It is always a challenge to write characters with complex disorders like Psychosis. However, in this day in age, we have more information than ever before on mental illnesses and as a population, we are more educated on the complexities of disorders that were once stigmatized.

Writing characters with psychosis in a humane and accurate way is important so that those suffering from this disorder feel represented and seen.

So, what exactly is psychosis?

Psychosis is often a symptom of schizophrenia and bipolar disorder. It involves a loss of touch with reality that often comes in the form of hallucinations and delusions.

Writing Characters with Psyhcosis: The Main Symptoms

Hallucinations

Hallucinations can be a multi-sensory experience. They can be visual, auditory, or even related to smell. This aspect of hallucinations is part of what makes them feel so real to the person experiencing them.

It is most common for those suffering from psychosis to experience auditory hallucinations which involve hearing sounds that aren’t really present. These sounds are often times voices of either real or imagined people. However, this is not always the case. Sometimes, the auditory hallucinations can come in the form of nonhuman sounds (ex: hearing animals, hearing footsteps, etc.) or even music.

Delusions

Delusions, on the other hand, affect a person’s thinking pattern. Delusions involve having false beliefs or unfounded fears that can affect the person’s behavior. There are many types of delusions that one can experience (ex: The person may believe that they have cancer or another type of life-threatening illness) but the most common ones are beliefs of persecution and delusions of grandeur.

Delusions of persecution involve believing that something or someone is going to harm you. Characters suffering from these types of delusions grow increasingly suspicious of others around them and may experience a fear that seems irrational to others.

A character experiencing delusions of grandeur will often believe that they are special or “chosen” in some way.

Other symptoms

Other than hallucinations and delusions, there are a number of other symptoms that plague characters with psychosis. These include disordered thinking, Catatonia, and some involuntary psychomotor behavior.

Disordered Thinking

Disordered thinking is when someone’s thought patterns become interrupted or disorganized. Disordered thinking not only affects how someone thinks but also how someone speaks or how they function. There are many ways disordered thinking can manifest. Here are a couple of examples:

• Some people that experience this symptom have difficulty finishing their thoughts because they get distracted and start talking about something completely different.

• Others are unable to complete a thought process because they go around in circles trying to explain their point but have difficulty actually getting to their point. Someone with this type of disordered thinking (which is referred to as Circumstantial Thinking) will often incorporate a lot of unnecessary details because they have difficulty filtering out the main points of their story.

• Another type of disordered thinking is called Tangential Thinking. A person affected by this will jump from one thought process to another without ever reaching an end point. Although their thought processes are connected to each other, it is in a very superficial way and makes it seem like they are rambling. For example: I went to the shoe store and got new shoes. I saw a lady there that reminded me of my mother. My mother cooked for me yesterday afternoon actually. It was chicken pot pie. You know, my ex used to love chicken pot pie.

• In some severe cases, the individual’s thoughts make no sense. It may seem as though they are using words without any concept of their meaning, and it is often difficult to interpret what they are saying. For example: I went to the lake to get vegetables and there were no cows there.

Catatonia

When a person experiences Catatonia, their ability to move is affected. This means that the pathway connecting the mind to the movement of the body is hindered. Catatonia is most commonly experienced as a state of “Stupor” where the person is unable to move or speak and doesn’t react to their environment. Some people may also experience hyperkinetic catatonia which is when the person’s movement seems agitated and faster than usual. Catatonia episodes may last hours, weeks, or even months long.

Involuntary Psychomotor behavior

Involuntary psychomotor behavior is when a person moves certain parts of their bodies without necessarily meaning to. These movements serve no purpose. For example, a person could randomly raise their arm above their head in the middle of a conversation.

Other examples of this symptom include tapping your fingers nervously on a table, fidgeting, or just pacing around an apartment endlessly. Characters with psychosis may also randomly move objects from one place to another and dress and undress multiple times.

These involuntary movements are thought to be caused by a feeling of agitation, restlessness, or anxiety. These movements are often repetitive and seem to be the body’s way of relieving tension and anxiety.

Although most of these psychomotor behaviors aren’t alarming or dangerous, in some severe cases, these behaviors may escalate to involuntary self-injury. A couple of examples include:

• Hard lip biting that leads to bleeding
• Ripping the skin inside your cheeks with your teeth

What are the early signs of Psychosis in a character?

