What I Talk About When I Talk About Psychosis
Psychotic, not psycho.
Though I occasionally mention the looming role of psychosis in my life, only one friend has directly asked me what the term psychosis really means. To be psychotic, as stereotyped, conjures images of a screaming homeless man on the bus, threatening and out of control; people who end up slaughtering and maiming while claiming they were ordered to by the Lord; maybe it means, A Beautiful Mind-style, that one is lost in a world of his or her own, with imaginary friends that appear and stay, constant enough to be believed as real people.
Let me begin with a disclaimer: I am not a psychiatrist or a psychologist. I received a BA in Psychology at Stanford University and, before that, studied psychology for two years at Yale; was a research assistant and then manager in a mood disorder and brain imaging laboratory for two years, where I was stringently trained to and routinely conducted three-hourlong structured clinical interviews (SCIDs) and co-managed a bicoastal longitudinal study about bipolar disorder; I had also have been living with a diagnosis of bipolar disorder from 2001 onwards, although I didn’t begin to have psychotic symptoms until a few years later. My approach to the concept of “psychosis” is therefore both highly medicalized and highly personal to my current diagnosis of schizoaffective disorder (bipolar type), as well as being informed by conducting hundreds of clinical interviews in which I heard personal stories of people who allegedly all had the same basic disorders, but experienced them in a multitude of complicated and nuanced ways.
Psychosis, in its most bare-bones clinical definition, can be categorized as either hallucinatory or delusional (or both). Hallucinations are experiences of sensory input, which do not exist in the outside world, but appear as genuine and indistinguishable from the reality of non-psychotic sensory input to the person experiencing it. Examples include auditory hallucinations (e.g. hearing voices), visual hallucinations (e.g. seeing things that aren’t there), and even tasting and experiencing tactile sensations. Delusions, on the other hand, are false beliefs that remain despite evidence to the contrary (e.g. I am Jesus, I can control the weather, I have caused genocide in Africa). Psychosis associated with different diagnoses can look different — schizophrenia is different from bipolar disorder, and so on. But I will primarily be talking about psychosis as I have experienced it, and do experience it. I must also emphasize very, very strongly that my experience of psychosis is not universal to all individuals who experience psychosis. I am not speaking for anyone but myself. But I do hope that perhaps, in these inquiries and recollections, that I will bring clarity to those who know me, and even those who don’t.
Although I had been living with bipolar disorder for approximately three years, with two hospitalizations during that timespan, I didn’t experience my first hallucination until I was a senior in college. I was in the shower, in the dorm bathroom. The bathroom was empty. Out of nowhere, and very clearly, as if someone were standing to the right of me and speaking directly into my ear, I heard a voice say, “I hate you.”
Bewildered, I finished my shower. That was the beginning of my hallucinatory phase.
Even though the first sign of something changing in my brain was auditory, the hallucinatory phase of my life manifested itself through both visual and auditory abnormalities. Sometimes, the things I saw were very clear, and only suspicious to me because of how ridiculous they seemed. My best example of this would be the time I saw a slumped and rotting corpse in the driver’s seat of a parked car, complete with eye sockets that would have been empty except for the crawling maggots. Even though that particular hallucination was certainly gruesome, I was far more disturbed by the impaired reality testing that I found myself spontaneously reacting to — the B-movie zombie being something that I could impassively ignore, therefore letting me “pass” as normal, and the latter being something that made me look like a lunatic. I would, for example, be walking across campus, and every few steps a birdlike shadow would dart at my head, which would cause me to duck for apparently no reason, or a nonexistent hole would open up in front of me, which would cause me to jump to the side. I hated these occurrences because I knew exactly what I looked like to anyone who happened to be watching: a crazy person. Which I was. And, try as I might to control my reactions to these things, I couldn’t control them any more than I would have been able to control my body’s natural reaction to an actual abyss opening up in front of me.
Such were the symptoms that I knew I had to do something about — symptoms that I honestly could not distinguish from reality. One night, I very clearly heard the sound of a woman being attacked and screaming outside my window. I even heard her feet running away from the attacker. So I did what pretty much anyone would do: I called 911, even though my roommate at the time insisted that she had heard nothing. Campus police showed up at my dorm. They looked around. After an hour or so, they came back to tell me that they had found nothing, including other witnesses. The next night, I heard the same thing: it was a woman being attacked and screaming outside my window. Instead of calling the police, I called my mother. “Go to sleep,” she said, even though I had mostly kept my burgeoning symptoms a secret; this was reminiscent of the time when I was 17 and drove home in hysterics, waking my parents up to tell them I had killed my co-worker, only to have my mother say, with bizarre maternal wisdom, “It’s okay. Don’t worry about it.” Now my mother added, “Don’t call 911 again.” The third night, I heard the screams again. I heard them through my ears as clearly as I heard my professors’ lectures on Gogol or my alarm clock in the morning, and yet I forced myself to analyze the situation: the odds of someone actually being attacked outside of my window three nights in a row, with the campus police already aware of a 911 call made on the first night, was very unlikely. I didn’t bother calling anyone that time.
