Q:  Multiple Questions re: Son's Illness

Dear Dr Phelps.
My 20 year old son was hospitalized a month ago.  He was living with friends for the prior 8 months, after i had asked him to leave due to chronic pot smoking and his inability to stay in college or hold down a job. He called me and we had dinner, he seemed odd. (I had taken him to a Pdoc a year before, because he thought the music he wrote and recorded on his electric piano was being stolen by a govt. agency) i thought this was the copious amount of pot he has chronically smoked since the age of 15.

To make a long story short, the next day he broke into my house and i found him sitting on my chair, fireplace going, under a blanket with a head band on. He wouldnt speak, and when i approached him he would raise up out of the chair and gesture for me not to speak. I called 911.

Since then ( his insight was horrible but much better now, he has started to accept he has an illness and is being med compliant) he is now out of a 3 week stay in the hospital and is in an outpatient program from 9-3pm where they teach clients how to recognize symptoms, and do a lot of cognitive psychology and behaviorl psy. The  program is very good and has a fantastic recovery model psycho social repuation. The
Pdoc there has a great reputation for not over medicating and tweaking meds.

His Pdoc in the stabilization unit said he was paranoid schizophrenic, but the Pdoc
at at the outpatient program changed the dianoses to Bipolar 1 mania psychosis.  I
tend to believe this dr more because of his 30 plus years of experience as opposed
to the 8 years out of med school the Dr had from the stabalization psych floor.
 
He has connected with the Pdoc and the psych nurses at the program and hes learning
a lot of skill.

THE PROBLEM is that he is dull minded, slow, and acts more like he is retarded at
times. It feels more like schizophrenia, but i am far from an MD. And the Pdoc
insists that my son has had one LONG ( a year) untreated manic episode that he is
still not quite over yet. His psychosis is finished due to the 3mg of riperdol ( he
started with 10mg of abilify for 2 weeks in the hospital that did nothing and
changed to 4 mg of risperdol for a week before being released) Hes now taking 3mg of
risperdol and 1500mg of Depakote.

For the past two days he has been so exhausted he was unable to make it to the program. ( i had his blood work done yesterday to see where the depakote levels were but it hasnt come back yet)  He has NEVER been depressed and still isnt. His psychiatrist said that he was young yet, and that in fact he probably will be some day. Is it possible to be only manic and be Bipolar? Is it normal for him to be this dull minded and tired? Is it the meds? Is it the disease? Will he ever be sharp again enough to hold down a job or go back to school? His memory is great ( long term) but its as if his decision making is so slow. Deciding to take a shower, or standing there looking at his gym bag and then leaving the shampoo on a bench and his clothes on another bench. Just simple automatic things that are taking him forever to figure out. He is/was very sharp, creative, artist musician.
 

Dear Mr. G' -- 
Sorry to hear this story. It must be awful, going through this (for you as well as for him). Let's see if I can tackle some of those questions: 

1. Is it possible to be only manic and be Bipolar? 
Yes, I've seen estimates ranging from 2% to 10% of bipolar patients only ever have manic episodes, not depression. 

2. Is it normal for him to be this dull minded and tired? Is it the meds? 
Could definitely be the medications, in part, but that sounds like pretty extreme dullness for 4 mg of risperidone (about a medium or medium high dose in most people's book at this point; we used to use considerably higher doses at one time, like 6-8 or more mg commonly). Sounds more like there's something else going on, but that's just a guess from a distance here.  As you saw with the aripiprazole at first, sometimes one medication can be very different from another; and that means that at some point, if this dullness did not seem to be resolving, it would be worth considering a medication change to see if something else would control the symptoms and possibly not have this effect. 

3. Is it the disease?  Bipolar depression can be very "dulling": people lose their motivation as well as their energy; but to just stand there looking at his gym bag, that's a little unusual, as you describe it.  But here's the way some doc's think, when it comes to differentiating bipolar disorder from schizophrenia, where the latter might more classically include "dullness" as part of the illness:  bipolar disorder has a better prognosis, in general, so why don't we start out trying to treat it as though it were bipolar disorder, i.e. look for all the features that could signify BPI instead of schizophrenia, so that we make sure we don't miss the opportunity to treat an illness that can really turn around.  At a practical level, this means using mood stabilizers, not just antipsychotics; perhaps thus the Depakote. If as things go along the mood stabilizers just don't seem to be adding anything, and/or the signs really look more like schizophrenia, then one can let the diagnosis gradually drift in that direction. Several mood stabilizers, like Depakote, have been shown to add value to the treatment of schizophrenia, so being wrong by leaning in the direction of bipolar disorder at first is not taking a risk, except for the risks that accompany any added medication. 

The point of all that is that perhaps the dullness you see is the disease; that would be more consistent with schizophrenia than with bipolar disorder, I think most doc's would agree. However, these two illnesses may not be as separable from each other as our diagnostic system suggests, as you may have learned. There is the intermediate "schizoaffective" label; and several of the genes once thought to mark schizophrenia have been found in families with bipolar disorder. As you've also likely learned, looking at your family, and his mother's, for other affected individuals and looking at their diagnoses may also provide a clue as to what you're more likely dealing with (although I often distrust a diagnosis of "schizophrenia" from 20 or 30 years ago, particularly if there are a lot of other relatives with mood problems in the family; that makes an unrecognized bipolar disorder a possible explanation for that uncle with "schizophrenia"). 

Will he ever be sharp again enough to hold down a job or go back to school?  As you can see, the answers to the questions above ought to shed light on this, and yet those answers are so equivocal -- not much light, is it. So, this one I can't really address. Some families like to hold out every hope for a full recovery, or a substantial recovery anyway; other families are more cautious, not wanting to add to the pain if those long-nurtured hopes are eventually dashed. A middle road works for some, staying open to either possible outcome (also known as "hope for the best, prepare for the worst").  I hope for the best for you both. 

Dr. Phelps

Published May, 2006