah. Off you go. Uh Come on, come on, you need to be walking. I I genuinely couldn't hear uh okay. You don't know what to say. Yeah, you need, you need to talk about Anila. Criticize her clothes, criticize what she's saying. Tell her how stupid people think she is. Yeah. Just be unkind, unleash the inner bitch. It's only for two or three minutes and we know you're pretending we know you're a lovely person. OK? Like can the hallucination be in the, in the uh we, but for example, yes, absolutely given. Oh Yeah, you, you just talk to each other criticizing and being unkind about Anila and then while you're talking, we're gonna ask Anila to try to give me instructions to a nearby coffee shop. Okay. Have a go. Yeah. Okay. Definitely. Okay. Today is definitely your dad. What are we doing here? Um We're definitely not going to make it today. Oh my God. Is that cause I think she's stupid. Yeah, I'm gonna crash, I'm gonna crash know. Okay. Everyone is looking at me, uh join in and try to give us some instructions. Yes. For the coffee shop you have to go straight on in the city center. Next Poundland and turn right. No, no, no. And then carrying on, you'll see a building read, you have to go on the first floor and take the elevation looking at my hair. Oh no. Uh What else? And you'll see the building there and then only we'll do my look weird. Yes, definitely. Do the coffee stain. Yes. Yes. OK. Well done. Well done. It's quite a difficult exercise to do because most of us are not normally mean voices. Okay. We have, we have our moments but mostly we try to be quite nice people and Neil a what was that like with that, that kind of background voices talking about you. Gossiping. What was that like? Trying to, to give us some instructions there? I think I could not focus on my thoughts and what the one said to you and uh just I got a bit disorganized. Well, in my brain, I don't know. And that was just after a couple of minutes when you knew what was gonna happen. Hmm. Somebody with auditory hallucinations, we'll have that 24 hours a day for weeks and months and years. And so if you're talking to a patient and you feel like they're not quite with you in any context, you know, sometimes when you're talking to someone on the telephone and you get this feeling that they're just not listening to you, they're doing something else. If you get that feeling when you're in the room with a patient, whatever your discipline is, wonder to yourself, think about is this patient experiencing hallucinations are their voices nagging up. So, again, little anecdote from my clinical past when I was an undergraduate in the genital urinary department, we had a patient come in, gentlemen who was very sexually promiscuous. He knew he was, he lived on the streets mostly. Um And so he was, you know, in lots of ways, he was quite sensible. He used to come in every three months and get himself checked out for stds and treated as needed. And I was in with the consultant because I was an undergraduate. So obviously they don't let you loose on the patient's, that's too. And he wasn't listening. You could tell he was, and she was raising her voice and raising her voice trying to get his attention and his focus and he remains my probably my second favorite patient of all time because he suddenly turned to her and said, there's no need to shout at me. This is a very small room, the walls are very thin and this is quite private stuff. And in any case, I have other voices to listen to. So he was having auditory hallucinations. So he was having trouble focusing even though he, he was there on purpose, he was actually being sensible and so on. Um And so that was a gentleman who among other things, was experiencing psychosis in his case, probably drug induced, but uh I wasn't a psychiatrist in those days, so I can't be certain. Okay. So if you're planning on joining the next session, which would be lovely. You've got that very basic spider do a little bit of thinking about hallucinations and we'll talk some more about that, have a bit of a think about causes and I'll give you a hint. My psychiatric list has six words on it and my medical causes, um which we're not going to talk about all of them because I think we would die. Um already has about 20 possible medical causes of psychosis. Okay. So lots to to think about lots to explore um management. Psychosis is very simple. In psychiatry, we quite often treat symptoms rather than diseases. Um If there's a medical cause you want to start treating that and almost everybody unless they're um hallucinations and delusions start resolving very quickly. Almost everybody will end up on antipsychotics to help them manage that symptom for at least a few months. Okay. So I think the next session is sometime next week, but I think you will, you will get a catalog and so on. So it would be lovely to see you. I hope you've enjoyed thinking a little bit today a bit of a change from death by powerpoint. Okay. And um hopefully I'll see you again soon and I hope you all have as good a day as you can. Thank you very much for being so attentive. Thank you. Okay. Thank you very much, Doctor. My pleasure. Just to remind everyone to please do the feedback. I've posted the link in the chat and you've also got the link for the next lecture. The part two of this psychosis uh lecture is on the 23rd of March. So it's next week. Uh Yeah, 11 am brilliant. Thank you very much for your heat today and hopefully I'll see some of you again soon. Thank you.