What is psychosis

Psychosis is a mental health problem that causes people to perceive or interpret things differently from those around them. This might involve hallucinations, paranoia or delusions. People with psychosis experience an altered sense of reality. They have difficulty with the way they interpret the world around them, and their thinking can be confused. They may experience hallucinations, such as hearing voices that aren’t there, or delusions, such as believing they have special powers. Imagine if someone could read your mind, or penetrate your head and influence the way you think. This is what it feels like for many people with psychosis. Someone affected by psychosis has difficulty with the way they interpret the real world.

The two main symptoms of psychosis are:

1. Hallucinations – where a person hears, sees and, in some cases, feels, smells or tastes things that aren’t there; a common hallucination is hearing voices
2. Delusions – where a person has strong beliefs that aren’t shared by others; a common delusion is someone believing there is a conspiracy to harm them

The combination of hallucinations and delusional thinking can cause severe distress and a change in behavior. Experiencing the symptoms of psychosis is often referred to as having a psychotic episode.

Psychosis may be caused by a mental illness, such as schizophrenia, bipolar disorder or severe depression. Psychosis can also be induced by drug use, or less commonly in response to a stressful event. Psychosis affects people differently.

The causes of psychosis are still being uncovered. There is no one cause, and researchers believe a combination of biological, genetic, social and environmental factors is involved. It may be associated with a chemical imbalance in the brain. Stress and some drugs (for example, marijuana, speed or LSD) can trigger the first episode of psychosis.

Treatment is available for people with psychosis. Medication, psychological therapy and community support can help reduce symptoms, allowing people to live a normal life. It’s important to talk to a doctor or a mental health professional if you think you may have symptoms of psychosis.

In severe cases, someone with psychosis may be at risk of self-harm, or harming others. About 3% of people will experience psychosis at some time in their lives. A first episode of psychosis is most likely to happen in a person’s late teens or early adult years.

If you or someone you know has attempted or is at risk of attempting to harm themselves or someone else, please call your local emergency services number for assistance.

Psychosis isn’t the same as psychopath

The terms “psychosis” and “psychopath” shouldn’t be confused.

Someone with psychosis has a short-term (acute) condition that, if treated, can often lead to a full recovery.

A psychopath is someone with an anti-social personality disorder, which means they:

• lack empathy – the capacity to understand how someone else feels
• are manipulative
• often have a total disregard for the consequences of their actions

People with an anti-social personality can sometimes pose a threat to others because they can be violent. Most people with psychosis are more likely to harm themselves than others.

Types of psychosis

Psychosis is often a symptom of another psychiatric illness or problem. The types of mental illnesses and circumstances that can cause psychosis include:

• Schizophrenia psychosis: most people with schizophrenia experience a range of psychotic symptoms and commonly have difficulty organising their thoughts.
• Bipolar disorder psychosis: this is a psychological disorder where a person experiences prolonged episodes of depression or mania (mood elevation) that can lead to psychosis.
• Drug-induced psychosis: using or withdrawing from alcohol, amphetamines, LSD, marijuana, ecstasy or magic mushrooms may induce psychotic symptoms that last for short or long periods.
• Severe depression psychosis: people with severe depression can experience psychotic symptoms. This includes postnatal depression, which some women experience after giving birth.
• Brief reactive psychosis: rarely, a stressful event may prompt psychotic symptoms that last less than 1 month. There is often a quick recovery.
• Organic psychosis: caused by chemical derangements in the body and brain from medicines, or because of illnesses affecting normal bodily functions. It can also be the result of damage to brain structures from diseases such as Alzheimer’s disease.
• Postpartum psychosis – postpartum psychosis is a serious mental illness that can develop in mothers soon after childbirth, causing major changes in mood and behavior. If you think you (or someone you know) could have postpartum psychosis, it’s important to see a doctor without delay.

The underlying psychological cause often influences the type of psychotic episode someone experiences.

For example, a person with bipolar disorder is more likely to have grandiose delusions. Someone with depression or schizophrenia is more likely to develop persecutory delusions.

Schizophrenia

Schizophrenia is a severe long-term mental health condition. It causes a range of different psychological symptoms.

