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Understanding Psychosis in Bipolar Disorder

What is bipolar psychosis?

Fast fact
The word “bipolar” describes the two poles, or extremes, of mood experienced by people with the disorder — mania and depression.

Psychosis is the inability to recognize what is real in the world around you. This is different from what your thoughts and perceptions tell you. People who are experiencing psychosis often have hallucinations or delusions.

People with bipolar psychosis have symptoms of both bipolar disorder and psychosis. Bipolar disorder is a mood disorder. People alternate between periods of manic highs and deep sadness and depression. Symptoms can vary among individuals. And some people may have more or less severe symptoms.

Bipolar psychosis can happen during manic or depressive phases. But it’s more common during manic episodes.

Most people associate psychosis with schizophrenia. But it can be a symptom of other mental and physical conditions and disorders. Bipolar psychosis is often misdiagnosed as schizophrenia.



People who have bipolar psychosis experience a combination of symptoms. The symptoms occur in both bipolar disorder and psychosis. Many people believe that psychosis is a sudden, severe break with reality. But psychosis usually develops slowly.

Many other mood disorders show symptoms of psychosis, too. This can make it difficult to recognize the initial stages of psychosis:

Symptoms of psychosisSymptoms of maniaSymptoms of depression
diminished performance at work or in schoolincreased energy and activity levelsprolonged sadness
less than normal attention to personal hygieneimpulsive or risky behaviorhopelessness and worthlessness
difficulty communicating clearlyracing speech that’s often disjointedloss of enjoyment in normal activities
difficulty concentratingdifficulty concentratingdifficulty concentrating
reduced social contactself-absorptionloss of energy and motivation
unwarranted suspicion of othersreduced need to sleepworrying and anxiety
less emotional expressionirritable and easily agitatedthoughts of death or suicide

The symptoms of bipolar disorder and psychosis vary with each individual. But it’s typical to have one or more of the following symptoms.


When people hallucinate, they experience things that are not real to others. They may hear voices, see things that aren’t there, or have unexplained sensations. Hallucinations can encompass all the senses.


Delusion is an unshakeable belief in something that isn’t real or likely to happen. People may have grandiose delusions. This means they believe they’re invincible, or have special powers or talents. Grandiose delusions are common during manic phases.

When experiencing depressive bipolar disorder, a person might have paranoid delusions. They might believe someone is out to get them or that their money has been taken, leaving them in poverty.

Incoherent or irrational thoughts and speech

People with psychosis often have irrational thoughts. Their speech may be rapid and hard to follow. And they may move from subject to subject, losing track of their train of thought.

Lack of awareness

Many people experiencing a psychotic episode may not be aware that their behavior is not within normal bounds. And they may not recognize that their hallucinations or delusions are not real. They also may not notice that other people aren’t experiencing them.

Types of psychosis

 Type 1

People who have bipolar disorder usually experience symptoms that are either mood congruent or mood incongruent. Sometimes both types of symptoms occur at the same time.

With mood-congruent psychosis, the delusions or hallucinations reflect the person’s mood or beliefs. For example, a person might have feelings of guilt or inadequacy. The may also believe they have an illness or are dying. These are common beliefs held by people who have depression.

In mood-incongruent psychosis, delusions or hallucinations are not related to the person’s beliefs or feelings. Hearing your thoughts or believing you’re being controlled by others are two examples. Mood-incongruent psychosis may be more severe. Studies have shown that people with mood-incongruent psychosis are more likely to need hospitalization.



The exact cause of bipolar psychosis is not well understood. This is true with most mental disorders. But several factors could play a role. These include:


Certain genes seem to make it more likely that a person will have bipolar disorder. Not all people who have these genes will get the disorder. Bipolar disorder does tend to run in families. But not all family members will have the condition.

Chemical imbalance in the brain

An imbalance of chemicals that carry messages in the brain (neurotransmitters) may have a role in causing bipolar disorder.

Structure of the brain

Some studies show that people with bipolar disorder have less gray matter in their brains. Gray matter transmits signals in the brain and processes thought. But the role played by loss of gray matter is not well understood.

Other causes of psychosis

Psychosis is a symptom that’s often experienced in bipolar disorder. It may also occur with some other conditions and situations, including:

  • severe unipolar depression, in which there are no manic phases
  • sleep deprivation
  • substance abuse
  • trauma
  • brain injury or brain infection
  • illnesses such as Alzheimer’s disease and Parkinson’s disease
  • certain medications or withdrawal from some medications



Diagnosis of bipolar disorder usually includes several steps. Your doctor will ask about your family history to identify other family members with mental health disorders. They may also do a physical examination. Your doctor may also order tests to rule out other health conditions or injuries.

You will also be referred to a psychiatrist or psychologist who will diagnose your condition using established diagnostic criteria.

Bipolar disorder is difficult to diagnose. Typical symptoms of psychosis may make diagnosis easier. If psychosis is treated early your outcome will often be better. That is usually the case during the first episode of the condition.



The most effective treatment for bipolar psychosis is holistic. That means that your treatment should include lifestyle changes, self-help, and personal relationships. These treatments are also used with more traditional treatment methods.

Medications: Your doctor may prescribe mood stabilizers, antidepressants, or antipsychotic medications.

Psychotherapy: Therapy may include one-on-one counseling, family therapy and education, group therapy, or peer support.

Electroconvulsive therapy (ECT): You may be offered ECT when medication and psychotherapy don’t provide relief. With ECT, a small electric current is applied to the brain, which causes a brief seizure. This “resets” the brain and provides rapid improvement for many people.



It’s not unusual for people to have only one episode of psychosis and recover with treatment. Early diagnosis and treatment are important to controlling the condition and improving quality of life. Bipolar disorder is not curable. But for many people it can be controlled successfully.

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