Human Growth and Human Growth and DevelopmentDevelopment

Group PresentationGroup PresentationSummer Session TwoSummer Session Two

August 2008August 2008

Presented By:Presented By:Erin AllenErin Allen

Laura BielanowskiLaura BielanowskiJoseph PalumboJoseph PalumboBernd WeishauptBernd Weishaupt

Group TopicGroup Topic• Gender Gender

–MaleMale

• Developmental transitional Developmental transitional periodperiod–Adolescent to adultAdolescent to adult

• Mental health issue…Mental health issue…

SchizophreniaSchizo-

split

Phrenia-mind

Schizophrenia• A chronic severe debilitating psychotic

disorder

• Characterized by:

– Disturbances of thought often with

– Delusions

– Bizarre behavior

– Inappropriate mood and

– Disturbances of perception affecting speech & emotions

Thought• Irrational

• Delusional

• Confused

• Distorted

Behavior• Unpredictable

• Erratic

• Irrational

• Dramatic

Mood• Depressed

• Disturbed

• Exaggerated

• Volatile

Perception• Distorted

• Bizarre

• Unrealistic

• Auditory & Visual

Hallucinations

Positive Symptoms (Criteria A1-A4) Excess or Distortion of Normal Functioning

A1-delusions A2-hallucinations A3-disorganized

speech A4-grossly

disorganized or catatonic behavior

Delusions• False ideas believed by

the patient but not by other people in the culture.

• Sensory experience that is misinterpreted.

• Person is convinced that random events relate to him

• May be paranoid or grandiose

• CIA, FBI, NSA, aliens, superman, Napoleon, Jesus, etc. I am Jesus Christ

Hallucinations• Gross distortions of

visual or auditory stimuli

• Brain may entirely make up stimuli

• Auditory are the most common

• Hearing voices, seeing things

• Religious visions & voices not typically included

You talkin’ to me?

Disorganized Speech

• Answers to questions may be unrelated

• May jump topics in same sentence

• Speech may be incomprehensible

• Possibly connected with disorganized thinking

Grossly Disorganized or Catatonic Behavior

• Disorganized-range from childlike silliness to unpredictable agitation

• Catatonic-decrease in reactivity to environment

Negative Symptoms (Criteria A-5)A Loss of Normal Functioning

All part of A-5

• Affective flattening

• Alogia

• Avolition

Affective Flattening

• Persons face appears immobile & not responsive

• Range of emotion is diminished

• Lack of eye contact

Alogia

• Lack of speech

• Brief or minimalist speech

• Inability to communicate

Avolition

• No will power

• Little or no social activity

• No interest in work

• No goals

Consider!

A person with Schizophrenia has

poor

occupational,

interpersonal

and

self-supportive abilities

Distressing Facts!• 2.2 million Americans suffer from

Schizophrenia

• Nearly half are not receiving treatment, resulting in homelessness, incarceration, and violence

• Of those treated, they often receive substandard care at general hospitals and nursing homes that lack special psychiatric care and rehabilitation capabilities

Medical Care• 26-53% untreated medical problems

• No coherent account of symptoms

• High pain threshold delays diagnosis

• Side effects of antipsychotic medication

• Unlikely to practice oral hygiene

• 20-30% capable of PT work

• 10-15% capable of FT work

• Few return to competitive employment

Unemployment

Homelessness

• 200,000 homeless 1/3 of homeless population

• Many eat from garbage cans and are regularly victimized

• 16% of all inmates• 40% in jail • 32% discharged

from psychiatric hospitals go to jail

• Most are misdemeanors

• 20% for violence or felonies

• 10% physically assaulted another

Incarceration

Privation…no

Money

Food

Housing

Employment

Friends

Family

Medical care

• Suicide #1 cause of premature death

10-13%• Most

intended• Some

accidental• 3 of 4 are

males

Hope is needed-help is available!

• Informed practitioners

• Physiological & neurological testing

• Basic lab work

• Mental & psychological testing

• Education

Competent CareTeam

usually required initially, only 1of 3

treated in psychiatric hospitals

Hospitalization

Alternatives To Hospitalization

• Drugs by injection in ER or medical clinics

• Partial hospitalization- day/night hospitals

• Mobile treatment teams that make house calls

• Short term stay in semi-hospitals- IMD’s (institutions for mental diseases) & crisis homes.

