Dr. Nick Dewan shares information about schizophrenia.
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Schizophrenia
Featured Speaker:
He is a member of the physician leadership team within the BayCare Health System providing input to the hospitals, medical group, accountable care organization, and insurance-based initiatives. He has the respect of national hospital, managed behavioral health, community mental health, and consumer advocacy groups, and sits on the Council of Healthcare Systems and Finance of the American Psychiatric Association. Dr. Dewan is also a member of the Board of the Positive Coaching Alliance of Tampa Bay. He is a graduate of the Medical College of Ohio, and completed his residency in psychiatry at Los Angeles County-USC Medical Center and UCSD School of Medicine. He is a Diplomate of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine. He is also a board certified physician executive and a former collegiate tennis player and coach.
Nick Dewan, MD
Dr. Nick Dewan is a pioneer and an accomplished physician leader and sports psychiatrist with a nationally respected track record in health care value improvement and information technology. Currently, he serves as Chief Medical Officer for the Behavioral Health Division of the BayCare Health System. In 2015, he published his third book on information technology “Mental Health Practice in a Digital World: A Clinicians Guide”. His clinical experience includes work in emergency, hospital, outpatient, addiction medicine, and sports medicine settings. He is a sought after speaker and is interviewed by local and national media on behavioral health issues and sports performance topics. His work on clinical guidelines, performance bonuses for quality, efficient use of healthcare, best practice adoption, and patient empowerment and technology positions him as a leading expert in an era of accountable healthcare.He is a member of the physician leadership team within the BayCare Health System providing input to the hospitals, medical group, accountable care organization, and insurance-based initiatives. He has the respect of national hospital, managed behavioral health, community mental health, and consumer advocacy groups, and sits on the Council of Healthcare Systems and Finance of the American Psychiatric Association. Dr. Dewan is also a member of the Board of the Positive Coaching Alliance of Tampa Bay. He is a graduate of the Medical College of Ohio, and completed his residency in psychiatry at Los Angeles County-USC Medical Center and UCSD School of Medicine. He is a Diplomate of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine. He is also a board certified physician executive and a former collegiate tennis player and coach.
Transcription:
Schizophrenia
Melanie Cole, MS (Host): Welcome. Today we're talking about schizophrenia. It's such a mysterious disease. It can be very misunderstood. Here to teach us about it today is Dr. Nick Dewan. He's the chief medical officer in the behavioral health division of BayCare. Dr. Dewan, we've seen movies and media about schizophrenia, but people really don't understand anything about it. Tell us what it is.
Nick Dewan MD (Guest): So schizophrenia is a brain disorder that causes people to lose their sense of reality. Historically when it was first termed it was actually termed what's called juvenile dementia. So back in the mid-1800s when people noticed this condition where young people had lost their sense of reality and weren't thinking as organized as normal, they thought this is a variant of dementia.
The term schizophrenia actually means sort of a torn life or a split life. That's where you originally got that term where it was a split personality. So schiz meaning sort of a gash and phrenic comes from the Greek origin of what's called life breathing. So it was a terminology of this is a very difficult disease that hits you in your young life and sort of splits you off from reality. So that's how you can sort of think about this disorder.
Now, in terms of the media, there are so many different types of schizophrenia. There are some types where people can be extraordinarily successful. They can function in society at different levels, but then there are other types that are so awful and so burdensome where somebody can be what's called catatonic or so disorganized that they really need daily care and daily support.
Then there are others that can work, live, function. So it is a wide spectrum kind of condition, but it is probably the most difficult condition in all of psychiatry to treat. It is recognized by the World Health Organization as one of the most burdensome illnesses in the world just because it affects people at an early age, as teenagers, and it lasts with them throughout their life.
Host: Wow. As mysterious as it has been to so many people, explain a little bit. Dr. Dewan, I know that this is a tough thing to do briefly but explain a little bit about the brain science behind schizophrenia and what you in the business—all of you—have come to understand that we did not understand about brain science 20 years ago.
