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Therapy with the Therapy with the Schizophrenic Schizophrenic
PatientPatient
Brooke Schauder, PhDBrooke Schauder, PhD
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DSM-IV-TR Defining DSM-IV-TR Defining FeaturesFeatures
2 or more:2 or more: DelusionsDelusions HallucinationsHallucinations Disorganized speechDisorganized speech Disorganized or catatonic behaviorDisorganized or catatonic behavior Negative symptomsNegative symptoms
Social/occupational dysfunctionSocial/occupational dysfunction Disturbance persists for 6 monthsDisturbance persists for 6 months
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Negative SymptomsNegative Symptoms
Apathy: Lack of interest or concernApathy: Lack of interest or concern Alogia: Poverty of speechAlogia: Poverty of speech Anhedonia: Inability to experience Anhedonia: Inability to experience
pleasurepleasure Avolition: Lack of motivation Avolition: Lack of motivation Affective FlatteningAffective Flattening
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Schizophrenia SubtypesSchizophrenia Subtypes
Paranoid Type: preoccupation with one Paranoid Type: preoccupation with one or more delusions or frequent auditory or more delusions or frequent auditory hallucinations.hallucinations. No disorganized speech, catatonic behavior, No disorganized speech, catatonic behavior,
or flat/inappropriate affect.or flat/inappropriate affect.
Disorganized Type: disorganized speech, Disorganized Type: disorganized speech, behavior, and flat/inappropriate affect.behavior, and flat/inappropriate affect. Not catatonic typeNot catatonic type
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(subtypes)(subtypes)
Catatonic Type: 2 ofCatatonic Type: 2 of Motoric immobility as catalepsy (waxy Motoric immobility as catalepsy (waxy
flexibility) or stuporflexibility) or stupor Excessive motor activityExcessive motor activity Extreme negativism (rigid posture) or Extreme negativism (rigid posture) or
mutismmutism Peculiarities of voluntary movement Peculiarities of voluntary movement
as posturing, stereotyped movements, as posturing, stereotyped movements, prominent mannerisms, or grimacingprominent mannerisms, or grimacing
Echolalia (repeating others) or Echolalia (repeating others) or echopraxia (repeating words)echopraxia (repeating words)
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Prevalence and Prognostic Prevalence and Prognostic CourseCourse
Annual Incidence: .5-5. Per 10,000 Annual Incidence: .5-5. Per 10,000 worldwideworldwide
Median Onset: mid-20s for men and Median Onset: mid-20s for men and late 20s for womenlate 20s for women Majority have prodromal phase: Majority have prodromal phase:
social withdrawal, loss of interest, social withdrawal, loss of interest, deterioration in hygiene, unusual deterioration in hygiene, unusual behavior, anger outbursts. Premorbid behavior, anger outbursts. Premorbid “character” (1 year)“character” (1 year)
Course: Complete remission is rare.Course: Complete remission is rare. Negative symptoms often persist in Negative symptoms often persist in
absence of positive symptoms.absence of positive symptoms.
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Positive Prognostic Course Positive Prognostic Course CorrelatesCorrelates
Good premorbid Good premorbid adjustmentadjustment
Acute onsetAcute onset Later age at onsetLater age at onset Absence of Absence of
anosognosiaanosognosia Being femaleBeing female Precipitating Precipitating
factorsfactors
Associated mood Associated mood disturbancedisturbance
Prompt medical Prompt medical treatment with treatment with onsetonset
Medication Medication compliancecompliance
Brief duration of Brief duration of active phase active phase symptomssymptoms
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Genetic FactorsGenetic Factors Evidence in Monozygotic twins reared Evidence in Monozygotic twins reared
without biological parents.without biological parents. 11stst degree relatives have 10x greater odds. degree relatives have 10x greater odds. Chromosomal differences: 5, 11, 18, 19, & X Chromosomal differences: 5, 11, 18, 19, & X
chromosome.chromosome. Neurological differences in the Limbic Neurological differences in the Limbic
System, Dopaminergic system, Basal System, Dopaminergic system, Basal Ganglia, and Cerebellum.Ganglia, and Cerebellum.
