Understanding Delusions Leading to Violence: Types, Assessment, AI Risks & Treatment in Forensic Psychiatry

In this episode, Dr. David Puder is joined by forensic psychiatrist Dr. Michael Cummings, who has spent his career at the world's largest forensic state hospital, and child psychiatrist Dr. Blaire Heath, to examine how fixed false beliefs, or delusions, can lead to aggression and violence. Each guest brings their expertise to discuss the major delusion types most associated with harm in forensic settings, including persecutory, Capgras (impostor syndrome involving loved ones), Cotard's ("I am dead"), erotomanic, jealous (Othello syndrome), somatic, and referential delusions. The episode covers practical clinical tools, including the Simple Delusional Syndrome Scale and Brown Assessment of Beliefs Scale, the role of clozapine in reducing violence risk, and the use of cognitive behavioral therapy to create psychological "escape routes" by treating delusions as testable hypotheses. Modern risks are also addressed, including how AI chatbots and algorithms can reinforce and amplify delusional thinking and contribute to emerging cases of AI-related psychosis. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-261-understanding-delusions-leading-to-violence-types-assessment-ai-risks-amp-treatment-in-forensic-psychiatry Link to YouTube video https://youtu.be/OsghkbgC3L8

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back to the podcast. I am going to introduce this podcast before we get started. We're going to have a great conversation on delusions, which are fixed, false beliefs that sometimes lead to aggression and violence. I have two guests who will be helping me articulate and deepen our understanding of this, both working with patients who acted upon their paranoid delusions, or different types of delusions, which led to an arrest. Dr. Cummings has spent his whole life working in the largest forensic state hospital in the world. He is a known expert who has been on multiple episodes prior. It will be great to have him back.

• 0:58David Puder?

  And Blair Heath, a child psychiatrist, who has a unique background as both a pharmacist and a nutritionist, who was mentored by Dr. Cummings for the last eight years, will also be with us. She was a former resident of mine, a true lifelong learner, and deeply invested in understanding and how to help this population.

• 1:25David Puder?

  I have an idea, I have a new idea I would like to propose, which I don't think I've ever heard in line with this type of conversation. It came to me last night as I was laying in bed. And before posting this episode, I thought I might record this, and it might help us understand and how to make sense of delusions and psychosis, and how they lead to violence. The idea actually came from a book of mine. I'm showing the book on YouTube here. It's called The Art of War by Sun Tzu. And he wrote about this idea of death ground.

• 2:07David Puder?

  So there was nine different types of geographic environments that he described, nine varieties of ground, and he talked about death ground. And in death ground, also called, in other translations, desperate ground, fatal ground, ground of death. It's the most extreme terrain that armies can find no escape. And therefore, the army survives only if it fights with the courage of desperation, the courage that comes from desperation. And he wrote, "Throw the troops into a position from which there is no escape, and even when faced with death, they will not flee.

• 2:52David Puder?

  For if prepared to die, what can they not achieve? Then officers and men together put forth their utmost efforts. In a desperate situation, they fear nothing. When there is no way out, they stand firm. Deep in hostile land, they're bound together. And there, there is no alternative. They will engage the enemy in hand-to-hand combat." And so, death ground is a place where, when your army is either deep in enemy territory or it is surrounded on all sides,

• 3:35David Puder?

  soldiers will ignite with a new courage that they may not have access to without being on death ground. And so, Sun Tzu explicitly advised his people who followed him to put their own troops in death ground. For example, with their backs to a river or deep in enemy territory without the ability to psychologically retreat. And if you can connect this to delusions already, you might be thinking like I am. But if not, I will further explain.

• 4:14David Puder?

  So he also wrote, "To not force the enemy into death ground." Like to not fully encircle an army that you're fighting against, leave a path out for people to retreat. So the basic idea of death ground is when you remove all path of safety, humans' survival capacity overrides any hesitation of fear and creates superhuman efforts. Leaders have subsequently used this. Hernan Cortez burned his ships in Mexico to eliminate any possible retreat for his

• 4:57David Puder?

  men, forcing his men to continue their conquest into Aztec, into the Aztec Empire. Geographically, this has been imposed in some of the most famous battles, like the 300 Spartans, Thermopylae, 400 AD BC. They were able to hold a narrow pass. There was no escape, right? Because of the geography of it. Also, you could think of allied forces during D-Day, 1944. There was no ability to escape because the sea was at their backs. They had to fight with life or death ferocity. So I also was thinking, this will be a small tangent, I promise, but you can imagine Iran

• 5:41David Puder?

  currently being considered in a death ground. And news articles, actually, I looked up, have even highlighted this. One news article pointed out that Iran is now on a death ground amid existential threat from the US attacks and could go big in retaliation. I also wonder if China, with 20% of their oil supply, coming from Venezuela and Iran, is in some way in its own death ground, or maybe the pressure is increasing. I also think about how Epstein's emails have put some of his prior clients on a sort of death ground publicly. And if further emails are released, maybe more incriminating emails that they don't

• 6:26David Puder?

  want to release, or maybe emails that they have blacked out for various reasons, it could put many very, very wealthy people who did horrific things on a sort of psychological death ground. Now, shifting to delusions and the link to death ground. Think about persecutory delusions, okay? Here you have an imminent threat, a threat of an omnipresent, invisible. Maybe they're being spied on, right? From all sorts of ways, maybe the CIA is following them. There is no place to run, no place to hide. Do you see how that could be kind of a death ground of sorts?

• 7:11David Puder?

  And violence could become the only survival option to defend themselves, their family, the world. They feel completely psychologically cornered. Likewise, you could think about cap grass, cap grass delusion, where your family is replaced by identical looking imposters, doubles, maybe even demons. Maybe also, if you mix that with some paranoia, they're these demon impostor look-alikes are conspiring against you. And we're going to be talking about this in the podcast, but imagine if the only way to get the real ones back was by taking out the replacements.

• 7:55David Puder?

  You could see how this kind of becomes a sort of a death ground internally, psychologically in their mind. We're going to, we'll talk about the Cotard delusion. This is where a person believes they're dead and therefore there may be nothing to lose. We're going to talk about erotomania or jealous delusions, maybe without love of a particular person. If the person puts up some sort of restraining order, it becomes, the erotomania turns to anger. Maybe they turn into a sort of a death ground with like this fear of annihilation if they don't receive the love from a particular object.

• 8:38David Puder?

  We'll also mention AI, modern AI chatbots, algorithms, how they could be death ground amplifiers. We won't say death ground in the podcast. This is something I've thought about since. But imagine them as death ground amplifiers, as sycophantically amplifying delusions, giving confirmatory bias, acting as confirmatory evidence, increasing bias. And therefore, this feeling of not being able to escape is amplified. I remember watching a man on YouTube, I talked about this in our episode on AI psychosis, where he was interacting with the chatbot and the chatbot was confirming his delusions.

• 9:19David Puder?

  The garbage truck could be, very much could be, some government agency, right? Or some hostile intruder. So in death ground, there is no safe retreat. And likewise, in the danger that delusions, the fixed false beliefs give a person, there can be this feeling of no safe retreat. And their preemptive strikes can be a way of survival. And that's where violence can happen, right? Treatment therefore can be framed with the thought that we need to not create death ground situations for patients that are struggling with this.

• 10:02David Puder?

  We need to create psychological outs, right? Just like Sun Tzu said, leave an outlet for the enemy to retreat. We as clinicians give an opportunity for a pathway to adore, right? We don't want to have them feel cornered in a room. We may give them an antipsychotic to reduce preoccupation and compulsion.

• 10:31David Puder?

  Uh, likelihood of violence, we know that clozapine decreases risk of violence as well. Cognitive behavioral therapy can create cognitive space for treating beliefs as testable hypothesis. You know, we want to create some room to consider if some of the things that are deeply entrenchedly believed are true. And so cognitive behavioral therapy can do that. So hopefully you enjoyed this linkage to ancient literature, Sun Tzu,

• 11:11David Puder?

  the art of war, and this idea of death ground. And hopefully this can kind of give you a way, a perspective of looking at this episode. And with no further ado, let the episode begin. Blair, how would you like to introduce the topic?

• 11:27Speaker 01

  Well, I worked at Patton a long time ago, and I think some of the really interesting cases of Capgras syndrome, and then more recently at the Department of Corrections, seeing risk for assaults and seeing how much delusions, paranoia play into that. It seemed like an interesting, important topic. And I know I've talked with Dr. Cummings, I definitely want him to chime in, but it seemed like a bigger topic now that I'm seeing it more on a day to day and the real risk it can pose.

• 11:55David Puder?

