Altered Sensory Phenomena Experienced in Bipolar Disorder
Publication: American Journal of Psychiatry
Which of the following are common altered sensory phenomena in bipolar disorder?
A.
Visual and auditory hallucinations in both depressive and manic phases.
B.
Increased sensory sensitivity in bipolar phases.
C.
Altered sense of danger in surroundings.
D.
All of the above.
“Ms. A” was a 51-year-old full-time teacher who was diagnosed as having a prototypic bipolar II disorder commencing in late adolescence. She spontaneously reported sensory changes during episodes, including in her sense of smell, taste, vision, touch, hearing, danger, and intuition, as well as in her connection with other people. She reported such senses as improved during hypomanic episodes (e.g., being “sharper” or “stronger”), but “worse” when she was depressed (i.e., variably “decreased” or “horrible”). In describing taste nuances, Ms. A reported generally that she enjoyed food more when she was hypomanic, although some foods (“like cheese and salt”) had too strong a taste, and that things “taste rotten” when she was depressed. Similarly, she reported her vision to be “immensely improved” during highs (and she might not need her reading glasses) and her hearing was “sharper” and “terrific.” By contrast, during depressive episodes, she stated, “I use my glasses a lot more, as things are out of focus” and “I’m as deaf as a head post.” While she enjoyed most of the sensory changes she experienced in hypomanic states, she reported unease about her heightened sensitivity to touch. “I have to avoid anything touching me. Clothes aren’t a bother, but tags and heavy touch are.” Ms. A also identified changes in her perception of danger when hypomanic—“I don’t have any sense of danger”—and noted that she tended to be reckless and to drive at speed. Conversely, during depressed periods, “Everything is dangerous and scary. I’m much more careful when driving.” She reported changes in her ability to connect with other people during both mood states. During hypomanic states, she observed, “I don’t give a hoot, really. I’m caught in this super-duper world and nothing bothers me,” whereas in depressed states, “I don’t feel connected to anyone, and I become a recluse.” She also observed changes in her intuition, with her ability to “read others” worsening during depressive episodes.
“Mr. B” was a 64-year-old married senior executive who experienced his first hypomanic/manic episode at age 18 and his first debilitating depressive episode at 36, but he had only recently been diagnosed as having a bipolar II condition. He spontaneously reported several sensory changes during mood episodes. When hypomanic, he said, “Wine smells stunning. I can taste what the wine taster says it’s supposed to taste like.” But during depressive states, “everything becomes dull. The smell gets through, but I just don’t notice it.” He described his sense of touch during hypomanic states as “more powerful”—“things are much more sensitive, and I recognize a heightened degree of sensuality”—whereas when depressed he felt that his sense of touch was markedly diminished. Mr. A also reported perceiving less danger during hypomanic states. Danger was then something to be relished and chased. “Should I list all the dangerous things I’ve done? I shouldn’t be alive.” Conversely, during depressed states, Mr. A said, “I feel fear, which can be paralyzing. I can’t work or take the usual risks that are part of my professional life.” He also reported problems in his ability to empathize when depressed (“I feel totally disconnected”) and a distinct improvement in his ability to connect with other people when hypomanic.
In an earlier report (1), the first author described a variety of altered nonpsychotic sensory changes reported to him or acknowledged on questioning by patients with bipolar II disorder. While such a phenomenon has been long described—with Clifford Beers observing in his 1908 classic, A Mind That Found Itself (2), “The tricks played upon me by my senses of taste, touch, smell, and sight were the source of great mental anguish” (p. 29)—it has been minimally detailed or studied. DSM-5 observes that during manic episodes some patients may perceive a “sharper sense of smell, hearing, or vision,” and ICD-10 lists hyperacusis as a possible concomitant of mania.
