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Study Underscores the Difficulty of Diagnosing Schizophrenia BY THOMAS CROCKER SCHIZOPHRENIA IS OF TEN MISDIAGNOSED, WITH POTENTIALLY FAR-RE ACHING CONSEQUENCES, BUT E ARLY REFERR AL TO A SPECIALT Y CLINIC FOR A SECOND OPINION CAN HELP ALLE VIATE THE PROBLEM, ACCORDING TO A NE W STUDY. A PSYCHOTIC DISORDER characterized by hallucinations and delusions, among other symptoms, schizophrenia hampers problem- solving, decision-making and emotional regulation. Schizophrenia affects 0.25% to 0.64% of people in the United States, according to the National Institute of Mental Health. Symptoms typically first appear in a person's teens or 20s, according to the American Psychological Association. Schizophrenia is notoriously difficult to diagnose accurately. Many clinicians lack the expertise to differentiate between attenuated psychosis symptoms — these may resemble delu- sions and hallucinations, but individuals retain insight that the experiences are not real — and true psychosis, including schizophrenia, according to Diana Perkins, MD, MPH, Professor in the Department of Psychiatry at the University of North Carolina School of Medicine. "[O]nly one in five people [who experience attenuated psychosis symptoms] will develop a full-blown psychotic disorder within two to three years … so we can't treat attenuated psychosis like psychosis, even though it kind of looks like psychosis," she says. EVIDENCE OF OVERDIAGNOSIS Mista king attenuated psychosis sy mptoms for psychosis may be one factor leading to misdiag nosis of schizophre- nia — a phenomenon that Russell Margolis, MD, Professor of Psychiatry and Neurology, Director of the Laboratory of Genetic Neurobiolog y, a nd Clinica l Director of the Johns Hopkins Schizophrenia Center at Johns Hopkins University School of Medicine, and colleagues at the university 's Early Psychosis Inter vention Clinic (EPIC) bega n seeing with increa sing frequency. They conducted a study to learn more about the drivers of schizophrenia misdiagnosis. Much is at sta ke. " The goa l of treatment for a n adolescent or young adu lt w it h a serious menta l i l lness such a s schizophrenia is to help keep them as close as possible to the life trajector y they would have been on if they had not gotten ill — able to follow their interests in school, work a nd/or relationship building," Dr. Ma rgolis says. "A n accurate diagnosis informs clinicia ns about the optima l treatment strategies to help patients return to that life trajector y. A n inaccurate diag nosis ca n lead to the wrong treatment, which may hinder rather tha n help." Dr. Margolis and his team analyzed the records of 78 patients who were refer red to EPIC bet ween Febr ua r y 2011 a nd Ju ly 2017 by psychiatrists, nurse practitioners a nd other medica l prov iders. For t y-t hree (55%) patients presented w it h a sch i zoph ren ia d ia g nosis, a nd cl i n icia ns at EPIC dia g nosed 22 (51%) w ith a dif ferent disorder. Eighteen of those 22 patients (41%) were found to not have a ny t y pe of psychosis. The most common factors prompting a cha nge of diag nosis were sy mptoms of a n xiet y a nd the absence of thought disorder. The f indings appea red in the Journal of Psychiatric Practice. " We were … sur prised by t he frequency w it h which we [cha nged diag noses for] patients who were thought to have sch i zoph ren ia or a related d isorder," Dr. Ma rgol is says. " Ba sed on our eva luation, the most common diag noses for these patients was … either a n a n xiet y or a mood disorder." The tea m suspects severa l factors contribute to excessive misdiag nosis of schizophrenia , including, the resea rchers w r ite, "a n overly l itera l i nter pret ation of patient s' sel f- repor ted sy mptoms, especia l ly ' hea ring voices.'" It is not uncommon for the genera l population a nd individua ls with anxiety disorders to hear voices, but the experience is different for people w ith schizophrenia , according to Dr. Ma rgolis. The resea rchers a lso point to widespread use of sy mptom checklists that lack the nuance and detail of full menta l hea lth histories, and def iciencies in the classif ication of psychiatric disorders as potentia l causes of schizophrenia misdiagnosis. CALLS FOR EARLY, EXPERT CONSULTATIONS AND MORE CLINICIAN EDUCATION For Dr. Margolis and his team, the study provides evidence that clinicians should consider referring patients with a suspected psychotic disorder to a specialty clinic as early as possible. "Our study suggests that general child or adult psychiatrists, and especially primary care clinicians, should frequently consider a second opinion [for patients with suspected psychotic disor- ders]," Dr. Margolis says. "This is most necessary in ambiguous or atypical cases." Dr. Perkins, who was not involved with the study, advocates for more provider education about the difference between attenuated psychosis and psychosis. "The mental health providers who treat schizophrenia all the time don't know the difference between attenuated psychosis and full psychosis," she says. "It's just not something people have learned in medical school … it's not something people are trained on in residency. It's still an academic issue rather than a bread-and-butter clinical issue, and it needs to start turning into [a clinical issue]." n M D N E W S . C O M /// M D N E W S C E N T R A L N E W Y O R K ■ 2 0 2 0 1 3