May 06, 2017
A lot has been written about handling depression and anxiety, and with good reason! They are very common and can be very debilitating.
But this piece addresses some less common problems: mania and psychosis. These are not as commonly understood, so people are often ill-equipped to recognize or handle them when they come up.
Why might the EA community need resources on this topic? We have a lot of young adults, who are particularly likely to be caught unprepared by mental health crises. And we have a lot of people traveling to areas where they have few supports and resources.
The National Institute of Mental Health estimates a 12-month prevalence for the following illnesses (the chance that an adult in the US met the criteria during the last year):
In other words, if you’re friends with 100 random American adults, around four of them will likely meet the criteria for one of these disorders this year. This doesn’t include people who experience psychosis but don’t meet all the criteria for schizophrenia (for example, because the psychosis is drug-induced).
Mania (or, in its lesser form, hypomania) is a period of heightened emotion, activity, and energy. Some people experience both periods of mania/hypomania and periods of depression, while others experience only mania/hypomania — these are both forms of bipolar disorder.
Hypomania might include some of the below signs but be shorter and less intense and not disrupt the person’s life as much. Mania is a more intense version that impairs a person’s normal functioning (for example, through risky behavior).
A hypomanic or manic episode might look like:
Decreased need for sleep
Talking more or faster than usual
Feeling euphoric or giddy, “on top of the world”
More irritable or hostile than usual
Feeling your thoughts are moving fast or won’t stop
Feeling very motivated, engaging in lots of activities at once
Lots of energy
More sociable than usual, talking or arguing with everyone
Easily distracted by unimportant details
Unusually high self-esteem
Pursuing fun and risky activities more than usual: shopping, sex, gambling, drug use, driving fast, unlikely business schemes
Feeling your brain is working on a whole new level, everything suddenly makes sense
Might lose touch with reality (seeing, hearing, or believing things that aren’t real)
These symptoms can last from days to months. Some people experience some of these at the same time as depression (a “mixed episode.”)
Sleep disruption, including due to crossing time zones
Recently starting or raising dose of antidepressant medication
Stimulants: caffeine, nicotine, cocaine, amphetamines, steroids, appetite suppressants, ADHD medications
Some cold medicine and thyroid medicine
Season/light changes — more common in summer
Missing doses of psych meds
Some people feel that the euphoria and creativity that comes with hypomania works well for them. Many others find that periods of hypomania, while enjoyable, are often followed by periods of depression or full mania which cause serious problems for them.
Psychosis is losing touch with reality.
This may look like:
Hallucinations (hearing, seeing, smelling, or feeling things that aren’t there). Sometimes people recognize that these aren’t real, while other times they’re very sure they’re experiencing something real. This can be very distressing for them.
Delusions (strongly held beliefs despite evidence to the contrary). Common delusions include:
Belief that people are trying to follow or harm you (paranoia)
Belief that things refer to you: thinking strangers are talking about you, that insignificant events have special importance, that mass media like TV has special messages for you
Belief that something is wrong with your body, in the absence of evidence
Belief that people are romantically or sexually interested in you, in the absence of evidence
Hugely overestimating your own importance and abilities
Unusual or bizarre behavior
Changes in physical motion: repeating meaningless motions, or not moving at all
Thoughts and speech seem disorganized, not making sense, getting distracted by thoughts in mid-sentence
Showing and feeling no emotion, “blank” look
Loss of interest in usual activities, apathy
Many of these symptoms may also occur for other reasons. Some may come from physical problems with the brain (for example, a stroke). This is one of the reasons it’s a good idea to get medically evaluated if things seem off.
Some people may experience these symptoms before a full psychotic episode:
Feeling your mind is playing tricks on you
Hearing things like your name being called
Seeing glimpses of that aren’t there out of the corner of your eye, or seeing moving patterns or shadows
Extreme sleep deprivation
Trauma or extreme stress
Some medications or drugs, especially marijuana, psychedelics, MDMA
Withdrawal from some drugs, especially alcohol
Physical illness or injury (head injury, infection, blood sugar imbalance, electrolyte imbalance, brain disease such as Parkinson’s)
The weeks after childbirth
No special trigger, just underlying genetic predisposition
A psychotic episode may or may not indicate an ongoing mental health problem. After a first episode, about ⅓ of people will have another episode within 3 years (source). In some circumstances, like sensory deprivation or bereavement, hallucinations are very common and not predictive of future problems.
Some people have only one episode and recover fully. Others have multiple episodes and benefit from ongoing treatment but retain basically normal functioning between episodes. Others get progressively worse. People with recurring episodes would probably be diagnosed with one of the schizophrenia spectrum disorders.
Bipolar disorder and schizophrenia seem to have some common genetic risk factors. People with a family history of either disorder are more likely to develop one of them.
