What Is Psychosis? Symptoms, Diagnosis and Treatment

Introduction. What is psychosis?

Psychosis is an abnormal psychological condition that affects thoughts and feelings. The condition is not a defined psychiatric diagnosis. Psychiatrists use the term psychosis to describe a group of symptoms which can appear in different mental and physical illnesses.

A person suffering from psychosis may be partially or completely detached from reality. This means that the person has difficulties determining what is real and what is the product of phantasy. Mental health experts describe the psychotic state akin to a psychological condition we experience while dreaming. People suffering of psychosis are like someone who dreams with open eyes.

Psychotic symptoms may appear as delusions (irrational thinking), hallucinations (false sensory perceptions), agitation, sometimes aggressive behaviour or its contrary, as social withdrawal from the real world while the patients feels trapped in the word of phantasy.

Psychiatrists consider psychosis one of the most common causes of social disability in adult men and women. According to DSM-5 psychotic symptoms occur in such disorders as: schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder, substance use disorders, bipolar disorder, and major depressive disorder. Psychotic symptoms can appear also in the context of other psychiatric disorders such as Post-Traumatic Stress Disorder (PTSD), and in several personality disorders.

Psychosis. Signs and symptoms

The most common symptoms of psychosis are delusions and hallucinations. Additional symptoms are incoherent thinking, disorganized speech, erratic and/or inappropriate behaviour. Other symptoms of psychosis, in psychiatric terms called “negative symptoms”, include apathy, diminished emotional expression and social withdrawal.

Delusions

One of the most common symptoms of psychosis are delusions. A delusion is a false belief contradicting reality while resisting any logical explanation or proof. Delusions may include various thematic content. They are context and culture dependent. Delusional themes reflect the current culture of a particular time and place. The DSM-5 characterizes a particular delusion as “bizarre” if it is clearly implausible or inconsistent with the surrounding cultural context.

Types of delusions

The German psychiatrist and philosopher Karl Jaspers proposed to classify psychotic delusions into primary and secondary types. He theorized that primary delusions appear suddenly and that they are irrational in terms of normal psychological processes. Jaspers describes secondary delusions that are influenced by the person’s current situation and personal and cultural background.

Persecutory delusions or paranoia

The most common type of delusions in psychosis are delusions of persecution. Symptoms of persecutory delusions include extreme paranoia, fears, and worries about imminent harm, even though the imaginary threat is unproven or impossible. In this type of delusion, the patient believes that someone (individual, organization, or group) is trying to harm him or his loved one.

These delusions can range from plausible concerns, for example, loud voices in the neighbourhood, the person refers to himself, or infidelity of a spouse, to impossible or highly unlikely stories. The person may believe that he or she is being spied on. He tends to repeat unsubstantiated accusations including police reports. The patient maintains and justifies his delusional ideas by any supporting, even unrealistic evidence, that he can find.

The fear and anxiety that accompanies paranoia is overwhelming. Depending on the severity of the condition, this could lead the sufferer taking radical measures to prevent or defend against the alleged threat. Left untreated, the persecutory delusions tend to get chronic and may persist life log.  

Delusions of reference

Referential delusions are one of the most common psychotic symptoms. The term describes an individual’s false belief interpreting ordinary events and normal human behaviour as hidden messages referring to him. People in the grip of referential delusion see themselves at the centre of someone else’s attention and they remain resistant to contrary evidence. These patients are convinced that people or secret services are watching them, talking about them, and planning to harm them. The patient interprets random or disconnected events as hidden message from the persecuting entity. They see themselves as the main protagonist of the story they created, and they perceive this story as real. The delusional scenario is based on defence mechanism called projection. Despite the apparent suffering, being at the centre of a plot supports the Ego which increases the subjective feeling of self-importance of those involved.

Delusions of grandeur or megalomania

Delusions of grandeur are also called megalomania. These delusions are common in the manic phase of bipolar disorder but can be observed in other psychiatric disorders. People who suffer from megalomania see themselves as great, highly skilled, more important than others. They also often feel they are equipped with magical powers. Delusions of grandeur can be persistent or intermittent.

Megalomania is more than simply having self-esteem that is too high. It marks a significant disconnection and alienation from the real world. People with megalomania may continue to believe in their delusions despite the contrary evidence. Psychiatrists note that megalomania may be associated with mental or physical health conditions, such as schizophrenia, bipolar disorder, or some forms of dementia.

