Schizophrenia, as we all know, is one of the most dibilating psychological disorder. It was primarily conceived of as a behavioral disorder, characterized by socially inappropriate and bizarre behavior, but much attention has been focussed nowadays on the cognitive component and the cognitive pathology underlying schizophrenia and it is not unusual for it to be characterized as a thought disorder nowadays . Bipolar , or Manic Depressive disorder, on the other hand, has been primarily conceived of as a mood or affective disorder , characterized by excessive swings of emotion and motivation. One of my earlier post
had tried to analyze the cognitive components involved in the Bipolar condition, and relate it to that found in unipolar depression. While in my earlier posts
, I have discussed the differences between the social and communicative difficulties of Autistic and Schizophrenic probands, especially in relation to their different cognitive styles, and how a milder form of such thinking can lead to different types of creativity, I had also promised for a similar dichotomous discussion of bipolarity at one end of the spectrum and depersonalization/ derealization/ 'Alienation' on the other hand- this time the important dimension being the feeling/emotion/motivation dimension. While that discussion still awaits, I have come across a fascinating article
by Lake et al(freely available, registration required) that tries to analyze the schizophrenic and bipolar type I disorders and concludes that there is no such thing as schizophrenia - the psychosis underlying schizophrenia, schizoaffcetive and Bipolar disorders is actually due to a not-yet-diagnosed Bipolar disorder in the patient. The extreme case of a Bipolar manic behavior would be a full-blown psychotic episode and in absence of proper assessment is likely to be diagnosed as schizophrenia. The article hopes, that identifying Bipolar in early stages would prevent unnecessary neuroleptics / anti-psychotics administration to the patient and prevent the significant side-effects of such medications and the rapid-cycling of the bipolar disorder itself, as mood stabilizers like Lithium and Valproate would not be given early on in the absence of bipolar diagnosis. The other rationale for a single unified diagnosis of Bipolar is to prevent stigma associated with a diagnosis of schizophrenia. There has been well-documented research on the creativity-bipolar linkages; a similar research exists for creativity and schizotypal individuals- but due to the chronic, dibilating and adverse effects of a full-blown schizophrenic diagnosis , the literature about creativity and full-blown schizophrenia is limited (and perhaps inconclusive). The comprehensive ill-effects of a wrong diagnosis are given below: For patient
- Less likely to receive a mood stabilizer or antidepressant
- Without a mood stabilizer, cycles increase and occur more rapidly; symptoms worsen
- More likely to receive neuroleptics for life, increasing risk for severe and permanent side effects
- Greater stigma with schizophrenia
- Less likely to be employed
- More likely to receive disability for life
- More likely to “give up”
- Increased risk of liability if patient given long-term neuroleptics instead of mood stabilizers develops tardive dyskinesia or commits suicide
The article takes a case study of a patient named Mr. C and tries to analyze how and why different diagnosis are made for the same patient depending on the presented symptoms and why Bipolar diagnosis occurs late in the cycle. Going through the case study may prove disheartening to many, and may make them skeptical of the whole psychiatry profession-leading to some anti-psychiatry rants too- yet one should realize that psychiatry is both an art as well as a science- asking the right question to get the patient (and disorder/ medication) history is very important. To appreciate this I would strongly recommend every body to read the "Selection of Antidepressant
' series on Corpus Callosum, which gives a fairly good idea of how psychiatrists make diagnosis in practice. It is instructive to recall that we have earlier reported on a study that leads to common genetic markers for Psychosis and Mania
- implying a single diagnosis, rather than a separate diagnosis of bipolarity or schizophrenia. The article cites the following DSM-IV diagnostic criteria for Schizophrenia and explains how each is explicable as symptoms of extreme manic episode resulting in psychosis /depression. Schizophrenia diagnosis6Seen in psychotic mood disordersCriterion A
Hallucinations and delusions50% to 80% explained by mood16,21
Catatonia75% explained by mood7,8
Disorganized speech and behaviorAll patients with moderate to severe mania1-5
