Psychosis And Co-Occurring Conditions In Mental Health Disorders: Could Something Else Be Going On?

Psychosis is a mental health symptom characterized by a loss of touch with reality. The experience of a psychotic episode is often due to the presence of a certain mental illness where psychosis is a possible symptom—commonly referred to as a psychotic disorder. There are several different psychotic disorders currently listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While many people are familiar with the relatively rare disorders that have a strong association with psychosis, such as schizophrenia, fewer are aware that more common illnesses like depression and substance use disorder can also manifest as psychosis in some cases. We’ll take a brief overview of four such illnesses below.

Psychosis, defined

The symptom of psychosis is defined by three key experiences: 

• Hallucinations, or sensory perceptions that do not actually exist, such as hearing voices that no one else can hear
• Delusions, or beliefs that do not align with reality, such as believing that the government is monitoring your thoughts
• Disorganized thinking, where thoughts do not connect, speech is jumbled, and movements may be unpredictable or bizarre

Although precise estimates are difficult to make, the National Institute of Mental Health reports that around 15 to 100 people out of every 100,000 will experience psychosis each year. It may be a single episode, or it may have the potential to recur throughout a person’s lifetime, depending on the cause. 

Certain factors may put a person at higher risk of experiencing psychosis, such as genetic predisposition, stress, substance use, and not following their professionally prescribed treatment regimen for a psychotic disorder. Treatment for psychosis depends on the cause, but it often includes antipsychotic medications along with certain therapeutic interventions and lifestyle changes.

Common mental health disorders that may manifest as psychosis

Again, there are several different mental health conditions that can cause psychosis as a possible symptom. Some relatively common mental illnesses that can sometimes manifest as psychosis are listed below. 

1. Substance use disorder and psychosis and co-occurring conditions

The American Psychiatric Association defines a substance use disorder as a condition characterized by “uncontrolled use of a substance despite harmful consequences” which results in impairment and difficulty functioning in day-to-day life. The substance in question is typically alcohol or an illicit drug.

The SAMHSA National Helpline for support with substance misuse is available 24/7 and can be reached by calling (800) 662-4357.

Substance use disorder and psychosis can be intertwined, and it may not always be clear to healthcare providers which led to the development of the other or if both developed along the same timeline. When substance use disorder and psychosis co-occur, the complex interplay of symptoms may require specialized treatment approaches to address both conditions effectively. Drug use can be a risk factor for psychosis or may even directly cause psychotic symptoms, and people with psychosis may be motivated to use substances as a result of psychotic delusions or as an unhealthy coping mechanism to address some of the adverse impacts of living with psychosis, such as social isolation.

The technical name for psychosis that is directly caused by substance use is substance-induced psychotic disorder, which is defined as experiencing psychotic symptoms as a result of using a particular substance, with symptoms ceasing once use of the substance ends. It can manifest while the person is under the influence of the substance or while they’re experiencing withdrawal symptoms. 

Other insights that research has suggested about the relationship between psychosis and substance use include the following: 

• People with a psychotic disorder are more likely to have a co-occurring substance use disorder than people who do not meet the diagnostic criteria for a psychotic disorder.
• People who demonstrate psychotic symptoms after using a substance—especially methamphetamine—may have a greater likelihood of developing schizophrenia.
• People who experience psychosis and drink alcohol are more likely to experience social impairment, not take their antipsychotic medications, and have an overall lower quality of life.
• There may be a connection between cannabis use and psychotic-symptom onset for young adults.
• For young adults with psychosis symptoms, tobacco use can cause cardiometabolic concerns.
• The co-occurrence of psychosis and a substance use disorder can lead to an increased risk of:
  • Physical health issues later in life
  • Future disability
  • More intense psychosis symptoms
  • Hospitalization
  • Homelessness

2. Bipolar disorder and psychosis in mental health treatment

Bipolar disorder is a mood disorder that can manifest as manic episodes—which are characterized by euphoria, high energy, and risky decision-making—and depressive episodes. If psychosis co-occurs alongside a diagnosis of bipolar disorder, it’s more likely to accompany an episode of mania than one of depression. The majority of psychotic episodes in those with bipolar disorder involve delusions rather than hallucinations or disorganized thinking. 

