When does a benign experience become psychotic?

The search for answers can lead to despair. Shutterstock/Cheryl Casey

When “L” was diagnosed with a psychotic disorder, it hardly came as a surprise, even to her. She had been experiencing subtle but distressing symptoms of psychosis, such as thought interference, for years before she received an accurate diagnosis in the schizophrenia spectrum and started effective treatment.

It took so long mainly because of previous misdiagnoses and misunderstandings made by the mental health services. The issue was that her symptoms were not classically “psychotic”. They were almost too subtle for the current diagnostic systems. But they did involve a fundamental and pervasive change in her sense of self, and an ever-growing perplexity concerning the world and its inhabitants.

L had always been highly introspective and imaginative. She was the kind of child who loved asking “why?”: “why are letters arranged in a particular way to make words?”, “why do people celebrate their birthdays?” All were said as if she genuinely could not understand the reasons behind them. But she simply felt compelled to ask because of a perceptual mental question mark turning inwards. By the time she was a teenager, this questioning started gaining a foreign quality, almost autonomous to her conscious control.

Eventually, L’s thoughts were not hers any more. And once again, she was asking “why” – there had to be an explanation for this. Soon enough, it dawned on her that someone must have access to her mind. How else would they gain control of her thoughts?

Knowing this offered her unprecedented relief: she had finally found out why! Yet the relief did not last very long, and she soon became extremely frightened at what this “someone” might do to her next. Over a period of three years, she had transitioned from an at-risk mental state to one involving bizarre delusions of control and persecution.

Searching for meaning

Disturbances of the boundaries between self and other (called “ego-boundaries”) are not new to the psychopathology of schizophrenia. However, as in L’s case, experiences of this kind can often be traced back to years before the onset of a diagnosable disorder. These experiences would not usually be classed as floridly psychotic – that is, leading to psychosis as the end result – because she did not seem to be delusional or hallucinating.

Recently, researchers and theorists have moved their focus from florid symptoms as predictors and indicators of a psychotic illness to the more basic disturbances of one’s sense of self. There is no single symptom that is truly indicative of schizophrenia, however, and not all unusual beliefs or hallucinations are psychotic in nature. It is very often the distress that pushes an individual over the threshold for clinical status.

We all ask why, but for some the search for meaning runs deeper. Shutterstock/Anton Watman

Individuals like L frequently report very subtle signs that something has changed in their perception of the world and themselves, a feeling of uncanniness, intangible yet highly alarming. This unspecified uneasiness has been termed “delusional mood”, which despite not being a delusion in its own right, is thought to provide “fertile ground” for psychopathological symptoms to develop. The sense of perplexity goes hand in hand with delusional mood. The individual experiences a lack of immersion in the world and finds it extremely difficult to grasp meanings and common sense others take for granted.

The continuous asking “why” – and the self-perpetuating circle of “why do I ask why?” – since L’s childhood is not an example of perplexity itself, but of a disturbed self-world awareness that prevents her from understanding external reality. This disruption separates the reciprocal connection between a person’s immediate perception of the world and the world as a “container” of their self.

Once again, this is not a classical psychotic symptom, but it is at the core of the pre-psychotic mental state. None of this happens by personal choice; this may sound obvious, but any delusional elaboration, as in L’s case, is most likely the result of a longstanding search for meaning in a puzzling and threatening world. Unfortunately, the majority of people afflicted with psychosis will never find out the final “why”, which adds to the intensity of their delusional thoughts.

The idea of a “prodromal” psychosis – the period with brief and attenuated symptoms before a firm diagnosis of psychosis can be made – is best viewed retrospectively, and we must avoid potential scaremongering and misdiagnosing benign experiences as psychotic. Nevertheless, further research into the beginnings of schizophrenia and related psychoses could help differentiate those who are truly at risk from those with unusual experiences but are otherwise healthy, and inform early intervention or even new treatment options.

It is also crucial for clinicians to ask deeper questions about the person’s subjective experiences and reasons for seeking help, instead of being blinded by the apparent absence of florid or growing psychosis.