- [Jeff] Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions either themselves or a loved one.

Do not suffer in silence with help, there is hope.

Today on "Healthy Minds."

- It's almost like family members describe it as the person's personality has been taken away by this illness.

You know, it's really difficult at the beginning of schizophrenia to know that what you've got is schizophrenia.

So, so many good things can happen for the person's trajectory if you're able to get them in treatment early.

- That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(ambient music) Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Today we discuss schizophrenia, the symptoms, the treatment what can be done to help people who have this condition.

I speak with Dr.

Dawn Velligan, an expert in schizophrenia treatment.

(ambient music) Dawn, welcome to "Healthy Minds."

Thank you for joining us today.

- Thank you for having me.

I'm really glad to be here.

- I wanna jump right in and ask you to describe schizophrenia.

People know the word have heard of it but unless if they themselves have the condition or are living with or have a friend with that condition often people don't know what it means.

So what Schizophrenia?

- Right, schizophrenia is a behavioral health condition that's characterized by a group of signs and symptoms.

So one of the things that happens is people have what we call positive symptoms and they're not positive 'cause you wanna have 'em.

They're positive because they're there and they really shouldn't be.

So people may hear noises or voices or see things in the absence of external stimuli and that can be very disruptive as you can imagine.

Some of the other symptoms include beliefs that other people don't agree with.

So beliefs like being followed or concerns that someone's tampered with your food which can also cause a lot of difficulty for you in your life.

And then in addition to the positive symptoms are negative symptoms and those are a problem because they're not there and they should be.

So things like having difficulty to being motivated, being able to get outta bed and shower and get ready for for the day and do things that seems to be diminished for people that have schizophrenia often.

Another sign would be that affect is blunted.

So monotone speech or limited facial expressions or limited feelings of emotion during the week.

You or I may have a week where we're happy and we're proud and we're sad and people with schizophrenia have just less of a range of those affects during the week.

And that can be very difficult in relating to other people.

And then there are some cognitive impairments.

So people often have difficulty with paying attention to things that require effort or being able to remember things that they've learned or things that they've heard.

And finally being able to plan and carry out activity and solve problems.

So all of those are some of the characteristics of this condition.

And of course everybody's different.

So different people present differently.

- So I want to zero in on a number of these symptoms and we'll start with the positive symptoms the hallucinations, the delusions, fixed false beliefs some of those symptoms that probably people are more would more likely associate with schizophrenia in the general public.

Tell us about some of the treatments for those symptoms.

- Right, so those symptoms are of course important because those are the ones that get people put in the hospital or get people to come to the attention of authorities or their family members.

And people are very worried about that 'cause they don't understand it.

And so some of the treatments for those symptoms include medications.

So there are medications called antipsychotic medications that treat the positive symptoms of the disorder and usually they work pretty well.

You can usually get the voices to quiet down or to occur less often or to fade a little bit into the background.

People may stop believing that, people are out to get them or against them slowly over time.

So those medications play a really important role in treatment.

However, often the medications don't take the voices completely away and often they don't take some of the beliefs completely away.

So people are still, can be afraid around other people or they can believe things that aren't true.

So there are treatments for those kind of positive symptoms that are there despite the best medical treatment that we have.

So things like cognitive behavior therapy for psychosis can be really effective.

And so what you do is you talk to people I had a woman come in recently who told me that she thought someone was stalking her because she saw the same car appear five times as she was walking to the store.

And so we went over what is the evidence that this person was stalking you what are some other reasons that you might see the same car over and over again?

And she was able to say, "Well maybe they were lost or maybe they're waiting for someone who's shopping at the store and they couldn't find a place to park."

So she was able to come up with other possible explanations and so we agreed that what she would do is over the next few days look for that car again and see whether she saw it again and when she didn't she was able to come back and say they probably weren't stalking me.

And so it's cognitive behavior therapy is about looking at the evidence for the beliefs that people have and trying to expand the possibilities for why those things could be occurring.

- So an important message of what you're describing is that often for people a combination of medication and therapy are useful for these positive symptoms the hallucinations, the delusions how to manage those symptoms.

I wanna now shift gears to the negative symptoms and ask you to say a little bit more about those symptoms and what's the treatment for them.

