Psycom spoke with Christine Crawford, MD, an adult and child psychiatrist based in Boston and the Associate Medical Director of the National Alliance on Mental Illness (NAMI). Here, Dr. Crawford shares her expertise and valuable advice on how to interact with a loved one before, during, and after a psychotic episode.

*Interview edited for clarity and space.

What Is Psychosis?

Psychosis is when a person loses touch with reality and shows signs of disorganized behaviors visible to people around them. They might experience auditory and visual hallucinations, hearing voices that no one else hears or seeing things no one else sees.

They may also have paranoid delusions such as believing that people are out to harm them and other fears and worries that aren’t consistent with what is going on in reality.

[Editor’s Note: Psychosis is a symptom, not an illness. Experiencing psychosis doesn’t necessarily mean a person has schizophrenia. Schizophrenia is a thought disorder characterized by disorganized thinking. It can cause psychosis but being diagnosed with schizophrenia is a complex process involving other symptoms. According to government sources approximately 100,000 young people experience psychosis each year. As many as 3 in 100 people will have an episode at some point in their lives.1,2]

Psychosis Symptoms

In addition to auditory and visual hallucinations, and paranoia, other symptoms of psychosis may include:

  • Thought Broadcasting

    Believing that other people are reading their thoughts or able to hear what they are thinking.

  • Ideas of Reference

    Seeing various symbols that they believe are trying to communicate something and deriving meaning from what they see or hear on TV and radio. For example, every time the radio plays a certain song that song is really communicating thoughts from God to them.

  • Thought Insertion

    Feeling like someone or something is putting thoughts into your head that aren’t your own.

  • Thought Withdrawal

    Believing that someone or something is plucking thoughts out of your head.

These symptoms can sometimes occur at the same time. For example, someone might have a paranoid delusion that the government has implanted a chip in their brain and is using a radio transmitting device to insert thoughts into their mind. On top of that, they may believe that the transmitting device is broadcasting their thoughts to people walking by.

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What Are The Early Warning Signs of Psychosis?

For most mental health conditions, there are going to be periods of recovery and relapse. And that’s just the nature of any mental health condition. Still, we know that stressors such as not sleeping or eating well, a traumatic event, or a loss can cause some symptoms of psychosis to reappear.

Many people experience their first psychotic episode in their 20s. And if they are diagnosed with schizophrenia, it’s quite apparent after talking to the family that there were these subtle signs and symptoms of schizophrenia that preceded the more obvious symptoms. For example:

If the person is in school and started falling behind in schoolwork or stopped showing up to class. Losing friends and not wanting to go out as often. If they work, missing work shifts. Disengaging socially can also be a sign.

Lack of personal hygiene, not bathing, and not taking care of themselves are other early signs as are saying things that don’t make sense and engaging in bizarre behavior. These are the things we tend to see early on.

We often tell family members to pay attention and seek professional help as soon as they start to notice these behavioral changes. What we do know is that when people receive treatment for psychotic disorders early, it helps reduce the duration and frequency of future episodes and also helps them recover a lot sooner.

What Happens If Someone Relapses?

When someone starts to experience psychotic symptoms again, the medication is usually adjusted. The dose may be increased or another medication may be prescribed.

I like to remind patients, that if they experience [a recurrence of] psychotic symptoms, it’s not a reflection of anything that they did wrong. It’s not that the treatment has failed. It’s just the natural course of the illness and we just have to fine-tune things so we can get them over the speed bumps and they can continue on their journey of recovery.

When Is A Psychotic Episode An Emergency?

If you’re a family member or caregiver, it can be difficult to know when you can handle a psychotic episode yourself and when it makes sense to call 911. You cannot handle a [full-fledged] psychotic episode on your own.

Call 911 if you have acute safety concerns and are worried that your loved one might hurt themselves or another person. Or if feel the person is exhibiting disorganized behavior such as hearing voices and insisting everyone around them put on earmuffs.

Another good reason to call for help is if your loved one is concerned about cameras being in the house and frantically covering up windows and electrical outlets. Or, if they are worried that your drinking water has been poisoned and slap glasses of water out of people’s hands.

These are the sorts of things we see sometimes and it’s important to seek immediate treatment for behavior like this.

If symptoms are present most of the day, nearly every day, your loved one needs help. If you are trying to intervene and having difficulty containing the person, certainly call 911. The same holds true if they are incredibly distressed by the delusions. When people become extremely distressed by their psychotic symptoms they can get physical without intending to and without the intention of hurting others.

I tell families not to delay calling and at the same time I validate their concerns about calling.

Here is some sample language you can use to make your reasons for calling clear to the 911 dispatcher:

I’m calling about an acute psychiatric concern. I’m worried that my loved one is experiencing a mental health problem.’ Then, before you open the door and allow the police to come in, meet them outside. Reiterate that what’s going on is not criminal. It’s okay to say, ‘I want you to know that this is a mental health issue. This is not a crime. This is not a domestic violence issue. This is a mental health issue and I want you to approach it as such.’

Calling the police is a difficult decision to make. And once they arrive, it’s very upsetting to see someone you love be put in handcuffs or forced into an ambulance. But as hard as it is in that moment, at least you know that your loved one is going to get the help they need to manage their complex medical issue.

