Finding out that a loved one has a psychotic disorder can be just as frightening as hearing your medical doctor use the dreaded word “cancer.” Both types of illness elicit feelings of dread and fear. In an instant, you know that life is never going to be the same because your whole world has just been turned upside down. Although there are several types of psychotic disorders, the one that typically comes to mind is schizophrenia. If depression is the “common cold” of mental illnesses, schizophrenia is the cancer. It is generally regarded as the most serious, and potentially most debilitating, psychiatric disorder. Schizophrenia affects about 1% of adults. Other psychotic disorders include:
- Schizoaffective Disorder
- Schizophreniform Disorder
- Delusional Disorder
- Brief Psychotic Disorder
- Shared Psychotic Disorder (also called “folie a deux”)
What is “Psychosis”?
Essentially, psychosis refers to a state of mind that involves being out of touch with reality. People who are psychotic have severely impaired judgment. This is part of what makes psychotic disorders so very challenging – and so debilitating. It’s impossible to function normally during a psychotic episode. The two primary symptoms of psychosis are hallucinations and delusions. Hallucinations involve perceptual disturbances. The most common types of hallucinations are auditory – e.g. “hearing voices” – and visual. However, hallucinations can also involve taste, smell and touch. Individuals with paranoid schizophrenia often experience auditory hallucinations. Delusions are comprised of a firmly held false belief that seems very real to the person. For example, a delusional person might think that aliens have put a tracking chip into his brain or removed one of his vital organs. One delusional patient believed she was romantically involved with a famous actor (whom she’d never met); while another believed that the chromosomes in his body were being “rearranged” by microscopic robots. Delusions are classified as either “bizarre” or “non-bizarre.” Bizarre delusions mean they are completely implausible (e.g. the delusion that aliens have surgically removed one’s heart). For a diagnosis of delusional disorder, the delusions must not be bizarre. Delusions typically have a theme, with the most common themes being persecutory, grandiose, erotomanic, somatic or jealous. Sometimes the definition of psychosis is extended to include “disordered” or severely disorganized thinking. For example, some individuals with disorganized schizophrenia speak in a “word salad”; everything that comes out of their mouths is gibberish because their thoughts are so disorganized. Pamela’s story
Pamela was a thin, gray-haired woman in her mid-60s when her family brought her in for treatment. She had been a relatively high-functioning individual up until the past several weeks. Her family had noticed several strange changes in her behavior. She had become increasingly paranoid and suspicious. She believed people were tapping her phone and that hidden cameras were everywhere, watching her every move. She had been losing weight because she was eating very little, due to her belief that her food was being poisoned. After ruling out any underlying medical cause of her symptoms, Pamela was diagnosed with delusional disorder. She was admitted to inpatient psychiatric treatment for several days and started on antipsychotic medication.
Eric was brought into the hospital emergency room by the police, with his parents right behind them. Just 19 years old, the handsome young man with piercing blue eyes looked terrified as the doctor attempted to talk to him. He was clearly distracted, and often whispered under his breath as if talking to someone only he could see. He was a sophomore in college.
Normally a straight-A student, his advisor had contacted his parents after his grades began to drop significantly and his class attendance had become sporadic. His roommate had also reported concerns about Eric’s odd behavior, noting that he would go days without sleeping. According to his roommate, Eric had recently been staying up all night writing pages and pages of scribbled notes, talking about his mission to “save the world” from the evil aliens that were circling the earth in their spaceships.
Eric was admitted to the inpatient psychiatric unit for three weeks. A thorough evaluation led to a provisional diagnosis of schizoaffective disorder. A combination of an antipsychotic medication and a mood stabilizer helped alleviate the psychotic and manic symptoms. Upon discharge, Eric continued his intensive treatment in an adult day treatment program.
As both Pamela’s and Eric’s story illustrate, psychosis causes a person to act in irrational ways. In Eric’s case, manic symptoms were also impacting his behavior. The combination of mood symptoms and psychotic symptoms suggested either schizoaffective disorder or bipolar disorder, hence his initial provisional diagnosis. In time, however, his psychiatrist ultimately determined that schizoaffective disorder was the more appropriate diagnosis.
