Psychiatry & Psychotherapy Podcast - Do I have Schizophrenia?

Episode Date: May 27, 2019

Clinical manifestations Many people worry that they have schizophrenia. I receive messages or inquires often of people asking about symptoms and manifestations. If you have those types of questions, or if you're a mental health professional who needs to brush up on symptoms and medications, this article should help you. There are many clinical observations of how schizophrenia presents itself. Cognitive impairments usually precede the onset of the main symptoms[1], while social and occupational impairments follow those main symptoms.   Here are the main symptoms of schizophrenia: Hallucinations: a perception of a sensory process in the absence of an external source. They can be auditory, visual, somatic, olfactory, or gustatory reactions. Most common for men "you are gay" Most common for women "you are a slut or whore" Delusions: having a fixed, false belief. They can be bizarre or non-bizarre and their content can often be categorized as grandiose, paranoid, nihilistic, or erotomanic Erotomania = an uncommon paranoid delusion that is typified by someone having the delusion that another person is infatuated with them. This is a common symptom, approximately 80% of people with schizophrenia experience delusions. Often we only see this from their changed behavior, they don't tell us this directly. Disorganization: present in both behavior and speech. Speech disorganization can be described in the following ways: Tangential speech – The person gets increasingly further off the topic without appropriately answering a question. Circumstantial speech – The person will eventually answer a question, but in a markedly roundabout manner. Derailment – The person suddenly switches topic without any logic or segue. Neologisms – The creation of new, idiosyncratic words. Word salad – Words are thrown together without any sensible meaning. Verbigeration – Seemingly meaningless repetition of words, sentences, or associations To note, the most commonly observed forms of abnormal speech are tangentiality and circumstantiality, while derailment, neologisms, and word salad are considered more severe. Cognitive impairment: Different processing speeds Verbal learning and memory issues Visual learning and memory issues Reasoning/executive functioning (including attention and working memory) issues Verbal comprehension problems By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Youtube channel  

Hello and welcome to the psychiatry and psychotherapy podcast, with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. Okay, welcome back. I am joined here with Dr. Ariana Cunningham. Hello. She is a psychiatry resident. We previously did an episode on schizophrenia, the cultural, aspects, how it's in the film, the history of it, and now we're going to dive into clinical manifestations. So where do you want to begin? So I think first off, just paint some broad

strokes. When we talk about clinical manifestations, there's usually terms thrown around like cognitive impairments, social occupational impairments, positive versus negative symptoms. And we're going to dive into each of those to kind of explain what that really means. And also to give some helpful tidbits as far as, which ones are more common, which ones are less common, and what you would even expect as far as the timeline of which ones would you expect to show up first. So something that we, I think, talked about last time in the other episode as well, is that when we look at impairments, we think of cognitive impairments coming before the onset of positive symptoms, an example of a positive symptom being like a hallucination. and that when we think about the positive symptoms,

because this are maybe the most famous of what you think of, we're talking about hallucinations, delusions, disorganization. So maybe let's dive into these positive symptoms and then kind of go stepwise from there. Sure, yeah. So positive symptoms, hallucination, general understanding you could say this is the perception of a sensory process in the absence of an external source,

auditory, visual, somatic, olfactory, a.k.a. something that you smell or gustatory, something that you taste. Versus a delusion. I think it's really helpful to kind of differentiate between those. A delusion is fixed false belief. They can be bizarre or non-bizarre, like it can be something that seems like extraterrestrial beings

or a perception of something that maybe really could happen in real life. But they can even be further sub-categorized, with grandiose, paranoid, nihilistic. And maybe it's helpful to kind of say here that the delusions is something that's really common in schizophrenia. In person studies that I was reading, they approximate like 80% of people with schizophrenia, you'd expect to see a delusion there.

Yeah. So the most common hallucination is auditory hallucination. Yeah. Most common for men in studies is that you're gay and for women it's that you're a slut or a whore. So these are bad negative messages that are coming to the people over and over again throughout the day. And then the delusions, you know, usually when they come to you, they may not directly tell you the delusion. They can be fairly guarded about the delusion, but their behavior may show you the delusion.

