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The Four Elements of Psychotic Symptoms


Symptoms of Stress

DID YOU KNOW that nearly any mental condition can produce “psychotic features” (temporary psychotic symptoms not usually the hallmark of a specific illness) when stress (which produces anxiety) rises to a high enough level? Many are surprised by the fact that, for example, severe depression or anxiety can result in temporary symptoms that meet criteria for psychosis.

ALL PSYCHOLOGICAL SYMPTOMS may be understood as attempts  to defend against unbearable anxiety. That is, as a means to find an explanation for sources of anxiety that will provide comfort. When psychotic symptoms are present, anxiety may be quite unbearable, calling for much stronger defenses.

PSYCHOLOGICAL SYMPTOMS – EVEN PSYCHOTIC ONES – are nearly always “normal” behavior, writ large. You doubt it? Who among us has not at one time or another thought we heard a noise when we later determined we had not.  Ever glimpsed something out of the corner of your eye when nothing was there? Ever had the thought that people laughing at the other side of a room might be laughing at you

FOUR ELEMENTS MUST BE CONSIDERED in the understanding and management of psychotic symptoms. The four elements inform and direct symptomatic behaviors. Considering them helps put behaviors into better perspective. Not everything about a symptom is an expression of illness, and remembering that can make it easier to empathize and connect with the one who is struggling.

HERE ARE THE FOUR ELEMENTS, along with some examples of how to begin thinking about them:

1. The Human Condition

Is it part of the overall human condition to become confused when we are anxious? If bad things have happened in our past, do we not become predisposed to expect bad things to happen in the future? If we have a sensory experience, do we look for ways to explain the experience to ourselves?

2. The Personality

Are not some of us more excitable than others? Are not differing levels of optimism and pessimism present in personality? Do some people become troubled in the presence of others’ anger? In other words, does anxiety cause different people, with different personalities, to react in different ways?

3. Individual History & Environment

Everyone, to some greater or lesser extent, is a product of cultural, family and social histories and environments. Responses and behaviors are shaped by experience.

4. Illness

So what causes a behavior to be considered as beyond the prior three elements: to rise to the level of being a symptom?  Intensity. A thoughtful examination of behaviors in the presence of psychotic symptoms can make it clear that with much less intensity, there would not be the need for such heightened concern.

THE POINT HERE?  We can choose to approach people living with psychotic symptoms differently when we realize that only one in four of the elements of their behavior is entirely about “illness.”

MIGHT THIS MAKE A DIFFERENCE  in how you respond to symptoms and behaviors?

Just askin’ … good question, isn’t it?




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A Few Words About Non-Compliance


illness (Photo credit: cambiodefractal)

I recently heard from a mother whose son was diagnosed several years ago with schizophrenia.  Her son has become homeless, and is unwilling to agree to take medication or work with a doctor.  She shared that she is discouraged in trying to work within a “broken” healthcare system, and asked for some feedback.

There is little that can be done to force an adult into treatment unless that person is a danger to self or others, or is “gravely disabled” (roughly, this means demonstrably unable to do what is necessary to stay alive and safe).  It is also true that the healthcare system for psychotic illness can be characterized as “broken.” Each individual situation is so unique that it is not possible to give concrete, blanket advice that will apply to all situations.  

That being said, here are just a few examples of things you might choose to consider.

It is always best to work collaboratively with a person affected by a psychotic illness. I believe the components that serve the patient and the family best are encouragement and praise (when appropriate and sincere), asking questions about the person’s own preferences, and listening. Symptoms are always an effort to defend against unbearable stress, anxiety and pain. It can be so easy to miss the clues provided by symptoms. Yet, they may be the only way to obtain insight into what is driving behavior.

Did I mention listening?  Their reasons for resistance to treatment, for example, often make a lot of sense. Too often, we don’t think about asking and listening because we are so affected by their odd behaviors and are trying so hard to help.  As parents, for example, we have a history of directing our children – a habit, if you will, and one that can be very hard to lose. When we make suggestions as to what they “should” do, bear in mind that their symptoms may render it impossible for them to comply, even if they were willing.  They may be unable to articulate their limitations because the illness affects their thinking and ability to communicate.   They may experience guilt and shame about not being able to please you.  They may be silently grieving the “unlived life” they started out expecting. The end result often leads to increased stress, which becomes expressed as frustrated anger.  Stress heightens the symptoms of psychosis. This loop shows up a lot, even within the scope of the best of intentions.

