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Overview
Psychosis is a commonly misunderstood condition which can occur as a part of the range of physical and mental health conditions.
In psychosis, an individual may experience a distortion of their reality, experiencing effects on perceptions, thought processes, cognition, mood and behaviour (World Health Organisation, 2004). Psychosis is more likely to occur during adolescence and early adulthood, although can occur at any age (National Institute for Health and Care Excellence (NICE), 2014).
It is essential to recognise that everyone’s experience of psychosis is unique; in their symptoms and how they are interpreted. A person-centred approach to psychosis acknowledges the uniqueness of their experiences and supports the individual to understand, find meaning and cope with their experiences. This is opposed to being led by diagnoses only.
It is also important to recognise that ’psychosis’, as termed in western psychiatry, is culturally and spiritually contextual. Individuals with the same experience may be
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Symptoms
In psychiatry, symptoms of psychosis are typically categorised into ‘positive’ and ‘negative’ symptoms. Positive symptoms are those with a new onset that generally do not occur for people without psychosis. Negative symptoms occur where there is a reduction in functioning resulting from psychosis, which can occur in other conditions (Siddle, 2009).
Positive symptoms
Delusions – Where an individual holds a belief that is often deemed illogical, often not based on fact and otherwise seen as untrue or implausible.
Delusions termed ‘grandiose’ relate to an inflated and exaggerated sense of importance and power, for example, a belief that they are monarchy or can fly. Sometimes people can experience paranoid delusions, where their belief held incorporates a perceived fear of danger or threat from known or unknown sources.
People can hold different levels of belief or conviction in these ideas and experience various levels of distress or preoccupation.
Hallucinations
Hallucinations
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Aetiology
There is no one clear cause for psychosis. The onset of psychosis can be linked to several different factors unique to the individual.
Biological
Abuse of some drugs, such as amphetamines and cannabis, can increase one’s risk of developing psychosis. Furthermore, research has identified some genetic traits which increase vulnerability to developing psychosis. Having a first-rank relative (parent or sibling) who has experienced psychosis may increase the risk. However, the lived experience of having a first-rank relative may also play a role in increased risk (Broome et al, 2005).
The links between the regulation of dopamine (a neurotransmitter) and psychosis is known as the ‘dopamine theory’. While most antipsychotics are targeted towards dopamine dysregulation, there is still much to be understood about dopamine’s links to psychosis (Harmer and Cowen, 2017). Furthermore, many researchers would dispute the dopamine theory and a biological ‘disease’ model of approaching people's experience
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Diagnosis
There are several psychiatric and medical diagnoses which can feature psychotic symptoms. Common psychiatric diagnoses include schizophrenia, bipolar disorder and schizoaffective disorder (NICE, 2014).
Receiving a diagnosis can be helpful for some to better understand their experiences and gain access to necessary treatment and support. However, many have argued that the diagnosis of schizophrenia is inappropriate, as well as stigmatising, disempowering and restrictive for the individual (Moncrieff and Middleton, 2015).
Many people may experience psychosis and never receive a diagnosis or even come into contact with mental health services. Furthermore, some people may identify as ‘voice hearers’, and there is an international network of peer support called the Hearing Voices Network (2022).
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Management
To support people experiencing psychosis, it is vital to take a normalising approach and provide opportunities to help the individual better understand their experiences.
Some people may be referred to early intervention services, which provide high-intensity intervention and support at the early onset of psychosis (NICE, 2014).
It is important to consider risk and how people’s symptoms can affect their behaviour and engagement with others. Sometimes individuals may be influenced by their experiences to engage in behaviours which can increase their social vulnerability or put themselves or others at risk of harm. Professionals should work with the individual, their support network and mental health services to appropriately manage risk.
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Treatment
NICE guidance recommends using antipsychotic medication (under the supervision of a psychiatrist) in conjunction with psychological interventions (NICE, 2014).
Antipsychotics can be categorised into the first and second generations, relating to when they were developed. These usually come with various side effects and the need for physical health assessment and monitoring.
Psychological interventions include cognitive behavioural therapy for psychosis and family interventions for psychosis.
Social support and interventions are also important in supporting individuals with psychosis. This can include peer support and self-management strategies, art therapy and supporting with occupation, education and employment activities. People with psychosis should also be supported by promoting healthy lifestyles such as weight management and stopping smoking (NICE, 2014).
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Resources
Broome M, Woolley J, Tabraham P et al. What causes the onset of psychosis? Schizophr Res. 2005;79(1): 23-34. https://doi.org/10.1016/j.schres.2005.02.007
Edwards VJ, Holden GW, Felitti V et al. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry. 2003;160(8): 1453-1460. https://doi.org/10.1176/appi.ajp.160.8.1453
Harmer C, Cowen P. How do drugs for psychiatric disorders work? Epidemiol and Psychiatr Sci. 2017; 27(2):141-142. https://doi.org/10.1017/S204579601700066X
Harris N. The Nature of Schizophrenia. In: Harris N, Williams S, Bradshaw T (eds). Psychosocial Interventions for People with Schizophrenia: A practical guide for mental health workers. Palgrave; 2002
Hearing Voices Network. 2022. https://www.hearing-voices.org/ (accessed 15 December 2022)
Lukoff D, Cloninger C, Galanter M et al. Religious and Spiritual Considerations in Psychiatric Diagnosis: Considerations for the DSM-V. In: P Verhagen, H van Praag,
J Loepiz-Ibor et al (eds). Religion and Psychiatry: Beyond Boundaries. New Jersey: John Wiley and
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