Introduction
One wonders what the world is like when a plank in reason splinters, as Emily Dickinson describes the slip into psychotic process. The more we, as clinicians, can develop a feeling for this world, the easier it is to uncover subtle psychotic states. As intuitive understanding increases, it also becomes easier to understand the needs of the patient, an understanding that leads directly into a more compassionate, person-centered interview.
To begin our exploration, we will turn to Gérard De Nerval, a poet of extreme talent, who had the misfortune of falling through a plank in reason sometime during the middle of the Victorian Era. De Nerval was a gifted Symbolist poet, who was also a world traveler and a man deeply interested in philosophy. He was blessed with a child-like awe of nature. In 1841 he experienced his first psychotic break. Some 14 years later, psychotic process would lead him on a cold winter night to an iron gate bordering an alley near the Boulevard St-Michel. There, the following morning, he was found hanging from a railing with his neck fatally embraced by an apron string.1
On the morning after his suicide, fragments of a work entitled Le Rêve et la Vie were found in his pocket. It is this piece that provides us with our first glimpse into the world of psychosis:
First of all I imagined that the persons collected in the garden (of the madhouse) all had some influence on the stars, and that the one who always walked round and round in a circle regulated the course of the sun. An old man, who was brought there at certain hours of the day, and who made knots as he consulted his watch, seemed to me to be charged with the notation of the course of the hours …
I attributed a mystical signification to the conversations of the warders and of my companions. It seemed to me that they were the representatives for all the races of the earth, and that we had undertaken between us to re-arrange the course of the stars, and to give a wider development to the system. An error, in my opinion, had crept into the general combination of numbers, and thence came all the ills of humanity. …
I seemed to myself a hero living under the very eyes of the gods; everything in nature assumed new aspects, and secret voices came to me from the plants, the trees, animals, the meanest insects, to warn and to encourage me. The words of my companions had mysterious messages, the sense of which I alone understood.2
In some respects, it is De Nerval’s last statement that provides one of the most telling clues as to the nature of psychotic process. As psychotic process becomes more intense, the patient’s world becomes progressively more unique to the patient, receding further from the experience of the world as witnessed by others. In this sense, psychosis can be defined in simple terms as a breakdown of perceptual, cognitive, or rationalizing functions of the mind to the point that the individual experiences reality very differently than other people within the same culture.
De Nerval’s world became filled with a maelstrom of curious and disturbing sensations. His words sensitively depict a variety of classic symptoms of psychosis, including delusions, ideas of reference, and hallucinations. It also demonstrates the fact that some aspects of psychotic process may be exciting and even beautiful. But – and this is an important “but” – psychosis is almost invariably ultimately accompanied by an intensely painful collection of fears. The patient senses impending catastrophe. For instance, De Nerval states, “An error, in my opinion, had crept into the general combination of numbers, and thence came all the ills of humanity.” Such paranoid perception can create a tremendous sense of urgency and responsibility in those experiencing psychotic process. Perhaps for De Nerval, it was the realization that he could not correct this heinous error in the universe that led him to believe that his life should be ended because he had failed both God and humanity.
There are many aspects of psychotic process that, to my mind, demarcate it from the innovative workings of eccentric and/or creative men and women, whose thought is clearly at variance with the worldview of most people but is not a psychotic process. Creative thinking may bear a resemblance to psychotic process, but it is not identical to it. We shall see that it is not so much the content of the psychotic thinking that is pathologic, but more the way in which the thinking occurs that marks the process as psychotic.
The Differential Diagnosis of Psychotic States
Now that we have arrived at a working definition of psychosis, an important point needs to be emphasized. The word “psychosis” is not a diagnosis. Psychosis is a syndrome that can result from any number of psychiatric disorders delineated in the DSM-5. As we have already seen, mood disorders such as major depressive disorder and bipolar disorder can present with psychotic symptoms. It is never enough to simply state that the patient appears to be psychotic, because one must proceed to determine what diagnostic entity is causing the psychotic process. With some disorders such as schizophrenia and psychotic bipolar disorder, timely recognition can lead to early intervention, lower doses of antipsychotic medications, and an untold reduction in the patient’s severity and duration of suffering. Other disorders that can sometimes feature psychosis such as deliria and central nervous system infections, can prove to be acutely life threatening, requiring immediate diagnostic recognition. In this chapter we will look at the interviewing techniques and strategies that will allow us to spot these diagnostic distinctions in a sensitive, rapid, and accurate fashion.
To accomplish this task, we will look at seven clinical vignettes that illustrate the diversity of possible disorders that can present with psychotic symptoms. Once again, the emphasis will be upon a discussion of both the symptoms experienced by the patients and the practical interviewing techniques that allow us to more sensitively and effectively uncover these symptoms. In the process we will explore the interface between interviewing and the delicate art of differential diagnosis.
Before proceeding with this clinical material, it may be of value to review the DSM-5 criteria for schizophrenia, because schizophrenia may very well represent the classic example of a psychotic illness. One of the main goals in the approach to any psychotic patient remains the determination of whether or not schizophrenia is present. To this end the DSM-5 criteria are as follows3:
It should be noted that there also exists a diagnosis, schizophreniform disorder, that is applied when a patient meets Criterion A of schizophrenia (as well as having ruled out depressive disorder with psychosis, bipolar disorder, and schizoaffective disorder) but the symptoms do not last for 6 months nor necessarily result in a marked decline in functioning. In the schizophreniform disorder, the symptoms (including prodromal, active, and residual phases) must last at least 1 month but less than 6 months. Many patients who have received this diagnosis provisionally will eventually receive the diagnosis of schizophrenia if their symptoms last longer than 6 months and significant impairment in functioning begins to appear.
For psychotic presentations of an even shorter duration, the DSM-5 delineates the diagnosis of brief psychotic disorder. This diagnosis is used when the patient has one (or more) of the following symptoms, with at least one of the symptoms being in the first three listed: (1) delusions, (2) hallucinations, (3) disorganized speech, and (4) grossly disorganized or catatonic behavior. The timeframe is at least 1 day but less than 1 month, with the patient eventually having a full return to his or her previous level of functioning. If the psychotic episode is triggered by a specific stressor, this stressor should be specified. Such psychotic episodes are often called brief reactive psychoses in the clinical literature.