So they won't eat anything in the cafeteria that is not from a can or wrapped. Yeah. wrapped. Often, I think probably the most common is the paranoid delusion. So it's the delusion of people are after me, but there's also the grandiose like I'm Jesus or Mary, Mother of Joseph. So usually you'll have delusions and auditory hallucinations together. Yeah. Those are sort of, like we said, delusions you expect an 80% and then when you look at the hallucination, auditory more common than visual, which is different from how it's represented oftentimes. in film. And then kind of the next thing that we'll look at is disorganization. This is including both

behavior and speech. And I think a lot of us, even if we haven't worked on an inpatient psychiatric unit, sometimes you'll see people acting out or speaking out in really abnormal ways. But I kind of want to give you some tools to understand if you have someone and you're trying to understand what kind of speech pattern are they displaying. It's definitely disorganized. Here's some kind of helpful ways to subcategorize that. It includes tangential speech. And this is really just think of someone when we talk about going off the tangent, increasingly further from the topic without really answering the question.

So if I ask you, what's your favorite food and you start? My favorite food. Let me think about my favorite food. Today I was at the grocery store and at the grocery store I saw this boy. And the boy was wearing a black cap. Black cap. When I was in the military, there was a man with a black. black cap. This is a sort of like patient interaction that you might have where it's really difficult

to get through your list of questions. You have to like reel them back in, kind of help redirect, but that's considered tangential speech versus circumstantial speech, which is something that I remember being a student having to kind of map out visually. Tangential, they're going off the course. Circumstantial, they wander off the path, but they'll eventually get back. Yeah, kind of like a circle. Yeah. Next up is the term is derailment, which is kind of suddenly switching topic without any logic or segue. Versus like earlier, Dr. Peter, when you were doing the tangential, there was connection points that would lead you from one to the other. Whereas derailment, you may not really be able to follow

what's connecting those thoughts for them. Yeah. Kind of like the letter I've read. You know, it's like, okay, how do those thoughts connect? They didn't really connect. No. Yeah. And then next up, neologism. So this is just the creation of a new, meaningless word that they might use and apply some significance to. I haven't often been present with patients who displayed this. I don't know.

Have you? Yeah, me neither. Yeah, but it's there. Yeah. One that I definitely have witnessed is word salad. And it is just what it sounds like. Words kind of jumbled together without sensible meaning, without being able to follow it. And then rebegration, this is a meaningless repetition of words, sentences, or associations.

And that might even be a little bit in what we saw in that letter that you were kind of remembering there. You know, and one little interesting thing to note about this is that when psychiatrists are called in to do forensic examinations on patients, and they're asked to, you know, is this patient schizophrenic? And the schizophrenia was part of the cause of the murder or whatnot. it's really hard to fake this all the time. So it's a lot easier to fake like, oh, I'm seeing things or hearing things or delusions, but it's really hard to fake this 24 hours a day.

Yeah. It's just almost impossible. Sounds mentally exhausting. And this is really what separates, like, if you want to separate someone who's borderline personality disorder, sometimes they can be hard to differentiate, but someone with borderline personality sort will not have these things.

Hmm, that's really helpful because as you sit down to interview a patient, if you try to, I remember I had one attending who's like, don't put too much in what you see in the charts, go, try to see and engage with them with a fresh open eye or in this case ear and just really try to notice patterns that are displayed in front of you. And what I would say also is if you are working as like a psychiatric nurse, don't put down patient as having word salad or patient is having tangential. speech, put down in the chart what is actually said, if possible. Like, patient said this, quote, blah, blah, blah, blah, blah, blah, blah, blah. And in that, it will show very clearly the severity of what's going on more clearly than just a word. Yeah. So often, you know, if you're new, if you're a medical student, if you're resident and you're having

this in the HPI, just put down what they're saying and how they're connecting. patient connecting the mind calendar with quantum physics and this and that and it's like put down that stuff as it is heard and sometimes try to put in quotes because that will be the most interesting stuff okay so instead of putting down person responding to internal stimuli put down in the chart patient batting their hands in the corner of the room at something that's not there yelling profanity it's such a more vivid picture an understanding of what's going on and the severity because RTIS responding to internal stimuli really has such a broad range of what could be manifesting.

