Psychiatr News December 7, 2007
Volume 42, Number 23, page 23
© 2007 American Psychiatric Association
Psychosis, Ordinary Thinking Not Distant Relatives
Mark Moran
The community buffers a variety of aberrant beliefs along the continuum
from "normal" to psychosis, but a catastrophic disruption may
occur that results in serious mental illness.
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 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." 
Related Article:
-
Residents Experience Mind's Continuum
Psychiatr News 2007 42: 23.
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