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(p. 3) What Is Psychosis? 

(p. 3) What Is Psychosis?
Chapter:
(p. 3) What Is Psychosis?
Author(s):

Beth Broussard

, and Michael T. Compton

DOI:
10.1093/med-psych/9780190920685.003.0001
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date: 13 April 2021

What is happening? What are these voices? These odd and unusual ideas? What is causing it? What will the doctors do? Is this treatment necessary? Is this curable? Will it come back? How can our family cope? What should I do next?

These are some of the many questions that often go through the minds of young people experiencing psychosis and their family members. An episode of psychosis can be frightening. It can be confusing. It can even seem like life is changing forever. However, there is support for young people and their families. Know that treatment works, and recovery is possible. This book is meant to help readers through a very difficult time by providing much-needed information when taking the first steps toward recovery. Part I of this book, Answering Some Key Questions, explains some of the most important facts about psychosis. This chapter addresses the first question: What is psychosis?

In this chapter, we define what psychosis is and then dispel some myths by describing what psychosis is not. We then briefly describe what percentage of people develop psychosis and when it usually first begins. Next, we present the idea of a “psychosis continuum,” which means that experiences of psychosis can differ in their level of seriousness. We then set the stage for later chapters by briefly introducing several other topics to come in the book, including causes of psychosis, treatments, and recovery.

What Psychosis Is

So what exactly does psychosis mean? Psychosis is a word used to describe a person’s mental state when he or she has in some way become disconnected from reality. For example, a person might hear voices that are not really there (auditory hallucinations) or believe things that are not really true (delusions). It is a treatable mental illness that occurs due to a dysfunction in the brain. A mental illness affects a person’s thoughts, feelings, and behaviors. You may be familiar with some other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder. People with psychosis have difficulty separating false personal experiences from reality. They may have confusing speech (p. 4) patterns or behave in a bizarre or risky manner without realizing that they are doing anything unusual.

Similar to any other health condition, psychosis consists of a combination of different types of symptoms, which are described in detail in Chapter 2, “What Are the Symptoms of Psychosis?” Some of the many symptoms of psychosis may include hearing voices when there is really no one there, having unusual beliefs, feeling frightened or paranoid, being withdrawn, having confused thoughts or confusing speech patterns, or displaying odd behaviors.

A psychotic episode is a period of time during which someone has psychotic symptoms. These symptoms may make it difficult for the young person to carry out daily activities. A psychotic episode may last from days to weeks, or in some cases even months or years, depending on the person and whether treatment is received. In some cases, psychotic-like symptoms may last for only seconds or minutes but cause no problems or impairments, in which case they wouldn’t be considered a psychotic episode.

People who have a psychotic disorder have a mental illness that interferes with their life. The various psychotic disorders and other illnesses that may cause psychosis are described in detail in Chapter 3, “What Diagnoses Are Associated with Psychosis?” Some people with a psychotic disorder have repeating episodes but are able to function normally between these episodes. Others may have repeating episodes without a full recovery between them. Yet others may have only one episode in their lifetime.

An episode of psychosis can seriously disrupt one’s functioning. Both “positive symptoms,” such as hallucinations and delusions (called “positive” because these symptoms are abnormal experiences added on to normal experiences), and “negative symptoms,” such as decreased energy and motivation (called “negative” symptoms because they have subtracted, or removed, something from the person’s experience), can interfere with school, work, and relationships. These and other types of symptoms are described in detail in Chapter 2.

Before a psychotic episode, family and friends may notice changes in emotions, behaviors, thinking, and beliefs about oneself and the world. They may see changes in mood, sleep habits, and participation in social activities. These changes, often called prodromal symptoms, are some of the early warning signs for a psychotic illness (see Chapters 2 and 10, “Knowing Your Early Warning Signs and Preventing a Relapse”).

