In Wednesday’s post, “Childhood Trauma Linked to Psychosis: Maybe Not,” I introduced a few terms and concepts that many people seem to wrestle with. In this post, I try to clarify the terminology and explain some of the concepts related to psychosis, hallucinations, and delusions.

Psychosis

Psychosis is defined as an abnormality of thoughts (content) or thinking (process). Psychosis is not a diagnosis in itself but a type of psychiatric symptom that occurs in a variety of diagnoses, including schizophrenia and bipolar disorder.

Schizophrenia is primarily a disorder of thinking – psychotic symptoms are the main presenting symptoms. Depressive or manic episodes sometimes include psychotic symptoms, but not always. Certain drugs such as LSD, mushrooms, and other psychedelics can also cause psychotic symptoms.

Abnormalities in Thought Content

Psychotic thought content consists of thoughts not based in reality. The most common forms of are hallucinations and delusions.

Hallucinations

Hallucinations are disorders of perception distinguished by the different senses:

• Auditory hallucinations: Hearing voices or other sounds not heard by anyone else.
• Visual hallucinations: Seeing things that are not there.
• Olfactory hallucinations: Smelling things that no one else smells.
• Tactile hallucinations: Such as feeling bugs crawling on you that are not there.

People with auditory hallucinations do not usually have awareness that the thoughts are in their head, at least until after they have recovered and can begin to work on identifying the voices. Even then, if they enter another acute episode, they often don’t have insight into where the voices are coming from or that they are saying things that are false. If someone tells you that they hear voices – and they know the voices are not real – it is less clear cut whether or not to identify this as a true hallucination.

In psychiatric illnesses, such as schizophrenia, the hallucinations are almost always primarily auditory. Visual, olfactory, and tactile hallucinations are much more likely related to other brain impairments, such as drugs or drug overdose or severe medical illness that compromises thinking, including organ failures, sepsis (blood infection), or seizures.

Delusions

Delusions are ideas or thoughts about the world that are not based in reality. Delusions may be present in any of the following forms:

• Paranoid delusion: Thinking that people or other beings are trying to hurt you or that organized systems out in the world are focused on harming you. Paranoid delusions are the most common type.
• Delusions of reference: Believing that messages are directed at you personally when they are not; for example, believing the television is addressing you personally or that the professor in your class is telling you coded messages during their lectures that no one else can hear.
• Delusions about thinking: Thinking that people are reading your thoughts, inserting thoughts in your head, or controlling your thinking and behavior.
• Grandiose and religious delusions: Thinking that one has super or supernatural powers and/or control over others; thinking one is a famous religious figure or closely connected to deities or other religious phenomenon.

Abnormalities in Thought Process

Disorders of thought process are also common in psychosis and are sometimes easier than disorders of perception to observe from the outside. They include the following:

• Loose associations: Someone’s thoughts are only loosely connected to each other in the person’s conversation.
• Tangential thinking: Someone gets off track onto other topics and never gets back to the original point.
• Circumstantial thinking: A less severe form of tangential thinking in which someone goes all around topics, but they still get back to the original point.
• Thought blocking: Someone’s thoughts appear to just stop randomly.
• Flight of ideas: A highly pressured and extreme form of tangential thinking or sometimes loose associations common in mania.

Photo by Vern Southern, available under a Creative Commons attribution license.

Other types of hallucinations and delusions are present in psychosis, but those described here are some of the most common.

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    Last reviewed: 4 Feb 2011