This qualitative study (n=19) of people with non-affective psychotic disorders who had used psychedelics found that, although there were some overlaps in altered thinking and meaning-making, most participants felt psychedelic experiences were not closely similar to psychosis. The authors conclude that psychedelics may be poor models of many psychotic symptoms, and that describing psychedelic effects as broadly psychosis-like may be misleading.
Despite a long-standing interest in the potential similarities between psychedelic and psychotic experiences, no recent research has systematically explored the subjective overlap between these states in individuals who have experienced both. To provide rich accounts of potential overlaps and distinctions, we conducted semi-structured interviews with 19 individuals diagnosed with non-affective psychotic disorders who had used psychedelics. Participants described perceived similarities and differences between the acute effects of psychedelics and their experiences during psychosis. The study used reflexive thematic analysis to analyze the transcripts. Participants identified several points of contrast, including sensory alterations, emotional experience, altered thinking, meaning attribution, sense of control, and self experience. Although some similarities were acknowledged, particularly in terms of altered thinking and meaning attribution, most participants reported that psychedelic experiences did not closely resemble their experiences with psychosis. When asked which drug most resembled their psychotic symptoms, the majority endorsed cannabis, followed by dissociative anesthetics and stimulants. Psychedelics may not accurately model many symptoms of psychosis despite impacting similar domains of experience. These findings have implications for potential tolerability studies of psychedelics in people with psychotic disorders and suggest that interpreting psychedelic-induced experiences as broadly psychosis-like may be misleading.
Papers cited by this study that are also in Blossom
Argyri, E. K., Evans, J., Luke, D. et al. · SSRN (2024)
Brouwer, A., Carhart-Harris, R. L. · Journal of Psychopharmacology (2020)
Carhart-Harris, R. L., Brugger, S., Nutt, D. J. et al. · Journal of Psychopharmacology (2013)
Carhart-Harris, R. L., Kaelen, M., Bolstridge, M. et al. · Psychological Medicine (2016)
Non-affective psychotic disorders such as schizophrenia have long been compared with the acute effects of serotonergic psychedelics because both can alter perception, thought, and self-experience. Earlier work often relied on indirect or historical comparisons, and while some studies suggested psychedelics can induce psychosis-like phenomena, it remained unclear how similar these states actually feel to people who have experienced both. The paper also notes that current psychedelic trials usually exclude people with personal or family histories of psychotic disorders, partly because psychedelics are assumed to be strongly psychotomimetic, yet that assumption has not been well examined from a lived-experience perspective. M. and colleagues therefore set out to explore, through qualitative interviews, how individuals with lived experience of non-affective psychotic disorders and psychedelic use describe similarities and differences between the two states. The study aimed to clarify whether psychedelic experiences are subjectively perceived as psychosis-like, which features overlap, and what this might mean for future tolerability studies, clinical support, and broader interpretations of psychedelics as psychotomimetics.
This was an exploratory qualitative study using criterion-based purposive sampling. Participants were recruited through digital flyers posted on drug- and psychosis-related online forums, including r/LSD and r/Schizophrenia, and through sharing in psychedelic social networks. The extracted text indicates that the researchers anticipated selection bias from this approach, but chose it because people with both psychosis and psychedelic experience are uncommon in the general population. Potential participants completed a Qualtrics screening survey covering demographics, mental health history, and drug use history. Those who met the inclusion criteria and did not show internal inconsistencies were invited to interview. Eligible participants completed two semi-structured Zoom interviews between February and June 2023. The first interview explored experiences of psychosis and psychedelics separately; the second focused more directly on comparing those experiences and on comparing psychedelics with other substances. Interviews were audio recorded with consent. The study yielded 31.5 hours of interview material, with an average interview length of about 50 minutes. No one withdrew after starting. The study was approved by the University of Alabama at Birmingham Institutional Review Board. Analysis used reflexive thematic analysis, following Braun and Clarke’s six-stage approach. The researchers describe this as a non-positivist method that treats researcher subjectivity as part of the analytic process. Transcripts were coded in NVivo 14 using a combined deductive-inductive approach: some codes came from the interview guide, but most were generated from the data itself. The first author conducted the interviews and initial coding, discussed codes with the second author, and the wider team reviewed and refined the themes. Saturation and intercoder reliability were not assessed, which the authors say is consistent with reflexive thematic analysis. Member checking was not conducted, and transcripts were not returned to participants.
