Signs of Psychosis and What to Do

What psychosis looks like

Hallucinations

Hearing, seeing, feeling, smelling or tasting things that are not there. Hearing voices is most common. Voices may comment, argue or give commands. See hallucinations.

Delusions

Strongly held false beliefs that do not change with evidence, for example:

• being watched, followed, poisoned or plotted against (paranoid delusions)
• receiving special messages from the TV, radio or strangers
• having special powers, wealth or a special mission
• thoughts being inserted, removed or broadcast

Disorganized thinking and behavior

Speech that jumps between unrelated topics or is hard to follow, odd or inappropriate behavior, or agitation. Some people become very withdrawn, stop talking, or stop caring for themselves.

Lack of insight

Many people experiencing psychosis do not recognize that their experiences are unusual. Family and friends often notice first.

Early warning signs of psychosis

Before a first episode, there is often a period of weeks to months (the prodrome) with subtle changes:

• withdrawal from friends and family
• a drop in performance at school or work
• trouble concentrating or thinking clearly
• suspiciousness or unease around others
• unusual beliefs or intense focus on odd ideas
• reduced self-care
• sleep problems
• strong, inappropriate emotions, or no emotion at all
• seeing or hearing things others do not, often briefly

These signs are not specific, and many teenagers go through some of them. A combination, especially getting worse, is a reason to seek an assessment. Early intervention services specialize in this.

Causes of psychosis

Mental health conditions

• Schizophrenia and related disorders: psychosis lasting more than 6 months with decline in functioning.
• Bipolar disorder: psychosis during severe mania or depression.
• Severe depression with psychotic features.
• Schizoaffective disorder: psychosis plus major mood episodes.
• Brief psychotic disorder: lasting less than a month, often after extreme stress.
• Postpartum psychosis: a rare emergency that usually starts within 2 weeks of giving birth.
• Severe PTSD: can include voices or flashbacks that feel real.

Drugs and alcohol

Substance-induced psychosis can follow cannabis (especially high-potency), methamphetamine, cocaine, hallucinogens, synthetic cannabinoids and ketamine. Alcohol withdrawal can cause delirium tremens with hallucinations. Daily cannabis use, especially in teenagers, increases the risk of later psychotic disorders.

Medicines

High-dose steroids, levodopa and other Parkinson's medicines, some antimalarials, stimulants, and some anticholinergic medicines can cause psychosis.

Medical causes

• Delirium from infections, dehydration, surgery or medicines, especially in older people. Attention fluctuates and visual hallucinations are common.
• Brain conditions: dementia (especially Lewy body), Parkinson's disease, epilepsy, brain tumors, stroke, traumatic brain injury.
• Encephalitis: including autoimmune encephalitis, which can begin with psychosis in young adults.
• Hormonal and metabolic conditions: thyroid disease, Cushing's syndrome, very low or high sodium or blood sugar, and vitamin B12 deficiency.
• Infections: HIV and syphilis.
• Severe sleep deprivation.

Clues to the cause

How to help someone with psychosis

• Stay calm. Speak slowly and clearly, in short sentences.
• Do not argue about their beliefs, but do not pretend to agree. You can acknowledge that their experience is real and frightening for them.
• Reduce stimulation: turn off the TV, keep the space quiet.
• Focus on their feelings ("you sound scared") and practical help.
• Encourage assessment with a doctor, crisis line or early intervention service.
• Get emergency help if there is any risk to their safety or others'.

How psychosis is assessed

A mental health professional or doctor will talk with the person and, with permission, with family. They will look for mood symptoms, drug use, medical causes and risk. Tests usually include blood tests (blood count, thyroid, electrolytes, blood sugar, B12, infection screens), a urine drug screen, and sometimes a brain MRI, EEG or lumbar puncture.

For an explanation of psychotic disorders, treatment options and recovery, see psychosis.

Frequently asked questions

What are the first signs of psychosis?

Early signs often include withdrawing from friends and family, worsening school or work performance, trouble concentrating, suspiciousness, unusual ideas, poor sleep and reduced self-care. Brief hallucinations or odd beliefs may follow. Early assessment leads to better outcomes.

What does a psychotic episode look like?

A person may hear voices, believe others are plotting against them, speak in a confused way, act unpredictably, or seem very withdrawn. They may not realize that their experiences are not real. Episodes can develop over days to weeks.

Can stress cause psychosis?

Extreme stress can trigger brief psychotic disorder, especially in people with other risk factors. Severe sleep deprivation and trauma also contribute. Stress is rarely the only cause, so a full assessment is still needed.

Can drugs cause psychosis?

Yes. Cannabis, especially high-potency forms, methamphetamine, cocaine, hallucinogens and synthetic drugs can trigger psychosis. It sometimes settles when the drug is stopped, but it can also unmask a longer-term psychotic disorder.

What should I do if someone is having a psychotic episode?

Stay calm, keep the environment quiet, avoid arguing about their beliefs, and help them get an urgent assessment. If there is any risk to their safety or someone else's, call 911 or call or text 988 in the US.