cognition, psychotic illnesses, antipsychotics

[gabaergic1]

So a few questions...
We know cognitive impairment is evident in schizophrenia.
Has this been shown to be equally true in the dumpster diagnosis we call schizoaffective d/o?
Am I correct that this impairment progresses even in schizophrenia that is never treated?
Has anyone shown whether cognitive impairment due to antipsychotics is permanent- even when they are totally off of them after years? i.e. we talk about neurotoxicity of haldol.
If so, why are we so focused on warning people about TD + metabolic effects and not that fact they we might compound the course of becoming dumb? Do we *cause* schizoaffective disorder depressive type when people who have enough awareness of their cog nos become... sad?
Is goldstein's catastrophic reaction sometimes confused with "the agitation of psychosis?"
Curious.

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[whopper]

Only to add to the confusion, the majority of psychiatrists (at least from my experience) out there don't even know Haldol is neurotoxic. Schizoaffective disorder (no longer in the current DSM V) has often been debated as not being a real pathology unto itself but merely the combination of schizophrenia + a mood disorder.

If so, why are we so focused on warning people about TD + metabolic effects and not that fact they we might compound the course of becoming dumb?

Just answered your question.

Do we *cause* schizoaffective disorder depressive type when people who have enough awareness of their cog nos become... sad?

IMHO, in some cases yes, though almost every case I've seen of it, the person didn't get it from the meds. I've seen several cases where patients were over-medicated, but they often-times did not become depressed, they became zombies or angry at their clinicians. I always teach students that passivity does not equate to treatment success. If that's the case you could Thorzine everyone into oblivion and be the best doctor ever. Any patient that was violent due to psychosis and now passive, you got to make sure it's not because they're zonked out. The goal should be to improve them for real. Whenever a patient is on an antipsychotic, always ask if they're sedated, confused, or if they can't say it, do a critical evaluation of how they looked before and after the medication.

Zonking a patient out is only acceptable if they were dangerous, and it's used as a temporary measure such as injecting an agitated patient with antipsychotic, until you can get them better in a long-term sense. Either that or the patient's best is being dangerous even when almost everything else was tried such as ECT or Clozaril, but even then I'd have serious misigivings and would want that specific patient evaluated by more than one doctor and an ethics committee to look over it. Even then I don't know if I'd find it acceptable. You usually only see that type of patient in a long-term facility. I've had a few. One of them never got better, even with Clozapine and ECT. She's simply just trapped in the facility, likely never to ever leave, and everytime she acts out they have to tranq her up. Some of the world's top psychiatrists have checked her out and nothing else could be thought up of what to do except for things that some of the docs don't feel comfortable doing such as Reserpine.

 

[nitemagi]

Schizoaffective is still in DSM-V.

 

[vistaril]

So a few questions...
We know cognitive impairment is evident in schizophrenia.
Has this been shown to be equally true in the dumpster diagnosis we call schizoaffective d/o?
.

Speaking of these terms as if they are well defined unique entities is a lost cause to start with..........that said, I saw 48 outpts patients last Saturday at a private cmhcish place(yes, you read that right....the race to the bottom and all), and I'd guess 35 of them had a listed dx of schizoaffective d/o. Once you see 3 pts(new to you) in a row like that you have a few choices:

1) quit the job on the spot
2) try to 'fix' everyone by starting from scratch and taking a real hx(again 48 pts to be seen)\
3) just hold your nose, play the game, and get through the day

So no, you actually only have one choice(choice #3 for the BIF crowd)

 

[shan564]

Has this been shown to be equally true in the dumpster diagnosis we call schizoaffective d/o?

I think it's hard to prove anything conclusive about a dumpster diagnosis, since it's diagnosed so differently by different people. I do think that schizoaffective disorder is a real thing, but I don't think that the DSM-III/IV were handling it appropriately. I think that the DSM-V criteria do a better job of figuring it out, but still not quite there. Based on familial studies, I think it's hard to dispute that bipolar type schizoaffective is distinct from schizophrenia + bipolar disorder. I don't think we can make the same conclusion about depressed type schizoaffective vs. schizophrenia + MDD, although this is one of the areas where the DSM-V did improve things a bit.
But I don't know the actual answer to the actual question.

Am I correct that this impairment progresses even in schizophrenia that is never treated?

Yes. The cognitive symptoms of schizophrenia are debilitating. I'd argue that they're more severe than the cognitive side effects of antipsychotics, especially if the antipsychotics are used at appropriate doses.

