Lesson 2 - Understanding Psychosis and Bipolar Disorder
1. Introduction
Psychosis and bipolar disorder are serious mental health conditions that case workers are likely to encounter across community, inpatient, crisis and social care settings. They can significantly affect a person's thinking, perception, mood, behaviour, relationships and ability to manage everyday life. At times, they may also be associated with significant risks to the individual or to others.
For a case worker, the aim is not to diagnose psychosis or bipolar disorder. Diagnosis requires a comprehensive clinical assessment and should be undertaken by an appropriately qualified clinician. The case worker does, however, have an important role in recognising changes in mental state, understanding what the person may be experiencing, identifying deterioration and ensuring that concerns are escalated appropriately.
This is particularly important because the early stages of psychosis or mania may not initially look like obvious mental illness. A person might become increasingly withdrawn, suspicious, irritable, unusually energetic, preoccupied with unusual ideas or significantly different from their usual self. Family members may notice the change before professionals do. A skilled case worker learns to notice these patterns without immediately jumping to diagnostic conclusions.
The case worker also has an important role after diagnosis. Recovery from psychosis and bipolar disorder involves much more than medication. Housing, relationships, employment, physical health, substance use, social isolation, finances and meaningful activity can all influence recovery. Case workers are therefore often ideally placed to understand how a person's mental health difficulties are affecting their everyday life and to support the wider recovery process.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Describe the main features of psychosis and bipolar disorder.
Recognise hallucinations, delusions, thought disorder and negative symptoms.
Distinguish broadly between mania, hypomania and depression.
Recognise changes that may indicate deterioration or relapse.
Communicate appropriately with someone experiencing psychotic or manic symptoms.
Identify situations requiring urgent escalation to senior clinicians or emergency services.
3. The Lecture
What Do We Mean by Psychosis?
Psychosis describes a state in which a person's perception or interpretation of reality becomes significantly altered. It is not a single diagnosis. Psychotic symptoms can occur in several different psychiatric disorders and can occasionally arise because of physical illness, medication or substance use.
The symptoms most commonly associated with psychosis include hallucinations, delusions and disorganised thinking. Some people also develop what are known as negative symptoms, where aspects of normal emotional expression, motivation and social functioning become reduced.
It is important to remember that psychosis exists on a spectrum. A person experiencing psychosis does not necessarily appear obviously unwell. They may speak normally for much of a conversation and only disclose unusual beliefs when discussing a particular subject. Other people may become profoundly distressed, confused or behaviourally disturbed.
A useful way of thinking about psychosis is:
Altered perception → altered interpretation → altered behaviour
For example, imagine that someone repeatedly hears a voice telling them that their neighbour is watching them. They may gradually become convinced that the neighbour is monitoring them. They might then cover their windows, stop leaving the house or confront the neighbour.
The behaviour may appear irrational when viewed in isolation. Once we understand the person's experience, the behaviour becomes much more understandable.
This is an important principle throughout mental health practice:
Before asking why someone is behaving unusually, ask what they might be experiencing.
Hallucinations
A hallucination is a sensory experience occurring without an external stimulus that other people can perceive.
Hallucinations can occur through any sensory modality.
TypeExampleAuditoryHearing voices when nobody is speakingVisualSeeing people, figures or objects that are not presentTactileFeeling something touching or crawling on the skinOlfactorySmelling something that others cannot smellGustatoryExperiencing unusual tastes without an obvious cause
Auditory hallucinations are particularly associated with psychotic disorders. A person might hear a single voice, several voices or voices commenting on what they are doing. Voices may be neutral, supportive, threatening or commanding.
The presence of voices alone does not tell us how much risk is present. What matters is what the voices are saying, how the person interprets them and whether they feel compelled to act upon them.
For example, someone occasionally hearing their name being called and recognising that this is probably part of their illness presents a very different situation from someone hearing a voice repeatedly instructing them to kill themselves and believing that they must obey it.
Case workers should therefore avoid reducing assessment to the question:
"Are you hearing voices?"
More useful questions include what the person hears, how frequently it happens, how distressing it is, whether the voices give instructions and how much control the person feels they have over their response.
Delusions
A delusion is a strongly held belief that is inconsistent with reality and is maintained despite evidence to the contrary. Delusions often feel completely real to the person experiencing them.
