What is Psychosis and Who Experiences These Symptoms? The term psychosis, or the presence of psychotic symptoms, implies a gross impairment in reality orientation— toward self, others and the world. Psychotic symptoms may emerge in a number of psychiatric illnesses and medical conditions. 1 Patients who have never exhibited psychotic symptoms may develop symptoms rather slowly or rapidly. In cases where we have an established therapeutic relationship (i.e.—seeing the individual for some time), the onset of new symptoms may make us feel uneasy. For example, in the course of a session, an established patient (with no prior history of psychotic symptoms) may relay paranoid ideation, delusions or frank auditory hallucinations.
There are three primary types of psychotic symptoms: hallucinations, delusions and thought disorders. The presence of these symptoms necessitates further investigation. Hallucinations Hallucinations are defined as perceptions that occur in the absence of corresponding stimuli.2 They are, however, perceived as real by the patient experiencing them. They may be associated with any of the senses, but most typically occur as auditory or visual hallucinations. Auditory hallucinations (AH) occur most commonly with psychotic thought processes. Visual hallucinations may occur in the context of acute psychotic episodes, but are more frequently experienced in organic disorders, substance abuse/withdrawal or secondary to medications.
Tactile hallucinations are commonly seen in substance abuse, especially cocaine or amphetamine, as well as alcohol withdrawal. Olfactory (smell) and gustatory (taste) hallucinations are far less common and are typically the result of organic brain disease. As auditory hallucinations are by far the most frequently encountered hal-lucinations, further discussion is warranted. Auditory hallucinations can range in quality from muffled sounds to music to one or multiple voices conversing with each other. The voices typically comment on the patient's actions or behavior and are generally pejorative.
Command type auditory hallucinations can be especially problematic in that psychotic patients experience these hallucinations and feel compelled to act on the commands. An example of this type of situation is the patient who hears voices telling him to harm himself (or someone else) and then acts on those commands. Patients who begin experiencing command type AH should be monitored closely, and hospitalization should be considered. Delusions Delusions are another way in which psychosis may be manifested. Delusions are firmly held false beliefs.
They may be characterized as bizarre (not plausible) or non-bizarre. Common delusions involve themes of paranoia, grandiosity, jealousy or somatic concerns. Examples of bizarre versus non-bizarre delusions include a patient reporting a federal agency is "after him" and has "removed all of his internal organs," versus a patient reporting his belief that his wife is having an affair with his boss (not necessarily likely, but possible). Disturbed Thought Processes Thought disorders may be separated into disturbances of process or content. Disordered thought content has been discussed above and includes hallucinations and delusions. Disturbed thought processes involve a disruption in the form of thinking. For example, individuals may exhibit any number of problems in relaying information.
They may exhibit racing thoughts, loosening of associations (talking about ideas that do not really connect together), flight of ideas, tangentially (never really answering a question, going down "bunny- trails" and never coming back to the point) or circumstantiality (giving so much detail about something that they cannot get to the point), thought blocking, thought broadcasting, neologisms (making up their own words), or clang associations (saying words because they rhyme, "I took the train, bang, fang, hang, tame…"), all of which impair the way in which individuals communicate their thoughts to others.
Psychotic Symptoms and Different Diagnosis The differential diagnosis of psychotic symptoms may be divided into: mood or affective disorders (depression with psychotic features, schizoaffective disorder, or bipolar disorder), brief psychotic reaction, schizophreniform disorder, schizophrenia, delusional disorders or organic etiologies. Psychotic Symptoms and Mood Dysregulation Individuals with mood disorders may exhibit psychotic symptoms at various times during the course of their illness. Patients with severe major depressive disorder may present with, or develop, psychotic symptoms (usually AH) at any time. The key to making this diagnosis is the presence of psychotic symptoms only when severe depression is present.
The treatment focuses on controlling the depression (treating to remission) with antidepressants and short-term use of atypical antipsychotic agents. Schizoaffective disorder is a type of mood disorder characterized by mood symptoms, as well as psychotic symptoms; however, the psychotic symptoms are present in the absence of mood symptoms (during periods of euthymia). Patients who are bipolar spend approximately two-thirds of the time with some type of affective dysregulation. Depressive episodes are much more frequent than manic episodes. In these individuals, psychotic symptoms are typically seen during the height of a manic episode. Treatment of schizoaffective disorder usually involves an antidepressant and/or a mood stabilizer.
