Psychosis explained
Psychosis is a state that causes the sufferer to experience the world in a different way to those around them. The main symptoms of psychosis are hallucinations and delusions.
Psychosis is not a condition but a symptom that can be caused by many things. The treatment will very much depend on the underlying cause. Many psychiatrists or doctors use the term ‘experiencing psychosis’ rather than giving a patient a specific diagnosis or label.
Dr Louise Wiseman explains what psychosis is, what it feels like, the possible causes and triggers of psychosis and what can be done to treat it.
What is psychosis?
Psychosis occurs when a person loses contact with reality and experiences the world differently to the people around them. This can also be called a ‘psychotic episode’, a ‘psychotic experience’ or ‘psychotic symptoms’. It is thought to be due to problems with functioning in the front part of the brain. The sufferer sees and thinks about the world differently to how they normally would, and may believe things that other people would not.
How long does psychosis last?
Psychosis can be something someone lives with for a long time or you may have short episodes throughout life or only suffer it once.
Psychosis symptoms
The main symptoms of psychosis are hallucinations and delusions.
These can make thoughts and emotions very confused and disorganised in themselves.
There is however a further group of symptoms called ‘disorganised thinking’ (also called ‘formal thought disorder’) that can be a specific type of psychosis in itself.
Less commonly, patients suffer ‘catatonic’ behaviour where they hardly move/speak or react to the world around them.
If you know someone who develops a psychosis you may interpret some of the symptoms as simply a change in personality.
Here we break down the main symptoms of psychosis:
Hallucinations
A person sees or hears things that do not really exist outside their mind. This can also extend to feeling, smelling or tasting things that are not there. These feel very real to the person experiencing it.
Examples of hallucinations include:
Seeing objects move in unusual ways or that are distorted from normal.
Seeing things that others do not (faces, animals, religious figures).
Tasting, smelling or having sensations for which there is no cause (e.g. feeling spiders crawling over your skin).
Hearing voices that other people don’t (these can be a positive, helpful voice or a voice with a threatening, nasty or hostile tone).
Delusions
A person has strong beliefs that others do not share. This is not the same as beliefs that are shared by different groups of people (e.g. faith, politics). A delusion is a belief in something that is false and to which there is clear evidence to the contrary.
Examples of delusions include:
Feeling you can control things e.g. the weather or other people.
Believing you are rich and powerful when it is not true (delusions of grandeur)
Believing that someone or something is trying to control you/cause you to harm/poison/kill you when there is no reason to believe this (paranoid delusions)
It is not automatic that everyone finds hallucinations and delusions distressing – many people are able to function in everyday life and live with these experiences.
Disorganised thinking and speech
Doctors use two terms regularly to describe this disordered thinking:
Racing thoughts – thoughts go through your head so fast they feel out of control.
Flight of ideas – thoughts jump from one idea to another; other people might not see the links between them like you do.
Disorganised thinking can mean you link words together due to how they sound rather than what they mean. This then might not make sense to the person you are talking to – it is sometimes called a ‘word salad’. Disorganised thinking can also mean you speak so quick the words are stumbled, you change topic so fast that others can’t keep up and you can’t pay attention to just one thing. These can also be symptoms of mania or hypomania.
Generally, when suffering psychosis symptoms, cognitive function is impacted. This means patients also suffer problems with memory, concentration and making decisions. This would be true in many states of stress, anxiety and depression as well.
Psychosis causes and risk factors
Causes of psychosis are divided by doctors’ classification into primary and secondary causes.
Primary causes
Doctors may decide in some patients that the cause of psychosis is actually another specific mental health diagnosis. We say that the primary cause of the psychosis is the mental illness. These include
Schizophrenia (this can include hallucinations and delusions)
Severe depression with psychotic symptoms
Schizoaffective disorder
Postpartum psychosis (happens rarely – 1 or 2 in every 1000 women within 4 weeks of giving birth)
Secondary causes
A secondary cause of psychosis is something that causes psychosis as a side effect or ‘accident’.
Psychosis can be very different for different people and there are many potential causes or triggers. Certain clinical and life scenarios can be risk factors for psychotic symptoms. Psychosis is not always part of a mental illness.
Triggers can include:
Abuse or trauma – these scenarios can make psychosis more likely – it could be a one-off traumatic event or long-term. It may be related to events in childhood or adulthood.
Extreme stress e.g. bereavement or losing one’s home
Extreme lack of sleep
Extreme low blood sugar or severe malnutrition
Physical illness or infection (delirium is the name for a state of confusion after an illness or operation)
e.g. high fever, heavy metal poisoning, thyroid problems, Cushing’s syndrome
infections that cause brain swelling including some sexually transmitted infections, Epstein-Barr virus, measles, mumps, rabies, certain parasites, malaria, fungal infections
Head or brain injury especially to the front of the brain
Certain vitamin deficiencies
Poisoning from toxins such as weedkillers or fertilisers (delirium is the name for a state of confusion after an illness or operation)
Neurological conditions such as MS, Epilepsy, Alzheimer’s, Dementia or Parkinson’s Disease, Fahr’s disease can cause hallucinations or delusions. Hallucinations can less commonly be a presenting symptom of a brain tumour or brain infection. Some rare genetic conditions can cause hallucinations.
