People can experience psychosis symptoms with bipolar disorder. Although psychosis is not an associated symptom for every individual diagnosed with bipolar disorder, approximately half of those diagnosed with BD will share at least one psychotic episode in their lifetime.1 Psychosis can occur during a manic or depressive episode, with grandiosity being the most common symptom amid a manic phase.1
What Is Bipolar Disorder?
Bipolar disorder, commonly referred to as “manic depression,” is an organic brain condition in which individuals experience unprecedented extreme fluctuations in mood from extreme highs (mania, hypomania) and drastic lows (depression).[F2]
Highs marked by mania or hypomania are periods in which individuals may feel atop the world. They are excessively happy, feel superhuman, and often make impulsive, irrational decisions. Lows are marked by negative emotions, including depression with potential suicidal ideation and attempts.
What Is Bipolar Psychosis?
Though psychosis is not the most common feature of bipolar disorder, with only approximately half of individuals diagnosed ever experiencing a single episode, it can happen at any stage (manic or depressive episode).1 Specifically, psychosis is marked by delusions (beliefs that are out of touch with reality) and hallucinations, which are unreal sensations that someone may feel among any or all of the five senses.3
This occurrence is similar in other DSM-5 clinically diagnosable conditions, such as:
- Major depressive disorder severe with psychotic features
- Schizophrenia and associated conditions
- Delusional disorder
- Psychotic disorder due to a medical condition
- Psychotic disorder induced by substance use
- Brief psychotic disorder
- Postpartum depression
Because psychosis is not a classic symptom of bipolar disorder, individuals diagnosed with the condition often meet the criteria for bipolar 1, bipolar 2, cyclothymic, or substance-induced psychosis as a specifier. Associated symptoms of psychosis do vary by manic or depressive episodes.
Types of Bipolar Disorder that can experience psychosis include: 8
- Bipolar I with psychosis: As the most severe type of bipolar disorder, individuals diagnosed with bipolar I are most likely to experience psychosis.3 Furthermore, women with this diagnosis are at very high risk for postpartum mania and psychosis. 4
- Bipolar II with psychosis: Though individuals diagnosed with bipolar II vs. bipolar I are less likely to experience psychosis, they are not immune. 4 Depending on genetics, various medical conditions, stress, environmental factors, substance use, et cetera, one may still be at an increased risk.
- Cyclothymic disorder: Cyclothymic disorder is less understood than bipolar I and II, as it shares similarities with both diagnoses and major depressive disorder but is met with less severe manic and depressive cycles. 5 Similar to bipolar II, however, if the conditions are right, individuals may experience psychosis.
- Substance-induced: Substance-induced psychosis, as the name implies, is a form of psychosis elicited explicitly by the onset of substance intoxication or withdrawal. 6 Commonly associated substances include but are not limited to psychedelics, methamphetamine, ecstasy, cannabis, and alcohol. 7
Types of Bipolar Psychosis
Individuals with bipolar disorder who experience psychosis are often unaware it is occurring. 3 They may appear incoherent and demonstrate tell-tale signs of cognitive dissonance that are noticeable to others but not themselves.
Here, there are two types of psychosis for consideration:
- Mood congruent bipolar psychosis is a state in which an individual’s mood and symptoms align. 3 For example, if an individual is in a manic state and feeling atop the world—delusions might entail believing that one is superhuman with super strengths, such as mind-reading. Corresponding auditory hallucinations may include “hearing” someone else’s thoughts in the room. This is an example of a delusion of grandeur. When depressed, an individual may believe they are worthless, and no one likes them.
- Mood incongruent bipolar psychosis, as the name implies, is when one’s mood and psychotic symptoms do not align. 3 Hallucinations and delusions are more likely to occur here. This experience is often more severe than episodes of mood-congruent psychosis and requires hospitalization. 3 In this case, individuals may hear voices telling them to harm themselves or others despite being in an elevated or positive mood.
Psychotic Symptoms of Bipolar Disorder
Common symptoms of bipolar psychosis include:
- Hallucinations: Vividly imagined perceptions that may occur along one or multiple senses making someone believe they saw, felt, heard, smelled, and tasted something that does not exist. There is no physical stimulus outside their perception, yet they feel as real as anything else. An example of a disturbing hallucination may be spiders crawling all over one’s skin without any being there.
- Delusions entail a false belief that something is true without evidence. They differ from hallucinations because no feeling is associated with any five senses. A common fallacy is that individuals believe they are being spied on or conspired against by others leading them to behave irrationally.
