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Psychosis

Original Editor - Sai Kripa Top Contributors - Farah Al Dweik, Alexandra Stead, Vidya Acharya and Sai Kripa


Introduction

Psychosis is a clinical syndrome rather than a diagnosis on its own.[1] It describes a cluster of symptoms that leave a person unable to reliably tell what is real from what is not.[2] The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not attempt a single fixed definition of psychosis; instead it describes psychotic disorders in terms of abnormalities across five symptom domains: delusions, hallucinations, disorganised thinking, grossly disorganised or abnormal motor behaviour, and negative symptoms.[1] Psychosis occurs across a wide range of conditions, including psychiatric, neurological, neurodevelopmental, and medical illnesses.[2] This matters for physiotherapists because people experiencing psychosis are just as likely to present in general rehabilitation, respiratory, or musculoskeletal settings as they are in mental health services.[3]

Aetiology

Substance abuse, primary psychiatric disorders, and other neurological or medical conditions can all lead to psychosis.[4] First episode psychotic disorders have been associated with structural brain abnormalities, including reduced grey matter volume in the prefrontal, superior temporal, and medial temporal regions.[2][5]

The development of psychosis is thought to result from an interaction between genetic, neurodevelopmental, and environmental factors.[4] Environmental risk factors include substance use, psychological stress, infection, migration, the postpartum period, and other medical conditions.[6] Primary psychotic disorders are believed to arise from neurodevelopmental changes beginning in utero.[6]

Growing evidence suggests that immune dysregulation may contribute to the pathophysiology of psychosis.[2] However, a 2025 study found that recent cannabis use influences the relationship between baseline immune markers and long-term clinical outcomes.[7] In addition, growing evidence suggests that immune dysregulation and inflammation may contribute to psychosis, although their role in diagnosis and prognosis remains under investigation.[2]

Epidemiology

The incidence of psychotic disorders varies across populations and is influenced by demographic and environmental factors.[8] Differences in incidence have been reported according to geographic location, age, sex, and other population characteristics, with higher rates observed in some urban and high-risk settings.[8] Childhood-onset psychosis is rare.[5] Recent population-based evidence also suggests that first-episode substance-induced psychosis has become more common in younger birth cohorts.[5]

Clinical Presentation

Psychosis is characterised by disturbances in perception, thinking, emotion, and behaviour.[9] Symptoms are commonly grouped into positive, negative, and cognitive domains, although many individuals experience symptoms across more than one domain.[10]

Positive Symptoms

Positive symptoms reflect an excess or distortion of normal mental functioning.[11] They include hallucinations (most commonly auditory), delusions (e.g. persecutory or grandiose beliefs), and disorganised speech or behaviour.[11] These symptoms are often the most noticeable during an acute psychotic episode.[11]

Negative Symptoms

Negative symptoms involve a reduction or loss of normal functioning and may persist after positive symptoms improve.[12] These include:

  • Blunted affect: reduced range and intensity of emotional expression, seen in the face, voice, and gestures.[12]
  • Avolition: reduced drive to start or follow through with goal-directed activities, including self-care and daily tasks.[12]
  • Alogia: reduced spontaneous speech, or speech that is brief and lacking in detail.[12]
  • Anhedonia: reduced capacity to experience pleasure from activities that would normally be enjoyable.[12]
  • Social withdrawal: reduced interest in or engagement with social contact and relationships.[12]

Negative symptoms are strongly associated with reduced functional recovery and poorer long-term outcomes.[13] They are often mistaken for low mood, laziness, or disengagement, when in fact they form part of the illness itself.[1] This distinction matters clinically, as it helps how a physiotherapist interprets a patient who appears unmotivated or withdrawn during a session.[14][15][16]

Cognitive Symptoms

Cognitive symptoms commonly affect attention, working memory, processing speed, learning, and executive function.[10] These impairments may be present before the first episode of psychosis and often persist despite improvement in positive symptoms.[10] Cognitive deficits can reduce an individual's ability to learn new tasks, follow instructions, and participate in daily activities.[9][10]

Many people with psychosis also have limited insight into their condition, which may affect help-seeking, treatment adherence, and engagement with rehabilitation.[9] Symptom severity and presentation vary considerably between individuals and over the course of the illness.[1]

[17]

Physical and Functional Presentation

People with psychosis often deal with more than psychiatric symptoms.[14] Physical and functional problems are also common, and they contribute significantly to the overall disability associated with the illness.[14][18] This comes from a mix of things: the illness itself, negative and cognitive symptoms making it harder to stay active, side effects of antipsychotic medication, and lifestyle factors.[13][18] As a result, people with psychosis are more likely to develop obesity, metabolic syndrome, and cardiovascular disease.[13] The main physical and functional problems are summarised in Table 1.

