This is a two part question that was asked to a doctor on CNN and I found his answers to be quite interesting so I decided to post both parts here.

Are bipolar disorder and schizophrenia very similar?

The issues you raise, Tony, are so interesting that I am going to devote this week and next week’s answer to addressing them. And apologies in advance for using a little more academic language than I normally do.

Modern psychiatry is built around diagnosing psychiatric disorders based on three primary factors: clustering of symptoms, course of symptoms over time and degree of life impairment that results from these symptoms.

Think for a moment about how different this approach is from the way most medical disorders are diagnosed and treated these days. Let’s say you develop crushing chest pain and shortness of breath. You go to the ER. Do they make a diagnosis of heart attack (myocardial infarction, or MI) based on your symptoms?

No, they order a blood test that will show whether heart muscle is dying. And they get an electrocardiogram, to measure electrical activity in the heart, which changes in very specific ways in the context of an MI. If these tests are positive, you are admitted and rushed off for other tests and interventions. If the tests are negative, you are told that you are probably having an anxiety problem and referred to a psychiatrist.

We have no blood tests in psychiatry, nothing like an electrocardiogram. All we have are symptoms we can watch over time. In this way, we are in a situation not so different from doctors in other fields of medicine 100 years ago, before organs such as the heart and lungs began yielding their secrets to technology.

I say all this as a prelude to addressing your first question about how similar schizophrenia and bipolar disorder are, and if they are similar, how they can be told apart. It turns out that this question is where modern psychiatry began.

In the 19th century, psychosis was considered to be a single condition characterized by various symptoms consistent with a person being disconnected from reality. It took a gentleman named Emil Kraepelin — who is often considered the father of biological psychiatry — to notice around the turn of the 20th century that although psychotic states looked similar to one another, people with psychosis seemed to follow one of two long-term disease courses.

One group of people developed psychosis early in life and had a progressive decline in their ability to think and function that was unremitting and terrible. Reflecting the degeneration that accompanied this state, Kraepelin called this condition “dementia praecox.” Today we call this schizophrenia.

Another group of people who developed psychotic symptoms tended to do so a little later in life. Rather than showing a constant decline, these people circulated in and out of madness, and they were always either depressed or elated when they lost touch with reality. To this condition, Kraeplin give the name manic depression — a term that although still in use, has been supplanted by the category of “bipolar disorder” in official psychiatric nomenclature.

So notice that the essence of the distinction between schizophrenia and bipolar disorder has nothing to do with the type of psychotic symptoms that a patient demonstrates, but rather with the course of the symptoms over time.

This insight got lost for half a century when psychoanalysis reigned supreme, but made a strong comeback in the 1960s and 1970s with the advent of new scientific techniques for studying the brain, and more importantly, the availability for the first time of medications that had profound effects on psychosis and mood disorders.

Especially relevant to the distinction between schizophrenia and manic depression was the discovery that lithium was often a miracle drug for people with bipolar disorder but was generally of little use in schizophrenics. This pharmacological truth seemed to powerfully validate Kraepelin’s ideas. From the marriage of Kraepelin, new scientific techniques and new medications was born the modern psychiatric diagnostic guidelines that can be found in the DSM-IV.

So that’s a little history. Next week I’ll turn to the task of answering your questions directly. But by way of preview I can tell you that the certainties that launched modern diagnostic psychiatry have mostly vanished, and continue to fade with each new scientific discovery. So the short answer to your questions is that schizophrenia and bipolar disorder are increasingly looking more similar than separate.

Part Two

This week we pick up where we left off last week. If you didn’t see last week’s entry regarding this question, click here.

When I was a psychiatry resident at UCLA I had an ongoing friendly disagreement with a friend of mine named Matthew State, who was one of the best residents I ever knew and who has gone on to become a famous psychiatric genetics researcher. Matt maintained steadfastly in those years that because psychiatric disorders actually existed as distinct entities, every patient could be described fully by one or more diagnoses. If you couldn’t do this you hadn’t tried hard enough.

In contrast, I maintained then, and still maintain, that psychiatric diagnoses are like Platonic ideals, they are “perfect types” that patients more or less approximate. Because of this some patients have histories that walked right out of the DSM-IV diagnostic manual, but others have stories that fall between the diagnostic cracks and that, therefore, will never fit a diagnosis very well no matter how hard you try.

You can see why I’m telling this story. While modern psychiatry was built to no small degree upon the belief that schizophrenia and bipolar disorder were separate psychotic illnesses, I think data increasingly suggest they are more similar than different. You can see this any way you look at it.

More and more studies suggest that they share genetic risk factors. That, in fact, there may be some genes that predispose one to psychosis and other genes that predispose one to mood disorders. If you just get the psychotic genes you look schizophrenic. To the degree you get both types of risk genes you look more bipolar. Although as I mentioned last week, lithium works for bipolar disorder but not for schizophrenia, in the last decade a small army of medications has been introduced onto the market that work well for both conditions, strongly suggesting a shared neurobiology.

Finally, long term follow-up studies have shown that schizophrenia doesn’t always lead to an unremitting downward spiral, and, unfortunately, bipolar disorder is not a condition characterized by no long-term damage. In fact, it is increasingly clear that the deterioration in functioning over time that was once thought to be a hallmark for schizophrenia is also very common in people with bipolar disorder.

So these comments answer your first and third question, leaving the question of how to tell a psychotic mania apart from a schizophrenic psychotic episode. Every psychiatrist in the world believes he or she can do this, but the best data on the issue suggest this isn’t true. In fact, any symptom present during a psychotic episode can occur in people who, over time, look more schizophrenic or who look more bipolar. Having said this, however, because I am a psychiatrist I, like everyone else, think I can make an educated guess about whether someone is manic.

Here are a few clinical “pearls” for identifying a manic psychosis. First, manias tend to come on more quickly than schizophrenic episodes. They are often preceded and accompanied by remarkable reductions in sleep. Classic manic episodes are characterized by profound mood changes. These are easiest to recognize when the mood is euphoric, but rage is just as common, and more dangerous. If you see a psychotic patient who is moving and speaking a million miles an hour, that doesn’t prove he is manic, but it is a pretty strong clue. Finally, although data show you can’t separate out manic from schizophrenic episodes by the quality of the psychotic delusions, I have always been impressed by the fact that at the core of manic delusions is a sense that everything in the universe is connected in strange and meaningful ways. Again this isn’t specific for mania, but if this type of thinking is present along with other symptoms I’ve described, it is a tip that someone is having a manic episode.

So let me end on one final note of confusion/uncertainty. Long-term studies of patients who are schizophrenic suggest that a high percentage of them will have at least one manic episode in their lives! So what is the take-home message? Both schizophrenia and bipolar disorder are serious and often devastating conditions that have the best outcomes when treated early and aggressively. You don’t want to leave someone in any type of psychotic state for one moment longer than you have to.

Original article link part one
Original article link part two

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