Treatment of bipolar disorder includes the use of a mood stabilizer (which may be an atypical antipsychotic agent) that may also be cautiously combined with an antidepressant. Schizophrenia A comprehensive discussion of schizophrenia is beyond the scope of this article; however, some details need to be addressed. Schizophrenia is a complex and chronic illness often characterized by medication noncompliance and frequent relapses. The five types of schizophrenia are: paranoid, catatonic, disorganized, undifferentiated and residual. Key issues related to making this diagnosis include the presence of psychotic symptoms for at least 30 days and a decreased level of functioning for at least six months.
Primary treatment includes atypical antipsychotic medications, social support and case management. Other Psychotic Disorders A Brief psychotic disorder is characterized by the sudden onset of a positive psychotic symptom (delusion, hallucination, disorganized speech or behavior) that occurs rapidly and is present one to 30 days, then resolves completely. This disorder is typically seen in high functioning individuals who are in extremely stressful situations. Treatment involves managing the stress and the short-term use of atypical antipsychotic agents. _Schizophreniform_ disorder is similar to schizophrenia, with the exception that comparable symptoms are present for one to six months, and a decline in function is not necessary to make the diagnosis. Treatment involves antipsychotic agents.
_A Delusional Disorder_ is characterized by the presence of one or more non-bizarre delusions. Olfactory or tactile hallucinations may be present and related to the delusional theme (i.e.—an individual believes a rat follows her around, and she believes, on occasion, she smells the rat). Auditory and visual hallucinations may be present, but not prominent. Patients with a delusional disorder generally do not have a significant impairment in social and occupational functioning. Delusional disorders are extremely difficult to treat, but antipsychotic agents may prove helpful. Organic Cause of Psychotic Symptoms Is Most Common The broadest category responsible for psychotic symptoms is organic.
This category includes, but is not limited to: substance use, medications, delirium, neoplasms, and nutritional deficiencies. This category exemplifies the importance of obtaining a complete and comprehensive history. Any concerns regarding the patient's medications or health considerations should be referred to the patient's primary care physician or psychiatrist for further evaluation and treatment. Substance abuse issues should be discussed with the patient, and then the patient should be referred for treatment. Key Issues in Assessment of Psychotic Symptoms When evaluating individuals with psychotic symptoms, several key issues need to be addressed. The first issue involves safety. The provider must ask the question, "Does this person pose a significant threat to himself or others?" If the patient is unable or unwilling to contract for safety, other measures are required (i.e.—calling the police, etc.).
It becomes very important to recognize that not every patient with psychotic symptoms requires hospitalization. The therapist is then put in a difficult position, as he or she must try to determine if someone is "safe" to leave the office. One has to balance the patient's safety versus risking, and potentially destroying, any therapeutic alliance. When in doubt, patient safety must come first. The patient should be detained until he or she can be appropriately transported to another facility for further evaluation and treatment. If a stable patient begins to exhibit mild psychotic symptoms, a referral can be made to a local psychiatrist or primary care provider for potential medication management.
Common Medication Treatments As we have discussed, the primary treatment for the emergence of psychotic symptoms involves antipsychotic agents. At this time, atypical antipsychotic agents appear to be the first line treatment for psychotic symptoms. These agents are felt to have a better side effect profile than older "typical" agents. Generally speaking, these newer agents are less likely to produce a number of side effects, most notably, extrapyramidal side effects or tardive dyskinesia. Atypical antipsychotic agents include: Risperdal (risperidone), Zyprexa (olanzapine), Seroquel (quetiapine), Geodon (ziprasidone), Abilify (aripiprazole), and Clozaril (clozapine). In addition to providing relief from psychotic symptoms, these agents also function as mood stabilizers. These "atypical" agents are therefore utilized as mood stabilizers in patients with bipolar disorder and schizoaffective disorder.
