Bipolar Disorder with Psychotic Features


Bipolar Disorder with Psychotic Features:

Bipolar disorder, also known by its older name “manic depression,” is a mental disorder that is characterized by constantly changing moods. A person with bipolar disorder experiences alternating “highs” (what clinicians call “mania“) and “lows” (also known as depression). Both the manic and depressive periods can be brief, from just a few hours to a few days, or longer, lasting up to several weeks or even months. The periods of mania and depression range from person to person — many people may only experience very brief periods of these intense moods, and may not even be aware that they have bipolar disorder.

A manic episode is characterized by extreme happiness, hyperactivity, little need for sleep and racing thoughts, which may lead to rapid speech. A depressive episode is characterized by extreme sadness, a lack of energy or interest in things, an inability to enjoy normally pleasurable activities and feelings of helplessness and hopelessness. On average, someone with bipolar disorder may have up to three years of normal mood between episodes of mania or depression.

Psychotic features are often present during the manic phase of bipolar I disorder. Aspects of psychosis may also manifest during extreme episodes of depression. They are also present in schizophrenia and schizoaffective disorder. These features include delusions (false ideas about what is taking place or who one is) and hallucinations (seeing or hearing things which aren’t there).

Psychosis: is a loss of contact with reality, typically including delusions (false ideas about what is taking place or who one is) and hallucinations (seeing or hearing things which aren’t there).

Delusion of Reference: Delusions of Reference refers to the strongly held belief that random events, objects, behaviors of others, etc., have a particular and unusual significance to oneself.

Delusions: are false beliefs that are firmly held. They are one aspect of the psychotic features of bipolar disorder, schizophrenia and schizoaffective disorder.

Hallucinations: are most often associated with mental illness schizophrenia. However, they may also occur for those with bipolar disorder when either depression or mania has psychotic features.


Bipolar disorder is recurrent, meaning that more than 90% of the individuals who have a single manic episode will go on to experience future episodes. Roughly 70% of manic episodes in bipolar disorder occur immediately before or after a depressive episode. Treatment seeks to reduce the feelings of mania and depression associated with the disorder, and restore balance to the person’s mood.

Those with bipolar disorder often describe their experience as being on an emotional roller coaster. Cycling up and down between strong emotions can keep a person from having anything approaching a “normal” life. The emotions, thoughts and behavior of a person with bipolar disorder are often experienced as beyond one’s control. Friends, co-workers and family may sometimes intervene to try and help protect their interests and health. This makes the condition exhausting not only for the sufferer, but for those in contact with her or him as well.

Bipolar cycling can either be rapid, or more slowly over time. Those who experience rapid cycling can go between depression and mania as often as a few times a week (some even cycle within the same day). Most people with bipolar disorder are of the slow cycling type — they experience long periods of being up (“high” or manic phase) and of being down (“low” or depressive phase). Researchers do not yet understand why some people cycle more quickly than others.

Living with bipolar disorder can be challenging in maintaining a regular lifestyle. Manic episodes can lead to family conflict or financial problems, especially when the person with bipolar disorder appears to behave erratically and irresponsibly without reason. During the manic phase, people often become impulsive and act aggressively. This can result in high-risk behavior, such as repeated intoxication, extravagant spending and risky sexual behavior.

During severe manic or depressed episodes, some people with bipolar disorder may have symptoms that overwhelm their ability to deal with everyday life, and even reality. This inability to distinguish reality from unreality results in psychotic symptoms such as hearing voices, paranoia, visual hallucinations, and false beliefs of special powers or identity. They may have distressing periods of great sadness alternating with euphoric optimism (a “natural high”) and/or rage that is not typical of the person during periods of wellness. These abrupt shifts of mood interfere with reason, logic and perception to such a drastic degree that those affected may be unaware of the need for help. However, if left untreated, bipolar disorder can seriously affect nearly every aspect of a person’s life.

