Understanding Psychosis Issues, Treatments, and

Challenges for Sufferers and Their Families

Visit the link below to download the full version of this book:

https://medipdf.com/product/understanding-psychosis-issues-treatments-and-challe
nges-for-sufferers-and-their-families/

Click Download Now

 Understanding Psychosis
Issues and Challenges for Sufferers, Families, and
Friends

Donald Capps

ROWMAN & LITTLEFIELD

Lanham • Boulder • New York • Toronto • Plymouth, UK
Published by Rowman & Littlefield
4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706
www.rowman.com

Estover Road, Plymouth PL6 7PY, United Kingdom

Copyright © 2010 by Rowman & Littlefield Publishers, Inc.

First paperback edition 2014

All rights reserved. No part of this book may be reproduced in any form or by any electronic or
mechanical means, including information storage and retrieval systems, without written permission
from the publisher, except by a reviewer who may quote passages in a review.

British Library Cataloguing in Publication Information Available

Library of Congress Cataloging-in-Publication Data

The hardback edition of this book was previously cataloged by the Library of Congress as follows:
Capps, Donald.
Understanding psychosis : issues and challenges for sufferers, families, and friends / Donald Capps.
p. cm.
Includes bibliographical references and index.
1. Psychoses—Popular works. I. Title.
RC512.C355 2010
616.89—dc22
2010018471

ISBN: 978-1-4422-0592-5 (cloth : alk. paper)

ISBN: 978-1-4422-0593-2 (pbk. : alk. paper)
ISBN: 978-1-4422-0594-9 (electronic)

™ The paper used in this publication meets the minimum requirements of American National
Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI/NISO
Z39.48-1992.

Printed in the United States of America

 Contents

Contents
Acknowledgments
Introduction
Chapter 1: The Epidemic of Psychotic Illness
Chapter 2: The Deinstitutionalization Era: Its Personal and Social Impact
Chapter 3: How Family Members Cope with Serious Mental Illness
Chapter 4: Rehabilitation Strategies for the Seriously Mentally Ill
Chapter 5: Prevention Strategies for Persons at Risk
Chapter 6: The Emergence of Psychotic Illness: The Role of Acute Identity
Confusion
Chapter 7: The Symptoms of Psychotic Illness: Delusions and
Hallucinations
Chapter 8: The Symptoms of Psychotic Illness: The Assumed Identity
Chapter 9: Achieving Equilibrium: Personal Strengths and Social Supports
Resources
Notes
Bibliography
About the Author
 Acknowledgments

I am especially indebted to Suzanne I. Staszak-Silva, senior acquisitions

editor at the Rowman & Littlefield Publishing Group, for her astute
editorial advice, her unfailing encouragement, and the efficient way in
which she kept this project on course. As one who appreciates sound
advice, steady encouragement, and a minimum of wasted time and effort, I
am extremely grateful to her for her role in bringing this book to fruition. I
also want to thank Evan Wiig for his gracious responses to my various and
sundry queries about technical matters. I am particularly indebted to the
production staff at Rowman & Littlefield, especially Alden Perkins, senior
production editor, and Nicole McCullough, who copyedited the manuscript.
From my vantage point at least, their professional wisdom and concomitant
skills made the whole process of turning a manuscript into a book seem
almost easy. Finally, I want to express my appreciation to the library staff at
Scottish National Gallery of Modern Art, especially Philip Hunt, for their
assistance in arranging for the use of Paul Klee’s “The Tightrope Walker”
on the book cover.
This book is dedicated to John Charles Nash, the son of John Forbes Nash
Jr., who, like his father, has been diagnosed with a serious psychotic illness
(paranoid schizophrenia) and continues to struggle with its major
manifestations (delusions and hallucinations) and personal consequences
(including the fact that he has not been able to pursue what would have
been a brilliant career in his chosen field of mathematics, in which he holds
a Ph.D.). Unlike his father, who was the recipient of a Nobel Prize in
Economics for his early work in mathematics, John Charles Nash is
unlikely to receive comparable recognition. His life, however, testifies to
the personal strengths that persons afflicted with psychotic illnesses rely
upon to help them cope with the consequences of their illness and to the
vital role that others play, especially, in this case, his parents, in providing
the social supports that enable persons afflicted with psychotic illnesses to
live in dignity and relative peace.
In an interview conducted in his home by Nancy C. Andreasen, he
acknowledged that he continues to experience not only auditory but also
visual hallucinations.1 When queried about what he sees, he was unable or
unwilling to respond, and when his mother, who was participating in the
interview, asked him whether what he sees are shadows, he rather abruptly
stood up, an indication that the interview was over. Although he did not
respond to his mother’s query, it would not be inappropriate to suggest that,
whatever the literal truth, her question had metaphorical value, for persons
afflicted with psychotic illnesses may be said to be living in the shadows of
the social world that they inhabit and that his rather abrupt termination of
the interview was itself a reflection of their shadowy existence due, in part,
to the effects of their illness but also to the fact that they and their illness are
not well understood by the vast majority of persons who inhabit the same
social world.
This book is written, therefore, as an effort, however modest, to bring the
seriously mentally ill out of the shadows and into the light so that they
might be perceived by others in their full humanity. This dedication of the
book to a person who lives a couple of miles or so from where I live, then,
reflects a personal desire for the full inclusion of the mentally ill in our
communities that I can trace back to my high school years and specifically
to a short story published in a scholastic magazine2 just two years prior to
the birth of John Charles Nash and the initial hospitalization of his father,
John Forbes Nash Jr.
 Introduction

