PTSD/PTSI & Psychosis

Q: Dear Frank, I found this article and wondered what you thought about the science behind it on PTSD and Psychosis. See (

A: Dear reader, The consultants who contribute to the site are high quality people in London but are not the UK ISTSS PTSD experts. They are psychosis experts.

PTSD, per se, is seldom a psychotic condition. People with PTSD may also have psychoses such as schizophrenia and should receive both diagnoses. PTSD often includes dissociation–an altered state of consciousness. Dissociation is not psychosis. The critical distinction has to do with “reality testing.” A person in a dissociated state has a sensation of being in an unreal situation and is aware of it. A psychotic person is deluded or hallucinating and usually unaware of having entered an unreal state.

In a flashback, a person with PTSD may feel and act as though he or she were in a place from the past. This may qualify as psychotic. The flashback state of PTSD can, in my opinion, cross from dissociation into psychosis when the trauma-survivor lacks the ability to know real from unreal and right from wrong. If a deadly crime is committed in a flashback, you can bet that well qualified experts will debate both sides of the case. The defense will claim insanity. There is a well-established diagnosis called brief psychotic disorder ( (formerly brief reactive psychosis). I have given this diagnosis as a forensic expert and prevailed in establishing “not guilty by reason of insanity.”

Technically, this diagnosis should be used rather than PTSD when the post-traumatic unreal symptoms last less than a month, more than a day, and fit the pattern described in DSM-5. But after a month, other diagnoses need to be used, including PTSD – if it fits.

In sum, PTSD and psychosis may co-exist but PTSD is usually not considered a psychotic condition.