Schizophrenia Disorder

Characteristics

Devastating Disease Affects thinking, emotions, ability to perceive

reality, responsible for longer hospitalizations, greater life chaos, and more fears than any other mental disorder

Psychotic Disorder Delusions, hallucinations, disorganization of

speech; these lead to severe deterioration of social and occupational functioning

Epidemiology

Prevalence

Onset

Males/ Females

Phases of Schizophrenia

Phase I: Premorbid Phase

Phase II: The Prodromal Phase

Phase III: Schizophrenia

Phase IV: Residual Phase

Phase I

Premorbid Phase: There is usually a period of normal

functioning. The indicators associated with this phase are shyness, withdrawn personality, poor peer relationships, poor academically, antisocial behavior

Phase II

Prodromal Phase: Begins with a change from normal

functioning and extends to the start of acute symptoms. This phase can be a few weeks or months, but usually lasts about 2-5 years before Active phase of disorder begins.

Symptoms: poor concentration, anxiety, changes in mood, ideas of reference may begin, deterioration of role functioning

Phase III

Active Schizophrenia Psychotic symptoms are prominent Delusions/ hallucinations/ disorganized

speech (Positive Symptoms) Flattened affect, alogia (poverty of

speech), avolition (lack of desire, drive) Self care is neglected, social and

occupational functioning deteriorates Duration

Phase III (con’t)

Exclusions have been made;this means that the pt has been ruled out as having the symptoms due to substance abuse, other personality or medical conditions

(These definitions are used to confirm the diagnosis per DSM-IV-TR)

Phase IV

Residual Phase Symptoms are absent or no longer as

prominent in this phase Negative symptoms may remain (flat

affect and impairment of role functioning)

Residual impairment will usually increase between each episode of active psychosis

Prognosis

Return to full premorbid functioning is not common.

Some factors which are associated with positive prognosis: Later age onset/ female gender/ abrupt onset Brief duration of active phase symptoms No family history of schizophrenia Absence of brain abnormalities

Co-Morbidity

Substance Abuse

Depressive Symptoms

Anxiety D/O

Psychosis induced Polydipsia

Predisposing Influences

Biological Huge genetic component/Dopamine

Hypothesis Psychological Environmental Stressful Life Events

Transactional Model

The most current theory: Schizophrenia although caused by

biological components; is influenced by factors within the environment (stress, sociocultural factors).

These environmental factors influence the severity and duration of disease.

Neuroanatomical Findings

Severe disruption in neural circuitry Brain imaging

Enlarged lateral cerebral ventricles/3rd vent. Dilation/ vent. Assymmetry

Cortical, cerebral, frontal lobe activity Increased sulci size

MRI/CT: Low brain volume and more CSF

PET: Low blood flow and glucose metabolism in frontal lobe of cerebral cortex

Prepsychotic Early Symptoms

Prodromal symptoms: month to a year before break, usually undiagnosed

Adolescence: may have been withdrawn, lonely as adolescent

Early Phase: difficulty concentrating, difficulty with completing projects, phobias, anxiety, obsessions

Treatment- Relevant Dimensions:

Favorable Prognosis Abrupt onset/ good prepsychotic functioning Positive symptoms have a better response to

antipsychotic meds.

Unfavorable Prognosis Insidious onset (2-3 yr) /childhood hx of tension,

depression Negative symptoms are most destructive and

lingering do not respond as well to treatment

Positive vs. Negative

Positive Hallucinations Delusions Bizarre Behavior Thought and speech

d/o

These are the Florid symptoms of the d/o..they catch your attention

Negative Affect flattening Alogia (poverty of

speech) Apathy/ no motivation Anhedonia (lack of

interest in anything) These are crippling

because they are taking something away from your personality, poor response to meds.

Positive: Content of Thought

Delusions: Persecution Grandeur Reference Of control or influence Somatic/Nihilistic Religiousity/Magical Thinking Paranoia

Form of Thought

Associative Looseness Neologisms Clang Association Concrete Thinking Word Salad Tangentiality/Circumstantiality Perseveration

Alterations in Perception

Hallucinations (90%)AuditoryVisualOlfactoryGustatoryTactileCommand hallucinations

Alterations in Behavior

Extreme motor agitation Stereotype behavior Automatic Obedience Waxy Flexibility Stupor Negativism Agitated Behaviors

Sense of Self

Echolalia Echopraxia Identification/ Imitation Depersonalization

Negative Symptoms

Apathy, anhedonia, poor social functioning, poverty of thought Insidious onset Atrophy on CT Abnormal neuropsychological tests Poor response to antipsychotics Develop over long time Impedes ability to initiate /maintain hygiene/

relationships/ conversation/ hold job Affects affect: flat/ blunt/ inappropriate/bizarre and

volition (motivation)

Affect

Inappropriate Affect Emotional tone is non-congruent

Bland/ Flat Affect Bland-emotional tone is weak Flat- void of emotion

Apathy Indifference to environment and others

Volition

Emotional Ambivalence

Opposing emotions interfere with person’s ability to make even the most simple of decisions.

For example: which shoes should I wear today?

