Schizophrenia: Diagnosis & Management

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: September 1, 2024

Expiration Date: September 1, 2025

Estimated Time of Completion: 27 minutes

Schizophrenia: Diagnosis & Management

Amanda Horrigan, MD

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD
Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Amanda Horrigan, MD
Center for Adult Behavioral Health

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Schizophrenia: Diagnosis & Management

Amanda Horrigan, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Imad Najm, MD	Eisai Advisor or review panel participant NIH Other activities from which remuneration is received or expected: Research Funding LivaNova, PLC Advisor or review panel participant SK Life Science Inc Advisor or review panel participant Teaching and Speaking
Glen Stevens, DO, PhD	DynaMed Consulting

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP; Amanda Horrigan, MD.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast September 1, 2024 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research, discoveries, and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Schizophrenia is a chronic and severe condition that affects the physical and mental wellbeing of millions worldwide. Its neuro biological underpinnings most often result in delusions, hallucinations, disorganized speaking, disorganized movements and negative symptoms. In today's episode, we're addressing the challenges facing patients with schizophrenia and provide listeners with tools to better serve and support these individuals.

I'm your host, Glen Stevens, DO, PhD, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute, and I'm very pleased to be joined by Amanda Horrigan, MD for today's conversation. Dr. Horrigan is a psychiatrist in the Department of Psychiatry and Psychology in Cleveland Clinic's Neurological Institute. Amanda, welcome to Neuro Pathways.

Amanda Horrigan, MD: Thank you for having me.

Glen Stevens, DO, PhD: So Amanda, first tell us a little bit about yourself, how you came to the Cleveland Clinic and what you do on a daily basis.

Amanda Horrigan, MD: Yeah. I've been with the clinic since September, like two years ago almost. So I'm originally from Cleveland, Ohio, born and raised and left for college, and then came back around after doing all my training and whatnot, about 20 years and then returned to Cleveland. Currently, I work mostly on the inpatient behavioral health units on a daily basis at Marymount. I also do ECT Mondays and Wednesdays at Marymount. And then I've maintained a small outpatient clinic seeing children, adults, as well as doing some forensic work.

Glen Stevens, DO, PhD: Well great. Well welcome. We're happy to have you.

Amanda Horrigan, MD: Thank you.

Glen Stevens, DO, PhD: My little foray into psychiatry, in 1978, I worked on a psychiatric unit in Canada, a locked forensic unit for the criminally insane, and it was the first co-ed ward in Canada that was there. So we had some schizophrenic patients there as well, but it was quite an experience that maybe we'll have to talk offline about at some point.

Amanda Horrigan, MD: No two days are the same, I'm sure, while you were there.

Glen Stevens, DO, PhD: Yeah, that is for sure. So to start today's conversation, you can provide background to our listeners on the different types of schizophrenia and how they present.

Amanda Horrigan, MD: The DSM kind of got rid of the different types of schizophrenia, the paranoid, the catatonic variations, and we just now see it as kind of this syndrome of these chronic recurring alterations and perception, thinking and behavior and these cognitive impairments. You mentioned earlier that what people mostly think about is the positive symptoms of schizophrenia with delusions, hallucinations, disorganized thinking, behaviors, but also part of it is negative symptoms of schizophrenia, which include this kind of withdrawal, flattening of their look, the poverty of even movements, kind of speaking and monotone, just this lack of pleasure seeking activities, just little engagement with others.

Glen Stevens, DO, PhD: Yeah, I'm glad you mentioned that because I was actually going to ask you to define the negative symptoms, so that's very helpful. Do we know what causes schizophrenia?

Amanda Horrigan, MD: Well, in terms of, it's not completely determined, but we believe there's a genetic portion and then there is environmental factors. So the kind of combination of them together resulting in schizophrenia. In terms of concordance rates with monozygotic twins, it's 40 to 50%. So that suggests that it's not all genes, that there is a large portion of the environmental factors that will cause a schizophrenia. It's kind of looking at it like you have some sort of predisposition and then you have environmental factors that trigger the onset or risk factors that trigger the onset. So in terms of the risk factors, there's a multitude, obstetrical complications, autoimmune disorders, substance use is also a big risk factor, specifically cannabis use as CBD increases psychotic symptoms.

