How do you see psychosis?

If you’re not a mental health professional, your exposure to psychosis may come through a variety of channels. You may know someone with a psychotic disorder; you may have a psychotic disorder yourself. You may have taken an introductory class on psychology in high school or college, and you may be aware of psychotic episodes as events in which people lose touch with some element of reality — they may have auditory or visual hallucinations, they may develop delusions. Or you may only see psychosis through the lens of popular media.

If you don’t have experience with psychosis, the behaviors involved can seem bizarre and frightening. Why is that man talking to himself? Is that person picking at their own skin? Why does that woman think I said something I didn’t? And what we often do with things that are uncomfortable because they’re bizarre and frightening is turn them into humor. We make jokes and turn people with psychotic disorders into punchlines.

I’ve seen this happen with multiple celebrities experiencing high-profile psychotic episodes in the press, both before and since studying psychology. The undercurrent of reporting on them is that we should laugh at their behaviors. Why wouldn’t we?

The answer is that a psychotic break with reality can be a profoundly frightening experience for the person with the disorder. When you can’t trust your perception of the world, or can’t make the linear, logical connections that most brains can most of the time, you’re left without a touchstone. And a surprisingly large number of disorders can produce psychosis: most people are aware that schizophrenia can lead to psychosis, but depression can be so profound that it also produces psychosis. Manic episodes for people with bipolar disorder can lead to psychotic symptoms. During withdrawal from alcohol or active use of a large range of drugs, people may experience hallucinations. Delirium is a condition common among the elderly in hospital settings that can involve many of the same symptoms and can be triggered by medications or other, less obvious factors. People with different forms of dementias may develop hallucinations or delusions.

Psychotic experiences and behaviors aren’t limited to one group of people. As we age, as we get sick, our brains can be susceptible to these experiences. It’s frightening to imagine no longer being fully grounded in reality, but it’s worth taking a moment to think about what that’s like. People with psychotic disorders have written extensively about their experiences. I would encourage you to read first-hand accounts.

Psychotic disorders can be temporary or chronic. Someone may have delirium once in a hospital setting, after a surgery — and never develop it again. Someone might develop schizophrenia in their early 20s and might never experience a full remission. Some people with psychotic symptoms have only one delusion, which may not interfere much with their lives. Others may have hallucinations that they are able to ignore, while others have frightening, abusive hallucinations — typically voices that say cruel, personally hurtful and threatening things.

The image of a psychotic person that springs to mind for many of us, thanks to the popular media, is a middle-aged, disheveled homeless person, rooting through garbage, perhaps guarding their worldly possessions in a shopping cart while talking to themselves. It is important to simultaneously recognize two things: first, that the vast majority of people who have had at least one psychotic break do not look like that; and second, that people who do look like that are human beings who deserve better than your scorn.

The thin edge of the feeling “there but for the grace of God go I” is where we find a lot of our humor. It’s easier to laugh at someone than to put ourselves in their shoes and to let ourselves feel the enormity and the weight of human suffering. It can feel senseless — why would brains be so fallible? Why would an organ dedicated to letting us interact with the world around us let us down in such key ways?

It helps to study brains because you can let go of the idea that “normal” brains are inherently good at perceiving reality. We are all constantly patching together our sensory experience of the world through incomplete and corrupted data. Psychosis tends to happen in situations where those data are being interrupted in some way — whether by connections that are physically altered, by drugs or by temporary shifts in neurotransmitter functioning.

One of the most simple and beautiful examples of how our brains make a complete picture for us of the world despite not having all the facts is how our brains gloss over the blind spot formed by the optic nerve on the retina. There are two circles in your vision where you actually can’t see because you have no sensors available, but even if you close one eye so it can’t compensate for the other, your brain will fill in the blanks by extrapolating from what it sees.

Reality is a moving target. Our brains try to do the best they can to keep it in view, and sometimes that’s not enough. When brains extrapolate incorrectly, they can create sensory experiences that aren’t there. Voices, fleeting shadows, a sense of being watched or of being judged. Medications can help but often come with side effects that people may or may not find tolerable. Antipsychotic medications negatively affect the same neurotransmitter system that is responsible for finding things enjoyable and rewarding.

Recognizing that we are all potentially vulnerable to psychosis can make us scared, and it can make us cruel to those already living with it in an attempt to distance ourselves from the pain. Or it can make us more empathetic: We can choose to learn more about psychosis and how to be good friends, good families and good medical providers for those people, who are already members of our communities and families.

Kristin Puhl is a medical student and can be reached on Twitter @kristinpuhl.

Image credit: Shutterstock.com

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