Commentary

Re-envisioning psychosis: A new language for clinical practice

Current Psychiatry. 2010 October;9(10):23-28

References

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Table 1

The ‘logic’ of schizoaffective disorder applied to anxiety and OCD

Symptom course	‘Primary’ feature	‘Secondary’ feature	Diagnosis
2 weeks of ≥2 psychotic symptoms outside of a major mood episode plus a manic or depressed episode	2 weeks of psychotic and negative symptoms	2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood	Schizoaffective disorder
1 month of social anxiety and avoidance outside of a major mood episode plus a manic or depressed episode	1 month of social anxiety and avoidance	2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood	‘Socio-anxious-affective disorder’*
1 month of obsessions and compulsions outside of a major mood episode plus a manic or depressed episode	1 month of obsessions and compulsions	2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood	‘Obsessocompulso-affective disorder’*
OCD: obsessive-compulsive disorder
* These diagnoses are hypothetical disorders used to illustrate how the criteria used to define schizoaffective disorder subsume other types of symptoms

A continuum approach

As a way out of this inductive logic trap, we suggest the following statements as evidence-based and clinically realistic ways of approaching psychosis assessment.

Clinical Point

Psychotic-like experiences are common and easily induced in otherwise healthy people

‘Normal sadness’ and ‘normal psychosis’ are equivalent. The DSM-IV-TR description of major depressive disorder, states that “periods of sadness are inherent aspects of the human experience.”¹² However, descriptions of psychosis rarely reflect that psychotic-like experiences are quite common^13-19 and easily induced in otherwise healthy people.²⁰ Psychotic symptoms are widely described as being genetically linked to normally distributed personality traits.^21-24 Finally, research on risk for developing chronic psychosis has identified that most patients who develop attenuated psychotic symptoms do not experience them chronically.^25-28 Together, these data argue strongly for a concept of psychosis as common and continuously distributed across large groups.

A psychosis screen can be much more than ‘+/- AH/VH/PI.’ We reject the idea that psychotic phenomena are fundamentally different from “normal” occurrences such as imagined or inner speech, perceptual fluctuations, distorted or rigid beliefs, or inability to accurately express one’s emotional state. Yet abnormal perception, affect flattening, and delusions often are viewed as “really weird,” which suggests most people never experience these phenomena, only “affected” people. This easily can lead to cognitive errors that associate psychosis as a state of mind that is fundamentally different from non-psychosis. In fact, DSMIV-TR categorizes the presence of persistent psychotic symptoms as evidence of disorder until proven otherwise.³

We feel that this simplistic language describing psychosis as inherently pathological ignores the clinical richness of psychotic experience. In our experience, many individuals who have been diagnosed with chronic psychosis have never been asked:

about the timing, intensity, and character of their abnormal sensory experiences²⁹
how their beliefs and schemas affect day-to-day behavior and choices
if their psychotic symptoms are bothersome or troubling.

We worry that a person experiencing impairing psychotic symptoms could become overshadowed by all-or-none assumptions about the symptoms themselves.

Clinical Point

Approaching psychotic symptoms as expressions on a continuum allows for a therapeutic alliance that focuses on patient recovery

We propose Table 2 as a guideline for approaching psychotic symptoms as expressions along a continuum of experience, one that shares much in common with recent well-developed biopsychosocial models of psychotic phenomena.³⁰ In our view, this allows for a therapeutic alliance that focuses on patient recovery, as opposed to seeing psychotic symptoms as the only treatment targets. By moving beyond all-or-none myths and approaching psychosis as a continuum with normal experience, we believe that patient recovery can become a realistic goal.

Table 2

Revising the clinical language of psychosis to separate presence from pathology

Symptom	Continuum	Attenuated experience	Pathological experience (‘disorder’)	Psychotherapeutic intervention
Paranoid ideation/delusions	Schematization and testing of environmental information	referential thinking suspiciousness negative attitudes of others confusion about accuracy of thoughts feelings of special purpose or meaning loss of control over own thoughts	frequent preoccupying leads to maladaptive behaviors	encourage curiosity about beliefs, evidence gathering, and alternative hypothesis testing design new and adaptive safety behaviors develop individual formulation of experience
Hallucination	Higher order sensory processing and self/other discrimination	perceptual changes increased sensitivity to light and sound senses ‘playing tricks’	frequent intrusive distressing conviction about external source leads to maladaptive behaviors	discuss phenomenon as exaggeration of normal brain function focus on socially appropriate coping skills (eg, talking into cell phone to have a ‘conversation’) develop individual formulation of experience
Disorganized speech / ‘thought disorder’	Social pragmatics and conceptual linking	difficulty ‘getting point across’	little insight little attentional control	emphasize social appropriateness of linearity and tangentiality encourage circumstantial thinking as a creative outlet
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