Psychosis & schizophrenia

What is psychosis?

Psychosis describes a set of symptoms in which a person loses some contact with reality. It is not a diagnosis in itself, in the same way that fever is a symptom with many possible causes. The main features are:

• Hallucinations: seeing, hearing, smelling or feeling things that others do not. Hearing voices is the most common, such as voices commenting on the person, criticising them or telling them what to do.
• Delusions: firmly held beliefs that are not based in reality and do not change with evidence, such as believing that neighbours are plotting against you, that the television is sending you special messages, or that someone is controlling your thoughts.
• Disorganised thinking and speech: jumping between topics, answers that don’t connect to the question, or speech that is hard to follow.
• Changes in behaviour: unusual or unpredictable behaviour, laughing or talking to oneself, or sitting still for long periods.

Some people also experience a slowing down of daily life, sometimes called negative symptoms: less motivation, reduced speech, little expression of emotion, and withdrawal from friends and family. These are easily mistaken for laziness or rudeness, but they are part of the illness.

To the person, these experiences feel completely real. That is why arguing with someone about their beliefs rarely helps, and why they may not feel that anything is wrong.

What is schizophrenia?

Schizophrenia is a long-term mental health condition and one of the more common causes of psychosis. It affects thinking, perception, emotions and behaviour. According to the World Health Organization’s ICD-11 classification, the diagnosis requires symptoms such as delusions, hallucinations or disorganised thinking lasting at least one month, which are not caused by a substance, a medicine or another medical condition.

People are usually first diagnosed between the ages of 16 and 30. The illness can follow different courses. Some people have a single episode and recover fully; others have episodes that come and go; a smaller number have symptoms that continue over time. With treatment, the outlook is often much better than families fear. The WHO states that at least one in three people with schizophrenia will be able to fully recover.

Other causes of psychosis

Psychosis can also occur with:

• Bipolar disorder: during severe episodes of mania or depression
• Severe depression: sometimes with beliefs of guilt, illness or ruin
• Substances: cannabis (ganja, bhang, charas), stimulants such as amphetamines and cocaine, and alcohol, during heavy use or withdrawal
• Medical conditions: including some illnesses that affect the brain, such as Parkinson’s disease and dementia
• Other factors: severe lack of sleep and certain prescription medicines

Because the causes and treatments differ, a careful medical and psychiatric assessment is essential before a diagnosis is made.

Early warning signs

Psychosis often does not start suddenly. Gradual changes in thinking, mood and social life often appear weeks or months before the first clear episode. Families may notice:

• Withdrawing from friends and family, or spending long periods alone
• A drop in marks at college or performance at work
• Becoming unusually suspicious or fearful of others
• Strange or intense new ideas, or a sudden preoccupation with religion, spirituality or special powers
• Trouble thinking clearly or concentrating
• Neglecting bathing, grooming or meals
• Sleeping very little, or at odd hours
• Speech that is confused or hard to follow
• Difficulty telling what is real from what is imagined

One of these alone is not a cause for alarm, especially in teenagers. But several together, particularly with a decline in daily functioning, deserve an assessment.

How common is it?

Worldwide, about 1 in 300 people live with schizophrenia. In India, the National Mental Health Survey 2015–16 found that about 1.4% of adults had experienced schizophrenia or another psychotic disorder at some point in their lives, and about 0.4% were affected at the time of the survey.

The same survey found a treatment gap of about 75% for psychosis, meaning that roughly three out of four people who needed care were not receiving it. Many families first turn to faith healers or wait for the problem to pass. Faith and prayer can be a real source of comfort, but psychosis also needs medical care.

Why does it happen?

There is no single cause. Several factors usually combine:

• Genes. Having a close relative with schizophrenia increases the risk, although most people with a family history never develop it.
• Brain development. Differences in how the brain develops and matures seem to play a role.
• Stress. Major life stress can trigger an episode in someone who is vulnerable.
• Cannabis and other drugs. Heavy cannabis use is linked to a higher risk of schizophrenia, and stimulants can trigger psychosis.

Psychosis is not caused by bad parenting, a weak character, black magic or evil spirits. No one is to blame.

Why early treatment matters

The time between the first symptoms of psychosis and the start of proper treatment is called the duration of untreated psychosis. Research, reflected in the Indian Psychiatric Society’s treatment guidelines, shows that a longer duration of untreated psychosis predicts poorer outcomes later.

Starting treatment early after a first episode helps:

• Symptoms settle faster and more completely
• Studies, work and relationships are less disrupted
• The risk of hospital admissions and crises is lower
• The risk of self-harm and violence falls with treatment

First-episode care focuses on a thorough assessment, gentle and well-monitored medicine, clear information for the person and family, and early return to college or work. Some people who receive early treatment never have another episode.

When to see a psychiatrist

Please arrange an assessment if you or someone close to you:

• Is hearing voices or seeing things others do not
• Has developed fixed, unusual or frightening beliefs
• Has become very suspicious, withdrawn or confused
• Has had a noticeable decline in studies, work or self-care
• Has had psychotic symptoms after using cannabis or other drugs
• Was treated for psychosis before and is showing similar early signs again

You don’t need to be certain it is psychosis. It is always better to check early.

