Bipolar disorder (also known as: bipolar disorder or bipolar mood disorder) is a type of mood (emotional) disorder, which refers to a mood disorder with manic or hypomanic episodes and depressive episodes since its onset. Manic episodes need to last for more than one week (light manic episodes also need to meet the criteria of lasting more than 4 days), and depressive episodes need to last for more than two weeks (note: both manic episodes and depressive episodes need to meet the diagnostic criteria most of the time every day), and manic and depressive episodes occur alternately or cyclically, or can occur simultaneously in a mixed manner (less common). It generally has an episodic course, with each episode followed by an intermittent remission period of normal mental status, and most patients have a tendency to have recurrent episodes. Schizophrenia, on the other hand, most often begins in young adults and manifests as disorders of perception, thinking, emotion, volitional behavior, and other aspects of mental activity that are incongruent with the surrounding environment and internal experience and detached from reality. There is usually no impairment of consciousness or obvious intellectual impairment, but as the disease progresses, there may be impairment of cognitive functions such as attention, working memory, abstract thinking and information integration. The course of the disease is prolonged and recurrent, and some patients experience mental activity decline and social function deficits of different degrees.
Basic differentiation points: ① Manic episodes are coordinated psychomotor excitement based on emotional highs, with pleasant, elevated and infectious moods. ② Depressive symptoms can occur during the course of schizophrenia, while bipolar disorder can be accompanied by psychotic symptoms, which should be distinguished. Bipolar disorder is characterized by affective disorder manifestations as the dominant symptom and throughout the course of the illness, with elevated or depressed emotions, accompanied by changes in thinking and behavior, and normal interictal periods. In contrast, schizophrenia manifestations are dominated by hallucinations, delusions, thinking and logic disorders, which are incompatible with the inner experience and the surrounding environment, and most of the inter-episode period has different degrees of residual social function deficits. ③If the manifestations of hallucinations, delusions, and thought-logic disorders occur in a state of mind not consistent with manic episodes or depressive episodes (i.e., a situation in which psychotic symptoms occur independently of affective symptoms), the diagnosis of bipolar disorder is generally not considered solely, and the clinical diagnostic direction of schizophrenia or schizoaffective psychosis should be considered.
Bipolar disorder refers to the presence of both manic or hypomanic episodes and depressive episodes since the onset of the disorder. Regardless of being in that kind of episodes, the performance of the diagnostic criteria of having manic episodes and depressive episodes for most of the consecutive day must be met respectively to be counted, and it cannot be asked to a little even, that is against the original definition of the disease diagnostic criteria. The detailed criteria are as follows.
Diagnostic criteria of manic episode
Manic episodes are dominated by high moods, which are not proportional to their situation, and can range from happy and cheerful to ecstatic, and in some cases, only irritability is dominant. In mild cases, there is no impairment of social function or only mild impairment; in severe cases, hallucinations, delusions and other psychotic symptoms may appear.
1. Symptom criteria
Emotional exaltation or irritability is the main symptom, and at least three of the following (if only irritability, at least four are required)
① Inattention or shifting with the situation.
(ii) Increased amount of speech.
(3) Experiences of racing thoughts (increased speed of speech, rapid speech, etc.), accelerated associations, or drifting thoughts.
④ overestimation or exaggeration of self-evaluation.
(⑤) Energetic, non-fatigue, increased activity, difficulty in being quiet, or constant changes in plans and activities.
(vi) Reckless behavior (e.g., profligate, irresponsible, or reckless behavior).
(vii) Decreased need for sleep.
⑧ Hyper sexual desire.
2.Severity criteria seriously impair social function, or cause danger or adverse consequences to others.
3.Course of illness criteria
① Meet the symptom criteria and severity criteria for at least one week.
② Some schizophrenic symptoms may exist, but do not meet the diagnostic criteria for schizophrenia.
If the symptom criteria of schizophrenia are met at the same time, the manic episode criteria are met for at least one week after the schizophrenic symptoms are relieved.
4.Exclusion criteria
Exclude organic psychiatric disorders, or mania due to psychoactive substances and non-addictive substances.
Diagnostic criteria for depressive episodes.
