155 Transcript

Dr. Jeremy Sharp Transcripts Leave a Comment

[00:00:00] Dr. Sharp: Hello, everyone. Welcome to the Testing Psychologist Podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR.

The TSCC and TSCYC screening forms allow you to quickly screen children for symptoms of trauma. Both forms are now available through PARiConnect- PAR’s online assessment platform. You can learn more at parinc.com.

Okay, everyone. Welcome to the episode. I am so excited about this episode y’all.

Today is the first episode in a brand new format that I’m trying out called masterclasses. The intent behind masterclass episodes is to bring on an expert practitioner in our field to talk through a case [00:01:00] presentation or case conceptualization in great detail so that we can really get some insight into the thought processes, the battery selection, the interviewing strategies, and of course, the way that someone might pull together the data to make a diagnosis or diagnoses.

In this case, we are starting off with a bang. I’ve got Dr. Stephanie Nelson here to do a masterclass with us all about psychosis. This is a fantastic episode. If you have not heard Stephanie on the podcast before, she did come on probably about a year ago, maybe a little more in episode number 84. It was a very popular episode.

Let me tell you a little bit about Stephanie.

She’s a pediatric neuropsychologist who specializes in complex differential diagnoses. She’s board-certified in both clinical neuropsychology and pediatric neuropsychology. Stephanie was also recently elected to a [00:02:00] member at large position on the ABPdN board.

She got her undergrad degree at Williams College and her doctorate in clinical psychology at the University of Vermont. She completed her internship and post-doc in pediatric neuropsychology at the University of Minnesota Medical Center.

After a few years in group practice in the Boston area, she returned home to the Pacific Northwest in 2014 and opened her own practice. Then in 2018, she founded Skylight Neuropsychology in Seattle. Stephanie currently provides comprehensive neuropsychology assessments and outreach to the community through presentations, workshops, and volunteer work. She also provides consultation to psychologists and neuropsychologists who specialize in pediatric assessment through her website, thepeerconsult.com.

So hot on the heels of our consultation episode from last week I believe. If you listened to this episode and find yourself wanting some consultation, Stephanie is an expert, [00:03:00] certainly in psychosis, but many other areas. She has frankly gotten rave reviews in the Facebook community about her case conceptualization and supervisory skills. So definitely check that out if you need a supervisor or consultant.

One last thing I’ll mention is that Stephanie did provide a very comprehensive PowerPoint presentation with all of the key points from our discussion and resources and so forth. She even included a transcript of the feedback session that she conducted with his family. So be sure to check that out in the show notes as well.

Okay. Without any more delay, let’s transition to our masterclass on psychosis with Dr. Stephanie Nelson.

[00:04:00] Hey Stephanie. Welcome back to the podcast.

Dr. Stephanie: Thanks so much. Glad to be here.

Dr. Sharp: It’s good to see you again. I’m so grateful to have you back. I think since your last episode, your celebrity status has only grown- your star shooting higher and higher in The Testing Psychologist Community. We are very lucky to have you back and have some more of your knowledge and thoughts. So thank you.

Dr. Stephanie: I don’t think any of that is necessarily true, but thank you for the warm welcome.

Dr. Sharp: Well, that’s what I do. I’m trying to make you comfortable, warm you up, and get ready to go here. No, all true.

Well, I’m excited about this. Like I said, this is a little bit different format. It’s a masterclass format. So something new here on the podcast, relatively new. I’m really thrilled to see where we end up on this.

We’re going to be talking today about [00:05:00] diagnosing psychosis and thought-disordered stuff in a kid. So I will turn it over to you here at the beginning and just let you dive into the background, and then we’ll proceed from there. So present away.

Dr. Stephanie: Fantastic. And you’re going to interrupt me anytime you have questions or thoughts, or if I get a little bit off track, but let me just start by telling you a tiny little bit about this young man and tell you what happened during the introductory phone call. I’m going to call this young man, I’m going to amalgamate a lot of different cases, to keep this de-identified. So if there are any continuity gaps, please forgive that. But that sometimes happens when you’re amalgamating.

But I’m going to call this child, his name is Alexander, but his family has always called him Sasha. They’re [00:06:00] the second generation. His father immigrated from Russia when he was very little. And so they keep their ties to Russia. He is 17 years old and is in the 11th grade. And then for the last name in case I need it, I’m just going to say Case. So we’ll just pretend the last name is Case.

He’s an only child. His dad is a CEO of a local major company, so a very high-up individual, and his mom describes herself as a household manager. He’s their only child. I told you a little bit about dad’s background. The other thing to know about dad is that his brother is a famous musician in this country. So they also have that as part of their history. And I knew a little bit about just from the intake questionnaire about their family history. What they wrote on the intake questionnaire, which we’ll find out was maybe not all [00:07:00] of the background history is that there’s some anxiety, depression, migraine, headaches, things like that. They didn’t really endorse too much.

I first heard from them when they gave me a call. That was back in the day when I answered my own phone. Now I have a virtual assistant, but I answered the phone and they told me that they had this son who is brilliant and musically talented and has a lot of what they called the angst emotion of a genius creator.

They said he’s been diagnosed with ADHD, anxiety with features of OCD, and depression at various points in his development. And they tied that in a lot to his angst and emotions that they see as fairly typical of a creator, but they feel like these concerns might be getting worse. They also said that something is a little bit off with his thinking. It feels like he’s [00:08:00] not really connecting cause and effect. Like he wants to be a famous musician and he is this incredible music prodigy, but he’s not practicing at all.

So they wanted to know what they can do to support him there and thought an evaluation might be the next best step. And then we arranged all the details for the intake. And then they added right there at the end, Oh, by the way, make sure you don’t wear any lipstick when you meet with him because he thinks it’s deeply disgusting. Your face is now doing what my face was doing on the phone because I was like, oh, okay. But it was one of those when people are leaving the room and they just add right as their hand is on the doorknob, this little thing that may have been important to bring up earlier.

It was right at the end of the phone call. So it was just like, oh, okay. I don’t [00:09:00] normally, so that’ll be fine. But it gives us a little insight into what the family is thinking about and how they’re thinking about this individual before I even sit down to meet with them. And so that’s the information that I had going into it.

And so now I’m thinking about doing the intake and I have this process that I do- these 10 steps that I do. My first step is really looking at finding really good referral questions that are going to be really helpful in clarifying the diagnosis and in writing a report and giving feedback that actually helps this family.

The way I was trained, the referral question is diagnosis and treatment recommendations, right? That’s what I want to do correctly and get my gold star for getting the right [00:10:00] diagnosis. But that’s not necessarily what the family has in mind. They may or may not be moved by the right diagnosis. Probably they want treatment recommendations, but they also probably have a lot more than they want from this process: reassurance, answers to some of their questions that they’re afraid to tell me about, and a deeper understanding of their child.

So what I’m trying to do during my intake is figure out what those referral questions are, so that I can really be helpful to see this is this family beyond just getting the answer, “right” as to whether or not this is psychosis.

Dr. Sharp: Are you asking that explicitly or is there a process or is it more of an implicit process that happens throughout the intake?

Dr. Stephanie: That’s such a great question. What I’m thinking about is I’m [00:11:00] looking at five different factors. I’m looking at the content, like what they actually say during the intake. That’s obviously going to be really helpful for me and something that I think we all do as part of our interviews, but I’m also looking at the process. So I’m looking at how they say it. I’m looking at how they tell the story, what they prioritize, and how they explain things, to get a sense of what they really want to know.

I’m also thinking about their behavior observations during the intake. So not just how they say it, but how they look while they’re saying it or how they act while they’re saying it and their interaction with me. So the fourth thing I’m looking at is how they relate to me, as I’m saying things. If I say something that, if I try to reflect and reflection is a little off, how do they respond to that? How do we regroup for example? And then, of course, I’m also [00:12:00] looking at what I call the white space- what they don’t say, what goes unspoken. So that is the fifth thing that I’m really looking at.

And I do some of these things more implicitly and some of them more explicitly. So I will actually at some point say what’s the worst thing that I could tell you as a result of this evaluation, which is a way to get at what they might not be saying themselves.

Dr. Sharp: I like that. I agree.

Dr. Stephanie: Okay. So what I thought we would do is since we only have a short amount of time, I’m going to focus mostly on the content and the process and a little bit on the white space and not as much on the behavior observations and interactions, just to condense this a little bit.

Dr. Sharp: Great.

Dr. Stephanie: So let’s just jump right into the context. Most of the time we get the birth history. What this family told me is that this is their only child, Mrs. Case experienced multiple previous [00:13:00] pregnancy losses before she had this child. And this was a much longed-for baby. Her pregnancy was mostly uneventful, but she did have a viral infection late in the second trimester and was briefly hospitalized for that.

