Understanding Psychosis

by Stuart Sorensen – RMN 

Ask the average citizen to define psychotic and they’ll revert back to the tired old Hollywood stereotype of sado-masochistic axe-wielding murderer so often described as psychotic in popular movies. They’d confidently list the callous characteristics of big screen villains with all the certainty of a university professor. And they’d be wrong!

What the media describes as ‘psychotic’ usually means a completely different disorder – psychopathy. It’s not the same thing! If you want more information on what it means to be a psychopath please see the information sheet on primary personality disorders.

Now that we’ve established what psychosis is not, let’s consider what it really is. There are many psychotic symptoms, all of which can be described as disorders of perception (the way we experience or make sense of the world). People suffering from psychotic disorders can exhibit any or all of these at different times depending upon the exact nature of their illness. Psychotic disorders include:

Schizophrenia

Drug-induced Psychosis

Psychotic Depression

Bi-Polar Disorder

Alzheimer’s disease

Multi-infarct dementia

Delirium Tremens

Korsakoff’s Syndrome (alcohol-related dementia)

Psychotic symptoms can also occur in a range of other conditions but these tend to present less often in acute psychiatric wards.

Generally speaking there are two main groups of psychotic symptoms: hallucinations and thought disorders. We’ll consider each group separately but please bear in mind that there can be considerable ‘cross-over’ in the pattern of symptoms an individual displays and that people generally present with only some of them.

Hallucinations

This category of psychotic symptoms can be further divided into three sub-categories called modalities. These are:

Auditory

Visual

Kinesthetic (e.g. Olfactory, tactile)

Auditory hallucinations can take the form of voices or other sounds which may or may not be distressing to the patient. Sometimes these voices are incoherent but at other times they are very clear and can be amusing or offensive, demanding or controlling and may represent several individuals or only one. Their intensity, frequency and volume are also variable. These variations in content and presentation of auditory hallucinations are part of yet another sub-category known as sub-modalities.

As well as being distressing in their own right auditory hallucinations can dramatically affect behavior. For example the multiple murderer Peter Sutcliffe (The Yorkshire Ripper) killed several prostitutes because the voices told him to. In his case the voices were perceived as the word of God and so he believed that his crimes were Divine retribution. Sutcliffe actually believed he was the instrument of God’s wrath on earth and waged a holy war against immorality similar to the Old Testament God’s destruction of Sodom and Gomorrah.

Of course murders are no more common among psychotic people than among the general public so don’t worry. It is a useful way to illustrate the point though! In the majority of cases hallucinatory voices are directed against the sufferer themselves (if anyone) which is why schizophrenia sufferers for example are much more likely to harm themselves than anyone else.

Visual hallucinations are equally disturbing and can be extremely confusing both for the psychotic person and those around him/her. Although visual hallucinations can be quite pleasant they are often extremely distressing (demons etc.). It is not unknown for psychotic patients to physically injure themselves in their attempts to escape the hallucinations they believe to be chasing them. Interestingly visual hallucinations are commonly experienced in alcohol-related psychoses – often in the form of rats, snakes, insects or even tiny people.

Kinesthetic hallucinations are hallucinations of touch or physical experience. People may feel insects crawling over them or experience pain or indeed a range of physical symptoms. The sensation of crawling in particular is commonly associated with alcohol-related psychotic states. It is worth bearing in mind that kinesthetic hallucinations should not be confused with conversion hysteria, another form of psychosomatic disorder which is essentially based upon unexpressed anxiety.

Thought disorder

Thought disorder means non-hallucinatory psychotic symptoms which have to do with problems in interpretation as well as understanding. This is not an exhaustive list by any means. However, here are some of the more common symptoms:

Knights move thinking:

In the game of chess a knight moves one square forward and then one diagonal. It goes off course if you like. This is exactly what happens in knight’s move thinking. It is possible to follow an individual’s train of thought as there is a link of sorts – a progression of ideas. The problem is that the ideas are linked in ways which make very little overall sense to anyone but the sufferer. This is often a feature of psychosis related to mania or dementing disorders. It is often mistaken for ‘flight of ideas’ which is more a symptom of elation although strictly speaking it does come under the umbrella of psychotic symptoms.

Thought insertion:

This is the experience of one’s thoughts not being one’s own but that they have been ‘inserted’ into one’s head by a third party. People experiencing this symptom find it extremely difficult to organize or control their thoughts, partly because they see little point in trying to control the thoughts which actually belong to someone else. These ‘inserted’ thoughts are often demanding or controlling and can lead the sufferer to behave in ways they normally wouldn’t because they believe that they have no choice.

Thought broadcasting:

This is the opposite of thought insertion. Here sufferers believe that their thoughts are being broadcast to one or more others. This can be extremely distressing, particularly when the sufferer is thinking about past regrets or secrets. Even without such thoughts the lack of privacy they perceive is very difficult to come to terms with. Conversations become strained and often bewildering for others, especially if the sufferer believes they only have to ‘think’ their part of the interaction. A particularly interesting version of thought broadcasting, Gedenkenlautwerden, has sufferers believing their thoughts are openly ‘bouncing’ around the room for all to notice.

Ideas of reference:

Quite simply this means that sufferers believe innocuous things refer to them. For example the people on the television may be talking about or even to them personally. A bird settling in a tree or the fact that there were exactly three people on a passing bus may represent some incredibly complex fantasy which may be extremely threatening. Other people’s casual conversations take on a whole new significance and can be extremely frightening. This is one of the most common symptoms of paranoid schizophrenia although it can occur in other disorders too.

Nihilistic delusions:

Nihilistic is the root of the word ‘annihilate’ and means destruction or death. People experiencing Nihilistic delusions believe things like they are decomposing, their bodies don’t work, their internal organs are rotten or solidifying or even that they are actually dead. In a few rare but well documented cases these delusions have been associated with negative visual hallucinations in which sufferers have become so convinced that a part of their body is missing that they actually stop seeing it! There is, however a separate condition known as sensory inattention which is due to direct damage to the parietal lobe of the brain. It is important to recognize this distinction and it’s implications for treatment.

Derealization

As the name suggests derealization is the perception of unreality in which people experience either themselves or their environment as somehow apart from reality, understandably an extremely distressing predicament. Closely related is the symptom of depersonalization in which people perceive themselves as apart from their ‘true’ selves. There is, of course much more to psychosis than we’ve covered here. However, this information should provide a good basis for further study.

Compliments of Stuart Sorensen – RMN