The experience of psychosis is different for each person. For some people, substance use, self-harm, or confusion may start or get worse with an episode of psychosis. Others may feel more tension or distrust. Family and friends should know that any unexpected or aggressive behavior is likely a reaction (p. 5) to hallucinations and/or delusions, which are very real for the person with psychosis. It is important to realize that unusual thoughts or behaviors are part of a treatable illness. Family and friends should understand that their loved one often does not have control over these thoughts and behaviors. Although the symptoms of psychosis may be frightening to the individual and his or her family, there are good treatments for these symptoms. Friends and family members should help the individual to receive the right mental health treatment.

First-episode psychosis is the period of time when a person first begins to experience psychosis. This book focuses on the first episode of psychosis because it is during this time that young people and their families need detailed information about the initial evaluation and treatment. The first few years during and after a first episode of psychosis is a critical period. That is, the early phase of psychosis is very important because it is during this time that long-term outcomes may be most improved by treatment. This is also a critical period because crucial psychological and social skills are developing, and mental health professionals want to minimize the interference to these skills that psychosis can cause. It is vital that individuals with psychosis and their families seek help in order to move toward recovery. The first episode of psychosis benefits most from specialized, thorough, and ongoing treatment that provides individuals with psychosis the best possible outcomes.

It is vital that individuals with psychosis and their families seek help in order to move toward recovery. The first episode of psychosis benefits most from specialized, thorough, and ongoing treatment that provides individuals with psychosis the best possible outcomes.

What Psychosis Is NOT

Before learning more about psychosis, it is important to address some common myths and misconceptions about psychosis.

  • Psychosis is not multiple personality disorder. In multiple personality disorder (a very rare psychiatric disorder that is now called dissociative identity disorder), a person unconsciously has two or more separate personalities. Each personality has its own thoughts, feelings, and behaviors. Although people with psychosis may hear voices or behave in response to (p. 6) delusions, they do not alternate between different personalities. So, psychosis is not “split personality” or multiple personality disorder.

  • Psychosis is not insanity. The word insanity is a historical legal term that usually meant that one was too mentally ill to be held responsible for a crime (as in the phrase “not guilty by reason of insanity”). A very small percentage of individuals with psychosis and criminal charges fall into this legal classification. Usually, people with psychosis are not legally insane, nor do they usually commit crimes. Insanity is a word that is no longer used in the medical field.

  • People with psychosis are not “crazy.” People with psychosis should not be called crazy; instead, they are suffering from a treatable mental illness. Mental health professionals view the word crazy as an outdated and damaging word, like insanity or lunacy. Nowadays, mental health professionals encourage others not to use the word crazy because it leads to stigma and discrimination. People with a mental illness can still have friends and meaningful relationships, as well as go to school and have jobs. So, even though it is a commonly used word in society, referring to someone as “crazy” is harmful.

  • Psychosis is not psychopathy. The word psychotic describes someone who is experiencing psychosis. Psychopathy is a personality disorder in which people lack empathy, have no regret for criminal or violent behaviors, and are socially manipulative. Although both mental illnesses contain the prefix psycho, they are completely different. Most people diagnosed with psychosis are not violent, and most people diagnosed with psychopathy (also called sociopathy or antisocial personality disorder) do not have hallucinations or delusions. So, psychosis does not equal psychopathy or criminal behavior.

  • Psychosis is not delirium. People with delirium, or a state of confusion, may have trouble with memory and concentration. They may be disoriented, meaning that they do not know the date, where they are, or possibly even who they are (see Chapter 3). Although some people with psychosis have poor memory, they generally know who they are, where they are, and what the date is. So, psychosis is not the same as being delirious. Psychosis is also very different from dementia, which is a slowly developing state of confusion and memory loss that usually occurs in old age (see Chapter 3).

  • People with psychosis are not usually violent or a threat to others. In fact, they are at greater risk for injuring themselves than injuring others. Family and friends should understand that people with psychosis are (p. 7) rarely violent. They are suffering from an illness and need the same caring attention as people with any other health condition.

