How to understand psychosis-we all can speak schizophrenageeze

The prejudice against people with mental illness is most apparent towards people who have had psychotic symptoms. These are the people most referred to as "crazy." We might not be so prejudiced when we realize that almost all of us have had psychotic symptoms but don't label them as such. Psychosis is defined as being out of touch with reality. In our DSM terms we think of hallucinations and delusions as the hallmark of psychosis. These might be visual or auditory images that others don't experience or misinterpretations of signals leading to mild paranoia or more elaborate schemes that require extensive stretches of the imagination connecting far away dots of information. How many of us have had these experiences while asleep and woken up not sure if things that occurred in the dream actually happened? What about religious experiences many refer to as feeling the presence of God? What about the belief in a all knowing omnipresent being who may decide the fate of mankind? People have fought wars over beliefs that their invisible "Being" wanted others to die or convert to believing in their version of this invisible deity. How many have felt that their boss, parent or friends were out to get them when the support for this belief was thin. How can two individuals on opposite sides of the political spectrum have vastly divergent interpretations of the same facts presented to them? Depending on how strongly felt these beliefs are it might be difficult to find the border between strongly held beliefs or intuitions and psychotic delusions.

We experience the world through our five senses of sight, sound, smell, touch and taste. We have receptors to pick up these senses that send nerve impulses to the brain where they are interpreted. The body also has sensors in our internal organs sending signals of pain and discomfort which might alert the brain to address a concern about breathing, digestion or other physical issues. We in addition have thought processes which we engage in for interpretation of social interactions, dietary needs and future planning. Our brains must be able to sort out all of this data and determine its sources or origins. It must determine whether the signals are coming from one of the five external sensing organs or are images from a sleep state or an awake but contemplative state. We interpret these signals using knowledge obtained from past experiences or early learning. But what if we encounter new novel signals that we can't interpret having never experienced them before? Individuals who have certain types of seizures or migraines might experience auras during which sensations occur without an external stimulus. People who have lost limbs have phantom limb pain. After some surgeries or injuries where nerves have been damaged may lead to similar phantom sensations.
What would happen if the brain got flooded with too many inputs and could no longer determine if the data was coming from outside or inside the body? Those inputs might be from both external clues and thoughts or worries. We would lose touch with reality. We might misinterpret a thought as an external voice. Or we might over interpret an observation such that it coincided with a thought or fear that we had. If we were concerned that people didn't like us and thought about the many reasons for this, we could interpret a nose rub by a coworker as a signal that we must be putting off an offensive odor. Or we might hear a boss speaking loudly on the telephone and think he is expressing discontent with your performance and discussing a plan to fire you.

Patients with psychosis usually report "racing thoughts." Many of us have had a similar experiences of being overwhelmed with too many things to do or problems that need to be processed and decided upon. Racing thoughts in psychosis are often so fast that the patient can't keep up with them let alone articulate them verbally to someone. They may be going so fast that the individual may not even be able to talk coherently. If the thoughts are so rapid only bits and pieces of them might be articulated giving the appearance of a "flight of ideas" or jumping from one topic to another without apparent connection between them. Sometimes the thoughts are going so fast that the patient can't speak at all and may only gesticulate or freeze. This used to be called "thought blocking" where the individual might stop in mid sentence and jump to another topic. The freezing up in extreme form can result in catatonia where the individual becomes mute and immobile. It was recognized many years ago that patients with catatonia who seem shut down and non verbal are racing inside. They race so fast that they can't communicate with the outside. It would be like trying to enter a revolving door that was moving too fast for us to enter. Many creative individuals have flurries of ideas. Society values individuals who make new connections leading to discoveries or new insightful ways of thinking. Where is the border between extreme creativity and psychotic thought process? Kay Jamison, a noted psychologist with bipolar disorder, wrote about this in her book, Touched by fire. She documents many of our brilliant creative people having mania but they usually are only able to be productive during relatively well periods between episodes.