Doctors often describe schizophrenia as a type of psychosis. This means the person may not always be able to distinguish their own thoughts and ideas from reality. A first acute episode of psychosis can be very difficult to cope with, both for the person who is ill and for their family and friends.

Drastic changes in behavior may occur, and the person can become upset, anxious, confused, angry or suspicious of those around them.

They may not think they need help, and it can be hard to persuade them to visit a doctor.

Symptoms of schizophrenia include:

• hallucinations – hearing or seeing things that don’t exist
• delusions – unusual beliefs not based on reality
• muddled thoughts based on hallucinations or delusions
• changes in behavior

Some people think schizophrenia causes a “split personality” or violent behavior. This is not true. The cause of any violent behavior is usually drug or alcohol misuse.

Schizophrenia causes

The exact cause of schizophrenia is unknown. However, most experts believe the condition is caused by a combination of genetic and environmental factors.

It’s thought that some people are more vulnerable to developing schizophrenia, and certain situations can trigger the condition.

Risk factors for schizophrenia

Genetics

Schizophrenia tends to run in families, but no single gene is thought to be responsible. It’s more likely that different combinations of genes make people more vulnerable to the condition. However, having these genes doesn’t necessarily mean you’ll develop schizophrenia. Evidence that schizophrenia is partly inherited comes from studies of twins. Identical twins share the same genes. In identical twins, if one twin develops schizophrenia, the other twin has a one in two chance of developing it, too. This is true even if they’re raised separately. In non-identical twins, who have different genetic make-ups, when one twin develops schizophrenia, the other only has a one in seven chance of developing schizophrenia.

While this is higher than in the general population, where the chance is about 1 in 100, it suggests genes aren’t the only factor influencing the development of schizophrenia.

Brain development

Studies of people with schizophrenia have shown there are subtle differences in the structure of their brains. These changes aren’t seen in everyone with schizophrenia and can occur in people who don’t have a mental illness. But they suggest schizophrenia may partly be a disorder of the brain.

Neurotransmitters

Neurotransmitters are chemicals that carry messages between brain cells. There’s a connection between neurotransmitters and schizophrenia because drugs that alter the levels of neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia. Research suggests schizophrenia may be caused by a change in the level of two neurotransmitters: dopamine and serotonin.

Some studies indicate an imbalance between the two may be the basis of the problem. Others have found a change in the body’s sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Pregnancy and birth complications

Research has shown people who develop schizophrenia are more likely to have experienced complications before and during their birth, such as:

• a low birth weight
• premature labor
• a lack of oxygen (asphyxia) during birth

It may be that these things have a subtle effect on brain development.

Triggers

Triggers are things that can cause schizophrenia to develop in people who are at risk.

These include:

• Stress
  • The main psychological triggers of schizophrenia are stressful life events, such as:
    • bereavement
    • losing your job or home
    • divorce
    • the end of a relationship
    • physical, sexual or emotional abuse

These kinds of experiences, although stressful, don’t cause schizophrenia. However, they can trigger its development in someone already vulnerable to it.

Drug abuse

Drugs don’t directly cause schizophrenia, but studies have shown drug misuse increases the risk of developing schizophrenia or a similar illness. Certain drugs, particularly cannabis, cocaine, LSD or amphetamines, may trigger symptoms of schizophrenia in people who are susceptible. Using amphetamines or cocaine can lead to psychosis, and can cause a relapse in people recovering from an earlier episode.

Three major studies have shown teenagers under 15 who use cannabis regularly, especially “skunk” and other more potent forms of the drug, are up to four times more likely to develop schizophrenia by the age of 26.

Schizophrenia signs and symptoms

Schizophrenia changes how a person thinks and behaves. Schizophrenia may develop slowly. The first signs can be hard to identify as they often develop during the teenage years.

Symptoms such as becoming socially withdrawn and unresponsive or changes in sleeping patterns can be mistaken for an adolescent “phase”.

People often have episodes of schizophrenia, during which their symptoms are particularly severe, followed by periods where they experience few or no symptoms. This is known as acute schizophrenia.

Positive and negative symptoms

The symptoms of schizophrenia are usually classified into:

• positive symptoms – any change in behavior or thoughts, such as hallucinations or delusions
• negative symptoms – a withdrawal or lack of function that you would not usually expect to see in a healthy person; for example, people with schizophrenia often appear emotionless and flat

Hallucinations

Hallucinations are where someone sees, hears, smells, tastes or feels things that don’t exist outside their mind. The most common hallucination is hearing voices.

