Psychoses

Psychoses are major psychological disorders in which a person experiences a breakdown of reality-orientation. Schizophrenia is defined as a "severe, chronic, and potentially disabling thought disorder" in DSM-5. A schizophrenic person may have trouble with routine tasks such as dressing appropriately or holding a job.

The distinction between different sub-types of schizophrenia was eliminated in DSM-5 because of "limited diagnostic stability, low reliability, and poor validity." DSM-5 now requires at least two of the following symptoms to diagnose psychosis: hallucinations, delusions, and disordered speech.

Hallucinations are perceptions of things that are not present. Delusions are persistently held, unrealistic, false beliefs.

Another symptom of schizophrenia is "marked reduction in functioning" in major life areas, such as ability to hold a job or maintain personal hygiene. Psychosis can be a danger to the patient and accounts for over 50% of the admissions to psychiatric wards and mental hospitals in the United States.

How is psychosis defined in DSM-5?

The onset of schizophrenia often occurs early in life, thus the old label for the syndrome: dementia praecox, "the dementia of youth." That label is not used any more, because the disorder is not limited to young people. Older people and children can develop psychosis, too.

The prefix schizo means split, but schizophrenia is not the same thing as "split personality." Mental health professionals were disappointed when a movie by comedian Jim Carrey re-introduced the error in 2000, referring to Carrey's character (who had a cartoonish version of multiple personality) as "schizophrenic."

The name schizophrenia comes from the gap that develops between a schizophrenic and reality. A schizophrenic may hear voices or develop strange delusional systems, giving the impression of being split off from normal reality.

To what does the prefix "schizo" (split) refer?

People with a psychosis may show disorganized speech and behavior as well as flat or inappropriate affect. (The word affect is pronounced AFF-ect in this context and means emotion.) A person with flat affect seems emotionless. A person with inappropriate affect may weep uncontrollably at something that seems harmless, or laugh hysterically at nothing in particular.

Loosely associated speech is perhaps the most striking feature of psychosis. This speech is sometimes described as a "word salad." It wanders all over the place, following any association that comes along. It may contain clang associations, which are strings of words having a similar sound.

Bootzin and Acocella (1984) cite the example of a patient who replied to the greeting of his doctor (Dr. Richard Hagen of Florida State University) as follows:

Well, when we was first bit on the slit on the rit and the man on the ran or the pan on the ban and the sand on the man and the pan on the ban and the can on the man on the fan on the pan. (p.341)

All of this was spoken "very rhythmically, beginning slowly and building up to such a rapid pace that the words could no longer be understood."

Catatonic schizophrenics have disordered motor activity. They can be wildly active with inappropriate and purposeless activity, or completely still.

DMS-5 dropped the sub-types of schizophrenia used for years: disordered, paranoid, catatonic, and undifferentiated types. Catatonia is diagnosed separately as a symptom.

The catatonic still reaction is what most people mean by a catatonic state. It is also called waxy flexibility. One can reposition the limbs of a person in a catatonic state, and that person will keep the same position, or the limbs will gradually fall due to muscle fatigue and the effects of gravity.

What is waxy flexibility?

Catatonia-like states occur in non-human animals, too. A rat injected with endorphins will enter a "profound catatonic state" (Bloom, Segal, & Guilleman, 1976). The researchers note the "total absence of spontaneous movement" and the fact that these "would remain in abnormal body positions...for indefinite periods" (p.631).

What are some examples of animals showing catatonic states?

In both humans and animals, catatonic states seem to be triggered by stress. Humans sometimes go into catatonia after a disastrous failure of business or romance. Catatonic states can also be triggered by seizure-like activity, in both animals and humans.

Newton and Gantt (1968) described a dog that went into a catatonic state when approached by a strange human. In this state the dog showed the waxy flexibility of catatonia. Its limbs could be placed into strange positions that it would maintain for ten minutes before "sinking gradually to the floor."

