All About Psychosis

All About Psychosis

When your thoughts, feelings, and senses don’t line up with reality, you may be experiencing psychosis.

During an episode of psychosis, the things you think and feel seem real to you. You’re unable to tell they aren’t happening to anyone else and can’t be convinced otherwise.

Approximately 3 out of every 100 people will experience a psychosis episode in their lives.

Psychosis doesn’t mean you’re dangerous, but it may increase the chances of harm to yourself and others.

Treatment options are highly successful and can help you fully recover after experiencing psychosis symptoms.

Psychosis occurs when your mind can’t distinguish between what’s real and what isn’t.

It’s the primary symptom of mental health conditions known as psychotic disorders, but it may also occur as a secondary feature in other conditions, such as bipolar disorder.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) considers psychosis a symptom of a mental health condition, not a diagnosis itself.

The DSM-5 categorizes it under “schizophrenia spectrum and other psychotic disorders.”

Psychosis may cause you to feel, taste, smell, hear or touch things that aren’t really there. It may also cause you to believe thoughts or have emotions that go against proven fact.

For some people, psychosis also involves catatonic behavior and significant cognitive impairment. This is not always the case, though.

Three stages of an episode of psychosis are recognized:

  • Prodrome phase. The early warning signs of psychosis appear. You may start experiencing changes in behaviors and thoughts.
  • Acute phase. During the acute phase of psychosis, reality-altering changes are active. You may be experiencing hallucinations or delusions – or both.
  • Recovery. The recovery phase of psychosis occurs when your symptoms improve. This is often after treatment or when an underlying cause of psychosis has been addressed.

Psychosis can have many unique presentations. What you experience during each phase may be different from what someone else experiences.

There are many instances in which symptoms of psychosis may appear:

  • psychotic disorders
  • brief psychotic disorder
  • postpartum psychosis
  • psychotic disorder due to another medical condition
  • substance/medication-induced psychosis
  • unspecified/other schizophrenia spectrum and other psychotic disorder

Psychotic disorders

Several other mental health conditions have psychosis as a primary symptom. These are called psychotic disorders and include conditions such as schizophrenia.

Brief psychotic disorder

This disorder is often caused by extreme stress and lasts less than a month. It often resolves after treatment and with a full recovery.

Postpartum psychosis

Among instances of brief psychotic disorder is postpartum psychosis. You may experience brief psychosis at any time in life, but when it occurs during the first 4 weeks after giving birth, doctors refer to it as postpartum psychosis. This is different from postpartum depression.

Psychotic disorder due to another medical condition

You may experience psychosis brought on by another medical condition or injury. For example, after you’ve severely hit your head.

Substance/medication-induced psychotic disorder

Psychosis may be the result of certain medications or drugs, such as ketamine or cocaine.

Unspecified/other schizophrenia spectrum and other psychotic disorder

Doctors may use this diagnosis when psychosis symptoms are present but don’t meet the full criteria for any other disorder or mental health condition.

Symptoms of psychosis are typically organized into two main categories: positive and negative.

Positive symptoms are those that add to or distort usual functioning. These include:

  • hallucinations
  • delusions
  • disorganized speech
  • disorganized behavior

Negative symptoms are those that cause a loss of usual functioning and may include:

  • withdrawn mood
  • decreased motivation
  • lack of emotional display
  • decreased gestures
  • lack of interest in other people, activities, or events
  • personality changes

Other symptoms that may overlap with psychosis include:

  • thoughts of suicide
  • difficulty sleeping
  • substance use
  • anxiety
  • depression

These symptoms, however, are not part of the formal criteria established by the DSM-5.

The exact cause of psychosis has not been yet established, though experts believe multiple factors are likely involved.

These include:

  • hormonal changes in the brain
  • traumatic events
  • other mental health conditions
  • physical injury or illness
  • genetics
  • substance use

Most episodes of psychosis don’t happen suddenly. When you experience your first episode, chances are there have been a number of slow, subtle signs leading up to that event.

Many of these early warning signs can be difficult to separate from everyday stress responses. You may not realize you’ve had a change in thinking or behavior if you’re experiencing thoughts of altered reality.

Early warning signs of psychosis may include:

  • significant changes in school or job performance
  • feelings of unease or suspicion around people
  • strong or absent emotions
  • a decline in personal hygiene
  • difficulty concentrating
  • social withdrawal
  • unusual, persistent thoughts/beliefs
  • seeing, hearing, or feeling things that aren’t there
  • confused or disorganized speech

Identifying these signs of psychosis early, especially during the first episode, can help you achieve the best recovery outcomes.

Psychosis often occurs as a symptom of other mental health conditions.

It can be a symptom of conditions such as:

  • schizophrenia
  • schizophreniform disorder
  • schizoaffective disorder
  • delusional disorder

In addition to psychotic disorders, psychosis may appear as a feature of other mental health conditions, including:

  • bipolar disorder
  • major depressive disorder


Two or more of the following psychosis symptoms are present for at least 6 months and have a significant impact on daily life:

  1. delusions
  2. hallucinations
  3. disorganized speech
  4. grossly disorganized or catatonic behavior
  5. negative symptoms

Schizophreniform disorder

This condition occurs when symptoms of psychosis are present for more than 1 month but less than 6 months.

Schizoaffective disorder

In schizoaffective disorder, there are symptoms of psychosis but also symptoms of mood disorders.

Delusional disorder

Symptoms of psychosis revolve around delusions or intense beliefs that go against what is proven to be true or accurate.

Bipolar disorder

In bipolar disorder, psychosis may present as more of a mood disturbance, as opposed to a thought disturbance.

Major depressive disorder

Major depression with psychotic features can present as hallucination or delusions often with negative depressive themes.

Psychosis is treatable. Depending on the type of psychosis, you may experience a full recovery.

Early treatment provides the best outcomes, and receiving care quickly can help reduce the chances symptoms will linger after treatment.

Left untreated, this condition may cause major disruptions in your routines and relationships.

Treatment for psychosis involves healthcare professionals who make up a coordinated specialty care (CSC) team.

When you experience a first-time psychosis episode, the CSC team will work with you to find a treatment routine involving:

  • psychotherapy
  • family support and education
  • medication
  • work assistance
  • case management

In many cases, there’s no single cure for psychosis. Treatment can help resolve or manage symptoms based on the type of psychosis you’ve experienced.

Some episodes of psychosis may resolve quickly and completely, such as those caused by medications, drugs, injuries, or extreme stress.

Depending on the type, psychosis may return if underlying causes are not addressed or treatment stops.

The &lsquoShared Psychosis&rsquo of Donald Trump and His Loyalists

The violent insurrection at the U.S. Capitol Building last week, incited by President Donald Trump, serves as the grimmest moment in one of the darkest chapters in the nation&rsquos history. Yet the rioters&rsquo actions&mdashand Trump&rsquos own role in, and response to, them&mdashcome as little surprise to many, particularly those who have been studying the president&rsquos mental fitness and the psychology of his most ardent followers since he took office.

One such person is Bandy X. Lee, a forensic psychiatrist and president of the World Mental Health Coalition.* Lee led a group of psychiatrists, psychologists and other specialists who questioned Trump&rsquos mental fitness for office in a book that she edited called The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. In doing so, Lee and her colleagues strongly rejected the American Psychiatric Association&rsquos modification of a 1970s-era guideline, known as the Goldwater rule, that discouraged psychiatrists from giving a professional opinion about public figures who they have not examined in person. &ldquoWhenever the Goldwater rule is mentioned, we should refer back to the Declaration of Geneva, which mandates that physicians speak up against destructive governments,&rdquo Lee says. &ldquoThis declaration was created in response to the experience of Nazism.&rdquo

Lee recently wrote Profile of a Nation: Trump&rsquos Mind, America&rsquos Soul, a psychological assessment of the president against the backdrop of his supporters and the country as a whole. These insights are now taking on renewed importance as a growing number of current and former leaders call for Trump to be impeached. On January 9 Lee and her colleagues at the World Mental Health Coalition put out a statement calling for Trump&rsquos immediate removal from office.

Scientific American asked Lee to comment on the psychology behind Trump&rsquos destructive behavior, what drives some of his followers&mdashand how to free people from his grip when this damaging presidency ends.

[An edited transcript of the interview follows.]

What attracts people to Trump? What is their animus or driving force?

The reasons are multiple and varied, but in my recent public-service book, Profile of a Nation, I have outlined two major emotional drives: narcissistic symbiosis and shared psychosis. Narcissistic symbiosis refers to the developmental wounds that make the leader-follower relationship magnetically attractive. The leader, hungry for adulation to compensate for an inner lack of self-worth, projects grandiose omnipotence&mdashwhile the followers, rendered needy by societal stress or developmental injury, yearn for a parental figure. When such wounded individuals are given positions of power, they arouse similar pathology in the population that creates a &ldquolock and key&rdquo relationship.