Yeah. We like specifics. I like the pictorial imagery. Okay. So next up is what we'd call negative symptoms. You know, earlier when we were doing the broad strokes understanding there's negative and positive symptoms of schizophrenia that are considered to be sort of typical to the disease itself. When we talk about negative symptoms, you can kind of differentiate into two subcategories

being one which is a diminished expression when we think about like emotionality. And the other one which would be kind of like a loss of motivation, what would they call like the abolition apathy cluster. So abolition or the apathy concept is just a decreased motivation to initiate or perform self-directed purposeful activities versus some of the other things we consider to be in the negative symptom category like anhydonia, affective flattening, it's just a decreased emotional expression, and you might really sense that when you're interviewing them, almost this lack of emotional energy that you can read from them. There's sometimes like a flattening or blankness

and the lack of motivation to initiate, you know, some of these patients, if you watch what they're doing, they're really just kind of sitting there. They're not really interacting with other people. They're just kind of, they're not doing anything. Yeah. They're just lying in bed. They're just, you know, there's no real interaction or seeking of interactions in the negative symptoms.

And the negative symptoms are harder to treat. Oh, yeah. Than the positive symptoms. And sometimes, you know, antipsychotics can induce some of the negative symptoms because of the blocking of dopamine, you know. But these things will be there anyways. So it's definitely from the disease, but the medications are not going to necessarily help. Yeah.

And that's important because I think I hear a lot from patients or their family members' this fear of becoming, quote, a zombie on medications. But to really kind of look at the cost benefit and see what the actual disease itself comes with, a lot of those things as well. And, you know, I think clausoryl, uniquely can help some of these types of symptoms. And we'll get to more of that in the future when we talk about this stuff. So then the next category is what we consider cognitive impairment.

And that includes like mental processing speed when you see someone try to engage in a problem or respond to a question. And you might feel that there's a certain amount of like sluggishness. Same thing with verbal or visual learning and memory, reasoning or executive function. verbal comprehension, social cognition, kind of this pattern where you might see, yeah, just feeling things are a little bit slow. And that can be present in other mental health conditions as well. But it's something that's, at least from my experience, can be really tangible when you interview them.

Yeah. And it's interesting, I've had a couple high functioning schizophrenic patients that I've had just the real pleasure of treating who have done well. on clausero, on zyprexa, and you know, you follow them for a long time. And they're able to do well. They're able to go on and get straight A's in college, go on to professional degrees and do well. And so although this is here, this is an issue, some people will have it more than others. And I think with the proper treatment, it is you can really optimize things more than,

you might consider. I would say also with cognitive impairment, like if you have someone on cogentin because you're worried about preventing EPS, you know, like with a medication with a dopamine blogger, the cogentin itself can cause some of this as well. So that's sort of anticholinergic. So, you know, moderating the anticholinergic burden can lessen the cognitive impairment. This is where there's a lot of nuance in psychiatry. It's like you both can cause some of the symptoms, but you can also have the symptoms there from the disease. Yeah. So we have to try to optimize everything we can.

And a lot of that happens outpatient, right? So inpatient, you're trying to get this guy out of psychosis. You only have a limited amount of days because the insurance companies want to get this person out of the hospital. And so you're really trying to get them as quickly as possible out of psychosis. And then once they're out of the, you know, once you're following them outpatient, it's like you're able to make nuanced small changes to optimize their cognitive function. And then another thing that I think is really important to touch on here is that schizophrenia

sometimes doesn't manifest in and of itself, like an island away from the other conditions that we see in mental health. And actually mood and anxiety disorders occur at a higher rate in the population of people with schizophrenia than in general. So there's a few different studies that I'll post up, but we see a lifetime prevalence of depression. in the schizophrenic population fairly varied, but it definitely does occur at a higher rate than the general population, along with a higher rate of suicide than the general population. 5% of 10% of all completed suicides are among people with schizophrenia. Kind of one pretty sad factoid.