Glen Stevens, DO, PhD: And neurotransmitters affected are primarily what?

Amanda Horrigan, MD: So we've always had this kind of dopamine hypothesis that there's this excess dopamine and the mesolimbic tract and that causes all the positive symptoms. And so we have antipsychotic medications, they block dopamine and that's why they work. But if people took these medications, you would expect all of their symptoms to go away if it was just down to dopamine, but that's not the case. They believe glutamate, GABAergic inner neurons, acetylcholine also involved in neuro transfer is involved in schizophrenia.

Glen Stevens, DO, PhD: So I come to see you and you're going to do a workup on me. I imagine its history, history, history, but anything on exam that's helpful?

Amanda Horrigan, MD: I mean in terms of the history, the more specific things, just timeline, how long the symptoms have been going on, is there any substance use involved? Is there family history? A history of trauma is also a very big risk factor. Is there medical history? We want to rule out any causes, medical causes, people have chronic conditions. Is this an exacerbation of a chronic condition that might cause delirium or we're looking at if this is substances, have you been using, well, an increased amount of cannabis recently on a daily basis in this onset of symptoms. And so you want to look at those kinds of things in the history as well as just ruling out any kind of medical concerns. So hyperthyroidism, vitamin deficiency, neurosyphilis, any kind of infection causes delirium, which people experience psychotic symptoms with, so.

Glen Stevens, DO, PhD: So you do the detailed history, background history, family history, those types of things. Tests that are helpful?

Amanda Horrigan, MD: Again, the main thing being complete CBC, CMP, TSH, B12, urine drug screen.

Glen Stevens, DO, PhD: So really the rule outs.

Amanda Horrigan, MD: And then we do neuroimaging. Certainly if someone comes in and they're young and it's new onset of these symptoms abruptly, we'll do a CT scan of their brain just to ensure or if it's outside the normal time, age wise of onset of something like this – over 40, over 50 something neurological going on. So we'll consider using neuroimaging as well.

Glen Stevens, DO, PhD: So let's go back to that typical age of presentation is what?

Amanda Horrigan, MD: So typically, males onset is earlier, so you're looking anywhere from 18 to 25 years of age. Female onset is later 25 to 35 years of age. And then females also have this other increase period of time of onset is in menopause. Estrogen is extremely protective and as a loss, some people have onset of schizophrenia.

Glen Stevens, DO, PhD: And you mentioned a little bit about the DSM criteria and how things have changed. Do you have a checklist you go through or what defines it for you?

Amanda Horrigan, MD: So I mean, it's usually, again, timeline having been going on for at least six months is not attributable to any other cause and you need those positive symptoms, at least two or more, hallucinations, delusions. Typically, the presentation is someone coming in experiencing auditory hallucinations or delusions. That's the most common in terms of onset of schizophrenia.

Glen Stevens, DO, PhD: I was just going to ask that, but I think you answered the question in terms of the hallucinations being visual versus auditory and primarily auditory, correct?

Amanda Horrigan, MD: Yeah. And when you think of other hallucinations such as tactile or olfactory, you're thinking more substance induced medical causes. We typically see mostly visual and auditory hallucinations.

Glen Stevens, DO, PhD: So I come and see you, you diagnose me with schizophrenia, I'm sorry to hear that for myself, but what do we do at this point? What are you going to do for me? What's my next step?

Amanda Horrigan, MD: So, medication is the main stay of treatment for whatever the symptoms you're experiencing, the psychotic symptoms for schizophrenia, so anti-psychotic medication. But even before that, I cannot emphasize enough developing a therapeutic alliance with this person. The hardest part of schizophrenia is many patients lack insight into the fact that they even have an illness. These things are very real to them, and you're asking them to take this medication with all these side effects for an illness they don't believe they actually have. So you're trying to build trust with this person. And also my approach being not necessarily this is for your delusions, but a person coming in and having such distress that they cannot sleep because they're looking out their window repeatedly because someone is out there and you saying, that sounds terrible. Can I help you with that? Getting some sleep and reducing your anxiety because it is upsetting. It's not that it's not upsetting, but it feels very real. And so going in that direction and building that trust versus trying to convince them what they're experiencing is not real, like that will just shut down an entire conversation about treatment.

