Psychosis can occur within a constellation of emotional dysfunctions, including schizophrenia, affective disorders, situational crisis, medical conditions, and exposure to exogenous substances. It even can present as a partial phenomenon in obsessive-compulsive disorder and posttraumatic stress disorder.
The REMINDER mnemonic (Table) can help you assess psychosis across all of these situations and evaluate the forensic implications of alleged psychotically driven behavior. The 8 components in REMINDER can guide whether you choose active listening, clarifying comments, confrontations, or interpretive commentary when working with psychotic patients. These aspects of psychosis also can be useful in differential diagnosis or in detecting feigned symptoms.
Table
REMINDER: 8 aspects of psychotic function
| Reality testing impairment |
| Empathic dysfunction |
| Mechanisms of defense regression |
| Impulse control problems |
| Narcissistic focus |
| Diffuse ego boundaries |
| Explosiveness |
| Rational thought impairment |
Reality testing. At some level, reality testing is impaired in all psychotic phenomena. Dysfunctional reality testing is evidenced by:
- auditory or visual hallucinations
- fixed false beliefs or delusions
- paranoia
- formications
- culturally bound syndromes
- psychotic constellations of Capgras or Cotard’s syndromes.
Empathic dysfunction. Individuals deteriorating into psychosis become increasingly autistic in their view of the world. Psychosis can whittle away patients’ capacity for empathy and to accurately perceive the intents and interests of others. Psychic censuring activities are paralyzed in psychotic individuals, and they cannot analyze others’ actions effectively.
Mechanisms of defense. When growth and development proceed normally, increasingly complex and sophisticated defenses evolve from immature to neurotic to mature. In psychosis, the process is arrested at or regresses to lower levels of defense. Impaired reality testing diminishes access to higher-level defenses because pathologic constraints can stunt psychological adjustments.
Impulse control. Deteriorated reality processing and empathy combined with diminished ego defense can leave patients unable to control aggressive and sometimes violent behavior. The patient often is “short-fused.” Regaining access to verbal defenses frequently requires pharmacotherapy.
Narcissistic focus. Psychotic patients shift to a narcissistic world view as their intra-psychic processing deteriorates. Sometimes they seem to have regressed to an earlier developmental stage and are described in juvenile or infantile terms. Clinicians can help patients move past this autistic affect and narcissism by forming a therapeutic alliance against the illness.
Diffuse ego boundaries. Patients often fail to perceive, maintain, and check adjustments of ego boundaries when they regress to earlier levels of functioning. Psychotic denial, psychotic introjects, projection, and pathologic enmeshments are examples of these failures. Many psychotic phenomena—especially paranoid thinking—can limit a patient’s ability to define and incorporate boundaries into ego defense mechanisms.
Explosiveness. Patients become less tolerant of frustration as psychosis worsens. The patient cannot accept or process any deviance from his or her pathologically structured world. Frequently the patient’s only defense is acting out verbally or physically. Actively psychotic patients might scream, curse, or strike out violently. Hospitalization diminishes the risk of suicide, reduces opportunity to craft violent plans, and removes access to weapons.
Rational thought impairment. Dysfunctional integration of psychotic features into patients’ emotional processing often causes their unpredictable behavior. A patient’s thought process may be influenced by any of the proceeding features to produce an illogical train of thought. Many clinicians have experienced confronting a patient’s delusional belief, only to watch the patient transform that belief into another illogical construct.
To better understand the patient and his or her needs, consider these 8 aspects of psychotic functions when evaluating a diagnosis and degree of impairment. Remember the adage “no collusion with the delusion,” but consider your timing when confronting illogical beliefs. Sometimes a neutral stance to a false belief is necessary to preserve the therapeutic alliance.