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. Others have lost jobs or damaged relationships because of acting erratically while hypomanic (or when hypomania turns into mania).

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.

US

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

UK

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

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