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The Nature of Psychosis

Mark Dombeck, Ph.D.

an example of psychotic writingYou hear the term "psychotic" used a fair amount when reading about mental illness, but it occurred to me recently that not everyone has a clear understanding of this important concept. So, the purpose of this essay is to explore and explain what it means to be (or call someone) psychotic.

Out of Touch with Reality

In a very basic and broad sense, to be psychotic means to have lost touch with reality. We all know what that means, right? Or do we? What does reality mean anyway? We certainly have to know a little bit about reality before we can talk about losing touch with it.

What we typically mean by reality is "that set of assumptions that you and I (and others we know) share about the nature of the world and the people, places and things in the world". Reality in this sense is something we share with other people. It is a necessarily social thing.

"What about my feelings and thoughts?", you might ask. "Aren't those part of reality?" Well, yes, these things do exist subjectively and as such can be said to be a part of your own personal reality, but they really are not a part of social reality until we take steps to share them. Until you share a thought with me, I have no way of knowing about it, and vice versa. God may be able to read minds and know individual's subjective realities in an objective manner, but regular people can't do this sort of thing.

You might ask, "Isn't there some sort of reality out there that is objective and real rather than just something shared and social or merely personal?" This is a much more difficult question to answer. We can be pretty sure that there is a reality outside our personal experience and outside what we share with one another, but it is difficult to know about that reality because we cannot experience it in an unmediated way. Everything we know about the world, we know through our senses, but our senses sometimes get things wrong! Consider the nature of optical illusions for a moment. It is easily possible to fool the eye into seeing things that aren't there or missing things that are. We can't trust our senses to get it perfectly right, and so must use other means of learning about objective reality. This much has been known for thousands of years as is evidenced by the ancient Greek philosopher Plato's Allegory of the Cave.

These days the two principle means of learning about reality are know as science and faith. Faith solves the problem by appealing to revealed truth (e.g., that truth communicated directly from God to his people through the vehicle of the Bible or the Koran or similar holy book). You either accept the revealed truths as true or you don't and this proves the measure of your faithfulness. Science approaches the problem by way of the scientific method, otherwise known as the empirical approach. A theory is formed from ideas about how reality might actually be, and then one or more testable questions are generated based on that theory, each of which can be proven wrong. The questions (now called hypotheses) are then tested (ideally, numerous times) by way of direct experimentation. The results of experiments are fed back into the theory to make it more accurate over time. The theory is never held to be absolutely true and perfect, but instead, just the best approximation of the truth that can be known at the time. There is room for revision and adjustment in the scientific worldview. Since what is known in the faith worldview is already perfect, it cannot easily change (unless there is a new revelation).

It turns out that science and faith are not terribly compatible ways of going about finding the truth, and because reasonable people cannot agree on which is a better way of finding out the truth, it is difficult to say definitively what the truth is. This will become relevant to our discussion later on. For the moment, suffice it to say that because of the incompatibility we tend to fall back on the next best thing we have, which is shared social reality.

It is pretty important to distinguish between subjective and social realities when talking about psychosis for this reason: Calling someone psychotic is a social judgment. Anyone making the claim that another person is psychotic (e.g., has lost touch with reality) is making the claim that that person is perceiving/thinking/acting in ways that don't make sense given the set of shared assumptions that make up social reality. You really can't call someone psychotic in reference to your own personal subjective understandings, because what if you are psychotic yourself and claiming that someone else is acting psychotically? How much sense would that make? Hopefully, no one would take you seriously.

Being psychotic, then, necessarily means that you are having experiences or acting in ways that most people around you find very odd, perplexing, incomprehensible, or irrational. This would be the lay person's relaxed understanding of what it means to be psychotic, anyway. Mental health professionals tend to use the term psychotic in a stricter way, to refer to the presence of particular kinds of symptoms that some people exhibit during the course of an illness; mental or otherwise, which lead them to act in odd, incomprehensible ways.

Illnesses Associated with Psychosis

A rather wide range of illnesses can produce psychotic symptoms, including:

  • Mood Disorders such as severe Major Depression or Bipolar Disorder during intense manic or depressive phases.

