High-Functioning with Schizophrenia and/or Bipolar

NY Times Article:
  Successful and Schizophrenic
  by Elyn R. Saks

This is a really excellent article by a person with schizophrenia who holds a professorship at the University of Southern California.  She is enormously successful as witnessed by many awards, not the least of which is the MacArthur "genius" grant.  She relates how she was given a grave prognosis for her disease which included a lack of happiness, fulfilment, and family.  She has disproved each of these by managing her illness successfully.  She shares the coping skills that have helped her and discusses those that have helped other people like her.

I am going to answer what she said by discussing the analogous setting for people with bipolar.  The setting is that of high-functioning people with bipolar.  Our first task when discussing this is to define what we mean by high-functioning.  Does it just mean success?  Does it mean disease remission?  Does it mean creativity or intelligence?  I would argue that an individual is high-functioning if their disease is in remission and their life is fulfilling and productive.  This is analogous to the archetype of a 'productive member of society.'  Notice my definition says nothing about intelligence or creativity.  While there is much written about the supposed creativity and intelligence of people with bipolar, I question whether manic creativity or intelligence equates to a high-functioning status, because it may not be a state that can be maintained in remission.

Returning to the article, the author lamented a lack of acknowledgement of high-functioning schizophrenics by medical community.  With bipolar, there seems to be a longer history of the medical community recognizing occasionally functional people.  However, this occasionally functional person is stereotyped: while they may be creative and high-functioning at times, they will crash into an episode at other times.   I would argue that this occasionally functional person is not high functioning as we have defined it.  Our definition requires remission.  This highlights the strong tendency by medical professionals to warn that a person having one episode will almost certainly experience another.  This attitude denies the existence of high-function people and flies in the face of evidence that people can become stable.

Just as the author of the article was discouraged by the medical community not acknowledging high-functioning schizophrenics, I am disappointed by my experiences of being denied treatment due to 'not needing it'.  That comment, made by a doctor, took acknowledgement of high-functioning bipolar to the extreme of assuming that such people do not need treatment. I wish there were more medical support for maintaining remission of psychotic illnesses and for maintaining a high-functioning status.  Furthermore, there should be an effort to discover how people are able to be high-functioning.  Perhaps the mental health community can learn much from those of us who successfully manage our illnesses.

The author warned against romanticizing illness by idolizing people like John Nash in "A Beautiful Mind" who was brilliantly productive while his symptoms slowly worsened.  The challenge when identifying high-function people is to not romanticize their experience.  Indeed we need to be careful about what we mean by high-functioning; is success in life enough to be considered high-functioning or is disease remission required?  With bipolar, there is a strong tendency to romanticize the supposed creativity and intelligence which is advertized to accompany the disease.  While people with mental illness may indeed have unique and productive ways of thinking, to romanticize a disease as a route to such uniqueness is dangerous.  It denies the crippling power of disease to destroy rather than create, as we see in the way that John Nash's illness overtook him.

The author also mentioned wanting to do a study on high-functioning schizophrenics in stable relationships.  This is a fantastic idea, and while we are at it, why not study high-functioning people with bipolar who are in stable relationships?  There is a stereotype that people with bipolar always have unstable relationships.  Since I know of several counterexamples to this, it would be nice to understand the coping strategies these people use, and to understand them well enough to teach the coping skills to other patients.

So, how do people attain and maintain their high-functioning status?  For schizophrenia, the author of the article points to a trifecta of disease management: drugs, psychotherapy, and family/friend support.  My experience is that while maintenance drugs can bring about remission, a plethora of coping skills are required to deal with break-through symptoms which are not controlled by maintenance drugs.  These coping skills involve managing sensory input (limit interactions with other people if social settings cause stress, limit light, noise, and movement if those are stressful), dealing with delusions, paranoia, and hallucinations (confronting them in a brutally honest and logical way), and dealing with voices (sometimes by ignoring them).  For those of us with bipolar, we share those coping skills, along with additional coping skills that involve managing: anger, mania, depression, and suicidal thoughts.  For both people with bipolar and those with schizophrenia, it always pays to avoid witnessing or participating in bullying situations.  Those situations can drive anyone to anxiety or paranoia.

Work is another critical coping skill that the author mentioned.  She mentioned that doing something that is valued and having time commitments can help manage the schizophrenia.  I second this, as I find that having responsibilities helps me keep from succumbing to paranoia, anger, or depression.  Doing something productive helps me manage mixed mood states.  Because of these things, the author reminds us that it can be devastating when doctors tell patients not to work or predict that they will not be able to work.

A final critical coping skill is learning to adjust medications in response to symptoms.  I believe that the ability to recognize worsening symptoms is key to being able to respond to them with medication.  This can be said of both schizophrenia and bipolar.  One needs to learn to recognize 'triggers' or events that tend to contribute to a developing problems.  One way to identify triggers is to examine past problems honestly and try to identify the turning points that lead to the worsening of symptoms.

I believe that bipolar and schizophrenia are not so different from each other, certainly in regards to how high-functioning patients are treated.  We must be careful not to stereotype people out of access to care or stereotype them out of remission into a worsening disease state by depriving them of needed coping skills like work.  Additionally, the coping skills that lead to the successful management of schizophrenia can help with the successful management of bipolar and vice verse.  In all cases the goal is to use a combination of therapy, medication and family/friend support, to develop and implement coping skills for the successful management of disease.