Overview

Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)..

Symptoms of psychosis

The 2 main symptoms of psychosis are:

• hallucinations – where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them; a common hallucination is hearing voices
• delusions – where a person has strong beliefs that are not shared by others; a common delusion is someone believing there is a conspiracy to harm them

The combination of hallucinations and delusional thinking can cause severe distress and a change in behaviour.

Experiencing the symptoms of psychosis is often referred to as having a psychotic episode.

When to seek medical advice

You should see a GP immediately if you're experiencing symptoms of psychosis.

It's important psychosis is treated as soon as possible, as early treatment can be more effective.

The GP may ask you some questions to help determine what's causing your psychosis.

They should also refer you to a mental health specialist for further assessment and treatment.

Getting help for others

If you're concerned about someone you know, you could contact a GP for them.

If they're receiving support from a mental health service, you could contact their mental health worker.

If you think the person's symptoms are severe enough to require urgent treatment and could be placing them at possible risk, you can:

• take them to the nearest (A&E), if they agree
• call their GP or local out-of-hours GP
• call 999 and ask for an ambulance

A number of mental health helplines are also available, which can offer expert advice.

Causes of psychosis

It's sometimes possible to identify the cause of psychosis as a specific mental health condition, such as:

• schizophrenia – a condition that causes a range of psychological symptoms, including hallucinations and delusions
• bipolar disorder – a mental health condition that affects mood; a person with bipolar disorder can have episodes of low mood (depression) and highs or elated mood (mania)
• severe depression – some people with depression also have symptoms of psychosis when they're very depressed

Psychosis can also be triggered by:

• a traumatic experience
• stress
• drug misuse
• alcohol misuse
• side effects of prescribed medication
• a physical condition – such as a brain tumour

How often a psychotic episode occurs and how long it lasts can depend on the underlying cause.

Treating psychosis

Treatment for psychosis involves using a combination of:

• antipsychotic medication – which can help relieve the symptoms of psychosis
• psychological therapies – the one-to-one talking therapy cognitive behavioural therapy (CBT) has proved successful in helping people with psychosis, and family interventions (a form of therapy that may involve partners, family members and close friends) have been shown to reduce the need for hospital treatment in people with psychosis
• social support – support with social needs, such as education, employment or accommodation

Some people are recommended to take antipsychotics on a long-term basis (and possibly for the rest of their lives). Other people may be able to gradually reduce their dosage and then stop taking them altogether if there is a marked improvement in symptoms.

Do not stop suddenly taking any prescribed medicines as this could trigger a relapse of your symptoms.

If a person's psychotic episodes are severe, they may need to be admitted to a psychiatric hospital for treatment.

Complications of psychosis

People with a history of psychosis are more likely than others to have drug or alcohol misuse problems, or both.

Some people use these substances as a way of managing psychotic symptoms.

But substance abuse can make psychotic symptoms worse or cause other problems.

Self-harm and suicide

People with psychosis have a higher than average risk of self-harm and suicide.

See a GP if you're self-harming.

You can also call the Samaritans, free of charge, on 116 123 for support.

The mental health charity Mind also has some useful information and advice.

If you think a friend or relative is self-harming, look out for signs of unexplained cuts, bruises or cigarette burns, usually on the wrists, arms, thighs, and chest.

People who self-harm may keep themselves covered up at all times, even in hot weather.

Read more about:

• getting help if you self-harm
• spotting the signs of self-harm in others

If you're feeling suicidal, you can:

• call the Samaritans support service on 116 123
• go to your nearest (A&E)  and tell the staff how you're feeling
• speak to a friend, family member, or someone you trust
• make an urgent appointment to see a GP, psychiatrist, or care team

Read more about:

• warning signs of suicide

Symptoms

Someone who develops psychosis will have their own unique set of symptoms and experiences, according to their particular circumstances.

But in general, 3 main symptoms are associated with a psychotic episode:

• hallucinations
• delusions
• confused and disturbed thoughts

Hallucinations

Hallucinations are where someone sees, hears, smells, tastes or feels things that don't exist outside their mind.

• sight – seeing colours, shapes or people
• sounds – hearing voices or other sounds
• touch – feeling touched when there is nobody there
• smell – an odour that other people can't smell
• taste – a taste when there is nothing in the mouth

Delusions

A delusion is where a person has an unshakeable belief in something untrue.

A person with persecutory delusions may believe an individual or organisation is making plans to hurt or kill them.

A person with grandiose delusions may believe they have power or authority. For example, they may think they're the president of a country or they have the power to bring people back from the dead.

People who have psychotic episodes are often unaware that their delusions or hallucinations are not real, which may lead them to feel frightened or distressed.

