What exactly is psychosis? What happens in the brain of a person with schizophrenia who is hallucinating?

Schizophrenic Rachel Star Withers shares her personal hallucinations and delusions and Dr. Joseph Goldberg, who specializes in researching what goes on in the brain when someone is experiencing psychosis, joins to break down how the brain functions during psychotic episodes.

Host Rachel Star Withers, a diagnosed schizophrenic, and co-host Gabe Howard delve into these intense subjects in this episode of Inside Schizophrenia.

[02:13]Rachel, do you hallucinate?

[03:40] What is psychosis?

[07:00]Signs to spot that someone might be starting to lose grip with reality

[09:00]The types of psychosis

[13:10]Rachel and her wings in Walmart

[17:00] Audio Hallucinations

[24:00]Guest Interview with Dr. Joseph F Goldberg

[29:00]What happens in the brain when you hallucinate

[41:00]The mouse study

[43:00]The empowerment of our brain

Joseph F Goldberg, MD, is a Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City and private practice in Norwalk, CT. His primary research interests include conducting clinical trials with novel pharmacotherapies for mania, depression, mixed and rapid cycling in patients with bipolar disorder. Dr. Goldberg has published over 180 research publications and 3 textbooks on psychopharmacology and mood disorders. Dr. Goldberg is a Distinguished Fellow of the American Psychiatric Association and has been listed for several years in Best Doctors in America and America’s Top Doctors.


Announcer: Welcome to Inside Schizophrenia, a look in to better understanding and living well with schizophrenia. Hosted by renowned advocate and influencer Rachel Star Withers and featuring Gabe Howard.

Sponsor: Listeners, could a change in your schizophrenia treatment plan make a difference?There are options out there you might not know about. Visit OnceMonthlyDifference.com to find out more about once monthly injections for adults with schizophrenia.

Rachel Star Withers: Welcome to Inside Schizophrenia, a Psych Central podcast. I’m your host Rachel Star Withers with my co-host, Gabe Howard. Last episode we explored the kind of boring symptoms of schizophrenia, like a lack of motivation. Today’s episode we are flipping it and we’re going to be looking at psychosis so hallucinations delusions all the fun stuff. And we actually have an awesome guest, Dr. Joseph Goldberg, who’s the clinical professor of psychiatry at the Mount Sinai School of Medicine. And he actually specializes in researching what goes on in the brain when someone is experiencing psychosis

Gabe Howard: This is like the popular one, right? This is the one that people think about when they think of schizophrenia. They often refer to it as going crazy. You’re schizo, you’re psycho. This is the language that people are using and it’s this psychosis that they’re thinking about when they’re talking about it. I’m not saying that those are great words, I’m just saying this is what the public has the most knowledge of.

Rachel Star Withers: Oh yeah. And then whenever someone’s like a college student and they’ll always be like, “Yeah, I want to major in psychology!” like this is this stuff they’re thinking of. They want to like major in crazy people like all this exciting and then they get stuff like our last episode, lack of motivation, they’re like, “Oh, maybe I’ll switch majors.”

Gabe Howard: I mean lack of motivation of course is very important as we learned.

Rachel Star Withers: Yes. Oh yeah.

Gabe Howard: But, you are right. This is when. When I first heard Rachel Starr has schizophrenia, I didn’t wonder if you were motivated. I wondered if you hallucinated. Rachel, do you hallucinate?

Rachel Star Withers: I do. I hallucinate, I always tell people, I mean this is just my guess, like 90 percent of the time. Just because it’s like constant little things. Like, I can’t just look into a mirror. I have to be real careful with my reflection because my mind will just kind of start manipulating it. Little things I constantly, like I’ll hear ticking and scratching noises that aren’t really there. I’ve had it since I was a kid. So I’ve learned to kind of live with these little ticking clocks and stuff that I can’t see. They just exist, yeah.

Gabe Howard: And just to clarify these hallucinations exist even though you are medicated and under the care of a psychiatrist and are living well in recovery? There’s still just that little bit that, for lack of a better phrase, bleeds through?

Rachel Star Withers: Oh yeah. And I’ve had much worse, which we’ll talk about in our episode today. But yeah, even being someone who, you know, would like you just said is recovered or very stable high functioning. My psychiatrist the other day told me that I was the most high functioning patient she had. And not just the schizophrenics. Like I was just the most high functioning period. I’m like, “Well thank you. I think.” It’s like, OK.

