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What are Psychotic Spectrum Disorders?

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Psychotic Spectrum Disorders: A Conversation with Dr. Jane Tillman

Dr. Jane Tillman, Director of the Erikson Institute for Education and ResearchIn this five-part series exploring psychotic spectrum disorders, we will present excerpts from a longer interview with Jane G. Tillman, PhD, ABPP, Evelyn Stefansson Nef Director of the Erikson Institute for Education and Research of the Austen Riggs Center, a member of the Riggs clinical staff and an authority on psychotic spectrum disorders. At the end of the series, we will make the interview, in its entirety, available in our Resource Center.

Part 1: What are Psychotic Spectrum Disorders?

“Psychotic” is a term that gets tossed around a lot in the culture. How would you frame it, as a clinician?

To start, psychosis represents a spectrum of disorders with many different etiologies or origins. People are most familiar with the term schizophrenia, but schizophrenia is probably going to turn out to be an umbrella diagnosis for many different conditions. People can be psychotic for all kinds of reasons, in the wake of substance abuse — with hallucinogens, for example— or because of schizophrenia. People who are bipolar can become psychotic, and so can people with various degenerative disorders. The interaction between biological and genetic vulnerabilities with family and cultural factors is known to be complex.  At the Austen Riggs Center we appreciate the complexity of the etiology and treatment of psychosis, providing an integrative treatment approach using psychotherapy, family therapy, and medication along with intensive social engagement through the therapeutic community program.

What are the chief symptoms?

The symptoms most people are familiar with are what we call positive symptoms: hallucinations, delusions, paranoid beliefs, unusual behavioral or mood manifestations. Those are often treated acutely with medications and patients respond well to that.

Once you’ve treated the positive symptoms, people can enter what’s called the negative phase of a psychotic disorder: lack of motivation, lack of direction, flatness. There’s a quality of just being slowed down, and a withdrawal or social isolation. This can be debilitating.  It is also much harder to identify and treat. Everyone is familiar with the worst-case psychotic disorder, which is the disheveled person in the street who makes everyone anxious. That’s the more obvious, positive symptom.

People in the negative phase don’t look so disorganized because they’re not having hallucinations or delusions, but they can be very isolated and shut down. They often don’t really know what they want to do. They may feel lost and ashamed. They’ve gotten help from medication, but they have a whole other road ahead of them. How are they going to pick up the pieces of their lives, go on and adapt?

One feature of these disorders is tremendous denial that a person is troubled, or needs treatment. It can be very hard to treat someone who other people think is impaired when that person doesn’t think so. Typically, you see problems with family members, problems in employment. These individuals see themselves in the world quite differently, and often aren’t interested in receiving any treatment. This creates a lot of frustration in attempting to offer help.

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