Psychosis
Overview
The National Alliance on Mental Illness (NAMI) describes psychosis as, “Disruptions to a person’s thoughts and perceptions that make it difficult for them to recognize what is real and what isn’t.”[1] Within the United States, it is estimated that 15 to 100 people per 100,000 develop psychosis each year,[2] and it is believed that 3 out of every 100 people will experience a psychotic episode in their lifetimes.[3] Psychosis is considered a symptom and is not categorized as a specific illness or diagnosis.[4] The most common time for it to appear is during young adulthood between the ages of 18-25 though it is not uncommon for the first episode to occur during childhood.[5]
A person experiencing psychosis might believe, hear, or see things that aren’t real; often described as hallucinations.[6] Hallucinations are considered to be sensory perceptions without an external source, and they may come in the form of tactile sensations, auditory sounds, visual images, and phantom smells.[7] The first time a person begins showing signs of losing contact with reality is described as first-episode psychosis (FEP).[8] Within the U.S., it is estimated that 56,000 individuals aged 15-29 and 58,000 individuals aged 30-59 will experience FEP each year.[9] Out of those who develop psychosis, 25% do not have another episode; an additional 50% may have additional episodes but can still have normal functioning lives.[10]
Not all individuals who have psychotic experiences are diagnosed with a psychiatric disorder. Research conducted by van Os & Linscott (2012) found that though the highest density prevalence of psychotic symptoms was found in those with psychotic disorders, episodes were also experienced by individuals who have non psychotic illnesses (e.g., depression or anxiety) as well as those categorized as “nonill” in the general population.[11] To determine whether a psychiatric disorder is present, the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders), provides guidelines for evaluating psychotic disorders that are distinguished from each other based on symptom etiology, duration, nature and mood changes.[12] Psychosis may also be the secondary result of a medical or neurological condition.[13]
Symptoms
Early warning signs of psychosis can include:[14]
Drops in job performance or grades
Declines in hygiene or self-care
Acting apathetic or having strong inappropriate feelings
Isolating oneself
Having trouble concentrating
Feeling suspicious or uncomfortable around others
Once psychosis develops, symptoms can include incoherent speech, abnormal movements, or catatonia (a state of remaining motionless).[15,16] They may also experience hallucinations, which take place through auditory, olfactory, tactile, visual or gustatory formats.[17]
Additionally, a person might experience delusions. A delusion is an idea that a person strongly believes to be true, even when presented with evidence that it is clearly false, that cannot be explained by a person’s cultural background, religious beliefs or level of intelligence.[18] Common examples include a person believing they have special powers, are being controlled by someone else or there is significant meaning in ordinary events.[19]
In young children, some of the symptoms may be similar to those of autism spectrum disorder (e.g., late crawling/walking, language delays, unusual motor behaviors). This overlap illustrates the necessity of a clinical diagnosis to determine whether a developmental disorder is present.[20]
Causes and Development
Psychosis does not have one specific cause, but risk factors include genetic predisposition, substance abuse, trauma, illness, prescription side effects, sleep deprivation and injury.[21,22] There is also evidence suggesting that psychosis can be triggered in some individuals as a result of a COVID-19 infection.[23] Though a genetic predisposition may make a person susceptible, it is possible for a person who has the predisposition to never experience a psychotic episode.[24]
Due to hormonal changes taking place in the brain, young adults and teens are at a higher risk of experiencing an episode of psychosis.[25] Delusion disorders (e.g., Frégoli syndrome or delusional companion syndrome) are most commonly developed during middle age, while psychosis due to neurological disorders (e.g., dementia) most commonly develop in older adults.[26] Psychosis due to substance use or medical conditions can occur at any age.[27] Over 25% of individuals who are diagnosed with amphetamine-induced psychosis are later diagnosed with psychotic disorders though some studies suggest these substances may uncover rather than cause the condition.[28]
Stages of Psychosis
There are three phases of psychosis that are experienced differently by each person:[29]
Prodrome (psychosis syndrome) – Changes in thoughts, perceptions, and feelings that become more difficult to process over time.