The few reports or studies of such phenomena have been limited to relatively narrow domains or research questions. For example, Lahera et al. (3) reported that euthymic bipolar patients showed impaired olfactory function; Cumming et al. (4) described olfactory identification as compromised in patients with a bipolar disorder; and Hardy et al. (5) reported that in manic states, some patients had a decreased sensitivity to odor detection. Swiecicki et al. (6) reported that patients with bipolar depression rated fewer gustatory stimuli as unpleasant and more olfactory stimuli as pleasant compared with unipolar depressed patients. O’Bryan et al. (7) reported a deficit in visual motion perception in bipolar patients (both when euthymic and when ill), and Kéri et al. (8) reported that bipolar patients had impaired visual processing during depressed phases, which normalized when euthymic.
As so little has been written on such sensory changes, we undertook a study examining multiple sensory domains, while also seeking to establish whether nonpsychotic sensory changes were limited to patients with bipolar II disorder or were also experienced by those with bipolar I disorder.
Participants were recruited via the Black Dog Institute Clinic. Patients who met DSM-IV criteria for a bipolar disorder were invited to take part in a study assessing perceptual changes experienced by those with a bipolar disorder. While 257 patients indicated their provisional willingness to take part, only 66 proceeded to the telephone interview—18 with bipolar I disorder, 36 with bipolar II disorder, and 12 with “soft” bipolar disorder (i.e., patients who did not meet the DSM duration criteria). The participants’ mean age was 35.9 years, and slightly more than half of the sample were women (55%).
The interviewer asked whether participants had experienced any of 10 differing “perceptions” during hypomanic/manic and/or depressive states, and if they did, the interviewer asked for details. Responses were coded as “heightened,” “muted,” or differing in some other way. Responses indicative of psychotic symptoms were excluded (only 29% had experienced delusions, and 24% hallucinations).
Among the primary senses (smell, taste, vision, touch, hearing), 82% experienced changes during a hypomanic/manic episode, and 65% during a depressive episode. Analyses failed to identify any significant differences in the number of sensory changes reported for participants with bipolar I, bipolar II, and soft bipolar disorder during depressive episodes, but a significantly greater number of sensory changes were reported during hypomanic/manic episodes for the bipolar I participants compared with the soft bipolar participants.
In relation to smell, during hypomanic/manic states, only one participant reported a weakening in smell, while 19 reported a heightening, using terms like “sharper,” “clearer,” “stronger,” and “more intense.” Some reported smelling things that other people could not smell. Of the 16 participants reporting such changes when depressed, 12 reported smells as weaker (e.g., dull, degraded, less strong) and two as stronger, and several described smells as annoying or sickening.
Of the 22 participants who acknowledged taste changes during a hypomanic/manic episode, most described tastes as stronger or heightened, and one described them as weaker or different (e.g., “metallic” or bland “like cardboard”). Thirty-three reported taste changes when depressed; most described having a weaker sense of taste, or food tasting bland, and three reported qualitative changes (two experiencing food as “bad” and one as “metallic”).
Of the 21 who acknowledged visual changes during a hypomanic/manic episode, 14 described them as an improvement (i.e., sight sharpened, colors brighter and more vibrant) and one a worsening (noting that things looked foggy and unclear), and several reported nonspecific changes. Thirteen experienced visual changes during depressive episodes—nine as worse (i.e., objects dull, gray, or gloomy, difficulties in seeing things or in focusing their vision) and one as improved, and three reported nonspecific changes.
Changes in sense of touch were acknowledged by 29 participants during hypomanic/manic episodes, with 24 reporting touch as more sensitive or hypersensitive, one as less sensitive, and three as “different.” Greater sensitivity was not always pleasant; three participants described feeling itchy or not being able to wear “itchy” clothes. Four participants highlighted feelings of sensuality and heightened pleasure from being touched. Of the 15 who affirmed changes during depressive episodes, five felt more sensitive, seven felt less sensitive, and three reported other experiences.
Nineteen participants affirmed changes in hearing during a hypomanic/manic episode, with 13 reporting improvement and six describing “different” hearing. Improved hearing generally involved amplification, sounds heard more clearly, or subthreshold sounds being heard distinctly. Eight affirmed changes during depressive episodes, with half reporting their hearing as worse and two as improved, and two describing nonspecific changes. Participants reported being more aware of certain sounds (e.g., yelling, chewing) and high-pitched sounds, or finding sounds “annoyingly loud.”
