Alterations: bizarre behavior- stilted rigid behavior, eccentric dress or grooming , and rituals Motor: excited physical behavior Stereotype: motor patterns originally had meaning to a person Obedience: performs commands in a robot fashion Waxy flex: excessive maintenance of posture Stupor: long periods of motionless Negativism: resistance Agitated : grabbing cigarettes, throwing food on floor
Although you may read about these, for the purposes of the class the previous subtypes are what we will focus on for class.
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
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 The indicators associated with this phase are shyness, withdrawn personality, poor peer relationships, poor academically, antisocial behavior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
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. NegativePositive Negative Hallucinations Affect flattening Delusions Alogia (poverty of Bizarre Behavior speech) Thought and speech Apathy/ no motivation d/o Anhedonia (lack of interest in anything) These are crippling These are the Florid because they are taking symptoms of the d/o..they something away from your catch your attention 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 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.
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
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 CriteriaDuring 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?