One of the primary problems with the newly proposed DSM-V disorder of "Psychosis Risk Syndrome" is, for me, not the diagnostic criteria itself, but rather the still extremely poor understanding in psychiatry and psychology of the fundamental nature and meaning of psychosis. What is psychosis? What causes it? And who is really at risk for developing it?
It is important to note that psychosis is a very broad category of severe mental disorder with a relatively vague definition. But most mental health professionals today would agree that, phenomenologically speaking, psychosis consists of the presence of hallucinations and/or delusions, marked impairment that grossly interferes with social, occupational, academic or basic day-to-day functioning, and extremely poor "reality testing" or a so-called "break with reality." Interestingly, psychosis has also long been associated with "a loss of ego boundaries," which, for some misguided New Age spiritual seekers, is their perceived transcendent goal: the dissolution of the ego.(See my prior post.) Indeed, there are certain transpersonally-oriented psychotherapists who insist that many examples of what would traditionally be diagnosed as psychosis are, in fact, not psychosis, but episodes of so-called "spiritual emergence."
Schizophrenia, which appears consistently in approximately .5 to 1.5% of the population across cultures, is one classic form of psychosis. But there are currently several other kinds of psychotic disorders specified in the DSM-IV-TR, including Schizophreniform Disorder, Schizoaffective Disorder, Brief Psychotic Disorder, Delusional Disorder, Shared Psychotic Disorder, Substance-Induced Psychotic Disorder, and Psychotic Disorder due to a General Medical Condition. In addition, psychosis may be experienced by sufferers of severe Major Depressive Disorder, Bipolar Disorder, Borderline, Paranoid and Schizotypal Personality Disorder. And although most psychotic disorders such as Schizophrenia are devastatingly debilitating, some, like Delusional Disorder or Shared Psychotic Disorder, are much less so as regards daily functioning.
Most mainstream psychiatrists and clinical psychologists today take (mistakenly, in my opinion) an almost exclusively biological view of psychosis, believing it to be a "broken brain" disease. A genetically inherited neurobiological abnormality. A purely physiological aberration. But this is just one medicalized theory of psychosis. In fact, there may be somewhat different etiologies for different psychotic disorders. In my book Anger, Madness, and the Daimonic (1996), I present some alternate ways of conceptualizing psychosis (colloquially called "madness") and discuss in depth its crucial relationship to chronically repressed anger or rage. Another way of psychologically conceptualizing psychosis is that it involves a major distortion of reality due to finding reality as it is unacceptable. From the perspective of depth psychology, psychosis occurs when consciousness is overtaken or inundated by the unconscious. In Jungian psychology specifically, psychosis can be seen as an extreme and therefore pathological form of introversion, wherein the person withdraws almost completely from the stressful, traumatizing or rejecting and rejected outer world into his or her own inner world. In one of my prior posts, I discuss the phenomenon known as folie a deux (which directly corresponds to the DSM-IV-TR diagnosis of Shared Psychotic Disorder), and how it clearly illustrates the basically psychological rather than biological nature of psychosis in at least some cases. Brief Psychotic Disorder demonstrates the direct correlation between extraordinarily stressful trauma, sudden reactive onset and equally sudden disappearance of psychosis within the span of one month.
Now, of course, how one conceptualizes psychosis, or any other mental disorder, informs how one goes about trying to treat that disorder. (Less than two-hundred years ago, psychosis, madness or insanity was believed to be the result of demonic possession, for which exorcism was considered the only remedy. In some cultures and theological circles today, psychosis is still seen in this way.) It also affects the capacity to understand the risks or vulnerabilities in particular individuals for becoming psychotic at some point in their lives. Some individuals seem more prone to psychosis than others, for reasons still poorly understood. Having said that, as a clinical and forensic psychologist, I contend that no one, even the most "normal" among us, is ever fully immune to becoming psychotic. Psychosis is a state of mind that anyone can potentially experience under the right or wrong circumstances. I understand that this is both a controversial and disturbing assertion. We prefer to think of psychosis as something that happens only to other less fortunate, genetically defective people neurobiologically predisposed or predestined to it. But this is not reality. (See Part One.) And if this is so, if we all to some extent contain the innate capacity or potentiality for psychosis, transitory or otherwise, does this mean that we all have the aberrant genetic predisposition for it? Or might psychosis, as I would argue, be less of an aberrant biochemical or neurological phenomenon and more of an elaborate psychological defense mechanism and archetypal human potentiality?
