Schizophrenia order 11


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Mental Health Fall '12

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  • 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.
  • Schizophrenia order 11

    1. 1. Schizophrenia Disorder
    2. 2. 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
    3. 3. Epidemiology Prevalence Onset Males/ Females
    4. 4. Phases of Schizophrenia Phase I: Premorbid Phase Phase II: The Prodromal Phase Phase III: Schizophrenia Phase IV: Residual Phase
    5. 5. 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 The indicators associated with this phase are shyness, withdrawn personality, poor peer relationships, poor academically, antisocial behavior
    6. 6. 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
    7. 7. 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
    8. 8. 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)
    9. 9. 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
    10. 10. 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
    11. 11. Co-Morbidity Substance Abuse Depressive Symptoms Anxiety D/O Psychosis induced Polydipsia
    12. 12. Predisposing Influences Biological  Huge genetic component/Dopamine Hypothesis Psychological Environmental Stressful Life Events
    13. 13. 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.
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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.
    18. 18. Positive: Content of Thought Delusions:  Persecution  Grandeur  Reference  Of control or influence  Somatic/Nihilistic  Religiousity/Magical Thinking  Paranoia
    19. 19. Form of Thought Associative Looseness Neologisms Clang Association Concrete Thinking Word Salad Tangentiality/Circumstantiality Perseveration
    20. 20. Alterations in Perception Hallucinations (90%)  Auditory  Visual  Olfactory  Gustatory  Tactile  Command hallucinations
    21. 21. Alterations in Behavior Extreme motor agitation Stereotype behavior Automatic Obedience Waxy Flexibility Stupor Negativism Agitated Behaviors
    22. 22. Sense of Self Echolalia Echopraxia Identification/ Imitation Depersonalization
    23. 23. 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)
    24. 24. 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
    25. 25. 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?
    26. 26. 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.
    27. 27. Psychomotor Anergia Waxy flexibility Posturing Pacing/ Rocking
    28. 28. 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
    29. 29. 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
    30. 30.  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!
    31. 31. 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.
    32. 32. Self Assessment Evokes intense, uncomfortable and frightening emotions  Identify personal feelings  Peer Groups supervision
    33. 33. Subtypes of Schizophrenia
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. 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
    38. 38. 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
    39. 39. 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
    40. 40. 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
    41. 41. 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
    42. 42. Other Subtypes: Schizoaffective Disorder Brief Psychotic Disorder Schizophreniform Disorder Delusional Disorder Shared Psychotic Disorder Psychosis due to medical condition or substance abuse
    43. 43. 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
    44. 44. 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
    45. 45. Basic Level Interventions In Acute phase  Counseling  Evaluations  Psychopharmacologic interventions  Limit setting/ Milieu / Safety
    46. 46. Basic Interventions (con’t) Other considerations would include:  Health teaching  Self care activities  Case Management  Health Promotion
    47. 47. 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
    48. 48. Milieu Therapy Hospital provides needed structure  Safety  Useful Activities  Resources for resolving conflict  Opportunities for learning social/ vocational skills
    49. 49. 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
    50. 50. Client / Family Teaching Include family in strategies to reduce exacerbation Educate:  Illness,medication  Relapse prevention  Impact of stress  Family support resources
    51. 51. Advanced Practice Interventions Medication compliance most important, biopsychosocial interventions help to prevent relapse
    52. 52. 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
    53. 53. 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)
    54. 54. Psychopharmacology With each relapse following medication discontinuation, it takes longer to achieve remission following restarting meds.  Types of Medications Conventional Antipsychotics Atypical Antipsychotics
    55. 55. 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
    56. 56. 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 $$$  Can all cause Tardive Dyskinesia  *Use with caution in seizure d/o
    57. 57. Why do clients quit??? Weight gain!!! Impotence!!! EPS!!  For Pseudoparkinsonism: anticholinergics (cogentin)  For Dystonic Reactions: antihistamines used (Benadryl)
    58. 58. Neuroleptic Malignant Syndrome Due to an acute reduction of dopamine levels Occurs- 0.2%-1.0% of clients who have taken antipsychotic agents Fatal-10% Symptoms: Decreased LOC, increased muscle tone, hyperpyrexia,labile HBP, tachycardia, tachypnea, diaphoresis, drooling RX: D/C antipsychotic  Maintain fluid balance, reduce temperature Medication  Bromocriptine (Parlodel) IV, Dantrolene (Dantrium), ECT
    59. 59. Atypical Antipsychotics (AAPS) First line antipsychotics…why?????  Minimal or no EPS or TD!!!  Treat positive and negative symptoms  May improve neurocognitive defects  May decrease anxiety/ depression/ suicide  Lowers relapse rates Clozaril (1990)-risk of agranulocytosis.8-1.0% and seizures ( aka . Clozapine)  Weekly WBC checks 1st 6 months  Due to this only a weeks supply of medication is filled at a time during first 6 months.
    60. 60. Atypical Antipsychotics New AAPs  Respiradone (respirdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Zisprasidone (Geodon), Ariprozole (Abilify)- free of agranulocytosis  Except for Geodon and Abilify cause significant weight gain and metbolic syndrome (glucose dysregulation, hypercholesteremia, hypertension) More $$$ than conventional*Geodon and Abilify very common due to no weight gain 
    61. 61. 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
    62. 62. 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.
    63. 63. 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
    64. 64. Case Study from Last Class Think! Pair! Share!  What are the interventions we could expect?  What would you say about her prognosis?