What is psychosis?

Psychosis is a condition where there is a loss of contact with reality. During an episode of psychosis, a person’s thoughts and perceptions are disrupted and they may have trouble distinguishing between what is real and what is not.¹ You may experience a combination of symptoms such as seeing or hearing things that are not there (hallucinations), delusions (false beliefs), and disordered thinking (disturbance in thoughts). Treatment for psychosis usually involves a combination of medication, talking therapies, and social support.

Psychosis refers to a collection of symptoms and is not an individual disorder. However, psychosis is seen in various mental disorders such as schizophrenia and bipolar disorder. 

Positive and negative symptoms of psychosis 

Symptoms of psychosis can be described as being 'positive' or 'negative'. Positive and negative symptoms do not refer to symptoms that are either 'good' or 'bad'. Rather a positive symptom is an experience 'added' to a person's usual way of functioning. Hallucinations are where you experience something that is not there. You may hear and see things that other people can not. There are many different types of hallucinations, they can affect any of the senses including taste, smell, or touch. People can experience sensations on their skin when nothing is touching them. Auditory hallucinations are the most common. There can be one voice or several voices. They may talk about you, talk directly to you, or talk about what you are doing, like a commentary. They can sometimes tell you what to do and make you feel like you have no choice but to do what they say. This can be very distressing. Hallucinations are described as a positive symptom of psychosis as they add to an experience. 

Delusions are another positive symptom that is often present in a psychotic illness. Delusions are false beliefs. These beliefs are not rational and are firmly held despite evidence that the belief is not real. Delusions can have many themes. Delusions of persecution are common and usually involve believing that others are acting against you in some way.  You might feel like you are being followed or that someone or something is interfering with your life in some way.

Delusions of grandeur are when a person believes that they are special or superior in some way. They may think that they have superpowers, are exceptionally smart, or that they are famous.

Delusions can come on suddenly but usually develop over time. They may begin as an explanation for a hallucination. For example, hearing voices talking about you might lead you to believe that you are being watched or monitored. Some people believe that the TV or radio is communicating directly with them or talking about them. These experiences can be very upsetting. Positive symptoms are often more noticeable than negative symptoms. 

Negative symptoms can be seen as the opposite of positive symptoms as they are 'taking away' from your normal behaviour and experiences. Motivation, interests, and socialising are areas that are primarily affected by negative symptoms. These tend to be reduced as you withdraw from interactions with others. You may experience a lack of facial expressions and have difficulty expressing your emotions. For example, you might not laugh after hearing a funny joke that you would usually find amusing. You may no longer enjoy things that previously brought you joy. 

Lack of motivation extends to everyday activities like getting out of bed and showering. There may be a decrease in eating and taking care of yourself and your living space. There may be a reduction in the quantity of speech. This occurs due to disorganised thinking.  

Diagnosing psychosis

Diagnosing psychosis requires a thorough investigation involving a team of mental health professionals who will carry out assessments to help identify what could be causing your symptoms. If there is evidence of psychosis, a referral will be made to a specialist team of mental health professionals who will work together to support you. The referral to a specialist will likely be urgent if you are experiencing psychosis. 

A full examination of your physical health will be carried out to look for a physical cause for your symptoms. This will involve a physical examination, and blood tests, and will likely include a brain scan and an electroencephalogram (EEG) as well, especially if this is your first episode of psychosis. This will look for any brain abnormalities that may be causing your symptoms. 

You will also be referred to the local mental health team who will monitor your symptoms and treatment(s). The services offered often depend on the combination of your symptoms and what is available in your local area.

Services you may be offered include:

• Community mental health team - Mental health professionals who provide support to people with a wide range of mental health conditions
• A crisis resolution team - Offer support for individuals in crisis in the community who would have otherwise required treatment in hospital 
• Early intervention in psychosis services (EI) - A specialist team of mental health professionals who support and treat first-episode psychosis
• Psychiatrists 
• Psychologists 
• Community mental health nurses 
• Support workers 
• Social workers

A hospital admission may be necessary if you become very distressed during an episode of psychosis. Inpatient treatment will aim to help you manage and treat your symptoms. However, services such as the crisis resolution team aim to support you within the community to reduce the need for hospital admissions. 

Treatment and monitoring will continue outside of the hospital. The community mental health team will monitor your symptoms and treatment. You may be assigned a key worker who will check in with you on a regular basis. They will be your main point of contact and are the first person you should contact if you have any questions or concerns. In addition, the mental health team can help with your social situation. 

Occupational therapists can help with getting back to work or returning to your usual activities. Social workers can help with your benefits and your housing situation. They can also help support your family and friends. 

Support workers are available to help you live an independent life. Their role is varied and they can provide emotional support as well as physical. They are good listeners and can be the first person to notice, and the first to help if you are struggling.

