Podcast: Recognizing and Treating Bipolar Disorder and Schizophrenia

Jeff talks to Dr. Kathryn Eve Lewandowski about both schizophrenia and the different types of bipolar disorder. Eve shares overviews on both disorders, tips for spotting their signs and seeking treatment, and answers audience questions about successfully supporting someone living with these conditions.

Kathryn Eve Lewandowski, PhD, is the director of clinical programming at McLean OnTrack™, a program for young adults in the early stages of psychotic disorders. She is also a member of the International Society of Bipolar Disorders (ISBD) Targeting Cognition Task Force and the International Consortium Investigating Cognition in Bipolar Disorder (ICONIC-BD).

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for yet another episode of our educational webinar series.

Today we’re going to focus on not one but two mental health conditions: bipolar disorder and schizophrenia. While they are very distinct conditions, both are complex and often misunderstood, and sometimes one is confused for the other.

So we thought we’d take some time today to provide an overview of both schizophrenia and bipolar disorder and share some tips for spotting their signs and exploring their treatment options.

We also know that you have lots of questions, so we have brought in an expert to answer them. Dr. Kathryn Eve Lewandowski is the Director of Clinical Programming at McLean OnTrack, a program for young adults in the early stages of psychotic disorders.

She is also an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. Eve, thanks so much for taking some time for us.

Eve:Thanks so much for having me. I’m glad to be here.

Jeff: We’re thrilled to have you with us. We have a lot of ground to cover today.

So before we get into some of the confusion between bipolar disorder and schizophrenia, I think it might make some sense to review some of the basic elements of each condition.

Let’s start with bipolar disorder. Can you give us a working definition?

Eve: Sure. So when we talk about bipolar disorder, we’re often kind of thinking of bipolar I disorder.

There’s actually, we kind of refer to bipolar disorder as the bipolar disorders ‘cause there are a few different ways that these illnesses can manifest, but the kind of hallmark of bipolar I disorder is that someone has experienced an episode of mania.

So this is people who experience a persistent, significant elevation in mood. They might feel euphoric. Alternatively, they might feel revved up but irritable. So mania doesn’t always look like something where people feel great. Sometimes people are very energetic, but in a kind of irritable, agitated way.

Another symptom of mania is a decreased need for sleep. So people may suddenly be sleeping a lot less than usual, by several hours a night, but not feel tired. So they get up and they’re ready to go. People often talk about having racing thoughts or they might be talking very quickly.

Sometimes people say it’s hard to keep up with their thoughts. They’re flying so quickly through their minds, and then another thing that we see with mania is people having this increase, what we call an increase in goal-directed behavior.

So they might be doing a lot of stuff more than usual. They might be staying up late working on, you know, writing a book or, you know, starting a robotics club or, you know, things like, these are the types of things that people often do.

But they can also be involved in risky behaviors, so driving too fast, driving under the influence, risky sexual behaviors that are out of character for someone.

And when these symptoms go on for a week or longer, then we would say that that person is in a manic episode, and if you’ve had a full manic episode, then that would potentially meet criteria for bipolar disorder.

Jeff: You mentioned bipolar I versus bipolar II. Do people shift from one to the other? Is there overlap between the two?

Eve: So typically if someone has had a diagnosis of bipolar I disorder, they would always carry that diagnosis unless new information came to light. So the difference between these two disorders is that in bipolar I disorder, someone’s had a full-blown manic episode that would meet criteria for full mania.

In bipolar II disorder, someone has had depressive episodes but may have had a hypomanic episode. So that’s manic symptoms that don’t quite reach the severity or duration of a manic episode.

So they’ve had the sort of elevated mood, you know, or a decreased need for sleep, but they never met criteria for mania. So that’s really the differentiation between these two.

Jeff: By way of perspective, what do we know about the prevalence of these two forms of bipolar disorder?

Eve: Yeah, this is a great question. So they’re actually a lot more common than I think people realize.

So for bipolar I disorder, there’s a worldwide prevalence rate of 3%. So 3 in 100 people will meet criteria for bipolar disorder at some point in their lifetime. So these are, you know, relatively common.

Jeff: And what do we know about causes?

Eve: So that’s a tricky one. You know, people, there’s no clear cause. There’s some evidence from genetic studies and also from family studies that there’s some degree of genetic or inheritance that’s related to bipolar disorder.

So if you have a close relative who’s been diagnosed, you’re more likely to experience bipolar disorder, but it’s not 100% or anywhere close to it. So we think it’s probably a combination of genetic and other biological factors together with environmental factors that contribute.

Jeff: How about signs and symptoms? We’ll get into the specific diagnostics from a professional standpoint in a moment here, but what about just some of the flags, if you will, that come up that people might spot?