In the pre-DSM-5 system, paranoid schizophrenia was the most common type of schizophrenia. Now it would be called schizophrenia with paranoid symptoms. It is characterized by delusions that involve threat or conspiracy, such as secret plots to control people's brains through radio transmissions.

A schizophrenic with paranoid symptoms may believe an alien force is controlling his or her thoughts. Also common in this disorder are delusions of grandeur, a feeling of possessing absolute truth or the solution to the world's problems.

The schizophrenic does not necessarily show flat or inappropriate affect. He or she may seem like an intelligent person who wants to hold an intense, earnest conversation about subjects that happen to be very weird and unbelievable.

What are characteristics of paranoid schizophrenia?

In July, 1998, a man named Russell Westen, who had been diagnosed as a paranoid schizophrenic, entered the Capitol Building in Washington, D.C., with a handgun, killing two security guards before he was shot and injured himself. He had stopped taking his psychiatric medications.

Westen was delusional, claiming that the President was conspiring to kill him. He claimed a satellite dish in his little town in Montana was spying on him for the CIA. His parents said that he believed secret powers were trying to control him through the TV set.

The man's symptoms read like a textbook description of schizophrenia. Not all schizophrenics are dangerous. However, when they begin to act on their fantasies, like Weston did, they can become dangerous.

Russell Weston's case was typical in one way. His psychosis was well controlled when he was on his medications, but when he did not take them, he became seriously disordered.

The Weston case brought attention to this issue, in part because he continued to refuse medications after his arrest. Four years after his killing spree, in 2002, the courts in the United States decided it was legal to compel Russell Weston to take his medications. Until then, he avoided trial by refusing medications, which left him in a psychotic state.

There is a difference between paranoia in the context of schizophrenia and the paranoid personality disorder we will discuss in the section on personality disorders. A schizophrenic shows a loss of reality-orientation with very unrealistic delusions. A person with a paranoid personality disorder is just chronically suspicious of other people.

How is paranoid schizophrenia distinguished from the paranoid personality disorder?

A schizophrenic with paranoid symptoms will sometimes develop a complex delusional system. A student brought in a post card his father's company received in their headquarters office. It was addressed to "President-Staff and Chaplain" and read as follows:

Gentlemen:

Do you allow spying by Mafia and Russians on defenseless children for incest, prostitution, robbery, rape, sacrifice, satanic gang power? Can humans be placed on meat grinders? Can Mafia drug pushers control children drug pushers? What are false claims for child support? Do crooked politicians appoint crooked judges, preachers, and doctors? Can Mafia prostitutes control our towns from N. Y., Chicago, etc? Why are spy prostitute gangs for military contracting to robbery children (civilian) by military Mafia "spy" police state? Are children surgical spy targets for Mafia and crooked police?

The wild associations, the suggestion of a far-reaching conspiracy, the compulsion to share this truth with strangers: all are characteristic of thought processes in a psychotic with paranoid tendencies.

Causes and Treatments of Psychoses

Schizophrenia tends to run in families. If one member of a pair of identical twins becomes schizophrenic, there is a 28% likelihood that the other will become schizophrenic (Torrey, Bowler, Taylor, and Gottesman, 1994). In one famous case, four quintuplets all became schizophrenic, one after another.

Researchers have found at least 42 locations on DNA where changes are predictive of schizophrenia (Arnedo et al, 2015). There might be eight or more different genetic diseases involving these sites, all causing psychosis.

A location on the genome called MHC may be especially important. A Harvard team screened 64,000 genomes of schizophrenics and found an uncommon number had defects in a protein called C4-A that is coded in the MHC region (Carey, 2016).

In animal studies, defects in C4-A production are associated with too much synaptic pruning. Normally, unused synapses are pruned in the normal process of neural evolution.

If the process goes awry, too many synapses are lost. This can be damaging in itself, or it may cause an inappropriate surge in production of synapses later. Both possibilities have been suggested by brain scanning evidence.

If genetic research identifies specific proteins linked to psychosis, doctors might be able to intervene. Diagnostic signs of psychosis (such as hearing voices) can occur in early childhood, so intervention to arrest development of psychosis may someday be possible.