Individuals with psychosis are trying to make sense of their misperceptions. They are making hypotheses for the unusual stimuli and impart special meaning where one doesn't exist. This leads to extreme vulnerability which requires some form of self protection. If you feel vulnerable you might project this fear onto others. If unconsciously you know that your work performance has been deteriorating due to your difficulty thinking you might project this fear onto your boss or co-workers and think they are out to get you. If you hear voices, maybe god or the devil or dead relatives might be trying to communicate with you. As your function deteriorates from your inability to sort thoughts from outside conversation, it wouldn't be unreasonable to think that these outsiders are trying to control you. If your thoughts are so loud you might think that others might be able to hear them. Schneider in 1959 wrote of schizophrenic first rank delusions of thought insertion, thought withdrawal, and belief that one's thoughts were being broadcast to the outside world.

When I was a resident on a research unit I had the rare opportunity to work with patients who came off all of their medications for up to several months while participating in double blind placebo controlled studies. One of my patients was a middle aged woman whose depression was not being adequately treated as an outpatient. She was an executive secretary for a medium sized company. Over the course of several weeks she developed a Capgras syndrome. This is a rarely seen syndrome where the patient believes that individuals have been replaced by imposters. She thought that her bosses had set up the unit to appear like a hospital but none of the people were really nurses, doctors or patients. I asked her what evidence she had for this. She noted that the nurses and doctors didn't wear uniforms and the patients didn't seem ill. She didn't see diplomas for the doctors either. I had her get up from her chair and look at my diplomas that were hanging on the wall behind her. She said, "maybe you are a doctor, but no one else is." I tried to have her tell me why her employer would go through so much effort and spend so much money on setting this up. She didn't know why but believed she was such a poor worker over the past year that they must have been upset and wanted to humiliate her. I informed my attending of her emerging psychosis so that the study would be terminated and she could be put on appropriate antipsychotic medication. The delusions cleared fairly quickly and it was apparent that her prior medication, while not completely effective, had given her some relief.

The longer the psychosis is allowed to persist the more likely these delusional beliefs are to become fixed into one's memory. I had a woman who thought that she controlled a major company by her thoughts. This went on for many years and she never told anyone as she thought everyone already knew. When I gave her medications these telepathic communications stopped. Then I asked her why they had stopped she said, "the medications stopped the communications." But she quickly added, "you don't believe that I did that?" Just because the medications stopped the acute misinterpretation of sensations doesn't mean the past memory of these beliefs would be changed. After all they have become memories and to change these memories would have been a blow to her self esteem and required her to think of herself as "crazy" rather than superbly helpful. Unfortunately, many prescribers misinterpret the persistent memory of delusional ideas with continuing psychosis and try to increase antipsychotic medication to the detriment of the patient. The clinician must ask "do you think these phenomenon are still occurring?" and not ask "do you still think that these phenomenon occurred?"

Over medicating a patient with psychosis results in worsening cognition and other serious side effects. These side effects often lead to non compliance with taking the medications, not realizing that many of the delusions have become memories and are tied to the person's sense of self and self esteem. Asking the patient to deny these beliefs could result in lack of acceptance of illness or even worse, severe depression with suicidal ideation. Compassionate psychotherapy is needed to help the patient introduce doubt of their past beliefs or at least not to carry them forward and use these beliefs to interpret current events so that they avoid making poor decisions in the future. This is no easy task. I will tell family members that trying to convince someone that they were delusional would be like trying to convince the Catholic Pope that Jesus was not the son of God. You wouldn't even think of doing this. Many patients feel that their psychotic experiences brought them closer to god. Why would you want to undo this?

Most grandiose delusions on the one hand make the patient feel special but on the other it causes an extreme burden. I had a patient who came to the "New Haven " (Connecticut that is) because god told him to run for president of the United States. I pointed out that he was only 33 and the Constitution stated that one needed to be at least age 35. He told me that they would make an exception. No logic was able to convince him that this was a delusional idea for which he needed treatment. But then I thought about what it might feel like to be asked by god to travel down to DC and overcome extreme obstacles in order to run for president. "Wow," I told him, "that must put a tremendous burden on you." He began to cry after I said that. Here was a manic patient, who is grandiose and supposed to be in a state of euphoria, crying. The psychoanalysts viewed mania as a defense against underlying depression. But I think I did something else. It was the first time I spoke schizophrenageeze to a psychotic patient.

