Lost touch with reality

Learning Objectives

  1. Categorize and describe the three major symptoms of schizophrenia.
  2. Differentiate the five types of schizophrenia and their characteristics.
  3. Identify the biological and social factors that increase the likelihood that a person will develop schizophrenia.

The term schizophrenia, which in Greek means split mind, was first used to describe a psychological disorder by Eugen Bleuler (1857-1939), a Swiss psychiatrist who was studying patients who had very severe thought disorders. Schizophrenia is a serious psychological disorder marked by delusions, hallucinations, loss of contact with reality, inappropriate affect, disorganized speech, social withdrawal, and deterioration of adaptive behaviour (Figure 13.13, “Schizophrenia”).

Figure 13.13 Schizophrenia. People with schizophrenia may exhibit disorganized behaviour, as this person does.

Schizophrenia is the most chronic and debilitating of all psychological disorders. It affects men and women equally, occurs in similar rates across ethnicities and across cultures, and affects at any one time approximately 350,000 people in Canada (Public Health Agency of Canada, 2012). Onset of schizophrenia is usually between the ages of 16 and 30 and rarely after the age of 45 or in children (Mueser & McGurk, 2004; Nicolson, Lenane, Hamburger, Fernandez, Bedwell, & Rapoport, 2000).

Symptoms of Schizophrenia

Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them (Lindenmayer & Khan, 2006). As you can see in Table 13.4, “Positive, Negative, and Cognitive Symptoms of Schizophrenia,” the symptoms are divided into positive symptoms, negative symptoms, and cognitive symptoms (American Psychiatric Association, 2008; National Institute of Mental Health, 2010). Positive symptoms refer to the presence of abnormal behaviours or experiences (such as hallucinations) that are not observed in normal people, whereas negative symptoms (such as lack of affect and an inability to socialize with others) refer to the loss or deterioration of thoughts and behaviours that are typical of normal functioning. Finally, cognitive symptoms are the changes in cognitive processes that accompany schizophrenia (Skrabalo, 2000). Because the patient has lost contact with reality, we say that he or she is experiencing psychosis, which is a psychological condition characterized by a loss of contact with reality.

Table 13.4 Positive, Negative, and Cognitive Symptoms of Schizophrenia.

Positive symptoms Negative symptoms Cognitive symptoms
Hallucinations Social withdrawal Poor executive control
Delusions (of grandeur or persecution) Flat affect and lack of pleasure in everyday life Trouble focusing
Derailment Apathy and loss of motivation Working memory problems
Grossly disorganized behaviour Distorted sense of time Poor problem-solving abilities
Inappropriate affect Lack of goal-oriented activity
Movement disorders Limited speech
Poor hygiene and grooming

People with schizophrenia almost always suffer from hallucinations — imaginary sensations that occur in the absence of a real stimulus or which are gross distortions of a real stimulus. Auditory hallucinations are the most common and are reported by approximately three-quarters of patients (Nicolson, Mayberg, Pennell, & Nemeroff, 2006). Schizophrenic patients frequently report hearing imaginary voices that curse them, comment on their behaviour, order them to do things, or warn them of danger (National Institute of Mental Health, 2009). Visual hallucinations are less common and frequently involve seeing God or the devil (De Sousa, 2007).

Schizophrenic people also commonly experience delusions, which are false beliefs not commonly shared by others within one’s culture, and maintained even though they are obviously out of touch with reality. People with delusions of grandeur believe that they are important, famous, or powerful. They often become convinced that they are someone else, such as the president or God, or that they have some special talent or ability. Some claim to have been assigned to a special covert mission (Buchanan & Carpenter, 2005). People with delusions of persecution believe that a person or group seeks to harm them. They may think that people are able to read their minds and control their thoughts (Maher, 2001). If a person suffers from delusions of persecution, there is a good chance that he or she will become violent, and this violence is typically directed at family members (Buchanan & Carpenter, 2005).

People suffering from schizophrenia also often suffer from the positive symptom of derailment — the shifting from one subject to another, without following any one line of thought to conclusion — and may exhibit grossly disorganized behaviour including inappropriate sexual behaviour, peculiar appearance and dress, unusual agitation (e.g., shouting and swearing), strange body movements, and awkward facial expressions. It is also common for schizophrenia sufferers to experience inappropriate affect. For example, a patient may laugh uncontrollably when hearing sad news. Movement disorders typically appear as agitated movements, such as repeating a certain motion again and again, but can in some cases include catatonia, a state in which a person does not move and is unresponsive to others (Janno, Holi, Tuisku, & Wahlbeck, 2004; Rosebush & Mazurek, 2010).

Negative symptoms of schizophrenia include social withdrawal, poor hygiene and grooming, poor problem-solving abilities, and a distorted sense of time (Skrabalo, 2000). Patients often suffer from flat affect, which means that they express almost no emotional response (e.g., they speak in a monotone and have a blank facial expression) even though they may report feeling emotions (Kring, 1999). Another negative symptom is the tendency toward incoherent language, such as repeating the speech of others (“echo speech”). Some schizophrenics experience motor disturbances, ranging from complete catatonia and apparent obliviousness to their environment to random and frenzied motor activity during which they become hyperactive and incoherent (Kirkpatrick & Tek, 2005).

Not all schizophrenic patients exhibit negative symptoms, but those who do also tend to have the poorest outcomes (Fenton & McGlashan, 1994). Negative symptoms are predictors of deteriorated functioning in everyday life and often make it impossible for sufferers to work or to care for themselves.

Cognitive symptoms of schizophrenia are typically difficult for outsiders to recognize but make it extremely difficult for the sufferer to lead a normal life. These symptoms include difficulty comprehending information and using it to make decisions (the lack of executive control), difficulty maintaining focus and attention, and problems with working memory (the ability to use information immediately after it is learned).

Explaining Schizophrenia

There is no single cause of schizophrenia. Rather, a variety of biological and environmental risk factors interact in a complex way to increase the likelihood that someone might develop schizophrenia (Walker, Kestler, Bollini, & Hochman, 2004).

