Psychosis

Psychosis (from the Ancient Greek ψυχή "psyche", for mind/soul, and -ωσις "-osis", for abnormal condition or derangement) means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are described as psychotic. Psychosis is given to the more severe forms of psychiatric disorder, during which hallucinations and delusions and impaired insight may occur. Some professionals say that the term psychosis is not sufficient as some illnesses grouped under the term "psychosis" have nothing in common. Indeed, a complex constellation of neurological and psychological factors can result in the altered signaling observed in psychosis. In otherwise normal individuals, exogenous ligands can produce psychotic symptoms. NMDA receptor antagonists, such as ethanol and ketamine, can replicate a similar psychosis to that experienced in schizophrenia.
Prolonged or high dose use of stimulants will alter of function like the manic phase of bipolar disorder. NMDA antagonists replicate some of the so-called "negative" symptoms e.g., thought disorder in subanesthetic doses, and catatonia in high doses. Stimulants, especially in one already prone to psychotic thinking, can cause some "positive" symptoms, such as delusional beliefs, particularly those persecutory in nature. However, some positive symptoms lack a simple neurotransmitter-based explanation, specifically, the auditory hallucinations observed in schizophrenia. These have a much more complex genesis, involving abnormal synaptic plasticity, and the formation of a "parallel process" within the brain. Of specific interest is the entorhinal cortex, which has far fewer indirect connections to the tertiary auditory cortex, as well as direct connections to the hippocampus, the most active region of neurogenesis in the adult brain.
The terms psychosis and psychotic are very broad and can mean anything from relatively normal aberrant experiences through to the florid and catatonic expressions of schizophrenia and bipolar type 1 disorder. Despite this, psychosis is a term generally given to noticeable deficits in normal behavior (known as deficit or negative signs) or more commonly to the florid experiences of hallucinations or delusional beliefs. People experiencing psychosis may exhibit personality changes and thought disorder. Depending on its severity, this may be accompanied by unusual or bizarre behavior, as well as difficulty with social interaction and impairment in carrying out daily life activities. It is also important to note that psychosis usually refers to negative expressions, that is paranoia, stereotypy etc. rather than ecstatic experience such as religious ecstasy, though with such a broad term, there are no hard and fast rules.
A wide variety of central nervous system diseases, from both external poisons and internal physiologic illness, can produce symptoms of psychosis.
==Signs and symptoms==
People with psychosis may have one or more of the following: hallucinations, delusions, catatonia, or a thought disorder, as described below.
===Hallucinations===
A hallucination is defined as sensory perception in the absence of external stimuli. Hallucinations are different from illusions, or perceptual distortions, which are the misperception of external stimuli. Hallucinations may occur in any of the five senses and take on almost any form, which may include simple sensations (such as lights, colors, tastes, and smells) to experiences such as seeing and interacting with fully formed animals and people, hearing voices, and having complex tactile sensations.
Auditory hallucinations, particularly experiences of hearing voices, are a common and often prominent feature of psychosis. Hallucinated voices may talk about, or to, the person, and may involve several speakers with distinct personas. Auditory hallucinations tend to be particularly distressing when they are derogatory, commanding or preoccupying. However, the experience of hearing voices need not always be a negative one. One research study has shown that the majority of people who hear voices are not in need of psychiatric help. The Hearing Voices Movement has subsequently been created to support voice hearers, regardless of whether they are considered to have a mental illness or not.
===Delusions===
Psychosis may involve delusional beliefs, some of which are paranoid in nature. Karl Jaspers has classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions may be understood as being influenced by the person's background or current situation (e.g., ethnicity, religious beliefs, superstitious belief).
===Catatonia===
Catatonia describes a profoundly agitated state in which the experience of reality is generally considered to be impaired. There are two primary manifestations of catatonic behavior. The classic presentation is a person who does not move or interact with the world in any way while awake. This type of catatonia presents with waxy flexibility. Waxy flexibility is when someone physically moves part of a catatonic person's body and the person stays in the position even if it is bizarre and otherwise nonfunctional (such as moving a person's arm straight up in the air and the arm stays there). The other type of catatonia is more of an outward presentation of the profoundly agitated state described above. It involves excessive and purposeless motor behavior as well as extreme mental preoccupation which prevents intact experience of reality. An example would be someone walking very fast in circles to the exclusion of anything else with a level of mental preoccupation (meaning not focused on anything relevant to the situation) that was not typical of the person prior to the symptom onset. In both types of catatonia there is generally no reaction to anything that happens outside of them. It is important to distinguish catatonic agitation from severe bipolar mania although someone could have both.