  Yeah. So there was something that happened in the

• 11:58Speaker 01

  Yeah. Yeah. Well, there, there's been definitely, there was some issues recently, but I think Dr. Cummings can also say that this even working at Patton, a lot of our patients are actually incarcerated because of delusions and paranoia and, you know, hallucinations too that they had that they acted out of. So, I mean, there's been some recent stuff with staff, but also a lot of their family members, they Dr. Cummings again can jump in. Even at Penn, they still, even with clozapine and extensive, they still are having certain types of delusions of their family being aliens or clones that they actually may have killed, waiting for the real ones to come back. And so we have really severe,

• 12:42Speaker 01

  often on family members, but even we'll see it transferred to staff and they're being continuing delusions, which may not even realize because they're quiet. People don't always talk when they're paranoid. And then they may act out of their belief they're being poisoned with their food, or this person is trying to control them. And so it's something that has really been coming more, since I've come back to the Department of Corrections, has really, I think, made an impact. Dr. Cummings, do you want to speak at all?

• 13:10Speaker 02

  Yeah, basically, Blair is exactly right. In forensic settings, there is a very strong bias for people to wind up in either state hospitals or prisons due to positive psychotic symptoms. And certainly, one of the most common scenarios in that regard is that people are experiencing persecutory ideation, believing that others are harming them in some way. And they therefore feel justified in acting violently toward the person. That's in contrast to more general functioning in the community, where actually negative symptoms and cognitive deficits are more impairing with

• 13:55Speaker 02

  respect to function. But in forensic settings, it's more often the positive persecutory delusional systems that get people in trouble with the law.

• 14:07David Puder?

  Okay, so maybe we should back up a little bit and just talk about like how we rate delusions, how we think about it. I know, Blair, you had written down some notes on like some ways of instruments, asking about this. Do you want to take us through that briefly? And then Cummings can kind of deepen it.

• 14:27Speaker 01

  Okay, so I mean, delusion, a fixed, a false belief, mistaken belief. The psychopathology, I didn't know how much I want to go into it, but I know the neurotransmitters look like, at least with delusional disorders, looking a little more dopamine based. But when you look at something like schizophrenia, dopamine's one of multiple neurotransmitters in a broader way that's related to it. I mean, this isn't just focused on delusional disorder, because that's kind of rare. But it really can be a part of a lot of different conditions like mania and schizophrenia. Of course, it's one of the main things that we think of. But Dr. Cummings provided some good, I think you probably received them, some articles. And there was a few that I really liked that were talking about scales. One is the simple delusional syndrome scale, and it kind of helps look at delusions in,

• 15:11Speaker 01

  I feel like, more of a dimension. Like it was talking about, is it logical? How is it organized? How strongly the person believes that delusion, the influence on their actions, their stability, extension, because also sometimes it's just an isolated delusion about one thing, but the rest of their reality is normal, reality based. That's kind of like a delusional disorder can be isolated versus, you know, it's something like schizophrenia where it may be very extensive with different parts of the reality. A lot of times it may not just be one delusion. They talk about like a theme, but there may be a mixture of different parts of the theme. And also talking about the characteristic of delusional experience for the person. Do they try to resist it?

• 15:56Speaker 01

  How preoccupied? And at least in my experience with antipsychotics, the person will still believe that thing. They will still have some, some inclination towards it, but they're able to dismiss it more, they're able to question it more, and they're becoming more reality based, but they still may stick with them to some extent, but they're not as the strong of conviction. So there's another one, the characteristic of delusional experience that talks about some of those, and the self-evidence and reassurance, happiness. But also, I think one of the things I liked that talked about the distress, belief, strength, obtrusiveness and concern. So how distressed the person is by the delusions, at least in my experience, is over time that

• 16:40Speaker 01

  lessens and that allows them to be more open to maybe like psychotherapy to question and look at their reality.

• 16:48Speaker 01

  Dr. Cummings, did you want to?

• 16:50Speaker 02

  Yeah, again, I think David and I have talked many times about the utility of rating scales in clinical practice and something certainly I tend to encourage people to do is find simple scales where they can actually track the person's condition over time. It's often difficult when you're seeing people intermittently to have a clear memory of, well, just how were they doing the last time I saw them? It can be very helpful to have a nice numeric anchor as to is my treatment working? Is it getting them better? Are they not getting better? It can help answer those questions.

• 17:33Speaker 02

  So, rating scales can be very important in this area, just as they can be in many other areas of psychiatry.

• 17:41David Puder?

  One thing I like about some of these rating scales, I sometimes kind of like blur your eyes a little bit and kind of get some of the big themes. The preoccupation, right? Like, is this something that they're thinking about one hour a day, 10 minutes a day, six hours a day, right? This can make a big difference. If they're preoccupied and then they're thinking about it and the delusion is shaping every action that they do, or it's just a kind of a passing thought a couple of times a day, right? This is a big difference.

• 18:20Speaker 02

  Yeah, indeed. And as Blair pointed out, often the improvement we see with antipsychotics is not so much that the delusional thought vanishes entirely, but it loses the degree of preoccupation it had initially, and the person is less compelled by the delusional content. And those are both very important clinical goals in terms of preventing harm to the person, as well as preventing harm to other people.

• 18:55Speaker 02

  You know, Carl Jasper's in 1913 originally defined delusions as a fixed false belief. His second description was that it was incorrigible, meaning you could not use logic to alter the delusional belief. Well, it turns out neither of those things is true. The strength of delusions varies over time. And indeed, there's now an entire psychotherapy, CBT for schizophrenia, that is focused on getting people with delusional beliefs to begin to treat those beliefs as hypotheses that they can test, which is a major advance

• 19:37Speaker 02

  for people once their more flagrant psychotic symptoms are under control.

• 19:42David Puder?

  Yeah, yeah. And I've, I've, I've done that psychotherapy somewhat. It's, it can, it can be a mixture of success initially. I think the most, the most important part of psychotherapy initially is of course getting them to come back to psychotherapy. And if you push too quickly, too hard, sometimes they just do not come back, is my experience.

• 20:06Speaker 02

  Yeah. Yeah. My experience has been you have to get the positive symptoms under better control and you need to get the preoccupation with and being compelled by the delusions down to a more manageable level. So that essentially the person has the cognitive space to begin to question the delusional content. It's at that point that they're ready for psychotherapy. I think if it's introduced too early, often the person will flee from it.

• 20:41David Puder?

  Yeah. And this is where I think that you have to be very calm and you have to, you know, people want to be with a person that is very calm. And if, if, if, if anything that we can provide to the audience is to reduce their anxiety of someone else's fixed false beliefs today, maybe a little bit so that they can sit calmly with them in the midst of them.

• 21:08David Puder?

  Blair, let's go through some of the different ones. Let's talk about them.

• 21:12Speaker 01

  Oh, yeah. And one other thing I did want to bring up that Dr. Cummings had brought up previously. There was one other skill, the Brown Assessment Skill, beliefs that one of the things he mentioned was timeout delusions associated with OCD, or maybe like biodysmorphia. Dr. Cummings, did you want to, you know, as far as looking at delusions based on different conditions like that? Or trying to distinguish them?

• 21:34Speaker 02

  Yeah, I mean, frankly, since both Blair and I work in settings that are very selective for people with serious mental illness, usually schizophrenia spectrum disorders. It's very easy to forget that delusional or false beliefs occur in a whole variety of both psychiatric and neurological conditions, including things like body dysmorphic disorder and obsessive compulsive disorder where the person may have varying degrees of insight that the belief may or may not be true, but it's important to recognize that delusion is not limited

• 22:19Speaker 02

  to a single psychiatric disorder. This is a symptom or mental state that can cross diagnostic boundaries.

• 22:29David Puder?

  Really, really important. Yeah, like body dysmorphic disorder. I've actually done an episode on that. You know, interestingly, we don't treat that with the dopamine medication often. It's SSRI based.

• 22:40Speaker 02

  Yeah, the pathophysiology seems to differ by condition, although I think the end areas of the brain involved are often the same. Certainly in the schizophrenia spectrum disorders, ventral tegmental increased dopamine plays a role. But regardless of whether it's a primary dysregulation of dopaminergic signaling or physical damage to the non-dominant dorsolateral prefrontal cortex by stroke. Both of those conditions can give rise to delusion, one by influencing the functioning of that part of the brain and the other by causing direct damage to it.

• 23:23Speaker 02

  You know, the two characteristics of delusions that seem to hold across categories of illness and types of delusions is that there's a failure of reality testing. I've always been impressed that in the healthy population, surveys indicate that up to a third to a half of people may experience occasional psychotic symptoms like hearing their name when there's no one there, or having the eerie feeling that they're being followed or watched. But they're able to dismiss those things because their dorsolateral prefrontal cortex basically evaluates, how likely is this? And says, it's not, ignore it.

