Psychosis is another psychiatric term that is frequently misused colloquially and misunderstood.  And its history is one of often inhumane and barbaric treatment. 

During medieval times, people exhibiting psychotic symptoms were generally thought to be demonically possessed.  They were locked up in prisons or asylums, physically restrained, given painful and dangerous treatments such as lobotomy or insulin coma therapy, or accused of witchcraft and burned at the stake. (There were a few exceptions to this thinking as early as the 1200s, including Thomas Aquinas, an Italian religious philosopher, and the German theologian and scientist Albertus Magnus, who hypothesized a medical basis for “insanity.”) 

The understanding and treatment of psychosis began to improve by the 1700s. The French psychiatrist Phillipe Pinel advocated for a more humane approach, including unshackling of patients, talking with them, and trying to better understand the illnesses. In the 1700-1800s, the understanding of psychosis evolved to the concept of a brain illness. In the late 1800s, the German psychiatrist Emil Kraeplin further advanced the understanding of mental illness as having a biological basis. Most famously, Kraeplin classified psychosis into two distinct forms: manic depression (with a significant mood component) and dementia praecox (closer to our current understanding of schizophrenia).

Psychosis is a disorder of thinking, a losing touch with reality. This can include perceptual disturbances such as hearing or seeing thigs that aren’t there (hallucinations), believing things which aren’t true (delusions), and disorganization of thinking and speech (not making sense). Sometimes people recognize that they are experiencing these symptoms and are frightened by them. For example, they may hear a voice that they know is not real. Often, however, “insight” is lacking, and people do not realize they are ill; they truly believe, for instance, that their family member is trying to harm them or that the government is spying on them.

Some signs/examples of psychotic thinking:

  • Delusions (false beliefs)
  • Confused or illogical thinking or speech
  • Paranoid thinking; suspiciousness
  • Strongly held strange ideas
  • Difficulty differentiating illusion from reality
  • Decline in functioning or self-care
  • Odd or disorganized behaviors
  • Being distracted without obvious stimuli (signs that they may be hearing voices in their head or seeing things which aren’t there)

It is especially concerning if someone is experiencing “command hallucinations,” voices telling them to do something dangerous or to harm themselves or someone else. Or if they are paranoid to the point where they believe they need to do something extreme or violent to protect themselves or someone else.

(Keep in mind that the vast majority of those with mental illness are not violent, and in fact are more likely to be the victims of violence than those without mental illness.)

There are many possible causes of psychosis, including medical illness, sleep deprivation, dementia syndromes, head injury, prescription medications, drug use, and psychiatric disorders such as schizophrenia and mood disorders (mania or depression). Other explanations should be considered and ruled out before making a primary mental illness diagnosis such as schizophrenia.

Women may develop a sudden-onset psychotic syndrome after giving birth (generally in the two-to-four week postpartum period). Any signs of postpartum psychosis should be treated as an emergency, for the safety of all involved.

Schizophrenia is a serious mental illness usually diagnosed after the first full-blown episode of psychosis, often during teen and young adult years. Subtle symptoms often appear earlier, such as odd thinking and behaviors, mood changes, and a gradual decline in social and cognitive functioning. Features of schizophrenia, in addition to psychosis (disorganization, hallucinations, and delusions), are cognitive impairment and “negative symptoms.” Negative symptoms include apathy, low motivation, monotone speech, poor eye contact, and lack of facial expression (resembling depression.) People with schizophrenia often lack insight into their illness or symptoms, not recognizing that they are ill and therefore not accepting treatment. This often leads to relapse when, for example, they may stop taking their medication. It is thought that this lack of awareness may, in fact, be a component of the neuropathology underlying the illness.

The causes of schizophrenia are not fully understood; contributing factors seem to involve genetics, brain chemistry, and environmental stressors. People with a family history of schizophrenia or bipolar disorder are at increased risk of developing schizophrenia. Early detection and treatment are crucial to improving the longer-term outcome.

Psychosis associated with mood disorders such as bipolar disorder and/or depression can be difficult to differentiate from schizophrenia during an acute episode.  The primary distinction is the mood component (depression and/or mania). An accurate diagnosis is helpful, as the treatment approach and prognosis are different. 

Drug-induced psychosis can be triggered by a wide variety of substances: cannabis (the most common), stimulants, “club drugs” and others.

It is worth focusing on cannabis induced psychosis (CIP), given widespread legalization and increasing use. The risks are both short term and longer term. Acute cannabis intoxication can result in psychotic symptoms, such as paranoia and hallucinations. The risks of developing CIP are higher with earlier age of use, more regular use, the amount consumed, higher potency products (higher % THC), and a family history of mental illness (such as bipolar disorder or schizophrenia). Those who use cannabis during adolescence are 2-4 times more likely to develop a schizophrenia-type illness. And the potency of cannabis is much higher now that in the past. For whole-plant cannabis, the average potency was 3-4% or less in the 1980s; now it’s over 12% (and much higher than that in some places). The potency of products such as edibles, waxes, and dabs are significantly higher and can be 60% or more.

Since psychosis can have many causes, it is important to undergo a thorough assessment for an accurate diagnosis. This includes ruling out a primary medical explanation (e.g., medication reaction, epilepsy, thyroid disorder, infection, brain tumor etc.). Treatment varies based on the underlying cause or illness.

Treatment for schizophrenia and psychosis associated with mood disorders (bipolar disorder and depression) may include hospitalization for acute stabilization and safety, different forms of psychotherapy, family support, lifestyle changes, stress reduction, and psychiatric medications. Anti-psychotic medications, while they are often literally lifesaving, do carry some significant possible side-effects including sedation, movement disorder, weight gain, elevated cholesterol, and diabetes. There are different medication options, so it may take a few tries to find the best fit for a given person.  There are also long-acting injectable options for people who prefer not to take a daily pill (or who tend to miss doses and fall ill again). For those with mood disorders, mood stabilizing medication or antidepressants may also be recommended. For CIP, abstinence from cannabis/drug use is the most important factor in recovery.

When psychosis is suspected, accurate and prompt assessment and intervention is crucial, to reduce acute risk and to improve long-term prognosis. 


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