- So negative symptoms are really difficult.

These are the symptoms that family members complain bitterly about.

So it's people staying in bed a lot, maybe getting up smoking cigarettes, and watching television and having a lot of sedentary activity, not wanting to become involved in family activities or socialize, not really having goals that they want to accomplish.

And so it's almost like family members describe it as the person's personality has been taken away by this illness.

And so it can be really devastating.

But one of the things about negative symptoms is that early on in the disorder you know you're bombarded with stimuli you're believing these things and all kinds of things are happening to you and you're trying to make sense of it.

And so you wanna withdraw to be protective of yourself.

And so that's a very normal phase in the illness is to withdraw and take care of yourself by being away from others.

The trouble is if that goes on for a long period of time you get into a comfortable space of not going out, not socializing, not interacting then you don't have anything to talk about when you do see people and you don't have anything to say and so then people don't really wanna talk to you and there becomes kind of a vicious cycle.

And so treating negative symptoms is really difficult.

Right now, we don't have any medications that are approved for the treatment of negative symptoms.

There are some treatments that help.

Cognitive Behavioral therapy with a big B focused on the behavior getting people moving and doing is one way to improve negative symptoms.

At our site we developed motivation and engagement therapy, it is called MovE.

It's again getting people moving and doing, getting them to anticipate that something's gonna be pleasurable.

One of the impairments with people who have schizophrenia is often that they don't anticipate that anything's gonna be worth the effort.

So what we do is we get 'em to say well how much do you think you're gonna like going to the zoo with us?

And they'll say maybe five outta 10.

And then we go to the zoo and they like it and they'll say, "Oh wow, that was a nine out of 10, I really enjoyed that."

And so then we can get them to understand that there's this impairment in anticipation.

And so even if you don't feel like doing something when you do it, you enjoy it.

So let's do more things and we get people moving and doing and back in the community.

And then secondary reinforcement takes place where people respond to them better.

They have something to talk about, oh they went to the zoo, oh they have a volunteer job.

So we get people involved in doing it takes a lot of effort.

And so when we present on treatments for negative symptoms it's hard to get people involved in the studies 'cause motivation is an issue and then it's hard to get people moving and doing but it's very rewarding when it happens.

So there are some treatments but they're not widely available.

- I wanna move now to that third area and all of these are extremely important and that has to do with cognition.

Tell us a little bit more about the symptoms and also about the treatment.

- So cognitive impairment is particularly important because cognition is the best predictor of how people are gonna do in the real world.

Can they do their independent living skills?

Are they able to have a job in the competitive marketplace?

And are they able to initiate and maintain social relationships?

So there are a lot of different impairments in cognitive functioning.

Some of them are in the area of attention the ability to focus your attention on something that requires effort over a long period of time.

So you can imagine someone sitting in a doctor's office and the doctor explaining which medicines are for what, what the side effects are, which ones you have to take with food.

And after a while the ability to pay attention is a problem.

And so there might may not be getting all the information.

The other issue is a focusing on what you're supposed to focus on when there's distraction.

So if you're in a crowded waiting room and someone's explaining to you how to get to the benefits office to get food stamps and there's the television on and people running around and children, you know having a tantrum, you're not gonna be able to turn your attention to what's important within that distraction.

Memory's also impaired and this is memory for faces, memory for verbal information or visual information.

And so you can imagine that it's difficult to work when you have trouble remembering what the boss tells you.

And finally the ability to plan, use judgment, solve problems in new situations, make it difficult for you to navigate even to navigate our healthcare system which is pretty fragmented.

And you have to go here for one thing and therefore another thing.

So that can be very difficult.

So cognition is a better predictor of how people do in the world than positive symptoms or negative symptoms.

But we do have some psychosocial treatments.

So one of them is cognitive remediation.

This is where you go into an office or you work on your home computer and you do tasks that help to focus your attention that help to train your memory.

And by doing that the idea is that those abilities are gonna generalize into your functional outcomes that you'll now be able to remember things so you'll do a better job at work.

The data support that cognitive remediation improves cognitive function, it helps people work more hours, earn more money, in vocational programs.

So it can be very beneficial.

The trick is how do you get people to sit at a computer and work over and over on these tasks?

