SCHIZOPHRENIA

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SCHIZOPHRENIA

• 2nd most frequent diagnosis of patients 14-64 y/o
  
• at CRH in 2008

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Target Audience

• Nursing Staff to include nurses and technicians

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In this module we will cover

• What is schizophrenia
• Symptoms of schizophrenia
• Types of schizophrenia
• Some of the more common treatments for
  schizophrenia

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CRH most frequent diagnosis in 2008

• Under 14 y/o
• Attention Deficit Disorder
• Oppositional Defiant Disorder
• PTSD
• Bipolar
• Adjustment disorder

• 65 and over
• Persistent mental disorder due to conditions
  classified elsewhere
• Alzheimer
• Schizoaffective disorder
• Other and alcohol dependence
• Bipolar, Manic episode

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CRH most frequent diagnosis in 2008

• 14-64 y/o
• Other unspecified alcohol dependence
• Schizoaffective disorder
• Cocaine dependence
• Depressive disorder
• Combo of drug dependence excluding opioid type
  drugs

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What is schizophrenia?

• A chronic severe brain disorder often they hear
  voices, believe media are broadcasting their
  thoughts to the world or may believe someone is
  trying to harm them.
• In men it usually develops in teen years and
  early 20s in women it usually develops in 20s
  and 30s.

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Diagnosis

• Currently there is no physical or lab test that
  can absolutely diagnose schizophrenia.
• A psychiatrist usually comes to the diagnosis
  based on clinical symptoms.

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Misdiagnosis

• This is a common problem since schizophrenia
  shares a significant number of symptoms with
  other disorders.
• Per the Natl Depression Bipolar Support
  Alliance there is an average of 10 years from
  onset to correct diagnosis tx.

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Disorders that may appear like Schizophrenia

• Schizoid personality
• Schizophreniform disorder
• Schizotypal personality
• Bipolar Disorder
• Aspergers syndrome

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Symptoms of Schizophrenia

• Profound disruption in cognition and emotion,
  affecting the most fundamental human attributes
  
• Language
• Thought
• Perception
• Affect
• Sense of self

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Positive Symptoms

• Those that appear to reflect an excess or
  distortion of normal functions.

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Positive Symptoms

• Delusions. Those where the patient thinks he is
  being followed or watched are common also the
  belief that people on TV, radio are directing
  special messages to him/her.

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Positive Symptoms

• Hallucinations. Distortions or exaggerations of
  perception in any of the senses.
• Often they hear voices within their own thoughts
  followed by visual hallucinations.

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Positive Symptoms

• Disorganized thinking/speech.
• AKA loose associations speech is tangential,
  loosely associated or incoherent enough to impair
  communication.

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Positive Symptom

• Grossly disorganized behavior.
• Difficulty in goal directed behavior (ADLs),
  unpredictable agitation or silliness, social
  disinhibition, or bizarre behavior.
• There is a purposelessness to behavior.

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Positive Symptom

• Catatonic behavior.
• Marked decrease in reaction to immediate
  environment, sometimes just unaware of
  surroundings, rigid or bizarre postures, aimless
  motor activity.

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Other Positive Symptoms

• Inappropriate response to stimuli
• Unusual motor behavior (pacing, rocking)
• Depersonalization
• Derealization
• Somatic preoccupations

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Summary of Positive Symptoms

• Delusions
• Hallucinations
• Disorganized thinking
• Disorganized behavior
• Catatonic behavior
• Inappropriate responses

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FYI Positive Symptoms

• Positive symptoms are those that have a positive
  reaction from some treatment.
• In other words, positive symptoms respond to
  treatment.

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Negative Symptoms

• Those that appear to reflect a diminution or loss
  of normal functions.
• May be difficult to evaluate because they are not
  as grossly abnormal as positive symptoms.

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Negative Symptoms

• Affective flattening.
• Reduction in the range and intensity of emotional
  expression, including facial expression, voice
  tone, eye contact and body language.

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Negative Symptom

• Alogia (poverty of speech)
• Lessening of speech fluency and productivity,
  thought to reflect slowing or blocked thoughts
  often manifested as short, empty replies to
  questions.

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Negative Symptom

• Avolition
• The reduction, difficulty or inability to
  initiate and persist in goal-directed behavior.
  Often mistaken for apparent disinterest.

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Examples of Avolition

• No longer interested in going out with friends
• No longer interested in activities that the
  person used to show enthusiasm
• No longer interested in anything
• Sitting in the house for hours or days doing
  nothing

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Disorganized Symptoms

• This one is somewhat new and may not be
  considered valid.
• It is thought disorder, confusion, disorientation
  and memory problems.

