Psychosis

 

The following handout was written by Stuart Sorensen and used in training or clinical work with service-users, relatives and others. Please feel free to use it either for training or for clinical work so long as you credit it as follows:

© Stuart Sorensen www.amjcaretraining.site50.net 

Loosely defined, ‘psychosis' might be described as ‘loss of touch with reality'. Certainly this is the traditional view. In recent years, however, the notion of ‘reality' itself has been challenged and, with it, the concept of psychosis too. 

The argument goes something like this: 

"If psychosis is loss of touch with reality and yet reality is changeable depending upon a person's individual perspective, then how can the notion of psychosis have any validity in the first place?" 

Regardless of these philosophical and sometimes even metaphysical musings the majority of people believe that reality can be defined and explained scientifically. This idea is known as ‘modernism' and it also insists that there can be only one reality and that the only way to understand it is by adopting scientific principles. Modernism explains the heavy emphasis upon scientific method and the tendency of doctors and other professionals to dismiss other ‘ways of knowing' that are thought to be ‘less worthy' of consideration. 

Unfortunately, even with the aid of scientific research, it has proven impossible to define reality or even adequately to demonstrate the nature of mental illness despite the huge amounts of time, effort and public money which have been showered upon the search. This is why many people reject the modernist/scientific view in favour of a more fluid explanation of both reality and mental disorder. 

It is not necessary here to champion any particular theory. Instead we will look at some different perspectives but concentrate fundamentally upon what works. So, with that in mind, let's begin with the traditional, medical view of psychosis. 

Positives and negatives 

Positive symptoms are those symptoms that exist ‘in addition' to the norm. For example visual hallucinations are extra experiences which most people do not have

Negative symptoms are detractions from the norm. For example apathy is a negative symptom that represents a lack of ‘normal' interest in life. Lethargy is ‘lack of energy'. 

So positive symptoms represent ‘extras' and negative symptoms represent ‘absences'. 

Hallucinations, Delusions & Thought Disorders - the three ‘legs' of the psychotic disorders:

Hallucinations

Hallucinations are sensory experiences in any modality or sense (sight, hearing, touch, taste, smell) that don't seem to have any empirical (real world) cause. For example an hallucination may be a voice which no one but the voice-hearer can hear or a vision which only they can see. 

Interestingly, many of the chief religious and political figures across the world achieved their status precisely because of experiences such as these and yet many less influential people who display the same characteristics are defined as mentally ill and treated (sometimes against their will) with powerful medications. Jesus, Joan of Ark, Sister Fatima, Moses, Saul, Samuel, Noah, Martin Luther King, Hitler, Alexander the Great, Various Catholic saints including the virgin Mary, and of course her husband, Joseph all reported visions or voices that others did not experience. 

Delusions

According to traditional thinking on the subject Delusions are ‘fixed, false beliefs' which are ‘not amenable to reason'. To put it another way, the client believes something that the doctor does not and the doctor cannot get him to change his mind. 

Some people argue that where the early observers of delusions fell down was in their prematurity. They weren't able to reason people's beliefs away because they didn't know how to. Furthermore they failed to appreciate the symbolism of these beliefs, how they protect the individual or even the possibility that it may, actually be they who were wrong and not the hapless inmate of the asylum.

Examples of delusions include: 

• ‘Persecutory' or ‘paranoid' delusion - someone or something is ‘out to get' the client - a belief that is often based on little or even no evidence that makes sense to other people;
• ‘Ideas of reference' - ordinary things appear to have significance for the client - they ‘refer' to him. For example a pigeon landing on a tree top at a particular time of day may suggest the presence of an international espionage ring plotting to kill him;
• ‘Delusions of grandeur' - the belief in one's own importance. For example clients may consider themselves to be Jesus or the world's greatest pizza maker or anything which has an air of ‘specialness' about it. Arguably paranoid delusions (see above) are also grandiose as they imply that the client is important or special enough to have others plot against them in the first place;
• ‘Delusions of guilt' - clients believe themselves guilty of some crime (known or unknown) despite contrary evidence;
• ‘Hypochondriasis' - the belief that one is unwell (even possibly terminally ill) without any real-world evidence;
• ‘Somatic delusions' - relating to bodily changes;
• ‘Nihilistic delusions' - relating to the death of all or part of the body. Clients may believe that their intestines are turning to stone for example or that they are actually dead themselves.
• ‘Religiose delusions' - also often grandiose - clients may believe that they have a special role in religious matters. Perhaps they must save the world or battle with the Devil for example. Or maybe a particular demon is trying to kill them to prevent them from developing into the next Messiah.
• ‘Passivity' - the client believes that they are being externally controlled - rather like a puppet. Passivity delusions include:

1. automatism - physical movements controlled by external force
2. thought insertion - thoughts inserted by external force
3. thought withdrawal - external influence robbing the client of thoughts
4. thought broadcasting - external forces broadcast client's thoughts to others.

