Complete remission of schizophrenia

[phantasmagoric]

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How often do you see complete remission of schizophrenia with proper treatment?
To my knowledge, it is relatively rare and I think I read on Stahl's saying 15 percent of cases.

This would have implications in terms of inheriting a patient on LAI with questionable schizophrenia diagnosis, particularly if the patient as they present to you today do not have any signs/symptoms of schizophrenia.

Let's say that they have historically reported AVH, paranoia, but you do not observe any formal thought disorder or residual/negative symptoms currently. Normal MSE. You could have never guessed that they would have schizophrenia today, but you are also not completely confident that stopping the antipsychotic would not de-stabilize the patient.

So for a patient with "true" schizophrenia (as opposed to brief psychosis, schizophreniform, borderline, "pseudo-psychosis"), how often can you see a complete remission?

 

[romanticscience]

Remission, as in no longer meeting DSM acute-phase criteria? I see that a lot. Unfortunately, I've never really seen a case that doesn't still exhibit a chronic self-disorder (i.e., Bleuler's fundamental symptoms). Those that "you could never have guessed" make me wonder about brief psychotic disorder and bipolar disorder. I routinely employ the EASE assessment to help differentiate.

 

[phantasmagoric]

Remission, as in no longer meeting DSM acute-phase criteria? I see that a lot. Unfortunately, I've never really seen a case that doesn't still exhibit a chronic self-disorder (i.e., Bleuler's fundamental symptoms). Those that "you could never have guessed" make me wonder about brief psychotic disorder and bipolar disorder. I routinely employ the EASE assessment to help differentiate.

Right. It sounds like cases in which "you could never have guessed" should be rare, and this being distinct from no longer meeting DSM acute-phase criteria (which I agree can be seen often).

I would be curious to hear others' thoughts. Hypothetically, if a patient under paranoid or mild undifferentiated sub type (as opposed to disroganized type, to follow DSM 4 terminology) were succesfully treated on antipsychotics for a period of time, could we possibly see that they are nearly without any evidence of previous self-disorder?

 

[romanticscience]

Maybe I was unclear; I use the term self-disorder as a sort of non-acute manifestation of schizophrenia, which antipsychotics wouldn't be expected to influence much. Though sometimes it's hard to tell if attenuated symptoms (e.g., audible thoughts) are the product of the treatment (i.e., improved from auditory hallucinations). I think it was called something like latent or residual schizophrenia back in the day. Current cognitive symptoms could also help, with a decline post-acute phase expected in schizophrenia.

It does seem there is a small group that does recover who may remain relapse-free without sustained treatment. I'd be curious as to how they define "recover"; my guess is it's some reduction on the BPRS or something. It's tough because there is mixed evidence about the longer-term course and the meaningful benefit of antipsychotics.

This might help: https://onlinelibrary.wiley.com/doi/10.1002/wps.20516

 

[phantasmagoric]

Yes, I may have used the terms bit loosely there, as I understood self-disorder as something akin to non-acute, residual symptoms often negative symptoms - something that would tell me something was "off" despite remission of first rank symptoms and overt disorganization.

My original question still stands though.

 

[psydocc]

Full remission of both positive and negative symptoms in someone with schizophrenia? Never. Our current treatment regimens have limited benefit to negative symptoms. A stark global improvement would make me think the schizophrenia was a misdiagnosis. Occam's razor.

 

[phantasmagoric]

What if the patient never had negative symptoms (or overt disorganization) in the first place, but rather presented as a relatively "mild" paranoid subtype per DSM IV (presenting with only AH + delusions), which improved significantly with antipsychotics?

Could we possibly see such a patient so improved that it would be difficult to guess that he was diagnosed in the past?

 

[FatherPsychiatry]

What if the patient never had negative symptoms (or overt disorganization) in the first place, but rather presented as a relatively "mild" paranoid subtype per DSM IV (presenting with only AH + delusions), which improved significantly with antipsychotics?

Could we possibly see such a patient so improved that it would be difficult to guess that he was diagnosed in the past?

Yeah. Especially with patients who have characteristics of those typical boards type questions about factors related to better outcomes - shorter sx duration, good premorbid functioning, acute psychosis vs long prodromal period, only positive and little/no neg sx, no cognitive impairment, strong psychosocial support, no drug use, etc etc... but I agree with posters above - more likely than not, the previous diagnosis was a misdiagnosis. Someone was stressed and used a little too much weed and Claude, mom drove them to a hospital but hospital can't bill for Cannabis/Claude induced psychosis so they gotta put Schizophrenia.

And that's even before getting into the weeds about the definition of "Schizophrenia" to begin with.

 

[mistafab]

What if the patient never had negative symptoms (or overt disorganization) in the first place, but rather presented as a relatively "mild" paranoid subtype per DSM IV (presenting with only AH + delusions), which improved significantly with antipsychotics?

Could we possibly see such a patient so improved that it would be difficult to guess that he was diagnosed in the past?

