Friday, February 23, 2007

Schizophrenia and Bipolar disorder: The propensity towards psychosis

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”

  For clinician

  • 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 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


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

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11 comments:

Colin said...

With all the evidence that schizophrenia is actually a collection of slightly related disorders, why would you try to reduce it to bipolar disorder? It's like trying to put a dog sweater on a multi-headed hydra. Sure there's similarities but that's not really surprising.

As a side note, I'm really tired of the constant associations between artistic vision and psychosis.

"...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!"

Personally as an artistically creative and sane individual, I find this insulting. Even if there is a higher likelihood of mental disorders with creative people it doesn't mean that the psychosis is a requirement for creative vision. Certainly there are well known outsider artists, but there is an a larger number of people with psychosis who are not artistic. And more to the point there is a larger number of highly skilled artists who are quite sane.

Sandy G said...

Colin,

We all know that schizophrenia is a heterogeneous disorder and my post also mentions it; but so is Bipolar - with Bipolar type I and Type II distinctions and even depression that comes in many flavors. There are reasons for treating them as different; but more importantly there are reasons to not miss the forest for the trees and have a bird's eye view of psychosis as the underlying pathology for both bipolar and psychosis.

My post mentions in detail, the reasons why one would like to reduce schizophrenia/ schizoaffective to bipolar -- for better patient outcome and early treatment with mood stabilizers; this is important as both pop psychology and even psychologists consider psychosis = schizophrenia. and not psychosis = bipolar. Also theoretically seeing similarities, and keeping in mind the differences would sure help in better theory of both Psychosis and negative symptoms of schizophrenia. Also recent genetic research also pints towards common genetic markers for psychosis in both disorders.


As for the passage about art and science , I would request you to read that in an evolutionary perspective. Why psychosis continues despite considerable reproductive and survival costs is an evolutionary mystery- Many theories ranging from language evolution to creativity have been proposed.

I believe there is considerable evidence linking creativity of imaginative and subjective type with schizophrenia/ bipolar probands (and all of those lying in the proband are not 'insane') and I find the theory that schizophrenia/ bipolar is the evolutionary cost we are paying for emergence of artistic creativity plausible.

You may differ here, but to feel 'insulted' on sharing genes with schizophrenics/bipolar is just pure and unbridled stigma and prejudice. Sane is a very relative term and if one reads Fromm's The Sane Society one would consider a majority of us insane.

The contention was never that all creatives are psychotic or vice versa- but the contention is that evolution of artistic (loosely meaning subjective and imaginative creativity) creativity is tied to the presence of psychosis in human populations. Some genes that , in combination with some malfunctioning genes give rise to psychosis, also give rise to creativity in combination with other good genes.

Also a last note of caution, I firmly believe that artistic and scientific achievement or skill is also largely dependent on practice and dedication and is not entirely due to talent/genes.

colin said...

You make some good points in your reply. I can agree that there is an overlap of symptoms which should not be overlooked. In fact, I feel that much of the history of psychology/psychiatry has been too focused on creating these overarching umbrella terms and thereby loosing focus on the trees, as it were.

The original post was seemingly focused on proving that much of schizophrenia is really bipolar disorder. Possibly a better way of saying it is that there is a lot of overlap in the symptomology of schizophrenia and bipolar disorder. And thus, it might be beneficial to treat said symptoms the same way as they are treated in the other disorder.

I grant you that it there may very well be a link between our brain evolution and psychosis -- recent research does indicate this. Possibly while making it more complex it also made it more brittle in the wrong situation. However, there is little reason to link it specifically to creativity rather than any of the other evolved aspects of human cognition.

I guess “insulted” was a somewhat ill-chosen word. However, I still feel a bit put off by the romanticism of mental illness whenever it is entwined with artistic creativity.

I understand where the idea originates, as there is an aspect of in disordered thinking in the creative act (i.e., thinking outside the box). This is kinda what the initial aspect of brainstorming is all about. However, creativity is more than just disordered thinking -- it also requires an ordered thinking.

From the other perspective, I can see where people see the delusions of schizophrenia as examples of creative vision. In a sense, the creative system takes over to cover up flaws in the cognitive system. But this doesn’t have to mean there was a flaw in the creative system. It could just be that there was a flaw in another aspect of cognition and as the gaps got larger the creative system just had to bridge ever wider stretches of improbability. And often times, the delusions really aren’t that creative – mostly just borrowing from various cultural aspects and traditions.

colin said...

