Understanding Psychosis

Psychosis exists along a continuum, with a wide range of individual experiences, health impacts and persistence. For some, psychotic experiences might be temporary or unburdensome. For others, these experiences progress to a psychotic disorder such as schizophrenia or bipolar disorder. Psychotic disorders affect 3%, or over 9 million Americans in their lifetime. Usually first appearing in late teen and early adult years, 100,000 Americans develop a new psychotic disorder each year.

It may be hard to know when a loved one is experiencing the first signs of psychosis. Understanding the warning signs, risks and how treatment works can help:

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What is psychosis?

Psychosis is a condition based in the brain that affects the processing of thoughts, feelings and sensory information. As the condition persists, it becomes more difficult to know the difference between what is real and what is imagined.

Psychosis can be caused by a wide range of things – most commonly psychiatric conditions such as schizophrenia and bipolar disorder; drug use/withdrawal/reactions; and other general medical conditions.

Psychosis exists along a continuum, with a wide range of individual experience of the condition, health impacts and persistence. Most people experience episodes of acute symptoms that come and go, most often first appearing during teenage and young adult years. Psychosis is characterized by unusual beliefs that impact everyday functioning (delusions); hearing, seeing, tasting or seeing things that are imperceptible to others (hallucinations); and impaired processing of thought and emotion.

Because psychosis is most often first experienced as a young person, it has the potential to impair the establishment of healthy foundations for friendships, relationships, school, and work.

Contrary to common assumptions, psychosis doesn't have to be forever. And it doesn't mean you can't lead the life you've envisioned. Psychosis, especially in its earliest stages, can be treated, and most people are able to fully recover. Without treatment and support, however, psychosis can be extremely disruptive to your life and health, so it's important to get help early.

What are the symptoms?

A person’s experience of psychosis is highly individual. But whether mild or severe, chronic or short-lived, symptoms most often come and go in an episodic fashion, and generally fall into three categories:

 “Positive” symptoms represent an increase in unusual behaviors or experiences, such as:

  • Delusions – Fixed, false beliefs, often about oneself or others. Beliefs can be benign or quite distressing.
  • Hallucinations – Hearing, seeing, feeling or tasting things that are imperceptible to others.
  • Thought disorders - Disorganized or illogical thinking.
  • Movement disorders – Some people experience increased, disorganized movement, or lack of response (catatonia).

 “Negative” symptoms represent an absence of typical behaviors or experiences. These often gradually appear first – sometimes months or years before positive symptoms, and can often be missed or misdiagnosed:

  • Loss of interest in everyday activities, especially related to self care
  • Feeling out of touch with family and friends; a desire to socially withdraw
  • Appearing to lack feeling or emotion
  • Decreased ability to plan activities
  • Loss of motivation
  • Disturbed sleep
  • Reduced ability to experience pleasure

 Cognitive symptoms involve difficulty with thought processing:

  • Organizing or making sense of information
  • Paying attention
  • Difficulty remembering things

With access to effective treatment and attention to self-care and stress management, many people are able to minimize disruptive symptoms, allowing for a full recovery and an independent life.

Who is affected?

There are still a lot of unknowns when it comes to brain-based disorders. If you or someone close to you has been touched by psychosis, you can know two things for sure:

  1. You are not alone.
  2. Scientific evidence shows that effective treatment combined with support from friends and family can help to maintain mental functioning and achieve personal goals.

Psychosis exists along a continuum, with a wide range of individual experiences, health impacts and persistence. For some, psychotic experiences might be temporary or unburdensome. For others, these experiences progress to a psychotic disorder such as schizophrenia or bipolar disorder. Psychotic disorders affect 3%, or over 9 million Americans in their lifetime. Usually first appearing in late teen and early adult years, 100,000 Americans develop a new psychotic disorder each year.

Psychosis is an equal-opportunity condition; it has no regard for ethnic background, gender, socioeconomic status or sexual preference. Even so, an increase in incidence is seen in urban (versus rural) dwellers and those who have experienced trauma, suggesting that external stressors likely contribute to the development of psychosis. While both men and women are equally susceptible to psychosis, the condition tends to manifest itself earlier in men – more often first appearing in teens or adolescence for men, and slightly later for women.

