This was intended to be the follow-up post to the paranoia post, in which I was going to dig into the different types of paranoia and ways it can manifest. However, I kept noticing that a lot of the research – like, almost all of it that I could find – was written about paranoia in the context of psychosis. And in trying to understand it, I noticed that my understanding of psychosis was pretty limited. As a result, I thought I’d write about it; partially to help me understand it, partially because it’s interesting, and partially because I honestly think this is necessary groundwork for the next paranoia post.
So, the question is, what is psychosis? What does it mean if someone is psychotic? Informally we often use the term “psychotic” to refer to someone who is violent or excessively aggressive, but that’s not the technical meaning of the term. Turns out, a rigorous definition of the term is difficult, but I generally think of it as a broad term referring to a state that includes a range of issues including (but not limited to) delusions, hallucinations, disorganised thought/behaviour, and flattened affect. That’s a lot of jargon, let’s quickly run through each of them, just so everyone’s on the same page.
(Just a quick note for all of these. In general, there’s an explicit requirement that to meet the criteria for a delusion/hallucination/whatever, the behaviour has to have a significant negative impact on the person’s functioning or happiness. The exact lines of this are complicated and subjective and philosophically questioned, but it’s worth bearing in mind while we run through these things.
Also, “psychotic” also refers to a personality dimension in a somewhat abandoned personality model. It’s almost entirely unrelated to what we’re talking about today, and you rarely hear it in that usage, but in case you go searching you might come across it.)
Delusions are often misunderstood, and are probably one of those things that exist along a gradient. Basically a delusion is a false belief that is held even in the fact of compelling evidence against it that is not consistent with an established cultural belief. So a person believing in a deity is not delusional, because that’s a legitimate cultural belief (that also probably doesn’t impact their functioning or happiness), but a person believing that the CIA is listening to their thoughts through their toaster, or that they are possessed of supernatural powers, or that their limbs are under outside control, probably is.
Hallucinations are what Hollywood has an annoying habit of calling delusions. Basically they’re false perceptions, experiences of sense-data that are not caused by external stimuli. While illusions (optical, auditory, whatever) are simply misinterpretations of external stimuli, hallucinations are just raw based-on-nothing. Me hearing someone talking to me when nobody is around is likely a hallucination, but hearing the descending Shepard tone isn’t. Interesting thing I learned: Wikipedia had a quote saying that chronoceptive (perceptions of time) hallucinations are a Thing, lifted from this chapter, but I can’t find any actual case studies of it. If you can, let me know in the comments or whatever, that’d be interesting.
Disorganised thought or behaviour is really hard to describe, but basically it’s just when people think or act in really weird ways. For example, it’s perfectly normal when eating to express happiness or disappointment or disgust or even anger in the right context. It’s not normal to put the food on one’s head and proclaim oneself the King of Spain. It’s perfectly normal to have a train of thought go something like “those shoes are purple, I like purple shoes, I like those shoes”. It’s not normal to think “those shoes are purple, Barney the Dinosaur is purple, therefore I’ll burn the shop down”. It’s tempting to describe this as irrational thought, but most human thought falls within what is generally called “bounded rationality”, as in “not perfectly rational, but not totally bizarre and random either” (usually). This refers to those thoughts or behaviours that are so drastically outside the bounds of what could even be thought of to make sense that we generally conclude there is no coherent organising principle behind them. “Those shoes are purple, I hate purple shoes, therefore I hate those shoes, therefore I hate this store, therefore I will burn the store down for selling them” has an underlying – if very disturbing – logic behind it, we can follow the reasoning. But the Barney thought train? Yeah, no clue.
Flattened affect is, comparatively, simpler to explain. Basically the person does not express emotion, or does so only in a very constrained and limited way – not necessarily because they don’t experience emotion (although that is definitely common), or because they’re just not a very emotional person, but in a way that is clearly outside the bounds of normality. It’s normal for me to not cry when I see a sad story on the news. It’s understandable – if I were stoic enough – to not cry at my mother’s funeral. It’s wildly not normal if I were not emotionally react if someone I cared about deeply was being viciously attacked in front of me. This is rarely obvious – think about your day to day experience with people; rarely do they express strong emotion, and if someone seems flat then we tend to assume they’re tired or maybe in a bad mood or just uninterested, or just not in a situation that causes a strong emotional reaction. This is a decent depiction of it, just to give you a taste.
Just a quick note, the first three – delusions, hallucinations and disorganised thought/behaviour – are all what is commonly referred to as “positive” symptoms of psychosis. Not called such because they’re good, they clearly aren’t, but because they represent something added to an otherwise normal functioning. We all believe things, but the psychotic person believes things in ways that are clearly different, and in a different way, to non-psychotic people. However, flattened affect is a “negative” symptom, because it represents something taken away – the person is no longer experiencing or expressing emotions in the way they normally would. Not important, just thought I’d mention it because a lot of my students in the past have gotten tripped up by that classification in the past.
Psychosis tends to manifest in a range of different disorders. Perhaps the best example of this is schizophrenia. The diagnostic criteria of schizophrenia basically reads like a textbook list of psychotic features, which makes sense – under DSM-IV schizophrenia was the flagship example of the “psychotic disorders” classification, and under DSM-5 that classification has been renamed “Schizophrenia spectrum and other psychotic disorders”. So in a very real sense, we define psychosis as “that thing that people with schizophrenia patients have”, which is totally philosophically fine and not at all circular we promise.
But you also see psychosis in other disorders. The first one that leaps to mind for me is bipolar disorder, especially (although not only) when the patient is manic. Delusions are very common, including delusions of reference (something irrelevant has some significance to you – an actor winking at the camera while on a talk show isn’t just a bit, they’re winking at you specifically) or grandiose delusions (e.g. that you have amazing supernatural powers, or that you are the ruler of a country when you definitely aren’t). Major depressive disorder can have psychotic features with it, around 15% or so of the time. Substance abuse and psychosis are deeply inter-related – many substances can create psychosis both while under the influence and through withdrawal; one of the most common kinds of hallucinations are the “bugs under the skin” sensation (a kind of tactile hallucination), and marijuana is well-known to create mild paranoia or even hallucinations. Caffeine has even been known to cause psychosis in high enough dosage.
So I’m sure you’re asking – but what does this have to do with privacy? Well, directly? Not much. Psychosis is pretty rare, all told – one study found a rate of around 0.3%, while another found between 0.3% and 1.2%. But it is important in my next post, where I talk about psychotic – and non-psychotic – paranoia.
However, it is important to bear in mind these things exist on a gradient. You might have thought while talking about disorganised thinking that “well, a lot of people think in ways that don’t make a whole lot of sense”, and yes, you’re right. Humans are not totally rational thinking machines, and drawing an exact line where normal human weirdness ends and clinically disordered thinking begins is difficult, and will almost certainly vary over time and situation and people. An artist can probably function a lot better in their job if their thinking is a bit more disordered than, say, a surgeon. And a lot of people have what can only be described as hallucinations all the time, and yet they’re totally functional. Hallucinations while grieving are also fairly common. And yes, for the atheists among you, there’s no clear dividing line between religious belief and a delusion beyond the functionality aspect and the (let’s be honest, kind of inelegant) “accepted cultural belief” exception.
But that doesn’t mean we can’t be aware of these problems. If we start accepting ideas to the point of resisting contrary evidence, then that limits our ability to accurately evaluate threats and adapt. If we don’t at least try to ground our reasoning in reasons, then we risk going off on totally irrelevant and not-helpful conclusions. And of course it’s important to acknowledge the role of emotion within the decision-making process.
Because while not all paranoia is psychotic, acting in a psychotic way is really