Psychosis and the first psychotic episode

Psychosis is a state in which a person loses contact with reality. They hear or see things that are not there (hallucinations), firmly believe things that are not true (delusions), or their thinking and speech become disorganised. It is not one diagnosis. It is a symptom with many possible causes, from schizophrenia and bipolar disorder to substances and physical illness. A first episode needs a prompt psychiatric assessment.

What the symptoms are

• Hallucinations: you hear, see or feel things that other people do not perceive.

• Delusions: fixed beliefs that do not change with evidence, for example that someone is watching you or wants to harm you.

• Disorganised thinking and speech: ideas jump from topic to topic and speech becomes hard to follow.

The person may not realise that something is changing, and those close to them may notice it first [1].

Is it common?

• Psychotic experiences do not always mean a mental disorder. In World Health Organization surveys of 31,261 adults in 18 countries, 5.8% had had a psychotic experience at some point, mostly hallucinations. For 32.2% of them it happened only once [2].

• Psychotic disorders are much rarer. In a study across 17 areas in six countries (five European countries and Brazil), there were 21.4 new cases per year per 100,000 people. The highest rates were in men aged 18 to 24 [3].

What causes psychosis

• Mental disorders: schizophrenia, bipolar disorder, severe depression [1].

• Substances: cannabis, stimulants such as amphetamines, hallucinogens, alcohol [1]. In a European study of 901 people with a first psychotic episode and 1,237 people from the general population, daily cannabis use was linked with about three times the odds of psychosis. Daily use of high-potency cannabis, with a THC content of 10% or more, was linked with almost five times the odds [4].

• Physical illness: brain tumour, dementia, head injury, temporal lobe epilepsy, autoimmune encephalitis. These psychoses are called secondary [5].

• Other situations: side effects of medication, severe stress or a traumatic experience, the period after childbirth [1].

In a first episode, before any label, we look for a physical cause or a substance that explains the picture. When a physical condition mimics or worsens the psychological symptoms, we treat it first. We ask about substances calmly and without judgement, because the answer changes the treatment.

Substance-induced psychosis: does it pass?

Not always. In an analysis of 50 studies, 25% of people with substance-induced psychosis were later diagnosed with schizophrenia. The rate was higher after cannabis (34%), hallucinogens (26%) and amphetamines (22%), and lower after opioids (12%), alcohol (10%) and sedatives (9%) [6]. That is why follow-up continues after the episode has passed.

Early warning signs

A first episode may be preceded by a period of milder changes: withdrawal, a drop in performance at work or in studies, suspiciousness, unusual ideas, changes in sleep. Not everyone goes on to develop psychosis. In an analysis of 27 studies with 2,502 people assessed as being at “high clinical risk”, 22% developed psychosis within one year and 36% within three years [7]. So most did not become ill in that period, but the risk is real and worth monitoring.

Why time matters

• In an analysis of 33 groups of patients with schizophrenia, the longer psychosis had gone untreated, the worse the long-term course of symptoms and social functioning. The association was small but consistent [8].

• The UK NICE guideline asks for early intervention services to be available to everyone with a first episode of psychosis, and for assessment to happen without delay [11].

• The outlook may be better than once believed. In a review of 79 studies with 19,072 people after a first psychotic episode, 58% had remission of symptoms (average follow-up 5.5 years) and 38% recovered (average follow-up 7.2 years). The authors note that gradual deterioration is not the usual course [9].

How it is treated

• Treating the cause, when there is one: stopping the substance, treating the physical illness.

• Antipsychotic medication. The patient and the doctor choose it together, as the NICE guideline sets out [11].

• Psychological therapy and family support. The same guideline recommends cognitive behavioural therapy for psychosis and family intervention [11].

How long treatment lasts is decided together with your doctor. In a review of six studies, people who stopped antipsychotic treatment after the symptoms of a first episode had settled saw symptoms return within a year in 77% of cases, and in more than 90% within two years. For those who continued, the first-year rate was estimated at 3% [10]. Do not stop treatment on your own.

After a first episode we make an “if… then…” plan together: what the first signs were this time, for example less sleep or suspiciousness, and what we do if they appear again. If the patient agrees, someone close to them knows the plan too.

How to help someone with psychosis

• Speak calmly and simply, without arguing hard against their ideas.

• Encourage them to see a psychiatrist or their doctor. If they are already in care, contact the people treating them.

• If they or others are at risk, get help immediately (see “Safety” below).

• Look after yourself too. The NICE guideline recommends intervention for the family as well [11].

We accept the feeling, not the content. Instead of “you’re right, they are watching you” or “you’re talking nonsense”, it helps more to say “I can see you’re scared, and I want to help you”. The fear is real, even if the idea is not.

When to ask for help

• You or someone close to you hears or sees things that other people do not perceive.

• Beliefs appear that someone is watching or harming you, and nothing changes them.

• There is a sudden change in behaviour, sleep or speech, especially after substance use or after childbirth.

• You have already had an episode and you are seeing the first signs again.

Safety: If there is a risk to the person or to others, or if the psychosis appeared after childbirth, get help immediately: 166 (ambulance, EKAV), 112 or the emergency department of the hospital on duty. For thoughts of suicide, you can also call the Suicide Prevention Line 1018.

How I can help

Book a psychiatric assessment, at the practice in Trikala or online. See also the page on schizophrenia and psychosis. For follow-up after the episode and for conversations with the family, especially if you live far away, see how working with an online psychiatrist works. For schizophrenia specifically, read schizophrenia: what it is, symptoms and treatment. If you are not sure which specialist to see, read psychiatrist or psychologist in Greece, or book an appointment.

This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.

Sources

1. NHS. Psychosis. Last reviewed 5 September 2023. https://www.nhs.uk/conditions/psychosis/

2. McGrath JJ, et al. Psychotic Experiences in the General Population: A Cross-National Analysis Based on 31,261 Respondents From 18 Countries. JAMA Psychiatry. 2015. https://doi.org/10.1001/jamapsychiatry.2015.0575

3. Jongsma HE, et al. Treated Incidence of Psychotic Disorders in the Multinational EU-GEI Study. JAMA Psychiatry. 2018. https://doi.org/10.1001/jamapsychiatry.2017.3554

4. Di Forti M, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. Lancet Psychiatry. 2019. https://doi.org/10.1016/S2215-0366(19)30048-3

5. Keshavan MS, Kaneko Y. Secondary psychoses: an update. World Psychiatry. 2013. https://doi.org/10.1002/wps.20001

6. Murrie B, et al. Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis. Schizophr Bull. 2020. https://doi.org/10.1093/schbul/sbz102

7. Fusar-Poli P, et al. Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Arch Gen Psychiatry. 2012. https://doi.org/10.1001/archgenpsychiatry.2011.1472

8. Penttilä M, et al. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2014. https://doi.org/10.1192/bjp.bp.113.127753

9. Lally J, et al. Remission and recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies. Br J Psychiatry. 2017. https://doi.org/10.1192/bjp.bp.117.201475

10. Zipursky RB, et al. Risk of symptom recurrence with medication discontinuation in first-episode psychosis: a systematic review. Schizophr Res. 2014. https://doi.org/10.1016/j.schres.2013.08.001

11. NICE. Psychosis and schizophrenia in adults: prevention and management (CG178). 2014, with later updates. https://www.nice.org.uk/guidance/cg178