frequency of psychotic features & challenging them

sorry for a second thread, but someone recommended me in PM to make a post about how frequent people with BP experience psychosis, I think as a means to challenge my thoughts.

my therapist has insisted (in the past) that psychosis is rare in people with BP. she says she has a bunch of bipolar patients who don't experience psychosis at all, or if they do, it's very, very rare even in manic episodes. what do you think?

how common is it for people to have psychosis independent of mood episodes?

what should we do to challenge our thoughts? (my therapist gave me some ideas, but I want to hear from you guys.)

I suffer psychosis mainly paranoia on a daily basis. I suffer delusions when I'm manic mixed in with the paranoia. I also had a few spells with hallucinations. I have Bipolar 1. I see people, hear people, talk to people I see etc. Never been hospitalised. Able to mostly control it myself with just making a laugh and a joke about it.

I only take 3 meds. So it's not like I'm on loads. Depakote, Aririprazole and (Propanol for anxiety).

I guess we are all definitely different. It only becomes problematic if I can't control like what is happening currently with me

I must have a pretty classic bipolar type 1. I have experienced a number of psychotic periods, but only when in extremely severe episodes -- mostly severe manic or manic with mixed features. It has been enlightening to learn how many people on forums seem to either have schizoaffective - bipolar type, or bipolar type 1 with psychotic features. I certainly get how people with schizoaffective - bipolar type would have a great deal of psychosis, but confess that I am totally perplexed by the "with psychotic features". That does NOT mean that I question its existence. I just can't quite relate to that. I guess why I say this is because when I do have psychosis, my other manic symptoms are so severe that they seem equally dominant. IOWs, my behavior is extremely out of control or over the top when I am severely manic enough to get psychosis. During those times, I totally lack insight into the psychosis and the manic symptoms themselves, so would not be discussing it, during the course of experiencing it. Instead, I might rather be hospitalized, near hospitalized, having emergency appointments, and/or possibly getting into trouble in public. My communication would be quite affected with disorganized and somewhat incomprehensible speech, perseveration, possibly screaming/violent, catatonic (a couple times), and the like. I would have a very difficult time concentrating on certain things. My physical expressions may also be concerning/scary/ to others. There is no "Am I psychotic?" for me. There is only "Was I psychotic?"

It took me a long time to reach the point where I could ask "Am I getting hypomanic?" and then do something about it. However, when I am full blown manic, I am not asking that question. It is true that since being medicated for bipolar disorder, I can often have periods when I fluctuate between full mania and mid to higher level hypomania. During the latter periods, I've gained some insight. However, when I get that insight (during hypomania), I am not psychotic. I do not get psychotic during hypomanic states. As for my past psychosis, though I've had hallucinations, I mostly experienced delusions (of grandeur or persecution) and paranoia.

sorry to hear you suffer from psychosis on a daily basis. my therapist and a psychologist who evaluated me think I experience it often (I have no idea), but I do not think it is on a daily basis. but then again, I am never aware, so who knows.

nevertheless, I am glad you're able to mostly control the psychosis yourself. that's really great to hear.

I hope you have found some way to cope by distracting yourself?

I see your point about schizoaffective vs "w/ psychotic features." I don't really understand it myself. I think the "w/ psychotic features" is just a classifier that says you have bipolar and psychosis, but that you don't have enough schizophrenic symptoms to meet the criteria for a schizoaffective Dx.

I think bipolar exists on a spectrum... so I think the "w/ psychotic features" classifier kinda like saying "bipolar NOS," where a dr gives you that diagnosis because you're kinda in between bipolar 1 and bipolar 2, but they cannot decide what you really are. so I think that's kinda what the "w/ psychotic features" is at.

I think of the bipolar spectrum being "connected" to a schizophrenia spectrum. basically, the spectrum starts off with cyclothymia, followed by bipolar 2, bipolar NOS, bipolar 1, bipolar 1 w/psychotic features, schizoaffective, then schizophrenia. I hope that makes sense? it's a bit difficult to describe what I'm envisioning in my mind right now.

So like:
[cyclothymia]--[bipolar2]--[bipolarNOS]--[bipolar1]--[bipolar1 w/pf]--[SzA]--[Sz]

Anyway, thank you for sharing your experiences

Hey...