Dr. Dewan: Okay. So this is—Schizophrenia probably has the most brain science dedicated to it and yet we still don't know. So let me go through the kinds of things that we know. We know that the actual architecture—the microarchitecture of the brain—the actual way the nerves are aligned. It's sort of like if you were building a building and instead of having the scaffolding be straight, it's twisted scaffolding. If the different receptors that communicate are inefficient or they're over productive in the communication, the multiple circuits of the brain do not communicate. It's sort of like having highways that are crisscrossed. Then there's also a shrinkage of parts of the brain that are responsible for memory, thought organization. So it is a total brain disease that includes all of those elements. That's why it's so difficult to understand.
There are so many genes that go into coding all those different parts of the brain from the meninges to the glial cells to the actual neurons to the actual receptors. That's why it's so complex. We've gone from thinking is this something that happens in utero? Is this some kind of viral infection that goes on? Is this something that happens in early childhood? Is it the teenage years? We know we can see it clinically sometimes in the early to late teenage years. More often than not somebody that goes to college and then gets this massive stress in their first year of college, suddenly they start getting delusional. They start hearing voices. You're thinking, "Oh my god. Things were just fine."
So we know a lot about the brain. We know this is an architecture issue. It's a function issue. It's a communication issue. And yet, we don't have cures for this illness. We just have what I would call things that mitigate the severity of the illness, but we don't have a cure.
Host: Wow, it's fascinating. I mean it really is absolutely fascinating. So what do we know about treatment options that are available and what signs should people look for? Is this something that just starts? You mentioned childhood dementia and back years ago, but how do you know? Is it something that just comes on or does it come on a little bit slowly? Then what are they supposed to do?
Dr. Dewan: The fancy term for this is insidious, which means it's a slow burn. So you see sort of withdrawing from people. Sort of a disinterest in kind of hanging out. Then you can see what I would call strange mannerisms and speech about, "Hey, so and so's really after me." Or, "Hey, I wonder if this person is plotting against me." Then people start having disorganized speech.
So you almost have to kind of listen really hard. You know what did they just say? What are they talking about? That doesn't make sense. If young people who start withdrawing socially, it goes back to they're into their own reality. They're uncomfortable with the true reality. So you invent stories about reality. That's really something you can pick up. Teachers can pick it up. Sometimes friends can pick it up. Sometimes parents can pick it up. They'll say, "Hey, I think something's going on." When they stop wanting to hang out at all and they're afraid and they stop taking care of themselves, they stop brushing their teeth or washing their face. It's they're in this different world. That's how you start recognizing it. Slowly, surely.
Then getting them into treatment is—there's two things that are used. Well, actually three things. Number one, you've got to get them medicine. It might not cure it, but it'll reduce the delusions. It'll reduce the hallucinations. It'll help them think more clearly. It'll allow the psychotherapy to work because we can teach people when you think somebody's out to get you, let's really look at the facts. Let's work through this. Then what I would call the—what we used to call vocational rehab is there are some skills you can do. You can still function in life. You can still work. You can still try to be a productive member of society. So it's those three things. The earlier you get them into treatment, the better it is. If you let this slow burn turn into a fire, putting out that fire and managing that fire over a lifetime becomes extremely complicated. It's a deteriorating—what we call—a neurocognitive illness with behavioral manifestations.
So it is a disease of the brain that impacts people's relationships and behaviors and life functioning. The quicker we can help somebody adapt to this illness the quicker we can get them to understand they have this illness. That's how we can get them to function throughout their life because this is an illness that has a high rate of, what I would call, mortality and morbidity. Which is fancy words for people do die early with this disease. People do lose their ability to function in society with this disease. So the earlier, the better. You've got to stay on the meds. You've got to stay connected. You've got to stay in treatment. It's a lifelong condition.
Host: The way you describe it, you're absolutely fascinating Dr. Dewan. What about some of the newer treatments as we get ready to wrap up here? What about research and transcranial direct current stimulation? Things that are going on in the field. What do you see happening?
Dr. Dewan: In schizophrenia, what you mentioned what I would call neuro-interventional psychiatry. That's really more for mood disorders like depression. For schizophrenia, it's really the "anti-psychotic" medication. We are having some success with what's called cognitive enhancers because there is a cognitive component to this illness that we really haven't focused on strongly in terms of medical interventions. When you look at the biggest research study ever done on schizophrenia, the primary result score that they were trying to get was not the result or the elimination of the illness. It was are you staying on medicine? Because staying on medicine makes you not get worse.
