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LEARNING OBJECTIVES FOR WEBINAR ON SCHIZOPHRENIA….. After content presentation, participants will be able to: p , p p Discuss importance of standardizing care. Discuss a plan for intervention. Identify and use standardized assessment tools

such as BPRS and AIMS. Structure interventions including use of CBT Structure interventions, including use of CBT-

current research findings on use in Schizophrenia. Use teaching tools from CareGuide©. Teach about medications and side effects Discuss value of telephone follow-up. Discuss case studies and appropriate interventions.

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SCHIZOPHRENIA FACTS…Disease of the brain 1% risk in general population 1% risk in general population Effects women and men equally

and people of all racial, ethnic , education and economic b k dbackgrounds

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SCHIZOPHRENIA: THE FACTS: CHRONIC AND DEBILITATING CHRONIC AND DEBILITATING

– MOST DEVASTAING OF ALL PSYCH DX

ONSET – LATE TEENS –TWENITESTWENITES

PERIODS OF REMISSION AND EXACERBATION

NO CURE – ONLY TREATMENTTREATMENT

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SCHIZOPHRENIA: THE FACTS… Potential Causes: Genetics Biochemical dysfunction Physiological factors Psychosocial factors

STRESS DIATHESIS THEORY A PEFECT STRESS DIATHESIS THEORY – A PEFECT STORM OF PHYSIOLOGY, STRESS AND UNHEALTHY RELATIONSHIPS TIP THE

BALANCEFOR THOSE AT RISK FOR THIS DISORDERDISORDER

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SCHIZOPHRENIA: COURSE

Onset in males – 18-25 yearsOnset in females: 25-35 yearsMales (when compared to females) More negative symptoms Poorer prognosis More hospitalizations More hospitalizations Don’t respond as well to meds

Females experience more dysphoria

Tend to have more paranoid delusions and hallucinationsdelusions and hallucinations

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Paranoid Type

Di i d T

Dx pre-DSM-5

Disorganized Type

Catatonic Type

Undifferentiated

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Schizophrenia spectrum and other psychotic Schizophrenia spectrum and other psychotic Disorders DSMDisorders DSM--V Diagnostic CriteriaV Diagnostic Criteria

Characteristic SymptomsCharacteristic Symptoms: : 2 or more of the following during a 2 or more of the following during a 2 or more of the following during a 2 or more of the following during a 1 month period with some of the 1 month period with some of the illness persisting for at least 6 illness persisting for at least 6 months.months.

1. Delusions1. Delusions2. Hallucinations2. Hallucinations3 Disorganized Speech 3 Disorganized Speech 3. Disorganized Speech 3. Disorganized Speech (incoherence)(incoherence)4. Grossly disorganized or 4. Grossly disorganized or catatonic catatonic

behaviorbehavior5. Negative symptoms5. Negative symptoms6. Social/Occupational 6. Social/Occupational DysfunctionDysfunction7. Duration7. Duration

ALL RIGHTS RESERVED, C&V SENIOR CARE SPECIALISTS, 2014

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SCHIZOPHRENIA – DIAGNOSTIC CRITERIA

CRITICAL TO RULE OUT OTHER POTENTIAL CAUSES OF SYMPTOMS BEFORE DIAGNOSIS IS MADE.

A. Brain TumorsB. Drugs of Abuse (LSD, Amphetamines, Marijuana)

C. Alcohol WithdrawalD DeliriumD. DeliriumE. Syphilis

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Schizoaffective DisorderThe biggest change to

schizoaffective disorder is that schizoaffective disorder is that a major mood episode must be

present for a majority of the time the disorder has been

present in the person present in the person.

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HOW DO WE DIAGNOSE SCHIZOPHRENIA?

IMPORTANT TO OBTAIN A DETAILED PATIENT HISTORY – NO DIPSTICK TEST TO DX SCHIZOPHRENIA – NO BLOOD TEST TO

RULE IN OR OUT DIAGNOSIS

SCHIZOPHRENIA IS A MIXTURE OF SIGNS SCHIZOPHRENIA IS A MIXTURE OF SIGNS AND SYMPTOMS THAT FALL INTO TWO

CATEGORIES.