Eve: Yeah, so I think some of the things that become kind of a red flag for people like relatives or friends would be a change, like a noticeable change in someone’s behavior. So if they’re suddenly very euphoric, they’re- or very irritable in the sort of agitated kind of way, revved up.

People often refer to someone as seeming like really revved up or almost like they’re driven by a motor. If people are talking a lot faster than normal, if they’re starting to say things that maybe don’t quite make sense, if they’re suddenly not sleeping, those would be signs that someone might want to check in with a treatment provider.

Jeff: And talk, if you would, Eve, about the official diagnostic process that takes place in a clinician’s office, for example.

Eve: Yes, so the gold standard for diagnosing bipolar disorder, really any psychiatric condition, would be an interview using a structured interview measure. So this might be something like the Structured Clinical Interview for the DSM, which is our kind of diagnostic tool.

And we would just ask people questions about the symptoms that we just reviewed about euphoria, about irritability, sleep, racing thoughts. Sometimes people with mania also experience psychosis.

So these are thoughts or perceptions that are kind of not in line with what the rest of us experience as a reality, so hearing or seeing things other people can’t, having beliefs that don’t really line up with what we would think of as being kind of reality based.

So those might creep into the picture too when someone’s experiencing a more severe depression or a manic episode, and then we would also, one of the things, so I’ll just sort of take a sidestep really quick if that’s okay.

Jeff: Sure. Of Course.

Eve: One of the things about diagnosing mood disorders is the first thing we’re diagnosing isn’t a disorder itself but the presence of mood symptoms that reach the threshold for a mood episode. So were they severe enough, did they go on long enough, and did they cause distress or impairment?

And so we would go through the diagnostic criteria for a manic episode, and if the person had severe enough symptoms that lasted a week or longer and caused distress or impairment, then they might meet criteria for mania, and then we would do the same thing for depression.

So we would go through the diagnostic criteria for depression. In the case of a depressive episode, that would need to last most of the day almost every day for two weeks or more, and if they met that threshold, then we would diagnose a depressive episode, and then it’s the sort of relative ratio of mania, depression and psychosis that would get us to a final diagnosis.

Jeff: So one of our goals for this webinar series, as you know, Eve, is to weave in as many audience questions as we can. I suspected we were going to get a lot of questions on this topic today, and we are indeed.

You’re going to be very busy. So let me start by working in a couple of questions that have to do with diagnosis of bipolar disorder. Can someone have a manic episode but not warrant a bipolar diagnosis?

Eve: That is a very good question. So technically no, and the reason is if someone can have manic symptoms and not get a bipolar disorder diagnosis, but if we go through the criteria and there are severe enough symptoms that lasted for a week or longer and caused significant distress or a lot of problems for someone.

If they got into trouble with the law or they got into a fight or something like that, then they would meet criteria for a manic episode, and that would, then the person would meet criteria for bipolar disorder. There’s a unless piece, but I’ll get to that when we talk about schizophrenia.

Jeff: Very good, and a question about vernacular as well because obviously these terms are precise and they do matter. How to distinguish between manic and hypomanic episodes?

Eve: Yes, this is a really good question. So in a hypomanic episode, someone will have experienced multiple symptoms of mania, but either they didn’t quite rise to the level of severity of a full manic episode or they might not have caused any problems for the person.

So we actually talk about the fact that many CEOs of Fortune 500 companies have hypomania. So in these cases, they’re very energetic, they have a lot of ideas, they may not need a lot of sleep at periods of time, but it’s not causing them any trouble, and so if there’s no distress and it’s not causing impairment, then we wouldn’t diagnose a manic episode.

The key differential is that in a hypomanic episode, those symptoms are a marked change from the person’s baseline. So if someone’s just always super high energy, we wouldn’t diagnose even a hypomanic episode because it’s just their personality organization.

So this would be that someone has a period of time distinct from their baseline behavior where they’re a little bit revved up, they’re a little bit elevated, but it’s not causing trouble for them, but it’s a noticeable change.

Jeff: A viewer would like me to ask you, how can family members better understand when their loved one is going through a manic episode?

Eve: That’s a great question, and it’s harder than it seems like maybe it would be. I would say that if someone is having trouble, like if they’re not engaging in social relationships or work or school in an effective way or they’re doing risky things, that’s definitely time for, you know, an intervention with a healthcare provider.

But you might notice that someone’s starting to feel a little bit elevated or they’re starting to sleep a little bit less than normal. That might be a good time just to sort of check in and see if we can kind of reverse course before the symptoms get progressively worse, and we’ll talk a little bit about that, I think, later when we talk about treatment.