Identifying the first episode of mania or depression and receiving early treatment is essential to managing bipolar disorder. In most cases, a depressive episode occurs before a manic episode, and many patients are treated initially as if they have major depression. Usually, the first recognized episode of bipolar disorder is a manic episode. Once a manic episode occurs, it becomes clearer that the person is suffering from an illness characterized by alternating moods. Because of this difficulty with diagnosis, family history of similar illness or episodes is particularly important. People who first seek treatment as a result of a depressed episode may continue to be treated as someone with unipolar depression until a manic episode develops. Ironically, treatment of depressed bipolar patients with antidepressants can trigger a manic episode in some patients.

Bipolar disorder affects about 2 million people in the United States in any given year. Both men and women are affected at the same rate. There are few risk factors that reliably predict a significant increased likelihood of being diagnosed with bipolar disorder.

Genetics and one’s family history appear to both have some influence over the likelihood of being diagnosed with bipolar disorder. Bipolar disorder is more common in those who have a sibling or parent with the illness and in families having several generations affected with mood disorders.

Differing rates of bipolar disorder have not been reported for different races. Lower socioeconomic status may be slightly linked to a higher rate of bipolar disorder.

Men and women have an equal chance of being diagnosed with the disorder. The first episode in men tends to be a manic episode, while women are more likely to first experience a depressive episode.

The estimated average age for the onset of bipolar disorder is during the early 20s, although there have been reports of the disorder beginning as early as elementary school. In fact, bipolar disorder appears before age 20 in about one in five manic individuals.

Younger patients first may suffer cyclothymia, which is basically a less extreme form of bipolar disorder characterized by hypomanic and mild depressive episodes. Although people with cyclothymia display less intense symptoms, nearly half of them will progress to having a full manic episode. Younger patients who have full manic episodes are called juvenile bipolar patients.

The cause of bipolar disorder is not entirely known. Genetic, neurochemical and environmental factors probably interact at many levels to play a role in the onset and progression of bipolar disorder. The current thinking is that this is a predominantly biological disorder that occurs in a specific part of the brain and is due to a malfunction of the neurotransmitters (chemical messengers in the brain). As a biological disorder, it may lie dormant and be activated spontaneously or it may be triggered by stressors in life.

Although, no one is quite sure about the exact causes of bipolar disorder, researchers have found these important clues:

Genetic factors in Bipolar Disorder:
Bipolar disorder tends to be familial, meaning that it “runs in families.” About half the people with bipolar disorder have a family member with a mood disorder, such as depression. A person who has one parent with bipolar disorder has a 15 to 25 percent chance of having the condition. A person who has a non-identical twin with the illness has a 25 percent chance of illness, the same risk as if both parents have bipolar disorder. A person who has an identical twin (having exactly the same genetic material) with bipolar disorder has an even greater risk of developing the illness about an eightfold greater risk than a nonidentical twin. Studies of adopted twins (where a child whose biological parent had the illness is raised in an adoptive family untouched by the illness) has helped researchers learn more about the genetic causes vs. environmental and life events causes.

Neurochemical Factors in Bipolar Disorder:

Bipolar disorder is primarily a biological disorder that occurs in a specific area of the brain and is due to the dysfunction of certain neurotransmitters, or chemical messengers, in the brain. These chemicals may involve neurotransmitters like norepinephrine, serotonin and probably many others. As a biological disorder, it may lie dormant and be activated on its own or it may be triggered by external factors such as psychological stress and social circumstances.

Environmental Factors in Bipolar Disorder: A life event may trigger a mood episode in a person with a genetic disposition for bipolar disorder. Even without clear genetic factors, altered health habits, alcohol or drug abuse, or hormonal problems can trigger an episode. Among those at risk for the illness, bipolar disorder is appearing at increasingly early ages. This apparent increase in earlier occurrences may be due to under diagnosis of the disorder in the past. This change in the age of onset may be a result of social and environmental factors that are not yet understood. Although substance abuse is not considered a cause of bipolar disorder, it can worsen the illness by interfering with recovery. Use of alcohol or tranquilizers may induce a more severe depressive phase. What is Medication-triggered Mania?

Medications such as antidepressants can trigger a manic episode in people who are susceptible to bipolar disorder. Therefore, a depressive episode must be treated carefully in those people who have had manic episodes. Because a depressive episode can turn into a manic episode when an antidepressant medication is taken, an antimanic drug is also recommended to prevent a manic episode. The antimanic drug creates a “ceiling,” partially protecting the person from antidepressant-induced mania.

Certain other medications can produce a “high” that resembles mania. Appetite suppressants, for example, may trigger increased energy, decreased need for sleep and increased talkativeness. After stopping the medication, however, the person returns to his normal mood.

Substances that can cause a manic-like episode include:

Illicit drugs such as cocaine, “designer drugs” such as Ecstasy and amphetamines. Excessive doses of certain over-the-counter drugs, including appetite suppressants and cold preparations. Nonpsychiatric medications, such as medicine for thyroid problems and corticosteroids like prednisone. Excessive caffeine (moderate amounts of caffeine are fine).

If a person is vulnerable to bipolar disorder, stress, frequent use of stimulants or alcohol, and lack of sleep may prompt onset of the disorder. Certain medications also may set off a depressive or manic episode. If you have a family history of bipolar disorder, notify your physician so as to help avoid the risk of a medication-induced manic episode.

In everyday life, people have a variety of moods and feelings. These feelings include frustration, joy and anger. Usually these moods last one day rather than several days. For people with bipolar disorder, however, moods usually swing from weeks of feeling overly “high” and irritable to weeks of feeling sad and hopeless with normal periods in between.

An important distinction between bipolar disorder and the normal emotions of life is that bipolar disorder results in an inability to handle daily activities. The person cannot work or communicate effectively and may have a distorted sense of reality (for example, unrealistically high or low opinion of one’s skills).

Bipolar disorder often is not recognized by the patient, relatives, friends or even physicians. However, recognizing the mood states that occur is essential. Treatment can help a person with bipolar disorder avoid harmful consequences such as destruction of personal relationships, job loss and suicide.

During a manic phase, symptoms include:
Heightened sense of self-importance

Exaggerated positive outlook

Significantly decreased need for sleep

Poor appetite and weight loss

Racing speech, flight of ideas, impulsiveness

Ideas that move quickly from one subject to the next

Poor concentration, easy distractibility

Increased activity level

Excessive involvement in pleasurable activities

Poor financial choices, rash spending sprees

Excessive irritability, aggressive behavior

During a depressed phase, symptoms include:

Feelings of sadness or hopelessness

Loss of interest in pleasurable or usual activities

Difficulty sleeping; early-morning awakening

Loss of energy and constant lethargy

Sense of guilt or low self-esteem

Difficulty concentrating

Negative thoughts about the future

Weight gain or weight loss

Talk of suicide or death


(“SIG-E-CAPS“) mnemonic explanation: this mnemonic can help you remember the vegetative signs that can be involved in depression or depressive phase of bipolar disorder.

S leep changes: increase during day or decreased sleep at night

I nterest (loss): of interest in activities that used to interest them

G uilt (worthless):  depressed elderly tend to devalue themselves

E nergy (lack): common presenting symptom (fatigue)

C ognition/C oncentration: reduced cognition &/or difficulty concentrating

A ppetite (wt. loss); usually declined, occasionally increased

P sychomotor: agitation (anxiety) or retardations (lethargic)

S uicide/death preocupation/talk.


Bipolar Disorder Fact Sheet

By Margarita Tartakovsky, M.S. (excellent summary:
All of us experience changes in our moods. Some days we might feel irritable and frustrated; other days, we’re happy and excited. However, individuals with bipolar disorder experience severe mood swings that impair their daily life and negatively affect their relationships.

Approximately 2.6 percent of American adults have bipolar disorder (formerly called manic depression and manic depressive disorder), according to the National Institute of Mental Health. These mood swings include “highs” (mania), when individuals feel either on top of the world or on edge, and “lows” (depression), when they feel sad and hopeless. Suicide attempts are common in bipolar disorder, especially during depressive episodes.

Bipolar disorder can be effectively treated with medication and psychotherapy. With proper treatment, individuals with bipolar can lead fulfilling, productive lives. This is why it’s so important to recognize the symptoms and see a mental health professional for an evaluation.

What Causes Bipolar Disorder?

There is no single cause for bipolar disorder. Indeed, like all psychological disorders, bipolar disorder is a complex condition with multiple contributing factors, including:

  • Genetic: Bipolar disorder tends to run in families, so researchers believe there is a genetic predisposition for the disorder. Scientists also are exploring the presence of abnormalities on specific genes.
  • Biological: Researchers believe that some neurotransmitters, including serotonin and dopamine, don’t function properly in individuals with bipolar disorder.
  • Environmental: Outside factors, such as stress or a major life event, may trigger a genetic predisposition or potential biological reaction. For instance, if bipolar disorder was entirely genetic, both identical twins would have the disorder. But research reveals that one twin can have bipolar, while the other does not, implicating the environment as a potential contributing cause.

What Are the Different Types of Bipolar Disorder?

  • Bipolar I is considered the classic type of bipolar disorder. Individuals experience both manic and depressive episodes of varying lengths.
  • Bipolar II involves less severe manic episodes than bipolar I; however, their depressive episodes are the same.
  • Cyclothymia is a chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.
  • Mixed episodes are ones in which mania and depression occur simultaneously. Individuals might feel hopeless and depressed yet energetic and motivated to engage in risky behaviors.
  • Rapid-cycling bipolar individuals experience four or more episodes of mania, depression or both within one year.

What Are the Risk Factors for Bipolar Disorder?

Risk factors include having:

  • Cyclothymia (see definition above). About half of individuals with cyclothymia will experience a manic episode.
  • Any other psychological disorder
  • A family history of bipolar or other psychological disorders
  • Alcohol and substance abuse
  • Medication interactions. For instance, antidepressants may trigger mania.
  • Major life changes
  • Severe stress

Symptoms of Bipolar Disorder

There are four possible bipolar states:

  1. Mania
  2. Hypomania
  3. Depression
  4. A mixture of mania and depression (called a “mixed episode”).

Mood states are highly variable. Some people can experience mood changes in one week, while others can spend months or even years in one episode.

What Does Mania Look Like?

  • Feelings of euphoria and elation or irritability and anger
  • Impulsive, high-risk behavior, including grand shopping sprees, drug and alcohol abuse and sexual promiscuity
  • Aggressive behavior
  • Increased energy and rapid speech
  • Fleeting, often grandiose ideas
  • Decreased sleep (typically the individual doesn’t feel tired after as few as three hours of sleep)
  • Decreased appetite
  • Difficulty concentrating; disorganized thoughts
  • Inflated self-esteem
  • Delusions and hallucinations (in severe cases)

What Does Hypomania Look Like?

Hypomania is less severe than a full-blown manic episode. Hypomanic individuals can seem pleasant, friendly, energetic and productive. Though it doesn’t sound problematic, increasing hypomania can lead to risky behaviors and full mania.

What Does Depression Look Like?

  • Feelings of hopelessness and sadness
  • Inability to sleep or sleeping too much
  • Loss of interest in formerly enjoyable activities; loss of energy (sometimes to the point of inability to get out of bed)
  • Changes in appetite and weight
  • Feelings of worthlessness and inappropriate guilt
  • Inability to concentrate or make a decision
  • Thoughts of death and suicide

What Does a Mixed Episode Look Like?

Mixed episodes involve simultaneous symptoms of mania and depression, including irritability, depressed mood, extreme energy, thoughts of suicide and changes in sleep and appetite.

A Note about Suicide

Because of the high suicide risk in those with bipolar disorder, it’s important to note the warning signs. In addition to those mentioned in the depression symptoms above, others include:

  • Withdrawing from loved ones and isolating oneself
  • Talking or writing about death or suicide
  • Putting personal affairs in order
  • Previous attempts

For more information about suicide, check out Frequently Asked Questions about Suicide.

How Is Bipolar Disorder Diagnosed?

There are no medical tests to diagnose bipolar disorder. However, a psychologist, psychiatrist or other trained mental health professional can diagnose the disorder by conducting a face-to-face clinical interview. Your clinical interview will include detailed questions about your and your family’s medical and mental health history and your symptoms.

What Treatments Exist for Bipolar Disorder?

Bipolar disorder can be effectively managed with a combination of medication and psychotherapy to help in reducing both the number of episodes and their intensity. Treatment also can help prevent future episodes if the individual is willing to work on personal issues and develop healthy habits.

What Kinds of Medication Are Used for Bipolar Disorder?

  • Mood stabilizers. These medications are prescribed to help stabilize manic symptoms, prevent future episodes and reduce suicide risk, and are the most commonly prescribed medications for bipolar disorder. The most well-known of these is lithium, which seems to be effective for most people who experience manic and hypomanic episodes. Other commonly prescribed medications for bipolar disorder include anticonvulsant (or anti-seizure) medications (because they also have mood stabilizing effects). These medications include: valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin) and topiramate (Topamax).

Every medication has its own set of potentially serious side effects. For instance, Lamictal can cause Stevens-Johnson syndrome, a potentially fatal skin disease, though this is rare and is entirely avoidable by careful, slow dose titration.

  • Atypical antipsychotics. The newest medications, atypical antipsychotics were originally developed to treat psychosis (a symptom of schizophrenia). Like the mood stabilizers above, atypical antipsychotics help to control mood swings. These seven medications are commonly prescribed for bipolar: aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), clozapine (Clozaril) and olanzapine/fluoxetine (Symbyax).

Contrary to popular belief, these medications aren’t without significant side effects, including rapid weight gain, high cholesterol and risk for diabetes, which occurs most commonly with olanzapine and clozapine. In some cases, atypical antipsychotics have been associated with a life-threatening condition known as diabetic ketoacidosis (DKA).

In June 2004, the U.S. Food and Drug Administration (FDA) requested that all companies who manufacture atypical antipsychotics include a warning about the elevated risk for hyperglycemia and diabetes (see here ).

In addition, several organizations, including the American Diabetes Association and American Psychiatric Association, have published recommendations for doctors on how to treat patients taking these medications. For more information, read the press release at the American Diabetes Association website.

  • Calcium-channel blockers. Used to treat angina and high blood pressure, these medications — including verapamil (Calan, Isoptin, Verelan) and nimodipine (Nimotop) — also have mood stabilizing effects. They have fewer side effects than other bipolar drugs but aren’t as effective.
  • Combination therapy. When one medication isn’t working, a doctor might prescribe two mood stabilizers or a mood stabilizer along with an adjunctive medication to treat symptoms such as anxiety, hyperactivity, insomnia and psychosis. For example, Xanax (alprazolam), a fast-acting benzodiazepine, typically is taken for two weeks before mood-stabilizing medication starts to work. Antidepressants might be prescribed for patients who are in a depressive phase, but research suggests they aren’t effective, can trigger mania and exacerbate episodes long term.



Psychotherapy is a crucial component of long-term bipolar disorder management. Even when your mood swings are under control, it’s still important to stay in treatment.

Several different psychotherapeutic methods have proved to be effective in treating bipolar disorder.

  • Cognitive behavioral therapy (CBT) helps individuals develop strategies to cope with their symptoms, change negative thinking and behavior, monitor their moods and predict their mood to try to prevent a relapse.
  • Interpersonal and social rhythm therapy is a combination of interpersonal therapy and CBT. This newer treatment focuses on circadian rhythms to help clients establish and maintain routines and build healthier relationships.
  • Psychoeducation teaches individuals about their disorder and treatment and gives them the tools to manage it and anticipate mood swings. Psychoeducation also is valuable for family members.

How Else Can I Manage Bipolar Disorder?

  • Take your medication.
  • See a therapist regularly.
  • Learn more about bipolar disorder and its treatment
  • Participate in online communities or in-person support groups
  • Adopt healthy habits, including exercising, practicing stress management techniques, eating healthy, avoiding alcohol and drugs, getting seven to eight hours of sleep and avoiding any potential triggers.

What Do I Do Next?

By starting to learn about bipolar disorder, you’ve already taken a significant first step. If you’d like to learn more, check out our detailed guide here.

If you think you or a loved one has bipolar disorder, it’s important to be evaluated by a trained mental health professional. To find a therapist in your area, use a search engine such as this one, or check with your primary care physician or community mental health clinic for referrals.



  1. National Institute of Mental Health.

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