12th Jan 2023
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 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 .
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 . 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 .
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 :
Delusions involve having a strong belief in something with no evidence, or that is clearly incorrect. Examples of delusions may include:
Delusions may be based on certain themes, such as:
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 .
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.
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 . 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.
While the exact cause of bipolar disorder is not known, there is evidence to suggest that several factors may be involved , including:
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 . 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 . As such, there is no clear cause for psychotic symptoms within bipolar disorder.
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 .
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 .
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.
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 .
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 :