To begin our discussion, let us meet some people who have had the misfortune of falling through a plank in reason. As with Chapter 9, where we examined the differential diagnosis of mood disorders, it is assumed, for the sake of discussion, that the following clinical material was obtained during an initial assessment interview unless otherwise noted.
Clinical Presentations and Discussions
Clinical Presentation #1: Mr. Williams
Mr. Williams presents to the emergency department (ED) accompanied by three police officers. His behavior has not put the officers in particularly good moods. As one officer states, “This guy is wacko. Every once in a while he tries to bolt, as if something was after him.” The officer has no idea what the “thing” is that appears so disturbing to Mr. Williams. In the interview, Mr. Williams presents as a 33-year-old male who initially appears relatively calm despite the beads of perspiration on his forehead. He is just finishing supper from his dinner tray and is neatly wiping his mouth with a napkin. His pants are torn and soiled; obviously, they are not strangers to the harshness of street life. He appears oriented to person, place, and time. As he begins to talk, he becomes more animated, displaying tangential speech with occasional glimpses of derailment (also known as a loosening of associations in the clinical literature). He also appears to be increasingly more distracted as evidenced by his having trouble focusing on the interviewer’s questions. He denies any recent drinking or drug use, but his story is vague, concerned primarily with the appearance of some creature that has been following him. Suddenly, in the middle of the interview, his eyes widen as he stares down at his feet. He cannot attend to the interview because his attention is riveted to the floor. He begins kicking at some invisible object and angrily looks at the clinician, yelling, “Get rid of that thing!”
Discussion of Mr. Williams
Phenomenology of Visual Hallucinations and Illusions: Their Diagnostic Implications
While with the police, Mr. Williams had appeared to be responding to visual hallucinations, a process that reappeared during the interview itself. And here is the first clue to the diagnostic entity causing his immediate psychosis: The presence of visual hallucinations should alert the clinician to the possibility that a general medical condition may be causing the disorder. Schizophrenia can cause visual hallucinations but auditory hallucinations are significantly more frequent. However, general medical causes of psychosis (e.g., substance abuse and withdrawal, endocrine disorders, infections, toxins, and seizures) frequently present with extremely vivid visual hallucinations, with or without auditory hallucinations.
Fish has suggested that the quality of the visual hallucination may tend to vary depending on whether schizophrenia or a general medical process is present,4 but no specific characteristics clearly differentiate them. Nevertheless, some characteristics seem to be more common in each category and may provide clues to etiology.
Visual hallucinations in patients whose psychosis is caused by a general medical condition, as seen with delirium, tend to vary from the classic psychoses by preferentially occurring at night, by being briefer in duration, and by being more frequently perceived as moving. They may also have little personal significance to the patient. For example, a patient with schizophrenia may hallucinate about a recently deceased relative, whereas the delirious patient may see snakes.5
With patients for whom the psychosis is caused by drugs or other general medical conditions, the hallucinations may appear more frequently and more vividly when the patient is in a darkened room or has his or her eyes shut. This is not the case with people with schizophrenia, who tend to see their hallucinations with eyes open or who experience little difference whether the eyes are open or closed.6,7 In this sense, it is of value to ask patients, “When you see your hallucinations, what happens if you close your eyes?” With a hospitalized patient it is of value to check with the nursing staff concerning whether the patient is hallucinating more at night.
With people suffering from schizophrenia, visual hallucinations seldom occur by themselves. They usually present with auditory hallucinations or hallucinations from some other sensory modality.8 Also of interest to the interviewer is the fact that schizophrenic hallucinations are frequently superimposed on an otherwise normal-appearing environment or may even appear with the surrounding environment absent. In hallucinogenic drug-induced psychoses, the entire environment frequently seems distorted with numerous illusions and hallucinations.9 In a similar vein, the visual hallucinations of schizophrenia tend to appear suddenly, without preceding visual illusions or less formed visual hallucinations; whereas visual hallucinations caused by a general medical condition, as seen in delirium, tend to have a prodrome of visual illusions, simple geometric figures, and alterations of color, size, shape, and movement.9
Patients with schizophrenia tend to see concrete things such as faces, body parts, or complete figures, as opposed to geometric patterns or poorly formed images. On the other hand, once patients whose psychosis is caused by a general medical condition begin seeing concrete images, it has been my experience that the images frequently appear extremely real to the patients. The delirious patient may look on with terror, pointing towards the hallucination, eyeing it warily, or moving away from it as it appears to approach. Occasionally the patient’s affective response may be pleasurable, as experienced with hallucinations of miniature people, so-called Lilliputian hallucinations, sometimes seen in the early stages of delirium tremens (DTs) and other medically related states.10
In Mr. William’s case, the interviewer asked him if he could point more closely to the creature in question. Mr. Williams hesitantly obliged by cautiously moving his hand towards the open space in front of his feet. Abruptly he halted, “I ain’t getting no closer!” It became even more apparent that the hallucination was vivid and quite realistic. At times, these types of hallucinations can create a peculiar sensation in the interviewer, because the actions of the patient, like the movements of a mime, create the feeling that one ought to be seeing something.
Sometimes the terms “hallucination” and “illusion” are confused. Mr. Williams presents with a true hallucination, for with hallucinations the perceptual image arises from an open space and is not triggered by an environmental stimulus. Whatever Mr. Williams is seeing, he is seeing it in the open space in front of his feet, not triggered by any object in the room itself. In contrast, with an illusion, the image is triggered by some actual object or stimulus. For instance, one patient vividly described watching the face of a man standing beside him on the bus. He saw the man’s face begin to twist in a grotesque fashion and saw his eyeballs shatter and begin to bleed. This experience represents a visual illusion and also emphasizes that such illusions may be as striking and terrifying as true hallucinations.
Recognizing Psychotic Process Induced by Alcohol Withdrawal
We have seen that the appearance of vivid visual hallucinations ought to arouse suspicion that an organic agent may be at work. Mr. Williams presents with one of the more typical organic causes of psychosis that the initial interviewer must constantly keep in mind – abuse and withdrawal from alcohol, street drugs, or medications. It is important to realize that there exist two different manners in which drugs may precipitate a psychosis: by acute intoxication or by withdrawal. First, let us look at the issue of withdrawal, because Mr. Williams is suffering from a substance withdrawal delirium caused by an abrupt discontinuation of his drinking. Such a delirium is traditionally called delirium tremens – DTs.
