Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and Psychosis

Описание: Subtle psychosis interview skills: how to detect psychosis early using countertransference, empathic mirroring, and focused clarification. Learn what to ask about delusions, paranoia, and voice hearing, including an OLDCARTS-style history.
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0:00 Intro And Sullivan Quote
1:12 Spotting Subtle Psychosis
2:10 Countertransference As A Clue
8:02 Sitting With The Patient
14:21 Handling Delusions Skillfully
21:01 How To Assess Voices
27:53 Bridging Treatment Disagreements
30:05 First Steps In Treatment

Subtle psychosis interview skills: how to detect early psychosis without blowing up rapport.

If psychosis is obvious, the interview is easy. The harder problem is the quiet, guarded patient where something feels “off,” but you can’t yet name it. In this episode we lay out a practical approach to detecting psychosis early by using your internal signal, staying inside the patient’s narrative, and asking cleaner questions.

What to notice first

Countertransference as a cue: uncanny, confusion, frustration, a “pit in the stomach,” a cold body, a sense of danger.

Treat that reaction as a signal to slow down and explore, not a diagnosis.

How to clarify without derailing
Clarification is powerful, but it’s easy to accidentally diverge from the patient’s narrative. We show how to “stay with the story” long enough to understand it.

“Tell me more.” “What happened next?”

If the conversation drifts, return gently: “I hear that, but go back to the neighbor piece.”

How to talk about delusions and paranoia
A useful stance is: don’t argue, don’t agree. Instead, mirror the emotional impact and clarify the details.

“That sounds terrifying.” (emotion)

“Walk me through what happened first.” (sequence)

“What do you think is causing it, and why?” (meaning)

“Do you think the experience is real, and what makes you think that?” (reality testing)

Alliance tricks for paranoid patients
We discuss a Sullivan-inspired idea: sit “alongside” the patient psychologically, looking outward together, so you don’t become the persecutor in the room. The goal is to externalize the threat, reduce guardedness, and gather better data.

Voice hearing history, made concrete
We adapt an OLDCARTS-style framework to voice hearing: onset, location (inside vs outside), duration, character, aggravating factors, associated symptoms, and timing. We also explain why it helps to ask the “why” more than once, given stigma and mistrust.

Next steps after you detect it
Once you have a clearer picture, you can bridge the treatment gap by starting with the patient’s problems (sleep, fear, stress, disorganization, staying out of the hospital) and connecting those to a plan. Outpatient psychosis is not always an emergency, so alliance and history can be the first intervention. When meds are indicated, we cover early principles like choosing weight-sparing antipsychotics when possible and screening for subjective akathisia and other EPS.

This content is for education and entertainment only and is not medical advice.

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