Jeff: Definitely, and in fact, that’s a perfect segue here ‘cause we will circle back to questions about symptoms and signs and diagnostics and so forth, but let’s talk about BD treatment. What is the gold standard? What does that look like?

Eve: Yes, so medication is usually a first-line treatment for people with bipolar disorder, at least to stabilize symptoms. We do know that some people aren’t on medication forever and are able to kind of taper off of medication, but some people will need to be on medication longer-term.

So those are typically mood-stabilizing medications, and if people have had psychotic symptoms, they may take an antipsychotic along with that, but there are a lot of non-pharmacological interventions that are effective for bipolar disorder as well, so individual and group therapy. Cognitive behavioral therapy is an effective treatment.

Psychoeducation can be really important, just understanding what are the kind of warning signs that you might be getting depressed or might be getting manic. How do everyday things like exercise, sleep schedules, you know, nutrition, how do those things play into maintaining mood stability over time?

Jeff: Is this treatment done both as an inpatient and an outpatient process?

Eve: Yes. Yes. So in inpatient, typically the symptoms have gotten severe enough that someone needs kind of more acute care, and the goal there is really stabilization, but then sometimes people will step down to, like, a partial hospital program where they can learn skills and, you know, continue getting more intensive care and then outpatient services as well.

But some people don’t ever need to have an inpatient admission. Sometimes these illnesses can be managed in an outpatient setting.

Jeff: Speaking of managing the disorder itself, what can somebody expect in terms of a long-term life with bipolar disorder? What does that look like, and can someone thrive and maintain a job and all that?

Eve: That is a great question. So the short answer is absolutely. So we see this all the time, that people find a treatment regimen that works really well for them.

They do all the things that they need to do to maintain stability, and, you know, one of our main goals as clinicians is to get people back doing the things that make life meaningful for all of us, you know, engaging in work and school, you know, building and maintaining social relationships, hobbies and leisure activities and independence.

And that is absolutely very possible for people with bipolar disorder. There is a lot of heterogeneity in bipolar disorder, and one of the gaps I think in care is that not everything works for everyone at every time.

And so figuring out how to better personalize treatment so that we have a better sense of what will work for any given person at any given point in their illness course is something that, you know, we’re actually really actively working on at this moment, so yeah.

Jeff: Let me ask one very specific question on behalf of somebody in the audience. Would you suggest using the Mood Disorder Questionnaire not for diagnosing bipolar disorder but just as a starting point for assessment?

Eve: Oh yeah, that’s a very good question. Yes, I actually think that using questionnaires, sort of standardized instruments to better understand how people are feeling at any given moment is important.

You know, one of the tricky things about bipolar disorder is that by its nature, it’s sort of a fluctuating illness, and so sometimes people feel fine. Sometimes people are depressed. Sometimes people are, you know, getting a little bit revved up, and it can be really helpful to track that information over time.

One of the things that we’re doing across the Mass General Brigham system, but I actually have a project starting up that’s trying to implement this more in a widespread way, is collecting patient-reported outcome measures.

So that would be things like short surveys that people can access on Patient Gateway or it can be emailed to people that would ask about, you know, today, how is your mood, how is your anxiety?

And then we can actually track those things graphically over time and see, you know, what does this look like and how can that help inform the care that we’re providing and people’s own understanding of their own symptoms.

Jeff: We’re getting flooded with questions for you, and we’re going to do our best to get as many of those questions to you as we go along here, but I do want to shift gears and talk about the other disorder that we want to focus on today, and that’s schizophrenia.

Again, walk us through the basics here, starting with a working definition.

Eve: Yes, so schizophrenia is a disorder that’s characterized by people having episodes of psychosis, and that can look, so there are a number of different kind of symptoms that we evaluate when we’re assessing for psychosis.

So people may have delusions. So these are beliefs that aren’t really clearly founded in reality, and those may be like suspicious paranoid delusions or, you know, grandiose delusions, things like this.

There’s also hallucinations, which are unusual perceptual experiences, and that can be in any sensory modality. The most common ones are auditory hallucinations, so hearing voices or noises that aren’t there, but people can also have visual hallucinations.

You can have tactile hallucinations, so feeling things in your body or on your skin that aren’t there, and then hallucinations related to taste and smell as well. So those are the symptoms that we think of most commonly in schizophrenia.

Those are the symptoms that tend to bring people to the attention of treatment providers because they can be quite noticeable and pronounced and interfere with people’s behavior, but other common symptoms of schizophrenia include negative symptoms.

So that’s sort of a weird term. It’s not meant to be a judgment call there. It just means the absence of experiences that people normally have, so loss of motivation, loss of interest or pleasure in things that people would normally enjoy. People might have sort of very flat affect or flattened expressivity.

