Psychotic Disorders

Delusions and hallucinations are symptoms of psychotic disorders.

Sometimes colloquially referred to as thought disorders, since the new psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) was published in 2013, psychotic disorders have been referred to as schizophrenia spectrum and other psychotic disorders. In addition to the more commonly known mental diseases like schizophrenia, other mental disorders in this group include brief psychotic disorder, schizotypal personality disorder, delusional disorder, schizophreniform disorder, schizoaffective disorder, catatonia, substance-induced or medication-induced (for example, alcohol-induced or cannabis-induced) psychotic disorder, psychosis due to another medical condition, other specified schizophrenia spectrum disorder, as well as unspecified schizophrenia spectrum and other psychotic disorder, which was formerly called psychotic disorder, not otherwise specified (NOS). As the number of different psychotic disorders indicates, while schizophrenia includes psychotic symptoms, psychosis and schizophrenia are not the same thing.

Besides catatonia, other catatonia-related diseases include catatonic disorder due to another medical condition, as well as unspecified catatonia. Women who recently had a baby (are in the postpartum state) may uncommonly develop postpartum psychosis. Also, mood disorders like major depressive disorder and bipolar disorder can become severe enough to result in psychotic symptoms like hallucinating or having delusions, also called psychotic features.

The percentage of people who suffer from any psychotic symptom at any one time (prevalence) varies greatly from country to country, from as little as 0.66% in Vietnam to 45.84% in Nepal. While the figure of one out of 100 people who qualify for the diagnosis of schizophrenia may sound low, that translates into about 3 million people in the United States alone who have schizophrenia. Except for the usually middle-aged onset of delusional disorder (around 48 years of age), the first time a person has psychotic symptoms is usually between the ages of 18-24 years, with related but less severe (prodromal) symptoms often start during the teenage years. Statistics for postpartum psychosis include that it occurs in one or two out of 1,000 births but increases greatly, up to one in seven mothers, in women who had postpartum psychosis in the past. Men are thought to develop psychotic illnesses more often and at younger ages than women.

Some medical diseases or the use of certain substances may cause psychotic disorders. For most psychotic disorders, specific causes are unknown. However, physicians believe the interplay of inherited (familial), biological, environmental, and psychological factors is involved. We do not yet understand all of the causes and other issues involved, but current research is making steady progress toward elucidating and defining causes of psychosis. For example, schizophrenia and bipolar disorder have many risk factors in common.

In biological models of psychotic disorders, researchers have investigated genetic predisposition, infectious agents, toxins, allergies, and disturbances in metabolism. Psychotic disorders run in families. For example, the risk of the disease in an identical twin of a person with schizophrenia is 40%-60% and in other siblings is 5%-15%. A child of a parent suffering from schizophrenia has about a 10% chance of developing the illness, in contrast to the risk of schizophrenia in the general population being about 1%. Toxins like ketamine or marijuana increase the risk of developing acute (rapid onset) psychosis.

The current concept is that multiple genes are involved in the development of schizophrenia and that risk factors such as prenatal (intrauterine), perinatal (around the time of birth), and nonspecific stressors are involved in creating a disposition or vulnerability to develop the illness. Neurotransmitters (chemicals involved in the communication among nerve cells) have also been implicated in the development of psychotic disorders. The list of neurotransmitters under scrutiny is long, but researchers give special attention to dopamine, serotonin, and glutamate.

Also, recent research studies have identified subtle changes in brain structure and function, indicating that, at least in part, schizophrenia could be a disease of the development of the brain. The fact that autism is a risk factor for developing psychosis during childhood seems to support that theory. Psychosis is more likely to occur in people who have poor medical health in a general sense or who suffer from another mental illness.

Environmental risk factors, like a history of problem drinking, using tobacco, marijuana, or other drugs, have been associated with the development of a psychotic disorder.

There are a number of medical risk factors for psychotic disorders. Steroid-induced psychosis is one example of the risk of certain medications causing this illness. Women who have recently delivered a baby (in the postpartum state) are at risk for a number of mental health problems, including postpartum psychosis. More than 25% of mothers with bipolar I disorder (those who have ever suffered from a full-blown manic episode, with possible symptoms of racing or other unwanted thoughts, pressured speech, and decreased need for sleep) may develop postpartum psychosis, and more than half of those who have both a personal history of bipolar disorder and a family history of postpartum psychosis tend to develop the condition. Children of mothers with a psychotic disorder may experience more than the genetic risk of developing a psychotic illness if their birth mother's pregnancy with them was characterized by problems like malnutrition, infections, high blood pressure, or problems with the placenta.