Throughout human history, mental illnesses have been subject to all sorts of
misunderstandings. This is especially true of psychotic illnesses. These
misconceptions have led to mistreatment and abuse of persons with these
mental illnesses. They have been stigmatized, and so have their relatives
and friends. This book discusses the importance of understanding psychotic
illnesses and their effects on persons who are afflicted with these illnesses.
It takes the view that persons afflicted with a psychotic illness do better if
those who care about them understand their illness and its effects on their
emotions and behaviors. The word “understanding” has two fundamental
meanings. One is comprehension, which involves having knowledge about
something—in this case, psychotic illness. The other is empathy, which
involves placing oneself in the other person’s situation—in this case, the
person who has a psychotic illness—and developing the capacity to share
this person’s emotions, thoughts, or feelings.1 These two meanings of
“understanding” are intimately connected, for we are more likely to have
empathy for a person who has a psychotic illness if we have a good and
accurate comprehension of the illness itself. Conversely, one of the ways
that we can gain a good and accurate comprehension of the illness is to
place ourselves in the situation of the person who has a mental illness and
to experience the situation from this person’s own point of view.
The purpose of this book is to assist those who care about a person or
persons afflicted with a psychotic illness, especially family members and
friends, to develop both forms of understanding. Students who anticipate
working with mentally ill persons in a professional capacity may also find
the book helpful in this regard. One of the best ways to develop both forms
of understanding is to focus on specific cases of persons who were or are
afflicted with a psychotic illness. Cases enable us to gain an understanding
of the illness, of how it manifests itself, of how it changes over time, and its
impact on the life of the person who is afflicted with the illness. Cases also
aid in our comprehension because they place the individual who is afflicted
with a psychotic illness in the context of his or her life. We can focus, for
example, on the age of the person when the illness began to manifest itself;
the possible role that the person’s gender plays in how he or she responds to
and copes with the illness; the effects of the illness on other persons,
especially family members and friends; and how the responses of these
persons are influenced by the social and cultural context in which they and
the afflicted person live. Cases also enable us to project ourselves into the
situation of a person with a psychotic illness and to share this person’s
emotions, thoughts, and feelings. In addition, they provide us with the
opportunity to discern the degree and extent of our empathy, for some cases
are likely to evoke greater empathy than others, and this being so, they
invite us to ask ourselves why our emotional responses differ between one
case and another.
I make substantial use of cases in this book, and because some cases are
historical and others contemporary, the cases, viewed collectively, serve the
purpose of illustrating that psychotic illness has been a human reality for a
very long time, and there is every reason to believe that this will continue to
be the case. In fact, in chapter 1, we will consider evidence that the number
of persons afflicted with psychotic illnesses is growing and that this is not
merely due to population increases. Thus, the number of cases presented in
this book are infinitesimal as far as the number of actual cases of persons
afflicted with psychotic illnesses are concerned, but they illustrate the
variety of ways in which individuals have coped with their illness and its
challenges, the variety of ways in which their families and friends have
supported—or not supported—them, and the variety of ways in which the
larger society has treated—or mistreated—them. Despite their obvious
differences, these cases reveal that there are certain personal qualities that
help individuals cope with their illness and other qualities that complicate
or even inhibit their capacity to cope. They also show how families and
friends respond in rather predictable ways and that their responses usually
go through predictable stages during the course of the illness. These cases
also provide evidence that despite widespread public misunderstanding of
psychotic illnesses and of the persons afflicted with these illnesses, there
have also been individuals who have treated the mentally ill as they would
have wanted to be treated if they themselves were mentally ill. These cases
therefore present a largely hopeful picture based on the ways in which
afflicted persons, family members and friends, and empathetic others have
responded to these devastating illnesses and joined forces against them. In
my view, the hopeful picture they present has its roots in the capacity to
understand the illness itself and the person who is afflicted with the illness.
Anyone who delves into the literature on psychotic forms of mental illness
will not be able to avoid books and articles that employ the word “madness”
in their titles or subtitles. The word “madness” implies lunacy, insanity, and
craziness. It suggests that one is wild, utterly out of control, maniacal, and
subhuman.2 A fundamental problem with the use of the word madness,
especially when it is employed by professionals in the mental health field, is
that it lends support to the commonly held view that psychotic illnesses are,