• Public health nursing at home

Therapy Spectrum

• Medication

• Supportive counseling and psychotherapy

• Rehabilitation & support services

• Cognitive Behavioral Therapy

• ECT (Electroconvuslive Therapy)

• Current Experimental Therapies•TMS (Transcranial Magnetic Stimulation)

•VNS (Vagal Nerve Stimulation)

MedicationPrimary focus is on

Antipsychotics

• Older medications available since 1950

• Effectively alleviate positive symptoms

• Not a cure for Schizophrenia

• Newer atypical antipsychotic drugs developed 1990’s

Older Antipsychotic Medications

•Chlorpromazine (Thorazine)

•Haloperiodol (Haldol)•Perpherenazine (Prolixin)

Cause extrapyramidal side effects:rigiditymuscle spasmstremors restlessness

Atypical Antipsychotics 1990’s

All are effective without causing extrapyramidalsymptomsGoal was to reduce side effectsEx: Clozapine wasproven effective for people who did notrespond to olderantipsychotics.

New Atypical Antipsychotics

• Risperidone (Risperdal)

• Olanzapine (Zypreza)

• Quetiapine (Seroquel)

• Sertindole (Serdolect)

• Ziprasidone (Geodon)

Length of Drug Treatment

Schizophrenia is a

chronic disorder,

because every person

is different, how long

a patient takes

medication varies.

Some patients may

take medication

their entire lives

Supportive CounselingTreatments designed to

assist patients who are

stabilized on medications

May include:• Individual counseling• Vocational counseling• Group counseling• Problem-solving• Psychoeducation• Co-occurring substance

abuse treatment

Rehabilitation & Support

• Money management

• Family education

• Job training

• Social skills training

• Support Groups

• Community resources

• Hygiene

• Transportation help

Cognitive Behavioral Therapy

Goals • Relieve symptoms for improved

functioning• Target delusional thinking and visual &

auditory hallucinations• Learn to differentiate between delusional

and rational thinking• Develop mastery by controlling or reducing

symptoms

Cognitive Behavioral Therapy

“Reactions”

Emotions

Behaviors

Physiological

A SituationAutomatic

Thoughts

Core Beliefs

I’ll Never Get better

Intermediate

Beliefs

delusions can’t be controlled

Activating

trigger or event

I must obey the voices

Electroconvuslive TherapyECT: used during acute onset when confusion and mood disturbances are present. Also forrelapse prevention

12-20 treatments suggested over 6 monthtime period

Current Experimental TherapiesTMS (Transcranial

Magnetic Stimulation)

VNS (Vagal Nerve

Stimulation)

History

Emil Kraepelin

1856–1926 German

Psychiatrist developed

The concept of dementia

Praecox (premature dementia)

History

Paul Eugen Bleuler

1857 –1939

Swiss psychiatrist

coined the term

Schizophrenia.

HistorySimilar signs and symptoms are traced from ancient

documents by the Egyptians as far back as 2000 B.C.

Mental disturbances were associated with demons and

Evil spirits.

Spirits could be excised through such varied

means as music therapy or dangerous and deadly

means of drilling holes in patients skulls.

To let the demons out, other signs and symptoms

have been described in ancient writings by the

Greeks, Romans, and Chinese.

History of Diagnosis• “Associative splitting: separation among

basic functions of human personality (cognition, emotions, perception) that was seen by some as the defining characteristics of Schizophrenia.

• Bleuler split the divided symptoms into either positive or negative in 1911 and divided the illness into four categories:• The four A’s: (autism, ambivalence, blunted

affect, and loosening of associations).”

Four A’s: Fundamental symptoms

1. Autism: unresponsive to the world2. Ambivalence: presence of

contradictory drives, tendencies, emotions or thoughts

3. Affective disturbances: problems in feeling or expressing full range of emotions

4. Associative disturbances: thinking & ideas are not connected.

Nosology of

Schizophrenia

DSM-IVSchizophrenia is a group of psychotic disorders characterized by disturbances in perception, affect, behavior and communication lasting longer than 6

months(this includes psychotic behavior). The person suffering from Schizophrenia hasdeteriorated occupational, interpersonal

andself-supportive abilities.