Nineteen participants were included. Most were men (15/19, 78.9%), and they came from several countries, including the USA, the UK, Germany, Canada, and other European countries. Participants reported diagnoses across the non-affective psychotic disorder spectrum and extensive lifetime psychedelic use, especially psilocybin mushrooms, LSD, and DMT. Cannabis and nicotine use were also common. Across the interviews, participants identified some overlap between psychedelic states and psychosis, but usually emphasised clear differences. Sensory alterations were a shared domain, yet participants generally described psychedelics as more sensory and psychosis as more thought-dominated. Visual effects were common with psychedelics for all participants, especially colour enhancement, objects “breathing” or morphing, and geometric patterns or fractals; by contrast, visual hallucinations in psychosis were less common and often involved shadows or peripheral misperceptions. Auditory hallucinations were frequently reported during psychosis, but many participants said they did not occur during psychedelics. Tactile and bodily effects were often described as pleasant or expansive with psychedelics, whereas psychosis was associated with more specific and sometimes painful bodily hallucinations. Affective experience also differed. Psychedelics were often linked to anxiety in parts of the experience but also to warmth, love, euphoria, and a broader emotional range. Psychosis was more often described as terrifying, fear-dominated, or emotionally blunted. Some participants described overlap in positive emotions, but usually with different causes: psychedelics were associated with sensory appreciation and emotional openness, whereas psychotic positive affect was often tied to delusional beliefs. Altered thinking and meaning attribution were a key similarity. In both states, participants reported hyperassociative thinking, stronger perceptions of connections, coincidences, or synchronicities, and heightened meaning. However, psychosis was commonly described as focused, self-referential, and supporting a delusional narrative with strong certainty, whereas psychedelics were described as more open-ended, questioning, and less likely to harden into fixed beliefs. A strong distinction was the sense of control. Participants often felt more in control of thoughts and emotions during psychedelics, partly because the drug effect was known to be temporary and had a clear cause, whereas psychosis was described as unpredictable, external, and overwhelming. Self-referential thinking and paranoia were also usually more prominent in psychosis. Some psychedelic experiences involved mild paranoia, typically about appearing intoxicated in public, but this lacked the more elaborate or magical quality often described in psychosis. A few participants reported altered self-experience in both states, such as feeling merged with everything during psychedelics or fading out of existence during psychosis, but these were not the dominant accounts. When asked which non-psychedelic drugs most resembled psychosis, cannabis was the most common answer (9 participants), followed by dissociative anaesthetics such as ketamine and DXM, then stimulants, and finally none. Only one participant said a psychedelic most closely resembled psychosis for them, and even that account included clear differences as the psychotic episode progressed. Participants also often described acute cannabis effects as worsening paranoia, auditory hallucinations, and cognitive symptoms, sometimes more strongly than sober psychosis.
The authors argue that, although psychosis and psychedelics both alter perception, thought, and self-experience, the acute subjective overlap is narrower than the historical psychotomimetic framing suggests. In their account, psychedelics are experienced mainly as expansive sensory and affective states, whereas psychosis is more often thought-centred and self-referential, with delusional meaning-making. They suggest that the historical focus on psychotomimetic similarity may have overemphasised shared sensory disturbance while underweighting differences in the quality, organisation, and emotional tone of experience. They position the findings relative to earlier research by agreeing that both states can produce hyperassociative thinking and heightened meaning attribution, which is consistent with prior experimental work in healthy volunteers. At the same time, they argue that the meaning generated in psychedelics is often exploratory or emotionally salient without fixing into a belief, whereas psychosis more often reinforces a specific delusional framework. They also note that emotional comparisons should go beyond valence alone: participants described psychosis as emotionally constricted or blunted and psychedelics as emotionally broader and more complex. The authors interpret the greater sense of control reported during psychedelics as reflecting both the voluntary, time-limited nature of taking a known substance and the way psychedelic contexts may reduce experiential avoidance rather than eliminate agency. The discussion also highlights cannabis as standing out as more psychosis-like than psychedelics for many participants, with particular concern about paranoia, hallucinations, and cognitive disruption. The authors say this aligns with evidence that higher psychosis proneness is associated with stronger psychotic-like responses to cannabis and suggest that public health messaging about high-potency THC should be clearer. The authors are careful to state that subjective similarity or difference does not by itself establish long-term psychosis risk or therapeutic relevance. They do not claim that psychedelics are treatments for psychotic disorders on the basis of this study alone. Instead, they say the findings have implications for future tolerability trials in people with non-affective psychotic disorders, because clinicians should not assume psychedelic distress simply reflects re-emergent psychosis. They also suggest that treatments for adverse psychedelic experiences may need to be psychedelic-specific rather than borrowed directly from psychosis frameworks, and that training in both clinical and harm-reduction settings should reflect this. Key limitations acknowledged by the authors include the small purposive sample, likely selection bias towards digitally literate and more psychedelics-interested individuals, self-reported diagnoses and substance histories, possible recall bias, and limited diagnostic certainty without structured interviews. They also note the absence of member checking and the possibility that different analysts might have emphasised different aspects of the data. They recommend future work that uses more recent experiences, structured diagnostic assessment, and attention to set and setting.
The authors conclude that the psychotomimetic model of psychedelics is limited when judged from lived experience. While some overlap exists, participants more often described differences than similarities, especially in sensory quality, emotional complexity, control, and the organisation of meaning. They argue that altered meaning attribution and hyperassociative thinking are genuine points of convergence, but that future research should compare psychedelic states and psychosis more specifically and focus on both shared and distinctive experiential components.
