Schizophrenia

[NeuroKlitch]

What is it about schizophrenia that makes it practically an exclusively psychiatric disease as opposed to having some neurological cross over? Although they are my favorite patients to deal with in all of medicine , what aspect of their treatment makes it so complicated that it is exclusively treated by psychiatrists . I mean no offense by this , but I feel like , the diagnosis is quite straight forward , once you are able to exclude drug tox , mood disorder with psychotic features , or schizoaffective. Is the expertise of a psychiatrist mainly in balancing and dealing with the side effect profiles of the antipsychotic drugs ? Because shouldn't neurologist have atleast some competency of dearling with these drugs due to the large cross over in some neuropsychiatric disorders ?

It seems to me that it's more of an issue logistics . Since it's easier to lock up a decompensating schizophrenic in the psych inpatient wards, as opposed to having them tied down at four points in the general floors.




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[MacDonaldTriad]

I think a neurologist probably could manage our medications fairly well. This isn't an unwillingness on their part, but a recognition that psychiatrists do a lot more than manage medications. There are all kinds of psychoeducational, behavioral, and family interventions that they are uncomfortable with.

 

[Merovinge]

I think a neurologist probably could manage our medications fairly well. This isn't an unwillingness on their part, but a recognition that psychiatrists do a lot more than manage medications. There are all kinds of psychoeducational, behavioral, and family interventions that they are uncomfortable with.

Agree with the latter but I think if you ask most Neurologists their thoughts on precribing Latuda their response would be similar to how comfortable I am prescribing Vimpat.

 

[wolfvgang22]

Yep. We have a collaborative relationship with neurology. I have many patients with a seizure disorder or Parkinson's, who also have depression or psychosis. I generally keep my hands off the Keppra and Dilantin for the most part, and stick to the SSRIs while the neurologist does the opposite. There are a lot of times mood stabilizers are used for seizures and migraines and at the same time I'm treating the patient's Bipolar I Disorder. Yesterday I had a patient with intractable migraines and bipolar and the neurologist called me and we agreed I will trial him on Abilify, because he is low on options for this patients migraines at this point and it's worked before. I am way more used to managing Abilify than he is. There is nothing wrong with a little collaboration with the neurologists, nerdy as they can be.

 

[wolfvgang22]

It's not a disease

Ok, if you're going to be pedantic with students at least teach them the concepts, lol.

 

[MacDonaldTriad]

OK kids, what splik is trying to say I think is that schizophrenia is a Syndrome, and not a disease. Disease have known biological etiologies, or at least we think we understand the mechanisms. We are mostly at the syndrome level in psychiatry because our illness definitions are based on a conglomeration of signs and symptoms.

 

[hamstergang]

Because shouldn't neurologist have atleast some competency of dearling with these drugs due to the large cross over in some neuropsychiatric disorders ?

Where are you seeing neurologists use antipsychotics with any regularity?

Psychiatrists treat schizophrenia because it's classified as a psychiatric condition and other fields haven't stolen it yet. Treating an ear infection isn't difficult but I don't do it because it's not my field. I don't study ear infections, I haven't seen many patients with ear infections across multiple settings in my residency, and I'm not up to date on ear infection treatment. It has nothing to do with how simple or complicated it is.

 

[NeuroKlitch]

Where are you seeing neurologists use antipsychotics with any regularity?

Psychiatrists treat schizophrenia because it's classified as a psychiatric condition and other fields haven't stolen it yet. Treating an ear infection isn't difficult but I don't do it because it's not my field. I don't study ear infections, I haven't seen many patients with ear infections across multiple settings in my residency, and I'm not up to date on ear infection treatment. It has nothing to do with how simple or complicated it is.

I agree , but in my opinion schizophrenia should be a gray area patient , or be classified as a patient in the cross roads of neurology and psychiatry . This whole rant is a mixture of curiosity and my personal frustration that I can't find a happy medium between the two fields to satisfy my love for schizophrenics and the puzzle finding aspects of neurology .


