Psychosis
Overview
If someone is struggling to tell what is real and what isn’t, they may be experiencing psychosis. Psychosis can cause a person to see or hear things that aren’t really there, have bizarre or irrational thoughts, or believe in things that aren’t real. These symptoms can vary from person to person, and often change depending on the length of the psychosis and/or psychotic disorder.
Symptoms of psychosis usually first appear during adolescence, with the onset of acute psychosis most likely to occur between the ages of 15-25 for men, and 25-35 for women. Drug use can accelerate the risk of psychosis symptoms and prolong long-term disorders like schizophrenia. Other causes for the onset of psychotic illness are genetics, physical illness, trauma, grief, or stress.
Disorders like schizophrenia, schizoaffective disorder, or delusional disorder may be diagnosed when psychotic symptoms continue over a long period of time. It is very important that at the first sign of psychosis, someone seeks treatment immediately. The earlier the treatment, the better the long-term outcomes will be.
Prevalence of psychotic disorders
The most recent national survey in Australia relating to psychosis and psychotic illness was in 2010. It is estimated that about 0.5% of Australian adults experience a psychotic disorder at some point in their life. At 5.4 per 1000 people, men were slightly more likely to experience a psychotic disorder than women, who were at 3.5 per 1000.
Typically, the onset of a psychotic disorder begins in adolescence and early adulthood. The peak period of onset is 15-25 years old for men, and 25-35 years old for women.
The most frequent principal diagnosis recorded for patients during mental-health service contact was schizophrenia (22.3%), followed by depressive episodes (6.7%) and schizoaffective disorder (6.4%).
Signs and Symptoms
- Hallucinations: A hallucination is when someone hears or sees something which isn’t actually there. Hallucinations can occur across all the senses (sight, sound, touch, smell, taste), and appear very realistic to the person experiencing them. They are vivid, clear, and have the full impact of a normal sensory experience. For psychotic disorders, the most common type of hallucination is auditory. This often manifests as voices or sounds which seem separate to a person’s own thoughts.
- Delusions: Someone experiencing delusions may believe certain things about the world, themselves, or other people, that aren’t necessarily true. These beliefs are maintained, even in the face of contradictory evidence. Delusions can take many different shapes. For example, a person could think their thoughts are being controlled, or that they are under surveillance from ‘the authorities’.
- Other cognitive symptoms: Along with delusions, someone experiencing psychosis may have memory issues, difficulty concentrating, and struggle to pay attention during conversation.
- Speech: A common symptom of psychosis is disorganised thinking, which often appears through someone’s speech patterns. When talking, someone experiencing psychosis may jump between topics that are only loosely related to each other, or not related at all. Their speech may sound jumbled up and be tricky to follow.
- Body language: Someone’s physical movement or mannerisms may change with the onset of psychosis. They could laugh at inappropriate times, sit and walk differently to normal, display excessive movement for no reason, or have a complete lack of verbal or motor response.
- Emotional expression and experience: Psychosis can cause a variety of emotional responses. Someone may have reduced emotional expression, with limited facial expression and eye contact. They may also experience mood swings, and appear either excessively excited or depressed, with no apparent cause for change. With the onset of psychosis, someone may feel detached from the world around them, and distanced from their own body or thoughts.
What causes psychosis
Some people are more at risk of psychosis than others. For example, if someone has a family history of psychotic disorder (like schizophrenia), they are more likely to develop psychosis symptoms than someone who doesn’t have a family history of psychotic disorder. The onset of psychosis can occur without any significant interference from outside influences, like drugs, stress, or trauma.
However, psychotic disorders more often arise because environmental factors, like drug use, mix with someone’s genetic vulnerability to psychosis. Environmental factors can trigger psychotic symptoms for the first time, and accelerate the onset of more long-term psychotic disorders.
It is important to define the difference between psychosis and a psychotic disorder (like schizophrenia). Psychosis can occur without someone developing a psychotic disorder. In fact, 75-90% of people who experience a psychotic episode have a ‘transitory psychosis’, where their symptoms disappear over time. If psychotic symptoms continue to return, this is when someone may be diagnosed with a psychotic disorder.
Here is a list of factors that contribute to the risk of psychosis, and potentially a psychotic disorder:
Genetics
If someone has a family history of psychotic disorder, they are more at risk of developing a psychotic disorder themselves.
Developmental delay
Problems through childhood relating to speech, movement, social skills, and academic achievement can suggest a vulnerability to psychotic disorder.
Trauma
Exposure to harm during childhood, like physical, sexual, and emotional abuse, neglect, or violence, can increase the risk of psychosis in later life.
Drug use
Drug use can trigger psychotic symptoms and accelerate the risk of someone developing a long-term psychotic disorder.
Mental illness
Mental health conditions like depression, bipolar, severe stress, or sleep deprivation can increase the risk of psychosis.
Migration
Statistically, people who have migrated from one culture to another are at greater risk of psychotic symptoms.
Urbanicity
Statistically, people who live in urban areas are more exposed to other environmental factors that create a higher risk of psychosis and long-term psychotic disorder.
How is psychosis diagnosed?
