In 2009 the UK government’s chief drug adviser, Professor David Nutt, claimed that the chance of experiencing psychotic illness as a result of consuming cannabis was “relatively small,” perhaps one in five thousand; “overall the mental health risks of alcohol and cannabis are not dissimilar.”(1) He was saying nothing new: in 1969 an earlier official inquiry into the effects and legal-classification of this drug, the Wootton Report, similarly declared cannabis to be “less dangerous than alcohol.”(2) That committee added: “There is no evidence that this activity… is producing in otherwise normal people conditions of dependence or psychosis requiring medical treatment.” Every subsequent governmental inquiry has come to the same conclusion and met the same fate, being “greeted with a chorus of abuse from politicians…”(3) In David Nutt’s case, he was sacked: the Home Secretary told him, “I cannot have public confusion between scientific advice and policy and have therefore lost confidence in your ability to advise me…”(4) The role of “scientific advice” is to support the authorities: where there is a discrepancy between the facts of any given matter and the State’s stance regarding that matter, it is the role of those facts to shut up, get lost.
Flash forwards to the first half of 2011 and a number of recent news reports have appeared arguing that there is, contra the Wootton Report et al, evidence of a causal link between smoking or eating cannabis and experiencing adverse mental health: “Using cannabis as a teenager or young adult increases the risk of psychosis, a report suggests,” says the BBC.(5) Professor Nutt has already pointed out the problematic nature of such an assertion: “[O]f course, the reason people take cannabis is that it produces a change in their mental state. These changes are a bit akin to being psychotic – they include distortions of perception, especially in visual and auditory perception, as well as in the way one thinks.”(6) A new study however claims to demonstrate that this drug can create not just hallucinogenic strangeness but actual illness, “significantly” so. The study was carried out by a team of six psychologists led by Professor Jim van Os; it took place in Germany, funded by the German government; it began with a sample group of 3021 randomly selected people aged 14-24, who were interviewed regarding their use of cannabis and their psychological health then asked follow-up questions on two subsequent occasions over a ten-year period, at the end of which 1923 members of the group were still available for questioning: the conclusions obtained from the decade-long examination of these 1923 people is presented in a paper entitled “Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study.”
Examining this paper, the first thing I noticed was that no definition of “psychosis” or “psychotic symptoms” is offered. Probably this is normal procedure: it would be unreasonable to expect academics to define every word they use in every work they publish. But it then struck me that I have no idea what this illness really consists of: a quick look at wikipedia reveals that “psychosis” means “abnormal condition of the mind”; as a medical condition it was invented a century and a half ago, a “generic psychiatric term” for “severe forms of psychiatric disorder” involving “a loss of contact with reality.” A couple of immediate observations: when newspapers routinely announce that lettuce causes cancer, then a week later that lettuce reduces the risk of getting cancer but that cabbage is a factor in heart disease, all but hypochondriacs know to disregard this fear-mongering. And yet cancer and heart disease are at least objective conditions, you either have them or you don’t, there’s very little room for controversy. On the other hand: “People experiencing psychosis may report hallucinations or delusional beliefs, and may exhibit personality changes and thought disorder.” Try pointing a microscope at a “thought disorder” and see where you end up; try quantifying “delusional beliefs,” is believing a virgin once gave birth evidence of mental imbalance? Is the belief that there are eleven dimensions to this universe, with a whole lot of other universes on either side of us, unhinged? “Personality changes”? Who decides? With reference to what standards of order, of normality, of truth?
