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Video Transcript: Schizophrenia

Ellen Beth Levitt: Welcome to "Maryland Health Today." I'm Ellen Beth Levitt. Schizophrenia is a mental health disorder that affects more than two million Americans. On the show today, we'll hear from an expert about symptoms and treatments for Schizophrenia, and we'll discuss some common misconceptions about the disease. My guest is Dr. Anthony Lehman. He's the Chief of Psychiatry at the University of Maryland Medical Center. Dr. Lehman is also professor and chairman of Psychiatry at the University of Maryland School of Medicine. Welcome to the show.

Anthony Lehman, M.D.: Thanks. It is nice be here.

Ellen Beth Levitt: First of all, how do you define Schizophrenia?

Anthony Lehman, M.D.: Sure. Well, Schizophrenia is a serious mental disorder, and it affects a little less than one percent of the population world wide, and, in general, it is a psychotic disorder. Now, a psychotic disorder is characterized by loss of contact with reality, and that is defined then by a series of symptoms. So, for example, some of the common symptoms of Schizophrenia are hearing voices or seeing things, we call those hallucinations, having false ideas that the person is very convinced are true, we call those delusions. A person may also show disorganized speech and thinking. They may show erratic behavior; loss of facial expression and emotional expression. The other characteristic that defines Schizophrenia is, first of all, it needs to be associated with a loss of functioning. So, a person could have certain symptoms, but not have any loss of functioning, that would not be schizophrenia. And the third criteria is it has to last for at least six months.

Ellen Beth Levitt: Does Schizophrenia sometimes get confused with multiple or split personality disorders?

Anthony Lehman, M.D.: Yes, especially in the lay press. So, we talk - even when we talk about what we're doing - something that's schizophrenic, we often mean we're doing one thing and we mean the opposite, but that's not at all what Schizophrenia is. Schizophrenia is not a split personality. That's called a dissociative disorder, and it is quite a different kind of mental disorder.

Ellen Beth Levitt: So, you were talking about disruptions in thinking...

Anthony Lehman, M.D.: Right.

Ellen Beth Levitt: Could you tell us a little bit more about what that means?

Anthony Lehman, M.D.: Sure. So, one of the common disruptions of thinking we see in Schizophrenia is delusions. These are false and fixed ideas. A good example is the paranoid delusion where the person may think that they are being watched or followed. They may think that their thoughts can be heard out loud. They may think that the thoughts are being monitored by the government, and these are, as you can imagine, very frightening thoughts to have, and the person finds these thoughts very compelling. And so, they often act on them or they behave in a way to protect themselves against those kinds of thoughts. The other kind of common thought disorder we see in Schizophrenia is disorganized thinking, and how one notices that, if one is talking to someone with Schizophrenia - with that kind of symptom - it is very hard to follow their train of thought. They may sort of mix words all together in a way that's very hard to comprehend.

Ellen Beth Levitt: Are there some problems with learning as well if somebody has Schizophrenia?

Anthony Lehman, M.D.: Yes, and actually, besides these sorts of symptoms - we have already talked about the delusions and hallucinations and formal thought disorder as we call it - many people with schizophrenia have cognitive impairments that are actually the most disabling aspect of the illness. Some of the problems you see in cognitive impairments are the inability to pay attention, difficulties in processing information, difficulties with problem solving, difficulties in interpersonal relationships - that capacity to see how someone might be feeling and to respond to that - they also have problems even carrying on a conversation. So, for example, the conversation we're having right now, you're hearing me, and you remember what I say enough to be able to follow me and to respond back, but if you could not remember what I had just said, you would have a very difficult time having a conversation with me, and people with Schizophrenia have those kinds of difficulties. So, you can imagine how impairing that is, in the normal course of the day, to not be able to have a conversation.

Ellen Beth Levitt: Sure. And, the symptoms that you describe, everything from delusions and hallucinations, to problems with short term memory and so forth, do these things come on suddenly when people have Schizophrenia, or is there sort of a gradual onset of these symptoms?

Anthony Lehman, M.D.: Well, there are many different types of onsets in Schizophrenia. For some people, they show early signs as a child of having problems with how they think or how they respond to other people. They may have problems in school, they may be a loaner in terms of not playing with other kids, and so on. So, those kids often have those sorts of signs early on, but don't develop the hallucinations and delusions until they become adolescents, so that's what we call a gradual onset form of Schizophrenia. There are other people who seem quite fine when they are children, and don't develop these symptoms until they are in high school, and may acutely develop hallucinations and delusions so they may have an acute onset of the illness. So, the onset of illness is quite - onset of the illness is quite variable.

