Current Understanding of Psychosis

Our current understanding of psychosis is based on the medical model, which in the United States is centered around the DSM.

DSM-5-TR = The Gold Standard

Schizophrenia spectrum and other psychotic disorders = An umbrella that refers to:

Delusional disorder, brief psychotic disorder, catatonia, schizoaffective disorder, schizophrenia, schizophreniform, delusional disorder, schizotypal (personality) disorder, substance-induced psychotic disorder, psychotic disorder due to another medical condition, unspecified catatonia and unspecified schizophrenia and related disorders and other unspecified schizophrenia and related disorders (American Psychiatric Association, 2022).

DSM-5-TR Criteria:

Delusions (persecutory, grandiose, erotomanic, nihilistic, referential, somatic)
Hallucinations (auditory, visual, olfactory, tactile, gustatory)
Disorganized thinking/speech (loose associations, tangentiality, and word salad)
Grossly disorganized or abnormal motor behavior (catatonia)
Negative symptoms (decreased emotional expression, avolition, alogia, anhedonia, and asociality

Delusions

Definition: Fixed, false beliefs that remain unchanged despite clear contradictory evidence.

Persecutory: Beliefs of being harmed or targeted, such as thinking the CIA is monitoring them.
Referential: Belief that neutral cues or gestures are directed at oneself, such as a newscaster sending secret messages.
Somatic: False beliefs involving the body, such as infestation with parasites.
Grandiose: Beliefs of exceptional abilities, supernatural powers, or special status.
Religious: Beliefs involving divine identity or mission.
Erotomanic: Belief that another person is in love with them, often someone with whom they have little or no relationship.
Nihilistic: Belief that catastrophic events are imminent, such as the world ending.

Bizarre vs. Non-Bizarre Delusions
Non-bizarre delusions involve beliefs that could theoretically be possible. Bizarre delusions involve beliefs that are impossible within physical reality, such as being able to fly. The distinction helps indicate the degree of separation from reality and informs treatment planning.

Cultural Context

Clinicians must consider cultural and religious norms when assessing delusional content.
A behavior that is unusual in one culture may be normal in another.
Individuals should not be considered mentally ill solely because they do not conform to dominant cultural expectations.
In the United States, many norms reflect the experiences of White, heterosexual, cisgender men, which can create bias in judging what is “normal.”
For example, public toplessness may be seen as pathological by some, while others consider it an expression of bodily autonomy.

Hallucinations
Definition: Sensory experiences that occur without an external stimulus.

Auditory: Hearing voices or sounds that are not present. Voices may be familiar, unfamiliar, or command-oriented.
Visual: Seeing shadows, shapes, or fully formed figures.
Tactile: Feeling sensations such as insects crawling or blood moving.
Gustatory: Tasting flavors without a source or tasting something different than expected.
Olfactory: Smelling scents that are not present, such as rotting flesh.

Interaction With Delusions

Hallucinations often reinforce delusional beliefs.
For example, smelling “rotting flesh” may intensify a delusion about someone hiding corpses.

Disorganized Thinking (Speech)

Loose associations: Abrupt topic changes that are not logically connected.
Tangentiality: Rapid speech with little relevance or focus.
Clang associations: Words linked by sound or rhyme rather than meaning.
Word salad: Severely disorganized and incoherent speech.

Clinical Considerations
Clinicians must differentiate true disorganization from communication challenges related to language barriers.

Disorganized or Abnormal Motor Behavior

Unpredictable agitation
Unusual or rigid postures
Slowed or reduced responsiveness
Catatonic states such as prolonged immobility

Negative Symptoms
Diminished emotional expression: Reduced facial expression, gestures, or vocal intonation.

Alogia: Limited speech output.
Avolition: Reduced motivation for daily tasks such as hygiene or eating.
Anhedonia: Decreased ability to experience pleasure.
Asociality: Reduced interest in social interaction.

Utility of the current model:

Designed to streamline records amongst third parties such as insurers, government agencies, and statistics for the World Health Organization (Tyrer, 2014).

Sources:

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Tyrer, P. (2014). A comparison of DSM and ICD classifications of mental disorder. Advances in Psychiatric Treatment, 20(4), 280–285. https://doi.org/10.1192/apt.bp.113.011296