Write a 2–3 page paper (excluding the title and reference pages) using the following criteria. 

a. Write a brief introduction of the topic and explain why it is important to mental health nursing. NR326 Mental Health Nursing NR320-326 Mental Health Nursing NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el 

b. Cite statistics to support the significance of the topic. 

c. Summarize the article; include key points or findings of the article.

d. Discuss how you could use the information for your practice; give specific examples. 

e. Identify the strengths and weaknesses of the article. 

f. Discuss whether you would recommend the article to other colleagues. 

g. Write a conclusion. 

4. Paper must follow APA format. Include a title page and a reference page; use 12‐point Times Roman font; and include in‐text citations (use citations whenever paraphrasing, using statistics or quoting from the article) 

I have included the instructions as well as the article.

NR320-326 Mental Health Nursing

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Required Uniform Assignment: Scholarly Article Review

PURPOSE
The student will review, summarize, and critique a scholarly article related to a mental health topic

.

COURSE OUTCOMES

This assignment enables the student to meet the following course outcomes.

• CO 4. Utilize critical thinking skills in clinical decision-making and implementation of the nursing process for psychiatric/mental health clients.

(PO 4)

• CO 5: Utilize available resources to meet self‐identified goals for personal, professional, and educational development appropriate to the mental

health setting. (PO 5)

• CO 7: Examine moral, ethical, legal, and professional standards and principles as a basis for clinical decision‐making. (PO 6)

• CO 9: Utilize research findings as a basis for the development of a group leadership experience. (PO 8)

DUE DATE

Refer to Course Calendar for details. The Late Assignment Policy applies to this assignment.

TOTAL POINTS POSSIBLE: 100 points

REQUIREMENTS

1. Select a scholarly nursing or research article (published within the last five years) related to mental health nursing, which includes content related

to evidence‐based practice.

*** You may need to evaluate several articles before you find one that is appropriate. ***

2. Ensure that no other member of your clinical group chooses the same article. Submit the article for approval.

3. Write a 2–3 page paper (excluding the title and reference pages) using the following criteria.

a. Write a brief introduction of the topic and explain why it is important to mental health nursing.

NR326 Mental Health Nursing

NR320-326 Mental Health Nursing

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

b. Cite statistics to support the significance of the topic.

c. Summarize the article; include key points or findings of the article.

d. Discuss how you could use the information for your practice; give specific examples.

e. Identify strengths and weaknesses of the article.

f. Discuss whether you would recommend the article to other colleagues.

g. Write a conclusion.

4. Paper must follow APA format. Include a title page and a reference page; use 12‐point Times Roman font; and include in‐text citations (use citations

whenever paraphrasing, using statistics, or quoting from the article). Please refer to your APA Manual as a guide for in‐text citations and sample reference
pages.

5. Submit per faculty instructions by due date (see Course Calendar); please refer to your APA Manual as a guide for in‐text citations and sample

reference pages. Copies of articles from any Databases, whether PDF, MSWord, or any other electronic file format, cannot be sent via the Learning

Management System (Canvas) dropbox or through email, as this violates copyright law protections outlined in our subscription agreements. Refer to
the “Policy” page under the Resource tab in the shell for the directions for properly accessing and sending library articles electronically using permalinks.

NR320-326 Mental Health Nursing
NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

DIRECTIONS AND ASSIGNMENT CRITERIA

Assignment

Criteria

Points % Description

Introduction 10 10 • An effective introduction establishes the purpose of the paper.

• The introduction should capture the attention of the reader.

Article summary 30 30 Summary of article must include the following.

• Statistics to support the significance of the topic

• Key points and findings of the article

• Discussion of how information from the article could be used in your practice (give

specific examples)

Article critique 30 30 Article critique must include the following.

• Strengths and weaknesses of the article

• Discussion of whether you would recommend the article to a colleague

Conclusion 15 15 The conclusion statement should be well defined and clearly stated. An effective
conclusion provides analysis and/or synthesis of information, which relates to the main

idea/topic of the paper. The conclusion is supported by ideas presented throughout the

body of your report.

Article Selection &

Approval
5 5 • Article is relevant to mental health nursing practice and is current (within 5 years of

publication).

• No duplicate articles within the clinical group.

• Article submitted and approved as scholarly by instructor.

Grammar/Spelling/
Mechanics/APA

format

10 10 • Correct use of Standard English grammar and sentence structure

• No spelling or typographical errors

• Document includes title and reference pages

• Citations in the text and reference page

Total 100 100

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

GRADING RUBRIC

Assignment
Criteria

Outstanding or Highest

Level of Performance

A (92–100%)

Very Good or High Level of

Performance

B (84–91%)

Competent or Satisfactory

Level of Performance

C (76–83%)

Poor, Failing or

Unsatisfactory Level of

Performance

F

(0–75%)

Introduction (10

points)
• Introduction is present and

distinctly establishes the
purpose of paper

• Introduction is appealing and
promptly captures the
attention of the reader

10 points

•

Introduction is present and
generally establishes the
purpose of paper

• Introduction has appeal and
generally captures the
attention of the reader

9 points

Introduction is present and
generally establishes the
purpose of paper

8 points

No introduction

0‐7 points

Article summary (30

points)
• Statistics presented strongly

support the significance of the
topic

• Key points and findings of the
article are clearly stated

• Thoroughly discusses how
information from the article
could be used in your practice
by giving two or more specific,
relevant examples

28‐30 points

• Statistics presented
moderately support the
significance of the topic

• Key points and findings of the
article are vaguely stated

• Adequately discusses how
information from the article
could be used in your practice
by giving two or more specific,
relevant examples

26‐27 points

• Statistics presented weakly
support the significance of the
topic

• Key points and findings of the
article are stated in a manner
that is confusing or difficult to
understand.

