PTSD with Psychosis

PTSD is a serious, long-term condition that includes a range of symptoms like avoidant behaviors, changes in mood, re-experiencing the initial trauma, and hyperarousal symptoms, like hypervigilance and anxiety. However, some PTSD patients also experience symptoms of psychosis, including delusions, hallucinations, and paranoia. Treatments like cognitive behavioral therapy and medication are helpful in treating PTSD and psychosis.

Can PTSD cause psychosis?

PTSD isn’t necessarily the cause of psychosis. Instead, the traumatic event that led to the development of PTSD is more likely the cause of psychotic symptoms.^[1]

For example, assume you experienced an assault outside a restaurant in your hometown. Upon driving past that restaurant, you might experience vivid memories of the assault, triggering symptoms of psychosis, such as paranoia.

As another example, after surviving a wartime situation during military service, you might experience hallucinations in which you hear the voices of colleagues calling out to you during a firefight. These voices seem real and can trigger extreme anxiety as part of your PTSD.

In both examples, it isn’t the PTSD that triggers the psychosis, per se, but the initial trauma. However, there is evidence that psychotic symptoms are more likely to occur in patients with more severe PTSD ^[2], suggesting that PTSD might be a risk factor for psychotic symptoms.

Furthermore, research indicates that there are genetic and biological differences between people with PTSD with psychotic features and people with non-psychotic PTSD.^[3] This again suggests that PTSD might be a risk factor for the development of psychosis in some people.

Additional risk factors that make PTSD with psychosis more likely are the presence of a psychotic disorder (e.g., schizophrenia), substance abuse, and physical illness. Likewise, specific traumas appear more likely to induce psychosis, including witnessing someone being injured or killed, being in a natural disaster, and having a loved one experience trauma.

Research also shows that psychosis can cause PTSD – as many as 47 percent of people with psychosis develop PTSD at some point.^[2]

The takeaway is this: PTSD psychosis is highly complex and likely occurs due to varying factors ranging from biology to personal trauma to one’s current psychological state.^[1]

Psychotic symptoms of PTSD

PTSD with psychotic features usually involves both positive and negative symptoms. Positive symptoms refer to thoughts and feelings that are ‘added’ to an individual’s experience, including hallucinations, delusions, and paranoia. Other common positive symptoms include disorganized behavior and dissociation.

Negative symptoms, on the other hand, refer to things that are absent. For example, you might lose the ability to speak or experience a lack of motivation. Positive and negative symptoms might occur together, too.^[3] Both are outlined in more detail below.

Positive symptoms of PTSD Psychosis

Hallucinations occur when you see, hear, feel, smell, or even taste things that aren’t really there. For people with PTSD and psychosis, these hallucinations revolve around the PTSD-inducing trauma experienced in the past.

Delusions, along with hallucinations, are the most common PTSD psychosis symptoms.^[2] Delusions are strongly held beliefs that are obviously false and demonstrate abnormal cognition ^[4]. Delusions can take many forms. However, when PTSD and psychosis occur together, delusions are usually persecutory or paranoid in nature.^[5]

Paranoia involves extreme anxiety, fear, and distrust of others, which can also be common symptoms of PTSD. Furthermore, paranoia usually involves hypervigilance, defensiveness, and the constant worry of being harmed by others.^[6]

Disorganized behavior is also typical with PTSD psychosis. Disorganized behavior can manifest in many ways, from bizarre behavior to speech that’s difficult to understand or has no apparent meaning to an inability to perform highly routine behaviors like bathing or brushing one’s teeth.^[7]

Dissociations refer to instances in which you feel disconnected from your identity. This might include feeling like you’re having an out-of-body experience and disconnected from your memories, thoughts, and feelings. Commonly, people with PTSD psychosis experience dissociation during a hallucination.^[8]

Negative Symptoms of PTSD psychosis

During a psychotic phase, patients might lose the ability to perform certain functions. For example, someone with PTSD psychosis might withdraw from friends and family or lose the ability to experience pleasure.

Additionally, negative symptoms often include a reduced ability to express emotions, a reduced capacity to speak, and difficulty in producing thoughts or ideas. There is often a reduced level of motivation as well, which makes it extremely difficult to start even menial tasks like getting dressed.^[9]

Diagnosing PTSD with psychosis

As discussed earlier, PTSD and psychosis can co-occur together, particularly if the PTSD symptoms are quite severe. As such, diagnosing these conditions revolves around examining the diagnostic criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

According to the DSM-5, a diagnosis of PTSD is contingent upon symptomatology in each of these four areas:

• Intrusive symptoms, such as distressing dreams
• Avoidance symptoms, such as avoiding visiting the location where the trauma occurred
• Cognition and mood symptoms, like a loss of interest in enjoyable activities and self-blame
• Arousal and reactivity symptoms, like hypervigilance and sensitivity to loud noises

These symptoms must cause clinically significant distress, making it difficult or impossible to function in everyday life, such as at work or in social situations. Furthermore, PTSD symptoms must not be the result of another condition.^[10]

The DSM-5 also outlines various psychotic disorders. In the case of suspected PTSD with psychosis, the diagnostic criteria for psychotic disorders might be used to eliminate other causes of the psychosis.

For example, if a patient presents with PTSD and psychotic symptoms, the DSM-5 could be consulted to rule out conditions like schizophrenia, schizophreniform disorder, or schizoaffective disorder. Ruling out other causes is crucial, as PTSD and psychosis share some symptoms, making a proper diagnosis difficult.^[3]

Furthermore, there is evidence that PTSD with secondary psychotic symptoms (PTSD-SP) is its own type of disorder separate from PTSD. Though PTSD-SP is not part of the DSM-5, potential diagnostic criteria have been proposed:^[3]

• Meets the criteria for a PTSD diagnosis
• Exhibits positive symptoms of psychosis, such as hallucinations and delusions
• Does not meet the diagnostic criteria for another psychotic disorder
• The onset of PTSD symptoms occurs before the onset of psychotic symptoms
• Psychotic symptoms extend beyond having flashbacks
• There is no formal thought dysfunction present, but preserved reality testing is required

In addition to these formal and informal diagnostic criteria, a doctor or mental health provider will also rely on a physical examination and a series of questions about your health and lifestyle. These processes are used to rule out other potential causes of the behavior in question rather than to confirm a PTSD psychosis diagnosis.

For example, a patient might be asked about:^[11]

• Drug or alcohol use
• Medications they are currently taking
• Dietary habits
• Past and current mental health issues
• Past and current medical issues
• Family history of mental illness
• Day-to-day functioning (e.g., if the patient is still working, able to cook and clean, etc.)

Ultimately, if a patient initially sees a general practitioner, they will be referred to a mental health provider for further evaluation if there’s concern that PTSD, psychosis, or both are present.

How to manage PTSD with psychosis

The difficulty in managing PTSD psychosis is that some symptoms, like delusions, negate one’s inability to understand what’s real and what isn’t. As such, someone with PTSD psychosis must get the appropriate mental health treatment, as outlined in the next section.

However, if you suffer from PTSD psychosis, there are things you can do at home to help manage your symptoms:^[12]

• Attend all appointments, counseling, and other services with your doctor and mental health provider. Ask a family member or loved one to remind you, drive you, or go with you to your appointments, as needed.
• Avoid drinking alcohol or ingesting illicit drugs.
• Take your medication, if prescribed, according to the doctor’s orders.
• Get plenty of rest and exercise, and eat a balanced diet. Doing so enables you to take care of yourself physically, which will also help your mental state.
• Be open with your loved ones about your condition to help them understand your experience.
• Read about your condition to learn more about PTSD psychosis and what you can expect. Though you can’t control your symptoms, it might be helpful to better understand the signs, symptoms, treatments, and so forth.

Other means of managing your symptoms include common PTSD self-help strategies, like:

• Practice mindfulness and focus on being in the present moment. This can help you manage your triggers in a healthy way.
• Join a PTSD support group. Having the support of others who share your experience can be extremely helpful in making positive forward progress.
• Consider getting an emotional support animal. Animals effectively treat PTSD and its symptoms in the short and long term.