So those are kind of lumped in as negative symptoms, and then people can also have cognitive and disorganized symptoms. So people experience impairment in memory, attention, concentration, that kind of thing.

That’s a very common symptom in schizophrenia, but also disorganized thinking and behavior, so thoughts that just don’t quite fit together and behavior that seems bizarre or erratic, and so those things together are all the kind of diagnostic criteria for schizophrenia.

Jeff: What about prevalence for schizophrenia?

Eve: It’s also more common, I think, than people realize. So about 1% of the population will have a diagnosis of schizophrenia, so about 1 in 100 people.

Jeff: Okay, and any word on causes from the research world at this point?

Eve: Similar to bipolar disorder, we don’t know exactly what causes schizophrenia. There’s some good evidence that there’s a genetic component both in terms of genome-wide association studies but also family studies where schizophrenia tends to co-aggregate in families.

But again, like bipolar disorder, these are, you know, not 100% explanatory in terms of schizophrenia. So we think that this is probably a combination of biological, psychological, and sort of environmental factors.

Jeff: Okay, and what should we know about treatment, Eve?

Eve: So the primary treatment for schizophrenia is antipsychotic medication. These can be very effective for a lot of people in bringing symptom levels down, but they often don’t eradicate symptoms altogether.

So people can have these sort of low-level residual symptoms, and they’re not very good at treating some types of symptoms. So they’re not good at treating cognitive impairments, and they’re not good at treating those negative symptoms, so lack of motivation and anhedonia.

So we also really recommend the use of kind of what we term coordinated specialty care at OnTrack. So this is individual and group therapy using things like CBT for psychosis. Acceptance and commitment therapy is actually very good for people with psychosis.

We do wellness groups, and I’m very happy to say we work with a couple of certified peer specialists who do a lot of really important work in providing support services to people at our program, and I think that’s getting kind of more and more baked into clinical programming, which is wonderful.

Jeff: And again, in terms of prognosis, you’re seeing people thrive with schizophrenia in the long haul as well?

Eve: Yes, absolutely. So we see people who recover and who are able to go back to work and school, enjoy social relationships, live independently, and it’s wonderful. So there’s a lot of hope and a lot of room for optimism. Just like bipolar disorder, it’s very heterogeneous in terms of its course, and not everyone responds to treatment as robustly as other people.

So it can be a tough road, but there’s a lot of reason to believe that people can meet their recovery goals and, you know, have the things in life that make us get out of bed in the morning.

Jeff: We have a lot of terms floating around today, and questions have come in about schizoaffective disorder. What should we know about that term and what specifically it refers to?

Eve: Yes, this is a great question. So I alluded to this a little bit earlier. So schizoaffective disorder refers to someone who has met criteria for schizophrenia but also has significant severity and duration of mood symptoms.

So you can have schizoaffective disorder depressive type and, excuse me, it’s a tongue twister, schizoaffective disorder bipolar type.

So if someone has met criteria for having a manic episode and their mania or depression has lasted for a significant proportion of the time that someone has also had psychotic symptoms, then they might meet criteria for schizoaffective disorder, in which there’s both prominent mood symptoms and prominent psychotic symptoms.

Jeff: So to put a finer point on this, I think our viewer asked a question that does just that. Can you discuss the differentiation between a bipolar diagnosis with psychosis and schizoaffective disorder with a mood component? Is the treatment for those two different?

Eve: This is a great question. This is super tricky. We do, as sort of a sidebar, a lot of our research projects involve conducting these diagnostic interviews just to better understand what people’s experiences are, and this distinction between bipolar disorder with psychosis and schizoaffective disorder bipolar type is very tricky, even for seasoned clinicians.

The main distinction I think is which word comes first. So if the mood piece comes first, it’s probably because someone has had more significant mood symptoms or longer duration of mood symptoms than psychotic symptoms.

So with someone who has bipolar disorder with psychosis, for example, they would have spent more time having manic and depressive episodes, and they may only experience psychosis in the context of a mood episode.

So they don’t experience psychotic symptoms in between mood episodes as often, and then the reverse being true for schizoaffective disorder, so the psychotic symptoms occur even in the absence of mood symptoms, and they’re kind of what we would think of as like the primary presenting symptoms.

Jeff: It sounds to me like it takes a specialist to be able to tease out a little of what’s what with all of this. I know we have a lot of clinicians on these webinar calls.

What do you want them to know in terms of when it makes sense for them to refer out and when it makes sense for them to treat themselves?

Eve: Yeah, this is a great question. I mean, I think that there are, these are tricky illnesses even for people in specialty clinics to kind of tease apart, but actually circling back to your last listener’s question, the treatments aren’t always dependent upon these sort of fine-grained distinctions and diagnosis.

