Writing Schizophrenia and Psychosis: Hallucinations and Delusions
[Plain text: Writing Schizophrenia and Psychosis: Hallucinations and Delusions]
So you've read our lovely guide on parts of schizophrenia and psychosis unrelated to hallucinations and delusions, you've skimmed our tag, but it's finally time to tackle the most commonly known part of schizophrenia: hallucinations and delusions.
So, hearing voices or seeing shadow people and thinking everyone is after you, right? I'm done?
Nope!
This is a guide to the many many kinds of hallucinations and delusions that exist, written with experience by people with psychosis.
A note obviously that psychosis is highly personal and your mileage may vary. This is not meant to be an all-encompassing post.
Conditions that can cause psychosis (not exhaustive):
Schizophrenia,
Schizoaffective Disorder,
Schizophreniform Disorder,
Delusional Disorder,
Brief Psychotic Disorder,
Major Depressive Disorder with Psychotic Features,
Bipolar Disorder,
Psychotic Disorder Due to Another Medical Condition (yes that's the real name and the Another Medical Condition usually refers to things like Alzheimer's, Parkinson's, brain tumors, etc.),
Substance/Medication-Induced Psychotic Disorder.
The first three are also known as the "schizo-spec" (schizophrenia spectrum) disorders, with delusional disorder and brief psychotic disorder sometimes also being included in that definition.
Hallucinations
[Plain text: Hallucinations]
There are many kinds of hallucinations, the most commonly discussed being auditory and visual. However, they are not the only ones! There are also tactile, olfactory, gustatory, and somatic ones (the latter are often categorized under tactile or vice-versa).
The most frequent kind of hallucination experienced changes depending on the exact disorder. Overall, the most common ones are either auditory or visual (e.g. auditory are the most common in schizophrenia, and visual in neurological disorders), then the other one of the aforementioned two, then tactile/somatic, then olfactory, and then gustatory.
A person can experience any number of those, and multimodality (involving multiple senses) is more common than unimodality (involving just one sense) in people who have a primarily-psychiatric condition. In other words, having hallucinations that involve multiple senses is common for those on the schizo-spec, but very rare for those with ocular conditions, for example.
Types of hallucinations:
[Plain text: Types of hallucinations:]
Auditory hallucinations: There are many things a person can hear, the most common and most discussed being voices. However, other common auditory hallucinations are whispering, hearing your name being called, music, and hearing people walking around.
Command hallucinations: a subset of auditory hallucinations. My absolute enemy. A hallucination, usually external voice but sometimes an "implanted voice" that commands the listener to do things, from something simple like standing up to hurting themselves or others. The listener can resist, but I personally find the longer I have command hallucinations the harder they become to resist or ignore. Often the thing that gets me sent to inpatient. The most important distinction for command hallucinations are that they are not intrusive thoughts - the person is insistent they are external from them.
Visual hallucinations: Less common than auditory hallucinations but still incredibly common. Not always shadow people or recognizable people - I see strangers and have never had the same visual hallucination twice, although some people do see returning "characters". I do see shadow people occasionally, but they aren't the only thing people see and can be a somewhat exaggerated depiction. I know a lot of people who see cats, for some reason. If you can think it, someone can see it!
Obviously hallucinations can but don't have to be scary, it simply depends on the person and experience.
A person can see almost anything as a hallucination. Some people experience what are known as "simple" visual hallucinations (as opposed to "complex" ones)ābasic patterns, spots, geometric shapes, lights, lines. They are not lifelike or clear, and are visibly out of place. Simple hallucinations are less common on the schizo-spec, but anyone can have them.
Tactile hallucinations: my absolute enemy (hey, different mod here). Tactile hallucinations are less common than visual or auditory ones, and often come with other kinds of hallucinations as a bonusāespecially somatic ones, since there's no clear distinction between those two a lot of the time. They encompass touch, feeling, and spatial sense in the broadest sense you can possibly imagine. They can be annoying in their own manner as there is often no way to check their validity; you usually can't just record or take a picture of them to verify them.
Tactile hallucinations can be, as most hallucinations, basically anything. One of the most common types is the feeling of parasites, bugs, or other animals, like snakes, moving across or under the person's skin.
Parasitic/formication hallucination is the main example of tactile hallucinations to the point that there are sometimes used as synonyms. It's also very often associated with delusional parasitosis, where the person actually believes that they are in fact infested, which will be mentioned in the "delusions" section.
