Introduction
Psychotic disorders are a group of mental illnesses that share psychosis as one of their clinical features. Psychosis involves a gross impairment in one’s sense of reality, as evidenced by symptoms such as delusions, hallucinations, thought disorder, and bizarre behavior. These psychotic symptoms may be a primary component of illness or may be secondary to a mental or physical condition.
Types of Psychotic Symptoms
Delusions
are false beliefs that are associated with misinterpretations of perceptions or experiences. There are different types of delusions. The most common are persecutory delusions and grandiose delusions. Persecutory delusions are delusions in which the person believes that he or she is being spied on or plotted against. Grandiose delusions are delusions in which the person believes that he or she possesses special abilities or is related to a famous person or deity.
Hallucinations
are false perceptions in the absence of any real stimulus. Hallucinations may involve any of the five senses. There are auditory hallucinations, such as hearing voices; visual hallucinations, such as seeing faces or flashes of light; tactile hallucinations, such as feeling a tingling, electrical, crawling, or burning sensation; and olfactory hallucinations, such as smelling something not perceived by others. Gustatory hallucinations, or false tastes, are very rare. Most hallucinations are auditory hallucinations.
Thought disorder is defined as a disturbance in the form or content of thought and speech. In psychosis, the person’s speech may be incomprehensible or remotely related to the topic of conversation. Examples of formal thought disorder are neologisms, which are made-up words whose meaning is only known to the psychotic person, and loose associations, in which the person’s ideas shift from one subject to another, loosely related topic, without the person seeming aware of the shift. Delusions are examples of disorders of thought content. Psychotic behavior is typically bizarre or grossly disorganized.
Psychotic symptoms can appear at any point during the life course, though it is difficult to diagnose psychotic symptoms in preverbal children (prior to age five or six). Psychotic disorders can appear for the first time in individuals over age sixty-five.
Conceptualizations of Psychotic Disorders
In 1896, the German clinical psychiatrist Emil Kraepelin
proposed that there were two broad yet fundamental categories of psychotic disorder: manic-depressive illness, which is now referred to as bipolar disorder; and dementia praecox, which was labeled schizophrenia
by the Swiss psychiatrist Eugen Bleuler in 1908. Kraepelin delineated dementia praecox on the basis of course and outcome, noting that it was associated with a deteriorating course and poor outcome. According to Kraepelin, manic-depressive illness was associated with a more episodic and less deteriorating course relative to dementia praecox.
Psychotic disorders are currently classified on the basis of presenting symptoms rather than on the basis of underlying etiological processes. Episodes of psychosis can be brief or chronic in duration, lasting from a few days to many years, and psychotic symptoms may be mild, moderate, or severe in form. Although the various types of psychotic disorders have some common symptoms, their onset, course, and development are often substantially different.
Ongoing research efforts to clarify the cognitive and physiological mechanisms associated with different psychotic illness will hopefully help to aid in future diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed., 2013), published by the American Psychiatric Association, psychotic symptoms are a central feature of schizophrenia and other psychotic disorders. Schizophrenia, which is often a severe and debilitating mental illness, is found in approximately 1 percent of the general population and affects more than 2.5 million Americans. Onset of the disorder is most likely to occur between the ages of fifteen and thirty-five; the average age of onset is eighteen for men and twenty-five for women. Schizophrenia can occur in childhood, although this is rare, and can also have a late onset after the age of forty-five. Rates of schizophrenia do not vary substantially in terms of gender, race, or ethnicity, but the disorder is more prevalent in urban than in rural areas.
The DSM-5 outlines other psychotic disorders, known as schizophrenia spectrum disorders, that differ from schizophrenia primarily in terms of illness duration and severity. Schizophreniform disorder is diagnosed when the individual shows symptoms of schizophrenia that last less than six months. As the term implies, the psychotic symptoms in schizophreniform disorder are identical in form to schizophrenia but they have a briefer duration. Some individuals with schizophreniform disorder will eventually develop schizophrenia. Schizoaffective disorder contains features of a mood disturbance, with manic or depressive episodes, as well as the symptoms of schizophrenia. For a diagnosis of schizoaffective disorder, rather than schizophrenia or a mood disorder with psychotic features, both schizophrenia and mood disorder symptoms must be present the majority of the time. Schizoaffective disorder is less common than schizophrenia and may be associated with better functional outcome. Brief psychotic disorder, which is diagnosed if psychotic symptoms last for more than one day but no longer than four weeks, may develop in response to severe environmental stress or psychological trauma. Delusional disorder (paranoia) is less common and less severe than schizophrenia. In delusional disorder, the person has one or more delusions for at least one month. Other than the delusions, the person does not share any of the other psychotic symptoms typically observed in people with schizophrenia.
As of the DSM-5, schizotypal personality disorder is listed under this category as well as under its original category of personality disorders. Schizotypal personality disorder is characterized by eccentric behavior, odd beliefs, and difficulty or lack of interest in forming social relationships.
Psychotic symptoms may also be present in bipolar disorder and major depression, though they are not typically categorized as psychotic disorders. Bipolar disorder is characterized by periods of elevated, expansive, or irritable mood that may alternate with periods of depressed mood. In 1990, Frederick K. Goodwin and Kay R. Jamison reported that approximately 58 percent of individuals with bipolar disorder have at least one psychotic symptom during their lifetimes, which is most likely to occur during a manic episode. Psychotic symptoms may also accompany major depression. Psychotic symptoms are most likely to be associated with severe episodes of affective disturbance and could be either mood congruent or mood incongruent. Mood congruent psychotic symptoms contain themes that are consistent with the current affective state, such as a depressed individual with delusional thoughts about death. Mood incongruent psychotic symptoms involve content that is inconsistent with the current mood state, such as a depressed individual with delusional ideas about possessing special powers.
