User login
Discuss this article at http://currentpsychiatry.blogspot.com/2010/10/re-envisioning-psychosis-new-language.html#comments
“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”
In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.1,2
The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.
Power of language
The word “psychosis” has enormous power for patients, families, clinicians, and the public. It often is used interchangeably with “craziness,” “insanity,” or “madness.” Mental health clinicians use psychosis to describe many phenomena, including:
- breaks with reality testing
- odd or delusional beliefs
- abnormal sensations
- catatonia
- bizarre behaviors
- so-called formal thought disorders.
It is likely one of the most heterogeneous symptom terms in psychiatry. DSM-IV-TR notes “the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance.”3
Psychosis myths. In addition to its phenomenological usage, the word psychosis also has various theoretical interpretations and often is used to demonstrate a fundamental pivot point for making qualitative distinctions. For example, clinicians and theorists have used “psychotic” to assume that someone experiencing psychosis:
- is operating on a core or primitive mode of thought, the so-called “primary process”4
- has a belief that is beyond understanding, one for which empathy is meaningless and misplaced5
- has clear convictions that violate social norms and refuses to accept society’s “proper” rules for logic and emotion6
- is in a state of “brain toxicity” with an “organic” cause (this comes from discussing psychosis with other clinicians, not from the literature).
Such seemingly disparate definitions share the assumption that psychosis represents a shift in categorical status, whether the category is developmental (advanced vs primitive), interpersonal judgment (able to be empathized with or not), sociopolitical status (conformist or not), or functional brain state (organic or non-organic).
Even the etymological basis for schizophrenia (its Greek roots signify “split mind,” which arguably spawned the long-held erroneous view that schizophrenia is a “split personality”) exemplifies this stance and reinforces the notion of discrete “all-or-none” categories of experience. In our view, such assumptions do not adequately reflect the reality of psychosis as a continuum of human experience, and could lead to serious, if unintended, stigmatization and oversimplification of persons who have psychotic symptoms. We argue that such all-or-none thinking reifies 2 clinical “myths” about what psychosis represents:
- Psychosis represents a fundamentally different type of cognitive process.
- Psychosis is so different from normal human experience that mood and anxiety symptoms become “subsumed” by it and treated as “secondary.”
Our goal is not to redefine psychosis or present an argument for diagnostically recategorizing schizophrenia, schizoaffective disorder, and bipolar disorder, which others have already done well.7-10 Instead we want to reinforce the evidence-based and clinically relevant concept that psychosis exists on a definable continuum of human experience and to offer practitioners a clinical language of psychosis for assessing and treating psychotic symptoms that avoids unsupported all-or-none distinctions.
Defining ‘the schizophrenic’
In our experience, an unintended consequence of assuming psychosis is an all-or-none state is the clinician’s perpetual search for “real psychosis” as separate from “psychosis for which I have a good explanation.” Although this distinction is reminiscent of earlier arguments regarding “neurotic” vs “endogenous” depression, we feel that in this case “real or not” acts at a more basic level: the characterization of person types.
We assume that every clinician—ourselves included—who has worked with seriously mentally ill patients has heard an individual with schizophrenia referred to as “a schizophrenic.” Although the problem of defining a person as an illness is not unique to psychosis, we think that you will agree that the phrases “a depressive,” “a bipolar,” or “a generalized anxiotic” [sic] are rare.
DSM-IV-TR specifically avoids using expressions such as “a schizophrenic…and [instead uses]…an individual with schizophrenia.”11 But we believe that DSM-IV-TR accidentally encourages the distinction of a “psychotic person type” by making schizoaffective disorder—a disorder that suggests a continuum—use Criterion A for schizophrenia as its defining feature. The implicit assumption is that “something categorical”—in this case defined by Criterion A—identifies a “psychotic person type,” as opposed to a person who simply has psychotic symptoms. If we see evidence of Criterion A, then the person is naturally moved into the realm of “schizophrenia and other psychotic disorders.” In other words, Criterion A subsumes other types of symptoms. In contrast, the presence of 1 month of social anxiety or obsessions and compulsions does not subsume other symptoms into primary anxiety disorders. To make this example explicit, we have developed a set of criteria for hypothetical disorders that overlap major categories of DSM-IV-TR (Table 1).
Table 1
The ‘logic’ of schizoaffective disorder applied to anxiety and OCD
| Symptom course | ‘Primary’ feature | ‘Secondary’ feature | Diagnosis |
|---|---|---|---|
| 2 weeks of ≥2 psychotic symptoms outside of a major mood episode plus a manic or depressed episode | 2 weeks of psychotic and negative symptoms | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | Schizoaffective disorder |
| 1 month of social anxiety and avoidance outside of a major mood episode plus a manic or depressed episode | 1 month of social anxiety and avoidance | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Socio-anxious-affective disorder’* |
| 1 month of obsessions and compulsions outside of a major mood episode plus a manic or depressed episode | 1 month of obsessions and compulsions | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Obsessocompulso-affective disorder’* |
| OCD: obsessive-compulsive disorder | |||
| * These diagnoses are hypothetical disorders used to illustrate how the criteria used to define schizoaffective disorder subsume other types of symptoms | |||
A continuum approach
As a way out of this inductive logic trap, we suggest the following statements as evidence-based and clinically realistic ways of approaching psychosis assessment.
‘Normal sadness’ and ‘normal psychosis’ are equivalent. The DSM-IV-TR description of major depressive disorder, states that “periods of sadness are inherent aspects of the human experience.”12 However, descriptions of psychosis rarely reflect that psychotic-like experiences are quite common13-19 and easily induced in otherwise healthy people.20 Psychotic symptoms are widely described as being genetically linked to normally distributed personality traits.21-24 Finally, research on risk for developing chronic psychosis has identified that most patients who develop attenuated psychotic symptoms do not experience them chronically.25-28 Together, these data argue strongly for a concept of psychosis as common and continuously distributed across large groups.