It is beyond the scope of this book to provide a thorough review of drug abuse, and the reader should study this topic elsewhere in detail. However, there are some basic facts with which all assessment clinicians should be familiar, for psychoses triggered by substance abuse can be life threatening in nature, whether presenting in a clinical environment where they are encountered frequently (emergency department, inpatient unit, community mental health center) or one where they are seen much less often, yet, nevertheless, can present (college counseling center or private practitioner’s office). They are also one of the most common causes of psychotic process. All initial interviewers need to be familiar with their symptomatic presentation and physical signs.
With regard to withdrawal states, alcohol and sedative/hypnotic drugs are the most likely to cause psychotic features. They are also the most likely to result in death if not recognized and treated. Withdrawal from these drugs is significantly more dangerous than withdrawal from drugs such as heroin or amphetamines. Some estimates of the mortality rate of patients with definite DTs from alcohol, who have been hospitalized, have been as high as 15%, although with good management this number should be markedly lower.11
As people begin to withdraw from alcohol and sedative hypnotics, they generally move from mild symptoms of withdrawal towards progressively more severe states such as DTs. As withdrawal occurs, patients frequently experience sleep disturbances, nausea, anxiety, over-alertness, tremulousness, and a peculiar intensification of their sensory modalities. Delirium tremens, itself, often persists about 5 to 10 days, with 62% of episodes resolving in 5 days or less.12
Even if patients such as Mr. Williams deny recent alcohol abuse, they may willingly admit to withdrawal symptoms if asked matter-of-factly and without the suggestion that they have “a personal problem.” In this regard, questions such as the following may be useful:
a. “Since you stopped drinking, have you been noticing any problems with your sleep, because many people use alcohol to help with their sleep and without it, they have problems falling asleep?”
b. “Have you been feeling edgy over the past couple of days, you know, just can’t seem to relax?”
c. “Over the past couple of days, have you been feeling sick in your stomach?”
d. “Recently, have you found yourself to be more edgy, you know, being startled by noises or upset by people moving or talking loudly near you?”
To develop DTs, the patient must have used alcohol heavily for a long period of time, minimally imbibing 4 to 5 pints of wine, or 7 to 8 pints of beer, or 1 pint of “hard” liquor every day for several months. It does not typically occur under the age of 30, although it clearly can, and it usually requires consistent use of large amounts of alcohol for several years,13 most often appearing after a decade or so of abuse. This chronic use of alcohol sets up a complex set of compensatory physiologic changes in autonomic body regulation. When the alcohol is abruptly stopped, these compensatory changes go unchecked, resulting in such abnormalities as increased pulse, increased temperature, normal or elevated blood pressure, rapid breathing, muscle twitching, and sweating. As the syndrome becomes more serious, the patient may become so tremulous that walking appears to be difficult.14
While interviewing the psychotic patient, the clinician should do a quick survey to see if any of these physiologic signs of withdrawal are present. With Mr. Williams, he was noted to appear sweaty. The clinician also knew that his pulse rate was elevated at 100, with a mild increase in temperature. This emphasizes an important point. In general, a patient presenting with an acute psychosis should have his or her vital signs taken before the clinical interview, thus alerting the clinician that an acute organic process may be at work.
Mr. Williams proceeded to become more agitated, claiming that some kind of bug was crawling on him and that some “wires are running around on the floor. They’re shocking the hell out of me, man!” It is not uncommon for people with DTs to hallucinate about small animals, and sometimes large objects such as trains or the proverbial pink elephant. Tactile hallucinations or illusions such as mice or lice crawling on the skin also occur, as seen with Mr. Williams.14
The clinician astutely cut this interview short, proceeding rapidly with a physical examination and appropriate medical management, which raises another important point. These patients need prompt medical attention. If one is not a physician, then one must immediately arrange to have such a patient seen by one. An appointment for “later in the day or tomorrow” is inadequate and potentially dangerous.
Before leaving the topic of DTs, a few more points are worth mentioning. Seizures (“rum fits”) sometimes precede DTs, usually occurring during the first 2 days after the cessation of drinking. More than one in three patients who have withdrawal seizures will go on to develop DTs. DTs usually begin 24 to 72 hours after the cessation of drinking but can appear much later, even as long as 7 or more days later.14 While performing an initial assessment on a psychotic patient in the hospital, a few issues are worth considering.
During their hospital stay, some patients may have a temporary alcohol or drug source, such as a friend, who eventually stops bringing them drugs. In these cases, DTs may not appear until much longer into the patient’s hospitalization. Keep in mind that even patients with a higher income may purposely lie about alcohol consumption and may consequently develop withdrawal problems only as the hospitalization proceeds. Curiously, surgery may delay the appearance of DTs as well. All these facts considered, clinicians should be alert to the possibility of drug withdrawal in any patient who develops a psychosis at any time during a hospital stay, especially if the patient’s vital signs are abnormally elevated.
Recognizing Psychotic Process Induced by Street Drugs
Violently psychotic patients, frequently brought in by the police, serve as a bridge to the next topic, patients who are acutely intoxicated by a psychosis-producing agent. The list of offending agents is extensive and includes common agents such as methamphetamine, lysergic acid diethylamide (LSD) and other hallucinogens, marijuana, cocaine, crack, and phencyclidine (PCP). For a concise and practical discussion, the reader is referred to specialized texts, such as Goldfrank’s classic article on PCP and outstanding general textbooks such as the recent work of Fischer and Harrison.15,16
By way of example, I will briefly describe some of the more typical aspects of a patient intoxicated on PCP, a drug originally developed in the 1950s as an anesthetic-analgesic agent. These patients frequently present as markedly psychotic, although they can present without any psychotic features. In addition, they can be extremely violent. In this regard, any violent patient should alert the clinician to the possibility of PCP abuse. Even at low doses this drug can produce the “three As” of PCP use: analgesia, amnesia, and ataxia (problems with gait). The analgesia can result in self-mutilatory behaviors such as eye gouging. If use of PCP is even remotely suspected, the initial interviewer should have safety officers informed and immediately available during the interview.