So usually I'm a very—I will tell people, hey we've got this great treatment. This great cure. What we have are treatments that reduce the dysfunction and have an opportunity to reduce sort of—what I would call—the severe symptoms. We are not there in terms of getting close to curing this illness. We are very good at managing the psychosocial aspects of this and we are pretty good at managing, what I would call, the biological or behavioral aspects of this illness, but boy we have a long way to go with this disease. A long way.
Host: What a great segment. So interesting. Dr. Dewan, thank you so much for coming on with us and explaining it in a way that we can understand since it is so mysterious for so many people to learn about. What a great lesson for us today. Thank you so much again. That wraps up this episode of BayCare HealthChat. You can go over to our website at baycarebehavioralhealth.org to learn more, to get more information, and to get connected with one of our providers. Please be sure and share this show with people that you know because we're all learning together, and these are the experts at BayCare that we're learning from. So that's the way we can all do it and be more informed and be our own best health advocates. Until next time, I'm Melanie Cole.
Schizophrenia
Melanie Cole, MS (Host): Welcome. Today we're talking about schizophrenia. It's such a mysterious disease. It can be very misunderstood. Here to teach us about it today is Dr. Nick Dewan. He's the chief medical officer in the behavioral health division of BayCare. Dr. Dewan, we've seen movies and media about schizophrenia, but people really don't understand anything about it. Tell us what it is.
Nick Dewan MD (Guest): So schizophrenia is a brain disorder that causes people to lose their sense of reality. Historically when it was first termed it was actually termed what's called juvenile dementia. So back in the mid-1800s when people noticed this condition where young people had lost their sense of reality and weren't thinking as organized as normal, they thought this is a variant of dementia.
The term schizophrenia actually means sort of a torn life or a split life. That's where you originally got that term where it was a split personality. So schiz meaning sort of a gash and phrenic comes from the Greek origin of what's called life breathing. So it was a terminology of this is a very difficult disease that hits you in your young life and sort of splits you off from reality. So that's how you can sort of think about this disorder.
Now, in terms of the media, there are so many different types of schizophrenia. There are some types where people can be extraordinarily successful. They can function in society at different levels, but then there are other types that are so awful and so burdensome where somebody can be what's called catatonic or so disorganized that they really need daily care and daily support.
Then there are others that can work, live, function. So it is a wide spectrum kind of condition, but it is probably the most difficult condition in all of psychiatry to treat. It is recognized by the World Health Organization as one of the most burdensome illnesses in the world just because it affects people at an early age, as teenagers, and it lasts with them throughout their life.
Host: Wow. As mysterious as it has been to so many people, explain a little bit. Dr. Dewan, I know that this is a tough thing to do briefly but explain a little bit about the brain science behind schizophrenia and what you in the business—all of you—have come to understand that we did not understand about brain science 20 years ago.
Dr. Dewan: Okay. So this is—Schizophrenia probably has the most brain science dedicated to it and yet we still don't know. So let me go through the kinds of things that we know. We know that the actual architecture—the microarchitecture of the brain—the actual way the nerves are aligned. It's sort of like if you were building a building and instead of having the scaffolding be straight, it's twisted scaffolding. If the different receptors that communicate are inefficient or they're over productive in the communication, the multiple circuits of the brain do not communicate. It's sort of like having highways that are crisscrossed. Then there's also a shrinkage of parts of the brain that are responsible for memory, thought organization. So it is a total brain disease that includes all of those elements. That's why it's so difficult to understand.
There are so many genes that go into coding all those different parts of the brain from the meninges to the glial cells to the actual neurons to the actual receptors. That's why it's so complex. We've gone from thinking is this something that happens in utero? Is this some kind of viral infection that goes on? Is this something that happens in early childhood? Is it the teenage years? We know we can see it clinically sometimes in the early to late teenage years. More often than not somebody that goes to college and then gets this massive stress in their first year of college, suddenly they start getting delusional. They start hearing voices. You're thinking, "Oh my god. Things were just fine."
So we know a lot about the brain. We know this is an architecture issue. It's a function issue. It's a communication issue. And yet, we don't have cures for this illness. We just have what I would call things that mitigate the severity of the illness, but we don't have a cure.
