Thought Disorders, Part II

Mark Vakkur, M.D.

2957 Clairmont, Suite 410
Atlanta, GA 30329
(404) 964-9883 (cell)
(404) 486-7450 (office)


Q: What is bipolar disorder?

A: Bipolar disorder is the current name for the illness once known as "manic depression." Someone suffering from bipolar disorder has periods of mania or hypomania alternating with periods of depression.

Q: What is mania?

A: Mania is a sustained period of elevated, grandiose, or expansive mood, decreased need for sleep, increase in goal-oriented activities, especially pleasurable ones that lead to painful consequences, racing thoughts, and rapid, pressured speech. Often, manic thinking will take the form of extreme religious or political ideas. Someone who is manic may have all or some of these symptoms, and they may last several days or weeks (typically), or come and go more quickly (rapid-cycling). Sometimes the symptoms are so disabling that the patient must be hospitalized or requires a more intensive setting for treatment.

Q: What is hypomania?

A: Hypomania can be thought of as a "little mania" (hypo- means "beneath or below"). Hypomania can be a period of extreme productivity for artists, entrepreneurs, and workers. The elevated and expansive mood coupled with a decreased need for sleep and increase in goal-oriented activities can lead to terrific output. Hypomanic people can make great sales-people. Unfortunately, hypomania often develops into full-blown mania if untreated.

Q: How rare is bipolar disorder?

A: Bipolar disorder is less rare than schizophrenia (about .5% have bipolar disorder versus 1% who suffer from schizophrenia) and much less rare than unipolar depression, which affects about 7% of the population.

Q: What causes bipolar disorder?

A: The exact cause is unknown, but it appears to be a dysregulation of our normal circadian rhythm, as well as an extreme oscillation of the normal variation in our appetites for new experiences, sex, or sleep. It tends to run in families.

Q: What is the treatment for bipolar disorder?

A: Mood stabilizing medications (also called thymoleptics) are the rule. There are 3 medications with FDA approval for the treatment of mania: lithium; Depakote; and Zyprexa. Other medications may be helpful, such as Tegretol, but they do not have the specific FDA indication. Antidepressants also may help, once the mood has been stabilized, but they may also increase the risk of mania and convert someone into rapid-cycling.

Q: Is bipolar disorder related to schizophrenia?

A: No, it's thought to be a mood disorder; schizophrenia is thought to be a thought disorder. Having a family history of schizophrenia (assuming the diagnosis has been well-made) means you are LESS likely to have bipolar disorder (and vice versa). The two can be roughly distinguished as follows:



Bipolar Disorder


Mood Congruence of Delusions



Bizarreness of Delusions



Interpersonal Engagement






Multiple goal-oriented activities

Common especially early in episode (hypomania)

Not characteristic

Downward Drift



Premorbid functioning


Odd or unusual, more socially withdrawn

Effect on Examiner

Infectious Euphoria


Return to Normalcy Between Episodes

The rule

The exception; patients may have negative or residual symptoms


Note that many people with bipolar disorder can be very charismatic and engaging. This is in contrast to many who suffer from schizophrenia, who often are withdrawn and "autistic."

Q: What is the biggest risk for someone with bipolar disorder?

A: Besides the consequences of behavior while manic (increased spending, reckless sexual behavior, substance abuse), suicide is a major concern. The suicide rate for clients suffering from bipolar disorder is higher than for any other major psychiatric illness. This is why close observation and/or hospitalization is often necessary, especially following the first episode.

Q: Are there other illnesses that can look like bipolar disorder?

A: Absolutely. Perhaps the most common is substance abuse, especially of a stimulating substance like cocaine or amphetamines. The grandiosity, irritability, increase in goal-oriented activities, hypersexuality, and pressured, rapid, loud speech seen in these clients is sometimes indistinguishable clinically from mania. Other illnesses include schizoaffective disorder, schizophrenia, and a variety of organic disorders (head injury, stroke, medication side effect).

Q: What is paranoia?

A: Paranoia is the persistent, extreme belief that others are trying to harm you. It is more than mere suspiciousness; paranoia is intrusive and often all-encompassing, and may trigger someone to change his or her lifestyle to avoid an assumed enemy. Unfortunately, given the high rate of assault and homicide in American society, it is often very difficulty to dismiss or discount someone's concern about being threatened as "paranoia." It is critical to take all reports of abuse, neglect, or threats very seriously, and if possible to gather as much external information as possible. Remember that with true paranoia, as with delusions, the person cannot be talked out of it. Instead, you should work on reducing the risk that someone will act on the paranoid delusion, e.g., limiting if at all possible exposure to the believed persecutor, limiting access to firearms, and avoiding substance abuse, all risk factors for violence.