Gabe Howard: All right, Rachel, what exactly is psychosis and what are some common misunderstandings that pop culture creates? Let’s get those right out of the way right up front

Rachel Star Withers: Kind of like the word schizophrenia, psychosis also is one of those like cool words that you just want to throw in for like effect. I think that’s what’s happened with our culture because even I, like when I was looking at this episode, I kind of was like, what exactly is it? But psychosis is an umbrella term. OK. So that’s for anybody who is having experiences that are not based in reality, and psychosis is a symptom it’s not a disorder. So I can’t go to the doctor and be diagnosed as psychotic. It’s a common symptom though of many mental disorders and especially schizophrenia. And just to be very clear, psychosis has nothing to do with psychopathy or being a psychopath, which I also was kind of like I had to look that up because I’m like what? What is the connection? Psychosis is a symptom while psychopathy is an actual personality trait.

Gabe Howard: We hear psychopath a lot, and again in pop culture, but I don’t think that psychopath and psychopathy is something that the medical establishment spends a lot of time on. Right? The only reason that it’s permeated our society is because it’s a storytelling device, not because it’s an actual mental illness that we all need to worry about. Right?

Rachel Star Withers: Yes. Yeah. Again has nothing to do with schizophrenia or psychosis

Gabe Howard: If someone is psychotic or has psychosis then it just means that their mind is losing grip on reality. Whereas, when we think of a psychopath, it’s somebody that doesn’t have feelings for others and could be violent or reckless or act in anti-social ways.

So to drill it down. What is psychosis?

Rachel Star Withers: It is used to describe conditions that affect the mind where there’s been a loss of contact with reality. So you might also hear a “psychotic episode” or “period of psychosis.” But it’s one of the defining criteria for diagnosing schizophrenia, as you have to have had some sort of episode of psychosis in some way. And different symptoms of what that is, so, delusions, believing things that are not true. Hallucinations, experiencing things that other people around you do not. And I find this really interesting is that also kind of what falls under that is incoherent speech or nonsense speech. So like that for family and friends who might be kind of worried. That’s what they see. So people on the outside, you might see a schizophrenic kind of saying things that don’t make sense. I even saw one thing that was like slurred speech, which my speech slurs all the time and people will think I’m on drugs or I’m like super drunk at work, and no it’s just something gets off in my speech and I just didn’t realize. Like, oh that’s a sign of starting to lose grip of reality

Gabe Howard: This is really important for friends and family members or any sort of support people in your life because what they see is the slurred speech, the depression, the anxiety, the social withdrawal, the word salad, and it looks off. But obviously psychosis is happening internally. So this is what they see, right? All of those symptoms that you just listed is what the person will see from somebody that is experiencing psychosis. Correct?

Rachel Star Withers: Yes. I’d say with me, sometimes people actually will tell me that my eyes look wild and I don’t really know what that means, but my mom has said it multiple times. I’ve even, I teach modeling and acting classes sometimes to kids and I’ve had kids like kind of raise their hand and say that that something looked odd about my face and they can’t really tell me what. So, I don’t know if maybe I’m like more expressive and I don’t realize what’s happening. But yes. So if you are like a loved one out there, my mom always asks, should she point it out or not? Like she’s afraid of making me self-conscious. I want to know. Give me a heads up that maybe things are not correct because I need to know, yeah, when my mind is starting to slip. So for me it definitely helps. So those little triggers. If you kind of start to notice them in your loved ones with schizophrenia, kind of point that out to them so they can be aware, okay, I might be starting to lose grip with reality.

Gabe Howard: It’s also important to know though if they argue back this is now not the time to plant your flag and be willing to die on the hill. For example if Rachel says it’s snowing inside my room, I will point out, I would say Rachel it’s not snowing in here. Now if she fires back, yes it absolutely is, I will say something along the lines of, okay, well how cold do you think it will get? And that way I can try to gauge her reaction to get her the best help possible without angering her and setting myself up as her enemy. Now that’s kind of tough because people feel like, no, no, no, I must convince the person experiencing psychosis that what they’re experiencing is wrong. But remember medical condition, medical help. So you know that’s a little tough, right? Because depending on where you are in your recovery that pointing it out may work or it may not. So it pays to be nimble.

Rachel Star Withers: And, one thing I try and stress to people to help them understand about like how intense hallucinations and delusions can be. You can tell me something isn’t real, but that doesn’t make me stop experiencing it. In my logical mind right now, I have no that let’s say there isn’t a dark figure standing beside me, but I’m still seeing it. So all the logic in the world doesn’t make me stop seeing that figure. I just have to kind of keep reminding myself it’s not really there, it’s not really there, and do my best not to react to it.