Depressive episodes are dominated by depressed mood, which is not proportional to its situation and can range from sullenness to grief and even malaise. In severe cases, psychotic symptoms such as hallucinations and delusions may occur. Anxiety and motor agitation are significant in some cases.
1.Symptom criteria
Depressed mood is predominant and at least four of the following are present.
① Loss of interest and no sense of pleasure.
② Loss of energy or fatigue.
(3) Psychomotor retardation or agitation.
④ Low self-esteem, self-blame, or feelings of guilt.
⑤ Difficulty in association or reduced ability to think consciously.
(6) Recurrent thoughts of death or suicidal or self-injurious behavior.
(7) Sleep disorders, such as insomnia, early awakening, or excessive sleep.
(8) Decreased appetite or significant weight loss.
⑨ Decreased sexual desire.
2.Severity criteria
Impaired social function, causing pain or adverse consequences to the person.
3.Course of illness criteria
① Meeting the symptom criteria and severity criteria has lasted for at least two weeks.
② Some schizophrenic symptoms may exist, but do not meet the diagnosis of schizophrenia. If the symptom criteria of schizophrenia are also met, the depressive episode criteria are met for at least two weeks after the schizophrenic symptoms have resolved.
4. Exclusion criteria
Exclude organic psychiatric disorders, or depression due to psychoactive substances and non-addictive substances.
Differential diagnosis points.
1. The psychomotor arousal or depressive symptoms seen in schizophrenia are not primary symptoms, but rather hallucinations, delusions, and thought-logic disorders are primary symptoms; mood disorders, on the other hand, have elevated or depressed mood as primary symptoms, and psychotic symptoms appear only in severe stages within the affective symptoms; most do not show obvious psychotic hallucinations or delusional symptoms, and even if they do, they are mostly mood-related or coordinated symptoms.
2, schizophrenia patients’ mental activities such as thinking, emotion and volitional behavior are mostly uncoordinated, often manifesting as disorganized speech, scattered thinking (giving the listener the feeling of talking in a rambling manner), uncoordinated emotion and bizarre behavior. In contrast, the emotional reactions of patients with bipolar disorder are coordinated with the external environment and internal experience.
3, most of the course of schizophrenia is episodic progression or continuous progression, the remission period is often functional level is mostly inferior to the pre-onset functional state; while bipolar disorder is an intermittent episodic course, intermittent periods are basically normal.
4. Pre-morbid personality, family genetic history, prognosis and response to medication can all help in differentiation. Individual patients may need to be judged in relation to past medical history, duration of illness, duration of symptoms, and disease regression. Bipolar disorder responds better to the efficacy of affect stabilizers, whereas schizophrenia responds well only to antipsychotic medications. Those who are able to maintain long-term treatment with relatively simple emotion stabilizers such as lithium carbonate, valproic acid, or lamotrigine alone, in turn, are more supportive of a clinical diagnosis of bipolar disorder.
5., Bipolar disorder may be accompanied by psychotic symptoms either in the manic or in the depressive state, but the psychotic symptoms arise in the context of high or low affect, in harmony with the patient’s state of mind. If the manifestations of hallucinations, delusions, and disorders of thinking and logic appear in a state of mind that does not correspond to manic episodes or depressive episodes (i.e.: a situation of psychotic symptoms independent of affective symptoms), the diagnosis of bipolar disorder is generally not simply considered, and the clinical diagnostic direction of schizophrenia or schizoaffective psychosis should be considered.
6. In bipolar disorder, manic patients may have exaggerated delusions and hallucinations, and depressed patients may have delusions of poverty or self-guilt and hallucinations, but the content is not as absurd as schizophrenic patients, and the logical reasoning process is basically normal. If symptoms such as logical reasoning disorder, primary delusions, absurd and bizarre passive delusions, tracing commentary hallucinations, or hallucinatory delusional thinking logic disorder do not appear during manic episodes or depressive episodes should be considered not to support the diagnosis of bipolar disorder.
