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My daughter has schizoaffective disorder. She fell ill at age 15 and had to be hospitalized twice. It was a terrible time for all of us, but today, I am happy to say, she is doing well. She graduated from a highly competitive college, got married, and writes amazing poetry and fiction. She still has delusions, but quietly so, and has developed a clear understanding of her illness and the necessity of mood stabilizers, though she still refuses antipsychotics. Why am I revealing the facts of my daughter’s illness in a public forum? In a word, stigma.

As a psychiatrist, I help patients and their families deal with stigma all the time. Having faced stigma in my own life, I know how upsetting it can be. When my daughter was hospitalized (at my institution), several well-meaning individuals told me how brave I was to allow that to happen. Whenever I heard that, I appreciated the sentiment, but also thought that nobody would have called me brave if my daughter had a brain tumor. Apparently it takes courage to reveal to your colleagues, even to your psychiatric colleagues, that your child is mentally ill—as if a serious mental illness in a child or relative is something to be hidden, not discussed. Through the worst of her illness, I lost a few friends who were uncomfortable with the fact that I had a mentally ill child. Some family members hid what was happening from others, I think out of a sense of shame and embarrassment.

Why is mental illness still considered shameful? At least part of the stigma arises because we do not entirely understand what causes mental illness, and because those with mental illness sometimes behave in baffling or even dangerous ways. On the other hand, many members of the public do not understand the gravity of mental illness. They believe that patients with depression, for example, just need to pull their socks up and 

 Finally, part of the stigma is a society level problem that humans tend to marginalize anyone who looks, acts, or thinks differently.

Widespread stigma and misunderstandings can have terrible consequences for patients. As a psychiatrist who specializes in treating psychiatric illness during and after pregnancy, I see them every day in my professional life. Every week I see patients whose doctors advised them to come off their psychiatric medications for pregnancy, not taking into account the severity of their illness, or the impact of untreated psychiatric illness on the developing child. I have patients and families who ask whether they should have children in the first place, as if someone with a mental illness cannot also be a nurturing and loving parent. It took until 2016 for the US Preventative Taskforce to recommend 

 for pregnant and postpartum women, even though peripartum depression is the most common complication of childbirth.

It is time to stop whispering and to start speaking out. The fact is that most, if not all, of us have family members who have struggled with some form of mental illness, and these numbers are only increasing during the pandemic. Across the world, 792 million people have mental health problems, and 

 individuals will experience a mental health or a substance abuse issue at some point in their lifetime.

 How can we continue to stigmatize something that is so common normal?

There are signs of change. A number of organizations are leading conversations about mental illness, educating the public, and speaking out about stigma. These include but are not limited to: 

. These organizations argue that the more we talk about mental illness as a common condition needing treatment, the more other individuals and families with mental illness will speak out too, and stigma will be reduced.

I believe this is the right approach. It is going to take regular doctors and patients speaking out routinely and treating mental illness like any other disease or condition. It is something that needs to be identified and treated, not something to be ashamed of. Discussing mental illness should be commonplace, like talking about diet and exercise and one’s cholesterol level. Only then can we dispel the stigma, support those who need help, and get them the care and treatments they deserve.

I have been open and frank with colleagues, friends, family, and strangers at times. I ask you to join me. Let’s tell the public that mental illness is common, treatable, and we all have been touched by it in one way or another. For the sake of our patients and ourselves, we need to do more to end the stigma of mental illness. Isn’t it past time?

is professor of Psychiatry and Vice Chair of Research in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia, Charlottesville, VA. Dr Payne and her daughter have published a 

 about their personal experiences of having or treating mental illness.

1. Do you know the facts? Breaking down the myths about depression. Back to Campus: A Program of Mental Health America. Accessed September 14, 2021. 

https://mhanational.org/sites/default/files/Breaking_Down_the_Myths_About_Depression.pdf

2. Beharry J. 5 myths that prevent men from fighting depression. National Alliance on Mental Illness. March 23, 2018. Accessed September 14, 2021. 

3. Toohey J. Depression during pregnancy and postpartum. 

4. Dattani S, Ritchie H, Roser M. Mental health. Our World in Data. April 2018. Updated August 2021. Accessed September 14, 2021. 

Mental illnesses are too often shrouded in secrecy and shame. What would happen if we spoke out about the cases we knew best—the ones in our own families?  

Speaking Out on Schizoaffective Disorder

(This is the second article in a series discussing psychotic disorders in late life. The 

appeared in the August issue, pages 16-17. —Ed)

Psychosis in late life may result from any of an array of different illnesses with varied etiologies. Indeed, available evidence indicates that secondary causes for psychosis are more common among older adults (65 years and older) when compared with 

 It is also necessary to distinguish between late-onset schizophrenia (LOS), very late–onset schizophrenia-like psychosis (VLOS), and early-onset schizophrenia (EOS). Having an appreciation of these possible etiologies is important, as this information will help with early identification and treatment of these disorders.

Cognitive decline, poor health status, visual impairment, and negative life events have been identified as 

 for the development of psychotic disorders among older adults.

 Older age of onset for schizophrenia is known to be associated with female gender, a lower family history of schizophrenia, lower rates of substance use, better early psychosocial functioning, higher educational attainment, and a greater number of comorbid physical health problems.

 For LOS and VLOS, female gender appears to be a prominent risk factor.

 Additional risk factors for VLOS are more abnormalities in brain structures, family history of schizophrenia or avoidant personality, paranoid or schizoid personality disorder, hearing loss, being from an immigrant population, or having a lower socioeconomic status.

A detailed cognitive assessment and thorough physical examinations can help differentiate among the various etiologies for psychotic symptoms in late life. Secondary causes for psychotic disorders in late life can be identified by a complete blood count and complete metabolic panel; further blood work that measures thyroid-stimulating hormone, vitamin B12, folate level, rapid plasma reagin, and erythrocyte sedimentation rate; urine toxicology; and autoimmune panels and HIV 

 Additionally, neuroimaging studies like magnetic resonance imaging or computerized tomography can rule out structural brain abnormalities causing psychotic symptoms. In complicated cases, neuropsychological testing can help differentiate among the possible etiologies for psychotic symptoms in late life.

