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Temitope Adetunji
A psychiatrist at the Neuropsychiatric Hospital, Aro, Abeokuta, Dr. Adebusola Adegbola Adefeso, discusses the causes, symptoms, treatment options and misconceptions about psychosis, commonly known as madness, in this interview with TEMITOPE ADETUNJI
How best can psychosis be described?
The word psychosis derives its root from the Greek origin ‘psyche’ for mind/soul and oasis for abnormal condition or derangement.
Pychosis refers to an abnormal condition of the mind and is a generic psychiatric term for a mental state often described as involving a loss of contact with reality.
In lay terms, it simply means that an individual’s words, feelings, and/or behaviour is not in tandem with reality. It is a psychological manifestation of brain disease.
What causes psychosis?
There are several causes of psychosis and it can occur in different contexts. It can be fleeting or lasting for a few days or persist for several weeks or months. It can occur following bereavement, severe sleep deprivation, reaction to prescribed medications, caffeine intoxication, extremely stressful event, and chronic use of psychoactive substances, such as alcohol, marijuana, codeine, cocaine, etc.
An imbalance of neurotransmitters in the brain, especially dopamine, can also be inherited from the family. Viral infections during pregnancy, complications during delivery, head injury, traumatic events, etc, can also lead to psychosis.
Is psychosis a serious mental illness?
Absolutely. In the past, mental illnesses were broadly categorised into psychosis and neurosis, with psychosis being the severe case of mental illness due to the loss of touch with reality and inability to function as before.
What are the symptoms of psychosis?
The core symptoms of psychosis are hallucinations, delusions, disorganised thoughts and disorganised behaviour. In lay terms, friends and family can suspect that all is not well when an individual starts doing exhibiting symptoms like hearing voices or sounds not heard by others; seeing things not seen by others; being unduly suspicious; saying they are being monitored or being referred to in conversation by others with no proof to support the claim or arriving at that conclusion illogically.
Other signs may come in form of a sudden drop in schoolwork or job performance; the person is withdrawing from friends and loved ones; they lose interest in personal grooming; they talk out of context in conversations, etc.
Is psychosis peculiar to people within a certain age bracket?
It can occur in all ages but is rarely seen in children younger than 15.
Is there an explanation for why children under age 15 years are less susceptible to psychosis?
Psychosis is rare in children below 15 compared to adults due to a number of reasons. Some components of brain development need to be present before one can identify some symptoms of psychosis. They may not easily admit to unusual experiences such as hearing or seeing things that are not there. They can also be misdiagnosed with pervasive developmental disorders such as autism. Early warning signs of psychosis called prodrome can be ignored or labelled normal childhood behavior, hence leading to a presentation at an older age because of the persistence of the abnormal behaviour.
A high index of suspicion is necessary if there is a family member with mental illness, or if there are problems during pregnancy, delivery, or development of the child.
How is psychosis different from Down Syndrome which is seen mostly in children?
Down syndrome is a genetic condition that occurs when there is an extra copy of a specific chromosome – chromosome 21. The extra chromosome 21 leads to physical features and developmental challenges. Down Syndrome, unlike psychosis, can be identified at birth. Children with Down Syndrome can, however, have some psychotic symptoms as they grow older.
What are the complications of psychosis?
It can lead to comorbidities such as substance abuse, depression, general medical condition, etc.
The risk of death is increased by 1.6-fold.
It can lead to suicide – about 4-10 per cent of patients die by suicide from schizophrenia, which is a major psychotic illness.
There is also stigma, loss of job, downward drift on the social ladder; risk of being unmarried; homelessness, etc.
How can the condition be prevented?
Staying off psychoactive substances and unprescribed medications in pregnancy; prompt treatment when a pregnant woman is ill; having antenatal care and delivery in a reputable hospital; ensuring proper care of childhood illnesses; raising children in a conducive and supportive family environment.
Avoidance of use of psychoactive substances in adolescence and adulthood; prompt therapy for traumatic experiences; healthy eating and exercise.
Is psychosis treatable?
Psychosis is usually treated under a big umbrella called biopsychosocial. The psychotic symptoms are treated with drugs called antipsychotics. The psychological and social factors that predisposed or precipitated the illness will also be addressed. However, this is usually individualised because it differs from one person to the other.
What is the prevalence of pychosis in Nigeria?
The prevalence of psychosis in Nigeria is 2.1 per cent according to a study done by Oye Gureje.
How is schizophrenia different from psychosis?
Psychosis is a symptom that refers to a loss of touch with reality. Schizophrenia is a mental health condition with many symptoms, and psychosis can be one of them. People living with schizophrenia have psychotic symptoms in addition to other symptoms like negative symptoms, cognitive symptoms, etc.
Is schizophrenia worse than psychosis?
In a way, yes. As earlier mentioned, there are different causes of psychosis. If it’s due to a medical illness or substance use, the psychosis clears off after the underlying cause has been treated.
Schizophrenia, on the other hand, is a chronic illness that sometimes requires lifelong treatment.
What triggers psychosis?
In someone already predisposed to having psychosis, things like stressful life events, substance use, medical illness, and head injury can trigger it.
When does psychosis become schizophrenia?
