Psychosis: Symptoms, Causes & Treatment Options

What Is Psychosis and How Does It Affect the Brain?

Psychosis is a mental state where a person loses touch with reality, experiencing hallucinations (sensing things that aren't there), delusions (fixed false beliefs), and disorganized thinking. It affects approximately 3% of people at some point in their lives and involves disruptions in brain chemicals, particularly dopamine.

Psychosis represents a significant change in how the brain processes information and interprets the world. When someone experiences psychosis, their perception of reality differs substantially from that of others around them. This isn't a choice or a character flaw—it's a medical condition that affects brain function.

The term "psychosis" describes a set of symptoms rather than a specific disease. Think of it like a fever: just as fever can be caused by many different infections or conditions, psychosis can result from various underlying causes including psychiatric disorders, medical conditions, substance use, or extreme stress. Understanding this distinction is crucial because treatment approaches vary depending on the root cause.

Psychotic disorders are a group of psychiatric conditions characterized by episodes of psychosis. The most well-known is schizophrenia, but the category also includes schizoaffective disorder, delusional disorder, and brief psychotic disorder. Each has distinct features, duration requirements, and treatment considerations.

Research has shown that psychosis involves changes in several brain systems. The dopamine hypothesis suggests that excessive dopamine activity in certain brain pathways contributes to positive symptoms like hallucinations and delusions. Meanwhile, reduced dopamine activity in other areas may contribute to negative symptoms like lack of motivation. Other neurotransmitters, including glutamate and serotonin, also play important roles, which explains why different medications can be effective.

Types of Psychotic Disorders

Several distinct conditions fall under the umbrella of psychotic disorders, each with unique characteristics:

Schizophrenia is the most common psychotic disorder, affecting about 1% of the global population. It typically develops gradually over months to years, with symptoms appearing in late adolescence to early adulthood. Diagnosis requires psychotic symptoms lasting at least one month, plus ongoing functional difficulties for at least six months. Schizophrenia often includes both "positive" symptoms (hallucinations, delusions) and "negative" symptoms (reduced motivation, emotional expression, and social engagement).

Schizoaffective disorder combines features of schizophrenia with mood disorder symptoms—either depression or manic episodes. People with this condition experience psychotic symptoms that persist even when their mood is stable, distinguishing it from mood disorders with psychotic features.

Delusional disorder involves fixed false beliefs without the prominent hallucinations or disorganized thinking seen in schizophrenia. People with this condition can often function relatively well in areas unrelated to their delusions. Common types include persecutory delusions (believing one is being targeted), jealous delusions (unfounded beliefs about partner infidelity), and grandiose delusions (believing one has special powers or importance).

Brief psychotic disorder involves sudden onset of psychotic symptoms lasting less than one month, often triggered by extreme stress or trauma. Full recovery is common, though the experience can recur with future stressors.

What Are the Symptoms of Psychosis?

The main symptoms of psychosis include hallucinations (most commonly hearing voices), delusions (false beliefs held with absolute conviction), disorganized thinking and speech, and changes in behavior and emotions. Symptoms can develop gradually over weeks or months, or appear suddenly.

Psychosis symptoms are typically divided into "positive" symptoms (additions to normal experience) and "negative" symptoms (subtractions from normal function). Understanding both categories helps recognize psychosis earlier and appreciate the full impact on someone's life.

Hallucinations

Hallucinations are sensory experiences that occur without external stimulation—perceiving something that isn't actually there. While they can involve any sense, auditory hallucinations (hearing things) are by far the most common in psychosis.

Auditory hallucinations often take the form of voices. These may be familiar voices or completely unknown ones. They might seem to come from inside one's head or from external sources. The voices may comment on the person's actions, criticize their appearance, or give commands. Some people hear multiple voices having conversations. The content can range from neutral observations to deeply disturbing or threatening messages.

What makes these experiences particularly challenging is their complete realism. To the person experiencing them, these voices are just as real as any other sound. This is why simply telling someone "the voices aren't real" rarely helps—from their perspective, the experience is undeniably real.

Visual hallucinations—seeing things that aren't there—are less common in primary psychotic disorders like schizophrenia but may occur, particularly when psychosis is caused by drugs, medical conditions, or delirium. Other sensory hallucinations include feeling things crawling on the skin, smelling odors others cannot detect, or experiencing unusual physical sensations.

