Your thoughts on the diagnosis: Schizoaffective Disorder

[Tapepsi]

I remember doing a presentation about the diagnosis during a rotation as a PGY2 at an off-site state hospital. Basically the attendings snickered when I explained the actual DSM V criteria and one said something about it being the “catch all” diagnosis he gives to most of his patients since it “covers everything” and that “it’s all on a spectrum anyway”.

Even med students get confused when I get to the part of “2 weeks of only psychotic symptoms” and “more than 50% of the time mood symptoms are present” and honestly I think it’s confusing myself. (If mood symptoms are less than 50% of the time we give them Schizophrenia and then if they have depression I list a separate depressive episode under diagnoses and then other providers tell me it should be schizoaffective?). It doesn’t help our patients (and even their families) are poor historians so it’s difficult to tease out the symptoms.

What are your thoughts on this?

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[MacDonaldTriad]

This controversy has been going on for a long time. DSM-III gave us operational criteria for everything except Schizoaffective disorder. They were fighting so long, the DSM was finally published without Schizoaffective disorder criteria. This wasn't fixed until DSM-IIIR (revised). The basic theoretical camps think schizoaffective disorder is either a variant of schizophrenia, a variant of a mood disorder, a combination or both disorders, a separate entity, or a disorder representing the middle range on a continuum between schizophrenia and mood disorders. Ming Tsuang has probably done the most genetic work to try and tease this out. My memory is that there are Schizoaffective patients who have a predominance of mood disorders in their family, and there are Schizoaffective patients who have predominately schizophrenia in their family so it isn't terribly satisfying.

 

[Linksawakening]

A great review article going over this very topic can be found here: Is schizoaffective disorder a distinct categorical diagnosis? A critical review of the literature

Personally, I think schizoaffective disorder has earned its reputation as a "garbage can" diagnosis into which clinicians can fit a wide range of patients with little or no effort. While the DSM has made efforts to tweak the criteria, many clinicians often still think of it as "any patients with both mood and psychotic symptoms" and diagnose accordingly. However, there are so many different kinds of patients that fall into this category that there is very little reliability. One of the most damning studies found very poor congruence within the diagnosis at six months, meaning that a patient diagnosed with schizoaffective disorder had only around a one-third chance of still being found to have that same diagnosis half a year later (compared to 92% for "vanilla" schizophrenia and 83% for "vanilla" bipolar disorder). Another study found that that exactly 0% of patients who were diagnosed with schizoaffective disorder in clinical settings actually "had" it when operationalized criteria were used.

In my own practice, the most common examples of schizoaffective disorder misdiagnoses that I've seen have been:

• Substance use disorders – A patient with a long history of methamphetamine abuse appears "manic" while intoxicated and then "psychotic" the rest of the time.
• Cluster B personality disorders – Almost all patients with borderline personality disorder have depressive symptoms, and up to 40% regularly experience symptoms resembling psychosis (paranoia, auditory hallucinations, etc.). While these psychotic symptoms are quite different than what you see in schizophrenia, if you don't assess the phenomenology closely it is easy to see "mood + psychosis" and diagnose schizoaffective disorder.
• Mood disorders with psychotic features – This goes directly against the DSM criteria, but nevertheless I have seen many cases where schizoaffective disorder is diagnosed even when there are no psychotic symptoms outside of mood episodes.
• Schizophrenia – Many patients with schizophrenia report depressive symptoms, especially in the early stages of the condition. The onset of psychosis can also appear "manic" if grandiosity or delusions of being persecuted because one is "special" are present.

That all being said, I have maybe seen one or two patients during my career that I would consider to genuinely meet criteria for schizoaffective disorder even after careful consideration, so I will not go so far as to say that it doesn't exist. However, I believe it to be exceedingly rare, and the diagnosis should be given cautiously.

 

[Armadillos]

This is an area where seems genuinely almost impossible to actually nail down the “right” diagnosis by the book in the real world. Seems like you would need to constantly follow someone around for a couple years to feel 100% confident. Especially when you toss in some occasional substance use.

Mercifully SGAs seem to be pretty good at treating it all regardless...

 

[Tapepsi]

It almost makes me wonder if they should just group schizophrenia and schizoaffective disorder under some new diagnosis like Psychotic Spectrum Disorder and give the ability to add specifiers like “with depressive features” or “with bipolar features”. If so many people are being misdiagnosed and from what I’ve seen most providers don’t even know the real criteria for schizoaffective disorder anyway why not change it?

 

[MacDonaldTriad]

A rose by any other name... Change it or not, people will still minimize the role of substance abuse, under diagnose personality disorders, or just be sloppy. Schizoaffective disorder is a real thing, but it is very much over used.

 

[Tapepsi]

people will still minimize the role of substance abuse, under diagnose personality disorders, or just be sloppy

Amen.

 

[whopper]

Kaplan and Saddock had written in their textbook that Schizoaffective Disorder had better outcomes that Schizophrenia which made me scratch my head and think "WTF?" If someone had Schizophrenia plus say MDD you figure they'd be worse off.

Of course when I tried to look at the source of the data in usual K&S disappointment fashion it wasn't specifically referenced. It only had all of the sources (dozens of them) listed at the end of the chapter and there was no way in Hell I was going to read a few dozen articles only to find out the above detail.

I speculate maybe there was a better outcome because maybe several subjects in the study really had MDD with psychotic features of Bipolar Disorder with psychotic features and were misdiagnosed.

 

[Jules A]

I speculate maybe there was a better outcome because maybe several subjects in the study really had MDD with psychotic features of Bipolar Disorder with psychotic features and were misdiagnosed.

Yup.

 

[clausewitz2]

The Roscommon family study did find two separate clusters of "schizo-depressive" and "schizo-manic" patients that did not especially overlap. Each was separated partly by predominant sx but also by the mood disorders their relatives tended to have. There is some utility in the idea of separating these from mood disorders with psychotic features; a very large study tracking outcomes over two decades for people discharged from a New York state hospital found that even a few weeks of clear psychosis without notable affective sx made outcomes comparable to psychosis without affective disturbance, i.e. much worse than people with psychotic sx only in context of affective episodes.

First episode literature regularly identifies a group that were unremarkable in academic/occupational functioning, tend to be highly distressed by their symptoms, help-seeking and have a better prognosis, and a group characterized by developmental delays, much less distress related to symptoms, and with a trend towards steady functional decline.

I agree that it is usually a garbage can diagnosis in practice. I mostly diagnose separate mood disorders when appropriate. Of course if anyone not still in early days of training thinks "hallucinations + paranoia = psychosis", the degree of ignorance or superficial thinking involved may not be correctable.