Psychological risks for developing a psychotic disorder include a history of mood problems, like an anxiety disorder, major depression, or bipolar disorder and trouble functioning socially or generally. People who are at risk for developing a psychotic disorder as the result of having a close relative with such symptoms are also more likely to have symptoms of attention deficit hyperactivity disorder (ADHD). Individuals who have frequent nightmares, tend to be suspicious of others or have unusual thoughts (for example feeling paranoid, believing that an ordinary event has special and personal meaning, having somatic symptom disorder) are also more likely to develop a psychotic disorder. Studies show that women with postpartum psychosis are frequently victims of domestic violence or abusive childhoods and often have histories of abandonment or substance abuse.

Conditions classified as neurocognitive disorders, like delirium and major neurocognitive disorders, formerly called dementia, can include psychotic symptoms. Delirium, a condition characterized by disruptions in attention and thinking (cognition), usually develops quickly, over a period of hours to days, and can include psychotic symptoms like hallucinations. Major neurocognitive disorder, formerly called dementia, can have identifiable or unidentifiable causes and is characterized by a marked decline in cognitive functioning that results in the sufferer's having trouble doing things (like cooking or driving) independently; the symptoms do not only occur in the context of delirium and are not better described by another mental disorder.

Those who have endured more negative life events, have poor housing, are more ethnically isolated where they live, or otherwise have little in terms of a support group are at higher risk for developing a psychotic disorder.

The definition of psychosis is a mental disease that includes symptoms like delusions or hallucinations that show impaired contact with and perception of reality. Usually with any psychotic disorder, the person's thoughts and behavior notably change.

Behavior changes that might occur during a psychotic break include the following:

• Social withdrawal/social isolation or loneliness
• Apathy
• Agitation, restlessness, hyperactivity, or excessive excitement
• Anxiety, nervousness, fear, or hypervigilance
• Hostility, anger, aggression
• Depersonalization (a combination of intense anxiety and a feeling of being unreal, detached from oneself, or that one's thoughts are not one's own)
• Loss of appetite
• Worsened hygiene and a lack of self-care
• Disorganized speech like rapid and frenzied speaking, incoherent speech, and excessive wordiness
• Disorganized behaviors, like a lack of discretion or restraint
• Catatonic behavior, in which the affected person's body may be rigid and the person may exhibit persistent repetition of words, a deficiency of speech, or be physically and/or verbally unresponsive. The catatonic individual might also engage in repetitive movements, slowness in activity, and thought or nonsense word repetition.

Changes/problems with thinking that may occur in a psychotic disorder include

• delusions (beliefs with no basis in reality),
• hallucinations (for example, hearing, seeing, or perceiving things not actually present),
• the sense of being controlled by outside forces, and
• disorganized thoughts.

A person with a psychotic disorder may not have any outward characteristics of being ill. In other cases, the illness may be more apparent, causing bizarre behaviors. For example, a person suffering from psychosis may stop bathing in the belief that it will protect against malicious individuals from attacking them.

People with psychosis vary widely in their behavior as they struggle with an illness beyond their control. Some may ramble in illogical sentences or react with uncontrolled anger or violence to a perceived threat. Characteristics of a psychotic illness may also include phases in which the affected individuals seem to lack personality, movement, and emotion (also called a flat affect). People with psychotic disorders may alternate between these extremes. Their behavior may or may not be predictable.