Confused and disturbed thoughts

People with psychosis sometimes have disturbed, confused, and disrupted patterns of thought. Signs of this include:

• rapid and constant speech
• disturbed speech – for example, they may switch from one topic to another mid-sentence
• a sudden loss in their train of thought, resulting in an abrupt pause in conversation or activity

Postnatal psychosis

Postnatal psychosis, also called puerperal psychosis, is a severe form of postnatal depression, a type of depression some women experience after having a baby.

It's estimated postnatal psychosis affects around 1 in every 1,000 women who give birth. It most commonly occurs during the first few weeks after having a baby.

Postnatal psychosis is more likely to affect women who already have a mental health condition, such as bipolar disorder or schizophrenia.

As well as the symptoms of psychosis, symptoms of postnatal psychosis can also include changes in mood:

• a high mood (mania) – for example, feeling elated, talking and thinking too much or too quickly
• a low mood – for example, feeling sad, a lack of energy, loss of appetite, and trouble sleeping

Contact your GP immediately if you think you or someone you know may have developed postnatal psychosis as it is a medical emergency. If this is not possible call 111 .

If you think there's an imminent danger of harm, call 999 and ask for an ambulance.

Psychosis isn't the same as psychopath

The terms "psychosis" and "psychopath" should not be confused.

Someone with psychosis has a short-term (acute) condition that, if treated, can often lead to a full recovery.

A psychopath is someone with an anti-social personality disorder, which means they:

• lack empathy – the capacity to understand how someone else feels
• are manipulative
• often have a total disregard for the consequences of their actions

People with an anti-social personality can sometimes pose a threat to others because they can be violent. Most people with psychosis are more likely to harm themselves than others.

Who can get it

Psychosis can be caused by a mental (psychological) condition, a general medical condition, or alcohol or drug misuse.

Psychological causes

The following conditions have been known to trigger psychotic episodes in some people:

• schizophrenia – a mental health condition that causes hallucinations and delusions
• bipolar disorder – a person with bipolar disorder can have episodes of low mood (depression) and highs or elated mood (mania)
• severe stress or anxiety
• severe depression – feelings of persistent sadness, including postnatal depression, which some women experience after having a baby
• lack of sleep

The underlying psychological cause often influences the type of psychotic episode someone experiences.

For example, a person with bipolar disorder is more likely to have grandiose delusions. Someone with depression or schizophrenia is more likely to develop persecutory delusions.

General medical conditions

The following medical conditions have been known to trigger psychotic episodes in some people:

• HIV and AIDS
• malaria
• syphilis
• Alzheimer's disease
• Parkinson's disease
• hypoglycaemia (an abnormally low level of glucose in the blood)
• lupus
• multiple sclerosis
• brain tumour

Substances

Alcohol misuse and drug misuse can trigger a psychotic episode.

A person can also experience a psychotic episode if they suddenly stop drinking alcohol or taking drugs after using them for a long time. This is known as withdrawal.

It's also possible to experience psychosis after drinking large amounts of alcohol or if you're high on drugs.

Drugs known to trigger psychotic episodes include:

• cocaine
• amphetamine (speed)
• methamphetamine (crystal meth)
• mephedrone (MCAT or miaow)
• MDMA (ecstasy)
• cannabis
• LSD (acid)
• psilocybins (magic mushrooms)
• ketamine

In rare situations, psychosis can also occur as a side effect of some types of medication or as a result of an overdose of that medication.

Never stop taking a prescribed medication unless advised to do so by a GP or another qualified healthcare professional responsible for your care.

See a GP if you're experiencing psychotic side effects caused by medication.

The brain

There's been a great deal of research into how psychosis affects the brain and how changes in the brain can trigger symptoms of psychosis.

Dopamine

Researchers believe dopamine plays an important role in psychosis.

Dopamine is a neurotransmitter, 1 of many chemicals the brain uses to transmit information from 1 brain cell to another. It's associated with how we feel whether something is significant, important, or interesting.

Disruption to these important brain functions may explain the symptoms of psychosis.

Evidence for the role of dopamine in psychosis comes from several sources, including brain scans and the fact medications known to reduce the effects of dopamine in the brain also reduce the symptoms of psychosis.

Diagnosis

You should visit a GP if you're experiencing symptoms of psychosis.

It's important to speak to a GP as soon as possible because earlier treatment can be more effective.

Initial assessment

There's no test to positively diagnose psychosis. However, a GP will ask about your symptoms and possible causes.

