How is madness different from psychosis

Psychiatry, Psychosomatics & Psychotherapy

Psychoses - clinical picture

The clinical picture of psychoses is very diverse. However, there are some symptoms that occur frequently: Disturbances of thinking and perception are the leading ones. Delusions and hallucinations (mostly acoustic, but also smell, taste, tactile and visual (facial) hallucinations) are particularly characteristic. Symptoms of delusion often take the form of paranoia or relationship delusions, in which the person concerned incorrectly relates perceptions to himself. Some people affected have the impression that the environment is no longer real or that they are not the person they appear to be themselves, and that their own thoughts can also be perceived or influenced by others (so-called ego disturbances). The thought disorders often show up in the form of problems in the formal thought process, which may appear as a lack of concentration or confusion. Mood swings often accompany the psychotic symptoms.

In addition, there are often limitations in performance and mood disorders such as depression and anxiety. However, limitations in performance are also caused by disorders of the drive, in advanced stages or in the case of severe disease processes also by so-called cognitive disorders, i.e. disorders of attention or memory.

While in a primary psychosis mainly psychotic changes such as delusions or hallucinations are in the foreground, in secondary psychoses states of confusion (disorientation), disturbances of consciousness and memory disturbances often occur.

In contrast to the secondary psychoses, the primary psychoses cannot be physically justified. They are divided into:

  • Schizophrenic psychosis with 5 subgroups. Here, formal and content-related thought disorders and perception disorders are in the foreground. (More information on this in the article "Schizophrenia")
  • Schizoaffective psychosis - This term is used for forms of psychosis in which symptoms of schizophrenic (delusion, hallucinations) and affective psychosis (depressive, manic states) mix or occur almost simultaneously. They neither meet the criteria for schizophrenia nor for a depressive or manic episode.
  • Schizotypic disorder - a form of psychotic disorders with unusual perceptual experiences and thought disorders, which, however, do not reach the severity and severity of schizophrenia. The disorder is characterized by abnormalities in thinking and mood that appear schizophrenic, although clear schizophrenic symptoms have never emerged. Possible are: a cold affect, anhedonia, tendency towards social withdrawal, paranoid ideas (no actual delusions), compulsive brooding, thought and perception disorders, occasional episodes with illusions, acoustic or other hallucinations and delusional ideas, usually without external cause. There is no clear beginning for the disorder.
  • Persistent delusional disorders - here a long-lasting delusion is the decisive clinical characteristic. Affected people develop a single delusional idea or several related delusions.
  • Acute transient psychotic disorders - Characteristic are an acute onset within two weeks and rapidly changing symptoms, in which, in addition to typical schizophrenic symptoms (delusions, hallucinations and other perceptual disorders), severe disturbances of normal behavior occur. The duration of the illness is a maximum of three months.
  • Induced delusional disorders - a rare form of disease in which the delusions of one person are transmitted (induced) to a close, otherwise healthy person. Both people are usually in a close emotional relationship. Occasionally, the disorder affects more than two people (e.g. parents and children)
  • Affective psychoses - This mainly affects mood, motivation and drive (psychotic depression, mania, bipolar diseases.

In primary psychoses, the first clinical symptoms (prodromal symptoms) usually appear months and years before an acute flare-up. However, they are unspecific and are usually not associated with early symptoms of psychosis, either by those affected or by the relatives of those affected. Those affected suffer from a lack of drive, sleep and concentration disorders. Some have been depressed for months. You are tense, at times nervous, or have trouble concentrating on tasks. Those affected often withdraw from their social environment, which can lead to problems in training or at work. If such early symptoms occur, a medical diagnosis should be carried out at an early stage.

A secondary psychosis is also known as a physically justifiable psychosis, symptomatic psychosis or organic psychosis. Secondary psychoses can be acute or chronically progressive. Acute secondary psychoses are usually reversible if the underlying cause / illness is identified and treated in good time; they can also improve spontaneously. Even with chronic psychoses, improvements are possible with adequate treatment.

Acute organic psychosis
Acute organic psychosis occurs suddenly and is accompanied by fluctuating disorders of cognition, psychomotor and affect. Forms with disorientation and a change in consciousness (e.g. delirium, twilight state) and expressions without a change in consciousness are possible. Acute organic psychoses are usually reversible, i.e. the various signs of illness usually recede quickly with appropriate treatment of the underlying disease.

This is one form of acute organic psychosis brain-local psychosyndrome, which is associated with impaired consciousness, memory disorders, disorientation, impaired self-awareness, delusions and hallucinations. The causes are diverse changes in the central nervous system that can be traced back to brain tumors, traumatic brain injury, early childhood brain damage, poisoning, infections (e.g. inflammation of the brain / meninges), epilepsy or circulatory disorders of the brain. Another form of acute organic psychosis is that Delirium (Delirium). This is understood to mean a state of fluctuating clouding of consciousness, which can set in with a seizure and can be accompanied by the symptoms of disorientation, memory disorders, hallucinations, anxious restlessness, pronounced shaking (tremor). Delirium can occur, for example, in the context of a high fever, poisoning, infections or lack of fluids (dehydration). Delirium can also occur with alcohol dependence during withdrawal or during an episode of very severe abuse. Delirium requires immediate emergency care. Furthermore, the Twilight state differentiated as a form of acute organic psychosis that occurs in the context of traumatic brain injuries, poisoning or epilepsy. A special case of acute organic psychosis is the so-called Continuity syndrome, that occurs for a limited time after surgical interventions. Symptoms such as forgetfulness, slow reactions or dizziness are at the center of the disorder. Clouding of consciousness, hallucinations and delusions, on the other hand, are only weakly pronounced or absent.

Chronic organic psychosis
Chronic organically caused psychotic disorders are the result of a chronic brain disease. They are characterized by an (acquired) impairment of memory, a limitation of cognitive abilities (especially abstract thinking is affected, as is the ability to concentrate and the ability to judge) as well as changes in psychomotor skills, drive, affect and the formation of social relationships.
These include, for example, diffuse or local psychosis syndromes that can occur in chronic diseases of the brain or in general diseases (e.g. severe metabolic disorders). Furthermore, chronic organic psychoses can also occur as a result of substance use (e.g. alcohol dependence). Finally, there is early childhood exogenous psychosyndrome, which is early childhood brain damage.

Technical support: Prof. Dr. med. Wolfgang Gaebel, Priv.-Doz. Dr. med. Jürgen Zielasek, Düsseldorf (DGPPN) and Prof. Dr. med. Anita Riecher-Rössler, Basel (SGPP)