Psychosis: Types, Treatment and Recovery

What happens in psychosis

The brain's systems for filtering information and deciding what is important become overactive or unbalanced. Research points particularly to excess dopamine signaling in certain brain pathways, alongside changes in glutamate and brain connectivity. As a result, ordinary events can feel highly significant, internal thoughts may be experienced as external voices, and the mind builds explanations (delusions) for these strange experiences.

Psychosis symptoms are grouped as:

• Positive symptoms: hallucinations, delusions and disorganized thought or behavior.
• Negative symptoms: reduced motivation, emotional expression, speech and social interest.
• Cognitive symptoms: problems with attention, memory and planning.

For the signs to look out for and what to do in a crisis, see signs of psychosis.

Types of psychotic disorder

Causes and risk factors

Psychosis develops from a mix of vulnerability and triggers:

• Genetics: a family history of schizophrenia or bipolar disorder raises risk, though most people with a relative affected never develop psychosis.
• Cannabis: frequent use, especially high-THC products and starting in adolescence, increases the risk.
• Other drugs: stimulants, hallucinogens and synthetic drugs.
• Childhood adversity and trauma.
• Migration, urban upbringing and social isolation.
• Pregnancy and birth complications.
• Severe stress and sleep loss as triggers.
• Medical conditions: brain injury, epilepsy, autoimmune encephalitis, dementia and delirium.

Diagnosis

There is no single test for psychosis. Diagnosis involves:

1. Psychiatric interview: symptoms, duration, mood, drug use, functioning and risk, with information from family where possible.
2. Physical examination.
3. Blood and urine tests: blood count, kidney, liver and thyroid function, glucose, calcium, vitamin B12, HIV and syphilis tests, and a drug screen.
4. Brain imaging and EEG when the presentation is atypical or neurological signs are present.
5. Lumbar puncture and antibody tests if autoimmune encephalitis is suspected.

Doctors usually describe a first presentation as "first-episode psychosis" while the long-term diagnosis becomes clear.

Treatment

Coordinated specialty care

For first-episode psychosis, coordinated specialty care (early intervention in psychosis) programs combine medicine, therapy, family education, help with school or work, and case management. They improve symptoms, functioning and engagement compared with usual care. Reducing the time from first symptoms to treatment improves outcomes.

Antipsychotic medicine

Antipsychotics reduce hallucinations, delusions and disorganized thinking, usually over days to weeks. Options include risperidone, aripiprazole, olanzapine, quetiapine, paliperidone and others, chosen partly by side effect profile. Long-acting injections help some people stay well. Clozapine is the most effective option for psychosis that has not responded to two other antipsychotics.

Side effects can include weight gain, raised blood sugar and cholesterol, sleepiness, restlessness, stiffness, and raised prolactin. Regular monitoring of weight, blood sugar and lipids is recommended. Do not stop antipsychotics suddenly without medical advice, because relapse risk is high.

Psychological and social treatment

• CBT for psychosis (CBTp): helps people understand and cope with voices and unusual beliefs and reduce distress.
• Family intervention: reduces relapse by improving understanding and communication at home.
• Supported employment and education.
• Peer support.
• Treating substance use, especially stopping cannabis.

Treating the cause

Medical and substance-induced psychoses are treated by addressing the underlying condition, such as treating infection, stopping the drug, or immunotherapy for autoimmune encephalitis.

Outlook

Recovery is possible. Many people who have a first episode recover and some never have another. Others have recurring episodes or ongoing symptoms that can still be managed well, with many leading full working and family lives. Factors linked to better outcomes include early treatment, staying on medicine during the recommended period, avoiding cannabis and other drugs, strong family support, and being engaged in work or study.

Frequently asked questions

What is psychosis?

Psychosis is a condition in which a person loses some contact with reality. They may have hallucinations, delusions, or confused thinking and speech. It is a feature of several mental health conditions and can also be caused by drugs or medical illness.

Can psychosis be cured?

Many people recover fully from a first episode, particularly with early treatment, and some never have another. Others have recurring episodes. Even then, treatment usually controls symptoms well enough for people to live independent, fulfilling lives.

How long does a psychotic episode last?

It varies. Brief psychotic disorder lasts less than a month. Substance-induced psychosis often settles within days to weeks after stopping the drug. Episodes in schizophrenia or bipolar disorder may last weeks to months without treatment, and usually improve within weeks of starting it.

Is psychosis the same as schizophrenia?

No. Psychosis is a set of symptoms; schizophrenia is one long-term condition that causes them. Psychosis can also occur in bipolar disorder, severe depression, drug use, delirium, dementia and other medical conditions.

How long do you need to take antipsychotics after a first episode?

Guidelines often recommend continuing medicine for at least 1 to 2 years after recovery from a first episode, because stopping early greatly increases the chance of relapse. Any reduction should be gradual and planned with your psychiatrist.