The Onset of Psychosis in Young People

What would you do if you started to hear sounds, or voices, but had no idea where they were coming from? What if you started to see things that other people couldn’t see? Or if you became convinced that the characters on your favourite television show had a special message for you? What if you believed that people… either strangers, or even those closest to you… were out to get you, or harm you in some way? 

Psychosis is a frightening experience for both those who suffer from it, as well as for the family and friends that surround them. Psychosis can, in fact, be debilitating and have a significant impact on a young person’s cognitive development, school performance, social relationships, and general life functioning. While many school professionals may have had experience with more common mental health symptoms, such as depression or anxiety, symptoms of psychosis might seem overwhelming and far beyond our interventions. It is true that psychosis is a serious mental illness that does require specialized psychiatric treatment. As school counsellors, we will never hold the direct responsibility of intervening with psychosis. However, it is helpful for school professionals to have some awareness or understanding of the nature of psychosis, as approximately 20-30% of those who are ultimately diagnosed with schizophrenia in adulthood experience their first symptoms of psychosis in adolescence (Maloney, Yakutis, & Frazier, 2012; Wozniak, et. al., 2008).

What is Psychosis?

Psychosis is often used synonymously with Schizophrenia, but psychosis is actually a symptom – or a cluster of symptoms – rather than a specific disorder itself. Psychosis is marked by a person’s disconnection from reality. What they perceive to be real is not the same as what others perceive to be real. Psychotic symptoms are typically grouped into three categories: hallucinations, delusions, and disorganized behaviour.

(Schwartz, et. al. , 2009)

Psychosis arises in the brain and may be caused by a number of different factors. It is believed that a genetic vulnerability exists towards psychosis. There are a number of psychiatric disorders where psychosis may be present, and in these cases symptoms may begin to appear as a result of stress or trauma, but also may materialize without any clear trigger. The most common psychotic disorder is Schizophrenia. However, psychosis may also be present in other disorders such as Bipolar Disorder, or severe Depression.

Psychosis may also present outside of a psychiatric illness and may be caused by substance use (“drug-induced psychosis”), or as a side effect of a medical disorder (e.g., epilepsy, infection, or head injury). If psychosis is caused by substance use or a medical condition, in most cases the psychotic symptoms will generally subside once the root problem is treated. For example, if someone begins to experience psychosis as a by-product of excessive marijuana usage, those psychotic symptoms will most often decrease once their substance use has been addressed.

“Prodromal” period

The most common age of onset for psychotic symptoms or schizophrenia is in early adulthood.  At the same time, a sizeable minority of those with Schizophrenia experience their first psychotic episode in late adolescence. As well, even for those who do not experience their first psychotic break until adulthood, psychosis and schizophrenia do not typically present “out of nowhere”. Early warning signs can begin to present during much earlier adolescence. This period, prior to the onset of full-blown psychosis or schizophrenia, is referred to as the “prodromal period”. As school professionals, it is most likely that we will encounter youth in this stage. Typical prodromal symptoms include: social withdrawal, a deterioration in self-care or hygiene, increased irritability, suspiciousness, difficulty organizing one’s thoughts, sleep disturbances, changes in appetite, and mood changes. Unfortunately, many of the symptoms of prodromal psychosis look very similar to the symptoms of other disorders – or even just a variation of “typical” teen behaviour. It can be extremely difficult to tease out prodromal symptoms, and often prodromal symptoms are only recognized in retrospect, after acute psychotic symptoms have appeared.

How is Psychosis Treated?

Research has shown that early identification is key to effective treatment and remission of psychosis, and to lessening the detrimental impacts of psychosis on cognitive development and overall functioning. Mental Health services across the country typically have a specialized Early Psychosis Program, designed to identify and intervene with early symptoms of psychosis. In cases where psychosis is suspected, such specialized programs will be able to perform a comprehensive assessment of symptoms. When identified quickly, early intensive intervention can decreased the rate of relapse by up to 50%.

Pharmacology (the use of anti-psychotic medication) is the most common form of treatment for psychosis and is typically the “first line of defence” in the effective treatment of symptoms. It is worth noting, that anti-psychotic medications can also come with significant side-effects (e.g., intense drowsiness, nausea, dizziness, weight gain, and an overall sense of “being drugged”), which may make some youth resistant to taking them.

Other components of treatment include psycho-education (educating youth and their families regarding the symptoms and how to respond), cognitive therapies (challenging thought patterns), and healthy self-care regimes.

What can School Counsellors do?

As noted, school professionals are not able to treat psychosis, and a youth who is presenting with psychotic symptoms, or who you suspect may be exhibiting prodromal symptoms, must be immediately referred to specialized medical or psychiatric professionals. However, there are ways that school professionals can support students who are suffering:

  • Talk to the youth, and their parents, about any symptoms you are seeing, and support them in contacting the relevant professionals;
  • Psychosis continues to carry intense stigma and judgement, and most adults and youth do not know what to do when they discover that someone they know is experiencing psychosis. School professionals can be integral to de-stigmatizing the youth’s symptoms to other staff and students.
  • When a youth returns from a period of treatment for their illness, they may have missed extensive amounts of school. Additionally, their recovery program (e.g., medication) may mean that they do not have the attentional capacity, or the energy, to succeed in their courses. A school counsellor can engage a youth in vocational/education assessment and counselling to determine their current strengths and help in setting realistic goals.
  • Psychotic symptoms are often triggered, or exacerbated, by stress and fatigue. Helping youth to learn healthy self-care strategies (e.g., relaxation, stress management, sleep hygiene, exercise) is a practical way that school staff can aid in the treatment of a youth’s symptoms.

Psychosis can be terrifying for those suffering from it, as well as their families, friends, and support network. But psychosis is treatable, and many youth can function well in their lives, with early identification and treatment. Early identification and intervention is key to hope and success in recovery, and school professionals can be integral resources in this regard.

By: Laura Hamilton

Helpful websites:

Maloney, A.E., Yakutis, L.J., & Frazier, J.A. (2012). Empirical evidence for psychopharmacologic treatment in early-onset psychosis and schizophrenia. Child and adolescent psychiatric clinics of north america, 21(4): 885–909.
Schwartz, C., Waddell, C., Barican, J., Garland, O., Nightingale, L., & Gray-Grant, D. (2009). Understanding and treating psychosis in young people. Children’s mental health research quarterly, 3(3), 1-24.
Wozniak, J. R., Block, E. E., White, T., Jensen, J. B., & Schulz, S. C. (2008). Clinical and neurocognitive course in early-onset psychosis: A longitudinal study of adolescents with schizophrenia-spectrum disorders. Early Intervention in Psychiatry, 2, 169–177.Third Reference