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Bipolar and Schizophrenia – Symptoms, Treatment and Recovery

Bipolar and Schizophrenia – Symptoms, Treatment and Recovery

Written by: Dr. Joseph Leong Jern-Yi

Understanding Bipolar & Schizophrenia

Both bipolar disorder and schizophrenia were considered severe mental illnesses with no recovery in the past. This is not true in modern psychiatry as we have developed more effective treatments such as medications (psycho-pharmacology) and psycho-social interventions (psycho-therapy and psycho-social rehabilitation) which help patients improve their quality of life as well as reduce symptoms and restore function.

Bipolar disorder and schizophrenia may have similar symptoms which are disturbances in thinking, feelings and behaviour. The major difference is that bipolar disorder is classified as a mood disorder whereas schizophrenia is classified as a psychotic disorder. Mental healthcare professionals make diagnoses based on reports of patients, caregivers, or other information sources as well as observations made during the assessment interview.

Experts have also formulated that schizophrenia and bipolar disorder may be a spectrum disorder with schizophrenia on one end and bipolar disorder on the other end with schizoaffective disorder in the middle of the spectrum.

What is more important however is not the exact diagnosis alone but rather the identification of symptoms so that treatment can be effectively targeted at the relief of the symptoms, restoring function and improving quality of life. This targeted symptom approach has proven to be one of the most effective ways of helping persons recover from these brain conditions.

Let’s discuss some of the common symptoms –

Delusions, which are untrue, unshakable, and unshared beliefs which can exist in both brain conditions.

For example, delusions of persecution which are beliefs of being targeted, being followed, being sabotaged (persecutory) are common in schizophrenia while delusions of grandiosity such as believing that they are particularly important persons and have special powers or ability to save the world (grandiose delusions) are more common in bipolar disorder. For persons with schizoaffective disorder, they might have both persecutory and grandiose delusions at the same time. It also has an underlying co-occurring mood disorder.  

Hallucinations which are perceptual disturbances such as hearing voices which are not heard by others, seeing, smelling, tasting or feeling things which are not present are more likely to happen in schizophrenia.

Severe mood swings and manic episodes where the person has fast speech and high energy levels are associated with abnormal spending, socialising, exercising, or expanding businesses with the need for very little sleep over a few days and weeks are more likely to happen in bipolar disorder.

More than half a century ago, most persons suffering from these brain conditions were isolated and confined to asylums as there were no effective treatments until the discovery of medications that can change brain chemistry. Neurotransmitters which are chemicals responsible for brain and other bodily functions were discovered. Noradrenaline, serotonin, and dopamine disturbances were more likely causes in bipolar disorder while dopamine imbalance was a more probable cause of schizophrenia. See https://dana.org/article/neurotransmitters/

 

The Help Of Modern Medicine

Modern psychopharmacology offers an array of medications which can act on various neurotransmitter sites in the brain. Several medications and several rounds of adjustment and fine-tuning may often be needed to achieve stabilisation with medications with relief of symptoms. This is best done collaboratively with the patient, psychiatrist, and caregiver at the consultation with all the medications brought in for review.

Adjusting to a new medication through an effective therapeutic trial may take at least 2 weeks, starting with the lowest dose and increasing dosing to a maximised symptom relief dose over 2 months. 

Medications need to be taken daily to be effective, and this is best done using a pill box and with supervision from a loved one. Medications are served by nurses in the inpatient hospital setting who ensure that the correct dose is directly observed to be taken by the patient – however, this is often lacking in the outpatient setting leading to the return of the symptoms causing distress and dysfunction.

 

Bipolar & Schizophrenia Treatment Methods

Comparing bipolar disorder and schizophrenia to other brain conditions may be helpful in understanding how one can better achieve remission and recovery. 

Epilepsy is a brain condition where there are electrical firing of neurons causing disturbances in thinking, feeling and behaviour. To stay in control of oneself, the doctor may recommend various combinations of anti-epileptic medications to prevent another seizure. In fact, the model of kindling in epilepsy has been used to understand mental health treatment in this highly readable resource essay – https://aeon.co/essays/should-the-kindling-concept-direct-mental-health-treatment

If you speak to someone with experience with epilepsy, they will tell you about ‘warning signs’ and the ‘confusional state’ after a breakthrough seizure.

Similarly, for those struggling with bipolar disorder and schizophrenia, one becomes more aware of ‘warning signs’, and ‘confusional states’ through direct feedback from loved ones who are observant and psycho-educated by healthcare professionals. Charting, monitoring and sharing your experience are key to success in achieving remission and recovery. Use this mood chart and share it with your mental healthcare professionals for more in-depth analysis – https://loricalabresemd.com/wp-content/uploads/2017/12/Personalized-Mood_Chart.pdf

Symptoms management starts with monitoring your symptoms and the response to the treatment – what makes it better, what makes it worse, whether it is mild, moderate or severe. The frequency, intensity and severity can be charted so that effective treatment of psycho-pharmacology (active use of medications) and psycho-social interventions (psycho-therapy and psycho-social rehabilitation) can be targeted to achieve the best outcome for you.