Table 1. Common physical and functional impairments in people with psychosis.[13][16][18]
Domain Common Presentation
Physical Activity Low activity, sedentary behaviour
Fitness Reduced cardiorespiratory fitness
Strength Lower muscle strength
Balance Reduced postural control
Function Reduced mobility and participation

Differential Diagnosis

The differential diagnosis of psychosis involves determining whether symptoms are due to a primary psychiatric disorder, a substance-induced condition, or an underlying medical or neurological cause.[1][2] Establishing the correct diagnosis early is essential, as it guides appropriate management and influences prognosis.[2]

Primary Psychiatric Disorders

Primary psychiatric disorders include schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, and brief psychotic disorder.[1] Diagnosis is based on characteristic symptom patterns after medical and substance-related causes have been excluded.[1][2] Postpartum psychosis is a distinct and time-critical presentation within this category, requiring urgent psychiatric assessment given its rapid onset and elevated risk.[19]

Substance-Induced Psychosis

Triggered by intoxication or withdrawal from substances such as cannabis, amphetamines, cocaine, alcohol, or certain prescribed medications (corticosteroids, some anticonvulsants).[7] Symptoms often resolve after the substance has been cleared; however, in some individuals they may persist or progress to a primary psychotic disorder.[7]

Medical and Organic Causes

Medical and organic causes include delirium, dementia, epilepsy, autoimmune encephalitis, CNS infection, metabolic disturbance (electrolyte imbalance, hypoglycaemia, thyroid dysfunction), and space-occupying lesions.[2] These conditions should be excluded early, as delayed diagnosis may postpone treatment of potentially reversible causes of psychosis.[6][8]

Delirium deserves separate mention because it is easily mistaken for a primary psychotic episode.[20] Delirium comes on suddenly, fluctuates through the day, and comes with impaired consciousness and attention features that are not typical of a primary psychotic disorder.[20] For physiotherapists, recognising an acute change in cognition, consciousness, or orientation is important, as these features may indicate an underlying medical condition requiring urgent medical assessment rather than a primary psychotic disorder.[16][20]

Diagnostic Procedures

The diagnosis of psychosis is based on a comprehensive clinical assessment rather than a single diagnostic test.[2] The key components of the diagnostic process are summarised in Table 2.[21][22]

Table 2. Components of the diagnostic assessment for psychosis.[1][21][22]
Component What it Involves
Clinical interview History of presenting symptoms, onset, substance use, psychiatric and medical history, family history, mental state examination, and collateral information where appropriate.
Diagnostic criteria DSM-5 used to classify psychotic disorders after excluding alternative causes.
Investigations Blood tests, urine toxicology, and neuroimaging (CT or MRI) when indicated to exclude medical or neurological causes.

Physiotherapy Assessment

Physiotherapy assessment should inform collaborative goal setting and the development of an individualised rehabilitation programme.[3][18] In addition to evaluating physical impairments, physiotherapists should assess cognitive function, motivation, medication side effects, comorbid physical health conditions, and environmental or social factors that may influence participation in rehabilitation.[14] Common assessment domains and recommended outcome measures are summarised in Table 3.

Table 3. Physiotherapy assessment domains and recommended outcome measures in psychosis.[14][18][23]
Assessment Domain Recommended Measures
Functional exercise capacity 6-Minute Walk Test, 2-Minute Walk Test
Balance and fall risk Berg Balance Scale, Timed Up and Go
Muscle strength Handgrip dynamometry, 30-Second Sit-to-Stand
Physical activity International Physical Activity Questionnaire (IPAQ)
Function Activities of Daily Living (ADL), participation measures
Cognition Observe ability to follow instructions; refer for formal cognitive assessment if indicated
Cardiometabolic risk Body Mass Index (BMI), waist circumference, resting blood pressure
Medication side effects Observe for tremor, rigidity, or akathisia; Simpson-Angus Scale where indicated
Motivation and engagement Discuss readiness for physical activity, identify barriers to participation, and monitor attendance and adherence over time.