- Incoherent or irrational beliefs and speech: This entails a breakdown in thoughts and communication that are out of touch with reality, making others struggle to understand where they stem. An example might entail an individual believing they are from a historical time and communicating with an accent that is not their own.
- Lack of self-awareness: This is a state of being out of tune with one’s “thoughts, feelings, and general world view.” 9 For example, an individual may appear dishevelled while believing one is well-kempt. Even when called out by others, they hold onto their perception of having it together.
- Confusion and disturbed thoughts: Here, one may struggle to make sense of otherwise straightforward things or catastrophize what otherwise are safe situations.
What Causes Bipolar Disorder Psychosis?
Despite our understanding of bipolar disorder, the exact reason or trigger for psychosis is not fully understood. More severe incidents of bipolar disorder, such as bipolar I, combined with other stress and compromising factors, increase the likelihood of experiencing an episode. Though the experience may be different for everyone, there are some similarities. The most common similarity is that when one experiences a psychotic episode, they act out of touch with themselves and reality.
The onset of bipolar psychosis is something that usually develops over time. Bipolar is a condition met with mixed thoughts regarding the age of onset and diagnosis. Traditionally, it was thought to be undiagnosable before age 14; however, research indicates that it may begin at any age, though it is primarily diagnosed in the late teens and 20s. 10
Causes of Bipolar Psychosis can include: 11
- Hormonal imbalance
- Genetic differentiation
- Sex, especially females with a bipolar I diagnosis
- Sleep deprivation
- Substance use
- Withdrawals
Warning Signs of Psychosis in Bipolar Disorder
Psychosis may develop gradually or occur in an intense, acute episode, but there are some early warning signs that, if present, may suggest an incoming psychotic episode.
Here are some early warning signs that a bipolar psychotic episode may be imminent:11
- Decreased performance at work or in school
- Less than ordinary attention to personal hygiene
- Difficulty communicating
- Difficulty concentrating
- Reduced social contact
- Unwarranted suspicion of others
- Less emotional expression
- Anxiety
This list is by no means all-inclusive. For anyone diagnosed with bipolar disorder, it is essential to remain aware that, although not imminent, a psychotic episode may occur. Should you or a loved one present differently, seemingly out of nowhere, it is important to take pause and explore the issue deeper. Awareness is the key to minimizing or preventing psychosis.
Treatment for Psychosis in Bipolar Disorder
Bipolar disorder is a treatable condition, although there is currently no known cure. Psychosis may be abnormal compared to typical symptoms of bipolar disorder and carry a heightened risk of harm to oneself or others. Accordingly, it typically requires more immediate and alternative treatments than customarily prescribed.
Treatments for bipolar disorder that aim to reduce psychotic episodes include:
- Bipolar medication
- Mindfulness-Based Cognitive Therapy (M-CBT)
- Mindfulness-Based Stress Reduction (MBSR)
- Electroconvulsive Therapy (ECT)
- Acceptance and Commitment Therapy (ACT)
- Group therapy and Support Networks
Safety Concerns
Bipolar psychosis does place one at an increased risk for safety concerns. We must consider that when one is in a compromised state of disordered thinking, feeling, and behaving, that atypical thing may happen.
Consequences of the atypical behaviors and thoughts may include:
- Compromised relationships
- Self-harm
- Suicidal ideation
- Danger to others
- The potential risk for legal outcomes
The best means of minimizing the consequences of psychosis is prevention. With self-awareness, one may enact adaptive coping skills to stop or at least reduce the episode. Should a psychotic attack occur, adaptive coping skills will help one de-escalate and ground oneself. This solution is ideal and often possible with ongoing treatment.
In more extreme cases, mainly in which one does not engage in therapy, one may require an immediate response from emergency responders such as calling a suicide hotline, 9-1-1, or crisis assessment team (CAT). Their services involve coming out to do a psychiatric assessment to determine the need for emergency medicine.
Here are four things to say to help someone experiencing psychosis to ensure their safety:
1. “Are you okay?”
Though a simple question, it may have profound implications. By asking this question, you do not directly call out the psychotic episode but indicate that something appears off. Responses received here may vary but provide enough detail to determine if assistance is needed. Ensure that when the question is posed that your tone is supportive.
2. “Please know that I am here for whatever you need.”
This response affirms your supportive stance. Again, it does not call out the psychotic episode, which may be scary for the individual, and allows an opportunity for one to tell you what they need without feeling attacked.