• Briefly discusses how
information from the article
could be used in your practice
by giving examples that are
not specific, yet are relevant

23‐2

5 points

• Statistics presented do not
support the significance of the
topic OR no statistics are
presented.

• Key points and findings of the
article are incorrectly
presented OR missing

• Briefly discusses how
information from the article
could be used in your practice
by giving examples that are
neither specific, nor relevant
OR implications to practice
not discussed

0‐22 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Article critique (30

points)
• The strengths and weaknesses

are

well‐defined and clearly
stated.

• Provides a thorough review of
whether or not they
recommend the article

28-30 points

• The strengths and weaknesses
are adequate and clearly
stated.

• Provides a general review of

whether or not they would

recommend the article

26-27 points

• The strengths and weaknesses
are brief and clearly stated.

• Provides a brief review of

whether or not they would

recommend the article.

23-25 points

• The strengths and weaknesses
are unclear or not stated.

• Provides an unclear or no
insight as to whether or not
they would recommend the
article.

0-22 points

.

Assignment
Criteria
Outstanding or Highest
Level of Performance

A (92–100%)
Very Good or High Level of
Performance

B (84–91%)
Competent or Satisfactory
Level of Performance

C (76–83%)
Poor, Failing or
Unsatisfactory Level of
Performance
F (0–75%)

Conclusion (15

points)
• The conclusion statement is

well‐defined and clearly
stated.

• Conclusion demonstrates
comprehensive analysis or
synthesis of information from
the article.

• The conclusion is strongly
supported by ideas presented
throughout the body of the
paper.

15 points

• The conclusion statement is
general and clearly stated.

• Conclusion demonstrates
comprehensive analysis or
synthesis of information from
the article.
• The conclusion is strongly
supported by ideas presented
throughout the body of the
paper.

13-1

4 points

• The conclusion statement is
general and clearly stated.

• Conclusion demonstrates
adequate analysis or synthesis
of information from the article.

• The conclusion is adequately
supported by ideas presented
throughout the body of the
paper.

12 points

• The conclusion statement is
vague or not stated.

• Conclusion demonstrates
inadequate analysis or
synthesis of information from
the article.

• The conclusion is inadequately
supported by ideas presented
throughout the body of the
paper.

0‐11 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Article Selection &
Approval
(5 points)

ALL Items MET

• Article is relevant to mental

health nursing practice and is
current (within 5 years of
publication).

• No duplicate articles within the
clinical group.

• Article submitted and
approved as scholarly by
instructor.

5 points

ONE item NOT MET

• Article is relevant to mental
health nursing practice and is
current (within 5 years of
publication).
• No duplicate articles within the
clinical group.
• Article submitted and
approved as scholarly by
instructor.
4 points

2 or more items NOT MET
• Article is relevant to mental

health nursing practice and is
current (within 5 years of
publication).
• No duplicate articles within the
clinical group.
• Article submitted and
approved as scholarly by
instructor.

0‐3 points

Assignment
Criteria
Outstanding or Highest
Level of Performance

A (92–100%)
Very Good or High Level of
Performance

B (84–91%)
Competent or Satisfactory
Level of Performance

C (76–83%)
Poor, Failing or
Unsatisfactory Level of

Performance F

(0–75%)

Grammar/Spelling/
Mechanics/APA
Format
(10 points)

• References are submitted
with assignment.

• Used appropriate APA format
and are free of errors.

• Includes title and reference

pages.

• Grammar and mechanics are
free of errors.

10 points
• References are submitted
with assignment.

• Used appropriate APA format
and has one type of error.

• Includes title and reference
pages.

• Grammar and mechanics have
one type of error.

9 points
• References are submitted
with assignment.

• Used appropriate APA format
and has two types of errors.

• Includes title and reference
pages.

• Grammar and mechanics have
two types of errors.

8 points

• No references submitted with
assignment.

• Attempts to use appropriate
APA format and has three or
more types of errors.

• Includes title and reference
pages.

• Grammar and mechanics have
three or more types of errors.

0‐7 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Total Points Possible = 100 points

COURSE OUTCOMES
DUE DATE
REQUIREMENTS
DIRECTIONS AND ASSIGNMENT CRITERIA
GRADING RUBRIC

S t a t e o f t h e a r t

Focus on psychosis
Wolfgang Gaebel, MD; Jürgen Zielasek, MD

Introduction

Psychosis is a clinical syndrome composed of sev-
eral symptoms. Delusions, hallucinations, and thought
disorder may be regarded as core clinical features. A
“nosology” of psychosis would need to be based on
the knowledge of the causes and pathophysiology of
these “psychotic” symptoms.1 Psychosis is a clinical syn-
drome, not a nosological entity. The history of the term
will be briefly described, followed by a description of its
use in the current classification systems for mental dis-
orders and a discussion on the necessity to deconstruct
the term, along with the challenges and future prospects
for psychosis research.

