Psychosis

Learn about signs and symptoms, standards for treatment,
linkages to cannabis use, and risks related to untreated psychosis.

What is psychosis? 

The severe mental illness (SMI) most commonly associated with psychosis is schizophrenia, with about 1.2 percent of U.S. adults ages 18-65 impacted. Bipolar and major depressive disorders are also considered SMI when symptoms include psychosis.

With or without an SMI diagnosis, psychosis can occur because of infection, an inflammatory condition, substance use, traumatic brain injury, or post-partem. Symptoms of psychosis can be temporary or chronic, and sometimes they come and go without explanation.

The APA Dictionary of Psychology defines psychosis as an “abnormal mental state involving significant problems with reality testing. It is characterized by serious impairments or disruptions in the most fundamental higher brain functions — perception, cognition and cognitive processing, and emotions or affect — as manifested in behavioral phenomena, such as delusions, hallucinations, and significantly disorganized speech.” 

A brain experiencing psychosis is unable to distinguish between its own dream-like inventions and reality. 

What are features of psychosis? 

These symptoms typically define a psychotic episode: 

• • • Delusions: beliefs that are clearly implausible and persist even with clear evidence that is obvious and convincing to others. 
    • Hallucinations: sensory experiences that don’t match reality, such as seeing, hearing, smelling, or feeling something that’s not actually occurring. A person might hear voices that could be complimentary, neutral, or damning.  
    • Disorganized thinking: speech that is so disorganized that it impairs basic communication. A person might rapidly switch from one topic to another or say things that are incoherent to others. 
    • Disorganized or abnormal motor behavior: decreased reactivity (catatonia), unpredictable agitation, or bizarre and rigid posturing. 
    • Negative symptoms: disengagement with the outside world. Negative symptoms are common with schizophrenia spectrum disorders and less common in other conditions with psychotic features. The person might be less expressive or stop initiating activities previously enjoyed, especially in social settings. They might communicate less and seem less capable of feeling positive emotions. 

What are types of delusions?

Some delusions are rare but dangerous. For example, Capgras syndrome describes a person’s fixed false belief that close family or friends are nefarious imposters. Violence against loved ones can occur because the person believes they are “saving” the real person highjacked by the imposter or that the imposter is a direct threat to them or someone else. TAC provides a resource about violence and safety planning.

Some irrational beliefs contribute to phobias, which may create risks for harm. A person with an irrational fear of being intentionally poisoned (iofobia) might suffer or even die from dehydration or malnutrition, including during incarceration, if psychosis goes untreated.

Common delusions are:

• • • Persecutorial: irrational paranoia about being threatened, harmed, or harassed.
    • Referential: belief that everyday people, places, events, and objects hold personal significance, such as strangers in a store sending secret codes to you or about you.
    • Grandiose: unsubstantiated belief in extraordinary power, wealth, fame, talents.
    • Erotomanic: fixed belief that another person (sometimes a celebrity) is in love with you, even if you’ve never met.
    • Nihilistic: obsessive thoughts that are catastrophic or relate to the end of humanity.
    • Somatic: preoccupation with health and organ function, often with an inaccurate self-assessment, such as misunderstanding hunger to mean stomach cancer.
    • Bizarre: implausible beliefs, like all of the home’s appliances being surveillance devices or a person’s organs being replaced by someone else’s. Bizarre delusions might generate a belief that an outside or alien force manipulates thoughts.

What might cause psychosis? 

Psychosis can be a singular event caused by drug use, fever, a brain injury, trauma, pregnancy, or something else. It can also mark the beginning of a lifelong disease — such as schizophrenia. A person might have a genetic predisposition, or they might not. If there are relatives with similar symptoms or a diagnosed condition, that information can be helpful for providers. 

Conditions that might cause psychosis or symptoms that mimic psychosis are Lyme disease, epilepsy, tumors, and autoimmune diseases. A bacteria called Bartonella may be linked to psychosis, and in that type of situation an antibiotic might be an important aspect of treatment.  

Traumatic brain injury (TBI) is a risk factor for psychosis, and treatment may differ when the brain has been physically damaged by a direct blow to the head, a penetrating object, a traffic accident, a fall, or blast exposure from weapons. Military service members and veterans, people in correctional facilities, those experiencing homelessness, and those with lower incomes or without health insurance are at increased risk for TBI. Symptoms may begin months to years after an injury and psychosis risks may depend on TBI severity, genetic predispositions, and whether the brain’s temporal and frontal lobes are harmed.

A rare but important risk factor for psychosis is pregnancy, with postpartum psychosis (PPP) affecting 1-3 of 1,000 U.S. births per year. Psychosis in a new mother increases the risks for self-harm and harm to children, making PPP a mental health emergency. While symptoms usually appear within several days of giving birth, PPP can happen up to six weeks later. A direct cause is unclear, but contributing factors may be a first birth, a personal or family history of mental illness, sleep deprivation, or hormone changes. Other physical changes related to maternity that could be factors are autoimmune and inflammatory diseases, electrolyte imbalances, vitamin deficiencies (B1 and B12), thyroid disorders, stroke, eclampsia and preeclampsia.

