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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2867_Библиотеки_им_академика_М_И_Перельмана.pdf
452
J. Seok
Introduction
Schizoaffective disorder is a serious psychiatric disorder in which people interpret
reality abnormally and have an unstable mood. There are two types: bipolar type
and depressive type. This case report will focus on schizoaffective disorder bipolar
type. Schizoaffective disorder bipolar type patients experience symptoms of both
schizophrenia and a mood disorder like bipolar disorder. Schizoaffective disorder
may present in some individuals as a combination of delusions, hallucinations, and
very disordered thinking and behavior which will impair daily functioning and can
be disabling like schizophrenia. In addition to the schizophrenia-like symptoms,
people with schizoaffective disorder also have mood symptoms of mania, hypomania, mixed episode (mania and depression), or depression and tend to be episodic
rather than continuous. It is estimated that the disorder affects 0.3 to 0.8% of people, but it is one of the most misdiagnosed mental health disorders [1]. There are
diagnostic tools to help providers diagnose patients with SZA, but the DSM-5 will
need to be followed closely in order to make a proper diagnosis. Recent endophenotype studies have also shown that there is a possible genetic difference between
the schizophrenia disorders [2]. This further validates the DSM-5′s changes to
schizoaffective disorder criteria for diagnosis. The patient in the case study reported
a multitude of clinical symptoms that can be misinterpreted for bipolar disorder
type [3].
Clinical Case Presentation
A 50-year-old African American female presented to the hospital with a “history of
bizarre delusions, hallucinations, disorganized behavior, and disorganized speech.”
[3] She has been experiencing these symptoms for the past 1.5 months and was
unable to tell the providers why she was in the psychiatric unit. She does not have
depression, homicidal, or suicidal ideations. Her past medical history showed that
she had previously had a history with acute myeloid leukemia (in remission), diabetes type 2, epilepsy, HIV, and hypertension. The patient was previously diagnosed
with bipolar type 1 disorder with psychotic features.
During the physical examination, her vitals were stable. She was asked about a
scar on the right knee, and the patient said the scar was a recent wound that occurred
when homeless people recently broke into one of her homes and attacked her (hallucinations). She kept insisting that the scar was still bleeding even though it had
healed [3]. The patient looked poorly groomed and unkempt.
Upon examining her mental status, her behavior was childish but she was also
very cooperative. She could read, comprehend, and repeat as well as name things
and knew what day and time it was. She was unable to write a complete sentence
nor was she able to recognize a person or situation. The patient was experiencing
euphoria, but her affect was appropriate to the content [3]. Her thought content
61 Schizoaffective Disorder Bipolar Type Misdiagnosed as Bipolar I with Psychotic…
453
included grandiose delusions and an overabundance of thought [3], while her
thought process consisted of loosening of associations, talking quickly and erratically, and unable to keep on topic.
During the initial presentation, the patient was manic and showed aggression
when she was not believed [3]. The patient would share extreme delusions that she
was a child celebrity and also believed she was the daughter of the US president.
She would remove her clothing in public, talking quickly and erratically jumping
rapidly between ideas, engaged in movements that served no purpose, as well as an
extreme need to share her ideas [3]. These symptoms were also observed by the
nursing home she resided in prior to her admission to the psychiatry unit. These
hallucinations, delusions, disorganized speech, and grossly disorganized behavior
were present for 2 weeks in the absence of her mood symptoms. After evaluation the
patient was diagnosed with schizoaffective disorder, bipolar type, according to the
DSM-5 criteria after being closely monitored. Her mood episodes were initially
reported to be present for most of her illness. This is why her disorder was confused
with bipolar disorder with psychotic features and initially misdiagnosed. The patient
was treated with a combination of drugs. They consisted of an antipsychotic (quetiapine 100mg) with a mood stabilizer (valproic acid 500mg) and an antidepressant
(sertraline 50mg) which is used to treat roughly 18% of schizoaffective patients.
Paliperidone is the normal rst-line antipsychotic for schizoaffective disorder, but
due to the patient’s limited nances, the drug could not be used in the treatment.
After consultation with a social worker, the patient was sent back to her nursing
home a week later with reconciled medications and scheduled cognitive behavioral
therapy [3].
Differential Diagnosis
1. Schizoaffective disorder bipolar type [4]
The correct diagnosis and rationale can be seen below in the discussion
section.
