How does someone know if they are in psychosis? As it turns out, this is precisely the correct question to ask. There is a simple and interesting answer to this question. But first, let’s begin with how NAMI (National Alliance On Mental Illness), an authority on mental illness, defines psychosis:
“Most people think of psychosis as a break with reality. In a way it is. Psychosis is characterized as disruptions to a person’s thoughts and perceptions that make it difficult for them to recognize what is real and what isn’t. These disruptions are often experienced as seeing, hearing and believing things that aren’t real or having strange, persistent thoughts, behaviors and emotions. While everyone’s experience is different, most people say psychosis is frightening and confusing.”
–nami.org, emphasis mine
Many people associate psychosis with its dramatic symptoms of hallucinations and bizarre beliefs. Disorganized thinking is another unmistakable sign of psychosis.
These are not wrong associations. However, the defining feature of psychosis is a lack of insight. In other words, a true psychosis is one where the person experiencing hallucinations or delusions believes these experiences to be real.
In the passage above, I emphasized the portion of NAMI’s definition wherein they capture that it is the believing of the hallucinations or delusions. The conviction and inflexibility around that belief is what distinguishes non-pathological disturbances in thinking from psychosis.
In fact, to get right down to it, delusions are the heart of psychosis. When hallucinations occur, they are only psychotic to the extent that the person experiencing them believes that they are real voices. What makes hallucinations psychotic is the inability to recognize that the voices the hallucinator hears are imagined. In other words, psychotic hallucinations are also delusions.
A psychotic person may have a vague sensation that something is “off” or that things are taking a dark turn when psychosis sets in. However, the defining feature of psychosis is that the experiencer does not know s/he is psychotic. The clinical phrasing of this is that the psychotic person “lacks insight.”
I’ll share one caveat to the way I’ve defined psychosis as delusions, hallucinations, and disorganized thinking with a lack of insight. A mentor of mine, David Shapiro, used to talk about the “double-bookkeeping” of psychosis. The term double-bookkeeping refers to the way a person can both know and not know something at the same time. The example Shapiro used to illustrate this point is the psychotic person on a psychiatric ward who has the unshakeable belief that he is Jesus, yet also stands in line to take his medication.
Consider a similar example:
A psychotic person shows up to the psychiatric ER. He is convinced that a chip has been implanted in his head by aliens. The patient becomes upset that the primary concern of the chip is not taken seriously by clinicians.
But why show up to a psychiatric ER? Why not seek out a brain surgeon?
This vague, dissociated, “knowing” that something is wrong is not sufficient to be meaningful insight into the condition. However, a faint awareness of the psychiatric nature of psychosis is somewhere on the mental books.
In their book Assessing Psychosis, the bible for understanding clinical presentations of psychosis, Khadivi and Kleiger describe how psychotic thinking really comes to the surface when a clinician probes the contradictions like the one above. Asking a patient to explain why he came to the psych ER when a surgeon would be required allows for a clinician to see the psychotic process in action.
One last implication of defining psychosis as a lack of insight, is that someone can experience hallucinations without being psychotic. Everyone has isolated experiences of delusions and hallucinations in their life. Though for most of us, these experiences are subtle, infrequent and safely contained.
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