On a behavioral level, the psychotic features of these patients may be quite bizarre, such as running naked in public or crawling around on all fours like an animal. They may develop paranoia, disorientation, auditory hallucinations, and visual hallucinations.
The physical examination may provide important clues, such as the various types of nystagmus (abnormal eye jerks) and hypertension, reported as occurring in 57% of these patients.17 These patients generally show miosis (smaller than normal pupils) but may also present with mydriasis (larger than normal pupils), especially if they also ingested an anticholinergic agent. Increased muscle tone and increased salivation are also common. Rather than presenting as agitated, these patients may present lethargically or in a coma if they have ingested high doses of the drug.
At the time of writing this chapter, a new, still-legal drug was hitting the streets. It can create psychotic states similar to PCP, but is more common than PCP. It is known as “bath salts” and, in actuality, is not a single agent but is often a concoction of chemicals that are sought for their psychedelic effect. Unfortunately, wildly psychotic states can result – ranging from public nudity to extreme violence. One rare, but particularly bizarre, behavior associated with bath salts has been cannibalism, as seen in a young man under the influence of bath salts, who was found naked, eating the flesh off of a homeless man’s face on a street in Miami. Another newer class of drugs that can also trigger psychotic states has been the synthetic cannabinoids, referred to by various street names including “spice.”
One cannot leave the topic of street-drug induced psychosis without addressing methamphetamine in more detail. The rise of illicit meth labs has been striking – so commonplace, in fact, that it has been the subject of a popular television series; Breaking Bad is based on the exploits of a former high school teacher turned master of meth production. Chronic use of methamphetamine can create a psychotic state that appears remarkably like paranoid schizophrenia or a mixed bipolar disorder such as a dysphoric mania with psychosis. The two most common psychiatric symptoms with meth use are persecutory delusions and auditory hallucinations.18 Even when patients stop the use of the drug, psychotic symptoms can persist.19,20 Other persistent symptoms, despite continued abstinence, can include cognitive impairment, social instability, and an increase in lifetime suicide attempts.21 For the initial interviewer, any patient presenting in an agitated state (often accompanied by severe problems sleeping), anger, paranoia, and auditory hallucinations should be considered as a potential methamphetamine user with appropriate drug screens ordered, even when street drug use is adamantly denied.
Returning in a more general sense to psychosis as precipitated by drugs, a few more points are worth noting. The rapid appearance of a full-blown psychosis in a matter of hours should make the clinician very suspicious of a drug-induced psychosis, as might be seen with LSD, PCP, or bath salts. Processes such as schizophrenia tend to develop more slowly over days, weeks, or months. Some patients may not know that they have been given a drug; it may have been slipped to them or sprinkled on a joint. In this regard, it is always worthwhile checking with friends who may know more about the actual circumstances surrounding the drug ingestion. One should always be on the lookout for two possibilities when faced with drug-intoxicated, psychotic patients:
Recognizing Medication-Induced Psychosis
I am reminded of a young woman with a chronic history of paranoid schizophrenia. She had been doing very well in the hospital and was consequently sent home on a pass. Within a few hours of returning from her pass, she began to appear agitated and reported feeling apprehensive. In another 30 minutes she became grossly psychotic and reported that small dragons were chasing her. Indeed, she was seen racing down the hall as if pursued by a bevy of such monsters. The physical examination revealed dilated and poorly responsive pupils, a dry mouth, and an elevated pulse. It was discovered that she had taken “a few extra” Cogentin (benztropine mesylate) tablets while at her apartment. Cogentin is a prescribed anticholinergic agent that helps to alleviate some of the side effects of antipsychotic medications such as a Parkinsonian syndrome.
If taken in excess, these anticholinergic agents can quickly precipitate a delirium, as was the case with this patient. Elderly patients appear to be particularly susceptible to such anticholinergic deliria. It is therefore important to inquire about both prescription and non-prescription medications. Keep in mind that specific medications may have a mild anticholinergic effect, but when given together these medications may have an additive effect strong enough to precipitate a delirium, especially in the elderly.
Classes of medications that may have anticholinergic properties include some over-the-counter hypnotics and “cold medicines,” certain antidepressants, some antipsychotics, certain antiparkinsonian medications, some medications for peptic ulcer disease, and even antihistamines.22 The clinician must always carefully elicit a medication history from both the patient and the patient’s family.
At the time of the writing of this third edition, the class of medications known as the semisynthetic opioids, such as oxycodone and OxyContin (its time-released preparation), as well as hydrocodone (Vicodin, Hycodan and, in combination with acetaminophen, Percocet) have achieved an epidemic prevalence in the United States. They have also led to a striking increase in the subsequent use of heroin and a sharp rise in heroin overdoses and deaths. OxyContin (because of the particularly high concentration of oxycodone in each tablet for it is a time-released medication) has become a major drug of abuse. Some of the common street names for oxycodone are: ox, oxy, kicker, cotton, hillbilly heroin, 40 and 80. I mention them here for a specific reason. In general, these substances are not highly associated with the production of acute psychotic symptoms,23 but because of this recent upsurge in their use, clinicians should keep them in mind as etiologic agents when patients are presenting with psychotic features and substance use is suspected.
These medications at high doses have been reported to cause vivid and terrifying visual hallucinations. If a patient presents with vivid visual hallucinations in a clinic or emergency department setting, abuse of these agents should be considered. Also, be on the lookout for these agents as the cause of psychotic process, including vivid visual hallucinations, in any post-operative or pain patient. Sometimes with post-operative patients, the hallucinations do not appear for days after the patient’s discharge from the hospital, until after they have returned home, much to the shock of both the patient and his or her family members. These psychotic presentations often have accompanying agitation and intense anxiety.
In concluding our discussion of medication-induced psychosis, the clinician should also keep in mind one other broad category of agents that could precipitate a medication-induced psychosis, namely, herbs and other natural agents. A naturally occurring source of anticholinergic agents is a family of plants known as the Solanaceae. Such an innocuous sounding name actually houses a variety of not so innocuous plants, including Atropa belladonna (commonly called deadly nightshade), jimsonweed, mandrake, and henbane.24 Historically, ointments and potions made from such agents may have resulted in the psychotic states that, at least partially, functioned as the source of the wild phenomena reported by the witches of the Middle Ages, such as flying through the night sky to a Sabbat. In the present, it remains important to consider the ingestion of herbs and other “natural foods” while evaluating an unexplained acute onset of psychosis.
