Understanding Psychosis: history, meaning and today's view

From Dr Linet Kendi's class on 15 October 2026 (Department of Psychiatry, School of Medicine, Mount Kenya University). After reading this note you will be able to name the people who shaped the idea of psychosis, say what psychosis is and why it is a syndrome, state how DSM-5-TR, the APA and ICD-11 describe it, and explain why many Kenyan families go to traditional healers first.

The main people in the history of psychosis

Many of the words you use on the ward come from a handful of people. Know them and the terms make sense.

• Emil Kraepelin (1856–1926, Germany): followed patients over many years. He named dementia praecox ("early dementia"), an illness that starts young and gets worse, and separated it from manic-depressive illness, which gets better between episodes. Remember: Kraepelin = the COURSE of the illness.
• Eugen Bleuler (1857–1939, Switzerland): saw that not all patients got worse, so he renamed the illness schizophrenia, "split mind", meaning that thinking, feeling and behaviour do not work together. It does not mean split personality. The 4 As: Associations loosened, Affect blunted, Ambivalence, Autism (withdrawal). Remember: Bleuler = the NAME and the 4 As.
• Karl Jaspers (1883–1969, Germany): taught doctors to describe exactly what the patient experiences, the basis of today's mental state examination. A delusion is held with certainty, incorrigibility (it cannot be argued away) and impossible or false content. Remember: Jaspers = how to DESCRIBE.
• Kurt Schneider (1887–1967, Germany): listed the first-rank symptoms, experiences that strongly suggest schizophrenia:
  • hearing your thoughts aloud
  • voices arguing about you or commenting on what you do
  • thoughts put in, taken out or broadcast
  • feeling controlled by an outside force
  • delusional perception
  • Today they are useful clues, but not proof on their own.
• Adolf Meyer (1866–1950, Switzerland and USA): saw mental illness as the whole person reacting to life events. He created the life chart, which led to today's detailed personal history and the biopsychosocial approach. Remember: Meyer = the PERSON and their story.
• T. Adeoye Lambo (1923–2004, Nigeria): one of Africa's first Western-trained psychiatrists. In 1954 he started the Aro Village System: patients lived with family in nearby villages, attended hospital by day, and healers were involved. He later became a senior leader at WHO. Remember: Lambo = care in the COMMUNITY.

Timeline

• 1840s: the word "psychosis" enters medicine, meaning a disease of the mind (psyche).
• 1899: Kraepelin describes dementia praecox.
• 1911: Bleuler renames it schizophrenia.
• 1913: Jaspers teaches how to describe symptoms and defines a delusion.
• 1939: Schneider lists the first-rank symptoms.
• 1952: chlorpromazine, the first antipsychotic, is discovered in France.
• 1954: Lambo starts village-based care in Nigeria.
• 1980 to 2022: DSM-III brings clear diagnostic criteria; DSM-5 (2013) and ICD-11 (2022) give today's system.

How the classification reached DSM-5-TR

Takeaways: history

1. Kraepelin described the course. Bleuler gave the name "schizophrenia" and the 4 As.
2. Jaspers taught us how to describe symptoms and what makes a delusion.
3. Schneider gave the first-rank symptoms. Meyer reminded us to see the whole person.
4. Lambo showed that people can recover in the community, with family.
5. Today we use DSM-5-TR and ICD-11, and neither has subtypes.

What psychosis is

Psychosis is when the mind loses touch with reality. A person believes, hears or sees things that are not real, and cannot tell that they are not real.

The three building blocks

• Believe: delusions, fixed false beliefs out of keeping with culture.
• Perceive: hallucinations, hearing or seeing things that are not there.
• Organise: confused thinking, speech or behaviour.

This is not psychosis

• Beliefs shared by the person's culture or church.
• Hallucinations while falling asleep or waking.
• Briefly hearing or seeing a loved one after a death.
• Misreading a real object in the dark (an illusion).

Psychosis is a syndrome, not a diagnosis

A syndrome is a group of symptoms that occur together, whatever the cause. Psychosis is like fever: it tells you something is wrong, not what is wrong. So always ask: what is causing this psychosis?

