Psychosis is a condition that affects the way the brain processes information. It can include sensory distortions, hallucinations (visual, auditory, olfactory), delusions or unusual beliefs, difficulty thinking or concentrating, neurological ‘soft signs’ (twitches, feeling hot or cold, electrical jolts). It can be difficult to distinguish psychosis from other conditions (OCD, autism).
It is important for those experiencing warning signs to seek help. Early treatment is important as early intervention can reduce relapse of acute symptoms by 50%. Additionally, about 17% of young adults have psychotic-like experiences will never develop a major psychotic disorder. Early detection and minimizing harm for the patient and family are key.
There are a lot of different factors that can cause psychosis. Some of these factors can include:
- Medical conditions (give examples of medical conditions).
- Psychiatric conditions
- Sensory and sleep deprivation
- Trauma (developmental and acute)
- Substances (intoxication or withdrawal)
- Life events and circumstances
- Inherited tendencies
- The way we make sense of the world
- Deprivation and trauma often play a large role
- Constant interactions for every experience between biology, psychology, and society
- An experience is both a brain-based event and a human interaction with the greater environment (like every medical condition)
Any of the following new or worsening signs in an adolescent or young adult should trigger assessment for psychosis:
Functional decline: Because psychotic experiences are not observable by others, the following observable changes should prompt careful inquiry into a young person’s internal experience:
- Decline in self-care
- Decline in attendance or performance at school/work
- Withdrawal from family, friends, and usual activities
- Reduced emotional expression
- Reduced interest in activities previously enjoyed
- Decreased ability to handle everyday stress
- Insomnia or altered sleep
- Decline in the amount or content of speech
Atypical perceptual experiences: These include false perceptions or misperceptions involving one or more of the five senses: hearing, sight, touch, taste or smell. The most common are auditory (hearing noises or voices). Visual disturbances can include distortions in color, lines, or perspective, as well as seeing things no one else can see.
People with psychosis experience these as real, although many may realize that even vivid experiences are the product of their own minds. Individuals with psychotic disorders describe feeling more sensitive to or overwhelmed by stimulation. Examples include:
- Sounds seeming louder than usual
- Seeing movement, shadows, or vague figures out of the corner of the eye
- Finding that everyday noises sound like words
- Hearing voices talking, giving commands, or narrating a person’s day
- Seeing people or animals outside a window or in the room
Cognitive difficulties: Basic neurocognitive disabilities are typically among the earliest signs of an emerging psychotic disorder. These difficulties may begin years before psychotic symptoms appear, and make a significant contribution to functional difficulties:
- Trouble with learning, memory, attention, mental speed, planning and organization
- Trouble with abstract reasoning and social cues
- Trouble with motivation or initiative
- Trouble with basic receptive and expressive language (the person may talk very little as a result)
Thought disturbance or unusual beliefs: The content of one’s thoughts can also be altered in psychosis. Delusions are false beliefs that do not fit within a person’s cultural, familial, or religious context. Even though delusions may seem odd or obviously irrational to others, they are captivating or compelling to the young person. In the early stages of psychosis, an individual may recognize these beliefs as illogical. Take note when your patients:
- Feel suspicious of friends or family without clear reasons
- Have concerns that there is something wrong with their bodies or brains for bizarre reasons or without medical findings
- Have unusual beliefs about their capacity to eat, or about physical sensations or pain
- Feel that their body or mind has been altered by an external force
Speech or behavior that is disorganized: A person experiencing psychosis may have trouble thinking clearly or putting their thoughts into words. They may speak in jumbled or hard to follow sentences, lose their train of thought, or be unable to put a thought into words. They may also have trouble following conversations, thinking abstractly, or capturing the “gist.” They may make meaningful connections between ideas and events that have no logical connection, leading them to say or do things that confuse others.
Psychotic individuals may dress inappropriately for the weather, wander aimlessly, shout at strangers, or otherwise behave in ways that appear bizarre or even dangerous. This behavior is often more obviously recognized as psychotic, but also can be mistaken for substance use or erratic youthful behavior.
Family History & Other Risk Factors
Family history of a major psychotic disorder (such as schizophrenia, schizoaffective disorder, bipolar disorder, or depression with psychotic features) remains the single best predictor that a person will develop a psychotic disorder.
That said, the vast majority of these individuals will NOT develop a psychotic disorder. Young people with a known family history of psychosis warrant careful monitoring for changes in either functioning or mental health.
- Genetic abnormalities & interactions
- Neurocognitive dysfunction
- Early social & motor abnormalities
- Structural brain alterations
- Perinatal complications
- Head injuries
- Minority Stress
- Familial Conflict
Substance Use (Distinguishing between substance-induced psychosis and a primary psychotic disorder can be challenging in young people. A careful review of the person’s symptoms along with a period of sustained abstinence is typically needed if symptoms do not quickly remit.)
A number of self-report screening tools, listed below, can help identify psychotic-like experiences. None of the available screens have established thresholds for screening in general medical settings. However, they can help elicit the initial disclosure of experiences.
Psychosisscreening.org is a great resource for help with psychosis screenings. There are videos that provide assistance on how to discuss screenings and case examples.
PQ-16: 16-item prodromal questionnaire
PQ-B: Prodromal questionnaire (brief version)
Y-PARQ: Youth psychosis at-risk questionnaire
PQ-BC: Prodrome questionnaire: brief child version (ages < 10)
Provider Information & Resources
Tips for talking about psychosis
Psychosis screening in primary care
Decision-making flowchart for all patients ages 12-35
Psychosis Screening in Primary Care Booklet - Authored by experts at the Center for Early Detection, Assessment and Response to Risk (CEDAR) this booklet addresses the need for early identification of youth at risk for psychosis. It offers helpful advice in evaluating concerning symptoms.
Parent & Family Information
Psychosis Screening Patients & Families Resource
AACAP Facts for Families: Schizophrenia In Children
NAMI: The National Alliance on Mental Illness is the nation's largest nonprofit, grassroots mental health education, advocacy and support organization dedicated (617) 580-8541)
PPAL: The Parent/Professional Advocacy League: statewide family organization dedicated to improving the mental health and well-being of children, youth and families through education, advocacy and partnership. email@example.com or (866)815-8122
Support for young people
OK 2 TALK – NAMI’s online support forum for youth
VOICES 4 HOPE – Youth-made resources
ULIFELINE – Educational resource & mental health support for college-age youth