Commentary

Re-envisioning psychosis: A new language for clinical practice

Author and Disclosure Information

Our language should reflect that psychosis exists on a continuum


 

References

Discuss this article at http://currentpsychiatry.blogspot.com/2010/10/re-envisioning-psychosis-new-language.html#comments

“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”

In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.1,2

The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.

Power of language

The word “psychosis” has enormous power for patients, families, clinicians, and the public. It often is used interchangeably with “craziness,” “insanity,” or “madness.” Mental health clinicians use psychosis to describe many phenomena, including:

  • breaks with reality testing
  • odd or delusional beliefs
  • abnormal sensations
  • catatonia
  • bizarre behaviors
  • so-called formal thought disorders.

It is likely one of the most heterogeneous symptom terms in psychiatry. DSM-IV-TR notes “the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance.”3

Psychosis myths. In addition to its phenomenological usage, the word psychosis also has various theoretical interpretations and often is used to demonstrate a fundamental pivot point for making qualitative distinctions. For example, clinicians and theorists have used “psychotic” to assume that someone experiencing psychosis:

  • is operating on a core or primitive mode of thought, the so-called “primary process”4
  • has a belief that is beyond understanding, one for which empathy is meaningless and misplaced5
  • has clear convictions that violate social norms and refuses to accept society’s “proper” rules for logic and emotion6
  • is in a state of “brain toxicity” with an “organic” cause (this comes from discussing psychosis with other clinicians, not from the literature).

Such seemingly disparate definitions share the assumption that psychosis represents a shift in categorical status, whether the category is developmental (advanced vs primitive), interpersonal judgment (able to be empathized with or not), sociopolitical status (conformist or not), or functional brain state (organic or non-organic).

Even the etymological basis for schizophrenia (its Greek roots signify “split mind,” which arguably spawned the long-held erroneous view that schizophrenia is a “split personality”) exemplifies this stance and reinforces the notion of discrete “all-or-none” categories of experience. In our view, such assumptions do not adequately reflect the reality of psychosis as a continuum of human experience, and could lead to serious, if unintended, stigmatization and oversimplification of persons who have psychotic symptoms. We argue that such all-or-none thinking reifies 2 clinical “myths” about what psychosis represents:

  • Psychosis represents a fundamentally different type of cognitive process.
  • Psychosis is so different from normal human experience that mood and anxiety symptoms become “subsumed” by it and treated as “secondary.”

Our goal is not to redefine psychosis or present an argument for diagnostically recategorizing schizophrenia, schizoaffective disorder, and bipolar disorder, which others have already done well.7-10 Instead we want to reinforce the evidence-based and clinically relevant concept that psychosis exists on a definable continuum of human experience and to offer practitioners a clinical language of psychosis for assessing and treating psychotic symptoms that avoids unsupported all-or-none distinctions.

Defining ‘the schizophrenic’

In our experience, an unintended consequence of assuming psychosis is an all-or-none state is the clinician’s perpetual search for “real psychosis” as separate from “psychosis for which I have a good explanation.” Although this distinction is reminiscent of earlier arguments regarding “neurotic” vs “endogenous” depression, we feel that in this case “real or not” acts at a more basic level: the characterization of person types.

We assume that every clinician—ourselves included—who has worked with seriously mentally ill patients has heard an individual with schizophrenia referred to as “a schizophrenic.” Although the problem of defining a person as an illness is not unique to psychosis, we think that you will agree that the phrases “a depressive,” “a bipolar,” or “a generalized anxiotic” [sic] are rare.

DSM-IV-TR specifically avoids using expressions such as “a schizophrenic…and [instead uses]…an individual with schizophrenia.”11 But we believe that DSM-IV-TR accidentally encourages the distinction of a “psychotic person type” by making schizoaffective disorder—a disorder that suggests a continuum—use Criterion A for schizophrenia as its defining feature. The implicit assumption is that “something categorical”—in this case defined by Criterion A—identifies a “psychotic person type,” as opposed to a person who simply has psychotic symptoms. If we see evidence of Criterion A, then the person is naturally moved into the realm of “schizophrenia and other psychotic disorders.” In other words, Criterion A subsumes other types of symptoms. In contrast, the presence of 1 month of social anxiety or obsessions and compulsions does not subsume other symptoms into primary anxiety disorders. To make this example explicit, we have developed a set of criteria for hypothetical disorders that overlap major categories of DSM-IV-TR (Table 1).

Pages

Recommended Reading

Late-Life Psychosis Mimics Schizophrenia
MDedge Psychiatry
Vital Signs: Antipsychotics Were the Top Therapeutic Class in 2009
MDedge Psychiatry
New Data Blur Typical-Atypical Drug Distinctions
MDedge Psychiatry
Consider Carcinogenicity of Psychotropics
MDedge Psychiatry
As in Adults, Most Adolescents Respond Early to Aripiprazole
MDedge Psychiatry
Schizophrenia in older adults
MDedge Psychiatry
Hallucinogen sequelae
MDedge Psychiatry
Should you order genetic testing to identify how patients metabolize antipsychotics?
MDedge Psychiatry
Uncooperative and manic
MDedge Psychiatry
The psychotic pot smoker
MDedge Psychiatry