We also inquired into five other sensory phenomena, with 53 participants reporting changes in danger perception, 39 changes in intuition, 55 changes in empathy or connectedness, and 29 changes in their ability to predict future events; five experienced synesthesia, which was reported during both hypomanic and depressive episodes. Table 1 provides exemplar descriptions of such phenomena experienced during hypomanic and depressive episodes.
| Sense | Hypomanic/Manic Episode | Depressive Episode |
|---|---|---|
| Smell | “I’m more sensitive. Things smell better and worse, everything is a bit more intense.” | “Everything becomes dull.” |
| “You can smell everything, you’re alert, it’s like, magical.” | “Things smell less vibrant. There is a lack of depth to whatever it is I’m smelling.” | |
| “I pay more attention to preferable smells, like flowers.” | “Definitely repressed. I really have to center in order to smell something.” | |
| “A smell of a rose means more to me.” | “All smells are less strong.” | |
| “I can smell things that other people can’t smell.” | ||
| “I can smell things that make me feel sick. Food smells.” | ||
| Taste | “Exaggerated, everything is more extreme. Spicy is spicier, sweet is sweeter.” | “Everything is bland.” |
| “Things are more tasty, tastes are heightened. I taste more flavors in what I’m eating.” | “Things don’t taste at all in some cases.” | |
| “Food tastes a lot better. I have gastrointestinal problems, but when I am high I eat more.” | “I only eat not to die, but I can’t taste anything.” | |
| “Fruit tastes better, I’m more inclined to eat it.” | “Reduced experience of tastes. I don’t enjoy things as much as I normally would.” | |
| “I will try more foods. I normally can’t stand mushrooms but I enjoy them when I’m high.” | “I don’t like anything. It all tastes rotten. Things just taste horrible.” | |
| Vision | “Everything is clearer. I don’t need my glasses for reading.” | “When I’m depressed, things aren’t as bright, like there’s a shade. Bright blues are dull.” |
| “I might have just been imagining it, but I see vertical white lines.” | “Sometimes I feel I don’t see anything. I don’t notice changes around me in my mind.” | |
| “I feel like I can see auras or glows around people. I can see what they’re thinking when they’re saying something.” | “I use my glasses a lot more, as things are out of focus.” | |
| “I see everything. You see things more with your head. Seeing with your third eye.” | ||
| Touch | “My skin feels more sensitive and more alive. Touch feels more real, especially humans or plants.” | “It becomes nothing. If I’m feeling depressed I can’t feel a hand on my leg.” |
| “Even my son tickling me is like someone stabbing me.” | “My body goes numb, I lose all sensation, it’s hard to discern things like temperature.” | |
| “Much more sensitive, sensual, sexual. Things are much more powerful. Heightened degree of sensuality.” | “Like my skin is crawling.” | |
| “When I feel high, it’s more a sense of being more sensitive to touch and your body feeling more connected to the universe.” | “I don’t want to be touched. Being touched feels almost repulsive and I recoil from it.” | |
| “My sense of touch is the same but my interest in different textures is heightened.” | ||
| “I’m much more tactile, I feel the need to touch things and have a tactile response, I especially notice it when shopping. I need to touch all the cushions.” | ||
| “I’m a very kinesthetic person. I went into a lift with laser-etched surfaces, and it was the most wonderful thing.” | ||
| Hearing | “Everything is louder, more crisp.” | “Minimal hearing. I don’t notice the things I do when I’m up.” |
| “I zone in on something I wouldn’t have otherwise noticed, like someone eating. It becomes a point of focus instead of being in the background.” | “I’m deaf as a head post.” | |
| “I guess that I hear things that other people struggle to hear or can’t hear, like a beeping or telephone.” | “I’m more aware of things, especially yelling, chewing, etc.” | |
| “I have tinnitus, but not so much when I’m high. This means I hear more.” | “Unable to handle certain sounds, especially high-pitched, like a spoon against a bowl or the sound of people eating.” | |
| “If listening to music, I can hear individual lines, not just the whole thing. Certain instruments stand out, my attention is caught.” | ||