===Thought disorder===
Thought disorder describes an underlying disturbance to conscious thought and is classified largely by its effects on speech and writing. Affected persons show loosening of associations, that is, a disconnection and disorganization of the semantic content of speech and writing. In the severe form speech becomes incomprehensible and it is known as Schizophasia.
==Psychiatric disorders==
From a diagnostic standpoint, organic disorders were those held to be caused by physical illness affecting the brain (that is, psychiatric disorders secondary to other conditions), while functional disorders were considered to be disorders of the functioning of the mind in the absence of physical disorders (that is, primary psychological or psychiatric disorders). The materialistic view of the mind-body problem holds that mental disorders arise from physical processes; in this view, the distinction between brain and mind, and therefore between organic and functional disease, is an artificial one. Subtle physical abnormalities have been found in illnesses traditionally considered functional, such as schizophrenia. The DSM-IV-TR avoids the functional/organic distinction, and instead lists traditional psychotic illnesses, psychosis due to general medical conditions, and substance-induced psychosis.
Primary psychiatric causes of psychosis include the following:
*Schizophrenia and schizophreniform disorder
*Affective (mood) disorders, including severe clinical depression, and severe depression or mania in bipolar disorder (manic depression). People experiencing a psychotic episode in the context of depression may experience persecutory or self-blaming delusions or hallucinations, while people experiencing a psychotic episode in the context of mania may form grandiose delusions.
*Schizoaffective disorder, involving symptoms of both schizophrenia and mood disorders
*Brief psychotic disorder, or acute/transient psychotic disorder
*Delusional disorder (persistent delusional disorder)
*Chronic hallucinatory psychosis
Psychotic symptoms may also be seen in:
*Schizotypal disorder
*Certain personality disorders at times of stress (including paranoid personality disorder, schizoid personality disorder, and borderline personality disorder)
*Major depressive disorder in its severe form although it is possible and more likely to have severe depression without psychosis
*Bipolar disorder in severe mania and/or severe depression although it is possible to have severe mania and/or severe depression without psychosis as well, in fact that is more commonly the case
*Post-traumatic stress disorder
*Induced delusional disorder
*Sometimes in obsessive-compulsive disorder
Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks. In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times.
===Normal states===
*Bereavement, in which hallucinations of a deceased loved one are common
*Severe sleep deprivation
*Sensory deprivation and sensory impairment
*Caffeine intoxication
===Medical conditions===
A very large number of medical conditions can cause psychosis, sometimes called secondary psychosis. Examples include:
*Disorders causing delirium (toxic psychosis), in which consciousness is disturbed
*Neurodevelopmental disorders and chromosomal abnormalities, including DiGeorge syndrome
*Neurodegenerative disorders, such as Alzheimer's disease
*Focal neurological disease, such as stroke, brain tumors, and some forms of epilepsy
*Malignancy (typically via masses in the brain, paraneoplastic syndromes, or drugs used to treat cancer)
*Infectious and post-infectious syndromes, including infections causing delirium, viral encephalitis, HIV, malaria, Lyme disease, and syphilis
*Endocrine disease, such as hypothyroidism, hyperthyroidism, adrenal gland failure, Cushing's syndrome, hypoparathyroidism and hyperparathyroidism; sex hormones also affect psychotic symptoms and sometimes childbirth can provoke psychosis, termed puerperal psychosis
*Inborn errors of metabolism, such as porphyria and metachromatic leukodystrophy
*Nutritional deficiency, such as vitamin B12 deficiency
*Other acquired metabolic disorders, including electrolyte disturbances such as hypocalcemia, hypernatremia, hyponatremia, hypokalemia, hypomagnesemia, hypermagnesemia, hypercalcemia, hypophosphatemia, hypoxia, and failure of the liver or kidneys
*Autoimmune and related disorders, such as lupus, sarcoidosis, Hashimoto's encephalopathy, and anti-NMDA receptor encephalitis
*Poisoning, by therapeutic drugs, recreational drugs, and a range of plants, fungi, metals, organic compounds, and a few animal toxins
*Some sleep disorders, including hallucinations in narcolepsy (in which REM sleep intrudes into wakefulness)
Psychosis can even be caused by familiar ailments such as flu or mumps.
