PTSD (Post-traumatic stress disorder) and psychosis are two distinct mental health conditions, but they can sometimes overlap. In some cases, PTSD can lead to psychotic symptoms. This is sometimes called “PTSD with secondary psychotic features”.
Read on to learn more about PTSD, psychosis, how they relate to each other, and how to treat them.
PTSD is a condition that can develop after experiencing or witnessing a traumatic event, such as violence, abuse, accidents, war, or serious illness.
It is not just about the event itself, but how the brain and body continue to react after it is over.
Key symptoms of PTSD
- Intrusive memories: These can look like flashbacks, nightmares, or unwanted thoughts.
- Avoidance: A person may avoid places, people, or thoughts that remind them of the trauma.
- Negative changes in mood and thinking: These may include guilt, shame, emotional numbness, and hopelessness.
- Hyperarousal: The person may be easily startled, feel on edge, have difficulty sleeping, and be irritable.
PTSD can make the brain feel constantly under threat, even in safe situations.
Psychosis is a mental state in which a person loses touch with reality. It can be a symptom of a mental illness, such as schizophrenia or bipolar disorder, or occur in response to trauma, substances, or medical conditions.
Key symptoms of psychosis
- Hallucinations: Seeing, hearing, or feeling things that are not there.
- Delusions: Strongly held false beliefs, for example, a person thinking others are out to get them.
- Disorganized thinking: Confused speech, trouble concentrating, or connecting thoughts.
- Disconnection from reality: Difficulty distinguishing between what is real and what is not.
In some cases, PTSD can lead to psychotic symptoms. This is sometimes called “PTSD with secondary psychotic features”. It is not the same as schizophrenia, but the person may:
- hear voices related to the trauma
- develop paranoid beliefs
- have distorted perceptions of reality during flashbacks
This is more likely when:
- The trauma was severe, chronic, or occurred early in life.
- There is a history of dissociation.
- The person lacks a support system or has other mental health conditions.
It is important to note that “PTSD with secondary psychotic features” is not an official diagnosis recognized in major psychiatric manuals such as the DSM-5.
While some research explores the presence of psychotic-like symptoms in people with PTSD, the current medical consensus emphasizes that PTSD itself does not include psychosis as a formal diagnostic category.
The DSM-5 includes a specifier for PTSD “with dissociative symptoms”, which can sometimes resemble psychosis but is different in nature. For example, dissociative symptoms involve feeling detached from reality or oneself, but do not typically include hallucinations or delusions seen in psychotic disorders.
It is also important to distinguish flashbacks, a hallmark of PTSD, from true psychotic symptoms. Flashbacks involve vividly re-experiencing traumatic events, whereas psychosis involves a break from reality, including hallucinations or fixed false beliefs.
While trauma can sometimes trigger brief psychotic episodes, these are usually diagnosed separately (e.g., brief psychotic disorder) rather than as part of PTSD. Thus, although some people with PTSD may experience psychotic-like symptoms, “PTSD with psychosis” is not an established or widely accepted diagnosis at this time, and more research is needed to understand the relationship between trauma and psychosis.
Trauma-focused therapies can help with PTSD. These therapies aim to help a person safely process the trauma.
EMDR (Eye movement desensitization and reprocessing)
EMDR can help reprocess traumatic memories using bilateral stimulation such as eye movements or tapping.
It is especially useful for vivid, distressing memories or flashbacks. A skilled therapist can adapt the therapy for people with dissociation or psychotic features.
TF-CBT (Trauma-focused cognitive behavioral therapy)
TF-CBT helps identify and change negative thought patterns linked to trauma. It uses gradual exposure to trauma-related memories in a controlled, safe setting.
It also includes emotion regulation and grounding techniques to help with day-to-day life.
When psychosis is also present, a person may need the following additional treatments.
Medication
Medications for PTSD include SSRIs such as sertraline, paroxetine, and fluoxetine. They are first-line treatments for PTSD.
They help with anxiety, depression, and emotional regulation, and can also reduce hypervigilance and improve sleep. Doctors may combine them with antipsychotics if both trauma and psychosis are present.
Antipsychotic medications can help reduce or eliminate hallucinations, delusions, and severe disorganized thinking.
Examples of antipsychotics include:
Some are also mood stabilizers, which can help if there are severe changes in mood or bipolar features too.
A person may use the medications in the short or long term, depending on symptoms.
These medications can be sedating or have side effects, so doctors usually recommend starting them on a low dose and working up to a higher dose.
CBT for psychosis (CBTp)
CBT for psychosis can help a person understand and respond to psychotic symptoms differently.
Rather than directly challenging delusions, it teaches ways to reduce distress, gain perspective, and feel more empowered.
People with PTSD and psychosis often live in a hyperaroused or dissociated state. Therapy works best when the nervous system is regulated.
Some useful techniques to help regulate the nervous system include:
- grounding techniques (e.g., 5-4-3-2-1 senses method)
- breathing exercises and vagus nerve stimulation
- yoga, dance, or somatic movement to reconnect to the body
- nature exposure and routine
Other therapeutic practices that can act as an additional therapy and support recovery include:
- art or music therapy
- peer support groups
- journaling or narrative therapy
A person should contact a doctor or mental health professional as soon as possible if they or a loved one experiences any of the following:
Signs of psychosis
These include:
- hearing voices or seeing things that others do not
- believing things that feel very real but others say are not true
- feeling detached from reality or confused about what is real
- becoming highly suspicious of others, even loved ones
- disorganized thinking or speech
These symptoms may signal a psychotic episode. Early intervention can help prevent worsening and reduce distress.
Worsening PTSD symptoms
These may include:
- flashbacks or nightmares that feel unbearable or are increasing in frequency
- intense avoidance that interferes with daily life
- constant hypervigilance, panic attacks, or feeling always “on edge”
- severe emotional numbness or feeling disconnected from self or others
- thoughts of self-harm or suicide
Help is out there
If you or someone you know is in crisis and considering suicide or self-harm, please seek support:
- Call or text the 988 Lifeline at 988 or chat at 988lifeline.org. Caring counselors are available to listen and provide free and confidential support 24/7.
- Text HOME to the Crisis Text Line at 741741 to connect with a volunteer crisis counselor for free and confidential support 24/7.
- Not in the United States? Find a helpline in your country with Befrienders Worldwide.
- Call 911 or your local emergency services number if you feel safe to do so.
If you’re calling on behalf of someone else, stay with them until help arrives. You may remove weapons or substances that can cause harm if you can do so safely.
If you’re not in the same household, stay on the phone with them until help arrives.
PTSD (Post-traumatic stress disorder) and psychosis are two different mental health conditions, but they can sometimes overlap.
PTSD develops after experiencing or witnessing a traumatic event and is marked by flashbacks, nightmares, hypervigilance, emotional numbness, and avoidance of reminders of the trauma.
Psychosis involves a loss of contact with reality, which may include hallucinations or delusions.
In some cases, people with severe or complex PTSD, especially those with a history of early or repeated trauma, may experience psychotic symptoms. These might include hearing voices related to the trauma or feeling paranoid or detached from reality.
When this happens, it is sometimes known as PTSD with secondary psychosis. Treatment often involves a combination of trauma-focused therapy and, if needed, medication such as antipsychotics or antidepressants.
It is important to work with a trauma-informed professional who understands how these symptoms interact and can create a tailored, safe treatment plan.