• 24:06Speaker 02

  The other element that appears to occur in almost all delusions is an inappropriate assignment of salience. The people who are delusional are assigning importance to things that in truth are often innocuous or unimportant in the environment, which may have to do with the reward pathway being abnormally activated by dopamine.

• 24:29David Puder?

  Hmm. Also OCD can have with and without delusions. And one, sometimes patients with schizophrenia can have coexisting OCD, which I've treated some of this recently, and it's very difficult.

• 24:43Speaker 02

  Yes.

• 24:44David Puder?

  The OCD, the insight into the obsessions can start out as very low. And so this, this is almost like a delusion, like the, the OCD thoughts can sound like a demon, right?

• 24:59Speaker 02

  Yes.

• 25:00David Puder?

  So the, so this is where it gets tricky. And I'm curious what your thoughts are on this. When is it, when is it of?

• 25:06Speaker 02

  I think, I, I think it's actually a mistake when we say people with OCD, the obsessions are not delusional, and some people they are delusional.

• 25:16David Puder?

  Right. Well, I, I think it can start out delusional until they gain a level of insight.

• 25:22Speaker 02

  Until they get better, yes. Just as in schizophrenic and people can be very delusional. And then over time, the delusions can become much less compelling and they may indeed reach the point where they can begin to question the content of their delusions.

• 25:38David Puder?

  Right. So, so, so let me, let me make this more real for the audience, so we're not like just lost. So specifically, you could have a delusion. Or it could be an obsession, right? And the obsession could be, don't go through the door. If you go through the door, something bad is going to happen. It can take on a delusional character when they believe that it is true. Is that, is that the way you see it? Okay.

• 26:01Speaker 02

  Yes, yes, indeed.

• 26:03David Puder?

  But then it can become like just an OCD thing when it's like, okay, I know that this is my OCD. This is not a rational thought. I'm going to be okay if I go through the door. I'm just going to struggle with my compulsions if I go through the door. I'm having a compulsion to not go through the door. I'm going to resist and not do the compulsion because that's going to help the OCD get better over time.

• 26:30Speaker 02

  Yes, indeed.

• 26:33David Puder?

  Okay. So yeah, thanks for bringing this up, Blair. I think, I think delusions can happen outside of schizophrenia. They can happen in mania. I've seen them in mania multiple times where people get manic, they'll, they'll develop a new delusion, they'll come out of mania, maybe on lithium, maybe on a landscape pain. And then the delusion is still there, right?

• 26:55Speaker 02

  Yes.

• 26:55David Puder?

  It lingers. They have a new belief about reality. It's can be very difficult.

• 27:04Speaker 02

  Yeah, I think that's one of the things that attracts psychiatry to delusions is they're one of the toughest symptom categories for, for our field to deal with. We really struggle to get people fast past delusional beliefs.

• 27:22David Puder?

  One of, one of my early mistakes, I was a resident. This is so, this is so far gone and so like vague of a, of a patient, but I had this patient who had a, who had a belief that his parents had tortured him and he was in a psychiatric hospital. And I believed him for the first two weeks. And I really believed that his parents were the worst people in the world until I didn't, until I realized like, oh, this is part of his schizophrenia, you know? And this, this is like first, the first year in residency, right? Where you just, you just do not know what you don't know, right? But I imagine there's some people out there who are hearing patients' delusions. And it's like, is this real?

• 28:05David Puder?

  Do this person, does this person have severe trauma? Or is this a delusion? And it's very hard to differentiate. And I would never want to tell a patient right off the bat, like, uh, this is a delusion.

• 28:15Speaker 02

  This is. Yeah, yeah. We know the, uh, the DSM divides delusions into four types. There's bizarre, which is usually fairly easy to spot for that reason that they are bizarre, not likely to occur in any form of reality. The non-bizarre, which is what you're talking about, though, are things that are possible, but don't seem likely. Uh, and then there are the mood congruent and mood incongruent delusions. You know, I think, and I've seen it go both ways. Uh, when I worked, when I worked at the VA, we had a patient who was manic. He was admitted.

• 28:54Speaker 02

  He claimed that he worked in the Senate and that he was friends with a number of very powerful people, senators. And of course, the staff all thought, oh, this guy's, he's grandiose, he's delusional, until he started getting get well cards two days later from DC.

• 29:17David Puder?

  Yeah, that's a great example. In, in my example, it started out as a non-bizarre delusion, but then I, as I heard his story more, it became more and more bizarre. And so then I, I was challenged to like either believe that this guy was the most abused person I'd ever met in the world, right? Or that some of his stuff was so over the top that it pot, it was impossible to happen. Right? And then it got, it got so over the top that it was truly unbelievable.

• 29:51Speaker 02

  Yeah, Blair, why don't you talk about some of the specific subtypes of delusions? Some of those are very fascinating and have gotten named simply because they are so unusual.

• 30:04Speaker 01

  I would say the persecutory are probably the ones that I think even early on, working at Patton, you know, a lot of the the paranoia is associated. I know when the articles that you put that the anger is often what drives the violence. And of course, that's our biggest concerns. But one of the biggest ones really, that was a main theme for ones that were at risk for violence, being spied on, conspiracy. I mean, often they're mixed themes. There may be other ones, grandiose, and you know, they may have bizarre ones. But I think that is a key one that I feel like really can go under the surface. And it can be like general mistrust. This is just more my experience, that general mistrust,

• 30:45Speaker 01

  which it actually can be a much deeper, very complex delusion going on. And like you said, all innocuous things in their environment reinforces it. And it's hard to know how that tip of the iceberg, we talk about how deep it is. And so at any time, someone they can know for months, years, and then suddenly they act out, even on a family member, on, you know, a person that may be trusted. So I think that one is a really big one to me, that especially in a forensic setting where there's already a trust, there's already a level of violence potential. When you add that, that seems to me probably one of the biggest risk factors that really stood out to me. Is there anything you would want to add to that?

• 31:28Speaker 02

  Well, I was gonna say, there also are some very unique delusions that crop up in settings where you treat a lot of psychosis, things like capgras delusion, where people believe that people they know have been replaced by imposters. Indeed, we have a number of patients who have harmed family members because they misidentified the family member as a demon, or the devil, or as someone else who was an enemy who had taken away their family member and had replaced them. Probably one of the most unusual named delusions I've come across, and I've only had a couple of these, was Cotard's delusion. I had a VA patient who

• 32:13Speaker 02

  Believed in all sincerity that he was dead. He was not. He was alive, walking, talking, breathing. Doing his neurological exam, he told me when I tested his strength. However, doc, that's not strength. This is just rigor mortis. You know, he was firmly convinced that he was dead. There are other culture bound delusions that are fairly unique to some cultures. Like Coru, believing that the genitals are being withdrawn into the body and that when that process is complete, the person fears that they will die.

• 32:54Speaker 02

  You know, there are a number of these kind of encapsulated, very unusual delusional beliefs. Did you want to comment further on those?

• 33:05Speaker 01

  I think one of the things that when I was looking more into this that I didn't realize was how they can be mixed. Like I didn't really think of, you know, there could be the gramios with hyper religious versus there's also a level of the persecutory, like you could have a mixture. So they may have like the cap grass, but would, you know, but by having believing this person you care about has been replaced, isn't there an aspect of paranoia or is it, you know, this person's conspiring against me? Like it's a mixture almost that might act, make someone act out?

• 33:39Speaker 02

  Yes. Yeah. Oh, I think the hypothesis I've read in the literature as well as my own hypothesis about why people become delusional is that if we lose the ability to test reality, we're then faced with having to explain these unusual psychotic experiences. As a species, we love stories. And I think what happens, albeit via different mechanisms, is that if the person cannot reject an unlikely experience, they then have to explain it.

• 34:21Speaker 02

  And the explanation can become a very elaborate story. Well, you know, this happened to me because the CIA is following, or that happened because the demons are after me. You know.

• 34:37Speaker 01

  You're talking to me and then I believe that this thing I saw, you know, the voices said this. So then this thing happened. So it must mean this delusion, I believe, is being reinforced by the voices.

• 34:49Speaker 02

  Uh huh.

• 34:50Speaker 01

  And kind of believe that. What do you, what grandiose, what would you kind of say as far as like, I don't know. They always think that has been as risky, but I mean, grandiose is a really interesting one. I feel like I don't always see anything more of maybe mania, but I there were times, you know, when my favorite patients at the state hospital had millions of dollars and servants and mansions and.