Another study outlined that there's a high comorbid anxiety disorder prevalence, and that includes like social phobias in about 14.9% of the schizophrenic population, PTSD 12.4, and OCD 12.1. And then kind of conversely, they found in some studies that people with OCD, social phobias or panic attacks had an increased odd of developing schizophrenia. I don't think I'd want to say this in a way to scare people out there, but I think it's more of a softening for those of us in a treating position to have your eye out for other things going on that might be adding to kind of the level of dysfunction or how difficult they are in regaining certain functionality levels with treatment that we don't want to miss these things.

Yeah, I definitely have seen the social phobia and it's hard to sometimes discern, is this the paranoia? Yeah. Or is this, you know, and then once you have the paranoid treated, like, is it the end? anxiety underneath with the OCD, the obsessive thoughts, you know, if they've been on the antipsychotic for a while and they're no longer having the positive symptoms, but they still have these repetitive, distressing thoughts, it can almost seem similar to the intrusive auditory hallucinations, but they're not, they're not the same, they're repetitive, they

want action, and they often, you know, they have compulsions that follow sometimes. So it can be a little bit hard to discern and delineate like what's what, but really getting a full history, I think is really helpful in making that. Yeah. And then another thing that was actually pretty interesting and new to me as someone who's young in this field right now is some associated physical manifestations, including what are called soft signs or the neurological signs that sometimes you see with someone with schizophrenia. So it includes some impairments on sensory integration and motor coordination. There's some examples of like right-left confusion, the inability to identify certain familiar objects. And granted, I think like you were saying, you really have to parse out like what is a manifestation of a different aspect or a different symptom of the disease and what is this in and of itself. Like the inability to recognize letters or numbers if they're traced on the skin.

Like, that's pretty specific sounding, but it's something that's really talked at least about in literature. I don't know how much you've seen of this in your practice, Dr. Peter. Yeah. That's interesting. Some of this stuff I probably don't look for it enough. Yeah. But it's interesting how, like, coordination movement, right, which is all sort of dopamine. is influenced by this disease as well.

Yeah. You know, you have the mesolimbic track, which is like where the schizophrenia tends to occur. And then you have the Niagara Straital, which is where the movement occurs. Yeah. And so in Parkinson's, when you have a deficit of dopamine, you get like very stiff and rigid and slow movements.

And, yeah, so it's interesting. And that kind of ties in, that some of the neurological disturbances, like you mentioned, could be more so in relation to, let's say, like, an adverse drug reaction. So it's important to differentiate, like, did some of these things, like if they're having tremor or bradykinesias or acute dystonia's or acesia, were these things coming on before you started meds, or did they only come up or worse and after starting certain meds and just really keeping an eye out for the things outside of what we consider to be those core, like positive negative symptoms, hallucinations, etc. To keep an eye,

just so we can really set people up for the most success possible. Yeah, and this is where, you know, I think there's a benefit of seeing someone long term. You know, you see you put someone on a medication, and then the next day they're very restless. It's like, okay, you probably cause that from the medication. So, you know, acesia, internal external restlessness, something we have to continue to monitor, continue to make sure that we're not causing that issue. because that is so, so anxiety provoking. Oh, yeah. It's torture.

So, you know, if they have it, we've talked, I've talked about this before, but propanolol or tasapine, clonopin are really the three treatments, if lowering the medication is not an option. There are certain antipsychotics that cause it more often, and there's certain that cause it less often. So switching it to one that causes it less, or, you know, listening to a good history from patients. like what caused more of a restlessness, what didn't cause a restlessness.