. The prevalence of schizophrenia among individuals 65 years or older is approximately 0.1% to 0.5%.

 Between 20% and 25% of schizophrenia cases are either LOS or VLOS, and the incidence of schizophrenia among individuals 65 years or older is 7.5 per 100,000.

 The incidence rate of VLOS is 37.66 per 100,000 person-years at risk (an estimation based on observation time per participant), and 60% of individuals with VLOS are women.

 Often debilitating in its own right, schizophrenia is also a risk factor for developing dementia (relative risk = 2.2).

. Among older adults, the prevalence of schizoaffective disorder is approximately 0.14%.

 Older adults have higher severity of illness, more treatment resistance, and higher risk for suicide when compared with younger adults.

 Not all schizoaffective disorders in older adults carry the same risk. Older adults with the depressive type of schizoaffective disorder have a higher history of suicide attempts and are more likely to take antidepressant medications when compared with those with the bipolar-type illness.

 The prevalence of delusional disorder is approximately 0.03% in this population.

 Individuals with this condition can have normal cognitive, personal, and occupational functioning, but significant social dysfunction.

Depressive and bipolar disorders (affective psychosis)

. Among older adults, the incidence of affective psychosis is approximately 30.9 per 100,000 person years.

 Older patients with bipolar disorder have more paranoia when compared to younger adults, and delusions are present in 45% of older adults admitted to hospitals for depression.

 Older adults with psychotic depression also have a higher prevalence of comorbid anxiety and somatic symptoms.

. Psychotic symptoms occur in approximately 40% of individuals with major neurocognitive disorders. Psychotic symptoms are seen in approximately 41.1% of individuals with Alzheimer disease.

 Psychosis occurs in 15% of the individuals with vascular neurocognitive disorders.

 Visual and auditory hallucinations and delusions occur in 78% and 25% of individuals with neurocognitive disorders with Lewy bodies.

. The prevalence of psychotic symptoms among individuals with delirium is approximately 42.7%.

 Visual hallucinations occur in 27%, delusions in 25.6%, auditory hallucinations in 12.4%, and tactile hallucination in 2.7%.

The risk for developing secondary psychosis due to drug use, environmental toxins like lead or mercury and medical illness is greater among older adults due to comorbidities, polypharmacy, and sensitivity to drugs.

When it comes to patient background and risk factors, there are significant differences between LOS, VLOS, and EOS (

It has been noted that LOS is associated with a genetic variant indopamine D2 receptor (DRD2), rs2734839.

 Additionally, individuals with LOS appear to have larger thalamic volumes and abnormalities in white matter integrity when compared with individuals with EOS.

 Individuals with LOS also present with reduced cerebral blood flow in both postcentral gyri when compared with individuals with EOS who present with reduced blood flow to the precentral gyrus and inferior frontal gyrus.

 Older adults with delusional disorders appear to have larger lateral ventricular volumes than older adults with schizophrenia and almost twice those of age-matched controls.

Psychosis in late life is not uncommon, with secondary causes of psychosis being more prevalent than primary psychotic disorders. Among older adults who present with psychotic symptoms, a thorough history, the evaluation of risk factors, and conducting an appropriate work-up that includes neuroimaging studies and neuropsychological testing for complicated cases will result in early identification of the etiologies and prompt treatment of these symptoms.

 is chairman of the Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, Ohio; chief, Section for Geriatric Psychiatry, Cleveland Clinic, Ohio; and professor of medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

1. Howard R, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group. 

2. Brunelle S, Cole MG, Elie M. Risk factors for the late-onset psychoses: a systematic review of cohort studies.

3. Chen L, Selvendra A, Stewart A, Castle D. Risk factors in early and late onset schizophrenia. 

4. Jeste DV, Symonds LL, Harris MJ, et al. Nondementia nonpraecox dementia praecox? late-onset schizophrenia. 

5. Reinhardt MM, Cohen CI. Late-life psychosis: diagnosis and treatment. 

6. Javadpour A, Sehatpour M, Mani A, et al. Assessing diagnosis and symptoms profiles of late-life psychosis.

7. Castle DJ, Murray RM. The epidemiology of late-onset schizophrenia. 

8. Copeland JR, Dewey ME, Scott A, et al. Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity, and outcome. 

9. Harris MJ, Jeste DV. Late-onset schizophrenia: an overview. 

10. Stafford J, Howard R, Kirkbride JB. The incidence of very late-onset psychotic disorders: a systematic review and meta-analysis, 1960-2016. 

11. Stafford J, Howard R, Dalman C, Kirkbride JB. The incidence of nonaffective, nonorganic psychotic disorders in older people: a population-based cohort study of 3 million people in Sweden. 

12. Riisgaard Ribe A, Munk Laursen T, Charles M, et al. Long-term risk of dementia in persons with schizophrenia: a Danish population-based cohort study. 

13. Cai L, Huang J. Schizophrenia and risk of dementia: a meta-analysis study. 

14. Meesters PD, de Haan L, Comijs HC, et al. Schizophrenia spectrum disorders in later life: prevalence and distribution of age at onset and sex in a Dutch catchment area. 

15. Post F. Schizo-affective symptomatology in late life. 

16. Baran XY, Young RC. Bipolar and depressive types of schizoaffective disorder in old age. 

17. González-Rodríguez A, Molina-Andreu O, Navarro V, et al. Delusional disorder: no gender differences in age at onset, suicidal ideation, or suicidal behavior. 

18. Depp CA, Jeste DV. Bipolar disorder in older adults: a critical review. 

19. Owoeye O, Kingston T, Scully PJ, et al. Epidemiological and clinical characterization following a first psychotic episode in major depressive disorder: comparisons with schizophrenia and bipolar I disorder in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS). 

