PhD/PsyD Is schizophrenia neurological or more psychosocial?

[MysteryDiagnosis]

I see a lot of debate with schizophrenia and other "mental illness" for that matter.

Some claim, such as psychiatrists for example that it is a "brain disease" with an organic basis and therefore believe that antipsychotics are the best form of treatment.

Others, usually psychologists and social workers believe that even though there are neural correlates involved like with any human emotion or behavior, that it is less of an organic "disease" and more of a psychosocial issue, that no lesions or chemical inbalance theory has been proven and therefore it's better to treat it with psychotherapy and possible a small dose of medication... as opposed to "medicalizing" it and treating it only with pharmacology.

Which leads to my next question, if the cause of schizophrenia or psychosis is proven to be more organic in nature, then why don't neurologists treat it instead of psychiatrists... and if it is more psychosocial in nature, then why don't social workers and psychologists treat it rather than a psychiatrist with medication?

I figures as neuropsychologists with training and an understanding of both the biological and psychosocial aspect of mental illness.l, that you would be the best ones to ask.

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[WisNeuro]

Neurological. Unless it's mild in nature, it generally needs medication to maintain quality of life. Psychosocial factors can affect the presentation in various ways, but anyone who tells you that it's purely psychological and that they can treat it, is likely a psychoanalyst, and full of ****.

 

[nononora]

anyone who tells you that it's purely psychological and that they can treat it, is likely a psychoanalyst, and full of ****.

Black and white thinking much?

Like any other nature vs nurture issue, it is likely to be a combination of both and arguments of whether it is more one or the other leads to a dead end because it varies person to person. Schizophrenia and its associated symptoms exist on a continuum, and on the severe end of the continuum (and like many other "severe" mental disorders), both medication and psychotherapy would most likely provide the most benefit.

 

[WisNeuro]

Nope, just empirically based thinking. My response did indicate a continuum of severity. And yes, psychotherapy can help, but it's usually very behaviorally based (medication compliance, voc therapy, etc) to manage their lives in the presence of disorder. This one is definitely more nature vs nurture, some of the more consistently higher heritability estimates than most other things we see.

 

[nononora]

Nope, just empirically based thinking. My response did indicate a continuum of severity. And yes, psychotherapy can help, but it's usually very behaviorally based (medication compliance, voc therapy, etc) to manage their lives in the presence of disorder. This one is definitely more nature vs nurture, some of the more consistently higher heritability estimates than most other things we see.

"full of ****" is not empirically-based thinking.

 

[WisNeuro]

"full of ****" is not empirically-based thinking.

I beg to differ.

 

[nononora]

I beg to differ.

 

[psychstudent5]

I've worked with clients with schizophrenia, but would not consider myself an expert on the disease. With that said, I've always viewed and understood as a neurological disorder. It's very brain/biology based. Psychotherapy treatment is usually geared towards modulating social skills, medication management, and the like. Medication is the tool that truly helps minimize the symptoms. That's been my (limited) experience of working with clients who have schizophrenia.

 

[MysteryDiagnosis]

Neurological. Unless it's mild in nature, it generally needs medication to maintain quality of life. Psychosocial factors can affect the presentation in various ways, but anyone who tells you that it's purely psychological and that they can treat it, is likely a psychoanalyst, and full of ****.

So if it's neurological then why don't neurologists treat it. I don't understand why psychiatrists treat illnesses that are neurological in nature and ap Pl y the biomedical approach to others that are psychosocial in nature

 

[pediatric_psydoc]

I've worked with clients with schizophrenia, but would not consider myself an expert on the disease. With that said, I've always viewed and understood as a neurological disorder. It's very brain/biology based. Psychotherapy treatment is usually geared towards modulating social skills, medication management, and the like. Medication is the tool that truly helps minimize the symptoms. That's been my (limited) experience of working with clients who have schizophrenia.

That's my experience as well. Usually schizophrenic patients cannot benefit from therapy, which is usually based on psychoeducation, encouraging adherence to pharmacological treatment, and social skills, unless they are being medically managed as well.


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[WisNeuro]

So if it's neurological then why don't neurologists treat it. I don't understand why psychiatrists treat illnesses that are neurological in nature and ap Pl y the biomedical approach to others that are psychosocial in nature

Because neurological disorders can have psychiatric presentations. And, in this case, it's a med management issue, something that neurologists by and large do not focus on.

