Psychotic disorders

Psychotic disorders are characterized by one experiencing psychosis. The most widely known and most chronic primary psychotic disorder is schizophrenia, but there are others.

Psychosis

At least 3 symptoms are expected in order for psychosis to occur:

• Presence of hallucinations
• Delusions
• Loss of reality testing/confusion
• Disturbed/disorganized thought, speech, behavior
  • Needs to be grossly disturbed for most psychotic disorders

Psychosis features can occur at any age, although it is more common in adulthood than childhood. Assessment for psychosis is required by a mental health professional; a careful history must be taken, and it is important to provide good historical information about when symptoms were present.

Causes of psychosis are manifold. There are many reasons why it could happen.

Physicians are familiar with psychosis; the most common place to present with psychosis is emergency room.

Treatment for psychosis is primarily medical, but patients need much more support than from just a physician. To treat psychosis, they also need a mental health professional to work with them closely in therapy, to ensure medication is taken and problems with life/living are resolved.

The differential diagnosis for psychosis is complex.

Consistent use of hard drugs can lead to psychotic disorders such as schizophrenia.

Hallucinations

• Perceptual distortion that are not attributable to environmental (sensory) stimuli but appear real to the person experiencing them
• Cannot argue people out of hallucinations, no way to distinguish between reality and hallucination
• Reality testing - having insight that this is a hallucination, not real

Normative hallucinations - hearing someone behind you calling your name without anyone there

Hallucinations can occur for all five senses

• Auditory and visual are common
• Auditory most common
• Tactile hallucinations are most common for drug-induced hallucinations

Delusions

• Ideas, false beliefs firmly and consistently held despite disconfirming evidence or logic
• If we present disconfirming evidence, they still won’t change their minds
• Bizarre vs. non-bizarre delusions
  • Bizarre - completely impossible: are Jesus Christ, are Marie Antoinette, was abducted by aliens, etc.
  • Non-bizarre - possible but didn’t happen: paranoia, husband trying to poison you, etc.

Types of delusions

• Grandeur - fame, important
• Control - someone is controlling you
• Thought broadcasting - thoughts are being broadcasted to others
• Persecution - someone is out to get you
• Reference - everything seen is referencing me, about me, sending me a message, etc.

Loss of reality testing/confusion

• Extreme: not oriented basic elements of reality
  • Not knowing who you are
  • Not oriented to time, place, context, etc.
• Lack of insight that they are not okay
  • Can make it difficult to convince them to get treatment
• Usually, close friends/family will realize they changed significantly and can determine they are very confused and need help at a hospital

Diagnosing psychotic disorders

Possible diagnoses for psychosis

• Acute environmental toxicity - smoke, environmental toxin
• Various general medical illnesses - sepsis
• Sleep deprivation
• Oxygen deprivation
• Starvation
• Postpartum, post-surgical
• Medication: combos, overdosing, adverse reactions, side effects
• Effects of substances of abuse
• Various mental illnesses

Differential diagnosis of psychosis

• As opposed to dissociation, seizure, or PTSD
• Brief psychotic disorder vs. schizophreniform disorder vs. schizophrenia
• Primary psychotic disorder vs. mood disorder
• Forensics: psychosis vs. ASPD

Psychosis in mental disorders

• Unipolar disorder - psychosis always at depressive peaks
• Bipolar I disorder - psychosis always at manic or depressive peaks
  • Bipolar II disorder does not involve psychosis
• Schizoaffective disorder - psychosis present at all levels of mood
  • At least 2 weeks of normal functioning while psychosis is present
• Schizophrenia - abnormally flat moods and psychosis can occur at any mood point

What’s needed for diagnosing psychosis

• Accurate history crucial but difficult to obtain
• Collateral sources almost always needed - someone who knows the patient well
• Definitive differential diagnosis difficult, often delayed
• First episodes especially mysterious, prognosis wildly variable