Welcome to day 24 in the #Write31Days challenge on mental health. As I said about a week ago, I’d write a post on schizophrenia and psychosis someday in this series. Today the day has come to write about this category of mental disorders. Most people admitted to psychiatric hospitals, and certainly most who are there long-term, have some form of a psychotic disorder. I do not and personally I find psychosis one of the most bewildering mental health symptoms.
Psychotic disorders are characterized by symptoms in one or more of the following five domains:
- Delusions: fixed beliefs that do not change when the sufferer is presented with conflicting evidence. An example is the unfounded belief that one is being persecuted. Delusions are classified as bizarre when they are not understood by people from the sufferer’s culture and do not derive from ordinary life experience. In other words, a non-bizarre delusion is about something that could technically happen to the sufferer; a bizarre delusion is about something that is truly impossible. An example of a bizarre delusion is the belief that an outside force has removed one’s internal organs and replaced them by someone else’s.
- Hallucinations: sensory perceptions (eg. smelling, hearing or seeing something) that occur without an external stimulus. Hallucinations are as clear and vivid as ordinary sensory perceptions. Hallucinations may occur in any sensory modality, but auditory hallucinations are most common in schizophrenia and related disorders. (Visual hallucinations are more common in neurological conditions.)
- Disorganized thinking (speech). Formal thought disorder (disorganized thinking) is generally apparent through a person’s speech. For example, a person may switch from one topic to another (derailment or loose association). Rarely, a person’s speech may be so severely disorganized that it is barely comprehensible. These people’s speech is referred to as “word salad” (thhat’s the actual term used in DSM-5).
- Grossly disorganized or abnormal motor behavior. An example of this is catatonia, a marked decrease in reactivity to the environment. People may “freeze” in a (usually odd) position. Other examples are complete lack of speech (mutism), repetitive, purposeless movements or repeating someone else’s words (echolalia) or actions (echopraxia).
- Negative symptoms. These include reduced emotional expression and avolition. Avolition is a decrease in motivated, self-directed, purposeful activity. People may sit for hours and not be motivated for occupational, social or even simple household activities. They may therefore appear lazy.
Psychotic disorders may affect only one domain of symptoms. For example, delusional disorder is characterized by delusions only and no other psychotic symptoms. Sometimes, a person experiences more severe psychotic symptoms but the symptoms disappear within a month. This is called a brief psychotic disorder.
Schizophrenia is the most severe form of psychotic disorder. Individuals with schizophrenia experience symptoms in at least two of the domains listed above most of the time over a period of at least a month (or less if successfully treated). At least one of these symptoms must be delusions, hallucinations or disorganized speech. Since the onset of their symptoms, their functioning has declined significantly relative to their pre-illness level of functioning (in children or adolescents, consider failure to meet expected achievements in functioning). Even if the active phase of psychosis has subsided after a month, signs of disturbance remain for at least six months. If a person has residual symptoms for less than six months, they should be diagnosed with schizophreniform disorder.
The course of schizophrenia includes an active phase (at least one month during which at least two psychotic symptoms are present). This active phase may be preceded by a prodromal phase and followed by a residual phase. During the prodromal and/or residual phase, a person may experience only symptoms in one domain (usually negative symptoms), or they may experience two ore more psychotic symptoms but in a less severe (attenuated) form. Attenuated psychotic symptoms are symptoms that are similar to hallucinations, delusions etc. but are not full-fledged. Examples include odd beliefs or unusual perceptual experiences. Almost everyone experiences these at times. They become significant when they appear regularly and interfere with a person’s daily functioning. Some research shows that having attenuated psychosis symptoms is a risk factor for actual psychosis. However, there is no evidence so far that antipsychotics can prevent full-fledged psychosis in people who have only experienced attenuated symptoms.