 

[student til 30]

Schizophrenia consists of changes in brain structure and functioning, neuropsychological performance, thoughts, emotions, behaviors, and social functioning. Medication, therapy, psychosocial interventions, and changes in a person's environment (e.g., hospitalization) can all be helpful in managing symptoms to different degrees, and meds are probably the most effective intervention overall. Just because someone is an MD looking at dopamine or brain imaging, or a psychologist looking at paranoid thinking, doesn't mean the disorder is inherently "medical" or "psychological." Our division into different disciplines is a better way to characterize different intervention approaches (psychiatric, psychological) than it is to characterize disorders themselves. Schizophrenia doesn't care about our different perspectives.

 

[Cantab109]

Something to consider here is what kind of symptoms are impairing for people with schizophrenia. Medications help to treat the positive symptoms, but research has demonstrated that the negative symptoms tend to be the most impairing in their ability to interact appropriately in society. Psychotherapy can help to address these negative symptoms. So while I do agree it is a neurologically based illness, and medication can help with that, added psychotherapy can help as well to target different symptoms.

 

[MysteryDiagnosis]

Because neurological disorders can have psychiatric presentations. And, in this case, it's a med management issue, something that neurologists by and large do not focus on.

But the distinction between psychiatry and neurology becomes a false one since the brain and mind are one

 

[WisNeuro]

But the distinction between psychiatry and neurology becomes a false one since the brain and mind are one

That's deep. I'll make sure to let my psychiatry and neurology colleagues know.

 

[MysteryDiagnosis]

That's deep. I'll make sure to let my psychiatry and neurology colleagues know.

That's what it appears after researching a lot

 

[PsyDr]

Since penetrance isn't 100% in twin models, there is likely some psychological or environmental contribution. Likewise, we see difference in the content of delusion and hallucinations in different cultures. Same as us not seeing the napolean delusion anymore.

In contrast to my colleague, @WisNeuro , I would opine that there is some limited evidence that CBT in schizophrenia is effective to some degree( e.g., Donald Turkington's publication history, which was taken on in a new group about a year ago). That being said, I tried it once and was ineffective but I'm not a skilled CBTer.

The idea of neurological vs psychiatric/psychological is mostly based on history rather than anything else. Psychiatry and neurology share the same board (I.e., ABPN). Ironically this was the same initials the American board of profession neuropsych had until they changed it to avoid confusion. You have to remember Freud's contribution was the gold stain for neurons before he went psych and that schizophrenia was initially considered an early progressive dementia by Pick. So why the difference? Same. Why doesn't ophthalmology make glasses? Why doesn't ENT do teeth? Neuropsychology only does neuro because imaging didn't exist and psych patients would drop dead because it was a tumor and not psych. Psychology was already there testing people and figure it out. One of the neuropsych imaging guys said he thought the field was over when he first saw a CT scanner.

A general conceptualization is that psychologists and psychiatrists treat the behavioral outcomes of things both medical and environmental. In Down's syndrome, the cause is purely neurological/genetic. But the behavioral outcome of the disorder requires behavioral treatment.

 

[WisNeuro]

There is definitely some psychological and environmental contribution, it's just the minority share of the etiology. I would add that CBT can be useful for managing symptoms of schizophrenia, in conjunction with pharmacological treatment. I have never seen any good data about psychotherapy treating it alone in all but the most mild of cases.

As to the "brain and mind are one" nonsense. It's all good and dandy to discuss this in a philosophical/historical context, but it's not how things work in healthcare. PsyDr summarized it nicely.

 

[pediatric_psydoc]

There is definitely some psychological and environmental contribution, it's just the minority share of the etiology. I would add that CBT can be useful for managing symptoms of schizophrenia, in conjunction with pharmacological treatment. I have never seen any good data about psychotherapy treating it alone in all but the most mild of cases.

As to the "brain and mind are one" nonsense. It's all good and dandy to discuss this in a philosophical/historical context, but it's not how things work in healthcare. PsyDr summarized it nicely.

WisNeuro, on a somewhat related topic, what is your experience in terms of neuropsychological symptom variance in schizophrenic patients? That is, do the impairments differ among schizophrenic patients, or would you say that the neuropsychological impairments are basically the same from patient to patient? I'm not sure how common it is for a neuropsychologist to see a patient who is schizophrenic unless they have a comorbid condition that needs assessment, but I figured I'd ask anyway.