• 35:11Speaker 02

  Often those seem to be in some ways often a counter response to exactly the opposite. Very difficult circumstances where the person may indeed, rather than being incredibly wealthy, they may have lost wealth. Uh, we had one banker who, because of his mental illness, had suffered

• 35:34Speaker 02

  truly impressive losses of wealth, but his response to that was to believe that he essentially owned everything.

• 35:42Speaker 01

  Well, that's interesting.

• 35:44David Puder?

  I was thinking about the, the cap grass and the, um, the Jim Carrey thing. I don't, I don't know if you guys heard about that. But after he gave like a speech, it, there was, there was pictures of him before and after, and it looked, it looked a little bit different. His eye color looked different. And so all these people on the internet were saying like, oh, Jim Carrey's gone. Jim Carrey's dead. You know, Jim Carrey's been replaced, but it was like a mass cap grass experience, right? Now.

• 36:12Speaker 02

  Mm hmm. Well, certainly trust has become more difficult now that we have things like deep fakes and so forth. So.

• 36:20David Puder?

  Exactly. Yeah, absolutely. Yeah.

• 36:23Speaker 02

  I don't know. I don't know if that will doom all of us to some extent to become somewhat delusional, but I hope not.

• 36:29David Puder?

  Or like, what do you, what do you call a, like, um, like, I remember before the Epstein files came out, like I was, I was, you know, a fan of conspiracy theory and I had some theories and they came actually true with the Epstein files. And so it's like, were my delusions well, well placed, you know, like, when are they poorly placed? How do we, how do we know for sure? Right?

• 36:52Speaker 02

  Well, I, I think in many cases, as your story with your patient illustrates,

• 36:59Speaker 02

  you know, for the psychiatrist working with an individual patient, I think it's always very important to check out as many. Collateral sources of information as you can now, in the case, for example, of the man who actually did work in the Senate, it became very obvious when he started getting get well cards from senators that he that was a reality based statement. That was not delusional on his part. You know, so it's worthwhile always to do a bit of investigating and figure out, is the person actually delusional or is what the person is saying actually true? Because that is a possibility, at least for the non bizarre delusions.

• 37:40David Puder?

  Or I remember I had this mother who was like, my son is is really going off the deep end. He believes that microplastics are in the foods and they're getting into his brain, you know? And then I was like, have you read the study about how we have about a spoonful of microplastics on average in our brain on autopsy? And, um, you know, maybe he was ahead of his time, right?

• 38:05Speaker 02

  Could be, uh, could be.

• 38:10David Puder?

  So on a side note with that, people, people are listening to worried about microplastics. I think the key is just not heat your food in plastics. Don't microwave your food in plastics. Don't use plastic tea bags. That's, that's my big takeaway.

• 38:22Speaker 02

  Yeah. The other good news of late is they have discovered that we as a species, we actually do eliminate microplastics over time. So we're not going to fill up to the point that we are nothing but microplastic.

• 38:35David Puder?

  Right, right, right, right. We, our body is constantly getting rid of them. Maybe a high fiber diet will help, right? Maybe if for the very small particles, they'll, they come out and sweat, you know, a good sauna once a day will take care of a lot of heavy metals, a lot of, you know, bad things in our environment.

• 38:55Speaker 02

  Yeah.

• 38:56David Puder?

  Okay, but getting back to like different, different types of delusions, let's go, let's go, let's make sure we cover all the, all the ones. Aroto manic, talk about aroto manic ones.

• 39:05Speaker 01

  Interesting one. I was thinking, I was looking up, it was John Hinckley Jr. with Jodie Foster. Wasn't that a famous one?

• 39:13Speaker 02

  Yes, yes.

• 39:15Speaker 01

  So that, that's when I know I, you know, I see, you know, if someone like, oh, when I get out, um, this famous person is gonna be, you know, is gonna take care of me. What is your plan? Well, this famous person is gonna have a relationship and they're gonna take care of me. Or, you know, this means this, like, there's, as far as, I know, that's more than maybe this forensic setting, but, you know, it looks like it can be a cause of violence. Do you have any thoughts about, uh, how we approach that or that larger view of?

• 39:47Speaker 02

  Well, yeah, aroto mania is a type of, uh, delusion and it does intersect with forensics in the sense that, you know, the person who believes that often stalks the person they believe is in love with them, uh, will show up in their home, for example. Uh, when the person rejects them or gets a restraining order, that feeling can turn to anger. And there have been a number of celebrities either harmed or killed as a result of people with aroto manic delusions. So certainly nothing to take lightly. Same thing similar in delusional disorder when people have jealous subtype,

• 40:28Speaker 02

  where they believe that their spouse or significant other is cheating on them, even though there's no evidence to support that. Uh, those people can become quite dangerous if they feel they're being abandoned or rejected.

• 40:45David Puder?

  Yeah. So, so the, um, the classic John Hinckley Jr. first.

• 40:52David Puder?

  Jodie Foster, he had watched Taxi Driver 15 times. You know, this 25 year old male developed this erotic fixation where he believed that she was in love with him. He moved to New Haven, stalked her at Yale, subsequently sent letters, poems declaring his love. She rejects him. He has this unshakable belief. She loves me back. She can't say it publicly yet. To win her heart, to create a legendary romantic bond, he does, he plans this very traumatic act of assassinating President Ronald Reagan on March 30th, 1981.

• 41:34David Puder?

  So he left her a letter in his hotel room, addressed to Foster. "Jody, I would abandon this idea of getting Reagan in a second if I could win your heart and live out the rest of my life with you." So think about it as also like this, like despite overwhelming evidence that the person is not in love with you, you continue to believe that the person is in love with you. That's the erotic delusion.

• 42:08Speaker 01

  I thought it was interesting. It's called the Othello subtype. That was kind of interesting. Dr. Cummings, if anyone would know, I mean, I know that's a talk about the infidelity, I think, in the Shakespearean play, but that was kind of an interesting association. Do you have any thoughts about how it's, how those two go together?

• 42:30Speaker 02

  Well, yeah, you know, Shakespeare was ahead of his time in terms of talking about human nature. And indeed rejection by someone who is the loved object, of course, can quickly become anger at that object, that person, or can be displaced onto another. In this case, Mr. Hinckley, since he had been rejected by Jodie Foster, essentially decided that, you know, if he did something famous enough, important enough, maybe he could overcome her rejection. But there was also an element of...

• 43:13Speaker 02

  Self defeat there. I think he was fully aware that he might well be killed in the process of attempting to assassinate a president.

• 43:23David Puder?

  So the Othello type is really a jealous delusion, right?

• 43:27Speaker 02

  Yes.

• 43:27David Puder?

  Where you have, you have Othello is convinced that his wife is cheating on him with Cassio. And in delusional rage, he murders her. So it's like a delusion of this, and I've actually seen this and I've actually seen it be as fixed as can fixed be initially, and I've worked to make it unfixed. But it's, it's this complete delusion of the unfaithfulness of your partner, despite no evidence that they're unfaithful.

• 43:59David Puder?

  I've also seen one patient who really believed this about their partner and then found out their partner was unfaithful. They had the intuition before they had the evidence, right?

• 44:08Speaker 02

  Yes.

• 44:08David Puder?

  So this is where it's like complicated as a psychiatrist or therapist. You're like coming into a situation, not fully knowing what's true or not true, trying to not make assumptions too early, right?

• 44:21Speaker 02

  Yeah, that's why we always need to be on the lookout for more evidence as well as collateral sources of information. You know, some delusions are obviously false, others not quite so much.

• 44:36David Puder?

  Yeah, or like, like they'll make evidence up that out of things that are not evidence. Like, oh, my partner, my partner was 10 minutes late. They're cheating on me, you know?

• 44:47Speaker 02

  Yeah, that gets back to the salience issue where they assign importance to things that are not important.

• 44:55David Puder?

  I don't know if either of you listened to my episode on ChatGPT psychosis, but we talked a lot about how often ChatGPT would actually strengthen the character of the delusion.

• 45:07Speaker 02

  Yeah.

• 45:08David Puder?

  Yeah. By the sycophantic nature of it, by the agreeableness of it, and they would actually like find new potential reasons for delusions, you know, or new paranoia, new, it would almost like strengthen the paranoia.

• 45:23Speaker 02

  Yeah. Well, certainly current large language model chatbots essentially are designed to agree with and support what the person says. And indeed, they will do that often to the person's detriment. Hopefully. As AI moves forward, they'll get some guardrails around that because it can be very dangerous.

