Metaphorical models - Psychotic Disorders

Psychosis is terminology of the medical model. It refers to symptoms (feelings, thoughts and behaviour) that doctors / mental health professionals objectively perceive in the patient. To the patient, a different perspective is experienced.

Telling a psychotic patient that the voice they are hearing is not real or the belief that a conspiracy is occurring around them is not real is like trying to convince someone that the chair they are sitting on does not really exist, that it's a figment of their imagination. You are mad, they will suggest.

When a patient is acutely psychotic, it is more likely than not that their judgement and insight has been affected. Insight is a multidimensional concept describing the ability of a patient to recognise (1) that they are ill (2) that their symptoms are part of the illness, and (3) that they need medical treatment.

Most patients do in fact have some insight, but it will vary as to how much and how patchy and whether or not its being affected will dissuade them from actively pursuing and accepting medical treatment, depending on the severity of the psychosis, type of psychosis, duration of symptoms and their personality, culture and education. Their responsiveness to medication will also be a big factor.

Pharmacotherapy is the cornerstone to effective treatment but other important components to treatment also include:

Psychoeducation of the patient and family

Psychosocial support and interventions such as community mental health team crisis management, vocational and financial assistance, family psychotherapy

Hospitalisation if the patient is a danger to themselves or others or if the patient and family are not coping or the patient requires removal from a noxious environment

Psychoeducating the patient and family may require finding a metaphorical explanation for what is happening to them to:

help promote the therapeutic relationship and participation with and cooperation with treatment avoid confrontation when the patient will not respond positively to this and it could even make them worse due to the resultant stress help them make some sense of their experiences using a model that is less maladaptive than the psychotic model their brain has developed to improve their insight

The Chemical Imbalance Metaphor

This is the most common metaphor used in psychiatry. Its simplicity makes it a highly effective. And its increasing acceptability also helps ...probably due to the increasing acknowledgement that our minds are the products of our brain function ...chemical reactions and circuit activation taking place, rather than some un-earthly, metaphysical, ghost-like, disembodied entity, separate from or inhabiting the brain.

Our brains are complex biological machines that can malfunction when the constituent chemicals become unbalanced. Our minds then become unbalanced, which leads to our emotions, thoughts and behaviours becoming abnormal. Medications and ECT help to right the imbalance by promoting the chemicals returning to the states they were in before, when the person was functioning normally. Stress and illicit drugs can cause chemical imbalances to occur. Some people are more genetically vulnerable for chemical imbalances to occur in them than others, which explains why some people develop mental illnesses after using drugs and some do not.

This successful metaphor is beginning to be be utilised for other disorders too, including OCD, major depression and even anxiety disorders. One other way this metaphor can be useful is in explaining why any substance that is ingested by the body may potentially affect the chemical balance in the brain (be "psycho-active"), including herbs, spices, hormone supplements, minerals, vitamins and even medications taken for bodily ailments below the neck. This is why patients should be encouraged to inform their treating doctor of all substances they take. For example, St Jon's Wart has been found to dramatically affect the concentrations of a number of pharmaceuticals if taken concomitantly.

The Chemical Storm Metaphor

A psychosis is like a physiological storm raging through the neural networks of the brain that relate mainly to thinking, emotions and expression of ideas. A different three dimensional spread of the storm causes different parts of the brain in these areas to be affected and thus a different profile of symptoms in every patient.

The particular spread of the storm (the land over which it is occupying) in each individual depends on their individual brain topography (or climate ... which is a result of both genetics and to a lesser extent early environment) and other significant influences on their current weather patterns (chemical factors such as illicit drug use and the emotional terrain around them).

Certain types of topography (such as mountains, temperature, climate and distance to water) predispose to or increase the vulnerability of an individual to getting these types of chemical storms in these areas of the brain.

These factors influence whether a storm is going to occur, where it is going to occur and the nature of the storm itself.

Lightning flashes, causing short-circuits that produce visions, misinterpretations and erroneous ideas. Thunder echoes, causing the experience of voices, apprehension and fear. Rain pelts down, causing withdrawal, isolation, lack of initiative and misery.

It's important to control the storm as soon as possible to prevent too much damage from occurring to the topography, so that the infrastructure necessary for normal life is maintained. If the land below is flooded for an excessive period, then it's going to be harder to rebuild and allow life to continue as normal.

The Merging Realities Metaphor

This metaphor is useful when a patient with psychosis has delusions or hallucinations and they have some insight into these symptoms. This is usually found in the early stages of relapse or the onset of a psychotic disorder, when the delusions are fleeting and unformed and unsystematised, and also often in drug-induced psychotic states.

The patient may accept the proposition that their internal / fantasy / spiritual world (whichever is most suitable) has merged with external reality / the world that they share with others.