2. Bipolar I disorder with psychotic features [4, 5]
The patient has mood episodes and has had them since the start of her illness.
This mood episode where the patient was manic and easily distracted can be
confused with bipolar disorder with psychotic features. The hallucinations, delusions, and confused thinking are all signs of bipolar I disorder with psychotic
features. The reason why this is schizoaffective disorder bipolar type rather than
bipolar I disorder with psychotic features is due to the timing of the symptoms.
The schizophrenic symptoms do not present when the patient is having the mood
episode. This is the key difference between schizoaffective disorder bipolar type
and bipolar disorder with psychotic features. The schizophrenic symptoms also
appear when the patient is not having mood symptoms or remains present after
the mood symptoms improve. It is this timeframe of when symptoms arise that
clearly distinguishes the two disorders.
454
J. Seok
3. Schizophrenia [4, 6]
Like bipolar disorder, schizophrenic symptoms present in patients with
schizoaffective disorder bipolar type. The similar symptoms make distinguishing schizophrenia difcult from schizoaffective disorder bipolar type. A lack of
mood disorders would instantly rule out schizophrenia, but the patient in this
case has mood disorder symptoms which makes schizophrenia unlikely and the
two previous differential diagnoses more likely.
4. Major depressive disorder with psychotic features [6]
The patient does not present with depressive symptoms. If the patient had
SZA depressive type, then this differential would be more likely and higher on
the list. It is important to distinguish between the two types of schizoaffective
disorder to make sure the correct one is diagnosed. The lack of depressive symptoms in the case is key here. The case had an excellent medical history on the
patient as well as a detailed list of current symptoms highlighting the importance
of history taking and prognosis in diagnosing schizoaffective disorder properly.
Discussion
The African American female patient “presented with a history of bizarre delusions,
hallucinations, disorganized behavior, and disorganized speech for the past one and
a half months.” She was admitted to the hospital and put in the psychiatric ward. On
initial interview and based on the symptoms, the initial diagnosis seems to point
toward the bipolar I with psychotic features which is what she was previously diagnosed with or schizophrenia [3].
Schizoaffective disorder (SZA) bipolar type is characterized by abnormal thought
processes and an unstable mood [7]. There are two types depending on the mood
disorder (bipolar and depressive) and the patient in this case had the bipolar version.
The most important distinguishing symptomology in order to properly diagnose
schizoaffective disorder is the appearance of psychotic symptoms for at least 2
weeks without any mood symptoms [7].
The bipolar type is distinguished by symptoms of mania, hypomania, or mixed
episode similar to bipolar type I.Importantly, she denied any depression, homicidal,
or suicidal ideations. This is an important part of the medical interview as it helps
distinguish what type of mood disorder she has [3]. In this case, the lack of depression and/or suicidal ideation allows for depressive mood disorders to be removed
from the differential [4].
When she was initially admitted, “the patient was manic, easily distracted, and
demonstrated aggression for not believing her.” During the initial stay, the patient
presents with symptoms of a mood disorder [3].
The common schizophrenic symptoms of the disorder include hallucinations,
delusions, and disorganized speech and thinking. Patients will also experience
61 Schizoaffective Disorder Bipolar Type Misdiagnosed as Bipolar I with Psychotic…
455
auditory hallucinations which usually present as “hearing voices.” [8] The onset of
mood symptoms begins in young adulthood as it usually occurs with mood disorders; the onset of schizophrenic symptoms will then conrm the schizoaffective
disorder (SZA) diagnosis. Other schizophrenic features include psychological
symptoms such as catatonia and negative symptoms (socially withdrawn, muteness,
apathy).
She states she constantly claims that her beach home is being burglarized, thinks
that her father is the president of the United States, that she is 10years old, and that
she is a celebrity as well as other grandiose delusions. She also believes that an old
scar on her leg is bleeding even though it is not. She exhibits childlike behavior and
is unable to complete thoughts or speak proper phrases. She had a global increase in
the quantity of thoughts, and her thought process showed signs of loosening of
associations as well as ight of ideas and tangentiality. Her grooming and appearance were both poor [3].
As the patient presents with both bipolar and schizophrenic symptoms at the
same time and as the diagnosis of bipolar I with psychotic features was already on
the patient’s chart, it would be very easy for most providers to miss the actual underlying diagnosis [3].
