This post will be rather long and likely in a bit different format than many will be, due to the fact that I wrote this a while back for my family. Hopefully it makes sense and is interesting to read. As stated previously, this is sort of intended to be a bit of background on me, I suppose. Without further ado, let’s begin.
I have a historical affiliation with psychosis and schizophrenia. I have spent hours upon hours studying and researching schizophrenia, and as such I believe that I have come to have a relatively competent understanding of schizophrenia. Despite this, there are still new things that I sometimes find regarding this topic. An instance of this relatively recently (at the time of writing) was the relationship between psychosis and traumatic brain injury. This paper will look at three specific topics: psychosis, post-concussion syndrome and traumatic brain injury, and my reason for this sort of research.
First, we will look at psychosis, largely at what it is. Psychosis is not a disease, rather it is the name for a group of symptoms, specifically when multiple symptoms in the group are seen together (Carey). Psychosis is also characteristic of a classification of mental disorders: psychotic disorders. As one may or may not have realized, schizophrenia is one of the disorders in the psychotic disorder classification. According to Healthline, psychosis is “characterized by an impaired relationship with reality (Carey).” The most obvious forms of this impairment are with hallucinations and delusions; however, there are many more types of symptoms than just these two. In fact, the Diagnostic and Statistical Manual of Mental Disorders considers the term “psychotic” in relation to the specific psychotic disorders, giving varying degrees of severity (American Psychiatric Association 297-298). That said, we will be looking at the array of symptoms that might be seen with schizophrenia. We will split these symptoms up, first looking at more general symptoms, the positive symptoms, and then the negative symptoms.
General symptoms are those that are more non-specific and are usually not considered core symptoms of psychotic disorders, but instead are usually associated symptoms. These symptoms include the following: difficulty concentrating, depression, sleep issues, anxiety, social withdrawal, and suicidal ideation or attempts (Carey). These—though they are often seen in psychotic disorders—are not usually used diagnostically for psychotic disorders.
The DSM IV-TR considers positive symptoms as symptoms that “appear to reflect an excess or distortion of normal functions (American Psychiatric Association 299).” This includes such symptoms as hallucinations, delusions, disorganized speech, and grossly disorganized or catatonic behavior (American Psychiatric Association 299).
As can be quickly seen by reading through Oliver Sacks’ book Hallucinations, there are so many causes of hallucinations without mental disorders even coming into play; so, what makes psychotic hallucinations unique? Well, for starters they are hallucinations that occur without any other normal cause of hallucinations present (American Psychiatric Association 300). According to the DSM IV-TR, hallucinations in psychosis can occur in any sense, but auditory hallucinations are overwhelmingly the most common (American Psychiatric Association 299-300). In addition, these are usually experienced “as voices, whether familiar or unfamiliar, that are perceived as distinct from the person’s own thoughts (American Psychiatric Association 300).” Hallucination types that are particularly characteristic and telling of psychosis are hallucinations that have “two or more voices conversing with one another or voices maintaining a running commentary on the person’s thoughts or behavior (American Psychiatric Association 300).” Of course, there is no single type of psychotic hallucination. Every individual’s hallucinations are their own unique experience, even if there might be themes across the board.
Delusions are considered “erroneous beliefs that usually involve a misinterpretation of perceptions or experiences (American Psychiatric Association 299).” These must be considered within cultural and religious contexts, as something that one people group might consider a delusional belief might be commonly excepted in another group. Delusions usually fall into one of five groups: persecutory, referential, somatic, religious, or grandiose. The characteristic delusions found in psychosis are usually considered bizarre; however, defining bizarre delusions can be quite difficult. The DSM IV-TR states that “Delusions are deemed bizarre if they are clearly implausible and not understandable and do not derive from ordinary experiences (American Psychiatric Association 299).”