Enlarged lateral and 3Enlarged lateral and 3rdrd ventricles. ventricles. Heterogeneous Basis – Stress-vulnerability Heterogeneous Basis – Stress-vulnerability
modelmodel
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Theoretical ModelsTheoretical Models
Psychoanalysis: The individual is Psychoanalysis: The individual is fixated at the oral stage and never fixated at the oral stage and never establishes object constancy. The establishes object constancy. The individual never achieves secure individual never achieves secure identity and remains dependent.identity and remains dependent.
Learning Theory: Children learn Learning Theory: Children learn irrational reactions and ways of irrational reactions and ways of thinking by imitating parents with thinking by imitating parents with significant emotional problems.significant emotional problems.
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TreatmentsTreatments
MedicationMedication Family PsychoeducationFamily Psychoeducation Cognitive Behavioral TherapyCognitive Behavioral Therapy
Social Skills TrainingSocial Skills Training Supported EmploymentSupported Employment
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Medications-AtypicalMedications-Atypical Clozapine (Clozaril): superior to many Clozapine (Clozaril): superior to many
others in symptom management, but others in symptom management, but fatality risk (1.3%). Highest risk of weight fatality risk (1.3%). Highest risk of weight gain.gain.
Risperdone (Risperdal): Less weight gain. Risperdone (Risperdal): Less weight gain. More sexual dysfunction.More sexual dysfunction.
Olanzapine (Zyprexa): Risk for high Olanzapine (Zyprexa): Risk for high cholesterol and weight gain.cholesterol and weight gain.
Quetiapine (Seroquel): May improve Quetiapine (Seroquel): May improve mental performance. May cause weight mental performance. May cause weight gain, but less than others.gain, but less than others.
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More AtypicalsMore Atypicals
Ziprasidone (Geodon): May also Ziprasidone (Geodon): May also reduce anxiety. No significant risk reduce anxiety. No significant risk for weight gain, but may affect for weight gain, but may affect heart.heart.
Aripiprazol (Abilify, Abilistat): Aripiprazol (Abilify, Abilistat): “third generation” antipsychotic. “third generation” antipsychotic. Less risk of extrapyramidal and Less risk of extrapyramidal and other side effects.other side effects.
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Antipsychotic / NeuropeticAntipsychotic / Neuropetic
Haloperidol (Haldol)Haloperidol (Haldol) Chlorpromazine (Thorazine)Chlorpromazine (Thorazine) Perphenazine (Trilafon)Perphenazine (Trilafon) Thioridazine (Mellaril)Thioridazine (Mellaril) Mesoridazine (Serentil)Mesoridazine (Serentil) Trifluoperazine (Stelazine)Trifluoperazine (Stelazine) Fluphenazine (Prolixin)Fluphenazine (Prolixin)
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Family PsychoeducationFamily Psychoeducation
GOALS:GOALS: Establish collaborative relationship Establish collaborative relationship
between family and treatment team.between family and treatment team. Psychoeducation about the diseasePsychoeducation about the disease Improve monitoring of psychiatric Improve monitoring of psychiatric
illness and recognize prodromal illness and recognize prodromal phase.phase.
NAMI support groupNAMI support group
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Family Psychoeducation: Family Psychoeducation: TreatmentTreatment
Long TermLong Term Future Oriented (not past)Future Oriented (not past) Focus on Psychoeducation, Focus on Psychoeducation,
improved communication, problem improved communication, problem solvingsolving
Help all family members pursue Help all family members pursue shared and personal goals shared and personal goals regarding patient. regarding patient.
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Cognitive Behavior Cognitive Behavior Therapy Therapy
Goal: Reduce severity of persistent Goal: Reduce severity of persistent psychotic symptomspsychotic symptoms
Encourages the patient’s ACTIVE Encourages the patient’s ACTIVE involvement in treatment.involvement in treatment.
Reduce Physiological Arousal.Reduce Physiological Arousal.
