Bipolar disorder involves episodes of mania, depression, or hypomania. These shifts in mood are the key characteristic of this mental health condition, but it’s not unusual for people living with bipolar disorder to also have symptoms of psychosis.
Bipolar with psychotic features can closely resemble schizoaffective disorder. People living with this condition have combined symptoms of schizophrenia and bipolar disorder — a mix of mania or hypomania, depression, and psychosis.
This complex array of symptoms can make schizoaffective disorder harder to diagnose. The fact that schizophrenia, like bipolar and schizoaffective disorders, can involve depression and psychosis only adds another layer of complication.
believethe significant overlap between these three conditions suggests they occur on something of a spectrum: Bipolar disorder at one end, schizophrenia at the other, and schizoaffective disorder representing a midpoint between the two.
For now, experts still recognize and diagnose these conditions separately. Treatment can also depend on the specific symptoms you experience. Below, we’ll explore the symptoms and causes of each, plus offer some guidance on getting the right diagnosis and treatment.
Symptoms of schizoaffective disorder and bipolar disorder share enough similarities that even mental health professionals sometimes find it challenging to distinguish between the two conditions.
Bipolar disorder with psychotic features, in particular, might involve a similar pattern of symptoms as schizoaffective disorder, which can lead to misdiagnosis.
Still, despite the overlap, a few key differences between the conditions do exist.
This condition involves episodes of mania, hypomania, or depression. These shifts in mood can come on gradually or suddenly, and they can have a major impact on day-to-day life.
Mania involves an elevated mood. You might feel excited, energized, even euphoric, though irritability is a possibility, too. You might need far less sleep than usual, get distracted easily, and notice racing thoughts or an urge to keep talking.
With hypomania, you’ll experience similar symptoms at a lower intensity. People who don’t know you well may not notice anything different about your mood.
An episode of depression involves a sad or low mood, along with a general disinterest in your usual activities or spending time with others. You might notice very little energy, feel guilty or worthless, and find it difficult to concentrate. Keep in mind you don’t need to experience an episode of depression meet the diagnostic criteria for bipolar I.
These episodes can last several days, and they happen with varying frequency: once every year or two, a few times a year, or nearly every month.
Serious mood episodes might also involve catatonia, a disruption in motor function that prompts a state of stupor, physical agitation, or affects movement in other ways.
Bipolar with psychotic features
Psychosis describes a disconnect from reality, a state of mind where you have trouble recognizing what’s real and what isn’t. In terms of bipolar disorder, psychosis mainly refers to hallucinations or delusions.
Other key symptoms of psychosis, such as changes in sleep patterns or problems with concentration, can seem very similar to those that characterize mood episodes.
Bipolar psychosis might involve:
- feelings of paranoia or suspicion
- delusions of grandeur, such as a feeling of invincibility
- racing or rambling speech
- hallucinations that affect any of your five senses
These symptoms can be mood congruent, meaning they’re consistent with your other symptoms. They can also be mood incongruent, or inconsistent with your other symptoms. Believing you have superpowers during an episode of depression, for example, would be considered mood-incongruent psychosis.
Psychosis can happen during both manic and depressive episodes. An episode of hypomania that involves psychosis automatically meets the criteria for mania.
The new edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorizes this schizoaffective disorder with other schizophrenia spectrum conditions, like schizophreniform disorder and schizotypal personality disorder. It’s sometimes misdiagnosed as schizophrenia.
Yet there’s one major difference. With schizoaffective disorder, you’ll experience mood episodes that also involve symptoms of schizophrenia:
- hallucinations, delusions, or both
- disorganized thoughts and speech
- negative symptoms, including diminished facial expressions or difficulty expressing emotions
These symptoms won’t only appear during the mood episode, which is the big difference between schizoaffective disorder and bipolar disorder with psychotic features. They’ll also show up when you aren’t having mood symptoms, or remain present after the mood symptoms improve.
Bipolar or schizoaffective disorder?
You’ve recently started feeling very low. Since you don’t have much energy, you spend most of the day sleeping, and you can’t bring yourself to go to work. After a few days, though, you wake up early and, worried about losing your job, push yourself to get up and try to get something done.
