Psychosis 101: Unmasking one of the brain’s most mysterious malfunctions

Our basic understanding of psychosis is as fuzzy as the condition itself.

The fragmentation, blurriness and incoherence many people in psychosis experience matches society’s knowledge of what it is, why it develops and how to think about the population it afflicts.

Oddly, we all experience a normal disconnection to reality, when our minds invent surreal, fictional and hallucinatory experiences. We call it dreaming. But if it occurs in our conscious, awake mind — and persists past what we might call a daydream or hypnotic state — such extreme cognitive distortion falls under medicine’s definition of psychosis.

And, as one might imagine, it can be seriously life-disrupting and frightening for many people who experience it, and for the people around them.

“Throwing you out of your normal life rhythms is where it can be really devastating,” said Kate Hardy, ClinPsyD, a Stanford Medicine clinical professor of psychiatry and behavioral sciences.

It’s also fairly common, particularly in young people. An estimated 100,000 teens and young adults in the U.S. experience a new onset of psychosis annually. American medicine has responded in recent years, with hundreds of centers devoted to psychosis risk and intervention springing up across the map, including Stanford Medicine’s INSPIRE Clinic and at least 30 others in California.

It’s an important development because, for many, psychosis can be a sign of a serious underlying mental health condition such as schizophrenia, schizoaffective disorder or bipolar 1 — conditions that can cause disability and can require prompt medical intervention. And hospital emergency rooms, often the first point of contact for a person in psychosis, can be ill-equipped to deal with the unpredictable nature of patients’ symptoms. 

This explains why Hardy, co-director of the INSPIRE Clinic, is a very busy — and inspired — person these days. She knows that the expert intervention given by care teams at the clinic can be crucial in redirecting a crisis into something manageable. And someday, she hopes, more normalized.

Hardy and clinic co-director Jacob Ballon, MD, recently helped demystify psychosis in a Stanford Medicine magazine video, Demystifying Psychosis, produced by Mark Hanlon. It features two individuals who do something that doesn’t happen often enough: They share their story publicly for the sake of helping others understand how they experience and cope with psychosis.

Shannon Pagdon, experienced her first episode of psychosis during high school, when she spotted a flying grape — with wings — as she exited an advanced placement psychology class. Pagdon, who was diagnosed with schizophrenia a year later, is a research coordinator with the INSPIRE Clinic and is studying at the University of Pittsburgh’s School of Social Work joint MSW/PhD program.

Ben, who received services at INSPIRE, first experienced psychosis in his early 20s when he began feeling like he was being watched, which ultimately led to a debilitating state of paranoia and a diagnosis of schizoaffective disorder. Ben, who asked that we use only his first name, is on the path to achieving his dream of studying physics. 

For both individuals, these experiences arose during adolescence or young adulthood — each involving a state of psychosis that presents an unconventional form of reality. But, as the researchers explain, not all psychosis shows up in the same way or emerges from an underlying neuropsychiatric disorder. 

Trauma, post-traumatic stress disorder and substance use are also common triggers. (One of the top substances of concern might surprise many — read on to learn what it is.) In older adults, Parkinson’s disease and dementia can invoke states of psychosis.

Hardy is committed to breaking through the fuzziness of — and discomfort surrounding — psychosis. Her approach centers on clarifying many of the elements of psychosis that make it confusing to the uninitiated: from the varied ways patients experience it, to the available therapies, to pop culture’s prominent role in its stigmatization. 

This Q&A from our interview with Hardy has been edited for clarity and length.

Are more young people experiencing psychosis today than in the past?

I haven’t seen anything to suggest we’re seeing higher rates. I think we’ve become better at recognizing that this happens to young people, and we should not be afraid of identifying and treating it. Australia led the way in this, incorporating it into youth mental health long ago. European countries, particularly where I trained, in England, followed. Recently, the U.S. has begun catching up. 

But the absolute tragedy of psychosis and schizophrenia is that many people go for years before they are accurately diagnosed and treated. If that was happening in cancer, there’d be a national outcry. Perhaps it’s been well-meaning, such as: “Schizophrenia is such a bad label, we can’t possibly go there until we’re absolutely sure.” In the meantime, precious time is lost in getting that person treatment. 

Talk about the challenge of stigma regarding terms such as psychotic episode.

