Academic journal article Current Psychiatry

Re-Envisioning Psychosis: A New Language for Clinical Practice; Our Language Should Reflect That Psychosis Exists on a Continuum

Academic journal article Current Psychiatry

Re-Envisioning Psychosis: A New Language for Clinical Practice; Our Language Should Reflect That Psychosis Exists on a Continuum

Article excerpt

"I haven't wanted to call it psychosis yet ... "

"I'm not sure if this is psychosis or neurosis."

"I wonder if there's a psychotic process underneath all of this?"

"Psychotherapy won't help psychosis."

In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience. (1), (2)


The above quotes speak of psychosis as an all-or-none distinction: a "switch," something fundamentally different from other psychological processes. In this article, we highlight common "all-or-none" myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of "weirdness" but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a "fast track" diagnosis that ignores the complexity of human experience.

Power of language

The word "psychosis" has enormous power for patients, families, clinicians, and the public. It often is used interchangeably with "craziness," "insanity," or "madness." Mental health clinicians use psychosis to describe many phenomena, including:

* breaks with reality testing

* odd or delusional beliefs

* abnormal sensations

* catatonia

* bizarre behaviors

* so-called formal thought disorders.

It is likely one of the most heterogeneous symptom terms in psychiatry. DSM-IV-TR notes "the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance."(3)

Psychosis myths. In addition to its phenomenological usage, the word psychosis also has various theoretical interpretations and often is used to demonstrate a fundamental pivot point for making qualitative distinctions. For example, clinicians and theorists have used "psychotic" to assume that someone experiencing psychosis:

* is operating on a core or primitive mode of thought, the so-called "primary process" (4)

* has a belief that is beyond understanding, one for which empathy is meaningless and misplaced (5)

* has clear convictions that violate social norms and refuses to accept society's "proper" rules for logic and emotion (6)

* is in a state of "brain toxicity" with an "organic" cause (this comes from discussing psychosis with other clinicians, not from the literature).

Such seemingly disparate definitions share the assumption that psychosis represents a shift in categorical status, whether the category is developmental (advanced vs primitive), interpersonal judgment (able to be empathized with or not), sociopolitical status (conformist or not), or functional brain state (organic or non-organic).

Even the etymological basis for schizophrenia (its Greek roots signify "split mind," which arguably spawned the long-held erroneous view that schizophrenia is a "split personality") exemplifies this stance and reinforces the notion of discrete "all-or-none" categories of experience. In our view, such assumptions do not adequately reflect the reality of psychosis as a continuum of human experience, and could lead to serious, if unintended, stigmatization and oversimplification of persons who have psychotic symptoms. We argue that such all-or-none thinking reifies 2 clinical "myths" about what psychosis represents:

* Psychosis represents a fundamentally different type of cognitive process.

* Psychosis is so different from normal human experience that mood and anxiety symptoms become "subsumed" by it and treated as "secondary."

Our goal is not to redefine psychosis or present an argument for diagnostically recategorizing schizophrenia, schizoaffective disorder, and bipolar disorder, which others have already done well. …

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