People often use the term “paranoia” loosely in conversation, but it’s a serious and challenging symptom of psychosis that occurs when an individual loses contact with reality, according to the National Institute of Mental Health (NIMH). While there’s no single cause of psychosis, it can be a symptom of bipolar disorder.

Paranoia is a persistent belief that someone is out to get you, conspiring against you, following you, or persecuting you. If someone really is surveilling you, that’s not paranoia. “A key thing about clinical paranoia is that it can’t actually be true,” notes Ken Duckworth, MD, chief medical officer at the National Alliance on Mental Illness (NAMI) and assistant professor of psychiatry at Harvard Medical School in Boston.

Paranoia is unlikely to be the only symptom affecting a person with psychosis and bipolar disorder. Other symptoms of psychosis may include:

Disrupted, disorganized, or hard-to-understand speech or thought patterns
Hallucinations (seeing things that other people do not see or recognize)
Hearing voices
Having fixed, false beliefs
Difficulty managing daily activities
Difficulty knowing what is real and what is not

The NIMH notes that someone experiencing psychosis may also have depression, anxiety, sleep problems, and withdrawal from social activities.

When Does Paranoia Occur in Bipolar Disorder and Why?

Bipolar paranoia and variations on it are not inevitable for people with bipolar disorder, and these symptoms also depend on which type of bipolar disorder someone has.

“People with bipolar disorder typically do not have, for most of their experience, paranoia, psychosis, and the severe sleep deprivation that is probably underlying the development of this alteration in consciousness. So, the thing about bipolar disorder that’s unusual is that most of the time people are either well or depressed. And the amount of time that they’re manic is relatively small, although each person has their own ‘signature,’” explains Dr. Duckworth, who is also the author of NAMI’s first book You Are Not Alone: The NAMI Guide to Navigating Mental Health.

Manic states are an aspect of bipolar I disorder. While it’s different for every individual, Duckworth estimates that over the course of a year, the average person with bipolar I disorder may have zero to 25 days of mania, although they may also have years without any manic symptoms. Most people with bipolar I spend the least amount of time of their illness manic — and within manic states, paranoia is even less common.

People with bipolar II, which is characterized by depressive episodes and hypomania, do not develop paranoia, notes Duckworth. People with this condition will experience periods of extreme energy or irritability, significant depression, as well as other disruptions in their life, but their mania is milder than in bipolar I and does not lead to psychosis, including paranoia.

As with many bipolar symptoms, the mechanism behind paranoia is not easily understood. There is some evidence that interrupted sleep — especially insomnia or a prolonged period of getting less sleep than normal — can trigger paranoia. Interrupted sleep is a hallmark of bipolar disorder, particularly when people enter the manic phase and sleep less than usual or not at all.

“When a person with bipolar disorder has sleep deprivation,” says Duckworth, “which is common when a person is manic and when a person is in a mixed state, the thinking is that their grasp on reality gets poorer and they can hallucinate — they can develop paranoid or delusional thoughts.”

Managing Paranoia in Bipolar Disorder

The best treatment for paranoia in bipolar disorder is typically a combined approach. “There’s rarely one tool that does everything,” says Duckworth. Optimal treatment, explains Duckworth, typically includes medication, such as antipsychotic medication or mood stabilizers, as well as psychotherapy.

Duckworth notes that medications are most effective at targeting out-of-control behavior and less so when it comes to fixed false beliefs and paranoid thoughts. But the idea, Duckworth explains, is that when your mania is controlled and you’re sleeping better, your thoughts should return to normal. This is one way in which psychosis related to mania is distinguished from psychosis in schizophrenia. Psychosis due to bipolar disorder only happens during an acute mood episode and not in the person’s typical state.

Antipsychotic medications can be used temporarily, or they may be used over a long period to stabilize thoughts and emotions.

In addition to medication, therapeutic approaches can help. “When people have some insight into these fears and thoughts, cognitive approaches can be useful, too,” says Michael J. Peterson, MD, PhD, a professor in the department of psychiatry at the University of Wisconsin School of Medicine and Public Health in Madison. It’s also important to prepare for the next possible episode and build up a support network. Although there are a number of different psychotherapies for bipolar disorder, if paranoia is a typical symptom for someone, the following therapies may be recommended.

Cognitive Behavioral Therapy (CBT) for Psychosis In this form of talk therapy, a clinician trained in cognitive behavioral therapy for psychosis (CBTp), a specific kind of CBT, establishes a trusting relationship with a client and helps them explore different interpretations of their paranoid thoughts or delusions, rather than simply trying to convince the client that what they’re experiencing isn’t real. “An example of this might be rationalizing why the fears may not be real or ways of testing how real these fears might be,” Dr. Peterson explains. Eventually, the therapist and client work to come up with strategies to change behavior and develop coping skills.
Coordinated Specialty Care (CSC) This early intervention program, developed in the last 20 years, is geared toward young people experiencing their first episode of psychosis. According to the NIMH, it involves a team approach that uses psychotherapy (generally CBTp) and medication management, family education and support, as well as peer support. “The idea is that we involve you in your care, learning about your experience,” says Duckworth.
Social Support Paranoia can have the unfortunate side effect of eroding even the closest relationships if it is not controlled. But involving your loved ones is important when managing bipolar disorder. “Reviewing these fears with a loved one or trusted friend, in addition to healthcare providers, can also be useful,” says Peterson. Family and friends can help identify and anticipate troubling behavior.
Support Groups A support group may not be especially helpful during a manic or psychotic episode, but it can be important once you’re stabilized. “In these groups, you anticipate, you reduce shame, you predict the future for yourself — you think about what could happen and you gather support, so that you’re more likely to engage in treatment, you’re less likely to drink or to stop your meds, all the things that increase risk,” says Duckworth. Look for a suitable support group through NAMI or the Depression and Bipolar Support Alliance. Remember that it’s okay to try out a few support groups until you find one that you are comfortable with.

While paranoia is a distinctly unpleasant experience for people with bipolar disorder, it can be controlled, managed, and reduced so that it has less impact on your daily life.