schizoaffective disorder: what the hell is it?

Schizoaffective disorder is a less well-known diagnosis than schizophrenia, depression, or bipolar disorder, and it tends to confuse people. It was categorized under schizophrenia in earlier versions of the DSM, but in the current version you have to have a mood episode for a “substantial portion” of the time, as well as having psychotic symptoms outside of a mood episode.

That last bit is important because some people with bipolar disorder have psychotic symptoms during manic periods, and some people with bipolar disorder and some people with major depressive disorder have psychotic symptoms during depression. But (according to the DSM-IV) they don’t have psychotic symptoms outside of mood episodes.

But we don’t know from this what schizoaffective disorder actually is. Is it having both a mood disorder and schizophrenia at the same time? Is it a separate disorder from either? (And what about if your depression isn’t long enough or severe enough to be schizoaffective disorder and you get diagnosed with schizophrenia with comorbid depression? Is that a totally different thing?)

Goodwin and Jamison do a quick review, which I will summarize:

The five major schools of thought are:

• a separate disorder (but it doesn’t run in families, so this seems less likely)
• “an intermediate form on the continuum of psychosis” (I think this means that if you think of disorders as lying along a continuum of psychosis, like you could think of bipolar symptoms as lying along a continuum of severity, schizoaffective is inbetween schizophrenia and bipolar with psychotic symptoms)
• comorbid schizophrenia and depression/bipolar
• more severe bipolar
• less severe variant of schizophrenia

Another school of thought might be that schizoaffective disorder is actually several different things, which is what they tentatively suggest (we’re a little short on actual research to draw strong conclusions):

• People who are primarily manic and less pronouncedly psychotic may have an especially severe form of bipolar disorder (suggested by studies showing that it is more associated with bipolar disorder and has a worse course: Gershon et al, 1982; Coryell et al., 1990).
• People who are predominantly psychotic and have less prominent, exclusively depressive symptoms may have a less severe variant of schizophrenia (suggested by studies showing outcomes or neuropsych profiles similar to schizophrenics: Brockington et al, 1980; Tsuang and Coryell, 1993; Evans et al, 1999).
• People who have about an equal mix are the unlucky bastards who just happened to get both a mood disorder and schizophrenia.  (suggested by the epidemiological prevalence of the disorder being a fraction of a percent, about what you’d expect for those two just happening to co-occur: Kendler et al, 1993, 1996).

Again, this is still speculative and we don’t have enough research to confirm (or deny) it.  But it’s pretty interesting, no?  Maybe we’ll get a bipolar 0.5 to complement I and II?  Since all the love’s been going in the other direction, maybe it’s time the crazier among us got a little more attention.  And what kind of “less severe” schizophrenia manages to hit you with something akin to major depressive disorder, yet still be less disabling than regular schizophrenia?

new visualization of comorbidity shows bipolar-schizophrenia-autism link, and much more

Columbia University researchers have created a visualization of disease comorbidity using health records from 1.5 million people (article and full-text paper). There’s a lot they’ll be able to do with this – look for genetic links, look to see if some conditions protect from other conditions, look for potential environmental triggers like bacterial or viral infections.

This sounds awesome in general – people can process complex information about associations much faster when represented visually than when they see a bunch of numeric correlations. (Way to go, information usability!)
They find that bipolar, autism, and schizophrenia are associated (quotes from the paper):

We estimate that 20–60% of autism-predisposing variations also predispose the bearer to bipolar disorder, and 20–75% of autism-predisposing variations also predispose the bearer to schizophrenia. It is therefore extremely likely that there is a three-way positive correlation among autism, bipolar disorder, and schizophrenia, a correlation that probably arises from a genetic variation that predisposes to all three disorders.

If so that’s extremely interesting, although I wonder how much of a link between autism and schizophrenia is due to the two being mistaken for each other (or perhaps the overlap in predisposing genes is why the two are mistaken for each other – our diagnostic categories are attempting to clearly delineate fuzzy categories).