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[WisNeuro]

WisNeuro, on a somewhat related topic, what is your experience in terms of neuropsychological symptom variance in schizophrenic patients? That is, do the impairments differ among schizophrenic patients, or would you say that the neuropsychological impairments are basically the same from patient to patient? I'm not sure how common it is for a neuropsychologist to see a patient who is schizophrenic unless they have a comorbid condition that needs assessment, but I figured I'd ask anyway.

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Depending on what your referral sources are, we still see plenty of patients with psychosis. Deficits in individuals with schizophrenia are fairly heterogeneous, so I wouldn't say that there is any one good "profile" that would fit for most. In meta-analyses, you see pretty global group differences across most domains. Perhaps more consistent deficits are found in attention, organization, and more executive functions. Outside of that, we have to be on the lookout for the side effects of some of the anti-psychotics (nms, motor issues, possible anti-cholinergic effects, etc).

 

[MysteryDiagnosis]

Depending on what your referral sources are, we still see plenty of patients with psychosis. Deficits in individuals with schizophrenia are fairly heterogeneous, so I wouldn't say that there is any one good "profile" that would fit for most. In meta-analyses, you see pretty global group differences across most domains. Perhaps more consistent deficits are found in attention, organization, and more executive functions. Outside of that, we have to be on the lookout for the side effects of some of the anti-psychotics (nms, motor issues, possible anti-cholinergic effects, etc).

Why hasn't there been a biological specialty of psychology to evolve that has expanded beyond just the brain and the nervous system as seen in neuropsychology to include all different organ systems and the whole body like a "medical psychology" or something and work with and understand patients who have various medical conditons that can impact their psychological status...

Or use this "whole body" or medical training or whatever to be able to do physical assessment's on patients presenting with mental/ emotional symptoms and be able to determine and differentiate between what is really psychological or possibly another medical cause that might be presenting with psychological symptoms and refer out.

 

[WisNeuro]

Why hasn't there been a biological specialty of psychology to evolve that has expanded beyond just the brain and the nervous system as seen in neuropsychology to include all different organ systems and the whole body like a "medical psychology" or something and work with and understand patients who have various medical conditons that can impact their psychological status...

We work with and consider the medical and health aspects on our patient's psychological functioning already. Why would we need another specialty to do what we already do?

 

[PsyDr]

Why hasn't there been a biological specialty of psychology to evolve that has expanded beyond just the brain and the nervous system as seen in neuropsychology to include all different organ systems and the whole body like a "medical psychology" or something and work with and understand patients who have various medical conditons that can impact their psychological status...

Or use this "whole body" or medical training or whatever to be able to do physical assessment's on patients presenting with mental/ emotional symptoms and be able to determine and differentiate between what is really psychological or possibly another medical cause that might be presenting with psychological symptoms and refer out.

You mean like medical psychology and health psychology?

 

[MysteryDiagnosis]

We work with and consider the medical and health aspects on our patient's psychological functioning already. Why would we need another specialty to do what we already do?

Yes but you can't do a physical exam or order lab tests for instance to determine if a person's depression might be to to let's say hypothyroidism for example... and then refer that information to an endocrinologist...

 

[MysteryDiagnosis]

You mean like medical psychology and health psychology?

There is a medical psychology specialty? I'd didn't see that on the APA website list of specialties and proficiencies... what is the difference between health psychology and medical psychology?

 

[WisNeuro]

Yes but you can't do a physical exam or order lab tests for instance to determine if a person's depression might be to to let's say hypothyroidism for example... and then refer that information to an endocrinologist...

Who cares? First off, I have a range of lab tests that have to be recently done in order for me to accept a referral in the first place. This stuff is already all done before I need to see that person. In cases where it's not, that's where a call into the PCP comes in. The majority of psychologists don't need the ability to order lab tests, simply because most don't know what the hell they are looking for anyway. If they have the training to interpret lab tests (e.g., neuropsychologists, RxPers) sure, but most don't.

