Bipolar disorder is a mental illness, predominantly categorized by changes in mood. Although this differs from person to person, many people with bipolar disorder experience periods of time feeling very low, called a depressive episode, alternating with periods of feeling very high or elated, called a manic episode. During a bipolar episode, you may experience severe changes in your mood, behavior, and sleep, and sometimes people experience psychosis during an episode. As such, bipolar disorder can be hugely disruptive, or even destructive, to your quality of life.

Bipolar psychosis symptoms

Bipolar disorder is typically categorized by episodes of mania and depression, ranging in severity and length.

During a manic episode, it is common to experience a decreased need for sleep, while also feeling very active and alert, be extremely talkative, have many ideas and thoughts, be unable to relax or stop activities, be impulsive, and experience feelings of grandiosity, such as feeling an inflated sense of importance, intelligence, or power [1].

During a depressive episode, it is common to experience low mood, either insomnia or a large increase in need for sleep, thoughts of suicide, feeling hopeless and worthless, and a lack of enjoyment in usually enjoyable activities.

Psychosis is a very common feature of bipolar disorder, occurring in over 50% of those with the diagnosis [2]. Psychosis does not appear in hypomania, so is more commonly a symptom of bipolar I, disorder although it can occur during a depressive episode.

Psychosis can occur in a number of mental health conditions, such as schizophrenia and schizoaffective disorder, with similar symptoms occurring within these conditions and bipolar disorder [3].

Symptoms of psychosis typically include hallucinations and delusions, which involves seeing and hearing things that are not real, and believing things that are not real, respectively.

Although visual and auditory hallucinations are most common, hallucinations can involve any of the five senses [5]:

  • Visual hallucinations: seeing things that are not there, such as people, lights, and shapes
  • Auditory hallucinations: hearing things, such as voices talking to you or about you
  • Olfactory hallucinations: smelling things that are not there
  • Tactile hallucinations: feeling things that are not there, such as bugs on your skin, someone touching you
  • Gustatory hallucinations: tasting things that are not there

Delusions involve having a strong belief in something with no evidence, or that is clearly incorrect. Examples of delusions may include:

  • Perception: a normal occurrence is given an abnormal meaning, for example, a bird flies overhead and this is means that an alien spaceship is going to land, or that a song comes on the radio and that means the radio is communicating a special message to you.
  • Memory: a past event or occurrence is believed to be true but is false, such as a belief that you were once the king of England, or were blown up by a bomb and died.
  • Idea: a current belief, such as the idea that the CIA are listening to your phone calls, or that someone is trying to kill you.

Delusions may be based on certain themes, such as:

  • Love: believing that a certain person is in love with you, such as a boss, a celebrity, or a fictional character.
  • Persecution: believing that someone is trying to harm or kill you, or you are to blame for a terrible occurrence.
  • Illness: being convinced you have a certain disease or medical
  • Jealousy: being convinced your partner is cheating on you.
  • Grandiose: feeling especially important, such as believing you are a celebrity or superhero.

Types of psychosis

Within bipolar disorder, psychotic symptoms could be based on the current mood or episode, called mood congruent psychosis, or completely unrelated to mood, called mood incongruent psychosis [6][7].

Mood congruent

For example, during a manic episode, it can be common to experience delusions of grandeur, feeling immensely powerful or invincible, or believing that you are of great importance.

Similarly, mood congruent psychosis could occur during a depressive episode, such as a belief that a destructive or negative event has occurred because of you, leading to feelings of guilt or depression.

Mood incongruent

If psychotic symptoms do not match the current mood, they are considered incongruent, for example, delusions of grandeur occurring during a depressive episode, or laughing at the death of a loved one.

Delusions of thought insertion, broadcast, and withdrawal are considered mood incongruent within bipolar disorder [6]. This could include symptoms such as believing that people can hear your thoughts, or that people or voices are telling you to harm yourself or others.

Causes of bipolar psychosis

While the exact cause of bipolar disorder is not known, there is evidence to suggest that several factors may be involved [1], including:

  • Genetics: you may be more likely to be diagnosed with bipolar disorder if a family member has the condition.
  • Brain functioning: certain neurotransmitters and brain structure may play a role in the development of themental
  • Stress: environmental and societal stressors could contribute to the development of bipolar or trigger a first episode.
  • Other mental health issues: if you or a family member has been diagnosed with another mental health condition, this may increase your chance of being diagnosed with bipolar disorder.
  • Pregnancy and childbirth: research suggests that during pregnancy and within the first four weeks following childbirth, there is an increase in the risk of a bipolar episode occurring, even for those who have not previously been diagnosed with the disorder [8].

