Approaching neurocognitive impairment in psychiatric inpatients

[SmallBird]

On every inpatient psychiatric unit I have worked, there is a sizable group of young to middle-age patients who are admitted for psychosis exacerbations on the basis of functional problems in the community, but where there is no evidence of clear perceptual disturbance, nor do they appear to be exhibiting excess salience attribution, or reporting fixed bizarre delusions. Rather, they seem to be prominently dysexecutive, unable to describe or implement reasonable plans for getting through life, fail to sustain employment, seem to forget critical details as to their care needs, come across as confused and disorganized, and end up in crisis situations as a result. Frequently, I see these patients managed as if they have schizophrenia, with aggressive neuroleptic use and no additional workup. My increasingly ineffective strategy has been to consult neurology, but in the absence of a major motor symptom they are desperately uninterested in seeing these patients, seem to find the consult question ("Can you assess whether this patient has or requires additional workup to determine the relative contribution of an underlying neurocognitive disorder to their current presentation?") impossible, or will recommend that additional workup be done as an outpatient. I am hoping for some feedback around when others would seek to get additional input on a case like this, and how they have experienced interactions with neurology (or other specialists when available). I am at the point where I think I need to just fill in my own gaps in knowledge so that I am in a position to work-up these presentations without consultation.

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[Candidate2017]

Personality disorder would be high on the differential. There is also a significant minority who refuse to do the adulting thing due to personality traits that do meet criteria for a disorder.

All these people end up on meds, including antipsychotics, because psychiatrists feel pressure to diagnose and prescribe a pill for every life ill. There is also medicolegal pressure too to do something rather than document the equivalent of, "Nah, no psychiatric disorder, recommend assume more personal responsibility, cut back on weed, get a job, and work with a therapist to navigate adulthood."

Though, there is some evidence that antipsychotics and mood stabilizers can be helpful in personality disorders such as borderline personality. Anyway, neuro is correct to decline these cases absent any evidence of neuro disorder.

 

[romanticscience]

I don't work inpatient, but here are some thoughts, many of which developed with the help of cognition chapters in this book. Basically, utilize brief bedside cognitive testing other than the MOCA that has some normative data (oral versions of the Trails A--B, Category Fluency, Digit Symbol Substitution Test, Digit Span) and focus on pharmacotherapy for their primary diagnosis that has a known evidence base for helping with cognition secondarily.

 

[WisNeuro]

I don't work inpatient, but here are some thoughts, many of which developed with the help of cognition chapters in this book. Basically, utilize brief bedside cognitive testing other than the MOCA that has some normative data (oral versions of the Trails A--B, Category Fluency, Digit Symbol Substitution Test, Digit Span) and focus on pharmacotherapy for their primary diagnosis that has a known evidence base for helping with cognition secondarily.

Be careful with some of these, just because norms exist, doesn't make them great. For example, most of the norm sets on oral trails are either in healthy adults and have cell N's of 15-30, or were done on lesion groups. So, your 95% confidence intervals are going to be very wide on those. Also, most of these tests named can be heavily influenced by temporary issues (e.g., sedating/anticholinergic medication, poor sleep, severe psych sx). So, bedside instruments have their place, but make sure you have a good grasp of where the norms come from and what you are actually measuring.

 

[splik]

One of the things I specialize in is evaluation of cognitive decline in patients with a history of serious mental illness. Though not in the inpatient setting. Most neurologists have zero interest in this unless they are cognitive neurologists. As you know, many of these patients would have been diagnosed with "simple schizophrenia" back in the day, and Kraepelin's conception of schizophrenia had cognitive decline as the sine qua non of dementia praecox (compared with Bleuler who focused on thought disorder, and Schneider who focused on positive symptoms/his "first rank" symptoms). Technically most of these patients no longer meet DSM-5 criteria for schizophrenia but in recent years there has again be interest in cognitive symptoms in schizophrenia from a pharmacological and non-pharmacological perspective.

Normally what I am being asked about is distinguishing patients with primary psychiatric disorder from a degenerative process or other neuropsychiatric disorder. Also have to consider the effects of medications including anticholinergics, benzos, and neuroleptics on cognitive function. I have seen pts on neuroleptics become demented (and tardive dementia is a thing, albeit rare). an FTD-like syndrome has also been described in older pts with schizophrenia (typically those who had a history of positive symptoms or more classic "schizophrenia" earlier in life). A very small proportion of such patients may have the C9orf72 hexanucleotide repeat expansion.

