Updates to Current Understandings of Psychosis and Schizophrenia

Drawing on research on epigenetics and structural determinants, researchers offer an updated and nuanced understanding of psychosis.

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In a new editorial published in Psychosis Psychological, Social and Integrative Approaches, editor Jan Olav Johannessen and his college from Stavanger University Hospital, Inge Joa, offer an overview of modern understandings of psychosis.

According to the authors, most textbooks present outdated theories of psychosis, and a great deal of new research has emerged in the past decade, shedding light on this experience. In their article, they present their understanding of the causes and proper treatment of psychosis in 2021.

“The past decade has seen significant development in our understanding of psychosis. We have come to recognize a clearer logic in the development of mental disorders through stages and phases, and we understand better how mental disorders develop gradually, and as a result of perceived stress,” they write.
“We have gained new knowledge about stress reactions, mental and physical, and we now understand more our mental experiences as internal imprints of external events. We further understand how the stress and immune systems interrelate, as a result of external stresses and life events, both in the past and present.”

The psy-disciplines have numerous understandings of the causes and multiple treatment protocols for psychosis. Some psychiatrists take an almost purely biological view of psychosis as a brain disease requiring interventions in the form of medications. Others have pointed towards environmental and systemic factors and recommend social interventions and increased access to resources to remedy psychotic episodes. Many psychiatrists and psychologists are divided on this issue, resulting in wildly different recommendations for service users depending on where they obtain their information.

While many approaches to the treatment of psychosis emphasize the “lack of insight” in patients, and therefore recommend treatment without much input from the service user (which can include the use of major tranquilizers and involuntary institutionalization), newer understandings of mental illness attempt to put the service user and their unique situation at the center of both causal understandings and treatment.

There is a large discrepancy between how service users and mental health professionals view the causes of mental illness, with service users preferring psycho-social causal explanations and mental health professionals preferring bio-genetic ones. This discrepancy between how service users and mental health professionals understand the causes of mental illness may affect the usefulness of treatment.

A preference for bio-genetic explanations of mental illness, as seen in many mental health professionals, is associated with increased stigma and discrimination towards those with mental health diagnoses. Conversely, a preference for psycho-social explanations is associated with reduced stigma.

Recently, the leading bio-genetic explanation of psychosis (the dopamine hypothesis) took a blow when a meta-analysis found no support for it in the literature. As bio-genetic explanations become increasingly tenuous, researchers have found more evidence pointing towards psycho-social factors. For example, studies have found strong associations between childhood and healthcare-related trauma and psychosis. Research has also shown that psychosis in the United States is inseparable from racism and structural inequality.

The current work attempts to briefly explain the most current understandings of psychosis from causes through treatment and recovery. The authors begin by charting the change in the psy-disciplines explanations for mental illness over the past 80 years. The environmental explanations of the 1940s through the 1960s gave way to the biological understandings of the 1970s through the 1990s. In the 2000s, epigenetic breakthroughs suggested that genes themselves are influenced by the environment, thus pushing the pendulum back towards environmental explanations of mental illness.

According to modern heritability research, genetics may account for as little as 5-6% of the risk of developing mental illness. With the move away from genetic explanations of mental illness, the authors assert that rather than brain diseases that are set in stone, mental illness is a constantly evolving transient mental state. The authors argue that individual service users will therefore not easily fit into any specific diagnostic category.

The authors explain that rather than existing in discreet diagnostic categories, mental illness develops in phases that defy our attempts at diagnosis, typically manifesting in observable symptoms between 15 and 24. First is the premorbid phase, before the disorder presents. Next, the prodromal phase, or “warning phase” coincides with the first signs of the mental illness, most typically anxiety and depressive symptoms. If we do not start treatment in some form during the prodromal phase, psychosis or other more extreme symptoms may occur.

The current work understands psychosis in terms of the stress-vulnerability model. This model explains that environmental stressors act on our vulnerabilities to cause psychosis. The authors chart how, within this model, the environment and our biology are inextricably linked. For example, stress from the environment triggers the production of stress hormones. Those stress hormones can lead to the overproduction of some neurotransmitters like dopamine. This overproduction causes the immune system to attack the production sites of dopamine, weakening and eventually destroying them.