by definition, incomprehensible and that it is therefore useless to try to
understand them. The word madness also makes the very notion that one
would place oneself in the situation of a person who is afflicted with a
psychotic illness to share this person’s emotions, thoughts, and feelings
seem rather ludicrous. How, after all, could any sane person share the
emotions, thoughts, and feelings of a madman or a madwoman? This book
challenges the madness view of psychotic illness by emphasizing that the
delusional thoughts and hallucinatory perceptions of persons afflicted with
psychotic illnesses are comprehensible and by advocating the idea that we
can, in fact, place ourselves in the situation of a person with a psychotic
illness and share this person’s emotions, thoughts, and feelings. To be sure,
we are unlikely to feel the full force of the effects of the illness—the
confusion, the social isolation, the despair over the very fact that one has a
serious mental illness—but the word madness implies that the person’s
emotions, thoughts, and feelings are of some different order from those of
sane persons and are therefore completely inaccessible to those who are not
afflicted with a psychotic illness. It is this view of psychotic illness and
persons afflicted with psychotic illnesses that this book seeks to challenge.
It does not challenge the view that persons who have themselves been
afflicted with a psychotic illness can help other persons with psychotic
illnesses in ways that others may not be able to help, but it calls into
question the tendency of the general public to distance themselves from
persons with psychotic illnesses on grounds that they are, by definition,
incomprehensible.
In noting the unfortunate use of the word madness, I need at this point to
say something about the word psychosis. This word has had its own
problems owing, in part, to the fact that the pejorative label “psycho” is a
shortened form for “psychosis” and “psychotic.” On the other hand, the
word psychosis alerts us to the fact that we are concerned with serious or
severe mental illnesses in which the personality is seriously disorganized
and contact with reality is usually impaired;3 however, as we will see, the
nature of and degrees to which the personality is disorganized and contact
with reality is impaired are not nearly as simple or self-evident as they may
initially seem to be, and for persons who have psychotic illnesses these
manifestations of their illness change, often radically, over time. So, to be
clear about the mental illnesses addressed in this book, I would now like to
identify them by name.
First, I would like to note that the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR), published by the American Psychiatric
Association, has a major section titled “Schizophrenia and Other Psychotic
Disorders.”4 In the introduction to this section, the nine disorders are listed
with the following brief descriptions:
1. Schizophrenia is a disorder that lasts for at least six months and
includes at least one month of active-phase symptoms (i.e., two [or more]
of the following: delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, negative symptoms).
2. Schizophreniform disorder is characterized by a symptomatic
presentation that is equivalent to schizophrenia except for its duration (i.e.,
the disturbance lasts from one to six months) and the absence of a
requirement that there be a decline in functioning.
3. Schizoaffective disorder is a disorder in which a mood episode and the
active-phase symptoms of schizophrenia occur together and are preceded
or followed by at least two weeks of delusions or hallucinations without
prominent mood symptoms.
4. Delusional disorder is characterized by at least one month of nonbizarre
delusions without other active-phase symptoms of schizophrenia.
 5. Brief psychotic disorder is a disorder that lasts more than one day and
remits by one month.
6. Shared psychotic disorder is characterized by the presence of a delusion
in an individual who is influenced by someone else who has a longer-
standing delusion with similar content.
7. Psychotic disorder due to a general medical condition involves
psychotic symptoms judged to be a direct physiological consequence of a
general medical condition.
8. Substance-induced psychotic disorder is a condition in which the
psychotic symptoms are judged to be a direct physiological consequence
of drug of abuse, a medication, or toxin exposure.
9. Psychotic disorder not otherwise specified is included for classifying
psychotic presentations that do not meet the criteria for any of the specific
psychotic disorders defined in this section or psychotic symptomatology
about which there is inadequate or contradictory information.
The DSM-IV-TR notes that the disorders included in this section of the
manual are all characterized by having psychotic symptoms as the defining
feature. It adds that other disorders not included in this section may present
with psychotic symptoms but not as defining features. It also notes that the
term psychotic has been defined, historically, in a number of different ways,
none of which has gained universal acceptance. It continues:
The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with
the hallucinations occurring in the absence of insight into their pathological nature. A slightly less
restrictive definition would also include prominent hallucinations that the individual realizes are
hallucinatory experiences. Broader still is a definition that also includes other positive symptoms
of schizophrenia (i.e., disorganized speech, grossly disorganized or catatonic behavior).5

