Psychosis

What is psychosis?

Psychosis is characterized by an impaired relationship with reality. It’s a symptom of serious mental disorders. People who are experiencing psychosis may have either hallucinations or delusions.

Hallucinations are sensory experiences that occur within the absence of an actual stimulus. For example, a person having an auditory hallucination may hear their mother yelling at them when their mother isn’t around. Or someone having a visual hallucination may see something, like a person in front of them, who isn’t actually there.

The person experiencing psychosis may also have thoughts that are contrary to actual evidence. These thoughts are known as delusions. Some people with psychosis may also experience loss of motivation and social withdrawal.

These experiences can be frightening. They may also cause people who are experiencing psychosis to hurt themselves or others. It’s important to see a doctor right away if you or someone you know is experiencing symptoms of psychosis.

Recognizing the symptoms of psychosis

Symptoms of psychosis include:

Suicide prevention

  1. If you think someone is at immediate risk of self-harm or hurting another person:
  2. • Call 999 or your local emergency number.
  3. • Stay with the person until help arrives.
  4. • Remove any guns, knives, medications, or other things that may cause harm.
  5. • Listen, but don’t judge, argue, threaten, or yell.
  6. If you or someone you know is considering suicide, get help from a crisis or suicide prevention hotline.

What are delusions and hallucinations?

Delusions and hallucinations are two very different symptoms that are both often experienced by people with psychosis. Delusions and hallucinations seem real to the person who is experiencing them.

Delusions

A delusion is a false belief or impression that is firmly held even though it’s contradicted by reality and what is commonly considered true. There are delusions of paranoiagrandiose delusions, and somatic delusions.

People who are experiencing a delusion of paranoia might think that they are being followed when they aren’t or that secret messages are being sent to them. Someone with a grandiose delusion will have an exaggerated sense of importance. Somatic delusion is when a person believes they have a terminal illness, but in reality they’re healthy.

Hallucinations

A hallucination is a sensory perception in the absence of outside stimuli. That means seeing, hearing, feeling, or smelling something that isn’t present. A person who is hallucinating might see things that don’t exist or hear people talking when they’re alone.

Causes of psychosis

Each case of psychosis is different, and the exact cause isn’t always clear. There are certain illnesses that cause psychosis, however. There are also triggers like drug use, lack of sleep, and other environmental factors. In addition, certain situations can lead to specific types of psychosis developing.

Illnesses

Illnesses that can cause psychosis include:

Some types of dementia may result in psychosis, such as that caused by:

Risk factors for developing psychosis

It’s not currently possible to precisely identify who is likely to develop psychosis. However, research has shown that genetics may play a role.

People are more likely to develop a psychotic disorder if they have a close family member, such as a parent or sibling, who has a psychotic disorder.

Children born with the genetic mutation known as 22q11.2 deletion syndrome are at risk for developing a psychotic disorder, especially schizophrenia.

Types of psychosis

Some kinds of psychosis are brought on by specific conditions or circumstances that include the following:

Brief psychotic disorder

Brief psychotic disorder, sometimes called brief reactive psychosis, can occur during periods of extreme personal stress like the death of a family member. Someone experiencing brief reactive psychosis will generally recover in a few days to a few weeks, depending on the source of the stress.

Drug- or alcohol-related psychosis

Psychosis can be triggered by the use of alcohol or drugs, including stimulants such as methamphetamine and cocaine. Hallucinogenic drugs like LSD often cause users to see things that aren’t really there, but this effect is temporary. Some prescription drugs like steroids and stimulants can also cause symptoms of psychosis.

People who have an addition to alcohol or certain drugs can experience psychotic symptoms if they suddenly stop drinking or taking those drugs.

Organic psychosis

head injury or an illness or infection that affects the brain can cause symptoms of psychosis.

Psychotic disorders

Psychotic disorders can be triggered by stress, drug or alcohol use, injury, or illness. They can also appear on their own. The following types of disorders may have psychotic symptoms:

Bipolar disorder

When someone has bipolar disorder, their moods swing from very high to very low. When their mood is high and positive, they may have symptoms of psychosis. They may feel extremely good and believe they have special powers.

When their mood is depressed, the individual may have psychotic symptoms that make them feel angry, sad, or frightened. These symptoms include thinking someone is trying to harm them.

Delusional disorder

A person experiencing delusional disorder strongly believes in things that aren’t real.

Psychotic depression

This is major depression with psychotic symptoms.

Schizophrenia

Schizophrenia is a lifelong disease that is generally accompanied by psychotic symptoms.

How is psychosis diagnosed?

Psychosis is diagnosed through a psychiatric evaluation. That means a doctor will watch the person’s behavior and ask questions about what they’re experiencing. Medical tests and X-rays may be used to determine whether there is an underlying illness causing the symptoms.

Diagnosing psychosis in children and teenagers

Many of the symptoms of psychosis in adults aren’t symptoms of psychosis in young people. For example, small children often have imaginary friends with whom they talk. This just represents imaginative play, which is completely normal for children.

But if you’re worried about psychosis in a child or adolescent, describe their behavior to a doctor.

