Dear Dr. Gorman,

I have a loved one who has been diagnosed with Bipolar Disorder (I do not know which type). He has been successfully treated with only 5mg of Abilify.

In the past, when not taking in the medication, he became extremely paranoid. For example, he believed the government had put a device in his brain & was demanding scans to prove its existence. At one point he flew overseas to "escape" the government. During another relapse episode, he stole a boat which he took out to sea to escape. In addition to paranoid delusions he has also experienced delusions of grandeur.

In the past, he has been hospitalized approximately 5 times. He has experienced some episodes of depression - but this has been more rare.

When he is stabilized on medication (only 5mg of Abilify and nothing else), one would not suspect he has a mental illness.

He does not present, as many people with schizophrenia - even on medications, with a blunted affect or awkward social skills, residual thought disordered sx, etc. Instead, he is extremely high functioning - he is able to work a complex full time job, have friendships and a significant, steady, romantic relationship. Miraculously he was able to achieve college degree - between the times he was in the hospital.

FYI: he has no history of drug use. He has struggled with alcohol abuse during social occasions, but has been sober for several months. His medication definitely is more effective when he is not drinking alcohol.

Given his propensity for paranoid delusions when off his medication, could he have been misdiagnosed with Bipolar? Given his symptoms and behaviors, does he meet the diagnostic criteria for schizophrenia more so than Bipolar Disorder and if so, what type?

If he has schizophrenia - it seems rare that he could present so incredibly stable - as if he does not have a mental illness at all - on just 5mg of Abilify.

Thank you for your assistance and feedback,
Sincerely - K

Dear K, thank you for asking this great question. Last week I spoke at our Grand Rounds (St. Paul's hospital in Vancouver) on this very topic.

Emil Kraeplin, a famous psychiatrist at the turn of the last century distinguished Manic Depressive insanity (of which he discovered 28 different variations, from Dementia Praecox (a much more accurate name for Schizophrenia). The difference is the profound thinking losses and functional disability in Dementia Praecox (i.e. Schizophrenia), of which there was no recovery; and Manic Depressive insanity (bipolar disorder), where the episodes are characterrized by mood, behavior and thinking difficulties, with ultimately full revcovery between episodes.

Ming Tsuang, a psychiatrist, colleague and professor at UCSD (University California San Diego) wrote a pivotal paper in the American Journal of Psychiatry 12 years ago suggesting we need to lookm at Schizophrenia differently than we do. Dr. Tsuang argued that there is too much emphasis on psychotic symptoms (delusions or false beliefs, hallucinations or perceptions without stimuli, and odd behavior), as many psychiatric syndromes have psychotic symptoms, however only schizophrenia had the profound thinking losses and problems (dementia like).

Your friend has impulsive "taking off" behavior which I think is rarley found in anything but mania; persecutory delusions (very common in mania because of all the people that are concerned about you and want you hospitalized makes you paranoid; grandiose delusions; preserved and enhanced ability to think; and response to Abilify, an excellent medication for mania, which may also prevent episodes and have some benefit for depression (even though Lithium is usually better, you can't argue with success.) The psychotic emphasis by DSM IV is incorrect, it is the ability to think and think fast that makes up mania; and the loss of thinking abilities that makes up Schizophrenia.

I hope this helps and thanks for writing in.