Studies in molecular genetics have not yet identified the particular genes responsible for schizophrenia, but it is evident from research using family, twin, and adoption studies that genetics are important (Walker & Tessner, 2008). As you can see in Figure 13.14 ,”Genetic Disposition to Develop Schizophrenia,” the likelihood of developing schizophrenia increases dramatically if a close relative also has the disease.

Figure 13.14 Genetic Disposition to Develop Schizophrenia. The risk of developing schizophrenia increases substantially if a person has a relative with the disease.

Neuroimaging studies have found some differences in brain structure between schizophrenic and normal patients. In some people with schizophrenia, the cerebral ventricles (fluid-filled spaces in the brain) are enlarged (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990). People with schizophrenia also frequently show an overall loss of neurons in the cerebral cortex, and some show less activity in the frontal and temporal lobes, which are the areas of the brain involved in language, attention, and memory. This would explain the deterioration of functioning in language and thought processing that is commonly experienced by schizophrenic patients (Galderisi et al., 2008).

Many researchers believe that schizophrenia is caused in part by excess dopamine, and this theory is supported by the fact that most of the drugs useful in treating schizophrenia inhibit dopamine activity in the brain (Javitt & Laruelle, 2006). Levels of serotonin may also play a part (Inayama et al., 1996). But recent evidence suggests that the role of neurotransmitters in schizophrenia is more complicated than was once believed. It also remains unclear whether observed differences in the neurotransmitter systems of people with schizophrenia cause the disease, or if they are the result of the disease itself or its treatment (Csernansky & Grace, 1998).

A genetic predisposition to developing schizophrenia does not always develop into the actual disorder. Even if a person has an identical twin with schizophrenia, that person still has less than a 50% chance of developing it, and over 60% of all schizophrenic people have no first- or second-degree relatives with schizophrenia (Gottesman & Erlenmeyer-Kimling, 2001; Riley & Kendler, 2005). This suggests that there are important environmental causes as well.

One hypothesis is that schizophrenia is caused in part by disruptions to normal brain development in infancy that may be caused by poverty, malnutrition, and disease (Brown et al., 2004; Murray & Bramon, 2005; Susser et al., 1996; Waddington, Lane, Larkin, & O’Callaghan, 1999). Stress also increases the likelihood that a person will develop schizophrenic symptoms; onset and relapse of schizophrenia typically occur during periods of increased stress (Walker, Mittal, & Tessner, 2008). However, it may be that people who develop schizophrenia are more vulnerable to stress than others and not necessarily that they experience more stress than others (Walker, Mittal, & Tessner, 2008). Many homeless people are likely to be suffering from undiagnosed schizophrenia.

Another social factor that has been found to be important in schizophrenia is the degree to which one or more of the patient’s relatives is highly critical or highly emotional in their attitude toward the patient. Hooley and Hiller (1998) found that schizophrenic patients who ended a stay in a hospital and returned to a family with high expressed emotion were three times more likely to relapse than patients who returned to a family with low expressed emotion. It may be that the families with high expressed emotion are a source of stress to the patient.

Key Takeaways

  • Schizophrenia is a serious psychological disorder marked by delusions, hallucinations, and loss of contact with reality.
  • Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them.
  • Because the schizophrenic patient has lost contact with reality, we say that he or she is experiencing psychosis.
  • Positive symptoms of schizophrenia include hallucinations, delusions, derailment, disorganized behaviour, inappropriate affect, and catatonia.
  • Negative symptoms of schizophrenia include social withdrawal, poor hygiene and grooming, poor problem-solving abilities, and a distorted sense of time.
  • Cognitive symptoms of schizophrenia include difficulty comprehending and using information and problems maintaining focus.
  • There is no single cause of schizophrenia. Rather, there are a variety of biological and environmental risk factors that interact in a complex way to increase the likelihood that someone might develop schizophrenia.

Exercise and Critical Thinking

  1. How should society deal with people with schizophrenia? Is it better to keep patients in psychiatric facilities against their will, but where they can be observed and supported, or to allow them to live in the community, where they may commit violent crimes against themselves or others? What factors influence your opinion?

De Sousa, A. (2007). Types and contents of hallucinations in schizophrenia. Journal of Pakistan Psychiatric Society, 4(1), 29.

Gottesman, I. I. (1991). Schizophrenia genesis: The origins of madness. New York, NY: W. H. Freeman.

Gottesman, I. I., & Erlenmeyer-Kimling, L. (2001). Family and twin studies as a head start in defining prodomes and endophenotypes for hypothetical early interventions in schizophrenia. Schizophrenia Research, 5(1), 93–102.

Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. Lancet, 363(9426), 2063–2072.

Rosebush, P. I., & Mazurek, M. F. (2010). Catatonia and its treatment. Schizophrenia Bulleting, 36(2), 239–242.

Skrabalo, A. (2000). Negative symptoms in schizophrenia(s): The conceptual basis. Harvard Brain, 7, 7–10.

Walker, E., & Tessner, K. (2008). Schizophrenia. Perspectives on Psychological Science, 3(1), 30–37.

Walker, E., Kesler, L., Bollini, A., & Hochman, K. (2004). Schizophrenia: Etiology and course. Annual Review of Psychology, 55, 401–430.

Image Attributions

Figure 13.13: by Max Avdeev, http://www.flickr.com/photos/avdeev/4203380988

Figure 13.14: Adapted from Gottesman, 1991.

Long Descriptions

Figure 13.14 long description: Genetic disposition to develop schizophrenia

Genes shared Relationship to person with schizophrenia Risk of developing schizophrenia (%)
Third-degree relatives (12.5%) First cousins 2%
Uncles and aunts 2%
Second-degree relatives (25%) Nephews and nieces 4%
Grandchildren 5%
First-degree relatives (50%) Half-siblings 6%
Parents 6%
100% Siblings 9%
Children 13%
Fraternal twins 17%
Identical twins 48%

How Is Schizophrenia Treated?