People with bipolar disorder who experience psychosis are also more likely to experience the following than people with bipolar disorder who don’t have psychotic symptoms:

• Agitation
• Anxiety
• Hostility
• Extended hospital stays
• More severe swings between mania and depression
• Overall poorer health outcomes

Integrating mental health treatment for both bipolar disorder and psychosis can help address these challenges and improve long-term outcomes. Note that the psychosis that may occur as part of bipolar disorder is also typically less intense than that associated with other psychotic disorders such as schizophrenia. 

3. Post-traumatic stress disorder and co-occurring disorders

Post-traumatic stress disorder (PTSD) is a serious mental health condition that can develop after a person has experienced or witnessed a traumatic event, such as war, a natural disaster, or an assault. Symptoms of PTSD commonly fall into four categories according to the American Psychiatric Association:

1. Intrusion, such as nightmares and flashbacks of the event
2. Avoidance, such as resisting talking about the event or engaging with people or places that may remind the person of it
3. Mood and cognition changes, such as social isolation, anhedonia, and distorted thoughts about the event, the self, or the world
4. Reactivity, such as increased irritability, engaging in reckless behaviors, hypervigilance, and trouble sleeping

The co-occurrence of psychosis and PTSD is unusual but not unheard of. Psychotic symptoms and disorders are more common in people with diagnosed PTSD than people without. According to research from 2017, 30% of individuals diagnosed with PTSD are estimated to experience a psychotic disorder in their lifetime versus only 8% of the general population. 

It’s still unclear if PTSD is a risk factor for developing psychosis or if trauma can increase the likelihood of developing both PTSD and psychosis. Understanding these co-occurring disorders is vital for creating effective, individualized treatment plans for those with PTSD and additional mental health challenges. Some evidence suggests that individuals with PTSD who experience dissociation (the feeling that they are removed from their bodies or experiencing a dream) as one of their key symptoms may be at a greater risk of developing psychosis.  

4. Major depressive disorder and co-occurring mental illness

Major depressive disorder (MDD), commonly referred to simply as depression, is a mental health condition in which a person experiences a variety of physical, emotional, and behavioral symptoms that can impact mood and daily functioning. Key symptoms of MDD include a persistent sense of hopelessness and low mood, but it can manifest as a variety of physical and emotional effects. Severe cases of MDD can sometimes result in the experience of psychotic symptoms as well. 

One reason why seeking treatment for signs of depression right away can be so important is that people with MDD who also develop psychosis may be at risk of the following outcomes and symptoms as well:

• Higher levels of functional impairment
• A decreased chance of recovery
• Lower cognitive performance
• Development of treatment-resistant depression
• An increased likelihood of suicide attempts

If you or someone you know is experiencing suicidal thoughts or behaviors, seek help immediately. The National Suicide Prevention Lifeline can be reached 24/7 by dialing 988.

Learning more about mental health in therapy

Since psychosis can be a distressing and disorienting experience and has the potential to result in harm to oneself or others, seeking immediate, in-person help if you notice symptoms in yourself or a loved one is recommended. Once you’ve sought treatment, your provider may recommend that you meet with a therapist regularly as part of your multi-faceted care plan. Those who are unable to attend traditional in-person therapy sessions may prefer to explore online options.

Accessing support through online therapy platforms

Through an online therapy platform like BetterHelp, you can fill out a brief questionnaire about your needs, preferences, and location, and get matched with a licensed therapist accordingly. You can then meet with them via phone, video call, and/or in-app messaging to address the challenges you may be facing—all from the comfort of home or another place where you have an internet connection. Although online therapy is not considered a first-line treatment for symptoms of psychosis, it can represent one component of longer-term treatment for those with psychosis-related conditions. Research suggests that online therapy can generally offer similar benefits to in-person care for non-emergency situations.

Takeaway

Psychosis is a mental health symptom characterized by a disconnection from reality. It can occur as a result of many different mental health conditions, including more common illnesses such as depression and substance use disorder. Seeking immediate, in-person support for symptoms of psychosis is generally recommended. If your care provider suggests therapy as a component of your longer-term treatment, online therapy is a convenient option that may be worth exploring.