The causes to think of:

• Primary psychotic disorders, for example schizophrenia.
• Mood disorders: mania and severe depression.
• Substances: bhang, miraa, alcohol.
• Infections: HIV, syphilis, malaria.
• Brain conditions: epilepsy, head injury.
• Delirium and dementia: confusion in the medically ill.
• Hormones and medicines: thyroid disease, steroids.
• After childbirth: postpartum psychosis.

Experience versus illness. About 1 in 17 adults (5.8%) has had at least one brief psychotic-like experience, such as hearing their name called when no one was there. Most fade away. It becomes an illness when the symptoms persist, are firmly believed, cause distress and disrupt daily life.

Takeaways: what psychosis is

1. Psychosis = losing touch with reality without realising it.
2. It is a syndrome: always look for the cause.
3. In Kenya, always think of HIV, syphilis, malaria, epilepsy, bhang and miraa.
4. A belief shared by the patient's culture or church is not a delusion.

How psychosis is defined

There is no single official definition. Each organisation describes it in its own way, but they agree on the core idea.

DSM-5-TR: the five features (criteria)

DSM-5-TR does not give one definition of "psychosis"; it describes the psychotic disorders through these five features.

Other definitions

• APA Dictionary of Psychology (paraphrased): an abnormal mental state with significant problems in reality testing, shown by delusions, hallucinations and disorganised speech.
• ICD-11, WHO (paraphrased, block 6A2): primary psychotic disorders are marked by significant impairment in reality testing and changes in behaviour. Beliefs or behaviours that are accepted in the person's culture are not counted.
• NIMH (USA): "a collection of symptoms that affect the mind, where there has been some loss of contact with reality."
• NHS (UK): "when people lose some contact with reality."
• Classic exam phrase: psychosis = impaired reality testing.

Kenya lens: the culture test. Belief in witchcraft or spirits that the family and community share is not a delusion. Suspect a delusion when the belief is stranger or more fixed than others in the community hold, or comes with voices, self-neglect or a change in behaviour. Ask the family: "Would people here think this way?"

Takeaways: definitions

1. DSM-5-TR: five features: delusions, hallucinations, disorganised speech, disorganised behaviour, negative symptoms.
2. APA and ICD-11: impaired reality testing.
3. NIMH: a collection of symptoms, which is what makes psychosis a syndrome.
4. Always consider the patient's culture before calling a belief a delusion.

Traditional healers and the treatment gap

The treatment gap is the share of people who need mental health care but do not receive it. In Kenya it is about 75%: 3 out of every 4 people. Only 1 in 4 reaches care, often late (Kenya Taskforce on Mental Health, 2020).

Across Africa, about half of the people who eventually reach mental health care first went to a religious healer (about 1 in 4) or a traditional healer (about 1 in 6) (Burns and Tomita, 2015). This delays treatment: in Africa, psychosis often goes untreated for more than a year.

Why do families go to traditional healers?

• Beliefs about cause: illness is often explained as witchcraft, curses, spirits or punishment. The healer answers "why my child, why now?"
• Easy to reach: healers live in every village. Kenya has only about 100 to 140 psychiatrists for over 50 million people.
• Cost: hospital fees, transport and medicines are expensive. Healers may accept flexible payment.
• Trust: the healer speaks the family's language and shares their beliefs.
• Stigma: families fear the label of a "mental hospital".
• Family decides: elders and relatives often choose where to seek help.
• Poor hospital experiences: long queues, no medicine, side effects, or feeling dismissed.
• Little awareness: many do not know psychosis is a treatable illness.

Why the treatment gap is so large

• The health system: very few psychiatrists and mental health nurses; few hospitals offering mental health care outside big towns; little money spent on mental health; medicines often out of stock; until recently, little insurance cover.
• The community: spiritual explanations of illness; stigma and fear; poverty and distance; the patient may not believe he or she is ill; little knowledge that treatment works.
• When care is delayed: a longer untreated psychosis means poorer recovery. Some people are even chained or denied food at home or in healing places, usually because families are afraid and have nowhere else to turn.