I just literally get on with it. Throw myself into thinking of others working my socks off as a volunteer. Which is why I'm struggling now. That's all been thrown out the window. If I get sever they up my meds for a brief time so I get support. They are really good with me. Hospital is off the cards for me so I will try anything to stay in the community. I feel like I'm Jekyll and Hyde as I can change how I am around people so if I'm volunteering or around people I'm normal then when I'm alone I'm the real me???

I’m not sure. A “therapist” told me I had “paranoid features” whatever the **** that means. I think he was a liar, amongst all his other appalling “gifts”

I’m not actually sure of my answer. Good thread

Maybe. I sort of thought it was simply that a person has bipolar type 1 and is especially vulnerable to long frequent periods of psychosis vs. being bipolar type 1 manic with severe manic symptoms, with only some periods of psychosis.

If I look at all of my past hospital records, the "specifiers" have varied according to the hospitalization. Or rather, the episode I had (or had most of) during specific hospitalizations. I do have some hospital records that indicated "with psychosis", and others not

My current diagnosis is schizoaffective bipolar type (though that's up for debate), so ignore this if you just want people dx'd with bipolar instead.
I get psychosis pretty much constantly whenever I'm not on a good antipsychotic. Sometimes I'll be on a certain med and it stops the psychosis, but not the mania (or depression) and then eventually the stress of being in a mood episode, the lack of sleep, and changes to my routine will bring the psychosis back (making me think I'm bp1 not sza). I do believe psychosis is more of a problem for me than mania/depression.

To challenge my thoughts I remind myself that my brain has made mistakes in the past and can make similar mistakes in the present/future. In PHP when I was dealing with a lot of paranoia around my meds I filled out this pretty helpful sheet where you fill out an "activating event" that causes irrational beliefs and thoughts, then explain what those beliefs are, the consequences of those beliefs (both feelings and behaviors), then you dispute the irrational thoughts, and to finish off the effect of more rational thinking. I think that worksheet was a turning point for me when it comes to "hey, I have irrational beliefs and they're interfering with my life, I really gotta fight these and think more rationally". It also helped me become more med compliant (although I'm not perfect at that quite yet!)

And here's a good video for the differences between bipolar, schizoaffective, and schizophrenia: YouTube

Yeah, lots of mental health providers are inconsistent with Bipolar Dx's. I don't think there is really a clear cut answer as to which specifier should be used when someone experiences psychosis. But I've always thought of it as I mentioned in my reply to you (with everything being on a spectrum, where it's in between BP 1 and SzA).

For me personally, all I need is a label that says I have BP and psychosis. I don't care if that means SzA, BP 1 w/ psychotic features, etc.. Heck, i could even be diagnosed with "bipolar 2 + psychotic disorder NOS" for all I care. All I need is my insurance company to cover my meds, because they sure as hell seem to enjoy rejecting things...

Absolutely. That's the whole darned point of all of those stupid codes. And of course we all want to find the right med cocktails for our specific "flavors" of the disorder they call "bipolar disorder".

“just getting on with it”

I've heard that one... helpful, huh?

The only time I was manic it coincided with extreme psychosis. I completely lost touch with reality. I'm not really an expert on it at all, but my biggest strategy is to rely on my support system as my mirror. If they feel my thoughts are out of touch, I'm dialing for help asap. Trusting in others is key.

My mother had psychosis with her mania both times. I personally think it is a lot more common than your therapist believes.

Myself I have BP2 and psychosis OR SZA. My meds bring my paranoia down to anxiety level. I have a dog so if I hear/see something I look to her to see if she's reacting. If she isn't it just me.

That's such a great thing about your dog!

Hmmm...I thought that part of the dx of BP1 was the presence of psychosis.

I experience psychosis, and maybe delusions, at a low level fairly consistently. Once in a while the psychosis will flare up, causing paranoia and other miserable symptoms.

My pdoc tells me that the psychosis and delusions are a part of BP1. Of course, as we all know BP is such a range of symptoms...I sure hope that at some point the diagnosis of BP is more clearly defined.

You can have bipolar 1 and not have psychosis.

By definition, manic symptoms and hypomanic symptoms are often very similar -- e.g., the criteria is more or less the same, such as recklessness, hyperactivity, etc. -- but what distinguishes mania from hypomania is the severity of those symptoms. The only exception is if a patient is experiencing psychosis on top of the elevated mood symptoms; in which case, that patient would be diagnosed as having a manic episode regardless of the severity of the other symptoms.

