Those of you who watched the opening scenes of the movie, A Beautiful Mind, witnessed a psychotic process unfolding in a college student. Initially, the fantasy world in this young man's mind was filled with pleasant thoughts, sights, and sounds. They entertained him and kept him company. He enjoyed this unreal world. But gradually these delusions and hallucinations became dark, frightening, and threatening to him. He isolated himself socially and exhibited erratic behaviors. Yet, no one could convince him that these experiences existed only in his mind.

What if you were convinced that strangers were plotting to harm you? What if you frequently heard people talking when there was no one else around? Life can be like that for someone who is psychotic. In a psychotic state, a person usually experiences delusions and/or hallucinations. Delusions are fixed false beliefs. Paranoid delusions (such as believing others plan to hurt you) and grandiose delusions (such as believing oneself has unusual gifts and powers) are among the most common types. People cannot be easily talked out of their delusions.

Hallucinations are sensory phenomena (e.g. sights, sounds, smells) that are also the product of the person's mind. Hearing voices repeating critical or commanding thoughts is common. People may repeatedly see things that are not there. Because delusions and hallucinations usually do not spontaneously go away, medications known as "antipsychotics" are essential in treating these symptoms.

A psychosis can occur in various situations. A severely depressed person may become delusional. A manic individual may hear voices talking to him/her. Older persons with a dementia may become paranoid about their caretakers. HIV-related infections in the brain can lead to irrational thinking. Cocaine and speed may induce paranoia. Some prescription drugs, if not correctly prescribed or properly taken, may precipitate hallucinations.

One kind of psychosis that we often hear about is schizophrenia, a psychotic condition that typically emerges in early adulthood and continues throughout a person's life. Although the genetics are not fully understood, there is evidence that it runs in families. Both hallucinations and delusions are common in schizophrenia.. Sometimes the psychosis begins suddenly. Other times, the person experiences depression, mood swings, anxiety, obsessions or compulsions for several years prior to the full emergence of the psychosis. This illness usually has a profound effect on the person's ability to function at work and in their personal relationships. Because psychotic persons lose some touch with reality, they are at higher risk for suicide and other potentially destructive behaviors. In order to ensure their safety and that of others, it is important to quickly get them professional help.

Diagnosis and Treatment
Due to the multiple potential causes of psychosis - prescription and illicit drugs, medical conditions (HIV, brain tumors), and psychiatric conditions (depression, bipolar disorder, schizophrenia), a person with a psychosis needs a comprehensive evaluation by a team of professionals in order to make an accurate diagnosis and provide appropriate care. In a residential setting, nursing staff will check for vital signs (blood pressure, pulse, temperature, etc.) that could indicate a physical illness. They also can observe and confirm unusual behaviors that the family and community have witnessed at home. Psychologists and therapists carefully evaluate for psychosocial factors such as family history and environmental stresses that would contribute to the condition. Neuropsychologists administer oral and written tests to help differentiate psychoses caused by dementia from ones caused by depression, mania, and schizophrenia. Internists examine the person for underlying medical conditions or drugs that may be the culprit. A neurologist may be consulted to oversee testing with MRI, CT scans, and brain wave tests known as electroencephalograms (EEG's).

"It takes a village" is an apt description of the community effort required to assist a psychotic person. Optimally, the treatment team establishes an underlying cause, makes an accurate diagnosis, then prepares an individualized treatment plan. Upon presenting this to the patient, psychotherapists offer understanding and emotional support. Nurses encourage those hesitant to take their medication and observe for side effects. Group therapists facilitate increased awareness of social cues and appropriate patterns of behavior. In art therapy, clients explore their inner worlds, and their art work often reflects the gradual lessening of distorted thoughts and perceptions. In psychodrama groups, clients identify resources, reclaim disowned parts of self, and practice healthy social skills. Case managers assist with job applications and housing arrangements. Meanwhile, the person's significant others lend emotional support and often need some themselves. Educators and support groups provide experienced speakers and a wealth of written information for all those involved to learn about this illness.

Psychiatrists prescribe antipsychotic medications to treat psychoses and schizophrenia. These medications primarily "block" the excessive dopamine found in brain neurotransmitters in a psychosis. The newer generation of antipsychotics (Abilify, Geodon, Risperdal, Seroquel and Zyprexa) were developed to decrease the risk of neurological side effects (Parkinsonism and movement disorders) that the older antipsychotic drugs (Haldol, Prolixin, and Thorazine) frequently caused. Despite this apparent improvement, some of these newer drugs have various side effects such as weight gain and elevated blood sugars. Dieticians work with physicians to help monitor and when necessary, attend to these side effects.

Relapsing into psychosis from not taking one's medication is common, especially early in treatment. This should be met with understanding rather than criticism. It usually takes some time for the person and his/her significant others to adjust. Often the person has little or no control over a recurring psychosis; yet taking the medication regularly and learning to manage stress through psychological, social, and physical modalities lessen the chance for relapse. Although many times a psychotic process does not completely go away and requires lifelong treatment, with appropriate care, the person's condition may improve so they can lead a fuller and more rewarding life.

Joseph P. Collins, Jr. D.O., a psychiatrist, is SLI's Director of Medical Services.

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