The baby was born in February. He was 41 weeks gestation, 9 lb 3 ozs. Labor was induced because he was late. And during the delivery, he had too slow of a heart rate after each contraction. And so they eventually went to a C-section, but he was in good condition at birth, at bars of 89% at 1hr 5 minutes. As a baby, they described him as alert. He was sleeping okay. I asked, was he an affectionate baby? And they said he was slightly below average in affection, which was an interesting way to put that.

And then mom told a lot [00:14:00] of details to me about him latching and how he had a lot of trouble latching. He was very distracted during the latching and would lose the latch and they needed a lactation consultant. And to me, that’s a small little soft sign of something that may be going on in terms of his motor system. But to mom, it was obviously a really important part of the story.

I recently had a consultee asked me, why do we gather all this information about the birth history and very early history. And I was like, that is such an amazing question because so often we don’t really stop to think about what we’re doing. We’re like, well, I’m supposed to get the birth history. And obviously, it has important implications for any neuropsychological evaluation that you might be doing or whether it’s neurodevelopmental disorders. But when you think about why you’re getting the birth history, what are you thinking about during that time?

[00:15:00] Dr. Sharp: I think for me, it’s two different prongs. There’s the very practical piece of, okay, let’s look at the birth history and see if there are any medical complexities or problems that may have come upon the medical side. Is there anything that we need to pay attention to or know about? But there’s also this more qualitative, the narrative component for me anyway, of what story they will tell about it and how maybe like you’re alluding to, how the parents started to create their life with this kid. And it starts at birth and really before that, so maybe those two if that makes sense, and how parents would just relate to the.

Dr. Stephanie: Exactly. And I think we all do that intuitively. That’s the exact word that I had written down, was the story. You’re getting the story from the beginning or at least how they [00:16:00] want to tell that story to you. And we have this story here that’s really important to the mom of this really longed-for baby during a pregnancy that included some scary moments, a delivery that included some scary moments, and maybe some difficulty with what the mom expected afterward.

Whatever slightly below average and affection means, her feelings around her difficulty with getting a good latch clearly were really important to her. So starting to think already about how these parents contextualize the story of this young man, and how is that going to inform the feedback that I do with them and the report that I eventually write for them. So that’s what I’m thinking about.

Dr. Sharp: Can I ask you a question? I love that you highlight that story piece. I think that’s right [00:17:00] on. On the medical side, you mentioned two things and just for the sake of what we’re doing here, do any of those things catch your eye? Like does a viral infection catch your eye? Does the D cells during labor catch your eye or anything like that? Because I think people hear that and they’re like, Ooh, maybe that’s a thing.

Dr. Stephanie: Right. Maybe it’s a thing. And the answer is that maybe those are things. Some of them are non-specific. So the difficulties during the delivery is a non-specific marker that there could be some neurodevelopmental things going on and some of them might be a little bit more specific to psychosis-like we’re talking about now.

So the viral infection during the second trimester and the February birthdate, both of those might be… the literature has suggested there could be a [00:18:00] relationship between those two things and later psychosis with the idea that there might be some viral or neuroinflammation or something that might be happening during development. There’s also an association between preterm birth and later schizophrenia. This child was not early but since we’re talking about it, I thought I’d throw that in.

Dr. Sharp: Nice. I have to ask, what does February birthdate have? How does that relate here?

Dr. Stephanie: There is some association in the literature between a winter birthday and later schizophrenia. Another large, more recent study actually showed a lot of people with schizophrenia have a June or July birthday, but the reason that they’re looking for this, is they’re not looking for like a horoscope association. They are thinking about possible viral infections [00:19:00] during the pregnancy and when you might have been exposed to more of those.

Dr. Sharp: That’s okay. You’re right.

Dr. Stephanie: All right. I’m going to jump right into the early developmental history. There really wasn’t much between the ages of zero and nine, between the ages of zero and five, the parents described him as pretty easygoing, with completely normal social relationships, really imaginative, and loved playing.

They could tell he was very bright right from the beginning from their report. They described him as a musical prodigy with two instruments, the piano, and the guitar from an early age. They used the phrase perfect pitch. They were very invested in his musical talent. He was on time in his motor development, a little clumsy, but fine there. He was late in speaking his first words, but he got ear tubes at 18 months when they figured out he had water behind the ears and he caught up and [00:20:00] surpassed his peers in speaking.

The first thing they noticed was he started having some specific phobias and they were both normal things like flying insects. And then also some things that were a little bit odd or he had a fear of water sprayed noise, and he had a fear of red cars. So some things that are a little bit odd, but that weren’t debilitating for him in any way. He also had some nightmares during this period, but no major medical history during this time, no accidents, injuries, nothing other than that ear tube placement, and eating is fine.

And academically he did great in early elementary school. His teachers really liked him. He had friends. His teachers thought he was a little bit anxious. He’d overreact to small bumps and bruises. He would occasionally become afraid of certain things, but not anything that disrupted him particularly. And he was [00:21:00] nominated and tested for the gifted program twice, but he didn’t quite test in either time. So that gives me a little bit of where his premorbid functioning is at.

Obviously, I’m thinking through this developmental history to rule in or out certain disorders later. So for example, a common question that I get from my consultees is autism versus psychosis. So here we’re really looking at that developmental history. Is it typical of, for example, autism spectrum disorder, or is it looking more like maybe something else?

Is there anything in that section that I left out or that you typically ask about or are wondering about for him?

Dr. Sharp: Let’s see. I may have lost track of it and I apologize. Did you talk about the social component?

Dr. Stephanie: He did just fine socially. Parents don’t really remember any concerns. Teachers don’t remember any concerns. They described him as really imaginative, really [00:22:00] loved playing. You and I had talked about how I’m going to have a PowerPoint presentation for people to follow along, because obviously as you’re listening to a podcast, you tune out and you’re thinking about your own thoughts, and then you’re like, wait, what did we talk about? So if people want to follow along, they’ll be able to.

Dr. Sharp: Cool. Yeah.

Dr. Stephanie: So now we start where things started. So ages 0-9, pretty uneventful. I’m going to pick up the history again at about age 10. He’s in 5th grade at this time. And this is really where the parents started the story, is that he fell and when he fell down, he stood up and then he said that he couldn’t use his legs and that they didn’t work at all. The school took him to the ER, and at the ER, his legs were functioning fine. He was walking. So the ER said, [00:23:00] this is psychological and ruled out any medical problems and they suggested ignoring it, which the parents did. And after about a week and a half, this complaint went away, and everything went back to normal.

But then in 6th grade, he began having what his parents called Fitz. He claimed that he would blackout and that when he woke up that it would feel like years had passed and he would flail his legs around when he woke up. And then he would also say that his parents were trying to kill him. The parents at this point thought that was odd, but they had had that earlier experience of ignoring it. And so they thought we’ll just ignore it again.

This time it took two months for these fits to go away. So they started some counseling, but he wouldn’t really engage with the counselor at all. Basically, he wouldn’t really talk. So after three months they stopped it and said, okay, that’s not something that really [00:24:00] is helpful. And then it seemed to go away on its own.

Dr. Sharp: Is this daytime or nighttime or both?

Dr. Stephanie: So these are mostly happening in the school setting. But that’s a great question because you’re already thinking about hypnopompic or hypnagogic experiences or night terror experiences, or just what is this, right? And that’s the experience that I’m having listening to it as well. It’s like, oh, this is interesting. And I’m going to sneak ahead a little bit that parents did not seem as concerned about these as I think I would have been. They related this is a perfectly common part of a child’s history, but I don’t hear this type of thing that often. 

Dr. Sharp: Yeah, me neither.

Dr. Stephanie: Okay. So [00:25:00] when we’re thinking about psychosis, obviously, there is a high rate of abnormal EEG findings in individuals with psychosis. So I should mention that they did a neurological evaluation and completely ruled out his EEG is actually clean. So did not seem to be seizures or anything like that.

Around 6th grade is also when he started getting really more intensely interested in music. And when his parents started deciding that he really wanted to become a famous musician and they started getting him private lessons and other experiences that would help him become a famous musician like his uncle.

In 7th grade, he transitioned to middle school and he started having trouble paying attention as his parents assumed that it was because he was going to a new, more rigorous school. And that’s what the pediatrician that they took him to thought as well. And so he was diagnosed with ADHD that had gone unrecognized because [00:26:00] he was so bright and he was started on stimulant medication at that time.

Between 7th and 8th grade, he started developing over the summer, some obsessional behavior around insects and sleep. He started asking his parents to check his room for spiders before he went to sleep. And then they developed a special spray that they could use to spray magically for spiders like you might do for maybe a much younger child.

And he also started saying that the spray would help him keep away bad dreams and keep away specifically something that he called smushy darkness that he felt sometimes happened at night. He also became obsessed with fire during this time and his parents thought it would help him to overcome this. They encouraged him to start fires on purpose so that he could experiment with fire.

He also started avoiding certain [00:27:00] colors, specifically red. He wore the same shirt for a few weeks in a row at school and he had developed some obsessional behavior around music. Now he would just play the same song over and over again for hours at a time.

