Psychosis Symptoms: Early Warning Signs, Causes and Duration

Psychosis symptoms are changes in thinking and perception in which a person loses some contact with reality, according to the National Institute of Mental Health (NIMH)^[1]. The two core symptoms are delusions, which are false beliefs, and hallucinations, which involve seeing or hearing things that others do not^[1].

Psychosis is a symptom, not a diagnosis. It occurs in most people with schizophrenia and in some people with bipolar disorder, severe depression or certain personality disorders^[7]. How often a first episode occurs, by age and group, is covered on the first-episode psychosis page.

Other symptoms include incoherent or nonsense speech, disorganized thoughts, and behavior that does not fit the situation^[1][7]. NIMH also lists broader changes that often accompany psychosis: emotional disruption, anxiety, lack of motivation and difficulty functioning overall^[1].

Studies estimate that between 15 and 100 people out of every 100,000 develop psychosis each year^[1]. It often begins between the late teens and mid-20s, though episodes can start at younger and older ages^[1].

A person will often show changes in behavior before psychosis develops^[1]. NIMH lists these early warning signs of psychosis^[1]:

• Suspiciousness, paranoid ideas or uneasiness with others
• Trouble thinking clearly and logically
• Withdrawing socially and spending much more time alone
• Unusual or overly intense ideas, strange feelings, or a lack of feelings
• Decline in self-care or personal hygiene
• Disrupted sleep, including trouble falling asleep and less sleep
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating
• A sudden drop in grades or job performance

NIMH's guidance is to contact a health care provider when these changes intensify or do not go away^[1]. Delays are common: people often have psychotic symptoms for more than a year before receiving treatment, and NIMH ties a shorter duration of untreated psychosis to better recovery^[1].

Onset ages vary more than the classic late-teens pattern suggests. In World Health Organization survey data from 18 countries, the median projected age of onset for psychotic experiences was 26, and nearly a quarter of projected first onsets came after age 40^[2].

Hallucinations

Hallucinations can involve more than one sense. MedlinePlus describes them as hearing, seeing or feeling things that are not there^[7]. In psychosis, voices may criticize the person or tell them to do something^[1].

Delusions

Delusions are false beliefs that are not based on reality, and unfounded fear or suspicion is especially common^[7]. NIMH's examples include believing that people on television are sending special messages or that others are trying to cause harm^[1].

Disorganized thinking and behavior

Disorganized thinking shows up as speech that is confused, incoherent or hard to follow^[1][7]. Behavior may look odd, out of character or inappropriate for the setting^[5][1].

Awareness of symptoms

A person in a psychotic episode may or may not be aware that their behavior has changed^[5]. Symptom patterns specific to schizophrenia, including negative and cognitive symptoms, are covered in schizophrenia signs and symptoms.

There is no single cause. NIMH describes psychosis as resulting from a complex combination of genetic risk, differences in brain development, and exposure to stressors or trauma^[1].

Psychosis can be part of a mental illness such as schizophrenia, bipolar disorder or severe depression, but a person can experience psychosis and never be diagnosed with any disorder^[1]. Schizophrenia is typically diagnosed only after other causes are excluded^[1].

Medical conditions and medications

MedlinePlus lists medical causes including Parkinson and Huntington disease, brain tumors or cysts, dementia, HIV and other infections that affect the brain, some types of epilepsy, stroke, and some prescription medicines such as steroids and stimulants^[7]. In older adults, psychosis can be a symptom of Parkinson's disease, Alzheimer's disease and related dementias^[1].

Alcohol and drugs

Alcohol and certain illegal drugs can cause psychosis both during use and during withdrawal^[7]. In a 2019 study of 901 people with first-episode psychosis and 1,237 controls at 11 sites in Europe and Brazil, daily cannabis use was associated with an adjusted odds ratio of 3.2 for psychotic disorder compared with never using, rising to 4.8 for daily use of high-potency cannabis^[8].

High potency meant THC of 10% or more^[8]. Assuming the link is causal, the authors estimated that 30.3% of new cases in London and 50.3% in Amsterdam could be prevented if high-potency cannabis were no longer available^[8].

Drug-induced psychosis does not always end when the drug clears. A 2020 meta-analysis of 50 studies covering 40,783 people found that 25% of people with substance-induced psychosis later transitioned to schizophrenia^[3]. Broader data are on the substance use disorder page.

Severe sleep loss

Going without sleep can produce psychosis-like symptoms in healthy people. A 2018 review of 21 studies with 760 participants found perceptual distortions, anxiety and irritability within 24 to 48 hours of sleep loss, complex hallucinations and disordered thinking after 48 to 90 hours, and delusions after 72 hours^[4]. Visual changes were the most consistent, reported in 90% of the studies^[4].

Extreme stress

Brief psychotic disorder is triggered by extreme stress, such as a traumatic accident or the loss of a loved one^[5]. It most often affects people in their 20s, 30s and 40s^[5].

After childbirth

Psychosis or mania after childbirth is a psychiatric emergency^[9]. A systematic review found incidence of postpartum psychosis ranging from 0.89 to 2.6 per 1,000 women across five studies^[6].

After a first episode, 20% to 50% of women have isolated postpartum psychosis; the rest have episodes outside the perinatal period, usually within the bipolar spectrum^[9]. Mental health data for new mothers are on the postpartum population page.

Duration depends on the cause. In brief psychotic disorder, symptoms last longer than a day but less than a month, followed by a return to the previous level of functioning^[5].

Psychosis from sleep loss resolved after a period of normal sleep in many, though not all, cases in the 2018 review^[4]. When psychosis has a correctable medical cause, MedlinePlus reports that the outlook is often good and antipsychotic treatment may be short term^[7].

Some episodes are the start of a longer illness. Brief psychotic disorder can be the beginning of schizophrenia or schizoaffective disorder^[5], and in the 2020 meta-analysis 36% of brief, atypical and unspecified psychoses later transitioned to schizophrenia^[3].

Recovery is possible. NIMH reports that some people who receive early treatment never have another psychotic episode, while for others recovery means a fulfilling and productive life even if symptoms sometimes return^[1].

No. Psychosis describes a set of symptoms, while schizophrenia is one of several conditions in which those symptoms occur^[7]. NIMH notes that a person can experience psychosis and never be diagnosed with schizophrenia or any other disorder^[1].

Psychotic experiences also occur outside diagnosed illness. In WHO World Mental Health surveys of 31,261 adults in 18 countries, 5.8% reported at least one psychotic experience in their lifetime^[2].

Family and genetic risk for schizophrenia is covered in Is Schizophrenia Genetic?, and prevalence data are on the schizophrenia and psychotic disorders page.

Evaluation aims to find the cause. Psychiatric evaluation is the main tool, and MedlinePlus lists tests that can help, including blood tests for electrolyte and hormone levels, blood tests for syphilis and other infections, drug screens and brain MRI^[7].

Treatment of psychosis usually includes antipsychotic medication^[1]. For early psychosis, coordinated specialty care is the standard of care under the American Psychiatric Association's schizophrenia practice guideline, as NIMH reports^[1].

Coordinated specialty care is a team approach that combines psychotherapy, family support and education, medication management, supported employment and education, and case management^[1]. Through the Early Psychosis Intervention Network, launched in 2019, NIMH funds a network connected to more than 100 coordinated specialty care programs in 17 states^[1].

NIMH reports that the risk of violence and suicide decreases with treatment for psychosis^[1]. Care in a hospital is often needed to ensure safety, according to MedlinePlus^[7]; what that involves is described in inpatient mental health treatment.