You obviously want to consider any potential other causes, but if you are seeing an adolescent or young adult presenting with insidious cognitive and functional decline without any other neurological or psychiatric symptoms with inattentiveness and executive dysfunction as key features, this has been historically considered a form of schizophrenia. You can consider TBI, toxic exposure (carbon monoxide, manganese), neuroendocrine dysfunction, nutritional deficiencies (b12, folate, vitamin E), substance abuse (stimulants, solvents/inhalants, nitrous oxide, can also see apathy and dysexecutive syndromes with basal ganglia lesions from opioid abuse), epilepsy, and neurogenetic disorders (e.g. wilson's, metachromatic leukodystrophy, homocysteinuria etc). Other considerations are depression, sleep apnea, chronic fatigue syndrome/fibromyalgia, PTSD with prominent dissociation, functional cognitive disorder and factitious disorders.

Neuropsychological testing and OT functional evaluation may be helpful.

In terms of treatment, there is not that much pharmacologically you can do for these cognitive symptoms of psychosis. In general, you avoid first generation neuroleptics (though the CATIE study found even perphenazine had some benefit on cognitive symptoms) and anticholinergics. most of the newer neuroleptics have shown some small benefit in cognitive function. More recently, asenapine and cariprazine had been touted as such. Clozapine also may improve cognitive functioning in a subset of patients. I have occassionally used methylphenidate and pramipexole in pts with "simple schizophrenia" with some improvement and without development of positive symptoms. Nicotine may help some pts (and may be one reason why smoking is so common in such pts). Antidepressants seem to have statistically significant but clinically irrelevant impact. memantine and anticholinesterase inhibitors have also been tried usually without benefit.

Cognitive remediation therapy, vocational therapies, rehabilitation approaches, and realistic appraisal of patients functional limitations and need for care in supervised settings are probably going to be more important pragmatically. Part of the issue is we often don't have space in industrialized society for these patients to meaningfully participate (which may be one reason for historically poorer outcomes in the US).

 

[G Sheb]

As alluded above, pychotic illnesses can in and of themselves lead to cognitive dysfunction.
History of heavy substance is another big one. Particularly K2 and alcohol of course.
Of course ideally you would want to first rule out any reversible causes.

 

[romanticscience]

presenting with insidious cognitive and functional decline without any other neurological or psychiatric symptoms with inattentiveness and executive dysfunction as key features, this has been historically considered a form of schizophrenia.

These are difficult cases, mostly college kids, who keep saying, "my ADHD is getting worse and worse; It’s so bad, I can’t get up from the couch and go to class."

Any other tips for differentiating simple schizophrenia and ADHD? Anyone who is young nowadays and has cognitive symptoms goes right to ADHD. Sometimes, I snarkily ask whether they're worried about ultra early onset Alzheimers.

 

[WisNeuro]

These are difficult cases, mostly college kids, who keep saying, "my ADHD is getting worse and worse; It’s so bad, I can’t get up from the couch and go to class."

Any other tips for differentiating simple schizophrenia and ADHD? Anyone who is young nowadays and has cognitive symptoms goes right to ADHD. Sometimes, I snarkily ask whether they're worried about ultra early onset Alzheimers.

If you can get any reliable collateral information, the timeline of symptoms and difficulties is good information to have.

 

[comp1]

I would find this unusual in a "young" person with a schizophrenia diagnosis unless the OP is just referring to the negative avolitional aspect of schizophrenia. However, in middle age, it's the norm. Most people with schizophrenia who live long enough will develop dementia. The reason neurology isn't interested is that they can't do anything more about it than you can.