&ldquoShared psychosis&rdquo&mdashwhich is also called &ldquofolie à millions&rdquo [&ldquomadness for millions&rdquo] when occurring at the national level or &ldquoinduced delusions&rdquo&mdashrefers to the infectiousness of severe symptoms that goes beyond ordinary group psychology. When a highly symptomatic individual is placed in an influential position, the person&rsquos symptoms can spread through the population through emotional bonds, heightening existing pathologies and inducing delusions, paranoia and propensity for violence&mdasheven in previously healthy individuals. The treatment is removal of exposure.

Why does Trump himself seem to gravitate toward violence and destruction?

Destructiveness is a core characteristic of mental pathology, whether directed toward the self or others. First, I wish to clarify that those with mental illness are, as a group, no more dangerous than those without mental illness. When mental pathology is accompanied by criminal-mindedness, however, the combination can make individuals far more dangerous than either alone.

In my textbook on violence, I emphasize the symbolic nature of violence and how it is a life impulse gone awry. Briefly, if one cannot have love, one resorts to respect. And when respect is unavailable, one resorts to fear. Trump is now living through an intolerable loss of respect: rejection by a nation in his election defeat. Violence helps compensate for feelings of powerlessness, inadequacy and lack of real productivity.

Expert on the psychology of Donald Trump and his supporters says their behavior can be explained by a &ldquonarcissistic symbiosis&rdquo and &ldquoshared psychosis.&rdquo Tayfun Coskun Getty Images

Do you think Trump is truly exhibiting delusional or psychotic behavior? Or is he simply behaving like an autocrat making a bald-faced attempt to hold onto his power?

I believe it is both. He is certainly of an autocratic disposition because his extreme narcissism does not allow for equality with other human beings, as democracy requires. Psychiatrists generally assess delusions through personal examination, but there is other evidence of their likelihood. First, delusions are more infectious than strategic lies, and so we see, from their sheer spread, that Trump likely truly believes them. Second, his emotional fragility, manifested in extreme intolerance of realities that do not fit his wishful view of the world, predispose him to psychotic spirals. Third, his public record includes numerous hours of interviews and interactions with other people&mdashsuch as the hour-long one with the Georgia secretary of state&mdashthat very nearly confirm delusion, as my colleague and I discovered in a systematic analysis.

Where does the hatred some of his supporters display come from? And what can we do to promote healing?

In Profile of a Nation, I outline the many causes that create his followership. But there is important psychological injury that arises from relative&mdashnot absolute&mdashsocioeconomic deprivation. Yes, there is great injury, anger and redirectable energy for hatred, which Trump harnessed and stoked for his manipulation and use. The emotional bonds he has created facilitate shared psychosis at a massive scale. It is a natural consequence of the conditions we have set up. For healing, I usually recommend three steps: (1) Removal of the offending agent (the influential person with severe symptoms). (2) Dismantling systems of thought control&mdashcommon in advertising but now also heavily adopted by politics. And (3) fixing the socioeconomic conditions that give rise to poor collective mental health in the first place.

What do you predict he will do after his presidency?

I again emphasize in Profile of a Nation that we should consider the president, his followers and the nation as an ecology, not in isolation. Hence, what he does after this presidency depends a great deal on us. This is the reason I frantically wrote the book over the summer: we require active intervention to stop him from achieving any number of destructive outcomes for the nation, including the establishment of a shadow presidency. He will have no limit, which is why I have actively advocated for removal and accountability, including prosecution. We need to remember that he is more a follower than a leader, and we need to place constraints from the outside when he cannot place them from within.

What do you think will happen to his supporters?

If we handle the situation appropriately, there will be a lot of disillusionment and trauma. And this is all right&mdashthey are healthy reactions to an abnormal situation. We must provide emotional support for healing, and this includes societal support, such as sources of belonging and dignity. Cult members and victims of abuse are often emotionally bonded to the relationship, unable to see the harm that is being done to them. After a while, the magnitude of the deception conspires with their own psychological protections against pain and disappointment. This causes them to avoid seeing the truth. And the situation with Trump supporters is very similar. The danger is that another pathological figure will come around and entice them with a false &ldquosolution&rdquo that is really a harnessing of this resistance.

How can we avert future insurrection attempts or acts of violence?

Violence is the end product of a long process, so prevention is key. Structural violence, or inequality, is the most potent stimulant of behavioral violence. And reducing inequality in all forms&mdasheconomic, racial and gender&mdashwill help toward preventing violence. For prevention to be effective, knowledge and in-depth understanding cannot be overlooked&mdashso we can anticipate what is coming, much like the pandemic. The silencing of mental health professionals during the Trump era, mainly through a politically driven distortion of an ethical guideline, was catastrophic, in my view, in the nation&rsquos failure to understand, predict and prevent the dangers of this presidency.

Do you have any advice for people who do not support Trump but have supporters of him or &ldquomini-Trumps&rdquo in their lives?

This is often very difficult because the relationship between Trump and his supporters is an abusive one, as an author of the 2017 book I edited, The Dangerous Case of Donald Trump, presciently pointed out. When the mind is hijacked for the benefit of the abuser, it becomes no longer a matter of presenting facts or appealing to logic. Removing Trump from power and influence will be healing in itself. But, I advise, first, not to confront [his supporters&rsquo] beliefs, for it will only rouse resistance. Second, persuasion should not be the goal but change of the circumstance that led to their faulty beliefs. Third, one should maintain one&rsquos own bearing and mental health, because people who harbor delusional narratives tend to bulldoze over reality in their attempt to deny that their own narrative is false. As for mini-Trumps, it is important, above all, to set firm boundaries, to limit contact or even to leave the relationship, if possible. Because I specialize in treating violent individuals, I always believe there is something that can be done to treat them, but they seldom present for treatment unless forced.

*Editor&rsquos Note (1/12/21): This sentence has been revised after posting to correct Bandy X. Lee&rsquos current affiliation.

COVID-19 and psychosis risk: Real or delusional concern?

Historical epidemiological perspectives from past pandemics and recent neurobiological evidence link infections and psychoses, leading to concerns that COVID-19 will present a significant risk for the development of psychosis. But are these concerns justified, or mere sensationalism? In this article we review the historical associations between viral infection and the immune system more broadly in the development of psychosis, before critically evaluating the current evidence pertaining to SARS-CoV-2 and risk of psychosis as an acute or post-infectious manifestation of COVID-19. We review the 42 cases of psychosis reported in infected patients to date, and discuss the potential implications of in utero infection on subsequent neurodevelopment and psychiatric risk. Finally, in the context of the wider neurological and psychiatric manifestations of COVID-19 and our current understanding of the aetiology of psychotic disorders, we evaluate possible neurobiological and psychosocial mechanisms as well as the numerous challenges in ascribing a causal pathogenic role to the infection.

Keywords: COVID-19 Encephalitis Neurology Neuropsychiatry Psychiatry Psychosis SARS-CoV-2 Schizophrenia.

Procedural Expertise

Psychiatry is situated in a middle ground between psychology (the study of behavior and the mind) and neurology (the study of the brain and nervous system). In practice, a psychiatrist will consider symptoms of mental health conditions in two ways:

  • Assessing the impact of a disease, physical trauma, or substance use on a person's behavior and mental state
  • Evaluating symptoms in association with a person's life history and/or external events or conditions (such as emotional trauma or abuse)

The approach, known as the biopsychosocial model, requires the psychiatrist to use multiple tools to render a diagnosis and dispense the appropriate treatment.

Mental Status Examination

Mental status examinations (MSE) are an important part of the clinical assessment of a psychiatric condition. It is a structured way of observing and evaluating a person's psychological function from the perspective of attitude, behavior, cognition, judgment, mood, perception, and thought processes.

Depending on the presumed condition, the psychiatrist would use a variety of psychological tests to establish the presence of characteristic symptoms and rate their severity. Based on the results, the psychiatrist would refer to the DSM-5 to see if the symptoms meet the diagnostic criteria for the mental disorder.

  • Anxiety tests such as the Beck Anxiety Inventory (BAI) and Liebowitz Social Anxiety Scale (LSAS)
  • Depression tests such as the Hamilton Depression Rating Scale (HAM-D) and the Beck Hopelessness Scale
  • Eating disorder tests such as the Minnesota Eating Behavior Survey (MEBS) and the Eating Disorder Examination (EDE)
  • Mood disorder tests such as the My Mood Monitor Screen and the Altman Self-Rating Mania Scale (ASRM)
  • Personality disorder tests such as the Shedler-Westen Assessment Procedure (SWAP-200) and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD)
  • Psychosis tests such as the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS)

Biomedical Diagnosis

As with many medical conditions, the diagnosis of mental illness will often involve a process of elimination to explore and exclude all possible causes. Known as a differential diagnosis, the process would involve a combination of MSE and biomedical tests to differentiate the presumed cause from others with similar symptoms.