 

[adaptation1]

Schizoaffective, Depressed type vs Major Depressive Disorder w/ persistent psychotic features. In practice, it's a none issue. Treatment is similar. Biologically, I doubt these are discrete disorders, anyhow, and simply a human construct. Many patients are -- understandably -- depressed when they are psychotic. Is that Schizophrenia or Schizoaffective, then? It's really hard to say.

 

[deleted736562]

It's actually a pretty hard diagnosis to make as the criteria are quite strict, so people who say it's a "catch all" don't really know what they are doing.

The reality is that we don't really understand the heterogeneity of psychotic illnesses with and without mood symptoms. The Bipolar vs Schizophrenia dichotomy is useful only to a certain extent; there are some patients who fall within the spectrum and I think the diagnosis is fair if they truly had psychosis without mood for >2 weeks and mood sx for the majority of their illness duration.

 

[deleted736562]

The Roscommon family study did find two separate clusters of "schizo-depressive" and "schizo-manic" patients that did not especially overlap. Each was separated partly by predominant sx but also by the mood disorders their relatives tended to have. There is some utility in the idea of separating these from mood disorders with psychotic features; a very large study tracking outcomes over two decades for people discharged from a New York state hospital found that even a few weeks of clear psychosis without notable affective sx made outcomes comparable to psychosis without affective disturbance, i.e. much worse than people with psychotic sx only in context of affective episodes.

First episode literature regularly identifies a group that were unremarkable in academic/occupational functioning, tend to be highly distressed by their symptoms, help-seeking and have a better prognosis, and a group characterized by developmental delays, much less distress related to symptoms, and with a trend towards steady functional decline.

I agree that it is usually a garbage can diagnosis in practice. I mostly diagnose separate mood disorders when appropriate. Of course if anyone not still in early days of training thinks "hallucinations + paranoia = psychosis", the degree of ignorance or superficial thinking involved may not be correctable.

That is the definition of psychosis, unless I'm missing something in your post.

 

[FatherPsychiatry]

I fail to see how anyone can make this diagnosis these days. Nobody (especially patients with these spectrum of illnesses) can remember exactly what symptoms were present / not present at which times. I highly doubt their families can either (and if they claim they can, they are either psychiatrists themselves or they are lying). Maybe the diagnosis can be made with a state hospital patient by a psychiatrist that evaluates the patient every day in a highly phenomenological way for hours. Gonna guess this pretty much never happens, and thus just about every schizoaffective disorder dx is BS. But who cares. Throw Abilify and Latuda and Vraylar at everyone and don't have to think.

 

[Alemo]

I’ve noticed Clausewitz has a tendency to end posts with ominous phrases to the effect of “If you think Jaws is a movie about a shark you weren’t paying attention!”

How these statements are interpreted by the reader is the important part. I mean they certainly aren’t explicitly corrective or classically educational. I guess it keeps people on their feet.

 

[clausewitz2]

That is the definition of psychosis, unless I'm missing something in your post.

...no, I don't think that's true at all. You can say maybe those are psychotic features, but if you call that psychosis then BPD, OCD, delirium, PTSD all become psychosis in many cases. Maybe also AN and BDD.

I am not sure which particular definition of psychosis I am willing to defend to the last, but I think a first pass is that unless there are a) more classic psychotic sx b) cognitive/thought/speech/motor disturbances c) delusional conviction of the reality of the experience then it is not really psychosis.

 

[deleted736562]

...no, I don't think that's true at all. You can say maybe those are psychotic features, but if you call that psychosis then BPD, OCD, delirium, PTSD all become psychosis in many cases. Maybe also AN and BDD.

I am not sure which particular definition of psychosis I am willing to defend to the last, but I think a first pass is that unless there are a) more classic psychotic sx b) cognitive/thought/speech/motor disturbances c) delusional conviction of the reality of the experience then it is not really psychosis.

hmm, we'll agree to disagree. "Psychosis" and "psychosis features" are pretty much equivalent in my book and all of these disorders can have psychotic features; for example, I don't know why you'd say psychosis is not a part of delirium. Someone who is seeing visual hallucinations in the hospital and acting on them is psychotic in my book - it may be acute and temporary, but it is psychosis.. It passes your test as well, btw. On the other hand, someone who took , I don't know LSD, and is being paranoid may not necessarily exhibit any "cognitive/thought/speech/motor..etc" and that is also psychosis in my book.

I think what you're getting at is that psychosis is a "chronic psychotic illness" like schizophrenia. That is far too restrictive imo. Psychosis is a break from reality, and the cardinal defining elements are hallucinations and delusions. Of course, that would also mean that psychosis comes in many settings, shapes and forms, and I am fine with the imprecision until we can refine the concept in a more meaningful way. I think the definition you're proposing will end being even more problematic.

 

[clausewitz2]

hmm, we'll agree to disagree. "Psychosis" and "psychosis features" are pretty much equivalent in my book and all of these disorders can have psychotic features; for example, I don't know why you'd say psychosis is not a part of delirium. Someone who is seeing visual hallucinations in the hospital and acting on them is psychotic in my book - it may be acute and temporary, but it is psychosis.. It passes your test as well, btw. On the other hand, someone who took , I don't know LSD, and is being paranoid may not necessarily exhibit any "cognitive/thought/speech/motor..etc" and that is also psychosis in my book.

I think what you're getting at is that psychosis is a "chronic psychotic illness" like schizophrenia. That is far too restrictive imo. Psychosis is a break from reality, and the cardinal defining elements are hallucinations and delusions. Of course, that would also mean that psychosis comes in many settings, shapes and forms, and I am fine with the imprecision until we can refine the concept in a more meaningful way. I think the definition you're proposing will end being even more problematic.

Something like the definition or criteria I suggested is very much in keeping with the traditional notions of what this term means in descriptive psychopathology. The idea that a smattering of perceptual disturbances and feeling judged constitutes psychosis makes the term almost meaningless. If you use your definition, you are using it as a label that means almost nothing in terms of clinical picture, prognosis, treatment, epidemiology, genetics etc. Why would you want to use a label that?

Having features of an entity does not mean what is in front of you is that entity. Otherwise anyone who doesn't sleep well and is agitated must be manic, because after all those are features of mania. I mean I guess our field did go that way for a while in the mid 90s-mid oughts but I rather think tacking away from "everyone is bipolar" was wise.

I notice you are moving the goal posts a bit, since now you're on to saying it is hallucinations and delusions together. That is much closer than hallucinations+paranoia. The concept I am highlighting isn't necessarily a chronic progressive mental illness - cycloid psychosis is a thing, as is psychotic bipolar I or forced normalization in epilepsy- but it does carry way more information about prognosis/treatment/heritability.

