A psychotic episode can be frightening to watch and even more frightening to live through. Psychosis means a person has lost some contact with reality, so their thoughts and senses are disrupted, and they find it hard to tell what is real and what is not [1].
This guide explains in plain English what to do in the moment, what to avoid, and how to get help. It draws on international health bodies and expert-consensus guidelines for the public.
The short answer
- Stay calm, speak quietly in short and simple sentences, and give the person space [2].
- Do not argue with, laugh at or dismiss what the person sees, hears or believes. Their experiences feel completely real to them [2].
- Check for danger. If the person may harm themselves or someone else, call emergency services, even if the person does not want help [2].
- Do not threaten, crowd, restrain or chain the person. Frightening them usually makes things worse [2].
- Get medical help as early as possible, because earlier treatment often means a better recovery [1].
What is a psychotic episode?
Psychosis is a group of symptoms, not one single illness [1]. The two main symptoms are delusions and hallucinations [1].
Delusions are strongly held false beliefs, for example that people on television are sending the person secret messages, or that others are trying to hurt them [1]. Hallucinations are seeing or hearing things that other people do not, such as a voice that criticises the person or gives orders [1]. Speech can also become jumbled, and behaviour may not fit the situation [1].
Studies estimate that between 15 and 100 people in every 100,000 develop psychosis each year [1]. It most often starts in the late teens to mid-20s, but it can happen at younger and older ages [1].
Psychosis is not the same as schizophrenia. It can be a symptom of illnesses such as schizophrenia, bipolar disorder or severe depression, but a person can have psychosis and never be diagnosed with any of them [1].
Other possible causes include sleep deprivation, some prescription medicines, and the misuse of alcohol or drugs [1]. In older adults, it can be part of diseases such as Parkinson’s disease or dementia [1].
Experts also warn that a single odd sign does not prove psychosis, and that a person who shows signs does not always have a psychotic illness [3]. This is why a qualified professional, such as a psychiatrist, psychologist or social worker, should make the diagnosis [1].
Warning signs that often come first
Changes in behaviour often appear before a full episode [1]. These include suspiciousness or paranoid ideas (the feeling that others are against you), trouble thinking clearly, and pulling away from people [1].
Other signs are unusual or very intense ideas, a drop in self-care or hygiene, disturbed sleep, confused speech, and a sudden fall in school or work performance [1].
Do not assume the person is just going through a phase or misusing drugs, or that the signs will pass by themselves [2]. Culture also matters, because what counts as a symptom in one culture may be seen as normal in another [2].
What to do right now: step by step
- Stay calm and check safety. Judge whether there is any risk that the person will harm themselves or others, and whether it is safe for them to be alone. If it is not, make sure someone stays with them [2]. Also make sure you have a clear way out of the room [2].
- Speak simply. Use short, plain sentences in a quiet, non-threatening voice at a moderate pace. Repeat yourself if needed, give the person plenty of time to answer, and answer their questions calmly [2].
- Treat voices and beliefs with care. Do not dismiss, play down or argue with them, and do not look shocked, horrified or embarrassed [2]. Use the same words the person uses for their experience, and avoid medical labels [3].
- Give the person a sense of control. Ask what would help them feel safe, offer choices, and agree to their requests unless they are unsafe or unreasonable [2]. Do not touch the person without permission, and do not stop them from pacing if they want to move around [2].
- Bring in someone they trust. Ask whether there is a close friend or family member the person trusts, and ask that person to help [2].
- Call for help if you cannot calm things or if anyone is at risk. This can be emergency medical services, a mental health crisis team or the police, depending on where you live [2]. Tell the dispatcher what you see and hear, how severe it is, and whether the person is armed [2]. You can say you are concerned the person may be experiencing psychosis, but describe symptoms rather than pinning a label on them [2, 3].
- Explain what is happening. When helpers arrive, tell the person who they are and that they are there to help [2]. Some steps, such as involving the police, can raise the person’s fear, so honest explanation matters [2].
- If the person becomes aggressive, do not answer with hostility, threats, a raised voice, fast talk or sudden movements [2]. Take threats seriously, especially if the person believes they are being persecuted [2]. Never put yourself at risk, and if things get out of control, step away and call emergency services [2].
Things to avoid
- Arguing, laughing, sarcasm or talking down to the person [2].
- Criticising or blaming them, or taking their words personally [2].
- Making promises you cannot keep [2].
- Threatening them with hospital or with the mental health law [2].
- Feeding or inflaming their fear and suspicion [2].
If the person refuses help
People developing psychosis often do not ask for help, and many try to keep their symptoms secret [2]. Fear and confusion can lead them to deny anything is wrong, and some do not realise they are unwell [2].
Unless a person meets the legal rules for forced treatment, they cannot be made to accept it. If there is no risk of harm, patience is advised, and you should stay friendly so they feel able to ask you later [2].
Both people with lived experience and professionals agreed that the helper should encourage the person to seek professional help [3]. Encourage them to talk to someone they trust [2].
Waiting has a cost. Delayed treatment of a first episode is linked to poorer outcomes [3], and it is common for symptoms to go on for more than a year before treatment starts [1].
Special case: new mothers
Psychosis can also appear after childbirth, which is called postnatal psychosis. Expert panels agreed that if you think a new mother may have it, you should call a mental health crisis team immediately, because it can get worse very quickly and delays raise the risk for the mother and baby [3].