Dr. Sharp: I just have to jump in. I’m curious. What are you thinking at this point if anything? Have alarm bells started to go off or when did that start to happen for you?

Dr. Stephanie: So alarm bells for me started to go off during that intake phone call. But when we’re thinking here, this part is making me think about that tricky differential diagnosis between OCD and psychosis. And it’s tricky because some OCD can [00:28:00] border on things that don’t necessarily seem to have a lot of touch with reality.

And then we know that for individuals with psychosis, especially as they’re starting to experience their prodrome somewhere around a third of them, something like between 10% and 60%, depending on the study, have these obsessions and compulsions possibly as a way to organize their thinking that is trying to help give some structure to some thoughts that are feeling a little disorganized or a little scary to them.

And the content in psychosis of the obsessions and compulsions. One of the differentials is that the content tends to be a little bit more unusual. It tends to be something that as you’re sitting in the intake, you’re thinking I’ve never heard that one before. I have never heard of obsession specifically around spiders and bad dreams that could both be taking care of the same compulsion. So [00:29:00] it’s interesting there.

And then I’m also thinking about the smushy darkness that feels a little bit less reality-tested to me than I would expect. And I’m also starting to wonder about these parents. I’m not sure that I would respond to a child being interested in fire by saying, oh, let’s start a bunch of fires. So I’m wondering about their way of responding to his maybe increasing disorganization and whether or not that’s helpful or maybe scary or confusing for him.

Dr. Sharp: Sure. Yeah, those things you meant, those are the same things that jumped out when you said smushy darkness. It was like, hmmm.

Dr. Stephanie: Yeah, I can see your face. You’re like, okay. Right?

Dr. Sharp: Yeah, it’s very clear.

Dr. Stephanie: Exactly. The parents took him back to the pediatrician and also to a therapist. [00:30:00] He was diagnosed with anxiety, OCD features, and depression at that time. Placed on antidepressants. They try to do therapy for the OCD portion of it, but his therapist said he refused to talk. She described him as intensely private, and he wouldn’t reveal his private thoughts to her. So they discontinued therapy at that time.

The other thing that happened, this is in 8th grade is that one of his major best friendships just completely disintegrated. And his parents don’t really know what happened. They suspect bullying or something along those lines. They’re just not sure what happened. They just know that he used to have this friendship and then it disintegrated. So they responded to that by switching him to a different school. And he switched halfway through 8th grade.

At first, he found this alternative group of kids that he seemed to be trying to fit in with, but he wasn’t very successful. His [00:31:00] parents saw him trying to interact with these kids and they noticed he would approach them and he would talk a lot, but not really say anything is the phrase that they used. They thought he seems to be having trouble fitting in with these kids.

And he’d started to have those academic difficulties like trouble paying attention and those didn’t really improve at the new school either. So they were starting to investigate this a little bit more. And one of the things that they found out is that one of these kids that he had tried to befriend had introduced him to marijuana and he was starting to use it daily. He would have been about 14 at that time.

We know that there’s a relationship between marijuana and psychosis. The directionality of the relationship is not necessarily clear. Certainly, if you have a child at risk for psychosis, you would want to try and stress, let’s not [00:32:00] use marijuana, but the truth of it is that most individuals who do end up having psychosis do at some point seem to try self-medicating. And that is a common medication that they seem to self-medicate with and may possibly increase paranoia or precipitate a psychotic episode in an individual who is predisposed to that.

Dr. Sharp: Are there any effects with the age of first user or the frequency at different ages or anything that you know of?

Dr. Stephanie: So earlier age at first use and higher frequency are both associated with worst outcomes as you might expect.

Dr. Sharp: Okay. Just making sure.

Dr. Stephanie: Yeah, exactly. And again, so moving on to 9th grade, his parents made another interesting decision. They thought, well, he’s self-medicating with marijuana. So instead of [00:33:00] having him buy marijuana on his own, they decided to start giving it to him nightly as a way to control his marijuana use.

It is legal in my state, as it is in yours, not at age 15 which he would have been at the time. But this is going to become something that we have to think about more in our evaluations as we move forward. And they’re easier access to these substances and a lot of states. So they were having him vape nightly before he went to bed.

And other things that were happening in ninth grade, he dropped out of all of his social relationships. He wasn’t even trying to interact with other kids anymore as far as his parents could tell. He was failing classes. They had him drop one and then two classes and they were replaced with a study hall, but it didn’t really help. The only thing they thought was helpful at that time was actually marijuana. They felt like that reduced his [00:34:00] anxiety a little bit.

By 10th grade, total school failure. He got an IEP through his local school district, even though he was at a private school. His OCD worsened according to his parents. And what they said is he started lying in a way that felt compulsive to them. And when I asked about that, they said he constantly says things that aren’t true and says things that don’t make sense. 

I tried to get two examples of that. And they said that he says that he knows famous people. He just lies about it and won’t accept that he doesn’t know them. He says that his parents told him something that they definitely did not tell him and clings to his version is what they said. They also said that he says that people are staring at him and want to fight him, which they said was not true. [00:35:00] He also started worrying obsessively about the family cat that someone was going to hurt her or take her.

The other behavior that his parents became really concerned about at that time is what they called stealing. They said he was helping himself to things that he found that were abandoned. Like if he found someone’s pen or a straw or a toothpick or a bit of paper, he would claim it. And sometimes even carry it around with him in like a little bag of reclaimed items.

By 11th grade, he started seeming afraid of things that his parents said aren’t really threatening. And they said it’s almost like he’s having nightmares during the day. So I asked, of course, if they thought he was seeing things that no one else could see or hearing things that no one could hear and his parents said they weren’t sure. And that they’d never asked him. But they did notice that he was starting to avoid things that he said were disgusting and that [00:36:00] reminded him of wounds like red lipstick or shirts that had splashes of their color red on them. And he would become very afraid of those.

His parents were really mostly concerned at this point. I could tell it was incredibly embarrassing to them about this lot, what they call lying behavior. They’d gotten him an interview with a music producer and he had told that person that he knew some famous people. He also had dressed really oddly to go to that interview. He had worn a hoodie and then like a blanket over the hoodie and they thought, well, he’s trying to be alternative and look cool, but it didn’t seem quite right to them. And he stopped practicing his music this year. And he says he doesn’t need to practice anymore because he’s going to become famous because it’s his destiny. Or he sometimes says he already is famous.

So here we can see that although [00:37:00] the parents are not necessarily concerned, we’re pretty concerned at this point. This is not a behavior that sounds defiant even though parents are describing it as lying and stealing. It’s not behavior that sounds within what we’d be thinking about for maybe something like OCD, or even impulsivity associated with ADHD or something like that. This case is not necessarily too much of a surprise in terms of the outcomes. So we can see the hints here at least have some psychotic thinking processes that might be happening for this young man.

Dr. Sharp: I think though, just to point out that the way that you have walked through this history, it really illustrates the slow burn of something like this, where I think for a lot of us it’s really hard unless it hits you in the face. So kiddo is 9 years [00:38:00] old and they’re seeing shadows and murderous figures and whatever, it really speaks to how hard it can be to separate some of these. Because a lot of this sounds like OCD stuff until we get later and later, and then it’s like, hmm, this is different.

Dr. Stephanie: Exactly. You raise such great points. And there are two that you were making me think of. And one is that for one, I’m telling the story in an organized way. This is not necessarily how the parents told me. Let’s start in 5th grade. We do have the benefit of seeing that trajectory over time. And what we’re really thinking about is what the history of the prodromal period is for individuals who have a prodrome associated with their psychosis. It is often long and is often confusing and it is often only recognized in retrospect.

I know [00:39:00] you had Michelle Friedman-Yakoobian on your podcast, and she’s with the CEDAR Clinic. The CEDAR Clinic has this really nice model where they talk about the trajectory of this case. We’re starting at age 12, there are some cognitive issues like some attention problems that didn’t seem to be there during early elementary school. And then later you get some affective problems, like some anxiety and some depression, and then you start having some of that social withdrawal, some of that educational failure. And then you get these at the end, these sub-threshold psychotic symptoms where you’re thinking as you’re listening during the intake, you’re thinking, is this psychosis, is this an atypical form of ADHD?

I’m sure some listeners are thinking, this sounds a little bit like some kids that I’ve seen who are on the spectrum and didn’t get diagnosed until later, or people who are thinking, bipolar. [00:40:00] I’m wondering about maybe some slight psychotic symptoms as part of a mood disorder. So it’s hard to piece out. And that’s part of why I’m doing testing in addition to just the intake is because this feels like it could go in some different directions.

Dr. Sharp: Sure. Sorry, go ahead. It’s hard not to keep asking questions. Continue, please.

Dr. Sharp: Oh, okay. I interviewed his teacher and I interviewed his current therapist. One of his teachers said he’s not doing the work at all. He doesn’t participate. He’s sitting in the back of the class most of the time. It looks like he’s sleeping. Oh, his teacher said, or it looks like he’s turning into something else.

