In psychopathology, psychosis is a condition in which a person is unable to distinguish between what is and is not real.[3] Examples of psychotic symptoms are delusions, hallucinations, and disorganized or incoherent thoughts or speech.[3] Psychosis is a description of a person's state or symptoms, rather than a particular mental illness, and it is not related to psychopathy (a personality construct[4][5] characterized by impaired empathy and remorse, along with bold, disinhibited, and egocentric traits). Common causes of chronic (i.e. ongoing or repeating) psychosis include schizophrenia or schizoaffective disorder, bipolar disorder, and brain damage (usually as a result of alcoholism).[6][7] Acute (temporary) psychosis can also be caused by severe distress, sleep deprivation, sensory deprivation,[8] some medications, and drug use (including alcohol, cannabis, hallucinogens, and stimulants).[9] Acute psychosis is termed primary if it results from a psychiatric condition and secondary if it is caused by another medical condition or drugs.[9] The diagnosis of a mental-health condition requires excluding other potential causes.[10] Tests can be done to check whether psychosis is caused by central nervous system diseases, toxins, or other health problems.[11] Treatment may include antipsychotic medication, psychotherapy, and social support.[1][2] Early treatment appears to improve outcomes.[1] Medications appear to have a moderate effect.[12] Outcomes depend on the underlying cause.[2] Psychosis is not well-understood at the neurological level, but dopamine (along with other neurotransmitters) is known to play an important role.[13][14][15] In the United States about 3% of people develop psychosis at some point in their lives.[1] Psychosis has been described as early as the 4th century BC by Hippocrates and possibly as early as 1500 BC in the Ebers Papyrus.[16][17] Signs and symptoms Hallucinations A hallucination is defined as sensory perception in the absence of external stimuli. Hallucinations are different from illusions and perceptual distortions, which are the misperception of external stimuli. Hallucinations may occur in any of the senses and take on almost any form. They may consist of simple sensations (such as lights, colors, sounds, tastes, or smells) or more detailed experiences (such as seeing and interacting with animals and people, hearing voices, and having complex tactile sensations). Hallucinations are generally characterized as being vivid and uncontrollable.[18] Auditory hallucinations, particularly experiences of hearing voices, are the most common and often prominent feature of psychosis. Up to 15% of the general population may experience auditory hallucinations (though not all are due to psychosis). The prevalence of auditory hallucinations in patients with schizophrenia is generally put around 70%, but may go as high as 98%. Reported prevalence in bipolar disorder ranges between 11% and 68%.[19] During the early 20th century, auditory hallucinations were second to visual hallucinations in frequency, but they are now the most common manifestation of schizophrenia, although rates vary between cultures and regions. Auditory hallucinations are most commonly intelligible voices. When voices are present, the average number has been estimated at three. Content, like frequency, differs significantly, especially across cultures and demographics. People who experience auditory hallucinations can frequently identify the loudness, location of origin, and may settle on identities for voices. Western cultures are associated with auditory experiences concerning religious content, frequently related to sin. Hallucinations may command a person to do something potentially dangerous when combined with delusions.[20] So-called "minor hallucinations", such as extracampine hallucinations, or false perceptions of people or movement occurring outside of one's visual field, frequently occur in neurocognitive disorders, such as Parkinson's disease.[21] Visual hallucinations occur in roughly a third of people with schizophrenia, although rates as high as 55% are reported. The prevalence in bipolar disorder is around 15%. Content commonly involves animate objects, although perceptual abnormalities such as changes in lighting, shading, streaks, or lines may be seen. Visual abnormalities may conflict with proprioceptive information, and visions may include experiences such as the ground tilting. Lilliputian hallucinations are less common in schizophrenia, and are more common in various types of encephalopathy, such as peduncular hallucinosis.[20][22] A visceral hallucination, also called a cenesthetic hallucination, is characterized by visceral sensations in the absence of stimuli. Cenesthetic hallucinations may include sensations of burning, or re-arrangement of internal organs.