===Recreational drugs===
Various psychoactive substances (both legal and illegal) have been implicated in causing, exacerbating, and/or precipitating psychotic states and/or disorders in users. This may be upon intoxication, for a more prolonged period after use, or upon withdrawal. Drugs that can induce psychotic symptoms include amphetamines, caffeine (which can worsen psychotic symptoms in schizophrenia and produce olfactory hallucinations at very high doses in normal volunteers), cannabis, cocaine, desoxypipradrol, dimethyltryptamine,[alcohol, inhalants, gamma-Hydroxybutyric acid (and its precursors gammabutyrolactone and 1,4-Butanediol), ketamine, LSD, mephedrone, methcathinone, mescaline and other phenethylamine hallucinogens, methamphetamine, MDMA (very rarely, likely due to different phenethylamines that are sometimes sold as MDMA, or even piperazine derivatives sold as "ecstasy"), opiates such as heroin, phencyclidine, piperazine-based drugs, psilocybin, and anabolic steroids at high doses.
Frequent users of cannabis have twice the likelihood of developing both psychosis and schizophrenia. Older studies indicate that certain strains containing large proportions of tetrahydrocannabinol and low proportions of cannabidiol merely lowers the threshold for psychosis, and thus helps to trigger full-blown psychosis in some people. On the other hand, cannabis use has increased dramatically over the past few decades but declined in the last decade, whereas the rate of psychosis has not increased. This suggests cannabis generally only hastens the onset of psychosis in those who would otherwise only become psychotic at a later date.
Another interpretation of these results is that maladaptive coping mechanisms are a root cause of schizophreniform disorders, and psychological disorders in general. These may be a "normal" response to the altered reelin, 5-HT, dopamine, and other plasticity-regulating neurotransmitters. Given the poorly understood nature of the endocannabinoid system, it will take many more generations of progress to even scratch the surface of the extraordinarily complex mechanisms that control neurological development/degeneration.
===Medication===
Administration, or sometimes withdrawal, of a large number of medications may provoke psychotic symptoms. Drugs that can induce psychosis experimentally and/or in a significant proportion of patients include amphetamines and other sympathomimetics, dopamine agonists, ketamine, corticosteroids (often with mood changes in addition), and some anticonvulsants such as vigabatrin.
==Pathophysiology==
The first brain image of an individual with psychosis was completed as far back as 1935 using a technique called pneumoencephalography (a painful and now obsolete procedure where cerebrospinal fluid is drained from around the brain and replaced with air to allow the structure of the brain to show up more clearly on an X-ray picture).
The purpose of the brain is to collect information from the body (pain, hunger, etc.), and from the outside world, interpret it to a coherent worldview, and produce a meaningful response. The information from the senses enter the brain in the primary sensory areas. They process the information and send it to the secondary areas where the information is interpreted. Spontaneous activity in the primary sensory areas may produce hallucinations which are misinterpreted by the secondary areas as information from the real world.
For example, a PET scan or Functional MRI scan of a person who claims to be hearing voices may show activation in the primary auditory cortex, or parts of the brain involved in the perception and understanding of speech.
Tertiary brain cortex collects the interpretations from the secondary cortices and creates a coherent worldview of it. A study investigating structural changes in the brains of people with psychosis showed there was significant grey matter reduction in the temporal lobe, and inferior frontal gyrus, and in the cingulate cortex bilaterally of people before and after they became psychotic. Findings such as these have led to debate about whether psychosis itself causes excitotoxic brain damage and whether potentially damaging changes to the brain are related to the length of psychotic episode. Recent research has suggested that this is not the case although further investigation is still ongoing.
