NP Notes: Overview of Schizophrenia (SCZ Episode 1)

Craig Chepke, MD, DFAPA: Hello and welcome to the Great Exchanges podcast series. My name is Dr Craig Chepke. I'm a psychiatrist in clinical practice at Excel Psychiatric Associates in Charlotte, North Carolina. I'm also the Scientific Director of Psych Congress. And joining me today as a cohost is my friend and colleague, Brooke Kempf.

Brooke Kempf, MSN, PMHNP-BC: Hi, Dr. Chepke. My name is Brooke Kempf. I'm a psychiatric mental health nurse practitioner out of Terre Haute, Indiana, where I'm an adjunct faculty member for Indiana University out of Indianapolis. And I have extensive history working in our community mental health center, and I am on the steering committee for Psych Congress.

Craig Chepke, MD, DFAPA: Well, I'm grateful for you to be joining me today, Brooke. I know you are as passionate about this topic as I am. And today, we're going to focus our discussion on the symptoms, diagnosis, and etiology of schizophrenia. So, I know we could both talk about this for hours at a time, but we're going to try and limit ourselves to about 15 minutes. Is that good with you?

Brooke Kempf, MSN, PMHNP-BC: That's good. I know that's going to be hard for us because we've worked together several times on this issue and we are both very passionate about it.

Craig Chepke, MD, DFAPA: Exactly. So, in terms of the symptoms of schizophrenia, I think our listeners are going to be familiar with the positive symptoms, the delusions or hallucinations that are associated with schizophrenia. But I want to dig in a little bit to the other core symptoms of schizophrenia. Can you tell us about those?

Brooke Kempf, MSN, PMHNP-BC: Sure, and I do, I think they're overlooked, and we shouldn't because they can be very, very impactful. I think a lot of the times, the decreased functioning for our patients is secondary due to some of the cognitive symptoms associated with schizophrenia along with negative symptoms of schizophrenia. So, when I think of negative symptoms of schizophrenia, I think of things that are removed from the patients’ lives. So, just thinking about motivation, just this lack of motivation, enjoyment of things, just the ability to enjoy things like a lot of people do. Decreasing socializing, they're not very social with others and they're not getting out and doing things. But all of these things are not necessarily because they're lazy. It's really, truly a symptom of their illness. Also, just with communicating, it may seem like they're not interested in having a conversation with you because they give these very short one-word answers, but really it is a symptom of their negative symptoms.

Brooke Kempf, MSN, PMHNP-BC: But when it comes to the cognitive symptoms, I kind of relate it to you or I, when we're listening to a lecture or we are supposed to be busy in our clinic during the day. And we just have an off day. And your brain feels foggy, and you can't focus, and you're having trouble saying the things that you want to say. Thoughts aren't organized. That's really what the cognitive impact can have on patients with schizophrenia. Their working memory isn't always the way that it should be. So, their ability to retain information, hear information, organize information so that they need—all those things that they need to do during the day to be organized and follow through with, they just don't always happen. Is there anything that I left out that you can think of that goes along with those?

Craig Chepke, MD, DFAPA: No, I think that was a fantastic in-depth overview. And I love the way that you characterize the cognitive symptoms in terms of what we as average individuals experience, but very briefly, transiently. Maybe if we get a bad night of sleep or if we're overworked and we're stressed and sometimes we can't find the right word to describe something. And that's something that happens for people with schizophrenia, but more consistently and chronically. And more severe and pervasive unfortunately. Yeah, the negative symptoms, definitely I think humans in general have a harder time seeing something that isn't there that's supposed to be there than something that is there that shouldn't be there. And I liken that to tardive dyskinesia versus drug-induced parkinsonism, It's relatively, I think, easier to see tardive dyskinesia because they're movements that are there that shouldn't be there. They're like positive symptoms as opposed to parkinsonism, which while there can be tremor, it’s more characteristic of having a slowing of movements and it's something that isn't there that should be there. That fluidity of movements, the regularity of movements, and we don't notice that as well.