[20] Delusions Psychosis may involve delusional beliefs. A delusion is a fixed, false idiosyncratic belief, which does not change even when presented with incontrovertible evidence to the contrary. Delusions are context- and culture-dependent: a belief that inhibits critical functioning and is widely considered delusional in one population may be common (and even adaptive) in another, or in the same population at a later time.[23][24] Since normative views may contradict available evidence, a belief need not contravene cultural standards in order to be considered delusional. However, the DSM-5 considers a belief delusional only if it is not widely accepted within a cultural or subcultural context.[25] Prevalence in schizophrenia is generally considered at least 90%, and around 50% in bipolar disorder. The DSM-5 characterizes certain delusions as "bizarre" if they are clearly implausible, or are incompatible with the surrounding cultural context. The concept of bizarre delusions has many criticisms, the most prominent being judging its presence is not highly reliable even among trained individuals.[20] A delusion may involve diverse thematic content. The most common type is a persecutory delusion, in which a person believes that an entity seeks to harm them. Others include delusions of reference (the belief that some element of one's experience represents a deliberate and specific act by or message from some other entity), delusions of grandeur (the belief that one possesses special power or influence beyond one's actual limits), thought broadcasting (the belief that one's thoughts are audible) and thought insertion (the belief that one's thoughts are not one's own). A delusion may also involve misidentification of objects, persons, or environs that the afflicted should reasonably be able to recognize; such examples include Cotard's syndrome (the belief that oneself is partly or wholly dead) and clinical lycanthropy (the belief that oneself is or has transformed into an animal). The subject matter of delusions seems to reflect the current culture in a particular time and location. For example, in the early 1900s in the United States, syphilis was a common theme in delusions. During the Second World War, it was Germany. In the Cold War era, communists became a frequent focus. Now, in recent years, technology is a common subject matter of delusions.[26] Some psychologists, such as those who practice the Open Dialogue method, believe that the content of psychosis represents an underlying thought process, that may in part, be responsible for psychosis,[27] though the accepted medical position is that psychosis is due to a brain disorder.[28] Historically, Karl Jaspers classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions are typically understood as being influenced by the person's background or current situation (e.g., ethnicity, religious, superstitious, or political beliefs).[29] Disorganized speech/thought and Disorganized behavior Disorganization is categorized into either disorganized speech (disorganized speech stemming from disorganized thought), and grossly disorganized motor behavior. Disorganized speech or thought, also formally called thought disorder, is disorganization of thinking that is inferred from speech. Characteristics of disorganized speech include rapidly switching topics which is called derailment or loose association, switching to topics that are unrelated which is called tangential thinking, incomprehensible speech which is called inchoherence and referred to as a word salad. Disorganized motor behavior includes repetitive, odd, or sometimes purposeless movement. Disorganized motor behavior rarely includes catatonia, and although it was a prominent symptom historically, it is rarely seen today. Whether this may be due to the use of historical treatments or the lack thereof is unknown.[20][18] Catatonia describes a profoundly agitated state in which the experience of reality is generally considered impaired. There are two primary manifestations of catatonic behavior. The classic presentation is a person who does not move or interact with the world in any way while awake. This type of catatonia presents with waxy flexibility. Waxy flexibility is when someone physically moves part of a catatonic person's body and the person stays in the position even if it is bizarre and otherwise nonfunctional (such as moving a person's arm straight up in the air and the arm staying there). The other type of catatonia is more of an outward presentation of the profoundly agitated state described above. It involves excessive and purposeless motor behaviour, as well as an extreme mental preoccupation that prevents an intact experience of reality. An example is someone walking very fast in circles to the exclusion of anything else with a level of mental preoccupation (meaning not focused on anything relevant to the situation) that was not typical of the person prior to the symptom onset. In both types of catatonia, there is generally no reaction to anything that happens outside of them. It is important to distinguish catatonic agitation from severe bipolar mania, although someone could have both. Negative symptoms See also: Clouding of consciousness and Depression (mood) Negative symptoms include reduced emotional expression, decreased motivation (avolition), and reduced spontaneous speech (poverty of speech, alogia). Individuals with this condition lack interest and spontaneity, and have the inability to feel pleasure (anhedonia).