Psychosis refers to a lack or loss of connection with reality and involves severe hallucinations and/or delusions. It can be a sign of different psychiatric disorders.
What Is Psychosis?
It is a severe psychological condition and syndrome marked by impaired perception of reality. It primarily involves delusional thoughts & beliefs and visual & auditory hallucinations. A person experiencing this condition may have distorted thoughts and emotions that makes them lose touch with their reality. Primarily a symptom of mental illness, like bipolar disorder and schizophrenia, onset can also occur due to conditions which affect the brain (migraine, epilepsy or Parkinson’s disease), neurocognitive conditions (dementia), excessive stress, trauma 1 , sleep deprivation, physical illness, substance use or medications. The sufferer may exhibit disturbed & disorganized thinking, abnormal speech, unusual behavior and false sensory impressions. They may be unaware of their condition and may have trouble differentiating fantasy from reality. According to a report, the median lifetime prevalence of this condition is about 7.49 per 1000.
According to a 2015 study 2 it is “not a nosological entity” but a syndrome. The researchers explain that “Psychosis is a clinical syndrome composed of several symptoms. Delusions, hallucinations, and thought disorder may be regarded as core clinical features.” Also known as a psychotic episode or psychotic experience, it can affect each person differently depending on the cause of onset. Some people may experience only one episode while others may have multiple episodes during their lifetime. An episode can drastically affect an individual’s perception of what is real and what is imagination. It impairs how the brain processes new and existing information leading to hallucinations and delusions. They may have false beliefs, such as believing that someone is trying to harm them, or hear, see or sense things that are not real or non-existent. Such experiences can be terrifying for the sufferer which can lead to distrust of loved ones, self-harm and even suicidal ideation. This is why it is crucial to seek medical attention. Effective treatment along with support from family and community can enable the person to live a healthier, more satisfying life.
It is a combination of psychological symptoms leading to a break from reality. Psychotic experiences are a common aspect of a number of medical, neurodevelopmental, neurologic 3 , neuropsychiatric and psychiatric conditions. According to a 2012 study 4 , “It includes hallucinations, delusions including paranoia, aggressive behaviour, apathy and other psychotic phenomena that occur in a wide range of degenerative disorders including Alzheimer’s disease 5 , synucleinopathies (Parkinson’s disease, dementia with Lewy bodies), Huntington’s disease, frontotemporal degenerations, motoneuron and prion diseases.” It can also lead to the eventual decline and impairment of cognitive function. Psychosis can also be caused by co-occurring substance use disorders. One 2011 study 6 shows that substances such as cannabis, amphetamines, cocaine and hallucinogens can cause psychotic reactions when used or abused. This syndrome can be exceptionally distressing and difficult to cope with not just for the patients, but for their family and loved ones as well.
The word psychosis is derived from the term ‘psyche’, referring to the Greek goddess of the soul, and means the mind or the soul. During a psychotic episode, a person’s mind tends to get affected which adversely impacts their thoughts, beliefs, perceptions and behaviors. Apart from hallucinations and delusions, other symptoms may include incoherent speech, inappropriate behavior, sleep difficulties, lack of motivation, stress, anxiety, depression, social withdrawal and impaired daily functioning. Psychosis is associated with different mental health disorders such as schizophrenia spectrum disorder (schizophrenia, schizophreniform disorder or schizoaffective disorder), bipolar I disorder, post-traumatic stress disorder (PTSD) and schizophrenia. One 2018 study 7 states that “Psychosis as a primary mental health disorder is a diagnosis of exclusion, as psychosis can be a direct symptom of underlying medical or neurologic disease.” However, this condition can also be experienced by someone with severe depression and postpartum psychosis. The sufferer can –
- Falsely believe that someone exists even though they may not be real
- Falsely believe that they are in danger
- Falsely believe that they are very important and are being tracked secretly
- See things, places or individuals that do not exist in reality
- Hear voices that are not real
- Smell odors that others can’t
- Have abnormal movements or motionlessness (catatonia)
As their hallucinations and delusions appear as real to them, they are mostly not aware that they may have a mental illness. Moreover, they may also distrust friends and family when presented with contradicting evidence or asked to seek medical support. They may also find it hard to trust the doctor and believe that healthcare professionals are trying to hurt them. In extreme cases, the condition can make the patient suicidal or homicidal. Recent research 8 has found that syndrome can be regarded as an evolutionary adaptive mechanism that responds to changing environments. The research paper explains that “psychotic symptoms may not be viewed as an illness but as an adaptation phenomenon, which can become out of control due to different underlying brain vulnerabilities and external stressors, leading to social exclusion.”
However, it should be noted that psychosis is not officially recognized as a diagnosable psychiatric disorder, rather it is a symptom of certain mental health conditions. Moreover, one should also understand that psychosis is different from psychotic disorders, which refer to serious & recognized mental illnesses.
