How Do We Know What Illness a Mentally Ill Person Has?

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My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. Also, I will provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, how to work with treatment providers, and how to handle medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

Schizophrenia

Schizophrenia, the first diagnosis Bill received, is the quintessential psychiatric illness, widely feared and stigmatized. A surgical colleague once asked me, “Why would you want to study cancer of the mind?” Emil Kraepelin, the founder of modern scientific psychiatry, who believed the chief origin of psychiatric disease to be biological and genetic malfunction, described schizophrenia as dementia praecox, a progressive deterioration leading to premature senility.

Rejecting the concept of inevitable dementia, Eugene Bleuler is perhaps best known for introducing the term and concept of schizophrenia, or more precisely, “the group of schizophrenias,” a physical disease process characterized by exacerbations and remissions. He argued that no one was ever completely “cured” of schizophrenia; even with remission, there was always some lasting cognitive “weakness” or defect that was manifest in behavior.

In 1911, Bleuler stated that repeated illness episodes should be thought of as “deteriorating attacks” rather than recurrence. He advocated for eugenic sterilization of patients diagnosed with schizophrenia to prevent “racial deterioration” resulting from the propagation of “mental and physical cripples.” This concept is abhorrent today but was widely accepted at the time—in the early 20th century—and related concepts of defect continue to sow the seeds of widespread stigma around the illness.

Although Bleuler’s advocacy for sterilization is outdated and abhorrent, his assessment of how schizophrenia manifests is still valid. He described its core feature as alteration of associations: “The connections between associations are lost. The disease interrupts the threads that give direction to our thoughts in an irregular fashion, sometimes affecting only a few, sometimes a large proportion of them. Thus, the result of the thought process is rendered unusual, and often logically incorrect” (Dementia Praecox or the Group of Schizophrenias).

Two other basic symptoms Bleuler identified were ambivalence (contradictory ideas and emotions) and autism (getting lost in personal ideas). Bleuler also distinguished between "positive" and "negative" symptoms of schizophrenia, a concept which has persisted into modern nosology. Positive symptoms include unusual symptoms not found in unaffected people, such as hallucinations or delusions. Negative symptoms, such as social withdrawal, describe the absence of typical experiences like social connectedness.

However, these descriptions apply to all disorders with psychotic features. A patient with psychotic depression may believe that because of mistakes that she made, the world will end, and she may spend hours lost in delusional ideas about her guilt. A patient with bipolar illness with psychotic features may believe that he has a special ability to receive messages from God or that he has become a saint. More typical in schizophrenia are paranoid delusions, such as receiving messages from the radio telling an individual that he is being controlled by the computer and that he is being watched.

In Bill’s case, when he was first hospitalized, his diagnosis was schizophrenia, based upon the paranoid symptoms that he was having—such as when he worried that the computer could be sending him messages and controlling him. He also experienced vivid visual hallucinations—the “positive symptoms” described by Bleuler. In addition, Bill had the loosening of associations that Bleuler outlined.

Other features that would point toward schizophrenia were the relatively young age of his illness onset at 19, and “autism,” or getting lost in his own ideas. However, the fact that these symptoms were preceded by increased activity and a decreased need for sleep made the diagnosis of bipolar disorder or schizoaffective disorder, bipolar type, also a consideration.

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His psychiatrist had diagnosed his illness as schizophrenia, based on Bill’s profound thought disorder, hallucinations, and delusions. But there were aspects that fit more into the camp of bipolar disorder, including decreased sleep and grandiosity. These distinctions matter because the treatment for each condition differs. Bill’s next several episodes made that distinction more apparent.