Gabe Howard: Rachel, let’s move on to types of psychotic episodes. I was really surprised that psychosis is not just one thing. There’s actually like subcategories of psychosis

Rachel Star Withers: And I thought this was so cool that there are subcategories because they’re ones that a lot of people experience. Most of the normal world thinks, OK, only people that are super mentally ill would have hallucinations or delusions. But one of the subtypes is a brief reactive psychosis, and that occurs during times of extreme stress. So for instance, the death of a family member, going through something like a traumatic car accident, or some sort of like big event like that, a surgery, and someone can yeah, go through a psychotic episode. It can be anywhere from days to a few weeks, but you usually come out of that with time. Then you have drug and alcohol related psychosis. So, obviously you know my ravers out there, that’s what we think of. But even, you know, if you’ve ever been under anesthesia and you’re coming out and you’re in that kind of loopy phase where you’re like a little bit giddy but also you’re not sure what’s real or not.

Gabe Howard: Right. And it’s very typical not just of, we understand that people do drugs or get drunk and they can experience these things, but it’s also important to understand that it can happen via pain medication. It can happen via surgery. It’s not a one size fits all. One of the things that we’re trying to establish is that psychosis is a lot more normal than I think people want to admit. As you said, it’s not just the severely mentally ill. But then of course the last one is organic psychosis which is due to disorder.

Rachel Star Withers: Right. So organic psychosis, that is due to some sort of mental disorder or injury. So, for instance, different types of brain injuries, yeah, will then cause some sort of psychotic episodes. That could be temporary or last forever.

Gabe Howard: And that’s really what we’re talking about mostly in this episode, organic psychosis as it relates to schizophrenia and mental illness. Right?

Rachel Star Withers: And it can either have a slow onset, which is actually good, a slow onset. You tend to have milder psychosis. Whereas something that’s very like quick and traumatic. So just suddenly being thrown into losing grips of reality those are pretty bad psychotic episodes. If someone stops taking their medication they usually will go into a pretty rapid transition of psychosis. And those are kind of like, for my schizophrenics out there and loved ones who live with them, I feel like those are the most noticeable when someone goes off their meds. Is those quick kind of dramatic transitions. For me, unfortunately, that has happened in the past where I thought I was, you get in this mindset of, oh I mean I’m better now, and you’ll just stop taking your meds. Don’t do that, it’s bad. But I did and yeah I spin out of control pretty quickly.

Gabe Howard: Rachel, let’s talk about personal experiences. As you said, you have hallucinations. You have delusions. Let’s talk about your, Rachel’s, personal experience with psychosis

Rachel Star Withers: I have the little baby ones all the time like I said earlier in the episode. Like I have to be careful around mirrors. And if you’re like, Okay, Rachel, just you know be careful brushing your teeth. You don’t realize how many mirrors there are in real life until you like try and avoid them. So think about your reflection in things, in windows. Where I work there’s like multiple rooms that have these giant mirrors on them and I always like kind of position myself to the side so that I’m in between them. So I can’t see my reflection because it just, it starts to mess with me. And those are just like my little baby ones that are kind of always floating around. One of the really intense ones that has always stood out in my mind was I was walking through Wal-Mart and suddenly I was like oh my god can they see my wings? And I was all crap do I have wings? I think I have wings. OK. Are they hidden? Shoot, should they see my wings> And I’m like sitting there in the middle of Wal-Mart like having this like huge crisis in my mind about my wings, and you know I’m like, what, should I ask someone can they see my wings? Do I call someone? And I mean this went on, I’m not sure how long, but it felt like hours of me being confused about me having wings or not. And eventually I just went to my car and I sat there until I was kind of stable. Sometimes when I get in that situation, and I don’t get stable I’ll call my parents to come and get me. So, they’ve had a few situations. They had to pick me up at a job once and I was hiding under the table. Very, for me that was embarrassing. I hated for co-workers to see me that way, but I just, I don’t know. I just crawled under the table and OK this is where I live now. So and if you’re like, Rachel, that’s stupid. You know why would you suddenly want to be under a table? Why would you think you have wings? I don’t know but that’s what I thought

Gabe Howard: When you thought you had wings, could you see the wings or did you just believe that the wings were there?

Rachel Star Withers: That case, I was confused. It was I’m going to say it wasn’t like I was like Yeah let’s go run and jump off the top of the Walmart and fly away. It was more of a confusion. I was like do I have wings? I think I have wings? They should be hidden. But it was more of just like this crisis in my thoughts of oh my god what do I do?

Gabe Howard: So that’s really the difference between a hallucination, which you can see it, and a delusion, which is you feel that it’s there but you can’t see it. Am I explaining the difference between hallucinations and delusions correctly?

Rachel Star Withers: Yes. Yes.

Gabe Howard: And both of them can be present in psychosis.

Rachel Star Withers: Mm hmm.

Gabe Howard: Like you can just have hallucinations, you can just have delusions, or you can have both.

