Five comorbidity psychoses from 5 primeval instincts
The 5 affective comorbidities described above contribute to the presence, subtype, and treatment approaches of 5 corresponding psychoses. Ordinary panic attacks might occur when feeling trapped or separated from home, so people want to flee to safety. Nonhuman species with limited consciousness and language are unlikely to think “time to head for safety.” Instead, instincts encourage flight from danger through internally generated perceptions of threat. Likewise, people with psychosis and panic, without sufficient conscious modulation, may experience sensory perceptions of actual danger when feeling symbolically trapped.1,10
One pilot study carefully examined the prevalence of these 5 comorbidities in an unselected group of psychotic patients.10 At least 85% met criteria for ≥1 of the 5 subtypes.10 Moreover, organic psychoses related to physical illness, substances, and iatrogenesis may also predict future episodes of functional psychoses.1
Using statistical analysis of psychosis rating scales, 2 studies took a “transdiagnostic” look at psychoses, and each found 5 psychosis subtypes and a generalized psychosis susceptibility factor.11,12 Replication of that transdiagnostic approach, newly including psychosis symptoms and our 5 specific comorbidities, might well find that the 5 subtype models resemble each other.11,12
Our proposed 5 comorbidity subtypes are1:
Delusional depression (melancholic depression). Most common in geriatric patients, this psychosis can also occur at younger ages. Prodromal melancholic depression can include guilt and hopelessness, and is acute, rather than the chronic course of our other 4 syndromes. Subsequent delusional depression includes delusions of bodily decay, illness, or death, as well as overwhelming guilt, shame, and remorse. The classic vegetative symptoms of depression continue. In addition to infectious disease issues, high suicide risk makes hospitalization imperative.
Obsessive-compulsive schizophrenia. Just as OCD has an early age of onset, obsessive-compulsive schizophrenia begins earlier than other psychoses. Despite preserved cognition, some nonpsychotic patients with OCD have diminished symptom insight. OCD may be comorbid with schizophrenia in 12% of cases, typically preceding psychosis onset. Obsessive-compulsive schizophrenia symptoms may include highly exaggerated doubt or ambivalence; contamination concerns; eccentric, ritualistic, motor stereotypy, checking, disorganized, and other behaviors; and paranoia.
Schizophrenia with voices (panic anxiety). Classic paranoid schizophrenia with voices appears to be the most similar to a “panic psychosis.” Patients with nonpsychotic panic anxiety have increased paranoid ideation and ideas of reference as measured on the Symptom Checklist-90. Schizophrenia is highly comorbid with panic anxiety, estimated at 45% in the Epidemiologic Catchment Area study.13 These are likely underestimates: cognitive impairment hinders reporting, and psychotic panic is masked as auditory hallucinations. A pilot study of schizophrenia with voices using a carbon dioxide panic induction challenge found that 100% had panic anxiety.14 That study and another found that virtually all participants reported voices concurrent with panic using our Panic and Schizophrenia Interview (PaSI) (Box 1). Panic onset precedes schizophrenia onset, and panic may reappear if antipsychotic medications sufficiently control voices: “voices without the voices,” say some.
Box 1
Panic and Schizophrenia Interview
Let’s talk for a minute about your voices.
[IDENTIFYING PAROXYSMAL MOMENTS OF VOICE ONSET]
Do you hear voices at every single moment, or are they sometimes silent? Think about those times when you are not actually hearing any voices.
Now, there may be reasons why the voices start talking when they do, but let’s leave that aside for now.
So, whenever the voices do begin speaking—and for whatever reason they do—is it all of a sudden, or do they start very softly and then very gradually get louder?
If your voices are nearly always there, then are there times when the voices suddenly come back, get louder, get more insistent, or just get more obvious to you?
[Focus patient on sudden moment of voice onset, intensification, or awareness]
Let’s talk about that sudden moment when the voices begin (or intensify, or become obvious), even if you know the reason why they start.