Ellen Beth Levitt: And people really believe these delusion they have. It is - they absolutely believe it is not something that they think they are imagining? It is - you can't convince them otherwise I guess?

Anthony Lehman, M.D.: Right. That's sort of, as I said at the beginning, the hallmark of a psychotic disorder is loss of touch with reality. So, the experience of these thoughts, or the voices that are being heard in, and so on, is just as real as you and I talking here right now. And so, they are very, very compelling experiences. If you tell the person with Schizophrenia they are not true, they don't believe you, and it is not because they are being argumentive, they just really find them very compelling, and they act on those.

Ellen Beth Levitt: How do you diagnose Schizophrenia? And, I would think that sometimes it gets misdiagnosed.

Anthony Lehman, M.D.: Yes, it does. Well, there is unfortunately no lab test yet, or brain test, to specifically diagnose Schizophrenia, so we rely on a variety of techniques. First of all, the history. We talk to the patient, we talk to the family, we hear about how the person developed. We hear about the onset of the symptoms, we hear about the types of symptoms they have, and what we look for in the history are the kinds of symptoms and problems that I have just described. We also conduct a physical examination; it is generally to rule out things that might be causing psychosis, but that are not actually Schizophrenia, such as, for example, signs of a brain tumor or signs of thyroid disease and so on. We conduct what's called a mental status examination, where we formally go through a range of questions to test how the person thinks and feels and see how they respond to certain kinds of standard types of questions. That helps us. We look at the past history in terms of what kind of hospitalizations they've had, what other kinds of problems they've had in terms of treatment, and then there are certain lab tests, again, more to rule out things rather than to have a specific test for schizophrenia.

Ellen Beth Levitt: Right, because some of the symptoms you were describing could go along with other health conditions as well.

Anthony Lehman, M.D.: Yes, that's - that's right.

Ellen Beth Levitt: Are there some subtypes of Schizophrenia?

Anthony Lehman, M.D.: There are - there are a number of subtypes. The most common subtype is paranoid Schizophrenia, and I have already described that a bit. The hallmark characteristics of paranoid Schizophrenia are delusions where the person is very paranoid; they believe that certain things are happening...

Ellen Beth Levitt: Someone is out to get them?

Anthony Lehman, M.D.: That's right. Someone is out to get them. Someone is doing something to them that is harmful, so you can imagine they are very frightened. Another form of Schizophrenia that's less commonly know is what is called catatonic Schizophrenia. In that, there is a behavioral disorder where the person actually assumes fixed positions and I'll kind of show you. They may have a position like this they sit in for hours, and if you move their hand, they'll move like this. We call that waxy flexibility. That's called catatonic schizophrenia. There is what is called a differentiated Schizophrenia, and that means these have a mixture of these kinds of symptoms. There is what is called residual Schizophrenia, which is sort of a - some of the symptoms that have remained on after an acute episode. And, disorganized schizophrenia is primarily disorders of thinking, so that the person basically talks in a word...

Ellen Beth Levitt: Is there a common age when these symptoms might begin? You were saying that sometimes the early onset is in childhood...

Anthony Lehman, M.D.: Yes, but it is pretty rare for it to begin with these symptoms in childhood. Often, the signs shown in childhood are mild kinds of things that you don't really know what is going on.

Ellen Beth Levitt: The person might be just a little different.

Anthony Lehman, M.D.: They are a little different...

Ellen Beth Levitt: Quirky?

Anthony Lehman, M.D.: A little different. But, often when the symptoms begin is in high school, so they are in adolescence or young adulthood, in the teens and the twenties. Interestingly, earlier in men than in women.

Ellen Beth Levitt: Really?

Anthony Lehman, M.D.: Yes, so boys tend, if they are going to develop Schizophrenia, may develop in their teenage years or early twenties. For women, it may be also in the teens, but more likely into the twenties. And, what you see then, often when the person is first becoming ill, it is hard to know what's happening. So, like an adolescent, they may have trouble sleeping, the school performance might start to go down, they might not get along with their friends the way they used to, they might begin to express odd ideas, and often it is hard early on to know whether they are just being an adolescent or actually developing the disorder. But, when you really begin to see them failing in school and withdrawing from friends, and then often what you begin to see is more unusual thinking, to the point that they begin to hallucinate and become paranoid and so on.

Ellen Beth Levitt: Is there a higher risk of drug use or alcohol abuse?

Anthony Lehman, M.D.: Going along with this if it is occurring in adolescence?

Ellen Beth Levitt: Right.