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CRITICAL TO RULE OUT CRITICAL TO RULE OUT OTHER POTENTIAL OTHER POTENTIAL

CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS BEFORE DX IS MADE.BEFORE DX IS MADE.Brain Tumors, Brain Tumors, Drugs of Abuse (LSD, Drugs of Abuse (LSD,

Amphetamines, Amphetamines, Marijuana)Marijuana)Marijuana)Marijuana)Alcohol withdrawal, Alcohol withdrawal, Delirium, Delirium, Syphilis.Syphilis.

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POSITIVE SYMPTOMS: Those that are present but should be absent; excess

distortion of normal function

NEGATIVE SYMPTOMS: Those that are absent but should be present- loss of

behaviors; loss of normal functionbehaviors; loss of normal function

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POSITIVE SYMPTOMS OF SCHIZOPHRENIA

DELUSIONS (ERRONEOUS BELIEFS) Common themes are persecutory are most common - patient believes he/she is being tormented, followed , tricked or common patient believes he/she is being tormented, followed , tricked or spied on.

REFERENTIAL – Comments made in newspaper, on television and songs on radio are directed toward patient

HALLUCINATIONS –False sensory perceptions; usually experienced as VOICES – FAMILIAR OR UNFAMILIAR, threatening voices most common, may be two or more voices conversing –or one voice making constant comments about the patient. How do we respond to a patient who is hearing voices? “I don’t her the voice, BUT I BELIEVE THAT YOU ARE HEARING THE VOICE”. NEVER DISCOUNT PATIENT’S EXPERIENCE – WE NEED TO KNOW IF VOICES ARE THREATENING OR “COMMANDING’ PATIENT TO HARM SELF!

BIZARRE BEHAVIORS – ranging from silliness to sudden agitation.

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NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

Qualities that are missing but should be presentAffect flattening – appears immobile and unresponsive – poor eye g pp p p y

contact.Anhedonia – no pleasure – often trigger for suicide in SchizophrenicsAsociality – may spend much of time alone where he/she feels safer –

may be in response to delusional thinking; appears detached and uncommunicative

Alogia – brief empty replies probably due to a decline in their thoughts Alogia – brief empty replies probably due to a decline in their thoughts that is reflected in decreased fluency and productivity of speechAvolition: lack of energy and drive; difficult for them to complete

simple tasks – often able to do little more than sleep and eat – lacks goal directed behavior; may appear lazy or sluggish to others – all

symptoms of disease

.

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MANAGEMENT OF SCHIZOPHRENIA

Safety – significant number will commit suicide must assess for “command suicide –must assess for “command hallucinations” may need to initiate “suicide precautions”

Cognitive-Behavioral Therapy (once compliant with meds)

Patient and Family Education –what would you want to include inFamily education

Medication management – what are major issues with compliance?issues with compliance?

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Management of SchizophreniaManagement of SchizophreniaPsychosocial RehabPsychosocial Rehab::

** ** Provides supportProvides support Provides supportProvides support

** Provides structure** Provides structure

** Vocational & social skills training** Vocational & social skills training

** Enhances socialization** Enhances socialization Enhances socialization Enhances socialization

** Teaches life skills to assist pt.’s with ** Teaches life skills to assist pt.’s with managing self in communitymanaging self in community

The bolded interventions can be The bolded interventions can be accomplished in home careaccomplished in home careaccomplished in home care.accomplished in home care.

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BEHAVIORAL TECHNIQUES FOCUS ON:

*STRESS MANAGEMENT*STRESS MANAGEMENTASSERTIVENESS TRAINING

COMMUNICATION SKILLS TRAININGPROBLEM SOLVING SKILLS

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The learning of maladaptive responses to problems is often the result of cognitive distortions or making mistakes in assessing cause and effect. That is why cognitive therapy and behavioral therapy are often combined. Individuals with schizophrenia often make incorrect assessments of cause and effect.

Also, they often do not learn as well from experience because of their disordered and disorganized thinking. Behavior therapy teaches them the Behavior therapy teaches them the social skills they never learned, and helps them understand when to apply those skills to problems in the world.

