Bipolar 1 Disorder with Mood-Congruent Psychosis: What you Should Know

Bipolar 1 disorder, (formerly manic-depressive disorder), is a mental illness where a person experiences drastic shifts in their mood, energy, ability to concentrate, activity levels, and the ability to carry out normal daily tasks.

What is Bipolar 1 Disorder according to the DSM-5-TR?

Bipolar 1 Disorder, according to the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), is a mental health condition characterized by at least one manic episode that lasts for at least one week, most of the day, nearly every day.
The DSM-5-TR criteria for Bipolar 1 Disorder include:

Manic Episode:

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least one week (or any duration if hospitalization is necessary).

During the mood disturbance, three or more (or four if the mood is only irritable) of the following symptoms must be present and represent a noticeable change from usual behavior:

Inflated self-esteem or grandiosity
Decreased need for sleep (e.g., feeling rested after only 3 hours of sleep)
More talkative than usual or feeling pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility (i.e., attention is too easily drawn to unimportant or irrelevant external stimuli)
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)
Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments)

Functional Impairment or Necessity of Hospitalization:

The mood disturbance is severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Not Attributable to a Substance or Medical Condition:

The episode is not due to the effects of a substance (e.g., drug of abuse, medication) or another medical condition.

Other Episodes (Hypomanic and Major Depressive):

While a manic episode is required for Bipolar I diagnosis, hypomanic and major depressive episodes may occur but are not required. If they do occur, they follow these criteria:

Hypomanic Episode (Not required for Bipolar I, but may occur):

Similar symptoms as mania, but less severe.
Lasts at least 4 consecutive days.
No marked impairment in social or occupational functioning, and hospitalization is not required.

Major Depressive Episode (Not required for Bipolar I, but may occur):

Five or more of the following symptoms over a 2-week period, representing a change from previous functioning, with at least one of the symptoms being depressed mood or loss of interest/pleasure:

Depressed mood most of the day
Markedly diminished interest or pleasure in all or almost all activities
Significant weight loss or gain, or decrease or increase in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, suicidal ideation, or a suicide attempt

Specifiers:

The DSM-5-TR also includes various specifiers to better define the episodes:

With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern

The diagnosis of Bipolar I Disorder hinges primarily on the manic episode, distinguishing it from Bipolar II Disorder, which requires a history of hypomanic and major depressive episodes, but not full-blown mania.

What are the Risk Factors for Bipolar 1?

Bipolar I Disorder is a complex mental health condition with various contributing factors. While the exact cause remains unknown, a combination of genetic, biological, environmental, and psychological factors appears to increase the risk of developing the disorder. Here are the main risk factors:

1. Genetic Factors

Family history of bipolar disorder: Having a parent or sibling with bipolar disorder significantly increases the risk. Studies indicate that genetics play a major role, with first-degree relatives having a higher likelihood of developing the disorder.
Twin studies: Research shows that identical twins have a higher concordance rate for bipolar disorder than fraternal twins, further suggesting a strong genetic influence.

2. Biological Factors

Neurochemical imbalances: Abnormalities in neurotransmitters like dopamine, serotonin, and norepinephrine are often linked to mood regulation issues in people with bipolar disorder.
Brain structure and function: Brain imaging studies suggest that individuals with bipolar disorder may have differences in the prefrontal cortex, hippocampus, and amygdala, which are involved in mood regulation and decision-making.
Circadian rhythm disturbances: Disruptions in the body’s natural sleep-wake cycles (circadian rhythms) have been implicated as potential contributors to mood episodes.

3. Environmental Factors

Stressful life events: Major life changes or traumatic experiences, such as the death of a loved one, divorce, financial troubles, or job loss, can trigger or exacerbate manic or depressive episodes in susceptible individuals.
Childhood trauma or abuse: Early exposure to traumatic events, including physical, emotional, or sexual abuse, can increase the risk of developing bipolar disorder later in life.
Substance abuse: Use of alcohol, drugs, or other substances may worsen or trigger mood episodes and has been associated with an increased risk of bipolar disorder onset.

4. Psychological and Cognitive Factors

Cognitive distortions: People who have maladaptive thinking patterns, such as extreme self-criticism or excessive rumination, may be at greater risk of developing mood disorders, including bipolar disorder.
Personality traits: Certain traits, like impulsivity or emotional instability, may increase vulnerability to manic or depressive episodes.