The assumption here is that the mind can be considered analogous to the body in the sense that because there exists a clear model of physical health, with deviations from the norm being invariably a sign of ill-health, then a person unable or unwilling to think in the manner his peers think can likewise be regarded as ill. Which, to state the obvious, gives tremendous power to the authorities to enforce a conception of “reality” by condemning deviations from it as sickness: but whereas a cancer is equally cancerous in England or Italy or South-East Asia, now or yesterday or forty thousand years ago, there is not a single belief or mode of personality that remains constant from one society to the next, from one century to the next; every person on this planet would be considered mad somewhere else on this planet. The only sensible position, to facilitate communication between parties who might be mutually convinced of the other’s insanity and also to ensure that psychiatry is not used as a weapon by the governments that own it, is the libertarian position, the “Mind Your Own Business” stance. By way of illustration: should a person retreat from the world into his attic to work on a machine made of bone with which he intends to wave at the angels resident in the sun, assuming that i) such is his expressed wish; ii) he can afford his new lifestyle; and iii) he has no obligations or dependants he is betraying, then no State or Concerned Citizen has the right to tag him with the label “psychotic” or with any other made-up medical condition. He’s a kook; only in totalitarian systems is one forbidden to be a kook. This person can properly be called insane and at risk/a risk if i) he does not want to be leading this new lifestyle, perhaps cannot afford to be living it, but he feels he has no choice: his volition has been removed from him. There is a big difference between hearing voices in one’s head and feeling compelled to obey those voices; ii) in adopting this lifestyle he causes not “distress” and “alarm” to the people who know him but actual measurable damage. If he has children and those children are going without food while this man builds his bone machine then that clearly constitutes a problem in which the State may presume to interfere; or iii) it turns out that the bones with which he’s been building have been forcefully evicted from the bodies of sundry locals…
So what about this study that suggests cannabis increases the risk of psychosis? Is it being asserted here that cannabis users are more likely to find themselves unable to actually live their lives, or rather that they are more likely to lead… odder lives? (The decision to use a psychoactive chemical in the first place may indicate a propensity towards – perhaps an active desire for – the latter.) Is “psychosis” being measured relative to the life each examined individual is leading and wants to be leading, or is it measured against certain “objective” standards of normality – “reality” – which have been determined by officials and experts and governments on high?
“We used the computerised version of the Munich composite international diagnostic interview (DIA-X/M-CIDI), an updated version of the World Health Organization’s CIDI version 1.2.”(7) So say the researchers, but the information they offer regarding this instrument and their use of it is sparse. Apparently the “computerised” interview “was conducted face to face by clinical psychologists” who were allowed to follow up with “clinical” inquiries to ensure they received “systematic and valid” answers. The specific questions asked; the actual wording; the extent to which the psychologist present was allowed to probe for data and to interpret answers; none of this is revealed. All we are told is that: “Items relate to classic psychotic symptoms involving, for example, persecution, thought interference, auditory hallucinations, and passivity phenomena. The psychologist invited participants to read a list of all the psychotic experiences and then asked them whether they ever experienced such symptoms (list and phrasing available on request).” (On June 18th I e-mailed Professor Jim van Os asking for the list; I will update this essay if and when it arrives.(8)) Looking online I have not been able to find a copy of the computerised nor the uncomputerised versions of the Munich composite international diagnostic interview nor details of their contents; ditto the original composite international diagnostic interview. Some information is however available about both: one article informs us that the CIDI was “written at the request of the World Health Organization (WHO) and the US Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)”(9) It is described as “closed ended (ie, answerable with a number or by choosing among predetermined alternatives).” One example of the “question format” – and therefore presumably an example of the questions – is given: “80. Has there ever been two weeks or more when nearly every day you talked or moved more slowly than is normal for you?” Then a follow-on question: “In the last month were you so slowed down that things around you seemed to go too fast?” If this looks like a promising avenue to sniff out some psychosis, the interviewer will continue: “80.A. In the last month, have you been bothered by a lack of energy or feeling slowed down? In the last month, have you been moving much less than is normal for you?” I’d say it’s normal for people in the age-group 14-24 to sometimes move much less than is normal for them. An article(10) championing the M-CIDI update of the CIDI (an article in which nine authors were incapable of catching the fact that “psychodelic” is a misspelling) adds little. So all we know is that the interviewees are asked to answer an undisclosed number of questions with “YES” or “NO” or a number or to provide dates of certain experiences or to choose symptoms from prepared lists, seemingly without the option to contribute context, personal analysis or evaluation – i.e. if those voices in your head offered valuable insights and stimulating information you can rest assured that no-one wants to know.