Studies with sensory deprivation have shown that the brain is dependent on signals from the outer world to function properly. If the spontaneous activity in the brain is not counterbalanced with information from the senses, loss from reality and psychosis may occur after some hours. A similar phenomenon is paranoia in the elderly when poor eyesight, hearing and memory causes the person to be abnormally suspicious of the environment.
On the other hand, loss from reality may also occur if the spontaneous cortical activity is increased so that it is no longer counterbalanced with information from the senses. The 5-HT2A receptor seems to be important for this, since psychedelic drugs which activate them produce hallucinations.
However, the main feature of psychosis is not hallucinations, but the inability to distinguish between internal and external stimuli. Close relatives to psychotic patients may hear voices, but since they are aware that they are unreal they can ignore them, so that the hallucinations do not affect their reality perception. Hence they are not considered to be psychotic.
Psychosis has been traditionally linked to the neurotransmitter dopamine. In particular, the dopamine hypothesis of psychosis has been influential and states that psychosis results from an overactivity of dopamine function in the brain, particularly in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine receptor D2 blocking drugs (i.e., antipsychotics) tend to reduce the intensity of psychotic symptoms, and that drugs which boost dopamine activity (such as amphetamines and cocaine) can trigger psychosis in some people. However, increasing evidence in recent times has pointed to a possible dysfunction of the excitatory neurotransmitter glutamate, in particular, with the activity of the NMDA receptor. This theory is reinforced by the fact that dissociative NMDA receptor antagonists such as ketamine, PCP and dextromethorphan (at large overdoses) induce a psychotic state more readily than dopaminergic stimulants, even at "normal" recreational doses. The symptoms of dissociative substance intoxication are also considered to mirror the symptoms of schizophrenia, including negative psychotic symptoms, more closely than amphetamine psychosis. Dissociative induced psychosis happens on a more reliable and predictable basis than amphetamine psychosis, which usually only occurs in cases of overdose, prolonged use or with sleep deprivation, which can independently produce psychosis. New antipsychotic drugs which act on glutamate and its receptors are currently undergoing clinical trials.
The connection between dopamine and psychosis is generally believed to be complex. While dopamine receptor D2 suppresses adenylate cyclase activity, the D1 receptor increases it. If D2-blocking drugs are administered the blocked dopamine spills over to the D1 receptors. The increased adenylate cyclase activity affects genetic expression in the nerve cell, a process which takes time. Hence antipsychotic drugs take a week or two to reduce the symptoms of psychosis. Moreover, newer and equally effective antipsychotic drugs actually block slightly less dopamine in the brain than older drugs whilst also blocking 5-HT2A receptors, suggesting the 'dopamine hypothesis' may be oversimplified. Soyka and colleagues found no evidence of dopaminergic dysfunction in people with alcohol-induced psychosis and Zoldan et al. reported moderately successful use of ondansetron, a 5-HT3 receptor antagonist, in the treatment of levodopa psychosis in Parkinson's disease patients.
Psychiatrist David Healy has criticized pharmaceutical companies for promoting simplified biological theories of mental illness that seem to imply the primacy of pharmaceutical treatments while ignoring social and developmental factors which are known to be important influences in the cause of psychosis.
Some theories regard many psychotic symptoms to be a problem with the perception of ownership of internally generated thoughts and experiences. For example, the experience of hearing voices may arise from internally generated speech that is mislabeled by the psychotic person as coming from an external source.
It has been suggested that persons with bipolar disorder may have increased activity of the left hemisphere compared to the right hemisphere of the brain, while persons with schizophrenia have increased activity in the right hemisphere.
Increased level of right hemisphere activation has also been found in people who have high levels of paranormal beliefs and in people who report mystical experiences. It also seems to be the case that people who are more creative are also more likely to show a similar pattern of brain activation. Some researchers have been quick to point out that this in no way suggests that paranormal, mystical or creative experiences are in any way by themselves a symptom of mental illness, as it's still not clear what makes some such experiences beneficial and others distressing.
==Diagnosis==
Diagnosing the presence and/or extent of psychosis may be distinguished from diagnosing the cause of psychosis.
