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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 Nat’l 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

Asperger’s 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/schizophreniaassociated withincreasedcancermortality. 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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