Towards a New Understanding of Psychosis

4. mai 2007

The Special Issue on Psychosis has been edited by Roger Hagen, Torkil Berge and Rolf W. Gråwe.

Historically, we distinguish between three paradigms in our understanding of psychosis (Morrison, Renton, Dunn, Williams, & Bentall, 2004). The illness paradigm was introduced by Kraepelin at the beginning of the twentieth century. A clear distinction was drawn between normality and abnormality, and the cause of a certain number of diagnosable mental illnesses was understood as inherited brain disorders. The second paradigm is called the stress vulnerability model: biologically predisposed individuals may become psychotic if they are exposed to stressing life experiences. The various disorders, for example schizophrenia, are thought to lie along a continuum with normal behaviour and experiences, and there is a possibility that one can make therapeutic change by influencing the environment and strengthening the person’s feeling of coping with the psychotic disorder. The third paradigm is the symptom-focused paradigm. Here each single symptom is emphasized, for example voice-hearing, delusions/unusual assumptions and depression, rather than using broad diagnostic categories. One is concerned with the possibility of coping with and understanding the symptoms and the ability to be able to function socially and professionally, more than curing the disorder as such.

Today there is full agreement on the fact that most people who are diagnosed with schizophrenia have a significant reduction in functioning in important areas in their life. The question is how suitable today’s diagnostic system is when it comes to understanding the background of psychosis, and how we can provide help to these people. Schizophrenia is used as a collective term for many different conditions. The same yardstick is applied to a very heterogeneous group of people, and therefore such categories can be unsuitable both in understanding the psychotic disorders, and how to treat them. For example, the course and expected outcome of the diagnosis schizophrenia varies extremely, as does the response to medication. The problem lies partly in the fact that schizophrenia has been regarded a syndrome, and little attention has been paid to the symptoms that after all constitute the disorder. Today many leading researchers have come to recognize the importance of focusing on each single symptom, as this creates the foundation for better results of treatment. Some keywords in this approach are normalisation of psychotic symptoms, user orientation and focus on coping and resilience. The exploration of the individual’s experience with the psychotic symptoms is essential, for example in how people perceive their voices, and to what extent the individual feels that he/she can act independently of them. Psychotic experiences are understood precisely as experiences, and not just as “symptoms of an underlying disorder”.

The point of departure for the Special Issue on Psychosis is the symptom-focused approach. The contributors are among the leading international experts, and the reader will be introduced to the most recent research on the subject and to the newest forms of treatment. The message we hope to convey is one of hope and optimism, which is good and important news to the patients, their relatives and professionals within health care.

Recovery is about more than the reduction of symptoms. Previous evidence-based approaches have mainly dealt with social skills training and family-based psychoeducation, but today research exists which demonstrates the effect of a range of other psychosocial and psychotherapeutic interventions. The Special Issue on Psychosis discusses measures against symptoms of psychosis, measures which promote employment and occupational functioning, and measures against comorbid disorders such as substance abuse, anxiety and depression.

Of course we have to be sober. There is still a lot we do not know. This relates in particular to the question of how to implement new methods in clinical practice, and how to secure the quality and content of services, regardless of where in the country one lives. We have to be able to provide differentiated treatment. Some keywords are individual therapy, group therapy, psychoeducation, family services, rehabilitation services, assertive outreach treatment, outpatients’ clinic services and 24 hour based services for individuals in case of emergency. The success of such services is still dependent on implementation in cooperation with the resources found in the patients’ surroundings, the support system of the municipality and the user organisations. The goal is to reduce the number of relapses, a reduction in time before treatment of psychosis, more patients integrated in colleges and universities, training and employment services, and improved treatment of comorbid disorders in psychosis. In addition, relatives should be offered appropriate support.

An area of utmost importance is this: A graded and dimensional understanding of psychotic experiences presupposes continuity between mental illness and mental health, and between the psychotic and the “normal”. One example is found in the extreme suspicion we call “paranoia”, but which lies along a continuum related to the suspicion anyone may feel. Another example is the fact that a substantial part of the population may experience hallucinations, such as hearing voices. This also applies to individuals who do not seem to suffer from a severe psychotic disorder, and who function well both socially and professionally. The new understanding of psychosis underlines that we are all part of a greater community. A man who was diagnosed with schizophrenia was asked what was needed in order for him to have a life outside the hospital. His answer was thought-provoking: What he needed was a place to live, something to make a living of, something to live for and someone to live with.

Teksten sto på trykk første gang i Tidsskrift for Norsk psykologforening, Vol 44, nummer 5, 2007, side 522-523

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Morrison, A. P., Renton, J. C., Dunn, H., Williams, S., & Bentall, R. P. (2004). Cognitive therapy for psychosis. A formulation–based approach. Hove, UK: Brunner-Routledge.