This page offers a full description of psychosis, what causes it, some examples of psychotic conditions, and how it is treated.
Here are some key points about psychosis. More detail and supporting information is in the main article.
- Psychosis is not a disease in its own right; it is a symptom
- A common psychotic delusion is a belief that the individual is an important figure
- Earlier diagnosis of psychosis improves long-term outcomes
What is psychosis?
Psychosis is a symptom rather than a disease.
Psychosis is an umbrella term; it means that an individual has sensory experiences of things that do not exist and/or beliefs with no basis in reality.
During a psychotic episode, an individual may experience hallucinations and/or delusions. They may see or hear things that do not exist.
This can be incredibly frightening for the individual and, sometimes, the symptoms can cause them to lash out and hurt themselves or others.
Psychosis is classically associated with schizophrenia spectrum disorders, and, although there are other symptoms, one of the defining criteria for schizophrenia is the presence of psychosis.
Symptoms of psychosis
The classic signs and symptoms of psychosis are:
- Hallucinations - hearing, seeing, or feeling things that do not exist
- Delusions - false beliefs, especially based on fear or suspicion of things that are not real
- Disorganization - in thought, speech, or behavior
- Disordered thinking - jumping between unrelated topics, making strange connections between thoughts
- Catatonia - unresponsiveness
- Difficulty concentrating
Depending on the cause, psychosis can come on quickly or slowly. The same is the case in schizophrenia, although symptoms may have a slow onset and begin with milder psychosis, some people may experience a rapid transition back to psychosis if they stop taking their medication.
The milder, initial symptoms of psychosis might include:
- Feelings of suspicion
- General anxiety
- Distorted perceptions
- Obsessive thinking
- Sleep problems
Hallucinations can affect any of the senses (sight, sound, smell, taste, and touch) in the person with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are auditory - hearing things and believing them to be real when they do not exist.
The following auditory hallucinations are common:
- Hearing several voices talking, often negatively, about the patient
- A voice giving a commentary on what the patient is doing
- A voice repeating what the patient is thinking
Bizarre delusions during psychosis
Paranoia is a common component of psychotic delusions.
Examples of psychotic delusions include the paranoid type - more likely to be associated with schizophrenia - and delusions of grandeur.
Paranoid delusions - these may cause the person with psychosis to be unduly suspicious of individuals or organizations, believing them to be plotting to cause them harm.
Delusions of grandeur - clearly false but strongly held belief in having a special power or authority - for instance, they may believe that they are a world leader.
Diagnosis of psychosis
In this section, we will discuss the available tests and methods for diagnosing psychosis.
Early diagnosis of psychosis improves long-term outcomes. This is not always achieved, however. The milder forms of psychosis that can lead to schizophrenia are left untreated for an average of 2 years, and even full psychosis can take a number of years before it receives the attention of medical professionals.
To increase the chances of early detection, guidance for healthcare systems drawn up by psychiatrists recommend that the "possibility of a psychotic disorder should be carefully considered" in a young person who is:
- Becoming more socially withdrawn
- Performing worse for a sustained period at school or work, or
- Becoming more distressed or agitated yet unable to explain why
There is no biological test for psychosis itself, and if laboratory tests are done, it is to rule out other medical problems that might provide an alternative explanation.
Questions for patient and family
Psychosis is primarily diagnosed by clinical examination and history - the doctor examines the patient and asks about their symptoms, experiences, thoughts, and daily activities; they will also ask if there is a family history of psychiatric illness.
Other medical conditions are ruled out first of all, especially delirium (sudden onset of a confused state), but epilepsy and a number of other medical explanations are possible.
Doctors will also check for any history of intoxication with drugs, both legal and illegal, and toxins, usually asking for a urine sample to check this.
Once psychosis is narrowed down to a psychiatric cause, there are clearly defined criteria that must be met before a diagnosis is confirmed. Psychiatrists generally rely on the American Psychiatric Association (APA)'s publication known as the DSM (Diagnostic and Statistical Manual of Mental Disorders) to make psychiatric diagnoses.
Brain scans may be done in the early stages of medical attention so that other conditions - often treatable and reversible - can be ruled out.
EEG (electroencephalography) testing records the brain's electrical activity and may help to rule out delirium, head injury, or epilepsy as possible causes of psychotic symptoms.