The goal of schizophrenia treatment is to ease the symptoms and to cut the chances of a relapse, or return of symptoms. Treatment for schizophrenia may include:

  • Medications: The primary medications used to treat schizophrenia are called antipsychotics. These drugs don’t cure schizophrenia but help relieve the most troubling symptoms, including delusions, hallucinations, and thinking problems.
    • Older (commonly referred to as “first-generation”) antipsychotic medications used include:
      • Chlorpromazine (Thorazine)
      • Fluphenazine (Prolixin)
      • Haloperidol (Haldol)
      • Oxilapine (Loxapine)
      • Perphenazine (Trilafon)
      • Thiothixene (Navane)
      • Trifluoperazine (Stelazine)
    • Newer (“atypical” or second-generation) drugs used to treat schizophrenia include:
      • Aripiprazole (Abilify)
      • Aripiprazole Lauroxil (Aristada)
      • Asenapine (Saphris)
      • Brexpiprazole (Rexulti)
      • Cariprazine (Vraylar)
      • Clozapine (Clozaril)
      • Iloperidone (Fanapt)
      • Lumateperone tosylate (Caplyta)
      • Lurasidone (Latuda)
      • Olanzapine (Zyprexa)
      • Paliperidone (Invega Sustenna)
      • Paliperidone Palmitate (Invega Trinza)
      • Quetiapine (Seroquel)
      • Risperidone (Risperdal)
      • Ziprasidone (Geodon)

Note: Clozapine is the only FDA-approved medication for treating schizophrenia that is resistant to other treatments. It’s also used to lessen suicidal behaviors in those with schizophrenia who are at risk.

  • Coordinated specialty care (CSC) : This is a team approach toward treating schizophrenia when the first symptoms appear. It combines medicine and therapy with social services, employment, and educational interventions. The family is involved as much as possible. Early treatment is key to helping patients lead a normal life.
  • Psychosocial therapy: While medication may help relieve symptoms of schizophrenia, various psychosocial treatments can help with the behavioral, psychological, social, and occupational problems that go with the illness. Through therapy, patients also can learn to manage their symptoms, identify early warning signs of relapse, and come up with a relapse prevention plan. Psychosocial therapies include:
    • Rehabilitation, which focuses on social skills and job training to help people with schizophrenia function in the community and live as independently as possible
    • Cognitive remediation, which involves learning techniques to make up for problems with information processing. It often uses drills, coaching, and computer-based exercises to strengthen mental skills that involve attention, memory, planning, and organization.
    • Individual psychotherapy, which can help the person better understand his illness, and learn coping and problem-solving skills
    • Family therapy, which can help families deal with a loved one who has schizophrenia, enabling them to better help their loved one
    • Group therapy/support groups, which can provide continuing mutual support
  • Hospitalization: Many people with schizophrenia may be treated as outpatients. But hospitalization may be the best option for people:
    • With severe symptoms
    • Who might harm themselves or others
    • Who can’t take care of themselves at home
  • Electroconvulsive therapy (ECT): In this procedure, electrodes are attached to the person’s scalp. While they’re asleep under general anesthesia, doctors send a small electric shock to the brain. A course of ECT therapy usually involves 2-3 treatments per week for several weeks. Each shock treatment causes a controlled seizure. A series of treatments over time leads to improvement in mood and thinking. Scientists don’t fully understand exactly how ECT and the controlled seizures it causes help, but some researchers think ECT-induced seizures may affect the release of neurotransmitters in the brain. ECT is less well-proven to help with schizophrenia than depression or bipolar disorder, so it isn’t used very often when mood symptoms are absent. It can help when medications no longer work, or if severe depression or catatonia makes treating the illness difficult.
  • Research: Researchers are looking at a procedure called deep brain stimulation (DBS) to treat schizophrenia. Doctors surgically implant electrodes that stimulate certain brain areas believed to control thinking and perception. DBS is an established treatment for severe Parkinson’s disease and essential tremor, but it’s still experimental for the treatment of psychiatric disorders.

The signs may be quite subtle at first. A friend or loved one may seem “off” recently, with an unkempt appearance that is not their norm at all. A coworker may have let their quality of work slip, becoming incrementally substandard over time. Maybe you are plagued with an unsettling sense that someone is watching you, or have become increasingly suspicious of others.

These early signs of a potential psychotic break from reality may not seem worrisome when seen in isolation, but when a cluster of unusual symptoms begin to gather steam it may indicate that you or someone you care about is experiencing the sense of losing touch with reality.

Psychosis—including such features as hallucinations and delusional thinking—is the symptom of an underlying mental health disorder, not an illness itself. According to the National Alliance on Mental Health, an estimated 100,000 Americans experience psychoses annually. Early intervention is key, so do not ignore the symptoms. These will center on difficulty recognizing what is real and tangible versus a figment of their imagination. Behaviors and thoughts will be unusual, not the norm for the afflicted person.

When you notice that you or a loved one seems to be losing touch with reality it is important to seek professional help. It may be that the symptoms are related to a physical or neurological condition that needs attention. If it is indeed the early signs of a psychotic disorder, receiving timely, proactive care is essential in containing the effects of the psychosis.

What are Psychotic Disorders?

Psychotic disorders represent the types of mental illnesses that feature symptoms around losing touch with reality. These disorders are characterized by odd behaviors, feelings, thoughts, and emotions, including seeing or hearing things that are not really there. When a mental health condition has psychosis as a primary symptom, it will be classified as a psychotic disorder.

According to an article published in JAMA Psychiatry, about 3.5% of the U.S. adult population will experience psychosis at some point. Psychotic features can be associated with severe anxiety, severe depression, and bipolar disorder, as well as identified as its own standalone mental health disorder.

The cause of psychotic disorders is still mainly unknown, although there are some theories exists to explain the cause. These include neurological malfunctioning, certain viruses, extreme trauma or prolonged excessive stress, certain drugs of abuse, and genetics.

Treatment for this complex mental health disorder will rely on a comprehensive approach of multiple elements for the best recovery results. Generally, an individual with a psychotic disorder can learn to manage many of the symptoms associated with the disorder.

