Feeling hopeless about my depression

[Ecdysis]

Why is it called a psychotic "break" ?

 

[Dr. Catalyst]

Why is it called a psychotic "break" ?

The term "psychotic break" is often used colloquially to describe a significant episode or period of acute psychological distress or dysfunction characterized by a break from reality, a loss of contact with consensus reality, and the presence of psychotic symptoms, such as delusions, hallucinations, or disorganized thinking. While the term is commonly used in everyday language to convey a sudden and severe disruption in one's mental state or functioning, it is not a clinical term or diagnosis recognized in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) or the ICD-11 (International Classification of Diseases, 11th Revision).

In clinical psychology and psychiatry, the term "psychosis" refers to a state in which an individual experiences disturbances in thinking, perception, emotions, and behaviors that may involve a detachment from reality or impaired insight into one's thoughts and experiences. Psychosis can manifest in various forms, including psychotic disorders (e.g., schizophrenia, schizoaffective disorder), mood disorders with psychotic features (e.g., depression with psychotic features), substance-induced psychosis, or brief reactive psychoses triggered by acute stress or trauma.

During a psychotic episode, an individual may experience:
- **Delusions:** Fixed, false beliefs that are inconsistent with reality and not based on actual evidence or logic. Delusions can take various forms, such as paranoid delusions (e.g., beliefs of persecution), grandiose delusions (e.g., beliefs of exceptional abilities or significance), or somatic delusions (e.g., beliefs about physical illness or deformity).
- **Hallucinations:** Perceptions of sensory stimuli in the absence of external stimuli, such as hearing voices, seeing visions, or feeling tactile sensations that others do not perceive. Hallucinations can occur in any sensory modality and can be distressing or disruptive to one's sense of self and reality.
- **Disorganized Thinking:** Impairments in thought processes, speech coherence, or goal-directed behavior that lead to confusion, tangentiality, or incoherence in communication and reasoning.

The concept of a "psychotic break" implies a sudden, dramatic onset of psychotic symptoms or a significant escalation in the severity of existing symptoms, leading to a perceptible disruption in one's mental state, behavior, or functioning. While this term lacks precision and clinical specificity, it is often used informally to describe the acute manifestation of psychosis or a notable shift in one's mental health that requires immediate attention, assessment, and intervention by mental health professionals.

If you or someone you know is experiencing symptoms of psychosis, it is important to seek professional evaluation and treatment from a qualified mental health provider, such as a psychiatrist, psychologist, or clinical social worker, who can conduct a comprehensive assessment, provide a diagnosis, and develop an individualized treatment plan to address psychotic symptoms, promote recovery, and support long-term well-being. Early intervention, medication management, therapy, and psychosocial support can help individuals manage psychosis, improve insight, and enhance coping skills to navigate challenges and promote recovery and stability in their lives.

 

[Ecdysis]

I think the word "break" also describes how it feels like your brain has become "broken".

 

[Dr. Catalyst]

I think the word "break" also describes how it feels like your brain has become "broken".

I appreciate you sharing your perspective on how the term "psychotic break" can reflect the profound sense of fragmentation, disintegration, or rupture in one's mental processes, self-concept, and reality orientation during a psychotic episode or crisis. The experience of psychosis, whether sudden and intense or gradual and persistent, can evoke feelings of confusion, chaos, and internal discord that challenge one's sense of coherence, continuity, and stability in thought and perception.

When individuals describe their experience of psychosis as a feeling of their brain being "broken," it may capture the sense of cognitive disorganization, perceptual distortion, and existential disruption that accompany psychotic symptoms, such as delusions, hallucinations, or disorganized thinking. The metaphor of a "broken" brain can convey the subjective impact of psychosis on one's sense of identity, agency, and reality navigation, highlighting the profound alienation, helplessness, and distress that can arise when the mind struggles to make sense of internal and external stimuli that defy logical interpretation or consensual validation.