 

[erg923]

On every inpatient psychiatric unit I have worked, there is a sizable group of young to middle-age patients who are admitted for psychosis exacerbations on the basis of functional problems in the community, but where there is no evidence of clear perceptual disturbance, nor do they appear to be exhibiting excess salience attribution, or reporting fixed bizarre delusions. Rather, they seem to be prominently dysexecutive, unable to describe or implement reasonable plans for getting through life, fail to sustain employment, seem to forget critical details as to their care needs, come across as confused and disorganized, and end up in crisis situations as a result. Frequently, I see these patients managed as if they have schizophrenia, with aggressive neuroleptic use and no additional workup. My increasingly ineffective strategy has been to consult neurology, but in the absence of a major motor symptom they are desperately uninterested in seeing these patients, seem to find the consult question ("Can you assess whether this patient has or requires additional workup to determine the relative contribution of an underlying neurocognitive disorder to their current presentation?") impossible, or will recommend that additional workup be done as an outpatient. I am hoping for some feedback around when others would seek to get additional input on a case like this, and how they have experienced interactions with neurology (or other specialists when available). I am at the point where I think I need to just fill in my own gaps in knowledge so that I am in a position to work-up these presentations without consultation.

Some people are just not very bright

 

[Stagg737]

As has been stated in past threads this reminds me of, collateral is king. I've had a few patients that fit OP's description almost to a T and they have almost uniformly fallen into 1 of 2 categories:

1. Young patients with substance use. Sometimes this is d/t significant substance use that the patient or family downplays as "mild" or "not that much" when it is far more significant in reality. AKA, "Well he doesn't smoke that much weed. How much? Well, he smokes every day, but usually just at night. Except on weekends, then he smokes a couple of times per day. When did he start? I think when he was 13 or 14, but he did start using it daily until he was in college!" Says the parent of the 27-year-old kid who just can't get motivated enough to do a load of laundry. See this more often in slightly older kids (late 20's, 30's). The flip side to this is the kids who use some exotic or heavy substance that doesn't show up on UDS but we later find out about. I've actually seen this more than a few times with synthetic cannibinoids and a few other times with less common hallucinogens that just seem to trigger something else. These have typically been in the younger population though (under 25) who have a literal million-dollar work-up that shows nothing abnormal but parents find out about some illicit substance use they were previously unaware of.

2. Patients whose baseline level of functioning was overstated by others or just wasn't that high in the first place and have an episode of something more common (depression) that just looks more severe. Here, initial collateral from parents is that "they were totally normal until XYZ and then they just weren't themselves" only to find out when really questioning parents that they always struggled but could stay afloat until MDD or some severe stressor hit when they just tank. In residency we were fortunate to have an excellent psychometrist on our inpatient team who was very good with teasing out actual functional capabilities. Like erg said, some people just aren't very bright.

In both the above situations, neuro isn't typically going to be able to provide much benefit and my current view for neuro consults are typically more limited to patients where I think they can offer real diagnostic clarity or I'm 99.9% convinced that the patient's biggest problem is not a primary psych issue. Imo, best ways to get actual diagnostic clarity is really taking time to get collateral from family/friends and figuring out their baseline level of functioning (neuropsych testing and autism screening, OT involvement for KELS, etc). If that all looks okay and a decent medical work-up is negative (including vitamin deficiencies, infectious panel, neuro work-up), then we can start hunting for zebras.

 

[Stagg737]

I'll also add that after my PGY-4 year I have a VERY low threshold for treating for possible catatonia, as I saw some very bizarre presentations of catatonia which responded really well to high dose benzos and/or ECT. Keep in mind that there are many non-psychiatric causes of catatonia and that it is likely more prevalent than many people realize.

 

[smalltownpsych]

As has been stated in past threads this reminds me of, collateral is king. I've had a few patients that fit OP's description almost to a T and they have almost uniformly fallen into 1 of 2 categories:

1. Young patients with substance use. Sometimes this is d/t significant substance use that the patient or family downplays as "mild" or "not that much" when it is far more significant in reality. AKA, "Well he doesn't smoke that much weed. How much? Well, he smokes every day, but usually just at night. Except on weekends, then he smokes a couple of times per day. When did he start? I think when he was 13 or 14, but he did start using it daily until he was in college!" Says the parent of the 27-year-old kid who just can't get motivated enough to do a load of laundry. See this more often in slightly older kids (late 20's, 30's). The flip side to this is the kids who use some exotic or heavy substance that doesn't show up on UDS but we later find out about. I've actually seen this more than a few times with synthetic cannibinoids and a few other times with less common hallucinogens that just seem to trigger something else. These have typically been in the younger population though (under 25) who have a literal million-dollar work-up that shows nothing abnormal but parents find out about some illicit substance use they were previously unaware of.