For many people tactile and somatic hallucinations will be one and the same, or otherwise inseparable, like the feeling of blood or urine dripping down their body, being burned, feeling their organs or bones "move around", or having their skin stretched.
In my personal experienceāYMMVātactile hallucinations are the most difficult to acknowledge as fake (for me, this is in comparison to visual and olfactory ones). Even if you are aware of the possibility of being in psychosis, since they can't be reliably verified for the most part, are often at least theoretically possible, and frequently co-appear with delusions of the same theme.
Olfactory hallucinations: smelling things that aren't there. Those can be pleasant, gross, or completely neutral, as most hallucinations in general. Smell hallucinations can be (unofficially; this is just a distinction I've used myself) categorized into external (smells "outside" the person having the hallucination, like a fire) and internal ("in/on" the person having the hallucination, i.e. a smell that's coming from their own body). In my anecdotal experience, people tend to have more of only one of these types rather than both.
One of the most common ones is the perception of having extremely offensive body odor or bad breath, but it can also do with urine, blood, even decomposition, etc. The hallucinations generally revolve around mundane things (there's nothing "OMG I must be in psychosis!" about thinking you smell bad), which might make them difficult to spot as fake, even if someone is aware that they are overall psychotic.
Many kinds of olfactory hallucinations might make the person feel insecure (body related smells), paranoid (chemical related smells; e.g. I had a recurrent hallucination of smelling spilled gasoline), or cause problems with things like eating (smelling non-edible things in food; rot, mold...).
Gustatory hallucinations [disclaimer: none of the mods have first-hand experience with this one; this is entirely based on external sources]: tasting things that aren't there. The rarest kind of hallucinations statistically, though it shows up in some non-shizo-spec conditions more often (e.g. epilepsy).
Gustatory hallucinations are mostly realistically plausible (for example, feeling a bitter or sour taste) or realistic but unusual (e.g. metallic taste). They often coexist with other kinds of hallucinations and delusions, often exacerbating the problem (e.g. a person with delusions of being poisoned might experience a hallucination of dangerous chemicals in their food, solidifying the delusion).
Hallucinations FAQ
[Plain text: Hallucinations FAQ]
Q: How to describe hallucinations in a sensitive manner?
A: Sensitivity and hallucinations is less about being sensitive about the hallucinations and more about the person having them. Hallucinations can be anything, and I mean it. For every "stereotypical" hallucination, there's a thousand real people who will have it. Unless you're considering doing something extremely out there, I wouldn't worry about the content of hallucinations being sensitive or not; anything that's common enough to be listed as an example of a hallucination is more than safe. Some hallucinations are scary, a lot are deeply unpleasant. That's okay to show.
So, how do you describe the person having the hallucinations?
First of all, don't make them violent towards others. This is a very harmful stereotype that writers love to use. Psychotic people can be violent since they are people, but they're much more likely to be victims of violence as well as committing violence towards themselves (both in the self-harm context, as well as in attempts of dealing with psychosis that ultimately result in unintentional self-injuries). Don't make someone into a murderer because they are hearing voices or smelling blood in their food.
Second, show them as a full person and that psychosis is part of them as that person. Why* are they psychotic? How do they experience it? When did it start, and how often do they have episodes? Do they go to therapy? Do they take medication? How do they feel about it? Make them seem human while integrating psychosis into their character, not just a "normal" person with a "scary gimmick" slapped on top without considering what it actually means for them.
*ānot as in "there needs to be a reason for a character to be disabled", but as in "what condition is causing them to hallucinate".
Third, don't push people with low insight under the bus. Someone who can't tell their hallucinations apart from reality isn't stupid or "worse" than someone who has higher awareness. It also doesn't translate to morals; someone who fully can't tell what's real isn't more likely to be evil. It also doesn't make them blissfully unaware angels that should be treated like children. Don't moralize a mental illness in either direction.
To go back to the actual hallucinationsātreat them as what they are: hallucinations. They aren't future-telling, prophecies, visions from an alternate dimension, sources of magic, whatever else, they aren't those things. A delusional person (or character) might believe that what they're experiencing is something "greater", but that'd be a part of a delusion; it's not something you should put as part of your objective worldbuilding. Even just implying that psychosis has some "deeper meaning" can mess some people up.