Coding Schizophrenia

•Schizophrenia •295.20 Catatonic type •295.10 Disorganized type •295.30 Paranoid type •295.60 Residual type •295.90 Undifferentiated type

•295.40 Schizophreniform disorder •295.70 Schizoaffective disorder

Making A Diagnosis (Criterion A-F)

A. Characteristic (active phase) Symptoms

2 or more (less if treated successfully)1. Delusions2. Hallucinations3. Disorganized speech4. Disorganized/catatonic5. Negative symptoms

Only 1 symptom required if Delusions are bizarre or hallucinations include persistentvoice(s)

B. Social/Occupational Dysfunction

Underachievement for an

Adolescent: failure to

achieve expected

academic, social, and

occupational

developmental levels

Making A Diagnosis (Criterion A-F)

C. Duration

6 months continuous

includes at least 1

month of Criterion A

symptoms (less if treated

successfully). During the

residual periods

symptoms must be

negative or reduced

Criterion A symptoms

D. Schizoaffective & Mood Disorder Exclusion

Rule out schizoaffectivedisorder and mood Disorder: (1) no concurrent major depressive, manic or mixed episodes during active phase symptoms (2) if the did occur they must be very brief

Making A Diagnosis (Criterion A-F)

E. Substance & General Medical Condition Exclusion

Rule out medication,

general medical condition

and/or substance abuse

F. Relationship To Pervasive Developmental Disorder

If Autistic Disorder or Developmental Disorderis present, diagnosis of Schizophrenia is addedonly if pronounced delusions or hallucinations meet criterion C (30+ days)

295.40 Schizophreniform Disorder

• Identical to Criterion-A with 2 differences:1. Total Duration between 1 & 6 months through three

phases (prodromal, active, & residual)

2. Impaired functioning may or may not be present

• This diagnosis is considered “provisional” because recovery is uncertain

– If symptoms persist beyond 6 months a diagnosis of Schizophrenia is needed

– 1/3 recover within 6 months, 2/3 progress to Schizophrenia or Schizoaffective Disorder.

295.70 Schizoaffective Disorder

• Uninterrupted illness characterized by one of the following concurrent with Criterion A for Schizophrenia:– Major Depressive Episode (must include Criterion A1

depressed mood.– Manic Episode– Mixed Episode

• Delusions or hallucinations must be present at least 2 weeks w/o prominent mood symptoms

• Mood episodes present during active & residual• Bipolar Type: manic, mixed &/or major

depressive episode• Depressive Type: only Major Depressive Episode

295.20 Catatonic Type

“The essential feature of catatonic type of Schizophrenia is a marked psychomotordisturbance that may involve motoricimmobility, excessive motor activity, extremenegativism, mutism, peculiarities ofvoluntary movement, echolalia, orechopraxia… the excessive motor activity isapparently purposeless and is not influencedby external stimuli.” DSM-IV-TR (2000) p. 315

295.10 Disorganized Type

“The essential feature of the disorganized

type of Schizophrenia are disorganized

speech, disorganized behavior, and flat or

inappropriate affect. The disorganized

speech may be accompanied by silliness and

laughter that are not closely related to the content of

the speech. The behavioral disorganization (i.e.,

lack of goal orientation) may lead to severe

disruption in the ability to perform activities of daily

living…” DSM-IV-TR (2000) p. 314

295.30 Paranoid Type

“The presence of prominent delusions or

auditory hallucinations in the context of a

relative preservation of cognitive functioning

and affect.” DSM-IV-TR (2000) p. 313

“Delusions are typically persecutory or

grandiose, or both, but delusions with other

themes (e.g., Jealousy, religiosity, or

somatization) may occur.” (Ibid) p. 313

295.60 Residual Type

“The residual type of Schizophrenia should

be used when there has been at least one

episode of Schizophrenia, but the current

clinical picture is without prominent positive

psychotic symptoms (e.g., delusions,

hallucinations, disorganized speech or

behavior).” DSM-IV-TR (2000) p. 316

295.90 Undifferentiated Type

“The essential feature of undifferentiated

type of Schizophrenia is the presence of

symptoms that meet Criterion A of

Schizophrenia but that do not meet criteria

for the paranoid, disorganized, or catatonic

type.” DSM-IV-TR (2000) p. 316

Associated Features

• Poor insight into acknowledgement of the disease.

• Poor insight is a symptom of disease, not a failure to cope with diagnosis.

• Controversy exists whether persons diagnosed with Schizophrenia exhibit greater incidences' of violence.

EtiologySchizophrenia is one

of the most serious,

and most mysterious

of all mental illnesses.

It has been described

as a monster, a

chimera and a

disaster for those who

get it.

What is it’s source?

EtiologyMany theories stress unfavorable social and emotional experiences as the probable cause. Harmful family influences or faulty child-rearing practices are blamed during the formative years. Some theorists claim the “double-bind” (no-win) situation as critical: “…the patient’s mother was always ready to criticize him for doing one thing and rejecting him for doing the opposite, resulting in constant frustration.”

