Faydra: My name is Faydra Aldridge. Welcome to Look Again: Mental Illness Re-Examined, a podcast about mental illness brought to you by the BC Schizophrenia Society and our BC partner organizations. Today, we're going to be taking a closer look at some of the symptoms of schizophrenia. We're going to be focusing on the cognitive losses and insight, or rather a lack of insight, that can accompany some mental illnesses like schizophrenia or bipolar disorder.This lack of insight is an inherent inability to be able to think clearly and consciously see, and truly understand their behaviors as indicators that something isn't right. The term is anosognosia meaning that someone is unaware, or cannot accurately perceive their own mental health condition. While, it's a common symptom of certain serious mental illnesses like schizophrenia. It's also one of the most difficult aspects to understand for those who have never experienced it. So what causes anosognosia? How do people put their hand up and ask for help if they don't even know that they’re sick? And what impact does this lack of insight have on treatment?These are just some of the questions we're going to be tackling on today's episode with Dr. Mahesh Menon. Dr. Menon is a clinical psychologist with Vancouver Coastal Health, and based at the BC Psychosis Program at UBC Hospital. He is also one of the key drivers of getting programs around cognitive remediation started in British Columbia. Dr. Menon, welcome to the show.
Dr. Menon: Thanks, Faydra.
Faydra: Okay, Dr. Menon, let's talk about anosognosia. It's a big word with huge consequences. Why does this happen?
Dr. Menon: I think we should start out by saying we don't really know why this happens in psychosis itself. When we look at anosognosia for other conditions, with neurological conditions, we know that there are some changes in brain structure or perhaps brain connectivity.With schizophrenia and spectrum disorders, there isn't actually structural damage to any part of the brain. But it might have to do with connectivity across different brain networks, which could be causing it.
Faydra: And now in terms of the rate of anosognosia, how often does it occur in people with schizophrenia or bipolar disorder?
Dr. Menon: One of the things that's quite important is it's not that people have it or don't have it. We can think about it as being along a continuum and they bring different aspects to the experience itself. So, one component would be the recognition that some of these experiences that they're having might not be quote on quote real, but maybe internally generated experiences.Then a second component will be if I'm having those difficulties, do I have the need for treatment for it? So do I need to take medication? Do I need other supports? Someone may have neither. Someone may have one or the other. Overall to varying levels, about 50% of people who experience schizophrenia will have some level of a lack of insight into the illness, or into the magnitude of those difficulties, or whether each of those things that's happening might actually just be a symptom of the disorder itself.
Faydra: Wow. So 50% Mahesh. So that must make it very difficult for you as a clinician when treating an individual that has schizophrenia and does have anosognosia in talking about treatment. How do you get around that as a frontline clinician?
Dr. Menon: I think that a lot of times, if we get really stuck on the diagnosis piece itself, that can sometimes be an impasse. I think what we are trying to get people to recognize is that we can have common goals that we are working towards. So if someone says “I'm hearing these voices and I feel like there are these people who want to harm me,” we have the common goal that, what can we do that can reduce the distress that's associated with those voices. That can reduce the impact that this is having on your day to day life and allow you to work towards that.
Faydra: Last season, we briefly touched on the difficulty of anosognosia with Dr. Fidel Villa-Rodriguez, who is an assistant professor with the Department of Psychiatry at UBC. Here's what Dr. Villa-Rodriguez had to say about it.
Clip: For people suffering from this schizophrenia, there is a particular symptom that it's very challenging. We call it lack of insight. It can be understood as lack of awareness. We take for granted a lot of the things that our brains do for us. From walking, from paying attention to things, from speaking. One of the things that our brain does is it allows us to be aware of our environment, of how we are doing, whether we are thirsty, whether we are hungry.It also made us aware whether we are struggling with pain or with any other symptoms. In schizophrenia it's difficult to realize that they are struggling with a medical illness. That's the lack of insight. So what follows is, if a person has difficulty to realize that they are suffering an illness, why would they need treatment? And so that is a very challenging situation.
Faydra: So with these very challenging situations that both you and Dr. Villa-Rodriguez describe, what can a family member or friend do if their loved one does not believe they in fact have an illness?
