Adrienne T. Gerken, MD

Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:

1. Do not begin by challenging delusions

People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.

2. Validate the emotion, not the psychosis

Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.

3. Explicitly state emotions and intentions

People with psychosis may have difficulty processing others’ emotions and facial expressions.¹ We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.

4. Reflect the patient’s own words

We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.² Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”

5. Be intentional with gestures and positioning

People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.¹ We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.³

Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:

1. Do not begin by challenging delusions

People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.

2. Validate the emotion, not the psychosis

Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.

3. Explicitly state emotions and intentions

People with psychosis may have difficulty processing others’ emotions and facial expressions.¹ We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.

4. Reflect the patient’s own words

We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.² Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”

5. Be intentional with gestures and positioning

People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.¹ We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.³

Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:

1. Do not begin by challenging delusions

People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.

2. Validate the emotion, not the psychosis

Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.

3. Explicitly state emotions and intentions

People with psychosis may have difficulty processing others’ emotions and facial expressions.¹ We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.

4. Reflect the patient’s own words

We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.² Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”

5. Be intentional with gestures and positioning

People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.¹ We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.³

Many atypical antipsychotics, particularly clozapine and olanzapine, are associated with weight gain, insulin resistance, and metabolic syndrome. Metabolic syndrome is associated with type 2 diabetes mellitus (T2DM) and cardiovascular disease, which are among the leading causes of morbidity and mortality in persons with severe mental illness.¹

Clinicians should take measures to prevent T2DM and weight gain in individuals taking antipsychotics before these conditions develop. Metformin re-sensitizes the body to insulin and is a first-line treatment for T2DM. Adding metformin when patients start metabolically high-risk antipsychotics or shortly after they begin gaining weight is an evidence-based strategy to prevent metabolic syndrome.

Evaluate the evidence

In randomized controlled trials, metformin was associated with modest weight loss and improvement in metabolic parameters (eg, fasting blood glucose, serum triglycerides, and total cholesterol) in patients with schizophrenia receiving antipsychotics.^1,2 Metformin is effective for preventing metabolic syndrome and as a treatment intervention; therefore, it may prove most beneficial early in treatment before weight gain or insulin resistance develop.

Importantly, weight gain and metabolic syndrome are risk factors for cardiovascular disease, but the number needed to treat for metformin to prevent cardiovascular outcomes, such as myocardial infarction, is not known. Also, metformin is not FDA-approved for this indication. Clinicians should discuss with the patient the risks and benefits of prophylactic metformin, and consider his (her) treatment preferences.

Tolerability and adverse effects

Metformin generally is well-tolerated. Gastrointestinal (GI) symptoms, including nausea and vomiting (14%) and diarrhea (7%), are the most common adverse effects.² Lactic acidosis is rare and is associated with alcohol use disorders and impaired renal, hepatic, or cardiopulmonary function.³ Because metformin is excreted renally, toxicity could occur in patients with impaired renal function.

Before initiating prophylactic metformin, confirm that the patient does not have T2DM (eg, hemoglobin A_1c <6.5%). A thorough medical history, including alcohol use and kidney and liver function tests, are needed to reduce the risk of lactic acidosis.³

Dosing

Although metformin has been studied at many dosages,² we recommend gradual titration to 1,000 mg, twice daily, taken with meals to reduce the risk of GI effects.

Additional interventions

Metformin alone is not sufficient to mitigate metabolic risk. Providers should address dietary interventions, exercise, and smoking cessation at each visit, and communicate actively with other providers to create a comprehensive treatment plan.

Many atypical antipsychotics, particularly clozapine and olanzapine, are associated with weight gain, insulin resistance, and metabolic syndrome. Metabolic syndrome is associated with type 2 diabetes mellitus (T2DM) and cardiovascular disease, which are among the leading causes of morbidity and mortality in persons with severe mental illness.¹

Clinicians should take measures to prevent T2DM and weight gain in individuals taking antipsychotics before these conditions develop. Metformin re-sensitizes the body to insulin and is a first-line treatment for T2DM. Adding metformin when patients start metabolically high-risk antipsychotics or shortly after they begin gaining weight is an evidence-based strategy to prevent metabolic syndrome.