Brooke Kempf, MSN, PMHNP-BC: Great examples.

Craig Chepke, MD, DFAPA: So, in terms of the symptoms of schizophrenia, how do they evolve over time in terms of those three core pillar symptoms?

Brooke Kempf, MSN, PMHNP-BC: Sure. Unfortunately, it is a natural progression of these symptoms to occur. And often, those cognitive and negative symptoms are present prior to the positive symptoms. So, we talk a lot about the prodromal stage prior to the actual diagnosis of schizophrenia. You can often see changes in an individual younger. So, basically going from their baseline level, there may have been some cognitive disturbances when they were earlier in their lifespan. But then, that true prodromal stage where you see this decline maybe in functioning or socializing. So, there's just this influence of negative symptoms and cognitive symptoms that we see prior to then the acute active illness rearing its ugly head with the positive symptoms. And those do unfortunately evolve over time. And then, unfortunately without treatment or when we allow progression to occur, multiple relapses, we can continue to see the etiology worsen and worsen over time due to chronic damage being done by the illness itself.

Craig Chepke, MD, DFAPA: Yeah, there's so many rich items for us to discuss. I mean, that kind of leads into a discussion of diagnosis, as you mentioned. That those negative and cognitive symptoms often precede the positive symptoms, and we really need all of them to make a diagnosis. But when we don't see those things being present, like the sociality and the anhedonia, then we may misperceive that as something else. Because, I mean, statistically schizophrenia is less common in the age group that people usually tend to present with schizophrenia. And so, I see very often people being misdiagnosed with one, two, three or more different psychiatric diagnoses before they finally get to a proper diagnosis. So, tell us about making the diagnosis of schizophrenia, Brooke.

Brooke Kempf, MSN, PMHNP-BC: Oh yeah, you nailed it. I mean, when you think about what does that look like when people are isolating and they're not socializing like they used to? We immediately think, oh, this must be a depressed individual. We label them with some type of mood disorder. And if we really talk—we just have to do a great assessment with the patient and talk to them about mood and is it truly depression? Trying to identify what occurred first, the chicken or the egg, and putting together this basket of symptoms and kind of looking over time. I often look at the genetic influences that impact schizophrenia. I try to get a good family history, see what's going on, get a good timeline of when these events have occurred and what has happened over time. And then, when we truly look at the criteria that we have to meet in order to meet schizophrenia, we want to rule out other things.

Brooke Kempf, MSN, PMHNP-BC: We want to rule out other medical problems that could be existing. We want to rule out substance use. Again, what happened first, the chicken or the egg there? But when it comes down to it, looking at the timeline. So, we know there's this prodromal stage, but symptoms have to be present and persist for at least six months. And so, if it's an acute episode, we might be looking at a brief psychotic disorder. If it happens for less than six months where you're talking about schizophrenia form, if it occurs persistent symptoms for at least a month, then we can start talking about the diagnosis of schizophrenia. But again, it has to include those symptoms of positive symptoms, negative symptoms, and then looking at some of their disorganized behaviors and attitudes going along with that.

Craig Chepke, MD, DFAPA: Yeah, I love the way that you are talking repeatedly about the timeline because I think as a field these days tend to look at just a single snapshot in time. And while we're trying to look for the diagnosis of schizophrenia—do they have these symptoms and those symptoms? But for me, it's the longitudinal course that is so much more important to track. And that goes along more with the historical definitions of schizophrenia. A pioneer by psychiatrists like Emil Kraepelin that initially called it dementia praecox, a premature dementia, focusing on the cognitive symptoms. Eugen Bleuler followed him with talking about the schizophrenias and pioneering the negative symptoms really. And putting those at the forefront and looking at how those evolve over time, to me, is how I try to make the diagnosis of schizophrenia. And I can see you're excited to jump in, too.

