Psychosis: Symptoms, Causes & Treatment Options

What Is Psychosis and How Does It Affect the Brain?

Psychosis is a mental health condition characterized by a disconnection from reality, primarily through hallucinations (perceiving things that aren't there) and delusions (fixed false beliefs). It affects approximately 3% of people at some point in their lives and involves changes in brain chemistry, particularly dopamine signaling.

Psychosis represents a significant disruption in a person's perception of reality and their ability to think clearly. When someone experiences psychosis, their brain processes information differently, leading to experiences and beliefs that others cannot share or verify. This isn't a matter of intelligence or willpower - it's a change in how the brain functions that requires proper medical treatment.

The condition affects the brain's ability to filter and interpret information from the senses and from memory. Under normal circumstances, our brains constantly evaluate incoming information, distinguishing between internal thoughts and external reality. In psychosis, this filtering mechanism becomes disrupted, causing internal experiences to feel as real and compelling as external ones.

Research has identified several brain changes associated with psychosis. The most well-established finding involves the neurotransmitter dopamine. In people experiencing psychosis, there appears to be increased dopamine activity in certain brain regions, particularly the limbic system. This excessive dopamine signaling may contribute to the "salience" or importance that the brain assigns to ordinary stimuli, potentially explaining why people with psychosis often find special meaning in coincidences or neutral events.

Brain imaging studies have also revealed structural changes in some people with psychotic disorders, including reduced gray matter volume in certain areas, particularly the prefrontal cortex and temporal lobes. These regions are crucial for executive function, memory, and language processing - all of which can be affected during psychotic episodes.

Types of Psychotic Disorders

Psychosis can occur as part of several different mental health conditions, each with distinct features and treatment approaches. Understanding the specific type of psychotic disorder is important for determining the most effective treatment plan.

Schizophrenia is perhaps the most well-known psychotic disorder. It typically involves persistent symptoms including hallucinations, delusions, disorganized thinking, reduced emotional expression, and cognitive difficulties. To be diagnosed with schizophrenia, symptoms must be present for at least six months and significantly impact daily functioning.

Schizoaffective disorder combines features of schizophrenia with mood episodes (either depression or mania). People with this condition experience psychotic symptoms alongside significant changes in mood that meet criteria for major depressive or manic episodes.

Brief psychotic disorder involves sudden onset of psychotic symptoms that last between one day and one month, with complete recovery afterward. This often occurs following extreme stress or trauma.

Delusional disorder is characterized by one or more persistent delusions without the other symptoms typically seen in schizophrenia. The delusions often involve situations that could theoretically occur (being followed, having a disease, having an unfaithful partner) rather than bizarre impossible scenarios.

What Are the Main Symptoms of Psychosis?

The hallmark symptoms of psychosis are hallucinations (hearing, seeing, or feeling things that aren't there) and delusions (fixed false beliefs). Additional symptoms include disorganized thinking and speech, reduced emotional expression, social withdrawal, and difficulty with concentration and memory.

Psychotic symptoms are typically divided into three categories: positive symptoms (experiences added to normal functioning), negative symptoms (experiences or abilities that are reduced), and cognitive symptoms (changes in thinking abilities). Understanding these different symptom types helps both patients and families recognize what's happening and communicate effectively with healthcare providers.

Positive Symptoms

The term "positive" doesn't mean these symptoms are good - rather, it indicates that something is added to the person's experience that wasn't there before. These are often the most noticeable and distressing symptoms of psychosis.

Hallucinations involve perceiving things that others cannot. Auditory hallucinations (hearing voices) are the most common type in psychotic disorders. These voices may seem to come from outside the person's head or from within it. They might comment on the person's behavior, carry on conversations, or give commands. Some people hear just one voice, while others hear multiple voices.

Visual hallucinations (seeing things that aren't there), tactile hallucinations (feeling sensations on the skin), olfactory hallucinations (smelling things others can't), and gustatory hallucinations (unusual taste experiences) also occur, though less frequently. When visual hallucinations are prominent, healthcare providers often look for underlying medical causes or substance use.