20. Gournellis R, Oulis P, Rizos E, et al. Clinical correlates of age of onset in psychotic depression. 

21. Ropacki SA, Jeste DV. Epidemiology of and risk factors for psychosis of Alzheimer’s disease: a review of 55 studies published from 1990 to 2003. 

22. Leroi I, Voulgari A, Breitner JCS, Lyketsos CG. The epidemiology of psychosis in dementia. 

23. Nagahama Y, Okina T, Suzuki N, et al. Classification of psychotic symptoms in dementia with Lewy bodies. 

24. Gareri P, Segura-García C, Manfredi VGL, et al. Use of atypical antipsychotics in the elderly: a clinical review. 

25. Keshavan MS, Kaneko Y. Secondary psychoses: an update. 

26. Voisey J, Swagell CD, Hughes IP, et al. A novel DRD2 single-nucleotide polymorphism associated with schizophrenia predicts age of onset: HapMap tag-single-nucleotide polymorphism analysis. 

27. Sachdev P, Brodaty H, Rose N, Cathcart S. Schizophrenia with onset after age 50 years. 2: neurological, neuropsychological and MRI investigation. 

28. Corey-Bloom J, Jernigan T, Archibald S, et al. Quantitative magnetic resonance imaging of the brain in late-life schizophrenia. 

29. Chen L, Chen X, Liu W, et al. White matter microstructural abnormalities in patients with late-onset schizophrenia identified by a voxel-based diffusion tensor imaging. 

30. Wake R, Miyaoka T, Araki T, et al. Regional cerebral blood flow in late-onset schizophrenia: a SPECT study using 99mTc-ECD. 

31. Howard RJ, Almeida O, Levy R, et al. Quantitative magnetic resonance imaging volumetry distinguishes delusional disorder from late-onset schizophrenia.

Secondary causes for psychosis are more common in older adults (65 years or older) than in younger patients. Here are 6 possible culprits. 

Exploring Possible Etiologies for Psychotic Disorders in Late Life

The US Food and Drug Administration (FDA) has approved Janssen Pharmaceutical’s long-acting atypical antipsychotic Invega Hayfera (6-month paliperidone palmitate), a one-of-a-kind twice-yearly injectable for the treatment of adults with schizophrenia.

 Patients wishing to take Invega Hayfera must first be treated with Invega Sustenna (1-month paliperidone palmitate) for at least 4 months, or Invega Trinza (3-month paliperidone palmitate) for at least 1 injection cycle.

“The approval of Invega Hayfera builds on our 60-year legacy of delivering transformational medicines for adults living with schizophrenia,” said Mathai Mammen, MD, PhD, Global Head of Janssen Research & Development at Johnson & Johnson. “This approval further underscores our steadfast commitment to addressing critical unmet needs, including treatment adherence concerns, faced by adults living with schizophrenia.”

Invega Hayfera is a long-acting injectable treatment administered by a health care provider in the upper buttocks area every 6 months, which dissolves slowly into the bloodstream.

FDA approval was based on the results of a 12-month, randomized, double-blind, noninferiority phase 3 global study. The study enrolled 702 adults from 20 countries, aged 18 to 70, living with schizophrenia. The results showed noninferiority of Invega Hayfera compared to Invega Trinza on the primary endpoint of time to first relapse at the end of the 12-month period, with relapse defined as psychiatric hospitalization, increase in Positive and Negative Syndrome Scale [PANSS] total score, increase in individual PANSS item scores, self-injury, violent behavior, or suicidal/homicidal ideation. Results also found that 92.5% of patients treated with Invega Hayfera and 95% treated with Invega Trinza were relapse-free at 12 months.

“For too long, we’ve accepted relapse as a normal part of living with schizophrenia, while research continues to demonstrate that stronger medication adherence means better patient outcomes,” said Gustavo Alva, MD, DFAPA, the Medical Director at ATP Clinical Research and 6-month paliperidone palmitate clinical trial investigator. “The Phase 3 trial results provide compelling evidence that 6-month paliperidone palmitate offers longer-term symptom control with the fewest doses per year, which may support greater patient adherence.”

The safety profile observed was consistent with previous studies of Invega Sustenna and Invega Trinza. The most common adverse reactions (≥5%) were upper respiratory tract infection (12%), injection site reaction (11%), weight increase (9%), headache (7%), and parkinsonism (5%).

“Long-acting injectable treatments offer a number of advantages compared to oral medication for schizophrenia, including relief from needing to remember to take medication daily, lower discontinuation rates, and sustained treatment over longer periods,” said Bill Martin, PhD, Global Therapeutic Area Head of Neuroscience at Janssen Research & Development. “Today’s approval enables us to rethink how we manage this chronic disease by offering patients and caregivers the potential for a life less defined by schizophrenia medication.”

1. Janssen Pharmaceutical Companies of Johnson & Johnson. Janssen announces US FDA approval of INVEGA HAFYERA™ (6-month paliperidone palmitate), first and only twice-yearly treatment for adults with schizophrenia. News release. September 1, 2021. 

https://www.prnewswire.com/news-releases/janssen-announces-us-fda-approval-of-invega-hafyera-6-month-paliperidone-palmitate-first-and-only-twice-yearly-treatment-for-adults-with-schizophrenia-301366768.html

The one-of-its-kind 6-month paliperidone palmitate treatment for schizophrenia has received FDA approval. 

