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For other uses, see Psychosis (disambiguation).
| Psychosis Classification & external resources | ||
| ICD-9 | 290-299 | |
|---|---|---|
| OMIM | 603342 608923 603175 192430 | |
| MedlinePlus | 001553 | |
| MeSH | F03.700.675 | |
Psychosis is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality." People suffering from it are said to be psychotic.
People experiencing psychosis may report hallucinations or delusional beliefs, and may exhibit personality changes and disorganized thinking. This may be accompanied by unusual or bizarre behaviour, as well as difficulty with social interaction and impairment in carrying out the activities of daily living.
A wide variety of nervous system stressors, both organic and functional, can cause a psychotic reaction. This has led to the belief that psychosis is the \'fever\' of mental illness—a serious but nonspecific indicator.DeLage, J. (February 1955). "[Moderate psychosis caused by mumps in a child of nine years.]". Laval Médical 20 (2): 175-183. PubMed.
However, most people have unusual and reality-distorting experiences at some point in their lives, without being impaired or even distressed by these experiences. For example, many people have experienced visions of some kind, and some have even found inspiration or religious revelation in them.Dick, P.K. (1981) VALIS. London: Gollancz. ISBN 0-679-73446-5 As a result, it has been argued that psychosis is not fundamentally separate from normal consciousness, but rather, is on a continuum with normal consciousness.Johns, Louise C.; Jim van Os (2001). "The continuity of psychotic experiences in the general population.". Clinical Psychology Review 21 (8): 1125-41. PubMed. doi:10.1016/S0272-7358(01)00103-9. PubMed. Retrieved on 2006-08-19. In this view, people who are clinically found to be psychotic, may simply be having particularly intense or distressing experiences (see schizotypy).
In contemporary culture, the term "psychotic" is often used incorrectly to refer to psychopathy.[citation needed]
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The word psychosis was first used by Ernst von Feuchtersleben in 1845 Beer, M D (1995). "Psychosis: from mental disorder to disease concept.". Hist Psychiatry 6 (22(II)): 177-200. PubMed. PMID 11639691. Retrieved on 2006-08-19. as an alternative to insanity and mania and stems from the Greek psyche (soul) and -osis (diseased or abnormal condition).Online Etymology Dictionary. Douglas Harper (2001). Retrieved on 2006-08-19. The word was used to distinguish disorders which were thought to be disorders of the mind, as opposed to neurosis, which was thought to stem from a disorder of the nervous system.
The division of the major psychoses into manic depressive insanity (now called bipolar disorder) and dementia praecox (now called schizophrenia) was made by Emil Kraepelin, who attempted to create a synthesis of the various mental disorders identified by 19th century psychiatrists, by grouping diseases together based on classification of common symptoms. Kraepelin used the term \'manic depressive insanity\' to describe the whole spectrum of mood disorders, in a far wider sense than it is usually used today. In Kraepelin\'s classification this would include \'unipolar\' clinical depression, as well as bipolar disorder and other mood disorders such as cyclothymia. These are characterised by problems with mood control and the psychotic episodes appear associated with disturbances in mood, and patients will often have periods of normal functioning between psychotic episodes even without medication. Schizophrenia is characterized by psychotic episodes which appear to be unrelated to disturbances in mood, and most non-medicated patients will show signs of disturbance between psychotic episodes.
During the 1960s and 1970s, psychosis was of particular interest to counterculture critics of mainstream psychiatric practice, who argued that it may simply be another way of constructing reality and is not necessarily a sign of illness. For example, R. D. Laing argued that psychosis is a symbolic way of expressing concerns in situations where such views may be unwelcome or uncomfortable to the recipients. He went on to say that psychosis could be also seen as a transcendental experience with healing and spiritual aspects. Thomas Szasz focused on the social implications of labelling people as psychotic; a label he argues unjustly medicalises different views of reality so such unorthodox people can be controlled by society. Psychoanalysis has a detailed account of psychosis which differs markedly from that of Psychiatry. Freud and Lacan outlined their perspective on the structure of psychosis in a number of works.
