2 NAMES, 1 DISEASE: Does schizophrenia = psychotic bipolar disorder?

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.”

Mr. C shows each of these. Staff changes his diagnosis again—to schizophrenia, disorganized type, which carries a poor prognosis.^11,12

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