Delusions are firmly held beliefs that persist despite clear evidence to the contrary and that are not shared by the person's cultural or religious community. Common types include:

• Persecutory delusions: Believing one is being watched, followed, or targeted for harm
• Referential delusions: Believing that random events, comments, or gestures are specifically directed at oneself
• Grandiose delusions: Believing one has special powers, wealth, or identity
• Control delusions: Believing one's thoughts or actions are being controlled by external forces
• Thought broadcasting: Believing that one's thoughts can be heard by others

Negative Symptoms

Negative symptoms represent a reduction or absence of normal functions. These symptoms are often more persistent than positive symptoms and can significantly impact quality of life and daily functioning.

Flat affect refers to reduced emotional expression through facial expressions, voice tone, and gestures. The person may speak in a monotone and show little reaction to situations that would normally provoke emotional responses.

Alogia (poverty of speech) involves reduced spontaneous speech and brief, empty responses to questions. The person may struggle to generate and express thoughts.

Avolition is a decrease in motivation to initiate and complete goal-directed activities. Simple tasks like personal hygiene, household chores, or attending appointments may become difficult to start or finish.

Anhedonia is the reduced ability to experience pleasure from activities that were previously enjoyable, including social interactions, hobbies, food, or physical intimacy.

Social withdrawal involves decreased interest in interacting with others and reduced participation in social activities. This can be both a cause and effect of the other negative symptoms.

Cognitive Symptoms

Cognitive symptoms affect thinking processes and can significantly impact daily functioning, work performance, and the ability to engage in treatment.

Attention and concentration difficulties make it hard to focus on tasks, follow conversations, or complete multi-step activities. Reading, watching movies, or participating in meetings may become challenging.

Working memory problems affect the ability to hold and manipulate information in mind. This can make it difficult to follow instructions, do mental arithmetic, or remember what was just said.

Executive function impairment affects planning, organization, and problem-solving abilities. Making decisions, prioritizing tasks, and adapting to new situations may become more difficult.

What Are the Early Warning Signs of Psychosis?

Early warning signs (prodromal symptoms) often appear weeks to months before a full psychotic episode. These include sleep disturbances, social withdrawal, declining work or school performance, unusual thoughts or suspiciousness, difficulty concentrating, and reduced emotional expression. Recognizing these signs enables early intervention.

The period before a first psychotic episode is called the prodrome. During this phase, subtle changes in thinking, feeling, and behavior often occur that, in hindsight, were early warning signs. Recognizing these signs is crucial because early intervention can significantly improve outcomes and may even prevent the development of a full psychotic disorder in some cases.

Research has identified several common prodromal symptoms. Changes in sleep patterns are frequently among the first signs - the person may start sleeping much more or much less than usual, or their sleep-wake cycle may become irregular. Sleep disturbance itself can worsen other symptoms and increase vulnerability to psychosis.

Social withdrawal often occurs gradually. The person may start declining invitations, spending more time alone, or showing less interest in relationships that were previously important. They may become suspicious of friends or family members or interpret neutral comments as hostile.

Academic or occupational functioning typically declines. Grades may drop, work performance may suffer, and the person may struggle to complete tasks that were previously manageable. Concentration and memory problems contribute to these difficulties.

Unusual perceptual experiences may begin, though they're often less defined than full hallucinations. The person might report feeling that things look or sound slightly different, that colors are more vivid or muted, or that they're having difficulty distinguishing their own thoughts from sounds in the environment.

Changes in thinking may manifest as difficulty expressing thoughts clearly, jumping between unrelated topics, or becoming preoccupied with unusual ideas. The person might develop new interest in supernatural or philosophical topics or become convinced they've discovered important patterns or meanings that others can't see.

What Causes Psychosis?

Psychosis results from a combination of genetic predisposition, brain chemistry changes (especially dopamine), and environmental triggers. Risk factors include family history, substance use (particularly cannabis), severe stress or trauma, and certain medical conditions. No single cause explains all cases.

