Bipolar I or Schizoaffective?
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Q:  Bipolar I or Schizoaffective?

Dear Dr Phelps

I had a manic episode in Feb 01 and I have long standing unusual beliefs.  I take 2 mg Risperidone.  Recently I became very stressed and I had sleep problems, spent far too much money, spiritual beliefs (being God and the first atom).  I went to the doctor 3 times who referred me to the psychiatrist.  I was not given an appointment as my dx  is mania with psychotic symptoms in remission.

Three days ago I slashed my arm and have been referred again by my GP but nothing so far.  I am not dx with depression although last winter I felt terrible.  I have calmed down again but my beliefs are stronger than ever.  Does this sound like Bipolar 1 as opposed to mania in remission or perhaps even schizoaffective disorder?  Thank you very much indeed for your comments.

Dear Sue -- 
The beliefs you have described do sound like the kind of "delusions" that characterize mania, which is what makes bipolar I different from BPII (the latter lacking delusions).  So, on the basis of what you've written here, it does sound like BPI.  BPI can have phases of severe "dysphoria": not depression in the typical sense, in some ways worse -- a period of intense negative feelings and thoughts, during which people often become suicidal and can also discover that in some odd way, self harm can somehow help them.  Fortunately there are other ways to cope, as described on this
excellent site about self harm.  

Thus we don't have to invoke some more complicated diagnosis to explain your symptoms.  You can have dysphoria with or without manic symptoms and still have BPI.  You can have delusions with BPI.  The only reason to invoke "schizoaffective" would be the presence of delusions without any mood symptoms.  Now, perhaps that's what you're describing with your statement "I have calmed down again but my beliefs are stronger than ever.".  In that case technically you might meet the diagnostic criteria for schizoaffective disorder.  

However, I've seen some people with some unusual beliefs that don't really evolve into "delusions" per se, they just kind of sit there, present but not dominating a person's life.  They don't go away on an antipsychotic, although the extent or the seeming implications may diminish some.  Is this "schizoaffective" too?  I don't really see it that way.  But somewhere around this point the diagnostic label begins to be less important and the question turns to treatment. 

Since the medication treatment for bipolar disorder is mood stabilizers; and the medication treatment for schizoaffective is mood stabilizers plus an antipsychotic,  after a while the question for a person like you becomes "is life better when you're on a mood stabilizer and an antipsychotic?"  Note that this raises the question as to whether life would be better for you at this point if you added a mood stabilizer.  With the guidelines for primary care providers on this site, you might be able to try that if you're having to wait many months yet to see a psychiatrist.  

Dr. Phelps

Published December, 2002


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