PTSD with psychosis treatment

There are two primary strategies for treating PTSD and psychosis – therapy and medication. In most cases, a combination of the two is most effective.

Therapeutic Treatments

PTSD and psychosis respond well to cognitive-behavioral therapy (CBT),^[13] a type of talk therapy that examines negative thought patterns and seeks to change them by learning how to control one’s beliefs, behaviors, and thinking patterns.

Exposure therapy has also shown efficacy in treating PTSD and psychosis.^[14] Exposure therapy entails presenting the patient with stimuli that cause fear. This is done in a safe, supportive space led by a mental health professional. As exposure to the fear stimuli continues, the associated fear and anxiety tend to diminish.

Another therapy that shows promise for treating PTSD and psychosis is eye movement desensitization and reprocessing (EMDR).^[15]

This highly structured treatment involves the patient recalling their trauma while experiencing bilateral stimulation at the same time. By briefly reliving their trauma while also focusing on simulation (usually eye movements), the patient might experience less vivid emotions regarding their traumatic memories.^[16]

Medications

Selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant – are highly effective in treating PTSD and are the first-line drug treatment for this disorder. Popular options include Paxil, Prozac, and Zoloft.

However, while SSRIs are the first choice for PTSD, antipsychotics are the first-line treatment for psychotic symptoms. These drugs include first-generation antipsychotics like Mellaril, Moban, and Orap, and second-generation antipsychotics like Risperdal, Zyprexa, and Clozaril.^[17]

While some research suggests that antidepressants and antipsychotics work well together,^[18] ultimately, a personalized approach to drug treatment is required because SSRIs and other antidepressants have a host of potential side effects. Antipsychotic medications do as well.

Since these side effects vary from one person to the next, it’s essential for all involved in treatment to consult and collaborate on a drug intervention that maximizes results and minimizes harm to the patient.

Complications of PTSD psychosis

Perhaps the most obvious complication of PTSD psychosis is increased distress due to a larger range of symptoms. PTSD and psychosis are complex enough on their own; experiencing them simultaneously is far more complicated.

A second potential complication was referenced in the previous section – treatment difficulties. While PTSD and psychosis can be treated with the same therapeutic treatments, drug treatments can get a little complicated.

For some, it might come down to a choice between taking medication for PTSD or taking medicine for psychotic symptoms. Or, if both antidepressants and antipsychotics are taken at the same time, there might be a greater risk of worse side effects, more side effects, drug interactions, or all the above.

Other conditions linked to psychosis

As mentioned earlier, many other conditions feature psychosis, which must be ruled out as a potential cause of psychosis in PTSD patients when evaluating them for PTSD with psychosis. These conditions include:^[19]

• Schizophrenia – a severe, long, term, complex disorder characterized by delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior, among others.
• Schizophreniform Disorder – a disorder with the same symptomatology as schizophrenia, but the symptoms last one to six months.
• Schizoaffective Disorder – a disorder in which psychotic symptoms present alongside mood disorder symptoms, such as depression.
• Delusional Disorder – a disorder in which one or more delusions last one month or longer. Psychotic symptoms similar to those of schizophrenia may also be present.
• Brief Psychotic Disorder – a short-term disorder in which psychotic symptoms like delusions, hallucinations, and disorganized behavior present for one day to one month.
• Bipolar Disorder – a severe disorder with periods of depression and mania, during which a person might experience symptoms ranging from a loss of interest in enjoyable activities to delusions of grandeur.

The DSM-5 outlines several other disorders that include psychotic symptoms, but the symptoms are caused by a specific trigger, like a medical condition, a substance, or a medication. Furthermore, the DSM-5 lists Unspecified Schizophrenia Spectrum and Other Psychotic Disorder and Other Specified Schizophrenia Spectrum and Other Psychotic Disorder as additional diagnostic options for situations in which the psychotic symptoms do not fit the criteria of the primary categories listed above.