Dr. Menon: I think that for a lot of the family members, they are having to deal with the day-to-day consequences. I think if the focus can be on one, making the person feel safe, reminding them that they are safe, finding a way to have the common grounds and saying, “We understand that you are dealing with having this distress, and this feels very real to you.” And then maybe saying “Can we allow for other people to come in, to have some of those difficult discussions.”And I think that there is a real advantage to having that because that way, the family member doesn't have to be in the role of the therapist and they can just be the family member. And at the same time, they can hopefully open the door to allow clinicians to be working with them. To have those hard conversations, to even bear the brunt of the conflict that can arise. An approach called the LEAP Method, can help family members communicate with their loved ones with psychosis. So that is I think, a really useful resource that I would suggest.
Faydra: You're listening to Look Again: Mental Illness Re-Examined. A podcast brought to you by the BC Schizophrenia Society and BC partner organizations. I'm your host Faydra Aldridge. This podcast would not be possible without the support of the entire community. From the bottom of our hearts, we want to thank you for caring about mental illness. Together, we truly can make a difference.We're back with Dr. Menon and we were just talking about the lack of insight in some serious mental illnesses, and how that impacts both the individual with the disorder, as well as their loved ones. Now we're going to move on and talk about cognitive losses. When we hear people talk about symptoms of schizophrenia, we first think about paranoia, hallucinations, delusions.But people living with schizophrenia can also experience a number of cognitive losses. Sometimes it's a result of the medication itself, but sometimes it is from the illness. I'm going to play a short clip from a panel where people with lived experience describe just some of the cognitive losses that they've experienced. Let's take a listen now.
Clip: I was conscious that I couldn't get my words out correctly, that they would come out almost like a, say I would say bicycle and it would be, but by some call. It would be incorrect.
Clip: And that was a constant, even though I knew how to say it, it wouldn't come out correct.
Faydra: Now Dr. Menon as a clinician, you would see patients all the time talking about their cognitive losses. Can you tell us more about what these losses are and how they do in fact, affect people with schizophrenia?
Dr. Menon: Sure. Now unlike the positive symptoms, and the negative symptoms that are quite specific to schizophrenia, cognitive difficulties can be seen in a number of psychiatric and neurological conditions. But we think about these as very common challenges that happen for people who are dealing with psychosis.There are a number of domains that we think of as traditionally in cognition. So attention, different types of memory and a number of aspects of what's called executive function. These are like the aspects of cognition, which are involved with planning, sequencing, problem solving. And when researchers have looked at the impairment in cognition, what we find is that people struggling with schizophrenia show impairments in almost all the domains of cognition to varying extents.So the most profound impairments tend to be involved in memory and some aspects of executive functioning, and a little bit to a slightly lesser extent, but still quite profoundly in processing speed and working memory. So we recognize that these difficulties are actually the ones that can have the most profound effect on people's ability to function every day.So finding ways to improve and address those cognitive difficulties is actually very important. The other really key component is that unfortunately, those aspects of cognition are not improved by anti-psychotic medications. So medications typically improve positive symptoms, but they don't have impact on cognition.
Faydra: So Dr. Menon, you just said that medication has a limited effect on cognitive deficits and illnesses like schizophrenia, but the growing implementation of CR or cognitive remediation is being described by some people as a game changer. What is cognitive remediation and what are your thoughts on it being considered this game changer?
Dr. Menon: I think cognitive remediation is one of the only interventions that we have, which can actually be helpful in improving these cognitive difficulties that are associated with the illness. Because again, most medications don't have a huge impact on cognition per se. When people are taking the medication, if they are symptomatically better, if the psych disorder is less, if the negative symptoms are a little bit better, we do see an improvement in some domains of cognition.But for many people, there are some difficulties which can persist. And I think this is where an intervention that cognitive remediation is really helpful. So there are three components to cognitive remediation programs. One aspect of that is we use a computer task, which is like these memory games, and retention games, and planning games.And the idea of those games is that they are challenging cognitive tasks that the person can engage. With the idea that working and challenging themselves, can help with potentially improving performance, increasing neuroplasticity is what we hope is happening. And hopefully improving, if we think about it as the hardware and the software components, it might help with improving the hardware.So our hope is that as people are doing challenging memory tasks and memory games, using their memory, it can cause improvements in at least some of the brain structures which are associated with memory. So not necessarily, even if they're not new neurons, it can be things like increased connections between the neurons.The second piece is actually improving their meta cognitive awareness of it. So to get people to recognize “this task is challenging for me, but I can use these strategies to improve my performance on that task.” So essentially greater awareness of the difficulties that they're having cognitively.So if we, again, think of it from the inside perspective, improving that insight around the specific cognitive challenges that they might be experiencing. As well as trying to recognize how they might be able to use strategies to overcome some of those challenges. And then the third component is then being able to take those strategies and generalize it to use in their daily life.So if I'm learning lists of words, and I'm using strategies, that isn't necessarily going to be something that I could use outside, besides let's say a grocery list. But if I'm able to recognize like some of those strategies that I'm using, I can also use to improve how well I'm remembering people's names, or how well I can remember the things that I need to do, or the ways to learn a new task, or new information at school. So finding ways to generalize that learning from the clinic to daily life. That's the third component.This is where we think that CR works best when it's done as a structured program with those three components. And works best when people are working with a clinician who can help to guide them through that. Through doing the computer tasks, recognizing the strategies, and figuring out how to generalize it to the world outside.