Effectively Interviewing and Collaborating With Law Enforcement Officers
Thus far, the material gained from the actual interview with Mr. Williams has been the focus of discussion. However, in addition, one of the most important interviews to perform when a patient is brought to the emergency department by the police is with the officers, and there is an art to this process. The first trick is training oneself to take the time to perform this interview. Both the police and the clinician are frequently harried, but nevertheless this interview can provide invaluable information.
In particular, one wants to establish the following: (1) What were the circumstances in which the patient was found? (2) Is the patient a known alcohol or drug abuser? (3) Do the officers know the patient’s family and has the family been contacted? (4) Did the patient appear disoriented or demonstrate any signs of psychosis? (5) Has the patient appeared drowsy or been unconscious? and (6) Has the patient been in a fight involving a possible head blow?
Actively psychotic patients, especially paranoid patients, can be surprisingly violent, especially if they perceive, from a paranoid perspective, that they are fighting for their lives. I believe it is important initially to inquire as to whether an officer may have been injured while bringing the patient under control. This inquiry is both medically important and builds sound collaborative relationships among law enforcement officers and emergency department staff.
As with any type of professional, a particular police officer may be talented or not so talented in their work. In this regard, officers vary on their understanding and effective handling of psychiatric patients. Since the last edition of this book, law enforcement agencies, coupled with concerned patients, family members, and mental health professionals, have developed several outstanding programs for training law enforcement officers to be particularly effective and compassionate with patients coping with mental illness. I believe all initial interviewers should be aware of such efforts and tap them, if possible, in building healthy collaborative relationships with police departments, whether the interviewer works in an emergency department, on a crisis team, or at a college counseling center. Two such innovative programs are the Crisis Intervention Team Memphis Model – CIT – (http://cit.memphis.edu/) and the Connecticut Alliance to Benefit Law Enforcement – CABLE – (www.cableweb.org).
Considering the difficulties of subduing a person experiencing an agitated psychotic process, it is expedient to discover how the patient was subdued, including whether or not a Taser was used. The clinician should also determine whether an officer delivered a head blow, either justly or unjustly. Uncovering a history of a physical confrontation can help alert the clinician to the possibility of a subdural hematoma or an intracranial bleed as the source of the psychosis, especially in older patients who have been struck. It may also help the clinician understand and perhaps decrease the patient’s fear that more violence may follow.
A sensitive interviewer approaches these topics in a manner that places the officers at ease. It is important to remember that most officers resort to violence only when absolutely necessary. Angry countertransference feelings directed towards the police can only get in the way of gaining valid information from them. The following type of approach may be useful:
Clin.: It really looks like you had your hands full tonight.
Police: You can say that again, this guy’s really out of it. It took three of us to get him down.
Clin.: Yeah, he’s wound up, maybe he’s on something. Listen, did any of your officers get hurt? We’d be glad to take a look at them and check them over.
Police: No, don’t worry about it, thanks anyway.
Clin.: By the way, did you need to Taser him to calm him or wrestle him down?
Police: Didn’t need to Taser him, but like I said, it took three of us to wrestle him down. I think he was hallucinating and must have felt we were after him or something.
Clin.: When you were wrestling him down, did he accidentally get struck on the head?
Police: No, can’t say that he did.
Clin.: The reason I ask is that if he got a blow on the head we need to make sure he didn’t get a small fracture or something like that?
Police: Hmmm … Well, you might want to take a look, this guy was really wild; someone might have used a baton on him or he could have smacked his head on the ground. I’m not sure. It all happened really fast. He was out of control.
Clin.: Okay, thanks a lot for all your help. We’ll take a look at him. I hope the rest of your night goes better than this. Sounds like you guys did a great job. Thanks for bringing him in.
This matter-of-fact type of exchange tends to yield accurate answers while unobtrusively reminding the officers of the dangers of a head blow.
Differential Diagnosis on Mr. Williams and Summary of Key Interviewing Tips
The interview with the police revealed that Mr. Williams had a long history of alcohol use (severe), although he did not appear intoxicated at that point in time. They also thought that he had a history of “stuffing his face with any drug he could get his hands on.” Further interviewing with Mr. Williams revealed that he had a history of DTs. The physical examination and lab work revealed no other probable cause for the psychotic presentation. He was felt to be in the early stages of DTs and was begun on Valium (diazepam). In a matter of several hours he calmed down, and all psychotic symptoms vanished. His case would be summarized as follows:
General Psychiatric Disorders:
Substance withdrawal delirium (alcohol)
Rule out unknown substance use disorder
Rule out a variety of alcohol-related diseases such as hepatitis, gastritis, and pancreatitis
As we leave the discussion of Mr. Williams, several key points are worth summarizing.
1. Visual hallucinations, especially if they appear to be particularly vivid and real to the patient, are frequently seen in psychoses caused by physiologic insults to the brain, including street drugs, medications, and medical disease.
2. Despite the fact that such physiologic psychoses may tend to have some features that distinguish them from entities such as schizophrenia, all psychoses can present in a similar fashion. Consequently, any patient presenting for the first time with psychotic features should be promptly medically evaluated.
3. One of the most frequent physiologic causes of psychotic symptoms is the use of street drugs or alcohol.
4. Withdrawal from alcohol in heavy drinkers may lead to an alcohol withdrawal delirium (commonly called DTs). DTs can be fatal if not treated promptly.
5. The onset of a marked psychosis in a matter of hours in a previously normal individual is strongly suggestive of a drug-related etiology.
6. Both over-the-counter and prescription medications may cause psychotic states, especially in the elderly. Anticholinergic medications are notorious for precipitating deliria.
7. Although not a common presentation, be on the lookout for psychotic process, especially visual hallucinations, triggered by the use and/or abuse of medications containing oxycodone or hydrocodone.
8. If police bring in the patient, the officers should be questioned thoroughly, for they may have pivotal information regarding differential diagnosis.
9. Any patient who presents violently should be thoroughly evaluated for evidence of psychotic process and the possible use of drugs such as PCP or newer “legal” drugs such as bath salts, synthetic cannabis, and other designer drugs.