Historical aspects

The term “psychosis” has been used for about 170 years,
and has evolved to reflect the scientific and social con-
texts of the respective times.2 It was first used by the
Austrian medical doctor Ernst von Feuchtersleben, who
used the term in a textbook published in 1845.3 This
reflected the current idea, of the time, of mental disor-
ders being diseases of the mind (Geisteskrankheiten or
Seelenstörungen in German), which von Feuchtersleben
thought was too narrow and did not convey the idea that
it was the interaction between the mind and brain that
caused mental disorders. A later position, strengthening
the concept of mental disorders as disorders of the brain,
was introduced by Griesinger in 1845.4 The term “psy-

Copyright © 20

15

AICH – Servier Research Group. All rights reserved 9 www.dialogues-cns.org

Keywords: classification of mental disorders; history of psychosis; psychosis;
schizophrenia

Author affiliations: Department of Psychiatry and Psychotherapy, Medical
Faculty, Heinrich Heine University, Düsseldorf, Germany

Address for correspondence: Wolfgang Gaebel, Department of Psychia-
try and Psychotherapy, LVR-Klinikum Düsseldorf, Bergische Landstrasse 2,
40629 Düsseldorf, Germany
(e-mail: wolfgang.gaebel@uni-duesseldorf.de)

The concept of psychosis has been shaped by traditions
in the concepts of mental disorders during the last 170
years. The term “psychosis” still lacks a unified defini-
tion, but denotes a clinical construct composed of sev-
eral symptoms. Delusions, hallucinations, and thought
disorders are the core clinical features. The search for a
common denominator of psychotic symptoms points to-
ward combinations of neuropsychological mechanisms
resulting in reality distortion. To advance the elucida-
tion of the causes and the pathophysiology of the symp-
toms of psychosis, a deconstruction of the term into its
component symptoms is therefore warranted. Current
research is dealing with the delineation from “normal-
ity,” the genetic underpinnings, and the causes and
pathophysiology of the symptoms of psychosis.
© 2015, AICH – Servier Research Group Dialogues Clin Neurosci. 2015;17:9-18.

S t a t e o f t h e a r t

chosis” was soon used by others, and a long and intricate
history of its meaning ensued.5,6 In the late 19th century,
the term was used widely and subdivided as exemplified
by Wernicke’s distinction between “somatopsychoses”
(affecting the consciousness of one’s own body), “au-
topsychoses” (affecting the consciousness of one’s per-
sonality), and “allopsychoses” (affecting the conscious-
ness of the outside world).7 While such subdistinctions
were the first indication that the term “psychosis” was
not a unitary principle, but needed to be deconstructed
into its component symptoms, these terms did not gain
widespread acceptance. More importantly, Kraepelin’s
dichotomy of psychosis into “dementia praecox” and
“manic-depressive insanity” became the rule of the day,
and the definition of the several dimensions of psycho-
sis became the center of research in the early and mid-
20th century. The concept of Jaspers’ “layers” of men-
tal disorders8 also comes into play here, in that Jaspers
hypothesized that neurotic, endogenous, and organic
(exogenous) mental disorders reflected three different
layers of mental disorders, in which psychotic symptoms
could be found on both the “endogenous” and “organic
(exogenous)” levels. The loss of reality underlying hallu-
cinations and delusions became important, and the term
“psychosis” has been used variably to denote a core syn-
drome of hallucinations, delusions, and disordered think-
ing, or in a wider sense, to encompass all severe mental
disorders. On the background of such clinical diversity
and variability, Schneider introduced a ranking of psy-
chotic symptomatology, bringing into the discussion the
notion that when diagnosing and classifying mental dis-
orders, some psychotic symptoms may be more impor-
tant than others.9
In today’s definition, the characteristic symptoms
of psychosis are related to the degree of severity (with
psychosis being the severe form of mental disorders),
lack of insight, communication disorders, lack of com-
prehensibility of the symptoms, and reduced social ad-
aptation.

