Aetiology

What is Psychosis?

Psychosis is an illness of the brain that involves an abnormal mental state. About 3% of the world’s population reports having displayed the symptoms of psychosis at some point in their lives. Based on Hong Kong’s population, there are 5 new cases every year in every 10,000 people. Psychosis affects people of all age groups, but it is most prevalent in 15-25 year olds, affecting about 700 individuals within this age range every year.

It is important for individuals suffering from psychosis to seek help as soon as possible. Local research shows that psychotic patients seek help on average 1.5 years after displaying symptoms, and this delay significantly impacts their recovery. If left untreated, psychosis may develop into more serious mental illnesses.

Patients’ thoughts, emotions and feelings detach from reality during their psychotic episodes. There are positive and negative symptoms:

Positive Symptoms

  • Positive symptoms are those that most individuals do not normally experience but are present in people with psychosis.Positive symptoms include hallucinations, delusions, and thought disorders (i.e. disorganised thoughts/speech).

Negative Symptoms

  • Negative symptoms include the loss of usual abilities. Affected patients will appear to be emotionless, displaying poverty of speech, lacking motivation, socially withdrawn, etc.

Most patients who seek help from professionals and receive treatment soon after they start to display symptoms are able to remit from these symptoms. Each patient’s behaviour and recovery process is affected by individual and environmental factors. Family and friends also play crucial roles in a patient’s recovery.

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What are the symptoms?

​If an individual displays the three key positive symptoms described below, they may be suffering from psychosis:

  • Disorganised speech and thoughts (Thought disorder)

The patient speaks very quickly or incoherently, the content of conversation is often empty, and they often digress, which makes it very difficult for others to understand.

  • Hallucinations

The patient may see, hear or feel something that does not exist, but the experiences are very realistic to them. For example, they may hear non-existing voices talking to them. In response to these voices, they may talk back and hence appear to be self-muttering, burst into laughter spontaneously or get angry.

Due to how realistic these experiences (hallucination and delusion) are to the patient, and how negative the contents are, their behaviour and emotions may also be affected. Therefore they may behave in a way others cannot understand.

Aside from the three key positive symptoms, individuals affected by psychosis may also display negative symptoms such as:

  • Lack of interest towards their surrounding

Not willing to interact with people or go to school or work; increased sleeping time; decreased activity time.

  • Appearance of being emotionless

Lack of facial expressions, apathy toward their surroundings.

  • Lack of speech

Becoming very quiet and rarely speaking.

  • Lack of self-care

The disregarding of personal appearance and hygiene, such as not showering, not paying attention to their clothing, or hair etc.

The above symptoms are less obvious and likely to overlap with other conditions. Family and friends may incorrectly attribute them to the patient’s personality, such as misinterpreting their lack of motivation as being lazy or unambitious.

If anyone you know displays the above symptoms, mood disturbances or deteriorating physiological functions that persist for one to two weeks or longer, affecting different aspects of their life (i.e. social, domestic), please seek help as soon as possible.

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What is a hallucination?

A hallucination is the experience of a sensory perception despite the absence of an external stimulus. Patients find these experiences very realistic, and these can occur with any senses- visual, auditory, gustatory, olfactory or tactile. Generally speaking, a hallucination can  be defined only when the person was conscious during the episode.


Auditory hallucinations (AH) are the most common type of hallucination in people with conditions such as schizophrenia and is normally described as ‘hearing voices in the head’. The voices can be complimentary, but are often critical with negative content. Sometimes the voices might be talking about the person, or even speak coherently to the person, giving out commands and engaging the person in conversation. One, or many voices can be heard at a time; most of the time the person is unable to control the onset or disappearance of the voices, leaving them feeling very helpless and frustrated. 
 

