When I think about mental health stigma, few diagnoses drip with stigma more than psychosis. Many of the the hurtful and loaded words associated with psychosis…crazy, psycho, insane…are so intertwined in our culture, yet they are used to describe a very real and very life altering condition that has a huge impact on real peoples’ lives.
When I was preparing to write this blog post, I spoke with a friend who had experienced psychosis in her life. I asked her what she felt was important for people to know. She said: “People see these symptoms and they think the person displaying them is making a choice to display them. The behaviors of people with psychosis or mental illness are literally the disease, not a character flaw. People who are in psychosis don't even know that they are in it…to this day I still don’t know what was real and what wasn’t when I was experiencing psychosis”.
Take a minute to think about that. When a person is experiencing psychosis, they literally think that what they are experiencing is real, and they have no idea that you are not seeing, hearing, or experiencing what they are. Yet, for some reason, everyone is looking at them differently and treating them differently. Imagine how frightening that would be. My friend went on to describe what that was like in more detail: “It’s like being in your own little world, and nobody else understands you…or like you’re the only one that feels sane and nobody else gets it”.
So what exactly is psychosis? According to Arciniegas (2015) both the American Psychological Association and the World Health Organization require that a person has hallucinations without insight and delusions to meet the criterion for psychosis. So what does that mean?
Hallucinations are sensory experiences that are in contrast with reality. So, seeing, hearing, or feeling things that aren’t there. When we say that someone has “insight” into hallucinations, we mean that they know that they are experiencing hallucinations. An example that was given in the Arciniegas article was a visual migraine aura. People who have migraine auras see these auras, and they know they are not really there, but in their visual experience, they are really seeing them. Therefore, they are hallucinations, but the person has insight. For the criteria of hallucinations for psychosis to be met, the person cannot have insight, so they must believe that what they are hallucinating is really happening.
Delusions are “fixed false beliefs (Arciniegas, 2015)”. When we say false beliefs, we mean that these are things that a person believes despite evidence that clearly contradicts the belief. When we say the belief is fixed, we mean that it is held over an extended period of time without changing. Delusions are broken down into two categories: “ordinary” and “bizarre”. (Arciniegas, 2015)
Ordinary delusions are ones that could be possible in the physical world but that the person believes despite being shown evidence that the belief is not true. An example from the Arciniegas article is the belief that someone’s money has been stolen despite being shown bank statements to prove that this is not the case. (Arciniegas, 2015)
Bizarre delusions are ones that are not within the cultural norms of what is considered realistic, for example (from the Arciniegas article) an older version of the DSM used the example that a patient might believe that someone took all their organs out of their body and replaced them with someone else’s without leaving any evidence or scars. Interestingly, delusions are only considered bizarre if they are “not accepted by members of a person’s culture or subculture” including their religion, because many religious beliefs could be categorized as bizarre, but since they are widely held, they are not considered delusions. (Arciniegas, 2015)
We do see a lot of common themes among the delusions of people experiencing psychosis. I think that this is where a lot of the stereotypes about people with psychosis are perpetuated, so I hesitate to go into a lot of detail about these. However, it may be important to be aware of the common types of delusions if you are concerned that you or a loved one may be developing psychosis and you would like to seek care proactively. For that reason, I will just say that you can find a pretty comprehensive list of types of delusions here.
It’s important to note that psychosis is not a diagnosis, but rather a symptom that can occur in several diagnosable mental health conditions, including, but not limited to, bipolar disorder, schizophrenia, and schizoaffective disorder. In my experience, many people confuse psychosis with schizophrenia. Schizophrenia is a diagnosis, and one of the common symptoms of schizophrenia is psychosis, but they are not one and the same.
Psychosis isn’t always caused by mental illness. It can also occur in “neurodevelopmental, neurologic, and medical conditions (Arciniegas, 2015)”. If you or someone you know might be experiencing psychosis, it’s important to get medical consultation from a doctor or a psychiatrist- don’t just see a therapist. This is because psychosis generally requires medication for treatment, and because it may be caused by a medical condition, not a mental health condition, and a therapist is not qualified to make that determination.
