History of bipolar disorder and schizophrenia?!

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Doctor Bagel

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I think every psych patient who visits our ED gets this put in their notes. They often have neither. I didn't think this combination was even possible -- wouldn't that be schizoaffective disorder? I never thought I'd see myself wishing that people would use schizoaffective disorder more frequently ... Maybe EM residents should actually rotate in psych since psych patients make up a good deal of their patients.

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I didn't think this combination was even possible -- wouldn't that be schizoaffective disorder?
Nope, it's certainly possible (I'm pretty sure). I'm just going to bed now so I can't expand until later.
 
Bipolar and Schizophrenia but not Schizoaffective: DIGFAST plus Pos Sx plus Neg Sx without 2 wks of Pos sx when mood is stable. Which means mood is always unstable, or there is a residual type Schizophrenia and bipolar symptoms without psychosis. EM is deep.
 
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EM pro tip: it's Schizoaffective. If anybody from EM is reading this I know you don't give a crap. We still love you. Thanks for running labs and asking the patient what year it is.
 
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EM pro tip: it's Schizoaffective. If anybody from EM is reading this I know you don't give a crap. We still love you. Thanks for running labs and asking the patient what year it is.

I'm little more annoyed with this latest patient because the doctor didn't tell me she had diabetes and a host of other medical comorbidities. It was one of those, "you'll admit this patient, right? Bye" before I had to chance to ask any questions.

I've got to say I never ever regret not doing emergency medicine (not that I ever thought of doing emergency medicine, but still).
 
Reminds me of the time I was a resident. Get a call from the ED. Patient with a long psych history presented to ED complaining of bugs crawling on her. I asked the ED resident, "did you make sure there actually aren't any bugs on her?" "Oh yeah. She's clean." Turns out she had scabies. I was nervously scratching for a week after that.


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The only people who seem to understand the Kraepelinian dichotomy are psychiatrists (and not all of them). And in my opinion, schizoaffective disorder is a cop out for bad history taking and an incomplete understanding of history, phenomenology, and longitudinal course: schizophrenics can present in full manic or depressed episodes- Kraepelin clearly described this. Also, bad Bipolars can looks so psychotic that is masks the pressure of speech, activity, etc and they look like pure schizophrenics until the psychosis is treated- then they appear manic. When treated and followed, they then have intact social functioning, return to normal insofar as med compliance is maintained, etc. But most of these people I have seen have compliance issues and are chronically ill, unfortunately.

Our upper level EM residents know that "bipolarschizophrenic" means one or more of the following: poor psych follow up, multiple past providers who are incompetent at taking histories combined with poor patient insight, inherent racism in some doctors (tendency to over diagnose SCZ in African American Bipolars), ASPD on crack, ASPD on meth, any and every substance use disorder, etc etc. The ED interns and other interns don't realize that SCZ and BPAD are mutually exclusive, so I have a brief education session with them when this issue comes up.
 
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The only people who seem to understand the Kraepelinian dichotomy are psychiatrists (and not all of them). And in my opinion, schizoaffective disorder is a cop out for bad history taking and an incomplete understanding of history, phenomenology, and longitudinal course: schizophrenics can present in full manic or depressed episodes- Kraepelin clearly described this. Also, bad Bipolars can looks so psychotic that is masks the pressure of speech, activity, etc and they look like pure schizophrenics until the psychosis is treated- then they appear manic. When treated and followed, they then have intact social functioning, return to normal insofar as med compliance is maintained, etc. But most of these people I have seen have compliance issues and are chronically ill, unfortunately.

Our upper level EM residents know that "bipolarschizophrenic" means one or more of the following: poor psych follow up, multiple past providers who are incompetent at taking histories combined with poor patient insight, inherent racism in some doctors (tendency to over diagnose SCZ in African American Bipolars), ASPD on crack, ASPD on meth, any and every substance use disorder, etc etc. The ED interns and other interns don't realize that SCZ and BPAD are mutually exclusive, so I have a brief education session with them when this issue comes up.

I trained in such a place that stressed that the Kraepelinian dichotomy is dead, and that "schizoaffective disorder" was likely our delusion. I'm not familiar with the most recent literature though.
 
I think every psych patient who visits our ED gets this put in their notes. They often have neither. I didn't think this combination was even possible -- wouldn't that be schizoaffective disorder? I never thought I'd see myself wishing that people would use schizoaffective disorder more frequently ... Maybe EM residents should actually rotate in psych since psych patients make up a good deal of their patients.

I usually interpret that to mean that there have been varying diagnoses made over the years. Obviously, its not unusual for patients to initially be diagnosed with one, only for it actually be the other down the line.
 
If you talk to the patients coming in off the street where I'm at, it's actually a very common diagnosis to have "schizophreniabipolarschizoaffective" (always a one word diagnosis) One of the unique features of this diagnosis is an insistence that their positive cocaine tox has nothing to do with their present symptoms.
 