5. Age of Onset

Adolescence and early adulthood: Bipolar I Disorder often emerges in late adolescence or early adulthood (usually between the ages of 18 and 30), although it can develop later in life. Early onset is associated with more severe episodes and increased comorbidities.

6. Comorbid Mental Health Disorders

Other mental health conditions: Having a history of conditions such as anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), or substance use disorders can increase the risk of developing bipolar I disorder or make it more challenging to manage.

7. Gender

Men vs. women: While the prevalence of Bipolar I Disorder is roughly equal between men and women, men are more likely to experience manic episodes as the initial presentation, while women are more prone to rapid cycling and depressive episodes.

8. Socioeconomic Factors

Lower socioeconomic status: Some studies have suggested that individuals from lower socioeconomic backgrounds may face an increased risk of developing bipolar disorder due to factors like increased stress, lack of access to mental health care, and unstable living environments.

9. Peripartum Factors (for Women)

Postpartum period: The risk of bipolar episodes, particularly mania or psychosis, is heightened in women during the postpartum period due to hormonal fluctuations and stressors associated with childbirth.

The development of Bipolar I Disorder is multifactorial, involving a complex interplay between genetic predispositions, biological abnormalities, environmental stressors, and psychological vulnerabilities. While none of these factors alone guarantees the development of the disorder, they can significantly increase the risk, especially when combined.

What is Bipolar 1 With Mood-Congruent Psychosis?

Bipolar I Disorder with mood-congruent psychotic features refers to a subtype of Bipolar I Disorder in which the individual experiences psychotic symptoms (such as delusions or hallucinations) that are consistent with the dominant mood episode, either mania or depression. The psychotic features align with the emotional tone of the mood episode, reinforcing the overall mood state.

Key Aspects of Bipolar I Disorder with Mood-Congruent Psychotic Features:

Manic or Depressive Episode: The individual is experiencing either a manic or depressive episode, which forms the basis of Bipolar I Disorder.

Manic episode: A period of abnormally elevated, expansive, or irritable mood, along with increased energy or activity.
Depressive episode: A period of significant sadness, hopelessness, or loss of interest, along with other symptoms of major depression.

Psychotic Features: During the mood episode, the person also exhibits psychotic symptoms, which may include:

Delusions: Strongly held false beliefs that are not based in reality.
Hallucinations: Sensory experiences, such as hearing voices or seeing things that aren’t there.

Mood-Congruent Nature of Psychosis:

In a manic episode, the psychotic features are consistent with the elevated mood. For example:

Delusions of grandiosity (believing one has special powers, influence, or abilities).
Hallucinations that reinforce a sense of invincibility or inflated self-importance.

In a depressive episode, the psychotic features are aligned with the depressive mood. For example:

Delusions of guilt or worthlessness (believing one is responsible for terrible things or is irredeemably flawed).
Hallucinations that emphasize themes of sadness, failure, or doom.

Examples of Mood-Congruent Psychotic Features:

Mania:

A person may believe they are a famous figure with great power, or that they have a special mission to save the world (grandiose delusions).
Hearing voices that praise or affirm their greatness.

Depression:

A person may believe they are being punished for past mistakes or that they are worthless (delusions of guilt or inadequacy).
Hearing voices that tell them they are a failure or that they deserve to suffer.

Distinction from Mood-Incongruent Psychotic Features:

Mood-incongruent psychotic features occur when the psychotic symptoms are not consistent with the mood episode.

For example, in a manic episode, a person may experience paranoia or delusions of persecution (believing they are being watched or plotted against), which does not align with the typically euphoric or grandiose nature of mania.

Diagnosis and Treatment:

A diagnosis of Bipolar I Disorder with mood-congruent psychotic features is made when these psychotic symptoms occur during manic or depressive episodes, and they reflect the emotional tone of that episode.
Treatment usually includes mood stabilizers (such as lithium or anticonvulsants) or antipsychotic medications (such as Quetiapine), and these medications may be used as monotherapy or in combination with another medication. Antidepressants may be used during depressive episodes and less commonly as monotherapy treatment. Psychotherapy and lifestyle interventions are also important in managing the disorder long-term.

Bipolar I Disorder with mood-congruent psychotic features involves psychosis that is directly aligned with the mood episode, either reinforcing the grandiosity and euphoria of mania or the guilt and worthlessness of depression.

Kasee Wiesen, DNP, APRN, FNP-C, is a Family Nurse Practitioner who owns her freelance writing business. She has a great passion for bedside and classroom education and has been a nurse educator for over ten years.

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