A psychosis screen can be much more than ‘+/- AH/VH/PI.’ We reject the idea that psychotic phenomena are fundamentally different from “normal” occurrences such as imagined or inner speech, perceptual fluctuations, distorted or rigid beliefs, or inability to accurately express one’s emotional state. Yet abnormal perception, affect flattening, and delusions often are viewed as “really weird,” which suggests most people never experience these phenomena, only “affected” people. This easily can lead to cognitive errors that associate psychosis as a state of mind that is fundamentally different from non-psychosis. In fact, DSMIV-TR categorizes the presence of persistent psychotic symptoms as evidence of disorder until proven otherwise.3
We feel that this simplistic language describing psychosis as inherently pathological ignores the clinical richness of psychotic experience. In our experience, many individuals who have been diagnosed with chronic psychosis have never been asked:
- about the timing, intensity, and character of their abnormal sensory experiences29
- how their beliefs and schemas affect day-to-day behavior and choices
- if their psychotic symptoms are bothersome or troubling.
We worry that a person experiencing impairing psychotic symptoms could become overshadowed by all-or-none assumptions about the symptoms themselves.
We propose Table 2 as a guideline for approaching psychotic symptoms as expressions along a continuum of experience, one that shares much in common with recent well-developed biopsychosocial models of psychotic phenomena.30 In our view, this allows for a therapeutic alliance that focuses on patient recovery, as opposed to seeing psychotic symptoms as the only treatment targets. By moving beyond all-or-none myths and approaching psychosis as a continuum with normal experience, we believe that patient recovery can become a realistic goal.
Table 2
Revising the clinical language of psychosis to separate presence from pathology
| Symptom | Continuum | Attenuated experience | Pathological experience (‘disorder’) | Psychotherapeutic intervention |
|---|---|---|---|---|
| Paranoid ideation/delusions | Schematization and testing of environmental information |
|
|
|
| Hallucination | Higher order sensory processing and self/other discrimination |
|
|
|
| Disorganized speech / ‘thought disorder’ | Social pragmatics and conceptual linking |
|
|
|
| Source: Bechdolf A, Phillips LJ, Francey SM, et al. Recent approaches to psychological interventions for people at risk of psychosis. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):159-173. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020. French P, Morrison AP. Early detection and cognitive therapy for people at high risk of developing psychosis: a treatment approach. West Sussex, United Kingdom: John Wiley and Sons; 2004. Christodoulides T, Dudley R, Brown S, et al. Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: a case series. Psychol Psychother. 2008;81(Pt 2):199-207. Davis LW, Ringer JM, Strasburger AM, et al. Participant evaluation of a CBT program for enhancing work function in schizophrenia. Psychiatr Rehabil J. 2008;32(1):55-58. Jackson HJ, McGorry PD, Killackey E, et al. Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: the ACE project. Psychol Med. 2008;38(5):725-735. Lecomte T, Leclerc C, Corbiere M, et al. Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. J Nerv Ment Dis. 2008;196(12):866-875. Loewy RL, Johnson JK, Cannon TD. Self-report of attenuated psychotic experiences in a college population. Schizophr Res. 2007; 93(1-3):144-151. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715. Mitchell AJ. CBT for psychosis. Br J Psychiatry. 2004;185:438; author reply 438. Rathod S, Kingdon D, Weiden P, et al. Cognitive-behavioral therapy for medication-resistant schizophrenia: a review. J Psychiatr Pract. 2008;14(1):22-33. Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc.; 2008. | ||||
Re-envisioning psychosis
We conclude with a reiteration of recovery in the language of the US Surgeon General almost 10 years ago: “…hope and restoration of a meaningful life are possible, despite serious mental illness… Instead of focusing primarily on symptom relief…recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society.”31 We see no reason why people cannot live meaningful lives while also having symptoms of psychosis. Data from well-designed studies32 and accounts from individuals who have experienced or continue to experience psychosis33 suggest that this is realistic.
By dispelling all-or-none myths, revealing the flawed logic of psychosis as “subsumer” of mood and anxiety, and describing the continuum of psychotic symptoms, we hope to encourage clinicians to be more positive and proactive in their approach to people experiencing impairing psychotic symptoms. Through assertive alliance and informed clinical technique, we envision a landscape in which psychosis is seen as a “normal” part of outpatient psychiatric practice.
Related resources
- Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
- Gleeson JFM, McGorry PD, eds. Psychological interventions in early psychosis: a treatment handbook. West Sussex, United Kingdom: John Wiley & Sons; 2004.
- Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
Disclosure
The authors report no financial relationship with any manufacturer of products mentioned in this article or with manufacturers of competing products.
Acknowledgement
The authors wish to acknowledge Dr. Carol Mathews for her comments on this manuscript.
1. Stefanis NC, Hanssen M, Smirnis NK, et al. Evidence that three dimensions of psychosis have a distribution in the general population. Psychol Med. 2002;32(2):347-358.
2. Verdoux H, van Os J. Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res. 2002;54(1-2):59-65.
3. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:297–343.
4. Tyson P, Tyson RL. Psychoanalytic theories of development: an integration. New Haven, CT: Yale University Press; 1990.
5. Schilpp PA. Philosophy of Karl Jaspers. Chicago, IL: Open Court Publishing Company; 1981.
6. Szasz TS. The second sin. Garden City, NY: Anchor Press; 1974.
7. Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
8. van Os J. ‘Salience syndrome’ replaces ‘schizophrenia’ in DSM-V and ICD-11: psychiatry’s evidence-based entry into the 21st century? Acta Psychiatr Scand. 2009;120(5):363-372.
