It has long been believed that a person is either psychotic, or not psychotic. There is no grey area, or ‘just a little bit psychotic.’ However, this may not be entirely true. Since psychosis is not a disorder in itself, but rather a set of symptoms with a myriad of causes, it becomes important that it is detected early, in order to provide the appropriate interventions.1
If psychosis is viewed as a spectrum or a continuum, much like autism or schizophrenia, it becomes easier to identify those at acute end of the spectrum who are at risk of developing clinical psychosis and the associated disorders such as schizophrenia, psychotic mood disorder, and bipolar disorder. With this change in perspective, more effective treatments can be explored.
Looking Below the Threshold
When a patient presents with only one diagnostic criterion for psychosis, such as delusions or hallucinations without an altered view of reality, they are considered sub-threshold. Until recently, this has been diagnostically insignificant. However, when these sub-threshold psychotic experiences (PEs) are taken into consideration and placed on a spectrum, a broader picture begins to emerge. This not only allows for closer study of the development of clinical psychosis, but also provides the patient with greater support, better education of their risk of developing a psychotic disorder, and access to possible interventions that may minimize that risk.
In a 2012 study on psychosis, the growing body of evidence supporting the theory of a psychotic spectrum or continuum, with demonstrably high rates of sub-threshold psychotic experiences, was acknowledged.2 The authors grouped PEs into five groups expressed across the spectrum: “(1) absence of psychosis, (2) subclinical psychotic experiences, (3) low-impact psychotic symptoms, (4) high-impact psychotic symptoms, and (5) full-blown clinical psychotic disorder.” When viewed in a range such as this, the number of people experiencing some form of psychosis is increased and a larger portion of the general population may be adversely affected by psychosis.
A cross-national analysis of community based surveys3 led by John McGrath, from the University of Queensland, suggests that many otherwise healthy people report PEs of hallucinations and delusions. Indeed, 14% of respondents from a general population survey responded that they “often or very often” experienced psychotic symptoms in the previous year.4 A large proportion of the people who develop a psychotic disorder initially experience sub-threshold psychosis. The early diagnosis and treatment would allow patients and medical practitioners to monitor the progress of PEs and perhaps even prevent the worsening of symptoms and the eventual full-blown clinical psychotic disorder.