[30] Altered Behavioral Inhibition System functioning could possibly cause reduced sustained attention in psychosis and overall contribute to more negative reactions.[31] Psychosis in adolescents Psychosis is rare in adolescents.[32] Young people who have psychosis may have trouble connecting with the world around them and may experience hallucinations or delusions.[32] Adolescents with psychosis may also have cognitive deficits that may make it harder for the youth to socialize and work.[32] Potential impairments include a reduced speed of mental processing, the lack of ability to focus without getting distracted (limited attention span), and deficits in verbal memory.[32] If an adolescent is experiencing psychosis, they most likely have comorbidity, meaning that they could have multiple mental illnesses.[33] Because of this, it may be difficult to determine whether it is psychosis or autism spectrum disorder, social or generalized anxiety disorder, or obsessive-compulsive disorder.[33] Causes The symptoms of psychosis may be caused by serious psychiatric disorders such as schizophrenia, a number of medical illnesses, and trauma. Psychosis may also be temporary or transient, and be caused by medications or substance use disorder (substance-induced psychosis). Normal states Brief hallucinations are not uncommon in those without any psychiatric disease, including healthy children. Causes or triggers include:[34] Falling asleep and waking: hypnagogic and hypnopompic hallucinations[35] Bereavement, in which hallucinations of a deceased loved one are common[34] Severe sleep deprivation[36][37] Extreme stress (see below)[38] Abnormal brainwaves[39][40] Abnormal brain networks[41][42][43] Traumatic Brain Injury[44][45][46] Trauma and stress Traumatic life events have been linked with an elevated risk of developing psychotic symptoms.[47] Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis.[48] Individuals with psychotic symptoms are three times more likely to have experienced childhood trauma (e.g., physical or sexual abuse, physical or emotional neglect) than those in the general population.[48] Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods.[48] Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent in which multiple traumatic life events accumulate, compounding symptom expression and severity.[47][48] However, acute, stressful events can also trigger brief psychotic episodes.[49] Trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects.[47] A healthy person could become psychotic if he or she is placed in an empty room with no light and sound. After about 15 minutes, psychosis can occur, this is a phenomenon known as sensory deprivation.[8] Neuroticism, a personality trait associated with vulnerability to stressors, is an independent predictor of the development of psychosis.[50] Psychiatric disorders From a diagnostic standpoint, organic disorders were believed to be caused by physical illness affecting the brain (that is, psychiatric disorders secondary to other conditions) while functional disorders were considered disorders of the functioning of the mind in the absence of physical disorders (that is, primary psychological or psychiatric disorders). Subtle physical abnormalities have been found in illnesses traditionally considered functional, such as schizophrenia. The DSM-IV-TR avoids the functional/organic distinction, and instead lists traditional psychotic illnesses, psychosis due to general medical conditions, and substance-induced psychosis. Primary psychiatric causes of psychosis include the following:[51][52][34] schizophrenia mood disorders including psychotic depression and bipolar disorder in the manic and mixed episodes of bipolar I disorder and depressive episodes of both bipolar I and bipolar II schizoaffective disorder delusional disorder brief psychotic disorder schizophreniform disorder Psychotic symptoms may also be seen in:[34] Personality disorders including Schizotypal personality disorder and borderline personality disorder Post-traumatic stress disorder obsessive–compulsive disorder dissociative identity disorder paraphrenia Subtypes Subtypes of psychosis include: Postpartum psychosis, occurring shortly after giving birth, primarily associated with maternal bipolar disorder Monothematic delusions Myxedematous psychosis Stimulant psychosis Tardive psychosis Shared psychosis Cycloid psychosis Cycloid psychosis is typically an acute, self-limiting form of psychosis with psychotic and mood symptoms that progress from normal to full-blown, usually between a few hours to days, and not related to drug intake or brain injury.