Saying all 'breaks with reality' (which historically often ends up meaning "asserting something the psychiatrist doesn't find plausible) are psychosis is how we ended up with Rosenhan's "being sane in insane places" and the embarrassment of vast overdiagnosis of schizophrenia in the 60s and 70s.

EDIT: I would also push back really hard against the idea that LSD induces psychosis. It is really nothing like any classic psychotix experience, even if it is a heavily altered state of consciousness. Also good luck treating BPD or PTSD primarily with antipsychotics.

2nd EDIT: you're right about delirium, my definition clearly needs revision, because I think that needs to be excluded. I'll have to have a think.

 

[deleted736562]

Something like the definition or criteria I suggested is very much in keeping with the traditional notions of what this term means in descriptive psychopathology. The idea that a smattering of perceptual disturbances and feeling judged constitutes psychosis makes the term almost meaningless. If you use your definition, you are using it as a label that means almost nothing in terms of clinical picture, prognosis, treatment, epidemiology, genetics etc. Why would you want to use a label that?

Having features of an entity does not mean what is in front of you is that entity. Otherwise anyone who doesn't sleep well and is agitated must be manic, because after all those are features of mania. I mean I guess our field did go that way for a while in the mid 90s-mid oughts but I rather think tacking away from "everyone is bipolar" was wise.

I notice you are moving the goal posts a bit, since now you're on to saying it is hallucinations and delusions together. That is much closer than hallucinations+paranoia. The concept I am highlighting isn't necessarily a chronic progressive mental illness - cycloid psychosis is a thing, as is psychotic bipolar I or peri-ictal psychosis in epilepsy- but it does carry way more information about prognosis/treatment/heritability.

Saying all 'breaks with reality' (which historically often ends up meaning "asserting something the psychiatrist doesn't find plausible) are psychosis is how we ended up with Rosenhan's "being sane in insane places" and the embarrassment of vast overdiagnosis of schizophrenia in the 60s and 70s.

EDIT: I would also push back really hard against the idea that LSD induces psychosis. It is really nothing like any classic psychotix experience, even if it is a heavily altered state of consciousness. Also good luck treating BPD or PTSD primarily with antipsychotics.

No, I am not moving the goal post at all. I meant delusions and/or hallucinations.

Much of what you are saying are non-sequitur. I mean, why would I need to treat BPD or PTSD "primarily" with antipsychotics to acknowledge that sometimes they are accompanied by psychotic experiences? Mania is defined as in the DSM; psychosis has no such definition for a reason. How is my definition of psychosis got anything to do with how you define mania? Why would this lead to an "overdiagnosis of schizophrenia"? Schizophrenia has its own set of criteria, including most importantly timeline criteria - as well disorganization, negative sx..etc.

Your assertion that it is meaningless because it has "no genetics, prognosis, treatment, epidemiology..etc" consequences. We still prescribe symptomatically for the most part - someone who is experiencing hallucinations even in something like LBD MAY end up getting seroquel and the evidence is that it helps. Do we really know the relationship between say, transient experiences of AH in otherwise normal individuals and risk for schizophrenia to say there is no genetic relationship? Someone with drug induced psychosis, which may not look like classical psychosis to you, may still end up with antipsychotics to control delusions or hallucinations.

I mean, for a concept to be useful, first of all it needs to have a somewhat of a definition so it can be used reliably between people. And I don't see a surviving definition from your part. I'd also argue that my definition is much closer to the current consensus.

 

[clausewitz2]

No, I am not moving the goal post at all. I meant delusions and/or hallucinations.

Much of what you are saying are non-sequitur. I mean, why would I need to treat BPD or PTSD "primarily" with antipsychotics to acknowledge that sometimes they are accompanied by psychotic experiences? Mania is defined as in the DSM; psychosis has no such definition for a reason. How is my definition of psychosis got anything to do with how you define mania? Why would this lead to an "overdiagnosis of schizophrenia"? Schizophrenia has its own set of criteria, including most importantly timeline criteria - as well disorganization, negative sx..etc.

Your assertion that it is meaningless because it has "no genetics, prognosis, treatment, epidemiology..etc" consequences. We still prescribe symptomatically for the most part - someone who is experiencing hallucinations even in something like LBD MAY end up getting seroquel and the evidence is that it helps. Do we really know the relationship between say, transient experiences of AH in otherwise normal individuals and risk for schizophrenia to say there is no genetic relationship? Someone with drug induced psychosis, which may not look like classical psychosis to you, may still end up with antipsychotics to control delusions or hallucinations.

I mean, for a concept to be useful, first of all it needs to have a somewhat of a definition so it can be used reliably between people. And I don't see a surviving definition from your part. I'd also argue that my definition is much closer to the current consensus.

I'll try to take things one at a time.

If "psychosis" doesn't guide you in choosing treatments, what good is it? What information does calling the hallucinations and/or persecutory thinking of PTSD "a psychotic experience" convey beyond saying "hallucinations and/or persecutory delusions"? Shorthands are great when they extract a useful core out of messy reality but that is not what is happening here.

If we are going to say that DSM definitions are constitutive of reality we are already on track to absurdity but I'll give it another shot. Lumping together any experience that has anything in common with psychosis is directly analogous to lumping together any experience that has anything in common with mania. For most people the later seems obviously absurd, but then think about how many patients you have seen who got told they were bipolar basically because sometimes they don't sleep well and are cranky. Labels end up mattering in practice and end up being very influential in what clinicians do. For example, in this country in the 20th century. psychosis came to be re-defined as "losing contact with reality'" by the psychoanalysts who were not especially interested in diagnosis beyond determining whether they thought someone would be a good psychoanalysis candidate. Once that became standard practice, lo and behold, suddenly vast swathes of the patient population became schizophrenic, like, say, Marsha Linehan.

Making distinctions is also important for guiding our thinking and research going forward. You're right, current US practice in many ways is much closer to your idea of psychosis. Current US practice also treats MDD as a valid category, though, so it is not a great guide to what is true about the world or sensible.

The point really is that you are casting too broad a net. Someone who is depressed can be quite convinced of their badness and the pointlessness of all things in a way that is very resistant to challenge and they often perceive clear negative significance in inocuous stimuli. Are they psychotic?

Someone with contamination OCD might be able to tell you in office they don't believe their fears are well-founded but when very distressed are much more convinced that refraining from rituals will mean their family will die from AIDS and have the experience of seeing contaminated things teeming with visible germs. Are they psychotic?

