2 NAMES, 1 DISEASE: Does schizophrenia = psychotic bipolar disorder?
When psychosis clouds mood symptoms, mismatched medication can worsen patients’ course.
When a patient presents with psychotic symptoms, you might not recognize or pursue hints of bipolarity if you assume psychosis means schizophrenia. Yet psychotic bipolar disorder can explain every sign, symptom, course, and other characteristic traditionally assumed to indicate schizophrenia (Table 1). The literature, including recent genetic data,1-6 marshals a persuasive argument that patients diagnosed with schizophrenia usually suffer from a psychotic bipolar disorder.
Consider here how a cascade of changing signs and symptoms, initially unrecognized, caused five sequential re-evaluations of one psychotic patient’s primary Axis I diagnosis. His case highlights why the correct initial diagnosis of the disease causing psychosis is essential to effective treatment.4,7-9
DSM-IV-TR criteria for schizophrenia vs. psychotic mood disorder
Seen in psychotic mood disorders
Hallucinations and delusions
Disorganized speech and behavior
All patients with moderate to severe depression4
Social and job dysfunction
Chronic continuous symptoms
Case: Carved in stone
Police officers carry Mr. C, age 30, into the emergency department. He is mentally disorganized and arrives in a rigid, catatonic posture. According to a neighbor, Mr. C was kneeling motionless on his mother’s front lawn, alternating between mutism and inappropriately loud, disorganized religious preaching. When his arm is lifted, it remains as placed. He is admitted to the acute care inpatient unit.
Mr. C’s most striking symptoms are catatonia and psychosis. Postural rigidity, waxy flexibility, and automatic obedience are characteristics of catatonia.6-8 An organic cause is first considered, such as hyperthyroidism, cerebrovascular accident, cerebral neoplasm, head trauma, seizure disorder, dementia, neuroleptic malignant syndrome, pheochromocytoma, or—especially—intoxication from illegal drugs.7
While awaiting results from physical, mental status, and lab exams and imaging studies, staff assign him two admitting diagnoses: catatonic disorder due to a general medical condition and psychotic disorder not otherwise specified.6
Case: Inconclusive workup
Mr. C denies using illegal substances or alcohol, which his mother confirms. He has no history of seizures or other medical conditions. His distractibility prevents him from focusing on a formal mental status exam. Physical exam, urine drug screen, lab results, and imaging studies are unremarkable except for an admitting blood pressure of 145/95 mm Hg and pulse of 115 beats per minute. These readings normalize within 1 hour. IM haloperidol and lorazepam are given as needed for agitation, but physicians withhold scheduled medications to allow staff to observe his symptoms.
Organic causes of catatonia now seem less likely, though past use of drugs such as phencyclidine that can cause chronic psychosis cannot be ruled out. Schizophrenia is considered likely because catatonia is one of schizophrenia’s five core diagnostic symptoms.6 Catatonia can also be a symptom of bipolar disorder.6-9 Staff make a preliminary diagnosis of schizophrenia, catatonic type.
Case: ‘Hit men are after me’
Staff observe Mr. C responding to threatening auditory hallucinations. His affect is “fearful to terrified.” He says he hears the voice of God warning him of danger and continuing a running commentary on his actions. He fears for his life because “hit men have been sent to kill me” and have “infiltrated” the inpatient ward. He does not eat, saying his food is poisoned. He says these beliefs have escalated over the past year.
Mr. C’s catatonic symptoms resolve overnight, but obtaining additional history is difficult because of his paranoia. He denies any history of bizarre behavior or past contact with mental health services. He claims not to be especially religious. He is unmarried and lives with his mother, is college-educated, but has held only menial jobs.
Inpatient staff shifts its diagnostic focus to functional disorders associated with auditory hallucinations, paranoid delusions, and gross disorganization. According to Schneider and the DSM-IV-TR,6,10 hearing a voice “keeping up a running commentary on one’s behavior” is especially diagnostic of schizophrenia.
