The End of Kraepelin’s Dichotomy
23 Jan, 09 | by Steven Reid
No, don’t worry; this isn’t a blog about metaphysics. It was over 100 years ago that Emil Kraepelin, widely considered the father of contemporary psychiatry, divided psychosis into two discrete disorders: dementia praecox (schizophrenia) and manic-depressive insanity (bipolar disorder). Hence the dichotomy, which remains a hallmark of the classification of mental illness.
This categorical approach to diagnosis has plenty of critics but the divide remains firmly in place. Why? Partly because making a psychiatric diagnosis is often an uncertain business. It’s inherently appealing to have just two options to choose from when trying to make sense of a complex clinical picture. Plus the textbooks tell you it’s straightforward: schizophrenia means an enduring illness, with a flat, unreactive mood, and inevitably a poor outcome, in contrast to bipolar illness which is episodic with dramatic changes in mood, and of course that flair for creativity. Well life’s not actually like that. In clinical practice it’s often difficult to discriminate between the two. Take a look at the casenotes of a person with schizophrenia and at some point it’s likely someone will have made a diagnosis of bipolar disorder, and vice versa. In fact we’ve even had to invent a new diagnosis - schizoaffective disorder - for those cases when you just can’t make up your mind. So there has been disquiet about Kraepelin’s dichotomy for some time and now we have a behemoth of a study which may well prove to be the final nail in its coffin.
Published in the Lancet this is a population-based study including over nine million Swedes, that teases apart the genetic and environmental contributions to both schizophrenia and bipolar disorder. Previous genetic studies have been nowhere near as big so the findings are compelling. We know that genes are important in both schizophrenia and bipolar disorder but here it’s demonstrated that they share a common genetic cause. First-degree relatives of people with bipolar illness had an increased risk for schizophrenia, including adopted children to biological parents with bipolar disorder. Similarly, relatives of those with schizophrenia were at increased risk of bipolar disorder.
So what next? Out with the old diagnostic criteria? Perhaps…it certainly gives the committees debating the next version of the psychiatrists’ diagnostic manual (DSM-V) plenty to think about. Maybe it’s time we moved toward a psychosis-spectrum disorder with a renewed emphasis on symptoms. After all, it’s the symptoms that predict response to a specific treatment, not the diagnosis. And what of Kraepelin, would he approve? Well he was having doubts about his own dichotomy back in 1920, “No experienced psychiatrist will deny that there is an alarmingly large number of cases in which it seems impossible, in spite of the most careful observation, to make a firm diagnosis…. It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses and this brings home the suspicion that our formulation of the problem may be incorrect”.
After reading what you wrote regarding the link between bipolar and schizophrenia I must say that I’m a little concerned. I’ve just been diagnosed with bipolar and my Dr hasn’t mentioned this at all. There is no history of schizophrenia in my family so one would hope that would make the chances neglible?! Your article is rather ’sensationalist’ but I am sure that you will claim you are stating facts!
Please check out my blog at bipolar999.blogspot.com
Greg Longley
February 9th, 2009 at 11:44 pm
Sensationalist? I don’t think so. Your doctor made a diagnosis of bipolar disorder presumably on the basis of prominent mood symptoms and I expect you have been prescribed lithium or another mood-stabilising drug. Rightly so.
My point is that bipolar and schizophrenia have a lot more in common than is often acknowledged - so much so that they are not really two distinct illnesses. The Lancet study supports this by showing that they have share many genes, hence the association between the two disorders in families.
Steven Reid
February 11th, 2009 at 12:57 am
Bipolar Disorder (manic-depressive illness) has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and embellished elation. These mental states can last for months in some bipolar disorder patients. These cyclical episodes are a catalyst for noticeable psychosocial impairment. Also, the episodes of both manic phases as well as depressive ones can last anywhere from weeks to months.
Bipolar Disorder also affect’s one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar by many. Yet Bipolar allows for exceptional abilities when a bipolar person is in their manic phase at times (http://www.howstuffworks.com/framed.htm?parent=mad-genius.htm&url=http://www.patienthealthinternational.com/features/3118.aspx).
The etiology for bipolar disorder is unknown. As many as half of those suspected as having a bipolar are thought to have at least one parent with some sort of mood disorder similar to bipolar disorder, which suggests a genetic predisposition may be present. Because of the complexity associated with bipolar disorder, greater than 50 percent of those afflicted are misdiagnosed as major depression, or perhaps schizophrenia.
It is also believed that bipolar presents itself with symptoms associated with the definition of bipolar when one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980, although bipolar disorder is thought to have existed for quite some time.
Also, those with bipolar are thought to be in possession of heightened creativity during their manic phases, as well as they have accelerated growth of their neurons. This is not necessarily a bad thing, it seems. Conversely, those with bipolar disorder experience up to 3 times the number of depressive episodes as manic ones.
Research has determined that as many as 15 to over 30 percent of bipolar patients commit suicide if they are left untreated, or undertreated. Also, as many as half of those affected with bipolar also have at times severe substance abuse issues along with their bipolar as well. Co-morbid medical conditions should be taken into consideration when evaluating one suspect of, or having bipolar disorder.
Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as a result of these medical issues. The disorder varies as far as severity goes- with some bipolar patients being more severely affected than others. In fact, there are at least 6 classifications of bipolar, according to the DSM.
Bipolar patients are thought to be symptomatic half of their lives. As stated previously, the depressive episodes occur more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some, when in their depressive state in particular. The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar rose from being about 25 per 100 thousand people to being 1000 per 100,000 people.
Most diagnosed with bipolar are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which may include as many as 12 million people in the United States. This is if the diagnostic criteria developed by others were to be fully utilized. An emphasis should be implemented by the health care provider to utilize available clinical evidence, and review this scientific literature.
A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar. Also, there is not any objective diagnostic testing to rely upon for bipolar. There is also a mental diagnosis of what is called mixed depressive disorder, which is one with depression who also has minimal manic episodes.
Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar.
While not recommended, about a half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years.
Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar - with a greater amount of research behind this class of drugs. Furthermore, therapy with any antidepressants has been associated with what is known as treatment-emergent mania. This is when a bipolar disorder that is in a depressive state rapidly enters a manic phase. This occurrence can be unmanageable by the bipolar disorder patient.
The most recognized treatments for bipolar long term are lithium (Ekalith or Lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
Atypical anti-psychotics have been prescribed for bipolar, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well.
As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar who are pregnant, however.
Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago.
Ekalith is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar. As should the health care provider keep in mind that the ultimate goal with this disorder is to stabilize the mood of the one affected.
http://www.dbsalliance.org
http://www.nmha.org
http://www.nami.org
Dan Abshear
Author’s note: What has been annotated is based upon information and belief.
Dan
February 26th, 2009 at 4:41 am