Subclinical Psychosis and the Spectrum: Distinguishing Psychotic Experiences from Related Mental States

This podcast episode, hosted by psychiatrist Dr. Tracey Marks, addresses a viewer's question about subclinical psychosis and the concept of psychosis as a spectrum. Dr. Marks clarifies that while subclinical psychosis is a term used by researchers to identify individuals at risk or experiencing psychotic symptoms without a primary psychotic illness, psychosis itself is practically binary—you either are or are not psychotic. She emphasizes that being "a little bit psychotic" is not an accurate description, but rather, the concept of a "psychosis spectrum" refers to the varying degrees of psychotic symptoms within specific diagnostic categories.

The episode details the five core psychotic domains: hallucinations, delusions, disorganized thinking (manifesting as disorganized speech), abnormal or disorganized behavior, and negative symptoms. Schizophrenia is presented as the most severe end of the schizophrenia spectrum disorders, which are defined by symptoms in one or more of these domains. Other conditions like delusional disorder and schizotypal personality disorder fall on the lighter end of this spectrum, indicating less severe psychotic symptoms and impairment. A crucial distinction is made between psychotic symptoms arising from schizophrenia spectrum disorders and those caused by other conditions.

Dr. Marks explains that psychotic experiences can be transient and occur in the context of other mental health issues, such as severe depression or mania, or even due to drug intoxication (e.g., morphine, prednisone) or medical illnesses like lupus. These transient symptoms, even if they involve multiple domains, are not considered part of a schizophrenia spectrum illness because they resolve as the underlying condition improves. She also touches upon Borderline Personality Disorder, noting that transient psychotic episodes under stress were the origin of the term "borderline," signifying a state between neurotic (prone to negative emotions) and psychotic (prone to disorganized behavior and severe impairment).

Finally, the episode differentiates dissociation from psychosis, highlighting that while dissociative experiences (feeling disconnected, out-of-body, sensory experiences) can feel similar to psychosis, their biological origins differ. Dissociation involves issues with memory retrieval, whereas psychosis involves the brain creating false information. Dissociation is described as a primitive, automatic defense mechanism that, when frequently used, can lead to feelings of disconnection from reality and memory gaps, but it does not constitute psychosis. The discussion underscores the importance of precise diagnostic criteria and understanding the nuanced presentations of mental health symptoms.

"Subclinical psychosis is a term that some researchers have used to describe psychotic symptoms in people who don't have a primary psychotic illness."

"Practically speaking, psychosis is binary. It's like a switch that's on or off, you either are, or you're not, but you're not a little bit."

"Psychotic symptoms fall into five categories, hallucinations, delusions, disorganized thinking, which shows up as disorganized speech, abnormal or disorganized behavior and negative symptoms."

"Schizophrenia is the granddaddy of psychotic disorders."

"So, the schizophrenia spectrum has more to do with how much psychosis you have, but you can have psychotic symptoms from a condition that is not on the schizophrenia spectrum."

"Because of this temporary come and go nature, psychotic depression is not a schizophrenia spectrum illness."

"People with borderline personality disorder can have transient psychotic episodes under stress. In fact, this is where the term borderline came from."

"Dissociation is a mental state where you feel disconnected from yourself or your environment."

"These sensory experiences aren't considered psychosis because they're related to how your mind is retrieving memories with hallucinations that come from a psychotic state, your brain is creating false information."

"So you can think of dissociation as a cousin of psychosis."