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Summary of Negative Symptoms

• Lack of emotion
• Low energy
• Lack of interest in life
• Affective flattening
• Alogia
• Inappropriate social skills
• Inability to make friends
• Social isolation

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Cognitive Symptoms

• Difficulties in concentration and memory
• Disorganized thinking
• Slow thinking
• Difficulty understanding
• Poor concentration
• Poor memory
• Difficulty expressing thoughts
• Difficulty integrating thoughts, feelings,
  behaviors

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FYI Negative Symptoms

• Currently there is no treatment that has a
  consistent impact on negative symptoms.

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Types of Schizophrenia

• Paranoid
• Hebephrenic
• Catatonic
• Residual
• Schizoaffective
• Undifferentiated

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Paranoid Schizophrenia

• Persons are very suspicious of others and often
  have grand schemes of persecution at the root of
  their behavior.
• During this phase they may have hallucinations
  and frequent delusions.

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Hebephrenic Schizophrenia

• AKA disorganized schizophrenia characterized by
  emotionless, incongruous, or silly behavior,
  intellectual deterioration, frequently beginning
  insidiously during adolescence.
• May be verbally incoherent and may have moods and
  emotions that are not appropriate to the
  situation.
• Hallucinations not usually present.

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Catatonic Schizophrenia

• Person is extremely withdrawn, negative and
  isolated.
• May have marked psychomotor disturbances.

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Residual Schizophrenia

• Lacks motivation and interest in day-to-day
  living.
• Person is not usually having delusions,
  hallucinations or disorganized speech.

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Schizoaffective Disorder

• There will be symptoms of schizophrenia as well
  as mood disorder (depression, bipolar, mixed
  mania).

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Undifferentiated Schizophrenia

• Conditions meeting the general diagnostic
  criteria for schizophrenia but not conforming to
  any of the previous types.
• Exhibits more than one of the previous types
  without a clear dominance of one.

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Summary

• Before a diagnosis the psychiatrist must make a
  thorough evaluation including a physical/medical
  exam, a mental status exam, appropriate labs, and
  a full history.
• History includes changes in thinking, behavior,
  movement, mood, etc. as seen by the family.

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Medications

• In general it may take up to 6 months for
  medications to show consistent effects.
• The newest medication is Invega.
• Meds include atypicals Abilify, Geodon,
  Clozapine, Risperidone, Seroquel, Zyprexa.
• Remember a giraffe can really see a zebra

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• These medications may have such intolerable side
  effects that the patient will stop the drugs.
• One study showed the average time the meds were
  taken regularly was 3 months.

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Treatments

• Psychotherapy - an adjunct to meds and is very
  useful to keep the patient on the meds.
• Group therapy
• Family therapy
• Community support groups

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• Early detection and treatment has the best
  results/response to treatment.
• Per patients, once you have schizophrenia you
  have it for life. The best you can hope for is
  control.

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FYI Cancer Study

• A study in France in 1993, with 3470 patients
  with schizophrenia, showed that breast cancer
  was the second most common cause of death.
• www.komen.org/schizophreniaassociatedwithincreased
  cancermortality. Cancer 2009.

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• The next few slides are a review of general
  psychiatric definitions, defense mechanism and
  communication techniques.
• They may or may not be related to the current
  topic.

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Psych Definitions

• Delusion fixed beliefs that usually involve a
  misinterpretation of experience. Client
  believes someone is reading his thoughts
• Several types grandiose, nihilistic,
  persecutory, somatic

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Psych Definitions

• Hallucinations perceptual experiences that
  occur in absence of actual sensory stimuli
  involves the 5 senses.

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Psych Definitions

• Illusions person misperceives or exaggerates
  stimuli that actually exist in the external
  environment.

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Defense Mechanism

• Affiliation
• Turning to others for help or support sharing
  problems with others without implying that
  someone else is responsible.
• Ex An individual has a fight with spouse and
  turns to their best friend for emotional support.

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Defense Mechanism

• Devaluation
• Attributing exaggerated negative qualities to
  self or others.
• Ex A boy has been rejected by his long time
  girlfriend. He tells his friends that he
  realizes that she is stupid and ugly.

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Defense Mechanism

• Displacement
• Transferring a feeling about, or a response to,
  one object onto another (usually less
  threatening) substitute object
• Ex A child is mad at her mother for leaving
  for the day, but says she is really mad at the
  sitter for serving her food she does not like.

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Communication Technique

• Confrontation
• Presenting the patient with a different reality
  of the situation.
• Ex My best friend never calls. She hates me.
  Nurse I was in the room yesterday when she
  called.

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Communication Technique

• Doubt
• Expressing or voicing doubt when a patient
  relates a situation.
• Ex My best friend hates me. Nurse From what
  you have told me, that does not should like her.
  When did she last call you?

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Resources

• Schizophrenia Symptoms, by NARSAD, The Mental
  Health Research Association.
• Schizophrenia Treatment, by John Grohol,
  PsychCentral, 08/07/08
• Psychiatric Study Guide by Central Regional
  Hospital

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