When speaking schizophrenageeze you respond to the emotion or feeling that you would anticipate having if you were experiencing the activities presented in the delusion. For example, if the individual felt that the government had implanted electrodes in their brain and were listening to all their thoughts, I would want to also know if the government was also controlling him. This would lead to a discussion of how it felt to lose control of one's body and mind. You might feel angry and frightened. You want to know how to ignore what was happening to regain a sense of control. From there you find out if he was obligated to do something against his will and maybe encourage him to resist. Medications could be offered to help with the overwhelming anxiety associated with this loss of control. You could try to find out what things were going on in his life where he felt he was losing control. This might lead you to real things that were happening for which you could give appropriate advise.

A middle aged African American woman came to me upset because White men were following her everywhere. She didn't see them but they spoke to her. She couldn't take it and was refusing to take her medications since she saw the solution was to escape from these men. She decided to sell most of her possessions so she could buy a plane ticket to California to get as far away from them as possible. She returned several weeks later. She told me that the men had followed her to California and it took her several weeks to get enough money to pay for a bus ride back. I spoke to her about the fear she was experiencing and that medications could help her be less frightened. She agreed to take the medication. I never tried to convince her that the men in her head were not real as this would have ignored her reality. I used her logic that since the men would follow her wherever she went, it would be best to figure out how best to live with them. Medications would help her cope with this. Within a few weeks the "men" stopped talking to her but she had no explanation for this happening. I tried to reassure her that the medications would let her cope and may prevent their return. As she was improving she was able to articulate her fear of men in general and the fear she experienced when "white men" had taken her against her will to the hospital in the past.

There is usually a kernel of truth in every delusion. The individual has an exaggerated emotional response to this event which leads to an over interpretation of the event. As speculation occurs this leads to false beliefs in an attempt to explain the reason for the extreme emotional reaction. Anyone who has watched Fox News can see how they feed into people's fears and add to conspiracy theories. When four soldiers were killed in Benghazi Libya speculation flew as to inappropriate actions by the secretary of State, Hillary Clinton. Any tidbit of fact was twisted to fit into a conspiracy theory. Months of Congressional investigation found no conspiracy but by then Fox had made so many speculations and wove them into a seemingly coherent story that they had the force of delusions which became resistant to the facts. Many of their listeners became believers tainting her election.

It's fairly easy to see how a delusion can be formed by making distant connections based upon limited information in the context of highly charged emotions. Take someone's fear of harm, or unexplained depression or free floating anxiety and project the cause on outside forces. Introduce vaguely related details and connect dots that shouldn't be connected and you have the makings of a conspiracy. Have an individual whose thinking is impaired by overwhelming situational factors and the delusion becomes real. Think of all the parents afraid that their children may develop autism and introduce them to a discredited study linking autism to vaccines and you find delusions in individuals who do not have major psychotic disorder. You can't convince many of these parents that the study was flawed and retracted. Conspiracy theories protected them from hearing the truth by introducing the notion that you can't trust the establishment including physicians, pharmaceutical companies and especially government. The only counter is to acknowledge the fears and provide support for how to cope with them. There have been outbreaks of preventable diseases now due to lack of vaccination and this fear is more real. The parents were presumably vaccinated and survived. I have treated some of these individuals overwhelmed by one conspiracy theory or another and I often have to resort to low dose antipsychotic medication. This usually reduces the intensity of the fear and slows their thinking enough to suggest they don't need to worry about the conspiracy. The medication won't eliminate or change their mind, just like a delusion, but they can move forward without adding new irrelevant data points to reinforce the belief. Also the medication may not be needed for more than several months similar to treatment of a brief reactive psychosis. I "sell" the medication as a way of reducing their anxiety and "not to treat psychosis." I point out that the dose prescribed is lower than that used to treat psychosis and that low dose antipsychotic medications have be helpful to treat depressions with severe anxiety. Remember that the patients didn't present to me because of their delusional beliefs but because they felt anxious, depressed and overwhelmed by their fears which they feel are justified by their beliefs. They didn't want me to argue against their beliefs and if I do, I may become part of the conspiracy to cover up "the truth" that they know is real.

