l.m.p., a 35 year-old married born again christian who lives in bacoor, cavite
DESCRIPTION
L.M.P., a 35 year-old married Born Again Christian who lives in Bacoor, Cavite. CHIEF COMPLAINT (Patient): “Hindi ako nakakatulog, hindi ako nakakakain at huminto kasi akong uminom ng gamot.” (Sister-in-Law): “Nagsasalita ng kung anu-ano.”. PERSONALITY PROFILE Premorbid Personality: - PowerPoint PPT PresentationTRANSCRIPT
L.M.P., a 35 year-old married Born Again Christian
who lives in Bacoor, Cavite
CHIEF COMPLAINT
(Patient): “Hindi ako nakakatulog, hindi ako nakakakain at huminto kasi akong uminom ng gamot.”
(Sister-in-Law): “Nagsasalita ng kung anu-ano.”
PERSONALITY PROFILE
Premorbid Personality:
“masinop, masayahin, sensitive”
Morbid Personality:
“tahimik, kung ano-anong sinasabi”
SOURCE AND RELIABILITY
Patient: 75%
Sister-in-Law: 85%
December 2004 increased preoccupation with religion
January 2005 more intense preoccupation with religion
quiet and overtly sensitive
believed that members of her church group were against her
HISTORY OF PRESENT ILLNESS
February 2005 God’s voice was “telling” her to do something
lost appetite
reduced amount of sleep
1st week of March 2005 blank stares
anxiety
God “communicated” with her
3rd week of March 2005 unusually quiet
barely did household chores
4th week of March 2005 felt something bad will happen to family
shouted at church members
asked forgiveness
commented on bystanders
something was “plotting” against them
speaking in tongues
hyperventilating
1st week of April 2005 continued to be suspicious of her surroundings
told her relatives not to worship idols
2nd week of April 2005 saw “strange people”
would not come out of van
irritable and shouted at relatives
10-day stay at USTH-CC
“maldita” and “matigas ang ulo”
Tx: Quetiapine 100 mg AM, 200 mg PM
Clonazepam, ¼ tab
3rd week of May 2005 Quetiapine 100 mg AM was discontinued
Patient refused to take medication
June 2005 resistive, hyper, violent
Given diphenhydramine 25 mg IM
and Haloperidol 5 mg IM
ADMISSION
REVIEW OF SYSTEMS
• No headache, loss of consciousness or convulsions
• No fever• (+) anorexia and weight loss• No cough or colds, no dyspnea• No chest pain, no easy fatigability• No change in bowel or bladder habits• No bleeding tendencies
PAST MEDICAL HISTORY
• Not known hypertensive, diabetic or epileptic
• No previous hospitalization or operation
FAMILY HISTORY
• (+ dependence) HPN – mother• (+) stroke – mother• (+) heart disease, PUD – father• (+) alcohol dependence – father• (?) nervous breakdown – great
grandmother
PERSONAL HISTORY
• She is a non-smoker and non-alcoholic beverage drinker
• She denies use of any prohibited substance
ANAMNESIS
PRENATAL AND PERINATAL HISTORY
• NSD at home with• Neurodevelopmental milestones were at
par with age.