And she mentioned something that the parents had not, which is that on a few occasions, he’d left school without permission and he’d been found several miles away just [00:41:00] walking with no purposeful destination. And she used a phrase where she said, I teach a lot of kids and I’m usually able to connect with them about something, but this kid feels unreachable to me. And that was the word that she used.

And his therapist said a similar thing. He said, I work with a lot of kids and I’m just really struggling to connect with this kid. He seems really odd in ways that I can’t really put my finger on. He talks to me, but I can’t always understand what he says. And he just doesn’t seem very in touch with his emotions. The therapist thought maybe this is autism, which I think is a common differential that we get. And then he is on medication, he’s on two different stimulant medications, guanfacine, and fluoxetine. I just have that in my notes of where he was at in terms of his medication.

Dr. Sharp: I got you. Great.  You walked us, so now we’re progressing past the intake/collateral interview and moving on to testing. So are there any other differential diagnoses that you haven’t mentioned so far that were maybe swirling in your mind at this point?

Dr. Stephanie: So my differentials that I’m thinking about, I’m thinking about possibly psychosis. I’m also thinking that he already has three diagnoses that maybe are pretty high incidents that maybe explain a lot of what’s going on with him that maybe the previous evaluators have been right. And this is ADHD and an atypical anxiety and depression with some psychosis features. I’m thinking about OCD, of course. I’m thinking about bipolar disorder, [00:43:00] autism.

Two other things that we didn’t mention, one would be trauma. His parents do suspect maybe some bullying there, and we know that three doses of trauma pretty reliably predicts auditory, at least hallucinations. So it is a really important rule out when we’re seeing that. And then of course the thing that I think a lot of us think about is like, could this be something medical?

It turns out that only about 3% of cases of psychosis are caused by something medical. But I think it’s something that we often think about. It’s actually so rare that typically more than routine medical workup isn’t recommended unless the symptoms are acute or unusual or not responding to typical treatment. But sometimes people do ask me, what the causes might be.

There are hundreds of possible causes of psychosis, but [00:44:00] roughly if they’re acute symptoms, we’re thinking about maybe something febrile, or a drug or toxicity problem, or a neoplasm, some brain tumor or a cephalic process, like some sort of inflammation type process.

If they’re episodic or fluctuating, we’re thinking about something like epilepsy or a possible aura associated with migraine or sleep disorders would be the main roll-outs in that case.

Dr. Sharp: Let’s take a quick break to hear from our featured partner.

With children currently exposed to conditions including a global pandemic, social injustice, natural disasters, and isolation, you need a trusted tool that can screen for symptoms of trauma quickly. The TSCC screening form allows you to quickly screen children ages 8-17 years for symptoms of trauma and determines a follow-up evaluation and treatment are warranted. The TSCYC [00:45:00] screening form does the same for children ages 3-12 years. Both forms are available in Spanish and support the trauma-informed care approach to treatment. These screening forms are now available through PARiConnect- PAR’s online assessment platform, which provides you with results even faster. Learn more at parinc.com\tscc_sf or parinc.com\tscyc_sf.

Dr. Stephanie: And so those are on my mind. And what I tried to do at that point was get some more helpful information from the family that would help me know where they’re at and what they want out of this evaluation. I’m going to skip that part. [00:46:00] I have some questions that I ask that are beyond the history. And I’ll just put those in the PowerPoint presentation that I got, but I’ll highlight two of them.

One of them, I ask families to get a sense of if there’s any, what I call secret family history. I’ll say something like, what parts of yourself do you see in your child? Or is there anyone in the family who he just really reminds you of, or sometimes anyone in the family who he’s just really different from? From those questions, I got a little bit more history, which is that mom has OCD with hoarding that she didn’t mention on the intake form and then dad’s cool older brother, who’s very successful in music has, what they said was ADHD, but sounded a lot like bipolar disorder when they described it. And then they mentioned that dad has an aunt back in Russia who lives in an [00:47:00] institution because she is so disabled with something that sounds a lot like schizophrenia.

So that’s an example of the types of questions that I’m asking. I’m also asking anything from what are kid’s communication and memory skills like to some pretty straightforward things to things that are a little bit more oblique, like what’s a sense of humor like to get a sense of his ability to abstract or if his thought process is off. About 50% of individuals in the prodrome period have a reduced tolerance to stress, so asking about resiliency, coping skills. I’m asking about regression. Does it feel like there’s something that he used to be able to do that he can’t do now- things along those lines.

And then, I borrow some things from the Therapeutic Assessment Model, and I know you’ve had lots of people talk about therapeutic assessment on your podcast. So hopefully listeners are really familiar with that.

And what I did is I had the family [00:48:00] come up with questions and they asked these questions of, he wants to be a famous musician, but he doesn’t want to put in the work. Why is that? And how can we support him in reaching his dreams? They said he’s always had an artistic temperament but now as anxiety seems to be getting worse and he’s lying and stealing, and he’s putting off people with his behavior that maybe could help him like this music producer. So they want to know how to interrupt this cycle.

They said he’s failing school. And so they wanted to know if he should just drop out so he can just focus on his music. And then they said that he’s not making social connections and his therapist is worried about autism. So they wanted to know that, is this the right therapist for him? Does his therapist see what we see?

When I ask them that question of like, what is the worst thing that I could tell you? What they said was we’re worried that you won’t see his talents and skills. Sometimes adults overlook that. And that seemed to be how they’re viewing that [00:49:00] therapist.

So when we’re thinking about the process and that white space of what these parents are like, people who consult with me know that one of the first questions that I always ask for a tricky case is like, just, what was it like to sit with these parents? What were they like in the room? And these parents were odd. It was an odd experience for me, with some of the decisions that they’re making.

Dad seemed very bordering on grandiose. He wanted to know a lot about my credentials. He wanted to talk a lot about how we’d both gone to the same undergraduate school. Mom in contrast seemed anxious, depressed, and downcast. She was 10 years younger than dad, but she looked about 10 years older than him. And I could really feel that parallel process happening in the room.

So they’re presenting as if things are [00:50:00] normal and I’m stuck with all these emotions. I’m feeling confused. I’m feeling scared. I’m feeling this pulled normalizing this kid and say, it’s fine. Things are okay. He really is the genius or I could figure out something like OCD that we could fix, really feeling that in the room. And I can tell that they’re giving that to me. And then I use that to think about what are the secret questions these parents might have? What are they not asking me? Does anything jump out at you about what they’re not asking me that you might ask if this were your child?

Dr. Sharp: Well, I think deep down, if it were my child, unless I was totally oblivious, which people have accused me of being at times, with the question that, deep down I’ll be like, is there something really wrong with my kid? Or like, [00:51:00] do I need to be worried about my kid? Should I be scared? That’s the first thing that comes to mind.

Dr. Stephanie: Yeah. That’s literally the first secret question that I had on my list of like, what I think this family is not asking me, is there something really wrong with my child? Another thing I was thinking about is I could feel that they’re really invested in their dreams for this much-longed-for child who they think of as a genius. And they’re thinking, are we going to have to give those dreams up? I could tell from mom’s discussion of the latching and some of the other things she said during the intake that she’s wondering if she might’ve done something that could have caused the problems that he’s having now. And I could tell that dad was worried that their child is going to end up like his aunt who is in an institution. So those are the secret unvoiced questions that I think we’re also in the room with us.

Dr. Sharp: Yeah. I love how [00:52:00] you’re highlighting that and calling out white space- all this process piece to the intake. It is so important and easy to forget or maybe not to forget, but hard to operationalize or execute on these harsh terms, but you see what I’m saying. It’s easy to look past and not know what to do with these things.

Dr. Stephanie: I know exactly what you’re saying. We are taught to get the facts. But that old trope of like we’re psychologists first and then assessment psychologists, there is all this other information. And trying to figure out what are some ways that we can use that in what, I think it was Erickson who called it a disciplined subjectivity, how do we gather that data in a way that’s useful and will really [00:53:00] inform the evaluation we’re doing, the recommendations we are making, the reports we’re writing in a systematic way so that I’m not just writing what age he had trouble latching, or when he was diagnosed with OCD. I am telling more of a story that’s helpful to this family.

Dr. Sharp: Right. Let me ask you a procedural question. Would you present these secret questions to a family or are these things you’re keeping in your back pocket for later?

Dr. Stephanie: That was a great question. I’m almost always presenting them obliquely during the feedback. I’m trying to maybe see if I can get them in the room a little bit during the intake. And if the family can do that, that’s often a good sign that the feedback is going to go well. This family, I don’t know you could do that. And that’s a sign that I’m going to have to work a lot harder during the [00:54:00] feedback.