Given the low base rates of people with psychotic disorders who have used psychedelics in the general population, criterion-based purposive sampling was used for this exploratory study. Digital flyers describing the study were posted on drugand psychosis-related web forums, including the subreddits r/LSD and r/Schizophrenia. Individuals with social influence in the psychedelic community were encouraged to share the flyers on social media. This recruitment strategy may have introduced selection bias favoring higher-functioning, digitally literate individuals with an interest in psychedelics; however, qualitative research aims to describe experiences in depth rather than to draw generalizable conclusions. Flyers included a link to a Qualtrics screening survey containing an information sheet about the study. The screening survey collected demographic information, mental health history, and drug use history. Participants were not asked to provide their names or geographic locations beyond their current countries. Respondents who met the inclusion criteria and did not show internal inconsistencies in survey responses were contacted by email to schedule interviews (Table). To accommodate the sensitivity of working with a trauma-exposed population with a history of psychosis, we incorporated multiple trauma-informed elements across the screening, recruitment, and interview processes, including proactive attention to potential distressing experiences. The study, from recruitment strategies through the interview guide, was designed with input from an individual with lived experience of both psychosis and psychedelic use (GAC), informing trauma-informed safeguards across screening, consent, and interviewing. Although the interview guide was not formally pilot tested, it was iteratively refined through team discussion. Collectively, these elements reflect trauma-informed principles by prioritizing participant safety, trust, collaboration, and empowerment. All interviews were conducted by the lead author (HMD), who disclosed that she was a doctoral student in a public health program and that the project was funded by a non-profit supporting student research (Source Resource Foundation). No relationship was established with participants prior to study commencement. Consistent with a trauma-informed approach, transparency was emphasized during informed consent, with the structure and purpose of the interviews clearly explained. Prior to participation, individuals were provided with an information sheet and given the opportunity to ask questions. Additionally, during recruitment and screening, participants were asked not to participate if they anticipated that discussing experiences of psychosis or psychedelic-induced states would be distressing and were encouraged to consult a mental health provider if they were uncertain about their ability to proceed. During interviews, participants were provided with free mental health resources and informed that they could end the interview at any time without providing a reason. Eligible participants completed two semi-structured interviews conducted via Zoom between February and June 2023, using a semi-structured interview guide. Interviews were audio recorded with participants' consent. Participants were asked to join interviews from a private setting where they would not be interrupted. The first interview focused separately on experiences with psychosis and psychedelics, in part to broadly verify experiences consistent with a non-affective psychotic disorder. The second interview emphasized direct comparison between psychedelic-induced experiences and psychosis, as well as comparisons with other substances. During the first interview, participants often spontaneously discussed similarities and differences, and in the second interview, they were explicitly asked to reflect on what stood out most from the prior discussion. Interviews were conducted in a collaborative and empathetic manner, allowing participants agency over how their experiences were shared. This design facilitated rapport and allowed for in-depth exploration of emergent themes while adhering to the semi-structured interview guide. Member checking was not conducted, and transcripts were not returned to participants. The study yielded 31.5 h of interview data (each interview averaging 50 min). No participants withdrew after beginning interviews. Participants are referred to using pseudonyms throughout the manuscript. Screening materials and the interview guide are publicly available on the Open Science Framework (. io/ asm7b). This study was approved by the Institutional Review Board of the University of Alabama at Birmingham.
This study used reflexive thematic analysis due to its flexibility in accommodating both experiential content and contextual factors. Reflexive thematic analysis takes a non-positivist stance, treating researchers' subjectivity as a resource rather than a bias to be corrected. It further emphasizes that lived experiences shape all aspects of the research process, from the questions asked to how data are interpreted. Our interpretive stance was shaped by the research team's backgrounds and lived experiences. The project lead (HMD) had prior involvement experience with trauma-informed harm-reduction work supporting individuals experiencing adverse effects of psychedelics in uncontrolled settings (e.g., festivals) and also volunteered at a crisis textline. HMD is neurodivergent, having been diagnosed with Asperger's syndrome at an early age, and has experienced stigma related to this diagnosis. Two other authors are neurodivergent, one with a personal history of autism spectrum disorder (MB) and one with firsthand experience of a psychotic disorder (GAC). Four coauthors held doctoral degrees, including two clinical doctorates (PSH, CRN), with additional expertise in neuroscience (psychosis research; JAT) and criminology (drug-focused; HC), and four coauthors are men. Authors varied in their firsthand experience with psychedelics, ranging from no lifetime use to more than 50 experiences. We recognize that other researchers might have emphasized different aspects of participants' accounts, but we view the inclusion of researchers who are neurotypical and non-neurotypical and those with lived experience perspectives as a strength of this analysis. Analysis followed Braun and Clarke's six-stage approach. The lead author conducted all interviews and familiarized herself with the data through transcription and transcript review. No formal field notes were taken; however, discussions about the interviews occurred throughout the analytic process, particularly among HMD, GAC, MB, HC, and PSH. The lead author read all transcripts multiple times and generated initial codes in NVivo 14, capturing both semantic and latent meanings relevant to participants' experiences. Initial codes were discussed with the second author before further coding. During analysis, we used a combined deductive-inductive approach. While some codes were informed by the interview guide (e.g., Comparison of Non-Psychedelic Drug Experiences), most codes were generated directly from the data. Following continued coding of all transcripts, the first and second authors met to develop broader themes reflecting shared patterns of meaning. Given the richness of the data, it became apparent that multiple manuscripts would result. Remaining coauthors reviewed and refined the themes and subthemes. The first and second authors drafted the results and selected illustrative quotations, while remaining authors reviewed findings to ensure consistency between data, interpretation, and research questions. Saturation and intercoder reliability were not assessed, consistent with recommendations for reflexive thematic analysis. Quotations were lightly edited (e.g., removal of filler words such as "like").