Acute – The critical period in which psychotic thinking occurs including confusion, hallucinations or delusions that cause a person to behave in ways uncharacteristic of previous behavior.
Recovery – The stage in which symptoms subside with treatment and individuals are able to return to their everyday lives.
The prodromal period can last days, weeks, or years.[30] If symptoms last less than a month, it may be characterized as a brief psychotic disorder. However, persistent episodes of psychosis may lead to a psychiatric diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder or schizophreniform disorder.[31]
Primary and Secondary Psychosis
Psychosis may be caused by a primary psychiatric disorder, such as: schizotypal (personality) disorder; delusional disorder; brief psychotic disorder; schizophreniform disorder; schizophrenia; schizoaffective disorder; and other specified schizophrenia spectrum and other psychotic disorders.[32] When a person experiences psychosis without it being related to a primary psychotic illness, it is called secondary psychosis.[33] These psychotic episodes tend to be temporary and are often related to another cause such as a medical condition or drug use.[34] Secondary psychosis can also be related to other nonpsychotic disorders (e.g., bipolar disorder or depression) or it can be the result of a neurological disorder.[35] For example, a person who has serious deficits in memory, attention and orientation may be more suggestive of dementia or delirium as opposed to a primary psychotic illness.[36] Delirium, idiopathic Parkinson disease, dementia with Lewy bodies, cerebrovascular disease, Alzheimer’s disease and epilepsy have also been shown to be associated with secondary psychosis in some patients.[37]
Treatment
Treatment for psychosis may vary depending on what is determined to be the cause after an evaluation is conducted. It is common for a person to have symptoms of psychosis for over a year before receiving treatment, though early interventions are believed to lead to better recovery.[38] Additionally, receiving treatment early can help to prevent interruptions to education, loss of employment, disruptions to relationships, self-injury, substance abuse, risk of suicide and the need for hospitalization.[39]
One promising method of treatment is Recovery After an Initial Schizophrenic Episode (RAISE), a type of coordinated care developed by the National Institute of Mental Health (NIMH) to treat early psychosis.[40] The RAISE program was a large-scale research initiative which tested the coordination of specialty care treatments to examine the best methods of assisting patients recovering from a psychotic episode and reduce the likelihood of future episodes.[41] Coordinated Specialty Care (CSC) is considered the gold standard for treatment and involves coordination between medication prescribers, family therapy, vocational counseling and individual therapy.[42] Those who received CSC through the RAISE program were found to stay in treatment longer, have stronger interpersonal relationships, and experienced greater improvement in symptoms compared to those who received typical care.[43] As a result of this research, in 2019, the Early Psychosis Intervention Network (EPINET) was formed which now has 100 clinics in 17 states that provide CSC services.[44] In addition to providing services, these hubs also conduct research related to mitigating suicide risk, reducing substance abuse, increasing quick access to intervention services, and sustaining long-term recovery.[45] Some people never have another psychotic episode after receiving early treatment.[46]
Regardless of the cause or stage, psychosis will often be treated through antipsychotic medication which can come in the form of liquid, pills or injections.[47] The first generation of antipsychotics were developed in the early 1950s and worked on the premise of blocking dopamine receptors but held the disadvantage of serious side effects including cardiovascular side effects and extrapyramidal side effects (EPS) which may include tardive dyskinesia after long-term exposure.[48,49] The second generation of antipsychotics, which first emerged in the 1990s, involved both dopamine and serotonin receptor blockades without the motor side effects of first-generation psychosis medications, though other side effects were found to develop including weight gain.[50,51] The third generation of antipsychotics, developed at the beginning of this century, are categorized as partial dopamine agonists (PDAs) that are believed to avoid some of the side effects of first and second generation medications with the potential additional benefits of alleviating negative impacts of specific psychotic disorders such as schizophrenia.[52,53]
In addition to medication, psychotherapy is another integral part of psychosis treatment. Cognitive behavior therapy (CBT) can be used to reevaluate fearful thoughts, reverse social withdrawal and regain positive feelings of control.[54] CBT is found to be most effective when combined with antipsychotic medication indicating the need for a multi-pronged approach when administering treatment.[55] Additionally, treatment may vary depending on the stage of psychosis, with inpatient hospitalization often being used to treat acute phases and later transitioning to outpatient care during the maintenance phase.[56]
Due to the complexity and variations in causes of psychosis (and the benefits of early treatment), if a person believes they may have experienced a psychotic episode it is recommended to speak with a licensed health professional to evaluate potential causes and determine a path to treatment.
