October brings Mental Illness Awareness Week, and I want to use it for the diagnosis people are most afraid to say out loud. No word in mental health carries more dread than psychosis; the popular imagination has filled it with violence, hopelessness, and otherness, three ideas that are each, as it happens, wrong. And because the word is so feared, the experiences it names go unmentioned; by the person having them, who senses exactly how they would sound, and by the family watching changes they cannot name. As with so much in this field, the silence does more damage than the symptom.
A Continuum, Not a Cliff
The first correction is the most surprising one: psychotic experience is not a separate country inhabited by other people. Large reviews of the general population find that psychotic experiences, hearing a voice, sensing a presence, holding a conviction others find baffling, occur in roughly five to eight percent of people, the great majority of whom never develop a psychotic disorder (van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009). The recently bereaved often hear the voice of the person they lost, and half-waking hallucinations at the edge of sleep are ordinary neurology. Psychosis, in other words, sits at the far end of a continuum that begins well inside common human experience. A disorder exists when such experiences become persistent, distressing, and entangled with a person’s functioning; but the capacity for them is simply human. This matters because the cliff-edge picture, sane on one side, mad on the other, is precisely what makes people hide their experiences rather than mention them to anyone who could help.
The Myths That Do the Damage
Three beliefs deserve direct correction.
The first is dangerousness. Decades of research are consistent: people with psychotic disorders are far more likely to be victims of violence than perpetrators of it. The frightening stranger of the evening news is a media artifact, and it is the single biggest reason families wait so long to seek help; nobody wants their child associated with that image.
The second is hopelessness: the belief that a psychotic disorder, schizophrenia especially, is a one-way deterioration. This was once clinical orthodoxy, and it is not what the evidence shows. The expected course is not relentless decline; most people improve or stabilize with treatment, many achieve lasting remission, and the old picture of schizophrenia as a progressively degenerating brain disease has been directly challenged in the modern literature (Zipursky, Reilly, & Murray, 2013). Recovery does not always mean the absence of every symptom. It means symptoms that quiet or lose their grip, work and relationships that resume, a life that is recognizably one’s own. That kind of recovery is common, and it is built, not wished for.
The third myth is that the person is gone; that psychosis replaces someone. Families often describe it exactly this way, and the grief in the description is real and deserves respect. But the person is not gone. They are in there, having experiences that are more frightening to them than to anyone watching, and they can tell, with painful accuracy, who still talks to them like a person.
Symptoms That Mean Something
Here is where a psychoanalytic sensibility has something particular to offer, because the prevailing approach treats psychotic symptoms purely as noise to be suppressed. Medication is often genuinely essential; I want to be unambiguous about that, and I work collaboratively with prescribing psychiatrists rather than around them. But a voice that is cruel in a specific register, a delusion with a specific architecture of persecution or grandeur or guilt; these contents are rarely random. They tend to carry the person’s actual fears, losses, and conflicts, translated into an extreme dialect, and a treatment that only silences them leaves their meaning unheard. In my work with psychotic disorders I take the experiences seriously as experiences: not agreeing with a delusion, not arguing with it either, but being curious about what it holds. People who have lived through psychosis often say that being asked what their experiences meant, rather than only how loud they were, was the beginning of trusting treatment at all.
Why Early Matters
There is one finding in this literature that families in particular should know: the longer psychosis goes untreated, the harder the recovery tends to be. Duration of untreated psychosis is one of the more consistent predictors of outcome (Marshall et al., 2005), which turns the natural instinct to wait and see into a quiet risk. The early signs are usually not dramatic; a gradual withdrawal, sleep coming apart, a slipping at school or work, perceptions turning strange at the edges, a new sense that ordinary events carry personal meaning. None of these, alone, is psychosis; most young people with any one of them are simply going through something. But the cluster, sustained and worsening, deserves a professional look rather than a year of hoping. And the look should be a careful one: mood disorders, trauma, and dissociation can each produce experiences that resemble psychosis, and distinguishing among them changes everything about treatment. Where the picture is unclear, psychological testing can do exactly this kind of untangling.
The Person Is Still There
If someone you love is changing in ways that frighten you, or if you have had experiences you have been afraid to name to anyone, the message of this awareness week is the same one I have written before about BPD and depression: this is more understandable than you fear and more treatable than you have been told. You can read about my approach to psychotic disorders, including how I work alongside psychiatric care, or schedule a consultation. And if any of this has tipped into crisis, the 988 Suicide & Crisis Lifeline is available by call or text, at any hour.
References
Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., & Croudace, T. (2005). Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: A systematic review. Archives of General Psychiatry, 62(9), 975-983.
van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P., & Krabbendam, L. (2009). A systematic review and meta-analysis of the psychosis continuum: Evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine, 39(2), 179-195.
Zipursky, R. B., Reilly, T. J., & Murray, R. M. (2013). The myth of schizophrenia as a progressive brain disease. Schizophrenia Bulletin, 39(6), 1363-1372.