Perspectives on Schizophrenia and Psychosis

Welcome to the NICE Implementation Resource Tool this section provides an explanation about schizophrenia and psychosis.

Within this section there is information on Mental Health Services, an over view of the different workers in Mental Health Services and what you might expect from them and examples of the way assessments of mental health are used including the sorts of questions that may be asked to help understand peoples experiences.

What is psychosis?

Psychosis is a general description of a number of conditions affecting a person’s mental state. It includes a number of diagnostic categories used by psychiatry to try and describe common experiences or symptoms that many people appear to share. Psychosis can be brief; can be related to using some street drugs or it can last for longer periods.

Psychosis is often recognised by distortions of thinking and perception and can be accompanied by disturbances in mood. These disturbances are driven by the person’s arousal system (their psychological and biological response to stress) and often involve problems with attention and processing (mostly social) information. As the person becomes more aroused there tends to be an increase in strange experiences, they may see or hear things that don’t appear to there, they may start to use language in an unusual or new way and their ability to do and enjoy things may reduce. It might appear that the persons concentration, (and as a result memory) is effected.

What is schizophrenia?

Schizophrenia is one of the categories of psychosis. It shares many of the features of psychosis, however to receive a diagnosis of schizophrenia there is often a requirement that the psychosis effects the persons social functioning for a considerable period, (for more detail see the links on the right of this page). Schizophrenia tends to appear in episodes, (although some people only ever have one episode). The person will recover but may be more vulnerable to future episodes particularly during periods of high stress.

What causes Psychosis?

We are all capable of having psychosis like experiences under certain conditions, (for example when we have not had enough sleep, or when we have suffered a fever). Generally though these experiences are only features of psychosis, not a full blown episode.

As mentioned above it is possible to have a full psychotic episode as a brief psychosis that appears to be in response to a particular set of circumstances, (some people who use the street drug ‘speed’ can have this experience).

To explain the cause of psychosis we need to look at two related areas, stress and vulnerability.

It would appear that some of us have more of a vulnerability to developing psychosis than others, this vulnerability consists of psychological vulnerabilities such as a kind of social sensitivity that does not allow the person to mix with others very well, together with biological vulnerabilities such as problems with arousal and processing social information which are probably linked to developmental problems in key areas in the central nervous system including the brain.

In some cases this vulnerability has appears to have a genetic strand to it, this is thought to be particularly true of psychosis described as schizophrenia. This does not mean necessarily that schizophrenia runs in families, but that the vulnerability to developing schizophrenia may be.

How Common is it?

Many people have psychotic like experiences and never come to the attention of mental health services, (they have probably had a single episode and recovered). Approximately 1 in 100 people develop a more persistent form of psychosis known as schizophrenia. Most of these individuals will present as young adults between the ages of 15 and 25, however schizophrenia may develop at any age. Men and women from all cultures are equally likely to develop schizophrenia although there is a tendency for men to develop the disorder slightly earlier in their lives than women.

Psychosis and Recovery.

It is possible to describe schizophrenia in ‘phases’ although it is often difficult to describe these as distinct from one another as there is considerable overlap.

There appears to be a pre-psychosis phase during this time number of non-specific signs can be present in the weeks or months preceding the first episode:

• A general loss of interest
• Avoidance of social interactions
• Avoidance of work or study (e.g. dropping out of school, college or university)
• Being irritable and oversensitive, perhaps a little more suspicious of others
• Changes in beliefs (increased interest in spiritual or philosophical ideas)
• Changes in behaviour (hoarding things avoiding friends and family)

These changes will often be distressing for the individual and puzzling for the family. Friends or relatives may find it hard to identify what is going wrong as schizophrenia often develops at the transition between adolescence and adulthood and some of the signs above could be seen as normal for a young adult.

Many months can pass and the strength of the non-specific signs may increase and give way to psychotic symptoms such as more conviction in certain beliefs the person did not have before, more obvious changes in behaviour, this may be accompanied by voice hearing experiences or strange visual experiences. Distress, anxiety, depression, and fear almost always become part of the picture.

Until recently this was generally the time that people came to the attention of services and required treatment or even hospital stays. With the advent of early intervention, (see link on left of page) services are more likely to work with individuals, friends and family to try and identify these changes earlier and introduce appropriate treatments

Recovery Phase.

Most people respond well to medication, and most modern medications are effective in controlling the more obvious psychotic symptoms such as voice hearing. However it is important to think of recovery on at least three different (but connected) levels:

Symptomatic Recovery.

As mentioned above this is the degree to which the person has recovered from symptoms such as belief changes voices and high levels of arousal. It may also be the degree to which their motivation and ability to become involved in pleasurable activity has returned. . 85% of people respond well to treatment at their first episode of psychosis

Psychological Recovery.

It has long been know that the experience of psychosis is in itself traumatic and that people often suffer feelings of shame humiliation and feelings of loss of control over their own minds. It is also common for people to experience a kind of depression that often follows the psychotic period, (known as post-psychotic depression). It is important that the persons psychological health is maintained in their recovery as this will assist them if they continue to be vulnerable to further episodes and help them to identify early signs of any future psychotic period.

Social Recovery

Social recovery is often the most illusive recovery point. As can be seen from above social recovery relies on a person being able to cope with any persisting, (or residual) symptoms they may have and to have come to a point where their psychological adjustment allows them to be around others comfortably. Although social recovery takes a little longer it is a goal worth pursuing as the more socially recovered the person becomes, the more evidence she or he gathers for their psychological recovery.

What Happens Next?

About 22% of people who attract a diagnosis of schizophrenia have one episode and recover. Others may have further episodes, however provided the areas of recovery above are paid attention to a person may learn how to mange these episodes in a way that minimises there impact. There are now a number of effective psychological therapies (see therapies link on the left of this page) that assist an individual to find a way of managing their psychosis. This coupled with early intervention will help the person to maintain a pattern of recovery that allows them to get on with their lives, getting appropriate support during vulnerable periods.

K. Fahy CSIPNW September 2006