The authors argue that to best treat mental illness that could ultimately devolve into psychosis, we should strive for early intervention, preferably during the prodromal phase when symptoms are typically anxiety and depression. Due to the typical ages of first symptoms of mental illness (15-24) and the exponentially increasing cascade of adverse effects as mental illness goes untreated, early detection and treatment are of paramount importance.

To this end, Johannessen proposes that treatment programs emphasizing things like educational advice, legal advice, employment offices, general practitioners, and specialist services within the community be made easily accessible to youth.

Their current work also recommends dividing aged-based treatment services differently. For example, rather than having one set of services for people aged 0-18 and another for everyone else, the authors propose a 0-12 and a 13-25 treatment plan, with the goal being to develop a 0-100 treatment plan.

 

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Jan Olav Johannessen & Inge Joa (2021) Modern understanding of psychosis: from brain disease to stress disorder. And some other important aspects of psychosis…, Psychosis, DOI: 10.1080/17522439.2021.1985162

13 COMMENTS

  1. See in Africa I think they treat schizophrenia by surrounding the person with people and social stimulation, and it works. At least in “primitive” Africa they have had this tradition.

    Maybe the person’s “lack of insight” is a behavior pattern that is crying out for him to be surrounded by people, surrounded by sociability, wherein people work very hard to convince him out of his lack of insight.

    Which happens to be the best treatment for schizophrenia anyway, is it not?

    It’s not lack of insight. Absent chemical restraints or interventions, it’s a behavior that works best to cajol other people into providing the environment that works best for treatment.

    The fact that trauma and stress seems to cause it also interesting. The person NEEDS more social support then.

    I think the current psychiatric system is based on efficiency and is tied to an atomized society, that seeks to limit human sociability and which has driven human beings apart so we are more isolated from each other today than we have ever been in our entire history.

    Psychiatry seeks to reinforce that isolation and “treat” those who can’t cope with it as well, all the while they do not have time to dedicate themselves properly to patients and spend the time necessary. Note how, as I mentioned, in Africa it would have been the people who know a schizophrenic very well who would have bombarded them with non-stop sociability and human connection, as a “treatment.”

    Now, in the West, Mental Illness is regarded as a thing to be handled by professionals and not the community. Professionals who do not have the time. Who cannot get intimate with patients. To the contrary, arm’s length “professional” — e.g., cold — relationships are the only thing that’s allowed.

    When, in fact, our brains need intimacy and social connection, and the mental health system should be regarded as something of a scam so long as it fails to recognize this.

  2. —-A preference for bio-genetic explanations of mental illness, as seen in many mental health professionals, is associated with increased stigma and discrimination towards those with mental health diagnoses. Conversely, a preference for psycho-social explanations is associated with reduced stigma.

    When HItler created the “reality”, the stigma of Jews, he enlisted an entire culture to support that reality. For generations the US did the same, creating the “reality”, the stigma of rape; generations adhered to it. For a briefer and terrible time, we adhered to the created “reality”, the stigma of AIDS.

    The attraction, seduction, of these created “realities” interests me.

    Harold A Maio, retired mental health editor

  3. “Due to the typical ages of first symptoms of mental illness (15-24) and the exponentially increasing cascade of adverse effects as mental illness goes untreated, early detection and treatment are of paramount importance.”

    I don’t know if that’s true, but I do know that the “mental health” workers can create “psychosis,” via anticholinergic toxidrome:

    https://en.wikipedia.org/wiki/Toxidrome

    if they treat people with the antidepressants and/or antipsychotics. It’s also my understanding that the ADHD drugs can also make people “psychotic.” And I’ve read horror stories about the anxiety drugs.

    So, “early … treatment” may be a good idea, so long as that “treatment” does NOT involve treatment with the psychiatric drugs.