Diagnoses associated with psychosis

Psychosis describes a combination of symptoms such as hallucinations and delusions as described above. However, there are several different mental illnesses that have psychosis within their diagnostic criteria. These include:

• Schizophrenia
• Schizophreniform disorder 
• Brief psychotic disorder 
• Bipolar disorder 
• Delusional disorder 
• Schizoaffective disorder 
• Psychotic Depression 
• Postpartum psychosis

Treatment for psychosis 

Psychosis often requires a multidisciplinary approach to treatment. You will likely receive a combination of treatments and support from different mental health professionals. Most people with psychosis will be offered an antipsychotic medication as a first line of treatment. Antipsychotic medications will help to manage your symptoms. Talking therapy may be offered in addition to drug therapy to help you understand your experience of psychosis. The treatment you receive will often depend on what symptoms you experience or depend on your diagnosis or any pre-existing conditions. 

Antipsychotic medication  

Antipsychotics are a type of medication used to treat symptoms of psychosis, such as hallucinations. Antipsychotic medications work by altering the balance of neurotransmitters within the brain, particularly dopamine and serotonin, as a chemical imbalance of these is thought to be a factor in the development of psychosis. Other medications such as antidepressants or mood stabilisers may be used on their own or in conjunction with antipsychotics as part of your treatment. Antidepressants and mood stabilisers will often be prescribed by your doctor if you have comorbid mood symptoms such as depression or mania. 

Antipsychotic medication can be characterised into two groups:³

• Typical antipsychotics (first generation) 
• Atypical antipsychotics (second generation)

You will likely be prescribed a second-generation antipsychotic as they typically have a lower risk of serious side effects than first-generation antipsychotics. 

Examples of second-generation antipsychotics include:

• Aripiprazole
• Risperidone
• Olanzapine
• Quetiapine
• Ziprasidone
• Clozapine

That is not to say that this group of antipsychotics do not have side effects. All medications have side effects. Side effects of these medications are related to weight gain and its associated complications. Any concerns should be discussed with your doctor and a decision can be made regarding the treatment that is best for you.

First-generation antipsychotics such as haloperidol may be used in hospitals to help treat distressing symptoms in a more timely manner. First-generation antipsychotics can cause extrapyramidal side effects that affect movement. These can be unsettling and distressing and can occur at any time after starting medication. This is why these antipsychotics are reserved for use when second-generation antipsychotics have not been effective.

Clozapine is a medicine that is reserved for the most severely ill patients who have not responded to other medications. The makers of a particular preparation are required to monitor blood tests on a regular basis. This is because of the uncommon but serious side effects that it can have on your white blood cells. It also causes weight gain and can lead to complications from constipation. It is, however, an effective antipsychotic, particularly in those who have not responded to other antipsychotics. 

Benzodiazepines 

Benzodiazepines are primarily used to treat anxiety disorders. However, they can be prescribed to manage symptoms of psychosis due to their calming effect. They should only be used in the short term and are used for distressing symptoms and agitation. Medicines such as diazepam and lorazepam have been proven beneficial in the management of sudden and distressing symptoms. They are encouraged only to be taken on a short-term basis to avoid the risk of tolerance to benzodiazepines. Benzodiazepines also have a risk for addiction, therefore treatment with benzodiazepines should always be taken as prescribed by your medical team and for as short a time as possible, with a decreasing dose to avoid withdrawal symptoms.

Talking therapies and support for managing psychosis 

After experiencing psychosis you may find talking therapies useful to help you to understand your condition and how it affects you. You may find it useful to work with a mental health professional to explore options that can help support your everyday life. Talking therapies are often offered in conjunction with drug therapies to manage the symptoms of psychosis. 

You may be offered Cognitive Behaviour Therapy for Psychosis (CBTp) to help you improve your insight into your condition and assist with the development of coping skills. This leads to a lower risk of relapse. 

Psychoeducation combines elements of CBT and aims to provide knowledge to the patient and their family about psychosis and how it affects them, treatment options, and coping skills to assist with managing the condition. It aims to provide a thorough education about psychosis so you can make informed decisions about your care and treatment alongside your mental health team. 

Acceptance and Commitment Therapy (ACT) is a therapy based on mindfulness. It can be a useful tool to learn to accept your situation without judgment. ACT can also be beneficial in learning how to stay focused on the present. ACT can help you move on from difficult experiences which may be particularly useful when coping with psychosis. 

Many other therapies are also available to help with the management of psychosis. Social support plays an important role in management and recovery. Psychosis can be an isolating experience. However, a supportive network of family, friends, and mental health professionals can improve the outcomes of psychosis. You may find that social support can help you with entering back into education, work, or assist with housing needs. 

Summary

Diagnosis of a psychotic disorder involves a thorough assessment by a specialist team of mental health professionals. They will assess your symptoms and decide on a treatment plan. Treatment usually involves medication, talking therapy, and social support. Antipsychotic medication and talking therapies play a crucial role in the long-term management of psychosis. Outcomes depend on several things, such as the severity of symptoms, early intervention, support networks, and access to treatment. People with psychosis have a higher risk of suicide and depression. While many factors influence this, the stigma around psychotic illnesses and the portrayal of psychosis in the media can lead to feelings of shame and isolation. Experiencing psychosis does not mean you have a split personality or that you are violent. The majority of people living with psychosis are not violent and are more likely to be victims of a violent crime.²

Psychosis can be managed successfully in the community with a personalised treatment plan.