The same advice applies if a mother has delusions that involve her baby [3].
Are people in psychosis dangerous?
Most are not. Expert guidance says people with psychosis are not usually aggressive and are at much higher risk of harming themselves than others [2].
A systematic review (a study that pools many other studies) found only a modest link between psychosis and violence, and found that people with psychosis are more likely to have been victims of violence [4]. It also notes that most adults with psychotic disorders do not act violently [4].
Where violence does happen, it is reported more often in the first episode and in untreated psychosis, and family carers are the most likely targets, often at home [4]. NIMH adds that the risk of violence and of suicide goes down with treatment [1].
So take threats seriously and keep yourself safe, but do not assume the worst about the person.
What treatment looks like
Treatment usually includes antipsychotic medicine, which reduces symptoms. Because these medicines have different side effects, the choice should be made with a health provider [1].
Many countries now use coordinated specialty care for early psychosis. This is a team approach that combines talking therapy, family education, medicine management, support to return to work or school, and case management for practical problems [1]. People do better when this care starts soon after symptoms appear [1].
Recovery is realistic. Some people who get early treatment never have another episode, and others lead full lives even if symptoms sometimes return [1]. WHO says at least one in three people with schizophrenia fully recover [5].
Good care is not available everywhere. WHO reports that only 29% of people with psychosis receive specialist mental health care, and more than two out of three do not [5]. WHO also says community-based care works better than mental hospitals, which often violate human rights [5].
Culture, faith and family: beyond one country
The main expert guidelines were built for adults and teenagers in high-income Western countries with developed health systems, and they do not cover cultural differences [3]. That is why researchers tested them elsewhere.
A study with Chinese experts and families found that 207 of 208 statements from the English guidance also fitted China [6]. The Chinese panels put more weight on involving family and on professional help, and they noted that stigma (shame and social rejection) is a barrier [6].
In an earlier four-province survey in China, 27.6% of people diagnosed with psychotic disorders had never sought any professional help [6]. Families can also be blamed for a relative’s illness, which pushes some to hide it [6].
A senior WHO officer says that in many low-income countries, people believe psychosis comes from possession by evil spirits [7]. Some families chain, starve or cage a relative to drive the spirits out, and WHO calls this a violation of human rights [7].
WHO’s Chain-Free Initiative began in 2006, and Somalia and Afghanistan now have chain-free hospitals that train staff and involve families [7]. WHO also says family and community support matters for recovery [5].
Prayer, elders and traditional support can sit alongside medical care, but they should not delay it, because earlier treatment gives better recovery [1].
Looking after yourself
Helping someone through psychosis can be tiring and upsetting. The 2021 expert update added a self-care section for helpers, and every statement in it was endorsed by more than 93% of the experts [3].
Myths vs facts
| Claim | Verdict | What the evidence says |
|---|---|---|
| People with psychosis are always violent | Myth | Most are not aggressive, and they are more often victims than attackers [2, 4] |
| Psychosis is caused by evil spirits or a curse | Myth | Research points to genes, brain development and stress or trauma working together [1, 7] |
| You should argue the person out of their beliefs | Myth | Experts advise against arguing with or dismissing delusions and hallucinations [2] |
| Psychosis always means schizophrenia | Myth | It can come from other illnesses, lack of sleep, some medicines, or alcohol and drug misuse [1] |
| Chaining, caging or beating a person drives psychosis out | Myth | WHO calls these practices human rights violations and works to end them [7] |
| Voices and strange beliefs feel completely real to the person | True | Guidelines tell helpers to remember this and never mock or minimise [2] |
| Earlier treatment improves recovery | True | Longer delays are linked to poorer outcomes [1, 3] |
| Heavy cannabis use can raise the risk | True | WHO links heavy cannabis use to a higher risk of schizophrenia, and NIMH lists drug misuse as a possible cause of psychosis [1, 5] |
| People can recover | True | At least one in three people with schizophrenia fully recover [5] |
| Anyone can force a person into treatment | Myth | Unless the legal rules for forced treatment are met, a person cannot be made to accept it [2] |
| Rest, exercise and sleep alone can treat psychosis | Unproven | Experts back these as helpful extras [3], but standard treatment is medicine plus team care [1] |
Bottom line
If someone is having a psychotic episode, your job is not to fix it or win an argument. Your job is to keep everyone safe, stay calm, speak simply, and help the person reach medical care as early as possible.
Call emergency services if anyone is at risk, and never use chains, threats or force. Psychosis is a treatable health condition, and many people recover, especially when care starts early.
Disclaimer: This article is for general education only and does not replace advice from a doctor or other qualified health professional, and anyone in immediate danger should contact local emergency services. If you notice an error or would like to send feedback or corrections, please contact us.
References
- [1] Understanding psychosis, National Institute of Mental Health (NIMH)
- [2] Psychosis first aid guidelines, Mental Health First Aid Canada, Mental Health Commission of Canada
- [3] Offering mental health first aid to a person experiencing psychosis: a Delphi study to redevelop the guidelines published in 2008, BMC Psychology
- [4] Informal caregiving relationships in psychosis: reviewing the impact of patient violence on caregivers, Frontiers in Psychology
- [5] Schizophrenia fact sheet, World Health Organization
- [6] Development of Chinese mental health first aid guidelines for psychosis: a Delphi expert consensus study, BMC Psychiatry
- [7] Breaking the chains that bind the mentally ill, NPR via Connecticut Public
