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This document discusses schizophrenia and its treatment. It defines the diagnostic criteria for schizophrenia according to the DSM-IV-TR as including delusions, hallucinations, disorganized speech or behavior, and negative symptoms. It describes the subtypes and prevalence of schizophrenia and reviews theoretical models, medications, family psychoeducation, cognitive behavioral therapy, social skills training, and cognitive remediation as common treatments.
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- 1. Therapy with theSchizophrenic Patient Brooke Schauder, PhD
- 2. DSM-IV-TR Defining Features2 or more: Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms Social/occupational dysfunction Disturbance persists for 6 months
- 3. Negative Symptoms Apathy:Lack of interest or concern Alogia: Poverty of speech Anhedonia: Inability to experience pleasure Avolition: Lack of motivation Affective Flattening
- 4. Schizophrenia Subtypes ParanoidType: preoccupation with one or more delusions or frequent auditory hallucinations. No disorganized speech, catatonic behavior, or flat/inappropriate affect. Disorganized Type: disorganized speech, behavior, and flat/inappropriate affect. Not catatonic type
- 5. (subtypes) Catatonic Type: 2 of Motoric immobility as catalepsy (waxy flexibility) or stupor Excessive motor activity Extreme negativism (rigid posture) or mutism Peculiarities of voluntary movement as posturing, stereotyped movements, prominent mannerisms, or grimacing Echolalia (repeating others) or echopraxia (repeating words)
- 6. Prevalence and PrognosticCourse Annual Incidence: .5-5. Per 10,000 worldwide Median Onset: mid-20s for men and late 20s for women Majority have prodromal phase: social withdrawal, loss of interest, deterioration in hygiene, unusual behavior, anger outbursts. Premorbid “character” (1 year) Course: Complete remission is rare. Negative symptoms often persist in absence of positive symptoms.
- 7. Positive Prognostic CourseCorrelates Good premorbid adjustment Acute onset Later age at onset Absence of anosognosia Being female Precipitating factors Associated mood disturbance Prompt medical treatment with onset Medication compliance Brief duration of active phase symptoms
- 8. Genetic Factors Evidencein Monozygotic twins reared without biological parents. 1 st degree relatives have 10x greater odds. Chromosomal differences: 5, 11, 18, 19, & X chromosome. Neurological differences in the Limbic System, Dopaminergic system, Basal Ganglia, and Cerebellum. Enlarged lateral and 3 rd ventricles. Heterogeneous Basis – Stress-vulnerability model
- 9. Theoretical Models Psychoanalysis:The individual is fixated at the oral stage and never establishes object constancy. The individual never achieves secure identity and remains dependent. Learning Theory: Children learn irrational reactions and ways of thinking by imitating parents with significant emotional problems.
- 10. Treatments Medication FamilyPsychoeducation Cognitive Behavioral Therapy Social Skills Training Supported Employment
- 11. Medications-Atypical Clozapine (Clozaril): superior to many others in symptom management, but fatality risk (1.3%). Highest risk of weight gain. Risperdone (Risperdal): Less weight gain. More sexual dysfunction. Olanzapine (Zyprexa): Risk for high cholesterol and weight gain. Quetiapine (Seroquel): May improve mental performance. May cause weight gain, but less than others.
- 12. More Atypicals Ziprasidone(Geodon): May also reduce anxiety. No significant risk for weight gain, but may affect heart. Aripiprazol (Abilify, Abilistat): “third generation” antipsychotic. Less risk of extrapyramidal and other side effects.
- 13. Antipsychotic / NeuropeticHaloperidol (Haldol) Chlorpromazine (Thorazine) Perphenazine (Trilafon) Thioridazine (Mellaril) Mesoridazine (Serentil) Trifluoperazine (Stelazine) Fluphenazine (Prolixin)
- 14. Family Psychoeducation GOALS:Establish collaborative relationship between family and treatment team. Psychoeducation about the disease Improve monitoring of psychiatric illness and recognize prodromal phase. NAMI support group
- 15. Family Psychoeducation: TreatmentLong Term Future Oriented (not past) Focus on Psychoeducation, improved communication, problem solving Help all family members pursue shared and personal goals regarding patient.
- 16. Cognitive Behavior Therapy Goal: Reduce severity of persistent psychotic symptoms Encourages the patient’s ACTIVE involvement in treatment. Reduce Physiological Arousal.
- 17. CBT Treatment: Exploration of circumstances in which psychosis emerged Consideration of alternative explanations for delusional beliefs or hallucinations Behavioral tests to assess beliefs related to psychotic symptoms.
