First Episode Psychosis: What It Is and What to Do Next

Psychosis is more common than most people assume. The National Institute of Mental Health (NIMH) reports that between 15 and 100 people out of 100,00 develop psychosis each year. Experiencing first episode psychosis can be frightening, disorientating, and isolating. However, early treatment can make a significant difference. Many people recover and return to work, school, and daily life with the right support. 

In this article, we’ll go over what the first episode of psychosis looks like and the early warning signs to watch for. We’ll also go over treatment and what long-term recovery looks like.

What is first episode psychosis?

First episode psychosis (FEP) is the first time that someone experiences an episode of psychosis. Psychosis is a cluster of symptoms that includes hallucinations or delusions. This makes it hard for people to know what is real and what isn’t.

What does a first episode of psychosis feel like?

A first episode of psychosis can feel like a sudden change in how you perceive or interpret the world around you. Someone experiencing a first episode of psychosis may experience hallucinations, meaning seeing, hearing, or feeling things that aren’t real. For example, someone experiencing psychosis might hear a voice speaking to them that no one else is able to hear. They might also experience delusions, which means believing things that aren’t true. Some people might feel paranoid, thinking others are plotting against them. Others may see themselves as godlike.

Other symptoms of psychosis include feeling that everyday sights or sounds are very vivid or overwhelming. You might not understand what is going on, but notice your thoughts feel confused or strange. Sometimes, your thinking might speed up or slow down. You might also notice that others struggle to understand you. While psychosis can feel overwhelming and frightening, it’s important to remember that it’s not a character flaw or a permanent state. 

How is psychosis different from other mental health experiences?

Psychosis is different from other mental health experiences because the way that you perceive or experience reality differs from that of those around you. In other words, psychosis makes it difficult to tell what is real or what isn’t.

What are the early warning signs of psychosis?

Early warning signs of psychosis often develop gradually over several months or years.

Early signs and symptoms to know

Early warning signs and symptoms include:

• Feeling uneasy or suspicious of other people
• Difficulty thinking clearly or concentrating
• Withdrawing from friends, family, or usual activities
• Irritability, anxiety, or a depressed mood
• A decline in performance at work or school
• Neglecting self-care or personal hygiene
• Confused speech or difficulty communicating
• Reduced energy or motivation
• Difficulty distinguishing what's real from what's not
• Changes in sleep or eating habits
• Unusual or inappropriate behaviors

How early symptoms can be mistaken for something else

Early symptoms of psychosis often show up as behavioral and emotional changes. Because of this, they can be mistaken for other mental health issues or normal life stages, like typical adolescence. If you notice symptoms in yourself or a loved one, try tracking these changes over time to see if symptoms are ongoing. If they are, it’s a good idea to get evaluated by a mental health professional. Experiencing these early symptoms doesn’t always mean you’ll develop psychosis. However, they may signal other mental health issues that could use support. 

What causes first episode psychosis?

First episode psychosis is usually caused by a mix of genetic, biological, and environmental factors.

Common risk factors

According to the NIMH, there is no single cause of psychosis. It is usually caused by a combination of genetic risk, brain development factors, and environmental factors, such as exposure to stress and trauma. In some cases, it may be a symptom of a mental health condition, such as schizophrenia or bipolar disorder. In other cases, there is no underlying mental health condition. Common risk factors for psychosis include:

• A personal or family history of psychotic disorders (such as schizophrenia or bipolar disorder)
• Use of psychoactive drugs, especially high-potency cannabis, methamphetamines, and cocaine 
• Severe stress or childhood trauma
• Complications during pregnancy or birth
• Brain diseases or injury, such as certain brain tumors, strokes, dementia, and Parkinson’s disease
• Sleep deprivation

At what age does psychosis usually start?

The NIMH states that psychosis usually starts in early adulthood, meaning the late teens to mid-20s. However, psychosis can develop at any age. Older adults with neurological conditions like Alzheimer’s, other dementias, and Parkinson’s disease have a higher risk of psychosis.

Is first episode psychosis a medical emergency?

First episode psychosis usually requires urgent mental health care for assessment and because early intervention increases the likelihood of a full recovery. It can be a medical emergency if there is an immediate safety concern. 

When to seek urgent or emergency help

Emergency help is needed when there is an immediate safety risk to the individual experiencing psychosis symptoms or those around them. This includes expressing plans for suicide or self-harm, showing uncontrollable aggression, or having medical signs like being unresponsive. Call 911 if this occurs. 

If there is no immediate danger, urgent help is suggested. Text or call the Suicide and Crisis Lifeline at 988 for support or go to a psychiatric urgent care clinic.