Upon further interviewing and observation of the patient at the hospital as well
as by interviewing the staff at the nursing home the patient stays at, there was a key
indicator that the patient was misdiagnosed. The patient’s “hallucinations (burglars
attacking her in her beach home and seeing blood on her knee), delusions, disorganized speech, and grossly disorganized behavior were present for two weeks in the
absence of her mood symptoms.” [3] It is this absence for 2 weeks that is critical to
changing the diagnosis to schizoaffective disorder (SZA) bipolar type. This highlights the importance of a thorough and complete interview of both the patient and
the patient’s caretakers and background check for patients with disorders that lie on
the schizophrenic spectrum as well as the importance of holding and observing the
patient.
The patient’s vital signs were stable. She had also been previously diagnosed
with type 2 diabetes, hypertension, HIV, epilepsy, and acute myeloid leukemia (in
remission) [3].
In order to conrm this diagnosis, we need to use the DSM-5 criteria to ensure
the change from bipolar type 1 with psychotic features to schizoaffective disorder
(SZA) bipolar type. Due to the provider’s in-depth interview of both the patient and
caretaker in the case, the DSM-5 criteria can be easily compared to, and the patient
had met almost all the criteria for SZA bipolar type. Additionally, the provider could
have also used the Self-assessment of Negative Symptoms (SNS) and the Patient
Assessment Questionnaire (PAQ) . The SNS would help screen for the schizophrenic symptoms, and the PAQ would help screen for general distress and side
effects. Both of which would help providers ll in the criteria for the DSM-5 [9].
Based on the DSM-5 criteria, the patient should be correctly diagnosed with
schizoaffective disorder (SZA) bipolar type.
456
J. Seok
Plan ofAction, thePoints Clinician Should Consider, Pitfalls
toAvoid, andPearls ofKnowledge toConsider
The diagnosis of schizoaffective disorder (SZA) bipolar type involves ruling out
other mental health disorders on the list of differential diagnosis. This also includes
ruling out symptoms that may be caused by substance abuse, prescription medication, or other medical issues. Ways to do this include physical exams, tests and
screenings, psychiatric evaluations, and most importantly diagnostic criteria using
DSM-5. Using the PAQ and/or SNS helps providers gather data points to help ll in
the criteria but cannot be solely used for diagnosis.
This patient had a complete psychiatric and neurologic evaluation done for her,
and key aspects of the patient’s history were uncovered and reevaluated by interviewing the patient’s caregivers. This is important to keep in mind and remember as
the patient may not always be reliable due to the symptoms of delusion and other
schizophrenic symptoms [10].
In addition, her admission to the hospital and observation was another key and
critical element to properly diagnosing her as the extended stay allowed for providers to witness the absence of mood disorder symptoms for 2 weeks which pointed
to SZA bipolar type instead [3].
The patient’s medication included sertraline, quetiapine, and valproic acid. The
patient was treated with what is known as a combination therapy of drugs. In this
case, she is being treated with a combination of an antipsychotic with a mood stabilizer and an antidepressant [3, 10] which is used to treat 18% of SZA patients. The
US Food and Drug Administration recommends paliperidone as the rst-line antipsychotic for schizoaffective disorder [4, 10], but the patient could not afford pali-
peridone, and it was not used in the treatment of the case patient. Along with
medication she was assigned a social worker and a cognitive therapist. The patient
was discharged back to her nursing home after a week with reconciled
medications.
However it is now recommended that patients with SZA bipolar type not take
antidepressants like sertraline. The provider needs to rule out bipolar disorder before
starting an antidepressant because this can risk making a manic episode worse [4, 8].
Second opinions at a specialized schizophrenia clinic after initial diagnosis
are wise efforts to reduce the risk of misdiagnosis and ensure prompt and appropriate patient treatment. These clinics also specialize in schizoaffective disorders
and are better able to identify the sometimes-subtle differences between these
disorders [6].
What WasMisdiagnosed inThis Case andWhy?
Patient was initially misdiagnosed by a previous provider. This was primarily due to
her mood episodes that were present for the majority of her illness when she was
initially diagnosed. This is why her disorder was confused with bipolar disorder
61 Schizoaffective Disorder Bipolar Type Misdiagnosed as Bipolar I with Psychotic…
457
with psychotic features instead of schizoaffective disorder, bipolar type. This misdiagnosis can be prevented by observing a patient for a longer period of time or by
looking for a lack of mood disorders when the patient comes back for follow-ups.
