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Does Bipolar 1 cause delusions?

Bipolar disorder is a mental health condition characterized by extreme shifts in mood and energy levels. The two main types are bipolar 1 and bipolar 2. Bipolar 1 is distinguished by the presence of manic episodes, while bipolar 2 only has hypomanic episodes. Both types involve depressive episodes.

One of the key symptoms of mania in bipolar 1 is delusions. Delusions are fixed false beliefs that are firmly held even when there is evidence to the contrary. People experiencing delusions often have little to no insight that their beliefs are unrealistic. Delusions are considered “positive symptoms” of mania, as they represent an excess or distortion of normal thinking.

So in summary, yes – the manic episodes of bipolar 1 can and often do cause delusional thinking. Below we will explore this connection in more detail, looking at:

  • The definition and main symptoms of bipolar 1 disorder
  • What delusions are and the types of delusions seen in bipolar 1
  • The underlying causes and mechanisms that lead to delusions
  • Treatments that can help reduce delusional thinking
  • Coping strategies for dealing with delusions

Bipolar 1 Disorder

Bipolar 1 disorder is a mental health condition characterized by extreme mood episodes ranging from mania to depression. According to the DSM-5 diagnostic criteria, a diagnosis of bipolar 1 requires:

  • At least one manic episode lasting 7 days or longer (or any duration if hospitalization is required). Symptoms include elevated mood, increased energy, reduced need for sleep, rapid speech, racing thoughts, impulsiveness, and loss of touch with reality.
  • One or more major depressive episodes lasting 2 weeks or more. Symptoms include depressed mood, loss of interest/pleasure, changes in appetite and sleep, fatigue, feelings of worthlessness, difficulty concentrating, and suicidal ideation.
  • The mood episodes cause significant distress or impairment in daily functioning.
  • The episodes are not better explained by another health condition or medication side effects.

Bipolar 1 is considered the classic, severe form of bipolar disorder. Around 1% of the population suffers from bipolar 1 at some point in life. Symptoms often start emerging in the late teens and early 20s.

The manic episodes represent the “up” phase of the disorder. Mania symptoms can range from euphoria and boundless energy at the milder end, to full-blown psychosis and detachment from reality at the most severe.

Main Symptoms of Mania

  • Elevated, expansive mood
  • Irritability
  • Decreased need for sleep
  • Racing thoughts
  • Fast, pressured speech
  • Impulsiveness
  • Risk-taking behaviors
  • Increased activity and energy
  • Poor concentration and distractibility
  • Loss of touch with reality/psychosis

The depressive episodes represent the “down” phase. Symptoms are typical of major depression and can include:

  • Depressed mood
  • Loss of interest and pleasure
  • Significant weight loss or gain
  • Sleep disturbances
  • Fatigue
  • Feelings of worthlessness and guilt
  • Difficulty concentrating and making decisions
  • Suicidal thoughts

Delusions in Bipolar 1

A delusion is defined as a fixed, false belief that is firmly held even when there is strong contradictory evidence. Delusions represent a loss of contact with consensual reality.

Delusions are considered a “positive symptom” of bipolar 1 mania, meaning they represent an excess or distortion of normal thoughts and behaviors. Up to 60% of people experience delusions during a manic episode.

Types of Delusions

Some of the most common delusional themes in bipolar 1 mania include:

  • Grandiose delusions – Belief that one has special powers, talents, or religious connections. For example, the person may believe they are Jesus Christ, or have a special message from God.
  • Persecutory delusions – Belief that one is being threatened, conspired against, spied on, or subject to negative intentions by an individual, organization, or hostile force. It may involve beliefs of persecution by the government, police, or other authority figures.
  • Referential delusions – Belief that certain gestures, comments, passages from books, newspapers, song lyrics, and other environmental clues are specifically directed at them.
  • Somatic delusions – False belief about bodily functions or sensations. For example, the person may believe something is terribly wrong with their internal organs, that there are bugs crawling under their skin, or that they don’t need food or water.
  • Delusions of thought insertion/withdrawal/broadcasting – Belief that thoughts are being inserted, withdrawn, or broadcasted from their mind by some external force or entity.
  • Erotomanic delusions – False belief that someone (often someone famous) is in love with them.
  • Nihilistic delusions – Belief that a major catastrophe will occur, such as the end of the world.

Delusions tend to be mood-congruent, meaning their themes match the person’s mood state. Manic delusions often have grandiose, expansive, or optimistic content while delusions experienced during bipolar depression are often persecutory, nihilistic, or paranoid.

