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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.

How common are these problems?

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):

  • Bipolar disorder: 2.6% (a proxy for people who experience mania)
  • Schizophrenia: 1.1% (a proxy for people who experience psychosis)

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).

A person is most likely to have their first manic episode between age 20-25 (source). Men are most likely to experience a first psychotic episode between age 18-25, and women age 25-35 (source).

About mania

What is mania?

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

  • Fascination with big ideas and grand plans
  • 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.”)


Common triggers of mania in people who are prone to it:

  • Sleep disruption, including due to crossing time zones

  • Stress

  • 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


Is hypomania always bad?

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.


About psychosis

What is psychosis?

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.


Early symptoms

Some people may experience these symptoms before a full psychotic episode:

  • Trouble concentrating

  • 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


Common triggers of psychosis

  • Extreme sleep deprivation

  • Trauma or extreme stress

  • Some medications or drugs, especially marijuana or 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


Does someone who experiences psychosis have a particular illness?

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.


Family history

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.


Drug use

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.”


How to help

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

  • Sleep

  • Validation of their experience; someone to listen who could be trusted

  • Information and explanation

  • Financial assistance


Professional help

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

Alameda County mental health resources

San Francisco mental health resources



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

More helplines

NHS mental health services

Crisis services


Other types of help

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.


Other resources

Someone I know is in crisis from Treatment Advocacy Center

Harm Reduction from Robot Hugs

Screen Shot 2017-05-03 at 1.56.06 PM.png

Some people find that mood/sleep tracking apps help them recognize when a manic episode is approaching.

Advance directives for mental health, sometimes called wellness plans or mad maps. These are plans for what steps you want to take when. This includes information like:

  • 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

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

Supporting a person with mania or hypomania

Reducing bipolar triggers

Helping a loved one manage a manic episode

Dealing with Psychosis: A Toolkit for Moving Forward with Your Life

National Alliance on Mental Illness

Sorted by Click to highlight new comments since:
Common triggers of psychosis... some medications or drugs, especially marijuana, psychedelics, MDMA

Re: psychedelics & psychosis risk, see Krebs & Johansen 2013, a study of National Survey on Drug Use and Health data (n = 130,152) which found:

21,967 respondents (13.4% weighted) reported lifetime psychedelic use. There were no significant associations between lifetime use of any psychedelics, lifetime use of specific psychedelics (LSD, psilocybin, mescaline, peyote), or past year use of LSD and increased rate of any of the mental health outcomes.
Rather, in several cases psychedelic use was associated with lower rate of mental health problems.

More detail on this comment thread.

I've looked at this study and others and I agree. I've updated that sentence.

Thanks, Julia.

Common triggers of psychosis? ... Some medications or drugs, especially marijuana or MDMA

What's the evidence for MDMA being especially likely to trigger psychosis?

From a quick look, I found a couple case reports (1, 2) where ecstasy appears to have caused a psychotic episode. But I couldn't find a population-level study on this (probably there isn't one).

Given that millions of people use MDMA each year and there's only a couple case reports of ecstasy-induced psychosis in the literature, MDMA doesn't seem especially likely to cause psychosis.

See also: https://en.wikipedia.org/wiki/Substance-induced_psychosis

I'm confused - the wikipedia article you link to lists MDMA as one of the substances that induces psychosis. See also: https://en.wikipedia.org/wiki/Stimulant_psychosis#Substituted_amphetamines


The fact that this study had 32 participants from 2 drug treatment centers indicates to me that it's not just a few cases.

The fact that this study had 32 participants from 2 drug treatment centers indicates to me that it's not just a few cases.

Thanks, I didn't find that study during my quick look.

I think this is a base-rates thing:

  • In the US, overall prevalence of schizophrenia is something like 7.2 people out of 1,000
  • In the US, around 3.1 million people use MDMA each year (In 2013, 1% tried in the last year * 2013 population of 316 million)
  • So, in the case where there's no causal relationship, we'd expect to see about 22,320 people in the US who both used MDMA in the last year and are schizophrenic (3,100,000 MDMA users * 0.72%)

Given that there doesn't seem to be a population-level study on this and the prevalence can explained without positing a causal relationship (definitely could find 32 folks at treatment centers out of 22,000), I think assuming causality here is a stretch.

Right, I linked to that wikipedia article because it gives a long list of drugs that may induce psychosis (including MDMA), and the citation it gives for MDMA causing psychosis is a single case report from 1991.

Before I should admit my bias here. I have a pet peeve about posts about mental illness like this. When I suffered from depression and my friend killed himself over it there was nothing that pissed me off more than people passing on the same useless facts and advice to get help (as if that magically made it betteR) with the self-congratulatory attitude that they had done something about the problem and could move on. So what follows may be a result of unjust irritation/anger but I do really believe that it causes harm when we past on truisms like that and think of ourselves as helping...either by making those suffering feel like failures/hopeless/misunderstood (just get help and it's all good) or causing us to believe we've done our part. Maybe this is just irrational bias I don't know.


While I like the motivation I worry that this article does more to make us feel better that 'something is being done' than it does anything for EA community members with these problems. Indeed, I worry that sharing what amounts to fairly obvious truisms that any google search would reveal actually saps our limited moral energy/consideration for those with mental illness (ohh good we've done our part).

Now I'm sure the poster would defend this piece by saying well maybe most EA people with these afflictions won't get any new information from this but some might not and it's good to inform them. Yes, if informing them were cost free it would. However, there is still a cost in terms of attention, time, pushing readers away from other issues. Indeed, unless you honestly believe that information about every mental illness ought to be posted on every blog around the world it seems we ought to analyze how likely this content on this site is to be useful. I doubt EA members suffer these diseases at a much greater rate than the population in general while I suspect they are informed about these issues at a much greater rate making this perhaps the least effect place to advertise this information.

