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Schizophrenia and Other Psychotic Disorders

Prof. David Roe, Clinical Psychologist, Department of Community Mental Health, Haifa University;  Dr. Gili Hoter Ishay, Occupational Therapist, Department of Community Mental Health, Haifa University ;  Dr. Aviv Segev, Specialist Psychiatrist, Director of the Center for Diagnosing and Treating Psychotic Disorders, Shalvata Mental Health Center
16 June 2025

Psychotic disorders are severe mental conditions that affect thinking, perception and behavior, in addition to affecting judgment of reality. The main symptoms include hallucinations (false sensory perceptions), delusions (fixed and unfounded beliefs), disorganized thinking and behavior, and diminished function. Psychotic conditions manifest as several disorders, including a brief psychotic episode, schizophreniform disorder, schizophrenia and schizoaffective disorder. 

The causes of these disorders are complex and involve a combination of genetic, biological, environmental and psychological factors. Risk factors include family history, use of psychoactive substances, stressful life events and certain medical conditions.  

The First Episode Psychosis largely occurs in young adulthood, by the age of 25, frequently parallel to the transition between significant life functions, and may suddenly or gradually occur. It is important to note that a psychotic episode, or psychosis, is not considered a disease in and of itself but a symptom. Its presence does not necessarily indicate a chronic and ongoing disease. 

It is not always easy to identify early warning signs of psychosis. They may assume different forms based on the cause of the psychosis itself and may occasionally occur days or even weeks before other symptoms or not appear at all. What should be noted is changes, particularly changes in behavior, mood, onset of anxiety, suspicion and distrust of others, increased interest in religion or mysticism, and occasionally even hearing voices or seeing things that do not exist in reality. In addition, behavioral changes, such as social distancing and withdrawal, diminished function at work or in studies, as well as changes in sleeping and eating patterns may occur. 

The good news is that with proper treatment, the chances of recovery can significantly improve, and prevent recurrence of episodes. 

Psychotic disorders are a group of mental conditions that affect emotion, lead to changes in thinking, perception, and behavior, and severely impair judgment of reality. For some people, this is a one-time, transient event, while others experience a more prolonged course that requires ongoing attention and treatment.

Over the years, there has been a significant change in the understanding and treatment of these disorders. The modern therapeutic approach combines pharmacological and psychosocial interventions, allowing many of those struggling with them to lead active and meaningful lifestyles.

Types of psychotic disorders

There are several forms of mental health disabilities that include psychotic symptoms: 

 

Sudden episode of psychotic symptoms, and short-term - up to one month, generally erupts after exposure to a serious stress factor (trigger). There are cases in which the episode occurs without a trigger, such as after a prolonged period of functional decline, known as prodrome, and manifests as symptoms such as unusual social withdrawal or detachment for the individual. If the episode erupts due to a trigger, acute and begins suddenly, the expected prognosis for the course of the disease and recovery is better. It may occasionally take a person time to recover and return to their life and needs assistance to rehabilitate the damages caused during the episode. 

a psychotic disorder that lasts over one month; but less than six months and includes a group of symptoms (but not all) of hallucinations, delusions, disorganized thinking or behavior as well as negative symptoms (social and functional withdrawal).   

a chronic psychotic disorder that was diagnosed with symptoms that last for over six months and characterized by chronic problems in thinking (cognition), behavior and emotions, as manifested in the symptoms that were noted: hallucinations, delusions, disorganized thinking or behavior and negative symptoms, i.e. social and functional withdrawal.  

characterized by a combination of schizophrenia and two possible types of mood disorders: symptoms of schizophrenia along with symptoms of depression, or symptoms of schizophrenia along with symptoms of bipolar disorder. 

presence of one or more delusions that last for one or more months, generally without any other psychotic symptoms. Any accompanying symptoms and dysfunction will center around the topic that the delusional thought is about, and therefore function is relatively preserved. This is a far rarer disorder, which, unlike other psychotic disorders, can occur across a wider age range.  

Psychosis that is caused or exacerbates due to physical illness, such as dementia, inflammatory or infectious disease, metabolic disorder or brain trauma. 

Psychosis that may erupt as a result of use of psychoactive or addictive substances, such as cannabis, amphetamines, other drugs and even alcohol, certain medications such as steroids and drugs used to treat Parkinson’s disease or as a result of quitting said substances. 

Symptoms of a psychotic episode

The course of disease in schizophrenia and other psychotic disorders is characterized by periods of flareup followed by remission  (waning of symptoms). Remission is sometimes full and sometimes partial, in other words - symptoms remain at low intensity. Remission may be spontaneous or may be achieved through medication. It is important to note the critical importance in preventing and rapidly treating acute psychotic flare-ups, because each such flare-up has very serious consequences by the mere dealing with the symptoms of the psychotic state. Furthermore, every psychotic episode increases the risk that the return to remission will be incomplete. 