In order to better understand psychotic diseases, the concept of clusters of symptoms is often used. Thus, people with psychosis can experience symptoms grouped under the following categories:

• Positive symptoms: hearing voices that are not actually present (auditory hallucinations) or other hallucinations (seeing things: visual hallucinations; feeling things: tactile hallucinations; smelling things: olfactory hallucinations, or tasting things: gustatory hallucinations); suspiciousness to the point of paranoia, feeling that one is under frequent or constant surveillance or pursuit (persecutory delusions), religious delusions like feeling one is a deity or other false belief of superiority; or making up words without meaning (neologisms)
• Negative symptoms (deficit symptoms): social isolation, limited range of emotions, difficulty in expressing emotions (in extreme cases called blunted affect), difficulty in taking care of themselves, inability to feel pleasure, general discontent (These symptoms cause severe impairment.)
• Cognitive symptoms: difficulties thinking and understanding information, remembering simple tasks, attending to and processing information, and understanding their environment confusion
• Affective (or mood) symptoms: often manifested by depression, accounting for a very high rate of having thoughts and attempts at suicide in people suffering from schizophrenia and other types of psychotic disorders

Postpartum psychosis, now described as brief psychotic disorder with postpartum onset, usually develops within the first three months after childbirth, often within three to 14 days. Symptoms may include auditory or visual hallucinations, delusions, or rapid mood swings. The hallucinations may have themes of violence toward herself or her baby. This condition may be associated with significant problems in thinking, ranging from disorientation and other symptoms of mental confusion and indecision to intrusive and bizarre thoughts. Also, symptoms can arise and disappear suddenly, with the mother appearing lucid one moment and exhibiting psychotic behavior the next.

In order to determine whether the diagnosis of a psychotic disorder is warranted, the health care professional has to first consider if a medical illness may be the cause of the behavioral changes. If a medical disease is identified or the psychosis is found to be the result of exposure to a medication or drug, the sufferer is assessed as having psychotic disorder due to a medical condition or psychotic disorder due to toxin exposure or withdrawal, respectively. On the other hand, if a medical cause and toxin exposure have been looked for and not found, a psychotic illness such as schizophrenia could be considered. The diagnosis will best be made by a licensed mental health professional (like a psychiatrist or clinical psychologist), who can evaluate the patient's well-being and carefully sort through the diagnostic criteria for a variety of mental illnesses that might look alike at the initial examination, like schizotypal or schizoid personality disorder or a mood disorder with psychotic features like severe depression, or the mania phase of bipolar disorder. Other health care professionals who may treat psychotic disorders may include licensed social workers, psychiatric nurses and nurse practitioners, mental health physician assistants, and sometimes non-psychiatric physicians.

• The physician will examine someone in whom psychosis is suspected either in an office (for example, a primary care doctor or neurologist), in an emergency department (by an emergency-room physician), or in a hospital. The physician's role is to ensure that the psychosis sufferer doesn't have any medical (referred to as organic) problems, including active drug use, since these conditions can mimic the symptoms of a psychotic disorder. The medical doctor takes the patient's history and performs a physical examination. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with psychosis or to the drugs or other substances the person may be taking.
  • People with a psychotic disorder can exhibit signs of mild confusion or clumsiness.
  • Subtle physical features, such as a highly arched palate or wide or narrow set eyes, have been described in psychotic disorders, but none of these findings alone allow the physician to make the diagnosis.
• Generally, results are normal for most psychotic disorders for the lab tests and imaging studies available to most doctors. If the person has a particular behavior as part of their mental disease, such as drinking too much water, then this might show as a metabolic abnormality in the person's laboratory results.

Family members or friends of the person with psychosis can help by giving the doctor a detailed history and information about the patient, including recent life stressors, behavioral changes, previous level of social functioning, history of mental illness in the family, past medical problems and psychiatric disorders, drugs, and allergies (to foods and medications), as well as the person's previous psychiatrists and other physicians. A history of hospitalizations is also helpful so that prior records at these facilities might be obtained and reviewed.

The diagnosis of another psychotic illness may be distinguished from schizophrenia based on the duration of symptoms (as with brief psychotic disorder), the specific kind of psychotic symptoms that occur with delusional disorder, the type of nonpsychotic symptoms that occur with it as with schizoaffective disorder, or what causes it, as with substance/drug-induced psychotic disorder and psychosis due to a medical condition. The diagnosis of other specified schizophrenia spectrum and other psychotic disorders is reserved for those individuals who have some psychotic symptoms but do not qualify for a specific psychotic diagnosis. Women who recently had a baby (are in the postpartum state) and who develop psychotic symptoms may be diagnosed with brief psychotic disorder with postpartum onset, formerly called postpartum psychosis. Also, a neurosis like major depressive disorder or bipolar disorder can become severe enough to result in psychosis symptoms, also called psychotic features.

