How to Help Someone Who is Having a Psychotic Episode

When a person has a psychotic episode, they lose touch with reality and may display a variety of unpredictable, abnormal, even bizarre behaviors. They may hear voices, become paranoid, or believe someone they are watching on television is sending them special messages. Their speech may become jumbled and no longer make sense.

Psychotic episodes are more common than most people realize. Studies have estimated that as many as three in every 100 people will have an episode at some point in their lives. Symptoms may last a day, weeks, months, or longer.

That means almost anyone could find themselves in the presence of a person who is having psychotic symptoms. It could be a friend, a family member, a coworker, or a stranger. What signs might indicate that you are witnessing a psychotic episode that requires some type of action—and what can you do? The answers aren’t always clear-cut, but it can help to have some understanding of what might be going on.

“You can think of a psychotic episode as you would a fever—it’s a signal that something is wrong,” says Vinod H. Srihari, MD, a Yale Medicine psychiatrist who directs the Yale School of Medicine’s Specialized Treatment Early in Psychosis (STEP) program. He says underlying causes of a psychotic episode could include illnesses such as schizophrenia or bipolar disorder, Alzheimer’s or Parkinson’s disease, or use of substances such as cannabis, cocaine, or amphetamines.

STEP is a collaboration between Yale School of Medicine and Connecticut’s Department of Mental Health and Addictions Services. Dr. Srihari was also the principal investigator behind the National Institutes of Health-funded Mindmap, an early detection campaign that successfully halved delays in accessing care across a 10-town region in southern Connecticut.

Mindmap used mass media and social media channels to raise awareness, worked with physicians to facilitate referrals, and used quality improvement tactics to reduce wait times to clinical engagement. Young people between the ages of 16 to 35 who had experienced a psychotic episode within the last three years were connected to best practice care at the STEP clinic in New Haven. Results of the original Mindmap study, covering a period from 2015 to 2019, were published in the journal Schizophrenia Bulletin Open. STEP embedded this campaign within a statewide network of clinics called the STEP Learning Collaborative in February 2024. The latter includes more than 20 clinics that together aim to offer rapid access to high-quality care to all individuals with recent-onset schizophrenia, regardless of health insurance status.

Getting immediate medical help for a psychotic episode is vital, as is awareness about the condition among teachers, college counselors, school nurses, primary care providers, therapists, clergy, and first responders, Dr. Srihari says. “If more people understood psychosis, we could avoid people inappropriately ending up in jail because they've started to behave in ways that scare others. Education about how to recognize psychosis and how to help can result in a pathway to appropriate health care, which is what we would want for someone with chest pain or a broken leg,” he says.

An important concern is that emergency response protocols, resources for treatment, and approaches to care for people with psychotic symptoms vary significantly across the country. Dr. Srihari says that while progress is needed, he hopes that the STEP Learning Collaborative will serve as a model. “We want to demonstrate how to scale an effective model across a state and hope that our results will inform national and international models of care,” he says.

Regardless of where a person lives, Dr. Srihari offers important facts about psychosis and helpful insights about how to help someone who is having a psychotic episode.

Psychosis is a term that covers a range of abnormal experiences or symptoms, such as paranoid thoughts, and signs including observable changes in speech or behavior. Similar to a fever, it can be identified readily, but requires medical evaluation to determine a specific diagnosis. A psychotic episode refers to the period of time during which a person is actively experiencing typical symptoms or exhibiting signs. The hallmark symptoms are hallucinations and delusions, described below. Although there are many other symptoms, a person having a psychotic episode may not experience all of them.

While experts can’t say for sure how psychosis develops, it’s believed that there are many potential contributing causes, including genetics, brain development, and environmental stressors, as well as substance use.

A person experiencing psychotic symptoms or displaying typical signs may not be aware that anything is wrong, but, according to Dr. Srihari, someone spending time with them may recognize one or more of the following:

• Hallucinations: These are disturbances in sensory perception: The person may see, hear, smell, taste, or feel things that aren’t real.
• Delusions: These are false beliefs or interpretations that are not based on reality. For instance, a person might believe they have magical or superhuman powers, or that they are being controlled by outside forces.
• Confused thinking or speech: A person might have difficulty concentrating, connecting thoughts, or slowing down racing thoughts. Speech may seem fragmented or incoherent.
• Suspiciousness, paranoia, or unease with other people: Examples include believing that a government agency is scheming against them or a family member is poisoning their food.
• Seeing patterns and signs in random occurrences: They might make predictions or seem convinced that specific problems are related to events that are not actually connected at all.
• Withdrawal from family and friends: This includes becoming isolated over time and losing interest in social activities the individual once enjoyed.
• Decline in self-care and motivation: They pay less attention to personal health, hygiene, and their living conditions.
• Cognitive disruptions: This can include problems concentrating, remembering things, and keeping track of a schedule.

Many individuals experience a prodromal period of disturbances before a first full-blown psychotic episode. The changes are often mild, Dr. Srihari says. For instance, the person might withdraw socially, become suspicious of people, affiliate with groups they didn’t care about before, and display difficulty functioning and a decline in personal hygiene.

“During this early period, they might acknowledge some perceptual aberrations—for example, when they're in the shower, they might hear noises that sound to them like voices,” Dr. Srihari says. “Such disturbances may resolve on their own, or progress to a psychotic or other disorder,” he says. People with symptoms like this may find it helpful to consult a mental health professional. At Yale, people with these concerns are referred to the Prevention through Risk Identification, Management & Education (PRIME) clinic, which is affiliated with STEP and evaluates anyone 12 or older who may be at risk for progressing to a psychotic episode.

