April 2016
Psychosis

What is psychosis?

Psyche means mind/soul, "osis“ means abnormal condition or derangement

A cluster of symptoms which results in “one’s mind playing tricks on that person” constitutes psychosis

It is a mental condition where a person’s contact with reality is distorted or lost

So a person with psychosis will have 1. Altered thinking and 2.Altered emotions

This can lead to Impaired functioning. 

Psychosis affects both men and women of all age groups. 

Symptoms of psychosis:

The symptoms of psychosis do not appear suddenly. They creep in stealthily and may be present for weeks to months before they progress to a full blown state. 

The symptoms exhibited at different stages are also different. 

In the very beginning there are some “Behavioral changes” which can pass for normal variations in daily life. It is very difficult to state that at this stage they clearly indicate a disorder. These changes are not just a set of particular symptoms but a definite variation in the routine behavior of the individual. 

This stage is called the prodrome. In this stage, “Things are not quite right” or “ he/she is not the same person”. 

The symptoms that appear in this stage are nonspecific and vague. They are:

  • Reduced attention and concentration ( difficulty in filtering out distracting information and sensations)

  • Reduced interest and motivation

  • Confusion ( about what is real and what is not real)

  • Depressed mood

  • Sleep disturbances

  • Anxiety/Fear

  • Social withdrawal ( feel more disconnected and prefer being alone)

  • Suspiciousness

  • Deterioration in role functioning

  • Irritability

This is followed by the acute phase when clear psychotic symptoms appear.

  • Delusions

  • Hallucinations

  • Disorganized speech

  • Emotional outbursts

  • Suicidal attempts

  • Difficulty in functioning

  • Disorganized behaviour

Psychotic disorders can be broadly classified into organic type and functional type Delirium and dementia are examples of organic psychosis

Functional psychotic disorders include

  • Schizophrenia

  • Schizoaffective disorder

  • Acute and transient psychotic disorders

  • Delusional disorder

  • Schizotypal disorder

 

Schizophrenia is a chronic, severe multifaceted and complex disorder of the mind, now being increasingly considered a brain disorder

It affects approximately 1% of the world population and has a ubiquitous distribution

It is considered as the “greatest disabler of youth” as it most commonly affects persons in the productive period of their life between15 and 35 years of age

Schizophrenia cuts across boundaries of gender, socioeconomic class, race, caste, creed and geographic location.

This implies that anybody can be affected by schizophrenia.

The World Health Organization (WHO) has identified schizophrenia as one of the ten most disabling disorders affecting all human beings.

What causes schizophrenia?

No single cause has been identified. A combination of genetic predisposition, inherent vulnerability and the presence of environmental factors such as prolonged stress seem to lead to schizophrenia.

Other environmental factors could be :

  • pregnancy and delivery complications

  • childhood and prenatal virus infection

  • urban birth and residence

  • psychosocial factors (dysfunctional family environment)

 

The disorder is triggered by an interplay of genetic and environmental factors which leads to alterations in the biochemical amines especially dopamine in the brain.

There is an excess of dopamine activity which is directly responsible for the signs and symptoms of schizophrenia. Other amines like serotonin, GABA etc are also implicated in schizophrenia.

There is no single diagnostic test to confirm this illness The information provided by an observant family member combined with the doctor’s clinical acumen go a long way in arriving at a diagnosis.

Besides, there are scientifically laid down guidelines and diagnostic criteria for arriving at a diagnosis, like the International Classification of Diseases and the Diagnostic and Statistical Manual of mental disorders ( V) which help a psychiatrist in making the right diagnosis.

The early symptoms ( prodrome) have already been listed.

The signs and symptoms of schizophrenia are broadly grouped into two: Positive symptoms and Negative symptoms.

Positive symptoms of schizophrenia are behaviors and experiences that the ill person has, that healthy people do not.

1. Delusions: These are false beliefs that are firmly held with conviction by the patient however untrue it may be to others. These include feelings of:

  • being watched by others all the time ( hidden cameras, walls being bugged).

  • their food being poisoned.

  • their partners/spouses being unfaithful to them.

  • their thoughts being known to others

  • people plotting against them and their dear ones

  • being controlled by external forces sometimes through electric/electronic devices secretly implanted in some part of their body

  • that everybody around them is talking about them /teasing them

  • things said or happening on television or radio having a special meaning or significance to them.

