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Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
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Welcome to the Two Minds
Better Than One podcast.
Docs Tracy and Paul Discuss it All.
Hello, and welcome to Docs
Tracy and Paul Discuss It All.
Today's topic is
schizophrenia, and welcome to our
podcast.
I have the great pleasure of
working with Tracy both as her husband,
but also in this podcast, and
I cannot think of anyone better suited
to discuss schizophrenia.
Traci was chief medical
officer at Cincinnati's largest community
mental health center, but in
addition to her administrative role,
she was a frontline clinician,
working with thousands of people
with schizophrenia over the years.
So I can't think of anybody
better, more expert to discuss this
topic than Traci.
Thank you, honey.
Thank you so much.
So, as you know, I've been so
excited about this podcast.
I wrote a paper in eighth grade.
They said pick any topic, and
I picked schizophrenia.
So I've just been fascinated
by this topic for my whole life,
and I'm really enthusiastic
about talking to everyone about this
today.
So feel free to jump in when
you can, because I feel like I might
monopolize this conversation
because this is.
I just could talk about this
all day, every day.
I think today I'm interviewing you.
Okay.
But one thing I want to say
out of the shoot, though, is schizophrenia
is not split personality disorder.
Thank you for saying that,
because I was getting my hair styled
today, and the woman was
saying, oh, what are you doing today?
And I told her, and she said,
oh, schizophrenia.
So, yeah, that's like having
lots of personality.
So it's funny that you said
that, because she just said that
this morning.
So tell more about that.
Well, I think it's a common
misconception, and it makes my teeth
grind when I hear people use
schizophrenia as a description for
split personality, which isn't
even called split.
It's dissociative disorder
now, anyway.
Right.
I think what gets confusing is
the schiz part.
C S, C, H, I, Z, the split.
And it's split from reality,
not split personalities.
Right.
So do you want to start by
talking about the key symptoms that
people with schizophrenia?
Well, I was wondering if you
could talk about statistics, because
you're our statistics person
in this.
In this couple.
So you want to talk about what
the prevalence or incidence.
Sure.
So schizophrenia is not
uncommon, unfortunately, because
it's a very serious mental illness.
It's been estimated, depending
on the studies, to range in prevalence,
meaning lifetime number of
people who have it, to be between
0.3 and 0.7%.
So roughly about 1 in 25 to 1
in 50 people will have schizophrenia
at some point in their Lives.
Okay, so this is where we go
again with statistics, because I
again, was always taught 1 out
of 100 people and what we said for
bipolar disorder as well, so
one out of 100.
I remember telling my daughter
when she went off to college, that's
kind of sobering.
But some people you go to
school with aren't coming back for
Christmas break, after
Christmas break.
And it was true.
She saw that.
So we typically see late
teens, early 20s, early 20s, typically.
But you can be later.
Our first break team, which
took people with psychosis within
six months of a break.
What's first break mean?
So for the first episode, the
very first episode of showing signs
of psychosis, so we would take
people as young as 14, 14 to 40,
and you could even have late onset.
The thing about schizophrenia,
there's no known one etiology for
this.
I feel like it's much like we
think of Parkinson's disease.
There's no specific reason for it.
So you can have multiple
etiologies, but there is a genetic
component.
Do you want to talk about that?
Yeah.
The genetics of schizophrenia,
first of all, it's heritable.
Probably not as heritable as
bipolar disorder.
Heritable, inherited.
Right.
But it's also clearly
triggered by environment.
There's a famous, actually,
PBS documentary about schizophrenia
in which they have identical
twin girls.
Now, young women, one of whom
perfectly healthy, successful, the
other who had severe schizophrenia.
Identical twins, same genes.
Well, I had identical twin
patients as well.
Well, I had the.
Actually, I had identical twin
patients that had schizophrenia,
and I had identical twin patients.
One had schizophrenia severe,
and one had depression.
But it was a lot of that was environmental.
So there are what are called
epigenetic factors at play here,
meaning some genes, after
you're born, seem to get turned on
or turned off, although we
still don't understand what those
are and how that happens.
The other factor to consider
is there's a viral hypothesis about
schizophrenia and also a
malnutrition hypothesis.
In the Netherlands, at the end
of World War II, when starvation
was rampant because of the
occupation, there was a huge number
of children who ended up
having schizophrenia.
And malnutrition could be also
a risk factor for infection.
Fuller Torrey, one of the
great researchers in schizophrenia,
also has a viral hypothesis
that maybe there's an infectious
etiology for some people.
Very interesting.
So that brings us back to what
are the signs and symptoms of schizophrenia?
So there's a variety of signs.
So we talk about positive
symptoms and negative symptoms.
So the positive symptoms
aren't, oh, good.
These are good.
Things.
It's an expressed.
An expressed emotion.
Essentially they're overt.
Overt.
The negative symptoms,
although we get.
Those are overt actually, too,
because we get used to identifying
those are the withdrawn symptoms.
So let's talk about the
positive symptoms.
And you don't have to have all
of these.
You could have some of these,
but not all of these.
Okay.
And one of them is hallucinations.
So that's very common.
There's a variety of different hallucinations.
You can talk about them.
Auditory.
What are some other hallucinations?
Any sensory system can have
hallucinosomatic olfactory meaning,
smells.
Visual.
Auditory.
But I think when we start to
see the more obscure things like
olfactory hallucinations, we
start to think about forms of epilepsy
and other temporal lobe epilepsy.
Visual hallucinations.
Also, we're thinking
potentially substances.
Head injuries.
With different kinds of hallucinations.
We're thinking.
Or tactile hallucinations.
Feeling bugs crawling on you.
Sometimes we're thinking of substances.
That doesn't mean you can't
have an olfactory.
I had somebody that moved from
apartment to apartment to apartment
because she always smelled
something burning or dead bodies
in these apartments everywhere.
And we did all.
We did MRI, CT scans, all that.
And it was part of her
hallucinatory material.
But typically it's auditory hallucinations.
Hearing voices.
Hearing voices.
So another reason I love
schizophrenia and talking to people
that have schizophrenia,
they're so uniquely different.
Everybody's story is not one
person has the same story as the
other person.