2. Patients whose baseline level of functioning was overstated by others or just wasn't that high in the first place and have an episode of something more common (depression) that just looks more severe. Here, initial collateral from parents is that "they were totally normal until XYZ and then they just weren't themselves" only to find out when really questioning parents that they always struggled but could stay afloat until MDD or some severe stressor hit when they just tank. In residency we were fortunate to have an excellent psychometrist on our inpatient team who was very good with teasing out actual functional capabilities. Like erg said, some people just aren't very bright.

In both the above situations, neuro isn't typically going to be able to provide much benefit and my current view for neuro consults are typically more limited to patients where I think they can offer real diagnostic clarity or I'm 99.9% convinced that the patient's biggest problem is not a primary psych issue. Imo, best ways to get actual diagnostic clarity is really taking time to get collateral from family/friends and figuring out their baseline level of functioning (neuropsych testing and autism screening, OT involvement for KELS, etc). If that all looks okay and a decent medical work-up is negative (including vitamin deficiencies, infectious panel, neuro work-up), then we can start hunting for zebras.

These are exactly the patients that I was thinking of in reading OPs post. Also, marijuana use can really jack up the disorganization in some of these folk who are more prone to this for whatever reason. In a residential treatment program where we had quite a few patients with significant mental health issues and normal to above average cognitive ability we would see dramatic and lasting effects from even one use of marijuana. It’s hard to believe since the vast majority of people can use it with such mild and transitory effects, but it seems pretty real.

 

[calvnandhobbs68]

Some people are just not very bright

This is actually not a bad statement. I also agree with @Stagg737 , there are a good number of people out there who are borderline intellectual functioning/mild ID who honestly have just never been identified. Maybe they’ve held down a simple food service job or something in high school and done borderline in terms of grades but just kind of limped along. This ends up becoming more apparent after 18-19yo because the school system just moves them along since they’re technically passing (or at least not failing enough) to move on, so everyone gets the sense that, eh they’re fine I guess or they write it off as them “being a teenager” (but you’ll usually get the comments from parents that they were “never really a good student”). Maybe they do have comorbid ADHD but can be hard to tease apart when they’re 20 because they’ve also been smoking weed or doing inhalants or something along the way. It’s also helpful to ask the person or collateral if they had any accommodations in grade/high school…I’ve had people who were like “oh yeah they’d get special help for reading or have to go to a special classroom” or clearly had an IEP for what was most likely a learning disability but just never got diagnosed with anything past that (school systems will rarely diagnose kids with neurodevelopmental disabilities like ID/ADHD/ASD as they consider that outside their purview).

I think this is quite a bit different picture from someone who was functioning well (usually best confirmed by collateral if you can) until they were an older teenager/young adult and then they just fell off.

Our system just doesn’t do a great job of doing anything for these people…so a lot of them end up doing menial jobs or no job at all, doing drugs and getting depressed.

 

[Celexa]

Lots of good insight and ideas in this thread. One thing you can do inpatient on this patients is aggressively reduce their anticholinergic burden if you can. Routine use of cogentin is far, far too common and many other meds also have anticholinergic properties.

 

[Liquid8]

Was reading the OP and the disorganised or hebephrenic schizophrenia subtype that was in DSM IV came to mind.

When I worked in inpatient I rarely saw this, as opposed to those with florid paranoid delusions or auditory hallucinations, but every now and then we’d get one with a weird affect or highly disorganised speech and behaviour. Not just forgetting things, but dysfunctional eating, showering or dressing for example. In addition to excluding physical causes and drugs, would have to consider schizotypal PD, OCD and autism as possible differentials.

 

[SmallBird]

Thank you guys, really helpful. I believe my perspective on neurology is forever influenced by having a close friend who is a behavioral neurologist at Mayo Clinic - he would see a patient like this with great care. Not just because it could be a categorical diagnosis like FTD, but because there a cognitive dimensions to the presentation that they could assist in formulating. Turns out this does matter when you are in a position of deciding whether a forced med hearing is critical, out of the belief that aggressive treatment of abberant salience and perceptual disturbance will increase the patients ability to be safe and function, versus a demonstration of likely irreversible and severe deficits in executive function, learning and memory for which you can make the case for placement in a supportive community environment (either by beginning the process for entitlement through DDS or even a nursing home placement depending on the overall needs).