Treating this mental disorder early may help get symptoms under control before
more serious complications develop and may help improve the patient’s long-term
outlook [6], making correct diagnosis critical in this case.
Conclusion
Living with SZA bipolar type can be a long-term challenge and it is a serious mental
health condition. Patients must seek treatment. Schizoaffective disorder bipolar type
is commonly misdiagnosed as bipolar I with psychotic features as both present with
schizophrenic and bipolar symptoms. Do not confuse a patient’s diagnosis by looking at the timeframe in which different symptoms arise. Be ready to get a good history and listen carefully for red ags during the interview as well as interview
caretakers, friends, and family for a complete medical history [3]. Then by using the
DSM-5 criteria along with other screening and diagnostic tools, the patient can be
properly diagnosed with SZA bipolar type. In most cases, SZA bipolar type
improves with medications. Therapy and social work can also help patients in managing their SZA. With proper treatment and medication, patients with SZA can
manage symptoms and lead a normal and fullled life.
References
1. Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V.Schizoaffective disorder: diagnostic issues and future recommendations. Bipolar Disord. 2008;10(1 Pt 2):215–30. https://doi.
org/10.1111/j.1399- 5618.2007.00564.x.
2. Martin LF, Hall MH, Ross RG, Zerbe G, Freedman R, Olincy A.Physiology of schizophrenia,
bipolar disorder, and schizoaffective disorder. Am J Psychiatry. 2007;164(12):1900–6. https://
doi.org/10.1176/appi.ajp.2007.06010017.
3. Paul T, Javed S, Karam A, Loh H, Ferrer GF.A misdiagnosed case of schizoaffective disorder
with bipolar manifestations. Cureus. 2021;13(7):e16686. https://doi.org/10.7759/cureus.16686
4. Wy TJP, Saadabadi A. Schizoaffective disorder. [Updated 2022 May 2]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.
ncbi.nlm.nih.gov/books/NBK541012/
5. Burton CZ, Ryan KA, Kamali M, etal. Psychosis in bipolar disorder: does it represent a more
“severe” illness? Bipolar Disord. 2018;20(1):18–26. https://doi.org/10.1111/bdi.12527.
6. Coulter C, Baker KK, Margolis RL.Specialized consultation for suspected recent-onset schizophrenia: diagnostic clarity and the distorting impact of anxiety and reported auditory hallucinations. J Psychiatr Pract. 2019;25(2):76–81. https://doi.org/10.1097/PRA.0000000000000363.
7. Malaspina D, Owen MJ, Heckers S, etal. Schizoaffective disorder in the DSM-5. Schizophr
Res. 2013;150(1):21–5. https://doi.org/10.1016/j.schres.2013.04.026.
8. Preda A, MacLean RW, Mazure CM, Bowers MB Jr. Antidepressant-associated mania and
psychosis resulting in psychiatric admissions. J Clin Psychiatry. 2001;62(1):30–3. https://doi.
org/10.4088/jcp.v62n0107.
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9. Heckers S, Barch DM, Bustillo J, etal. Structure of the psychotic disorders classication in
DSM-5. Schizophr Res. 2013;150(1):11–4. https://doi.org/10.1016/j.schres.2013.04.039.
10. Joshi K, Lin J, Lingohr-Smith M, Fu DJ, Muser E. Treatment patterns and antipsychotic
medication adherence among commercially insured patients with schizoaffective disorder
in the United States. J Clin Psychopharmacol. 2016;36(5):429–35. https://doi.org/10.1097/
JCP.0000000000000549.
J. Seok
Chapter 62
Borderline Personality Disorder
Misdiagnosed asBipolar Disorder
AemilPalm andCarlaRodriguez
Learning Objectives
By the end of this presentation, the clinician will be able to:
1. Compare and contrast the differences and similarities between the clinical presentations of bipolar disorder (BD) and borderline personality disorder (BPD).
2. Discuss why borderline personality disorder is often misdiagnosed as bipolar
disorder.
3. Assess the consequences of misdiagnosis of borderline personality disorder as
bipolar disorder.
4. Distinguish nuanced concepts of patient history, especially when attempting to
differentiate bipolar disorder and borderline personality disorder.
5. Analyze the statistical data that distinguishes bipolar disorder and borderline
personality disorder.