Rachel Star Withers: Yes, happening at the same time which can really feed into each other even. Last night, I had a pretty bad episode where I was just laying in bed like I was just you know trying to go to sleep and there was something in the ceiling above me running around. Now I know in real life, there was not something in the ceiling above me running around, but I just kept hearing it. It just went on and on just back and forth back and forth back and forth. In the meantime, there’s also like this weird crackling noise outside of my door and I can tell you exactly where it was like It’s like it’s out the door to the right about two feet you know that’s where the sound was coming from. And then I have this radio that wouldn’t stop playing and it’s caught between stations so I can’t make out what they’re saying on the radio but that’s what it sounds like. And I’m just like this goes on for like a while last night until I finally took a sleeping pill because I’m like this is, this is a lot. This is a lot. And it was just kind of all that stuff together just going on that was like I you know and I don’t know how to make it stop. And I knew the crackling noise wasn’t real because my dog would have like been searching for a tree like you know anytime they hear like a bag or something. So, like I know that part’s not real because he was passed out.

Gabe Howard: When we talk about hallucinations and delusions. Let’s talk about what makes a hallucination because that can affect any of the senses right sight sound smell taste and touch. But I understand that one of them is more common in schizophrenia than all the others

Rachel Star Withers: Yes. So two thirds of patients with schizophrenia have auditory hallucinations. That does not mean they only have auditory. That just is like the the predominant one the voices and whatnot. And I used to think like oh God I don’t have those because I didn’t have like a voice that just talked to me all the time minor very subtle it’s more like I said a radio is playing like talk radio and it’s caught between stations so I can’t make out what they’re saying but they’re like they’re just talking non-stop. Again no clue if it’s about me or what. It’s just on and on and on and I’ll hear my name being called a lot which is it’s usually my mother’s voice which is kind of freaky because like she won’t be home and I’ll hear it. I think she’s like something’s wrong with her so I’ll go through the house searching and now I usually end up texting her like hey where are you at? Just like oh I’m at Starbucks. I’m like OK, I obviously didn’t hear you screaming my name. But it kind of freaked me out a little bit, you know? I worry that she’s hurt or something.

Gabe Howard: That’s very interesting to me because my understanding of auditory hallucinations are that you hear it inside your head. But what you’re describing you would have to hear it outside your head because you said that you feel like you hear that your mother is calling you from other rooms. So?

Rachel Star Withers: Yes, Gabe, and fun fact is that people with schizophrenia usually hear audio hallucinations outside of their heads, not inside. So usually schizophrenics, people schizophrenia, hear their audio hallucinations like around them. So for instance, they might hear something in the wall behind them it’s not inside your head like Oh my God where is it? I hear things a lot of times that I would be like Yeah that came from upstairs probably the kitchen area by the way it sounded. So the sound kind of like my mother’s voice calling out it comes from a specific direction not just this booming voice inside your head

Gabe Howard: Let’s move on to delusions because that’s the other common symptom of psychosis and I understand that there are two main types but can you define delusions simply for us

Rachel Star Withers: Delusion is a strongly held belief that is false. And to me there’s so many things that you could apply that to. But the two main ones in mental disorders are paranoid delusions and delusions of grandeur. And the one most associated with schizophrenia is paranoid. So that’s where you think like someone is after you. You are suspicious of individuals organizations. Somebody is plotting against you tracking you. I’ve never had to the extent of you know the FBI is after me kind of delusion but I get very paranoid in work situations. And it’s something I have to watch because I’ll just start thinking that people hate me for no reason and that they want me gone that they’re plotting against me you know. And it’s just like I, it’s the same thoughts through the years I’ve noticed. So I’ve kind of gotten used to noticing like OK oh that’s the same thought I had back when I worked here and here. That’s not real, Rachel. And I’m kind of learning to just notice when that comes up and then delusions of grandeur that is where like you have authority power that you really don’t or you think you’re some sort of like savior. And I once had a friend who had schizophrenia and she believed she was an Aztec god, and like bought a plane ticket and was going to go, straight up go, to South America, and her family stepped in. But she really thought that no this is yeah this is real.

Rachel Star Withers: And to get a little personal, so the past two years I have been dealing with a rare flesh eating bacteria

Gabe Howard: Because just because you’re schizophrenic doesn’t mean that physical health isn’t an issue.

Rachel Star Withers: Right. And it’s been though the biggest issue with it has been going to different doctors and then them seeing the diagnosis of schizophrenia on there. Then seeing that oh she’s been on antipsychotics and the fact that I was so healthy, the flesh eating bacteria wasn’t tearing me apart the way it would normally because I was healthy and it was kind of scary because I start to like not believe myself either. I had some doctors saying that OK because she’s on Adderall, she’s doing this to herself. Kind of like meth addicts. And I was just kind of like I’m not doing this to myself but maybe I am you know if the doctor if this doctor says I am then maybe I am. And my psychiatrist I actually set up like a special meeting for them to evaluate me because I was like I I don’t know am I causing this or not. And they went through and it was deemed that I was not causing it. It was not because of my, you know, antipsychotics and antidepressants and different things like that. But, it kind of freaks you out because I’m dealing with a physical thing but I’m not sure if it’s real or not. And it caused a lot of pain. And what had happened was the bacteria, it got into my facial nerves on my right side. So I’m in so much pain but I’m like, oh crap I want to go the hospital if it’s a hallucination. You know, they’re gonna think I’m crazy. And I’m like, is it real or not? It turns out it was real. I did have bacteria eating at the side of my face. But, it’s just like I doubted myself. I had no clue like and I was scared. If I’m making this up Oh God like I’m gone I need to be like inpatient now.