9. Lake CR, Hurwitz N. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders. Psychiatry Res. 2006;143(2-3):255-287.
10. Craddock N, Owen MJ. The Kraepelinian dichotomy—going, going…but still not gone. Br J Psychiatry. 2010;196(2):92-95.
11. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:xxxi.
12. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:345–428.
13. Yung AR, Buckby JA, Cotton SM, et al. Psychotic-like experiences in nonpsychotic help-seekers: associations with distress, depression, and disability. Schizophr Bull. 2006;32(2):352-359.
14. Tien AY. Distributions of hallucinations in the population. Soc Psychiatry Psychiatr Epidemiol. 1991;26(6):287-292.
15. Eaton WW, Romanoski A, Anthony JC, et al. Screening for psychosis in the general population with a self-report interview. J Nerv Ment Dis. 1991;179(11):689-693.
16. Poulton R, Caspi A, Moffitt TE, et al. Children’s self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry. 2000;57(11):1053-1058.
17. van Os J, Hanssen M, Bijl RV, et al. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry. 2001;58(7):663-668.
18. Sommer IE, Daalman K, Rietkerk T, et al. Healthy individuals with auditory verbal hallucinations; who are they? Psychiatric assessments of a selected sample of 103 subjects. Schizophr Bull. 2010;36(3):633-641.
19. Strauss JS. Hallucinations and delusions as points on continua function. Rating scale evidence. Arch Gen Psychiatry. 1969;21(5):581-586.
20. Merabet LB, Maguire D, Warde A, et al. Visual hallucinations during prolonged blindfolding in sighted subjects. J Neuroophthalmol. 2004;24(2):109-113.
21. Fanous AH, Neale MC, Gardner CO, et al. Significant correlation in linkage signals from genome-wide scans of schizophrenia and schizotypy. Mol Psychiatry. 2007;12(10):958-965.
22. Fanous A, Gardner C, Walsh D, et al. Relationship between positive and negative symptoms of schizophrenia and schizotypal symptoms in nonpsychotic relatives. Arch Gen Psychiatry. 2001;58(7):669-673.
23. Webb CT, Levinson DF. Schizotypal and paranoid personality disorder in the relatives of patients with schizophrenia and affective disorders: a review. Schizophr Res. 1993;11(1):81-92.
24. Asai T, Sugimori E, Bando N, et al. The hierarchic structure in schizotypy and the five-factor model of personality. Psychiatry Res. 2010 May 26. [Epub ahead of print].
25. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715.
26. Meyer SE, Bearden CE, Lux SR, et al. The psychosis prodrome in adolescent patients viewed through the lens of DSM-IV. J Child Adolesc Psychopharmacol. 2005;15(3):434-451.
27. Cannon TD, Cadenhead K, Cornblatt B, et al. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Arch Gen Psychiatry. 2008;65(1):28-37.
28. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull. 1996;22(2):353-370.
29. Nasrallah HA. The hallucination portrait of psychosis. Current Psychiatry. 2009;8(5):10-12.
30. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020.
31. US Department of Health and Human Services. Mental health: a report of the surgeon general—executive summary. Washington, DC: US Department of Health and Human Services; 1999. Available at: http://www.surgeongeneral.gov/library/mentalhealth/summary.html. Accessed September 10, 2010.
32. Kane JM. An evidence-based strategy for remission in schizophrenia. J Clin Psychiatry. 2008;69(suppl 3):25-30.
33. Wagner PS. First person account: a voice from another closet. Schizophr Bull. 1996;22(2):399-401.
Discuss this article at http://currentpsychiatry.blogspot.com/2010/10/re-envisioning-psychosis-new-language.html#comments
“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”
In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.1,2
The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.
Power of language
The word “psychosis” has enormous power for patients, families, clinicians, and the public. It often is used interchangeably with “craziness,” “insanity,” or “madness.” Mental health clinicians use psychosis to describe many phenomena, including:
- breaks with reality testing
- odd or delusional beliefs
- abnormal sensations
- catatonia
- bizarre behaviors
- so-called formal thought disorders.
It is likely one of the most heterogeneous symptom terms in psychiatry. DSM-IV-TR notes “the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance.”3
Psychosis myths. In addition to its phenomenological usage, the word psychosis also has various theoretical interpretations and often is used to demonstrate a fundamental pivot point for making qualitative distinctions. For example, clinicians and theorists have used “psychotic” to assume that someone experiencing psychosis:
- is operating on a core or primitive mode of thought, the so-called “primary process”4
- has a belief that is beyond understanding, one for which empathy is meaningless and misplaced5
- has clear convictions that violate social norms and refuses to accept society’s “proper” rules for logic and emotion6
- is in a state of “brain toxicity” with an “organic” cause (this comes from discussing psychosis with other clinicians, not from the literature).
Such seemingly disparate definitions share the assumption that psychosis represents a shift in categorical status, whether the category is developmental (advanced vs primitive), interpersonal judgment (able to be empathized with or not), sociopolitical status (conformist or not), or functional brain state (organic or non-organic).
Even the etymological basis for schizophrenia (its Greek roots signify “split mind,” which arguably spawned the long-held erroneous view that schizophrenia is a “split personality”) exemplifies this stance and reinforces the notion of discrete “all-or-none” categories of experience. In our view, such assumptions do not adequately reflect the reality of psychosis as a continuum of human experience, and could lead to serious, if unintended, stigmatization and oversimplification of persons who have psychotic symptoms. We argue that such all-or-none thinking reifies 2 clinical “myths” about what psychosis represents:
- Psychosis represents a fundamentally different type of cognitive process.