I sometimes run into this in younger patients who got appropriate treatment, and the disorder did not do significant chronic damage to IQ and deep negative symptoms. For example, a 28 yo who had prodrome-> psychosis from 20-22. Stayed on meds, had minor blips of symptoms trying to peel them off, so stayed on. Shows up in office at 28 rock solid stable.

I had one such case where there was mild tardive symptoms and some looser associations - but overall was remitted. He was insistent on keeping the same meds because he was deeply disturbed by the psychosis when it occurred. He was working full time and getting back into school when I had been helping him.

Early intervention and med compliance with good insight is the best shot you have at this.

 

[phantasmagoric]

Thank you for your responses. I agree that in most clinical settings a misdiagnosis is going to be the most likely scenario in general.

 

[futureapppsy2]

Yeah. Especially with patients who have characteristics of those typical boards type questions about factors related to better outcomes - shorter sx duration, good premorbid functioning, acute psychosis vs long prodromal period, only positive and little/no neg sx, no cognitive impairment, strong psychosocial support, no drug use, etc etc... but I agree with posters above - more likely than not, the previous diagnosis was a misdiagnosis. Someone was stressed and used a little too much weed and Claude, mom drove them to a hospital but hospital can't bill for Cannabis/Claude induced psychosis so they gotta put Schizophrenia.

And that's even before getting into the weeds about the definition of "Schizophrenia" to begin with.

A patient at my postdoc would be totally fine if they stayed away from marijuana, but any use would trigger a full psychotic break requiring hospitalization. Their treatment team finally had a serious talk with them about how they absolutely needed to avoid pot, no matter how much use was normalized in their peer group.

 

[Orgone]

I agree that misdiagnosis is a real possibility, or even likelihood, in these scenarios. But I've been burned by going down or off meds and come to find out ... nope, they were real deal. Getting good collateral from records or family if possible can really help, obviously. I also slightly disagree from some of the other posters in that I've treated a number of patients who I've thought I would "never know" they had schizophrenia if I didn't have good history.

Any of our experiences are also highly shaped by where we work. Some areas are exposed a lot more to shoddy clinicians who have no trouble slapping a schizoaffective bipolar type diagnosis on someone who heard a voice once when they were falling asleep and one time stayed up all night at a party and gets irritable when their mom throws out their pot.

 

[comp1]

Definitionally, you shouldn't. Symptoms can certainly improve. Heck people may appear pretty darn functional, holding down jobs, paying taxes, etc, but a "full resolution" with no residual symptoms was not schizophrenia.

 

[FlowRate]

I had one patient with persistent relatively severe visual hallucinations which went away with antipsychotics. He then vehemently wanted to get off of AP's after a couple of years and remained hallucination free for as long as I was able to follow up with him (his employer switched insurance plans after a year.) Maybe slightly odd, but overall normal seeming guy.

I have another patient who had mild-moderate thought disorder and likely cognitive decline from peak--very high premorbid function--who also remains slightly odd but otherwise you also wouldn't think he had schizophrenia if you didn't know his premorbid function.

By definition the vast majority of my patient population has income and/or is holding down a job, i.e. is not medicaid primary, so I don't really see the people clustered at the academic center or the CMHC's. Probably 5-10 of my ~600-something patients have some sort of psychotic disorder. Usually relatively atypical (and mild) presentations.

 

[splik]

A substantial minority of patients full recover. Even in the days before antipsychotics. Of course psychiatrists won’t see patients who fully recover so tend to have a very negative view. It doesn’t help that the American concept of schizophrenia is more bleak than in the rest of the world so people seem to think if patients get better they never had it to begin with, which is circular logic. If you believe that then of course you won’t see it

 

[comp1]

Yeah, like I said it's a definitional thing. I mean most of psychiatry is a definitional thing and I'm definitely only talking about American concepts. If you get into how China, Nigeria, India or Russia conceptualize schizophrenia...you'd be essentially talking a different language. Even much of Western Europe would have very different definitions. This is why FMGs have to do American residencies.

 

[Cath Up]

A substantial minority of patients full recover. Even in the days before antipsychotics. Of course psychiatrists won’t see patients who fully recover so tend to have a very negative view. It doesn’t help that the American concept of schizophrenia is more bleak than in the rest of the world so people seem to think if patients get better they never had it to begin with, which is circular logic. If you believe that then of course you won’t see it

How about an individual with schizophrenia following million dollar work up to rule out infectious/substance/autoimmune/gluten/CNS/etc confounders, and with a prodrome + 5-10 years of psychotic symptoms - have you seen or do you believe anyone in that cohort can fully recover and not need ongoing treatment? I have never encountered that, but most with schizophrenia will generally be difficult to remove all those confounders, so perhaps I am back at circular reasoning. At the same time, I would be most interested in what was going on with people who really had a longstanding neurodevelopmental condition… that remitted.

I generally assume that the folks who spontaneously remit had some unexplained cause that went away. Then for the 15-20% of folks who are able to work and exist quite stably, they seem to have a distinct and lighter subtype of schizophrenia.