But really what I’m thinking is if I don’t answer these questions, the family won’t be able to hear anything else that I have to say. If I don’t tell them that there is something wrong with their child but we know what it is and what to do with it, and if we do intervene early, we have a good chance that he won’t end up like dad’s aunt. If I don’t tell them they didn’t cause this, if I don’t help them understand, you do have to have different dreams for your child, but that doesn’t mean I’m giving up on dreams altogether. If I don’t answer those, they won’t hear anything else that I say.

Dr. Sharp: Such a great. Let me ask you one more question before we move forward. And that is, I’m guessing people are listening and thinking. That sounds great. I’m not sure if I have those skills. So there’s a little bit of intuition here. There’s some clinical experience. There’s some [00:55:00] training I’m sure. But are there particular resources or strategies or ways that you’ve worked to hone those skills? And if not, that’s okay. You can say, I’m just intuitive. I just do it. And that’s totally okay. But are there any resources that folks may benefit from?

Dr. Stephanie: Let me answer your question in two ways. The first is that anyone who’s listening to this podcast does have these skills already. They have them. I was listening to your interview with, Jordan Ray, and I thought it was funny because he was saying he expects everyone to suck at assessment at first. I go the other way. I think everybody is amazing at assessment at first, and then we build on these layers that make us less effective. And that part of what we need to do is chip away at those a little bit and get back in touch with our natural curiosity and empathy.

[00:56:00] You’re just sitting here listening to a story of a kid who wasn’t even in your office, and I can see that from your facial expressions, part of it is catching your attention. And you’re like, oh, what’s going on there? And it’s grasping your curiosity. So part of it is just getting back in touch with the parts of us that are already great at this because if you have people who are listening to this podcast, they’re interested in the topic and they already are amazing at this, but to give yourself permission to do that, I would recommend looking at the therapeutic assessment literature. , they do a really great job of that.

And then I am absolutely in love with this book called Psychological Testing That Matters, which is by Anthony D. Bram and Mary Jo Peebles, that talks a lot about white space and the conditions under which kids or adults thrive. I’m looking for those during the evaluation. So those are two… When you’re carving your [00:57:00] marble to find the statue of David underneath to make your stuff into the evaluator that you want to be, those are two resources that I think will really give you permission to do that.

Dr. Sharp: Wonderful. Thank you.

Dr. Stephanie: So we’ve gotten through step 1 of my processes. That’s obviously the biggest one. Step 2, we also touched on a little bit. I call step two my preflight checklist, which is where I’m really trying to generate all the possible hypotheses of what this might be. And I’m thinking about all of the base rates of those different hypotheses so that I don’t over-identify with one particular thing. Schizophrenia, for example, is a pretty low-base rate disorder. So I better have really good evidence of that if I’m going to say that that’s what it is as opposed to something like ADHD and anxiety [00:58:00] and depression, all of which are much higher.

Autism that has been undiagnosed until 17 in an individual who is high functioning is an even lower base rate than schizophrenia. So I better have really extraordinary evidence if I’m going to think that it’s that.

This is called taking the outside view. And if you read any of that literature, I know you from one of your… I’m sorry, I sound like a super fan that stocks you on your podcast, …but I know that you talked about The Book Range and how you’ve read that book. And he talks about some of this decision-making research by Philip Tetlock or Daniel Conaman or people like that, where they’re talking about making really good decisions and how you have to start with this outside view where you assume this kid is no different than any kid off the street so that you’re not over-identifying with any particular diagnosis and that you’re thinking about all of your possible options.

[00:59:00] So what I do is I literally just start Googling. I’m like, here are my hypotheses, let me Google what the base rate of these is because I don’t know them all off the top of my head. And then I type in like autism versus psychosis review. And I look for what are the discriminators, what are the things the research shows me best discriminate between these two disorders and how can I look for those during my evaluation?

I’ll include some information about that if people are really interested in that. But just for the sake of time, let me move on to the next step which is thinking about the context of this kid. So this is another thing that gets trained out of us as we learn to become evaluators is we’re all told kids exist in this really rich matrix of family and culture and education [01:00:00] and environment. And we’re supposed to be thinking a lot about those as we’re doing our evaluation, but we don’t usually do it in any way that as you put it sort of that’s operationalized.

So I have this thing that I call my preflight checklist. That’s literally just a checklist of all of the context areas that I need to be thinking about what I know and whether or not that explains or adds to the problem in each of these areas. This is similar to Pamela Hayes. I think her name is Pamela. Pamela Hayes’s ADDRESSING framework, for example, or Daryl Fujii has an ECLECTIC framework .

And I just had my own thing where I think through the physical health of this child, what do I know about how his body responds to stress, his arousal levels, things like that. I’m thinking about the development of this child. What developmental [01:01:00] task is he on or stuck on? How attached is he to his family? Were there any disruptions during development that may be traumatic that help explains what’s going on? And then I think through the culture of this child- is there anything I need to know there, et cetera.

I literally write down, what do I know in this area? Does this explain or add to my understanding of the problem? And then I think, is this child different than his family or what his family expects in this area? And then I also think, is this kid different from me in this area? So that I don’t over or under identify with certain things.

Like I have a tendency as someone who self-identifies as an introvert to think, oh, well, this kid’s just introverted in an extroverted family. Is he? Or is that me over-identifying with something that describes me? [01:02:00] So I just go through that.

Let me highlight one area here that I’m thinking about for this kid. I’m thinking about what developmental task is he on. And I’m thinking he’s really struggling a lot with those tasks of finding his peer group and establishing his own identity. He’s really not doing a lot of, much of anything really, but he’s not driving or dating or showing any sexual interest or showing any interest in getting a job other than becoming famous. So I’m thinking about that.

And what I really noticed is, dad did not have any trouble with this developmental stage. He already had his friends and his whole life planned out for him when he was probably in middle school. And is really puzzled and stuck with how different he is from this kid in this area. So I’m thinking about that [01:03:00] as well as the DSM type differentials that I’m making if, that makes sense.

Dr. Sharp: Great.

Dr. Stephanie: All right. We got to get into the testing.

Dr. Sharp: Let’s start.

Dr. Stephanie: So I’m going to just condense steps 3, 4, and 5. And basically what we’re trying to do in this area is again, to think about the content of the kid, the actual scores that he gets, and also the process of how he responds, his behavioral observations during the testing. I’m thinking about his interaction with me and what that’s like, and I’m thinking about that white space. What does he not do those other kids his age typically do, or that I wish he would have done to make the situation more comfortable or more motivated for me.

So those are the things that I’m thinking about. I’m also trying to refine refute or recontextualize any of my hypotheses. I have like a dozen [01:04:00] at this point. I want to be able to reject 11 of them, if I can. I’ll take rejecting nine of them, right? And then during this stage, I’m looking for repetition of things that seem to keep popping up. I’m looking for convergence- multiple data sources that all point to the same thing. I’m looking for representativeness- how much does this profile look like any particular disorder? And then I’m also looking for singularity. So for example, one of the things that this kid did was a lot of clang associations at neologisms during memory and verbal fluency tasks.

Dr. Sharp: What is the first thing you said?

Dr. Stephanie: Clang associations.

Dr. Sharp: Could you explain that a little bit?

Dr. Stephanie: Yeah. That is when you give a rhyming answer, usually, that’s off-topic. For example, he was listing fruits I think during a fluency task. And he said, cantaloupe and then antelope and then said [01:05:00] cantaloupe, which I think was meant to be kind of like a joke. And at another point, I’m trying to remember another one. At some point he rhymed pantaloons with Spanish doubloons, which is not something that I’ve had a child or any other kid does during testing.

So those are clang associations. And those are pretty singular to some disorders with a psychotic thought process. So I’m looking for those. I don’t have to see very many of those to be concerned. So I don’t necessarily need as much convergence or repetition if I’m seeing those or if I’m seeing a lot of unusual neologisms where the child is making up their own word. That is not necessarily specific to psychosis, but it’s more specific to [01:06:00] psychosis than a lot of other things that I might be seeing.

I tend to, in my testing, follow similar to the matrix consensus battery that’s out there on the areas that I’m wanting to look at that have been shown to be affected in individuals with schizophrenia or individuals who are in an ultra high-risk state. So I’m looking at overall reasoning and problem-solving, processing speed, working memory, verbal learning, social cognition, attention, and vigilance. And then I add in a few things in addition to that.

If people are thinking, where do I even start, start with looking up the matrix consensus cognitive battery and see what you can give in those domains for example. I would also really recommend any of the articles by Fusar-Poli [01:07:00] and colleagues on individuals in the high-risk state. And they have a lot of good information on the cognitive deficits that you can see in this area.

But really my battery doesn’t look that different for individuals who I think of as tricky cases versus regular cases that I might be spending more time on, more personality type measures, and social cognitive type measures than I might on academics, for example, but roughly I’m covering a lot of the same domains. I do add in prodromal-type questionnaires. So in this case, I gave Sasha the prodromal questionnaire, the BRIEF version, which is 16 items. And I’ll include a link to that.