Causes and Mechanisms

Researchers have identified a number of factors that contribute to the development of delusions in bipolar 1:


Bipolar disorder has a strong genetic component, suggesting that inherited biological factors make an individual vulnerable. Studies have found that delusional symptoms are more common in relatives of bipolar patients with a history of delusions, indicating a heritable basis.

Neurotransmitter Imbalances

Mania and psychosis are thought to stem from excessive dopamine activity and glutamate excitotoxicity in limbic brain regions implicated in emotion regulation and motivation. Antipsychotic medications, which block dopamine D2 receptors, are effective at reducing manic and delusional symptoms.

Circadian Rhythm Disturbances

Disruptions in circadian rhythms and sleep-wake cycles can trigger switching between mood states. Sleep deprivation is known to heighten manic symptoms. Fixing sleep disturbances can help stabilize mood.

Stress and Trauma

Highly stressful life events, childhood adversity and trauma appear to trigger onset and recurrences of bipolar episodes and psychotic symptoms in genetically vulnerable individuals. Stress may impact brain pathways regulating emotional responses.

Cognitive Distortions

Cognitive and information-processing biases such as “jumping to conclusions”, externalizing attributional style, and theory of mind deficits may contribute to irrational belief formation and maintenance.


Kindling refers to the sensitization of neurons and circuits after repeated manic episodes. Over time, progressively less stress is required to precipitate shifts into mania and Mixed Episodes. This may result in more prominent mood instability and psychotic features.

Treatments for Delusions

While delusions can feel intensely real when experienced, a number of medical and therapeutic treatments are available to help eliminate or reduce these distorted beliefs:


  • Antipsychotics like olanzapine, risperidone, aripiprazole are first-line. They work by blocking dopamine activity.
  • Lithium has robust evidence for preventing manic relapses and treating acute mania. It impacts multiple neurotransmitters.
  • Anticonvulsant mood stabilizers like valproate, carbamazepine, and lamotrigine are also commonly prescribed as maintenance treatment.
  • Antidepressant and benzodiazepine medications may be used short-term but can also provoke manic switches.

Of these options, antipsychotics tend to be the most directly effective for quickly resolving bipolar delusions during acute manic episodes. The goal is to find the most efficacious medication with minimal side effects.


Talk therapy approaches aimed at correcting faulty thinking patterns and developing coping strategies include:

  • Cognitive behavioral therapy
  • Psychoeducation
  • Family-focused therapy
  • Interpersonal and social rhythm therapy

These modalities can complement medication in helping to prevent relapse of mood episodes and rehospitalization. Therapy provides support, promotes treatment adherence, and improves functioning during periods of remission.

Brain Stimulation Treatments

  • Electroconvulsive therapy (ECT) – for severe mania unresponsive to drugs, ECT can provide rapid resolution of symptoms.
  • Repetitive transcranial magnetic stimulation (rTMS) – experimental, targets underactive brain regions.


During periods of severe mania with active delusions or hallucinations, inpatient psychiatric hospitalization may be required to ensure safety, stabilize medication regimen, and monitor progress.

Coping with Delusions

Living with delusional thinking can be extremely distressing. Supportive psychotherapy can help patients develop practical coping techniques:

  • Maintain healthy sleep, exercise, and stress management routines to help regulate mood.
  • Surround yourself with supportive friends and family who understand your experience.
  • Limit excessive sensory stimulation that may worsen confusion.
  • Carry an emotional first aid kit – items that comfort you and remind you of reality.
  • Write down your beliefs to evaluate them more objectively.
  • Check in with your doctor regularly and take medications as prescribed.
  • Join a support group to share stories and know you’re not alone.
  • If thoughts spiral out of control, use grounding techniques – focus on your senses, breathe deeply.
  • Be compassionate with yourself – healing and recovery take time.

With proper long-term treatment and self-care, many people with bipolar 1 can gain control over their delusional thoughts and live balanced, fulfilling lives.


In summary, bipolar 1 disorder substantially increases the risk of delusional thinking due to the biological effects of manic episodes and their detachment from reality. Delusions represent a core symptom of full-blown mania. While delusions feel convincingly real, a range of modern medicines and therapies can help eliminate or manage them effectively. With concerted effort, even those with frequent delusional symptoms can regain stability and experience extended symptom-free periods. Consistent treatment is key for keeping bipolar 1 under control and reducing the impact of delusions over the long-term.