The Relationship Between PTSD and Psychosis

Hallucinations and Delusions in People with PTSD

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What is the relationship between post-traumatic stress disorder (PTSD) and psychosis?. Frank van Groen / LOOK-foto/Getty Images

Post-traumatic stress disorder (PTSD) and symptoms of psychosis, such as hallucinations, often occur together. In clinical terms, PTSD is described as consisting of three clusters of symptoms: re-experiencing symptoms, avoidance symptoms and hyperarousal symptoms. However, some mental health professionals believe that the experience of psychotic symptoms should be considered as an addition to that list, given that they commonly occur among people with PTSD.

Types of Psychotic Symptoms

Psychotic symptoms can be divided into two groups: positive symptoms and negative symptoms. This does not mean that some psychotic symptoms are good and that some are bad. Rather, positive symptoms refer to an experience (such as hallucinations) whereas negative symptoms refer to the lack of an experience.

Positive Psychotic Symptoms

Positive psychotic symptoms are characterized by the presence of unusual feelings, thoughts or behaviors. This includes includes experiences such as as hallucinations or delusions.

Hallucinations refer to sensations of something that is not really there. An auditory hallucination refers to the experience of hearing voices which are not there. A visual hallucination would involve seeing something which is not there. Tactile hallucinations occur when a person feels something that is not there. Olfactory and gustatory hallucinations involve the experience of smelling or tasting something which is not present.

Delusions are ideas that a person believes are true despite the fact that they may be unlikely or odd. For example, people with delusions may believe that the CIA is spying on them or that aliens are controlling their behaviors or thoughts.

Disorganized behaviors are also very common with psychosis. A person may, for example, make up words, speak in unintelligible ways, or stand in an odd pose.

Negative Psychotic Symptoms

Negative psychotic symptoms are characterized by the absence of experience. For example, a person with negative symptoms may not be emotionally expressive. She may have difficulty speaking, may not say anything for days on end (alogia) or be unable to accomplish simple tasks or activities, such as getting dressed in the morning. A person with negative psychotic symptoms may appear very unmotivated and withdrawn. Mental health professionals may refer to this lack of emotional expression as a person having a "flat affect."

Flashbacks and Disassociation

Flashbacks and dissociation occur commonly with PTSD, and though they are not psychotic symptoms, they share some features with psychosis.

In a flashback, a person may temporarily lose connection with his present situation; being transported back in time to a traumatic event. In a severe flashback, a person may see, hear, or smell things that other people do not, consistent with a hallucination. Flashbacks often occur during periods of high stress and can be very frightening to the person experiencing them.

Dissociation is an experience in which a person feels disconnected from his body. He may not have any memory of what is happening in his environment for a period of time.

The experience is similar to a daydream, but unlike a normal daydream, is very disruptive to a person's life.

What Mental Health Disorders May Include Psychotic Symptoms?

These positive and negative psychotic symptoms may be seen with a number of different mental health disorders, including:

  • PTSD
  • Bipolar disorder
  • Schizophrenia
  • Major depressive disease with psychotic features
  • Schizoaffective disorder
  • Schizophreniform disorder
  • Delusional disorder

The distinction between these conditions is sometimes difficult, as there can be considerable overlap between different symptoms and conditions.

Schizophrenia and PTSD

Considering that schizophrenia is one of the most common psychiatric diagnoses, it's not surprising that some people may have both schizophrenia and PTSD.

PTSD most commonly occurs after a traumatic experience, and it's been found that traumatic experiences are more common for those with schizophrenia than for the general population. A recent study, in addition, found that there is significant genetic overlap between schizophrenia and PTSD.

Treatment for both disorders is critical, yet some physicians are reluctant to use some of the normal approaches. For example, using exposure therapy for PTSD might not be the best choice when a person also has schizophrenia, since exposure therapy may worsen the symptoms of schizophrenia. That said, studies have found that well thought out treatment can reduce the symptoms of PTSD. For those who have this combination of conditions it's important to find a mental health provider who is familiar with the treatment of these coinciding conditions.

Psychotic Symptoms in Post-Traumatic Stress Disorder (PTSD)

As we will discuss below, we are learning that psychotic symptoms may be more common with PTSD than previously thought. Let's take a look at how common these occur, what types of symptoms are usually seen, and those people with PTSD who are at the greatest risk of having positive or negative psychotic symptoms.

How Common are Psychotic Symptoms with PTSD?

Researchers at the University of Manitoba, Columbia University and the University of Regina examined the data on 5,877 people from across the United States in order to determine the rates with which people with PTSD experience different psychotic symptoms. They found that among people with PTSD, the experience of positive psychotic symptoms was most common. Approximately 52 percent of people who reported having PTSD at some point in their lifetime also reported experiencing a positive psychotic symptom.

Most Common Symptoms of Psychosis with PTSD

The most common positive symptoms in the study above were:

  • Believing that other people were spying on or following them (27.5 percent)
  • Seeing something that others could not see (19.8 percent)
  • Having unusual feelings inside or outside of their bodies, such as feeling as though they were being touched when no one was really there (16.8 percent)
  • Believing that they could hear what someone else was thinking (12.4 percent)
  • Being bothered by strange smells that no one else could smell (10.3 percent)
  • Believing that their behaviors and thoughts were being controlled by some power or force (10 percent)

Which People with PTSD Have the Greatest Risk of Psychosis?

Not surprisingly, it appears that the more PTSD symptoms a person is experiencing, the greater the likelihood that they will also experience positive psychotic symptoms.

Researchers have also looked at which traumatic events are most commonly related to the experience of psychotic symptoms. The events that put people most at risk include being involved in a natural disaster, seeing someone injured or killed or experiencing shock as a result of a traumatic event that happened to a loved one.

Meaning of Psychotic Symptoms with PTSD

The experience of psychotic symptoms may tell the story of just how severe a person's case of PTSD is and how well he or she is coping with the condition. It may also raise red flags about the likelihood of potentially dangerous behaviors.

It has been suggested that the experience of psychotic symptoms in those with PTSD may be connected to the experience of dissociation described above. Frequent dissociation may increase the risk for the development of psychotic symptoms.

Studies have shown that people with PTSD who experience psychotic symptoms, as compared to those who do not, may be at greater risk for a number of problems, such as suicidal thoughts, suicide attempts and greater overall distress. It's important for everyone with PTSD and their loved ones to know the risk factors and warning signs for suicide.

What Should You Know if You or a Loved One Have Psychotic Symptoms with PTSD?

If you or a loved one who had PTSD is experiencing psychotic symptoms, it is very important to seek out treatment. Positive psychotic symptoms can usually be effectively managed through medicationAddressing PTSD symptoms in treatment may also result in a reduction of psychotic symptoms.


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Diagnostic and Statistical Manual of Mental Disorders DSM-5. Arlington, VA, American Psychiatric Association, 2013.

Powers, A., Fani, N., Cross, D., Ressler, K., and B. Bradley. Childhood Trauma, PTSD, and Psychosis: Findings from a Highly Traumatized, Minority Sample. Child Abuse and Neglect. 2016. 58:111-8.

OConghaile, A., and L. DeLisi. Distinguishing Schozophrenia from Posttraumatic Stress Disorder with Psychosis. Current Opinion in Psychiatry. 2015. 28(3):249-55.

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