Psychosis: a loss of contact with reality
The term psychosis is a very general term used to indicate a loss of contact with reality, both in terms of how reality is perceived and how it is interpreted and judged.
A person experiencing psychosis has beliefs that are not the result of a critical process of examining their own impressions or reasoning, but arise directly, as though thoughts were being translated into reality.
A psychotic state is common to several different illnesses and may occur as a crisis, characterized by agitated or dangerous behavior, or as a more stable condition.
“Acute psychosis” is a diagnosis that may appear on a hospital discharge report when the person is already receiving treatment. However, the diagnosis of acute psychosis needs to be clarified after the initial emergency phase, because treatment strategies and the course of the illness vary according to the underlying disorder.
Some distinctions can be made immediately, for example through tests looking for substances capable of causing psychosis, such as cannabis, hallucinogens, cocaine, or amphetamines, and less frequently alcohol, or by identifying withdrawal syndromes involving alcohol or tranquilizers. These conditions are relatively common in patients hospitalized for another reason who suddenly become agitated, confused, and delusional.
Sometimes the terms “psychosis NOS” (not otherwise specified) or “paranoid psychosis” are used. The latter simply indicates the presence of a delusion (paranoia), without providing precise information about the underlying illness.
Causes of psychosis and diagnosis
Some causes can be identified immediately, such as drug use or withdrawal from drugs or medications that the person had been taking. Depending on the person’s age group, some hypotheses may be more or less likely.
In a young person, excluding drug-induced psychosis, the most likely psychotic disorders range from a first episode of schizophrenia to the more common manic-depressive psychosis (otherwise known as bipolar I disorder), as well as schizophreniform disorder and brief reactive psychosis.
Some of these diagnoses are stable, meaning that they identify actual disorders that do not change over time (manic-depressive psychosis, schizophrenia), whereas others are provisional diagnoses for which observation over time is necessary.
According to statistics, a brief psychosis—that is, one that resolves spontaneously within less than a month, with complete recovery of functioning—is confirmed as a single episode after years of follow-up in approximately one third of patients. In the remaining cases, new episodes occur over time, eventually corresponding either to bipolar disorder or, much less frequently, schizophrenia.
In an adult or elderly person with no previous psychiatric history, acute psychosis should instead raise suspicion of an underlying localized or diffuse neurological disorder, the latter potentially being cerebrovascular or dementing in nature. It should be remembered that Alzheimer’s disease can initially present with psychotic symptoms, and that this may occur even in the presenile age group.
Some psychoses, on the other hand, develop in patients with Parkinson’s disease who are taking antiparkinsonian medications.
Among younger people, psychotic presentations have changed somewhat over recent decades because of the frequent presence of drugs. Drug use can modify the classic course of the illness, increase the persistence of psychotic symptoms even after an episode of agitation has resolved, limit the return to good functioning, and facilitate the recurrence of episodes.
These presentations sometimes resemble previously recognized forms, with the drug simply acting as a triggering factor. In other cases, it is hypothesized that drug exposure produces lasting changes in the brain over time, with a substantial difference in prognosis in the latter situation.
Brief reactive psychosis is a benign form. However, it cannot be diagnosed with certainty if the person has meanwhile been treated with antipsychotic medication. The diagnosis is generally based on the type of clinical presentation and its development: sudden onset in response to clearly identifiable stressful factors, together with a “dreamlike” state of consciousness during the episode, sometimes accompanied by disorganization in the sequence of past and present events or by anachronisms.
This should be considered a definitive diagnosis and should not be made after only a few days while the person is receiving antipsychotic treatment, because this misunderstanding often leads the person to believe that they can stop treatment without risk.
At present, a reliable diagnosis that at least distinguishes among the main psychotic disorders requires several months of observation, unless clear signs of a manic affective episode are immediately apparent (manic-depressive psychosis), or there is already a history of previous untreated episodes of the same type.
An important criterion to consider is whether, during the months following the start of treatment, the person tends to return to their normal responsibilities and concerns (perhaps even complaining that they are unable to function well), or instead remains passively “cold” and uninterested, particularly in relationships with others and in productive activities.
Treatment of acute psychotic episodes
Acute psychotic episodes can be brought under control with treatments that work effectively on symptoms—hallucinations, delusions, agitation, and aggression—regardless of the underlying illness, much like a medication used to treat inflammation or pain.
However, it is important to identify the underlying disorder as soon as possible, so that the most appropriate treatment can be selected, both to improve the course and residual symptoms and to prevent relapses.
Treatment during an acute episode may differ from subsequent treatment if the psychosis is part of a manic-depressive illness. In schizophrenic psychosis, it may simply be a matter of planning continued treatment and adjusting the dosage.
The antipsychotic treatment that is useful during an acute episode does not always provide effective relapse prevention. This is particularly important in manic-depressive psychosis, which is intermittent and recurrent by nature.
In this illness, continued use of antipsychotic medications, especially at full doses, may also facilitate the depression that follows an agitated phase. Once the acute phase has resolved, it may instead be possible to use other types of medication, or at least lower doses, moving from a strategy aimed at containing an emergency to one focused on preventing relapses and limiting side effects.
Preventing and managing psychosis
From the standpoint of management and risk prediction, there are substantial differences between disorders.
A person with manic-depressive psychosis may, by the nature of the illness, find certain side effects intolerable, potentially leading to discontinuation of treatment. They may also seek out situations or substances that act as triggers for relapse because, in those circumstances, they are attempting to induce a state of greater gratification.
In the absence of these possibilities, a person with manic-depressive psychosis, even when adequately treated, may complain of a state of apathy and emotional dulling, together with social withdrawal and a loss of initiative.
In conclusion, after a psychotic episode, the diagnosis should be oriented toward identifying the underlying disorder, in order to improve treatment selection both in terms of preventive efficacy and the type of side effects involved.
Depressive symptoms are frequently present after a psychotic episode has resolved; their significance also varies depending on the underlying illness.