EARLY-MIDDLE CHILDHOOD
Lived with parents and three siblings Left in the care of the father, an alcoholic Father had occasional fights with his wife Patient admits his father had his
“weaknesses” but was very affectionate and loving
EARLY-MIDDLE CHILDHOOD
• Mother strict and disciplinary• Mother and father occasionally fight• Grew up closer to her father
MIDDLE CHILDHOOD
• Primary education at Malubog-lubog Elementary School in Capiz
• Average student and had very few friends• 6th grade - father died which caused
extreme sadness• Left in the care of the eldest sibling
ADOLESCENCE
• Family Relationship– after father’s death, mother married a
policeman– Siblings were against the marriage– had a harmonious relationship with stepfather
and stepsiblings– Stepfather was kind and approachable but was
not able to fill the void left by her father
ADOLESCENCE
• Social Relationships– Had a number of friends– stayed at home on weekends
• School History– Wanted to take up AB Philosophy – forced by mother to take up BS Nursing– Graduated on time
ADOLESCENCE
• Academic Achievement– failed Nursing Board Exams – failure due to “poor preparation”– had guilt feelings
YOUNG ADULTHOOD
• 1993 - nurse in Capiz and resigned after 6 months– Patient was pious and hardworking– Gave portion of salary to patients
• Also worked in a government hospital in Capiz and resigned as to the request of elder sister
YOUNG ADULTHOOD• Meaningful Long term relationship
- did not have serious relationships
- 1994 - met Norman and married him after two years
- Stayed with husband’s family
- Got pregnant and went back to Capiz
- 1997 – CSD with her 1st child
• 1998 – went to Abu Dhabi with husband and had no difficulty in adjusting
• 1999 – decided to return to Manila due to 2nd pregnancy
• 2000 – gave birth to second child• Stayed with her mother, who sometimes
helped out with her grandchildren• Longed for her husband
YOUNG ADULTHOOD
YOUNG ADULTHOOD
• 2001 – returned to UAE because of argument with mother
• Was baptized to a Born-Again Christian group
• Got pregnant with her 3rd child
YOUNG ADULTHOOD
• Work Experience- First worked as an assistant nurse - Very little compensation while waiting for the
next board exams- resigned to take 2nd board exam- Worked as Ticketing supervisor and resigned
after 2 mos - Petition by her maternal aunt was declined by
the German Embassy
WORK EXPERIENCE
• 1998 - sales clerk in a pharmacy in Abu Dhabi
• 1999 - resigned because of 2nd pregnancy– No difficulty adapting to new environment– No difficulty adjusting to new role as mother
FAMILY PROFILE
4
Leicel35
Norman38
Julius33
Paul Christopher
8
Patricia Louis
5
TimAlbert
2
Cesar45 Ricardo
60
Gina38
5 2
1996
Minerva58
LEGENDHeart attack
Stroke
PHYSICAL EXAMINATION• General Survey
- Conscious, coherent, not in cardio-respiratory distress, ambulatory
• Vital SignsBP: 115/80PR/CR: 90/min regularRR: 18 cpm Temp: 37.1°C
• Skin- Warm, moist skin, no active dermatoses
PHYSICAL EXAMINATION• EENT
- Pink palpebral conjunctivae, anicteric sclerae- No naso-aural discharge, nasal septum midline- Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged
• Neck-supple neck, no palpable cervical lymph nodes, no anterior neck mass
PHYSICAL EXAMINATION• Respiratory
- Symmetrical chest expansion, no retractions, clear breath sounds
• Cardiovascular- Adynamic precordium, AB 5th LICS, MCL, no
murmurs• Gastrointestinal
- Flat abdomen with NABS, soft, non tender, no organomegaly- Warm, moist skin, no active dermatoses
PHYSICAL EXAMINATION• Extremities
- No cyanosis, no clubbing, no edema• Peripheral Vascular
- Pulses are full and equal
NEUROLOGICAL EXAMINATION• Conscious, coherent, oriented to time, place and
person• Intact remote, recent and immediate memory• Cranial Nerves:
- Pupils 2-3mm ERTL, (+) direct and consensual light reflex- Fundoscopy: (+) ROR, clear media, distinct disc margins, C/D ratio 0.3, AV ratio 2:3
NEUROLOGICAL EXAMINATION• Cranial Nerves:
- No visual field cuts- EOMs full and equal- Can clench teeth, no facial sensory deficit- No facial asymmetry, can raise both eyebrows, can smile, can purse lips- (+) gag reflex, uvula midline on phonation- Can shrug shoulders against resistance- Tongue midline on protrusion
NEUROLOGICAL EXAMINATION• MMT no atrophy, no fasciculations, normal
muscle tone• 5/5 in all extremities• Can do APST and FTNT with ease• DTR: ++ in all extremities• (-) Babinski reflex, no frontal release signs• No sensory deficits• No nuchal rigidity
Mental Status Examination on Admission
• Awake but agitated• Well kempt wearing T-shirt and pants• Speech was modulated but repetitive words were spoken• Good eye contact but inattentive when interviewed• Had preoccupation in getting out the Community Center• Oriented to time, place and person• Affect: appropriate• Anxious and uncooperative• Other examinations not performed – Px uncooperative
SALIENT FEATURES• 35 y/o / Female• Born again Christian• Unemployed• preoccupation with at
least 2 delusions (Jan-Apr 2005)
• Bizaare aggressive/agitated behavior (Apr & June 2005)
• Avolition-apathy (3rd wk & 27 Mar)
MSE:• Awake and agitated• Modulated speech
with verbigeration• Inattentiveness• Oriented to time,
place and person• Appropriate affect• Anxious and
uncooperative
DSM-IV TR Criteria for Schizophrenia
A. Characteristic Symptoms– 2 or more of the ff during a 1-month period.1. Delusions2. Hallucinations3. disorganized speech4. grossly disorganized or catatonic behavior5. Negative symptoms (affective flattening, alogia or
avolition)Note: Only one symptom is required if delusion is bizarre or hallucinations
consist of a voice keeping up a running commentary on the persons behavior or thoughts, or 2 or more voices conversing with each other.