A megalomaniac feels an exaggerated sense of importance. Megalomania is a false or abnormal belief in one’s own greatness. For example, a person may believe that he or she is famous or has unlimited power. People who suffer from megalomania see themselves as great, highly skilled, more important than others, and even magical. Delusions can be persistent or intermittent. Some people with megalomania also experience other delusions, such as fear of persecution or unusual religious beliefs. But megalomania is not just about having very high or excessive self-esteem. It marks a significant disconnect from the real world. People with megalomania may continue to believe in their delusions despite conflicting evidence.

Delusions of thought broadcasting

Thought broadcasting is the belief that one’s thoughts are audible. Patients believe that other individuals can overhear and control their thoughts. They may also become convinced that their thoughts can be broadcast on radio, television, or on internet. The patient will conclude that whatever he thinks is transparent to others. Patients with delusions of any type, including thought broadcasting, often do not discuss their symptoms with family or friends. This is especially the case if they keep some confirmation of reality. They wind up living in two worlds: in the real world where they act normally and in their delusional world. Psychiatrist that diagnoses patients with thought broadcasting have found that it can take years to discover this delusion. Even family and friends do not notice the patient’s symptoms. This is a common delusion among patients with schizophrenia.

Thought insertion

This type of delusion is a belief that one’s thoughts are made by someone else, by an external power. Such external entity, believed by the patients to be the “thought Inserter” could be a particular person, an institution, group of people or someone unknown. The person affected thinks that his mind has been intruded and that his thoughts do not belong to him, that they originate in the minds of others. The patient frequently does not even know why inserts the thoughts in his mind, but he is convinced that the insertion process insertion is real. He feels in the power of some incomprehensible external force. Apart of the conviction that someone else “implanted” the thoughts in his mind, the patient may think that this entity also controls his thoughts.    

As similar phenomenon happens in intrusive thought in the obsessive – compulsive disorder. The OCD patient is not able to block the thoughts, feeling that they are imposed on him. However, the main difference between thoughts insertion and the obsessive-compulsive thoughts is the absence (thoughts insertion) or presence (OCD thoughts) of the insight. In case of thoughts insertion, the patient has no or little insight that the process of insertion/thoughts control is not real. In the OCD, even though the patient is not able to block the thoughts, he is able to recognizes that they are not a part of his personality and frequently knows that they are nonsensical. The thoughts insertion is Ego-synthym (belonging to Ego) while the OCD thoughts are not regarded as a part of the patient’s personality.  

Somatic delusions

A somatic delusion is person’s wrong and not correctable belief that his/her organs or body shape are ill or abnormal. The person can be convinced that the body is not symmetrical, or its parts are distorted. Sometimes a person can be convinced that some part of the body is atrophic (decreased muscle bulk). On other occasion he might think not to be able to move a part of his body or move at all. The imagined but for the patient fully real problem can lead to protecting the imaginary affected part of the body or stopping moving. By not moving his legs, arms, or head can lead to a real muscle atrophy, stiffness of the joints; abandoning walking can cause a full invalidism.

Another frequent theme of somatic delusion is the conviction that the body is affected by germs or parasites. The patients affected by such delusion may feel parasites crawling under the skin, accumulating in one part of their body and causing pain.

Bizarre and not bizarre somatic delusions

They are two categories of somatic delusions: bizarre and not bizarre. A bizarre somatic delusion is farfetched from a situation that can happen in real life. An example of such delusion could be the conviction that one underwent some miraculous operation, for example that someone removed his organs but without any visible marks or scars on their body. The explanation of such “organ removal” is equally bizarre as the delusion itself.

The scenarios behind the non-bizarre somatic delusion are theoretically possible but by closer investigation it could be proved that they are the product of the person’s phantasy.

In cases in which a patient complains of a functional symptom that are more probable such as headache, weakness or pain, they can be easy misdiagnosed as a somatic disorder by neglecting the psychological origin of the problem.

Disorders with somatic delusions

The somatic delusions can appear in delusional disorder, schizophrenia, dismorphic disorder, depression with psychotic features or dementia. A form of somatic delusion is body dysmorphia. Temporarily somatic delusions can be observed also by intoxication with delirium.