The presence of psychosis is typically diagnosed by clinical interview, incorporating mental state examination. Its extent may be established by formal rating scales. The Brief Psychiatric Rating Scale assesses the level of 18 symptom constructs of psychosis such as hostility, suspicion, hallucination, and grandiosity. It is based on the clinician's interview with the patient and observations of the patient's behavior over the previous 2–3 days. The patient's family can also provide the behavior report. During the initial assessment and the follow-up, both positive and negative symptoms of psychosis can be assessed using the 30 item Positive and Negative Symptom Scale.
Establishing the cause of psychosis requires clinical examination, and sometimes special investigations, to diagnose or exclude secondary causes of psychosis; if these are excluded, a primary psychiatric diagnosis can be established.
==Treatment==
The treatment of psychosis depends on the cause or diagnosis or diagnoses (such as schizophrenia, bipolar disorder and/ or substance intoxication). The first line treatment for many psychotic disorders is antipsychotic medication (oral or intramuscular injection), and sometimes hospitalization is needed. There is growing evidence that cognitive behavioral therapy and family therapy can be effective in managing psychotic symptoms. When other treatments for psychosis are ineffective, electroconvulsive therapy is sometimes applied to relieve the underlying symptoms of psychosis due to depression. There is also increasing research suggesting that animal-assisted therapy can contribute to the improvement in general well-being of people with schizophrenia.
===Early intervention===
Early intervention in psychosis is a relatively new concept based on the observation that identifying and treating someone in the early stages of a psychosis can significantly improve their longer term outcome. This approach advocates the use of an intensive multidisciplinary approach during what is known as the critical period, where intervention is the most effective, and prevents the long term morbidity associated with chronic psychotic illness.
Newer research into the effectiveness of cognitive behavioral therapy during the early pre-cursory stages of psychosis (also known as the "prodrome" or "at risk mental state") suggests that such input can prevent or delay the onset of psychosis.
==History==
The word psychosis was introduced to the psychiatric literature in 1841 by Karl Friedrich Canstatt in his work Handbuch der Medizinischen Klinik. He used it as a short-hand for 'psychic neurosis'. At that time neurosis meant any disease of the nervous system, and Cannstatt was thus referring to what was thought to be a psychological manifestation of brain disease. Ernst von Feuchtersleben is also widely credited as introducing the term in 1845, as an alternative to 'insanity]' and 'mania'.
The term stems from the Greek ψύχωσις (psychosis), "a giving soul or life to, animating, quickening" and that from ψυχή (psyche), "soul" and the suffix -ωσις (-osis), in this case "abnormal condition".
The word was also used to distinguish disorders which were thought to be disorders of the mind, as opposed to "neurosis", which was thought to be a disorder of the nervous system. The psychoses thus became the modern equivalent of the old notion of madness, and hence there was much debate on whether there was only one (unitary) or many forms of the new disease. One type of broad usage would later be narrowed down by Julius Ludwig August Koch in 1891 to the 'psychopathic inferiorities' - later renamed abnormal personalities by Kurt Schneider.
The division of the major psychoses into manic depressive illness (now called bipolar disorder) and dementia praecox (now called schizophrenia) was made by Emil Kraepelin, who attempted to create a synthesis of the various mental disorders identified by 19th century psychiatrists, by grouping diseases together based on classification of common symptoms. Kraepelin used the term 'manic depressive insanity' to describe the whole spectrum of mood disorders, in a far wider sense than it is usually used today. In Kraepelin's classification this would include 'unipolar' clinical depression, as well as bipolar disorder and other mood disorders such as cyclothymia. These are characterized by problems with mood control and the psychotic episodes appear associated with disturbances in mood, and patients will often have periods of normal functioning between psychotic episodes even without medication. Schizophrenia is characterized by psychotic episodes which appear to be unrelated to disturbances in mood, and most non-medicated patients will show signs of disturbance between psychotic episodes.
