What do you think of when you hear the word “psychosis”? Have you experienced psychotic symptoms or observed someone while they are in the middle of a psychotic episode? Have you heard someone being described as “psychotic,” most likely with a negative connotation? If you listen to pop radio, you probably have!
As is too frequently true, mental illness often has a negative stigma associated with it. To demonstrate how pervasive our misconceptions are, there have been several people in the public eye who have recently opened up about their personal struggles with mental illness and the importance of seeking help. In recent interviews timed with her Golden Globes nomination and long career as an actress, Glenn Close talked about how some of her roles perpetuated that stigma and the things she has been doing to change that.¹
Psychosis is one of the most frightening and difficult to understand of mental health symptoms, both to those who experience it and to those who observe it, because it involves experiencing altered reality. Because it is so scary and carries negative connotations, those who are forced to contend with it are often afraid to tell anyone when they experience symptoms. If they do tell someone, the reaction they get may just reinforce their fears and cause delays in seeking help.
Early intervention by qualified professionals is very important. If treated early by a professional trained in early psychosis intervention, known as First Episode Psychosis (FEP) treatment,² the potential for those who suffer from psychosis to be able to lead fulfilling lives is greatly enhanced. The earlier the intervention the better the quality of the outcome. They may be able to effectively manage their symptoms so that they are minimal, if in fact they experience them at all. But early intervention is critical, preferably within 18 months, or at most within 5 years.³ It is important to note that longer untreated psychosis, a concept known as “Duration of Untreated Psychosis” or DUP, “predicts poorer outcomes.” ⁴
Here are a few important things to understand about psychosis:
- Psychosis is a symptom, not a disorder. There are several disorders which commonly have psychosis as possible symptoms, including schizophrenia, bipolar disorder, schizoaffective disorder, and even severe clinical depression.
- Age of onset most commonly occurs in late adolescence or young adulthood, between ages 18-24, but can occur as early as 13 and as late as 30; it usually starts earlier in men than in women by about two years.⁵ Late-onset psychosis does occur, usually after age 40, and is more common in women than men. It is not clearly understood why, but there are theories that estrogen during reproductive years may protect women but that protection may decline after menopause.⁶
- For many people, onset of psychosis may be a unique combination of predisposition caused by genetic factors (quite possibly previously unknown). If one of more of the events listed below also occurs, when mixed with this predisposition, the individual develops psychosis. The specific nature of the psychosis and its duration are unique to the individual and duration and intensity may vary. Causal factors may include: ⁷ ⁸
‣ Use of substances including marijuana (and related cannabis substances), hallucinogens such as LSD, methamphetamine, alcohol, and others; in this case, psychosis may occur as a result of substance use by those who are already vulnerable in some way, such as genetic predisposition.
‣ Traumatic injury or other major physical illness including sometimes traumatic brain injury, brain tumors, strokes, diseases of the brain such as Parkinson’s, Alzheimer’s, dementia and some things that manifest with HIV, epilepsy, or other infections.
‣ Traumatic experience such as assault, death, or war and even something seemingly harmless, such as moving away for college, may cause a psychotic episode or result in what is called a psychotic break. The nature of the episode, the age of the individual, etc., determine whether the event will result in psychosis and for how long.
- Psychosis usually begins with small warning signs, known as the prodromal phase, long before the actual crisis⁹ that makes one realize that there is a true psychotic episode taking place. Some of the early warning signs are unfortunately similar to other common behaviors shown by adolescents which make them hard to differentiate. The National Alliance on Mental Illness (NAMI) lists these as possible early warning signs:¹⁰
‣ A worrisome drop in grades or job performance
‣ Trouble thinking clearly or concentrating
‣ Suspiciousness or uneasiness with others
‣ A decline in self-care or personal hygiene
‣ Spending a lot more time alone than usual
‣ Strong, inappropriate emotions or having no feelings at all
- The nature and duration of a psychotic episode varies significantly from one person to the next. Each individual may experience different combinations of “positive” symptoms, meaning the presence of something that should not be there, as opposed to negative symptoms, meaning the absence of things that are usually there. Examples of positive symptoms such as hallucinations, delusions, disorganized thoughts or behaviors, and paranoia, are described below.
‣ Hallucinations - may involve hearing, seeing, feeling, smelling or tasting things, all of which seem very real to the individual, but are not actually present. Among the most common are voices which may say mean things or provide direction to do something, or visual hallucinations as in seeing an object or colors that aren’t really there. It is the person’s response to these hallucinations that often causes others to realize that something is wrong.¹¹
‣ Delusions - are beliefs that the individual has that are inconsistent with what most people believe to be true, such as that he or she is receiving communications from aliens in outer space, or that that aliens are spying on him or her through a car radio, TV or cell phone camera, or a belief that his/her thoughts are able to control others through one eye unless it is kept closed or covered.
