Psychosis is a condition of the mind broadly defined as a loss of contact with reality. It is estimated that 13 to 23 percent of people experience psychotic symptoms at some point in their lifetime and 1 to 4 percent will meet criteria for a psychotic disorder. 

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Psychotic symptoms can increase patients’ risk for harming themselves or others or being unable to meet their basic needs. Most clinicians will encounter patients with psychosis and will thus benefit from knowing how to recognize psychotic symptoms and make appropriate initial evaluation and management decisions. Other clinicians, particularly mental health specialists, will conduct a more thorough patient assessment, consider the patient’s differential diagnosis, and determine the patient’s diagnosis to guide long-term treatment.

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Clinical Manifestations

 

Psychosis can present with a wide variety of signs and symptoms which are described below:

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Delusions — Delusions are defined as strongly held false beliefs that are not typical of the patient’s cultural or religious background. They can be categorized as bizarre or non-bizarre based on their plausibility (eg, a belief that family members have been replaced by body-doubles is bizarre and a belief that a spouse is having an affair is non-bizarre). Frequently encountered types of delusions include:

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●Persecutory delusions (eg, believing one is being followed and harassed by gangs)

●Grandiose delusions (eg, believing one is a billionaire CEO who owns casinos around the world)

●Erotomanic delusions (eg, believing a famous movie star is in love with them)

●Somatic delusions (eg, believing one’s sinuses have been infested by worms)

●Delusions of reference (eg, believing dialogue on a television program is directed specifically towards the patient)

●Delusions of control (eg, believing one’s thoughts and movements are controlled by planetary overlords)

 

Hallucinations — Hallucinations can be defined as wakeful sensory experiences of content that is not actually present. They are differentiated from illusions, which are distortions or misinterpretations of real sensory stimuli. While hallucinations can occur in any of the five sensory modalities, auditory hallucinations (eg, hearing voices) are the most common, followed by visual, tactile, olfactory, and gustatory hallucinations. Auditory hallucinations can present as speech (including spoken commands or a running commentary on the patient’s actions) or other sounds. Visual hallucinations can range from recognizable objects to more unformed lights or shadows. Olfactory hallucinations are frequently of unpleasant odors.

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Thought disorganization — Evidence for thought disorganization is derived from patients’ patterns of speech during the interview. While disorganized speech is a frequently observed symptom in psychosis, it is nonspecific and can also be present in delirium or other neurological or cognitive disorders. Commonly observed forms of thought disorganization include:

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●Alogia/poverty of content – Very little information conveyed by speech

●Thought blocking – Suddenly losing train of thought, exhibited by abrupt interruption in speech

●Loosening of association – Speech content notable for ideas presented in sequence that are not closely related

●Tangentiality – Answers to interview questions diverging increasingly from topic being asked about (called circumstantiality if content eventually returns to original topic)

●Clanging or clang association – Using words in a sentence that are linked by rhyming or phonetic similarity (eg, “I fell down the well sell bell.”)

●Word salad – Real words are linked together incoherently, yielding nonsensical content

●Perseveration – Repeating words or ideas persistently, often even after interview topic has changed

 

Agitation/aggression — Agitation is an acute state of anxiety, heightened emotional arousal, and increased motor activity. Although not specific to psychosis, untreated psychosis is associated with an increased risk for agitation and aggressive behaviors. These can sometimes lead to intentional or unintentional bodily harm to self or others. Clinicians should observe the patient’s behaviors, including body language and voice intonation, and use appropriate safety measures for the evaluation.

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Types of Psychotic Disorders: 

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Schizophrenia – This disorder is defined by the presence of psychotic symptoms (eg, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or diminished emotional expression or volition) for a “significant portion of time during a one-month period (or less if successfully treated).” DSM-5 requires that the symptoms be associated with a decline in functioning or failure to achieve the expected level of functioning. Signs of the disturbance must persist for at least six months. Schizoaffective disorder, mood disorders with psychotic features, and attribution to substance use or medical conditions must be ruled out. Additional diagnostic requirements must be met if there is a history of another childhood-onset psychiatric disorder.

 

●Schizophreniform disorder – This disorder can be considered to have similar symptomatic presentation as schizophrenia, except with an episode lasting greater than one month but less than six months. In addition, functional decline does not need to be present. Schizoaffective disorder, mood disorders with psychotic features, and attribution to substance use or medical condition(s) must be ruled out.

 

●Schizoaffective disorder – This disorder is defined by the individual having “an uninterrupted period of illness during which there is a major mood episode” concurrent with psychotic symptoms as well as “delusions or hallucinations for two or more weeks in the absence of a major mood episode” during the duration of the illness. Individuals with this disorder must have symptoms that meet criteria for a major mood disorder “for the majority of the total duration of the active and residual portions of the illness.” Disorder presentation cannot be attributable to substance use or another medical condition.

 

●Delusional disorder – This disorder is characterized by the “presence of one (or more) delusions with a duration of one month or longer”; the absence of meeting criteria for schizophrenia; a lack of marked impairment in functioning or obvious bizarre behaviors; and a lack of attribution to manic or depressive episodes, substances, other medical conditions, or better explanation by another mental disorder. The delusions are classified as erotomanic type, grandiose type, jealous type, persecutory type, somatic type, mixed type, or unspecified type, and by whether they have bizarre content.

 

●Brief psychotic disorder – This disorder is characterized by the presence of psychotic symptoms (eg, delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior) with duration ≥1 day and <1 month, with eventual return to premorbid functioning. The episode cannot be a culturally sanctioned response or better explained by another mental disorder, substance, or medical condition. These episodes are often associated with an intense stressor or traumatic event.

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●Schizotypal (personality) disorder – This is considered a personality disorder in the DSM-5 and schizotypal disorder in the ICD-9 and ICD-10. It is defined in the DSM-5 as “a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of context, as indicated by five (or more) of the following: ideas of reference, odd beliefs or magical thinking; unusual perceptual experiences; odd thinking and speech; suspiciousness or paranoid ideation; inappropriate or constricted affect; behavior or appearance that is odd; lack of close friends or confidants; excessive social anxiety.” The criteria specify that the syndrome does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, other psychotic disorders, or autism spectrum disorder.

 

●Major depressive disorder with psychotic features – Major depressive disorder is characterized by the individual experiencing five or more depressive symptoms (including depressed mood, diminished interest in pleasure, change in appetite, sleep disturbance, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or guilt, poor concentration, and recurrent thoughts of death) for a two-week period, along with significant distress or functional impairment. The depressive episodes cannot be attributable to substance use, other medical conditions, or other psychiatric illnesses including schizoaffective disorder or bipolar disorder. 

 

●Bipolar disorder with psychotic features – Bipolar (I) disorder is characterized by periods of mania (“distinct periods of abnormally and persistently elevated, expansive, or irritable mood” for “at least one week and present most of the day, nearly every day” in conjunction with symptoms and behaviors such as decreased need for sleep, racing thoughts, and increased goal-directed activity). The manic episodes must be severe enough to cause “marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.” The episodes also cannot be attributable to substance use or other medical conditions.

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Substance-induced psychoses — Many prescription medications as well as illicit substances can induce transient psychotic symptoms. The DSM-5 defines “substance/medication-induced psychotic disorder” as having the presence of delusions and/or hallucinations during or soon after intoxication, withdrawal, or exposure to a substance, with the disturbance not being better explained by another type of psychotic disorder. The disturbance cannot “occur exclusively during the course of a delirium” and must cause significant distress or impairment in function. 

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