Host: Wow, it's fascinating. I mean it really is absolutely fascinating. So what do we know about treatment options that are available and what signs should people look for? Is this something that just starts? You mentioned childhood dementia and back years ago, but how do you know? Is it something that just comes on or does it come on a little bit slowly? Then what are they supposed to do?
Dr. Dewan: The fancy term for this is insidious, which means it's a slow burn. So you see sort of withdrawing from people. Sort of a disinterest in kind of hanging out. Then you can see what I would call strange mannerisms and speech about, "Hey, so and so's really after me." Or, "Hey, I wonder if this person is plotting against me." Then people start having disorganized speech.
So you almost have to kind of listen really hard. You know what did they just say? What are they talking about? That doesn't make sense. If young people who start withdrawing socially, it goes back to they're into their own reality. They're uncomfortable with the true reality. So you invent stories about reality. That's really something you can pick up. Teachers can pick it up. Sometimes friends can pick it up. Sometimes parents can pick it up. They'll say, "Hey, I think something's going on." When they stop wanting to hang out at all and they're afraid and they stop taking care of themselves, they stop brushing their teeth or washing their face. It's they're in this different world. That's how you start recognizing it. Slowly, surely.
Then getting them into treatment is—there's two things that are used. Well, actually three things. Number one, you've got to get them medicine. It might not cure it, but it'll reduce the delusions. It'll reduce the hallucinations. It'll help them think more clearly. It'll allow the psychotherapy to work because we can teach people when you think somebody's out to get you, let's really look at the facts. Let's work through this. Then what I would call the—what we used to call vocational rehab is there are some skills you can do. You can still function in life. You can still work. You can still try to be a productive member of society. So it's those three things. The earlier you get them into treatment, the better it is. If you let this slow burn turn into a fire, putting out that fire and managing that fire over a lifetime becomes extremely complicated. It's a deteriorating—what we call—a neurocognitive illness with behavioral manifestations.
So it is a disease of the brain that impacts people's relationships and behaviors and life functioning. The quicker we can help somebody adapt to this illness the quicker we can get them to understand they have this illness. That's how we can get them to function throughout their life because this is an illness that has a high rate of, what I would call, mortality and morbidity. Which is fancy words for people do die early with this disease. People do lose their ability to function in society with this disease. So the earlier, the better. You've got to stay on the meds. You've got to stay connected. You've got to stay in treatment. It's a lifelong condition.
Host: The way you describe it, you're absolutely fascinating Dr. Dewan. What about some of the newer treatments as we get ready to wrap up here? What about research and transcranial direct current stimulation? Things that are going on in the field. What do you see happening?
Dr. Dewan: In schizophrenia, what you mentioned what I would call neuro-interventional psychiatry. That's really more for mood disorders like depression. For schizophrenia, it's really the "anti-psychotic" medication. We are having some success with what's called cognitive enhancers because there is a cognitive component to this illness that we really haven't focused on strongly in terms of medical interventions. When you look at the biggest research study ever done on schizophrenia, the primary result score that they were trying to get was not the result or the elimination of the illness. It was are you staying on medicine? Because staying on medicine makes you not get worse.
So usually I'm a very—I will tell people, hey we've got this great treatment. This great cure. What we have are treatments that reduce the dysfunction and have an opportunity to reduce sort of—what I would call—the severe symptoms. We are not there in terms of getting close to curing this illness. We are very good at managing the psychosocial aspects of this and we are pretty good at managing, what I would call, the biological or behavioral aspects of this illness, but boy we have a long way to go with this disease. A long way.
Host: What a great segment. So interesting. Dr. Dewan, thank you so much for coming on with us and explaining it in a way that we can understand since it is so mysterious for so many people to learn about. What a great lesson for us today. Thank you so much again. That wraps up this episode of BayCare HealthChat. You can go over to our website at baycarebehavioralhealth.org to learn more, to get more information, and to get connected with one of our providers. Please be sure and share this show with people that you know because we're all learning together, and these are the experts at BayCare that we're learning from. So that's the way we can all do it and be more informed and be our own best health advocates. Until next time, I'm Melanie Cole.