7., depressive xylophobia and catatonic xylophobia both have essentially different affective disorders and contact with the environment. The depressed patient’s emotion is low rather than indifferent, patient’s patient can get some answers to patient’s patient’s patient’s expressions and movements, although slow and difficult, but the flow of worried eyes and the desire to speak but difficult to express the expression, indicating that the patient and the surrounding still have emotional communication. In contrast, the patient with catatonia is indifferent to the lack of emotional communication, no matter how hard the doctor tries, the patient is often indifferent and lacks the corresponding emotional response.
8, acute episodes of manic patients will also appear uncoordinated psychomotor excitement, but when the behavioral symptoms are controlled, the patient will still reveal high emotional experience or interest and excessive volitional activity and other manic episodes entry performance, and different from schizophrenia.
9. Patients with mania and depression may also occasionally experience some hallucinatory and/or delusional symptoms that are incompatible with the current state of mind, but these symptoms are often not the main clinical phase of the disease, generally do not last long, often lack the characteristic symptoms of schizophrenia, and all occur during manic episodes or depressive episodes, and disappear in the inter-episode period.
To conclude, there is a very clear and fundamental difference between these two disorders: the main problem and symptom tone throughout the course of schizophrenia is “thought disorders” (i.e., various delusions and strange ideas or logical reasoning disorders or loose thought structures, although hallucinations, disintegrative and catatonic behaviors are certainly important). of course, hallucinations, disintegrative and catatonic behaviors are also important) (depressed mood can occur at some time during the development or treatment of the disease or secondary to the effects of pathological symptoms, but is not the main line and tone of the entire disease process).
In contrast, the main problem and tone of bipolar disorder patients throughout the course of the disease is “affective problems” (i.e., excessive low or high mood and the resulting excessive reduction or increase in activity, which is infectious to surrounding bystanders and is an expression of emotional ups and downs in harmony with the environment and internal experience), and if high and low mood If such emotional disorders are no longer evident or have disappeared and the patient continues to have one of the three main symptoms of “delusions” or “hallucinations” or “bizarre disorganized behavior”, then it is no longer appropriate to have such symptoms. If one of the three main symptoms of “delusions” or “hallucinations” or “bizarre disorganized behavior” persists, then the diagnosis of bipolar disorder should not be considered. In fact, if there is no pharmaceutical company’s advocacy, scientific research, economic interests misleading, the identification of these two diseases is not difficult at all, when this uncritical, unscientific psychiatric diagnostic trend has become popular, and the resulting unnecessary combination of drug treatment (magnesium valproate, sodium valproate, Depakene, lithium carbonate, lamotrigine, etc., if the right medicine is a good medicine to save lives, not the right diagnosis (If the medication is prescribed for the patient, the above drugs may only leave a bunch of unnecessary adverse reactions for the patient to bear), and ultimately the only victims will be the patient and family (i.e., to bear the unnecessary economic burden and adverse reactions).
Another point is that many psychiatrists do not have a good understanding of psychopathology and have a very vague grasp of clinical symptomatology, which can lead to the interpretation of symptoms or personal feelings of the doctor, and then to the diagnostic assessment of the patient, which will lose the rational and scientific direction of the diagnostic assessment.
A good professional psychiatrist should have a strict grasp of psychiatric symptomatology and diagnostic criteria, and should not arbitrarily make up a diagnosis, for example, saying that a patient has a manic phase or a mixed phase easily if he or she is excited, agitated, impulsive, or talkative, or making up other inaccurate symptoms and saying it is schizophrenia if he or she has delusions of victimization. I advocate a strict grasp of the diagnostic criteria for bipolar disorder that is not subjective, but we should also grasp the diagnostic criteria for schizophrenia more strictly and not expand the diagnosis. This article will be updated whenever the Chinese versions of the DSM-5 diagnostic system and the international ICD-11 diagnostic system are released, in case the contents of this article are outdated.
I only hope that the above content will be helpful to patients as a reference for self-diagnosis of their loved ones’ conditions, in order to clarify some of the current problems of confusion in the diagnosis of these two disorders that are causing delays in patients’ conditions.
