Understanding Psychosis

Our conception of the human "mind" is a manifestation of brain function. In turn, the brain is composed of numerous autonomous, but highly coordinated functional units.

If one information-processing unit malfunctions or slows down, the effect cascades — compromising the functioning of connected regions that rely on it. Some have analogized this to an airplane factory with multiple coordinated assembly lines. Smaller problems in one line may go unnoticed, yet manufacturing defects introduced eventually lead to a critical component failing, ultimately compromising the whole aircraft.

It is poorly understood what causes the mental disintegration we term psychosis, but it appears to be evenly attributable to genetic predisposition and environmental triggers — the Stress-Vulnerability Model. That stress plays such an important role in the development of psychosis is why two of the best-described risk factors are physical trauma and psychological trauma.

When the mind begins to shatter, it does so incompletely and insidiously — without detection. What people often term a "psychotic break" is not a sudden event like a heart attack, but rather the end stage of progressively deteriorating brain function. The period leading up to florid psychosis, when schizophrenia can be diagnosed, is termed the "psychotic prodrome" and can last years. Because symptoms onset gradually, patients, families and close friends will often unconsciously overlook or rationalize them.

"I have seen mad people, and I have known some who were quite intelligent, lucid, even clear-sighted in every concern of life, except on one point. They could speak clearly, readily, profoundly on everything; till their thoughts were caught in the breakers of their delusions and went to pieces there, were dispersed and swamped in that furious and terrible sea of fogs and squalls which is called MADNESS." — Guy de Maupassant

This compartmentalization of insanity is the norm early in the illness, allowing delusional beliefs or misperceptions to remain hidden. Simple, everyday conversations will not uncover growing psychosis until very late in the illness.

What is psychosis?

Psychosis (aka positive-symptom psychosis) is a symptom of mental dysfunction spanning three domains — distorted thought process, faulty sensory perception (hallucinations, illusions), unusual thought content (delusions) — accompanied by little to no insight.

• Thought disorder: normal thought processing flows like a stream. Each new thought flows directly from the previous one (linearity) in a sensible way (logical).
• Delusions: fixed false beliefs unshakable with logic. Common examples include paranoia, grandiosity, replacement, or reference.
• Hallucinations: false perceptions like seeing or hearing what is not there. Illusions are misperceptions of real things.

For example, it is common for patients with schizophrenia to hear voices of people who are not there and "see" people lurking in the shadows. What starts as suspiciousness can turn to full paranoia — enemies are everywhere, and eventually one may believe those enemies have replaced trusted people. At this point, fear and helplessness can overwhelm what little capacity for logical thought remains, leading to impulsive aggression.

What is schizophrenia?

Schizophrenia comprises four domains of brain dysfunction accompanied by little to no insight (anosognosia):

• Positive symptoms: hallucinations, delusions, and disorganized thinking (as above).
• Negative symptoms: often mistaken for depression — anhedonia, lack of motivation, isolation, and blunted affect.
• Neurocognitive impairment: impaired memory, attention, and processing speed, plus cognitive biases like jumping-to-conclusions and bias against disconfirmatory evidence.
• Social-cognition deficits: inability to read non-verbal cues or discern the mental state of others, leading to disproportional responses to perceived threats or slights.

If something about your child's behavior has you concerned — even if you're not sure what it means — you don't have to figure it out alone. Reach out to California OnTrack at Pand Health to connect with a clinician who understands early psychosis in teens and young adults.