As humans, we fear the unknown. Inaccurate media portrayals of mental illness can add to the confusion, blurring the reality of what many individuals suffer with. On its website, the National Institute of Mental Health states: “Three out of 100 people will experience psychosis at some time in their lives.” (1)  That’s a lot of people. And yet, there is still so much stigma surrounding what psychosis really is.

Are people experiencing psychosis dangerous?

With misconceptions that psycho, psychotic and psychopath are all different ways of saying the same thing, it can be easy to understand where the confusion comes from.

However, a psychopath is someone who lacks empathy (the ability to share and understand the emotions of another); they can be manipulative and exploitative. “‘Psycho’ is a slang term that derives from the Latin word psyche, meaning mind or soul, but gets tossed around loosely to label anyone who’s seen as ‘crazy’, despite being both insensitive and offensive to those with psychosis.” (2)

Though people with psychosis are often portrayed as violent, they are not any more violent than the rest of the population. In reference to delusional disorder, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5’ states: “Anger and violent behavior can occur with persecutory, jealous, and erotomanic types.” (3) However, a person experiencing psychosis is not inherently dangerous and is more likely to be victimised, is “more likely to harm themselves than others” (4) and “have a higher than average risk of self-harm and suicide.” (5)

As with those who do not suffer from any mental health disorders, there are other factors at play that help determine whether an individual is more likely to be violent or not. These include a history of childhood physical abuse, substance misuse, a history of prior violence, and even one’s environmental/socioeconomic factors can all help contribute to violent behaviour. (6) But that still doesn’t mean an individual will turn to violence.

So then, what is psychosis?

Psychosis is an altered state of reality, meaning that an individual with a psychotic disorder experiences reality very differently to the rest of the population. Psychotic symptoms can be disorienting, confusing, and frightening for the individual. Though some individuals may be aware that others do not share their beliefs, seeing them as unusual or irrational, they themselves do not accept this view. While they show factual insight, they lack any true insight into their condition. Others, however, are able to recognise that they are experiencing irrational beliefs.

There are different psychotic disorders, and they all, to varying degrees, share five key features:

  1. Delusions – strongly held beliefs that are not true. These will not change even when an individual is presented with conflicting evidence. They can take a number of forms, such as:
  • Persecutory – when the individual believes that they are going to be harmed, harassed etc. by an individual, group or organisation.
  • Referential – beliefs that perfectly ordinary occurrences are aimed specifically at the individual. These could be gestures, comments, a piece of dialogue in a TV programme, or a news bulletin.
  • Grandiose – involves believing that one has (often unrecognised) exceptional abilities, he or she is God, or they are on a special mission.
  • Jealous – when an individual believes a spouse or partner is being unfaithful.
  • Erotomanic – when an individual falsely believes that another individual is in love with him or her. It could be someone they know personally, a stranger or a celebrity.
  • Nihilistic – delusional beliefs of being dead, decomposed or annihilated, having lost one’s own internal organs or even not existing entirely as a human being.
  • Somatic – a preoccupation with health and organ function, often believing one’s bodily functions are abnormal.

It is important to take into account the different cultural/spiritual/religious beliefs when considering whether an individual is experiencing psychotic symptoms. A belief that God is speaking to an individual may be part of the shared beliefs of their religious community and not necessarily a symptom of a psychotic disorder.

  1. Hallucinations – involuntary perceptual disturbances, without external stimuli, which are vivid and clear as though they were normal. To be considered a psychotic symptom, the hallucination must not be in the context of falling asleep or waking up as these are perfectly normal experiences.
  • Auditory (sound) – these are usually voices, whether familiar or not, and appear distinct from one’s own thoughts. According to the ‘DSM-5’, they are the most common form of hallucination. (7)
  • Gustatory (taste)
  • Visual (sight)
  • Olfactory (smell)
  • Tactile (physical sensations)
  1. Disorganised thinking – evidence of which is usually picked up on through the individual’s speech. This involves switching between topics, answering questions with vaguely or completely unrelated subjects, and, though rarely, can also be in the form of incomprehensible speech that resembles a word salad.
  2. Abnormal behaviour – an individual experiencing psychosis may act in inappropriate ways to the situation they are in. They may become child-like, seem agitated and mumble. Taking care of personal hygiene and doing household chores may become challenging. Depending upon severity of symptoms, they may become catatonic which is a state of decreased responsiveness to their environment.
  3. Negative symptoms – involve a decrease in a person’s abilities. For example, a person’s ability to express their emotions, motivation to complete tasks, making eye contact etc. Some people may sit for long periods of time or lose interest in activities they once enjoyed.

Types of psychotic disorders:

  • Brief Psychotic Disorder

Symptoms last for more than one day for a maximum of one month.

  • Schizophreniform Disorder

Has a similar symptomatic presentation to schizophrenia but lasts for less than six months

  • Schizophrenia

Symptoms last for at least six months

  • Schizoaffective Disorder

Has mood symptoms that occur within the context of schizophrenia. For two weeks prior to or after the accompaniment of mood symptoms, the delusions or hallucinations occur without them being a prominent feature.

  • Delusional Disorder

Tends to occur with no hallucinations. If hallucinations are present, then they would tie in with the theme of the delusions, for example believing they are infested with a parasite and experiencing sensations of a parasite inside them.

Psychotic disorders can also be due to substance/medications, medical conditions or as part of another mental condition. Usually associated symptoms decrease when the substance/medication is removed, or the medical/mental condition has been resolved.

In summary

People experiencing psychosis are not ‘mad’, ‘crazy’, or killers. They are people who view the world differently to others, who have potentially frightening experiences, and respond to unwitnessed stimuli. They are people in need of compassion and understanding. People who need to feel heard and seen, not marginalised, and certainly not people to be feared.

Sources:

(1) https://www.nimh.nih.gov/health/topics/schizophrenia/raise/fact-sheet-first-episode-psychosis

(2) https://www.nami.org/Blogs/NAMI-Blog/October-2020/Why-Stereotypes-About-Psychosis-Are-Harmful

(3) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5, page 92, subheading ‘Associated Features Supporting Diagnosis’

(4) https://www.nhs.uk/mental-health/conditions/psychosis/symptoms/

(5) https://www.nhs.uk/mental-health/conditions/psychosis/overview/

(6) https://www.apa.org/monitor/2021/04/ce-mental-illness

(7) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5, page 87, subheading ‘Hallucinations’

Written by Hannah Telford, November 2021.

Approved by Adil Jawad, Consultant Psychiatrist, December 2021.