Dangers of Psychosis
If left untreated, psychotic disorders can be dangerous. Although violence is not common with disorders like schizophrenia, a person who has become paranoid or grandiose – and especially both – may become violent, particularly if he or she feels threatened or challenged. One older woman who had likely suffered from untreated schizophrenia her entire life – shielded and cared for by her doting husband who had passed – was brought into the hospital after pulling a gun on a caregiver who had come to her home. She stated that the “voices” had told her she needed to protect herself from the “scary people” who were plotting against her. Fortunately no one was harmed, but sometimes the consequences of psychosis are deadly. Psychosis is dangerous in many cases because of its impact on decision-making and judgment. Some people who hear voices may attempt suicide – not because they want to die, but rather because a voice (or several voices) is telling them to. This type of auditory hallucination is referred to as a “command hallucination.” Had Pamela’s family not intervened, she could have slowly starved to death due to her delusional belief that her food was poisoned.
Psychosis and Other Conditions
While psychotic symptoms are often due to schizophrenia, schizoaffective disorder, and other more common psychotic disorders, they may also be caused by (and thus secondary to) another medical or mental health condition. For example, someone with a brain tumor may experience visual hallucinations. When a medical condition is the cause, the diagnosis is “psychotic disorder due to a general medical condition.” Many substances cause psychotic symptoms. For example, someone using cocaine may experience paranoid delusions. When the cause of the psychotic symptoms is due to drugs or alcohol, the diagnosis is “substance-induced psychotic disorder.” In many cases, the psychotic symptoms disappear when the drug clears the person’s system. Several psychiatric disorders that don’t fall under the category of “psychotic disorders” also include psychotic symptoms at times. For example, individuals with bipolar I disorder may become psychotic during a manic episode. In rare cases of severe major depression, psychotic symptoms may also occur. Individuals with borderline personality disorder often experience fleeting psychotic symptoms. Elderly patients with Alzheimer’s disease often experience delusions and hallucinations.
Diagnosis and Treatment
If you’ve noticed bizarre behaviors in a loved one that may suggest the presence of psychotic symptoms, it’s critical that he or she is evaluated as soon as possible. If you’re not sure, it’s always better to be safe than sorry, as psychosis can lead to disastrous consequences if left untreated. In the case of schizophrenia, for example, research has shown that early intervention often leads to a better long-term prognosis. Even if drugs are causing the psychosis, it should not be ignored. Don’t wait until someone gets hurt. In some cases, you may have to involve the police to get your loved one to a hospital or mental health clinic for an evaluation. Remember, when psychosis is present, rationale is not. You can’t expect your loved one to use good judgment, understand your intentions, or cooperate with the process. If he or she is paranoid, you will almost always meet with resistance. Your efforts to help will likely be misinterpreted as part of a bigger, evil conspiracy in which everyone is “out to get them.” You could put yourself, your loved one and others in danger if you attempt to handle things alone. Let the police bring your loved one in instead. Diagnosing a psychotic disorder often involves three things: 1) a drug screening test (or “tox screen”) to rule out any substances that may be causing the symptoms; 2) a medical evaluation to rule out any underlying medical causes; and 3) a psychiatric evaluation, including a personal and family history (which may be obtained from a family member if the patient is floridly psychotic and unable to competently answer questions). Treatment for psychotic disorders typically requires antipsychotic medication. Commonly prescribed antipsychotics include Haldol (if agitation is present), Zyprexa, Seroquel, Abilify and Risperdal. Antipsychotic medications can be very effective. However, they are powerful medications that have many potential side effects – some of which can be very serious. These medications should be taken only as prescribed and under the careful supervision of a psychiatrist or other medical doctor. With psychosis, if the symptoms are active, hospitalization may be necessary to stabilize your loved one and keep him or her (as well as others) safe. Inpatient treatment also provides the opportunity for close observation, which can help further establish the appropriate diagnosis. This is particularly valuable if this is the patient’s first psychotic episode. An accurate diagnosis helps ensure proper treatment. Once the psychotic symptoms have subsided, it’s essential that treatment continue – at least for a while. Schizophrenia and schizoaffective disorder typically require lifelong treatment, including ongoing medication. Medications help prevent (or at least reduce the frequency of) future psychotic episodes, although there are no guarantees. Therapy – individual, family, or both – can also play an important role in the treatment process. Individual therapy can be beneficial for the patient, helping him or her learn to manage the disorder and deal with the stigma that often accompanies psychotic disorders. Family therapy can help you and other family members learn how to provide the best support for your loved one, and also help all of you gain a deeper understanding of how such a disorder can and will impact everyone involved – including your loved one. Psychotic disorders can be incredibly challenging. While they may lead to total disability, that is not always the case. Many people function quite well and lead fulfilling lives in spite of schizophrenia or another psychotic disorder.