Etiology• Other researchers see Schizophrenia as a

physical disease of the nervous system. For example, the patient may be “intoxicated” by some chemical (possibly similar to LSD, DMT, or mescaline) which his body may be producing due to a genetically inherited error in metabolism.

• Recently, advances in technology (supported by brain imaging ) and research findings suggest that Schizophrenia is a biologically based disease of the brain.

Diathesis – Stress Model

The diathesis-stress model is a model that combines interaction of biological and genetic factors to explain disorders. Diathesis refers to a hereditary predisposition toward disease or disorder.

Diathesis – Stress Model

Diathesis Stress – Model

• “Figure 1 illustrates a contemporary version of the diathesis-stress model that encompasses all of the factors that are currently considered to play a significant etiologic role in Schizophrenia. This model postulates that constitutional vulnerability to Schizophrenia (i.e., The diathesis) can result from both inherited and acquired constitutional factors.” p. 422 walker et. al.

Diathesis Stress - Model

• “The picture that has emerged from research on Schizophrenia, as well as other psychotic disorders, is best described in an expansion of the diathesis stress model that has dominated the field for several decades.” P.422 walker et.al.,

Preschizophrenic Children • Premorbid Development

– Schizophrenia is diagnosed in late adolescence or early childhood (normally)

– Signs are usually present before diagnosis, subtle but can be seen when compared to adolescence with healthy outcomes

• Cognitive Functioning of children who later develop Schizophrenia– Perform below age level– Poor grades– Has hard time interpreting information and able to use

that information– Inability to sustain attention

Preschizophrenic Children• Social Situations

– Less responsive– Less positive emotion– Poor social adjustment– More negative facial expressions during first year

of life

• Motor Development– Delays and abnormalities– Late walkers

  *Early and middle childhood aged children

are rarely diagnosed with Schizophrenia.

Adolescence

• Symptoms– Major adjustment problems– Depression– Social withdrawal– Irritability– Noncompliance

*The problem is these symptoms do not go along with just Schizophrenia they are present in mood disorders, substance abuse, and some other behavioral disorders

Schizotypal Personality Disorder (SPD) • Sometimes preschizophrenic adolescents have sings

of psychotic symptoms, the DSM IV defines these as SPD

• Diagnostic Criteria for SPD – Social anxiety/withdrawal– Affective abnormalities– Eccentric behavior– Unusual ideas

• Persistent beliefs in extrasensory phenomena

– Unusual sensory experiences• Repeated experiences with confusing noises with peoples voices• Seeing objects move

*(All of these symptoms are recurring) *Schizotypal Personality Disorder patient’s symptoms are not as severe as

having delusions or hallucinations

Schizotypal Personality Disorder Schizophrenia

• The transition from SPD to Schizophrenia usually happens in young adulthood

• Studies show that 10% to 40% of youth with SPD signs eventually show an Axis I Schizophrenia spectrum disorder

• The others with SPD either end up with adjustment problems or a complete decrease of symptoms in young adulthood

*Research is being done to see if prevention programs could be used with youth with SPD to prevent Schizophrenia from developing

SPD and Schizophrenia have some similar functional

abnormalities• Motor abnormalities

• Cognitive deficits

• Increase in cortisol (stress hormone)

ReferencesAmerican Psychiatric Association. (2000). Diagnostic and statistical.

manual of mental disorders (4th ed.). Washington, DC: author.Annual Review. Psychology. 2004. 55:401-30.http://associatedcontent.com/article/76943.Durand, V. M. & Barlow, David. H. (2006). Essentials of abnormal

psychology. (4th ed.) Belmont, CA: Thomson Wadsworth, Inc.Journal of Clinical Psychology, May, 1993, vol. 49, no. 3.Journal of Clinical Psychology, November, 1984, vol. 40 no.Mental Health America. (2006). Schizophrenia: What you need to

know. [Brochure]. Alexandria, VA: Author.National Institute of Mental Health. (2007). Schizophrenia. [Brochure].

Bethesda, MD: Author.Noll, Richard A. (Ed.). (2000) Schizophrenia and other psychotic

disorders. New York: Facts On File, Inc. http://samian.colorado.edu.http://Schizophrenia.com/history.htm.Torrey, E. F, (2006). Surviving Schizophrenia: A manual for families,

patients and providers. New York: HarperCollins Publishers.http://www.usefilm.com/image/765556.htmlhttp://web.ebscohost.com/ehost/delivery.