The word psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. When someone becomes ill in this way, it is called a psychotic episode. During a period of psychosis, a person’s thoughts and perceptions are disturbed, and the individual may have difficulty understanding what is real and what is not.

Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there.

Schizophrenia is one type of psychotic disorder. People with bipolar disorder may also have psychotic symptoms. Other problems that can cause psychosis include alcohol and some drugs, brain tumors, brain infections, and stroke.

Treatment depends on the cause of the psychosis. It might involve drugs to control symptoms and talk therapy. Hospitalization is an option for serious cases where a person might be dangerous to himself or others.

It is difficult to know the number of people who experience psychosis. Studies estimate that between 15 and 100 people out of 100,000 develop psychosis each year.

Psychosis often begins in young adulthood when a person is in their late teens to mid-20s. However, people can experience a psychotic episode at younger and older ages and as a part of many disorders and illnesses. For instance, older adults with neurological disorders may be at higher risk for psychosis.

There is no one cause of psychosis. Psychosis appears to result from a complex combination of genetic risk, differences in brain development, and exposure to stressors or trauma. Psychosis may be a symptom of a mental illness, such as schizophrenia, bipolar disorder, or severe depression. However, a person can experience psychosis and never be diagnosed with schizophrenia or any other disorder.

For older adults, psychosis symptoms can be part of a physical or mental illness that emerges later in life. Psychosis can also be a symptom of some diseases of older age, including Parkinson's disease, Alzheimer’s disease, and related dementias.

Other possible causes of psychosis include sleep deprivation, certain prescription medications, and the misuse of alcohol or drugs. A mental illness, such as schizophrenia, is typically diagnosed by excluding these other causes.

A qualified mental health professional (such as a psychologist, psychiatrist, or social worker) can provide a thorough assessment and accurate diagnosis. 

People with psychosis typically experience delusions (false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them) and hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them). Other symptoms can include incoherent or nonsense speech and behavior that is inappropriate for the situation.

However, a person will often show changes in their behavior before psychosis develops. Behavioral warning signs for psychosis include:

• Suspiciousness, paranoid ideas, or uneasiness with others
• Trouble thinking clearly and logically
• Withdrawing socially and spending a lot more time alone
• Unusual or overly intense ideas, strange feelings, or a lack of feelings
• Decline in self-care or personal hygiene
• Disruption of sleep, including difficulty falling asleep and reduced sleep time
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating
• Sudden drop in grades or job performance

Alongside these symptoms, a person with psychosis may also experience more general changes in behavior that include:

• Emotional disruption
• Anxiety
• Lack of motivation
• Difficulty functioning overall

In some cases, a person experiencing a psychotic episode may behave in confusing and unpredictable ways and may harm themselves or become threatening or violent toward others. The risk of violence and suicide decreases with treatment for psychosis, so it is important to seek help. If you find that you are experiencing these changes in behavior or notice them in a friend or family member and they begin to intensify or do not go away, reach out to a health care provider.

Studies have shown that it is common for a person to have psychotic symptoms for more than a year before receiving treatment. Reducing this duration of untreated psychosis is critical because early treatment often means better recovery. A qualified psychologist, psychiatrist, or social worker can make a diagnosis and help develop a treatment plan.

Treatment of psychosis usually includes antipsychotic medication. There are several different types of antipsychotic medications, and they have different side effects, so it is important to work with a health care provider to determine the medication that is most effective with the fewest side effects.

Treatment also often includes other elements. There is substantial research support for coordinated specialty care, which is a multi-element, recovery-oriented team approach to treating psychosis that promotes easy access to care and shared decision-making among specialists, the person experiencing psychosis, and family members. People experience better outcomes from coordinated specialty care if they begin treatment as soon as possible after psychotic symptoms emerge.

Coordinated specialty care is now the standard of care for early psychosis, according to “The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.”

NIMH research on coordinated specialty care

The Recovery After an Initial Schizophrenia Episode (RAISE) research project, supported by NIMH, established coordinated specialty care as an effective treatment for early psychosis and identified important elements for helping people lead productive, independent lives. 