In medical practice today, a descriptive approach to psychosis (and to all mental illness) is used, based on behavioral and clinical observations. This approach is adopted in the standard guide to psychiatric diagnoses employed in the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Since the DSM provides a widely-used standard of reference, the description presented here will largely reflect that point of view.
According to the DSM-IV-TR, the term psychosis has had many definitions in the past, both broad and narrow. The broadest was not being able to meet the demands of everyday life. The narrowest was delusions or hallucinations without insight. A middle ground may be delusions, hallucinations with or with out insight, and well as disorganized behavior or speech. Thus, psychosis can be a symptom of mental illness, but it is not a mental illness in its own right. For example, people with schizophrenia often experience psychosis, but so can people with bipolar disorder (manic depression), unipolar depression, delirium, or drug withdrawal.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition - Text Revision (Published by the American Psychiatric Association, 2000). Tsuang, Ming T.; William S. Stone, Stephen V. Faraone (July 2000). "Toward Reformulating the Diagnosis of Schizophrenia". American Journal of Psychiatry 157 (7): 1041-1050. PubMed. Retrieved on 2006-08-19. People diagnosed with these conditions can also have long periods without psychosis. Conversely, psychosis can occur in people who do not have chronic mental illness (e.g. due to an adverse drug reaction or extreme stress).Jauch, D. A.; William T. Carpenter, Jr. (February 1988). "Reactive psychosis. I. Does the pre-DSM-III concept define a third psychosis?". Journal of Nervous and Mental Disease 176 (2): 72-81. PubMed.
Psychosis should be distinguished from:
The DSM-IV-TR lists 9 formal psychotic disorders, but many other disorders may have psychotic symptoms. The formal psychotic disorders are:
Causes of symptoms of mental illness were customarily classified as "organic" or "functional". Organic conditions were primarily medical or pathophysiological, whereas, functional conditions are primarily psychiatric or psychological. The DSM-IV-TR no longer classifies psychotic disorders as functional or organic. Rather it lists traditional psychotic illnesses, psychosis due to General Medical conditions, and Substance induced psychosis.
Functional causes of psychosis include the following:
A psychotic episode can be significantly affected by mood. For example, people experiencing a psychotic episode in the context of depression may experience persecutory or self-blaming delusions or hallucinations, while people experiencing a psychotic episode in the context of mania may form grandiose delusions.
Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks. In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times.
Sleep deprivation has been linked to psychosis.Sharma, Verinder; Dwight Mazmanian (April 2003). "Sleep loss and postpartum psychosis". Bipolar Disorders 5 (2): 98-105. doi:10.1034/j.1399-5618.2003.00015.x. PubMed. Retrieved on 2006-09-27. Chan-Ob, T.; V. Boonyanaruthee (September 1999). "Meditation in association with psychosis". Journal of the Medical Association of Thailand 82 (9): 925-930. PubMed. Devillieres, P.; M. Opitz, P. Clervoy, and J. Stephany (May-June 1996). "[Delusion and sleep deprivation]". L\'Encéphale 22 (3): 229-231. PubMed. However, this is not a risk for most people, who merely experience hypnagogic or hypnopompic hallucinations, i.e. unusual sensory experiences or thoughts that appear during waking or drifting off to sleep. These are normal sleep phenomena and are not considered signs of psychosis.Ohayon, M. M.; R. G. Priest, M. Caulet, and C. Guilleminault (October 1996). "Hypnagogic and hypnopompic hallucinations: pathological phenomena?". British Journal of Psychiatry 169 (4): 459-467. PubMed. Retrieved on 2006-10-21.
Psychosis arising from "organic" (non-psychological) conditions is sometimes known as secondary psychosis. It can be associated with the following pathologies:
Fallon BA, Nields JA. "Lyme disease: a neuropsychiatric illness". Am J Psychiatry. 1994 Nov;151(11):1571-83.Hess A, Buchmann J, Zettl UK, Henschel S, Schlaefke D, Grau G, Benecke R."Borrelia burgdorferi central nervous system infection presenting as an organic schizophrenialike disorder". Biol Psychiatry. 1999 Mar 15;45(6):795.van den Bergen HA, Smith JP, van der Zwan A. "Lyme psychosis". Ned Tijdschr Geneeskd. 1993 Oct 9;137(41):2098-100.
