Psychotic disorders are composed of symptoms that are either fixed, false perceptions or cognitions, or grossly disorganized cognitions or behaviours.
Types of symptoms of psychotic disorders
There is always a level of fracture from reality, with symptoms generally fitting into four categories:
Delusions are fixed, false beliefs (cognitions) about absolutely anything, which are not open to change in the light of conflicting evidence. So believing the Earth to be flat is not in and of itself a delusion. However, believing the Earth to be flat after being shown a photograph of the Earth taken from space would indeed be delusional. Many delusions are paranoid or persecutory in nature. However, delusions can also be grandiose, erotomanic (the false believe that someone is in love with them), nihilistic, somatic or anything else. Most delusions are considered non bizarre, in that they remain plausible or at least understandable to some degree. However, there are also others that are classified as bizarre, especially on themes that express a loss of control of mind or body. These are regarded as not being understandable or making any sort of sense, within the socio-cultural perspective of the individual. Examples of this might be the fixed belief that thoughts have been inserted into someone’s head via alien means, or that a person’s thoughts have been removed from their head, or that the person / their body is being controlled by a being outside of themselves, or that an organ has been removed without any sign of surgery.
Hallucinations are fixed, false perceptual distortions – distortions in any of our five senses. They need to occur without an external occurrence (eg. a trick of light) and be held onto unerringly. So if I hear a dog bark in the yard, and investigate and can agree that there never was a dog in the yard and that I merely misheard something else, then this would not be a hallucination. If I continued to hear the dog barking in the yard, despite investigation or without there being any mistakeable noise in my environment, then this would be a hallucination. Hallucinations can occur with any of our senses, though they tend to be auditory. Olfactory hallucinations without any discernable cause (eg. COVID) are quite often indicative of organic brain trauma.
Disorganized thinking is most readily evidenced through disorganized speech. Forms of switching topic readily might include circumlocution (frequent and severe meandering of point before coming back to the original topic), loose association or derailment (meandering off point where the original point is never revisited). At this point many of you may feel that your spouse suffers from this problem. Let me persuade you that the symptoms need to be severe and that the person needs to be incapable of – for example – staying on topic. Severely disorganized speech often begins to resemble “word salad”, where words uttered may merely be linked by theme (e.g. throwing out names of fruit) or have nothing in common whatsoever.
Disorganized behaviour or motor functioning
It must be stressed that behaviour or motor functioning must be grossly disorganized – we are not talking about your spouses’ 2 am meanderings around the garden! An example of this is catatonia or catatonic behaviour, where an individuals grossly reduced sensitivity to environmental stimuli might lead them to assuming the same position for hours or even days.
The four categories above are classified as positive symptoms, in the sense that there tends to be the presence or accentuation of something, for example, a fixed false belief. Negative symptoms involve the absence or significant reduction in something. These might include the following:
- Avolition is a reduction in motivation,
- Lack of or diminished effect – this is viewed through the objective observation of a reduction in range of tone of voice or behavioural expression,
- Asociality is a reduction in interest in social activities,
- Anhedonia is a loss of interest or pleasure,
- Alogia is a reduction in speech output.
Delusional Disorder is a psychotic disorder where the only symptoms are delusional in nature (fixed, false beliefs). Any diagnosis of schizophrenia would preclude one of delusional disorder. General level of functioning of someone with delusional disorder remains fairly high.
The lifetime prevalence of delusional disorder is low at around 0.2%.
Because of the absence of other psychotic symptoms, many people with delusional disorder function sufficiently in society to hold jobs and have relationships. They are often only diagnosed later in life, as they often gravitate towards expressing the extremes of their beliefs. So someone might go to therapy – or be packed off their by their spouse – as their delusional system has become more debilitating over time or their spouse has had enough of dealing with the paranoia. A different person with delusional disorder might slowly gravitate towards more and more extreme religious affiliations until even the fringe denominations oust them from their congregations, at which point the subjective distress might lead them to get help.
Cognitive behaviour therapy is often successful with delusional disorder in interrogating the fixed, false beliefs.
Schizophrenia is a psychotic disorder where at least two of the above five symptoms of delusions, hallucinations, disorganized speech, disorganized behaviour and negative symptoms needs to be present. One of these symptoms must be delusions, hallucinations or disorganized speech. With untreated schizophrenia, unlike with delusional disorder, level of functioning in areas such as work, interpersonal relations, or self-care tends to be low.
Prevalence of schizophrenia is surprisingly high at around 1%. I often get asked the question: “then where are all the schizophrenics”. Many people suffering from schizophrenia require permanent inpatient treatment or supervision or live in some degree of a sheltered environment, either in a home or with their loved ones. However, there are other people with schizophrenia who manage to hold down autonomous jobs or at least some form of sheltered employment. Most of these take their anti-psychotic medication religiously (defaulting on medication is a big problem with psychotic disorders).
Generally speaking, positive symptoms of schizophrenia tend to kick in between the ages of eighteen and thirty, though there are much rarer cases of children developing schizophrenia. When psychotic symptoms develop in an individual it is always important to also get hold of a medical doctor, who may refer you on to a neurologist or neuropsychologist to make sure that these symptoms are not being caused by a medical condition. Nasty things like space-occupying lesions in the brain can cause psychotic symptoms, and these are much more effectively treated if picked up early on.
The symptoms of schizophrenia that respond poorest to medication tend to be delusions and negative symptoms. Delusions can be stubborn and hard to dispel, but in recent years there has been a substantial amount of success in challenging these through the process of Cognitive Behaviour Therapy.