Participants (N = 19) are described in terms of demographic, mental health history, and drug use history characteristics in Tablesand. Most participants were male (n = 15, 78.9%), with widely varying educational attainment and employment status. This sample featured people from a variety of countries, including the USA (n = 7, 36.8%), the UK (n = 3, 15.8%), Germany (n = 3, 15.8%), Canada (n = 2, 10.5%), and several other European countries (n = 4, 21%). The participants varied in their psychotic disorder diagnoses but expressed an average age of diagnosis consistent with population norms. As seen in Table, participants reported extensive use of various psychedelics, the majority having experience with psilocybin-containing mushrooms, LSD, and DMT. Rates of use of novel psychedelics (e.g., 1P-LSD) and atypical psychedelics (e.g., 5-MeO-DMT) were also reported frequently. High rates of lifetime, past year, and past month use of cannabis and nicotine were reported (see Table). For an overview of themes and subthemes, see Fig.for a coding tree of themes and subthemes.
Although participants could describe some overlapping characteristics between psychedelic-induced experiences and psychosis, many suggested that psychedelic-induced states and psychosis did not feel very similar. Others also clarified that despite some of the comparable characteristics, psychedelic-induced experiences and psychosis had an ineffable different quality to them. Nevertheless, a few participants reported the feelings experienced during psychosis and psychedelic-induced states had similarities.
Alterations in sensory perception, including hallucinations, were a common point of comparison between psychedelic-induced experiences and psychosis across all participants. Although both psychedelic-induced and psychotic experiences often included alterations in visual, auditory, and tactile or somatic perception, many differences existed in how sensory experiences were impacted. Psychedelics were reported to produce more sensory alterations than psychosis, which was more often described as a cognition-dominant experience. Bill shared: Psychedelics are very feeling, and physical, sense-oriented and emotionally oriented... Psychosis doesn't enhance any of that for me. It was all intense, disordered thinking. I didn't have any of those cool kinds of sensory-enhancing parts of psychedelics that I actually enjoy. Itwas just really intense, delusional thinking. Additionally, participants reported that the sensory alterations that occurred in psychosis (e.g., auditory hallucinations) were often true hallucinations for which they lacked insight, rather than sensory distortions that occurred during the effects of psychedelics.
Some participants described experiencing visual alterations or hallucinations during both the effects of psychedelics and during psychosis. Visual effects reported during psychedelics were ubiquitous, with all participants reporting experiencing pseudohallucinations during the acute effects. Often these included a sense of seeing existing objects around them "breathing," "drifting," or "morphing" (Ian). Seeing "fractals" or "geometric patterns" (Ella) overlayed on surfaces (Marek) was also commonly mentioned. The intensification of colors, which John described as "everything [looking] more HD," was also prevalent. In contrast, visual hallucinations and alterations were only experienced by some people during psychosis, and many also said they never experienced visual hallucinations during psychosis. For instance, Anna said, "There's a complete lack of visual hallucinations when you're psychotic." When visual alterations did occur, people commonly experienced "seeing things out of the corner of your vision" (Ian), especially "shadows in the night" (Chris) or "shadowy spots" (Nick). Occasionally, people reported multisensory hallucinations, including an auditory component, such as "seeing animatedlooking people that you could interact with" within a wall (Ian). This contrasted with the pseudohallucinations that occurred during the effects of psychedelics that did not appear as life-like. Some also contrasted more general visual effects, such as describing a sense that his vision was "fading out" (Alex) or that his sight was "less colorful" (Ivan) during psychosis. Occasionally, people remarked on some overlapping visual changes during both psychedelic-induced experiences and psychosis. Felix reported an increased intensity of color and Chris reported a sense of altered motion perception. Nevertheless, within the sample, seeing shadows was exclusive to the effects of psychosis, whereas seeing "fractals" or geometric pseudohallucinations was described as nearly exclusive to psychedelics.
Many participants reported that they experienced no auditory hallucinations during the effects of psychedelics, despite having experiences with auditory hallucinations during psychosis. For example, Bill said, "I did have some thinking [that] people were talking about me, or a little bit of hearing voices. I've never really experienced that from psychedelics." This was echoed by George's experience: "I would never visually hallucinate when I was in a psychotic episode anyway. I never auditory hallucinated whilst under the influence of the drugs." In contrast, a few participants described some auditory hallucinations during the effects of psychedelics. Auditory hallucinations are rarely discussed during the effects of psychedelics in people without a history of psychotic disorders. The presence of auditory hallucinations in some of our participants may reflect residual psychotic symptoms rather than typical effects of psychedelics in neurotypical populations.
