What Are The Three Stages Of Psychosis, And How Can You Recognize Them?

Psychosis can have dramatic symptoms that cause an affected individual to sense stimuli that aren’t there, exhibit confusing behavior, and develop false beliefs that seem resistant to evidence or logic. Yet these symptoms don’t usually appear out of the blue. Psychosis commonly occurs in three distinct stages. Knowing how they typically unfold may help you recognize the warning signs in yourself or a loved one.

Mental health experts usually categorize the phases of psychosis as prodromal, acute, and recovery. In general, only the acute phase involves the frequent appearance of active psychotic symptoms, such as delusions and hallucinations. In the prodromal and recovery periods, an individual may display disturbances in thinking and behavior while still being mostly aware of what is and isn’t real. Therapy can often be helpful during the prodromal and recovery phases.

Symptoms of psychosis

The word “psychosis” is sometimes tossed around casually as a synonym for “mental illness.” However, in modern medicine, psychosis largely refers to a specific type of dysfunctional mental state in which a person’s experience of reality is severely distorted. This can involve several different symptoms:

• Hallucinations: Perceptions of stimuli that aren’t really present, such as hearing voices no one else hears or perceiving nonexistent insects

• Delusions: Incorrect beliefs that persist even when they’re highly improbable or contradict existing evidence, such as the idea that you’ve been targeted by a conspiracy or that you are secretly the extraterrestrial ruler of Earth

• Disorganization: Confused, illogical mental processes, speech, or behavior, such as assuming a connection between two people because their names rhyme

• Negative symptoms: The loss or diminishment of certain ordinary mental processes, such as a decreased ability to feel emotions or motivation

What is a psychotic episode? 

Even in people diagnosed with psychotic disorders, the “active symptoms” of psychosis (hallucinations, delusions, and disorganized thinking or behavior) may not be present at all times. Instead, an individual may experience one or more psychotic episodes, or periods of days, weeks, or months during which they frequently experience active symptoms. Between these episodes, a person may have a fairly clear grasp of reality, though other kinds of psychiatric symptoms can still be present. 

Stage 1: The prodromal phase of psychosis

Psychotic episodes are often preceded by a period of atypical thoughts, feelings, and behavior known as the prodromal stage or prodrome. During this time, the person may display early signs of psychosis that aren’t yet severe or persistent enough to meet the criteria for diagnosis. The prodromal phase typically lasts between one and five years before first-episode psychosis, with an average duration of 21 to 22 months. The prodrome may be significantly shorter in people who have had previous psychotic episodes and are at risk of relapse. In individuals experiencing first-episode psychosis, the prodromal phase may not be recognized until after acute psychosis begins. Many prodromal symptoms can resemble other psychiatric illnesses, including depressive and anxiety disorders. 

Evidence suggests that most people (around 80%) who exhibit prodromal symptoms will not go on to develop psychosis. Some kinds of psychiatric or medical interventions may further reduce the risk. However, people who have experienced prodromal symptoms may still be at higher risk of psychosis than the general population. They could also have an elevated risk of developing other types of mental illness.

The prodromal phase typically lasts between one and five years before first-episode psychosis, with an average duration of 21 to 22 months. It may be significantly shorter in people who have had previous psychotic episodes and are at risk of relapse.

Recognizing the prodromal phase of psychosis

The exact features of the psychosis prodrome phase may vary between individuals, but they commonly include the following:

• Withdrawal from social engagement

• Lack of interest in activities

• Marked decline in performance at school, work, hobbies, and other fields of achievement

• Cognitive deficits, such as slower thinking or difficulty concentrating

• Sleep disturbances

• Suspicion or paranoia

• Depression or anxiety

• Decrease in personal grooming and hygiene

• Unusual or overly intense emotional reactions

As the prodromal phase continues, the individual may exhibit symptoms that resemble a mild form of psychosis:

• Atypical ideas similar to delusions, such as perceiving hidden meanings and patterns in ordinary events

• Difficulty telling reality from imagination

• Unusual or incoherent speech patterns

• Odd perceptual experiences, sometimes including brief or indistinct hallucinations

• Actions that seem out of character or don’t appear to serve a logical purpose

These psychosis-like symptoms can be signs that a person is nearing a psychotic episode.