Contributed by: Theresa Nair
Editor: Jennifer (Ghahari) Smith, Ph.D.
REFERENCES
1 National Alliance on Mental Illness (NAMI). Early psychosis and psychosis | NAMI: National alliance on mental illness. National Alliance on Mental Illness (NAMI) Web site. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Psychosis. Accessed Apr 5, 2023.
2 National Institute of Mental Health (NIMH). Understanding psychosis. NIH | National Institute of Mental Health (NIMH) Web site. https://www.nimh.nih.gov/health/publications/understanding-psychosis. Updated 2023. Accessed Apr 5, 2023.
3 Morris M. Helping your college student cope with psychosis . Psychology Today Web site. https://www.psychologytoday.com/us/blog/college-wellness/201610/helping-your-college-student-cope-psychosis. Updated 2016. Accessed Apr 6, 2023.
4 Nami (2023)
5 Washington State Health Care Authority. Early signs of psychosis | washington state health care authority. Washington State Health Care Authority Web site. https://www.hca.wa.gov/free-or-low-cost-health-care/i-need-behavioral-health-support/early-signs-psychosis. Updated 2023. Accessed Apr 6, 2023.
6 Contributors WE. Psychosis and psychotic episodes. WebMD Web site. https://www.webmd.com/schizophrenia/guide/what-is-psychosis. Updated 2021. Accessed Apr 6, 2023.
7 Freudenreich O, Goff DC. 12 - psychotic patients. In: Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF, eds. Massachusetts general hospital handbook of general hospital psychiatry (sixth edition). Saint Louis: W.B. Saunders; 2010:119-132. https://www.sciencedirect.com/science/article/pii/B9781437719277000121. 10.1016/B978-1-4377-1927-7.00012-1.
8 Nami (2023)
9 Simon GE, Coleman KJ, Yarborough BJH, et al. First Presentation With Psychotic Symptoms in a Population-Based Sample. Psychiatr Serv. 2017;68(5):456-461. doi:10.1176/appi.ps.201600257
10 Yale School of Medicine. What is psychosis. https://medicine.yale.edu/psychiatry/step/psychosis/. Accessed Apr 5, 2023.
11 van Os J, Linscott RJ. Introduction: The extended psychosis phenotype--relationship with schizophrenia and with ultrahigh risk status for psychosis. Schizophr Bull. 2012;38(2):227-230. doi:10.1093/schbul/sbr188
12 Julayanont P, Suryadevara U. Psychosis. Continuum (Minneapolis, Minn.). 2021;27(6):1682-1711. doi: 10.1212/CON.0000000000001013.
13 Ibid.
14 Nami (2023)
15 England ML, Ongür D, Konopaske GT, Karmacharya R. Catatonia in psychotic patients: clinical features and treatment response. J Neuropsychiatry Clin Neurosci. 2011;23(2):223-226. doi:10.1176/jnp.23.2.jnp223
16 Washington State Health Care Authority (2023)
17 Julayanont & Suryadevara (2021)
18 Kiran C, Chaudhury S. Understanding delusions. Ind Psychiatry J. 2009;18(1):3-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016695/. Accessed Apr 12, 2023. doi: 10.4103/0972-6748.57851.