First and Only Twice-Yearly Treatment for Schizophrenia Receives FDA Approval

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Wouter Kusters, PhD, is a Dutch linguist and philosopher. He is the author of 

; Lemniscaat, 2014). An English translation of 

 was published in 2020 by MIT press with the title 

A Philosophy of Madness: The Experience of Psychotic Thinking

 (translated by Nancy Forest-Flier). Dr Kusters works as an independent researcher, writer, teacher, and consultant in Gouda, Netherlands. For details, see his website 

 was based on Dr Kusters’s own experience of a psychotic episode in 1987. It won a pair of prizes in the Netherlands: the Van Helsdingen Award (2004) for the best work on the intersection of philosophy and psychiatry, and the Socrates Award (2005) for the best and most inspiring Dutch philosophy book of the year. After the publication of this book, Dr Kusters made a career switch from academic linguistics to a career as an independent writer and researcher, and started studying again as an undergraduate philosophy student, during which time he published his second book on psychosis 

 (Lemniscaat, 2007). Shortly afterwards, in the summer of 2007, he experienced his second episode of psychosis, which led to a psychiatric hospitalization, and provided further impetus for him to continue his work on philosophy and madness. He finished his Masters’ thesis in philosophy in 2010, which formed the basis of an updated version of 

. His books were a success in Netherlands and were met with widespread acclaim. The publication of the English translation of 

 has brought his work to the attention of the English-speaking world, and it has prompted a renewed debate on philosophical and phenomenological perspectives on psychosis as well as the relationship between philosophy and psychosis.

: I imagine you may be getting tired of introducing your book again and again! Perhaps we can spare you some of that repetition by linking to sources where such introductions are available, but I think it would be prudent for us to begin with at least a few words regarding the nature of inquiry you are undertaking in 

, and how that relates to your own experiences of psychosis.

: My book is a philosophical treatise in the tradition of Montaigne’s 

; in the vein of Nietzsche’s and Kierkegaard’s approaches to thought, writing, and life; and with affinities to the early works of the French existentialists, Sartre and Camus. What brings these works together is the focus on philosophical problems of good and evil, life and death, I and the other, without getting lost in arid, abstract, academic reasoning for the sake of reasoning itself. On every page the driving question with these authors is: “what does all this thinking, reflection, and all these ideas, actually mean for my life as a writer, and for the life of the reader?” My book does not have the form of problem-solving argumentation, let alone that of a psychopathological theory, with a set of propositions about a clearly delineated empirical phenomenon. It could be categorized as 

, with inclusion of the darker aspects of spiritual travelling. It has also been called auto-ethnography: a description of personal experiences and reflections, undertaken in order to examine the wider ethos against which the experience takes place. The particular ethos that is at stake in my book would be the ethos, the mores, the habits, and discursive practices that are called philosophy in relation to madness.

My book does not present a psychopathological theory, but it does focus on madness as a lived experience, as a concept in philosophy, and as a phenomenon called psychosis in psychiatric practice and theory. By stressing the experiential character of psychosis, which I have access to via my own memory, as well as via all kinds of reports and first-person narratives, the direction of my exploration is towards comparable experiences and their expressions. This brings us to all kinds of philosophical thoughts, bordering on reflections around religion, mysticism, and spirituality, but also to important themes of language, fiction, and nonfiction. For any psychiatrist educated a little beyond the mainstream medical illness, cure, and therapy narratives, it must be clear that my exercise brought me into the small but highly professional and well-informed tradition of phenomenological psychiatry.

For a further overview of what my book is all about, I recommend the short interview in the 

: You have argued that a philosophical investigation of psychosis provides a better and less prejudicial approach than many mainstream psychological and psychiatric accounts. What sort of prejudices do you have in mind?

: The main prejudice concerns the usual way of approaching psychosis as a negative or a lack and leaving it there. That is, seeing it purely as a deficit, a disorder, a nonfunctioning of some aspect of the mind/brain/body that is supposed to be well-functioning in the nonpsychotic individual. Take for example the idea, found in various kinds of mainstream accounts, that psychosis is some kind of 

. Such a judgement implies that there is good, proper thought, and that psychotic thought can be sufficiently defined as a disturbance, a disordering of this normal, natural way of thinking. It may be said that the disorder is one of jumping too fast to conclusions, or a dysregulation of perceiving salience properly, or an inability to synthesize information coherently, or it is just being plainly illogical. All such approaches share the assumption (the prejudice) that psychosis can be sufficiently defined by what it is not.

The implication of such accounts is that the psychosis is just a disruption that should be suppressed and taken away in order to let the normal flow of experience run again uninterruptedly. It is assumed that there is a healthy, sane part, and an insane, psychotic part, both manifesting themselves in various contexts and intensities. Therapy then consists in identifying and annulling the psychotic part (eg, by medication, by CBT, or by so-called ‘psychoeducation,’ and stimulating the healthy part). The patient then eventually learns to associate him- or herself with the healthy part, dissociate from the disordered part, and to consider the psychosis as the illness, not belonging to who he or she really is, but as something that was intruding from the outside. They learn to say: “the psychosis disturbed the real me.” Instead of: “the psychosis showed a different aspect of me.” It thereby dissociates them from their own experiences, memories, and past.

So, the assumption in much theory, and the accompanying practices, is that the life-world of the individual is affected by a natural disorder, which eventually impairs the individual in his or her freedom, in his or her meaningful interaction with others, and in his or her sense of being a conscious individual. What most of these accounts simply miss is that the psychotic experience itself is meaningful. In fact, psychotic individuals often experience more freedom, instead of less, and they feel their consciousness is not troubled or darkened, but they report all kinds of experiences that are phrased with positive light metaphors. By defining psychosis basically as a certain lack, mainstream psychiatry and psychology imply that meaning, freedom, and truth are only found in the nonpsychotic way.

What philosophy has to offer here is an examination of both sides, an inquiry into those notions that are so often assumed to be absent in psychosis. Philosophy investigates the power and implications of the negative: for instance, in what world does the psychotic live, when it is claimed that s/he does not live in a real world? How is this supposed unreality experienced? Why does it often feel more real than so-called ordinary reality? And so on. Only by letting go of our own prejudices about reality and thought, about how language and meaning operate, may we gain a deeper understanding of other (psychotic) kinds of organizations, other kinds of being-in-the-world than that of the nonpsychotic individual.

To be sure, I do not have any principled criticism of the use of medication or cognitive behavioral therapy in itself. But the pretension that often accompanies the provision of effective treatment, that the clinicians know and understand what psychosis is better than the persons themselves—

 can have a negative impact on people’s lives. I mean, the reason why I receive a continuing stream of all kinds of emails and reactions from those who underwent psychosis, sometimes even more than 40 years after their psychosis, is significant here. If psychosis were really just like diabetes or a broken leg, a temporary natural disturbance of the mind, why would so many remain so puzzled afterwards? Why do they want to go back there, consciously or unconsciously? What is this mysterious, seductive quality of psychosis? Psychosis is not only a disorder. It is also the basis for thinking towards a different order.

