Psychosis or psychotic disorders are mental health conditions in which there is a significant disconnect with or loss of perception of reality, as opposed to other mental health disorders of mood, stress, and anxiety.
The most well-known psychosis is schizophrenia (schizo-split; phren-mind) characterized by a split or disconnect between intellect, emotion, and reality.
It is characterized by
- delusions- fixed beliefs
- hallucinations- unreal perceptions
- disorganized or incoherent speech
- disorganized or catatonic behavior
- negative symptoms of lack of emotional expression or motivation.
The first four symptoms are also called positive symptoms. To make a diagnosis, 2 or more (with atleast 1 of the first 3) of these symptoms should have been present over a period of 6 months with at least 1 month of prominent active symptoms (symptoms present most of the time) which are causing a disturbance in personal, social, and occupational functioning.
It is important to rule out other mental health disorders like bipolar disorder, depression with psychotic features, substance abuse, and schizoaffective disorder (mentioned below).
Delusions are misplaced fixed beliefs or disturbed thinking. Sometimes there is a feeling of these thoughts being controlled by others or being inserted into one’s brain (thought insertion), or one’s private thoughts being publicly broadcasted (thought broadcasting). Other delusions include those of being robbed of one’s thoughts (thought withdrawal), misreading a public message or activity as being especially intended for oneself, or bodily changes like malfunctioning or absence of some organ.
Some delusions seen include persecutory (going to be harmed by people), referential (being sent secret signals), grandiose (considering oneself rich and famous), nihilistic (thinking the end of the world is coming), somatic (magical powers of one’s organs) and erotomaniac (convinced that another person is in love with oneself).
Hallucinations are unreal perceptions most commonly auditory in nature of hearing voices that are influencing, compelling, and may even force the affected person to act on them. These have been medically postulated to be a result of affected speech areas in the brain that cannot differentiate internal self-generated verbalized speech from an external one.
Disorganized speech is a result of expressing disturbed thought content, and does not make sense even though grammar and syntax may be correct. Sometimes new words may be created (neologisms).
Disorganized behavior may manifest as lack of personal care or hygiene, unusual dressing, agitation, giddiness, and abnormal social interaction. Catatonia can occur that refers to a stupor-like behavior with the absence of body movement, expressions, and speech.
Negative symptoms are a lack of emotional facial, gestural, or verbal expressions (blunted affect and alogia), lack of motivation or goal-directed activity (avolition), and diminished ability to experience pleasure (anhedonia). This is mainly due to an inability to express emotions even though they can feel them. The presence of negative symptoms is a poor prognostic sign.
Sometimes subtypes of schizophrenia may be mentioned as part of the diagnosis in accordance with the more prominent symptoms like paranoid (delusions of mistrust and persecution), disorganized (speech and behavior) or catatonic.
OTHER PSYCHOTIC DISORDERS
Brief psychotic disorder is a sudden, and short episode, also called acute psychosis that lasts a few days to less than 1 month, with complete resolution within 30 days. So it is also sometimes called transient psychosis. It is usually brought on by intense stress or emotional turmoil. The person may not have such an episode again or may have one or more recurrences after a period due to a similar stressful trigger.
Psychotic affective disorder is diagnosed in the presence of a major mood component with symptoms of depression or mania. Even with treatment, a patient with affective disorder with psychosis is not expected to return to baseline in 30 days, unlike patients with brief psychotic disorder.
Schizophreniform disorder is the given diagnosis when symptoms of schizophrenia are present for at least 1 month but for less than 6 months. One may recover from such psychotic episode and not go on to schizophrenia. Such an episode can be once off or sometimes recur after a period of time.
Delusional disorders (previously called paranoid disorders) are diagnosed when fixed false beliefs like irrational suspicions of deceptions or conspiracy, grandiosity of self, thinking one is diseased, etc. last more than 1 month, without the presence of the other symptoms of schizophrenia. The person may have hallucinations related to delusions that are not prominent or influencing. However gross impairment of personal and social functioning, negative symptoms, and disorganized speech or behavior are absent.
Schizoaffective disorder is a hybrid condition of psychosis and mood disorder. There should be accompanying episodes of major depression or mania (unipolar) or both (bipolar), along with the symptoms of schizophrenia, with the period of delusions and hallucinations lasting for 2 weeks or more without a major mood episode, so as to not qualify for a mood disorder alone.
Attenuated psychosis syndrome, is a term sometimes used for those who are showing early, mild prodromal schizophrenic symptoms that may suggest that some of them may progress to full-blown schizophrenia with prominent symptoms. This can be an apt stage of medical intervention, and more research is still ongoing in this direction.