There are a lot of them. You could also use the PRIME or you could use the [01:08:00]Early Psychosis Screener from Columbia University. We’ll include links to all of these if people want to look at them, but really they’re ways to get kids to endorse if they’re having these attenuated positive symptoms. And sometimes you can get it through interviews and sometimes, kids are guarded during the interview and don’t necessarily want to say, or they’re not good reporters or they have so many negative symptoms that they really can’t report. So these are other ways of getting at this same information.

In this case, I gave him, like I said, the prodromal questionnaire. There are 16 items and he endorsed, I think about 7 or 8 of them. And 6 is the cutoff where you get concerned. So he’s endorsing anhedonia, some auditory hallucinations, confusion, anxiety when meeting people, possible.[01:09:00] delusions of reference, possible delusions of grandiosity, some paranoid delusions, things along those lines. He’s endorsing all of those.

And then you can also look at some interview options to get some of the same information. There’s the K-SADS or the SIPS, or some of those things that I know other people have talked about. One thing that I really liked that I haven’t heard anyone mention on your podcasts is just, I think his first name is James Morrison’s book, The First Interview. He has some nice interview questions if you don’t interview around this a lot; how to interview around seeing or hearing things that you haven’t seen that the other people can’t see or hear, tasting or smelling things.

And then if they say, yes, he has some other questions. Like how lifelike are the voices? Do they sound as real as my voice is [01:10:00] right now? When did you start hearing them? Sometimes I like to ask, if I met you in 5th grade, would the voice be there? How often are they occurring things along those lines? So that’s a good resource that you could pick up a used copy of Amazon if you’re wondering about what questions can I ask if the questions in K-SADS seem a little abrupt to you.

Dr. Sharp: I got you. Nice. Yeah. And this will be extensive show notes for this episode. I’m putting all these things in there, so don’t worry folks about remembering all these things. There’ll be links.

Dr. Stephanie: Perfect. And then, of course, I’m also looking for negative symptoms as well as positive symptoms but there are not as many ways to get at those. You can do something like the PANSS, the positive and negative symptoms of schizophrenia, I think it’s called or the [01:11:00] scale of prodromal symptoms where they’re clinician-rated and you’re looking for these things. I do it a little bit more informally and I follow the CAMPS Model.

I call it the CAMPS Model. I don’t think the authors call it that, but I’m looking for problems and communication. Problems in an affect or emotional expressiveness. Problems with motivation, psychomotor problems, and social problems. And so those are some of the things that I’m looking for. And Sasha definitely had a lot of these. He was talkative, but there was what’s called poverty in the content of his speech. His speech was vague, it was disconnected, it was overly generalized. It was hard to understand what he was saying. The same thing that his parents and therapist had called out.

He also had started this blunted effect, not a lot of spontaneous movement during social interactions, not being able to describe his emotions. I asked [01:12:00] him if he could demonstrate what it looks like to feel happy and sad, and he could not do either in a way that seemed comfortable. Also a lot of reduced initiation. During the interview, he definitely reported he is not interested in dating or sex or activities of self-care. It showers grudgingly with a lot of prompting.

Physically, he was dressed a bit oddly. He was wearing multiple shirts to look disheveled. I did see some gazing blankly in no particular direction, which is often considered a psychomotor sign. And definitely, some psychomotor slowing both qualitatively but also on standardized things like the group pegboard or things like that. And mostly he just appeared odd. It was just odd to interact with him.

So [01:13:00] that’s what I do as I’m thinking about negative symptoms. I actually have just written them down on a piece of paper. I keep notes in each of those areas if this is one of the things that I’m thinking about. Obviously, a lot of those overlap with some other disorders as well.

And then I gave him an extensive battery of testing, and let’s just hit the highlights. Overall, IQ is a 95, which I think is well below what my estimate of his premorbid functioning would be. I did the RIAS with him. It looks like I did the first edition, so this must have been a while ago. And he really liked actually that. There was a lot of structure to it. So part of what I’m getting as well is not just the test score, but when he does best. He seemed to do best with those really familiar verbal questions.

It was very slow on the [01:14:00] non-verbal questions where you pick an answer. So I scored it on timed. I didn’t penalize him if he didn’t give me an answer in 20 seconds because he couldn’t. He did seem very internally distracted during this. He kept referring to me as she, as opposed to you. So I noticed some pronoun slips during that. He also had some… I did not wear lipstick, but I accidentally had a scratch on my face and he kept asking me if his face was red, like staring at the scratch and asking if his face was red. And that seemed to distract him during that task.

But overall, he was able to get a score in the broad average range, just, I think a lot lower than what his parents led me to believe might be the case based on his premorbid functioning.

Tests of [01:15:00] processing speed and working memory were in the low average range around about the 10th percentile. He liked doing the CPT. Most kids hate that, but he seemed to enjoy the structure of that. He had seven atypical scores, but they were all low atypical, T scores in the low 60s. Obviously, attention is not great. Comprehensive trails, he got a T score in the first percentile. I told you a little bit about verbal fluency and how there are a lot of set losses and clang associations during that task. And he didn’t do that well on it.

The other thing I did after the D-KEFS was 20 questions and it was the most interesting 20 questions that I’ve ever done. He was trying to guess based on what he could tell about me, what choice I would pick out of the options. So he was trying to read me to see what choice I [01:16:00] might make based on what he could read. He was also very paranoid about what I was writing down. And he only got two of the categories, but he was also guessing things that were not on the page. So I did not score it because I don’t even know if he understood the task. I also didn’t score the Tower of London because the first two items, which are relatively simple, he could not do within the 20 moves. So we discontinued that.

But there is some evidence that individuals with psychosis might be better able to do something that involves immediate feedback, like the Wisconsin card sort. So I don’t always give that, but I pulled that out for this kid and he did get all six categories and he got a standard score, the broad average range on that task. So he is showing better skills when he gets immediate feedback. But when things are unstructured, he rarely couldn’t do them.

Your viewers [01:17:00] won’t be able to see this, but I’m going to show you what he did for the Rey if you ever give the Rey.

Dr. Sharp: Yes.

Dr. Stephanie: Well, how would you describe that?

Dr. Sharp: I would describe that as an abstract mouse that is injured and two ways. I’m reaching here.

Dr. Stephanie: I think that’s a great description. You can see the slash mark with the five hash marks. You can see the O with the dots. So you could see portions of it, but a mouse that’s abstract and has been injured is a good description. So we didn’t score that either. And you could see, he also wrote some notes to me on there, but it’s unreadable.

Dr. Sharp: Was that the copy by the way?

Dr. Stephanie: That was the copy. We didn’t do anything else. I’ve made [01:18:00] a copy of this copy, so it’s not in color, but yeah, that’s the drawing there.

Other things that were intact for him, the Boston Naming Test was fine. So he did okay on that, but he did make odd errors. I won’t give away any item content, but there are a lot of musical instruments on there. And one of the musical instruments that he didn’t know, he said, is that the box that you keep your trophies in? I don’t even know what he might have been seeing at that moment.

So those are the types of singular responses that you’re looking for. Obviously, I don’t want to make a diagnosis just based on that, but it goes in the category of like I’m getting this across multiple tests that he is struggling with.

Regular verbal, memory for stories was okay. Nonverbal memories were not, but list learning was terrible. 1st [01:19:00] percentile on the CVLT-3. Intrusions set losses, neologisms, more clang associations just really couldn’t do that task, but he did fine on the TOMM. So validity was okay. It wasn’t great, but he passed on that.

The PEGS really serious psychomotor slowing. I have standard scores here in the 30s. So several Z scores are below average. It’s not good. The VMI also just even basic drawing was a little too hard for him. I also did the ADOS with him. Obviously, his therapist is concerned about autism and so it was already part of my battery, but I actually really like getting to the ADOS individuals with psychosis.

They will score above the cutoff based on the research and my clinical experience. But [01:20:00] if you give the ADOS alot, anything that kids do that’s unusual really stands out because it is a semi-structured observation. So getting information about the form and quality and function of his social interaction skills, is a nice way to gather some observations. He absolutely scored above the cutoff. His total raw score is a 14, which is well about the cutoff.

But what I’m thinking about here is what didn’t he do that I wish that he had? What’s some of that white space that was missing? Or what did he do that was really unusual? And those are the kinds of things that I’m trying to think about that helped me in my mind. Mostly they just helped me feel really comfortable with my diagnosis. This is a heavy diagnosis to be making. So as many data points as I have that make me feel good about the more comfortable [01:21:00] that I am, the more comfortable the feedback will be. So that’s part of what I’m doing in this area.

Dr. Sharp: I think that people will probably be wondering about this. Are there any examples from the ADOS that you can recall or that you may have recorded that stood out to you as atypical, based on your experience?

Dr. Stephanie: So things that he did that were noticeable were, I saw a little bit of thought blocking. He would start to respond and then seemed to have to stop like something else was stopping him. So that’s not necessarily associated with autism in any way, that would be a symptom. And that really stood out.