And that can be very difficult.

Another intervention for cognitive impairment is to simply bypass cognition.

So we use prosthetics or environmental supports to bypass cognitive problems.

We have a treatment that we developed called cognitive adaptation training.

And in that treatment we use environmental supports, signs, checklists, text messages, Alexa or some kind of other programs, specialized pill containers with alarms.

We use all of that to bypass cognitive problems so that everyday activities are made easier and you don't have to remember as many things and you don't have to pay attention to as many things because we're directing your attention with the use of those supports.

We've found that if you use cognitive adaptation training people are functioning better they're less likely to go to the hospital they're more likely to take their medications and they're more likely to follow through on appointments and their general level of social and occupational function improves.

- So in this instance and what you're describing sort of giving somebody some added tricks to help them get through with some of the problems they face.

And I'm gonna just take off my glasses and say you wear glasses they don't fix your eyesight directly but they make it fine for you to be able to see.

And in some ways some of these tricks of the trade that you're describing can really help the person move forward in a healthy way.

- That analogy is exactly correct.

- And a lot of them and this is what I find so appealing are basic common sense ideas that if you think about the person's day-to-day functioning you could sort of give them assistance in their day-to-day functioning.

- They absolutely are.

It's not rocket science.

My husband says that I made a career out of sticky notes and he's not far from correct.

And so what we do is we do complete behavioral analysis of what's going on with the person, what they're able to do and what they actually do.

'Cause just because a person can make a healthy meal doesn't mean that they do.

We look at their environment.

Do they have the things that they need to be successful?

So people may have soap and they may not because if you're on a limited budget and you have a choice between cigarettes and soap and you have an addiction, you're gonna go for the addiction and you're gonna buy the cigarettes and then you don't have soap.

So even if you shower, it's not effective.

So we look in their environment do they have what they need and where is it placed?

So I went to a guy's apartment and his toothbrush and toothpaste were literally in his bottom dresser drawer.

And I said, "Well, how often do you use those?"

And he said, "Well, maybe once a month or twice a month."

And so I took them out of the bottom dresser drawer and put them on a suction cup device on his mirror.

So at least he's seeing them every single day.

So he will be prompted to use them.

So it's a whole analysis of the environment and the person and their behavior.

You have to start with where people are and then you change the behavior just enough and then you can kind of build on that over time.

- I wanna turn to one of the challenging issues which is adherence to medication.

And we know that in all conditions, medical conditions, other psychiatric conditions, people often don't take their medicine as they're supposed to.

And in schizophrenia this can become a problem.

And I'd like you to speak about how to address that problem.

- One of the things that's really important is that everybody's on the right page and they understand what the medicine is for.

When you get a young person and the very first time they have a psychotic episode where they're hearing voices and the medicine takes it away very quickly they wanna forget that ever happened.

They wanna just go back to their normal life.

Nope, nothing's wrong with me, I'm good.

And taking medicine every day kind of reminds them that there's this issue.

And I tell 'em, "We like you to stay on the medicine for about a year at least, right?"

But everybody eventually wants to get off 'cause they don't quite believe that they have this illness.

And so I predict at some point you're gonna wanna do that.

And when you do, I want you to make sure we know and your prescriber knows and your mom and dad know and I want you to think about how far do you want things to go.

It's possible that you'll never ever need medicine again but that's very rare.

So do you wanna go all the way to where you have to go to the hospital or at the first sign do you wanna get back on and what is that first sign?

And what's your plan?

If somebody notices is that enough to help you go back on?

What are we gonna do?

So we organize sort of a time to go off medicine and try that.

So early on there's a tendency to kind of wanna go off the medicine.

Once you've had a few episodes and you know then there's still a tendency to sometimes wanna go off medicine.

And it's important that everybody understand what it is for and what it does and doesn't do.

Sometimes prescribers are overpromise.

Oh this medicine's gonna take care of things and it doesn't all the way.

So people think, well what's it for anyway?

So then they'll go off.

One of the things that's so important is how does your doctor know what to do if you're not taking the medicine that they prescribed?

What happens a lot of times is prescribers have no idea if you're not doing well if that's because the medicine isn't right for you or you're not taking it right.

