Some of the most serious and pernicious psychological disorders are psychotic disorders. While many are familiar with schizophrenia, there are several other types of psychotic disorders, along with other mental and medical disorders that can produce psychotic features. It’s important to understand these psychological conditions for better treatment outcomes, and to reduce the stigma that people with psychotic disorders often have to endure.
Psychotic symptoms and features can make any mental health condition worse and often more difficult to treat effectively. In particular, suicide can be of great concern when someone has some form of psychosis. Suicide is not limited just to people who suffer depression, but potentially anyone who displays symptoms.
Key Features of Psychotic Disorders
The symptoms of psychosis can present themselves in different ways depending on the specific mental disorder diagnosis. In every case, psychotic disorders typically result in profound changes in a person’s ability to function adequately in daily life.
Psychotic disorders, or more generally known as psychosis, are defined by the existence of one or more of these key features:1
Delusions
Delusions are false beliefs that are generally fixed and not immediately changed, even when a person with these beliefs is presented with conflicting evidence. Delusional thought patterns can have a variety of themes.
- People with persecutory delusions develop ideas that various people, groups, agencies, or institutions are working to harm or injure that individual in some way.
- Related to persecution, referential delusions occur when someone believes that actions or remarks by others, or occurrences in the world around them, are directed at the individual.
- Grandiose delusions involve ideas of wealth, fame, or extraordinary skills beyond what the person truly possesses, or could ever hope to achieve in reality.
- Similarly, erotomanic delusions occur when someone falsely believes someone else is in love with them.
- Somatic delusions involve false beliefs about an individual’s bodily functions and overall health.
- People with nihilistic delusions are convinced without evidence that some major catastrophe is about to occur and will sometimes engage in various conspiracy theories to support their claims.
Delusions always involve false beliefs, but can be divided between bizarre and non-bizarre types. Delusions that are non-bizarre reflect situations that can actually happen in life, though they are not probably happening to that individual. An example of a non-bizarre delusion would be someone falsely believing that the police are surveilling them. It is considered “non-bizarre” because the police do surveillance on certain suspected people.
A bizarre delusion involves something that does not occur in reality, such as someone believing that space aliens inserted microchips in their brain while asleep. Overall, bizarre delusions can include ideas that one’s mind or body in being taken over or controlled in some way.
When assessing for delusions in psychotic disorders, understanding the individual’s cultural and religious associations is important in developing a context for the person’s beliefs. Generally, ideas are considered delusional if they are both implausible and not relatable for anyone else within that culture or religion.
Hallucinations
While delusions involve false beliefs, hallucinations are experiences of false perceptions that occur outside of reality. Hallucinations in psychosis are powerful sensory experiences that are very often convincing as real to the individual, occurring while fully awake, and are otherwise difficult to ignore. Hallucinations can be auditory, visual, tactile (touch), somatic (bodily), or gustatory (taste/smell).
The most common hallucination, especially in schizophrenia, is auditory.1 People with auditory hallucinations can hear voices of a person or persons talking to the individual, or to each other about the individual. Sometimes, voices can be nothing more than gibberish, but if someone hears a voice telling them what to do, this is known as a “command voice.”
Hallucinations in psychosis generally coincide with a pattern of delusional thinking. While delusions can exist without hallucinations, the opposite is rarely true, especially as the overall mental illness progresses over time. Because psychotic hallucinations can be so vivid and persistent, their development can shape the nature of delusions within the individual, thus deepening a more elaborate and entangled pattern of thinking.
Disorganized Thinking or Speech
Some people with delusions can retain a fairly organized thought pattern around the delusion, and even come across to others as relatively articulate, especially in the early stage of the psychosis. However, another specific psychotic feature is the presentation of disorganized thinking inferred from an individual’s speech.
This symptom can develop as the psychosis worsens over time and make it increasingly difficult for basic communication. People with this symptom can switch from one topic to another or follow a disjointed path of logic through many unrelated topics, becoming less able to answer simple questions directly. In the most severe form, they may become incomprehensible, with persistent muttering or “word salad.”
Grossly Disorganized or Abnormal Motor Behavior
This feature is more typical of an advanced psychotic disorder, especially when matched against a person’s level of functioning prior to the onset of psychosis. The overall presentation of behavior is very inappropriate to any given situation or social context, and results in difficulties in daily or usual functioning.
For example, an adult could appear child-like or throw tantrums. Motor behavior can become rigid or with bizarre postures, known as catatonia. Or they may become non-responsive, or with staring or grimacing behaviors.
Negative Symptoms
Here, the word “negative” essentially refers to “reduction,” in the sense that behaviors are significantly diminished in presentation and functioning. These negative symptoms include a gross lack of emotional expression and motivation. Speech patterns may be very labored and flat, without inflection. Anhedonia, which is the absence of any sense of pleasure in usual activities, may also be present in psychosis. Social avoidance is also common.
Types of Psychotic Disorders
Types of psychotic disorders include delusional disorder, schizophrenia, Schizophreniform, brief psychotic disorder, and schizoaffective disorder. Psychosis can also be triggered by another medical condition, or it can be induced by a substance or medication.