Okay, to recap: a team of researchers randomly selected a group of 14-24-year-olds of whom 1923 were available for the full length of the study. Participants were asked if they had used cannabis before or if they had experienced psychotic symptoms before. Other information was collected relating to living environment, economic background, use of other drugs, etc. (But not, interestingly, about family history of psychosis: in investigating possible causes of psychosis, psychosis among family-members was not considered data worth collecting. The proposition that in some cases – how many cases? – cannabis may be activating latent psychoses rather than creating new ones consequently cannot be examined.) Three and a half years after the first meeting the participants were again questioned; after about five more years they went through this process one final time. In the meetings they would be asked whether they were a cannabis user – “cannabis use was defined as lifetime use of cannabis of five times or more” – and offered a number of indications of psychosis, for each of which they had to say if they had ever experienced it and, if so, when. After the results were collated it appeared that in a “significant” number of cases cannabis use was followed by psychotic symptoms(11); by a venerable logical process known as a “fallacy” news outlets over the world were then able to conclude that cannabis causes psychosis, or can cause it, or may be a factor in causing it, depending on the bias of the editor being fed this information.
Let’s have a closer look at the study. “Cannabis use was defined as lifetime use of cannabis of five times or more.” Five times! I’ve been to Thailand five times in my life, and most of those visits occurred before the occasion I smoked salvinorin A and suffered the worst few minutes of my life: Thailand, we might want to conclude, is a gateway drug to powerful psychedelics and a cause of bad trips.(12) More: “As in previous work presence of psychotic experiences was broadly defined as any rating of present on any of the 20 DIAX/M-CIDI core psychosis items… including 14 delusion items, five hallucination items, and one item on passivity phenomena.” “Broadly,” yes. A single deviation from normality, one “delusion item” in the years of puberty and young adulthood, a lone “passivity phenomenon,” is enough to qualify you as suffering, sick. When the researchers repeat this information later on – “Furthermore, we used a rather broad outcome measure, defined as a minimum of one positive rating on a G section item, representing psychotic experiences rather than clinically relevant psychotic disorder” – the scam becomes apparent: the confusion of an experience of a disorder with the “clinically relevant” disorder itself is akin to arguing that one instance of bad temper should ipso facto see you on an Anger Management course; that if you once rode on a unicycle you can justifiably be labelled a unicyclist; that etc. etc. etc. Nowhere does the report answer or even ask crucial questions such as: how many of the participants were ever actually hospitalised or otherwise incarcerated as a result of psychotic disorder? How many said of themselves that they were unable to function in the way they would like to be functioning? No: “one positive rating on a G section item…” What sort of person, from the ages of 14-24, or 24-34 for that matter, doesn’t occasionally go a bit nuts? Aren’t so-called psychotic experiences, as distinct from “clinically relevant psychotic disorder,” common enough? The authors of this study do answer that last question: “23% of participants reported lifetime subclinical psychotic symptoms at [the second of the three interviews], which is in keeping with the estimated 15-28% rate of subclinical psychotic symptoms in the general population.”(13) Again I have to ask: what is normal and who gets to decide?
“Jason, do you ever hear voices in your head?”
“Well, er… I mean, obviously I hear my own voice, and, er, sometimes that can split into two voices but that’s just, you know, dialectics, or sometimes trialectics or there might be a whole crowd in there but they’re all me, except when, I mean, obviously there’s a condition where you’re writing and you start hearing your characters talking and, I mean the whole point of that phenomenon is that it doesn’t seem to be coming from you, you can have fictional people dictating dialogue in voices you haven’t consciously given them, you can have the structure of a story revealing itself in all sorts of uncanny ways, sometimes you hear or even see people and places and plots unfolding like a movie in your head and you’re just desperately trying to write it all down, poems too will flow out of you with a voice of their own, but still, that’s creativity, that’s different, right? If you’re making stories out of it then it’s not madness or anything like