“Schizophrenia [like psychosis] cannot be understood without understanding despair.” –R.D. Laing
According to the latest definition in the Merriam Webster Online Dictionary, psychosis is a “fundamental derangement of the mind (as in schizophrenia) characterized by defective or lost contact with reality especially as evidenced by delusions, hallucinations, and disorganized speech and behavior.”
Have you ever been told your mind was deranged? Or that your reality was defective? It’s not an easy pill to swallow.
Imagine each day starts with a sunrise, wife at side, drinking reheated coffee and joking about what you’ll both do when graduate school is over and you can afford to feed the kids more than Raman. Imagine then waking up alone in a hospital. You’re informed your entire life was a dream. You aren’t a graduate student. You don’t have a house. Your wife and kids never existed. For you, they’re real. For the rest of the world, your reality is a sign of disease. In fact, the doctors insist you take medications that will make you agree with them. They threaten to call security each time you ask for a phone.
What’s going on? Either this is a movie, where your wife rescues you from the clutches of some evil plot meant to stifle your presence in the real world — or you ARE crazy.
Here’s the next step: imagine you ARE crazy. A calm, collected, reflective, and insightful sort of crazy. All you know is you have memories that seem real to you, but aren’t. As you begin to accept the enormity of the situation, and enormous it is, as now you bring your own judgment into question, you’re constantly plagued by the fact that your memories of your past life are real to you. And, whether real or not, you mourn the loss of a life you loved. You miss the challenge of your 8AM astrophysics course, the drawings your kids leave on the fridge, and the reheated coffee you shared each morning with your partner and best friend. You don’t want to forget them. You don’t want to forget who you are. Here’s where the identity crisis starts:
Why would my reality be different to everyone else’s? Who decides which reality is the correct one? If my judgment is considered to be defective, and if I can’t recognize what is real, how do I make decisions in the future? How do I know I can trust myself? Or anyone? Or… could I be right, and everyone else be wrong.
A broken mind is a hard thing to accept. Especially when it doesn’t feel broken. The ego doesn’t reconcile itself to this sort of experience easily, even when it sees the memories or thoughts are mistaken.
So what is psychosis? Understanding what it’s like to be psychotic doesn’t explain what it is to be psychotic. In the textbooks, “psychosis” is a technical word that describes the presence of hallucinations, delusions, or confused speech/behaviors.
Hallucinations are usually experienced as voices. These voices can be pleasant or downright terrifying. Brain scans taken while people are hallucinating reveal increased activity in the parts of the brain that handle hearing. That means hallucinations aren’t experienced as “loud” thoughts; they are heard with the ears, as though someone were standing in the room with the patient talking to them.
Delusions occur when the individual’s reality, or belief system, is off-kilter compared to what the rest of the world deems real. There are many types of delusions. The most common is the paranoid delusion, where a person incorrectly believes someone or something is trying to control or kill them. It isn’t unusual for psychotic people to believe they have children (or siblings, friends, neighbors) when in reality they don’t, like in the example above.
Confusion can range from tendency to wander between topics to being utterly and entirely nonsensical. Sometimes patients’ sentences don’t fit together, making it hard for others to follow what they are saying. Other people while psychotic move in strange ways, wear clothes incorrectly, exhibit poor social skills, or move things around in ways that make no sense.
Keep in mind that hallucinations, delusions, and/or confusion are symptoms, not a diagnosis. There’s always a reason for psychosis, even if we don’t know what it is. That reason might be psychiatric, as seen in Schizophrenia, severe depression, bipolar disorder, and substance abuse. It might be related to a medical problem, like Alzheimer’s, meningitis, lupus, or adverse effect to Prednisone or Parkinson’s medications. Often the experience of psychosis is temporary.
One attempt at an answer, and lots of new questions..
–People with chronic psychosis fare better in rural settings than in the city. Why?
–A belief system can be considered abnormal and thus pathological in one culture (i.e. thus a “delusion” requiring treatment) but entirely normal and even expected in another (meaning the person is not sick at all). Does that mean that “normal” is subjective, that society decides whether delusions are normal or not? How is that scientific?
— Most people with chronic psychosis, like Schizophrenia, never recognize they’re sick, even once stabilized on medication. Their hallucinations and delusions disappear completely, yet they don’t notice a difference. How is that possible?
Seems we have many potential blogs waiting in the wings, questions ready for the answering, when pen and paper are in hand. For now stay tuned.
Kim Rosenthal, MD