Psychosis is a mental health condition characterized by a disconnect from reality. The main symptoms of psychosis include delusions, hallucinations, and disorganized thinking and speech. Psychosis often occurs in conditions like schizophrenia, bipolar disorder, and severe depression. Understanding what is happening in the brain during psychotic episodes is an important area of research that can help improve treatments.
What are the main symptoms of psychosis?
The key symptoms of psychosis include:
- Delusions – Fixed, false beliefs that are firmly held even when there is evidence to the contrary. For example, a person may believe they are being followed or that a celebrity is in love with them.
- Hallucinations – Seeing, hearing, feeling, tasting or smelling things that are not really there. Auditory hallucinations of hearing voices are most common.
- Disorganized thinking and speech – Incoherent or nonsense speech patterns. Jumping between topics at random. Thoughts that are disjointed.
In addition, other signs of psychosis can include agitation, strange behavior, lack of insight, social withdrawal, lack of motivation, and difficulty functioning. The symptoms cause significant distress and problems functioning in daily life.
What brain changes occur in psychosis?
Modern brain imaging techniques have allowed researchers to study the brains of people experiencing psychosis. This has provided insight into the possible brain abnormalities linked to psychotic symptoms. Some key findings include:
Dopamine dysfunction
One of the leading theories is that excess dopamine in certain brain pathways plays a central role. Dopamine is a neurotransmitter that is important for many brain functions including motivation, pleasure, and reward pathways. Excess dopamine activity, particularly in the striatum region, may lead to the development of psychosis. Medications that block dopamine activity are often effective at treating psychosis.
Reduced gray matter volume
Brain imaging studies show reductions in gray matter volume in certain regions in people with schizophrenia and other psychiatric disorders associated with psychosis. Gray matter areas that show lower volume include the insula, anterior cingulate, hippocampus, and frontal and temporal lobes. Losing gray matter is linked to problems with cognition and several psychotic symptoms.
Less coordinated brain activity
Functional imaging of the brain shows less coordinated activity between different regions in people with psychosis. Normally various regions work together for complex thinking and behavior. Less synchronized activity between the frontal, temporal, parietal and subcortical regions could help explain cognitive deficits.
Problems with brain connections
The brain has highly interconnected networks that link distributed but complementary regions. Disruption in connectivity, both structurally and functionally, is now thought to be a core pathology in schizophrenia. This affects pathways like thedefault mode network, making it act abnormally, and may help explain psychotic symptoms.
Neurotransmitter imbalances
In addition to excess dopamine, other neurotransmitter systems also show changes in psychotic disorders. For example, reduced functioning of N-methyl-D-aspartate (NMDA) glutamate receptors may play a role in schizophrenia symptoms including paranoia and hallucinations.
What causes these brain changes?
The exact causes of the brain changes seen in psychosis are still not fully understood. A number of interacting factors are likely involved:
- Genetics – Many genes may each make small contributions to increasing risk of psychosis. Certain gene variants affect dopamine, glutamate, and other neurotransmitters.
- Environmental factors – Exposure to stress, trauma, malnutrition, substance use while young, etc. may interact with genetic vulnerability.
- Neurodevelopmental processes – Problems during pregnancy and birth, head injuries early in life, etc. may alter brain development.
- Brain chemical imbalances – Changes in neurotransmitters like dopamine and glutamate may arise and worsen over time.
- Stress and inflammation – Increased inflammation and cortisol stress hormone changes may alter brain function.
The interplay between these factors likely induces the grey matter loss, connectivity changes, and neurotransmitter imbalances seen in imaging studies. However, more research is still needed to clarify the complex causes.
What are the stages of psychosis development?
Psychosis usually develops gradually over several years, progressing through various stages:
Premorbid stage
Before any psychotic symptoms, some subtle cognitive and behavioral changes may be noticeable in childhood or adolescence. For example, a person may have mild problems with certain mental tasks, anxiety, or socializing.