10

Current use of the term “psychosis” in the
classification systems of mental disorders

Classifications of mental disorders and the necessary
definitions of the clinical symptoms of mental disorders
are mainly based on scientific evidence and aspects of
practical utility. While drawing the line between “dis-
order” and “normality” is an important aspect of such

classification systems and symptom definitions, ques-
tions regarding the validity of the concepts of mental
disorders come into play, as well as the quest for defining
disease entities. This reflects etiopathological or patho-
physiological insights, lending credibility to a concept
of psychosis due to valid constructs. In a seminal paper,
Robins and Guze11 inspired the search for a psychiatric
nosology based on etiology and pathophysiology.
Psychosis is conceptualized as a composition of
clinically observable features. It is a clinical syndrome
composed of various symptoms. The rationale is that,
while there are some insights into the etiopathology
and pathophysiology of psychotic symptoms, we cannot
yet determine the exact mechanisms that are at work
in individual cases of psychotic clinical manifestations.
Thus, psychosis is still defined by the clinical picture and
not by laboratory, genetic, or neuroimaging investiga-
tions. The set of symptoms used for a definition should
be clearly observable, should be typical of psychosis,
and should help to delineate psychotic states from oth-
er syndromes and “normality.” Of note, the degree to
which these symptoms affect everyday functions should
not be a part of the definition of psychosis—the pres-
ence of the necessary symptoms should suffice to diag-
nose a “psychosis” on a level of clinical observation.
Table I provides an overview of psychotic disorder
groups from the American Diagnostic and Statistical
Manual of Mental Disorders (DSM)-5.

12

The introduc-
tory text states that psychotic disorders are defined by
abnormalities of one, or more, of five domains: delu-
sions, hallucinations, disorganized thinking (speech),
grossly disorganized or abnormal motor behavior (in-
cluding catatonia), and negative symptoms. Note that
a formal definition of “psychosis” is not given in the
glossary of the DSM-5; only “psychotic features” are
defined (“Features characterized by delusions, halluci-
nations, and formal thought disorder”12) and “psychoti-
cism” as a feature of personality disorders (“Exhibiting
a wide range of culturally incongruent odd, eccentric or
unusual behaviors and cognitions, including both pro-
cess [eg, perception and dissociation] and content [eg,
beliefs]”). Psychoticism is one of the five broad person-
ality trait domains defined in Section III, ‘Alternative
DSM-5 Model for Personality Disorders.’12 At the time
of writing, there was only an initial beta version of the
International Classification of Diseases (ICD)-11 online,
but not the final version. ICD-10 had no definition of
the term “psychosis.”

10

Focus on psychosis – Gaebel and Zielasek Dialogues in Clinical Neuroscience – Vol 17 . No. 1 . 2015

It is evident that the main differences in metastructure
occur for the following: (i) brief psychotic disorders, for
which DSM-5 has a special category; (ii) schizotypal
disorder, which is classified as a personality disorder in
DSM-5; and (iii) secondary psychotic disorders, which
are grouped together with the primary psychotic disor-
ders in DSM-5, but not ICD. Both classification systems
also include other mental disorders, in which psychosis
may occur, like states of delirium or mood disorders with
psychotic features. Both classification systems keep psy-
chotic syndromes in mood disorders separate from the
“schizophrenia spectrum” (DSM-5 terminology) or the
group of “schizophrenia and other primary psychotic

disorders” (ICD-11). Ostergaard et al

13

have reviewed
the evidence for, and against, separating psychotic de-
pression from the other psychotic disorders, as well as its
status compared with the affective disorders, and have
made suggestions for the diagnostic criteria of psychotic
depression in ICD-11 as part of the mood disorders.
In the process of developing DSM-5, a working
group by the American Psychiatric Association on
Psychotic Disorders reviewed the available evidence
for regrouping the psychotic disorders. The group did
acknowledge that the previous DSM-IV grouping had
been based on tradition and shared psychopathology,
and that the evidence for adding bipolar disorder was,
at best, modest, while the evidence for including schizo-
typal personality disorder was stronger, but that the
absence of frank psychosis in schizotypal personality
disorder posed a conceptual problem. No decisive evi-
dence for clustering psychotic disorders based on etiol-
ogy was identified.

14

DSM-5 still uses a categorical classification of psy-
chotic mental disorders since the working group found
that “the research needed to establish a new nosology
of equal or greater validity is lacking.”15 Details of the
proposals for ICD-11 are provided in refs 16 and 17.
Neither DSM-5 nor ICD-11 opted to use an “at-
tenuated psychosis syndrome” as a full diagnostic dis-
ease entity. DSM-5 has defined such a syndrome as a
clinical condition warranting more research, and the
clinical criteria state that it is a syndrome characterized
by psychosis-like symptoms below a threshold for full
psychosis.18 This implies two nosological conundrums,
in that “psychosis-like” as compared with “psychosis”
is not defined, and it is unclear how a “threshold” for
“full psychosis” can be operationalized. In DSM-5, it is
suggested to include that the symptoms are “less severe
and more transient,” and “insight is relatively main-
tained.” DSM-5 emphasizes that functional impairment
must have occurred. ICD-11 is still in the process of
developing its version of this subclinical state. DSM-5
and ICD-11 are moving toward harmonization (eg, the
course specifiers of the psychotic disorders), but major
differences will remain (eg, the time criterion of schizo-
phrenia or the concept of schizoaffective disorder).