A person struggling with anorexia is absolutely convinced they are disgustingly fat when they are emaciated by anyone else's standards and systematically mispercieves spatial dimensions of their body even when looking in a mirror. Are they psychotic?

"Giving neuroleptics" = psychotic is a really poor justification given how many people are taking these things because they are depressed or anxious. I agree with you that they treat non-specifically but then their utility can't very well be cited as evidence for the specificity of a concept, can it?

Realistically dictionary-style definitions of anything rarely survive logical scrutiny and a prototype/exemplar model is more consistent with how humans conceive of these things but give me a few days and I will try to come back with operationalized criteria for you.


At the end of the day, what on Earth do you gain from calling so many different phenomena "psychosis"? Why not just describe what is actually happening? What does lumping it all together buy you? Just because the DSM is designed to be usable by undergraduate research assistants and minimally-experienced mid-level clinicians doesn't mean we have to accept its simplifications and elisions as accurate or meaningful!

 

[Mad Jack]

True schizoaffective disorder is rare and it is one of those diagnoses that I always am skeptical of when a patient comes in with it. You should not use it as a catch all, it should be used appropriately for those that meet proper DSM criteria. If a person only has psychotic symptoms in the setting of exacerbations of a mood disorder, your primary maintenance is usually going to be with a mood stabilizer (or treatment of their depression if they have psychotic features with depression) and antipsychotic medication can be avoided during maintenance treatment. If their symptoms are primarily psychotic but they happen to have a depressive or manic episode (which seems to be stressor related in the former and drug related in the latter more often than not) then they should be treated as having a primary psychotic disorder and their maintenance will be primarily antipsychotic medication with mood symptoms being managed as they arise.

Once you give them the schizoaffective label, they become polypharmacy magnets. Giving this diagnosis inappropriately is therefore doing patients a disservice in my opinion, and to just hand wave it away as "oh I give it because it's easy" is irresponsible.

Bipolar disorder is a similar diagnosis that I've got one hell of a bone to pick with, because it seems to get thrown at BPD patients that don't meet criteria in any appreciable way with great frequency, resulting in them being on piles of ineffective abs often metabolically devastating medication.

 

[hamstergang]

At the end of the day, what on Earth do you gain from calling so many different phenomena "psychosis"? Why not just describe what is actually happening? What does lumping it all together buy you?

That's not how language really works. That is, we don't choose what words mean based on the utility of doing so; words mean what they mean because of how they get used. You may not call a hallucination psychosis, but if the rest of is do then that's what psychosis is.

I think where some of the problem is is that you're making a distinction between psychotic features and psychosis. I think those disagreeing are lumping the terms psychotic features and psychosis, while differentiating psychotic disorders.

 

[clausewitz2]

That's not how language really works. That is, we don't choose what words mean based on the utility of doing so; words mean what they mean because of how they get used. You may not call a hallucination psychosis, but if the rest of is do then that's what psychosis is.

I think where some of the problem is is that you're making a distinction between psychotic features and psychosis. I think those disagreeing are lumping the terms psychotic features and psychosis, while differentiating psychotic disorders.

As a former linguist I agree with you about how normal human language works. "Silly" originally meant "holy, beatified, rapturous" in English (cf. German "selig") but over time it has shifted and it is not plausible to go back. I think it's different when we are talking about terms of professional art and technical vocabulary, where we can as a profession specify what we mean by the words we use. For example, physicists mean something very specific when they say "work", and if you try to interpolate a different meaning when reading a physics text you are simply wrong. As such while psychosis is used widely in the way described, I think it's perfectly reasonable to say "no, we should not be using this this way, we should be thinking about it like this." An analogy is the shift in meaning "acid" and "base" have undergone in chemistry in the past couple centuries.

You are right that I am splitting "psychotic features" and "psychosis". The fact that they are getting lumped speaks directly to my point about why we ought to be limiting the referent of "psychosis" to a greater degree.

 

[Mass Effect]

hmm, we'll agree to disagree. "Psychosis" and "psychosis features" are pretty much equivalent in my book and all of these disorders can have psychotic features; for example, I don't know why you'd say psychosis is not a part of delirium. Someone who is seeing visual hallucinations in the hospital and acting on them is psychotic in my book - it may be acute and temporary, but it is psychosis.

I think language is very important, particularly as we are not the only people caring for the patient. If you're evaluating delirium, I'm going to assume it's for consultation to a medical service. Calling the patient psychotic versus using the terminology that the patient is experiencing psychotic symptoms (or perceptual disturbances) in the context of delirium muddies the water for our medicine colleagues and implies the patient him/herself has a psychotic illness versus the fact that psychotic symptoms are a part of delirium. This is why we sometimes get calls about transferring delirious patients to the inpatient psych unit. If I see a delirious patient who is seeing things, I may say they're experiencing auditory hallucinations, but I would not diagnose them as being psychotic.

Going back to the DSM and schizoaffective disorder, this is my main issue with psychiatry. The DSM is great and it really does give you a guideline for not over-pathologizing normal human behavior (i.e. the lady who's been crying over the death of her cat for 2 days being started on an SSRI), but when people get into the weeds on the criteria, I think it does more harm than good. This is the difference in doing a psychiatric interview versus doing a psychiatric evaluation. Evaluate what you think is going on -- small picture AND big picture (borderline with hallucinations doesn't need clozapine) -- and treat accordingly. This is where having an in-depth understanding of psychiatric illness and pathology is so important and what differentiates us from NPs who are treating symptoms.

 

[SourceOfDenial]

EDIT: I would also push back really hard against the idea that LSD induces psychosis. It is really nothing like any classic psychotix experience, even if it is a heavily altered state of consciousness. Also good luck treating BPD or PTSD primarily with antipsychotics.

People who write LSD or psychedelics induce psychosis haven’t taken LSD or psychedelics.

This is what gets me about most of these diagnoses—the criteria and diagnosis is made by people not having the experience. If you look at someone on psychedelics and say they are psychotic, yet know nothing about the internal experience, to me at least it casts a lot of doubt on how one constructs the diagnosis of other psychotic illnesses.

Can’t we all just agree that the DSM is trash and move on?

 

[deleted736562]

I'll try to take things one at a time.

If "psychosis" doesn't guide you in choosing treatments, what good is it? What information does calling the hallucinations and/or persecutory thinking of PTSD "a psychotic experience" convey beyond saying "hallucinations and/or persecutory delusions"? Shorthands are great when they extract a useful core out of messy reality but that is not what is happening here.

