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Key points
- Bipolar manic psychosis usually causes an individual to be unaware of the pathological aspects of their thoughts and behaviors
- When the manic psychotic individual is not receptive to treatment, involuntary hospitalization is often a necessary intervention.
In bipolar I disorder, the onset of a manic, psychotic episode often represents the most destabilizing aspect of the illness. Judging from my clinical observations, mania alone, without psychosis, involves symptoms such as unusually strong energy, decreased need for sleep, racing thoughts, rapid speech, impulsivity, impaired judgment, hypersexuality, cognitive disorganization, and significant decline in self-care. When combinations of these symptoms become accompanied by delusional thinking (grandiosity, paranoia, and more), hallucinations, and distorted perceptions of reality, then the manic psychotic symptom mix results in significant functional impairment, usually eventuating in psychiatric hospitalization.
Bipolar I disorder is also viewed as separate from bipolar II in that bipolar II involves episodes of depression and hypomania (less acute than mania), but the elevated mood states do not progress into mania and or psychosis. If they did, even if occurring rarely, the diagnosis would be bipolar I.
This post and its follow-up, Part II, will address the situations of those with bipolar I who are then faced with significant derailment or decompensation as a result of manic, psychotic relapse. Such individuals are prone to living a Dr. Jekyll and Mr. Hyde-type existence and the challenges of integrating their experience of sanity with their opposing experience of psychosis are immense.
During the progression of a manic episode, there often comes a point where individuals become swept up in their mood intensity and lose awareness that they’ve become manic. Once delusional psychosis becomes the lens through which individuals are interpreting reality, rational connection to reality unravels while they perceive their own behavior as appropriate. They don’t perceive anything as wrong.
Anyone who encounters someone in a manic, psychotic state usually recognizes that the individual is impaired, particularly if they have known that same person during periods when they’ve been asymptomatic. However, if they don’t know the individual well, they probably won’t understand why the individual is acting as they are. High energy, grandiosity, paranoia, agitation impaired judgment, impulsivity, and disorganized behavior don’t remain under the societal radar. Most who have not been exposed to it perceive psychotic behavior as abnormal and frightening.
The tragedy of this situation is that the manic, psychotic individual is often wreaking havoc in their life, though certainly not in an intentional way. They usually cannot remain functional at work. Continued successful academic progression isn’t viable. Relationships are negatively impacted as people feel frightened or offended by the manic psychotic behavior. Spouses, partners, close friends, and family members are highly concerned about the individual’s well-being. But if the individual has not yet reached the threshold of involuntary hospitalization (typically reflecting danger to self or others), then state laws usually don’t support psychiatric hospitalization.
During consults for this kind of situation, people often inquire: What can we do to get our loved one help? How do we protect him or her from the consequences of manic mood intensity and impaired reality testing? The obvious answer is that one tries to communicate and point out the range of behaviors that are indicative of the manic episode as well as the negative consequences that are occurring. The individual who is manic needs to hear the non-judgmental concerns of others as well as their willingness to assist the individual in getting professional help.
But the highly unfortunate reality is: If that individual disagrees and is not receptive to the help being offered, then there’s usually not much that can be done to intervene until such time as involuntary hospitalization becomes an appropriate option.
It’s also not uncommon when people are reticent to initiate involuntary hospitalization on a close friend, spouse, or family member as they don’t want the manic individual to harbor resentment towards them. After all, being transported by police to a short-term locked psychiatric facility most often feels like an assault on one’s dignity.
That said, a point is reached in the progression of a manic psychotic episode where an individual’s perception of reality and accompanying judgment are truly impaired and the capacity to be aware of their dysfunction is no longer intact. Once that threshold has been reached, particularly where there are elements of danger to self or others or the incapacity to meet basic needs for health and safety, then mental health clinicians or loved ones in close contact with the individual need to take action to protect the manic psychotic individual from themselves.
Typically, state laws and regulations determine the threshold for the initiation of legal processes required for involuntary hospitalization. The threshold entails evidence of danger to self or others and or the incapacity to take care of oneself. Guidance about initiating involuntary hospitalization can usually be obtained by entering “involuntary psychiatric commitment” and the name of your state and county into an internet search browser.
Mental health clinicians are well-informed about these processes. If a mental health clinician is not currently involved with the manic individual, there is information about involuntary hospitalization available online. Embedded links to documents from Virginia NAMI as well as one from Fairfax Virginia Community Services Board are good examples of available guidance and regulations in each state.
Once hospitalized and treated with mood stabilizers and or antipsychotic medication, resolution of the manic episode is usually achieved. And while the entire process is essential to helping the individual restabilize, it’s also just the beginning of the important work that follows, which entails rebuilding the individual’s healthy and meaningful connection to life.
This discussion will be continued in Part II of this series, which will provide a case study of an individual with relapsing bipolar manic psychosis and the challenges faced in the aftermath of a recent psychiatric hospitalization.