: How do you think such prejudices can be avoided?

: It is not so difficult to avoid these prejudices. The essential thing is to drop the assumption that those who are called psychotic no longer have meaningful consciousness, are no longer competent language users, uttering meaningless sentences. This kind of prejudice may partly be overcome in psychiatric practice by not approaching patients with psychotic symptoms from a purely scientific perspective, with all its supposed application of evidence-based knowledge. Instead, we ought to engage with psychotic individuals as unknown human beings, who are basically thrown into the same puzzling world as yourself, a world in which we are entangled, which defines us, but which at the same time is defined by us, and in which we experience freedom.

In fact, psychopathological theories that start from this perspective are numerous, but no longer mainstream in our age. We may think of all kinds of psychoanalytic theories, phenomenological theories, enactivist theories, and so on. But the danger with any of these alternatives is (and that is due to the fact that it concerns scientific theories or models) that they reduce and categorize the psychotics again under just another determining and defining order, and treat them as having some kind of deviant mind, ruled by just another set of natural laws. A theory may be helpful for the first steps towards contact, but all too soon they become obstacles, closures of the mind, that prevent the soul from seeing another soul, outside of his own, outside of the theory.

Nothing in this negates or takes away from the fact that these individuals may be greatly distressed and impaired, and they may be in need of clinical care. To say that psychosis is meaningful is also not to deny that there are differences from ordinary states of consciousness. On the contrary, this difference and its exploration is what the whole engagement with psychosis starts with, both in psychiatric practice as well as in my book. There is a paradox here. There is simultaneously a continuity in experience between psychosis and non-psychosis, as well as a discontinuity, a definite break and identifiable difference, between psychotic and non-psychotic experience.

: How does this inform the philosophical approach you take in your book?

: My philosophical approach tries to avoid such theorizing. I do not seek to construct yet another theory about empirical patterns of behavior and thought in psychosis. Instead of a theoretical monologue about some scientifically well-defined object, my book is a philosophical dialogue between several undefined subjects. My book is essentially dialogical, notwithstanding the fact that many of its dialogues are internal dialogues. These dialogues represent a kind of dance, and sometimes a battle, between on the one hand the rational philosopher or curious researcher, and on the other hand, the psychotic, the madman—with inclusion of relatives like the religious zealot, the mystic visionary, and the nihilist skeptic, who in the course of the text change position. Meanwhile, it remains unclear who is leading, who is following, who is analyzed by whom, and who is stimulated by whom.

The knowledge or theory that my book might yield, and that might be transmitted to a reader, only emerges by following this dance from a starting point in a third position, that of the reader, who can only extract sense from my book when he or she is open for internal dialogues from within him- or herself. This dialogical character (some use here the term 

), by the way, is the basis for all philosophy. It is a way of essentially opening, disclosing, of bringing thoughts into the spotlight (also discussing this spotlight), of exploring hidden perspectives and possibilities. It is different than the closing character of scientific discourse, which is more interested in defining, reducing, ordering, and controlling. In this respect, my book differs widely from the methods and ends of psychological or psychiatric theories. Scientific discourse is successful when the theories and predictions are confirmed by observation in practice, and when these theories are implemented in new regimes of social order, psychological management, and action schemas. My book will be successful when the fundamentals of all regimes of order are suspended into disbelief during a momentary glimpse in the mind of the reader, and the reader is able to see that we all just dance in the void.

 (the snake that eats its own tail) and the 

 play a central role in your discussion of psychosis. Can you elaborate on the significance of this motif?

: The Mobius ring is indeed an important image. It helps me visualize an underlying motif in my book. Let me explain: Initially, in my book, there is a difference between, let’s say the meta-level, the thinker (philosophy), and the data, or object level (madness). On the theoretical meta-level with its numerous concepts, argumentations, and analyses, I try to make sense of the data: how do time and space change in psychosis, what happens to reality, the self and the other? This concerns Part One of my book, in which I present an introduction into the findings of phenomenological psychiatry, with help of philosophers like Edmund Husserl, PhD, Maurice Merleau-Ponty, PhD, Ludwig Wittgenstein, PhD, and René Descartes. At this level in Part One of my book, the front side of the Mobius ring, where the philosopher-narrator meets the reader, is clearly philosophy, and the (hidden) back side is madness. With philosophy as a tool, as a way of thinking, I try to capture something of that enigmatic hidden domain of madness. So far so good.

Then in Part Two the narrator, the philosopher notices that with this philosophical theorizing there remains a distance between 1) the meta-level of philosophy with its concepts and learned discourse, and 2) the object-level where madness rules, with its anxieties, delusions, ecstasies, and its word plays and other-worldliness. Then from Part Two on until the end of Part Four of the book, the philosopher converges closer and closer to the madman. The philosopher no longer stays on the firm shore of his identity and self-assured discourse, but embarks with the madman, in order to not only describe and explain madness, but to think/experience him- or herself what it is like to be psychotic. In other words, the philosopher engages in some serious (psychotic) thought experiments and becomes entangled in the same quagmires as the madman. In the end, the philosopher has become mad and has reached the other side of the Mobius ring, the back side.

So, the Mobius ring is hidden in the book, and also reflects my own paradoxical experiences. I was doing serious research as a philosopher about psychosis (in fact, a substantial portion of the first part of my book is based on the papers I wrote during that time) while having in the back of my mind the data of my own psychosis from 15 years before. Then during that study of psychosis, my philosophizing intensified, and philosophy led to madness, and madness emerged out of philosophy.

: Even since becoming familiar with your book, I have been wondering about the relationship between psychosis and philosophy.