Delusions

Delusions are fixed, false beliefs held with absolute certainty despite contradictory evidence. Unlike ordinary mistaken beliefs, delusions are not corrected by presenting facts and typically influence behavior significantly.

Common types of delusions include:

• Persecutory delusions: Believing one is being watched, followed, harassed, or conspired against. The person may believe specific individuals, organizations, or vague forces are targeting them.
• Referential delusions: Believing that unrelated events have personal significance—that the television is sending special messages, that strangers are communicating through gestures, or that song lyrics contain hidden meanings meant specifically for them.
• Grandiose delusions: Believing one has special powers, extraordinary importance, or a unique mission. This might include believing one is a religious figure, has discovered a world-changing secret, or has abilities others lack.
• Control delusions: Believing one's thoughts, feelings, or actions are being controlled by outside forces. This might involve beliefs that thoughts are being inserted into or withdrawn from one's mind.
• Somatic delusions: False beliefs about one's body—that organs are rotting, that parasites are infesting the body, or that one's physical form is changing.

Thought Disorder

Thought disorder refers to disruptions in the organization and expression of thoughts. People experiencing this symptom may have difficulty thinking clearly, following a train of thought, or communicating coherently.

Signs of thought disorder include jumping between unrelated topics mid-sentence, using words in unusual ways, creating new words (neologisms), or producing speech that sounds fluent but lacks logical connection. The person may start answering a question but veer off into tangents, never returning to the point. In severe cases, speech becomes so disorganized it's essentially incomprehensible—often called "word salad."

Thought disorder can also involve the experience that thoughts are being broadcast to others, that others can read one's mind, or that foreign thoughts are being inserted. These experiences are deeply distressing and contribute to social withdrawal.

Negative Symptoms

Negative symptoms represent reductions in normal emotional and behavioral functioning. While less dramatic than hallucinations or delusions, they often cause more long-term disability:

• Reduced emotional expression: Decreased facial expression, vocal tone variation, and body language
• Avolition: Decreased motivation to initiate and follow through on activities
• Anhedonia: Reduced ability to experience pleasure from activities previously enjoyed
• Social withdrawal: Decreased interest in social interactions and relationships
• Poverty of speech: Reduced quantity and spontaneity of speech

These symptoms can be mistaken for laziness or depression, but they represent actual changes in brain function. They often persist even after positive symptoms improve and can significantly impact quality of life and functional recovery.

How Is Psychosis Noticed by Others?

Others may notice someone developing psychosis through personality changes, social withdrawal, deteriorating self-care, talking to oneself, inappropriate emotional reactions, difficulty following conversations, or expressing unusual beliefs. Changes often develop gradually over weeks to months.

Psychotic symptoms affect people differently. Some individuals express their experiences openly—talking about their beliefs, responding to hallucinations visibly, or behaving in ways that clearly deviate from their normal patterns. Others become increasingly withdrawn, passive, and isolated, making the changes subtler but equally concerning.

Family members and friends often notice that something seems "off" before recognizing specific psychotic symptoms. The person may seem preoccupied with internal experiences, making it difficult to engage them in conversation. They might appear to be listening or responding to something others cannot perceive. Their emotional responses may seem inappropriate—laughing at serious moments or showing no reaction to news that would normally affect them.

Common observable changes include:

• Speaking about unusual beliefs, such as being followed, watched, or having special powers
• Appearing distracted or responding to stimuli others cannot perceive
• Sudden, unexplained laughter or distress
• Increasing social isolation and avoidance of previously enjoyed activities
• Declining performance at work or school
• Neglecting personal hygiene and self-care
• Speaking in ways that are difficult to follow or don't make sense
• Expressing paranoid concerns or suspicion about others

If you're concerned about someone you know, approach the situation with compassion rather than confrontation. Arguing about whether their experiences are "real" is rarely productive. Instead, express concern for their wellbeing and encourage them to speak with a healthcare professional. Our guide for supporting someone with mental health concerns offers additional guidance.

When Should You Seek Medical Care for Psychosis?

Seek medical care immediately if you or someone you know experiences hallucinations, delusions, disorganized thinking, or significant changes in behavior and personality. Call emergency services if there's any risk of self-harm or harm to others. Early treatment dramatically improves outcomes.

