Transcript Overview of Schizophrenia

Schizophrenia
Origins and Treatment Considerations
by Elijah Levy, Ph.D.
www.thelevylaunch.com
[email protected]
(562) 230-3334
Dr. Elijah Levy
Director of Founders Outreach: A nonprofit center providing psychosocial rehabilitation to 90 mentally ill
residents at Founders House of Hope (18 years)
Ph.D . in Clinical Psychology, 25 years experience treating the mentally ill in inpatient and residential care
settings implementing psychiatric/psychosocial rehabilitation programs.
Adjunct Faculty at University of Redlands teaching in the undergraduate and graduate school (23 years)
and adjunct at Southern California University of Health Sciences teaching psychology (2 years).
Director of The Levy Launch: A Consulting & Resource Center www.thelevylaunch.com providing
corporate education and training, management development and strategy consultation.
Author of two books and editor of anthology of poetry written by the mentally ill, producer of documentary
on mental illness.
Awarded excellence in teaching award several times and history of recognition for volunteering.
Deinstitutionalization
Camarillo State Hospital closed in 1997 by Gov. Pete Wilson due to rising costs and
low
patient
numbers.
It costs the state about $1,000 a day to treat patients at these large psychiatric
facilities.
The majority of the patients in these facilities are violent sexual offenders/predators
who
are
not
likely
to
be
discharged.
Hospitals in California: Atascadero, Coalinga, Metropolitan, Patton, Napa, Salinas
Valley,
Stockton,
Vacaville
Welfare
&
Institutions
Code:
5150: Three day involuntary hold due to being a danger to self, others, or being gravely disabled.
5250:
Fourteen
day
involuntary
hold.
5270.15:
Certification
for
an
additional
30
day
involuntary
hold.
5353:
Thirty
day
temporary
conservatorship.
5358:
Full
Conservatorship;
renewable
annually.
In 1963 President John F. Kennedy established Community Mental Health Act
Only 50% of the community mental health care centers were built in America;
the ones being operated provided insufficient services.
Many of the large psychiatric institutions were closed or reduced the number
of beds.
The criteria for admission became much more stringent.
Between 1955 and 1994, roughly 470,000 mentally ill patients were
discharged from state hospitals
In 2010 – there were only 43,000 beds for the mentally ill in the country.
Why Deinstitutionalization Failed
Federal funding for the mental health centers was not enough.
It was too difficult to coordinate with state and local funding to create any
comprehensive programs; lack of support services.
The mentally ill were discharged home, to SRO’s (single room occupancy
hotels), nursing homes, groups homes, supervised apartments with little
support and poor follow-up.
The courts made it almost impossible to commit anyone against their will;
stricter hospital admission criteria
Funding and coordination for a vast expansion of community and
supported housing programs wasn’t available.
Services such as supported employment, vocational rehabilitation,
outreach weren’t available; needs of the severely, mentally ill weren’t met.
What is Mental Illness?
Principle: How you think guides how you act.
True Definition: condition that significantly impairs one’s ability
to function due to a mood disorder, thought disorder, impaired
sensory system, psychosis
Different types of MI:
Anxiety Disorders (PTSD)
Schizophrenia (subtypes)
Mood Disorder (Bipolar Disorder)
Onset, course of illness, diagnosis and prognosis
Is it both genetics and environment?
Schizophrenia
Chronic, severe and disabling brain disorder (affects about 1% of
Americans)
Hallucinations: disturbances of sense perception
• The voices are predominantly devaluing, critical of their behavior and selfdenigrating; example: you are worthless, stupid, it’s all your fault; may be
a constant buzz or static
• May believe others are reading their minds or plotting against them
(paranoia)
• May believe you are inserting thoughts into their head, reading their
thoughts
• May be delusional (having false beliefs; inability to separate real from
unreal events
• Other hallucinations: Gustatory (taste) Olfactory (smell) Tactile (skin)
Visual (seeing things not there)
• May be irrelevant, incoherent and not make sense when communicating.