I don't mean to downplay these diseases. They are serious problems and to the extent there is something we can do with a high benefit/cost ratio we should. So maybe a post identifying media that is particularly likely to serve afflicted individuals who would benefit from this and urging readers to submit this information would be helpful.

I did question whether this was on-topic enough to be a good fit for this forum. (I don't think awareness about every health issue that affects EAs would be a good use of the space, even if it affects a higher proportion than these problems.)

I do think these problems can be unusually and spectacularly destructive when unchecked, and often even when much effort has been made. I also think most people don't have a good concept of how to recognize these conditions or even what to google; I certainly wouldn't have before getting training as a social worker.

I definitely don't want us to congratulate ourselves for having dealt with these problems, because there have been cases when people in this community have needed help here and not gotten enough. I wrote this in the hope that it will tip the balance in some future crisis toward people having the knowledge they need, not so that we can check this off our list as a solved problem. These are really hard problems to deal with, both for people who have them and for people trying to help, and that's exactly why I wanted a resource available.

I'm so sorry about your friend. This kind of information definitely isn't fail-safe, but I think it's the best we have.

Yes and reading this again now I think I was way too harsh. I should have been more positive about what was obviously an earnest concern and desire to help even if I don't think it's going to work out. A better response would have been to suggest other ideas to help but other than reforming how medical practice works so mental suffering isn't treated as less important than being physically debilitated (docs will agree to risky procedures to avoid physical loss of function but won't with mental illness ...likely because the family doesn't see the suffering from the inside but do see the loss in a death so are liable to sue/complain if things go bad).

More than half of the time, people who have a psychotic episode will have already had one before. I think the same is true of mania. The incidence for a first episode of psychosis is fairly low, about 0.03% per year [1].

[1] "Over the 8-year period May 1995–April 2003, there were 194 cases of any DSM-IV psychotic illness (117 male, 77 female; Table 2). The annual incidence of “all psychoses” was 31.6/100,000 aged >15, this being higher in males (37.2) than in females (25.7; risk ratio [RR] = 1.44 [95% CI 1.08, 1.93], p < .02; Table 3)."


Yeah, incidence for someone who's never had any episodes before is unlikely. So you can assume that your own risk is very low if you know you've never experienced these things before and don't have a family history.

But if a friend seems off and you're not certain of their personal or family history, I do think it's worth considering that they might have experienced mania or psychosis before without you knowing about it.

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.

In many venues, I think it's okay to tell people the official narrative for dealing with mental health without evidence, but in this space, I would like to see evidence for a claim like "Most people don’t get help soon enough". This means I would like a discussion of the likely impact of seeking professional care vs. not seeking it before making such a claim.

National suicide prevention chat now has different URL -- https://suicidepreventionlifeline.org/chat/

Thanks, updated!

Thanks for writing this! It's really helpful to have the basics of what the medical community knows.

I've been trying to figure out how to help in ways that respect neurodiversity. Psychosis and mania, like other mental conditions, aren't just the result of some exogenous force - they're the brain doing too little or too much of some particular things it was already doing.

So someone going through a psychotic episode might at times have delusions that seem to their friends to be genuinely poetic, insightful, and important, and this impression might be right. And yet, they're still having trouble tracking what's real and what's just a thought they had, worse at caring for themselves, and really need to eat and get a good night's sleep and friends to help them remember to do this.

Yes, I think that's where some kind of an advance plan can be useful: "When I start acting like X, I want you to take step Y" or "When you act like X, I'm going to stop engaging with the conversation and start focusing on helping you get some rest, and we can write down where we were in the conversation and resume 48 hours later if you want."

I appreciate this article because it makes these emotional problems – and ways to prevent and deal with them – visible and dispels the impression that we're all rational, calculating evaluators, all of the time. I recall 2 cases in the EA community of people who I chatted with online in the last year who seemed (disclaimer: by my amateurish reasoning for their extreme behaviour) to experience mania and/or psychosis at a point.

Great post. I'll try to make a useful contribution. Maybe this can be of help as well: the APA list of evidence based treatments:

Maybe one sentence that can use some more context:

They also listed their most important needs during periods of crisis: Getting rid of voices and paranoia

There is nothing that you can do to help someone getting rid of their voices. On the contrary, encouraging them not to hear voices might make it worse. This is why Acceptance and Commitment Therapy is on the list of evidence based approaches. And why Validation of their experience; someone to listen who could be trusted is on that list of needs as well.

As with most psychopathology, trying not to experience stuff that often results in more of those experiences. Off course, do get help, and medication might help to get rid of voices. But changing how you cope with such experiences is also of use.

Eric Morris is one of the researchers on this topic http://drericmorris.com/ & this is a Twitter feed aimed at contextual behavioral science and psychosis https://twitter.com/ACBSPsychosis

Thank you!

I agree that trying to force hallucinations and paranoia away or talk someone out of them almost never works. I was citing verbatim the list of what people from the NAMI survey listed as their needs.

Just a note that the APA here is the American Psychological rather than Psychiatric Association (both go by APA, confusingly) and lists only talk therapy and social support methods, not including medication. For psychosis in particular, I think virtually anyone in the field would say medication is the first line of treatment. The kinds of treatment listed there are good for ongoing management, but if I ever became psychotic I would absolutely want a psychiatrist or emergency room to be my first stop. Talk therapy would be good to add in later.

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