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If you talk to the patients coming in off the street where I'm at, it's actually a very common diagnosis to have "schizophreniabipolarschizoaffective" (always a one word diagnosis) One of the unique features of this diagnosis is an insistence that their positive cocaine tox has nothing to do with their present symptoms.

word...
 
Why does it matter what the EM doc calls it? I find that they throw out psych labels with about the same level of thought as the rest of the staff in the ED. Isn't that why they call us?

My own frustrations with he incorrect dx from EM is that the social worker reads that and not my consult and then starts sending that info to wherever we are trying to turf. It usually is a problem more when it is someone with borderline intellectual finctioning being called psychotic than it is Bipolar vs Schizophrenia. We get so many 70 something IQ patients in the system being treated for "mental illness" when they just need a little extra support... Ugh! don't even get me started on that rant!
 
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They are all probably the same thing: Newest paper from American Journal of Psychiatry (http://www.ncbi.nlm.nih.gov/pubmed/26651391) "
Identification of Distinct Psychosis Biotypes Using Brain-Based Biomarkers" agrees on the problem and concludes
"These data illustrate how multiple pathways may lead to clinically similar psychosis manifestations, and they provide explanations for the marked heterogeneity observed across laboratories on the same biomarker variables when DSM diagnoses are used as the gold standard."
 
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Why does it matter what the EM doc calls it? I find that they throw out psych labels with about the same level of thought as the rest of the staff in the ED. Isn't that why they call us?

My own frustrations with he incorrect dx from EM is that the social worker reads that and not my consult and then starts sending that info to wherever we are trying to turf. It usually is a problem more when it is someone with borderline intellectual finctioning being called psychotic than it is Bipolar vs Schizophrenia. We get so many 70 something IQ patients in the system being treated for "mental illness" when they just need a little extra support... Ugh! don't even get me started on that rant!
What wonderful magic land do you live in where you're able to get either of those services for your MR/DD patients? I'm jealous.
 
The ED interns and other interns don't realize that SCZ and BPAD are mutually exclusive, so I have a brief education session with them when this issue comes up.
Am I reading this wrong, or is this wrong? I read it as "schizophrenia and bipolar are mutually exclusive, no one can have both."
 
What wonderful magic land do you live in where you're able to get either of those services for your MR/DD patients? I'm jealous.
They don't get services because they are not under 70 IQ. Sure they can see the NP at the CMH to get medication that does not help them and can exacerbate their difficulties and that is about all they get.
 
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The intellectual disability/mood instability/bipolar problem is more frustrating than schizophrenia/schizoaffective one. It also leads to more problems down the road.
 
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I'm not sure I care what the ER calls it (or what anyone calls it). Psychotic vs. not psychotic would be more than sufficient and, unfortunately, not well recognized. Even by psychiatrists.
 
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Am I reading this wrong, or is this wrong? I read it as "schizophrenia and bipolar are mutually exclusive, no one can have both."

That is what I meant. Is the Kraepelinian Dichotomy perfect? Of course not, but I think it is one of the richest concepts in all of psychiatry and every psychiatrist should have a solid understanding of it (ie, more than just SCZ and BPAD are 2 separate illnesses) and more importantly the many flaws and limitations therein. Even Kraepelin questions its consistency if you read him closely; if you read Dementia Praecox he says that the definitive diagnosis is made by longitudinal course and issue; ie, does the patient ultimately end up "weak minded" with an "injury to the emotional and volitional sphere"? or, has he or she retained his or her psychic functioning? So how do you make a diagnosis without knowing the terminal state? Somewhat of a non sequitur... Danny Weinberger had a great paper in the 90s in which they referred to the dementia associated with SCZ as a "stable encehalopathy".

In reality, are the Dementia Praecox and Manic Depressive Insanity manifestations of the same amorphous entity? Possibly (or probably). Nevertheless, absent an actual, consistent biomarker/external validator (I do like that Tamminga AJP paper BTW), we have to use some phenomenological classification system, and I think the Kraepelinian Dichotomy is the best in terms of conceptualizing the illnesses, teaching purposes, and relaying to other providers my thought processes in terms of diagnosis and management.
 
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there are many patients who can present as manic at some point in their illness despite having had non-affective psychotic presentations in the past, and likewise patients with frank mania who later present with non-affective psychotic episodes (not simply mania that has become so disorganized as to look like a primary psychotic diagnosis). Schizoaffective criteria do not apply there as they are quite firm about the temporality of the symptoms. The Kraepelinian dichotomy has long been exploded. There are studies that show it is possible to have both, though technically using our neokraepelinian criteria, you can't because each has an exclusion criterion for the other.

