When someone you love starts acting paranoid or hearing voices, they often have no idea anything’s wrong—and it’s not denial or stubbornness. A surprising neurological condition explains why most people experiencing psychosis truly don’t realize they’re ill.
When a loved one begins showing signs of psychosis, families often ask: "Do they know something's wrong?"
The truth is complex. Most people with psychosis don't realize they're unwell—a neurological condition known as anosognosia, or "lack of insight." It's not denial or stubbornness. It's that their brain can no longer accurately process reality.
In simple terms, what looks like a red car to you might trigger a hallucination or paranoid belief in someone with psychosis. Their perceptions feel as real to them as your car does to you.
This lack of awareness makes early intervention difficult. People with psychosis may resist treatment, not out of refusal—but because, to them, nothing is wrong. Understanding the difference between delusions and hallucinations—the two most common psychotic symptoms—can help families recognize what's happening and respond with empathy.
Experts at mental health provider A Mission for Michael (AMFM) say distinguishing the symptoms is critical to getting loved ones the right help.
When someone with psychosis denies they're unwell, it's neurological. The condition, called anosognosia, stems from dysfunction in the frontal lobe, the part of the brain responsible for self-awareness. When this area misfires, people lose the ability to recognize their symptoms as abnormal. It's similar to a stroke survivor not realizing their arm is paralyzed—the brain simply isn't registering the loss.
This explains why logical arguments rarely help. Families may try to reason, present evidence, or explain what's happening, but reasoning requires brain circuits that psychosis disrupts. Understanding this shift can help families respond with less frustration and more empathy.
About 60% of people with schizophrenia experience anosognosia, though it ranges in severity. Some retain partial insight, especially early on or between episodes, while others remain completely unaware. The condition also affects around 40% of people with bipolar disorder, and between 15-25% of those with Alzheimer's disease, with some studies citing even higher rates.
Because insight can fluctuate, treatment must be personalized. Some individuals regain awareness as symptoms stabilize, while others need continued support over time.
Psychotic symptoms don't feel imaginary to the person experiencing them. Hallucinations—like hearing voices—are vivid, sensory events generated by the brain. Delusions, such as believing one is being followed, feel just as real. They're not "overreactions" or "drama"—they're altered perceptions rooted in brain function.
During early phases, some may sense something is off. But as psychosis deepens, their grasp on reality fades. This mismatch between external reality and internal experience often creates a painful rift between individuals and their families. What looks obviously false to others feels absolutely true to the person living through it.
Hallucinations involve sensing things that aren't there. Auditory hallucinations—hearing voices—are the most common, but people may also see, feel, smell, or taste sensations without any external trigger. These episodes happen spontaneously and feel completely real to the person experiencing them.
The voices often sound like they're coming from outside the person's head. They may talk to these voices, follow their instructions, or feel deeply distressed by what they hear. From the outside, it can look like someone is talking to themselves, but in their reality, they're responding to what feels like "someone."
Delusions are fixed false beliefs that don't change, even when there's clear evidence against them. Common types include:
People experiencing delusions often weave unrelated events into a cohesive, though distorted, belief system. They aren't choosing to ignore reality—their brain has restructured how they interpret it. No amount of logic or reassurance can override what feels true.
Psychosis also disrupts how people think and behave. Speech may become jumbled or hard to follow—jumping between unrelated topics, inventing new words, or trailing off mid-sentence. Behavior can seem unpredictable: laughing at odd moments, neglecting hygiene, or making strange gestures.
But this isn't attention-seeking—it's, again, neurological. When the brain's executive functions break down, organizing thoughts and actions becomes difficult.
Psychosis rarely appears overnight. In many cases, it builds gradually during a stage known as the prodromal phase. This is when changes begin to surface, but often go unnoticed. According to mental health experts at AMFM, early warning signs can include:
These behaviors might look like stress or depression at first. But when multiple signs show up together and worsen over time, they may signal the onset of psychosis. That said, these early symptoms are non-specific and can also stem from anxiety, trauma, or mood disorders. Context and progression matter.
As psychosis progresses, symptoms become more distinct. These include both positive symptoms (added experiences) and negative symptoms (loss of healthy functioning).
Positive symptoms:
Negative symptoms:
These symptoms don't always arrive all at once, and some may appear more prominently than others depending on the individual.
Early symptoms of psychosis often resemble common life stressors or mood shifts, especially in teens and young adults. Gradual changes make it hard for families to pinpoint when something's truly wrong. Behavior may be dismissed as burnout, substance use, or "just a phase."
Stigma plays a role too. For many, there's a quiet hope the behavior will pass. Facing the possibility of serious mental illness can feel overwhelming, even frightening—and that fear can delay seeking help.
When someone doesn't recognize they're unwell, direct arguments rarely help. Trying to "prove them wrong" or challenge delusions often leads to more resistance, confusion, and isolation. Instead, mental health professionals recommend the LEAP method—a communication strategy built for situations where insight is impaired.
LEAP stands for: Listen, Empathize, Agree, Partner. The goal isn't to debate what's real—it's to build trust, validate emotions, and work toward support, without forcing awareness of illness they can’t see.
Start by giving them space to talk. Use open-ended questions like "Can you tell me more about that?" or "How did that make you feel?"
Avoid dismissive phrases like "That's not real" or "You're imagining it." Instead, acknowledge their emotional reality with "That sounds terrifying" or "I can see how that would worry you." Validating feelings doesn't mean agreeing with those beliefs—it means showing that you care how they feel, even if you don't share their version of reality.
Put yourself in their world. If someone believes they're being followed, they're genuinely afraid. If they think they have powers, they might feel overwhelmed or pressured. Simple responses like "That must be exhausting" or "I understand why you feel overwhelmed" help preserve connection during a time when reality feels unstable.
Find neutral or emotional points of agreement. If they mention hearing upsetting voices, try "Hearing things like that would be incredibly distressing." If they say they're being watched, say: "Feeling unsafe must be so stressful." This keeps your response honest without reinforcing the delusion, and builds the trust needed to move forward.
Once rapport is established, gently shift toward solutions. Focus on reducing distress, not correcting beliefs. For example: "It sounds like you've been carrying a lot. Would you be open to talking with someone who might help you feel less overwhelmed?"
Avoid tying help to insight. Instead, frame treatment as a step toward comfort, safety, or relief—not as a fix for something they don't believe is broken. This partnership approach is one of the most effective ways families can support someone through early psychosis and increase the chances of accepting care.
Psychosis is not something to wait out. Left untreated, it can severely impact quality of life—damaging relationships, disrupting work or school, and eroding a person's ability to function. The longer symptoms persist without intervention, the harder recovery becomes. Early treatment leads to better outcomes, higher stability, and a greater chance of full recovery.
That said, non-adherence to treatment is common in psychotic disorders, especially when insight is impaired. Without proper support, this can lead to relapse, hospitalization, or self-harm. But with early, structured intervention, many people regain functioning and maintain long-term stability.
If you're supporting someone through this experience, know that help is available and it makes a difference. Providers such as AMFM offer specialized treatment for individuals experiencing psychosis, offering comprehensive support for both patients and their families.