DSM-IV TR Criteria for Schizophrenia
• B. Social/Occupational Dysfunction– in 1 or more areas of functioning– work– interpersonal relationship– self-care
DSM-IV TR Criteria for Schizophrenia
• C. Duration– continous signs for atleast 6 months that must include:
• 1 month of active symptoms (or < if succesfully treated)• ± periods of prodromal or residual symptoms
– only negative symptoms– 2 or more Criteria A symptoms in attenuated form (eg. Odd beliefs,
unusual perceptual experience
DSM-IV TR Criteria for Schizophrenia
• D. Schizoaffective and mood disorder exclusion:1. No major depressive, manic, or mixed episodes
concurrently during active symptoms.2. If mood episodes have occurred during active-
phase symptoms:• duration of : mood disorders < active and
(brief) residual periods
DSM-IV TR Criteria for Schizophrenia
• E. Substance/ General medical condition exclusion– disturbance NOT due to:
• a substance ( illicit drug , medication)• general medical condition
DSM-IV TR Criteria for Schizophrenia
• F. Relationship to a pervasive developmental disorder:– w/ Hx of autistic disorder, pervasive developmental
disorder• additional dx of schizophrenia be made only if prominent
delusions or hallucinations are present for atleast 1 month.(or < if successfully treated)
DSM-IV TR Criteria for Schizophrenia
• Classification of Longitudinal Course– can be applied ONLY AFTER at least 1 year since the
initial onset of active-phase symptoms.
PARANOID TYPE•Preoccupation with one or more delusions or frequent auditory hallucinations•No prominent s/s of disorganized type
DISORGANIZED TYPEProminent:1. Disorganized Speech2. Disorganized Behavior3. Flat / Inappropriate Affect
DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPES
CATATONIC TYPEAt least two of the following:1. Motoric Immobility - Catalepsy or Stupor2. Excessive motor activity - purposeless,not influenced by external stimuli3. Extreme Negativism4. Posturing
RESIDUAL TYPE• Absence of prominent delusions, hallucinations, disorganized
speech, and grossly disorganized, or catatonic behavior• Continuing evidence of disturbance
-negative symptoms in attenuated form
UNDIFFERENTIATED TYPEmeet Criteria A but not for the paranoid, disorganized or catatonic type.
DSM - IV Diagnosis
• Axis I: Schizophrenia, paranoid type• Axis II: none• Axis III: none• Axis IV: psychosocial problems• Axis V: GAF: 20 - some danger of hurting
others
ICD-10 Diagnostic Criteria for Schizophrenia
Comments
In evaluating the presence of these abnormal subjective experiences and behavior, special care should be taken to avoid false-positive assessments, especially where culturally or subculturally influenced modes of expression and behavior or a subnormal pattern level of intelligence are involved.
Pattern of courseIn view of the considerable variation of the course of
schizophrenic disorders it may be desirable (especially for research) to specify the pattern of course by using a fifth character. Course should not usually be coded unless there has been a period of observation of at least 1 year.