  • Psychotic Disorders, including of course Schizophrenia, but also various other disorders involving psychosis such as Delusional Disorder.

  • Cognitive Disorders affecting the brain such as Dementia (due to Alzheimer's, AIDS, etc.), and also Delirium.

  • Substance Abuse Disorders involving stimulants like Cocaine or depressants like Alcohol, and of course hallucinogens like LSD

  • Dissociative Disorders, including Dissociative Identity Disorder (more commonly known as multiple personality)

  • If we range away from the mental illnesses, we also find that more purely Medical Illnesses can produce psychosis too, as can the medical treatments and surgeries that are used to correct medical problems. Psychotic delusions are a common side effect of recovery from open heart surgery, for instance.

Causes of Psychosis

Not only are there a wide variety of illnesses associated with psychotic symptoms. It is also the case that psychotic symptoms can be produced in different ways; through very different mechanisms. Though patients with different conditions may appear to be identically psychotic, their delusions may have very different origins.

In order to describe the different ways that psychotic symptoms can occur, it will be helpful to introduce a metaphor here. Brains are like computers in that they have both hardware and software aspects. The physical brain is akin to the physical computer, while the mind is akin to the computer operating system or to software that runs on the physical hardware. Most commonly, psychotic symptoms occur due to brain hardware problems, where the brain is either damaged in some fashion, or goes out of the proper alignment needed to sustain the normal range of conscious experiences. However, sometimes psychotic symptoms are present in the context of a healthy brain, and it is the mental software that is the cause. Finally, sometimes both a healthy brain and reasonably healthy mental software are present, and yet psychotic-like symptoms can still occur.

The majority of psychotic symptoms seem to occur due to problems with the physical hardware of the brain. For instance, schizophrenic hallucinations are thought to be due to brain damage and/or to 'chemical imbalances' (e.g., to disregulation of the brain's various neurotransmitter systems, including dopamine and serotonin systems). Such chemical imbalances can be caused by brain damage or trauma of known and unknown types (sufficient to push vulnerable people into active psychosis), or they can be induced with drugs like cocaine and alcohol.

In contrast, when psychosis occurs in cases of Dissociative Identity Disorder (DID, what used to be called multiple personality disorder), the cause more likely involves the peculiar architecture of those minds than any significant brain damage or imbalance.

The typical DID story involves fairly severe and protracted child abuse starting in early childhood. DID patients learn to cope with this abuse by dissociating themselves from the abuse experience, which is accomplished by mentally "looking the other way" while it is occurring; by learning to experience the abuse as though from a distance; and by making copious use of imagination and fantasy. As they age, habitual use of such distancing and fantasy techniques produces a fractured, un-unified sense of self which sees itself from multiple points of view rather than from one. The different aspects of self typically specialize, with one point of view (or "alter" as they are called) holding memory for troubling events, another being angry, another retaining a innocent perspective, and another taking on a coordinator's role. Some alters may gain a lot of social experience while others may remain isolated within the system. As maturity tends to be a function of social experience, isolated alters tend to remain quite immature and to heavily invest in fantasy, while more social alters will understand how to navigate the world better. Since these aspects are dissociated, they do not communicate easily and typically cannot or will not benefit from one another's experience. Alters tend to alternate their expression from one to another over time. Alters that are "on" will have memory for events, while alters that are "off" may not. Some alters may be aware of the presence of other alters while others are not.

What does this have to do with psychosis, you might be wondering. The answer is apparent if you can imagine what happens when an alter who has not been aware of the larger system it is a part of starts becoming aware of that larger system. Such a "person" starts hearing voices and may have what can be thought of as possession experiences (where other alters gain control). Such a person's behavior is often erratic, illogical and fantastic. This is especially the case as immature childlike and heavily fantasy dependent alters are expressed (e.g., "littles"), and as various alters act out conflicting motivations. I have seen a grown woman babbling in a childlike manner one moment, propositioning me the next, later telling me she is a sixteen year old boy, and still later going off to work as a healthcare professional. DID produces a hidden sort of psychosis which is not apparent to the casual observer, but which is nevertheless every bit as severe in its own way as the sort characteristic of schizophrenia.