Recognizing when to seek help is crucial because early intervention significantly improves prognosis. The longer psychosis goes untreated, the more difficult recovery can become. Research consistently shows that duration of untreated psychosis is one of the strongest predictors of long-term outcomes.

Contact a mental health professional or primary care provider if you notice:

• Persistent unusual thoughts or beliefs that seem unfounded
• Hearing voices or seeing things others don't perceive
• Increasing difficulty thinking clearly or communicating
• Feeling detached from reality or one's own thoughts
• Significant decline in work, school, or social functioning
• Progressive social withdrawal and isolation

If you've experienced psychosis before and notice warning signs returning—increased suspiciousness, difficulty sleeping, heightened anxiety, or early symptoms you recognize—contact your psychiatric care team promptly. Having a crisis plan in place can help you get appropriate care quickly.

What Causes Psychosis?

Psychosis results from a combination of genetic vulnerability, brain chemistry changes, and environmental triggers. Common causes include psychiatric disorders (schizophrenia, bipolar disorder), drug use (cannabis, stimulants), medical conditions, severe stress, and sleep deprivation. There is rarely a single cause.

Understanding the causes of psychosis requires appreciating that multiple factors typically interact. The "stress-vulnerability model" helps explain this: some people have a greater inherent vulnerability to psychosis (due to genetics or early brain development), and various stressors can trigger episodes in vulnerable individuals.

Psychiatric Disorders

Psychosis occurs as a core feature of several psychiatric conditions. Schizophrenia is the most common primary psychotic disorder, but psychotic symptoms can also occur in bipolar disorder (during manic or depressive episodes), severe depression, and schizoaffective disorder. In these conditions, psychosis results from underlying changes in brain function and chemistry.

Genetic Factors

Family history significantly influences psychosis risk. Having a first-degree relative (parent, sibling) with schizophrenia increases one's risk approximately tenfold. However, genes don't determine destiny—most people with genetic vulnerability never develop psychosis, and many people with psychosis have no family history. Current understanding suggests that multiple genes each contribute small amounts of risk, interacting with environmental factors.

Drug-Induced Psychosis

Many substances can trigger psychotic symptoms:

• Cannabis: Particularly high-potency products and heavy use during adolescence significantly increase psychosis risk
• Stimulants: Amphetamines, methamphetamine, and cocaine can induce paranoia and hallucinations
• Hallucinogens: LSD, psilocybin, and similar drugs cause temporary psychotic experiences
• Alcohol: Severe withdrawal can cause delirium with psychotic features
• Other substances: PCP, synthetic cannabinoids, and various new psychoactive substances

Drug-induced psychosis typically resolves once the substance clears the system, but repeated use increases the risk of developing a persistent psychotic disorder. The relationship between cannabis and psychosis has received particular attention—while most cannabis users never develop psychosis, heavy use (especially during adolescence) approximately doubles the risk in vulnerable individuals.

Medical Conditions

Various medical conditions can cause psychotic symptoms, making thorough medical evaluation essential:

• Brain tumors, infections, or inflammation
• Epilepsy and some seizure disorders
• Hormonal disturbances (thyroid disorders, adrenal conditions)
• Autoimmune conditions affecting the brain
• Dementia and neurodegenerative diseases
• Severe nutritional deficiencies
• Some medications, particularly corticosteroids

Stress and Sleep Deprivation

Extreme stress and severe sleep deprivation can trigger psychotic symptoms even in people without other risk factors. Prolonged sleep deprivation disrupts brain function and can cause hallucinations and paranoid thinking. Severe trauma or overwhelming stress can trigger brief psychotic episodes, particularly in vulnerable individuals. These causes underscore the importance of stress management and healthy sleep in maintaining mental health.

Postpartum Psychosis

Postpartum psychosis is a rare but serious condition occurring in approximately 1-2 per 1,000 births, typically within the first few weeks after delivery. It involves rapid onset of confusion, mood instability, and psychotic symptoms. This is a psychiatric emergency requiring immediate treatment, but with proper care, most women recover fully. Women with a history of bipolar disorder or previous postpartum psychosis are at higher risk.

How Is Psychosis Diagnosed?

Psychosis is diagnosed through comprehensive psychiatric evaluation, including detailed symptom history, mental status examination, and physical tests to rule out medical causes. Blood tests, brain imaging, and sometimes lumbar puncture help exclude conditions that can mimic psychosis.