• 45:45Speaker 01

  It can get to God and people think they're God, the the the type of it's the only relationship they have. I have talked to Dr. Cummings before. I mean, it it's pretty scary and I'm sure you you know that it definitely can get more and more

• 46:02Speaker 01

  problematic to try and address. And again, is it silent? The person's just that their whole their whole world and their whole social interaction is with these AI.

• 46:15David Puder?

  Right. Normally, normally a friend will start to try to question some of the, you know, delusions that don't make sense, right? And then in in the in the case of AI, AI can sometimes just agree because, you know, they're often trained by other people using AI and AI will say like, do you like response A or B better? And the more agreeable one gets voted up. And so the AI gets trained over time to be more agreeable.

• 46:47Speaker 02

  Yeah, which is of of concern. Now, this is kind of off topic, but I read a survey recently, I think it was by the Pew Research Corporation where they found that roughly forty percent of junior high school students say that their best friend is a chatbot.

• 47:08David Puder?

  That seems very high, but scary.

• 47:11Speaker 02

  It seems very high to me, too, but also very scary.

• 47:15Speaker 02

  Although I can I can see it because, as you know, junior high school can be a kind of hyper, hypercritical, very stressful time. And here you have this thing that will talk to you and it's never critical.

• 47:28Speaker 01

  Or as a child psychiatrist and did a fellowship in child psychiatry, a lot of socially awkward, you know, and their parents may not, they're not involved in extracurriculars, they have online friends, but we wonder, is the online friend AI? Is the online friend real? Is the online friend someone that just got out of a? You know, Department of Corrections that might be targeting this person, they send inappropriate pictures. I mean, the online or even taking pictures, a lot of pressure that they're sending pictures of themselves. They get distributed to other kids in the school where a lot of the depression or, you know, that you like you mentioned, the deep fakes. I mean, they

• 48:09Speaker 01

  are so susceptible. And not only, I would say to the AI part, but just they're so susceptible in so many different aspects of social media and being preyed upon and the impact that can have, I think mentally and not understanding what they're doing and the impact.

• 48:25Speaker 02

  Well, I think you've now reached the point where we're talking about, in some ways, delusional beliefs that go beyond the individual and begin to resonate in kind of a sound chamber provided by the internet.

• 48:41David Puder?

  Mm hmm.

• 48:42Speaker 02

  Um, so I do, I do wonder sometimes, does that mean that we're becoming more potentially delusional as a society?

• 48:53David Puder?

  I, I have found that it's with the algorithm, you know, like when I got on the Jim Carrey kick, I it all of a sudden started to show me video after video of this, you know? And, and it's like, you're getting, and this is a great example of like, you could get pulled too far into it, you know? And then you could start to think like, oh, man, is it, is it, is he really Jim Carrey? Is he not Jim Carrey? You know? It's kind of, for me, it's kind of like, like, I'm like, holding this loosely, but you can imagine if someone had more of a paranoid personality, if someone has a little bit less of a, I don't know, like different types of personality structures, they may

• 49:38David Puder?

  be more likely to start just believing something early on in a fixed way.

• 49:44Speaker 02

  Or, I think what might be concerned is, is, you know, for indeed as Blair is pointing out for the awkward, socially limited adolescent who's growing up.

• 49:58Speaker 02

  You know, if you have real friends, they will say, wait, that's dumb.

• 50:02David Puder?

  Mm hmm.

• 50:03Speaker 02

  That's not real.

• 50:04David Puder?

  Yep.

• 50:05Speaker 02

  Uh. The internet sources are not going to say that. In fact, the AIs will go, oh, yeah, well, that's a possibility. Here, let me tell you 500 stories about this.

• 50:15David Puder?

  Exactly. Oh, and and I I get um, I get questioning as well on some of these like dating apps because male patients of mine will meet females and I'm like, I don't think that that's a real person.

• 50:28Speaker 02

  Yeah.

• 50:29David Puder?

  And they're not. They're catfished. Actually, some some of my patients, like most, pretty much every girl he matches with is catfished. Now, if you if you saw his profile, you would understand why he might be overly catfished. But this is a real, this, you know, is he talking to an AI bot? It's more and more likely he's talking to a sophisticated AI bot.

• 50:50Speaker 02

  Yeah. Oh, indeed, there have been people who've lost huge amounts of money because their quote girlfriend who just happens to be in another country says, oh, I really have this need and that need and could you send me some money? Maybe I'll come visit you. Of course, the visit never happens because the girlfriend is an AI bot.

• 51:11David Puder?

  Right. And and or or, yeah, and this is, this is the world we face. We need to prepare our patients for it. We need we need to ask the right questions to see what are the influences bringing them further into a delusion, right? Because there could, it's it's like for a lot of these patients of mine, it's a very nice delusion to have, that there's a very attractive female that's very interested in them, that's in another country that they're going to spend their future with, right? You could see how that starts to.

• 51:41Speaker 02

  Yeah, I think, you know, I think as this worsens, we may get into the into a state where we have essentially internet-induced delusions.

• 51:52Speaker 02

  Which, uh, you know, certainly we have now in the appendices of the DSM internet addiction disorder. Well, we may have eventually internet delusional disorder.

• 52:04David Puder?

  Well, I think it's probably here. It just hasn't been put in the, it hasn't been codified in the DSM, right?

• 52:10Speaker 02

  Yes. Oh, that's because the DSM committee is indeed lagged behind just a bit.

• 52:16Speaker 01

  And say another, I know there was some other ones, we'll go back to the referential ideas of reference, there's the like thought insertion, but I was gonna say, I think another big one's somatic, because in medical, we have a lot of patients that can be convinced, I remember Dr. Peter, I don't know if he was, there was, I remember even in residency, Dr. Peter having a patient, patient, there was a clinic and people wanted to find a reason, they'll want to find a medical reason for what's going on with them. And so, a lot of times, I think somatic, I think one of the things is it's not just believing, it's not just hypochondriasis, illness, anxiety, or which, that's kind of, I don't know if we put that completely, but people believing they have a microchip in their brain, or the parasite, them having parasite.

• 52:58David Puder?

  Parasitosis.

• 53:00Speaker 01

  Yeah, I thought somatic is really interesting. Did you both want to expand on that at all?

• 53:05Speaker 02

  Yeah, I mean, there's an entire literature on Morgellons disease, which is essentially delusional parasitosis, where people will go to extreme lengths to try to prove that they are infested by parasites. Even though when people finally look at samples that they've dug out from under their skin, there are no parasites. It can be a very damaging delusion, especially when it's a parent who essentially is engaging in munchausings by proxy, where they're, you know, taking the child from place to place to place and saying, oh, the

• 53:47Speaker 02

  child has parasites. And the poor kid winds up with all sorts of tests, all of which, of course, are negative. Somatic delusions are one of the toughest categories of delusion to overcome.

• 54:02David Puder?

  I, I, I've seen the parasite one, Ekabob syndrome is another word for it, delusional parasitosis, the crawling under the skin, I remember one patient, I figured out it was because he was using some meth, and once he cut the meth, it went away. And he had seen a couple of different people for that. Lyme disease, I know, you know, some people do have Lyme disease, acute Lyme disease, but there's a lot of people who, despite You know, real infectious disease specialist saying, no, you don't have Lyme disease. They'll find some expert that they pay cash pay, by the way, and it's very expensive, that believes that they have Lyme disease and they'll put them on years of antibiotics

• 54:43David Puder?

  and they'll have huge side effects. They'll get C. difficile, they'll end up in the, in the, in the hospital. I had a very good friend of mine, infectious disease doctor, UCSF, across from one of the big Lyme disease places in San Francisco. He said he would get these cases of people having awful side effects of being on chronic antibiotic treatment from these patients for years. But, you know, people are looking for an answer for their suffering, right? And it's very hard to discern the cause of the suffering. Sometimes it's psychological. It's like, it's easier to believe it's actually physical. If you have a psychological problem, you may not get the empathy from your spouse. If you have

• 55:26David Puder?

  a physical issue, you may get empathy, you may get kindness from your spouse.

• 55:29Speaker 02

  Yes, yes. And physical illness doesn't come with typically the same degree of stigma as psychological or mental illness.

• 55:41Speaker 01

  Dr. Cummings, would you speak to body dysmorphia versus maybe a somatic delusion? It would you, how do you?