The biomedical tools used by a psychiatrist may include:

  • A physical examination such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) to check for tumors, hemorrhage, or lesions to identify irregularities in brain electrical activity, including epilepsy, a head injury, or a cerebral blood obstruction
  • Blood tests to evaluate blood chemistry, electrolytes, liver function, and kidney function that may directly or indirectly impact the brain
  • Drug screening to detect illicit or pharmaceutical drugs in a blood or urine sample
  • STD screening to detect syphilis, HIV, and other sexually transmitted infections that can affect the brain


Psychotherapy is integral to both the diagnosis and treatment of mental illness. It involves meeting with patients on a regular basis to talk about their problems, behaviors, feelings, thoughts, and relationships. The goal of the psychiatrist is to help people find solutions to their problems by exploring thought patterns, behaviors, past experiences, and other internal and external influences.

People undergoing psychotherapy might meet with their psychiatrist individually or as part of a family or group session. Depending on the diagnosis and/or severity of symptoms, psychotherapy may be used for a specific period of time or an ongoing basis.

Many people who've experienced a major depressive episode are likely to have another. A 2014 meta-analysis looked at the long-term relapse rates of depression after psychotherapy. Researchers found an average relapse rate of 0.39, but people who'd had psychotherapy were less likely to experience relapse than those who'd undergone comparison treatments.

Psychiatric Medications

Medications are commonly used in psychiatry, each of which has differing properties and psychoactive effects. A psychiatrist needs to be well versed in both the mechanism of action (how a drug works) and pharmacokinetics (the way a drug moves through the body) of any prescribed medication.

Combination drug therapy (the use of two or more drugs) is often used in psychiatry and may require ongoing adjustments to achieve the intended effect. Finding the right combination may take time and is often a process of trial-and-error.

The medications used in psychiatry are broadly classified by six different classes:

    used to treat depression, anxiety disorders, eating disorders, and borderline personality disorder
  • Antipsychoticsused to treat schizophrenia and psychotic episodes used to treat anxiety disorders , such as hypnotics, sedatives, and anesthetics. used to treat episodic anxiety, insomnia, and panic
  • Mood stabilizersused to treat bipolar disorder and schizoaffective disorder used to treat ADHD and narcolepsy

Other Treatments

Other interventions may be used when a mental disorder is treatment-resistant or intractable (difficult to control). These include:

  • Deep brain stimulation (DBS), involving the implantation of electrical probes to stimulate parts of the brain in people with severe depression, dementia, OCD, or substance abuse , involving the external delivery of electrical currents to the brain to treat severe bipolar disorder, depression, or catatonia
  • Psychosurgery, using surgical techniques like cingulotomy, subcaudate tractotomy, and limbic leucotomy to sever specific circuits in the brain associated with severe OCD and depression

Despite evidence of their benefits, all of these interventions are considered highly controversial, with variable results and degrees of success.

It’s important to get treated early, after the first episode of psychosis. That will help keep the symptoms from affecting your relationships, work, or school. It may also help you avoid more problems down the road.

Your doctor may recommend coordinated specialty care (CSC). This is a team approach to treating schizophrenia when the first symptoms appear. It combines medicine and therapy with social services and work and education support. The family is involved as much as possible.

What your doctor recommends will depend on the cause of your psychosis.

Your doctor will prescribe antipsychotic drugs -- in pills, liquids, or shots -- to ease your symptoms. They’ll also suggest you avoid using drugs and alcohol.

You might need to get treated in a hospital if you’re at risk of harming yourself or others, or if you can't control your behavior or do your daily activities. The doctor will check your symptoms, look for causes, and suggest the best treatment for you.

Some clinics and programs offer help just for young people.

Is a Mass Psychosis the Greatest Threat to Humanity?

“All one’s neighbours are in the grip of some uncontrolled and uncontrollable fear. . . In lunatic asylums it is a well-known fact that patients are far more dangerous when suffering from fear than when moved by rage or hatred.”

Carl Jung, Psychology and Religion

According to the psychologist Carl Jung the greatest threat to civilization lies not with the forces of nature, nor with any physical disease, but with our inability to deal with the forces of our own psyche. We are our own worst enemies or as the Latin proverb puts it “Man is wolf to man”. In Civilization in Transition Jung states that this proverb “is a sad yet eternal truism” and our wolf-like tendencies come most prominently into play at those times of history when mental illness becomes the norm, rather than the exception in a society, a situation which Jung termed a psychic epidemic.

“Indeed, it is becoming ever more obvious” he writes “that it is not famine, not earthquakes, not microbes, not cancer but man himself who is man’s greatest danger to man, for the simple reason that there is no adequate protection against psychic epidemics, which are infinitely more devastating than the worst of natural catastrophes.”

Carl Jung, The Symbolic Life

In this video we are going to explore the most dangerous of all psychic epidemics the mass psychosis. A mass psychosis is an epidemic of madness and it occurs when a large portion of a society loses touch with reality and descends into delusions. Such a phenomenon is not a thing of fiction. Two examples of mass psychoses are the American and European witch hunts of the 16th and 17th centuries and the rise of totalitarianism in the 20th century. During the witch hunts thousands of individuals, mostly women, were killed not for any crimes they committed but because they became the scapegoats of societies gone mad:

“In some Swiss villages, there were scarcely any women left alive after the frenzy had finally burned itself out.”

Frances Hill, A Delusion of Satan

The totalitarian experiments of the 20 th century are a more recent, and a more deadly, example of a mass psychosis. In countries such as the Soviet Union, Nazi Germany, North Korea, China and Cambodia it was a collective detachment from reality and a descent into delusions and paranoia that permitted the rise of the all-powerful totalitarian governments that destroyed the lives of hundreds of millions:

“. . .the totalitarian systems of the 20th century represent a kind of collective psychosis. Whether gradually or suddenly, reason and common human decency are no longer possible in such a system: there is only a pervasive atmosphere of terror, and a projection of “the enemy,” imagined to be “in our midst.” Thus society turns on itself, urged on by the ruling authorities.”

Joost Meerloo, The Rape of the Mind

When a mass psychosis occurs the results are devastating. Jung studied this phenomenon thoroughly and wrote that the individuals who make up the infected society “become morally and spiritually inferior” they “sink unconsciously to an inferior…intellectual level” they become “more unreasonable, irresponsible, emotional, erratic, and unreliable,” and worst of all

“Crimes the individual alone could never stand are freely committed by the group [smitten by madness].”

Carl Jung, The Symbolic Life

What makes matters worse is that those suffering from a mass psychosis are unaware of what is occurring. For just as an individual gone mad cannot step out of his mind to observe the errors in his ways, so too there is no Archimedean point from which those living through a mass psychosis can observe their collective madness, or as Jung writes concerning the psychic epidemic that swept through Germany under Hitler’s rule:

“The phenomenon we have witnessed in Germany was nothing less than [an] outbreak of epidemic insanity. . . No one knew what was happening to him, least of all of the Germans, who allowed themselves to be driven to the slaughterhouse by their leading psychopaths like hypnotized sheep.”

Carl Jung, After the Catastrophe

But what gives rise to a mass psychosis? And what makes a society susceptible to this devastating phenomenon? For an answer we must begin at the basics. We must explain what is meant by a psychosis and what leads an individual into a state of madness. With this information we can then examine how this process plays out on a mass scale.

A psychosis can be defined as a detachment from reality or the loss of an adaptive relationship to reality. In place of thoughts and beliefs that conform to the facts of the world the psychotic becomes overrun by delusions which are false beliefs considered to be true despite the existence of evidence that proves the contrary. Delusion, writes Joost Meerloo can be defined as

“…the loss of an independent, verifiable reality, with the consequent relapse into a more primitive stage of awareness.”

Joost Meerloo, The Rape of the Mind

Delusions can take many forms. Some psychotics develop delusions of paranoia and believe they are constantly being followed, tracked and observed. Others, such as catatonic schizophrenics, develop delusions about their ability to alter the state of the universe merely with the movement of their body and so remain constricted in statue like poses. But while delusions are false in the sense of not conforming to the facts of the external world, they are considered true to the psychotic and so influence how they interact with the world and with other people, or as Jung writes:

“If a man imagined that I was his arch-enemy and killed me, I should be dead on account of mere imagination. Imaginary conditions do exist and they may be just as real and just as harmful or dangerous as physical conditions. I even believe that psychic disturbances are far more dangerous than epidemics [of physical disease] or earthquakes.”

Carl Jung, Psychology and Religion

While a descent into the delusions of a psychosis has many triggers such as an excessive use of drugs or alcohol, brain injuries and other illnesses, these physical causes will not concern us here. Our concern is with psychological, or what are called psychogenic triggers, as these are usually what lead to the mass psychosis. The most prevalent psychogenic cause of a psychosis is a flood of negative emotions, such as fear or anxiety, that drives an individual into a state of panic. When in a state of panic one naturally seeks relief as it is too mentally and physically draining to subsist in this hyper-emotional state for a prolonged period of time. To escape the fear and anxiety of the panic state a positive or negative reaction can take place and the positive reaction takes the following form:

A greater effort is called forth. The individual will show more strength and will-power and will try to overcome the obstacle or the cause of misery through physical, intellectual, and moral effort. . .If the strength of one individual is not sufficient he will seek the help of others. . .If such an ultimate attempt fails, or if an individual is too weak from the start to show fight, then a negative reaction takes place.”