16

Deconstruction of the construct “psychosis”

The composition of psychosis of several symptoms has
led to the suggestion of deconstructing the term accord-

11

Table I. Psychotic disorders in DSM-5 (published in 2013) and ICD-11
(proposed revision as of September 2014). DSM, Diagnostic
and Statistical Manual of Mental Disorders; ICD, International
Classification of Diseases

DSM-5 ICD-11

Schizophrenia spectrum
and other psychotic disor-
ders

Schizophrenia and other pri-
mary psychotic disorders

Schizotypal (personality)
disorder

Schizotypal disorder

Delusional disorder Delusional disorder

Brief psychotic disorder
Acute and transient psychotic
disorder

Schizophreniform disorder

Schizophrenia Schizophrenia

Schizoaffective disorder Schizoaffective disorder

Substance/medication-in-
duced psychotic disorder

(To be listed in ICD-11 among
the substance-related mental
disorders)

Psychotic disorder due
to another medical
condition

(To be listed in ICD-11 among
the organic mental disorders)

Catatonia associated with
another mental disorder
(catatonia specifier)

Catatonic disorder due to
another medical condition

Unspecified catatonia

Other specified schizophre-
nia spectrum and other
psychotic disorders

Other specified schizophrenia
and other primary psychotic
disorders

Unspecified schizophrenia
spectrum and other psy-
chotic disorders

Schizophrenia and other pri-
mary psychotic disorders, un-
specified

S t a t e o f t h e a r t

ing to its component symptoms.19-21 Factor analyses of
the symptoms of psychosis in severe mental disorders,
like schizophrenia, usually lead to a five-factor solution
comprising hallucinations, delusions, disorganization,
excitement, and emotional distress.22 If psychotic symp-
toms in the general population are taken into account,
depressive and manic symptoms also come into play, re-
flecting the occurrence of the core clinical syndrome of
psychosis in affective and other mental disorders.23 Po-
tuzak et al, after reviewing the available studies on the
dimensional structure of psychosis, latent class analyses,
and factor analyses, came to the conclusion that there
is relatively consistent evidence on appropriate catego-
ries and dimensions for characterizing psychosis24: the
majority of the studies showed that either four or five
dimensions describe psychosis, with positive, negative,
disorganization, and affective symptom dimensions
most frequently reported. Similarly, studies showed that
the distinction between affective and nonaffective psy-
chotic disorders still has validity and that the symptoms
of psychotic disorders are rather stable clinical fea-
tures when group analyses are carried out over longer
observation periods of several years.25 Importantly, in
the early stages of disease development (ie, prodromal
stages), affective disorders and schizophrenia are simi-
lar with dominating affective symptoms, but the occur-
rence of positive symptoms (eg, hallucinations or delu-
sions) usually sets the mark for differentiation between
affective disorders and schizophrenia.26

A cluster of clinical symptoms encompassing, in a
number of possible compositions of symptoms in indi-
vidual patients, the psychopathologic domains of delu-
sions, hallucinations, and disorganized thinking supple-
mented by affective domains is the core of psychosis.
This notion is supported by the factor analysis results
and the finding that these symptoms are characteristic
of psychosis across traditional classificatory boundar-
ies. They occur in different mental disorders and there
is a considerable overlap between clinical presenta-
tions in different mental disorders, although there are
symptoms that occur more often in schizophrenia com-
pared with affective disorders with psychotic symptoms,
for example.27 This may indicate that the causes and
pathomechanisms of psychotic symptoms in affective
disorders are different from schizophrenia and related
disorders. However, studies are lacking that address
the question about the overlap frequency of symptom
domains of the psychosis syndrome (eg, hallucinations,

disorganized thinking, or delusions) in individual pa-
tients, and about whether these show specific patterns
of variation over time. The triad is not necessarily pres-
ent in all patients, as is shown by disorders like delu-
sional disorders. Of note, the clinical psychosis dimen-
sions, such as “delusions” or “hallucinations,” need to
be subdivided as they are composed of individual symp-
toms and associated latent factors.28 Attempts are now
under way to subdivide the three core psychopathologi-
cal domains of psychosis even further, indicating that
they may be “mixed bags” of symptoms with different
etiopathogenesis, complicating the picture of “psycho-
sis” even further.29

Another unresolved issue is the question of the tem-
poral variability of the psychotic symptoms in individu-
als. This leads to a very complex clinical situation: while
there is a distinct “psychotic syndrome” of hallucina-
tions, delusions, and disorganized thinking, the clinical
appearance of “psychotic symptoms” may intraindivid-
ually vary greatly over time. This leads to the necessity
of group analyses, which by their nature, limit the use-
fulness for determining the causes and pathophysiology
of the symptoms in individual patients.

Future challenges for psychosis research

In the future, some major steps remain for the field of
psychosis research. First, the causes and etiopathogen-
esis of the symptoms of psychosis need to be defined.
Second, a succinct, clinically useful, and internationally
harmonized definition of “psychosis” needs to be pro-
vided. Such a definition should also provide operation-
alized clinical criteria. Research into the etiopathogen-
esis and pathophysiology will benefit from harmonized
definitions using research into the essential components
of psychosis, which would most likely include delusions
and hallucinations.
Drugs, substances of abuse and their withdrawal, or
organic brain disorders (either primary brain disorders
or secondary brain disorders that are found in general
somatic disorders) may lead to psychosis in any person
who may be exposed to these conditions. There has been
progress in elucidating the pathophysiology of psychot-
ic symptoms, such as delusions and hallucinations, and
one of the new “organic” aspects is that neuronal auto-
antibodies have been found to be associated with psy-
choses.30 This puts the argument of shared biomarkers
into a new light, since there is now a small percentage

