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What is bipolar psychosis?
Does this mean that everyone with bipolar disorder is psychotic?
“Psychosis” is a distorted or nonexistent connection with reality.
A person with psychosis cannot distinguish between the external, objective “real world”, and their own subjective perceptions which are distorted and characterized by delusions and/or hallucinations.
During psychosis in bipolar, for example in extreme mania, a person can experience a break with reality, where thinking is affected along with mood.
In bipolar psychosis this loss of contact with reality is usually a feature of the severe mania experienced in Bipolar Type 1. However, it can also be associated with bipolar depression but this is far less common.
In fact, psychotic symptoms can occur during manic, depressive, or mixed episodes in bipolar disorder. 4 (the morbidity of psychosis in bipolar)
Studies have shown that approximately two-thirds of bipolar patients will experience at least one psychotic symptom over a lifetime, with approximately one-third of patients never becoming psychotic.5 (pooled analysis of 33 studies showing bipolar patients with 61% lifetime prevalence of psychotic episode)
Although the evidence is inconclusive, it seems that in general the presence of psychotic symptoms is correlated with a worse course of illness and poorer overall outcomes.1
However, there does NOT seem to be a link between the presence of bipolar psychosis and bipolar suicides.
A good overview is this fact sheet on bipolar psychotic symptoms from the Black Dog Bipolar Institute.
Who becomes psychotic?
Reminder
Not everyone with Bipolar 1 experiences psychosis. Also, the risk can be reduced with treatment and lifestyle choices.
The emergence of bipolar psychosis does NOT appear to be related to any demographic features.
That is, it occurs equally across all genders, races and age groups.
Research has also shown that patients who experience psychosis are not more aggressive or disruptive, but they do tend to be more grandiose and expansive.
They are also more energetic, likely to suffer more sleep disturbance, and to be more hypersexual.
Bipolar versus schizophrenia
There is a tendency for bipolar people who are experiencing bipolar depression to be misdiagnosed as simply depressed, especially if they are women.
There is a tendency for bipolar people who are experiencing bipolar mania to be misdiagnosed as schizophrenic, especially if they are men.
However, there are some key differences between the psychosis of bipolar and the psychosis of schizophrenia, and an experienced and skilled expert should be able to make this assessment.
Schizophrenic delusions continue for much longer periods of time – for months, even years. In fact, they may be so persistent as to be a fixed (although false) belief.6 (schizophrenia involves chronic/recurrent psychosis)
In contrast, bipolar delusions have a more transitory, evanescent quality. They are often episodic associated with an acute episode.
Also, schizophrenic delusions tend to be a more negative experience for the patient. They may believe they are being persecuted and involve feelings of isolation and alienation. This is a part of what makes schizophrenia so isolating and debilitating.
In bipolar disorder, the delusions often have a wish-fulfillment dimension. They are more optimistic and reflect “great expectations” – albeit ill-founded and unlikely.7 (grandiosity in bipolar delusions)
Rather than the paranoia, hostility, or isolation of schizophrenia, bipolar delusions are more likely to incorporate an extreme or even inappropriate degree of sharing, intimacy, or sense of connection.
There are physical differences as well. This article on Resting EEG in schizophrenia patients and psychotic bipolar patients describes how brain waves differ with bipolar patients showing additional right hemisphere activity that was not present among the schizophrenia patients.
Bipolar delusions
Although delusions are not well understood by science yet, and appear to be complex mental events, their manifestation is pretty simple – false, illogical, or irrational beliefs.
Most bipolar delusions are grandiose, involving exaggerated feelings of power, wealth, sexual attractiveness, luck, or insight.7
These inflated beliefs about ability, or overall situation and prospects, can be very dangerous and may lead to reckless financial or sexual behavior.
The risky behavior, crazy business ventures, gambling, sexual promiscuity, and physical recklessness seen in Bipolar I mania stem from grandiose delusions and are a main reason for the destructiveness and downward spiral often evident in people with bipolar disorder.
Bipolar hallucinations
Hallucinations involve hearing, seeing, feeling, smelling, or sensing things which are not really there.
Bipolar hallucinations tend to be brief, grandiose, often related to delusional beliefs, and often religious or mystical in nature. For example, “seeing the face of God”.
The most common forms of bipolar hallucinations are visual or auditory – that is, seeing things or hearing things that are not there.2,7 (most hallucinations in bipolar are auditory)
Often people also experience heightened sensory perceptions such as colors being brighter and more vivid or music being “sweeter” and more complex and meaningful.
Bipolar hallucinations are often an even more exaggerated form of this. In fact, some experts have described them as being psychedelic, and frequently are pleasurable or even ecstatic.
Again, they tend to often be religious in nature.
These pleasurable, brief, fleeting hallucinations are very different from the persistent and unpleasant or persecutory hallucinations of someone with schizophrenia.
Red flags
Although someone with bipolar psychosis may not be experiencing their state as something negative, they are in a very dangerous situation that must be contained and controlled.
The hospital or a very calm and structured and confined environment is needed so that the manic episode can be brought to a close and any dangerous bipolar behavior minimized.3
Recurrent episodes are a major red flag and may require changes in medication and a high degree of professional intervention.
The most comprehensive source of information on bipolar psychosis is Goodwin and Jamison’s Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. (Please understand this is an academic text and is not for the casual reader.)