So I might hear voices, you
might hear voices, but our voices
are completely different in how.
How they affect us.
But imagine you're a young
college student and you're trying
to study for an exam or take a
test, and these voices are talking
to you, and you can't
concentrate, or you're in a job interview.
You can't concentrate.
You're distracted by this,
even if you try to dampen them out.
And some people believe that
part of schizophrenia is you can't
filter out all the stimuli
that's coming in.
So we're in a room or in a
podcast studio today, and I can hear
there's a fan, there's some
air conditioning, there's some outside
noise.
We can filter that out.
But if you have schizophrenia,
some people can't.
They're just getting
stimulation from everywhere, and
it's very distracting.
And there are also things
called command hallucinations.
So command.
So auditory hallucinations,
you're hearing something that the
rest of us aren't Hearing.
Okay.
And there's different kinds.
So command hallucinations,
that's the worst kind because it
could say things like, hurt
yourself, jump out of the car.
So we have, we worked with
many care managers, so young social
workers that were working with
our patients and they would be in
a car and you know, somebody's
trying all suddenly heard a voice
saying, jump.
Or it could be very impulsive,
jump off of something high or, you
know, it's very terrifying.
So we always ask the nature of hallucinations.
I always want to know what,
what the voices are saying to them.
So sometimes people we've.
In a psygnosia, we've talked
about that in other podcasts and
we'll talk about it again.
Lack of insight.
You really don't believe
there's anything wrong.
But we will say, I'll see
somebody and I'll say, I'm, you know,
John, it looks like you're
hearing something.
What's going on?
What are you hearing?
I'm not hearing anything, but
I can.
I see your lips moving and I
see you looking up at the ceiling.
What's going on?
So we start talking about that
over time and it's matter of fact,
it's not judgmental.
And we say, I'm not trying to
judge you.
This is just what I'm observing.
You can imagine if someone's
responding to auditory stimuli that
the society perceives them differently.
They're like, who's this
person talking to themselves over
there?
That's strange.
And I'm going to walk across
the street.
At our agency, we welcome you
with open arms.
Come, let's talk.
Let's talk about what's going on.
It's very frightening illness
to have.
Can you imagine that you never
heard voices before and suddenly
you're hearing voices.
So the brain tries to
interpret what's going on.
This can't.
Why am I hearing these voices?
Oh, the FBI must have, the CIA.
Somebody implanted something
in me and they're tracking me.
Oh, I am very special.
I'm hearing messages from God
that nobody else can hear.
So then it's a way of
explaining away what's happening
to them.
But it's a very distracting
thing for them to hear voices.
So that's positive symptoms
and command hallucinations, particularly
concerning another positive
symptom, delusions.
So a delusion is a fixed
belief that is not reality based.
So Paul, maybe we can talk a
little bit.
There's such a thing called
delusional disorder.
That's not schizophrenia.
Do you want to mention that at all?
Yeah.
If you look at DSM5TR, which
is the encyclopedia of psychiatric
diagnoses, the schizophrenic
spectrum is arranged across the spectrum,
all characterized by psychosis.
Psychosis, delusions,
hallucinations, disorganized thinking.
Delusional disorder is a
disorder that's not very common,
but consists purely of a.
It's usually one.
It's usually one delusion and
it's difficult to treat.
It is, and it's very fixed.
A lot of anosognosia
associated with that.
And also, I have to say, a lot
of people we thought maybe had a
delusional disorder ended up
having a schizophrenia diagnosis.
But I wanted to bring that up
because it's just a very specific
delusion, schizophrenia.
By the way, there's something
called schizophreniform disorder.
So talk about that in terms of timing.
Well, that's probably the
beginning of schizophrenia.
But there's a distinction made
between duration of psychosis and
to meet criteria for
schizophreniform disorder, you have
to have symptoms of psychosis
for at least a month.
But less than six months.
Less than six months.
So the six month is the marker
that we say officially.
So we could say provisional too.
We're thinking this is a
schizophrenia diagnosis.
It's provisional.
But once it's six months or
longer and it's schizophrenia.
Correct?
Yes, yes.
And then there's
schizoaffective disorder.
So schizoaffective disorder I
was gonna talk about at the end,
but once we get over.
So schizoaffective disorder is
confusing to some people because
there's affect, a mood
component to it.
And how we make that
distinction is there has to be at
least a two week period where
there's psychosis, meaning disorganization,
hallucinations or delusions,
that is not related to the mood.
The person is neither
depressed nor are they manic or they're
euthymic, but they're psychosis.
And that distinguishes it from
bipolar disorder with psychotic features.
So with bipolar disorder you
can have psychosis.
Mood congruent would be, I'm
in a mania and I think I am Jesus
Christ King president.
It's congruent with my high
elevated state.
I had someone with depression
while they were in their depressed
state.
They thought the faucet
instead of water had blood coming
out of it.
Their organs were all rotting,
you know, death, dying, that kind
of thing.
Mood incongruent means it's
not consistent with your mood.
So if you were in a manic
state and you were having this Negative
stuff that would be incongruent.
Correct.
So that's the distinction.
You have to have a mood component.
But sometimes we find that out
later on, you know, sometimes it
takes a while.
So there's these nuances which
we'll get into because depression
and negative symptoms
sometimes gets confused.
And I want to dig deeper into that.
But let's go.
Let's talk more about delusions.
So many different kinds of delusions.
A paranoid delusion.
So a paranoid delusion is a
fixed belief that's not reality based.
But you think your wife is
having an affair, but she's not.
You think you're being
poisoned, but you're not.
Your wife could be having an
affair, you could be poisoned.
These are all things that
could happen, but they're not happening.
So that's a paranoid delusion.
Tends to be tricky to treat,
much like you were talking about
pure delusional disorder.
Tends to be pretty tricky
because there's always ways they
find of adding to their case,
you know, making a case about it.
Grandiose delusion.
Like we mentioned, they're an
average Joe and they think they have
superpowers or something.
You know, there's religious
delusions, which gets tricky too.
We always take into account
people's religious beliefs ahead
of time.
But it gets to beyond thinking
you have a special relationship with
God.
It goes beyond that.
Erotomanic delusions.