Clinical Presentation #2: Mr. Walker
Mr. Walker is a 20-year-old male. He is thin and his hospital gown tends to hang forlornly on his gaunt frame. Beneath his black hair a rather handsome face sits quietly darkening with a day’s worth of beard. He has been admitted to an inpatient unit after having been referred by a college counseling center, who had seen the student shortly after his return from Christmas break. One of the unit’s social workers is performing an initial intake. As the interviewer enters the room, Mr. Walker acknowledges him with a slight nod of his head. His speech is soft and mildly slowed. He appears almost shy. As he speaks, there is barely a hint of facial expression, his voice painted gray by a conspicuous lack of highlights. All seems bland. Mr. Walker proceeds to describe a chaotic situation at home. He is being avidly pursued by three filthy women who enter his house at night. They attempt to force sex on him. When asked if he knows who these women are, he nods, stating that one is “that devil Miss Brown.” He proceeds to describe a recent party he attended, where sex games were played. He relates that he had been tricked into going. As he entered the kitchen three men tied him to a chair and stripped him. When asked what happened, he pauses and proceeds to say, “They violated my anus.” As he says these words a slight smile steals across his face. It had been verified that no such rape had occurred. His speech is without any evidence of derailment (loosening of associations), tangential thought, thought blocking, or illogical thought. He is alert and well oriented. Both he and his family deny that he has used any street drugs. His family says he has been acting oddly for almost a year, making vague accusations about a Miss Brown even during the summer. During the interview the clinician feels uncomfortable and somewhat frightened.
Discussion of Mr. Walker
Spotting Disturbances of Affect as Seen in Schizophrenia
One of the first things to note about Mr. Walker is the peculiar blandness that he demonstrates when describing brutal scenes of sexual abuse. This blandness represents an important diagnostic clue, because Mr. Walker is suffering from schizophrenia.
Affect refers to a patient’s manner of expressing emotion and spontaneity through facial expressions. Criterion A-5 from the DSM-5 includes “diminished emotional expression,” a concept that is traditionally described as a reduction in affect. Diminished affect is viewed as one of the negative symptoms of schizophrenia, a cluster of symptoms we will explore in detail shortly. Abnormalities in affect can be seen in other psychotic states, but it is particularly common in schizophrenia. At present, let’s turn our attention to the changes in affect typical of schizophrenia.
A useful interviewing habit consists of asking oneself if the patient seems to be appropriately disturbed while describing traumatic incidents. In the case of Mr. Walker, as he related his rape, there was little display of fear, anxiety, or anger. His affect changed very little. When present in a mild degree, this type of affect is usually called “restricted.” If present to a moderate degree, this type of unresponsive affect is usually called “blunted.” If the patient demonstrates essentially no change in affect, it is usually referred to as a “flat” affect. Mr. Walker also nicely demonstrates the concept of an inappropriate affect. Rape victims do not generally smile as they describe their assaults. This peculiar combination of flattened affect and inappropriate affect is not infrequent in schizophrenia. It is one of the qualities that can create an unsettling emotional response in a clinician, as it did in this case.
An important point to remember concerning reduced affects is the ironic and sometimes confusing fact that some antipsychotic medications frequently also cause a blunting of affect as a side effect. The wary clinician must keep this point in mind, because a patient inappropriately labeled as having schizophrenia by a previous clinician may present with a blunted or flat affect related to current medication. This blunted affect may be misinterpreted by the new clinician as further “proof” that the patient has schizophrenia, resulting in a perpetuation of the first diagnostic error.
Diagnostic Significance of the Presence of Delusions: Delineating Schizophrenia From Delusional Disorders
Perhaps even more striking than Mr. Walker’s blunted affect is the fact that he is clearly delusional. The appearance of delusions of any kind should alert the clinician to the possibility of schizophrenia. A delusion is a false belief that is firmly held by a patient but is not believed by others in the patient’s general culture. When firmly entrenched, a patient will persist in his or her delusional belief despite incontrovertible evidence that it is false. Over the course of time, patients may vary on the intensity of their belief, a process I like to call having greater or lesser distance (insight) from their delusional belief. When a patient has gained considerable distance from a delusion, the patient will be able to see that the belief may very well be untrue. If this perspective is maintained, one can say that the patient is no longer delusional but is now experiencing an overvalued idea.
The delusions of schizophrenia are frequently bizarre in the sense that they are patently absurd and have no possible factual basis. The patient may feel that alien or demonic forces are controlling his or her body or that thoughts are being inserted or withdrawn from his or her body. Other delusions tend to be concerned with magical, grandiose, or intensely hyper-religious themes. For example, a patient may believe that God wants the patient to cut off a finger and sprinkle the blood over the earth in order to bring flowers into bloom. When schizophrenia is highlighted by paranoia, the patient may present with delusions of persecution or jealousy, as did Mr. Walker. Such delusions, although clearly not true, may not be bizarre in nature.
But this point raises an important diagnostic issue, for how does one separate schizophrenia from a different DSM-5 diagnosis called a delusional disorder? The distinction is actually somewhat easier to make than one might assume if one keeps the following guidance in mind.
In schizophrenia the delusions are only part of the pathologic process. Other aspects of psychotic process are present in addition to the delusion itself. Specifically, in schizophrenia, if delusions are present, the patient’s delusions are accompanied by one of the following: some type of hallucinatory process, evidence of disorganized thought, grossly disorganized or catatonic behavior, or the presence of “negative symptoms” such as the affective flattening seen with Mr. Walker. Problems with the formation of thought may manifest as incoherence or as a marked loosening of associations (referred to as “derailment” in the DSM-5). In addition, patients with true schizophrenia will invariably demonstrate a significant decrease in social and/or occupational functioning over time.
In contrast, patients with delusional disorders tend to demonstrate only delusions, although they can show infrequent hallucinations. If present, these infrequent hallucinations are always tied directly into the patient’s delusional system (as with a patient with a paranoid delusion about his neighbor complaining of occasionally hearing his neighbor yelling, “I’ll get you someday, watch your back, watch your back,” or a patient deluded that he is infested with parasites may have tactile hallucinations within his abdomen). Also in contrast to schizophrenia, patients with delusional disorders tend to show surprisingly good baseline functioning at home and at work, as well as demonstrating a reasonably normal and appropriately reactive affect. We will look at the phenomenology of delusions and delusional disorders in more detail later in this chapter.