Gabe Howard: And obviously having schizophrenia on your medical record made people look in a different direction. So you weren’t sure if it was a hallucination or a delusion. They weren’t sure if you were doing it to yourself and just forgetting. So this was another barrier to getting the correct diagnosis which of course.

Rachel Star Withers: Mm hmm.

Gabe Howard: It is another barrier to getting the correct care. These are real realities to people.

Rachel Star Withers: Oh yeah. And to be fair it was a rare flesh eating bacteria. That is not a normal, everyday thing. And you had someone who says they’re schizophrenic like Yeah well clearly you doing this to yourself is the most realistic answer.

Gabe: Well be right back after these messages.

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Gabe: And were back, discussing psychosis.

Gabe Howard: Rachel, earlier you had the opportunity to speak to Dr. Joseph Goldberg who is the clinical professor of psychiatry at the Mount Sinai School of Medicine about psychosis, and he’s an expert in psychosis

Rachel Star Withers: Yes. So awesome. Let’s roll that interview right now.

Rachel Star Withers: We’re here with Dr. Joseph Goldberg who is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York City, and he has a private practice in Norwalk, Connecticut. Thank you so much for being here, sir.

Joseph Goldberg, MD: My pleasure. Thanks for having me.

Rachel Star Withers: Now you have a very extensive background of research which is why the reasons we wanted you here on this episode today you’ve definitely explored a lot of different situations in different mental disorders. Based on your research what causes psychosis in mental disorders

Joseph Goldberg, MD: Well probably the short answer and the most honest answer is no one knows exactly for sure, but the best guess thinking is that there are particular circuits in the brain that regulate perception and thinking and that those circuits can become dis regulated under certain circumstances. They can become dis regulated when someone takes a hallucinogenic drug like LSD or cannabis or PSP. They can become deregulated when someone’s in a delirium. Like if you’re really sick with an infectious disease your mind can play tricks on you and you have misperceptions of things or psychosis which by definition means false perceptions or false ideas. Psychosis can also happen sometimes just because of innate problems with those circuits not caused by any drug or infection or any other identifiable cause. There may be some genetics involved people with psychotic illnesses like schizophrenia or manic depression. Sometimes not always but sometimes have a higher chance of the family member with a similar condition. But at the end of the day we think it’s problems with brain circuits that regulate perception and thinking and we have some ideas about which circuits are the ones involved and how certain chemicals in the brain regulate those circuits but that’s about as close as I think we can get to understanding what causes psychosis

Rachel Star Withers: Across the board what have you found more people struggle with during psychosis, hallucinations or delusions?

Joseph Goldberg, MD: I think it depends on what the nature of the problem is. If someone has schizophrenia, for example, typically you’ll see both delusions and hallucinations. They can occur at the same time or they may be more of a predominance delusions probably tend to be more persistent because when you think about it if you’ve attached importance to a particular idea like let’s say you think you’re being followed by the FBI or you think you’re being spied on people tend to invest some belief into that idea and to have a belief break up to the point where someone could look back and say oh that was a false idea why did I think that usually takes more time. So delusions tend to not resolve quite so quickly whereas a hallucination which is a misperception any of our five senses could play tricks on us. Sometimes they’re more transient. Not always people with schizophrenia can have long standing or chronic hallucinations they may hear voices every day they may hear voices periodically but then in between the experience of the hallucination they have delusions about the voices. So for instance I hear the devil talking to me and telling me to do bad things and when I’m not hearing the devil I’m thinking about the devil coming back. So I’d say beliefs tend to be somewhat more enduring in let’s say primary psychotic disorders schizophrenia being the best example in the world of mood disorders like manic depression or just what’s called unipolar depression psychosis can happen also but it’s usually less extensive. It’s only in the context of the mood problems so examples there might be if I’m manic and psychotic I might think God is telling me that I’ve been chosen for some important project or I might have fantastical ideas that I’ve invented something and I’m going to be the most important person in the world and it’s all in the context of my mood. So if I have a mood episode of mania then I might have delusions that go along with it or if I’m depressed they might have false ideas that I’m worthless I’m no good I deserve to be punished. Delusions tend to be more common than hallucinations in mood disorder patients. It certainly can happen if I’m depressed I’ll hear a voice telling me that I’m bad but more often than not. If psychosis happens if I have a break with my ability to tell what’s real from what’s not it tends to coalesce around my beliefs about myself. So psychosis your tendency delusions and hallucinations more commonly but delusions can be persistent and in psychotic mood disorders usually delusions or the more common thing hallucinations a little less common