Psychosis can even be caused by apparently innocuous ailments such as fluSteinberg, D.; S. R. Hirsch, S. D. Marston, K. Reynolds, and R. N. Sutton (May 1972). "Influenza infection causing manic psychosis". British Journal of Psychiatry 120 (558): 531-535. PubMed. Maurizi, C. P. (February 1985). "Influenza and mania: a possible connection with the locus ceruleus". Southern Medical Journal 78 (2): 207-209. PubMed. or mumps.Keddie, K. M. (August 1965). "Toxic psychosis following mumps". British Journal of Psychiatry 111: 691-696. PubMed.
Psychotic states may occur after ingesting a variety of substances both legal and illegal and both prescription and non prescription. Psychoactive drug intoxication or withdrawal. Drugs whose use, abuse or withdrawal are implicated include:
Intoxication with drugs that have general depressant effects on the central nervous system (especially alcohol and barbiturates) tend not to cause psychosis during use, and can actually decrease or lessen the impact of symptoms in some people. However, withdrawal from barbiturates and alcohol can be particularly dangerous, leading to psychosis or delirium and other, potentially lethal, withdrawal effects.
Some studies indicate that cannabis use may lower the threshold for psychosis, and thus help to trigger full-blown psychosis in some people. Degenhardt, L; Smith J, Steel R, Johnstone CE, Frith CD (2003). "Editorial: The link between cannabis use and psychosis: furthering the debate.". Psychological Medicine 33: 3-6. PubMed. PMID 12537030. Retrieved on 2006-08-19. Early studies have been criticized for failing to consider other drugs (such as LSD) that the participants may have used before or during the study, as well as other factors such as pre-existing ("comorbid") mental illness. However, more recent studies with better controls have still found a small increase in risk for psychosis in cannabis users.Moore, TH; Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, Burke M, Lewis G (28). "Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review.". Lancet 370: 319-28. PMID 17662880.
It is not clear whether this is a causal link, and it is possible that cannabis use only increases the chance of psychosis in people already predisposed to it; or that people with developing psychosis use cannabis to provide temporary relief of their mental discomfort. The fact that cannabis use has increased over the past few decades, whereas the rate of psychosis has not, suggests that a direct causal link is unlikely for all users. Degenhardt L, Hall W, Lynskey M (2001). "Comorbidity between cannabis use and psychosis: Modelling some possible relationships." (PDF). Technical Report No. 121.. Sydney: National Drug and Alcohol Research Centre.. Retrieved on 2006-08-19.
People with psychosis may have one or more of the following:
Hallucinations are defined as sensory perception in the absence of external stimuli. They are different from illusions, or perceptual distortions, which are the misperception of external stimuli.Harper, Douglas (November 2001). hallucinate. Online Etymology Dictionary. Retrieved on October 15, 2006. Hallucinations may occur in any of the five senses and take on almost any form, which may include simple sensations (such as lights, colors, tastes, and smells) to more meaningful experiences such as seeing and interacting with fully formed animals and people, hearing voices and complex tactile sensations.
Auditory hallucinations, particularly the experience of hearing voices, are a common and often prominent feature of psychosis. Hallucinated voices may talk about, or to the person, and may involve several speakers with distinct personas. Auditory hallucinations tend to be particularly distressing when they are derogatory, commanding or preoccupying. However, the experience of hearing voices need not always be a negative one. Research has shown that the majority of people who hear voices are not in need of psychiatric help. Honig, A; Romme MA, Ensink BJ, Escher SD, Pennings MH, deVries MW (1998). Auditory hallucinations: a comparison between patients and nonpatients. Journal of Nervous and Mental Disease. Retrieved on 2006-08-19. The Hearing Voices Movement has subsequently been created to support voice hearers, regardless of whether they are considered to have a mental illness or not.