Also, everything under the sun is associated with autism, apparently (I wonder whether there’s a causal relationship, and if so which way, or whether it’s third variables, or all of the above):

[A]utism, which typically manifests before the affected child is 3 years old, has a strong positive correlation with a number of neurological disorders, some of which have a late-age onset…: attention deficit, epilepsy, cerebral palsy, depression, schizophrenia, bipolar disorder, neurofibromatosis, Parkinson’s disease, and migraine. Our estimated significant overlap between autism and tuberculosis may indicate that both diseases are associated with genetic changes weakening the immune system.

They also mention associations between allergies/autoimmune disorders and autism, schizophrenia, and bipolar disorder. And here’s something totally new: female breast cancer is negatively associated with schizophrenia and bipolar disorder. They proposed an explanation involving schizophrenia and bipolar being associated with increased probability of abnormal cell death in some tissues, and breast cancer being associated with an increased probability of abnormal cell proliferation. And they mention that tamoxifen (a breast cancer treatment drug) can help treat bipolar disorder – I’ll try to follow up on that in a future post.

And the credits go to: Andrew Rzhetsky, David Wajngurt, Naeun Park, and Tian Zheng of the University of Columbia. And any unnamed undergraduate or graduate assistants.

(For anyone who’s requested an entry on a specific topic: I haven’t forgotten you, I’ve just been too busy to do background research because of moving this weekend, and have been doing stuff I could sit down and type out instead. Entries on schizoaffective disorder, kindling, worries about personality change on meds, and lots of stuff on culture coming up, among other things.)

insomnia predicts future anxiety but not future depression

Based on two surveys 11 years apart headed up by Dag Neckelmann of Haukeland University Hospital in Norway. Reuters article. Via Spikol. Insomnia at time 1 predicted anxiety disorder at time 2, but not depression, although depression and insomnia co-occurred.

I thought the fact that it wasn’t significantly predicting depression (despite predicting anxiety) was pretty interesting, since insomnia and depression are widely known to be related (and anxiety and depression can both co-occur and each cause the other). Maybe insomnia is a byproduct of early anxiety that isn’t yet diagnosable? Maybe it’s a version of the same phenomenon where lack of sleep can make bipolar people hypo/manic?

bipolar mixed states: all the flavors of suckage

People with bipolar disorder often have symptoms of hypo/mania and depression at the same time, and everything I’ve heard or experienced suggests that this is much, much worse than depression alone.  (The first time I had plain vanilla depression instead of anxious misery, I thought I was just fine because I was so relaxed after six years of unrelenting anxiety – it was entirely unlike what I thought of as “depression”.  I just couldn’t manage any stress, started crying all the time, and couldn’t function very well.)

Under the current DSM, in order to be diagnosed with a mixed state, you have to meet ALL the criteria for BOTH a depressive episode and a manic episode (not hypomanic, but actually manic) almost every day for at least a week.

In practice, though, things that don’t meet that definition – like depressive symptoms occurring with hypomania – still occur plenty often. For example, in a study published in 2005 that assessed mixed and euphoric hypomanias (i.e., mixed and regular) in 908 patients over 7 years found that mixed hypomania was more common than euphoric hypomania (and especially in women) (Suppes et al., 2005, cited in Goodwin & Jamison, 2007). You can get mixed symptoms at different levels of severity, for example “only” with hypomanic and dysthymic symptoms (I really recommend this link for anyone with a mood disorder who is stressed out and miserable all the time – when I first read that page I realized that maybe all those things I thought were components of my personality were actually related to mental illness. More on this when I do a post on personality and identity later.)

The notion here is that mania and depression are not polar opposites, but separate systems. This is where the idea of mixed states as mania + depression comes from.

But, more complicatedly, bipolar disorder may involve several separate systems each of which can be overactive or underactive, and which can cycle independently. Those mood, activity, and thought. So you can have euphoric or depressed mood; be over- or underactive; and have too rapid thought or too little thought. Dr. Jim Phelps of psycheducation.org has a quick presentation of the ideas, complete with graphs and he cites the original which I have not yet gotten ahold of (MacKinnon and Pies, 2006).