Faydra: Dr. Menon I can only imagine how difficult it would be to talk about anosognosia and what it means to both the individual that has the illness, as well as the family members that are caring for that person. Walk me through a conversation, as to how you would bring it up and how people respond when you talk about anosognosia.
Dr. Menon: we would probably have very different kinds of conversations with the family members, and with the person that's actually struggling with the illness itself. With the family members it's really helpful for them to be able to recognize that the person who is having those difficulties that is itself, a symptom of the illness. Helping them to understand what is this dumb anosognosia.And to help them to recognize that this is not their family member being obstinate or willful or denying something, but that it's really a symptom and it might be related to things that are going on in their brain. And that their experiences are so real and all encompassing to them, that it can be hard for them to step outside and for them to see that. When I'm having the conversation with the patient, I don't actually get into, “this is what we would call anosognosia,” because I don't think that's necessarily helpful.I think what we're working on with them is just to say, what is causing you distress, and how do we find ways to minimize that distress? I think with the patient or client, the discussion of anosognosia would come much later. As the end of a process of therapy and improved functioning, hopefully.
Faydra: I can also imagine that having anosognosia would also have a large impact on whether an individual stays on or goes off their medication. Because if they don't recognize they're ill, why would they continue taking medication then if they don't understand that they actually in fact have an illness.
Dr. Menon: Absolutely. And I think that poor illness insight is associated with people stopping their medications, and is associated with more frequent relapses, and hospitalizations, and so on. So that is absolutely important just to get people to recognize what is the reason that they might be taking their medication.And oftentimes, I think finding common ground, finding a reason that the person would agree with this, “that if I take this medication, I noticed that my anxiety is a little bit less. I noticed that my sleep is a little bit better. My stress levels are less.” That may be a reason that they would be willing to take it.But I think if it was, “you have to take it because you have schizophrenia,” and the person says no, then the chances of them taking it are a lot less. I think the second piece is helping people to understand that when you take the medications, you can't just stop it abruptly. This is conversations that their psychiatrist would have to have with them.Whether or not someone has insight, if someone chooses to abruptly stop their medication, that hugely increases the risk of relapse. So lots of times people may also stop their medications because they say “I'm doing fine. I actually feel good. I have recovered my insight. I don't think I need it.” And then they may choose to stop it, and that can also be risky.So it's like we can have this insight and they may stop. So helping the person whose insight has improved to recognize that okay, this is a chronic illness. There is a risk. And there are changes that happen in the brain related to the medication.Another underlying issue is also, we know that as people's insight into the illness improves, there are other challenges that can arise. Often improved insight is associated with, sometimes with depression. Um, because someone looks back and says, “Oh my God, I feel so bad about all of these things that I may have said or done.” So I think that was also where helping them to understand that, you know, this was related to the illness. And finding a way to integrate some of those experiences into their sense of self, in a way that isn't stigmatizing. That isn't making them feel bad about what has happened over the course of the illness, is really important to do.
Faydra: That's a really good point. So how do you as a clinician deal with that extra component, of now having the realization that they are sick, and do have an illness, and now dealing with everything that would go along with that realization?
Dr. Menon: When we're working with people, we want to find this empowering middle ground.Which is to say, this is not your fault in any way. This was an illness. This was not in your control. You didn't choose this. And at the same time, you have within you the capacity to do things which can help you engage more fully in the world, which can help you navigate your own recovery process. And to have a way that we can integrate that illness idea into their sense of self, but not have it be the thing that defines them as people know. I can be someone who is an artist who has schizophrenia. Right. So finding that way. I think those are some of the pieces that where working with therapists, um, supportive friends and family, to have that integrated sense of self can be really helpful.
