Boredom, dopamine, and the thrill of psychosis: psychiatry in a new key.

Medication non-adherence is a great challenge in the treatment of psychotic disorders. Several factors leading to medication non-adherence in schizophrenia have been identified: drug side-effects, lack of illness insight, negative attitude of the patient and friends/relatives toward medication, stigma of mental illness and taking medication, poor therapeutic alliance, substance abuse, and role of the illness in maintaining the family system. In this work I propose a new vista on the phenomenon of medication non-adherence in psychosis. Rather rule than exception, non-adherence is to be expected in psychosis, it can be considered as a symptom of psychosis similarly as substance craving and use are symptoms of the substance use disorders. Relying on the last refinements of the concepts of boredom, anticipatory anhedonia, intrinsic motivation, and thrill I assume that there is a lure of psychotic episode. In order to escape an extremely unpleasant and distressing experience of boredom and to experience the thrill of psychosis, the patients are prone to quit antipsychotic therapy. The phenomena of boredom and the thrill of psychosis are evident but unexploited for strengthening the therapeutic adherence. Making the lure of psychosis an explicit reason for medication non-adherence would bring to the awareness a personal choice between short-term pleasure of the psychotic thrill and prevention of long-term losses due to a psychotic episode. Neurobiological and psychobiological underpinning of the psychotic thrill has been suggested. An explanation of the pleasure of psychosis and substance use, which overcomes the circular explanation of reward in which dopamine appears as the cause and consequence of reward, has been proposed. The present synthesis can be regarded as a contribution to the field of theoretical psychiatry. It points to a chance for psychiatry to do more for patients' wellbeing and treatment adherence performing in a new key - dealing with boredom and pleasure in patients' everyday life.