This is my least favorite form of psychosis representation in media. Honestly, personally, I'd rather be portrayed as violent than like I have some secret gift, but don't do either.
Q: How to integrate hallucinations into a story without the story becoming about them?
A: Depends greatly on whose POV you're writing from, how much insight the character has, and what emotions do they experience while hallucinating.
If it's a non-POV character who is aware they are in psychosis and are relatively unbothered by it, you can just describe them glancing around, or otherwise checking where the hallucination is. In most cases someone with high insight won't be interacting with a hallucination (an exception could be a pleasurable hallucination that the person enjoys).
They might ask another character if they also see/hear/feel the hallucinationāeven if someone is fully aware they are currently in psychosis, it might be difficult to verify which things are fake and which aren't. Maybe the character is sure that the person they're "seeing" is fake, but aren't sure about the dog that's with them.
You can describe the character being clearly distracted by something; looking into a specific place, moving weirdly, or not being able to stay on topic.
If you're trying to write about the character experiencing hallucinations and having low insight, it might be much more difficult to not make the story (or the scene) about itāif you don't go out of your way to acknowledge them as hallucinations then it will look like there is no hallucinations present, since the character will just consider them to be real. It'd just be another part of the settingāyou can obviously throw in something that would be clearly out of place for the reader, but it will raise questions that you should probably address, thus making the scene about the hallucinations.
A similar thing can happen if your character is experiencing an unpleasant hallucination: you kinda have to make the scene about it. if the character is scared, it'd be weird to ignore that. You can of course go "they saw a peculiar creature in the yard, one so weird that they knew right away it wasn't really there, so they decided to ignore it," since you can be aware of a hallucination being fake while still being disturbed. In that situation you can have the character purposefully trying to distract themself, show them being under stress, or having another kind of reaction (e.g., using some sort of grounding technique, having a panic attack, etc).
Q: What are some common ways to tell what is and isn't a hallucination?
A: Visual: taking pictures/videos, taking off your glasses (hallucinations will sometimes stay in-focus when the real world blurs accordingly), asking another person if they also see it.
Auditory: recording the sound, asking another person.
Blind people having visual hallucinations and deaf people having auditory ones usually just assume that the hallucination is fake, especially if it's the only thing they are able to see/hear.
Olfactory: asking another person.
Tactile/somatic: no consistent way as far as I'm aware. In some circumstances you can tell by just looking (e.g. you feel like you're having a nosebleed, you can just look in the mirror to check) or asking another person (e.g. you feel like you're levitating), but for most hallucinations there is no way of telling (e.g. how would you check if there's something happening to your internal organs? Get a body scan of some sort maybe?).
Gustatory: if it's about a real food you can ask another person if they also feel the same taste, otherwise no way of telling as far as I'm aware.
Q: Does being able to logically differentiate between reality/hallucinations stop emotional responses?
A: It can, but it's not a guarantee by any means. Imagine you're on a rollercoaster or watching a horror movie: logically speaking, you know that you are safeābut still, you get scared, it's a natural response. If the insight helps someone emotionally, it's usually partial.
That said, being able to recognize something as a hallucination might (key word here) help someone stop having a psychotic episode, which could end the emotional response. But just because you know that something is fake doesn't mean you'll stop believing it. In fact knowing that you're believing something that is fake can be even more distressing than not knowing it's fake.
For some people, a hallucination could be traumatic or plain upsetting and continue to disturb them even after it's gone and they are no longer having an episode.
Not everyone will be particularly emotional though. Some people hallucinate 24/7 and just treat their hallucinations as another part of their day, even if they're fully conscious of them being fake.
Q: Can blind people have visual hallucinations/deaf people have auditory hallucinations?
A: Yes. For those where the two are connected, the former is called Charles Bonnet syndrome, the latter Musical Ear syndrome. The major distinction is that in both of those, the person experiencing the hallucinations usually has high insight (i.e., is aware that they are hallucinations) and they don't generally co-occur with delusions.
Blind and deaf people with residual vision/hearing can also experience "regular" visual/auditory hallucinations as well (and obviously other kinds tooānothing is stopping a deaf person from having olfactory hallucinations).
The one important caveat is that people with congenital (!) cortical (!) blindness do not, for unknown reasons, ever develop schizophrenia.
