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Q:  BP & Crossing Over Into Schizoaffective?

Dr. Phelps,
My boyfriend is Bipolar I and has been hospitalized three times in the last year for extreme manic episodes, during the last of which he punched a wall and broke his hand.  While he seems to be getting better help than before from a new hospital and set of doctors, and a change of meds, he still suffers from some delusions since his last episode (two weeks ago).  I know it takes some time to stabilize, however, a well-educated therapist recently told me that should he drink alcohol or smoke marijuana he could become permanently delusional and cross over into schizoaffective disorder.  While he's not dual-diagnosis, he does enjoy drinking and I'm very worried about what this will do to him.  I know you're not a substance abuse expert, but have you ever witnessed this happen with a patient?  The thought of losing him to permanent delusions is completely terrifying me.  Please let me know your thoughts on this.

Dear Kerri -- 
Number one: bipolar disorder does not "cross over into schizoaffective disorder".  If the bipolar I diagnosis is pretty firm, then this statement is almost certainly wrong, just on the basis of the fact that we think the definitions refer to "real things" that are not changed from one to another even by substance use.  However, there is some truth to what she or he is saying:  drinking can (but is not certain to) make bipolar disorder worse.  When bipolar I worsens, 
psychosis is common. Delusions are frequently part of psychosis.  

So, he could become more prone to psychosis through the drinking.  That much is clear and not controversial.  But "permanent", that's going a bit too far.  We can't even say that bipolar disorder is "permanent".  People rather commonly have fewer symptoms as they age, some to the point where a diagnostic label is probably not warranted anymore.  So "permanent" is too strong.  But "worse", that's fair.  

If your boyfriend "enjoys drinking" despite the experiences you describe, then his ability to recognize what the alcohol is very likely doing (making his risk of relapse much higher -- another non-controversial statement about alcohol in bipolar disorder) sounds pretty limited.  That means he may have more difficulty getting his bipolar disorder controlled; which also means that you could see him go through this kind of thing again (and again, perhaps).  That means that you yourself are possibly having some difficulty recognizing what alcohol means, to him and to you:  basically, a disaster.  People who cannot recognize when they are part of the cause of their own disasters need some specific help for that.  So, he might need to have a very serious AA involvement to get well, or something very close to that kind of program, which "externalizes" the insight; that is, it lets other people be the "recognizers", if he'll trust them, which is what AA is all about.  For you, you might want to look at Al-Anon, the AA program for people who are in a relationship with someone who has a drinking problem.  Some such groups have been very helpful to my patients' family members.  They're not always good, but they can be excellent.  Good luck with all that.  

Dr. Phelps

Published Jan. 2005


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