SCHIzOAffECTIvE DISORDER 125
CBT, modified for this population, focuses on symptom management, symptom
recovery in acute psychosis, relapse prevention, and early intervention. Patients are taught coping strategies, attention switching or attention narrowing, especially useful for dealing with hallucinations, modified self-statements and internal dialog, reattribution, awareness training, de-arousing techniques, increased activity levels, social engagement and disengagement, and reality-testing techniques.
Electroconvulsive therapy (ECT) has been suggested as a treatment for resistant
schizoaffective disorders; however, the evidence has been limited to case studies and uncontrolled studies. In general, antipsychotic treatment alone has produced better outcomes than ECT.
Emphasis is being placed on early identification of any of the schizophrenic spec-
trum disorders, including schizoaffective disorders. Earlier identification allows for earlier intervention and not requiring patients and/or families to reach a high threshold of risk, disruption, or deterioration before accessing treatment. There is evidence that if symptoms are treated prior to the onset of a psychotic episode, full-blown consequences (such as schizoaffective disorder or schizophrenia) may be delayed or even prevented.
Chronic Treatment
Patients who have schizoaffective disorder can benefit greatly from psychotherapy
as well as psychoeducational programs and regularly scheduled outpatient medi- cation management.
When making the transition to outpatient, stressing the importance of medication
compliance is crucial.
If possible, select once-daily or long-acting medications to help with patient
compliance.
Therapy is most effective if it involves their families, develops their social skills,
and focuses on cognitive rehabilitation.
Psychotherapies should include supportive therapy and assertive community
therapy in addition to individual and group forms of therapy and rehabilitation programs.
Family involvement is needed in the treatment of this particular disorder.
Treatment includes education about the disorder and its treatment, family assis-
tance in compliance with medications and appointments, and maintenance of structured daily activities.
Otherwise, encourage patients who are schizoaffective to continue their normal
routines and strengthen their social skills whenever possible.
Recurrence Rate
A good outcome is predicted in the presence of a good premorbid history, acute
onset, a specific precipitating factor, few psychotic symptoms, a short course, and no family history of schizophrenia.
The prognosis for patients with schizoaffective disorder is thought to lie between
that of patients with schizophrenia and that of patients with a mood disorder.
Therefore, the prognosis is better with schizoaffective disorder than with a schizo- phrenic disorder but worse than with a mood disorder alone.
Individuals with the bipolar subtype are thought to have a prognosis similar to
those with bipolar type I, whereas the prognosis of people with the depressive sub- type is thought to be similar to that of people with schizophrenia.
Overall, determination of the prognosis is difficult.
PATIENT EDUCATION
Discuss compliance with patients as well as with family members. Always discuss
all the risks, benefits, adverse effects, and alternatives of each medication.
Stress-reduction techniques are employed to prevent relapse and possible
rehospitalization.
Education should also include social skills training and cognitive rehabilitation.
Family education should involve reducing of expressed emotions, criticism, hostil-
ity, or overprotection of the patient.
MEDICAl/lEGAl PITfAllS
Patients with schizoaffective disorder often lack judgment and insight into their
illness. They commonly refuse to continue the medications started in the hospital after they are discharged. Noncompliance may also be the result of adverse effects of the medication, such as sedation and weight gain.
SCHIzOPHRENIA 127
Patients may begin to feel better as a result of their medications and believe that
they no longer need to take them. This thinking leads to discontinuation of the medication and can result in rehospitalization.
Be familiar with local mental health laws as patients with schizoaffective disorder,
who represent a danger to self or others or are unwilling to seek help on a volun- tary basis, may need to be committed for further evaluation and treatment.
If nonadherence with medications is an issue, a court order may be necessary to “to
treat the patient over his/her objection.”
Physical restraints may also be indicated for protection of self and/or others.
Schizophrenia
BACKGROUND INfORMATION Definition of Disorder
This is a chronic, severe, and disabling brain disorder characterized by disordered
thoughts, delusions, hallucinations, and bizarre or catatonic behavior.
Etiology
Several genes are found to be strongly associated with schizophrenia. However,
genes alone are not sufficient to cause this disorder.
Imbalance of the neurotransmitters dopamine and glutamate (and possibly others)
are found to play a role in schizophrenia.
Scientists believe that interactions between genes and the environment are neces-
sary to develop schizophrenia. Environmental risk factors (e.g., exposure to viruses or malnutrition in the womb, problems during birth) and psychosocial factors (e.g., stressful conditions) are found to increase the risk of schizophrenia.
Research shows that schizophrenia is hereditary. People who have first-degree
relatives (a parent, sibling) or second-degree relatives (grandparents, aunts, uncles, cousins) with this disorder develop schizophrenia more often than the general population. The identical twin of a person with schizophrenia has the highest risk (40%–65%) of developing this disorder.
Demographics
Schizophrenia occurs in 1% of the general population.
