psychosis case study quizlet

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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Two key brain systems are central to psychosis, Stanford Medicine-led study finds

When the brain has trouble filtering incoming information and predicting what’s likely to happen, psychosis can result, Stanford Medicine-led research shows.

April 11, 2024 - By Erin Digitale

People with psychosis have trouble filtering relevant information (mesh funnel) and predicting rewarding events (broken crystal ball), creating a complex inner world. Emily Moskal

Inside the brains of people with psychosis, two key systems are malfunctioning: a “filter” that directs attention toward important external events and internal thoughts, and a “predictor” composed of pathways that anticipate rewards.

Dysfunction of these systems makes it difficult to know what’s real, manifesting as hallucinations and delusions. 

The findings come from a Stanford Medicine-led study , published April 11 in  Molecular Psychiatry , that used brain scan data from children, teens and young adults with psychosis. The results confirm an existing theory of how breaks with reality occur.

“This work provides a good model for understanding the development and progression of schizophrenia, which is a challenging problem,” said lead author  Kaustubh Supekar , PhD, clinical associate professor of psychiatry and behavioral sciences.

The findings, observed in individuals with a rare genetic disease called 22q11.2 deletion syndrome who experience psychosis as well as in those with psychosis of unknown origin, advance scientists’ understanding of the underlying brain mechanisms and theoretical frameworks related to psychosis.

During psychosis, patients experience hallucinations, such as hearing voices, and hold delusional beliefs, such as thinking that people who are not real exist. Psychosis can occur on its own and isa hallmark of certain serious mental illnesses, including bipolar disorder and schizophrenia. Schizophrenia is also characterized by social withdrawal, disorganized thinking and speech, and a reduction in energy and motivation.

It is challenging to study how schizophrenia begins in the brain. The condition usually emerges in teens or young adults, most of whom soon begin taking antipsychotic medications to ease their symptoms. When researchers analyze brain scans from people with established schizophrenia, they cannot distinguish the effects of the disease from the effects of the medications. They also do not know how schizophrenia changes the brain as the disease progresses. 

To get an early view of the disease process, the Stanford Medicine team studied young people aged 6 to 39 with 22q11.2 deletion syndrome, a genetic condition with a 30% risk for psychosis, schizophrenia or both. 

Kaustubh Supekar

Brain function in 22q11.2 patients who have psychosis is similar to that in people with psychosis of unknown origin, they found. And these brain patterns matched what the researchers had previously theorized was generating psychosis symptoms.

“The brain patterns we identified support our theoretical models of how cognitive control systems malfunction in psychosis,” said senior study author  Vinod Menon , PhD, the Rachael L. and Walter F. Nichols, MD, Professor; a professor of psychiatry and behavioral sciences; and director of the  Stanford Cognitive and Systems Neuroscience Laboratory .

Thoughts that are not linked to reality can capture the brain’s cognitive control networks, he said. “This process derails the normal functioning of cognitive control, allowing intrusive thoughts to dominate, culminating in symptoms we recognize as psychosis.”

Cerebral sorting  

Normally, the brain’s cognitive filtering system — aka the salience network — works behind the scenes to selectively direct our attention to important internal thoughts and external events. With its help, we can dismiss irrational thoughts and unimportant events and focus on what’s real and meaningful to us, such as paying attention to traffic so we avoid a collision.

The ventral striatum, a small brain region, and associated brain pathways driven by dopamine, play an important role in predicting what will be rewarding or important. 

For the study, the researchers assembled as much functional MRI brain-scan data as possible from young people with 22q11.2 deletion syndrome, totaling 101 individuals scanned at three different universities. (The study also included brain scans from several comparison groups without 22q11.2 deletion syndrome: 120 people with early idiopathic psychosis, 101 people with autism, 123 with attention deficit/hyperactivity disorder and 411 healthy controls.) 

The genetic condition, characterized by deletion of part of the 22nd chromosome, affects 1 in every 2,000 to 4,000 people. In addition to the 30% risk of schizophrenia or psychosis, people with the syndrome can also have autism or attention deficit hyperactivity disorder, which is why these conditions were included in the comparison groups.

The researchers used a type of machine learning algorithm called a spatiotemporal deep neural network to characterize patterns of brain function in all patients with 22q11.2 deletion syndrome compared with healthy subjects. With a cohort of patients whose brains were scanned at the University of California, Los Angeles, they developed an algorithmic model that distinguished brain scans from people with 22q11.2 deletion syndrome versus those without it. The model predicted the syndrome with greater than 94% accuracy. They validated the model in additional groups of people with or without the genetic syndrome who had received brain scans at UC Davis and Pontificia Universidad Católica de Chile, showing that in these independent groups, the model sorted brain scans with 84% to 90% accuracy.

The researchers then used the model to investigate which brain features play the biggest role in psychosis. Prior studies of psychosis had not given consistent results, likely because their sample sizes were too small. 

Vinod Menon

Comparing brain scans from 22q11.2 deletion syndrome patients who had and did not have psychosis, the researchers showed that the brain areas contributing most to psychosis are the anterior insula (a key part of the salience network or “filter”) and the ventral striatum (the “reward predictor”); this was true for different cohorts of patients.

In comparing the brain features of people with 22q11.2 deletion syndrome and psychosis against people with psychosis of unknown origin, the model found significant overlap, indicating that these brain features are characteristic of psychosis in general.

A second mathematical model, trained to distinguish all subjects with 22q11.2 deletion syndrome and psychosis from those who have the genetic syndrome but without psychosis, selected brain scans from people with idiopathic psychosis with 77.5% accuracy, again supporting the idea that the brain’s filtering and predicting centers are key to psychosis.

Furthermore, this model was specific to psychosis: It could not classify people with idiopathic autism or ADHD.

“It was quite exciting to trace our steps back to our initial question — ‘What are the dysfunctional brain systems in schizophrenia?’ — and to discover similar patterns in this context,” Menon said. “At the neural level, the characteristics differentiating individuals with psychosis in 22q11.2 deletion syndrome are mirroring the pathways we’ve pinpointed in schizophrenia. This parallel reinforces our understanding of psychosis as a condition with identifiable and consistent brain signatures.” However, these brain signatures were not seen in people with the genetic syndrome but no psychosis, holding clues to future directions for research, he added.

Applications for treatment or prevention

In addition to supporting the scientists’ theory about how psychosis occurs, the findings have implications for understanding the condition — and possibly preventing it.

“One of my goals is to prevent or delay development of schizophrenia,” Supekar said. The fact that the new findings are consistent with the team’s prior research on which brain centers contribute most to schizophrenia in adults suggests there may be a way to prevent it, he said. “In schizophrenia, by the time of diagnosis, a lot of damage has already occurred in the brain, and it can be very difficult to change the course of the disease.”

“What we saw is that, early on, functional interactions among brain regions within the same brain systems are abnormal,” he added. “The abnormalities do not start when you are in your 20s; they are evident even when you are 7 or 8.”

Our discoveries underscore the importance of approaching people with psychosis with compassion.

The researchers plan to use existing treatments, such as transcranial magnetic stimulation or focused ultrasound, targeted at these brain centers in young people at risk of psychosis, such as those with 22q11.2 deletion syndrome or with two parents who have schizophrenia, to see if they prevent or delay the onset of the condition or lessen symptoms once they appear. 

The results also suggest that using functional MRI to monitor brain activity at the key centers could help scientists investigate how existing antipsychotic medications are working. 

Although it’s still puzzling why someone becomes untethered from reality — given how risky it seems for one’s well-being — the “how” is now understandable, Supekar said. “From a mechanistic point of view, it makes sense,” he said.

“Our discoveries underscore the importance of approaching people with psychosis with compassion,” Menon said, adding that his team hopes their work not only advances scientific understanding but also inspires a cultural shift toward empathy and support for those experiencing psychosis. 

“I recently had the privilege of engaging with individuals from our department’s early psychosis treatment group,” he said. “Their message was a clear and powerful: ‘We share more similarities than differences. Like anyone, we experience our own highs and lows.’ Their words were a heartfelt appeal for greater empathy and understanding toward those living with this condition. It was a call to view psychosis through a lens of empathy and solidarity.”