Once you arrive, you head to your desk and suddenly begin to hear whispering. You turn around, but no one’s there. The whispering continues throughout the day, making it tough to focus. You can’t make out what the whispers say, but you think you hear your name a few times. You’re convinced the entire office is complaining about your poor work ethic and lack of responsibility.
Whenever someone walks by or starts a conversation, you get the impression they’re just looking for a reason to criticize you. This leaves you feeling guilty for not coming into work and wondering whether you should just quit since you can’t seem to do your job properly.
When it’s time to go home, the whispering gets louder as you leave your desk, almost as if it’s following you out the door. But you still can’t see anyone nearby.
The example above could characterize a depressive episode with psychotic features orschizoaffective disorder. The key difference lies in whether the hallucinations and delusions continue after the mood episode ends.
Researchers haven’t found one single cause for bipolar or schizoaffective disorder. Rather, evidence suggests several factors most likely play a role.
Factors believed likely to contribute to bipolar disorder include:
- differences in brain structure
- imbalances in the brain’s chemical messengers, or neurotransmitters, such as norepinephrine and serotonin
- a family history of any type of bipolar disorder
Environmental triggers, such as trauma, major life stress, or chronic illness, won’t directly cause the condition, but they can trigger a first mood episode if you have an underlying risk.
Maybe your high-pressure job has proven something of a challenge. Keeping up with your workload leaves you little time to sleep, and you worry constantly about making a serious mistake. On top of everything else, your partner of 5 years has just moved out after a long and miserable breakup.
This situation won’t automatically cause a mood episode — but if you have a parent or sibling with bipolar disorder, your chances of experiencing one do increase.
Factors believed likely to contribute to schizoaffective disorder include:
- differences in the brain’s white matter and hippocampal volume
- imbalances in neurotransmitters such as serotonin, norepinephrine, and dopamine
- a family history of schizophrenia, schizoaffective disorder, or bipolar disorder
- traumatic experiences, including childhood neglect or abuse
Notice a few similarities between the possible causes of each condition? You’re not alone. Some
Before diagnosing either condition, a therapist or other mental health professional will ask questions about:
- Key symptoms you experience. These might include depression, mania, anxiety, hallucinations, or trouble thinking clearly.
- Patterns in symptoms. Maybe they mostly appear when you’re tired or coping with more stress than usual.
- How long symptoms last. Do they clear up within just a few days as your mood improves? Or do they linger for weeks?
- Their impact on your life. Perhaps changes in your mood cause difficulties at work and home, or feelings of paranoia and suspicion create tension and strain in your personal relationships.
Mental health professionals will also pay attention to how your symptoms change or improve once treatment begins. If hallucinations or catatonia begin to lift as your mood episode improves, they might diagnose bipolar with psychotic features.
On the other hand, they might be more likely to diagnose schizoaffective disorder when treating your mood episode has little effect on psychosis.
They’ll use criteria from the DSM-5 to make a diagnosis.
Three main types of bipolar disorder exist: bipolar I, bipolar II, and cyclothymia. If you have four or more mood episodes in a year, though, you might receive a more specific diagnosis of rapid-cycling bipolar disorder.
A diagnosis of bipolar I requires at least one manic episode that:
- lasts a week or longer
- has a significant impact on daily life
- may require inpatient care
You may also have episodes of depression or hypomania, along with periods of euthymia, where your mood remains relatively stable.
A diagnosis of bipolar II requires:
- at least one episode of hypomania that lasts at least 4 days
- at least one episode of depression that lasts at least 2 weeks
The depressive episode must involve a low mood or a loss of pleasure and interest in everyday activities, or life in general, along with at least four other symptoms of major depression. These symptoms also need to cause distress and problems functioning in everyday life.
Symptoms of hypomania, however, may not always seem distressing.
As for cyclothymia, diagnosis requires symptoms of hypomania and depression that don’t meet the full criteria for a mood episode. You might, in other words, have just two or three symptoms. Symptoms may fluctuate, but they’re generally milder than those that appear with either bipolar I or II.
