Psychosis: Causes and Treatments

Overview

Psychosis is an episode when a person has a break or disconnect from reality, which can involve delusions and hallucinations. Delusions are strong beliefs that are very unlikely to be true and usually seem irrational to other people (Psychosis, 2015). Hallucinations are when someone sees, hears or physically feels things that aren’t actually present. (Psychosis, 2015) Psychosis is an umbrella term that describes the hallucinations and delusions that a person may experience. According to the National Alliance on Mental Illness’ website, psychosis is not an illness, but it is a symptom which can be caused by mental or physical illness, substance abuse, trauma or extreme stress (Psychosis, 2015).

Delusions and Hallucinations

  Delusions of persecution are the most common form of delusions. They involve the belief that someone or something is out to get you. persecutor may be animate or inanimate, other people, machines; may be systems or organizations or institutions rather than individuals (Kiran, Chaudhury, 2009). Delusions of infidelity involve morbid jealousy with disorders of passion in which there is an overwhelming sense of entitlement and that others are intruding on whom is rightfully theirs. This threat to their possession of a person can stem from conflicts inside oneself and is a major contributor to wife battering (men battering) and is one of the most common motivations for homicide (Kiran, Chaudhury, 2009). Delusions of love are characterized by the delusions that a person, typically, a woman, believes that a man, who is older and of higher social status than she, is in love with her (Kiran, Chaudhury, 2009). This can go both ways though, as a man can experience these types of delusions about a woman. Grandiose delusions are when a person may believe that they are a famous celebrity or have supernatural powers (Kiran, Chaudhury, 2009). Delusions of guilt and unworthiness are self-critical and may lead to delusions in which the patient believes that they are bad or evil and have ruined their family or have committed a sin that is unforgivable. These delusions are most common in depressive illnesses and may lead to suicide or homicide in some cases (Kiran, Chaudhury, 2009). Delusions of negation/nihilistic delusions are the reverse of grandiose delusions in which the person is blessed or gifted with popularity, fans, or special powers. Feelings of guilt and hypochondriacal ideas are developed to the extreme (Kiran, Chaudhury, 2009). Somatic delusions are when a person experiences bodily sensations and feelings and begin to think that they have an illness or that something is wrong with their body despite contradictory evidence or medical opinion (Smith, 2018).

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Auditory hallucinations are most commonly experienced by people with schizophrenia these may include hearing voices, or multiple voices or even other sounds. These voices could whisper or yell at the person experiencing them.  They may also make demands to the person experiencing them (Smith, 2018). Visual hallucinations are when a person sees objects, such as people, lights or patterns that are not actually there. They may see dead loved ones or friends and people that they know.  In some cases, perception may be altered, and they will have trouble judging distances (Smith, 2018). Olfactory hallucinations are experienced by smell and taste. The smell may be a good smell or a bad one. Sometimes this can be dangerous because the person may believe that they are being poisoned and will not want to eat (Smith, 2018). Tactile hallucinations are experienced by feeling a movement or sensation on your body. The person may feel that they have insects crawling around on or inside their body (Smith, 2018).

Anxiety and Depression: an impact on the content of delusions and hallucinations

 The rates of depression and anxiety have been linked to the severity and distress associated with the symptoms of Psychosis. The rates of depression and anxiety are also very high amongst patients with Schizophrenia with estimates around 25% and 45% respectively (Hartley, Haddock, Barrowclough, 2012). 

 In an article written by Daniel Freeman and Phillipa Garety, they state that delusions can be a direct representation of a person’s emotional concerns. They believe that anxiety and its associated processes are likely to be an important factor in the formation and maintenance of depressive delusions (Freeman, Garety, 2003). The authors have referred to different types of emotions and a theme that may be expressed in the person’s delusions.  Depression can bring about delusions of guilt and sometimes persecution or catastrophe (Freeman, Garety, 2003). Anger can lead to delusions of persecution such as “people are doing things to deliberately annoy me.” Happiness tends to lead to delusions of grandiose because the person is experiencing high self-esteem, achievement or success (Freeman, Garety, 2003). Disgust can lead to persecutory delusions (Freeman, Garety, 2003). Jealousy can lead to delusions of infidelity (Freeman, Garety, 2003). I found this article very interesting because it shows how other mental illnesses can play into the exact symptoms of psychosis that are displayed from person to person.