First Episode Of Psychosis (FEP)
Psychotic episodes typically appear initially during a person’s adolescence or during their young adulthood. It is believed that young individuals have an increased risk of experiencing this condition. However, a young adult may show certain subtle signs before experiencing the first episode of psychosis (FEP 9 ). A person may be confused, behave unusually, have difficulties with daily tasks & education, may become withdrawn or suicidal 10 . This phase is identified as the prodromal stage 11 of psychotic illness. The sufferer may eventually begin to develop a distorted perception of reality and slip into psychotic experiences. They may see or believe things that aren’t true or present in the environment, believe in abstract thoughts and become unable to interpret social cues and interactions appropriately. One should seek professional help immediately when the syndrome is suspected as early diagnosis and treatment can help.
Researchers 12 explain that “first-episode psychotic patients typically experience 12 to 24 months of psychosis before receiving treatment, and a long duration of untreated psychosis may be associated with a poorer treatment response.” However, early intervention 13 can help to improve outcomes. Further studies 14 have found that primary universal prevention of the syndrome can also be helpful in reducing the symptoms and mental disorders.
Signs And Symptoms Of Psychosis
The signs and symptoms for the prodromal stage of psychotic illness and the eventual psychotic experience may be different. Early warning signs of this syndrome may include –
- Behavioral changes before actual psychotic episodes
- Reduced performance in school or work
- Inappropriate emotions
- Lack of mental clarity
- Memory and cognitive problems
- Lack of attention or concentration
- Rapid and incoherent speech with peculiar words and phrases
- Highly sensitive to stimuli
- Lack of self-care
- Intense and inappropriate emotions or a lack of emotions
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Here are the primary symptoms of a full psychotic episode:
The sufferer may see, hear, sense, smell, taste and feel things which are not real and non-existent. However, it may feel very real to them. “Hallucinations are perceptions in the absence of an external stimulus and are accompanied by a compelling sense of their reality,” explains a 2009 study 15 .
The individual may strongly hold false beliefs that may generate from their disturbed thoughts and perceptions. For instance, they may mistakenly believe that others are trying to harm them or that they have special abilities. According to a study 16 , “A delusion is a belief that is clearly false and that indicates an abnormality in the affected person’s content of thought.”
Other common symptoms of psychosis include the following:
- Disordered thinking
- Abnormal or inappropriate behavior
- Disorganized speech
- Reduced emotional expression
- Lack of motivation
- Inability to experience joy or pleasure
- Stress, anxiety and depression
- Trouble concentrating
- Sleep difficulties
- Social withdrawal
- Suicidality 17 or homicidality 18
Causes Of Psychosis
The exact causes of psychotic episodes have not yet been fully identified as every individual may experience it differently. Hence, the cause of the syndrome can be different for every patient. “Psychosis is a heterogeneous psychiatric condition for which a multitude of risk and protective factors have been suggested,” suggests a 2018 study 19 . However, there are certain common factors that may trigger the onset of psychosis, such as:
Research 20 shows that there is strong evidence of genetic predisposition in the development of psychotic disorders. Hence, it may run in families. So if you have one or more first degree relatives, like a parent or a sibling, who have had psychotic episodes, then you have a higher risk of developing psychosis.
Traumatic experiences, like war, abuse, loss of a loved one or sexual assault, is another contributing factor. Childhood trauma 21 is significantly associated with adolescent & adult psychotic experiences. “Psychotic patients who suffered an early trauma usually need psychiatric treatment at a younger age, have more severe symptoms and need to be hospitalized more often than those who have not experienced early traumatisation,” explains a 2007 study 22 .
3. Psychiatric disorders
This syndrome can be a symptom for a wide range of mental illnesses like bipolar disorder, schizophrenia, posttraumatic stress disorder, major depressive disorder, obsessive compulsive disorder & dissociative disorders. Other conditions like Alzheimer’s disease, Parkinson’s disease, dementia, Huntington’s disease, chromosomal disorders, brain tumors, HIV, syphilis, stroke and epilepsy may also have a significant impact. According to a recent research paper 23 , “Psychosis may result from a primary psychiatric illness, substance use, or another neurologic or medical condition. Brain abnormalities have correlated with first-episode psychotic disorders, including reduced prefrontal, superior, and medial temporal grey matter.”
4. Drugs and substances
Different kinds of psychoactive substances 24 , such as amphetamines, LSD, cocaine, psilocybin, ketamine and marijuana can lead to psychotic episodes. Substance-induced 25 psychosis can make patients become aware of their psychotic experience and lead to higher levels of suicidality. Studies 26 show that such “drugs affect the dopaminergic and glutaminergic systems in the brain, which have both been associated with psychotic symptoms such as hallucinations and delusions.” But it has been observed that substance-induced psychotic symptoms do not tend to last as long as psychosis in schizophrenia. Moreover, alcohol and smoking can also be a contributing factor.
Certain types of prescribed medications 27 can also cause psychotic episodes as a side effect. Known as prescription drug-induced psychosis, it can occur due to sedative-hypnotics, stimulants or narcotics. “An association between abnormal involuntary movements and psychotic relapse was previously reported in a group of patients compliant with antipsychotic medication,” explains a 2012 study 28 . Talk to your doctor about probable side effects before taking any medications.