 

[MysteryDiagnosis]

Who cares? First off, I have a range of lab tests that have to be recently done in order for me to accept a referral in the first place. This stuff is already all done before I need to see that person. In cases where it's not, that's where a call into the PCP comes in. The majority of psychologists don't need the ability to order lab tests, simply because most don't know what the hell they are looking for anyway. If they have the training to interpret lab tests (e.g., neuropsychologists, RxPers) sure, but most don't.

Well what I meant was more for private practice when you are doing and intake or evaluation on a new client... it could be helpful... you as a neuropsychologist can read labs?

 

[WisNeuro]

Well then, you can still consult with a PCP to check out medical causes for possible psych symptoms. And yes, most of us have training in reading and understanding certain lab tests that can affect cognition.

 

[pediatric_psydoc]

Well what I meant was more for private practice when you are doing and intake or evaluation on a new client... it could be helpful... you as a neuropsychologist can read labs?

There is a controversial diagnosis for children called PANDAS (controversial in that not all providers agree it is a diagnostic entity separate from child OCD). The specialists that evaluate this condition are often child psychiatrists who have additional specialty training in immunology and infectious disease. These physicians often perform neurology exams to evaluate for the presence of choreiform movements, among other abnormalities. The diagnostic criteria for PANDAS isn't completely established, but experts from various fields are collaborating and updating the guidelines. Anyways, I cite this example and encourage you to look into it more, as I think it demonstrates the point that the connection between brain and behavior are being explored by psychologists as well as medical professionals (this has been happening for decades, but this is an example of a more recent diagnosis that is being explored and whose criteria are being established).


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[MysteryDiagnosis]

Well then, you can still consult with a PCP to check out medical causes for possible psych symptoms. And yes, most of us have training in reading and understanding certain lab tests that can affect cognition.

Interesting to know... like what are some examples of lab tests you read?

And from one of the previous posts... what is medical psychology? I did not see it on the APA website under specialties

 

[WisNeuro]

Interesting to know... like what are some examples of lab tests you read?

And from one of the previous posts... what is medical psychology? I did not see it on the APA website under specialties

Electrolyte labs, liver panel, kidney labs, treponemal, and on and on. Additionally, if they have neuroimaging, that can be helpful to look at personally due to the generally shoddy nature of radiology reports.

 

[MysteryDiagnosis]

Electrolyte labs, liver panel, kidney labs, treponemal, and on and on. Additionally, if they have neuroimaging, that can be helpful to look at personally due to the generally shoddy nature of radiology reports.

I see, very interesting... so what ecxactly is medical psychology... is it a specialty?

 

[pediatric_psydoc]

I see, very interesting... so what ecxactly is medical psychology... is it a specialty?

PhD/PsyD - Medical psychology specialty


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[jadedphysiotherapist]

I see, very interesting... so what ecxactly is medical psychology... is it a specialty?

RxP
Same legalities as a psychiatrist I believe.

Different training pathway through the psychology model (i.e. environmental based and linear to the mind) with psychopharm courses post graduation...but w/o 24-30 hr shift monitoring following med Rx during a medical residency.

Psychiatry learns their craft in residency after the psych rotation and subIs and completion of the other work in medical school reserved for other practices, but learn on the biological approach foremost.

There's a lot of controversy with it.

Someone slam me if I'm wrong. I always find these discussions interesting

 

[jadedphysiotherapist]

Yes but you can't do a physical exam or order lab tests for instance to determine if a person's depression might be to to let's say hypothyroidism for example... and then refer that information to an endocrinologist...

They interpret tests. My field does in the hospital as well before activity either aerobic or physical. Conducting a physical isn't practiced in psychiatry or psychology I believe.

 

[MysteryDiagnosis]

RxP
Same legalities as a psychiatrist I believe.

Different training pathway through the psychology model (i.e. environmental based and linear to the mind) with psychopharm courses post graduation...but w/o 24-30 hr shift monitoring following med Rx during a medical residency.

Psychiatry learns their craft in residency after the psych rotation and subIs and completion of the other work in medical school reserved for other practices, but learn on the biological approach foremost.

There's a lot of controversy with it.

Someone slam me if I'm wrong. I always find these discussions interesting

Why be slammed? I find it interesting as well. So medical psychology = prescribing rights? The two are synonymous with each other?

Well what about in states where psychologists haven't yet gained the right to prescribe... then what do these medical psychologists do with their medical/ psychopharm training? Conduct psychopharm research or act as consultants for questions on medications?