Treatment of psychosis

Treating psychosis may involve a combination of medications and therapy. Most people will experience an improvement in their symptoms with treatment.

Rapid tranquilization

Sometimes people experiencing psychosis can become agitated and be at risk of hurting themselves or others. In these cases, it may be necessary to calm them down quickly. This method is called rapid tranquilization. A doctor or emergency response personnel will administer a fast-acting injection or liquid medicine to quickly relax the patient.

Medication

Symptoms of psychosis can be controlled with medications called antipsychotics. They reduce hallucinations and delusions and help people think more clearly. The type of antipsychotic that is prescribed will depend on the symptoms.

In many cases, people only need to take antipsychotics for a short time to get their symptoms under control. People with schizophrenia may have to stay on medications for life.

Cognitive behavioral therapy

Cognitive behavioral therapy means meeting regularly to talk with a mental health counselor with the goal of changing thinking and behaviors. This approach has been shown to be effective in helping people make permanent changes and better manage their illness. It’s often most helpful for psychotic symptoms that don’t completely resolve with medications.

Complications and outlook of psychosis

Psychosis doesn’t have many medical complications. However, if left untreated, it can be challenging for people experiencing psychosis to take good care of themselves. That could cause other illnesses to go untreated.

Most people who experience psychosis will recover with proper treatment. Even in severe cases, medication and therapy can help.

Schizophrenia

Schizophrenia is a diagnosis given to some people who have severely disrupted beliefs and experiences.

During an episode of schizophrenia, a person’s understanding and interpretation of the outside world is disrupted – they may:

  • lose touch with reality
  • see or hear things that are not there
  • hold irrational or unfounded beliefs
  • appear to act strangely because they are responding to these delusions and hallucinations.

An episode of schizophrenia can last for several weeks and can be very frightening. About one in 100 people will have one episode of schizophrenia, and two thirds of these will go on to have further episodes. Schizophrenia usually starts in the late teens or early 20s, but can also affect older people for the first time.

The causes are unknown but episodes of schizophrenia appear to be associated with changes in some brain chemicals. Stressful experiences and some recreational drugs can also trigger an episode in vulnerable people.At least 26 million people are living with schizophrenia worldwide according to the World Health Organization, and many more are indirectly affected by it.

Symptoms

Doctors describe two groups of symptoms in people with schizophrenia: positive and negative. Although the positive symptoms are often the most dramatic and, at least initially, the most distressing, the negative ones tend to cause the most problems, as they tend to be longer lasting.

Positive symptoms

The three main positive symptoms are:

  • feelings of being controlled by outside forces (ie. having one’s thoughts and actions taken over)
  • hearing, seeing, smelling or feeling things which are not there (hallucinations)
  • irrational and unfounded beliefs (delusions).

The delusions can often be very frightening – the person may believe that others are plotting to kill them or that their conversations are being recorded. Positive symptoms all tend to occur during acute episodes and can be particularly frightening.

Negative symptoms

The negative symptoms include tiredness, loss of concentration, and lack of energy and motivation, which may be exacerbated by the side-effects of drugs used to treat the positive symptoms. Because of these symptoms, people with schizophrenia are often unable to cope with everyday tasks, such as work and household chores. Suicide and self-harm are common in people with a diagnosis of schizophrenia: around one in 10 take their own life.

Misconceptions about schizophrenia

There is more media misinformation about schizophrenia than about any other type of mental health problem. A diagnosis of schizophrenia does not mean ‘split personality’, or indicate that someone will be calm one minute and then be ‘out of control’ the next. 

Sensational stories in the media tend to present people with schizophrenia as dangerous, even though most people diagnosed with schizophrenia don’t commit violent crimes. Another misconception is that people who hear voices are dangerous, but actually voices are more likely to suggest that you harm yourself than someone else and people have a choice in whether they do what the voices say.

Treatments

Most people with schizophrenia are prescribed drugs to reduce the positive symptoms. The drugs may be prescribed for long periods and may have unpleasant side effects.

Some people need a great deal of help in managing the symptoms of schizophrenia. Others find ways to cope with experiences such as hearing voices and do not necessarily wish to receive any treatment.

Sometimes, people in an acute phase of the illness may need to be admitted to hospital under the Mental Health Act for their own, or other people’s, safety. People with schizophrenia are not usually dangerous to other people; they are more at risk of harm from others, or themselves.

Many people who are at risk of relapse carry Crisis Cards or have written up Advance Directives stating how they would like to be treated and what they do and do not find helpful. Mental health professionals do not have to follow these instructions, but it is considered good practice to take the person’s wishes into account.

Getting help

If you, or someone you care for, are experiencing the symptoms of schizophrenia you may wish to contact your GP who can prescribe drug treatments and refer you for psychiatric help. You may also be referred to social services and the local community mental health team who can support you at home.

If you need urgent support or you feel like harming or hurting yourself or anyone else, call 999 or go to the nearest hospital accident and emergency department.

If your need is less urgent, you can contact the NHS Direct helpline on 111, which is open 24 hours a day, 365 days a year. They can also provide information about your nearest A&E and other support services.