Most research into the differences between bipolar disorder with and without psychotic features indicates that there is no significant predetermining factor for the development of psychotic symptoms [9][10]. It may be more likely for bipolar disorder with psychosis to occur if there is a family history of psychosis, but this is not clearly evidenced [11][12]. As such, there is no clear cause for psychotic symptoms within bipolar disorder.

Bipolar psychosis treatment

Medication

Treatment for bipolar disorder with psychosis may require a combination of medications, to treat various aspects of the condition. This may include an antidepressant, such as fluoxetine and sertraline, an antipsychotic, such as aripiprazole and risperidone, and a mood stabilizer, such as lithium, carbamazepine, and valproate [1].

Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline, are often very helpful for lifting mood during a period of depression, but for people with bipolar disorder, they can cause a dramatic mood swing from depression into elation, thereby causing a manic episode [13].

If you are prescribed antidepressant medication for depressive symptoms within bipolar disorder, it is likely that your doctor will also prescribe medication with a mood stabilizing effect, to help prevent a manic episode being caused by your medication.

It is important that you take your medication exactly as prescribed by your doctor, as taking too much, missing doses, or suddenly stopping or starting a medication could have a negative impact on your mental and physical health. Ensure you consult with your doctor about any side effects or concerning changes in your condition.

Therapy

Various types of therapy are available to help you understand your condition and learn ways to cope with the symptoms you may experience, providing you with the tools you need to live a good quality of life and potentially prevent or lessen manic, depressive, or psychotic episodes.

Cognitive behavioral therapy can help with symptoms of depression and anxiety, helping you to manage and cope with negative thoughts, and to learn helpful behaviors and coping strategies for difficult or triggering events and circumstances.

Other useful therapies include family therapy, group therapy, and individual psychotherapy, all of which can help you and your loved ones better understand and manage your condition, focusing on helpful coping strategies, support, and self-care [1][13].

Self-care

  • Avoid alcohol and drugs: substances can have a negative impact on your mental state and may also interact with your medication, causing an increased risk of serious side effects.
  • Learn your triggers: psychosis can be scary to experience, but once you learn to recognize your triggers and any changes in your mood, you may develop a better understanding and management of your condition. Communicate with your loved ones about any triggers you have experienced, or signs that they can look out for, so that they can support you and help to prevent a psychotic episode from occurring.
  • Activities: you may find it helpful to engage in calming activities or exercise when you notice changes in your mood. These could help you to prevent an episode from occurring, reducing your psychotic symptoms.
  • Sleep: maintaining a regular and consistent sleep cycle is crucial to improving and maintaining mental health. Try to go to sleep and wake up at the same time every day, sticking to a regular schedule, as this can help to prevent your symptoms from worsening.

Helping someone with bipolar psychosis

If you know someone with a diagnosis of bipolar disorder with psychotic symptoms, the following can be useful for the management of their condition and for the ongoing support of both you and them [1]:

  • Therapy: you may wish to attend family therapy sessions with your loved one, as this can help promote open and positive communication around their disorder, help them to express their emotions or difficulties, and provide you with therapeutic support.
  • Education: psychoeducation is important for families of people with this diagnosis, as it can be very complex and challenging. Learning about bipolar disorder, the symptoms, and prescribed medications can be very useful in providing support, as well as learning helpful and unhelpful ways of communicating with someone during or following a psychotic episode.
  • Helping with medication compliance: one of the biggest causes of relapse for people with a mental health disorder is medication noncompliance, as they often forget or choose not to take their medication. You may be able to provide reminders for your loved one to take their medication, or to remind them of the importance of doing so.

