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Key points
- Psychosis is an umbrella term for a number of conditions affecting perception and thought.
- The average gap between psychosis onset and treatment is 22 months.
- Early intervention improves outcomes and treatment response and may prevent changes to the brain.
At age 13, I found myself in a hospital. My discharge paperwork listed a word I didn't like, "psychosis."
That diagnosis changed several times. Still, the ways my experiences impacted me have led me to pull apart and try to rebuild over and over in the following years. Each time I added a new piece, I created something new.
Returning to school, reconnecting with others socially, seeking support, and working to understand my mind were all parts of my healing. I found ways to make meaning of this through art, advocacy, and helping others. This guided me to my vocation as a psychotherapist specializing in mental illness. It's like putting together a puzzle with the pieces of a bunch of puzzles all mixed up.
This has been my recovery. It has been the most difficult and meaningful journey of my life.
Most people are aware that receiving intensive intervention after a stroke is essential for recovery. The "fifteen minutes earlier" slogan highlights that even a fifteen-minute time difference makes a difference.
With mental health, this critical period is not often acknowledged.
Yet, research shows that intervention in early psychosis and receiving quality treatment within the first 2-5 years of these illnesses is just as vital for recovery. Longer duration of untreated psychosis is associated with poorer treatment outcomes, more significant symptoms, and worse functioning in the case of schizophrenia (Perkins et al., 2005). Research also suggests this is reflected in the brain with decreased connectivity in individuals who have had a longer period of illness without help (Maximo et al., 2020).
In the U.S., the average duration of untreated psychosis is 21 months. (Maximo et al., 2020)
Psychosis vs. Schizophrenia
Psychosis is an experience that involves changes in integrating perceptions. It is marked by voices, visions, unusual/unshared beliefs, severe difficulties organizing words, and thought disorganization. It is usually a temporary experience but can become chronic.
Schizophrenia is one of many causes of psychosis. The list is extensive including substance use, spiritual experiences, sleep deprivation, multiple medical illnesses, severe depression, bipolar disorder, and post-traumatic stress disorder, to list a few.
Schizophrenia is associated with at least one month of psychosis and marked changes in a person's functioning that can not be explained through other diagnoses.
Early in these illnesses, differentiating the cause is tricky. It's not uncommon for someone to receive multiple, changing diagnoses. Still, even during this period, early intervention is essential to minimize the negative effects psychosis can have on a person's life.
Phases of Early Psychosis
Psychosis is insidious. Initially, there is a space called "clinically high risk." This is a label used to describe individuals who are showing sub-threshold psychotic symptoms. This may involve very brief experiences, such as hearing a voice one time and knowing it was a voice.
These are called brief limited intermittent psychotic symptoms. This clinically high-risk period is also associated with loss of motivation, loss of interest, social withdrawal, concentration difficulties, and cognitive challenges. The good news is that 65 percent who experience this phase do not proceed into a full psychotic disorder.
Lowered stress and avoidance of substance use are protective factors, whereas having a family history of psychosis can make it more likely for the illness to progress. For people in this phase, watchful waiting along with treatment for current mental health challenges, family psychoeducation, stress relief, and substance use counseling is recommended.
The next stage of psychosis is called the first episode. This is when a person crosses the threshold and has clear psychotic symptoms, such as a belief that the government has a plot against them or ongoing, distressing voices.
The sooner a person receives help the more positive the trajectory. Even after the first episode of psychosis, several people never have another episode. Coordinated specialty care is the ideal treatment.
Finally, some individuals do go on to have subsequent psychotic episodes or to develop a symptom profile of a psychotic spectrum disorder, such as schizophrenia, schizoaffective disorder, or a mood disorder with psychotic features.
Coordinated Specialty Care
Within the U.S., the gold standard for early psychosis treatment is coordinated specialty care. This includes specialized psychotherapy, family psychoeducation, psychiatric services following specific guidelines for first-episode psychosis, and assistance with returning to work/school.
A study of 325 young adults receiving services within this model showed that after just six months of treatment, 80 percent had returned to work, there had been a steep decline in hospitalizations, and general functioning continued to rise (Nossel et al., 2018).
These services are available within 48 out of 50 states. Not all counties are covered, leaving many places without service.
Concerned About Yourself or Someone Else
Reaching out to a mental health provider is the first step to seeking help. Several conditions can mimic psychosis, so specialized assessment is often necessary. Coordinated specialty care with early psychosis programs does exist in many areas. Many of these are housed within community mental health centers or universities.
Know that you or your loved one are not alone; many people live through psychosis and recover.
What Mental Health Professionals Can Do
While many mental health professionals do not seek to work with people who have psychosis or do not believe they treat psychosis, statistically, most therapists do. The lifetime prevalence of psychosis is 1 in 33. How we respond to someone presenting with psychosis can alter their trajectory.
Just as most therapists have some training on depression and cultural competence, they should also have universal education on psychosis intervention.
System-wide initiatives to improve accessibility to early-psychosis specialty care, and to improve earlier identification of these conditions, are underway. In time, it can be hoped, this resource will be accessible to anyone who needs it within that critical period.
To find a therapist, visit the Psychology Today Therapy Directory.
References
De Pablo, G. S., Radua, J., Pereira, J., Bonoldi, I., Arienti, V., Besana, F., ... & Fusar-Poli, P. (2021). Probability of transition to psychosis in individuals at clinical high risk: an updated meta-analysis. JAMA psychiatry, 78(9), 970-978.
Maximo, J. O., Nelson, E. A., Armstrong, W. P., Kraguljac, N. V., & Lahti, A. C. (2020). Duration of untreated psychosis correlates with brain connectivity and morphology in medication-naive patients with first-episode psychosis. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 5(2), 231-238.
Nossel, I., Wall, M. M., Scodes, J., Marino, L. A., Zilkha, S., Bello, I., ... & Dixon, L. (2018). Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatric Services, 69(8), 863-870.
Perkins, D. O., Gu, H., Boteva, K., & Lieberman, J. A. (2005). Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. American journal of psychiatry, 162(10), 1785-1804.