  • Psychosis and disability do not always go hand in hand. Recovery is possible. The experience of psychosis is different for every person who has it. Psychosis is more disabling for some people than for others because of individual differences in personality, social support, genes, and life experiences. The right treatment can help lessen or remove the distressing symptoms of the illness. Many people with psychosis can recover to participate in their communities.

Developing Psychosis

Psychosis affects both men and women across all cultures. When the symptoms of psychosis come together to form a syndrome that lasts for some time and causes impairment, it is often called a psychotic episode. That syndrome of psychosis, or the psychotic episode, can be classified into several different diagnoses, as described in Chapter 3, including psychotic disorders such as schizophrenia. Very few people (about 3%, or 3 in 100) will experience a psychotic episode in their lifetime. Although it can happen at any time in life, the onset or beginning of an episode of psychosis that is diagnosed as a psychotic disorder is usually in late adolescence or early adulthood. For men, the usual age of onset may be earlier than for women. That is, on average, men who develop a psychotic disorder experience their first psychotic symptoms up to three to five years before women do. For example, the symptoms of schizophrenia usually first become apparent in men between the ages of about 20 and 30, and in women between the ages of about 24 and 34. Schizophrenia is one of the most serious psychotic disorders, and about 1% of people will develop schizophrenia during the course of their lifetime.

The Psychosis Continuum

Everyone has some tendency to have psychotic-like experiences or even psychosis, just as everyone has the potential to become depressed or anxious. Normal experiences that are similar to psychosis, though much milder, do not interfere with an individual’s regular functioning. Abnormal experiences of psychosis interfere with functioning and make it difficult for a person to live a regular life. The more an experience interferes with daily life, the more serious the condition.

(p. 8) Researchers who study psychosis use the phrase psychosis continuum to describe the different levels of experiences. This means that there is a range of severity or seriousness across the different types of experiences of psychosis. The different types of experiences range from normal experiences that are similar to psychosis and that cause little or no distress, to the full syndrome of psychosis that causes much distress or many difficulties in life. Although normal psychotic-like experiences are fairly common, psychotic disorders that cause the full syndrome of psychosis are quite rare. Figure 1.1 illustrates how the different types of experiences of psychosis relate to one another. The following five paragraphs relate to the five parts of Figure 1.1.

Figure 1.1 The Psychosis Continuum. Shown here is the range of severity among the different types of psychotic-like and full psychotic experiences. These experiences range from experiences that produce no or minimal levels of distress (left side) to those that cause a lot of distress (right side).

Figure 1.1 The Psychosis Continuum. Shown here is the range of severity among the different types of psychotic-like and full psychotic experiences. These experiences range from experiences that produce no or minimal levels of distress (left side) to those that cause a lot of distress (right side).

First, some normal human experiences that do not affect regular functioning are similar to psychosis. They cause no distress and do not interfere with life. We have all had the occasional experience of wondering if someone might be talking about us (which is a normal curiosity) or thinking that we hear the phone ring while taking a shower (which is a normal experience of attention being drawn to sounds that may be heard over noise). Some people occasionally may have minor psychotic-like symptoms, such as hearing a voice or suspecting that someone is following them. These brief, infrequent symptoms do not disrupt functioning. About one-fourth (25%, or 25 out of 100) of people in the general population will experience these types of symptoms at some point in their lifetime. These are brief experiences that usually go away, and not the full syndrome of psychosis. Psychosis is an exaggeration of these experiences—to the point that they become troubling and interfere with life—caused by a dysfunction in the brain.

