ABC Health & Wellbeing

Fact File

Psychosis

by Peter Lavelle

A person with psychosis 'loses touch with reality': they may have disorganised thoughts, hallucinations or delusions and find it difficult to interact with others. They may have a one-off episode or it may be part of an ongoing illness such as schizophrenia.

Published 14/09/2006

[Image source: iStockphoto]

• Background
• Symptoms
• Diagnosis
• Treatment
• Prognosis
• More info

Background

Few conditions are as misunderstood and feared as psychosis. Hence pejorative terms such as 'schizo' and 'psycho' – so beloved by tabloid news editors as in: 'Savage attack by knife-wielding psycho' (asthmatics wielding knives don't seem to interest newspapers nearly as much). There is something about the mind that, when it doesn't work, scares us – much more so than afflictions of the body.

But things are a lot better than they were 100 – even 50 years ago – when people with psychotic symptoms were locked up in asylums. These days, effective treatments mean that most people who experience psychotic episodes can live a normal and fulfilled life.

About three in 100 people will experience a psychotic episode at some point during their lives. Some experience only a few episodes, or one episode lasting just a few days or weeks. Others will experience symptoms more frequently, and some will have the condition for life.

What causes psychosis isn't fully understood. It's probably caused by a combination of hereditary and other factors. It may be due to a chemical imbalance in the brain. A stressful event may trigger a psychotic episode. Certain drugs (for example, marijuana, speed or LSD) can trigger psychosis, especially if these drugs are taken in large amounts or over a long period.

Symptoms

The early symptoms of psychosis are often very mild, gradually worsening over months or years. Day-to-day thoughts become confused. People with psychosis might believe their thoughts are being interfered with, or think other people can read their thoughts or they can influence the thoughts of others.

People may have delusions, or false beliefs. There are various types of delusions:

• Paranoid delusions: for example, the person believes they are being watched and singled out for some harmful purpose.
• Grandiose delusions: for example, the person believes they have special powers or that they are an important religious or political figure.
• Depressive delusions: for example, the person believes they are guilty of some terrible crime.

They may also have hallucinations, for example, hearing voices (auditory hallucinations), or seeing things that aren't there (visual hallucinations – though these are less common).

They may have difficulty expressing their emotions, or have no emotions or very flat emotions. They may become very lethargic, so that even small tasks like getting up in the morning or doing the dishes may seem impossible. They may lack motivation and become socially withdrawn.

Psychosis is usually classified into different types:

• Brief reactive psychosis: psychotic symptoms lasting less than a month and due to a stressful event.
• Drug-induced psychosis: caused by drugs like speed, LSD, marijuana, ecstasy or magic mushrooms. The symptoms last until the effects of the drug wear off (hours or days).
• Schizophrenia: the most well known of the psychotic illnesses. A person affected by schizophrenia experiences a range of psychotic symptoms and commonly has difficulty organising their thoughts. (Schizophrenia doesn't mean more than one personality or a 'split' personality: this is a myth created by movies.)
• Bipolar disorder: also known as manic depression. Bipolar disorder involves very extreme moods (either very high or very low). People with this condition may also develop psychotic symptoms both in the high or low mood phases.
• Severe depression: depression can be so intense that it causes psychotic symptoms.

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Diagnosis

There's no specific test for psychosis – it's a matter of the health professional recognising the behavioural and thought disorder patterns to make the diagnosis. Usually, doctors will do a physical examination, blood tests and other investigations to make sure the symptoms aren't due to another condition.

One of the difficulties with psychosis in its early stages is that it can easily be mistaken for something else, like drug and alcohol use or even just bad behaviour. These misunderstandings can lead to alienation from family and friends, and perhaps even difficulties with the police.

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Treatment

We've come a long way in psychosis treatment since the 18th Century, when the armoury included cold baths, blood-letting, purgatives, solitary confinement in the dark, and for hopeless cases, manacles and straightjackets.

Since the mid 1950s, drug treatments have revolutionised the way psychosis is treated and dramatically improved the outcome for people suffering from it.

Someone with severe psychosis will still need to be hospitalised, and they may need to be admitted against their will if there's a danger of suicide or violence. Managing someone who is acutely psychotic can be challenging for hospital staff; the person may be anxious, agitated, hostile, distressed and sleep-deprived. They may have no idea that they are psychotic – they may believe their own delusions are real, for example.

But increasingly the trend is to treat people out of hospital if possible, with GPs, psychiatrists and community psychiatric workers managing the person in a team effort.

There is also a trend towards early intervention – before too much damage has been done to a young person's life and relationships. Studies show the earlier psychosis is treated, the less chance there is of further episodes.

Medications are the mainstay of treatment. Antipsychotic drugs are thought to block a neurotransmitter (messenger chemical) called dopamine in the brain. The drugs reduce or minimise delusions, hallucinations, thought disorder and abnormal mood states. They can take a few weeks before they begin to work.

There are older antipsychotics such as chlorpromazine and haloperidol, and newer drugs such as risperidone, olanzapine and amisulpride. Studies have shown no difference in effectiveness or side effects between the older and the newer drugs.

Medication is generally taken for a year following a first episode of psychosis, longer if there are relapses. They're generally stopped after the person has become stable. They shouldn't be taken permanently, because they tend to have side effects affecting movements of muscles in the limbs – face, similar to those seen in Parkinson's disease. They may also cause dry mouth, constipation, urinary retention and hormonal problems. Higher doses make side effects more likely.

If a person is very agitated and distressed, sedatives such as benzodiazepines may be given. Antidepressants and mood stabilisers are also sometimes prescribed if there is depression or bipolar disorder.

Psychotherapy, particularly cognitive behavioral therapy (in which the person is taught how to rationalise and modify their thought patterns), is also very helpful.

A person with psychosis often needs help organising accommodation, finding employment they can manage, and developing social and personal skills so they can continue to live independently in the community. Families and carers often need support and education too.

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Prognosis

A person who has a psychotic episode will probably recover, though they may need weeks, months or even longer to recover fully. About a third will never have another episode. Another third will go on to have two or more further episodes – but most of these people will still be able to lead fairly normal lives. Another third will have multiple ongoing episodes and have difficulty functioning, despite treatment and community and family support.

People with psychosis have higher rates of smoking, don't exercise as much as the general population and may have poor nutrition, so are prone to conditions like heart disease and diabetes. So it's important that they look after their general health as well.

With medical treatment and social and community support, most people with psychosis can lead productive and useful lives.