Common forms include persecutory beliefs, grandiose beliefs and beliefs involving reference or control.
A person with persecutory beliefs might become convinced that other people are following them or trying to harm them. Someone experiencing grandiose beliefs might believe that they possess extraordinary abilities or have a unique religious or political role. A person experiencing ideas of reference may believe that television programmes, social media posts or conversations between strangers contain messages specifically intended for them.
The important point for case workers is that arguing about the belief is rarely helpful.
Imagine someone tells you:
"The people living next door have installed cameras because they are working for the government."
Responding with:
"That's ridiculous. There aren't any cameras."
is unlikely to help. The person may feel dismissed and become less willing to communicate.
Equally, agreeing with the belief is inappropriate:
"Yes, they probably are watching you."
This risks reinforcing the delusion.
A more useful response might be:
"That sounds frightening. I can see that you feel very unsafe at the moment."
This acknowledges the person's emotional experience without confirming the belief.
Thought Disorder
Psychosis can also affect the organisation of thinking.
Speech may become difficult to follow because thoughts move between subjects in unusual ways. In more severe cases, sentences may become fragmented or appear to have little connection with one another.
The person is not deliberately being difficult. Their ability to organise and communicate thoughts may itself be affected by the illness.
Case workers may notice that conversations become increasingly difficult to follow or that the person repeatedly moves between apparently unrelated ideas.
A change from someone's normal communication style is particularly important.
Someone who has always communicated in an unusual or highly detailed way is different from someone whose previously organised speech has suddenly become confused or disjointed.
Negative Symptoms
Psychosis is often associated in the public imagination with dramatic symptoms such as hallucinations and delusions. In practice, negative symptoms can be equally disabling.
These may include reduced motivation, reduced emotional expression, social withdrawal, reduced speech and loss of interest in previously meaningful activities.
A person experiencing these symptoms may spend much of the day in bed, stop seeing friends, neglect household tasks and struggle to initiate even simple activities.
These behaviours can sometimes be misinterpreted as laziness or lack of cooperation.
The distinction matters.
If someone repeatedly fails to complete agreed tasks, the question should not immediately be:
"Why aren't they trying?"
It may be more useful to ask:
"What is preventing them from being able to do this?"
Depression, negative symptoms, medication side effects, cognitive difficulties, anxiety and environmental factors can all contribute.
Psychosis Is Not a Diagnosis
One of the most important concepts in this lesson is that psychosis describes a group of symptoms rather than one particular disorder.
Psychotic symptoms may occur in:
schizophrenia
schizoaffective disorder
bipolar disorder
severe depression
substance-induced states
medication-related states
delirium
neurological disorders
some other physical illnesses.
This is why case workers should avoid assuming that someone who hears voices has schizophrenia.
The context matters.
A 24-year-old who has gradually become socially withdrawn and suspicious over six months presents differently from an 80-year-old who suddenly becomes confused and reports seeing people in the room during a urinary infection.
Both may describe unusual perceptions. The underlying clinical situations are very different.
Understanding Bipolar Disorder
Bipolar disorder is characterised by episodes of significant mood disturbance. These usually involve periods of depression and periods of elevated or irritable mood known as mania or hypomania.
People sometimes misunderstand bipolar disorder as simply having frequent mood swings. Everyone experiences changes in mood. Bipolar disorder involves much more substantial changes in mood, energy, activity, thinking and behaviour.
The changes typically occur over a sustained period and represent a significant departure from the person's usual functioning.
A simplified representation is:
Depression ← Usual mood → Hypomania → Mania
People do not necessarily move through these stages in sequence. The diagram simply illustrates the broad range of mood states that can occur.
Mania
Mania is a period of abnormally elevated, expansive or irritable mood accompanied by increased energy and activity.
A person experiencing mania may sleep very little without feeling tired. Their speech may become rapid. Thoughts may move quickly from one subject to another. They may become extremely confident and develop ambitious plans that would normally be unrealistic.
Judgement can deteriorate considerably.
Someone who is usually financially cautious might suddenly spend thousands of pounds, start several businesses, give money away or make major purchases they cannot afford.
Another person may become sexually disinhibited, unusually confrontational or impulsively travel long distances.
The key is change from baseline.
