Manic-Depressive Psychosis: Features

Manic-depressive psychosis is an antiquated term that was commonly used to describe what we now know as bipolar disorder. Bipolar disorder is characterized by intense shifts in mood marked by periods of extreme highs (called manic episodes) and extreme lows (called depressive episodes). In addition to shifts in mood, more than half of people diagnosed with bipolar disorder will experience symptoms of psychosis at some point in their lives. In this article, we’ll explore the defining features of bipolar disorder.

What are the defining features of bipolar disorder?

Bipolar disorder is characterized by significant changes in mood, energy, and activity levels. Bipolar disorder may cause mood swings consisting of alternating manic episodes (extreme highs) and depressive episodes (extreme lows). 

Someone experiencing a manic episode may experience an extreme increase in energy levels, irritation, a decreased need for sleep, and euphoria. A person experiencing a depressive episode may experience symptoms like hopelessness, intense sadness, and low energy.

Periods of bipolar depression may be more prevalent than mania, but depressive episodes may be considered more dangerous due to the associated risk of suicide. Features of bipolar depressive episodes tend to be similar to major depressive episodes.

Bipolar disorder is characterized into three main types. While people diagnosed with different types of bipolar disorder may experience similar symptoms, symptom severity and how long symptoms last will determine someone’s specific diagnosis.

Bipolar I disorder

Usually considered the classic form of bipolar disorder, bipolar I generally involves at least one manic episode. Mania generally refers to a period of at least a week "in which a person experiences a change in normal behavior that drastically affects their functioning." 

Symptoms of mania typically include talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, anxiousness, and psychomotor agitation. Mania may also be accompanied by a euphoric or expansive mood, mood impulsivity, irritability, and a sense of grandiosity. 

It can also be possible to have mixed features of depression and mania at the same time. When a person experiences four or more episodes of depression or mania in one year, this is normally referred to as rapid cycling. 

Bipolar II disorder

With bipolar II, a person has generally had at least one hypomanic episode and a period of depression, but not a manic episode. Hypomania may be seen as a milder form of mania in which delusions and hallucinations are not present. The American Psychological Association (APA) defines it as "a state of enhanced mood and increased energy and activity that resembles mania but is milder."

Another distinguishing characteristic between mania and hypomania may be the duration of episodes. Whereas manic episodes tend to last at least a week, hypomanic episodes usually last for a minimum of four consecutive days.

Cyclothymic disorder

Cyclothymic disorder can be defined as a mood disorder involving periods of depressive and hypomanic symptoms that occur over a period of at least two years. Considered a milder form of bipolar disorder, it does not meet the full criteria for a major depressive episode or hypomanic episode. 

A person with cyclothymic disorder may experience fluctuations of hypomania and a milder form of depression. 

Mixed features

Mixed features can refer to experiencing depressive and manic symptoms at the same time. Findings indicate that people with manic/hypomanic or depressive episodes with mixed features may have a more severe form of bipolar disorder. Mixed features may also correlate with a higher rate of coexisting mental health disorders. 

Manic symptoms and psychosis 

According to an article in the World Journal of Psychiatry, ''lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment." However, some studies indicate that psychotic symptoms don’t necessarily have a negative impact on bipolar disorder. 

When connected to bipolar disorder, psychosis can also be associated with hallucinations, delusions, or both, and these symptoms tend to be more frequent during manic episodes. 

Similarities between bipolar disorder and schizophrenia

The similarities of the psychotic features associated with bipolar disorder and schizophrenia have led researchers to speculate that bipolar disorder may "lie in an intermediate position between psychotic and non-psychotic disorders," along "a continuum of psychosis stretching from major depressive disorders with psychosis to psychotic BD and schizophrenia." 

Some forms of bipolar disorder, such as mood-incongruent psychotic bipolar disorder, which can be considered a severe form of the disorder, are thought to overlap with schizophrenia. Bipolar disorder may also be classified as falling between unipolar depression and schizophrenia. 

Psychotic symptoms can influence the way bipolar disorder is diagnosed and treated, sometimes leading to a misdiagnosis of schizophrenia.

Treating bipolar disorder 

A person with bipolar disorder may require treatment throughout their life to relieve symptoms and improve overall function. Early diagnosis tends to be associated with a better prognosis. However, many people experience a delay in appropriate treatment following an initial depressive episode. 

Treatment may include the use of mood stabilizers and antipsychotic medication, which must be prescribed and closely monitored by a doctor or psychiatrist.

As stress can be a major trigger for episodes of depression and mania, it can also be important to seek psychotherapy. The National Alliance on Mental Illness (NAMI) generally suggests that those with bipolar disorder should engage in medication management with a psychiatrist, as well as weekly or biweekly therapy sessions. 

Therapy can help individuals manage symptoms and cope with stress. Therapeutic modalities that may be especially helpful for individuals with bipolar disorder can include interpersonal and social rhythm therapy, family-focused therapy, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and group psychoeducation. 

Seeking mental health support for bipolar disorder

Therapy can be invaluable when you're struggling to balance your emotions and keep symptoms of mania and depression at bay. A therapist can also introduce helpful ways to manage stress, such as mindfulness meditation. Online therapy through platforms like BetterHelp can be convenient for many people who prefer to speak to a therapist by phone, video, or online chat. 

According to a 2021 randomized comparative effectiveness trial, online and in-person therapy appear to produce the same results when used to treat individuals with bipolar disorder. While in-person care may be necessary for acute psychotic symptoms, online therapy may be a helpful form of treatment outside of psychotic episodes.