Psychosis and Schizophrenia

WHEN WE SAY SOMEONE IS psychotic, what does that actually mean? Well, in the clinical setting, it means they’re exhibiting certain, specific signs and symptoms that indicate something may be wrong inside the brain. If when the word “psychosis” is mentioned you immediately think of schizophrenia, you’re not alone.

Though sometimes confused in common parlance, psychosis and schizophrenia are two different things, but they are related. Psychosis is a hallmark symptom of schizophrenia, but not all cases of psychosis are related to schizophrenia, and it’s important to understand how the two are different and where they overlap.

What Is Psychosis?

The National Alliance on Mental Illness reports that “psychosis is a symptom, not an illness, and it is more common than you may think.” The National Institute of Mental Health reports that "three out of 100 people will experience psychosis at some time in their lives," and "about 100,000 adolescents and young adults in the U.S. experience first episode psychosis each year."

Aubrey Moe, a psychologist with the Early Psychosis Intervention Center at The Ohio State University Wexner Medical Center, describes psychosis as a syndrome. “It’s a collection of signs and symptoms,” and it can be triggered by a range of underlying medical conditions or other factors.

Dr. Andrei T. Nemoianu, a psychiatrist with Geisinger in Danville, Pennsylvania, says, “psychosis is defined most broadly as an impairment in reality testing and distinguishing what is real from what is not real.” In simpler terms, “psychosis occurs when there is a change in condition of the mind, causing a loss of contact with reality,” says Dr. Steven Tam, associate clinical professor of geriatrics at the University of California, Irvine.

Symptoms of psychosis include:

Delusions – strongly held false beliefs that can interfere with everyday life.Hallucinations – sensory experiences that aren’t caused by an external stimulus, such as hearing, seeing, tasting or smelling something that isn’t there.Rapid mood swings.Difficulty concentrating.Anxiety and irritability.Depressed mood.Changes in sleep patterns.Paranoia.Withdrawing from family or social settings.Disorganized speech and racing thoughts.Suicidal thoughts or actions.

What Causes Psychosis?

“A large number of medical and psychiatric diseases can cause psychosis, including infections, systemic illnesses, medications and primary psychiatric disorders,” Tam says. Conditions that can trigger psychosis or psychotic episodes include:

Bipolar disorder and depression. When a patient is in the manic state of bipolar disorder, psychosis can be a prominent feature. But, “you can also have major depression with psychosis,” Moe says. Post-partum depression. New moms who experience depression after giving birth may be experiencing post-partum depression, and in some cases, these symptoms can become very severe and trigger psychosis.

Metabolic or endocrine disorders. Hyperthyroidism, in which the thyroid makes too much of a certain hormone, can trigger psychosis. So can Addison’s disease, a hormonal disorder in which the body doesn’t produce enough of the hormone cortisol. At the other end of the spectrum, Cushing syndrome, in which the body makes too much cortisol can also trigger episodes of psychosis in some people.

Genetic diseases. Certain genetic disorders such as Huntington’s disease, which is a fatal condition that causes the progressive breakdown of brain cells, can lead to psychosis.

Autoimmune conditions. Some autoimmune disorders – in which the immune system mistakenly attacks the body’s own cells – can trigger psychosis, “particularly if they affect the brain,” Nemoianu says, such as lupus or multiple sclerosis.

Renal or hepatic failure. Failure of internal organs including the kidneys or liver can also induce psychosis because the body can’t remove toxins that sometimes can affect how the brain functions.

Autism. People with autism spectrum disorder are at higher risk of developing psychosis.

Drugs and medications.

“The other big category that can cause psychotic symptoms are adverse reactions to prescription medication or the effects of drug use,” Nemoianu says. “In particular stimulants like methamphetamines or cocaine,” can trigger psychotic episodes, “although other things like cannabis can also lead to psychotic symptoms.” Therefore, it’s important to “assess whether that’s present or if someone has recently started a drug that has a known risk of causing psychotic symptoms. A commonly used one is the steroid medication prednisone, which is an anti-inflammatory used for a variety of medical conditions, but depending on the individual and the dose used it can lead to psychotic symptoms,” he explains.

