Bipolar Psychosis

Bipolar psychosis, or bipolar with psychotic features, is common among those diagnosed with bipolar disorder, which is why it’s crucial for mental health and psychiatric providers to be able to identify, evaluate, and treat psychosis in patients with bipolar disorder. 

According to a 2022 review of 339 bipolar disorder (BD) studies, “over half of the patients with BD develop psychotic symptoms during their lifetimes.”

In this article, we will go over the signs and symptoms of bipolar psychosis, how long psychosis can last, and how bipolar psychosis symptoms differ from other forms of psychosis. 

How does psychosis present in bipolar disorder?

Psychosis is a broad term that encompasses experiences that are out of touch with reality. 

In addition to bipolar disorder, psychosis can occur in conditions such as:

• Schizophrenia
• Severe depression
• Personality disorders, such as borderline personality disorder or paranoid personality disorder 
• Postpartum depression or mania
• Delusional disorders

Regardless of the diagnosis associated with psychosis, there are many different forms of psychosis—each exhibiting a unique set of symptoms. These include hallucinations and delusions.  

Hallucinations

Psychosis can take the form of hallucinations, which may be auditory, visual, olfactory, or tactile. 

Auditory hallucinations can vary as well, ranging from distinct voices, to whispering, mumbling, or other sound effects. 

Delusions

People can also experience delusions, which are false beliefs that individuals maintain despite evidence to the contrary. 

Delusions may be bizarre, physically impossible, or non-bizarre, such as situations that can occur in real life (such as having a belief of being followed, poisoned, infected, or having a disease). 

While bizarre delusions are easily identifiable, non-bizarre delusions may initially appear to be entirely plausible, and other individuals may become convinced of their veracity. The individual experiencing these delusions likely has no insight into the idea that their belief may be untrue—and often will hold it as a steadfast conviction.

Bipolar psychosis symptoms

Theoretically, an individual with bipolar psychosis may experience any of the aforementioned types of psychosis.However, this is not what is most commonly seen in a clinical setting. 

An individual experiencing bipolar psychosis may exhibit an unusually euphoric mood, unabating levels of energy, new goals or projects, and a disregard for safety (increased risk-taking). 

Delusions are congruent with this symptomatology, and are the most common form of psychosis in bipolar patients. 

Here are three delusions that are often associated with bipolar disorder psychosis:

Grandeur 

An individual experiencing delusions of grandeur may display an inflated sense of importance or a need to prophesize

Referential 

When experiencing referential delusions, an individual senses or receives  messages from people, music, or signs

Nihilistic

Those experiencing nihilistic delusions feel compelled to prepare for an impending catastrophe 

As noted earlier, an individual experiencing delusions will not have any awareness or insight that they are having these delusions—and is therefore unlikely to seek treatment. In fact, individuals may be very resistant to treatment if their manic state is momentarily or acutely pleasurable. 

Bipolar I mania 

Some individuals with bipolar disorder do not experience psychosis. However, individuals with severe bipolar I disorder can experience a disconnect from reality, even without evidence of frank delusions or hallucinations.. 

Symptoms such as elevated energy, a heightened sense of importance, and disregard for consequences shows psychotic behavior on some level, and many would consider bipolar I to be a “psychotic disorder.” 

Individuals diagnosed with bipolar with psychosis may experience psychosis as part of their bipolar I disorder—specifically during manic episodes. 

During a manic episode, psychotic symptoms bipolar patients exhibit include writing or speaking profusely in a manner called “pressured speech,” where it is difficult to converse or introduce other perspectives. For example, they may fill up notepads with their writing or attempt to write books—feeling their message is highly important or prophetic. 

Another symptom of mania is disorganized thought and behavior—appearing very distractible, unfocused, and restless. For example, the individual may attempt to take on new projects and jump from activity to activity, taking none to completion. Everything seems interesting and of heightened importance, causing racing thoughts and feeling overwhelmed, but energized. 

Diagnosing bipolar with psychotic features 

If someone has psychotic symptoms bipolar, the formal diagnosis would be “bipolar with psychotic features.” 