So, according to this model, you can have different kinds of mixed states. Goodwin and Jamison go into more depth on each and I’m cribbing from that here, and adding some subjective descriptions (beware: anecdotes follow and may not be accurate).

Situation 1: depressed mood, manic activity, and manic thought. You’re miserable, can’t stop moving, your thoughts are racing and your concentration sucks.

Situation 2: you’re just as depressed (mood) and just as physically agitated (activity), but you can’t think. You’re going going going but you’re miserable and your brain just won’t kick in.

Situation 3: your physical energy bottoms out and your mental energy is going and going. You’re still depressed, and have no energy, but your thoughts are going like crazy. You’re miserable and you just sit there while your thoughts churn and you can’t stop them.

I don’t have intuitive descriptions for the euphoric mood ones (off meds my own mood stays almost exclusively in the depressed-dysthymic range), but I hope someone will share some.

Situation 4: your mood is euphoric, you’re overactive, but you can’t think.

Situation 5, a “manic stupor”, you’re still euphoric, but you can’t move or think – except occasionally when you (meaning, some but not all patients) suddenly get loud or violent.

Situation 6: “inhibited mania”, in which you’re euphoric, you still can’t move unless you suddenly get loud or violent (again meaning some, not all, patients) and you can’t stop thinking.

Whee.  Anyway, I like this research (and these classification schemes) because it accounts for a broader range of symptoms  than manic/depressed.  I really hope it’s going to leak into the hypersimplified and inaccurate common stereotype where bipolar disorder = unhappy vs. real real happy.

Bipolar rapid cycling: A type of bipolar? The result of kindling? A temporary phase?

On CrazyBoards, the support and education boards I help moderate, people with bipolar disorder who rapid cycle are pretty common.  Rapid cycling refers to having four or more distinct mood episodes a year, although usually what people are referring to on CB is more frequent.  This may reflect who winds up on support boards or may reflect actual distribution, I don’t know right now.

It looks like almost always, rather than being a type of bipolar or a set pattern that’s persistent throughout the lifetime, rapid cycling is transient. It may or may not be a result of kindling (untreated mood episodes getting worse over time). We’ve known this for a long time, even if it isn’t widely known among patients: the studies referenced here (Goodwin and Jamison again) mostly range from late 1908s to mid-1990s.

Some additional things I’m wondering about:

If rapid cycling isn’t a type of bipolar disorder, is degree of variation in cycle lengths? For example, some people have a classic pattern consisting of a mania in the spring and a depression in the fall, and don’t deviate. But other people might sometimes have years between episodes and sometimes days between episodes.

If rapid-cycling is a result of kindling, and rapid-cycling is transient, does that mean people are getting kindled and later unkindled? Spontaneously, or due to medication, or both?

Goodwin and Jamison

A book I’ve been mentioning (and will continue to use in my entries) is:

Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression by Frederick K. Goodwin and Kay Redfield Jamison (Hardcover – Mar 9, 2007)

If you like research on bipolar disorder and/or recurrent depression, this is the freaking awesomest book ever – a huge collection and summary of available research on every aspect, with commentary. If you like it enough to consider getting it, I encourage you to get it through the link above, which will benefit crazyboards, the support and education boards that I help moderate and that have helped me a whole hell of a lot.

If you can’t afford the price tag, you may be able to get it through inter-library loan. The current one is the second edition.

manic mice? and circadian rhythms

Manic mice

Mice engineered to lack a specific gene showed behaviors similar to human mania in a study funded in part by NIMH; they were hyperactive, slept less, appeared less depressed and anxious, and craved sugar, cocaine and pleasure stimulation. The rodents’ behavior was more normal after lithium treatment or restoration of a functioning CLOCK protein, which the knocked-out gene codes for.

The article says this is similar to human mania, and it sounds like it’s similar enough to tell us useful stuff, although the mice don’t sound bipolar, just, as they say, behaving similarly to some aspects of manic humans.