So this is sometimes we've
heard about these star stalkers and
people that think they have a
special relationship with a celebrity
and they go try to find them
and they believe they truly the celebrity's
in love with them and that
leads to all kinds of trouble.
I have worked with people over
the years that worst stalkers, it's
very tricky because you must
address it.
They don't like to address it.
They get very defensive about it.
But we've had several
situations, particularly with local
news anchors because they're
on the screen and they smile and
they're pleasant and they're
pretty and someone that's sitting
alone in their house and they
have psychosis, somehow that becomes
they're talking to them.
They're talking to them.
So that's another kind of delusion.
So we have thought
broadcasting and thought insertion.
So that.
So thought broadcastings also
can be.
You're saying, you know, wet
cleanup on aisle three.
Or you hear, we hear wet
cleanup on aisle three at the grocery
store.
And they hear something very
much directed at them.
They're somebody's
broadcasting, but it's directed at
them.
And the TV people are
broadcasting to Them I had voice
at our agency, voicemail.
You could just do your first
initial and last name and anybody
could find you in a voicemail.
So I had all kinds of colorful voicemails.
And one day I had a voicemail
that was frantic and said, Dr.
Skill, get out of my TV.
Get out of my TV.
Why are you in my TV?
And thought that I was somehow
talking, you know, to them from the
tv.
Thought insertion.
I can put.
I can put things in your mind
and that some people think that you're
putting things in my mind.
What are some of the other.
By leaving out some of the delusions.
Paranoid, manic, grandiose.
Are there other ones?
Those are the top ones.
But yeah.
Paranoid delusions tend to get
people in all kinds of trouble.
Now, people with paranoia,
with their schizophrenia, they can
look really good.
They don't.
They're not disorganized necessarily.
They could.
Could be us right now.
But if I start talking,
believe me.
But if I start talking over time.
That's another reason why I
really advocate for longer appointments.
Because a lot of people have
gotten good at containing their psychosis
for limited periods of time.
They have to if they're going
to get along in society.
And that's why some people
don't get work in society.
But if they've managed to kind
of COVID for a while, short conversations,
they don't show it.
But I knew.
I knew key things with all of
my patients.
And if I would say the
particular person, what's going on
with that lady in the red dress?
Then went from everything was
perfect to not.
But it's there and we have to
talk about it.
Because I need to know that
that's still there because someone
had a delusion about a lady in
a red dress that's following them
everywhere.
So.
But they can look very
organized in their conversation.
They dress appropriately and
the conversation makes sense.
But then when you get to that
delusion, it's a fixed belief that's
not true, but it really haunts
them and it adversely affects their
lives.
Before I get into this,
though, Paul, you and I were having
this discussion the other
night when we were looking at DSM
5.
I don't like that they changed
the nomenclature and how to describe
schizophrenia.
I've been doing.
They used to have subtypes.
Subtypes which were good.
Honestly, I.
So I've been working with
people with schizophrenia over three
decades.
And it used to be you'd have
schizophrenia, paranoid type, schizophrenia,
disorganized type,
schizophrenia, catatonic.
There were types.
I know you Were saying you
think that partly why they took it
away is that it didn't make a
big difference treatment wise, but
it absolutely makes a big
difference in description wise because
it's very, very different.
So someone with disorganized
schizophrenia looks very different
than someone with paranoid
schizophrenia, but the distinctions
are erased.
So we have not talked about
disorganized features.
What are those like?
So disorganized is kind of.
I feel like that's more what
you see depicted on television.
The stereotype, you know, the
person that's got tin foil on their
head or they're just very
disheveled and they're talking in
a really bizarre man.
Oh.
So I have to go back to delusions.
Thank.
That's just glad that I said bizarre.
So a bizarre delusion as
opposed to a paranoid delusion.
We said that can happen.
A bizarre delusion is not a judgment.
It's that it is not consistent
with our cultural norms.
So right now, if you think
little green men are living in your
ear and broadcasting things
and controlling your life, that's
not consistent with our
cultural norms right now or anything.
That's.
It just doesn't make any kind
of sense.
I work with people that would
sit in my office and say they were
dead.
I'm dead.
I was killed multiple times.
I keep getting killed and I
keep coming back to life.
That's a bizarre delusion.
Or someone that's 300 pounds
and 5ft tall saying they're a blonde
supermodel.
This is a bizarre delusion.
So I wanted to bring that up.
But disorganized, their
behavior is erratic.
The conversation can be all
over the place.
And again, we used to call there.
Used to.
People talked about word salad
and loosening of associations, which
I loved.
Loosening of associations.
You see where they're going.
If you've been doing this long
enough, they're having a conversation.
And then this leads to that
leads to that leads to that tangential.
Now it's derailment.
We say their conversation is derailed.
You can't follow it.
I got pretty good at following
it, though.
I kind of feel like I.
The average person can.
The average person cannot.
Again, I just did that all
day, every day.
Right.
I couldn't speak the language,
but I could understand the language,
let's put it that way.
But it shows how what's going
on in the brain.
There's so much happening in
the brain with someone with schizophrenia.
Just what's going on
chemically, what's going on electrically,
I don't know.
It's Just lots of things are
happening at the same time and it's
just too hard to keep up with.
So people with disorganized
schizophrenia sometimes will present
malodorous, disheveled here,
all wild and unkempt, like we said,
the conversation all over the place.
So that's, that's a whole
different ball game.
It leads to further stigma, as
you put it.
Discriminate discrimination
because people get, the average person
gets pretty frightened of
somebody that's presenting so far
different than what they're
used to.
Negative symptoms, again not a
judgment, it's just different.
So the positive symptoms would
end up getting you in the hospital
because it's your erratic or
responding, you're acting on your
delusional material or your hallucinations.
The negative symptoms, not so much.
You kind of can live quietly
with your negative symptoms in your
little apartment, staring at
the ceiling all day long, withdrawn.
Symptoms we talk about a flat
affect, not much facial expression
at all.
They, there's no smiling.
It's just blank.
It's kind of blank.
Poverty of content.
They don't have a lot to say.
So it's typically one word.
Monosyllabic responses.
Some yes, no in a monotone way.
And again, this is different
from their baseline.
They weren't born like this.