When writing of a character with psychosis, it is important to note that there are several ways that the disorder may manifest. Psychosis may be mild or severe but usually, the first few times a character experiences psychosis, the symptoms are milder, and they progress over time.

Early symptoms may include the following:

• Anxiety
• Difficulty concentrating/low attention span
• Feelings of depression
• Insomnia or Hypersomnia
• Low energy
• Difficulty thinking/talking
• Increased suspicion of others
• Weird thoughts/ideas or behaviours

The main types of psychosis a Character can Experience

Psychosis from Schizoaffective disorder: Schizoaffective disorder is a mental health disorder that includes many symptoms of schizophrenia and symptoms of depression. Someone affected by this disorder will experience psychotic episodes in the form of hallucinations and delusions.

Brief psychotic disorder: Brief psychotic disorder can happen as a result of an extremely traumatizing or stressful life event. This type of psychosis typically occurs suddenly and lasts only about a month.

Psychosis from Bipolar Disorder: Bipolar characters can also experience psychosis as a part of their disorder, especially during their manic episodes.

Depressive Psychosis: In the case of extreme depression, psychotic episodes may ensue. These types of psychotic episodes can be very dangerous because the person experiencing them might want to hurt themselves or others.

Substance-induced psychosis: Psychosis may ensue as a result of certain drugs (whether they be recreational or prescribed) or from excess alcohol consumption.

How long do psychotic episodes last?

Psychotic episodes can last from a couple of weeks to a month or even multiple months depending on the cause of the psychosis and the type of disorder affecting the character experiencing these episodes.

For example, if someone is experiencing substance-induced psychosis, the episode will typically only last until the substance is out of the person’s system (although, the psychosis can sometimes persevere even after the drugs/alcohol has waned).

On the other hand, someone experiencing brief psychotic disorder will typically have episodes that last a month or less whereas someone with schizophrenia may have episodes that can last up to six months. With bipolar disorder, psychotic symptoms will usually last up to two weeks (the usual duration of a manic episode).

There are three main stages that characterize psychotic episodes:

Prodrome stage: During this stage, your character may exhibit multiple behavioral changes that indicate the beginning of a psychotic episode. Symptoms may include difficulty concentrating, insomnia or other sleep problems, seclusion and feeling overwhelmed.

Acute Stage: In the acute stage, hallucinations and delusions appear. This stage represents the height of a psychotic episode and can be extremely overwhelming and confusing for the character. The symptoms may affect your character’s ability to function normally or do everyday tasks.

Recovery Stage: In the recovery stage, the symptoms are starting to reduce, and the person slowly goes back to a normal state.

Diagnosing a character with psychosis

If you are to write about psychosis, knowing how it is diagnosed and the steps that are usually taken can be essential to your story. It is important to note that psychosis is a serious disorder and anyone who experiences the symptoms is usually immediately seen by a medical professional.

The age of onset of psychosis seems to be between the late teens and Early Adulthood. The first psychotic episode is usually experienced between the ages of 15 and 25. When the first symptoms start to appear (the social withdrawal, the false beliefs, and disorganized thinking), the entourage of the person is usually frightened by the sudden change in behavior of the person. As the psychotic episode progresses, it is usually friends or family members that admit the person into the hospital or call 911.

This is when a medical professional will examine the patient. The doctor will usually start by asking a few questions in order to rule out other possibilities. They may ask if the person has a history of drug use and about the types of symptoms the patient is experiencing. They may also ask whether the patient has family members that have mental disorders.

The doctor may also check for a head injury, a tumor in the brain or record the person’s brain activity using an electroencephalogram to check for abnormalities. The patient may also be subjected to a urine or a blood test to check for any abnormal substances.

After all other options are ruled out, the doctor will then check for a psychiatric disorder by using the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a guide.

The underlying causes of psychosis

Currently, it is not clear why psychosis develops in certain individuals. There are a number of theories possible theories that are being explored.

The main possible causes of psychoses include:

Genes: Some research has demonstrated that genes may play a role as to why some individuals develop this disorder. Other highly heritable disorders such as schizophrenia and bipolar disorder may be caused by the same genetic components as psychosis.

