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

Tags: schizophrenia, depression, cognition, mania, creativity

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Praise: how to hand it and when to hand it

The traditional press seems to be catching up. The New York Magazine has an article on how praising children for their innate intelligence can backfire, but praising them for their efforts can be redeeming. We, at the Mouse Trap, have already covered the studies of Prof Carol Dwecke here, here and here and had come to the same conclusion that giving positive, specific and outcome based praise is better than giving general and innate/ trait/ talent based praises.

Much of the literature on praise that the New York Magazine author discounts and dismisses, needs to be reviewed with the praise-is-specific vs praise-was-for-talent variable taken into account. Throwing praise out with the 'talent' myth would be throwing the baby out with the bathtub. So the only quibble I have with the article is the leaning towards the elimination of all praise for children, a quibble in common with Mind Hacks through which I discovered this article.

Tags: intelligence, learning

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Encephalon #16 is online now!

Well, the sweet sixteens are all over us on this valentine's day. The sixteenth installment of encephalon was published recently by Mind Hacks and has interesting articles ranging from how the aggression and stress cortisol levels may be inversely linked (BTW, this new blog Do you Mind seems very promising) to how we make decisions. Also While I was on Hiatus, the 15 th edition of encephalon was published at the very good SharpBrains blog.

Tags: blogs, carnival

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Love, actually

There is a fasinating article in The Independent summarizing much of Dr Helen Fisher's work related to Love and its neural basis as well as many other aspects of Love. As per Dr. fisher Love comprises of three systems: Lust, Romance and Attachment.

Lust is a craving for sexual gratification, which you can feel for a whole range of people.

Those caught up in romantic love focus all their attention on the object of their affection. Not only do they crave them, but they are highly motivated to win them, they obsessively think about them and become extremely sexually possessive.During this state the brain is driven by dopamine, a neurotransmitter central to the reward system.

The third brain system is attachment - that sense of calm and security you can feel for a long-term partner. It is associated with the hormones vasopressin and oxytocin, which are probably responsible for the sense of peacefulness and unity felt after having sex. Holding hands also drives up oxytocin levels, as does looking deeply into your loved one's eyes, massage, and simply sitting next to them.

As I am prone to using analogical thinking to extremes, this seems to me like the 3 memory systems that have recently been discovered- one for novelty detection, the other for familiarity detection and the third for recollection. Lust to me mirrors the novelty drive: craving for new partners or new and unusual sexual experiences with the same partner. Romantic love is all about feeling a special bond with one (or more) person and being in special resonance with them to the exclusion of everything else. It leads to much more lasting recollections that do behaviors triggered by Lust or Attachment. The Attachment love is actually the long-term commitment and trust triggered by being vulnerable to a familiar person and involves the generational of feelings of familiarity/trust etc amongst long-term couples.

While the evolutionary rationale for Lust -having sex with as many new individuals as possible- is clear in that it distally takes care of the need to procreate and spread one's genes around; and the evolutionary rationale for Attachment is also clear - the long-term pair bonding ensures that the need of children's would be taken care of and both parents would do the parental investment- the evolutionary rationale for Romantic love is not that clear. If one looks at the costs associated with this, then the mystery appears to be more depended. Dr fishes offers a very plausible explanation- that romantic love is to ensure we are monogamous and our mating choice is restricted in the crucial young ages to one person.

Scientists have discovered that certain parts of the brain become deactivated when we're in love, including areas linked with negative emotions, planning, critical social assessment, the evaluation of trustworthiness and fear.

Biological studies have found that this phase of reduced cognitive function, during which faults are ignored, can last from one to two and a half years. This temporary state of delusion has a vital human function. If we immediately saw all our partner's faults, we would be less likely to form a stable relationship in which to produce children.

And it is just as well that it is short-lived: romantic love is has an enormous metabolic cost. "I think romantic love evolved to enable people to focus their mating energy onto just one person at a time, thereby conserving mating time and energy," says Dr Fisher. "It's not conducive to real life to live in this state for 20 years because you're distracted by it, you can't think of other things, you forget what you are doing, you probably don't eat properly, you certainly don't sleep well and you go through highs and lows."