And then they might add some stuff, they might increase doses, and that might not at all be necessary.

So I recommend to people that they follow through with what has been prescribed and when there's difficulties they communicate with their doctor because then the doctor knows oh you've been taking it and this is happening or that isn't happening now we can adjust things.

It gives them all the data that they need.

And so I recommend to a lot of people to use long-acting injectables because then they don't have to remember to take a pill every day.

And I think that that can be very helpful for people.

They don't have to remember to take their pills when they go hang out with their friends or so there's less stigma involved sometimes.

So there are different ways of addressing the problem.

We also address it in cognitive adaptation training.

We put the pills and containers with special alarms to remind people to take it.

I've used smart pill containers that alarm and the person opens the compartment and it says are you really taking it?

And then I can go on an on internet site and I can check did people take their medicine?

And that can be very helpful.

So there are a lot of ways to encourage people.

We also need to listen to people 'cause there are side effects of some of these medicines that are not tolerable.

- And I want to emphasize the side effect aspect in terms of adherence to medicine.

It is important to speak up if you start to have side effects so that your physician knows about this and can make adjustments because sometimes we can lower the dose or change to a different classification of medicine that may be less likely to cause the side effects and still have the therapeutic effects.

- Absolutely.

- I wanna ask you about early diagnosis and some of the initial symptoms and warning signs that somebody may be at risk of developing schizophrenia and what should be done if those symptoms and warning signs occur.

- It's really difficult at the beginning of schizophrenia to know that what you've got is schizophrenia.

A lot of times parents will see people not go to school and withdraw and that can be a sign of depression.

But it can also be the beginning or the onset of some of the negative symptoms of schizophrenia or some of the withdrawal that's associated with schizophrenia.

And so it's difficult to know when somebody's behavior changes like that.

They used to be a good student and now they're not.

It's important to go to a professional and have them evaluated as early as possible.

It's a lot of people have difficulty and we're not really sure.

Is that difficulty a mood disorder in its early phases?

Is that difficulty a psychotic disorder in its early phases?

Sometimes we don't know.

And so it's really important to get professionals involved early.

Being a parent, you understand this my kid's okay, it's very important, not my kid's okay.

And you kind of don't wanna notice these symptoms and it's really important to get help early because the earlier we treat this the less time there is for someone to believe for a long period of time in these unusual things.

And if you can get things early, it can be treated early you can preserve a lot of brain function.

It shows the earlier treatment is better.

So many good things can happen for the person's trajectory if you're able to get them in treatment early.

- Right and I think a key point is as a parent if you're seeing behaviors that are of concern a change in your child's behavior, in your child's work at school, socializing, that's a reason to have an evaluation.

It may be schizophrenia may be something else but in any of the above an early intervention can make a big difference.

- Absolutely.

Absolutely.

- And finally, I want to ask you what do you say to a family who has a loved one with schizophrenia and to the person who has schizophrenia?

What's your guidance to them?

What do you have to say to them right now?

- The most important things for somebody who's young who's just been diagnosed with schizophrenia and their family is that it's important to find a good treatment team and to work with their treatment team to figure out what to do about medicine and what to do about treatment to email the experts.

I get emails all the time from family members asking me questions and I try to get them involved in treatments in their area 'cause I think it's really important to do that early on.

And I think that staying away from substances is key to the early development of the disorder.

It can certainly make things much worse.

It can make things much more difficult for your treatment team to figure out what illness you have and what to do about it when substances are involved.

So staying on medicine, not doing substances and getting involved in active psychosocial treatments are probably the most important things to do.

- Dawn, I want to thank you for joining us and for the extraordinary guidance that you're giving to families and really the general public to understand this illness and the treatment for it.

Thank you so much.

- Thank you so much for having me.

It was a pleasure.

(ambient music) - People with schizophrenia should make use of the full gamut of treatment that's available including medication, including torque therapy, including cognitive therapy and others.

All of these treatments together can help the person achieve their highest level of functioning and live a full healthy life.

(ambient music) Do not suffer in silence with help, there is hope.

(ambient music) This program is brought to you in part by the American Psychiatric Association Foundation (ambient music) and the John and Polly Sparks Foundation.

(ambient music)