Broadly speaking, psychosis means a loss of contact with reality; it is a symptom of mental illness rather than a medical condition in its own right.
Generally, there are two types of psychiatric disorder that produce psychotic symptoms: schizophrenia and mood disorders, such as bipolar disorder.
This page offers a full description of psychosis, what causes it, and how it is treated.
Fast facts on psychosis
Here are some key points about psychosis. More detail and supporting information is in the main article.
- Psychosis is not a disease in its own right; it is a symptom
- A common psychotic delusion is the belief that the patient is an important figure
- Earlier diagnosis of psychosis improves long-term outcomes
What is psychosis?
Psychosis is a symptom rather than a disease.
Psychosis is an umbrella term and means that an individual experiences things that no one else experiences and has beliefs with no basis in reality.
Psychosis is classically associated with schizophrenia spectrum disorders, and, while there are other symptoms, one of the defining criteria for schizophrenia is the presence of psychosis.
- Schizoaffective disorder and other subtypes of schizophrenia
- Acute and transient psychotic disorders
- Bipolar disorder (previously known as manic depression)
- Major depressive disorder with psychotic features
- Postpartum (also called postnatal) psychosis - a severe form of postnatal depression
- Substance-induced psychosis (including alcohol, certain illegal drugs, and some prescription drugs, including steroids and stimulants)
These are the primary causes of psychotic symptoms, but psychosis can also be secondary to other disorders and diseases, including:
- Brain tumor or cyst
- Dementia (Alzheimer's disease, for example)
- Neurological illness, such as Parkinson's disease and Huntington's disease
- HIV and other infections that may affect the brain
- Some types of epilepsy
Causes of psychosis
The exact causes of psychosis are not well understood but might involve:
- Genetics - research shows that schizophrenia and bipolar disorder may share a common genetic cause.
- Brain changes - alterations in brain structure and changes in certain chemicals are found in people who have psychosis. Brain scans have revealed reduced gray matter in the brains of some individuals who have had a history of psychosis, which may explain effects on thought processing.
- Hormones/Sleep - postpartum psychosis occurs very soon after giving birth (normally within 2 weeks). The exact causes are not known, but some researchers believe it might be due to changes in hormone levels and disrupted sleep patterns.
Symptoms of psychosis
Psychotic symptoms can be separated out and given specific descriptions. The classic signs of psychosis are:
- Hallucinations - hearing, seeing, or feeling things that do not exist
- Delusions - false beliefs, especially based on fear or suspicion of things that are not real
Psychotic symptoms in disorders such as schizophrenia may also include:
- Disorganized thought, speech, or behavior
- Disordered thinking - jumping between unrelated topics, making strange connections between thoughts
- Catatonia - unresponsiveness
Depending on the cause, psychosis can come on quickly or slowly. The same is the case in schizophrenia, although symptoms are more likely to have a slow onset and begin with milder psychosis, which in some cases does not convert to the full disorder.
The slow onset of schizophrenia (also called the prodromal phase) is often not recognized by the patient or their family and friends. The milder, initial symptoms of psychosis might include:
- Feelings of suspicion
- Distorted perceptions
- Depression and suicidal feelings
- Obsessive thinking
- Sleep problems
Hallucinations can affect any of the senses (sight, sound, smell, taste, and touch) in the person with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are auditory - hearing things and believing them to be real when they do not exist.
The following auditory hallucinations are common in schizophrenia:
- Hearing several voices talking, often negatively, about the patient
- A voice giving a commentary on what the patient is doing, or
- Repeating what the patient is thinking
Bizarre delusions are experienced during psychosis
Paranoia is a common part of psychotic delusions.
Examples of psychotic delusions include the paranoid type - more likely to be associated with schizophrenia - and delusions of grandeur.
Paranoid delusions: these may cause the person with psychosis to be unduly suspicious of individuals or organizations, believing them to be plotting to cause them harm.
Delusions of grandeur: clearly false but strongly held belief in having a special power or authority - for instance, they may believe that they are a world leader.
Diagnosis of psychosis
In this section, we will discuss the available tests and methods for diagnosing psychosis.
Early diagnosis of psychosis improves long-term outcomes. This is not always achieved, however. The milder forms of psychosis that can lead to schizophrenia are left untreated for an average of 2 years, and even full psychosis can take a number of years before it receives the attention of medical professionals.
To increase the chances of early detection, guidance for healthcare systems drawn up by psychiatrists recommend that the "possibility of a psychotic disorder should be carefully considered" in a young person who is:
- Becoming more socially withdrawn
- Performing worse for a sustained period at school or work, or
- Becoming more distressed or agitated yet unable to explain why
There is no biological test for psychosis itself, and if laboratory tests are done, it is to rule out other medical problems that might provide an alternative explanation.
Questions for patient and family
Psychosis is primarily diagnosed by clinical examination and history - the doctor examines the patient and asks about their symptoms, experiences, thoughts, and daily activities, and they will also ask if there is a family history of psychiatric illness.
Other medical conditions are ruled out first of all, especially delirium (sudden onset of a confused state), but epilepsy and a number of other medical explanations are possible.
Doctors will also check for any history of intoxication with drugs, both legal and illegal, and toxins, usually asking for a urine sample to check this.
Once psychosis is narrowed down to a psychiatric cause, there are clearly defined criteria that must be met before a diagnosis is confirmed. Psychiatrists generally rely on the American Psychiatric Association (APA)'s publication known as the DSM (Diagnostic and Statistical Manual of Mental Disorders) to make psychiatric diagnoses.
Brain scans may be done in the early stages of medical attention so that other conditions - often treatable and reversible - can be ruled out.
EEG (electroencephalography) testing records the brain's electrical activity and may help to rule out delirium, head injury, or epilepsy as possible causes of psychotic symptoms.
Treatments for psychosis
In this section, we discuss the treatments for psychosis and some methods of prevention.
Treatment with a class of drugs known as antipsychotics is the most common therapy for people with a psychotic illness.
Antipsychotics are effective at reducing psychosis symptoms in psychiatric disorders such as schizophrenia, but they do not themselves treat or cure underlying psychotic illnesses.
So-called second-generation antipsychotics are most commonly used by doctors to treat psychosis. While their use is widespread in the United States, this is controversial. The World Health Organization (WHO) does not recommend them, except clozapine (branded Clozaril and FazaClo in the U.S.), which may be used, under special supervision, if there has been no response to other antipsychotic medicines.
Acute and maintenance phases of schizophrenia
Antipsychotic treatment of schizophrenia is in two phases - the acute phase to treat initial psychotic episodes and a lifelong phase of maintenance therapy.
During the acute phase, a stay in hospital is often needed. In the maintenance phase, treatment of schizophrenia is in the community and antipsychotics help to prevent further psychotic episodes, although relapses often occur, sometimes due to a failure to take the medications.
Lifelong treatment of schizophrenia may involve other interventions and support, including the role of the family in care.