- Psychosis is an abnormal mental state characterised by loss of contact with reality.
- Psychosis is associated with several medical conditions, such as schizophrenia.
- First-episode psychosis occurs most often in the late teens to mid-twenties.
- In vulnerable people, psychosis may be triggered by environmental stressors.
- Symptoms of psychosis include delusions and hallucinations, and inappropriate or bizarre emotional and behavioural responses.
- Treatment with medication and therapy has varying success, depending on the type of psychosis.
Alternative Name: Psychotic episode
What is psychosis?
Psychosis is an abnormal mental state characterised by loss of contact with reality. Symptoms may include delusions and hallucinations, and inappropriate or bizarre emotional responses and behaviour. However, the manner in which psychosis manifests varies widely. A component of several distinct medical disorders, psychotic disorders are mental illnesses in which symptoms of psychosis are experienced, and include disorders such as schizophrenia and bipolar disorder (formerly known as manic depressive illness).
A "psychotic episode" is the period during which someone experiences symptoms of psychosis. “First-episode psychosis" means the person is experiencing psychosis for the first time.
A psychotic episode occurs in four phases:
- Premorbid phase: period prior to onset of symptoms.
- Prodromal or pre-psychotic phase: early symptoms involving changes in thoughts, feelings and behaviour may occur prior to the onset of the frank psychotic symptoms.
- Acute phase: psychotic symptoms, such as hallucinations, delusions, disorganised behaviour and disorganised thinking are experienced.
- Residual or recovery phase: acute symptoms have subsided; some odd beliefs, vague abnormal perceptions and negative symptoms may persist. Many causes of psychosis are treatable and many people recover, either partially or fully.
It is often difficult to differentiate these four phases, and symptoms of psychosis may occur, to varying degrees, in all four.
Symptoms and signs of psychosis
Psychosis affects thoughts, feelings and behaviours in various ways. Symptoms may include:
- Delusions: false beliefs that are firmly held despite evidence and argument to the contrary. Persecutory delusions, a belief that you are being followed, watched, tormented or ridiculed, is the most common type of delusion. Delusions are considered “bizarre” if they are obviously implausible and not derived from ordinary life experiences, such as believing you are a visitor from another planet or that there is a monster living inside your head. Believing you are being followed by the police would be considered non-bizarre.
- Hallucinations: perceiving non-existent sensory stimuli (seeing, hearing, smelling, touching or tasting something that is not actually there). Auditory hallucinations of voices, perceived as distinct from your own thoughts, are the most common.
- Cognition (thought) difficulties: Thoughts become confused and may seem either to speed up or slow down. A person who is thought disordered may be difficult to follow or understand when spoken to. Other problems include difficulties with concentration and memory, and uncertainty about time, place or identity.
- Changed feelings:
- Feeling strange and cut off from the rest of the world
- Mood swings
- Emotions may appear dampened or blunted
- Extreme excitement (agitation): a state of extreme arousal, increased tension and irritability
- Mania: Inappropriate feelings of happiness, often associated with grandiose ideas. This may also manifest as irritability and thinking that feels very fast or pressured.
- Disturbed speech: frequently jumping between seemingly unrelated topics; or speech is so disorganised it cannot be understood.
- Disturbed behaviour which may involve:
- Difficulties performing daily activities
- Dishevelled appearance, or unusual or inappropriate dress
- Inappropriate sexual behaviour
- Strange or inappropriate emotional reactions
- Strange, abnormal or antisocial behavioural responses
Lack of insight into one's own mental state: a psychotic person often does not realise he or she cannot think, perceive or judge normally. However, people do vary in their ability to perceive their condition. For example, some people who hear voices can become aware that these are originating from their own brain and not an external source.
Intelligence is generally not defective: comprehension of reality is distorted rather than reduced.
Types of psychosis
Psychosis is associated with several medical disorders and conditions. Some of the different types of psychosis include:
- Schizophrenia: a psychiatric disorder characterised by disordered thinking and behaviour, and which often includes delusions and hallucinations. Psychotic symptoms are experienced for at least six months, together with significant social or occupational dysfunction.
- Schizophreniform disorder: symptoms are similar to schizophrenia, but persist for between one and six months.
- Schizoaffective disorder: prominent mood symptoms occur with the characteristic symptoms of schizophrenia, but occasionally psychotic symptoms are experienced in the absence of mood symptoms.
- Delusional disorder: involves holding strong, false beliefs (delusions). Hallucinations are usually not present. Apart from the impact of the delusions, psychosocial functioning may not be markedly impaired nor behaviour blatantly strange. However, under some circumstances delusions are sufficiently false to cause problems with day-to-day life.
- Substance-induced psychosis: drug and alcohol use or withdrawal can result in psychotic symptoms. These may disappear once the effects of the substances or withdrawal symptoms wear off. In some cases, psychosis persists after the initial substance-induced psychosis. This is common with stimulant drugs, e.g. methamphetamine (“tik”).
