Psychosis and Schizophrenia: Whose Reality is This, Anyway?

We all receive information about the world through our senses, in a manner that seems unremarkable. Our common sensory experiences enable us to build models of reality that are similar, and this shared understanding helps us to live and work together in a reasonably smooth fashion.

These models are not completely consistent with each other, of course, or we would not have different beliefs. We also wouldn't make the common mistake that just because we believe something, everyone else should believe it, too! However, these differences are the result of different priorities and thought processes, not disagreement about the reality we perceive through our senses.

Yet not everyone shares this consensus. Some people perceive a reality that is both quite different from the norm, and has elements that are clearly wrong. They suffer from a set of symptoms called "psychosis."

The most dramatic symptoms of psychosis are hallucinations (false perceptions), and delusions (false beliefs).

Hallucinations are sensory perceptions that do not originate in physical reality. Because these are perceived as coming from the senses, it can be difficult for the person to tell that they are not real. Hallucinations can take the form of false images, sounds (often voices), physical touch, or even smell and taste.
Delusions are powerful beliefs that are clearly wrong and impervious to evidence. Delusions are often paranoid in nature, with individuals believing, for example, that secret government agencies are spying on them, or trying to control their minds.

Hallucinations and delusions are the primary symptoms of psychosis. They are often accompanied by an inability to recognize that anything is wrong. This lack of insight, which is called anosognosia, makes treatment very difficult.

People who are in the grips of a severe psychotic episode seem "crazy" to onlookers, but their behavior makes perfect sense from the right perspective: The psychotic person is responding rationally to experiences that the rest of us do not share.

Psychotic episodes can arise from many different reasons. Many illegal drugs and prescription medications (such as cocaine and amphetamines), taken at a large enough dose, can cause psychotic symptoms. Psychotic episodes can also occur during severe manic episodes, for people who have bipolar disorder. However, the illness most associated with psychosis is schizophrenia.

Schizophrenia is a very serious illness. While it includes psychosis as the most obvious set of symptoms, this illness often causes severe suppression of the normal range of emotions as well. The blunted emotions can rob the ill person of all joy in life, and produce a strange, almost emotionless style of behavior ("flattened affect") that is very disturbing to others.

Treatment for schizophrenia is less advanced, and less satisfactory, than for depression and bipolar disorder. The newest generation of "atypical" antipsychotic medications does a better job in treating schizophrenia than the older "typical" antipsychotics, but is far from ideal. On the positive side, these medications frequently help with both psychosis and blunted emotions. On the negative side, they seldom do a perfect job of either, and the side effects can be severe. Side effects include diabetes, permanent movement disorders (such as Tardive Dyskinesia), Parkinsonism, serious weight gain, depression, and sexual dysfunction.

Treatment for psychosis arising from bipolar disorder tends to be more successful, partly because the psychosis is more episodic than for schizophrenia, and partly because there are fewer to treat. Atypical antipsychotics are used in this case as well, so while the treatment may work, the side effects remain as significant problems.

The bad news is that much remains to be done in understanding and treating psychosis, in all the cases where it arises. The good news is that the last few decades have seen much progress, and more will come.

Kevin Thompson, Ph.D. is the author of Medicines for Mental Health: The Ultimate Guide to Psychiatric Medication. You can find information about treatments for depression, bipolar disorder, schizophrenia, and sexual problems on his Web site at www.MentalMeds.org.