• 55:48Speaker 02

  Uh, I think that body dysmorphia, that is the feeling that something is wrong or irregular, even though it is not, is a form of somatic delusion. Frankly, it leads to a lot of unnecessary plastic surgery. Now, I think that that's something if you're, if you're a plastic surgeon, you need to be on the lookout for. And if somebody is wanting, you know, multiple revisions of a perfectly healthy, well-shaped nose or ears or anything

• 56:29Speaker 02

  else, you know, they're taking a lot of risk by having multiple, these people usually have multiple surgeries. You know, I think it's, it's, the onus is on the plastic surgery community to say, no, this is not reasonable. You know, having your, having rhinoplasty because you don't like the shape of your nose is perfectly fine. Having 15 rhinoplasties is not.

• 56:55David Puder?

  Well, it's 15 going on 30, right? There's no end to it. And that's, that's the problem with delusional body defects is that, you know, they could believe my nose is massively deformed. It's rotting from the inside. They could say something like, my penis is, is shrinking and disappearing into my body. It's an odd shape. It's hideous, you know, coral like delusion, uh, where it's like shrinking inside of my body. My face is asymmetrical. Everyone's noticing it. Everyone's looking at it. I could never date because of it. I had a patient like that and tried to help him through just realizing that this wasn't going to be the thing that kept him from success in dating. Right?

• 57:39David Puder?

  It's like, so we have to use cognitive behavioral therapy on these things. Otherwise, the delusion doesn't just go away. You know, it's not like you, you get 15 plastic surgeries and the delusion is gone. It's always one more, right? And, and that's the problem with this type of patient is that then if you're the plastic surgeon, you're going to get sued maybe, or you're, you're, they're going to go from idealization, oh, you're the best plastic surgeon ever. You're going to be able to fix this thing that no one else has been able to fix to, I hate you, you're evil, you're the worst doctor ever, you know? And so it could be very litigious at that point.

• 58:16Speaker 02

  Well, it becomes the same goal that covers all of the delusions we've been talking about. Our goal in mental health is to try to help the person achieve the delusion becoming less compelling of behavior. We may or may not be able to make the delusional thought go away completely. But as a first goal, we should try to make the delusional belief less dangerous for them and less dangerous for other people as well.

• 58:51Speaker 01

  I think that's just one of the few things that we're talking about, like plastic surgery can intervene. So different than just this belief, we give them the antipsychotic, hopefully it lessens. But is it enough that they won't keep pursuing the surgery or, you know, they're gonna?

• 59:04Speaker 02

  Well, I, I think, I think Dr. Peter is right. I think it takes a combination in many cases of both. Medication and in terms of body dysmorphic disorder, the SSRIs seem to do better than the antipsychotics. But with that cognitive behavioral therapy, I think it's key to get the person to question the validity of their delusional thought. If they can begin to treat it not as a firm, this is truth, but as a hypothesis. Could this be truth? Is it true or isn't it? What's the evidence for and against?

• 59:47Speaker 02

  If they can reach that point, they're regaining some of that reality testing.

• 59:51Speaker 01

  Another one I really like that you pointed out, Dr. Cummings, the nihilistic, I mean with depression or certain ones that can be more key based on their, the disorder, the mood, the mood issue, like your term mood congruent versus incongruent. Do you want to discuss that though?

• 1:00:08Speaker 02

  Yeah. People who are severely depressed often suffer from extreme guilt, delusional guilt, meaning they believe they are responsible for things they are not responsible for. You know, oh, I caused all of the deaths of the world or all of the wars in the world. Well, that's, it's both grandiose and nihilistic. Or my organs are turning to dust is the classic nihilistic delusion.

• 1:00:38David Puder?

  My, my organs are rotting away. I'm already dead. Nothing exists anymore, including me, right?

• 1:00:46Speaker 02

  Yeah. Yeah. And of course, the key for that is you're usually at that point of dealing with a psychotic mood disorder, which from a pharmacologic standpoint, the key is to treat them with both an antidepressant and an antipsychotic. The response rate to antipsychotic alone in those cases is somewhere between 20 and 30%. But if you add an antipsychotic to an antidepressant, you can get the response rate up into the 60 to 70% range, which gets the person usually better enough that you can then begin to,

• 1:01:27Speaker 02

  again, support them with, in this case, psychotherapy based, treating both their depression and their delusional beliefs.

• 1:01:39Speaker 01

  I think kind of going to your time out the guilt, the sin, poverty, fear of being ruined. There's kind of overall maybe a negativity, like a negative delusion, maybe that you would say expression or?

• 1:01:52Speaker 02

  Yeah, well, it it comes down to the person believes they are delusionally guilty of something. And therefore they need to be punished and often they delusionally believe that they either have been or are being punished in some way.

• 1:02:08Speaker 01

  And would they maybe not see treatment because they feel like they're being punished?

• 1:02:13Speaker 02

  Uh, that is a possibility. I as most of the delusionally depressed people that I've treated in my career were brought by family members. They did not bring themselves into treatment.

• 1:02:30Speaker 01

  And I think one of the things I did want to go back that we didn't talk as much is ideas of reference, believe that mutual events, I've had patients, oh, the TV's talking to me or it has a special message for me. Uh, it's good they have enough insight where they say, okay, I turned off the TV because I realized I I read into it or certain stories mean something to you. Do you have any um thoughts about that one specifically?

• 1:02:54Speaker 02

  Oh, I think that's also an example of deranged or abnormal salience assignment.

• 1:03:00Speaker 01

  Okay.

• 1:03:01Speaker 02

  You know, see something that is ordinary, mundane, routine, you know, people talking down the hallway, uh, the TV's on and they begin to make assumptions that, oh, that's important. Somehow it's related to me. They're talking about me or the TV's talking to me. Or people are be able to read my mind or I'm, uh, people are, you know, inserting thoughts in my head. In fact, we have a one patient here at Patton who committed homicide because he believed that his victim was stealing his thoughts.

• 1:03:39David Puder?

  Uh, or or could be like, a patient could be watching two people laugh across across the street and then they're talking about me, they're laughing about me.

• 1:03:51Speaker 02

  Mm hmm. Yes. Yeah, it's that inappropriate assignment of what they're doing is referential to me.

• 1:03:59David Puder?

  Right.

• 1:04:00Speaker 02

  Which can, which, which can have both persecutory and grandiose elements. Well, you know, if you believe that everyone on the street is talking about you, well, you must be pretty important. On the other hand, there's often a persecutory element of, well, they're talking about me because they don't like me. They're plotting against me in some way.

• 1:04:19David Puder?

  Every, every lyric of Taylor Swift is talking really about me. You know?

• 1:04:26Speaker 01

  Yeah, I, I think that goes along with the thought insertion, withdrawal, broadcasting, basically the thoughts, either, you know, being, other people being privy to their thoughts, or it coming or going. And I think, I feel like a lot of times it's mixed with one of the other ones. I could be wrong, but kind of like you're, there's a bit of a paranoia or, you know, associated with it.

• 1:04:50Speaker 02

  Well, I think in, in many of these, as you look at all of the different specific named delusions, in many respects, they'll, they share a lot of common characteristics in terms of having elements of persecution, elements of grandiosity.

• 1:05:08David Puder?

  Yep. Or like, like the envious one. Have you ever heard of the delusions of envy?

• 1:05:14Speaker 02

  Yeah, oh, yes.

• 1:05:14David Puder?

  So the, this person stole my success, right? They, they, so it's like the, the envy of, or

• 1:05:24David Puder?

  the person next to me, you know, the next to my cell, next to my thing is like stealing something from me, right? And it's like they're stealing my thoughts or.

• 1:05:34Speaker 02

  Yes.

• 1:05:34David Puder?

  Or maybe that's different. Stealing thoughts is different, but it's stealing my success would be envy of the thing. So it's like, there's a level of anger in there. Do you have any other examples of that one?

• 1:05:44Speaker 02

  Yeah, the person who delusionally believes that in some way

• 1:05:51Speaker 02

  everyone else has secretly cheated them out of their success. They're never quite clear about how that happened, but I've met people ranging from paranoid personality disorder up to primary psychosis, who, you know, the rest of society was in some way cheating them, basically. Which I think, again, we get back down to the two main elements of a failure of reality testing and this abnormality and salience assignment that given those two things together, you can create all sorts of stories, basically.

• 1:06:29David Puder?

  And say something about salience assignment. Can you describe that again?

• 1:06:34Speaker 02

  Well, salience assignment is being able to distinguish what is important in the environment versus what is not. And many of the delusions that we've been talking about have at their core two elements. One, the person is unable to accurately assess reality. In other words, they're not able to weigh how likely is it that what I just thought is true?

• 1:07:01Speaker 02

  But coupled with that, they have an inability to distinguish what in the environment is important and what isn't. Good example is two people laughing across the street, as you pointed out. Not an important event relative to, you know, they don't know you, they don't, they're not laughing at you, they're just laughing. But for the person with a defect in that area, that somehow is important, it's related to them. And then we're again, we're a species that loves stories. So it's very easy to move from that to then trying to create a whole narrative about, well, why are they laughing at me? Is it part of some conspiracy?

