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NEW YORK – Psychiatric disorders comorbid with schizophrenia often pose a diagnostic challenge, but they can be the key for improving outcomes when they are addressed along with the core schizophrenia symptoms, according to a workshop on treatment-refractory disease at the American Psychiatric Association annual meeting.
Looking for comorbidities such as depression, panic disorder, and obsessive-compulsive disorder (OCD) is important, because treatment directed at those conditions “can have a significant effect on the psychosis as well,” reported Jeffrey P. Kahn, MD, clinical associate professor of psychiatry, Cornell University, New York.
“Schizophrenia is a syndrome. It is a collection of symptoms, not a disease,” explained Michael Y. Hwang, MD, an attending physician at Veterans Affairs Hudson Valley Healthcare System, Montrose, N.Y. He believes that comorbid OCD, like comorbid panic disorder, might identify a subtype of schizophrenia that requires distinct therapeutic strategies.
The principle that schizophrenia represents a group of distinct illnesses with similar presentations is several decades old. Both Dr. Kahn and Dr. Hwang, who have published on this topic, acknowledged that efforts so far to identify those distinct diseases have failed. However, they suggested that the presence of comorbidities probably establishes clinically relevant subtypes.
Among psychiatric comorbidities, major depression is the most common, identified in more than half of patients with schizophrenia in some studies, according to Dr. Hwang. He reported that diagnostic criteria for OCD is met by about 12%, while Dr. Kahn estimated the prevalence of panic disorder in individuals with schizophrenia at about 20%.
In an individual with active positive symptoms of schizophrenia, isolating comorbid OCD or panic disorder often is a challenge. In older textbooks and guidelines on schizophrenia, comorbidities were not even discussed, Dr. Hwang said. Although the DSM-5 now acknowledges elevated rates of OCD and panic disorder in individuals with schizophrenia, Dr. Hwang and Dr. Kahn each indicated that the comorbidities still are not receiving adequate attention from clinicians.
“In general, individuals with schizophrenia who have comorbid OCD tend to do worse,” said Dr. Hwang, explaining the rationale for both looking for and treating OCD. He presented data from several studies, including his own, suggesting that symptoms of OCD can be improved with individualized pharmacotherapy. In addition to such considerations as the potential for interactions between OCD therapies and concurrent atypical antipsychotics, heterogeneity in response underlies the recommendation for individualized therapy. He added that in those with preserved executive functioning, cognitive-behavioral therapy “is always more helpful that pharmacotherapy alone.”
Comorbid panic disorder also can be difficult to recognize, particularly in individuals with active symptoms of schizophrenia, according to Dr. Kahn. . He advised against trivializing the importance of panic disorder symptoms.
“The tendency is to think, so what if the patient has symptoms of panic. Wouldn’t you if you had schizophrenia?” Dr. Kahn noted. However, identifying and then treating the panic has implications for better control of schizophrenia, he said. For the panic symptoms, there is evidence to suggest that clonazepam is effective, he said, but he advised a slow upward titration to avoid sedation and other risks that include addiction. He, like Dr. Hwang, also advised that the value of psychotherapy should not be underestimated.
“It is very important, particularly with outpatients, to spend time with that patient in order to build a therapeutic alliance and from there, progress to supportive psychotherapy,” Dr. Kahn said.
Dr. Kahn and Dr. Hwang reported no potential conflicts of interest related to this topic.
NEW YORK – Psychiatric disorders comorbid with schizophrenia often pose a diagnostic challenge, but they can be the key for improving outcomes when they are addressed along with the core schizophrenia symptoms, according to a workshop on treatment-refractory disease at the American Psychiatric Association annual meeting.
Looking for comorbidities such as depression, panic disorder, and obsessive-compulsive disorder (OCD) is important, because treatment directed at those conditions “can have a significant effect on the psychosis as well,” reported Jeffrey P. Kahn, MD, clinical associate professor of psychiatry, Cornell University, New York.
“Schizophrenia is a syndrome. It is a collection of symptoms, not a disease,” explained Michael Y. Hwang, MD, an attending physician at Veterans Affairs Hudson Valley Healthcare System, Montrose, N.Y. He believes that comorbid OCD, like comorbid panic disorder, might identify a subtype of schizophrenia that requires distinct therapeutic strategies.
The principle that schizophrenia represents a group of distinct illnesses with similar presentations is several decades old. Both Dr. Kahn and Dr. Hwang, who have published on this topic, acknowledged that efforts so far to identify those distinct diseases have failed. However, they suggested that the presence of comorbidities probably establishes clinically relevant subtypes.
Among psychiatric comorbidities, major depression is the most common, identified in more than half of patients with schizophrenia in some studies, according to Dr. Hwang. He reported that diagnostic criteria for OCD is met by about 12%, while Dr. Kahn estimated the prevalence of panic disorder in individuals with schizophrenia at about 20%.
