Psychosis & schizophrenia

A hallucination is when your senses pick up something that isn’t really there. Hearing voices is the most common kind. The voices might talk to the person, talk about them, or comment on what they are doing.

Hallucinations can include

• Hearing voices or sounds when no one is there
• Seeing shapes, people or things that others can’t see
• Feeling touches or movement on the skin
• Smelling or tasting things that aren’t there

To the person, a hallucination feels just as real as anything else they hear or see. Telling them “it’s not real” usually doesn’t help, and can make them feel alone or not believed.

A delusion is a firm belief that isn’t based in reality, and that doesn’t change even when there is clear evidence against it. The belief often fits with how the person is feeling, such as scared, unsafe or special.

Examples

• Believing someone is plotting to harm them or following them
• Believing the TV, radio or social media is sending them personal messages
• Believing their thoughts are being read or controlled

Arguing with a delusion rarely works. It can make the person feel more unsafe, and push them away from people who care. It’s usually more helpful to listen to the feeling underneath, such as fear, and offer calm support.

During psychosis, thoughts can become disorganised. A person might jump quickly from one topic to another, lose their train of thought, or say things that are hard for others to follow. Sometimes they even make up new words.

This can make school, work and conversations very tiring. The person is not being difficult on purpose. Their brain is under a lot of strain.

Psychosis doesn’t only change thoughts and senses. It can also bring strong feelings, like anxiety, fear or low mood, and make it hard to get motivated or to take care of daily tasks.

Because hallucinations and delusions can be so distressing, a person may act in ways that seem unusual to others, such as staying in their room, covering windows or avoiding phones. These actions usually make sense from inside their experience.

Schizophrenia is a serious mental health condition that affects how a person thinks, feels and behaves. Many people with schizophrenia experience psychosis at times, but schizophrenia is about more than psychosis.

People are usually first diagnosed between ages 16 and 30, often after a first episode of psychosis. It is rare in young children. In men, it tends to show up in the late teens to early twenties; in women, the early twenties to early thirties.

Experts often describe three kinds of experiences

• “Cognitive”: changes in attention, memory and decision-making, like finding it hard to focus, to use information right after learning it, or to make decisions
• “Negative”: things taken away, like energy, interest, enjoyment, facial expression, or wanting to be with friends and family. These are often mistaken for depression or laziness. They’re neither: they are part of the condition, and support can help
• “Positive”: things added (it doesn’t mean good), like hallucinations, delusions and jumbled thinking. These often come and go in episodes, with long stretches of feeling more like yourself in between

Everyone’s mix is different, and it can change over time. Cognitive remediation, which is like brain training with a coach, can help people build thinking skills back up.

Big stresses, like losing someone, moving, exams, money worries or abuse, can trigger psychosis in people who are more vulnerable to it. Trauma is listed as a trigger by the NHS.

Stress doesn’t cause psychosis in everyone. But for someone who already has some risk, a stressful time can be the spark. Learning ways to manage stress is part of staying well.

Sleep deprivation is one of the causes of psychosis that NIMH lists. When the brain goes too long without rest, it can start to misread what the senses pick up.

Disturbed sleep is also a common early warning sign that someone is becoming unwell. A large review of studies found that improving sleep led to small improvements in psychosis experiences like hallucinations and unusual beliefs.

Alcohol and drug misuse can cause psychosis, and heavy use can make symptoms worse for people who already experience it.

Using substances can also get in the way of recovery. Getting care for both mental health and substance use together tends to work best.

Psychosis can come from physical conditions, such as a head injury, a brain tumour, or dementia. In older adults, it can come along with Parkinson’s disease or Alzheimer’s disease. Some people experience it after giving birth.

This is why a full health check is an important first step. If you notice sudden changes in yourself or someone else, consult with your clinical provider.

Psychosis can be one part of several mental health conditions, including schizophrenia, bipolar disorder and severe depression.

Having an episode of psychosis does not automatically mean a person has schizophrenia. A clinician looks at the whole picture over time, and rules out other causes first.

Psychosis and schizophrenia can run in families. But having a relative with schizophrenia does not mean you will develop it. Many genes are likely involved, each adding a small amount of risk.