19 WebMD (2021)
20 Nationwide Childrens'. Psychosis. https://www.nationwidechildrens.org/conditions/psychosis. Accessed Apr 6, 2023.
21 WebMD (2021)
22 NIMH (2023)
23 Vasile CI, Vasile MC, Zlati ML, et al. Post COVID-19 Infection Psychosis: Could SARS-CoV-2 Virus Infection Be a Neuropsychiatric Condition That Triggers Psychotic Disorders? - A Case-Based Short Review. Infect Drug Resist. 2022;15:4697-4705. Published 2022 Aug 22. doi:10.2147/IDR.S373578
24 Nami (2023)
25 Ibid.
26 Julayanont & Suryadevara (2021)
27 Ibid.
28 WebMD (2021)
29 Yale (2023)
30 WebMD (2021)
31 Psychology Today Staff. Psychosis | psychology today. Psychology Today Web site. https://www.psychologytoday.com/us/basics/psychosis. Accessed Apr 6, 2023.
32 Julayanont & Suryadevara (2021)
33 WebMD (2021)
34 Ibid.
35 Julayanont & Suryadevara (2021)
36 Freudenreich & Goff (2010)
37 Julayanont & Suryadevara (2021)
38 NIMH (2023)
39 Yale (2023)
40 NIMH (2023)
41 National Institute of Mental Health (NIMH). Recovery after an initial schizophrenia episode (RAISE). National Institute of Mental Health (NIMH) Web site. https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/recovery-after-an-initial-schizophrenia-episode-raise. Updated 2022a. Accessed Apr 7, 2023.
42 Morris (2016)
43 NIMH (2022a)
44 National Institute of Mental Health (NIMH). Early psychosis intervention network (EPINET). National Institute of Mental Health (NIMH) Web site. https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/early-psychosis-intervention-network-epinet. Updated 2022. Accessed Apr 7, 2023.
45 Ibid.
46 NIMH (2023)
47 World Health Organization (WHO). Pharmacological Treatment of Mental Disorders in Primary Health Care. Geneva: World Health Organization; 2009. Chapter 3, Medicines used in psychotic disorders. Web site. https://www.ncbi.nlm.nih.gov/books/NBK143209/ Updated 2009. Accessed Apr 16, 2023.
48 Tamminga CA, Lahti AC. Treatments for chronic psychosis. Dialogues Clin Neurosci. 2001;3(4):281-292. doi:10.31887/DCNS.2001.3.4/ctamminga
49 Mailman RB, Murthy V. Third generation antipsychotic drugs: partial agonism or receptor functional selectivity?. Curr Pharm Des. 2010;16(5):488-501. doi:10.2174/138161210790361461
50 Mailman & Murthy (2010)
51 Tamminga & Lahti (2001)
52 Mailman & Murthy (2010)
53 Hope J, Keks N. Cariprazine: A third-generation antipsychotic with a twist | medicine today. . 2022. https://medicinetoday.com.au/mt/2022/june/regular-series/cariprazine-thirdgeneration-antipsychotic-twist#subscribe. Accessed Apr 13, 2023.
54 Daniel Freeman P. Cognitive-behavioral therapy for psychotic disorders. Psychiatric Times. 2013;30(12). https://www.psychiatrictimes.com/view/cognitive-behavioral-therapy-psychotic-disorders. Accessed Apr 14, 2023.
55 Health Quality Ontario . Cognitive Behavioural Therapy for Psychosis: A Health Technology Assessment. Ont Health Technol Assess Ser. 2018;18(5):1-141. Published 2018 Oct 24.
56 Medical News Today. Psychosis: Causes, symptoms, and treatments. https://www.medicalnewstoday.com/articles/248159. Updated 2020. Accessed Apr 14, 2023.