Psychedelic experiences were described as having a "physical high" (Sophie) or a significant, often pleasurable, somatic component. For example, on psychedelics, participants described a "relaxing" feeling (Nick) or a sense of "warmth through my body" (Ian) or "rhythmic waves" (Sophie). These altered somatic experiences on psychedelics were described as more general than experiences that occurred during psychosis, which were more specific. Several participants described specific tactile hallucinations during psychosis. For instance, Marek said, "I could feel the armor, and [it] was actually like a proper proprioceptive hallucination." Merlin similarly stated that during psychosis, "I believed that my entire body was being swapped out bit by bit, constantly, sometimes in a very, excruciatingly painful way." Sophie similarly felt that her head was bleeding, and Alex experienced "crawling hallucinations" during psychosis.
Many participants also discussed differences and overlaps with specific emotions or moods within psychedelic-induced experiences and psychosis. Although participants often described experiencing some anxiety during a portion of their psychedelic experiences, many stated that psychosis was "terrifying" or "scary." As Alex shared: The emotions I feel with psychosis are usually like threatened, defensive, scared, confused. Kind of like, things are eerie. Whereas I think with psychedelics, I'll be like crying or I feel like really warm, loving. Sometimes, I'm scared and panicky, but it's not the same type of thing. ... It's not like it's all positive or something with the psychedelics and not even fearless. In contrast, some participants shared that there were aspects of positive mood that could overlap between psychedelics and psychosis, including a sense of "presence of love" (Felix) and euphoria. Those who had described pronounced positive emotions as a similarity in both experiences often described different causes for each. During psychosis, positive emotions often related to specific delusions, such as believing themselves to be a religious figureor believing that they were married (John). During psychedelic experiences, positive emotions often occurred without a specific cause or due to enhanced appreciation of sensory experience (e.g., a sunrise for Sophie). Some described the effects of psychosis on positive emotions as more intense than psychedelics. For example, David said, "Between psychosis and psychedelics, if I had to choose one, I would prefer to be in psychosis. Because it's a much more intense high than psychedelics would ever give you." Despite these similarities in specific emotions occasionally occurring, people still described the range and complexity of emotional experiences in psychosis and psychedelicrelated experiences as generally distinct. People described there being a broader range of emotions during the effects of psychedelics than during psychosis. Importantly, this was not only a change in emotional valence but in the complexity in which emotions were felt. Even negative emotions were occasionally described as being experienced positively during the effects of psychedelics, as Harry shared: I think there tends to be some range of emotions with psychedelics. It can feel good to be sad about something that it's appropriate to be sad about. … It feels like there's a more emotional range, whereas psychosis is just one note. Usually, it's just fear. That's it. And even when psychosis, for me, is the sort of grandiose type, it's still one note. In contrast to the one-dimensional feeling of fear or grandiosity, some participants described psychosis as a state with a lack of emotions. Alex went so far as to describe the reduced emotional embodiment as a "dead inside" feeling. As he said, "The thing I noticed with psychedelics is I think it actually really successfully pulls me out of the dead feeling. Almost like forcing me to become emotional."
As previously mentioned, participants described psychosis as a more "mental" experience than the effects of psychedelics, which often had changes in sensory and affective experience in the forefront. According to Bill, "The sort of thinking patterns from when I was psychotic was very ideas-based. There was more thought in it. For me, I feel like psychedelics are very feeling-oriented, and I don't do a lot of like really deliberate linear thinking." Ella echoed this by stating that her psychedelic experiences compared to psychosis were "opposite ends" of the spectrum with psychedelics "promoting more mental quietness, more sensory attunement to the outside world, and less preoccupation with my own thoughts." Nevertheless, in both states, participants discussed experiencing a style of thinking where more "connections" were readily made. Some people reported an increased sense of "coincidences" (Sophie) or "synchronicities" (Merlin) in both psychosis and psychedelic experiences. Some participants also shared that an increased sense of connections and heightened sense of meaning was the main similarity between psychedelic-induced experiences and psychosis for them. Harry said, "I would say the only really common element between the two is that in both states, there's this sort of sense of association between things. Other than that, there's not really any similarities I can think of." Despite increases in meaning and a more hyperassociative thought style occurring in both experiences, some important distinctions were made among participants. Notably, people discussed how psychosis was more "laser-focused on one thing" (Ivan), which often supported a "delusional narrative" (Merlin). In contrast, as Harry shared, "with psychedelics, there doesn't seem to be any like endpoint. There doesn't seem to be anything that they're going toward." Psychedelic-induced hyperassociative thought was often described as more "unfocused" (Ivan) or having a "sort of scatteredness" (Bill) compared to the sense of connecting ideas to support a narrative in psychosis. Additionally, the increases in meaning experienced during psychedelics often related more to the intensity of a sensory experience or heightened affective sensitivity than to meaning applied to a specific "narrative" or belief. For example, Sophie described experiencing a sunrise during the effects of psychedelics as "absolutely amazing," and never having appreciated sunrises before. In contrast, she said that during psychosis, "I would be noticing what was going on and getting every single detail out of it, which would all be about threat." For psychosis, hyperassociative thoughts and heightened meaning were often experienced as facilitating delusional beliefs. These beliefs were often experienced with a sense of complete certainty. For example, David said, regarding delusional symptoms during psychosis, "You think that whatever you're thinking is true. So, I really thought that I was Jesus Christ…There was no ambiguity. I was completely caught up in my delusion." In contrast, when people described the effects of psychedelics on their beliefs, there was often more ambiguity and a sense of questioning, rather than needing to develop a delusional framework, as Ivan explained: With psychosis, it is vastly more focused on that exact [same] problem that's imaginary. Whereas with psychedelics, it's more open and evolves into different questions that have more positive answers. Similarly, John reported that psychedelics provoked more belief in "a higher power" that was grounded more in a sense of feeling than in factual certainty. He did not take this increase in belief as certain, but rather a belief he needed to consider more, but felt true "emotionally." He contrasted this with beliefs he had developed during psychosis, which he experienced as "factually believing." In short, psychedelics provoked more questioning of beliefs in participants leading to re-evaluation, whereas psychosis tended to lead to the development of specific "certain" delusional beliefs that would be reinforced through random events having heightened meaning that was attributed back to that framework. As Jordon shared, "psychedelics shift the paradigm. Psychosis reinforces a paradigm in my experience."