that, so… And there’s the hypnagogic state, I presume you’re not including the hypnagogic state? Everyone can hear voices when they’re a bit tired, maybe late at night or early in the morning, that’s normal isn’t it? Mostly just gobbledygook; sometimes for me it’s like my skull’s picking up radio stations and stuff, but, I suppose sometimes those voices can be a bit more… meaningful, like I remember this one time not that long ago when there was a voice that definitely wasn’t mine and it was taunting me, jeering over and over that my favourite deity, the god Mercury, was dead, and… Oh I remember a time before that, this would have been, what, two years ago? I was lying in bed, I was so exhausted but I couldn’t get to sleep because, I eventually drowsily realised, there was a voice droning on inside me in a bland monotone, and as I forced myself to listen if only in the hope that it might shut up I heard what it had been saying all this time, it had been saying that if a person had Multiple Personalities then a Personality buried deep within him would most likely attempt to make contact with that person late at night when the ego was starting to unwind, the Personality would appear as a bland voice droning on, perhaps telling about how a buried Multiple Personality might attempt to make contact with a person by blah blah blah… Tired as I was I forced myself to formulate the thought: ‘If such an entity were to make contact with a person in such a way, presumably the next step would be for it to offer its name and any other information relating to…’ at which point there was an almighty BANG from outside, definitely not in my head it sounded like a door being slammed open or shut; I bolted upright, fully awake, I never heard any more from that voice, not then nor since. Yeah, that was weird. So, er…”
“Jason, do you ever hear voices in your head?” – well that’s my answer right there but it won’t suffice, my answer has to be “YES” or “NO” and I’m not sure whether the above constitutes a “YES” or a “NO.” The interviews are conducted with a trained psychologist: would s/he be able to analyse my response on strictly scientific lines to determine whether I should say “YES” or “NO”? Or would s/he offer a subjective opinion representing her/his human biases? And can we speculate what those biases might be? Because it seems to me that a doctor wants people to be sick as surely as a television producer wants people watching TV. For financial reasons – both in terms of the number of customers and the amount of funding available – a veritable plague of psychosis is more profitable than an occasional instance; for personal prestige, too, it is altogether more satisfying to be on the frontline battling against an onrushing pestilential madness than to be dealing with the rare man or woman who simply couldn’t take it, who cracked. “Do you ever hear voices in your head?” “Well I suppose I maybe do but I, I wouldn’t necessarily want to stamp out the possibility of that happening, in fact I, I must admit I’d kind of like more of…” “Look, just say ‘YES’ and we can move onto the next question.”
“Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study”: the paper contains three illustrations, the first two simply showing the course of the ten-year process while in the third the researchers summarise their findings in pictorial form:
This is the image they chose to use to present their work and therefore I think it’s reasonable for me to examine this graph seriously and, doing that, the first thing I notice is that the good citizen who never meddles with cannabis – whose lifetime use of the vile poison amounts to no more than four reckless tokes – experiences around adolescence a brief surge in mental disorder which never comes close to reaching the subclinical level(14) and which soon drops to a position which is actually slightly lower than at the far left side, meaning that non-users go through adulthood and old age experiencing less psychotic material than they did around the time of their birth. This, I would have thought, is somewhat controversial, but these are psychologists and this is their graph. Take a look at the top line: it begins above the bottom line, and in a period of what must represent a few years it has already surged much higher than the drugless will reach throughout their entire life. So we’re talking about, what, crazy babies hearing voices? Four-year-olds who demonstrate delusional beliefs and incomprehensible personality shifts? Then, at what looks to be around seven years of age, they reach the dreaded moment of “cannabis exposure” (refuting the whole point of the study which is supposed to show that cannabis use precedes psychosis), pushing them even further towards states of acute derangement: I can understand why that would be the case for your average seven-year-old pot-smoker.
I smell pseudoscience.