Brooke Kempf, MSN, PMHNP-BC: And it can be so difficult though because if you think about the individual that you're trying to have this assessment with and communicate these things, they often don't recognize those own things about themselves. So, trying to get any type of outside input is so beneficial during these times. If you can talk to a mother or a grandmother or an associated loved one that has watched the change occur in their loved one over time, that is just so key and enabling us to get a good look at that timeline.

Craig Chepke, MD, DFAPA: Yeah, and I liked how you added in grandmother, and also it's almost always women. I ask women for family histories.

Brooke Kempf, MSN, PMHNP-BC: You noticed I had that mom, grandma in there.

Craig Chepke, MD, DFAPA: Yeah, very important. I mean, not to diminish the role of men, but women usually have better memories of healthcare and generally, regardless of diagnosis, make more healthcare decisions disproportionately compared to men. But getting a grandmother in there would be fantastic because we don't often get good transmission of psychiatric healthcare data between generations. There's so much stigma in psychiatric diagnoses that it's just not talked about that people can often give very detailed cardiac histories. “Oh, my grandfather had stroke. My grandma had CHF. My mom had a heart attack,” whatever. “What's your family mental health history?” “Oh, I don't know.”

Brooke Kempf, MSN, PMHNP-BC: We don't talk about that.

Craig Chepke, MD, DFAPA: We don't really talk about that in my family. And then, usually what I get is, “But everyone's crazy in my family, doc. All of 'em went crazy.”

Brooke Kempf, MSN, PMHNP-BC: And so, I ask details, “Which one are you most like?”

Craig Chepke, MD, DFAPA: Yeah, that's a great one. But someone like a grandmother might say, oh yes. Well, they might know the word of mouth of what was going on in their generation that didn't pass down to her child and then the child below that. And the wider the net you can cast, the better you're going to try to get some data there. And it may not be a diagnosis of schizophrenia, maybe just that someone was institutionalized at ECT, were on lithium, various things like that that connote a very severe serious mental illness in the family. That might be the best we may be able to get a lot of time. And then, definitely looking at the longitudal course, as you mentioned, and the issue of substance abuse. And we're trying to tease out— you mentioned the timeframe, brief psychotic disorder, schizophreniform, and then also schizophrenia with six months or more, but are there other items that might be on your differential diagnosis?

Brooke Kempf, MSN, PMHNP-BC: Absolutely. Substance use is obviously a huge issue. Rarely do I encounter a patient in my office that hasn't experienced some influence of substance use within there. So, really, we know that unfortunately if they're predisposed for schizophrenia and that can be exacerbated even by something as simple as what they believe— marijuana use being not harmful at all —can actually be impactful when it comes to individuals already predisposed for schizophrenia. So, I really, again, looking at that timeline, try and identify when it comes to substance use, look at when that began. And just ruling out—I really want to find a time period when an individual is not actively using so I can ensure that these symptoms are not associated with some form of substance use. That's probably one of my biggest concerns, particularly working on an inpatient unit when patients come in looking at their urine drug screens, those types of things.

Brooke Kempf, MSN, PMHNP-BC: And then, looking back at the timeline. Okay, this is, they're not behaving this way just because of the impact of substances. They've had these experiences before or they haven't used for quite some time, or they're this way even when they're using and when they're not using. That often comes, but we also have other psychiatric disorders that can have psychotic features. So, patients can become so depressed that they have psychosis. Patients with bipolar disorder can have symptoms of mania in which they become delusional or they hallucinate during those periods. So, really try to identify the key diagnosis. Is this a mood disorder? Is this the primary thing that is there, present the majority of the time, and then psychosis just happens intermittently only when that mood is occurring. Then, I can associate the psychotic features just with a mood episode versus schizophrenia. These symptoms are happening the majority of the time, no matter what their mood is.