Some autoimmune conditions in certain people e.g. with inadequate nutrient absorption, such as coeliac disease
Recreational drugs (e.g. cocaine, cannabis, amphetamines, PCP, glue, aerosols, nitrites) or alcohol misuse. Some of the effects may only occur at high doses or in withdrawal. Research is ongoing but it seems that drugs like cannabis and LSD can make you more likely to hear or see things and once you have had a psychotic experience certain drugs can make a recurrence more likely.
Drug or alcohol withdrawal can trigger symptoms such as hallucinations.
Prescribed medication can cause psychotic symptoms as a side effect or whilst you withdraw from them (e.g. anticholinergics, dopamine agonists, steroids, thyroid hormones, herbal remedies containing ephedra, some antibiotics and antivirals (rare) cough and allergy medicines)
You can be more likely to experience psychosis if a parent or sibling has experienced similar but doctors are not sure why this happens. It is sometimes difficult to work out what is genetic and what is from upbringing.
Some people describe hearing voices or seeing visions as part of a religious worship and this can be seen as a good or bad experience depending on how the person interprets it.
Treatment will be tailored according to the underlying cause of the psychosis in all these cases. If the cause is medical then the illness needs to be treated, if it is medication then this needs to be carefully altered, if drug or alcohol abuse then you may need help to carefully cut down and stop.
What does BPD or brief psychotic episode mean?
This is a type of psychosis that comes on suddenly, lasting from days to a month and then the symptoms stop and do not usually return. This is a more common pattern with an extreme stressful event as a trigger, or in postpartum psychosis or sometimes the cause is not known. It is really a diagnosis made after the event when it has gone away (by its very nature). This can be more common in developing countries, in patients with a personality disorder, women exposed to stress in pregnancy or those with a history of mental health problems or a family history. In these scenarios response to medication treatment is usually very successful and the medications are unlikely to be needed long term once the symptoms have resolved.
Psychosis diagnosis
You should contact your GP urgently if you are experiencing psychotic symptoms. Early treatment is more effective and everyone’s priority is to keep you safe.
It might be helpful to take a trusted relative or friend to the consultation and if it helps, write a list of your symptoms and when they have occurred.
The GP will ask you some further questions including:
Medical conditions
Mental health problems in the past
Medications
Use of recreational drugs and alcohol
Head injuries or trauma
Contact with toxic chemicals
They will then examine you; they may check urine and blood tests in the surgery or get these done at hospital (this also excludes any toxins you may or may not know you have ingested) and/or if necessary, refer you direct to a Mental Health Specialist team. This might be called an EARLY INTERVENTION TEAM (EIT) or COMMUNITY MENTAL HEALTH TEAM (CMHT) or a crisis team.
The priority of all of the clinical team is to keep you safe. If the clinical team are concerned about you and your safety, they may choose to admit you to hospital. You might not want to, but the doctor will make this decision if they think you are a danger to yourself or others.
What to do if you are worried about someone with psychosis symptoms
If you think a friend or relative is experiencing psychotic symptoms you will want them to see a doctor, but they unfortunately may not believe they are ill. This is called ‘lacking insight’ into illness.
If you are concerned you can follow the appropriate advice given on the Rethink.Org website:
Contact the person’s GP or
Call for an ambulance if you think it is appropriate or
Take them to A+E or
In certain situations use your nearest relative rights to ask for a Mental Health Assessment. Your ‘nearest relative’ is different to ‘next of kin’ under the Mental Health Act. The community mental health team or mental health crisis team or social services organise for an Approved Mental Health Professional (AMHP) to assess the person to see if they are at high risk to themselves or others and whether they will need hospital admission potentially against their will. It is always best to encourage someone to get help themselves via their GP but in certain circumstances a team needs to be involved. This procedure is called sectioning
Psychosis treatments
Your treatment may be initially as an inpatient or entirely managed in the community at home and clinic.
NICE guidelines recommend that alongside antipsychotic medication all patients should also receive some kind of ‘talking therapy’.
Medical treatments for psychosis
You and your doctor will jointly decide on the best medication. The group of medicines used is called antipsychotics and you will be counselled regarding side effects. Sometimes the first medicine does not work, or you find the side effects too severe so make sure you discuss this with your doctor. Some people find weight gain is an issue with certain medications.
There will be a correct medicine for you.
The doctor will regularly review you to check on progress.
If at any point in your illness you are feeling suicidal or having thoughts of self-harm discuss this with your Medical team or GP urgently and get help.
Talking treatments for psychosis
These include:
Cognitive Behavioural Therapy – this can help you change your patterns of thinking and your beliefs and gives you a way of coping and reducing stress and aims to improve your functioning and enjoyment in everyday life.
Family intervention – this can help those close with you work with you and support you for a good outcome. It may teach loved ones to help you prevent or manage a crisis and improve communication all round. Sometimes those close to a sufferer can spot the signs of a relapse before the patient themselves.
Art therapy – this can help some patients.
Trauma counselling – if the cause of psychosis was trauma it may helped by specific types of trauma counselling.
Sometimes ‘recovery colleges’ and ‘peer support’ (where you work with someone who has gone through similar experiences) are available in some areas in the NHS. Managing stress is also a long-term goal to prevent relapses.
Helping yourself
Self-management techniques are a form of self-help including relaxation techniques, mindfulness and meditation. Sticking to routine and looking at eating well and exercising can all help. The charity mind recommends keeping a diary to look for triggers and reflect on what has been helpful in the past. If you learn to recognise warning signs you can take action early to try to prevent your psychosis getting worse.
Other helpful resources include:
Last updated: 08-10-2020
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