 

Recovery Is Possible

Your mental healthcare professional can coach and pace you so that it will not be overwhelming. Recovery starts with taking it one day at a time. Be gentle with yourself. Learn to trust and entrust your healing to people who care about you. Learning from feedback as well as charting, monitoring and sharing your experience with loved ones – trusted family or friends or co-workers greatly enhance effectiveness.

Atomic habits by James Clear is an excellent book which illustrates the importance of charting, monitoring and shaping your habits, on the premise of improving 1% daily leading to more than 365% improvement in one year. This is Youtube illustrates how that can happen – “How to become 37.78 times better at anything”. 

There are many services available at Promises Healthcare and Community Partners which can help reduce symptoms, restore function, and improve quality of life. Recovery is possible and becomes a reality with appropriate support and adequate skill training. With the right help and support, persons in recovery can live meaningful and satisfying lives.

Here are some real stories that illustrate many facets of mental health and recovery:

What is the Lasting Power of Attorney (LPA)?

What is the Lasting Power of Attorney (LPA)?

The idea of becoming mentally incapacitated is often so frightful that most people simply avoid the issue. Discounting the various other ways someone can lose control of their mental faculties, in Singapore, 1 in 10 people above 60 will succumb to dementia and 3.6% of people will suffer from obsessive-compulsive disorder, 1 in 50 people will experience a psychotic episode at some point in their lives, and 1% will suffer from schizophrenia, all conditions that might precipitate the loss of mental faculties. It’s a statistic that we’ve not brought up to alarm you, but simply to help you decide if you have someone in your life you trust to protect your interests, in the realm of your personal welfare, and property and affairs.

You simply have to be above the age of 21, by law in Singapore, to appoint one or more “donees”, who are people you trust “to make decisions on your behalf, in your best interests”. You, as the appointer of your donee(s), are known as the “donor”.

The Ministry of Social and Family Development suggests that it is beneficial to make an LPA as a protective measure against any untoward happenstance as it relates to your mental well-being. It is obviously best to decide what the best permutation for you is while you are capable of making rational decisions on your own behalf. Broadly, your appointed donee(s) will have control over one or both of the following aspects of your life: your personal welfare; and your property and affairs.

The LPA is designed to safeguard your interests, so it grants you the latitude of choice in deciding if: you want a single donee, whose powers are defined in Part IV of the Mental Capacity Act, or multiple donees. In the event that you decide that you would prefer multiple donees, you also have the power to decide if you will allow any one of them to act alone in making a decision on your behalf, or have them come to a consensus on undertaking a decision.

The difference between LPA Form 1 and LPA Form 2 is that LPA Form 2 allows you to appoint more than 2 donees, more than 1 replacement donee, or grant your donee(s) customised powers above the general powers with basic restrictions that donees are granted under LPA Form 1. LPA Form 2 requires the services of a lawyer.

After you have decided what’s best for you, and filling up LPA Form 1, or LPA Form 2, which you can do with the help of a lawyer, there is a “critical safeguard” in place to ensure that the LPA is not made under duress. This means that your LPA form will have to be witnessed and certified by an LPA certificate issuer, which can be:

  1. an Accredited Medical Practitioner;
  2. lawyer; or
  3. registered psychiatrist

As the writer of this article is none of the above, we recommend that you speak to your chosen LPA certificate issuer to fully understand the nuts and bolts of the LPA.

Nobody wishes to have the eventuality of an LPA come to pass, but we hope you will consider that “a stitch in time saves nine”. For Singapore citizens, the LPA Form 1 is free, until 31 August 2020.

Please refer to the MSF’s LPA FAQ for further details.

 


  1. Singapore Mental Health Study, 2016.
  2. Psychosis – Institute of Mental Health. https://www.imh.com.sg/clinical/page.aspx?id=258, accessed 8/6/20
  3. SA Chong, et al. A Risk Reduction Approach for Schizophrenia: The Early Psychosis Intervention Programme, Annals Academy of Medicine, Sep 2004 Vol 33 No. 5.
  4. Photo by Scott Graham on Unsplash
An interview about Psychosis on Vasantham’s En Ullae S2 with Dr Jacob Rajesh

An interview about Psychosis on Vasantham’s En Ullae S2 with Dr Jacob Rajesh

Vasantham (Mediacorp’s Tamil & Hindi TV Channel) studios reached out to Promises Healthcare’s Senior Consultant Psychiatrist, Dr Jacob Rajesh, in the name of bringing greater mental health awareness to the Indian community in Singapore.