Different Types of Psychotic Disorders

Psychotic disorders emerge in varying ways and with differing features, while sharing core characteristics. The different types of psychotic disorders include:

  • Schizophrenia, embodies the sense of losing touch with reality, with audible and/or visual hallucinations, delusional thoughts, angry, erratic behavior, and extreme moodiness.
  • Schizoaffective disorder, combines features of schizophrenia with a mood disorder involving depressive or manic episodes.
  • Brief psychotic disorder is a short-lived disorder that is sometimes triggered by a traumatic event, such as the death of a loved one, a natural disaster, or a serious accident that lasts less than a month.
  • Schizophreniform disorder is like schizophrenia but tends to affect young adults and teens, and lasts 1-6 months in duration.
  • Shared psychotic disorder is one that involves two people who both believe in a delusional situation, such as a husband and wife who both believe the same delusion.
  • Delusional disorder features false and often suspicious beliefs that the individual believes are true, such as thinking someone is out to murder you or your spouse is having an affair.
  • Substance induced psychotic disorder is the presence of hallucinations or delusions occurring as a withdrawal symptom for several drugs, including alcohol, LSD, methamphetamine, cocaine, benzodiazepines, and PCP.

What Are the Symptoms of Psychosis?

Generally, psychosis comes on gradually, with signs that indicate a developing mental illness. Those might include inappropriate emotions, a decline in personal hygiene, difficulty thinking straight or concentrating, a decline in job or academic performance, emotional detachment or intense inappropriate emotions, isolating behaviors, and acting highly suspicious of others. These are psychotic features, early symptoms of a possibly emerging psychotic disorder.

The primary feature of psychosis is losing contact with reality. While the different types of psychotic disorders will have unique features, there are some general symptoms that can indicate the onset of a psychotic disorder. These include:

  • Insomnia
  • Persistent feelings of being watched.
  • Increasingly disorganized thinking
  • Mental confusion
  • Auditory and visual hallucinations
  • Delusional thoughts
  • Strange or disorganized speech or writing
  • Inappropriate behavior
  • Avoidance of social situations
  • Decline in academic or work performance
  • Unusual body positioning or movement
  • Suspicious or paranoid behavior
  • Unusual preoccupation and fears centered on a person or situation
  • Irrational or angry behaviors
  • Inability to concentrate
  • Loss of interest in appearance and hygiene
  • Personality changes

Treatment for Psychotic Disorders

Generally, a residential setting provides a more intensive and tailored treatment approach in a setting that is safe and offers 24-hour monitoring and support. However, if the individual is displaying signs of a psychiatric break or has become a danger to themselves or others, they should be admitted to a psychiatric hospital for stabilization.

Treatment of psychotic disorders relies primarily on psychotherapy and psychotropic drug therapy will likely involve an integrated approach, including:

Psychotherapy: While in a residential treatment the individual will be involved in various types of psychotherapy. The focus for therapy involves helping the individual recognize irrational thoughts and behaviors and to replace those with healthy thought-behavior patterns. Individual therapy, group therapy, and family therapy are all provided in a residential program as part of the psychotherapy piece of treatment for psychosis.

The individual cognitive behavioral therapy sessions allow the therapist to help the individual identify irrational thoughts and fears and maladaptive emotional responses.

Group therapy: Group sessions provide opportunities for small groups to discuss and share their mental health issues while being facilitate by a therapist who guides the topics. These intimate group settings provide a safe environment for sharing and foster peer support in the process.

Psychosocial interventions: An important component of treatment is assisting the individual in improving their ability to get along with others. These interventions can offer new communication skills, conflict resolution techniques, and vocational rehabilitation.

Medication: Medication will be prescribed depending on the specific diagnosis. In many cases medication will include antipsychotics, benzodiazepines, antidepressants, and mood stabilizers. For some individuals with a psychotic disorder, these medications will necessary to help manage the disorder on a daily basis, and will likely be prescribed for a lifetime.

Adjunctive therapies: Electroconvulsive therapy (ECT) is reserved for the most severe forms of psychosis in individuals who are not responsive to the medications.

Holistic therapies: Increasingly, holistic therapies, most of which are derivative of Eastern practices, are utilized for the treatment of psychosis or other mental health disorders with psychotic features. Activities such as yoga, mindfulness training, guided meditation, acupuncture, and massage therapy are helpful in controlling stress and promoting relaxation. Patients can learn how to initiate mindfulness exercises on their own at any time of day, which is helpful when sudden symptoms emerge.

When Does a Psychotic Break Require Hospitalization?

When someone experiences a psychotic break, or the sense that they are no longer tracking with reality, it may be appropriate to consider hospitalization. This might be a psychiatric hospital or a psychiatric wing within a general hospital. This level of care is distinct from residential care, in that the hospital environment is equipped to manage a psychiatric emergency. In the hospital setting the individual will likely be segregated from other patients and may be restrained to avoid the risk of self harm or harm to others.

In the hospital settling, the individual will receive very close observation. Medications will be reviewed and adjusted, and the emphasis will be on acute stabilization measures. This process of stabilizing the individual may take a couple of days, before they can be released to a residential mental health treatment center.

When Severe Depression Causes Psychosis

In some severe cases of depression, the emotional anguish may cause an individual to exhibit a break from reality with symptoms of hallucinations or delusions. The actual diagnosis may be coined depression with psychotic features or psychotic depression. In the case of depression that is so profound that it sparks feelings of losing touch with reality, there may be a co-occurring medical condition or substance use disorder that is contributing to the symptoms.

Psychotic depression features the following symptoms:

  • Sleep disturbances
  • Experiencing hallucinations, voices or visions, telling them they are worthless or evil
  • Delusional thoughts
  • Suicidal ideation
  • Difficulty concentrating
  • Falsely thinking they have another disease or illness

When Severe Anxiety Causes Psychosis

Can severe anxiety cause psychosis? Research suggests that symptoms of psychosis may be preceded by an extreme even, such as a panic attack or trauma. The intense emotional distress suffered as a result of anxiety can trigger psychotic symptoms. According to a study published in the Journal of Clinical Psychiatry, anxiety disorders, such as panic disorder, OCD, or PTSD can result in psychotic symptomology. These symptoms resolved with treatment involving both benzodiazepines and antidepressants.

When this condition occurs it may be referred to as a psychotic break or a nervous breakdown. The symptoms are clearly related to the anxiety disorder, rather than a psychotic disorder such as schizophrenia. Stabilizing the individual should be the first step in care, followed by enhanced treatment for the core anxiety disorder.

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What Really is a “Psychotic Break with Reality”?

Image credit: New York Daily News

The recent horrific events in a Colorado movie theater have sparked questions about how someone who appears to be a highly functioning person–a neuroscientist in this case–can become a psychotic mass murderer, seemingly without warning. This has made me wonder about the term “psychosis” itself and whether we really have a good handle on what it means.