Impaired Interpersonal Functioning

Some clients may cling to people or invade personal space.

Some may socially isolate. Some may focus inwardly on their own

world (Autism). Grooming and hygiene deteriorates; look

untidy, disheveled.

Psychomotor

Anergia Waxy flexibility Posturing Pacing/ Rocking

Associated Negative Symptoms

Anhedonia Inability to experience pleasure, this is

the symptoms that will compel client to suicide attempt

Regression Retreat to earlier stage of development This is a defense mechanism for

decreasing anxiety

CASE STUDY

Sara is a 24 year old , newly diagnosed with Schizophrenia. Has been admitted for a suicide attempt at age 19, on and off antidepressants. She admits to you she has no close friends or boyfriend. Her affect is severely blunted. During the conversation she tilts her head and after listening states that her friend “likes your hair”. She says her parents don’t like her and are continually trying to drive her crazy. She says they tell all their friends about her and discuss how they should handle her. She says she is the leader of a group of superwomen who all have magic powers. They tell her that if she will “blink at the people who

aggravate her she will be able to “make them all go away”. She asks you to help her escape from the unit promising that you can join the group too. As you walk with her she hisses and grimaces bizarrely placing a “hex” on those who come close to her.

Okay so find a partner!

THINK! PAIR ! SHARE!

1. What is the objective data? Subjective? 2. Go back to your power points to determine what

delusions are in play. 3. What kind of hallucinations is she experiencing? 4. What are the positive and negative symptoms she

is displaying?

We will come back to this after learning interventions next class.

Self Assessment

Evokes intense, uncomfortable and frightening emotions

Identify personal feelings

Peer Groups supervision

Subtypes of Schizophrenia

Disorganized Schizophrenia

Most regressed and socially impaired

Marked looseness of associations, grossly inappropriate affect, bizarre mannerisms, incoherent speech, extreme social withdrawal, fragmented and poorly organized H/D

Disorganized (con’t)

Odd, giggly, grimacing behavior to internal stimuli

Early onset and poor premorbid functioning

Most in state hospitals or homeless May live with family for support,

respite care and day hospital affiliation

Catatonia (withdrawn phase)

Behaviors include: posturing, waxy flexibility, stereotyped behavior, extreme negativism or autonomic obedience, echolalia, echopraxia

Abrupt onset Favorable prognosis Rarely seen today Counseling Self Care Milieu Needs

Catatonia ( Excited phase)

Talks or shouts continually May be incoherent

Communication needs to be clear, direct and reflect concern for safety

Risk of exhaustion IM antipsychotic Fluids, calories, rest Destructive and aggressive response

to H/D

Paranoia

Paranoid: Paranoia-intense, irrational suspicion Projection: defense mechanism Later age of onset Good pre-morbid functioning & outcome Frightened, deep feelings of loneliness,

despair; helplessness, fear of abandonment

Paranoia: Interventions

Counseling Communication guidelines: guarded, tense, reserved,

superior, hostile, sarcastic, despair, and dwell on others short comings, “ideas of reference”

May make offensive statements yet accurate statements about unit policies/staff. Do not react with anxiety or rejection. Staff conferences, peer groups

Self Care: grooming not a problem, nutrition/sleep may be an issue

Milieu Needs: provide sense of safety and security to minimize anxiety / environmental distractions

Undifferentiated Schizophrenia

Active signs of d/o do not meet criteria for paranoia, catatonia, or disorganized type

Early and insidious onset- usually early to mid-teens

Disability stable, but persistent

Residual Type

No active-phase symptoms At least 2 residual symptoms:

Lack of initiative, interest, energy Marked social withdrawal Impairment in role function Marked speech deficits Odd beliefs, magical thinking, unusual

perceptual experiences

Other Subtypes:

Schizoaffective Disorder Brief Psychotic Disorder Schizophreniform Disorder Delusional Disorder Shared Psychotic Disorder Psychosis due to medical condition

or substance abuse

Outcome Criteria, Planning, Intervention– depends on phase

Focus on strengths/ minimize deficits Acute Phase

Outcome Criteria-Overall goal- crisis intervention Safety/ self injury Refrains from acting on H/D Symptom stabilization

Planning Brief hospitalization Safety Specific hospitalization Neurological workup Identify aftercare needs

Outcome Criteria

During the Maintenance and Stabilization Phase Outcome Criteria

Medication compliance Understand schizophrenia/ pt & family

psychoeducation, target negative symptoms Social/ vocational/ self care activities

Planning Pt/Family education Skills training Relapse Prevention Vital

Basic Level Interventions

In Acute phase Counseling Evaluations Psychopharmacologic interventions Limit setting/ Milieu / Safety

Basic Interventions (con’t)

Other considerations would include: Health teaching Self care activities Case Management Health Promotion

Maintenance & Stabilization Phases Interventions

Health Teaching Schizophrenia process Medication Instruction re: cognitive skills Strategies to decrease stress and anxiety