Somatic Symptom Disorder (SSD)

Mental health researchers have also identified somatic delusions. Somatic Symptom Disorder (SSD) formerly called Somatoform Disorder is such a condition. Disorders Related to Somatic Symptom Disorder are Hypochondriasis and the Conversion Disorder. Patients with hypochondriasis firmly believe they have a serious disease despite the opposite medical evidence. In the conversion disorder people experience symptoms such as pain, neurological symptoms or gastrointestinal problems without any identifiable medical condition.

Monosymptomatic Hypochondriacal Psychosis (MHP)

The somatic delusions can appear also in Monosymptomatic Hypochondriacal Psychosis (MHP). The Monosymptomatic Hypochondriacal Psychosis is a different entity than Hypochondria. Hypochondria (called also Hypochondriasis) is a sub-category of the Somatic Symptom Disorder. In Hypochondria the somatic delusions are “less deep”, allowing the affected individual some insight that the delusions don’t make sense, despite that they can’t oppose the ideas. In hypochondriacs the logic says “it can’t be” but the feelings undermine the logic, and the latter surrender.

While hypochondriacs understand that the feared disease is not real, in somatic-type delusional disorder the patients are unshakable convinced of the physical root cause of their complaints. So, the only difference between delusional disorder and hypochondria is of quantitative nature.

Hallucinations

Psychiatrists maintain that hallucinations are false sensory perceptions. In essence, there is no external stimulus that causes the hallucinations. They can occur in any of the senses, such as hearing, seeing, feeling, tasting, or smelling. They are often vivid and realistic, and the person experiencing them might not be able to recognize them as not being real. The person affected by hallucinations is unable to control them. Hallucinations can be caused by a variety of factors, including psychiatric conditions, physical disorder, medications, and substance use disorders. Hallucinations can be categorized based on the affected sensory quality.

Categories of hallucinations

Auditory hallucinations

are the false perception of hearing sounds or voices that are not actually present. Examples include hearing voices or music that is not there. They are the most common type of hallucinations. They can range from simple sounds, such as a ringing in the ears, to more complex experiences, such as hearing voices having conversations, or hearing music. Patients that hear auditory hallucinations sometimes perceive them as coming from inside the person’s head or from outside the person. They can be a single voice or multiple voices, and the voice(s) can be familiar or unfamiliar. The voices can be friendly or hostile, and can give commands or make critical comments. Auditory hallucinations are also a common symptom of some mental health conditions such as schizophrenia, bipolar disorder, and depression.

Visual hallucinations

are the false perception of seeing things that are not actually present. Examples include seeing people, animals, or objects that are not there. Visual hallucinations can have a wide range of causes, including medical and surgical conditions, as well as certain medications and substance use disorders. The underlying mechanism of visual hallucinations can vary depending on the cause. Some of the possible causes and mechanisms of visual hallucinations include:

• Psychosis

• Substance use disorders such as alcohol and drug abuse can also lead to visual hallucinations.

• Neurological conditions such as Parkinson’s disease, dementia, and stroke, can cause visual hallucinations due to changes in the brain that affect vision and perception.
• Other causes of visual hallucinations include sleep disorders, migraines, and certain metabolic disorders.

Tactile hallucinations

are the false perception of feeling something that is not actually present. Examples include feeling someone touch or tickle you or feeling bugs crawling on your skin.

It’s also worth noting that there are other ways to categorize hallucinations. For example, some people may experience hallucinations that involve more than one sense at the same time, such as seeing and hearing something that is not there. Psychiatrists call these “multisensory hallucinations.” Additionally, some people may experience hallucinations that are not specific to any particular sense, but rather involve a general feeling of unease, such as a sense of presence or a feeling of being watched. It’s important to note that treatment of visual hallucinations typically depends on the underlying aetiology, so a proper diagnosis is essential. In order to determine the cause of visual hallucinations, a psychiatrist will do a complete medical history, physical examination, and appropriate diagnostic tests.