- Psychosis is so different from normal human experience that mood and anxiety symptoms become “subsumed” by it and treated as “secondary.”
Our goal is not to redefine psychosis or present an argument for diagnostically recategorizing schizophrenia, schizoaffective disorder, and bipolar disorder, which others have already done well.7-10 Instead we want to reinforce the evidence-based and clinically relevant concept that psychosis exists on a definable continuum of human experience and to offer practitioners a clinical language of psychosis for assessing and treating psychotic symptoms that avoids unsupported all-or-none distinctions.
Defining ‘the schizophrenic’
In our experience, an unintended consequence of assuming psychosis is an all-or-none state is the clinician’s perpetual search for “real psychosis” as separate from “psychosis for which I have a good explanation.” Although this distinction is reminiscent of earlier arguments regarding “neurotic” vs “endogenous” depression, we feel that in this case “real or not” acts at a more basic level: the characterization of person types.
We assume that every clinician—ourselves included—who has worked with seriously mentally ill patients has heard an individual with schizophrenia referred to as “a schizophrenic.” Although the problem of defining a person as an illness is not unique to psychosis, we think that you will agree that the phrases “a depressive,” “a bipolar,” or “a generalized anxiotic” [sic] are rare.
DSM-IV-TR specifically avoids using expressions such as “a schizophrenic…and [instead uses]…an individual with schizophrenia.”11 But we believe that DSM-IV-TR accidentally encourages the distinction of a “psychotic person type” by making schizoaffective disorder—a disorder that suggests a continuum—use Criterion A for schizophrenia as its defining feature. The implicit assumption is that “something categorical”—in this case defined by Criterion A—identifies a “psychotic person type,” as opposed to a person who simply has psychotic symptoms. If we see evidence of Criterion A, then the person is naturally moved into the realm of “schizophrenia and other psychotic disorders.” In other words, Criterion A subsumes other types of symptoms. In contrast, the presence of 1 month of social anxiety or obsessions and compulsions does not subsume other symptoms into primary anxiety disorders. To make this example explicit, we have developed a set of criteria for hypothetical disorders that overlap major categories of DSM-IV-TR (Table 1).
Table 1
The ‘logic’ of schizoaffective disorder applied to anxiety and OCD
| Symptom course | ‘Primary’ feature | ‘Secondary’ feature | Diagnosis |
|---|---|---|---|
| 2 weeks of ≥2 psychotic symptoms outside of a major mood episode plus a manic or depressed episode | 2 weeks of psychotic and negative symptoms | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | Schizoaffective disorder |
| 1 month of social anxiety and avoidance outside of a major mood episode plus a manic or depressed episode | 1 month of social anxiety and avoidance | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Socio-anxious-affective disorder’* |
| 1 month of obsessions and compulsions outside of a major mood episode plus a manic or depressed episode | 1 month of obsessions and compulsions | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Obsessocompulso-affective disorder’* |
| OCD: obsessive-compulsive disorder | |||
| * These diagnoses are hypothetical disorders used to illustrate how the criteria used to define schizoaffective disorder subsume other types of symptoms | |||
A continuum approach
As a way out of this inductive logic trap, we suggest the following statements as evidence-based and clinically realistic ways of approaching psychosis assessment.
‘Normal sadness’ and ‘normal psychosis’ are equivalent. The DSM-IV-TR description of major depressive disorder, states that “periods of sadness are inherent aspects of the human experience.”12 However, descriptions of psychosis rarely reflect that psychotic-like experiences are quite common13-19 and easily induced in otherwise healthy people.20 Psychotic symptoms are widely described as being genetically linked to normally distributed personality traits.21-24 Finally, research on risk for developing chronic psychosis has identified that most patients who develop attenuated psychotic symptoms do not experience them chronically.25-28 Together, these data argue strongly for a concept of psychosis as common and continuously distributed across large groups.
A psychosis screen can be much more than ‘+/- AH/VH/PI.’ We reject the idea that psychotic phenomena are fundamentally different from “normal” occurrences such as imagined or inner speech, perceptual fluctuations, distorted or rigid beliefs, or inability to accurately express one’s emotional state. Yet abnormal perception, affect flattening, and delusions often are viewed as “really weird,” which suggests most people never experience these phenomena, only “affected” people. This easily can lead to cognitive errors that associate psychosis as a state of mind that is fundamentally different from non-psychosis. In fact, DSMIV-TR categorizes the presence of persistent psychotic symptoms as evidence of disorder until proven otherwise.3
We feel that this simplistic language describing psychosis as inherently pathological ignores the clinical richness of psychotic experience. In our experience, many individuals who have been diagnosed with chronic psychosis have never been asked:
- about the timing, intensity, and character of their abnormal sensory experiences29
- how their beliefs and schemas affect day-to-day behavior and choices
- if their psychotic symptoms are bothersome or troubling.
We worry that a person experiencing impairing psychotic symptoms could become overshadowed by all-or-none assumptions about the symptoms themselves.
We propose Table 2 as a guideline for approaching psychotic symptoms as expressions along a continuum of experience, one that shares much in common with recent well-developed biopsychosocial models of psychotic phenomena.30 In our view, this allows for a therapeutic alliance that focuses on patient recovery, as opposed to seeing psychotic symptoms as the only treatment targets. By moving beyond all-or-none myths and approaching psychosis as a continuum with normal experience, we believe that patient recovery can become a realistic goal.
