The Real Patient Burden of Schizophrenia

Video Transcript

So, we believe that all the symptoms, including suicidality positive, but especially negative and cognitive symptoms, converge as the final common pathway in functional disability. So, you might think positive symptoms and suicide are relevant—they are, they are. That's what brings people into the hospital; that’s what can also really cause serious damage. But there is the softer damage that is much more pervasive, and that is the disability that patients face. 80% of patients are neither married nor never married.

They don't stay employed, they don't finish their education, and they have a hard time living independently. So, many of the things that we take for granted, that we also think our kids will do, are suddenly taken away from these patients.

And the disability relates mostly to the cognitive inability to integrate what we need to integrate and understand and foresee, especially also in social interactions, but things that are needed for education. And then there are the negative symptoms, lack of motivation and ability or want to be with other people. And that's convertible.

Then, onto the functional capacity problems. So, we have positive, negative, and cognitive problems. And you know the positive symptoms are the delusions, hallucinations, thought disorder, and also disturbed behaviors. But it's really the negative and cognitive symptoms that are problematic: the alogia, the affective blunting, asociality, avolition, and anhedonia. And when you read Bleuler, he felt the positive symptoms; they were just accessory. They were, yeah, they're part of schizophrenia. But guess what? They're also part of depression, mania, problems with dementia, and also issues when you have, like, physical disorders.

But what was core were the ACEs, and that was the problem with drive, with affect, with associations. That means cognition, and also what he calls autism—so being in their own world. That's a little bit—also the anosognosia, which would be another a here. And then cognition, I mean, the negative symptoms are in your face. You can ask about it, and Forman gives you the information. You can also observe some of it. Some of the negative symptoms are just observational, but cognition is somewhat a black box. And unless you're an expert and have a PhD in cognitive neuroscience, it's hard.

We don't have a bedside test at the moment. We don't have treatments really dedicated for negative and cognitive symptoms. So, if that happens—when that happens—we will need tools that we can employ on a bedside basis. Be it something that someone can upload on their smartphone or a test that is not specific for many individual domains but may be somewhat sensitive to picking up the current status and then also the improvement. So, what happens in terms of the trajectory of these problems? Cognition seems to be the first one. If you go back from the first episode and look at school performance, there is a drop-off in adolescence, most likely when the over-pruning occurs.

Because we are born with a lot of neuronal interactions that are driving behavior and impulsivity, we need to be active to run away from threats. But then, as we become adolescents and adults, we should be able to inhibit more. And obviously, only the connections that are used and used for are being kept.

But it seems that in people on the route for schizophrenia and psychosis, there's an over-pruning. And then, negative... symptoms often emerge as part of the prodrome, and that happens before the first episode that we currently define by emergence of positive symptoms.