Seeing spirits or psychosis?

One reader writes:

"As a therapist, how do you help someone distinguish between seeing "spirits" and psychosis? What are your thoughts on this?"

Of course, as a therapist I'd first want to know, Why do you ask?

But let's start with psychosis since I'm not as well-informed about spirits. We'll trust the American Psychiatric Association's Diagnostic Statistical Manual, the DSM IV-TR.

According to the DSM, the word psychotic historically has had many definitions, none of them universally accepted (figures). The most restrictive definition requires delusions or prominent hallucinations that the patient believes to be real.

Hallucinations are experienced as real events, things "sensed" by the body(visions, touches, words, smells,tastes) that are not sensed by anyone else. They can be perceived or sensed by any of the five senses.

Odd people on the street who are talking to themselves are probably talking to voices in their own heads, responding to auditory hallucinations. If the voices get threatening or command a person to violence they can trigger a homicide or more commonly, a suicide. Auditory hallucinations are signature symptoms of paranoid schizophrenia, never a funny illness.

Delusions are misinterpretations of experiences, erroneous beliefs. Persecutory delusions are most common. In these, people believe that they're being followed or spyed upon. (Having been identity thefted sometimes I really relate to this, but I wouldn't be considered psychotic).

Referential delusions are misperceptions that something or someone is trying to tell you something. So if you read an article in the newspaper and believe it had been put there for one reason only, to tell you something, then you have a referencial delusion. In the movie, A Beautiful Mind, John Nash (Russell Crowe) has ideas of reference every time he reads a magazine or a newspaper.

Less restrictive definitions of psychosis include delusions and hallucinations that you know are all in your head. But if you're going to say that you have them just before falling asleep, or upon waking, it doesn't count. Neither does hearing your name called occasionally when no one's around.

A definition of psychosis that is broader still, according to the DSM, is one that includes other symptoms such as grossly disorganized or catatonic (immobile) behavior. Some psychotic individuals have disorganized thinking. They can't keep to any one subject. They are thought disordered. A doctor would not use cognitive therapy approaches with such patients because their inability to "think straight" literally disables them. Making them think with a cognitive intervention would increase the patient's already very high anxiety, not lessen it.

A definition that is broader still is one that defines psychotic as a loss of ego boundaries. So if you think you're me, or vice versa, we both might think twice. On the other hand, if you took my identity, perhaps you are me.

Now, TO ANSWER THE SPIRITS QUESTION, or not. The DSM IV allows for hallucinations that are a normal part of religious experience in certain cultures.

The DSM continues (my commentary always parenthetical):

Illness is considered the body's response to distress, communicating a need for social support.

"Locura, " for example, is a term used by Latinos that refers to a severe form of chronic psychosis, including hallucinations. (Seeing SPIRITS might be an example, but the DSM doesn't specify).

"Zar" is a general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies. It refers to the experience of SPIRITS possessing an individual. Persons possessed by a spirit may experience shouting, laughing, hitting the head against a wall, singing, or weeping. They may withdraw, show apathy, refuse to eat and may develop a relationship with the possessing spirit. It's not considered pathological locally..

Zar is apparently about being possessed, not about seeing spirits. Unfortunately, nowhere does the DSM IV discuss seeing spirits, per se. The DSM, unless someone can tell me differently, does not include paranormal experience. Only empirically validated disorders make it in as diagnostic categories. If seeing spirits is a paranormal thing, and you have it, your insurance company won't pay to have you treated for it. I admittedly am no expert in this area.

Thinking with a culturally sensitive medical model, however, we might guess that some people want to see spirits so much that they convince themselves that they do.

Otherwise, this experience would be considered either a type of hysteria or a conversion disorder. In conversion disorders the body responds to stress by developing some rather bizarre symptoms. These could include visual hallucinations.

Asked to distinguish the difference between psychosis and seeing spirits, I'd ask culturally sensitive questions and go from there.

One thing's certain. Really seeing something that no one else agrees is visible can be a bad sign. At best, the person is very religious. At worst, he or she is severely distressed.

Copyright 2006, TherapyDoc