Craig Chepke, MD, DFAPA: So, you’re trying to identify a potential cause and effect relationship. Definitely very important. Something else that I really try to do is, and I try to do this with all patients, but I think it's especially helpful here in trying to tease out is this schizophrenia diagnosis? The chicken or is it the egg of the substance use disorder? Is trying to really ally with them and find out, “What is it that you're using this substance for? What does it help you to feel? What are you trying to get out of this?” Because if, let's say they feel uncomfortable around their peers when they never used to, which could be an emergent negative symptoms, and they just want to feel more normal. And they don't want to feel so disconnected from their peer group and that's why they're using marijuana, say. Or they are not being able to achieve because they're having that fuzzy foggy brain, like you described, and maybe they've either been prescribed a stimulant with a presumptive diagnosis of ADHD or this is often occurring in college-age individuals much of the time. And it's really breathtaking how casual stimulants are shared between college students, not for money, not for—just as if they're saying, “Oh, do you want a stick of gum?” is what—I have my college patients tell me that the level of like, “Oh, you've got a paper due? Like, here, have some of my methylphenidate,” or whatever.

Craig Chepke, MD, DFAPA: They don't think of it as a controlled substance that should not be shared technically. Is it legal to do so? They just think, “Oh, I want to do something nice for my roommate or my home mate or my friend,” or whatever with no ill intent, not for any secondary gain. Just yeah, “Well, I've got an extra blanket if you're cold.” That sort of thing. And maybe they're trying to mean really great.

Brooke Kempf, MSN, PMHNP-BC: And then, also then that impacts though too when you're trying to explain a diagnosis to a patient, if they have in the past used a substance and we're talking about an initial diagnosis. We've got that timeline, we've got some genetic history, we're certain what we're dealing with and trying to educate a patient on diagnosis and plan of care. Then they're minimizing, “Oh, no, no, I'm not really ill. I was smoking weed or I used this at a party.” It's got to be just that when we unfortunately have put the puzzle pieces together and are thinking, no, it's probably more than just that.

Craig Chepke, MD, DFAPA: Right. Absolutely. And this is, I think what really clouds our ability to make a good diagnosis early on is not just the stigma, which we've discussed a little bit, but also we're afraid to make the diagnosis, I find in general amongst healthcare providers. One of the titans in the field, Dr. Henry Nasrallah, recently gave an interview for a magazine or newspaper where he called schizophrenia the cancer diagnosis of psychiatry. And I've very often found patients who, to me, clearly have met the criteria for schizophrenia. But it's almost as if the provider has gone out of their way to not diagnose it, as it seems like, as they're afraid of having that conversation, discussing the prognosis with them, something like that. Do you see that as well?

Brooke Kempf, MSN, PMHNP-BC: Oh, absolutely. And not only, you mentioned the cancer diagnosis. Not only are we hesitant to put this label on there, but we're also hesitant when a patient is resistive about that treatment, of emphasizing the need that we need to tackle this like it's cancer. We need to get these symptoms to remission. That is always our goal. I think as providers, we can be okay with patients getting better but not getting well. So okay, well, they're not out there getting in trouble. Their voices have minimized. They're at home alone, but they're not hurting anybody or anything. So, we leave that be. No, we're going to go after those negative symptoms. Let's go after the cognitive symptoms. Let's allow them to be at their full functional ability.

Craig Chepke, MD, DFAPA: So, as often happens when we present or discuss things together, it's almost like you're finishing my sentences, Brooke. Because I agree, I think we need to own that cancer diagnosis because cancer is not homogenous and is not always a death sentence. Many forms of cancer when aggressively treated can have very good prognosis. And so, I like to own that and say, I'm going to act like an oncologist. They go for remission every time. They don't always get it, but that's what they're fighting for and that's what I'm going to go with you. I'm going to try to get you to remission if I possibly can. We're going to do everything in my power to act aggressively, and I want us to really drive after this and do the best we possibly can. I think we all should be doing that.

Brooke Kempf, MSN, PMHNP-BC: Yeah, think about the hope that that gives the patients.