- Dementia: psychotic symptoms may appear with memory disturbances in conditions that cause physiological deterioration of the brain, such as a head injury, AIDS, post-encephalitis, Alzheimer’s Disease or a brain tumour.
- Bipolar disorder (manic depression): psychosis generally appears as part of a more general severe mood disturbance. Psychotic symptoms tend to match your mood. (For example, when depressed, you may hear voices urging you to commit suicide.)
- Major Depressive Disorder: psychosis can be a feature of a severe major depression.
- Postpartum psychosis: psychosis that may develop during the six month period after childbirth. This is usually part of a severe mood disorder.
- Delirium: Psychotic symptoms may be part of an acute confusional state that results from another severe medical disorder, such as meningitis, septicaemia or after an epileptic convulsion.
- Brief psychotic episode: psychotic symptoms appear suddenly in response to a recognisable and highly stressful life event, such as being a victim of violent crime. Symptoms may be severe but are short-lived: the psychosis lasts between one day and one month. You may or may not be aware of your bizarre behaviour.
- Psychosis due to a general medical condition: psychotic symptoms may appear as a result of brain tumours, epilepsy, and other chronic medical conditions. The psychotic symptoms can sometimes be the first sign of the underlying medical condition.
Who gets psychosis and who is at risk?
- About 3% of people will experience a psychotic episode during their lifetime.
- About 1% of the population suffer from schizophrenia.
- Men and women are equally affected by psychotic disorders.
- First-episode psychosis generally occurs in the late teens to mid-twenties.
- Psychosis occurs across cultures and socio-economic groups.
People are at higher risk of developing psychotic disorders if they have:
- A family history of psychotic disorders.
- Substance abuse especially substances like cannabis and methamphetamine (“tik”).
- A schizotypal or paranoid personality disorder (personality disorders characterised by odd beliefs, peculiar behaviour and speech or longstanding suspiciousness and mistrust of people).
- A history of a head injury or other conditions which affect the brain e.g. multiple sclerosis or a brain tumour.
- A history of complications or trauma (weak risk factor) during pregnancy or birth.
Causes of psychosis
The cause of psychosis remains unknown. What has been found is an accumulation of associated factors, some of which appear to be risk factors. It is likely that the “cause” of psychosis is multifactorial. Ongoing research in this field is uncovering more factors involved in causing psychosis.
Given that psychosis is associated with a variety of medical conditions, it is likely that a number of psychological, social and biological factors are involved in its development. Possible causative factors include:
- Dysfunction in the regulating of neurotransmitters e.g. dopamine, causes psychotic symptoms (neurotransmitters being chemical substances involved in transmission of impulses between nerve cells).
- Genetics: people whose close relatives suffer from a psychotic disorder are at increased risk.
- Structural changes to the brain: lesions apparently present since birth or early childhood have been found in the brains of some patients with schizophrenia.
- Stress: some psychoses, such as brief psychotic episodes, appear to be primarily a reaction to stress. In other cases, an inherent vulnerability to psychosis may be triggered by stress.
- Substances: Some substances (e.g. methamphetamine) can induce psychosis; others (e.g. cannabis) can increase certain people's vulnerability to psychosis and may trigger an episode.
It is likely that these factors also work together to cause psychosis. Certain people may acquire vulnerability to psychosis genetically or through an environmental factor, such as a head injury or drug abuse. This vulnerability may then be triggered by additional environmental stressors, such as traumatic life events, further drug abuse or stressful living conditions. People with psychosis may have a low tolerance for stress and intense emotions from others, such as anger or criticism.
How is psychosis diagnosed?
Psychosis can be diagnosed by any mental health professional or general practitioner. A full psychiatric assessment and physical examination are the main methods used to help make the diagnosis of a psychotic illness.
During the assessment, the mental health professional takes a full history that may include asking about family history of mental illness, physical illnesses, developmental information, school or occupational history, and social, family, financial, legal or drug addiction problems. The interviewer will ask in detail about the presenting problem to find out when, and under what circumstances, it began, how it affects daily functioning, and its specific symptoms. With the patient’s consent, a family member may be asked to sit in on the interview at some point to help clarify information.
The mental health professional will then make a diagnosis and suggest treatment. If it is unclear whether a psychiatric illness is present, the mental health professional might refer the person for further investigations, or a second opinion. Sometimes laboratory or radiological testing is needed to exclude treatable causes e.g. a brain tumour. These investigations can include blood tests and brain scans e.g. CT (computerised tomography) scan or MRI (magnetic resonance imaging).
How is psychosis treated?
Treatment varies depending on the cause of the psychosis, but usually consists of a combination of medication, education, support and counselling. It is possible to control most psychotic disorders with appropriate long-term treatment. Care in a hospital is sometimes necessary during the acute phase. Involvement and support of the family will facilitate the treatment and recovery process.