Researchers contributed to the study from UCLA, Clinica Alemana Universidad del Desarrollo, Pontificia Universidad Católica de Chile, the University of Oxford and UC Davis.

The study was funded by the Stanford Maternal and Child Health Research Institute’s Uytengsu-Hamilton 22q11 Neuropsychiatry Research Program, FONDEYCT (the National Fund for Scientific and Technological Development of the government of Chile), ANID-Chile (the Chilean National Agency for Research and Development) and the U.S. National Institutes of Health (grants AG072114, MH121069, MH085953 and MH101779).

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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• Schizophrenia

Psychosis: Causes, Symptoms, and Treatment

What Is Psychosis?

Psychosis affects the way your brain processes information. It causes you to lose touch with reality. You might see, hear, or believe things that aren’t real. Psychosis is a symptom, not an illness. It can be triggered by a mental illness, a physical injury or illness, substance abuse, or extreme stress or trauma.

Psychotic disorders, like schizophrenia, involve psychosis that usually affects you for the first time in the late teen years or early adulthood. Even before what doctors call the first episode of psychosis (FEP), you may show slight changes in the way you act or think. This is called the prodromal period and could last days, weeks, months, or even years.

Sometimes you can lose touch with reality even when you don’t have a primary psychotic illness such as schizophrenia or bipolar disorder. When this happens, it's called secondary psychosis.

These episodes stem from something else, like drug use or a medical condition. Whatever the reason, they tend to disappear in a short time, and they often stay away if you treat the condition that caused them.

Who gets psychosis?

Young people are especially likely to get it, but doctors don’t know why. It most often starts when you're in your teens to late 20s. But it can also affect older people and, rarely, children.

How common is psychosis?

It's hard to know exactly how common psychosis is. Studies have shown that it affects from 15 to 100 out of every 100,000 people each year.

Psychosis vs. schizophrenia

Psychosis is a symptom of schizophrenia, a complicated mental illness that also has other symptoms. Psychosis can also be a symptom of other conditions, such as serious depression. 

Psychosis vs. neurosis

Doctors used to use the term "neurosis" to describe what they now call anxiety disorders. Symptoms of these disorders may include obsessive thoughts, irrational fears, or compulsive behaviors. But unlike psychosis, they don't involve losing touch with reality.

Symptoms of Psychosis

Psychosis doesn’t start suddenly. It usually follows a pattern.

Warning signs before psychosis

It starts with gradual changes in the way you think about and understand the world. You or your friends or family members may notice:

• A drop in grades or job performance
• Trouble thinking clearly or concentrating
• Suspiciousness or unease around others
• Lack of self-care or hygiene
• Spending more time alone than usual
• Stronger emotions than situations call for
• No emotions at all

Signs of early psychosis

• Hear, see, or taste things others don’t
• Hang on to unusual beliefs or thoughts, no matter what others say
• Pull away from family and friends
• Stop taking care of yourself
• Not be able to think clearly or pay attention

What does a psychotic episode look like?

Usually you’ll notice all of the above psychosis symptoms, including:

Hallucinations. These could be:

• Auditory hallucinations: Hearing voices when no one is around
• Tactile hallucinations: Strange sensations or feelings you can’t explain
• Visual hallucinations : You see people or things that aren’t there, or you think the shape of things looks wrong.
• Olfactory hallucinations: You smell odors no one else can.

Gustatory hallucinations: You taste things when there's nothing in your mouth.

Delusions: Beliefs that aren’t in line with your culture and that don’t make sense to others, like:

• Outside forces are in control of your feelings and actions.
• Small events or comments have huge meaning.
• You have special powers, are on a special mission, or actually are a god.

You might have persecutory delusions, in which you think a person or group of people wants to harm you. Or you could have grandiose delusions , in which you believe you are all-powerful or in a position of authority. Religious delusions, sometimes called spiritual psychosis , center on spiritual or religious themes.

Unstable thought patterns could cause outward symptoms, like:

• Suddenly losing your train of thought, in conversation or while doing a task
• Speaking quickly
• Talking constantly

Can you be aware of your own psychosis?

Often, people with psychosis don't know it . Your hallucinations and delusions may seem very real to you.

3 Stages of Psychosis

Experts say there are three stages of psychotic episodes. What each stage looks like and how long it lasts will vary from person to person.

In this stage, you have mild changes in your thoughts and moods that tend to come on gradually. They might include:

• Trouble sleeping
• Loss of concentration and motivation
• Avoiding friends and family members
• Suspiciousness and strange beliefs

This is when you have typical symptoms of psychosis, like:

• Hallucinations
• Behavior and personality changes

These changes may be apparent to others around you.

While some of your symptoms may remain for a while, they eventually go away, allowing you to return your usual daily routines. Most people recover if they get the right treatment. You may never have another psychotic episode.

Psychosis Types

Along with secondary psychosis and psychosis due to a mental illness, you might hear about these types:

Postpartum psychosis

This is a rare but serious type of postpartum depression that can happen from a few days to a few weeks after you give birth. It's more likely to affect those who already have a condition like schizophrenia or bipolar disorder. Doctors aren't sure what causes it, but they think sleep loss, hormone changes, and your genes could play a role.

Along with hallucinations and delusions, you could have mood changes like sadness and/or joy. If you or someone you know has these symptoms, seek medical help right away. 

Bipolar psychosis

About half of people with bipolar disorder sometimes have delusions and/or hallucinations, usually when they're in a state of mania (a period of high energy and mood). Treatments include antipsychotic drugs and electroconvulsive therapy (ECT), which involves passing mild electric currents through the brain. 

Postictal psychosis (PIP)  

This happens in some people with epilepsy who've had a number of seizures in a row. It's more likely when you've had a seizure disorder for a long time or you've had mental illness in the past.

Antipsychotic drugs like olanzapine and risperidone can stop symptoms and may help prevent future episodes.

Myxedematous psychosis (also called myxedema psychosis)

You can get this when your thyroid gland doesn't work well, a condition known as hypothyroidism. Because of the way thyroid hormone affects your brain, you may have hallucinations, delusions, and changes to your sense of taste or smell if there's not enough in your body. Your doctor can test your level of thyroid-stimulating hormone (TSH) to confirm myxedema psychosis and rule out other conditions like schizophrenia.

Taking thyroid hormone can help balance your gland's activity and end the psychosis.

Korsakoff psychosis

This is a complication of a condition called Wernicke encephalopathy, a brain disorder caused by a shortage of vitamin B1 that most often affects those who have alcohol use disorder. 

Along with serious memory problems, it can cause disorientation and emotional changes. You may tell false or confused stories when you can't remember what really happened.

It's treated by restoring your levels of B1 along with good nutrition and hydration.

Menstrual psychosis

This extremely rare type of psychosis can appear at the beginning of your period, around ovulation, or during the few days before your period starts. It happens because out-of-balance hormones at different points in your cycle can affect thinking and moods. It may show up quickly and disappear just as fast. During the episodes, you may be confused about what's real, hallucinate, and believe things that aren't true. 

Cognitive behavioral therapy (CBT) and antipsychotic drugs can help ward off symptoms, even with hormone levels that are hard to predict.

Causes of Psychosis

Doctors don’t know exactly what causes psychosis. Genes are thought to play a role, but they don't in every case.

What can trigger a psychotic episode?

In general, you develop psychosis due to a mental or physical condition, alcohol or drug use, or a traumatic event.

Psychological causes . Along with schizophrenia and bipolar disorder, serious stress, anxiety, or depression can trigger a psychotic episode. Serious sleep loss could also be a cause. 

Trauma. The death of a loved one, a sexual assault, or war can lead to psychosis. The type of trauma and the age you were when it happened also play a role.

Medical conditions. Besides epilepsy and thyroid problems, illnesses and injuries that can bring on psychosis include:

• Traumatic brain injuries
• Brain tumors
• Parkinson’s disease
• Alzheimer’s disease
• HIV and AIDS
• Multiple sclerosis
• Low blood sugar (hypoglycemia)

Drug-induced psychosis. Both drugs that depress the nervous system, like cannabis (marijuana), and stimulant drugs, like cocaine and amphetamines, can affect your brain activity in dramatic ways, so that what seems real to you doesn't match with the world. Some prescription medications can also lead to psychosis.