In an individual with active positive symptoms of schizophrenia, isolating comorbid OCD or panic disorder often is a challenge. In older textbooks and guidelines on schizophrenia, comorbidities were not even discussed, Dr. Hwang said. Although the DSM-5 now acknowledges elevated rates of OCD and panic disorder in individuals with schizophrenia, Dr. Hwang and Dr. Kahn each indicated that the comorbidities still are not receiving adequate attention from clinicians.
“In general, individuals with schizophrenia who have comorbid OCD tend to do worse,” said Dr. Hwang, explaining the rationale for both looking for and treating OCD. He presented data from several studies, including his own, suggesting that symptoms of OCD can be improved with individualized pharmacotherapy. In addition to such considerations as the potential for interactions between OCD therapies and concurrent atypical antipsychotics, heterogeneity in response underlies the recommendation for individualized therapy. He added that in those with preserved executive functioning, cognitive-behavioral therapy “is always more helpful that pharmacotherapy alone.”
Comorbid panic disorder also can be difficult to recognize, particularly in individuals with active symptoms of schizophrenia, according to Dr. Kahn. . He advised against trivializing the importance of panic disorder symptoms.
“The tendency is to think, so what if the patient has symptoms of panic. Wouldn’t you if you had schizophrenia?” Dr. Kahn noted. However, identifying and then treating the panic has implications for better control of schizophrenia, he said. For the panic symptoms, there is evidence to suggest that clonazepam is effective, he said, but he advised a slow upward titration to avoid sedation and other risks that include addiction. He, like Dr. Hwang, also advised that the value of psychotherapy should not be underestimated.
“It is very important, particularly with outpatients, to spend time with that patient in order to build a therapeutic alliance and from there, progress to supportive psychotherapy,” Dr. Kahn said.
Dr. Kahn and Dr. Hwang reported no potential conflicts of interest related to this topic.
NEW YORK – Psychiatric disorders comorbid with schizophrenia often pose a diagnostic challenge, but they can be the key for improving outcomes when they are addressed along with the core schizophrenia symptoms, according to a workshop on treatment-refractory disease at the American Psychiatric Association annual meeting.
Looking for comorbidities such as depression, panic disorder, and obsessive-compulsive disorder (OCD) is important, because treatment directed at those conditions “can have a significant effect on the psychosis as well,” reported Jeffrey P. Kahn, MD, clinical associate professor of psychiatry, Cornell University, New York.
“Schizophrenia is a syndrome. It is a collection of symptoms, not a disease,” explained Michael Y. Hwang, MD, an attending physician at Veterans Affairs Hudson Valley Healthcare System, Montrose, N.Y. He believes that comorbid OCD, like comorbid panic disorder, might identify a subtype of schizophrenia that requires distinct therapeutic strategies.
The principle that schizophrenia represents a group of distinct illnesses with similar presentations is several decades old. Both Dr. Kahn and Dr. Hwang, who have published on this topic, acknowledged that efforts so far to identify those distinct diseases have failed. However, they suggested that the presence of comorbidities probably establishes clinically relevant subtypes.
Among psychiatric comorbidities, major depression is the most common, identified in more than half of patients with schizophrenia in some studies, according to Dr. Hwang. He reported that diagnostic criteria for OCD is met by about 12%, while Dr. Kahn estimated the prevalence of panic disorder in individuals with schizophrenia at about 20%.
In an individual with active positive symptoms of schizophrenia, isolating comorbid OCD or panic disorder often is a challenge. In older textbooks and guidelines on schizophrenia, comorbidities were not even discussed, Dr. Hwang said. Although the DSM-5 now acknowledges elevated rates of OCD and panic disorder in individuals with schizophrenia, Dr. Hwang and Dr. Kahn each indicated that the comorbidities still are not receiving adequate attention from clinicians.
“In general, individuals with schizophrenia who have comorbid OCD tend to do worse,” said Dr. Hwang, explaining the rationale for both looking for and treating OCD. He presented data from several studies, including his own, suggesting that symptoms of OCD can be improved with individualized pharmacotherapy. In addition to such considerations as the potential for interactions between OCD therapies and concurrent atypical antipsychotics, heterogeneity in response underlies the recommendation for individualized therapy. He added that in those with preserved executive functioning, cognitive-behavioral therapy “is always more helpful that pharmacotherapy alone.”
Comorbid panic disorder also can be difficult to recognize, particularly in individuals with active symptoms of schizophrenia, according to Dr. Kahn. . He advised against trivializing the importance of panic disorder symptoms.
“The tendency is to think, so what if the patient has symptoms of panic. Wouldn’t you if you had schizophrenia?” Dr. Kahn noted. However, identifying and then treating the panic has implications for better control of schizophrenia, he said. For the panic symptoms, there is evidence to suggest that clonazepam is effective, he said, but he advised a slow upward titration to avoid sedation and other risks that include addiction. He, like Dr. Hwang, also advised that the value of psychotherapy should not be underestimated.
“It is very important, particularly with outpatients, to spend time with that patient in order to build a therapeutic alliance and from there, progress to supportive psychotherapy,” Dr. Kahn said.
Dr. Kahn and Dr. Hwang reported no potential conflicts of interest related to this topic.
REPORTING FROM APA