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
Table 1
DSM-IV-TR criteria for schizophrenia vs. psychotic mood disorder
Schizophrenia diagnosis6 | Seen in psychotic mood disorders |
---|---|
Criterion A | |
Hallucinations and delusions | 50% to 80% explained by mood16,21 |
Paranoia | Hides grandiosity4 |
Catatonia | 75% explained by mood7,8 |
Disorganized speech and behavior | All patients with moderate to severe mania1-5 |
Negative symptoms | All patients with moderate to severe depression4 |
Criterion B | |
Social and job dysfunction | All patients with moderate to severe bipolar disorder5,13 |
Criterion C | |
Chronic continuous symptoms | Patients can have psychotic symptoms continuously for 2 years to life5,6,13 |
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.