Apart from these, there may be some other probable causes and risk factors associated with the onset of psychosis such as:
- Brain changes
- Medical conditions
- Physical illness or injury
- Female hormonal shifts 29
- Sleep deprivation 30
- Grief and bereavement
- Stress and anxiety
- Spiritual experiences
Diagnosis Of Psychosis
It is a syndrome and a symptom of different physical and mental health conditions. Hence, it is not considered a separate diagnosis by itself. If you or someone you love is experiencing psychotic episodes, then it is best to consult a doctor, psychologist or a psychiatrist. The doctor may conduct a psychiatric evaluation to determine any underlying conditions that may cause the syndrome. They may ask certain questions about the symptoms, duration and severity, check the patient’s medical and family history, conduct a few lab tests etc.
After the doctor has successfully done a proper diagnosis and identified the cause(s) of psychosis, they will recommend an effective treatment plan best suited for the patient and their condition.
Treatment Of Psychosis
The treatment for this syndrome is based on the specific cause for the onset and development. As a result, the treatment plan may vary and be complex for certain individuals. While in some cases hospitalization may be required, for most sufferers a combination of medications, therapy and support can prove to be effective. Although treatment cannot fully relieve the symptoms, it can help the individual better manage their hallucinations and delusions so that they can function better in daily life and experience less overall impairments.
Here are some of the most common treatment approaches for this condition:
Research 31 indicates that both first-generation or typical antipsychotics and second-generation or atypical antipsychotics can prove to be beneficial in reducing the severity and frequency of hallucinations and delusions. The first generation drugs, such as chlorpromazine (thorazine), haloperidol (haldol), fluphenazine (prolixin), loxapine (loxitane) and perphenazine (trilafon), can be high effective but may lead to some serious side effects as well. However, second-generation drugs, like aripiprazole (abilify), ziprasidone (geodon), risperidone (risperdal), olanzapine (zyprexa) and clozapine (clozaril), can also be effective but with lower side effects and risks. According to a 2001 study 32 , atypical “antipsychotic drugs have potent therapeutic actions on the positive symptoms of psychosis with far fewer side effects, especially motor effects.”
Psychotherapy, also known as talk therapy, can also be recommended by the doctor for the treatment of psychosis. Therapy approaches like cognitive behavioral therapy (CBT) can enable patients to identify their distorted thoughts & behaviors and develop coping techniques to overcome them. Psychotherapies like CBT 33, 6(12), 32–39. )) can be especially effective for patients with comorbid conditions. Cognitive behavioral therapy for psychosis (CBTp) is often recommended to patients. It is a distinct form of psychotherapy that is utilized along with medications for the management of psychotic episodes and schizophrenia. According to a 2018 study 34 , “Compared with usual care or any control, CBT for psychosis significantly improved psychotic symptoms, based on evidence of moderate to adequate quality; no significant improvements were observed for social function, relapse, or quality of life outcomes.”
Other treatment approaches that may be recommended along with medications and cognitive behavioral therapy may include the following:
- Cognitive enhancement therapy (CET 35 )
- Supportive psychotherapy
- Art therapy 36
- Family psychoeducation & family intervention
- Coordinated specialty care (CSC)
- Community support and care
- Self-care such as avoiding substances & alcohol and a healthier lifestyle
As treatment is targeted at the psychiatric disorder causing psychosis, the patient and their families need to have patience and determination as recovery may be slow and take time. However, support, treatment compliance and attending therapy sessions regularly can reduce the symptoms and lead to better outcomes.
Support For Caregivers
Living with and caring for a loved one or a family member with psychosis can undoubtedly be challenging and stressful. This is why it is crucial and caregivers learn to build healthy boundaries while being empathic and compassionate. Here are some suggestions that can enable you to better care for your patient and look after yourself as well:
- Listen actively to them and understand their thoughts, emotions and problems. By being calm and supportive, you can listen to them and find out how you may help them.
- Try to understand what the patient is feeling instead of what they are believing or experiencing. Their thoughts may be unreal but their emotions and responses to those thoughts are real.
- Be respectful and compassionate to them. Instead of forcing your opinions and thoughts on them, even though you may be right, avoid making their decisions. Don’t be overly critical of them.
- Ask how you can help them and support them in completing normal, daily tasks and chores, if they need you to.
- Be prepared for a crisis situation by keeping all important contact details and other things, like medications, easily available and accessible.
- Practice self-care and don’t avoid your own needs. Look after yourself and seek therapy for yourself, if needed.
- Help other family members, friends and loved ones understand what the patient is going through.
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Recovering From Psychosis
Effective treatment involving medications and therapy can help people experiencing psychotic episodes to recover faster. However, support from family and friends, along with self-care, also plays a crucial role in the recovery process. By following the treatment plan, one can reduce the symptoms and build a better life for themselves.
Psychosis At A Glance
- Psychosis is a lack or loss of connection with reality and involves severe hallucinations and/or delusions.
- It primarily involves delusional thoughts & beliefs and visual & auditory hallucinations.
- The sufferer may exhibit disturbed & disorganized thinking, abnormal speech, unusual behavior and false sensory impressions.
- Psychotic episodes typically appear initially during a person’s adolescence or during their young adulthood.
- A combination of medications, therapy and support can prove to be effective.
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