You'll hear people say he was
a friendly little kid and then what
happened?
It's just, you know, kind of
over time this starts happening.
So I, I would do something
with my patients that had negative
symptoms that I kind of just
made up.
It just made sense to me.
And it was similar to the
situation when I was a teenager working
at that state institution then.
And people were like that guy
doesn't talk.
And I talk to him every day
and he's talked back to me.
I think if you have your
expectations a little higher, sometimes
people respond to that.
So my patients over time knew
I was going to say how was your weekend?
And I'm chatty, you can tell
how was your weekend?
And I would ask things that
were open ended and I think there's
a lot to it.
And also modeling, I was
modeling conversation and affect
and animation.
And I found that over time
many of my patients with negative
symptoms responded to that.
They would come in with
something to say and their home operators
or family members would say, I what?
Like I don't, he doesn't talk
at all.
But I talked to him and he and
I made eye contact and I smiled.
And then they would respond
back sometimes with negative symptoms
too.
Paul People have avolition, so
they don't have the desire to do
anything or the energy really
to do anything.
And people.
Families get really frustrated
with that.
So we've seen the positive
symptoms get better because some
of the medicines, and we'll
talk about this sometimes can help
the voices and the delusions.
And that's our goal.
We want to get rid of the
voices, rid of delusions, not leave
a little bit there.
We're always trying to hope
for remission, Correct?
Right.
But the negative symptoms will
persist and families get frustrated.
Like, wait, he's not hearing
voices anymore.
Why isn't he going back to school?
Why isn't he getting a job?
Why isn't he mowing the lawn?
Why doesn't he shower?
And it's.
I have learned so much from my
patients over the years, but this
one young man, and I told him
that I tell this story a lot.
And he gives me.
It's a great story, permission
to tell it, and I'll never, ever,
ever forget it.
He was in the room with his
father and me, and we were having
a conversation.
It was a touchy subject about hygiene.
And the father was thrilled
that he was no longer hearing voices.
And he wasn't going in and out
of the hospitals, but he wasn't attending
to hygiene at all.
And that he was extremely malodorous.
And that was awkward for the family.
So they were trying to work on
that now.
And again, this is.
We're working up.
That was better.
Now he's safe.
Thank goodness he's not in the hospital.
Now.
We're going to keep working on
moving up that Maslow's, you know,
triangle there.
Right.
So touchy subject.
And so it kind of came out at
different angles.
And I wanted him to save face.
And he was the sweetest guy.
So sweet.
And I make up a name.
So, John, what's.
I'm just curious.
So what's going on about.
What's going on about taking a shower?
Can you tell me how that's going?
And he was quiet and monotone,
but he started to break down what
it was like to take a shower
for him.
And he said, well, you know.
Sigh.
He's like, you have to turn on
the water and you have to get undressed,
and then you have to get in
the shower, and then you have to
get wet, and then you have to
use soap and so on.
And he kept saying, and then
you have to use shampoo and then
you have to rinse.
And he was the dad who I
adored to.
Wonderful, wonderful man.
Such a supportive dad.
And I looked at each other and
we Both had light bulbs go off in
our head.
And I said to him, john, I
still, I have chills telling the
story because I'll never, ever
forget it.
I said, john, thank you so
much for explaining to me what it's
like for you to take a shower,
because that sounds overwhelming.
And I also would not want to
take a shower if it felt like that.
Thank you for sharing that
with us.
And I think it helped the
father have so much compassion because
it wasn't that he was just
being difficult, he was truly overwhelmed
by it.
And then we came up with,
first of all, we validated that for
him.
And then we came up with some
ideas that maybe we could simplify
things like all in one body,
you know, body wash and shampoo and
all these just different
things to make it simpler.
But it was such an eye opener.
So when our case managers
would get frustrated with our patients
because they'd say, I was
going to take them to do laundry,
and we had it carved out in a
schedule to do laundry today.
And they were completely
overwhelmed and I couldn't get them
out of the door to do laundry.
And they had piles of.
Every piece of clothing they
had was piled up and dirty.
It's because they were overwhelmed.
It's just too much to take on.
That's negative symptoms.
Yeah.
So DSM 5tr breaks down
disorganization into behavioral and
mental.
The residual subcategory of.
From earlier versions, as we
discussed, there's no more disorganized,
paranoid, etc.
Still catatonia.
What is catatonia?
So catatonia, we see that with
bipolar disorder too.
You can have a catatonic excitement.
So people, people are
literally can be frozen.
They.
They will stand in one place.
I've had several people that
was literally standing in one place
urinating on themselves.
They wouldn't move.
They couldn't move to go to
the bathroom.
Like frozen.
So it feels like they're
slowed down, but really they're sped
up.
Right.
That's a catatonic excitement
we see, I have to say, 30 years plus
of doing this.
I hardly saw catatonia in my
early days.
And again, you used to think
about the old asylum thing.
Pictures you'd see.
You'd see people catatonic in
the state hospitals frozen in a position.
Waxy flexibility.
You could literally put
someone's arm in a position and they
would stay in that position then.
I didn't see much of that for years.
The last three years of my
practice, I saw many young men, men,
actually, I didn't have women
with Catatonia.
I don't know why, I can't
explain it, but my hospital colleagues,
we would discuss.
I'm sending Jason in and he's
in a catatonic state.
So we would say, what is going
on with this catatonia?
So I don't know what to make
of that, but it's very frightening
for the person involved.
It's very frightening for the
family members to see that.
The.
I. I've had many people, you
might watch them from the.
We start engaging from the
minute we're in the waiting room.
Hi, you know Sue.
Nice to see you.
Come on back.
And I watch how they walk and
I watch how they get up and how they're
interacting with other people
in the waiting room.
And you will see people having
a hard time just getting going.
So very difficult to treat also.
So it's.
We do treat with the
antipsychotics, but we also treat
with benzo, high dose benzodiazepines.
So think the Ativans, the
Valium, Valium, which.
That'll be a different topic.
Typically, we're not loving
using benzodiazepines as a high addictive
potential for things like
that, but for catatonia, that's what
you have to do.
So you'll see people in
extreme amounts of a benzo because
it's that catatonic excitement
and that's what brings them down.