It goes on to note that “unlike these definitions based on symptoms,” the

definition used in earlier editions of the manual “was probably far too
inclusive” in that it focused “on the severity of functional impairment,” so
that “a mental disorder was termed ‘psychotic’ if it resulted in ‘impairment
that grossly interferes with the capacity to meet ordinary demands of life.’”
It also observes that the term “has also been previously defined as ‘a loss of
ego boundaries’ or a ‘gross impairment in reality testing.’”6
Instead of favoring one or another of these definitions, the manual states
that the different disorders presented in this section emphasize different
aspects of the various definitions. Thus, in the cases of schizophrenia,
schizophreniform disorder, schizoaffective disorder, and brief psychotic
disorder, the term psychotic refers to delusions, any prominent
hallucinations, disorganized speech, or disorganized or catatonic behavior.
In the cases of psychotic disorder due to a general medical condition and
substance-induced psychotic disorder, psychotic refers to delusions or only
those hallucinations that are not accompanied by insight. Finally, in the
cases of delusional disorder and shared psychotic disorder, psychotic is
equivalent to delusional. Thus, for certain psychotic disorders, broader
definitions of psychotic apply, whereas for others, narrower definitions
apply.
The manual also identifies other mental disorders in which psychotic
symptoms may be present but are not the defining features. It specifically
identifies dementia of the Alzheimer’s type and substance-induced delirium
in the section on “Delirium, Dementia, and Amnestic and Other Cognitive
Disorders”7 and major depressive disorder with psychotic features in the
“Mood Disorders” section.8 In addition, bipolar I disorder (historically
known as manic-depressive illness) is a major mood disorder that is very
likely to have psychotic features. The manual notes that it may therefore be
difficult to differentiate bipolar I disorder from such psychotic disorders as
schizophrenia, schizoaffective disorder, and delusional disorder, especially
in the case of adolescents. This is because bipolar I disorder may share with
these other disorders a number of presenting symptoms, such as grandiose
and persecutory delusions, irritability, agitation, and catatonic symptoms.
The primary difference between it and the other disorders is that the other
conditions are all characterized by periods of psychotic symptoms that
occur in the absence of prominent mood symptoms.9
Another disorder that is not technically a psychotic disorder but that
belongs in a book dealing with psychosis is dissociative identity disorder
(formerly known as multiple personality disorder). It is characterized by the
presence of clear-cut dissociative symptoms with sudden shifts in identity
states, the persistence and consistency of identity-specific demeanors and
behaviors over time, reversible amnesia, and evidence of dissociative
behavior that predates the clinical presentation (e.g., reports by family or
coworkers).10 The manual indicates that the differential diagnosis between
dissociative identity disorder and a variety of other mental disorders,
including schizophrenia and other psychotic disorders and bipolar disorder,
is complicated by the apparently overlapping symptoms presentations:
For example, the presence of more than one dissociated personality may be mistaken for a
delusion or the communication from one identity to another may be mistaken for an auditory
hallucination, leading to confusion with psychotic disorders, and shifts between identity states
may be confused with cyclical mood fluctuations leading to confusion with bipolar disorder.11

