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What are psychotic disorders?
What are psychotic disorders?
When you look at the world around you, can you tell the difference between what is real and what isn’t? People who experience psychosis are out of touch with reality. They have trouble figuring out what parts of their life are real - they may see things that aren’t there or believe things that can’t possibly be true. Psychosis is a key feature of psychotic disorders, which are mental illnesses that cause changes in how a person perceives and interprets information. Three common psychotic disorders are schizophrenia, schizoaffective disorder, and schizotypal personality disorder.
How are things supposed to work normally?
Usually, your brain works constantly to gather and understand information about your body and its environment. To do this efficiently, your brain uses chemical messengers called neurotransmitters to help cells communicate with one another. Each neurotransmitter carries different messages throughout the brain and has important roles in controlling the body’s systems and functions. For example, normally glutamate manages the flow of information throughout the brain and keeps messages from becoming overwhelming, while dopamine tells different parts of the brain to turn on and off. When neurotransmitters work together properly, you are able to accurately perceive and interact with the world around you.
What happens when things go wrong?
Sometimes the communication system breaks down because there is too much or too little of a neurotransmitter in the brain (there is a chemical imbalance). When this happens, information isn’t processed correctly and the brain starts to make mistakes when it tries to interpret information or tell the rest of the body how to act. The effects of chemical imbalances can change based on the area of the brain that is affected and the neurotransmitters that are involved. Psychotic disorders are linked to abnormally high amounts of dopamine and low amounts of glutamate in many different parts of the brain, including areas that are involved in gathering and processing information about the world, controlling the body’s movement and emotions, thinking critically, and learning new things.
| Part of the Brain | Function | |
|---|---|---|
| Occipital lobe | seeing and understanding sight and visual information | |
| Frontal lobe | solving problems, planning, and organizing thoughts | |
| Limbic system | emotion | |
| Auditory system | hearing and understanding speech | |
| Basal ganglia | movement, emotions, and integrating sensory information | |
| Hippocampus | learning and memory |
Symptoms
When a person loses touch with reality and experiences psychosis, there are several main symptoms they might have, which include:
- beliefs that are abnormal, bizarre, or very clearly false
- changes in perception, like sensing something that isn’t there
- altered thinking patterns or speech patterns
- decreases in motivation and emotional expression
- changes in social relationships and behaviors
These symptoms vary from person to person – some experience brief periods of mild psychosis, while others have severe symptoms throughout their life and need to be hospitalized.
Schizophrenia: person experiences a severe break from reality that can continue for years. Symptoms of schizophrenia are usually mild at first but gradually become worse over time. For men, this process usually begins in the early to mid-twenties, and women start to develop symptoms in their late twenties. To be diagnosed, a person has to experience symptoms for at least 6 months, and must be psychotic for at least 1 month. More specific symptoms of schizophrenia include:
- Delusions, or unusual beliefs about themselves or others that continue to be held despite exposure to the facts. Delusions can be about anything, but common ones are persecution (belief that they’re being harassed), grandeur (belief that they’re exceptional or have special talents) and thought control (belief that someone is influencing what thoughts are in their mind).
- Hallucinations, or sensory perceptions that happen without any connection to a source or stimulus. Hallucinations can affect any of the five senses, but hearing voices or seeing things that aren’t there are most common.
- Changes in thought and speech patterns, like loose association (trouble connecting ideas), or word salad (linking random words together in a sentence
- Negative symptoms that take away from normal functioning, like flat or blunted affect (not being able to express feelings), avolition (not having energy or motivation to participate in life), anhedonia (not being able to feel pleasure in life), or asociality (losing interest in making friends)
| Two or more of the following psychotic symptoms: | Don't forget about: | |
|---|---|---|
| 1. Delusions | Duration: symptoms occuring for 6 months or more, including 1 month of delusions, hallucinations, or disorganized speech. | |
| 2. Hallucinations | Distress: cause significant problems with work, social relationships, and personal life. | |
| 3. Disorganized speech | ||
| 4. Abnormal psychomotor behavior | ||
| 5. Negative symptoms | ||
| at least one of these symptoms must be 1, 2, or 3 |
Schizoaffective disorder: person has an extreme break from reality and severe changes in mood at the same time. The disorder is like a cross between schizophrenia and a mood disorder, and symptoms of psychosis, depression, and mania can all overlap and mix together over time. To be diagnosed with schizoaffective disorder, a person has to experience symptoms for at least 1 month, and must have symptoms of schizophrenia without any symptoms of a mood disorder for at least 2 consecutive weeks during that month. More specific symptoms of schizoaffective disorder can include:
- delusions
- hallucinations
- changes in thought and speech patterns
- negative symptoms
- moods that are abnormal and excessive (depression: feelings of extreme sadness; mania: feelings of extreme happiness and irritability)
- changes in body’s processes, like sleeping or eating
- dysfunction in social relationships or behaviors
- changes in overall activity level
- thoughts of suicide
| Two or more of the following psychotic symptoms: | Don't forget about: | |
|---|---|---|
| 1. delusions | Duration: symptoms occur for at least one month, and psychotic symptoms occur for at least two weeks on their own | |
| 2. hallucinations | ||
| 3. disorganized speech | ||
| 4. abnormal psychomotor behavior | ||
| 5. negative symptoms | ||
| symptoms of a major mood episode (depressive or manic) at the same time |
| Week 1 | Week 2 | Week 3 | Week 4 |
|---|---|---|---|
Schizotypal personality disorder: person has abnormal thoughts, emotions, and behaviors that start during their childhood and continue when they become adults. They might experience brief periods of psychosis during their lifetime, but most of the time symptoms are mild. They have trouble relating to others and people usually think they’re very odd or eccentric. More specific symptoms can include:
-suspicious or paranoid beliefs, like someone is following them
- superstitious beliefs, like magical thinking or telepathy
- difficulty with relationships, including problems like anxiety around strangers, uncomfortable relating to others, desire to keep to themselves and don’t feel they have to fit in, or inattention to social conventions like eye contact
- illusions, or perceiving an object or stimulus as something else, like seeing a coat hanging up and thinking it is a person
| Pattern at least five or more of the following long-lasting symptoms: | Don't forget about: | |
|---|---|---|
| 1. strange beliefs about self-importance | Duration: symptoms begin early in life and continue over time | |
| 2. superstitious beliefs or magical thinking | Different Contexts: displays same symptoms in different envronments | |
| 3. abnormal thinking and speech | ||
| 4. abnormal perception, like body illusions | ||
| 5. excessive suspiciousness or paranoia | ||
| 6. inappropriate displays of emotion | ||
| 7. odd appearance or eccentric behavior | ||
| 8. lack of social relationships | ||
| 9. social anxiety |
What causes psychotic disorders?
