I have written in earlier posts about the idea of anxiety and psychosis as part of a continuum, a spectrum of fear-based symptoms. This post is inspired from questions that I have around the relationship between anxiety and psychosis. I am not writing in a professional capacity as a doctor, or psychiatrist or mental health worker. I am writing as a person of lived experience who is also a writer integrating research and the experience of professionals working in the mental health field. My purpose is to examine evidence-based therapeutic interventions, with a focus on healing the emotional and psychological contributors to mental illness. The following are some of the questions that come up for me when I reflect on my experiences of anxiety and psychosis:
- What do anxiety and psychosis have in common?
- Does anxiety contribute to psychosis?
- Why is Cognitive Behavioural Therapy (CBT) used to treat both anxiety and psychosis?
- Why is Art Therapy used to treat both anxiety and psychosis?
- What are implications of the relationship of anxiety and psychosis for recovery?
Let’s start with my personal experience of severe anxiety and psychosis through examining hypothetical situations and paying attention to what is happening in my mind and body.
Imagine this scenario: I am feeling very anxious because I have a job interview. My palms are sweaty. My heart is pounding. I feel a bit dizzy. My digestion is off. I am fighting thoughts that tell me I won’t be able to handle it. I’m afraid that when I answer questions my mind will go blank. My thoughts go to the time I took an exam and didn’t remember a single thing for the first ten minutes. These thoughts intensify the discomfort in my body. Waiting for this job interview feels excruciating uncomfortable.
Imagine another scenario: My heart is pounding. I feel dizzy. I can’t speak because I am terrified. I know something bad is happening. I think that my family is in danger even though there is no evidence of danger, outside my head. I don’t want to be left alone and I don’t want my family member to leave me. I feel like there is danger everywhere. I’m not sure exactly who is behind this but my fear is so powerful I can’t eat or sleep much. I feel trapped inside myself and have difficulty speaking. I feel frozen. Eventually this anxiety leads to more severe symptoms such as hallucinations. This is how psychosis feels like for me. This is what is going through my head and how I feel in my body.
Do you see some similarities between the two symptom states? Some of the physiological symptoms are similar…like feeling dizzy, and having a racing heart. In both states I am experiencing acute fear. Some of the distorted thoughts are similar. That something bad is happening or going to happen. There is nothing dangerous about a job interview and my family is not in danger so there is a sense of disconnection from reality in both, however psychosis is a state of being far more disconnected from reality. Both states invoke the freeze response of the nervous system, like feeling unable to talk or having m mind go blank.
Obviously psychosis is different than anxiety and can lead to more serious outcomes and not all people who have anxiety disorders experience psychosis and vice versa. However, there is enough similarity and overlap to open up some dialogue on the relationship between both and how this impacts our understanding of mental illnesses, such as anxiety disorders and schizophrenia and those that have both diagnoses.
In my efforts to understand the connection between these two symptom states, I found some interesting information. A 2012 study on psychosis in those with anxiety and depression, found that 27% of those with disorders of anxiety and depression displayed one or more psychotic symptoms and “…the great majority of help-seeking individuals meeting ultra-high risk criteria for psychotic disorder in fact initially presents with an anxiety disorder or major depression, and the same is reported in individuals at psychometric risk for psychosis” (Wigman et al., 2012, pg. 247).
I find this true to my own experience and what I’ve observed in those with diagnoses of major mental illness: anxiety is often comorbid with psychotic symptoms.
The article, “What to Know about Anxiety and Psychosis,” says that a 2022 study found research to support the idea that extreme anxiety in children and teens may be contribute to an episode of psychosis (Warner, 2024). This also rings true for me as I experiences a lot of anxiety and fear as a child.
I also found some people experience anxiety with psychosis but what is different from “psychotic disorders” is that the psychotic symptoms leave typically when the anxiety is treated and can be resolved through therapy alone (Warner, 2024).
Personally, I can’t separate the two states because they are so interrelated. In psychosis, I am living in the highest level of anxiety. Perhaps had anxiety been treated before psychosis, with therapy and other interventions, I would have had less of a chance of it evolving into psychosis. This is why I think its so important to address anxiety when it starts, as well as make sure certain functions such as sleep and eating are stabilized.
There is definitely a complex relationship between these two states. When we look at evidence-based therapies for anxiety and psychosis, it’s not surprising that there are therapies that help both these symptom-states.
Cognitive Behavioral Therapy (CBT) is used as a therapeutic treatment for anxiety, depression and psychosis. CBT works by helping people have more realistic thoughts, therefore improving mood and behaviour. For example, if you were anxious about a job interview, you might shift your thinking by recognizing that you have successfully interviewed before. In psychosis, a CBT practitioner, might help you find evidence to disprove your paranoia and/or hallucinations. By addressing faulty thinking, change can happen in how you feel and behave. Your physiology also changes. If you tackle anxious/paranoid thoughts, your body calms down, which changes chemistry in the body and brain.
Let’s look at how art therapy treats anxiety and psychosis. Art Therapy is different than CBT because art therapists can directly address trauma in the body. This gives it a therapeutic edge when it comes to mental health treatment and art therapy has been used in inpatient settings for a very long time. Generally, art therapy can address anxiety because art making with a trained therapist can help someone become more present, work through difficult life situations, provide emotional release, and work with past trauma.