Accurate diagnosis is crucial because treatment depends on identifying the underlying cause. A thorough evaluation typically includes several components:

Psychiatric Assessment: A psychiatrist or mental health professional conducts detailed interviews about symptoms, their onset and progression, personal and family psychiatric history, substance use, and how symptoms affect daily functioning. They assess the nature of hallucinations and delusions, thought organization, insight into the condition, and suicide risk.

Physical Examination: Since many medical conditions can cause psychotic symptoms, physical examination is essential. This includes neurological examination looking for signs of brain pathology.

Laboratory Tests: Blood tests help rule out medical causes including thyroid disorders, vitamin deficiencies, infections, and substance use. Drug screening is typically performed since substance-induced psychosis requires different management than primary psychotic disorders.

Brain Imaging: MRI or CT scans may be performed, especially in first-episode psychosis, to rule out tumors, stroke, or other structural brain abnormalities. While these scans cannot diagnose psychiatric conditions, they help exclude medical causes.

Diagnosis follows established criteria from classification systems like the DSM-5 (Diagnostic and Statistical Manual) or ICD-11 (International Classification of Diseases). Specific diagnoses depend on symptom patterns, duration, and associated features. For example, schizophrenia requires at least six months of illness including at least one month of active psychotic symptoms.

How Is Psychosis Treated?

Psychosis treatment typically combines antipsychotic medication to reduce symptoms with psychological therapies like CBT to help manage experiences and prevent relapse. Comprehensive care includes family education, social support, and rehabilitation services. Early treatment significantly improves outcomes.

Effective treatment of psychosis involves multiple components tailored to individual needs. The goals extend beyond symptom reduction to include preventing relapse, improving quality of life, and helping people achieve their personal goals.

Early Intervention Is Critical

Research consistently demonstrates that the duration of untreated psychosis predicts long-term outcomes. Specialized early intervention programs that provide rapid assessment and comprehensive treatment show significantly better results than standard care. These programs combine medication, therapy, family work, and practical support.

If you notice early warning signs in yourself or someone else, seeking help promptly can make a substantial difference in recovery.

Medication Treatment

Antipsychotic medications are the cornerstone of psychosis treatment. They work primarily by reducing dopamine activity in brain pathways involved in psychotic symptoms. Two main generations exist:

Second-generation (atypical) antipsychotics are typically used first. They include risperidone, olanzapine, quetiapine, aripiprazole, and others. These medications effectively reduce positive symptoms and generally have fewer movement-related side effects than older medications, though they may cause weight gain and metabolic changes.

First-generation (typical) antipsychotics like haloperidol remain effective options, particularly when second-generation medications haven't worked adequately. They're associated with movement disorders but may be preferred in some situations.

Finding the right medication often requires patience. Not everyone responds to the first medication tried, and dosing may need adjustment. Side effects vary between medications, so if one causes intolerable effects, alternatives exist. It's crucial not to stop medication without medical guidance, as abrupt discontinuation significantly increases relapse risk.

Long-acting injectable antipsychotics offer an alternative to daily pills. Given every 2-4 weeks (or longer with newer formulations), they ensure consistent medication levels and remove the need to remember daily doses. Many people find these preferable once stable.

Psychological Treatments

Psychological therapies play an essential role alongside medication:

Cognitive Behavioral Therapy for psychosis (CBTp) helps people understand and manage their symptoms. It doesn't aim to eliminate hallucinations or delusions but helps reduce distress they cause and develop coping strategies. CBTp can help people test the accuracy of beliefs, reduce anxiety about symptoms, and improve functioning.

Family intervention involves educating family members about psychosis and teaching communication and problem-solving skills. This approach reduces relapse rates and improves outcomes, recognizing that family environment significantly impacts recovery.

Psychoeducation helps people understand their condition, recognize warning signs of relapse, and take an active role in their treatment. Knowledge empowers people to make informed decisions about their care.

Social skills training and cognitive remediation programs help address functional difficulties many people experience, improving abilities needed for work, relationships, and daily life.

Support Services

Recovery from psychosis often requires support beyond clinical treatment:

• Care coordination: A dedicated contact person helps navigate services and ensures continuity of care
• Supported employment: Programs helping people find and maintain competitive employment
• Housing support: From supported living to help maintaining independent housing
• Peer support: Connecting with others who have experienced psychosis can be invaluable

When Is Hospital Care Needed for Psychosis?