12

Focus on psychosis – Gaebel and Zielasek Dialogues in Clinical Neuroscience – Vol 17 . No. 1 . 2015

of persons, among all persons with a psychotic disorder,
who carry these autoantibodies. Another recent trend in
psychosis research relates to the fact that some neuro-
biological signs are only detectable using sophisticated
instrumentation and experimental paradigms in group
analyses because the observed alterations of brain cir-
cuits are very small and prone to interindividual varia-
tion. For example, resting network alterations have been
described in schizophrenia, which may help bridge the
gap between minor structural brain alterations in pa-
tients with schizophrenia, but major disturbances of
brain functions such as in perception and thinking. Cur-
rently, theories are being developed to conceptually link
the areas of measurable neurobiological alterations and
psychotic phenomenology.31 It seems unlikely that “neu-
ral signatures” of psychosis can be expected to be simple
and straightforward. On the contrary, changes are mani-
fold and often subtle, they are detectable with sufficient
statistical significance based on group analyses, but
hardly on an individual level, and they overlap bound-
aries of traditional ICD-10 or DSM-5 mental disorder
categories. Investigations into the genetic underpinnings
of psychotic disorders have also shown a bewildering
number of genetic alterations, affecting a wide variety of
biological pathways32,33 and a rather large overlap of dif-
ferent mental disorders. Studying distinct symptom di-
mensions of psychosis, even in large-scale genetic analy-
ses, did not result in clear associations of specific genes
with specific clinical dimensions of psychosis.34 This ge-
netic research, together with the previously mentioned
clinical-course observations in psychotic disorders, sup-
ports the notion that psychotic clinical phenomena are
spanning traditional classificatory boundaries and may
indeed share etiopathology and pathophysiology across
diagnostic borders.35

The National Institute of Mental Health (NIMH)
Research Domain Criteria (RDoC) initiative is fol-
lowing the path of putting symptoms, syndromes, and
neurobiological signatures into the conceptual center
of research, thus using the “deconstructing” approach.36
Conceptual challenges arise because it remains to be
seen whether identifying underlying neurocircuits will
lead to new nosological definitions, and how the other
aspects of the etiopathogenesis (eg, social and environ-
mental factors) will be incorporated. There are prob-
ably a vast number of potential individual combina-
tions of relevant factors leading to the clinical picture
of psychosis. An important conceptual issue for RDoC

to address is how biological predispositions lead to
symptoms of psychosis, which is only one of the con-
ceptual and methodological challenges for the RDoC
initiative.37 In the long term, it would be desirable to
use additional investigations from the fields of neuro-
imaging, psychophysiology, and genetics to reclassify
psychosis into neurobiologically based subcategories
of signs and symptoms. Research regarding the asso-
ciation of the symptoms of psychosis with structural or
functional brain factors is just beginning (see below),
lending some insight into differential associations of
some psychotic symptoms with cortical thickness mea-
sures, which are, however, not sufficiently distinct on an
individual level to provide a novel direction for “objec-
tivating” and replacing clinical assessments with struc-
tural brain measurements.38 Taken together, these find-
ings seem to indicate that the symptoms of psychosis
may find neurobiological explanations, but the road to
achieving this aim is still long.39 One of the issues to ad-
dress is whether a specific bias of reality testing and the
resulting reality distortion could be a common denomi-
nator of psychosis, with some evidence supporting the
notion that impaired reality testing is found in several
psychotic disorders and may be further deconstructed
into refined neuropsychological dysfunctions.40,41 Psy-
chological constructs associated with this model would
be impaired source monitoring, increased proneness to
jumping to conclusions and jumping to perceptions, and
aberrant salience of irrelevant information, for which
evidence from studies is available.42-46 The jumping-to-
conclusions mechanism is also associated with other
factors in patients with schizophrenia (eg, impairment
of working memory),47 while there is some evidence
indicating that alterations of dopamine neurotransmis-
sion are involved in the aberrant salience dysfunction.48
Based on these and other findings, recent theories pro-
pose that several dysfunctional brain networks inter-
act in schizophrenia, including the salience network,
executive network, and default resting state network.49
Such neuropsychological and neurophysiological con-
structs and other factors (eg, genetic factors), could
then be part of the endophenotype assessment battery
of psychotic disorders, which could result from such re-
search.50 Endophenotypes are quantitative, heritable,
trait-related deficits typically measured with laboratory
tests including neuropsychological tests, which could
be used to detect the underlying impairments of reality
testing in psychotic disorders. Delineating and defining

13

S t a t e o f t h e a r t

assessments will be part of the RDoC approach, as was
recently shown for hallucinations.51,52

Pending the results of such sophisticated analyses
and ensuing revelations of putative highly intricate
etiopathogenetic mechanisms, psychosis will remain a
clinical description of a set of core symptoms, which can
be detected by psychopathological investigations. Nota-
bly, this concept should be regarded philosophically as
a “realistic” concept, which entails that the conceptual
scheme mirrors the real world.53 This means that psy-
chosis is not a social or theoretical construct, but that
psychosis is observable—in the world outside theories
and concepts. As Malmgren et al put it, “Our concepts
are formed while we are interacting with these natural
phenomena.”53 The border toward normality and ques-
tions about the early detection of psychosis emerge as
essential critical issues, which are, however, an issue for
all mental disorders and not just psychosis.54