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[HarryMTieboutMD]

What is it about schizophrenia that makes it practically an exclusively psychiatric disease as opposed to having some neurological cross over? Although they are my favorite patients to deal with in all of medicine , what aspect of their treatment makes it so complicated that it is exclusively treated by psychiatrists . I mean no offense by this , but I feel like , the diagnosis is quite straight forward , once you are able to exclude drug tox , mood disorder with psychotic features , or schizoaffective. Is the expertise of a psychiatrist mainly in balancing and dealing with the side effect profiles of the antipsychotic drugs ? Because shouldn't neurologist have atleast some competency of dearling with these drugs due to the large cross over in some neuropsychiatric disorders ?

It seems to me that it's more of an issue logistics . Since it's easier to lock up a decompensating schizophrenic in the psych inpatient wards, as opposed to having them tied down at four points in the general floors.




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This is a conceptual error made by a lot of medical students. Our diagnostic criteria are merely indexes of the illnesses we treat and as Kender has been writing about a lot recently should not be taken for the things themselves. Phenomenology of Schizophrenia and the Representativeness of Modern Diagnostic Criteria. - PubMed - NCBI

Any layperson can memorize "6 months of decline in function with at least one month of the following criteria, one of which must be hallucinations/delusions/disorganized speech) and see how that must differ from other things in the DSM. In reality using our wholly imperfect classification system there are very straightforward cases and a lot of nebulous cases that take a lot of training time and patient exposure to get comfortable diagnosing with some degree of confidence. I have had a lot of affective disorder, unspecified, substance, etc patients where I have had to make a judgment call, and I was informed by my previous patient exposure, teaching from attendings with decades of experience, reading the historical, phenomenologically rich descriptions (Kraepelin), etc.

That said, psychiatric illnesses represent pathology of the non sensorymotor neuronal system (how Danny Weinberger put it to me). You do not have a localizing pathology, but you do have decades of evidence showing a strong genetic risk architecture with a distributed heritability with known risk factors, pretty consistent fMRI and resting state findings (not going to go into the issues with these but I think most of the experts agree on the main findings). In general neurologists HATE antipsychotics except seroquel or clozapine for sinemet/DLB psychosis and homeopathic seroquel dosing for delirium. Titrating antipsychotics is again not that difficult (though plenty of people don't know the literature and screw it up) but there are a fair amount of cases that are very difficult to treat and require some extra thinking and a more-than-superficial knowledge of pharmacokinetics, drug drug interactions, receptor binding, etc.

I agree , but in my opinion schizophrenia should be a gray area patient , or be classified as a patient in the cross roads of neurology and psychiatry . This whole rant is a mixture of curiosity and my personal frustration that I can't find a happy medium between the two fields to satisfy my love for schizophrenics and the puzzle finding aspects of neurology .


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[deleted736562]

That said, psychiatric illnesses represent pathology of the non sensorymotor neuronal system (how Danny Weinberger put it to me). You do not have a localizing pathology, but you do have decades of evidence showing a strong genetic risk architecture with a distributed heritability with known risk factors, pretty consistent fMRI and resting state findings (not going to go into the issues with these but I think most of the experts agree on the main findings). In general neurologists HATE antipsychotics except seroquel or clozapine for sinemet/DLB psychosis and homeopathic seroquel dosing for delirium. Titrating antipsychotics is again not that difficult (though plenty of people don't know the literature and screw it up) but there are a fair amount of cases that are very difficult to treat and require some extra thinking and a more-than-superficial knowledge of pharmacokinetics, drug drug interactions, receptor binding, etc.

This is what it mostly comes down to. Traditionally, neurologists have occupied themselves with diseases with gross lesions in the nervous system. In schizophrenia, these are not easily observable so neurology shys away. It does not mean that psychotic disorders are not "diseases". It just means we haven't as of yet figured out the etiology (ies). Our theoretical understanding remains remarkably poor; there are actually barely any meaningful theories, nevermind if they are proven right or wrong. This is, I believe, the next frontier. Mining data is nice if you can tie it to certain outcomes but it won't really help you putting out a coherent theory.

Pretty consistent fmri and resting state findings is definitely something I disagree with. If there's anything consistent is that findings certainly pertaining to schizophrenia have been really inconsistent. The only possibly consistent finding is thalamocortical disconnections but the jury is still out on this one.