Causes of psychosis
The exact causes of psychosis are not well understood but might involve:
- Genetics - research shows that schizophrenia and bipolar disorder may share a common genetic cause.
- Brain changes - alterations in brain structure and changes in certain chemicals are found in people who have psychosis. Brain scans have revealed reduced gray matter in the brains of some individuals who have a history of psychosis, which may explain effects on thought processing.
- Hormones/sleep - postpartum psychosis occurs very soon after giving birth (normally within 2 weeks). The exact causes are not known, but some researchers believe it might be due to changes in hormone levels and disrupted sleep patterns.
Treatments for psychosis
In this section, we discuss the treatments for psychosis and some methods of prevention.
Treatment with a class of drugs known as antipsychotics is the most common therapy for people with a psychotic illness.
Antipsychotics are effective at reducing psychosis symptoms in psychiatric disorders such as schizophrenia, but they do not themselves treat or cure underlying psychotic illnesses.
So-called second-generation antipsychotics are most commonly used by doctors to treat psychosis. While their use is widespread in the United States, this is controversial. The World Health Organization (WHO) does not recommend them, except clozapine (branded Clozaril and FazaClo in the U.S.), which may be used under special supervision if there has been no response to other antipsychotic medicines.
Acute and maintenance phases of schizophrenia
Antipsychotic treatment of schizophrenia is in two phases - the acute phase to treat initial psychotic episodes and a lifelong phase of maintenance therapy.
During the acute phase, a stay in hospital is often needed. Sometimes a technique called rapid tranquilization is used. A fast-acting medication that relaxes the patient will be used to ensure that they do not harm themselves or others.
In the maintenance phase, treatment of schizophrenia is in the community and antipsychotics help to prevent further psychotic episodes, although relapses often occur, sometimes due to a failure to take the medications. Lifelong treatment of schizophrenia may involve other interventions and support, including the role of the family in care.
Psychotherapy can also be useful in treating cognitive and residual symptoms of schizophrenia and other psychotic disorders.
Types of psychosis
A number of disorders can display psychotic symptoms, including:
- Schizophrenia - a serious mental health disorder affecting the way someone feels, thinks, and acts. Individuals find it difficult to distinguish between what is real and what is imaginary.
- Schizoaffective disorder - a condition similar to schizophrenia that includes periods of mood disturbances.
- Brief psychotic disorder - psychotic symptoms last at least 1 day but no longer than 1 month. Often occurring in response to a stressful life event. Once symptoms have gone, they may never return.
- Delusional disorder - the individual has a strong belief in something irrational and often bizarre with no factual basis. Symptoms last for 1 month or longer.
- Bipolar psychosis - individuals have the symptoms of bipolar disorder (intense highs and lows in mood) and also experience episodes of psychosis. The psychosis more commonly occurs during manic phases.
- Psychotic depression - also known as major depressive disorder with psychotic features.
- Postpartum (also called postnatal) psychosis - a severe form of postnatal depression.
- Substance-induced psychosis - including alcohol, certain illegal drugs, and some prescription drugs, including steroids and stimulants.
These are the primary causes of psychotic symptoms, but psychosis can also be secondary to other disorders and diseases, including:
Janet opened her eyes - Florida's prehistoric glare dazzled outside the motel window. A dog barked; a car honked; a man was singing a snatch of a Spanish song. She absent-mindedly touched the scar from her bullet wound beneath her left rib cage, a scar that had healed over, bumpy and formless and hard, like a piece of gum stuck beneath a tabletop. She hadn't expected her flesh to have healed so blandly - What was I expecting, a scar shaped like an American flag?
Janet's forehead flushed: My children - where are they? She did a rapid-fire tally of the whereabouts of her three children, a ritual she'd enacted daily since the birth of Wade back in 1958. Once she'd mentally placed her offspring in their geographic slots, she remembered to breathe: they're all going to be here in Orlando today.
She looked at the motel's bedside clock: 7:03 AM. Pill o'clock. She took two capsules from her prescription pill caddie, and swallowed them with tapwater gone flat overnight, which now tasted like nickels and pennies. It registered on her that motel rooms now came equipped with coffee makers. What a sensible idea, so bloody sensible - why didn't they do this years ago? Why is all the good stuff happening now?
