Understanding psychosis: what the mind may be trying to say

Have you ever stayed awake for a night and a day, and noticed how strange the world began to feel? Sounds get sharper. Shadows seem to move at the edge of your vision. A stranger’s glance feels a little too long.

This is what a healthy brain can do when it is pushed far enough. In studies where volunteers went without sleep, distorted perception and anxiety set in within a day or two. By the third day awake, some heard and saw things that were not there, and held beliefs that made little sense to anyone else. In many of them, a period of normal sleep made these experiences fade.¹

What psychosis is

Psychosis is a state in which a person loses some contact with the reality other people share.² They may hear or see things that other people do not. These are called hallucinations (opens in a new tab). They may also hold delusions (opens in a new tab) – strong beliefs that feel completely true to the affected person, but don’t seem plausible to anyone else. For example that people on television are sending them messages, or that someone is trying to harm them. Thoughts can come out tangled, and speech can become hard to follow.²

Psychosis is not a diagnosis in itself. It can be part of schizophrenia, bipolar disorder or severe depression. It can also follow a lack of sleep, some prescribed medicines, or the use of alcohol or drugs. And a person can go through psychosis without ever receiving a diagnosis.²

It is also more common than many people think. In a survey of more than 31,000 adults in 18 countries, about 6 in 100 had heard or seen something others could not, or held a belief of this kind, at least once in their lives. For most of them, it happened no more than a handful of times.³

When the brain’s signals get crossed

So what is happening in the brain?

One influential idea comes from the psychiatrist Shitij Kapur. Your brain has a system that marks what deserves your attention, such as your name called across a busy room or the smell of smoke. The messenger substance dopamine (opens in a new tab) helps to run it. Kapur proposed that in psychosis, this system starts to flag ordinary things as significant. A number plate, a cough on the bus or a song on the radio suddenly feels charged with meaning, as if it were meant for you. The mind then looks for an explanation, and a belief that you are being watched can be the explanation it finds.⁴

Seen this way, psychosis may be the brain communicating in an unproductive way. Its signals are real, but they arrive at the wrong volume, about the wrong things.

The meaning behind a voice or a belief

If the signals are real, so is the material they draw on. What a voice says, or what a belief is about, can come from the person’s own life.

In one study of people with psychosis who had lived through trauma, more than half had hallucinations that echoed it. In a few, they repeated what had happened. In many more, they carried its themes without repeating the events.⁵ Hard experiences in childhood, such as neglect, bullying or the death of a parent, are also linked to psychosis: across 36 studies, people who had faced them were almost three times as likely to develop it.⁶

Fears of being harmed can be understood in a similar way. Researchers describe them as beliefs about threat, kept going by worry, low self-confidence and the habit of avoiding situations that feel dangerous. Treatment based on this idea helps people learn, step by step, that they are safe again.⁷

Behind a voice or an unusual belief, there may be a fear, a loss or a memory looking for a way to be heard. Not every voice can be traced back to a story, and some show no link to the person’s past at all.⁵ But asking what an experience might mean can be a better start than asking whether it is true.

Listening for what lies underneath

If someone close to you is in psychosis, you may not be able to talk them out of what they hear or believe. You can still listen for what lies underneath. What is the fear inside this belief? What does the voice keep coming back to? Asking about feelings, rather than arguing about facts, keeps the conversation open.

Psychosis is not a fixed fate either. Across 79 studies that followed people for years after a first episode, more than half reached remission, a period with few or no symptoms, and nearly 4 in 10 recovered. A steady decline, the authors concluded, is not the typical course.⁸ Early help tends to mean a better recovery,² so if you notice the first signs in yourself or someone you love, contact a GP. Services that specialise in psychosis in the Netherlands and Belgium are listed in Find a clinic (opens in a new tab).