Being energetic, talkative or confident does not mean that someone is manic. What matters is whether there has been a significant and sustained change from their usual functioning.
Sleep as an Important Warning Sign
Reduced need for sleep is particularly important in mania.
This is different from insomnia.
Someone with insomnia may sleep for three hours and feel exhausted the next day. Someone becoming manic may sleep for three hours and report feeling completely refreshed, energetic and ready to begin multiple new projects.
Sleep disturbance can also precede relapse.
A person's usual pattern might be:
Normal sleep → increasingly reduced sleep → increased energy → increased activity → escalating mania
For this reason, changes in sleep can be extremely useful when monitoring someone with established bipolar disorder.
Families and case workers may notice this before more obvious symptoms develop.
Hypomania
Hypomania shares many characteristics with mania but is less severe.
The person may become more energetic, sociable, productive, confident and talkative. They may need less sleep and take on additional activities.
At first, this can feel positive.
Some people describe hypomania as a period when they feel particularly productive or creative. This can make early intervention difficult because the person may not perceive anything as being wrong.
The concern is that judgement may still become impaired and hypomania can sometimes progress into mania.
Case workers should therefore pay attention to the trajectory rather than simply whether the person's current behaviour appears dangerous.
Mania and Psychosis
Severe mania can include psychotic symptoms.
For example, someone experiencing mania might become convinced that they have been selected by the government to solve an international crisis. Another person might believe that they possess extraordinary religious powers.
These beliefs often correspond with the person's elevated mood.
When psychosis occurs alongside severe mood disturbance, specialist psychiatric assessment is required.
Bipolar Depression
Depressive episodes in bipolar disorder can resemble depression occurring outside bipolar disorder.
The person may experience persistent low mood, reduced enjoyment, fatigue, hopelessness, reduced concentration, sleep disturbance and changes in appetite.
Suicidal thoughts can occur and require careful assessment.
One practical difficulty is that professionals may meet someone during a depressive episode without knowing that they have previously experienced periods of hypomania or mania.
This illustrates why understanding someone's history is so important in mental health work.
Mixed Presentations
Not every episode fits neatly into the categories of "high" or "low".
Some people experience symptoms of mania and depression at the same time. They might feel intensely agitated and energetic while also feeling hopeless or suicidal.
These presentations can be particularly concerning because increased energy may coexist with severe emotional distress.
A person who appears energetic should therefore not automatically be assumed to be well.
Recognising Deterioration
Case workers often know individuals over long periods. This means they can notice subtle changes that might not be obvious during a brief clinical appointment.
Potential warning signs include:
AreaPossible ChangeSleepSleeping much less or becoming awake throughout the nightSpeechBecoming unusually rapid, pressured or difficult to followActivitySudden increase or reduction in activitySocial behaviourWithdrawal or unusually intense social contactBeliefsIncreasing suspiciousness or unusual ideasSelf-careDeterioration in hygiene, eating or household managementMedicationStopping medication or becoming reluctant to take itFinancesUncharacteristic spending or giving money awaySubstance useIncreased alcohol or drug useRiskIncreasing aggression, vulnerability or suicidal thinking
No single sign necessarily indicates relapse.
Patterns are more informative.
For example:
Sleeping less + increasingly rapid speech + impulsive spending + grandiose plans
is much more concerning than any one of those features in isolation.
The Importance of Baseline
A central principle in mental health work is:
Know the person's baseline.
One person may naturally sleep for five hours, speak rapidly and run several businesses. For them, these behaviours may be entirely normal.
Another person may normally sleep for eight hours, speak quietly and be financially cautious. If they suddenly begin sleeping for two hours, speaking continuously and spending thousands of pounds, the change is clinically significant.
This is why information from family members, carers and professionals who know the individual well can be extremely valuable.
Communicating With Someone Experiencing Psychosis
Communication should remain calm, respectful and straightforward.
Avoid confronting unusual beliefs aggressively. At the same time, do not pretend to share beliefs that you do not share.
It is usually possible to validate the person's emotional experience without validating the belief itself.
If someone says:
"There are people outside waiting to kill me."
You do not need to say either:
"Yes, there are."
or:
"That's nonsense."
You might instead say:
"It sounds as though you're feeling extremely frightened and unsafe. I'd like us to think about what we can do to help you feel safer."