ContinuousNo remission of psychotic symptoms throughout the period of observation.
Episodic with progressive deficitProgressive development of “negative” symptoms in the intervals between psychotic episodes.
Episodic with stable deficitPersistent but non progressive “negative” symptoms in the intervals between psychotic episodes.
Episodic remittentComplete or virtually complete remissions between psychotic episodes.
Incomplete remission
Complete remission
Other
Course uncertain, period of observation too short
DIFFERENTIAL DIAGNOSIS
Psychiatric disorders
Psychotic disorder Neurotic disorder
Schizophrenia Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Secondary psychotic disorder
PDNOS
mood
anxiety
others
SALIENT FEATURES
SCHIZOPRENIA SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
1. Epidemiology
Prevalence1% 0.2% 0.5% - 0.8% 0.025% -
0.03%
Gender - female
F=M F=M F>M F>M
Age – 35 y/o 25 – 35 y/o M=18-24; F=24-35
Older age Mean = 40 Range = (18-
90’s)
Family Hx ?grandmother
(+) stressor
Genetic predisposition / stressor
Genetic predisposition / stressor
Genetic predisposition / stressor
Genetic predisposition / stressor
Social Hx stressor stressor stressor stressor
SALIENT FEATURES
SCHIZO-PRENIA
SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
2. Consciousness – oriented to PPT
Usually oriented Usually oriented Usually oriented
Usually oriented
3. Emotion a. affect:
appropriate
b. mood: irritable
c. others: anxiety, agitation
d. physiologic disturbance: anorexia, insomnia
Appropriate/ restricted/ flat/
blunt (accdg. To subtype)
Appropriate/ restricted/ flat/
blunt (accdg. To subtype)
Appropriate/ inappropriate
Appropriate
emotional
responsiveness or overly active and inappropriate emotion
emotional
responsiveness or overly active and inappropriate emotion
Depressed or elevated move
Mood congruent or incongruent
+/- +/- - +/-
SALIENT FEATURES
SCHIZOPRENIA SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
4. Motor
Normal to aggressive
Normal to disorganized or catatonic
Normal to disorganized or catatonic
Intermittent but frequent forms of catatonic behavior, posturing, waxy flexibility
None
5. Speech
Normal Normal to disorganized
Normal to disorganized/
confused alogia
Normal to grossly irrelevant or incoherent speech - pressure speech
Normal
SALIENT FEATURES
SCHIZO-PRENIA
SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
6. Thinking
a. process of thinking: psychosis
b. form of thought
- Glossolalia
- Verbigeration
c. content of thought
Delusion Noesis
psychosis
Neologism,verbigeration,word salad- looseness of assoc.- derailment, incoherence- echolalia, mutism- tangientiality, circumstantiality
Delusion
psychosis
Neologism,verbigeration,word salad- looseness of assoc.- derailment, incoherence- echolalia, mutism- tangientiality, circumstantiality
Delusion
psychosis
Neologism,verbigeration,word salad- looseness of assoc.- derailment, incoherence- echolalia, mutism- tangientiality, circumstantiality
Delusion
psychosis
Depends on delusion
Non-bizarre delusion
SALIENT FEATURES
SCHIZO-PRENIA
SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
7. Perception a. distribution:visualauditory hallucination
b. Assoc with cognitive disorder:Anosognosia
All types of hallucination
All types of hallucination
All types of hallucination
No hallucinations but may be present of
consistent w/ delusion
8. Memory: normal intact intact intact intact
9. Insight and judgement: impaired
impaired impaired impaired normal / impaired
SALIENT FEATURES
SCHIZO-PRENIA
SCHIZO-PHRENIFORM
SCHIZO-AFFECTIVE
DELUSIONAL DISORDER
10. Social functioning:
impaired
impaired impaired impaired normal
11. Grooming: poor
poor poor well to overly groomed
well
12. Time period of patient: 6mos
6months; 1 month
symptomatic 1-6 months
Mood Sx: substantial portions of total duration of patients illness Psychotic Sx: at least 2 weeks without the prominent mood symptom
At least 1 month
TREATMENT
OVER-ALL TREATMENT GOALS
• Reduce or eliminate the symptoms• Maximize quality of life and adaptive
functioning• Promote and maintain recovery from the
delibitating effects of illness to the maximum extent as possible
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
TARGETS OF TREATMENT
.
