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Phases of Psychosis

Course of Illness
 
The typical course of the initial psychotic episode can be conceptualised as occurring in three phases. Once an episode as happened we can see that there was the prodromal phase, the active phase and the recovery phase. 
 
 
The At-Risk or “Prodrome” Phase – Something is not quite right
 
Psychotic illnesses rarely present out of the blue. Almost always, these disorders are preceded by a gradual change in psychosocial functioning, often over an extended period. This is the period during which the individual may start to experience a change in themselves, but have not yet started experiencing clear-cut psychotic symptoms. This is the prodromal phase of the illness, which is known as the "at risk mental state" phase.
Changes in this phase vary from person to person and the duration of this phase is also quite variable, although it is usually over several months. In general, the at risk phase is a fluctuating and fluid process, with symptoms gradually appearing and changing over time.
 
Some of the changes seen during this phase include:

  • Changes in affect such as anxiety, irritability and depression
  • Changes in cognition such as difficulty in concentration or memory
  • Changes in thought content, such as a preoccupation with new ideas often of an unusual nature
  • Physical changes such as sleep disturbance and loss of energy
  • Social withdrawal and impairment of role functioning, which can include deterioration in school or work performance

 
The person may also experience some attenuated positive symptoms such as mild thought disorder, ideas of reference, suspiciousness, odd beliefs and perceptual distortions which are not quite of psychotic intensity or duration.
These may be brief and intermittent at first, escalating during times of stress or substance abuse and then perhaps subsiding, before eventually becoming sustained with the emergence of clear-cut psychosis.
Clearly many of these changes are quite non-specific and can result from a number of psychosocial difficulties, physical disorders and psychiatric syndromes. However, it is clear that persistent or worsening psychological changes in an adolescent or young adult may herald the development of a mental health disorder such as psychosis and this possibility needs to be kept in mind, particularly if other risk factors are present.
 
 
 
The "Active" Phase
 
The active phase of psychosis is characterised by the presence of positive psychotic symptoms which include thought disorder, delusions and hallucinations, and negative symptoms, such as loss of motivation and withdrawal. 
Hallucinations are sensory perceptions in the absence of an external stimulus. The most common type are auditory hallucinations, where a person may hear voices or other noises when no-one else is present. Other types of hallucinations are visual, tactile, gustatory and olfactory, where people see, feel, taste, or smell stimuli which are not present. These are less common and an organic cause may be evident in these situations.
Delusions are fixed, false beliefs out of keeping with the person’s cultural environment. They may be sustained despite proof to the contrary. These beliefs are often idiosyncratic and very important to the person, but hard for other people to understand. Delusions often gradually build up in intensity, being more open to challenge in the initial stages, before becoming more entrenched. They can take many forms. Common types of delusions include:

  • Persecutory delusions; where the person believes that they are being, watched, followed, or talked about in a negative way, or that people are planning to, or actually, harming them
  • Grandiose delusions; where the person believes that they have special powers or abilities
  • Delusions of reference; where the person believes that television shows, songs, or newspaper/magazine articles are referring to them
  • Somatic delusions; where the person experiences unusual beliefs about their body or appearance, for example, a part of their body is abnormal, or 'rotting'
  • Passivity delusions; where a person believes that others are putting thoughts in their head, or taking thoughts out of their head, or that others can read their minds
  • Delusional guilt; where the person falsely believes that they are responsible for negative events, such as natural disasters

 
Thought disorder refers to a pattern of vague or disorganised thinking. Mild thought disorder might be manifest as someone finding it hard to express themselves or complaining of feeling like their thoughts are sped up or slowed down, whereas someone with severe thought disorder might have disjointed speech which is hard to follow.
 
It is also important to remember that many young people with an underlying psychological disorder will initially present with physical symptoms, such as tiredness, mood changes, repeated headaches or insomnia. An underlying psychological disturbance should always be considered in an individual presenting with persistent or ill-defined somatic complaints in the absence of demonstrable physical pathology on examination or investigation.
 
 
The Recovery Phase
 
The majority of young people experiencing their first psychotic episode will make a complete recovery, although a significant minority (around 10-20%) will develop persistent symptoms.
The trajectory of recovery, however, is quite variable. Once treatment is instituted, some people will gradually get better, whilst others will go through a period of delayed progress and then make sudden shifts in well-being.
Slow or partial recovery needs to be managed in an early and assertive fashion and in general requires the use of more sophisticated psychological and pharmacological strategies. Once full recovery is achieved the major focus is on maintaining and promoting wellness and preventing relapse.
Each relapse represents a potential risk point for the development of more enduring impairment and disability and appears to contribute to treatment resistance. Long-term, assertive follow-up is essential for the vast majority of people with a psychotic illness.
 
 
Continuing Care
 
Recovery is the norm after an initial psychotic episode and around 25% of affected young people will then never experience a further psychotic episode. The rest remain vulnerable to future exacerbations of their psychotic disorder.
Given the importance of continuing care, it is essential that the person’s first experience of psychiatric care is managed carefully. Because of the great stigma attached to mental illness, the experience of psychiatric treatment may be traumatic.
The greater the trauma attached to the first treatment experience, the greater the risk that the young person will fail to engage with psychiatric care in the longer term. Overall, the treatment of adolescents and young adults with a psychotic illness requires that the clinician maintain a balance between assertive care in order to promote harm reduction whilst encouraging the young person to be active in their treatment decisions.
This also involves striking a balance between acknowledging the reality of the illness, whilst maintaining the focus on the person. The clinician needs to assist the client to work against the trauma and stigma of the illness and gradually share the responsibility for care with the client.
Since many young people are overwhelmed by the thought of having a vulnerability to serious mental illness, such collaboration may take time to achieve. 
 
 
 
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