Psychosis is a severe mental state characterized by a loss of contact with reality, which often involves experiencing hallucinations or holding false, fixed beliefs known as delusions. Bipolar Disorder (BD) is a mood disorder defined by extreme shifts in mood, energy, and activity levels, oscillating between periods of elevated mood (mania or hypomania) and depression. Psychosis can occur in Bipolar Disorder, typically during severe mood episodes. More than half of individuals diagnosed with BD will experience at least one psychotic episode over the course of their lives.
The Context: When Psychosis Appears in Bipolar Disorder
The manifestation of psychosis in Bipolar Disorder is directly tied to the specific mood state the individual is experiencing at the time. Psychotic features are most commonly observed during a full manic episode, which is characteristic of Bipolar I Disorder. If psychotic features are present, the episode is considered severe enough to be classified as mania, even if other symptoms might not fully meet the duration requirement. Psychosis is significantly less likely to occur during the milder, less impairing state of hypomania, which is a feature of Bipolar II Disorder.
Psychosis presents differently depending on the direction of the mood episode. During a manic phase, the delusions often reflect an inflated sense of self, involving themes of grandiosity, special powers, or extreme wealth. Conversely, psychosis experienced during a major depressive episode typically involves themes of worthlessness, extreme guilt, or nihilism, such as believing one is responsible for a global catastrophe or that one’s body is decaying. While less frequent, psychosis can also occur during a mixed episode, where symptoms of both mania and depression are present simultaneously.
Understanding the Nature of Psychotic Symptoms
Auditory hallucinations, such as hearing voices, are a common presentation in both manic and depressive states. A defining characteristic of bipolar psychosis is the concept of mood-congruence, which means the content of the delusions or hallucinations aligns with the person’s prevailing mood.
For instance, a person in a manic state might delusionally believe they are a deity or a prophet, which is congruent with their elevated and expansive mood. Similarly, a person experiencing depressive psychosis might hear accusatory voices or believe that law enforcement is pursuing them for an imagined crime, aligning with feelings of guilt or paranoia.
Less frequently, a person may experience mood-incongruent psychotic features, where the content of the psychosis does not match the mood state. An example would be someone in a severely depressed state having grandiose delusions that they are secretly wealthy. Mood-incongruent psychosis often suggests a more complex presentation and may be associated with a more severe course of illness.
Treatment Approaches for Bipolar Psychosis
Managing Bipolar Psychosis requires a specialized approach to address both the severe mood episode and psychotic symptoms concurrently. Treatment typically involves a combination of medication to achieve acute stabilization. Mood stabilizers, such as lithium or certain anticonvulsants like valproate, are fundamental to managing the underlying Bipolar Disorder by regulating the extreme mood swings.
Antipsychotic medications resolve psychotic symptoms, including delusions and hallucinations. These medications, which include agents like olanzapine, quetiapine, or risperidone, are often used in combination with mood stabilizers, particularly during acute manic or depressive episodes with psychotic features. This combined pharmacotherapy quickly stabilizes the individual and restores contact with reality.
Once the acute episode has been managed and the person is stable, psychosocial interventions become an important part of long-term recovery. Psychotherapy, such as Cognitive Behavioral Therapy (CBT) or Family-Focused Therapy, helps the individual develop coping strategies, recognize early warning signs of an episode, and improve social functioning. Ongoing treatment is crucial for preventing future episodes of psychosis and maintaining mood stability.