If we are going to say that DSM definitions are constitutive of reality we are already on track to absurdity but I'll give it another shot. Lumping together any experience that has anything in common with psychosis is directly analogous to lumping together any experience that has anything in common with mania. For most people the later seems obviously absurd, but then think about how many patients you have seen who got told they were bipolar basically because sometimes they don't sleep well and are cranky. Labels end up mattering in practice and end up being very influential in what clinicians do. For example, in this country in the 20th century. psychosis came to be re-defined as "losing contact with reality'" by the psychoanalysts who were not especially interested in diagnosis beyond determining whether they thought someone would be a good psychoanalysis candidate. Once that became standard practice, lo and behold, suddenly vast swathes of the patient population became schizophrenic, like, say, Marsha Linehan.

Making distinctions is also important for guiding our thinking and research going forward. You're right, current US practice in many ways is much closer to your idea of psychosis. Current US practice also treats MDD as a valid category, though, so it is not a great guide to what is true about the world or sensible.

The point really is that you are casting too broad a net. Someone who is depressed can be quite convinced of their badness and the pointlessness of all things in a way that is very resistant to challenge and they often perceive clear negative significance in inocuous stimuli. Are they psychotic?

Someone with contamination OCD might be able to tell you in office they don't believe their fears are well-founded but when very distressed are much more convinced that refraining from rituals will mean their family will die from AIDS and have the experience of seeing contaminated things teeming with visible germs. Are they psychotic?

A person struggling with anorexia is absolutely convinced they are disgustingly fat when they are emaciated by anyone else's standards and systematically mispercieves spatial dimensions of their body even when looking in a mirror. Are they psychotic?

"Giving neuroleptics" = psychotic is a really poor justification given how many people are taking these things because they are depressed or anxious. I agree with you that they treat non-specifically but then their utility can't very well be cited as evidence for the specificity of a concept, can it?

Realistically dictionary-style definitions of anything rarely survive logical scrutiny and a prototype/exemplar model is more consistent with how humans conceive of these things but give me a few days and I will try to come back with operationalized criteria for you.


At the end of the day, what on Earth do you gain from calling so many different phenomena "psychosis"? Why not just describe what is actually happening? What does lumping it all together buy you? Just because the DSM is designed to be usable by undergraduate research assistants and minimally-experienced mid-level clinicians doesn't mean we have to accept its simplifications and elisions as accurate or meaningful!

The issue with your examples is whether you would call these "delusions" in the first place is controversial. These aren't "fixed false beliefs" by most people's standards. That you are perceiving yourself as fat even though everyone else thinks you're thin isn't really a false belief. Now if you think you weigh 220 lbs while you weigh 100, that;'s different... That's where the hesitancy comes from in calling them psychotic, NOT from their dx per se. On the other hand, no one has qualms calling someone with delusional disorder "psychotic", even though the only major symptom can be delusions.

I also really question again your assertion that the concept as currently defined is useless. There's a reason why delusions and hallucinations tend to cluster together and why both tend to respond to antipsychotics, particularly D2 antagonists, regardless of the disorder they show up in. You mentioned BPD and PTSD... most will tell you you would be justified to use antipsychotics in cases where the AH persist after exhausting more standard forms of treatment. There is also evidence for their utility in treating psychotic symptoms in various other disorders, including dementia and neurological disorders like Parkinson's , LBD and others - which probably would not make it to your definition. No, I am clearly not saying "antipsychotic rx = psychotic"... but you mention that the concept has no useful "epidemiological, diagnosis, treatment"..etc, and I don't think that's in line with current evidence. Mentioning depression and anxiety is quite unfair.... I'm saying they are useful to specifically target delusions and hallucinations, in many disorders and in many forms they can come in.

Now yes, it clearly is a loaded term and its utility is limited and there are places where it probably fails like everything else in psychiatry. But until you come up with a better alternative, I'd stick with the current consensus (see, Psychosis) "... and "cognitive/motor/..etc" will not make it - sorry.

 

[hamstergang]

You are right that I am splitting "psychotic features" and "psychosis". The fact that they are getting lumped speaks directly to my point about why we ought to be limiting the referent of "psychosis" to a greater degree.

Sorry, I was rushing before and could not get the words out all right. what I'm seeing is the three terms psychotic features, psychosis, and psychotic disorders. I would combine the first two as one entity differentiated from the last, while I believe you are combining the latter two and differentiating them from the first. If that's an accurate assessment, I don't know that it would be easy to claim one is clearly superior to the other.

 

[clausewitz2]

People who write LSD or psychedelics induce psychosis haven’t taken LSD or psychedelics.

This is what gets me about most of these diagnoses—the criteria and diagnosis is made by people not having the experience. If you look at someone on psychedelics and say they are psychotic, yet know nothing about the internal experience, to me at least it casts a lot of doubt on how one constructs the diagnosis of other psychotic illnesses.

Can’t we all just agree that the DSM is trash and move on?

So much this. At a minimum, very careful attention to phenomenology (in the philosophical sense, not the "checklist of symptoms" sense) and sensitivity to the intersubjective experience is critical for a legitimate construct in my view. Obviously lived experience is all to the better.

 

[clausewitz2]

Sorry, I was rushing before and could not get the words out all right. what I'm seeing is the three terms psychotic features, psychosis, and psychotic disorders. I would combine the first two as one entity differentiated from the last, while I believe you are combining the latter two and differentiating them from the first. If that's an accurate assessment, I don't know that it would be easy to claim one is clearly superior to the other.

I am a splitter at the end of the day, not a lumper. It would be fine to paint with a broad brush if reducing everything to broad categories had led to amazing pharmacological or therapeutic progress since the 70's. If someone would like to assert this, let me know so I can sit down first as I don't want to fall on the floor laughing.

 

[clausewitz2]

The issue with your examples is whether you would call these "delusions" in the first place is controversial. These aren't "fixed false beliefs" by most people's standards. That you are perceiving yourself as fat even though everyone else thinks you're thin isn't really a false belief. Now if you think you weigh 220 lbs while you weigh 100, that;'s different... That's where the hesitancy comes from in calling them psychotic, NOT from their dx per se. On the other hand, no one has qualms calling someone with delusional disorder "psychotic", even though the only major symptom can be delusions.

I also really question again your assertion that the concept as currently defined is useless. There's a reason why delusions and hallucinations tend to cluster together and why both tend to respond to antipsychotics, particularly D2 antagonists, regardless of the disorder they show up in. You mentioned BPD and PTSD... most will tell you you would be justified to use antipsychotics in cases where the AH persist after exhausting more standard forms of treatment. There is also evidence for their utility in treating psychotic symptoms in various other disorders, including dementia and neurological disorders like Parkinson's , LBD and others - which probably would not make it to your definition. No, I am clearly not saying "antipsychotic rx = psychotic"... but you mention that the concept has no useful "epidemiological, diagnosis, treatment"..etc, and I don't think that's in line with current evidence. Mentioning depression and anxiety is quite unfair.... I'm saying they are useful to specifically target delusions and hallucinations, in many disorders and in many forms they can come in.