Delusions
[Plain text: Delusions]
Delusion is a fixed belief in something that is considered false, even after seeing evidence for the thing being untrue. The delusional belief isn't a part of the person's culture or religion, and isn't accepted as true among other members of their community. The belief is generally disturbing to the person and causes them distress.
The delusions that one can have are basically endless in terms of options, but they can be broadly put into two categories:
Bizarre: delusions that are impossible to occur in real life.
Examples:
being abducted by aliens,
having your thoughts broadcast over the radio,
being a supernatural entity.
Non-bizarre: delusions that are possible to occur, even if highly unlikely.
Examples:
being poisoned,
having a partner cheat on you,
being watched by the government.
Of course, in terms of fiction, what's considered "possible to occur in real life" might differ from these examples.
Delusions can also be categorized in "themes", such as:
Persecutory: the theme surrounds believing that one is being harassed, attacked, stalked, or conspired against, often by powerful entities. Frequently reported as the most common type of delusion, especially in schizo-spec disorders.
Grandiose: surrounds believing that one has special powers, status, knowledge, skills, has relationships with famous, powerful, and otherwise important people, or is such a person themself.
Jealousy: surrounds believing that one's partner is unfaithful.
Erotomanic: surrounds believing that another personāoften of higher status, such as a celebrityāis in love with them.
Somatic: surrounds believing that there is something wrong with one's physical body, such as being infested with parasites, having blood replaced with a different liquid, or missing internal organs.
Religious: surrounds believing that one is a god or another religious figure, like a prophet or a saint, and/or is receiving directions/commands from those. A person doesn't have to actually be religious to experience religious delusions, nor has to be of the same religion that the delusion is about.
Thought manipulation: surrounds believing that one's thoughts are being manipulated in some way. Common examples include believing that one's thoughts are being broadcast, or that foreign thoughts are being purposefully inserted into their brain.
Mixed: delusions that match multiple of the aforementioned types. E.g. a character who thinks the government wants to kidnap them for their magical powers (persecutory+grandiose); a character who thinks that they are married to a famous pop star and that she's cheating on them (erotomanic+jealousy), etc.
Unspecified: literally everything else.
There are also specific delusions which are often referred to as their own syndromes/disorders. They are generally considered very rare but they are frequently referenced in media. Some of them are:
Clinical lycanthropy: a delusion that one is turning into a werewolf. Often clinical lycanthropy is a catch all term now for clinical zooanthropy, which is the belief you are transforming into any sort of animal. It's very rare and can be part of a disorder such as schizophrenia or exist as a delusion on its own. Often people with it will start to behave alongside the disorder, such as eating raw meat or feeling somatic transformation, or hiding so as not to hurt others in their beastly state.
Delusional parasitosis/Ekbom's syndrome: a somatic delusion where you believe there are bugs/bacteria/parasites inside your body, generally under the skin. Commonly co-occurs with tactile/somatic hallucinations, adding realism to the delusion.
It very frequently results in self-harming behaviors in an attempt to "get them [parasites] out". That can be anything from skin scratching to auto-amputation or disembowelment. The less extreme ways can result in infections and painful skin conditions, sometimes solidifying the person in the delusion that their body is in fact infested. The more extreme ways can and probably will result in death for obvious reasons.
A common phenomenon associated with it is the "matchbox sign" where the person finds "evidence" of the "parasites" (usually dead skin, fabric, small pieces of food, etc.) and shows it to someone, often a doctor, as proof of the infestation (matchbox coming from it being the go-to container for the "specimen", but honestly it can be anything. Who even has matchboxes anymore). A person with this disorder can also obsess over parasites/other animals that can in fact infest humans, potentially forcing them to avoid certain activities as much as possible (not eating meat, not going into forests, obsessively washing themself, etc).
To my knowledge this is the most common syndromic delusion, though it could be related to the fact that people with delusional parasitosis are also the most likely to see a doctor about it (though the doctor of choice would practically always be a dermatologist, not a psychiatrist) and thus get counted in statistics.
[Disclaimer: the next three are entirely based on external sources since no mods have first-hand experience with them.]
Capgras syndrome: a delusional misidentification syndrome where the person believes that someone else has been replaced by a clone/double/impostor. Most commonly the person who was "replaced" is a close family member or a spouse. Rarely, a person can also think that multiple people or a group were "replaced". Very rarely, the person with the delusion might think that they themself have been "replaced".
