What Are the 5 Stages of Psychosis?

In this article, we will be going over the 5 stages of psychosis—in addition to the various psychosis symptoms to look out for, psychosis causes and triggers, and the psychosis treatments available. 

What is psychotic behavior?

Psychotic behavior refers to the actions of an individual experiencing psychosis. There are a variety of ways psychosis can present or be experienced. 

Psychotic behavior can be a symptom of an ongoing mental health diagnosis (like schizophrenia or bipolar disorder). It can also occur as a result of other medical reasons, and/or as an isolated incident. 

When an individual is experiencing psychosis, their behavior can be unpredictable and potentially dangerous. 

Find out how to spot the signs and symptoms of psychosis and how they may present in patients.

The 5 stages of psychosis

There are 5 stages of psychosis which depend on age, along with precipitating and perpetuating factors. 

Acute precipitating factors might include recent substance use such as hallucinogens. Perpetuating factors might be stress or insomnia. 

The stages of psychosis are:

1. Prodrome

This phase lasts about two years. Symptoms are mild and hard to distinguish as indicative of psychosis—symptoms may come and go sporadically. 

2. Acute

This phase lasts one to two years and includes florid or intense symptoms of psychosis that are more easily identifiable. 

3. Early recovery

This phase lasts two to four months and involves the remission of some positive symptoms (delusions, hallucinations, and disorganized thoughts and behaviors). Some individual’s symptoms may fully remit. 

4. Late recovery

This phase may last one to two years, and it involves continued negative symptoms and intermittent exacerbations of positive symptoms. 

5. Incomplete recovery

If applicable, this phase lasts the remainder of one’s life and involves persistent symptoms and continued functional impairment.

Psychosis causes 

There are many different mental and physical, or medical, triggers that can cause psychosis. 

The first and most important part of the workup for psychosis is to rule out any medical conditions that may be causing it. 

Psychosis can occur with the following medical conditions:

• Infections or sepsis
• Delirium
• Dementia
• Abnormal cellular growth (cancerous or otherwise)
• Physical injury that affects neurological function 
• Substances or other intoxicating agents
• Withdrawal from substances

Once potential medical conditions are ruled out, then clinicians can evaluate the patient’s psychosis for a psychiatric cause. 

Possible psychiatric conditions that may induce psychosis are:

• Severe depression
• Bipolar disorder
• Schizophrenia
• Personality disorders
• Delusional disorders
• Brief psychotic disorders

There are instances when the cause of psychosis may not be immediately discernible by the provider. In these cases, hospitalization may be necessary to continue the evaluation beyond the confines of a standard office visit. 

Psychiatric evaluation takes into consideration data from standardized rating scales, clinical interviews, team meetings, and group therapy. 

What are the warning signs of psychosis?

Psychosis warning signs may be noticeable during the prodrome, or initial stage. 

During the prodrome stage of the 5 stages of psychosis, it may be difficult to discern if the symptoms are psychosis or simply odd and unusual thoughts and behaviors. 

For example, if the patient exhibits some warning signs, but has a lack of functional impairment, this could be less concerning or noticeable than if the patient showed major deterioration in daily activities. 

In addition, unusual thoughts and behaviors do not always lead to psychosis. 

The individual may have some understanding that their behaviors are odd or unusual, but they also may not be aware. 

While there isn’t one single telltale warning sign, a professional should be able to consider all the signs comprehensively to paint a bigger picture. 

Some warning signs of psychosis are:

• Disturbances in perception and trouble thinking clearly
• Changes in initiative, such as a decline in self-care or hygiene
• Reduced levels of energy or stress tolerance
• Increased tendency to isolate due to suspiciousness, paranoid ideas, or uneasiness with others
• Mood swings with anger and irritability

Psychosis symptoms 

Certain psychosis symptoms are prevalent in all 5 stages of psychosis and may also appear to be warning signs prior to the onset of psychosis. 

These include common psychosis symptoms, such as: 

• Responding to internal stimuli
• Acting erratically
• Quick and impulsive actions
• Emotional lability
• Easily becoming agitated

In addition to these common symptoms, there are two distinct types of psychiatric symptoms for psychosis: positive and negative.

