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Psychotic episodes

Psychosis is a mental health problem that causes people to perceive or interpret things differently from those around them. This might involve hallucinations or delusions.

This page covers:

Symptoms

When to seek medical advice

Getting help for others

Causes

Treatment

Complications

Symptoms of psychosis

The two main symptoms of psychosis are:

  • hallucinations – where a person hears, sees and, in some cases, feels, smells or tastes things that aren't there; a common hallucination is hearing voices
  • delusions – where a person has strong beliefs that aren't 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.

Read about the symptoms of psychosis.

When to seek medical advice

You should see your 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.

Your 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.

Read more about diagnosing psychosis.

Getting help for others

If you're concerned about someone you know, you could contact their GP. 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 placing them at possible risk of harm, you can:

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

Read more about how to get help for others.

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:

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

Read about the causes of psychosis.

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; 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

After an episode of psychosis, most people who get better with medication need to continue taking it for at least a year. Around 50% of people need to take long-term medication to prevent symptoms recurring.

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

Read about treating psychosis.

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. However, 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 your 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:

If you're feeling suicidal, you can:

Read more about:

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

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

  • hallucinations
  • delusions
  • confused and disturbed thoughts
  • lack of insight and self-awareness

These are outlined in more detail below.

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.

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

Lack of insight

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

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 someone you know may have developed postnatal psychosis. If this isn't possible, call NHS 111 or your local out-of-hours service.

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

Psychosis can be caused by a mental (psychological) condition, a general medical condition, or a substance such as alcohol or drugs.

These three main causes are described in more detail below.

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:

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 your GP or another qualified healthcare professional responsible for your care.

See your 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, one of many chemicals the brain uses to transmit information from one 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.

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

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

Initial assessment

There's no test to positively diagnose psychosis. However, your 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 their 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 for psychosis involves a combination of antipsychotic medicines, psychological 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
  • medication
  • psychological 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 dopamine, a chemical that transmits 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 one injection every two to six weeks.

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:

Tell your 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.

Never stop taking medication 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 medication, it will be done gradually. 

Psychological treatment

Psychological treatment can help reduce the intensity and anxiety caused by psychosis. Some possible psychological treatments are discussed below.

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.

Mental Health Act (1983)

If you're experiencing a particularly severe psychotic episode and it's felt you present a significant danger to yourself or others, you can be compulsorily detained at a hospital under the Mental Health Act (1983).

If you're detained under the Act, every effort will be made to obtain your consent to treatment.

However, treatment can be carried out without your consent if it's required.

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 perpetrators.

However, there may be times when your behaviour places yourself or others at risk of harm. Mental health staff have been specially 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 medication 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

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.

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Andrew is in his 50s and lives on the south coast. His early psychotic experiences lasted a number of years and had a profound effect on his life.

He got better, however, and has been free of symptoms for more than 15 years. He recently completed an MA in social policy.

"The first time things didn't feel right was when I was in my early 20s at university. I'd got some compensation money following an accident in my teens when I lost a leg.

"My friends were trying to persuade me to buy a house. The idea of going to see an estate agent was intensely frightening. They seemed like oppressive 'non-beings' who could expose me as inadequate in some way.

"This uncomfortable feeling got stronger. I stopped going to lectures because I thought it would be too much and failed my degree as a result.

"I then fell out with my parents because of my mental state. Simple misunderstandings preoccupied me and seemed sinister. I was mistrustful and thought they were deliberately not looking after me and trying to make things difficult.

"I ended up living in my car. As I drove around, it seemed that other drivers were singling me out for observation. Certain features of the landscape, like radio masts, would also make me feel suspicious.

"I neglected myself. I felt disadvantaged by my circumstances and by the fact I couldn't have the happiness that a good job and a relationship would bring. I thought this could make everything right, but nobody understood.

"I went into hospital a number of times, was given injections, improved a bit, and was then discharged to a hostel. I would get a low-paid job and after a while stop taking my medication. My false or erroneous beliefs became more powerful, and at the time they seemed very real.

"I used to imagine that the place where I worked and the people in it weren't what they seemed, that it was all hiding something else going on beneath the surface.

"My colleagues seemed to drop significant words or phrases into conversations and give each other signals that excluded me. I would interpret personal or distinctive features as clues to hidden identities, part of another secret world.

"When these false beliefs became stronger, it became too difficult to stay in a job. I became a vagrant. The delusions preoccupied me, and I travelled around the country trying to uncover signals or evidence of enemy plans to assassinate the Archbishop of Canterbury and bring down the state.

"I believed that people in public sector jobs could live for 500 years and had spent a period of their life as a monarch. The phrase 'Jesus Lives' also took on a literal sense.