Comprehensive evaluation by licensed medical providers is necessary to consider all possible diagnoses. The individual or family might consult psychiatrists, neurologists, infectious disease doctors, and other specialists who might contribute relevant insights.  

Research has identified a part of the brain called the “salience network” as important in psychosis. When the salience network isn’t working correctly, a person can have a difficult time understanding reality versus what the brain is inventing — like believing that a dream is true and happening. 

Is psychosis caused by cannabis use? 

A diagnosis of cannabis-induced psychosis is increasingly common. Professional care is necessary to determine whether psychosis related to cannabis use is temporary or if there is onset of a chronic mental illness.  

Research showing a link between cannabis usage and the onset of schizophrenia offers the following information:   

• • • THC, the active ingredient in marijuana, can cause temporary psychotic symptoms, which may increase the risk of developing a mental health disorder. 
    • Cannabis use increases the likelihood that adolescents will develop schizophrenia or bipolar disorder, particularly if they have other risk factors. 
    • Individuals with schizophrenia tend to use marijuana at higher rates.
    • Families need education about linkages between cannabis use and psychosis. 

A parent-run website, Johnny’s Ambassadors, offers information and resources about early onset psychosis and cannabis use. Included are state-by-state treatment options.

What symptoms might show up first? 

Prior to a psychotic break, symptoms of psychosis may be “prodromal.” The person may still differentiate between reality and their experience, but others may see behavioral changes that are out of character.

Primary features of prodromal psychosis might look like anxiety, stress, uncertainty, inattention, poor concentration, or expressions of feeling left out. The prodromal phase is sometimes only identifiable in hindsight.   

Many states have programs specifically for young people experiencing psychosis for the first time. TAC provides an article about first episode psychosis, with links to help you look for a program in your area. Early intervention programs are often called Coordinated Specialty Care (CSC).  

What is anosognosia? 

Psychosis often comes with a symptom called anosognosia, a neurological condition that impairs a person’s ability to understand or perceive hallucinations or delusions as false. This symptom is the single largest reason why a person might refuse medication or be unwilling to seek treatment. At least half of people with schizophrenia and bipolar disorder experience anosognosia, and this inability of self-awareness is common with any type of psychosis.

Without awareness of the illness, refusing treatment appears rational, no matter how obvious the symptoms are to others.

How do you talk with someone who may be experiencing psychosis and anosognosia? 

Trying to motivate someone with a psychotic condition to seek help and adhere to a treatment plan can be challenging. TAC provides an article with communication tips and places to seek guidance about motivational interviewing as an evidence-based strategy.  

A starting point is to recognize that a person having delusions and hallucinations believes they are real. Trying to convince them otherwise can damage trust. Offering empathy that their experiences are uncomfortable or scary is a place to begin. It’s okay to add, “I’m having a different experience, though.”

A person in psychosis doesn’t have stamina for long-winded explanations. Keep your language simple and gentle and try not to tell the person what to do. Asking careful, basic questions might help motivate the person to agree to something reasonable.  

What do I do if psychosis leads to a crisis? 

When psychosis is severe, the person who is ill may lose the ability to care for basic health and safety. Emergency, involuntary interventions may be the only option. TAC provides an article to help with emergency planning.  

For an emergency related to a psychotic episode, call a local mobile response service, if one is available. The Right Response provides a directory of crisis response organizations. Request that someone authorized to initiate an involuntary hold be part of the response team, and describe how symptoms of psychosis create a risk for harm. TAC’s resource for seeking commitment offers additional tips.

If there is a weapon or violence, call 911 and request response from officers with Crisis Intervention Team (CIT) training. If there is no immediate threat of harm but suicide is a risk factor, another option is to call 988, the National Suicide & Crisis Lifeline.

Provide the location of the person in crisis. Explain that the person is having a mental health emergency and describe symptoms of psychosis. Describe any known triggers that might worsen the crisis by making the person afraid and likely to lash out. Provide information about how to safely approach your loved one, if known. 

Proper terms to avoid prejudice 

Psychosis has been poorly represented by the media and people who don’t understand how devastating it can be for the person who is ill and those who love them.  

To help people talk about schizophrenia and psychosis, the National Alliance on Mental Illness (NAMI) published Schizophrenia & Psychosis Guide: Care, Advocacy, Engagement which includes examples of terms commonly used in a clinical setting, terms that support understanding, and terms that are best avoided to reduce prejudice.  

What are best practices for the diagnosis and treatment of psychosis?  

Initial stabilization often requires medication. TAC provides a resource about medication management that lists anti-psychotic medications and includes a downloadable form to track prescriptions, dosages, effectiveness, and side effects. The resource includes national and international best-practice standards for the use of psychiatric medications.   

The American Psychiatric Association provides best-practice guidelines that extend beyond medication for the treatment of schizophrenia spectrum disorders.