The process that underlies AH remains largely unknown, AH is commonly found in persons with schizophrenia, with a prevalence of 70% in that population (1). 8-15% of AH have been estimated to occur without any neuropsychiatric illnesses (2); these may have been triggered by traumatic events, drug intoxication or other diseases such as visual impairment. Whilst simpler AH such as the inability to distinguish between noise and a tune are thought to be related to other brain pathologies, complex AH with organised and structured sentences are more likely to be due to schizophrenia.


According to the Dialogical Self Theory, our brain ‘rehearses’ conversations unconsciously. When there is a problem in our thought processing, we may mistake our own thoughts as signals from the surroundings thus hallucinations are heard. Whereas the Attribution Theory however suggests that patients attribute all sounds heard as someone else’s.  


Contrary to AH, visual hallucinations (VH) are less prevalent in persons with schizophrenia.  VH are seeing things that do not exist; these ‘things’ can be an object, a person or a picture, e.g. when the person hallucinates, (s)he may see a non-existent person whom no one else can see. Like AH, VH can occur as a result of schizophrenia as well as other brain pathologies; simpler VH such as colours and shapes are related to the latter, ranges from encephalitis, meningitis to hypoglycaemia and low levels of oxygen in the blood. More complex VH are more closely related to delirium and schizophrenia. 
 

Other patient may have tactile hallucination, felt that there are moving objects on their body such as insects, or their organs moving within their body and being touched.

 

As these hallucinations are very realistic for the patient, if your loved one is experiencing hallucinations, do not deny their existence, instead listen to them and give appropriate responses. If you wish to find out how to manage hallucinations, please click here.


(1) Tracy, D.K.; Shergill, S.S.    Mechanisms Underlying Auditory Hallucinations—Understanding Perception without Stimulus. Brain Sci. 2013, 3, 642-669.


(2) L.J. Johns, J.Y. Nazroo, P. Bebbington, E. Kuipers. Occurrence of hallucinatory experiences in a community sample and ethnic variations. Br. J. Psychiatry, 180 (2002), pp. 174–178

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What is a delusion?

A delusion is a belief that is false and lacking in any supporting evidence. The affected person is convinced and holds on to this belief firmly despite evidence or past experiences pointing to the contrary. People with delusion often misinterpret or highly exaggerate experiences and perception such that everything is relatable and concerned with them.

There are many types of delusion, classified according to their content, here are a few examples:


Delusion of Reference

This is the most common form of delusion seen in people with schizophrenia, thus it is often a warning sign for prodrome for psychosis and its relapse. The patient believes that the surroundings have a special message for him. Examples of this are people on television or blogs talking about him; gestures of strangers having ‘hidden messages’ contained that only he can perceive, or particular actions from strangers purposely annoying him.


Misidentification

- Capgras syndrome where the patient believes that one of his family members has been replaced by an identical impostor, or

- Fregoli syndrome where a family member is disguised as a stranger.


Being controlled

The patient believes that his thoughts, his actions and his speech are under the control of external forces and he has no control over it. The patient anticipates the forces are from the spiritual world, for example they believe the evil spirits are moving his/her shoulder, or God is controlling his/her arm.


Hypochondriasis

People with delusion may also hold beliefs that they have a medical condition or a serious disease. They are obsessed with this idea that their illness is not yet diagnosed even though no medical evidence to support this. Some of them may also deny the existence of certain things there is in the real world.


Delusion of persecution

The patient believes that he has been targeted by others, often ‘they’ are ‘after him’ to harm him.


Delusion of grandeur

The patient has a false belief that he/she is ‘special’; (They may be famous, have special powers or wealth. For example, the patient may believe they have a close relationship with a very prominent person.


Thought block, insertion, withdrawal

The patient has the idea where someone else can think through the person’s mind, placing thoughts into their head, stopping thoughts or thoughts are being ‘taken’ from their head.


Psychiatrists have gathered their clinical experiences, their understanding for delusions and speculations in attempt to explain this disorder, and the following are a few of the theories mentioned:


Attributional bias

A negative event widens the gap between our ideal self and the reality. Self-serving bias is a cognitive error which the person attribute their failure to external forces, rather than accepting personal responsibility. The tendency to hold self-serving bias is particularly severe in deluded patients.


