Saturday, 19 May 2018

Exploring Bipolar Disorder and the Sister Diagnosis of Schizoaffective Disorder. Is My Friend or Sibling Underdiagnosed?

By Julie A. Fast

Fran and I are delighted to present the first in a new series of articles by author, writer, and family coach Julie A. Fast. Please read Julie’s book Take Charge of Bipolar Disorder to learn more about bipolar disorder management. You can post questions and comments below and we will pass them along to Julie.

Hello everyone! This is Julie A. Fast. It’s an honor to work with Marty and Fran to help the world discover their important work and how those of us with bipolar disorder so deeply need our friends. Friends (and siblings who are often our friends) need help understanding the up and down nature of our moods as well as our other symptoms that might not fit easily into a depression or mania category.

My goal is to teach you how people with bipolar disorder think and why we act in certain ways so that you can be a part of our healing as well as our happiness. We want and need you in our lives! I am also passionately vocal about the responsibility we have as people with bipolar disorder to Treat Bipolar First and not overwhelm friends with our mental health needs. It’s a tough balance, but it is possible.

This two part series is one close to my heart. In part one I explain the difference between bipolar disorder and schizoaffective disorder. In part two, I explain how the psychotic symptom of paranoia can ruin relationships if the symptom is missed or misunderstood.

Let’s get started!

Exploring Bipolar Disorder and the Sister Diagnosis of Schizoaffective Disorder. Is My Friend or Sibling Underdiagnosed?

Bipolar disorder is a genetic illness that affects a person’s ability to regulate their mood. People with bipolar are average in terms of mood when stable, which means that bipolar is not a part of our personality. It’s an illness that sits on top of us as people. This is the main difference between bipolar disorder and personality disorders such as borderline or narcissism. People with bipolar have zero symptoms when they are not manic or depressed whereas people with borderline or other personality disorder illness will have symptoms which are consistent over time.

Without exception, bipolar mood swings are episodic. They can be darn long, but they have what is called a discrete beginning, middle and end. The only thing consistent about bipolar is that our moods are not consistent!

Anything that is consistent over time and is not episodic can’t be traditional bipolar. This is confusing as our mood swings of depression and mania can look exactly like other illnesses such as narcissism, borderline, hypochondria, explosive anger and schizophrenia. But bipolar symptoms are always encased in either a manic or depressed mood swing. And although I am repeating myself this is such an important concept I’m going to say it again: bipolar disorder mood swings have a beginning, a middle and end, after which the person with bipolar always returns to stability even if it is a brief stability.

My bipolar is disorder is chronic but I still know what it feels like to be stable. Stability is a rare rainbow unicorn for me, but it’s there and is always a goal.

(Please note that it’s uncommon for people who only have bipolar to self-harm. Suicide behaviors are common in bipolar but are not the same as self-harm. This will help you figure out what is happening with a friend: if you see self-harm you are seeing more than bipolar.)

What is Psychosis?

All people with bipolar disorder have the possibility of psychosis either during a depressed or manic episode, depending on their particular type of bipolar. What exactly does this mean? It means that the bipolar brain when depressed or manic can easily slip into psychosis as well. This is more common with full blown mania in bipolar one, but many people with bipolar depression get psychotic and simply don’t know what to look for in terms of symptoms.

Psychosis is simple. It’s a hallucination or a delusion. To reiterate, and to truly hammer this point into the ground, people who only have bipolar disorder can absolutely get psychotic, but it will only be when they are manic or depressed.

Hallucinations are of the senses. If you take your finger and point to your eyes (visual hallucinations are seeing something that is not really there,) your ears (audio or aural hallucinations are hearing something that is not really there), your nose (olfactory hallucinations are smelling something that is not really there,) your skin (tactile hallucinations where you feel there is something on your skin that is not really there) and finally your mouth (gustatory hallucinations where you taste something that is not really there) you have just described sensory hallucinations.

Delusions are more complicated. Delusions are false beliefs. They are not false thoughts or false sensations such as hallucinations. Delusions go much, much deeper into what is called an unshakable belief. Paranoia, the topic of part two of this series is a delusion. Delusions involve the real world and are combined with an imaginary world that feels just as real as what we call reality. For example, when a person believes they are being followed, they believe it. It’s not a hunch or a possibility; it’s a strong belief that has to be acted on. It is set in stone. It’s unshakable.