Most of the time, this goes away when you stop using the drug. But there’s a strong link between all these drugs and primary psychosis. More than 25% of those who are diagnosed with amphetamine-induced psychosis later have psychotic disorders . Cannabis is involved in roughly half of all cases.

Studies suggest that these drugs may not so much cause psychosis as uncover the condition when it’s already present among people with psychiatric conditions, such as schizophrenic disorders or a family history of psychosis.

If you've been using a drug for a while, you could also have psychotic symptoms when you suddenly stop taking it.

Drugs used to treat mental illness can lead to problems as well. Although it’s rare, if you've been taking an antipsychotic (such as chlorpromazine, fluphenazine, haloperidol, perphenazine, and others) for many months or years, you could develop a movement disorder call tardive dyskinesia because of the long-term effects of the medication on your brain.

And if you stop taking an antipsychotic medicine, you may get supersensitivity psychosis. Doctors think it happens because ongoing use of this type of drug changes how your brain responds to the chemical dopamine. The use of some antipsychotic medications, like aripiprazole (Abilify), carries a higher risk of psychosis.

Most drug-triggered symptoms will clear up after the drug leaves your system. But psychosis from cocaine, PCP (phencyclidine, or "angel dust"), and amphetamines could last for weeks. While you wait for the episode to pass, your doctor can ease the symptoms with an anti-anxiety drug such as lorazepam (Ativan) or maybe an antipsychotic.

Alcohol-induced psychosis. You can get delusions or hallucinations when you're intoxicated on alcohol, suddenly stop using alcohol, or have long-term alcoholism . Your doctor can treat you with antipsychotics or other medications. If you're able to stop using alcohol, your psychosis symptoms probably won't come back.

When to See a Doctor

If you have any psychosis symptoms or notice psychotic behavior in someone around you, contact a doctor or mental health professional right away. The sooner you get treatment, the more effective it's likely to be.

Keep in mind that those with psychosis often don't recognize that they're having symptoms.

Psychosis Diagnosis

You can see a psychologist, psychiatrist, or a social worker. They’ll find out what might have caused your symptoms and look for related conditions. They may do drug screening tests as well as blood tests to look for physical causes. Doctors diagnose mental illnesses after ruling out other things that could be causing psychotic symptoms.

Psychosis tests

There aren't any tests your doctor can use to diagnosis psychosis. Instead, they'll ask you several questions, such as:

• If any mental health conditions run in your family
• Whether you take any medications or use illegal drugs
• What kind of moods you've had lately
• How well you're able to do your usual activities
• If you've had hallucinations or delusions, what they were like

Psychosis Complications

When you have psychosis, you may not be able to care for yourself or do the things you normally do. Some people develop substance use disorders when they use drugs or alcohol to try to deal with their symptoms.

People with psychosis have a higher risk of self-harm and suicide. If you're thinking of hurting yourself, or know someone who is, call or text 988 or chat 988lifeline.org .

Psychosis Treatment

It’s important to get treated early, after the first episode of psychosis. That will help keep the symptoms from affecting your relationships, job, or schoolwork. It may also help you avoid more problems down the road.

Medical treatment

Your doctor may recommend coordinated specialty care (CSC). This is a team approach to treating schizophrenia when the first symptoms appear. The family is involved as much as possible.

The psychosis treatment your doctor recommends will depend on the cause of your psychosis.

Your doctor will prescribe antipsychotic drugs – in pills, liquids, or shots – to ease your symptoms. They’ll also suggest you avoid using drugs and alcohol.

Inpatient care

You might need to get treated in a hospital if you’re at risk of harming yourself or others, or if you can't control your behavior or do your daily activities. The doctor will check your symptoms, look for causes, and suggest the best treatment for you.

Some clinics and programs offer help just for young people.

Counseling, along with medicines, can also help manage psychosis.

• Cognitive behavioral therapy(CBT) can help you recognize when you have psychotic episodes. It also helps you figure out whether what you see and hear is real or imagined. This kind of therapy also stresses the importance of antipsychotic medications and sticking with your treatment.
• Supportive psychotherapy helps you learn to live with and manage psychosis. It also teaches healthy ways of thinking.
• Cognitive enhancement therapy (CET) uses computer exercises and group work to help you think and understand better.
• Family psychoeducation and support involves your loved ones. It helps you bond and improves the way you solve problems together.
• Coordinated specialty care (CSC) creates a team approach in treating psychosis when it’s first diagnosed. CSC combines medication and psychotherapy with social services and work and education support.

When you have psychosis, you have a hard time understanding what's real and what's not. Many things can cause it, including physical and mental illnesses and substance abuse. Treatment, especially when you get it early in the process, can be very effective.

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Article contents

Cognitive behavior therapy for psychosis (cbtp).

• Anthony P. Morrison Anthony P. Morrison University of Manchester
•  and  Lisa J. Wood Lisa J. Wood North East London Foundation Trust, National Health Service
• https://doi.org/10.1093/acrefore/9780190236557.013.329
• Published online: 22 November 2023

Cognitive behavior therapy (CBT) is an evidence-based psychological therapy that has been shown to have small to medium effects in improving outcomes for people experiencing psychosis. CBT’s theoretical model, drawing together cognitive and behavioral theories, outlines that it is the appraisal and response to an event which maintains distress rather than the event itself. CBT for psychosis (CBTp) specifically aims to modify appraisals and responses to psychotic experiences in order to reduce distress. CBTp has a substantial evidence base and is the most frequently offered psychological treatment for psychosis. There have been significant advancements in the field, with process-oriented therapies and digital interventions showing promise; however, more large-scale trials are required. Moreover, service users report positive experiences with CBTp and value the normalizing therapeutic relationship, improved personal understanding, and acquisition of new coping strategies. Improving dissemination and adapting CBTp so that it is appropriate for all populations is an ongoing priority for future research. Moreover, the evidence base requires more user-centered research to ensure CBTp is meeting the needs of service users.

• cognitive behavior therapy
• schizophrenia

Origins and Development of Cognitive Behavioral Models of Psychosis

Psychosis comprises experiences such as hearing voices or seeing things that others do not, strongly held beliefs that others do not share, and difficulty with thinking and concentration ( British Psychological Society, 2017 ). People who experience psychosis are often diagnosed with a psychotic disorder which includes schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder ( National Institute of Clinical Excellence [NICE], 2014 ). Psychosis has the potential to be an extremely debilitating mental health difficulty, which can significantly impact on a person’s functioning and quality of life ( Yi Chong et al., 2016 ). The typical onset for psychosis is between the age of 14 and 35 years, with a high likelihood of further episodes throughout life ( Di Capite et al., 2018 ).

Cognitive behavior therapy (CBT) is an evidenced-based formulation-driven psychological therapy which aims to reduce emotional distress and improve functioning by targeting underlying cognitions and behaviors ( Beck, 1979 , 2005 ). CBT was developed by Aaron Beck, drawing upon existing behavioral and cognitive theories. CBT is based on the premise that it is the way a person makes sense of an event which is important rather than the event itself and that emotional distress occurs when a person’s interpretation of an event is excessively threatening and disproportionate ( Mander & Kingdon, 2015 ). CBT theory states that cognitions, behaviors, emotions, and physiology are interdependent and collectively contribute to the development and maintenance of emotional distress ( Beck, 2005 ).

