Psychotic Behaviour

Psychotic behaviour occurs when people lose touch with reality, experiencing a disconnection that can involve seeing or hearing things that aren’t there, holding strong beliefs that aren’t true, or having confused patterns of thinking and speaking.

Table of contents

• What is Psychotic Behaviour
• Main Symptoms of Psychotic Behaviour
• What Causes Psychotic Behaviour
• Types of Psychotic Disorders
• How Psychotic Behaviour is Diagnosed
• Treatment Options
• Potential Complications
• Getting Help for Yourself or Others

What is Psychotic Behaviour

Psychotic behaviour happens when a person has trouble telling the difference between what’s real and what’s not. This disconnection from reality is not a disease itself, but rather a collection of symptoms that can occur for several different reasons^[4]. People experiencing psychotic behaviour lose some contact with reality, which might involve seeing or hearing things that other people cannot see or hear, or believing things that are not actually true^[3].

Psychotic behaviour is more common than most people realize. Studies have estimated that around three out of every 100 people will experience an episode at some point in their lives^[11]. In any given 12-month period, just under one in every 200 adult Australians will experience a psychotic illness^[6]. The period of time where people experience psychotic symptoms is known as an episode of psychosis^[6].

The first episode of psychosis usually occurs in a person’s late teens or early 20s^[6]. Some people only experience a few episodes, or a brief episode that lasts for a few days or weeks. Others will experience symptoms more frequently, in association with a longer-term illness^[6].

Main Symptoms of Psychotic Behaviour

The three main symptoms associated with psychotic behaviour are hallucinations, delusions, and confused or disturbed thinking and speaking^[3]. Each person who develops psychosis will have their own unique set of symptoms and experiences, according to their particular circumstances^[7].

Hallucinations

Hallucinations are when parts of your brain mistakenly act like they would if your senses picked up on something actually happening^[4]. They involve seeing or hearing things that do not exist outside a person’s mind but can feel very real to the person affected by them^[3]. Hallucinations can involve different senses:

• Hearing voices that aren’t there (a common hallucination)^[3]
• Seeing colours, shapes or people that other people cannot see^[7]
• Feeling someone touching you when there is nobody there^[7]
• Smelling an odour that other people cannot smell^[7]
• Tasting something when there is nothing in the mouth^[7]

Delusions

Delusions are false beliefs that someone holds onto very strongly, even when others don’t believe them or there’s plenty of evidence that a belief isn’t true^[4]. They are beliefs that are not shared by others^[3]. A person with delusions has an unshakeable belief in something untrue^[7].

Common types of delusions include:

• Believing there’s a conspiracy to harm them^[3]
• Thinking someone is plotting against them^[2]
• Believing they have special powers or authority^[7]
• Feeling like someone is controlling their thoughts or actions remotely^[4]

Confused and Disturbed Thinking

People with psychotic behaviour may have confused or disordered thinking and speaking. Their thoughts and ideas come very quickly, which can make their speech fast and confusing^[3]. Signs of disturbed thinking include:

• Rapid and constant speech^[7]
• Speaking in muddled-up sentences or using the wrong words to describe things^[6]
• Switching from one topic to another mid-sentence^[7]
• A sudden loss in their train of thought, resulting in an abrupt pause in conversation or activity^[7]
• Making up words^[6]

Changes in Behaviour and Feelings

The combination of hallucinations and delusional thinking can cause severe distress and a change in behaviour^[3]. People may experience:

• Withdrawal from family and friends^[18]
• Changes in sleep patterns, including sleeping during the day and being awake at night^[18]
• Changes in appetite^[18]
• Decreased attention to personal hygiene^[18]
• Strange or seemingly uncharacteristic behaviours^[18]
• A dramatic drop in ability to function at work or school^[18]
• Extreme fear for no apparent reason^[18]
• Feeling disconnected or out of control^[18]

What Causes Psychotic Behaviour

Psychotic behaviour can happen because of a wide range of conditions that affect your brain and body. It’s sometimes possible to identify the cause as a specific mental health condition^[3].

Mental Health Conditions

Psychotic behaviour is a common symptom of many mental health conditions^[4]. These include:

• Schizophrenia – a condition that causes a range of psychological symptoms, including hallucinations and delusions^[3]
• Bipolar disorder – a mental health condition that affects mood; a person with bipolar disorder can have episodes of low mood (depression) and highs or elated mood (mania)^[3]
• Severe depression – some people with depression also have symptoms of psychosis when they’re very depressed^[3]
• Schizoaffective disorder^[4]
• Brief psychotic disorder^[4]
• Delusional disorder^[4]

Medical Conditions

Various medical conditions affecting the brain and body can also cause psychotic behaviour, including:

• Alzheimer’s disease and other types of dementia^[4]
• Brain tumours^[2]
• Brain infections such as encephalitis or meningitis^[4]
• Stroke and other neurological conditions^[4]
• Hormone-related conditions like Addison’s disease and Cushing’s disease, and when your thyroid gland is too active or not active enough^[4]
• Lupus^[4]
• Lyme disease^[4]
• Multiple sclerosis^[4]
• Postpartum psychosis (a rare, severe mental health emergency related to postpartum depression)^[4]
• Vitamin B1 (thiamine) and vitamin B12 deficiencies^[4]

Other Triggers

Psychotic behaviour can also be triggered by:

• A traumatic experience^[3]
• Unusually high levels of stress or anxiety^[4]
• Drug misuse^[3]
• Alcohol misuse^[3]
• Side effects of prescribed medicine^[3]
• Severe head injuries (concussions and traumatic brain injuries)^[4]
• Childbirth^[3]

How often a psychotic episode occurs and how long it lasts can depend on the underlying cause^[3].