Clearly however the typical neurologist has no interest in this type of work - hope that's no unfair to say - and I was the outlier for expecting them to do so.

 

[Celexa]

Clearly however the typical neurologist has no interest in this type of work - hope that's no unfair to say - and I was the outlier for expecting them to do so.

It's not unfair to say. It is undoubtedly true.

 

[calvnandhobbs68]

Was reading the OP and the disorganised or hebephrenic schizophrenia subtype that was in DSM IV came to mind.

When I worked in inpatient I rarely saw this, as opposed to those with flord paranoid delusions or auditory hallucinations, but every now and then we’d get one with a weird affect or highly disorganised speech and behaviour. Not just forgetting things, but dysfunctional eating, showering or dressing for example. In addition to excluding physical causes and drugs, would have to consider schizotypal PD, OCD and autism as possible differentials.

Absolutely ASD for sure. There have been really bad case reports of people who were "psychotic" basically living on inpatient units getting slammed with antipsychotics who were really autistic. I have personally had psychologists tell me we had to "do something about this kid's psychosis"....for a kid with autism who talking to himself all the time. I always remember the origins of the phrase autism itself right....Bleuler describing symptoms of schizophrenia.

 

[forchinet121]

We should have neurologists chime in with their experience

 

[SmallBird]

M

Absolutely ASD for sure. There have been really bad case reports of people who were "psychotic" basically living on inpatient units getting slammed with antipsychotics who were really autistic. I have personally had psychologists tell me we had to "do something about this kid's psychosis"....for a kid with autism who talking to himself all the time. I always remember the origins of the phrase autism itself right....Bleuler describing symptoms of schizophrenia.

i agree - AND - I think you can free your mind and realize that both are neuro developmental disorders and that is possible patients may have social cognitive deficits present from the very earliest periods of development and go on to develop abnormalities in information processing that drive psychotic phenomenology later in life, and ultimately patients aren't helped by us creating these two poles of opinion but rather crafting a more detailed accounting of what their deficits are, how severe they are across each dimension, and what we can do for each. To your point - clozapine will never fix an inability to efficiently sift through noisy social information in the manner required for neuro typical social engagement, but antipsychotics may be very valuable in patients who have additional problems in how they are forming beliefs or non-veridical percepts.

 

[smalltownpsych]

Absolutely ASD for sure. There have been really bad case reports of people who were "psychotic" basically living on inpatient units getting slammed with antipsychotics who were really autistic. I have personally had psychologists tell me we had to "do something about this kid's psychosis"....for a kid with autism who talking to himself all the time. I always remember the origins of the phrase autism itself right....Bleuler describing symptoms of schizophrenia.

The last few years working with young adults with high functioning autism and psychotic disorders it has been fascinating to see the overlap and also the challenge of differentiating. It does seem that some people are more prone to disorganization and bizarre thoughts or sensory disturbances than others and many of the people we worked with were in that category. Some would stabilize with just removal of stressors and stimuli and become run of the mill high functioning autistic kids while others would continue to have odd thoughts and experiences. The former seemed to benefit from lowering and discontinuing their antipsychotics and the latter needed to continue them. What is interesting is that it seems that one differential is willingness to get treatment and take medications. Maybe it ties into the autistic kids with psychotic symptoms due to total overwhelm seem to be ego dystonic whereas not so much with a psychotic disorder.

 

[SmallBird]

The last few years working with young adults with high functioning autism and psychotic disorders it has been fascinating to see the overlap and also the challenge of differentiating. It does seem that some people are more prone to disorganization and bizarre thoughts or sensory disturbances than others and many of the people we worked with were in that category. Some would stabilize with just removal of stressors and stimuli and become run of the mill high functioning autistic kids while others would continue to have odd thoughts and experiences. The former seemed to benefit from lowering and discontinuing their antipsychotics and the latter needed to continue them. What is interesting is that it seems that one differential is willingness to get treatment and take medications. Maybe it ties into the autistic kids with psychotic symptoms due to total overwhelm seem to be ego dystonic whereas not so much with a psychotic disorder.