Assessment findings should influence next steps, such as exercise prescription and rehab planning, which both need to be built around the person's need.[24]

Barriers to participation should be identified early in rehabilitation.[18] Negative symptoms, transportation difficulties, and limited access to safe environments for physical activity may reduce engagement.[24] Addressing these barriers during assessment can help improve long-term adherence to rehabilitation.[14] [16]

Management

Medical Management

Management of psychosis typically includes antipsychotic medication, psychiatric follow-up, and psychological interventions such as cognitive behavioural therapy for psychosis (CBTp).[2] Early intervention services are recommended, particularly following a first episode, as they are associated with improved long-term outcomes.[2] A 2024 systematic review and meta-analysis of 33 studies found that early intervention was associated with improved quality of life, employment, negative symptoms, and reduced relapse and hospital admission rates compared with standard care.[25] Antipsychotic medication reduces positive symptoms reliably, but negative symptoms, cognitive impairment, and physical health problems often require additional rehabilitation interventions.[14]

Physiotherapy Management

Physiotherapists play an important role in improving physical health, functional capacity, and participation in people with psychosis.[16][24] Management should be individualised, taking into account symptom severity, physical health, cognitive function, medication side effects, and the person's own goals.[16][24] Core physiotherapy interventions include education, exercise, balance and mobility training. [24][26][27][28]

Education

Patient education should include the benefits of regular physical activity, strategies for self-management, recognition of medication-related side effects, and the importance of maintaining an active lifestyle.[24] Where appropriate, family members or carers may also be involved to support participation and adherence.[24]

Exercise and Physical Activity

Exercise is recommended as an adjunct to standard psychiatric care and should form the foundation of physiotherapy management in people with psychosis.[28] Programmes should be tailored to the individual's physical capacity and may include:

  • Aerobic exercise to improve cardiorespiratory fitness, physical activity levels, and cardiometabolic health.[26]
  • Progressive resistance training to improve muscle strength and functional performance.[27]
  • Balance and functional mobility training to reduce falls risk and improve mobility.[29]
  • Flexibility and mobility exercises where movement limitations or musculoskeletal pain are present.[28]

A 2025 network meta-analysis of 32 randomised controlled trials involving 1,773 participants found that yoga, resistance training, aerobic exercise, and mind-body interventions significantly reduced negative symptoms, with yoga demonstrating the largest effect.[28] A 2024 Bayesian network meta-analysis of 47 studies involving more than 4,000 participants reported that an exercise dose of approximately 1,200 MET-minutes per week was associated with the greatest improvement in overall symptom severity.[27] This is broadly equivalent to around five 30-minute sessions of brisk walking each week and may help guide exercise prescription in clinical practice.[27]

A 2024 randomised controlled trial also demonstrated that six months of aerobic exercise increased the volume of specific hippocampal subfields in people with schizophrenia.[26] These findings suggest that exercise may contribute to neuroplastic changes associated with improvements in cognitive function and symptom severity, although the underlying mechanisms continue to be investigated.[26]

[30]

Balance

Balance impairments are common in people with psychosis and may contribute to an increased risk of falls.[29] A 2024 study using force-plate testing found that people with schizophrenia and psychomotor slowing had significantly worse postural stability than both patients without slowing and healthy controls, and that poorer balance was linked to more severe negative symptoms and lower activity levels.[29] Balance impairment may result from both the underlying condition and medication-related motor side effects, highlighting the importance of routine physiotherapy assessment and targeted intervention.[29]

Emerging Approaches

Technology-assisted rehabilitation is an emerging area of physiotherapy practice in psychosis.[31] Early studies suggest that virtual reality-based exercise and rehabilitation programmes may improve motivation, balance, and cognitive engagement while providing a safe and structured environment for rehabilitation.[31] Although findings are encouraging, further high-quality studies are needed before these approaches can be recommended as routine clinical practice.[31]

Barriers to Engagement

Negative symptoms, cognitive impairment, medication side effects, fatigue, anxiety, transportation difficulties, and limited access to safe exercise environments may reduce participation in rehabilitation.[23] Collaborative goal setting, graded activity, clear communication, and supervised exercise programmes can improve engagement and adherence.[18]

Ongoing Monitoring

Physical health should be monitored throughout rehabilitation, rather than only during the initial assessment.[24][32] Regular monitoring of BMI, waist circumference, blood pressure, physical activity, and functional capacity is recommended because antipsychotic medication and sedentary behaviour increase the risk of obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease.[14]

Multidisciplinary Communication

Effective communication with psychiatrists, psychologists, occupational therapists, nurses, and primary care providers supports coordinated care and optimises both physical and mental health outcomes.[24]

