Could You Recognize the First Signs of Psychosis?
Why all therapists need a working knowledge of psychosis.
Updated May 28, 2026 | Reviewed by Michelle Quirk
Psychosis and schizophrenia are among the most common mental health concerns. Yet, these terms remain draped in misunderstanding, even among clinicians.
As a therapist who has experienced psychosis herself, I often find myself seeking to correct misunderstandings. No, not all (or even most) extreme or difficult-to-understand behavior is considered "psychosis." Yes, people can have a first episode of psychosis after their 20s, especially women (Díaz-Pons et al., 2022). In psychosis care, multiple diagnoses are often the norm, not the exception, with many individuals' experiences falling outside the straightforward confines of DSM criteria. Watchful waiting is not always a good idea, even when we want to protect someone from the stigma of particular diagnostic labels.
And yes, often, people do get better.
Why All Therapists Need a Working Knowledge of Psychosis
I recognize the lack of knowledge. Psychosis is one of thousands of difficulties that lead people to see mental health practitioners, and aspects of psychosis remain mysterious even to psychosis experts and researchers.
Still, with early detection and intervention being documented as one of the best predictors of quality of life and recovery (Salazar de Pablo et al., 2024), being able to identify the signs of psychosis and route to appropriate care when necessary is essential for mental health clinicians.
Within the United States, more than 400 early psychosis specialty clinics exist. Mostly funded through a large block grant through the Substance Abuse and Mental Health Services Administration (SAMHSA), these programs offer wraparound assessment and support to individuals in the earliest stages of psychosis. Called coordinated specialty care (CSC) programs, the philosophy of these centers is that through specialized psychotherapy , family interventions, psychiatric care, peer support, and assistance with work or school, individuals experiencing psychosis can live well with their conditions.
And the evidence has been outstandingly positive, with many such programs showing results of 80 percent of participants re-engaging with work or school after 6 months, and just 10 percent needing hospitalization after 3 months (Nossel et al., 2018).
Laurie Stephens is a psychologist and senior director of Autism Services at the Help Group, which offers such an early psychosis program. I spoke with her about what clinicians and others can look out for in terms of the early signs of psychosis.
Together, we identified four key signs.
While schizophrenia is one cause of psychotic symptoms, several origins exist. The most prevailing theory of what causes psychosis involves a mix of genetic vulnerability to stress and stress/ trauma , with sufficient stress being believed to ignite a cascade of biological events culminating in psychosis (Grąźlewski et al., 2023). The stress hormone cortisol appears to be a key player, with individuals at high risk of psychosis having alterations in the cortisol awakening response.
Stephens shares, "Trauma exposure has a high correlation with psychosis, and there is a genetic component. When you put the genetic component in with these extremely high stressors, it becomes very difficult to cope." She expands, " PTSD and trauma have a high comorbidity with psychosis."
Stephens emphasizes that it is important to ask, "Could this be because of extreme and new kinds of stress? In those cases, we might deal with that instead of moving straight into medication management for psychosis...It is a dual-modality treatment of trauma-informed care and treatment for psychosis."
Autistic individuals are also at a heightened risk of psychosis. Stephens reflects, "Out of our population, about 35 percent either carry an autism spectrum diagnosis or are suspected of having an autism spectrum diagnosis."
What is most important to know is that the outlook for people experiencing psychosis is bright. People living with these conditions can have meaningful relationships and chase their dreams just like everyone else. A study that followed people who received treatment for a first episode of psychosis over 10 years found that 60 percent reported satisfaction with their lives, a number likely comparable to the general population (Simonsen et al., 2024).
For those in need, SAMHSA offers a treatment locator for early psychosis care. To find a therapist near you, visit the Psychology Today Therapy Directory.
Díaz-Pons, A., González-Rodríguez, A., Ortiz-García de la Foz, V., Seeman, M. V., Crespo-Facorro, B., & Ayesa-Arriola, R. (2022). Disentangling early and late onset of psychosis in women: identifying new targets for treatment: Archives of Women's Mental Health , 25 (2), 335–344.
Grąźlewski, T., Kucharska-Mazur, J., Misiak, B., & Samochowiec, J. (2023). Disturbances of cortisol awakening response in psychotic disorders and at-risk states—a literature review. Archives of Psychiatry and Psychotherapy , 25 (2), 7–14.
Nossel, I., Wall, M. M., Scodes, J., Marino, L. A., Zilkha, S., Bello, I., ... & Dixon, L. (2018). Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatric Services , 69 (8), 863–870.
Salazar de Pablo, G., Guinart, D., Armendariz, A., Aymerich, C., Catalan, A., Alameda, L., & Correll, C. U. (2024). Duration of untreated psychosis and outcomes in first-episode psychosis: systematic review and meta-analysis of early detection and intervention strategies. Schizophrenia Bulletin , 50 (4), 771–783.
Simonsen, C., Åsbø, G., Slade, M., Wold, K. F., Widing, L., Flaaten, C. B., & Melle, I. (2024). A good life with psychosis: rate of positive outcomes in first-episode psychosis at 10-year follow-up. Psychological Medicine , 54 (9), 2112–2121
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Jennifer Gerlach, LCSW, is a psychotherapist based in Southern Illinois who specializes in psychosis, mood disorders, and young adult mental health.
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