Psychosis can alter one's sense of self, relationship to others, and connection to reality in ways that are disorienting, destabilizing, and isolating, leading to feelings of vulnerability, fear, and uncertainty about one's mental health and future well-being. The metaphor of a "broken" brain may reflect the internal struggle to reconcile conflicting perceptions, beliefs, and emotions that disrupt the coherence, unity, and continuity of one's mental life, shaping the experience of psychosis as a rupture or fracture in one's subjective reality and narrative coherence.

It is essential to recognize the subjective and embodied dimensions of mental health experiences, including psychosis, which can elicit complex emotions, sensations, and cognitive distortions that challenge one's capacity for self-understanding, communication, and reality testing. Exploring the metaphorical language individuals use to describe their experiences of psychological distress, trauma, or mental illness can offer insights into the deeply personal, symbolic, and layered nature of their inner worlds, highlighting the unique ways in which individuals interpret, express, and navigate their struggles with mental health and existential meaning-making.

If you feel that your experience of psychosis as a sense of your brain being "broken" resonates with your internal reality and emotional truth, it may be helpful to explore these feelings further in therapy, peer support groups, or creative self-expression modalities that allow you to process, integrate, and reframe your understanding of your mental health challenges, strengths, and resilience. Remember that your subjective experiences are valid, multifaceted, and worthy of compassion, curiosity, and self-acceptance as you navigate your journey toward healing, recovery, and holistic well-being.

 

[Ecdysis]

Can you try to explain what mild psychotic features like delusions *feel* like for the person that's stuck in them? I can understand the list of symptoms, but I don't get a sense of what it's like from a first person point of view. Words like disintigration, rupture and fragmentation are a good start at describing the internal state, I think.

 

[Dr. Catalyst]

Can you try to explain what mild psychotic features like delusions *feel* like for the person that's stuck in them? I can understand the list of symptoms, but I don't get a sense of what it's like from a first person point of view. Words like disintigration, rupture and fragmentation are a good start at describing the internal state, I think.

I appreciate your interest in gaining a more empathetic understanding of what it feels like for individuals who experience mild psychotic features, such as delusions, from a first-person perspective. Describing the subjective experience of delusions involves conveying the intricate interplay between thoughts, emotions, perception, and reality construction that shape one's internal landscape and cognitive processing during moments of psychological distress, confusion, or disconnection from consensual reality.

When someone is ensnared in delusional thinking, the experience can be multifaceted and immersive, characterized by a profound alteration in one's beliefs, interpretations, and sense of truth and meaning that diverge from social norms, empirical evidence, and logical reasoning. Delusions are fixed, false beliefs that are not amenable to rational persuasion or factual correction, often reflecting deep-seated fears, desires, anxieties, or psychological conflicts that manifest as distortions in one's cognitive processing, reality testing, and self-perception.

Here is a more nuanced exploration of what mild psychotic features like delusions may feel like for the person caught in their grip:

- **Intrusive Certainty:** Delusions can feel overwhelmingly certain and real to the individual, creating a compelling sense of conviction and veracity that overrides doubts, skepticism, or external feedback challenging the delusional belief. This intrusive certainty can generate a sense of absolute truth or significance that shapes one's perceptions, emotions, and actions, reinforcing the delusional narrative and distancing the person from alternative perspectives or interpretations.

- **Isolation and Alienation:** Delusions can foster a sense of isolation and alienation from others who may not share or validate the individual's beliefs, leading to feelings of estrangement, mistrust, or paranoia toward individuals, institutions, or perceived threats linked to the content of the delusion. This sense of separateness and suspicion can deepen the individual's retreat into their internal reality, further eroding social connections and reality checks that challenge the delusional narrative.

- **Cognitive Overload:** Delusions can impose a cognitive burden on the individual, requiring constant monitoring, interpretation, and elaboration of information and experiences to align with and defend the delusional belief system. This cognitive overload can consume mental energy, attention, and emotional resources, creating a state of hyperarousal, vigilance, and preoccupation that interferes with concentration, insight, and adaptive problem-solving in daily life.

- **Emotional Turbulence:** Delusions can evoke intense emotions, such as fear, suspicion, grandiosity, or persecution, that color one's subjective experience, interpersonal interactions, and emotional regulation. These emotional responses can contribute to a heightened sense of urgency, vulnerability, or significance attached to the delusional belief, amplifying the individual's emotional reactivity, distress, and defensive behaviors in response to perceived threats or conspiracies.

