psychosis

psychosis, any of several major mental illnesses that can cause delusions, hallucinations, serious defects in judgment and other cognitive processes, and the inability to evaluate reality objectively. A brief treatment of psychosis follows. For full treatment, see mental disorder.

The term psychosis is derived from the Greek psyche, meaning “soul,” “mind,” or “breath.” The ancient Greeks believed that the breath was the animating force of life and that when the breath left the body, as happened in death, the soul left the body. Because words that contain the root psyche (e.g., psychiatrist, psychiatry, etc.) are associated with the essence of life (usually related to the soul or human spirit) psychosis has come to mean that a person has lost the essence of life—that he or she has developed a private view of the world or a private reality not shared by others.

It is difficult to clearly demarcate psychoses from the class of less-severe mental disorders known as psychoneuroses (commonly called neuroses) because a neurosis may be so severe, disabling, or disorganizing in its effects that it actually constitutes a psychosis. However, in general, patients suffering from the recognized psychotic illnesses exhibit a disturbed sense of reality and a disorganization of personality that sets them apart from neurotics. Such patients also frequently believe that nothing is wrong with them, despite the palpable evidence to the contrary as evinced by their confused or bizarre behaviour. Psychotics may require hospitalization because they cannot take care of themselves or because they may constitute a danger to themselves or to others.

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The major defining symptoms of psychosis are hallucinations and delusions. A hallucination is a sensory perception experienced only by the affected person; it is not shared by others. For example, persons experiencing hallucinations may hear a voice telling them to commit suicide or to cut themselves, but no one else can hear this voice. A delusion is a belief not credible to others. The belief expressed by the affected person usually has little basis in the person’s past. For example, a casually religious person who is experiencing a psychosis may suddenly begin to tell other people that he is Christ, Muhammad, or Buddha or that he has been selected by God for some special task. There is no evidence that would make anyone else share this belief. A person can experience both hallucinations and delusions or just one or the other. Hallucinations and delusions are most often caused by a disturbance or change in brain function.

Psychoses may be divided into two categories: organic and functional. Organic psychoses are characterized by abnormal brain function that is caused by a known physical abnormality, which in most cases is some organic disease of the brain. However, altered brain function that precipitates hallucinations and delusions is more often associated with specific psychiatric disorders, which are categorized as functional psychoses.

Functional psychoses

Schizophrenia is the most common and the most potentially severe and disabling of the psychoses. Symptoms of schizophrenia typically first manifest themselves during the teen years or early adult life. The primary symptoms are the presence of hallucinations and delusions, disorganized speech and behaviour, a lack of emotional expression, and a marked lack of energy. In order for a definitive diagnosis of schizophrenia to be made, these symptoms must be present for at least six months and must impair the person’s ability to function. The course of the disease is variable. Some schizophrenics suffer one acute episode and then permanently recover; others suffer from repeated episodes with periods of remission in between; and still others become chronically psychotic and must be permanently hospitalized.

Despite prolonged research, the cause or causes of schizophrenia remain largely unknown. It is clear that there is an inherited genetic predisposition to the disease. Thus, the children of schizophrenic parents stand a greatly increased chance of themselves becoming schizophrenic. While no causative link has been identified, many neurological findings have been noted in the examination of schizophrenic patients. These include subtle problems with coordination, changes in brain structure such as enlarged cerebral ventricles, and abnormal electrical signaling in the brain. In addition, the levels of several neurotransmitters (chemicals that facilitate the transmission of nerve impulses), particularly dopamine and glutamate, are altered in the brains of schizophrenic individuals.

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The symptoms of schizophrenia can be treated, but not cured, with such antipsychotic drugs as chlorpromazine and other phenothiazine drugs and by haloperidol. These medications affect neurotransmission in the brain. For example, haloperidol has strong antidopaminergic actions that facilitate the regulation of dopamine activity and thus reduce certain symptoms of schizophrenia. Psychotherapy may be useful in alleviating distress and helping the patient to cope with the effects of the illness.

