What Psychotic Episodes Really Look and Feel Like

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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

Original Artwork by Michelle Hammer

“[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.

The Role of Mental Illness in Mass Shootings, Suicides

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By Amy Swearer

This week marks the one-year anniversary of the horrific Parkland school shooting. That tragedy sparked an intense national debate over how best to protect our children from school shootings.

Some have pushed for more restrictions on the constitutional rights of law-abiding citizens. Among them are the American Federation of Teachers and the National Education Association. These groups released a new set of proposals on Monday that they say “can prevent mass shooting incidents and help end gun violence in American schools.”

Unfortunately, these proposals miss the mark by neglecting to focus on the real problems, including, among other things, the role of mental illness in certain types of firearm-related violence.

How does serious mental illness factor in? And what steps can government take to mitigate the role of untreated mental illness in producing violent threats?

These questions merit deliberate, thoughtful examination, not reflexive calls for broad gun control.

For that reason, The Heritage Foundation recently published a legal memorandum, “Mental Illness, Firearms, and Violence,” as part of a series of papers by John Malcolm and myself exploring some of these deeper issues.

The paper makes clear that, while most mentally ill individuals are not and never will become violent, certain types of serious mental illness—especially when untreated—are associated with a higher prevalence of certain types of firearm-related violence.

In particular, individuals with serious mental illness are at a greater risk of committing suicide and are responsible for a disproportionate number of mass public killings.

Mass Public Shootings

There’s no evidence that all mentally ill people constitute a “high risk” population with respect to interpersonal violence, including firearm-related violence against others.

In fact, most studies indicate that mental illness is responsible for only a small fraction (about 3 percent to 5 percent) of all violent crimes committed in the United States every year, and most of those episodes of violence are committed by individuals who are not currently receiving mental health treatment.

There is, however, a strong connection between acts of mass public violence—including mass public shootings—and untreated serious mental illness.

While acts of mass public violence are extraordinary and rare occurrences, they are often high-profile events that deeply affect the national view of violent crime trends. Mass public shootings in particular stoke national conversations on gun violence and gun control, for understandable reasons.

The majority of all mass public killers (some studies estimate as many as two-thirds) likely suffered from a serious mental illness prior to their attacks, and often displayed clear signs of delusional thinking, paranoia, or irrational feelings of oppression associated with conditions such as schizophrenia and bipolar-related psychosis.

This includes many individuals who committed atrocious attacks on students, including the Parkland shooter, the Virginia Tech shooter, and the Sandy Hook shooter—all of whom had long histories of untreated mental health problems.

Unfortunately, hardly any of these individuals were receiving psychiatric treatment at the time of their attacks.

Even without access to firearms, individuals with untreated serious mental illness can and do find ways to commit mass public killings.

Activist groups and politicians who point to mass public shootings as a reason for broad restrictions on firearm access by the general public largely miss the underlying reality: The real problem is not the prevalence of firearms among the general public, but the prevalence of untreated serious mental illness that causes some individuals to become violent in catastrophic ways, regardless of lawful access to firearms.

Suicide

The most significant link between mental illness and firearm-related violence is suicide, which accounts for almost two-thirds of all annual firearm-related deaths in the United States.

Of course, not every suicide is necessarily related to an underlying mental illness, but there is little doubt that the presence of a mental illness substantially increases a person’s risk for committing suicide.

The most common method of suicide in the U.S. is through the use of a firearm, an unsurprising reality given that the U.S. has the highest per-capita number of privately owned firearms in the world.

Despite the nation’s exceptionally high rate of suicide by firearm, however, it does not have a particularly high overall suicide rate, compared with other countries.

Our national suicide rate stands at roughly the world average and is comparable to the rate experienced by many European countries with significantly lower rates of private firearm ownership.

At the same time, a number of countries with severely restrictive gun control laws have much higher rates of suicide than the United States, including Belgium, Finland, France, Japan, and South Korea.

The connection between general measures of firearm access and general suicide rates is limited, at best. The U.S. suicide rate has remained relatively stable over the past 50 years, even though the number of guns per capita has doubled.

Moreover, the percentage of suicides committed with firearms has actually decreased since 1999, even though the number of privately owned firearms has increased by more than 100 million.

As this data suggests, broad restrictions on firearm access are unlikely to have a meaningful effect on general suicide rates, and there are other socioeconomic factors beyond firearm availability that better account for differences in suicide rates.

These factors largely include measures of “social cohesion,” such as divorce rates, unemployment, poverty, past trauma, and family structure, and it’s increasingly clear that more socially integrated communities also tend to have lower suicide rates.

Access to firearms may, however, exacerbate the danger for people who are already at a heightened risk for committing suicide. For example, when individuals have a serious mental illness, access to firearms appears to increase their risk of committing suicide.

But it’s also more complicated: While individuals with serious mental illness may have an increased risk of committing suicide when they have ready access to firearms, they may also be less likely than the general population to commit suicide with firearms.

Why? Because they often have greater barriers to legal firearm access, including disqualifying mental health histories under state or federal law, and concerned friends or family members who may limit their unsupervised access to firearms.

Several studies suggest, then, that reducing unsupervised access to all commonly employed means of suicide (including firearms, but also sharp objects, medications, and rope material) for at-risk persons reduces their individual risk of suicide.

In short, broad limitations on firearm access for individuals who are not necessarily at heightened risk for committing suicide are unlikely to meaningfully affect overall suicide rates and should be viewed with a heavy dose of skepticism, but policies designed to limit firearm access for individuals with serious mental illness may be an important step in the right direction for reducing state and national suicide rates.

Policy Implications

It is clear that mental illness—especially untreated serious mental illness—plays a significant role in certain types of firearm-related violence that cannot be ignored.

This is not to suggest that individuals with mental illness should be treated as community pariahs or that they are even the cause of most firearm-related violence in the United States. But any holistic approach to reducing suicide and violent crime rates in our communities must account for the role played by serious mental illness.

The reduction of suicide rates requires a comprehensive approach that addresses all of the various factors related to suicide risk, including mental illness, socioeconomic variations, and access to a support system.

Similarly, policies to reduce the rate of mass public shootings in the United States must account for the significant role played by untreated serious mental illness in such killings.

The broad-scale disarmament of the general population is an inappropriate and unnecessary substitute for dealing with the underlying problems.