Changes in Brain Chemicals: Studies have found that there are differences in the brain chemicals of those who suffer from psychosis. Dopamine, which is a ‘pleasure’ neurotransmitter, may be at fault. A disruption of the amount of dopamine in the synapses of neurons may be what is causing some of the psychotic symptoms.

Other Possible causes

• Dementia
• Neurological conditions
• Infections that reach the brain (ex: HIV)
• Epilepsy
• Strokes
• Brain tumors
• Multiple sclerosis
• Excessive stress

How your character can seek treatment

The main way that psychosis is treated is through antipsychotic drugs. If taken regularly, these drugs will drastically reduce the symptoms the person experiences but if they stop taking them, usually the symptoms will return. These drugs are not a “cure” for the disorder, but they can help manage it and make life a little easier for a character with psychosis.

There are two main types of antipsychotic drugs:

• Typical antipsychotics (first generation drugs)
• Atypical antipsychotics (second generation drugs)

Both types of drugs work great to reduce psychotic symptoms. However, they do differ in how they work inside the body. The typical antipsychotics work to block dopamine receptors in the brain while the atypical antipsychotics affect both dopamine and serotonin levels.

When prescribing an antipsychotic to a patient it is normal and expected that certain types of drugs will work for some people and won’t for others. So, your character may have to try multiple types of antipsychotics before finding one that works for them.

Examples of atypical antipsychotic drugs

• Risperidone
• Clozapine
• Olanzapine
• Ziprasidone
• Paliperidone

Possible Side effects of atypical psychotic drugs

• Dizziness
• Blurred Vision
• Dry month
• Weight gain
• Agitation  
• Stiffness
• Tremors
• Low energy
• Decreased sex drive

Note: Seizures may also be a side effect, but this rarely happens.

Examples of typical psychotic drugs

• Flupenthixol  
• Aluphenazine
• Haloperidol
• Loxapine
• Perphenazine
• Pimozide
• Trifluoperazine

Side effects of typical psychotic drugs

• Drowsiness
• Constipation
• Blurry vision
• Stiff muscles/ Involuntary muscle movements
• Weight Gain
• Dry Mouth
• Dizziness

Note that both typical antipsychotics and atypical psychotics may cause a woman to miss her periods.

Tips for writing characters with psychosis

The experience of psychosis is different for every individual

Psychosis is a very complex disorder that can be manifested in so many different ways. There is no one size fits all description for any mental disorder. Hence, when writing characters that have psychosis, make sure that you avoid being too generic or vague about their hallucinations, delusions, or general symptoms. Avoid basing your representation of the disorder on a general trope. Usually, a person’s psychotic symptoms have some basis in their reality and will make sense with their personality.

For example, if you’re writing about a character that is obsessed with making sure that everything is clean and organized then you could include this aspect of their personality in their psychotic symptoms.

What I’m basically trying to say is that you should personalize the symptoms of your character rather than taking vague tropes and running with them.

Writing Psychotic Villains

It is common in the literary world to write villains that have mental disorders. However, when taking this route, there is a very fine line between negatively misrepresenting mental disorders in order to make your villain more interesting and using mental illness in a productive way and doesn’t villainize the disorder itself.

Most people who are affected by psychosis don’t want to hurt anyone. It is important to understand that when a person is undergoing a psychotic episode, they sometimes really believe their hallucinations are real. If they happen to cause harm during one of these episodes, they probably didn’t mean to.

When associating villains and evil with this disorder, things can get complicated because it may seem as though the psychosis is the source of the evil (which causes a warped representation of the real people that have psychosis).

Hence, if you do decide to write psychotic villains, make sure you avoid making this mistake. Psychosis does not cause people to become evil so either your character was evil before they started having psychotic episodes, or perhaps they became a villain due to an external traumatic event that had nothing to do with the disorder.

It is possible to write about a character that hurts others or themselves during their psychotic episodes (this can happen in real life, especially during depressive psychotic episodes) but keep in mind that the characters in this situation are victims of their own disorder and should not be portrayed as villains.

Make sure you properly convey the complexity of this mental disorder

Psychosis is more than just hallucinations. There is a multitude of symptoms that comes with the diagnosis of psychosis. When writing about this disorder, avoid oversimplifying to one or two symptoms simply because those symptoms serve your plot whilst the others don’t.