A few days back, on the phone, her daughter, Sarah, had said, "Mom, at least buy Evian, okay? The tap water in that heap is probably laced with crack. I can't believe you chose to stay there."
"But dear, I don't mind it here."
"Go stay at the Peabody with the rest of the family. I've told you a hundred times I'll pay."
"That's not the point, dear. A hotel really ought not cost more than this."
"Mom, NASA cuts deals with the hotels, andÉ" Sarah made a puff of air, acknowledging defeat. "Forget it. But I think you're too well off to be pulling your Third World routine."
Sarah - so cavalier with money! - as were the two others. None had known poverty, and they'd never known war, but the advantage hadn't made them golden, and Janet had never gotten over this fact. A life of abundance had turned her two boys into an element other than gold - lead? - silicon? - bismuth? But then Sarah - Sarah was an element finer than gold - carbon crystallized as diamond - a bolt of lightning frozen in mid-flash, cut into strips and stored in a vault.
Janet's phone rang and she answered it: Wade, calling from an Orange County lock-up facility. Janet imagined Wade in a drab concrete hallway, unshaven and disheveled, yet still radiating 'the glint' - the spark in the eye he'd inherited from his father. Bryan, the youngest of her three children, didn't have it and Sarah didn't need it, but Wade had glinted his way through life, and maybe it hadn't been the best attribute to inherit after all.
Wade: Janet remembered being back home, and driving along Marine Drive in the morning, watching a certain type of man waiting for a bus to take him downtown. He'd be slightly seedy and one or two notches short of respectability; it was always patently clear he'd lost his driver's license after a DWI, but this only made him more interesting, and whenever Janet smiled at one of these men from her car, they fired a smile right back. And that was Wade and, in some unflossed cranny of her memory, her ex-husband, Ted.
"Dear, aren't you too old to be calling me from - jail? Even saying the word 'jail' feels silly."
"Mom, I don't do bad stuff any more. This was a fluke."
"Okay then, what happened - did you accidentally drive a bus load of Girl Guides into the Everglades?"
"It was a bar brawl, Mom."
Janet repeated this: "A bar brawl."
"I know, I know - you think I don't know how idiotic that sounds? I'm phoning because I need a ride away from this dump. My rental car's back at the bar."
"Where's Beth? Why doesn't she drive you?"
"She gets in early this afternoon."
"Okay. Well let's go back a step, dear. How exactly does one get into a bar brawl?"
"You wouldn't believe me if I told you."
"You'd be amazed what I'm believing these days. Try me."
There was a pause on the other end. "I got in a fight because this guy - this jerk - was making fun of God."
"God." He can't be serious.
"Yeah, well, he was."
"In what way?"
"He was being so nasty about it, saying, 'God's an asshole,' and 'God doesn't care about squat,' and he kept on going on and on, and I had to put a stop to it. I think he got fired that day."
"You were defending God's honor?"
"Yeah. I was."
Tread carefully here, Janet. "Wade, I know Beth is very religious. Are you becoming religious, too?"
"Me? Maybe. Nah. Yes. No. It depends on how you define religious. It keeps Beth calm, and maybe..." Wade paused. "Maybe it can calm me, too."
"So you spent the night in jail, then?"
"Safely in the arms of a four-hundred pound convenience store thief named Bubba."
"Wade, I can't pick you up. I think it's going to be one of those no-energy days. And besides, the car I rented smells like a carpet in a frat house - and the roads down here, they're white, and the glare makes me sleepy."
"Mom, come on..."
"Don't be such a baby. You're forty-two. Act it. You couldn't even get to the hotel in time yesterday."
"I was making a quick detour to visit a friend in Tampa. I stopped for a drink. Hey - don't treat me like I'm Bryan. It wasn't like I started the fight or..."
"Stop! Stop right there. Call a cab."
"I'm short on cash."
"Simple cab fare? Then how are you paying for the hotel?"
Wade was silent.
"Sarah's covering it for us until we can pay it back." An awkward silence followed.
"Mom, you could pick me up if you really wanted to. I know you could."
"Yes, I suppose I could. But I think you should phone your father down in ... what's that place called?"
"Kissimmee - and I already did call him."
"He's gone marlin fishing with Nickie."
"Marlin fishing? People still do that?"
"I don't know. I guess. I thought they were extinct. They probably have a guy in a wet suit who attaches a big plastic marlin onto their line."