These patients illustrate the necessity of examining the longitudinal history, inter-episodic functioning, and detailed descriptions of symptoms. Patients can first present with florid mania, which then resolves through treatment or as part of the natural course, but longitudinally they develop weak mindedness and have an exacerbation of non-affective psychosis. Thus the diagnosis can CHANGE from BPAD to SCZ, but they can't have both simultaneously. And additionally, there are patients like this who can have less florid mania or a mixed state as a subsequent episode, which, if one is not paying close attention to symptomatology and really taking the time to take a thorough history, the more subtle mania/mixed state can be missed can be missed (ie, they have prominent hallucinations and delusions but they also aren't sleeping, they are irritable, have subtle signs of either pressure of activity or inhibition of activity, etc). Also, if you read Kraepelin, he notes that a not insignificant amount of patients did recover and were safe for discharge, but ultimately their issue is that of weak mindedness, hence their inclusion in the Dementia Praecox.
 
I think every psych patient who visits our ED gets this put in their notes. They often have neither. I didn't think this combination was even possible -- wouldn't that be schizoaffective disorder? I never thought I'd see myself wishing that people would use schizoaffective disorder more frequently ... Maybe EM residents should actually rotate in psych since psych patients make up a good deal of their patients.

Whenever I see that in the chart, I assume chronic psychotic disorder with substance use (either from stimulants/cocaine/PCP or crashing from the same), +/- malingering ("sure, sometimes I can go days without sleeping and doing tons of things all at the same time... Can I have a place to sleep now?").

As for the EM residents perpetuating the diagnoses, I think it's up to us to prove that it's meaningful for them to distinguish between the two. If they're acutely agitated, bipolar or schizophrenia, they get the same meds. If they are dangerous to themselves or others, they get the same disposition. Why is it worthwhile from their standpoint to parse the differences?
 
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Whenever I see that in the chart, I assume chronic psychotic disorder with substance use (either from stimulants/cocaine/PCP or crashing from the same), +/- malingering ("sure, sometimes I can go days without sleeping and doing tons of things all at the same time... Can I have a place to sleep now?").

As for the EM residents perpetuating the diagnoses, I think it's up to us to prove that it's meaningful for them to distinguish between the two. If they're acutely agitated, bipolar or schizophrenia, they get the same meds. If they are dangerous to themselves or others, they get the same disposition. Why is it worthwhile from their standpoint to parse the differences?

The EM resident does not need to take the history to actually decide whether the patient is Bipolar or Schizophrenic- that's our job. I think the comment about having EM residents doing a psych rotation is somewhat hyperbolic, but I try to educate them on why schizophrenia and bipolar are mutually exclusive, and furthermore when they see that on a chart it refers to the heuristic you described in your first statement. The EM physician has to determine sick vs not sick, and if they have even a superficial understanding of the Kraepelinian dichotomy and why our eyes roll when we see bipolarschizophrenic on a chart, it can change his or her degree of clinical suspicion for chronic primary psychotic/affective illness vs substance vs personality vs malingering etc.
 
In reality, are the Dementia Praecox and Manic Depressive Insanity manifestations of the same amorphous entity? Possibly (or probably). Nevertheless, absent an actual, consistent biomarker/external validator (I do like that Tamminga AJP paper BTW), we have to use some phenomenological classification system, and I think the Kraepelinian Dichotomy is the best in terms of conceptualizing the illnesses, teaching purposes, and relaying to other providers my thought processes in terms of diagnosis and management.

These are the discussions I find interesting yet ultimately hate in this field. Absent a biomarker (and I'm one of the pessimists who don't feel that one will ever be found during our careers), yes we need a descriptive system. I just think that too much intellectual energy is fought over debating whether or not teal is blue or green when said dichotomy doesn't do as good of a job as we'd like to think it does when it comes to determining causation or treatment.

We're ultimately limited by our own descriptive language. What color is the sky to a culture whose language doesn't contain a word for blue?
 
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We're ultimately limited by our own descriptive language. What color is the sky to a culture whose language doesn't contain a word for blue?

As an empirical matter, the absolutely simplest color systems known in human languages just encode "bright" versus "dark." This is rare, but surprisingly common to find "bright", " dark" and "red."

Also as an empirical matter, these speakers are grossly fine at doing color discrimination. The strong Sapir-Whorf hypothesis is supported by basically no modern linguists.

As for your specific question, lots of languages don't have specific words for "blue" that do not also encompass "green". Welsh is one; Polish is another. You could probably find some elderly monoglot Polish speakers in Chicago still to put the question to.

My guess is " bluegreen," and, if pressed, "bluegreen but more like the sea than grass" or something along those lines.
 
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As an empirical matter, the absolutely simplest color systems known in human languages just encode "bright" versus "dark." This is rare, but surprisingly common to find "bright", " dark" and "red."