A very salient distinction between psychedelic-induced states and psychosis was a sense of control being present in psychedelics, while there was often a sense of a "lack of control" in psychosis. Chris reported that during psychosis, there was "a sense of something beyond your control. That just sort of takes over a piece in your mind." Anna said: [LSD] feels more as if I'm in control, and it doesn't feel like something external has been added, which was a constant experience during psychosis, like something else is inside of me or something else is hanging around me, something is taking away parts of my speech, parts of my thoughts so that I'm not complete. It's a very different experience. Nick, who regularly experienced low-level psychotic symptoms, reported a similar lack of thought control during his experience of psychosis that was alleviated during the effects of psychedelics: I feel like I have this part of my thoughts that is trying to argue with me or put me down. I felt like I always had to argue against that in my head, and it was tiring. And I felt like once I took acid, finally it would be peaceful. I felt like I was in control of everything in my head finally. I finally felt like I could relax in my own head. Participants also described having greater emotional control during the acute psychedelic effects. Carlos shared that during his experiences with LSD, "I really can control much more easily my feelings. I cannot control what's going to happen, but I can control how I feel against something when it's coming to my mind with LSD." This experience was echoed by Nick: When I'm on psychedelics, it feels like I can really control how I'm feeling. I can really calm myself down if I need to. Like once I recognize where things are going, I can put the brakes on it when I'm on psychedelics, but when I'm not it feels really difficult to do that. The sense of control experienced during the effects of psychedelics seemed partially due to the sense that psychedelics provoked "predictable" and "consistent" experiences (Merlin). Participants reported that when they took a psychedelic, there was a sense of "knowing what is going to happen" (Ivan). This was contrasted with the lack of predictability with psychotic experiences, which Nick described as "volatile, scary, like it'll come out of nowhere." This experience of predictability also contributed to a sense of "safety" with psychedelics. This sense of temporariness and identifiable cause was described as a key differentiator even for more challenging experiences, as George explains: Because when you take a psychedelic you know you've taken something. This thing you've taken has caused you to maybe think in a certain way. I guess psychedelics aren't really scary. Psychosis is a bit more scary, and you don't have an awareness... You actually believe whatever delusions you're being told. I've had bad trips before. And even during bad trips, I sort of know it's temporary. As seen with George's experiences, even when psychedelic experiences were difficult, participants expressed their awareness of having taken a drug and their belief that its effects were temporary as an important distinguishing factor from their experiences during psychosis.
Psychotic experiences were often much more dominated by self-referential thoughts than psychedelic experiences. These self-referential experiences could be positive, negative, or neutral in emotional valence and often facilitate belief in specific delusions (e.g., being a religious figure (David)). Contrastingly, psychedelic experiences were rarely described as involving significant self-referential content. For example, Jordan said: I never, in a psychedelic experience, felt like it was about me in a tangible me-ness sort of way. I recall noticing patterns of light covering my skin. I didn't think that meant something about me. Psychosis, on the other hand, was very much attached to my place in the world in relation to the construction of my identity. This experience again emphasizes that psychosis was often described as a more cognitive experience, whereas with psychedelic experiences, sensory alterations and affect were more prominent focal points. Nevertheless, occasionally, people did experience paranoia during the effects of psychedelics. Often paranoia was based on concern surrounding appearing as if one was on drugs in an inappropriate setting (e.g., a public park (Jordan)). Even if these experiences prompted heightened self-monitoring, they did not generally have the contrived or magical quality that psychotic paranoia often included. For example, Felix said, during his psychedelic experience, "I didn't have a feeling that people really could read my mind. I was just wondering whether they thought that I'm using something or that I'm behaving in any way that could be inappropriate." More fundamental alterations in self-experience in psychedelics and psychosis occurred in both experiences for some participants. These alterations were not typically a focal point of discussion during either psychosis or psychedelic experiences, though they were mentioned by some. During the effects of psychedelics, people commonly described a sense of "feeling part of everything, everywhere" (Chris) or that they were "increasingly connected to everything" (Alex). During the acute experiences of psychosis, a few people described an experience of "disappearing," which was contrasted with experiences with psychedelics. For example, Alex stated, "In psychosis, it almost feels like I'm fading out of existence or something weird…I'm just becoming more faded. … And, usually, with psychedelics, it's like I'll actually have sensory enhancement." These feelings of fading out of existence were generally only described with psychosis, whereas psychedelics often led to experiencing a sense of merger with the environment.