Causality

There are many different factors that can cause an episode of psychosis. Genetics can be involved. Research has shown that there are many genes associated with the development of psychosis but having the genes does is not sufficient or necessary to develop psychosis (Psychosis, 2015). Trauma in childhood, or adulthood has shown to be associated with the development of Psychosis, such as a traumatic event like a death, war, sexual assault or sexual abuse, and neglect (Psychosis, 2015). Substance use and or abuse has also shown to increase the risk of Psychosis in people who are already vulnerable. The most common drugs that can lead to this disposition are: marijuana, LSD, and amphetamines (Psychosis, 2015). Physical illnesses or injuries have also been shown to cause people to have episodes of Psychosis. Psychosis can also be caused by secondary means. People that have experienced traumatic brain injuries, brain tumors, strokes, HIV, and brain diseases such as Parkinson’s, Alzheimer’s and dementia can also lead people to experience Psychosis (Psychosis, 2015).

In a study conducted in 2017, researchers sent out a questionnaire to 219 clinicians in various mental health fields. The questionnaire addressed the clinician’s beliefs about the causes and most effective treatments for psychosis. The majority of the clinicians that participated had a multi-causal ideology of causation but were more likely to endorse psychosocial causes rather than biological (Carter, Read, Pyle, Law, Morrison, 2017).  There appears to be many factors that can lead to Psychotic episodes. The clinicians that participated in the study were: CPN’s, occupational therapists, psychiatrists, and social workers.

In a meta-analysis study regarding Childhood trauma done in 2012, many different studies were examined and evaluated against a control group, being outputted into an odds ratio or O.R. This review finds that childhood adversity and trauma substantially increase the risk of psychosis. Their findings also suggest that if the adversities that were examined as risk factors were entirely removed from the population (with the assumption that the pattern of other risk factors remain unchanged), and assuming causality, that the number of people with psychosis would be reduced by 33% (Varese et al., 2012) This is a very bold statement which places a lot of causality on childhood trauma. When examining the specific traumas and adversities experienced during childhood all of them, except for parental death, showed an increase in psychotic risk (Varese et al., 2012).

 Impact of drugs on Psychosis

 It has been documented that the reports of abuse of drugs usually predates the onset of psychotic symptoms. In a study done in 2009, (Smith, Thirthalli, Abdullah, Murray, Cottler, 2009), 476 intravenous drug users were recruited via street outreach were interviewed and asked questions regarding their drug use and psychotic symptoms using the Composite International Diagnostic Interview-Substance abuse model. They were asked questions about whether they experienced any psychotic symptoms while using a specific drug or during withdrawal from that drug. The drugs included in the study were: cocaine, Cannabis, Opiates, and Amphetamines. The results of this study showed that the psychotic symptoms increased as the severity of drug use for each specific substance increased. (Smith, Thirthalli, Abdullah, Murray, Cottler, 2009). Each substance abuse dependence was measured from no diagnosis of dependence to severe dependency. Astonishingly, the users that had a sever dependence on amphetamines all reported psychotic symptoms either while under the influence of or during withdrawal from amphetamines (Smith, Thirthalli, Abdullah, Murray, Cottler, 2009). I feel that it is necessary to mention that I am not trying to say that drugs cause Psychosis, but that they do have a significant impact on the severity of symptoms and may increase the risk of experiencing a psychotic episode.

 In another study done by Komuravelli, Poole, and Higgo in 2011, records of patients with no psychiatric history who had been discharged from January 2002- April 2006 with a firm diagnosis of drug induced psychosis were identified by the ICD 10 codes that were applied to their care. A follow up was done by reviewing the records for the next two years regarding their future diagnosis and recovery status. Nearly all of the patients who had remained in psychiatric care had a change in their diagnosis. The most common diagnosis of these patients after a 2 year follow up was Schizophreniform disorder (Komuravelli, Poole, Higgo, 2011). These results imply that either the patients were experiencing the effects of drug intoxication that may have led into psychosis symptoms, or an ordinary (pre-existing) episode of psychosis that was complicated by drug-use.

