‘Most people recover from psychosis’

Prof. dr. dr. Stijn Vanheule (47) is professor of psychology and psychoanalysis at Ghent University. He is an expert in the field of psychosis and psychiatric diagnosis. In 2021 his book Why a psychosis is not so crazy (Publisher LannooCampus) was published.

What is the reason you wrote this book, Why Psychosis Isn’t So Crazy?

“Many people have a stereotypical image of psychosis. Patients fear that they will never get rid of it and will have to take heavy pills for the rest of their lives. Bystanders immediately think of dangerous madmen, whom they would rather have nothing to do with. I thought it was high time to paint a different picture. An image of hope instead of despair. Most people who have psychotic experiences recover. And often such a psychotic episode is a one-off.”

Where does your fascination for psychosis come from?

“I had a great-aunt who had psychotic experiences. That fascinated me even as a child. But when it came up in the family, my grandmother said: ‘Shut up, that will keep the children awake.’ When I started working with psychotic patients as a psychologist, I talked about this with family members. I discovered that the taboo surrounding psychosis also ran in our family: don’t talk to people who have psychotic experiences, you’ll make it worse. In the meantime, I noticed that it actually helped my patients to talk about it.”

Psychotic experiences are usually triggered by a deep personal crisis, you say. Can you explain that?

“When faced with something particularly difficult, your mind can run wild. For example, if you lose your partner or your job. Such an experience can be so confusing that you have no words for it and do not know how to maintain it. As a result, the basic trust in yourself and reality can disappear. This can lead to a derailment in thinking and perception: for example, you think that your thoughts are no longer your own, reality behaves differently: sometimes strangers whisper messages in your ear, you see things that are not there. Those strange, frightening sensations, delusions, and hallucinations can completely disrupt your thoughts.”

How many people experience psychosis in their lives?

“Research shows that 15 percent of the population has experienced mild psychotic experiences at some point. These are people who occasionally hear voices, or sometimes see things that don’t match reality. For one in a hundred people, the impact of psychotic experiences is so great and undermines the sense of reality so severely that psychiatric treatment is necessary. Sometimes there is a sensitivity in the family. But you can’t predict who will get psychosis based on family history; the environment also contributes to vulnerability. For example, people who experienced trauma in their youth seem to respond more quickly to stressful events with symptoms of psychosis.”

Isn’t psychosis primarily a brain disease?

“Of course the brain plays a role, but that applies to all our experiences. We know from research that the brain produces more dopamine during psychosis. That is a messenger substance, marking what is important and needs to be given more meaning. As a result, things that are usually not important are now considered important and someone can become overstimulated. That is not to say that the increase in dopamine is the cause. That link is made too quickly, while there is no scientific evidence for it.”

Are psychoses more common in the elderly?

“The most vulnerable period is young adulthood. But psychosis can show up at any time in life. There are many people who only have psychotic experiences as they get older. Sometimes it is difficult to distinguish between onset dementia and psychotic experiences. People with early stages of dementia may also feel that they have no words for what is happening to them and become suspicious. It is important to take the time to make a correct diagnosis.”

Is delirium also a form of psychosis?

“Delirium also involves confusion. That can resemble psychotic experiences. The difference is that delirium has a physical cause; medication or an infection, for example. Once the medication has worn off or the infection has subsided, the confusion disappears.”

How can psychosis best be treated?

“Almost always anti-psychotic drugs are given. Research shows that these only work well in a quarter of the patients. Half of them have to compromise between the benefits and often serious side effects, such as loss of control over the musculoskeletal system. A quarter was not helped at all; sometimes drugs actually make the psychotic experiences worse. I think it should be handled much more carefully, by examining the effects in each patient and looking for the lowest possible dose. It is at least as important to enter into a dialogue with people who are psychotic, no matter how confused a person may be. Good care providers are not deterred by the bizarre nature of a psychosis. We now know that good guidance and psychotherapy can make the difference.”

What is needed for that?

“As a therapist you stand next to someone: ‘I’m here, we can talk. Even though I don’t understand what you’re saying right now, I’m going to try. Maybe we can think together why you’re having such a hard time.’ What manifests in a psychosis is not total nonsense. Often those strange thoughts refer to something that is bothering someone. The trick is to find out what, and to find words for it. During a psychosis a kind of private language emerges, which people do not share. If you can help them to name what is going on in them, peace often arises and the psychotic experiences diminish. But it is often difficult for practitioners to remain calm in the face of the intense cry for help they hear.”

Can talking about those strange experiences also make psychosis worse?

“The crisis can temporarily intensify, because you are approaching the difficult point. As long as you let the patient decide what they want to talk about, that shouldn’t be a problem. It is important to act quickly. In the first weeks, many psychotic people are still open to contact. If you can really connect, the psychotic experiences can disappear after a few days or weeks. But with someone who has been trapped in psychosis for years, the chance of recovery is much smaller.”

What can relatives and friends do?

“Try to listen, even if your friend or family member says strange things. The reflex is to run away or to counteract: what you see is not right! But as bizarre as it may be, the person with a psychosis experiences it as real. One who hears voices is not pretending! He really hears those voices. If you deny that, he or she will feel even lonelier. It’s better to say, “I don’t hear those voices, but I notice that you do hear them.” Furthermore, it is important to continue doing the usual things you used to do together as much as possible: drinking coffee, going for a walk. Not only does that reduce the feeling of isolation, it can also make someone more in touch with reality.”

This article previously appeared in Plus Magazine March 2022. Want to subscribe to the magazine? You can do that in an instant!