20.9 — Bipolar Disorder and Schizophrenia

People with schizophrenia are far more likely to be victims of violence than perpetrators of it.

That single fact contradicts most of what the public absorbs about these conditions, and it is worth putting first, because the stigma around them causes measurable harm — it delays treatment, and delayed treatment produces worse outcomes.

Both conditions are treatable. Many people with either live full working lives. That is not optimism; it is what long-term follow-up studies show.

Bipolar disorder

Episodes of elevated mood alternating with episodes of depression, with periods of normal mood between.

Affecting around 1 to 2 percent of people, with a strong genetic component — around 60 to 80 percent heritability, among the highest in psychiatry.

Mania

Elevated or irritable mood, lasting at least a week, with a marked change in functioning.

Reduced need for sleep — and this is the key one. Not insomnia, where a person wants sleep and cannot get it, but feeling fully rested after three hours. It is frequently the earliest sign of an episode starting, which makes it the single most useful thing for a person and their family to watch.

Also: rapid, pressured speech; racing thoughts; inflated self-esteem, sometimes reaching grandiose beliefs; distractibility; increased activity and goal-directed behaviour; and risky behaviour — spending, sexual behaviour, driving, business decisions — with consequences that outlast the episode by years.

Psychotic symptoms occur in a substantial proportion of manic episodes, which is one reason bipolar disorder is sometimes initially diagnosed as schizophrenia.

Hypomania — the same features, milder, lasting at least four days, without psychosis and without severe impairment. And it frequently feels good, which is why it is rarely reported and why the diagnosis is so often missed.

Bipolar depression

And this is where people spend most of their time — depressive episodes are more frequent and longer than manic ones, and they cause most of the disability.

It looks like ordinary depression, with some tendencies toward more sleeping, more eating, and heavier limbs.

And here is the clinically critical point:

Average delay from first symptoms to correct diagnosis is around 6 to 10 years, because people seek help when depressed and not when hypomanic.

Antidepressants alone can trigger mania or rapid cycling.

Which is why anyone presenting with depression should be asked directly about periods of elevated mood, reduced need for sleep, and uncharacteristic behaviour — and why a family history of bipolar disorder changes the treatment plan.

The types

Bipolar I — at least one full manic episode.

Bipolar II — hypomania plus major depression, never full mania. Not a milder illness, because the depressive burden is typically greater.

Cyclothymia — chronic milder fluctuation.

Rapid cycling — four or more episodes a year, harder to treat.

Treatment

Lithium, and it deserves its position.

The most effective mood stabiliser, and the only medication with good evidence for reducing suicide risk specifically.

It needs monitoring, because the therapeutic and toxic ranges are close: blood levels, kidney function and thyroid function.

Toxicity is a medical emergency — coarse tremor, vomiting, diarrhoea, confusion, unsteadiness, and eventually seizures. Dehydration, NSAIDs, ACE inhibitors and some diuretics all raise lithium levels, which is the practical thing to know: an episode of vomiting and diarrhoea in someone on lithium is a reason to check.

Long-term it can affect the kidneys and the thyroid, which is why the monitoring is lifelong and not optional.

Sodium valproate — effective for mania, and highly teratogenic, so it is not used in women of childbearing potential (Chapter 20.2).

Lamotrigine — better for the depressive pole than the manic one.

Antipsychotics — used for acute mania and for maintenance; quetiapine and lurasidone have evidence in bipolar depression specifically.

Psychological therapy — and the most useful component is unglamorous: recognising early warning signs and having a written plan for what to do.

Regular routine matters more than in almost any other condition — consistent sleep and wake times, because sleep disruption both signals and triggers episodes. Shift work and long-haul travel are genuine risks.

And a practical protection: arranging in advance that a trusted person can restrict access to money and credit during an episode, because financial damage done in three manic weeks can take a decade to undo.

Outlook: with treatment, many people have long stable periods and full careers. Adherence is the main determinant, and the commonest reason for stopping is missing the hypomania — which is a real loss for some people and needs discussing honestly rather than dismissing.

Schizophrenia

Affecting around 0.3 to 0.7 percent of people, typically beginning in the late teens to twenties in men and slightly later in women.

And it is not "split personality" — the name has caused a century of confusion. It refers to a disruption in the integration of thought, perception and emotion.

The symptoms

Positive symptoms — things added:

Hallucinations, most often auditory. Voices, often commenting or conversing, experienced as coming from outside the head and as real as any other sound, because the brain regions that process heard speech are genuinely active.

Delusions — fixed false beliefs held despite contrary evidence. Commonly persecutory, or beliefs about being controlled or about thoughts being inserted or broadcast.

Disorganised thinking, showing up as speech that moves between loosely connected ideas.