Psychosis is more common in bipolar one simply because the majority of full blown manic episodes come with psychosis, but many people who are depressed can get psychotic as well. It is very rare to have psychosis with hypomania. Think of psychosis in bipolar as case by case and the possibility that your friend or sibling may not even know they are having psychosis until someone explains the symptoms.

For example, if you notice that your depressed friend often asks, “Do I smell bad? Do I smell dirty?” you can look into other areas where they might be having hallucinations and make sure their health care team knows of this symptom.

And now, I’m finally to the topic of this article! I like to take the audience on a journey to get to a big topic as simply talking about schizoaffective disorder without explaining psychosis and the role psychosis plays in bipolar disorder makes the topic difficult to understand. But you are now ready!

What is Schizoaffective Disorder?

Schizoaffective means schizo (psychotic) and affective (mood). It is a genetic illness where a person has a full diagnosis of bipolar disorder and a separate diagnosis of a psychotic disorder that is made up of hallucinations and delusions. It is not bipolar disorder plus schizophrenia, as I will explain below. People with schizoaffective disorder get manic and depressed. They still can have psychosis when manic or depressed, but they can also become psychotic when they are not manic or depressed. In other words, they can be psychotic when the mood is stable.

(Please note, there is a schizoaffective disorder called depressive type which means a person has unipolar depression and a separate psychotic disorder. If you have bipolar and a separate psychotic disorder, it’s schizoaffective, bipolar type technically. But to be honest, most people mean bipolar type when they say schizoaffective disorder!)

I have schizoaffective disorder which means that I can go to a university class and be really happy to be there with a stable mood and then the overwhelm of the big class and being surrounded by people can trigger something in my brain that brings up paranoia (a psychotic delusion.) It was one reason college was so difficult for me.

To recap: people with schizoaffective disorder have bipolar disorder and a separate psychotic disorder. This is often misdiagnosed as bipolar disorder with psychotic features. There is not really a diagnosis of this type. The correct diagnosis is schizoaffective.

Does Schizoaffective Mean Schizophrenia?

NO. There are many types of psychotic disorders with schizophrenia being one of them. Those of us with bipolar disorder who get psychotic when we are NOT manic or depressed have a separate psychotic disorder that is made of hallucinations and delusions. We simply get psychotic. This is not schizophrenia. Schizophrenia has hallucinations and delusions, but also carries many more symptoms that people with schizoaffective disorder do not experience.

Please stick with me here if this is your first time reading about this diagnosis! It does get easier as you read more about these very interesting and interconnected mental health disorders.

If a person has bipolar disorder and psychosis (hallucinations and delusions) when not manic or depressed, this is schizoaffective disorder. If a person has bipolar disorder and schizophrenia, an illness that includes psychosis as well as many, many other symptoms this is not schizoaffective disorder. It is considered a separate diagnosis of bipolar disorder and schizophrenia.

I really like the Mayo Clinic webpage for a very basic explanation of mental health symptoms. Here is what they have to say about schizophrenia. Notice that it is much, much more than hallucinations and delusions.

If you are reading this and you visit the page about schizophrenia and you think, “Oh my goodness. My friend or sibling is showing signs of schizoaffective disorder or even schizophrenia,” what is your next step?

Here is what I recommend.

  1. Find out how aware your friend is about psychosis in bipolar disorder by asking questions. Part two of this article will show you how to talk about paranoia with a friend.
  2. Do your own research into the other symptoms of schizophrenia such as hygiene challenges, eye contact, social skill decline and cognitive changes and think about your friend or sibling’s behavior outside of mania and depression.

Then, decide what you need to say or do in order to keep the friendship stable and intact. It’s not the job of a friend or sibling to change another person. Our job as a friend or sibling is to learn what we can and then decide what we need from a relationship. You can’t save someone with a mental illness, just as I can’t save someone with a mental illness. But wow, can we make an impact by learning the signs and symptoms of bipolar disorder and possibly schizoaffective disorder or schizophrenia and addressing our fears and worries about what is means to care about someone with these symptoms.

By being honest with ourselves and admitting, well, it looks like my friend gets psychotic or my sibling is showing a lot more symptoms than just mania and depression, we will not be confused, but empowered.