For insight, I’ve turned to fellow-Forbes contributor, Todd Essig, who is a licensed psychologist in the State of New York, a Training and Supervising Psychoanalyst at the William Alanson White Institute, and a Clinical Assistant Professor in Psychiatry at New York Medical College. He’s also a heck of a writer who really knows his stuff, as anyone who reads his Forbes blog, Managing Mental Wealth, already knows.

DiSalvo: When we hear the term “psychotic break with reality” – what does that really mean?

Essig: The first thing to understand is that psychosis is not one thing. It is multi-dimensional in description and it has multiple causes. Frequently the cause is a severe mental illness such as schizophrenia, bi-polar disorder, major depression, delusional disorder, as well as being a transient symptom of a variety of personality disorders. Some become psychotic from taking illegal drugs, like bath salts. Plus, various medical conditions can cause psychosis. Some mis-use psychiatric medications, such as benzodiazepines and stimulants. And then there are general medications, like steroids, that can cause a psychotic reaction.

In terms of what it means, a “psychotic break with reality” means losing contact with reality, such as hearing, seeing, tasting, smelling, or feeling something that has no external correlate (i.e., hallucinations) or believing something to be true that is false, fixed, and fantastic (i.e., a delusion) or being unable to sequence one’s thoughts or control a flight of ideas that becomes increasingly tangential (i.e., thought disordered), or emotions wildly inconsistent with external reality (such as catatonia, the wild flights of someone in a manic episode, or a complete absence of affect).

Is this truly an abrupt “snap” with reality?

Other than what may occur with some drugs, people don’t really “snap.” Snap implies an on/off switch. But for most people suffering from an illness that has psychotic symptoms or from mis-using drugs — illicit or prescription — it would be more accurate to describe it as a slide than a snap, with some slides being steeper than others.

So it sounds like our typical assumptions about psychosis aren’t quite on the mark.

Yes, psychosis is largely misunderstood in our society, although most know it when they see it. To sum up, psychosis has multiple causes and many different features. What they share is that the person loses contact with external reality. This usually takes the form of hallucinations, delusions, disordered thinking, and disturbances in affect. Other than transient drug-induced psychoses, people don’t snap into psychosis, they slide. And they can slide in-and-out, back-and-forth. People can and do recover, sometimes temporarily and sometimes permanently. A psychotic “break” is not at all a Humpty-Dumpty situation; people do get put back together again.

Are certain personality types more prone to such a break?

Don’t mean to dodge but this is a complicated question. Personality is kind of who we are. But psychosis is a symptom of an illness a person has. So, for example, schizophrenia or bi-polar disorder can hit anyone.

As background there are personality disorders in which there is an increased likelihood for moments of psychotic range functioning. But this is not usually what is meant by a psychotic break. Rather these are people we know to be incredibly quirky or difficult or troubled. For example, someone with borderline personality disorder can become so emotionally disregulated when abandoned by a loved one that they can appear frankly psychotic. But then the loved one returns or their attention gets captured by something else and their thinking gets back on track.

Someone with a paranoid personality disorder might be so mistrustful as to make one think they are psychotic. But believing everyone is trying to rip them off does not have the same quality as a psychotic paranoid delusion in which there is a false, fixed, and fantastic belief in a conspiracy to implant shitake mushroom spores in one’s dental work.

Is there a progression that others can be looking out for to “predict” when someone is sliding into psychosis?

When someone is sliding into a psychotic episode, the people with whom they have contact pretty much know it. You can tell something is going on. Unfortunately, people suffering from a psychotic slide tend to isolate themselves so that it is often impossible to predict. In student health service work, the staff are usually well-attuned to who among their caseload is doing well, improving, and declining.

The big problem is not that no one knew James Holmes—the shooter in the Colorado movie theater—was probably seriously ill with a psychotic-range problem. Rather, there was nothing to do with the knowledge. Even psychotic individuals retain their basic rights to refuse treatments and to buy as much ammunition as they care to possess.

Are psychotic breaks always accompanied by violence?

Not at all. In fact, people who are psychotic from whatever cause are far more likely to be the victims of violence. People who suffer from psychosis deserve our compassion and help, not our fear. Here’s a reference that notes that and then also looks to the association between psychosis and violence and what can be done about it: http://www.ncbi.nlm.nih.gov/pubmed/18940033

Read more from Todd Essig at Managing Mental Wealth.

You can find me on Twitter @neuronarrative and at my website, The Daily Brain.

Growing Up in a False Reality

Source: Cindy Eckard/Creative Commons

This guest post is by Cindy Eckard, a Maryland parent who has spearheaded legislation in her state to create medically-sound safety guidelines for the use of digital devices in public schools.

Many people are focused on reducing screen time for children; I’m one of those people. The health risks are enormous for our kids, in a variety of ways, from their vulnerable, undeveloped eyes to their growing bodies and minds. And while I am the first to advocate for schools and parents to limit the amount of time our children spend on digital devices, per se, I am also growing increasingly convinced that our emotive relationships with these machines – which correlates to screen time – needs more exploration. What psychological needs are these digital devices filling – and what price is being paid when they dominate our lives?
Not long ago, I reluctantly signed up for a social media account, recognizing the efficacy of that medium for instantly reaching large, targeted audiences. Because I was pursuing the passage of specific statewide legislation, the timeliness of the messaging was important to me, to educate stakeholders and mobilize political support as quickly as possible.
With nearly the same speed that my messages were being sent, my own need to know how my messages were being received, emerged. It was remarkable how quickly I felt compelled to look at my hit count or check for messages. Hit that bar and get that pellet. No pellet? Hit the bar again. Ah. Pellet. Good pellet. Hit the bar. How many people reacted to my message? That’s it?! Send another message. Get another pellet.
It quickly became evident that I was drawn back to the computer with growing frequency, and increased emotional investment. If my message was well received, I felt validated, vindicated, and smart. And if my message was ignored, it was certain proof that no one cared about the things that interested me most, and I felt isolated.
This, from a grown woman, with a lifetime of professional communications and technology experience.
So I can hardly imagine the emotional roller-coaster that many children are now experiencing. It’s very easy to see how cyber-bullying has become such a crisis, since our children’s self-esteem is now hinging on uncontrollable virtual approval, and invisible, shifting, unpredictable digital feedback. The validation we all crave is now seemingly only available to our kids in an artificial way. Even their grades are impersonally emailed to them – no more dirty looks or pats on the back from their teachers.
How uncomfortable, and insecure, then, our children must feel. Whatever approval kids may receive from one another is fleeting, fickle, and unreliable. “Friends” are not real friends. And any embarrassment is amplified, shared universally, and inescapable.
What used to happen and be forgotten in a week when we were kids, now lingers and taunts. A cell phone snapshot can persist online forever, and humiliate a child for years. There is no escape, no relief, no place to hide. It’s cruel. How damaged will this generation be, from the stress of performing for each other, to avoid being “unfriended”? Social media is a sneaky little medium, that hurts. The girl at the lunch table doesn’t yet know she’s the target of criticism by the other kids at the same table.
So the need to stay on top of the latest, artificial developments becomes paramount to kids. Who’s in and who’s out and who said what and what picture was posted, and what replies were sent becomes a constant obsession. It gratifies immediately, defines group cohesion, quenches curiosity, excites, and motivates kids to check into their virtual experience nonstop, or be left out of everything. It’s a sad situation, made sadder because their parents are doing the exact same thing, modeling the exact same obsessions.
Seeking artificial validation not only results in addictive, destructive behaviors, it also displaces the very experiences that would otherwise offer us authentic validation. Actual experiences are no longer valued over virtual ones. My family had an outdoor adventure party not long ago that featured a huge boa constrictor, hissing cockroaches, and a bearded dragon lizard. Although encouraged by the handler, none of the 11-year old kids at the party would even touch the critters. Instead, they pulled out their cell phones and took pictures of them. They didn’t want to actually experience what a snake or a lizard felt like. They just wanted to show their friends the cool snake pictures.
Even common interactions are now being avoided because of these devices, and replaced with disingenuous placations. Technology enables us to avoid conversation, confrontation, rejection, disapproval, honesty. We can avoid any personal risk, ensuring we are always “liked.” An emoticon parades as an emotion. A series of exclamation marks masquerades as enthusiasm. We LOL when we don’t even think it’s funny. How can a whole, healthy person of any age develop or thrive under these circumstances?
We are bankrupting our spirits, our relationships and our society. Peace and quiet are the new enemies of happiness. We need so much constant distraction these days to avoid our own realities, that gas stations now have television screens on the pumps, so that we can maintain the constant stimulation we had in our cars, in our homes, in our offices. Schools are encouraging ever more use of screens for communication among students… who are sitting next to each other in class.
With eyes on screens, we are not looking at each other. We are not noticing anything or anybody around us. So our children are losing the ability to converse or to cope with emotions, their own, or anyone else’s. They require constant noise and colorful, moving pictures or they are immediately irritated, bored and – increasingly – they are anxious, depressed, suicidal. They are out of touch with their own hearts and minds, with each other, and with the natural world around them.
Limit screen time? Absolutely. We must save our children’s retinas from blue light, protect them from myopia, get them a good night’s sleep, and insist they go outside and play. We must make sure their growing muscles and bones aren’t twisted and bent from staring into ill-fitting equipment. We must demand that schools live up to their legal obligation to provide safe and healthy classrooms.

But the price to be paid by our children because of these devices needs to be understood beyond the damage to their bodies. We need to consider our children’s humanity and perspectives – their spirits. We must turn off these devices and teach our children how to build true friendships, cope with actual challenges, explore their own emotions, contribute, appreciate the natural world and enjoy the rich, meaningful experiences of real life.

To view legislative hearings on this topic, hear interviews, and access medical studies on the health risks of digital devices, visit Cindy’s website at www.screensandkids.us

For more help reducing screen-time at home and school, see Reset Your Child’s Brain: A Four Week Plan to End Meltdowns, Raise Grades, and Boost Social Skills by Reversing the Effects of Electronic Screen Time

Psychotic Depression: Losing Touch With Reality

You may be familiar with some of the symptoms of clinical depression — profoundly depressed mood, fatigue, and feelings of hopelessness. But did you know that depression may also be linked to psychosis?

The National Institute of Mental Health (NIMH) defines someone who is “psychotic” as out of touch with reality, likely experiencing false beliefs, known as delusions, or false sights or sounds, known as hallucinations. So when do depression and psychosis go hand in hand?

Psychotic Depression: What Is It?

“Psychotic depression is a relatively rare condition that occurs when someone displays both severe depression and a break with reality. The loss of contact with reality may take the form of delusions, hallucinations, or thought disorders,” explains James C. Overholser, PhD, professor of psychology and director of clinical training at Case Western Reserve University in Cleveland.

Approximately 25 percent of people who have depression that is severe enough to cause them to be admitted to a hospital also have psychosis or psychotic depression. “Major depression with psychosis” is another term used to describe the condition of psychotic depression.

Psychotic Depression: Symptoms

The delusions or hallucinations of people who have psychotic depression often involve beliefs, voices, or visions telling them that they are worthless or evil. In some cases, people may hear voices telling them to harm themselves. In addition to these symptoms, psychotic depression may also cause the following:

  • Feeling persistently worried and on edge
  • Falsely believing you have other illnesses or diseases
  • Difficulty sleeping
  • Poor concentration

Psychotic Depression: Getting a Diagnosis

If you or a loved one has symptoms of psychotic depression, see your doctor right away. Your doctor will perform a medical examination and blood work to make sure your symptoms are not caused by a medical disease or a reaction to medications. A complete psychiatric evaluation will also be done to distinguish psychotic depression from other types of depression and from other psychotic disorders such as schizophrenia.

The cause of psychotic depression is not known, but having a family history of depression or psychosis increases the risk. One of the differences between psychotic depression and schizophrenia is that people with schizophrenia believe their hallucinations or delusions are real. In most cases, people with psychotic depression know their symptoms are not real. They may actually be afraid or ashamed to tell their doctor about these symptoms, which can make the disorder that much more difficult to diagnose.