Understanding what causes psychosis requires appreciating that it typically results from multiple factors interacting together. The current scientific understanding suggests a "stress-vulnerability" model, where some people are born with greater biological vulnerability to psychosis, and environmental stressors can trigger episodes in these vulnerable individuals.

Genetic Factors

Genetics play a significant role in vulnerability to psychotic disorders. If you have a first-degree relative (parent or sibling) with schizophrenia, your risk of developing the condition is about 10 times higher than the general population. For identical twins, if one twin has schizophrenia, the other has about a 50% chance of also developing it.

However, genetics alone don't determine who develops psychosis. Many people with genetic vulnerability never develop the condition, and many people who develop psychosis have no family history. Researchers have identified many genes that each contribute a small amount of risk, rather than a single "psychosis gene."

Brain Chemistry and Structure

The dopamine hypothesis remains central to understanding psychosis. Medications that increase dopamine can cause psychotic symptoms, while medications that block dopamine receptors (antipsychotics) reduce them. However, the relationship is more complex than simply "too much dopamine" - different brain regions may have different levels of dopamine activity.

Other neurotransmitters, including glutamate, serotonin, and GABA, also appear to be involved. Brain imaging studies have shown structural differences in some people with psychotic disorders, including reduced volume in certain areas and altered connectivity between brain regions.

Substance Use

Certain substances can trigger psychotic episodes, particularly in vulnerable individuals. Cannabis use is a well-established risk factor, with studies showing that heavy cannabis use, especially starting in adolescence, significantly increases the risk of developing a psychotic disorder. High-potency cannabis and synthetic cannabinoids carry particularly high risks.

Stimulants including amphetamines, methamphetamine, and cocaine can cause psychotic symptoms during intoxication or withdrawal. In some cases, stimulant-induced psychosis persists even after the person stops using the drug.

Hallucinogens like LSD and psilocybin can cause temporary psychotic-like experiences during intoxication. In rare cases, particularly with repeated use, these experiences may persist or trigger an ongoing psychotic disorder.

Psychological and Social Factors

Childhood trauma, including physical, sexual, or emotional abuse, significantly increases the risk of later psychosis. The relationship appears to be dose-dependent - more severe or repeated trauma confers greater risk.

Immigration and urban living have been associated with increased psychosis rates, possibly due to social stress, discrimination, or reduced social support.

Social isolation and lack of support can both increase risk and worsen outcomes in people who develop psychosis.

Medical Conditions

Various medical conditions can cause psychotic symptoms, which is why thorough medical evaluation is essential. Conditions that can cause or contribute to psychosis include:

• Brain tumors or injuries
• Epilepsy, particularly temporal lobe epilepsy
• Dementia and neurodegenerative diseases
• Autoimmune conditions affecting the brain (e.g., anti-NMDA receptor encephalitis)
• Infections affecting the brain (HIV, syphilis, encephalitis)
• Severe thyroid disorders
• Severe vitamin deficiencies (B12, folate, thiamine)
• Delirium from any cause

How Is Psychosis Diagnosed?

Psychosis is diagnosed through comprehensive psychiatric evaluation including detailed history, mental status examination, and physical tests to rule out medical causes. There's no single test for psychosis - diagnosis relies on clinical assessment of symptoms, their duration, and their impact on functioning.

Diagnosing psychosis and determining its underlying cause requires a thorough evaluation by qualified mental health professionals. The process typically involves multiple components, as accurate diagnosis is essential for appropriate treatment planning.

Psychiatric Evaluation

The cornerstone of psychosis diagnosis is a comprehensive psychiatric assessment. This includes a detailed interview about current symptoms, their onset and duration, and how they've affected the person's life. The clinician will ask about the nature of any hallucinations (what senses are involved, what the experiences are like) and explore the content and conviction of any unusual beliefs.

A complete psychiatric history covers previous mental health episodes, family history of mental illness, developmental history, substance use history, and any previous treatments and their effectiveness. Understanding the timeline of symptoms is crucial for distinguishing between different psychotic disorders.