[53] While proposed as a distinct entity, clinically separate from schizophrenia and affective disorders, cycloid psychosis is not formally acknowledged by current ICD or DSM criteria.[53] Its unclear place in psychiatric nosology has likely contributed to the limited scientific investigation and literature on the topic. Postpartum psychosis Postpartum psychosis is a rare yet serious and debilitating form of psychosis.[54] Symptoms range from fluctuating moods and insomnia to mood-incongruent delusions related to the individual or the infant.[54] Women experiencing postpartum psychosis are at increased risk for suicide or infanticide. Many women who experience first-time psychosis from postpartum often have bipolar disorder, meaning they could experience an increase of psychotic episodes even after postpartum.[54] Medical conditions A very large number of medical conditions can cause psychosis, sometimes called secondary psychosis.[34] Examples include: disorders causing delirium (toxic psychosis), in which consciousness is disturbed neurodevelopmental disorders and chromosomal abnormalities, including velocardiofacial syndrome neurodegenerative disorders, such as Alzheimer's disease, dementia with Lewy bodies, and Parkinson's disease[55] focal neurological disease, such as stroke, brain tumors,[56] multiple sclerosis,[3] and some forms of epilepsy malignancy (typically via masses in the brain, paraneoplastic syndromes)[3] infectious and postinfectious syndromes, including infections causing delirium, viral encephalitis, HIV/AIDS,[57] malaria,[58] syphilis[57] endocrine disease, such as hypothyroidism, hyperthyroidism, Cushing's syndrome, hypoparathyroidism and hyperparathyroidism;[59] sex hormones also affect psychotic symptoms and sometimes giving birth can provoke psychosis, termed postpartum psychosis[60] inborn errors of metabolism, such as Wilson's disease, porphyria, and homocysteinemia.[61] nutritional deficiency, such as vitamin B12 deficiency[9] other acquired metabolic disorders, including electrolyte disturbances such as hypocalcemia, hypernatremia, hyponatremia, hypokalemia, hypomagnesemia, hypermagnesemia, hypercalcemia, and hypophosphatemia, but also hypoglycemia, hypoxia, and failure of the liver or kidneys[59][9] autoimmune and related disorders, such as systemic lupus erythematosus (lupus, SLE), sarcoidosis, Hashimoto's encephalopathy, anti-NMDA-receptor encephalitis, and non-celiac gluten sensitivity[62][63] poisoning by a range of plants, fungi, metals, organic compounds, and a few animal toxins[34] sleep disorders, such as in narcolepsy (in which REM sleep intrudes into wakefulness)[34] parasitic diseases, such as neurocysticercosis Psychoactive drugs Main article: Substance-induced psychosis Various psychoactive substances (both legal and illegal) have been implicated in causing, exacerbating, or precipitating psychotic states or disorders in users, with varying levels of evidence.[64] This may be upon intoxication for a more prolonged period after use, or upon withdrawal.[34] Individuals who experience substance-induced psychosis tend to have a greater awareness of their psychosis and tend to have higher levels of suicidal thinking compared to those who have a primary psychotic illness.[65] Drugs commonly alleged to induce psychotic symptoms include alcohol, cannabis, cocaine, amphetamines, cathinones, psychedelic drugs (such as LSD and psilocybin), κ-opioid receptor agonists (such as enadoline and salvinorin A) and NMDA receptor antagonists (such as phencyclidine and ketamine).[34][66] Caffeine may worsen symptoms in those with schizophrenia and cause psychosis at very high doses in people without the condition.[67][68] Cannabis and other illicit recreational drugs are often associated with psychosis in adolescents and cannabis use before 15 years old may increase the risk of psychosis in adulthood.[32] Alcohol Further information: Long-term effects of alcohol consumption § Mental health effects Approximately three percent of people with alcoholism experience psychosis during acute intoxication or withdrawal. Alcohol related psychosis may manifest itself through a kindling mechanism. The mechanism of alcohol-related psychosis is due to the long-term effects of alcohol consumption resulting in distortions to neuronal membranes, gene expression, as well as thiamine deficiency. It is possible that hazardous alcohol use via a kindling mechanism can cause the development of a chronic substance-induced psychotic disorder, i.e. schizophrenia. The effects of an alcohol-related psychosis include an increased risk of depression and suicide as well as causing psychosocial impairments.[69] Delirium tremens, a symptom of chronic alcoholism that can appear in the acute withdrawal phase, shares many symptoms with alcohol-related psychosis suggesting a common mechanism.[70] Cannabis Further information: Causes of schizophrenia § Cannabis, and Long-term effects of cannabis § Chronic psychosis and schizophrenia spectrum disorders According to current studies, cannabis use is associated with increased risk of psychotic disorders, and the more often cannabis is used the more likely a person is to develop a psychotic illness.