  • thoughts being removed, inserted in their brains and also that their thoughts are being read by others.

  • Being extremely powerful , very wealthy , or being gods or kings etc.

 

2.Hallucinations: These are false perceptions i.e., they are imaginations involving all the five sense organs namely eyes, ears, nose, tongue and skin. They see imaginary figures, hear imaginary voices and smell, taste and feel sensations that are not real.

The imaginary voices (auditory hallucinations) are most common in schizophrenia. Visual hallucinations can also occur. The other modalities of sensation can also be involved though not very common in schizophrenia.

The voices in schizophrenia which form the hallmark of the disease are of many types.

  • They may comment on the person’s behavior continuously (mostly derogatory).

  • There may be more than one voice and they can discuss the person in question among themselves.

  • The voices can threaten the person of harm befalling him or his family

  • Voices can command the person to perform certain acts and control the person completely.

The hallucinations can be very strong and overpowering driving the person to do things which he would not otherwise do. This can result in violent behavior, causing harm to self and others.

3.Disorganised speech: Schizophrenia is primarily a disorder of thinking which is reflected in the spoken words which can be difficult to understand. It can be incoherent and irrelevant to the context of a conversation. There may be jumps from one topic to another which are unrelated. Sometimes the ill person says that he/she feels confused or muddled.

4.Disorganized Behavior: There can be problems in performing directed daily activities leading to neglected personal hygiene and appearance and disinterest in the surroundings.

5.Catatonic Behavior: The individual remains unaware and does not respond to things happening around him, has a rigid posture, resists movement or instructions and sometimes maintains odd postures for prolonged periods of time. We are seeing less of catatonia nowadays.

 

Negative symptoms of schizophrenia refer to the absence or reduction of certain behaviours that are normally present in people.

The range and intensity of emotional expression, communication, body language and interest in normal activities are restricted.

  • Blunted (or flat) Affect: Decreased emotional expressiveness, unresponsive immobile facial appearance, reduced eye contact and body language.

  • Alogia: Reduced speech. Responses are detached and speech is not fluid.

  • Avolition: Lacking motivation, spontaneity, initiative. Sitting for lengthy periods or ceasing to participate in work or daily activities.

  • Anhedonia: Lacking Pleasure or interest in activities that were once enjoyable.

  • Attention Deficit: Difficulty in concentrating

In addition, persons with schizophreni a can also feel depressed and anxious.

MANAGEMENT

Effective management of schizophrenia always involves a multidisciplinary team of psychiatrists, social workers, psychologists, occupational therapists and families.

Medication is the mainstay of treatment in schizophrenia.

There is a wide range of medication to choose from depending on the person’s age, nature of illness, affordability, side effect profile etc.

Treatment in schizophrenia does not stop with symptom control. It extends to include rehabilitation and reintegration back into the society.

Rehabilitation involves helping those affected with schizophrenia to return to the roles they were performing before they became sick.

Schizophrenia is a treatable neurobiological disorder. Like in medical disorders, good improvement is seen if treatment is initiated early in the course of illness.

Acute and transient psychotic disorders

  • Abrupt onset (<48 hours)

  • Presence of acute stressful event common

  • The person has predominant confusion and perplexity

  • Quick and complete recovery in 2-3 months

  • Do not resemble schizophrenia or mood disorders in clinical picture or course.

  • Commonly seen in India and other developing countries

Persistent delusional disorders

  • Non bizarre delusions-most prominent feature

  • At least 3 months duration

  • Delusions of persecution, grandeur, jealousy, erotomania and somatic commonly seen

  • Absence of hallucinations/organic conditions/schizophrenia/mood disorders

  • Stable and chronic course.

  • Near normal social and occupational functioning

Schizoaffective disorder

  • Borders between schizophrenia and mood disorders.

  • Features of both can be prominent within the same episode

  • Present simultaneously or follow within few days of each other

  • 3 types : Manic, depressive and mixed

  • Usually episodic, can be chronic.

  • Prognosis better than schizophrenia

 

Dr. R. Thara,
Director, SCARF, India

Dr. R. Mangala
Psychiatrist, SCARF, India

Supported by Unrestricted Educational Grant by SUN Pharma SUN LOGO

>> Please click here the pdf version of this document

  

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