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P ho o ial RehabP ho o ial RehabPsychosocial RehabPsychosocial Rehab::** ** Provides supportProvides support** Provides structure** Provides structure** Vocational & social ** Vocational & social skills trainingskills training

** Enhances ** Enhances socializationsocialization

** Teaches life skills to ** Teaches life skills to assist pt.’s with assist pt.’s with managing self in managing self in communitycommunitycommunitycommunity The bolded The bolded

interventions can be interventions can be accomplished in home accomplished in home care.care.

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Coping Guidelines For The FamilyCoping Guidelines For The Family

Family therapy can significantly decrease relapse rates Family therapy can significantly decrease relapse rates for the schizophrenic family member. In highfor the schizophrenic family member. In high--stress stress p y gp y gfamilies, schizophrenic patients given standard aftercare families, schizophrenic patients given standard aftercare relapse 50relapse 50--60% of the time in the first year out of hospital. 60% of the time in the first year out of hospital.

••Establish a daily routine for the patient to follow. Establish a daily routine for the patient to follow. ••Help the patient stay on the medication. Help the patient stay on the medication.

••Keep the lines of communication open about problems Keep the lines of communication open about problems or fears the patient may have. or fears the patient may have.

••Understand that caring for the patient can be Understand that caring for the patient can be emotionally and physically exhausting. Take time for emotionally and physically exhausting. Take time for

yourself. yourself. ••Keep your communications simple and brief when Keep your communications simple and brief when

speaking with the patient. speaking with the patient. B ti t d l B ti t d l ••Be patient and calm. Be patient and calm.

••Ask for help if you need it; join a support groupAsk for help if you need it; join a support group

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PSYCHOTHERAPY WITH SCHIZOPHRENIA

TRADITIONAL PSYCHOTHERAPY WITH A FOCUS ON INSIGHT IS NOT HELPFUL IN SCHIZOPHRENIA – USED AS AN ADJUNCT TO HELPFUL IN SCHIZOPHRENIA – USED AS AN ADJUNCT TO

MEDICATION TX – CAN BE USEFULFocus on their medication, Learning needed social skills, Supporting person's weekly goals and activities Giving advice, reassurance, education, modeling, limit setting, and reality testing with the therapist. g, y g pEncouragement in setting small goals Reaching them can often be helpful. Needing help with skills such as cooking and personal grooming + communicating with others in the family and at work. Therapy or rehabilitation therapy can help a person

regain the confidence

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CBT USE WITH PATIENTS WITH SCHIZOPHRENIA

Approximately 40% of people with schizophrenia are unable to understand that they have the disorder, because the part of the brain that is damaged by y , p g yschizophrenia is also responsible for self-analysis. It's important to note that the person is not "in denial" (which suggests that through education alone the person might understand that they have schizophrenia). With schizophrenia, you are frequently asking the sick brain to diagnose itself, which may simply be impossible.

Cognitive deficits, confusion, disorganization Possible solution - Some types of psychotherapy interventions(for example, cognitive-behavioral therapy) have shown promise in alleviating some of the cognitive symptoms of schizophrenia.

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Cognitive Therapy with Schizophrenia

Misinterpretation of events in the world is common in Schizophrenia.

CBT Cognitive therapy requires accepting that cognitive distortions and disorganized thinking are producedby a biological problem that will not change with the

"correct“ interpretation of reality – must accept th li t' ti f lit the client's perception of reality;

Determines how to use this "misperception" to assist the client in correctly managing life problems.

Goal is to help the client use information from the world (other people, perceptions of events, etc.)

to make adaptive coping decisions. Goal is to improve the client's ability to manage life problems Goal is to improve the client s ability to manage life problems,

to function independently, and to be free of extreme distress and other psychological symptoms.

ALL RIGHTS RESERVED, C&V SENIOR CARE SPECIALISTS, 2014

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The learning of maladaptive responses to problems is often the result of cognitive distortions or making

mistakes in assessing cause and effect. That is why cognitive therapy and behavioral therapy are often

combined. Individuals with schizophrenia often make incorrect assessments of cause and effect.

Also, they often do not learn as well from experience because of their disordered and

disorganized thinking. Behavior therapy teaches them the social skills

they never learned, and helps them understand when to apply

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understand when to apply those skills to problems in the world.