CAUSES OF PSYCHOTIC DISORDERS
The causes attributed to psychotic disorders through research and study are multifactorial. The underlying pathology is linked to abnormal brain development and neuro-connections. These include deficient social and neurocognition, smaller brain volumes especially of white matter, hippocampus (involved in memory), amygdala (involved in emotion), and thalamus (involved in receiving sensory inputs), along with abnormal integration, functioning and cytoarchitecture of the frontal cortex (seat for higher functions).
Neurotransmitters (neurochemicals) have also been implicated. Increased levels or abnormal transmission of dopamine, has been seen to make a person give more importance to less relevant and significant stimuli (aberrant silence) leading to the positive symptoms of schizophrenia. Decreased level of glutamate and reduced activity of glutamate receptors (NDMA receptors) has also been seen to play a role. These neurochemicals are often the target of treating drugs.
While genetic factors may play a role, early life factors can also increase the risk of schizophrenia, like infections in early pregnancy (influenza, rubella, toxoplasmosis), Rh incompatibility between mother and child, pregnancy/delivery complications, head injury, severe maternal stress, and infant or early childhood nutritional deficiency.
Psychosocial, family, and cultural factors also play a role. Childhood disturbance and stressors especially in the family and high expressed emotions (EE- hostility, criticism or emotional overinvolvement) have been studied to increase risk. Other factors include any kind of discrimination in society (racial, immigrant, etc.), abuse or emotional trauma in childhood, and substance abuse (especially cannabis).
Schizophrenia affects 1% of the population and presents in the 2nd or 3rd decade of life. Even though there is no direct gender predilection, schizophrenia in men manifests earlier and is more severe. This may be due to the protective effects of estrogen in women against psychotic symptoms, thereby making them more susceptible during later peri-menopausal years or during periods of hormonal imbalance.
Schizophrenia if left untreated not only causes severe impairment in daily life functioning, but can also lead to physical health problems and other psychological problems like depression, anxiety, phobia, substance abuse, and even crime or suicide.
Schizophrenia can be managed with medicines and therapy, that can help the person to lead a socially and functionally fulfilling life. Institutionalization may be needed in 10-15% of patients. The presence of negative symptoms signifies a poor prognosis. Spontaneous improvements and unpredictable relapses can also occur. Overall schizophrenia is more challenging to treat, needs long-term follow-up, and can also lower overall life expectancy, as compared to the other psychotic disorders.
A diagnostic workup with a medical history, examination, blood tests, and in required cases a CT/MRI brain imaging is done before commencing treatment. Psychosis should be treated by a psychiatrist with support from psychologists, therapists, counselors, and social support groups.
The drugs used to treat schizophrenia and other psychotic disorders are called antipsychotics.
First-generation antipsychotics (typical or neuroleptics) like chlorpromazine, thioridazine, haloperidol, fluphenazine, etc. act as inhibitors of dopamine D2 receptors and thus are effective for positive schizophrenia symptoms, especially delusions. However, they produce side effects like sedation and dry mouth (low with haloperidol; high with chlorpromazine) and weight gain. Sometimes they can produce extrapyramidal side effects (EPS – abnormal involuntary movements like shaking, spasms, or rigidity). Long-term (many years) use can also produce tardive dyskinesia (involuntary movements of lip, tongue, and limbs). Very rarely, a condition of high fever and muscle rigidity may be seen that is life-threatening (malignant neuroleptic syndrome).
Second-generation antipsychotics (atypical) like clozapine, olanzapine, risperidone, aripiprazole and quetiapine are newer drugs that have a much lower rate of causing EPS. They are now being increasingly and more commonly used, and some like clozapine may also help in cases refractory to the first-generation antipsychotics. However, clozapine can cause a rare side effect of a drastic fall in white blood cells (agranulocytosis), so needs regular blood tests for monitoring. Other side effects of atypical antipsychotics include drowsiness, weight gain, and sometimes developing diabetes that is a concern. Overall antipsychotics can increase negative symptoms like tiredness and low mood.
Psychological and Social Therapy
It is important to address the personal care of people with schizophrenia and psychotic disorders like nutritious diet, adequate physical activity, sleep, and hygiene.
Family therapy to reduce expressed emotions, and increase understanding, coping, and support can help in better response to treatment as well as lower relapses. Working on social and cognitive skills is a challenge. Cognition refers to gaining, comprehending, and interpreting knowledge, and this is significantly affected in psychosis. This requires cognitive remediation therapy (CRT) and cognitive-behavioral therapy (CBT). Training in social skills involves working on communication, eye contact, understanding social hints, speaking at a moderate pace, employment skills, self-care, and managing relationships. This is done by breaking down into simple tasks with everyday action points.
Personal therapy focuses on a staged approach of starting with counseling and understanding the relationship between symptoms and stressors, learning relaxation techniques followed by CBT/CRT, and then social and vocational skills. Community awareness should be built continuously and can play an important role in reducing institutionalization, cost and stigma.