When we hear someone is psychotic, we automatically think of psychopaths and cold-blooded criminals. We automatically think “Oh wow, they’re really crazy!” And we automatically think of plenty of other myths and misconceptions that only further the stigma surrounding psychosis.
In other words, the reality is that we get psychosis very wrong.
For starters, psychosis consists of hallucinations and/or delusions. “You can have one or both at the same time,” said Devon MacDermott, Ph.D, a psychologist who previously worked in psychiatric hospitals and outpatient centers, treating individuals experiencing psychosis in various forms.
“Hallucinations are sensory perceptions in the absence of external triggers,” MacDermott said. That is, “the trigger comes from inside [the person’s] own mind,” and involves one of their five senses. The most common is hearing voices, she said. People also can “see or feel things that aren’t there.”
“Delusions are persistent beliefs without sufficient evidence to back up those beliefs—and often with substantial evidence to refute the belief,” said MacDermott, who’s now in private practice where she specializes in trauma and OCD.
Psychologist Jessica Arenella, Ph.D, describes psychosis as a disruption in meaning-making: “The person may be finding meaning in otherwise random or inconsequential things (e.g., license plate numbers, TV ads), while minimizing or failing to grasp the importance of basic needs (e.g., showing up for work, changing one’s clothes).”
The signs of a psychotic episode differ depending on the person, because the symptoms are “an extension of each person’s unique thinking patterns,” MacDermott said.
Generally, people’s speech can be tough to follow or not make sense (because the person’s thoughts are disorganized); they might mutter or talk to themselves; say extraordinary, often unlikely things (e.g., “An actor is in love with me”), she said.
During a psychotic episode, it’s common for individuals to act in ways that are strange or out of character for them, MacDermott said. “This can range from something small like wearing more layers of clothes than is appropriate for the temperature all the way to sudden bursts of emotion that seem to come out of nowhere.”
What Psychotic Episodes Feel Like
“[During a psychotic episode], I zone out. I’m gone. I leave reality,” said Michelle Hammer, who has schizophrenia. She’s the co-host of Psych Central’s A Bipolar, a Schizophrenic, and a Podcast and founder of Schizophrenic.NYC, a clothing line with the mission of reducing stigma by starting conversations about mental health. “I can be thinking of anything. A past conversation. A made-up conversation. A weird dreamlike situation. I lose reality of where I actually physically am.”
“I mainly just feel ‘off,’ Things just aren’t right,” said Rachel Star Withers, who has schizophrenia and is an entertainer, speaker and video producer. She creates videos documenting her schizophrenia and ways to manage it, and aims to let others like her know they are not alone and can still live an amazing life.
“The biggest tell for me is that I start talking to myself and thinking in third person,” Withers said. She’ll tell herself things like:”OK Rachel, just walk; be normal.”
A patient once described psychosis in this way to MacDermott: “Imagine that you summon a picture in your mind like, say, a baseball. Imagine a baseball. Now imagine what it would be like to have the knowledge that you put that image in your mind taken away. Now, all you are left with is a thought having no idea how it got there. That’s what it’s like to be psychotic.”
MacDermott’s patients also have told her that they struggle with interpreting situations and see special meaning in everyday things. “That same patient once saw a family member put a knife down while they were cooking and had the thought that the family member was trying to send the patient a message that they were going to be killed because a knife represents death.”
In this piece on The Mighty individuals shared what it’s like to experience psychosis. One person wrote, “For me, it felt like I was watching a movie that was my life. I knew bad things were happening and I couldn’t stop it.” Another person described having an “out of body experience,” along with “excruciating sensations amplified by 1,000 at the tip of every sensor in my body.”
Someone else explained it in this way: “Every sense is heightened and colors are especially bright. The world is on a giant flat screen TV. Everything seems more crystal clear than you ever knew, but then it all becomes confused and muddled. You make your own realities, constantly decoding messages that seem extremely important, but are ultimately meaningless. They further the storyline in your head that seems so real.”