: I would say so! In my mind, one way to approach it would be to treat psychosis as a method of inquiry into the nature of reality such that, at the end of it, something is revealed about the nature of the world and our existence. Another approach might be more negative. In this approach, psychosis by itself does not tell us what reality is, but it throws our everyday epistemic complacency into disarray. We can no longer trust our sensory inputs, our perception of space and time, our social instincts, etc, and this provokes a state akin to Cartesian doubt, where we can no longer take our ordinary understanding of the world for granted. With some poetic license and over-simplification, perhaps I can refer to these positions as the 

, respectively. Certainly, there can be all sorts of interesting combinations and variants of these approaches. Would you consider this to be a useful framing? And if so, do you lean towards a particular position?

: That is a very illuminating framing indeed, and relates to the power of the negative, that I referred to above. Let me comment on both positions and their relation to madness. In the original version of the Cartesian thought experiment, the one described by Descartes himself, a subject throws himself into full doubt, distrusts his senses, and searches within his own thought for a firm ground for existence, an undeniable truth, beyond all doubt. Descartes describes how in this process of radical doubt, everything is rejected because of its principled uncertainty, mutability, and transiency. The only thing that cannot be doubted, is that there is me, enveloped in a doubting process. And then from this elementary given, the famous rationalist adage follows, 

: “I think, therefore I am.” In the dark nights of the mad soul (compare for instance my autobiographical notes at the end of Part Two of my latest book), the individual with psychosis may have an analogous thought process, and he or she may end up in a kind of intellectual and existential despair, driven by radical self-doubt. But this despair may also take the form of an experience of perplexity about the undeniability and givenness of one’s own existence. The argumentative structure in Descartes’ texts shows similarities with the existential doubts the madman is in.

What is often forgotten in popular considerations of Cartesianism is that building on 

, Descartes goes on to prove the existence of God as well as reality, using arguments that are today seldom accepted as self-evident truths. Descartes draws the conclusion that from being able to think an utterly perfect being (God), we must conclude that this utterly perfect being exists, otherwise it would not be utterly perfect. Now the madman may in myriad ways follow, mirror, and deviate from such ways of thinking, and may get fully lost in all kinds of imaginations that are very difficult to understand for an outsider. However, when we are aware of these philosophical problematics and this basic scheme of Cartesian reasoning, we might come a little closer to some understanding.

Of course, there are also many differences between the Cartesian and the mad thought experiments. An important difference is that for Descartes this was simply a thought experiment, an epistemological exercise, but for the madman the radical doubt is a serious matter; he is drowning existentially, losing all firm ground, and desperately searching for an anchor. We might say indeed that Descartes performs an epistemological experiment, while, following the ideas of the Dutch psychiatrist and philosopher Antoine Mooij, PhD, the psychotic is involved in an ontological experiment.

Let’s look at mysticism in comparison. In the older days of Christianity, mysticism was an intellectual and theological way to argue, to contemplate, to pray, to envision, and eventually to experience awe at the greatness and the power of the Almighty God. Then there was no essential difference between mysticism, theology, and philosophy. It was only much later that mysticism became associated with visions in the West, in an epochal historical change in which visual hallucinations also became ascribed as a dominant characteristic of psychosis. Just as I stress the partially passive, experiential character of the active Cartesian doubt experiment, I view mysticism as a more active and intellectual undertaking than it is usually considered to be. The usual distinction made between active thought and passive perception (and their counterparts in psychopathology, delusions versus hallucinations) is too rigid, and it is in mad philosophy and philosophical madness that we see a continuing doubting of both, and a crossing of the separation between them, by way of the viability and flexibility of language signs and experience.

To come back to what you said, a kind of claim, or at least, something that is often argued for, is that within mysticism [quoting you:] “at the end of it something is revealed about the nature of the world and our existence.” Now, what I demonstrate, especially in the second part of my book (called 

), are the analogies between such a mystic path that seeks revelation, and the psychotic rollercoaster, that also traverses a world where things are revealed, signs are given, and the transcendent sacred, as well as its dark counterpart, the horror, seem to become immanent. It is then as if you have found a way out of the restricted ego or self, out of your own private thoughts, your historically accidental mindset, towards an outside, a real, that presents itself as more real than anything, and that consists of both good and evil forces, both personal as well as mechanical and impersonal. I use this mystic path, with its semireligious language, to shed light on a range of terms and kinds of discourse that we also find in psychosis, like 

I argue that there is a lot of overlap between what is going on in that spiritual branch of experience and language, and what is going on in the psychotic world. But I never argue, not in my book, neither anywhere else, that there is a special secret path towards truth, and towards ultimate knowledge of reality. Nor do I argue that the mystic or the madman are simply affected by a 

. To understand what they/we/you say in various kinds of exalted, psychotic, spiritual language, it is just not enough to assume that the psychiatrist knows beforehand what kind of language game, and what kind of experience, is at stake in a conversation with a psychotic.

I understand the daily, down-to-earth problems in psychiatric practice, so it is not the actual practitioner my criticism is aimed at. Instead, it is aimed at those who pretend to have insight into the deepest questions and perplexities about reality, meaning, language, and who from there then judge that other individuals’ ways of expression are nonsensical or illogical. Here lie also further social and political implications: What voices have the right to expression and to be part of the common world of sense and meaning, and what kind of communication and interaction is deemed to be sick, meaningless, illogical, psychotic, and is therefore given no place in the space of reasons

: From a phenomenological and philosophical perspective, does it matter what the source of, or the cause of, the psychotic experience is? For example, does it matter that psychosis is a result of substance intoxication or a result of metabolic delirium? Or does any psychosis, regardless of origin, offer the same possibility to explore philosophy? In other words, is the philosophical value of psychosis independent of the etiology of the psychosis?