So if someone’s experiencing psychotic symptoms and they’re experiencing manic symptoms, you know, the medication regimen that someone gets put on might at least start off the same regardless of what you call that illness.

So I think in pragmatic terms, these sort of finer-grained distinctions don’t always have a huge influence over the course of treatment or at least the starting point for intervention, but I would say, you know, and this is true for myself too, you know, it never hurts to get a consult.

It never hurts to refer to kind of a specialty clinic if things are murky and you could benefit from a little bit more information. We do this kind of stuff a lot at OnTrack because people often come in with sort of a confusing constellation of symptoms, and we want to make sure that we’re understanding things correctly.

My advisor used to say, “If you’re a hammer, everything looks like a nail.” So we want to make sure that we’re not, you know, hammering away at something when it could be better understood in a different way.

Jeff: Wise words indeed. A viewer wants to know what is the earliest age of onset for schizophrenia.

Eve: So we would consider early onset as being sort of pre-adolescent. So during childhood, those are more unusual. So the typical age of onset is usually in adolescence and early adulthood. Sometimes we talk about clinical high risk for psychosis.

So those would be young people who are experiencing what might be emerging psychotic symptoms, and they’ve also experienced a decline in functioning, but they don’t meet criteria for psychosis yet. So that typically occurs at a little bit of an earlier age.

We have a clinical high risk clinic at McLean now that sees young people around ages 12 to 18 or maybe older but with these sort of questionable emerging psychosis symptoms, and one of the aims there is to make sure that we have eyes on people as soon as possible so that if the psychosis does progress, that we can, you know, start treating as soon as we can.

Jeff: In terms of who is at risk, is schizophrenia more prevalent in men or women?

Eve: Yes, that’s a good question. So it’s somewhat more prevalent in men. It tends to occur earlier in men than in women and can be somewhat more severe in men than in women. So there does seem to be kind of a gender effect in schizophrenia.

Jeff: All right, let’s start talking about some of the confusion between these two disorders and others. Is it possible to morph from one to the other, if you will? Can you start with bipolar disorder and wind up being diagnosed with schizophrenia or vice versa?

Eve: Yes. Yes. This is a very good question, and the answer is yes, and we see this happen a lot. So the distinction between these diagnostic categories is often one of, is sort of a, or excuse me, a quantitative distinction.

So these are the relative amount of time over the course of the illness that people have experienced mood symptoms versus psychotic symptoms, and that can definitely shift over time. So we do see diagnostic changes over the course of illness.

Jeff: Can you speak to the connection between trauma and bipolar disorder or schizophrenia?

Eve: Yes. So we know that people with both bipolar disorder and schizophrenia have higher rates of childhood trauma than the general population. There seems to be a connection between the experience of trauma and the onset of these illnesses, even if it’s sort of years later.

We also know that people with schizophrenia are more likely to be victims of violent crimes and violent incidents than the general population, which can worsen symptoms as well.

And the mechanism is not into entirely clear, like how do these things relate, but some people are thinking it may have to do with, like, stress and inflammation and brain development and that kind of thing, so.

Jeff: We’ve had several questions come in about BPD, borderline personality disorder. How does BPD differentiate itself from bipolar disorder? What should we know about that distinction?

Eve: Yeah, yeah, so these can actually be hard to differentiate sometimes. It’s not always clear because borderline personality disorder can also be characterized by sort of mood lability, where people’s moods are shifting. People with BPD are more likely to be diagnosed with major depressive disorder as well.

There’s also increased rates of trauma in people who end up diagnosed with borderline personality disorder. I think the big distinction is that in BPD, what we think of is that these are kind of more personality traits.

So this sort of mood lability and stormy relationships and sometimes erratic behavior doesn’t kind of concentrate in episodes of time that are then interspersed with episodes of not feeling that way, right?

For most people with BPD, while symptoms may exacerbate during, you know, times of stress, they tend to be more continuous, and in people with bipolar disorder, these tend to be kind of distinct episodes where people are experiencing either kind of mania or depression.

Jeff: We’ll talk a little bit more about BPD, but I do want to ask a question about ADHD. That also is coming up in a number of questions and how it fits into a bipolar and schizophrenia spectrum, if you will.

Eve: Yes. So this is a another sticky diagnostic question. So people with bipolar disorder are more likely than the general population to have been diagnosed with ADHD during childhood. It may be that kind of what we think of as premorbid or prodromal bipolar disorder looks like inattention and hyperactivity.

You know, you can kind of imagine where those things would fit in, and what was originally thought of as ADHD has sort of evolved into bipolar disorder, but it’s also possible that, through some shared mechanisms, that these two illnesses are related to each other, and so people who are at risk for developing bipolar disorder are also at greater risk for developing ADHD.