Schizophrenia affects men and women equally and occurs at similar rates in all
ethnic groups worldwide.
Patients with schizophrenia are found to abuse alcohol and/or drugs more often
than the general population. Abusing a substance can reduce the effectiveness of treatment.
Patients with schizophrenia are more likely to be addicted to nicotine as
compared with the general population (75%–90% vs. 25%–30%).
Patients may need higher doses of psychotropic medication if they smoke and
dose reductions for some antipsychotics on cessation of smoking. Nicotine replacement does not mitigate the metabolic consequences of cessation.
Patients with schizophrenia attempt suicide much more often than people in the
general population; approximately 10% succeed, especially among young adult males.
Risk factors Age
In men, onset of symptoms typically emerges in the late teens and early 20s and in
women, in the mid-20s to early 30s.
Psychotic symptoms seldom occur after age 45 years and only rarely before
puberty (although cases of schizophrenia in children as young as 5 years have been reported).
Gender
The prevalence of schizophrenia among men and women is about the same.
Pregnancy can worsen mental health in a subset of women with schizophrenia.
Women are found to be especially susceptible for acute exacerbation of symptoms in the postpartum period.
Compared to men, women tend to experience more pronounced mood symptoms.
The gender differences in course and outcome are probably due to the effect of
estrogen in women before menopause.
Family History
Patients with immediate family members diagnosed as schizophrenic have approx-
imately a 10% risk of developing the disorder.
Factors Associated With Birth
Infants who experience a complication while in mothers’ wombs or who experience
trauma during delivery are at higher risk for developing schizophrenia.
Intrauterine viral infection may occur in the womb.
Environmental Stressors
Environmental stressors are found to be associated with the development of schizo-
phrenia, including problems with interpersonal relationships, difficulties at school/
work, and substance abuse.
Substance Abuse
Most researchers do not believe that substance abuse causes schizophrenia; how-
ever, patients with schizophrenia abuse alcohol and/or drugs more often than the general population.
DIAGNOSIS
Differential Diagnosis
Psychotic disorder due to a general medical condition, delirium, or dementia
Substance-induced psychotic disorder, substance-induced delirium, substance-
induced persisting dementia, and substance-related disorders may be seen Brief psychotic disorder
Delusional disorder
Schizophreniform disorder
Psychotic disorder may not be otherwise specified
Schizoaffective disorder
Mood disorder with psychotic features
Mood disorder with catatonic features
SCHIzOPHRENIA 129
Depressive disorder may not be otherwise specified
Bipolar disorder may not be otherwise specified
Pervasive developmental disorders (e.g., autistic disorder)
Childhood presentations combining disorganized speech (from a communica-
tion disorder) and disorganized behavior (from attention-deficit/hyperactivity disorder)
Schizotypal personality disorder
Schizoid personality disorder
Paranoid personality disorder
ICD-10 Codes Schizophrenia (F20)
Schizotypal disorders (033) Schizotypal disorders (F21)
Delusional disorders (034) Persistent delusional disorders (F22)
Acute and transient psychotic disorders (F23) Schizoaffective disorders (036)
Induced delusional disorders (F24)
Acute and transient psychotic disorders (035) Schizoaffective disorders (F25)
Other nonorganic psychotic disorders (037) Diagnostic Workup
Check for Drug Interactions
Physical and mental status examination
CBC, including hemoglobin, hematocrit, red blood cell (RBC) count, white blood
cell (WBC) count, WBC differential count, and platelet count
Hepatic and renal function tests, including alanine transaminase (ALT), aspartate
transaminase (AST), alkaline phosphatase (ALP), blood urea nitrogen (BUN), and creatinine
Thyroid function tests (T3, T4, and TSH)
Electrolytes (potassium, chloride, sodium, bicarbonate), glucose, B
12, folate, and
calcium level
For patients with a history of suspicion, check for HIV, syphillis, ceruloplasmin,
antinuclear antibody test, urine for culture and sensitivity and/or drugs of abuse, and 24-hour urine collections for porphyrins, copper, or heavy metals
Alcohol and drug screening
Pregnancy test for female patients of childbearing age
Initial Assessment
Current physical status and physical history
Current mental status and mental health history, including symptoms patient
experiences, how long patient has been having symptoms, when the symptoms started, how often the symptoms occur, when and where symptoms tend to occur, how long symptoms last, and what effect symptoms have on patient’s ability to function
Drug history including prescribed and over-the-counter drugs
Safety needs
Clinical Presentation
Positive symptoms are extreme or exaggerated behaviors, including:
Delusions (somatic, ideas of reference, thought broadcasting, thought insertion,
and thought withdrawal)
Hallucinations (visual, auditory, tactile, olfactory, and gustatory)
Inappropriate or overreactive affect
Negative symptoms:
Blunted or flat affect, unable to experience pleasure or express emotion
(anhedonia)
Inability to carry out goal-directed behavior (avolition)
Limited speech (alogia)
Lack of energy and initiative
Poor coordination and self-care
Thought disorganization
Abnormal thoughts
Tangential, incoherent, or loosely associated speech.