Because of the rapid resolution of his “catatonic” symptoms and prominence of paranoia, they change his diagnosis on day 2 to schizophrenia, paranoid type. Mr. C meets all diagnostic criteria for schizophrenia except one: the staff has overlooked and has not adequately excluded a psychotic mood disorder.
Case: A turn for the worse
That night, nursing staff find Mr. C naked and cowering in the fetal position in a corner of his room. He has smeared his feces on his face and in his hair and mouth. While being cleaned up, he suddenly begins quoting scripture in a loud, disorganized voice. His expressed thoughts are incomprehensible. He is given haloperidol and lorazepam immediately; oral haloperidol is continued at 10 mg bid.
Both Bleuler and Kraepelin concluded “coprophilia and coprophagia are unique to children and patients with schizophrenia.”11,12 The DSM casebook cites Kraepelin’s description of a catatonic patient who “smeared feces about” as a “classic, textbook case” of schizophrenia.11 The casebook goes on to say: “In the absence of any known general medical condition, the combination of coprophilia, disorganized speech, and catatonic behavior clearly indicates the diagnosis of schizophrenia.”
Case: Banking and ray guns
By day 5, Mr. C’s mental status is normalizing and his psychosis improving. He volunteers for a weekly student case conference. There, he reveals additional information that staff could have discovered at admission with more-focused questions.
He reports that 2 years earlier he suffered severe suicidal depression. Six months later, during a hypomanic episode, he began “toying with the idea” that he might become part owner of his local bank. He believes “the Secret Service decided to transfer ownership to me.”
His plans upon acquiring the bank include buying three houses and six cars valued at several million dollars and running for state governor. For weeks before admission, he did not need sleep, experienced an increase in energy and activities, and his mind was racing. His job seemed so “trivial” that he quit. Immediately before his hospital admission, his delusions intensified to include an “evil conspiracy” to murder him for ownership of the bank and he feared his execution was imminent.
He explains his catatonic behavior on the lawn by his belief that “hit men” hiding across the street aimed a “motion-detecting, heat-seeking ray gun” at him so that if he had “moved an inch,” he would die. He says the “feces incident” was an effort to get himself transferred to the state hospital, where he thought he would be safer because his present caretakers were “infiltrated.” He also says his mother received electroconvulsive therapy in her 20s.
These symptoms—especially the striking grandiosity, lack of need for sleep, racing thoughts, hallucinations and delusions—define a manic episode with psychotic features. Only one manic episode as described here is diagnostic of bipolar disorder, type I.2,6,13 Staff changes his diagnosis to schizoaffective disorder, a compromise used to include patients with bipolar and psychotic (schizophrenic) features. Some authors contend schizoaffective disorder is psychotic bipolar disorder and not a separate disease.3,4,9
Case: From SSRI to lithium
After 2 weeks, Mr. C is discharged on haloperidol, 5 mg bid, but no mood stabilizer. He receives follow-up care at a community mental health center. When he develops severe depressive symptoms 6 months after discharge, the attending psychiatrist starts him on a selective serotonin reuptake inhibitor (SSRI). Within 2 weeks, Mr. C switches from depression to a mixed, dysphoric mania. After the SSRI is discontinued and lithium is added to his haloperidol, his mood gradually stabilizes to moderate depression. He develops rigidity, masked faces, and a fine tremor in his hands.
About 10% of bipolar depressed patients given an antidepressant—especially without a mood stabilizer—switch to mania, and their cycle frequency increases.2,13-15 A correct initial diagnosis and treatment with a mood stabilizer might have avoided Mr. C’s switch.