Carl Jung, Psychology and National Problems

At the extreme, the negative reaction is a psychotic break. A psychotic break is not a descent into a state of greater disorder as many believe, but a re-ordering of one’s experiential world which blends fact and fiction, or delusions and reality, in a way that helps end the feelings of panic. Silvano Arieti, one of the 20 th century’s foremost authorities on schizophrenia, explains the psychogenic steps that lead to madness: firstly there is

“…[the] phase of panic – when the patient starts to perceive things in a different way, is frightened on account of it, appears confused, and does not know how to explain “the strange things that are happening.”

Silvano Arieti, Interpretation of Schizophrenia

The next step is what Arieti calls a phase of psychotic insight, whereby an individual

“…succeeds in “putting things together” [b]y devising a pathological way of seeing reality, [which allows him] to explain his abnormal experiences. The phenomenon is called “insight” because the patient finally sees meaning and relations in his experiences. . .”

Silvano Arieti, Interpretation of Schizophrenia

But the insight is psychotic because it is based on delusions not on adaptive and life-promoting ways of relating to whatever threats precipitated the panic. The delusions, in other words, allow the panic-stricken individual to escape from the flood of negative emotions, but at the cost of losing touch with reality and for this reason Arieti says that a psychotic break can be viewed as “an abnormal way of dealing with an extreme state of anxiety. . .” The American psychologist Alexander Lowen echoes this sentiment:

“Two factors are important [in the dynamics of a psychotic break]:” he writes “one is an ego that is weak or insecure. . The other factor is a flood of feeling that cannot be integrated by the ego.”

Alexander Lowen, The Voice of the Body

When it is understood that a flood of negative emotions, in conjunction with a weak and insecure sense of self, can trigger a descent into madness it becomes clear how a mass psychosis can occur. A population first needs to be induced into a state of intense fear or anxiety by threats real, imagined, or fabricated and once in a state of panic the door is open for either the positive or negative reaction to unfold. If a society is composed of self-reliant, resilient and inwardly strong individuals a positive reaction can take place, but if it is composed of mainly weak, insecure and helpless individuals a descent into the delusions of a mass psychosis becomes a real possibility. Great stress, in other words, can bring out the best in an individual or society at large, but it can also bring out the worst, or as the psychologist Anthony Storr writes about the potential for a mass psychosis:

“. . .it is only if we accept the existence of a latent paranoid potential lurking in the recesses of the normal mind that we can explain the mass delusions which led to the persecution of witches and the Nazi slaughter of Jews. Vast numbers of ordinary men and women held beliefs about witches and Jews which, if they had been expressed by one or two individuals instead of by whole communities, would have been dismissed as paranoid delusions. There are extremely primitive, irrational mental forces at work in the minds of all of us which are usually overlaid and controlled by reason, but which find overt expression in the behaviour of those whom we call mentally ill, and which also manifest themselves in the behaviour of normal people when under threat or other forms of stress.”

Anthony Storr, Solitude: A Return to the Self

In the next video of the series we will explore how certain ideas, or what the Russian author Fyodor Dostoevsky called demons, can induce a societal-wide flood of negative emotions and therefore pave the way for a mass psychosis. Ideas, as we will learn, are so powerful that at times they can posses us, consume us or even destroy us. Those who control the flow of information in a society, and the ideas we accept as true or false, exert a great power over the course of civilization.

“It was not you who ate the idea, but the idea that ate you.”

Fyodor Dostoevsky, Demons

“Once upon a time men were possessed by devils, now they are not less obsessed by ideas. . .”

Carl Jung, Psychology and Religion


Hallucinations Edit

A hallucination is defined as sensory perception in the absence of external stimuli. Hallucinations are different from illusions and perceptual distortions, which are the misperception of external stimuli. Hallucinations may occur in any of the senses and take on almost any form. They may consist of simple sensations (such as lights, colors, sounds, tastes, or smells) or more detailed experiences (such as seeing and interacting with animals and people, hearing voices, and having complex tactile sensations). Hallucinations are generally characterized as being vivid and uncontrollable. [16] Auditory hallucinations, particularly experiences of hearing voices, are the most common and often prominent feature of psychosis.

Up to 15% of the general population may experience auditory hallucinations (though not all are due to psychosis). The prevalence of auditory hallucinations in patients with schizophrenia is generally put around 70%, but may go as high as 98%. Reported prevalence in bipolar disorder ranges between 11% and 68%. [17] During the early 20th century, auditory hallucinations were second to visual hallucinations in frequency, but they are now the most common manifestation of schizophrenia, although rates vary between cultures and regions. Auditory hallucinations are most commonly intelligible voices. When voices are present, the average number has been estimated at three. Content, like frequency, differs significantly, especially across cultures and demographics. People who experience auditory hallucinations can frequently identify the loudness, location of origin, and may settle on identities for voices. Western cultures are associated with auditory experiences concerning religious content, frequently related to sin. Hallucinations may command a person to do something potentially dangerous when combined with delusions. [18]

Extracampine hallucinations are perceptions outside the normal sensory apparatus, such as the perception of sound through the knee. [18] Visual extracampine hallucinations include seeing persons nearby that are not there. [19]

Visual hallucinations occur in roughly a third of people with schizophrenia, although rates as high as 55% are reported. The prevalence in bipolar disorder is around 15%. Content commonly involves animate objects, although perceptual abnormalities such as changes in lighting, shading, streaks, or lines may be seen. Visual abnormalities may conflict with proprioceptive information, and visions may include experiences such as the ground tilting. Lilliputian hallucinations are less common in schizophrenia, and are more common in various types of encephalopathy such as peduncular hallucinosis. [18]

A visceral hallucination, also called a cenesthetic hallucination, is characterized by visceral sensations in the absence of stimuli. Cenesthetic hallucinations may include sensations of burning, or re-arrangement of internal organs. [18]

Delusions Edit

Psychosis may involve delusional beliefs. A delusion is commonly defined as an unrelenting sense of certainty maintained despite strong contradictory evidence. Delusions are context- and culture-dependent: a belief which inhibits critical functioning and is widely considered delusional in one population may be common (and even adaptive) in another, or in the same population at a later time. Since normative views may contradict available evidence, a belief need not contravene cultural standards in order to be considered delusional.

Prevalence in schizophrenia is generally considered at least 90%, and around 50% in bipolar disorder.

The DSM-5 characterizes certain delusions as "bizarre" if they are clearly implausible, or are incompatible with the surrounding cultural context. The concept of bizarre delusions has many criticisms, the most prominent being judging its presence is not highly reliable even among trained individuals. [18]

A delusion may involve diverse thematic content. The most common type is a persecutory delusion, in which a person believes that an entity seeks to harm them. Others include delusions of reference (the belief that some element of one's experience represents a deliberate and specific act by or message from some other entity), delusions of grandeur (the belief that one possesses special power or influence beyond one's actual limits), thought broadcasting (the belief that one's thoughts are audible) and thought insertion (the belief that one's thoughts are not one's own).

The subject matter of delusions seems to reflect the current culture in a particular time and location. For example in the US, during the early 1900s syphilis was a common topic, during the second world war Germany, during the cold war communists, and in recent years technology has been a focus. [20] Some psychologists, such as those who practice the Open Dialogue method believe that the content of psychosis represents an underlying thought process that may, in part, be responsible for psychosis, [21] though the accepted medical position is that psychosis is due to a brain disorder.

Historically, Karl Jaspers classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions are typically understood as being influenced by the person's background or current situation (e.g., ethnicity also religious, superstitious, or political beliefs). [22]

Disorganization Edit

Disorganization is split into disorganized speech or thinking, and grossly disorganized motor behavior. Disorganized speech or thinking, also called formal thought disorder, is disorganization of thinking that is inferred from speech. Characteristics of disorganized speech include rapidly switching topics, called derailment or loose association switching to topics that are unrelated, called tangential thinking incomprehensible speech, called word salad or incoherence. Disorganized motor behavior includes repetitive, odd, or sometimes purposeless movement. Disorganized motor behavior rarely includes catatonia, and although it was a historically prominent symptom, it is rarely seen today. Whether this is due to historically used treatments or the lack thereof is unknown. [18] [16]

Catatonia describes a profoundly agitated state in which the experience of reality is generally considered impaired. There are two primary manifestations of catatonic behavior. The classic presentation is a person who does not move or interact with the world in any way while awake. This type of catatonia presents with waxy flexibility. Waxy flexibility is when someone physically moves part of a catatonic person's body and the person stays in the position even if it is bizarre and otherwise nonfunctional (such as moving a person's arm straight up in the air and the arm staying there).