Rachel Star Withers: You talked a little about circuits and of course no one knows exactly what’s causing psychosis but have you been able to notice like a difference? So I’m a schizophrenic. Between how my brain would let’s say when I’m a good solid normal like at the moment kind of you know basic state versus if I’m having a hallucination? From different research have you seen a difference in the brain of those two like situations?

Joseph Goldberg, MD: When symptoms are active, the brain areas that are responsible for processing information become more active sometimes abnormally so let’s take delusions for instance if I’m having active delusions Oh that I don’t know my food is being poisoned or my life is in danger circuits that are involved in judging reality in that sense or that sort of make me hyper alert to sort of a fear of a predator or fight or flight or suspicion about someone’s malicious intent. There’s particular circuits of the brain that we know become overactive and if one was measuring say blood flow in those parts of the brain you’d find that they’d run a little hotter. Just like if you were running a coffeemaker it might heat up or any electrical device that there’s more flows through the circuitry so you’ll actually see more activity, excessive activity in those areas. You can also see diminished activity in other areas. So one of the problems, say in schizophrenia, isn’t just having psychosis, it’s also having what we call negative symptoms, where there is the absence of normal functioning. So that may mean having very few thoughts or having a hard time coming up with thoughts. Thoughts get blocked, they get slowed down. It’s hard to muster the emotion it’s hard to have attention and processing of information. So in other parts of the brain in particular an area called the prefrontal cortex we can see on say brain imaging scans less activity than normal. So areas that are running too hot or overactive you might see more brain activity and blood flow in areas that are under active you might see less and then the last thing I guess worth noting when it comes to the brain is over the course of time in persistent psychotic disorders like schizophrenia there’s an awful lot of concern that it’s an illness that may be a degenerative illness which means that over the course of many years nerve cells get lost they die and that’s sometimes evidence on a brain scan for someone who’s been ill for many many years. One might see abnormally large areas of empty space in the brain. We all have empty space in our brain. All those squiggles that you see when you look at a picture of the brain called GI rye and salt say that’s the space between your brain and the skull and when nerve cells die off that space gets bigger. So we call that cortical atrophy and that can be bigger in people that have been ill with psychosis for many years. And then in the middle parts of our brain we have spaces called ventricles that’s where cerebrospinal fluid flows through and in people that have had psychosis for many years. Those empty spaces get bigger because when nerve cells die off they’re replaced by empty space. So people talk about enlarged ventricles or abnormal atrophy in the cortex as signs that nerve cells have died off in someone that’s been ill for for many many years.

Rachel Star Withers: I’m asking because I think it’s very you know we have the media’s representation and then the public tends to go with whatever the media shows us with in regards to mental disorders. But I think like if I’m watching let’s say well one of the new movies out the Joker or whatever it kind of seems like psychosis is a switch a person is either you know normal or they’re out of their minds whereas me as a schizophrenic so many times you know I can still hold a conversation and I know that I am hallucinating I’m having issues. And to me there’s like different levels where yes sometimes I can’t leave my bed I’m like totally I call it tripping but I’m not on drugs. Totally tripping. Can you talk a little about that? As far as being able to still function with psychosis to the point of then not?