TREATMENT: ACUTE PHASE
ACUTE PHASE TREATMENT
• Goals:• Prevent harm• Control disturbed behavior• Reduce severity of symptoms• Identify factors that led to recurrence of acute
episode• Effect a rapid return to the best level of functioning
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
PHARMACOLOGIC INTERVENTION
• Non- emergency situation– Partial Compliant patient
• Liquid ( eg. Risperidone, Haloperidol)• Quick- dissolving ( eg. Olanzapine, Risperidone)• Short acting Intramuscular ( eg. Haloperidol)
– Non- compliant• Long- acting Injectable
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
• Initiate rapid emergency treatments when an acutely psychotic patient is exhibiting aggressive behaviors toward self or others.
• Short-acting parenteral formulations of 1st- or 2nd- generation antipsychotic agents w/ or w/o parenteral benzodiazepines.
-OR-
• Oral Quick Dissolving 2nd- generation agents (Olanzapine , Risperidone)
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS
• immediate blockade of dopamine D2 receptors • ↓ release of dopamine from presynaptic terminals• Two-year studies:
• relapse during tx: 30% only vs. 80% w/o tx
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18
FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS
• Disadvantages• Positive symptoms only• Only 20% of patients recover to normal functioning• Side effects:
• Akathisia, Parkinsonian-like symptoms• Tardive dyskinesia, Neuroleptic Malignant
syndrome
In comparison with conventional antipsychotics, atypical antipsychotics show at least an equal
efficacy against positive symptoms
- hold true for first- episodes as well as chronic multi-episode patients
- when used as long term maintenance, atypicals demonstrate a positive effect on relapse prevention in controlled trials
Bridler, Rene, Daniel Umbricht. 2003. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly. 133: 53-76.
PHARMACOLOGIC INTERVENTIONS
2nd – Generation - Atypical Antipsychotics
> exert more beneficial effects in the reduction of negative symptoms
> greatly reduced occurrence of acute extrapyramidal side effects & reduced incidence of tardive dyskenisia
> decrease affective symptoms and suicidality
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18
Bridler, Rene, Daniel Umbricht. 2003. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly. 133: 53-76.
2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:
On Negative Symptoms
true ameliorative effect shown by substituted benzamide amilsupride:
50 – 300 mg/d demonstrated a significantly greater decrease of negative symptoms
after 6- 26 weeks of Tx
Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.
2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:
On Negative Symptoms
In a 1-yr controlled trial in pxs with chronic stable schizophrenia with only moderate levels of
positive symptoms but high levels of negative symptoms, ziprasidone was associated with a
small, but statistically significant improvement in negative symptoms compared to placebo
Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.
2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:
On Negative Symptoms
Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.
In a 38 week comparison of ziprasidone and haloperidol in stable schizophrenic outpatients,
significantly more patients treated with ziprasidone demonstrated a reduction of negative symptoms of 20 % or more than
patients treated with haloperidol.
2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:
On Treatment - Refractory Cases
Treatment-refractory patients – fail to adequately respond, ie, show reduction of symptoms to at least two antipsychotics belonging to a different class given in sufficiently high doses of 6-8 weeks
The superiority of clozapine over conventional antipsychotics in the treatment of refractory patients with schizophrenia is well established
Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.
A double blind, random assignment, prospective study that assessed the effects of clozapine and
olanzapine on suicidality and suicide risk over two years showed a significantly reduced suicidality and suicide risk with clozapine than olanzapine.
2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:
On Affective Symptoms And Suicidality
Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.
Therefore, the overall risk benefit ratio is more favorable for the atypicals,
making them the preferred treatment for most patients.
Atypical antipsychotics are recommended as first line treatment.