| Danger | “I don’t think that I’ll get hurt; climbing around rocks on a cliff face, I thought I could jump and not get hurt. My husband had to physically hold me back.” | “Everything is dangerous, everything is scary. My driving is different, I’m much more careful.” |
| “Danger is something to be relished/chased. Should I list all the dangerous things I have done? I shouldn’t be alive. I perceive my ability to handle it is far greater.” | “I don’t care. I’m not afraid because I don’t care if I die.” | |
| “I find I am more likely to take risks. I don’t believe bad things will happen to me.” | “I just don’t care about my personal safety.” | |
| “At work when people don’t reply to e-mails, I worry I’ve done something wrong.” | “I perceive danger as good because it could kill me and maybe I would feel something for a second.” | |
| “When I’m feeling high, I feel like people are watching. When I look into people’s eyes, they can feel quite ominous and frightening.” | ||
| Intuition | “I can understand what they’re meaning even if they’re not saying it.” | “I tend to focus on other people, be more observant.” |
| “I read into things that aren’t there. I pick the most outlandish explanation, and assume people are thinking negative things about me.” | “I’d misinterpret interpersonal changes.” | |
| “I don’t really pay attention to people’s intentions.” | “I assume everyone thinks badly of me.” | |
| “I find it hard to understand where people are coming from, what they’re saying and their motives.” | ||
| Empathy | “Feel connected to everything and everyone. Feel like you can have deeper conversations and more intense connections.” | “I feel completely disconnected from everyone around me, as though they’re inside a bubble and I’m walking on the outside.” |
| “Everybody is my best friend and I’m everyone’s best friend. I’m exceedingly gregarious.” | “I don’t connect with anyone because I’m so wound up in my issues.” | |
| “I’m less empathic. I have had issues understanding how something would affect another person. I can become quite selfish.” | “I feel empathic towards people, but I don’t feel connected to my husband or son, etc.” | |
| “I can understand what they’re meaning even if they’re not saying it. I can feel their aura or emotions just by being near them” | “I’m there for others, but they’re not there for me. I notice more.” | |
| “I find it difficult when people don’t keep up. It irritates me.” | ||
| “I feel like I’m just that great, I can understand everyone.” | ||
| Prediction | “I feel very psychic. I feel like I can see the future.” | “Very clouded thinking. It felt like I was trapped in my own body, I couldn’t react instinctively like I could when high.” |
| “I know I’ll get a car park.” | “It becomes unclear. I see what some of the alternatives are, but I can’t filter out the unlikely ones and find myself in a loop of what-ifs.” | |
| “When I’m high and playing soccer, my reflexes are so much faster.” | “I probably overthink things, so I’m more aware of what could happen.” | |
| “When playing sport, it was like everything was slowed down and I could see the way things would go.” | “More negative. I think bad things are going to happen to me.” | |
| “I’m just more aware of my surroundings, looking a bit further, and I can see what’s going to happen quite easily.” | “Everything is futile.” | |
| “I think and it happens.” | “I don’t care what is going to happen next.” | |
| “It’s too quick. It occurs to you mentally—you can see it but you’re too fast to do anything about it.” | ||
| Synesthesia | “Music. I see music as having colors or shapes.” | “I can taste words.” |
| “See music in color, and everyday objects will get a personality.” |
Among the study limitations were that only a minority of invitees proceeded to interview and that our sample was unlikely to be representative of all patients with a bipolar condition, as our recruitment strategy would have resulted in overrepresentation of those who experienced altered sensory episodes and who were perhaps keen to learn more about the meaning of such phenomena. Also, while we examined changes in accepted sensory domains (smell, taste, vision, touch, and hearing, as well as synesthesia), the extent to which changed perceptions of connectedness, empathy, danger, and intuition are sensory changes or are more related to intrinsic hypomanic/manic mood states is somewhat problematic.