CBT was first applied to psychosis in 1952 by Beck, who undertook a case study of CBT aiming to treat a veteran’s delusional beliefs ( Beck, 1952 ). However, this early work did not instantly lead to the development of CBT for psychosis (CBTp), as Beck’s initial body of work prioritized developing CBT for depression and anxiety. Manualized CBT approaches for anxiety and depression emerged in the 1970s whereas manualized approaches for psychosis developed later in the 1990s ( Beck, 2005 ). One of the reasons for this delay was due to the medicalized conceptualization of psychotic symptoms and perceptions that they are fixed and less susceptible to change ( Mander & Kingdon, 2015 ). However, evidence was forming to demonstrate that psychosis was not a permanent medical disorder but an experience that was on the continuum of normal experience and modifiable. As a result, the CBTp model evolved and a number of theories were established ( Fowler et al., 1995 ; Freeman & Garety, 1999 ; Garety et al., 2001 ; Morrison, 2001 ). Early forms of CBTp primarily prioritized behavioral strategies to affect change, such as coping strategy enhancement ( Tarrier et al., 1990 ), with cognitive strategies as secondary ( Tai & Turkington, 2009 ). However, as the evidence has progressed, the equal importance of cognitive strategies in CBTp was recognized. Currently, the CBTp model assumes that adverse life events in childhood lead to the development of underlying core beliefs about the self, the world, and others and that psychosis is maintained through threat-based cognitions, behaviors, emotions, and physiological responses ( Morrison, 2001 ). Two influential CBTp models describing this process are discussed in more detail here.

Figure 1. Garety et al. (2007) cognitive model of psychosis.

Garety (2001) developed a model to explain the development and maintenance of psychosis, which is outlined in Figure 1 . The model outlines that people who experience psychosis have a vulnerable disposition (a biopsychosocial vulnerability) and develop psychosis within the context of adverse environments, illicit drug use, and stressful life events. Once a triggering event is present, psychosis can develop via two proximal routes: one via cognitive and emotional change and the other through affective disturbances alone. The first route is more common. This leads the individual to appraise experiences as external (i.e., as more threatening and uncontrollable) and develop positive symptoms of psychosis. The model outlines that the development of psychotic symptoms is influenced by underlying reasoning and attribution biases, dysfunctional schemas of the self and world, isolation, and adverse environments. Garety (2001) emphasized that the different types of reasoning and attribution biases impact on the development and maintenance of psychosis. She explained that people with psychosis are likely to jump to conclusions more quickly, believe that internal events have an external cause, and have little flexibility in their beliefs ( Garety, 2001 ).

Another CBTp model was developed by Morrison (2001) . This model emphasized that it is the culturally unacceptable interpretations or appraisals of events which are key to the development and maintenance of psychosis. For example, if someone had palpitations and believed they were having a panic attack, they would more likely present with panic disorder, but if they interpreted the palpitations as caused by someone who had attempted to drug and kill them, they would present with psychosis. It is these culturally unacceptable interpretations that distinguish psychosis from other mental health difficulties. The nature of the culturally unacceptable interpretations is determined by a combination of personal experiences, beliefs, and knowledge. These culturally unacceptable (i.e., psychotic) interpretations are then maintained by safety-seeking behaviors and other responses, faulty self-knowledge (including metacognition) and social knowledge, negative mood, and physiology. This model is outlined in Figure 2 .

Figure 2. Morrison (2001) cognitive model of psychosis.

Since the development of these models, symptom-specific approaches have also emerged, which focus on particular symptoms of psychosis ( Birchwood et al., 2014 ; Freeman et al., 2015 ; Palmier-Claus et al., 2017 ; Thomson et al., 2017 ). Birchwood and colleagues developed a model which specifically targeted command hallucinations ( Birchwood et al., 2014 ). This model outlines that it is the belief that an auditory hallucination is malevolent and powerful along with compliance behaviors that can cause and maintain command hallucinations. The approach aims to reduce compliance and reevaluate appraisals to reduce distress. A CBT model for visual hallucinations has also been developed ( Thomson et al., 2017 ). This model aims to target the appraisals and safety behaviors maintaining the visual hallucination to reduce the frequency and related distress ( Dudley et al., 2012 ). Freeman and colleagues developed a modularized approach for working with persecutory delusions ( Freeman, 2015 ; Freeman et al., 2021 ). This approach asserts that there are six key psychological mechanisms that cause and maintain persecutory delusions, which include worry, negative self-belief, anomalous experiences, sleep dysfunction, reasoning biases, and safety behaviors. This modularized approach attempts to reduce these maintenance factors, reduce the frequency and distress of persecutory delusions, and increase an individual’s sense of safety. Other approaches are also emerging for other symptoms such as negative symptoms ( Staring et al., 2013 ) and thought disorder ( Palmier-Claus et al., 2017 ). Therapeutic approaches to treat posttraumatic stress disorder symptoms in psychosis have also been developed ( Peters et al., 2020 ; Steel et al., 2017 ).

Outlines of Treatment

Although there are many different approaches and intervention protocols that fall under the umbrella of CBTp, there are many commonalities. The treatment begins with a cognitive-behavioral assessment that usually would include a brief history taking as well as a focus on current difficulties, examining relevant thoughts, feelings, and behavior. A problem list would be collaboratively generated, and one or more goals would be identified. This information would commonly be used to develop a formulation, which may focus on maintenance factors for a specific problem, such as hearing distressing voices, or a developmental formulation that focuses on the relationship between past experience, beliefs formed as a result, and current difficulties. The format of the formulation would usually be based on one of the specific development or maintenance models already described; however, some of the treatment protocols are not formulation driven and may apply specific change strategies in a more rigid manner (e.g., coping strategy enhancement). The change strategies in formulation-driven CBTp are selected on the basis of the formulation and include both cognitive and behavioral strategies. Cognitive strategies include consideration of alternative explanations and advantages and disadvantages of appraisals, evidential analysis, schema change strategies, imagery modification, and problem-solving. Behavioral strategies include behavioral experiments (often testing the usefulness of safety-seeking behaviors), activity scheduling, graded exposure, and skills practice. Normalization and psychoeducation regarding psychotic experiences are also commonly involved. The use of specific strategies would be emphasized to a greater or lesser degree, depending on the specific model, treatment targets, and manual. Most approaches to CBTp would also incorporate an element of summarizing progress within therapy, consolidating treatment gains, staying well, and relapse prevention. Most approaches would also emphasize the importance of principles such as collaboration and between session or homework tasks. The duration of CBTp and the frequency and format of sessions is variable, but the National Institute of Clinical Excellence guidelines recommends a minimum of 16 sessions along with individual delivery (rather than group) and use of a manualized treatment. A Delphi study has highlighted consensus among expert CBTp practitioners regarding essential elements and important principles ( Morrison & Barratt, 2010 ). A competency framework distilled from the manuals used within the clinical trials has also been developed in order to specify the skills, knowledge, and experience that are required to deliver CBTp ( Roth & Pilling, 2012 ).

Efficacy and Evidence

The evidence base for CBTp has grown extensively over the past 25 years and there are now over 60 randomized controlled trials (RCTs) which have examined its efficacy ( Hardy, 2021 ). There is consensus that CBTp is an effective treatment on a number of key outcomes and has small to medium effect sizes ( Bighelli et al., 2018 ; Wykes et al., 2008 ). This was also identified in a recent systematic review which examined individual patient data across 23 RCTs ( Turner et al., 2020 ). Overall, systematic reviews of CBTp have shown small to moderate effects on a number of important outcomes, including a reduction in overall symptoms of psychosis, positive symptoms (auditory hallucinations and delusions), functioning, mood, social anxiety, and negative symptoms at the end of therapy and at follow-up ( Bighelli et al., 2018 ; Health Quality Ontario, 2018 ; Wykes et al., 2008 ). However, other systematic reviews have not shown any benefit of CBTp over other active control interventions ( Jones et al., 2012 ). Two reviews found that CBTp was not favorable over other psychosocial therapies on the outcomes of relapse, rehospitalization, quality of life, positive or negative symptoms, or social functioning ( Jones et al., 2012 ; Laws et al., 2018 ). Jones et al. (2012) also identified only limited evidence for longer-term impacts of CBTp on affective symptoms such as depression. However, one of these reviews has been criticized for a number of methodological flaws, including analyzing incorrect time point data and the arbitrary separation of interventions into small, medium, and long-term ( Hutton et al., 2013 ). As a result, it is generally accepted that CBTp is an effective intervention for psychosis with small to medium effect sizes on psychotic symptomology, particularly positive symptoms ( Bighelli et al., 2018 ).