To me the dopamine connection of romantic love seems very intriguing and hard to swallow!!

Tags: love, evolution, neuroscience

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Scientific Blogging redefined!

I have recently discovered a new community of great scientists and science bloggers (world's best as the tag line goes) at the Scientific Blogging portal. I would also be writing a column there called The Undercover Psychologist , though this column would be different from my blog posts on The Mouse Trap. There I would try to write more full-length articles. For some time though the content may be same.

I know that many of you readers are good science bloggers yourself, and those who have not joined the Science Blogs at the SEED, now have another very promising option in the form of Scientific Blogging. Do have a look at that and let me know how you like the other authors there.

Tags: blogs

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Depression and Mania: The Bipolar thinking style

PsyBlog has recently posted an article on Cognitive Therapy (CBT) and how it is useful in Depression treatment. this therapy has been shown to be equally effective in Depression as is medication, though this woks in a top-down fashion in the brain (revealed by brain scans), while anti-depressants work in a bottom-up fashion.

PsyBlog quotes the following irrational beliefs , as outlined by Beck, that are prominent in Depression.

* Over-generalization. Drawing general conclusions from a single (usually negative) event. E.g. thinking that failing to be promoted at work means a promotion will never come.
* Minimalization and Maximization. Getting things out of perspective: e.g. either grossly underestimating own performance or overestimating the importance of a negative event.
* Dichotomous thinking - Thinking that everything is either very good or very bad so that there are no gray areas. In reality, of course, life is one big gray area.

To me all of these beliefs are equally relevant for Manic thinking, although in the Manic case these beliefs would be about positive events and have a different spin.

• Over-generalization: a single instance of success at some endeavor disposing one to think that one can achieve anything in unrelated fileds. Also more co-incidence detection and more correlation-is-causation type of thinking that may ultimately lead to the Magical Thinking of full-blown Psychosis.
• Minimalizations and Maximizations: Here, again, things go out of perspective: Overestimating one's own performance and underestimating the importance of external happenstances that might have led to success.
• Dichotomous thinking: thinking that things are mostly good/bad and unfounded optimism/faith/trust - the opposite of the depressive feeling. Although the reverse thinking that things are mostly bad (external environment is bad, I am good) can also kick in. The point is seeing the world in Black/white but not in shades of gray.

PsyBlog also has an earlier post on depressive thinking style in which it elaborates on the internal-locus-of-control predisposition in depressive probands. Thus, the depressive style is marked by the following internal, global and stable attributions: :

* It is my fault that I didn't get the job. Here I have made an internal attribution.

* I think I am worthless: a thought that is likely to affect all areas of my life. Now I am making this attribution global.

* I see no reason for the fact that I am worthless to ever change. Now the attribution is stable

It is clear that the Manic person too makes the similar attributions: His success (maybe a single, lucky success) is due to his genius(internal attribution). His genius is not limited to one field- he is generally the most valuable, productive and creative genius and is an all-rounder(global attribution). His genius is not a short-lived entity- he will continue to remain a productive genius no matter what external circumstances / reality (stable attribution). He may thus have no drive to learn about external reality as he suspects that the external reality is not relevant and he can predict outcomes (which are bound to be good) based on his skills, expertise, grandiosity alone. An extreme form of this thinking may lead to the loss of reality characteristic of a full blown Psychotic episode.

While the minimalisations and maximizations are explained by the internal locus of control, the over-generalization is explicable by a propensity of jumping-to-conclusions sort of thinking that leads to global, stable over-regularizations. Another feature important in my view would be the mixing of contexts, where things from one context are referenced in another, dissimilar context. One could call this mixing up of metaphorical thinking where wrong analogies are applied and thus wrong (positive or negative) conclusions are arrived at. The third factor of dichotomous thinking is also very important though hard to pin down. Why should everything appear black and white in depressive or manic thinking and why in one case(depressive ), black is the color of self, while in Manic white is the color of self, remains a mystery. Answering how and when the switch from a grayish-world to a black-me-world(I'm a piece of shit) or white-me-world(I'm the next Einstein) happens would go a long way in making the bipolar patient control his moods and if he has to be sick then enable him to go for a manic episode (where the price may be insanity- a psychotic episode) instead of a depressive one (where there is a real risk of life).