Keep in mind that not all patients with schizophrenia have delusions.
Negative (Deficit) Symptoms of Schizophrenia
An important advance in the DSM-IV system that was continued in the DSM-5 was the addition of the term “negative symptoms” and a recognition of their importance in the amount of pain they cause patients. Historically, in the DSM-III, much emphasis was placed upon those symptoms that people with schizophrenia show that most people do not experience, such as hallucinations and delusions. These “extra” phenomena are now called “positive symptoms,” indicating that they are an unwanted “excess.”
We are now aware that schizophrenia also afflicts brain structures in such a way that the person loses certain normal functions. These lost functions are referred to as “negative symptoms” or “deficit symptoms,” the latter being the term that I prefer. Such symptoms include decreased affect, as described above, alogia (decreased speech production and interest in speaking), avolition (decreased drive and ability to sustain interest), anhedonia (loss of interest in pleasurable activities), and asociality (reduced interpersonal interactions).25 Some clinicians also view anergia (loss of energy) as a deficit symptom.
Empirically, Rado summarized the research findings on the impact of the “deficit syndrome,” a term referring to patients afflicted with a predominance of negative symptoms.26 During the first episode of schizophrenia, negative symptoms appear in patients somewhere between 50 and 90% of the time. The deficit syndrome is associated with more severe cognitive disorganization, as well as poorer insight into the illness. Patients with significant amounts of these deficit symptoms tend to have poorer psychosocial, vocational, and recreational functioning. They also tend to experience higher levels of anxiety and a lower appraisal of competence, as well as a decrease in interpersonal skills. As we shall see later in this chapter, these deficit symptoms are frequently devastating to both functioning and self-esteem and are in some instances more disabling than positive psychotic symptoms such as hallucinations and delusions.
The Importance of Family Members in Uncovering Psychotic Process
Mr. Walker’s presentation becomes even more clearly typical of schizophrenia following an interview with his mother.
Clin.: What does your son do down in his room all day long?
Moth.: That is what is so peculiar. He talks with her.
Moth.: He talks with this devil woman. I’ll hear voices that sound like a woman’s voice coming up out of the basement. It is really weird. Late at night I can hear him arguing with her, swearing at her, and sometimes it sounds like holy hell is breaking out down there. I’m terrified; I never go down there.
Clin.: When he is with you, does it ever look like he is hearing voices?
Moth.: Oh yes, he’s always mumbling to himself like he’s answering someone. But the strange thing is that he’s not always like this. Sometimes he seems so calm and almost normal and other times he’s in a frenzy. Just last night he came screaming up out of that basement with a butcher knife in his hand. He kept screaming at me that I’d better make them stop. I couldn’t take it anymore so I brought him in.
From the above, it is apparent that Mr. Walker is hearing voices and clearly fulfills the criteria for schizophrenia. It also serves to stress the importance of carefully interviewing family members or other significant others. For whatever reasons, psychotic patients may withhold information critical to the diagnosis, and the family often gratefully provides the missing pieces.
Mr. Walker also illustrates the fluctuating nature of psychotic process. Even in schizophrenia, as we shall see later in the chapter, the severity of the psychotic process may vary substantially. Many an interviewer has been lulled into a belief that a patient is not psychotic during the interview. In such cases it is always wise to listen carefully to the family, because the interviewer may simply be catching the patient during a period of decreased psychotic process. Moreover, patients with psychotic process may not be too eager to tell the “shrink” that they are plagued by voices. Their more rational side warns them that such talk may provide a quick ticket into the hospital.
Differential Diagnosis Between Schizophrenia and Mood Disorders With Psychotic Features
Let us turn our attention to one of the exclusion criteria for schizophrenia as delineated by the DSM-5. Criterion D directly addresses the issue of affective symptoms. Several points are worth remembering here that can help us to differentiate between schizophrenia and mood (affective) disorders with psychotic features. In the preceding chapter we noted that a major depression or a bipolar disorder may eventually manifest with psychotic symptoms; thus these diagnoses are important to rule out when psychosis is suspected. The particular psychotic symptoms may be either mood-congruent or mood-incongruent. It is important to note that in a major depressive disorder with psychotic features or a bipolar disorder with psychotic features, the psychotic symptoms generally appear a considerable time period after the onset of the mood disorder. It is almost as if the depressive or manic process builds to a crescendo that culminates with the blooming of psychotic process. In contrast, with schizophrenia, the psychotic process is usually an earlier part of the process, predating the most severe mood symptoms.
Diagnostic mistakes can be made in either direction (mislabeling someone with schizophrenia as having a psychotic mood disorder and vice versa). Factors in such misdiagnoses can range from sloppy interviewing and/or a misunderstanding of the phenomenology of these disorders to the fact that some people present with confusing admixtures of psychotic and mood symptoms. In this regard, Guze reports that most people suffering from schizophrenia experience affective syndromes at some time during the course of their illness.27 Moreover, anhedonia is frequently seen in schizophrenia, where it presents as one of the negative symptoms.28 Such patients may be mistakenly diagnosed as having a mood disorder. In contrast, some patients are mislabeled as having schizophrenia when, in actuality, they have a bipolar disorder or major depression. This error is not a benign one, for such patients might benefit from lithium or antidepressants. American psychiatrists have tended to over-diagnose schizophrenia, while under-diagnosing bipolar disorder.29
Two points are worth emphasizing here that can help us with our differential diagnosis. First, family members and the records of other mental health professionals can be invaluable in gaining a clear history of which came first, the psychotic symptoms or the mood symptoms. Second, it is always important when evaluating a patient who has had numerous psychotic breaks to return to the first break in an attempt to determine the role of depressive or manic symptoms in the chronology of the illness.
The role of the timing of mood versus psychotic symptoms is particularly important in the differential between bipolar disorder (manic phase) and schizophrenia, for an agitated mania can look exactly like the psychotic presentation of a patient suffering with schizophrenia. Keep in mind that a patient can be manic without being psychotic. The mania itself is manifested by excessive energy, unstable mood, agitation, decreased need for sleep, pressured speech, and other classic manic symptoms. The mania does not become psychotic unless reality contact is disturbed, as manifested by the presence of delusions, hallucinations, or other psychotic symptoms such as grossly disorganized thought. It has been estimated that about 50 to 70% of manic patients display psychotic symptoms.30
As with depression, psychotic symptoms in mania tend to appear significantly later than the mood symptoms. This point once again helps to ease the difficulty of distinguishing between schizophrenia and mania with psychotic process. However, to make use of this difference, the interviewer must make a concerted effort to learn about the very first episode of the patient’s illness.