In terms of presentation, the evidence for CBTp has been demonstrated that it has more effect in high-risk and first episode groups than those with more severe and enduring presentations. For example, van der Gaag et al. (2013) conducted a systematic review and demonstrated that the risk of developing a first episode of psychosis was reduced by 54% when CBTp was offered over usual treatments. Developments in the evidence base have demonstrated that CBTp is a feasible and acceptable treatment in comparison to antipsychotic medication in a first episode sample ( Morrison et al., 2020 ). Previous research has usually offered CBTp to samples already taking antipsychotic medication and a head-to-head comparison had never previously been completed. Thus, this study provides initial evidence that CBTp may be a useful alternative to medication, but further research is required. Most recently, there is evidence that modularized approaches to CBTp are beneficial. The feeling safe program, a modularized approach to persecutory delusions, has demonstrated to have moderate effects on persecutory beliefs compared to an active control ( Freeman et al., 2021 ).

As a result of this extensive body of research, CBTp is recommended as the first line of psychological intervention for psychosis in U.K. and U.S. clinical guidelines ( Keepers et al., 2020 ; NICE, 2014 ).

Relapse Prevention

Relapse rates are high for people experiencing psychosis. It is estimated that 80%–90% of people who have experienced a first episode of psychosis go on to experience a relapse in their psychosis, leaving a large proportion of people at risk of relapse ( Emsley et al., 2013 ). In a longitudinal observational study following up with people after their first episodes of psychosis, 32.8% had relapsed after 12 months, 53.4% at 24 months, and 63.8% at 36 months ( Pereira et al., 2017 ). CBTp can prevent relapse by using change strategies that specifically target relapse-related appraisals and behavior ( Birchwood et al., 2000 ; Gumley et al., 2003 ). Psychoeducation, normalizing, and identifying and targeting early warning signs and relapse appraisals have been demonstrated as strategies integral to relapse prevention CBTp ( Birchwood et al., 2000 ; Gleeson et al., 2009 ; Gumley & Power, 2000 ).

There are a number of randomized controlled trials (RCTs) examining the efficacy of CBTp interventions on relapse-related outcomes, including relapse in psychotic symptoms, rehospitalization, and readmission ( Hutton & Taylor, 2014 ; Wykes et al., 2008 ). However, the evidence base for the efficacy of CBTp to reduce relapse is mixed, with some studies demonstrating that CBTp is not indicated for relapse prevention ( Garety et al., 2008 ). For example, Gleeson et al. (2009) undertook an RCT of relapse prevention CBTp with people experiencing their first episode of psychosis ( Gleeson et al., 2009 , 2013 ). The intervention significantly reduced relapse rates and prolonged the time to relapse when compared to treatment as usual (TAU) in the short-term (at 7 and 12 months) but not at long-term follow-up (18, 24, or 30 months; Gleeson et al., 2013 ). Moreover, Gumley and colleagues examined the efficacy of early intervention CBTp for relapse in schizophrenia and found that the CBTp group had significantly reduced levels of relapse compared to TAU at 12-month follow-up, but not rehospitalization ( Gumley et al., 2003 ). Finally, a large RCT ( n = 301) of relapse focused CBTp was conducted with people who had recently relapsed ( Garety et al., 2008 ). Findings demonstrated that CBTp had no effects on rates of remission, relapse, or number of days in hospital at 12 or 24 months.

There is a wider evidence base of CBTp RCTs (delivering therapy not specifically focused on relapse) examining efficacy on relapse outcomes. A systematic review conducted by Bird et al. (2010) examined the efficacy of CBTp on relapse and hospital admission. The review identified that CBTp for first episode patients had no effect on relapse or readmission rates 2 years after the receipt of the intervention ( Jackson et al., 2019 ; Lecomte et al., 2009 ; Lewis et al., 2002 ). In another large review, CBTp was examined for its efficacy against TAU and an active control on relapse outcomes ( Health Quality Ontario, 2008 ). It was identified that CBTp did not have an effect on relapse or number of days in hospital at the end of treatment compared to TAU ( Baandrup et al., 2016 ). It was also identified that CBTp did not have an effect on relapse (one RCT) or hospitalization (five RCTs) at the end of treatment or at follow-up compared to other psychotherapies ( Jones et al., 2012 ).

Overall, there seems to be limited evidence to support the use of CBTp for relapse prevention in psychosis, even in exclusively early onset populations. If CBTp is to be used for relapse prevention, a specific relapse prevention model should be offered.

Mediating Factors

There are several factors that could influence response to treatment in CBTp, including patient characteristics (e.g., psychological factors, motivation to change, symptom profiles, and current context and life history), therapist factors (e.g., specific skills and competencies and assumptions about psychosis), therapy factors (e.g., number of sessions, use of specific intervention strategies, emphasis on active change and between session tasks, and conceptual model), and interactions of these factors (e.g., a good therapeutic alliance may increase the likelihood of between session task completion).

Some studies have examined patient characteristics by considering baseline variables as predictors of response to CBTp. One study found that, among patients with delusions, the “possibility of being mistaken” (in relation to their delusional belief) was associated with good response to therapy ( Garety et al., 1997 ). Insight at baseline has been shown to be associated with good outcomes in CBTp ( Naeem et al., 2008 ), and another study found that lower levels of conviction at baseline in people with delusional beliefs were associated with good response to CBTp ( Brabban et al., 2009 ). Beck and colleagues conceptualized insight in psychosis as a combination of the ability to reflect on the unusualness of experiences and overconfidence in judgments ( Beck & Warman, 2004 ); higher baseline cognitive insight predicted reduced delusional severity posttreatment ( Perivoliotis et al., 2010 ). Other patient characteristics, including recent hospital admissions ( Garety et al., 1997 ) and severity and type of symptoms ( Tarrier et al., 1998 ), have been shown to be associated with better outcomes, which may relate to motivational issues that could affect engagement in CBTp. Shorter duration of illness has also been shown to be associated with response to CBTp ( Drury et al., 1996a , Drury et al., 1996b ; Morrison et al., 2004 , 2012 ). Finally, female gender has been shown to be associated with better outcomes ( Brabban et al., 2009 ; Drury et al., 1996a , 1996b ).

With regard to therapy and therapist characteristics and their interactions with patient variables, comparatively less research has been conducted. A Delphi study examining expert consensus regarding the essential elements of CBTp found that factors such as homework, an emphasis on active change strategies, and therapist assumptions about psychosis were considered important ( Morrison & Barratt, 2010 ), but there are no studies that systematically relate such factors to treatment response. Studies have shown an incremental beneficial effect of each additional CBTp session ( Morrison et al., 2018 ; Spencer et al., 2018 ). The therapeutic relationship is also related to treatment response in CBTp ( Dunn & Bentall, 2007 ; Goldsmith et al., 2015 ). There is also an indication from a meta-analysis of cognitive therapy for psychosis trials that the incorporation of behavioral elements within interventions may be an important predictor of effect size ( Wykes et al., 2008 ); it is important to note that this does not contradict cognitive mediation of change, as it is generally recognized that behavioral methods are often the best way to evaluate cognition within cognitive therapy for psychosis ( Chadwick & Lowe, 1990 ).

Some studies have examined the effects of therapy on specific cognitive processes that are hypothesized to mediate change. A series of causal interventionist studies by Freeman and colleagues have shown that targeting specific maintenance mechanisms (e.g., sleep, worry, and negative beliefs about self) can lead to changes in these mechanisms and also result in changes in paranoid thinking ( Freeman et al., 2021 ). Changes in cognitive insight have also been associated with improvements in positive and negative symptoms ( Granholm et al., 2005 ). Morrison et al. (2012) found that changes in appraisals of voices and paranoid thinking were related to changes in symptomatic outcomes and social recovery.

Turner et al. (2020) conducted individual participant data meta-analyses exploring the role of patient factors as modifiers of treatment outcome but found no robust demographic (e.g., age, gender, ethnicity, education, employment status) or clinical characteristics (e.g., severity of psychosis, illness duration) modifying outcomes for CBTp, although sensitivity analysis suggested the number of sessions attended was important. A larger, more comprehensive individual participant data meta-analysis is currently being conducted in an attempt to identify treatment effect modifiers ( Sudell et al., 2021 ) but has yet to report findings.

Given the majority of factors found to predict outcome have been in small, underpowered studies and are usually not replicated, very little is known about who is most or least likely to benefit from CBTp. Therefore, the current National Institute of Clinical Excellence guidelines, which recommends that CBTp be offered to all patients who meet criteria for schizophrenia or psychosis, would seem appropriate.