Glen Stevens, DO, PhD: Yeah, I can see how that would be very difficult and very time-consuming. So it's probably just not the physician psychologist involved with this, other folks I imagine, support groups maybe. I don't know, maybe this isn't a support group thing.

Amanda Horrigan, MD: NAMI, National Alliance on Mental Illness, is a wonderful support group. They have groups that meet, they have it for families as well who have loved ones who are suffering with severe mental illness. Also involving therapists, psychologists to help with, family is a huge portion of the treatment. Helping the family understand the illness, educating them about medication and how to support their loved one. Again, avoiding that, no, no one's outside, that's nothing. That's not really going on, that's not happening. That's very upsetting to a person who feels these things are happening and trying to help the family understand how to talk about what a person is struggling with. So there's a variety of other sources in community mental health, like a case manager, they can help a person get to appointments, help them get their medication, help with housing, navigating getting disability. So it's definitely a multidisciplinary group helping to support this patient.

Glen Stevens, DO, PhD: Yeah. I just wonder how you get their trust. Right. I mean, they would have these feelings of delusions and they just wouldn't believe it. It just seems like such a complicated process to really get somebody's trust. Right.

Amanda Horrigan, MD: Yeah. And I think it's treating a person like a person. Just tell me about you. What are you about? Trying to connect with them as a human being rather than I have this objective and I need them to take these medications, trying to get to know the person and a genuine interest in listening. I think that goes a very long way.

Glen Stevens, DO, PhD: I always think that TV does a big disservice to people with schizophrenia. They portray them as very bizarre people and they always also portray them that they go off their medicine because they feel so badly on the medication that it doesn't do much to help, I don't think. Right.

Amanda Horrigan, MD: No. And I think it also portrays people with schizophrenia as violent, and that's not the case at all.

Glen Stevens, DO, PhD: Yeah. Most are withdrawn, right?

Amanda Horrigan, MD: Right. And it's scary and frightening and I think very isolated as people.

Glen Stevens, DO, PhD: So does everybody need medication or are there some patients that don't or everybody really probably needs medication?

Amanda Horrigan, MD: They probably need medication. Now to what degree dosage-wise and how much I think varies. Some people who are intellectually advanced and working and can have more insight basically, they might need less medication and they can work with their therapist. I'm having this thought that so-and-so is following me. And they're able to hear the therapist be like, okay, let's look at this. What would make you think that? How can we view this as maybe part of a delusion? Actually using reasoning. So some people can do that and use less medication. It's not as common, but it is possible.

Glen Stevens, DO, PhD: I get the sense that people that have bipolar if they're in a manic-type phase, can be very productive and get a lot of stuff done. But my sense would be that the schizophrenics are on the other side, right? They're not very productive or is there a productive core of schizophrenic people?

Amanda Horrigan, MD: Yes, I definitely think there are. There is a law professor at USC and she wrote a book about her experience with schizophrenia. She works full time and she goes and gives talks about this in terms of how she's very high functioning, very successful and has managed her illness for her entire life with medication as well as using her therapist. So there are rare, but definitely people who are/can be high functioning.

Glen Stevens, DO, PhD: So I have schizophrenia. I come in and see you, we have lots of nice chit-chats. I trust you. I'm seeing the psychologist. I'm doing all those types of things. There's not an obvious treatable condition that I have. I'm not doing drugs or that type of thing. What do you put me on? What's the drugs?

Amanda Horrigan, MD: Anti-psychotic medications. So we have first generation anti-psychotics. These are meds that were developed in the 60s and there are things, most people have heard about haldol, haloperidol, thorazine, stelazine. These meds have a higher risk of tardive dyskinesia and EPS. So typically we start with a second generation anti-psychotic because of the less of risk of that. Those are medications people have heard of. You might've heard of Risperdal, Abilify, Zyprexa. We try to pick one and keeping in mind the person's possible chronic medical conditions because all of these medications have a risk of increasing cholesterol, causing increased blood sugar. So if someone already has diabetes, we're trying to pick ones that are less risk of weight gain and metabolic issues. So you kind of guide it that way. There could be another person who doesn't sleep at all and has lost weight. So you could pick a medication that might be more sedating. So trying to work around the side effects, not making anything worse but possibly aiding. So it really depends on the person. They all are effective for treatment for schizophrenia.