In general, initiation was really hard for him. So he would respond to my overachievers, but there was this long latency before he would respond. And then the [01:22:00] quality of them was blunted and flat, which is not necessarily diagnostic, but also just odd in ways that are, again, you have to just give the ADOS to know but he just didn’t really seem to understand what I was asking. His responses would contain a lot of words once he got started, but I couldn’t tell, does he know what it means to be a friend? Does he know what it feels like inside to be happy? It wasn’t just that he couldn’t explain his own experience. It’s that I couldn’t even understand what he was trying to explain.

Those are some of the things that stood out for me.

Dr. Sharp: Thanks, yeah.

Dr. Stephanie: I did a lot of parent and self-report questionnaires. He was pretty good at filling out questionnaires for me. [01:23:00] Sometimes kids are not able to in the state or sometimes they don’t want to, or they’re guarded. He reported all of the things that you might expect. So when we look at the BASC, the BRIEF, and the SRS that the parents filled out, they’re all elevated for most things. His atypicality score on the BASC is a 90, T score somatization is an 88, and sense of inadequacy is an 89. So those are some of the things that he’s recording.

I gave him the CMOCS as a questionnaire for OCD and there weren’t any elevations on that. So he’s not just reporting anything. He endorsed some things on the CMOCS but not the type of specific obsessions and compulsions that that asks for. I also gave him the MMPI-A which he was able to fill out high elevations on scales [01:24:00] 8, 7, 6, and 1. The thought disorder T score is a 91. So even if you’re not familiar with the MMPI at all, that probably stands out as a very high T score on a thought disorders index.

The other thing I really liked doing with kids like this just to be really comfortable with my diagnosis is storytelling-type tasks. And so I did the Thematic Apperception Test with him. I am in no way doing it diagnostically. I’m not really trying to hang a diagnosis on how the individual responds to the TAT. What I’m doing is gathering hypothesis information here.

I’m trying to see what type of themes stand out, but I’m also getting a good language sample. I’m getting a sample of how organized [01:25:00] this individual is. I’m getting a sample of what they do with something really ambiguous with something emotionally activating. And I’m trying to compare that to other things that were emotionally activating or unstructured. And to the opposite to things that were less emotionally activating and more structured, like the RIAS verbal subtests or the Boston Naming Tests, or the Wisconsin, where he was able to use that structure to do well in those areas.

I just thought, I’d tell you one of his TAT stories, just so you can get a sense of it if that sounds all right.

Dr. Sharp: Yes.

Dr. Stephanie: If you’re familiar at all with the TAT, this is just card one. There was a very long latency to get started, but once he got started, he was able to give me a good response. He said, Tommy is a very religious boy and he’s praying over his violin. It’s the soul of his father who used to kill people with [01:26:00] violin wire in the gang lord style. Tommy is praying over it.

He never really liked the violin. He liked the piano. An image appears before him. It’s not a God. It’s not his God’s brother. It’s someone who said, avenge your father. He was killed unjustly and Tommy knows exactly what to do. So he plays a verse. He tries to play the violin, but it makes no noise. And he said, “This should work.” So he goes to a psychic and asks him why the violin is not working. And the psychic says, “Go to the mountains. It’s your true calling.” And he dies climbing up the mountain.

And then he paused for a very long time. And he said the moral is, don’t try to follow in your father’s footsteps. Be your own man. Otherwise, you’ll die trying. I didn’t ask him for a moral, obviously, that’s not part of the task, but he added one. He did for all of his stories.

So you can see that the content is somewhat unusual. [01:27:00] The organization of it is unusual. The response to the card, that’s not the story. That’s doesn’t really necessarily match with what’s in the story, or at least not how most people respond to it. And there are also just parts where the grammar, or just following what he’s trying to say is difficult. And this is just one story, he told a lot like this, that helps me feel more confident in my diagnosis.

One of the differentials between kids with autism and kids with psychosis, for example, is that kids with psychosis tend to tell otter stories. And this would be an example of that. This isn’t just you can’t tell what the people are feeling. This is an odd interpretation of the story. Would you agree?

Dr. Sharp: Yeah. I would agree with that, Stephanie. Yes.

Dr. Stephanie: And then for some reason I did [01:28:00] a tiny bit of academic testing with him as well. So I don’t remember why. Basic reading and spelling were fine there are almost exactly average 101 and 99, and calculation is poor probably due to limited persistence. So that’s the testing data that I have on him.

And then what I’m trying to do to wrap it all up is, first I’m really checking myself for cognitive bias. I want to make sure that I am thinking this through really clearly. So just like I did with my preflight checklist, I also have this post-flight checklist where I go through all the various cognitive biases that I could be making, and think through is that what’s happening here.

So a really common one, for example, would be the effective error where we want really good things for our patients and we don’t want them to have schizophrenia. So am [01:29:00] I unwilling to diagnose schizophrenia because I don’t want him to have it. I think that’s a really important thing for us to be thinking about as we’re doing that. So then I do my post-flight checklist.

And then I think at this point, my case conceptualization feels pretty clear to me in the sense that this feels like psychosis.

I feel like I have ruled out other explanations for what might be going on. This is beyond what we would expect for the diagnosis he currently has. It’s beyond what we would expect for OCD. He’s on paper meets the criteria for autism, but that does not in any way fully explain some of the concerns that we’re having. We’ve looked at the anxiety and depression and try to see, are they [01:30:00] more primary or are they more secondary to how confused and worried he is about these experiences that he’s having?

So I feel reasonably confident in my diagnosis at this point of psychosis. And usually, I don’t really define it too much beyond that. I don’t necessarily unless the child is, I sometimes see young adults and they clearly meet the criteria for schizophrenia and maybe had acute onset and clearly, it’s easier to make the call. At this point, I know that parents are going to have a strong reaction to the word schizophrenia. And I also just want to hold onto the idea that I am trying to make a diagnosis of something that is emerging and that is understudied and that we don’t necessarily know a lot about.

We do know that some individuals only [01:31:00] have one episode of psychosis and go on to recover, others have a more fluctuating course, others it will get progressively worse. I don’t know what’s going to happen to this young man. I also don’t know if it’s associated necessarily with maybe a mood component to it really. So I don’t really try to identify it much beyond this is clearly a psychosis and we clearly need to set up a plan to help his parents understand what’s happening to him, help him understand what’s happening, and then help move him in a direction that’s positive.

Dr. Sharp: Can I ask a question there? I think that’s something to dig into a little bit just in, I think a lot of us have either been trained or just philosophically appreciate the clarity or perceived clarity that comes from a specific diagnosis. [01:32:00] I’m guessing, people are like, well, how do you do that? How do you just say it’s generally psychosis versus something a little more specific. Which for me begs the question…

Then the follow-up question is, well, as long as he’s getting the right treatment and then the follow-up, or that’s not a question, that’s a statement. But then the follow-up question to that is, well, does treatment matter if it’s bipolar with psychotic features versus Schizoaffective disorder versus depression with mood-congruent psychotic features? Is that going to make much difference? So that’s a lot of questions wrapped up in one.

Dr. Stephanie: Right. And those are the questions we’re all asking ourselves. And we’re all going to end up in a slightly different place in how we do that because there is no perfect answer for that. What I have found in following individuals over time and in having psychosis in my own family is, you can look at a child or an adult for years [01:33:00] and still not be able to answer the question of what exactly is this. There’s discussion in the research of does Schizoaffective disorder has, does it stands up at all as something?

The genetic risk that comes from bipolar disorder also contribute to the risk for schizophrenia. So how separate are those? And can you really separate out schizophrenia with depression and anxiety because your life is being disrupted or is it a part and parcel of the diagnosis?

So trying to separate out all of that, for me, isn’t as helpful in making a treatment plan. I don’t necessarily right now need to respond to insurance pressures. So part of it is I just can call it psychosis at this point. [01:34:00] And you may not be able to be at the setting that you’re at. But in terms of your question of treatment, we do know that if it is something more like Schizoaffective or bipolar with psychotic features you are likely to have a better outcome than if it doesn’t have a mood component, which is the opposite of what you might intuitively think.

But in terms of the recommendations, it doesn’t really make a difference. We know trying to figure out people who are at what they called a clinical high risk for psychosis versus what they call bias brief intermittent psychotic symptoms versus what they call the attenuated psychotic symptoms syndrome versus genetic risk plus deterioration versus schizophrenia form versus schizotypical versus schizophrenia. That for me is something that we can watch over time and try and figure out what this [01:35:00] kid, as the family processes this information, but what the kid, what Sasha needs to know about himself, and what the case family needs to know in general is that this is psychosis. We know what it is, it’s treatable or at least manageable. We have a plan and we understand what’s happening. So that’s sort of where I land on that.

Dr. Sharp: Yeah. That makes sense. I wonder then if that’s maybe a nice segue just briefly to what you recommended and how you presented this to them.

