On the last track, we discussed three types of resistant adult
bipolar clients. Those were clients who reject diagnosis; the under identifying;
and the over-generalizing client.
Generally, when a client hears the words, "psychotic symptoms" a
variety of unrealistic thoughts come to mind. Often, the term "psychosis" conjures
up images of raving lunatics unable to control their murderous impulses. This
image has been perpetuated by pop literature, the media, and a societal interpretation. When
a client has a clear misinterpretation of psychosis, I explain to them that psychosis
is merely a break with reality during which everyday occurrences may seem strange
On this track, we will examine characteristics of adult bipolar
clients who come under the influence of psychosis: delusional thoughts;
hallucinations; and paranoia.
3 Characteristics of Psychosis
1. Delusional Thoughts
The first characteristic of a client during a psychotic break is delusional thoughts. These
delusions include a grandiose image of themselves such as the client believing
he or she is a messenger of god or is in fact a deity. Often, this kind of augmented-purpose
delusion occurs during mania. Clients under depression, however, may exhibit somatic delusions in which they believe
that their body is rotting away.
During delusions, as you know, a
client becomes utterly unreasonable and very difficult to communicate with so
convinced are they of their delusions. During a delusional episode and
especially during a depressive delusional episode, the client’s potential
for suicidal or self-harming behavior increases. I ask family members or
loved ones to monitor the client’s behavior carefully and to understand
that he or she has no control over what they say or believe. If the client
has no one to look after them and they are an extreme risk to themselves or to
others, hospitalization may be necessary.
Darcy was a 23 year old bipolar client I was treating. During her mania,
Darcy would often believe herself to be cursed by the devil, who, she claimed,
made bad things happen. If she dropped a mug and it broke, Darcy believed
that this was the work of Satan. While under the influence of this delusion, Darcy became increasingly more at risk for suicidal tendencies. Because
she was living with her mother, Cecilia, I asked that she be kept in sight of
family members at all times and her behaviors watched. I also
told Cecilia to give Darcy as much a feeling of security as possible. With
the support of her mother and medication, Darcy was able to come through her
delusions relatively unscathed.
The second characteristic of psychosis manifested in bipolar clients is hallucination,
as you are aware. Generally in bipolar clients, these hallucinations are auditory and internal resulting in negative self-talk. Occasionally,
clients’ hallucinations may also become visual as well. Most of the
time, clients know they are hallucinating, but still react to the hallucinations
because they have lost the ability to appreciate the unreality of such
Chris’s hallucinations were chronic and extremely vivid.
Chris stated, "I have many different types of hallucinations. I often
see myself being bitten by a dog or hit by a car. I see my body fly in the
and land on the ground in front of me. I have looked down and seen my wrists cut and bleeding. I smell things more strongly and hear voices that
tell me I should not be where I am or that I’m a failure and should die. It scares the shit out of me every time."
hallucinations were accompanied by a great deal of anxiety which threatened his
help. Although I could not prevent
hallucinations without medication, I gave Chris a breathing exercise to
practice when he became overwhelmed by his hallucinations.
Technique: 5-to-1 Count
The breathing technique I recommended Chris try is called the 5-to-1 Count.
I asked Chris to follow these directions whenever he felt anxious when he
was experiencing a particularly frightening hallucination.
1. Say the number 5 to yourself, and as you focus on the number take a deep,
full, slow breath. Exhale fully and completely, making sure to get the
bit of air out of your lungs.
2. Mentally count 4 and inhale. As you
the exhalation, tell yourself: 'I am more relaxed now than I was at number
5.' Be sure not to rush the thought.
3. Inhale, mentally counting
yourself: "I am more relaxed now than I was at number 4," as
fully and completely.
4. Count number 2 and then number 1, mentally repeating
the phrase: "I am more relaxed now than I was at number 2." Allow
to feel the deepening relaxation.
As you approach number 1, you should
calmer and more relaxed.
I recorded this exercise onto a tape so Chris could easily play it to
himself without having to memorize the entire exercise. I also find the
helps clients to hear their therapist’s voice when there are especially
In addition to delusions and hallucinations, a third characteristic of psychosis
common in bipolar clients is paranoia. Paranoia involves a
heightened sense of danger and alertness within a client resulting in
suspicion of people that they may have trusted their entire life. Often
this is coupled with accusations against family members and spouses who I
remind that the client is experiencing paranoia and in no way is basing
their contentions in reality.
Carol, age 34, has damaged several of her
relationships. Carol stated, "I’ve lost so many friends because
of paranoia. I can feel that they’re saying things about me and I
have to tell
them what I feel. It’s as though I’m just sitting there and
suddenly I have
the idea that my friends don’t want to be with me and that they’re avoiding me. When I ask them why they are treating me this way, they truly have
idea what I’m talking about. They then think I’m totally weird
friendship is over."
Technique: The Trust List
To help Carol during her paranoid stages, I asked her to make a "Trust
I told her to divide a sheet of paper into two columns. At the top
column, I asked her to write "Name" and the other to title it "Why
Them". Under "Name", Carol wrote the names of all the
loved ones she trusted. She wrote, "Mom, Dad, Aunt Bernice, Shelly, Tom, and Pastor
In the column "Why I trust them", I asked her to write in detail
in which each person proved beyond a doubt their trustworthiness.
example, for the name "Pastor Davis", Carol wrote "Invited
me over to his
house for dinner to meet his family, even when several families in the
parish thought I was dangerous. He let me talk and play with his young
children and his wife listened to me without judgment."
episode, I asked Carol to pull out her list and think on the times in the
past that people have proven themselves trustworthy. Many times, Carol
reported that this list calmed her paranoia.
Think of your client with
chronic paranoia. Would
she benefit from a "Trust List"?
On this track we presented characteristics of clients who exhibit a psychosis. These
Characteristics are delusional thoughts; hallucinations; and paranoia.
On the next track, we will examine techniques to predict manic and
depressive states and to aid clients through these cycles we will discuss Listing
According to Category; Preventative Maintenance Plan; and Three-Part
Peer-Reviewed Journal Article References:
Martins, M. J. R. V., Castilho, P., Carvalho, C. B., Pereira, A. T., Santos, V., Gumley, A., & de Macedo, A. F. (2017). Contextual cognitive-behavioral therapies across the psychosis continuum: A review of evidence for schizophrenia, schizoaffective and bipolar disorders. European Psychologist, 22(2), 83–100.
Strauss, G. P., Thaler, N. S., Matveeva, T. M., Vogel, S. J., Sutton, G. P., Lee, B. G., & Allen, D. N. (2015). Predicting psychosis across diagnostic boundaries: Behavioral and computational modeling evidence for impaired reinforcement learning in schizophrenia and bipolar disorder with a history of psychosis. Journal of Abnormal Psychology, 124(3), 697–708.
Swartz-Vanetik, M., Zeevin, M., & Barak, Y. (2018). Scope and characteristics of suicide attempts among manic patients with bipolar disorder. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 489–492.
Online Continuing Education QUESTION
What are three characteristics of clients under exhibiting symptoms of a
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