In the majority of cases (72%), when one identical twin becomes schizophrenic, the other does not become schizophrenic. Clearly, whatever the underlying process, schizophrenia is based on more than patterns in DNA.

Epigenetics may explain this. Epigenetics is the alteration of gene expression after an organism starts developing. It occurs in all organisms including identical twins, producing differences in their biological systems.

In other words, despite starting off as embryos with identical DNA, one twin can end up with a faulty biological system. An event (perhaps flu during the late stages of pregnancy, which is statistically associated with schizophrenia) results in a gene not being expressed properly. In the other twin, the same system might be healthy.

What is evidence of a genetic component in schizophrenia? What is evidence that genes alone do not cause the disease?

While experts regard schizophrenia as a brain disease, they also recognize that the brain is affected by experiences such as stress. Some psychologists argue that environmental influences on the development of schizophrenia can be quite strong.

Jortner (1990) wrote that 30 years of experience with schizophrenics convinced him that "families can indeed be pathogenic" (crazy-making). He noted that sometimes when family problems are corrected "the formerly mentally or emotionally ill patient can become well enough to hold a job, socialize, and function relatively normally."

What did Jortner maintain, based on 30 years of experience?

In some cases families are not "pathogenic." In some cases they are pillars of strength in a schizophrenic's life. Sometimes family love is the schizophrenic person's reason for living and staying as normal as possible.

One student wrote an essay about what it was like to have a schizophrenic mother:

A woman who hears voices and sees spirits raised me. She spends her days following a simple routine of washing clothes, cooking and maintaining the tidiness of the household.

Unlike many schizophrenics, my mother tried to control her illness so it would not cause her children harm. But while she protected us from physical harm, the emotional and psychological pain my sister and I suffered will remain with us forever.

I have learned so much about this mental illness which causes its victims to suffer disturbances in speech or thought, inappropriate or blunted affect, hallucinations and delusions. My mother cannot withstand stressful situations.

She becomes confused and her speech sounds choppy. It is like she goes into a zombie stage where she doesn't respond to conversation.

Painted on her face is a portrait of a beautiful woman trapped in another world. Misery and unhappiness seep from her if I try to talk to her in an attempt to keep her in my world.

What was the student's experience with a schizophrenic mother?

During one severe episode, she sensed I was afraid. My mother was running frantically around the house trying to get my sister and me to leave because "the voices said they were going to kill us."

My sister and I refused because we were determined to show her that voices in her head could not harm us. My mom became hysterical. She broke glasses, began screaming and caused a lot of chaos. I was scared.

I thought that finally she had completely converted over and was never coming back. But to my surprise, in a calm voice she said, "Mommy will never hurt you, baby." I didn't know what to say.

But I believed her, and she did not hurt me. She has never hurt me intentionally. After that episode, I went to my room and cried silently and went to sleep.

From my experiences, I have learned that I cannot change or correct her illness. Since college I have learned more about the scientific details of the illness.

I have also learned that I am not alone. Knowledge of the abnormality makes it easier to cope and encourages me to be more sensitive to the needs of my mother.

I am confident that somewhere inside my mother's mind she is normal and seeks to have a normal life. Patience and compassion play a significant role in maintaining a semi-stable environment for my family.

Schizophrenics do not handle drastic changes well, so my sister and I try to minimize the occurrence of change. Although I regret that my mother depends so heavily on my sister and me, it is our duty to protect her by any means necessary so she can continue to live comfortably at our home where she belongs. [Author's files]

Historically, there has been no effective treatment for schizophrenia. The disorder has been described as recurrent and disabling. Recurrent means it tends to come back again and again. Disabling means that some people with the disorder eventually lose their ability to cope with normal life.

What does it mean to call schizophrenia "recurrent and disabling?"

The first generation of anti-psychotic medications, such as chlorpromazine (Thorazine), was notoriously unpleasant for patients. In mental hospitals, psychotic patients would commonly take their medications from a little cup, tilting their head back as if swallowing the contents, but keeping the pills hidden in their cheeks so they could spit them out later.

