Psychotic Disorders

What is Psychosis?

Psychosis is a nonspecific term to describe a mental state in which an individual’s connection with reality is weakened or lost.  Symptoms of psychosis include disturbances in perceptions, thoughts, moods, and behaviors.

Sensory hallucinations may occur in any of the senses. Hallucinations occur when an individual perceives a stimulus when no stimulus is present (e.g., hearing voices when no one is there or seeing things that aren’t real). In contrast, illusions occur when individuals misperceives a stimulus when there actually was one (e.g., misperceiving a piece of lint for a spider).

Delusions may also occur. Delusions are illogical and sometimes bizarre beliefs (or system of beliefs) even in the presence of refuting evidence (e.g., believing one is God or believing one’s food is being poisoned). Delusional systems or delusional themes can develop that are complex and elaborate. During a psychotic episode, there may be disorganized, illogical speech and behaviors. 

Other symptoms of psychosis include social withdrawal (isolating), apathy, alexithymia (i.e., inability to describe emotions), blunting of affect (i.e., minimal emotional expression), inappropriate behaviors (e.g. standing in one position for long periods of time), avolition (i.e., no motivation or lack of goal-directed behavior), depression, anxiety, and sleep disturbances. 

It is important to note that symptoms of Psychosis are traditionally separated into positive symptoms (hallucinations, delusions, and disorganized speech/behaviors) and negative symptoms (avolition, social withdrawal, depressed mood, apathy, blunting of affect, and/or catatonia).

 

What Causes Psychosis?

Psychosis, or psychotic episodes, may be associated with illicit drug use, medical problems, medications, and/or primary psychiatric disorders. 

(1) Illicit drugs: Magic mushrooms/psilocybin, ecstasy/MDMA, methamphetamine, cannabis).

(2) Medical conditions: Thyroid disease, encephalitis, brain tumors, dementia/neurocognitive disorders, seizures/epilepsy)

(3) Medications: Steroids, opioids, anticholinergic toxicity, certain antibiotics.

(4) Primary psychiatric disorders: Schizophrenia, Bipolar disorder, or severe Depression. 

Below is a review of the most common primary psychiatric disorders associated with psychosis. 

For a more in-depth review, click here!

  • Schizophrenia

Schizophrenia is diagnosed when two (or more) of the following 5 symptoms occur for a significant portion of time during a 1 -month period. However, at least one of the symptoms must be (1 ), (2), or (3):

  1. Delusions.
  2. Hallucinations.
  3. Disorganized speech (e.g., frequent derailment or incoherence).
  4. Grossly disorganized or catatonic behavior.
  5. Negative symptoms (i.e., diminished emotional expression or avolition).

For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal (i.e., time period leading up to psychotic episode) or residual symptoms (i.e., time period after psychotic episode resolves).

 

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  • Schizoaffective Disorder

Schizoaffective disorder is similar to schizophrenia except that the patient also experiences mood episodes (depression or mania).

Bipolar type: Manic episode is part of the presentation. Major depressive episodes may also occur.

Depressive type: Only major depressive episodes are part of the presentation.

  • Delusional Disorder

Delusional Disorder can be diagnosed with the presence of one (or more) delusions with a duration of 1 month or longer and the criteria for schizophrenia have never been met. If hallucinations are present, they are not prominent and are related to the delusional theme (e.g., delusional parasitosis where the sensation of being infested with insects is associated with delusions of infestation). Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.

Types of Delusions

Erotomanic type: Central theme of the delusion is that another person is in love with the patient

Grandiose type: Central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.

Jealous type: Central theme of the individual’s delusion is that his or her spouse or lover is unfaithful.

Persecutory type: Central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.

Somatic type: Central theme of the delusion involves bodily functions or sensations.

Mixed type: No one delusional theme predominates.

  • Treatment of Psychotic Disorders

Treatment of psychosis depends upon the underlying cause. If medication-induced, then stopping the problematic medication is the treatment. If due to drug intoxication, supportive treatment until the drug is out of the body followed by interventions such as drug rehab should be strongly considered. If due to a primary psychotic disorder (e.g., schizophrenia) or mood disorder (e.g. bipolar disorder with psychotic features), a combination of medications and psychosocial interventions should be considered. Psychosocial interventions include group therapy, social skills training, recreational therapy, case management, and/or placement in a structured environment. Although the psychosocial treatment of psychosis is essential to recovery, it is not reviewed here in-depth. Below is a brief outline of the medical treatment of psychosis. 

The following are common treatments for Psychosis

Antipsychotic Medications

Benzodiazepines

Hospitalization

Electroconvulsive Therapy (ECT)

Psychosocial treatments