From what I've observed, though, every doctor and therapist has their own "criteria" (AKA opinions) on the difference between hypomania and mania, so it's very subjective, especially since hypomania and mania manifest themselves differently in every person with bipolar. For that reason, it's kind of hard to have a concrete set of "rules" when it comes to diagnosing someone with hypomania or mania. That's why I personally think the DSM is all so vague.

I will give an example, though: I once read a reddit post of someone who was clearly experiencing a manic episode. He did not have psychosis as far as I know, but apparently he impulsively booked a flight to Hawaii (like in less than 24 hours from when he started thinking about it), had sex with one of the flight attendants in a hotel room, and then gambled away like $30,000 or some crazy sh_t like that. Now in my personal (i.e., non-professional) opinion, that is clearly manic behavior because it is BEYOND reckless. The degree to which that guy was experiencing symptoms was very high. I don't think *anyone* with hypomania would go as far as that guy did. (Of course, this is all assuming the story isn't a farce.)

That's great! I had a service dog for PTSD and it was such a relief. She kept watch for me. I watched her to see what cues her behaviors would give to me.

She truly helped me to get some decent sleep. I was no longer hyper vigilant with her around. She was a 110 pound German Shepherd. One of the biggest ones I have ever seen. She was a very serious "guard" when I'd rest.

I lost her to cancer. I miss her very much!

Hey blue, My apologies for going a bit OT.

Love ya!

Timely thread for me. Absolutely fascinating posts!!! I am so interested in this topic, but then, I suppose I am a bit biased...

I think the nomenclature is just terribly confusing--for patients, doctors, families, everyone. For example, I personally really, truly have no idea whatsoever what the precise difference between schizoaffective disorder, psychotic type and bipolar 1 with psychotic features actually is. No clue.It's all very blurry to me.

When I think of psychosis in broad terms, I think of a loss of contact with reality, generally speaking. But what exactly is the experience in mania of believing Nicole Kidman is romantically chasing you and emailing you and so forth (one of my prior manic episodes)? Or of believing you may be Jesus, for example? To me, grandiosity on steroids is, in fact, a loss of contact with reality. Why? Because Nicole Kidman is not chasing after you. That is not actually occurring, outside of your brain, that is. Ditto, the Jesus issues. Those experiences are not occurring in the real, actual world.


I say all this only to offer that I believe that florid mania is marked by its own loss of contact with reality at times. Conceptually, to me, that is not a whole lot different than receiving special messages from the television or having infrared cameras in my walls. I actually don't see a ton of difference there. It's just that in florid psychosis those breaks are more dramatic and profound, usually.


My bipolar symptoms have changed dramatically over the years. Early on, it was heavy on depression. Was initially diagnosed as major depression. Missed the diagnosis.


That said, even my first big manic episode had some marked psychotic features back in 2005. Other manias have been more pure in the interim or, like BirdDancer describes, have been mixed.

In more recent years, my symptom profile has shifted hard to psychosis. As most of you are too aware, it has been fairly constant for several months now. Both coexisting with mania and on its own two painful legs. Things in my brain have really, really changed. Depression almost killed me in my thirties, but now, i face totally different issues. And so it goes.

I am sure I am remembering this wrong, but I really loved the movie Shakespeare in Love. In it, the show keeps being delayed for some reason and eventually, representatives of the local royalty show up--translation, the muscle--to confront Geoffrey Rush's character, who is in some position of responsibility of some sort for all this. Sure I am getting this totally wrong, but it's how I remember it.

Anyhow, one of the thugs throws Rush up against a wall and demands to know when the show is going to actually happen. Patience is thin. He hems and haws a bit. Some muscle is applied. There is no getting out of it. They ask again. He is terrified, but finally, he just breaks down and, looking incredibly bewildered by it all, admits: "It's. it's a mystery!"

And that is exactly how I feel about about bipolar disorder, about all its different names and specifications and symptom complexes. I have it. I definitely have it.


But it's a mystery. The whole thing is just a giant mystery to me..

Here is how it was explained to me. BP I with psychotic features means you are psychotic at your mood extremes, like mania. So it is dependent on your mood. Schizoaffective means the psychosis is independent of your mood swings.

As a side note, IMO even though schizophrenics in part suffer from psychosis, psychosis itself is not what I would call strictly a schizophrenic feature. It is just a symptom that can actually be associated with multiple dxs. At least this is the way I think of it. IOW I may be wrong, but I think schizoaffective has nothing to do with schizophrenia. They just have similar names, and only share psychosis in common.

Have others here found this to be true?