  4. This article is confusing to me. One line seem to be arguing that the dopamine hypothesis holds no water in regards to the cause of schizophrenia. So lets go with that. But another seems to say that stress, especially in childhood, has a bad effect on neurotransmitters in the BRAIN, such as DOPAMINE.
    So our brains, according to this aricles authors, do seem to be a focal point where illness settles in, and not just our amorphous psychology. Although (winking here) I myself feel that brain and psychology and body and soul all interweave. This article seems to want to say schizophrenia has nothing to do with the brain. Another article may say trauma affect the brain and you can see it on brain scans. If trauma does so why cant schizophrenia also affect the brain? Are we to think that schizophrenia is the same thing as trauma? If so why? If I have a dry crispy cough from a bacterial infection affecting my lung tissues and you have a wet barking cough from a viral infection affecting your lung tissues these things, bacterially caused disruption and virally caused disruption are DIFFERENT causes of disruption to biological tissues. Why should we view them as the same?

    The article seems to hold the view that environment affects everything. I fail to see how environment would not. Stick a covid sufferer in an ICU environment and they will get better. Stick them on a park bench and they may not. Stick a kid in a mansion and the kid will probably flourish, even its brain. Stick a kid in a lean to hut with no food and the kid may not flourish, its brain may wither. It is obvious the environment is important. But you can stick a person with terminal cancer in a mansion and that environment may be the death of them nonetheless. And you can stick a man like my friend Tom, who is dying of cancer, in a slum and expect him to give up the ghost but miraculously he is now fighting fit.
    So yeah environment does matter but it is not simplistic when it comes to how our biology responds. Billions of people in places like India live in squalid environments yet have less heart disease and cancer. There is a word…eustress. Look it up. Without bits of stress, some of it coming from the environment, people suffer mentally and biologically. I am against zoos but as an example this is why some animals kept in zoos died of boredom. The animals are now given something called “enrichment”. Look that up too. Its basically a way of frustrating their instant gratification and making them expend an effort to derive environmental stimulus. If it is not done the animal goes into decline not through trauma but the lack of eustress. Environment matters but a pandering environment is as sad a sight and just as bad for biological health as a derelict environment.
    The authors go on to say that a bad environment has a deliterious effect on genes. So I am wondering if the authors think that the genes do not have any effect on the brain. If the genes do affect the brain then presumably that affected brain might be disrupted in its dopamine production. And if the brain so affected by the genes is derailed in its dopamine production why do the authors assume this cannot hint at some cause of schizophrenia? Perhaps I should call it not schizophrenia but trauma, since trauma is nicely not about the brain but feelings. Oh wait, the trauma brain scans show trauma does affect the brain. So maybe other stuff affects the brain too, like a motor cycle crash or brain cancer or hormones or alcohol or antipsychotics or environmentally damaged genes or bacteria or viruses and lord knows what, which makes me wonder why I feel coaxed to now call my schizophenia by another name not of my choice.
    If these authors maintain that in respect to schizophrenia the dopamine hypothesis holds no water then would they now be saying that maybe we can all chew our antipsychotics with carefree abandon since those wont lead to dopamine disruptions that cause schizophrenia style personality upsets?
    Maybe the authors want to say schizophrenia does not exist and only trauma exists. How do they know this absolutely? How do they measure the difference between trauma symptoms and schizophrenia symptoms? Is there a metaphorical measuring tape put in the brains of research cohorts that has a line on it that says before this point on the measuring tape what’s going on in the brain must be trauma and after that point it must be schizophrenia? Do they take that measuring tape and find nothing beyond the line? No schizophrenia? Only trauma? If so how do they know? Granted they seem to say that schizophrenia must just be trauma but how do they deduce that a supposed random trauma symptom is not schizophrenia? How does a doctor know that a lung inflamation is from a bacteria or a virus? She can see them and she has a measuring tape to deduce a point of difference where a bacteria is not a virus. So a bacterial cause is held as different from a viral cause. When the brain is compared to a lung and dopamine going erratic can be compared to a cough, the cause of the cough may be anything. The dopamine disruption could be from the metaphorical bacteria that results in key features of schizophrenia or the metaphorical virus that results in key features of trauma. The confusion deepens because the key features of schizophrenia can sometimes seem like trauma and the key features of trauma can sometimes seem like schizophrenia, being as basic human psychology only has a dozen spectacular ways to shout…”I feel awful!!!”. Just like the lung has only a dozen ways to say it feels awful. A dry cough. A wet cough. A whooping cough. A smokers cough. A cancer cough. And because there are only a dozen ways it is virtually impossible to deduce such coughs are caused by this, that or the other without examining the lung and trying to detect a cause like cancer or allergy or bird fanciers lung. A cough alone won’t be an adequate way to discern much beyond that the person feels awful. Dopamine disruption is like that cough. But who knows why it became disrupted. Was it genes? Was it environmentally compromised genes? Was it not genes but antipsychotics? Was it abuse? Was it politics? Was it poor housing? Was it a foetal bacteria? Was it gaslighting or autosuggestion caused the dopamine to fizzle and pop? Was it depression? Was it bad diet? Was is gut biome? Was it concussion from being dropped on a road as a newborn?
    The authors seem to want to have the dopamine cake and eat it. Either dopamine IS affected by any or all of the above or it is not. And what about all the other neurotransmitters in the BRAIN, do their fluctiations and disruptions also have an effect on the dozen ways we might cough or weep or sing or scream? Or do they not? Are we for saying the brain is important and can produce all sorts of metaphorical coughs for all sorts of reasons or are we saying the brain was just psychiatry’s brainchild and even that psychiary invented the brain and dopamine and the dozen schizophrenia symptoms? Symptoms which inevitably can be dressed up to look like trauma symptoms, just as scandalously easy as trauma symptoms can be dressed up in a straight jacket to look like schizophrenia symptoms. The same cough can be sent home with syrup or surgery, depending on the doctor. You can be sent home with rotten treatment whether that metaphorical cough is caused by schizophrenia or trauma.