The diagnostic issue aside, it makes sense to include dissociative identity

disorder in a book on understanding psychosis, especially since we will be
devoting chapters to acute identity confusion as a precursor to psychosis
and a chapter to the assumption of an identity that is not one’s ascribed
identity.
The fact that a number of mental disorders fall within the purview of this
book makes it all the more important that we approach the task of
understanding psychosis with some sense of the procedure or sequence of
steps to follow. One approach would be to begin with the individual who
manifests psychotic symptoms. This is essentially the way that the DSM-IV-
TR goes about it. The manual, after all, is intended for psychiatrists and
other mental health professionals who are involved in the diagnosis and
treatment of persons with mental disorders. However, there are other ways
to go about the task of understanding psychosis. The one that especially
appeals to me is to begin with the larger picture, that is, the fact that the
psychotic self has been an integral part of the human experience for a very
long time and millions of people have been afflicted. This being the case, it
is remarkable that it is not well understood and disconcerting, too, because
the lack of understanding has led to the stigmatization and social ostracism
of persons who have these illnesses, thus exacerbating the social isolation
that is often a more direct effect of the illness itself. On the other hand, this
book is intended to be practical and useful to individuals, families, and
other nonprofessional readers, so there is no need to discuss the whole
history of psychotic illness. Providing some sense of its prevalence and
magnitude is a more useful approach. Thus, chapter 1 focuses on the thesis
presented by E. Fuller Torrey and Judy Miller in The Invisible Plague,
which outlines how psychotic illnesses have been steadily increasing in the
United States during the course of its history (as measured by number of
persons afflicted per capita) and that we have no reason to believe that the
trend is leveling off, much less declining. On the contrary, it has reached
epidemic proportions.12
Given this increase, we might have expected that there would be a larger
allocation of the nation’s economic resources toward addressing this
problem. The fact that this has not occurred is discussed in chapter 2, which
takes up Torrey’s discussion in The Insanity Offense of the
deinstitutionalization of the seriously mentally ill that got underway in the
late 1950s and continued throughout the 1960s and 1970s.13 He shows how
this program has resulted in greater rather than lesser mistreatment of the
mentally ill. Also, as a way to encourage the public to press for better
treatment of the mentally ill, he focuses on the small minority of individuals
with psychotic illnesses who are prone to violence. By appealing to the
public’s self-interest, he hopes that we will encourage our public officials to
do something about the plight of the seriously mentally ill including, of
course, the very large majority who pose no physical danger to other
individuals. The fact that he makes his appeal on the basis of the self-
interest of the endangered citizenry is itself an indication that there is a need
for greater understanding of psychosis, in terms both of comprehension and
empathetic awareness. To facilitate such understanding, the chapter focuses
on Torrey’s case of Malcoum Tate, a young African-American man whose
family, after many efforts of trying to get him involuntarily committed to a
mental health facility, decided to take matters into their own hands.
As chapter 2 demonstrates, a major consequence of the
deinstitutionalization of the seriously mentally ill has been the fact that
family members have been placed in the position of significant
responsibility for the care and support of a parent, sibling, son, or daughter
who would otherwise have been institutionalized. Although it is true that
important community alternatives to the large mental hospitals of the pre-
1950 era have emerged during the past several decades, there is simply no
question that family members have assumed a great deal of the
responsibility for the care and support of their afflicted relative. This raises
the question with which chapter 3 is concerned, namely, in what ways do
family members shoulder the burden of care, what burdens do they
especially resent, and, alternatively, what unexpected benefits do they
derive from caring for and supporting their mentally ill relative? My
primary resource for this chapter is Richard Tessler and Gail Gamache’s
Family Experiences with Mental Illness.14 They present the results of
interviews conducted with hundreds of family members. They found that
how families experience the serious mental illness of a relative depends on