Now yes, it clearly is a loaded term and its utility is limited and there are places where it probably fails like everything else in psychiatry. But until you come up with a better alternative, I'd stick with the current consensus (see, Psychosis) "... and "cognitive/motor/..etc" will not make it - sorry.

The philosophy of psychiatry literature has pointed out for a long time that defining delusions as "fixed false beliefs" gets very circular and hard to sustain very quickly. I'd point to Peter McKenna's book on delusions as a good introduction to this problem. Using that definition absolutely ensnares some of the cognitions of depression. "I am worthless and nothing in my life will get any better and I will always feel this way" is, 99% of the time, factually incorrect. Similarly, setting aside the question of whether reality-testing is intact when someone looks like a Holocaust survivor and is convinced they are overweight, people with AN have been demonstrated to have objectively distorted visual percepts. They absolutely fit your criteria for psychosis, which is why they are not good criteria.

I absolutely have qualms about calling everyone with a delusional d/o dx psychotic. They certainly can be but not uniformly.

I would say that neuroleptics generally make thoughts less compelling and reduce motivation and drive in a way that is pretty agnostic as to what sorts of thoughts you are having or what you are motivated to do. Seroquel is not much of a dopamine antagonist at the doses used in the past majority of LBD patients I have ever seen so I don't think you can attribute it to D2 antagonism. See also clozapine, which is absolutely helpful where nothing else is for psychosis in some cases but also is absolutely not a good D2 antagonist.

I think if you are treating the BPD experiences of hearing your name being called or shadowy figures out of the corner of your eye or even some of the more extravagant ways derealization is sometimes described with neuroleptics on a regular basis it is a problem.

I think psychosis used in the incredibly watered down sense that is common nowadays has the dual disadvantages of not meaning very much and also still carrying the implication of severe mental illness and all the baggage that entails.

I still have not seen you say what benefit there is to calling hallucinations + delusions alone "psychosis". What is gained beyond noting the symptoms themselves? What else does it but you? I can't see a point to it. It's like if we started using "borderline" to just mean someone who is moody, self-harms, and thinks about suicide a lot - oh, wait, d*mn, we already do that. I am sure that doesn't have any consequences.

 

[deleted736562]

The philosophy of psychiatry literature has pointed out for a long time that defining delusions as "fixed false beliefs" gets very circular and hard to sustain very quickly. I'd point to Peter McKenna's book on delusions as a good introduction to this problem. Using that definition absolutely ensnares some of the cognitions of depression. "I am worthless and nothing in my life will get any better and I will always feel this way" is, 99% of the time, factually incorrect. Similarly, setting aside the question of whether reality-testing is intact when someone looks like a Holocaust survivor and is convinced they are overweight, people with AN have been demonstrated to have objectively distorted visual percepts. They absolutely fit your criteria for psychosis, which is why they are not good criteria.

I absolutely have qualms about calling everyone with a delusional d/o dx psychotic. They certainly can be but not uniformly.

I would say that neuroleptics generally make thoughts less compelling and reduce motivation and drive in a way that is pretty agnostic as to what sorts of thoughts you are having or what you are motivated to do. Seroquel is not much of a dopamine antagonist at the doses used in the past majority of LBD patients I have ever seen so I don't think you can attribute it to D2 antagonism. See also clozapine, which is absolutely helpful where nothing else is for psychosis in some cases but also is absolutely not a good D2 antagonist.

I think if you are treating the BPD experiences of hearing your name being called or shadowy figures out of the corner of your eye or even some of the more extravagant ways derealization is sometimes described with neuroleptics on a regular basis it is a problem.

I think psychosis used in the incredibly watered down sense that is common nowadays has the dual disadvantages of not meaning very much and also still carrying the implication of severe mental illness and all the baggage that entails.

I still have not seen you say what benefit there is to calling hallucinations + delusions alone "psychosis". What is gained beyond noting the symptoms themselves? What else does it but you? I can't see a point to it. It's like if we started using "borderline" to just mean someone who is moody, self-harms, and thinks about suicide a lot - oh, wait, d*mn, we already do that. I am sure that doesn't have any consequences.

We're kind of starting to run in circles here, so we will just have to agree to disagree. It's easy to point out flaws in the concepts of delusion and psychosis as well, since as acknowledged from the start they are loaded and imprecise - not a particular achievement I'd say - but until you come up with a reasonable alternative in x days that can actually be useful to the clinical/scientific community, I am sticking with the current consensus with all of its shortcomings (your examples still fail to make the threshold of delusions and hallucinations as commonly defined and diagnosed, so they cannot fit with "my conception of psychosis"). Muddling clinical language with undefined terms will certainly not be an improvement. Re: usefulness, I actually did answer this, but you're free in thinking this doesn't answer your question.

Just FTR: never claimed that antipsychotics only work on psychotic sx through D2 antagonism or that psychotic experiences in BPD/PTSD should be treated first line or routinely with antipsychotics.

 

[clausewitz2]

We're kind of starting to run in circles here, so we will just have to agree to disagree. It's easy to point out flaws in the concepts of delusion and psychosis as well, since as acknowledged from the start they are loaded and imprecise - not a particular achievement I'd say - but until you come up with a reasonable alternative in x days that can actually be useful to the clinical/scientific community, I am sticking with the current consensus with all of its shortcomings (your examples still fail to make the threshold of delusions and hallucinations as commonly defined and diagnosed, so they cannot fit with "my conception of psychosis"). Re: usefulness, I actually did answer this, but you're free in thinking this doesn't answer your question.

Just FTR: never claimed that antipsychotics only work on psychotic sx through D2 antagonism or that psychotic experiences in BPD/PTSD should be treated first line or routinely with antipsychotics.

You're right, you just that D2 antagonism is especially effective in treating hallucinations and delusions and that therefore your concept of psychosis was justified. Your words: "There's a reason why delusions and hallucinations tend to cluster together and why both tend to respond to antipsychotics, particularly D2 antagonists, regardless of the disorder they show up in"

Maybe I'm just too thick to understand: you talked about treating hallucinations and delusions the same regardless of context, which...disagree, but fine, comprehensible. But what does labelling it as psychosis, which inherently suggests affinity for psychotic disorders, accomplish, precisely?