NIMH continues to prioritize research on and expansion of treatments for early psychosis with the launch of the Early Psychosis Intervention Network (EPINET) in 2019. Through EPINET, NIMH funded awards to establish a national data coordinating center and regional scientific hubs connected to more than 100 coordinated specialty care programs that provide early psychosis treatment in 17 states. The EPINET website provides resources for researchers, health care providers, administrators, and people experiencing psychosis and their families.

Coordinated specialty care consists of multiple components:

• Individual or group psychotherapy is tailored to a person’s recovery goals. Cognitive and behavioral therapies focus on developing the knowledge and skills necessary to build resilience and cope with aspects of psychosis while maintaining and achieving personal goals.
• Family support and education programs teach family members about psychosis as well as coping, communication, and problem-solving skills. Family members who are informed and involved are more prepared to help loved ones through the recovery process.
• Medication management (also called pharmacotherapy) means tailoring medication to a person’s specific needs by selecting the appropriate type and dose of medication to help reduce psychosis symptoms. Like all medications, antipsychotic medications have risks and benefits. People should talk with a health care provider about side effects, medication costs, and dosage preferences (daily pill or monthly injection).
• Supported employment and education services focus on return to work or school, using the support of a coach to help people achieve their goals.
• Case management provides opportunities for people with psychosis to work with a case manager to address practical problems and improve access to needed support services.

People with psychosis should be involved in their treatment planning and consulted in making decisions about their care. Their needs and goals should drive the treatment programs, which will help them stay engaged throughout the recovery process.

It is important to find a mental health professional who is trained in psychosis treatment and who makes the person feel comfortable. With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Some people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to lead a fulfilling and productive life, even if psychotic symptoms sometimes return.

Psychotic disorders such as schizophrenia can be highly disabling. An episode of psychosis involves experiences that aren’t based in reality. These can include hallucinations and delusions, such as feeling that people are trying to harm you. If researchers could identify when people with psychotic disorders are verging on psychosis, promising methods to delay or stop the process could be tested.

Studies suggest that language patterns may help predict if someone is likely to experience psychosis. Drs. Neguine Rezaii, Elaine Walker, and Phillip Wolf of Emory University tested whether machine learning could help identify such patterns. They used sophisticated computer programs to analyze patterns of speech from 40 people enrolled in a long-term study of youth who are at risk of developing psychosis. The participants were enrolled because of unusual patterns of thought, perception, and communication.

The researchers collected recordings of interviews when participants joined the study. The team used machine learning to rate the complexity of speech and categorize the subject matter used by participants. After the interviews, participants were followed for two years to determine who developed psychosis. The team looked for specific patterns of language that might mark the earliest phase of illness.

The study was funded in part by NIH’s National Institute of Mental Health (NIMH). Results were published on June 13, 2019, in NPJSchizophrenia.

The machine learning system was trained using language samples from 30 of the 40 participants. It found that samples from those who progressed to psychosis had lower semantic density (less meaning conveyed in their sentences) than samples from a large database of normal language. The system's predictive value was then tested against the remaining 10 participants’ outcomes. This language trait could predict which of the remaining participants would later develop psychosis with 80% accuracy.

The system also found that words related to voices and sounds were used much more frequently in those who later had a psychotic episode than in conversations among 30,000 contributors on Reddit. The social network was used for comparison because the casual language used online closely matched that in the study interviews.

Using the combination of differences in semantic density and word choice, the system could predict which of the remaining 10 participants would develop psychosis with 93% accuracy.

“If we can identify individuals who are at risk earlier and use preventive interventions, we might be able to reverse the deficits,” Walker says. “There are good data showing that treatments like cognitive-behavioral therapy can delay onset, and perhaps even reduce the occurrence of psychosis.”

The results need to be confirmed in larger groups of people at risk for psychosis. This type of machine-learning language approach has the potential to detect emerging mental illness as well as to provide insights into how the human brain normally processes thoughts and ideas.

—by Sharon Reynolds