Table 2
Revising the clinical language of psychosis to separate presence from pathology
| Symptom | Continuum | Attenuated experience | Pathological experience (‘disorder’) | Psychotherapeutic intervention |
|---|---|---|---|---|
| Paranoid ideation/delusions | Schematization and testing of environmental information |
|
|
|
| Hallucination | Higher order sensory processing and self/other discrimination |
|
|
|
| Disorganized speech / ‘thought disorder’ | Social pragmatics and conceptual linking |
|
|
|
| Source: Bechdolf A, Phillips LJ, Francey SM, et al. Recent approaches to psychological interventions for people at risk of psychosis. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):159-173. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020. French P, Morrison AP. Early detection and cognitive therapy for people at high risk of developing psychosis: a treatment approach. West Sussex, United Kingdom: John Wiley and Sons; 2004. Christodoulides T, Dudley R, Brown S, et al. Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: a case series. Psychol Psychother. 2008;81(Pt 2):199-207. Davis LW, Ringer JM, Strasburger AM, et al. Participant evaluation of a CBT program for enhancing work function in schizophrenia. Psychiatr Rehabil J. 2008;32(1):55-58. Jackson HJ, McGorry PD, Killackey E, et al. Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: the ACE project. Psychol Med. 2008;38(5):725-735. Lecomte T, Leclerc C, Corbiere M, et al. Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. J Nerv Ment Dis. 2008;196(12):866-875. Loewy RL, Johnson JK, Cannon TD. Self-report of attenuated psychotic experiences in a college population. Schizophr Res. 2007; 93(1-3):144-151. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715. Mitchell AJ. CBT for psychosis. Br J Psychiatry. 2004;185:438; author reply 438. Rathod S, Kingdon D, Weiden P, et al. Cognitive-behavioral therapy for medication-resistant schizophrenia: a review. J Psychiatr Pract. 2008;14(1):22-33. Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc.; 2008. | ||||
Re-envisioning psychosis
We conclude with a reiteration of recovery in the language of the US Surgeon General almost 10 years ago: “…hope and restoration of a meaningful life are possible, despite serious mental illness… Instead of focusing primarily on symptom relief…recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society.”31 We see no reason why people cannot live meaningful lives while also having symptoms of psychosis. Data from well-designed studies32 and accounts from individuals who have experienced or continue to experience psychosis33 suggest that this is realistic.
By dispelling all-or-none myths, revealing the flawed logic of psychosis as “subsumer” of mood and anxiety, and describing the continuum of psychotic symptoms, we hope to encourage clinicians to be more positive and proactive in their approach to people experiencing impairing psychotic symptoms. Through assertive alliance and informed clinical technique, we envision a landscape in which psychosis is seen as a “normal” part of outpatient psychiatric practice.
Related resources
- Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
- Gleeson JFM, McGorry PD, eds. Psychological interventions in early psychosis: a treatment handbook. West Sussex, United Kingdom: John Wiley & Sons; 2004.
- Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
Disclosure
The authors report no financial relationship with any manufacturer of products mentioned in this article or with manufacturers of competing products.
Acknowledgement
The authors wish to acknowledge Dr. Carol Mathews for her comments on this manuscript.
Discuss this article at http://currentpsychiatry.blogspot.com/2010/10/re-envisioning-psychosis-new-language.html#comments
“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”
In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.1,2
The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.
Power of language
The word “psychosis” has enormous power for patients, families, clinicians, and the public. It often is used interchangeably with “craziness,” “insanity,” or “madness.” Mental health clinicians use psychosis to describe many phenomena, including:
- breaks with reality testing
- odd or delusional beliefs
- abnormal sensations
- catatonia
- bizarre behaviors
- so-called formal thought disorders.
It is likely one of the most heterogeneous symptom terms in psychiatry. DSM-IV-TR notes “the term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance.”3
Psychosis myths. In addition to its phenomenological usage, the word psychosis also has various theoretical interpretations and often is used to demonstrate a fundamental pivot point for making qualitative distinctions. For example, clinicians and theorists have used “psychotic” to assume that someone experiencing psychosis:
- is operating on a core or primitive mode of thought, the so-called “primary process”4
- has a belief that is beyond understanding, one for which empathy is meaningless and misplaced5
- has clear convictions that violate social norms and refuses to accept society’s “proper” rules for logic and emotion6
- is in a state of “brain toxicity” with an “organic” cause (this comes from discussing psychosis with other clinicians, not from the literature).
Such seemingly disparate definitions share the assumption that psychosis represents a shift in categorical status, whether the category is developmental (advanced vs primitive), interpersonal judgment (able to be empathized with or not), sociopolitical status (conformist or not), or functional brain state (organic or non-organic).
Even the etymological basis for schizophrenia (its Greek roots signify “split mind,” which arguably spawned the long-held erroneous view that schizophrenia is a “split personality”) exemplifies this stance and reinforces the notion of discrete “all-or-none” categories of experience. In our view, such assumptions do not adequately reflect the reality of psychosis as a continuum of human experience, and could lead to serious, if unintended, stigmatization and oversimplification of persons who have psychotic symptoms. We argue that such all-or-none thinking reifies 2 clinical “myths” about what psychosis represents:
- Psychosis represents a fundamentally different type of cognitive process.
- Psychosis is so different from normal human experience that mood and anxiety symptoms become “subsumed” by it and treated as “secondary.”
Our goal is not to redefine psychosis or present an argument for diagnostically recategorizing schizophrenia, schizoaffective disorder, and bipolar disorder, which others have already done well.7-10 Instead we want to reinforce the evidence-based and clinically relevant concept that psychosis exists on a definable continuum of human experience and to offer practitioners a clinical language of psychosis for assessing and treating psychotic symptoms that avoids unsupported all-or-none distinctions.