 

[WingedOx]

This is what it mostly comes down to. Traditionally, neurologists have occupied themselves with diseases with gross lesions in the nervous system. In schizophrenia, these are not easily observable so neurology shys away. It does not mean that psychotic disorders are not "diseases". It just means we haven't as of yet figured out the etiology (ies). Our theoretical understanding remains remarkably poor; there are actually barely any meaningful theories, nevermind if they are proven right or wrong. This is, I believe, the next frontier. Mining data is nice if you can tie it to certain outcomes but it won't really help you putting out a coherent theory.

Pretty consistent fmri and resting state findings is definitely something I disagree with. If there's anything consistent is that findings certainly pertaining to schizophrenia have been really inconsistent. The only possibly consistent finding is thalamocortical disconnections but the jury is still out on this one.

Plus, medical students come into the field of psychiatry with this belief that all of this cutting-edge revolutionary technology is just around the corner to transform the field... biomarkers, advanced neuroimaging, etc. In truth, while there's some cool research being done in labs out there, I'm not expecting much of any of it to ever filter down here to the clinical trenches during my lifetime, and I'm young. Some of the drugs have marginally improved over time, but we're still practicing the same way we've been doing it for decades, and that involves making assessments based on what you see and hear right in front of you.

I've seen stuff come through like that genetic test that's supposed to determine the best antidepressant for you, but I haven't seen much evidence toward its validity, and the couple times I've seen patients get it done my response is something along the lines of "well, the test recommended a med that's still on-patent and has a $50 co-pay. How about we start you on some $4 sertraline plus some CBT for those nasty cognitive distortions... plus some social work help given it seems you're in an abusive relationship."

Hell, it's only a little hyperbolic to say that all those fMRI studies are less likely to affect me in clinical practice down the line than the "hey, let's pump some people full of ketamine and see what happens" studies out there.

 

[clausewitz2]

Hell, it's only a little hyperbolic to say that all those fMRI studies are less likely to affect me in clinical practice down the line than the "hey, let's pump some people full of ketamine and see what happens" studies out there.

Given that intranasal esketamine is starting Phase III trials at this very moment for TRD, I think the smart money is on this being available as a treatment option before we are very far into the 2020s.

 

[SeniorWrangler]

As someone who spends a lot of time on the neurology side of the house, I will say that neurology is a *lot* more rooted in brain science than psychiatry, and not for lack of trying by psychiatrists. There is really interesting work being done with identifying specific genetic abnormalities that cause specific channelopathies in specific (very rare) familial forms of epilepsy, and sometimes even treating otherwise untreatable seizures based on this knowledge of specific channel abnormalities.
There's *nothing* like that in schizophrenia research.

 

[Merovinge]

As someone who spends a lot of time on the neurology side of the house, I will say that neurology is a *lot* more rooted in brain science than psychiatry, and not for lack of trying by psychiatrists. There is really interesting work being done with identifying specific genetic abnormalities that cause specific channelopathies in specific (very rare) familial forms of epilepsy, and sometimes even treating otherwise untreatable seizures based on this knowledge of specific channel abnormalities.
There's *nothing* like that in schizophrenia research.

What? There is exactly that kind of research being done in schizophrenia and there are specific genes that have been found (including a dopamine receptor gene) that convey huge vulnerabilities to schizophrenia. Autism is similarly getting a ton of genetic studies being done with increased research funding. Our illness tend to be more polygenic than Neurology which means the research is more difficult and requires large samples of complete coding sequence genomes but it absolutely is getting done in psychiatry.

 

[deleted736562]

Plus, medical students come into the field of psychiatry with this belief that all of this cutting-edge revolutionary technology is just around the corner to transform the field... biomarkers, advanced neuroimaging, etc. In truth, while there's some cool research being done in labs out there, I'm not expecting much of any of it to ever filter down here to the clinical trenches during my lifetime, and I'm young. Some of the drugs have marginally improved over time, but we're still practicing the same way we've been doing it for decades, and that involves making assessments based on what you see and hear right in front of you.

I've seen stuff come through like that genetic test that's supposed to determine the best antidepressant for you, but I haven't seen much evidence toward its validity, and the couple times I've seen patients get it done my response is something along the lines of "well, the test recommended a med that's still on-patent and has a $50 co-pay. How about we start you on some $4 sertraline plus some CBT for those nasty cognitive distortions... plus some social work help given it seems you're in an abusive relationship."

Hell, it's only a little hyperbolic to say that all those fMRI studies are less likely to affect me in clinical practice down the line than the "hey, let's pump some people full of ketamine and see what happens" studies out there.

