Psychosis

Diagnosis and definition

Therapy and prevention

Social and legal aspects

Research

BIBLIOGRAPHY

It is a generally accepted statistic that about half of all the hospital beds in the United States are occupied by psychiatric patients. Since neurotics are rarely hospitalized, one can define the public health aspect of the problem of the psychoses simply by saying that psychotics occupy about half the beds of the nation on any given day. Approximately half of these beds again are occupied by people diagnosed as suffering from schizophrenia, the major so-called functional psychosis. The majority of the remaining psychiatric beds are occupied by those with a variety of organic psychoses, predominantly aged people suffering from senile or arteriosclerotic psychoses. From the standpoint of the numerical significance of the problem alone, psychoses merit major interest. If one keeps in mind that schizophrenics are likely to become incapacitated early in life, with the mean onset occurring between 20 and 30 years of age, the problem gains in importance. Although the average length of hospitalization of psychiatric patients decreased by 10 per cent between 1954 and 1964, the number of admissions per year nearly doubled during that period.

Statistics, of course, are only a small part of the problem. They do not tell about the immense human suffering involved in psychoses, nor do they picture the fascination which the topic has aroused from time immemorial. By and large, the term “psychosis” is used as an equivalent of “a major psychiatric disorder,” with all the limitations of any such generalization. It has been equated with being possessed by spirits or by the devil, as well as, on the other hand, being revered as a manifestation of divinity. It is also often referred to as “craziness” and is considered by many as a profound revelation of all that goes on in the deep recesses of the human mind.

The fact is that most American clinicians today do not consider a person suffering from a psychosis (a psychotic) to be basically or qualitatively different from so-called normal people. These psy-chotics may be quantitatively different. They presumably are less able to keep the “deeper” layers of their minds (the primary process) from showing in their daily activities; in some ways, then, they may be more profoundly human.

If one would make a tentative and very limited attempt at defining psychosis, one would have to say it refers to a major psychiatric disorder, one aspect of which is usually some obvious conflict with reality, or a difference from the way a majority of the population perceives reality, or a difference from the expected cultural norms concerning behavior. In the first place, this definition alone makes quite clear that there are areas for disagreement. Not everyone showing such difference or conflict is psychotic. Furthermore, not all people considered psychotic by specialists are necessarily manifestly disturbed in the ways mentioned— either in those actions which are to their own detriment or in those detrimental to society. During most of their lives they may show no obvious sign of any major disorder at all. It may either erupt suddenly or make itself felt only latently and subtly, or be disguised in culturally acceptable forms, such as religious or political fanaticism.

The fact that abnormal behavior of psychotics involves social and cultural norms makes it quite obvious that psychoses are an appropriate concern of such social sciences as sociology, cultural anthropology, and social psychology, and also of allied fields such as jurisprudence and criminology. What is more, psychotic manifestations are also clearly influenced by cultural factors. This holds true not only for different cultures and subcultures but also for temporal changes—for example, within Western culture. What used to be thought possession by the devil has become paranoid ideation involving electric influencing machines, radio, television, radar, or electronic snooping devices.

The etiology of psychoses also spans the physical sciences and the social sciences, and there has been much argument over the primacy of organic or “functional” (often equated with psychogenic) causes of psychoses.

The American Psychiatric Association (1952) categorizes psychotic disorders as follows:

Involutional psychotic reaction

Affective reactions: manic-depressive reactions (manic type, depressed type, other), psychotic depressive reaction

Schizophrenic reactions: simple type, hebephrenic type, catatonic type, paranoid type, acute undifferentiated type, chronic undifferentiated type, schizo-affective type, childhood type, residual type

Paranoid reactions: paranoia, paranoid state

Diagnosis and definition

Psychiatry does not abound in operational definitions, and the term “psychosis,” unfortunately, provides no exception. Definition and diagnosis are often closely related in medicine. Therefore, we can say that traditionally and clinically, a patient was diagnosed as psychotic by some simple clinical rules of thumb—if there was a disturbance in orientation regarding time, place, and person; if affect was not appropriate; if the thought processes were found not to be intact (not coherent, relevant, and connected); if the memory of recent or past events was disturbed; if the behavior was inappropriate or obviously influenced by delusions and hallucinations.

This definition includes, of course, both organic and “functional” psychoses. With regard to these terms, there are some more subtle problems of definition, for there are traditionally two basic schools of thought: (1) that psychotics are qualitatively different from nonpsychotic people; this concept is held primarily by those who see schizophrenia or other “functional” psychoses as diseases with a clear-cut somatic matrix; (2) that psychotics in general, and schizophrenics in particular, are only quantitatively different from nonpsychotic normal personalities. Adolf Meyer, pioneering the concept of psychobiology, formulated the concept of psychotic reaction types in keeping with the idea that psychoses are a variation of ordinary “reaction types.” Most of all, the psychoanalytic school of thought comprises psychoses within its general theory of personality. Neither school of thought necessarily excludes organic etiologic factors.

Certainly, black-and-white thinking about the concepts “organic” and “functional” seems to be outdated, although the journals hardly reflect this fact. Furthermore, one of the difficulties with the classical scheme of static classification of psychoses is the fact that so many labels are obviously artificial. For, to the chagrin of clinicians, patients often do not seem content to stay in an assigned group, and not only overlap symptomatologically but tend to behave in such a way as to lead clinicians to change their diagnosis of manic-depressive psychosis to schizophrenia, and occasionally vice versa. What is more, diagnoses such as puerperal psychoses, involutional psychoses, arterio-sclerotic and senile psychoses often are hardly more than superficial labels. In many patients labeled “psychoses with arteriosclerosis,” one is hard put to find evidence of arteriosclerosis, or at least more arteriosclerosis than is found in people of the same age group who are not so diagnosed in vivo or post mortem. In many of these patients, symptoms, character traits, and fragile defenses seem to have been present long before pregnancy, involution, or old age; and the best one can surmise is that the advent of any of these events— hormonal changes, psychological trauma, decreased oxygenation due to an aged circulatory system, decreased social usefulness and esteem— has finally either added the necessary strain or has decreased the integrative capacity, thus producing the change from the latent to the manifest disorder. [SeeAging, article onPsychological Aspects.]

A useful definition—and theory—of psychosis has to accommodate all these observed clinical facts and allow for forces of primarily somatic and primarily experiential factors to play their roles singly and in combination, on different levels of interaction: molecularly as well as grossly (for instance, in the case of bacterial or physical trauma), psychologically as well as sociologically and anthropologically.

In my own thinking, it appears that a unified theory of psychosis can be formulated that integrates the organic and the experiential vantage points and offers many advantages.

The conceptual framework, as suggested before, would be that of psychoanalytic ego psychology. The manifestation of any psychosis with any etiology could then be described and understood in terms of changes in ego functioning within a given cultural setting. For this purpose, psychosis is seen as a behavioral syndrome, not a single disease. The somewhat variable symptoms generally associated with this diagnostic label must be understood as the final common path of a number of conditions which may lead to, and manifest themselves in, a severe disturbance of the ego. These conditions may range from a relatively purely psychogenic (experiential) weakness of the ego to afflictions of ego functioning caused by disturbances brought about by infections, by arteriosclerotic, enzymatic, or toxic states, or by traumatic, constitutional, or genetic factors: in short, by any number of chemogenic, histogenic, genogenic, sociogenic, or psychogenic factors, or by any combination thereof. While an outstanding somatic factor may be present, usually this must be accompanied by some psychological predisposition (in terms of ego patterns) to produce the psychotic picture. Conversely, certain somatic factors are probably secondarily brought about by the psychogenic etiology of psychosis, at least for those cases of early onset and severe outcome.

In brief, the multiple-factor, psychosomatic theory of psychoses permits one to understand psychosis as the common result of a variety of individually differing etiologic factors. It enables one to make a prognosis on the basis of a careful study of the specific etiology involved in a specific case, and permits optimal therapeutic control of the highly individual constellation of forces resulting in the manifestly common path of the syndrome, by directly or indirectly, somatically, psychologically, or environmentally, producing better ego functioning.

