Ideas and Delusions of Reference in Bipolar Disorder

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In people with bipolar disorder, mania and hypomania can comprise various symptoms, from reckless spending to sexual promiscuity. In addition, some more subtle symptoms may also occur, such as the belief held by some patients that everything occurring around them is related somehow to them when in fact it isn't. This symptom is known as ideas of reference. An extension of those irrational beliefs, delusions of reference, can cause patients to change their behavior significantly because of this mistaken belief.

These two symptoms—ideas of reference and delusions of reference—can affect people in very different ways. For example, a man might believe that secret messages about him are broadcast in a weekly television show, to the point where he records the programs and watches them again and again. Meanwhile, a woman might be convinced that all the notices posted on boards outside churches are aimed directly at her, which frightens her so much that she refuses to leave the house.

Ideas of Reference vs. Delusions of Reference

Some clinicians and researchers use the terms ideas of reference and delusions of reference interchangeably. Other sources differentiate between the two, saying that ideas of reference have less impact on the person's life as a whole.

Whereas ideas of reference are real events that are internalized personally, delusions of reference are not based in reality. However, ideas of reference may act as a precursor to delusions of reference. 

Many people will experience passing thoughts or ideas of reference. For example, you go to a party and just for a minute honestly believe everyone is whispering about you. This is within the scope of normal human behavior unless it happens to you constantly.

It's when these thoughts cross the line outside of actual facts or events (when you believe people you don't even know are whispering about you, and you proceed to hide out at home because of this) that the thoughts turn into delusions.

The 3 Criteria for Delusion

Karl Jaspers, a German-Swiss psychiatrist, described the main criteria for a true delusion in a groundbreaking 1913 book, General Psychology. They include:

  • Certainty (the person is convinced the delusion is real).
  • Incorrigibility (the person cannot be convinced otherwise or have the belief shaken in any way).
  • Impossibility (the delusion is bizarre and not real at all).

Some people have only occasional, random delusions of reference, while others have them all the time.

If delusional thoughts occur for more than one month and they involve events that actually could happen (such as being followed, infected with a disease, or loved at a distance), delusional disorder is the diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) clarifies the criteria for delusional disorder, which may appear in people with Bipolar disorder. Specifically, the DSM-5 specifies that those with the disorder may have nonbizarre delusions, meaning what you’re imagining is happening could really happen (such as being followed).

The key difference between delusions of reference and delusional disorder is delusions of reference are most definitely not real while the thoughts in delusional disorder could possibly be real (although they're quite unlikely).

Other Types of Delusions

  • Bizarre delusions have no possibility or basis to happen in reality.
  • Delusions of control mean that a patient's thoughts, feelings, and actions are not his or her own, but instead originate from some external force or person.
  • Depressive delusions are marked by a predominant depressive mood. These might include delusions involving a serious illness, poverty or spousal infidelity.


Antipsychotic medications can help with delusions of reference, as can counseling and psychotherapy. Cognitive behavioral therapy is used to help people reframe their thoughts and explore logical explanations for their line of thinking.

3 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Institute of Mental Health. Bipolar Disorder.

  2. Cermolacce M, Sass L, Parnas J. What is bizarre in bizarre delusions? A critical review. Schizophr Bull. 2010;36(4):667-79. doi:10.1093/schbul/sbq001

  3. National Center for Biotechnology Information. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health.

Additional Reading
  • Jaspers, Karl. "General Psychopathology." JHU Press, Nov 18, 1997.

  • Kiran C, Chaudhury S (2009). "Understanding Delusions" Ind Psychiatry J. 18:3–18.

By Marcia Purse
Marcia Purse is a mental health writer and bipolar disorder advocate who brings strong research skills and personal experiences to her writing.