This episode of En Ullae touches on psychosis. This case study was about a man who had developed schizophrenia and became obsessed with the ‘spiritual safety’ of his partner. The building tension served to demonstrate the dangers of ignoring the symptoms of psychosis, which his partner was predisposed to do, in her untoward position as the long-suffering partner in a dangerously unstable relationship. Dr Rajesh characterised psychosis as rooted in an unshakeable belief in false delusions – people who suffer from the condition are often willfully blind to reason, which he cautions against trying to impose on them when the time is inclement. 

Prem, the unfortunate man with all the symptoms of hallucinatory schizophrenia, began to cast an evermore imposing spectre in the relationship, causing much distress to Rani. His delusions began to take such a toll on their relationship, with even the good tidings of a baby in the oven twisted into a string of abortion by Rani, afraid that he would bring harm to her and any prospective child she would bequeath upon them – he professed to see the child as a harbinger of doom, as the embodiment of the devil. Midway through the episode, the viewer is treated to the appearance of two ambiguous personalities – a man and a woman, whose blue lanyard faintly conveyed some sense of authority. We are left uncertain as to their actual responsibilities – they are at times quizzical, unwilling to manifest the “good cop, bad cop” trope. No matter, it is not the point of the episode to further entangle the convoluted plotlines – they serve as plot devices which encourage Prem’s own narrative to unfold – to the end, he remains stolidly convinced that his stabbing of Rani had taken her to a better place, the expression on his face almost beatific at times. 

Dr Rajesh, at this point, sees fit to caution the viewer against harshly attributing homicidal tendencies to persons with psychosis. He presents the statistic that even less than 15% of homicides are perpetrated by people mentally unsound. Noting the prevalence of drug use and antisocial tendencies that colour this 15%, he confidently steers the viewer away from making too quick a conclusion – it is in everyone’s best interest to step back and evaluate statistics grounded in good science, instead of leaping to the easy conclusion that Prem was beyond rehabilitation.

 

(Click on the link for a version with English subtitles. Remember to click on the ‘Settings’ button to reveal the English subtitle selection. https://www.mewatch.sg/en/series/en-ullae-s2/ep6/952940 )

From The Cradle To The Grave: A Mother’s Enduring Love

From The Cradle To The Grave: A Mother’s Enduring Love

Written & Translated by: Dr Terence Leong, Senior Consultant Psychiatrist

First published on Wan Bao Fu Kan on 19 Jan 2020 in Mandarin


 

Many years ago, whilst I was a trainee, I used to work in the Institute of Mental Health. One night, while I was on duty in the emergency room, an old lady in her 90s brought her 60-year-old daughter to the clinic. With a calm and friendly smile, she told me that her daughter had relapsed. It turned out that her daughter had been suffering from schizophrenia for many years, with frequent relapses that required innumerable hospitalizations. At the age of 16, she started to suffer from hallucinations and paranoid delusions. She became suspicious of others, and her temper became extremely volatile. In the early days, she resisted taking medication, resulting in a rapid deterioration in her condition. Within a few months, she was forced to drop out of school. Subsequently, she did try to work, but was unable to hold on to a job. Without a stable income, she was unable to support herself and was unable to lead an independent life. Moreover, her psychotic symptoms worsened, impacting on her self-care. She had to stay at home near-daily, relying on her mother to care for her. 

The old lady was a senior nursing officer in our country before her retirement. She made many important contributions to our country’s healthcare system and she was a pioneering leader in the nursing profession. Unfortunately, her husband passed away early on, and she had to raise all their three children by herself. Her eldest son went abroad to start a business and now has a successful trading company in the United States. Her second child also did well in her studies. After getting her master’s degree, she taught at the university for several years but decided to become a housewife after getting married. The third child was originally the smartest and most sensible amongst the three children. She studied hard since young, and did well academically, with excellent grades every year. She was a filial child, who would always help her mother with housework. In short, she was never a trouble to her parents.

Unfortunately, she fell ill during the first year of junior college, resulting in a dramatic change in her personality and behaviour. Formerly a cheerful, vivacious and enthusiastic young lady, she became irritable and impulsive. Her paranoia resulted in her isolating herself from her friends and loved ones. The old lady took care of her with infinite love and silently accepted this difficult mission. But the eldest brother and the second sister refused to associate with her, and did not welcome their visits even during the Lunar New Year.

The years gradually passed. The old lady is now retired and the frailties of age took a toll on her physical health. In her twilight years, she sincerely begged her two elder children to take care of their sister. But they both adamantly refused to accept this burden. After asking several times, and after having the door literally closed on them on the 2 older children, the old lady finally understood. She courageously continued her lifelong mission and patiently looked after her daughter. By then, she was in her early 90s, and her daughter was in her 60s. That night, she quietly told me: “I’m actually tired, but I cannot die. Because she still needs me.”

That night, I truly understood the greatness and self-sacrificing nature of a mother’s love. 

Schizophrenia is a serious, long-term disease. The support of family members is very important to the patient’s recovery. Without the help of family members, even if you take the best medicine and see the best doctor, it will be to no avail.