The delusion might be persecutory in nature, where the person believes the "clone" is there to spy on them or hurt them. This can sometimes lead to attempts of "unmasking" or confronting the "impostor" in an attempt to get their loved one "back".
Fregoli syndrome: a delusional misidentification syndrome where the person believes that strangers or acquaintances are someone they know in disguise. While generally it centers around people, it can also happen with animals or objects. It usually has a persecutory aspect to it, where the person thinks the "disguised" person is trying to follow or harm them in some way.
Cotard syndrome: also sometimes known as "walking corpse syndrome". It's a wide-spectrum delusion where the person believes that they already are dead, are currently dying, are immortal (and thus unable to die), have died but were reborn in some way, or just don't exist. People who have it might also believe that their organs are gone, rotting, or dying. Some can also abandon their basic human needs (such as eating) since they think it's no longer necessary.
Cotard syndrome is very rare in real life, especially in young people.
This is not an exhaustive list, just some examples.
Delusions FAQ
[Plain text: Delusions FAQ]
Q: What do delusions feel like?
A: So, it primarily depends on "insight"āwhether the person has no, low, or high insight into their own delusion. The vast majority of people who experience delusions will have very little to no insight during their psychotic episodes.
Delusions feel like every other thing that's real, except they aren't, well, real. During a psychotic episode, delusions are facts as much as everything else around you. You don't question them since they feel obvious.
In delusions, there's lack of proofāwhich can be filled in by hallucinations (person believes they have a lethal disease, and starts hallucinating symptoms), explained by the delusion itself (person believes that someone else is in love with them, and interprets regular behaviors as "signs"), or simply ignored (the average person also doesn't know how [random everyday technology] actually works, but knows that it's a real thing that existsāpeople don't tend to question things they simply consider to be true, even if they don't really understand them).
Q: How to describe delusions in a sensitive manner?
A: To quote myself from earlier: sensitivity and delusions is less about being sensitive about the delusions, and more about the person having them. Delusions can be of anything, about anything, they can sound stupid and seem absurd to outsiders. I'm not saying "write the most ridiculous delusion you can think of for fun", more so "yes, some people do have unusual beliefs due to having the Unusual Belief Disorder".
Delusions are frustrating for everyone involved almost by definition. They aren't true and they directly affect what you believe, so they make you believe nonsense. And you can't "just explain lol" to the person that what they're saying/thinking is untrue because, well, it's a delusion. By definition, the belief being verifiably false really doesn't matter.
What's important to remember is that the delusional person isn't doing it on purpose. It's not a case of someone Purposefully Spreading Misinformation or rejecting factual data to further their agenda, it's a mental illness. Portraying it as a choice or some moral failure is simply incorrect. You can't just "opt-out" and magically stop being delusional.
So, what to actually do?
Recognize that delusions generally aren't fun. Obviously, everyone's experience is different, but delusions tend to be distressing. Persecutory ones will almost always be very negative, while a religious or grandiose one could even feel positive for someone if they think they are an angel or have some amazing talent.
Try to show the character's feelings in a sympathetic way, not a mocking one. What they believe isn't true, but their feelings are as real as anyone else's.
It's also important to remember that a delusion is something you genuinely believe. Try to put yourself in that position: you simply know some things. What your name is, how your pet looks like, where you live, whatever. If someone tried to convince you that you are wrong about these things, you'd think they're crazy. Imagine your coworker talking to you like they know your home life better than you do. Depending on the exact circumstances, you would probably have some sort of reactionāwhether that be anger, being baffled, or just kinda weirded out.
It's the same when someone is delusional, and the "things you simply know" just happen to not actually be true.
This kinda leads to considering the ways in which a delusional character interacts with others. Some delusions are ignorableāthe other character can kinda just nod and change the topic and move on. Others are a bit more in your face (e.g. the character thinks they are some higher being, or they think the character they're directly talking to wants to hurt them). Again, just telling someone "that's not true lol" doesn't really do much, if anything it can make the delusion worse (again: imagine you confront someone who you think is poisoning you, and they just say "um but I'm not?? what are you talking about lol you sound crazyy"). Try to consider what the relationship between the characters is, and what their personalities areāare they considerate, are they impatient, do they understand how the delusions affect the other character? Does the other character realize/know that the psychotic character is in psychosis at all?
Q: How do I incorporate delusions into a character's voice realistically?