It’s really challenging. If any of us goes to the doctor’s office and gets a diagnosis, we immediately do a web search, right? You search for psychosis or schizophrenia, and you don’t find helpful, positive messaging, thanks to media portrayals and Hollywood representations. 

I think that as best as we can educate people and normalize it — to create an understanding that these conditions are part of the human experience — we can get away from the othering of psychosis. 

We can all experience, from time to time, hearing something in the absence of external stimuli. It’s very common. But for an individual experiencing that more persistently and more intensely, it happens to be something more disruptive that needs treatment.

So, it sounds like psychosis encompasses a range of experiences and levels of symptoms.

We see psychosis as an umbrella term, a catchall for different symptoms or experiences that are usually, but not always, distressing. It’s essentially a loss of contact with consensus reality. Symptoms, presentations or experiences might include things like hallucinations or delusions or extreme beliefs. 

Under that umbrella are the diagnostic classifications like schizophrenia and schizoaffective disorder. In our clinic, we also work with individuals who are termed as having a clinical high risk of developing psychosis — a period before onset where there isn’t enough of an expression of those experiences for us to fully say that it is psychosis. They aren’t yet experiencing fully formed psychotic symptoms. That population can go in many different directions. They may go on to develop psychosis; they may not. But they can certainly benefit from the support we provide.

A lot of what you do is try to minimize the collateral damage of the experience, right?

Correct. It can be very disruptive to someone’s work, school and social life. And the impact of that, particularly with young people, is huge. And it can be devastating.

If you’re out of school for just a couple of days from the flu, everything can seem to have changed quickly. Homework changed, friend groups moved on, something is now cool that didn’t used to be. If you’re out for a couple of weeks because of psychosis and you’ve been hospitalized, everything shifts. We can help people recover their normal activities, retain those friendships and relationships and activities. That’s really one of the key parts of all of this.

What are the main concerns about substance use when it comes to its influence on psychosis?

The two primary substances of concern are cannabis and meth when it comes to psychosis. I have a friend, a cannabis researcher, who always says, “The cannabis people are smoking today is not the cannabis people were smoking in the ’60s.” The THC levels are so much higher. And there are theories around the use of high-THC cannabis unlocking psychosis.

There are different paths into psychosis, and substance use is one. Trauma and intense stressors can be others. Individuals can also be genetically predisposed to psychosis. 

For some it can take a very small trigger for the psychosis to present itself and for others it can require a much larger one. It’s hard to classify when we have all of these different pathways into it. We’re not yet as sophisticated in understanding underlying causal pathways of psychosis as we hope to be.

What are the best available therapies for psychosis?

The one that has gained a lot of traction and has a strong, robust evidence base is cognitive behavioral therapy. It’s what we do in our clinic. The core component, if practiced well, is about working with the individual to help them create meaning out of their experience. 

It’s never about the therapist coming in and saying, “You have schizophrenia and until you accept that we can’t do anything.” It’s more about, “What did this mean to you, and how are you making sense of it?” 

Whatever meaning we can create that helps someone get back to a way of living that is aligned with who they are and the values they have, that’s what we’re doing. It’s a lot of identity formation and the understanding of self in relation to the experience of psychosis.

There appear to be a growing number of resources dedicated to this. Are levels of understanding and acceptance following?

There is definitely more federal and state funding available than there used to be. We’re certainly seeing things change. However, we need to train a clinical workforce and pay them adequately. There’s been big growth in the kind of coordinated specialty care we provide. It’s now found in every state but still isn’t available for all young people with a recent onset of psychosis and it should be.

In addition, the mainstream openness to talking about depression and anxiety, with celebrities really endorsing the importance of therapy and youth mental health care, is creating a sea change. It just takes longer to get to there with conditions like psychosis, where people perceive it as being something more extreme. It’s moving in the right direction but we need to keep being proactive about knowledge and education to the population at large, highlighting that psychosis is an understandable, and treatable, experience and that recovery is very possible.

Shannon Pagdon helped launch a program called Psychosis Outside The Box, which emphasizes the importance of direct accounts from people who have experienced psychosis. If you or a loved one is experiencing a mental health crisis, the U.S. national suicide and crisis lifeline is available by calling or texting 988 or by chatting at 988lifeline.org.