So that’s not entirely clear. What we do know though is that a colleague of mine, Lauren Moran, wrote a really interesting paper looking at the rates of stimulant medication in people who go on to experience a psychotic disorder, and people who have had psychosis have much higher rates of having been prescribed stimulant ADHD medication.

And so I think the kind of message there is that we want to be, you know, cautious about, you know, the use of stimulant medication, particularly in people who might be at risk for developing psychosis.

Jeff: I have to ask you, given the complexity of all of this, in your practice, how often do you find that somebody comes in who has in fact been misdiagnosed?

Eve: Oh, all the time. Yeah. Yeah. I read a statistic the other day that more than 70% of people with bipolar disorder have been misdiagnosed with at least one other mental disorder at some point in their life, so.

Jeff: Did you say 70%?

Eve: Yes, 70.

Jeff: Wow.

Eve: So these are really, as you say, they’re complex illnesses. There’s a lot of other psychiatric symptoms that kind of look like these symptoms or these symptoms that look like other psychiatric diagnoses, and so they can be very difficult to pin down.

Jeff: A viewer would like me to ask you to talk a little bit about co-occurring substance use disorder along with these diagnoses.

Eve: Very common. So I would say in our clinic, it’s about 50% of our clients are using significant amounts of substances. So it is very common.

It’s something we don’t recommend, because using substances, even things like cannabis, which a lot of our young people see as kind of natural and not potentially risky, is associated with onset of new psychotic episodes, and the age of onset of schizophrenia is younger in people who are smoking cannabis heavily during their teenage years.

So we do see these things kind of co-occurring frequently, and, you know, it can be tricky to encourage people to at least, you know, reduce their harm risk.

Jeff: How common is suicidality in BP and schizophrenia?

Eve: So unfortunately, it is common in schizophrenia. The rate’s about 10%, which is very high. People are often at risk for having suicidal ideation or making a suicide attempt after they’ve stabilized from a severe psychotic episode.

So people start to get a little bit of insight into what’s been happening, and that can lead to feelings of despair, and so the risk for suicidality is high during that time, and those are periods of time that we’re very careful to watch and evaluate and check in with people.

Jeff: You and I were talking, Eve, before the webinar started a little bit about stigma, and it’s the roadblock that it presents for a lot of people with treatment. Speak to that a little bit, what you see what can be done about the stigma and so forth.

Eve: Yes, I think this is so important. So, you know, across mental health, we still are struggling with stigma, and there’s in McLean, and a lot of places have really powerful anti-stigma campaigns going on to try to reduce the stigma around mental health and mental health care. I would say in psychosis, the stigma is particularly challenging.

A lot of people have a lot of misconceptions about schizophrenia and bipolar disorder, what it means and what people are like.

And, you know, because we all grow up surrounded by this stigma, if you receive a diagnosis of schizophrenia or your relative does, we may have self-stigma around those diagnoses, where we have internalized the stigma about a diagnosis that we’ve received or we may have stigmatizing beliefs about a diagnosis that a loved one has received.

So I think, you know, the first order of business, as with most things, is to just sort of tune in to our own way of thinking about these illnesses and, you know, what is the evidence that these, that our belief systems are correct, and then I think another big way to deal with stigma is by addressing it head-on.

You know, we can do that one-on-one with our patients just asking, you know, what do they think about these diagnoses. How do they think about themselves in the context of having this diagnosis?

Also with families, I think it’s important to address, and then sort of broader campaigns addressed at de-stigmatization.

And then there’s some wonderful organizations like the National Alliance on Mental Illness, NAMI, which is, you know, the largest grassroots mental health organization in the country, and they do a lot of work to reduce stigma in mental illness just broadly.

So I think that there are a lot of ways that we can work on reducing stigma so that we can get people feeling hopeful and optimistic and also get them into care as soon as possible.

Jeff: It’s such important work, and since you brought it up, I will put it in a shameless plug for McLean’s wonderful program called Deconstructing Stigma, which folks can find through the McLean website, in which a number of individuals living with various forms of mental illness share their stories in hopes of breaking down some of that stigma.

It’s very important work indeed. I know from experience, Eve, that we have a lot of loved ones on the calls that we do these webinars, folks who are supporting somebody living with one of these conditions.

What guidance do you have for them in a broad sense in terms of how they can best support somebody living with bipolar disorder or schizophrenia or any of these other conditions that we’ve talked about today?

Eve: Yeah, this is so important. You know, I think having the support of friends and loved ones is so critical in helping people achieve their recovery goals.