    I notice the article does the common error of thinking that all we need to do in relation to psychosis is what has always been glibly done by professionals, which is hunt for the “cause” so that the “cause” can be got rid of by swift “treatment”.
    It may surprise the authors to know that I feel rejecting of this “medical paradigm” hangover that sees the erradication of “causes” of illness as tantamount to “treatment”. I believe that leads to an escalation of “bad treatment”, often making people much iller. I am for the notion of “treatment” being “no treatment” for anything. No treatment of the metaphorical cough. Let the cough itself BE the treatment. But anyone with a cough needs compassionate care. Care and support. You dont need to convince the person they definitely have a “cause” of a “this” illness, or a “cause” of a “that” illness, or indeed that they don’t, if they feel happiest believing all they have is trauma or all they have is schizophrenia. To professionals and anyone involved in mental health I would say treatment is not about what makes “you” and “you” and “you” and “you” and “you” feel okay, if you are not the one with the trauma or schizophrenia, but whatever makes the individual sufferer feel happy. And I would sometimes also say it to research reviewers. Its not your brain. Its not your life. Its not your cough.
    Merely having a brain does not mean you have it as a doormat to welcome “bad treatment”. Merely having big breasts does mean you want to fall into bed with your plumber.
    Cutting out the brain just because it has been defiled by psychiatry is letting psychiatry contuinue to take away what is rightfully yours. Regardless of what its dopamine is doing or not doing. Or dopamine fluctuations mean or does not mean. Or dopamine dwindling is caused by or is not caused by. The hunt for “causes” is the hunt for “cures”. The body and its blobby brain already have “cures” and those are often the symptoms. Nobody would say the symptoms are not rough to live with. Which is why the real notion of “treatment” means stopping the search for “causes” and just ramp up enormous “support”. While the brain is healing itself. As we see in other cultures. But what is not supportive to one may be supportive to another. What is not supportive to my cough is getting told it doesnt exist.