Also as an empirical matter, these speakers are grossly fine at doing color discrimination. The strong Sapir-Whorf hypothesis is supported by basically no modern linguists.

As for your specific question, lots of languages don't have specific words for "blue" that do not also encompass "green". Welsh is one; Polish is another. You could probably find some elderly monoglot Polish speakers in Chicago still to put the question to.

My guess is " bluegreen," and, if pressed, "bluegreen but more like the sea than grass" or something along those lines.

Niebieski vs Zielony? (though I'm sure there's more nuanced differences for people who've done more speaking of the language than me and the Rosetta Stone Level 1 I took off of BitTorrent a few years ago... Every time I get motivated to try to learn Polish I give up quickly because of the insane wall of Grammar.)

Actually there was a radio show in NPR a few years ago in which they found a remote culture that didn't have a word for blue. They considered the sky to be white.

My overall point though is that Patient A, B, and C could all exist with somewhat different presentations. A and B could be clearly separated into dx 1 while C fits into dx 2 even though B and C are ultimately more similar than A and B. Too often there's no DSM dx for teal and we're forced to choose blue or green.
 
Niebieski vs Zielony? (though I'm sure there's more nuanced differences for people who've done more speaking of the language than me and the Rosetta Stone Level 1 I took off of BitTorrent a few years ago... Every time I get motivated to try to learn Polish I give up quickly because of the insane wall of Grammar.)

Actually there was a radio show in NPR a few years ago in which they found a remote culture that didn't have a word for blue. They considered the sky to be white.

My overall point though is that Patient A, B, and C could all exist with somewhat different presentations. A and B could be clearly separated into dx 1 while C fits into dx 2 even though B and C are ultimately more similar than A and B. Too often there's no DSM dx for teal and we're forced to choose blue or green.


You're right - welsh turns out to still be correct but I confused myself on the relevance of Polish, but it is still relevant to my minor digression from your larger point! Polish speakers generally considered blekitny (azure) and granatowy (navy blue) as basic colors that are in no way shades of blue. This lack of apparently obvious-to-Polish-speakers categorical separation does not seem to noticeably hinder Anglophone interior designers.

Agreed though on your broader point - if we insist on different diagnostic categories being Very Different Entities with no internal structural elements in common you will of course have this problem. You can almost always describe empirical reality more accurately if you take a gradient approach or use some kind of compositional feature system without rigid categorical boundaries.

There is a tension there between accurate description and the clinical utility you previously mentioned wanting. To make treatment decisions systematically you ultimately need either a distinct decision point ("This is X and not Y") or you need a clear mapping between features and treatments (" This presentation has characteristics Alpha and Beta, therefore approach Gamma is called for"). Perhaps this is simply my callow inexperience talking, but I haven't seen proposals in the direction of the later being widely used.

Also sufficiently-powered research becomes much harder without category boundaries that you can at least pretend are without overlap.
 
That is what I meant. Is the Kraepelinian Dichotomy perfect? Of course not, but I think it is one of the richest concepts in all of psychiatry and every psychiatrist should have a solid understanding of it (ie, more than just SCZ and BPAD are 2 separate illnesses) and more importantly the many flaws and limitations therein.
I'll be honest, I hadn't heard of it before this thread. I did some looking into it, and I can't find a real justification for it. I think that's one of my biggest problems here -- so much of psychiatry seems arbitrary already and I hate that, especially when presenting our field to others. IMO, this is one of the problems we have in getting respect from other fields and the public and in attracting med students.

So, without recommending that I read an entire book, why is it that the Kraeplin Dichotomy is reasonable and useful?
 
These are the discussions I find interesting yet ultimately hate in this field. Absent a biomarker (and I'm one of the pessimists who don't feel that one will ever be found during our careers), yes we need a descriptive system. I just think that too much intellectual energy is fought over debating whether or not teal is blue or green when said dichotomy doesn't do as good of a job as we'd like to think it does when it comes to determining causation or treatment.

We're ultimately limited by our own descriptive language. What color is the sky to a culture whose language doesn't contain a word for blue?

So then what is the best descriptive system? The Feighner Criteria (1972) from the Wash U group defined the following criteria for establishing validity (based on how diseases were classified in other branches of medicine): Clinical description, laboratory studies (now generalized to biomarkers), delimitation from other disorders, follow up studies, and family studies. In psychiatry we are obviously lacking the second, but I think that the Kraepelinian dichotomy is the best descriptive system when looking at the other four. And again, in reality one is probably not establishing complete validity, but we can at least have a more RELIABLE diagnostic schema, which was the point of DSM 3. Prior to DSM3 SCZ was way over diagnosed (read case reports of the whole catatonia/NMS/malignant catatonia debacle from pre 1970s and this is evident and the patient is clearly manic) because academic psychiatrists were making diagnoses based on the psychodynamic interpretation of the delusional formation rather than rigorous history taking, looking at longitudinal course and family history, etc.
 