Hallucinations are very real to the person experiencing them, even though people around them can’t hear the voices or experience the sensations.

Research using brain-scanning equipment shows changes in the speech area in the brains of people with schizophrenia when they hear voices. These studies show the experience of hearing voices as a real one, as if the brain mistakes thoughts for real voices.

Some people describe the voices they hear as friendly and pleasant, but more often they’re rude, critical, abusive or annoying.

The voices might describe activities taking place, discuss the hearer’s thoughts and behavior, give instructions, or talk directly to the person. Voices may come from different places or one place in particular, such as the television.

Delusions

A delusion is a belief held with complete conviction, even though it’s based on a mistaken, strange or unrealistic view. It may affect the way the person behaves. Delusions can begin suddenly, or may develop over weeks or months.

Some people develop a delusional idea to explain a hallucination they’re having. For example, if they have heard voices describing their actions, they may have a delusion that someone is monitoring their actions.

Someone experiencing a paranoid delusion may believe they’re being harassed or persecuted. They may believe they’re being chased, followed, watched, plotted against or poisoned, often by a family member or friend.

Some people who experience delusions find different meanings in everyday events or occurrences.

They may believe people on TV or in newspaper articles are communicating messages to them alone, or that there are hidden messages in the colours of cars passing on the street.

Confused thoughts (thought disorder)

People experiencing psychosis often have trouble keeping track of their thoughts and conversations.

Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV programme.

People sometimes describe their thoughts as “misty” or “hazy” when this is happening to them. Thoughts and speech may become jumbled or confused, making conversation difficult and hard for other people to understand.

Changes in behavior and thoughts

A person’s behavior may become more disorganized and unpredictable, and their appearance or dress may seem unusual to others. People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason.

Some people describe their thoughts as being controlled by someone else, that their thoughts aren’t their own, or that thoughts have been planted in their mind by someone else.

Another recognized feeling is that thoughts are disappearing, as though someone is removing them from their mind.

Some people feel their body is being taken over and someone else is directing their movements and actions.

Negative symptoms of schizophrenia

The negative symptoms of schizophrenia can often appear several years before somebody experiences their first acute schizophrenic episode. These initial negative symptoms are often referred to as the prodromal period of schizophrenia. Symptoms during the prodromal period usually appear gradually and slowly get worse. They include the person becoming more socially withdrawn and increasingly not caring about his or her appearance and personal hygiene.

It can be difficult to tell whether the symptoms are part of the development of schizophrenia or caused by something else.

Negative symptoms experienced by people living with schizophrenia include:

• losing interest and motivation in life and activities, including relationships and sex
• lack of concentration, not wanting to leave the house, and changes in sleeping patterns
• being less likely to initiate conversations and feeling uncomfortable with people, or feeling there’s nothing to say

The negative symptoms of schizophrenia can often lead to relationship problems with friends and family as they can sometimes be mistaken for deliberate laziness or rudeness.

Schizophrenia treatment

Schizophrenia is usually treated with a combination of medication and therapy tailored to each individual. In most cases, this will be antipsychotic medicines and cognitive behavioral therapy (CBT).

People with schizophrenia usually receive help from a community mental health team, which offers day-to-day support and treatment.

Many people recover from schizophrenia, although they may have periods when symptoms return (relapses). Support and treatment can help reduce the impact the condition has on daily life.

Bipolar disorder

Bipolar disorder, formerly known as manic depression, is a condition that affects your moods, which can swing from one extreme to another.

People with bipolar disorder have periods or episodes of:

• depression – feeling very low and lethargic
• mania – feeling very high and overactive (less severe mania is known as hypomania)

Symptoms of bipolar disorder depend on which mood you’re experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer), and some people may not experience a “normal” mood very often.

Depression

You may initially be diagnosed with clinical depression before having a future manic episode (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, which can potentially lead to thoughts of suicide.

If you’re feeling suicidal or having severe depressive symptoms, contact your doctor or local mental health emergency services as soon as possible.

Mania

During a manic phase of bipolar disorder, you may feel very happy and have lots of energy, ambitious plans and ideas. You may spend large amounts of money on things you can’t afford and wouldn’t normally want.

Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of this phase.

You may feel very creative and view the manic phase of bipolar as a positive experience. However, you may also experience symptoms of psychosis, where you see or hear things that aren’t there or become convinced of things that aren’t true.

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown, although it’s believed a number of things can trigger an episode. Extreme stress, overwhelming problems and life-changing events are thought to contribute, as well as genetic and chemical factors.

Bipolar disorder signs and symptoms

Bipolar disorder is characterized by extreme mood swings. These can range from extreme highs (mania) to extreme lows (depression).

Episodes of mania and depression often last for several weeks or months.

Depression

During a period of depression, your symptoms may include:

• feeling sad, hopeless or irritable most of the time
• lacking energy
• difficulty concentrating and remembering things
• loss of interest in everyday activities
• feelings of emptiness or worthlessness
• feelings of guilt and despair
• feeling pessimistic about everything
• self-doubt
• psychosis — being delusional, having hallucinations and disturbed or illogical thinking
• lack of appetite
• difficulty sleeping
• waking up early
• suicidal thoughts

Mania

The manic phase of bipolar disorder may include:

• feeling very happy, elated or overjoyed
• talking very quickly
• feeling full of energy
• feeling self-important
• feeling full of great new ideas and having important plans
• being easily distracted
• being easily irritated or agitated
• psychosis — being delusional, having hallucinations and disturbed or illogical thinking
• not feeling like sleeping
• not eating
• doing things that often have disastrous consequences – such as spending large sums of money on expensive and sometimes unaffordable items
• making decisions or saying things that are out of character and that others see as being risky or harmful

Patterns of depression and mania

If you have bipolar disorder, you may have episodes of depression more regularly than episodes of mania, or vice versa.

Between episodes of depression and mania, you may sometimes have periods where you have a “normal” mood.

The patterns aren’t always the same and some people may experience:

• rapid cycling – where a person with bipolar disorder repeatedly swings from a high to low phase quickly without having a “normal” period in between
• mixed state – where a person with bipolar disorder experiences symptoms of depression and mania together; for example, overactivity with a depressed mood

If your mood swings last a long time but aren’t severe enough to be classed as bipolar disorder, you may be diagnosed with cyclothymia (a mild form of bipolar disorder).

Living with bipolar disorder

The high and low phases of bipolar disorder are often so extreme that they interfere with everyday life.

However, there are several options for treating bipolar disorder that can make a difference. They aim to control the effects of an episode and help someone with bipolar disorder live life as normally as possible.

The following treatment options are available:

• medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilizers and are taken every day on a long-term basis
• medication to treat the main symptoms of depression and mania when they occur
• learning to recognize the triggers and signs of an episode of depression or mania
• psychological treatment – such as talking therapy, which can help you deal with depression, and provides advice about how to improve your relationships
• lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, as well as advice on improving your diet and getting more sleep

It’s thought using a combination of different treatment methods is the best way to control bipolar disorder. Help and advice for people with a long-term condition or their carers is also available from charities, support groups and associations. This includes self-help and self-management advice, and learning to deal with the practical aspects of a long-term condition.

Bipolar disorder treatment

If a person isn’t treated, episodes of bipolar-related mania can last for between three and six months. Episodes of depression tend to last longer, for between six and 12 months.

However, with effective treatment, episodes usually improve within about three months.

Most people with bipolar disorder can be treated using a combination of different treatments. These can include one or more of the following:

• medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilizers and are taken every day on a long-term basis
• medication to treat the main symptoms of depression and mania when they occur
• learning to recognize the triggers and signs of an episode of depression or mania
• psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
• lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital. However, hospital treatment may be needed if your symptoms are severe, or if you’re being treated under the Mental Health Act, as there’s a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilize mood swings. These are commonly referred to as mood stabilisers and include:

• lithium carbonate
• anticonvulsant medicines
• antipsychotic medicines

If you’re already taking medication for bipolar disorder and you develop depression, your doctor will check you’re taking the correct dose. If you aren’t, they’ll change it.

Episodes of depression are treated slightly differently in bipolar disorder, as the use of antidepressants alone may lead to a hypomanic relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabilizer. However, antidepressants are commonly used alongside a mood stabilizer or antipsychotic.