Disorganized speech is sort of multifaceted, involving both disorganization of thought and speech. According to the DSM IV-TR, this is often looked at as disorganized speech due to the fact that the clinical differentiation between disorganized speech and thought is quite difficult, in particular because identifying disorganized thought is largely based on an individual’s speech—the outward manifestation (American Psychiatric Association 300). This can be shown in several different ways, including the following: loose associations or derailment, tangential speech, or incoherence or “word salad.” Of course, because speech disorders are not horribly uncommon and can be related to many different things, the severity of this sort of thing is an important aspect in its use as part of clinical diagnosis (American Psychiatric Association 300).
The last of the positive symptoms is grossly disorganized or catatonic behavior. This is looking at motor and behavior issues, which can include such sort of things as not maintaining proper hygiene, starkly unusual clothing choices (ie. wearing “multiple overcoats, scarves, and gloves on a hot day”), or unpredictable and agitated behavior for grossly disorganized behavior; and catatonic stupor, rigidity, negativism (active resistance to attempts to be moved), posturing (assuming bizarre postures), and excitement (motor activity without purpose or apparent stimulation) (American Psychiatric Association 300). These—like much of the other symptoms of psychosis—should be considered carefully as they not specific to psychosis, but are simply part of the array of psychotic symptoms.
The DSM IV-TR considers negative symptoms as symptoms that “appear to reflect a diminution or loss of normal functions (American Psychiatric Association 299).” This includes such symptoms as affective flattening, alogia, and avolition (American Psychiatric Association 299). These each are the restriction of normal activity in the associated areas. Affective flattening refers to the reduction in facial expression, eye contact, and body language (American Psychiatric Association 301). This is not to say that an individual suffering from psychosis cannot or will not smile; however, there is a clear diminishment of emotional expression from normal. Alogia is also called “poverty of speech” as it is usually seen in “brief, laconic, empty replies.” Notably, this is not the same as not wanting to speak. Avolition is the “inability to initiate or persist in goal-directed activities.” According to the DSM IV-TR, individuals experiencing avolition may simply sit for extended periods of time and have little to no apparent interest in “work or social activities (American Psychiatric Association 301).” Of note, the negative symptoms should be looked at very carefully and used cautiously, because they exist on a continuum with normality.
Next, let us look at post-concussion syndrome and traumatic brain injury. According to the Beth Israel Deaconess Medical Center, post-concussion syndrome is a disorder that can result from a concussion or traumatic brain injury (“Post Concussion Syndrome.”). There does not appear to be a direct link between the severity of injury and the chance that an individual will be effected by post-concussion syndrome (Bowman). This can result in a spectrum of symptoms that last usually weeks to months after the injury, though some can last longer, even lasting a year or more for some individuals (“Post-Concussion Syndrome.”). The general symptoms looked at include the following: headaches (usually like tension headaches or migraines; often not helped by medication or are persistent), dizziness, fatigue, irritability, anxiety, insomnia, loss of concentration or memory, noise and light sensitivity, vertigo, restlessness, apathy, depression, and personality changes (“Post-Concussion Syndrome.”, Bowman, Centers For Disease Control And Prevention 4, 5). Other symptoms can occur depending on the specific part of the brain that received trauma; however, the above is the generally accepted list (“Symptoms of Brain Injury”). To make things all the more complicated in this vast sea of symptoms, these symptoms can come and go as they please (Centers For Disease Control And Prevention 6).
Post-concussion syndrome becomes even more messy because it has been found to be a potential cause of psychosis. According to a study in the University of Cambridge’s journal Psychological Medicine, they looked at 90 patients who had recent head injuries between 1987 and 1997 (Sachdev, et al.). Forty-five of these patients had schizophrenia-like psychosis and were matched, based on age and gender, with 45 who did not. They systematically reviewed the cases for each of the individuals and used neuroimaging to determine extent of brain damage. They found that the individuals with schizophrenia-like psychosis showed more “widespread brain damage on neuroimaging, especially in the left temporal and right parietal regions, and were more impaired cognitively.” They also found the mean age of onset of this psychosis in these head injuries to be 26.3 years with a mean latency of 54.7 months. They concluded that “A genetic predisposition to schizophrenia and severity of injury with significant brain damage and cognitive impairment may be vulnerability factors (Sachdev, et al.).”