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I'll be honest, I hadn't heard of it before this thread. I did some looking into it, and I can't find a real justification for it. I think that's one of my biggest problems here -- so much of psychiatry seems arbitrary already and I hate that, especially when presenting our field to others. IMO, this is one of the problems we have in getting respect from other fields and the public and in attracting med students.

So, without recommending that I read an entire book, why is it that the Kraeplin Dichotomy is reasonable and useful?

So I personally think every psychiatrist should read the Dementia Praecox and Manic Depressive Insanity with someone who knows Kraepelin well and can highlight the salient parts (not an easy read). Fortunately our program director/associate PD are true Kraepelinians and go through both texts with us our intern year. But I will try to summarize why I think it is vital. First, as I have said numerous times, we do not have external validators (yet), so we have to rely upon clinical observation, longitudinal course, family studies, and delimitation from other illnesses. Our modern concept of Schizophrenia is most closely tied to Kraepelin's Dementia Praecox, whereby he describes psychic functioning in terms of cognition, emotion, and motivation, which is interestingly how many neuroscientists today conceptualize the mind in terms of respective brain systems. Anyway, after much arduous and time consuming clinical observation and meticulous research, Kraepelin surmised that hallucinations and delusions do NOT define the illness; it is really a destruction the emotional and motivational systems resulting in a premature dementia, the degree of which can vary from patient to patient, which today we conceptualize as negative symptoms. Kraepelin noted that basic cognitive abilities are largely intact and that the debilitation is caused chiefly by emotional and volitional problems (though we now know that chronic SCZ is associated with many deficits that are strictly speaking, cognitive in nature- working memory, attention, etc). The hallucinations and delusions, are merely symptoms but not completely diagnostic (though they can be suggestive in certain circumstances). One of Kraepelin's most brilliant feats was thus saying that this unifying feature was common to all different clinical forms, which Pre DSM 5 were subtypes: Simplex (negative symptoms), Silly dementia (hebephrenia or disorganized), Circular/Agitated/Periodic (prominent affective components), Paranoid (paranoid), and Catatonic (catatonic). Recent GWAS studies have supported grossly this classification system (though catatonia is another issue that is probably not an individual SCZ subtype given its predominance in BPAD). Also, untreated positive symptoms can definitely come and go, which is why the inter episodic period is so vital for diagnosis.

The Manic Depressive Insanity, conversely, does not result in a terminal state of weak mindedness or dementia, and the patients may make full recovery and are stable for discharge. And Kraepelin describes their non-episodic debilitation as more temperamental in nature (ie, manic temperament sounds like ASPD, irritable temperament sounds like Borderline, etc), but generally their social, emotional, and motivational functioning remains intact when they are not in episodes, which is the principle delimitation criterium from the Dementia Praecox. Also, mania is conceptualized as an over activation of the volitional (impulsive behavior, incr goal directed activity), emotional (lability, elevation of affect), and cognitive (flight of ideas) spheres, whereas depression is conceptualized as an underactivation. Mixed states can either exist as a transition between the two or independent states (one are where DSM V probably improved from DSM IV).

The point is that cross sectionally, Bipolar and schizophrenia are not discernable by descriptive psychiatry alone, which is why longitudinal course is so vital. Kraepelin notes that the ultimate delimitation is based on issue, or terminal state, and that the true diagnosis can only be made at the end of the disease course (ie, did the patient become weak minded/demented/stably encephelopathic?. This is the most difficult feature of Kraepelin's system: without knowing the terminal state, how does one make the diagnosis? Thus, diagnoses can certainly change, but given the critical feature of weakmindedness that is necessary for SCZ but absent from BPAD, they are absolutely mutually exclusive. I will relay this dilemma with several examples of cases in which I was involved (just using clinical course so I don't break HIPAA)- and in all of these cases organic and substance causes were ruled out.

1) High functioning patient first had depressive episode in 20s and was diagnosed with MDD, treated and recovered. Shortly thereafter had a manic episode and then recovered. Diagnosis changed to BPAD Had several more presentations of psychosis without affective symptoms and when treated responded somewhat well but has been frequently noncompliant. Also has experienced significant downward drift. Largely asocial on mental status exam even with treated psychosis. After much discussion diagnosis was changed to SCZ.

2) Patient presented very disorganized and delusional; did not have clear signs of mania (or depression). Lack of reliable history prompted diagnosis of SCZ. When florid psychosis was treated with D2 blockade, patient became manic (classic picture). When mania was treated with Lithium, patient displayed normal affect, intact social engagement, appropriate grooming and hygiene. More history revealed that patient has definitely met criteria for mania, but this has never been aggressively treated, and the patient is chronically noncompliant. I left the diagnosis as Schizoaffective Bipolar type because I don't have objective documentation of history, but in discussion with multiple attendings, this patient is most likely severe Bipolar.