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Behavioral Techniques Focus on:

•Stress Management Training

•Assertiveness Training

•Communication Skills Training

•Problem Solving Skills

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Schizophrenia combination of a thought disorder, mood disorder, and anxiety

disorder.

Management of schizophrenia antipsychotic, antidepressant, and

antianxiety medications.

After the first year of treatment, 75% of people will discontinue their use of

medications, especially ones where the side effects are difficult to tolerate. side effects are difficult to tolerate. .

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PsychopharmacologyPsychopharmacology--NeurolepticsNeuroleptics

Conventional (older) or Conventional (older) or Typical antipsychotic Typical antipsychotic yp p yyp p y

MedicationMedication

Newer or Atypical Newer or Atypical antipsychotic Medication.antipsychotic Medication.

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Atypical AntipsychoticsAtypical Antipsychotics

AtypicalsAtypicals--Risperdal, Zyprexa, Geodon, Risperdal, Zyprexa, Geodon, Seroquel AbilifySeroquel AbilifySeroquel, AbilifySeroquel, Abilify

*Clozaril may cause*Clozaril may cause-- agranulocytosisagranulocytosis--

WBC weekly WBC weekly ––but incredibly effective for but incredibly effective for positive and negative symptomspositive and negative symptoms

Introduced in 1990’sIntroduced in 1990’s

Considered 1Considered 1stst line agents in tx of line agents in tx of schizophreniaschizophrenia

Regulate dopamine & serotoninRegulate dopamine & serotonin--both positive both positive & negative symptoms& negative symptoms

F id ff t th ld F id ff t th ld t i l t i l Fewer side effects than older Fewer side effects than older ––typical typical antipsychotic medsantipsychotic meds

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Conventional (older) Conventional (older) antipsychoticsantipsychotics ––(Thorazine, (Thorazine, Haldol, Prolixin) Haldol, Prolixin) I t d d i 1950’I t d d i 1950’Introduced in 1950’sIntroduced in 1950’sSecond line treatment. Second line treatment. Accidentally found to Accidentally found to improve improve sx’ssx’s–– block block dopamine receptors dopamine receptors ––d d i ti it d d i ti it decrease dopamine activity decrease dopamine activity in the CNS. in the CNS. Tx positive symptoms only Tx positive symptoms only of schizophrenia. of schizophrenia. Have serious ( bad) side Have serious ( bad) side

ff t ff t effects effects

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Extrapyramidal Symptoms (EPS)

Dystonic Reactions

Pseudo parkinsonism

AkathisiaAkathisia

Tardive Dyskinesia

Neuroleptic Malignant Syndrome

Other side effects include sedation, weight gain, orthostatic hypotension, photosensitivity

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CAREGUIDE – STRUCTURE

INTRODUCTORY LETTER – ESTABLISHES PARTNERSHIPSchizophrenia and Other Thought Disorders Clinical p gGuidelines®CLINICAL QuickGuide®PSYCHOSIS RATING SCALES AND OTHER ASSESSMENT TOOLS PHQ2 and PHQ9 Beck Depression Inventory

All Rights Re Beck Depression Inventory

Geriatric Depression Scale (Short Form) SAD PERSONS Suicide Risk Assessment AIMS BPRS

eserved 2013 C&V Senior C

Specialists, Care Inc.

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CAREGUIDE – STRUCTURE15 STEPS OR LESSONS SPECIFIC TO SCHIZOPHRENIA EACH CONTAINS:

Educational componentAssignment to be completed between visits

Each step may take more than one visit to completeADDITIONAL TEACHING TOOLS ON MEDICATIONS GENERAL POST TEST ON PAGE 83 THAT COULD GENERAL POST TEST ON PAGE 83 THAT COULD BE USED WITH MOST MEDICATIONS.

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LAST THING – DON’T FORGET TO USE THE TELEPHONE ASSESSMENT USE THE TELEPHONE ASSESSMENT TOOL!

The use of this tool increases compliance with the treatment plan compliance with the treatment plan – there is a powerful message that

accompanies a telephone call just to say “how are you doing?

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ANY…….