Psycho-Babble Medication Thread 289

Shown: posts 1 to 6 of 6. This is the beginning of the thread.


Schizophrenia/ Neuropathology

Posted by Levi on August 13, 1998, at 2:54:27

As far as I know, reaserchers have not noticed any nerve cell degeneration. In other M.S. or Parkinson's, there is a visible criterion for diagnostic/treatment incentives. In schiz, what is "hiding" - does the answer perhaps lean toward the physiological structure, or activity of the nerve cells, or is it bad synaptic transmision? Or both? And We seem to be treating this NBD by means of neurotransmision, but is it possible that there is a structural, nerve cell disfigurement that for some reason doesn't show up on any microscope or scan,etc. Does anyone have input on this? When can we take the leap and diagnose NBD/schiz by physical "tests"? Does this in anyway challenge the Biological model? I guess not... It's probrably like looking for your keys when they are in your hand. Or, perhaps. a bit more complex...


Re: Schizophrenia/ Neuropathology

Posted by Toby on August 13, 1998, at 16:23:23

In reply to Schizophrenia/ Neuropathology , posted by Levi on August 13, 1998, at 2:54:27

CT scans in schizophrenics show that the ventricles in the middle of the brain are enlarged and their brains are somewhat smaller than normal. It is unknown whether that decrease in brain tissue is due to degeneration or to abnormal development. MRI scans show samller limbic areas in schizophrenics which seems to correlate with the severity of symptoms. PET scans which measure blood flow to the brain show decreased activity in the frontal regions and less activation when undergoing certain kinds of cognitive tests. EEG studies show abnormal electrical activity. Schizophrenics show alot of neurologic abnormalities like abnormal eye movements, abnormal reflexes, speech difficulties, tics, impaired fine motor skills, and abnormal movements. Unfortunately, so far none of these findings is completely consistent between patients and none by themselves is diagnostic. Maybe in some patients, it take a little bit of all of the abnormalities to make them schizophrenic and in other patients it takes a lot of one abnormality to make them schizophrenic. More thoughts?


Re: Schizophrenia/ Neuropathology

Posted by Levi on August 14, 1998, at 1:02:38

In reply to Re: Schizophrenia/ Neuropathology , posted by Toby on August 13, 1998, at 16:23:23

More thoughts? You bet...
I have found the diagnosis of schizoaffective (hmm..) to be quite puzzling. I view it as a sort of "dumping ground" for patients who warrant a full affective diagnosis and also cannot be excluded from the schizophrenia spectrum. I've come across many different opinions - one which I don't seem to agree with - is that SCAF is "between" bipolar (perhaps w/f psychotic features...) and schizophrenia. The patient seems to be both, but at the same time not exclusively an element of one diagnosis. I think, i.e. it is my opinion that the "between" thing is just a misunderstanding on behalf of the mysterious "duality" that is presented - why did the DSMIV seperate this and not include it as a subtype of schiz - because people kept "missing" theses two diagnoses or because people kept having these two diagnoses (affective+shiz symptoms). It seems a mask that the DSM claims that the patient has to have a..."two week vacation" from mood disruption. My Doc has emphasized, and I'm sure you do, that the diagnosis is not so as important as the symptoms (which are inevitably going to lead one to one or another diagnosis anyway). But the Doc treats the symptoms. My Doc has said his definition - he has stated that person A is more on the schiz side, and person B is more on the affective (low, high, mixed) side, etc. He has also stated that his definition of 295.7 is Shiz+affective. But why? Schizophrenia will almost always induce, say, post-episodic depression, and the suicide rate speaks for itself. Schizophrenia is not exclusively "no" affect but "inappropriate" affect, or any affect at all is present. So why extract 295.7 from shiz? I do know that the thought disorder is related to dopaminergic action in areas...and that depression is wrapped up with other neurotrans..etc. The kreaplin dichotemy obviously is true in that it is the case that thought and mood are different areas of the brain - obviously they "affect' eachother. But is this dichotomy still acceptable? Will 295.7 evolve into something else, stay as it is, or go back to an earlier model? Sure, there's a ton of cases where mood and thought go awry, but this seems to debunk the kreaplien distinction. Not warrant it - or maybe 295.7 is an expression of the error of the dichotomy? What will become of this? What about schizo-obsessive! Or shizapanica! Or schizo-add. In these, schiz would be primary, and the other diagnoses would be secondary - i.e. they would not be the number given to the wonderful insurance companies. But "affective" - this really warrants its own correlation, as if reg. shiz don't get depressed? The DsM makes it clear that there must be mood-incongruent symptoms, delusions,etc. What's the deal?