What helps close the gap

• Working with healers. In a trial in Ghana and Nigeria (COSIMPO), healers and health workers shared care; patients improved more and chaining fell. In Makueni, Kenya, healers and clinicians who met and talked built trust and began referring to each other.
• Training primary care workers to recognise and treat psychosis (WHO mhGAP).
• Insurance: mental health is covered under SHA / Taifa Care since October 2025.
• The law: the Mental Health (Amendment) Act 2022 protects patients' rights.

How to ask the family, respectfully

• "What do you think is causing this?"
• "Why do you think it started now?"
• "Have you seen a pastor, imam or traditional healer? What did they say?"
• "Can we work together, so prayer continues alongside medicine?"

Takeaways: healers and the treatment gap

1. About 3 in 4 Kenyans who need mental health care do not get it.
2. About half of Africans who reach care see a religious or traditional healer first.
3. Families choose healers because of beliefs, access, cost, trust and stigma.
4. The gap comes from both the health system and the community.
5. Respect and partnership with healers bring patients to care sooner.

Psychosis in the 21st century

Today we see psychosis as a treatable illness shaped by genes and life experiences. Early help and respect for the person make the biggest difference.

1. A continuum, not a switch. Brief unusual experiences are fairly common. Illness is the end where symptoms persist and disrupt life.
2. Early help matters. The sooner psychosis is treated, the better the recovery. Many countries now run early intervention services for young people.
3. Genes plus environment. Many genes each add a little risk; there is no single "schizophrenia gene". Environment adds more: cannabis (bhang), childhood trauma and stress.
4. Look for medical causes. In a first episode, rule out infections (HIV, syphilis), drugs, epilepsy and rare autoimmune brain inflammation, which is treatable.
5. Treatment is more than tablets. Antipsychotics (mainly acting on dopamine) plus family support, talking therapy and rehabilitation. In 2024 the first antipsychotic that does not act on dopamine (Cobenfy) was approved in the USA.
6. Recovery and rights. People with psychosis can live full lives. Care should respect their rights, avoid force where possible, and use person-first language: "a person with schizophrenia", never "a schizophrenic".

Kenya today

• 2015: Kenya Mental Health Policy 2015–2030.
• 2020: Taskforce on Mental Health calls mental health a national emergency.
• 2021: Mental Health Action Plan moves services closer to counties and communities.
• 2022: Mental Health (Amendment) Act: patients' rights, support in decision-making, county funding.
• 2025: mental health included in SHA / Taifa Care insurance.

Ten things to remember

1. Psychosis = losing touch with reality without realising it.
2. It is a syndrome, not a diagnosis: like fever, find the cause.
3. Kraepelin = course. Bleuler = the name "schizophrenia" and the 4 As.
4. Jaspers = describing symptoms; a delusion is certain, incorrigible and false.
5. Schneider = first-rank symptoms. Meyer = the whole person. Lambo = community care.
6. DSM-5-TR: five features. APA and ICD-11: impaired reality testing.
7. A belief shared by the patient's culture is not a delusion.
8. Kenya's treatment gap is about 75%. About half of Africans see a healer first.
9. Healers are chosen for beliefs, access, cost, trust and stigma. Work with them, not against them.
10. Today: early help, genes plus environment, rule out medical causes, rights-based care.

High-yield exam points

• Psychosis = losing touch with reality without realising it. It is a syndrome, not a diagnosis: like fever, find the cause.
• Kraepelin = course. Bleuler = the name "schizophrenia" and the 4 As. Jaspers = describing symptoms. Schneider = first-rank symptoms. Meyer = the whole person. Lambo = community care.
• DSM-5-TR: five features. APA and ICD-11: impaired reality testing.
• A belief shared by the patient's culture is not a delusion.
• Kenya's treatment gap is about 75%. About half of Africans see a healer first.
• Healers are chosen for beliefs, access, cost, trust and stigma: work with them, not against them.
• Today: early help, genes plus environment, rule out medical causes, rights-based care.

