This case presentation discusses a 50-year-old African American female patient admitted to the hospital for schizoaffective disorder, manic episode. The patient has a history of schizoaffective disorder and has been living in a nursing home. The goals of hospitalization are to decrease restlessness, irritability, worry, anxiety and increase self-control and medication compliance. Interventions include medication management with Lamictal and Invega, nursing care, social work support, and education. The presentation provides context on schizoaffective disorder, symptoms, course, and treatment goals for managing the manic episode.

1. Case Presentation: Schizoaffective
Managing the Manic Episode

2. Objectives
• Identify the characteristics of schizoaffective disorder, manic
episode
• Establish therapeutic rapport with schizoaffective manic patient
• Coordinate discharge planning needs of nursing home patient

3. Assessment
• Biographical data
– 50 yr, old African-American
female
• Psychiatric admission
– Voluntary admission
• Reason for admission
• Past psychiatric history

4. 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

5. 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

6. Assessment
• Family History
– Patient denies familial psychiatric
history
• Psychological Testing/Psychiatric
Assessment
• Labs/Other Tests
– Toxicology screen unavailable
• Past Discharge Plans/Continuity of Care

7. Pathophysiology
Schizoaffective Disorder

8. Define
Schizoaffective 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.

9. Schizoaffective Disorder in the DSM-IV-TR has four
(4) diagnostic criteria
A. 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.

10. 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).

11. 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.

12. 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.

13. Schizoaffective Disorder in the DSM-IV-TR has four
(4) diagnostic criteria
B. During the same periods of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent
mood symptoms.

14. Schizoaffective Disorder in the DSM-IV-TR has four
(4) diagnostic criteria
C. 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

15. Schizoaffective Disorder in the DSM-IV-TR has four
(4) diagnostic criteria
D. 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.

16. Associated Features and Disorders
There may be poor occupational
functioning, a restricted range of
social contact, difficulties with
self-care, and increased risk of
suicide associated with
Schizoaffective Disorder.
Residual and negative symptoms
are usually less severe and less
chronic than those seen in
Schizophrenia. Anosognosia
(i.e., poor insight) is also
common in Schizoaffective
Disorder.

17. Course
The typical age at onset of Schizoaffective Disorder is early
adulthood, although onset can occur anywhere from adolescence to late
in life. The prognosis for Schizoaffective Disorder is somewhat better
than the prognosis for Schizophrenia, but considerably worse than the
prognosis for Mood Disorders.

18. Prevalence
Detailed information is lacking, but Schizoaffective Disorder appears to
be less common than Schizophrenia.

19. Hospitalization Goals and Plan
Patient stated goals
1. To experience decrease in
behavior that is injurious to
self and others.
2. To decrease
hallucinations, delusions.

20. 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

21. 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.

22. 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.

23. Interventions
• Nursing
– Medication treatment
and education
– Administer PRN meds
– Stress management
techniques
– Anger management
– Reality orientation
– Monitored Q15 mins.
on assault precautions

24. Interventions
• Social Work
– Milieu therapy etc.
– Patient family education

25. 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

26. 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.

27. 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

28. 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

29. Discharge Summary
• Patient behaviors indicating
readiness for discharge
• Hospitalization goals met
• Discharge and continuity of
care plan

30. Evaluation
• Evaluate effectiveness of goals/plans/interventions
• Course of treatment conditions
• Complications
• Lessons learned (if relevant)

31. Bibliography
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Edition 4 (text revision), Washington, DC: American Psychiatric
Association
Major M. Pirozzi R, Formicola AM, et al.: Reliability and Validity of DSM-IV
diagnostic category of schizoaffective disorder: preliminary data. S Affect Disord
2000, 57: 95-98.

32. Behavioral Health Program 15th Floor
Presenting: Schizoaffective Disorder
Managing The Manic Episode
Date: March __, 2011 - Time: 12pm – 1pm - Place: TBD
(CEUsare offered)