Patterns of ego functions and disturbances

Psychoanalytic theory is predicated upon propositions concerned with the dynamic interaction of environmental and organismic (maturational and congenital) forces with learned responses. Character and personality can thus be understood as patterns of compromise, as resultants of a field of diverse forces. Ego functioning, more specifically, must be described in terms of its pattern: While it may be rather uneven—one ego function may be “better” than another—and the blend ultimately unique, each given pattern may be classified roughly under diagnostic or descriptive headings.

Inasmuch as assessments of the degree of functioning are involved in descriptions of patterns of ego functioning, quantitative assumptions cannot be avoided. Psychoanalytic theory includes many quantitative statements, as might be expected in a theory in which concepts of force and economy play leading roles. The entire concept of libidinal cathexis in object relations and internal representations is, of course, a basically quantitative one.

However, psychoanalysts generally have not addressed themselves to attempts at precise quantification. It should be possible, though, to adapt the experimental methods of measurement to psychoanalytic variables.

Meaningful methods of measuring ego strength are possible if ego strength is defined as “the totality of the ego’s capacity to perform its many functions.” Each individual ego function could be quantitatively assayed, given a weighted score, and combined into a total score, much as the IQ is arrived at in the Wechsler-Bellevue Intelligence Test. Also, ego strength must be viewed globally, very much like Wechsler’s view of intelligence (1939). The ego cannot be conceptualized as a perfect sphere, of course, with each area of ego functioning constituting a radius, nor can it even be compared in this context to the segments of an orange. The image that suggests itself is that of an uneven raspberry on which each surface point constitutes the terminus of one of the many ego functions. Furthermore, this protean raspberry might be made of stretchable rubber which would change its shape developmentally and would be subject to momentary and daily variations.

Table 1 presents some important groups of ego functions and disturbances.

Multiple-factor theory

The concept of psychoses as disorders that have many different etiologies but share a final common path of ego disturbance leads quite logically to the concept that the diagnosis of psychosis at present can best be made on the basis of the degree of ego disturbance in a given patient. It also follows that the degree of ego disturbance that we are willing to call psychosis is based on rather arbitrary decisions.

As mentioned, there are variations of ego functioning in every person—that is, healthy people exhibit certain ego functions which are of a very high quality and others which are less so. It is probably true that a surprising number of ego disturbances, sometimes of considerable severity, appear in a large number of people who are generally considered normal statistically and in terms of lifelong functioning. These are still “normal” people, however, by virtue of the fact that the ego disturbance occurs in a relatively small segment of their personality or one which, in their particular setting, does not crucially interfere with functioning. A fear of deep water, for instance, is not likely to be a vital disturbance in an inland state such as Kansas. Obviously, forms and expectations of ego functions will vary culturally.

Also, one may find, on taking a careful life history, that there was some episode in ego disturbance at a certain age which, although fairly severe, was self-limited and had no further consequence. Chance is involved in such matters: a marked disturbance in military service may become a matter of troubling public record and later secondary pathology; some private disturbance may forever remain unknown and become a subject of amnesia.

Under certain conditions, e.g., those of extreme deprivation, some delusions or hallucinations (of food, water, companions) must be considered virtually as adaptive functions of the ego which usually promptly disappear when the emergency does; they may in fact have definite survival value during the emergency: for example, they may bolster the person with the irrational feeling that a special deity is guarding him and with the certainty that all will be well. Then there are, of course, a wide variety of neurotic ego disturbances that must be considered. All these facts will serve to highlight further the difficulties in forming a diagnosis of psychosis on the basis of one specific syndrome.

It is to be remembered that from a theoretical viewpoint we postulate that psychosis is not one condition, not one point on a continuum of ego strength, but a range along a continuum: within a group diagnosed as psychotic one could classify those who are sicker and less sick, patients with more and less over-all ego strength (also varying ego strength in different areas at different times). In this sense ego functioning not only must be seen as a quantitative proposition but also must be viewed as greater or lesser in different areas at different times.

It is useful to remember that, in essence, the diagnosis of psychosis is a phenomenological diagnosis predicated upon the observable failure of ego functions (including reported ones, of course), rather than upon assumptions concerning dynamic structure or other criteria.

The diagnostic continuum. Psychosis can be conceptualized as ranging at the low end of the continuum of ego strength, while normality covers a range at the other end. Presumably, schizophrenia, manic-depressive psychosis, obsessive-compulsive neurosis, severe character disorders, phobias, anxiety hysterias and neuroses, and hysterias lie approximately in that order, reading from left to right, between these two points. Figure 1 depicts this continuum. However, this traditional viewpoint is of limited value, since each of these conditions is characterized only by a symptom picture that expresses a single outstanding defensive compromise formation. There can be no question that a severe hysteria may involve a weaker ego and may

be a condition relatively closer to a psychosis (schizophrenia) than to a mild obsessive-compulsive disorder or a circumscribed phobia.

A psychosis may sometimes be difficult to diagnose in its early stages because the clinical picture may involve a vast variety of patterns of ego functioning. These might, of course, also be present in neurosis, circumscribed neurological disorders, character disorders, psychopathic (sociopathic) personalities, perversions, and other disorders, and the psychosis may overlap with them.

It is not the intention here to discuss in detail the clinical problems of differential diagnosis but, rather, to attempt a conceptual clarification: the clinical diagnosis of early psychosis must be predicated upon the judgment that the degree of ego disturbance is so severe and the defenses so pathological that one may expect the development of a full-blown psychosis if there is no skilled intervention.

Just as there are many varieties of full-blown psychoses, so there are many forms of early psychotic symptomatology. Sociopathic irresponsibility is indicative of poor integration of the superego and poor frustration tolerance; poor reality testing and poor object relations (by the ego) may occur in a person previously conscientious, polite, and kind to children and animals. Thus tabloids frequently print lurid accounts of choir-member offspring of pillars of the community who, apparently, suddenly become psychotic and commit criminal acts. Yet it is quite possible that signs of disturbance had been present for a long time. Seclusive-ness, as well as sudden extreme “extroversion,” may be a first indication of a psychotic break. Lability of mood often signifies impaired control.

Nor are the specific manifestations of ego disturbance the only prodromal signs of psychosis: the prepsychotic personality may be sociopathic, infantile (little control, many pregenital drives), brilliantly high-strung (artistic or intellectual achievement at the cost of other development), excessively religious (i.e., a reaction formation to poorly controlled hostility), dull and apathetic (because of early disturbance of autonomous functions and object relations), or have poor achievement (because of preoccupation with fantasies, etc.), despite high intelligence.

A good account of the great variety of full-blown psychoses has yet to be written. In essence, one psychotic may differ almost as much from another as any individual may differ from another. There are those who never progressed, and those who regressed from the highest levels of achievement; those who are obviously bizarre and hard to empathize with, and those whom one is likely to consider less disturbed than they actually are because of a good facade. Some psychotics are very kind; others are cold and sadistic. Some are very productive and sensitive; others are seemingly without drive or ability. Psychotics have been unjustly downgraded and romantically overestimated as artists, intellectuals, or, as some would have it, revolutionaries whom society of necessity secludes. It is easier to be categorical about psychotics if one does not have too much understanding and knowledge of them.

Differential diagnostic concepts

In the diagnosis of psychosis a number of diagnostic labels of secondary order are frequently used, sometimes in unclear and confusing ways.

Borderline psychosis. Borderline psychosis can be quite accurately defined as a condition of ego strength and personality functioning which lies on the continuum between a psychotic and a neurotic condition. In an appraisal of the ego strength of such a patient, one finds that thinking, affective control, perceptual reliability, and object relations are all of questionable soundness without being quite disturbed enough to merit the diagnosis of psychosis.