Types of Psychotic Disorders

Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions^[2]. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), psychotic disorders include several conditions^[4]:

Schizophrenia

This is a serious psychiatric condition. To be diagnosed with schizophrenia, a person must have had two or more specific symptoms for at least a month, including delusions, hallucinations, disorganized speech, disorganized or catatonic behaviour (a condition wherein a person moves abnormally, has abnormal behaviours, and may withdraw completely), or negative symptoms (such as diminished emotional expression or a lack of motivation)^[5]. The person must have continuous signs of schizophrenia for at least six months^[5].

Brief Psychotic Disorder

This condition involves psychotic symptoms that last for a brief period. Because of the short duration, treatment is brief and focused on being as nonrestrictive as possible^[13].

Schizoaffective Disorder

This is a psychiatric condition where a person experiences symptoms of both psychosis and mood disorders^[4].

Delusional Disorder

This condition is characterized primarily by the presence of delusions^[4].

Substance or Medication-Induced Psychotic Disorder

This occurs when psychotic symptoms are caused by the use of alcohol, prescription medications, or recreational drugs^[4].

How Psychotic Behaviour is Diagnosed

Diagnosis of psychotic behaviour involves ruling out other mental health conditions and making sure that symptoms aren’t due to substance misuse, medicine, or a medical condition^[15].

The process may include:

• Physical exam – This may be done to rule out other problems that could cause similar symptoms and check for any related complications^[15]
• Tests and screenings – These may include tests that help rule out conditions with similar symptoms and screening for alcohol and drug use. A healthcare professional also may request imaging studies, such as an MRI or a CT scan^[15]
• Mental health evaluation – A healthcare professional or mental health professional checks mental status by noting how a person looks and behaves, and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This evaluation includes family and personal history^[15]

Your GP may ask you some questions to help determine what’s causing your psychosis. They should also refer you to a mental health specialist for further assessment and treatment^[3].

Treatment Options

Treatment for psychotic behaviour can depend on the cause, but usually involves a combination of antipsychotic medicine, talking therapies, and social support^[3]. Lifelong treatment with medicines and psychosocial therapy can help manage conditions involving psychotic behaviour, though there is no cure^[15].

Medication

Antipsychotic medicines are usually recommended as the first treatment for psychosis^[8]. They work by blocking the effect of neurotransmitters, such as dopamine, which are chemicals that transmit messages in the brain^[8].

Oral second-generation antipsychotic drugs, including olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, or paliperidone, are first-line treatment^[13]. Antipsychotics can usually reduce feelings of anxiety within a few hours of use, but they may take several days or weeks to reduce psychotic symptoms, such as hallucinations or delusional thoughts^[8].

Antipsychotics can be taken by mouth (orally) or given as an injection. There are several slow-release antipsychotics, where you only need an injection every one to four weeks^[8].

Side effects can include drowsiness, shaking and trembling, weight gain, restlessness, muscle twitches and spasms, blurred vision, dizziness, constipation, loss of sex drive, and dry mouth^[8]. It’s important to tell a GP or mental health worker if you have side effects that are becoming particularly troublesome, as there may be an alternative medicine you can take^[8].

Talking Therapies

Talking therapies can help reduce the intensity and anxiety caused by psychosis^[8].

Cognitive behavioural therapy (CBT) for psychosis is based on an understanding of how people make sense of their experiences and why some people become distressed by them. A CBT therapist may encourage you to consider different ways of understanding what’s happening to you. The aim is to help you achieve goals that are meaningful and important to you, such as reducing your distress, returning to work, education or training, or regaining a sense of control^[8].

Family intervention is known to be an effective form of therapy for people with psychosis. It’s a way of helping both you and your family cope with your condition^[8]. Family therapy involves a series of meetings that take place over a period of three months or more^[8].

Social Support

Support with social needs, such as education, employment, or accommodation, is an important part of treatment^[3]. If you’re experiencing episodes of psychosis, you may benefit from being around other people who’ve had similar experiences through self-help groups^[8].

Hospital Care

Some people may need to be admitted to a psychiatric hospital during a crisis if symptoms are severe^[4]. If a person’s psychotic episodes are severe, they may need to be admitted to a psychiatric hospital for treatment^[3].

Early Intervention

If this is your first psychotic episode, you may be referred to an early intervention team. An early intervention team is a team of healthcare professionals set up specifically to work with people who have experienced their first episode of psychosis^[8]. Getting immediate medical help for a psychotic episode is vital, as early treatment can be more effective^[11].

Potential Complications

People with a history of psychosis are more likely than others to have drug or alcohol misuse problems, or both. Some people use these substances as a way of managing psychotic symptoms, but alcohol or drug use can make psychotic symptoms worse or cause other problems^[3].

People with psychosis have a higher than average risk of self-harm and suicide^[3]. If you’re self-harming or having thoughts about ending your life or harming yourself, it’s important to seek help immediately^[8].

Getting Help for Yourself or Others

It’s important psychosis is treated as soon as possible, as early treatment can be more effective^[3]. You should see a GP immediately if you’re experiencing symptoms of psychosis^[3].

If you’re concerned about someone you know, you could contact a GP for them. If they’re receiving support from a mental health service, you could contact their mental health worker^[3].

If you think the person’s symptoms are severe enough to require urgent treatment and could be placing them at possible risk, you can:

• Take them to the nearest A&E, if they agree^[3]
• Call their GP or local out-of-hours GP^[3]
• Call 999 and ask for an ambulance^[3]

Education about how to recognize psychosis and how to help can result in a pathway to appropriate health care, which is what we would want for someone with chest pain or a broken leg^[11].