As to the early detection of psychotic disorders, it
is currently clear that many psychotic disorders have a
long period in which “subdiagnostic” or “subthreshold”
symptoms occur and in which psychosocial interven-
tions may be helpful to prevent the progression toward
schizophrenia, for example.55 Another aspect is that
even after frank psychotic symptoms have occurred, the
duration until appropriate treatment is initiated is very
long, but a long duration of untreated psychosis implies
a less favorable prognosis, although other factors (eg,
involvement of cognition) are also important for pre-
dicting functional outcomes.56
Another aspect is that there are symptoms of psy-
chosis (or “psychosis-like” experiences), mostly of a
fleeting nature in the population, leading to the ques-
tion of the “border toward normality.” Over the life-
span of an individual affected by such symptoms, these
are sometimes followed by progression to a mental
disorder, but the symptoms usually subside spontane-
ously. The transition from “psychosis-like” experiences
in otherwise healthy adolescents to psychosis is at a
low rate of approximately 0.56% per year in persons
with such “psychosis-like experiences,” which is, how-
ever, greatly increased compared with persons without
such experiences (0.16% per year).57 Also, such periods
may be due to identifiable and treatable or prevent-
able clinical situations, such as sleep problems, sensory
deprivation, intoxicating effects of drugs or substances
of abuse, states of withdrawal from drugs or substances
of abuse, or they may be associated with somatic dis-

orders including brain disorders (see van Gastel et al58
on the association with cannabis use). Such psychotic
symptoms and psychosis-like experiences may signal
hitherto unidentified mental disorders.59

In the unselected, general population, as many as
17% endorse having had lifetime psychotic symptoms
(as defined by the Composite International Diagnostic
Interview [CIDI]), but only 2% to 5% have ever had a
diagnosis of a psychotic disorder. In such studies, there
are some associations (eg, for delusions and female sex,
and hallucinations and male sex), but there is consider-
able overlap between associated factors and symptom
profiles.60 Also, in such studies, a range of mental dis-
orders (eg, substance addiction or affective disorders),
emerge as psychosis-associated, besides the “primary”
psychotic disorders (eg, schizophrenia). Research in ad-
olescents who are “at risk” of psychosis indicate that the
overlap of these symptom groups and the ensuing pat-
tern of psychotic symptoms may become an indicator
of progression to psychotic disorders, although research
into this question is still in its infancy.61 How can “truly”
psychotic symptoms be differentiated from “psychotic-
like experiences,” “unusual subjective experiences,” and
similar experiences, and what is their prospective value
for predicting the future occurrence of mental disor-
ders in general and psychotic disorders in particular?62
Obviously, further research is necessary to delineate
the experiences of psychotic symptoms from those of
a “psychosis-like” nature, and such psychopathological
research is just beginning.63 Given the high frequency
of such experiences in the general population, and the
impairments and suffering associated with them if they
progress, there is a clear clinical need to address these
questions, which may have consequences for the noso-
logical status of “mild” or “attenuated” psychotic expe-
riences in the general population.

Future research in psychosis:
where is it heading?

Three avenues of progress are currently shaping the
field. First, there is now stereoelectroencephalographic
evidence derived from studies with intracranial elec-
trodes during epilepsy surgery showing that some
symptoms of psychosis may result from stimulation in
different brain areas, and that complex brain networks
are obviously involved. Interestingly, there seems to be
considerable overlap in the pathophysiology of hallu-

14

Focus on psychosis – Gaebel and Zielasek Dialogues in Clinical Neuroscience – Vol 17 . No. 1 . 2015

cinations and delusions using such technologies, which
has prompted a debate on whether the “psychiatric”
distinction between hallucinations and delusions was
warranted.64 The question arises whether the same prin-
ciples apply to nonictal psychosis.
A second technique is the use of neuroimaging
methods to identify areas of the brain involved in the
pathophysiology of hallucinations and delusions. While
this research is ongoing, it seems clear that there are no
single brain regions that are more decisive, but that com-
plex network disturbances occur in the context of these
phenomena and that many combinations of functional
alterations may be detectable.65 The question is whether
the symptoms of “primary” (or “endogenous”) psychot-
ic disorders will prove to have similar pathophysiology
compared with those in other brain disorders (eg, Al-
zheimer’s disease).66 The genetics of psychotic manifes-
tations in Alzheimer’s disease show some overlap with
schizophrenia genetics, but both fields of research have
so far yielded a bewildering array of associations with a
multitude of genes. It seems impossible to pinpoint indi-
vidual genes in individual cases.67