But aceshesia is one of those things that I constantly am looking for because if you miss it, you're going to miss this really, really debilitating and painful thing that we are causing essentially from the antipsychotic. Yeah. A lot of people who are very resistant to antipsychotic, if you get a good history, it's actually probably because the antipsychotic, they were put on caused acesia. And so it's something that I'm going to do a full episode on it in the future. Okay, let's keep going.

And then another thing, kind of when we imagine a patient with these symptoms presenting, with these different manifestations, another thing to really think about is catatonia itself. So we're going to post up, it's called the Bush Francis catatonia rating scale, that oftentimes my initial imagery of what catatoni looks like is someone who's like blank slate, not moving, you know, like stuprous gaze, but there's a lot more to it. And I think that this rating scale, it has 23 kind of, I guess you could say categories that you go through examples including excitement, immobility or stupor, mutism, staring, posturing, grimacing, ecopraxia, stereotypy, mannerisms, etc. It's a pretty good list. So definitely take a look at that rating scale because it's, yeah, it's different than what maybe we see, once again, in film, what kind of colors our perception of what something looks like, that when you have someone who's exhibiting a lot of negativism in terms of like the symptoms that can be associated with schizophrenia to keep that in mind. And catatonia is, we treat it differently. Yeah.

Okay. And so catatonia is like one of those things that you're going to want to know. in your mind, that pattern, you're going to want to be able to see that. It's a great diagnosis. Yeah. It's a great diagnosis. For the people, you know, on Twitter and all the anti-psychiatry people out there, I often think to myself, okay, you treat a couple catatonic depressed patients.

Yeah. Or catatonic, schizophrenic patients without meds. And you let me know how that goes. Yeah, I cannot even imagine. Or like ECT can be really, really helpful for any catatonic. the pressure. And if you've treated these patients, you've tried other things. A high dose of Atavan can be really, really helpful. I mean high dose, like up to 18 milligrams. Like a normal adult will get like one milligram three times a day for like alcohol withdrawal or like two

milligrams three times a day. So like 18 milligrams a day, that's a big dose of Ativan. You don't go up there all of a sudden. And if you give them out of van and nothing happens, it might be a lower likelihood of having Catatonia. You know, so read the list. We'll put that up there. Yeah, it's important to, I had an attending who was both a JDMD, so he's both a lawyer and a medical attending. And kind of the sense of there's certain things you would never want to miss,

not just for the care of a patient, but also from a legal standpoint, that if you're treating and going down one path and didn't consider this alternative, that would be, yeah, that could have a lot of ramifications. And when you look at the history of psychiatry, a lot of the patients they're describing, I feel like the severe cases, you know, before medications were around, this is what was going on. Yeah.

Because Catatonia may be like one of those like final common pathways for like really, really severe mental illness. And it's sad that someone could get locked in. Like people with catatonia, I've had people that I've caught who stop drinking, who stop eating. They've lost, you know, 20 or 30 pounds in a month. Oh, man. And they're slowing down. You know, it looks like severe Parkinson's disease without Parkinson's disease.

Like, they're so slow. They're walking around. You know, they're talking slow. And then the catatonic excitement could be the other end of it. Yeah. It's, yeah, it just, it really doesn't look how I first imagined it the first time I printed this off and took it to bed. So I was like, oh my goodness, I never even thought.

Well, another thing that I did want to mention is, um, some of the metabolic disturbances that they've found are linked to or, you know, have a higher prevalence in the population with schizophrenia and that includes diabetes, hyperlipidemia, and hypertension. And kind of unfortunately, and I'm sure, even as we've discussed with the support system and maybe difficulty with follow-up, this could be a part of it, but the life expectancy for someone with schizophrenia is actually reduced by 10 years in comparison

to the general population, and the main medical mortality, and I'll post up the article where this was outlined, is heart disease. So, I mean, when we consider support structures and medication compliance, this isn't just for the mental health itself, it's for the whole person

in all of their medical comorbidities. Yeah, and, you know, Type two antipsychotics, second generation antipsychotics, increase the risk of metabolic disease. And so one of the big things that I do for patients is I try to get them on an exercise routine. Once they get more stable, once they're not hearing things, once they're on medications and they're stable outpatient, you know, get squatting, get deadlifting.