 

  • Delusions
  • Hallucinations
  • Disorganized thinking
  • Unacceptable behavior
  • Diminished function
  • Delusions: fixed, false and baseless beliefs that no fact or argument will cancel them. There are many types of delusions, such as delusion of control, thought broadcasting, guilt, etc. Among the most common delusions are:  
    • persecutor delusion: characterized by the feeling that someone wants to harm you, injure you or monitor you.  
    • Reference delusion: characterized by a false addressing of hints, messages or signs from the external environment and perception of them as if they were personally directed at them.   
    • Grandiose delusions: grandiose thoughts,  such as the feeling of having special powers, special identity or mission. 
  • Hallucinations: sensory misperception. In other words, a perception that seemingly arrives from one of the individual’s senses but is not related to external reality. The most common form is auditory (hearing sounds that are not real) and visual hallucinations but on extremely rare occasions, odor, taste and tactile hallucinations (to smell, taste and feel things that do not actually exist). 
  • Disorganized thinking: primarily manifested in the way an individual expresses himself, i.e. in the way he speaks. Speech may be unfocused, quickly jumping from one subject to the next, speech that is cut off or disconnected. In these situations, speech becomes meaningless and illogical, and the environment can find it difficult to understand what the person is trying to say. 
  • Disorganized, odd or unacceptable motor behavior: this may manifest in several ways, from repetitive, purposeless movements to freezing or alternatively - significant unrest, tumultuous and unexpected behavior. 
  • Significant decline in normal function (negative symptoms): manifests as impaired normative functional capacity, such as lack of enjoyment and lack of motivation, social withdrawal, neglect in personal hygiene, etc. These types of negative symptoms are less visible in the First Episode Psychosis than early symptoms that were listed but these include health and social risks, due to passivity, withdrawal, detachment and neglect. Negative symptoms largely do not appear in the acute stage of the disease, and more characterize the course of a chronic, long-term disease. 

Risk factors for psychosis

The exact causes of psychotic disorders are still not completely understood, despite the many years of research in this area. However, the understanding that has been gained over the years is that this is a neurodevelopmental disease, meaning that the seeds for it exist in a person many years before the onset of the disease, and that various factors can cause these seeds to germinate and become an active disease, or to remain dormant throughout life.  

There is currently solid evidence that reveals a combination of genetic, biological, environmental and psychological factors that trigger the onset of the disorder:

  • Genetics
  • Brain chemistry and structure
  • Substance abuse
  • stressful life events
  • other medical event
  • Genetics: Family history of psychotic disorders increases the risk. Many studies indicate that psychotic conditions involve a strong genetic component, and they are more common in individuals who have one or more family members who suffer from a psychotic disorder. At the same time, an individual may develop one of these conditions without having a family history, and individuals with a family member who suffers from a psychotic disorder may not necessarily develop this disorder. A large number of genes were identified as increasing the risk of onset of a psychotic disorder, but the contribution of every gene is extremely limited, thereby preventing genetic identification prior to onset of the disorder.   
  • Brain chemistry and structure: An imbalance in the neurotransmitters in the brain and differences in brain structure may contribute to the development of psychosis. For example, many studies have repeatedly proven that in most people who suffer from a psychotic disorder, there is a disruption in transport of dopamine in a certain area of the brain (the mesolimbic pathway). Other cases reveal another disruption in the glutamate neurotransmitter in another area of the brain (known as ACC). It may reasonably be assumed that in the future, other areas and substances will be identified as being linked to the development of psychotic conditions.  
  • Use of psychoactive substances: Abuse of such substances as cannabis, LSD or amphetamines (stimulants) may trigger psychotic episodes. The increased rate of psychotic disorders in users of these substances has been proven in dozens of studies, and accordingly, use of these substances is unquestionably a risk factor and trigger of psychotic conditions. It should be noted that symptoms of the disorder do not always appear after single use or limited use. The effect may occasionally be cumulative and attributed to prolonged use and may lead to psychosis. It is also important to note that transient psychosis may appear as a side effect of prescription medication, such as treatment with steroids, treatment of Parkinson’s disease.  
  • Stressful life events: Every individual experiences these events during their life, some negative and some positive, such as divorce, termination from job, death of a relative, as well as wedding, birth, etc. These types of stressful events, personal or national, may trigger the onset of a psychotic disorder, or cause a recurrence of an episode in a person who has already coped and been diagnosed with said disorder.   
  • Psychotic disorder attributed to another medical condition: Neurological conditions such as CVA, tumors, infections, inflammatory diseases that involve the brain as well as neurocognitive disorders, such as Alzheimer Disease and vascular dementia, endocrinological diseases, metabolic diseases as well as certain genetic disorders may cause symptoms of psychosis. 

Dealing with psychotic disorders or conditions can be complex and upsetting for both the person experiencing them and those around them, but it is important to remember that this is a medical condition that can usually be treated successfully. With early identification, appropriate treatment, and professional support from the person's natural environment, it is possible to significantly improve the chances of recovery, allow a gradual return to routine and meaningful functioning, and reduce the chance of relapse. In recent decades, advanced tools and approaches have been developed that combine medication with emotional, social, and occupational support, with the aim of providing the person with optimal conditions for a sense of stability and capability and to return to optimal functioning and a routine. With a holistic approach and appropriate support, it is possible to live a full and satisfying life.