Olfactory hallucinations

Olfactory hallucinations, also known as phantom smells, are the false perception of smelling odors that are not actually present. Patients often associate smells with a strong emotional component, as the sense of smell is closely linked to memories and emotions. Olfactory hallucinations can occur in a variety of conditions, including:

• Schizophrenia: Olfactory hallucinations are a common symptom of schizophrenia, a severe mental disorder characterized by abnormal thinking, emotions, and behavior. In this condition, the patient may experience phantom smells that are often unpleasant, such as rotting flesh or burning rubber.
• Epilepsy: Olfactory hallucinations can also occur in some types of seizures, particularly temporal lobe seizures, which can affect the brain’s olfactory centers.
• Other medical conditions: Olfactory hallucinations can also occur in other medical conditions such as brain tumours, head injury, and certain metabolic disorders.
• Certain medications, drug use, or exposure to certain chemicals can also be a trigger. As with other types of hallucinations, it is important to determine the underlying cause of olfactory hallucinations in order to provide appropriate treatment.
• Olfactory hallucinations occur in epilepsy, especially in association with a temporal lobe focus, and commonly form the aura (or earliest phase) of such fits. A patient described a smell of burning rubber regularly just before he became unconscious.

Olfactory Reference Syndrome (ORS)

A delusion of malodour, also known as olfactory reference syndrome (ORS), is a type of delusion in which a person believes that they emit a foul body odor, even though there is no actual odor present. This is a common symptom in schizophrenia and related paranoid states. People with ORS experience significant distress, shame, and social isolation as a result of this belief.

In this condition, the patient may have an intense preoccupation with the belief that they emit a bad odor, even though they have no olfactory hallucinations. They may constantly check themselves, bathe excessively, or use excessive amounts of deodorants and perfumes in an attempt to mask the imagined odor.

ORS can also be a symptom of other mental health conditions, such as depression, obsessive-compulsive disorder (OCD), and body dysmorphic disorder. Psychiatrists do not understand the underlying mechanism of ORS very well. Mental health researchers believe that ORS is related to abnormal activity in certain brain regions involved in the processing of olfactory information.

Treatment for ORS typically involves a combination of behavioural-behavioral therapy, medication, and supportive therapy. The goal of treatment is to help the patient recognize the delusional nature of their belief and improve their quality of life.

A visceral hallucination

Visceral hallucination, also known as coenesthetic hallucination, is a type of hallucination that involves the perception of physical sensations within the body in the absence of any external stimuli. These sensations can include feelings of discomfort, such as burning, twisting, or squeezing, as well as perceptions of movement or re-arrangement of internal organs. These hallucinations can be very distressing to the person experiencing them.

Coenesthetic hallucinations are relatively rare and are less well-understood than other types of hallucinations. They can occur as a symptom of certain medical conditions such as schizophrenia, or as a side effect of certain medications. Other causes of coenesthetic hallucinations include psychological conditions such as depersonalization disorder, and dissociative disorders, as well as substance use disorders.

Organic factors can also cause coenesthetic hallucinations, such as gastrointestinal or genitourinary disorders, and certain neurological disorders. Therefore, it is important to rule out any organic causes before making a diagnosis of a coenesthetic hallucination.

Treatment for coenesthetic hallucinations typically depends on the underlying cause. In cases when a medical condition causes the hallucination, treatment may involve addressing the underlying condition. When a psychological condition causes the hallucination, treatment may involve psychotherapy and/or medication.

Psychosis. Diagnostics and Treatment

Psychosis, a disconnection from reality, impacts cognitive functions, causing one to experience unreal perceptions.

It impacts the way your brain processes information. This causes you to see, hear, or believe things that are not real. Psychosis is a symptom, not an illness and can be triggered by a range of factors including mental disroders and substance abuse.

The age factor in psychosis

Young people are especially prone, typically starting in their teens to late 20s. However, older individuals can also be affected as well as, on rare occasions, childeren.

The exact prevalence remains elusive, with studies suggesting a wide range of impacts from 15 to 100 cases per 100,000 people annually.

The gradual onset of psychoses

Psychosis doesn’t strike suddenly; it follows a pattern of warning signs, gradually changing your thought processes. These signs, observable to friends and family, include academic or work performance decline, difficulty concentrating, suspiciousness, social withdrawal, emotional fluctuations, or a lack of emotions.

Hallucinations and delusions are common elements of a psychotic episode. You may hear, see, or taste things others don’t, or hold unusual beliefs regardless of contradictory evidence.

Understanding a Psychotic Episode

During an episode, hallucinations manifest, encompassing various sensory experiences: auditory, tactile, visual, and olfactory hallucinations. Delusions, ranging from grandiose to persecutory themes, add complexity.

The challenging self-recognition

Individuals with psychosis are often unaware of their condition, as their hallucinations and delusions seem genuinely real.

Triad of psychotic stages

Psychotic episodes evolve through three distinct stages, the specifics varying from person to person.

1. The Prodrome Stage

Mild changes in thought and mood gradually appear in this initial stage. Symptoms may include sleep disturbances, sadness, anxiety, reduced concentration, social withdrawal, and suspicious beliefs.

2. The Acute Phase

The typical symptoms of psychosis emerge, involving confusion, delusions, hallucinations, and shifts in behavior and personality, often noticeable to those around you.

3. The Path to Recovery

Recovery signifies the gradual fading of symptoms, enabling a return to daily routines. With the right treatment, many people never experience another psychotic episode.

Unveiling causes of psychosis

Although not yet fully understood, a combination of genetic, psychological, and environmental factors contributes to psychosis.

Triggers of psychotic episodes

Psychosis can be triggered by varying factors. These include: mental or physical conditions, alcohol or drug use, and traumatic events. Psychological stress, anxiety, or depression can trigger episodes, while severe sleep deprivation can worsen the condition.

Role of trauma in oncet of psychosis

Traumatic experiences, such as the death of a loved one, sexual assault, or war, can lead to psychosis, influenced by the nature and timing of the trauma.

Medical implications

Numerous medical conditions, from brain injuries to diseases like Parkinson’s and Alzheimer’s, can trigger psychosis.

The drugs abuse as a trigger factor of psychoses

Substances like cannabis, cocaine, and amphetamines can significantly affect brain activity, leading to distorted perceptions.

Understanding the link

Research suggests that drugs may not directly cause psychosis but rather unveil latent conditions, especially among individuals with psychiatric disorders or a family history of psychosis.

The Alcohol Paradox

Alcohol, whether during intoxication, withdrawal, or in cases of chronic abuse, can induce delusions or hallucinations. Stopping alcohol often alleviates symptoms.

Seeking Timely Intervention

If you or someone exhibits psychosis symptoms, reaching out to a healthcare professional is vital. Early treatment significantly enhances effectiveness.

Diagnosing Psychosis

Psychologists, psychiatrists, or social workers conduct thorough evaluations to pinpoint potential causes and related conditions.

Diagnostic process

While there are no specific tests for psychosis, medical professionals rely on detailed questioning, inquiring about family mental health history, medication use, mood patterns, daily functioning, and the nature of any hallucinations or delusions.

Effective Treatment of psychosis

Early intervention following the first episode is crucial, helping to preserve relationships, work, and education.

Medical approaches

The specific treatment for psychosis depends on its cause, typically involving antipsychotic medication and drug and alcohol avoidance.

Medication in treatment of psychosis

The treatment of psychosis involves antipsychotic medications, which can improve the course of the condition. These medications, known as antipsychotics or formerly as “Neuroleptics,” target the core symptoms of delusions and hallucinations, often leading to rapid improvements.

Psychotherapy in treatment of psychosis

Counseling, combined with medication, offers an effective strategy for managing psychosis. Cognitive-behavioral therapy (CBT) helps recognize psychotic episodes, distinguishing between reality and imagination, emphasizing the importance of medication adherence.

Psychoeducation and family support

Family psychoeducation and support improve problem-solving and strengthen family bonds.

Summary

Psychosis blurs the line between reality and illusion, creating a complex challenge. Yet, early treatment is highly effective and key to preventing long-term disruptions in relationships, work, and education.

History of Psychosis

The psychiatric term “psychosis” describes disorders distorting reality proof, creating delusions and hallucinations was and still is associated with such negative terms as “madness”, “lunacy” or “insanity”. This enigmatic human condition has accompanied mankind through its history.

Historical and ethnographic studies have demonstrated that schizophrenia was and still is present in all existing cultures, from the pre-literate to the most highly advanced.

In this article we reflect on the perception of psychotic disorders, especially schizophrenia, the epitome of madness, from the earliest records to the modern time.