If you’re prescribed lithium, stick to the prescribed dose and don’t stop taking it suddenly (unless told to by your doctor). For lithium to be effective, the dosage must be correct. If it’s incorrect, you may get side effects such as diarrhea and vomiting. However, tell your doctor immediately if you have side effects while taking lithium. You’ll need regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels aren’t too high or too low.

Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases. While you’re taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they’re prescribed by your doctor.

Psychological treatment

Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:

• psychoeducation – to find out more about bipolar disorder
• cognitive behavioural therapy (CBT) – this is most useful when treating depression
• family therapy – a type of talking therapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of six to nine months.

Postpartum psychosis

Postpartum psychosis also called postnatal psychosis, or puerperal psychosis, is a mental illness that can affect any mother, including those without any history of mental illness. Postpartum psychosis can come on very suddenly – sometimes within hours of giving birth.

The word ‘psychosis’ refers to a loss of sense of reality. If you have postpartum psychosis, you may have hallucinations, paranoia and delusions, which makes it hard to distinguish between reality and illusion. Women with postpartum psychosis need specialized psychiatric treatment to get better.

Postpartum psychosis is not the same as postnatal depression, which begins after giving birth. While postnatal depression affects more than 1 in 7 new mothers each year, postpartum psychosis is rare, affecting only about 1 or 2 women in every 1,000 mothers.

Postpartum psychosis signs and symptoms

Signs of postpartum psychosis usually start to show in the first week or two after childbirth, although they may take up to 12 weeks to appear.

Postpartum psychosis causes significant changes to mood and behavior. Like the mental illness bipolar disorder, it can cause a mixture of depressive symptoms and manic symptoms, which are the opposite of one other.

Manic symptoms may include:

• insomnia
• high energy levels, including racing thoughts and fast talking
• difficulty concentrating
• paranoid beliefs (e.g. that your baby will be harmed)
• hallucinations (hearing voices, or seeing things)
• delusions (believing things are real when they are not).

Depressed symptoms may include:

• having very little energy
• feeling negative about life
• finding it hard to keep things in perspective
• feeling hopeless, or helpless
• having thoughts of harming yourself or your baby.

If you notice these kinds of changes in yourself, or someone close to you, you should seek professional help. See your doctor, local hospital emergency department.

How is postpartum psychosis diagnosed?

Postpartum psychosis is a serious mental health illness, and diagnosis is made by a psychiatrist. Most women with postnatal psychosis need to be admitted to hospital for psychiatric assessment and treatment.

Postpartum psychosis treatment

Postpartum psychosis is treatable. After getting the necessary treatment, most women make a full recovery.

To begin with, you will most likely need to be admitted to hospital, where you will be safe and doctors can monitor you closely. This first phase of treatment can take weeks or months, depending on your symptoms and how well you respond to treatment.

It will take more time and further treatment for you to recover fully.

Treatment options for postpartum psychosis include:

• medications such as antidepressants, mood stabilisers, and antipsychotics (drugs that help with psychotic symptoms such as hallucinations)
• electroconvulsive therapy (a process that stimulates brain neurons with an electric current to treat mania, psychosis and severe depression)
• psychological therapies, such as cognitive behavior therapy (CBT).

Advice for a partner, family and friends

If you suspect your partner or loved one is showing signs of postpartum psychosis, you may need to help her seek treatment. While this may be difficult, it is necessary. Both the mother and the baby could be at risk, and delaying treatment may mean it becomes more complex and recovery takes longer.

What causes psychosis

The causes of psychosis are complex and researchers are still trying to understand them fully. However, psychosis is thought to be caused by an interaction between genetic and environmental factors. It’s likely that some people are born with a predisposition to develop this kind of illness and that certain things – for example, stress or the use of drugs such as marijuana, LSD (lysergic acid diethylamide) or speed (amphetamine) – can trigger their first episode.

The main categories of causes of psychosis are:

• Mental illness: Psychosis can be caused by a mental illness, such as schizophrenia, bipolar disorder, or severe depression.
• Genetics: People with a family history of psychotic disorders such as schizophrenia have a slightly increased chance of developing psychosis. For example, if you have a first degree relative with schizophrenia, you may have a 10% chance of developing psychosis. There is no single gene that causes psychosis, but a number of different genes may increase the likelihood of developing it.
• Recreational drugs: Psychosis can be triggered by the use of drugs, including cannabis, amphetamines (including speed and ice), LSD (acid), magic mushrooms, ketamine, ecstasy and cocaine.