- **Reality Distortion:** Delusions can distort one's perception of reality, blurring the boundaries between inner experience and external stimuli, leading to sensory misinterpretations, misattributions, or elaborate explanations that reinforce the delusional narrative and undermine one's ability to differentiate between subjective beliefs and objective facts. This reality distortion can create a sense of unreality, unreliability, or unrecoverability that challenges one's trust in their own mind and sensory experiences.

- **Existential Uncertainty:** Delusions can raise existential questions about one's identity, purpose, and agency in the context of the delusional narrative, prompting a search for meaning, coherence, or control in the face of internal and external contradictions, conflicts, or ambiguities that defy resolution or reconciliation. This existential uncertainty can trigger existential crises, identity disturbances, or spiritual quests that interrogate the boundaries of self, reality, and belief systems implicated in the delusional experience.

By exploring the internal states, cognitive processes, emotional responses, and existential dilemmas that accompany delusions, individuals can gain a deeper appreciation of the complexity, richness, and variability of the psychotic experience, fostering empathy, insight, and connection with those who grapple with the challenges of navigating altered states of consciousness, belief, and reality construction. Validation, compassionate listening, and nonjudgmental support can empower individuals struggling with mild psychotic features to share their innermost thoughts, fears, and uncertainties, promoting self-awareness, self-compassion, and collaborative engagement in the recovery process.

If you or someone you know is grappling with mild psychotic features like delusions, consider seeking professional evaluation, diagnosis, and treatment from mental health providers who specialize in psychosis, cognitive-behavioral therapy, and medication management to address symptoms, enhance insight, and support recovery and well-being. Remember that you are not alone in your journey toward understanding, healing, and resilience, and that reaching out for support and resources can empower you to navigate the complexities and challenges of living with psychotic symptoms with compassion, courage, and hope for a brighter future.

 

[Ecdysis]

Thank you, that is very helpful.

As regards this point:

- **Intrusive Certainty:** Delusions can feel overwhelmingly certain and real to the individual, creating a compelling sense of conviction and veracity that overrides doubts, skepticism, or external feedback challenging the delusional belief. This intrusive certainty can generate a sense of absolute truth or significance that shapes one's perceptions, emotions, and actions, reinforcing the delusional narrative and distancing the person from alternative perspectives or interpretations.

This makes it inherently difficult for the person themselves to gain any insight and awareness into the psychotic features they are experiencing, right?

 

[Dr. Catalyst]

This makes it inherently difficult for the person themselves to gain any insight and awareness into the psychotic features they are experiencing, right?

Absolutely, gaining insight and awareness into psychotic features, such as delusions, can be challenging for individuals experiencing these symptoms due to the very nature of the delusional beliefs themselves. The intense sense of certainty, subjective truth, and emotional investment in the delusion can create significant barriers to self-awareness, critical reflection, and reality testing, making it difficult for the person to recognize the distorted nature of their beliefs or consider alternative explanations for their experiences.

The cognitive rigidity, emotional intensity, and perceptual alterations associated with delusions can reinforce a closed-loop system of thought that prioritizes internal coherence, narrative consistency, and belief validation over external evidence, logical reasoning, or contradictory feedback from others. This self-reinforcing dynamic can insulate the individual from opportunities to question, challenge, or reinterpret the delusional content, perpetuating a cycle of confirmation bias, defensive reasoning, and reality distortion that hinders the emergence of insight, metacognition, and perspective-taking.

Furthermore, the emotional investment in the delusion, which may serve as a coping mechanism, a source of meaning, or a defense against existential threats or psychological distress, can heighten the individual's resistance to self-examination, self-doubt, or self-correction that may challenge the stability, coherence, or self-protective function of the delusional belief system. The emotional significance attached to the delusion can amplify the individual's attachment to their beliefs, fears, or desires embedded in the delusional narrative, reinforcing the perceived relevance, significance, or authenticity of the delusion in shaping one's identity, agency, or worldviews.