During the 1960s and 1970s, psychosis was of particular interest to counterculture critics of mainstream psychiatric practice, who argued that it may simply be another way of constructing reality and is not necessarily a sign of illness. For example, R.D. Laing argued that psychosis is a symbolic way of expressing concerns in situations where such views may be unwelcome or uncomfortable to the recipients. He went on to say that psychosis could be also seen as a transcendental experience with healing and spiritual aspects. Arthur J. Deikman suggested use of the term "mystical psychosis" to characterize first-person accounts of psychotic experiences that are similar to reports of mystical experiences. Thomas Szasz focused on the social implications of labeling people as psychotic, a label he argues unjustly medicalizes different views of reality so such unorthodox people can be controlled by society. Psychoanalysis has a detailed account of psychosis which differs markedly from that of psychiatry. Freud and Lacan outlined their perspective on the structure of psychosis in a number of works.
Since the 1970s, the introduction of a recovery approach to mental health, which has been driven mainly by people who have experienced psychosis (or whatever name is used to describe their experiences), has led to a greater awareness that mental illness is not a lifelong disability, and that there is an expectation that recovery is possible, and probable with effective support.
==Subtypes==
Subtypes of psychosis include:
*Menstrual psychosis, including circa-mensual (approximately monthly) periodicity, in rhythm with the menstrual cycle.
*Postpartum psychosis, occurring recently after childbirth
*Monothematic delusions
*Myxedematous psychosis
*Occupational psychosis
*Stimulant psychosis
*Tardive psychosis
*Shared psychosis
*Cycloid psychosis
===Cycloid psychosis===
Cycloid psychosis is psychosis that progresses from normal to full-blown usually within a few hours, not related to drug intake or brain injury. In addition, diagnostic criteria include at least four of the following symptoms:
*Confusion
*Mood-incongruent delusions
*Hallucinations
*Pan-anxiety, a severe anxiety not bound to particular situations or circumstances
*Happiness or ecstasy of high degree
*Motility disturbances of akinetic or hyperkinetic type
*Concern with death
*Mood swings to some degree, but less than what is needed for diagnosis of an affective disorder.
Cycloid psychosis occurs in people of generally 15–50 years of age.
==On the series==
===The Perfect Mom===
Margo Dalton was a dedicated and busy mother and businesswoman who was admitted when she started having uncontrollable flailing movements. She was initially given vecuronium to control the flailing, but as the obvious causes of those symptoms were ruled out, she was weaned off the drug. However, once she started having spasms again, she started snapping at her husband and daughter. This convinced Eric Foreman, who was temporarily in charge of the diagnostics department because House was being disciplined, that the patient had Huntington's disease and needed treatment with valproic acid. House resisted, but when the patient started suffering from severe psychosis, House gave in despite the risk of liver damage.
However, the tests for Huntington's were negative. Further investigation showed that she was also using ritalin, which had actually been prescribed for her daughter. As she was improving, she was ordered discharged. However, before she was, she suffered a stroke. After further investigation, they found a liver tumor, which also explained the psychosis.
House wasn't convinced. Instead of focussing on the symptoms, he started looking at the patient's personality - Margo was a person who avoided confrontation and loved to please people. She was trying to have another child by using fertility treatments, but House wondered why when she already had a daughter and was stretched to the limit professionally. He suddenly realized something else would cause psychosis and all the other symptoms - her being on a contraceptive pill together with the fertility treatments.
Dr. House confronted Margo with his conclusions, but she denied it and insisted on surgery to remove the tumor, even thought if House was right it would disappear on its own if she just got off both the pill and fertility treatments. After the surgery, she asked Foreman if she could lie to her husband and say it was a bad idea for her to have more children. However, he refused.
===The Break===
Gregory House goes through a lengthy period of psychosis in Season 5, suffering from hallucinations (of Amber Volakis, who relentlessly mocks him) and delusions (that he has both given up his Vicodin habit and had sex with Lisa Cuddy).
However, the key feature of House's psychosis is how normal he seems to everyone around him. This is not atypical with certain types of psychosis, in which the delusions are not bizarre and the person suffering from the condition can still correctly perceive what is going on around them, even going as far as making rational judgments on how to deal with the delusional situations.
Despite this, as the psychosis progresses, House clearly starts losing his skills, instead becoming obsessed with his own condition and Cuddy's "inexplicable" indifference to him after an intimate night together. Although it is clear that House has one foot solidly in reality and reason, the other foot is floating through fantasy and intuition.
