Like with the fictional patient on The Pitt, this psychiatric condition can be challenging

Each season of the critically acclaimed HBO Max medical drama The Pitt takes place in real-time over a 15-hour shift in a fictional Pittsburgh hospital emergency department. Healthcare workers in the field of emergency medicine say the show is the first to accurately describe the reality of their jobs – from paperwork overload to trying to provide care to patients with no health insurance to uncontrollable patients who injure medical staff.

In an episode of the current season, a law student named Jackson arrived in a state of psychosis, having thrown a chair at a security guard in his college library. Since psychosis can be misunderstood, we asked psychiatrist Cathy Perkins, MD, who is the medical director of Emergency Psychiatry Services at Cape Cod Hospital Emergency Department, to talk about the condition – what it is, how it presents and how it is treated.

"Psychosis is an overarching term that is a broad description of symptoms when someone has lost touch with reality," she said. “What that can mean are a few different things, either individually or in combination. (Patients) could have the experience of hearing voices. They could have the experience of having delusions, which are beliefs that are not real, and they can fall into different categories. A common type is paranoid delusions, but it could also be grandiose delusions or bizarre delusions.”

In The Pitt, Jackson’s family at first expressed disbelief that their peaceful son and brother could suddenly become so violent. When fictional medical student/resident Dr. Javadi talked to Jackson’s sister, Java, she revealed that there had been hints that something was wrong. He had been hearing voices for months telling him they didn’t want him to pass the bar.

That kind of early warning is a fairly classic occurrence with psychosis patients, according to Dr. Perkins.

“Usually it doesn’t erupt overnight,” she said. “It’s different for everybody but usually there’s what we call a ‘prodrome’ where if you really get an accurate history from family members you can maybe pinpoint when things changed. Maybe it was a month ago; maybe it was six months ago. Maybe it was a year ago, even, where they might notice subtle versions of what suddenly is much more intense.”

Symptoms and Action

Some of the symptoms people notice include sleep disruption, changes in habits, routines, appetite or doing things out of character. The patients themselves might be aware of some of the changes in the beginning, but once it crosses the official line into psychosis, they almost always need somebody to step in and get them help.

If family members or friends notice the early prodrome symptoms, they shouldn’t hesitate to try to get the person help before the psychotic break occurs. Like with most medical conditions, early treatment is the best chance for a good outcome.

“The long-term prognosis depends on the diagnosis,” Dr. Perkins said. “If you are talking about delusions, they are often a part of paranoid schizophrenia, but they could be part of extreme either mania or depression bipolar disorder. Or it could be a pure delusional disorder where they just have a delusional belief but no voices or that sort of symptom.”

Patients with advanced dementia who become paranoid and people who partake in substance use, especially with high THC marijuana, and stimulants like cocaine and methamphetamine, can appear to have psychosis, she said. When substance use is the cause of the psychotic behavior, presumably the cure would be to stop using the substance, but that can also depend on the duration and severity of their use, she added.

Treatment and Challenges

If the psychosis is primarily a psychiatric disorder, the treatment would predominantly be antipsychotic drugs and possibly a mood stabilizer and something to help the patient sleep.

“Like any area of medicine, the trick is getting the patient to continue to take them over time,” she said. “There’s a good chance that symptoms can re-emerge if they’re not taking the medications, especially if they have a severe form of schizophrenia or bipolar disorder.”

The three most common reasons she sees patients discontinue the medication are:

• They feel better so they don’t think they need to continue the medication.
• They actually liked some of the symptoms to a degree, so they feel off when on the meds.
• The meds make them feel subdued or dulled.

“I think it’s important to work with your provider, like your psychiatrist, and say, ‘these are my side effects, these are my concerns,’ and hopefully the doctor can try their best to meet them in the middle,” she said.

Sometimes the physician can tweak the medications or cut back just enough to ease symptoms while still treating the psychotic symptoms. There are also new delivery systems that are more apt to ensure a patient’s compliance.

“We have many different antipsychotics, but there’s several that do have long-acting injections that last for a month, so that’s a really important thing for people to be aware of,” Dr. Perkins said. “That can actually treat symptoms for a month’s time without having to take medications, so we try to encourage that with patients.”