Here are examples: 

• • • An assessment should consider the patient’s goals and preferences and a comprehensive review of mental health history, substance use, physical health, psychosocial and cultural factors, current mental status, cognitive capacity, and risk for suicide and aggressive behaviors.  
    • A person-centered treatment plan should include evidence-based pharmacological and non-pharmacological treatments (medication and more). 
    • Anti-psychotic medications should be prescribed, carefully monitored, continued if working, and adjusted if not working.  
    • Side effects should be treated. For patients with dystonia (involuntary muscle movements that resemble Parkinson’s symptoms), the APA recommends use of anticholinergic medication. For patients with uncontrolled muscle movements from tardive dyskinesia, the APA recommends VMAT2 inhibitors. 
    • Patients with treatment-resistant schizophrenia should be treated with clozapine, as should those who are at high risk for suicide or aggressive behavior if those risks don’t abate with other medications.  
    • A long-acting injectable (LAI) is recommended for patients with a history of poor or uncertain medication adherence. 
    • Patients early in their illnesses should be cared for through a coordinated specialty care (first episode psychosis) program. 
    • Psychosocial interventions should include cognitive behavioral therapy for psychosis (CBT-p), psychoeducation, cognitive remediation, and supported employment services. 
    • When there is a history of poor engagement with services, frequent relapses, and social disruptions such as homelessness, legal difficulties and/or incarceration, a patient should be served through assertive community treatment (ACT).  
    • Patients who have ongoing contact with family should receive family interventions. 
    • Interventions should be person-oriented and support the development of self-management and social skills. 

Is a psychotic break a medical emergency? 

Emergency responders rarely act with alarm when a crisis is related to psychosis, even if someone shows obvious and concerning signs of a break from reality. Instead, the medical system has deferred to the legal system to make decisions about whether a mental health crisis is a medical emergency that warrants intervention.  

Every state has its own laws with criteria for an initial “hold” for an emergency psychiatric evaluation. This is often the only doorway into treatment for someone unaware that they are having a psychotic break from reality. TAC provides each state’s emergency evaluation statute, searchable from our interactive U.S. map.  

In general, the legal system has decided that psychosis in and of itself does not warrant an emergency evaluation. Family members calling for help might be told that because psychosis is “not a crime” or “not illegal,” there is nothing to be done unless there is an obvious threat to life, with suicidal or homicidal risks. In many states, that threat must be unfolding in real time. This unfortunately leads to a de facto situation where violence against someone else or oneself is a prerequisite for intervention. 

At the same time, a psychotic break is a medical emergency. Writing for Psychology Today, Bethany Yeiser described her own psychosis experiences as “brain attacks,” comparable in risk to heart attacks. Her article, published March 16, 2024, is titled “Heart Damage and Brain Damage.”  

“My psychiatrist, who brought me to full recovery in 2008, called psychotic episodes ‘brain attacks’ because, like a heart attack that destroys part of the heart myocardium, a psychotic episode damages the structure of the brain,” Yeiser wrote. “That’s why people with schizophrenia, with the help of their psychiatric physicians, must do everything in their power to avoid another ‘brain attack’ and avoid further brain damage that can lead to functional disability.” 

Yeiser shares about her first psychotic break and that she was incapable of seeing what was happening. “When I was diagnosed with schizophrenia at age 21, I was absolutely convinced that nothing was wrong with my mind,” she wrote.  

Yeiser authored a book, “Mind Estranged: My Journey from Schizophrenia and Homelessness to Recovery.”  Her journey toward recovery included many rounds of treatment non-adherence and hospitalizations. She eventually came to believe that psychiatric medications were necessary and helpful:  

“I am very familiar with the antipsychiatry movement, where people with schizophrenia are invited and sometimes even pressured to discontinue medication. But I will never go off my antipsychotic medication ever again. Today, I understand the devastating personal consequences of risking another ‘brain attack.’” 

What happens when psychosis is left untreated? 

A person with psychosis in the United States remains untreated, on average, for about a year and a half (74 weeks). While untreated, a person’s insight can get worse, symptoms can become more severe, and brain damage can occur.  

TAC published a Research Summary about impacts of untreated psychosis, including: 

• • • Scarring of the brain, changes in structure, chemical compounds, and/or neuronal connections.  
    • Loss of gray matter in the temporal and occipitotemporal lobes—parts of the brain responsible for physical movement, memory, and emotions.  
    • Reduction in the brain’s “executive networks,” necessary for planning and problem solving. 
    • Higher levels of a fatty acid (amide hydrolase), impairing feelings of pain and fear. 

Consequences of untreated psychosis also include collateral damage from behaviors initiated by an unwell brain—often leading to incarceration, trauma, damaged work opportunities, homelessness, and ruined relationships.  

Suicide is a significant contributor to the early mortality of individuals with schizophrenia and bipolar disorder, whose life expectancy in the United States is approximately 25 years shorter on average than the general public. TAC provides resources for safety planning. 

Early detection and treatment can reduce these adverse effects and give individuals with psychosis a better chance at recovery. 

Seek a clinician’s guidance for individualized information 

The information in this article is not intended to be diagnostic or to be taken as medical advice. A provider qualified to evaluate or diagnose these complicated illnesses is the best person to talk with about the range of conditions and symptoms that may be present.