While the "atypical" agents are felt to have a safer side effect profile, they are not without side effects. The primary problems, which generally speaking appear to be a class effect, involve weight gain and metabolic issues (diabetes, elevated cholesterol/triglycerides). Older, "typical" antipsychotic agents are considered second line therapy. Examples of these agents include: Haldol, Navane, Prolixin, Thorazine, Trilafon and Stelazine. While these medications are efficacious, their side-effect profiles have made them second line agents. Of note, is that patients with major depressive disorder who develop psychotic features are typically treated appropriately with antidepressant agents. The short-term use of antipsychotic agents may also be indicated. Counseling and Psychotherapy: Key to Preventing Relapse Counseling can be helpful for clients who have problems with reality testing and psychotic symptoms.
One of the chief goals for working with such clients is to prevent relapse. There are many strategies for accomplishing this goal, but we believe two are most important. First, we focus on helping clients remain compliant with their medications. This may be especially challenging for clients with Bipolar Disorder, who may actually enjoy their manic symptoms. It is also challenging for Christian clients who believe that using medication is a sign of "lack of faith in God's healing power." We work to help these clients realize that taking antipsychotic medication does not imply a lack of faith. It is also important to address misconceptions that psychotic symptoms are a direct result of sin (i.e.—many people who live in debauchery never have psychotic symptoms and many people who really care about their relationship with God and are committed to their faith have struggled with psychotic symptoms).
This is not to say that sin and psychosis can't run together, or that losing control of one's behavior does not create a risk for relapse, however. We encourage clients to see that these medications can remove many barriers that make it difficult for them to enjoy and participate in their spiritual growth and healthy relationships. Also, just as certain physical problems such as diabetes, heart disease or chronic rheumatoid arthritis can negatively impact the joy of one's salvation, so can a serious mental illness. And just as we don't hesitate to tell people who suffer from these physical ailments that it is important for them to take their medication, it is equally important that we encourage patients with severe mental illness to take their medications to manage their symptoms.
This strategy can be enhanced by using a specific type of cognitive-behavior therapy (Acceptance/Commitment Therapy) designed for patients with psychotic disorders. It focuses on helping patients accept (which does not mean they have to like or want) their symptoms and simultaneously commit to seeking their goals and values. This approach is beginning to show promising results.3 Another important strategy for preventing relapse is helping patients establish more secure-based relationships in their family and other important relationships. Research shows that patients are more likely to relapse when their most important relationships are characterized by a high degree of Expressed Emotion.4 Such families tend to be highly judgmental, hostile and emotionally overinvolved with family members. They are also more likely to make negative attributions about the client's mental illness, believing that symptoms are directly under the patient's control. Research indicates that when families are highly critical of the patient's symptoms and attribute them to personal deficits, patients are more likely to relapse.
It is important for the clinician to work with these families closely and attempt to establish a collaborative working relationship. It is also important to address some of the misconceptions that these families have about serious mental illness, similar to those noted above concerning the causes of mental illness. This strategy can play a very important role in helping the family reduce hostile criticism and other forms of negative emotional expressions. Helping the family establish secure-based relationships involves not just decreasing the amount of negativity, but also increasing the level of warmth and acceptance. Enhancing secure-based relationships in these families includes (1) assessing the degree of Expressed Emotion (using Family Emotional Involvement and Criticism Scale),5 (2) teaching the family skills for recognizing their patterns of criticism and hostility, (3) how to use appropriate empathy and warmth, and (4) how and when to use effective communication and problem-solving skills. Take help from telephone psychologist .
Finally, it is helpful to discuss with the patient the paradox of support-seeking for those with serious mental health problems.6 Research shows that when patients express too much distress and neediness, others either become critical or withdrawal and avoid. On the other hand, when patients do not discuss or express their distress, others view them as not wanting any support or help. Consequently, in both circumstances the patient is left feeling rejected and alone. This pattern can be exacerbate symptoms and lead to relapse. Alternatively, we help patients find a middle ground where they express their needs, but do so in a manner that does not overwhelm their caregivers or support figures. As they learn to express themselves more effectively and their caregivers learn to respond more sensitively, the patient is significantly less likely to relapse and more likely to comply with medication treatment. This may free them from the burdens of significant psychiatric symptoms so they can better pursue their growth and enjoyment in the kingdom of God.
