On the latest season of the HBO Max hospital drama “The Pitt,” a law student named Jackson arrived in the emergency room in a state of psychosis after he “flipped out in the library” and threw a chair at a campus security guard.
The news that he might have a mental illness comes as a shock to Jackson’s family, but it soon becomes clear that his break with reality didn’t come out of nowhere.
Jackson has been hearing voices for months, viewers learn: “They don’t want me to pass the bar,” he says. “That’s what they told me.”
It’s often assumed that psychosis symptoms such as auditory hallucinations and paranoid delusions appear out of the blue. But in reality, most patients with a first episode of psychosis have experienced milder symptoms for months or even years. What’s important, experts say, is recognizing and addressing those symptoms early.
“I always tell people if I broke my leg today and got it treated today, it would heal much better than if I waited 18 months,” said Nicholas J. K. Breitborde, director of the Early Psychosis Intervention Center at the Ohio State University Wexner Medical Center.
Here’s how to recognize the early signs of psychosis.
First, what is psychosis?
Psychosis is a disruption of the mind’s thoughts and perceptions that causes someone to lose contact with reality. People with psychosis might hear voices, as Jackson did, or see things that other people don’t. They may also have difficulty thinking clearly and may harbor false beliefs, for example the idea that other people are trying to hurt them. Other symptoms include incoherent speech and inappropriate behavior.
When psychosis is connected to a mental illness like schizophrenia or to a mood disorder with psychotic features, like bipolar disorder, it tends to first emerge between a person’s late teen years and mid-20s.
Because psychosis can be brought on by stress, first-time cases may pop up during a finals week or while completing a thesis, said Dr. Ramon Solhkhah, the chair of the department of psychiatry at Endeavor Health in the Chicago area.
“People are off their sleep cycle — they’re not eating right, they may be taking extra caffeine drinks,” he added. “They start messing with their chemistry in a way that sort of tips them over the edge.”
Psychosis can also originate from physical or neurological disorders such as hypothyroidism, pancreatic disease, dehydration or head trauma, or from alcohol or drug use.
What does the lead-up to psychosis look like?
The milder symptoms that precede full-blown psychosis are referred to as the prodromal phase. They include symptoms like withdrawing from others, mild hallucinations and paranoia.
But the most predictive signs that someone may develop psychosis are suspiciousness, for example worrying that other people are saying bad things about you, and unusual thoughts such as, “I think maybe other people can read my mind, but I’m not sure about it,” said Carrie E. Bearden, the director of the Center for the Assessment and Prevention of Prodromal States at the University of California, Los Angeles.
Typically these types of symptoms would occur an average of once a week for at least a month for someone to be considered at high risk for developing a psychotic disorder, the experts said. But not everyone with prodromal symptoms will go on to have psychosis.
These lower-level symptoms differ from full-blown psychosis in part because patients still understand that something is amiss. A person experiencing actual psychosis wouldn’t simply feel suspicious, for example, they would be certain that the police or the F.B.I. was tracking them, despite there being no reason for that to be true.
Auditory and visual hallucinations are hallmark symptoms of psychosis, but in the prodromal stage, a patient might describe hearing whispers or footsteps or notice brief distortions when looking at their face in the mirror, Dr. Bearden said. Other red flags in the lead-up to psychosis include difficulty in school or a decline in work performance.
People don’t often disclose these early symptoms to loved ones for fear they will be perceived as “crazy,” said Dr. Cheryl Corcoran, a professor of psychiatry at the Icahn School of Medicine at Mount Sinai.
Keeping the symptoms a secret can be dangerous.
“The longer psychosis is not treated, the worse it is for the brain,” Dr. Corcoran said.
How are the symptoms treated?
One of the biggest misconceptions about psychosis is that it’s not treatable, Dr. Corcoran said.
“In fact, many people who have had psychosis have rewarding jobs and successful relationships,” she added.
If someone has developed psychosis, doctors would typically prescribe an antipsychotic medication like risperidone and see how the person responds to it.
The experts said it is also important to offer patients psychotherapy and psychoeducation, a therapeutic intervention that teaches people how to better understand and cope with their symptoms. Patients can further benefit from social services like peer support.
These interventions can also help those who are at high risk of developing a psychotic disorder. There is no F.D.A.-approved medication, however, for people who are experiencing early, lower-level symptoms of psychosis. Antipsychotic medication may help in certain cases, but it also has unwanted side effects.
Dr. Bearden and Dr. Scott W. Woods, a professor of psychiatry at the Yale University School of Medicine, are among a group of experts leading large-scale studies to investigate new medications that may improve the symptoms of people who are experiencing prodromal symptoms.
“One way to destigmatize a condition is to develop an effective treatment for it,” Dr. Woods said. “We really need something approved with a strong evidence base specifically for this population.”
Christina Caron is a Times reporter covering mental health.
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