Anthony Lehman, M.D.: Well, of course we know unfortunately many adolescents experiment with alcohol and drugs, and that's no different for adolescents that develop Schizophrenia. If you have a tendency to develop Schizophrenia and you use drugs or alcohol as an adolescent, it may tend to cause the symptoms to come out. We don't really think that these drugs and alcohol cause Schizophrenia, but as you can imagine, if you have a tendency to be paranoid, and you take a drug that may make a person paranoid even without the illness, it will bring out those symptoms. There is some research in the United Kingdom that suggests that adolescents have a genetic risk for Schizophrenia - those who smoke a lot of pot - may have an increased risk of earlier onset of the illness, but again it is not really that causes Schizophrenia. It can bring out the tendencies in some adolescents experiencing a lot of anxiety or difficulty because of the illnesses being - they may experiment with drugs and alcohol to try to control the symptoms.

Ellen Beth Levitt: Does Schizophrenia affect other parts of the body in addition to the brain?

Anthony Lehman, M.D.: Well, it is of course a brain disorder. We know that people with Schizophrenia develop a lot of other kinds of medical problems, and in fact, the life expectancy for people with Schizophrenia is about 25 years shorter than the general population.

Ellen Beth Levitt: Really?

Anthony Lehman, M.D.: Most of that is not from suicide or accidents, it is primarily from medical problems like heart disease, lung disease, cancer.

Ellen Beth Levitt: Do we know why that is?

Anthony Lehman, M.D.: Not completely. We think that it is related to two primary things. First of all, it is poor health habits. We know there is very high rate of smoking in people with Schizophrenia, so in the general population, about 20 to 25% of the general population smokes; whereas, in people with Schizophrenia, about 75% of people smoke with Schizophrenia.

Ellen Beth Levitt: Why is that? Why do they turn to tobacco?

Anthony Lehman, M.D.: It is interesting. It is probably related to the nicotine receptors in the brain. We used to think the reason why people with Schizophrenia smoked excessively...

Ellen Beth Levitt: A social thing?

Anthony Lehman, M.D.: It was a social thing, and unfortunately even in institutions long ago, we used cigarettes as behavioral reinforcers. So, if a patient...

Ellen Beth Levitt: Did what they were supposed to do...

Anthony Lehman, M.D.: ...did what they were supposed to do, that the earned the right to have a cigarette, which is horrifying to think of now. So, we used to think the reason why there was excess smoking in people with Schizophrenia was because of those old practices, but now there is much more sophisticated brain research going on that shows there is probably something different in the nicotine receptors in people with Schizophrenia, and they are actually smoking to try to affect those receptors. And, some of the newer research that's going on, which I know we'll get to later, has to do with studying other ways to treat that, other than having a patient smoke.

Ellen Beth Levitt: What impact does it have on a person's family when they have Schizophrenia? It must have a huge impact on the family.

Anthony Lehman, M.D.: Yes. And of course, the tragedy of the illness is that it begins at a young age, and it lasts for a time, so essentially - a lifetime. Essentially, when a family has a young person that develops the illness, it is very traumatic initially often to have it because you don't know what is happening. It is not like the child comes home one day and you say, "Oh, you have schizophrenia." But, they begin to have a variety of problems that often go on for months or years, and in school, with friends, interpersonally in the family. That's stressful, and the family does not know what's happening, and they find that the child finally ends up in treatment settings, and they are diagnosed with Schizophrenia, and that, in itself, is a scary word, and folks don't know what to do about that. And then, they are told of course that this is really a life-long disorder. We have a variety of treatments, but it is something they'll have to live with for a long time.

Ellen Beth Levitt: We'll talk about treatment in the second half of the show, but we have to take a break. So, when we come back, we'll talk about the variety of treatments for schizophrenia. So stay with us.

Part Two:

Ellen Beth Levitt: Welcome back to "Maryland Health Today." I'm Ellen Beth Levitt. My guest is Dr. Anthony Lehman. Hes the Chief of Psychiatry at the University of Maryland Medical Center. Dr. Lehman is also professor and chairman of Psychiatry at the University of Maryland School of Medicine. Do we know what causes Schizophrenia?

Anthony Lehman, M.D.: We don't know exactly, but we're making a lot of progress in that there are two factors related to the development of Schizophrenia. The first is a genetic factor. About 1% of the general population is at risk to develop Schizophrenia in their lifetime, but if you look at people with more and more shared genes, for example, parents and children, if one parent has Schizophrenia, the the risk of a child having Schizophrenia may be about 10%, so it is higher than in the general population. If you look at identical twins, if one twin has Schizophrenia, the risk is 50% in the other twin. What is of interest is that, first of all, the risk is much higher in identical tween twins genetically than in the general population - 50% compared to 1%. But it is not 100%. So, we know that there is something else going on besides genes in the development of Schizophrenia, and it is thought to be probably a variety of environmental factors, which maybe occur before birth, such as infections in the mother, trauma that the mother experiences. Starvation in certain populations has been associated with Schizophrenia for women who are pregnant. Exposure to toxins in childhood, and so on can bring out the expression of these genes, so we know it is a combination of genes and the environment.