For example, they may ask you:

• whether you're taking any medication
• whether you've been taking illegal substances
• how your moods have been – for example, whether you've been depressed
• how you've been functioning day-to-day – for example, whether you're still working
• whether you have a family history of mental health conditions, such as schizophrenia
• about the details of your hallucinations, such as whether you've heard voices
• about the details of your delusions, such as whether you feel people are controlling you
• about any other symptoms you have

Referral

The evidence supporting the early treatment of psychosis means you're likely to be referred to a specialist urgently.

Who you're referred to will depend on the services available in your area. You may be referred to:

• a community mental health team – a team of mental health professionals who provide support to people with complex mental health conditions
• a crisis resolution team – a team of mental health professionals who treat people who would otherwise require treatment in hospital
• an early intervention team – a team of mental health professionals who work with people who have experienced their first episode of psychosis

These teams are likely to include some or all of the following healthcare professionals:

• a psychiatrist – a qualified medical doctor who has received further training in treating mental health conditions
• a community mental health nurse – a nurse with specialist training in mental health conditions
• a psychologist – a healthcare professional who specialises in the assessment and treatment of mental health conditions

Your psychiatrist will carry out a full assessment to help identify and diagnose any underlying mental health condition that could be causing your symptoms. This will help when planning your treatment for psychosis.

Helping others

The lack of insight and level of distress associated with psychosis means people experiencing it aren't always able to recognise their symptoms.

They may be reluctant to visit a GP if they believe there's nothing wrong with them. You may need to help them get support and treatment.

Someone who has had psychotic episodes in the past may have been assigned a mental health worker, who works in mental health or social services, so try to contact them.

If someone has very severe psychosis, they can be compulsorily detained at hospital for assessment and treatment under the Mental Health Act (1983).

Mental Health Act (1983)

The Mental Health Act (1983) is the main piece of legislation that covers the assessment, treatment, and rights of people with a mental health condition.

Under the Act, a person can only be compulsorily admitted to hospital or another mental health facility (sectioned) if they:

• have a mental disorder of a nature or degree that makes admission to hospital appropriate
• should be detained in the interests of their own safety, for the protection of others, or both

Depending on the nature of the mental health disorder and the individual's circumstances, the length of time a person can be sectioned is:

• 72 hours
• 28 days
• 6 months

Before these time periods have elapsed, an assessment will be carried out to determine whether it's safe for the person to be discharged or further treatment is required.

If you're held under the Mental Health Act (1983), you can be treated against your will. However, certain treatments, such as brain surgery, can't be carried out unless you consent to treatment.

Any person compulsorily detained has the right to appeal against the decision to a Mental Health Tribunal (MHT). This is an independent body that decides whether a patient should be discharged from hospital.

Driving

Having psychosis could affect your ability to drive.

It's your legal obligation to tell the Driver and Vehicle Licensing Agency (DVLA) about any medical condition that could affect your driving ability.

GOV.UK provides details about telling the DVLA about a medical condition.

Treatment

Treatment for psychosis involves a combination of antipsychotic medicines, talking therapies, and social support.

Your care team

Your treatment is likely to involve a team of mental health professionals working together. If this is your first psychotic episode, you may be referred to an early intervention team.

Early intervention teams

.An early intervention team is a team of healthcare professionals set up specifically to work with people who have experienced their first episode of psychosis.

Depending on your care needs, early intervention teams aim to provide:

• a full assessment of your needs
• medicine
• talking therapies
• social, occupational, and educational interventions

Read more about mental health services.

Treatment for psychosis will vary, depending on the underlying cause. You'll receive specific treatment if you've been diagnosed with an underlying mental health condition as well.

Antipsychotics

Antipsychotic medicines are usually recommended as the first treatment for psychosis. They work by blocking the effect of neurotransmitters, such as dopamine, which are chemicals that transmit messages in the brain.

However, they're not suitable or effective for everyone, as side effects can affect people differently. In particular, antipsychotics will be monitored closely in people who also have epilepsy, a condition that causes seizures or fits.

People who have cardiovascular disease – conditions that affect the heart, blood vessels, or circulation, such as heart disease – will also be closely monitored.

Antipsychotics can usually reduce feelings of anxiety within a few hours of use, but they may take several days or weeks to reduce psychotic symptoms, such as hallucinations or delusional thoughts.

Antipsychotics can be taken by mouth (orally) or given as an injection. There are several slow-release antipsychotics, where you only need an injection every 1 to 4weeks.

Side effects

Antipsychotics can have side effects, although not everyone will experience them and their severity will differ from person to person.

Side effects can include:

• drowsiness
• shaking and trembling
• weight gain
• restlessness
• muscle twitches and spasms – where your muscles shorten tightly and painfully
• blurred vision
• dizziness
• constipation
• loss of sex drive (libido)
• dry mouth

Tell a GP or mental health worker if you have side effects that are becoming particularly troublesome. There may be an alternative antipsychotic medicine you can take that causes less side effects.