3) Patient with long history of Bipolar with both severe manic and depressive episodes with excellent inter episodic functioning but marred by noncompliance- patient had frequent presentations with the most florid mania one could imagine. Consequently the patient was observed in clinic to have inter episodic psychosis (at a late decade in life) and diagnosis was changed to schizoaffective disorder; however, when looking back carefully at the inter episodic psychosis, the patient was irritable, not sleeping, had inhibition of activity (and was likely in a mixed state). Kraepelin's longitudinal diagrams show similar clinical courses of Manic Depressive Insanity.

4) Very high functioning patient who had first break psychosis with very intricate, complex delusions; some elements of downward drift (quit job, stopped talking to friends) but at first history did not discern if this was truly prodromal or unnoticed mania. Patient was hypertalkative and elevated on exam, though did not appear to be floridly manic. Patient was lost to follow up but then re presented with impulsive behavior, delusions of persecution, hypertalkativity, some question of decreased need for sleep. Importantly she had appropriate social engagement with normal/possibly elevated affect and appeared cognitively intact. More rigorous history taking revealed a true prodromal phase absent manic criteria, and when observed on the inpatient unit the patient did not meet true criteria for mania. The patient had significant downward drift and avolition compared to previous level of functioning, so the diagnosis of Schizophrenia was made.

The catch with all of this is that in order for the Kraepelinian Dichotomy to make sense patients should be followed prospectively with clear descriptions of symptoms and medication changes noted. Kraepelin charted out the courses of all of his patients from his clinical observations, which provided the data from which he drew is inferences and deductions.

And I'm post call and somewhat delirious now...
 
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These patients illustrate the necessity of examining the longitudinal history, inter-episodic functioning, and detailed descriptions of symptoms. Patients can first present with florid mania, which then resolves through treatment or as part of the natural course, but longitudinally they develop weak mindedness and have an exacerbation of non-affective psychosis. Thus the diagnosis can CHANGE from BPAD to SCZ, but they can't have both simultaneously. And additionally, there are patients like this who can have less florid mania or a mixed state as a subsequent episode, which, if one is not paying close attention to symptomatology and really taking the time to take a thorough history, the more subtle mania/mixed state can be missed can be missed (ie, they have prominent hallucinations and delusions but they also aren't sleeping, they are irritable, have subtle signs of either pressure of activity or inhibition of activity, etc). Also, if you read Kraepelin, he notes that a not insignificant amount of patients did recover and were safe for discharge, but ultimately their issue is that of weak mindedness, hence their inclusion in the Dementia Praecox.
no it doesn't. it illustrates the flaw of carving nature at the joints and assuming there are two different kinds of madness - dementia praecox and manic depressive insanity - that are mutually exclusive when in fact time and again this has been shown not to be true. The Kraepelinian dichotomy has had its day, but for too long stifled the progress of our field. Social scientists and philosophers had long held that this dichotomy was flawed and only in the past 15 years do the geneticists seem to have realized this.

I like Kraepelin only for his rich descriptions of various mental states (the prose is quite beautiful) and the way he documented the clinical course of insanity, particularly with his mood charts, that illustrate that the many years of remission that today we might attribute to medication occur within the normal course of illness. Kraepelin was not some intellectual heavyweight. He wasn't terribly bright and his understanding of psychopathology is infinitely dwarfed by Jaspers. A master of observation, Kraepelin was seriously lacking when it came to deduction, completely missing the meaning of his patient's symptom and prone to dogmatism, as well as being utterly inept at following his own call for an empirical approach to psychiatric diagnosis. He was also a complete hypocrite - lambasting the psychoanalysts for attempting to posit an etiology to various mental states, and arguing for a descriptive approach, Kraepelin himself had no problem ascribing a biological etiology to the symptoms he was seeing.

However the historian Hannah Decker, has argued quite persuasively that Kraepelin was never as Kraepelinian as the neo-Kraepelinians would have us believe, himself stating, sounding more like Adolf Meyer, "there are no fixed, only blurred borders, between mental health and mental illness" which flies in the face of the faulty epistemological assumptions of our current ("neo-Kraepelinian") psychiatric classification.
 
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Maybe EM residents should actually rotate in psych since psych patients make up a good deal of their patients.

I would not have minded a rotation in emergency psych during residency. But then again, my job is to differentiate stable crazy with unstable crazy, which is not that hard. What's hard is finding a bed for the unstable crazy. That's hard. There's only so much haldol, ativan, zyprexa, and ketamine I can give before they just lie there in a little puddle.
 