A subtle onset of symptoms, and/or hesitation or inability to get treatment most often results in a lag in initial diagnosis and treatment. And yet, on average, people go untreated for the first 1-2 years. Knowing the warning signs can help close this gap, and potentially radically improve a person’s prognosis.

What causes psychosis? What are the risk factors?

Psychosis is thought to be triggered by a mix of two factors: genetic vulnerability (i.e. inherited traits) and stress or environmental influences from life events, drugs or other medical conditions. The exact interplay between these factors is still an active area of research today, but here's a little about what we know: 

You can think about genetic vulnerability and environmental stressors as a dangerous combination - a lot of both can trigger changes in the brain that lead to psychosis. While it’s possible for anyone to experience psychotic symptoms given the right set of stressors, it will generally take a smaller amount of stress to trigger psychosis in people who are born with a larger genetic vulnerability.

 Genetic Risk Factors

  • Schizophrenia, the most common psychotic disorder, is highly heritable and remarkably complex: studies suggest that there are more than 100 genetic regions are associated with the illness.
  • Disrupted neurotransmitters (chemicals that transmit electrical impulses between nerve cells) in schizophrenia include dopamine, serotonin, glutamate and y-aminobutyric acid systems.
  • Lifetime risk for a parent, sibling or child of someone with schizophrenia is 6.5%, versus ~1% for the general population. For twins, it is 40%.

 Environment / Stress / Trauma Risk Factors

  • Stressful life events such as a death in the family, transition to a new school, extreme work or academic pressure, relationship break up
  • Childhood trauma
  • Drug use/withdrawal: high THC marijuana (skunk), speed, cocaine, crystal meth, ecstasy (MDMA), acid (LSD), mushrooms, special/”vitamin” K (ketamine) and heroin (opiates)
  • Lack of sleep
  • Difficult delivery at birth
  • Being born in the winter months
  • Growing up in a big city
  • Moving to a new country

While we’re stuck with our genetic makeup, we can sometimes do something about limiting stress.  If you have a family history of psychosis or mental health issues, taking good care of yourself and limiting stressors on the brain is extra important.

Recovery from psychosis not only means treating symptoms with medication and/or targeted therapy, it also means finding ways to address stressors that are getting in the way of us living the lives we want to lead. Healthy habits such as getting enough sleep, exercise and a nutritious diet can go a long way toward finding and keeping a state of wellbeing.

Sources: Schizophr Bull. 2014 Apr; 40 Suppl 3:S165-94andAbi-Dargham, A. Schizophrenia: Overview and Dopamine Dysfunction. CME Institute, 2014.

What are the different kinds of conditions in which psychosis can occur?

Psychosis can occur in a number of conditions, including mental health conditions considered to be "psychotic disorders," drug use and other medical conditions:

Mental Health Conditions

  • Schizophrenia: Symptoms of psychosis have continued for at least six months, often with “negative” symptoms, such as difficulty or loss of interest in interacting with people and everyday activities.
  • Schizoaffective disorder: Symptoms of schizophrenia, while also having drastic changes in mood (mania or depression, or both).  
  • Bipolar disorder: Sometimes psychosis accompanies bipolar disorder, marked by periods of depression and periods of mania.
  • Depression: Psychosis can occur with very severe depression, which is often marked by periods of intense hopelessness and lack of energy.
  • Brief psychotic disorder: Usually occurs suddenly after a major stressful event, such as a death of a loved one. Recovery is often relatively quick, within a few weeks.  
  • Psychosis Not Otherwise Specified (“Psychosis NOS”):  A diagnosis often used with first episode psychosis, allowing a treatment team time to find the right diagnosis, or freedom to find the things that help a person without a focus on a specific diagnostic label.
  • Borderline Personality Disorder: Includes problems regulating emotions and thoughts, leading to impulsive behavior and unstable relationships.  Can include brief periods of psychosis.
  • Post-Traumatic Stress: Occurs after a traumatic event. Can include include psychotic experiences.
  • Postpartum psychosis: Most often occurs within the first few weeks of giving birth, either as a part of postpartum depression, or on its own.

Drug Use/Withdrawal

  • Drug-induced psychosis: Using or withdrawing from drugs can cause psychotic symptoms that last for short or long periods.

Other Medical Conditions

  • Certain medical conditions, such as heavy metal poisoning, neurological disorders, nutritional deficiencies and toxic reactions can also cause psychosis. Check out this comprehensive list of conditions to learn more.
How is psychosis diagnosed?