Conclusion

Psychosis is a complex syndrome that affects mental, physical, and social functioning.[2] While medical and psychiatric management remain central to care, physiotherapists play an important role in addressing physical health, functional limitations, and participation restrictions.[16] Through assessment, exercise, education, and collaborative goal setting, physiotherapy can improve quality of life, and help reduce the long-term physical health burden associated with psychotic disorders.[23]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 American Psychiatric Association. DSM-5-TR® Update: Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. September 2025. Washington (DC): American Psychiatric Association; 2025
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Hasan A, Falkai P, McGorry P, et al. Guidelines for the prevention of psychosis from the World Federation of Societies of Biological Psychiatry (WFSBP) and EPI Canada. World J Biol Psychiatry. 2026;27(7):509–552.
  3. ↑ 3.0 3.1 Szortyka MF, Batista Cristiano V, Belmonte-de-Abreu P. Differential physical and mental benefits of physiotherapy program among patients with schizophrenia and healthy controls suggesting different physical characteristics and needs. Front Psychiatry. 2021;12:536767.
  4. ↑ 4.0 4.1 Owen MJ, O'Donovan MC. Rethinking schizophrenia: insights from genomics and implications for research. Molecular Psychiatry. 2026.
  5. ↑ 5.0 5.1 5.2 Myran DT, Gibb M, Pugliese M, Fiedorowicz J, Kirkbride JB, Anderson KK, et al. First-episode psychosis and substance use involvement across birth cohorts in Canada: a retrospective longitudinal population-based study. Lancet Psychiatry. 2026.
  6. ↑ 6.0 6.1 6.2 Grotzinger AD, Werme J, Peyrot WJ, et al. Mapping the genetic landscape across 14 psychiatric disorders. Nature. 2026;649:406-415.
  7. ↑ 7.0 7.1 7.2 Kreis I, Wold KF, Åsbø G, Flaaten CB, Engen MJ, Lyngstad SH, et al. Recent cannabis use affects the association between baseline immune markers and long-term outcomes in psychosis. Transl Psychiatry. 2025;15:282.
  8. ↑ 8.0 8.1 8.2 Zhan Z, Wang J, Shen T. Results of the Global Burden of Disease study for schizophrenia: trends from 1990 to 2021 and projections to 2050. Front Psychiatry. 2025;16:1629032
  9. ↑ 9.0 9.1 9.2 Hong Y, Chen Y, Bai Y, Tan W. Cognitive-behavioral therapy for the improvement of negative symptoms and functioning in schizophrenia: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2025;20(5):e0324685.
  10. ↑ 10.0 10.1 10.2 10.3 Kokou M, Stavridis PD, Ntoskou-Messini A, Messinis L. Cognitive remediation as a tool for enhancing treatment dimensions of schizophrenic symptomatology: a systematic review of randomized controlled trials. Brain Sci. 2025;15(10):1130.
  11. ↑ 11.0 11.1 11.2 Hany M, Rizvi A. Schizophrenia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2026.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Cova F, Rocca P, et al. Assessment of negative symptoms in schizophrenia: from the consensus conference-derived scales to remote digital phenotyping. [Journal name]. 2025.
  13. ↑ 13.0 13.1 13.2 13.3 Burschinski A, Schneider-Thoma J, Chiocchia V, et al. Metabolic side effects in persons with schizophrenia during mid- to long-term treatment with antipsychotics: a network meta-analysis of randomized controlled trials. World Psychiatry. 2023;22(1):116-128.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 Warren N, O'Gorman C, Dark F, Every-Palmer S, Halstead S, Korman N, Lappin J, Lawn S, O'Donoghue B, Suetani S, Thompson A, Loi SM, Scott JG, Runnegar N, Pillinger T, McCutcheon RA, Blackman G, Skerlj T, Firman J, Siskind D. Initial physical health assessment for psychosis in Australia and New Zealand: 2026 recommendations. Aust N Z J Psychiatry. 2026.
  15. ↑ Gorwood P, Yildirim M, Madera-McDonough J, et al. Assessment of functional recovery in patients with schizophrenia, with a focus on early-phase disease: results from a Delphi consensus and narrative review. BMC Psychiatry. 2025;25:398.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Stubbs B, Soundy A, Probst M, De Hert M, De Herdt A, Vancampfort D. Understanding the role of physiotherapists in schizophrenia: an international perspective from members of the International Organisation of Physical Therapists in Mental Health (IOPTMH). Physiother Res Int. 2014;19(4):202-209.