Or to answer your question Harry, in simple terms. Regardless of what the best classification system me, we need to always be sure to remember that any classification system is limited and somewhat arbitrary. When we become too concrete about how we classify, we often miss the forest for the trees.

Concrete thinking and a psychiatric prescription pad makes for a dangerous interaction.
 
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I think some of the criticism against the dichotomy is valid, in the sense that it's still little more than hypothetical. A useful way to conceptualize mental illness but quite limited.

However the historian Hannah Decker, has argued quite persuasively that Kraepelin was never as Kraepelinian as the neo-Kraepelinians would have us believe, himself stating, sounding more like Adolf Meyer, "there are no fixed, only blurred borders, between mental health and mental illness" which flies in the face of the faulty epistemological assumptions of our current ("neo-Kraepelinian") psychiatric classification

How does it fly in the face of our current psychiatric classification when all definition of mental illness is based on a subjective parameter i.e personal/social dysfunction?

He was also a complete hypocrite - lambasting the psychoanalysts for attempting to posit an etiology to various mental states, and arguing for a descriptive approach, Kraepelin himself had no problem ascribing a biological etiology to the symptoms he was seeing.

I don't think the problem was positing an etiology as much as the methodological system used to come up with causative theories. Is it based on the scientific method or not? That's the major talking point.
 
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How does it fly in the face of our current psychiatric classification when all definition of mental illness is based on a subjective parameter i.e personal/social dysfunction?

I don't think the problem was positing an etiology as much as the methodological system used to come up with causative theories. Is it based on the scientific method or not? That's the major talking point.
The DSM-III project was based on the notion that there was a discrete difference between mental health and mental illness. DSM-5 while flirting with the concept of dimensionality is still ultimately based on this notion.

Kraepelin's suggestion of a biomedical etiology was no more based on the scientific method than psychoanalytic theory. So I'm not sure what your point is. The debate was between verstehende psychologie and erklärende psychologie.
 
no it doesn't. it illustrates the flaw of carving nature at the joints and assuming there are two different kinds of madness - dementia praecox and manic depressive insanity - that are mutually exclusive when in fact time and again this has been shown not to be true. The Kraepelinian dichotomy has had its day, but for too long stifled the progress of our field. Social scientists and philosophers had long held that this dichotomy was flawed and only in the past 15 years do the geneticists seem to have realized this.

I like Kraepelin only for his rich descriptions of various mental states (the prose is quite beautiful) and the way he documented the clinical course of insanity, particularly with his mood charts, that illustrate that the many years of remission that today we might attribute to medication occur within the normal course of illness. Kraepelin was not some intellectual heavyweight. He wasn't terribly bright and his understanding of psychopathology is infinitely dwarfed by Jaspers. A master of observation, Kraepelin was seriously lacking when it came to deduction, completely missing the meaning of his patient's symptom and prone to dogmatism, as well as being utterly inept at following his own call for an empirical approach to psychiatric diagnosis. He was also a complete hypocrite - lambasting the psychoanalysts for attempting to posit an etiology to various mental states, and arguing for a descriptive approach, Kraepelin himself had no problem ascribing a biological etiology to the symptoms he was seeing.

However the historian Hannah Decker, has argued quite persuasively that Kraepelin was never as Kraepelinian as the neo-Kraepelinians would have us believe, himself stating, sounding more like Adolf Meyer, "there are no fixed, only blurred borders, between mental health and mental illness" which flies in the face of the faulty epistemological assumptions of our current ("neo-Kraepelinian") psychiatric classification.

Yawn. Maybe in 2005 editorializing that Kraepelinian Dichotomy is not absolute truth because large scale genetic studies show shared genetic risk architecture for SCZ/BPAD was revolutionary, but I don't know; I was in college debating Locke vs Rousseau, Rawls vs Nozick, Tocqueville vs the Revolutionaries, why Michigan football was better than everything else, etc. Every psychiatrist knows that it's not absolute truth and has significant limitations, which multiple people in this thread have already detailed. However, as long as we have an operational diagnostic system and still don't have more precise definitions than "schizophrenia" and "bipolar," it works well. Danny Weinberger wrote a great editorial on the subject (more related to RDOCS specifically, but his point is generalizable...) http://www.ncbi.nlm.nih.gov/pubmed/26558844

And the Dichotomy is not a metaphysical/esoteric/difficult concept to explain; it's elegance is in its simplicity. Kraepelin's criticism of psychoanalysis was largely that Freud portrayed "arbitrary assumptions and conjectures as assured fact", whereas Kraepelin cast constant self doubt and revised his works tirelessly based on his clinical experience. Both men were without question absolutely brilliant and two figures indispensable to psychiatry.