Psychotic Depression: Getting Treatment

Antidepressants and antipsychotic drugs are often used to treat psychotic depression. “It is likely that psychotic depression has more of a biological basis , and seems to respond more to biological interventions. Treatment usually requires a combination of medications,” notes Overholser. Electroconvulsive therapy, or shock therapy, may also be effective in some cases.

A recent review of 10 studies involving over 500 patients treated for psychotic depression concluded that it may be best to start with an antidepressant drug alone and then add an antipsychotic drug if needed. Using an antipsychotic drug alone is not appropriate therapy. Treatment of psychotic depression is more likely to require hospitalization than other types of depression, and long-term medications may be necessary.

If you have symptoms of depression combined with hallucinations or delusions, don’t hesitate to ask for help. It is particularly important to share the details of your symptoms with your doctor, because psychotic depression must be managed differently than other types of depression. The most serious risk of psychotic depression is suicide, so getting appropriate treatment as soon as possible is crucial.

Psychotic depression is an illness, not something to be ashamed of or a weakness. It is also a treatable condition, and most people recover within a year.


Shraddha, a 20-year-old Indian girl studying in the UK, called her mother late one night screaming that somebody was trying to kill her. She said her computer had been hacked into, and the hacker spoke to her through the computer. He kept telling her to run out into the traffic as she didn’t deserve to live. Sometimes he called her vulgar names and mocked her.

She had shared a flat with two other girls for a couple of years when she started her undergraduate course in the UK. Everything had been fine and the girls had become good friends. Six months ago she had begun suspecting that her flatmates were spying on her. So she had taken to staying holed up in her room, door locked and curtains drawn. As she avoided going to the kitchen to cook, and the bathroom to bathe, her health and hygiene were neglected. She stopped attending classes and exams as well, and her grades suffered. Finally, she moved out into a small flat to live alone. As she had informed her parents about the move and given a credible reason for it, they did not suspect anything to be amiss.

Following that phone call, her panic-stricken mother caught the first flight out and brought her home.

She came in for a consultation a day or two later accompanied by her mother. As her mother laid out the facts, Shraddha sat quietly in her chair looking utterly exhausted and blank. She did not add anything, nor did she contradict her mother. She did not even seem to register where she was, or with whom. When I asked her a simple question – was she sleeping well? – she merely directed a perplexed gaze at me but did not reply. She seemed to be somewhere else altogether.

This is not an uncommon presentation in psychiatric clinics. All the symptoms Shraddha experienced were typical:

  • Hallucinations – she heard a voice saying things to her
  • Delusions – she completely believed that her computer was hacked, also that her friends were spying on her
  • Disorganisation – the way she had started to live, neglecting herself, lacking motivation to do things
  • Social withdrawal, lack of normal feelings, poverty of speech

When people bring in a family member or a friend who has been through this harrowing experience they usually refer to it as a nervous breakdown. In psychiatric parlance it is simply called an acute psychotic episode, meaning it is something that has suddenly happened (acute), there are symptoms like hallucinations and delusions that show a lack of touch with reality (psychotic) and it may be temporary (episode).

Sometimes people present with sleeplessness, along with mild psychotic symptoms such as odd thoughts or behavior that they recognise as irrational, or vague doubts about the intentions of neighbours or co-workers. There is an awareness of this change at a subliminal level, a feeling that something is not quite right. This is called the prodromal phase. A prodromal phase lasting a few months before the full syndrome develops is common. This might have been the clinical picture if Shraddha had presented four or five months before. Had her mental state been examined once a week or so by a psychiatrist, treatment could have been started earlier, and the breakdown averted.

When such a person is first seen in the hospital the focus is on controlling psychotic symptoms with antipsychotic medications. However, as there are other disorders that present with psychotic symptoms in adolescence, it is necessary to wait for a few months and watch what happens. These disorders are relatively rare, e.g. tumours of the temporal lobe, metabolic diseases like disorders of copper metabolism, certain types of epilepsy, etc. Even a head injury that was not considered serious when it happened may cause similar symptoms days or months later. These can be diagnosed only by regular reviews and appropriate investigations. It is important to comply with the prescribed treatment, because the doctor’s next step depends on the patient’s response to medication and other parameters used to assess progress.

Early intervention is imperative. For one thing, it improves the chances of complete recovery. Secondly, there are these benefits:

  • Good response to medication and lower risk of relapse
  • Quicker return to school/work and normal life
  • No loss of social skills, intact interpersonal relationships
  • No need for hospitalization
  • Reduced risk of suicide (that can happen in response to hallucinations, as it could have in the case above)
  • Less stress on family members

In this series Dr Shyamala Vatsa highlights the fact that teenage changes can mask incipient mental health problems. These articles show how early symptoms of mental disorder can be taken for ordinary teenage behavior. As illustrated by the stories of young people who have suffered unnecessarily, it is important for friends and family to recognize when a behavior is outside normal limits, and seek help before things spin out of control.

Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at [email protected]

Child, Adolescent and Adult Psychiatry

Psychotic Disorder: Losing Touch With Reality

Reality is the one thing that keeps us grounded. When times get tough and we feel as if we are drifting away from our lives to be swept along by the current of unfavorable circumstances, it is the certainty and tangibility of events and situations that help us remain firm in our world. Reality gives us the ability to remain fully conscious of our surroundings, thus giving us the necessary focus to distinguish what can and cannot be.

To lose touch with reality is a difficult thing to grasp, but it does happen to individuals. This is known as a psychotic disorder— when individual perceptions become untrustworthy and unrealistic, such as in a dream. While dreaming, one can always escape into the waking world and plant their feet back onto the ground, however, because of symptoms such as hallucinations and delusions, there is no easy escape which can make a victim feel trapped in their own mind.

When one’s mind— the only place where one can truly feel safe from the spontaneities of the outside world, is no longer functioning in the way it should be, it can lead to abnormal levels of stress as the victim tries to deal with placing real events from unreal events. Fighting one’s own mind is a terrible battle, as it can project realities that can interfere with daily routines.

Each of the five senses has a corresponding type of hallucination.

  • Seeing : Visual hallucinations
  • Hearing: Auditory hallucinations
  • Smelling: Olfactory hallucinations
  • Tasting: Gustatory hallucinations
  • Touching: Tactile hallucinations

The most common forms of hallucinations that are experienced from psychotic disorder mainly come from visual and auditory.