This maintains trust while allowing appropriate assessment and escalation.
Communicating With Someone Who Is Manic
Communication during mania may present different challenges.
The person may speak rapidly, interrupt frequently or move quickly between subjects. They may become frustrated when others attempt to slow them down.
Keep communication clear and relatively brief.
Avoid becoming drawn into lengthy debates about unrealistic plans. Focus on immediate practical concerns such as sleep, safety, medication, finances and contact with the clinical team.
If the person is becoming increasingly agitated, reducing stimulation can also help. Several professionals talking at once, repeated questioning or an argumentative approach may increase distress.
Insight and Engagement
People experiencing psychosis or mania may have limited awareness that they are unwell.
Someone may genuinely believe that nothing is wrong and that professionals are interfering unnecessarily.
This can create difficult situations for case workers.
It is useful to remember that refusal of help does not automatically mean that someone is being deliberately difficult.
Their understanding of the situation may be profoundly different from yours.
Where insight is limited and risk is increasing, the appropriate response is not endless persuasion by the case worker. The situation should be discussed with the clinical team.
Physical Health and Substance Use
Changes in mental state should never automatically be assumed to be psychiatric.
Alcohol, cannabis, stimulants and other substances can contribute to psychotic or mood symptoms. Withdrawal from certain substances can also cause serious mental state changes.
Physical illness may cause confusion, behavioural disturbance or hallucinations, particularly in older people or those who are medically vulnerable.
Sudden onset of confusion, fluctuating consciousness or visual hallucinations should therefore raise the possibility of an acute physical cause.
This is particularly important when the presentation is dramatically different from the person's normal psychiatric symptoms.
Treatment and Recovery
Treatment varies according to the underlying diagnosis and the individual's circumstances.
Psychotic disorders may be treated with antipsychotic medication alongside psychological interventions, social support and rehabilitation.
Bipolar disorder may involve mood-stabilising medication, antipsychotic medication and psychological interventions. Treatment will also commonly include monitoring of sleep, relapse prevention and support with lifestyle and social factors.
The case worker does not need to become an expert in psychopharmacology. Their role is to understand the broad purpose of treatment and recognise concerns such as non-adherence, significant side effects or deterioration despite treatment.
Recovery should also be understood broadly.
For one person, recovery might mean returning to university. For another, it may involve maintaining stable accommodation, rebuilding relationships or being able to manage daily activities independently.
Good case work therefore asks not only:
"Are the symptoms better?"
but also:
"Is this person getting their life back?"
4. Clinical Perspective
Look for Change Rather Than Labels
One of the most useful skills a case worker can develop is recognising when someone is behaving differently from usual.
You may not know whether the person is developing mania, psychosis, depression, substance-related difficulties or another problem.
You do not need to solve the diagnostic puzzle before raising concern.
A statement such as:
"Over the last week he has gone from sleeping eight hours to approximately two hours per night, has become much more talkative and yesterday spent £2,000 unexpectedly"
is far more useful to a senior clinician than:
"I think he is bipolar."
Describe what you have observed.
Ask About Function
Symptoms make more sense when considered alongside their impact.
If someone reports hearing voices, find out whether they can continue working, sleeping and caring for themselves.
If someone appears unusually energetic, consider whether they are still making safe decisions.
Changes in functioning often help indicate severity.
Do Not Argue With Delusions
Trying to prove that someone's delusion is false rarely resolves the situation.
Focus instead on distress, safety and practical needs.
You can say that you do not share the person's interpretation while still acknowledging how real and frightening the experience feels to them.
Do Not Assume Someone Is Safe Because They Appear Cheerful
Mania can involve elevated mood while judgement and risk deteriorate considerably.
Similarly, mixed mood states may involve considerable energy alongside suicidal thinking.
Appearance alone is therefore an unreliable measure of risk.
Take Family Concerns Seriously
Families often recognise relapse before professionals because they know the person's baseline.
A parent saying:
"This is exactly how he was two weeks before his last admission"
is clinically important information.
It does not automatically prove that relapse is occurring but it should not be dismissed simply because the individual appears relatively settled during a brief meeting.
Think About Vulnerability as Well as Risk to Others
A person experiencing mania or psychosis may be vulnerable to exploitation.
