Bipolar & Schizophrenia: Dual Diagnosis or Schizoaffective Disorder?

Can You Have Bipolar & Schizophrenia?

It’s estimated that about half of people with schizophrenia also experience depressive episodes, manic episodes, or both.^{4, 5, 6} When this occurs, it complicates the diagnostic process and can lead a person to receive one or two different diagnoses.^{1, 2} Some clinicians will diagnose comorbid schizophrenia and bipolar as two separate disorders, while others will diagnose these symptoms under the umbrella of schizoaffective disorder.

Schizoaffective disorder is a diagnosis that was created to help categorize these individuals, but it has been the subject of scrutiny. It is also one one of the most misdiagnosed mental illnesses,  due to confusion and controversy surrounding the diagnosis.^{4, 5} At first, schizoaffective was considered a subtype of schizophrenia, but has since been classified as a different disorder.⁴ Researchers have debated about how to diagnose co-occurring symptoms of schizophrenia and bipolar for over a decade.

Positions on diagnostic criteria for comorbid bipolar and schizophrenia include:^{1, 7}

• Position 1: Schizophrenia and bipolar disorder are two separate disorders, and it is possible to be diagnosed with both
• Position 2: Schizoaffective disorder is the correct diagnosis for people who have schizophrenia in addition to symptoms of either bipolar or depression
• Position 3: Schizoaffective disorder may be an atypical type of either bipolar disorder, depression, or schizophrenia
• Position 4: Schizophrenia and bipolar disorder are linked and schizoaffective disorder represents an overlap between the two disorders

Overlapping Schizophrenia & Bipolar Symptoms

People who experience overlapping symptoms of both schizophrenia and bipolar disorder experience psychosis in addition to manic and/or depressive episodes. Some will experience an overlap in symptoms while others do not. Whether or not the psychotic symptoms (i.e. delusions and hallucinations) occur at the same time as the manic or depressive episodes can help to determine a person’s diagnosis.^{1, 2, 3}

When psychotic symptoms only occur during a depressive or manic episode, a person is more likely to be diagnosed with either major depressive disorder or bipolar disorder with psychotic features.²When the psychotic symptoms occur separately from the symptoms of a mood disorder, a person is more likely to be diagnosed with either schizoaffective disorder or receive two separate diagnoses.³

Symptoms of Schizoaffective Disorder

There are two subtypes of schizoaffective disorder: bipolar type and depressive type. Someone with the bipolar type has symptoms of schizophrenia in addition to manic and depressive episodes. Alternatively, a person with depressive type has symptoms of schizophrenia in addition to symptoms of depression.³

The symptoms of schizoaffective include:³

A. Two or more of the following symptoms of schizophrenia:

• Delusional thoughts that are irrational, abnormal, and held with strong conviction or belief (i.e. delusions of grandeur, persecutory delusions)
• Hallucinations where a person sees, hears, or perceives things that aren’t really there (auditory or visual hallucinations)
• Disorganized speech which can involve saying things that don’t make sense, echolalia (repeating words), or pressured speech
• Disorganized behavior which may include involuntary speech or movement or  catatonic symptoms where a person becomes unresponsive
• Negative symptoms like a flat or blunted affect, lack of motivation or interest, or being emotionally detached or unresponsive

B. Five or more of the following depressive symptoms and/or three or more of the following manic symptoms (depending on whether the person has the bipolar or depressive type of schizoaffective):

Depressive type symptoms	Bipolar type symptoms
Depressed mood or feeling sad/down	Elevated mood and increased energy
Lack of interest or pleasure in activities	Inflated self-esteem or grandiosity
Decrease or increased appetite	Decreased need for sleep
Sleeping more or less than normal	Being more talkative than usual
Moving slower or faster than normal	Racing thoughts or ideas
Loss of energy or feeling fatigued	Being more easily distracted
Feelings of worthlessness or guilt	Increase in goal-directed activity
Impaired concentration or thinking	Impulsive or reckless behavior
Thoughts of suicide or death	Increased irritability

C. There can be some overlap between the mood and psychotic symptoms, but there must be some separation (times when psychosis is present without depressive or manic symptoms)

Differences Between Bipolar & Schizophrenia

One of the reasons that schizoaffective disorder is such a controversial diagnosis is because traditionally, it was believed that people with schizophrenia experience a restricted emotional range. For example, those with schizophrenia often have a flat affect and are less emotionally responsive than normal. Someone with schizoaffective disorder presents with a wider range of emotions that includes periods of emotional highs and lows, but also has many of the characteristic symptoms of schizophrenia.^{2, 3}