• Incidence slightly higher in males than females; females have later onset
Sixty to seventy percent of Schizophrenics do not ever marry
Onset of symptoms may be abrupt (sudden) or insidious
(gradual)
In most cases the first acute, psychotic episode is preceded
by a prodromal (warning) phase where you see oddities in
behavior: delusions, hallucinations, poor hygiene, withdrawal
Course of illness:
1) Continuous without temporary improvement
2) Episodes of illness lasts months with remission of
symptoms between episodes
3) Fluctuating course where symptoms are continuous
Factors Related to Good Prognosis in Sz
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Late onset
Married
Good support system
Good premorbid social and work history
Family/Personal history of mood disorders Obvious precipitating factors
Acute onset
Factors Related to Poor Prognosis in SZ
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Young and insidious onset
No precipitating factors
Poor premorbid social, sexual, and work histories
Withdrawn, autistic behavior; assaultive history
Single, divorced or widowed
Neurological signs and symptoms/prenatal trauma
Family history of schizophrenia
No remission in 3 years; many relapses
Schizophrenia
Four Subtypes:
 Paranoid:
delusions are persecutory; organized around a coherent theme
hallucinations center around one theme
speech organized
the paranoid Sz is more likely to be violent due to their delusions
are higher functioning than the other subtypes of Sz
 Disorganized:
odd mannerisms and behavior
delusions and hallucinations
disorganized speech and behavior
flat/ inappropriate emotional responses to situations
silliness; withdrawal
making up words (neologisms);
Schizophrenia
Catatonic:
unaware of surroundings
symptoms are at extreme opposites
physical immobility to excessive motor activity, motionless
body in rigid position; catatonic stupor
echolalia: repeating your words
echopraxia: mimicking your movements
making peculiar sounds
Undifferentiated:
may include all of the above symptoms but not meet criteria for the other
three; delusions, hallucinations; disorganized speech; agitation; affective
flattening; avolition (lack of purposeful movement)
Causes of Schizophrenia
Genetic: if there is a first degree biological relative (one parent) you have a 10% risk
of developing Sz; 40% if both parents have Sz; identical twin of a person with Sz has
a 40-50% risk; Sz considered a polygenic disorder (combination of genes)
Neurodevelopmental Hypothesis: there is a “silent lesion” in lobes of brain such as
frontal, parietal and temporal caused by factors such as genetic, infection of CNS,
trauma.
Neurobiological: Positron Emission Tomography scans (PET) shows reduced
activity in prefrontal cortex; abnormally elevated levels of dopamine likely causes
delusions and hallucinations
Structural changes: Enlargement of lateral ventricles, extra fluid causes brain to
shrink; ventricles are about 15% larger in Sz; enlarged ventricles tend to be
associated more with producing the negative Sx’s of Sz and greater cognitive
disturbances.
Decrease in cerebral blood flow to frontal lobe creating deficits in thinking
Frontal lobe is the seat of emotion, judgment, sequencing, planning, problem
solving, impulsivity, memory and initiation.
Schizophrenia
Brain Chemistry – “Dopamine Hypothesis”
 A chemical that occurs naturally in the brain and causes psychotic
symptoms such as hallucinations and delusions.
 Dopamine is one of the substances in the brain responsible for
transmitting messages across the gaps, or synapses, of nerve cells.
 Excessive dopamine in a person's brain speeds up nerve impulses to
the point of causing hallucinations, delusions, and thought disorders.
 By blocking the dopamine receptors, antipsychotics reduce the
severity of these symptoms.
Environmental Factors:
Prenatal stressors: using alcohol or drugs may cause delays
in brain development during fetal development.
Developmental: hypoxia and infection, or stress and malnutrition in the
mother during fetal development may slightly increase the risk for Sz by
delaying brain development
Complications during pregnancy or birth, such as maternal illness,
exposure to certain toxins or viruses such as the flu virus, severe
maternal stress
Stressful conditions: living in urban environment causes a slight
increase; social isolation slightly related.
Substance Abuse: amphetamine and cocaine use can produce
psychosis similar to Sz; these illicit substances are psychotomimetic
(producing psychosis)
Environmental factors do not cause the disease but are linked and
include: trauma or highly stressful life conditions; family dysfunction;
during pregnancy mother’s exposure to influenza in 2nd trimester, viral
infections
Schizophrenia
Positive Symptoms: (psychosis)
Delusions (false beliefs), Auditory Hallucinations (voices); Thought Disorder
(garbled speech, disjointed thoughts), Movement Disorder (may be clumsy,
grimace, unusual mannerisms)
Negative Symptoms: (what the illness takes away)
Loss of ability to speak or limited expression of emotion; can be mistaken for
depression or laziness. Flat affect (emotional flatness); lack of pleasure in life,
limited speech; neglecting hygiene; lack of motivation; impaired reasoning.
Cognitive/Disorganized Symptoms:
Confused thinking and speech; difficulty integrating thoughts, feelings,
behaviors; nonsensical behavior; incoherence; being irrelevant; anosognosia,
poor concentration & memory; (not knowing they are seriously ill)
When Does Sz Emerge?
