Understanding Schizophrenia and Psychosis with Randall White

May 24th marks the National Schizophrenia and Psychosis Awareness Day.

On Thursday May 24th, Dr. Randall was featured on Breakfast Television in a segment to change how individuals talk and think about Schizophrenia and Psychosis.

Explaining the difference between Schizophrenia and Psychosis.

Psychosis is a generic term of a mental disorder. It occurs in several conditions, and schizophrenia is one of them, in addition to bi-polar disorder along with other brain diseases. It is a rupture with reality. People with psychosis are often paranoid with thoughts of other people trying to harm them. Other symptoms include hearing voices and as a result these individuals do not perceive the world as others typically do. They perceive the world in an augmented reality, which can be extremely scary. Also with schizophrenia, there are components of basic human function that are taken away from individuals. For example, they can lose the ability to connect with people emotionally, begin to feel withdrawn, or even lose certain cognitive abilities. These include but are not limited to the ability to plan for the future and memory function.

Highlighting common misconception about aggression for individuals with Schizophrenia and Psychosis.

There is a common misconception that people with psychosis are dangerous and aggressive or violent. While that can happen, it is actually pretty rare. People with chronic mental illness are more likely to be victims than perpetrators.

Treatment and Rehabilitation plans for patients with Schizophrenia and Psychosis and their families.

As far as treatment goes, medication is used to control the voices, scary ideas, and the anxiety. However, a patient’s recovery process is also dependent on additional factors beyond the medicinal treatment. In order for individuals to regain their basic function and ability to relate to other people, services such as counselling and cognitive remediation are crucial to aid in the recovery process. This can help with patients’ memory and problem solving skills. Another big factor is support from peers and families. Mental illnesses like Schizophrenia and Psychosis can affect entire families. It is crucial to get as much support from the whole family, if possible. As this has been shown to significantly impact the individuals healing process.

Click here for a list of helpful resources and organizations for individuals impacted by Schizophrenia and Psychosis.

Cognition in treatment resistance

Patients with treatment-resistant schizophrenia or schizoaffective disorder have the most severe form of the illness at least as determined by persistence of positive symptoms, but the other aspects, including negative and cognitive impairments, are typically not as well assessed clinically or in research. Most clinicians may assume that treatment-resistant patients, who often have profound functional deficits, have worse cognition than patients who respond to non-clozapine antipsychotics. This is an hypothesis that requires investigation, and a team from New Zealand have recently published such a study. They went further and also looked at the cognitive status of a group of clozapine-resistant (ultra-resistant) patients.

The 51 patients were recruited from outpatient and inpatient settings; 5 had schizoaffective disorder and the rest had schizophrenia. The control group comprised 22 healthy adults matched for age and sex. The mean age of the subjects was about 33 years. The researchers classified the patients into 3 groups based on treatment response: first-line antipsychotic responders (n=16), treatment-resistant but clozapine responders (n=20), and clozapine nonresponders (ultra-resistant; n=15). The latter group had a 8-week trial of monotherapy, and all ended up on at least 2 antipsychotics, most often clozapine and a another second-generation antipsychotic. Despite the designations, the 3 groups had no significant difference in PANSS total or subscale scores at the time of evaluation. The mean antipsychotic dose as measured in chlorpromazine equivalence was significantly greater in the clozapine-resistant group, but the mean duration of illness did not differ among groups. The control group had slightly greater mean educational attainment than the treatment-resistant group.

The cognitive assessments consisted of neuropsychologic tests covering the domains of the MATRICS Consensus Cognitive Battery developed by the U.S. National Institutes of Mental Health, considered the standard in psychosis cognitive evaluation. In this study, the testing was computerized and included such domains as executive function, social recognition, processing speed, and verbal and nonverbal learning and memory. The raw scores were converted to Z-scores normalized for age, sex and education.

The results showed that the patients overall had significant impairment in cognitive performance compared with healthy subjects, but the differences among the 3 patient groups were minimal. The treatment-resistant group, however, had a mean verbal fluency Z-score equal to that of the control group whereas the other patient groups had significantly worse performance in this domain, but subsequent analysis did not support a significant difference in verbal fluency performance in patient groups or controls. The researchers mention that pre-existing work has found that clozapine is associated with improvement in verbal fluency, an intriguing finding especially since in this study, verbal fluency was correlated with the negative-symptoms subscale of the PANSS in patients who responded to clozapine monotherapy.

The study is small, and the equivalent positive symptoms scores in the 3 patient groups raises questions about the distinctions based on treatment response, the findings tend to disconfirm the hypothesis that treatment resistance as defined by antipsychotic response necessarily indicates greater cognitive impairment.

Anderson VM, McIlwain ME, Kydd RR, Russell BR. Does cognitive impairment in treatment-resistant and ultra-treatment-resistant schizophrenia differ from that in treatment responders? Psychiatry Res. 2015; published online Oct 2015; http://dx.doi.org/10.1016/j.psychres.2015.10.036