[71] Furthermore, people with a history of cannabis use develop psychotic symptoms earlier than those who have never used cannabis.[71] Some debate exists regarding the causal relationship between cannabis use and psychosis with some studies suggesting that cannabis use hastens the onset of psychosis primarily in those with pre-existing vulnerability.[71][72][73] Indeed, cannabis use plays an important role in the development of psychosis in vulnerable individuals, and cannabis use in adolescence should be discouraged.[74] Some studies indicate that the effects of two active compounds in cannabis, tetrahydrocannabinol (THC) and cannabidiol (CBD), have opposite effects with respect to psychosis. While THC can induce psychotic symptoms in healthy individuals, limited evidence suggests that CBD may have antipsychotic effects.[75] Methamphetamine Main article: Stimulant psychosis Methamphetamine induces a psychosis in 26–46 percent of heavy users. Some of these people develop a long-lasting psychosis that can persist for longer than six months. Those who have had a short-lived psychosis from methamphetamine can have a relapse of the methamphetamine psychosis years later after a stressful event such as severe insomnia or a period of hazardous alcohol use despite not relapsing back to methamphetamine.[76] Individuals who have a long history of methamphetamine use and who have experienced psychosis in the past from methamphetamine use are highly likely to re-experience methamphetamine psychosis if drug use is recommenced. [citation needed] Methamphetamine-induced psychosis is likely gated by genetic vulnerability, which can produce long-term changes in brain neurochemistry following repetitive use.[77] Methamphetamine users with more ADHD-related behaviours in childhood experience methamphetamine-related psychosis more frequently.[78] Psychedelics A 2024 meta-analysis found an incidence of psychedelic-induced psychosis at 0.002% in population studies, 0.2% in uncontrolled clinical trials, and 0.6% in randomised controlled trials.[79] This meta-analysis found that in uncontrolled clinical trials involving only patients with schizophrenia, 3.8% developed prolonged psychotic reactions. A 2024 study found that psychedelic use was not generally associated with a change in the number of psychotic symptoms.[80] This study found that psychedelic use interacted with a family history of bipolar disorder, such that in those with a family history of bipolar disorder, psychedelic use was associated with an increase in the number of psychotic symptoms, while in those with a personal history of psychosis but no family history of psychotic disorders, psychedelic use was associated with a decrease in the number of psychotic symptoms. A 2023 study found an interaction between lifetime psychedelic use and family history of psychosis or bipolar disorder on psychotic symptoms over the past two weeks. Psychotic symptoms were highest among individuals with both a family history of psychosis or bipolar disorder and lifetime psychedelic use, while they were lowest among those with lifetime psychedelic use but no family history of these disorders.[81] Medication Administration, or sometimes withdrawal, of a large number of medications may provoke psychotic symptoms.[34] Drugs that can induce psychosis experimentally or in a significant proportion of people include: stimulants, such as amphetamine and other sympathomimetics, dopamine agonists, ketamine, corticosteroids (often with mood changes in addition), and some anticonvulsants such as vigabatrin.[82][83][84] Pathophysiology Neuroimaging The first brain image of an individual with psychosis was completed as far back as 1935 using a technique called pneumoencephalography[85] (a painful and now obsolete procedure where cerebrospinal fluid is drained from around the brain and replaced with air to allow the structure of the brain to show up more clearly on an X-ray picture). Both first episode psychosis, and high risk status is associated with reductions in grey matter volume (GMV). First episode psychotic and high risk populations are associated with similar but distinct abnormalities in GMV. Reductions in the right middle temporal gyrus, right superior temporal gyrus (STG), right parahippocampus, right hippocampus, right middle frontal gyrus, and left anterior cingulate cortex (ACC) are observed in high risk populations. Reductions in first episode psychosis span a region from the right STG to the right insula, left insula, and cerebellum, and are more severe in the right ACC, right STG, insula and cerebellum.[86][87] Another meta analysis reported bilateral reductions in insula, operculum, STG, medial frontal cortex, and ACC, but also reported increased GMV in the right lingual gyrus and left precentral gyrus.