That Guy's Nuts!

What does it mean to be psychotic?

Psychosis describes a loss of contact with reality. Thoughts and perceptions are disturbed to the degree that the psychotic person cannot distinguish between what is real and what isn’t.

About 100,000 new cases of psychosis are reported each year in the U.S. It’s not hard to recognize psychosis – the psychotic person is crazy.

Psychosis is associated with hallucinations and delusions.

Hallucinations are common – seeing things that aren’t there (visual hallucinations), hearing sounds or voices that don’t exist (auditory hallucinations), or feeling things crawling on their skin when nothing is there (tactile hallucinations).

Delusions are also common. Psychotic people believe things about themselves that are not true, like being convinced the CIA is implanting thoughts in their brains, or that they are really Napoleon. Delusions are either grandiose (I’m Napoleon) or paranoid (everybody’s plotting against me). In either case, the universe revolves around the deluded person. You must be pretty important if everyone is out to get you. Delusions tend to be culture specific. A Jew might think he’s Moses; a Christian thinks he’s Jesus.

In addition to mental illnesses like schizophrenia, paranoia/delusional disorder, and bipolar disorder, psychosis can be caused by dementia, substance abuse, alcohol intoxication, hallucinogens, urinary tract infections, brain injuries, brain tumors, or other physical problems. That’s why a competent team of physicians is needed to make a diagnosis.

Schizophrenia causes hallucinations and delusions. Paranoia/delusional disorder and bipolar disorder are characterized by delusions.

In the manic phase, it’s common for people with bipolar disorder to feel invincible, to have an inflated opinion of their own abilities. They are deluded into believing they are on top of the world. In the depressive stage, the world feels like it is on top of them.

I knew a psychiatric inpatient who never had any hallucinations, but was deeply convinced that he was a brilliant political leader on the order of Winston Churchill, destined to save humankind through his diplomatic skill. He was diagnosed with paranoia/delusional disorder.

There are various kinds of schizophrenia. All of them include hallucinations and delusions.

Paranoid schizophrenia is the most common type. Most often, it develops in a person’s early 20s. It is the most dangerous form of psychosis. About 10% of all homicides, and fully a third of all mass killings are committed by people with paranoid schizophrenia. Think Charles Manson, Son of Sam, and Ted Bundy. But, of course, most people with paranoid schizophrenia are not dangerous at all. As the name implies, these people are highly paranoid, suspicious, and distrustful. They hear voices telling them what to do, and they feel like everyone is out to get them. I knew a paranoid schizophrenic who thought he was a cookie and angrily accused me of stealing his fingers. I calmly told him I didn’t have his fingers.

Hebephrenic, or disorganized schizophrenia, usually develops in the teen years. It is characterized by disorganized speech, behaviors, and thoughts. This person makes no sense when they talk and usually presents with a flat affect – their facial expressions and voice tones show no emotions no matter what they are talking about. A hebephrenic schizophrenic was walking towards me in the hall, and said, “the flowers are superior turtles the nonjudgmental starlight barking cats.” That’s called a word salad.

Catatonic schizophrenia is rarest schizophrenia diagnosis, characterized by strange postures and movements. A catatonic person may, for example stand with arms outstretched for days. Attendants could bend one guy I knew into any position and he’d simply stay there. They would fold him out of bed and into his clothes, stand him up, then gently push him from behind to get him to shuffle down the hallway. They could fold him into a car and take him for drives in the country. He had not spoken in 20 years. Catatonic people may either remain silent or mimic others.

People with cenesthopathic schizophrenia experience unusual bodily sensations, like cold running through the body, feeling like part of the body is detached, like their brain is melting, or that part of them is literally hollow.

Residual schizophrenia is a diagnosis given to those with a history of psychosis, but who now only experience symptoms like slow movement, poor memory, lack of concentration, or poor hygiene, but no longer have hallucinations or delusions.

Unspecified schizophrenia is a waste basket diagnosis for someone with general schizophrenia symptoms who doesn’t fit into any of the other categories. Back in the day, many patients in state hospitals were diagnosed “SCUT” – schizophrenia, chronic undifferentiated type, which, as one psychiatrist told me, “Means you’re crazy and we don’t know what’s wrong with you.”

You cannot reason with a psychotic person. They cannot simply snap out of it or choose to change their thoughts. Their illness is caused by a chemical imbalance in their brains. It’s not their fault, not a moral failure, not something they can control. It’s best to approach them very calmly and gently.

Psychotic people need a team of physicians to rule out differential diagnoses, a psychiatrist to prescribe and manage anti-psychotic medication, and intensive individual and group therapy. During psychotic breaks, those with schizophrenia, paranoia/delusional disorder, or bipolar disorder (as well as those who are psychotic for other reasons) need to be hospitalized for their own safety (as well as that of others). Most of the time, patients are hospitalized only as long as it takes to get their medication stabilized.

It is essential that anyone with any psychotic disorder be on medication and stay on medication. Unfortunately, many of the medications have unpleasant side-effects, so people stop taking them. They also often feel they don’t need the medicine any longer because they are living normal lives free of symptoms. As soon as they go off the meds, however, the psychotic hallucinations and/or delusions roar back.

One evening in the psych hospital, a man was admitted who was totally crazy. He was disheveled, speaking nonsense, ducking because he saw things flying at his head, and hearing voices. His eyes were glaring and darting. The next day, I was greeted by a well-groomed man in a suit and tie. He approached me with hand extended to shake mine and said, “I’m sorry for any problems I caused last night when I was crazy. I was off my meds. Now, I’m back on. Thank you for your patience.”

It used to be fairly easy to have someone committed involuntarily to a mental hospital, and conditions in some state institutions were deplorable. (“One Flew Over the Coocoo’s Nest)” Law suits were filed and laws changed making it very difficult to treat a psychotic person unless they want to be treated. As a result, many wind up homeless on the streets. Although a significant percentage of homeless people are either mentally ill or addicted to substances, many are not – they’re simply down on their luck, so don’t make assumptions based on appearances.

Every human being is created in God’s image and uniquely loved by God. None are less. All deserve to be treated with dignity, respect, and compassion. As a psychology professor of mine used to say, “The mentally ill person is like us, only more so.”

As followers of Jesus, let us advocate for affordable housing, healthy food, and to make medical and psychological care available to all. May God help us to see all others as beloved of God – people for whom Christ died. As Mother Theresa said, these people are Jesus in distressing disguise. Jesus called them the least of his siblings, and told us to love and care for them.