Ironically, his best ideas during this period come from Amber, who taps into the more intuitive part of House that can assimilate more information unconsciously than he is able to handle consciously. Even with Wilson double checking his every move, his team starts to recognize that there is something wrong with their boss' skills even as his behavior only seems a bit more quirky than normal.
In the end, it is only when his delusions are broken that his rational mind can see enough to realize he's too far gone to help himself. House eventually enters Mayfield Psychiatric Hospital to seek treatment.
However, the next time this break with reality happens is at the end of the series in Everybody Dies when his psychosis returns with a vengeance after he indulges in heroin with a junkie.
However, this time, he's able to work through the issues on his own and even comes up with a plan to save what few months left he has with Wilson who was diagnosed with stage II thymoma, a terminal and fatal form of cancer.
===The Incident===
Bill Koppelman was admitted when he collapsed while jogging. He regained consciousness after being given steroids and his symptoms were determined to be caused by inhaling caustic chemicals. He improved greatly when given a risky treatment of aerosolized heparin and was about to be discharged when he started to become agitated while being given a bath.
Park was sure it was steroid induced psychosis, while Adams thought it was a staphylococcus infection and Taub argued for granulomatosis with polyangiitis. House finally realized that steroids would make the perfect test. The patient would either get more psychotic, proving Park right, would develop a fever, proving Adams right, or get better, proving House right.
However, Chase thought Adams was right and agreed to help her do a skin biopsy. They went into the room with a biopsy kit containing a dose of lidocaine and a scalpel. However, the patient's psychosis manifested itself when Adams went to give him the lidocaine, and Chase had to struggle with the patient to keep him from hurting Adams. Unfortunately, in the scuffle, Chase was badly cut with the scalpel and needed emergency surgery to repair a wound to his heart and repair a hole in a major artery.
===The Perfectionist===
Peter Treiber was a pathologist who was hated by just about everyone in the hospital for his constant criticism of the competence of the other doctors. When he developed psychosis, he refused to be treated by anyone other than Dr. House.
When it was discovered that Dr. Treiber had been consuming large amounts of caffeine, House jumped to the conclusion that it was stimulant psychosis, which only needed fluids and observation. He left on a road trip with Wilson.
However, Dr. Treiber just continued to get worse, and his psychosis was intermittent. Robert Chase, who had a rivalry with Treiber dating back to the time Chase beat him out for a fellowship with House, decided to treat Trieber without letting him know House had left the hospital. Chase was sure that Treiber had screwed up somehow while he was working in the morgue and became infected by one of the cadavers he examined.
This line of inquiry turned out to be fruitless and Treiber lapsed into a coma. However, Chase finally hit on the right answer - hypothyroidism. It was set off by Treiber's antibacterial soap, which contained chemicals that mimicked thyroid hormones and made the body produce fewer of them. It was exacerbated by the caffeine, which further drove his hormone levels down. As a final coup de grace, when the emergency room gave him sedatives for his psychosis, those completely shut down his thyroid. Treiber came out of his coma quickly once he was given thyroid hormones.
===Other appearances===
*Jessica Simms exhibits psychosis related to her Cushing's disease.
*In House vs. God, House tries to explain Boyd's religious experiences as a manifestation of psychosis.
*In The Right Stuff, Greta Cooper has a psychotic episode after suffering from a hallucination during a procedure.
*In Emancipation, Lawrence Kutner gets into trouble when he gives Sophia steroids instead of beta blockers and she develops psychosis as a result.
*In Carrot or Stick, Driscoll has a psychotic break when Martha M. Masters attempted to take a blood sample. An antihistamine overdose was the first diagnosis, but it was later determined to be variegate porphyria.
*In Recession Proof, Bert Eskey has psychosis that manifests as paranoia. It was thought to be due to the steroids they gave him, but he was finally diagnosed, too late, with Muckle-Wells syndrome.
==See also==
*Delusion
*Hallucination
==External links==
*psychosis-bipolar.com - For people afflicted, relatives, and professionals: information, trialog, interactive therapy portal
*Understanding psychotic experiences from mental health charity Mind
This article was the featured article for July, 2012. It was the first featured article to feature a symptom.
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