Mixed bipolar disorder with overlapping depressive and manic symptoms is often resistant to monotherapy, requiring two or more mood stabilizers such as lithium and an anticonvulsant.14 Without a mood-stabilizing combination, the mixed, rapid-cycling type of bipolar disorder is likely to progress, with more-rapid and more-severe episodes.2,13-15 Adding lamotrigine, a mood stabilizer with antidepressant effects, can help.2,14
Stopping the SSRI is correct, despite Mr. C’s severe depression, to avoid increasing the cycle frequency.13-15 Some authors recommend tapering the antipsychotic, using it only as needed for psychotic features after psychosis has resolved.14-17 Continuing antipsychotic drugs after psychosis has remitted increases rates of cycling to depression, depressive and extrapyramidal symptoms, and medication discontinuation.17 Lithium may have aggravated Mr. C’s antipsychotic-induced parkinsonism, but discontinuing haloperidol may have been the most therapeutic decision.
The community mental health staff changes his diagnosis again, this time to bipolar disorder, type I, mixed, severe with psychotic features. We concur that this is correct.
Case: A diagnostic step back
Two years later, Mr. C is working and continues to take lithium and haloperidol prescribed at the mental health center. His intermittent depressive episodes persist, but—apparently because he has not had another manic episode—the staff switches his diagnosis back to schizoaffective disorder.
We disagree with this change. A diagnosis of schizoaffective disorder precludes ideal pharmacotherapy for Mr. C’s rapid-cycling bipolar disorder and increases the risk of adverse drug effects and stigma. Persuasive evidence shows that schizoaffective disorder is psychotic bipolar disorder; there is no schizoaffective disorder (Box).3,4,16-18
Schizophrenia: No such disease?
Three disorders—schizophrenia, schizoaffective disorder, and psychotic bipolar disorder—have been evoked to account for the variance in severity in psychotic patients, but psychotic bipolar disorder expresses the entire spectrum. We concur with others that psychotic bipolar disorder includes patient populations typically diagnosed as having schizophrenia and schizoaffective disorder.3,4,9,16-18 In other words, there is no schizophrenia or schizoaffective disorder.4,19
Based on these data, we advocate re-evaluating all patients diagnosed with schizoaffective disorder and schizophrenia, with detailed inquiry for personal and family histories of mania or hypomania. A mood stabilizer may be warranted in some patients with psychosis but without clear manic symptoms. In such cases, we suggest using a provisional DSM-IV-TR diagnosis of psychotic disorder not otherwise specified while you seek obscure mood and/or organic causes.
Misdiagnosis of psychosis
Bipolar disorder can be missed when patients present with psychotic symptoms, but clinicians could have initially recognized Mr. C’s bipolar disorder. His diagnostic trail illustrates important points about psychotic presentations:
- Predominant psychotic symptoms can obscure mood disturbances.
- Mistakenly believing that psychosis means schizophrenia can jeopardize patient care.
- When paranoia and fear hide grandiosity, then mania—not schizophrenia—is likely.
- Psychotic mood disorders—not schizophrenia—cause functional psychosis; there is no schizophrenia (Box).
- Pursuing mood symptoms in psychotic presentations is critical in an initial diagnostic interview.
Questioning the concept that hallucinations, delusions, catatonia, and disorganization are specific to and diagnostic of schizophrenia is not new. In 1978, Pope and Lipinski compared symptoms, course, outcome, family history, and responses to lithium in bipolar disorder and schizophrenia.3 They and others find no symptom, group of symptoms, or course that differentiates schizophrenia from psychotic bipolar disorder.3-5,8,9,16,18,19 They conclude that most cases diagnosed as schizophrenia or schizoaffective disorder are misdiagnosed cases of bipolar illness, whereas others question the validity of schizophrenia.20
Bipolar disorder has a broad spectrum of severity and course; it frequently reaches psychotic levels that can become chronic.2,5,21 Psychotic symptoms of rigorously diagnosed bipolar patients can deteriorate until their overwhelming psychosis obscures bipolar symptoms.5,6,13,21 Like most, if not all, acutely psychotic bipolar patients, Mr. C shows all diagnostic criteria for schizophrenia.1-6,21