Joseph Goldberg, MD: Yeah sure. So I wouldn’t look at the joker as a good example of mental illness. I mean that that portrayed a lot of very various kinds of mental illness that don’t usually fit together and I wouldn’t use that as an example of anything except a lot of fiction. But yeah and people with schizophrenia there can be periods of episodes where symptoms are just more prominent and then more quiet periods. So if I have schizophrenia I may have an episode where I am especially suspicious of people or disorganized or able to take care of myself or I might stop eating because I think the food is poisoned or I just withdraw within to myself with a lot of negative symptoms. And during those times during an episode or a flare it’s certainly more hard to function. It becomes a source of disability if you’re trying to maintain a household or go to school or have friendships or relationships or hold a job in between episodes. The hope is that with proper treatment and good recovery strategies people are able to to have more of a life so they’re able to go to work and go to school and take care of their families. And some people who are you know very able to call upon their resilience and their strength you know become people like John Nash who won the Nobel Prize or you know leaders in their fields and very effective. But then there’s also a substantial number of people who never really quite regain the level of functioning that they had before they first got sick. Some experts would say that’s maybe a third to a half of people with schizophrenia who certainly can function but not quite at the. So that might be somebody who was a promising student and looked like you know the world was open to them and then somewhere in late adolescence usually or college years they might have had a psychotic episode and never fully recovered from it and then they didn’t quite get back to school and then they can sometimes have a decline from what their highest level of functioning might have been and even if they are aren’t having active psychotic symptoms or negative symptoms sometimes people with schizophrenia also can have what would be called cognitive symptoms where it’s just hard to process information. Their attention is jeopardized their ability to reason and think through things is poorer than then would be the case in somebody without schizophrenia. The original name for schizophrenia was dementia peacocks and by dementia. It’s similar to the idea of Alzheimer’s disease but unlike Alzheimer’s disease it’s a condition that comes along and youth and young people. Alzheimer’s is an older adults but many people still think that for some people not all but for some people with schizophrenia that dementia type course can happen if it’s there and someone has persistent problems over time and they never really regain their personal best than they sometimes have to revise expectations and for them can sometimes be very disabling. I’d say there is heterogeneity there are the John Nash’s there are the more middle of the road people that may not quite have reached the expectations they might have anticipated when they were when they were younger or where they got sick and then there are some people who have unfortunately more of a deteriorating course over time

Rachel Star Withers: How do different medications work to prevent psychosis?

Joseph Goldberg, MD: So we are still kind of in a primitive place with understanding the pharmacology of schizophrenia. One of the circuits that I was talking about before that’s involved with a psychosis types of symptoms is a circuit that tends to run on a chemical called dopamine. And so for many many decades our medicines have been drugs that will tweak or modulate how dopamine works on those circuits picture a circuit like goal cars on a highway. And by controlling the flow of cars on the highway you make the highway more efficient let’s say. So these chemicals you know we used to think about chemical imbalances and that’s no longer thought to be a valid way to think of these things it’s more about problems with circuitry so the chemicals aren’t imbalanced it’s just that the way they run on the highway makes the highway more efficient or less efficient. Think of rush hour versus normal traffic flow versus nobody is getting on the road too much activity too little activity. So all of our medicines to some degree regulate how dopamine flows across these circuits the receptors that dopamine binds to and there are some receptors that seem especially important for psychosis. There is some that seem especially important for motivation and for rewarding activities there is some that seem especially important for attention and cognition. Some of the newer medicines that are coming along are meant to target specific subtypes of receptors that dopamine binds to but the limitation in our field is that we haven’t really broken beyond the role of dopamine and dopamine is important in schizophrenia and psychosis in general. But it’s probably not probably it is not the whole story and we know that there are other chemicals and circuits and pathways of higher up in the brain that tell these dopamine circuits what to do. There are pathways that come from higher up in the brain that run on a different chemical called glutamate. And there’s some thinking that people with schizophrenia may have problems with specific receptors for glutamate and we haven’t yet figured out a good way to get to those receptors so there’s optimism that in years to come we’ll have other circuits and other pathways or other ways to get at those circuits than just blocking dopamine or modulating dopamine by getting at some of these other higher up circuits that control things. But we haven’t even broken through there yet

Rachel Star Withers: Where do you see pharmacological industry going in terms of treating different mental disorders?

Joseph Goldberg, MD: Well so as I was just saying that there’s great interest in exploring medications that work on other chemicals in circuits than just the dopamine circuits. There’s interest in certain kinds of Syria tone and receptors that might modulate psychosis. There’s one in particular called the 5-HT2A receptor in a few years ago a new drug came out and it’s another way of trying to treat psychosis. It’s been studied and gets used to treat psychosis very specifically only in people with Parkinson’s disease. It’s beginning to get looked at in schizophrenia. So far the results are not as robust as people would hope. But that’s a different circuit that people try to get at. There is a class of schizophrenia medicines known as dopamine partial agonists. We have three there’s a fourth one that’s in development coming along and those are medicines that are more like smart drugs they know which circuits dopamine runs to slow on and they know which circuits dopamine ones to fast on and it kind of modulate things it increases or decreases traffic based on whether the traffic is too high or too low. So that’s a kind of a nice innovation above and beyond just blocking dopamine all over the brain. So I don’t think the field is as interested in inventing yet another dopamine blocking drug like the kind we’ve had since the 1970s I think the interest is more coming up with smarter drugs to modulate too much or too little and in which parts of the brain and how to get at these higher up circuits that ultimately will influence the effects of dopamine in other circuits.

Rachel Star Withers: Well thank you so much, Dr. Goldberg. I love this interview with you. Thank you for letting us kind of get a glimpse into your side there, the research of pharma therapies and whatnot. Thank you so much, sir, for being here on our podcast.

Joseph Goldberg, MD: My pleasure. Thanks for having me.

