PSYCHOSIS


Geraldo José Ballone

Psychosis,according to several authors, is a mental condition characterized by adistortion of the sense of reality, an imbalance and lack of harmony between reason and affectivity.

All psychiatrists should be aware, as Uchoastates, of the importance of factors such as constitution, temper, character, typological peculiarities, background experiences and family and/or social environment in the onset and development of psychosis. The links of this multiple causality in psychosis have drawn the permanent attention of researchers in psychopathology and have resulted in endless discussion among the different programs in Psychology.

If any conclusion about this bitter quarrel between the several tendencies on mental disease can be drawn, it is simply that there is a fundamental incompatibility between the two major approaches to deal with insanity: the clinical view and the cultural view.  The clinical approach of mental disease will always differ from the cultural and philosophical approaches.


CLASSIFICATION

The several tendencies of reflection on mental disorders, notably about psychosis, although arising from different historical moments in psychological thought, stimulate the discussion about the subject.There are authors who support the sociogenic model, where a complex and demanding society is the exclusive responsible for human madness; aswell as authors who support the organogenic model, totally opposed to the previous one, where the organic elements of brain functions are the absolute responsible for mental disorders;  and those who favour the psychogenic model, where the psychic dynamics is solely responsible for the disease and where personal constitution dispositions should not matter. Finally there is the organodynamic model, which encompasses all the previous ones in a bio-psycho-social approach.

In clinical psychiatry there is an almost unanimously consent regarding the association of some configuration of predisposed personality and the onset of psychosis. These personalities are called pre-morbidity personalities, whose concept is dealt under the chapter of "Personality Problems", both by the ICD (International Classification of Disease) as well as by the DSM   (Diagnostic and Statistical Manual of Mental Disorders). It refers to the constitution of problematic personalities that, by themselves,cause a major change in the life of the person, not allowing him or her to reach a total development and, under certain circumstances, provoking a higher susceptibility to the onset of some psychic conditions.The pre-morbid constitution (personality) is considered in psychopathology as a variation of being human and translates a possibility more prone to the development of certain psychic vulnerability. Here the term "possibility" must be considered in its full acception, that is, it is not a mandatory character but nevertheless it must be taken very seriously.
 

SYMPTOMS AND PROCESSES

Clinically and as a generalization, we can say that neurosis differ from psychosis from the level of involvement of personality, as its disorganization and breaking apart is much more pronounced in psychosis. The link with reality is much thinner and weaker than in neurosis. In the latter, reality is not denied, but experienced with more suffering, it is valued and perceived according to the filter of a problematic affectivity and it is represented according to conflictive needs. As in psychosis, some aspects of reality are denied al together and replaced by peculiar and particular conceptions that respond solely to the characteristics of the disease itself.

Psychotic symptomatology is characterized mainly by changes at thought and affectivity spheres and therefore, affects all behaviors and all existential performance of the person will suffer.  While in neurosis, thought, feelings and affectivity are quantitatively altered, in the case of psychosis these psychic attributes are displayed as qualitatively ill, as a pathologic happening chronologically located in the life history of the patient, and that, from this moment on, acts morbidly upon his whole psychic performance.

Psychotic process imposes upon the patient a pathologic way of representing reality, of elaborating concepts and relating itself to the object word.  What counts here is not so much the quantitative variations of perception of reality, as it might take place in depression, for instance, but rather something new and qualitatively different from all variation normally allowed in normal people, something essentially pathologic, morbid and suffering.
 

SCHIZOPHRENIA

Schizophrenia, the most representative characteristics of psychosis, is a disease of the total personality that affects the central part of the ego and alters the whole living structure.  Culturally, the schizophrenic represents the stereotype of the "mad", an individual that produces great social strangeness as the recognized reality is despised. Acting as someone who broke the boundaries of cultural agreement, the schizophrenic feels contempt for reason and lose his freedom to escape his own fantasies.

According to Kaplan, approximately 1% ofthe population suffers from this disease,  which,  generally, is shown before the age of 25 and reaches all  socio-cultural levels. The diagnosis of the disease is still exclusively based upon a psychiatric history and an examination  of the mental state, although  news ways of investigation by means of functional imaging are advancing rapidly and will provide a more precise diagnosis.   It is extremely rare that schizophrenia manifest itself before the age of 10 or after theage of 50 and it seems to prevail equally between men and women.