The mental status examination assesses the person's appearance, behavior, speech, mood, thought content, thought process, perceptions, cognition, and insight. This standardized assessment helps clinicians document current functioning and track changes over time.

Medical Evaluation

Because many medical conditions can cause psychotic symptoms, physical examination and laboratory tests are essential parts of the diagnostic workup. Standard tests typically include:

• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• Vitamin B12 and folate levels
• Urine drug screen
• HIV testing (in appropriate circumstances)
• Syphilis testing

Brain imaging (MRI or CT scan) may be ordered, especially if this is a first episode of psychosis, if there are unusual features suggesting a neurological cause, or if the person has focal neurological signs. An EEG may be performed if seizures are suspected.

Diagnostic Criteria

The specific psychotic disorder diagnosis depends on the pattern, duration, and combination of symptoms. For schizophrenia, the DSM-5 requires at least two of the following for a significant portion of time during a one-month period, with at least one being from the first three: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. Some signs of the disorder must persist for at least six months.

Other psychotic disorders have different criteria - for example, brief psychotic disorder requires symptoms lasting at least one day but less than one month, while delusional disorder involves primarily non-bizarre delusions without the other features of schizophrenia.

How Is Psychosis Treated?

Treatment for psychosis typically combines antipsychotic medication with psychosocial interventions. Second-generation antipsychotics are usually first-line treatment, with 70-80% of patients showing significant improvement. Cognitive behavioral therapy, family therapy, and social skills training support recovery.

Effective treatment of psychosis requires a comprehensive approach that addresses both the acute symptoms and the person's long-term recovery and functioning. The goals of treatment include reducing symptoms, preventing relapse, minimizing medication side effects, and helping the person achieve their personal goals for life, work, and relationships.

Antipsychotic Medications

Antipsychotic medications are the cornerstone of treatment for psychotic disorders. These medications work primarily by blocking dopamine D2 receptors in the brain, which helps reduce positive symptoms like hallucinations and delusions. About 70-80% of people with psychosis show significant improvement with antipsychotic treatment.

Second-generation (atypical) antipsychotics are typically the first choice for treatment. These include risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, paliperidone, lurasidone, and others. They generally have a lower risk of movement-related side effects compared to older medications, though they may cause weight gain and metabolic changes.

First-generation (typical) antipsychotics such as haloperidol and chlorpromazine are still used, particularly when newer medications aren't effective or affordable. They're highly effective for positive symptoms but carry a higher risk of movement disorders (extrapyramidal symptoms and tardive dyskinesia).

Long-acting injectable antipsychotics are available for many medications and can be given every 2-4 weeks or even less frequently. These can be helpful for people who have difficulty remembering daily pills or who prefer not to take daily medication.

Finding the right medication often involves some trial and error, as people respond differently to different medications. The goal is to find the medication that provides the best symptom control with the fewest side effects. Regular monitoring is essential, including checks of weight, blood sugar, cholesterol, and for some medications, blood counts.

Psychosocial Treatments

Cognitive Behavioral Therapy for Psychosis (CBTp) helps people examine and modify their thoughts about their experiences. It can help reduce distress from hallucinations, test the validity of delusional beliefs, develop coping strategies, and improve functioning. CBTp is recommended as an adjunct to medication by major treatment guidelines.

Family intervention involves education and support for family members, along with improved communication strategies. Studies consistently show that family involvement improves outcomes and reduces relapse rates. Family members learn about psychosis, how to recognize early warning signs, and how to support their loved one's recovery without being overprotective.

Social skills training helps people develop or regain abilities needed for daily functioning and social interaction. This may include practicing conversations, learning to manage medication, navigating public transportation, or handling job interviews.

Supported employment and education programs help people return to or maintain work and school. Evidence shows that with appropriate support, many people with psychotic disorders can work, and that working itself supports recovery.

Cognitive remediation therapy uses exercises and strategies to improve cognitive functions like attention, memory, and problem-solving. This can help address the cognitive symptoms that often interfere with daily functioning and work.

