What Does "Psychotic" Really Mean?

People tend to throw around the term “psychotic” (and its more colloquial cousin “crazy”) to explain all sorts of behavior, usually incorrectly.

It’s one way to account for behavior that seems outlandish, over-the-top, or otherwise inexplicable. Murderers – particularly serial killers -- are often assumed to be psychotic. Sky-divers “must be crazy to jump out of a perfectly good airplane” (as my skydiver friend put it). Ex-wives are called “psychos” by their former spouses because of behavior that seems completely abhorrent.

And kids are sometimes assumed by their parents to be psychotic or “not in their right mind” because of the outlandish things (at least as defined by their parents) that they do.

The vast majority of the time, people use the term psychotic incorrectly. So, what does the term really mean?

Let’s start what psychosis doesn’t mean: it doesn’t mean wild, outlandish, or upsetting behavior. In fact, it’s got nothing to do with behavior at all. To be sure, behavior may be an indicator of psychosis, but the fact that someone is psychotic has nothing to do with the behavior itself.

To put it simply: It’s not what you do, it’s why you do it. Rather than referring to a state of behavior, psychosis refers to a state of mind. More specifically, it refers to a state of mind in which a person cannot accurately distinguish between what is real and what is not. There are really three types of ways this “impaired reality testing” (in psychiatrist jargon) manifests: hallucinations, delusions, or disorganized thinking.

Hallucinations are disturbances in sensory input. By far the most common type of hallucination in psychiatry is auditory, primarily hearing voices when no one else is around. Auditory hallucinations can come in different varieties, but they are rarely pleasant. Usually, they take the form of voices saying disparaging things about the individual (e.g. “You’re ugly,” or “You’re fat,” or “You’re worthless). There are also so-called “command hallucinations” that instruct the individual hurt or kill themselves, or more rarely others.

Visual hallucinations, on the other hand, are much more likely to be caused by a medical condition, such as infection, tumor, or substance abuse.

Delusions can be simply defined as “fixed false beliefs.” They are erroneous beliefs that don’t change, even in the face of overwhelming evidence to the contrary. A common delusion is paranoia, which is the belief that someone or some agency is spying on you, following you, playing tricks on you, or trying to kill you. There are all kinds of other delusions that include grandiose delusions (for example believing you are Jesus Christ sent down to save humanity), somatic delusions (for example believing that your organs are rotting from the inside out), and bizarre delusions (for example believing your mother has taken up residence in your left eyeball).

Delusions are called “fixed false beliefs” for a reason. Delusions can be extremely entrenched and do not change (at least without medication), no matter how much evidence is presented that the belief is incorrect. The delusional individual will simply come up with exceedingly complicated rationalizations explaining any discrepancy away from his or her belief. Often, the more intelligent the person is, the more elaborate the rationalizations. You simply can’t talk someone out of a delusion.

Disorganized thinking is a thought process that follows little or no logical sequence. The person’s thinking is impossible to understand for the outside observer. It is seen most often in severe mental illness (such as schizophrenia), which may manifest for example as a person’s speaking in “word salad,” or random strings of words that are complete gibberish.

Psychosis is about faulty thinking, which ultimately may manifest as unusual behavior. It’s important to remember, however, that it is only one cause of unusual behavior. Serial killers usually kill for “rational” reasons (e.g. they want to cash in someone’s insurance policy, or have a sexual drive that is deeply entwined with hurting or killing others). Skydivers feel the adrenaline rush is worth any risk to life and limb. The accusation that his ex-wife is a “psycho” may say more about the accuser than the accused. And the kid who is “acting crazy” may be doing what he is because he is on drugs, is being defiant, or simply is being a boneheaded teenager.

Much less likely, the serial killer may be hearing voices to kill others, the skydiver may think he is an angel who can fly, the ex-wife may think her former spouse is part of the CIA, and the teenager may be experiencing his first manic episode.

But the point is that psychosis is not about what you do, it’s why you do it.

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