Prodromal stage
As psychosis develops, more noticeable symptoms start emerging. This can include depression, social withdrawal, suspicion or paranoid ideas, mildly disorganized thinking and speech, lack of motivation, or a decline in functioning.
Active psychosis
Symptoms worsen and become clearly abnormal. Delusions and hallucinations occur. Thinking and speech becomes more disorganized. Major decline in functioning in work, school, self-care, and relationships.
Remission and recovery
With treatment and antipsychotic medications, the florid positive symptoms of delusions and hallucinations can often be controlled. But cognitive deficits and negative symptoms tend to persist at lower levels, and relapses may occur.
Identifying people early in the prodrome phase and providing preventative treatment is an important goal, before severe symptoms and major functional impacts emerge.
How do antipsychotic medications work?
Antipsychotic medications are the primary treatment for acute psychosis and maintenance treatment. All antipsychotics block dopamine receptors, particularly D2 receptors. By reducing dopamine signaling, they can suppress positive symptoms like delusions and hallucinations. Antipsychotics also impact other neurotransmitters like serotonin and glutamate.
The major antipsychotic drug classes include:
- Typical antipsychotics – The first generation antipsychotics, like haloperidol. They are potent dopamine blockers but have more side effects.
- Atypical antipsychotics – Second generation, like olanzapine and risperidone. They target dopamine but also impact serotonin, reducing side effects.
- Partial dopamine agonists – Newer drugs like aripiprazole, they reduce dopamine activity less completely. May have benefits for cognitive symptoms.
Finding the most effective antipsychotic with the fewest side effects can take some trial and error. Most evidence suggests starting with an atypical drug. Psychosocial interventions also help with recovery.
What supportive therapies help?
In addition to antipsychotic medication, various psychosocial interventions and lifestyle changes are important elements of treatment for psychosis. These include:
Psychotherapy
Talk therapy can help people understand and manage their illness. Cognitive behavioral therapy is often used to challenge problematic thoughts and behaviors. Psychoeducation teaches coping skills. Counseling provides emotional support.
Social skills training
Many people with psychosis have difficulty with social interactions. Direct coaching on conversation skills, body language, maintaining relationships, independent living abilities, and other areas can help recovery.
Family therapy and support
Including loved ones in therapy sessions can help them better understand psychosis and identify signs of relapse. Support groups connect families facing similar challenges.
Case management
Case managers coordinate care needs including medication, appointments, housing, disability benefits, employment assistance, and other services. This helps maintain treatment engagement and stability.
Substance avoidance
Drug and alcohol use can exacerbate psychosis. Preventing use of cannabis and stimulants is an important goal. Nicotine may also worsen symptoms.
Stress management and lifestyle changes
Reducing stress through relaxation techniques, balanced exercise, nutritious diets, journaling, art, music, and nature exposure can help in recovery. Keeping a stable sleep routine is also important.
What is the prognosis and course of psychotic disorders?
The long-term prognosis for conditions involving psychosis varies:
- Schizophrenia – This chronic condition often follows a course of acute symptom relapses and remissions. Many people show a gradual improvement over years.
- Schizoaffective disorder – There is a better prognosis than schizophrenia if mood symptoms predominate.
- Brief psychotic disorder – By definition this resolves in under a month, so prognosis is good with proper treatment.
- Drug-induced psychosis – Psychosis will clear with discontinuation of the causative drug. But substance abuse problems may persist.
- Psychotic depression – The addition of psychotic features indicates more severe major depression. Treatment response is often good.
With any psychotic disorder, early intervention and consistent long-term treatment provides the best opportunity for recovery of functioning. Supportive therapies and services are key to maintaining gains.
Conclusion
In summary, psychosis involves many complex changes in brain activity, structure, and chemistry. While the exact causes are still not fully clear, a number of interacting genetic, developmental, biological, and environmental factors are likely at play. Dopamine and other neurotransmitter imbalances induce the positive and negative symptoms. Antipsychotic medications help control acute symptoms while psychosocial interventions support long-term recovery. More research to better understand psychosis pathology and develop novel treatment approaches continues.