Some psychotic disorders are the direct result of external or environmental factors. Psychotic symptoms that result from psychoactive substance use or toxin exposure are classified as a substance-induced psychotic disorder. For example, some people may appear at hospital emergency rooms because of amphetamine-induced psychosis or cocaine-induced psychosis. In these cases, psychotic symptoms appear to arise because of the ingestion of a psychoactive (psychomimetic) substance. However, it is not known whether the people who experience psychotic symptoms while using a drug were already prone to psychosis (diathesis) and the drug was the additional stressor, or whether the drug was the proximal causal agent in the development of the psychosis.
Psychotic symptoms can be present in other disorders but are not considered to be defining features of the illness. Psychotic symptoms, especially paranoid delusions, are observed in people with dementia. Dementia is any condition in which there is a progressive deterioration of one’s memory, abstract thinking, and judgment and decision-making abilities. The most common types of dementia are Alzheimer’s disease and vascular dementia. Psychotic symptoms may also accompany a disorder known as dissociative identity disorder. Dissociative identity disorder (formerly known as multiple personality disorder) is associated with a failure to integrate various aspects of identity, memory, and consciousness.
Differential Diagnosis
Because the symptoms found across psychotic disorders greatly overlap, differential diagnosis of these conditions is often challenging. If a patient presents with psychotic symptoms, each of the psychotic disorders is considered when making a differential diagnosis. When diagnosing a psychotic disorder, it is important for mental health professionals to first obtain a thorough personal and family history of the patient. Information about the onset and course of presenting symptoms should also be obtained. If necessary, a physical examination or laboratory tests may be required to rule out other causes of the symptoms, such as brain injury.
Often, other psychotic disorders, such as schizoaffective disorder or schizophreniform disorder, must be ruled out from schizophrenia. The duration of psychotic symptoms will help differentiate whether the disorder is schizophrenia, schizophreniform disorder, or brief psychotic disorder. The length of affective impairment as well as the overlap between mood and psychotic symptoms is often helpful when distinguishing between schizoaffective disorder and psychotic mood disorder. The presence of other conditions, such as dementia or amnesic episodes, along with psychotic symptoms may aid in differential diagnosis as well.
Etiological Factors
Diathesis-stress models have been proposed as a way to explain the onset and development of many of the psychotic disorders. In this view, the diathesis, or underlying predisposition to illness, remains latent and unexpressed until it interacts with a sufficient amount of environmental stress. Individuals may vary in terms of the amount of their underlying diathesis and the stress required to bring about disorder. If an individual has a large diathesis, less stress is required to bring about illness onset. Conversely, if an individual with a substantial genetic diathesis is in a relatively low-stress environment, he or she may be protected from developing the illness. Diathesis-stress models have formed the basis for research on the role of genetic and environmental factors in the development of schizophrenia and related psychotic disorders.
Treatment Approaches
Antipsychotic
medications are considered an effective means of alleviating psychotic symptoms. Conventional (typical) antipsychotics were used to treat psychotic symptoms beginning in the 1950s. More recently, novel (atypical) antipsychotics, such as clozapine, risperidone, and olanzapine, have been introduced, which greatly reduce the severity of extrapyramidal side effects and are more effective at reducing negative or deficit symptoms relative to the typical antipsychotics. The optimal medication dose required is often obtained through a series of judgments made by the psychiatrist, who gradually increases or tapers the dosage based on observed treatment response. Psychopharmacological treatment has been found to be very effective in reducing symptoms during acute psychotic episodes and in preventing future relapses.
Typically, the treatment of choice for individuals with mood disorders, such as bipolar disorder or major depression, is a mood stabilizer or antidepressant. If psychotic features are present, an antipsychotic medication may be added to the treatment regimen.
Psychotherapy may also be helpful to individuals with psychotic disorders to assist them in medication compliance and other aspects of having a chronic mental illness. Psychosocial treatments, such as social skills training and family psychoeducation, can enhance the daily functioning and quality of life of individuals with psychotic disorders. By strengthening social support networks and teaching life skills, such interventions could improve social and vocational functioning, enhance one’s ability to cope with life stressors, and potentially protect against illness exacerbation.
Bibliography
Cardinal, Rudolf N., and Edward T. Bullmore. The Diagnosis of Psychosis. Cambridge: Cambridge UP, 2011. Print.
Goodwin, Frederick K., and Kay R. Jamison. Manic Depressive Illness. 2d ed. New York: Oxford UP, 2007. Print.
Gottesman, Irving I. Schizophrenia Genesis: The Origins of Madness. New York: Freeman, 1991. Print.
Lucas, Richard. The Psychotic Wavelength: A Psychoanalytic Perspective for Psychiatry. London: Routledge, 2009. Print.
Moskowitz, Andrew, Ingo Schafer, and Martin J. Dorahy. Psychosis, Trauma, and Dissociation: Emerging Perspectives on Severe Psychopathology. Chichester: Wiley, 2009. Print.
Oltmanns, Thomas F., and Richard E. Emery. Abnormal Psychology. 5th ed. Upper Saddle River: Pearson, 2009. Print.
Weiden, Peter J., Patricia L. Scheifler, Ronald J. Diamond, and Ruth Ross. Breakthroughs in Antipsychotic Medications. New York: Norton, 1999. Print.
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