As a side-note, psychosis can also be induced by drug or alcohol use. Alternatively, the use of substances can exacerbate latent psychosis in people who may have been prone to these disorders, but who have not experienced psychosis prior to use of certain substances. It is difficult to determine whether psychosis is brought on by drug use or if it would have occurred anyway and drug use made it occur faster, as we cannot know what would have happened if the person had not used the substance the preceded the onset of psychosis. Psychosis caused by drug use can wear off in a matter of hours, or can last for years.
People who have disorders associated with psychosis do not necessarily experience psychosis at all times. For most people, psychosis is treatable through the use of medications, medical interventions, and/or psychotherapy. Many people who experience psychosis are able to make a full recovery from this symptom with the right treatment.
According to NAMI, there are some early warning signs that you can keep an eye out for if you are worried that you or a loved one may be at risk for psychosis. These include “a drop in school or job performance, trouble thinking clearly or concentrating, suspiciousness or uneasiness around others, a decline in self-care or personal hygiene, spending a lot more time alone than usual, and strong, inappropriate emotions, or having no feelings at all” (NAMI, 2015).
There are also factors that may make it more likely that a person could develop psychosis. These are genetics, trauma, drug use, and physical illness or injury (specifically brain injuries/tumors, strokes, HIV, and brain diseases such as dementia) (NAMI, 2015). It’s important to remember that just because a factor increases the likelihood that someone might develop psychosis, does not mean that the person with this risk factor will definitely develop it.
While psychosis can be quite distressing for some people, it can be minimally distressing or not distressing at all for others. It depends on the nature of the delusions and hallucinations that the person is experiencing. Since the person who is experiencing psychosis does not have insight into their delusions, they may not want help once they are in the midst of the psychosis. If you feel that you may be at risk for psychosis, it may be wise to develop a plan with your therapist so that you can get help if psychosis starts to develop. Perhaps you would like to sign a release of information so that your therapist can speak with your doctor or psychiatrist, and ask them to do so if they suspect that you are slipping into psychosis. Unless you pose an immediate danger to yourself or others, you cannot be involuntarily committed to a psychiatric hospital due to psychosis (for good reason, in my opinion, as this would be a violation of your civil liberties), so you will need to be proactive about developing a plan to prevent things from getting worse and getting yourself out of psychosis as quickly as possible.
While psychosis is a very rare condition, occurring in about 1 out of 150 people in their lifetime (Moreno-Küstner, 2018), it’s important to remember that psychosis can happen to anyone, including you. Therefore, we should all have compassion for people experiencing this symptom, and understand that while their behavior may appear out of the norm, it makes sense given what they are experiencing. If you suspect that you or someone you care for may be experiencing psychosis, seek medical attention from your doctor or a psychiatrist, or call your local chapter of the National Alliance on Mental Illness for further resources. You can call the national line at 800-950-6264 to be directed to your local chapter. Finally, the next time you hear someone using words that create or perpetuate stigma for those who experience psychosis, speak up to end stigma! If we all do that, we can make a huge collective difference.
by Leora Mirkin, LCSW
TOOLS:
1. Prodrome and Early Psychosis Program Network: “PEPPNET's mission is to support the national network of programs providing services to those at risk for or experiencing early psychosis by promoting communication, collaboration, and best practices so that individuals and families experiencing early psychosis have timely access to specialized, appropriate, and affordable care.” Find out more here.
2. National Early Psychosis Directory: You can use the spreadsheet to find contact information for early psychosis programs all over the USA. Access it here.
3. National Institute of Mental Health Recovery After an Initial Schizophrenia Episode Webpage: Offers information and resources to help families and loved ones as well as the person experiencing schizophrenia understand the symptoms and access resources. Access the webpage here.
4. Create a plan with your therapist and doctor or psychiatrist if you are worried that you may be at risk for slipping into psychosis.
5. Reach out to NAMI if you don’t know how to help yourself or a loved one who may be experiencing psychosis. You can call the national line at 800-950-6264 to be directed to your local chapter.
6. Be aware of the early warning signs of psychosis. These include “a drop in school or job performance, trouble thinking clearly or concentrating, suspiciousness or uneasiness around others, a decline in self-care or personal hygiene, spending a lot more time alone than usual, and strong, inappropriate emotions, or having no feelings at all” (NAMI, 2015).
CITATIONS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455840/
https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
https://www.nami.org/NAMI/media/NAMI-Media/Images/FactSheets/Psychosis-FS.pdf
https://www.nami.org/learn-more/mental-health-conditions/schizophrenia
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896987/