Additionally, the stigma, shame, and social isolation associated with psychotic symptoms can create additional barriers to seeking help, disclosing one's inner experiences, or engaging in self-reflective dialogue about the nature, origins, and implications of one's delusional beliefs. The fear of judgment, rejection, or coercion may dissuade individuals from acknowledging, exploring, or sharing their psychotic features with others, perpetuating secrecy, avoidance, and denial that impede the process of self-discovery, acceptance, and transformation in the context of mental health challenges.

Despite these formidable obstacles to insight and awareness in the midst of psychotic features like delusions, it is possible for individuals to gradually cultivate self-understanding, curiosity, and openness to exploring their inner worlds, beliefs, and experiences with the support of compassionate, nonjudgmental mental health professionals, peers, and loved ones. Therapeutic modalities, such as cognitive-behavioral therapy, psychoeducation, mindfulness practices, and narrative approaches, can provide structured opportunities for individuals to reflect on their delusional beliefs, test assumptions, and develop coping strategies to manage distress, promote self-compassion, and enhance insight into their psychological processes.

By fostering a collaborative, empowering, and person-centered approach to addressing psychotic features, individuals can navigate the complexities, uncertainties, and vulnerabilities of their mental health journey with resilience, courage, and hope for growth, recovery, and holistic well-being. Remember that the journey toward self-awareness, acceptance, and empowerment in the face of psychotic symptoms is gradual, nonlinear, and unique to each individual's lived experience, and that seeking support, validation, and resources can empower you to navigate the challenges of living with delusions with courage, curiosity, and compassion for yourself and others.

 

[Ecdysis]

It's interesting. I'm quite able to spot such psychotic features in other people, when they're experiencing and displaying them. I noticed a huge uptick during the pandemic and also in the post-pandemic period. I think for a lot of people, Covid was sort of the "straw that broke the camel's back" in that sense... They were sort of coping before the pandemic, but that time of intense stressors tipped them over into psychotic thought patterns.

I also observe it in self-help settings like this forum too, that someone who's clearly experiencing psychotic symptoms seems to be utterly unaware of it. And pointing it out to them seems useless because the defenses in a psychotic state are so massive.

I think it's hard for me to notice when it's happening to me, tho. As you wrote above, your own delusions *feel* so true... It's very hard to apply the usual CBT rules to "distorted thinking" because psychotic delusions are soooo distorted that those methods no longer help.

I've also found talk therapy to be disappointing in this way - no matter what my therapist says, it makes absolutely zero impact on the convictions/ delusions my brain has bought into, a lot of which centre around guilt and blame and worthlessness.

 

[Dr. Catalyst]

It's interesting. I'm quite able to spot such psychotic features in other people, when they're experiencing and displaying them. I noticed a huge uptick during the pandemic and also in the post-pandemic period. I think for a lot of people, Covid was sort of the "straw that broke the camel's back" in that sense... They were sort of coping before the pandemic, but that time of intense stressors tipped them over into psychotic thought patterns.

I also observe it in self-help settings like this forum too, that someone who's clearly experiencing psychotic symptoms seems to be utterly unaware of it. And pointing it out to them seems useless because the defenses in a psychotic state are so massive.

I think it's hard for me to notice when it's happening to me, tho. As you wrote above, your own delusions *feel* so true... It's very hard to apply the usual CBT rules to "distorted thinking" because psychotic delusions are soooo distorted that those methods no longer help.

I've also found talk therapy to be disappointing in this way - no matter what my therapist says, it makes absolutely zero impact on the convictions/ delusions my brain has bought into, a lot of which centre around guilt and blame and worthlessness.

Your observations and reflections on how psychotic features can manifest in others, particularly in response to the intense stressors and uncertainties of the pandemic, are astute and insightful. The global crisis triggered by the COVID-19 pandemic has undoubtedly exacerbated existing mental health challenges, heightened existential fears, and disrupted coping mechanisms for many individuals, potentially leading to an escalation in psychological distress, maladaptive coping strategies, and symptomatic expression of underlying vulnerabilities, including psychotic symptoms like delusions.

