Type 1 and Type 2 psychosis-related disorders for optimal treatment and management

Psychosis and psychosis-related disorders (including schizophrenia) have been one of the most challenging psychiatric disorders to treat. Despite successful recovery and relapse rates, a substantial number continue to struggle with ongoing “psychotic symptoms” and residual functional impairments needing ongoing treatment and support services (Ahmed et al., 2007; Jaaskelainen et al., 2013; Javitt & Coyle, 2004; Owen et al., 2016). Psychosis may reflect an underlying deficit in “information processing” that may contribute to “atypical” thoughts, feelings, and behaviors with impaired level of functioning and at-risk behaviors raising need for clinical services (Ahmed & Boisvert, 2013; Ahmed et al., 2014; Bodatsch et al., 2013; Turetsky et al., 2009).

The “atypical” life adaptations in psychosis may be considered to be akin to Freud's theory of Ego's defense with projection against “conscious Id” (Fenichel, 2014; Freud, 1961). and the cognitive behavioral theoretical formulation of individuals adaptations to atypical information processing with perceptual misattribution (Allen et al., 2004; Costafreda et al., 2008; Kingdon & Mander, 2015). These atypical experiences may originate from multiple factors including genetic predispositions that interact with unique adverse personal and social experiences contributing to a heightened sense of existential uncertainty and anxiety (Braehler et al., 2013; Legge et al., 2021; Longden & Read, 2016; Mayo et al., 2017; Merikangas et al., 2022). This developmental process is further compounded by increased confusion relating to self-identity and age-expected role functions during the challenging transitional period of experiencing changes from adolescence to adulthood (Braehler et al., 2013; Legge et al., 2021; Longden & Read, 2016; Mayo et al., 2017; Merikangas et al., 2022).

Human beings routinely engage in “autistic imageries” with an inward focusing of the mind as expressed in daydreaming and fantasies. For many it may supply inspiration for all forms of creativity and self-reflection and can contribute to innovative scientific developments and varied creative expressions in arts and writings appreciated by others. While engaging in such “autistic” preoccupations, people can navigate between both worlds and redirect themselves, for example, from the inner world of self-refection and fantasy to the outer world of social reality in response to various social cues or role expectations. However, due to various bio-psycho-social experiences not yet fully understood, this self-redirection may be more challenging for some people who may find themselves incessantly preoccupied with the inner world of fantasy and rumination leading to a blurring of the boundaries between objective and subjective realities. This blurring of the boundaries may contribute to significant impairments at times with social communication and the concomitant expression of psychotic symptoms.

Crow (1980) proposed a “two process approach to schizophrenia with underlying biogenetic causality: Type 1 syndrome, “acute schizophrenia,” and Type 2 syndrome that he characterized as “defect state” with irreversibility a la Kraepelin's Dementia Praecox. Later clinical theoreticians, such as Bleuler, Meyer and others underemphasized the organic hypothesis that Kraepelin proposed and emphasized psychodynamic origins and psychotherapeutic treatment approaches to schizophrenia (Heckers, 2011; Hoff, 2008; Katzelbogen, 1942).

It is worth noting that the debate over the heredity-environment issue is becoming less relevant in modern times with our increased knowledge and understanding that both biological and psychosocial-environmental factors contribute to human functioning to a varying degree. The emerging epigenetic research for genotype-phenotype dimension of gene expressions in traits and behaviors is increasingly confirming how effects of psychosocial and environmental experiences of one generation may affect the following generations (Dempster et al., 2013; Lind & Spagopoulou, 2018). While the biological and psychosocial sciences may emphasize different focus and emphasis of influences—reflecting preferences for individual professional interests for clinical practice and for conducting discipline-oriented investigative research—there is a need for synthesizing and collaboration across disciplines for developing the most effective clinical practice approaches.

Type 1 Psychosis can be of a short-term duration that may resolve with or without any psychiatric interventions. Upon recovery many with Type 1 Psychosis may present limited or no residual effects. Others, however, may need periodic or a sustained level of degree of elements of psychiatric support services to support their ongoing  recovery functioning. Some may even report a higher level of creativity from such transient psychotic experiences. Some also report functioning productively in their daily lives despite continued experiencing elements of psychosis symptoms (e.g., hearing voices) as “lived experiences” (Ahmed et al., 2016; Crabtree & Green, 2016; Dillon & Hornstein, 2013; Lally et al., 2017; Peters et al., 2016; Warner, 2009).

Type 2 Psychosis refers to persistent presentations of atypical thinking, behavior, and mood symptoms that are associated with continued compromised functioning with evidence of impaired personal independence and social communication across various domains. This condition with presentation of a degree of at-risk behavior to self or to others may persist over many years despite receiving various levels of psychiatric care, and many often need periodic inpatient and follow-up ongoing outpatient psychiatric treatment.