Re: Schizophrenia/ Neuropathology

Posted by Toby on August 19, 1998, at 9:53:32

In reply to Re: Schizophrenia/ Neuropathology , posted by Levi on August 14, 1998, at 1:02:38

At times it does seem that 295.7 is indeed a dumping ground for patients that present with a complicated picture of psychosis and mood symptoms. It is precisely for that reason that the criteria is the DSM are written the way they are. The DSM should prevent a patient with a mood disorder with psychotic features from being diagnosed as schizphrenic. It doesn't always work because docs sometimes don't look closely enough at the patient and plot the course of illness adequately.
From all the available data, it seems that patients with a diagnosis in their chart of schizoaffective disorder are a very varied group: some have schizophrenia with prominent affective symptoms, others have a mood disorder with prominent schizophrenic symptoms, and a third group have a distinct clinical syndrome (which goes to your thought that it is maybe an error in the Kraeplin dichotomy). It does not seem that these patients have BOTH schizophrenia and a mood disorder as separate but co-existing entities. In clinical practice a preliminary diagnosis of schizoaffective disorder is frequently used when the clinician is uncertain of the dignosis (and that's OK if they then go on to figure what the real diagnosis is, but often the patient gets stuck with this diagnosis and that goes on to shape what treatment they get and affects the prognosis as well -- the prognosis of 295.7 is better than schizophrenia but worse than bipolar with psychotic features and much worse than depression with psychotic features).
Schizophrenia and mood disorders seem to be closely related genetically. Relatives of patients with 295.7 (depressed type) are more at risk for having schizophrenia than for having a mood disorder. But relatives of patients with 295.7 (bipolar type) are not at higher risk for schizophrenia. And there aren't alot of schizoaffective patients who also have relatives with schizoaffective disorder (supporting the idea that it is not a distinct disorder; but I think it CAN be a distinct disorder that just isn't genetically based).
Now, as to the DSM criteria... The clinical signs and symptoms include all the signs and symptoms of schizophrenia, mania dn depressive disorders. The schizophrenic and mood disorder symptoms can present together or in an alternating fashion. The course can vary from one of exacerbations and remissions to one of a long-term deteriorating course. There is a lot of debate about the mood incongruent psychotic features. In general, if there are mood-incongruent psychotic features during a mood episode, that is a poor prognostic indicator. The reason the psychotic symptoms must be present for at least 2 weeks without mood symptoms (and 2 weeks was pretty arbitrary I think but they had to have some guideline) is to prevent a diagnosis of schizoaffective disorder from being made when it's really just a severe episode of a mood disturbance with psychotic features (remember that 295.7 has a worse prognosis and that 295.7 would probably require lifelong treatment with an antipsychotic, whereas the psychosis that occurs only during a mood episode can be treated temporarily, until the mood episode is over). The same is true for the criteria that says the mood symptoms must be present for a SUBSTANTIAL portion of the total duration of the active and residual periods of the illness -- you don't want to put somebody on lifelong Lithium for a diagnosis of schizoaffective disorder when they are just having a post-psychotic depression that can be treated with an antidepressant for awhile and then stopped. As an aside, I feel that many patients can be treated with only mood stabilizers (and/or antidepressants) and that the antipsychotics should be used as needed for short-term control. Only if mood stabilizers are not effective on an ongoing basis should antipsychotics be used continuously.
That's all I can think of right now.


Re: Schizophrenia/ Neuropathology

Posted by Levi on August 21, 1998, at 3:46:48

In reply to Re: Schizophrenia/ Neuropathology , posted by Toby on August 19, 1998, at 9:53:32