To further understand similarities and differences between psychedelic use and psychosis, participants were also asked to describe which drug, if any, was most similar to their experiences during psychosis. The most common answer was cannabis (n = 9), followed by dissociative anesthetics (ketamine, n = 3; DXM, n = 1), stimulants (cocaine, n = 1; methamphetamine, n = 1; "stimulants" n = 1), and none (n = 3). Ivan said both stimulants and supratherapeutic doses of diphenhydramine were similar. Additionally, when asked, Merlin initially said "none," but stated that methamphetamine was the most problematic for worsening his psychotic symptoms.
Only Felix reported that a psychedelic was the most similar feeling substance he had used to his experience during psychosis. Felix initially falsely believed during the onset of his second psychotic episode that he had been given LSD without his consent. He described experiencing feelings "of being very light, seeing very clearly, and having a lot of thoughts at once," which he perceived as LSD-like. Felix also shared there were some differences as the psychotic episode progressed. He shared, "It became more negative, and I became more aggressive, and those were feelings that I didn't experience during the psychedelic trips." Felix also felt as if "the people on the street seemed like they were acting in a film staged just for me. I never experienced anything like that during a psychedelic experience." Taken together, for Felix, altered sensory experiences and hyperassociative thinking during psychosis paralleled the effects of LSD, but his experiences diverged in terms of selfreferential ideation and aggression.
People often reported a worsening of paranoia, auditory hallucinations, and cognitive symptoms during the acute effects of cannabis. For some, these symptoms were less intense than what they would experience in an acute psychotic episode. However, more often people described that the acute effects of cannabis would provoke psychotic symptoms of a greater intensity than what they experienced in their day-to-day lives or during an acute psychotic episode. Nick shared, "It [cannabis] would be even worse than sober psychosis. It feels like sober psychosis, but with really strong auditory hallucinations and like almost feeling stuff that's not there." This sentiment was echoed by Alex, "A lot of the worst psychotic states I've had, I should mention are with cannabis," and Ella, "Just pure THC will be way beyond what I experienced every day."
Although both psychotic disorders and psychedelics have long been recognized to alter sensory perception, thought, and self-experience, people who have experienced both described numerous differences and occasional overlap. Psychedelic-induced experiences primarily involved expansive sensory and affective experiences as focal points, whereas psychosis was characterized as a thought-oriented experience often centered on self-referential delusional beliefs. Both experiences, according to participants, do elicit salient changes across many sensory modalities, but these were often not described as similar. Other substances, such as deliriants, may be more capable of producing sensory alterations that overlap with psychosis, such as the experience of shadow-like hallucinations and auditory hallucinations. The saliency of altered sensory perceptions occurring might explain why these states were historically compared, despite many of the sensory changes not being very similar. Conversely, people shared that in both psychosis and psychedelic states, they experienced heightened hyperassociative thinking and meaning attribution, consistent with prior findings that psychedelics can transiently model aspects of psychotic-like thinking in healthy volunteers. Nevertheless, participants often described differences in how meaning was experienced. During psychosis, meaning was often enhanced by relating ordinary experiences or objects to self-referential delusions. In contrast, psychedelic experiences often involved heightened sensory or emotional significance that felt meaningful without supporting any specific belief. These distinctions suggest that apparent experiential overlap can mask potentially clinically relevant differences between states. Prior work has suggested that emotional valence explains differences between psychosis and psychedelic experiences. Participants commonly described emotional blunting during psychosis, consistent with negative symptoms, whereas they described emotions during psychedelics as richer and more nuanced. This suggests psychosis may involve a reduced emotional range, while psychedelics may enhance emotional complexity through increased awareness of internal states. One possibility is that psychedelics may transiently reduce psychotic disorder-associated alexithymia (i.e., difficulties identifying and describing emotions). Focusing solely on emotional valence may therefore overlook important differences in emotional awareness and range between the two states. In our sample, participants reported a greater sense of control over thoughts and affect during psychedelic experiences compared to psychosis, in which delusions of control and thought insertion are well documented. This finding may seem counterintuitive given that psychedelic-assisted therapy often emphasizes "surrender" to the experience. However, this framing likely reflects discouraging experiential avoidance rather than a reduction in agency. Additionally, the voluntary decision to take a substance and the awareness of a known, time-limited cause likely contributed to participants' sense of control. In contrast to the nuanced similarities described between psychedelic-induced states and psychosis, many participants reported experiencing distinctly psychotic-like effects during the acute effects of cannabis. This aligns with evidence that individuals with greater psychosis proneness are more likely to experience psychotic-like symptoms following cannabis use. Although cannabis is often perceived as having milder effects than psychedelics, growing evidence suggests that frequent use of high-potency THC products can substantially exacerbate psychotic symptoms in vulnerable individuals. Public health messaging should more clearly communicate these risks through warning labels on recreational cannabis products.