Although the other wrong attributions and thinking styles also need to be addressed, the mechanism of the switching of mood/ black-white world view would help the most and should be the first one targeted in CBT/ medications.

Tags: attribution, cognition, therapy, depression, mania

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The inaugral edition of Brain Fitness blog carnival

SharpBrains has come up with an inaugural edition of the Brain Fitness Blog Carnival.

The cover article (if I may say so), by Alan Deutschman of Fastcompay, is an engaging look at how we may solve the wrong problems, like that of overeating- and ignore the real problems- those of stress, depression, existential angst that actually lead to overeating. The article is an important reminder that in the brain fitness domain, we need to frame the right questions and solve the right problems.

Other articles range form those on the importance of sleep for brain health to those explaining how CBT affects and heals the brain. There are a lot of gems to be discovered, so head over straight to the SharpBrainsn blog and indulge in some gold-mining.

PS: To regular readers of this blog who have been missing the regular posts,I'm sort of on a hiatus. Will, hopefully, blog more in the future.

Tags: carnival, blogs

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Science Blogger Reality Challenege

Watching too many Reality TV shows has been taking its toll on me, so I have come up with this absurd idea of an Internet Reality Show (aka American/ Indian Idol, Nach Baliye etc) for the Science bloggers (Psychology & Neurosciences to be precise, so that I have a fair chance of winning:-).

The Idea is like this:

1. Put up a pageflakes or some other type of page where RSS feeds (title only of 5 posts or so) of all participating bloggers are available.

2. Put another weekly challenge page that has RSS links of Full length articles by the participants on a particular weekly theme. These would be tagged with the theme keyword (say Evolution for 1st week) , so one can automatically have all the articles syndicated to that page. All authors would be expected to contribute one and only one article with that label in that week and this would be considered their weekly entry. One can even become traditional here, with time restrictions, and give a just released Seed/ NYT article as input for the theme article and just give a day (24 hrs) to blog about that. (Maybe seed or NYT can sponsor this:-)

Thus, we have a continuous RSS feed of all entries that simulates the practice or daily life behavior (blog posts) of the bloggers and we have a particular challenge entry on a given topic for a given week and this simulates their weekly 'performances'.

3. We have a polling system : Like thimble that allows all readers to vote juts once each week for the participant they think wrote the best 'performance article' . This poll page would be present on the 'performance page' only, so thta as far as possible people vote based on performances.

4. We will allow comments on the performance entries by everyone; but the we'll also have 2-3 highlighted comments by the Judges: Some judges chosen from blogosphere (Say Vaughan of Mind Hacks or P Z Myers of Pharyngula) and providing helpful comments about blogging style as well as content; while others may be practicing and famous scientists that do not find the time to blog usually but would anyway like to motivate us bloggers and would focus mostly on content; others may even be form professional journalistic field and enlighten us more about journalistic and media implications.


5. We might have eliminations at each stage (every week), so that only a few people remain in the end. (say only 2 in the final round, starting with 20 in the first round)

To ensure that people vote after reading the performance articles (and not based on the fact that they already are a reader of a particular blog) we can restrict the polling to happen only after a user (IP address) has browsed through all performance entries, but this seems unduly restrictive to me. I'll let it on the readers to vote conscientiously and read the good blog entries that would be surely be generated as performance entries.

I know that we have Carnivals that already satisfy the need to collect the best of the blogosphere; but this may add some glamour to the blogging community and get more readers involved.

I would love if someone suffering from Blogorrehea (aka Coturnix at The Clock) could come forward and take the responsibility of organizing this. I would definitely help, and if no one sponsosrs, will sponsor this----if an award would seem like a good incentive---Anyway we will have the Blogosphere Idol or some such title that should keep us bloggers motivated enough (and of course the increased readership would be the best reward).

So drop me a mail/ comment below if you are interested in elaborating on this theme/ participating etc.

Email me at sandygautam17ATgmailDOTcom

Lets get the first Internet Reality Show going!!

Tags: blogs, carnival

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