Engelska - What is a psychosis?
When reality disintegrates life can seem like a nightmare. The person may experience thoughts of being followed or subjected to evil by others resulting in feelings of panic. A psychosis constitutes of a loss of contact with reality consisting of delusions, hallucinations, cognitive deficits, and odd behavior.
Delusions can consist of thoughts such as of being pursued, that the food is poisoned, or that of being chosen to perform some important task such as being God.
Hallucinations are perceptions without the corresponding outer stimuli. Hallucinations can be perceived from all the different senses (visual (sight), auditory (sound), smell, touch, and taste) but auditory hallucinations are the most common. Auditory hallucinations can be voices commenting on what the person does or commanding the person to do certain things. There can also be sounds such as from steps that are heard as if they are coming from the surroundings, or from within the persons head.
Cognitive deficits can be difficulties concentrating of planning and performing tasks and difficulties with attention or memory. One may feel as if the head is overfull of thoughts, or in contrast, empty of thoughts. Staying on the subject in a conversation can also become difficult.
A lack or decline in emotional response, speech, or motivation is called negative symptoms. The person may experience apathy, joylessness, and lack interest, engagement and drive to participate in activities.
Odd behavior may be that the person talks to himself in public or avoids things or situations for no apparent reason.
The psychotic syndromes
A brief psychosis heals relatively quickly and usually does not reoccur. It is usually characterized by confusion or paranoid symptoms such as being pursued and of intense anxiety. Hallucinations can occur. The psychosis can be triggered by acute stress.
In an affective psychosis the main illness is a depression or a bipolar disorder, but the person develops a psychosis that lasts a shorter period of time than the affective disorder. In the case of depression the thoughts can dwell upon ones own incompetence, worthlessness, or death. In the case of mania the delusions may relate to being chosen to be God or the devil himself. Hallucinations may occur.
In a delusional disorder misinterpretations of the world predominate. The delusions may pertain to one’s partner being unfaithful or that other people are against the person and want bad things to happen to him.
In psychosis NOS (not otherwise specified) the symptoms are uncharacteristic or too uncertain to give a more specific diagnosis.
In schizophrenia the psychotic symptoms last at least a month, and loss of function in several areas lasts at least half a year, and may persist throughout life. Symptoms include thought disorders, inappropriate affect, apathy, ambivalence, introversion, and delusions, hallucinations, and sometimes odd behavior. Speech can become difficult to understand and reasoning may follow an unusual pattern of logic. In schizophrenia it is common to function less adequately in the areas of work, studies, and social relations than before becoming ill. In schizophrenia it is usual for the illness to reoccur if one does not treat the illness. The risk of developing functional deficits increases with each episode of illness.
In schizophreniform disorder the symptoms are similar to those of schizophrenia, but the period of illness is shorter, and resolves within a six month period.
In schizoaffective disorder, schizophrenia occurs concurrently with a depression or a bipolar disorder.
How common is psychosis?
Every year between 10 and 20 people per 100,000 inhabitants become psychotic for the first time in their lives. For a third, the psychosis passes rather quickly and does not reoccur. For another third, the psychosis will reoccur, but the person recovers well between the episodes of illness. The last third develops functional deficits that can lead to the need for help in everyday life tasks. There are about 40 000 persons in Sweden with functional deficits due to psychiatric conditions such as psychosis.
What causes psychosis?
Many factors contribute to the development of a psychosis, and one simple cause does not exist. One can talk about a vulnerability that implies that the person has a strong tendency to react with psychosis when subjected to stress. Schizophrenia, for example, has a complex heredity where several genes interact, creating a risk to develop the illness. Neurobiological factors such as malnutrition or oxygen deprivation during the fetal stage can increase the risk of developing schizophrenia later in life. Environmental factors during childhood are also of importance, where seriously disturbed conditions during childhood can strengthen the biological vulnerability, and good conditions may protect against a later development of the illness.
A person with high vulnerability can live without problems until something happens that triggers the psychosis. It can be the stress of moving from the parental home, commencing studies, entering military duty, having a first child, or a physical strain such as an illness, long term sleep deprivation, or drug abuse.
What helps?
Treatment
When someone has developed a psychosis, help is needed quickly, preferably within a day. The family should be included from the start of treatment. If the person receives support at home by well educated staff, hospitalization may be avoided. A calm environment is important for the treatment of psychosis. When someone is hospitalized the ward should be small and homelike. The person should be met with a clear, kind, and empathetic treatment.