We have to do a slow taper
over my career.
And as you know, I mostly work
with people with bipolar disorder
where catatonia also happens.
Early on, I was working with
someone who was catatonic and I was
teaching back then was talk to
them, talk to them, talk to them,
even though they won't talk to
you back.
See, I feel like that's a
negative symptom thing, not a catatonia.
These people who are frozen.
Okay.
So one day I talked to this
young man who was in the hospital
for about 30 minutes.
I couldn't tell if he was
receiving any of it.
Put him on benzodiazepines.
A couple days later, I said,
do you remember talking to me?
He said, oh, yeah.
And then he recited.
So he remembered hearing you
everything that I said.
Interesting.
And so I said, what was it
like for you when you were listening
to me?
He said, for me, I was in such
a state of panic, I couldn't respond.
And everybody I've ever talked
to after they've come out of catatonia
has told me that they were in
a state of extreme terror.
That makes sense, actually.
Oh, that's so sad.
That makes sense.
I'm so overstimulated, I can't
move, I'm frozen.
That's actually really heartbreaking.
I used to call it status
panicus, like status epilepticus,
you know.
Oh, that's really sad.
Let's talk about another part
of schizophrenia that gets overlooked
a lot.
And partly why, by the way,
people don't talk about negative
symptoms a lot even is because
we don't have any medicine to treat
negative symptoms.
We have things that treat the
positive symptoms.
Okay?
We have way lots and lots of
room for improvement.
But negative symptoms, people
keep trying, pharma keeps trying,
and nothing so far that
targets the negative symptoms.
Right.
As far as you know.
But we need to keep trying
because quality of life wise, that's
not a good quality of life to
have the negative symptoms.
Well, I think there's some
weak support that the atypical antipsychotics,
the newer generation, are a
little bit better.
A little bit.
Oh, they're better, but they
still don't.
Target the negative symptoms
in treating negative symptoms.
Partly why that is, Paul, is
because they're not so heavily sedating.
Neuropotentially neurotoxic,
there's a little bit of stimulation.
They're the serotonin
component to it.
They're not causing as many
neurologic side effects.
Right.
So the atypicals are atypicals
because the traditionals are strong,
strong dopamine blockers.
And the atypicals have
serotonergic properties as well.
So that's the difference.
So mood stabilizing as well.
But actually I want to talk
about cognitive symptoms, but before
I forget, we just mentioned dopamine.
Probably in my 8th grade
schizophrenia paper a million years
ago, I probably talked about
the dopamine hypothesis and that
was the big deal.
People like this is the answer
to schizophrenia.
They have too much dopamine.
We need to block their
dopamine with these antipsychotic
medications.
And then they'll be better?
Well, they block the dopamine
and some of them got a lot better.
But then what happens when you
block dopamine?
What's the flip side of that?
You get Parkinson like side effects.
Exactly.
So then they had abnormal
movements associated with them.
So there's Parkinson like movements.
People would get pill rolling.
Some people got what we call
tardive dyskinesia.
Can you discuss what that is?
Abnormal involuntary movements
that people can't control.
They cannot control them.
Typically we see them from
neuroleptic medications.
Neuroleptics Are first
generation antipsychotics?
Yes, first generation antipsychotics.
But we can see them with
anything that blocks dopamine.
But that was supposed to be.
That was exciting.
It was dopamine hypothesis.
There was the decade of the brain.
I remember all the
pharmaceutical reps were giving us
brain models and brain charts
and everything.
Much appreciated.
Actually, I have many of them.
And in fact, when we were
moving from Cincinnati, I remember
you saying, do you really have
to take all those brains with you?
But I had to.
I love those brains.
I did give some to some of my
young nurse practitioners when I
left.
Well, on the dopamine
hypothesis, though.
So the field of
psychopharmacology drugs for psychiatric
illness has been based on
random observations.
So the first antipsychotic
drug, Thorazine, Chlorpromazine,
1950, 1950s, it was developed
actually to be a better antihistamine.
And then it was discovered to
have antipsychotic effects.
So then scientists said, well,
what's different about this drug?
And it was discovered that it
blocked dopamine.
So it was basically reverse engineering.
Right.
So the dopamine hypothesis was
born of the observation that a drug
that blocks dopamine had
antipsychotic effects.
Right.
Well, a lot of medicine is
like that.
Antidepressants wasn't thought
out to be that way.
Well, no wonder.
So you said Thorazine has.
Was thought to be an antihistamine.
It sure is.
So it has anticholinergic
properties and it's strongly anticholinergic.
So people, that's why people
get a gut.
We don't use it anymore.
I have to say, there was one
person, and I would be so embarrassed
prescribing a case.
Like he and his father said,
the only thing that helps me is Thorazine.
And I had to prescribe Thorazine.
But I'm like, I hate
prescribing Thorazine.
But constipation, dry mouth,
blurred vision, urinary retention.
Urinary retention, yeah.
So luckily they keep coming up
with better things, but not enough
yet.
So we just didn't.
We don't have anything really
that targets negative symptoms.
Is that how we got on this?
Yes.
Oh, no.
Dopamine hypothesis.
So you said when we block
dopamine, we can decrease the positive
symptoms, not so much the
negative symptoms, but then we can
potentially get abnormal
movements, you know.
But that sounds like
Parkinson's disease.
So what's Parkinson's disease?
We have too little dopamine.
Patients often get Sinemet or
L Dopa.
It's a Dopamine precursor.
We're going to give them more dopamine.
What happens?
Their movements get better.
But then what can happen to
some people with Parkinson's on L
dopa?
They get psychosis.
They can get psychosis.
I mean, it's such a cruel thing.
Fine line.
And it's such a balance and
such a.
That's why I feel like there's
a link somewhere with that.
But one thing that we.
That's often not looked at
with schizophrenia are the cognitive
symptoms.
So we have positive symptoms,
we have negative symptoms.
Disorganization.
Yes.
Which is part of positive symptoms.
And there's cognitive symptoms.
But again, we don't really
have anything for that either.
People are trying to treat
that as well.
So over years, some people
with schizophrenia can have cognitive
decline.
And again, I had the great
fortune of having people for entire
30 years, so I saw them over time.
