What Psychosis Looks Like

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Psychotic Spectrum Disorders: A Conversation with Jane G. Tillman, PhD, ABPP 

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 3: What Psychosis Looks Like 

One source of dignity is work, but that must be challenging with people with symptoms of psychosis. 

Yes, sadly, it is. Concentration and attention become very difficult. Certainly, if you have the negative symptoms, you’re not likely to be motivated. Really it’s a long, long process to get people rehabilitated to the point that they can consistently work in a job. It is quite demoralizing to be disabled by a serious illness. This frequently leads to t shame and humiliation. Often people with psychosis are dependent on their families for ongoing financial and social support. 

There also can be a lot of family strife about what is expected in return for that support. Families may feel angry because they see the symptoms of the disease — out of control drinking, say — as simply bad behavior. When parents find out they have a child with schizophrenia, you have to do a lot of education, and help them manage their grief--particularly when it looks like it’s going to be impairing over the long-term.

What portion of the psychotic population will fall into this category of long-term struggle?

About a third of people diagnosed with psychosis will have one episode, recover, and that’s it. Another third will have an episode, recover fairly well, though maybe not to baseline, and have recurrent episodes. So you’ll see a pattern of remitting and relapsing over the course of their life. Another third of people will have a break, and never really recover. They may be paranoid or delusional in a very chronic or ongoing way. What I’ve seen is that when you tell people they have schizophrenia, they all assume they’re in that last category. But a lot of people with schizophrenia do recover, and go on to lead productive and satisfying lives.

The Austen Riggs Center is an open psychiatric treatment facilityWhat do people suffering psychosis look like and talk like? In other words, how would they appear to a clinician or family member?

One sign would be serious disruption in social relationships, family relationships and a loss of overall functioning such as an inability to work, go to school, volunteer, really to function in the world.

We often encounter patients who have serious substance abuse symptoms, perhaps in an effort to treat their own symptoms via alcohol or other substances. The negative symptoms of schizophrenia likely have some relation to depression and patients following an acute psychotic episode often feel extremely depressed and defeated. 

Many antipsychotic medications have significant weight gain as a side-effect, and that’s one reason why the mortality rate is higher in this population. Smoking is also prevalent in patients with psychotic illnesses, contributing to ongoing health concerns.

What’s it like on the inside? What do people psychotic people feel like and think like?

I think people can feel extremely lonely. People with psychotic disorders may push people away with odd, angry, scary behavior. And the patients themselves know something is not right and so they may avoid other people. Patients often have the feeling that no one understands them, because the reality of the psychotic person is often quite at odds with the perceptions of the people around them. So they can become angry, puzzled, and frightened by that. 

Does it manifest physically?

I think people can be either cut off from their bodies, or very frightened that they don’t look right. They might fear they’re being stared at. They sometimes have odd ideas about illnesses, for example, or bodily delusions. 

When does psychosis typically manifest?

For males, probably between ages 16 and 30. And a little later in women, maybe around 24 to mid-30s.

There's also childhood schizophrenia, and there are older people who have late in life onset schizophrenia, but the predominant onset is around late adolescence early adulthood, right when people are making the move to leave home, go to school, and function independently.

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