Today, we lack definitive, biological tests to diagnose psychosis, however, science is inching closer with EEG (recording electrical activity in the brain), brain imaging, saliva (cortisol levels), and blood tests being explored. Developing this capability requires a better understanding of the complex interplay between genetic makeup, brain and central nervous system differences, and environmental influences.

Currently, psychosis is diagnosed using a comprehensive, structured, and culturally sensitive interview to identify symptoms or early warning signs potentially leading to psychosis. Ideally, co-occurring conditions, such as substance addiction, mood or personality disorders, are also screened for during this interview process. In some cases, an individual’s family is interviewed as well.

If you are concerned about signs or symptoms, an online psychosis screener offers a first step toward understanding if your experiences warrant speaking with a trusted doctor (ideally an early psychosis specialist).

Knowing the warning signs can often help someone get potentially life-changing treatment earlier, before more disabling effects of the condition emerge. Some early signs are:

  • Increased trouble thinking clearly, concentrating, or understanding what others are saying
  • Suspiciousness of others
  • Spending more time alone
  • Becoming easily confused
  • Uncharacteristic, bizarre behavior, statements and/or writing
  • Decline in self-care or personal hygiene
  • Increased sensitivity to sights or sounds
  • Mistaking noises for voices, or hearing sounds or voices that other people don’t
  • Trouble reading or understanding complex sentences
  • Drop in grades or job performance
  • Strange new feelings or having no feelings at all

While identifying psychosis very early can be challenging, initiating a treatment plan as soon as symptoms emerge can radically alter a person’s prognosis.

Visit our Finding Treatment page to find an early treatment program.

Sources: National Alliance on Mental Illness and Early Assessment & Support Alliance

Can psychosis be prevented?

Psychosis is not yet preventable, but it is highly treatable, such that symptoms remain in remission for long periods, and for some, forever. Similar to an early treatment course for cancer, early intervention for psychosis can prevent the progression to a disabling or chronic form of the condition.

Detecting and treating psychosis in its early stages can help ensure continued successful mental and social functioning and increase the odds of living life to one’s full potential. Please see our About Treatment page to learn how.

Is recovery possible? How long does it take?

Psychosis is treatable, and many people fully recover. According to the World Health Organization and the International Early Psychosis Association, early treatment for psychosis can reduce relapse of acute symptoms by more than 50%. Early treatment can also help to improve social interactions, school and work participation, and cognitive function such as focusing, planning, and memory.

The recovery process is different for everyone, so bring a whole lot of patience, courage and discipline with you.  Choosing recovery – meaning, choosing to do the things that make you feel better day after day – is often as rewarding as it is difficult.  And, as much as we want it to be, recovery is almost never a straight line, but instead a winding path with a few detours along the way.

Even so, full recovery can and does happen every day.  Some people return very quickly and get back to their life and responsibilities soon after an acute experience, and others need up to a few years to return more gradually.  For some, long-term medication is necessary, and for others, it can be temporary or avoided. We’re all a bit different. All experiences are valid.

See our Resources page for tools and information on managing symptoms, and join our Facebook and Twitter communities for tips and inspiration for staying strong.

The first few months (and even years) following an initial psychotic episode is the time when treatment can have the greatest impact on prognosis. Research has shown that shorter duration of untreated psychosis is linked to higher functional improvement in social skills, meaningful relationships, participation in meaningful work or school, and decreased rates of substance use, hospitalizations, and suicide.

Learn more About Treatment.

Where can I find treatment and resources?

Please visit our Finding Treatment page for a comprehensive directory of early detection and intervention services.

For links to our favorite resources, from books and films to apps and talks, please visit our Resources page.

How can I become part of a clinical trial?

Click here to review available clinical trials related to psychosis.

How can I help?

There is a solution to manage psychosis successfully: early intervention treatment. Early intervention treatment clinics for psychosis are already flourishing in Europe, Canada, and Australia, where universal healthcare has allowed implementation with fewer policy and budgetary barriers.

We need your help to turn a gradual shift into a revolution in the standard of care for psychosis for the current generation of young Americans – 100,000 of whom face psychosis for the first time each year. (NIMH)

Please learn more about early treatment, share what you learn, and make a gift to expand early treatment services and research today.

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