Researchers have also found small differences in how some brain areas develop and connect, some of which may begin before birth. Things in a person’s surroundings, like poverty or living in a dangerous place, can add to the risk.

One of the most common early changes is social withdrawal. A person might stop replying to friends, skip family meals, quit a team or club, or stay in their room for long periods.

This can happen because being around people feels overwhelming, confusing or unsafe. It can also look like low mood.

Someone might start to feel watched, talked about, or uneasy around people they used to trust. They may worry a lot about what others are “really” up to.

These feelings can be very scary. Reacting with patience, not mockery or anger, helps the person feel safer to share what’s going on.

A person may get caught up in new, very intense ideas, feel that things around them have special meaning, or have strange feelings they can’t explain. Some people feel the opposite: flat, numb, or unable to feel much.

They may also find it harder to tell the difference between what’s real and what’s imagined, or hear quiet sounds or voices now and then.

Sleep disruption is a common early sign. A person might stay up most of the night, sleep through the day, or seem unable to rest at all.

Because lack of sleep can itself trigger psychosis, sleep changes are worth taking seriously. Tracking sleep can help you notice a pattern.

A sudden drop in grades or work performance is an important sign. So is trouble thinking clearly, concentrating or making plans.

Teachers, coaches and managers are often among the first to notice. A caring “I’ve noticed you seem different lately, how are you doing?” can open the door.

A decline in self-care or personal hygiene can be an early sign. The person might stop showering, wear the same clothes for days, or forget to eat.

This is usually not laziness. Low motivation and trouble planning can make everyday tasks feel very hard.

Some people start speaking in ways that are hard to follow, or have trouble thinking clearly and logically.

If this is new and keeps happening, it’s a good reason to check in with a clinical provider.

This is the type most people picture. The person is awake but may not speak, move or react, even to pain or loud noises. They may stare, hold one position for a long time, or keep a stiff, unusual posture.

Signs can include

• Little or no speech
• Staying in one position, even an uncomfortable one, for a long time
• Staying in a position someone else moves them into
• A blank or fixed facial expression
• Not eating or drinking
• Resisting being moved or not responding to instructions, without a clear reason
• Losing control of bladder or bowels

This is not someone being stubborn or “ignoring” you. Their brain is struggling to start and control movement and responses.

Some people with catatonia become very agitated instead of still. They may pace, move in repetitive ways, or behave in unusual ways, often with no obvious trigger.

Signs can include

• Pacing or constant, purposeless movement
• Repeating the same movement again and again
• Copying other people’s words (echoing) or movements (mirroring)
• Odd or exaggerated versions of normal movements
• Grimacing
• Agitation, aggression or self-harm

Some people switch quickly between the still and excited types. This is called mixed catatonia.

When someone can’t move, eat or drink for a while, their body can quickly get into trouble. Complications can include dehydration, poor nutrition, pneumonia, blood clots and other serious problems.

A rare form called malignant catatonia affects the body’s automatic systems. Warning signs include a high temperature, a fast heart rate, heavy sweating, blood pressure that swings up and down, and bluish lips or nails. It is life-threatening without fast treatment.

Doctors look for catatonia with a physical and brain (neurological) exam and a rating scale, and they search for the condition behind it. Tests may include blood and urine tests, brain scans or a test of brain waves (EEG) to rule out seizures.

Most people respond well to treatment, and many start to improve within hours to days. The outlook is generally good, and treating the underlying condition matters too. For treatment choices, consult with your clinical provider.

Treatment works best when it starts quickly. Episodes that last longer or keep coming back can be harder to treat. Don’t wait to see if it passes on its own.

What you can do

• Get medical help right away: go to the emergency room or call 911
• Stay with them and speak calmly. Assume they may be able to hear you, even if they can’t respond
• Tell doctors when the changes started, and about any recent illness, anything new they have been taking (including alcohol or drugs), and their mental health history
• Mention the word “catatonia” to doctors if you’re worried it’s being missed
• After they recover, help them rest and keep up follow-up care

Gentle, respectful words matter, even when someone seems unaware. Talk to them, not about them, and tell them what is happening: “I’m here. We’re going to see a doctor who can help.”

Seeing someone you love like this is frightening. Once they are safe and in care, reach out for support for yourself too, such as the NAMI HelpLine or a family support group.