    • “I notice the article does the common error of thinking that all we need to do in relation to psychosis is what has always been glibly done by professionals, which is hunt for the ’cause’ so that the ’cause’ can be got rid of by swift ‘treatment’.”

      I’m pretty certain the ’cause’ of most so called ‘psychosis,’ is the ‘treatment.’ Given the fact that the ‘antipsychotics’ can cause ‘psychosis,’ via anticholinergic toxidrome poisoning. See my above post for the link to this fact.

      • Yes, antipsychotics cause dreadful effects. I am glad you are not tolerating them. But I am glad “for you” that this certainty is the foundation of what feels true and absolute for you. I am not going to disagree with what feels right for you to conclude. I celebrate your finding a theory that explains everything for you. I do not have any wish to snatch it out of your hands. It is your precious understanding.

        All I am going to do is also celebrate that I have a theory for me. It is a theory of what feels all chaotic in me. Finding my theory makes me feel more comfortable.

        Your celebration
        And
        My celebration
        makes us both happy.
        This is good in the world. It is great because this world is rapidly becoming a rage-fest, with everyone raging at everyone else for not agreeing.
        I feel that “agreement” is overrated anyway and you do not have to agree with anyone just to free yourself up to celebrate what you hold as dear and true for you. And you do not really have to agree with another person to bond with them in their common struggle through life’s ordeals.
        I am seeing in the world a ghastly rise in rage. A conflagration of accusation and hostility to fellow human beings who have done no wrong.
        It is a ruse to fall into the idea that you can only get clear of that by getting stuck into a never ending brawl with it. That is what everyone is thinking is the answer.
        But I feel that for me the answer is pacivism.
        So even though you may not agree on my way of understanding what is occurring in me, I am not going to do anything to inveigle you to swap your way of healing you for my way of healing me, which for all I know may be rotten for you. Instead I celebrate that you are happy in your way. I want you to be happy, and the person next to you and the next and the next, until the whole planet feels happy in their individual celebrations of whatever makes them feel well.

  5. The source of a lot of Mental Illness comes from the representations of the professionals involved – which could be literally – Anything.

    In normal medicine doctors represent evidence of what they suspect or are treating. But in Psychiatry Normal Human behaviour can be easily represented as Defective – and the Doctors ‘Opinion’ in Mental Health is often taken as fact.

    For Example – A psychiatrist In the 1980s continually represented me as “unwell” on account of my inability to apply myself to routine. I challenged him (on a friends advice), on the medication he had been prescribing me – causing me involuntary movement problems. He wasn’t able to right this problem so I had to stop taking the medication. I was then able to return to gainful employment.

    When I explained my Recovery to him – he left the country.

  6. Yes, let’s drug people between the ages of 15-24 when the brain is developing rapidly and making its march towards maturity. Yes, let’s begin drugging with the youthful teenage brain so that they are deprived their chance to start learning who they are, etc. But then drugs at any age are the problem. However, it is not only drugs but the “mental health professionals.” “Mental health professionals” are just paid “gaslighters.” Therapy at any any age is dangerous. A diagnosis of an alleged mental illness is dangerous. So why wait until the individual reaches “maturity.” Let’s steal their youth. Only people filled with so much hate would think of diagnosis, therapy and drugging of people of any age. How tragic to label a young person with some stupid diagnosis that is as false as the synthetic drugs they give a person for it. On a deep level, the brain and body, (the whole individual) can tell the difference between the real, the natural, and the false, the synthetic. Noting in psychiatry and psychology is real. If you like horror and fiction, then believe psychiatry and psychology as “gospel truth.” For they have plans to harm you, not help you at all. Thank you.

  7. Neither my diagnosis, nor myself, has ever…

    *hit someone
    *bruised someone.
    *spat at someone.
    *coerced someone.
    *tricked someone.
    *manipulated someone.
    *drugged someone.
    *maimed someone.
    *wrestled with someone.
    *engineered someone.
    *controlled someone.
    *trampled on someone.
    *locked up someone.
    *arrested someone.
    *sedated someone.
    *brain damaged someone.
    *caused the suicide of someone.