Why does my doc (take a guess) always use the term schizophrenia when relating to me diagnostically? I'm not quite sure of his thoughts - only what I had mentiones in the last letter. There is one thing that keeps occuring, and is, withought doubt, flat out shizophrenia. When my doc asks how things are going, mood doesn't really fall into light. It's more questions that relate to voices, delusions, or circular (i.e. getting stuck - not in the OCD way, but a disorganization). I am responsive to the atypicals. But I still have relapses. Througout my course - say the past three years - the central element is neuroleptic and response. My doc is good for me in terms of therapy - but I'm sceptical in the sense that he once thought that I was 295.7 and did for a while. Over time, and I am taking antidepressents (Bad response to lithium, depakote...) - I think that he has come to the conclusion that I clearly (just about) am svhitzophrenic. This is probrably why he says I'm a schizophrenic but one with affective symptoms that keep him on the 295.7 thing. So he will tell me the truth - perhaps not the DSM or even the psychiatric truth - but he refers to me, openly (I'm fine with that) as schizophrenic. It's just that the receipts always say 295.7. So, I infer two things. (1)In light of the problematic diagnosis of 295.7, he has seen enough (over 20 yrs...) that he (somehow) can make the distinction quite accuratelly. And he believes, it seems clear, that I sway towards the schizo part. He perhaps has his own, which is in the boundries, defenition of who qualifies (?) as 295.7. So, since I must stay on antidepressent med - and I do have to....- and the neuroleptic is even more "staple" - it is the bread - perhaps this warrants his diagnosis. (2)I show affect. I have a sense of humor, and I am sarcastic and intelligent (I hope..) and have the big one - INSIGHT. But, I still over the long term course have battled over what is clearly shizophrenia, which is why he must refer to me as such. It has something to do with the form, or the intensity, or the unstable equality of theses two 'disorders' that warrants the diagnosis. One omore thing...(3)This is my belief, and I think it is really his too. I have shizophrenia. Not severe, but its proven itself again and again over the years, despite the neuroleptics - which I am lucky enough to derive a good amount of benefit from, as you can (hopefully...) tell. I think he thought I had 295.7 and I think at this time in therapy he refers to me as schizophrenic not just because of his belief that 295.7 can, or is sometimes the case, Schizophrenia+affective. But what about being depressed about being schizophrenic. Or grandiose because I think that the guy on tV is refering to me, on account of my central role in the worlds ultimate outcome. I think I have Paranoid Shizophrenia. Not a very good self-image... But I am not babbling, no echolalia, no posturing, none of these are in my bag. But I've got all the other junk. Mainly, a significant degree of confusion of thought thought derailment, thought blocking, thought insertion, thought broadcasting. Sometimes I think that I should reveal myself once and for all and wake up the sleeping ones...Sometimes I feel like a laghing stock, everyone in town is thinking about me at the same time - etc. So I have mild persecutory delusions, and hefty grandiose delusions (some of which i can't believe I believed!). I also fit a wide enough spectrum of symtomology so there is no possibility of differential diagnosis - just the two at hand. Grandiosity is the main thing. But my doc and i a5re far away from any ultimate disgnosis of manic delusions, for i fit not into that but much more obviously, to myself and my doc, in delusions that are goverened by "bizarre" thoughts, backing them up. I don't think I'm great and Madonna is in love with me. It's more like everyone who sees me notices my special powers, but I cannot at this momemt reveal my global significance. Yes, bizarre. So, perhaps he knows, and believes that I am definately schizophrenic, but since i have affective disorder, it makes me 295.7. I also think, many, many times that he regards "diagnosis" as secondary to symptoms. He treats the symptoms and doesn't really think that by changing my diagnosis it will do any help (and I see his point, if this is the case). Perhaps he lust feels, leave the diagnosis alone. After all I have symptoms of both, just more on the schizo side. Or it could be for insurance company reasons, and who knows what else. I would greatly appreciate an response that might say that I certainly may have 295.7 Or a response that he doesn't want to change the "number" but regards me as shizoohrenic. In short, if anyone can bear the time to answer, clarify, or just an opinion on the above, it would settle many misunderstandings, many things, indeed. Thanks....


Re: Schizophrenia/ Neuropathology

Posted by Toby on August 21, 1998, at 10:08:01

In reply to Re: Schizophrenia/ Neuropathology , posted by Levi on August 21, 1998, at 3:46:48

Ever asked your doc why he persists with 295.7 if he believes you are in fact 295.3?
It sounds as if you have what I talked about in my last posting -- mostly schizophrenia with affective symptoms. If so, it may be more convenient for the doc to just say, "you have schizophrenia" but for you both to be aware of the depression and the need for the antidepressants. But with the presence of the depression, diagnostically you would have to be listed as 295.7 for insurance purposes, etc to justify the use of the antidepressant on a long term basis. Also, remember that the prognosis is much better for 295.7 than 295.3. That's probably why you respond so well to the neuroleptics and, judging by your vocabulary and syntax, cognitively you seem to be doing very well. With plain schizophrenia, that's not always the case (although there was the schizophrenic fellow who went to Yale of Harvard or something and did great).

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