The diagnosis of borderline psychosis is indicated if the condition described refers to an apparently stable condition of functioning, perhaps even a lifelong one, without signs of progressive deterioration. In that sense, “borderline” is identical with the term psychotic character, and it relates to a character formation with many unfortunate defensive traits that are likely to make a person appear quite peculiar (even though he may often be quite brilliant and useful in isolated areas) without his ever developing a frank psychosis.

Incipient psychosis. If the picture of dubious functioning described as borderline psychosis is present and is accompanied by signs of increasing lability of mood, progressive inability to control impulses, increasing emergence of the primary process, and increasing crumbling of defenses, with deja vu experiences, feelings of unreality, impaired sleep, impaired appetite, and a rising anxiety level, then we are dealing with incipient psychosis, and steps must be taken to avoid its further progress.

This discussion implies quite clearly that in diagnosis it is important to judge not only the nature of functioning and the quality of the defense patterns but also the stability of the defensive patterns. Clinical experience permits little doubt that many people arrive at certain character formations— more or less pathological or normal—which they maintain all their lives. Not only do some people remain “borderline” all their lives, but some psychotics remain stabilized at certain levels of illness and do not regress further; others do regress. Some psychotics have four, five, or more episodes during their lives which always take the same form and which then show spontaneous remission. And some people have character peculiarities—psychotic or otherwise—which are lifelong, without any progression or regression of note. Clinical experience suggests the hypothesis that each person has a certain amount of ego strength—or, more specifically, strength of the synthetic functions of the ego—and this very often involves the stabilizing at a certain level of pathology, below which a person does not go under ordinary or possibly even extraordinary life circumstances.

Potential psychosis. Potential psychosis seems a useful diagnosis if one can observe poor ego functioning together with defenses that could eventually lead to a psychosis. That is, one might note the same symptoms that occur in borderline conditions, but accompanied by less stability in the defensive pattern. In the potential psychotic one may note previous episodes of increasing precariousness of balance between drive and defense, with outstanding defenses of denial and projection, and signs of loss of perceptual and motor control. In other words, the diagnosis “potential psychosis” may be useful to connote a condition ranging between “borderline” and “incipient,” that is, more labile than the former and less labile than the latter.

Latent psychosis. The designation “latent psychosis” might be employed when there is evidence of an existing psychosis which is, for practical purposes, covered up most of the time: i.e., in psychotherapy one might see that somebody is usually under the influence of primary process thinking and constantly beset by severe distortions of reality, but he manages to keep all these problems private by the use of intelligence and clever rationalizations. Such a person requires a favorable environment in order to continue to appear manifestly normal. Usually a forced change in environment or a change in living circumstances will suddenly disrupt the delicate arrangement; the patient will then surprise the world with the emergence of full-blown delusions of obviously long standing. The concept of latency thus refers in essence to the social impression which this individual makes. This nonpsychotic impression may also prevail in an ordinary clinical examination if the patient feels uncooperative, but it is extremely likely to appear in projective and other diagnostic testing, and in prolonged psychoanalytic interviews.

Therapy and prevention

The problem of a systematic and effective therapy for the psychoses is, of course, related to the matter of etiology: one usually wants to affect the causes of a disturbance. Since there is no general agreement on the causes of the “functional” psychoses and even very little on the etiology or pathogenesis of the organic psychoses, e.g., the so-called arteriosclerotic or senile psychoses, there is not much consensus about therapy for any of them.

If one accepts the proposition that there are multiple etiologies, it follows that one must attempt to treat each patient as much as possible within the individual constellation of causative factors.

A few therapies enjoy particularly widespread usage. Of the “shock treatments,” insulin therapy has lost the importance it had in the decade after World War II, but it is still used in some cases of schizophrenia. Its relative expense in terms of personnel and the need for considerable experience essential for its use are responsible in part for its decline. Electroshock therapy, or, as it is more often called, ECT (for electroconvulsive therapy), at first replaced insulin treatment to a large extent both for schizophrenia and, especially, for depressions. In turn, it lost popularity with the development of psychotropic drugs in the 1950s. By 1965 the tide seemed to have turned to a certain extent. The anti-depressants, for instance, have not proved miracle drugs after all, although undoubtedly they are often clinically useful (Cole 1964). ECT has been greatly refined by use of intravenous anesthetics and muscle-relaxing drugs, obviating the panic some patients felt and the danger of fractures. [SeeElectroconvulsive Shock; Mental Disorders, Treatment Of, article OnSomatic Treatment.]

The psychotropic drugs were the most important therapeutic modality in the mid-1960s. Popularly, the “tranquilizers” are most widely known and, among them, especially the phenothiazines. There is little question that the psychotropic drugs have changed much of psychiatric practice, for they often decrease or remove psychotic symptoms, make disturbed patients behave without violence, and decrease panic, delusions, and hallucinations. Thus, state hospital stays have been decreased, rehabilitation is markedly helped, and hospitalization in general hospitals is made possible.

Nevertheless, the psychotropic drugs are by no means curative, nor is their over-all effectiveness proved beyond doubt or the mode of their beneficial effect agreed upon. Empirically, however, they seem to create at least the conditions in which other therapy, spontaneous improvement, or at least socially acceptable behavior is possible for many psychotics who could not profit similarly without them.

As in all therapy, controlling variables other than the therapeutic agents, providing comparable groups of patients, and ruling out the effect of time alone are very difficult. The most promising development might well be Chassan’s development of the intensive design (Chassan & Bellak 1966). [SeeDrugs, article onPsychopharmacology.]

Social aspects of therapy have found their expression especially in community psychiatry (Bellak 1964). Keeping the patient close to home and providing early treatment in community clinics and follow-up in the community after a rather prompt hospital discharge play a marked role. Rehabilitation programs, as well as group therapy and family-centered therapy, play an often-constructive role.

The psychotherapy of psychoses plays more of a role for the extramural patient, if for no other reason than that the large state hospitals still rarely have enough staff for it. In clinic and private office practice, however, it often leads to empirically satisfying results. The adjunct treatment, by drugs, milieu therapy, and other measures, is becoming more popular.

For some of the organic psychoses, such as acute alcohol psychoses, there are specific, somatic treatment forms.

It is difficult to generalize about the effectiveness of treatment of psychoses as a group. In the case of an acute schizophrenic or depressive psychosis, it is not unusual today that as high as 80 per cent of all first admissions to a therapeutically active hospital may be discharged within 30 days. On the other hand, for about 7 per cent of all schizophrenics, the length of hospitalization still remains 20 years.

Primary prevention in the public health sense is also closely related to concepts of etiology. Since even most geneticists admit the significance of environmental factors at least for the manifestation of latent liabilities, and hardly anybody doubts the effect of experiential factors, a great deal more could be done for prevention of psychoses by public education, psychiatric well-baby clinics, and, where need be, legislation concerning the disposition of children with unsuitable parents, or whose parents are divorced or otherwise separated.

Secondary prevention, by early treatment of incipient disturbances, is making progress by virtue of greater federal and state investment in community mental health. Similarly, tertiary prevention (of chronicity) by rehabilitation is in the process of development.

Social and legal aspects

As long as psychotics were considered to suffer from a disease, they were usually studied as individuals in isolation, as it were. With an increasing awareness of the importance of interpersonal relationships, both the genesis and the cause of psychosis in relation to social interaction have attained more importance. Also, the ward setting and its effect on psychoses have been described by Stanton and Schwartz (1954), and social and epidemiological aspects of psychoses have been formulated by Hollingshead and Redlich (1954), Faris and Dunham (1939), Lemkau and Crocetti (1958), and others. The differing patterns in the family structure, especially of schizophrenics, have been discussed, e.g., by Opler and Singer (1956) and Sanua (1963). [SeePsychiatry, article onSocial Psychiatry.]

Because of the impairment of judgment and the lack of impulse control in many psychotics, and the occasional commission of crime by psychotics, special social-legal problems exist with regard to the involuntary commitment of the mentally ill to hospitals and the observation of their constitutional rights under such circumstances. Furthermore, the specific problem of legal responsibility for crimes has to be considered [Roche 1964; see alsoPsychiatry, article onFORENSIC PSYCHIATRY].