Mild symptoms and signs should not be dismissed or ignored, Dr. Srihari says. “There’s no reason to catastrophize, but it can help to have a professional make an assessment, even if that means monitoring the person without specific treatment. And psychotherapy that's supportive and allows the person to talk about what's going on can help no matter what the diagnosis, and can make the next steps more acceptable if treatment is necessary for psychosis.”

The majority of schizophrenia spectrum disorders are identified after a first psychotic episode in teenagers and young adults. Schizophrenia refers to a group of illnesses that are chronic and, like diabetes, benefit from specialized long-term treatment. Early diagnosis and intervention can improve the ability of individuals to live full lives in their communities, Dr. Srihari says.

Not everyone who has a psychotic episode has schizophrenia—there are other conditions that can trigger symptoms. The list includes high fevers, infections (like HIV), and among older people, Alzheimer’s or Parkinson’s diseases (as mentioned above).

In rare cases, some medications—including even such common ones as antibiotics, antihistamines, corticosteroids, heart medications (such as beta-blockers), and amphetamines—can cause psychotic symptoms.

Research shows a strong link between use of cannabis and psychosis, although scientists are still investigating the connection. “For a small subset of people, stopping the cannabis resolves the psychosis," Dr. Srihari says. "But in most of these cases, we're also going to be treating a primary psychotic disorder that might have been hastened in its onset by cannabis.”

A person who is experiencing psychotic symptoms may be more willing to talk about them when they first notice that something feels wrong, Dr. Srihari says. This is one key reason why early medical help is important. “Once they develop fully formed delusions, they may not be willing to accept that something is wrong with them,” he says.

If you are in conversation with someone who is expressing concerns about possible psychotic symptoms, the following actions can help.

• Remain patient and calm, avoid being confrontational or judgmental, and communicate clearly using short sentences.
• Listen with concern and curiosity when the person is talking. Validate their feelings, maybe saying, “I can see this is making you very anxious.”
• If possible (i.e., you live with the person or are close to someone who does), make sure that firearms, medication, and other potentially harmful items are safely locked up.
• Calmly, but firmly encourage the person to go to a doctor for a mental health assessment. Ideally, the person should make an appointment as soon as possible with a mental health provider with whom they can establish a trusting relationship, so they have someone to turn to if the situation worsens.

It may be necessary to call 911 if a psychotic episode becomes severe—if the person is exhibiting extreme agitation, severe paranoia, uncontrollable aggression, or is threatening harm or violence to themselves or others, according to National Alliance for Mental Illness (NAMI). This grassroots mental health organization recommends telling the 911 operator that a person is having a mental health crisis or psychotic episode and making it clear that you are seeking medical help—and not an arrest. If you are at home, NAMI suggests meeting the emergency responder outside to brief them on the situation and share any helpful information.

Not all police officers are trained to handle psychiatric crisis calls—but it’s important to ask if a trained officer is available, Dr. Srihari says. Those with training have learned how to help calm the person and convince them to go to the hospital voluntarily. More police departments around the country now host crisis intervention teams that include trained clinicians and can offer a more effective response to a situation in which someone appears to be a threat, but, in fact, requires treatment rather than a law enforcement response, he says.

State laws regarding involuntary hospitalization vary significantly. It’s considered a last resort, but if a psychotic episode is severe enough to pose a danger to anyone, it may be a necessity, Dr. Srihari says.

Early treatment of a first episode can reduce the chance of recurrence or the intensity of future episodes significantly, Dr. Srihari says. “With appropriate care and treatment, a few people will never have another psychotic episode, and many will have recurrences but will learn to manage them better. For all, recovery can mean the ability to lead a fulfilling and productive life, even if psychotic symptoms sometimes return,” he adds.

Caregivers in a hospital emergency department can stabilize a person experiencing psychosis, usually by creating a calm environment and administering antipsychotic medications. There are a number of medications that can reduce psychotic symptoms within hours or days, although they can take weeks to reach full effect, Dr. Srihari says. Psychotherapy and support for basic needs, along with educational and vocational goals, is important as well, he adds.

Regardless of where you live, if you or someone you know is struggling with symptoms of psychosis, these resources might help:

• If you are looking for resources in your area or want to talk to someone: The Substance Abuse and Mental Health Services Administration (SAMHSA) has an Early Serious Mental Illness Treatment Locator. NAMI also offers a helpline, among other resources.
• If you or a loved one is in danger of self-harm: People with psychosis are at increased risk for suicide. Call or text the government’s Suicide & Crisis Lifeline at 988, (TTY users can use their preferred relay service or dial 711 then 988), or chat at 988lifeline.org to connect with a trained crisis counselor 24/7/365. In life-threatening situations, call 911.

If you live in Connecticut, are age 16 to 35, and need a referral for care, call the STEP Learning Collaborative at 203-200-0140 or submit an online referral form. Assessment coordinators screen for psychosis over the phone and connect people to care. All calls are confidential.

“Never worry alone,” Dr. Srihari says. “Psychosis is a social puzzle, and I’d like to encourage people to think of it as a solvable puzzle and not a catastrophe. This means that educating yourself about how to get help—either for yourself or others—will empower you. And remember you are not alone. Someone else in your community probably has some experience with the same problem. You’d be surprised at how many people in your community have dealt with a psychotic episode.”