Finally, there is a third type of psychosis, characterized by neither a damaged brain or damaged mind, but instead by naiveté. Shared Psychotic Disorder (otherwise known by the more colorful name Folie à Deux) is a socially created form of psychosis that occurs when one person is influenced by another person who happens to be delusionally psychotic, and takes on that psychotic person's disordered belief system in an uncritical manner. This condition is rare when you consider only cases that meet the strict DSM criteria. Something like this might seem quite common to you, however, depending upon how tolerant you are of people who come from different cultures than yourself and who are invested in beliefs that make sense within those other cultures but not within your own.

Psychotic Symptoms

By any definition, being labeled psychotic means that you are manifesting particular symptoms and behaviors that demonstrate to others that you are out of touch with (shared social) reality. The most common and prototypical psychotic symptoms are known as hallucinations and delusions, and these are what we will focus on here. Keep in mind that there are sometimes also other symptoms present that indicate psychosis, including speech and language impairments and disorganized or catatonic behavior. These latter symptoms tend to be limited mostly to physical hardware problem sorts of psychosis like schizophrenia.

Hallucinations occur when someone perceives something that isn't there in any objective sense. Perception implies the senses, and there are five senses: seeing, hearing, smelling, touching and tasting. Hallucinations can occur in any of the senses, but they are particularly prone to happen within the dimension of hearing. A common sort of hallucination involves hearing voices of people who aren't there. The voices may be talking to you, or talking at you. Two voices may be having a conversation about you, or just making a running commentary, almost like a narrator or a sportscaster. They may be saying terrible and critical things about you, or urging you to engage in risky behavior. You may not know who is speaking to you, or you may mistake the voice for God, an angel, a devil, an alien or even a dog.

The presence of hallucinations is typically a sign that there is a brain problem (a hardware problem) happening. This brain problem may be the result of a disease process, due to brain damage, or due to the effects of medications or drugs such as hallucinogens (like LSD) or stimulants (like cocaine and methamphetamine). For what ever reason, the brain is not functioning normally, and as a result, normal sense is not being made out of experience. Events that are happening are experienced in odd ways, or events are experienced that have not happened out there in the world.

Hallucinations are probably a side effect of the brain's rather global tendency to organize perceptions into recognizable patterns even when those patterns don't fit particularly well. All brains do this sort of thing, healthy and ill. The more ill the brain happens to be, however, the more noise that brain has to organize, and the more bizarre, loose and ill-fitting the patterns it comes up with to make the whole thing make "sense".

Where hallucinations have to do with making sense of odd sensory perceptions, delusions have to do with making sense of experience. Delusions are fixed beliefs that are both: 1) untrue, and 2) resistant to alteration even when there is good evidence to the contrary to disprove them. Delusions can vary widely in their plausibility. Very bizarre delusions may occur, such as for instance, when a psychotic person believes that the television is implanting thoughts into their heads for purposes of mind control. More plausible delusions can occur too, such as when someone believes that the FBI or other government agency is out to get them. This is at least possible, even if unlikely (although these days what with warrentless wiretapping and the like, we are all potentially being watched (!). Correspondingly, one's threshold for judging what is bizarre with regard to paranoid delusions has to go up in response). A very plausible delusion could occur when a woman decides her husband is cheating on her in the absence of any good evidence that this is the case. This sort of thing does happen frequently, unfortunately, and is not at all strange to contemplate.

Delusions tend to come in particular formats, so much so that a category system has evolved to classify them:

  • Erotomanic delusions are false beliefs that involve romantic or sexual interest, such as when someone believes that a celebrity is in love with them.

  • Grandiose delusions are false beliefs concerning a given person's importance in the public arena, such as when someone believes they are a prophet of God.

  • Jealous delusions are false beliefs usually concerning the idea that a spouse or partner is cheating.

  • Persecutory delusions are false beliefs concerning persecution; that people are out to get you (this is the classic paranoid delusion).