Glen Stevens, DO, PhD: And what percentage of people will be compliant? I know it's hard to know, but.

Amanda Horrigan, MD: Yeah, because I work in inpatient and so I would say 90% of the people who come in are not compliant with their treatment.

Glen Stevens, DO, PhD: Not compliant.

Amanda Horrigan, MD: Yeah. And they've decompensated and require hospitalization.

Glen Stevens, DO, PhD: And the reason they're not compliant is side effects?

Amanda Horrigan, MD: Yes, these medications can be very difficult tolerance wise in terms of the sedation and the weight gain. Patients don't necessarily love them.

Glen Stevens, DO, PhD: And before we go on to other treatment options, does it comorbid with other diseases, schizophrenia or it exists alone?

Amanda Horrigan, MD: Comorbid in terms of substance use issues is very common with people with schizophrenia. Depression as well in terms of psychiatric comorbidities, yes.

Glen Stevens, DO, PhD: So I come in and see you, you start me on a medication and I just tell you that I just can't tolerate the medicine. I'm regressing. You try two or three of the other ones, go to second, third generation drugs, same type of an issue. What's the next step if the medicines just aren't working?

Amanda Horrigan, MD: So I guess treatment-resistant schizophrenia, more along the lines of they're not working, we go to Clozapine, which is another anti-psychotic and it's kind of gold standard for treatment-resistance schizophrenia, not necessarily due to side effects because Clozapine causes a lot of weight gain and sedation as well. The other option is ECT, electroconvulsive therapy, some efficacy for schizophrenia, but those are pretty much the options.

Glen Stevens, DO, PhD: And the electroconvulsive therapy is used in what percentage of patients, do you know?

Amanda Horrigan, MD: We've used it on a lot of patients who might be catatonic or very aggressive. So those would be people inpatient or they've tried everything under the sun and we really have not one medication option. It can be very effective.

Glen Stevens, DO, PhD: And the role of admitting patients and having them in a psychiatric unit is to try and regulate their medication safety. Why would I have to be admitted to a psych unit?

Amanda Horrigan, MD: Well, typically the person is in a state where they are unable to care for themselves due to their symptoms. Maybe they're not sleeping, eating, they're so disorganized in their thoughts that they can't do those things. And so they need to be stabilized on medication to get back to their baseline. Some people become very agitated. They can become violent and fearful and scared of things because of the paranoia. So for safety reasons, we certainly have patients being admitted and families get concerned and they bring their family members in to get medications restarted or adjusted.

Glen Stevens, DO, PhD: So I think I'd mentioned to you in the 70s, I worked in a psych unit up in Canada and it was a forensic unit, but then Canada tried to move everybody out of the hospitals. Right. So then they weren't admitting patients to hospitals. And now it's all sort of outpatient based and you don't have that available other than extreme situations. Did the same thing happen here? I mean, a lot more people in the community caused other problems, I guess.

Amanda Horrigan, MD: Very much so because it was the start of the first generation antipsychotics in the 60s. It was the first treatment, like they had nothing before. People would remain in the hospital indefinitely in these state hospitals because there was no treatment. So these treatments came available and they're like, wait a minute, these people can go be discharged and live life outside of here. And so they developed all these community mental health agencies managing their symptoms. But the thing is, is that I don't think the system was built all that well into consider variety of other factors that might come into play.

So we frequently have a lot of issues with housing for patients and that makes it really hard to comply with medication. So there's just kind of like a knock on effect. So then they forget their medication, they lose it. So there's multiple things that they need to be able to be successful and stable. But there certainly are still state hospitals that we have sent people to as well due to severity of illness. And inpatient units, these are short stays. You're talking 7 to 10 days and some are more, but we're not built for lengthy hospitalization stays and some people need a much longer time to stabilize.

Glen Stevens, DO, PhD: So it takes a village, who's the team?

Amanda Horrigan, MD: So your psychiatrist, your case manager, therapist, other parts of your team, your medical doctor, managing any comorbidities, your family members. Also involving patients in community day programming to allow work and socialization. So all those people are part of the team. Sometimes dietician to help with the weight gain, dietary modifications.

