Bruce Dow, M.D.

PTSD and Psychiatric Diagnosis

In psychiatry we have three important diagnoses that command attention and respect. Insurance companies are more likely to pay when patients have one of these “parity” (equivalent to medical) diagnoses: schizophrenia, bipolar disorder, major depression. Genetic studies attempt to locate the genes for these diagnoses on our chromosomes. Imaging studies attempt to locate brain centers responsible for these illnesses.

Schizophrenia

Schizophrenia is characterized by delusions, hallucinations, disorganized speech or behavior, flat emotion, low motivation. Bipolar disorder is characterized by episodes of mania: persistently elevated, expansive, or irritable mood; grandiosity; reduced sleep; pressured speech; flight of ideas; distractability; increased goal-directed activity; excessive pleasurable activity. Major depression is characterized by depressed mood, loss of interest, weight loss, sleep disturbance (too much or too little), loss of energy, reduced concentration, feelings of worthlessness, thoughts of death.

These syndromes seem different enough to be readily distinguishable. However, patients with clear evidence of schizophrenia may have episodes of either mania or depression or both. An additional diagnosis, schizoaffective disorder, is required to characterize such patients, and there are two sub-categories of schizoaffective disorder: bipolar type and depressed type.

Bipolar Disorder

Furthermore, bipolar disorder can be characterized by periods of depression as well as mania; hence its name, bipolar disorder. Bipolar patients can have mood swings from one state to the other. Sometimes the “switch” can be quite dramatic. Two types of bipolar disorder are recognized: bipolar I and bipolar II. The difference is that bipolar II patients mostly look depressed, but have occasional episodes of mild mania, referred to as hypomania. Bipolar I patients show full-blown mania, with or without episodes of depression.

Patients with severe depression can become psychotic and have delusions or hallucinations, which tend to be self-deprecatory: “you’re a bad person”, “you’re no good”, “you would be better off dead”.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) can lead to severe depression with psychotic features. People with PTSD can become very angry or fearful, and seem manic. They can become emotionally flat and withdrawn and appear schizophrenic. PTSD flashbacks can look like psychosis. Some of the apparent overlap between schizophrenia, bipolar disorder, and major depression can be explained by the presence of PTSD. It is important whenever one makes the diagnosis of schizophrenia, bipolar disorder, or major depression to consider the possibility of superimposed PTSD. One needs to ask about trauma history: life-threatening events during which one felt intense fear, helplessness, or horror. One also needs to ask about recurrent nightmares, flashbacks, disturbing memories, avoidant behaviors.

Superimposed PTSD can cloud the distinctions between schizophrenia, bipolar disorder, and major depression. Many patients with the diagnosis of schizoaffective disorder or depression with psychotic features turn out to have PTSD, along with one of the “parity” psychiatric disorders. By definition (according to the current psychiatric Bible, the DSM-IV), one cannot have both schizophrenia and bipolar disorder, or both bipolar disorder and major depression. One can have both schizophrenia and major depression, but the depression has to be brief and episodic; if the depression is persistent, the diagnosis would be schizoaffective disorder, depressed type. Schizophrenia and bipolar disorder are considered to be life-long illnesses; major depression is considered to be time-limited, with complete recovery between episodes.

Because of the ubiquity of trauma in our lives, it is important to consider PTSD as a possible contributor whenever one is making the diagnosis of schizophrenia, bipolar disorder, or major depression. This step is critical as we develop new treatments for PTSD and a greater understanding of its reach.