Psychosis is a general term to describe a mental health problem in which a person experiences changes in thinking, perception, mood and behavior which can severely disrupt their life. Relationships, work and self-care can be difficult to initiate or maintain. The main psychotic diagnoses are schizophrenia, bipolar disorder (manic depressive disorder), psychotic depression, schizoaffective disorder and drug-induced psychosis. Any person showing symptoms of early psychosis may be eventually diagnosed as having any of the illnesses above. Dialogical self-theory by Hubert Herman’s (1990) is applied to explore ‘Voices’ and ‘I’ positioning both in the internal and external dialogue in the mind. Dialogical Self-Theory was created and developed by the Dutch psychologist Hubert Herman’s since the 1990s. Hermans emerged from working with valuation theory and the self-confrontation method in theory and practice and from a historical analysis of the psychological and novelistic literature. The concept of the dialogical self, (DST), proposed originally by Herman’s, professor of psychology, inseminated a dynamic development in psychology and the social sciences. It was a case study of three adults who had symptoms of mental health issues using qualitative method. Interview guide and observation guide were used as a tool to identify and explore their situations. Qualitative analysis were applied and presented in a narrative form. Secondary data was also collected from the journals and books to affirm and support the findings. It was discovered that the mental health illnesses can affect individuals differently but the symptoms are more or less the same. Different cases may require different skills and approach depending on the diagnosis and the level of the mental health. In all, people should be aware of the risk factors and learn to apply the first aids skills when the professional are not around and before they are sent to the hospital for retreatment.

Keywords: Psychosis, Schizophrenia, Anxiety, Risk factors, Case study, Paranoid Schizophrenia

INTRODUCTION

The inception of psychosis in childhood is rare. However, the rates of beginning increase sharply, during adolescence of at least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized speech or incoherence. Sudden onset is defined as change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually without a prodrome [1].

Prodrome is a premonitory sign or symptom of a developing disorder or attack, such as an aura before an attack of epilepsy [2]. It tends to occur earlier in males, usually in their mid to late teens or early twenties. The onset of the illness may be rapid, with symptoms developing over several weeks, or it may be slow and develop over months or years [1].

It can take one to two years before a person experiencing a first episode of psychosis receives appropriate treatment. A number of factors contribute to this delay. One explanation is that some early symptoms of psychosis can involve behaviors and emotions common in adolescents and young adults. Duration of untreated psychosis is important; the longer the duration, the worse the outcome with more severe overall symptoms, depression/anxiety, negative and positive symptoms, and worse overall function [3].

More than 80% of people experiencing a first episode of psychosis will recover [4] although without appropriate care a high proportion will go onto experience further relapses. In England, the government, as part of mental health service modernization [5] has invested in early intervention in psychosis services which help to reduce DUP and facilitate and sustain recovery [6]. They provide a range of evidence-based interventions including psychological and social interventions as well as medical treatment.

In some cultures, such experiences are understood as spiritual, positive and acceptable. The individual may willingly offer information and need reassurance from you about their experiences that may make you feel awkward. We need to be aware of individual cultures and worldview because along with religion and religious values, these influence the presentation of psychosis [7].

According to Carey (2018) [8] the common symptoms when psychosis is developing include:

Changes in emotion and motivation

•     Depression, anxiety, irritability, suspiciousness, blunted, flat or inappropriate emotion, change in appetite, reduced energy and motivation, change in thinking and perception, difficulties with concentration or attention, sense of alteration of self, others or the outside world, odd ideas.

Some of these emotions were very visible in the participants used for this study. The thinking was completely distorted at some stage and 42-year-old man regenerated to 8-year-old boy in his thinking and actions (Participant, case one, 2019).

Changes in behavior

•     Sleep disorder

•     Social isolation or withdrawal

•     Reduced ability to carry out work and social role

Associated features supporting diagnosis

Individuals with brief psychosis disorder typically experience emotional turmoil or over-whelming confusion. They may have rapid shifts from one intense affect to another. Although the disturbance is brief, the level of impairment may be severe, and supervision may be required to ensure that nutritional and hygienic needs are met and that the individual is protected from the consequences of poor judgment, cognitive impairment, or acting on the basis of delusions. There appears to be an increased risk of suicidal behavior, particularly during the acute episode [1].