I'm actually rather optimistic about the prospects of translating fmri findings into the clinic. There is already some very interesting work being done: http://www.nature.com/nm/journal/v23/n1/full/nm.4246.html . I don't think though they will answer really critical questions about pathophysiology but more so for providing a wealth of data that can be useful in classification and prediction of response with the help of machine learning. The field has been surprisingly limited due to studies of poor quality (small sample sizes and findings that are not validated in independent samples, even though resting state fmri has been here for the better part of a decade). Only recently there has been a concerted effort towards wide scale collaboration, studies in samples of 100s rather than 10s and validation in independent samples. But for the more critical questions about pathophysiology, I think without a good understanding of much, much more basic processes, this will likely remain elusive. As Chomsky once put it, we can't even understand why a cockroach turns right or left.

 

[WingedOx]

Given that intranasal esketamine is starting Phase III trials at this very moment for TRD, I think the smart money is on this being available as a treatment option before we are very far into the 2020s.

Back in residency I had a long-term patient of mine participate in the trial for IV admin of one of the ketamine analogs...without telling me for like 6 months of course. One of those research studies that advertises for participants on the subway. It seemed she was in the placebo group based on her experiences with it, though I found her selection as a patient to be highly questionable based on the criteria they listed.

 

[smalltownpsych]

I think one thing that the OP is missing is that psychiatrists need to have training on how to work with psychotic individuals (as well as the rest of the people we work with that the rest of the hospital doesn't like); whereas, I don't think neurologists have to do much of that. In fact, if a patient is exhibiting any type of clinically significant cognitive, affective, or interpersonal difficulty who do you think the neurologists refer them to? Either me or a psychiatrist or both.

 

[WingedOx]

I think one thing that the OP is missing is that psychiatrists need to have training on how to work with psychotic individuals (as well as the rest of the people we work with that the rest of the hospital doesn't like); whereas, I don't think neurologists have to do much of that. In fact, if a patient is exhibiting any type of clinically significant cognitive, affective, or interpersonal difficulty who do you think the neurologists refer them to? Either me or a psychiatrist or both.

Yeah, one thing a family member, who's in an unrelated health care discipline asked me when I decided to go into psych was if I worried if neuro was one day going to "take over" psychiatry and cannibalize the field. To the uninitiated that's a reasonable question, but it's one that's easily answered by asking a room full of neurologists "Hey, how many of you want to see more psych patients!?"

 

[WingedOx]

I'm actually rather optimistic about the prospects of translating fmri findings into the clinic. There is already some very interesting work being done: http://www.nature.com/nm/journal/v23/n1/full/nm.4246.html . I don't think though they will answer really critical questions about pathophysiology but more so for providing a wealth of data that can be useful in classification and prediction of response with the help of machine learning. The field has been surprisingly limited due to studies of poor quality (small sample sizes and findings that are not validated in independent samples, even though resting state fmri has been here for the better part of a decade). Only recently there has been a concerted effort towards wide scale collaboration, studies in samples of 100s rather than 10s and validation in independent samples. But for the more critical questions about pathophysiology, I think without a good understanding of much, much more basic processes, this will likely remain elusive. As Chomsky once put it, we can't even understand why a cockroach turns right or left.

This is the type of thing that really doesn't help my skepticism though. (admittedly now that I'm at home, I've lost access to the paper). I'm not saying research like this doesn't produce a lot of interesting or fascinating data. It's just how useful that data actually is in terms of treatment both in theory and in practice is pretty questionable. So we have a maybe on TMS susceptibility that could theoretically tell us if a third line treatment might work for a patient, but there are plenty of other variables at play there. If it actually could work in practice is another thing entirely. I mean, in theory GeneSite should work and revolutionize the way we do things. In practice, we've got a lot of anecdotes, good and bad without any real independent data besides the balance sheets of the company that produces it.

We have a lot of reasons why we fail to get the outcomes we want in psychiatry. Inadequate technology is way down the list.

 

[hamstergang]

"schizophrenia" (which doesn't exist).

Schizophrenia, the psychiatric disorder being referred to in this thread, most certainly exists. You saying otherwise without explanation offers no value to this thread.