Schizophrenia is a type of psychotic illness. Psychosis does not necessarily lead to schizophrenia. But psychotic symptoms persist for a month in the absence of an underlying medical cause, it’s often termed schizophrenia.
What are the types of psychosis?
A brief psychotic disorder occurs in response to a stressful life event. It’s called brief because the person recovers in less than four weeks.
The substance-induced psychotic disorder occurs following the use of psychoactive substances like alcohol, marijuana, methamphetamine, codeine, etc.
Schizophrenia is a chronic psychotic disorder that affects how people think, feel and behave.
Schizoaffective Disorder is a combination of psychotic symptoms and mood symptoms such as feeling sad, having low energy, loss of interest in previously pleasurable activities, undue irritability, over-generosity, high energy, over-activity, an exaggerated sense of self-worth, etc.
A delusional disorder involves believing firmly in things that aren’t real, even when presented with contrary evidence. Psychosis can also be seen in mood problems like depression or mania.
Does psychosis damage the brain?
No. It’s the other way around. An insult to the brain can result in psychosis.
Can anxiety cause psychosis?
Yes, in severe cases of anxiety. But it usually occurs during an episode of anxiety. If it occurs in the absence of other anxiety symptoms, a diagnosis of a psychotic disorder will be considered.
What happens if psychosis is not treated?
Depending on the cause, it can resolve on its own after some time. Often times though it can progressively worsen.
Is psychosis part of a nervous breakdown?
Not necessarily. A nervous breakdown is a generalised term used to describe a situation where someone is going through a challenging time that they are unable with.
Can one go back to normal after psychosis?
Absolutely. Most people do well after treatment. It’s just that some might be on medication for a long time.
In Africa, it is believed that psychosis, which is commonly called madness, has a spiritual undertone or causes. What can you say about that as a psychiatrist?
You can take a man from culture but it is difficult to take a culture from a man. In Africa, affliction from the witches, demonic attacks, and offence against the gods and ancestors are believed to be capable of causing ill health, not just mental illness. But we know that is not true as the prevalence of psychosis is the same in the general population throughout the world without much difference across various races, religions, and cultures. Scientific causes are being more believed with increasing westernisation and treatment outcomes.
Africans believe that a person can come down with psychosis or run mad as a result of Karma or as a consequence of an evil they have done. What is your view on this belief?
Culture has a significant impact on how people perceive the cause and cope with everyday problems and adversities, including mental illnesses. It is not surprising that Africans have this belief because it is inherent in our culture. As we embrace determination and orthodox treatment for psychosis, our belief is shifting towards other viable explanations. If we can ask ourselves how using a pill can successfully treat something caused by karma or evil, then we can consider that it’s probably not due to karma.
What are some of the most prominent misconceptions you’ve observed in the public space among laymen about psychosis?
That psychosis can be passed from one person to the other through contact; that psychosis is untreatable medically; that psychosis is afflicted by trado-spiritual causes and can only be treated through native or spiritual means.
I have also heard people say that persons suffering from psychosis are dangerous and less competent to handle their own affairs and that one should not marry into a family with someone who has psychosis.
I think the movie industry is also fuelling these myths with wrong interpretations and presentations of mental illness in movies. We really need to do better in this regard.
What immediate steps should the family take if a member of the family begins to exhibit signs of psychosis?
Take the individual to the hospital. Even if it is a general hospital; the person will be reviewed and treated appropriately.
Nigerians commonly take patients with psychosis to traditional healing homes. Will you say this is right?
Native healing practice is the most popular form of mental health care in Africa. The native healers are patronised by Africans, irrespective of their socio-cultural status. People seek traditional healing homes because they believe that is the cause and also because the stigma associated with mental illness is magnanimous.
The problem with traditional treatment is that some of the herbs used are not standardised and their side effects may be toxic.
The approach or treatment method is often dehumanising and inhumane, with the use of shackles, ropes, chains, and whips, sometimes soaked in the medicinal concoction. These methods are specially used for violent patients. There is an expression in Yoruba that says: “Egba ni nko were l’ogbon,” which means ‘We use whips to chastise a madman’.
Some traditionalists also add medications to the herbs they give their patients and we have also seen cases where drugs are added to the holy water given to people in churches. Most of the time, medical treatment is sought after failed traditional and spiritual attempts.
Madmen are often seen roaming about the streets and sleeping under bridges, etc. Does Nigeria have an adequate number of psychiatrists and equipment to treat persons suffering from psychosis?
No! In Nigeria today, the ratio of psychiatrists to the general population is one psychiatrist to one million people. The treatment gap is huge.
What kind of improvement will you advocate based on your experience in the field?
Mental health services work best when integrated into “usual” health care services at all levels (primary, secondary, and tertiary) instead of stand-alone facilities, especially because of the stigma associated with going to stand-alone facilities.
Mental health services provided within the health sector should be associated with “sister services” provided in other sectors, such as education, social services, justice, housing. Mental health services should be available in the communities in which people live, work and receive other services.
People with mental disorders should not be discriminated against on the basis of their mental illnesses. People with mental disorders should receive the same quality and standards of care as other people receive. There should be mental health awareness and education to improve public perception and reduce stigma. There should be a collaboration with community leaders and trado-spiritual healers for immediate medical referrals.
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