- 18. CBT Techniques Attemptto ID psychotic experience function in real life: “they are poisoning me with drugs” “ My thoughts are being broadcast” : Utilize records to write incidences, who is speaking, where they occur, what they say, etc. For negative symptoms: establish daily structure and schedule.
- 19. CBT: Techniques ReasoningBiases: Belief Inflexibility Jumping to Conclusions Extreme Responding Therapy: Developing and exploring alternative perceptions or explanations. Direct work on anxiety can alter distortions.
- 20. Psychoeducation / CognitiveRemediation Goals: Improve understanding about schizophrenia and management Increase medication adherence Prevention of relapse and recognition of prodromal phase Enhance coping with distressing symptoms
- 21. Psychoed. Treatment: Psychoeducationabout illness Develop strategies for taking medication regularly Teach strategies for realizing relapse Development of relapse prevention plan -Wallet sized pocket card with diagnosis, medication, emergency contact numbers.
- 22. Cognitive Remediation NeuropsychologicalProblems in Schizophrenia: Frontal Executive Functions: Reasoning, problem solving, abstract thinking, mental flexibility Memory Problems Attention Problems/Distractibility Motor Coordination Problems
- 23. Cognitive Remediation TherapyGoal: Teach patient specific strategies for enhancing attention, memory, and learning. Using schedulers, alarms, pill boxes, mnemonic devices, etc. Website for memory and attention enhancement strategies: http://ccvillage.buffalo.edu/wc.html
- 24. Social Skills TrainingGoal: Increase social skills such as having conversations, making friends, resolving conflict, expressing feelings, assertiveness, dealing with problems at work, developing leisure activities.
- 25. Social Skills: TechniquesModeling Role Playing and corrective feedback Group Therapy
- 26. Common Comorbidities SubstanceAbuse Anxiety Depression Family Dysfunction
- 27.
Editor's Notes
- #7 Often individuals who develop schizophrenia have had a schizoid or schizotypal character for some time. They are often quiet, passive, and introverted individuals. only 10-20% have what could be considered “good” outcome -remission rates are low – 10-50%
- #8 Some factors that are indicative of a better course prognostically are: -another distinction - not made in DSM, is that individuals with more positive symptoms are “type 1” and have a better response to treatment. Those with more negative are type II and have a poorer response
- #9 Genetics and neurological abnormalities are by and large the most accepted models in terms of causality The Stress-vulnerability model posits that schizo is caused by underlying psychobiological vulnerability, determined early in life by genetic and early environmental effects. Onset and the course of illness are determined by dynamic interplay of biological and psychosocial factors.
- #12 All of these drugs work on the dopamine system, which is irregularly excessive in schizo – the atypicals also work on other neurotransmitters – mainly seratonin Atypicals are the newer drugs with fewer side effects – better tolerated Clozapine is probably the most effective, particularly with negetive symptoms. However there is a risk of life-threatening decrease in white blood cells.
- #14 You may have a patient that is still on the older class of antipsychotics – what they used before the atypicals/ These drugs are more apt to cause extrapyramidal symptoms involving nerves and muscles, tremors, and may also elevate risk of heart failure and therefore are used less and less. However, they have less risk of weight gain than the newer atypicals.
- #19 Here are Some specific examples of CBT techniques you can use 1 st , attempt to ID the hallucination, or delusions function or relationship to real life – often it is metaphorical to some extent So if a patient states “they are poisoning me with drugs” you may need to use psychoeducation to explain the side effects he perceives as “poison” If the patient is experiencing “thought broadcasting” you can ask about the evidence for this belief and suggest an alternative or rational explanation. A good strategy is having them keep a log of details about he voices, who what where when. The goal is to get them to realize that they are generating the voices themselves. for negative symptoms, you’ll want to do what you would with a severely depressed patient – attempt to set daily goals for a structure or schedule. Also remember to use rewards for small steps and keeping the schedule.
- #26 A note regarding all therapies is that an integrative approach tends to work best – integration between medication, CBT, psychoeducation, and family therapy works better than any approach used alone. A few studies I found comparing the different psychosocial approaches did support CBT as the most beneficial in terms of relapse and re-hospitalization, so those strategies, getting the patient to challenge distortions and even hallucinations, can be extremely beneficial.
- #27 Finally, it is important to remember that a diagnosis of schizophrenia is often comorbid with another problem that you’ll have to treat.