• 1:07:47Speaker 02

  Is there some giant joke or conspiracy going on that I don't know about?

• 1:07:52David Puder?

  And then if they have a a somatic delusion of their nose being off, they can then intertwine that they're laughing really because of my nose.

• 1:08:01Speaker 02

  Yes. Yeah. So you can weave all sorts of things into this, which is why. Some of the delusional stories become incredibly complex and organized. And for the truly organized ones, they would make a great piece of fiction in some cases.

• 1:08:20Speaker 01

  Well, one of the things I really liked that you mentioned before, Dr. Cutman's was how different times and well, we mentioned cultures, but in general, like the society someone lives in influences their their delusions and what it looks like in the maybe in that someone that yeah, do you want to speak to that?

• 1:08:38Speaker 02

  Uh, yeah, I mean, you and I, Blair, have talked about the fact that the content of delusions, even if the process is the same, the content is very much history and culture dependent. And I think the example we've talked about is there, there were no alien abduction, UFO, delusions before about the 1950s. Those began to occur after the launch of Sputnik and with the introduction of all of those RKO grade B sci fi movies, things like, you know, it came from outer space, etc. That caught the public imagination and then people

• 1:09:20Speaker 02

  prone to delusions started to incorporate the content into their delusional beliefs.

• 1:09:29David Puder?

  One of my favorite stories of a delusional thing, a jealousy delusion is the Kreutzer Sonata by Tolstoy. I don't know if you've heard of this, but the Pezochev, I think the protagonist believes that his, his wife is having a sexual affair with a violinist. And despite, despite no evidence, and he's come to this based on the them playing a sonata together. And so, yeah, then he stabs his wife to death.

• 1:10:03Speaker 02

  Uh huh.

• 1:10:05David Puder?

  It's so this is it's rich in it's rich in the literature. I think it's very interesting what you said that alien delusions increased after the after the cultural increase and talking about things through movies. I've seen the same thing with like matrix like things like post post matrix. There's there's a

• 1:10:24Speaker 02

  Yes.

• 1:10:24David Puder?

  More delusions about like, oh, we're part of the matrix. We're part of a simulation. Right. And so it's like as the culture and what

• 1:10:34David Puder?

  kind of the that maybe the what what are people consuming? Right?

• 1:10:40Speaker 02

  Yes, exactly.

• 1:10:41David Puder?

  It changes the nature of delusions.

• 1:10:43Speaker 02

  I can't tell you, you know, at one point when I was a psychiatry resident, because of course we're talking about ancient history. There was a re-release in theaters of an updated version of The Exorcist, which I which I didn't see, but by reputation, it was even scarier than the first one.

• 1:11:05Speaker 02

  I can't tell you how many people I saw in the ER the week after that movie aired, who believed they were demon possessed. It it, you know, that became that became the complaint of the day in terms of psychiatric cases in the emergency room.

• 1:11:25David Puder?

  Which speaks to the emotive effect of film, right?

• 1:11:28Speaker 02

  Yes, it does.

• 1:11:29David Puder?

  And stories and and how like we have to remain reflective on how these things are influencing us.

• 1:11:37Speaker 02

  Yes.

• 1:11:38Speaker 01

  And the cultural view of the person that's coming, if they're from a different culture, a different country, a different, you know, what they present, if I'm not as aware or understanding, you know, is it, you know, based on their their what where they came from, you know, sometimes it's hard to judge, I would say, if I'm not as familiar with what their life is like or where they came from, for me to be accurate, perhaps, I mean, I had some patients that I was seeing from that came from the Middle East and they really were tortured by terrorists. They were kidnapped. Their houses were burned. They were kidnapped. You know, there there was these horrible atrocities. But understanding, you know, they really were around this versus someone that has never had any exposure that maybe watches something on TV.

• 1:12:20Speaker 01

  You know, trying to understand the actual context of this person, what they've experienced. You know, versus this person, you know, living on the streets. I think that was something I feel like working with a lot of different populations from homeless people, Skid Row, you know, kids, adults in different cultures has been really insightful. To be like, I, I really don't know to some extent that, you know, growing up in downtown LA or Oakland, you just get shot walking down the street. You might see a dead body just walking on your way. If you go to school, your family, the gang. You know, that runs the city and it's, it's very different. And what is delusional, what is, you know, what is that is, I think can be very interesting.

• 1:13:01Speaker 02

  Well, I think that's why it's very important to help our patients that we try as much as we can to understand their background. And that means sometimes going and doing some research and finding out about the culture they came from or the area they came from. So that, that you can understand what they're trying to tell you.

• 1:13:21David Puder?

  Yeah, I, I appreciate this kind of like, we have to be culturally sensitive, especially to, to where people are coming from. Cause if they come from very different cultures than ourselves. Like maybe their delusions actually makes sense, you know?

• 1:13:36Speaker 02

  Yes. Yeah. Yeah. They may still be delusions, but it makes much more sense. If you understand the cultural context, those delusions arose in.

• 1:13:46David Puder?

  Yeah, like the delusion of being pregnant could come in the context of a, a person that really does want to get pregnant, right? They really do want to have a child. Um, I've seen a couple of these in the ER and like been calling, you know, called for consults on these patients. You know, when they come in and they're very convinced that they're pregnant, that they're not, they don't have a baby in, in them at all.

• 1:14:10Speaker 01

  My favorite pregnant man was from Patton on my first patient years ago. And he was in his sixties. He, you know, at least, cause back then I was a dietitian. He at least wanted to eat healthy for his baby. So we focused on that, you know, trying to make healthy choices. Cause he was very convinced it's the only pregnant man I've met so far, but uh, you know what I was like, you know, if that healthy be healthier, I'm not here to treat that part of it. But you know, even it can be a man, right? Dr. Cummings?

• 1:14:38Speaker 02

  Yes. In some ways, delusions don't know a lot in the way of boundaries.

• 1:14:43David Puder?

  Yeah. Let's talk about when, when should we as providers, let's say outpatient providers, be a little bit more concerned when patients come in regarding their delusions? Like, when, when is it, when does it cross the line? Because I know, I know you, you both deal with the sickest of the sick population, right? But I'm curious, like, what kind of input you would have for outpatient professionals?

• 1:15:09Speaker 02

  I think for me, the elements I always look for are, does this person's delusion include elements of paranoia or persecution that are coupled with being angry? Because that's a very potent combination for being at risk of harming someone else. Or are there delusional beliefs such that it's a great risk to them? You know, and I'm thinking here of things like delusional guilt, where the person may indeed be saying, well, you know, I'm sure I'm responsible for all these horrible things, I really should die.

• 1:15:53Speaker 02

  You know, that person's going to be up on the urgency scale for me.

• 1:16:01David Puder?

  Yeah. The, the degree of anger, how do you determine the degree of anger?

• 1:16:08Speaker 02

  In part indirectly, starting by asking, well, you know, you say these people are

• 1:16:14Speaker 02

  plotting against you. They're persecuting you. How dangerous are, are they to you? Are they going to physically harm you? Or kidnap you? Are they going to harm members of your family? And if they say yes to any of those things, my next question is, well, doesn't that make you angry that they're, they're going to harm you or your family members? And that usually leads into a discussion of, well, if you're

• 1:16:40Speaker 02

  Angry, how angry are you and when would you think about harming them first?

• 1:16:46Speaker 01

  One thing I would probably throw in there because I worked outpatient for a few years. I know you guys, both of you have a lot more experience than I do, but I will say that I think one of the things that I really, it's like, when do you kind of poke, you know, when do you poke what's going on? And a lot of it, at least for me personally, was the occupational and relational. If it's really causing an impact on their ability to have relationships, I had someone that kept losing jobs because we got paranoid or we had delusions about people being against us. We lost our housing. It was, you know, I feel like, you know, how much are they even believe me? But trying to focus on, well, look at our unstable housing, look at our, you know, the instability of our life. I think for me, that was something I tried to go into, okay, let's really treat

• 1:17:31Speaker 01

  that we're having problems even maintaining regular occupational, social relationships because we're constantly mistrustful or we, this is a problem where we believe these people are against us. I guess that was kind of, I don't know if that's helpful, but I, I think with me that was where I might get away with a milder antipsychotic, go on to an antidepressant or like trying to frame it in a way.