For someone experiencing psychosis, the assessment process can be a potentially stressful, scary, and isolating experience. They may struggle to understand why the assessment is taking place, feel suspicious towards the assessing clinician, or have already explained their story countless times before. Conducted respectfully, a psychosis assessment should resemble a conversation between the clinician and the patient.
The clinician should clearly explain the purpose of the assessment, what kind of information they need from the patient, and how long the assessment process will take.
Assessment for psychosis can happen for a variety of reasons. Someone experiencing a sudden onset of hallucinations may go to a hospital’s emergency department or an early psychosis clinic. Whereas someone living with long-term schizophrenia may need to be reassessed when they change psychiatrists. Here is a list of different contexts where people may be assessed for psychosis:
- To understand the needs of someone being assessed
- To provide a diagnosis
- To confirm or ascertain need for care
- To determine which treatments might be appropriate
- To tailor specialist psychological therapy
- For legal purposes, like insurance or court
A psychosis assessment is not just ticking off a list of symptoms. It is an ongoing process designed to gain a full picture of a patient’s health and help build their relationship with the treating clinician. This list details the different areas covered in a psychosis assessment:
- History of mental illness symptoms (psychiatric assessment)
- Mental state examination
- Medical (physical) assessment
- Risk assessment of violence and/or suicidal ideation
- Understanding of social context and risk of adversity
- Cognitive ability, especially the patient’s understanding of the assessment process and their ability to maintain treatment
- Substance-use history
How is psychosis treated?
Treatment approaches vary depending on how long someone has experienced psychotic symptoms. Across the board, a holistic approach to treatment is common, where a person may experience a combination of medication, psychological therapy, and social support.
If possible, ensuring the early detection and treatment of psychotic symptoms is vital to long-term recovery. The early phases of psychosis include the following categories: ultra-high risk (UHR), first experience psychosis (FEP), and acute relapse. These phases track the onset of signs and symptoms before the first acute psychosis (UHR), the first experience of acute psychosis (FEP), and then, if they occur, the following instances of acute psychosis (acute relapse).
Early intervention services are the best place to receive comprehensive treatment for psychosis. They are designed to meet the needs of young people experiencing psychosis for the first time, and to keep them engaged in necessary services.
Early intervention services may offer:
- Psychological therapy (cognitive behavioural therapy)
- Medication, which is closely monitored for potential side effects
- Family counselling
- Case management relating to educational and vocational opportunities
- Education programs regarding psychosis and related disorders
It is very important to maintain treatment; failing to follow guidelines can result in lower levels of recovery and persistent psychotic issues throughout a person’s life.
If multiple episodes of psychosis develop into a long-term psychotic disorder, it may be necessary to reframe the treatment, focussing on the person’s goals and working with a therapist on a ‘life worth living’ approach. This includes managing treatable factors, like adherence to medication, managing mental health issues like depression, controlling substance use, and developing social skills.
Help & Support
Psychotic illness can have a significant impact on someone’s daily life. Many of the symptoms make interacting with the outside world a stressful and potentially confusing experience. If a psychotic disorder is left untreated, it can be difficult to keep a job, maintain relationships, learn new skills, and remain in good health. The life expectancy of people experiencing a long-term psychotic illness is reduced by approximately 20%. There are also more suicide-related deaths associated with psychosis and psychotic disorder.
Early treatment gives someone the best chance of recovery. This can prevent further episodes of psychosis, and keep someone actively participating in work, education, and social activities. Statistically, the longer a person goes without treatment, the harder it is to return to a stable, functional life. It is therefore very important to seek treatment at the first sign of psychosis.
That said, there is support available at all stages of psychosis and psychotic disorder. The symptoms of psychosis can make it hard to feel understood, yet there are always mental health professionals to guide someone to a brighter future.
Next Steps
Dealing with psychosis first-hand, or as a family member, can be a stressful experience. It is important to reach out to your GP as soon as possible, and, if you can, access an early intervention psychosis service.
The youth mental health organisation headspace has multiple services around the country specialising in early psychosis treatment. Go to headspace to find contact information and opening hours.
A GP can also direct you to appropriate services in your area. These services may be a psychiatrist or psychologist, other hospital-based psychosis services, or rehabilitations services.
If someone experiencing psychosis is in immediate danger to themselves or others, call Triple Zero (000).
Websites
People living with psychotic illness: A SANE Response
The People Living with Psychotic Illness 2010 study is one of the most detailed studies of its kind in the world. It provides a comprehensive insight into the impact of psychotic illness on the lives of Australians today, and how this has changed since the previous People Living with Psychotic Illness study conducted in 1997-98. Visit site(Opens in a new tab)
Orygen: Resources on Psychosis
Orygen advocates to make sure policy makers understand the need and cost of mental ill-health in young people. Orygen also conducts research and evidence-based practice to develop innovative training programs and resources, and to identify new, positive approaches to the prevention and treatment of mental disorders. Visit site(Opens in a new tab)
headspace: Identification of young people at risk of developing psychosis
This summary focuses on identification and assessment, describing the criteria most commonly used to identify young people who are at increased risk of developing a psychotic disorder. Visit site(Opens in a new tab)
Psychosis Australia: Information and Research on Psychosis
This website contains information about Psychosis, research and upcoming conferences relating to Psychosis in Australia.