In our earlier report (1), it was implied that altered sensory phenomena may be confined largely to patients with a bipolar II disorder and relatively rare in bipolar I disorder. Despite limitations in sample representativeness and the comparatively small number of participants with bipolar I disorder, a key finding of the present study is that such phenomena may be equally common in bipolar I and II disorders, and perhaps even more common in bipolar I disorder. Our earlier report limited consideration of sensory changes to hypomanic/manic states. By asking our participants about such constructs during their depressive episodes, we also established the presence of depression-related sensory changes but with most changes being the converse of those experienced during hypomanic/manic states and generally evidencing a dampening or tamping phenomenon (a bipolar dimension)—although some participants reported a greater sensitivity to some stimuli during depressed states.
We sought to identify only nonpsychotic sensory experiences and changes, but the degree to which we can be confident that psychotic phenomena as well as overvalued ideas were excluded is unclear. The table details some descriptors that might be viewed as psychotic (e.g., feeling “like people are watching,” seeing “vertical white lines,” and perceiving auras or glows around people). In the first author’s judgment, it is not uncommon, however, for those with nonpsychotic bipolar states to report seeing things out of the corner of their eye or seeing lines, while simply “feeling” being watched is not necessarily “psychotic.”
One limitation to our methodological approach is that we failed to establish the mood state of the study subjects at the time of their interview, and it may be that such recollections were influenced by the individual being hypomanic, depressed, or euthymic.
These observations allow several conclusions and raise several questions. It would appear that sensory changes during mood swings in individuals with a bipolar disorder are unlikely to be rare, and it is therefore of interest that they have not been detailed in phenomenological descriptions of the bipolar disorders. As patients rarely volunteer comments on such perceptions, is it that they are concerned that reporting them might be judged as evidencing psychosis (and does that indeed occur?), or do they simply view them as correlates of their mood state? If such sensory changes are limited to the bipolar disorders, the phenomenon has the potential to advance detection and formal diagnosis of these disorders. Furthermore, functional MRI studies and examination of physiological responses to laboratory stimuli during manic and depressive phases would be worth undertaking in patients reporting such phenomena. Finally, do such phenomena have ecological advantages, perhaps contributing to the recognized overrepresentation of creativity among individuals with a bipolar disorder?
D. All of the above.
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Acknowledgments
The authors thank Kerrie Eyers and Leah Greenfield for their assistance.
References
1.
Parker G: The suprasensory world of bipolar II disorder. Am J Psychiatry 2014; 171:614–615
2.
Beers CW: A Mind That Found Itself. New York, Longmans, Green, and Co, 1908
3.
Lahera G, Ruiz-Murugarren S, Fernández-Liria A, et al: Relationship between olfactory function and social cognition in euthymic bipolar patients. CNS Spectr 2016; 21:53–59
4.
Cumming AG, Matthews NL, Park S: Olfactory identification and preference in bipolar disorder and schizophrenia. Eur Arch Psychiatry Clin Neurosci 2011; 261:251–259
5.
Hardy C, Rosedale M, Messinger JW, et al: Olfactory acuity is associated with mood and function in a pilot study of stable bipolar disorder patients. Bipolar Disord 2012; 14:109–117
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Swiecicki L, Zatorski P, Bzinkowska D, et al: Gustatory and olfactory function in patients with unipolar and bipolar depression. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:827–834
7.
O’Bryan RA, Brenner CA, Hetrick WP, et al: Disturbances of visual motion perception in bipolar disorder. Bipolar Disord 2014; 16:354–365
8.
Kéri S, Benedek G, Janka Z: Vernier threshold and the parallel visual pathways in bipolar disorder: a follow-up study. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:86–91
Information & Authors
Information
Published In
History
Received: 13 December 2016
Revision received: 23 January 2017
Accepted: 13 February 2017
Published online: 1 December 2017
Published in print: December 01, 2017
Keywords
Authors
Funding Information
National Health and Medical Research Council of Australia: Program Grant (1037196)
Supported by Program Grant 1037196 from the National Health and Medical Research Council of Australia.The authors report no financial relationships with commercial interests.Metrics & Citations
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