Given the severity and often chronic nature of psychotic disorders, home remedies (for example, those not devised and administered by professionals) are not deemed to be appropriate. Antipsychotic medications are proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. For example, the treatment of schizophrenia or bipolar disorder with psychotic features thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further psychotic episodes. If symptoms reappear on a lower dosage, a short-term increase in dosage may help prevent a relapse.

Even with continued treatment of the more chronic or recurring psychotic disorders, some patients experience relapses. By far, though, the highest relapse rates for such diseases are seen when medication is discontinued. The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them.

Antipsychotic medications are the cornerstone in the management of psychosis. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and usually allow the patient to function better, have a better quality of life, and enjoy an improved outlook. The choice and dosage of medication are individualized and are best done by a physician who is well-trained and experienced in treating severe mental illness.

The first antipsychotic medication was discovered by accident and then used for schizophrenia. This was chlorpromazine, which was soon followed by medications such as haloperidol, fluphenazine, thiothixene, trifluoperazine, perphenazine, and thioridazine. These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorders, loose associations, ambivalence, or mood swings/emotional lability), they can cause side effects, many of which affect the neurologic (nervous) system. Examples of such neurologic side effects include muscle stiffness or rigidity, painful spasms, restlessness, tremors, and muscle twitches. These older medications are thought to be not as effective against so-called negative symptoms such as decreased motivation and lack of emotional expressiveness.

Since 1989, a new class of antipsychotics (atypical antipsychotics) has been used. At clinically effective doses, none (or very few) of these neurological side effects of traditional antipsychotics, which often affect the extrapyramidal nerve tracts, are observed.

Clozapine (Clozaril), the first of the new class, is the only agent that has been shown to be effective in situations where other antipsychotics have failed. Its use is not associated with extrapyramidal neurologic side effects, but it can produce other side effects, including a possible decrease in the number of white blood cells. Therefore, blood cell counts need to be monitored prior to starting this medication, every week during the first six months of treatment and then every two weeks to detect this side effect early if it occurs.

Other atypical antipsychotics include risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone, lurasidone, and brexpiprazole. The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.

Although at least equally effective and often better tolerated, the use of these agents is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.

Most of these medications take two to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, or another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with clozapine).

A major challenge for many people who suffer from a psychotic disorder is compliance with taking medication. Therefore, the availability of medication that only needs to be taken on a biweekly or monthly basis may be of great benefit to some individuals. Fortunately, there are a number of medications to choose from, each of which can be taken daily by mouth or monthly by injection, including chlorpromazine, haloperidol, fluphenazine decanoate, olanzapine, risperidone, paliperidone palmitate, and ziprasidone.

Since people with a psychotic disorder are at increased risk of also developing depression, medications that address that symptom may be of great benefit, as well. Doctors often prescribe serotonergic medications like fluoxetine, sertraline, paroxetine, citalopram, escitalopram, vortioxetine, and levomilnacipran because of their effectiveness and low incidence of side effects. Other prescribed antidepressant medications for depression that can be associated with psychotic illnesses include venlafaxine, duloxetine, desvenlafaxine, and bupropion.

Because the risk of relapse of illness is higher when antipsychotic medications are taken irregularly or discontinued, it is important that people with a psychotic disorder follow a treatment plan developed in collaboration with their doctors and with their families. The treatment plan will involve taking the prescribed medication in the correct amount and at the times recommended, attending follow-up appointments, and following other treatment recommendations.

People with psychosis often do not believe that they are ill or that they need treatment. Other possible things that may interfere with the treatment plan include side effects from medications, substance abuse, negative attitudes toward treatment from families and friends, societal stigma about mental illness, or even unrealistic expectations about treatment. When present, these issues need to be acknowledged and addressed for the treatment to be successful.

Is it possible to treat psychotic disorders without medication?

In spite of successful antipsychotic treatment, many patients with psychosis have difficulty with motivation, activities of daily living, relationships, and communication skills. Also, since an illness like schizophrenia typically begins during years that are critical to education and professional training, these patients often lack social and work skills and experience. In these cases, the psychosocial treatments are all the more important, and many useful treatment approaches have been developed to assist people suffering from a psychotic disorder.