 The comorbidity of schizophrenia and substance abuse is well documented already. Up to 60% of patients are reported to use or abuse illicit drugs (Dixon, Haas, Weiden, Sweeney, Frances, 1990).  My reason for mentioning this fact is that Schizophrenia patients commonly experience the same Psychotic symptoms that are similar to those in umbrella term of Psychosis.

The majority of reports found in literature show that drug use generally makes symptoms worse. However, after their analysis on the reports in this particular study, the authors have discovered that drug use has a heterogenic effect on the patients with psychotic symptoms. Experiments done in the 1950’s and 1960’s in which schizophrenic patients were given hallucinogenic drugs revealed that most patients experienced an increase in an anxiety and psychotic symptoms, but some actually felt more euphoric, and relaxed (Hoch, 1951

In all of these studies I have mentioned multiple drugs were used amongst the people, and sometimes multiple drugs per person. It is impossible from this data to come to a causal explanation. Also considering the fact that the drugs have a different effect across the samples there is no way to place any kind of blame on a particular substance, or to drugs in general.

Treatments

As with any illness or disease early treatment has the best outcomes. There will be more of a chance to prevent the illness from progressing. Treatment of psychosis can be a combination of psychotherapy, medication, complementary health approaches, or in some cases hospitalization (Psychosis, 2015). Antipsychotic medicines are the most commonly prescribed medication. These medications work by blocking the effect of dopamine, which transmits messages in the brain (Treatment-Psychosis, 2016).  Cognitive behavioral therapy (CBT) for psychosis is based on an understanding of how people make sense of their experiences and why some people become distressed by them. A CBT therapist will focus on helping the patient to consider different interpretations of   what is happening to them. The aim of CBT is to help the patient to achieve goals that are meaningful and important to them, such as reducing distress, returning to their job, their school or training, and regaining a sense of control (Treatment-Psychosis).

In the previously mentioned questionnaire given to various health professionals regarding treatment of psychosis the responses revealed that providers are twice as likely to offer medication rather than Cognitive Behavioral Therapy (Carter, Read, Pyle, Law, Morrison, 2017).

• Smith, M.J., & Thirthalli, J., & Abdallah, A.B., & Murray, R.M., & Cottler, L.B. (2009) Prevalence of psychotic symptoms in substance abuse users: a comparison across substances. Comprehensive Psychiatry, (50), 245-250.
• Carter, L., & Read, J., & Pyle, M., & Law, H., & Morrison, A.P. (2017) Mental health clinicians’ beliefs about the causes of psychosis: Differences between professions and relationship to treatment preferences. International Journal of Social Psychiatry. 63 (5), 426-432.
• Psychosis. (2015). [PDF file]. Retrieved from https://www.nami.org/NAMI/media/NAMI-Media/Images/FactSheets/Psychosis-FS.pdf
• Freeman, D., & Garety, P.A. (2003). Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations. Behaviour Research and Therapy. 41, 923-947.
• Hartley, S., & Haddock, G., & Barrowclough, C. (2012). Anxiety and depression and their links with delusions and hallucinations in people with dual diagnosis of psychosis and substance misuse: a study using data from a randomized controlled trial. Behaviour Research and Therapy. 50, 65-71.
• Komuravelli, A., & Poole, R., & Higgo, R. (2011). Stability of the diagnosis of first- episode drug-induced psychosis. The Psychiatrist. 35, 224-227.
• Varese, F., & Smeets, F., & Drukker, M., & Lieverse, R., & Lataster, T., & Viechtbauer, W., & Read, J., & Os, J.V., & Bentall, R.P. (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient- control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin. 38 (4), 661-671.
• Hoch, D.H. (1951). Experimentally produced psychoses. American Journal of Psychiatry. 107, 607-611.
• Kiran, C, & Chaudhury, S. (2009). Understanding delusions.  Industrial Psychiatry Journal. 18 (1), 3–18.
• Smith, K. (2018). [Web Article]. Retrieved from https://www.psycom.net/schizophrenia-hallucinations-delusions/.
• Treatment-Psychosis. (2016). [Web Article]. Retrieved from https://www.nhs.uk/conditions/psychosis/treatment/.