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Transcript of Schizophrenia
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.