A third approach utilizes novel methods of brain
network analyses (“connectome”)68 and the results
are preliminary and complex, and have not yet pro-
vided distinguishing landmarks for analysis suitable
for clinical practice. However, research advances in
the brain network analysis of the symptoms of psy-
chosis (eg, relevant neurotransmitter systems includ-
ing γ-aminobutyric acid [GABA] and glutamate) as
well as proteomic approaches combined with genomic
approaches are beginning to reshape the concept and
therapeutic approaches of psychotic disorders.69,70 New
concepts of psychosis are emerging as the result of the
neurobiological research progress, including the theo-
ry of dopamine hypersensitivity caused by a range of
pathological insults that may be a common denomi-
nator, with the concept also taking into account brain
reactions in the different dopamine pathways (both in-
tracellular and intercellular) and the counterreactions
by the same pathways or due to altered interactions
among each other.71 Today, alterations of the dopamine
system and their interactions with other neurotrans-
mitter systems are viewed not as the causes, but rather
as the consequences of a cascade of events in the etio-
pathogenesis of psychosis.72 They seem to represent a
common final pathway, amenable to treatment with an-
tipsychotic drugs across traditional diagnostic boundar-

ies of mental disorders. Gene-environment interactions
are another important aspect here as it appears highly
likely that not only do “endogenous” processes play a
role, but also exogenous factors (eg, environmental fac-
tors) codetermine the timing, type, and course of psy-
chosis.73,74 However, large-scale epidemiological studies
indicate that the gene-environment-symptom pathway
is complex and highly variable between individuals,
leading to weak associations between these factors,
even in large-scale studies.75 Now there are attempts
to associate specific developmental insults with specific
symptoms or specific disease trajectories of psychotic
disorders, but this research is just beginning.76-78 Once
psychotic disorders have developed, studies in patients
with treatment-refractory vs nonrefractory psychotic
disorders show that the “old” differentiation between
schizophrenia, bipolar disorder, and schizoaffective dis-
order still has prognostic validity. These classes of men-
tal disorders are associated with differential treatment
responses in specific clinical domains of psychosis,79
and they emerge in latent class analyses in cohorts of
patients with mental disorders and healthy controls.80
These findings indicate that there may be differential
pathways into these specific symptoms, which need to
be unraveled by future research in more detail. While
this research has a rather long-time perspective be-
tween the insult and ensuing symptoms, research is now
also addressing fluctuations of psychotic symptoms on
a micro-timescale of hours. Initial results indicate that
such assessments are feasible, may lend insight into
the complex array of environmental or affective fac-
tors influencing the clinical presentation of psychosis,
and indicate that such momentary states are the basic
units of psychosis.81,82,83 The expected progress in these
areas of (neuro) systems-oriented research will clearly
bear on the concept of psychosis and the methodology
of elucidating the etiopathogenesis of mental disorders
in general.84

Taken together, the etiopathogenesis of the symp-
toms of psychosis is complex and involves a number of
environmental and endogenous factors (eg, genetic and
neurodevelopmental factors), which interact in an intri-
cate manner leading to a range of structural and func-
tional adaptive or maladaptive responses of the brain.85
Novel research approaches based on the deconstruc-
tion of the psychosis syndrome into its symptoms hold
promise for unraveling the causes and pathophysiology
of these symptoms in the future.

15

S t a t e o f t h e a r t
16

Conclusions

Psychosis is a clinical syndrome composed of several
symptoms. It is not a nosological entity. Symptoms of
psychosis occur in a wide range of mental disorders
and show a high degree of interindividual variability
between persons with different mental disorders, and
a high degree of intraindividual variability over time.
Symptoms of psychosis are usually embedded in the
wider clinical picture of the mental disorder, which
may include symptoms of mania and depression. The
elucidation of the symptoms of psychosis by drugs or
brain disorders indicates that every person may ex-
perience symptoms of psychosis. While the concept
and definition of psychosis are characterized by the
core clinical symptoms of delusions, hallucinations,
and disorganized thinking, it is most likely that these
symptoms are common final outcomes of a range of
different causes and etiopathogenetic pathways, which
may all lead to a similar clinical picture. As Kraepelin

put it, the human brain only has a limited number of
reaction types (a concept relating to Bonhoeffer’s re-
action types)86 in the face of etiopathogenic insults.87
The clinical efficacy of antipsychotic drugs against the
symptoms of psychosis, irrespective of the mental dis-
order, indicates that such final common pathways play
a role. The symptoms of psychosis are a common clini-
cal result of a number of causes and pathomechanisms.
Therefore, the need arises to deconstruct the construct
into its clinical dimensions with a view to identifying
the causes and pathomechanisms of each of the symp-
toms of psychosis. There may be shared causes and
pathomechanisms, since the symptoms of psychosis
commonly occur together, which seem to converge on
some common final pathways of the brain, leading to
the similar efficacy of antipsychotic drugs in different
mental disorders where these symptoms occur. Future
challenges are to identify the causative and patho-
physiological components, and their interplay in indi-
vidual cases. o

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17

Foco en las psicosis

Durante los últimos 170 años el concepto de psicosis se
ha configurado a través de las tradiciones de los con-
ceptos sobre los trastornos mentales. El término “psico-
sis” todavía carece de una definición unificada, pero da
cuenta de un constructo clínico compuesto por varios
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Cap sur la psychose

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