Finally, I would like to send you a quote that I often use in my training and teaching for psychiatrists and students: “The best psychiatrist is the one who applies the least amount of medication after a precise diagnosis, treats the patient well with a standardized psychotherapy approach, and gives more consideration to reducing the risk of relapse, adverse drug reactions, and financial burden for them afterwards. —- Jung Young-jun “.
Differences between medication for bipolar disorder and schizophrenia?
Differences in the main medication treatments.
(1) The treatment of bipolar disorder is based on the use of emotion stabilizers, with more than 2 or more medications combined in the acute phase, and medications are selected according to the difference in manic or depressive symptoms. In the maintenance period, the medication can be combined or single medication can be chosen, but it is advocated to maintain the treatment with emotion stabilizer, use cautiously or only short-term combined use of antidepressant drugs that are not easy to turn manic, prevent relapse and avoid developing into rapid-cycling bipolar disorder, which is the basis of all treatment. This is because the development of rapid cycling type is the main culprit of disability in bipolar disorder. Treatment should be highly conscious of the need to avoid rapid cycling caused by antidepressants.
Drug combination is not equal to the more drugs combined the better, according to the individual patient, a reasonable minimum of kinds of combination, as much as possible short-term multi-drug combination, not only to reduce medical costs beneficial, but also to reduce the impact of adverse drug reactions is significant.
(2) The pharmacological treatment plan for schizophrenia should be based on a single antipsychotic drug as much as possible. Short-term combination of antidepressants is possible in the acute phase according to the depressive symptoms, but not in the long term. In the maintenance treatment of schizophrenia, it is recommended to try to treat with a single antipsychotic drug, which is very helpful to improve treatment compliance. Evidence-based clinical studies in persuasive SCI papers show that emotion stabilizers such as lithium carbonate, valproate analogs, and lamotrigine have no adjunctive therapeutic effect on maintenance treatment of schizophrenia, merely increase medication side effects, and increase the economic burden on the patient’s family. This point exemplifies the importance of differential diagnosis.
The above brief explanation is intended to answer a simple question: the treatment concepts of bipolar disorder and schizophrenia are different, both in the acute and maintenance phases, and there is no such thing as “psychiatric diagnosis is the same, treatment is the same. If the diagnosis and treatment of psychiatric disorders were “common”, there would be no development of the discipline, and clinical research would be in vain.
Schizophrenia and bipolar disorder are two disorders that should not and will not be confused. In recent years, because of the boom in the diagnosis of affective mental disorders abroad, some people in China have followed suit, often misdiagnosing some schizophrenia as bipolar disorder, to the detriment of the patients.
What is the problem? It lies in the misunderstanding of the meaning of ‘mania’. Mania’ is the translation of manic; it is not aptly translated and has attracted a lot of misunderstandings. In fact, patients do not make a lot of noise. They are in a high mood, very pleasant, very self-congratulatory, often arrogant, and think they are very smart and capable. This ‘madness’ means just arrogance, not ‘manic and irritable’ ‘madness’. They will not be unreasonable and will not impulsively hit others. They don’t usually beat up their relatives, but on the contrary, they look cute. In Shanghainese, they are very ‘sensible’ and not unreasonable like schizophrenia. ’Manic depressive disorder’ is the original name used, which is characterized by a period of high mood excitement and a period of low mood depression. ‘Tantrums’ are not a characteristic of its performance. When some parents or doctors hear that a patient is ‘throwing tantrums’, they lean the diagnosis towards bipolar disorder and use ’emotion modifiers’ indiscriminately. Some doctors or parents think that ’emotion adjusters’ can adjust emotions, and use sodium valproate or lithium carbonate at every turn. In fact, here’s the story: when lithium carbonate was found to be able to treat ‘mania’, it was named ‘anti-manic drugs’. Later found that some anti-epileptic drugs (such as sodium valproate, etc.) also have the same therapeutic effect, they are also included in the ‘anti-manic drugs’. Later, it was found that they not only have a calming effect on the high emotion in the manic period, but also have a therapeutic and preventive effect on the low emotion in the depressive period, so they were renamed as ’emotion adjusters’. In fact, they only have a therapeutic and preventive effect on patients with ‘manic-depressive disorder’, and have no adjustment effect on the emotions of other diseases (such as schizophrenia).
