The word “crazy” means different things to different people. A cat lady is crazy. That homeless guy on the street is crazy. Your ex girlfriend is crazy (or at least she has a personality disorder).
However, there is a much more interesting, much more dangerous form of crazy – psychosis.
I throw around the words “psychotic” and “psychosis” a lot at work, and sometimes I forget most people don’t know what those terms mean (I didn’t before going through medical school). So here I’m going to break down the concept.
When someone is psychotic it means they are experiencing one (or more) of the following symptoms:
- Hallucinations, or a sensory stimulus that isn’t there. For example, a person may see an image that isn’t there (visual hallucination) or hear voices that aren’t there (auditory hallucination).
- Delusions. A delusion is a firmly held, fixed, and false belief. Delusions can be nonbizarre, meaning that the belief is unlikely, but within the realm of possibility, such as thinking the CIA is following you. Or they can be bizarre, meaning that the belief is totally impossible, such as thinking aliens implanted a microchip in your brain (this type of delusion is characteristic of schizophrenia).
- Disordered thinking. Disordered thought is a hallmark of schizophrenia. It’s evidenced by disordered speech, such as loose associations (jumping from one unrelated topic to the next), thought blocking (stopping conversation midsentence), and “word salad” (speech that is incoherent because words are meaninglessly strung together).
The interesting thing about psychosis is that only a handful of disorders cause these symptoms, so it’s usually not too tricky to narrow down the diagnosis.
[As a side note: Psychosis is not caused by stress (although stress can bring out underlying symptoms). It is (usually) an indication of a serious mental or physical illness. Or an indication that you just did some LSD. It often requires treatment with heavy-duty antipsychotic medications.]
Here’s an overview of the most common conditions leading to psychosis.
Probably the most common cause of psychosis is the use of illicit drugs, such as marijuana, hallucinogens (LSD, acid, schrooms), or amphetamines (meth, cocaine). If you don’t experience psychotic symptoms while using hallucinogens you’re probably not getting your money’s worth.
Usually the effect wears off when the drug wears off, although I’ve seen patients who used so many drugs for so long that they have lingering psychotic symptoms even after a period of time off substances.
I see patients who are psychotic after taking drugs at the VA all the time. They go out, do some meth, and then come into the ER sure that the Mexican mafia is trying to kill them or that they’re being followed.
I had a patient who, after snorting bath salts (a new synthetic amphetamine derivative that is can be purchased at head shops), abruptly left the hotel room where he was staying because he became paranoid that people were trying to break in and kill him. He left all of his stuff behind (including wallet, ID, money) and then after wandering the city streets for a few hours wasn’t able to find the hotel, and lost all of his valuables.
Substance-induced psychosis will usually go away on it’s own once the person stops taking drugs. However, for people with lingering symptoms off drugs, a psychiatrist may prescribe antipsychotic medication as treatment.
Major Depressive Disorder with Psychotic Features
When people get really, really depressed, they can become psychotic. This is extremely common in older adults. I had a patient at UCLA last year who was a woman in her 80s. Over a period of months prior to her hospitalization she became increasingly depressed.
As she became worse, she started to have delusional beliefs that the devil was “influencing” her.” She was convinced the devil was calling her on the phone and then hanging up once she answered. She thought the devil had bugged her house and was listening in on all of her conversations. Even in the hospital she attributed small incidents, such as not being able to find the remote, to the devil’s influence.
The psychotic symptoms in psychotic depression are congruent with the person’s depressed mood. For example, people may here voices telling them they’re a bad person, or that they should hurt themselves. They may have delusional beliefs about people trying to punish them.
Treating Major Depressive Disorder with Psychotic Features almost always requires medication. Psychotic symptoms indicate severe depression. A psychiatrist would use both an antidepressant to treat the mood symptoms and an antipsychotic to treat the psychotic symptoms.
In older adults, we often use ECT (electroconvulsive therapy) to treat psychotic depression because it’s extremely effective and has fewer side effects than medications.
Bipolar Disorder in a Manic Episode
Bipolar Disorder is characterized by alternating periods of depression and mania. Mania is characterized by a period of a persistently elevated and euphoric mood, decreased need for sleep, rapid and pressured speech, increased goal-directed activity (such as staying up all night to write “the next great American novel”) and reckless behavior, such as gambling, sexual promiscuity, or spending large sums of money on things the person can’t afford (like buying a yacht). When people are manic, they often become psychotic.
People who are manic will have mood congruent, grandiose delusions. They’ll think they’re the president of the United States. They’ll think they’re Jesus. They’ll think they have six PhDs and that they’re dating Lindsay Lohan.
We typically treat a person who is manic and psychotic with a newer generation atypical antipsychotic, such as Zyprexa, Risperdal or Abilify, plus/minus a mood stabilizer such as Lithium or Depakote.
Schizophrenia or Schizoaffective Disorder
Schizophrenia (or Schizoaffective Disorder, which is Schizophrenia plus a prominent mood disorder, such as Depression or Bipolar Disorder) is a primary psychotic disorder. This means that the psychotic symptoms are a primary feature of the disorder and are not resulting from mood symptoms.
Schizophrenia is characterized by:
- Hallucinations (usually auditory hallucinations of voices)
- Disordered speech or behavior
- Negative symptoms, such as blunted affect, poverty of speech, and decreased motivation
Certain psychotic symptoms are so characteristic of schizophrenia that they are diagnostic of the disorder. These are “first rank symptoms.” They include:
- Auditory hallucinations or two voices arguing with each other.
- Auditory hallucinations of a single voice making a running commentary on the person.
- Thought withdrawal – the delusion that thoughts are being pulled out of the person’s head.
- Thought insertion – the delusion that thoughts are being put into the person’s head.
- Thought broadcasting – the delusion that other people can “hear” a person’s thoughts.
Schizophrenia is a serious, lifelong mental illness that requires ongoing treatment with antipsychotic medications.
Delusional Disorder is uncommon and difficult to treat. It is diagnosed when a person who is otherwise normal has a fixed, nonbizarre delusion that they continue to believe even in the face of evidence to the contrary. For example, a woman who becomes absolutely fixated on the idea that her husband is cheating on her, which no evidence to support it, may have delusional disorder. She’ll attribute small, insignificant things, such as seeing a door left ajar or there being less milk left in the fridge than she remembers, as evidence of her delusion.
Psychosis Secondary to a General Medical Condition
Sometimes a person has psychotic symptoms because of a physical, rather than mental illness. For example, a brain tumor pushing on the visual cortex might lead to visual hallucinations. When a patient with no past psychiatric history comes into the hospital with new-onset psychotic symptoms, we often do head imaging such as a CT or MRI to ensure there is not a tumor.
Delirium is a condition very common in medical ill people (such as patients with infections, metabolic abnormalities, or who recently had surgery) that results in confusion, disorientation, and often hallucinations or delusions. The term “ICU psychosis” (not actually a medical diagnosis) refers to the delirium that commonly occurs when a patient is in the ICU.
Just last week I had a patient who was in the hospital with a subdural hematoma from a ground-level fall. In the ICU she became confused, thinking she was in her house and accusing nursing staff of being intruders who had misplaced her furniture. After a few days her mental status cleared and she was able to go home. She joked that she was “crazy” for believing some of the things she did when she was delirious. Often we use short-term low-dose antipsychotics – most often haldol – to treat delirium.
I Bet You Didn’t Know There Was So Much to Psychosis
Next time you call that random person on the street “crazy,” I want to hear what your diagnosis is :-).
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Image by Morgaine