Most of the time psychotic disorders don’t have a single cause. Instead, they are the result of the interplay between multiple risk factors.
- Biological factors: if one of your family members has a psychotic disorder, you are much more likely to develop one yourself.
- Illnesses or injuries: Any time you have a physical illness or an injury that involves your brain, psychotic disorders can be triggered. Traumatic brain injury, tumors, Parkinson’s disease, Alzheimer’s disease, or dementia have all been linked to psychosis.
- Behavioral factors: increases in alcohol consumption or drug use can lead to the development of a psychotic disorder. Some hallucinogenic drugs (like LSD) can cause hallucinations or delusions, but the effects are usually short-lived. Other drugs can trigger severe psychosis – for some people (especially younger men who are predisposed and use large amounts frequently) cannabis can actually quadruple the risk of developing a psychotic disorder!
How common are psychotic disorders?
About 3% of US adults and 21 million people worldwide experience a psychotic disorder at some point during their life. Of those, only half are receiving treatment. Each year, 1% of Americans are diagnosed with schizophrenia, 0.3% are diagnosed with schizoaffective disorder, and 4.6% are diagnosed with schizotypal personality disorder. Men are more likely to be diagnosed with schizophrenia and schizotypal personality disorder, and women are more likely to be diagnosed with schizoaffective disorder. Many people with psychotic disorders are at a high risk for suicide, and approximately 1/3 attempt suicide after being diagnosed.
Is it possible to prevent psychotic disorders?
Most scientists and mental health practitioners believe that psychotic disorders are not preventable and that anyone can experience psychosis. Instead of prevention, many health providers stress the importance of identifying symptoms of psychotic disorders before they become severe and debilitating. Early diagnosis and treatment can improve the person’s long term outcomes and increase their chance recovery. That said, if you have a history of psychiatric problems in your family, it is really important to be proactive with your health and avoid drugs and alcohol (especially cannabis) since it may affect your risk of developing a psychotic disorder.
How are psychotic disorders treated?
Treatment for psychotic disorders usually involves a combination of medication and psychotherapy, based on the specific needs and symptoms of the patient. These treatments work together to improve functioning and decrease symptom severity over time.
Medications:
The medications used to treat schizophrenia, schizoaffective disorder, and schizotypal personality disorder are called antipsychotics. Antipsychotics improve the functioning of different neurotransmitters in the brain, which shortens the duration of psychosis and prevents reoccurrences. Typical antipsychotics and atypical antipsychotics both focus on blocking dopamine and are used to improve symptoms like delusions, hallucinations, and changes in thoughts or speech. Atypical antipsychotics also focus on other neurotransmitters (like serotonin), so they can be used to improve negative symptoms as well, like anhedonia and flat affect.
Psychotherapy:
- Therapy for schizophrenia usually involves a combination of cognitive behavioral therapy (CBT) and supportive psychotherapy. CBT focuses on helping the patient identify their negative or abnormal thoughts, emotions, beliefs, and behaviors, and replacing them with more adaptive ones. Supportive psychotherapy usually focuses on helping patients to regain confidence and social skills.
- Therapy for schizoaffective disorder usually involves helping the patient improve their social relationships in a supportive setting. For example, family based therapy focuses on improving the patient’s symptoms and functioning by educating the family about the disorder, supporting problem solving as a family, and improving communication skills.
- Supportive psychotherapy is used to treat schizotypal personality disorder, and usually focuses on helping the patient improve their social and communication skills
Although medication and psychotherapy are helpful for many individuals with psychotic disorders, only 10-20% of patients fully recover from psychosis. Almost all patients (recovered or not) have to stay on medication for the rest of their life, and many end up living at inpatient psychiatric facilities. Even after receiving successful treatment, many don’t have a normal life – almost 86% of patients with schizophrenia are disabled or unemployed.
Consider the following:
- People with schizophrenia are much more likely to smoke cigarettes. Why do you think that is? Some scientists believe it may actually be a form of self-treatment. Nicotine use helps to regulate the levels of glutamate and dopamine in the brain, which can help decrease some of the symptoms of schizophrenia.
- Early versions of diagnostic criteria (found in the DSM IV) separated symptoms into two groups - positive and negative symptoms. Positive symptoms were experiences that a person had in addition to their normal functioning, like delusions and hallucinations. Negative symptoms were experiences that took away or detracted from normal functioning, like anhedonia or blunted affect.