Arenella’s clients have described their psychotic episodes as “disorienting, overwhelming, frightening and isolating. They often describe heightened sensitivity, believing that there are no boundaries, that everything is related and transparent, and there is no privacy.”
Some might believe that they’re part of, or at the center of, a critical life-altering mission or plan, Arenella said. Which might lead to intense activity or the complete opposite: a feeling of paralysis.
Myths about Psychotic Episodes
One of the biggest and most harmful myths about psychosis is that people are dangerous and violent. Both MacDermott and Arenella emphasized that individuals in the throes of psychosis are much more likely to be victimized than to victimize.
Similarly, psychosis is not the same as psychopathy, MacDermott said. “Psychopaths are people who don’t feel empathy, are thrill seeking, and often are parasitic, aggressive, or manipulative to others. Psychosis is completely different and unrelated.”
Another misconception is that psychosis is always indicative of schizophrenia. Sometimes, psychotic episodes occur on their own, or as part of a different mental illness, such as depression, Arenella said. Most people only experience one or a handful of psychotic episodes in their lifetime, she said. (“Only approximately one third of people who experience psychotic episodes go on to have persistent psychotic states.”)
And if someone’s psychotic episodes are part of schizophrenia, it’s important to understand that people can and do recover from this illness, Arenella said.
Arenella, a founding board member of Hearing Voices NYC, also noted that eliminating voice hearing isn’t an essential part of treatment. “How a person interprets and interacts with their voices is more important for recovery than hearing them or not hearing them.” (This TED talk from Eleanor Longden, who has schizophrenia, provides more insight.)
Moreover, even many mental health professionals believe the widespread myth that medication successfully treats psychosis, said Arenella, the president of the United States chapter of the International Society for Psychological and Social Approaches to Psychosis. While medication can decrease the intensity of symptoms, many people still hear voices and have difficulty in social relating, she said. Many also experience bothersome or serious side effects.
“Medication works for some people, some of the time, but it is not a cure all.” Psychosocial treatments, such as cognitive behavioral therapy for psychosis (CBT-p), have been shown to be effective in treating psychosis.
What Causes Psychotic Episodes
MacDermott noted that there’s a lot we still don’t know about psychosis, and that includes its causes. Genetics likely plays a role. “People with an immediate family member with schizophrenia are much more likely to have schizophrenia themselves than someone who doesn’t have an immediate family member with the disorder,” she said.
Adverse childhood events and trauma can contribute to psychosis, as well, even though the episode can occur years later, Arenella said. She also identified other common factors: loss, social rejection, insomnia, illegal and prescribed drugs and hormonal changes.
“A lot of antipsychotic medication reduces the amount of certain neurotransmitters, like dopamine, in the brain,” MacDermott said. This suggests that too much dopamine (and other neurotransmitters) might be involved in psychosis. But, as MacDermott noted, “People and brains are so complicated that we can’t know for sure exactly what triggers psychosis in each person.”
A big reason psychosis scares and confuses us is because it seems so out of the realm of “normal.” But in actuality, “psychosis is part of the normal range of human experience,” Arenella said. “While it is unusual, it is not fundamentally different from other human experience.”
That is, she said, “people who hear voices actually hear them and they sound just as real as all of the other voices of people. Imagine if someone were talking to you all day long while you’re trying to have a conversation with someone else; you might be distracted, confused, irritable, and want to avoid conversations. This is a normal response, albeit to an unusual stimuli.”
Also, many people hear voices, and aren’t having a psychotic episode. Arenella noted that after a loved one dies, some people report hearing the person talking to them. “Musicians and poets often hear tunes and verses in their heads and may not feel as if they created them, but more like they received them somehow.” Many people also talk about hearing the voice of God or Jesus during pivotal moments in their lives.
We tend to be taught, both implicitly and explicitly, that psychosis is unlike any other mental health issue—such as anxiety or depression, and “is not amenable to regular therapeutic techniques,” Arenella said. “This fosters a profound othering and harmful stigma toward people who experience psychosis.”
And such teachings simply couldn’t be further from the truth.