Understanding Psychosis—Without Fear

Although the word “psychosis” may make some people think of scary movies or headlines, the truth about this condition is very different. Psychosis can affect how people think, see, hear, or feel the world around them. It can be confusing, frightening, and often misunderstood, but it doesn’t mean a person is “crazy” or “dangerous.”

Psychosis is not a disease itself, but a psychiatric condition defined by a group of symptoms that can range from mild to severe. Psychosis occurs with mental illnesses like schizophrenia, bipolar disorder, or severe depression, and it can be caused by stress, drug use, or certain medical conditions.

It is also more common than most people think. While the number of people who experience psychosis is difficult to determine, some studies estimate between 15 to 100 people out of 100,000 develop psychosis each year, according to the National Institute of Mental Health.

“With psychosis, many people don’t even realize what’s happening to them at first,” says Columbia psychologist Alice Medalia, PhD. “But with the proper support and treatment, people with psychosis can and do get better.”

Dr. Medalia and her colleague Lauren Gonzales, PhD, explain common symptoms, effective treatments, and how a collaborative approach with the lived experience of psychosis can help end the fear and stigma for people living with this condition.

What are some of the symptoms of psychosis?

Psychosis is an umbrella of symptoms that include changes in thinking, perception, feelings, and behavior. The symptoms are commonly grouped under the categories of “positive” and “negative,” which do not mean good or bad but rather whether the symptom is added to or subtracted from a person’s usual experience.

Examples of positive symptoms include:

• Hallucinations: Seeing, hearing, feeling, tasting, or smelling things that others do not.
• Delusions: Holding strong beliefs that others, even those from similar cultural backgrounds, do not share.

Examples of negative symptoms include:

• A decrease in usual levels of motivation, socialization, self-care, and emotional expressiveness.
• Reduced abilities to concentrate, remember, and process information quickly, and decreased ability to think and express thoughts clearly.

Can people have psychosis and not know it?

People can have psychosis without realizing that’s what they’re experiencing. This is because symptoms may start slowly over time, and also because it can be hard to know when thinking and perceptions are so unusual as to be pathological. Symptoms such as hallucinations are usually easier to identify. But delusions can be more difficult to distinguish since everyone has at least some beliefs that are not widely shared, so the line between “eccentric” and “delusional” can seem like a matter of opinion.

The most important factor in identifying psychosis is whether quality of life and functioning are affected. So, we ask our patients: Is this belief completely upending your behavior or your life? Is it so distressing that you can’t focus on much else? That’s where the label of psychosis might be valuable because it can help people get treatment.

What are some of the causes of psychosis? Is it genetic?

Researchers have been trying to identify a genetic cause of psychosis for decades. Studies indeed suggest psychosis tends to run in families. But finding a specific “cause” can be challenging because the experience itself is such a spectrum. Most studies focus on particular disorders that include psychosis, such as schizophrenia, when trying to nail down a genetic cause. The best theory we have right now is that psychosis is caused by a combination of biological, genetic, and environmental factors, such as stress.

What are some of the treatments for psychosis?

Medications, such as antipsychotics, are the primary treatment for many who experience positive symptoms. In the last 30-40 years, behavioral treatments, like psychotherapies, have also become a first-line treatment; these focus on managing distressing symptoms, as well as helping people with other skills that may be impacted in psychosis, including social skills training and building community connection. There are also specific treatments targeting the cognitive challenges associated with psychosis.

A combination of medication and psychotherapy has made recovery from psychosis very possible.

What Is CBT-p?

CBTp refers to Cognitive Behavioral Therapy for Psychosis, which several decades of research have shown to be effective for treating psychotic symptoms. CBTp is also recommended as the standard of care with psychosis in the United States. CBTp does not focus on taking psychotic symptoms away, but instead treats the distress associated with psychotic symptoms.

For example, we may not be able to eliminate the experience of a hallucination, even though antipsychotic medications can help reduce these experiences. However, with CBTp, we can help a person think about their psychosis experiences and the emotional and behavioral impacts they have. CBTp is a collaborative, person-centered treatment that emphasizes working within a client’s belief system or “personal reality” to help them improve their quality of life.

Can a person with psychosis lead an everyday life, and what have you learned from a lived experience approach to treatment?

Absolutely, and many people with psychosis do lead not just everyday, but fantastic lives! As mental health providers, it is essential to listen to and work with the people you want to help. The Western mental health system has historically treated people with psychosis as incapable of thinking for themselves or having any say in what happens to them—effectively dehumanizing them. A collaborative approach with mutual trust between provider and patient is vital. This includes working collaboratively with people with lived experience of psychosis, not only in the therapy room, but also in research and policy efforts concerning psychosis.

Imagine a college student who has a schizophrenia diagnosis and works hard to maintain recovery, sitting in a psychology class and hearing their professor say that schizophrenia is a chronic and untreatable illness that leads to institutionalization. This kind of stigmatizing misinformation not only impacts the student’s sense of self but also signals to them that aspects of an independent, quality life may be inaccessible to them.

Psychotic disorders such as schizophrenia remain the most severely stigmatized psychiatric diagnoses—not just at the interpersonal level, but also at social and structural levels that can be built into policies and even the mental health treatment system.

Stigma has been identified repeatedly as a massive barrier to recovery for people with psychotic disorders, sometimes even a bigger barrier than psychotic symptoms themselves. Discussing stigma openly in both community and treatment contexts is so important. Addressing stigma is an important part of treating psychosis so people living with this condition have more opportunity to recover and thrive. 

Alice Medalia, PhD, is a professor in the Department of Psychiatry at CUIMC, the founding Director of the Lieber Recovery Clinic at CUIMC, and Director of Cognitive Health Services for New York State Office of Mental Health.

Lauren Gonzales, PhD, is an assistant professor of Clinical Psychiatry at CUIMC and director of CBTp Services for New York State Office of Mental Health.