Q: My doctor rattled off a list of medications. How do I know which one is right for me?

A: Medications fall into several different classes. The medications most commonly used for clients suffering from thought disorders are the neuroleptics, or medications commonly known as "anti-psychotics." This is somewhat of a misnomer, however, since many of the newer agents have mood-stabilizing properties. To find out what medication is right for you is a process of trial and error, since no one can predict ahead of time whether you or a loved one will respond to a given medication. Many medications, however, have been shown to be effective in a majority of people with a given diagnosis, but of course this does not guarantee the medication will work in an individual case.

Q: What is an anti-psychotic medication?

A: This is the general name given to a whole host of medications that all have the effect of improving reality-testing (decreasing delusions) and decreasing sensory perceptual disturbances (such as auditory hallucinations). They can be divided into 2 broad classes, the "typical agents" and the "atypical agents." The typical agents include older medications such as Haldol, Prolixin, Navane, and Thorazine. All of these medications had rather severe side effects ranging from stiffness and difficulty moving to sexual inhibition and sedation. The "atypical agents" are the newer medications (most developed within the past 15 years or so) and generally have less severe side effects. Also, the atypical agents have been shown to be effective against the negative symptoms of schizophrenia (e.g., social isolation, withdrawal, lack of motivation).

Q: How do the atypical agents stack up against the typical agents?

All of the atypical agents are more effective and have a better safety profile than the older typical antipsychotics. They can also be divided into first-, second- and third-generation agents, is based on the efficacy and side effect profile.

First-generation antipsychotics are typical agents, including chlorpromazine, thioridazine, and haloperidol, among others. These medications are effective primarily for positive symptoms. Some of the side effects include elevation of prolactin and acute and chronic extrapyramidal symptoms.

The second-generation agents include risperidone and ziprasidone. They have a broader spectrum of clinical efficacy than first-generation agents in that they ameliorate both positive and negative symptoms. These agents are more tightly bound to the dopamine 2 (D2) receptor than are the other atypical agents and this may explain some of the side effects.

The third-generation agents include clozapine, olanzapine, and quetiapine. These agents have a lower risk of extrapyramidal symptoms and tardive dyskinesia, less influence on prolactin levels, and a broader spectrum of action. They also work on positive symptoms but appear to have a greater effect on negative symptoms and mood compared with both the typical and second-generation atypical agents.

Q: How do these medications work?

A: All of these agents work, in part, through their effect on the dopamine system. They block dopamine receptors in a part of your brain called the mesolimbic and mesocortical pathways. (If dopamine receptors are blocked in the nigrostriatal system, then movement side effects will occur.) Long-term blockade of this system may result in tardive dyskinesia, a serious illness that may not be reversible upon stopping the medication. Clozapine, olanzapine, and quetiapine are specific for the mesolimbic and mesocortical systems and do NOT have a significant risk of tardive dyskinesia

Q: Is it unusual for someone with schizophrenia to stop taking his or her medications?

A: Unfortunately, not at all. About 50% of patients stop taking their medications by the end of the first year. Compliance is more like a cycle or a learning curve than a straight line. Ironically, sometimes going off medications can actually be helpful (assuming nothing very bad occurs), since it demonstrates that the medications are actually working (note: this is NOT a recommendation to stop medications!). The newer agents have less side effects, so clients tend to stick with them more.

Q: How can I make it more likely someone with schizophrenia will take his or her medications?

A: There are several ways to improve compliance rates. Medications should be given on a once-daily basis if possible because compliance decreases with more frequent administration. Talk to your doctor about this. Sedating medications should be given at night. If they make the client very groggy the next morning, moving up the dose to earlier in the evening can help. Having reasonable target times after which the medication can be reduced (e.g., if after 2 months, you hear no auditory hallucinations, we can work together to decrease the dose) can give the patient something to look forward to and increase compliance. It is absolutely critical to have a physician you can trust and talk to. Distressing symptoms, such as insomnia, should be addressed. Embarrassing side effects, such as sexual side effects, should be raised by your doctor, but if not, they should be raised by the client.

Q: What are some resources that can help those who suffer from thought disorders and their families?

A: There are many:

Your mental health providers would be happy to provide you with additional information for everything from medication side effects to support groups.