: Yes, it does matter, but not for everybody. Let me give an analogy here. Suppose we are all used to and educated within a tradition of classical realist paintings. And then we meet this quite varied but troublesome group of modern paintings, some recognized by us as art, but others, we just do not know what they mean. We suspect some of them to not be paintings at all, but canvases on which paint has been randomly thrown, a kind of fake Jackson Pollock. In addition, consider that the painters of some of these paintings acknowledge an inability to paint in a realist way. They miss the right brushes, do not have the right paint, are not skilled in painting, or do not have proper motor control over their fingers. However, we will not be able to determine whether the painting is problematic (and if it is, the exact nature of the problem), simply by examining the paint, because it is always possible that what appears to us to be failures of the artistic method are deliberate and perfectly executed works of art. The meaning and value of the famous 

 painting, cannot be reduced to properties of the paint or the finger movements of the painter. This distinction between levels is so easily grasped when discussing art, but so often not understood or forgotten when we talk about the life of the soul in madness. In other words, the material (the neurobiological dimension) is of course an important aspect of psychosis, just like the brushstroke technique or the choice of paint are important aspects of painting. I am more interested in the history and meaning of art than in the artistic skill of painters or in the chemical analysis of paint.

I do not think in terms of hypotheses of causation with respect to psychosis, but only in terms of plausibility of interpretations. There may be facilitating circumstances that bring individuals into various states of madness and psychosis. These facilitating circumstances can be anything, from using of certain drugs, to having a traumatic childhood, to having a certain neurobiological disposition, to having been in war, to abruptly losing a significant other, to living in socially and culturally painful and oppressive circumstances, and so on, and so on. But what I am interested in is not the explaining of the illness, but the understanding of the individual, and his or her ontological position. And in that latter exercise, we must follow the individual with psychosis down the rabbit hole of those fundamental questions.

: How do you approach the experience of delusions, which on the surface represent the antithesis of philosophical thinking? Instead of an on-going grappling with a confusing reality, in the case of delusions we see a closing down of inquiry, resulting in what has traditionally been described as a fixed, false belief, unshakeable in the face of reasoning or contrary evidence. Perhaps it is only after the delusional force of the beliefs has dissipated that we can begin to philosophically understand the meaning of that experience?

: I think that delusions in the way you describe them here are only one side of the delusional story. Unlike many superficial cognitive accounts of delusion, I think that so-called delusions are better analyzed as reactions to an underlying, and temporally preceding, delusional mood, which is in fact also the position of most phenomenologists as well as psychoanalysts. A famous adage of the latter is that delusions are not the problem, but they are instead the first attempts to express and deal with another problem, of a quite different order. Nevertheless, I fully agree that a philosophical understanding, in the common understanding of this phrase, can only happen 

. A self-understanding and a philosophical elaboration that is intelligible to others, communicable in common language, must handle and circumnavigate the seduction to remain trapped by the awe for the ineffable, both in its ecstatic as well as despairing forms. The paradox of any such understanding, including mine, is that with this understanding, the thing itself, the psychosis, is in danger of retreating beyond the horizon. And this same striving towards understanding may attract and provoke psychosis to rise up again from the invisible. I know that some readers of my book put it down, but then had to resist being drawn back towards that enigma.

, you say at one point: “Philosophy never promised you a rose garden, neither do I. Furthermore, it could well be argued that there is some kind of antihuman tendency in extreme philosophical and psychotic thought. Both philosophy and madness may have intense ‘superhuman’ or ‘a-human’ powers that burn anything substantial, anything meaningful, away into a hole of nothingness. But, well, the interests of life are not necessarily those of philosophy.” Can you comment more on this misalignment between the interests of life and the interests of philosophy/psychosis?

: Most modern philosophy starts from and leads back to common sense assumptions. Many are rooted in the Age of Enlightenment and have the overt values of modern society as their implicit background. They assume that what is argued by human thought (including the findings and results of philosophizing) are and should be beneficent for (human) life. We find that assumption under all kinds of moral and political philosophies, but also under so-called philosophy of psychiatry. However, it is not so obvious that philosophical thought should lead to beneficial effects on society or the individual.

There are a range of extreme critical philosophical views, such as views of ultra-conservative, nationalist, racist, antihumanist, transhumanist, and even antinatalist nature. While some of these views are considered dangerous to society, they still remain sustained within a broadly defined space of reasons, although this may be contested by others. Some philosophical ideas go even further and have the paradoxical capacity to be self-undermining for the thinker who thinks them. They may be detrimental to what we usually consider the space of reason; they are contra (human) life. That is, they argue in quite sophisticated ways that 

. They use notions of emptiness, the void, and nothingness, not to draw positively flavored, so-called 

 conclusions, but only to affirm annihilation, death, suicide, destruction, and (auto-)extinction. Such philosophies can be seen as a variety of nihilism (although this term refers to a much larger range of philosophies) with important names such as Friedrich Nietzsche, PhD, of course, but also Emil Cioran and especially Ray Brassier, PhD, with his devastating book 

. Just being against life does not mean that these ideas are untrue or can be excluded from the realm of philosophical thought. When we take philosophical thought seriously, we cannot reject conclusions just because they do not fit our restricted human-centric point of view. That is what I mean by saying the interests of life are not necessarily those of philosophy.

In the context of the relation between psychosis and philosophy, this is important to consider, and this also sweeps away all romantic humanist notions of both philosophy and psychosis. Consider the case of someone like Anders Breivik, the Norwegian terrorist and right-wing extremist. Some particular philosophies or world views, as well as some particular forms of madness, are thoroughly destructive and devoid of good intentions. They are closer to the darker variety of the mystical aspect of madness. American philosopher William James, MD, described it as 

In delusional insanity, paranoia, as they sometimes call it, we may have a diabolical mysticism, a sort of religious mysticism turned upside down. The same sense of ineffable importance in the smallest events, the same texts and words coming with new meanings, the same voices and visions and leadings and missions, the same controlling by extraneous powers; only this time the emotion is pessimistic: instead of consolations we have desolations; the meanings are dreadful; and the powers are enemies to life.