These symptoms will continue for 2 years or more. You might have brief periods of relief, but these symptom-free intervals won’t last any longer than 2 months. If at any time you do experience a full mood episode, your diagnosis will change from cyclothymia to bipolar I or II.
There are two types of schizoaffective disorder:
- Bipolar type. You’ll mainly experience mania along with schizophrenia symptoms, though you might experience depression, too.
- Depressive type. You’ll only have depression, not mania.
A diagnosis of either type requires four main criteria.
First, during mood episodes, you’ll also experience at least two of the following for most of a month:
- confused, disorganized, or difficult-to-understand speech
- negative schizophrenia symptoms
Untreated, these symptoms will typically last the better part of a month, if not longer.
Still, schizoaffective disorder goes beyond a combination of bipolar and schizophrenia symptoms. This diagnosis also requires:
- hallucinations or delusions for 2 weeks or longer with no symptoms of depression or mania at the same time
- symptoms of a mood episode for the majority of the time you’ve had any symptoms
- that your symptoms don’t relate to substance use, medication side effects, or another health condition
Basically, if you’ve experienced symptoms of psychosis off and on for years, but only ever experienced one episode of mania or depression, your mental health professional may consider another diagnosis. You could, for example, have both bipolar disorder and a separate condition that involves psychosis.
Similarly, you likely won’t receive a schizoaffective disorder diagnosis if you:
- never experience psychosis outside of mood episodes
- have hallucinations, but no other schizophrenia symptoms, during mood episodes
Why does the correct diagnosis matter so much?
Diagnosis helps guide treatment, and misdiagnosis can make treatment less effective. Sometimes, this may just mean your symptoms don’t improve as quickly. In some cases, though, the wrong treatment can make your symptoms worse.
Treatment for both bipolar and schizoaffective disorders generally involves a combination of therapy and medication.
The medication your psychiatrist prescribes will usually depend on the specific mood symptoms you experience.
Common medications for bipolar disorder include:
- mood stabilizers
- atypical antipsychotics
- anti-anxiety medications, including benzodiazepines
Finding the right balance often takes time
Certain medications might cause unwanted side effects. Others may fail to relieve your symptoms, or even leave you feeling worse. Certain antidepressants can even trigger manic episodes if they aren’t combined with a mood stabilizer.
Sharing all of your concerns about your medication with your care team will allow them to help you find the best treatment plan that involves the fewest side effects.
Therapy can always have benefits, too. A few options include:
- cognitive behavioral therapy
- family or relationship counseling
- interpersonal and social rhythm therapy
Therapy offers a safe space to:
- share your symptoms and get more insight on what it means to live with bipolar disorder
- explore strategies to cope with stress
- identify helpful self-care tips and lifestyle changes to better manage symptoms
- identify patterns in symptoms that can help you address potential triggers
Your therapist can also offer more guidance on any alternative approaches you might be interested in exploring, such as electroconvulsive therapy (ECT), mindfulness, or art therapy.
Medications used to treat schizoaffective disorder include:
- mood stabilizers
- antidepressants, usually selective serotonin reuptake inhibitors (SSRIs)
Therapy can make a difference, too.
CBT and other one-on-one approaches offer the chance to learn more about the condition and get guidance on managing your symptoms and related emotional distress.
Your mental health professional might also encourage you to consider other options, like group therapy or relationship counseling, depending on how your symptoms affect daily life.
Bipolar disorder and schizoaffective disorder may seem closely related, and some experts believe they aren’t entirely distinct. All the same, the right diagnosis can set you on the path toward the most effective treatment.
Reaching out to an experienced mental health professional who can recognize and treat both conditions can go a long way toward helping you find support — and relief.
Crystal Raypole writes for Healthline and Psych Central. Her fields of interest include Japanese translation, cooking, natural sciences, sex positivity, and mental health, along with books, books, and more books. In particular, she’s committed to helping decrease stigma around mental health issues. She lives in Washington with her son and a lovably recalcitrant cat.