Service User Perspectives

Research examining service user experiences of CBTp has become an integral part of the evidence base, with qualitative studies now embedded in the vast majority of CBTp randomized controlled trials (RCTs). The literature examining service user perspectives of CBTp has grown considerably over the past 15 years, giving insight into the service user experience, including research that has been led by user researchers ( Berry & Hayward, 2011 ; Brabban et al., 2016 ; Wood et al., 2015 ). Overall, there is evidence that service users find CBTp a useful and acceptable therapy. The qualitative literature has outlined that CBTp was helpful in addressing a wide array of issues, including improvements in psychotic symptoms, emotional distress, anxiety, depression, self-esteem and self-concept, and internalized stigma ( Berry & Hayward, 2011 ; Wood et al., 2015 ). Service users found that CBTp helped facilitate personal recovery as it was flexible, could be adapted to meet their goals, and did not just focus on psychotic symptom reduction ( Kilbride et al., 2013 ). Service users found that CBTp helped them develop knowledge on managing experiences of psychosis, understand and accept their psychosis, learn new coping strategies, gain hope and independence, and improve their relationships and general functioning ( Kilbride et al., 2013 ).

Service users have also identified the key components of CBTp that they found most helpful. Across the literature, person-centered engagement was prioritized ( Berry & Hayward, 2011 ; Kilbride et al., 2013 ). A number of studies have found that a strong trusting relationship, based on partnership and collaboration, was key to the delivery of CBTp ( Kilbride et al., 2013 ; Morberg Pain et al., 2008 ). Without this, it was unlikely that the delivery of CBTp would be successful. In addition to a strong therapeutic relationship, the literature outlined that service users valued the opportunity to develop new skills and strategies through a process of structured learning ( Kilbride et al., 2013 ). In particular, service users valued developing a formulation of their difficulties, reappraising and reevaluating thoughts, monitoring their progress, normalizing, and learning about their experiences of psychosis through psychoeducation ( Morberg Pain et al., 2008 ; Wood et al., 2015 ).

Service users have also identified some challenges with undertaking CBTp. Kilbride et al. (2013) identified that CBTp was challenging work as it required motivation and personal agency. CBTp was also emotionally demanding due to discussing emotive and potentially traumatic issues. Other studies have identified that service users felt CBTp had limited gains and did not work when it was offered in coercive conditions or when a shared goal could not be identified ( Kilbride et al., 2013 ; Wood et al., 2015 ). Also, service users identified that CBTp could be difficult on a personal level as it involved being able to acknowledge and discuss personal difficulties, undertake work outside of therapy, and apply new ideas to potentially distressing situations—all of which could be very draining and exhausting ( Wood et al., 2015 ).

Service users have described a number of benefits of CBTp and stressed the importance of a therapeutic relationship. However, it has been acknowledged that there is a gap in the literature from the perspective of those who have dropped out of CBTp or not found therapy helpful ( Wood et al., 2015 ). Further exploration of the adverse effects of CBTp from a service user perspective is also required. There also needs to be more user-led and user-centered design (UCD) in the CBTp field. A study by Hardy et al. (2018) utilized a UCD to adapt a digital CBTp intervention for psychosis, SlowMo, ensuring that service users were central to every stage of the research process. By doing so, they were able to develop an acceptable intervention that met the needs of service users experiencing psychosis. More research utilizing UCDs needs to be undertaken to ensure future CBTp interventions meet the needs of service users.

Process-Oriented Therapies

There has been considerable development in the application of process-oriented therapies, also often referred to as third-wave approaches, to psychosis over the past 15–20 years. All process-oriented therapies incorporate a focus on metacognition which is defined as an awareness of one’s own thought processes and an understanding of the patterns behind them ( Hayes, 2004 ). Rather than focusing on changing psychological events directly, process-oriented interventions seek to change the function of those events and the individual’s relationship to them ( Hayes, 2004 ).

One prominent process-oriented therapy for psychosis is acceptance and commitment therapy (ACT; Hayes et al., 2006 ). ACT is underpinned by relational frame theory and outlines that psychological distress is caused by cognitive entanglement, experiential avoidance, and belief inflexibility which inhibits an individual from living their life in line with core values ( Hayes & Smith, 2005 ). ACT aims to improve a person’s relationship with their thoughts and feelings rather than changing the content of them. It aims to increase psychological flexibility and support a person to live their life in accordance to their values. ACT has been applied to a wide range of populations, and there is a growing evidence base for its effectiveness; however, its application to psychosis is still developing. A recent systematic review identified 11 randomized controlled trials (RCTs) examining ACT for psychosis ( Yildiz, 2020 ). The review did not undertake a meta-analysis but found that a number of individual RCTs uncovered a small to moderate effect for ACT on emotional distress, negative symptoms, depression, and anxiety. There is less evidence for ACT’s effects on psychotic symptoms, with only a handful of studies finding a small effect on psychotic symptoms and the rest reporting mixed findings ( Yildiz, 2020 ).

Compassion-focused therapy (CFT) is an integrated approach drawing upon evolutionary, social, developmental, and Buddhist psychology ( Gilbert, 2010 ). It asserts that all humans have motivational and emotional systems rooted in mammalian heritage ( Heriot-Maitland et al., 2019 ). These systems serve to ensure survival by having basic needs met, helping to forge relationships, and keeping people safe from harm. However, if people have experienced interpersonal trauma or had difficult attachment relationships, these emotion systems can be more sensitive to threat and lead one to experiencing high levels of shame and self-criticism ( Gumley et al., 2010 ). CFT aims to help people cultivate compassionate attributes and skills in order to influence affect regulation ( Gumley et al., 2010 ). It does this by concurrently targeting shame and self-criticism and increasing warmth and compassion through a variety of therapeutic strategies ( Heriot-Maitland et al., 2019 ). CFT has been utilized with psychosis, and there is some evidence of its use with people who hear voices ( Braehler et al., 2013 ; Laithwaite et al., 2009 ; Mayhew & Gilbert, 2008 ). However, the evidence base of CFT for psychosis is still limited despite increasing interest in the approach for psychotic experiences. One feasibility RCT was undertaken to examine the usefulness of CFT for psychosis in a sample of 40 service users ( Braehler et al., 2013 ). They were offered 16 sessions of group CFT, and the trial demonstrated that compared to treatment as usual, the CFT group was associated with greater observed clinical improvement, significant increases in compassion, and significant reductions in depression and social marginalization. It has been postulated that CFT is likely to have good clinical applicability to psychosis, but more research is required ( Heriot-Maitland et al., 2019 ; Tai & Turkington, 2009 ).

Metacognitive therapy (MCT) draws upon the self-regulatory executive function model and asserts that emotional distress occurs as a result of unhelpful metacognitive processes ( Moritz et al., 2011 ). Therefore, it is not the content of one’s thoughts that causes distress but rather the way the thoughts are controlled ( Lysaker et al., 2018 ). For example, unhelpful metacognitive processes include worry and rumination, an attentional focus on threat and negative information, and thought suppression and avoidance. It is by targeting these processes that emotional distress is reduced ( Tai & Turkington, 2009 ). It has been highlighted that unhelpful metacognitive processes are prevalent in people experiencing psychosis ( Sellers et al., 2017 ), and are key to development and maintenance of psychosis, which is why there has been interest in applying MCT to this presentation ( Lysaker et al., 2018 ). However, similar to other process-oriented therapies, the evidence base for MCT in psychosis is limited but developing. A small feasibility study ( n = 10) examined pre-post outcomes following 12 sessions of MCT ( Morrison et al., 2014 ). It found a moderate to large effect on psychotic symptoms at the end of treatment and follow-up ( Morrison et al., 2014 ). It also found that 50% and 40% of participants achieved at least a 25% reduction in psychotic symptoms by the end of therapy and follow-up, respectively. Similar findings were identified in a small ( n = 10) pilot study on ultra-high-risk individuals with moderate to large effect sizes on psychotic-like experiences, anxiety, depression, and functioning ( Parker et al., 2020 ). A larger RCT of MCT for psychosis ( n = 176) has demonstrated that it can improve positive symptoms, cognitive biases, and theory of mind in people with moderate to severe psychosis ( Schneider et al., 2018 ). Another study has also shown that the effects of MCT on delusions are maintained over a follow-up period ( Liu et al., 2018 ).