Manic-depressive disorder (bipolar disorder) is a cyclical disorder, with one episode lasting half a month to six months. Between episodes, they can return to full normalcy; they are asymptomatic even without the use of antipsychotics; and they have sufficient self-awareness to know that they were mentally abnormal during the previous period and that they want help with a view to preventing relapse.
Schizophrenia is a persistent illness and can fluctuate; however, symptoms do not disappear completely without the use of antipsychotics. Even with the use of antipsychotics, complete remission is not always possible. Even if complete remission is achieved, once the medication is stopped, relapse occurs within a few months. In some patients, self-consciousness can be completely restored; however, generally speaking, self-consciousness is often insufficient during the onset period.
Manic-depressive disorder has two manifestations: the depressive phase and the manic phase. The manifestations of the depressive phase are exactly the same as those of depression (monophasic), mainly depressed mood, lack of interest, loss of appetite, insomnia and early awakening, decline in various mental functions, and even negative thoughts, self-injury or self-murder. There are usually no hallucinations or delusions. Only a few very severe patients (or before negative self-injury) may experience self-blaming and self-criminal delusions (thinking that they caused others to suffer and that they deserve to die!) or brief hallucinations (e.g., “Go to hell!” ), but not lengthy hallucinations. There is no other bizarre behavior. Patients are generally self-aware, recognizing that their depressed mood is abnormal and therefore requesting therapeutic help.
In schizophrenia, depression may be present in a third of cases. However, often, they do not recognize their low mood as pathological and instead of blaming themselves, they blame others for causing them to be so pathetic and difficult. The depressed mood can be followed by an inexplicable self-congratulation that makes people elusive (doctors who nowadays indiscriminately expand the bipolar diagnosis would fondly call it ‘mixed’) and laughable. The most extraordinary thing is: no self-awareness, no perception that one’s low mood is pathological, no request for treatment or help.
The manic phase of manic-depressive disorder is characterized by high mood and excitement and multilingualism. His high mood tends to infect others and provoke laughter. He is not alone and excited and talkative, but busy conversing with others. He is happy, not angry. He will be eager to do good things and will not cause havoc for no reason. He will not lose his temper, much less hit someone, unless his activities are interrupted or chastised. He is not emotionally indifferent, so he will not beat up his loved ones mercilessly and unjustly. Except for extremely severe periods, it is generally said that there is still fairly good self-awareness, that one knows that the emotions are a little too excited, and that one agrees and accepts treatment.
Schizophrenia, which may have ‘manic’ manifestations, should not be called ‘mania’ (‘mania’ is the translation of mania, which is only the elevated mood that only manic-depressive disorder has expression. Because the translation is not good enough, it can be easily mistaken for ‘mania’). They may be dominated by hallucinations or delusions, appearing to rage, lose their temper, make a lot of noise, beat and curse people, be ruthless, beat their loved ones, destroy property, or even set fire and kill people. Their manic manifestations do not make others happy, but only annoy and anger them. They have no self-awareness, do not recognize their mistakes, let alone admit that they are pathological, and will not admit their mistakes or apologize at all afterwards.
Manic depression can be treated with only ’emotion stabilizers’ such as lithium carbonate or sodium valproate. Generally speaking, the effect is slower, at least 2 weeks or more. If maintenance doses can be applied and well maintained, there can be no more relapses for life. It is usually not necessary to apply antipsychotic treatment. If it is because of too much excitement, it can be suppressed first with olanzapine or risperidone, etc., and should be stopped when excitement is controlled. If it can be maintained by ’emotion stabilizers’ such as lithium carbonate or sodium valproate alone, it is true manic-depressive disorder. Otherwise, it may be an imposter and actually a misdiagnosed schizophrenia.
Schizophrenia must be treated with antipsychotics. ‘Emotional stabilizers’ such as lithium carbonate or sodium valproate do nothing at all for schizophrenia. Don’t ever think, as the name implies, that ’emotion stabilizers’ such as lithium carbonate or sodium valproate can stabilize all kinds of emotions! This is an overwhelming misconception! Yet, this misconception is currently prevalent among some psychiatrists.