Health Promotion & Maintenance Signs of relapse/ prevention Deficits of self care, work, and social functioning Encouraging participation in activities/social

relationships Interaction

Milieu Therapy

Hospital provides needed structure Safety

Useful Activities

Resources for resolving conflict

Opportunities for learning social/ vocational skills

Counseling: Communication

Hallucinations Try to understand what voices are telling person to do

Delusions Try to see world through pt’s eyes Clarify reality Empathize with pt’s experience and feelings Never argue regarding content Distract from delusional material

Associative Looseness Don’t pretend to understand/ tell them if you can not understand Look for recurring themes/ stress here and now...reality based Reinforce clear communication, accurate expression of needs

Client / Family Teaching

Include family in strategies to reduce exacerbation

Educate: Illness, medication Relapse prevention Impact of stress Family support resources

Advanced Practice Interventions

Medication compliance most important, biopsychosocial interventions help to prevent relapse

Advanced Practice (con’t)

Individual Therapy SST: improve social activity, foster contacts, improve quality

of life, lower anxiety Cognitive Remediation—practice Cognitive adaptation training (CAT) Improve adaptive function Cognitive Behavioral Therapy (CBT) change abnormal

thoughts/ responses

Group Therapy Interpersonal skills development Resolve family problems Effect use of community services

Advanced Practice (con’t)

Family Therapy 60% return to family of origin after discharge Family members often become isolated from relatives and

community Families need to be full partners in treatment Family therapy and pharmacotherapy result in 50% relapse

reduction

Psycho-education programs combine educational and behavioral approaches (fears, distortions, faulty communication, problem-solving)

Psychopharmacology

With each relapse following medication discontinuation, it takes longer to achieve remission following restarting meds.

Types of Medications

Conventional Antipsychotics Atypical Antipsychotics

Conventional Meds

Target positive symptoms (H/D, disordered thinking, paranoia)

Antagonists at the D2 receptors site at the limbic and motor centers

All can cause TD (Tardive Dyskinesia) Undesirable side effects leads to noncompliance—

EPS (akathesia, dystonia, parkinsonism, tardive dyskinesia) and agranulocytosis

Additional adverse effects Anticholinergic, orthostasis, lower seizure threshold

Conventional Meds (con’t)

Drug chosen for side effects Thorazine- highest sedative and hypotensive

effects/Increases sensitivity to the sun

Haldol— used for assaultive clients/ low sedative properties/does not cause hypotension (used for elderly due to this)/ ^ EPS

Advantages: less $$$ Can all cause Tardive Dyskinesia *Use with caution in seizure d/o

Why do clients quit???

Weight gain!!!

Impotence!!!

EPS!! For Pseudoparkinsonism: anticholinergics (cogentin) For Dystonic Reactions: antihistamines used

(Benadryl)

Neuroleptic Malignant Syndrome

Due to an acute reduction of dopamine levels

Occurs- 0.2%-1.0% of clients who have taken antipsychotic agents

Fatal-10% Symptoms: Decreased LOC, increased muscle tone,

hyperpyrexia,labile HBP, tachycardia, tachypnea, diaphoresis, drooling

RX: D/C antipsychotic Maintain fluid balance, reduce temperature

Medication Bromocriptine (Parlodel) IV, Dantrolene (Dantrium), ECT

Atypical Antipsychotics (AAPS)

First line antipsychotics…why????? Minimal or no EPS or TD!!! Treat positive and negative symptoms May improve neurocognitive defects May decrease anxiety/ depression/ suicide Lowers relapse rates

Clozaril (1990)-risk of agranulocytosis.8-1.0% and seizures ( aka . Clozapine) Weekly WBC checks 1st 6 months Due to this only a weeks supply of medication is filled

at a time during first 6 months.

Atypical Antipsychotics

New AAPs Respiradone (respirdal), Olanzapine

(Zyprexa), Quetiapine (Seroquel), Zisprasidone (Geodon), Ariprozole (Abilify)- free of agranulocytosis

Except for Geodon and Abilify cause significant weight gain and metbolic syndrome (glucose dysregulation, hypercholesteremia, hypertension)

More $$$ than conventional*Geodon and Abilify very common due to no weight gain

Adjuncts to Antipsychotic Drug Therapy

Antidepressants Depression common

Antimanic—Lithium or Valproate Lithium reduces violence, helps w/ symptoms Valproate enhances antipsychotic efficiency

Benzodiazepines (Valium/ Xanax/ Klonopin) Augmentation can improve +/- symptoms by 50% May diminish anxiety, agitation, and psychosis

Client Education

Drowsiness / dizziness can occur Use sunblock, skin is more prone to sunburn on these

meds Have blood levels drawn if necessary Do not drink ETOH, no OTC drugs without MD’s knowledge Rise slowly to avoid orthostatic hypotension Be aware of the side effects and what to expect Take frequent sips of water, chewing gum for dry mouth Report severe effects: difficulty urinating, jaundice, severe

headache, rapid pulse, unusual bleeding Continue to take medication even if you’re feeling better.

Evaluation

Important step in plan of care

Determine if expected behavioral outcomes have been met

Reassess existing problems

Revise plan and change interventions/ medications as indicated/ Relapse Plan

Case Study from Last Class

Think! Pair! Share!

What are the interventions we could expect?

What would you say about her prognosis?