Negative symptoms — things removed, and these cause most of the long-term disability:

Reduced motivation, reduced emotional expression, reduced speech, social withdrawal, and reduced ability to experience pleasure.

They respond far less well to medication than the positive symptoms, and they are frequently mistaken for laziness or depression, including by families.

Cognitive symptoms — attention, memory and executive function, present before the first episode and the strongest predictor of whether someone will work.

What causes it

Genetics contribute substantially — heritability around 70 to 80 percent, spread over many common variants plus some rare ones of large effect.

Prenatal factors — maternal infection, malnutrition, and complications of birth.

Cannabis, and this deserves accuracy rather than either alarm or dismissal. Regular use in adolescence increases the risk of psychosis, with a dose-response relationship, and high-potency preparations carry higher risk. It is a contributing factor in a vulnerable minority, not a cause in most users, and both halves of that sentence are supported.

Urban upbringing and migration — consistently found, probably reflecting social adversity.

Childhood trauma.

The dopamine hypothesis — excess dopamine signalling in specific pathways underlies the positive symptoms, which is why all effective antipsychotics block dopamine D2 receptors (Chapter 11.2). It does not explain the negative or cognitive symptoms, which is the main gap, and glutamate abnormalities are the leading candidate for those.

Treatment

Antipsychotics.

All block dopamine D2 receptors to some degree, and they differ mainly in their side effects.

Side effects worth knowing, because they determine whether treatment continues:

Movement effects — parkinsonism, restlessness, and tardive dyskinesia, involuntary movements typically of the face and mouth that can persist after stopping. Commoner with the older drugs.

Metabolic effects — weight gain, diabetes and raised lipids, particularly with olanzapine and clozapine. These cause real physical harm and they are the main reason life expectancy in schizophrenia is reduced by 15 to 20 years, mostly from cardiovascular disease — not from the illness itself. Physical health monitoring is therefore part of psychiatric care, and it is delivered poorly.

Raised prolactin, causing sexual dysfunction and breast changes.

Sedation.

Neuroleptic malignant syndrome — rare and life-threatening: high fever, severe rigidity, confusion and autonomic instability. An emergency requiring the drug to be stopped and intensive support.

Clozapine, and it deserves a paragraph.

It is clearly the most effective antipsychotic, working in around 30 to 60 percent of people who have failed two others.

It requires regular blood monitoring, because it can cause agranulocytosis — loss of the white cells that fight infection — in around 1 percent. It also causes drooling, constipation that can become dangerous, seizures at higher doses, and inflammation of the heart muscle rarely.

And the practical problem: it is substantially under-used, with typical delays of years, because the monitoring is inconvenient. Someone whose illness has not responded to two drugs should be offered it.

Psychological and social treatment:

CBT for psychosis — working with distressing beliefs and voices rather than trying to argue them away. Real evidence, particularly for distress and functioning.

Family intervention — one of the best-evidenced interventions in psychiatry, reducing relapse substantially. It works by reducing criticism and over-involvement in the home, both of which measurably predict relapse.

Supported employment, using the "place then train" model, which works far better than lengthy pre-vocational preparation.

Early intervention services — specialist teams for the first few years, which improve outcomes measurably.

And the reason is duration of untreated psychosis: the longer someone is psychotic before treatment starts, the worse the long-term outcome. Which makes early recognition genuinely important, and it is the strongest practical argument against the stigma that delays help-seeking.

The outlook, stated accurately

The common belief is that schizophrenia means inevitable decline. Long-term follow-up does not show that.

Roughly: a proportion recover substantially and remain well; a larger group have episodes with good function between; and a proportion have persistent symptoms and significant disability.

Better outcomes are associated with: later onset, acute rather than gradual onset, a clear precipitating stress, good functioning beforehand, prominent mood symptoms, and short duration of untreated psychosis.

And the largest single threat to life expectancy is physical health, not the psychiatric illness — cardiovascular disease, smoking, and reduced access to routine medical care. Which means that treating blood pressure, cholesterol, diabetes and smoking in someone with schizophrenia is among the highest-value medical interventions available.

What to do if someone is in a psychotic episode

Stay calm and speak simply.

Do not argue with a delusion, and do not pretend to agree with it. Both fail. What works is acknowledging the feeling without endorsing the belief — "that sounds frightening" is honest and does not require you to confirm anything.

Reduce stimulation — fewer people, less noise, a quieter room.

Keep everyone safe, and give the person space rather than crowding them.

Get professional help — the person's mental health team where one exists, otherwise emergency services.

And in an emergency, say clearly that it is a mental health crisis so that the right team responds.

What the next page fixes

Chapter 20.10 covers addiction — what dependence actually does to the brain's reward system, and why the treatments that work are not the ones people expect.