Second, certain experiences can cause a psychotic episode, such as major stress, drug use, and even some medical problems. Some examples of psychosis caused by stressors include stress-induced psychosis, drug-induced psychosis, and psychosis related to a medical problem. People who experience a great deal of physical stress from lack of sleep, hunger, torture, or severe psychological stress, may experience stress-induced psychosis. Drug-induced psychosis may happen when a person is using drugs like cocaine, LSD, marijuana, methamphetamine, PCP, or synthetic cannabinoids. People with certain physical illnesses, such as meningitis, certain types of seizures, or a brain tumor, may experience psychosis related to a medical problem (see Chapter 3). In all of these cases, the symptoms of psychosis often, but not always, go away after removing the stressor, drug, or medical problem. Some people do not fully recover from an episode of psychosis if the stressor or cause of psychosis is too intense or lasts for too long, or if they are at genetic risk for a psychotic illness. (p. 9) (p. 10)

Third, some people are particularly at risk for psychosis due to their genes or due to exposure to factors that may have occurred in early life. Such factors may include having an infection as a fetus or baby, a difficult labor or delivery when being born, having had a head injury, trauma or adverse experiences in childhood, or drug use in adolescence (see Chapter 4, “What Causes Primary Psychotic Disorders Like Schizophrenia?”). It should be noted that having any one or more of these risk factors increases one’s risk only slightly. Some people are more likely to develop psychotic symptoms than others. That is, some people are more psychosis-prone than others. They may or may not develop psychosis, but have a tendency toward it.

Fourth, people who experience mild, ongoing difficulties from symptoms but usually still function well enough to work and maintain relationships may have schizotypal personality features. People with schizotypal personality features can seem to have fewer social skills at times or may have suspicious or paranoid thinking. They also tend to withdraw from society. Typically, they do not experience full hallucinations or delusions. When many schizotypal personality features are present and long-lasting, a person might be diagnosed by mental health professionals as having schizotypal personality disorder (or just schizotypal disorder). Schizotypal personality disorder is a stable set of personality traits that appear as a milder form of the symptoms of schizophrenia.

Fifth, people who have a full syndrome of psychosis and are diagnosed with a psychotic disorder often have more difficulty with employment, living independently, and maintaining personal and professional relationships. They may be unable to work, attend school, or participate in some social activities. Some of the treatments described in Chapters 5, “Finding the Best Care,” and 8, “Psychosocial Treatments for Early Psychosis,” are designed specifically to help with these difficulties. Either hallucinations, delusions, or both may be present during a psychotic episode. In addition, people with psychosis may experience slow or confused thinking and speech, and their behavior may be odd or risky. People with this experience of psychosis may have schizophrenia or another “primary psychotic disorder.” On the other hand, they may have a different type of mental illness, such as depression with psychotic features or bipolar disorder (also called manic-depressive illness). We describe these different psychiatric illnesses that can cause psychosis in more detail in Chapter 3.

There are also cases when the cause and trajectory of a psychotic-like experience are not clear. For example, some people have reported abilities related to their spirituality or religion, such as seeing or hearing things that other people cannot. These experiences usually do not interfere with an individual’s (p. 11) functioning, and one’s specific religion or culture considers them to be normal or special experiences. This book focuses on the types of experiences of psychosis that are abnormal or distressing.

Schizophrenia and Other Primary Psychotic Disorders

When someone has a headache, he or she may not know what is causing the headache. Is the headache from stress? Does the person have a cold or the flu? Or is the headache related to something more serious, like high blood pressure, or even a brain tumor? If the headache worsens or does not go away, it is a good idea to visit the doctor for medical evaluation and treatment. In the same way, psychosis can happen in several different illnesses, mostly in mental illnesses. For example, people with severe depression, with bipolar disorder, or with schizophrenia can have an episode of psychosis. There are many different types of psychotic disorders, and they are diagnosed based on the types of symptoms and how long those symptoms last.

