Progression of Psychosis in Bipolar Disorder

Bipolar psychosis moves along a continuum. Explanation, examples of how psychosis progresses in bipolar disorder.

Bipolar psychosis moves along a continuum. Explanation, examples of how psychosis progresses in bipolar disorder.

The following section explains how bipolar disorder with psychosis progresses. There are three terms you need to know:

Euphoric Mania: This mania includes expansive, grandiose, upbeat and on top of the world feelings.

Dysphoric Mania: In this episode, the person is agitated and depressed as well as manic. This is also called a mixed episode.

Up to 70% of people with severe euphoric or dysphoric mania have psychosis. Psychosis is more common in euphoric mania.

Psychotic Depression: It's so easy to confuse the negative, hopeless and often suicidal thoughts of depression with psychotic thoughts- but depression is not psychotic unless there are specific hallucinations and delusions associated with the depression. Up to 50% of people with bipolar depression have some form of psychosis.

The Bipolar Psychosis Continuum

It's helpful to think of bipolar psychosis as lying on a continuum of severity from left to right. On the left side, where there is no psychosis, symptoms can range from mild to severe mania and depression. Those on the left side of the continuum may be very ill, but they have not lost touch with reality and there are no hallucinations or delusions. When pressed, the person can at least admit there may be an illness involved and that their thinking is different from the norm. I

n the middle of this line is a gray area where over 50% of bipolar symptoms move into psychosis. When a person hits this gray area, they start to become unrealistic and eventually bizarre in their thinking. Many of us go in and out of the gray area and don't know it simply because we were never taught the signs of psychosis and we never cross into full-blown psychosis. And as I mention often in this article, up to 70% of those with bipolar I mania cross over the gray area into full-blown psychosis that often needs hospitalization (take psychosis test).

Here is an example of a psychosis continuum experience:

Left side of the line bipolar symptoms without psychosis: I feel helpless and hopeless. I don't think I'll ever have friends. It all seems so pointless. Why should I even get out of bed? I can't sleep. My body is so restless. I feel like I'm going to jump out of my skin sometimes. I'm so lonely. I'm so lonely! Where are my friends? Will I always be like this? (Realistic self-talk: Ok, I can see this is depression. I need to work on the depression. I have no proof that the friends I have are upset with me. In fact, I do have a lot of friends. What is wrong with me? It's like my brain is lying! It is lying- my meds aren't working. The reality check is intact. )

In the gray area: Milder psychosis: I think that people are upset with me. When I call them on the phone there is a silence I didn't hear before. They are not emailing me and I think they are talking about me behind my back. Yesterday, when I walked down the street, I had the feeling that someone was following me. I'm not sleeping well. I try but my mind is too busy. I just can't get the idea out of my head that all of my friends are conspiring against me. I think I saw a face in my TV last night but the TV was off. (Realistic self-talk: But I just don't have proof- what is wrong with me! It just feels so real. I need to call my doctor. This is a moderate reality check. )

Out of the gray area: Moderate psychosis: Last night, I heard the people next door talking about me. I could hear their voices like they were in the room. I think the manager was there. Is he out to get me? I can hear people all around my apartment. I haven't slept for over four days. I'm wound up. I just have too much to do. They will not stop talking!!!!!! If I could just turn up my music loud enough. Wait., wait. Is this real? It has to be real. This can't be real. I can't hear people through a wall. But I do hear them! (A little bit of reality is left, but self-talk is almost gone. The lack of sleep and stress have made a reality check almost impossible. )

Far right side of the line: Full-blown psychosis: My friends got together with my neighbors and created a plot to get me in the hospital. I showed them what I thought about that! I snuck out. I could hear them in there. Laughing and talking about me. I yelled, what do you want with me! I saw a few of them at the windows. They wanted me to drink their urine. I will drink my own urine and die! I will drink it and cure myself. I .. .DO... NOT ... WANT... TO ... BE ... STOLEN....! Someone is coming to take parts of my body. I cut out the pictures from the magazines and put them on my walls to show people what was happening to me! (Full-blown dysphoric manic psychosis. Zero reality testing.)

The above describes a psychotic dysphoric manic episode with hallucinations and paranoid delusions. That is quite a mouthful, but if you break down the description, it's easy to see what happened. The person started with agitated mania that involved depression (dysphoric mania). It then moved into the realm of mild paranoid ideas and eventually psychotic paranoia that crossed into delusions. The person thought they heard something and was able to reality check, but eventually, they experienced hallucinations they perceived as real. Finally, the psychotic mania became so severe the person was hospitalized. This is actually a very common pattern for people with Bipolar I, especially for a first episode. The above can happen in just a few days. Especially if a person is not on medications or goes off their medications!

Here is what Dr. John Preston says about the psychosis continuum:

"A depressed person can have very strong impulses, thoughts, feelings and a strong urge of wanting to be dead. They have intrusive thoughts such as I wish I were dead or I should be dead. They don't feel in control of their moods, but they don't hear a voice outside of their head or see images of their own death. The thoughts of wanting to be dead feel very odd and strong, but they have not crossed over into psychosis. If you ask the person if someone outside of their mind put the thoughts there, they would be able to say no. There is a sense of ownership to the thoughts as terrible as they are. Now, if a person thinks, feels and then says that the thoughts were put in their head by Satan, you have crossed over to delusional psychosis. They have moved from the gray area into psychosis."

Where do you, or the person you care about, exist on the psychosis continuum?

Here is the short recap of this more technical part of the article:

  • Psychosis is a break with reality that has two symptoms: hallucinations and delusions. Hallucinations involve the senses and are experienced outside of the body- such as voices that are not your own or seemingly real visions that are not real. Delusions are feelings and false beliefs such as believing the government has installed cameras in your house to monitor your every move.
  • Bipolar psychosis is different than schizophrenia psychosis as it is always combined with either depression, mania or both. The psychosis does not exist on its own.
  • Bipolar psychosis is more common in Bipolar I with full-blown mania and severe depression though it often occurs in a milder form with Bipolar I and Bipolar II depression. It is very rare with Bipolar II hypomania. It's estimated that 70% of people with Bipolar I have mania with psychotic features and 50% of people with Bipolar I and Bipolar II have depression with psychotic features.
  • Psychosis works on a continuum. There is a point where typical and even very strong and 'odd' bipolar symptoms such as seen in grandiose mania or suicidal depression move into the gray area between typical symptoms and these symptoms combined with psychosis.
  • Psychotic symptoms are 'bizarre' and don't respond well to reality testing.

APA Reference
Fast, J. (2021, December 28). Progression of Psychosis in Bipolar Disorder, HealthyPlace. Retrieved on 2024, July 22 from

Last Updated: January 7, 2022

Medically reviewed by Harry Croft, MD

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