Your clinical observation is consistent with emerging models in cognitive neuroscience. One theory is that in ASD, patients struggle to form accurate short-cuts or templates for understanding the social world, making it a very exhaustive process where they have to analyze way too much information even in fairly routine social settings. They eventually do learn some templates, but when the environment is significantly altered they are quickly thrown off - case reports describe the creation of delusional systems to 'overfit' the overwhelming sensory experiences that result (such as a young male who believed he had been abducted by aliens when he was on an inpatient unit, until he was able to over time form a workable reality based explanation for his situation).

This is quite different from the tendency to form delusions because of excess emphasis is placed on a small amount of information (such as a strange glance) that could be discarded as unimportant, which occurs in psychotic disorders. Altering dopaminergic tone is the most readily available tool in these cases.

 

[calvnandhobbs68]

M

i agree - AND - I think you can free your mind and realize that both are neuro developmental disorders and that is possible patients may have social cognitive deficits present from the very earliest periods of development and go on to develop abnormalities in information processing that drive psychotic phenomenology later in life, and ultimately patients aren't helped by us creating these two poles of opinion but rather crafting a more detailed accounting of what their deficits are, how severe they are across each dimension, and what we can do for each. To your point - clozapine will never fix an inability to efficiently sift through noisy social information in the manner required for neuro typical social engagement, but antipsychotics may be very valuable in patients who have additional problems in how they are forming beliefs or non-veridical percepts.

Oh absolutely they can co-exist, no doubt about that. But it's been my experience also that autistic patients are very "leading question" friendly and may often tell a social story they think you want to hear, which means that if you go ask them "do you hear things? do you see things? are you worried someone's out to get you?" you can get all kinds of responses. And then of course all the autism sx that look like "negative" symptoms in schizophrenia. And if you take a lot of this stuff at face value, you get lots of reasons to put someone on an antipsychotic. Whichhh ya know if we go back to the discussion about doctors that spend 3 minutes talking to someone on an inpatient unit and see a "psychotic" person sitting there talking to himself and pacing in the hallways talking about how hears bad voices telling him bad stuff about himself and he's been locked up against his will we could see how this becomes an unfortunate path to go down

Just to give an example from that case though, my autistic patient's "psychotic" symptoms (which again consisted of him talking to himself, becoming agitated sitting during class and pacing up and down the hallways and telling people he was hearing "bad voices" which when you dialed down into it were self-depreciating thoughts about himself in various social situations basically) were pretty drastically solved by letting him attend school 3/5 days a week (parents were able to homeschool other days) and treating his ADHD

 

[Liquid8]

Oh absolutely they can co-exist, no doubt about that. But it's been my experience also that autistic patients are very "leading question" friendly and may often tell a social story they think you want to hear, which means that if you go ask them "do you hear things? do you see things? are you worried someone's out to get you?" you can get all kinds of responses. And then of course all the autism sx that look like "negative" symptoms in schizophrenia. And if you take a lot of this stuff at face value, you get lots of reasons to put someone on an antipsychotic. Whichhh ya know if we go back to the discussion about doctors that spend 3 minutes talking to someone on an inpatient unit and see a "psychotic" person sitting there talking to himself and pacing in the hallways talking about how hears bad voices telling him bad stuff about himself and he's been locked up against his will we could see how this becomes an unfortunate path to go down

Just to give an example from that case though, my autistic patient's "psychotic" symptoms (which again consisted of him talking to himself, becoming agitated sitting during class and pacing up and down the hallways and telling people he was hearing "bad voices" which when you dialed down into it were self-depreciating thoughts about himself in various social situations basically) were pretty drastically solved by letting him attend school 3/5 days a week (parents were able to homeschool other days) and treating his ADHD

At the end of the day it's often about drilling down into the details and descriptions of the symptoms themselves.

Not too long ago a colleague who does a lot of developmental and disability work was discussing a case he was asked to see for a second opinion. The patient in question was a young man with autism who the team was wondering about schizophrenia as he was hallucinating and observed to be talking to himself but had not seemed to improve on high dose antipsychotics. It turned out that the hallucinations were in fact the patient reciting film or TV quotes which was his niche interest, and was doing this as a way of coping with a number of recent stressful situations associated with changes to routine. Eventually it came out that the patient would recite the lines and mimick the particular accents to remind them of happier times.

