Psychosis, Ordinary Thinking Not Distant Relatives

A newly widowed woman wanders the rooms of her now empty home hearing the voice of her dead spouse.

A Gallup poll reveals that a significant percentage of people believe in the devil, black magic, the ability to foretell the future, and extrasensory perception.

A patient on a psychiatric ward confides that sparrows nesting on a neighbor's roof had urged him to destroy the neighbor's satellite dish since it was intruding on nature; the nurse who hears this revelation has spent the morning hiking in the woods and meditating on the importance of“ communing” with the natural world.

These examples underscore what two decades of cognitive psychology and neuropsychology have revealed: that the “ordinary” mind is not so very ordinary, and the psychotic mind is no alien from another planet.

In a lecture at APA's Institute on Psychiatric Services in New Orleans in October, psychiatrist Michael Garrett, M.D., said a newly emerging understanding of the continuum between psychosis and “ordinary” mind is changing the traditional view of the radically “other” nature of psychotic thoughts and delusions, with important implications for treatment of schizophrenia.

“In a classic diagnostic interview we try to elicit symptoms in order to make a diagnosis and a treatment plan,” Garrett said. “But patients often experience this as labeling, which can lead to withdrawal. In a situation in which clinicians can find analogies to psychosis within themselves [and can relate them to a patient], it creates a radically different relationship with the patient. The patient is liable to think, 'If the doctor has had an experience like mine, I can risk talking about it.'”

Garrett, who is vice chair of psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y., said that while medication remains the essential element in the biological treatment of schizophrenia, the recognition of a continuum between psychosis and ordinary mind is an essential element in the cognitive-behavioral therapy (CBT) of psychosis. CBT can help to“ de-catastrophize” the anomalous experiences of psychosis, he said.

“This is a normalizing approach that says to the patient, 'There is a range of human experience. Tell me about yours. I may have had experiences that are similar.'”

'One Extreme of Human Experience'

Garrett outlined some 20 years of cognitive psychological research showing the continuity between psychosis and ordinary mind. A psychoanalyst, he also drew on the depth psychology of Melanie Klein— especially her conception of internalized and externalized “object” relations—as well as everyday examples to show ways in which psychotic symptoms are apt to be eccentric extensions of ordinary cognition.

In a workshop for medical educators following the lecture, Garrett offered participatory cognitive exercises dramatizing the continuity between ordinary thinking and psychosis, which he has used in teaching residents and medical students to better understand schizophrenia (see Original article: Residents Experience Mind's Continuum).

A recognition of that continuum counters the more traditional conception postulated by Karl Jaspers that psychotic delusions occur in a vacuum without rhyme or reason, unconditioned by circumstance or the environment, and are therefore inaccessible to the “normal” mind.

Garrett said that more traditional conception has tended to exile patients from the community. “Some patients are entirely consumed by their mental illness label,” he said. “But if psychosis lies along a continuum, then everyone has a bit of what the patient has. And in that case the patient has never left the community, but is at one extreme of human experience.”

Scientists Reach Consensus

The continuity between psychosis and ordinary mind is supported by a scientific consensus that has formed around criteria for“ prodromal” schizophrenia, a subclinical state in which individuals may have anomalous perceptual experiences but are not yet psychotic.

And it is supported by the lack of a sharply distinctive pattern of symptoms for frank psychosis. “There is no single distinctive symptom that occurs in schizophrenia and nowhere else, an observation that weakens the idea that schizophrenia is a single disease state,” Garrett said.

Moreover, it is supported by—and lends support to—a new appreciation of the way a host of environmental influences can act upon the genetically predisposed individual to produce schizophrenia. These factors include, among others, high “expressed emotion” in families, substance abuse, and physical and sexual trauma.

“All this suggests that psychosis can be reconceptualized not as a disease with a single etiology, but as a final common breakdown product of multiple environmental insults on a vulnerable brain,” Garrett said.“ This breakdown follows contours that are latent in the normal mind and the normal brain.”

He cited research by Dutch researcher Jim van Os, Ph.D., whose studies of community samples showed that the prevalence of aberrant or psychotic thinking was as high as 17 percent, far higher than the generally accepted community prevalence of 1 percent for schizophrenia. And he also cited a host of studies, especially by British researchers, examining the phenomenology of psychosis and finding similarities with ordinary cognition, as well as studies of normal subjects showing latent features of psychosis.

One 1983 paper by Posey and Losh, in the journal Imagination, Cognition, and Personality, for example, reported at least a brief experience of hearing voices in over two-thirds of 375 “normal” subjects recruited from the community.

“Our community is capable of buffering an enormous variety of beliefs along the continuum, and then at a certain point there may be a catastrophic disruption of function when those beliefs can no longer be contained, resulting in frank mental illness,” Garrett said. “One conclusion is that psychotic thinking can be seen as an exaggeration of cognitive biases that are found in ordinary thinking.

“Two decades of investigation has not elicited a particular kind of thinking that defines schizophrenia and that has no analogy in ordinary mind,” he said. “Psychosis is latent in the ordinary mind and brain, but is brought to the fore by a disease process or environmental insult.” ▪