They may give away money, invite strangers into their home, enter unsafe relationships, disclose personal information or make impulsive financial decisions.
Risk assessment should therefore include what might happen to the person as well as what the person might do.
Escalate When Appropriate
Case workers should seek urgent senior clinical advice where there is significant concern about deterioration.
Particular concerns include suicidal intent, command hallucinations involving harm, severe self-neglect, rapidly escalating mania, significant aggression, dangerous impulsivity, inability to meet basic needs, severe confusion, substantial vulnerability or rapidly worsening psychotic symptoms.
Immediate emergency assessment may be required where there is an imminent risk of serious harm.
The principle is simple:
If you are worried that waiting could result in serious harm, escalate rather than trying to manage the situation alone.
5. Summary
Psychosis involves significant changes in the way a person perceives or interprets reality. Symptoms may include hallucinations, delusions, disorganised thinking and negative symptoms. Psychosis is not itself a diagnosis and can occur in several psychiatric, substance-related and physical health conditions.
Bipolar disorder involves episodes of significant mood disturbance, including mania or hypomania and usually episodes of depression. Mania can involve reduced need for sleep, increased energy, rapid speech, grandiosity, impulsivity and impaired judgement. Severe mania may also involve psychosis.
Case workers are not expected to diagnose these conditions. Their role is to recognise important changes, understand the person's experience, observe functioning, communicate effectively and escalate concerns.
The most useful question is often not:
"What diagnosis does this person have?"
but:
"What has changed from their normal baseline and what does that change mean for their safety and functioning?"
6. Further Reading
Learners who would like to develop their understanding further should review the relevant National Institute for Health and Care Excellence guidance on psychosis, schizophrenia and bipolar disorder.
Particularly useful areas for further study include the recognition and management of first-episode psychosis, relapse prevention, psychological interventions, family intervention, physical health monitoring and the assessment and treatment of mania and bipolar depression.
Useful resources include:
National Institute for Health and Care Excellence guidance on Psychosis and schizophrenia in adults: prevention and management
National Institute for Health and Care Excellence guidance on Bipolar disorder: assessment and management
National Institute for Health and Care Excellence guidance relating to psychosis and schizophrenia in children and young people
Royal College of Psychiatrists patient and professional information on psychosis, schizophrenia and bipolar disorder
NHS information on psychosis and bipolar disorder
7. Knowledge Check
Question 1
Which of the following best describes psychosis?
A. A diagnosis that always means schizophrenia
B. A state involving significant alteration in perception or interpretation of reality
C. Any period of severe anxiety
D. Rapid changes between feeling happy and sad
Correct answer: B
Psychosis describes a group of symptoms involving altered perception or interpretation of reality. It is not a single diagnosis.
A is incorrect because schizophrenia is one disorder in which psychosis can occur but psychosis also occurs in several other conditions.
C is incorrect because anxiety can be severe without involving psychosis.
D is incorrect because ordinary or rapid mood changes do not define psychosis.
Question 2
A person tells you that their neighbours have installed cameras to monitor them. What is generally the most appropriate response?
A. Tell them firmly that the belief is ridiculous
B. Agree that the neighbours are probably monitoring them
C. Acknowledge that the experience sounds frightening without confirming the belief
D. Ignore the statement completely
Correct answer: C
The case worker should acknowledge the person's emotional experience without reinforcing the delusional belief.
A is incorrect because direct confrontation may damage trust and increase distress.
B is incorrect because agreeing with the belief may reinforce the delusion.
D is incorrect because the belief may be important for understanding distress and risk.
Question 3
Which feature would be particularly suggestive of mania?
A. Sleeping three hours and feeling exhausted
B. Sleeping three hours and feeling unusually energetic and refreshed
C. Sleeping nine hours following a busy day
D. Difficulty sleeping before an important meeting
Correct answer: B
A reduced need for sleep without corresponding tiredness is an important feature of mania.
A is incorrect because this is more consistent with sleep deprivation or insomnia.
C is incorrect because this may represent normal sleep.
D is incorrect because temporary sleep disturbance related to anxiety does not indicate mania.
Question 4
Which statement about hallucinations is correct?