Mindfulness is described as the process of being able to intentionally and nonjudgmentally pay attention and be in the present moment ( Kabat-Zinn, 2003 ). This practice stems from the Buddhist religion where mindfulness meditation is a key part of practice ( Kabat-Zinn, 2003 ). Mindfulness-based cognitive therapy (MBCT) is the combination of mindfulness practice and cognitive therapy to help cultivate a present-focused nonjudgmental attitude ( MacKenzie & Kocovski, 2016 ). It aims to train the mind to disengage from negative automatic thoughts by being able to notice thoughts rather than getting preoccupied by them ( MacKenzie & Kocovski, 2016 ). Individuals are encouraged to focus their attention on their internal experiences in order to find better ways of relating to difficult thoughts and feelings ( Tai & Turkington, 2009 ). This mindfulness approach has been found to be helpful within the context of psychosis experiences and can help people better manage voices and delusional beliefs ( Khoury et al., 2013 ). Chadwick and colleagues have been prominent in the application of MBCT in psychosis ( Chadwick et al., 2016 ). They undertook a pragmatic RCT of a 12-week group MBCT intervention with n = 108 participants and found that MBCT significantly improved depression, voice hearing, and behavioral disturbance. However, they did not find significant improvement of psychological distress and disturbance.

The evidence base for process-oriented therapies shows some promise; however, further large-scale research is required to definitively determine its effectiveness for psychosis.

Dissemination and Implementation

Despite National Institute of Clinical Excellence (NICE) guidelines (CG155 and CG178) for treatment of psychosis and schizophrenia recommending that treatment options should include CBTp, it is currently very difficult to access ( Schizophrenia Commission, 2012 ), with recent national audit data from the United Kingdom suggesting that 26% of service users have received it ( Royal College of Psychiatrists, 2018 ). This has been the case in all previous national audits of care for schizophrenia and psychosis despite CBTp having been a NICE-recommended intervention since the first NICE guideline was published in 2002 (CG1). CBTp is also excluded from the curriculum for Improving Access to Psychological Therapies Programme (IAPT) ( Clark et al., 2009 ). The recent Schizophrenia Commission executive summary asks: “Why is it that the integrated therapies that work so well in early intervention are not being offered to people throughout the course of their illness?” In addition, it states: “. . . it is unacceptable that only 1 in 10 of those who could benefit get access to true CBT despite it being recommended by NICE.”

There are many barriers to the implementation of CBTp. Berry and Haddock (2010) identified resource constraints, including lack of funding and workforce problems (e.g., not enough clinical psychologists working in secondary care), structural service-related issues (mental health professionals trained in CBTp returning to generic roles where management of risk issues and high caseloads prevent implementation of CBTp and cause difficulties releasing staff for training, as well as limited availability of supervisors), and service culture issues (prioritization of biomedical approaches over psychosocial approaches, insufficient management support resulting in psychological interventions not being given priority, and resistance to change). It is also clear that perceptions regarding relevance and efficacy of CBTp and pessimistic attitudes held by clinicians also contribute to lack of access ( Carter et al., 2017 ; Prytys et al., 2011 ).

There has been significant investment in additional posts and training initiatives in recent years in an attempt to address some of these barriers, but a change in service culture and a challenge to the biomedical dominance of mental health services is likely to be required before access to and provision of CBTp is considered to be as important as antipsychotic medication.

Digital Interventions

The evidence base for CBTp continues to evolve and a significant area of advancement is the application of technology to the delivery of CBTp. The main areas of development include the application of virtual reality (VR), apps, and websites. In terms of VR, it has been applied to a variety of different symptoms of psychosis. Freeman et al. (2016) have used VR cognitive therapy to treat both persecutory delusions and social anxiety by exposing people to their feared situation, testing their belief predictions about what would happen in the situation, and asking them to drop their safety behaviors ( Freeman et al., 2016 ). A large multisite trial of VR for social anxiety is currently being undertaken and will provide definitive evidence of its efficacy ( Freeman et al., 2019 ). VR has also been applied to omnipotent voices. AVATAR is a therapeutic approach underpinned by cognitive therapy principles that develops a digital visual representation of the entity to which the omnipotent voice belongs to ( Craig et al., 2018 ). The aim of the therapy is to facilitate a dialogue between the patient and the avatar in order to reduce distress and gain control. Initial evidence demonstrates that AVATAR is feasible and acceptable and can significantly reduce the frequency, intensity, and omnipotence of the voices ( Craig et al., 2018 ). A large multisite trial is currently ongoing in the United Kingdom, which will provide more definitive evidence.

In terms of apps and websites, several novel CBTp-informed interventions have been developed. Actissist, a CBTp-informed self-directed app, draws upon psychoeducation and self-help to target relapse in early psychosis ( Bucci, Barrowclough, et al., 2018 ). Early evidence demonstrates that it is feasible, acceptable, and safe, and a large multisite trial is currently underway ( Bucci, Barrowclough, et al., 2018 ). Another, HelpID, is a self-directed digital intervention that aims to target depression and positive symptoms in psychosis ( Moritz et al., 2016 ). It incorporates belief testing, psychoeducation, strengthening social relationships, attention strategies, and relapse prevention exercises. A small randomized controlled trial (RCT) demonstrated that the intervention helped reduce depressive symptoms posttreatment compared to a wait-list control ( Moritz et al., 2016 ). An app-assisted CBTp intervention has also been developed for negative symptoms in psychosis and examined in a small feasibility RCT, which was found to have high retention and a reduction of experiential negative symptoms ( Granholm et al., 2020 ). Another app-based intervention is SlowMo, a digital intervention delivered by a trained therapist which targets the “fast thinking” reasoning style, often associated with paranoia ( Garety et al., 2021 ). It aims to increase a person’s awareness of their thinking biases and increase belief flexibility. The app includes psychoeducation, vignettes, games, and strategies to increase belief flexibility. A large multisite trial ( n = 361) was recently conducted but demonstrated that SlowMo did not reduce paranoid thoughts compared to treatment as usual at 24 weeks ( Garety et al., 2021 ).

Service user perspectives on digital interventions for psychosis have identified key facilitators and barriers to the implementation of digital CBTp interventions. A qualitative study conducted by Bucci, Morris, et al. (2018) (with n = 21 early intervention in psychosis service users) identified that digital interventions were progressive, modern, and largely supportive; however, concerns regarding digital exclusion, privacy, and data security were also identified. Advancements in technology may improve access to CBTp across mental health services in the future; however, the evidence base is still developing and further large-scale trials are required.

Future Directions

It is becoming increasingly acknowledged that further work is required to ensure that CBTp is appropriately adapted to meet the needs of certain populations. It is now widely acknowledged that CBTp needs to be more accessible to those from racialised minorities. Some initial work has been undertaken to examine the usefulness of culturally adapted CBTp models, but more is required to ensure that CBTp is culturally competent ( Habib et al., 2015 ; Rathod et al., 2019 ). There is also limited evidence for the usefulness of CBTp for older adults and adolescents. Therefore, further trials of CBTp for these populations are required ( Mander & Kingdon, 2015 ).

Considerable work needs to be undertaken to ensure that CBTp is disseminated and accessible to everyone rather than just to a small percentage of people who currently have access. Further research needs to be undertaken to explore structural barriers and implementation challenges and to identify initiatives to overcome these impediments. For example, CBTp could be delivered as a low-intensity intervention using psychology graduates (i.e., assistant psychologists) to those with less complex needs ( Hayward et al., 2020 ).

In summary, CBTp has a robust evidence base demonstrating small to medium effects in improving outcomes for people with psychosis, particularly positive symptoms ( Bighelli et al., 2018 ). Service users have reported that CBTp is a useful intervention that helps them understand and normalize their experiences of psychosis and find ways to cope, but further research is needed to understand the adverse effects of CBTp. The evidence base for digital CBTp interventions is also emerging and may assist with wider dissemination of CBTp, but further large-scale research is needed to determine its effectiveness. CBTp needs to be suitable and accessible to everyone; therefore, future research needs to explore its usefulness with older people, adolescents, and those from racial minorities.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Alcohol related psychosis.