What a psychosis crisis can look like

A psychosis crisis can occur suddenly and looks like difficulty distinguishing between what’s real and what’s not. Specific signs include:

• Hallucinations, meaning hearing, seeing, smelling, or feeling things that aren’t there
• Delusions, or believing things that aren’t true
• Disorganized speech, thinking, or behavior
• Intense fear or confusion

How is first episode psychosis treated?

Early intervention for psychosis is very effective. It reduces the need for hospitalization and lowers the risk of relapse (Correll et al., 2018). According to the NIMH, coordinated specialty care is the evidence-based standard treatment for first episode psychosis. 

Coordinated specialty care

Coordinated specialty care is a team-based approach to care for first episode psychosis. This means that professionals, the person with psychosis, and their family all work together to decide on care. This care usually involves medication and therapy. It also provides support when needed for housing, transportation, and going to work or school. 

Where crisis stabilization fits

Crisis stabilization acts as a bridge between outpatient care, such as coordinated specialty care, and the ER. The focus is on stabilizing crisis symptoms so that you are able to meaningfully engage in your treatment. Depending on the need for supervision, you can receive crisis stabilization in person at a crisis stabilization unit or online through a virtual crisis clinic like Willow Health.

Can you recover from first episode psychosis?

Yes, it is possible to recover from first episode psychosis. According to the Yale School of Medicine, 25% of people who develop psychosis only experience a single episode. Another 50% experience more than one episode but are able to go on to live full lives.

What recovery looks like

Psychosis recovery is individual and non-linear. It often looks like initially working to manage or stabilize disruptive symptoms, such as hallucinations and delusions. It then shifts to establishing supportive daily routines, making time for rest, and reconnecting with loved ones. Over time, it progresses to resuming daily responsibilities, such as returning to work or school. Recovery doesn't always mean symptoms never return. For many people, recovery means learning to manage symptoms while living a meaningful and fulfilling life. 

How to support long-term recovery

Long-term recovery can mean taking medication and engaging in therapy, such as cognitive behavioral therapy (CBT) for psychosis. It can also mean finding peer support and making lifestyle changes to support your mental health and overall well-being, such as practicing good sleep hygiene and managing stress.

How Willow Health can help

Willow Health offers virtual crisis stabilization. This service helps those who need more support than an ER can give but can't wait days or weeks for an intensive outpatient program (IOP). Willow Health can provide immediate, sustained support during and after a first episode, and is currently available in New York and expanding. There is no need to face this alone. Willow Health can provide fast access to compassionate care. Talk to a clinician now.  

First episode psychosis: Frequently asked questions

Can a first episode of psychosis happen only once?

Yes, a first episode of psychosis can happen only once. In fact, about 25% of people who experience psychosis only experience one episode. Most people who have more than one episode are able to live full lives.

How long does a first episode of psychosis last?

A first episode of psychosis can last a few days to months if left untreated. When treated early, most psychosis episodes resolve within a few weeks. 

Does psychosis go away on its own?

If psychosis has a certain trigger, such as sleep deprivation or substance use, it can resolve when these triggers are removed. However, underlying causes do need treatment. Because early intervention is so important to full recovery, it’s best to be assessed if you are experiencing an episode of psychosis. 

Sources

Correll, C. U., Galling, B., Pawar, A., Krivko, A., Bonetto, C., Ruggeri, M., Craig, T. J., Nordentoft, M., Srihari, V. H., Guloksuz, S., Hui, C. L. M., Chen, E. Y. H., Valencia, M., Juarez, F., Robinson, D. G., Schooler, N. R., Brunette, M. F., Mueser, K. T., Rosenheck, R. A., … Kane, J. M. (2018). Comparison of early intervention services vs treatment as usual for early-phase psychosis: A systematic review, meta-analysis, and meta-regression. JAMA Psychiatry, 75(6), 555–565. https://doi.org/10.1001/jamapsychiatry.2018.0623 

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National Alliance on Mental Illness. (n.d.). Psychosis. https://www.nami.org/types-of-conditions/psychosis/ 

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National Alliance on Mental Illness. (2023). What is early and first-episode psychosis? https://www.nami.org/wp-content/uploads/2023/08/What-is-Early-and-First-Episode-Psychosis.pdf 

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National Institute of Mental Health. (2023). Understanding psychosis. U.S. Department of Health and Human Services, National Institutes of Health. https://www.nimh.nih.gov/health/publications/understanding-psychosis 

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Yale School of Medicine. (n.d.). Psychosis. Program for Specialized Treatment Early in Psychosis (STEP). https://medicine.yale.edu/psychiatry/step/psychosis/