Psychosis in the antiquity

Psychotic symptoms and schizophrenic-like syndromes were clearly present in ancient civilizations. Recorded descriptions of the disorder appeared before 1500 BC in the ancient Egyptian Book of Hearts, which is part of the Ebers papyrus.

Throughout millenia psychotic behaviours were thought to be caused by demonic or supernatural forces.

Although theories of demonic influences also held sway in Greek conceptions of madness and rationalist theories began to take hold. Plato, writing in the 5th and 4th centuries BC, advocated a very modern integrative conceptualization of the relationship between the mind and body. In his book “The Dialogues” he wrote that “…to think about curing the head alone, and not the rest of the body also, is the height of folly….and therefore if the head and body are to be well, you must begin by curing the soul.”

The Greek physician Hippocrates, widely considered the father of modern medicine, built upon the Greek tradition of rational and empirical explanations of nature and behaviour. He dismissed the idea of demonic causation of psychosis and instead suggested that madness originated entirely from the brain. In his book “Holy Disease” he contended that “…only from the brain spring our pleasures, our feelings of happiness, laughter and jokes, our pain, our sorrows and tears…. This same organ makes us mad or confused, inspires us with fear and anxiety….” In order to explain the presence of various mental and physical disturbances, he postulated the existence of body “humors”. Optimal mental and physical functioning could only be achieved if these humors were in balance and harmony. He believed that an uneven distribution of these fundamental elements was the cause of madness.

Madness and insanity in the Middle Ages

The treatment and understanding of madness in medieval Europe varied. However, madness in Europe was mostly associated with demonic possession. Consequently, such individuals were subjected to barbaric treatments even burned at the stake. Mostly mentally ill were confined in cages or in towers known as “fools’ towers.” In some, rare case institutions, mostly monasteries attempted to offer care.

In the Islamic world, so the treatment of mentally ill was in general much better. They were taken care in so called Bimaristans, however their reach was limited.

Psychosis. Change of paradigm in Renaissance and Enlightenment

First the Renaissance brought about a transformation in the perception of mental illnesses. It witnessed a shift toward a more humane understanding of madness, with the emergence of the first mental asylums. Despite primitive condition these institutions provided care and treatment to the mentally ill.

First the Enlightenment era with its admiration for reason and rationality ignited a revolution in the approach to mental illnesses. This led to the birth of psychiatry as a medical discipline, spearheaded by figures like Philippe Pinel liberating the mentally ill from lunatic asylums.  

Philippe Pinel. Pioneer of clinical psychiatry

Philippe Pinel (1745-1826) initially studied mathematics and medicine in Toulouse and Montpellier, obtaining degrees in both fields. At the age of 41, he worked at the private institution Maison Belhomme in Paris, before assuming the directorship of the Bicêtre Asylum, the Hospital for the Poor, Sick, and Criminal, in 1792, followed by the Hôpital de la Salpêtrière two years later. He held these positions until his death, while also serving as a professor at the Ecole de Santé and as Napoleon’s medical advisor from 1805.

Pinel’s reforms and “traitement morale”

Based on enlightened humanism, Pinel advocated for the reduction of coercive measures. In his major work, A Philosophical-Medical Treatise on Mental Disorders from 1801, he declared:

“Undoubtedly, one can maintain a semblance of order in asylums, just as in despotic states, through involuntary and unlimited confinement, through chains, and through barbaric treatment; but is this not the tranquility of graves and death? Calculated freedom, in accordance with the strict principles of humanity, distinguishes the maintenance of such an order, which spreads some gentleness over the unfortunate existence of the insane, often dispelling the symptoms of madness entirely and, in any case, reducing their severity.”

According to Pinel the mad person, as a citizen, has a natural right to assistance. This perspective forms an ethical core of early psychiatry as a civil reform institution. Pinel developed an educational “moral” treatment (“traitement morale”), which was developed in parallel in Scotland by Sir John Batty Tuke, in Germany by Johann Christian Reil, who coined the term “psychiatry”, and in Italy by Vincenzo Chiarugi. 

Shift from “madness” to “psychosis”. Beginning of modern psychiatry

One of the first to classify the mental disorders into different categories was the German psychiatrist, Emil Kraeplin. Within the group of psychoses, schizophrenia is the most typical. Kraeplin used for it the term “dementia praecox” for individuals who had symptoms that we now associate with schizophrenia. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox and manic depression.

Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia. He named the disorder “dementia praecox” (early dementia) to distinguish it from other forms of dementia (such as Alzheimer`s disease) which typically occur late in life. Kraepelin also emphasized the genetic (inheritance) factor but added physical illnesses like brain inflammation in the childhood.

The term “schizophrenia” has been introduced for the first time 1911 by the Swiss psychiatrist, Eugen Bleuler (1857-1939). He was also the first who described the “positive” or “negative” symptoms of schizophrenia. Bleuler changed the name to schizophrenia as it was obvious that Kraepelin`s term “dementia praecox” was misleading as the illness was not a dementia (it did not always lead to mental deterioration) and could sometimes occur late as well as early in life.

Both, Kraepelin and Bleuler, were both in favour of the hereditary cause of schizophrenia. Bleuler wrote on the root cause of schizophrenia: “Schizophrenia appears to be independent of external conditions and circumstances.” However, today’s view on the origin of schizophrenia also includes the external triggering factors.

Social Darwinism, eugenics, and euthanasia

The story about schizophrenia and development of modern psychiatry wouldn’t be complet without mentioning the darkest chapter of psychiatry.

Early sociologists embraced Darwin’s ideas too eagerly, misapplying concepts such as the struggle for existence and survival of the fittest to political phenomena. This gave rise to Social Darwinism, a disreputable movement. Precursors of this movement can be found as early as Charles Darwin (1809-1882, “Struggle for life”) and Herbert Spencer (1820-1930), who coined the term “survival of the fittest.”

Unfortunately, Social Darwinism was employed by imperialists to justify the extermination of primitive populations, by Marxists to incite class struggle massacres, by Hitler to support his genocidal fantasies, by militarists as a justification for war and finally by eugenicists to justify selective euthanasia.

In the course of emerging heredity studies, the eugenics movement as a “branch” of social Darwinism gained increasing popularity in many countries since the late 19th century. Eugenics is a term that encompasses strategies to “improve” human heredity. According to this idea, there are hereditary traits that are worth promoting and desirable. Conversely, it was intended to prevent the reproduction of individuals whose genetic traits were deemed negative. The early eugenic approaches were already discussed and implemented in antiquity for example in Sparta, where the new-born children considered to be unfit as warrior were dropped into caves.

However, eugenics unfolded the most horrific effect in the 20-century ending in extermination of mentally ill in Nazi Germany.

Racial hygiene and the “Aktion T4”

Although the eugenics movement led to inhumane measures in other countries as well (such as forced sterilizations), this social Darwinist approach formed a particularly ominous alliance with Nazi “racial hygiene” in the Third Reich.

Systematically, several hundred thousand people with disabilities or mental illnesses, became victims of measures aimed at the “extermination of life unworthy of living.” Notorious among these were “Action T4” and child euthanasia. The Aktion T4 took place from September 1939 until the end of the war in 1945. By using gas, lethal injections, or starvation the Nazis killed an estimated number of 300,000 mentally ill in psychiatric hospitals across Germany, Austria, occupied Poland, the Protectorate of Bohemia and Moravia (now the Czech Republic) and the occupied parts of the Soviet Union.

Discovery of medication for treatment of psychosis

With the discovery of chlorpromazine in 1952, the foundation for psychiatric pharmacotherapy was laid. It was the first antipsychotic used in treatment of psychosis. Chlorpromazine became prototype for numerous subsequent products and were considered a major breakthrough in modern psychiatry.

In the early 1960s, the group of benzodiazepines also entered the market as sedatives. However, the first so called “typical neuroleptics” caused major side effects and many patients rejected medication. They were referred to as “chemical straitjackets” since these early medications primarily induced sedation and motor restriction.

The 1990s were marked in psychiatry by a series of new, so-called atypical antipsychotics, intended to be less prone to side effects and more effective than the old medications. Drugs such as risperidone, amisulpride, and quetiapine were introduced to the market.

Today, a wide range of different psychopharmaceuticals is available. Current pharmaceutical research approaches spsychoses, among them schizophrenia, as the result of chemical imbalance of neurotransmitters in the brain, which on the neurobiological level is true. However, the oset of psychosis depends not only on the genetic, inherited predisposition but also on external triggers such as environmental and traumatizing life events.