For example, schizophrenia is a type of psychotic disorder in which at least two of the following occur for at least one month, but often much longer: hallucinations, delusions, disorganized speech, disorganized behavior, or “negative symptoms” (these symptoms are described in Chapter 2). Young people, in the age range of about 16 to 30, with a first episode of psychosis may or may not go on to develop schizophrenia. Nevertheless, mental health professionals always recommend a thorough evaluation (see Chapter 6, “The Initial Evaluation of Psychosis”), treatment (see Chapters 7, “Medicines Used to Treat Psychosis,” and 8), and follow-up (see Chapter 9, “Follow-Up and Sticking with Treatment”).

Schizophrenia is only one type of psychotic disorder, as described in Chapter 3. Others include brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, and delusional disorder. These disorders differ from schizophrenia by the types of symptoms present and the length of time those symptoms last.

Psychotic disorders have a unique set of symptoms that make them different from other mental illnesses, placing them in their own class of disorders. All mental illnesses are defined by a specific group or set of symptoms. For example, people with obsessive-compulsive disorder do not have hallucinations, but people with psychosis often do. In other words, the symptoms of obsessive-compulsive disorder, depression, social anxiety disorder, autistic disorder, or a number of other mental illnesses differ from the symptoms of psychosis.

(p. 12) Possible Causes of Psychosis

Although Chapter 4 goes into detail about the causes of psychosis, it is important to begin to understand the causes here. Psychosis researchers believe there are two main models for the causes of the illness. These two models are not competing; they go hand in hand. One involves the developing brain (neurodevelopmental model), and the other is about the relationship between genes and stress (diathesis–stress model).

Psychosis is a medical condition of the brain, but scientists have not figured out exactly what is happening in the brain to cause this illness. Some think that it is a result of minor injuries to the brain during its growth and development or biological mishaps during brain development. They call this idea the neurodevelopmental model. Problems with brain development can happen for several reasons, as described further in Chapter 4.

Adolescence is a time when the brain goes through major changes. The minor brain injuries that may have happened during fetal brain development may become more apparent in adolescence when the brain develops further. These injuries can start to affect a person’s thinking, feelings, and behavior. That is, some doctors and researchers think that psychosis happens as an individual is maturing in adolescence because he or she was born with minor brain development problems. This view explains why psychotic illnesses rarely occur in young children. Additionally, it can explain why first-episode psychosis is most common in late adolescence and young adulthood.

The other main explanation for why psychosis happens involves the relationship between genes and risk factors in early life. In this diathesis–stress model, it is thought that some people are born with genes that put them at greater risk for having psychosis. However, according to this model, it is thought that genes alone may not be enough to start a psychotic episode; there must also be a stressor to trigger an episode, such as a stressful life event or drug use. The combination of certain genes and a stressor can cause psychosis. Again, Chapter 4 provides much more detail on the causes of psychotic disorders like schizophrenia.

Taking Action: Treatment and Recovery

There are three phases of psychosis. The first is the prodromal phase, the time before a psychotic episode begins, when subtle symptoms may first appear. The prodromal phase may last from several weeks to several years. It is often not recognized as the early stages of a mental illness. The acute phase (p. 13) is the time during the psychotic episode when symptoms are most disruptive. The acute phase usually lasts until treatment is sought and symptoms are first evaluated and treated. The third is the recovery phase, the time after the episode when symptoms of psychosis lessen or sometimes go away completely with treatment. The recovery phase is often considered to be the first 6 to 18 months of treatment.

People who get into treatment earlier often do better. In many places, specialty treatment programs now exist that specifically focus on first-episode psychosis. They often provide treatments designed to help young people with psychosis get back on track in terms of school and work goals. The best help for someone with psychosis is to be active about seeking treatment and following through completely with treatment. To be active about seeking treatment means doing several things. It means going to see a mental health professional as soon as any disturbing symptoms appear. It also means learning about psychosis by talking to others or reading books. There are many resources in the community, as well as on the internet, to help understand this experience. When going to the mental health professional, do not hesitate to ask questions or express concerns. Psychosis is a treatable mental illness.