Introduction
Borderline personality disorder (BPD) is dened by the American Psychiatric
Association’s DSM-V criteria as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by
A. Palm (*) · C. Rodriguez
St. Martinus University Faculty of Medicine, Willemstad, Curacao
e-mail: aemil.palm@martinus.edu; carla.rodriguez@martinus.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Tohid et al. (eds.), The Misdiagnosis Casebook in Clinical Medicine,
https://doi.org/10.1007/978-3-031-28296-6_62
459
460
A. Palm and C. Rodriguez
early adulthood and present in a variety of contexts, as indicated by ve (or more)
of the following:
1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include
suicidal or self-mutilating behavior covered in Criterion 5).
2. A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense
of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include
suicidal or self-mutilating behavior covered in Criterion 5).
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely
more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difculty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical ghts).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms [1] .”
Borderline personality disorder is found in approximately 1–6% of the general
population [2]. Although BPD and BD are most often separately diagnosed in
80–90% of cases, 20% of people with borderline personality disorder have comorbid bipolar disorder, and 15% of people with BD have comorbid BPD, a higherthan- expected comorbidity rate for disorders that are often separately diagnosed.
This suggests that the number of people with underlying BPD may be much higher
than thought [7]. The etiology and pathophysiology of borderline personality disorder are still obscure. Studies on the association of 5-hydroxytryptamine receptor 2A
(HTR2A) gene variants, as well as on serotonin transporter genes, serotonin receptor genes, and tryptophan hydroxylase genes, have yielded inconclusive results [3,
4]. Despite a low association with studied genetic variants, the heritability of BPD
has been estimated at 40%. This could mean that the etiology of BPD is more associated with genetic plasticity than genetic vulnerability [4].
Clinical Case Presentation
A 29-year-old female patient was admitted to a psychiatric hospital by the police
after she had consumed ve alcoholic beverages and texted a male friend repeatedly, stating that she wanted to commit suicide. The patient was docile and responsive the following day during her psychiatric consultation but could not fully recall
what had happened the previous day. The patient was diagnosed with bipolar
62 Borderline Personality Disorder Misdiagnosed asBipolar Disorder
disorder in the past and conrmed that she had experienced symptoms that point
toward manic episodes, such as intense mood; irritability; increased libido; racing
thoughts; hyposomnia; hasty, disorganized thoughts; feelings of grandeur; and
rapid, frenzy speech. She also demonstrated impulsiveness and displayed mood
swings. The patient herself admits to having issues with her affect (more so with
feelings of loneliness and rage), disinhibited actions (suicidality, improper sexual
conduct, and drug abuse), and social interactions (feelings of abandonment, overdependency, and entitlement). The patient elucidated several sources of stress in her
life, including marital problems and a strained relationship with her own mother.
She has three children and is married to a husband, who the patient said would
always remain loyal to her despite her indelity during her manic episodes. The
patient denies a previous diagnosis of borderline personality disorder; however, she
made it known that she had a history of self-mutilation, anorexia for 3 years in adolescence, and two attempted suicides via medication overdose, one at age 15 and
one at age 21. After the rst interview with the patient, the psychiatric team concluded that the patient was currently suffering from a depressive episode directly
related to her previously diagnosed bipolar disorder. She was restarted on quetiapine, which the patient reports had a positive impact in the past, and in addition, she
was started on lithium. The patient remained compliant with her treatment during
the 4-day inpatient hospitalization period, and her new diagnosis of borderline personality disorder was disclosed to and discussed with her [2].
461
Differential Diagnosis
1. Bipolar disorder—The patient was previously diagnosed with BD.However, the
enduring pattern of behavior that the patient presented with since adolescence is
not typical of BD.
2. Alcohol abuse—In the initial presentation of the patient, she had consumed ve
alcoholic beverages. However, this does not explain the enduring pattern of
behavior of the patient when she was not intoxicated.
What WasMisdiagnosed inThis Case, andWhy?
The patient was correctly diagnosed with BD, but her other diagnosis of BPD was
missed. The patient did meet DSM criteria for manic episodes, but there were other
behavioral symptoms present that were not dened by those episodes. The symptoms occurred in an enduring pattern throughout the patient’s life, even during the
remission of manic episodes. Through diligent history-taking, the clinicians were
able to spot the missed diagnosis.