Mental Health Fall '12

1. Schizophrenia Disorder

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. Epidemiology
 Prevalence
Onset
Males/ Females

4. Phases of Schizophrenia
 Phase I: Premorbid Phase
 Phase II: The Prodromal Phase
 Phase III: Schizophrenia
 Phase IV: Residual Phase

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with this phase are shyness, withdrawn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. 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. 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. 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. 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. 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. Co-Morbidity
 Substance Abuse
 Depressive Symptoms
 Anxiety D/O
 Psychosis induced Polydipsia

12. Predisposing Influences
 Biological
 Huge genetic component/Dopamine
Hypothesis
 Psychological
 Environmental
 Stressful Life Events

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. 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. 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. 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. Positive vs. Negative
Positive 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. Positive: Content of Thought
 Delusions:
 Persecution
 Grandeur
 Reference
 Of control or influence
 Somatic/Nihilistic
 Religiousity/Magical Thinking
 Paranoia

19. Form of Thought
 Associative Looseness
 Neologisms
 Clang Association
 Concrete Thinking
 Word Salad
 Tangentiality/Circumstantiality
 Perseveration

20. Alterations in Perception
 Hallucinations (90%)
 Auditory
 Visual
 Olfactory
 Gustatory
 Tactile
 Command hallucinations

21. Alterations in Behavior
 Extreme motor agitation
 Stereotype behavior
 Automatic Obedience
 Waxy Flexibility
 Stupor
 Negativism
 Agitated Behaviors

22. Sense of Self
 Echolalia
 Echopraxia
 Identification/ Imitation
 Depersonalization

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. 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. 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. 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. Psychomotor
 Anergia
 Waxy flexibility
 Posturing
 Pacing/ Rocking

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. 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.  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. 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. Self Assessment
 Evokes intense, uncomfortable and
frightening emotions
 Identify personal feelings
 Peer Groups supervision

33. Subtypes of Schizophrenia

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. 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. 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. 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. 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. 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. 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. 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. Other Subtypes:
 Schizoaffective Disorder
 Brief Psychotic Disorder
 Schizophreniform Disorder
 Delusional Disorder
 Shared Psychotic Disorder
 Psychosis due to medical condition
or substance abuse

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. Outcome Criteria
During 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. Basic Level Interventions
 In Acute phase
 Counseling
 Evaluations
 Psychopharmacologic interventions
 Limit setting/ Milieu / Safety

46. Basic Interventions (con’t)
 Other considerations would include:
 Health teaching
 Self care activities
 Case Management
 Health Promotion

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. Milieu Therapy
 Hospital provides needed structure
 Safety
 Useful Activities
 Resources for resolving conflict
 Opportunities for learning social/
vocational skills

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. Client / Family Teaching
 Include family in strategies to
reduce exacerbation
 Educate:
 Illness,medication
 Relapse prevention
 Impact of stress
 Family support resources

51. Advanced Practice Interventions
 Medication compliance most
important, biopsychosocial
interventions help to prevent
relapse

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. 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. Psychopharmacology
 With each relapse following
medication discontinuation, it takes
longer to achieve remission
following restarting meds.
 Types of Medications
 Conventional Antipsychotics
 Atypical Antipsychotics

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. 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. Why do clients quit???
 Weight gain!!!
 Impotence!!!
 EPS!!
 For Pseudoparkinsonism: anticholinergics
(cogentin)
 For Dystonic Reactions: antihistamines used
(Benadryl)

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. 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. 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. 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. 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. 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. Case Study from Last Class
 Think! Pair! Share!
 What are the interventions we could
expect?
 What would you say about her
prognosis?