The Differences Between Psychosis and Altered States

Source: Unsplash/David Marcu

This post is part one of a four-part series interviewing psychologist Lisa Dahlgren.

When I was first experiencing psychosis, I had to confront a problem. Was my psychosis needing medical attention, or was it just an eccentric nature of my brain? With the plethora of spiritual and alternative options available to me, I wandered between groups.

I sought out the Hearing Voices Network, which is a movement that attempts to de-medicalize what the West understands as hallucinations. I attempted to reframe my disorder in terms of a spiritual awakening. Then I thought of myself as a mystic, where I learned the concept of the “dark night of the soul."

Ultimately, I accepted that my experiences constituted a disorder. I embraced my diagnosis as schizoaffective, and I vowed to take my medications daily (and have for the past seven years).

This got me thinking, however. It is true that some people don’t experience psychosis as a disorder. For some, experiences that seem otherworldly or different from “normal” people can pass from time to time and don’t cause the same severe, debilitating schism in reality breaking. When I spoke to some of these people, I learned very specific reasons about why we called mine a disorder and why others called theirs an altered state of reality. I decided that mine caused true stress, distress, and dysfunction, while others didn’t experience any dysfunction or distress during their reality breaks.

I spoke with a psychologist from St. Louis, Missouri, who has learned to integrate altered states into her practice. Serving the greater St. Louis area for decades as a licensed clinical psychologist Lisa Dahlgren was educated at Washington University in St. Louis. I found her views on the differences between altered states and psychosis to be informative, and interviewed her here.

This is a four-part interview answering some questions about the differences between altered states and psychosis we traditionally view within the DSM-V-oriented psychiatry field.

SM: How do you define psychosis and altered states, and in your expert opinion, what is the difference between the two? How can different perspectives cross-culturally help us understand psychotic features and integrate them into our lives?

LD: As a psychologist, I define psychosis as having hallucinations and delusions, which give rise to or are accompanied by disorganized thinking, speaking, and behavior, generally within a context of other difficult and life-altering symptoms, such as depression, mania, and limited insight. I believe that definition arises from the diagnostic manual for mental disorders, and is pretty consistent with what I was taught during my clinical training.

I define non-ordinary reality states as being in a perceptual state which is inconsistent with the usual or typical ways I and others perceive the world and includes seeing and hearing and sensing things that others do not see, hear, or sense.

“Altered states” is a term that describes movement along a continuum of awareness. On one end of this continuum is what is called the default mode network (DMN). The DMN is an interconnecting neural network that is active when we are absorbed by and focused on things related to our selfhood. On this end of the continuum, we feel contained and cohesive in ourselves as well as separate from other people and other aspects of the world.

On the other end of this continuum is being open and receptive to information and ways of processing that involve less of the DMN. On this end of the continuum is a loosening or loss of feeling self-contained and a reduced feeling of oneself as being a separate, cohesive, identity.

In everyone's daily life, we vacillate on this continuum naturally and continuously without even thinking about it. When we engage in things such as practicing mindfulness, formal hypnosis, daydreaming, and being involved with music, poetry, and creativity, we are allowing ourselves to engage and disengage with the DMN.

We know we have reached a place on the continuum that is apart from the DMN that we call “altered states” when we experience losing a sense of linear and consistent time, spontaneous creative thought, and transcendent experiences. People report that when they are at the extreme end of the continuum, they experience a dissolution and expansion of their sense of self, a breakdown of the barrier between themselves and others, the world, and the universe. People also report feeling awe, wonder, love, and gratitude as well as the ability to shift personal perception.

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The use of psychedelics for therapeutic measures has been coming back to mainstream psychology. Anecdotal information from cultures that incorporate the use of psychedelics into their social structure and the research on therapeutic psychedelics that has been conducted for several decades seems compelling toward mental health.

In the past couple of decades, the field of psychology in the United States has started bringing other cultures and their spiritual practices into psychological techniques, and has found doing so has led to useful treatments. There was a moment of revelation that top-down (i.e., default mode network, problem-solving, and rational thought) mental health tools may not be the only or even the best solution to mental health problems. With those successes, psychologists and psychiatrists in the United States are looking at how other cultures—and now how their own culture–can successfully use psychedelics for mental health.

The success seems to be heightened when the individual receiving a psychedelic has a preparation phase that includes working on the awareness continuum, personal and non-directive support is given throughout the psychedelic experience, and there is a post-psychedelic consolidation phase that emphasizes the positive aspects of the expansive qualities of the experience.

It also seems natural to look at other cultures that appear to be successful in helping those who hallucinate and lose their sense of self without using psychedelics.

These cultures do not appear to use the illness model of psychotic disorders. These are the cultures in which there is a designated role for that individual with the assumption that what is occurring for them contributes to the greater good of their society. To that end, the culture offers resources of training and mentorship to develop what is seen as the individual's gifts, in service of those gifts being used to better their community.