Negative symptomsAll patients with moderate to severe depression4Criterion B
Social and job dysfunctionAll patients with moderate to severe bipolar disorder5,13Criterion C
Chronic continuous symptomsPatients can have psychotic symptoms continuously for 2 years to life5,6,13
I would like to pause here and group the symptoms of schizophrenia according to the basis they have:
- A sensory basis (hallucinations etc, which may be due to senosrimotor gating as well as a lack of proper inhibition mechanisms; delusions of reference which may be due to inability to gate the inputs and thus end up treating everything as salient and consequently referring to self),
- A cognitive basis (delusions - which may be due to extremes of normal cognitive biases that we all have - a manic delusion of grandeur- that may also lead paradoxically to delusions of paranoia( fear and suspicion) as one thinks of oneself as very special and hence vulnerable to the evil out there in the world)
- A motor basis (catatonia - which may be due to problems with volitional control of motion- either too much control or too little- in one case ending up in the positions in which someone else has put them in- in the other remaining in the same position (samadhi in religious contexts) by exercising the will to move. Here again dopamine dysfunction would be relevant as it is involved in motor pathways.
- A social/theory of mind basis (disorganized speech(flight of ideas) as one assumes too much ToM abilities in others and believes that the specifics one has left unsaid- and the abstract way in which one is talking - is comprehensible to others; disorganized behavior- which may be due to not taking social appropriateness into account as one is presumably on a very important mission on Earth.
- An embodiment/ grounding basis and problems with agency(religiosity as one thinks of oneself as not grounded in the body and thus may lead to delusions of control and persecution (as a shadow that is embodied elsewhere is trying to control one) . Here metaphorical thinking and use of symbols as symbols for something else (an overarching idea) rather than referring to something out in the world may lead to loss with reality and magical thinking that takes too much correlation-is-causation kind of thinking and extends it to non-material and non-living things.
- An Affective basis ( related to the fifth point for those who believe that emotions are due to body states) : the characteristic anhedonia , alogia and avolition. Symptoms that are similar in many ways to the symptoms of depressive state.
- A Volitional basis (social and job dysfunction may be due to disturbances in the volitional system- too much goal direction (and where the goal happens to be not socially or work-place acceptable) leads to job dysfunction as does too less of goal-directed behavior.
- Chronic nature: once neuroleptics are started one gets caught in the downward vicious circle. Also the nature of the disorder is cyclic just like the Bipolar with Positive symptoms more prominent in one phase and negative symptoms more prominent in the other phase. In between there can be remission and proper functioning.
Thus, I agree with the broad assessment of Lake et al, that most cases of schizophrenia may be juts an undiagnosed psychotic bipolar episode. Yet, I believe that schizophrenia is a heterogeneous disorder and there may be one or more sub-types. In my view schizophrenia proper leans more towards ToM/ social/ cognitive/ agency dysfunctions while Manic depressive is more about affective and volitional and recurrent dimensions. In my developmental framework; while the schizophrenic struggle with the first five developmental tasks; the bipolar struggle with the next three. Yet their common psychotic style confers susceptibility to psychosis in both cases. This would be as opposed to the same developmental challenges also faced by those with Autism/ depersonalization/ derelaization etc., who have an entirely different take on these issues. While one leans towards science (whose utility is well established); the other leans towards arts (whose utility is doubted sometimes), but which in my view is very important. We are getting evidence of how emotions can affect decisions towards a better outcome and how having a framework that gives one a sense of meaning and purpose is essential. Science and evolutionary thinking at times robs us of these finer appreciations of life- at that time we do need a counter-dose of Art to keep us more grounded and to make life more enjoyable and worth living- even if that costs some people their sanity!! Maybe we need both GOD and evolution; both science and faith to keep us sane and on the right course. Hat Tip: Neurofuture Tags: schizophrenia