Psychosis

Psychosis is a loss of contact with reality.

Psychosis often involves harboring false beliefs (delusions) and seeing or hearing things that no one else sees or hears (hallucinations). People with psychosis often become unreasonably fearful or suspicious (paranoid). People with psychosis are sometimes referred to as being psychotic.

Psychosis may develop suddenly or gradually. Psychosis may be a temporary symptom of a physical or mental health disorder or the primary symptom of a chronic disorder (a psychotic disorder). Even when psychosis is part of a chronic disorder, the symptom may fluctuate, so that at times the person seems to have a grasp on reality.

Some older people with a psychotic disorder first developed symptoms as an adolescent or young adult or during middle age as part of a disease called schizophrenia. However, most older people with a psychotic disorder develop symptoms for the first time during old age. Many of them have paraphrenia, which is characterized by paranoid delusions and hallucinations. Psychotic disorders may affect as many as 1 out of every 50 older people.

Psychosis is usually very distressing, both to the person who experiences it and to family and friends who witness the strange behaviors of their loved ones. Fortunately, people with psychosis often respond well to treatment with drugs, especially when accompanied by reassurance and support from family, friends, and health care practitioners.

Causes

Psychosis may occur as part of other mental health disorders. Some older people with severe depression also become psychotic. And some people with dementia have psychosis.

Severe physical illness, such as severe infection, can cause temporary psychosis. Injury to the brain from a stroke or tumor can also lead to psychosis. Even extreme stress can lead to temporary psychosis. When older people are cared for in intensive care units, where they are deprived of sleep and bombarded by tests, psychosis is common.

Certain drugs, such as opioid analgesics, benzodiazepines, digoxin, and drugs with anticholinergic side effects, can also cause temporary psychosis. Excessive alcohol use can cause temporary psychosis; chronic psychosis can result if the drinking is long-term.

The exact cause of psychotic disorders is unknown. Many experts think that these disorders develop because the brain overreacts to certain substances that carry messages between nerves (neurotransmitters) in the brain. Heredity may play a part as well, because some psychotic disorders, especially schizophrenia, tend to run in families.

Symptoms

Some people with psychosis have false beliefs that can best be described as fearfulness and suspiciousness (paranoia). They may have vague fears or complaints about others controlling their lives, but many describe consistent suspicions of very specific, elaborate, and persistent plots against them. Very often, these beliefs are directed at family members or friends. For example, people with psychosis may believe that their spouse or children have deserted them or that their family or friends are scheming to obtain control of their finances or property.

Hallucinations—seeing or hearing things that no one else sees or hears—are sometimes experienced by people with psychosis. These hallucinations may seem dangerous and threatening to the person, although in some cases they are taken in stride.

People with psychosis may lose the ability to take care of their personal hygiene. They may seem withdrawn and without any emotions. However, when a psychotic disorder, such as paraphrenia, develops during old age, it is common for a person to communicate and function quite well despite delusions or hallucinations.

When psychosis is part of a disorder that impairs memory and the ability to think clearly, such as dementia, the nature of false beliefs often becomes increasingly paranoid. The person may become distraught, accusing others of stealing personal belongings or of attempting poisoning or molestation. The paranoia associated with dementia is usually very unpredictable and changeable. For example, a demented person with paranoia may accuse a particular person of some behavior yet shortly thereafter describe that same person as his best friend. The demented person with paranoia can be very irritable and angry, sometimes even to the point of striking out at others.

Diagnosis

A doctor diagnoses psychosis by reviewing and exploring the person's symptoms. When a person who is dependent on someone else's care strongly and consistently feels endangered and unable to protect himself, the doctor must entertain the possibility that some real danger exists, given how common the problem of mistreatment of older people has become.

After a person has been diagnosed as having psychosis, the doctor focuses on identifying the cause. A review of prescription and nonprescription drugs is important. A physical examination is performed to determine if disorders are present that might be causing or contributing to the psychosis. Similarly, medical tests may be useful. For example, the blood may be tested for evidence of certain drugs that can cause psychosis. Blood tests help exclude many physical disorders as a cause. If any unusual neurologic abnormalities are found, such as weakness of only one side of the body, a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the brain may be performed.

Treatment

When a person develops psychosis as part of another disease, such as depression, appropriate treatment for that disease may lessen or even stop the psychosis. When people are sleep-deprived because they are in intensive care, moving them to a quieter environment, if possible, usually cures the psychosis. Recovery may take time, however; thus, other steps may be needed to treat the psychosis.

Treatment of psychosis involves an effort on the part of health care practitioners, family, and friends to support and reassure the person rather than confront him about delusions or hallucinations. People with psychosis living in long-term care facilities (such as nursing homes) have better control of their symptoms when the staff reminds them of who everyone is and reassures them of their safety. Treatment also usually involves drug therapy.

Drug therapy: Drugs called antipsychotics can be effective in reducing or eliminating symptoms, such as delusions and hallucinations. After the immediate symptoms have subsided with treatment, antipsychotics may need to be continued to help reduce the likelihood of future episodes.

Unfortunately, antipsychotics can have many side effects, including sedation, muscle stiffness, tremors, weight gain, and restlessness. Antipsychotics may also cause tardive dyskinesia, a disorder in which a person has one or more types of involuntary movements. These movements most often involve puckering of the lips and tongue or writhing of the arms or legs. Tardive dyskinesia may not go away, even after the drug that is suspected of causing the problem is discontinued. If tardive dyskinesia persists, no effective treatment is available.

A number of new antipsychotics that cause fewer side effects, such as risperidone, olanzapine, and quetiapine, have become available. However, in people with dementia, risperidone may increase the risk of stroke.

Outlook

The outlook depends greatly on the cause of psychosis. When psychosis is caused by depression, sleep deprivation, or another treatable disorder, treating the other disorder often cures the psychosis. However, for people whose psychosis is part of dementia and for those whose psychosis is the primary symptom of a chronic disorder (a psychotic disorder), long-term treatment must usually include drug therapy and supportive care if it is to succeed in controlling symptoms and preventing relapses. If the person with psychosis is followed closely by health care practitioners, treated appropriately, and cared for in a supportive environment, then quality of life can improve significantly.

See the table Drugs Used to Treat Psychosis (Antipsychotics).