Gabe Howard: Rachel, another incredible interview. Excellent job

Rachel Star Withers: And I absolutely loved how he explained the change in medication and pretty much where the look of medication is going for people with mental disorders. I like that it’s no longer looked at as a chemical imbalance but there’s just so much more going on in the brain. And we did cut the interview a little short. I’ll go and tell you I asked him so many more questions about tardive dyskinesia which is not the focus of this podcast but just pretty much the research going on of what causes that different things and it’s all fascinating and for me it’s all hopeful that there’s so many like. I want to say options but yeah that could be available to us in the near future for treating schizophrenia and it reminds me so there was this mouse study that I’m obsessed with. They had all these mice and they were given hallucinogenics. So LSD. And then they showed them several onscreen images. They recorded their brain cell activity in the mice as they were tripping and looking at these images. And so what they thought they would see was that like the mice were just being like bombarded with all these like crazy stuff and like the brain was just like whoa overwhelmed. And actually it was the opposite. They found out that the mice actually still saw the exact same thing as they would had they not been on the drugs but the brain couldn’t understand that information. So the hallucinogenics the drugs wasn’t affecting what they saw it was affecting how it perceived it. I don’t know to me that’s just like really interesting

Gabe Howard: It does make sense because we tend to think about psychosis as it’s changing what is happening around us and that’s the way that it’s played out in pop culture right. Whenever somebody you know does drugs or gets drunk or gets high or whatever everything gets psychedelic and wavy and but what it’s saying is that no your brain sees it for what it is. It takes it in exactly how it is and then it misinterprets that information. So you see blue but your brain tells you that it’s red. And why this is important of course is because it lets us know how to treat it how to get ahead of it and hopefully in the future there will be better solutions to this process. As long as we understand what the process is

Rachel Star Withers: Something that for me has always had like an odd comfort is that my brain is making the hallucinations and growing up. I’ve always had a lot of very scary ones dark figures just very scary imagery. Growing up religious I was told it was demons. So that helped. Oh you’re just seeing Satan manifest. Like Oh. OK. All right, that seems normal. But now having still having these exact same hallucinations my whole life and knowing that my brain is making them it’s kind of cool like how fascinating. Like our brains are what they can create what they can make. You know the fact that I know it’s not real but I hear these voices you know it’s just it’s really fascinating to me and to me. I don’t know it’s kind of empowering to know that my brain is that smart that it can do like all that cool stuff. I wish I could control it a little better but it is my brain it is a part of me.

Gabe Howard: Rachel I do think that is empowering. I think that knowledge is empowering. I think that information is empowering. You know one hundred years ago, one hundred and fifty years ago, or even seventy five years ago, this was so misunderstood that people with the illness had little choice but to believe that they were possessed or that their brains were just so broken that they would have no quality of life. Understanding the process understanding what’s going on and being able to openly discuss what’s going on it really can’t be anything other than empowering. It shows great progress and I think that’s what’s important. That’s why shows like inside schizophrenia are so important because we’re talking about these things in an understandable and relatable way that everybody can figure out and participate in sincerely. Fifty years ago this was so incredibly misunderstood. We were just putting people in institutions and frankly throwing away the key. That’s literal sometimes.

Rachel Star Withers: Mm hmm.

Gabe Howard: We need to move past that because people who experience psychosis are living full and productive lives. You are complete proof of that, Rachel

Rachel Star Withers: Thank you, Gabe. An early diagnosis of psychosis is what improves long term outcomes. Friends and family do your best to notice things some of the red flags are someone who’s becoming socially withdrawn. If it’s always like a straight A student and the person starts performing you know dramatically less. They start failing that is a huge red flag. Same thing with work. Someone who is always on time isn’t suddenly, they’re always getting like late write ups and things like that and even just someone who’s more distressed or agitated but they can’t really understand or tell you why. These are all red flags that psychosis could be starting. Notice those things point them out. Track them but don’t feel that it’s your job to make the person change. It is a medical situation. Do however make yourself open so that the person with schizophrenia like totally feels they can talk to you about it. Me and my mom will go on long walks and sometimes that’s when I’ll tell her like this weird hallucination because I don’t want her to freak out. I don’t want her to run and get me medical help. I’m just telling her Hey last night this happened. It was just super weird. I just want to like tell you about it. Psychosis is very serious and it is a difficult symptom but finding ways to manage it is. Absolutely possible and very important.

Gabe Howard: Rachel, as always thank you for being so candid with us

Rachel Star Withers: You’re welcome.

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Rachel Star Withers: Thank you so much for listening. We will see everybody next month and if you haven’t checked out some of our past episodes, we’ve hit on violence in schizophrenia, loved ones, family members, childhood schizophrenia, all different topics so please check those out. Share, subscribe and we will be back with you next time.