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

Does the diagnosis matter? Failing to make an accurate initial diagnosis can worsen the course of patients who present with psychosis (Table 3):

• Bipolar illness not treated with mood stabilizers progresses, with episodes becoming more frequent and severe.^2,14,15
  
• Antipsychotics are given longer and in higher dosages for schizophrenia than for psychotic bipolar disorder and tend to have more common, chronic, and disabling adverse effects than do antidepressants and mood stabilizers.^14,16
  
• Mr. C was given an antidepressant without mood stabilization, which is contraindicated in bipolar I disorder (especially mixed type) because the cycling rate increases.^2,14,15
  

Paranoia and fear often hide grandiosity that is diagnostic of bipolar disorder, but patients such as Mr. C focus on perceived threats to their lives, not their grandiose delusions. Admitting physicians listening to their paranoid complaints may overlook the grandiose source and the possibility of psychotic bipolar disorder. Mr. C’s manic grandiosity explains the motivation for each of his psychotic behaviors: paranoid delusions, catatonia, and coprophilia.

Several initial signs could have raised suspicion that Mr. C had psychotic bipolar disorder (Table 4). Standard-of-care treatment in psychotic patients is predicated on early and correct diagnosis. On the basis of the evidence and our experience, we recommend that you look for bipolar symptoms when a patient:

• presents for the first time with psychosis, and you rule out an organic cause
  
• is readmitted for treatment of psychotic symptoms after having been diagnosed with schizophrenia.
  

Table 3

Consequences of misdiagnosing psychotic mood disorder as schizophrenia

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

Table 4

Mr. C’s symptoms that indicated bipolar disorder

Religiosity	Loud preaching and no past special interest in religion
Catatonia	Most frequently associated with bipolar disorder
Paranoia; fear	Usually hides grandiosity, which is diagnostic of mania
Distractibility	Could not stay focused in the diagnostic interview; showed ‘flight of ideas’
Pressured speech	Rapid, disorganized thoughts
Disorganization	Hallmark of mania; present in all patients with severe mania
Functional psychosis	If an organic cause is ruled out, a psychotic mood disorder is the most likely diagnosis
Trouble with the law	Police found patient disturbing neighborhood and escorted him to hospital
Patient history	Severe depression
Family history	Mother was treated for depression with ECT
ECT: electroconvulsive therapy

What is standard of care? Patients with psychotic mania warrant polypharmacy:

• an antipsychotic, with or without a benzodiazepine for sedation, to enhance ward safety and treat acute psychotic symptoms
  
• and a first-line mood stabilizer such as valproate, carbamazepine, lithium, or lamotrigine, followed by atypical antipsychotics.
  

Antidepressants appear to be contraindicated, even in psychotic bipolar depressed patients.^14,15 We suggest that you taper and discontinue the initial antipsychotic when psychotic symptoms resolve. Some data indicate that continuing antipsychotics in psychotic bipolar patients is detrimental after the psychosis has resolved.¹⁷ Medication-resistant cases may require two or three mood stabilizers and possibly an atypical antipsychotic.

The idea that “symptoms should be treated, not the diagnosis” is inaccurate and provides substandard care. When psychotic symptoms overwhelm and obscure bipolar symptoms, giving only antipsychotics is beyond standard of care.

Related resources

• Berrettini WH. Molecular linkage studies of bipolar disorders. Bipolar Disord 2001;3:276-83.
  
• Lake CR, Hurwitz N. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders. Psychiatry Res 2006 (in press).
  
• Pope HG, Lipinski JF. Diagnosis in schizophrenia and manic-depressive illness, a reassessment of the specificity of “schizophrenic” symptoms in the light of current research. Arch Gen Psychiatry 1978;35:811-28.
  
• Post RM. Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. Am J Psychiatry 1992;149:999-1010.
  

Drug brand names

• Haloperidol • Haldol
  
• Lamotrigine • Lamictal
  
• Lithium • Lithobid
  
• Lorazepam • Ativan
  
• Carbamazepine • Tegretol
  
• Valproate • Depakote
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgements

The patient described in this case report gave informed, written consent to interviews and to the anonymous publication of his treatment.

The authors thank Anita Swisher for technical assistance.