Finally, why have I spent so much time and effort researching this? What relation do I have to this topic? Many individuals have spent countless hours researching such things without a direct, invested interest besides sheer intrigue or a desire to help others; however, I do have a specific reason for this research. I have an invested interest. As such, let me tell you the tale that illuminates the reason for my interest, in a chronological order. When I was a child the age of ten, my brother and I joined a local martial arts group. When I was about fifteen I was in a sparring match. My sparring partner brought their heel right into my jaw, knocking me unconscious and, according to those around, dropping me like a bag of sand. I, of course, don’t remember that part, I just remember getting kicked and then hearing my teacher asking if I was alright. Eventually, I slowly started being able to see again, waking to my teacher and one or two others whom I don’t specifically remember over me, asking if I was alright. Foolishly, and due in part to the sort of teaching in martial arts, I said I was fine, got up, and continued the sparring match, although in quite a daze.
Not long after, I started experiencing terrible headaches which were not lessened using Ibuprofen or other such pain relievers. They seemed to last continuously, not letting up much. For some time, I thought that this was due to my time around the same point at which these headaches started when I was helping with my church’s youth group with the hurricane Katrina relief efforts in New Orleans. I was helping clean up an individual’s backyard and was helping clean out a sort of tent that they had set up in the yard with wooden pallets in the base of it. We did not have any sort of face masks and these pallets were horribly moldy and covered in mildew. As such, I thought that I had simply breathed in too much of this abominable air and had gotten some sort of sinus infection.
Though the exact starting point I do not remember, it was sometime while I was fifteen that I began experiencing symptoms indicating that something was very wrong. Part of the reason I don’t remember the exact point is that I only realized what was wrong over time. The things I remember first were a lack of enjoyment in social situations—while I am introverted and don’t engage socially often now, I do usually enjoy that sort of engagement to one degree or another—as well as cloudiness of thought. To match this cloudiness to a previously listed symptom would probably be describing it as disorganized thought. I have also likened it to a “poverty of thought”, similar to the aforementioned “poverty of speech”, as it felt like it was simply difficult to think in a logical or coherent manner. It was as if there were a fog clouding my mind, making it difficult or near impossible to think logically. It is a bit hard to describe in any better fashion, as that is the most accurate way I can portray it, like what can be seen in major depression (American Psychiatric Association 350). These both eventually faded away, the headaches when I was around seventeen, I believe, and the mental fog around eighteen.
The next symptom I noticed was hallucinations. I did not realize anything was abnormal at first, I just heard these strange incomprehensible whispers from dozens of voices, like they were talking in another language. I did not notice them at first, which may sound strange but it was like having some background sound that just slowly built over time. You don’t necessarily notice it at first and it increases so slowly that you are accustomed to it. It was almost like “everyone hears this, right?” In time, it became more insidious. I started “having thoughts” that felt like they were in response to other thoughts. It sounded sort of like my voice, just a bit different. I don’t remember when it happened, but at some point, I realized that these were not my thoughts…they were the voice of something else. When I realized that these were not my thoughts, the voice became more distinct from mine and more overt in the fact that they were not my thoughts. The types of responses to my thoughts changed, becoming more dark and mocking. Cussing and attempting to drag me down into the dirt became the “objective” of this voice now, telling me how worthless and incompetent I was or to go kill myself, that sort of thing. I even often had dialogue with this voice, which answered in the most real and “genuine” way. I realized that this—as well as the background voices—were hallucinations, but that did not change their realness. Regardless of whether I knew that this voice in my head was a hallucination or not, it felt real and hurt like a knife. Over time, the background voices changed as well, around the same time as the singular voice changed, instead of a whisper they rose to a cacophony that felt deafening at times. Thankfully, I experienced minimal visual hallucinations, mostly just in the form of bizarre figures in the windows at night and an accompanying feeling of sheer dread. Much more could be exposited in regards to the hallucinations I experienced, for I experienced them for nearly three full years, constantly barraging my mind; however, that will be for another time. For now, let us leave it with that, as these hallucinations faded right around the time I turned eighteen years old.