And some people, for real, they.
We have what's called a full
steam mini mental status exam that
we work with people that we
think might have dementia.
We, you know, you know, point
to a watch.
What's this?
Write any sentence, draw a clock.
There's just different pieces
of that.
And we can go over that in
another podcast, actually.
And people that had normal
intellectual function, they were
fine.
They had been to high school, college.
Or whatever, sometimes very,
very bright people.
Very, very bright people.
Over time, they lost some of
their cognitive skills.
And that was very sad to see.
And again, we don't have a lot
to do for that.
We just have to watch for that
and treat early treatment.
So the belief is the earlier
you treat and the less time you spend
in this actively psychotic
state, the less damage hopefully
you're having to your brain.
I believe it was the Thompson
studies that had the serial MRIs
that they looked at people
with schizophrenia versus people
without schizophrenia.
And they saw over time, some
people had increased size of the
ventricles, which is the space
in your brain, and decreased gray
matter, frontal, parietal, and
temporal lobes.
Important stuff.
And that's not good.
So.
And it got worse.
The more episodes, the more
episodes you.
Have, which is why we want, we
encourage people to stay on medications
as best they can.
We just want to.
We mostly just want to avoid
future episodes.
We had talked about this.
Whether it's a manic episode
or psychotic episode of seizure.
Yeah, there's all insults to
your brain.
We don't want that.
So we watch for cognitive science.
So again, a lovely, sweet
patient and her mother.
We'll do a whole episode on
families because it's very Difficult
to have a loved one with major
mental illness.
And my heart goes out to
families because it never ends.
You're 15 year old that
started hearing voices is now your
55 year old and you're 85.
So I would have many older
parents come into appointments if
the patient was lucky.
A lot of patients no longer
had family.
There's a downward drift and
families kind of disappear and they
end up alone or in the system.
But I remember this one woman,
I'm going to call her Melanie here.
And she was one of my first
ever patients and she was very sweet.
But she heard voices starting
in college, typically the age.
And the voices would scream
and she would hear this blood curdling,
screaming all the time and
threatening, scary voices and.
And she would run and cry and
it was terrible.
She ended up dropping out of college.
Many, many hospitalizations.
And then I had her for years
and we had her on different medications
that she took, but they could
only do so much.
And she is one of the people.
The voices never went away,
but they changed.
So her voices over time went
from screaming and saying horrible
things about her.
Oh, so derogatory
hallucinations is another kind of
hallucination that's really awful.
I'm going to go pop back to that.
In light of Melanie, think of this.
If you're just minding your
own business, you're trying to watch
TV or you're trying to read or
just eat dinner, and the voice is
saying, you're no good, you're
ugly, you're stupid, you don't deserve
to live.
How horrible is that?
And you just hear it and hear
it and hear it.
And one of my patients said,
imagine if someone's calling you
names, you can walk out of the room.
If it's coming from your own
head, you can never escape it.
And that really struck a chord
with me, right?
So Melanie, over time, her
voices no longer were screaming and
derogatory.
And over time, they said
things to her like, you're so pretty,
you have the best singing voice.
And she would hum and sing and
things like that.
So better than it was, but
it's still sad, right?
And she would smile.
She ended up smiling all the time.
She lived in a group home, but
I would see her in the waiting room
and we used to have books and
there was like a phone book or something
out there.
And she had, when they had
phone books.
And I remember she was sitting
with the phone book upside down and
just smiling, looking at this
upside down phone book and flipping
pages.
And her cognitive decline had
gone it was dramatic.
And her sweet 85 year old
mother would come into these appointments
crying.
She never didn't cry for 30
years because again, as a mom, right.
And she said somebody must
have put something in her drink because
she was.
I have three daughters and
one's a lawyer and one's a successful
businesswoman.
And Melanie was the brightest
of the three.
And she was in college, she
had all these dreams and aspirations
and now she's reading a phone
book upside down.
And mom was crying and crying
and Melanie was just kind of humming
to herself and she hardly talked.
She was very withdrawn.
A lot of negative symptoms too.
And I remember mom was crying
and I said, you know, I know this
is sad to see, but Melanie
right now is not in distress.
And I feel like Melanie kind
of came out of her psychosis and
tapped her mom on the arm and
she said, it's okay, it's okay, Mommy,
it's okay.
It's brutal.
But it was, I mean, I remember
it was.
I mean, I've seen so many
different, different scenarios of
this that the voices change
over time, but the cognitive symptoms
are a thing and we wanted to
avoid that if we, if we can.
So just a couple things about
treatment and we don't have to get
into medicines, although I
assume you think that antipsychotic
medicines are the foundation
of treatment of people with schizophrenia.
But they often need so much
more and families need so much more.
Well, you and I are big
advocates of nami, national alliance
of Mental Illness.
In fact, we did before we were
together as a married couple.
We did presentations, we did
workshops and presentations together
because we feel it's really
important to speak to families.
Families are so desperate for
information, so education is key.
Helping them be as supportive,
supportive to their loved one and
as supported as they can be
because it's a rough road.
I've seen so many families,
you see the parents just worn down
over time.
They just look really
beleaguered, wiped out.
You know, it's a, it's a rough thing.
What about.
This may be the wrong phrase,
but wraparound services, things like
vocational support, peer
support, I think community mental
health systems tend to offer
those things more than the private
sector does.
For example.
Right.
Thanks for bringing that up.
Because some people feel like
if you pay more money for it, it's
better.
We lived in a fancy area in
Cincinnati and now we're in a fancy
area and Arizona.
But so I have seen a lot of
people think if it doesn't cost a
lot of money, it isn't good.
You Know what I mean?
In terms of medical care, if
you have a loved one that has schizophrenia,
for example, they will do
better, probably in a community mental
health center.
So I am in the trenches,
community doc.
I've never done anything but
community work.
And I took great care of my patients.
You did, thank you.
This is great, great pride.
I'm very, very proud of that.
And I loved it.
I loved every second of it.
And I specialize in working
with people with major mental illness.
Our private sector colleagues,
not taking anything away from our
private sector colleague.
That's just not the thing.
And we give lots of talks.
I go to private psychiatrists
around here all the time.
