What Does Psychosis Look Like in People With Bipolar Disorder?

Summary: To understand what psychosis may look like in people with bipolar disorder, it’s important to understand that symptoms of psychosis, such as delusions and hallucinations, are not uncommon in people with bipolar disorder, and may appear similar to symptoms of psychosis in other mental health disorders.

Key Points:

• Psychosis in people with bipolar disorder can appear in the form of delusions and hallucinations.
• Psychosis in people with bipolar disorder is more common in people with BD I, compared to people with BD II.
• Patients with severe mania show the highest rates of psychosis among people with bipolar disorder.
• The presence of psychosis in people with bipolar disorder does not predict a more severe course of illness, nor does it predict less favorable long term outcomes.

Psychosis in People With Bipolar Disorder

In the review article “Psychotic Symptoms in Bipolar Disorder and Their Impact on The Illness: A Systematic Review,” a group of researchers conducted an in-depth analysis of the available literature on psychosis in people with bipolar disorder with the following goal:

“To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.”

The research team collected data from over 300 studies of patients with a clinical diagnosis of bipolar disorder. Before we report the details of the study, we’ll offer a brief review of bipolar disorder and psychosis, including what they are and their general prevalence rates. First, however, we’ll report the top-line findings from the study we introduce above.

Here’s what the research team found:

• About two-thirds of people with bipolar disorder report symptoms of psychosis at any point during their lifetime.
• Less than half of people with bipolar disorder report current symptoms of psychosis

We’ll take a moment to discuss bipolar disorder and psychosis in general, then return to this study and share the details, and offer a more detailed answer the question we pose in the title, What Does Psychosis Look Like in People With Bipolar Disorder?

What is Bipolar Disorder?

Here’s how the American Psychological Association (APA) defines bipolar disorder:

“Bipolar disorder is a serious mental illness in which common emotions become intensely and often unpredictably magnified. Individuals with bipolar disorder can quickly swing from extremes of happiness, energy, and clarity to sadness, fatigue, and confusion. These shifts can be so devastating that individuals may consider suicide. All people with bipolar disorder have manic episodes—abnormally elevated or irritable moods that last at least a week and impair functioning. But not all become clinically depressed.”

In this article, we’ll focus on the most common types of bipolar disorder, bipolar I and bipolar II, although other forms of bipolar disorder do exist, such as cyclothymic disorder, which resembles BD, but is less severe and disruptive.

BD I & II Among Adults 18+ in U.S.: Facts and Figures

• Bipolar I:
  • Patients most often experience manic episodes, depressive episodes, or mixed episodes.
  • Some patients with BD I don’t experience depressive episodes
• Bipolar II:
  • Patients experience depressive episodes, hypomanic episodes (less intense form of mania), or mixed episodes. Symptoms of BD II are most often less severe than symptoms of BD-I.
• Prevalence among adults 18+ in U.S:
  • Diagnosis at any time during life: 4.4%
  • Past-year diagnosis: 2.8%
• Level of impairment among adults with BD:
  • Moderate: 17.1%
  • Severe: 82.9%

Those figures show that at any given time, between 5-10 million people in the U.S. have BD, with the majority experiencing significant impairment associated with BD.

Now let’s shift our focus to psychosis.

What is Psychosis?

The first thing to understand about psychosis is that it’s not a mental health disorder, but a specific type or set of symptoms present in various mental health disorders.

Here’s a definition of psychosis provided by Merck Professional Manuals:

Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and atypical/inappropriate motor behavior, including catatonia, that indicate loss of contact with reality.

What that means, in essence, is that people with psychosis sometimes experience the world in a different way than most of us. People with psychosis may see, hear, or feel things other people can’t, or believe things that aren’t supported by facts or what most of us recognize as reality.

Types of psychotic symptoms include delusions and hallucinations:

• Delusions refer to thoughts or beliefs that cannot be objectively verified, and do not correspond with reality.
• Hallucinations refer to seeing, hearing, feeling (i.e. touch), tasting, or smelling things that aren’t really there, and that others present cannot verify

The prevalence of symptoms of psychosis in the general adult population is small:

• Lifetime prevalence: 1.5% – 3.5%
• Past-year prevalence: 0.4%

However, experiences that resemble psychosis, called psychotic experiences (PE), which are isolated, one- or two-off events, are more common:

• Around 6% of people report at least one PE during their lifetime
• Around 2% of people report at least one PE in the past year

With that information on bipolar disorder and psychosis in mind, let’s shift gears back to the study we introduce above, and explore the details related to our central question: What Does Psychosis Look Like in People With Bipolar Disorder?

