A patient described hearing voices that weren't there—voices that commented on his actions, criticized his decisions, and sometimes commanded him to do things. "I know they're not real," he said, "but I can't make them stop." This wasn't just "hearing things." This was psychosis—specifically, auditory hallucinations resulting from dysregulation of the brain's reality monitoring system, where internal thoughts are misattributed as external perceptions.
Psychotic disorders aren't just "losing touch with reality." They're dysregulation of reality monitoring—the brain's capacity to distinguish internal from external experience. When I assess psychosis, I'm evaluating how the brain processes sensory information, attributes experiences, and maintains reality testing. The classic schizophrenia presentation is recognizable, but many patients have subtler presentations: brief psychotic episodes, schizoaffective disorder combining psychosis with mood symptoms, or psychosis secondary to other conditions.
What makes integrative psychiatry essential for psychotic disorders is recognizing that psychosis has multiple drivers. A patient might have classic schizophrenia with dopamine dysregulation, but also sleep disruption that worsens reality monitoring, circadian rhythm disruption that destabilizes cognition, and sometimes nutritional factors affecting neurotransmitter synthesis. I've seen patients whose psychotic symptoms improved when we addressed their sleep architecture and optimized their circadian rhythms—not because psychosis is "sleep-related," but because sleep disruption can worsen the cognitive deficits that psychosis depends on.
Patients don't need to understand the neurobiology of dopamine and reality monitoring to benefit from treatment. But they do need to understand that what they're experiencing isn't just "thinking strange things"—it's neurobiological dysregulation of reality testing. The distinction matters because it changes how we approach treatment. If psychotic symptoms are purely psychological, you'd use psychological interventions. But when they're neurobiological, you need interventions that target the underlying systems: antipsychotic medications that reduce dopamine signaling, lifestyle modifications that support cognitive function, and sometimes interventions that address the sleep and circadian disruption that worsen psychosis.
Here's what I've learned treating hundreds of patients with psychosis: psychotic symptoms aren't uniform. Some patients have classic schizophrenia with persistent psychosis. Others have brief psychotic episodes triggered by stress. Some have schizoaffective disorder combining psychosis with mood symptoms. Some have psychosis secondary to other conditions—medical conditions, substance use, or mood disorders. Each requires different approaches. Classic schizophrenia needs antipsychotic medications. Brief psychotic episodes might resolve with treatment of underlying stress. Psychosis secondary to medical conditions needs treatment of the underlying condition.
There's a common misconception that treating psychosis is just about antipsychotic medications. That's part of it, but not all of it. Psychosis requires more than medication—it requires cognitive support, sleep optimization, stress reduction, and sometimes nutritional support. This is why I assess sleep patterns, cognitive function, stress levels, and lifestyle factors alongside traditional psychiatric evaluation. Psychosis is exquisitely sensitive to disruption—sleep disruption, stress, and substance use can all worsen symptoms.
What I tell patients with psychosis: understanding the mechanism matters. Psychotic symptoms result from dysregulation of dopamine signaling in the brain, particularly in pathways involved in reality monitoring. Antipsychotic medications work by reducing dopamine signaling, improving reality testing. But they work best when combined with interventions that support the systems maintaining cognition: sleep optimization, stress reduction, and sometimes nutritional support. I'm particularly cautious about patients who've been misdiagnosed—psychotic symptoms can be secondary to medical conditions, substance use, or mood disorders. Proper assessment requires careful history-taking and sometimes ruling out other causes.
But here's what most articles don't tell you: psychotic symptoms can also be a downstream effect of other conditions. Medical conditions can cause psychosis. Substance use can cause psychosis. Mood disorders can cause psychosis. Sleep disorders can worsen psychosis. I've diagnosed patients who thought they had schizophrenia but actually had medical conditions or substance-induced psychosis. Proper psychiatric assessment requires ruling out these possibilities—not just assuming psychotic symptoms mean schizophrenia.
What I've learned after years of integrating multiple approaches is that psychosis treatment requires addressing multiple systems. Antipsychotic medications are essential, but they work best when combined with lifestyle modifications that support cognition: sleep optimization, stress reduction, and sometimes nutritional support. I've seen patients whose psychotic symptoms improved when we optimized their sleep architecture and reduced their stress alongside medication.
If you're experiencing psychotic symptoms, here's my practical guidance: get proper assessment—not just for schizophrenia, but for medical conditions, substance use, mood disorders, and other conditions that can cause or maintain psychotic symptoms. Treatment requires antipsychotic medications, but it should also involve lifestyle modifications: optimizing sleep, reducing stress, and sometimes nutritional support. The goal isn't just to reduce symptoms—it's to restore the brain's capacity for reality testing and prevent episodes before they start.