Schizophrenia

Schizophrenia is nothing to do with ‘split character.’ The term schizophrenia means ‘split mind’ and refers to changes in mental function whereby thoughts and perceptions become disordered. This occurs in the context of significant social or occupational dysfunction. Two or more of the following will be present during a 1-month period [7].

•        Delusion: Delusion is false beliefs. These can include beliefs of persecution, of guilt, of having a special mission or exalted birth or of being under outside control.

•        Hallucinations: These are false perceptions. It involves hearing voices. It can involve seeing, feeling, tasting or smelling things. These are perceived as very really by the person experiencing them. Hallucinations can be very frightening especially when voices make negative comments about person or contain unpleasant ideas. They may not be ready for alternative explanation. This is where people’s culture and background have to come in.

•        Disorganized speech: There may be difficulties in concentration, memory and ability to plan. The person may not be able to reason, communicate and complete daily tasks. These are sometimes called cognitive impairment.

•        Grossly disorganized or catatonic behavior: The person lacks motivation and this can extend to self-care. This should not be interpreted as laziness.

•        Negative symptoms: (diminished emotional expression) the person has a lack of emotions or has inappropriate emotion.

•        Social Withdrawal: Social withdrawal is a common feature of people experiencing psychosis. The longer the treatment delay, the more socially withdrawn an individual is likely to become (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2013).

Risk factors for psychotic disorder

Cornblatt et al. [9] believed that psychosis is caused by a combination of factors including genetics, biochemistry, stress and other factors.

Genetic and physiological: Although psychotic illnesses are not directly inherited, people who have a parent who is affected are more likely to develop psychosis. There is a strong contribution for genetic factors in determining risk for schizophrenia, although most individuals who have been diagnosed with schizophrenia have no family history of psychosis. Liability is conferred by a spectrum of risk alleles, common and rare, with each allele contributing only a small fraction to the total population variance. The risk alleles identified to date are also associated with other mental disorders, including bipolar disorder, depression, and autism spectrum disorder. (Allele is a gene that can occupy a particular locus on a chromosome each responsible for a different characteristic or phenotype, such as a different eye colour).

Environmental: Season of birth has been linked to the incidence of schizophrenia, including late winter/ early spring in some locations and summer for the deficit form of the disease. The incidence of schizophrenia and related disorders is higher for children growing up in an urban environment and for some minority ethnic groups. Pregnancy and birth complications with hypoxia and greater paternal age are associated with a higher risk of schizophrenia for the pregnant mothers. Genetic vulnerability combined with environmental factors are more likely to be associated with a diagnosis.

Biochemistry: The changes in the brain caused by psychosis are not fully understood. A chemical messenger called dopamine seems to be involved in schizophrenia and mania, like depression, is believed to be associated with a chemical imbalance in the brain. However, it remains very difficult to know whether these changes are a cause or an effect of having a psychotic condition.

Stress: Stress may play a part in triggering symptoms in vulnerable people. The onset of psychotic illness often follows stressful events in a person’s life such as severe emotional trauma. Different people have different thresholds for a psychotic response to stress (Vulnerability) and that this relationship between stressors and vulnerability is an important factor in understanding risk factors for psychosis. Family tension may contribute to an individual’s stress and to the risk of relapse.

Other factors: include head injury, complications around birth. Alcohol misuse can cause alcohol-induced psychosis. Alcohol interferes with some anti-psychotic medications, causing poisoning in some cases and extreme drowsiness in others. Alcoholic misuse makes mental health problem worse. It adds to stress by making day to day living very difficult. All kinds of illegal drugs make mental health problems worse and more dangerous.

MENTAL HEALTH FIRST AID FOR PSYCHOSIS (2017) [10]

Assess the risk of suicide or self-harm:  People who are experiencing psychosis may be at risk of self-harm or, very rarely, of harming others. This can be associated with a longer duration of untreated psychosis.

A person can feel so weighed down and helpless that the future appears hopeless. They may think suicide is the only solution. If you feel that someone may be having such thoughts.

Engage the person in serious conversation about how the person is feeling: Let the person describe how and why he/she is feeling this way. Be aware of any cultural context that may have impact on why the person is feeling this way now. Be polite and respectful.