 

[MysteryDiagnosis]

PhD/PsyD - Medical psychology specialty


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I read through this thread... Interesting that someone noted that medical psychology is not a specialty recognized by the APA

 

[Justanothergrad]

I read through this thread... Interesting that someone noted that medical psychology is not a specialty recognized by the APA

http://www.apa.org/ed/graduate/specialize/recognized.aspx

It's not. It's a misnomer used to describe something that is not an actual thing. It's not a clear bar of professional attainment; it's just a term folks use colloquially that lacks specificity (via a specific population, specific intervention method, etc.)

 

[deleted343839]

Why hasn't there been a biological specialty of psychology to evolve that has expanded beyond just the brain and the nervous system as seen in neuropsychology to include all different organ systems and the whole body like a "medical psychology" or something and work with and understand patients who have various medical conditons that can impact their psychological status...

This sounds a lot like psychosomatic medicine or C-L psychiatry: Psychosomatic Medicine

 

[MysteryDiagnosis]

http://www.apa.org/ed/graduate/specialize/recognized.aspx

It's not. It's a misnomer used to describe something that is not an actual thing. It's not a clear bar of professional attainment; it's just a term folks use colloquially that lacks specificity (via a specific population, specific intervention method, etc.)

So then what exactly is it for folks that use it?

 

[MysteryDiagnosis]

This sounds a lot like psychosomatic medicine or C-L psychiatry: Psychosomatic Medicine

That's a psychiatric subspecialty though, there is no equivalent psychological specialty is behavioral or psychosomatic medicine?

 

[deleted343839]

That's a psychiatric subspecialty though, there is no equivalent psychological specialty is behavioral or psychosomatic medicine?

Clinical health psychology is closest, but you asked for a "biological" specialty and the biological part is important but not really what the specialty is about: Clinical Health Psychology

 

[deleted343839]

Other specialties such as rehabilitation psychology, sleep psychology, and geropsychology also require an understanding of underlying physiological or disease/injury processes, but their methods and tools are predominantly based on principles of learning, memory, cognition, etc. Of course there is some overlap with medicine, PT/OT/ST, and other fields, but these psychological specialties are defined by the unique knowledge and skills that psychologists bring to the table and use to inform assessment and treatment. Having some knowledge of each other's disciplines is important for multidisciplinary teams, and it's up to each team member to respect the limits of his or her competence and scope of practice.

 

[Justanothergrad]

So then what exactly is it for folks that use it?

There isn't an answer because there is no consensus, because its not a thing. There are specialties which are similar to the general idea (see MamaPhD's post for examples- particularly health psych), but there is no 'medical psychology' specialty. Its like people who say "I like the color Zarf". They may like something. It may be called zarf in their mind. The rest of us just have no clue what they are talking about.

 

[deleted343839]

So then what exactly is it for folks that use it?

The not-very-interesting history is that "medical psychology" mostly got absorbed by the larger RxP movement (health psychologists didn't want to be associated), and today the term generally has more to do with practicing medicine (e.g., prescribing) than working with patients who have medical conditions. In fact, prescribing psychologists in Louisiana are called medical psychologists and are regulated by the board of medical examiners.

 

[MysteryDiagnosis]

The not-very-interesting history is that "medical psychology" mostly got absorbed by the larger RxP movement (health psychologists didn't want to be associated), and today the term generally has more to do with practicing medicine (e.g., prescribing) than working with patients who have medical conditions. In fact, prescribing psychologists in Louisiana are called medical psychologists and are regulated by the board of medical examiners.

Oh yes, I have seen that there is a lot of controversy over all of that. Half are for it and half are against it it seems.

 

[jadedphysiotherapist]

Why be slammed? I find it interesting as well. So medical psychology = prescribing rights? The two are synonymous with each other?

Well what about in states where psychologists haven't yet gained the right to prescribe... then what do these medical psychologists do with their medical/ psychopharm training? Conduct psychopharm research or act as consultants for questions on medications?

I believe most psychologists are against.

I have a wonderful one in my family and she didn't even know it existed actually

 

[smalltownpsych]

I see a lot of debate with schizophrenia and other "mental illness" for that matter.

Some claim, such as psychiatrists for example that it is a "brain disease" with an organic basis and therefore believe that antipsychotics are the best form of treatment.