And I'll say, do you ever see
anybody with schizophrenia?
And they'll say, oh, I have
one person with schizophrenia.
I had every.
Almost all of my patients had
schizophrenia, schizoaffective or
severe bipolar disorder.
So it's what we do all day
long and what we love to do.
And you do need.
It absolutely.
Takes a village.
You need case manager, case manager.
I love case managers.
Sometimes called care managers.
They are the backbone of
community mental health.
I'm the doctor, I can't be
with that person all the time.
The care managers with them a lot.
They're helping take someone
into the grocery store, get their
Social Security benefits if
they need that.
Help them with housing, legal,
whatever they need.
The case manager is the key
person and they give us lots of information.
I again, Johnny could be fine
in the office and the case mayor
said I was with them this half
hour ride to get to the appointment
and he was talking to himself
or screaming at the radio because
he thought the radio was
giving him special messages and things
that I might not know.
Vocational support, helping
people get back into the, back into
jobs.
It's really important.
They have a sense of meaning
and purpose.
Housing support, medical support.
Often people with major mental
illness have comorbid associated
medical problems or untreated.
If you are really disorganized
in your thinking, it's hard to keep
track of your diabetes
medications and your high blood pressure
medications.
So it was not uncommon to have
so many of our patients have hugely
out of control blood pressures.
You know, we would take, I
insisted that we had blood.
We had med assistants that
took blood pressures and weights
and all that kind of stuff
because it's medical stuff going
on.
And people would be 210 over
115, you know, and they'd be used
to it.
They're sitting around used to
that or would do a finger stick.
And some was, you know, having
a glucose of 600.
You and I would be in the hospital.
But they were so used to it.
But meanwhile, damage to the
kidneys, you know, we've had people
not taking care of their
diabetes and toes getting amputated.
And I also had more people
with head injuries than any.
Like people with major mental
illness often are.
They're the most vulnerable
among us and they are often victims
of assault, of assault and
yeah, violence.
I have all these people that
were unhoused that here the poor
guy is on a bench or under a
tree and someone tries to roll him
for 50 cents.
He has no money, you know, but
for a pack of cigarettes or something
and just head injuries and things.
So all this support of medical
care and.
Oh, and therapy, let's not
forget therapy.
So we would do what we call
supportive psychotherapy.
So if someone is hearing
voices and things it's hard for them
to do, sit down with a
therapist and let's talk about your
childhood.
We're not doing that kind of therapy.
We're like, how can we support
them with their illness, with what
they need to do on a daily basis?
But there's also such a thing
called cognitive behavioral therapy
for psychosis, a cbt.
And we would send people.
There was a great program in
the Cincinnati area and we would
send people for that.
And it was, it was a
commitment and there was a money
commitment to some
scholarships, but some families had
their adult children doing this.
It was like a one year commitment.
And there's.
It's programmed, there's
worksheets and things help helping
them understand their illness and.
And have improved function.
It was a big advance in the field.
Yeah, yeah.
But sometimes being again
another guy that was my age, I remember
I was 32.
I was just becoming medical
director at the time.
And you know, here I was
medical director.
I had a child, you know, I had
a good life going on there.
And I was another young man
that was 32 and he saw.
He was my birthday and
somebody had birthday card or something.
That's how he saw.
And he was at that point, his
psychosis was under control.
But he had been in and out of
the hospital, including the state
hospital, many, many times.
And he was this brilliant guy.
And he was also an incredible
pianist, just really talented guy.
But he has severe
schizophrenia and the meds that he
had to be on to get out of his
psychosis were debilitating to him.
So he had horrible.
So tardive dyskinesia is.
Those are the movements that
don't change, right, Those permanent.
Well, they're treatable.
Treatable now.
Treatable now.
They work for years.
They work for years.
They could be right.
But extrapyramidal symptoms.
Describe that.
Talk about eps.
Extrapyramidal symptoms are
basically Parkinsonian side effects.
So muscle stiffness, tremor.
Yeah, they call it cogwheel rigidity.
Right.
Of your arms, mass facies,
shuffling gait.
You can't really, really walk normally.
You could also have dystonic.
You could have acute, like,
fidgety kinds of movements and stuff.
Like extra pyramidal symptoms.
You could have.
So we monitor those things.
You can have fidgety movements.
He had those to the max.
He had every kind of movement
of his body.
And he walked down the hallway.
He felt very stigmatized
because every part of his body was
jerking, jerking, jerking.
He probably.
He had tardive dyskinesia.
It was years ago.
We didn't have anything to
treat it.
So he had horrible, horrible movements.
And he was this handsome young
man, but now worn out by the system.
He had akathisia.
Talk about that.
Akathisia is a paradoxical restlessness.
So when you see somebody doing
this, sometimes that's just normal.
But if they're on an
antipsychotic medicine, it means
that the antipsychotic
medicine is making them paradoxically
agitated.
Why is it paradoxically?
What do you mean, paradoxically?
Antipsychotic drugs are
supposed to be calming.
Oh, tranquilize.
So they're calming the brain.
They're calming the.
Well, not necessarily.
Even akathisia feels like
severe anxiety too.
Right?
They feel like they're.
But it's calming the voices or
something like that.
They're calming the target symptoms.
But yes, it's a.
It's a terrible side effect.
To me, it's the worst side effect.
I agree.
So it's that sense that
they're going to jump out of their
skin.
I've had.
Again, this other sweet woman
came, older woman, skinny older woman,
came out of the hospital.
She was my intake, and she was
coming down the hallway.
Remind me to get back to this
other guy, though, okay?
Please.
I remember her coming down the
hallway and she had all these movements,
movements, movements, movements.
And then she sat in the chair,
and then she stood up and sat down
and stood up and sat down.
And she said, oh, honey, I'm
so sorry.
I don't.
I'm so sorry.
I can't.
I can't sit down.
And she didn't know, but she
was embarrassed by it.
And I said, oh, no, no, I'm so sorry.
It's just not your fault.
That you're standing up and
sitting down.
And what had happened.
The hospital, I'm furious
about this.
The hospital had given this
woman high dose Haldol injection,
long acting.
So Haldol, very potent
dopamine blocker and a huge amount.