3. “How about we take a time out for a moment?”
Suppose you have been actively engaged in the treatment process and support to the individual who is aware of potential psychotic episodes. In that case, a statement like this indicates that you see something is off, and it is time to engage in adaptive coping skills. Both of you may work together to help de-escalate and ground the individual.
4. “Do you feel safe right now?”
In more extreme cases of psychosis, asking the individual if they feel safe may elicit a direct answer as to whether there is a safety concern. If the answer is “yes,” you may work together using adaptive coping skills. If the answer is “no,” that is when it is appropriate to reach out to 9-1-1, CAT, et cetera. If the client says “yes” but acts incongruently, this is still a time to reach out for support.
Here are four things not to say to someone experiencing psychosis to ensure your safety:
1. “You are scaring me.”
Although this may be true, the focus is now more on you than the individual experiencing the psychotic episode. Given that they may not realize they are amid a psychotic episode, this can create panic, which escalates the issue. The statement also takes the focus off the individual and places it on you.
2. “What is wrong with you?”
Although likely not intended to be a direct attack on one’s personality, it may be perceived that way. Now, the issue is internalized as some personal defect rather than more focused on the condition, which is something the individual does not desire. A question like this may lead one to act out further.
3. “I refuse to be around you when you act like this.”
Although a psychotic episode may be scary and place you at risk, a statement like this indicates that you are non-supportive and lack an understanding of the condition. One may feel alone and as though they have no support.
4. “You’re insane.”
It should go without saying that telling someone you are trying to support that they are “insane,” “crazy,” or otherwise only serves to intensify the issue. The individual may feel less than, defective, and a hindrance (among other negative things). Even more negative thoughts and emotional spirals may occur, leading to more outlandish behavior—placing everyone at risk.
How to Move on After a Psychotic Bipolar Episode
Should one experience a psychotic bipolar episode, it is vital to move forward with life. Realize that the psychotic episode is not a weakness of self or anything done intentionally to harm anyone. Instead, it is an unfortunate condition that requires attention. When we dwell on the past, we become stuck. Accordingly, it is important not to define oneself by the episode.
One is encouraged to take accountability if relationships are broken because of the psychotic episode. Acknowledge what happened and apologize. Try to make amends following the severity of the situation. It may help explain what happened, too, mainly if the episode occurred in front of someone unknowing of the condition.
Arriving at a mutual understanding is an ideal means of getting on the same page and moving forward. Inform them of the disease, share what helps with de-escalation, and move forward in a manner where you inform them when you notice any warning signs.
For loved ones of someone who experienced psychosis, the best means of moving on is to become educated on the issue, have a supportive conversation with the individual, and seek one’s treatment—whether that be in individual therapy or a support group. When everyone receives the necessary assistance, it becomes much more likely they will move on healthily.
When to Seek Medical Attention
The longer time passes without addressing the issue, the more severe the disease typically becomes. A common misconception among people struggling with bipolar diagnoses is that they are cured when treatment works. The truth is that when treatment is working, you should continue it. Early detection and treatment are more manageable and can remain an outpatient treatment. While finding a therapist can feel overwhelming, you can ask for a referral from your primary care provider, or utilize an online therapist directory for further assistance.
Untreated cases may warrant more invasive measures such as checking into an inpatient unit, psychiatric hospital, or crisis residential stay. In this case, you may receive an involuntarily committed psychiatric hold or 5150 mandate. The experience may feel uncomfortable but is necessary for stabilization and safety. The best thing to do is stay consistent with therapy, honestly disclose challenges, and adjust accordingly.
Final Thoughts
Psychosis is an abnormal experience in bipolar disorder, but it can dramatically affect someone’s life. Though even with treatment, they may occur, having the support of a professional can minimize more significant consequences than trying to face the issue yourself. Fortunately, there are unique treatments involved in handling psychosis. Should an episode or multiple ones occur, there are effective ways to move on from a psychotic episode and learn how to prevent further experiences in the future.
For Further Reading
- Depression and Bipolar Support Alliance (DBSA)
- National Alliance on Mental Illness (NAMI)
- Substance Abuse and Mental Health Services Administration (SAMHSA)
- 15 Best Bipolar Disorder Youtube Channels
- 15 Best Mental Health Blogs
- 21 Best Books About Bipolar Disorder
- Mental Health America
- National Alliance on Mental Health
- MentalHealth.gov
Bipolar Psychosis Infographics