Delaying may, unfortunately, lead to a situation in which the police may not arrive in time. You don’t want your loved one so upset by the voices and paranoia that they do something unintentionally that can cause serious harm to themselves and other people.

Intervene early. It’s going to hurt a lot at the beginning but ultimately it’s about safety.

What to Expect During Psychosis Hospitalization

Once you arrive at the hospital, ask to speak to the behavioral health clinician in the emergency room.  There is always one in the emergency room even in ERs that don’t have a dedicated section for psychiatric patients.

Be your loved one’s advocate.

Even if your loved one says, ‘I don’t want the doctor or anyone to talk to my family member’ and refuses to have you involved in their care, you can still provide information to the behavioral health clinician or social worker.

How to Reduce Stress And Offer Psychosis Support At Home

Some people continue to have symptoms of psychosis when they return home from the hospital. Medications may reduce the severity of the symptoms but they don’t always make them stop for everyone.

Some people continue experiencing auditory hallucinations, hearing voices, and/or sounds that others don’t hear.

Activity can be a good way to distract them from lingering symptoms. Go for a walk with them, visit a botanical garden, or enjoy a fun activity together. These kinds of activities can help them be less preoccupied with paranoia or auditory or visual hallucinations.

Encourage your loved one to maintain overall wellness. Sleep is important. Assist them in creating a healthy sleep environment—remove possible distractions such as a television and bright lights. Find ways to reduce noise.

It’s equally important to support healthy eating habits, especially given that some antipsychotics are associated with a fairly significant weight gain. As psychiatrists we often see that people will do really well on an antipsychotic, their symptoms improve, but then they gain weight and stop taking their medication altogether, which can be dangerous.

Weight gain can pose a significant challenge after psychosis. Some patients become so distressed about it their moods are impacted and they get depressed. Depression can contribute to the emergence of some psychotic symptoms.

It’s important for psychiatrists to help educate and counsel the family around the weight-gain issue. We talk to our patients about incorporating physical activity and other tools that help maintain a healthy lifestyle and minimize the weight gain associated with medications.

Family support is extremely important. As a family have a conversation with your loved one about healthy eating options and commit—as a family—to a nutritional and healthful eating plan.

How to Encourage Social Engagement

Many families want to know if they should urge their loved ones to socialize or if it’s best to leave them alone. This is challenging because people may still have ongoing symptoms of paranoia and feel uncomfortable leaving their homes.

A lot of programs geared to people after first psychosis involve group therapy which promotes social connections. This is because given the symptoms they’re previously experienced, and the possibility of ongoing psychosis, they may be socially disconnected.

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It’s important to validate their experience. Try using supportive language like this: “I know that you are really scared and it’s hard for you to leave the house but I think it could be helpful for you to talk to other people who are going through the same thing you are. They may share strategies that help them cope and can help you, too.

It helps to frame group therapy as a place where people struggling similarly can learn from each other and better tolerate the day-to-day challenges.

For some people that can be an effective strategy. Others may still not be ready. Never force your loved one into social settings and situations if they are not ready.

Participating in group therapy doesn’t have to happen immediately. What’s important is that over time, they will be ready to engage. We want them to know that opportunities are available when they are ready.

Other Ways to Support Someone with Psychosis

It’s important to allow the patient to have some sense of power and control over their lives.

Imagine what it might feel like to have a serious mental illness. Going through hospitalization and being prescribed medication can be scary and stressful. Your loved one may feel they have little agency and are just being told what to do.

This lack of control can be especially problematic for some people who are experiencing something called command auditory hallucinations in which a voice tells them what to do and what not to do.

That puts the person with schizophrenia in the position of feeling they have very little control over themselves. The more we can engage the person in planning their treatment and including them in conversations about their future, the greater sense of control the person feels and the less frustrated, anxious and depressed the person [is likely to] be.

What Should You Not Say to Someone with Psychosis?

Be curious, not confrontational.

Your loved one may be responding to what we call internal stimuli, meaning you might be talking to the person but they are not interacting with you—they may be laughing or smiling inappropriately or looking away or around. Don’t say:  ‘Are you hearing voices?’  Instead, say: ‘I see that you looking around a lot’ or  ‘I see that you’re laughing at something. Can you tell me what’s on your mind?

If the person tells you that they are seeing things that aren’t there, you can simply respond by telling the truth. If they say, ‘Don’t you see the devil right next to you?‘  respond by saying “No, but given that I don’t and you do, I’m wondering how that makes you feel?

If the person says that seeing the devil makes them feel uncomfortable, suggest going to another room.

Again, your response validates their distress and shows that you understand and support them.

Psychosis Is Treatable, Recovery Is Possible

I think it’s important to recognize that for many people there is a significant amount of stigma associated with mental health conditions especially when it comes to psychotic disorders.

The stigma that people experience often involves feelings of guilt or shame about their mental health issues. There is also a fear of being discriminated against because of the condition. Psychosis can be treated and recovery is possible. It’s important to get the treatment you need because having a psychotic illness is a medical condition.

It’s not who you are and it doesn’t define you. Don’t suffer alone and in silence. Get the help you need because with treatment you’ll be able to enjoy life.

Resources for Psychosis

The National Alliance for Mental Illness (NAMI) has valuable information for caregivers and family members. Visit the following links for more information and support:

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Last Updated: Oct 7, 2021