Psychosis is the modern day equivalent to the term madness and is an umbrella term for a series of diagnosable conditions that are considered by the areas of the medical profession and the American Psychiatric association to be a severe mental health disorder. While the psychiatric profession largely considers it to be an illness, others view it as pathways to spiritual enlightenment and enrichment due to the emergent nature of chaotic subconscious forces. Either way psychosis is one of the most extreme, intense and potentially devastating conscious experiences an individual can have, and therapy can be a crucial and essential way to provide grounding, narrative and context for people who have become overwhelmed, confused and disorganised as a result.
Psychosis is defined by the Oxford Dictionary as ‘a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.’ Psychiatry and the Diagnostic and Statistical Manual for Mental Disorders provide key criteria that must be fulfilled in order to be diagnosed and potentially sectioned with a psychotic disorder, schizophrenia understood to be one of the most debilitating due to its devastating impact.
The Five Criteria:
Delusions are when it is believed the individual is experiencing and believing in things contrary to perceived objective reality. Although some would argue this can be seen in religious ideology and belief, often delusional states when diagnosed for a mental health disorder will be more immediately present and explicitly consequential to the individual – i.e. a paranoid delusion that MI5 are about to arrive to take you into custody, or a delusion of grandeur whereby you are about to discover the cure for cancer or have been reincarnated as a celebrity or famous historical figure.
A hallucination is a conscious perception of something not actually present. Hallucinations can be auditory (sound), visual (sight), olfactory (smell), gustatory (taste) or tactile (touch). Often with mental health disorders, the most common diagnoses are due to auditory or visual hallucinations, although others are not uncommon.
3) Disorganised Speech
Disorganised speech is believed to indicate an inability to coherently link and structure thinking within an individual’s mind. It is diagnosed through a number of different criteria, including:
Tangentiality is characterised by oblique, digressive or irrelevant replies to questions, particularly through word association i.e.:How are you today, Tom?
I don’t know Tom, Tom is the King. The King of England wants to come to my house.
Derailment is the persistent digression of thought and therefore speech from the topic being discussed often via the words being used in the process of thinking, i.e.:
I’m going to be out tomorrow, like the rest going to the beach, the beaches in Southern Greece have the most sandcastles. The biggest castles are in Scotland.
The combination of words to form new words in an apparently random context. Considered normal in children, it is considered a potential presentation of thought disorder in adults, i.e.:
I was so cross I jumped up and down on the ground in ‘pritulence’. Those people I saw this morning were so ‘sloozranuled’.
Clanging is the use of associated words based on sound with no applicable meaning, i.e.:
How are you feeling today?
I’m feeling yes, reeling to be peeling.
4) Disorganised / Catatonic Behaviour
Disorganised behaviour is considered to be manifestable in a number of different ways but often needs to present as an inconsistent combination to warrant a diagnosis. The individual may be unkempt, with poorly maintained hygiene and clothing, or dress flamboyantly and inappropriately. He or she may be susceptible to anger, joy, sadness or grief in brief and extreme oscillations. Bizarre, unusual and purposeless movements may also be present.
Catatonic behaviour is the presentation of behaviours largely physical in nature at one end of an extreme. They will either lack animation, movement or responsiveness as in a catatonic stupor, or show an extreme of animation, movement and hyperactivity. This may include the mimicking of sounds (echolalia) or the mimicking of movements (echopraxia), often considered to be catatonic excitement.
5) Negative Symptoms
Negative symptoms refer to a flatness of affective expression and energy. Individuals presenting negative symptoms will typically show little reaction or responsiveness, and may also be experiencing Alogia or poverty of speech whereby an individual is unable to speak fluidly or spontaneously. It is also characterised by Avolition, a complete disinterest in undertaking any goal-related behaviour even as simple as getting dressed or preparing food.
The diagnostic criteria for these symptoms have changing in various editions of the Diagnostic and Statistical Manual. Version IV required two of these five symptoms to be present for a diagnosis, although if delusions were considered bizarre enough or hallucinations included commentary on thoughts or behaviour or conversations between multiple voices, only this was symptom was required. This was updated in DSM-V due to its ambiguity and possible cultural bias. The latest diagnostic criteria requires that at least one symptom must be delusions, hallucinations or disorganised speech, and a second symptom must be present across the five. Depending on the severity of the symptoms, the duration and the history of the presentation would depend on what kind of psychotic disorder would be diagnosed.
Notes on the DSM
Although diagnostic criteria has proved extremely useful to many people, the DSM should be treated with some caution. The National Institute of Mental Health in the United States removed support for the DSM, the Director, Tom Insel stating that :
‘Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.’
Essentially this is suggesting that the limitation and the flaw in the DSM system is the lack of scientific and statistical support for any of the diagnostic criteria which raises considerable concerns about the pharmaceutical consequences of the drugs prescribed as a result of presenting symptoms and to what extent their benefits have been empirically validated. This is a significant problem in the United States as insurance will often not pay for medication without an official diagnosis.
For more on the history of the DSM, this excellent article from the New Yorker gives an insightful insight into the history of psychiatric diagnosis and its relationship with the pharmaceutical industry.
Another important perspective on psychosis is that of spiritual emergence. Stanislav Grof argues that psychosis can often be seen as a ‘spiritual emergence’, a processing and merging of the conscious and unconscious in order to reevaluate and reengage with the world. In times when individuals are experiencing huge emotional upheavals and inner transformations, psychotic symptoms may be present.
See Stanislav Grof speak on Altered States, Psychiatry and Spiritual Emergence below:
Further resources on psychosis:
This is an excellent resource from the BPS for anyone suffering or impacted by psychosis or schizophrenia.