12 Comments
Thank you for reflecting my experience with manic hypersexual delusions so precisely. I feel so tremendously relieved, even if it is only me who understands the truth. In other words, I know I was not lying about a particular relationship because in order to be lying, you must know and believe that the information you are sharing is false. My delusions told me the information was true. I understand that this does not excuse my behavior. But it does help explain it. I hope that makes sense.
Hey Julie,
I have just read your comment on here about your life experiences as I thought I try and reach out to someone else to try and grasp a better understanding of the bipolar condition.
I have an ex-girlfriend who has bipolar psychotic behaviour, and has worsened, but am trying to push her in the right direction to the doctors atm.
I am wandering if you are in a relationship and how you deal with relationship situations??
All these traits portrayed on here ring true with my ex, and am not sure if I could maybe look after her, minus any relationship tagging us, as she is hypersexual.
Pretty accurate.
I have had pschotic epsisodes, in and out of hospital. Auditory hallucinations are pretty much ongoing. Not to an extent that it is “dangerous” though. What determines a genuinely dangerous situation? I tend to think life or death. And my delusions and hallucinations have rarely led to that. I live a fairly functional life in spite of this. Hospitalization should be for destructive or self destructive cases. I am done with hospitals, as sometimes they can make things worse. I will only go if I am suicidal.
I found the differences described between bipolar and schizophrenia the be grossly inaccurate. Delusions may or may not be “dark” in either scenario. Everyone’s bipolar is different, as they say. Mania may be expressed as rage, for example. The hallmark symptom of schizophrenia is auditory and visual hallucinations. Not merely delusions of thought it perception.
Your statement:
“Bipolar psychosis is NOT like the psychosis you usually see on TV. “TV psychotics” are usually schizophrenic with darker and more enduring delusions.”
is a disgrace to those labelled with a diagnosis of Schizophrenia – how dare you publish such a sweepingly harmful and frankly false piece of information? ‘TV Psychotics’ are generally inaccurate and sensationalised depictions, often of the mentally ill, and further add to the crushing stigma that hampers recovery for the mentally unwell. There is indeed more likelihood of someone to be attacked by a gang of thugs than ‘an axe-wielding psycho’.
I suggest you remove this statement to save offending or in fact depressing others who have the misfortune to come across your site.
Hello,
We apologize for the unintentional offensive statement. I can see how the use of the word “schizophrenic” can seem like a stereotype. We appreciate your feedback and our goal is make this website a safe place for everybody.
Thank you
Sarah and Team
I suffered from bi polar all of my life undiagnosed until I was about 29 I believe that I experienced a psychotic break at that time and that caused me to start to experience auditory hallucinations I was terrified it was to much for me to bear I believe that I was going through extreme spiritual warfare and that my soul was being tormented by demons trying to keep me from the love of God it was unrelenting they say bipolar psychosis is not as long and frequent as the schizophrenic experience it was unrelenting day and night for about 2years and then it went away for about 8 months not a peep and then all of a sudden it came back starting as whispers I immediately checked into a hospital didn’t know if I could survive another bout… But according to this article with bipolar and I’m bipolar 1 it could be a once in a lifetime experience that’s encouraging… I thought it was a life sentence. In my reality I believe God said that’s enough and that’s why it stopped.
Romans 8:38_39
For I am convinced that neither death nor life neither Angeles nor demons neither present nor future nor any powers height nor depth nor anything else in all creation will be able to seperate us from the love of God that is in Christ Jesus our Lord.
And don’t you ever forget it.
My 14yr old was recently diagnosed with Bipolar 1 with psychosis. she is on meds and doing good so far. I am concerned if she will have to be on meds for life?
I was diagnosed bipolar phycosis and manic depressed, I’ve had two bad episodes that landed me into the hospital. I can’t eat, sleep or talk. And the things I’ve seen has took me to hell, I’ve had no good experiences while in a episode. I thought the nurses was posioning me, only to eat and not die. Thought if I set outside in the sun too long I’d burst into flames. My first episode was the worst I was gave five shots at the er and still couldn’t sleep. It’s like I’m someone else, so my question did they maybe dignose me wrong or is it also common for a bipolar phycosis episode to be negative? I read the differences between sciz and bio p and now I’m so confused.
I am currently experiencing psychotic symptoms. I have bipolar 1 , with psychosis ,and a cluster b personality disorder.
I have to strongly disagree with your summation of what is experienced while having a pcycotic episode. It is not by far pleasurable , or spiritual. I haven’t been in my meds for about 2 months now and I thought i would be ok ( wrong) . Now I’m back to square one ,if not worse than I’ve ever been . I’m cycling rapidly , and having horrible insomnia , and now this the hallucinations are back both auditory and visually . Long story short they are terrifying nothing pleasurable at all . Just want to say that .
Thank you for your site , it is informative , just has a couple of inaccuracys that need to be rectified .
Psychosis in bipolar may be just as bad for bipola r people. We also tend to have panic disorder or other anxiety disorder and personality disorders. I for example have strong sociopathic tendencies, although shizoid personality is also very likely.
I have had many delusions during one severe depressive phase where I ended up being hospitalized. Bipolar people like me also suffer frlm insomnia quite regularly. Manic depression is the most downplayed disorder.