This post is in response to DSM5 'Psychosis Risk Syndrome'--Far Too Risky by Allen J Frances

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?

Can psychosis be predicted? I think not. But, like the risk of suicidality (or, even less accurately, of  violence) it can be imperfectly prognosticated. Who is most at prognostic risk for psychosis? To begin with, based on my own more than three decades of clinical experience, individuals who have a prior history of psychosis (as with those with a prior history of suicidal behavior) are probably most at risk for repeated episodes. There are other individuals who, while never having had a psychotic episode, harbor what historically was referred to as a "latent psychosis": an underlying biological or psychological vulnerability in the personality that, under intense stress, can become manifest. Such individuals normally compensate fairly well for this latent psychosis, but tend to decompensate when severely stressed. If someone suffers from diagnosable Borderline, Schizotypal, Schizoid or Paranoid Personality Disorder, this tends to make them much more susceptible than others to psychosis under stress. Patients diagnosed with Bipolar Disorder are always at serious risk of experiencing psychotic symptoms during a full-blown manic episode. Abusers of psychoactive substances such as methamphetamine, crack cocaine, and hallucinogens are also prone to developing psychotic symptoms. And individuals who are seriously depressed can sometimes become psychotic, something clinicians refer to as "psychotic depression." Psychosis can sometimes occur during postpartum depression, and is much more likely in women with prior postpartum mood disorder. The risk of recurrence of psychosis in women giving birth who have previously experienced postpartum psychosis can be as high as 50%. Patients with Dissociative Identity Disorder and severe Obsessive-Compulsive Disorder are also at increased risk. Severe PTSD may also similarly make patients more susceptible to psychosis. Such psychotic states occur far more frequently than most imagine, and are seen every day by psychiatrists and psychologists in private practice, in psychiatric hospitals and clinics, in jails and prisons, and during forensic evaluations of criminal defendants. Antipsychotic drugs, including the newer  "atypical" antipsychotics, can sometimes control psychotic symptoms, for example, enabling a previously grossly psychotic defendant to become competent to stand trial, but many of these symptoms, such as paranoia, residually remain, partially masked by the medication. And how do these antipsychotic medications work? Well, they are believed by most to, like antidepressants, regulate neurotransmission. But I believe their efficacy, such as it is, resides mainly in their potent ability to dampen down what I call the "daimonic." and especially to biochemically suppress both anxiety and anger.

Psychosis can't be statistically predicted based on concordance rates and other risk factors such as having been raised by one or even  two psychotic parents. But, while not predictive, these powerful familial influences genetically and/or psychologically certainly can set the stage for psychosis. According to DSM-IV-TR, "the first-degree biological relatives of individuals with Schizophrenia have a risk for Schizophrenia that is about 10 times greater than that of the general population." At the same time, it acknowledges the equally important influence of "environmental factors" in this psychotic disorder. The onset of psychosis is usually slow and insidious. As with all mental disorders, there are always warning signs when a person is veering headlong toward the abyss of psychosis. Social withdrawal. Diminished functioning. Strange or bizarre behavior. Lack of affect. Poor personal hygiene. Disorganized speech. Uncharacteristic fits of rage.

Dr. Frances' description of the proposed Psychosis Risk Syndrome seems distorted, and his vehement opposition somewhat baffling. His greatest concern appears to be the possibility of misdiagnosis or "false positives," especially in children and adolescents. (While rare in children, schizophrenia first tends to appear in males during late adolescence and early adulthood, and from 25 -35 in females.) Basically, the proposed diagnosis requires the presence of "attenuated" or relatively mild psychotic symptoms like delusions or hallucinations (albeit with generally intact reality testing) to have been present at least once per week for the past month, worsening progressively within the past year, causing some degree of debilitation, subjective discomfort or sufficient concern on the part of others to seek treatment. I would call this "incipient psychosis syndrome," and consider the person (adolescent or adult) clearly in need of immediate treatment to try to prevent the psychosis from deepening. How this newly proposed diagnosis differs from the current DSM-IV-TR designation of Psychotic Disorder Not Otherwise Specified is not clear to me, except perhaps for the fact that such a patient would not yet be formally diagnosed with a potentially more stigmatizing fully formed psychotic disorder. That's a good thing. And if such a diagnosis were to help bring such patients, young or old, to the attention of mental health professionals at this incipient stage of psychosis, that would also be a good thing.

Aggressive early intervention in the psychotic process is absolutely essential. And these early warning signs must be heeded and responded to. I believe that the right type of treatment provided early on, especially in adolescents, can make a dramatic difference in the course of this disastrous mental illness. Herein lies the potential value in such a diagnosis. But the truly crucial question is how to treat such a patient. Even if we could accurately prognosticate psychosis, what could be done to prevent it? From a psychiatric standpoint, the likely answer would be to immediately start them on some antipsychotic medication prophylactically. But, as Dr. Frances points out, such medications are unproven and have very serious side-effects, including but not limited to oversedation, significant weight gain and temporary or permanent neurological symptoms. Moreover, they are so limited in efficacy precisely because they address only the symptoms and not the underlying source of the psychosis. It may even be that, in the long-term (and this has also been suspected regarding the chronic use of antidepressant drugs), antipsychotic medications might paradoxically make the patient more rather than less prone to chronic debilitation. If we were able to correctly identify individuals who are brought for evaluation in the earliest stages of psychosis, my own recommendation would be for intensive psychotherapy, either on a residential or out-patient basis. Such profoundly disturbed patients require a psychotherapy that can help them to address their underlying traumas and unconscious emotional "demons," especially their dissociated anger and rage. What I want to make clear is that the problem with Psychosis Risk Syndrome goes way beyond the potential pitfalls of DSM-V's diagnostic criteria. It is more deeply rooted in the way psychosis has been medically misunderstood and tragically mistreated in our present mental health system. While antipsychotic drugs may be necessary, they are insufficient. Patients suffering from incipient or chronic psychosis deserve and require much more than medication. They  need intensive psychotherapeutic intervention based on a better and deeper understanding of the psychology of psychosis.

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