Holly A. Stankewicz ; John R. Richards ; Philip Salen .

Affiliations

Last Update: July 10, 2023 .

• Continuing Education Activity

Psychosis associated with alcohol can occur with acute intoxication, alcohol withdrawal, and chronic alcoholism. Alcohol-related psychosis is also known as alcohol hallucinosis. Providers must be able to not only recognize and manage patients affected by this condition but must educate patients on ways to prevent alcohol-related psychosis. This activity reviews the evaluation and management of alcohol-related psychosis and highlights the role of the interprofessional team in the recognition and management of this condition.

• Identify the etiology of alcohol-related psychosis.
• Outline the typical presentation of a patient with alcohol-related psychosis.
• List the treatment options available for alcohol-related psychosis.
• Describe interprofessional team strategies for improving care coordination and communication to improve outcomes in patients with alcohol-related psychosis.
• Introduction

Psychosis associated with alcohol can occur with acute intoxication, alcohol withdrawal, as well as in patients with chronic alcohol use disorder. The specific diagnosis of alcohol-related psychosis is also known as alcohol hallucinosis. It is a relatively rare consequence of alcohol use. However, it may be more prevalent than classically thought depending on the inclusion criteria used for diagnosis. In alcohol-related psychosis, symptoms of psychosis present during or shortly after heavy alcohol intake. Clinically, alcohol-related psychosis is similar to schizophrenia but has been found to be a unique and independent condition. It is characterized by hallucinations, paranoia, and fear. [1] [2] [3]

There are a variety of hypotheses to describe the etiology of alcohol-related psychosis, but none of them can fully explain the development of acute or chronic hallucinations in certain patients with alcohol use disorder. Therefore, the exact etiology of alcohol-related psychosis is unknown. It is likely related to dopamine, serotonin, and other neurotransmitters.

• Epidemiology

A 2015 Dutch literature review on alcohol-related psychotic disorder found that there is a 0.4% lifetime prevalence in the general population and a 4% prevalence in patients with alcohol dependence. The incidence is highest in working-age men. There is also a higher prevalence of alcohol-related psychosis in 1.) patients who became dependent on alcohol at a younger age, 2.) those with a low socioeconomic status, 3.) individuals who are unemployed or living on their pension, and 4.) those who live alone.  In patients with alcohol use disorder, paternal alcohol and mental health problems were found to be associated with a higher incidence of alcohol-related psychosis. Twin studies also suggest a genetic predisposition to the development of alcohol-related psychosis. Once diagnosed with alcohol-related psychosis, there is a 68% chance of re-admission and a 37% co-morbidity with other mental disorders. Patients with alcohol-related psychosis have a 5% to 30% risk of developing a chronic schizophrenia-like syndrome. [4]

• Pathophysiology

The pathophysiology of alcohol-related psychosis is unclear. Several hypotheses exist. Some studies suggest that an increase in central dopaminergic activity and dopamine receptor alterations may be associated with hallucinations in patients with alcohol use disorder. However, serotonin may also be involved. Other studies imply that amino acid abnormalities may lead to decreased brain serotonin and increased dopamine activity leading to hallucinations. Elevated levels of beta-carbolines and an impaired auditory system have also been associated with alcohol-related psychosis. Neuro-imaging studies have suggested that perfusion abnormalities to various regions in the brain may be associated with the hallucinations in alcohol dependence. [4]

• History and Physical

As with any form of psychosis, patients with alcohol-related psychosis may present with a wide range of symptoms. However, the presence of significant hallucinations or delusions must be evident. The psychosis is more extreme than what could potentially be attributed to alcohol intoxication or withdrawal. Special attention should be paid to mental status including flat affect or responding to internal stimuli. Additionally, a good physical exam needs to be done to look for possible trauma or infectious causes of altered mental status.

The majority of patients presenting with psychosis for the first time have some substance abuse. A detailed history is important in the evaluation of alcohol-related psychosis. Specifically, it is imperative to determine the patient's alcohol use history. It may be difficult to determine whether a patient’s psychotic symptoms are due to a primary psychotic disorder or due to substance use, including alcohol. This may be especially difficult in the emergency department where the history is frequently lacking. No family history of psychotic disorder in a patient who has a clear history of alcohol use supports the diagnosis of alcohol-related psychosis. Alcohol-related psychosis must be differentiated from other causes of psychosis and specifically from schizophrenia. When compared to schizophrenia, patients with alcohol-related psychosis tend to have significantly lower education levels, an onset of psychosis at an older age, more intense depressive and anxiety symptoms, and fewer negative and disorganized symptoms. Patients with alcohol-related psychosis also usually have better insight and judgment. [5] [6]

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) states that the diagnosis of substance-induced psychotic disorder requires the presence of significant hallucinations or delusions. There must be evidence that the hallucinations or delusions started during or soon after substance intoxication or withdrawal or the substance used is known to cause the disturbance. The symptoms are not better explained by a psychotic disorder unrelated to substance use. The psychosis does not occur only with delirium. The symptoms cause clinically significant distress or difficulty with normal activity such as work or social interactions.

A detailed physical exam is also important. Stability of the patient, including airway, breathing, and vital signs must be assessed first. Special attention needs to be paid to general appearance including if the patient is unkempt, has a flat affect, smells of alcohol, or appears to be responding to internal stimuli. Additionally, the patient should be evaluated thoroughly for any sign of trauma, especially head trauma. Other causes of altered mental status must also be evaluated, including infection, trauma, metabolic causes such as liver disease, and electrolyte abnormalities. Therefore, CT imaging of the brain, urinalysis, urine drug screen, lab evaluation including electrolytes, liver function tests, ammonia, and toxicology screening may be indicated.

• Treatment / Management

The priority is to stabilize the patient paying close attention to airway, breathing and vital signs. If the patient requires sedation due to alcohol-related psychosis, neuroleptics, such as haloperidol, have been considered the first-line medications for treatment. Benzodiazepines, such as lorazepam, are used if there is a concern for alcohol withdrawal and seizures. Certain atypical antipsychotics, such as ziprasidone and olanzpine, have also been used to help sedate patients with acute psychosis. Some patients may require the use of physical restraints to protect the patient as well as the staff. Patients with alcohol-related psychosis must also be evaluated for suicidality since it is associated with higher rates of suicidal behaviors. The prognosis for alcohol-related psychosis is less favorable than earlier studies had speculated. However, if the patient can abstain from alcohol, the prognosis is good. If patients are unable to abstain from alcohol, the risk of recurrence is high. [7] [8] [9]

• Differential Diagnosis
• Bipolar disorder type 1
• Cannabis-related disorders
• Cocaine-related psychiatric disorders
• Delirium tremens (DTs)
• Hallucinogen use
• Major disruptive disorder, single or recurrent, with severe psychotic features
• Schizophrenia
• Wernicke-Korsakoff syndrome
• Complications
• Major psychosocial impairment
• Enhancing Healthcare Team Outcomes

In general, most cases of alcohol-related psychosis come to light when patients are admitted to the hospital and then develop withdrawal symptoms with or without delirium tremens. The presence of alcohol-related psychosis usually is an indicator of something very serious and if not treated promptly can lead to negative outcomes. Healthcare workers should be familiar with this disorder and make appropriate recommendations to specialists if they have such a patient. Besides psychosis, these patients have a much higher rate of anxiety, depression and suicide. In addition, the patients can be unpredictable and resort to violence. These patients need to be managed by an interprofessional team of allied healthcare workers to mitigate morbidity and mortality. The prognosis for most patients with alcohol-related psychosis is poor, and even with recovery, major neuropsychiatric deficits persist. [10] [11] (Level V)

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Disclosure: Holly Stankewicz declares no relevant financial relationships with ineligible companies.

Disclosure: John Richards declares no relevant financial relationships with ineligible companies.

Disclosure: Philip Salen declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Stankewicz HA, Richards JR, Salen P. Alcohol Related Psychosis. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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