You're right in that the false fixed beliefs and perceptual distortions of anorexia nervosa and severe depression are not commonly called delusions and hallucinations, but that should suggest to you that this means that there is something wrong with the definitions of these terms, since these phenomena are being excluded on the basis of judgments beyond the formal definitions. For what it's worth, for a long time people did think about AN as a kind of psychosis.

It's almost as if the superficial combination of MSE buzzwords doesn't give rise to coherent constructs.

If the concept is incoherent or pointless, let's not use it.

 

[SourceOfDenial]

If a delusion is a fixed false belief and is treated by antipsychotics, is it a delusion? Seems like if treated it’s no longer a fixed false belief.

Delusions are not a medical construct, but a social one.

 

[Liquid8]

I think if you are treating the BPD experiences of hearing your name being called or shadowy figures out of the corner of your eye or even some of the more extravagant ways derealization is sometimes described with neuroleptics on a regular basis it is a problem.

The problem here is that seeing "shadowy figures" is actually a misperception of an external stimulus or an illusion (i.e. not psychosis), but our borderline patients, their families and even our non-psychiatrist colleagues will use less precise descriptors, apply the terminology incorrectly and draw different conclusions on how said patients should be managed. The same BPD patients can also present with true hallucinations or any variety of reasons - as the experts in phenomenology, we ought to be able to tease all that stuff out. For this reason I also find the broader term of "psychosis" to not have much in the way of clinical utility, as a I ultimately have to do more digging around to work out what I'm dealing with.

In some ways the last sentence also applies to Schizoaffective disorder. Working mainly in private, it's not really a diagnosis I see much of these days although in my public training which was done under DSM IV-TR, SAD was really common. Looking back I think the time pressures and acute nature of presentations led to this diagnosis being used as a catchall for anyone who presented with any history of psychotic and affective symptoms, and establishing an accurate timeline was far more difficult given the setting.

 

[deleted736562]

You're right, you just that D2 antagonism is especially effective in treating hallucinations and delusions and that therefore your concept of psychosis was justified. Your words: "There's a reason why delusions and hallucinations tend to cluster together and why both tend to respond to antipsychotics, particularly D2 antagonists, regardless of the disorder they show up in"

Maybe I'm just too thick to understand: you talked about treating hallucinations and delusions the same regardless of context, which...disagree, but fine, comprehensible. But what does labelling it as psychosis, which inherently suggests affinity for psychotic disorders, accomplish, precisely?

You're right in that the false fixed beliefs and perceptual distortions of anorexia nervosa and severe depression are not commonly called delusions and hallucinations, but that should suggest to you that this means that there is something wrong with the definitions of these terms, since these phenomena are being excluded on the basis of judgments beyond the formal definitions. For what it's worth, for a long time people did think about AN as a kind of psychosis.

It's almost as if the superficial combination of MSE buzzwords doesn't give rise to coherent constructs.

If the concept is incoherent or pointless, let's not use it.

lol, if you want to ditch the concept, be my guest - though my guess is that you will have a hard time implementing such a change. I believe the whole premise of the conversation was that there is a different, more correct definition/use of the term.

For now, the term will continue to mean primarily a disconnect from reality through delusions and hallucinations, and all the baggage that entails.

 

[clausewitz2]

lol, if you want to ditch the concept, be my guest - though my guess is that you will have a hard time implementing such a change. I believe the whole premise of the conversation was that you had a different, more correct definition/use of the term.

For now, the term will continue to mean primarily a disconnect from reality through delusions and hallucinations, and all the baggage that entails.

I am talking about discarding the idea that "psychosis" just means delusions and hallucinations. If that is what the term is going to mean than yes, discard it.

I am still waiting to hear about why a special term for delusions+hallucinations means anything and is useful for any purpose. Given your definition, if you never used the term again, what would change?

I am also waiting to hear a reason why, say, AN is not described as psychosis beyond "well people don't call it that". I happen to agree that it is not, but it 100% had delusions and hallucinations and a failure of reality testing. Circumscribed, sure, but that is also not at all uncommon for delusional d/o folks, who you assert are all psychotic.

I think reasonable people can disagree about what a meaningful idea of psychosis is. Pretty sure I said operationalized DSM-style criteria are not a way forward on this and so I don't have one at hand. I would suggest it requires some disturbance of belief fixation, a jumping-to-conclusions/premature epistemic closure cognitive style, disruption of ipseity/sense of self, experiences of thought or action alienation, and a general disruption of reciprocal intersubjectivity. The phenomenological psychiatry literature is pretty rich when it comes to ideas about this, I can't do it justice briefly. I will point out the idea of Praecoxgefuehl i.e. "praecox feeling" that an experienced clinician can develop based on how they are able (or unable) to relate to patients in a clinical encounter. The idea goes back to the 40s with Rumke, but there is a small modern English-language literature, a bit more in German, providing some empirical evidence for the accuracy of this.

Consider whether the probably true contention that 'most psychiatrists are fine with just saying it's delusions and hallucinations' should make you despair about the state of the field.

 

[deleted736562]

I happen to agree that it is not, but it 100% had delusions and hallucinations and a failure of reality testing.

Based on the 5/6 examples you provided, none of which comprise true delusions or hallucinations, certainly part of the disagreement is that you are misunderstanding those concepts and projecting that confusion onto the concept of psychosis. Your retort "well delusions is also not a good concept" - fine, but unless you come up with another proper alternative here, we might as well stop practicing psychiatry all together.

I would suggest it requires some disturbance of belief fixation, a jumping-to-conclusions/premature epistemic closure cognitive style, disruption of ipseity/sense of self, experiences of thought or action alienation, and a general disruption of reciprocal intersubjectivity. The phenomenological psychiatry literature is pretty rich when it comes to ideas about this, I can't do it justice briefly. I will point out the idea of Praecoxgefuehl i.e. "praecox feeling" that an experienced clinician can develop based on how they are able (or unable) to relate to patients in a clinical encounter. The idea goes back to the 40s with Rumke, but there is a small modern English-language literature, a bit more in German, providing some empirical evidence for the accuracy of this.

OK, good luck trying to implement any sort of objective standards with that one that can actually be useful in clinical practice or in research to move the field forward.

----

In the meantime, as long as we don't have a proper understanding of all the nuances of the term and how it manifests similarly and/or differently in different disorders, it will remain an umbrella term for better or for worse. And this isn't even my opinion - cause as I pointed out, this is the actual definition of the term and how it used currently.

 

[Armadillos]

Wow this conversation has gotten over my head, what sort of practice setting are you all in where thinking about this language is relevant to your practice?