 

[Armadillos]

This is the type of thing that really doesn't help my skepticism though. (admittedly now that I'm at home, I've lost access to the paper). I'm not saying research like this doesn't produce a lot of interesting or fascinating data. It's just how useful that data actually is in terms of treatment both in theory and in practice is pretty questionable. So we have a maybe on TMS susceptibility that could theoretically tell us if a third line treatment might work for a patient, but there are plenty of other variables at play there. If it actually could work in practice is another thing entirely. I mean, in theory GeneSite should work and revolutionize the way we do things. In practice, we've got a lot of anecdotes, good and bad without any real independent data besides the balance sheets of the company that produces it.

We have a lot of reasons why we fail to get the outcomes we want in psychiatry. Inadequate technology is way down the list.

I can't claim to understand anything at all about the brain imaging methodology in that paper, but I've been pretty pumped up for the future ever since I saw it a few months back. IIRC the TMS remission rates for the different bio types was something like 20-30% to 70-80% which is a massive finding in my opinion if it's reliably reproduced.

 

[Salpingo]

What is it about schizophrenia that makes it practically an exclusively psychiatric disease as opposed to having some neurological cross over? Although they are my favorite patients to deal with in all of medicine , what aspect of their treatment makes it so complicated that it is exclusively treated by psychiatrists . I mean no offense by this , but I feel like , the diagnosis is quite straight forward , once you are able to exclude drug tox , mood disorder with psychotic features , or schizoaffective. Is the expertise of a psychiatrist mainly in balancing and dealing with the side effect profiles of the antipsychotic drugs ? Because shouldn't neurologist have atleast some competency of dearling with these drugs due to the large cross over in some neuropsychiatric disorders ?

It seems to me that it's more of an issue logistics . Since it's easier to lock up a decompensating schizophrenic in the psych inpatient wards, as opposed to having them tied down at four points in the general floors.




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Neurology is typically about finding the lesion, presuming the nervous system is a well-organized network that has been disrupted at discrete points, which can then by clarified. Then dowsing everything in steroids.

Psychiatry is about... Well, I'm not really sure what psychiatry is about.

And that's why we treat schizophrenia.

But in all seriousness, schizophrenia shouldn't be associated with either specialty. Think about autism, which involves behaviorists, psychologists, geneticists, developmental specialists, family interventionists, occupational therapists, etc. MDs are actually on the periphery (at least where I am), called in to help manage medications when necessary, or treat associated conditions, but not truly running the show. Schizophrenia as a psychiatric disorder is a holdover from the days when we mainly existed to run asylums.

 

[SeniorWrangler]

Nobody else wants a piece of schizophrenia; it is the ultimate psychiatric diagnosis, whatever its ontological status.

Part of the reason doctors are somewhat marginalized in autism care is that we don't have any nifty billion-dollar "anti-autism agents" that can be injected, infused, or fed to autistic kids. Once something is developed, the laws of commerce will ensure that autism centers will pop up like mushrooms all over the land.

 

[Salpingo]

Nobody else wants a piece of schizophrenia; it is the ultimate psychiatric diagnosis, whatever its ontological status.

Part of the reason doctors are somewhat marginalized in autism care is that we don't have any nifty billion-dollar "anti-autism agents" that can be injected, infused, or fed to autistic kids. Once something is developed, the laws of commerce will ensure that autism centers will pop up like mushrooms all over the land.

We have medications to treat agitation in autism, and they come in long term injectable form as well, with as much evidence to back their use as anything we have for schizophrenia. The difference is that there are more parents advocating for something better, celebrities getting on TV to advocate the cause, centers being formed, etc. It helps that the symptoms present at an age when more interventions are available...

 

[SmallBird]

It's not a disease

To the extent that schizophrenia is used to describe an illness of late-adolescent/early adult onset characterized by psychotic symptoms with significant social impairment that is responsive to antipsychotics and family based interventions, it is more like a disease than some other psychiatric conditions. It may be heterogenous in prognosis but so are other diseases.

 

[thoffen]

Diagnosing a person with schizophrenia correctly and choosing a high quality medication regimen are not skills that other practitioners can't easily learn.

But then again how about all the people with psychosis who don't have schizophrenia? Not that this is an area of strength for many psychiatrists either.

But, as said, the choice of good medicine for schizophrenia is a piece of treatment only, and not very often the most important piece.