Research

Research in psychoses has suffered greatly from a lack of conceptual clarity. And a lack of methodological sophistication among clinicians who usually engaged in research only as a by-product of clinical and therapeutic work has bedeviled the field. As examples one might mention the tremendous popularity of Kretschmer’s morphological classification (athletic, asthenic, pyknic) and the complete absence of valid supporting data for it from controlled studies. The same can be said for the welter of genetic studies: if anywhere there are diagnoses of family members which have been made under blind, controlled conditions so as to avoid contamination of diagnostic judgment of the incidence of psychoses in the relatives of the patient (as compared with a control group), I have never run across them. As Tienari points out (1963), most of the genetic studies have been particularly poor methodologically. [SeeMental Disorders, article onGenetic Aspects; Psychology, article onConstitutional Psychology.]

There are some methodologically sophisticated studies by social scientists and by physicians with training in the various medical and basic sciences. These researchers do not usually have clinical psychiatric experience and are rarely psycho-dynamically trained. Rather than cast aspersions on their undertakings, one simply has to acknowledge that psychoses are protean manifestations of all facets of human life and that research has suffered from the fact that it is difficult to marshal all the knowledge and experience needed to deal with the many facets involved.

There is no bodily system or organ which has not been more or less extensively implicated in the cause of psychoses, especially of schizophrenia (Bellak 1948). Psychoanalysts and psychologists have described psychotogenic mothers, fathers, and general family settings, aside from specifics of individual development (Lidz et al. 1956). Sociologists have shown relationships to urban and rural populations and socioeconomic classes (Faris & Dunham 1939). Cultural anthropologists differ on whether more advanced cultures may have a greater incidence of psychoses than do primitive ones (Benedict 1958). Semanticists have related schizophrenia to the double bind and to semantic confusion. Geneticists have had a field day only occasionally interrupted by careful studies (Tienari 1963). Physical anthropology, by way of Kretschmer and Sheldon, has not lacked a voice, nor has such a factor as birth date (season of the year) been neglected (Barry & Barry 1964). In fact, hardly a week goes by without some etiological claim being mentioned in the popular or scientific press, and hardly a year without the total crop of claims being thoroughly discredited.

Just as the implication of the spirochetes in general paresis and the ensuing fever treatment raised the hope for similar etiology and therapy of psychoses, so the physical treatment modalities, by inference, were held a promising road for the uncovering of etiology. Sakel, Meduna, Cerletti and their followers were thus influenced, respectively, by insulin, metrazol, and electric shock treatment; they all formulated etiological theories which did not bear the burden of systematic investigation. The latest flurry of this type of research was produced by the advent of psychotropic drugs: if tranquilizers produce symptomatic changes in psychotics, and if these tranquilizers seem to have an effect, for example, on serotonin metabolism, then one might suggest that a serotonin disorder produces psychoses. By the same reasoning, if monoamine oxidase (MAO)-inhibiting drugs benefit depressions, it was felt that maybe MAO is etiologically implicated in the production of depression. Of course, it quickly turned out that different tranquilizers have their effect by different pathways and that drugs not affecting MAO also could lift depressions (for instance, amitriptyline). [SeeMental Disorders, article onBiological Aspects.]

Some of the most ambitious research was carried out by means of the so-called model psychoses and experimental analogues. Long ago, it was known that certain drugs, notably mescaline, bulbocap-nine, and others could produce psychoses not unlike schizophrenic psychoses. The most widely heralded drug in the 1960s was LSD (lysergic acid diethylamide-25). The most ambitious hope was to produce psychoses experimentally, then to be able to abolish them with a tranquilizer. As it happens, LSD-induced psychosis has only little resemblance to schizophrenia (except in borderline schizophrenics, in whom LSD, like many other traumata, can apparently induce a genuine psychosis, if one is not cautious enough to screen subjects). Other physiological experimental investigations only suffered from oversimplification and artifacts.

To confound the issue further, or, rather, to clarify the fact that psychosis is apparently a condition which is merely the final common path of many different effects on ego functions, interesting experiments in sensory deprivation or perceptual isolation (Lilly 1956) showed that psychosis-like conditions with hallucinations and delusions could be induced in some subjects put into these experimental conditions. [SeePerception, article onPerceptual Deprivation.]

The subject of research in psychosis can, therefore, be summarized by saying that hardly any of a worthwhile nature exists so far, with the exception of some rather careful work refuting a variety of heuristic claims (Kety 1959). Such claims have usually been the result of oversimplification, lack of controls, and lack of sophistication. It is my strong personal belief that progress will come only when an integrated, highly coordinated, multidis-ciplinary, extremely extensive and intensive approach is made, preferably under one roof, such as a “national institute for psychoses research.” Because of a lack of coordination and integration of research, the awarding of individual research grants has so far shown nothing but disappointment, from any basic standpoint.

Leopold Bellak

[Directly related are the entriesDepressive Disorders; Mental Disorders; Neurosis; Schizophrenia. Other relevant material may be found inMental Disorders, Treatment Of; Mental Health; Psychiatry; Psychoanalysis, especially the article onEgo Psychology; Psychosomatic Illness; and in the biographies ofFreud; Meyer; Sullivan.]

BIBLIOGRAPHY

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Stanton, Alfred H.; and Schwartz, M. S. 1954 The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. New York: Basic Books.

Tienari, Pekka 1963 Psychiatric Illnesses in Identical Twins. Acto psychiatrica scandinavica 39 (Supplement 171). → The entire issue is devoted to Tienari’s study.

Wechsler, David (1939) 1958 The Measurement and Appraisal of Adult Intelligence. 4th ed. Baltimore: Williams & Wilkins. → First published as The Measurement of Adult Intelligence.

Psychosis

Definition

Psychosis is a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality.

Description

Patients suffering from psychosis have impaired reality testing; that is, they are unable to distinguish personal subjective experience from the reality of the external world. They experience hallucinations and/or delusions that they believe are real, and may behave and communicate in an inappropriate and incoherent fashion. Psychosis may appear as a symptom of a number of mental disorders, including mood and personality disorders. It is also the defining feature of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, and the psychotic disorders (i.e., brief psychotic disorder, shared psychotic disorder, psychotic disorder due to a general medical condition, and substance-induced psychotic disorder).

Causes and symptoms

Psychosis may be caused by the interaction of biological and psychosocial factors depending on the disorder in which it presents; psychosis can also be caused by purely social factors, with no biological component.

Biological factors that are regarded as contributing to the development of psychosis include genetic abnormalities and substance use. With regard to chromosomal abnormalities, studies indicate that 30% of patients diagnosed with a psychotic disorder have a microdeletion at chromosome 22q11. Another group of researchers has identified the gene G72/G30 at chromosome 13q33.2 as a susceptibility gene for child-hood-onset schizophrenia and psychosis not otherwise specified.

With regard to substance abuse, several different research groups reported in 2004 that cannabis (marijuana ) use is a risk factor for the onset of psychosis.

Migration is a social factor that influences people's susceptibility to psychotic disorders. Psychiatrists in Europe have noted the increasing rate of schizophrenia and other psychotic disorders among immigrants to almost all Western European countries. Black immigrants from Africa or the Caribbean appear to be especially vulnerable. The stresses involved in migration include family breakup, the need to adjust to living in large urban areas, and social inequalities in the new country.

Schizophrenia, schizophreniform disorder, and schizoaffective disorder

Psychosis in schizophrenia and perhaps schizophreniform disorder appears to be related to abnormalities in the structure and chemistry of the brain, and appears to have strong genetic links; but its course and severity can be altered by social factors such as stress or a lack of support within the family. The cause of schizoaffective disorder is less clear cut, but biological factors are also suspected.

Delusional disorder

The exact cause of delusional disorder has not been conclusively determined, but potential causes include heredity, neurological abnormalities, and changes in brain chemistry. Some studies have indicated that delusions are generated by abnormalities in the limbic system, the portion of the brain on the inner edge of the cerebral cortex that is believed to regulate emotions. Delusional disorder is also more likely to develop in persons who are isolated from others in their society by language difficulties and/or cultural differences.