There are a wide range of bipolar psychosis phenotypes, therefore, two individuals with the same diagnosis may look very different and no two individuals are totally alike in their symptoms. 

Bipolar disorder exists along a spectrum—some individuals experience very extreme symptoms that are long lasting and very consequential, while other individuals may experience mild symptoms for a day or two. The severity of bipolar disorder can depend on a number of factors, such as genetic loading, substance use, insomnia, or other environmental factors such as travel or acute stress. 

To meet the definition of bipolar I disorder, according to the DSM-5, an individual needs to only have one manic episode in their lifetime. The manic episode involves changes in mood and energy lasting more than one week—present most of the day, nearly every day. 

For more information about diagnosing bipolar disorders and getting insurance coverage to treat bipolar, check out our ICD-10 Bipolar Disorder Coding Guide.

How long does bipolar manic psychosis last?

Because the severity of bipolar varies from case to case, the length of an untreated episode of bipolar mania can last a week to years.

Some individuals may experience mania on a much shorter scale. “Rapid cycling” is defined by having four or more episodes of mania in a 12-month period. 

Even more frequently than rapid cycling, “ultra-rapid cycling” refers to mania experienced in 24 hour cycles. However, ultra-rapid cycling is not a formal diagnosis and is considered controversial—since mood shifts occurring at this frequency are often indicative of certain personality disorders, like borderline personality disorder. 

There may be clear external factors precipitating and/or perpetuating the manic episode, making the diagnosis challenging.

Consequences of untreated bipolar psychosis 

Bipolar with psychosis causes one’s mood to be extremely euphoric or irritable that they act in impulsive and irrational ways that can lead to serious legal or vocational consequences. 

Individuals may get in accidents or get arrested because of their behavior. 

They may say or do embarrassing things that may lead to termination from their place of employment. 

Ultimately, these actions may cause them to sever relationships. 

For these reasons, and the risk of potential death from an accident or suicide, a manic episode is considered to be a psychiatric emergency. 

Elevated mood with a disregard for consequences also increases the risk of substance use, which only worsens the problem. Alcohol use can further cause disinhibition, sedation, and insomnia, all of which alter judgment and worsen mania. Cannabis use causes changes of sensorium (or understanding of one’s environment) and further impairments in judgment, which is already problematic in bipolar disorder. 

Since symptoms of mania can lead to serious consequences, timely recognition and treatment is pertinent to avoid the exacerbating effects of a prolonged manic episode. 

Bipolar psychosis vs. schizophrenia

There are both similarities and key differences between bipolar with psychotic features and psychosis found in schizophrenia. 

In schizophrenia, an individual must experience delusions, hallucinations, or disorganized speech in order to meet the criteria for the diagnosis. Therefore, psychosis is a key component of schizophrenia. 

Disorganized behavior in schizophrenia can look like a reduction in mood (anhedonia) or motivation (avolition). 

The type of delusions that are most commonly seen in patients with schizophrenia are paranoid delusions (also known as persecutory delusions). This type of delusion is characterized by feeling watched, targeted, harassed, or monitored by others. 

Hallucinations are common with schizophrenia, but less common in bipolar psychosis. 

Hallucinations in schizophrenia are typically auditory in nature, meaning someone hears something that is not there. The auditory hallucinations may be nonsensical voices, words, whispers, or repetitive sounds. These may be very distracting and upsetting and may lead the person experiencing them to act on the voice’s commands or requests or react to the noise in an unpredictable way. 

One method of treating auditory hallucinations is by using cognitive behavioral therapy (CBT) for psychosis, which teaches individuals to build empowerment and cope with distress in the presence of the noises.  

Another key difference is that psychosis in schizophrenia is usually related to delusions of persecution or influence, while in bipolar disorder, it is more related to a sense of great self-significance. 

Delusions of influence relate to being controlled—believing thoughts are being inserted, broadcast into, or withdrawn from one’s head. These delusions are usually congruent with the individual’s mood—such that if their mood is positive, the delusions are positive in nature, and vice versa. 

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.

READ NEXT: What Are the 5 Stages of Psychosis?