Psychosis

Psychosis (also called a “psychotic episode”) is a group of symptoms indicating some loss of contact with reality. The term was first introduced in 1841 by Karl Friedrich Canstatt. It is derived from the Greek word psyche, or “mind,” and the suffix -osis, or “an illness of.” Historically, the term psychosis was used to refer to some mental disorders and brain diseases, and it was related to terms like neurosis and psychopathy. 

DSM-5 & psychosis

In the modern day, the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) defines psychosis as a group of symptoms, which must include the presence of hallucinations without insight, delusions, or both. A central component to psychosis is an impaired version of reality. In primary psychosis, meaning psychosis resulting from a mental disorder and not a psychoactive substance or another condition, symptoms can range from mild to severe. 

Psychosis causes

Psychotic symptoms affect the mind, but the reason they occur in some mental disorders is unclear. During psychotic episodes involving hallucinations (e.g., hearing voices), regions of the brain associated with imagination are typically activated in a similar way to dreaming. This finding has led some scientists to hypothesize that primary psychosis may be driven by low control over imagination regions in the brain. Other scientists believe psychotic disorders are linked to excessive dopamine or glutamate in the brain.  

Psychosis is often thought of as an abrupt break from reality. However, symptoms of psychosis may develop slowly and gradually worsen over time. In the weeks, months, or years before a psychotic episode occurs, some people experience symptoms that they may ignore or try to hide, often due to fear of judgment or stigma. 

First-episode psychosis phases

First-episode psychosis often follows three distinct phases: 

• Prodrome phase: During this phase, changes begin occurring, though clear symptoms of psychosis may not be present. 
• Acute phase: During this phase, clear psychotic symptoms typically occur.
• Recovery phase: With treatment, most people experience recovery from their first episode of psychosis. Effective treatments often include a combination of medications, talk therapy, and social support. 

Symptoms of psychosis typically first develop in an individual’s teens or early 20s. Psychosis is a common mental health challenge facing young people. According to the National Alliance on Mental Health (NAMI), 100,000 young people in the United States experience psychosis each year. Treating underlying mental health conditions proactively may improve prognosis and prevent or reduce the intensity of symptoms.

First-episode psychosis symptoms

When early episodes of psychosis go untreated, symptoms may become more severe and potentially lead to irreversible brain damage, which may explain why FEP is more responsive to medications than prolonged psychosis. FEP includes:

• Disorganized thoughts or behavior 
• Increasing suspicion, isolation, anxiety, tension, mood swings, or apathy 
• Reduced control over thoughts
• Trouble sleeping, changes in appetite, and/or low energy
• Worsening school or work performance
• Substance use
• Changing perception of self
• Confusion about reality
• The feeling that the mind is playing tricks, as evidenced by hearing strange noises or seeing shadows that aren’t there
• Social withdrawal
• Decline in self-care
  
  

Psychosis prevention

Intervening during the prodrome phase may improve outcomes and reduce the likelihood of experiencing acute psychosis. 

Although symptoms of acute psychosis are often unique, the following symptoms commonly occur when someone experiences a psychotic episode: 

Hallucinations are sensory perceptions that occur without the presence of a stimulus. Although hallucinations in general may occur with or without someone’s awareness (insight) that a stimulus is not present, when hallucinations occur without insight, they are classified as a symptom of psychosis. Hallucinations can include the following: 

• Auditory: Hearing voices or other sounds
  • For example, in some cases of schizophrenia, people describe hearing commentary about their life or hearing their thoughts spoken aloud. 
• Tactile: Sensing touch without the presence of physical stimuli
• Visual: Seeing things, such as lights, shadows, objects, shapes, animals, or people that are not there
• Olfactory: Smelling things, in one or both nostrils, without the presence of a chemical stimulus
• Gustatory: Tasting things without eating or drinking
  • People who have experienced psychosis sometimes describe an unpleasant, constant taste in their mouth.
    
• Disorganized or disturbed thoughts and behaviors, such as: 
  • Disorganized or disturbed speech that is confusing or difficult to follow (non-linear thoughts) 
  • Rapid speech 
  • Socially inappropriate actions 
• Negative symptoms: While delusions and hallucinations are positive symptoms (meaning additions or excesses), negative symptoms describe the absence or reduction in expected behaviors. Negative symptoms can include: 
  • Lack of facial expression 
  • Monotone voice or reduced speech 
  • Reduced initiation or interest in others 
• Delusions: Delusions are false beliefs that are maintained regardless of evidence that clearly disproves the belief. They may present in different forms, such as persecution (belief that you are being persecuted by others), grandiosity (belief that you are exceedingly important), or erotomania (believing that someone else is in love with you). They are often characterized as ordinary or bizarre: 
  • Ordinary: Ordinary delusions are those that may come from incorrectly interpreting routine information. For example, someone experiencing ordinary delusions may think that someone is stealing from them despite evidence that they have not had anything stolen. 
  • Bizarre: Bizarre delusions are those that are not typically representative of real possibilities. For example, someone experiencing bizarre delusions may believe that an organ has been taken from their body.