And I'll remind them almost every visit of the importance of it. and the ones that do it, it's like so good, so good. You know, how does diabetes progress? Well, it starts in your quads, probably 10 years before you actually get uncontrolled glucose, you know. And so having an exercise routine will be so helpful. But in your study, in your look on this, it's not just from the medication. Is that what I'm finding? I mean, yes, there are components where some of the medications that are used to control

schizophrenia and its symptoms can have an effect here, but it's also outside of just as a medication side effect, which is important to emphasize. Plus, everything we talked about with like, you know, if you have a person who's experiencing homelessness and schizophrenia, like that combination and medication follow-up and regular visits and even glucose monitoring, just all those things. I mean, treating the schizophrenia and getting them as functional as possible is all you can do to help with these other things that are associated. Like, it's really, I think it's crucial for every aspect of their health. I once called to the ER and there was a patient that had psychotic illness.

And as I spoke to the patient, the patient said that they had worms crawling on their legs. so I looked at their legs and lo and behold the patient had cellulitis. I called back the ER doctor and I said, okay, you know, have you thought about their, you know, infection? They're like, what infection? So often people who have psychotic illness,

the way they describe their physical illness will be twisted with psychosis involved with it, which will not get them the treatment that they need. So there's a bunch of things leading to this, I think, 10-year. Part is just like advocating for themselves. You know, how do you advocate for yourself in the same way as a normal person if you're acutely delusional or psychotic? And if you're a complaint of chest pain and frequent urination is embedded in your, you know, paranoid delusions that you're expressing, it's easy to see why a provider might kind of, you know, already start disengaging and not pay much heed to the actual content of what.

they're saying but. Yeah. Or a lot of people who are on the street, it's like, they're paranoid to the point that any pill is poison. And so, you know, they're not going to take a medication, any, any medication they're not going to take. Yeah. Okay, so disease course.

Yeah. So this is, I know we've kind of touched on this, but typical onset, young adulthood, we think 21 years old for males, 25 year old for female. If it's occurring outside of that range, your index is suspicion that this. this might be something else gets higher. There was a really cool person, Manfred Bluther, in 1972, and then later studies kind of helped take a look at basically the pattern of the disease course itself and looking at when the symptoms onset and how the outcomes go.

And when we talk about onset being abrupt versus insidious in this particular disease, they found like an overwhelming majority had an abrupt. onset when you talk about the symptoms. But again, kind of like we said earlier, is that oftentimes you would expect some of the functional or cognitive deficits before a positive deficit like the hallucinations, which are much more apparent. So I think even in reading this, we need to have some index of suspicion of what people are catching as far as this abrupt onset versus all those precursor signs.

Right. So abrupt is like 80%. Insidious is like 20%. So most of the people, like the first symptom is that that is going to get noticed, right? Is that psychotic symptom. And it's good to become really familiar with the different symptoms and how they present because the main studies that we've found is encouraging in the sense that timely and intensive treatment can impact functional recovery.

Really cool study kind of outlines these things that I'll post up, but that really being able to have a good eye for catching this is really, really helpful and could make a huge difference in the patient's life. So they had a really fun study that was following people after two years who had an intensive intervention and showing that they had a greater improvement as far as functionality at school work, less psychopathology. Yeah, just an interesting, like randomized study with 34 community health centers in 21 of the United States. and basically looking at different types of intensive treatments and going into that. We'll get more into those details in the future as far as like what treatments can maybe have some support for making a bigger difference or impact.

But the key here is like early treatment and intensive treatment, treatment that involves the family, the stress that's going on in the home, you know? Can we reduce the stress in the home? Can we get them on the right medications? Can we get them some psychotherapy? if all those things take place, the long-term trajectory changes. Yeah, it does. And I've seen this.