Craig Chepke, MD, DFAPA: Absolutely.

Brooke Kempf, MSN, PMHNP-BC: Versus the stigma that we've placed on this diagnosis of the hopelessness associated with it. When we have effective treatment options and we can explain that and verbalize that to our patients and give them a glimpse of hope, they're more likely to invest in their own treatment and have more positive outcomes.

Craig Chepke, MD, DFAPA: Absolutely. So, we're getting close to our time here, but I want to circle back to etiology just a little bit, and talk to me about neurotransmitter imbalances. And for time purposes, let's just focus on dopamine right now.

Brooke Kempf, MSN, PMHNP-BC: Sure. So, we focused a lot on the dopamine hypothesis for quite some time now when it comes to schizophrenia. So, it's not just too much dopamine, too little dopamine. We have to really look at circuitry when it comes to all of our mental health diagnoses and all of these things that need to work together. But we've primarily identified that there is, when we look at the dopamine pathways, we do believe an excess dopamine in the striatal regions, in the mesolimbic pathway are associated more with the positive symptoms. And then, looking at the hypofunction of dopamine when it comes to the prefrontal cortex and that mesocortical pathway, looking at those being associated with negative and positive symptoms has been probably that primary focus, I believe, in the diagnosis and the treatment when it comes to the treatment of schizophrenia.

Craig Chepke, MD, DFAPA: And then, to bring it back to a longitudinal course and tie that to prognosis. Are we seeing structural changes in individuals with schizophrenia over time?

Brooke Kempf, MSN, PMHNP-BC: Absolutely. So, we know that there were already structural differences in patients with schizophrenia and their brain. And looking at things like ventricle sizes, and then the loss of gray matter and all of these structural changes that are already there to begin with can only continue to worsen as time goes on. We often just talk about brain shrinkage when it comes to unfortunate relapses and prolonging of allowing patients to be ill. I mean, we are causing permanent brain damage whenever we allow patients to stay ill.

Craig Chepke, MD, DFAPA: Yeah, absolutely. And that's really key. I mean, when we talk about other conditions like acute stroke, “time is tissue” is a famous phrase. And we need to think the exact same way about a relapse that includes psychotic features in an individual with schizophrenia. “Time is tissue.” Their brain is on fire at that moment. We need to extinguish it and we need to make sure it doesn't happen again. We don't just go around and every time a fire starts in our home to use a fire extinguisher. We put in sprinklers, we have smoke detectors, we put in place systemic things to try to prevent the next fire. And that's why we need to prevent relapse by any means possible because the best way to avoid that tissue damage is to prevent it from happening in the first place,

Brooke Kempf, MSN, PMHNP-BC: Prevent it. And if it does happen, be sure that we put the fire out completely. We're not going to allow just a little bit of a fire to burn in our house. No. We want it to be put out completely by identifying positive symptoms, negative symptoms, and cognitive symptoms, all. Just allowing those negative symptoms to continue to burn there, as you mentioned, is going to cause ongoing damage,

Craig Chepke, MD, DFAPA: An early aggressive intervention. You don't wait to call the fire department until the house is already burned down. At the first sign of a fire that can't be contained, that's when you call the fire department. So, be aggressive in our treatment with schizophrenia.

Brooke Kempf, MSN, PMHNP-BC: Yes. Can't be afraid to diagnose, can't be hesitant on giving the patient the best treatment options we have available.

Craig Chepke, MD, DFAPA: Absolutely. Well, this has been a wonderful discussion. I could go on all day.

Brooke Kempf, MSN, PMHNP-BC: Yes.

Craig Chepke, MD, DFAPA: But we're going to call it a wrap for this one and look forward to seeing our listeners back for our next episode of this series of the Great Exchanges in schizophrenia.

Brooke Kempf, MSN, PMHNP-BC: Thanks for being with us today.

Brooke Kempf, MSN, PMHNP-BC: It's been a pleasure. Thank you so much.