The next thing I noticed was the reaction to this voice: suicidal ideation. The amount of stress placed on my mind by the constant harassment and berating of this voice—along with depressive symptoms co-morbidly—drove me to the point where I had near constant thoughts of suicide. And I mean near constant. At least once every five minutes—usually more often—I would think of suicide, every day for at least two years, starting probably around sixteen years old or a bit before. By some means I never actually attempted suicide, but I was romancing it all day in my mind. That said, I did engage in self-harm, usually in the form of bruising, but thankfully I never cut myself.
The next symptom that I noticed were delusions. This was the most difficult to deal with in some ways and the easiest in others, as by the definition of delusions I believed they were true. I only experienced religious delusions, though these were very unpleasant and complicating. As with the hallucinations, this aspect had a lot of complicated aspects; however, they are much less clear to me as they were the primary symptom that I realized retrospectively instead of in the moment. These ended a little bit after my eighteenth birthday.
The final symptom that I have noticed as of more recent is sleep issues, specifically insomnia. This started when I was when I twenty-two, at the beginning of the spring semester and has continued—with more severe and less severe periods—till now continuing, though it has mostly abated by now. While there might be a genetic predisposition to this, due to my mother having sleep issues as well, I never had sleep issues till that point, at which point they started suddenly and starkly for no apparent reason. These may or may not be related to my head injury, but as it is a symptom of post-concussion syndrome I thought it worth mentioning.
It is because of this array of symptoms that I experienced over this time, all following being knocked unconscious, that has led to my theory about what all has happened. These symptoms fit within the established array of symptoms of schizophrenia-like psychosis and post-concussion syndrome, as aforementioned. As such, and because in all my research I have not come across a better or more reasonable explanation for what has occurred, I believe that at the time I was knocked unconscious I suffered a concussion. This was likely aggravated by continuing sparring, leading to the development of post-concussion syndrome. Due to this, I experienced these previously listed symptoms, including schizophrenia-like psychosis. Fortunately—and unfortunately—, and uncommonly, I was aware of what was happening during this psychosis.
To conclude, psychosis is a complicated symptom with its own subarray of symptoms, post-concussion syndrome can result from a concussion or traumatic brain injury and can have severe symptoms, including schizophrenia-like psychosis, and I have a dark interest in both. Thankfully, most of these issues—all but the sleep issues and some depressed tendencies—have been gone for the last five years.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington, DC, American Psychiatric Association: 2000. Print.
Bowman, Joe. “Post-Concussion Syndrome.” Healthline. Heathline, n.d. Web. 18 June 2016.
“Symptoms of Brain Injury.” Brain Injury. Brain Injury, n.d. Web. 18 June 2016.
Carey, Elea. “Psychosis.” Healthline. Healthline, n.d. Web. 17 June 2016.
Centers For Disease Control And Prevention. Facts about Concussion and Brain Injury. n.p., n.d. Print.
“Post Concussion Syndrome.” Beth Israel Deaconess Medical Center. Beth Israel Deaconess Medical Center, n.d. Web. 18 June 2016.
“Post-Concussion Syndrome.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 19 August 2014. Web. 18 June 2016.
Sachdev, P., J. S. Smith, and S. Cathcart. “Schizophrenia-like psychosis following traumatic brain injury: a chart-based descriptive and case–control study.” Psychological Medicine 31.02 (2001): 231-239. Web. 18 June 2016.