Resources:

  1. Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK558998/
  2. Dunayevich, E., & Keck, P.E., Jr (2000). Prevalence and Description of Psychotic Features in Bipolar Mania. Current Psychiatry Reports, 2(4), 286–290. Retrieved from https://doi.org/10.1007/s11920-000-0069-4
  3. Soares-Weiser, K., Maayan, N., Bergman, H., Davenport, C., Kirkham, A.J., Grabowski, S., & Adams, C.E. (2015). First Rank Symptoms for Schizophrenia. The Cochrane Database of Systematic Reviews, 1(1), CD010653. Retrieved from https://doi.org/10.1002/14651858.CD010653.pub2
  4. Chaudhury, S. (2010). Hallucinations: Clinical Aspects and Management. Industrial Psychiatry Journal, 19(1), 5-12. Retrieved from https://doi.org/10.4103/0972-6748.77625
  5. Kiran, C., & Chaudhury, S. (2009). Understanding Delusions. Industrial Psychiatry Journal, 18(1), 3-18. Retrieved from https://doi.org/10.4103/0972-6748.57851
  6. Goes, F.S., Zandi, P.P., Miao, K., McMahon, F.J., Steele, J., Willour, V.L., Mackinnon, D.F., Mondimore, F.M., Schweizer, B., Nurnberger, J.I., Jr, Rice, J.P., Scheftner, W., Coryell, W., Berrettini, W.H., Kelsoe, J.R., Byerley, W., Murphy, D.L., Gershon, E.S., Bipolar Disorder Phenome Group, Depaulo, J.R., Jr, …& Potash, J.B. (2007). Mood-Incongruent Psychotic Features in Bipolar Disorder: Familial Aggregation and Suggestive Linkage to 2p11-q14 and 13q21-33. The American Journal of Psychiatry, 164(2), 236–247. Retrieved from https://doi.org/10.1176/ajp.2007.164.2.236
  7. Chaudhary, P., Parikh, N., & Sharma, P. (2021). Characteristics of Mood-Congruent and Mood-Incongruent Psychotic Features in Bipolar Disorder. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology, 16(1), 66-75. Retrieved from https://doi.org/10.5114/nan.2021.108035
  8. 11. Gilden, J., Poels, E.M.P., Lambrichts, S., Vreeker, A., Boks, M.P.M., Ophoff, R.A., Kahn, R.S., Kamperman, A.M., & Bergink, V. (2021). Bipolar Episodes After Reproductive Events in Women with Bipolar I Disorder, A Study of 919 Pregnancies. Journal of Affective Disorders, 295, 72–79. Retrieved from https://doi.org/10.1016/j.jad.2021.08.006
  9. Bora, E., Yücel, M., & Pantelis, C. (2010). Neurocognitive Markers of Psychosis in Bipolar Disorder: A Meta-Analytic Study. Journal of Affective Disorders, 127(1-3), 1–9. Retrieved from https://doi.org/10.1016/j.jad.2010.02.117
  10. Burton, C.Z., Ryan, K.A., Kamali, M., Marshall, D.F., Harrington, G., McInnis, M.G., & Tso, I.F. (2018). Psychosis in Bipolar Disorder: Does it Represent a More "severe" Illness? Bipolar Disorders, 20(1), 18–26. Retrieved from https://doi.org/10.1111/bdi.12527
  11. Potash, J.B., Willour, V.L., Chiu, Y.F., Simpson, S.G., MacKinnon, D.F., Pearlson, G.D., DePaulo, J.R., Jr, & McInnis, M.G. (2001). The Familial Aggregation of Psychotic Symptoms in Bipolar Disorder Pedigrees. The American Journal of Psychiatry, 158(8), 1258–1264. Retrieved from https://doi.org/10.1176/appi.ajp.158.8.1258
  12. Keck, P.E., Jr, McElroy, S.L., Havens, J.R., Altshuler, L.L., Nolen, W.A., Frye, M.A., Suppes, T., Denicoff, K.D., Kupka, R., Leverich, G.S., Rush, A.J., & Post, R.M. (2003). Psychosis in Bipolar Disorder: Phenomenology and Impact on Morbidity and Course of Illness. Comprehensive Psychiatry, 44(4), 263–269. Retrieved from https://doi.org/10.1016/S0010-440X(03)00089-0
  13. Geddes, J.R., & Miklowitz, D.J. (2013). Treatment of Bipolar Disorder. Lancet (London, England), 381(9878), 1672–1682. Retrieved from https://doi.org/10.1016/S0140-6736(13)60857-0