A: TLDR: It's can be hard to make dialogue that sounds realistic for a character who has the disconnect-with-reality disorder.
First, try to consider how your character experiences their delusions in general. Are they extremely disturbed and can't stop thinking about their delusion when they're having an episode, or is it more of a background noise?
If it's disturbing them, then it probably won't sound realistic. When the delusion is all-consuming, the person having it might talk about it in circles and relate everything to it. Depending on how the psychotic character actually behaves, other characters might feel like they're being pranked because it just seems like "too much". It might be "like in the movies". The character can be going in circles trying to figure out how to stop NASA from broadcasting their thoughts around the globe; this happens.
At the same time, sometimes the delusion is much more covert. Sometimes on purpose (e.g. character with persecutory delusions believes that they are being observed, and doesn't want the observer to realize that they are aware of the observing, so they actively choose not mention anything about it), sometimes as a by-product of the way the delusion affects them (e.g. character with an erotomanic delusion isn't distressed by it, and they just vaguely mention their 'partner' in a way that doesn't really even tip anyone off).
If it's the first, you might be dealing with a character who is simply nervous/hiding something (because, well, they are). They might avoid certain topics or visibly get more stressed if the conversation goes into uncomfortable territory.
If it's the second, it will probably be more subtle. Perhaps you-wouldn't-be-able-to-tell-it's-a-delusion subtle. It depends on the character's exact delusion. Some would just be considered non-events (they say they have a partner who's famous, or that they are accomplished in some way), relatively normal/common events (partner is cheating on them, they have some serious illness), and some would be clearly bizarre (they say that their parents have been replaced by robotic clones, or that they are some mythical creature). If it's the first or the second, there might be no "tell", or maybe there will be some logical errors that other characters can catch on to, maybe there will be some inconsistencies when the character asks about it further, or maybe there will be nonsensical changes that happen between different retellings of the story that let others know something is off.
If it's the third clearly-bizarre option, then the "delusion reveal" might feel like it's coming out of nowhere, or create a sudden tone shift. It will be explained further in the post more, but psychosis isn't always obvious. Sometimes you learn that someone is psychotic because they say one thing that makes absolutely no sense. Again: it might feel abrupt, unexpected, other characters might think that they are being pranked at first. Just don't make the narrative make fun or mock the delusional character.
As to what you shouldn't do: no matter how delusional someone is, people still have other traits. Delusions aren't a replacement for backstory, relationships, preferences, or personality. They can and do affect them (and vice-versa), but if all the character talks about is their delusions, it will come off as either boring and flat, or a parody.
Psychosis FAQ
[Plain text: Psychosis FAQ]
Q: Can psychosis go undetected by the people around the person experiencing it, or is it very obvious?
A: Depends (sorry). But yes, sometimes it can absolutely go undetected, especially in case of a person experiencing mundane non-bizarre delusions and/or hallucinations.
It can also depend on the actual cause of the psychosisāfor example, schizophrenia often comes with disorganized speech (among other things) which is definitely noticeable.
On the other hand, delusional disorder is often referred to as a "high functioning" disorder where it can be very hard for others to notice anything is wrong. It's generally characterized by non-bizarre delusions, unremarkable behavior ("not odd"), relatively non-impaired functioning, and any hallucinations that come with it are relatively minor and most importantly, fit the theme of the (probable) delusion.
My own absolutely worst psychotic episode went undetected by everyone I was living with at the time (in a tiny apartment at that). For someone else, a stranger could notice that they are experiencing psychosis from the other side of the road. It's a very wide spectrum, and a person can be on different ends of it at different times of their life.
It's basically: could you tell that your coworker who is ranting about their wife cheating on them is having a psychotic episode? Because they could be, and you probably wouldn't even consider it as an option since it's a very mundane delusion. On the other hand, if the coworker told you that their wife has been replaced by an identical evil clone overnight, you will know there's something going on because that's not a thing that happens.
Q: What impacts what hallucinations and delusions come up? Are they random?
A: As far as I'm aware, there's no actual research on this. We know that certain types of hallucinations and delusions are more common in specific disorders (e.g. in schizophrenia, auditory hallucinations and persecutory delusions are more common than other types), but that's about it. We don't know why certain people hallucinate cats meowing, and other ones hear demonic screaming.