It is important to acknowledge that acute subjective similarity or dissimilarity between psychosis and psychedelic-induced experiences does not necessarily imply long-term psychosis risk or therapeutic relevance for psychotic disorders. Accordingly, these findings alone do not suggest that psychedelics have therapeutic effects for psychotic disorders. Nevertheless, a companion manuscript examining the perceived long-term impact of psychedelic use in this sample suggests that some people with a history of NAPD may benefit or may not experience negative effects. However, comparing the acute effects of psychedelics to psychosis has implications for potential tolerability trials of psychedelics in people with NAPD. Based on our results, people with NAPD are unlikely to universally experience psychedelics as resembling prior psychotic episodes, though selective overlaps may occur. Clinicians in future tolerability studies should anticipate common psychedelic challenges (e.g., severe anxiety) without assuming patients are re-experiencing psychotic symptoms. It is plausible the increases in emotional awareness and sensory embodiment reported by participants may contribute to potential therapeutic effects. More broadly, the limited overlap between acute psychedelic effects and psychosis suggests that extrapolating treatments for adverse psychedelic experiences from psychosis-based frameworks may be inappropriate. For example, some first-generation antipsychotic medications administered during acute psychedelic states may exacerbate psychotic symptoms or worsen anxiety. Similarly, adverse long-term effects, such as hallucinogen persisting perception disorder (HPPD) or other outcomes, may benefit from psychedelic-specific, bottom-up approaches rather than treatments extrapolated from treating psychotic disorders (e.g., antipsychotic medication). Training and education for supporting people using psychedelics in both clinical and harm-reduction contexts should therefore emphasize increasing awareness of challenges unique to psychedelic-induced experiences and ways to manage them.
The transferability of our findings to other samples with NAPD may be limited by the characteristics of our purposive sample. Our recruitment strategy likely favored individuals who were more digitally literate, higher functioning, and more interested in psychedelics than those recruited through other sampling approaches. Diagnoses and substance use histories were based on self-report and may therefore be inaccurate. Recall bias may also have influenced accounts, particularly for psychotic experiences that occurred many years prior. Future studies might consider restricting inclusion based on the recency of both psychotic and psychedelic experiences. Reliance on self-reported diagnoses further limits diagnostic certainty. Psychotic disorders are highly heterogeneous, and misclassification along the psychotic-affective continuum is common. Although individuals with bipolar disorder with psychotic features were excluded, two participants described experiences suggestive of prominent affective symptoms despite reporting a schizophrenia diagnosis (American Psychiatric Association, 2022). Future studies could incorporate structured diagnostic interviews to improve diagnostic specificity. Future studies might also consider memberchecking and more explicit examination of environmental context, given the well-established role of "set and setting" in influencing the effects of psychedelics. Lastly, as is the case with much qualitative work, a different research team might have emphasized different aspects of participants' experiences.
This study highlights the limitations of the psychotomimetic model of psychedelics from a subjective experience standpoint. Although some similarities between psychosis and psychedelic-induced states were identified, participants with experience of both more often emphasized their differences. Sensory alterations were generally described as distinctive, though both states could influence overlapping modalities. Altered meaning attribution and hyperassociative thinking emerged as an important similarity that may have been underemphasized in prior research. Overall, our study underscores the importance of making specific comparisons between psychedelic-induced experiences and psychotic disorders and stresses the importance of examining subjective experience to better understand both. Future research comparing these states, particularly their most similar and most distinctive experiential components, may yield valuable insights into the mechanisms underlying both.
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Dourron, H. M., Strauss, C., Hendricks, P. S. · Pharmacological Reviews (2022)
Evans, J., Robinson, O., Ketzitzidou-Argyri, E. et al. · PLOS ONE (2023)
Gashi, L., Sandberg, S., Pedersen, W. · International Journal of Drug Policy (2021)
Geyer, M. A., Vollenweider, F. X. · Trends in Pharmacological Sciences (2008)
Gouzoulis-Mayfrank, E., Heekeren, K., Neukirch, A. et al. · Pharmacopsychiatry (2005)
Johnson, M. W., Hendricks, P. S., Barrett, F. S. et al. · Pharmacology and Therapeutics (2019)
Johnson, M. W., Richards, W. A., Griffiths, R. R. · Journal of Psychopharmacology (2008)
Torre, J. T. L., Gallo, J., Mahammadli, M. et al. · Journal of Psychedelic Studies (2024)
La Torre, J. T., Mahammadli, M., Faber, S. et al. · International Journal of Mental Health and Addiction (2023)
Leptourgos, P., Fortier-Davy, M., Carhart-Harris, R. L. et al. · Schizophrenia Bulletin (2020)
Osmond, H. · Annals of the New York Academy of Sciences (2010)
Sabé, M., Sulstarova, A., Glangetas, A. et al. · Molecular Psychiatry (2024)
Simonsson, O., Goldberg, S. B., Chambers, R. et al. · Psychopharmacology (2023)
Simonsson, O., Hendricks, P. S., Chambers, R. et al. · Journal of Affective Disorders (2023)
Simonsson, O., Mosing, M. A., Osika, W. et al. · JAMA Psychiatry (2024)
Timmermann, C., Vollenweider, F. X. · Trends in Cognitive Sciences (2023)
Wießner, I., Falchi, M., Palhano-Fontes, F. et al. · Psychological Medicine (2021)
Wolff, M., Evens, R., Mertens, L. J. et al. · Frontiers in Psychiatry (2020)