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CBTCBT
Treatment: Exploration of Treatment: Exploration of circumstances in which psychosis circumstances in which psychosis emergedemerged
Consideration of alternative Consideration of alternative explanations for delusional beliefs explanations for delusional beliefs or hallucinationsor hallucinations
Behavioral tests to assess beliefs Behavioral tests to assess beliefs related to psychotic symptoms.related to psychotic symptoms.
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CBT TechniquesCBT Techniques
Attempt to ID psychotic experience Attempt to ID psychotic experience function in real life: “they are function in real life: “they are poisoning me with drugs”poisoning me with drugs”
““My thoughts are being broadcast” My thoughts are being broadcast” : Utilize records to write : Utilize records to write incidences, who is speaking, where incidences, who is speaking, where they occur, what they say, etc.they occur, what they say, etc.
For negative symptoms: establish For negative symptoms: establish daily structure and schedule.daily structure and schedule.
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CBT: TechniquesCBT: Techniques
Reasoning Biases:Reasoning Biases: Belief InflexibilityBelief Inflexibility Jumping to ConclusionsJumping to Conclusions Extreme RespondingExtreme Responding
Therapy: Developing and exploring Therapy: Developing and exploring alternative perceptions or explanations.alternative perceptions or explanations.
Direct work on anxiety can alter Direct work on anxiety can alter distortions.distortions.
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Psychoeducation / Psychoeducation / Cognitive RemediationCognitive Remediation
Goals: Improve understanding Goals: Improve understanding about schizophrenia and about schizophrenia and managementmanagement
Increase medication adherenceIncrease medication adherence Prevention of relapse and Prevention of relapse and
recognition of prodromal phaserecognition of prodromal phase Enhance coping with distressing Enhance coping with distressing
symptomssymptoms
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Psychoed. Treatment:Psychoed. Treatment:
Psychoeducation about illnessPsychoeducation about illness Develop strategies for taking Develop strategies for taking
medication regularlymedication regularly Teach strategies for realizing relapseTeach strategies for realizing relapse Development of relapse prevention Development of relapse prevention
planplan-Wallet sized pocket card with -Wallet sized pocket card with diagnosis, medication, emergency diagnosis, medication, emergency contact numbers.contact numbers.
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Cognitive RemediationCognitive Remediation
Neuropsychological Problems in Neuropsychological Problems in Schizophrenia:Schizophrenia: Frontal Executive Functions: Frontal Executive Functions:
Reasoning, problem solving, abstract Reasoning, problem solving, abstract thinking, mental flexibilitythinking, mental flexibility
Memory ProblemsMemory Problems Attention Problems/DistractibilityAttention Problems/Distractibility Motor Coordination ProblemsMotor Coordination Problems
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Cognitive Remediation Cognitive Remediation TherapyTherapy
Goal: Teach patient specific Goal: Teach patient specific strategies for enhancing attention, strategies for enhancing attention, memory, and learning.memory, and learning.
Using schedulers, alarms, pill Using schedulers, alarms, pill boxes, mnemonic devices, etc.boxes, mnemonic devices, etc.
Website for memory and attention Website for memory and attention enhancement strategies: enhancement strategies: http://ccvillage.buffalo.edu/wc.htmlhttp://ccvillage.buffalo.edu/wc.html
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Social Skills TrainingSocial Skills Training
Goal: Increase social skills such as Goal: Increase social skills such as having conversations, making having conversations, making friends, resolving conflict, friends, resolving conflict, expressing feelings, assertiveness, expressing feelings, assertiveness, dealing with problems at work, dealing with problems at work, developing leisure activities.developing leisure activities.
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Social Skills: TechniquesSocial Skills: Techniques
ModelingModeling Role Playing and corrective Role Playing and corrective
feedbackfeedback Group TherapyGroup Therapy
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Common ComorbiditiesCommon Comorbidities
Substance AbuseSubstance Abuse AnxietyAnxiety DepressionDepression Family DysfunctionFamily Dysfunction
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THE ENDTHE END