Drugs that may be relatively safe for some people may be much less safe for others.
There’s not clear evidence as to whether marijuana increases risk for psychosis, but it seems very plausible that it worsens existing psychosis and makes people who already have risk factors (like a family history) more likely to develop psychosis.
While drugs such as MDMA have been tested as therapies for conditions like PTSD, the findings of these studies may not be very generalizable because:
The studies screen out participants that are seen as being at high risk (for example because they already had other medical or mental health problems).
The participants were given actual MDMA, while what’s bought on the informal market is often diluted with other substances, ranging from harmless (chalk) to ones that may cause unwanted effects (methamphetamines, which like other stimulants can kick off mania in some people).
In other words, what was safe for carefully selected study participants with carefully selected drugs may not be safe for you.
The Drug Policy Alliance’s statement on psychedelics:
“An individual's experience using a psychedelic drug is strongly influenced by two key factors: set and setting. The set is the internal mental environment, and the beliefs, of the person who has ingested the substance. Setting is the external environment. If someone uses a psychedelic in a threatening or chaotic set or setting, that person is more likely to have a threatening or chaotic experience. Likewise, if psychedelics are used in a safe, supportive environment, it will be easier for the person to allow his or her experience to develop in a coherent, potentially meaningful manner – though some parts may still be overwhelming or psychologically jarring.”
Most people don’t get help soon enough. Someone who experiences psychosis usually doesn’t get treatment until more than a year later. Someone with bipolar typically isn’t diagnosed until more than three years after their first mood episode.
A survey by the National Alliance on Mental Illness asked people who have experienced psychosis who helped them during the early stage of their illness. The most common answer was “no one.” (Parents, psychiatrists, and therapists were the next most common answers.)
In the survey, people who had experienced psychosis listed ways others had helped them:
Identifying problems early
Listening patiently and compassionately, without making judgments
Making suggestions without being confrontational; remaining gentle and calm
Keeping them from harming themselves
Taking them to an emergency room or making appointment and taking them to a doctor
Providing a safe place to rest or recover
Flying or driving long distances to be with them
Explaining the nature of the illness and what was happening
Building trust by making decisions together
Prescribing the right medication
Prescribing cognitive behavioral therapy
Providing child care, cooking, or taking on other daily chores
Providing financial support
Encouragement that “normalized the experience,” such as to finish school or return to work
They also listed their most important needs during periods of crisis:
Getting rid of voices and paranoia
Knowing the difference between what was real and unreal
Hospitalization, medication and stabilization
A safe place and protection
Access to a good psychiatrist or counselor
Validation of their experience; someone to listen who could be trusted
Information and explanation
Seek medical care if you’re concerned that you or someone else isn’t doing well. This is the standard advice for a good reason, which is that things may get worse if you try to just wait it out. You may miss the opportunity for treatment that would have been helpful. The problem may be due to something you don’t expect (like a neurological problem, a substance you didn’t realize the person took, or an infection). Or it may get beyond what you can safely handle.
In an emergency, call 911 or go to an emergency room (would be called A&E in UK) at a local hospital.
Many areas have a psychiatric crisis team that can send trained mental health staff to where you are; call 911 or the local non-emergency police number.
National suicide prevention chat or hotline: 1‑800‑273‑8255
Suicide crisis text line: Reach a counselor 24/7 by texting 741-741
Berkeley Mobile Crisis Team: (510) 981-5900
National Alliance on Mental Illness (NAMI) hotline: 800-950-6264
In an emergency, call 999 or go to an A&E department (would be called emergency room in US) at a local hospital.
Mental health helpline: 116 123
If, for whatever reason, you decide not to get medical help, here are some basic safety tips.
Get the person to a calm, quiet environment.
Help them establish a regular routine of sleeping, eating, and quiet activity. During mania, trying to “work off” excess energy through activity is counterproductive; getting lots of rest is better.
Help them stay hydrated, particularly if they’ve had a lot of alcohol or MDMA.
Contact someone who knows more about what’s been helpful to them in the past, like their family.
If they’re agitated or aggressive, take this seriously. Keep yourself safe and re-consider calling for medical help.
Someone I know is in crisis from Treatment Advocacy Center
Harm Reduction from Robot Hugs
Some people find that mood/sleep tracking apps help them recognize when a manic episode is approaching.
What I’m like when I’m well
Things that have helped in the past
Symptoms that indicate I’m no longer able to make decisions for myself
People I do and do not want involved in my care
Preferred treatments and treatment facilities
Contact information for people you would want to contact in a crisis
How to get therapy from Kate Donovan
Things that sometimes help if you have depression from Scott Alexander (including info on why people with bipolar need different treatment from people with depression).
Navigating Crisis from Icarus Project