Case Presentation: Schizoaffective Managing the Manic Episode
Objectives• Identify the characteristics of schizoaffective disorder, manic episode• Establish therapeutic rapport with schizoaffective manic patient• Coordinate discharge planning needs of nursing home patient
Assessment• Biographical data – 50 yr, old African-American female• Psychiatric admission – Voluntary admission• Reason for admission• Past psychiatric history
Assessment • Medical Comorbid Conditions – Hypertension • Current Medications – Clonidine 0.1 mg PO BID – HaldolDecanoate 150 mg IM monthly – Lamictal 25 mg PO BID – Invega 3 mg PO daily
Assessment• Social/Work Data – Single, never married, no children – Before residing at NH patient lived with mother but is not allowed to return – Currently unemployed
Assessment • Family History – Patient denies familial psychiatric history • Psychological Testing/Psychiatric Assessment • Labs/Other Tests – Toxicology screen unavailable • Past Discharge Plans/Continuity of Care
DefineSchizoaffective Disorder• Schizoaffective Disorder is a disorder in which a mood episode and the active phase symptoms of Schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms.• Frequently used to describe a psychotic person with significant symptoms of depression and/or mania.
Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteriaA. An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet criterion A for schizophrenia (i.e., at least 2 of 5 symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms), each present for a significant portion of time during a 1- month period.) Symptoms for Schizophrenia fall into three (3) broad categories: Positive symptoms, Negative symptoms and Cognitive symptoms.
Positive Symptoms• Positive symptoms: The term positive symptoms is confusing, because positive symptoms (as the term might suggest) aren’t “good” symptoms at all. They’re symptoms that add to reality, and not in a good way. People with schizophrenia hear things that don’t exist or see things that aren’t there (in what are known as hallucinations). People with schizophrenia can also have delusions (false beliefs that defy logic or any culturally specific explanation and that cannot be change by logic or reason).
Negative Symptoms • Negative symptoms: These symptoms are a lack of something that should be present. They may be much slower to respond than most other people, have little to say when they do speak, and appear as if they have no emotions, or exhibit emotions that are inappropriate to the situation.
Cognitive Symptoms• Cognitive symptoms: Most people with the disorder suffer from impairments in memory, learning, concentration, and their ability to make sound decisions. These so-called cognitive symptoms interfere with an individual’s ability to learn new things, remember things they once knew, and use skills they once had.
Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteriaB. During the same periods of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteriaC. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. Specify type – Bipolar type: If the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes) – Depressive type: If the disturbance only includes major depressive episodes
Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteriaD. The disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medication condition.
Associated Features and DisordersThere may be poor occupationalfunctioning, a restricted range ofsocial contact, difficulties withself-care, and increased risk ofsuicide associated withSchizoaffective Disorder.Residual and negative symptomsare usually less severe and lesschronic than those seen inSchizophrenia. Anosognosia(i.e., poor insight) is alsocommon in SchizoaffectiveDisorder.
CourseThe typical age at onset of Schizoaffective Disorder is earlyadulthood, although onset can occur anywhere from adolescence to latein life. The prognosis for Schizoaffective Disorder is somewhat betterthan the prognosis for Schizophrenia, but considerably worse than theprognosis for Mood Disorders.
PrevalenceDetailed information is lacking, but Schizoaffective Disorder appears tobe less common than Schizophrenia.
Hospitalization Goals and PlanPatient stated goals1. To experience decrease in behavior that is injurious to self and others.2. To decrease hallucinations, delusions.
Hospitalization Goals and Plan • Interdisciplinary team goals: Nursing – Decrease restlessness and irritability – Improve worry and anxiety – Increase self control and medication compliance – Prevent injury to self and others – Decrease hallucinations/delusions – Increase adaptive coping skills
Hospitalization Goals and Plan• Multidisciplinary team goals: Activity Therapy – Compliance with functional assessment group therapy participation, increased self expression by providing structure and support, health education, and group therapy.
Hospitalization Goals and Plan • Multidisciplinary team goals: Social Work – Compliance with psychosocial evaluation, identify placement through family contact, group therapy, reality orientation, and health education.
Interventions• Nursing – Medication treatment and education – Administer PRN meds – Stress management techniques – Anger management – Reality orientation – Monitored Q15 mins. on assault precautions
Interventions • Social Work – Milieu therapy etc. – Patient family education
Medications• Medications upon admission – Haldol D115 mg IM monthly – Clonidine 0.1 mg PO BID – Haldol 7.5 mg PO BID – Lithium Carbonate 600 mg QHS and 300 mg QAM• Response to medications
Medications• Patient remained noncompliant with oral Haldol and Lithium.• They were discontinued and replaced with: – Lamotrigine (Lamictal) 25 mg PO BID • Mood stabilizer – Invega 3 mg PO daily • Antipsychotic• Patient was compliant with Lamictal and Invega.
Medications: Monitoring• Lamictal • Invega – Mood stabilization – Improvementof signs – Suicidality and symptoms – Rash – CBC – Plasma levels of – Orthostatic vital signs lamotrigine – Suicidality – Fasting blood glucose in those with/at risk for diabetes mellitus
Medications: Education• Lamictal • Invega – May cause – May impair heat nausea, tremors, dizz regulation iness, fatigue, malais – May cause EPS e – Tablet and core – Immediately report components of tablet are rash insoluble, may appear in – Do not discontinue stool suddenly, this may – Should be swallowed induce seizures whole – Do not drink alcohol with this medication
Discharge Summary• Patient behaviors indicating readiness for discharge• Hospitalization goals met• Discharge and continuity of care plan
Evaluation• Evaluate effectiveness of goals/plans/interventions• Course of treatment conditions• Complications• Lessons learned (if relevant)
BibliographyAmerican Psychiatric Association. Diagnostic and Statistical Manual of MentalDisorders, Edition 4 (text revision), Washington, DC: American PsychiatricAssociationMajor M. Pirozzi R, Formicola AM, et al.: Reliability and Validity of DSM-IVdiagnostic category of schizoaffective disorder: preliminary data. S Affect Disord2000, 57: 95-98.
Behavioral Health Program 15th FloorPresenting: Schizoaffective Disorder Managing The Manic EpisodeDate: March __, 2011 - Time: 12pm – 1pm - Place: TBD (CEUsare offered)