The other type of catatonia is more of an outward presentation of the profoundly agitated state described above. It involves excessive and purposeless motor behaviour, as well as extreme mental preoccupation that prevents an intact experience of reality. An example is someone walking very fast in circles to the exclusion of anything else with a level of mental preoccupation (meaning not focused on anything relevant to the situation) that was not typical of the person prior to the symptom onset. In both types of catatonia there is generally no reaction to anything that happens outside of them. It is important to distinguish catatonic agitation from severe bipolar mania, although someone could have both.

Negative symptoms Edit

Negative symptoms include reduced emotional expression, decreased motivation, and reduced spontaneous speech. Afflicted individuals lack interest and spontaneity, and have the inability to feel pleasure. [23]

Psychosis in adolescents Edit

Psychosis is rare in adolescents. [6] Young people who have psychosis may have trouble connecting with the world around them and may experience hallucinations and/or delusions. [6] Adolescents with psychosis may also have cognitive deficits that may make it harder for the youth to socialize and work. [6] Potential impairments include the speed of mental processing, ability to focus without getting distracted (attention span), and problems with their verbal memory. [6]

The symptoms of psychosis may be caused by serious psychiatric disorders such as schizophrenia, a number of medical illnesses, and trauma. Psychosis may also be temporary or transient, and be caused by medications or substance use disorder (substance-induced psychosis).

Normal states Edit

Brief hallucinations are not uncommon in those without any psychiatric disease. Causes or triggers include: [24]

  • Falling asleep and waking: hypnagogic and hypnopompic hallucinations, which are entirely normal [25] , in which hallucinations of a deceased loved one are common [24]
  • Severe sleep deprivation[26][27][28]
  • Extreme stress [29]

Trauma Edit

Traumatic life events have been linked with an elevated risk in developing psychotic symptoms. [30] Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis. [31] Approximately 65% of individuals with psychotic symptoms have experienced childhood trauma (e.g., physical or sexual abuse, physical or emotional neglect). [32] Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods. [31] Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent in which multiple traumatic life events accumulate, compounding symptom expression and severity. [30] [31] This suggests trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects. [30]

Psychiatric disorder Edit

From a diagnostic standpoint, organic disorders were believed to be caused by physical illness affecting the brain (that is, psychiatric disorders secondary to other conditions) while functional disorders were considered disorders of the functioning of the mind in the absence of physical disorders (that is, primary psychological or psychiatric disorders). Subtle physical abnormalities have been found in illnesses traditionally considered functional, such as schizophrenia. The DSM-IV-TR avoids the functional/organic distinction, and instead lists traditional psychotic illnesses, psychosis due to general medical conditions, and substance-induced psychosis.

Primary psychiatric causes of psychosis include the following: [33] [34] [24]

    and schizophreniform disorder
  • affective (mood) disorders, including major depression, and severe depression or mania in bipolar disorder (manic depression). People experiencing a psychotic episode in the context of depression may experience persecutory or self-blaming delusions or hallucinations, while people experiencing a psychotic episode in the context of mania may form grandiose delusions. , involving symptoms of both schizophrenia and mood disorders , or acute/transient psychotic disorder (persistent delusional disorder)

Psychotic symptoms may also be seen in: [24]

Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks. [36] In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times.

Neuroticism is an independent predictor of the development of psychosis. [37]

Subtypes Edit

Subtypes of psychosis include:

    , including circa-mensual (approximately monthly) periodicity, in rhythm with the menstrual cycle. , occurring shortly after giving birth

Cycloid psychosis Edit

Cycloid psychosis is a psychosis that progresses from normal to full-blown, usually between a few hours to days, not related to drug intake or brain injury. [38] The cycloid psychosis has a long history in European psychiatry diagnosis. The term "cycloid psychosis" was first used by Karl Kleist in 1926. Despite the significant clinical relevance, this diagnosis is neglected both in literature and in nosology. The cycloid psychosis has attracted much interest in the international literature of the past 50 years, but the number of scientific studies have greatly decreased over the past 15 years, possibly partly explained by the misconception that the diagnosis has been incorporated in current diagnostic classification systems. The cycloid psychosis is therefore only partially described in the diagnostic classification systems used. Cycloid psychosis is nevertheless its own specific disease that is distinct from both the manic-depressive disorder, and from schizophrenia, and this despite the fact that the cycloid psychosis can include both bipolar (basic mood shifts) as well as schizophrenic symptoms. The disease is an acute, usually self-limiting, functionally psychotic state, with a very diverse clinical picture that almost consistently is characterized by the existence of some degree of confusion or distressing perplexity, but above all, of the multifaceted and diverse expressions the disease takes. The main features of the disease is thus that the onset is acute, contains the multifaceted picture of symptoms and typically reverses to a normal state and that the long-term prognosis is good. In addition, diagnostic criteria include at least four of the following symptoms: [38]

  • Confusion
  • Mood-incongruent delusions
  • Hallucinations
  • Pan-anxiety, a severe anxiety not bound to particular situations or circumstances
  • Happiness or ecstasy of high degree
  • Motility disturbances of akinetic or hyperkinetic type
  • Concern with death
  • Mood swings to some degree, but less than what is needed for diagnosis of an affective disorder

Cycloid psychosis occurs in people of generally 15–50 years of age. [38]

Medical conditions Edit

A very large number of medical conditions can cause psychosis, sometimes called secondary psychosis. [24] Examples include:

  • disorders causing delirium (toxic psychosis), in which consciousness is disturbed
  • neurodevelopmental disorders and chromosomal abnormalities, including velocardiofacial syndrome
  • neurodegenerative disorders, such as Alzheimer's disease, [39]dementia with Lewy bodies, [40] and Parkinson's disease[41][42]
  • focal neurological disease, such as stroke, brain tumors, [43]multiple sclerosis, [42] and some forms of epilepsy
  • malignancy (typically via masses in the brain, paraneoplastic syndromes) [42]
  • infectious and postinfectious syndromes, including infections causing delirium, viral encephalitis, HIV/AIDS, [44]malaria, [45]syphilis[46]
  • endocrine disease, such as hypothyroidism, hyperthyroidism, Cushing's syndrome, hypoparathyroidism and hyperparathyroidism [47] sex hormones also affect psychotic symptoms and sometimes giving birth can provoke psychosis, termed postpartum psychosis[48]
  • inborn errors of metabolism, such as Succinic semialdehyde dehydrogenase deficiency, porphyria and metachromatic leukodystrophy[49][50][51][52]
  • nutritional deficiency, such as vitamin B12 deficiency[9]
  • other acquired metabolic disorders, including electrolyte disturbances such as hypocalcemia, hypernatremia, [53]hyponatremia, [54]hypokalemia, [55]hypomagnesemia, [56]hypermagnesemia, [57]hypercalcemia, [58] and hypophosphatemia, [59] but also hypoglycemia, [60]hypoxia, and failure of the liver or kidneys and related disorders, such as systemic lupus erythematosus (lupus, SLE), sarcoidosis, Hashimoto's encephalopathy, anti-NMDA-receptor encephalitis, and non-celiac gluten sensitivity[49][61]
  • poisoning, by therapeutic drugs (see below), recreational drugs (see below), and a range of plants, fungi, metals, organic compounds, and a few animal toxins [24]
  • sleep disorders, such as in narcolepsy (in which REM sleep intrudes into wakefulness) [24]
  • parasitic diseases, such as neurocysticercosis

Psychoactive drugs Edit

Various psychoactive substances (both legal and illegal) have been implicated in causing, exacerbating, or precipitating psychotic states or disorders in users, with varying levels of evidence. This may be upon intoxication for a more prolonged period after use, or upon withdrawal. [24] Individuals who experience substance-induced psychosis tend to have a greater awareness of their psychosis and tend to have higher levels of suicidal thinking compared to those who have a primary psychotic illness. [62] Drugs commonly alleged to induce psychotic symptoms include alcohol, cannabis, cocaine, amphetamines, cathinones, psychedelic drugs (such as LSD and psilocybin), κ-opioid receptor agonists (such as enadoline and salvinorin A) and NMDA receptor antagonists (such as phencyclidine and ketamine). [24] [63] Caffeine may worsen symptoms in those with schizophrenia and cause psychosis at very high doses in people without the condition. [64] [65] Cannabis and other illicit recreational drugs are often associated with psychosis in adolescents and cannabis use before 15 years old may increase the risk of psychosis later in life as an adult. [6]

Alcohol Edit

Approximately three percent of people who are suffering from alcoholism experience psychosis during acute intoxication or withdrawal. Alcohol related psychosis may manifest itself through a kindling mechanism. The mechanism of alcohol-related psychosis is due to the long-term effects of alcohol consumption resulting in distortions to neuronal membranes, gene expression, as well as thiamin deficiency. It is possible that hazardous alcohol use via a kindling mechanism can cause the development of a chronic substance-induced psychotic disorder, i.e. schizophrenia. The effects of an alcohol-related psychosis include an increased risk of depression and suicide as well as causing psychosocial impairments. [66] Delirium Tremens, a symptom of chronic alcoholism which can appear in the acute withdraw phase, shares many symptoms with alcohol-related psychosis suggesting a common mechanism. [67] [68]