Glen Stevens, DO, PhD: Somewhere in the back of my brain, I have this thought that smoking is very prevalent in schizophrenic patients. Is that true, that they have to stimulate the nicotinic receptors or something?

Amanda Horrigan, MD: Yes, it's very true. It's a very common and they can't determine if it's because of schizophrenia. Frequently I've had patients who would describe to me like I'm so tired, I just smoke all day to stay awake or drink tons, they drink a lot of coffee too to combat the medications, are not really doing a lot and sitting there just chain-smoking all day. But there's also this research that says that this is due to having schizophrenia versus helping stimulate them to keep them awake.

Glen Stevens, DO, PhD: So I guess we could say that we have medicines that effectively could treat schizophrenia, but if patients can't tolerate it, it's really not an effective treatment.

Amanda Horrigan, MD: Yeah. If they can't stay compliant.

Glen Stevens, DO, PhD: And it sounds like that's pretty significant in the patient population. Yes?

Amanda Horrigan, MD: Yes. And the advent of long-acting injectable medication has been huge. So anti-psychotics can now come in injections, anywhere from once a month to once every six months they get their medication and it's kind of slowly released throughout the month. So you don't have to deal with taking pills.

Glen Stevens, DO, PhD: Well that would help compliance, but how are the side effects?

Amanda Horrigan, MD: The same side effects. I mean, if they're tolerating the oral medication fairly well, then you use the long-acting injectable. But the side effect profile is the same and not everyone has these horrible side effects I'd like to say as well. So yeah, that helps significantly with compliance. And the longer a person is stable, they do gain more insight into seeing like, oh, I feel like I'm doing better if I'm taking the medication. I don't know why, but it seems like it's helping with something.

Glen Stevens, DO, PhD: I'm looking for something positive here. What's on the horizon? What gets you up in the morning? What keeps you going treating these patients?

Amanda Horrigan, MD: People do get better. The medications do work. They do get better. I've seen it happen many, many times. In terms of new developments, it's trying to get away from this dopamine blockading agent because that's where all the side effects come from. So they're looking at new medications targeting acetylcholine, GABA, glutamate, and MDA receptors, TAAR which is trace amine-associated receptor type one. So it's kind of they impact those and it has the down cycle effect of decreasing dopamine without actually targeting the dopamine receptors.

Glen Stevens, DO, PhD: Okay.

Amanda Horrigan, MD: So you have less side effects. So that's kind of the direction. There's multiple medications in the pipeline that are in clinical trials. So in terms of getting away from this direct dopamine blocking agents.

Glen Stevens, DO, PhD: So I read articles about using mushrooms for certain types of psychiatric disorders. You had mentioned drug use, so maybe these aren't good things to use in this patient population, but any of these types of things helpful?

Amanda Horrigan, MD: No. So actually any kind of hallucinogen as well as cannabis actually makes psychosis worse. Big no-no. Those medications typically more PTSD or depression, but with anyone who has a primary psychotic disorder, it would be contraindicated for sure.

Glen Stevens, DO, PhD: And you mentioned ECT. Anything surgical?

Amanda Horrigan, MD: No.

Glen Stevens, DO, PhD: So anything we've not talked about that you thinks important for the audience to know?

Amanda Horrigan, MD: My wish is people to look at these people with schizophrenia as not scary, but scared people. They're frightened and most of the time no one listens to them. And the ability to listen and support and be empathetic, it doesn't cost anything. And it's incredibly powerful. It actually improves their prognosis. Having that type of relationship with a patient or anyone, it helps prognosis, it's shown to.

Glen Stevens, DO, PhD: Well, I like the empathy part. Right. I like what you're saying there because I think that we do get very skewed, right, all the concern and talk about the homeless population and all these people that have been moved out of institutions and are sort of on their own. And it's just scare, scare, scare. And we could probably all do better and manage and live our life better if we're more empathetic to individuals and find better ways to help manage people.

Amanda Horrigan, MD: Yes, most definitely.

Glen Stevens, DO, PhD: Well, listen, Amanda, it's been great chatting with you. I applaud all that you do. It sounds like you have monumental tasks to overcome, but we appreciate everything that you're doing. Thank you very much.

Amanda Horrigan, MD: Thank you. Thank you for this opportunity.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.