Substances misuse

Alcohol misuse and drug misuse can trigger a psychotic episode. A person can also experience a psychotic episode if they suddenly stop drinking alcohol or taking drugs after using them for a long time. This is known as withdrawal.

It’s also possible to experience psychosis after drinking large amounts of alcohol or if you’re high on drugs.

Drugs known to trigger psychotic episodes include:

• cocaine
• amphetamine (speed)
• methamphetamine (crystal meth)
• mephedrone (MCAT or miaow)
• MDMA (ecstasy)
• cannabis
• LSD (acid)
• psilocybins (magic mushrooms)
• ketamine

In rare situations, psychosis can also occur as a side effect of some types of medication or as a result of an overdose of that medication. Never stop taking a prescribed medication unless advised to do so by your doctor or another qualified healthcare professional responsible for your care. See your doctor if you’re experiencing psychotic side effects caused by medication.

The following conditions have been known to trigger psychotic episodes in some people:

• severe stress or anxiety
• severe depression – feelings of persistent sadness, including postnatal depression, which some women experience after having a baby
• lack of sleep

Some medical conditions have been known to cause psychosis. These include:

• HIV and AIDS
• malaria
• syphilis
• Alzheimer’s disease
• lupus
• Lyme disease
• multiple sclerosis (MS)
• hypoglycemia (an abnormally low level of glucose in the blood)
• brain tumors.

There’s also research showing that dopamine may be associated with psychosis. Dopamine is one of the neurotransmitters in the brain that sends information from one brain cell to another. People with psychosis are thought to have dopamine levels that are too high. This could interrupt the pathways in the brain responsible for memory, emotion, social behavior and self-awareness. Evidence for the role of dopamine in psychosis comes from several sources, including brain scans and the fact medications known to reduce the effects of dopamine in the brain also reduce the symptoms of psychosis.

Although the causes are still being uncovered, psychosis is treatable. With medication and support, people with psychosis can recover from their illness.

Psychosis signs and symptoms

Someone who develops psychosis will have their own unique set of symptoms and experiences, according to their particular circumstances.

But in general, five main symptoms are associated with a psychotic episode:

• Confused thinking and disturbed thoughts: thoughts don’t join up properly, causing confusion. A person’s thoughts may speed up or slow down, their sentences may be unclear and hard to understand, and they may have difficulty following a conversation.
• Delusions: the person may hold beliefs that are not usual for someone of the same cultural background. This can take different forms, such as paranoia (thinking they are being watched or singled out for harm), grandiosity (believing they have special powers or are an important religious or political figure) or depressive (believing they are guilty of a terrible crime).
• Hallucinations: the person may see, hear, feel, smell or taste something that doesn’t actually exist. Auditory hallucinations are the most common form: hearing voices that are not there.
• Lack of insight and self-awareness.
• Thoughts of self-harm or suicidal thoughts: the person may have feelings of wanting to harm themselves. Suicide is a medical emergency so please call your local emergency services number or go to the closest hospital emergency department.

Sometimes a person with psychosis can act inappropriately, such as laughing at sad news or becoming angry for no apparent reason. Associated agitation or apparent aggression can occur and must be managed under the supervision of a healthcare team to prevent harm to others.

The symptoms of psychosis can be disturbing, affecting a person’s concentration, memory and ability to plan. Hallucinations may cause distress and agitation. People with psychosis may find it difficult to understand and communicate their feelings. Psychosis can cause people to feel apathetic, lack motivation and withdraw from contact with others. A simple task, such as washing up, can seem like a major event.

Treatment is available to help people with psychosis to manage their symptoms.

Hallucinations

Hallucinations are where someone sees, hears, smells, tastes or feels things that don’t exist outside their mind.

• sight – seeing colors, shapes or people
• sounds – hearing voices or other sounds
• touch – feeling touched when there is nobody there
• smell – an odor that other people can’t smell
• taste – a taste when there is nothing in the mouth

Delusions

A delusion is where a person has an unshakeable belief in something untrue.

