Introduction

Psychosis and bipolar disorder are two complex mental health conditions that can significantly impact the thoughts, emotions, and behaviours of an individual. These two conditions can sometimes overlap, particularly during manic or depressive episodes, making diagnosis and treatment challenging. This article will introduce bipolar disorder and its relationship with psychosis, its symptoms and management for effective intervention and support. 

Definition of bipolar disorder and psychosis

Bipolar disorder, or bipolar affective disorder, is a mental health condition.¹ If you have bipolar disorder you are likely to experience extreme mood changes, often between depressive and manic episodes.¹ Some people with bipolar disorder also develop psychosis, a condition that causes them to experience hallucinations or delusions.² It may also involve disordered thinking and speaking.²

Understanding bipolar disorder and psychosis, and the link between them, is very important for the affected individual's personal and social well-being. Both bipolar disorder and psychosis can be distressing and impact daily life, so understanding the conditions well is important to recognise triggers and warning signs. 

What is bipolar disorder?

Bipolar disorder was previously known as manic depression. It is a mental health condition that causes extreme changes in mood between:¹ 

• Depression - feeling lethargic and low in mood
• Mania or hypomania - feeling overactive and high in mood 

Sometimes individuals with bipolar disorder will also experience psychosis, which will be introduced later in this article.¹

Types of bipolar disorder 

There are several types of bipolar disorder, including bipolar I, bipolar II, and cyclothymic disorder.^3,4 Detailed information on the types of bipolar disorder can be found on the Mind UK website. 

Bipolar I

Individuals with bipolar I have experienced at least one episode of mania that lasted longer than one week with or without some depressive episodes.³

Bipolar II

Individuals with bipolar II have experienced at least one depressive episode and hypomania symptoms which lasted at least four days.³

Cyclothymic disorder

Individuals with symptoms that are less severe than bipolar I or II, but have experienced episodes of depression and hypomania over a period of at least two years, may be diagnosed with cyclothymic disorder.⁴ Sometimes individuals with cyclothymic disorder will go on to develop bipolar I or II if not managed appropriately.⁴ 

Symptoms of bipolar disorder

Individuals with bipolar disorder experience extreme changes in mood between manic or hypomanic and depressive episodes.¹

Manic and hypomanic episodes

Episodes of mania and hypomania both result in feeling high in mood.⁵ However, mania is more severe than hypomania, often requiring hospital treatment, fully disrupting daily activities, and lasting for a longer period.⁵ Hypomania may still impact your daily life but to a lesser extent.⁵

During a manic or hypomanic episode, you may feel:⁵ 

• Very happy and joyful 
• Excited, often to an uncontrollable level 
• Agitated or restless 
• An increase in your sexual energy 
• More easily distracted
• An increase in your confidence 
• Focused and determined
• Like you need less sleep than usual and energised

These feelings may result in certain behaviours:⁵

• Becoming more active than usual 
• Talking more than usual, and at a quicker pace
• Being more friendly to other people 
• Doing things that are out of character or even inappropriate 
• Reducing the amount of sleep you get 
• Becoming rude or aggressive 
• Using drugs or alcohol 
• Spending money excessively/changing your spending habits
• Taking more risks than usual 

Further information on the feelings and behaviours observed in manic or hypomanic episodes can be found on the Mind UK website. 

Depressive episodes

Depressive episodes in bipolar disorder result in feeling low in mood.⁶ These episodes will last at least two weeks but will often go on for longer.¹ Similar to mania and hypomania, depressive episodes can substantially impact your daily life.⁶ 

During a depressive episode, you may feel:⁶

• Low in mood, very upset, and tearful 
• More tired than usual 
• A loss of interest in things or activities you usually enjoy 
• A lack of self-esteem and confidence
• Feelings of hopelessness, worthlessness, or guilt 
• Loss of concentration 
• Feeling more agitated or tense 
• An increase in suicidal thoughts 

These feelings may result in certain behaviours:⁶

• Not participating in activities you usually enjoy 
• Sleeping too little or too much 
• Eating too little or too much 
• Using drugs or alcohol 
• Withdrawing from and avoiding social contact 
• Not exercising as much as usual 
• Self-harm behaviours or suicidal attempts

Further information on the feelings and behaviours observed in depressive episodes can be found on the Mind UK website. 

What is psychosis?

While bipolar disorder is characterised by extreme mood swings, psychosis involves a loss of contact with reality, often featuring hallucinations or delusions. Psychosis results in individuals ‘losing contact’ with reality, meaning you may interpret or perceive reality differently from those around you.² 

Causes of psychosis

Psychosis can stem from a variety of causes, both biological and environmental. Understanding these factors can help in identifying and addressing the condition early.