Has anyone shown whether cognitive impairment due to antipsychotics is permanent- even when they are totally off of them after years? i.e. we talk about neurotoxicity of haldol.

If that existed, then I'm sure that the makers of Latuda would have made sure that we know about it.

If so, why are we so focused on warning people about TD + metabolic effects and not that fact they we might compound the course of becoming dumb?

In general, I think that the cognitive benefits of treating schizophrenia outweigh the cognitive adverse effects of the antipsychotic. Overall, I'd say that the net cognitive effect is positive, especially with most second-generation antipsychotics. Of course, this involves different cognitive pathways and different specific effects, so it's hard to make any firm statements, since we barely know anything about the mechanism behind either of those cognitive impairment processes.

Do we *cause* schizoaffective disorder depressive type when people who have enough awareness of their cog nos become... sad?

Again, I think that untreated schizophrenia will lead to more rapid cognitive decline than antipsychotic therapy will cause. But if somebody suddenly developed schizoaffective disorder depressed type after several years of having non-affective schizophrenia treated with antipsychotics, I might second-guess the diagnosis.

 

[splik]

cognitive impairment is a problem in schizophrenia and also in bipolar disorder. so one would think that patients with schizoaffective disorder also have cognitive impairment.

schizophrenia used to be called 'dementia praecox' so in the Kraepelinian concept of the illness the cognitive manifestations were seen as key, and early degeneration was noted in the pre-neuroleptic era. Today's concept of schizophrenia is more Schneiderian and we tend to emphasize bizarre positive symptoms though cognitive deficits are causing much of the impairment.

There is a limited amount of data suggesting a neuroleptics may induce a tardive dementia syndrome putatively related to chronic dopaminergic inhibition in the prefrontal cortex. Very little has been studied on this for various reasons, but it is deliberate. Recently it has become clear that antipsychotic therapy (both conventional and second generation antipsychotics) cause significant cortical atrophy which one presumes is associated with cognitive impairment but we really don't know what this means functionally. There is a literature on 'schizophrenic dementia' with predominant fronto-temporal deficits and hypoactivity on functional imaging - how much of this is illness related and how much neuroleptic related is unknown.

The literature for years has shown poorer functional outcomes with chronic neuroleptic therapy vs. no treatment, and the recent data suggests this is also true for atypical neuroleptics too. This is undoubtedly related to the significant cognitive impairment that is drug-related. We have turned a blind eye to this, because people were too scared that patients who already reluctant to take these drugs would stop taking them. That is the reason Nancy Andreasen gave for not publishing her findings of antipsychotic-related brain rot for many years. However this does not seem to be true, or a good reason to hide the truth. People who won't take their meds won't do so whatever, and those who will, will do so by making an informed choice of what matters to them.

depression in schizophrenia is depression, it's not schizoaffective disorder. schizophrenics get depressed too, and more often than someone without the illness.

 

[shan564]

The literature for years has shown poorer functional outcomes with chronic neuroleptic therapy vs. no treatment, and the recent data suggests this is also true for atypical neuroleptics too. This is undoubtedly related to the significant cognitive impairment that is drug-related. We have turned a blind eye to this, because people were too scared that patients who already reluctant to take these drugs would stop taking them. .

I think that this literature has to be limited by quite a bit of selection bias. A patient who is untreated is probably more likely to have less severe disease, and a patient who is receiving chronic neuroleptic therapy is probably more likely to have more severe disease. You can't do an RCT, and it would be very difficult to conduct a reliable a case-control study because there are so many variables to control for. This is one of the limitations of evidence-based medicine as a whole... I don't think that such data is adequate to say that it's "undoubtedly related to the significant cognitive impairment that is drug-related."

I recognize that this is descriptive rather than quantitative, but I think that your reference to Kraepelin is quite appropriate for this discussion. He describes cognitive deterioration beyond anything I've ever seen in patients who have had access to treatment. And he describes it as the natural history of the disease, not as an unusual complication. This has to be taken with a grain of salt - he also thoroughly describes catatonia and visual hallucinations, which are clearly not common findings - but the cognitive symptoms were common enough in the pre-antipsychotic era so that the disease was actually considered to be a "dementia" - Kraepelin described dementia praecox as a degenerative disease. Today, 60-year-old schizophrenics are commonly no less functional than 30-year-old schizophrenics.