Recently, medications for the disorder have been improving, and the newer generations of drugs have fewer unpleasant side-effects. One medication in particular, Clozapine, has enabled some schizophrenics to return to a near-normal mental state after decades of disability.

All the approved antipsychotic drugs block dopamine receptors. Clozapine targets a variety of the neurotransmitter dopamine–the D4 type–which is concentrated in areas of the brain most affected by schizophrenia (Taubes, 1994).

As of 2016, clozapine was one of the only antipsychotic drugs producing better results than the original treatments such as chlorpromazine discovered over 60 years ago. Most of those older drugs target a slightly different dopamine receptor (D2).

Why is there real hope for better treatments?

Because genetic analyses suggest multiple, distinct reasons for psychoses, there may eventually be prescription treatments for psychoses that are highly individualized. However, "these studies are in flux and will take years or even decades, to explore how particular constellations of symptoms should be treated" (Maric, Jovicic, Mihaljevic, and Miljevic, 2016).

Meanwhile, psychosocial interventions such as talk therapy and day treatment centers continue to be important. Schizophrenia is a stress-related disorder, as the student's essay about her mother (above) makes clear.

Currently none of the talking therapies or social support techniques stands out as more effective than others. Experts are open to anything that reduces stress for a patient or a family.

Families can be given support by day-treatment centers, where people with a history of psychosis are provided with activities in a safe and supervised environment. That allows family members go to work or school or take a break from home care.

As biological research becomes more sophisticated about the multiple forms of psychosis, the very concept of schizophrenia may become obsolete, giving way to a more complex and biologically-grounded classification. The editor of Schizophrenia Bulletin, William T. Carpenter, wrote in 2016:

It is strange...that I have recently become a bit uneasy with the title of our journal...

The term [schizophrenia] is experienced as stigmatizing by persons afflicted with psychotic illness, impedes public education, is often misrepresented in the media, and avoided by clinicians who may prefer terms such as "psychosis not otherwise specified" or schizoaffective disorder.

Why did the editor of Schizophrenia Bulletin suggest renaming his journal?

Carpenter said research on genetics and neurotransmitters was resulting in "porous diagnostic boundaries with increased attention to similarities and differences between disorders." He suggested renaming Schizophrenia Bulletin to Psychosis Bulletin or something similar.

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References:

Arnedo J. [plus 10 more authors and 15 collaborators] (2015) Uncovering the hidden risk architecture of the schizophrenias. American Journal of Psychiatry, 172, 139-153. doi:10.1176/appi.ajp.2014.14040435. Retrieved from: https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2014.14040435

Bootzin, R. R. & Acocella, J. R. (1984) Abnormal Psychology: Current Perspectives. (1984) New York: Random House.

Carey, B. (2016, January 27). Scientists move closer to understanding schizophrenia. New York Times. Retrieved from: https://nyti.ms/1SbqRGE

Carpenter, W. T. (2016) Shifting Paradigms and the Term Schizophrenia. Schizophrenia Bulletin, 42, 863-864. doi:https://doi.org/10.1093/schbul/sbw050

Jortner, S. (1990). Schizophrenia is usually psychogenic. American Psychologist, 45, 551.

Maric, N. P., Jovicic, M. J., Mihaljevic, M., & Miljevic, C. (2016) Improving Current Treatments for Schizophrenia. Drug Development Research, 77, 357-367. doi:10.1002/ddr.21337

Newton, J. E. O. & Gantt, W.H. (1968). The history of a catatonic dog. Conditional Reflex, 3, 45-61.

Taubes, G. (1994) Will new dopamine receptors offer a key to schizophrenia? Science, 265, 1034-1035.

Torrey, E. F., Bowler, A. E., Taylor, E. H., & Gottesman, I. I. (1994) Schizophrenia and Manic-Depressive Disorder: The Biological Roots of Mental Illness Revealed by the Landmark Study of Identical Twins. New York: Basic Books.

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