Interestingly, there is mounting evidence that the clear-cut distinctions between schizophrenia and psychotic bipolar disorders, delineated above, may be somewhat misleading.
Let me explain more clearly what I mean. We have already seen in Chapter 9 that even within the broad category of mood disorders, diagnoses sometimes seem to overlap. For instance, within mood disorders, especially with late adolescents and young adults who present with angst ridden depressions (sometimes including psychotic features), the diagnosis of an agitated major depression is sometimes wrong. In reality, some of these patients are suffering from a type of mixed bipolar disorder called a dysphoric mania. In short, there may be more of a continuum within broad diagnostic categories, such as the mood disorders, than was formally thought. Specifically, the mood disorders of depressive disorder and bipolar disorder may be more related than has been traditionally recognized.
Extending this idea, then, is it possible that there may exist continua not just within a single broad diagnostic category like mood disorders but also between broad diagnostic categories themselves, for instance, between mood disorders and schizophrenia?
The answer appears to be evolving towards “yes.” The clear-cut distinctions described above that can distinguish schizophrenia from psychotic mood disorders may prove to be most true for patients at each end of what, for want of a better term, we will call the schizo–bipolar continuum. In short, there may be many patients who have a relatively pure form of schizophrenia (psychotic symptoms appear early, followed by marginal mood disturbances relatively late in the process) and there may be patients with a relatively pure form of bipolar disorder (manic symptoms appear quite early, followed by psychotic symptoms relatively late in the disorder). But a significant cohort of patients seems to lie in-between these two diagnoses.
Schizoaffective Disorder and the Schizo–Bipolar Continuum
It is now apparent that we have stumbled upon a curious diagnostic dilemma. We have seen that in schizophrenia the psychotic symptoms usually predate marked mood symptoms. And in the mood disorders the psychotic symptoms generally appear later in the process, after the mood symptoms have been around for a while. But what diagnosis is appropriate when the psychotic symptoms appear at or near the same time as the affective symptoms? Indeed, even in patients with a relatively classic presentation of schizophrenia, one can find that during the prodrome of the illness, there may be many months of low-grade mood disruption, especially of a dysthymic nature.
The diagnosis that helps to fill this gap is “schizoaffective disorder,” and it is defined in the DSM-5 as follows31:
The vagueness of this definition certainly would be at home in the campaign speech of any presidential candidate. But then at this stage of current diagnostic knowledge, this degree of vagueness may be appropriate. The vagueness of the definition serves to remind us that categorical diagnostic entities are not necessarily real-life entities, but rather represent labels for the most commonly observed patterns of behaviors. In this regard, there has been growing recognition that traditional diagnostic “entities” such as schizophrenia, schizoaffective disorder, and psychotic bipolar disorder, may perhaps be better conceptualized as being on a dimensional continuum rather than being a set of distinct disease entities. Future versions of the DSM system may more accurately reflect this dimensional quality.
In the late 1970s, Tsuang pioneered the idea that the diagnosis of schizoaffective disorder represents a heterogeneous category with two probable subtypes, an affective subtype and a schizophrenic subtype. According to this theory, schizoaffective disorder is not likely to represent a genetically distinct category.32 It appears that Tsuang was ahead of his time. More recent studies have indicated substantial genetic overlap between schizophrenia and psychotic bipolar disorder.33,34
In addition to genetic evidence, there is increasing data from cognitive, neurobiological, and epidemiological studies that there is significant overlap between schizophrenia and psychotic bipolar disorder.35,36 Even in their prodromal states, there seems to be some overlap – for example, the appearance of subtle cognitive changes in both disorders during this phase.37 A nice summary of how the concept of schizophrenia has been evolving over the past two centuries, up to and including the DSM-5, has been provided by Bruijnzeel and Tandon.38 The net result of this exploration of the overlapping characteristics of schizophrenia, schizoaffective disorder, and bipolar disorder is the growing interest in conceptualizing a “psychosis spectrum” between schizophrenia and bipolar disorder, in which the schizoaffective states lie between the purer forms of the syndromes located at opposing poles of the spectrum.39,40
At the present moment, the bottom line with the differential diagnosis of schizoaffective disorder is that people with schizoaffective disorders have many of the striking psychotic processes seen in schizophrenia but also have persistent and significant mood disturbances. They seem to differ from people who have psychotic bipolar disorder or an agitated, psychotic depression in that people with schizoaffective disorder have periods when they are quite psychotic but their mood is fairly normal. This latter state is seldom seen with people suffering from a pure mood disorder, whose psychotic process tends to “rear its head” primarily during a marked disturbance in mood. People with schizoaffective disorders seem to differ from those with classic schizophrenia in having prolonged periods of time, both early and throughout the process, in which there are striking mood symptoms, frequently without accompanying psychotic symptoms. In the DSM-5, the diagnosis of schizoaffective disorder requires that the disturbance in mood continues for the majority of the duration of the disorder (as seen in Criterion C, above). If psychotic symptoms begin to appear without concurrent mood symptoms, then the diagnosis must be changed to schizophrenia.
These recent insights into the nature of schizoaffective disorder (including the concept of a schizo–bipolar spectrum) are not merely of academic interest – they have practical implications for initial interviewers and their patients, for diagnoses play a significant role in future treatment interventions. When an initial interviewer determines that a patient meets the criteria for schizophrenia, future clinicians may be less likely to consider the use of mood stabilizers such as lithium and Depakote.
In contrast, the diagnosis of schizoaffective disorder serves to remind clinicians that the patient may have an affective component to the illness, suggesting the use of such medications. If there is a bipolar quality to the schizoaffective disorder, it also alerts the clinician to be cautious in adding an antidepressant, for fear of exacerbating or unleashing an underlying manic process. The diagnosis may also have some prognostic importance, because some authors feel that schizoaffective disorders have a significantly better prognosis than schizophrenia.41
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