[88] The Kraepelinian dichotomy is made questionable[clarification needed] by grey matter abnormalities in bipolar and schizophrenia; schizophrenia is distinguishable from bipolar in that regions of grey matter reduction are generally larger in magnitude, although adjusting for gender differences reduces the difference to the left dorsomedial prefrontal cortex, and right dorsolateral prefrontal cortex.[89] During attentional tasks, first episode psychosis is associated with hypoactivation in the right middle frontal gyrus, a region generally described as encompassing the dorsolateral prefrontal cortex (dlPFC).Altered Behavioral Inhibition System functioning could possibly cause reduced sustained attention in psychosis and overall contribute to more negative reactions.[90] In congruence with studies on grey matter volume, hypoactivity in the right insula, and right inferior parietal lobe is also reported.[91] During cognitive tasks, hypoactivities in the right insula, dACC, and the left precuneus, as well as reduced deactivations in the right basal ganglia, right thalamus, right inferior frontal and left precentral gyri are observed. These results are highly consistent and replicable possibly except the abnormalities of the right inferior frontal gyrus.[92] Decreased grey matter volume in conjunction with bilateral hypoactivity is observed in anterior insula, dorsal medial frontal cortex, and dorsal ACC. Decreased grey matter volume and bilateral hyperactivity is reported in posterior insula, ventral medial frontal cortex, and ventral ACC.[93] Hallucinations Studies during acute experiences of hallucinations demonstrate increased activity in primary or secondary sensory cortices. As auditory hallucinations are most common in psychosis, most robust evidence exists for increased activity in the left middle temporal gyrus, left superior temporal gyrus, and left inferior frontal gyrus (i.e. Broca's area). Activity in the ventral striatum, hippocampus,[94] and ACC are related to the lucidity of hallucinations, and indicate that activation or involvement of emotional circuitry are key to the impact of abnormal activity in sensory cortices. Together, these findings indicate abnormal processing of internally generated sensory experiences, coupled with abnormal emotional processing, results in hallucinations. One proposed model involves a failure of feedforward networks from sensory cortices to the inferior frontal cortex, which normally cancel out sensory cortex activity during internally generated speech. The resulting disruption in expected and perceived speech is thought to produce lucid hallucinatory experiences.[95] Delusions The two-factor model of delusions posits that dysfunction in both belief formation systems and belief evaluation systems are necessary for delusions. Dysfunction in evaluations systems localized to the right lateral prefrontal cortex, regardless of delusion content, is supported by neuroimaging studies and is congruent with its role in conflict monitoring in healthy persons. Abnormal activation and reduced volume is seen in people with delusions, as well as in disorders associated with delusions such as frontotemporal dementia, psychosis and Lewy body dementia. Furthermore, lesions to this region are associated with "jumping to conclusions", damage to this region is associated with post-stroke delusions, and hypometabolism this region associated with caudate strokes presenting with delusions. The aberrant salience model suggests that delusions are a result of people assigning excessive importance to irrelevant stimuli. In support of this hypothesis, regions normally associated with the salience network demonstrate reduced grey matter in people with delusions, and the neurotransmitter dopamine, which is widely implicated in salience processing, is also widely implicated in psychotic disorders. Specific regions have been associated with specific types of delusions. The volume of the hippocampus and parahippocampus is related to paranoid delusions in Alzheimer's disease, and has been reported to be abnormal post mortem in one person with delusions. Capgras delusions have been associated with occipito-temporal damage, and may be related to failure to elicit normal emotions or memories in response to faces.[96]맛깔없는 무거운 중간자 J/ψ(제이/프시)ϒ(입실론)θ(세타)χ(키)ηc/b/t(에타 쿼코늄)hc/b/t
맛깔 없는 무거운 중간자 J/ψ(제이/프시) ϒ(입실론) θ(세타) χ(키) η c/b/t (에타 쿼코늄) h c/b/t In psychopathology , psychosis is a condition in which a person is unable to distinguish between what is and is not real . [ 3 ] Examples of psychotic symptoms are delusions , hallucinations , and disorganized or incoherent thoughts or speech. [ 3 ] Psychosis is a description of a person's state or symptoms, rather than a particular mental illness, and it is not related to psychopathy (a personality construct [ 4 ] [ 5 ] characterized by impaired empathy and remorse , along with bold , disinhibited , and egocentric traits). Common causes of chronic (i.e. ongoing or repeating) psychosis include schizophrenia or schizoaffective disorder , bipolar disorder , and brain damage (usually as a result of alcoholism ). [ 6 ] [ 7 ] ...