Psychosis may involve delusional beliefs, some of which are paranoid in nature. Karl Jaspers classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising out of the blue and not being comprehensible in terms of normal mental processes, whereas secondary delusions may be understood as being influenced by the person\'s background or current situation (e.g., ethnic or sexual discrimination, religious beliefs, superstitious belief).Jaspers, Karl [1963] (1997-11-27). Allgemeine Psychopathologie (General Psychopathology), Translated by J. Hoenig & M.W. Hamilton from German, Reprint edition (in English), Baltimore, Maryland: Johns Hopkins University Press. ISBN 0-8018-5775-9.
Formal thought disorder describes an underlying disturbance to conscious thought and is classified largely by its effects on speech and writing. Affected persons may show pressure of speech (speaking incessantly and quickly), derailment or flight of ideas (switching topic mid-sentence or inappropriately), thought blocking, and rhyming or punning.
One important and puzzling feature of psychosis is usually an accompanying lack of insight into the unusual, strange, or bizarre nature of the person\'s experience or behaviour.Carpenter, William T., Jr., John S. Strauss, and John J. Bartko (December 21, 1973). "Flexible system for the diagnosis of schizophrenia: Report from the WHO international pilot study of schizophrenia" (PDF). Science 182 (4118): 1275-1278. doi:10.1126/science.182.4118.1275. PubMed. Retrieved on 2006-10-21. Even in the case of an acute psychosis, people may be completely unaware that their vivid hallucinations and impossible delusions are in any way unrealistic. This is not an absolute, however; insight can vary between individuals and throughout the duration of the psychotic episode.
It was previously believed that lack of insight was related to general cognitive dysfunctionLysaker, Paul H.; Morris D. Bell (November 1994). "Insight and cognitive impairment in schizophrenia. Performance on repeated administrations of the Wisconsin Card Sorting Test". Journal of Nervous and Mental Disease 182 (11): 656-660. PubMed. or to avoidant coping style.Lysaker, Paul H.; Gary J. Bryson, Rebecca S. Lancaster, Jovier D. Evans and Morris D. Bell (January 1, 2003). "Insight in schizophrenia: associations with executive function and coping style". Schizophrenia Research 59 (1): 41-47. doi:10.1016/S0920-9964(01)00383-8. PubMed. Retrieved on 2006-10-22. Later studies have found no statistical relationship between insight and cognitive function, either in groups of people who only have schizophrenia,Freudenreich, Oliver; Thilo Deckersbach and Donald C. Goff (July 2004). "Insight into current symptoms of schizophrenia. Association with frontal cortical function and affect". Acta Psychiatrica Scandinavica 110 (1): 14-20. doi:10.1111/j.1600-0447.2004.00319.x. PubMed. Retrieved on 2006-10-22. or in groups of psychotic people from various diagnostic categories.Cuesta, Manuel J.; Victor Peralta, Amalia Zarzuela, and Maria Zandio (May 31, 2006). "Insight dimensions and cognitive function in psychosis: a longitudinal study". BMC Psychiatry 6: 26-35. doi:10.1186/1471-244X-6-26. PubMed. Retrieved on 2006-10-22.
Brain imaging studies of psychosis, investigating both changes in brain structure and changes in brain function of people undergoing psychotic episodes, have shown mixed results.
The first brain image of an individual with psychosis was completed as far back as 1935 using a technique called pneumoencephalography Moore, M T; Nathan D, Elliot AR, Laubach C (1935). "Encephalographic studies in mental disease.". American Journal of Psychiatry 92 (1): 43-67. (a painful and now obsolete procedure where cerebrospinal fluid is drained from around the brain and replaced with air to allow the structure of the brain to show up more clearly on an X-ray picture).
More recently, a 2003 study investigating structural changes in the brains of people with psychosis showed there was significant grey matter reduction in the cortex of people before and after they became psychotic. Pantelis, C; Velakoulis D, McGorry PD, Wood SJ, Suckling J, Phillips, LJ, Yung AR, Bullmore ET, Brewer W, Soulsby B, Desmond, P, McGuire PK (2003). "Neuroanatomical abnormalities before and after onset of psychosis: a cross-sectional and longitudinal MRI comparison.". Lancet 25 (361 (9354)): 281-8. PubMed. PMID 12559861. Retrieved on 2006-08-19.