I can say from my experience at OnTrack in particular, we’re working with, you know, adolescents and young adults who many of whom are still living with family or have returned to living with family, and so those relationships are really critical.

I would say education as much as people can educate themselves about these illnesses on reliable websites, so things like NAMI. Their website contains a lot of great information.

There are other advocacy organizations, like One Mind and Mental Health America, that also provide a lot of information, a lot of which is geared towards support of others, you know, caregivers, loved ones, friends.

So getting as much information as you can, I think trying to work with whatever stigmatizing beliefs, you know, we all have been exposed to in the media and just in the general culture can be really helpful.

We might have some implicit beliefs about what these illnesses mean, and then I think checking in with your loved ones regularly but in a very open way.

I think letting people guide their care is really important, and sometimes family members can have their own thoughts about what their loved one should or shouldn’t be doing, and I think being careful to give people autonomy to work with their providers is important, and just being there, you know, being a supportive figure for someone.

Jeff: This is a very relevant question for this topic that just came in here. How does one speak to someone experiencing a psychotic episode to help calm them enough to suggest support by a therapist?

Eve: This is very difficult. So one of the hardest things I think about psychosis and psychosis treatment is that it is sort of, by definition, it involves a lack of insight.

So people, in order for these, like, delusions and experiences to rise to the level of psychosis, people have to believe that it’s true, and so it becomes very challenging to figure out how to intervene in that situation.

It’s easier when you’ve got a little bit of wiggle room and someone’s not sure. Maybe they feel fearful or they suspect something’s going on, but they’re not 100% convinced.

That can be helpful, and then I think the other thing that can be helpful is, you know, if you have a trusting relationship with someone who’s experiencing psychosis, you might be able to partner with them to say, you know, “It seems like you’re not feeling well or you aren’t engaging in things that you usually enjoy. Might you want to talk to someone about that?”

So, you know, getting people into care around something that is meaningful to them even in that moment can be helpful.

Jeff: A viewer would like you to weigh in on catatonia, what it is, why it happens, and what we should know.

Eve: Great question. So catatonia, what we typically think about is people who are kind of frozen in a position for long periods of time, but it can also involve sort of non-goal-directed repetitive behaviors, like buttoning and unbuttoning a button over and over again, but this isn’t like a nervous behavior.

It might go on for, like, hours, days even. So it’s not entirely clear why people experience catatonia. It’s not very common, but it’s not unheard of either. We certainly see it at the hospital, and the treatment for catatonia is very high doses of Ativan. So for whatever reason, something that sort of depresses your central nervous system seems to unlock catatonia.

If that doesn’t work, ECT can be effective as well, but it can be difficult to diagnose and treat because it’s not always clear why someone isn’t speaking or why someone isn’t moving.

Jeff: Question came in that would be near and dear to your heart. How can someone get more information about the OnTrack program, which is of course at McLean, and this is your program that you run.

Eve: It is, yes. Thank you for asking. So there is a website for OnTrack at the McLean Hospital website. So you can Google McLean OnTrack, and it’ll take you to our page on the website, and I think there will be a list of resources provided with the recording. Is that right?

Jeff: Yes, yes, in fact there will be, and we’ll have that up probably later this week.

Eve: Perfect, so we can include that link as well, and there’s a phone number to the referral line and a program description.

Jeff: Eve, I want to circle back to the whole misdiagnosis challenge. I mean, you talked about a statistic that was pretty eye-opening in terms of how many people are in fact misdiagnosed along the way with some of these disorders.

What can be done about that systemically? I mean, could there be better training, better referring within the profession itself? How is that best addressed at the professional level?

Eve: Yes, this is a tough question. You know, I think the answer depends on kind of the case, because there are a number of ways in which people may get misdiagnosed.

One way is that people’s symptoms actually evolve over time, and what looked like one thing at one point in time looks like bipolar disorder down the road, and so even though it’s a misdiagnosis, it wasn’t due to kind of any kind of professional incompetence. It actually was reflecting changes in the illness presentation over time.

Another though is that people aren’t carefully asking the questions that need to be asked in order to come up with a diagnosis, and for that, I think that we do need kind of more systematic training and support.

Bipolar disorder in particular has been historically underfunded by funding agencies, much more than like major depressive disorder or even schizophrenia.

So I’m actually part of an initiative right now called Breakthrough Discoveries for Thriving with Bipolar Disorder, which is a nationwide network of programs that are aiming to better understand the mechanisms of bipolar disorder but also to better implement clinical best practices, improve training availability and diagnostic availability and treatment availability at bipolar disorder clinics across the country.

So McLean and the Brigham have teamed up to be one of the sites for this integrated network. So we’re just getting launched, but it’s very exciting, and we’re hoping to be able to improve diagnosis and our understandings of best clinical practices.