As frightening as this psychotic split with reality can be, there are ways of resolving it by treating the underlying medical condition that’s causing it. At the first signs of psychosis, called early or first-episode psychosis, you should seek medical attention. “Acting quickly to connect a person with the right treatment during early psychosis or FEP can be life-changing and radically alter that person’s future,” NAMI reports.

What Is Schizophrenia?

By comparison, schizophrenia is a mental illness. Psychosis is a hallmark symptom of schizophrenia. But schizophrenia has other symptoms as well. Symptoms of schizophrenia include:

Hallucinations.Delusions.Paranoia.Unusual or agitated movements or aimless activity.Difficulty making decisions.Loss of focus or attention.Disorganized thinking or memory lapses.Negative symptoms such as a loss of emotional expression or a loss of motivation and ability to complete tasks and withdrawing from social situations.

“Schizophrenia is one type of psychiatric condition that can cause psychosis,” Tam says. “It is persistent for a significant period of time, by definition at least six months, and causes changes in a person’s daily functioning. It differs from psychosis associated with other conditions due to symptoms or findings associated with those illnesses.”

Nemoianu adds that “in order to meet the diagnostic criteria set out by the American Psychiatric Association for schizophrenia, a person has to have at least two or more symptoms that include delusions or hallucinations, disorganized speech, disorganized behavior and what we call negative symptoms. Examples of negative symptoms would be diminished emotional expression, decreased interest and motivation.” Those symptoms must also be associated with “what we call a decline in functioning,” so loss of ability to work or attend school and a loss of ability to socialize or an impact on relationships. “To meet the definition of schizophrenia, the whole disorder has to be present for at least six months,” he says.

In addition, “the physician has to make the determination that the symptoms are not attributable to either the effects of a substance – either a prescribed medication or a recreational drug – or another medical condition that can cause similar symptoms or a different mental disorder that can also cause psychotic symptoms such as depression or bipolar disorder.”

Making the diagnosis isn’t always a straightforward proposition. Sometimes it takes a while to get there because schizophrenia can be quite heterogeneous, meaning that it can manifest differently in different people.

What Should You Do If You or a Loved One Is Experiencing Psychosis?

“If someone is experiencing psychotic symptoms, it is very important to seek medical attention. Doctors can carefully evaluate for different causes and implement the appropriate intervention or referral,” Tam says.

Moe agrees. “If you or someone you know is experiencing psychosis, seek care.” Particularly when symptoms become “interfering – either it’s scary, confusing, or distressing to the person,” you should seek care, Moe says.

The NIMH notes that despite the common myth that a person with psychotic symptoms is dangerous, the fact is, "it is more likely these people will harm themselves than someone else. It is important to help a person with psychotic symptoms get treatment as quickly as possible."

If the situation is dire or symptoms are very severe, seek emergency care. For concerns that aren’t emergent or a crisis, “I think always a reasonable first step is to call a primary care provider and get guidance whether they want to see the patient in clinic first or want to refer directly to another service or mental health services,” Nemoianu says. “The exception to that would be if the individual is exhibiting behavior that suggests they’re a risk to themselves or others or their well-being is at imminent risk,” in which case you should seek emergency care.

Seeking that care sometimes isn’t originated by the person experiencing the psychosis, but rather others around them. “Sometimes people who develop psychiatric conditions with psychosis have some impaired insight, that’s actually part of the illness,” Moe says. And because mental illnesses such as schizophrenia that feature psychosis often get their start in adolescence or young adulthood, “it’s important that if family members or loved ones notice changes,” in a loved one’s mental state “that concerned family members reach out and consult with family doctors or other health care providers.” Despite the lingering stigma surrounding mental health issues, it’s important to “reach out to a mental health provider,” if you have concerns.

Because so many different conditions and factors can lead to symptoms of psychosis, “that’s why people need a full medical evaluation, which includes a careful history and a physical exam and in some cases lab testing and imaging to land on a diagnosis of schizophrenia as opposed to other medical conditions,” Nemoianu says. Once an accurate diagnosis is made, appropriate treatment can be started.

And Moe emphasizes that treatment is available for most of the conditions that can trigger psychosis, but specifically for schizophrenia. “There are good, evidence-based treatments that really help people recover and get back into their lives in a way that oftentimes people don’t know are out there.”

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