Defining ‘the schizophrenic’
In our experience, an unintended consequence of assuming psychosis is an all-or-none state is the clinician’s perpetual search for “real psychosis” as separate from “psychosis for which I have a good explanation.” Although this distinction is reminiscent of earlier arguments regarding “neurotic” vs “endogenous” depression, we feel that in this case “real or not” acts at a more basic level: the characterization of person types.
We assume that every clinician—ourselves included—who has worked with seriously mentally ill patients has heard an individual with schizophrenia referred to as “a schizophrenic.” Although the problem of defining a person as an illness is not unique to psychosis, we think that you will agree that the phrases “a depressive,” “a bipolar,” or “a generalized anxiotic” [sic] are rare.
DSM-IV-TR specifically avoids using expressions such as “a schizophrenic…and [instead uses]…an individual with schizophrenia.”11 But we believe that DSM-IV-TR accidentally encourages the distinction of a “psychotic person type” by making schizoaffective disorder—a disorder that suggests a continuum—use Criterion A for schizophrenia as its defining feature. The implicit assumption is that “something categorical”—in this case defined by Criterion A—identifies a “psychotic person type,” as opposed to a person who simply has psychotic symptoms. If we see evidence of Criterion A, then the person is naturally moved into the realm of “schizophrenia and other psychotic disorders.” In other words, Criterion A subsumes other types of symptoms. In contrast, the presence of 1 month of social anxiety or obsessions and compulsions does not subsume other symptoms into primary anxiety disorders. To make this example explicit, we have developed a set of criteria for hypothetical disorders that overlap major categories of DSM-IV-TR (Table 1).
Table 1
The ‘logic’ of schizoaffective disorder applied to anxiety and OCD
| Symptom course | ‘Primary’ feature | ‘Secondary’ feature | Diagnosis |
|---|---|---|---|
| 2 weeks of ≥2 psychotic symptoms outside of a major mood episode plus a manic or depressed episode | 2 weeks of psychotic and negative symptoms | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | Schizoaffective disorder |
| 1 month of social anxiety and avoidance outside of a major mood episode plus a manic or depressed episode | 1 month of social anxiety and avoidance | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Socio-anxious-affective disorder’* |
| 1 month of obsessions and compulsions outside of a major mood episode plus a manic or depressed episode | 1 month of obsessions and compulsions | 2 weeks of low mood or anhedonia or 1 week of elevated or expansive mood | ‘Obsessocompulso-affective disorder’* |
| OCD: obsessive-compulsive disorder | |||
| * These diagnoses are hypothetical disorders used to illustrate how the criteria used to define schizoaffective disorder subsume other types of symptoms | |||
A continuum approach
As a way out of this inductive logic trap, we suggest the following statements as evidence-based and clinically realistic ways of approaching psychosis assessment.
‘Normal sadness’ and ‘normal psychosis’ are equivalent. The DSM-IV-TR description of major depressive disorder, states that “periods of sadness are inherent aspects of the human experience.”12 However, descriptions of psychosis rarely reflect that psychotic-like experiences are quite common13-19 and easily induced in otherwise healthy people.20 Psychotic symptoms are widely described as being genetically linked to normally distributed personality traits.21-24 Finally, research on risk for developing chronic psychosis has identified that most patients who develop attenuated psychotic symptoms do not experience them chronically.25-28 Together, these data argue strongly for a concept of psychosis as common and continuously distributed across large groups.
A psychosis screen can be much more than ‘+/- AH/VH/PI.’ We reject the idea that psychotic phenomena are fundamentally different from “normal” occurrences such as imagined or inner speech, perceptual fluctuations, distorted or rigid beliefs, or inability to accurately express one’s emotional state. Yet abnormal perception, affect flattening, and delusions often are viewed as “really weird,” which suggests most people never experience these phenomena, only “affected” people. This easily can lead to cognitive errors that associate psychosis as a state of mind that is fundamentally different from non-psychosis. In fact, DSMIV-TR categorizes the presence of persistent psychotic symptoms as evidence of disorder until proven otherwise.3
We feel that this simplistic language describing psychosis as inherently pathological ignores the clinical richness of psychotic experience. In our experience, many individuals who have been diagnosed with chronic psychosis have never been asked:
- about the timing, intensity, and character of their abnormal sensory experiences29
- how their beliefs and schemas affect day-to-day behavior and choices
- if their psychotic symptoms are bothersome or troubling.
We worry that a person experiencing impairing psychotic symptoms could become overshadowed by all-or-none assumptions about the symptoms themselves.
We propose Table 2 as a guideline for approaching psychotic symptoms as expressions along a continuum of experience, one that shares much in common with recent well-developed biopsychosocial models of psychotic phenomena.30 In our view, this allows for a therapeutic alliance that focuses on patient recovery, as opposed to seeing psychotic symptoms as the only treatment targets. By moving beyond all-or-none myths and approaching psychosis as a continuum with normal experience, we believe that patient recovery can become a realistic goal.