People who get into treatment earlier often do better. In many places, specialty treatment programs now exist that specifically focus on first-episode psychosis. They often provide treatments designed to help young people with psychosis get back on track in terms of school and work goals.

An episode of psychosis can be a frightening and stressful experience for both the person with psychosis and their loved ones. Untreated psychosis can disrupt the life of both the individual and their family and friends. It is perfectly understandable that both the person and their family members would feel scared, disappointed, or upset when dealing with the new onset of psychotic symptoms. Psychosis, though often frightening and confusing, should be treated promptly when at all possible, like any other illness.

For many individuals with first-episode psychosis, their “positive” psychotic symptoms (such as hallucinations or delusions) will clear up partially or completely within weeks of starting treatment. Treatment includes both medicine (see Chapter 7) and psychosocial treatments (see Chapter 8). Hospitalization is sometimes needed, as described in Chapter 6. Nowadays, even though psychiatric inpatient units might be “locked” (such that individuals receiving treatment can’t simply walk out), treatment strives to be compassionate, of high quality, and effective, with the stay being as short as possible, and the individual and family having a voice in decisions. In many (p. 14) settings, a typical hospital stay for the evaluation and treatment of an episode of psychosis might be several days or up to a couple of weeks, with 7 to 10 days often being about the average. Then, outpatient treatment becomes very important. Following through with treatment is crucial for recovery. Recovery, which is much broader than just eliminating symptoms, is described in detail in Chapter 12.

Putting It All Together

Psychosis is a treatable disorder of the brain that disrupts an individual’s ability to understand the difference between personal experiences and reality (for example, hearing voices or having unusual beliefs). Many of society’s ideas about psychosis are not true, such as the notion that people with psychosis have multiple personality disorder, are insane, are dangerous, or cannot recover. Everyone has the potential to experience some psychotic-like experiences or even psychosis. The continuum of psychosis ranges from normal, everyday experiences that interfere very little in people’s lives to more serious experiences that greatly interfere with everyday life. The different psychotic disorders vary in the types and duration of symptoms associated with them. We explain these symptoms and diagnoses in Chapters 2 and 3.

While the exact cause of psychosis is not yet known, there are two main hypotheses. One is the neurodevelopmental hypothesis, which means that psychosis is a result of minor injuries to the brain during its growth and development or biological mishaps during brain development. The second is the diathesis–stress model, which means that psychosis is a result of the relationship between genes and factors in early life.

Even though researchers are still trying to figure out the exact causes of psychosis, effective treatments are available. For most people with psychosis, many symptoms clear up with treatment, and they can move forward with their life goals through recovery.

Even though researchers are still trying to figure out the exact causes of psychosis, effective treatments are available. For most people with psychosis, many symptoms clear up with treatment, and they can move forward with their life goals through recovery. It is important to actively seek treatment and stick with it. This will help to increase chances of recovery and reduce relapse and rehospitalization.

(p. 15)

Key Chapter Points

  • Psychosis is a treatable mental illness. A mental illness affects a person’s thoughts, feelings, and behaviors. For many people with first-episode psychosis, symptoms begin to clear up partially or completely within weeks of starting treatment.

  • Although the symptoms of psychosis may be frightening to the individual and his or her family, there are some good treatments for these symptoms. Friends and family members should help the individual receive the right mental health treatment.

  • First-episode psychosis is the period of time when a person first begins to experience psychosis. It is during this time that young people with psychosis and their families need detailed information about the initial evaluation and treatment.

  • Young people, in the age range of about 16 to 30, with a first episode of psychosis may or may not go on to develop schizophrenia. Nevertheless, mental health professionals always recommend a thorough evaluation, as well as treatment with both medicine and psychosocial treatments.

  • People who get into treatment earlier often do better. In many places, specialty treatment programs now exist that specifically focus on first-episode psychosis. They often provide treatments designed to help young people with psychosis get back on track in terms of school and work goals.

(p. 16)