Tricky questions examiners ask

Q1. Who coined the term "schizophrenia", and does it mean split personality? Answer: Eugen Bleuler, in 1911. No: "split mind" means that thinking, feeling and behaviour do not work together.

Q2. Name Bleuler's 4 As. Answer: Associations (loosened), Affect (blunted), Ambivalence, Autism (withdrawal).

Q3. Give Jaspers' three features of a delusion. Answer: Certainty, incorrigibility (it cannot be argued away), and false or impossible content.

Q4. Name two of Schneider's first-rank symptoms. Answer: Any two of: hearing thoughts aloud, voices discussing or commenting, thought insertion, withdrawal or broadcasting, feeling controlled by an outside force, delusional perception.

Q5. Why is psychosis called a syndrome? Answer: It is a group of symptoms that occur together and can have many causes, like fever, so the task is always to find the cause.

Q6. List DSM-5-TR's five features of psychotic disorders. Answer: Delusions, hallucinations, disorganised speech, grossly disorganised or abnormal motor behaviour (including catatonia), and negative symptoms.

Q7. Give three reasons families go to traditional healers. Answer: Any three of: beliefs about cause, access, cost, trust, stigma, the family's decision, poor hospital experiences.

Q8. What is Kenya's mental health treatment gap? Answer: About 75%: three in four people who need care do not receive it.

Q9. A family says their son is bewitched and that the whole village believes it. Is that a delusion? Answer: Not by itself. A belief shared by the family and community is not a delusion. Suspect one if the belief is stranger or more fixed than the community's, or comes with voices, self-neglect or a change in behaviour.

Practice questions

Question 1

Who introduced the term "schizophrenia" and why?

A. Kraepelin, to describe the course of the illness B. Bleuler, because thinking, feeling and behaviour do not work together C. Schneider, to list the first-rank symptoms D. Jaspers, to describe how to examine a patient

Answer: B. Bleuler, because thinking, feeling and behaviour do not work together Explanation: Bleuler renamed dementia praecox in 1911 after seeing that not all patients got worse; "split mind" does not mean split personality.

Question 2

A patient says everyone in his village believes a neighbour has bewitched him, and he has no voices and is looking after himself. What is the best interpretation?

A. A delusion, because witchcraft is not real B. A shared cultural belief, which is not by itself a delusion C. A first-rank symptom D. A hallucination

Answer: B. A shared cultural belief, which is not by itself a delusion Explanation: Beliefs held by the family and community do not count as delusions; look for beliefs stranger or more fixed than others hold, or for voices, self-neglect or behaviour change.

Question 3

Which statement about psychosis is correct?

A. It is a diagnosis equal to schizophrenia B. It is a syndrome with many possible causes, so the cause must always be looked for C. It always starts in adolescence D. It only occurs in primary psychotic disorders

Answer: B. It is a syndrome with many possible causes, so the cause must always be looked for Explanation: Like fever, psychosis tells you something is wrong but not what; infections, substances, epilepsy, mood disorders and medical illness can all cause it.

Question 4

Which of these is one of the five features DSM-5-TR uses to describe psychotic disorders?

A. Ambivalence B. Negative symptoms C. Loosened associations as a named subtype D. Paranoid subtype

Answer: B. Negative symptoms Explanation: The five features are delusions, hallucinations, disorganised thinking, abnormal motor behaviour and negative symptoms. Subtypes were removed in DSM-5, and ambivalence belongs to Bleuler's 4 As.

Question 5

About what share of people in Kenya who need mental health care do not receive it?

A. About 25% B. About 50% C. About 75% D. About 95%

Answer: C. About 75% Explanation: The Kenya Taskforce on Mental Health (2020) puts the treatment gap at about 75%, that is three in four people.

Further reading: DSM-5-TR (APA, 2022) · ICD-11 (WHO) · NIMH, "What is psychosis?" · Burns and Tomita 2015, healers in the pathway to care in Africa · Gureje et al. 2020 (COSIMPO), Lancet · Kenya Mental Health (Amendment) Act 2022.

Prepared from Dr Kendi's class summary of 15 October 2026 and edited for the site. Check details against your lecture notes and current guidelines; this is not a doctor's review.