Psychosis

Psychosis is an abnormal condition of the mind that leads to difficulties in determining what is real and what is not. Symptoms include delusions, hallucinations, incoherent speech, and inappropriate behaviour.

The condition can lead to severe complications such as self-harm and suicide. Treatment typically involves antipsychotics, counselling, and social support.

Signs and Symptoms

Hallucinations

Hallucinations are sensory perceptions without external stimuli, often manifesting as vivid and uncontrollable experiences. They can affect any of the senses, with auditory hallucinations, such as hearing voices, being the most common.

Delusions

Delusions are fixed, false beliefs that remain unchangeable despite contradictory evidence. They are context- and culture-dependent, with persecutory delusions being the most common type. Delusions often involve themes like grandeur, reference, thought broadcasting, and thought insertion.

Disorganised Speech/Thought or Behaviour

Disorganised speech or thought includes rapid topic switching (derailment), unrelated topics (tangential thinking), and incomprehensible speech (word salad). Disorganised motor behaviour can range from repetitive movements to catatonia, which may present as either profound immobility with waxy flexibility or excessive purposeless movement.

Negative Symptoms

Negative symptoms include reduced emotional expression, decreased motivation (avolition), and reduced spontaneous speech (alogia). Other symptoms are social withdrawal and anhedonia (inability to feel pleasure).

Causes

Psychosis can result from various psychiatric disorders, medical conditions, trauma, and substance use.

Psychiatric Disorders

Primary psychiatric causes include schizophrenia, bipolar disorder, schizoaffective disorder, delusional disorder, and brief psychotic disorder.

Medical Conditions

A wide range of medical conditions can cause psychosis, such as neurocognitive disorders (e.g., Alzheimer's disease), endocrine diseases (e.g., hypothyroidism), and infections (e.g., HIV/AIDS).

Psychoactive Drugs

Substances like alcohol, cannabis, cocaine, and certain medications can induce psychotic states. Substance-induced psychosis is often characterised by higher awareness of psychosis and increased suicidal thinking.

Diagnosis

Diagnosing psychosis involves excluding other potential causes through a comprehensive history, physical examination, and various tests. Blood tests can rule out metabolic disturbances, vitamin deficiencies, and infections. Imaging studies like MRI or CT scans can exclude brain lesions. The DSM-5 and various rating scales such as the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Symptom Scale (PANSS) assess the severity and type of psychosis.

Treatment

Medication

Antipsychotics are the first-line treatment for most psychotic disorders. The choice of medication depends on benefits, risks, and costs. Both typical and atypical antipsychotics are used, with some evidence suggesting amisulpride, olanzapine, risperidone, and clozapine may be more effective for positive symptoms. Clozapine is particularly useful for treatment-resistant cases.

Psychotherapy

Psychological treatments such as Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are beneficial. Metacognitive training (MCT) can reduce delusions, hallucinations, and negative symptoms. Early intervention and various psychosocial interventions like Open Dialogue and need-adapted treatment improve long-term outcomes.

Systematic Reform

Systematic reform includes addressing educational and social support to improve participation in society. Specialised supported education can lead to successful academic and employment outcomes for those with psychosis.

History

Etymology and Classification

The term "psychosis" was introduced in the 19th century to describe a disorder of the mind. Emil Kraepelin further classified psychoses into manic depressive illness and dementia praecox (schizophrenia). Historical treatments included exorcism, bloodletting, and early forms of psychosurgery.

Treatment Evolution

Early treatments included insulin shock therapy, electroconvulsive therapy, and psychosurgery. The advent of antipsychotic drugs in the 1950s marked a significant advancement, with chlorpromazine being the first approved antipsychotic. Dopamine antagonists continue to be effective, though they come with various side effects.

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Self-assessment MCQs (single best answer)

Which of the following is the most common type of hallucination in psychosis?

What is the term for fixed, false beliefs that remain unchangeable despite contradictory evidence?

Which symptom involves rapid switching between unrelated topics?

Which of the following is NOT a negative symptom of psychosis?

Which psychiatric disorder is most commonly associated with psychosis?

Which substance is NOT mentioned as potentially inducing psychosis?

Which diagnostic tool is used to exclude brain lesions in patients with suspected psychosis?

Which antipsychotic is particularly useful for treatment-resistant cases of psychosis?

Which psychological treatment is mentioned as being beneficial for psychosis?

Who performed the first medically sanctioned psychosurgery?