I realized after posting that my last sentence ("...the delusions really aren’t that creative...") was vague to the point of meaninglessness. What I'm getting at is that I have a feeling that a majority of delusions that people suffer from are mundane. While the exceptionally weird delusion are definitely creative I don't believe that is is caused by this. It might be just an overcompensation for other issues and a breakdown in one's ability to judge whether a thought is veridical.

Sandy G said...

Colin,

I agree that it is best to not equate schizophrenia with bipolar but just to highlight their commonalities and the implications these commonalities/ misdiagnoses may have for the patient's well-being and timely remission.

Creativity does involve flexible and rapid thinking, novel uses of familiar objects (all of these are also elevated in psychotic patients); but I agree that not all creativity is brainstorming.

Neither do I think that any delusions suffered during psychosis are a manifestation or example of creative thinking. when a person is deluded, he/she is definitely not being creative about how to cope with life.

Anonymous said...

Schizophrenia, bipolar disorder, and other "disorders" are related by common causation.

This can be shown by investigating Subliminal Distraction.

When you view Schizophrenia as an altered mental state created by SD exposure many of the mysteries of mental illness disappear.

The connection between mental illness, intelligence, and creativity is that those with increased cognitive gifts are more likely to have behaviors that allow SD exposure.

VisionAndPsychosis.Net is a five year investigation to find the connection between mental illness and Subliminal Distraction.


http://VisionAndPsychosis.Net

Anonymous said...

Could mirror neuron abnormalities be a cause of bipolar/schizo-affective disorders?

Recent articles in mainsteam media have discussed deficits in mirror neuron activity as a likely factor in autism-spectrum problems.

Conversely, could a surplus of mirror neuron activity lead to the onset of bipolar/schizo-affective episodes?

A member of our family has annual manic/schizo-affective episodes (correlated with change of season).

Each episode typically begins with a hyper-empathetic response to others' qualities and experiences.

As boundaries between self and the universe dissolve, sharp mood swings follow. He describes an elation based on a belief/certainty of his ability to read thoughts and for his thoughts to influence others. And then he despairs given a sense of complete identification with the suffering of others, and of vulnerability to their bad thoughts.

Could such symptoms result from the lack of hormones or other biochemical suppressors that normally regulate mirror neuron activity?

And are researchers or pharmaceutical companies now considering this scenario -- and potential treatments based upon it -- as an opportunity to ease the suffering of those afflicted with bipolar and bipolar-linked schizophrenic disorders?

Look forward to hearing...

Sandy G said...

Hi Anonymous,

You make some very good points in your post. It is indeed plausible that some of the problems / causes off bipolar/ scizophrenic persons may be because of an over activity of the mirror neuron system. This may be genetic, hormonal or environmental. To my knowledge known of the univs/ pharmacuies are looking into that aspect of psychosis and I agree that research in this direction would be fruitful.

Thanks for your insightful comments and for sharing the experience opf your relative, whihc rings very much typical of a schizo-affective/ bipolar person.

Anonymous said...

The purpose of diagnostic classification is to make distinctions so that we can isolate the differences in people's behavior. We know that to a large extent, we are still ignorant of what is occurring inside the black box and we are making our classifications based upon the behaviors we see. No doubt very different causes may give rise to very similar behaviors, resulting in our treating as a single disorder problems that have totally different origins. At this time, our knowledge does not allow us to do better.

The process of lumping dissimilar behavior patterns together into one Super Disorder is a regression. In the case of schizophrenia and Bipolar, it is worse -- the combination goes directly against clincial observations. Catatonics are different from Bipolars in either manic or depressive state. Delusions of persecution and/or granduer are quite different from manic spending at Neiman Marcus.

The article's other idea that we should cease giving the schizophrenic label because there is a stigma attached to the name schizophrenia is similarly unacceptable. The stigma exists because people with the diagnosis behave strangely. We've been through this name game silliness with sociopath, psychopath and now antisocial. In time, each name comes to carry the stigma because the persons with the diagnosis present very real dangers to others.

Changing a label in order to avoid a well earned stigma is intellectually dishonest. In fact, it is a type of fraudulent misrepresentation to deceive laymen into thinking that the person is not seriously disorded.

sy said...

Depression only man makes unhappy. So we try to control it. Prevention is better than cure.

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symonds
Dual Diagnosis

Dual Diagnosis

herhtdm said...
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