Let us strive to keep in mind that a person with a mental illness is still a person, more than anything else. In directing our attention and energy to their humanity (in favor of focusing entirely on symptoms and illness), we can help them to do the same. Any opportunity to provide acquiescence, dignity or encouragement is a chance to connect with the healthy part of your loved one – an essence that remains intact, no matter how small it gets in the face of symptoms.

Let’s face it: the medications are not always helpful. Often, they come with a terrible price paid in side effects. Fortunately, therapy can take many forms.  One example: good nutrition can make an enormous difference. If the relationship is intact enough, having your loved one over to dinner without talking about illness at all has been known to be very soothing, and may begin to re-establish and nurture a two-way loving relationship.  If they cannot tolerate a family dinner, you might consider baking some cookies (healthy ones, oatmeal is great) “to go.”  A gift with no strings. Anything that plants the seeds of a supportive, loving relationship without making demands is a good start. Positive relationships for these individuals cannot be overrated.  The task need not always be about symptoms or getting into treatment.

When we begin to work collaboratively with our loved ones within the context of their own felt needs, desires and preferences, we may be able to begin to establish a connection that will help them to trust us and begin to explore options from that place of trust and safety.  The key is patience.  Success is measured over long periods of time, in small increments.  There is always hope.  Always.

Patricia O’Neill, PhD

Los Angeles, California

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Patricia O'Neill, Ph.D.

Dr. Michael A. Fuller, the Director of Psychiatric Forensic Services at University of Texas, Medical Branch in Galveston, joined one of a growing number of mental health professionals and other achievers today in disclosing his own diagnosis of bipolar disorder. In an article (see below) published in the Health Section of the Longview News-Journal, Fuller talked about his own experience of the management and sustained recovery that can be achieved, even in the absence of a cure.

It is such a good thing for the public to be made aware that mental illness does not always keep people from high achievement. I really appreciate the many people who have “come out” and shared their personal experiences of living with a severe mental illness. There’s Ellen Saks, a professor at the University of Southern California, who wrote about her lifelong struggle with severe schizophrenia.  The popularity of Saks’ book, “The Center Cannot Hold,” makes it clear that public interest in mental illness is neither limited to horror movies nor extreme cases that make headlines, such as that of Levi Aron, the Brooklyn man accused of murdering a child. Another celebrated case is that of mathematician and Nobel Laureate, Dr. John Naish, whose struggle was portrayed, albeit in a somewhat fictionalized fashion, in the hit film “A Beautiful Mind.” The number of celebrities disclosing their bipolar illness during the last few years has become too long to list in a blog post.

I have long been a proponent of illness management toward sustained recovery, which is meant to be about personal best rather than striving to “be normal,” whatever that is. Living with chronic mental illness is surely different from living without it. But there is treatment, and a great quality of life is possible.  A multifaceted illness management plan is invaluable.

In setting up an illness management plan, one of the most important aspects is having people who can be counted on to tell one honestly when symptoms begin to show.  And who can tell one early. Even one person can be enough, if contact is frequent.  That means making a decision to trust someone, which may be difficult at first. It’s not as hard as one might think; people who care are already aware when someone is struggling, and most always want to feel like they can help. It may even bring them closer.

Even when one is doing everything “right” — taking medication as prescribed, good self care, excellent nutrition, social interaction, and so forth, unavoidable external stressors can build up and cause return of symptoms.  Bringing a trusted friend or friends on board, or a family member where there is good rapport is a great way to start. “Hey, if you notice that I am getting angry more easily than usual, let me know.” Or “If I start spacing out a lot, tell me.” If you are one of the lucky people who has a strong therapeutic alliance with a therapist, she can tell you right away when she notices a resurgence of symptoms or help to respond quickly when someone else notices, by strategizing to avoid a downward spiral: an important part of illness management.


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