I've seen patients who have had, you know, they're in and out of psych hospitalizations, and every time they have a psychotic illness, there's, like, damage to the brain going on. And then compare that to patients who early on, they get, you know, first break psychosis gets sort of identified, early diagnosis of schizophrenia, get them on the right medications. they don't need very high medications. And then I follow these people and they do so much better because their cognitive function is not attacked by multiple psychotic episodes. Yeah.

Which like I think really does damage the brain long term. Oh yeah. I have an attending who you probably worked with as well who gives the analogy that being in an active psychotic episode and to some degree an active, like intensive depressive episode or these different things are like small bouts of traumatic brain injury being inflicted on you with each round. So if we can decrease the number of those before treatment isn't put in or avoid as many of those as possible, we're saving their functionality for future. Absolutely. Okay, so we're going to wrap this up today. So what are the biggest sort of aha

moments that you had when researching this part? I think the biggest aha moments is really that schizophrenia looks different than what we imagine sometimes and to have your eye out, not just for visual and auditory hallucinations, but for the negative symptoms, for the cognitive delays, for the different speech patterns that really, yeah, your mental snapshot, if you were to close your eyes and imagine someone that, let's say you've encountered in whatever setting as a provider or is a pedestrian, what have you. We're like, ah, this person might have schizophrenia. And then to really expand that picture so that someone doesn't kind of fall through the cracks

when you could really change their life trajectory. Yeah. And I want to leave people with hope that if properly treated, you know, people can do so much better. If they can get the proper treatment, if they can, you know, if you build a strong connection with them. and it increases medication compliance. So therapeutic alliance, medication compliance. I see it because there's some people I connect really well with.

There's some people I have a harder time connecting with. It changes medication compliance. And then how can we also integrate the family into the treatment through psychoeducation? I'm hoping that this episode can provide some psychoeducation maybe for families that are out there listening to this. and then looking also at the comorbid diseases. That's what we talked a lot about. We talked about social anxiety disorder and PTSD and obsessive compulsive disorder.

Also being present there. And then there are metabolic ones as well and cardio. Talked about the importance of looking at the metabolic, you know, continuing to screen for metabolic issues. You know, you should be running labs consistently over the course of treating these people long term. And also I would say, you know, if new symptoms arise in a person that was previously stable,

did something metabolic happen and keep that in your mind as well? And, you know, like I had a patient develop diabetes, and it changes the treatment. Yeah. Luckily, this person was just on a steroid dose, an oral steroid dose for really bad asthma attack. And so this, the diabetes sort of was not really diabetes in the end. it was a steroid-induced hyperglycemia,

but it increased their anxiety quite a bit, having their glucose that high and being on the steroids as well, probably. But it's kind of like, you know, as we approach this population to think through, okay, is it medical issues, and not be distracted by only psychotic symptoms. So that would be another big sort of aha moment.

I hope that you would have as well, is that you would actually consider, oh, maybe there is medical issues going on that are making or defining how they will psychotically present. Okay. Yeah. And we'll dive more into things like smoking and how that affects things, different substances, how that affects things. But there's just so much. We got a lot to go. Okay. So this is going to be the schizophrenia series. Like I said, in the previous episode, we're going to have some of this on YouTube with like video clips. So if you haven't checked out my YouTube and subscribe to it, go over to the, I think it's

psychiatry and psychotherapy. There will be links from my website, from the show notes of this to that. Also, the Instagram, if you haven't joined the conversation there, for every episode, I put a post up and people put up comments and try to create some interaction. That's kind of the biggest place to interact with the people who enjoy this podcast. and yeah really good job ariana pulling some of these notes together oh yeah and we'll post up all the links so if you have questions about the articles we reference and things like that it all go in the resource library yeah and we'll have a blog that goes with the episode kind of talking about

it as well so all right thank you cool thanks for having me