Positive symptoms 

Positive symptoms of psychosis include hallucinations, delusions, and disorganized speech and behavior. 

Delusions

Delusions are firmly held beliefs despite evidence that they are untrue. 

The individual experiencing delusions may display a strong resistance to any alternative viewpoints. Their beliefs may be bizarre (where the idea is a physical impossibility), or they may be non-bizarre delusions (untrue but possible beliefs). 

Here are three types of delusions an individual may exhibit signs of:

1. Persecutory or paranoid

Patients believe, without evidence, that a group or individual plans to act nefariously against them.

2. Referential

Finding hidden or special meaning in the ordinary, despite no logical connection.

3. Grandiose

An unsubstantiated belief that the individual possesses unique abilities, talents, or high-importance. 

The delusions may cause an individual to act in erratic, unpredictable ways due to these untrue beliefs. These behaviors may lead to functional impairments with work or relationships. 

In addition, an individual may hold a fixed delusion, but display organized and coherent goal-oriented activity surrounding the delusion. 

Hallucinations 

Many individuals with psychosis also report hallucinations, or perceptions in the absence of external stimuli that are not under voluntary control. 

They can affect any of the senses, but auditory hallucinations, such as hearing voices, are the most common. These voices are typically heard “outside” one’s head. Individuals may also see things that aren’t there. Hallucinations can be very distracting and disturbing for the people who experience them. 

Disorganized thoughts and behaviors  

Some individuals may also display disorganized speech and behaviors. 

Disorganized speech involves nonsensical or illogical speech. 

Disorganized behavior involves unusual or odd actions, or purposeless behavior that others notice as being strange and out of place. An example of this would be inappropriate laughter, or making a headdress out of shirts.

Negative symptoms (aka the 5 A’s of psychosis)

Negative symptoms are exhibited while carrying out normal activities and don’t necessarily ring alarm bells. 

This can make negative symptoms more difficult to treat and, at times, more difficult to identify. They might be perceived as personality traits or lack of interest related to attentional issues. 

The “5 As of psychosis” is a pneumonic to remember the negative symptoms of psychosis:

1. Affective flattening

Lack of emotional reactivity, or reduced emotive intensity and expression. 

2. Alogia

Speech may be lower volume or become less spontaneous, and the individual may give short responses to questions and appear to put minimal effort in conversations

3. Anhedonia

Experience of less pleasure in activities, which may be wrongfully interpreted as a lack of initiative or willingness to engage in hobbies or other activities

4. Asociality

Interest in social engagements is reduced, which may be induced by distracting auditory hallucinations 

5. Avolition

Motivation is severely diminished—seen as an indifference or ambivalence to action

Can you be aware of your own psychosis?

Typically, early in the course of psychosis, an individual has little to no awareness of the development of psychosis. 

Symptoms are typically observed by friends and family who encourage a visit with a mental health professional. 

As treatment ensues and patients are educated about psychosis symptoms, why they happen, when they worsen, and what improves them, they are able to get a better understanding and awareness of psychosis. 

This is the premise of using cognitive behavioral therapy (CBT) for psychosis. 

How do you treat psychosis?

Psychosis treatments involve a variety of approaches. For many patients, psychosis doesn’t fully remit, so learning how to live with the symptoms is crucial. 

Treatment involves patient education on coping strategies for the symptoms of psychosis. 

A version of cognitive behavioral therapy has been developed specifically to help individuals gain a better understanding of their symptoms—such as auditory hallucinations and delusions. 

The patient and provider will collaborate to challenge beliefs about the voices, learn how to control the voices, and uncover the origins of the voices. For example, the patient may be taught how to do “reality testing” of the voices by asking if others can hear them and by trying to record them and play it back. 

Medications can also be crucially important. While considered by many to be just one piece of the treatment algorithm, medication options are evidence-based solutions and a component of various international guidelines for the treatment of psychosis.

Medications known as antipsychotics can treat psychosis. They can also be used for mood disorders such as bipolar disorder, depression, and anxiety (with or without signs of psychosis). 

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