When American art therapist Shaun McNiff writes about working with psychosis with his clients, he says, “We worked directly on reorganizing perceptual and cognitive disintegration through the process of making art, looking at it, and talking about it. We were treating disorders of the imagination through the constructive workings of the imagination. From the very beginning the work with images was phenomenological, social, imaginative. We engaged people where they were, and introduced art to their lives. This orientation does not deny psychopathology and its presence in our expression. Art therapy’s embrace of pathos can actually contribute to the revitalization of art, which flourishes when it opens to the troubles of the soul.” (1992, pg. 15).
McNiff is identifying that the fundamental task with a client with psychosis is to help conflicts in the unconscious and to create more solid cognitive organization. In schizophrenia one of the symptoms is cognitive disorganization which McNiff is saying can be addressed in art therapy (this is often along with traditional treatment).
Also he is talking about how psychosis is a state of a problematic imagination and how engaging in art – which requires constructive imagination – can be healing. Psychosis, according to my experience, has my imagination going off the charts in a negative, disorganized way (much like a nightmare) and I can’t distinguish these thoughts and hallucinations from reality. Engaging in creativity is a way for my imagination to become healthy, focused, and leads to clearer thinking and integration of experiences. Talk therapy alongside with trauma therapy has also been very beneficial in helping to make sense of confusing experiences.
In an an online article, in Psychology Today, called “Emotional Intelligence, Art Therapy and Psychosis,” it is said that individuals with psychosis “…are overly involved in their mental realm” (Olsen, 2013). This articles talks about the difficulty of persons with schizophrenia to socialize and talks about how auditory hallucinations might have to do with perceptions of self and others (Olsen, 2013). I can concur from my own auditory hallucinations in the past that a lot of the content had to do with interpersonal conflicts and larger fears about human suffering and behaviour, such as war, sexual assault, illness.
The article concludes that, “Art therapy could be an important avenue toward increased mental health in the psychotic individual. Engaging in art not only allows the psychotic individual to express his own emotions to others, but the canvas (whether a poem, song or literal canvas) can reflect back to him his internal state” (Olsen, 2013).
A PsychCentral online article outlines the benefits of art therapy for anxiety: “We get people to stop and focus on one thing. People can also do this with deep breathing and other strategies, but art-making can be an easy, accessible way to do this, too,” says Carlock Russo. “Art expression also provides sensory input in other ways because you are touching materials, and it also [initiates] the release of stress from the playfulness of it all” (Cassata, 2021).
This research and reflection opens questions and wonderings about how we can work with anxiety disorders and also maybe how we can prevent and/or stabilize psychosis to increase the chance of recovery.
Medications are always the first line with psychosis and getting people out of that state because that state impacts the safety of the person and sometimes other people. But recovery over the long term – using my personal experience – requires therapeutic interventions like CBT and art therapy (or other professional therapy, in particular trauma therapies) to heal what is happening in the mind and unconscious. Art therapy also addresses trauma as well as works with the mind and this could be why it is one of the best therapies for working with those with lived experience of mental illness. I think that the evidence shows that CBT and art therapy can be significantly beneficial for those with anxiety as well.
We don’t always have access to individual art therapy, but many mental health services and community programs have CBT and art making groups. The local mental health services in my community do have a group art therapy program for clients of their services, as well as a day program that offers CBT for psychosis. If you can afford to have a professional counsellor, then that is a gift and, from my perspective, so helpful on so many levels when you have a mental illness. As well, art making and therapeutic writing can be done on your own, as well as learning the basic CBT understanding and working with anxious and paranoid thoughts.
My final thoughts: I think it is important to recognize that some of what happens in psychosis is an extreme form of anxiety. I hope this reduces stigma. We usually don’t think of people with anxiety as “crazy” whereas people experiencing psychosis and psychosis itself are often seen as “crazy.” Strange beliefs and behaviours are often interpreted this way. The more we examine experience and the content of psychosis I think we can make sense of some of it.
Reducing stigma helps people get help and be able to talk about their illness. Mental illness is a sign that there is something that needs to be healed, whether this is a biological brain imbalance or psychological and emotional wounds (often both and many more contributors to mental illness). This is true of many illnesses. Let’s reduce stigma and allow people to get the help they need to recover, instead of judging them and putting negative labels on them.
For all the people living with anxiety and psychosis, I hope this post offered some insight and perhaps some ideas about what therapies might be helpful as you live with these challenging symptom states. Always I encourage you to practice self-compassion for your struggles and hold the belief that recovery is possible 💜💜💜
Sources:
Cassata, Cathy. (2021). Does Art Therapy Help You Manage Anxiety Symptoms? https://psychcentral.com/anxiety/art-therapy-for-anxiety-relief
McNiff, Sean. (1992). Art as Medicine. Shambhala Press: Boulder.
Olsen, Ann. (December 29th, 2013). Psychology Today. “Emotional Intelligence, Art Therapy and Psychosis.” https://www.psychologytoday.com/us/blog/theory-and-psychopathology/201312/emotional-intelligence-art-therapy-and-psychosis
Warner, Daisy. (July 18th, 2024). Medicalnewstoday.com. “What to Know about Anxiety and Psychosis.” https://www.medicalnewstoday.com/articles/anxiety-psychosis
Wigman JT, van Nierop M, Vollebergh WA, Lieb R, Beesdo-Baum K, Wittchen HU, van Os J. Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity–implications for diagnosis and ultra-high risk research. Schizophr Bull. 2012 Mar;38(2):247-57. doi: 10.1093/schbul/sbr196. Epub 2012 Jan 18. PMID: 22258882; PMCID: PMC3283146.
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