Anecdotally speaking, people tend to stick to their delusions rather than have a completely new kind every time they have a new psychotic episode. It could be literally the same delusion following them ("the government is watching me"), it could branch out over time ("the government is spying on me and stealing my thoughts"), or incorporate other delusions that still somewhat connect, either in theme (in this case persecutory) or in subject (in this case government-related). In my experience, it would be very unusual for a person to have a psychotic episode where their delusions center around one thing with a specific theme, go into remission, and then have their next episode center something completely different with a fully unrelated theme (excluding "major event happening between the two episodes" type stuff).
Having unrelated hallucinations is more frequent since multimodality is very common.
The content of delusions or hallucinations is essentially "anything". It can be related to trauma, but doesn't have to. It can be related to the person's daily life, but doesn't have to. It can make sense from the outside, but doesn't have to.
Q: What do antipsychotics do from a more first-person perspective? How do they affect the symptoms of psychosis?
A: Make you sleepy... no, the biggest thing my antipsychotics have done when dosed correctly and on the right mix is they have helped give me a tool to more easily establish what is real or true and not. Even "in remission", a person with psychosis may experience hallucinations or mild delusions. It's less the symptoms that stop and more that they stop being as disturbing and disruptive, in my (mod bert again!) experience. They do not affect speech or negative symptoms for me, however.
Other mod here! When on the wrong antipsychotic, my delusions and hallucinations got meaner. They were more persecutory and I also experienced "old" hallucinations that I had not seen in a while returning. However, on my best dosage, my antipsychotics made my hallucinations nicer and quieter. Not as in like literally less loud, but they became easier to ignore. Like above, I have never seen an improvement in my speech or cognitive symptoms from medication.
Q: What kind of things can trigger a psychotic episode?
A: Technically speaking, anything can. It depends a lot on the actual disorder causing the psychosis (no points for guessing what triggers an episode in someone who has Medication-Induced Psychotic Disorder), but the most common triggers would be:
high stress,
recent traumatic event,
substance use,
sleep deprivation,
and social isolation.
My symptoms can be triggered by talking about them or seeing content similar to my hallucinations and delusions. For example, hearing a bible story triggered a religious hallucination, etc.
Sometimes the trigger is also "nothing" as far as the person experiencing the episode knows.
Things to Avoid
[Plain text: Things to Avoid]
Violent psychotic characters, especially ones that kill others because of "the voices"/"the visions". Psychotic people are much more likely to be violent towards themselves than anyone else.
Magical psychotic characters where the psychiatric disorder is some sort of magic system mechanic. A mentally ill character can have powers or whatever, but don't make symptoms into something they aren't.
Delusions/hallucinations that predict the future or have some other kind of omniscient quality to them. Again, this is a real medical condition, not a writing prompt.
Rule of thumb: would you still make the character psychotic even if their symptoms served no purpose in terms of worldbuilding and/or establishing something supernatural? Because if the answer is no, you have to rethink some things.
Psychotic characters who always have to be one of the like, four possible character archetypes (evil cannibalistic serial killer/mad scientist/Victorian era child in a horror movie/side character whose delusions are played for a joke and/or to show how 'dumb' they are).
Things We Want to See
[Plain text: Things We Want to See]
Regular people who just happen to be psychotic because of a mental health condition.
Psychotic characters who also experience other symptoms of their condition. Schizophrenia, the most commonly portrayed psychotic disorder, has many more symptoms than just that.
Psychotic characters who aren't young. Elderly people are actually the most likely to develop psychosis, childhood onset is extremely rare in comparison.
Psychotic characters who aren't white, physically abled men. Your character can be of literally any background, anyone can develop psychosis. In media it's almost exclusively either white men with poorly "researched" schizophrenia to portray them as crazy and dangerous, or sometimes women with delusions (usually erotomanic/jealousy type for obvious reasons) to portray them as crazy and unbearable to be around.
Characters who experience other kinds of hallucinations than just auditory and visual ones.
Characters who experience cognitive and speech symptoms.
Characters with other disabilities.
Characters who need a lot of support as a direct result from their psychosis. This should be portrayed as a neutral thing.
Psychotic characters who still have a social life! And hobbies!
Characters with MDD [major depressive disorder] that experience hallucinations/psychosis as a result. This was something I experienced during one of my worse periods and I have quite literally never seen anyone talk about MDD with psychosis outside of a medical context.
Happy writing!
mod Sasza, mod Bert, & mod Patch