This perception might reduce their levels of frustration, anger or anxiety that others do not support their views.

It might help them "save face", permitting their being spared from any sense of humiliation or despair. There is always a narcissistic injury that goes with acknowledging that one has developed a mental disorder. Partly because the symptoms are intangible, partly due to grandiosity that may be present, partly due to fear of ostracism and being negatively stereotyped by their community, partly due to their own prejudices and fears regarding what their prognosis may be (many have very pessimistic expectations of chronicity or being institutionalised or being unemployable etc) and partly due to the sense of loss of control over one's mind that has occurred.

The concept of a merging having taken place spares the sufferer from the perception that they are being judged and condemned as mad. It gives value to their internal worlds. It acknowledges that the patient's experiences and beliefs and self-view are real (at least to them) and relevant and are human. Certainly most of the emotional responses they are experiencing are likely to be real response to their particular situation. Denying this would be perceived by the patient as unempathic, uncaring and unsympathetic, hardly a good way of beginning a therapeutic relationship.

Treating a patient requires the development of a trusting, respectful, empathic relationship whether the patient is entirely reality oriented or not.

Most patients who are paranoid and frightened will want assistance to escape this situation. The doctor should remind the patient they are not a legal enforcement officer but wish to ensure the patient is safe (e.g. provide the safe haven of hospital ... often a relief to be in a secure environment) or to help the patient come back down to Earth to deal with their situation more rationally ... even the patient may acknowledge they are unable to think clearly due to the strong emotions they are experiencing (e.g. fearfulness) although they are likely to ascribe this to their (?delusional) state of affairs.

Offering to treat whatever symptoms the patient can acknowledge is another face-saving measure for the early stages of treatment ... in other words, avoiding the situation of a patient refusing treatment because they feel they have been misunderstood and therefore will not accept antipsychotic medication as they do not believe they have a psychotic disorder.

Such symptoms include fear, anxiety, low frustration tolerance, racing thoughts, inability to think clearly, poor concentration, easy distractibility by the new phenomena they are experiencing, insomnia, poor appetite, restlessness and other somatic symptoms they may complain of.

Acknowledging that there are two perspectives regarding the patient's state of affairs (their own and the medical model's) may reassure them that their experiences are not being dismissed. They may appreciate the recognition that making a diagnosis is part of the medical model ...which is only a model ...used to help guide and inform regarding what treatments may be optimal for them, not a judgemental act or something that is absolute. Indeed, diagnoses are not set in stone and, especially in the early stages, certainly are not very reliable for the long-term.

When they begin to recover, many patients go through a process of "double awareness". This refers to the step-wise, often fluctuating, gradually increasing gaining of insight. At times, the patient may hold two belief systems. They may appreciate being guided gently.

Confrontation occasionally helps in patients who persistently request an explanation for their having been treated, especially if they are being involuntarily treated in a hospital accredited to care for patients under a state's Mental Health Act. It may also help if a patient persistently refuses to cooperate with treatment when they clearly need it and will otherwise be likely to be hospitalised involuntarily. Confrontation should always be as gentle as possible and conducted without the treater becoming overly emotional or annoyed even if explanations aren't accepted or understood. There is no place for anger nor for lengthy sessions that are escalating with a patient growing increasingly frustrated. This is a good measure for how successful this strategy is turning out ... whether the patient is growing calmer or more agitated.

The religious experience metaphor

This is another version of the merging reality metaphor. It is helpful when the content of the patient's delusions or hallucinations is religious. For example, believing that one is Jesus Christ or has a mission to heal the world or communications with a deity.

Coming to the position with the patient that they are having a religious experience but one that is causing negative consequences for them or others and therefore they need to be brought back down to Earth to some extent, may assist to gain their allegiance and cooperation with treatment.

A patient with florid grandiose delusions may accept that their racing thoughts, lack of sleep, motor agitation, irritability or impulsiveness may be inhibiting them from getting on with their life or being organised enough to carry out their goals.

Patients with grandiose delusions are often the most insightless into the fact that these symptoms are part of a mental illness, but may well accept they are not thinking or acting like they usually do or that they are overwhelmed by their situation (the actual one they are in or the psychotic world they are experiencing).

The Excessive Pruning (or Too-much -is-not-necessarily -a-good-thing) metaphor

A fascinating evolutionary theory that patients with psychotic disorders usually respond very positively to is the theory that their proclivity to having psychotic symptoms is related to the process of evolution selecting for genes that improve human intelligence and creativity.

Perhaps it is not a coincidence that many patients with psychotic disorders were premorbidly very high functioning in school, sports or artistically. The rates of psychotic disorders is higher amongst artisans such as poets, for example, than the general community.