According to the University of Michigan School of Medicine, just as a fever can indicate many sicknesses, such as a bacteria or virus, psychosis is a group of symptoms that are associated with many different conditions. 

While there is no single cause of psychosis, the following factors can influence whether someone experiences psychosis:

• Genetics 
• Age 
• Differences in brain development
• Major stressors, including trauma
• Head injuries
• Sleep deprivation
• Mental health disorders
• Infections, such as meningitis
• Physical conditions 
• Substance use 

Physical conditions that can cause psychosis include: 

• Alzheimer’s disease 
• Brain tumors 
• HIV and AIDS (secondary mania) 
• Hypoglycemia (low blood glucose) 
• Lupus 
• Multiple sclerosis

Mental disorders that can cause psychosis include: 

• Schizophrenia
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder
• Other specified or unspecified schizophrenia spectrum and other psychotic disorder
• Bipolar disorder 
• Severe anxiety disorders 
• Post-traumatic stress disorder (PTSD)⁴
• Severe depressive disorders, including postpartum depression 

Psychosis refers to a set of symptoms rather than a specific diagnosable disorder. However, medical professionals can often diagnose underlying conditions that may be causing psychosis. Psychosis can be caused by several diagnosable mental health conditions, including schizophrenia, bipolar disorder, schizoaffective disorder, and depression.

Mental illness & psychosis

To diagnose a mental illness marked by psychosis symptoms, a professional may: 

• Ask you questions about your symptoms: This process may include asking about your moods, your ability to carry out daily functions, your family history of mental or physical disorders, any hallucinations or delusions you experience, your medical history, your social history, any history of trauma, and any medications or substances that you’re taking. 
• Conduct medical testing: This process may include ordering urine samples and blood tests (including blood counts and metabolic panels, liver function tests, immunologic tests, communicable disease testing, and vitamin deficiency tests). In some cases, X-rays, MRIs, and EEGs (brain activity recordings) may be considered. 
• A medical practitioner or qualified mental health professional may diagnose a primary psychotic disorder after ruling out other conditions and substance-induced psychosis. 

Treatment strategies can vary considerably, depending on the underlying cause of psychotic symptoms. However, the following mental health care approaches can often be combined to effectively address psychosis: 

Medications

Antipsychotic medications are considered the first-line treatment for psychotic episodes and are often prescribed on a long-term basis. Antipsychotics are shown to reduce symptoms in up to 80% of people experiencing first-episode psychosis. 

However, antipsychotics may be more effective in treating positive symptoms (such as delusions and hallucinations), compared with negative symptoms. Additionally, antipsychotics can cause potentially serious side-effects, though fewer side-effects may be present in newer (second-generation) antipsychotics. 

Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis. 

Social support 

People experiencing psychosis often have fewer opportunities for social inclusion, often living in isolation and experiencing unemployment, discrimination, and reduced close relationships. These factors can contribute to withdrawal, low self-esteem, and internalized self-stigma. Interventions that promote social inclusion can improve mental health, physical health, and quality of life in people who experience psychotic disorders. For people with psychosis, support groups, such as Schizophrenics Anonymous and GROW, can improve social inclusion, improve quality of life, and reduce the risk of hospitalization. 

Cognitive-behavioral therapy for psychosis (CBTp) 

Cognitive-behavioral therapy (CBT) is a type of psychotherapy (or talk therapy) that can be adapted to address psychosis. In people at risk of experiencing psychosis, CBTp can effectively reduce the risk of experiencing FEP, and it can reduce symptoms of depression and anxiety, while improving self-esteem, sleep quality, well-being, and quality of life. 

CBTp is an evidence-based approach that aims to address hallucinations, delusions, and negative symptoms to reduce psychological distress and improve the ability to carry out daily functions. During sessions, therapists may work with their clients to evaluate thoughts and behaviors and assess whether they are accurate or helpful. Thoughts and behaviors that are unhelpful may then be re-evaluated, which may improve emotional and behavioral responses. 

People who have psychosis commonly report experiencing trauma, with a 2019 study finding that 80% of 404 people sampled with first-episode psychosis had experienced at least one traumatic event. Individuals who have experienced repeated childhood trauma or adverse life events may be at a particularly high risk of psychosis. Mental health professionals may benefit from incorporating assessment for trauma in their patients to detect those at risk of first-episode psychosis.

Trauma & psychosis

A 2022 study published in BMC Psychiatry sought to address the perception of trauma in people experiencing psychosis. The authors found significant barriers to discussing experienced trauma in clinical settings, including provider concern over distressing clients, high provider workload, and client reluctance to share. They identified the importance of addressing trauma, as traumatic experiences can increase psychosis severity, contribute to substance use, increase suicidal ideation, and act as a barrier to engagement. By asking clients about trauma and creating a strong therapeutic alliance, therapists may find that they can effectively help clients reduce negative self-perceptions, improve self-esteem, and reduce psychotic hallucinations and delusions.

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