Identifying Schizophrenia and Bipolar Disorder from a Sea of Mimics Michael Sean Stanley, MD Assistant Professor OHSU Department of Psychiatry Identifying Schizophrenia and Bipolar Disorder from a Sea of Mimics No Disclosures. • Objectives: – Understand the clinical presentation and approach to treatment of Schizophrenia and Bipolar Disorder Psychotic disorders are: Mood Disorders are: • primarily problems of • Primarily problems of sensory processing prolonged extreme and association, not emotional tone (mood). emotion • Exhibit excessive high or • Exhibit profound low mood/motivation disconnection from from normal state sensory reality Psychosis Schizophrenia • a neurodevelopmental syndrome • associated with functional impairments Schizophrenia • no single unifying cause • emerges when environmental accelerants act upon genetic predisposition • May be at the more severely impairing end of a spectrum of disorders. + - C Positive Symptoms Negative Symptoms Cognitive Symptoms New abnormal sx Loss of normal fxn Accompany and likely - Hallucinations - Affective flattening precede +/- sx (auditory most - Anhedonia - Attentional problems commonly) - Asociality - Slower processing - Delusions - Alogia - Difficulty with - Significant planning/prob disorganization of solving thought/behavior - Memory problems May come and go A stable loss, do not Prodromal sx? fluctuate significantly once lost. May decrease to some May be responsive to Minimally responsive to degree with tx of pos sx, antipsychotic meds antipsychotic meds if at but rarely completely. all. For 6 mo or longer; Not due to medical or substance use cause. Positive Symptoms Most commonly during teens-20s Neuro-Cognitive Inappropriate Network Imbalance Pruning or Synaptic • Lack of coordination Changes: of neural tasks • Decr grey matter • Lack of inhibition of • Prefrontal neural tasks • Parahippoca Inappropriate salience – mpal hallucinations/delusions • Temporal • thalamic • Decr dendritic spines Inflammatory Events Damage Events Genetics: • Pathways implicated by Genes (a selection) • Highly heritable – 30% of offspring • Synaptic function (DRD2, GlutR, voltage- • Many genes with small effect size dependent calcium channels) • Some genetic overlap with other psych dx: • Synaptic plasticity BPAD, MDD, Autism Spectrum DO • Cytoskeletal development • Genes point to multiple mechanisms • Immune response/modulation Schizophrenia Onset • One peak in men: generally adolescence to early 20s • Two peaks in women: similar as above + over 40s Prevalence • Lifetime likelihood of 0.7% Disability • 80-90% unemployed • Life-expectancy 10-20 years reduced • Most likely due to cardiovascular and other health problems • High prev of smoking • High prev of dietary indiscretions • Low medical care use • Cardiometabolic effects of medication treatments Schizophrenia Illness Template Schizophrenia Template Present? DSM5 Stereotypic Positive Sx (Hallucinations, Delusions, Disorg) Stereotypic Negative Sx (Affective Flattening, Alogia, Apathy, Asociality) Functional Impairment Duration > 6 mo Absence of Medical/Substance Cause Research-based factors that increase probability of Schiz Age of onset during teens-20s (or ~40s if F) Family History of psychotic disorder Prodrome – cognitive, negative sx Course – subacute onset, fluc +, stable - Typical Treatment Response? Schizophrenia Template Case • 19 yo male • CC: Presents for auditory hallucinations of his high school physics professor arguing with his parents about implanting novel “microcircuits” in his body. Feels this might be true, and has shaved parts of his body to scan the “microcircuits” • HPI (from collateral): sx began about 1 year ago, have fluctuated, and have been associated w/ performance decline at community college, last quarter his teachers expressed concern and he was on monitoring plan by student health center. Per family, throughout high school, patient displayed some thoughts of supernatural causes, but they had not caused functional problems. Gradually late in high school he became increasingly reclusive, stopped being interested in things that previously interested him, these sx have continued. • Family Hx: Paternal uncle with schizophrenia • Exam: Medical exam benign, has never used drugs other than tobacco. • Mental Status Exam: + AH and delusions, thought blocking, appeared to attend to internal stimuli, flat affect, paucity of spontaneous thought. • Course: saw psychiatrist who Rx’d Risperidone 2mg qhs, which significantly decreased AH. Stopped medication after 6 mo, when noticed gynecomastia, and AH restarted. Schizophrenia Illness Template Schizophrenia Template Present? DSM5 Stereotypic Positive Sx (Hallucinations, Delusions, Disorg) Yes Stereotypic Negative Sx (Affective Flattening, Alogia, Apathy, Asociality) Yes