Table 2
Revising the clinical language of psychosis to separate presence from pathology
| Symptom | Continuum | Attenuated experience | Pathological experience (‘disorder’) | Psychotherapeutic intervention |
|---|---|---|---|---|
| Paranoid ideation/delusions | Schematization and testing of environmental information |
|
|
|
| Hallucination | Higher order sensory processing and self/other discrimination |
|
|
|
| Disorganized speech / ‘thought disorder’ | Social pragmatics and conceptual linking |
|
|
|
| Source: Bechdolf A, Phillips LJ, Francey SM, et al. Recent approaches to psychological interventions for people at risk of psychosis. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):159-173. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020. French P, Morrison AP. Early detection and cognitive therapy for people at high risk of developing psychosis: a treatment approach. West Sussex, United Kingdom: John Wiley and Sons; 2004. Christodoulides T, Dudley R, Brown S, et al. Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: a case series. Psychol Psychother. 2008;81(Pt 2):199-207. Davis LW, Ringer JM, Strasburger AM, et al. Participant evaluation of a CBT program for enhancing work function in schizophrenia. Psychiatr Rehabil J. 2008;32(1):55-58. Jackson HJ, McGorry PD, Killackey E, et al. Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: the ACE project. Psychol Med. 2008;38(5):725-735. Lecomte T, Leclerc C, Corbiere M, et al. Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. J Nerv Ment Dis. 2008;196(12):866-875. Loewy RL, Johnson JK, Cannon TD. Self-report of attenuated psychotic experiences in a college population. Schizophr Res. 2007; 93(1-3):144-151. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715. Mitchell AJ. CBT for psychosis. Br J Psychiatry. 2004;185:438; author reply 438. Rathod S, Kingdon D, Weiden P, et al. Cognitive-behavioral therapy for medication-resistant schizophrenia: a review. J Psychiatr Pract. 2008;14(1):22-33. Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc.; 2008. | ||||
Re-envisioning psychosis
We conclude with a reiteration of recovery in the language of the US Surgeon General almost 10 years ago: “…hope and restoration of a meaningful life are possible, despite serious mental illness… Instead of focusing primarily on symptom relief…recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society.”31 We see no reason why people cannot live meaningful lives while also having symptoms of psychosis. Data from well-designed studies32 and accounts from individuals who have experienced or continue to experience psychosis33 suggest that this is realistic.
By dispelling all-or-none myths, revealing the flawed logic of psychosis as “subsumer” of mood and anxiety, and describing the continuum of psychotic symptoms, we hope to encourage clinicians to be more positive and proactive in their approach to people experiencing impairing psychotic symptoms. Through assertive alliance and informed clinical technique, we envision a landscape in which psychosis is seen as a “normal” part of outpatient psychiatric practice.
Related resources
- Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
- Gleeson JFM, McGorry PD, eds. Psychological interventions in early psychosis: a treatment handbook. West Sussex, United Kingdom: John Wiley & Sons; 2004.
- Wright JH, Kingdon D, Turkington D, et al. Cognitive-behavior therapy for severe mental illness. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
Disclosure
The authors report no financial relationship with any manufacturer of products mentioned in this article or with manufacturers of competing products.
Acknowledgement
The authors wish to acknowledge Dr. Carol Mathews for her comments on this manuscript.
1. Stefanis NC, Hanssen M, Smirnis NK, et al. Evidence that three dimensions of psychosis have a distribution in the general population. Psychol Med. 2002;32(2):347-358.
2. Verdoux H, van Os J. Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res. 2002;54(1-2):59-65.
3. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:297–343.
4. Tyson P, Tyson RL. Psychoanalytic theories of development: an integration. New Haven, CT: Yale University Press; 1990.
5. Schilpp PA. Philosophy of Karl Jaspers. Chicago, IL: Open Court Publishing Company; 1981.
6. Szasz TS. The second sin. Garden City, NY: Anchor Press; 1974.
7. Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
8. van Os J. ‘Salience syndrome’ replaces ‘schizophrenia’ in DSM-V and ICD-11: psychiatry’s evidence-based entry into the 21st century? Acta Psychiatr Scand. 2009;120(5):363-372.
9. Lake CR, Hurwitz N. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders. Psychiatry Res. 2006;143(2-3):255-287.
10. Craddock N, Owen MJ. The Kraepelinian dichotomy—going, going…but still not gone. Br J Psychiatry. 2010;196(2):92-95.
11. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:xxxi.
12. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:345–428.
13. Yung AR, Buckby JA, Cotton SM, et al. Psychotic-like experiences in nonpsychotic help-seekers: associations with distress, depression, and disability. Schizophr Bull. 2006;32(2):352-359.
14. Tien AY. Distributions of hallucinations in the population. Soc Psychiatry Psychiatr Epidemiol. 1991;26(6):287-292.
15. Eaton WW, Romanoski A, Anthony JC, et al. Screening for psychosis in the general population with a self-report interview. J Nerv Ment Dis. 1991;179(11):689-693.
16. Poulton R, Caspi A, Moffitt TE, et al. Children’s self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry. 2000;57(11):1053-1058.
17. van Os J, Hanssen M, Bijl RV, et al. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry. 2001;58(7):663-668.
18. Sommer IE, Daalman K, Rietkerk T, et al. Healthy individuals with auditory verbal hallucinations; who are they? Psychiatric assessments of a selected sample of 103 subjects. Schizophr Bull. 2010;36(3):633-641.
19. Strauss JS. Hallucinations and delusions as points on continua function. Rating scale evidence. Arch Gen Psychiatry. 1969;21(5):581-586.
20. Merabet LB, Maguire D, Warde A, et al. Visual hallucinations during prolonged blindfolding in sighted subjects. J Neuroophthalmol. 2004;24(2):109-113.
21. Fanous AH, Neale MC, Gardner CO, et al. Significant correlation in linkage signals from genome-wide scans of schizophrenia and schizotypy. Mol Psychiatry. 2007;12(10):958-965.
22. Fanous A, Gardner C, Walsh D, et al. Relationship between positive and negative symptoms of schizophrenia and schizotypal symptoms in nonpsychotic relatives. Arch Gen Psychiatry. 2001;58(7):669-673.
23. Webb CT, Levinson DF. Schizotypal and paranoid personality disorder in the relatives of patients with schizophrenia and affective disorders: a review. Schizophr Res. 1993;11(1):81-92.
24. Asai T, Sugimori E, Bando N, et al. The hierarchic structure in schizotypy and the five-factor model of personality. Psychiatry Res. 2010 May 26. [Epub ahead of print].
25. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715.
26. Meyer SE, Bearden CE, Lux SR, et al. The psychosis prodrome in adolescent patients viewed through the lens of DSM-IV. J Child Adolesc Psychopharmacol. 2005;15(3):434-451.
27. Cannon TD, Cadenhead K, Cornblatt B, et al. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Arch Gen Psychiatry. 2008;65(1):28-37.
28. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull. 1996;22(2):353-370.
29. Nasrallah HA. The hallucination portrait of psychosis. Current Psychiatry. 2009;8(5):10-12.
30. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020.
31. US Department of Health and Human Services. Mental health: a report of the surgeon general—executive summary. Washington, DC: US Department of Health and Human Services; 1999. Available at: http://www.surgeongeneral.gov/library/mentalhealth/summary.html. Accessed September 10, 2010.
32. Kane JM. An evidence-based strategy for remission in schizophrenia. J Clin Psychiatry. 2008;69(suppl 3):25-30.
33. Wagner PS. First person account: a voice from another closet. Schizophr Bull. 1996;22(2):399-401.
1. Stefanis NC, Hanssen M, Smirnis NK, et al. Evidence that three dimensions of psychosis have a distribution in the general population. Psychol Med. 2002;32(2):347-358.
2. Verdoux H, van Os J. Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res. 2002;54(1-2):59-65.
3. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:297–343.
4. Tyson P, Tyson RL. Psychoanalytic theories of development: an integration. New Haven, CT: Yale University Press; 1990.
5. Schilpp PA. Philosophy of Karl Jaspers. Chicago, IL: Open Court Publishing Company; 1981.
6. Szasz TS. The second sin. Garden City, NY: Anchor Press; 1974.
7. Bentall R. Madness explained: psychosis and human nature. London, United Kingdom: Penguin Books; 2003.
8. van Os J. ‘Salience syndrome’ replaces ‘schizophrenia’ in DSM-V and ICD-11: psychiatry’s evidence-based entry into the 21st century? Acta Psychiatr Scand. 2009;120(5):363-372.
9. Lake CR, Hurwitz N. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders. Psychiatry Res. 2006;143(2-3):255-287.
10. Craddock N, Owen MJ. The Kraepelinian dichotomy—going, going…but still not gone. Br J Psychiatry. 2010;196(2):92-95.
11. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:xxxi.
12. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:345–428.
13. Yung AR, Buckby JA, Cotton SM, et al. Psychotic-like experiences in nonpsychotic help-seekers: associations with distress, depression, and disability. Schizophr Bull. 2006;32(2):352-359.
14. Tien AY. Distributions of hallucinations in the population. Soc Psychiatry Psychiatr Epidemiol. 1991;26(6):287-292.
15. Eaton WW, Romanoski A, Anthony JC, et al. Screening for psychosis in the general population with a self-report interview. J Nerv Ment Dis. 1991;179(11):689-693.
16. Poulton R, Caspi A, Moffitt TE, et al. Children’s self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry. 2000;57(11):1053-1058.
17. van Os J, Hanssen M, Bijl RV, et al. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry. 2001;58(7):663-668.
18. Sommer IE, Daalman K, Rietkerk T, et al. Healthy individuals with auditory verbal hallucinations; who are they? Psychiatric assessments of a selected sample of 103 subjects. Schizophr Bull. 2010;36(3):633-641.
19. Strauss JS. Hallucinations and delusions as points on continua function. Rating scale evidence. Arch Gen Psychiatry. 1969;21(5):581-586.
20. Merabet LB, Maguire D, Warde A, et al. Visual hallucinations during prolonged blindfolding in sighted subjects. J Neuroophthalmol. 2004;24(2):109-113.
21. Fanous AH, Neale MC, Gardner CO, et al. Significant correlation in linkage signals from genome-wide scans of schizophrenia and schizotypy. Mol Psychiatry. 2007;12(10):958-965.
22. Fanous A, Gardner C, Walsh D, et al. Relationship between positive and negative symptoms of schizophrenia and schizotypal symptoms in nonpsychotic relatives. Arch Gen Psychiatry. 2001;58(7):669-673.
23. Webb CT, Levinson DF. Schizotypal and paranoid personality disorder in the relatives of patients with schizophrenia and affective disorders: a review. Schizophr Res. 1993;11(1):81-92.
24. Asai T, Sugimori E, Bando N, et al. The hierarchic structure in schizotypy and the five-factor model of personality. Psychiatry Res. 2010 May 26. [Epub ahead of print].
25. Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophr Bull. 2003;29(4):703-715.
26. Meyer SE, Bearden CE, Lux SR, et al. The psychosis prodrome in adolescent patients viewed through the lens of DSM-IV. J Child Adolesc Psychopharmacol. 2005;15(3):434-451.
27. Cannon TD, Cadenhead K, Cornblatt B, et al. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Arch Gen Psychiatry. 2008;65(1):28-37.
28. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull. 1996;22(2):353-370.
29. Nasrallah HA. The hallucination portrait of psychosis. Current Psychiatry. 2009;8(5):10-12.
30. Bentall RP, Fernyhough C. Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull. 2008;34(6):1012-1020.
31. US Department of Health and Human Services. Mental health: a report of the surgeon general—executive summary. Washington, DC: US Department of Health and Human Services; 1999. Available at: http://www.surgeongeneral.gov/library/mentalhealth/summary.html. Accessed September 10, 2010.
32. Kane JM. An evidence-based strategy for remission in schizophrenia. J Clin Psychiatry. 2008;69(suppl 3):25-30.
33. Wagner PS. First person account: a voice from another closet. Schizophr Bull. 1996;22(2):399-401.