Stage 2: The acute phase of psychosis

The acute stage (sometimes also called the “active stage”) typically begins when a person begins displaying clear signs of a psychotic disorder, meaning at least one of the following:

1. Delusions

2. Hallucinations

3. Disorganized speech

A person in the active phase may talk in a way that’s extremely difficult to follow, such as jumping rapidly between apparently disconnected topics or giving answers that don’t relate to the questions you ask. They may also describe seeing or hearing stimuli that you don’t perceive or insist on beliefs that seem impossible or highly unlikely. Severely disrupted behavior can also be a component of acute psychosis, but this is not enough on its own for a diagnosis. 

The duration of acute psychosis can be highly variable. Some people may experience what’s known as “brief psychotic disorder,” in which their symptoms go away within a few weeks. Others may remain in a state of active psychosis for years. 

Stage 3: The recovery phase of psychosis

In some cases, psychotic episodes may fade away on their own, while in other cases, they may persist until the individual receives effective psychiatric treatment. Either way, once the acute symptoms of psychosis are no longer present, the recovery stage begins. This doesn’t necessarily mean that the person is cured. While some people successfully recover from first-episode psychosis and never experience another occurrence, there can be a risk of recurring episodes. Still, a two-year study published in 2015 reported that about 69% of patients did not relapse within one year of their initial remission. About 57% of patients did not relapse after two years of initial remission. 

The risk may be considerably higher when people don’t receive proper treatment or follow treatment recommendations for their condition. One study found that discontinuing the use of antipsychotic medication led to a relapse rate around five times higher than the baseline. Although people in the recovery stage typically have few or no active symptoms of psychosis, they may still experience other forms of mental distress. Many people exhibit negative symptoms, such as the following:

• Lack of motivation or volition

• Diminished ability to function socially

• Decreased sense of pleasure and enjoyment

• Limited speech and movement

• Low emotional responsivity

Managing the stages of psychosis

Responding effectively to a psychotic disorder may depend on correctly identifying the various stages of the illness. Different phases often call for different treatment approaches.

Prodromal stage

Some studies have found that psychosocial treatments during the prodromal stage may reduce the risk that the affected individual will transition to a psychotic episode. Learning to recognize risk factors and common signs of early psychosis could enable people to recognize when their friends or family members need psychiatric assistance. Watching for telltale signs in young people may be especially advisable. Prodromal psychosis most commonly appears in adolescence or early adulthood in men. In women, the onset tends to be later, typically beginning in the late 20s or early 30s rather than the late teens or early 20s. 

When young people begin displaying disorganized thinking or reporting abnormal auditory or visual experiences, encouraging them to seek appropriate treatment is often beneficial. Psychological methods such as cognitive behavioral therapy (CBT) may effectively prevent the development of acute psychosis.

Acute stage

Treatment of acute psychosis may require antipsychotic medication to realign a person's thoughts and perceptions with reality. Some people may have difficulty accepting that they have a problem, let alone following treatment guidelines, when they’re experiencing severe hallucinations and delusions. Antipsychotics must be prescribed by a doctor or psychiatrist and typically require regular monitoring for side effects and efficacy.

Recovery stage

Once a person enters the recovery stage, an ongoing regimen of antipsychotic medication can help them prevent relapse. Some clinical trials suggest that long-acting injectable medications might be particularly effective since they only require administration once a month instead of every day. Other helpful factors can include those listed below:

• Psychotherapy to assist with negative symptoms and support mental health

• Cognitive training to improve mental and social function

• Psychosocial interventions, such as supportive employment, to enable greater engagement in community life

• Education of family members on how to support a loved one with psychosis

If you’re in recovery from psychosis and having a hard time finding the right therapist to help manage your symptoms, online treatment may be a helpful option. Internet-based mental health care may put you in touch with a wider pool of professionals than you’d be able to find in your immediate area, often making it easier to connect with one whose expertise and demeanor match your needs.

Connecting with a mental health provider through online therapy

Early research suggests that online psychotherapy can be an effective approach to managing psychosis, although those experiencing acute symptoms may need to seek care in person. A 2017 trial showed evidence that an online CBT program for people with schizophrenia (a psychotic disorder) could both reduce psychotic symptoms and improve social cognition.