Faydra: So where are things at then in British Columbia, in regards to expanding the CR or the cognitive remediation program, and making it more mainstream for people?
Dr. Menon: There are groups being run in Victoria, Penticton, Kamloops, in Vancouver. And our hope is that we're going to just be expanding that out, so that there will be groups which will be offered through a number of the different mental health teams, um, across BC.
Faydra: Okay, I have to ask Dr. Menon, if cognitive remediation or CR can make such a huge difference, as you were just describing for people living with schizophrenia, why aren't we using it more?
Dr. Menon: I think it's probably a combination of how it is developed and validated. And there's been a huge body of research around it over the last 20 plus years that has yet been widely disseminated. I think that many people are unaware of the extent of the cognitive difficulties that we see in schizophrenia. And also the idea that it's the level of these cognitive difficulties, which is a better predictor of day-to-day functioning compared to even say, the severity of someone's hallucinations or delusions.The fact that cognitive difficulties actually predict functioning better than the positive symptoms, is something that people don't think about. I think the second reason is that we have taken a fairly limited view of recovery -- we just need to get them to take the medications and that's it. Whereas now I think we've started to take a much broader, holistic view of recovery. To say that it isn't just about reducing the severity of the paranoia that someone's experiencing, but also helping them to have more meaningful, richer lives. And then trying to understand what are the values that are getting in the way of that? And then how could we address all of that? So I think our view of recovery has, in my impression, it's gotten broader, more nuanced. And I think that's been something which has opened the door for, for a plethora of these psychosocial interventions as well.
Faydra: So Dr. Menon, you just use the word recovery and I know that can be quite controversial. Especially because we know that there is at least at this time, no cure for schizophrenia. So what did you mean by using the term recovery?
Dr. Menon: So I'm going to embrace the controversies as you've may have guessed from my other responses. I do think about recovery as a larger process than just an improvement in delusions or hallucinations. I actually think about recovery as someone having a sense of purpose in their life, a sense of themselves beyond the illness. So that idea that I am a writer who has schizophrenia, or I am an artist who has psychosis, or I'm a brother who has that. So that they have a sense of themselves beyond the illness. But they recognize, “Okay, this is something that I need to manage. I have to minimize the negative impact that it has in my life.” And perhaps, if that is a motivator for them to say, “Okay, you know what I have had these difficulties, how might I use this to make positive change in the world?” That's to me like the epitome of where someone has recovered symptomatically, but also has engaged with life, found meaning and purpose and connection. And is able to feel like they're truly living the life that they would want to choose. I think that would be my hope and my ideal picture of recovery itself.
Faydra: And perfect segway. So Dr. Menon, one final question. What do you hope the future will look like for people living with schizophrenia?
Dr. Menon: My hope is that when people are getting treatment, that they have access to actually get actively engaged in a range of interventions for themselves. I think addressing the medications which can help to address delusions and hallucinations, but also psychotherapies, which can help to address the self-esteem, the stigma, the developing a better understanding of those difficulties. Social skills training, which can help them to engage better with people.Because for people who've been unwell for a while, you know they've led these isolated lives. They've fallen out of society at those key junctions, their teenage years. So having a chance to re-engage them. So social skills training, cognitive remediation, which can really help them. And then finding ways to help them be connected with work, or other opportunities, or even just more social engagements. And ways to assign meaning, and purpose, and joy. I think all of those should be part of the collection of services that we offer to them, would be my hope.
Faydra: Dr. Mahesh, thank you so much for speaking with me today, it was truly a pleasure and I'm so glad that you were involved in so many initiatives, including cognitive remediation in our province.
Dr. Menon: Thank you. It's it's been a real privilege to get
Dr. Menon: to do this. Really appreciate it.
Faydra: And thank you for joining us today. And if you didn't get a chance to hear our previous episodes from season one, that touched on anosognosia as well as the cognitive losses, we hope you will take the time to listen to them now. And just a reminder that we will be posting all of the relevant links from this conversation in our show notes and on our website, www.bcss.org. And to get all of the latest podcasts episodes, be sure to hit follow on Apple Podcasts, Spotify, or anywhere you listen to our podcasts.Talk to you soon.
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