Psychosis is a set of symptoms characterized by a person losing touch with reality.
Common manifestations of psychosis include hallucinations, delusions, and disorganized thinking, all of which significantly affect daily functioning.
It’s important to note that psychosis is not a disorder on its own, but rather a feature that can be present in several mental health conditions.
Common symptoms and disorders
According to DSM-5, psychotic symptoms include delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behavior, and other negative symptoms (meaning, instead of leading to abnormal experiences like hallucinations or delusions, psychosis can take away normal emotional and behavioral capacities).
Understanding these categories helps clinicians and caregivers recognize psychotic experiences early and respond appropriately.
Delusions are firmly held false beliefs.
They can come in different themes, depending on an individual’s experience:
- Persecutory delusions are beliefs an individual has that somebody is either spying on them or plotting against them.
- Grandiose delusions are beliefs that they hold a special power, knowledge, insight, discovery, or relationship with a deity.
- Erotomanic delusions include convictions of another person, often someone important or famous, being deeply in love with them, sometimes leading to attempts to contact that person or stalking them.
- Somatic delusions are focused on a belief that they have some sort of medical problem or defect, for example, missing a body part or having insects inside their body.
- Nihilistic delusions typically involve a belief that a major catastrophe will occur.
- Bizarre delusions usually involve beliefs that somebody has control over their mind or body in some way. For example, believing that their thoughts have been “removed” by aliens (thought extraction) or that alien thoughts have been put inside their mind (thought insertion). Another example is believing an outside force has full control of their body and actions (delusions of control).
It’s important to note that due to cultural differences, delusions can sometimes be hard to notice. For example, beliefs in spirits or witchcraft may be considered delusional in some places but are viewed as normal in others.
Hallucinations are involuntary sensory experiences that occur without external stimuli. They can be auditory (ex. hearing voices, music, or footsteps), visual (ex. seeing things that aren’t there), tactile (ex. feeling bugs crawling on your body), olfactory (ex. experiencing smells that nobody else can experience) or gustatory (ex. strange and unpleasant tastes).
Disorganized thinking and speech can manifest in different forms:
- Loose association is characterized by an individual switching from one topic to another.
- Tangential speech, which involves an individual answering a question with a completely unrelated answer.
- Incoherence or “word salad”—severely disorganized speech that is almost or completely incomprehensible.
Grossly disorganized or abnormal motor behavior (including catatonia) can be characterized by a wide range of presentations, from childlike behavior to unpredictable agitation, leading to problems with goal-directed behavior and daily functioning. In addition, catatonia can lead to a significant decrease in reactivity to the environment.
It can manifest in different forms, such as:
- Negativism – resistance to instructions.
- Bizarre or inappropriate posture.
- Mutism and stupor – complete absence of verbal and motor responses.
- Catatonic excitement – purposeless and excessive motor activity.
Negative symptoms refer to reductions in normal functioning, which can be difficult to recognize. Different types are:
- Affective flattening, characterized by limited emotional expressions, where an individual’s face may seem unresponsive.
- Alogia reflects diminished thought processes through reduced speech or brief replies.
- Avolition is the absence of motivation, which makes daily tasks difficult.
- Anhedonia refers to the inability to experience pleasure from activities an individual once enjoyed.
- Social withdrawal is characterized by difficulty initiating and maintaining relationships.
Psychosis can manifest in different disorders, however it is prominent in: Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Schizophreniform Disorder, Brief Psychotic Disorder, Schizotypal Personality Disorder, Catatonia associated with another mental health disorder or medical condition, and Substance or Medication Induced Psychotic Disorder.
Other disorders such as Bipolar and Major Depressive Disorder can have psychotic features, however they usually occur during mood episodes.
Treatment
Due to the complexity of psychotic symptoms, effective treatment includes a combination of psychotherapy and medication, each depending on the presented symptoms and diagnosis.
Medication
Antipsychotics are the first-line treatment for schizophrenia, schizoaffective disorder, and psychotic features in mood disorders. They target dopamine pathways in the brain in order to reduce delusions and hallucinations.
Typical options include risperidone, olanzapine, and aripiprazole. In addition, mood stabilizers and antidepressants are used when psychosis occurs alongside mood disorders.
Psychotherapy
Psychotherapy can be very useful in the treatment of psychotic symptoms, however this treatment method must be approached with care.
Therapists usually avoid challenging symptoms directly because it can lead to the opposite of the intended effect, with individuals feeling threatened or provoked. Instead, therapists focus on building trust, improving coping skills, and helping patients feel empowered and recognized.
Some evidence-based approaches in the management of psychotic symptoms include:
- Cognitive-Behavioral Therapy (CBT) helps individuals recognize early signs of relapse, reduce distress, and improve daily functioning.
- Family therapy aims to educate and support family members.
- Social Skills Training enhances communication and daily functioning.
Hospitalization can be necessary in cases of acute psychosis or safety risk, in order to stabilize and monitor the patient’s symptoms.
Additional resources
- National Institute of Mental Health (NIMH) – Understanding Psychosis
- American Psychiatric Association (APA) – Schizophrenia
- Early Psychosis Intervention Network (EPINET) – A national initiative connecting community-based psychosis treatment programs and research hubs
- Massachusetts General Hospital – Psychosis Clinical and Research Program