An example of a mild form of visual hallucination is seeing faint movement around the peripheral vision. These range from seeing shadows, figures, or distinct shapes flitting around quickly. Usually, these visions disappear instantaneously.

There are also mild auditory hallucinations which involve hearing noises and/or voices. These can be multiple voices at once or a single voice, also varying in volume.

The more complex hallucinations are intriguing phenomenon, especially when it is classified as visual. They cause individuals to unintentionally conjure entire situations, completely made-up by the disorder. Whatever the scenario, all hallucinations are characterized by witnessing non-existent occurrences and false perceptions of sight and sound. When dealing with psychotic disorder, its best to approach a health care professional who specializes in studying each disorder comprehensively in order to give the most appropriate treatment.

oiradmin September 13th, 2017

Posted In: blog



Postnatal psychosis

Postnatal psychosis, also called puerperal psychosis, is a severe form of postnatal depression, a type of depression some women experience after having a baby.

It’s estimated postnatal psychosis affects around 1 in every 1,000 women who give birth. It most commonly occurs during the first few weeks after having a baby.

Postnatal psychosis is more likely to affect women who already have a mental health condition, such as bipolar disorder or schizophrenia.

As well as the symptoms of psychosis, symptoms of postnatal psychosis can also include changes in mood:

  • a high mood (mania) – for example, feeling elated, talking and thinking too much or too quickly
  • a low mood – for example, feeling sad, a lack of energy, loss of appetite, and trouble sleeping

Contact a GP immediately if you think you or someone you know may have developed postnatal psychosis as it is a medical emergency. If this is not possible, call NHS 111 or your local out-of-hours service.

If you think there’s an imminent danger of harm, call 999 and ask for an ambulance.

Psychosis is not the same as psychopath

The terms “psychosis” and “psychopath” should not be confused.

Someone with psychosis has a short-term (acute) condition that, if treated, can often lead to a full recovery.

A psychopath is someone with an antisocial personality disorder, which means they:

  • lack empathy – the capacity to understand how someone else feels
  • are manipulative
  • often have a total disregard for the consequences of their actions

People with an antisocial personality can sometimes pose a threat to others because they can be violent. Most people with psychosis are more likely to harm themselves than others.

Feelings of unreality, depersonalixation, derealization, feeling disconnected from the real world, dreamlike, unreal

Written by: Jim Folk.
Medically reviewed by: Marilyn Folk, BScN.
Last updated: November 11, 2019

Feelings of unreality, depersonalization, derealization, unreality anxiety symptoms description:

You feel like you are not a part of what is going on, or that you feel like you are in a dream state or ‘out of touch with things’. You might also feel that you are an outside observer of the world, or even yourself, but not of the world or able to feel a part of reality. Sometimes you might feel very unreal then think that you are losing your mind or will cross over into some other non-real world or consciousness.

You might also have thoughts that can have you questioning your sanity, reality, and/or the reality of the world, which may cause you to become fearful and even to the point of panic.

Also, things around you may seem like they are shimmering, foggy, hazy, or too bright.

This feelings of unreality symptom dropping sensation can persistently affect one area only, can shift and affect another area or areas, and can migrate all over and affect many areas over and over again.

This feelings of unreality symptom can come and go rarely, occur frequently, or persist indefinitely. For example, you may feel a pins and needles feeling once in a while and not that often, feel it off and on, or feel it all the time.

This feelings of unreality symptom may precede, accompany, or follow an escalation of other anxiety sensations and symptoms, or occur by itself.

This feelings of unreality symptom can precede, accompany, or follow an episode of nervousness, anxiety, fear, and elevated stress, or occur ‘out of the blue’ and for no apparent reason.

This feelings of unreality symptom can range in intensity from slight, to moderate, to severe. It can also come in waves, where it’s strong one moment and eases off the next.

This feelings of unreality symptom can change from day to day, and/or from moment to moment.

All of the above combinations and variations are common.

What causes the feelings of unreality anxiety symptom?

Anxiety causes the body to produce the stress response (also known as the fight or flight response). The stress response stresses the body. When the body becomes overly stressed, which we call stress-response hyperstimulation, the body can exhibit a wide variety of odd and unusual sensations and symptoms. The feelings of unreality symptom is one of them.

How to get rid of the feelings of unreality anxiety symptom?

Because this feelings of unreality symptom is just a symptom of elevated stress, it needn’t be a cause for concern. It will subside when you reduce your stress and give your body ample time to calm down. As your body’s stress returns to a more normal level, symptoms of stress subside, including the feelings of unreality anxiety symptom. Therefore, this feelings of unreality symptom needn’t be a cause for concern.

For more information, visit our “Depersonalization” symptom, which is often associated with the “Feelings of Unreality” symptoms.

Chapter 9 in the Recovery Support area of our website is our anxiety symptoms chapter. It contains detailed information about all anxiety symptoms, including what they are, why they occur, what you can do to eliminate them, and how many people experience them (the percentage of people who experience each anxiety symptom). Our anxiety symptoms chapter includes a more detailed description and explanation about the feelings of unreality anxiety symptom.

The combination of good self-help information and working with an experienced anxiety disorder therapist is the most effective way to address anxiety disorder and its many symptoms. Until the core causes of anxiety are addressed – the underlying factors that motivate apprehensive behavior – a struggle with anxiety disorder can return again and again. Identifying and successfully addressing anxiety’s underlying factors is the best way to overcome problematic anxiety.

Additional Resources:

  • For a comprehensive list of Anxiety Disorders Symptoms Signs, Types, Causes, Diagnosis, and Treatment.
  • Anxiety and panic attacks symptoms can be powerful experiences. Find out what they are and how to stop them.
  • How to stop an anxiety attack and panic.
  • Free online anxiety tests to screen for anxiety. Two minute tests with instant results. Such as:
    • Anxiety Test
    • Anxiety Disorder Test
    • OCD Test
    • Social Anxiety Test
    • Generalized Anxiety Test
  • Anxiety 101 is a summarized description of anxiety, anxiety disorder, and how to overcome it.

Return to Anxiety Disorders Signs and Symptoms section.

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