What Does "Crazy" Really Mean?

Psychosis: Hiding and afraid

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The word “crazy” gets tossed around quite a bit. In my psychiatry practice, people were often concerned that someone in their life was crazy. “My husband is nuts, crazy! He gets raging mad at the smallest things.” Or “My sister is crazy; she dates men everyone knows are cheats and then gets her heart broken.” Or “My crazy son quit his good job to find himself—he has really lost touch with reality.”

Others fear they themselves are crazy. They may have a new onset depression, panic attacks, or inability to cope with some life problem. In each case the question is, “am I going crazy?” What is common to each case is the feeling of being out of control of their emotions. From this they conclude they are out of control of their minds.

Lastly, we sometimes hear commentaries, often from otherwise reputable journalists, about public figures. “They are demented,” “unhinged,” “clearly delusional,” when they may be untruthful or using questionable judgement.

None of the above is even remotely crazy. I might have included much more destructive behavior such as addictions, violence, or pointless destruction, etc. Although very troubled, none of these are by themselves crazy either.

Let’s clarify a few terms before considering what crazy really means. “Crazy,” “out of their minds,” “off the deep end,” all describe a level of irrationality that is deemed abnormal and excessive. Expressions like “unhinged” and “out of touch with reality” are more examples of the way in which these terms describe a break with normal thinking and rationality. As we’ll see this is part of an accurate portrayal of what crazy really is.

“Demented” does not belong here. Dementia occurs in Alzheimer’s and other diseases that damage the brain and decrease intelligence and other higher mental functions. The affected person may be forgetful, confused, or unable to reason.

Something I often hear is the idea that doing the same thing over and over, with the expectation of a different result, is the definition of insanity. It is not. This idea is used in Alcoholics Anonymous as a teaching tool for problem solving (i.e., if your first attempt didn’t work, try something different). If you do the same thing over and over, it is not insane to think the outcome will be different. It is a common human bias. We hope something has changed over time, and with it a new outcome.

What then is crazy? In psychiatry crazy may refer to psychosis (the word “crazy” has no official role in psychiatry). The definition of psychosis is the presence of delusions, hallucinations, and disorganization of thought and speech. You only need to have one of these to be considered psychotic. Delusions and hallucinations are the usual things we see with disorganization tagging along.

Psychosis may happen quickly over days or even hours in cases of drug use or medical illness. On the other end of the spectrum, schizophrenia may have an insidious onset over months or even years. Following below are the definitions of each component of psychosis.

Hallucinations: the experience of having a perception (to see, hear, taste, smell, or touch) of something that is not present. In psychiatric illness this is usually hearing voices (when no one is there) but can be visions especially in the medically ill or drug induced states.

If I suspect auditory hallucinations I ask: if they hear voices just like mine, outside of their head, not their own voice, when no one is there, and they are up and wide awake. As you can see there are many qualifiers. This is to rule out things like hearing someone call when you are in the shower or noises when falling asleep (these are usually illusions, the misinterpretation of other sounds, sights, etc.) If the answer is yes, I dig deeper for a detailed description.

Delusions: Delusions are untrue beliefs, which are not amenable to contrary information. They are often, though not always, paranoid (being followed, spied on, targeted for violence). In psychiatric disease they can become bizarre (such as thoughts from aliens are beamed into your head).

Disorganization: Thoughts, speech, and actions become illogical, not related to one another by reason. Speaking and acting may become silly, odd, or incomprehensible.

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Although accurate, these definitions leave much unsaid. It is not easy to imagine what a psychotic person is like, especially when all these factors are present. When in the context of a psychiatric illness you will also find problematic thoughts, emotions, and behaviors. Unfortunately, the media rarely give an accurate portrayal of psychosis. They are often romanticized as being the result of hidden trauma or being able to see truths that others are blind to. When not romanticized they are often portrayed as violent killers.

An example is in order, but keep in mind that there are many manifestations of psychosis: from mildly paranoid to full blown, disorganized, bizarre thinking, hallucinating individual who cannot function or take basic care of himself.

As an example: A young man of 17 comes to the office with his parents. His grades have been falling for two years, during which time he became more isolated and did not see his usual friends. Recently he stopped going to school and just lies on his bed. He says odd things like “grandma is dead” when she is alive and well. He is afraid to go out and covers his ears several times when in my office.

When I speak to him, he is guarded but tells me the voices are telling him he is a child molester and should kill himself. He believes his room is bugged because he has committed sex crimes. None of this is true. At times he is difficult to understand as his sentences do not make sense. He becomes agitated and wants to leave. He becomes very loud, and his father walks him outside on my recommendation.

This young man has paranoid schizophrenia and is in a psychotic state. If we insist on using "crazy," it may be for this. This state will resolve with medication, but he will never quite be himself again. He is nothing like the husband, sister, and son we saw in the first paragraph. He is quite ill, cannot function on his own, and needs significant amounts of professional help. This is what “crazy” means.

Schizophrenia is a common cause of psychosis but not the only one. There are three categories of illness that may cause psychosis.

These are: diseases of the brain itself, other illness affecting the brain, and drugs. Stress may lead to psychosis only if a person is already biologically vulnerable. Otherwise, no amount of stress can make you psychotic.

The primary brain diseases are usually psychiatric in nature. Schizophrenia is always psychotic, but bipolar disorder and other mood disorders may also have a psychotic component. Neurological illness, like Alzheimer’s and multiple sclerosis can also have psychotic symptoms.

Illnesses outside the brain may affect it via toxins from infections, high fevers, or imbalances in the blood. These all cause delirium, which often has psychotic symptoms. The potential causes here are legion. Anyone who works in an ICU sees these every day.

Drugs such as hallucinogens get their name by causing hallucinations and thus a brief psychosis. Other drugs such as strong stimulants can deliver a full-blown psychosis that is not distinguishable from schizophrenia except that it goes away in a couple of days. Newer street drugs such as methamphetamine have both hallucinogen and stimulant properties making them very potent causes of psychosis.

Why is it so important that we understand what crazy means? First, speaking primarily of psychiatric illness, afflicted people are both common and very sick. They are on streets, and at our tables for thanksgiving. Roughly 2% of people have a psychotic illness, while many more will become psychotic because of other illnesses or drug use.

Second, the state of affairs with “crazy” betrays our poor general understanding of psychology, both normal and abnormal. We are aware of things such as what our organs do and the difference between cancer and a heart attack, but analogous comprehension of how our minds function is lacking.

Lastly, “crazy” seems to be one of the remaining reputable prejudices. Such people are thought of as dangerous and unpredictable, when mostly they are frightened and hiding. We use common terms referring to psychotic symptoms in a derogatory and erroneous way. It’s time to give “crazy” a decent burial. If you think someone is unreasonable, uninformed, dishonest, or plain old evil, just say so.