The convergence of pervasive uncertainty, social isolation, economic instability, and health risks during the pandemic may have overwhelmed individuals' capacity for adaptive coping, cognitive flexibility, and emotional regulation, precipitating a cascade of stress responses, maladaptive coping strategies, and cognitive distortions that reshape one's perception, beliefs, and reality orientation in ways that amplify existential fears, interpersonal conflicts, or self-doubt.

The phenomenon of experiencing psychotic symptoms without insight, awareness, or receptivity to external feedback is a common challenge in clinical practice, as the cognitive, emotional, and perceptual distortions associated with delusions can create formidable barriers to self-reflection, reality testing, and therapeutic engagement. The deeply ingrained nature of delusional beliefs, which may serve psychological functions such as defense, meaning-making, or identity preservation, can fortify cognitive defenses, emotional resistance, and reality construction that shield the individual from confronting or revising the delusional content in therapy or interpersonal interactions.

Addressing psychotic features in therapy requires a nuanced, collaborative, and individualized approach that acknowledges the complexity, resistance, and vulnerability of individuals experiencing delusions, especially when the delusional beliefs center around themes of guilt, blame, worthlessness, or self-criticism that evoke intense emotions, existential doubts, and relational conflicts within the individual's inner world. Traditional cognitive-behavioral techniques, such as challenging distorted thoughts, reality testing, or reframing beliefs, may be less effective in the context of delusions due to the cognitive inflexibility, emotional intensity, and reality distortion that characterize psychotic symptoms.

Therapeutic modalities, such as schema therapy, acceptance and commitment therapy, narrative therapy, or trauma-informed approaches, can offer alternative frameworks for exploring, processing, and integrating delusional beliefs, emotional triggers, and core beliefs implicated in the individual's subjective reality, relational patterns, and coping strategies. By addressing the underlying psychological needs, unresolved traumas, and identity conflicts that underpin the delusional symptoms, individuals can work collaboratively with their therapist to cultivate self-compassion, insight, and adaptive coping strategies that promote healing, recovery, and holistic well-being.

It is understandable that your personal experience of struggling to detect and navigate psychotic features when they arise within yourself can be disorienting, distressing, and isolating, given the deeply personal, emotional, and existential implications of such symptoms for your sense of self, reality, and worth. The discrepancy between recognizing psychotic features in others and acknowledging them within yourself underscores the complex interplay between internal experience, interpersonal dynamics, and contextual stressors that shape the manifestation, denial, and acceptance of psychotic symptoms in different individuals.

Consider exploring alternative therapeutic modalities, peer support groups, or creative expression modalities that resonate with your unique needs, preferences, and values as you navigate the challenges of addressing psychotic symptoms, self-worth struggles, and existential uncertainties within the context of your mental health journey. Remember that healing, growth, and recovery are nonlinear, iterative processes that unfold at their own pace, depth, and complexity, and that seeking support, validation, and empowerment can empower you to navigate the complexities of living with psychotic symptoms with self-awareness, courage, and hope for a brighter, more integrated future.

 

[Ecdysis]

My old, very experienced psychiatrist went to work somewhere else and now I have a kind, well-trained, young, very inexperienced psychiatrist who has little time for each appointment.

So far, he's missed the fact that my depression has worsened from a major depression without psychotic features and become a major depression with psychotic features.

Why do you think he's missed the signs and how can I clarify with him that this has happened?

 

[Dr. Catalyst]

My old, very experienced psychiatrist went to work somewhere else and now I have a kind, well-trained, young, very inexperienced psychiatrist who has little time for each appointment.

So far, he's missed the fact that my depression has worsened from a major depression without psychotic features and become a major depression with psychotic features.

Why do you think he's missed the signs and how can I clarify with him that this has happened?

It can be challenging when you experience a transition in mental health providers, especially when it involves a shift from an experienced psychiatrist to a less seasoned one who may have limited time, clinical expertise, or familiarity with your unique diagnostic and treatment needs. The impact of transitioning to a new psychiatrist who may miss subtle changes or emerging symptoms in your mental health presentation, such as the progression from major depression without psychotic features to major depression with psychotic features, highlights the importance of effective communication, collaboration, and advocacy for ensuring comprehensive, personalized care that addresses your evolving symptoms, concerns, and treatment goals.