So let me ask and attempt to answer seriously, or at least at a level more serious than the junior-school dope-hungry loons the above graph offers: does consumption of cannabis cause or at least increase the risk of psychosis? There seem to be a number of anecdotal instances of it doing just that so I certainly wouldn’t want to deny the proposition, same as I could not deny that there are people in the 14-24 age-group who snap under the pressure of school-exams or failed romances or boredom, nor could I deny that if powerful moneyed interests were waging war against exams or love or ennui there would be plenty of studies reminding us so. A certain number of people will always be unlucky: by all means criminalise cannabis to ensure not a single soul has to risk the miniscule risk involved, but please also ban roads and power-drills and the insides of people’s homes, they’re loci of misfortune too. The real question is not whether it’s possible for cannabis to have negative effects but rather how possible is it, exactly? How much of a threat does this plant pose? How many potheads are actually incapable of living life the way they would like to be living it, how many are a threat to themselves and/or their neighbours? Based upon statistical evidence – the number of cannabis users versus the number of people afflicted by severe, disabling mental illness – and based also upon the anecdotal evidence amassed by me and by most other people you might chance to meet, it seems the majority of people I’ve encountered in my life have smoked cannabis more than five times and none of them have been undone by it; I’m not convinced there’s any serious danger and studies like the one under examination don’t change my mind. For one thing, the results assume rather than prove a causal link, when a complementary relationship is just as feasible: that is to say, there are people who like to experiment and there are people who do not; to use cannabis, even to try it just once, is clear evidence of an experimental drive, it shows both a desire to experience altered states of consciousness (which, as Professor Nutt reminds us in the quote above, are often indistinguishable from psychosis(15)) and a willingness to step outside the confines of the law to do so. It doesn’t seem unreasonable to me to suggest that people who lack this drive, this desire to transcend linear-logical everyday awareness, will naturally tend to go through life without having to question their sanity; why would they? If you only think the thoughts you’re expected to think, if you only experience those soap-opera areas of your mind the State has determined you must limit yourself to, what (except in cases where there is an innate genetic predisposition to mental illness) would prompt you to ever doubt you were normal, right and proper? (at least until you hit forty and suffer that massive nervous breakdown.) Conversely, those who experiment in one aspect of life are likely to experiment in others, are more inclined to explore new territories, new ideas, new areas of the psyche – not all of which are necessarily wholesome, some in fact are downright dangerous. The statement “cannabis causes psychosis” could therefore to a certain extent be reworked as: “The process that leads a person to consume cannabis is identical to the process that can lead a person to damaging, debilitating mental conditions.” And our laws, what part do they play in this? For myself – and, I suspect, for many others – the worst and most disabling states of cannabis intoxication, those that derange in the short-term and can linger long after the drug has worn off, are the paranoias. Is it perhaps possible that one major cause of paranoia could be the fact that there are men armed with clubs and poison-gases who can kick my door down and drag me off into a cage where they are legally entitled to keep me for five years of my life, as per the directives of the owners of this world who would for some reason prefer me to be drinking alcohol instead?(16)
It’s all for our own good, of course: but it doesn’t work. Psychosis or none; paranoia or joy; high risk, low risk, no risk at all: people are curious, threats and lies and expensive “Just Say No” propaganda don’t change that. There will always be people who like to tie a strip of cord around their ankles and jump from bridges; you can think that’s stupid and reckless, but if you outlaw it you betray the people you claim to be helping, you abdicate your responsibility to protect them, you instead ensure – predictably; Prohibition always fails and always in the same ways – that more people will be drawn to the activity which will be overseen by more and more gangsters who are invariably happy to supply a demand; accidents and fatalities increase. There is another way: compassion and understanding and education, based on the not-too-hard-to-get-one’s-head-around fact that people are going to do what they’re going to do, so provide what safety-nets can be provided, encourage accurate information about both the positive and the negative effects of these substances. An unprepared swimmer might be fooled by riptides; someone who has received accurate information and is able to talk freely about these matters with their peers and elders is more likely to avoid serious risks, is more likely for instance to be able to readjust to consensus reality after a bad trip that could be devastating to someone who had never been told truthfully what bad trips entail and how to recover from them. You can try to scare and intimidate people into abnegating their natural curiosity out of fear of the risks, but I would argue that that is no way to promote genuine mental health: running from the fear of madness is like running from bullies, it only encourages them. On the other hand, to take the example of paranoia, I have found after repeated brutal immersions therein that there are specific tactics you can use to rescue yourself from its sordid grip, to argue the worst of the voices into submission so to access more playful and productive areas of your head instead; it would be endlessly better to teach people such tactics than to deny the facts of what they’re doing, to try futilely to convince them that cannabis isn’t fun and scary and thought-provoking and bewildering and weird and erotic and etc. etc. Doubtless there will always be victims, same as there will always be victims of alcohol, and of peanuts, and bungee-jumping and swimming and going out or staying in: but crime-and-punishment isn’t working, you’re-sick-and-you-need-a-doctor isn’t working; trusting people with their bodies and their minds is the only honourable and effective way to deal with cannabis and other psychedelic drugs.
(8) June 20th: “Dear Jason, I am currently not in my lab in the Netherlands and do not have access to the questionnaire. As soon as I am back (mid July) I will get back to you and send you a copy. Kind regards, Rebecca [Kuepper].”