I work mostly with psychotic folks and what seems a lot more relevant is figuring out what pharmacy best balances distance from patient’s mom’s residence to their cash price of zyprexa. (Hint, it is NEVER cvs)

 

[clausewitz2]

Wow this conversation has gotten over my head, what sort of practice setting are you all in where thinking about this language is relevant to your practice?

I work mostly with psychotic folks and what seems a lot more relevant is figuring out what pharmacy best balances distance from patient’s mom’s residence to their cash price of zyprexa. (Hint, it is NEVER cvs)

I mean, once you have the clarity of knowing what you are working with, focusing on practicalities makes all the sense in the world.


..also I have the luxury of being in a town in a state that expanded Medicaid where pretty much every CMHC has a pharmacy in the building. Also, probably more ACT teams than strictly necessary, so people with SMI typically don't have a problem accessing meds. Taking them, however...

 

[clausewitz2]

Based on the 5/6 examples you provided, none of which comprise true delusions or hallucinations, certainly part of the disagreement is that you are misunderstanding those concepts and projecting that confusion onto the concept of psychosis. Your retort "well delusions is also not a good concept" - fine, but unless you come up with another proper alternative here, we might as well stop practicing psychiatry all together.



OK, good luck trying to implement any sort of objective standards with that one that can actually be useful in clinical practice or in research to move the field forward.

----

In the meantime, as long as we don't have a proper understanding of all the nuances of the term and how it manifests similarly and/or differently in different disorders, it will remain an umbrella term for better or for worse. And this isn't even my opinion - cause as I pointed out, this is the actual definition of the term and how it used currently.

You defined delusions as "fixed false beliefs" and I said that definition is not really tenable. I gave examples of why the definition is a problem in practical terms. Your response is that no one calls those things delusions because... reasons. I don't think the misunderstanding is mine. Delusions can be a useful concept, it's just that a glib catch phrase doesn't really cut the mustard, just like defining psychosis with two buzzwords is pointless.

Again, what is the point of this umbrella term? What does it add, exactly, with the impoverished semantic content you are defending? I keep asking, you keep not saying.

You keep saying it is used this way by many people. That is true AND I think this is not a good or helpful thing. You may think it's not your opinion but It -becomes- your opinion when you say that that's the way it is, no point in arguing. I will note that at least one other poster in this thread has agreed that they don't find this reduced sense of psychosis very helpful, so this is not just me shouting in the wilderness.

You are weaving back and forth between saying 'psychosis' is just a formalism for "delusions + hallucinations'" and then talking as if it refers to some real underlying phenomenon manifesting in different ways in different disorders. Which is it?

Research is going to be far better served by increasingly fine-grained distinctions then by increasingly vague and meaningless labels that apply equally well to very disparate phenomena. Psychiatric genetics has abandoned the idea of progress by finding associations with DSM categories because there is almost nothing to show for decades of this approach. Being very careful about describing patient's actual experience to make fine distinctions doesn't guarantee progress but I wager it is far more likely to be fruitful in the long run. This I don't think you can do this in a strictly objective way, if by objective you mean reducible strictly to acontextual behaviors removed from learning history and a checklist that a research assistant with zero clinical experience can interpret just as well as anyone else.

Of course it means talking to patients a lot and trying to inhabit their mental worlds more, and who has time for that, ammirite?

(J/k I think experienced and thoughtful clinicians actually do this even if they are not engaging with the conceptual arguments above, but I think they also are unlikely to think anyone who has had a fixed false belief and perceived a stimulus not present in consensus reality was automatically psychotic)

 

[deleted736562]

You defined delusions as "fixed false beliefs" and I said that definition is not really tenable. I gave examples of why the definition is a problem in practical terms. Your response is that no one calls those things delusions because... reasons. I don't think the misunderstanding is mine. Delusions can be a useful concept, it's just that a glib catch phrase doesn't really cut the mustard, just like defining psychosis with two buzzwords is pointless.

Again, what is the point of this umbrella term? What does it add, exactly, with the impoverished semantic content you are defending? I keep asking, you keep not saying.

You keep saying it is used this way by many people. That is true AND I think this is not a good or helpful thing. You may think it's not your opinion but It -becomes- your opinion when you say that that's the way it is, no point in arguing. I will note that at least one other poster in this thread has agreed that they don't find this reduced sense of psychosis very helpful, so this is not just me shouting in the wilderness.

You are weaving back and forth between saying 'psychosis' is just a formalism for "delusions + hallucinations'" and then talking as if it refers to some real underlying phenomenon manifesting in different ways in different disorders. Which is it?

Research is going to be far better served by increasingly fine-grained distinctions then by increasingly vague and meaningless labels that apply equally well to very disparate phenomena. Psychiatric genetics has abandoned the idea of progress by finding associations with DSM categories because there is almost nothing to show for decades of this approach. Being very careful about describing patient's actual experience to make fine distinctions doesn't guarantee progress but I wager it is far more likely to be fruitful in the long run. This I don't think you can do this in a strictly objective way, if by objective you mean reducible strictly to acontextual behaviors removed from learning history and a checklist that a research assistant with zero clinical experience can interpret just as well as anyone else.

Of course it means talking to patients a lot and trying to inhabit their mental worlds more, and who has time for that, ammirite?

(J/k I think experienced and thoughtful clinicians actually do this even if they are not engaging with the conceptual arguments above, but I think they also are unlikely to think anyone who has had a fixed false belief and perceived a stimulus not present in consensus reality was automatically psychotic)

Actually those examples you made were to prove that there are instances of delusions that don't qualify as psychosis. The reality is that none of your examples are delusions. I do think there's a real misunderstanding here of what a delusion or a hallucination is.
I only brought up "fixed false belief" just to show that at least one of your examples is clearly false. I think that's been a major confounding part in the whole conversation. As another poster pointed out, another confounding factor was limping psychosis with psychotic disorder. That's fine.

Now I'm really tired of this and I believe most people who have checked this thread are. I will hopefully end it on my part by saying that we actually agree that the term, as commonly defined, has LIMITED use. Perhaps you have a different understanding of it, and I thank you for explaining it.

 

[Armadillos]

I mean, once you have the clarity of knowing what you are working with, focusing on practicalities makes all the sense in the world.


..also I have the luxury of being in a town in a state that expanded Medicaid where pretty much every CMHC has a pharmacy in the building. Also, probably more ACT teams than strictly necessary, so people with SMI typically don't have a problem accessing meds. Taking them, however...

That sounds amazing, maybe there is hope for my state!

 

[FatherPsychiatry]

As a phenomenology fan, and integration of multiple disciplines beyond medicine into our field, this thread has been a Christmas gift for me. Great discussion all around. It’s why I love psychiatry so much. And the lifestyle of course.