Question: What causes psychotic symptoms in bipolar disorder?
Dr. Haupt: Psychotic symptoms include some of the most severe manifestations of bipolar illness. These symptoms commonly include auditory hallucinations and delusions. Auditory hallucinations may consist of hearing voices that engage in conversations with the sufferer or provide running commentaries on the sufferer’s life or they can be completely nonsensical. Delusions are defined as false, unwavering beliefs that are not shared by others.
Psychotic symptoms also occur as part of the course of schizophrenia and schizoaffective disorder. When someone has psychotic symptoms for the first time, it can be difficult to determine if they are suffering from schizophrenia, schizoaffective disorder, or bipolar disorder. Because of this, it is frequently necessary to modify or change a psychiatric diagnosis over the course of someone’s illness.
Current evidence blames excess activity of dopamine in the brain for the development of psychotic symptoms. In this theory, excess dopamine activity causes people to misinterpret the world around them. For example, a college student suffering from her first episode of mania may notice a campus police officer passing by her classroom one day. Due to the excess dopamine activity in her brain, she begins to form a complex delusion that the police are monitoring her activities under the dean’s orders because he is threatened by her superior understanding of mathematics. Earlier in the year, when her dopamine activity was normal, police officers likely passed by her classroom, and she literally didn’t give their presence a second thought. This is because when dopamine activity is normal, we are ignoring thousands of meaningless events every day so that we may focus on the tasks at hand.
Antipsychotic medications are essential for treating psychotic symptoms in bipolar disorder. Antipsychotic medications all share a common feature of reducing dopamine activity in the brain. However, these medications are unable to discriminate between blocking delusional associations and useful thought processes. This can sometimes result in the sensation that one’s thoughts are not as rich or complex, or that one’s creativity is impaired.
For this reason, it is important to continuously reevaluate the benefits and side effects of treatments for bipolar disorder. Patients play an essential role in letting their doctors know how their symptoms are changing. Even if these reports don’t result in a change in treatment, they provide useful information for considering future changes. For example, I once had a patient who would have fleeting thoughts that she was responsible for the fall of the Berlin Wall that would increase in severity over the days and weeks prior to a manic episode (in previous episodes requiring hospitalization, this had become a full-fledged delusion). Once she was aware of this aspect of her illness, she would call me at the first sign of these thoughts. Usually a few days of low dose antipsychotic treatment would abort her manic episode, and has kept her out of the hospital.