The use of medication is the primary mode of treatment of psychosis. Medications used for the treatment of psychosis are referred to as anti-psychotic drugs. These drugs are prescribed to reduce and treat psychotic symptoms. However, these drugs often have unwanted side-effects which can reduce compliance with taking medication. Examples of side-effects include abnormal muscular movements, sedation, weight gain and lethargy. Some of these side-effects contribute to the social stigma surrounding psychotic disorders and may therefore cause distress. Careful attention to the dose of medication and additional medication can be used to offset certain side-effects.
Anti-psychotics are usually started in the acute phase and continued afterwards, even if symptoms have remitted. They reduce symptoms in the acute phase and help prevent the return of symptoms (relapse) during remission. Medication is usually continued for at least 12 months after a first episode psychosis, but often it is necessary to continue taking medication for life. Studies show that people who take medication as prescribed over one year have a less than 20% chance of relapsing, while those who do not, have a 60-80% chance of relapsing.
Additional medication is often prescribed for specific disorders related to the psychosis (for example, mood stabilisers such as lithium are prescribed for bipolar disorder and antidepressants for depression).
Counselling and psychotherapy
Mental health professionals now believe that talking therapies (such as psychotherapy, cognitive-behavioural therapy and family therapy) conducted in a measured, careful manner can complement other treatments well, and help many people cope with their condition. In cases of brief reactive psychosis, psychotherapy may help the patient cope with the emotional stress that triggered the psychosis.
Cognitive-behavioural therapy helps you recognise how your thinking patterns can influence your feelings and behaviour. This therapy is often used with other treatments and can help in developing strategies to deal with symptoms such as hallucinations and delusions.
Family therapy involves working together with the patient and the family. Family therapy can help people with psychotic conditions maintain mental health, and provides support during stressful times and psychotic episodes, for both the person with psychosis and other family members.
During the recovery phase, important elements of counselling also include educating the patient and the family about the condition and encouraging full participation in treatment by all. Information about the risk of relapse, and guidelines for recognising and seeking treatment for relapses should also be provided as part of individual and family education. Stress management is an important area in which the family can contribute by creating a calm, structured home environment.
Specific issues to be dealt with in the recovery phase include helping both the patient and family make sense of the illness experience and helping the patient to re-establish a confident sense of self, which allows them to return to their previous level of functioning. Problems such as post-psychotic depression, anxiety disorders, altered sense of self, loss of confidence and social withdrawal need to be addressed. Skills training to reacquire social and occupational skills lost to the illness may be necessary, as well as practical assistance with housing and employment.
What is the outcome of psychosis?
Prognosis varies for different types of psychosis. The recovery process is affected by several interacting factors, including the treatment environment, medication and psychological therapies, as well as the family and social environment.
Many people who experience a first episode of psychosis recover well or completely. Others will develop recurring episodes of psychosis, but will be relatively well in between and be able to pursue a productive life.
With brief reactive psychosis, symptoms usually respond to treatment within a week, and the disorder is associated with a good outcome. Repeat episodes may occur in response to ongoing or new stresses.
Chronic or recurrent psychosis may interfere with normal functioning. People who suffer psychotic illness are at increased risk of suicide compared to the general population.
Early treatment usually results in a better outcome. Treatment delays may make the condition get worse, be less responsive to treatment, and make it take longer to go into remission. The lesser the degree of remission, the greater chance of early relapse.
Can psychosis be prevented?
Whether prevention is possible depends on the type of psychosis, in other words, the condition causing it. For example, abstaining from drugs avoids drug-induced psychosis. Some disorders, such as schizophrenia, have no proven prevention strategies.
However, some cases of psychosis can be alleviated, and even prevented, if treatment is started early in people who show signs that they may be at risk. The possibility of an impending psychotic episode should be considered if you experience a persistent change in behaviour or functioning, particularly when there are other risk factors present, such as a family history of psychotic illness.
Someone thought to be in a pre-psychotic phase should be monitored so that treatment can be started without delay, should psychotic symptoms develop. In the meantime, possible causes, such as drug abuse and family problems, can be addressed to reduce the risk of progression to psychosis.
In cases where there has been a previous psychotic episode, or recurrent psychotic episodes, it is important for you and your caregivers to recognise the typical pre-psychotic symptoms, in order to prepare for or avoid an impending psychotic episode.
For people who are prone to brief reactive psychosis, counselling in times of stress may help prevent an episode. Many cases are not easily preventable, however.
When to call the doctor
Call your doctor or mental health professional without delay if you or a friend or family member exhibits behaviour that suggests loss of contact with reality, or if any other symptoms suggestive of psychosis develop.
Consult a mental health professional if you are concerned that you, or someone close to you, may be developing signs of psychosis.
Reviewed by Dr Bonga Chiliza, psychiatrist, Department of Psychiatry, University of Stellenbosch.