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Key points
- Psychosis is associated with symptoms such as hallucinations, delusions, and disorganized speech.
- The earliest stages of psychosis may show up with changes to personality and subthreshold symptoms.
- Research suggests that intervention in those who are at high risk of psychosis may prevent it in some cases.
A first episode of psychosis often strikes with a storm of alterations in how a person experiences the world ranging from hearing voices to bizarre beliefs and speech or behaviors that are difficult to follow or understand. The typical age of onset is in adolescence and young adulthood just as someone is walking into ventures such as college, the work world, romantic relationships, and all the beautiful things that make up emerging adulthood. An episode of psychosis can present a detour to one's plans.
Yet, the process is not usually all at once. Within the early rumblings of psychosis, a person may lose interest in activities, motivation, and social engagement. This prodromal phase can mark a fading away that often goes unnoticed.
But what if we could catch the condition before it starts? Is there anything we can do to stop it?
Early Psychosis
Psychosis is known for its hallmark symptoms of delusions, hallucinations, and disorganized thinking. An individual might be described as having a "psychotic break" from reality or the first episode of psychosis. Yet the beginnings of psychosis are typically much more subtle.
The term "clinically high risk of psychosis" is utilized to describe individuals who have been deemed at a heightened risk of developing psychotic disorders. This could include individuals who have a first-degree relative with a psychotic disorder or who have a schizotypal personality disorder that places them at increased vulnerability of developing psychosis and those with subthreshold psychotic-like symptoms. Subthreshold symptoms could include things like unusual thoughts that do not quite reach a level of delusion or that can still be challenged. Another example could be alterations in perceptions such as visual illusions or distortion in senses that do not qualify to the level of a hallucination.
Very brief psychotic experiences called "brief limited intermittent psychotic symptoms" (BLIPS) such as feeling bugs crawling on one's skin or a sense that a TV show could have been referring to one's self that last less than a week and resolve without intervention could also classify a person as at a clinically high risk of developing a psychotic disorder.
Tools including the Structured Interview for Psychosis Risk Symptoms (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CHAARMS) have been utilized to assist in identifying individuals at high risk for psychosis and those in its earliest stages, including those who may be having altered perceptional or thought experiences (Addington et al., 2024).
Is Prevention Possible?
Among those identified as having a clinically high risk of developing a psychotic disorder, only about one-third transition to a first episode of psychosis (De Pablo et al., 2021) with the majority of that cohort developing the condition within the first three years. Yet, identification could assist with preventing or intervening in cannabis use, which has been shown to be a risk factor for the development of a psychotic disorder (Bucci et al., 2010). It could also be a pathway toward providing care to assist in this high-risk stage, such as with family psychoeducation surrounding stress and mental health and/or cognitive behavioral therapy (CBT).
Some have suggested that these efforts may even serve to prevent psychosis in some cases. Meta-analysis has shown, for example, that administration of CBT to individuals who are clinically at high risk for developing a psychotic disorder appears to reduce the likelihood that those individuals will experience a first episode of psychosis within the following four years (Worthington and Cannon, 2021).
Early Intervention
For those who do transition from being at clinically high risk for psychosis to a first episode of psychosis, early intervention can mark a significant difference in outcomes. Research suggests that progressive changes in the brain may occur in individuals in early psychosis presenting a critical period for intervention (Vinogradov et al., 2023). Often, the longer an individual experiences psychosis symptoms without support, the worse the outcomes. Research has shown that a longer duration of untreated psychosis correlates with decreased functional connectivity within specific brain networks as well as a poorer response to interventions (Maximo et al., 2020).
The first few years of psychosis also often involve social deterioration—things like lost jobs, leaving school, and withdrawing from friendships. Early intervention, particularly when community support and education/vocational support are involved, may assist individuals in recovery before significant damage has been done (Coentre et al., 2011).
Recovery
With early intervention, many individuals recover from a first episode of psychosis and can resume the music of young adulthood with decreased interruption. Initial evaluation of an early psychosis intervention program in Washington found increased quality of life and school attendance along with decreases in psychotic and anxiety symptoms along with several emergency room visits and hospitalizations (Oluwoye et al., 2020).
For those experiencing early psychosis or who are at a high risk of such, there is much reason for hope.
To find a therapist, visit the Psychology Today Therapy Directory.
References
Addington, J., Woods, S. W., Yung, A. R., Calkins, M. E., & Fusar‐Poli, P. (2024). Harmonizing the structured interview for psychosis‐risk syndromes (SIPS) and the comprehensive assessment of at‐risk mental states (CAARMS): An initial approach. Early Intervention in Psychiatry, 18(4), 248–254.
Bucci, S., Baker, A., Halpin, S. A., Hides, L., Lewin, T. J., Carr, V. J., & Startup, M. (2010). Intervention for cannabis use in young people at ultra high risk for psychosis and in early psychosis. Mental Health and Substance Use: Dual Diagnosis, 3(1), 66-73.
Coentre, R., Levy, P., & Figueira, M. L. (2011). Early intervention in psychosis: first-episode psychosis and critical period. Acta Medica Portuguesa, 24(1), 117–126.
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.
Oluwoye, O., Reneau, H., Stokes, B., Daughtry, R., Venuto, E., Sunbury, T., & McDonell, M. G. (2020). Preliminary evaluation of Washington State’s early intervention program for first-episode psychosis. Psychiatric Services, 71(3), 228–235.
Worthington, M. A., & Cannon, T. D. (2021). Prediction and prevention in the clinical high-risk for psychosis paradigm: a review of the current status and recommendations for future directions of inquiry. Frontiers in Psychiatry, 12, 770774.
Vinogradov, S., Chafee, M. V., Lee, E., & Morishita, H. (2023). Psychosis spectrum illnesses as disorders of prefrontal critical period plasticity. Neuropsychopharmacology, 48(1), 168–185.