I’m going to ask you about some symptoms that you might have at that same sudden moment when the voices start (or intensify, or become obvious). If you have any of these symptoms at the other times, they do not count for now.
So, when I ask about each symptom, tell me whether it comes on at the same sudden moments as the voices, and also if it used to come on with the voices in the past.
For each sudden symptom, just say “YES” or “NO” or “SOMETIMES.”
[Begin each query with: “At the same sudden moment that the voices come on”]
- Sudden anxiety, fear, or panic on the inside?
- Sudden anger or rage on the inside? [ANGER QUERY]
- Sudden heart racing? Heart pounding?
- Sudden chest pain? Chest pressure?
- Sudden sweating?
- Sudden trembling or shaking?
- Sudden shortness of breath, or like you can’t catch your breath?
- Sudden choking or a lump in your throat?
- Sudden nausea or queasiness?
- Sudden dizziness, lightheadedness, or faintness?
- Sudden feeling of detachment, sort of like you are in a glass box?
- Sudden fear of losing control? Fear of going crazy?
- Sudden fear afraid of dying? Afraid of having a heart attack?
- Sudden numbness or tingling, especially in your hands or face?
- Sudden feeling of heat, or cold?
- Sudden itching in your teeth? [VALIDITY CHECK]
- Sudden fear that people want to hurt you? [EXCESS FEAR QUERY]
- Sudden voices? [VOICES QUERY]
[PAST & PRODROMAL PANIC HISTORY]
At what age did you first see a therapist or psychiatrist?
At what age were you first hospitalized for an emotional problem?
At what age did you first start hearing voices?
At what age did you first start having strong fears of other people?
Before you ever heard voices, did you ever have any of the other sudden symptoms like the ones we just talked about?
Did those episodes back then feel sort of like your voices or sudden fears do now, except that there were no voices or sudden fears of people back then?
At what age did those sudden anxiety (or panic or rage) episodes begin?
Back then, was there MORE (M) sudden anxiety, or the SAME (S) sudden anxiety, or LESS (L) sudden anxiety than with your sudden voices now?
[PAST & PRODROMAL PANIC SYMPTOMS]
Now let’s talk about some symptoms that you might have had at those same sudden anxiety moments, in the time before you ever heard any voices. So, for each sudden symptom just say “YES” or “NO” or “SOMETIMES.”
[Begin each query with: “At the same moment the sudden anxiety came on—but only during the time before you ever heard sudden voices”]
[Ask about the same 18 panic-related symptoms listed above]
[PHOBIA-RELATED PANIC AND VOICES]
Have you ever been afraid to go into a (car, bus, plane, train, subway, elevator, mall, tunnel, bridge, heights, small place, CAT scan or MRI, being alone, crowds)?
[If yes or maybe: Ask about panic symptoms in phobic situations]
Now let’s talk about some symptoms that you might have had at some of those times you were afraid. So, for each symptom just say “YES” or “NO” or “MAYBE.”
[Ask about the same 18 panic-related symptoms listed above]
At what age did you last have sudden anxiety without voices?
Has medication ever completely stopped your voices? Somewhat?
If so, did those other sudden symptoms still happen sometimes?
Thank you for your help, and for answering all of these questions!
Persecutory delusional disorder (social anxiety). Some “schizophrenia” without voices may be misdiagnosis of persecutory (paranoid) delusional disorder (PDD). Therefore, the reported population prevalence (0.02%) may be underestimated. Social anxiety is highly comorbid with “schizophrenia” (15%).16 Case reports and clinical experience suggest that PDD is commonly preceded by social anxiety.17 Some nonpsychotic social anxiety symptoms closely resemble the PDD psychotic ideas of reference (a perception that low social rank attracts critical scrutiny by authorities). Patients with PDD may remain relatively functional, with few negative symptoms, despite pronounced paranoia. Outward manifestation of paranoia may be limited, unless quite intense. The typical age of onset (40 years) is later than that of schizophrenia, and symptoms can last a long time.18
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