Others, usually psychologists and social workers believe that even though there are neural correlates involved like with any human emotion or behavior, that it is less of an organic "disease" and more of a psychosocial issue, that no lesions or chemical inbalance theory has been proven and therefore it's better to treat it with psychotherapy and possible a small dose of medication... as opposed to "medicalizing" it and treating it only with pharmacology.

Which leads to my next question, if the cause of schizophrenia or psychosis is proven to be more organic in nature, then why don't neurologists treat it instead of psychiatrists... and if it is more psychosocial in nature, then why don't social workers and psychologists treat it rather than a psychiatrist with medication?

I figures as neuropsychologists with training and an understanding of both the biological and psychosocial aspect of mental illness.l, that you would be the best ones to ask.

Back to the original topic. Some psychological disorders are the result of normative neurological function to various environmental stressors. We have Adjustment Disorders and Acute Stress Disorder to account for that. Some are within the realm of an expected response to stressors, but for a variety of reasons the response is more impairing. PTSD, MDD, Reactive Attachment Disorder, and possibly Personality Disorders can be thought of as that way. From what I have seen of schizophrenia and also more severe forms of Bipolar Disorder I, they don't really fit that pattern of an expected response even if it is thought of as an exaggerated response. In other words, these disorders clearly appear to be the result of some type of significant malfunction. There is not really a normal range of psychotic thought processes that is more extreme in certain individuals. I am oversimplifying quite a bit so keep that in mind.

As far as the statement about medication verses psychological, the reaction of myself is that there is too much emphasis on medications to treat schizophrenia and not enough emphasis on the psychological factors. When iI work with someone with schizophrenia, they tend to do better than when they don't have psychotherapy and a big focus of my work is to help them to effectively advocate for themselves as far as medications go.

Another important point, people with schizophrenia often (almost always?) have impaired social relationships for a number of reasons and the medication doesn't help with those. All people (except for the rare true schizoid types) do better when they have healthy relationships and psychotherapy helps with that too.

I guess what i am saying is that despite the fact that schizophrenia is most likely due to neurological dysfunction, that doesn't mean that we have a medical treatment for that dysfunction that is effective enough to negate the need for additional psychological treatment. My patients and my friend with schizophrenia wish that there was a reatment that effective, but in the meantime they avail themselves of what is available that does help.

 

[MysteryDiagnosis]

.

I believe most psychologists are against.

I have a wonderful one in my family and she didn't even know it existed actually

Yeah from what I've seen snd heard, it's seems 50/50... some are hardcore against it and wants psychology to remain a drug free profession... others are for it because they want to use it to unprescribe feel combining therapy and med management with one provider is best.

 

[MysteryDiagnosis]

Back to the original topic. Some psychological disorders are the result of normative neurological function to various environmental stressors. We have Adjustment Disorders and Acute Stress Disorder to account for that. Some are within the realm of an expected response to stressors, but for a variety of reasons the response is more impairing. PTSD, MDD, Reactive Attachment Disorder, and possibly Personality Disorders can be thought of as that way. From what I have seen of schizophrenia and also more severe forms of Bipolar Disorder I, they don't really fit that pattern of an expected response even if it is thought of as an exaggerated response. In other words, these disorders clearly appear to be the result of some type of significant malfunction. There is not really a normal range of psychotic thought processes that is more extreme in certain individuals. I am oversimplifying quite a bit so keep that in mind.

As far as the statement about medication verses psychological, the reaction of myself is that there is too much emphasis on medications to treat schizophrenia and not enough emphasis on the psychological factors. When iI work with someone with schizophrenia, they tend to do better than when they don't have psychotherapy and a big focus of my work is to help them to effectively advocate for themselves as far as medications go.

Another important point, people with schizophrenia often (almost always?) have impaired social relationships for a number of reasons and the medication doesn't help with those. All people (except for the rare true schizoid types) do better when they have healthy relationships and psychotherapy helps with that too.

I guess what i am saying is that despite the fact that schizophrenia is most likely due to neurological dysfunction, that doesn't mean that we have a medical treatment for that dysfunction that is effective enough to negate the need for additional psychological treatment. My patients and my friend with schizophrenia wish that there was a reatment that effective, but in the meantime they avail themselves of what is available that does help.

I really like the way you explained all of this!