The CLOCK protein is involved in circadian rhythms. And so here is some interesting stuff on circadian rhythms in bipolar disorder, and on how lithium works, from one of my favorite bipolar disorder sites, Jim Phelps’ Psych Education. Lots of science, lots of high-level information that isn’t very widely spread, and an excellent site for info on bipolar II in general and on anxiety in bipolar.

bipolar in kids

Pediatric bipolar disorder has been coming up more frequently over the last few years, and the current flap is about Joseph Biederman, who is an advocate of the view that bipolar can exist as early as birth. There’s also scandal (from back in December) over a four-year-old who died from being given too much medication by her parents, and that’s being brought up in this as well.

Those are the extreme cases. I’m going to write about the typical stuff.

(But first: At birth? Why at birth? I’m pretty sure our emotional regulation systems neither suddenly turn on nor suddenly break then. I know he’s using it for dramatic effect, but it bugs me.)

The news coverage I’ve seen tends to have one of two themes:

1. “Kids will be kids”: You can’t diagnose bipolar in children because that’s just what children are like – they change by nature. (This is similar to the incorrect argument that AD/HD doesn’t really exist, because to be bored by school is to be a normal child.)
2. We’re overprescribing antipsychotics to children. They should only be prescribed for their intended purpose. (Meaning, to treat psychosis, or, even more restrictedly, to treat schizophrenics.)

I’m going to talk about the “kids will be kids” aspect, and then talk about why it actually is hard to diagnose bipolar disorder in children, and will talk about antipsychotics later in the week. I’m pulling heavily from Goodwin & Jamison’s “Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression”, second edition. The first edition is considered the classic work in the field; the second edition is just out as of a couple months ago and I heart it down to my research-loving bones.

Okay:

Bipolar disorder occurs in young children.

There are debates over how common it is, what it looks like when it happens, and whether we can diagnose it and when, but it’s not at all like being a normal child.

Here are a couple parallel normal and pathological examples from the Goodwin and Jamison book (originally from Geller et al, 2002a and if anyone really wants cite that I’ll get it for you):

Happiness: Child was extremely happy on days family went to Disneyland, on Christmas morning, during grandparents’ visits (joy appropriate to context, not impairing).

Elated mood: 9-year-old continually danced around at home, stating, “I’m high, over the mountain high” after suspension from school.

Sexuality: 7-year-old child played doctor with a friend of the same age.

Hypersexuality: Girl faxed a note to the local police station asking police to ____ her [underlines in the original]

And you can find all kinds of examples on websites for parents of bipolar children – kids trying to spontaneously jump out of cars, that kinds of thing.

It’s hard to diagnose because kids with bipolar frequently meet criteria for other disorders too

Like ADHD, conduct disorder, and oppositional defiant disorder. Some kids have a *lot* of problems, and it’s not clear whether they have one disorder that’s causing other disorders (for example, bipolar disorder can cause anxiety) or whether they have multiple disorders (bipolar disorder can coexist with a separate anxiety disorder). This happens with adults as well, but it’s particularly common for kids with bipolar-ish symptoms.

This leads to a disturbing situation that I would like to see get more press: although the popular controversy is about whether bipolar exists in kids, it should really be about what is going on with these kids who are badly impaired and difficult to diagnose and treat. It’s not about whether they’re bipolar or not, with “not bipolar” meaning “normal”, because they’re not normal. It’s about what should we be doing to help them.

Children with bipolar disorder also tend to look different from adults with bipolar disorder. They are more likely to rapid-cycle (go through many mood shifts throughout the day); to be irritably instead of happily manic; and to not have well periods between mood episodes. So they’re less likely to be recognized by practitioners whose mental picture of bipolar disorder is based on an average adult.