I am a huge fan of Hannah Decker, and The Making of DSM III is a must read, but she is a historian (and a very astute one). And historians are revisionists and interpreters. Kraepelin self doubting his dichotomy and his approach to psychiatry isn't unsurprising; it's expected. But that doesn't preclude us from considering the value of the Dichotomy in clinical practice- or that Mandel Cohen, Eli Robbins, Sam Guze, and by extension Robert Spitzer used him as an inspiration. Bill Wilson used LSD with Aldous Huxley, tried to commercialize AA before being shot down, and was probably the original 13th stepper, and whether Rowland Hazard actually met with Carl Jung is another point of extreme contention. Nevertheless AA is still a life saving program for millions, and the historical issues do not prevent me from strongly recommending patients with substance use disorders engage in 12 Step Recovery.
 
"My borderline is flaring up again..." something I've heard numerous times, like it is MS or something.

A mental health professional upset at a patient for medicalizing personal behavior . . .

That's one of the cruxes of opposition to psychiatry. And it's the basis for psychiatry's legitimacy in the field of medicine.

A patient may not massage the message the way a professional wants; but it's not patients who have medicalized these problems.

I'm not saying that there isn't a place for the medicalization, but if you can get people to accept an entirely new language, I don't know that you can be upset if they have a slightly different dialect.
 
The DSM-III project was based on the notion that there was a discrete difference between mental health and mental illness. DSM-5 while flirting with the concept of dimensionality is still ultimately based on this notion.

Kraepelin's suggestion of a biomedical etiology was no more based on the scientific method than psychoanalytic theory. So I'm not sure what your point is. The debate was between verstehende psychologie and erklärende psychologie.

Huh? Kraepelin clearly saw psychiatric disorders as syndromes and attempted to classify them for further study, which is what the rest of European medicine was doing at that time. He clearly made observations, asked questions, did background research, constructed hypotheses, tested those hypotheses, developed theories based on results, which he continued to refine throughout his career. As a colleague of Alzheimer, he carefully looked at neuropathologic and gross morpoholgic changes in an attempt to describe a clinicopathologic correlate. Yes, he was "wrong," but he approached psychiatry as a clinician and a scientist. Interestingly, if you read the section on Morbid Anatomy from the Dementia Praecox, he is on the verge of describing the illness as a disorder of brain development, which Danny Weinberger essentially confirmed ~100 years later.

Freud was a very astute neurologist and neuropathologist rigorously indoctrinated in the scientific method and culture of Viennese Academic Medicine, though cocaine and interactions with Charcot (specifically his more obscure interests) allowed him to look beyond the dogmatisms of Vienna. He thus deliberately rejected the scientific method and anything modern medicine was doing.

Also, consider the patient populations. If one is psychotic enough to be admitted to Kraepelin's institution in Munich (and in some cases through the natural history of the illness becomes stable for discharge), there is a clear line between "sick" and "not sick." Whereas Freud's skill of transforming ... "hysterical misery into common unhappiness" makes this boundary more obscure.
 
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The DSM-III project was based on the notion that there was a discrete difference between mental health and mental illness. DSM-5 while flirting with the concept of dimensionality is still ultimately based on this notion.

Kraepelin's suggestion of a biomedical etiology was no more based on the scientific method than psychoanalytic theory. So I'm not sure what your point is. The debate was between verstehende psychologie and erklärende psychologie.

Well I disagree, ultimately both "biomedical" and psychoanalytic causative etiologies are hypotheses and speculations, except one is rooted in our current scientific understanding of behavior and organism in general while the other is not at all. Note however that psychology (and in particular cognitive psychology) is very much part of the "biomedical model". In that sense, Kraeplin isn't really contradicting himself for simply speculating about the cause of mental illness if he believes he's doing this while sticking to the best of his abilities to the current state of science, while still placing far less importance on such speculations relative to the descriptive method he pioneered. It would be totally absurd if one thought that etiology in psychiatry simply doesn't exist.
 
So I guess I need to brush up my high school German if I want to make it in psychiatry...
 
One of the many reasons psychiatry >>>>>>>>>> everything else. I use "gedankenlautwerden", "mitgehen", and "mitmachen" regularly in my notes!

I am but a fourth year and have already had occasion to document "no mitgehen or gegenhalten" in notes previously, and I look forward to being able to continue to be absolutely insufferable via the medium of German.
 
I think every psych patient who visits our ED gets this put in their notes. They often have neither. I didn't think this combination was even possible -- wouldn't that be schizoaffective disorder? I never thought I'd see myself wishing that people would use schizoaffective disorder more frequently ... Maybe EM residents should actually rotate in psych since psych patients make up a good deal of their patients.

I'd actually prefer the EM doctors I or my family see in the future to have spent more time training on emergency medicine, medicine, and surgery rotations than spending a month in psych. I'd rather them be able to resuscitate someone rather than them knowing specific dsm criteria of various disorders.

Maybe thats just me though.
 
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