People with bipolar disorder spend, on average, half their lives in phases of depression or mania. More than 40% of that time is spent in various degrees of depression, whether subthreshold, moderate or severe. Patients with bipolar II and rapid cycling spend more time depressed than those with bipolar I. This is part of why bipolar disorder is so often diagnosed as major depressive disorder. Depression has set, relatively easily recognizable symptoms when it appears on its own. However, psychosis is a common complication in bipolar depression, with its own distinction of “depression with psychotic features.”
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), these are the symptoms of depression. At least five should be present for at least two weeks.
- Depressed mood most of the day
- Markedly diminished interest or pleasure
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate or indecisiveness
- Recurrent thoughts of death (not just fear of dying) or suicidal behavior
For psychosis, there are two general categories of symptoms: positive and negative. Positive symptoms are “added on” to what the patient is already feeling, whereas negative symptoms are significantly lowered forms of normal behavior.
Positive symptoms of psychosis include:
- Delusions: these are firmly held, but false beliefs like believing one is a god or has super powers. Paranoia is also a delusion.
- Hallucinations: this is when a patient sees, hears, feels tastes or otherwise experiences something that isn’t there. Hearing voices is the most common.
- Disorganized behavior: examples are disorganized or nonsensical speech, socially inappropriate behavior and lack of self-care
Negative symptoms of psychosis include:
- Lack of emotion or expression
- Problems with motivation
There are other symptoms of psychosis that closely mimic those of depression like diminished cognitive function, depression, anxiety and trouble sleeping.
About half of bipolar disorder patients experience psychotic symptoms at some point in their lives. It happens mostly during manic phases in which grandiosity and paranoia are easily spotted by others. When it occurs in bipolar depression, it may not be as obvious as patients may be more likely to internalize them or avoid mentioning them.
There is a limited area of severity in which a person can discern whether what they are experiencing is real or not real. In mild psychosis, patients may hear voices or music but recognize they are not coming from external sources. In severe cases, patients may not be able to discern what is real or not real at all.
Psychosis in bipolar depression may stem from feelings of pathological guilt and suicidal behavior. What can start out as thinking “everyone is better off without me” can devolve into the delusion that they are actively avoiding you and paranoia that leads to thinking they might even be conspiring to kill you just to get you out of their lives.
Patients can literally hear voices telling them how worthless they are and that they should kill themselves. They can also consider themselves dangerous or literally poisonous to everyone around them, resulting in isolation.
These are far from the all the possible hallucinations and delusions that can be experienced in psychosis. They are unique to the patient. In addition to the psychological symptoms of psychosis, patients also frequently experience severe physical agitation. The urge to move or fidget often stems from anxiety that may accompany the psychosis, depression or both.
Depression with psychotic features is typically treated with atypical antipsychotics or electroconvulsive therapy. It may require inpatient care, depending on the severity. It’s important for anyone with bipolar disorder to have a plan in place for what to do in case of a psychotic episode.
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