  17. ↑ University of California Television (UCTV). Symptoms of Psychosis [YouTube]. Published 15 July 2017. Available from: https://www.youtube.com/watch?v=qtUZvsVI56o [Last accessed 8 July 2026]
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 18.6 Vancampfort D, Firth J, Stubbs B, Schuch F, Rosenbaum S, Hallgren M, Deenik J, Ward PB, Mugisha J, Van Damme T, Werneck AO. The efficacy, mechanisms and implementation of physical activity as an adjunctive treatment in mental disorders: a meta-review of outcomes, neurobiology and key determinants. World Psychiatry. 2025;24(2):227–239.
  19. ↑ oor R, Wiese M, Croicu C, Bhat A. Postpartum psychosis: a preventable psychiatric emergency. Focus (Am Psychiatr Publ). 2024;22(1):44–52.
  20. ↑ 20.0 20.1 20.2 Oldham MA, et al. Pseudodelirium: psychiatric conditions to consider on the differential for delirium. J Neuropsychiatry Clin Neurosci. 2022;34(2):e56–66.
  21. ↑ 21.0 21.1 Winter S, Kelleher I, et al. First episode psychosis medical workup: evidence-informed recommendations and introduction to a clinically guided approach. Focus (Am Psychiatr Publ). 2020;18(1):19–26.
  22. ↑ 22.0 22.1 Lundin NB, Blouin AM, Cowan HR, Moe AM, Wastler HM, Breitborde NJK. Identification of psychosis risk and diagnosis of first-episode psychosis: advice for clinicians. Psychol Res Behav Manag. 2024;17:1365–1383.
  23. ↑ 23.0 23.1 23.2 European Psychiatric Association. EPA guidance on lifestyle interventions for adults with severe mental illness: a meta-review of the evidence. Eur Psychiatry. 2024;67(1).
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 24.6 24.7 24.8 Selb M, et al. A systematic review of Clinical Practice Guidelines for the development of the WHO's Package of Interventions for Rehabilitation: focus on schizophrenia. Front Psychiatry. 2023.
  25. ↑ Salazar de Pablo G, Guinart D, Armendariz A, Aymerich C, Catalan A, Alameda L, et al. Duration of untreated psychosis and outcomes in first-episode psychosis: systematic review and meta-analysis of early detection and intervention strategies. Schizophr Bull. 2024;50(4):771–783.
  26. ↑ 26.0 26.1 26.2 26.3 Roell L, Fischer T, Keeser D, Papazov B, Lembeck M, Papazova I, et al. Effects of aerobic exercise on hippocampal formation volume in people with schizophrenia: a systematic review and meta-analysis with original data from a randomized-controlled trial. Psychol Med. 2024;54(15):4009–4020.
  27. ↑ 27.0 27.1 27.2 27.3 Yang Y, Yuan Y, Zhang H, Fu X, Wang T, Wang J, Fang CC, et al. Optimal exercise dose and type for improving schizophrenia symptoms in adults: a systematic review and Bayesian network meta-analysis. Neurosci Biobehav Rev. 2024.
  28. ↑ 28.0 28.1 28.2 28.3 Wang Z, Li J, Wang L, Wei Q. Comparative effects of exercise modalities on negative symptoms in schizophrenia: a systematic review and network meta-analysis of 32 RCTs. J Psychiatr Res. 2025.
  29. ↑ 29.0 29.1 29.2 29.3 Nuoffer MG, Schindel A, Lefebvre S, Wüthrich F, Nadesalingam N, Kyrou A, et al. Psychomotor slowing in schizophrenia is associated with aberrant postural control. Schizophrenia. 2024;10:127.
  30. ↑ UNSW. Exercise therapy for mental illness [YouTube]. Published 7 June 2017. Available from: https://www.youtube.com/watch?v=_6JIXnwW03Q [Last accessed 14 July 2026]
  31. ↑ 31.0 31.1 31.2 Huang H, Chen Y, Wang X, et al. Effects of virtual reality technology on core symptoms of schizophrenia patients: a systematic review and meta-analysis. Arch Psychiatr Nurs. 2026;62:152131.
  32. ↑ Gorwood P, Yildirim M, Madera-McDonough J, et al. Assessment of functional recovery in patients with schizophrenia, with a focus on early-phase disease: results from a Delphi consensus and narrative review. BMC Psychiatry. 2025;25:398.
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