Cannabis Edit

According to some studies, the more often cannabis is used the more likely a person is to develop a psychotic illness, [69] with frequent use being correlated with twice the risk of psychosis and schizophrenia. [70] [71] While cannabis use is accepted as a contributory cause of schizophrenia by some, [72] it remains controversial, with pre-existing vulnerability to psychosis emerging as the key factor that influences the link between cannabis use and psychosis. [73] [74] Some studies indicate that the effects of two active compounds in cannabis, tetrahydrocannabinol (THC) and cannabidiol (CBD), have opposite effects with respect to psychosis. While THC can induce psychotic symptoms in healthy individuals, CBD may reduce the symptoms caused by cannabis. [75]

Cannabis use has increased dramatically over the past few decades whereas the rate of psychosis has not increased. Together, these findings suggest that cannabis use may hasten the onset of psychosis in those who may already be predisposed to psychosis. [76] High-potency cannabis use indeed seems to accelerate the onset of psychosis in predisposed patients. [77] A 2012 study concluded that cannabis plays an important role in the development of psychosis in vulnerable individuals, and that cannabis use in early adolescence should be discouraged. [78]

Methamphetamine Edit

Methamphetamine induces a psychosis in 26–46 percent of heavy users. Some of these people develop a long-lasting psychosis that can persist for longer than six months. Those who have had a short-lived psychosis from methamphetamine can have a relapse of the methamphetamine psychosis years later after a stressful event such as severe insomnia or a period of hazardous alcohol use despite not relapsing back to methamphetamine. [79] Individuals who have a long history of methamphetamine use and who have experienced psychosis in the past from methamphetamine use are highly likely to re-experience methamphetamine psychosis if drug use is recommenced. Methamphetamine-induced psychosis is likely gated by genetic vulnerability, which can produce long-term changes in brain neurochemistry following repetitive use. [80]

Medication Edit

Administration, or sometimes withdrawal, of a large number of medications may provoke psychotic symptoms. [24] Drugs that can induce psychosis experimentally or in a significant proportion of people include amphetamine and other sympathomimetics, dopamine agonists, ketamine, corticosteroids (often with mood changes in addition), and some anticonvulsants such as vigabatrin. [24] [81] Stimulants that may cause this include lisdexamfetamine. [82] and Desoxyn, a prescription formulation of Methamphetamine Hydrochloride. [83]

Medication may induce psychological side-effects, including depersonalization, derealization and psychotic symptoms like hallucinations as well as mood disturbances. [84]

Neuroimaging Edit

The first brain image of an individual with psychosis was completed as far back as 1935 using a technique called pneumoencephalography [85] (a painful and now obsolete procedure where cerebrospinal fluid is drained from around the brain and replaced with air to allow the structure of the brain to show up more clearly on an X-ray picture).

Both first episode psychosis, and high risk status is associated with reductions in grey matter volume (GMV). First episode psychotic and high risk populations are associated with similar but distinct abnormalities in GMV. Reductions in the right middle temporal gyrus, right superior temporal gyrus (STG), right parahippocampus, right hippocampus, right middle frontal gyrus, and left anterior cingulate cortex (ACC) are observed in high risk populations. Reductions in first episode psychosis span a region from the right STG to the right insula, left insula, and cerebellum, and are more severe in the right ACC, right STG, insula and cerebellum. [86] [87]

Another meta analysis reported bilateral reductions in insula, operculum, STG, medial frontal cortex, and ACC, but also reported increased GMV in the right lingual gyrus and left precentral gyrus. [88] The Kraepelinian dichotomy is made questionable [ clarification needed ] by grey matter abnormalities in bipolar and schizophrenia schizophrenia is distinguishable from bipolar in that regions of grey matter reduction are generally larger in magnitude, although adjusting for gender differences reduces the difference to the left dorsomedial prefrontal cortex, and right dorsolateral prefrontal cortex. [89]

During attentional tasks, first episode psychosis is associated with hypoactivation in the right middle frontal gyrus, a region generally described as encompassing the dorsolateral prefrontal cortex (dlPFC). In congruence with studies on grey matter volume, hypoactivity in the right insula, and right inferior parietal lobe is also reported. [90] During cognitive tasks, hypoactivities in the right insula, dACC, and the left precuneus, as well as reduced deactivations in the right basal ganglia, right thalamus, right inferior frontal and left precentral gyri are observed. These results are highly consistent and replicable possibly except the abnormalities of the right inferior frontal gyrus. [91] Decreased grey matter volume in conjunction with bilateral hypoactivity is observed in anterior insula, dorsal medial frontal cortex, and dorsal ACC. Decreased grey matter volume and bilateral hyperactivity is reported in posterior insula, ventral medial frontal cortex, and ventral ACC. [92]

Hallucinations Edit

Studies during acute experiences of hallucinations demonstrate increased activity in primary or secondary sensory cortices. As auditory hallucinations are most common in psychosis, most robust evidence exists for increased activity in the left middle temporal gyrus, left superior temporal gyrus, and left inferior frontal gyrus (i.e. Broca's area). Activity in the ventral striatum, hippocampus, and ACC are related to the lucidity of hallucinations, and indicate that activation or involvement of emotional circuitry are key to the impact of abnormal activity in sensory cortices. Together, these findings indicate abnormal processing of internally generated sensory experiences, coupled with abnormal emotional processing, results in hallucinations. One proposed model involves a failure of feedforward networks from sensory cortices to the inferior frontal cortex, which normally cancel out sensory cortex activity during internally generated speech. The resulting disruption in expected and perceived speech is thought to produce lucid hallucinatory experiences. [93]

Delusions Edit

The two-factor model of delusions posits that dysfunction in both belief formation systems and belief evaluation systems are necessary for delusions. Dysfunction in evaluations systems localized to the right lateral prefrontal cortex, regardless of delusion content, is supported by neuroimaging studies and is congruent with its role in conflict monitoring in healthy persons. Abnormal activation and reduced volume is seen in people with delusions, as well as in disorders associated with delusions such as frontotemporal dementia, psychosis and Lewy body dementia. Furthermore, lesions to this region are associated with "jumping to conclusions", damage to this region is associated with post-stroke delusions, and hypometabolism this region associated with caudate strokes presenting with delusions.

The aberrant salience model suggests that delusions are a result of people assigning excessive importance to irrelevant stimuli. In support of this hypothesis, regions normally associated with the salience network demonstrate reduced grey matter in people with delusions, and the neurotransmitter dopamine, which is widely implicated in salience processing, is also widely implicated in psychotic disorders.

Specific regions have been associated with specific types of delusions. The volume of the hippocampus and parahippocampus is related to paranoid delusions in Alzheimer's disease, and has been reported to be abnormal post mortem in one person with delusions. Capgras delusions have been associated with occipito-temporal damage, and may be related to failure to elicit normal emotions or memories in response to faces. [94]

Negative symptoms Edit

Psychosis is associated with ventral striatal hypoactivity during reward anticipation and feedback. Hypoactivity in the left ventral striatum is correlated with the severity of negative symptoms. [95] While anhedonia is a commonly reported symptom in psychosis, hedonic experiences are actually intact in most people with schizophrenia. The impairment that may present itself as anhedonia probably actually lies in the inability to identify goals, and to identify and engage in the behaviors necessary to achieve goals. [96] Studies support a deficiency in the neural representation of goals and goal directed behavior by demonstrating that receipt (not anticipation) of reward is associated with a robust response in the ventral striatum reinforcement learning is intact when contingencies about stimulus-reward are implicit, but not when they require explicit neural processing reward prediction errors (during functional neuroimaging studies), particularly positive PEs are abnormal. A positive prediction error response occurs when there is an increased activation in a brain region, typically the striatum, in response to unexpected rewards. A negative prediction error response occurs when there is a decreased activation in a region when predicted rewards do not occur. [96] ACC response, taken as an indicator of effort allocation, does not increase with reward or reward probability increase, and is associated with negative symptoms deficits in dlPFC activity and failure to improve performance on cognitive tasks when offered monetary incentives are present and dopamine mediated functions are abnormal. [96]

Neurobiology Edit

Psychosis has been traditionally linked to the overactivity of the neurotransmitter dopamine. In particular to its effect in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine receptor D2 blocking drugs (i.e., antipsychotics) tend to reduce the intensity of psychotic symptoms, and that drugs that accentuate dopamine release, or inhibit its reuptake (such as amphetamines and cocaine) can trigger psychosis in some people (see stimulant psychosis). [97]

NMDA receptor dysfunction has been proposed as a mechanism in psychosis. [98] This theory is reinforced by the fact that dissociative NMDA receptor antagonists such as ketamine, PCP and dextromethorphan (at large overdoses) induce a psychotic state. The symptoms of dissociative intoxication are also considered to mirror the symptoms of schizophrenia, including negative symptoms. [99] NMDA receptor antagonism, in addition to producing symptoms reminiscent of psychosis, mimics the neurophysiological aspects, such as reduction in the amplitude of P50, P300, and MMN evoked potentials. [100] Hierarchical Bayesian neurocomputational models of sensory feedback, in agreement with neuroimaging literature, link NMDA receptor hypofunction to delusional or hallucinatory symptoms via proposing a failure of NMDA mediated top down predictions to adequately cancel out enhanced bottom up AMPA mediated predictions errors. [101] Excessive prediction errors in response to stimuli that would normally not produce such a response is thought to root from conferring excessive salience to otherwise mundane events. [102] Dysfunction higher up in the hierarchy, where representation is more abstract, could result in delusions. [103] The common finding of reduced GAD67 expression in psychotic disorders may explain enhanced AMPA mediated signaling, caused by reduced GABAergic inhibition. [104] [105]

The connection between dopamine and psychosis is generally believed to be complex. While dopamine receptor D2 suppresses adenylate cyclase activity, the D1 receptor increases it. If D2-blocking drugs are administered, the blocked dopamine spills over to the D1 receptors. The increased adenylate cyclase activity affects genetic expression in the nerve cell, which takes time. Hence antipsychotic drugs take a week or two to reduce the symptoms of psychosis. Moreover, newer and equally effective antipsychotic drugs actually block slightly less dopamine in the brain than older drugs whilst also blocking 5-HT2A receptors, suggesting the 'dopamine hypothesis' may be oversimplified. [106] Soyka and colleagues found no evidence of dopaminergic dysfunction in people with alcohol-induced psychosis [107] and Zoldan et al. reported moderately successful use of ondansetron, a 5-HT3 receptor antagonist, in the treatment of levodopa psychosis in Parkinson's disease patients. [108]

A review found an association between a first-episode of psychosis and prediabetes. [109]

Prolonged or high dose use of psychostimulants can alter normal functioning, making it similar to the manic phase of bipolar disorder. [110] NMDA antagonists replicate some of the so-called "negative" symptoms like thought disorder in subanesthetic doses (doses insufficient to induce anesthesia), and catatonia in high doses). Psychostimulants, especially in one already prone to psychotic thinking, can cause some "positive" symptoms, such as delusional beliefs, particularly those persecutory in nature.

To make a diagnosis of a mental illness in someone with psychosis other potential causes must be excluded. [111] An initial assessment includes a comprehensive history and physical examination by a health care provider. Tests may be done to exclude substance use, medication, toxins, surgical complications, or other medical illnesses. A person with psychosis is referred to as psychotic.

Delirium should be ruled out, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, indicating other underlying factors, including medical illnesses. [112] Excluding medical illnesses associated with psychosis is performed by using blood tests to measure:

    to exclude hypo- or hyperthyroidism, and serum calcium to rule out a metabolic disturbance, including ESR to rule out a systemic infection or chronic disease, and to exclude syphilis or HIV infection.

Other investigations include:

Because psychosis may be precipitated or exacerbated by common classes of medications, medication-induced psychosis should be ruled out, particularly for first-episode psychosis. Both substance- and medication-induced psychosis can be excluded to a high level of certainty, using toxicology screening.

Because some dietary supplements may also induce psychosis or mania, but cannot be ruled out with laboratory tests, a psychotic individual's family, partner, or friends should be asked whether the patient is currently taking any dietary supplements. [113]

Common mistakes made when diagnosing people who are psychotic include: [111]

  • Not properly excluding delirium,
  • Not appreciating medical abnormalities (e.g., vital signs),
  • Not obtaining a medical history and family history,
  • Indiscriminate screening without an organizing framework,
  • Missing a toxic psychosis by not screening for substances and medications,
  • Not asking their family or others about dietary supplements,
  • Premature diagnostic closure, and
  • Not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder.

Only after relevant and known causes of psychosis are excluded, a mental health clinician may make a psychiatric differential diagnosis using a person's family history, incorporating information from the person with psychosis, and information from family, friends, or significant others.

Types of psychosis in psychiatric disorders may be established by formal rating scales. The Brief Psychiatric Rating Scale (BPRS) [114] assesses the level of 18 symptom constructs of psychosis such as hostility, suspicion, hallucination, and grandiosity. It is based on the clinician's interview with the patient and observations of the patient's behavior over the previous 2–3 days. The patient's family can also answer questions on the behavior report. During the initial assessment and the follow-up, both positive and negative symptoms of psychosis can be assessed using the 30 item Positive and Negative Symptom Scale (PANSS). [115]

The DSM-5 characterizes disorders as psychotic or on the schizophrenia spectrum if they involve hallucinations, delusions, disorganized thinking, grossly disorganized motor behavior, or negative symptoms. [16] The DSM-5 does not include psychosis as a definition in the glossary, although it defines "psychotic features", as well as "psychoticism" with respect to personality disorder. The ICD-10 has no specific definition of psychosis. [116]

Factor analysis of symptoms generally regarded as psychosis frequently yields a five factor solution, albeit five factors that are distinct from the five domains defined by the DSM-5 to encompass psychotic or schizophrenia spectrum disorders. The five factors are frequently labeled as hallucinations, delusions, disorganization, excitement, and emotional distress. [116] The DSM-5 emphasizes a psychotic spectrum, wherein the low end is characterized by schizoid personality disorder, and the high end is characterized by schizophrenia. [42]

The evidence for the effectiveness of early interventions to prevent psychosis appeared inconclusive. [117] But psychosis caused by drugs can be prevented. [118] Whilst early intervention in those with a psychotic episode might improve short-term outcomes, little benefit was seen from these measures after five years. [119] However, there is evidence that cognitive behavioral therapy (CBT) may reduce the risk of becoming psychotic in those at high risk, [120] and in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT for people at risk of psychosis. [121] [122]

The treatment of psychosis depends on the specific diagnosis (such as schizophrenia, bipolar disorder or substance intoxication). The first-line treatment for many psychotic disorders is antipsychotic medication, [123] which can reduce the positive symptoms of psychosis in about 7 to 14 days. For youth or adolescents, treatment options include medications, psychological interventions, and social interventions. [6]

Medication Edit

The choice of which antipsychotic to use is based on benefits, risks, and costs. [119] It is debatable whether, as a class, typical or atypical antipsychotics are better. [124] [125] Tentative evidence supports that amisulpride, olanzapine, risperidone and clozapine may be more effective for positive symptoms but result in more side effects. [126] Typical antipsychotics have equal drop-out and symptom relapse rates to atypicals when used at low to moderate dosages. [127] There is a good response in 40–50%, a partial response in 30–40%, and treatment resistance (failure of symptoms to respond satisfactorily after six weeks to two or three different antipsychotics) in 20% of people. [128] Clozapine is an effective treatment for those who respond poorly to other drugs ("treatment-resistant" or "refractory" schizophrenia), [129] but it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people. [119] [130] [131]

Most people on antipsychotics get side effects. People on typical antipsychotics tend to have a higher rate of extrapyramidal side effects while some atypicals are associated with considerable weight gain, diabetes and risk of metabolic syndrome this is most pronounced with olanzapine, while risperidone and quetiapine are also associated with weight gain. [126] Risperidone has a similar rate of extrapyramidal symptoms to haloperidol. [126]

Counseling Edit

Psychological treatments such as acceptance and commitment therapy (ACT) are possibly useful in the treatment of psychosis, helping people to focus more on what they can do in terms of valued life directions despite challenging symptomology. [132]

There are psychological interventions that seek to treat the symptoms of psychosis. In a 2019 review, nine classes of psychosocial interventions were identified: need adapted treatment, open dialogue, psychoanalysis/psychodynamic psychotherapy, major role therapy, soteria, psychosocial outpatient and inpatient treatment, milieu therapy, and CBT. This paper concluded that when on minimal or no medication "the overall evidence supporting the effectiveness of these interventions is generally weak". [133]

Early intervention Edit

Early intervention in psychosis is based on the observation that identifying and treating someone in the early stages of a psychosis can improve their longer term outcome. [134] This approach advocates the use of an intensive multi-disciplinary approach during what is known as the critical period, where intervention is the most effective, and prevents the long-term morbidity associated with chronic psychotic illness.

Etymology Edit

The word psychosis was introduced to the psychiatric literature in 1841 by Karl Friedrich Canstatt in his work Handbuch der Medizinischen Klinik. He used it as a shorthand for 'psychic neurosis'. At that time neurosis meant any disease of the nervous system, and Canstatt was thus referring to what was considered a psychological manifestation of brain disease. [135] Ernst von Feuchtersleben is also widely credited as introducing the term in 1845, [136] as an alternative to insanity and mania.

The term stems from Modern Latin psychosis, "a giving soul or life to, animating, quickening" and that from Ancient Greek ψυχή (psyche), "soul" and the suffix -ωσις (-osis), in this case "abnormal condition". [137] [138]

In its adjective form "psychotic", references to psychosis can be found in both clinical and non-clinical discussions. However, in a non-clinical context, "psychotic" is generally used as a synonym for "insane".