Functional Impairment Yes Duration > 6 mo Yes Absence of Medical/Substance Cause Yes Research-based factors that increase probability of Schiz Age of onset during teens-20s (or ~40s if F) Yes Family History of psychotic disorder Yes Prodrome – cognitive, negative sx Yes Course – subacute onset, fluc +, stable - Yes Typical Treatment Response? Yes Differential Diagnosis of Schizophrenia Other Psychiatric Disorders • Schizophrenia spectrum • Bipolar Disorder, Manic with Psychotic features • Major Depressive Episode with Psychotic features • Body Dysmorphic Disorder Non-Psychiatric Disorders • Medication-Induced Psychosis • Substance-Induced Psychosis • Epilepsy • Cerebrovascular Disorders • Neoplasm • Dementia with Lewy bodies • Delirium • Autoimmune: Anti-NMDA receptor encephalitis Schizophrenia Spectrum Del only 2+ sx 1 mo 6 mo Normal Cognitive or perceptual distortions Delusions only, or behavioral function not eccentricities that grossly affect social impaired Schiz + connections, but not prominent gross biological affective sx function Psychotic symptoms, such as auditory hallucinations and paranoid thinking, occur in attenuated forms in 5–8% of the healthy population • a disorder of emotional tone Bipolar Disorder – Elevated = hypo/mania – Low = major depressive episodes • associated with functional impairments at peaks • emerges when environmental accelerants act upon genetic predisposition Bipolar Disorder !!MANIC EPISODE!! majordepressiveepisode Epidemiology of Bipolar Disorders: Bipolar Disorder • Lifetime prevalence of Bipolar Disorders is 1-3% worldwide • Female:Male = 1:1 • Mean onset of Bipolar I DO is 18yo • About 1/3 of patients with a parent with Bipolar Disorder will go on to have Bipolar Disorder • Depressive Episodes are actually more common in Bipolar Disorder than are Manic/Hypomanic Episodes • 10-15% of patients with Bipolar Disorder die by suicide, which is estimated at 12-15x greater rate than in the general population Elation, irritable mood, MDD with excess energy, subsyndromal talkativeness, racing mania, cylothymia, Mood lability, thoughts, decreased or psychosis subsyndromal need for sleep depression or mania symptoms Genetic Risk Gestational or Birth Stress Head Injury Life Stressors Substance Early Life Stress Use Prodrome Comparison Bipolar Prodrome Schizophrenia Prodrome • Strange/Unusual Ideas • Frequent Mood Swings • Irritability • Physical Agitation • Suspiciousness • Concentration/Attention Probs • Hallucinatory Experiences • Difficulty • Anhedonia Thinking/Communicating Clearly • Decreased Functioning • Obsessions Compulsions • Social Isolation • Depressed Mood • Tiredness Lack of Energy • Thinking About Suicide Bipolar DO Illness Template Bipolar Disorder Template Present? DSM5 Manic Episode (Mood&Energy +3/7sx) x 1 week or hospitalition Major Depressive Episode (not needed if manic) Functional Impairment Absence of Medical/Substance Cause Research-based factors that increase probability of Bipolar DO Age of onset during teens-20s Family History of Bipolar Disorder Prodrome – isolated manic sx Course – episodic, relapsing/remitting Typical Treatment Response? Absence of other atypical features Bipolar DO Template Case • 20 yo male • CC: Elevated mood, Increased energy, beliefs of God-given mission to spread “heal broken street children” through “parkour science”. Accompanied by agitation, decreased need for sleep, disorganized behaviors, rapid speech. • HPI: sx started ~10 days ago, after returned from study abroad in Europe, increased gradually over 2-3 days. • Collateral noted the following: • Cousin with Bipolar I Disorder on Lithium • Successfully recently completed 6 mo study abroad program in global finance in Switzerland. • Has a girlfriend and 2 friends who accompanied him to ED, and who are very worried about him, as this is very different behavior for him, as he has not been spiritual. • Girlfriend noted that he had had sporadic periods of decreased need for sleep in past, but never like this. • Med hx/Psych hx: no med probs, no psych dx, has never used drugs other than remote brief cannabis trial in high school • Exam: agitation, talking mildly rapidly, focuses on spiritual mission, requires interruption, denies AH/VH, denies SI/HI. • Course: Risperidone 2mg qhs, responded well, tapered off 12 mo later, did not have recurrence of delusions immediately, although 2 years later had beginning of similar sx. Bipolar DO Illness Template Bipolar Disorder Template Present in this case? DSM5 Manic Episode (Mood&Energy +3/7sx) Yes x 1 week or hospitalition Major Depressive Episode (not needed if manic) N/A Functional Impairment Yes Absence of Medical/Substance Cause Yes Research-based factors that increase probability of Bipolar DO Age of onset during teens-20s