Ellen Beth Levitt: You have a genetic vulnerability, and something else is actually triggering it?

Anthony Lehman, M.D.: Right, and the interesting thing about these genes is that they are not even - though the person has the genes at birth - the illness does not become apparent, as we have already talked about, until adolescence. So, the genes are probably genes that are silent for a period of time of development, and then turn on in the normal person at adolescence. When they turn on in someone who is developing Schizophrenia, things go a bit awry.

Ellen Beth Levitt: Are there some physical changes in the brain when somebody has Schizophrenia?

Anthony Lehman, M.D.: Yes, there are. So, for example, we have been able to do what is called functional imaging of people's brains with Schizophrenia when they are hearing voices, and there are certain parts of the brain that are associated with hearing, so just as we're talking now, there are certain parts of the brain that become more active as we're listening to each other. What's interesting is, in someone hearing voices with Schizophrenia, and there is no external voice, the same parts of their brain become active, so those parts of the brain light up. So, it is interesting, the brain is hearing sounds that are not there on the outside.

Ellen Beth Levitt: So, the person actually is hearing something? They could be in a totally quiet room?

Anthony Lehman, M.D.: Yes.

Ellen Beth Levitt: But the functional MRI scan shows the parts of the brain lighting up when you hear sounds?

Anthony Lehman, M.D.: Right. The switch gets turned on that shouldn't be.

Ellen Beth Levitt: And that must have been a very interesting finding when people started to notice that.

Anthony Lehman, M.D.: Yes.

Ellen Beth Levitt: We also know that, in people who are learning, we talked a bit about the cognitive impairments of Schizophrenia, and we all know, if we have to learn something, when we first try, it takes a lot Of effort to try to learn something, and as we become more - as we learn it - it takes less brain effort to do those things.

Anthony Lehman, M.D.: Right.

Ellen Beth Levitt: And people with Schizophrenia, the effort continues, actually increases?

Anthony Lehman, M.D.: If you imagine folks who are with Schizophrenia trying to learn something, we see that the brains works harder ongoing to try to learn that thing, so that tells us there is something about the brain that is different than someone without Schizophrenia that makes it harder to learn.

Ellen Beth Levitt: We see this graphic here. There is a brain of somebody with Schizophrenia, and the - oh no, the top is a healthy volunteer.

Anthony Lehman, M.D.: Yes, so on the left hand side of that screen, so the healthy volunteer, you see when they are first trying to learn something. Certain parts of the brain light up, and then after they learned the task, other parts of the brain are active, but it is essentially where the tasks now is learned. And, someone with Schizophrenia, different parts of the brain light up, and the brain, though, does not sort of learn quite the way it does in the normal volunteer. So, that's why, often, folks with Schizophrenia have to work harder to learn things.

Ellen Beth Levitt: Is it important that we now know that there are definite changes in the brain connected with Schizophrenia, and perhaps with other mental illnesses as well?

Anthony Lehman, M.D.: Yes, because I think, for a long time, there are - there has been - belief sometimes of mental illnesses are just figments of psychiatrists imagination, and that is always a tragedy because, for the patients and their families who are really struggling with very significant brain disease, they have people say really it does not exist. It is really very painful for those patients and families, so having evidence to show that there really are changes in the brain is important in that regard. It is also important in trying to learn more about exactly how the brain functions, and what kinds of treatments might be helpful going forward.

Ellen Beth Levitt: To target treatments to those particular parts of the brain?

Anthony Lehman, M.D.: That's right.

Ellen Beth Levitt: So, what are some of the treatments now? Are there good medications that can help prevent some of these very disabling symptoms that go along with Schizophrenia?

Anthony Lehman, M.D.: Yes. We have drugs that are called anti-psychotic drugs. They essentially treat some of the symptoms of Schizophrenia, so the hallucinations, delusions and disordered thinking are very much helped by the anti-psychotic drugs. Generally, someone starts on an anti-psychotic drug, it can take a few weeks, but a lot of those symptoms will largely be controlled with the medication. Now, the drugs have side effects, but now we have a wide range of different types of drugs to try in this category, so we can often adjust the choice of the drug and the dose of the drug, so the person is experiencing as few side effects as possible.

Ellen Beth Levitt: Will people need to take these drugs for the rest of their lives?