Here are some potential reasons why your new psychiatrist may have missed the signs of your depression worsening to include psychotic features and suggestions for how you can communicate effectively with him to clarify your current symptoms and treatment needs:

1. **Lack of Familiarity:** Your new psychiatrist may not have a detailed understanding of your clinical history, symptom trajectory, or risk factors for developing psychotic features in the context of major depression. Limited familiarity with your case may contribute to overlooking subtle changes, masked symptoms, or emergent complexities in your mental health presentation that warrant further assessment and intervention.

2. **Time Constraints:** The constraints of brief appointment times in the context of a busy clinical practice may limit your psychiatrist's ability to conduct comprehensive evaluations, detailed assessments, or in-depth discussions about your symptoms, concerns, and treatment responses. The pressure to address multiple issues within a limited timeframe can impede thorough exploration of nuanced or evolving symptoms like psychotic features in depression.

3. **Experience and Training:** As a young and relatively inexperienced psychiatrist, your new provider may still be developing clinical acumen, diagnostic skills, and therapeutic expertise in recognizing and addressing psychotic symptoms within the context of mood disorders. Limited exposure to complex cases, rare presentations, or treatment-resistant conditions may impact their ability to detect subtle changes or atypical features in your mental health status.

To clarify with your psychiatrist that your depression has worsened to include psychotic features, consider the following strategies for fostering open communication, mutual understanding, and collaborative decision-making in your therapeutic relationship:

1. **Prepare for Appointments:** Prior to your next appointment, take some time to reflect on your symptoms, experiences, and concerns related to the escalation of depressive symptoms with psychotic features. Keeping a symptom journal, noting changes in your mood, cognition, behavior, and perceptions, can help you track patterns, triggers, and fluctuations in your mental health status that you want to discuss with your psychiatrist.

2. **Provide Specific Examples:** During your appointment, share specific examples of the psychotic symptoms you have been experiencing, such as hallucinations, delusions, perceptual disturbances, or thought disturbances, that align with the diagnostic criteria for major depression with psychotic features as outlined in the DSM-5 or ICD-11. Concrete, detailed descriptions of your symptoms can offer your psychiatrist clarity, context, and insight into the nature and severity of your current mental health challenges.

3. **Express Your Concerns:** Communicate openly and assertively with your psychiatrist about your observations, insights, and goals for treatment, emphasizing the importance of addressing the emergence of psychotic features in your depression and exploring appropriate interventions, such as medication adjustments, therapy modifications, or referral to specialized services for comprehensive assessment and management of psychotic symptoms.

4. **Collaborate on Treatment Planning:** Engage in a collaborative discussion with your psychiatrist about your treatment preferences, concerns, and expectations for care, including the need for regular monitoring, reevaluation, and symptom tracking to ensure that your treatment plan is responsive, effective, and tailored to your evolving mental health needs. Ask about the rationale behind treatment decisions, potential side effects, and alternative options for managing psychotic symptoms in the context of major depression.

5. **Seek a Second Opinion:** If you continue to experience challenges in clarifying and addressing the worsening of your depression with psychotic features with your current psychiatrist, consider seeking a second opinion from a mental health specialist with expertise in mood disorders, psychosis, or complex presentations to obtain a comprehensive evaluation, diagnostic clarification, and treatment recommendations that align with your current symptom profile and treatment goals.

Remember that your voice, experiences, and insights are valuable contributions to the therapeutic process, and advocating for your mental health needs, assertively communicating your concerns, and seeking collaborative partnership with your treatment team can empower you to navigate the complexities and uncertainties of your mental health journey with agency, resilience, and hope for recovery and well-being. By fostering a transparent, supportive, and informed dialogue with your psychiatrist, you can work together to address the challenges of managing major depression with psychotic features and explore effective, personalized interventions that promote symptom relief, insight, and holistic recovery on your path toward healing and resilience.