    My diagnosis cannot grow a pair of legs and run around town stoning people. It is not three dimensional animate form. It is not a demon or a devil or a sign of sin. It was not foisted on me by a doctor. I realised my diagnosis way before I ever saw a doctor. So not even the doctor foisted upon me some bizarre super power diagnosis that could absurdly do all the above either.
    Astonishingly, my diagnosis is an inanimate piece of paper with no power over my life.

    Could my having my diagnosis lead to some misfit psychiatrist using HIS or HER or THEIR power over me, enough to give me “bad treatment”…yes.

    Could my being a woman, which I suppose is another sort of diagnosis, get me scorned? Yes.

    Should I get rid of my being a woman? No.
    For that would be defeatist.
    Instead I should campaign to stop anyone scorning and vilifying anyone.

    Should I get rid of my diagnosis to stop my being given “bad treatment”? No.
    For that would be letting people get away with abuse of power.
    Instead I should demand “good treatment”. Treatment I like. Treatment that dovetails with my own idea of what I need to make me feel better. Which laughably for me means “no treatment”.

    Does my wanting “no treatment” mean I should bin my diagnosis?

    Does my not wanting a boyfriend right now mean I should bin being a woman?

    My knowing I am a woman helps me make sense of myself in myriad ways.

    My having my diagnosis helps me make sense of my nightmare illness, in myriad ways.

    ALL of this is quite quite different to the intolerable abuse that happens to some people where they have a diagnosis they do not want foisted on them like some hideous arranged marriage. It is right and proper to want to bin such an inflicted diagnosis, especially one that does not help the person make any sense of what is bothering them.

    I liken the situation to feminism. Many women want nothing more to do with men. They feel bullied and beaten by them. They do not want to wear the trappings of being the love interest of men. They want to get rid of the lot. They may even want to get rid of being a woman, as if that is to blame.

    But another population of women do not understand the pressure to go to such extremes. Those women may have had fine encounters with men. Those women may not want to give up being women just to please the women who have met with monsters.

    Lastly, there is something marvellous to be found in adopting any stance in relation to diagnosis. Binning a diagnosis could be the resurrection you need. Freeing yourself from the way you feel it defining you and undermining you might be the saving of you. Equally though, for someone else, a diagnosis may be the calming of a nightmare psychotic reality, a horror show in their mind that keeps relentlessly and compellingly luring them into feeling it is real reality. A diagnosis can be the only thing they’ve got that stands between them and hell.

    All facets of this antipsychiatry diamond contain a spark of healing and a sharp edge of discomfort.

    To only favouritize, or polish to a frenzied gloss, one bland facet, because all the others are dismissed as too sharp, loses for other seekers, the beautiful healing that all facets offer in radiance of the diamond.

  8. Sometimes, we don’t understand that when we accept the diagnosis given to us by a psychiatrist or a therapist or when we attempt to diagnose ourselves, we have done the most grievous of harm to ourselves. We may not have harmed another person, or locked another person up for no reason, or maimed another person or whatever. But we have done something to ourselves; we have injured someone—ourselves….just like the common drunk on the corner. We are not without blame. We must accept responsibility for what we have done to ourselves and ask forgiveness from both ourselves and God. We also may need to ask forgiveness from family, friends. Whom we ask for forgiveness is a highly individual thing, except that we must ask for forgiveness from God and from ourselves or will we never be whole or healed. I realize that many don’t want to take that kind of responsibility. And yes, some of this was done to us. And yes it could be argued whether we let it happen to us or not. Age is also a consideration; whether we were actually an adult or not. And the thought occurs if I forgive myself, does that lesson the reponsibility of the person or persons who did that to me? All of these questions, perhaps, can only be answered on a individual basis. But to still to grow and be free, with the help of God, we must accept our own responsibility towards what happened and then ask for forgiveness. We have no other choice no matter if we are wishing to either reform psychiatry or for the ultimate good for all humanity, end psychiatry. Thank you.

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