Esquirol (1772-1840) considered madness as the sum of two elements:  a predisposition cause, bolted to personality, and an exciting cause, supplied by the environment. Nowadays, after many years of reflection and research, modern psychiatry reaffirms the same with updated words. The main model for the integration of ethiologic factors in schizophrenia is the stress-diatesis model, which supposes the person possesses certain specific vulnerabilities, which is under the influence of stressing environmental factors (exciting cause).
Under certain circumstances the binomial diatesis-stress would lead to the development of schizophrenia. Until anetiological factor for this disease is identified, this model seems to satisfy  the accepted theories regarding  this theme.

Nowadays, by means of the ICD-10, Schizotypical Disorder has been included among schizophrenia. In fact, we do consider it as yet another kind of disease, but maybe rather a specific stage of the same disease. Taking into consideration the general and first-degree symptoms of schizophrenia, we could understand Schyzotypical Disorder as being a pre-morbid phase of psychosis.  It would constitute a stage more serious than the Schizoid Personality Disorder and less morbid than full Schizophrenia.  This view is so adequate that ICD-10 itself considers this disorder as synnomin with  Prodromic, Borderline or Pre-Psychotic Schizophrenia. .

Some symptoms, although not specific of schizophrenia, are of considerable diagnostic value. They include:

1- listening to your own thoughts (like voices)
2- audio hallucinations that comment upon the patient own behavior
3- somatic hallucinations
4- feeling of external thought control
5- irradiation of thoughts
6- sensation of his own actions controlled and influenced by some external object or force.

Trying to group to symptomatology of schizophrenia to sum um the main scholars in the field, we should underline three attributes of psychic activity that are morbidly involved: behavior, affectivity and thought.  Deliria appear as changes in the content of schizophrenic thought and hallucinations as belonging to sensoperception. Both are at the same time cause and/or consequence of the alterations in the areas affected by the disease (behavior, affectivity and thought).
 

DELIRIUM

Delirium in schizophrenia can arise from a false interpretation of  perceived reality. Such is the case, for instance, of a patient who feels something is being plotted against him just because he sees two people having a normal conversation. In this case,it consists of a delirious perception.   In this way, delirious perception needs some stimulus to be deliriously interpreted (in the example,  people talking). Sometimes there is no need for a stimulus to be interpreted, as in the examples when someone assumes to be a god. This case is referred to as delirious occurrence. The most frequently delirium found in schizophrenia is the paranoid or referential type, that is, with themes about persecution or harm in the  first case and  when the patient thinks everybody refer to him (the radio, neighbors, tv and so, on) in the second case.
In schizophrenia, deliria appear gradually, being steadily noticed by people who are more intimate with the patient. In relation to the referential delirium, initially the family perceive it as the appearance of a certain aversion to TV, to neighbors and so on.
 

HALLUCINATIONS

The most common hallucinations in schizophrenia are first, the audio hallucinations followed by visual ones.  According to Schneider, "of a considerable diagnosis value to the diagnosis of schizophrenia are certain types of hearing voices: listen the own thought (thinking aloud), voices in the shape of speech and answer and voices that comment upon the actions of the patient". This so-called thought sonorization, together with some other symptoms that involves audio hallucinations and sensation of the own thoughts being influenced by external elements, composes what Schneider has considered as a first degree symptomatology. Aschizophrenic might be listening to his own voice, day and night, under the form of comments and anticipations of what he is going to or intend to do, as for instance: "he is going to eat" or "what is he doing now? "He is changing clothes". Another important symptom of schizophrenia is the sensation of thought being broadcast or even extracted or "stolen" by something in the exterior. Subreaction and thought broadcast, are also considered first degree symptomatology. Again we can find the feeling that the actions are being controlled by external forces or influences.
 
 

FIRST DEGREE SYMPTOMS

According to Schneider
 
  • Thought sonorization 
  • Thought abstraction 
  • Thought broadcast (or diffusion) 

    • Feeling of controlled actions

All the other hallucinations, either sensorial ones such audio, visual, touch, smell or cenestesic and kynestesic ones, although considered as accessory symptoms by Bleuler, appear in schizophrenia with a highly significant frequency. Normally audio hallucinations are the first to appear and the last to disappear.

The Author

 
Geraldo J. Ballone
 Site Coordinator PsiqWeb  - Clinical Psychiatry-  didática para pesquisas e consultas

Copyright (c) 2000 State University of Campinas, Brazil
An initiative: Center for Biomedical Informatics
Published: 15.Jan.2000