A. Hallucinations are always auditory
B. Anyone experiencing hallucinations has schizophrenia
C. Hallucinations can occur through several sensory modalities
D. Hallucinations are always dangerous
Correct answer: C
Hallucinations may be auditory, visual, tactile, olfactory or gustatory.
A is incorrect because hallucinations are not limited to hearing.
B is incorrect because hallucinations can occur in many psychiatric and physical health conditions.
D is incorrect because risk depends on the nature of the experience, the person's response and the wider clinical situation.
Question 5
Which of the following is an example of a negative symptom?
A. Hearing voices
B. Believing that the government is monitoring you
C. Markedly reduced motivation and emotional expression
D. Rapidly spending large amounts of money
Correct answer: C
Reduced motivation, emotional expression and social engagement can occur as negative symptoms.
A is incorrect because hearing voices is a hallucination.
B is incorrect because this describes a possible persecutory delusion.
D is incorrect because impulsive spending may occur during mania but is not a negative symptom.
Question 6
Why is understanding a person's baseline important?
A. Because everyone with psychosis behaves in the same way
B. Because changes from someone's usual functioning can indicate deterioration
C. Because diagnosis can be made solely by comparing current behaviour with previous behaviour
D. Because family information is more reliable than speaking to the individual
Correct answer: B
Changes from baseline can provide important early warning signs of deterioration.
A is incorrect because presentations vary considerably between individuals.
C is incorrect because diagnosis requires a much broader clinical assessment.
D is incorrect because both the individual's account and collateral information can be valuable.
Question 7
Which statement best describes hypomania?
A. It is identical to severe mania
B. It involves elevated or irritable mood and increased activity but is less severe than mania
C. It always involves hallucinations
D. It is another term for anxiety
Correct answer: B
Hypomania shares features with mania but is less severe.
A is incorrect because the severity and functional consequences differ.
C is incorrect because psychotic symptoms are not a defining feature of hypomania.
D is incorrect because hypomania is a mood state rather than an anxiety disorder.
Question 8
A person with bipolar disorder has begun sleeping for two hours per night, speaking much more rapidly and spending unusually large amounts of money. What should the case worker do?
A. Wait until hallucinations develop before taking action
B. Diagnose mania independently
C. Document the changes and raise concerns promptly with the clinical team
D. Tell the person to stop spending money and review them in several months
Correct answer: C
This pattern represents a significant change that could indicate emerging mania and warrants clinical review.
A is incorrect because psychosis does not need to develop before intervention is appropriate.
B is incorrect because diagnosis is not the case worker's responsibility.
D is incorrect because the pattern may represent significant deterioration requiring timely assessment.
Question 9
Which situation should raise particular concern when someone reports hearing voices?
A. They occasionally hear an indistinct sound and are not distressed
B. They hear a voice commanding them to seriously harm themselves and believe they must obey it
C. They sometimes think they hear their phone ringing
D. They report having experienced voices several years ago but none currently
Correct answer: B
Command hallucinations involving serious harm require careful and potentially urgent risk assessment, particularly when the person feels compelled to act.
A is incorrect because although it may still warrant exploration, it does not automatically indicate immediate risk.
C is incorrect because occasional misperceptions can occur without psychosis.
D is incorrect because historical symptoms remain clinically relevant but do not necessarily indicate current acute risk.
Question 10
What is the most useful general principle for a case worker concerned about possible relapse?
A. Wait until you are certain of the diagnosis before informing anyone
B. Focus only on whether hallucinations are present
C. Describe specific changes from baseline and consider their impact on safety and functioning
D. Reassure the person that everything will probably settle by itself
Correct answer: C
Case workers provide valuable clinical information by describing observable changes in behaviour, sleep, functioning, beliefs, mood and risk.
A is incorrect because case workers do not need diagnostic certainty before escalating concerns.
B is incorrect because relapse may involve many different changes and hallucinations are only one possible symptom.
D is incorrect because unexplained deterioration should not simply be assumed to resolve without assessment.
Key Message to Take Into Practice
When working with psychosis or bipolar disorder, you do not need to have all the diagnostic answers.
Your job is to notice, listen, understand, document and escalate.
Learn what the person is normally like. Pay attention when their sleep, thinking, behaviour, functioning or relationships begin to change. Try to understand unusual behaviour in the context of what the person may be experiencing and never manage significant deterioration or risk alone.