Work in Europe - particularly in the UK and in Holland is said to have overturned the assumptions of ‘fixed false beliefs unamenable to reason' as clients with delusional beliefs have entered into discussion with skilled therapists and reasoned themselves out of their delusions. This is often done without the aid of medication - even by reducing or withdrawing medication. 

Delusion formation

In the fictional book ‘1984', George Orwell coined the term ‘doublethink'. His is the ability to hold two or more conflicting beliefs in your head at the same time and agree with them all. Everyone is able to do this and most if not all of us do from time to time. This is particularly evident when people are describing themselves. 

For example, a man might believe himself to be fair and reasonable in all things and yet still make snap judgements whenever his children are accused of wrongdoing. This is because he is emotionally involved with his children and so his decision-making becomes less fair and reasonable and much more unfair.

He can be very well aware of this bias and admit it to himself and others in certain circumstances but at other times he simply ‘forgets' the uncomfortable truth and will genuinely believe himself to be fair, perhaps when speaking to his boss or some other authority figure. 

The man is not being dishonest - he's just using ‘doublethink'. 

An example that may be more relevant to social care would be the service-user who believes on one hand that all care workers are cruel but on the other hand believes that one particular worker, John, is compassionate and caring. So he has three beliefs:

1. John is a nice bloke;
2. John is a care worker;
3. All care workers are evil.

He can continue to believe all three things (maintain the beliefs) provided that he doesn't think about them all at the same time. He sets up a ‘mental barrier' that keeps the ideas separate.

 One way to get people to re-evaluate their beliefs is to get them to think about their conflicting beliefs at the same time. This could be as straightforward as asking the service-user how his belief that all care workers are evil fits in with his opinion about John. Usually when this is done the service-user modifies or changes one belief to fit another. So he may decide that some but not all care workers are evil - that means that he can start to see people in a fairer light.

Be warned though - the other idea might change instead. He might just decide that John must be evil too which would be rather less positive. 

This principle, known as ‘belief modification' is used by therapists to reason with delusional service-users and it can be extremely effective. However unless you have been trained specifically to do it, it would be inadvisable and possibly even dangerous to attempt it. However it's good to know the basic principles so that you can support service-users while suitably trained clinicians do the therapy itself. 

Belief modification techniques should never be ‘forced'. This is a gentle process - the service-user will modify his/her beliefs if they're ready to but not before. 

What conflicting beliefs do you hold?

 

Belief	Middle ground (modification)	Belief
I support the fair trade movement	Sometimes I buy fair trade goods but sometimes I need to watch my pocket. My conscience only goes so far.	I buy cheap coffee because it's silly to spend more than I need to

Thought disorders 

There are many types of thought disorder. These tend to be differences in the ‘process' of thought itself rather than in the ‘outcome' of thought. Thought disorders include:

• ‘Flight of ideas' - thoughts rapidly replace each other in the client's mind, often with only very flimsy links to each other;
• ‘Clang association' - clients associate different concepts or subjects because of links such as rhymes, synonyms, or puns. For example;

"I'm telling you - ewes are female sheep and He is a very sheepish man but you shouldn't eat a mandrake - male ducks don't lay eggs";

• ‘Poverty of thought' - absence of thoughts;
• ‘Thought blocking' - the client's chain of thought abruptly ceases;
• ‘Knight's move thinking' - in chess the knight moves one square forward and one diagonal - to put it another way he ‘goes off at a tangent'. Thought and conversation make apparently unconnected leaps from one topic to another ;
• ‘Word salad' - a jumbled mass of apparently unrelated and incoherent words;
• ‘Neologism' - The client uses words they have just invented as though they are part of normal vocabulary;
• ‘Perseveration' - similair to obsession - particular thoughts or perhaps even phrases or syllables repeat in the mind and/or conversation over and over again. They ‘persevere';
• ‘Concrete thinking' - inability to think abstractly;
• ‘Over-inclusivity' - the client includes a great deal of insignificant information when speaking. For example an account of a walk to the shops may contain a lengthy description of the sound the front door made as it closed behind the departing client, which ultimately adds nothing to the real information in question. 

Specifics and ‘one-offs'

• Othello syndrome - a delusional jealousy. Named after Shakespeare's Othello who, becoming jealous of his wife smothered her with a pillow. In fact Othello's wife, Desdemona, had not been unfaithful but Othello refused to believe that.
• Cap Gras syndrome - the belief that one's loved ones or familiar associates are imposters. Think of the film ‘invasion of the body snatchers' to get a feel for this syndrome. It seems to be a way to make sense of the fact that people don't ‘feel' familiar any more. This might be the result of a communication problem between various physical centres in the brain.
• Folie a deux - literally ‘foolishness shared by two' this is a delusional belief shared by two people, generally close to one another such as lovers.

 Psychosis is the main feature of serious and enduring mental disorder (SEMI) like schizophrenia. For a long time workers believed that recovery from psychotic illnesses such as this was impossible but modern methods are overturning that belief. For more information about the nature of recovery and how it is achieved have a look at the handout 'Understanding Recovery' in this series.