How psychosis is diagnosed

The first consultation is an unhurried conversation with the person and, with their permission, the family. The psychiatrist asks about the symptoms, when and how they began, sleep, mood, substance use, stress, physical health, medicines and family history. Families often provide important details that the person may not recognise as unusual.

A physical examination and investigations, such as blood tests and sometimes a brain scan, help rule out medical causes and substance-induced psychosis. The diagnosis follows international criteria (ICD-11). Sometimes the exact diagnosis becomes clear only over weeks or months of follow-up, but treatment can start straight away.

Treatment

Treatment is tailored to the person and usually combines the following.

1. Antipsychotic medicines

Antipsychotic medicines reduce hallucinations, delusions and disorganised thinking, and help prevent relapse. They are not sleeping pills and they are not addictive. The psychiatrist chooses a medicine based on your symptoms, physical health and preferences, starts with a low dose and reviews regularly. Some are available as long-acting injections for people who find daily tablets difficult.

Side effects such as weight gain, sleepiness, restlessness or stiffness can occur, so regular checks of weight, blood sugar and cholesterol are part of good care. Medicines should only be started, changed or stopped with your doctor.

2. Talking therapies and psychosocial support

• Psychoeducation: clear information about the illness, treatment and warning signs
• Cognitive behavioural therapy (CBT): learning ways to cope with distressing voices and beliefs
• Social skills and stress management: rebuilding confidence in daily situations
• Help with substance use: treating cannabis, alcohol or other substance problems at the same time

3. Family work

Families are partners in care. Family sessions explain the illness without blame, help relatives recognise early warning signs, and teach calm ways to communicate and solve problems. A home with less criticism and conflict makes relapse less likely.

4. Rehabilitation: study, work and daily life

Recovery means more than reducing symptoms. Rehabilitation helps people return to a daily routine, to studies or work, and to social life. This may include structured activities, vocational guidance, and step-by-step goals such as travelling independently or managing money.

Outpatient, online or hospital care?

• Outpatient care suits most people, with regular reviews while living at home.
• Online consultations are convenient for follow-up, medicine reviews and family guidance.
• Hospital care may be advised during a severe episode, when there is risk to the person or others, or when the person is not eating, drinking or sleeping.

Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, and online.

Staying well: relapse prevention

Once symptoms settle, the focus shifts to staying well. After a first episode, medicines are usually continued for at least one to two years, and often longer. Many people feel well and want to stop, but stopping suddenly, or without medical advice, is a common reason the illness returns. Any reduction is done slowly and with close monitoring.

A relapse prevention plan helps. It lists your personal early warning signs (such as poor sleep, irritability or growing suspiciousness), what to do, and whom to contact. Regular sleep, avoiding cannabis and other drugs, managing stress, and keeping follow-up appointments all protect against relapse.

Your rights under the Mental Healthcare Act, 2017

The Mental Healthcare Act, 2017 protects people with mental illness in India. Among other rights, it gives every person:

• The right to access mental healthcare from services run or funded by the government
• The right to live with dignity and to be protected from cruel, inhuman or degrading treatment
• The right to be treated equally with people with physical illness, without discrimination
• The right to confidentiality about their mental health and treatment
• The right to information about their illness and treatment

Adults can also make an advance directive: a written statement of how they wish, and do not wish, to be cared for and treated if they later lose the capacity to make these decisions. It does not apply to emergency treatment. Adults can also appoint a nominated representative to support decisions on their behalf if needed.

For families

Seeing a loved one with psychosis can be frightening and heartbreaking. Families in India often carry most of the care, and they need support too. A few things help:

• Stay calm and speak simply. Don’t argue about delusions, but don’t pretend to agree either. Acknowledge feelings: “That sounds frightening.”
• Encourage treatment gently and help with appointments and medicines
• Learn the early warning signs and keep the relapse prevention plan handy
• Keep home life calm, predictable and free from criticism
• Remove cannabis, alcohol and easy access to means of self-harm
• Take any talk of self-harm seriously and seek help promptly
• Look after your own health, rest and support

You are welcome to consult Dr. Tarwani first, on your own, to plan the next steps.

Common myths

• “People with schizophrenia are dangerous.” Most people with schizophrenia are not violent. They are more likely to be harmed by others than to harm anyone, and the risk falls further with treatment.
• “Schizophrenia means a split personality.” It does not. It affects thinking and perception, not a person’s identity.
• “It is caused by black magic or bad parenting.” Psychosis is a health condition with biological and environmental causes. No one is to blame.
• “Once diagnosed, a person can never live a normal life.” Many people recover, work, marry and raise families.
• “Marriage will make the illness go away.” Marriage does not treat psychosis, and the added stress can trigger a relapse. Treatment comes first.
• “Medicines are only needed while someone is very unwell.” Continuing treatment after recovery is an important protection against relapse.