What is First Episode Psychosis?

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Summary: First episode psychosis refers to the first time a person experiences symptoms of psychosis associated with several types of severe mental illness.

Key Points:

Psychosis and psychotic disorders typically appear between ages 15 and 24, but may develop throughout adulthood, into the 40s.
Symptoms can be confusing and frightening for the person experiencing them and for their family members.
Symptoms may appear as the early signs of psychotic disorders, but may also appear in mood/depressive disorders, and/or as a response to extreme stress.
People experiencing first episode psychosis (FEP) should understand that effective treatment is available and people who experience psychosis can live full, productive lives.

First Episode Psychosis: Basic Facts

To understand what we mean by first episode psychosis, it’s important to understand by the term it includes: psychosis. Here’s how experts from the American Psychological Association (APA) define the term:

“…a mental state involving significant problems with reality testing, characterized by serious impairments or disruptions in the most fundamental higher brain functions – perception, cognition and cognitive processing, and emotions or affect – as manifested in behavioral phenomena, such as delusions, hallucinations, and significantly disorganized speech.”

At its core, psychosis refers to dysfunction – or significant difference, compared to most people – in the way an individual experiences reality. A person may experience distorted perceptions, called hallucinations, distorted beliefs, called delusions, distortions in their capacity to engage in logical, consistent thought and communicate those clearly and effectively, called thought disorder.

Based on that definition and brief explanation, it’s easy to understand what we mean by first episode psychosis, also called FEP:

First episode psychosis refers to the first time an individual experiences psychotic symptoms such as hallucinations, delusions, or disordered thoughts/thinking.

The latest data on the prevalence rates of psychosis in the general adult population shows:

Past-year psychosis: 3.95 per 1,000
Ever had psychosis: 7.5 per 1,000

Transition from FEP to psychotic disorder: ~20% of people with FEP

Applying basic math to an adult population in the U.S. of around 270 million, those rates work out to roughly one million people experiencing psychosis in any given year, and over two million people developing psychosis at any point during their lives.

What Disorders Include Psychotic Symptoms?

Research shows symptoms of psychosis may appear in several types of mental health disorders, including, but not limited to:

Schizophrenia
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic disorder
Major depressive disorder (MDD)
Bipolar disorder I & II
Borderline personality disorder (BPD)
Post-traumatic stress disorder (PTSD)

As we mention above, symptoms most often appear during late adolescence or early adulthood, but may develop later in life. Children and pre-teens/younger adolescents rarely develop psychotic symptoms.

Substance-induced psychosis may resemble first episode psychosis, but if symptoms fade and never return, then the event was not FEP, but rather the consequence of ingesting psychotropic substances such as cannabis, LSD, or psychedelics.

Now let’s learn more about the primary symptoms of psychosis, hallucinations and delusions.

Hallucinations and Delusions in Psychosis

Here’s a good definition of hallucinations, also provided by the National Institutes of Health (NIH):

“Things a person sees, hears, or feels – i.e. sensory perceptions – when there is no real or identifiable source that causes those perceptions.”

Here’s a quick summary of the primary types of hallucinations that occur in psychosis and/or first episode psychosis.

Hallucinations in First Episode Psychosis

Auditory hallucinations:

- Hearing sounds that don’t originate externally, in the outside world. Hearing voices is the most prevalent type of auditory hallucination.

Visual hallucinations:

- Seeing things that aren’t actually present externally, in the outside world. Visual hallucinations exist on a spectrum from odd/perplexing/atypical to frightening and disruptive.

Olfactory hallucinations:

- Smelling odors that aren’t present externally, in the outside world These odors can be nice and comforting or bad and disturbing, and may happen for a moment or persist constantly.

Tactile hallucinations:

- Having physical sensations without identifiable external causes. A person may feel like someone taps them on the shoulder when alone, or feel things on their skin – tingling sensations, the sense of something crawling on them – that have no external origin.

Early Onset Psychosis: Delusions

Here’s an evidence-based definition of delusions, also provided by the National Institutes of Health (NIH):

“Thoughts or beliefs held by a person that are objectively and demonstrably false or untrue.”

Here’s a quick summary of the primary types of delusions that occur in psychosis and/or first episode psychosis.

First Episode Psychosis: Delusions

Delusions of grandeur:

- When a person believes they’re endowed with special abilities, have access to hidden information, possess unique skills, or are capable of things no one else is capable of doing.

Delusions of persecution:

- Belief that external entities or powers control them and mean them harm, with no observable basis in actual experience of the persecution.

Thought delusions:

- These are distorted beliefs about personal thoughts and ideas. People with thought delusions may believe:
- External forces/people control their thoughts.
- Outside forces/people place thoughts and ideas in their head.
- External forces/people steal thoughts and ideas directly from their minds.
- Their thoughts are accessible to external – often malevolent – forces.

Relationship delusions:

- In relationships with real people, a person might believe their partner is not faithful/planning to leave them, with no evidence to support the belief. They may also assign negative intent to people in their lives, such as friends or family, with no evidence to support the belief.
- In some cases, a person may develop the belief that they’re in a romantic relationship with, or a special connection to a person they’ve never met. The focus of this type of relationship delusion is often a well-known public figure, such as a pop star, a movie icon, or a high-profile politician.

When we review these symptoms – hallucination and delusions – it’s easy to see why experiencing them for the first time can be disturbing and disruptive for the person experiencing them, and confusing and often frightening for friends and family. However, it’s important to know that effective treatment for first episode psychosis – as well as fully diagnosed psychotic disorders – is available, and people can and do learn to manage these symptoms and live the lives they choose.

Diagnosis and Treatment for First Episode Psychosis

Research shows that about 20 percent of people who experience an initial episode of psychosis transition to and develop a psychotic disorder. That means about 80 percent don’t transition, and the symptoms enter remission.

However, after FEP occurs, it’s essential to seek professional support and arrange a full psychiatric evaluation to assess the presence of and risk of further psychosis.

A mental health provider will administer a range of evidence-based metrics to identify psychosis. These may include the 21-question prodromal screen, the 16-question prodromal screen, or the short five-question prime screen, and others. These tests and screenings can help a provider determine the presence of and the risk of developing a psychotic disorder, which requires specialized treatment and care.

The most effective treatment for psychosis and first episode psychosis is an approach called coordinated specialty care (CDC), which we’ll discuss in the following article on our blog: