Learn how to recognize hallucinations and delusions during mood episodes and why early support and treatment matter.
Key Takeaways
- Psychosis is when someone loses touch with reality. It can mean seeing or hearing things that aren’t there, or feeling completely convinced of things that aren’t true.
- Early support is crucial. If you notice changes in your loved one — like paranoia, social withdrawal, or speech that’s hard to follow — it can help to respond calmly and use the LEAP approach: listen, empathize, agree, and partner.
- Triggers such as sleep deprivation, substance use, and high stress can increase psychosis risk. Stable routines and self-care are essential prevention strategies.
- If you or a loved one shows signs of psychosis, get medical help right away to support safety and start treatment, which may include medication and therapy.
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When bipolar disorder includes psychosis, your thoughts and perceptions may not match reality. You might hear voices, see things that aren’t there, or believe something untrue with conviction. These experiences can feel frightening or overwhelming and may require immediate medical attention or hospitalization to keep you safe.
Psychosis is more common in bipolar disorder than many people realize. A systematic review published in Psychological Medicine showed that nearly two-thirds (63 percent) of people with bipolar 1 disorder experience psychosis at some point in their lives. For those who require hospitalization, the number climbs to about 71 percent. In bipolar 2 disorder, about 1 in 5 people (22 percent) experience psychosis.
Psychosis can take many forms and appear during different mood episodes, such as mania, depression, or mixed states. Plus, it’s an important factor that can raise the risk of suicidal behavior and other complications for people with bipolar.
Understanding what’s happening during a psychotic episode — or even recognizing it as such — isn’t always easy. Yet knowing how and why these symptoms emerge is an important step toward getting help and managing bipolar disorder.
Understanding Bipolar Psychosis
Rather than being a diagnosis in itself, psychosis describes a symptom or collection of symptoms that are often — but not always — caused by another condition, such as bipolar or schizophrenia. Bipolar psychosis describes psychosis that occurs as part of living with bipolar disorder.
Psychosis can involve delusions, hallucinations, disorganized thinking or speech, and changes in behavior. It’s a “fully fledged belief in things that are bizarre, impossible, or highly improbable, with behavioral changes associated with it and a strong conviction,” says Jacob S. Ballon, MD, MPH, co-director of Stanford’s INSPIRE clinic, which provides care for people with psychosis.
When experiencing psychosis, a person will have a near-complete certainty in a highly unlikely event (like the idea that they’re a multimillionaire), and they will follow it up with behaviors (such as trying to purchase one or several expensive cars), Dr. Ballon explains.
You might hear or see things that aren’t there, known as hallucinations. Or you might experience delusions, firmly believing things that aren’t true — which may be obviously bizarre or seem plausible but still be incorrect — such as thinking you’re being watched or followed or that you possess special information or powers, says Ballon.
Conditions Associated With Psychosis
Having a psychotic episode doesn’t automatically mean you have a lifelong mental health diagnosis. Psychosis refers to a set of symptoms (like hallucinations and delusions) that can show up in many different conditions.
Experiencing psychosis may signal a diagnosis of:
- Schizophrenia
- Schizoaffective disorder
- Bipolar disorder (especially bipolar 1, during mania or severe depression)
- Major depression with psychotic features
- Postpartum psychosis (often linked to an underlying mood disorder)
MedlinePlus notes that psychosis can also affect people with:
- Substance- or medication-induced psychosis (for example, related to alcohol, cannabis, stimulants, or certain prescription medications)
Medical or neurological conditions that affect the brain, such as:
- Brain tumors
- Infections that have reached the brain (for example, encephalitis or meningitis)
- Some forms of dementia or other autoimmune or neurological illnesses affecting the brain
In bipolar disorder, psychosis can occur during manic, depressive, or mixed episodes, per a systematic review of research published in the World Journal of Psychiatry. If you have psychosis in bipolar, you might be diagnosed with bipolar disorder with psychotic features — namely, mania with psychotic features or depression with psychotic features, says Ballon.
Signs and Symptoms of Psychosis
The National Institute of Mental Health (NIMH) points to the following signs and symptoms of psychosis:
- Feeling suspicious or paranoid about other people’s intentions
- Feeling uneasy around people and withdrawing socially
- Finding it difficult to think or speak clearly
- Having unusual or unusually intense ideas or feelings
- Lacking in feeling (emotional numbness)
- Struggling to tell what’s real and what isn’t
- Trouble sleeping or insomnia
- Feeling very anxious or on edge
- Sudden drop in school or job performance
- Finding it difficult to maintain self-care and hygiene, or to manage daily activities
Psychosis During Mood Episodes
Not everyone with bipolar disorder experiences psychosis, but many people do during severe mood episodes, and the content of delusions or hallucinations often matches their mood, such as grandiose themes during mania or guilt and persecution themes during depression.
There are two types of psychosis related to bipolar, according to the American Psychological Association (APA):
- Mood Congruent The delusions or hallucinations are consistent with the themes of the manic or depressive state in which they occur.
- Mood Incongruent The psychotic features aren’t consistent with the manic or depressive themes.
In bipolar 1 disorder, about two-thirds of psychosis is mood-congruent, suggests a study of 162 patients.
Psychosis in Mania vs. Depression
Psychosis is more common in manic or mixed states than in depression. Only about 20 percent of psychotic episodes happen in bipolar depressive states. About 57 percent of people with bipolar 1 disorder experience psychosis during manic episodes.
Grandiosity — a feeling of being special — is a common feature of mania, Ballon says. Psychosis can take this to the next level. A person might, for example, believe they are a prominent religious figure such as Jesus.
If someone has an inkling that their belief could be untrue, they might be experiencing mania without psychosis, says Ballon. But if they can’t be talked out of it, that’s more likely psychosis.
“It really comes down to: What is the level of conviction that a person has on that belief?” explains Ballon.
Someone in a manic state might call the bank, wondering where their nonexistent $10 million went, or they might accuse their spouse of cheating with no evidence, says Melvin G. McInnis, MD, the Thomas B. and Nancy Upjohn Woodworth professor of bipolar disorder and depression at the University of Michigan in Ann Arbor. McInnis is also the director of the Heinz C. Prechter Bipolar Research Program at Michigan Medicine.
In depression, the psychosis often takes a different form, where the person blames themselves for something bad that has happened. “In the context of depression, psychosis could refer to someone who feels that they’re responsible for something that happened, such as a ship sinking or an airplane crashing, when in fact, it would be totally irrational that they would have any responsibility for that,” he says.
In bipolar 2 disorder (which features hypomania, not mania), psychosis is seen only during depressive episodes, per the review in Psychological Medicine.
Dr. McInnis recommends working with your healthcare provider to gain insight into your individual mood patterns so you can better anticipate mood changes.
Common Triggers in Psychosis
There’s not one single trigger for psychosis, and researchers are still working to fully understand what causes it. However, there are several factors that raise the risk of a psychotic episode, and they include:
- Sleep Deprivation A sudden lack of sleep — even just one sleepless night for someone with bipolar — can trigger a manic episode of unpredictable severity, says McInnis. “It’s very important for an individual who lives with bipolar disorder that they maintain a stable routine, that they get a good night’s sleep, and that they’re careful and attentive to their habits,” he says.
- Hormonal Changes and the Postpartum Period Postpartum psychosis is associated with bipolar disorder, says Ballon. “A person who’s experienced a postpartum psychosis, even if this is their first episode, should really be followed beyond that episode by a psychiatrist to see if they develop bipolar disorder down the line,” he says.
- Genetic Predisposition Scientists have identified multiple genes that might contribute to the risk of psychosis, says Ballon. However, there’s no genetic test that can estimate your odds, nor does it mean that you’ll develop psychosis if you have the genes that predispose you to it.
- Recreational Drug Use Stimulants, alcohol, and anything that destabilizes mood can make psychosis more likely. “The risk factor that’s becoming increasingly of concern is the use of cannabis,” says McInnis, noting that with the legalization of cannabis, the rates of psychosis have been driven up extensively.
- Certain Medications Some medications, such as Parkinson’s disease treatments, opioid pain medications, digoxin for heart failure, and corticosteroids for inflammation, have been linked to psychosis in a small number of patients, according to an article in U.S. Pharmacist.
- Acute Stress or Trauma Trauma can sometimes trigger psychosis, says Ballon, either immediately or weeks or months after the traumatic event.
- Infections There are some people for whom post-infectious scenarios, such as long COVID or other viral infections, sometimes precipitate psychosis, says Ballon. More research is needed to determine how the post-infectious period affects risk, but immune system changes that affect the brain may be involved, he adds.
Early Signs of Possible Psychosis — and What Helps
Getting help quickly from a mental health clinician is key to safety and recovery.
Many people experiencing psychosis, especially the first time, don’t recognize that their symptoms stem from a mental health condition and that help is needed, noted an analysis of patient interviews. Some people even try to hide symptoms.
Friends, family, and loved ones can watch for early signs, such as paranoid or delusional ideas, incoherent speech, social withdrawal, or slips in personal hygiene and self-care. These early warning signs sometimes occur before psychosis develops, according to the NIMH.
When you notice early signs, follow what experts call the LEAP model:
- Listen
- Empathize
- Agree
- Partner
When someone is saying things that don’t make sense, don’t argue with them.
“You don’t really want to take somebody head-on by trying to talk them out of a psychotic belief,” says Ballon. The belief feels like a fact to the person living with psychosis. Arguing isn’t going to help. Instead, find areas where you can agree.
“You’re not going to agree with somebody that they’re Jesus, but what you might be able to agree on is that things aren’t going quite right,” says Ballon. “You can say, ‘My goodness, things seem chaotic and moving very quickly.’ Find something you can agree on, and partner to work on that together.”
Let your loved one know that you’re worried about them. Encourage them to seek help from their psychiatrist (or seek one out if they’re not currently being treated), Ballon advises.
Treatment for Psychosis in Bipolar Disorder
In bipolar, psychosis might require a trip to the emergency department or an urgent visit to a psychiatrist. Mood stabilizing and antipsychotic medications can help bring symptoms under control.
“Sometimes this can be done with the same medicine, because many of the antipsychotic medications are also antimanic agents,” says Ballon. For example, lithium can be beneficial for treating mania with psychotic features, an analysis of clinical studies shows. But other times, the person might need more than one medication, Ballon adds.
An experienced mental health clinician can help assess what level of care is needed. For some people, increasing a medication dose and checking in a week later is sufficient. Others might need to be admitted to the hospital or to an intensive outpatient program.
Holistic Management Strategies
Medications are often the starting point, but holistic management of psychosis also includes psychotherapy, Ballon says. For example, cognitive behavioral therapy for psychosis (CBTp) is a form of therapy that can reduce distress, improve functioning, and even help prevent psychosis, according to Stanford Medicine.
If a person can “open the door just a little” to the possibility that their psychotic belief may be unfounded, “they’re likely to do better when it comes to using CBTp,” says Ballon.
Lean on friends, too. Strong social networks help recovery from psychosis, according to a longitudinal study.
Treating any coexisting mental health or behavioral health conditions, such as substance misuse, attention deficit hyperactivity disorder, anxiety, or agoraphobia, is also an important part of recovery, says McInnis. These conditions can otherwise complicate recovery, and “what’s needed is really a comprehensive approach to the condition,” he notes.
The good news? Says Ballon, “Recovery is absolutely possible, and people can do quite well after experiencing psychosis — whether it’s with bipolar disorder or not.”
The Impact of Psychosis on Bipolar Disorder
“Many clinicians often consider the presence of psychosis to indicate a more severe form of the illness,” says McInnis. Psychosis in bipolar disorder can be associated with additional anxiety, agitation, and hostility, according to the World Journal of Psychiatry.
More research is necessary to understand what’s happening inside the brain during psychosis. Numerous analyses of brain MRI data have uncovered differences between people who experience psychosis in bipolar compared with those who experience psychosis in schizophrenia, schizoaffective disorder, and those without any mental health conditions. Specifically, these studies found differences in gray matter volume, brain structure, and patterns of brain connectivity (how brain areas and networks communicate). Such insights could someday aid early diagnosis and treatment.
It’s challenging to study the brain during psychosis. Still, based on the limited information we have, it appears that certain brain regions become overactive in the manic state and underactive in the depressive state, says McInnis.
As you gain insight into your symptoms and triggers, work with your clinician and loved ones to develop a rescue plan to help prevent psychosis and get help if it does develop, suggests McInnis.
“Often, people will talk with their provider about having extra medication on hand that’s likely to provide them some reprieve or calm them or help them sleep, and to minimize the likelihood that they will sail forward into a manic episode,” he says.
Ask a trusted family member or friend to help you identify mood changes early, he says. “It’s often very helpful to have a discussion with a family member or close friend to suggest to them, ‘If you see me revving up like this, you really need to have a conversation with me and really strongly urge me to take the medication that would help calm me down,’” he says.
Frequently Asked Questions
What is bipolar psychosis?
Bipolar psychosis is a loss of touch with reality that affects some people with bipolar during certain mood states. “When we talk about somebody being psychotic, it means that they’re experiencing phenomena that are outside of the range of normal experiences,” says McInnis.
How long can bipolar psychosis last?
It varies from individual to individual, McInnis adds. For some people, psychosis is short-lived and resolves in days. For others, it can last several weeks.
What does a bipolar psychotic break look like?
While experiences range widely, there’s sometimes a gray zone between mania and psychosis. “An overvalued idea can become a psychotic belief, and it’s difficult to know exactly when and how that happened,” says McInnis. “But all of a sudden, it’s just clear to the person around them that this just doesn’t make any sense whatsoever.”
How often do people with bipolar experience psychosis?
There’s no definitive way to predict how often you’ll experience psychosis. Recurrence risk is high in bipolar disorder generally, with studies showing substantial relapse rates over years, though exact timelines vary by individual and treatment adherence. When someone has had psychosis, “What we say to the person is that there’s a high likelihood you’ll have another one of these within the next five, six years or so,” explains McInnis. Then the treatment focuses on minimizing that risk. Some people can go decades before experiencing psychosis again.
Editorial Sources and Fact-Checking
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