SIDE EFFECTS OF ATYPICAL ANTIPSYCHOTICS
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
2nd - GEN. ANTIPSYCHOTIC + ADJUNCTIVE MEDICATION
• Study: Effect of Divalproex Combination with Olanzapine or Risperidone on the Acute Phase of Paranoid Schizophrenia
• earlier improvement of symptoms rather than monotherapy• Divalproex: form of valproic acid that is slowly absorbed
– increases GABA, modulating activity of dopaminergic and other NT activity within cortico-striatal-thalamic pathway.
Casey, D.E., et al. 2003. Effect of Divalproex Combination with Olanzapine or Risperidone in Patents with an Acute Exacerbation of Schizophrenia. Neuropsychoparmacology. 28: 182-192.
ADJUNCTIVE MEDICATION•Benzodiazepines / Lorazepam
– Managing catatonia or to decrease anxiety and agitation; sleep disturbances
•Anti-depressants–For co-morbid major depression & OC disorder
•Beta-blockers–Decrease severity of recurrent hostility & aggression
•Mood Stabilizers –Lithium
•reduce symptoms up to 50%; for mood swings.•Decrease severity of recurrent hostility & aggression
–Anticonvulsants (Valproic acid/ carbamazepine)
•Reduce episodes of violence
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins: USA.
“Lack of improvement in the first 1-4 weeks should prompt an increase in the dose, followed by a change to another drug after an additional four to six weeks, if the response remains inadequate.”
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18
PSYCHIATRIC MANAGEMENT
• Structured and predictable environment• Low performance requirement• Tolerant, non demanding, supportive
relationships• Promoting relaxation and reduced arousal
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
TREATMENT: STABILIZATION PHASE
STABILIZATION PHASE• Goals
– Reduce stress on patient & provide support to minimize likelihood of relapse
– Enhance patient adaptation to life in community
– Facilitate continued reduction in symptoms & consolidation of remission
– Promote process of recovery
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
PHARMACOLOGICAL INTERVENTION
• Continue medications for 6 months– Adjust dose or change drug to minimize side
effects– Prevent premature lowering of dose or
discontinuation • Recurrence of symptoms & possible relapse
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
TREATMENT: MAINTENANCE PHASE
MAINTENANCE PHASE
• Goals– enusure symptoms of remission or control is
sustained– Improve or maintain level of functioning or
QOL– Monitor side effects of treament
American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.
PSYCHOSOCIAL THERAPIES
Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins: USA.
SOCIAL SKILLS TRAINING
• Also referred to as behavior therapy• Improve social abilities and interpersonal
communication• Increase practical skills and self-sufficiency• Reduce the frequency of maladaptive or
deviant behavior
FAMILY-ORIENTED THERAPY
• Involves preparing the family and the patient going home
• Includes postdischarge period, the recovery process, its length and its rate
• Help the family and the patient learn about schizophrenia and its psychotic episode
• Control emotional intensity of family sessions with the patient
CASE MANAGEMENT
• to have one person aware of all the forces (psychiatrists, social workers, occupational therapists, etc.) acting on the px
• case manager – ensures that their efforts are coordinated and the px keeps appointments and complies w/ tx plans- make home visits and even accompany px to work
Assertive Community Treatment (ACT)
• for the delivery of services for persons with chronic mental illness
• Team has a fixed caseload of pxs and delivers all services when & where needed by the px, 24/7.
• Adv: decrease the risk of rehospitalization• Disadv: labor-intensive and expensive
GROUP THERAPY
• focuses on real-life plans, problems, and relationships
• may be behaviorally oriented, psychodynamically or insight oriented, or supportive
• effective in reducing social isolation, increasing the sense of cohesiveness, and improving reality testing
• improve cognitive distortions• reduce distractibility• correct errors in judgment
COGNITIVE BEHAVIORALTHERAPY
INDIVIDUAL PSYCHOTHERAPY
• therapist’s reliability, emotional distance & genuineness
• long term• good outcomes at 2-year follow-up evaluations
• personal therapy
TREATMENT OPTIONS
2nd – Generation Antipsychotic
DrugEfficacy Safety Suitability Affordability Total
Risperidone +++ + ++ ++ 8
Olanzapine +++ + ++ + 7
Quetiapine +++ ++ ++ + 8
Ziprasidone +++ +++ + 0 7