Psychosis in People With Bipolar Disorder: What the Latest Research Says

If we want to know what psychosis might look like in people with bipolar disorder, then we should understand that psychosis, in general, often appears as though the person experiencing it thinks and/or believes things that are objectively false or easily disprovable, or may hear, see, taste, feel, or smell things that aren’t there.

These experiences may manifest as atypical behavior, speech, affect (i.e. emotional expression), manner of interaction, or communication style, and the specific way they manifest will vary from one person to another.

Let’s take a look at the results, with a quick reminder of the goal of the study:

“To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.”

Here’s what the research team found:

Experience of Psychosis During Lifetime Among People With Bipolar Disorder

All Bipolar Diagnoses:

• Total: 57% reported symptoms of psychosis
  • Delusions: 69%
  • Hallucinations: 34%

Bipolar I:

• Total: 62.5% reported symptoms of psychosis
  • Delusions: 55%
  • Hallucinations: 32%

Bipolar II:

• Total: 22% reported symptoms of psychosis
  • Delusions: 4%
  • Hallucinations: 1%

This data clearly indicates that psychosis and psychotic symptoms are far more common in people with BD I compared to people with BD II. This implies that psychosis is more often associated with the manic phases of bipolar disorder rather than the depressive phases common to BD I & II and the hypomanic phases associated with BD II.

Specifics: Delusions and Hallucinations in Bipolar Disorder

Now let’s dive deeper and learn what types of psychotic symptoms – e.g. delusions and hallucinations – people with bipolar disorder may experience.

Delusions and Hallucinations Among People With Bipolar Disorder

Types of delusions in bipolar disorder, from most to least common:

• Grandiosity:
  • People may believe they have special gifts, powers, or greater insight than others, which are unique to them and them alone.
• Referential, i.e. assigning inflated importance to self without evidence
  • People may believe that current events/significant world events are directly related to or involve them in some way.
• Persecutory:
  • People may believe others are out to get them, or that external entities/others conspire to cause them harm, make life difficult, or are the source/cause of any problems they have.
• • People may believe they’re directly involved in events concerning religious issues or themes, or that aspects of religion revolve around them.
• Erotomanic, i.e. believing – without evidence – that another person is in love with them, most often a high-status or famous person
  • A person may believe they’re in a relationship with a celebrity, despite never having met, spoken to, or directly interacted wit them.

Types of hallucinations in bipolar disorder, from most to least common:

• Auditory:
  • Most common type of hallucination in bipolar disorder
  • Verbal, i.e. hearing voices saying distinct words no one else hears.
  • General, i.e. hearing non-verbal sounds no one else hears
• Visual, somatic, tactile, olfactory:
  • Less common in bipolar disorder, but do occur

Overall, delusions and hallucinations are more common in people with BD I with significant mania and/or manic episodes. This affirms the observation that symptoms of psychosis in bipolar disorder are more often associated with mania and manic episodes than depression and depressive episodes. Therefore, psychosis is more common in people with BD I, which includes mania, than in people with BD II, which includes a less severe/intense form of mania, hypomania.

We’ll discuss these results further below.

Does Psychosis Make Bipolar Disorder More Difficult to Manage?

Based on what we know about psychosis in other disorders, such as schizophrenia or personality disorders, it would be logical to conclude the presence of psychosis might significantly complicate management of the disorder for patients with BD.

However, that’s not necessarily the case.

In some instances of psychosis in BD, when hallucinations or delusions contrast with current mood – i.e. delusions of grandeur occurring during a depressive phase – psychosis is associated with a more severe form of BD called mood-incongruent psychotic BD, which is more difficult to manage for the individual, and more challenge to treat for the provider.

However, that’s the exception, rather than the rule. In general, the presence of psychosis in bipolar doesn’t have a significant impact on the course of the disorder throughout the lifetime of the individual.

Here’s how the research team characterizes their findings:

“The overall conclusion from these studies was that psychotic BD was not inevitably associated with a more adverse course and poorer outcome of BD.”

Our takeaway from the information in this study is threefold.

First, psychosis is not uncommon in bipolar disorder: the numbers make that clear. Second, psychosis appears most often in people with BD I: the numbers also make that clear. Third, and finally, we’ll reiterate the point the researchers make above: although the presence of psychosis may make the condition seem worse/more severe to others, long-term results show that the presence of psychosis in bipolar disorder does not predict more negative outcomes, compared to people with BD with no psychosis.