Delusional Disorder
In delusional disorder, a person can maintain any type of delusion or combination of delusions, but often without hallucinations involved. If hallucinations are present, they tend not to be as obvious and influential as in schizophrenia. The delusional pattern must occur for at least one month. Often, people with delusional disorder may retain a reasonable level of functioning, and can display behavior that would appear normal to most people.
Schizophrenia
This psychotic disorder represents a spectrum of different subtypes, and is often identified as paranoid, disorganized or catatonic. What really sets schizophrenia apart from other psychotic disorders is that it includes both positive and negative symptoms.
The diagnosis of schizophrenia also requires a persistent reduction in social and occupational functioning, as well as self-care. A dramatic decline in school, work, relationships, usual activities, and personal responsibilities is common as schizophrenic symptoms take hold.
Schizophrenia is a progressive mental illness with little chance of improvement or reversal of symptoms without treatment. The diagnosis itself requires at least six months of continuous signs of the disorder, unless interrupted by early treatment intervention.
Schizophreniform
This diagnosis is dedicated to the early development of schizophrenic symptoms during a one-month to six-month period of time. If the symptoms persist beyond six months, then the diagnosis switches to schizophrenia. The consequences of this disorder are similar to schizophrenia, but the prognosis can be better due to the early detection and available treatment opportunities.
Brief Psychotic Disorder
A sudden appearance of any psychotic symptom defines this diagnosis. Essentially, someone who goes from a non-psychotic state to psychosis as quickly as one day, but less than one-month in duration, is suffering from a brief psychotic disorder.
This usually occurs in response to an overwhelmingly stressful event, and eventually resolves with a full return to the level of functioning seen prior to the episode. This is often diagnosed retrospectively, so that it’s not confused with other psychotic disorders.
Schizoaffective Disorder
This psychotic disorder involves significant changes in mood states along with the symptoms of psychosis. However, it differs from bipolar I disorder with psychotic features and major depression with psychotic features in that the psychotic symptoms last at least two weeks after any mood episode subsides.
There is generally a loss of functioning similar to schizophrenia, but it may be less consistently disturbed, since shifts in mood and the presence of psychotic symptoms in schizoaffective disorder can change the level of functioning, as well.
Psychotic Disorder Due to Another Medical Condition
If prominent hallucinations or delusions occur along with a clear diagnosis of a medical condition known to potentially cause psychotic symptoms, then this psychotic disorder is considered to be a direct consequence of the medical problem, and not the result of any other mental disorder.
The psychotic symptoms would generally be expected to improve if the medical condition could improve, but in certain chronic conditions, this may not be the case. Diseases that can cause psychotic symptoms include some neurological, endocrine, metabolic, or autoimmune disorders.
Substance/Medication-Induced Psychotic Disorder
This diagnosis applies when hallucinations or delusions follow the use or immediate withdrawal of a drug, including alcohol, cannabis, sedatives, opioids, hallucinogens, amphetamines or any other drug that can induce intoxication or withdrawal symptoms.
Certain medications can also induce psychotic symptoms in some people. If it is medically determined that drugs are the direct cause of the psychotic disorder, it essentially rules out any other psychotic disorder diagnosis.
However, in some cases, such drug-induced psychoses could actually be catalysts for underlying mental disorders. One example is mania in bipolar disorder that can be triggered by certain antidepressant medications.
Psychosis in Other Disorders
Psychosis can occur in other disorders, including bipolar I and major depressive disorder. A psychotic disorder may also begin after childbirth, or alongside symptoms of catatonia.
Bipolar I Disorder With Psychotic Features
When people suffer from extreme mood swings, they likely would be suffering from bipolar disorder. There are three forms of bipolar: Bipolar I, bipolar II, and cyclothymic disorder. In bipolar I disorder, a person may have severe episodes of mania that include hallucinations or delusions.
These may also be present when the mood condition swings to severe depression. These psychotic features tend to resolve once the mood episode ends and the person returns to a more balanced mood state.
Major Depressive Disorder with Psychotic Features
Similar to bipolar I disorder with psychotic features, a severe form of depression can include the psychotic features of hallucinations or delusions. This diagnosis is only applicable if there is no other diagnosis better suited to describe the course of the psychosis, including any history of mania that would mean that bipolar I disorder is present.
Postpartum Onset
Although this is not technically an official diagnosis, postpartum onset is an important distinction in understanding if a psychotic condition begins during pregnancy or after childbirth, and is a direct consequence of related hormonal changes. For many women who develop a postpartum psychotic disorder or postpartum bipolar disorder, it can be the first instance in their lifetime, and can occur after the first childbirth or any subsequent childbirth.
This condition can go overlooked, so any presentation of changes in mood and behavior that suggests psychosis requires immediate medical and psychological attention.
Catatonic Features
Symptoms of catatonia can occur with psychotic disorders, along with other types of mental or developmental disorders, such as catatonic depression. These symptoms include expressionlessness, odd postures, little or no verbal response, repetitive movements, grimacing, or mimicking another’s speech or behaviors. The presence of these symptoms often suggests a more severe level of dysfunction and can make interactions with treatment professionals more complicated.