In such cases, the philosophical aspect of the psychosis would not only consist of the strange ineffable character of an experience filled with awe and puzzlement, but also of an intra- and interpersonal struggle between life-affirming forces and life-denying, a-human or antihuman forces. The implicated question is whether we must eradicate such poisonous ideas, or must we taste and experience them ourselves, to examine the enemy, and immunize ourselves against them, with all kinds of risk of contamination? The implicated practical problem for psychiatrists is to make responsible decisions in matters that comprise both philosophical, theological, as well as political complexities. What is demanded of the psychiatrist here has hardly anything to do with scientific knowledge, is also difficult to be captured in ethical guidelines, and can only be referred to with notions like prudence.

: Something that has struck me watching how various individuals engage with you on various platforms is that there appears to be a desire (conscious or unconscious) on the part of your many interlocutors—I would not consider myself immune either!—to co-opt your views for their own agendas, and there are certainly many competing agendas vying for power, resources, and respectability in the mental health arena. Is this something you are also cognizant of? If so, how do you feel about being thrown into this state of affairs?

: Yes, I know. When I wrote my book, I had in the back of my mind a reader like myself, but then many years younger. I wanted to show where thought may lead you, what the extremities of existence and experience are, and what the attraction and the repulsion of madness (and philosophy) are. Whereas Thomas Nagel, PhD, titled his famous paper on consciousness, “

,” I wanted to write a “What Is It Like to Be Mad?” The only thing I strongly oppose is the idea that everything that is said, everything that is experienced in psychosis, would somehow be unreal, epiphenomenal of a sick brain, illogical, and so on. This does however not imply that I would defend some kind of alternative theory of psychosis—not psychoanalytical, not phenomenological, not antipsychiatric. I am simply not interested in making theories about psychosis when these do not somehow also contain dialogues with psychosis. I give advice and courses about psychosis and philosophy to all kinds of professionals and nonprofessionals in the Netherlands and Belgium, and I do not have a kind of ideological or philosophical stance about what the world is, what psychosis is, and how psychiatric practice should be. I prefer to think and talk more about what is going on in madness than about the best way for the professionals to do their work, although the latter is often a theme that results from considerations of the former.

: You have warned against romanticization of psychosis. From what I can tell, while you seem to be in favor of controlled explorations of psychosis by means of philosophy or mysticism, you do not seem to wish the clinical, raw experience of psychosis upon anyone. While you have derived insights from your experience of psychosis, I imagine that you are also glad to have come out of psychosis. How do you think we can reconcile the tension, to the extent that it exists, between the clinical and philosophical attitudes towards psychosis? Individuals with psychosis are often tremendously distressed and impaired, and they typically require some form of clinical care to help navigate this distress and impairment. How do we reconcile this with the romantic image of the madman as a misunderstood mystic or an unrecognized philosopher or with the more prosaic image of a deviant whose deviance has been pathologized?

: I think that the clinical attitude should incorporate the philosophical attitude, and clinicians should be educated in this. In fact, [laughing] I would recommend that they should all read my book, or perhaps follow the 

 I teach about my book! In my book, they would indeed meet these images of the misunderstood mystic, the unrecognized philosopher, and the pathologized deviant. However, my book does not want them to accept these images as the essence of psychosis, but as starting points from which a dance, dialectic, or conversation may begin between philosophy and madness, the rational and the irrational, without being condemned to one position or the other.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the

Dr Aftab has no relevant financial disclosures or conflicts of interest. Dr Kusters receives royalties from the sales of his book and generates income from the online course he offers on his website.

. The Varieties of Religious Experience: A Study in Human Nature

Critique of Pure Madness: Wouter Kusters, PhD

Schizophrenia affects roughly 1% of the global population and is a leading cause of suffering and disability worldwide. Despite advances in the pharmacological management of the disease, some patients with 

 remain consistently symptomatic, and others experience periodic exacerbations. Sadly, community services for those with chronic schizophrenic illness are lacking in many areas, rendering the emergency department (ED) a primary location for care of this severe mental disorder.

We wish to provide a psychologically- (and psychodynamically-) informed guide to the management of schizophrenia in the ED, incorporating relevant research in the areas of pharmacotherapy, psychology, and 

. One of us (Furiato) is an emergency medicine physician with interest in the management of acute psychiatric presentations. The other (Ruffalo) is a psychotherapist with interest in the psychotherapy of schizophrenia.

Attempts to distinguish schizophrenia from the psychotic symptoms that occur in other mental and medical disorders date at least to Kraepelin’s pioneering work in the late 1800s. Another German psychiatrist, Kurt Schneider proposed the “first-rank symptoms” of schizophrenia in 1939, and his theory held widespread popularity throughout the 20th century. A recent 

of Schneider’s first-rank symptoms (FRS) concluded that FRS correctly identifies individuals with schizophrenia 75% to 95% of the time.

Schneider’s FRS include: auditory hallucinations; thought withdrawal, insertion, or interruption; thought broadcasting; somatic hallucinations; delusional perception; and feelings or actions as made or influenced by external agents. While reliance on FRS alone may not be sufficient to diagnose schizophrenia,

 recognition of FRS can aid ED physicians and mental health workers in the triage and care of patients presenting with psychotic disturbance.

Since the course of schizophrenia is generally chronic, and because comprehensive mental health systems are sorely lacking in many geographic regions of the United States, patients with schizophrenia presenting to EDs may be well-known to hospital staff. In cases wherein the patient is a poor historian, or past records are otherwise unable to be obtained, reliance on clinical skill, such as knowledge of FRS, is necessary to ascertain the diagnosis of 

In certain instances, such as a clinical suspicion of new onset schizophrenia or abnormal neurologic exam findings, use of brain imaging in the ED may be necessary to rule out organic disease of the nervous system. While a comprehensive review of brain imaging in psychosis is outside of the scope of this paper, 

 note that neuroimaging is particularly useful in first-episode psychosis when patients are of old age, have neurological symptoms, or have an atypical clinical picture.

In the ED setting, the first and most important consideration upon presentation of the acutely agitated patient with psychosis or schizophrenia is the level of risk of harm they have on themselves and on staff.

The emergency department is a primary care location for patients with schizophrenia. Here’s how to manage schizophrenia in this particular setting in an informed and caring manner. 

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