A major health inequality is that people with a diagnosis of schizophrenia die, on average, 20 years younger than the general population – this is unacceptable. Poor physical health can arise as a side effect of anti-psychotic medication – for example through weight gain and increased risk of developing diabetes. Poor physical health can also result because of a failure to monitor risk factors. We want GPs to carry out regular health checks for all people with severe mental health problems. 

Self-management of schizophrenia

Through self-management, many service users gain confidence, skills and knowledge to better manage their mental health and gain more control of their lives at a time when they may feel they have lost control. The Foundation is developing, delivering and evaluating a range of self-management interventions for people with severe psychiatric diagnoses in Wales including schizophrenia.

Melancholic Depression

Melancholic depression is a form of major depressive disorder (MDD) which presents with melancholic features. Although melancholic depression used to be seen as a distinct disorder, the American Psychiatric Association (APA) no longer recognizes it as a separate mental illness. Instead, melancholia is now seen as a specifier for MDD — that is, a subtype of major depressive disorder.

MDD is a significant mental health condition characterized by persistent and intense feelings of sadness and hopelessness. The disorder can affect many areas of life, including work, school, and relationships. It may also impact mood and behavior as well as various physical functions, such as appetite and sleep. People with MDD often lose interest in activities they once enjoyed and have trouble getting through the day. Occasionally, they may also feel as if life isn’t worth living.

The severity and type of MDD symptoms vary greatly from person to person. Some people experience traditional symptoms of MDD, while others develop additional syndromes, such as melancholia and catatonia. Most symptoms can be managed with treatment, which may consist of medication and talk therapy.

Symptoms of Melancholic Depression

People with melancholic depression may experience symptoms of MDD, such as:

  • persistent feelings of extreme sadness for a long period of time
  • loss of interest in activities that were once enjoyable
  • having a lack of energy or feeling fatigued
  • feeling anxious or irritable
  • eating too much or too little
  • sleeping too much or too little
  • experiencing changes in body movement (for example, jiggling your leg when you didn’t before)
  • difficulty concentrating, making decisions, and remembering things
  • thinking or talking about death or suicide
  • suicide attempt

They may also experience melancholic features of MDD, which include:

  • loss of pleasure in all or most daily activities
  • lack of reactivity to positive news and events
  • deep feelings of despair and worthlessness
  • sleep disruptions
  • significant weight loss
  • persistent feeling of excessive or inappropriate guilt
  • symptoms of MDD that are worse in the morning

Melancholic features are more likely to occur in people who frequently experience severe symptoms of MDD. They are also seen more often in those who have MDD with psychotic features.

Diagnosing Melancholic Depression

The APA no longer recognizes melancholic depression as a distinct form of depression, and it is listed as a type of MDD. When someone shows signs of depression and melancholia, the diagnosis is “major depressive disorder with melancholic features.” To make this diagnosis, a doctor will usually ask some of the following questions:

  • Do you have difficulty getting out of bed and getting started in the morning?
  • Are your symptoms generally worse in the morning or in the evening?
  • How do you sleep?
  • Has there been a change in your sleep patterns?
  • What does a typical day look like for you?
  • Has your daily routine changed recently?
  • Do you enjoy the same things you once did?
  • What, if anything, improves your mood?
  • Do you have more trouble concentrating than usual?

Treatments for Melancholic Depression

MDD is often treated with newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). These include well-known medications, such as fluoxetine (Prozac), citalopram (Celexa), or paroxetine (Paxil). However, many people who have MDD with melancholic features may respond better to older antidepressants such as the tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs), as well as serotonin-norepinephrine reuptake inhibitors, such as venlafaxine (Effexor). These medications help inhibit the breakdown of serotonin and norepinephrine in the brain, resulting in higher amounts of these “feel good” chemicals. Sometimes, certain atypical antipsychotics such as Abilify (aripiprazole) may be used to augment the effects of antidepressants.

In addition to medication, talk therapy is commonly used to treat people who have MDD with melancholic features. A combination of these two treatment methods is usually more effective than either approach on its own. Talk therapy involves meeting with a therapist on a regular basis to discuss symptoms and related issues. It can show people how to:

  • adjust to a crisis or other stressful event
  • replace negative beliefs and behaviors with positive, healthy ones
  • improve communication skills
  • cope with challenges and solve problems
  • increase self-esteem
  • regain a sense of satisfaction and control in life

Group therapy can help in a similar way and give you the ability to share your feelings with people who can relate.

In severe cases, electroconvulsive therapy (ECT) may be performed to help relieve symptoms of MDD with melancholic features. This treatment involves attaching electrodes to the head that send electrical impulses to the brain, triggering a mild seizure. ECT is now considered a safe and effective treatment for mood disorders and mental illnesses, but there’s still a stigma surrounding it. As a result, it may not be used as the primary treatment for symptoms of melancholia. However, a combination of medication, talk therapy, and ECT may be the best treatment for MDD with melancholic features.

Suicide prevention

If you think someone is at immediate risk of self-harm or hurting another person:

  • Call 999 or your local emergency number.
  • Stay with the person until help arrives.
  • Remove any guns, knives, medications, or other things that may cause harm.
  • Listen, but don’t judge, argue, threaten, or yell.