If you’ve never really understood what bipolar disorder is, it’s a mental illness characterized by unusual changes in a person’s mood, thinking, energy levels, activity output, and ability to function. There are a lot of misconceptions about bipolar disorder, and one of the most commonly misunderstood aspects is the link between bipolar disorder and psychosis.
Psychosis is a mental state in which someone becomes detached from reality and experiences delusions (incorrect beliefs), hallucinations (seeing and hearing things that don’t exist), or both.
Here are eight things to know about the interesting link between the two.
1. People can experience psychosis during severe bipolar mood episodes of mania or depression.
Manic episodes involve having an abnormally elevated mood and activity levels for at least seven days, according to the National Institute of Mental Health (NIMH). (Or severely enough to warrant hospitalization.) Depressive episodes are on the other end of the spectrum, meaning someone is grappling with a debilitatingly low mood and energy levels for at least two weeks. Here’s more about bipolar disorder symptoms.
“We say that in bipolar disorder, the person can have psychotic symptoms during the peaks of mania or the depths of depression,” Descartes Li, M.D., clinical professor in the department of psychiatry and director of the Bipolar Disorder Program at the University of California, San Francisco, tells SELF. Signs of psychosis can also occur during severe mixed-mood episodes, where the person experiences symptoms of both mania and depression.
2. Psychosis can occur in both bipolar I and bipolar II.
People with bipolar I can experience a broader range of symptoms than those with bipolar II, but both can go through psychosis.
If you have bipolar I, it means you may experience manic episodes, hypomanic episodes (having an elevated mood and energy levels but on a less severe scale than mania), depressive episodes, and mixed episodes. If you have bipolar II, you only have hypomanic and depressive episodes. You can read more about the similarities and differences between the two here.
Psychosis does not occur in [cyclothymia](https://www.self.com/story/understanding-cyclothymia-cyclothymic-disorder] (a less severe form of bipolar disorder), according to the National Alliance on Mental Illness (NAMI). It may or may not happen in Other Specified and Unspecified Bipolar and Related Disorders, which is when someone experiences symptoms of bipolar disorder that don’t fit the criteria of any of the above conditions.
3. Not everyone who has bipolar disorder experiences psychosis.
Conclusive data on how prevalent psychosis is in bipolar disorder are scarce. One 2007 meta-analysis pooling data on 5,973 people with bipolar disorder from 33 studies conducted between 1922 and 2005 found that 61 percent of them experienced at least one symptom of psychosis at some point in their lives.
What is clear is that while psychosis appears to be relatively common in bipolar disorder, a fair number of people with the condition will never experience it, Dr. Li says.
Similarly, not everyone who experiences psychosis during a mood episode will experience it with every mood episode, Dr. Malaspina says. And just because someone hasn’t experienced psychotic symptoms during an episode before doesn’t mean they never will.
4. Psychosis during a bipolar mood episode can look a lot like the psychotic episode of someone who has schizophrenia.
If a doctor saw a new patient in the middle of a manic or depressive episode with psychosis, without any knowledge of their medical history, it would be extremely difficult to tell whether they were looking at somebody with bipolar disorder or schizophrenia, Dr. Malaspina explains. Indeed, people with bipolar disorder who experience psychosis are sometimes misdiagnosed with schizophrenia, according to the NIMH. This is why it’s important to get a full medical history and observe the patient over time.
5. In bipolar disorder, delusions and hallucinations are often mood-congruent, meaning they reflect a manic or depressed disposition.
When someone’s delusions and hallucinations match their mood, their psychotic episodes are called mood-congruent, Dr. Li says.
For example, someone experiencing psychosis during a manic episode may have grandiose delusions about how rich and powerful they are or display levels of confidence that are detached from reality, Dr. Li says.
On the other hand, someone experiencing psychosis during a depressive episode may believe they’ve caused the breakout of a terrible illness or are a delinquent criminal and feel horrible about themselves in ways that are are not based in fact.
6. Mood-incongruent episodes, where the person’s delusions or hallucinations are not aligned with their mood, seem to be rarer.
For example, Dr. Li says, someone having a manic or depressive episode may believe there is a microchip implanted in their head telling them what to do or hear their thoughts being broadcast. These delusions and hallucinations are not any more or less false or imagined than mood-congruent ones, but they are not consistent with the person’s emotional state in a manic or depressive episode.
Though there aren’t hard numbers on how common mood-congruent vs. mood-incongruent psychosis is in bipolar disorder, the general understanding in the psychiatric field is it’s most common for a person’s delusions and hallucinations to match their mood, Dr. Li says. There is, however, evidence that mood-incongruent psychotic episodes may be more dangerous to the person with bipolar disorder.
A study published in the American Journal of Psychiatry in 2007 compared 291 people with bipolar I disorder who had mood-incongruent psychotic features to 404 people with bipolar I disorder with mood-congruent psychotic features. (Researchers also included 866 people who did not experience psychosis.) They found that the mood-incongruent group was more likely to have been hospitalized, have attempted suicide, and have a history of substance use issues. The people in this group also had a significantly higher lifetime prevalence of auditory and visual hallucinations overall, as well as what are called persecutory delusions—delusions in which the person believes others are intentionally threatening or attempting to cause them harm. Researchers are investigating a possible genetic reason underlying the disparity.
7. Psychosis is treated with antipsychotics.
“You have to treat psychosis with antipsychotics immediately, [because] it can be dangerous to lose touch with reality,” Dr. Li says.
People with bipolar disorder who are experiencing psychosis are usually prescribed what are called atypical antipsychotics, or second-generation antipsychotics, according to the NIMH. They work by affecting various neurotransmitters in the brain, including dopamine. Typical, or first-generation antipsychotics, which also reduce dopamine, are used less commonly, Dr. Malaspina says. This is due to a difference in side effects.
The most common side effects of antipsychotics in general are sedation and drowsiness, Dr. Li says, but they can also include things like nausea, blurred vision, and low blood pressure, according to the NIMH. Atypical antipsychotics are more likely to cause metabolic side effects, like weight gain, while typical antipsychotics are more closely connected with movement-related side effects, like tremors. As a whole, typical antipsychotics tend to cause more serious long-term side effects, like the movement disorder tardive dyskinesia, which can prompt uncontrollable muscle movements, often around the mouth.
Antipsychotics begin to treat some symptoms, like hallucinations, within days, while it may take weeks for delusions to fully recede, according to the NIMH. Often, the person experiencing psychosis needs to be hospitalized or otherwise under medical supervision to prevent harm to themselves, Dr. Li says.
The duration of treatment is highly variable depending on the patient. Some people with bipolar disorder only take antipsychotics when symptoms begin to come on and stop a few weeks or months after they feel normal again, Dr. Li says. Others may stay on a low dose of antipsychotics for a year or so before tapering off in order to prevent another episode, Dr. Malaspina says. And sometimes, people stay on them indefinitely as a maintenance treatment.
Most often, antipsychotics are just one component of the drug regimen used to treat bipolar disorder, according to the NIMH. Other medications, like mood stabilizers, may be used as well. Here’s more information about the different types of drugs used to treat bipolar disorder.
8. The best way to manage psychosis is to prevent as many mood episodes as possible.
“The longer [a person with bipolar disorder] can stay stable early in their illness, the better their prognosis in the long term,” Dr. Malaspina says. Achieving that stability usually entails sticking to a treatment plan, including medication and therapy, and avoiding episode triggers like extreme stress, sleep deprivation, and substance abuse, Dr. Li says. It also involves checking in with a doctor often and adjusting that treatment plan as needed.