There needs to be a discussion of obsessions as distinct from delusions. Individuals suffering from obsessive compulsive disorder (OCD) don't speak schizophrenageeze. They are aware that their obsessions and compulsive rituals are irrational but feel too much anxiety to stop them. They haven't created elaborate conspiracy theories to justify their irrational behaviors and trying to give meaning to their actions only serves to give rationale to continue them. The person with OCD needs to just resist the compulsions and obsessions and learn to cope with the ensuing anxiety until it passes. The anxiety associated with delusions doesn't pass and logical reasoning often feeds in to paranoid ideation about the person trying to dissuade them. Telling the delusional person that their ideas are "crazy" only makes them distrust you because to them they are real. The feelings behind them are real and only compassionate acceptance of this fact will allow an outsider the ability to present more logical explanations to re-interpret the data upon which the delusions are built. The best that can be expected is to spread doubt on the delusional beliefs. There are no logical explanations for OCD as the individual already is aware that they are irrational.

Thought processing for these two conditions is also different. In psychosis thoughts jump from one loosely connected thought to another like a discordant symphony. Obsessive thinking is more like a broken record skipping in the same groove unable to advance to the next track. The delusions flow too freely sweeping up ideas and events along the way like a funnel cloud only to pile the debris in a totally distant spot. The obsessive never leaves the spot where he started. Jane was a 40 year old married woman whose OCD got out of hand. She began checking the door locks 10 times but this didn't satisfy her needs. It spread to the garage doors, then the car doors, the stove, the faucets and furnace. The rituals ended up taking several hours per day such that she couldn't leave the house. If she had to leave, she instructed her husband to assist in her rituals to try to shorten the time but each instruction led to more time. She knew these were irrational and had no explanation for the need to do them except that it felt bad if she didn't do them. But it also it took more and more time to reach satisfaction. She was given medication to reduce her anxiety and instruction to limit each ritual. Her husband was discouraged from participating and to remind her that performing the rituals only led to worse anxiety. Eventually she reduced her time in ritual to under an hour and was able to participate in activities outside of the home again.

John worked for an IT company and was sent to do repair work on various computer equipment. He noted that some of the repair work was unnecessary and thought the customers were scheming to get new equipment. He began to get concerned that the customers were setting him up and he would be accused of defrauding the company. However, his bosses seemed content with his work and he was providing good customer service. His fears got so great that he began to suspect other coworkers of setting him up so they could take his job. He then wondered if this wasn't a money laundering operation for his company and he was being drawn into an elaborate illegal operation. He got depressed and panicked and came to see me. I began him on antipsychotic medication and his fear began to diminish. I was able to provide alternative interpretations for the events he observed. This included the notion that the company was willing to accept some losses to encourage good customer relations which might lead to more business. His delusions had only been present for a short while so they were not so impervious to re-interpretation. He was able to accept that he might have over interpreted the situation. But residual doubt persisted such that he chose to leave this company and take a different job. My work with him validated his feelings that things were not being managed the way he thought they should be but I was also able to provide reassurance that he would not get blamed for this. This allowed enough time for him to find a more suitable job that didn't compromise his integrity.

Some of my patients often ask me how they can deal with a psychotic family member. I tell them that first they can't argue with them over any delusional ideas. Then provide empathic support for any feelings that might be associated with the delusions. Try not to be sucked into the delusional net by doubting its reality but this doesn't mean you have to go along with it either. Remain neutral and provide sympathy for their plight. While medication may make the individual less prone to add to the delusion going forward they may not accept that they were wrong in the past. Medications may take weeks to months to soften delusions. Leave the past in the past and don't challenge what the patient felt happened. They have no way of knowing what really happened since their perceptions were distorted. You can only talk of the present and that the delusional ideas are not still happening. Have sympathy for the anxiety, fear and humiliation of not knowing what really happen in the psychotic state. Challenging the beliefs and actions may lead to defensive maneuvers and hostility. Provide support for having survived and moved forward despite overwhelming feelings. Remind them of the relief of agitation and anxiety provided by the medications. And that is how one speaks schizophrenageeze.