‣ Disorganized thoughts or behavior - include going off on a lengthy tangent, or expressing a thought that does not match the question.¹² Responding with inappropriate behavior (such as laughing when told about something sad) and not dressing appropriately for weather conditions can be seen as part of a pattern of disorganized thinking too if this represents a change in behavior from previous behaviors.
‣ Paranoia is a very common thought or feeling associated with psychosis and results in behaviors including lack of trust, avoidance, etc. It is a frequent barrier to seeking treatment and trusting resources that may be legitimately trying to help.
‣ Other common symptoms of psychosis are called “negative” symptoms, meaning that the individual stops doing normal things, for example, becomes more withdrawn, stops showing emotion, loses initiative, may speak in a monotone, stops coming up with ideas, becomes more depressed, etc. There is a long list, but these are all commonly seen during a psychotic episode.
‣ An episode may last for hours or days, but for some it may last weeks or years. With early intervention programs, it is possible to learn how to recognize onset and learns tools to use to help stave off an episode before it takes hold. Treatment includes a combination of medication and other tools taught by teams of professionals.
Newer treatment approaches, called First Experience Psychosis or FEP, emphasize the importance of beginning treatment as soon as possible. With early treatment, preferably within 18 months though some stretch that to within 5 years, there is real hope that individuals suffering from psychosis can live functional lives, something they would never have thought possible. Among the most important aspects of these programs is identifying the best mix of medications and fostering adherence to taking them. Adhering to the medication regimen is one of the most critical factors to success in treating psychosis and one of the most challenging, especially in young adults. The FEP programs work because they incorporate multidisciplinary teams, including community-based components, to make sure they proactively reach their clients and support healthy lifestyles. To learn more about programs like these, please consult the NAMI brochure¹³ or peruse this extensive Canadian website Early Psychosis Intervention (Canada) (in Canada, these are called Early Psychosis Intervention programs). The Canadian website has a wealth of information, although their resources are not available to us in the US. This video provides a powerful and uplifting set of stories showing how well these programs can work: Beyond Psychosis: Exceeding Expectations from First Episode to Recovery Part 2 ¹⁴
Psychosis is hard to understand and scary to watch. If you know someone who you think is experiencing psychotic symptoms, be supportive. Just be there. Recognize it is hard for them and that the paranoia that frequently accompanies the other symptoms of psychosis makes it harder for them to believe that you are really there to help. Aggressive efforts on your part to push help on someone in an acute psychotic episode are likely to escalate their behaviors. It is why more and more first responders, police, and emergency room professionals are being trained to work with those presenting with mental illness. If not properly trained, they can severely exacerbate the problem, increasing the potential for violence when there may not have been any. Individuals in the throes of a psychotic episode can become physical but that is not the norm and is frequently the result of how they were handled. Promoting understanding of these symptoms will go a long way towards helping to minimize the risk to everyone who encounters them.¹⁵
¹ Rosa, J. (2019, February 8). Glenn Close says she wants to change stigma of mental illness in media: ‘I was part of it’. ABC News.
² What is Early and First-Episode Psychosis? (2016, July). National Alliance of Mental Illness.
³ Importance of Early Intervention Why Intervene Early? (n.d.)
⁴ Barnes, T. R., DSc, Leeson, V. C., PhD, Mutsatsa, S. H., MSc, Watt, H. C., MSc, Hutton, S. B., DPhil, & Joyce, E. M., FRCPsych. (2008). Duration of untreated psychosis and social function: 1-year follow-up study of first-episode schizophrenia. The British Journal of Psychiatry, 193(3).
⁵ What is Psychosis? Who gets Psychosis? (n.d.)
⁶ Seeman, M. V., MD. (2010). Psychosis in women: Consider midlife medical and psychological triggers. Current Psychiatry, 9(2), 64-65.
⁷ What is Psychosis? Who gets Psychosis? (n.d.)
⁸ Early Psychosis And Psychosis. (n.d.)
⁹ What is Psychosis? Phases of Psychosis. (n.d.)
¹⁰ Early Psychosis And Psychosis. (n.d.)
¹¹ What is Psychosis? Symptoms of Psychosis. (n.d.)
¹² What is Psychosis? Symptoms of Psychosis. (n.d.)
¹³ What is Early and First-Episode Psychosis? (2016, July). National Alliance of Mental Illness.
¹⁴ Recovery The process of recovery. (n.d.)
¹⁵ Many thanks to Ian McLoone, LPCC, LADC, Lead Therapist at Alltyr Clinic, St Paul, MN for his invaluable input and resources.