When I did begin to talk to my psychiatrist about these symptoms, we both had a shared concern in addition to the obvious ones: I wasn’t having manic or depressive episodes during these episodes of what I called “impaired reality testing.” It is common, in severe cases of depression or bipolar disorder, for psychosis to occur during mood episodes, usually in the “tone” of the particular episode (for example, it would have made sense, although an unpleasant sort of sense, for me to hallucinate a corpse had I been depressed). As far as I was concerned, my mood was perfectly fine — it was these hallucinations that were impairing my life. She ordered a full neurological workup, which included everything from an MRI to an EEG to vision exams. Eventually, the neurologist assigned to my case called me. “Everything checked out,” she said. “Your problem is most likely psychiatric, not neurological.” (The difference between the two boils down to the way we currently understand brain versus mind; however, I’m nowhere near qualified enough to speak directly to how these lines are drawn. I took her results to mean that I didn’t have a brain tumor, which was enough for me.)
My diagnosis, which lay somewhere between Bipolar I and Bipolar II at that time, was “upgraded” to Bipolar I. I began taking levels of antipsychotics more targeted toward psychotic symptoms than mood stabilization. For a few years, I became mostly free of hallucinations. Sometimes, I would get stressed — usually about work — and the symptoms would recur. Sometimes my commute to the office filled with auditory hallucinations, which I ignored, and then I’d contact my doctor and we’d adjust the medication until I stabilized and stayed that way, and then, because less medication is usually better than more medication, we’d go back down on the dosage until the next trigger occurred. Because a part of me is fundamentally lazy, and because increasing dosages of an antipsychotic often come with side effects, including rapid weight gain and fatigue, I eventually wondered if it was worth going through all of the rigamarole with contacting Dr. C, explaining my symptoms, and so on, when all I was experiencing was, say, a few days of a repeating loop of the same annoying music in my ear (imagine when you get a song stuck in your head; now imagine that you are actually hearing the song, as if someone has attached earbuds to you without your permission); I would ignore it, and it would go away. Through all of this, I remained high-functioning.
In 2008, without any apparent explanation, my symptom profile of psychosis switched from mostly hallucinatory to mostly delusional. After seven years of being together, my boyfriend was considering formally proposing to me, while I unexpectedly launched into approximately ten days of confusion.
The first time that I experienced the onset of a delusion was at work. It happened very quickly, and without warning — I looked up from my computer in the office at the two coworkers sharing the room with me, and was overwhelmed with a terrifying feeling that they had been replaced by foreign beings. The “reality” of those people was no longer a certainty for me. In fact, my next conclusion was that they were now robots who wanted to do me harm.
For the next week, this delusion continued. It spread beyond the two women in my office and expanded to strangers and loved ones. The delusion had its own logic, including the notion that eye contact was dangerous; if a stranger could look me in the eye, I would be destroyed. The nature of the destruction was not obvious to me. I started looking at the sidewalk, wearing sunglasses, and clothing myself in big hooded sweatshirts with the hood pulled down over my eyes. My fear blossomed.
This type of psychosis is similar to what is known as a Capgras delusion, in which a person believes that his or her loved ones have been replaced by doubles. It is the main delusion that comes in and out of my life. Sometimes it goes away in a few hours; other times, it takes as long as a week.
I’ve had other delusions. Once, I called my husband, sobbing about the spiders that had invaded and were eating my brain. This notion stayed with me for days. These beliefs are very hard to eliminate; in order to maintain a high-functioning exterior, it is important to not voice such fears, as all-consuming as they might be. I grit my teeth. I let them pass.
At the writing of this piece, Haldol is keeping my psychotic symptoms in check. My husband jokes that after trying all of the newfangled “atypical antipsychotics,” it’s only fitting that I, a devotee of vintage fashion, should therefore find solace in a vintage antipsychotic. One and a half pills of Haldol a night allow me to see the world as it really is; and yet I know that the psychosis could return at any time, ready to coax me into believing that my life is not what it seems.