  • Somatic delusions are false beliefs concerning the body, generally to the effect that something is wrong with the body when it isn't. A bizarre somatic delusion might involve someone believing that their skin is rotting off their body, for instance.

  • Delusions can also be of Mixed type (combining categories without one category dominating ), or of an Unspecified type (for those occasions when truly novel delusions are encountered).

Where the presence of hallucinations is a pretty clear indicator of a brain problem, this is not necessarily the case with regard to delusions. Delusions and hallucinations can and do frequently co-occur, but delusions can also occur just fine when no sign of hallucinations are evident. Brain damage or impairment is not necessary in order for delusions to occur. I'd like to say that you can use the bizarreness of delusions as an indicator of brain impairment, where the more bizarre the delusion is, the more likely the person exhibiting that delusion is to have a brain impairment, but this isn't necessarily the case. To clarify, it is the case that more bizarreness suggests a greater likelihood of brain impairment, except when those bizarre beliefs are widely held within the cultural group that the person happens to belong to. This is to say, if the delusion is a societal or sub-cultural delusion and not just an individual one, a person holding that delusion could be very much delusional but have a perfectly healthy brain and mind. From their own perspective and from the perspective of those around them sharing in the same culture, they would be sane. From the outside perspective of a different culture, they would appear delusional. Again, psychosis is in the eye of the beholder; it is a social process, and what makes sense within one society may not make sense in another.

Nowhere is this phenomena more apparent then when you compare cultures with high-contrast belief differences. A good example occurs in America today when people talk about evolution. On the one side of the evolution divide are scientists who take an empirical approach wherein the theory of evolution represents the best way currently known to account for the carefully accumulated and scrutinized data concerning human and animal origins. On the other side are people from faith-based backgrounds who practice bible literalism wherein if the bible says that creation happened as it says in Genesis, then that is exactly the way it happened. Each side's position looks fully delusional to the other side, I suspect. There is no way to say who is right without making a commitment yourself to one or another ways of understanding the nature of what is reality, so there is no ready resolution to the issue.

Psychosis is not the same thing as Psychopathy!

A few more things ought to be said before I close. You hear people talk about Psychopaths sometimes. Despite the similarity in the name, being a psychopath has little to do with being psychotic. Psychopaths are otherwise normal people (from a cognitive perspective) who for one reason or another have a terrible empathy deficit with regard to other people. They either cannot appreciate that other people have rights and feelings and lives that matter, or do not care for other reasons. Whatever the cause, they act as though they are the only important person in the world. Some psychopaths are skilled con-artists who are very good at leading people to trust them or fall in love with them, only to betray those people later on. Some become criminals. And, yes, some become violent murderers. So far as a diagnosis goes, psychopaths are more likely to be categorized as Antisocial Personality Disorders or Narcissistic Personality Disorders than as Schizophrenics, or Dissociatives. It's not hard to argue that psychopaths are delusional (due to their extreme empathy problems), but if this qualifies them for being psychotic it is a very different kind of psychotic than clinicians normally encounter.

Anyway, there is this myth that won't die that Schizophrenic and other psychotic patients are particularly violent, and this is just not the case by and large. Most of the psychotic patients I've know have been rather sweet people when you get to know them. Some act very strangely, and sometimes in alarming ways, but as a group they are not a particular threat. Its not that psychotic patients are never violent, but rather that they are not more violent than other groups of patients like substance abusers, for instance. I have this idea that people confuse psychotics with psychopaths and that may account for the persistence of this myth, but I'm not really sure.

Having made the points I wanted to make, I'll stop here. There is a lot more to say on the subject of psychosis (such as how it can be treated) but instead of making this essay overly long, I will refer people who are interested in additional material to our Schizophrenia topic center where a whole lot more on the subject is available.

Please feel free to ask further questions on the topic below at the bottom of the essay. I'll do my best to get them answered. And, should anyone who has experienced psychotic episodes read this, please add a comment describing your experiences so that they can become more clear and understandable to people who have not experienced what you have. When it comes to psychosis, having the right perspective counts for a lot.