Anthony Lehman, M.D.: Often, yes. Yes. Now, it is always - there is always a tendency to - hope that I could stop the medicine, but often, when folks stop the medicine, they have a relapse of symptoms. Unfortunately, with the medicine, these do not treat some of the impairments in cognition that we have talked about; the problems with the tension and learning and so on are not helped by the drugs. So often, folks still have impairment at work and interpersonal relationships and school, despite the fact that the symptoms are under control.

Ellen Beth Levitt: How do you encourage patients to stay on the medications, especially if they are having side effects or maybe have the false thinking that, "Okay, now I'm all better, I don't need this anymore"?

Anthony Lehman, M.D.: Right. Well, first of all, it is very important to have a good relationship with the patient, so it is not just about giving somebody a prescription, you really have to develop a relationship with the person to know that, for that person to know that, you are there for them to help them, you'll be with them in the long term, and you have to educate them about the illness and the reasons for the medicine. It is very important to keep the side effects at a minimum, so when a patient complains of a side effect, the doctor really needs to attend to that and do the variety of things that can be done to minimize the side effects. And also, to educate folks that, when you're feeling better, it is not the time to stop the medicine. Just like with high blood pressure, other things, just because the symptoms are gone doesn't mean that you can stop the medicine.

Ellen Beth Levitt: Does counseling play a role in helping people cope with Schizophrenia?

Anthony Lehman, M.D.: Yes, and it is very important, actually, because it is a chronic disease, it is something that the person needs to live with, learn how to live with it, and to maximize their ability to function. Counseling is really an essential part of ongoing treatment for the person with Schizophrenia to be able to talk about their feelings about having the illness, to talk about the experiences that they have been having, and to figure out how to problem solve.

Ellen Beth Levitt: You also have to work with the family as well?

Anthony Lehman, M.D.: Yes, and helping the families in the same way to know about the illness, and know about the treatment and, now, how to deal with crises when they occur. These are all important components of treatment.

Ellen Beth Levitt: Are there employment opportunities for people with Schizophrenia?

Anthony Lehman, M.D.: There are. If you look at the employment rate for people with Schizophrenia, it is pretty low, generally around 20% at the most. We have a variety of programs, supported employment, used to help people with Schizophrenia get competitive jobs. The older form of voc rehab, which may be, folks often think about - shelters, workshops, and so on - were places for patients to go, but essentially many people did not go on to have real jobs.

Ellen Beth Levitt: More like daycare, I guess.

Anthony Lehman, M.D.: And a lot of patients chose not to go. They wanted to have an income, so the program called Supported Employment focuses on helping a person get a competitive job, at least at a minimum wage, and we help the person find jobs they want, and not a lot of pre-vocational training. If you have trouble concentrating, it is hard to sit in a class for a long time. And, there is ongoing support for the program.

Ellen Beth Levitt: If people have schizophrenia, are they generally violent, or is that a misconception? People are afraid of folks who have mental illness. Is that a justified concern?

Anthony Lehman, M.D.: We're all aware of the cases that hit the press, somewhere, someone went psychotic and committed a terrible crime, and that tends to become the stereotype of somebody with Schizophrenia. But actually, in general, the rates of violence committed by people with Schizophrenia is no different than the general population. There is an increased risk of violence when someone is acutely psychotic, or when they are intoxicated with drugs, but in general folks with Schizophrenia are no more violent than the general population, and in fact, are often the victims of violence because they tend to be rather vulnerable people; quiet and passive, and other people take advantage of them.

Ellen Beth Levitt: Is there another misconception about people with Schizophrenia?

Anthony Lehman, M.D.: I believe a common misconception is that it is a hopeless disease. Actually, there is much more hope today with the new findings we talked about, new treatments, and we think that, actually, there is much reason to be hopeful if someone knows this disorder. There is a lot of research going on as well, to improve therapy and so forth, yes.

Ellen Beth Levitt: Great. Well, thank you very much for being on the show today.

Anthony Lehman, M.D.: Nice to be here.

Ellen Beth Levitt: My guest has been Dr. Anthony Lehman. He's the Chief of Psychiatry at the University of Maryland Medical Center. Dr. Lehman is also professor and chairman of Psychiatry at the University of Maryland School of Medicine. If you have any comments or questions about this program, please contact me by e-mail at eblevitt@umm.edu. If you'd like to reach Dr. Lehman, or any other University of Maryland physician, call 1-800-492-5538, or visit the web site, where you'll find a great amount of health information and be able to see other Maryland Health Today programs. The address is www.umm.edu. Take good care of yourself. We'll see you next time for "Maryland Health Today."

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This page was last updated on: August 26, 2009.

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