Psychosis in Bipolar Disorder: Diagnosis Impossible?

Patient Expert

I'm still hard at it, working on the first of a series of books on bipolar. The exercise has been especially useful for me in finding order and coherency to what is essentially a chaotic topic. Psychosis is a case in point.

We identify psychosis with hallucinations and delusional thinking. In some cases, we may see a breakdown in personal identity. In our popular culture, we associate the condition with shock-horror headlines, but that is not going to aid us in our understanding. Instead, let's start from normal and work our way up "

Situation normal "

We all get disoriented. The brain plays tricks on us. It processes simultaneous sensory information at different speeds at varying levels of completion. To compensate, we are constantly filling in the blanks, adjusting, anticipating, often seeing and hearing what is not there.

On top of that, we are filtering this information through our own cognitive biases. Basically, we have constructed a working reality that gets us through the day. It's how the healthy brain works. But it would be a mistake to view your version of reality as definitive.

Think of all those times we swore we thought we saw or heard something or when our food took on a metallic taste and so on. But then our internal reality-checks kicked in. We reset to normal and thought no more of it. But imagine if things go wrong.

Situation not normal "

In her highly acclaimed 2007 book, The Center Cannot Hold, Elyn Saks recounts how as a graduate student at Oxford she caught herself talking to herself on the street and didn't regard this as strange. Things went downhill from there. Nevertheless, with professional help, she managed to hold herself together and complete her degree, taking four years instead of two.

Today, she is a chaired professor of law at USC, with other academic and professional appointments, plus is married. But it has been a long journey.

Psychosis in bipolar "

Psychosis is most associated with schizophrenia - which is Dr Saks' diagnosis - but it is best to think of it as a condition that may affect anyone at anytime, often temporarily. In the context of bipolar, we can regard psychosis as attaching itself to either depression or mania.

In other words, where there is no mood episode there should be no psychosis. The DSM-5 acknowledges that psychosis may occur in both unipolar depression and bipolar I, but unaccountably not in bipolar II. Let's not quibble.

In bipolar, psychiatry has come up with the tern, "mood-congruent." Thus, when floridly manic you may think you're king of the world and while depressed you may think you deserve to be punished.

"Mood incongruent," by contrast, is more associated with the type of bizarre delusions we identify in schizophrenia, including hearing voices and thinking what they are telling us is real.

As my own rough guide, I have come up with the term "free-floating" to describe psychosis not attached to mood. In other words, if the psychosis appears to operate outside of the laws of gravity, we need to be looking outside the bipolar diagnosis. Here's where the confusion begins "

**Schizoaffective disorder "  **

The DSM-III of 1980 urged psychiatrists to make this diagnosis when they couldn't decide between bipolar and schizophrenia. Back in the old days, when clinicians were inclined to diagnose manic patients - with or without psychosis - with schizophrenia, this may have represented an improvement.

The DSM-IV of 1994 introduced a detailed symptom checklist. A nearly identical list appears in the DSM-5 of 2013. But in the real world, doctors are operating as if they are living in 1980.

The key clue the DSM serves up has to do with "free-floating." Is there evidence of psychosis, in other words, where there is no evidence of mood? If so, that implies schizoaffective.

But making that kind of call demands spending a long time with the patient, getting a detailed history, and tracking that patient over the long term. Who has time for that?

Treating psychosis "

Psychosis strongly implies treatment with an antipsychotic, and in a crisis situation we can certainly regard this as our best option. And if your psychosis is of the "free-floating" variety, this may be your best long-term strategy, as well.

But if your psychosis is comes attached to your moods, a different long-term strategy may be called for. This assumes your doctor, with your help, has made the right call - "bipolar I with psychosis" rather than "schizoaffective."

This would involve treating the mood - generally with mood-stabilizers - to prevent a recurrence of the psychosis. I have heard this raised by leading experts at psychiatric conferences, so I'm not just making this up.

It may turn out that an antipsychotic is your best option, anyway. But the matter is at least worthy of your doctor's consideration. Do not be afraid to bring it up.

Another option is cognitive therapy (typically as an adjunct to meds treatment). Once thought of as a therapy mainly for mood and related disorders, the therapy is now being applied with some degree of success to help those with schizophrenia to spot and manage their thought disturbances.

Wrapping this up "

If you have experienced psychosis, chances are you have already gone though more diagnostic labels than Katy Perry's costume changes during her Superbowl half-time performance.

Trust me, I feel your pain. But I also acknowledge the wisdom you have gained. Do not be afraid to stand up for yourself. Be strong. Live well "