The trial of Massachusetts mother Lindsay Clancy has raised difficult questions about postpartum psychosis and whether someone experiencing a profound break from reality can behave in ways that would otherwise be completely unthinkable.
Dr. Reena Kapoor, a forensic psychiatrist and director of Yale's Law and Psychiatry division, says psychosis is a mental state in which a person loses touch with reality. That can involve hallucinations, delusions, paranoia and disorganized speech or thinking.
"It doesn't tell you anything about the underlying cause of that psychosis," Kapoor told Connecticut Public's "All Things Considered." "It's kind of like saying that someone has a fever."
Kapoor says schizophrenia, which is a common cause of psychosis, affects about 1% of people worldwide. But she says psychosis can have many different causes, and the experience can look different from one person to another.
The signs aren't always obvious
Kapoor says family members and friends sometimes notice changes before someone experiencing psychosis reaches a crisis point. A person may begin acting strangely, talking to themselves or withdrawing socially.
"From the outside, sometimes there are signs that someone's going through an episode," Kapoor said.
But Kapoor says those signs can be subtle, and some people experiencing psychosis recognize that others may think they're "crazy" and deliberately conceal what they're experiencing. In other cases, the psychosis may appear to develop suddenly even though it had been developing for some time.
A person can be organized and deeply psychotic
One of the most difficult aspects of psychosis for the public to understand, Kapoor says, is that a person can remain capable of carrying well-thought-out plans while simultaneously experiencing profoundly distorted beliefs.
She described a hypothetical patient who showers, eats breakfast, takes public transportation, waits for traffic signals and checks in for a medical appointment — all while believing an ex-partner is surveilling them and using a microwave to send harmful signals through their clothing.
"Those two things, the really profound psychosis that I was just describing, and the organized behavior, even just to get to the appointment, can exist in the same person," Kapoor said.
That distinction can become particularly important in criminal cases involving claims of insanity. Kapoor says forensic psychiatrists don't simply take a person's account of their mental state at face value.
"It's reviewing records, it is talking to friends and family members, to treatment providers," Kapoor said. "It's examining all the evidence around the crime itself."
She says evaluators also examine whether a person's description of their mental state at the time of a crime is consistent with the known symptoms and behavior associated with mental illness.
What loved ones can do
Kapoor says families can play an important role when they recognize that someone may be experiencing psychosis, although getting a person into treatment can be difficult. In the United States, she says, there are strict circumstances under which someone can be forced to receive treatment against their will.
"If they're willing to see a healthcare professional, certainly a family member facilitating that can be helpful," Kapoor said.
When someone refuses treatment, Kapoor says a trusted relative or friend can still help the person develop ways to cope with their experiences. She also says simply listening can be valuable, particularly because people experiencing psychosis may already feel judged or misunderstood.
"Having that open-mindedness and listening to the person's experiences, validating their emotional reaction to it while not feeding into the delusional content," can be helpful, Kapoor said.
Kapoor says that approach allows loved ones to acknowledge the fear or distress a person is experiencing without reinforcing beliefs that are disconnected from reality.
If you or someone you know is in crisis, you can call, text or chat with the Suicide and Crisis Lifeline at 988, or contact the Crisis Text Line by texting TALK to 741741.