Jeff: I’m going to try to work in a couple more of our viewer questions before we have to start wrapping things up. How does PTSD fit into this conversation?

Eve: That’s a great question. So PTSD can come with psychotic symptoms. We call that complex PTSD.

So this may be that people who’ve had a traumatic event and have post-traumatic stress symptoms also begin to develop psychotic symptoms around that experience, and it can be very difficult to differentiate and treat these illnesses, but yes, this is something that we see.

Jeff: Sean tells me, our question screener Sean tells me that we’re getting a lot of questions from family members relevant to our conversation about getting involved and when and where to do that and how to do that.

One question is how to help a family member that does not believe that they have schizophrenia and are very sensitive to the idea of treatment.

Eve: Yes, so I think this is a great question and something that we deal with clinically a lot too. One of the things that, you know, I tell trainees and that we do at the clinic is we really try to partner with our patients in figuring out what their treatment goals are, and very often, they don’t involve deconstructing delusional belief systems.

It’s really about, like, I feel socially isolated or I want to get back to work or someone doesn’t have motivation to get up and out of bed, and so we’re working on kind of helping them do those kinds of things a little bit more.

So it can be helpful to kind of partner with the person that you’re trying to get into treatment to kind of suggest that the treatment might be able to help them achieve whatever they’ve identified as a goal or whatever’s getting them stuck.

Jeff: Is there an evolutionary explanation for BD and schizophrenia? Is it hereditary?

Eve: So there is evidence that there’s a hereditary component. People with a first-degree relative with one of these two illnesses is more likely to have one of these two illnesses, and, like, identical twins are concordant for schizophrenia, for example, about 50% of the time.

So there does seem to be a genetic component, but in terms of the sort of evolution, I’m not sure. I think that there must be some extent to which these genes and these kind of risk factors are getting passed along, but I think part of the issue is that there’s no one gene that codes for any of these illnesses.

And so it’s very likely that for any given person, you know, two people with the same disorder may have no risk factors in common but both got the same illness. So that makes it hard to think about how that would get sort of phased out evolutionarily.

Jeff: You’ve been kind enough to share many resources throughout the conversation today, and again, we will be posting those along with the video from this webinar. Are there other resources that you want to put out there before we wrap things up?

Eve: Sure. So for people who are interested in clinical high risk, there’s a large NIMH program that’s called Accelerating Medicines Partnership for Schizophrenia.

There’s a website that’s called AMPSCZ, ampscz.org, and it’s got both information about how to participate in this study but also just resources for people who might want to learn more, researchers, clinicians but also family members who might want to learn more about this.

And I would say the NAMI website is a fantastic place to start for anybody who’s wanting to learn more information about these disorders. One Mind has a great website and Mental Health America also.

These are advocacy groups, and they have really great resources for people looking to sort of dig into this information.

Jeff: Quick question about how schools can best support somebody who is struggling with psychosis.

Eve: Yes, this is difficult. So I would say that in the school setting, if people are noticing a big drop-off in someone’s academic performance, if someone’s behavior has changed markedly or if they’re starting to kind of withdraw, then it’s never a bad idea to check in with kids who are experiencing these things.

And, you know, I think a lot of these resources that are available on the NAMI website, but also I would say McLean’s Clinical High Risk program has a lot of information to help support schools as well because this is school educators see kids more than anybody else probably in their lives, including their parents.

And so, you know, people may notice these changes or someone might be coming to the attention of counselors, and so I think kind of connecting people, families with resources is really helpful.

Jeff: We have 60 seconds left, and I’d like to use those seconds, if you will, to talk about some of the hope that is afforded through the work that you and others are doing. Let’s wrap this up on a hopeful note.

Let’s talk about the hope that treatment affords anybody who’s dealing with these conditions.

Eve: Absolutely. We’ve come a long way in treating these illnesses. I think we really understand the importance not only of medication but also of, you know, therapy and skills work to help support people in maintaining stability, and we see this every day.

We see people who go back to law school, medical school, who, you know, get their dream job, who live independently. So I think while there’s still a lot of work to do, there’s a lot of room for optimism, and one of our jobs and what I see as one of my most important jobs is just holding hope for people who come to see us because there’s a lot of reason to be hopeful.

Jeff: What a great place to wrap this up. Eve, I can’t thank you enough for taking the time to share with us your expertise today. We covered a lot of ground. You did a fabulous job of fielding all those questions. Thank you.

Eve: Thank you so much for having me. It’s been great.

Jeff: I look forward to picking up our conversation again soon, Eve. To those of you watching today, thank you for your interest in our educational webinar series. We hope you’ll come back for our future sessions, and we wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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