Classification Edit

The word was also used to distinguish a condition considered a disorder of the mind, as opposed to neurosis, which was considered a disorder of the nervous system. [139] The psychoses thus became the modern equivalent of the old notion of madness, and hence there was much debate on whether there was only one (unitary) or many forms of the new disease. [140] One type of broad usage would later be narrowed down by Koch in 1891 to the 'psychopathic inferiorities'—later renamed abnormal personalities by Schneider. [135]

The division of the major psychoses into manic depressive illness (now called bipolar disorder) and dementia praecox (now called schizophrenia) was made by Emil Kraepelin, who attempted to create a synthesis of the various mental disorders identified by 19th-century psychiatrists, by grouping diseases together based on classification of common symptoms. Kraepelin used the term 'manic depressive insanity' to describe the whole spectrum of mood disorders, in a far wider sense than it is usually used today.

In Kraepelin's classification this would include 'unipolar' clinical depression, as well as bipolar disorder and other mood disorders such as cyclothymia. These are characterised by problems with mood control and the psychotic episodes appear associated with disturbances in mood, and patients often have periods of normal functioning between psychotic episodes even without medication. Schizophrenia is characterized by psychotic episodes that appear unrelated to disturbances in mood, and most non-medicated patients show signs of disturbance between psychotic episodes.

Treatment Edit

Early civilizations considered madness a supernaturally inflicted phenomenon. Archaeologists have unearthed skulls with clearly visible drillings, some datable back to 5000 BC suggesting that trepanning was a common treatment for psychosis in ancient times. [141] Written record of supernatural causes and resultant treatments can be traced back to the New Testament. Mark 5:8–13 describes a man displaying what would today be described as psychotic symptoms. Christ cured this "demonic madness" by casting out the demons and hurling them into a herd of swine. Exorcism is still utilized in some religious circles as a treatment for psychosis presumed to be demonic possession. [142] A research study of out-patients in psychiatric clinics found that 30 percent of religious patients attributed the cause of their psychotic symptoms to evil spirits. Many of these patients underwent exorcistic healing rituals that, though largely regarded as positive experiences by the patients, had no effect on symptomology. Results did, however, show a significant worsening of psychotic symptoms associated with exclusion of medical treatment for coercive forms of exorcism. [143]

The medical teachings of the fourth-century philosopher and physician Hippocrates of Cos proposed a natural, rather than supernatural, cause of human illness. In Hippocrates' work, the Hippocratic corpus, a holistic explanation for health and disease was developed to include madness and other "diseases of the mind." Hippocrates writes:

Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter, and jests, as well as our sorrows, pains, griefs and tears. Through it, in particular, we think, see, hear, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant…. It is the same thing which makes us mad or delirious, inspires us with dread and fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absentmindedness, and acts that are contrary to habit. [144]

Hippocrates espoused a theory of humoralism wherein disease is resultant of a shifting balance in bodily fluids including blood, phlegm, black bile, and yellow bile. [145] According to humoralism, each fluid or "humour" has temperamental or behavioral correlates. In the case of psychosis, symptoms are thought to be caused by an excess of both blood and yellow bile. Thus, the proposed surgical intervention for psychotic or manic behavior was bloodletting. [146]

18th-century physician, educator, and widely considered "founder of American psychiatry", Benjamin Rush, also prescribed bloodletting as a first-line treatment for psychosis. Although not a proponent of humoralism, Rush believed that active purging and bloodletting were efficacious corrections for disruptions in the circulatory system, a complication he believed was the primary cause of "insanity". [147] Although Rush's treatment modalities are now considered antiquated and brutish, his contributions to psychiatry, namely the biological underpinnings of psychiatric phenomenon including psychosis, have been invaluable to the field. In honor of such contributions, Benjamin Rush's image is in the official seal of the American Psychiatric Association.

Early 20th-century treatments for severe and persisting psychosis were characterized by an emphasis on shocking the nervous system. Such therapies include insulin shock therapy, cardiazol shock therapy, and electroconvulsive therapy. [148] Despite considerable risk, shock therapy was considered highly efficacious in the treatment of psychosis including schizophrenia. The acceptance of high-risk treatments led to more invasive medical interventions including psychosurgery. [149]

In 1888, Swiss psychiatrist Gottlieb Burckhardt performed the first medically sanctioned psychosurgery in which the cerebral cortex was excised. Although some patients showed improvement of symptoms and became more subdued, one patient died and several developed aphasia or seizure disorders. Burckhardt would go on to publish his clinical outcomes in a scholarly paper. This procedure was met with criticism from the medical community and his academic and surgical endeavors were largely ignored. [150] In the late 1930s, Egas Moniz conceived the leucotomy (AKA prefrontal lobotomy) in which the fibers connecting the frontal lobes to the rest of the brain were severed. Moniz's primary inspiration stemmed from a demonstration by neuroscientists John Fulton and Carlyle's 1935 experiment in which two chimpanzees were given leucotomies and pre- and post-surgical behavior was compared. Prior to the leucotomy, the chimps engaged in typical behavior including throwing feces and fighting. After the procedure, both chimps were pacified and less violent. During the Q&A, Moniz asked if such a procedure could be extended to human subjects, a question that Fulton admitted was quite startling. [151] Moniz would go on to extend the controversial practice to humans suffering from various psychotic disorders, an endeavor for which he received a Nobel Prize in 1949. [152] Between the late 1930s and early 1970s, the leucotomy was a widely accepted practice, often performed in non-sterile environments such as small outpatient clinics and patient homes. [151] Psychosurgery remained standard practice until the discovery of antipsychotic pharmacology in the 1950s. [153]

The first clinical trial of antipsychotics (also commonly known as neuroleptics) for the treatment of psychosis took place in 1952. Chlorpromazine (brand name: Thorazine) passed clinical trials and became the first antipsychotic medication approved for the treatment of both acute and chronic psychosis. Although the mechanism of action was not discovered until 1963, the administration of chlorpromazine marked the advent of the dopamine antagonist, or first generation antipsychotic. [154] While clinical trials showed a high response rate for both acute psychosis and disorders with psychotic features, the side effects were particularly harsh, which included high rates of often irreversible Parkinsonian symptoms such as tardive dyskinesia. With the advent of atypical antipsychotics (also known as second generation antipsychotics) came a dopamine antagonist with a comparable response rate but a far different, though still extensive, side-effect profile that included a lower risk of Parkinsonian symptoms but a higher risk of cardiovascular disease. [155] Atypical antipsychotics remain the first-line treatment for psychosis associated with various psychiatric and neurological disorders including schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, dementia, and some autism spectrum disorders. [156]

Dopamine is now one of the primary neurotransmitters implicated in psychotic symptomology. Blocking dopamine receptors (namely, the dopamine D2 receptors) and decreasing dopaminergic activity continues to be an effective but highly unrefined effect of antipsychotics, which are commonly used to treat psychosis. Recent pharmacological research suggests that the decrease in dopaminergic activity does not eradicate psychotic delusions or hallucinations, but rather attenuates the reward mechanisms involved in the development of delusional thinking that is, connecting or finding meaningful relationships between unrelated stimuli or ideas. [97] The author of this research paper acknowledges the importance of future investigation:

The model presented here is based on incomplete knowledge related to dopamine, schizophrenia, and antipsychotics—and as such will need to evolve as more is known about these.

Freud's former student Wilhelm Reich explored independent insights into the physical effects of neurotic and traumatic upbringing, and published his holistic psychoanalytic treatment with a schizophrenic. With his incorporation of breathwork and insight with the patient, a young woman, she achieved sufficient self-management skills to end the therapy. [157]

Lacan extended Freud's ideas to create a psychoanalytic model of psychosis based upon the concept of "foreclosure", the rejection of the symbolic concept of the father.

Society Edit

Psychiatrist David Healy has criticised pharmaceutical companies for promoting simplified biological theories of mental illness that seem to imply the primacy of pharmaceutical treatments while ignoring social and developmental factors that are known important influences in the etiology of psychosis. [158]

Further research in the form of randomized controlled trials is needed to determine the effectiveness of treatment approaches for helping adolescents with psychosis. [6]

Roland Littlewood, BSc, MBBS, FRCPsych, DipSocAnthrop, D.Phil, D.Litt., DSc, is Professor of Anthropology and Psychiatry, and a Crabtree Scholar at University College London. He is an Honorary Consultant Psychiatrist, has carried out fieldwork in Trinidad, Haiti, Albania, Lebanon and Italy, and is a Past-President at the Royal Anthropological Institute.

Simon Dein, BSc, MSc, MBBS, PhD, MRCPsych, is a Senior Lecturer in Anthropology and Medicine at University College London. He is a part-time psychiatrist working in the NHS. He has written extensively on religion and health and on millennialism in Judaism and is the author of Religion and Healing Among The Lubavitch Community Of Stamford Hill: A Case Study in Hasidism. He is Chair of the Master's Degree Programme in Culture and Health at University College London and is Visiting Professor in Psychology at Glendwyr University, Wales. He is one of the editors of the journal Mental Health, Religion and Culture.

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