Other important differences between bipolar and schizophrenia include:^{1, 2, 3}

• Schizophrenia is a psychotic disorder while bipolar is a mood disorder
• Schizophrenia is usually treated with antipsychotic medication while bipolar disorder is normally treated with either antidepressants or mood stabilizers
• Schizophrenia usually develops later in life (20’s or 30’s), but bipolar can arise in adolescence or early adulthood
• Schizophrenia often involves more psychotic symptoms (i.e. hallucinations and delusions) than bipolar disorder

How Are Co-occurring Schizophrenia & Bipolar Diagnosed?

Because of the confusion surrounding comorbid schizophrenia and bipolar disorder, it’s possible to be diagnosed with both conditions or to be diagnosed with schizoaffective disorder. Whether a person receives a dual diagnosis or is diagnosed with schizoaffective depends largely on the clinician who is doing the evaluation. Some clinicians will give both diagnoses, while others will use the schizoaffective disorder diagnosis for clients with overlapping symptoms of bipolar and schizophrenia.

Treatment for Bipolar & Schizophrenia VS Schizoaffective Disorder

Regardless of how overlapping symptoms of bipolar and schizophrenia are diagnosed, the treatments for dually diagnosed and schizoaffective clients is the same. Treatment for bipolar and schizophrenia, and schizoaffective disorder include a combination of psychiatric medication and therapy.^{4, 8, 9}

Medications

Medication is a recommended component of treatment for people who are struggling with symptoms of bipolar and schizophrenia. Normally, someone with symptoms of both conditions will be treated using two or more medications. Often, this includes an antipsychotic drug to treat the hallucinations, delusions, or other psychotic symptoms. Additionally, an antidepressant or mood stabilizer may be prescribed to treat the symptoms of bipolar or depression.^{4, 8}

Because both bipolar and schizophrenia are linked to chemical imbalances in the brain, most people with these conditions need medication to manage their symptoms. Psychiatric medication can be prescribed by a psychiatrist or by a doctor, nurse practitioner, or physician’s assistant who specializes in treating mental illness.⁹

Therapy

The first step towards recovery is often to make an appointment with a licensed mental health specialist who can confirm your diagnosis, and provide tailored treatment recommendations. Therapy is often recommended for people who are diagnosed with comorbid bipolar and schizophrenia or schizoaffective disorder.

Therapy options for managing symptoms include:^{4, 8, 9}

• Individual, group, or family therapy sessions
• Support groups for people with mental illnesses
• Peer support professionals who are also in recovery
• Social skills or life skills group to improve functioning or independence
• Electroconvulsive Therapy (ECT) to trigger electrochemical changes in the brain
• Intensive outpatient group therapy
• Inpatient mental health hospitalization to stabilize someone/intervene in a crisis

The kind of therapy recommended for symptoms of schizophrenia and bipolar depends on how severe the person’s symptoms are. People with more severe symptoms may be recommended for intensive outpatient or inpatient care, while more mild symptoms may be treated in outpatient therapy.^{4, 9}

How to Find a Therapist For Bipolar Disorder and Schizophrenia

If you or a loved one is experiencing symptoms of bipolar and schizophrenia, it’s important to seek the help of a professional. Finding a therapist or clinic that specializes in treating mood and psychotic disorders is a good idea, and helps ensure that someone receives an accurate diagnosis. Consider looking for clinics that have an on-site psychiatric provider, so you can get your medication and therapy at the same place.^{4, 9}

Many people begin their search using an online therapist directory that helps filter results based on their location, insurance type, and therapist’s specialty. Early treatment is key to improving outcomes in treatment for people experiencing symptoms of schizoaffective disorder.⁴ With a combination of long-term medication and therapy, people can often manage associated symptoms.⁹

Final Thoughts

It is not uncommon for someone to experience symptoms of both schizophrenia and bipolar.^{4, 5} Not all experts agree on how to diagnose overlapping bipolar and schizophrenia.^{1, 2, 4, 7} Because of this, when these disorders co-occur, they are sometimes diagnosed separately. Other times, they may be diagnosed as schizoaffective disorder. Regardless of how symptoms are diagnosed, the treatments used involve a combination of medication and therapy. Studies suggest that getting treatment early is linked to a better prognosis and functioning for people experiencing symptoms of both a mood and psychotic disorder.⁴