Psychosis and Psychopathy: Two Very Different Conditions

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Many people don’t really understand the difference between psychosis and psychopathy. This article outlines the core features of each diagnosis, and highlights the essential differences between them.

It always surprises me that even in our age of abundant information — including a plethora of information about psychological issues — many folks still confuse the concepts of psychosis and psychopathy. While perusing the comments sections of several blogs, and reviewing various articles during the past few weeks, I was stunned by the extent to which the two terms are misunderstood. One woman posted a comment on a women’s issues forum, that she had come to realize her estranged husband “must be psychotic,” and then went on to describe all manner of behaviors typically associated with psychopathy. So, although it’s impossible to thoroughly differentiate these conditions in a brief article, I thought it potentially helpful to readers to outline the core characteristics of these very different conditions and to highlight their essential differences.

The term “psychosis” has its roots in the ancient Greek words for an aberration or abnormality (osis) of the mind or soul (psyche). Thus, the psychotic mind is literally a mind that has stopped functioning normally. Persons in the throes of psychosis have lost the capacity to think and behave rationally, and this usually results in greatly impaired contact with reality. The most typical manifestations of psychosis are bizarre and false beliefs (otherwise known as delusions), and unusual or false perceptions (perceptions that occur in the absence of genuine external stimuli, and otherwise known as hallucinations). By far, auditory hallucinations (i.e., “hearing voices”) are the most frequently occurring, but psychotic individuals can also experience other false perceptions such as visual hallucinations (i.e., “seeing things that aren’t really there”), tactile hallucinations (e.g., feeling like bugs are crawling on your skin when there are no such bugs present), and even olfactory hallucinations (e.g., smelling something in the absence of any aroma or odor-producing substance).

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People can be in a psychotic state as the result of many different underlying conditions. For example, certain substances such as alcohol and other drugs (including prescription drugs such as steroids, stimulants, and opiates), can induce a psychosis. Brain tumors, or other physical abnormalities of the brain can also produce psychotic symptoms. So can brain diseases such as Alzheimer’s and other types of dementia. Certain mental illnesses are commonly associated with psychotic states, especially schizophrenia, and less frequently, bipolar disorder. Schizophrenia is a condition in which rational thought processes are impaired, and hallucinations and/or delusions are prominent. A person with schizophrenia might even have such a disturbance of thought process that they speak incoherently or in “word salad” (i.e., stringing words together that have no logical relationship to one another, and fail to express a complete thought). Sometimes, persons with schizophrenia have delusions with a paranoid character. Such delusions can be of the grandeur type, where the person might believe that they are incapable of dying or have supernatural or magical powers. Delusion can also be of the persecutory type, where a person might believe (erroneously) that they are being pursued by government agents or have been targeted by extraterrestrial aliens. Delusions similar to some of the aforementioned can also occur in individuals with bipolar disorder, especially during full-blown manic episodes. Suffice it to say that these individuals are simply not in their right mind. Their brains are malfunctioning in such a way that they have lost the capacity to correctly judge things in their environment and to relate to others in a coherent, rational fashion.

The term “psychopathy” was first used in the early 19th century to describe a pathology of personality characterized by an extreme lack of empathy that leads to guiltless and remorseless use and abuse of others. Shallow emotions, a chilling lack of fear, extreme manipulativeness, frequent and seemingly nonsensical lying, and behavioral irresponsibility are common, as is the tendency to display superficial charm. Perhaps the confusion between the concepts of psychosis and psychopathy started with Hervey Cleckley’s landmark book The Mask of Sanity , in which he argued that the facade of civility and charm that psychopaths deliberately project masks an irrationally antisocial and exploitative mindset. But, although psychopaths have a world view greatly aberrant compared to most, they are neither out of contact with reality nor incapable of rational thought. In fact, their thinking is often distinctly rational and goal-oriented, albeit foreign in character to those of us who do not see our fellow human beings as mere objects to possess, exploit, abuse, or destroy. Perhaps that’s what makes psychopaths so dangerous. It’s precisely because they think so clearly and calculatingly about how to victimize their targets, and have such keen perceptions about the vulnerabilities of their intended victims, that they pose such a threat to the well-being of others. And perhaps another reason for confusion regarding the term psychopathy is the fact that, over the years, many researchers and clinicians have favored an alternate label, sociopathy, to the term psychopathy, because of the distinctly antisocial character of the psychopath’s world view. But not all psychopaths lead openly antisocial lifestyles. They can even be heads of corporations, or your next door neighbor. That’s why, in my book Character Disturbance, I suggest that the term “predatory aggressive” is actually a better descriptive label for these individuals, as it attests to what I and several researchers agree is their unique status as the human race’s only known intra-species predators. They can come across as harmless and even appealing, but they are predators nonetheless. And in my book In Sheep’s Clothing, I discuss the characteristics of these predatory aggressors that make them the penultimate manipulators.

While they have a pathological love for and have mastered the art of the “con,” psychopaths are definitely not insane. But because they are such aberrant creatures, and so good at coming across as deceptively normal or even appealing, they certainly can test the sanity of those unfortunate enough to have contact with them. It’s unfortunate, but most victims of psychopaths find out all too late what they’re really like.

Perhaps if Cleckley had titled his book “The Mask of Civility,” there would not be as much confusion as there still is about psychopaths. It’s important to remember that for the most part, people afflicted with the mental illnesses that can cause psychosis are essentially decent personalities whose brains have stopped functioning normally. Psychopaths, on the other hand, are disturbingly aberrant personalities whose brains may lack the capacity for empathy, but are nonetheless functioning in a chillingly rational enough way for them to slickly plot the victimization of those they have targeted as prey.

All clinical material on this site is peer reviewed by one or more clinical psychologists or other qualified mental health professionals. This specific article was originally published by on and was last reviewed or updated by Pat Orner Oliver on .

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