About the Author

Julie A. Fast is the author of Loving Someone with Bipolar Disorder, Take Charge of Bipolar Disorder, Get it Done When You’re Depressed and The Health Cards Treatment System for Bipolar Disorder. Julie is a board member of The International Bipolar Foundation, a columnist and blogger for BP Magazine, and won the Mental Health America journalism award for the best mental health column in the US. Julie was the recipient of the Eli Lily Reintegration award for her work in bipolar disorder advocacy. She is a bipolar disorder expert for the Dr.Oz and Oprah created site ShareCare.

Julie is CEU certified and regularly trains health care professionals including psychiatric residents, social workers, therapists and general practitioners on bipolar disorder management skills. She was the original consultant for Claire Danes for the show Homeland and is on the mental health expert registry for People Magazine.

She works as a coach for parents and partners of people with bipolar disorder. Julie is currently writing a book for children called Hortensia and the Magical Brain: Poems for Kids with Bipolar, Anxiety, Psychosis and Depression. She struggles a lot due to bipolar disorder. Friendships keep her going.

You can find more about her work at and



  1. my son is taking 3 different antipychotic meds foe his diogose of Schizoaffective disorer amomh other benzoids. Do u think that thats too much?

  2. My brother has schizophrenia and schizoaffective disorder. What does this mean? He has up and down mood episodes and psychosis on top of his schizophrenia?

  3. Someone I care about has started showing very bad mood swings since a back injury put him out of work last August. I have known him for 8 years and never have I experienced what has happened in the last 1 1/2 years. He has had hallucinations of seeing things and often has dreams where he’s yelling out to the point I have to wake him up. He is a daily pot smoker and thinks because it’s “medical marijuana” that it’s ok. How do I help him figure his mental health out when he thinks everything is ok and he is fine!? He is not fine he is a total different person from who he used to be. He is against taking meds and has even gone as far a not using hand soap, toothpaste/mouth wash (makes his own all natural) because he says it’s all poison! He needs help and he has made many mistakes with friends and family and just expects people to get over it. What can I do to help him!? Thanks for your insight and knowledge!

    1. Hello. This is Julie. Martin just let me know about your comment.

      Cannabis use is the biggest problem I see in our bipolar community today. THC is a strong hallucinogenic and due to the bipolar brain's propensity towards psychosis, it usually makes us psychotic. I wish we could use weed. Believe me, I have tried it all, but the psychosis is serious and I don't recommend any cannabis use if a person has bipolar. The goal is to get him help for the psychosis. You can't talk someone out of psychosis.

      Please feel free to join me on The Stable Table on Facebook. This is my group for friends and caregivers. I talk a lot about psychosis in this group. The goal is for everyone around him to make a list of the symptoms they see - this includes his family if possible and then get this list to someone who can address the psychosis. It can be a general doctor at first, but eventually, he will have to see someone who can prescribed anti psychotics.

      This is what works. It's a process, but it's possible. If he continues to use weed as a person with bipolar, this psychosis can continue.


    2. I’ve heard all sorts of stuff over the years about weed being somehow good for the mind (mostly because it’s natural, just like death cap mushrooms and deadly nightshade) I suppose it takes all sorts but there’s a lot of people out there who are not helped by cannabis not even in tiny quantities and all it’s done is caused a lot of suffering that could have been avoided by just not going there!

  4. Hi Julie this is Cathy. I was a participant on the Zoom meeting last night hosted by Joanne. It was great to “meet” you finally as I have been reading your contributing articles on bphope for years. I have a question about something that you mentioned yesterday regarding disability focused treatment centers that offer structured housing & mental health services. My son is currently in jail in Boston MA because he’s unfortunately been entangled in the legal system & we are trying desperately to free him from this “neo asylum” & get him into an appropriate treatment setting. Are there any such facilities in MA? If so how do we go about initiating the process? Thanks

  5. Hi Cathy, I realize your comment is from several months ago. Try McLean (Mass) if you haven't already found them. They have residential treatment for bipolar (and other) disorder and they, along with Menninger (Houston, TX), have been highly recommended to us (our daughter lives with BP Type 1 with psychotic features. These places are not cheap. Not sure if insurance will cover some of cost. Wishing you the best.