Continuing on with my current series on psychosis ...
The current DSM makes reference to bipolar disorder “with psychotic features,” but one has to flip the pages to the obscure diagnosis of “brief psychotic disorder” for a symptom list, namely:
Delusions; hallucinations; disorganized speech; psychomotor symptoms, including catatonic behavior.
Most of us with bipolar have experienced at least a taste of psychosis, maybe not a full-blown episode, but enough to perceive a rent in the fabric of reality. It’s a pretty scary experience. We not only question our sanity, but wonder - like the lost Odysseus in Homer’s Odyssey - if we will ever find our way back home to reality.
But, of all things, even if we kind of know what psychosis is, there is no definitive definition. The glossary to the DSM-IV concedes that none of the historic definitions “has achieved universal acceptance.” There are four views in play:
One view, according to the DSM glossary, refers to hallucinations and delusions to which the individual has insight. In other words, you know your hallucinations and delusions are not real. This implies you are working with a rational brain. If you’re cool with the weird stuff running through it, then perhaps it would be okay to regard this as “benign” (my term) psychosis.
Benign becomes “malignant” (my term) once the individual actually begins regarding the weird stuff as real. In two previous posts, I referred to John Nash, the Princeton mathematician, who lost decades of his life to schizophrenia. In "A Beautiful Mind," author Sylvia Nasar relates this exchange:
"How could you," a colleague asked back in 1959, "believe that extraterrestrials are sending you messages?"
"Because," Nash replied, "the ideas that I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously."
In her book, Ms Nash comments on a phenomenon that struck her as odd. For instance, even when John Nash thought the government was plotting against him and he tried to renounce his US citizenship, he still had the wits to organize a trip to Europe. Perhaps this was a hopeful sign?
Decidedly less hopeful would be this version of psychosis, served up in the DSM glossary: “Loss of ego boundaries or gross impairment in reality testing.” Here, no one is present in the control room.
Of all things, the DSM does not distinguish between psychosis in bipolar and psychosis in schizophrenia. Is it the same? Or different?
Back in 2007, at a bipolar conference, one of the top schizophrenia researchers, Carol Tamminga MD of University of Texas Southwestern Medical Center in Dallas, grabbed a seat at the dinner table next to me. At the time, she was chairing a “Deconstructing Psychosis” project to assist the Task Force working on the DSM-5.
Her point of view was there might be something more general in psychosis that crosses diagnostic boundaries. Nevertheless, she noted, the condition may be mediated by different neural pathways. Then again, she added, it could well be that psychosis is equivalent to “fever” and that we may need to dig deeper to find out what is really going on.
In other words, our ignorance of psychosis far exceeds our knowledge. In the meantime, we know psychosis when we see it - uh, sort of.
Published On: March 14, 2011
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