August 14th: having received no further contact, I sent another e-mail repeating my request. August 16th: “Hello Jason, I will look into it as soon as possible and will send you the according pdf file. Best, Rebecca.” Shortly afterwards I received a copy of the M-CIDI (Lifetime Version) and was able to examine the G-section questions which were asked in the course of this study; these include “Have you ever believed people were spying on you?”, “Have you thought that people you saw talking to each other were talking about you or laughing at you?”, “Have you ever felt strange forces working on you, as if you were being hypnotised or magic was being performed on you, or you were being hit by x-rays or laser beams?”, and “Have you ever been convinced that your spouse or partner was being unfaithful, although he/she told you that was not true?”
(9) “The Composite International Diagnostic Interview: An Epidemiologic Instrument Suitable for Use in Conjunction With Different Diagnostic Systems and in Different Cultures,” by Lee N. Robins, PhD; John Wing, MD, PhD; Hans Ulrich Wittchen, PhD; John E. Helzer, MD; Thomas F. Babor, MD; Jay Burke, MD; Anne Farmer, MD; Assen Jablenski, MD; Roy Pickens, PhD; Darrel A. Regier, MD; Norman Sartorius, MD; Leland H. Towle, MS.
(10) “Structure, Content and Reliability of the Munich-Composite International Diagnostic Interview (M-CIDI) Substance Use Sections” by Gabriele Lachner; Hans-Ulrich Wittchen; Axel Perkonigg; Alexandra Holly; Peter Schuster; Ursula Wunderlich; Dilek Türk; Ela Garczynski; Hildegard Pfister.
(11) “The incidence rate of psychotic symptoms over the [first of the two phases of the study] was 31% (152) in exposed individuals [i.e. cannabis users] versus 20% (284) in non-exposed individuals; over the [second phase] these rates were 14% (108) and 8% (49), respectively.” The first phase lasted three and a half years; the second phase lasted about five years; the mean age of the participants at the start of the study was 18. Instead of criminalising cannabis for the sake of our collective mental hygiene we would evidently be much better served by banning the period of late adolescence.
(12) To be fair and precise with our analogies we should also have to show that people who do not visit Thailand are less likely to sample extracts from the salvia divinorum plant. Given the personality makeup of your typical backpacker I would hazard a guess that this is the case: people not inclined to go looking for obscure entheogens – or endiablogens as the case may be – are probably not so inclined to immerse themselves in a landscape of tropical diseases, communication breakdowns, criminally spicy food and the rest of it. But I cannot provide statistics to prove this link because no such statistics have been collected because no government is throwing money at people attempting to investigate such a link.
(13) 15-28%? For perspective: “Approximately 1% to 2% of the human population has red hair. It occurs more frequently (between 2% and 6% of the population) in northern and western Europeans…” according to wikipedia. If around a fifth of “the general population” experiences a certain phenomenon then by what right does the medical profession decide that this phenomenon constitutes sickness? The argument that “psychotic experiences show continuity with psychotic disorders” could just as effectively be used against the eating of food: having an appetite “shows continuity” with obesity, bulimia, and I daresay various other conditions.
(14) How does this fit with that “estimated 15-28% rate of subclinical psychotic symptoms in the general population” mentioned by the researchers a couple of paragraphs later?
(15) This prompts a question: does the interview – in which a single instance of a single psychotic phenomenon is taken as a sign of disorder – exclude times of drug intoxication from its scope? i.e. if I enjoy a delusion for an hour or two while stoned, is that a “delusion item” qualifying me for membership in the psychosis society? Nothing is said about this in the study itself, but at the bottom of it is a collection of links to “Rapid responses to this article” (http://www.bmj.com/content/342/bmj.d738.full/reply#content-block), one of which purports to answer the question: in a letter from “Lauri O. Kauppila, Med student” we read: “I have corresponded with the authors about this, and share Rebecca Kuepper’s response: ‘Individuals being questioned were instructed to report only those psychotic experiences that occurred independently of intoxication. So in that sense, we did control for the effects of acute intoxication.’” I find this frankly suspicious: are these instructions a part of the M-CIDI or were they specific to this study? If the latter, what other instructions were given? When and in what manner? Shouldn’t such details have been written up by the investigators rather than left to a postscript added by someone unconnected to the research?
(16) “Persecution,” you’ll recall, was listed by the authors of this cannabis-psychosis study as the first of their “classic psychotic symptoms.”