And this is a skinny older
woman, huge amount in the hospital.
She was restless.
So somebody had the bright
idea, sarcastic, not at all.
To give her more.
So they gave her way more of
this very potent, potentially toxic
medication.
And we can't.
It's long acting.
We can't suck it out of her.
It's, you know, so I felt so
sorry for this woman and I explained
to her what was going on and I
said, this is what's happening.
This has to get out of your system.
We'll come up with some other
plan for the voices for you, but
nothing that's going to be
doing this kind of stuff for you.
I'm so sorry, but it's the.
That is no quality of life to
have akathisia.
So when other medications came
out that were potential weight gainers,
we didn't like that either.
But I'm like, if I have to
pick between something that's causing
weight gain and something
that's causing akathisia, I'm going
to lean more to the weight gain.
Because I always say, what
would I do for myself or my children?
That's how I think of
medications all the time.
But now, luckily, there's some
things that,.
Before we get too pessimistic
about those Akathisia is treatable
and so is weight gain.
Well, akathisia is treatable,
but I would rather not treat the
Akathisia like.
So if you.
So again, cleaning up charts,
when I was leaving, I saw some of
my staff had people on a
medication and then they had three
medications for the akathisia.
I don't like that.
You don't want to be adding three.
But if you have to, you have to.
Right?
But you don't want to if you
can avoid it.
But akathisia is a very
uncomfortable feeling, so we're trying
to avoid that.
So I like that there's newer
medications out that avoid akathisia.
The whole thing is you want,
you have to have efficacy, but then
you don't want to have all
these side effects either.
So you don't want akathisia.
You don't want abnormal
movements, you don't want weight
gain, you don't want sexual
dysfunction, you don't want any of
that.
No Parkinson's side effects.
Yeah.
So we keep trying to work on
cleaner and cleaner Medications and
luckily there's so many more
things than there were when we were
practicing.
But we're not where we need to be.
So this young man, in his very
clear state, no psychosis, said,
look, first of all, look where
you were the same age, look where
you are, and look where I am.
He had been a Harvard undergrad.
Brilliant young man, got into
the system, community mental health,
which.
That's what I started to say.
If you end up in the community
mental health system, that's better
for you, probably because
we're going to wrap around all these
services if you're in a good
system that we can try to take the
best possible care of you.
So don't feel horrible if your
child ends up in a community mental
health setting, because that's
where the training is to deal with
major mental illness.
Okay, but.
So he said, I can't live like this.
I would rather be psychotic
and I don't want to be on these meds
anymore.
Can't force them.
He made a really good point.
So tragic, so sad.
And he stopped taking the meds.
He ended up back in the state hospital.
I don't ever know what ended
up happening to him after that.
My guess is it wasn't a good outcome.
He probably, if he survived,
he had cognitive decline, I'm sure.
And maybe he didn't survive
because that's the kind of thing
that it's hard to take.
So suicidality with
schizophrenia, when you have unremitting
psychotic symptoms, sometimes
that's hard for a person to take.
So I always, again, learned a
lot from him.
It was just really sad and
very tragic.
But the dopamine hypothesis.
So we were talking about that,
but then now there's newer thinking
about schizophrenia.
Thank goodness.
There's so much more to explore.
But now they're thinking
medications that worked with the
dopamine dampening dopamine,
they worked presynaptically for that's.
You're gonna have to explain
that then presynaptically for what
potentially is a postsynaptic problem.
You know, and we're trying to.
We're looking at medications
now that can help the psychosis and
not have those abnormal
movements associated with it.
So the synapse is the
interface between the transmitting
end of a nerve cell and the
receiving end of a nerve cell.
Nerve cells communicate by
neurochemicals, not electrically.
They transmit electricity
within themselves, but that's how
nerve cells communicate.
So presynaptic means the
releasing part, where chemicals are
shot out.
Post synaptic means where
they're Received and.
Hopefully we'll start treating
much earlier and recognizing symptoms
earlier.
By the time the symptoms
manifest, there's some damage already
done.
Again, we're all about hope,
but recognizing symptoms early is
important.
That's why I'm all about that
first break team.
We would get referrals from
children's hospital, high schools,
pediatricians, people who say
something is not right.
That's difficult information.
To tell a family that they're
scholar athlete, 17 year old, has
schizophrenia is a rough
conversation to have.
However, we wrap services
around them, try to keep them on
the trajectory of wellness and
maybe they can get away with one
medication and try to keep
them doing well.
I've always thought that
community mental health is a great
phrase because it's about a
community that you guys have provided
for people and families.
And we are always about hope here.
And we've talked about how,
not sugarcoating it, but how devastating
schizophrenia can be.
But in my career, your career,
there have been huge advances.
We talked about the CBT psychosis.
We talked about to some degree
about the advances in medicines.
There are so much better
medicines now than there were 30,
40 years ago.
So point is, don't give up hope.
Not at all.
And I have to tell you, I
totally lost track of time and I
thought we had another half an hour.
I'm not even kidding.
I saw you looking, I thought so.
Now I'm like, oh, no.
Because I wanted to say I have
to get this in.
One of the reasons I love
working with people with schizophrenia
is the innocence.
There's such sincerity.
People are so earnest.
And when they think, why don't
you understand?
The FBI planted a chip in my
arm and they're controlling my every
move.
It's just, it just tugs at
your heartstrings.
There's just such a.
There's such an innocence
about it and it's, it's.
I don't know, I just, I'm so
glad that that's what I spent my
life doing in my career.
And every time I go to a
community mental health agency, I
feel so at home there.
I love being there and I just
understand and I.
We just need to have
compassion and be hopeful because
these treatments are coming up
all over the place now, which be
supportive of research for sure.
And if, you know, we probably
have to do a second episode on this
because I have more to say.
Can you tell?
Because I really do want to.
I definitely wanted to leave
with hope because I didn't get enough
of that information out there,
but I wanted to make people aware
what schizophrenia is about,
but people do and can get better,
and we'll be talking about
that in future episodes.
Thanks so much for letting me
ramble and ramble and ramble important
topics, and we'll be here to
talk to you about many more things.
Thank you.
Thanks for listening and watching.