Biological factors

A family history of psychosis, such as a parent or sibling with the condition, may increase your susceptibility to developing it.⁷

Environmental triggers

Environmental factors contributing to psychosis can emerge during childhood or adulthood. Common triggers include:⁸

• Experiencing abuse or traumatic events
• Physical injury or illness
• Use of drugs or alcohol and smoking
• A side effect of specific prescribed medications
• Hunger and lack of sleep 
• Bereavement or loss
• Intense spiritual experiences 

Further information on the environmental triggers of psychosis can be found on the Mind UK website. 

Symptoms of psychosis

The three most common symptoms of psychosis are hallucinations, delusions, and disorganized thinking.² Other potential symptoms include disorganised behaviour, negative symptoms (such as lack of motivation or emotional expression), and catatonia, which involves abnormal movement or immobility. Each of these symptoms can vary in intensity and presentation, making the experience of psychosis unique to each individual.²

Hallucinations

Hallucinations involve perceiving things that are not present or real to others. This can include:²

• Seeing objects, people, or events that others around you cannot perceive
• Observing objects moving or becoming distorted in unusual ways
• Tasting, smelling, or feeling sensations without any clear cause
• Hearing voices or sounds that others cannot hear

These experiences can feel very real to the person, even though they are not shared by those around them.

Delusions

A delusion is a strongly held belief that is not shared by others, even when evidence or experiences suggest it is untrue.² If you are experiencing a delusion, it can feel completely real and influence how you interpret the world around you, despite contradictions from reality or others' perceptions.

Disorganised thinking

Disorganised thinking refers to racing thoughts and a “flight of ideas”.² This causes your thoughts to move rapidly, jumping between ideas and creating connections that others may not perceive. If you experience disorganized thinking, you may speak very quickly, link words based on their sounds, jump between conversation topics, and find it increasingly difficult to stay focused.

Relationship between bipolar disorder and psychosis

Whilst bipolar disorder and psychosis are individual diagnoses, many individuals with bipolar disorder will experience psychosis.⁹ 

Impact on diagnosis and treatment

Given the close link between psychosis and bipolar disorder, diagnosis of each condition can often be difficult. Treatment plans may also be determined depending on the presence or absence of psychosis. However, it has been shown that psychosis is not always associated with negative outcomes in individuals with bipolar disorder.⁹ 

Managing bipolar disorder and psychosis

Medications for bipolar disorder and psychosis

Various medications may be prescribed for bipolar disorder, and these may vary depending on the type and severity of your condition.¹⁰ Generally, antidepressants are prescribed for depressive episodes, while antipsychotics are used during manic episodes. Certain anticonvulsants are also commonly used as mood stabilisers in bipolar disorder. Similar medications may be used to treat psychosis.¹⁰ 

Mind UK provides detailed information on the medications available for bipolar disorder and psychosis, respectively. 

Psychotherapy and counselling

Several talking therapies may be offered for the treatment of bipolar disorder and psychosis.¹¹ These include cognitive behavioural therapy (CBT), interpersonal therapy, family-focused therapy, behavioural couples therapy, group psychoeducation, and individual psychoeducation.¹¹ 

Mind UK provides detailed information on the types of talking therapies and counselling. 

Lifestyle modifications for managing symptoms

Employing lifestyle modifications may also be beneficial for managing bipolar disorder and psychosis symptoms. These include:¹²

Stress management

Stress is well known to trigger mood changes. Try to look after yourself when you feel stressed and find ways to minimise stress in your life. Mind UK provides tips on managing stress. 

Sleep hygiene

Making sure you get enough sleep is important to manage bipolar disorder symptoms. Enough sleep may help to shorten episodes or keep your mood more stable. 

Support networks

Building strong support networks is useful in the management of bipolar disorder. A strong support network of family and friends may be able to help you recognise the warning signs of episodes, help you keep to a healthy routine, listen and help you plan for a potential crisis.

Mind UK provides detailed information and resources to help manage your bipolar disorder and psychosis symptoms through lifestyle modifications. 

Summary

Bipolar disorder is a mental health condition that causes extreme mood changes. You may experience manic, hypomanic, and depressive episodes. Different types of bipolar disorder exist that differ in their severity and presentation. Psychosis results in individuals ‘losing contact’ with reality and may lead to hallucinations, delusions and disorganised thinking.

Many individuals with bipolar disorder will also experience psychosis. Bipolar disorder and psychosis can be managed with several medications, talking therapies, counselling, and lifestyle modifications. If you are concerned or unsure about your bipolar disorder or psychosis speak to your healthcare professional for more information.