Identify if the person is at risk: Show that you care and ready to talk with them about any issues burdening them. This will give them great relief that someone cares. Listen non-judgmentally and do not be critical or express frustration with the person for having such symptoms.

Explore and assess how high the risk is by asking what the person is thinking about. Try to get more information about the person’s state of mind. Do not give advice such as ‘pull yourself together’, ‘be brave’ ‘be a man’.

Find out about their prior behavior by finding if they have attempted suicide before? If they do self-harm in any way or taking drugs in excess, driving faster, taking risks with sexual partners? Help the person to feel hope and optimism and to know that she or he can get medical help and/ or counseling/psychological help.

Find if they have people who support them and who they think they could run to for help. What resources do they have? You need to discourage the person from taking alcohol or drugs. Make sure the person is not alone. Plan and take the person to the hospital. Most people with mental health problems remain at home and receive care.

Try to create a calm, non-threatening atmosphere. Do not get too close to the person, being close may be dangerous and it may also make the person feel threatened.

For someone experiencing acute psychosis, do not argue with the person or get irritated or shout or criticise. Remember they are vulnerable and incongruent.

Encourage the person to use self-help strategies for example hearing voices network and recovery network. Support groups for people who experience psychosis. If the person has a loving family and friends they can help as well.

ANALYSIS

Three adults were interviewed and observed at different times of the year.

Case One

Peter is a Nigerian, a 42-year-old man. It was the case of drug-induced psychosis. He was forced to drink a concoction by the group of boys who captured him while in school. The induced fear in him and he continued to collect money for them and they rewarded him with more drugs mixed with what he was not sure. The concoction made him feel high, bold, and fearless and gave him great energy. He found it hard to concentrate or pay attention in the class since then. He became a member of the group and stopped going to classes completely. He did not do well in his exams and he was sent out of school. He became depressed, anxious and irritable. He began to suspect everyone around him and began to show inappropriate emotions. The drug they gave him eventually changed his appetite and lowered his energy and motivation.

He realized that there was a change in thinking and perception and sense of alteration of self, others or the outside world. He developed odd ideas that the world hated him. He began to attack the members of his group and he was thrown out and they even threatened to kill him. During the interview, he said that when he came back to his father’s house, they took him to a prayer place where the pastor claimed to be a psychiatric doctor. They bit him and forced him to take some medicines to calm him down. He never liked the place and the voices in the brain were telling him that he is getting mad. The treatments he received there were inhuman as he was left outside the building and beating either by surging rain or scourging sun. He hated his family for taking him there. He kept mentioning that his senior brother promised him a good job. That was before his condition changed but he still believed that he should be given the job no matter how he is. Severally, the family tried to see if he could be engaged in some activities but to no avail because he leaves the place and wonder around.

At some stage, he thought he got better and wanted to go back to school, but it was not possible. He was tested using [11]. He was not clear and steady in responding to some of the questions. It was clear that his mind is distorted and he could not think properly or cohesively. A 42-year-old man regenerated to 8-year-old boy in his thinking and actions (Participant, case one, 2019). To stop drinking was a bigger issue since he finds it difficult to control the urges. The family seems to get tired and abandoned him when he refuses to take his drugs. He shows signs of violence and aggression. He explained that the voices often want him to beat people but he has never done so. He is also afraid that the police will come for him though he would fight them.

Case two

This was a case of Kamande, a 54-year-old lady from Sierra Leone, diagnosed with paranoid Schizophrenia. Her misapprehension and delusion about others was very vivid. She has false beliefs about others that she cannot accept or eat anything prepared by other people. Often, she locks herself up in a room for a long time due to fear of people around her. These could be as a result of her beliefs of persecution, of guilt, of having a special mission or exalted birth or of being under outside control.

She hallucinates. This is false perception. It involves hearing voices. It can involve seeing, feeling, tasting or smelling things. These seemly made her to have incense and smelly creams that supposed to take away those suspected smells. These she perceived as very really to her. Hallucinations can be very frightening especially when voices make negative comments about person or contain unpleasant ideas. They may not be ready for alternative explanation. She would laugh alone and move out when she sensed that everyone has gone.