Dr. Stephanie: Yeah. So there are two good models out there in the literature of ways that you could do feedback. The CEDAR clinic, for example, has one that you can find. I also really liked the work of Johnstone, who’s a neurologist who gives really difficult feedback cause he tells people that they have functional disorders and that it’s not medical. It’s not at all about schizophrenia, but it’s very difficult feedback.

[01:36:00] He has a great model that he uses. His model is, you explain what they have, you educate them about what they do not have, you listen for and address their fears, you emphasize that this is a common and treatable problem. You hold hope for the family and you emphasize the potential for recovery, and then you direct them to specific resources and materials. So that’s one model that you can use.

I use a pretty similar model myself. I start by asking if the family can come in. In this case, it was pre-COVID. So they could come into my office. I could make them a cup of tea. I could check in on what their experience was like. I can get them to agree with me about something so we’re in a positive frame of mind. I could be thinking about their secret questions that they have, but then I solicit their invitation to give them the test results, which is from the SPIKES protocol about giving [01:37:00] bad medical news, where they’ve shown in medicine that if you ask, if you can share the information, you get more buy-in and you help the family realize this is a dialogue.

And so then I say, Sasha has a condition called psychosis. I explain what that means in the family’s language. I try and use the words that they used if they can. I try and say, you thought his thinking is a little off and you’re exactly right. That’s exactly what psychosis is. I try and answer their secret questions secretly at this point. So I say you didn’t cause this, for example. I say, he’s not making these things up. He’s not saying them for attention. He’s not trying to lie or steal for example.

Then I talk about the things that Sasha can do and the things that he’ll have more trouble doing. So I say, in this case often when I’m saying what the child can do. I’m talking about strengths. Sasha doesn’t have a lot of them [01:38:00] right now. He’s really struggling. So what I focus on is that he can do things to manage his symptoms. He can build his resilience, he can build his coping skills, he can build good relationships that will help him through this illness. And then I talk about what he will need or what he’ll struggle with, which is to help manage his symptoms.

And then I try and put together a plan and I try and keep it a three things. Sometimes I sneak, as you could tell extra things into my numbered system. But I try and say, we’re just going to do three things. Often those three things are, first, we need to make sure he’s medically healthy. So let’s share this with his pediatrician. Let’s get him on the right medication. Let’s see if we need any further medical workup. Let’s get him exercising, eating well, let’s get a sleep schedule regulated.

The second thing is usually setting up his support team. So we got to get the school on board. We need the psychiatrist and the [01:39:00] therapist talking to each other. I try and write down names for them if they don’t have resources so that it’s written down, that they could take it away with them.

And then the third thing is usually, well, I should say the thing I sneak in is a part of the support team is making sure that parents have support so that they’re aware that their child is counting on them to manage themselves through this difficult time. And during this, I’m trying to help them understand that part of their work is going to be having a place where they can grieve and where they can change their dreams that they might’ve had for him as they might need to, and that that’s going to be really important to his treatment and recovery.

And then the third thing in my plan is usually making sure that Sasha knows what’s happening to him. I almost always have teenagers come back and explain to them what psychosis is and what’s happening, and that it’s treatable and that we [01:40:00] can put this together. And then I check in with how they’re feeling about it. I make sure they know that we’re holding up that he can manage these symptoms and that some recovery may be a possible outcome for him, and that this will change his life, but he can still have a meaningful important valuable life. And that I’m making sure that they know that this is an open dialogue and that they can ask me any questions.

I try to invite them right then, but often that’s a lot. We’re usually all crying at this point. So I also make sure that we know that this is not going to be our only conversation. And I try and have the kid come in within the week. And then the parents come in again a week or two later so that they can ask the questions that they’ve had time to think about at that point.

Dr. Sharp: Yeah. That’s heavy.

Dr. Stephanie: It’s really heavy. [01:41:00] One of the things that I get asked a lot is, is there anything that I can do to prepare to give this news? And what I often talk to people who ask that question about is understanding that psychosis really is common and that it really is treatable. And that we do have some medications that can help manage it or help make it less of a concern. If possible, getting some experience with individuals with psychosis.

I mentioned I happen to have it in my family, so I know in my bones that people with psychosis can have meaningful fulfilling lives. Lives that maybe we’ll not always necessarily envision as our dream for our child, but lives that are rich and rewarding and meaningful. And so really knowing that and being able to hold on to that dream while you’re [01:42:00] giving the feedback, I think helps make that conversation a little bit less heavy. But you are giving bad news. So if you’re laughing and having a good time during these feedbacks, you might want to check if that’s really right.

Dr. Sharp: Fair enough. Check your own odd behavior in those situations.

Dr. Stephanie: Exactly. And I will tell you, we all react to discomfort differently. So I was slightly joking in that way, but you do find yourself in a lot of discomfort and distress during these. So checking in with your peer consult group, checking in with someone who has a lot of experience in this area, talking to a friend. This is hard. And there’s also just that Pull. You want to downplay it. I can feel myself doing it right now. I’m saying like [01:43:00] you can get better and it’s true you can get a little bit better, but this is a lifelong disorder that comes with significant cognitive deterioration in most cases.

So there is that pull that we want to minimize or soft puddle or react in an odd way. So you also have to just give yourself some grace that your feedback may not be exactly what you wanted, but what the family will remember is that you were there with them during these hard times.

Dr. Sharp: Yeah. I think that’s such a good point to focus on- sitting with them. Ultimately, that’s what it’s about. We have this information to share and we’re going to do a great job with that. And I just think back to, I think it was Karen Postal, maybe who said, the feedback can often be just making space for grief- [01:44:00] what families are giving up and the life that they may have envisioned for their kid and adjusting expectations and the loss of some of those things. So I think that’s been a nice theme.

Dr. Stephanie: Exactly.

Dr. Sharp: Yeah. That’s been a nice theme throughout your presentation here is just the humanity in this process. We are psychologists first and in your case, neuropsychologists second, right? So just keep it in mind.

Dr. Stephanie: Or third or fourth.

Dr. Sharp: Right. So not burying those people’s skills; ability to just sit and honor someone’s experience.

Well, this is personally speaking, pretty incredible. I really appreciate you coming through and just doing such a thorough presentation on something that is really challenging for a lot of us as [01:45:00] clinicians. I’m guessing that people are going to take a lot away from this. So huge thanks, first of all.

Dr. Stephanie: Thanks for the opportunity.

Dr. Sharp: Yeah. Well, I want to make sure to highlight it too… Oh, go ahead.

Dr. Stephanie: I wanted to say, I love hearing other people’s case presentations and getting a glimpse of how other people work and how they think through things. And no matter who it is, I always learn something or take away something or jot down some notes. So I love that you’re going to be maybe doing some of these that people can borrow and learn from something we don’t always get to see our peers do.

Dr. Sharp: Absolutely. Yeah. That’s really the intent. I think once we get into private practice and get on our own, and for a lot of us, we turned into the supervisor, and then it gets tough to get this experience where someone else’s presenting in a masterful [01:46:00] way.  So, I think it’s going to be valuable for folks.

And I also, of course, want to highlight, you mentioned consulting a few times during the presentation that that is absolutely something that you can do, is this clinical consultation piece with folks who have tricky cases. I’ll make sure to put the link to your website, the Peer Consult, in the show notes. I’m just thankful that you are out there for those services.

Dr. Stephanie: Thanks so much. The consultation has been just the most rewarding experience. I feel almost like I’m cheating because I almost learned as much from the people who consult with me. I think it’s just fascinating to do such rewarding work. I am saying that now because as you were talking to me, I was nodding and then I was realizing, oh, people can’t see me nod, but yes, I do consultation. And it’s [01:47:00] so wonderful. So if anybody wants to know more about that or find out if it’s right for them or anything like that, please let them shoot me an email or give me a call, or whatever works for them.

Dr. Sharp: Sure. All right. Well, I will say goodbye for now Stephanie. I really appreciate it.

Hey everyone. Thank you so much for tuning into this masterclass with Dr. Stephanie Nelson all about the differential diagnosis of psychosis. This was a brand new podcast format. I would love to get some feedback from you. Please let me know if you enjoyed the episode, if you did not enjoy the episode, thoughts, suggestions, et cetera. I would love to hear that. You can reach me at jeremy@thetestingpsychologist.com or you can simply leave comments on the episode webpage, which will be linked in the show notes.

If you have not subscribed to the podcast, I would love for you to do that, of course. [01:48:00] Related to that, if you have a moment to give a quick rating, if you find the podcast helpful, I would be very appreciative. So you can do that easily in the podcast app that you are listening to. Apple was particularly easy. Others, you might have to search for it a bit, but I would be very grateful for any feedback or rating, or review that you might be willing to leave.

Again, thank you so much for listening. I will be back next Thursday with a business episode. I hope you’re all doing well. Thanks. Take care.

The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this [01:49:00] podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and the listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.