Coordinated Specialty Care

For people experiencing a first episode of psychosis, coordinated specialty care (CSC) programs have shown excellent results. These programs provide a team-based approach including case management, family support, individual therapy, medication management, education and employment support, and crisis planning - all coordinated around the individual's recovery goals.

Research has shown that people who receive CSC have better symptom outcomes, stay in treatment longer, and have better quality of life and functioning compared to those receiving standard care. Many countries have developed early intervention services based on this model.

When Should You Seek Help for Psychosis?

Seek help immediately if you or someone you know experiences hallucinations, delusions, confused thinking, or significant behavioral changes. For immediate safety concerns, contact emergency services. For non-emergency situations, contact a mental health professional, primary care doctor, or mental health crisis line.

Knowing when and how to seek help for psychotic symptoms is crucial, as early treatment significantly improves outcomes. Unfortunately, many people delay seeking help due to fear, stigma, lack of awareness, or because the nature of psychosis itself can impair insight into the need for treatment.

Signs That Require Immediate Attention

Certain situations require urgent evaluation or emergency services. Contact emergency services or go to an emergency department if:

• There's risk of harm to self or others
• The person is unable to care for themselves (not eating, drinking, or staying safe)
• Symptoms have come on suddenly, especially if accompanied by fever, confusion, or neurological symptoms
• The person is experiencing severe distress and cannot be calmed
• Psychotic symptoms are accompanied by substance intoxication or withdrawal

Non-Emergency Situations

For concerning symptoms that don't require emergency care, options include contacting a mental health professional, speaking with a primary care doctor who can provide initial assessment and referrals, calling a mental health crisis line for guidance, or reaching out to early intervention services if available in your area.

Many areas have specialized first-episode psychosis programs that prioritize rapid assessment and treatment initiation. These programs understand the importance of early intervention and work to minimize delays in care.

What Is Living with Psychosis Like?

Living with psychosis involves ongoing management including medication, therapy, and lifestyle factors. Many people achieve stable recovery and lead fulfilling lives with work, relationships, and personal goals. Recovery is a personal journey that extends beyond symptom control to reclaiming meaningful life activities.

Living with a psychotic disorder is different for everyone, and outcomes vary widely. While psychosis can be a serious and challenging condition, it's important to emphasize that many people recover well and lead meaningful, satisfying lives. Understanding what to expect and developing effective coping strategies can make a significant difference.

The Recovery Journey

Recovery from psychosis is typically viewed as a journey rather than a destination. For some, recovery means complete freedom from symptoms without medication. For others, it means managing ongoing symptoms while pursuing personal goals and maintaining quality of life. The concept of recovery emphasizes hope, empowerment, and building a meaningful life, not just symptom reduction.

Studies show that long-term outcomes are better than many people expect. About 25% of people who experience a first episode of psychosis will never have another. Many others achieve good symptom control with treatment and are able to work, have relationships, and pursue their goals. The trajectory of recovery often improves over time, with many people functioning better in later years than in the years immediately following diagnosis.

Practical Aspects of Management

Medication adherence is one of the most important factors in preventing relapse. Finding a medication regimen that provides good symptom control without intolerable side effects is essential. Working collaboratively with healthcare providers, keeping track of symptoms and side effects, and not stopping medication without medical guidance are all important.

Recognizing early warning signs of relapse allows for early intervention that can often prevent a full episode. Common early warning signs include sleep disturbances, increased anxiety, social withdrawal, and the return of unusual thoughts or perceptions. Many people work with their treatment team to develop a personalized early warning signs list and action plan.

Lifestyle factors that support mental health include regular sleep schedules, physical exercise, stress management, avoiding substance use, and maintaining social connections. These factors won't replace treatment but can significantly support overall wellbeing and stability.

Building a Support System

Support from family, friends, and peers who understand the condition can make a tremendous difference in recovery. Support groups, whether in-person or online, provide opportunities to connect with others who have similar experiences, share coping strategies, and reduce isolation.

Many people find that education and advocacy activities - helping others understand psychosis and fighting stigma - become meaningful parts of their recovery journey. Speaking openly about mental health can help reduce the stigma that often accompanies psychotic disorders.