Anywhere she went and was giving a room; she locked it and made sure no one entered the room while she was away. She ended up locking several rooms in different places not her own. She was very paranoid and felt that everyone was talking negatively about her. Once she had a celebration and when people gathered to celebrate for her, she left them there and went away. She felt danger everywhere and would not share anything with another person. However, she could relate with domestic workers and chat with them. The writer experienced this lady personally and observed her for two years. There appeared to be an increased risk of suicidal behavior, particularly during the acute episode (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2013). This was clear when she locked herself in a room for days and the door was forced open. The room was stinking, supposedly because of lack of air and cleaning. She now decided to leave alone in a new apartment.

Case three

This was a referred case from Kenya who was initially diagnosed as a mental psychiatry illness and was sent to psychiatric hospital. She received treatment for six months and the condition did not change. She is 38 years old. She used to hear voices that tell her what to do irrespective of the realities around her. She came with her mother who made sure she followed her where the voices are leading for safety. The voices prevented her from eating most of the time. The mother could see her daughters’ hand been removed from the food but she would not hear the voices commanding. The voices often commanded her to stand up inside the vehicle while travelling. Due to that the mother always chooses the big buses where she could stand. When she was referred to me, for the four sessions we could not establish what it was. Then I applied focusing Healing therapy by Gendlin [12] and there she was able to see an image like a bundle filled with darkness. The image was moving and looking very angry. It was discovered that it was a spiritual case to deal with a spirit. The spirit made her feel paranoid most of the time. She was not violent but she could not listen to her mother except what the spirit said. She was not happy that no one could believe her and looked at her as a mad person. During one of the sessions, she was scared that the spirits would attack her on her way. She suggested visiting her Pastor. She was not able to dialogue with the voices as they seem to create fear and commanding tone in her. Hermans [13] talked about Valuation, innovation and critical personalism which helps one to get in touch with the self. She trusted the process of counseling but was scared each time the session is coming to an end. Jane believed strongly that those voices lived outside her but she could not engage in dialogue with them. The spirit seems to threaten violence if she disobeys them.

Okpalaenwe [7] explained what to do if a person experiencing psychosis is threatening violence.

Step 1

1.   Ensure your own personal safety. Do not get involve physically to stop the behavior (fight or to restrain the person, unless self-defense).

2.   Call the police. Tell them that the person has a mental illness and needs to get medical help. Ask them to send a plain-clothes police officer if available, so that the person will feel less threatened. You could also call the mental health crisis team.

3.   Try to create a calm, non-threatening atmosphere. Do not get too close to the person, being close may be dangerous and it may also make the person feel threatened.

4.   Do not try to reason with someone experiencing acute psychosis. Try not to express irritation or anger. Do not threaten, shout or criticize. It will probably make the person feel angrier or out of control.

5.   Express empathy for the person’s emotional distress. However, do not pretend that the delusions or voices are real to you.

6.   Comply with reasonable request voices that are somewhat in control. (Jesus and the demonic who he sent to the pigs) [14,7].

Step 2

Listen non-judgmental. Listen to the person without judging them as weak. Speak calmly, clearly and in short sentences. Do not be critical or express frustration. Do not offer advice such as ‘pull yourself together. Do not argue with a person about hallucinations or delusions. Accept that they are real for them but do not agree or make fun of it.

Step 3

Give assurance and information: you can only give assurance when the person is thinking more clearly and is in touch with reality, try to help the person to realize that you want to help them, they have a real medical condition. Psychosis (schizophrenia or bipolar disorder) is not a common illness but it is very well known and researched. Do not make promises that you cannot keep. Do not lie to them.

CONCLUSION

Psychosis is a disorder that affects the way your brain processes information. It makes one to lose touch with reality. You might see, hear, or believe things that are not real. Psychosis is a symptom, not an illness. A mental or physical illness, substance abuse, or extreme stress or trauma can cause it. Psychotic disorders, like schizophrenia, involve psychosis that usually affects you for the first time in the late teen years or early adulthood. Young people are especially likely to get it, but doctors do not know why. Even before what doctors call the first episode of psychosis (FEP), you may show slight changes in the way you act or think. This is called the prodromal period and could last days, weeks, months, or even years. The experiences from the three clients show that the behaviors varied according to issues presented. The treatments used were different and varied. It still remains difficult to understand exactly what goes on in the brain. 

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