This is one of the most common mix-ups. People with schizophrenia do not have a split personality. Schizophrenia affects how a person experiences reality, thinks and feels. It is not about having two or more different identities.

Most people with schizophrenia are not violent. In fact, they are more likely to be harmed by other people than to harm anyone.

The risk of harm is highest when the condition isn’t treated, or when alcohol or drug misuse is involved. That’s one more reason why quick, caring support matters.

The World Health Organization says at least one in three people with schizophrenia will be able to fully recover. Many people recover from schizophrenia, according to the NHS, even if symptoms sometimes come back.

Some people who get early treatment for psychosis never have another episode. For others, recovery means living a full, productive life even if symptoms return now and then.

No one chooses psychosis or schizophrenia, and families don’t cause it. It comes from a mix of genes, brain differences and things in a person’s life and surroundings.

Families are actually one of the most important parts of recovery. Family education and support programmes help everyone cope better.

Psychosis can come from lack of sleep, substances, medical conditions, severe stress, bipolar disorder, severe depression and more. Only some people who have an episode of psychosis are later diagnosed with schizophrenia.

Most people get care while living at home, going to school or work, and spending time with family and friends. The WHO calls for care to move out of hospitals and into community services, like community mental health centres and home support.

Sometimes a short hospital stay is needed to keep someone safe during a crisis. Crisis teams try to support people at home or in the least restrictive setting possible.

The time between when psychosis starts and when someone gets care is called the “duration of untreated psychosis”. Shorter is better. People who get help sooner tend to recover better.

In a large U.S. study called RAISE, 404 people going through a first episode of psychosis got either a team-based programme or usual care. Those in the team programme stayed in care longer, and had better quality of life, fewer symptoms, and more days at work or school. The benefits were biggest for people who started care sooner.

This team-based approach is called Coordinated Specialty Care (CSC). The American Psychiatric Association considers it the standard of care for early psychosis. Decisions are shared between the specialists, the person and their family, and the person’s own goals, like finishing school, getting a job or reconnecting with friends, guide the plan.

A CSC team usually offers

• Case management: help with housing, transport, benefits and keeping track of appointments
• Family support and education: learning what psychosis is, how to communicate in hard times, how to spot warning signs and how to look after yourselves. When families feel more confident and less stressed, home becomes a calmer place to recover
• Health care: regular check-ins with a clinical provider, who can talk through all treatment options and check physical health
• Talking therapy: one-to-one or group therapy to make sense of what happened, cope with distressing experiences, manage stress and build confidence
• Work and school support: help to stay in or return to school or work, such as talking to a school, finding a job that fits or starting with fewer hours. Purpose and a daily routine are a big part of recovery for many people

Cognitive behavioural therapy helps people notice thought patterns that cause distress and find more balanced ways of thinking. In psychosis, it can help a person recognise delusional thinking and avoid acting on it.

It also builds practical skills for daily life, like coping with voices, handling stress and solving problems. Most people have a series of hour-long sessions over several months.

Family therapy or family education supports both the person and the people close to them. In the NHS, it usually involves informal sessions over about 6 months.

Sessions may cover

• What psychosis and schizophrenia are
• Ways to offer support without taking over
• Solving practical problems together
• Planning for a crisis
• How family members can manage their own stress

Supported employment helps people with serious mental health conditions find and keep work. It’s one of the psychosocial treatments NIMH lists for schizophrenia, and the WHO also recommends it.

Work can bring routine, confidence, income and friendships, all of which support recovery.

Behavioural skills training helps people practise skills for daily life, like conversations, cooking or managing money. Cognitive remediation uses exercises to strengthen attention, memory and planning.

The WHO also lists psychosocial rehabilitation, like life-skills training, as part of good care.

Arts therapy uses creative activities to help people express their experiences without needing words. The NHS says it may help ease negative experiences, like low motivation, for some people.

Assertive community treatment brings a team of professionals to people where they live. It’s often used for people who have been in hospital many times or are experiencing homelessness.

Community mental health teams can include social workers, nurses, occupational therapists and psychologists, helping people stay as independent as possible.

Physical health is part of mental health. Care plans should include healthy eating, physical activity, and help to stop smoking.