A person with persecutory delusions may believe an individual or organization is making plans to hurt or kill them.

A person with grandiose delusions may believe they have power or authority. For example, they may think they’re the president of a country or they have the power to bring people back from the dead.

Confused and disturbed thoughts

People with psychosis sometimes have disturbed, confused, and disrupted patterns of thought. Signs of this include:

• rapid and constant speech
• disturbed speech – for example, they may switch from one topic to another mid-sentence
• a sudden loss in their train of thought, resulting in an abrupt pause in conversation or activity

Lack of insight

People who have psychotic episodes are often unaware that their delusions or hallucinations aren’t real, which may lead them to feel frightened or distressed.

Psychosis diagnosis

The first step towards finding out if you or someone else is experiencing psychosis is to see a doctor or a mental health professional via your local hospital.

Psychosis assessment

A health professional will do a complete mental health assessment through an interview and may also wish to speak to a relative for more information. The purpose of the assessment is to find out:

• if the person is experiencing psychosis
• what might be causing it
• if there’s an underlying mental illness
• what’s the relevant family and medical history
• what’s the best course of treatment.

When someone has an episode of psychosis, a full medical examination is required. The person will need to be observed by a team of mental health professionals, either at home or in hospital.

Who you’re referred to will depend on the services available in your area. You may be referred to:

• a community mental health team – a team of mental health professionals who provide support to people with complex mental health conditions
• a crisis resolution team – a team of mental health professionals who treat people who would otherwise require treatment in hospital
• an early intervention team – a team of mental health professionals who work with people who have experienced their first episode of psychosis

These teams are likely to include some or all of the following healthcare professionals:

• a psychiatrist – a qualified medical doctor who has received further training in treating mental health conditions
• a community mental health nurse – a nurse with specialist training in mental health conditions
• a psychologist – a healthcare professional who specializes in the assessment and treatment of mental health conditions

Your psychiatrist will carry out a full assessment to help identify and diagnose any underlying mental health condition that could be causing your symptoms. This will help when planning your treatment for psychosis.

Different tests may be required to work out the diagnosis and any underlying causes. Tests may include:

• Medical tests: There are a range of tests the doctor may perform, such as blood tests for abnormal electrolyte and hormone levels or for syphilis and other infections. These tests can help work out the cause of the psychosis.
• Drug checks: Some drugs, such as LSD, marijuana and amphetamines, can cause psychosis. It’s important for a health professional to understand whether symptoms are associated with drug use.
• Brain scans: Sometimes doctors will scan the brain, using an MRI to check for any abnormalities.

Psychosis treatment

Recent advances in therapies mean that psychosis is now more treatable than ever before. Treatment usually involves medication, education about the illness, counseling, family support and practical support. Avoiding drugs, reducing stress and learning ways to cope with stress can help prevent psychosis symptoms from coming back.

Treatment may require a team of mental health professionals including a psychiatrist, mental health nurses, occupational therapists or psychologists.

• Early intervention: Research has suggested the best outcomes for treatment occur when psychosis is detected and treated early, before the illness has a chance to develop.
• Medication: A person with psychosis may be prescribed antipsychotic medicines. Treatments work by altering chemicals in the brain, including dopamine. Antipsychotics usually take several weeks to reduce symptoms, such as hallucinations or paranoia. But they may immediately produce a calming effect and aid sleep. Antipsychotic medications may cause side effects, so it is important to find the right medication for each person.
• Psychological therapy: There are several psychological treatments available to people who are experiencing psychosis, depending on their individual needs. These include supportive psychotherapy, cognitive behaviour therapy (CBT), family therapy and self-help groups.
• Community support programs: Mental health services can also provide practical support for people with psychosis. Stable accommodation, financial security, social support and having a meaningful role in society are essential components of recovery. People suffering from long-term psychosis may require rehabilitation and assistance to find suitable work.

If someone is experiencing psychosis, their doctor can help put them in touch with the best people to treat the psychosis and support them through treatment. Professional help will make managing the symptoms much easier.

If there is a risk of the person causing harm to themselves or others then seek urgent medical help with a doctor or at a local hospital emergency department. Any risk of suicide must be treated as a medical emergency and an ambulance should be called by dialing your local emergency services number.