"Marlins are so ugly. They remind me of basement rec rooms that people built in 1958 and never used again."
"I know. It's hard to imagine they ever existed in the first place."
"So he's out marlin fishing with Nickie then?"
"Yeah. With Nickie."
"That cheesy slut."
"Wade, I'm not a saint. I've been holding stuff inside me for decades - girls my age were trained to do that, and it's why we all have colitis. Besides, a dash of spicy language is refreshing every so often. Just yesterday I was hunting for information on vitamin D derivatives on the Internet, and suddenly, doink! I land in the "Anal Love" web site. I'm looking at a cheerleader in a leather harness on the - "
"Mom, how can you visit sites like that?"
"Wade, may I remind you that you are standing in a human dumpster somewhere in Orlando, yet hearing a 67-year-old woman discuss the internet over a pay phone shocks you? You wouldn't believe the sites I've visited. And the chat rooms, too. I'm not always Janet Drummond, you know."
"Mom, why are you telling me this?"
"Oh, forget it. And your stepmother Nickie is still a cheesy slut. Phone Howie - maybe he can come fetch you."
"Howie's so boring he makes me almost pass out. I can't believe Sarah married such a blank."
"I'm the one who gave birth to her, and I'm the one who has to drive with him to Cape Canaveral today."
"Ooh - bummer. Another NASA do?"
"Yes. And you're welcome to come along."
"Wait a second, Mom - why aren't you at the Peabody with everybody else? What are you staying in a motel for? By the way, it took thirty rings for the clerk - who, I might add, sounded like a kidney thief - to answer the phone."
"Wade, you're changing the subject. Phone Howie. Oh wait - I think I hear somebody at the door." Janet held the phone at arm's length from her head, and said, "Knock knock knock knock."
"Very funny, Mom."
"I have to answer the door, Wade."
"That's really funny. I - "
The motel room made her feel slightly too transient, but it was a bargain, and that turned the minuses into pluses. Nonetheless, Janet missed her morning waking-up rituals in her own bedroom. She touched her body gently and methodically, as though she were at the bank counting a stack of twenties. She gently rubbed a set of ulcers on her lips' insides, still there, same as the day before, not just a dream. Her hands probed further downward - no lumps in her breasts, not today - but then what had Sarah told her? We've all had cancer thousands of times, Mom, but in all those thousands of times your body removed it. It's lazy bookkeeping to only count the cancers that stick. You and I could have cancer right now, but tomorrow it might be gone.
The motel room smelled like a lifetime of cigarettes. She looked at Sarah's photo in the Miami Herald beside the phone, a standard NASA PR crew photo: an upper body shot against a navy ice-cream swirl background and complexion-flattering lighting that made one suspect a noble, scientific disdain for cosmetics. Sarah clutched a helmet underneath her right arm. Her left arm, handless, rested by her side: space knows no limitations.
Janet sighed. She twiddled her toes. Ten minutes later her phone rang again: Sarah calling from the Cape.
"Hi Mom. I just spoke to Howie. He'll go pick up Wade."
"Good morning, Sarah. How's your day?"
"This morning we had a zero-G evacuation test, but what I really wanted to do was sit in a nice quiet bathroom and test out a new brand of pore-cleansing strips. The humidity in these suits is giving me killer blackheads. They never talked about that in those old Life magazine photo essays. Have you eaten yet?"
"Come eat at the Cape with me. We can have dehydrated astronaut's ice cream out of a shiny Mylar bag."
Janet sat up on her bed and pulled her legs over the side. She felt her skin - her meat - hanging from her bones as though it were so much waterlogged clothing. She needed to pee. She began to meter her words as she eyed the bathroom door. "I don't think so, Dear. The only time they ever allow me to have with you are three seconds for a photo op."
Sarah asked, "Is Beth arriving today?"
Beth was Wade's wife. "Later this afternoon. I think I'm going to dinner with the two of them."
"How far along is she?"
"I think this is her fourth month. It may even be a Christmas baby."
"Huh. I see."
"Something wrong, Sarah?"
"It's just that - "
"Mom, how could Wade marry ...her. She's so priggish and Born-Again. I always thought Wade would marry Miss Roller Derby. Beth is so frigging sanctimonious."
"She keeps him alive."