People with schizophrenia tend to die earlier than the general population, often from heart, metabolic and other physical illnesses. Regular health check-ups really matter.

Remember that hallucinations and unusual beliefs feel real to the person. Be respectful, supportive and kind.

Things that often help

• Speak slowly and calmly, using short, clear sentences
• Give them space; don’t crowd them or stand over them
• Turn down noise: the TV, music, other people talking
• Listen to how they feel: “That sounds really scary”
• Ask simple questions: “What would help right now?”
• Be honest: you can say “I don’t hear the voices, but I believe they’re upsetting you”

Things to avoid

• Arguing about whether the voices or beliefs are real
• Laughing, teasing or sounding shocked
• Blaming them or telling them to “pull yourself together”
• Making sudden moves or touching them without asking

Encourage your loved one to start treatment and to keep going. Offer to help find a mental health professional trained in psychosis, someone they feel comfortable with.

Practical ways to help

• Offer a lift to appointments, or to sit in the waiting room
• Help them write down questions beforehand
• Respect their goals and choices about care
• Notice and praise small steps forward

If you are worried about safety

1. Stay calm and stay with them, or make sure someone else is.
2. If it is safe to do so, remove things that could be used for self-harm, such as sharp objects.
3. Call or text 988 for crisis support, any time, day or night.
4. If a life is in danger, call 911.
5. Let them know they’re not alone and that help is coming.

Warning signs of suicide risk

• Talking about death or not wanting to be here
• Giving things away or making final arrangements
• Self-harm
• A sudden lift in mood after a very low time

You don’t need perfect words. What matters is that your loved one feels respected and safe with you, especially when their experiences feel real and frightening.

Words that can help

• “I’m here. You’re not alone.”
• “That sounds really frightening.”
• “I don’t see it, but I believe it feels real to you.”
• “What would help you feel a bit safer right now?”
• “I’m proud of you for going to your appointment.”

Try to avoid

• “That’s crazy.” or “You’re being paranoid.”
• “Just snap out of it.”
• Talking about them as if they aren’t in the room
• Making promises you can’t keep, like “I’ll never call for help”
• Using labels like “schizo” or “psycho,” even as a joke

Recovery often happens step by step. Family and friends can help by making daily life a bit easier and by believing that things can get better.

Ideas

• Help keep a steady daily routine, with regular sleep
• Keep home calm and low-stress where you can
• Encourage small goals, like a short walk or a phone call with a friend
• Support work, school or volunteering goals, at their pace
• Gently discourage alcohol and drugs, which can make psychosis worse
• Spend relaxed time together that isn’t about the illness

Family and friends are often the first to notice early warning signs, like poor sleep, pulling away, or new fears. Agree together, while things are calm, how you’ll tell them if you notice changes.

Supporting someone with psychosis can be exhausting. Family education programmes help families manage their own stress, not just support their loved one.

Ways to refill your cup

• Join a family support group, such as those run by NAMI
• Talk to a therapist or counsellor for yourself
• Keep doing things you enjoy, even for short times
• Share caring with other family members or friends

The National Alliance on Mental Illness (NAMI) runs a free, confidential HelpLine. You can call 1-800-950-NAMI (6264). NIMH points families to the NAMI HelpLine as a place to find support.

NAMI also runs family programmes and support groups, where you can meet other families who understand.

Many people find it helpful to talk with others who have similar experiences. Peer support groups and day centres can offer reassurance, ideas and friendship.

Some early psychosis programmes include peer specialists: people with lived experience who are trained to support others.

Small changes, like extra time for assignments, a quiet place to take breaks, or a slow return to full hours, can help someone stay in school or work. Supported education and employment teams can help plan this.

Places of worship and cultural groups can offer belonging, routine and practical help, like meals or rides to appointments. Leaders can help by speaking openly about mental health and encouraging people to seek care.

Stigma and discrimination are common for people with schizophrenia. They can lead to being left out, and to unfair treatment in health care, education, housing and work.

Small swaps that help

• “A person living with schizophrenia” instead of “a schizophrenic”
• “Experiencing psychosis” instead of “psycho”
• Avoid using “schizo” or “crazy” as jokes or insults