Evaluate the evidence

In randomized controlled trials, metformin was associated with modest weight loss and improvement in metabolic parameters (eg, fasting blood glucose, serum triglycerides, and total cholesterol) in patients with schizophrenia receiving antipsychotics.^1,2 Metformin is effective for preventing metabolic syndrome and as a treatment intervention; therefore, it may prove most beneficial early in treatment before weight gain or insulin resistance develop.

Importantly, weight gain and metabolic syndrome are risk factors for cardiovascular disease, but the number needed to treat for metformin to prevent cardiovascular outcomes, such as myocardial infarction, is not known. Also, metformin is not FDA-approved for this indication. Clinicians should discuss with the patient the risks and benefits of prophylactic metformin, and consider his (her) treatment preferences.

Tolerability and adverse effects

Metformin generally is well-tolerated. Gastrointestinal (GI) symptoms, including nausea and vomiting (14%) and diarrhea (7%), are the most common adverse effects.² Lactic acidosis is rare and is associated with alcohol use disorders and impaired renal, hepatic, or cardiopulmonary function.³ Because metformin is excreted renally, toxicity could occur in patients with impaired renal function.

Before initiating prophylactic metformin, confirm that the patient does not have T2DM (eg, hemoglobin A_1c <6.5%). A thorough medical history, including alcohol use and kidney and liver function tests, are needed to reduce the risk of lactic acidosis.³

Dosing

Although metformin has been studied at many dosages,² we recommend gradual titration to 1,000 mg, twice daily, taken with meals to reduce the risk of GI effects.

Additional interventions

Metformin alone is not sufficient to mitigate metabolic risk. Providers should address dietary interventions, exercise, and smoking cessation at each visit, and communicate actively with other providers to create a comprehensive treatment plan.

Many atypical antipsychotics, particularly clozapine and olanzapine, are associated with weight gain, insulin resistance, and metabolic syndrome. Metabolic syndrome is associated with type 2 diabetes mellitus (T2DM) and cardiovascular disease, which are among the leading causes of morbidity and mortality in persons with severe mental illness.¹

Clinicians should take measures to prevent T2DM and weight gain in individuals taking antipsychotics before these conditions develop. Metformin re-sensitizes the body to insulin and is a first-line treatment for T2DM. Adding metformin when patients start metabolically high-risk antipsychotics or shortly after they begin gaining weight is an evidence-based strategy to prevent metabolic syndrome.

Evaluate the evidence

In randomized controlled trials, metformin was associated with modest weight loss and improvement in metabolic parameters (eg, fasting blood glucose, serum triglycerides, and total cholesterol) in patients with schizophrenia receiving antipsychotics.^1,2 Metformin is effective for preventing metabolic syndrome and as a treatment intervention; therefore, it may prove most beneficial early in treatment before weight gain or insulin resistance develop.

Importantly, weight gain and metabolic syndrome are risk factors for cardiovascular disease, but the number needed to treat for metformin to prevent cardiovascular outcomes, such as myocardial infarction, is not known. Also, metformin is not FDA-approved for this indication. Clinicians should discuss with the patient the risks and benefits of prophylactic metformin, and consider his (her) treatment preferences.

Tolerability and adverse effects

Metformin generally is well-tolerated. Gastrointestinal (GI) symptoms, including nausea and vomiting (14%) and diarrhea (7%), are the most common adverse effects.² Lactic acidosis is rare and is associated with alcohol use disorders and impaired renal, hepatic, or cardiopulmonary function.³ Because metformin is excreted renally, toxicity could occur in patients with impaired renal function.

Before initiating prophylactic metformin, confirm that the patient does not have T2DM (eg, hemoglobin A_1c <6.5%). A thorough medical history, including alcohol use and kidney and liver function tests, are needed to reduce the risk of lactic acidosis.³

Dosing

Although metformin has been studied at many dosages,² we recommend gradual titration to 1,000 mg, twice daily, taken with meals to reduce the risk of GI effects.

Additional interventions

Metformin alone is not sufficient to mitigate metabolic risk. Providers should address dietary interventions, exercise, and smoking cessation at each visit, and communicate actively with other providers to create a comprehensive treatment plan.