"I guess she does. When does Bryan arrive?"
"He and his girlfriend are already here. He called from the Peabody."
"Girlfriend? Bryan? What's her name?"
"If I tell you, you won't believe me."
"It can't be that bad. Is it one of those made-up names like DawnElle or Kerrissa or CindaJo?
"What could be worse?"
"I beg your pardon?"
"Shw. That's her name: Shw."
"Spell that for me."
"S. H. W."
"There's no vowel, if that's what you're waiting for."
"What - her name is Shw? Am I pronouncing that properly?"
"I'm afraid so."
"That is the most ...impractical name I've ever heard. Is she from Sri Lanka or Finland or something?"
Janet's eye lingered on he bathroom door and the toilet beyond. "As far as I know she's from Alberta. Bryan worships her, and she's also knocked up like a prom queen."
"Bryan's pregnant? How come I don't know any of this?"
"I just met her last week, myself, dear. She seems to rather like me, though she treats everybody else like dirt. So I don't mind her at all, really."
"Bryan is such a freak. I'm not going to be able to keep a straight face, you know - when she tells me her name, that is."
Janet said, "Shw!"
"Shw! Shw! Shw!"
Sarah laughed. "Is she pretty?"
"Sort of. She's also about eighteen and an angry little hornet. In the fifties we would have called her a pixie. Nowadays we'd call her hyperthyroid. She's bug-eyed."
"Where'd they meet?"
"Seattle. She helped Bryan set fire - I believe - to a stack of pastel-colored waffle-knit T-shirts in a Gap - back during the World Trade Organization riots. They were separated, then a few months ago they met again destroying a test facility growing genetically modified runner beans."
Janet could sense Sarah changing gears; she was finished discussing the family. Next would come business-like matters: "Well, good for Bryan. You're okay for today's NASA gig?"
"Howie will pick you up at 9:30, after he picks up my darling brother. By the way, Dad's broke."
"That doesn't surprise me. I'd heard he'd lost his job."
"I tried to loan him some money, but he, of course, said no. Not that there's much to loan. Howie lost the bulk of our savings in some web site that sells products for pets. I could strangle him."
"Oh dear." It's so easy to fall into the mother mode.
"Tell me about it. Hey, when was the last time you even saw Dad?"
"Half a year ago. By accident at Super-Valu."
"I can handle him."
"Good. See you there."
On the walkway outside her room, Janet heard children mewling as they set off to Walt Disney World with their families. She walked to the bathroom across a floor made lunar from eons of cigarette burns and various stains better left uninvestigated. She thought of serial murderers using acids to dissolve the teeth and jawbones of their victims.
She unsuspectingly caught sight of herself in a floor-length mirror by the sink and the sight stopped her cold. Yes Janet, that's correct: you are shrinking - sinew by sinew, protein molecule by protein molecule you are turning into an É an elf, yes, you, Janet Drummond, once voted 'Girl We'd Rob a Bank For.'
She was transfixed by the view of herself in a blue nightie, as if she were once again young and this image had been delivered to her from the future as a warning - If I squint I can still see the cool immaculate housewife I once dreamed of becoming. I'm Elizabeth Montgomery starring in Bewitched. I'm Dina Merrill lunching at the Museum of Modern Art with Christina Ford.
Oh forget it. She peed, showered, dried and then modified those traces of time's passage on her face that she could.
There. I'm not so bad after all. A man might still rob a bank for me, and men still do flirt - not too frequently - and older men perhaps - but the look in the eyes never changes.
She dressed, and five minutes later she was a block away sitting in a Denny's reading a paper. The North American weather map on the rear page was a rich, unhealthy crimson, with only a small strip of cool green running up the coast from Seattle to Alaska. Outside the restaurant window the sun on the parking lot made the area seem like a science experiment. She realized she no longer cared about the weather. Next.
Back in her motel room, she lay down on the bed haunted by a thousand sex acts. Okay - this place is creepy but at least I'm not throwing away money. Her lips were sore to the point that speech was painful, and it hurt to exhale. Her pill buzzer buzzed; she sat up. She reached into her purse and removed a prescription bottle. She turned on the TV, and there was Sarah being interviewed on CNN. As always, her daughter looked glowingly pretty on TV, like a nun who'd never touched make-up.