Causes of Psychosis
There appear to be different factors that can cause psychosis depending on the specific diagnosis. For example, schizophrenia likely involves several genes in the individual’s DNA that would form the basis for the disorder later in life.2 The cause of brief psychotic disorder episodes can be limited to very stressful or traumatic events. However, it also appears that preexisting traits of certain personality disorders may predispose individuals to brief psychotic disorder.3
There may be a combination of factors in the development of any psychotic disorder. While a detailed personal and family history is useful to produce a clear assessment and accurate diagnosis, it’s important to remember that no one needs to feel at fault for a psychotic disorder, whether you’re the person with the diagnosis or you’re helping a loved one cope with psychosis.
Treatments for Psychotic Disorders
The treatment for psychosis of any kind usually involves a collaborative approach among various mental health providers and services that address the different areas of dysfunction. Typically, treatment is best in a team approach from:
- Psychiatrist: Provides medical evaluation and treatment services
- Clinical Psychologist: Provides additional assessment tools
- Psychotherapist: Provides psychotherapy in the individual, family and/or group modalities
Depending on the level of impaired functioning, people can also benefit from psychosocial rehabilitation services from any number of qualified professionals to improve functioning and insure ongoing health and safety. Those with a more severe level of symptoms may require psychiatric hospitalization, especially if they pose a threat to themselves or others. In disorders with more manageable symptoms and adequate functioning levels, treatment can often be performed in an outpatient clinic or office.
It’s not unusual for anyone with psychosis to push back on efforts to receive proper treatment, especially if they’ve felt paranoid or have held persecutory delusions. However, trained professionals can be helpful in guiding a patient with psychosis to gradually feel more at ease and understood as a human being who has likely gone through some very frightening experiences.
Medications for Psychosis
Treatment typically requires antipsychotic medications, along with other medications to help improve functioning. Antipsychotic medications have been called neuroleptics, or major tranquilizers. They are divided into the older, first-generation medicines known as typical antipsychotics, and the newer, second-generation medicines known as atypical antipsychotics.4
Both kinds can be effective in the reduction and management of positive symptoms, particularly with hallucinations and disorganized thinking. Sometimes, people attempting to cope with their psychotic symptoms fear that medications might control them in some harmful way. Good approaches to the fear inherent in psychosis can go a long way to reducing those fears.
People also have some real and valid concerns about medication side effects. Generally, the atypical antipsychotics have fewer or more manageable side effects compared to the older medications. These side effects can include tremors, slurred speech, tongue protrusions, muscle dystonia, and anxiety. Drugs used for Parkinson’s disease can also be used to control these side effects.
Another common side effect to the antipsychotics is what is known as metabolic syndrome. These medications are often correlated with weight gain and the development of diabetes and high cholesterol. Regular monitoring for these conditions is required when the medications are used.
Patients sometimes complain that antipsychotic medications may make them feel tired or sluggish, and they may actually miss some of the mental acuity not disturbed by hallucinations. Psychiatrists who treat psychosis are familiar with these side effects and understand how to approach dosage requirements and changes in medication variety to find the best treatment approach.
Some of these medications are available in long-acting injectable formulations for patients who struggle with taking a medication daily.
Doctors can use other psychiatric medications often in tandem with antipsychotics to improve related symptoms, including depression and anxiety, to round out an effective treatment profile.
Psychotherapy for Psychosis
While medications are needed to reduce and manage psychotic symptoms, it’s also important for people entering this often scary and disorienting experience of treatment to have therapists work with them to improve feelings of trust, even as forces within them pose resistance.
Therapists who specialize in working with people suffering from psychosis help them face delusional thoughts and perceptual distortions without judgment or reproach. Instead of just telling them, “Those voices in your head aren’t real,” the communication begins with, “I’d like to know more about the voices and how you feel about them.”
Essentially, mental health professionals trained in the treatment of psychosis will often try to go with patients into their experiences to understand their fears and unfulfilled desires. Therapists can begin to explore feelings that are often hidden, repressed, or blunted within the individual, and develop a sense of trust as an antidote to paranoid thoughts and commands.
With increased trust, patients can face reality with less anxiety and a greater sense of planning and organization.
Living and Coping With Psychosis
During the initial phase of treatment, medications and psychotherapy ideally work together to improve symptoms and functioning. It can also be beneficial, when appropriate, to involve specific family members, such as parents, spouses, partners, or caregivers.
Family education and support are important factors in the overall treatment of psychotic disorders. Moreover, family members will likely need support, and perhaps their own therapy, due to the emotional strain that the consequences of psychotic symptoms have caused in their lives.
Depending on the extent of consequences and functional impairments, a complete array of therapy services can be useful to restore a person’s ability to cope in life as a functioning member of society. In severe instances of psychotic disorders, especially those that take longer to improve, community services become a vital part of the overall treatment experience. These services may include help in housing, job skills, and if appropriate, addiction treatment and support.
