Depending on the cause, psychosis can come on quickly or slowly. The same is the case in schizophrenia, although symptoms are more likely to have a slow onset and begin with milder psychosis, which in some cases does not convert to the full disorder.4
In those people who do go on to display clear-cut psychosis, the slow onset, or prodromal phase of schizophrenia, is often found later to have gone without recognition by the patient or their family and friends.4
Prodromal psychosis goes on untreated for an average of two years, and even fully psychotic symptoms can be untreated for a number of years, too.4
The milder initial symptoms of psychosis might include:4
Feelings of suspicion
Distorted perceptions
Depression and suicidal feelings
Obsessive thinking
Sleep problems.
An online resource developed by psychiatrists gives a list of questions based on the sort of symptoms that, particularly when clustered together and getting worse, may be a signal of psychosis or schizophrenia.13
The full test produces a score based on self-reported ratings of delusional and hallucinatory experiences.
The examples tested include belief in possession of magical powers that other people do not have, and belief that other people are plotting against the person. Other items rate how much trust the person has in the reality of their thoughts, and how much control they feel they have over their thoughts.
Hallucinations can affect any of the senses (sight, sound, smell, taste and touch) in the person with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are auditory - hearing things and believing them to be real when they do not exist, there is no actual external noise to produce the stimulus.4
The following auditory hallucinations are common in schizophrenia:4
Hearing several voices talking, often negatively, about the patient
A voice giving a commentary on what the patient is doing, or
Repeating what the patient is thinking.
Delusions are defined as beliefs that are not supported by the cultural or religious context and there is clear evidence that they are false - nevertheless, they are strong convictions that the patient believes in completely.4,14
The type of delusion differentiates the psychosis of schizophrenia from that of other delusional disorders:4
Non-bizarre delusions - false but feasible beliefs
Bizarre delusions - impossible, such as contrary to the laws of physics.
Bizarre delusions are experienced during psychosis.4
Examples of psychotic delusions include the paranoid type - more likely to be associated with schizophrenia5 - and delusions of grandeur.15
Paranoid delusions: these may cause the person with psychosis to be unduly suspicious of individuals or organisations, believing them to be plotting to cause them harm. Such delusions can be very frightening and may result in unusual behaviour to avoid things - for example, staying out of a room with certain devices in it, believing them to be controlling thoughts, or locking up the front door with an excessive number of padlocks.3,15
Delusions of grandeur: clearly false but strongly held belief in having a special power or authority - the person with psychosis may, as examples, believe that they are a world leader, very rich, that they are able to bring dead people back to life, or that they can control the weather.3,15
While the classic hallmarks of psychosis are hallucination and delusion, other symptoms persist in disorders such as schizophrenia - known as negative symptoms. That is, cognitive and motivational impairments, which can be disabling and do not respond to drug treatment.9
The UK mental health charity Rethink Mental Illness has listed examples of negative symptoms of schizophrenia:16
Lack of motivation
Slow movement
Change in sleep patterns
Poor grooming or hygiene
Difficulty in planning and setting goals
Not saying much
Changes in body language
Lack of eye contact
Reduced range of emotions
Tendency not to interact with other people
Little interest in having hobbies
Little interest in sex.
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Tests and diagnosis
Early diagnosis
Early diagnosis of psychosis improves long-term outcomes.17 This is not always achieved, however. The milder forms of psychosis that can lead to schizophrenia are left untreated for an average of two years, and even full psychosis can take a number of years before it receives the attention of medical professionals.4