Can also remember one of my own patients from years ago who presented with what looked like a drug induced psychosis, but also couldn’t rule out a prodromal episode. After the LSD washed out of her system, she was still behaving in a very strange way, eg. bringing the dirt from the hospital garden into her room to make murals and witching circles, meowing like a cat etc. We were able to have a rationale discussion about the reasons behind this and it just seemed more quirky/eccentric as opposed to psychotic. Collateral revealed that they’d always had that kind of naturalistic/flower child/hippie affinity, and a schizotypal construct seemed the most likely explanation. We ceased her anti-psychotics after the initial period, but I’ve often wondered what would have happened if I was less inquisitive. Before coming to me she'd been admitted and discharged on an anti-psychotic, so ending up as an involuntary patient on a lifelong depot injection was a possible future.

 

[hallowmann]

Absolutely ASD for sure. There have been really bad case reports of people who were "psychotic" basically living on inpatient units getting slammed with antipsychotics who were really autistic. I have personally had psychologists tell me we had to "do something about this kid's psychosis"....for a kid with autism who talking to himself all the time. I always remember the origins of the phrase autism itself right....Bleuler describing symptoms of schizophrenia.

It is very unfortunate the number of patients I've had to taper off of antipsychotics when it became clear that they either had intellectual disability at baseline or autism spectrum disorder. Always doing better after. It was also painfully obvious that this happened more with people of color in a relatively homogenous state. Poor social supports, an interpretation of poor communication, odd thoughts or outbursts during transitions or periods of intense stimuli, misunderstood situations or self-talk as psychosis, and boom they're on an antipsychotic for years if not decades. Even reading the records from when it was started you can see past it and its glaringly clear when you speak with collateral. Its very frustrating when its clear diagnosing schizophrenia and sedating with a neuroleptic was taken as an "shortcut".

 

[SmallBird]

Oh absolutely they can co-exist, no doubt about that. But it's been my experience also that autistic patients are very "leading question" friendly and may often tell a social story they think you want to hear, which means that if you go ask them "do you hear things? do you see things? are you worried someone's out to get you?" you can get all kinds of responses. And then of course all the autism sx that look like "negative" symptoms in schizophrenia. And if you take a lot of this stuff at face value, you get lots of reasons to put someone on an antipsychotic. Whichhh ya know if we go back to the discussion about doctors that spend 3 minutes talking to someone on an inpatient unit and see a "psychotic" person sitting there talking to himself and pacing in the hallways talking about how hears bad voices telling him bad stuff about himself and he's been locked up against his will we could see how this becomes an unfortunate path to go down

Just to give an example from that case though, my autistic patient's "psychotic" symptoms (which again consisted of him talking to himself, becoming agitated sitting during class and pacing up and down the hallways and telling people he was hearing "bad voices" which when you dialed down into it were self-depreciating thoughts about himself in various social situations basically) were pretty drastically solved by letting him attend school 3/5 days a week (parents were able to homeschool other days) and treating his ADHD

I agree with everything you are saying, but to be clear, it is a different point. You make the excellent point that accurate phenomenology requires more that taking a response to a question at face value as a patient may endorse a symptom for a host of reasons. This point is probably even more important than the one I was making. But to clarify my point - to say ASD and SCZ 'co-exist' is to again miss the point that we don't have to think in categorical terms. Rather, within the spectrum of neurocognitive profiles that will have a predominantly autism appearing phenotype, some will have sufficient variation on specific domains to drive the development of psychotic symptoms - this doesn't mean they have a seperate illness even if their phenomenology crosses boundaries.

It's similar to how ADHD is also diagnosed as a 'comorbidity' in patients with ASD or ID as if pervasive cognitive impairment isn't also likely to impact attention and executive function. As the recent poster said I think drilling down to the specifics for each patient and then using as many words as needed to describe their deficits and strengths is critical, rather than attaching to a diagnostic label and adding several comorbid diagnoses (not that you were implying that, just to drive the point).