Probabilistic reasoning

Patient may show a ‘jumping to conclusion’ style of probabilistic reasoning even when there isn’t enough information.


Aberrant salience

Due to the huge amount of information that surrounds us in our daily environment, not all information exchanged will be registered into our conscious mind. The more relevant and significant the information we receive, the more activated our dopaminergic system becomes, resulting in ‘salience’. When chaotic dopamine firing occurs, stimuli that would normally be considered irrelevant becomes ‘salient’. As a result, when the person is experiencing aberrant salience, there is a greater likelihood of developing delusions.


Studies have shown that around half of those with delusion will carry out subsequent actions, mostly defensive actions for him/herself or others; people with delusion are not usually violent. It may be difficult for the patients’ family and friends to understand the patient at times, as the delusional thoughts can be very incomprehensible; Even when family and friends refute the delusions with logic and evidence, the patient will remain adamant and is unable to accept another explanation. We must understand that these delusional thoughts are brought on by the illness, and therefore avoid arguing with the patient. The patient’s delusion can affect the emotional well being of the family, however as their loved ones, we should avoid emotional over involvement, ridicule their beliefs or be intimidating.


If you wish to find out more on how to deal with delusions, please click here.

 

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What are negative symptoms?

​Under the influence of negative symptoms, patients’ abilities may be lost or attenuated. These negative symptoms include:

Blunted affect
Reduced intensity and variety in emotional expression; flat expression; and not reacting to circumstances at all

Restriction in thinking ability and language fluency
Alogia; poverty of speech, and lack of additional, unprompted content

Lack of motivation
Lack of desire to form relationships: asociality, unwillingness to go to school or work, hypersomnia, and low activity level, increasing lack of care about own appearance and personal hygiene


It is more likely that negative symptoms cripple a patient’s life quality more than positive symptoms do. As such, caregivers nursing people who exhibit negative symptoms may feel an onerous burden. In general, negative symptoms last longer than positive ones in the majority of patients, and are more difficult to treat. There exists a close relationship between improving negative symptoms and enhancing own functions, which include independent living abilities and social abilities.  

Family members may find it difficult to assess whether the patient is under the influence of negative symptoms, because these symptoms are similar to normal behaviours. Furthermore, many pertinent factors are involved, for example, medication side-effects, and mood problems. Contrary to positive symptoms, we may pay less attention to negative symptoms, but mistakenly attribute that our relationship with the patient is strained. We should be patient in encouraging the patients to overcome the difficulties brought by negative symptoms.

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What are the stages of Psychosis?

What are the stages of Psychosis?

Prodromal Stage
Certain signs may occur for a few months or even a few years prior to the onset of psychosis, such as deterioration in one’s social life, academic performance, working abilities, or psychological conditions. The patient may also display some of the prodromal symptoms such as insomnia, paranoia, difficulty in concentration, depression, anxiety, and irritability. These symptoms are vague and not obvious, and are therefore often overlooked instead of being treated as prodromal symptoms of psychosis. If a friend or a family member displays the above symptoms for a substantial period, professional help may be needed.

Active Stage
Patients in the active stage may display obvious symptoms such as thought disorders, delusions and hallucinations. If someone you know displays these symptoms, they should seek help as soon as possible. If the affected individual can receive treatment earlier on, usually these symptoms can be under control quickly and the outcome is likely to be better.

Recovery Stage/ Residual Stage
Most patients are able to recover after treatment, however, the time needed for recovery is variable for each individual. During the course of recovery, it is possible for the patient to continue to display some symptoms, such as reluctance to interact with people, apathy towards their surroundings, lack of speech, insomnia/oversleeping, mood disturbances or aberrant behaviours. The improvement of these symptoms may take a much longer period, and help from different professionals and support from wider community is crucial. Once the individual has entered the recovery stage, we should be prepared in order to prevent any relapses.

 

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