Medication against the psychotic delusions, the anxiety and sleep disorder can ameliorate symptoms. Antipsychotic medication reduces symptoms such as paranoia, delusions, and hallucinations. Minor tranquilizers reduce anxiety, and sleep medication may be needed for a period of time. If the person is depressed, anti-depressive medication may be given.
Psychological treatment is often offered in the form of supportive sessions or therapy sessions. Cognitive behavior therapy is often an effective aid to recovery by strengthening the problem solving capacity and improving self esteem.
Rehabilitation
It is important with a holistic view early in treatment. The Occupational therapist can asses and treat functional deficits and by that contribute to making everyday life easier. The physical therapist can improve body awareness, coordination and strength, and train in relaxation techniques. The social worker or counselor can asses the person’s economy and see to it that he or she receives that economic support to which he or she is entitled to. A case worker can provide help in the tasks of independent living when such help is needed. A personal representative can help if there are difficulties in the contact with authorities.
The Swedish Social Insurance Administration offers economic support when work capacity is reduced. Occupational rehabilitation is offered by the community. The Swedish Employment Services may provide supported employment.
Recovery
Most people who develop a psychosis recover and live a good life. Some still have contact with psychiatry and take medication, but everyday life and social relations function well. Important factors in recovery are, for an example, medication, and other people who can provide support and encouragement. Recovery takes place in small steps, and with recovery comes a new identity, where the experience from the psychosis becomes an asset.
Living with psychosis
Tips
Medication is usually necessary to avoid additional episodes of the psychosis, especially for the diagnosis schizophrenia. But medication can also have side effects. Usual side effects are tiredness, weight gain, and stiffness or shakiness in the hands. Hormonal influence may also give sexual side effects such as milk production, irregular periods, or lessened sexual drive and function. If the side effects are bothersome, it may help to change medication, as some newer medications have fewer side effects than older ones. To find a medication that fits well can take a little time, but can then be a real help in recovery.
It is important to control the level of stress following a psychosis. The person must learn how much stress he or she can handle, and what level of activity that is tolerated. Eating and sleeping regularly are also important and provide some protection against reoccurrence of the illness.
Exercise is important for health, especially when taking antipsychotic medication that can give an increase in appetite and weight gain. Certain medications also increase the risk of developing diabetes, and this may be countered by regular exercise. Exercise also gives a sense of wellbeing and reduces the risk of depression.
Talk to your doctor about your use of alcohol and ask for advice concerning your specific situation and medication. Alcohol may be contradicted in combination with certain medications.
It is important to avoid drug abuse after a psychosis. Drugs can trigger episodes of the illness. Drugs such as marijuana, hashish, LSD and PCP can also trigger a psychosis in people who have never before had a psychosis, and increase the risk of developing schizophrenia. Drug abuse also increases the risk of becoming a victim of violence and of acting violently. Drug abuse is therefore very inappropriate in combination with a psychotic tendency.
Early signs
If the person learns to recognize early signs of illness, he or she can avoid additional episodes of illness by seeking help. The early signs of illness differ between individuals, but may include a feeling that people dislike or are against the person, that relationships become full of conflict, that the person becomes irritable and emotionally unstable, or that delusions and hallucinations begin to occur. Once aware of the early signs, one can reduce stress and seek additional support, or adjust the dose of medication in consultation with the psychiatrist, and avoid an episode of the illness.
Handling voices
Disturbing voices can be handled in different ways. Medication usually helps, but sometimes the voices can remain despite adequate medication. Then strategies of handling voices are needed. What works for one person may not work for another, but the strategies are worth a try:
Reducing stress and avoiding situations that are too difficult is a strategy that may help. Ensuring that one gets enough rest and sleep, and eating regular meals is also important. Activities such as listening to music, reading, solving crossword puzzles, watching TV, or exercising can act as a distraction against the voices. Talking to friends may also help.
Put up boundaries to the voices; say no to them, you’re the one in charge, not the voices. If it works for you, you may reserve a period of time each day to talk to the voices, and ask them to be silent the rest of the day. You may also ignore the voices and decide not to listen to what they say. Create a good collaboration with your psychiatrist in order to get additional help in handling your voices if they are disturbing or threatening you.
Written by: Elisabet Alphonce
Factual information checked by Professor Frits-Axel Wiesel, Psychiatry, University of Uppsala