"In 1991 I ended up back in hospital. I was given tablets I'd never tried before. They made me feel better, and after a few months I was discharged.

"Since then, I've never needed to go back. I take my pills every day. I see a counsellor once a week and don't have any more strange ideas. I enjoy my independence and the choices I can make for myself."

Sarah lives in the north of England. She had a significant psychotic episode in her early 20s, during which she was abducted and assaulted.

She has since made a full recovery, worked in fundraising and events management, and studied for a PhD.

"I had a phase of depression while I was at university, but when I finished my degree that lifted. I got a very competitive publishing job, moved to London, and had a cool social life.

"I was everyone's best friend, had huge amounts of energy, and was staying up later and later. Nobody really noticed anything, especially as my work wasn't being affected, but mania was creeping up on me.

"After a row with my boyfriend at three in the morning, I decided to head for my parents' house in Yorkshire. Outside my flat, I got into what I assumed was a cab. It wasn't.

"My memory of what happened over the next three days is very jumbled. My mind was running away with itself and I was developing full-blown psychosis. I became convinced that the man I was with was Stevie Wonder's son, and that he and I were secret agents on some sort of secret mission.

"I had developed something of an obsession with royalty as my mania emerged, and kept thinking it was unfair that they had so much money and influence. I remember feeling very powerful and that my secret mission was to redistribute their wealth.

"This was my first experience of losing touch with reality. It was made all the more extraordinary because the man I was with seemed to be my closest ally at one moment, then the next he threatened me with a knife and raped me. My psychotic mind couldn't make sense of what was going on.

"I was found three days later and spent the next month in hospital, eventually being diagnosed with manic depression. My hospitalisation was, I believed at the time, part of a role play to trick the authorities and hospital staff. The mission I thought I was on was so top secret that I wasn't allowed to know what it was.

"For a while I thought the side effects of my medication were a deliberate attempt to disable me because people were afraid that I was a threat and might see through my mission. It was as if I was doing something important that others didn't want me to do and I needed to be controlled.

"Reality started to come back slowly. The police were interviewing me to find out what had happened. I thought I was doing some part-time espionage before getting back to my regular life, but when I heard I'd lost my job, something clicked and I realised my psychotic thoughts hadn't been real at all.

"About a year later I stopped taking my medication and had another episode of mania. I'm still on medication and did self-management training with Bipolar UK.

"It's odd having a chronic mental health diagnosis. I've been well for much longer than I was ever ill, but the diagnosis is with me every day."

Delusions and voices have been a daily feature of Richard's life for more than 10 years.

Despite this, he recently completed a master's degree in broadcast journalism and successfully runs his own business.

"When I was 21, I had a bad experience with hallucinogenic mushrooms, after which I started having delusions and hallucinations.

"Voices in my head said unkind things and I had suspicious thoughts that felt like they came from outside me. I was diagnosed with paranoid schizophrenia, and the thoughts and voices have been with me ever since.

"A lot of the time the thoughts and voices are like another layer of interaction with people and the world. It's as if there are two coexisting realities.

"If I am listening to the radio, for instance, the rational part of me knows that the programme is being transmitted to lots of listeners and that it's a one-way form of communication.

"My delusional thinking, however, makes me think that the radio can project what I say out loud to the people making the show and all the listeners.

"My delusions will also make me think that a lot of the discussion in the programme has a special meaning or relevance to me. For example, the host of a show might mention that they're going to the dentist soon.

"If I happen to have a dental appointment in the near future, then it can seem like the presenter has just dropped that into the conversation as a hidden message. They aren't going to the dentist, but they want me to understand that they know I will be.

"In truth, when something like that happens it is, of course, just a coincidence, but there's a part of my thinking for which it becomes another reality.

"I've come to accept that they're an ongoing part of my life, but there are times when it is hard to deal with. Out shopping, it sometimes seems people are looking at me in a sinister way because they don't like something about me. The truth is they're probably noticing my clothes or are just looking in my direction.

"Nonetheless, it can get me down to the point where I won't go out of the house. In the past it has made me feel depressed, even suicidal.

"At times like that, it helps to have friends who can either tell me to stop thinking rubbish or, if needs be, help me work through my delusions and do some reality checking.

"I had some cognitive behavioural therapy (CBT) when I first got these symptoms. It was helpful because it gave me another way to work through negative emotions and keep on top of things that could be disabling. I also take medication, and have decided that I always will.

"The media consultancy company I've just set up keeps me busy. That's important, too, because when I have lots of work on it helps me keep focused, rather than drift off with my delusions."

 

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