Summary: Psychiatrists identify the early signs of psychosis in two ways: through observation of patient behavior, and with the use of psychometric evaluations such as self-report questionnaires designed to detect early symptoms of psychosis.
Key Points:
- Psychosis is primarily associated with mental disorders such as schizophrenia
- Diagnostic tools for psychosis include the PQ-16, the PQ-21, the PSR-5, and the SIPS and Mini-SIPS
- Among adults in the U.S., the prevalence of psychosis is about 3%
- About 25% of people with early signs of psychosis develop full psychosis
- Treatment for psychosis can improve outcomes and reduce suicide risk associated with psychosis
What is Psychosis?
It’s important to understand that psychosis is not a diagnosis and does not meet criteria for a standalone mental health disorder in the Diagnostic and Statistical Manual of Behavioral Disorders, Volume 5, TR (DSM-5 TR). Rather than a disorder, think of psychosis as a category of symptoms associated with several different mental health disorders.
Here’s how mental health experts define psychosis:
Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and atypical/inappropriate motor behavior, including catatonia, that indicate loss of contact with reality.
In other words, people with psychosis, or people with psychotic symptoms, have different experiences of the world, and different perceptions of the world, than most of us. Loss of contact with reality means the things people with psychosis see, hear, and feel cannot be accessed by anyone else, and don’t align with the consensus reality most of us agree we live in.
Disorders most often associated with psychosis include:
- Schizophrenia
- Schizoaffective disorder
- Major depressive disorder (MDD) with psychosis
- Bipolar I with psychosis
Disorders with psychosis-like symptoms, or early symptoms of psychosis, sometimes called early psychosis, may include:
- Post-traumatic stress disorder (PTSD)
- Obsessive-compulsive disorder (OCD)
- Personality disorders
- Autism spectrum disorders
- Substance-related disorders
Let’s take a moment to define the new term we use before that bullet list, early psychosis. This is sometimes called prodromal psychosis, early onset psychosis, or subthreshold psychosis. Here are the diagnostic criteria for this variation of psychosis:
- Presence, in attenuated form – i.e. less severe/intense – of the following symptoms:
- Delusions, hallucinations, disorganized speech
- Symptoms present once a week for past month
- Symptom onset in past year
- Symptoms cause significant distress
- Symptoms not better explained by another diagnosis
- No previous presence of psychosis
- Presence of relatively intact reality testing
Note: in the first criterion, the term attenuated is somewhat inaccurate and questioned by many practicing psychiatrists, as it implies a diminished form of something full or complete, which is not the same as the early stages of something that may or may not become full or complete.
However, that last bullet point is pivotal. One of the main features that distinguishes early psychosis from full psychosis the connection to consensus reality: people with early psychosis know their new, changed perceptual experiences are not real, whereas people with full psychosis believe their experience are real.
Now let’s review the symptoms of psychosis and early psychosis.
Psychosis and Early Psychosis: The Symptoms
Remember: in people with early psychosis, the symptoms are less frequent, less severe, and less distressing, and the people experiencing them know they aren’t real.
People with psychosis experience changes in thoughts and beliefs, such as:
- Persistent thought or idea that people are out to get them/cause them harm
- Belief that they’ve developed special powers other people don’t have
- Persistent though or idea that something or someone – an external force of person – controls their thoughts and behavior
They also experience changes in sensory perception, such as:
- Hearing voices or noises other people don’t hear/can’t hear
- Seeing things other people don’t see/can’t see
In addition, people with psychosis experience changes in communication and behavior, including
- Extreme difficulty sharing ideas or thoughts in a clear and lucid manner
- Feedback from others that their ideas are difficult to understand, and/or wat they’re saying isn’t logical, sensible, or connected to facts that correspond with reality
We explain the differences between early psychosis and full psychosis above, which are related to frequency, intensity, and duration of symptoms, with people with early psychosis understanding their new/different experiences/perceptions are not real.
How Psychiatrists Identify Early Signs of Psychosis
Several tools exist as an initial screen for psychosis, including:
- Prodromal Questionnaire (PQ-16): a 16-item questionnaire designed to identify risk of psychosis and psychotic disorders
- Prodromal Questionnaire (Brief Version): a 21-item questionnaire designed to identify risk of psychosis and psychotic disorders
- Prime Screen-Revised-5: a 5-item questionnaire designed to quickly identify risk of psychosis and psychotic disorders
These screening tools assess risk and detect the early symptoms of psychosis, help providers identify the presence of early, prodromal psychosis, and determine level of risk for conversion to disorders such as schizophrenia or schizoaffective disorder.
A positive result from these screens is not a diagnosis. If a patient returns a positive result, the provider will follow up with additional questions in order to:
- Confirm presence of psychosis
- Follow up on answers from screening tools to avoid misdiagnosis
- Explore/clarify answers on screening tools to avoid normalizing pathological behavior
- Explore/clarify answers on screening tools to avoid pathologizing typical behavior
If follow-up confirms risk of psychosis, then the provider will screen for first for safety, then for presence of full psychosis with a screening tool such as the Structured Interview for Psychosis-Risk Syndromes (SIPS) or the Mini-SPS, a tool designed specifically to offer clinicians the “…minimum information needed to support a DSM-5 Attenuated Psychosis Syndrome (APS) diagnosis.”
The Importance of Timely Diagnosis of Early Signs of Psychosis
Evidence shows that only 25 percent of people who report early psychosis develop full psychosis and 75 percent experience remission of symptoms. However, people with psychosis, or people with a family member or loved one with psychosis or early psychosis, should understand that early, timely diagnosis and treatment can improve overall outcomes.
With an approach called coordinated specialty care (CSC), it’s possible for patients to manage the symptoms of psychosis and lead full, fulfilling, and productive lives. While people with psychosis have an elevated risk of suicide, evidence-based treatment significantly reduces that risk.
To learn more about CSC and effective treatment for early psychosis, please visit our treatment page:
Early Onset Psychosis
If you or someone you know needs support for psychosis or a mental health disorder with symptoms of psychosis, please contact us today by filling out a contact form, or call (844) 763-5532 for a free screening.