People with Type 2 Psychosis receiving psychiatric support services to a varying degree may be living in a various living setting such as independent living, family, group homes, or supervised apartment programs of the Community Support Program (CSP) of community mental health centers (CMHCs). Some may be found among homeless populations without receiving any psychiatric support services. Many others may have a dual diagnosis of substance abuse and mental health conditions, while others having criminal justice system involvements are living in forensic psychiatric inpatients or are incarcerated in prisons.

Type 2 Psychosis used here does not hold any implication for non-reversibility. With evolving development of mental health science and advancements in technology for compensating for all forms of disabilities, and with proper therapeutic management, people with this condition may increasingly function adaptively to one's living circumstances with varied degree of recovered functioning and improvements in their Quality of Life.

While there has been considerable success in reducing and managing presence of psychosis symptoms especially for Type 1 Psychosis with standard clinical practice involving a varied combination medication regimen and psychotherapeutic practice, however, using the same approach with Type 2 Psychosis may unwittingly increase iatrogenic effects especially in terms of medication side effects from polypharmacy usage. One should also be mindful that repeated focusing on atypical thoughts and feelings associated with psychosis symptoms for clinical assessment or for promoting insight and understanding may unwittingly reinforce the long-standing habit of obsessive preoccupations with atypical thoughts and behaviors for people with Type 2 Psychosis. As such, it may be more proper to emphasize a management approach over treatment in working with this population (Ahmed et al., 2007, 2016).

We are all social human being with interdependent relationships, and we respond to social cues and prompts for engaging in various activities of our daily lives where both self-regulation and social regulation play an important part in our daily activities. Our behavior and habits are influenced by our awareness of negative or positive consequences to our behaviors (e.g., operant conditioning learning), social cues and prompts (e.g., social learning theory), as well as by use of a variety of positive redirection strategies (e.g., use of classical counter conditioning principle) (Boisvert & Ahmed, 2018). Management concept with Type 2 Psychosis does not necessarily imply an increased promotion of external control or direction to one's life. Like management of other persistent illnesses, it emphasizes promoting self-management in collaboration with support from one's current therapeutic milieu including psychiatric support service providers and significant others (e.g., relatives, friends, or other social support people) to improve one's functioning. Management may include use of prompts or suggestions that may be self-initiated or by others for adherence to a therapeutic regimen and participation in a productive day routine as well as to promote practice in positive redirection strategies to counter or disrupt preoccupation with maladaptive negative thoughts, feelings, and behaviors in everyday functioning.

While elements of the management approach are currently used in many psychosocial and psychiatric rehabilitation services, the Individual Treatment Plan protocols for people with Type 2 Psychosis continue to typically target elimination of “atypical symptoms” despite persistency of such symptoms. Given the status of current mental health science, it may be more effective to design clinical interventions that focus less on eliminating atypical and persistent symptoms for persons with Type 2 psychosis and focus more on stimulating clients' intact functioning and adaptive behaviors and highlighting progress in their Quality of Life.

Medication practitioners in collaboration with psychosocial support and therapeutic milieu staff should primarily focus not on elimination of atypical thoughts and feelings associated with psychosis symptoms, but on reduction of agitation mood, normalization of vegetative functions, adherence to therapeutic daily routines, and reduction and management of at-risk status (Ayano et al., 2019; Brunette et al., 2009; Jarrett et al., 2012; Thornicroft et al., 2016).

Psychosocial approaches should actively incorporate mind stimulation-related activities using neutral and less emotionally laden exercises to promote logical thinking and memory exercises and increase attention to the immediate social and physical environment. Mental health clinicians may find it useful for adopting elements of mind stimulation exercises as adjunct to their ongoing clinical practice (Ahmed, 2019; Ahmed & Boisvert, 2003; Ahmed & Boisvert, 2013; Lally et al., 2017). The emerging use of technology such as computer-facilitated or visually aided dialogue in counseling (Ahmed, 1998; Ahmed & Boisvert, 2006; Ahmed et al., 1997), Avatar therapy (Aali et al., 2020), Artificial Intelligence (AI) (Pham et al., 2022), computer games (Fisher et al., 2016) a combination of thereof as clinically appropriate may aid in counseling and therapy practice and assist people with Type 2 Psychosis to compensate for behavioral deficits associated with their psychosis symptoms and thus help to maximize their adaptive functional behaviors. Additionally, increased opportunities for participation in supported employment (Bond et al., 2008), greater social and client advocacy involvements such as Open Dialogue type of approach (Frese, 1998; Seikkula et al., 2003), and changing of social mores for a wider acceptance of diversity would continue to contribute to more effective treatment and management as well as in the diminution of negative stigmas associated with Type 2 psychosis (Scheff, 2017).

Hopefully, mental health clinicians will increasingly choose to work with this challenging psychiatric population for opportunities to design and implement innovative clinical strategies. With increased advancements in mental health knowledge and technology contributing to reduction and compensation for symptom-related deficits in psychosis with demonstrated efficacy for functional outcome, and with corresponding reduction in distress experienced by persons with psychosis and involved family and social community, differentiating Type 1 and Type 2 dimensions for psychosis-related disorders may no longer be useful in the future for clinical practice.