• 1:17:55Speaker 02

  Mm hmm. I think this brings us back to something we touched on very early on. Those rating scales that we mentioned can be very useful in trying to evaluate how likely is it the delusion is going to lead to dangerous behavior because you're asked to, and these scales all have anchors. You're asked to rate, well, how intense is this? How much is the person preoccupied with it? And basically, the more intense it is, the more they're preoccupied, the more likely they're going to act on these thoughts.

• 1:18:33David Puder?

  With the, so number one, persecutory delusions, paranoid type, right? Are these, these are a little bit more dangerous? I would say specifically when you, the provider, become part of the conspiracy, right? You are poisoning me with these meds. You are implanting chips, Dr. Pewter. You are spying on me. You're controlling my thoughts. You're in on it with the government. If they give hints of this, does that raise your concern? I mean,

• 1:19:02Speaker 02

  Uh, yes. Uh, you know, there have been a few providers, um, killed over the years because they were, frankly, they were foolishly overconfident. Oh, this is my patient. They couldn't possibly harm me. And they would, you know, they would do foolish things like agree to see the patient after hours alone in the office. That was the last case of this I saw because I was consulted by the attorney who was investigating the case.

• 1:19:34David Puder?

  Um, I'm actually building a database on this because of the recent homicide that happened in my city, Winter Park with Rebecca White. She was murdered by her patient. Um, so I'm building a,

• 1:19:45Speaker 01

  You got it.

• 1:19:46David Puder?

  A database of this. It'd probably be done in a month or so.

• 1:19:49Speaker 02

  Yeah.

• 1:19:49David Puder?

  But, uh, it's, it's about, it's about one or two per year. So it's, it's not a huge amount, which I think should be a little bit relieving to us as providers.

• 1:19:59Speaker 02

  Yes. But it's an area that obviously people should pay attention to.

• 1:20:04David Puder?

  Yeah. Um, I just don't want to freak, freak every provider out that listens to this.

• 1:20:09Speaker 01

  I was gonna say though, also your study makes a difference, you know, uh, that awareness.

• 1:20:14Speaker 02

  Well,

• 1:20:15David Puder?

  If, if there's, um, if there's also a delusion, like I have to stop you before you kill me. Like if that's sort of like preemptive defensive violence type of narrative comes in, that's, I think the risk goes up.

• 1:20:28Speaker 02

  Mm hmm. Yes, very much so. Oh, you know, one of the, one of the things about, um, persecutory slash paranoid delusions is the person's own inhibitions against being violent are often.

• 1:20:44Speaker 02

  Overcome by the fact that in their mind, they're just defending themselves.

• 1:20:50David Puder?

  Yeah, well, they they they could be defending themselves. They could be saving the world. They could be defending their their family, right? And that's where it gets dangerous. Like usually people. It it's it's like the moral quality in the defensiveness increases the risk, right? Like the moral justification in the delusion.

• 1:21:14Speaker 02

  Well, yeah, I mean, the person may have very strong inhibitions against violence or killing, except in this case, that can be

• 1:21:24Speaker 02

  obviated by the fact that they're saying, well, but I'm just defending myself. You know, I mean, that is actually a, you know, a societally recognized reason to be violent is you're permitted to be violent in your own self-defense. And for many of these patients, that's the way they perceive it.

• 1:21:46David Puder?

  I think I think risk also increases with a history of violence.

• 1:21:51David Puder?

  When when they have a history of attacking multiple people in the past like that, that really does increase the risk, especially if it's been lethal, especially if they have like a history of going to jail for it.

• 1:22:05David Puder?

  Being in jail, currently in jail.

• 1:22:09Speaker 01

  Looking seeking out.

• 1:22:12Speaker 02

  Yeah, which is why I think the the take home lesson for providers in this regard is, you know, if you have a patient who's making statements like that, that, oh, you're poisoning me, you're doing bad things to me. Uh, I don't think you need to abandon that patient immediately, but I do think you need to think about the context and the circumstances under which you interact with the patient.

• 1:22:36Speaker 02

  You know, this may be somebody in whom you only see them in a well-staffed office, or maybe you only see them via video conference.

• 1:22:47Speaker 01

  Be aware of them seeking opportunities. I think that's one of the biggest things learning, even at the, you know, state hospital and stuff like that. The people are resourceful and they are looking, if they're looking for opportunities, you can't always be like trying to be as vigilant as possible because it's so easy to drop your guard.

• 1:23:07David Puder?

  Yeah, I think, I think that keeping the frame, right? And then getting supervision from a good forensic, a forensically trained person, you know, if you're, if you're listening to this and you have a particular patient you're thinking about and your anxiety is super high and you lose sleep over it, that's a good, that's a good reason to reach out to an experienced colleague in the community to get, you know, a one-time consult. Most, most psychiatrists will do a one-time consultation. They're more than happy to it, especially if you're like, you know, if you're, if you're a little bit less experienced, if you're out,

• 1:23:46David Puder?

  you know, in a small city, please reach out, please, you know, I'm sure Blair wouldn't mind getting an occasional consult. I don't know if I could put you out there, no?

• 1:23:59Speaker 01

  No, I'll ask Dr. Cummings or, you know, I'm still very much learning, especially in different populations. I mean, especially with parents and kids. I mean, there's so many, there's a lot of parents that were scared of their kids, you know, there's so many different situations to be cautious. But I mean, that's a little outside this realm, but the, the truth is, one thing I did want to just kind of close it. Dr. Cummings, as far as treatments, I know one of the articles you sent talked about first generation, I know we mentioned serotonin, you know, as far as more of the bi dysmorphic disorder, but it may be more of an OCD type nature, but one of the articles that I know you had sent, you said maybe the first generation, it wasn't, wasn't a lot better, but like, what do you think about us treating as far as pharmacologically?

• 1:24:44Speaker 01

  I know we talked about maybe the CBT part.

• 1:24:47Speaker 02

  Certainly the broadest category of medication that's been used to treat.

• 1:24:54Speaker 02

  Delusions, particularly given the evidence that elevated dopamine signal transduction appears to play a role in a large number of delusional contexts are dopamine antagonists. I don't have a strong opinion about whether first or second generation are better. I think that depends on the individual and what they respond best to. But my first choice, given absence of any other guiding data would be probably a dopamine antagonist and somebody who is delusional.

• 1:25:31David Puder?

  So, so you start with a dopamine antagonist. When would you think as well about something like clozapine?

• 1:25:42Speaker 02

  If the person has evidence of treatment resistance.

• 1:25:45David Puder?

  Yeah. And then when you, when you think of injection versus not injection?

• 1:25:52Speaker 02

  Oh, I think of injection very early on. You know, it's one of the major faults in the U.S. is we don't use long-acting injectable antipsychotics nearly as often as we should. And that's one of the reasons we have frequently bad outcomes is that, you know, the, the rate of adherence to oral antipsychotics universally across all the studies done in that area is below 40%, often below 30%. Well, these medications don't work if people don't take them.

• 1:26:25David Puder?

  Very good. Yeah, so start with an antipsychotic cognitive therapy, right? Can be of some help.

• 1:26:32Speaker 02

  Mm hmm. Oh, yes. But, but wait for the cognitive therapy until you get the delusional intensity down to the point where the person appears able to begin to entertain the idea that maybe their delusional thought just might not be true.

• 1:26:54Speaker 02

  Because at that point, then you're ready to embark on cognitive behavioral therapy to try to help the person.

• 1:27:02Speaker 02

  Use psychological tools to overcome their delusions.

• 1:27:06Speaker 01

  And there could be a serotonin, like you mentioned for, you know, by dysmorphia. There's more of an OCD, maybe there could be more of a serotonin agent like a or something.

• 1:27:16David Puder?

  More, more, more for the like body dysmorphia, OCD. Yeah.

• 1:27:22Speaker 02

  Yeah. Although even in those, if you have somebody who's on a robust dose of SSRI and they're still, you know, their obsessions are still more in the delusional camp, then addition of a dopamine antagonist may be worth considering. Although I will say the other thing that the common mistake with the SSRIs and OCD is underdosing. People, people tend to want to use the antidepressant dose range. For most more severely OCD patients, that's not going to be sufficient. OCD requires higher doses and longer exposure.

• 1:28:01David Puder?

  Yep. Yep. Okay. Well, we need to actually wrap this up. This has been a great discussion. Blair, thank you for reaching out and recommending this topic. Really appreciate connecting with you again. It's been, it's been some years. Glad you're thriving out there and Dr. Cummings, always good to see you.

• 1:28:19Speaker 02

  Yes. Good to see you too.

• 1:28:21Speaker 01

  Thank you.

• 1:28:22David Puder?

  Okay, guys. Take care. Have a good one.