many social factors, including how public mental health services in their
communities are organized and financed, whether they feel judged or
supported by professionals, and that the amount of stress that family
members experience depends, in part, on the nature of the burden being
assumed and, more specifically, whether they feel that the burden is
reasonable and that their relative is cooperating through his or her own self-
care. Because psychotic illnesses affect the persons with whom the
individual associates, knowledge about its effects on family members is an
important aspect of understanding psychosis. So, too, is the fact that
persons with psychotic illnesses are often aware of these effects, and such
awareness can play an important role in their own understanding of their
illness.
As noted, important alternatives to the large mental hospitals that were
systematically dismantled during the deinstitutionalization era have
emerged during the past several decades. If the discovery of antipsychotic
medications in the late 1940s was a major catalyst behind the
deinstitutionalization of the seriously mentally ill, it was immediately
evident that medications, however effective they might be, would need to
be supplemented with other social structures. Many other forms of
treatment and support have been developed during the past several decades,
including group homes, assisted housing arrangements, psychotherapy and
other forms of counseling, support groups, hospital psychiatric wards that
provide for brief hospitalizations, and instructional programs in self-
management skills. A term that has come to express the eclectic and
pragmatic diversity of these various treatments is that of psychiatric
rehabilitation. Chapter 4 focuses on some of the more important features of
the rehabilitation model presented by Patrick W. Corrigan and his coauthors
in their book Principles and Practice of Psychiatric Rehabilitation.15 This
approach is the offspring of psychosocial rehabilitation centers of the 1950s
that were, in turn, the progeny of social learning programs (including
occupational therapy) for long-term residents of psychiatric hospitals. Thus,
many of the psychiatric rehabilitation initiatives in place today have roots in
the more positive therapeutic initiatives which were employed in the mental
hospitals closed during the deinstitutionalization era. On the other hand, the
fact that seriously mentally ill persons are no longer permanent or
semipermanent residents of these hospitals has presented the communities
in which they live with challenges (housing, employment, recreation, etc.)
which these communities have been relatively slow to address. Yet, as
Corrigan and his colleagues show, progress is being made, and knowing
about rehabilitation programs and the theories and concepts that undergird
these programs is an integral part of understanding psychosis, for these
programs are based on the belief, supported by concrete evidence, that
persons with serious mental illnesses can lead productive lives and
experience inclusion in the communities where they live.
The fact that persons with psychotic illnesses with access to enlightened
rehabilitation initiatives experience fewer psychotic episodes and relapses
has stimulated an emphasis on prevention, the subject of chapter 5. If
persons with a psychotic illness can be helped to experience fewer
psychotic episodes and relapses, it would follow that persons who are at
risk of developing a psychotic illness may, through therapeutic
interventions developed for persons who have already been diagnosed, be
spared this very outcome. Thus, this chapter centers on one among the
many prevention programs that have emerged in recent years, the treatment
model developed by Paul French and Anthony P. Morrison for at-risk
persons living in and around Manchester, England.16 Employing cognitive
behavioral and relapse prevention strategies, they and their colleagues
demonstrated that full-blown psychotic illnesses were preventable in the
majority of cases of persons they treated who were at risk of transitioning to
one or another psychotic disorder. Given the increasing number of persons
afflicted with psychotic illnesses and the relatively small size of their
treatment program (58 persons), their results might be viewed as rather
inconsequential, but if we consider the fatalism that surrounds serious
mental illnesses—the widely held assumption that if a person is destined to
become mentally ill, it is simply a matter of time until it occurs—such
preventive approaches are far more significant than we may think,
especially if educational programs based on these preventive treatment
methods are made available to the wider public through schools, churches,
and other community organizations.