Brief psychotic disorder

Trauma and stress can cause a short-term psychosis (less than a month's duration) known as brief psychotic disorder. Major life-changing events such as the death of a family member or a natural disaster have been known to stimulate brief psychotic disorder in patients with no prior history of mental illness.

Psychotic disorder due to a general medical condition

Psychosis may also be triggered by an organic cause, termed a psychotic disorder due to a general medical condition. Organic sources of psychosis include neurological conditions (for example, epilepsy and cerebrovascular disease), metabolic conditions (for example, porphyria), endocrine conditions (for example, hyper- or hypothyroidism ), renal failure, electrolyte imbalance, or autoimmune disorders.

Substance-induced psychotic disorder

Psychosis is also a known side effect of the use, abuse, and withdrawal from certain drugs. So-called recreational drugs, such as hallucinogenics, PCP, amphetamines, cocaine, marijuana, and alcohol, may cause a psychotic reaction during use or withdrawal. Certain prescription medications such as steroids, anticonvulsants, chemotherapeutic agents, and antiparkinsonian medications may also induce psychotic symptoms. Toxic substances such as carbon monoxide have also been reported to cause substance-induced psychotic disorder.

Shared psychotic disorder

Shared psychotic disorder, also known as folie à deux or psychosis by association, is a relatively rare delusional disorder involving two (or more) people with close emotional ties. In the West, shared psychosis most commonly develops between two sisters or between husband and wife, while in Japan the most common form involves a parent and a son or daughter. Shared psychosis occasionally involves an entire nuclear family.

Psychosis is characterized by the following symptoms:

• Delusions. Those delusions that occur in schizophrenia and its related forms are typically bizarre (i.e., they could not occur in real life). Delusions occurring in delusional disorder are more plausible, but still patently untrue. In some cases, delusions may be accompanied by feelings of paranoia.

• Hallucinations. Psychotic patients see, hear, smell, taste, or feel things that aren't there. Schizophrenic hallucinations are typically auditory or, less commonly, visual; but psychotic hallucinations can involve any of the five senses.
• Disorganized speech. Psychotic patients, especially those with schizophrenia, often ramble on in incoherent, nonsensical speech patterns.
• Disorganized or catatonic behavior. The catatonic patient reacts inappropriately to his/her environment by either remaining rigid and immobile or by engaging in excessive motor activity. Disorganized behavior is behavior or activity that is inappropriate for the situation, or unpredictable.

Diagnosis

Patients with psychotic symptoms should undergo a thorough physical examination and history to rule out such possible organic causes as seizures, delirium, or alcohol withdrawal, and such other psychiatric conditions as dissociation or panic attacks. If a psychiatric cause such as schizophrenia is suspected, a mental health professional will typically conduct an interview with the patient and administer one of several clinical inventories, or tests, to evaluate mental status. This assessment takes place in either an out-patient or hospital setting.

Psychotic symptoms and behaviors are considered psychiatric emergencies, and persons showing signs of psychosis are frequently taken by family, friends, or the police to a hospital emergency room. A person diagnosed as psychotic can be legally hospitalized against his or her will, particularly if he or she is violent, threatening to commit suicide, or threatening to harm another person. A psychotic person may also be hospitalized if he or she has become malnourished or ill as a result of failure to feed, dress appropriately for the climate, or otherwise take care of him- or herself.

Treatment

Psychosis that is symptomatic of schizophrenia or another psychiatric disorder should be treated by a psychologist and/or psychiatrist. An appropriate course of medication and/or psychosocial therapy is employed to treat the underlying primary disorder. If the patient is considered to be at risk for harming himself or others, inpatient treatment is usually recommended.

Treatment of shared psychotic disorder involves separating the affected persons from one another as well as using antipsychotic medications and psychotherapy.

Antipsychotic medication such as thioridazine (Mellaril), haloperidol (Haldol), chlorpromazine (Thorazine), clozapine (Clozaril), sertindole (Serlect), olanzapine (Zyprexa), or risperidone (Risperdal) is usually prescribed to bring psychotic symptoms under control and into remission. Possible side effects of antipsychotics include dry mouth, drowsiness, muscle stiffness, and tardive dyskinesia (involuntary movements of the body). Agranulocytosis, a potentially serious but reversible health condition in which the white blood cells that fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with this drug should undergo weekly blood tests to monitor white blood cell counts for the first six months, then every two weeks.

After an acute psychotic episode has subsided, antipsychotic drug maintenance treatment is typically employed and psychosocial therapy and living and vocational skills training may be attempted.

Prognosis

Prognosis for brief psychotic disorder is quite good; for schizophrenia, less so. Generally, the longer and more severe a psychotic episode, the poorer the prognosis is for the patient. Early diagnosis and treatment are critical to improving outcomes for the patient across all psychotic disorders.

Approximately 10% of America's permanently disabled population is comprised of schizophrenic individuals. The mortality rate of schizophrenic individuals is also high—approximately 10% of schizophrenics commit suicide, and 20% attempt it. However, early diagnosis and long-term follow up care can improve the outlook for these patients considerably. Roughly 60% of patients with schizophrenia will show substantial improvement with appropriate treatment.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Psychiatric Emergencies." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Schizophrenia and Related Disorders." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Addington, A. M., M. Gornick, A. L. Sporn, et al. "Polymorphisms in the 13q33.2 Gene G72/G30 Are Associated with Childhood-Onset Schizophrenia and Psychosis Not Otherwise Specified." Biological Psychiatry 55 (May 15, 2004): 976-980.

Hutchinson, G., and C. Haasen. "Migration and Schizophrenia: The Challenges for European Psychiatry and Implications for the Future." Social Psychiatry and Psychiatric Epidemiology 39 (May 2004): 350-357.

Sharon, Idan, MD, and Roni Sharon. "Shared Psychotic Disorder." eMedicine June 4, 2004. 〈http://www.emedicine.com/med/topic3352.htm〉.

Sim, M. G., E. Khong, and G. Hulse. "Cannabis and Psychosis." Australian Family Physician 33 (April 2004): 229-232.

Tolmac, J., and M. Hodes. "Ethnic Variation among Adolescent Psychiatric In-Patients with Psychotic Disorders." British Journal of Psychiatry 184 (May 2004): 428-431.

Verdoux, H., and M. Tournier. "Cannabis Use and Risk of Psychosis: An Etiological Link?" Epidemiologia e psichiatria sociale 13 (April-June 2004): 113-119.

Williams, N. M., and M. J. Owen. "Genetic Abnormalities of Chromosome 22 and the Development of Psychosis." Current Psychiatry Reports 6 (June 2004): 176-182.

KEY TERMS

Brief psychotic disorder— An acute, short-term episode of psychosis lasting no longer than one month. This disorder may occur in response to a stressful event.

Delirium— An acute but temporary disturbance of consciousness marked by confusion, difficulty paying attention, delusions, hallucinations, or restlessness. Delirium may be caused by drug intoxication, high fever related to infection, head trauma, brain tumors, kidney or liver failure, or various metabolic disturbances.

Delusional disorder— Individuals with delusional disorder suffer from long-term, complex delusions that fall into one of six categories: persecutory, grandiose, jealousy, erotomanic, somatic, or mixed.

Delusions— An unshakable belief in something untrue which cannot be explained by religious or cultural factors. These irrational beliefs defy normal reasoning and remain firm even when overwhelming proof is presented to refute them.

Hallucinations— False or distorted sensory experiences that appear to be real perceptions to the person experiencing them.

Paranoia— An unfounded or exaggerated distrust of others, sometimes reaching delusional proportions.

Porphyria— A disease of the metabolism characterized by skin lesions, urine problems, neurologic disorders, and/or abdominal pain.

Schizoaffective disorder— Schizophrenic symptoms occurring concurrently with a major depressive and/or manic episode.