- Do you think you and children like you, born with damage caused by thalidomide, have other messages to tell the world?
- Of course. We were the canaries in the coal mine. We were the first children born in which it was proved that chemicals from the outside world - in our case thalidomide - could severely damage the human embryo. These days, most mothers don't smoke or drink during pregnancy. They know that the outer world can enter their babies and cause damage. But in my mother's generation, they didn't know this. They smoked and drank and took any number of medications without thinking twice. Now we know better, and as a species we're smarter as a result - we're aware of teratogens.
- Yes. It means 'monster forming.' A horrible word, but then the world can be a horrible place. They're the chemicals that cross the placenta and affect a child's growth in utero.
The host turned to the camera: "Time for a quick break. I've been speaking with Sarah Drummond-Fournier, a one-handed woman, and one heck of a fighter, who'll be on Friday's shuttle flight. We'll be right back."
How on earth did I give birth to such a child? I understand nothing about her life. Nothing. And yet she's the spitting image of me, and she's gallivanting up into space. Janet remembered how much she'd wanted to help the young Sarah with her homework, and Sarah's polite-but-resigned invitations to come do so when Janet popped her head into Sarah's doorway. Invariably Janet would look down at the papers that might as well have been in Chinese. Janet would ask a few concerned questions about Sarah's teachers, and then plead kitchen duty, beating a hasty retreat.
She turned off the TV.
She once cared about everything, and if she couldn't muster genuine concern, she could easily fake it: too much rain stunting the petunias; her children's scrapes; stick figure Africans; the plight of marine mammals. She considered herself one of the surviving members of a lost generation, the last generation raised to care about appearances or doing the right thing - to care about caring. She had been born in 1934 in Toronto, a city then much like Chicago or Rochester or Detroit - bland, methodical, thrifty and rules-playing. Her father, William Truro, managed the furniture and household appliance department of the downtown Eaton's department store. William's wife, Kaye, was, well ...William's wife.
The two raised Janet, and her older brother, Gerald, on $29.50 a week until 1938, when a salary decrease lowered William's pay to $27 a week, and jam vanished from the Truro breakfast table, the absence of which became Janet's first memory. After the jam, the rest of Janet's life seemed to have been an ongoing reduction - things that had once been essential vanishing without discussion, or even worse, with too much discussion.
Seasons changed. Sweaters became ragged, were patched up and became ragged again, and were grudgingly thrown out. A few flowers were grown in the thin band of dirt in front of the brick row house, species scavenged by Kaye for their value as dried flowers, which scrimped an extra few months' worth of utility from them. Life seemed to be entirely about scrimping. In fall of 1938, Gerry died of polio. In 1939 the war began and Canada was in it from the start, and scrimping kicked into overdrive: bacon fat, tin cans, rubber - all material objects - were scrimpworthy. Janet's most enjoyable childhood memories were of sorting neighborhood trash in the alleys, in search of crown jewels, metal fragments and love notes from dying princes. During the war, houses in her neighborhood grew dingy - paint became a luxury. When she was six, Janet walked into the kitchen and found her father kissing her mother passionately. They saw Janet standing there, a small, chubby, fuddled Campbell's Soup kid, and they broke apart, blushed, and the incident was never spoken of again. The glimpse was her only evidence of passion until womanhood.
An hour passed and Janet looked at the bedside clock: almost 9:30, and Howie would have already picked up Wade by now. Janet walked down to the hotel's covered breezeway to wait for her son-in-law. A day of boredom loomed.
Then, pow!. She was angry all of a sudden. She was angry because she was unable to remember and reexperience her life as a continuous movie-like event. There were only bits of punctuation here and there - the kiss, the jam, the dried flowers - which, when assembled, made Janet who she was - yet there seemed to be no divine logic behind the assemblage. Or any flow. All those bits were merely ... bits. But there had to be logic. How could the small, chubby child of 1940 imagine that one day she'd be in Florida seeing her own daughter launched into outer space? Tiny little Sarah, who was set to circle the Earth hundreds of times. We didn't even think about outer space in 1939. Space didn't exist yet.
She removed a black felt Sharpie pen from her purse, and wrote the word laryngitis on a folded piece of paper. For the remainder of the day she wouldn't have to speak to anybody she didn't want to.
I wonder if Howie is going to be late? No - Howie's not the late type.