• Individual psychotherapy: This involves regular sessions between just the patient and a therapist focused on past or current problems, thoughts, feelings, or relationships. Thus, via contact with a trained professional (like a psychiatrist, clinical psychologist, or psychoanalyst), people with psychosis become able to understand more about the illness, learn about themselves, and to better handle the problems of their daily lives. They can become better able to differentiate between what is real and what is not and can acquire beneficial problem-solving skills.
• Rehabilitation: Rehabilitation may include job and vocational counseling, problem-solving, social skills training, and education in money management. Thus, patients learn skills required for successful reintegration into their community following discharge from the hospital.
• Family education: Research has consistently shown that people with a psychotic disorder who have involved families have a better prognosis than those who battle the disease alone. Insofar as possible, all family members should receive family-focused therapy, including emotional support and psychoeducation about psychotic disorders and be involved in the care of their loved one.
• Self-help groups: Outside support for family members of those with any psychotic disorder is necessary and desirable. The National Alliance for the Mentally Ill (NAMI) is an in-depth resource. This outreach organization shares information on all treatments for psychosis, including home care.

Many symptoms found in psychotic individuals are related to movement (motor symptoms). Some of these can be side effects of prescribed medications. Medication side effects may, for example, include dry mouth, constipation, drowsiness, stiffness on one side of the neck or jaw, restlessness, tremors of the hands and feet, and slurred speech.

Tardive dyskinesia is one of the most serious, although quite uncommon, side effects of medications used to treat schizophrenia and other psychotic disorders. It is usually seen in older people and involves facial twitching, jerking, and twisting of the limbs or trunk of the body, or both. It is a less common side effect with the newer generation of medications used to treat schizophrenia. It does not always go away, even when the medicine that caused it is discontinued.

A rare but life-threatening complication resulting from the use of neuroleptic (antipsychotic, tranquilizing) medications is neuroleptic malignant syndrome (NMS). It involves extreme muscle rigidity, sweatiness, salivation, and fever. If this complication is suspected, it should be treated as an emergency.

Other potential complications of antipsychotic medications include significant weight gain and sleepiness, depending on the medication. To address weight gain, prescribing physicians often counsel their patients with psychotic disorders on nutrition and exercise. Dose and timing adjustments may alleviate sleepiness. For pregnant women, the potential risks of the medication to a developing fetus must be balanced with the potential benefit to the mother and fetus of treating the illness.

The fact that men seem to develop these illnesses at younger ages may contribute to men having more episodes of the illness that are more severe compared to women. People with a psychotic disorder typically have fewer interactions with peers, tend to prematurely leave school, have low self-esteem, and are at higher risk for experiencing unemployment, repeated psychiatric hospitalizations, and substance abuse compared to people without a psychotic disorder. Psychotic disorder sufferers also often have trouble accessing and receiving medical care and therefore are at risk of medical illness and early death from conditions like diabetes and heart disease. While research reports vary on whether people with a psychotic disorder are at greater or less risk for developing different cancers, this population's vulnerability to having a poorer outcome from any medical illness highlights the importance of vigorous screening for cancers and other major medical conditions. The importance of assertively addressing the direct and associated symptoms of psychotic disorders is further indicated by the higher risk of suicide or engaging in self-harm that sufferers experience.

While more than two-thirds of people who have a psychotic disorder may suffer a return of those symptoms at some time, the combination of medications, psychosocial treatment, and education of the psychotic disorder sufferer and their loved ones tends to greatly improve how well the person is able to function. The shorter the amount of time from when the person begins having psychotic symptoms to when comprehensive treatment begins, the better the prognosis.

Cognitive behavioral therapy (CBT) for the person who is at high risk for developing psychosis but has yet to have such symptoms has been found to be more effective than medication at preventing such symptoms. In individuals who have developed psychotic symptoms, providing his or her family with support and education about their loved one's condition have been found to be quite helpful in the prevention of the recurrence of psychotic symptoms in the individual with the illness. For women who have developed postpartum psychosis in the past, preterm delivery of subsequent pregnancy has been found to help prevent further episodes of the disorder.

Action Postpartum Psychosis
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American Psychological Association

American Psychiatric Association

National Alliance for the Mentally Ill (NAMI)

Postpartum Support International

Schizophrenics Anonymous