Rarely, antipsychotics can trigger suicidal feelings or an urge to self-harm. Call 999 or go to A&E now if you have thoughts about ending your life or harming yourself.

Never stop taking medicine prescribed for you unless advised to do so by a qualified healthcare professional responsible for your care.

Suddenly stopping prescription medication could trigger a return of your symptoms (relapse). When it's time for you to stop taking your medicine, it will be done gradually.

Talking treatment

Talking treatment can help reduce the intensity and anxiety caused by psychosis. There are several possible talking therapies.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) for psychosis is based on an understanding of how people make sense of their experiences and why some people become distressed by them.

A CBT therapist may encourage you to consider different ways of understanding what's happening to you. The aim is to help you achieve goals that are meaningful and important to you, such as reducing your distress, returning to work, education or training, or regaining a sense of control.

Family intervention

Family intervention is known to be an effective form of therapy for people with psychosis. It's a way of helping both you and your family cope with your condition.

After having an episode of psychosis, you may rely on your family members for care and support. While most family members are happy to help, the stress of caring for somebody can place a strain on any family.

Family therapy involves a series of meetings that take place over a period of three months or more. Meetings may include:

• discussing your condition and how it might progress, plus the available treatments
• exploring ways of supporting someone with psychosis
• deciding how to solve practical problems caused by psychosis, such as planning how to manage future psychotic episodes

Self-help groups

If you're experiencing episodes of psychosis, you may benefit from being around other people who've had similar experiences.

For example, the mental health charity Mind has more than 150 local Mind networks, which may be able to put you in touch with a support group in your area, as well as provide a range of other useful services.

Rehabilitation for psychosis

If your treatment for psychosis is not working, you might be offered rehabilitation.

The aim of rehabilitation is to build your confidence and skills so you can cope with your condition and become as independent as possible.

You'll be offered different types of support as your needs change, and you can go through the rehabilitation process more than once if you need to.

Your rehabilitation team will include people from different parts of the health and care system, such as a rehabilitation psychiatrist, mental health nurse, occupational therapist and social worker. Depending on your needs, you might also see other people who can help, such as a dietitian or exercise coach.

Rehabilitation should happen close to where you live, but sometimes the services you need might be outside your local area.

Your team will work with you to decide on the types of care you need for your physical and mental health, which is called your care plan. They'll also help you set goals you want to achieve, such as managing in your own cooking and shopping, or going back to work.

Mental Health Act (1983)

If you're experiencing a particularly severe psychotic episode and your care team think you would be best cared for in a hospital or clinic, they will explain this to you and encourage you to admit yourself for care.

If you refuse to go to hospital and it's felt you present a significant danger to yourself or others, you can be compulsorily admitted to a hospital (detained) under the Mental Health Act .

You’ll be kept in hospital only for as long as needed, so you can have appropriate treatment.

If you're detained under the Act, every effort will be made to obtain your consent to treatment. Healthcare professionals will explain to you any treatment you need. You may be treated without consent (against your will).  However, you cannot be treated for any physical condition if you do not consent to treatment, unless the physical condition is linked to your mental health condition.

Violence and aggression

Acts of violence and aggression are fairly uncommon in people with psychosis. They're more likely to be victims of violence than those being violent.

However, there may be times when your behaviour places yourself or others at risk of harm. Mental health staff have been trained to deal with aggressive behaviour.

They will try to help reduce any distress, agitation and aggression, but it may be necessary to hold you down without hurting you. This is known as physical restraint. You may then be moved to a secluded room.

In some cases, you may need to be given medicine that will quickly make you very relaxed.

You'll be offered the medication voluntarily, in the form of tablets, but you can be treated against your consent if you refuse. This may involve giving you an injection of a tranquilliser (rapid tranquillisation).

It's important to stress that these methods are only used in extreme circumstances and are not routinely used to treat psychosis.

Advance decisions to refuse treatment

If you're at risk of having psychotic episodes in the future and there are certain treatments you don't want to have, it's possible to pre-arrange a legally binding advance decision, previously known as an advance directive.

An advance decision is a written statement about what you'd like health professionals and your family or friends to do if you experience another psychotic episode. You may also want to include the contact details of your care team.

To create an advance decision, you need to make your wishes clear, in writing, and ask a witness to sign it. You should include specific details about any treatments you don't want and specific circumstances in which they may apply.

However, an advance decision can be overruled if a person is subsequently detained under the Mental Health Act.

Although your doctors will try to take your wishes into account when deciding on treatment, they may decide it's in your best interests not to follow the advance decision.