Psychosis medication

Antipsychotic medicines are usually recommended as the first treatment for psychosis. They work by blocking the effect of dopamine, a chemical that transmits messages in the brain.

However, antipsychotic medications not suitable or effective for everyone, as side effects can affect people differently. In particular, antipsychotics will be monitored closely in people who also have epilepsy, a condition that causes seizures or fits.

People who have cardiovascular disease – conditions that affect the heart, blood vessels, or circulation, such as heart disease – will also be closely monitored.

Antipsychotics can usually reduce feelings of anxiety within a few hours of use, but they may take several days or weeks to reduce psychotic symptoms, such as hallucinations or delusional thoughts.

Antipsychotics can be taken by mouth (orally) or given as an injection. There are several slow-release antipsychotics, where you only need one injection every two to six weeks.

Antipsychotic medicines side effects

Antipsychotics can have side effects, although not everyone will experience them and their severity will differ from person to person.

Side effects can include:

• drowsiness
• shaking and trembling
• weight gain
• restlessness
• muscle twitches and spasms – where your muscles shorten tightly and painfully
• blurred vision
• dizziness
• constipation
• loss of sex drive (libido)
• dry mouth

Tell your doctor or mental health worker if you have side effects that are becoming particularly troublesome. There may be an alternative antipsychotic medicine you can take that causes less side effects.

Never stop taking medication prescribed for you unless advised to do so by a qualified healthcare professional responsible for your care. Suddenly stopping prescription medication could trigger a return of your symptoms (relapse). When it’s time for you to stop taking your medication, it will be done gradually.

Psychological treatment

Psychological treatment can help reduce the intensity and anxiety caused by psychosis. Some possible psychological treatments are discussed below.

Cognitive behavioral therapy

Cognitive behavioural therapy (CBT) for psychosis is based on an understanding of how people make sense of their experiences and why some people become distressed by them.

A cognitive behavioural therapy (CBT) therapist may encourage you to consider different ways of understanding what’s happening to you. The aim is to help you achieve goals that are meaningful and important to you, such as reducing your distress, returning to work, education or training, or regaining a sense of control.

Family intervention

Family intervention is known to be an effective form of therapy for people with psychosis. It’s a way of helping both you and your family cope with your condition. After having an episode of psychosis, you may rely on your family members for care and support. While most family members are happy to help, the stress of caring for somebody can place a strain on any family.

Family therapy involves a series of meetings that take place over a period of three months or more. Meetings may include:

• discussing your condition and how it might progress, plus the available treatments
• exploring ways of supporting someone with psychosis
• deciding how to solve practical problems caused by psychosis, such as planning how to manage future psychotic episodes

Self-help groups

If you’re experiencing episodes of psychosis, you may benefit from being around other people who’ve had similar experiences.

Violence and aggression

Acts of violence and aggression are fairly uncommon in people with psychosis. They’re more likely to be victims of violence than perpetrators. However, there may be times when your behavior places yourself or others at risk of harm. Mental health staff have been specially trained to deal with aggressive behavior.

They will try to help reduce any distress, agitation and aggression, but it may be necessary to hold you down without hurting you. This is known as physical restraint. You may then be moved to a secluded room.

In some cases, you may need to be given medication that will quickly make you very relaxed. You’ll be offered the medication voluntarily, in the form of tablets, but you can be treated against your consent if you refuse. This may involve giving you an injection of a tranquilizer (rapid tranquilization).

It’s important to stress that these methods are only used in extreme circumstances and are not routinely used to treat psychosis.

Advance decisions

If you’re at risk of having psychotic episodes in the future and there are certain treatments you don’t want to have, it’s possible to pre-arrange a legally binding advance decision, previously known as an advance directive. An advance decision is a written statement about what you’d like health professionals and your family or friends to do if you experience another psychotic episode. You may also want to include the contact details of your care team.

To create an advance decision, you need to make your wishes clear, in writing, and ask a witness to sign it. You should include specific details about any treatments you don’t want and specific circumstances in which they may apply. However, an advance decision can be overruled if a person is subsequently detained under the Mental Health Act. Although your doctors will try to take your wishes into account when deciding on treatment, they may decide it’s in your best interests not to follow the advance decision.