Hospital admission for psychosis may be needed when symptoms are severe, there's risk to self or others, the person cannot care for themselves, or intensive treatment is required. Most people can be treated as outpatients, but hospital care provides safety and intensive support when needed.

Hospital admission is considered when the severity of symptoms or associated risks exceed what can be safely managed in the community. This includes situations where someone is actively suicidal or homicidal, so disorganized they cannot meet basic needs, or at risk due to dangerous behavior driven by psychotic symptoms.

Hospitalization provides a safe environment, close monitoring, rapid medication adjustments, and intensive therapeutic input. Length of stay varies based on treatment response but is typically as brief as possible while ensuring safe discharge.

In some situations, treatment may be necessary even when the person refuses it. Involuntary treatment is a last resort, governed by mental health legislation that balances individual autonomy with the need to protect people who cannot make safe decisions due to their illness. Such decisions require careful evaluation by qualified psychiatrists and include safeguards and appeal processes.

Can You Recover From Psychosis?

Yes, many people recover fully from psychosis. Research shows approximately 25% of first-episode patients recover completely, while another 50% improve significantly with ongoing treatment. The earlier treatment begins and the more actively one engages with it, the better the outcomes.

Recovery from psychosis is not only possible but common with appropriate treatment. The outdated view that psychotic disorders inevitably lead to decline has been replaced by recognition that many people live full, satisfying lives.

Several factors influence recovery:

• Duration of untreated psychosis: Shorter duration before treatment begins predicts better outcomes
• Medication adherence: Consistent treatment dramatically reduces relapse risk
• Social support: Strong family and social connections aid recovery
• Absence of substance use: Continued drug use worsens prognosis
• Engagement with treatment: Active participation in therapy and rehabilitation improves outcomes

Recovery is often a gradual process. The acute psychotic symptoms typically improve within weeks to months of starting treatment, but full recovery—regaining previous functioning and quality of life—often takes longer. Many people continue to improve for years after their first episode.

It's important to have realistic expectations while maintaining hope. Some people may have persistent symptoms or experience recurrent episodes despite good treatment. But even when symptoms persist, people can learn to manage them effectively and live meaningful lives. The concept of "recovery" in mental health has evolved to encompass not just symptom elimination but living well despite ongoing challenges.

How Can You Prevent Psychosis Relapse?

Preventing psychosis relapse involves continuing prescribed medication, learning to recognize early warning signs, managing stress, maintaining regular sleep patterns, avoiding substances, staying connected with support networks, and having a crisis plan in place.

Once someone has experienced a psychotic episode, preventing recurrence becomes a key treatment goal. While complete prevention isn't always possible, many strategies significantly reduce relapse risk.

Medication Adherence

Continuing antipsychotic medication as prescribed is the single most important factor in preventing relapse. Studies show that stopping medication—even after years of stability—dramatically increases relapse risk. If you have concerns about medication (side effects, feeling you don't need it anymore), discuss these with your doctor rather than stopping independently. Adjustments can often be made to address concerns while maintaining protection.

Recognize Your Early Warning Signs

Most people experience characteristic warning signs before a full relapse. These might include:

• Sleep disturbances—sleeping too little or too much
• Increased anxiety, tension, or irritability
• Social withdrawal
• Difficulty concentrating
• Increased suspiciousness
• Changes in eating patterns
• Neglecting responsibilities or self-care

Learning your personal warning signs allows early intervention. Working with your treatment team and family to identify these signs—and agreeing in advance what to do when they appear—can prevent minor deterioration from becoming full relapse.

Develop a Crisis Plan

A written crisis plan specifies what you want to happen if you become unwell. It might include who to contact, what treatments you consent to, and what support you need. Creating this while you're well ensures your preferences are known and can guide care during a crisis when you might not be able to communicate them clearly.

Lifestyle Factors

Several lifestyle modifications support mental stability:

• Sleep: Maintain regular sleep patterns; sleep deprivation is a significant trigger
• Stress management: Learn and practice stress reduction techniques
• Substance avoidance: Abstain from cannabis and other drugs; limit alcohol
• Physical activity: Regular exercise benefits both physical and mental health
• Social connection: Maintain supportive relationships
• Structured routine: Regular daily patterns provide stability