Another interesting question is whether the kids we’re identifying with bipolar disorder are going to grow up to look like most adults with bipolar disorder – do they have an early version of the disorder that changes as they mature? Do they have a more severe version of it that doesn’t? Or do they have something that’s just different?

wearable tech and bipolar vs. schizophrenia

UCSD researchers have come up with a shirt that takes various physiological measurements from people, and have found distinct patterns between people with schizophrenia and people with bipolar disorder. This is of note particularly because it can be very hard for clinicians to distinguish someone having a manic episode from someone who is schizophrenic. But it’s also interesting because anything that tells us more about what’s going on can lead to better treatment…

Here’s the link with the somewhat misleading headline (it’s not really about monitoring in the treatment sense, it’s not even in the pipeline, but it is an extremely interesting study):

Wearable Technology Helps Monitor Mental Illness

I also like that they mention difficulty filtering information. It can be a pretty big issue but because it’s not psychosis, nor mood, it’s not so well-known. One of my own problems, whenever I feel off in whatever way, is getting overwhelmed by sensory input and having to leave social situations because I can’t take it anymore. (Medication has definitely helped with that.)

Anyway. I wonder if something like this will eventually come into play in childhood bipolar diagnosis? That’s contentious in part because it’s very hard to diagnose in kids who don’t have clearcut manic periods.

Personally, I think they should make it Hypercolor and just have it turn different colors.

"sub-threshold bipolar disorder" posts

(I wouldn’t exactly call this high-quality – rather, I’d call it “strung-out after work” – but it puts together some of the issues that I’ve been thinking about lately.)

There was recently a news article about researchers finding that 2.4% of americans will have subthreshold bipolar disorder (as they defined it) at some point during their lifetime.

Check this post out, in which the author, whose bio states that he is an academic with clinical experience, starts with that article and works up to arguing that anyone who isn’t bipolar type I should not be receiving long-term medication because “there is scant if any research on what appropriate medication is for bipolar II and there is not a damn bit of research attesting to medication for SBD” (subthreshold bipolar disorder).

I do not think he is an academic with training on the research side of psychology. He also seems to have difficulty understanding that different diagnoses of bipolar disorder almost certainly involve similarities in etiology which are relevant to treatment.

A blogger called Furious Seasons links to “>this article, which says: “People with bipolar disorder not otherwise specified (BD-NOS), sometimes called subthreshold bipolar disorder, have manic and depressive symptoms as well, but they do not meet strict criteria for any specific type of bipolar disorder noted in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), the reference manual for psychiatric disorders. Nonetheless, BD-NOS still can significantly impair those who have it”.

Now, check out his later entry where he/she invites readers to rename SBD, in which he/she states that, in comparison to cyclothymia “SBD is like so totally better! Cyclothymia includes alternating periods of low scale hypomania and low scale depression. But SBD is skipping the depression altogether, so we can focus on people who are chronically productive and medicate them until they put on 100 pounds.”
Many of the people responding are equating hypomania to extra nice happiness, which it can involve, but it may also involve severe irritability, racing thoughts, and lots of other fun things.

There are some very interesting things in all this to write about, but they are not being written about well in the blogs I have seen so far. For example, some questions I’m thinking about (most of which I would answer “no”, but at least I’m still thinking about them):

Are our current, DSM-IV views of abnormality the ones that should define what is normal and abnormal? If not, should something else define them (such as, the subjective perceptions of normal/mentally ill that a particular generation on average grew up with)? Should our diagnostic definitions be open to research finding that a set of people formerly included in “normal” have persistent problems that resemble those of people who are currently included in a diagnosis, and bring that information to attention?

On a related note, should our current rates of diagnosis be the “right” ones? (Or, possibly, our rates from the 90s, or the 80s, or what…) Or should we look at population data to see how many people who would benefit from accurate diagnosis and treatment have not received either? (These issues come up all the time with ADD and autism, and to some extent bipolar II and bipolar disorder in general.)

Should people who don’t have “enough” (for whatever definition of enough) problems not receive diagnoses that will help direct them toward the treatment they need to handle those problems effectively?

——-

Stuff like this makes me so angry – it’s often seems like a failure to admit that someone really could have severe problems, sometimes combined with a need to gatekeep diagnoses so that nobody less troubled can “get in.” It’s not an exclusive club, it’s a set of labels that can help people, but do not currently label all the people they can help.