Other functional psychoses include mood disorders, which are also known as affective disorders. Examples include bipolar disorder and major depressive disorder. Mood disorders are characterized by states of extreme and prolonged depression, extreme mania, or alternating cycles of both of these mood abnormalities. Depression is a sad, hopeless, pessimistic feeling that can cause listlessness; loss of pleasure in one’s surroundings, loved ones, and activities; fatigue; slowness of thought and action; insomnia; and reduced appetite. Mania is a state of undue and prolonged excitement that is evinced by accelerated, loud, and voluble speech; heightened enthusiasm, confidence, and optimism; rapid and disconnected ideas and associations; rapid or continuous motor activity; impulsive, gregarious, and overbearing behaviour; heightened irritability; and a reduced need for sleep. When depression and mania alternate cyclically or otherwise appear at different times in the same patient, the person is termed to be suffering from bipolar disorder. Bipolar patients also frequently suffer from delusions, hallucinations, or other overtly psychotic symptoms. Bipolar disorder often first manifests itself around age 30, and the disease is often chronic. Many bipolar patients can be treated by long-term maintenance on lithium carbonate, which reduces and prevents the attacks of mania and depression. However, the suicide rate associated with severe bipolar disorder is high, ranging from an estimated 5 to 15 percent of patients.

Depression alone can be psychotic if it is severe and disabling enough, and particularly if it is accompanied by delusions, hallucinations, or paranoia. Mania and many cases of depression are believed to be caused by deficiencies or excesses of certain neurotransmitters in the brain, particularly norepinephrine and serotonin. Therefore, antidepressant drugs that act to reestablish normal norepinephrine and serotonin levels are often effective for bipolar and major depressive disorders. Treatment often involves the administration of a tricyclic antidepressant (e.g., amitriptyline, amoxapine, or imipramine) or an agent from a class of antidepressants known as monoamine oxidase inhibitors (e.g., phenelzine, tranylcypromine, or selegiline). Shock (electroconvulsive) therapy is useful in some cases, and psychotherapy and behavioral therapy may also be effective.

Paranoia is a special syndrome that can be a feature of schizophrenia (paranoid schizophrenia) and bipolar disorder or that can exist by itself. A person suffering from paranoia thinks or believes that other people are plotting against or trying to harm, harass, or persecute him in some way. The paranoiac exaggerates trivial incidents in everyday life into menacing or threatening situations and cannot rid himself of suspicions and apprehensions. Paranoid syndromes can sometimes be treated or alleviated by antipsychotic drugs.

The functional psychoses are difficult to treat; drug treatments are the most common and successful approach. Psychoanalysis and other psychotherapies, which are based on developing a patient’s insight into his or her presumed underlying emotional conflicts, are difficult to apply to psychotic patients.

Organic psychoses

Many medical conditions can affect brain function and cause symptoms of hallucinations and delusions. For example, dementia is the gradual and progressive loss of intellectual abilities, such as remembering, thinking, paying attention, and perceiving; it is often a chronic condition. Delirium, which commonly occurs in patients with dementia, is a clouded, confused state of consciousness and is usually only a temporary condition. Dementia is the principal syndrome in the most common and widespread organic psychosis, Alzheimer disease. An elderly person with this disease experiences chronic confusion and loss of memory and may experience paranoia or other personality changes. The memory loss becomes increasingly far-reaching, and the patient gradually becomes lethargic and inactive; death is the end result. The course of the disease may last from 2 to 20 years. Disturbances in the blood supply to the brain caused by cerebral arteriosclerosis (hardening of the arteries) produce symptoms similar to those of Alzheimer disease. Other medical conditions associated with psychoses include thyroid disease, vitamin deficiencies, liver disease, epilepsy, Parkinson disease, and encephalitis. Disorders of sleep or prolonged sensory deprivation can also cause hallucinations and delusions.

Many drugs can alter brain function and cause symptoms of psychoses. For example, certain drugs—such as narcotics to treat pain, levodopa for Parkinson disease, prednisone for inflammation, and digitalis for heart conditions—can give rise to hallucinations and delusions. Perhaps the greatest cause of these symptoms in otherwise healthy individuals is drugs of abuse, such as alcohol, cocaine, and hallucinogenic drugs (e.g., LSD [lysergic acid diethylamide], PCP [phencyclidine], and Ecstasy [3,4-methylenedioxymethamphetamine]). Chronic alcoholics often exhibit psychotic symptoms. Alcohol-induced brain damage can also result in memory defects and a major decline in intellectual abilities and social skills (see alcoholism).