Schizophrenia— A debilitating mental illness characterized by delusions, hallucinations, disorganized speech and behavior, and inappropriate or flattened affect (a lack of emotions) that seriously hampers the afflicted individual's social and occupational functioning. Approximately 2 million Americans suffer from schizophrenia.

Schizophreniform disorder— A short-term variation of schizophrenia that has a total duration of one to six months.

Shared psychotic disorder— Also known as folie à deux, shared psychotic disorder is an uncommon disorder in which the same delusion is shared by two or more individuals.

Tardive dyskinesia— Involuntary movements of the face and/or body which are a side effect of the long-term use of some older antipsychotic (neuroleptic) drugs. Tardive dyskinesia affects 15-20% of patients on long-term neuroleptic treatment.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. 〈http://www.apa.org〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. 〈http://www.nimh.nih.gov〉.

OTHER

The Schizophrenia Page. 〈http://www.schizophrenia.com〉.

Psychosis

What Is Psychosis?

Psychosis and the “Insanity Defense”

Resources

Psychosis (sy-KO-sis) is a broad term covering a range of mental illnesses associated with a loss of connection to reality. Illnesses that involve psychosis may severely impair a person’s ability to relate to other people and to perform basic tasks of daily life.

KEYWORDS

for searching the Internet and other reference sources

Delusions

Dementia

Hallucinations

Schizophrenia

What Is Psychosis?

“Psychosis” is a medical term used to describe serious mental disorders that cause a person to lose touch with reality. People with psychosis may have delusions*, hallucinations*, or dementia*, they may lose the ability to speak coherently or to understand what others say to them; and their thoughts, feelings, and behaviors may be inappropriate and disconnected from the reality around them without their being aware of the disconnection.

* delusions

(duh-LOO-zhunz) are beliefs that are false and have no basis in reality. People may think, for example, that someone is trying to harm them or that they have great importance, power, wealth, intelligence, or ability.

* hallucinations

(huh-LOO-sinNAY-shunz) are sensory perceptions without a cause in the outside world. People may hear voices or see things that are not really there.

* dementia

(duh-MEN-shuh) is a gradually worsening loss of mental abilities, including memory, language, rational thinking, and judgment.

Disorders associated with psychotic symptoms

In some cases, psychosis lasts only for a few days or weeks (acute or brief psychosis), but sometimes it is a chronic* condition. Some of the disorders associated with psychosis include:

* chronic

(KRAH-nik) means lasting a long time or recurring frequently.

• Schizophrenia (SKIT-zo-free-nee-a) and related conditions, including brief psychotic disorder and schizophreniform (SKIT-zo-fre-ni-form) disorder, which are characterized by hallucinations or delusions and may lead to problems in daily functioning.
• Serious mood disorders, for example major depression or bipolar disorder with psychotic features.
• Alzheimer disease, a progressive disorder that affects the brain, most often in older adults, that usually causes dementia. Alcoholism, which causes many physical problems including liver disease and delirium tremens, a temporary condition involving hallucinations, delusions, fears, sweating, and discomfort, which typically occurs in the first few days after people with alcoholism stop drinking completely.
• Wernicke-Korsakoff syndrome (VER-ni-kee KOR-sa-kof SINdrome), sometimes called Korsakoff’s psychosis, which causes confusion, severe memory loss, and inability to control muscle activity, often resulting from advanced alcoholism or thiamine (a B vitamin) deficiency.
• Seizure disorders, which may temporarily disrupt the electrical patterns in the brain and the thought processes controlled by brain cell activity.
• Postpartum psychosis, a disorder that sometimes affects women who recently have given birth.
• Substance abuse, particularly relating to use of opiates, steroids, and hallucinogens like PCP and LSD.

Treatment

Psychosis is a sign of serious illness, and people with psychosis must be thoroughly evaluated and should receive appopriate medical treatment. Treatment often involves medication and psychotherapy and sometimes requires that a patient be hospitalized.

Medical treatment for people with psychosis has improved greatly in recent years. Safer and more effective medications have been developed. There also have been many reforms to the laws that safeguard the rights and freedoms of people with mental illnesses, so that they no longer can be hospitalized against their will without a fair hearing and legal representation.

Cultural Beliefs About Mental Illness

The fact that definitions of psychosis and mental illness have changed over the years has led to debate about whether mental illness really exists.

The astronomer Galileo Galilei (1564–1642), for example, was considered to be mentally ill because he believed that the earth revolved around the sun during an era in which everyone else in his culture believed the opposite. Galileo’s belief threatened the religious institutions of his day, and he was called before the Inquisition in 1633 and was asked to abandon his belief. When he refused to do so, he was condemned for heresy and held under house arrest for the last nine years of his life. Galileo was not mentally ill. Galileo understood that his culture did not accept his belief, but his personal commitment to scientific reality was more important to him than acceptance by his contemporaries.

British psychiatrist R. D. Laing (1927–1989) believed that mental illness was a form of withdrawal from reality that people chose when they no longer could tolerate situations that other members of their family or society found acceptable. He thought that “mental illness” was a sane response to an insane world. Laing believed that psychiatrists sometimes diagnosed mental illness when the true problems were in fact rebellion and a refusal to live in an unlivable situation. Laing’s publications include Sanity, Madness, and the Family; Self and Others; The Divided Self; and The Politics of Experience.

American psychologist Thomas Szasz (b. 1920) believes that mental illness is a metaphor for thoughts, feelings, and behaviors of which society disapproves. His well-known book The Myth of Mental Illness holds that society uses “mental illness” as a label to control people, forcing them to accept unwanted treatment and hospitalization. Dr. Szasz believes that all medical treatment must be voluntary.

While it is certainly true that medical diagnoses sometimes have been misused for social control, most mental health professionals today do not agree with Laing and Szasz that mental illness is a myth, metaphor, or chosen response. To believe this would be to deny a biological basis for many instances of mental illness and to deny the pain, disorientation, and fear that people with mental illnesses experience.

People with psychosis are seriously ill with medical conditions that affect their thoughts, feelings, and ability to understand reality, sometimes even the reality that they need medical treatment. In fact, many patients later thank those who insisted they receive treatment, because when they recover they recognize that their illness had been affecting their thinking.

Thomas Szasz, author of The Myth of Mental Illness, believes that people should not be hospitalized without consent and that “insanity” should not be used as a defense in courts of law. AP Laserphoto

Psychosis and the “Insanity Defense”

Our legal system rests on the notion of personal responsibility. To find a person guilty of a crime requires proof that the person committed the crime and that he or she can be found blameworthy. When might a person not be found at fault? One clear case where the law allows for a verdict of innocence, even when a crime has been committed, is when the crime was done in self-defense. The other extreme circumstance that might “excuse” a crime often is called the “insanity defense.”;

John Hinckley, Jr., tried to assassinate President Ronald Reagan in 1981. In 1982, a Washington, D.C., jury determined that he was “not guilty by reason of insanity.” Ted Streshinsky/Corbis

Psychosis is a medical term involving illnesses that cause people to lose touch with reality. Insanity is a legal term used to determine whether there are some mental states that limit people’s ability to understand their actions so severely that they cannot be held accountable for those actions. Legal tests for determining sanity during court trials using the insanity defense usually focus on whether the people on trial understood what they were doing when they committed crimes, understood the difference between right and wrong, and were able to control their own behavior.

At present, the legal test for insanity varies from location to location. Some states use the British “M’Naghten Rule,” named after Daniel M’Naghten, who attempted a political assassination in England in 1843. Other states use the American Law Institute (ALI) Test, also called the Model Penal Code. The ALI test was used during the 1982 trial of John Hinckley, Jr., who attempted to assassinate President Ronald Reagan in 1981. When Hinckley was found “not guilty by reason of insanity,” a political backlash occurred, and the U.S. Congress introduced the legal concept of “guilty, but mentally ill.”;

The American Psychiatric Association (APA), the medical group that publishes standards for classifying mental illnesses and supports research about their treatment, does not use the legal term insanity. The APA maintains that psychiatrists may testify in court to help trial participants understand mental illness and psychosis, but that questions of innocence, guilt, and moral responsibility need to be left to judges and juries.