Onset occurs on average between 18-25 in males and 25-35 in females; incidence
slightly higher in males than females
Seldom occurs after the age of 45
Occurrence of substance abuse 50% higher in Schizophrenics
Treatment includes
programming.
meds,
psychosocial
rehabilitation;
community
based
Individuals with Schizophrenia can be expected to live 12-15 years less than the
general population; 30-50% have untreated medical conditions
About 10% commit suicide ten years after diagnosis; 40-60% attempt suicide
Medical conditions and suicide (5% higher than general population; hypertension,
CAD, diabetes, COPD, emphysema, liver disease, kidney disease, seizure disorder,
obesity)
Schizophrenia and Violence
Studies find that unless drugs or alcohol are involved, people with
mental disorders do not pose any more a threat to the community
than anyone else.
The mentally ill account for about 3%-5% of violence in society.
The mass media seems fascinated with reporting bizarre murders,
dismemberment of animals, or other gruesome acts by Sz’s
• As a general rule, they simply want to be left alone.
• Violence is usually directed at family members, (86%) and occurs in
the home.
• Risk factors include: being male, under age 30, being paranoid, and
heavy substance abuse.
• History of juvenile detention
Approaches to Rehabilitation
Psychosocial Rehabilitation: Skills Based Groups
1)
2)
3)
4)
5)
6)
7)
8)
Symptom Management
Social Problem Solving
Relapse Prevention
Assertiveness Training
Community Reintegration
Vocational Rehabilitation: Supported Employment
Hope & Optimism
Impulse Control
Psychopharmacology
 Control through medications
 Drugs alter operation of neurotransmitters in the brain
 Antipsychotics
 Antidepressants
 Mood Stabilizers
 Antianxiety drugs
 The same drugs do not necessarily work for the same
symptoms for each patient
Antipsychotics
 Introduced in 1950’s
 One of the first –
Thorazine, Haldol
 Newer generation of
atypical antispychotics
introduced in 1990’s
called Serotonin
Dopamine Antagonsists
 Clozaril
 Abilify
 Geodon
 Seroquel
 Risperdal
 Zyprexa
Side effects:
Dry mouth, blurred vision, loss of
muscle control, sun sensitivity,
nausea,
sedation,
diarrhea,
muscle spasms, tremors, weight
gain
Antidepressants
Used for depressive disorders, such as anxiety and
bulimia
Medications:
• Lexapro, Prozac, Imipramine, Wellbutrin, Elavil
• Changes the concentration of specific neurotransmitters in the
brain
• Can provide lasting long-term recovery from depression
• Could be used for bi-polar individuals
Mood Regulators for Bipolar Disorder
Mood stabilizers balance certain brain chemicals that control emotional states and
behavior.
Mood stabilizers can help to treat mania and to prevent the return of both manic and
depressive episodes in bipolar disorder. They may also help treat the mood disorder
problems associated with Schizophrenia such as depression
Medications:
Depakote, Lithium and Tegretol
Side effects of these medications:
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Nausea,
Vomiting
Diarrhea
Increased thirst and need to urinate
Weight gain
Drowsiness
Anti-Anxiety Medications
• High-potency benzodiazepines combat anxiety and have few
side effects other than drowsiness.
• Because people can get used to them and may need higher
and higher doses to get the same effect, benzodiazepines are
generally prescribed for short periods of time,
• Klonopin is used for social phobia and GAD
• Ativan is helpful for panic disorder
• Xanax is useful for both panic disorder and GAD.
• Some people experience withdrawal symptoms if they stop
taking benzodiazepines abruptly instead of tapering off, and
anxiety can return once the medication is stopped.
Treatment
In general, anxiety disorders are treated with medication, specific
types of psychotherapy, or both. Treatment choices depend on the
problem and the person’s preference.
Antidepressants
• SSRIs: Some of the newest antidepressants are called selective
serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of
the neurotransmitter serotonin in the brain, which, like other
neurotransmitters, helps brain cells communicate with one
another.
• Prozac, Zoloft, Lexapro, Paxil, Celexa are some of the SSRIs
commonly prescribed for panic disorder, OCD, PTSD, and social
phobia.
Psychotherapy
• Psychotherapy involves talking with a trained mental
health professional, such as a psychiatrist, psychologist,
social worker, or counselor, to discover what caused an
anxiety disorder and how to deal with its symptoms.
Cognitive-Behavioral Therapy
• Cognitive-behavioral therapy (CBT) is very useful in
treating anxiety disorders. The cognitive part helps people
change the thinking patterns that support their fears, and
the behavioral part helps people change the way they
react to anxiety-provoking situations.
What is a Crisis?
• Any mention or threat of suicide, including gestures or
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attempts
Any threat or action to harm another person
Observed violent or reckless behavior, including property
destruction
Extreme agitation, anxiety, or panic
Person seems to be immobilized by depression, unable to
care for self
Person seems extremely irrational, confused, illogical, or
paranoid
Alcohol/drug intoxication or withdraw that could present
an immediate health risk
Contact Information
Dr. Elijah Levy
[email protected]
(562) 230-3334
Website: www.thelevylaunch.com