In favour of this theory is a neural networks study done using a computer processing word recognition. It was discovered that increasing computer processing power (in the form of CPUs) improved performance up to a peak and then the performance dropped due to excessive numbers of CPUs reducing efficiency. Removing the CPUs gradually increased the performance again and to an even higher peak than before at a lower number of CPUs than the previous peak because the period of learning was complete and now the processing power was being devoted purely to speech recognition and checking against the updated database of words.

Problem was, if too many CPUs were removed, the performance dropped again and strange errors were being made such as words appearing when no speech was inputted. This is akin to hallucinations.

The process of pruning is a known developmental stage occurring in late adolescence to the human cental nervous system with regard to synapses ... the connections between the billions of neurones. And the volume of synapses in parts of the brain have been found to be reduced in schizophrenia.

It is possible that psychotic disorders are due to synaptic reserve being reduced to levels that cause the particular symptoms to occur, depending on where in the brain the synapses have been reduced, due to a process of excessive pruning. The evolutionary pressure is the positive natural selective pressure for humans to become smarter, as intelligence and creativity are highly sought after characteristics. This might be the reason that the rates of psychotic disorders appears to be stable over time even though if you lump people with psychotic disorders together and look at their fertility rates compared with that of the general population the rates are lower.

An increased risk of psychosis may be the price Nature is willing to pay for increased intelligence and creativity in the population, even though the risks are increased for the development of schizophrenia and bipolar disorder, respectively (or a combination), in some people in the population. This may be akin to an increased risk of anxiety disorders and major depression in highly anxious people prone to worry, be perfectionistic, hypervigilent and self-conscious, with an ability to get highly focused, be very driven to succeed and to be politically minded.

The strength of this model is that it is positive, focusing on potential strengths in the patient ... the potential benefits of the same genes that have predisposed or caused the emergence of the symptoms, like a two-edged sword. Who would not like to be told they have too much of a good thing??

The illness spectrum of mental disorders

There are different types of psychotic disorders and different classificatory systems.

The simplest classification is psychotic disorders with or without mood symptoms. Then there are brief psychotic episodes (usually delirious or drug-induced states) and chronic disorders. Then there are those that are primary (schizophrenia or schizoaffective disorders) and secondary, meaning the psychotic symptoms are being fuelled by some other disorder, such as a mood disorder (such as depression or mania), anxiety disorder (such as OCD or hysteria) or personality disorder (such as borderline patients in crisis).

DSM (the American Diagnostic & Statistical Manual) uses a categorical approach to classification with qualifiers that provide some colouring of the above ideas, as opposed to a dimensional classificatory approach that perceives disorders as being on a spectrum.

Even though psychotic disorders are seen as organic/biological as dementia or delirium, it is increasingly being recognised that environment influences these as much as the internal chemistry of the sufferer.

Many are beginning to take an Orwellian double-think approach to classification, perceiving illness states in both a DSM-like categorical way in order to allow communication, research and to inform decision-making (as is the case in the rest of clinical medicine - hence also to permit psychiatry to rejoin medicine - a political reason) but also in a dimensional way as well, to reflect the fact that every patient presents with a unique symptom profile and one that is also modifiable by non-pharmacological means.

We are increasingly realising that it is oversimplistic to say that medications should be used for organic conditions and non-pharmacological means for the reactive (or physiological or functional) conditions. Both medications and non-pharmacological interventions (such as psychotherapy, behavioural change, lifestyle measures) can be of assistance to illnesses whatever they are, be they dementia with psychotic and depressive features or a grief state. Pharmacological interventions are merely more potent, unsurprising as they are directly modifying one's nervous system biology rather than more subtly, as is the case with other interventions.

What about bipolar disorder and psychotic symptoms?

Psychotic symptoms tend to arise in bipolar affective disorder (BPAD) when the mood symptoms are at their peak, in the midst of an episode of mania or, less commonly, depression. In this way, the psychotic symptoms may be seen to be secondary ...or 'fuelled' by the extreme mood state.

Psychotic symptoms are not uncommon in BPAD-Type 1, but are uncommon in BPAD-Type 2. The differences between these are explained in discussion of the illness spectrum of mental disorders (diagram page).

You occasionally come across patients with continuous symptoms of psychosis and mania, and it is difficult to decide whether they have a chronic (untreated or under-treated) manic psychosis or a schizoaffective disorder. This distinction is important in that the latter diagnosis would suggest that the patient would benefit from ongoing treatment with an antipsychotic medication as well as mood stabiliser (rather than only when psychotic symptoms arise in the context of a manic or depressive episode). The latter suggests that the patient has a 'double whammy' of psychotic and mood symptom clusters as primary disorders, rather than one fuelling the other.

The echoes bouncing between closing walls metaphor

The castles in the air metaphor "A Neurotic is a person who builds a castle in the air. A Psychotic is the person who lives in it. A Psychiatrist is the one who collects the rent." Jerome Laurence