See also

Alcoholism

Alzheimer Disease

Bipolar Disorder

Delusions

Depression

Hallucination

Schizophrenia

Substance Abuse

Resources

Organizations

U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This division of the National Institutes of Health oversees research on mental disorders and provides information for professionals and the public. Telephone 301-443-4513 http://www.nimh.nih.gov

American Psychiatric Association, 1400 K Street NW, Washington, DC 20005. An organization of physicians that publishes the Diagnostic and Statistical Manual of Mental Disorders, a guide to the definitions of various disorders. This group also publishes the Let’s Talk Facts pamphlet series for the public. Telephone 888-357-7924 http://www.psych.org

American Academy of Psychiatry and the Law, P.O. Box 30, One Regency Drive, Bloomfield, CT, 06002-0030. This organization promotes scientific and educational research in how psychiatry is applied to legal issues (forensic psychiatry). Telephone 800-331-1389 http://www.aapl.org

National Alliance for the Mentally Ill, Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042. An information, advocacy, and support organization for people with serious mental illnesses and their families and friends. Telephone 800-950-NAMI or 703-524-7600 http://www.nami.org

psychosis The Greek psyche (‘life’ or ‘soul’) today can be translated as ‘mind’. The suffix ‘-osis’ means ‘any illness of’.

The Oxford English Dictionary defines psychosis as:
Any kind of mental affectation or derangement; especially one which cannot be ascribed to organic lesion or neurosis. In modern use, any mental illness or disorder that is accompanied by hallucinations, delusions or mental confusion and a loss of contact with external reality, whether attributable to an organic lesion or not.

The question of how far psychosis is an organic condition of the body or brain has fascinated psychiatrists ever since the term's origins a century and a half ago.

Origin of the term

The mid-nineteenth-century Austrian poet, politician, and psychiatrist, Feuchtersleben, introduced ‘psychosis’ to denote serious mental conditions affecting the personality; it was a subcategory of (Cullen's) neuroses. Psychosis soon comprised conditions besides the insanities and mental handicap, including minor psychological conditions and major organic disorders. Feuchtersleben coined the terms ‘psychosis’ and ‘psychopathy’ as identical terms because they were ‘diseases of the personality’ — and not of the body, nor of the soul or of the mind alone.

Psychosis-neurosis debate

Neurosis was already a popular term, and psychosis and neurosis were soon viewed in conjunction. Psychosis was seen as the psychological aspect of a neurosis — hence psychoneurosis. Thus the confusing picture arose whereby, in the late nineteenth century, there were three terms — psychosis, psychoneurosis, and psychopathy — for the same condition; by the late twentieth century by contrast these terms all referred to separate conditions. The development of this process of change over the course of the century will now be outlined, along with the different types of psychosis that were described.

At the end of the nineteenth century, attempts were made to find organic/cerebral causes for mental illnesses. The trend of ‘organicization’ increased and culminated in the discovery in 1905 that general paralysis was caused by a physical agent (syphilis). However, there remained many mental disorders that had no known organic cause. The term ‘functional’ was applied to these psychoses in 1881 by the German psychiatrist Fuerstner. However, his compatriot, the anatomist Nissl, claimed that ‘in all psychoses of whatever type there are always positive cortical findings’ (i.e. anatomical evidence of pathology). A functional illness therefore meant one that was suspected of having a physical origin, which had not yet been discovered.

By the mid 1920s, in the absence of the discovery of physical causes for Kraepelin's dementia praecox (schizophrenia) or for manic–depressive insanity, Bumke, his successor as Professor of Psychiatry at the world famous Chair in Munich, unequivocally labelled these as functional as opposed to organic illnesses. An examination of the latter should be conducted in the brain, while the study of the former had to be made in the mind, according to Bumke. The highly influential psychiatrist and philosopher Jaspers listed the functional psychoses as schizophrenia, manic–depressive insanity, and epilepsy.

Today, using computerized imaging techniques, we know that functional psychoses are accompanied by organic changes in the brain. This has made the use of the term ‘functional psychosis’ unhelpful. In the nineteenth century, many mental disorders were considered to be due to degeneration, that is ‘being predisposed to a disorder which led to deterioration, either in that individual or in succeeding generations’. These disorders were termed ‘endogenous’, which could apply both to the psychoses and to disorders of personality (psychopathies).

In 1881 the German degenerationist psychiatrist, Schuele, began the process whereby psychoses were associated with the more serious, organic conditions — cerebropsychoses — and psychoneuroses with the less serious ones. Freud emphasized and popularized the ‘psychoneuroses’ at the turn of the century, and the successful treatment of otherwise healthy soldiers suffering from shellshock in World War I established the entity of the neuroses, as they were to become known.

By 1925 Bumke was writing that ‘there has been no such thing as psychoneuroses for a long time. They have been reclassified into nervous reactions (neuroses), nervous constitutional states, psychopathies and functional psychoses.’ The neuroses were further delineated from the psychoses by Jaspers because ‘they do not wholly involve the individual himself, while those which seize upon the individual as a whole are called psychoses … [and] are generally thought to open up a gulf between sickness and health.’

In the early twentieth century, various terms were used for those conditions, which were deemed psychoses but which were not manic– depressive insanity or schizophrenia, but in the main these two remained the recognized ‘mental illnesses’. Some have upheld the significance of atypical psychoses. The recent debate on these psychoses has also generated much renewed research in the unitary theory of mental illness.

Unitary psychosis

In the mid nineteenth century, the unitary psychosis theory referred to a continuum of mental conditions from health to disease and was based on the importance of symptoms. In the twentieth century, by contrast, the term ‘unitary psychosis’ was applied to the two psychoses, schizophrenia and manic–depressive insanity, with the atypical psychoses bridging these two. Contemporary British psychiatrists have split two ways in their views on this question. Some, who analysed symptoms and emphasized the genetic basis of these disorders, have favoured the concept of unitary psychosis. Others, on the basis of neuroimaging, have rejected the unitary theory in favour of three categories of psychosis: congenital dementia praecox with poor prognosis; an adult form of schizophrenia with good prognosis; and bipolar affective disorder.

‘Psychosis’ — useful or not

There are certain problems with the use of ‘psychosis’ in contemporary psychiatry. Firstly, its very definition is difficult because its defining criteria are not specific (Oxford Textbook of Psychiatry). ‘Lack of insight’ is difficult to define. If ‘severity of illness’ is used as a criterion, the problem then arises that conditions falling into the psychosis category can occur in mild as well as severe forms. Moreover, non-psychotic conditions such as obsessional–compulsive disorder can also be very severe. ‘Impaired contact with reality, as evidenced by delusions and hallucinations’ has been considered difficult to apply. Secondly, conditions to which the term refers appear to have little in common, especially from an aetiological viewpoint. For example, some psychoses can be caused by known organic factors, while others represent a severe depressive illness. Thirdly, it may be better to classify an individual condition like schizophrenia as such, rather than as a member of an umbrella term like psychosis. So, recent classifications have renamed paranoid psychosis as paranoid disorder and affective psychosis as bipolar affective disorder. Fourthly, the tenth International Classification of Diseases (ICD 10) no longer distinguishes between psychosis and neurosis.

The arguments for retaining the term are as follows. Firstly, the psychoses are recognizable — as the ICD 10 proposes — by the presence of delusions and hallucinations without the patient having insight into their morbid nature. Secondly, on a purely practical level, psychosis has carried with it less stigma than the alternative term of ‘insanity’. Thirdly, it is very difficult always to use the term ‘disorder’ as an alternative for psychosis. For example, when it comes to the atypical psychoses the term ‘atypical disorder’ or ‘atypical insanity’ is unsatisfactory. Fourthly, the adjectival use of psychosis is a helpful shorthand term. This can be as in ‘psychotic symptom’ (delusion or hallucination) or ‘antipsychotic’ medication. To use ‘severe unipolar depression with delusions, hallucinations, and loss of insight’ as a replacement for ‘psychotic depression’ is cumbersome.

The contemporary British professor of psychiatry, Tyrer, has written that ‘classification stands or falls by its usefulness.’ In the last two decades the psychiatric profession has made many improvements in the sphere of reliability, but it has been said that there has not been comparable progress in the validity of psychiatric diseases. Therefore, there is a continuing need for the ‘umbrella’ categories such as psychosis and neurosis. The danger with an unquestioning use, and one which does not take cognisance of its abuse and attempted reification as a disease concept earlier this century, is that the mistakes of the past are repeated and an overly organic approach is adopted at the expense of a careful consideration of other — for example psychosocial — factors.

In a clinical and pragmatic sense the combination of one of the definitions of psychosis as ‘gross impairment in reality testing’ and the evident possibility in clinical practice of differentiating psychosis from normality, make psychosis a term that is accessible and acceptable, and yet one which does not necessarily carry the longer term or immutable connotations of its fellow term ‘insane’. Thus for the clinician and the man in the street, a psychotic person differs qualitatively from normal, while someone suffering an understandable neurotic or emotional disturbance usually only differs quantitatively from normal. The psychiatric profession should continue to use the term, but its conceptual limitations should not be overlooked.

M. Dominic Beer

Bibliography

Berrios, G. E. and and Beer, M. D. (1995). Unitary psychosis concept. In A history of clinical psychiatry. The origin and history of psychiatric disorders, (ed.) G. E. Berrios and R. Porter. Athlone Press, London.

Psychosis

Forms of psychosis

Symptoms of psychosis

Medications for treatment

Dosages

Resources

A psychotic state is one in which a person suffering from one of several mental illnesses loses touch with reality. People experiencing psychosis may be diagnosed as schizophrenic, manic-depressive, or delusional. Psychosis can also be induced from drug or alcohol abuse, reaction to medication, from exposure to some toxic substance, or from trauma to the brain. Psychotic episodes have a duration that may last for a brief period or may last for weeks and months at a time. Since the 1950s new medications have been developed to effectively treat psychosis and allow the person suffering from delusions or hallucinations to regain a more accurate view of reality.

There is significant evidence that the cause of psychosis lies within the limbic system, an area of the brain that lies deep within the lower, center portion of the brain and is believed to control the emotion, behavior, and perception of external and internal stimulation. The limbic system connects to all areas of the brain. It can be compared to a telephone network. If one line is down, communication cannot be made. Likewise, if an area within the limbic system is not functioning properly, appropriate signals cannot be sent or received, or inappropriate ones may be sent when the system is overloaded and working too hard.

Forms of psychosis

Before the careful classification of mental illnesses, anyone exhibiting psychotic behavior was thought to be schizophrenic, which is the mental illness most frequently associated with psychosis. Schizophrenia is a mental illness that is characterized by delusions, hallucinations, thought disorders, disorganized speech and behavior, and sometimes catatonic behavior. Emotions tend to flatten out and it becomes increasingly more difficult for the person to function normally in society. It is estimated that 1% of the American population is currently affected by this illness, which means there are about 1.5 million people who are ill from this disease.

In certain states of manic-depressive illness, or bipolar disorder, a patient may also suffer psychotic symptoms of delusions, hallucinations, and thought disorder. Unlike schizophrenia, those who suffer from manic-depressive illness are involved in a mood disorder, while schizophrenia is considered more of a thought disorder. In schizophrenia the mood is flat, but in manic-depression the mood can swing from great excitability to deep depression and feelings of hopelessness. In both phases of manic-depressive illness, many patients also experience delusions and hallucinations, which lead to misperceptions of reality.

Other psychiatric illnesses that produce psychotic episodes are delusional disorders, brief psychotic disorders that may remit within a month, substanceinduced psychotic disorders, psychotic disorders due to a general medical condition, and a number of others given separate classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a publication that presents guidelines for the diagnosis of serious mental illnesses. Diagnosis is based both on the nature of the psychosis and its duration.

Symptoms of psychosis

Hallucinations are a major symptom of psychosis and can be defined as a misperception of reality. Auditory hallucinations are the most common form. Patients hear voices that may seem to be outside his or her head or inside. The voices may be argumentative or congratulatory. Patients who exhibit visual hallucinations may have an organic problem, such as a brain lesion. Other types of hallucinations involve the sense of smell and touch.

There are various types of delusions that psychiatrists classify when diagnosing a patient. Erotomanic delusions involve the conviction that someone is in love with the patient. Grandiose delusions have a theme of inflated importance, power, knowledge, or a special relationship with someone important, perhaps a political leader, God, or a famous person. In a jealous type of delusion, the person feels their sexual partner is unfaithful even when there is no evidence of the fact. The main theme of a persecution delusion is that the patient is being mistreated by someone. In somatic delusions, patients feel they have a disease or physical defect that is also not present.

Medications for treatment

Antipsychotic medications were first used after it was noticed that a newly synthesized anesthetic had unusual ability to sedate patients who did not become unconscious from its use. Dr. Henri Laborit, a French physician, encouraged his psychiatric colleagues to try the drug on their schizophrenic patients. They were so successful with this drug, chlorpromazine, that its use spread quickly throughout the world. This was in 1952. Since then, seven different types of antipsychotic medications have been developed. Some of the brand names include Thorazine, Trilafon, and Haldol.

These medicines are administered by tablet or liquid, and under circumstances where the patient may be likely not to take the medicine, time-released injections are given. The psychiatric community approaches the prescribing of antipsychotic medicines, also called neuroleptics, somewhat on the basis of trial

KEY TERMS

Delusions— Incorrect beliefs about reality that may involve one’s self-importance or the false belief that one is being persecuted when no such persecution is taking place.

Hallucination— A sensory experience of something that does not exist outside the mind. A person can experience a hallucination in any of the five senses.

Manic-depressive illness— Bipolar disorder, a mental illness in which psychosis may present as a symptom and where the patient exhibits both an excited state, called mania, and a depressed state.

Neuroleptics— Medications that treat psychosis, also called antipsychotics.

Schizophrenia— A mental illness characterized by thought disorder, distancing from reality, and sometimes delusions and hallucinations.

and error. They have found that when one type of antipsychotic does not work, another type very well may reduce the symptoms of psychosis. It is sometimes helpful for them if another family member is suffering from the same illness. They have found responses within families to medicines to likely be the same. This suggests that there is a genetic factor involved in mental illness that leads to psychosis.

Dosages

Antipsychotic medicines vary widely in the amount of dosage needed to stabilize patients. One patient may need only 10 or 20 mg of an antipsychotic, while another will need hundreds of milligrams. The blood is monitored to determine the necessary dosage. A group of patients receiving the same medication can need widely differing amounts of the same medicine to achieve the desired effect.

While medication is the foremost element of current treatment for most situations of psychosis, counseling for the patient and family is also considered an important part of treatment, both to help them understand the role of the medicine and how to deal with the illness. Before antipsychotic medication came into common use, many people suffering from psychosis had to be hospitalized. Today, with a careful diagnosis and treatment therapy, many lead relatively normal and socially useful lives.

See also Antipsychotic drugs.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed. Washington, D.C.: American Psychiatric Press, 2000.

Evolving Psychosis: Different Stages, Different Treatments, edited by J.O. Johannessen, et al. New York: Routledge Press, 2006.

First, Michael B., and Allan Tasman. DSM-IV-TR Mental Disorders: Diagnosis, Etiology and Treatment. New York: John Wiley & Sons, 2004.

PERIODICALS

Golden, Frederic. “Mental Illness: Probing the Chemistry of the Brain.” Time 157 (January 2001).

Hyman, S.E. “The Genetics of Mental Illness: Implications for Practice.” Bulletin of the World Health Organization 78 (April 2000): 455-463.

Vita Richman