DSM-5 Diagnostic Guidelines
The diagnosis is given if two Criterion A symptoms are present:
Delusions
Hallucinatons
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
The individual must have at least one of these three symptoms: delusions, hal-
lucinations, and disorganized speech.
Continuous signs of the disturbance are exhibited for at least 6 months
Schizoaffective disorder and mood disorder have been excluded
Substance abuse and other general medical conditions have been
excluded
Schizophrenia subtypes are defined by the predominant symptomatology at the
time of evaluation. The five subtypes of schizophrenia are paranoid type, disorga- nized type, catatonic type, undifferentiated type, and residual type.
The first signs for the adolescent population may include drops in academic per-
formance, changes of friends, sleep problems, or irritability. A diagnosis of schizo- phrenia can be difficult to make for members of this age group since many normal adolescents also exhibit these behaviors.
TREATMENT OvERvIEW Acute Treatment
Inpatient treatment is necessary for patients with a serious suicidal or homicidal
ideation and plan, whose behavior can unintentionally be harmful to self or others, who are incapable of providing self-care, or who are at risk for behavior that may lead to long-term negative consequences.
The goal of acute-phase treatment, usually lasting for 4 to 8 weeks, is to alleviate
the most severe psychotic symptoms, such as agitation, frightening delusions, and hallucinations.
SCHIzOPHRENIA 131
Low-dose, high-potency antipsychotics have been found to be safe and effective in
managing agitated psychiatric patients. For instance:
Haloperidol (Haldol) intramuscular (IM) is used to calm patients with moder-
ately severe to very severe agitation. Subsequent doses may be needed within 1 hour depending on the responses.
Ziprasidone (Geodon) IM is recommended.
A low dose of a short-acting benzodiazepine (e.g., lorazepam [Ativan]) is also
found to be effective in decreasing agitation during the acute phase and may reduce the amount of antipsychotic needed to control patients’ psychotic symptoms.
Atypical (second generation) antipsychotic drugs are suggested to be used as
a first-line treatment of schizophrenia because of their fewer side effects than conventional or typical antipsychotic medications.
ECT, in combination with antipsychotic medications, can be considered for
patients with schizophrenia who do not respond to antipsychotic agents. The rate and number vary from patient to patient depending on clinical responses and side effects.
Substantial improvement of symptoms is seen in many patients by the 6th week
of treatment. Providers may switch to other antipsychotic medications if patients are not responding to an adequate trial of a prescribed medication, are not able to tolerate a medication, or have poor medication adherence.
PSYCHOPHARMACOlOGY Of SCHIzOPHRENIA Second-generation
(atypical) antipsychotic drugs: These are used as a first-line treat- ment of schizophrenia due to fewer side effects when compared to conventional or typical antipsychotic medications.
Commonly used
second-generation atypical antipsychotic drugs include aripiprazole (Abilify), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), quetiapine fumarate (Seroquel XR), risperidone (Risperdal), long-acting risperidone (Risperdal Consta), ziprasidone (Geodon), and paliperidone (Invega). A newer atypical antipsychotic is asenapine (Saphris sublingual formulation) and is getting good reviews as effective for schizophrenia, especially if there is a mood component involved.
Clozapine (
Clozaril) is the drug of choice for treatment-resistant schizophrenia (little or no symptomatic response to at least two antipsychotic trials of an adequate duration—at least 6 weeks—and at a therapeutic dose range) and it has a lower risk of tardive dyskinesia (TD). However, due to the potential side effect of agranulocytosis (loss of WBC), a blood test is required weekly for the first 6 months, and biweekly for the next 6 months. Monitoring can be done monthly if no hematological problems are found after 1 year of clozapine treatment.
First-generation (typical or conventional) antipsychotic drugs:
Commonly used
first-generation (typical or conventional) antipsychotic drugs: haloperidol (Haldol), fluphenazine (Prolixin), thioridazine (Mellaril), trifluoperazine (Stelazine).
Low-dose, high-potency antipsychotics such as haloperidol IM 2 to 5 mg have
been found to be safe and effective in managing agitated psychiatric patients.
Subsequent doses may be needed within 1 hr depending on responses.
Short-acting benzodiazepine:
A low dose of a short-acting benzodiazepine (e.g., lorazepam 0.5 to 2 mg every 1 hour IM or intravenous [IV] as needed no more than
2 mg every minute—maximum daily doses vary with diagnosis and condition;) is effective in decreasing agitation during the acute phase, and may reduce the amount of antipsychotic needed to control patients’ psychotic symptoms.
ECT in combination with antipsychotic medications can be considered for patients
with schizophrenia who do not respond to antipsychotic agents. The rate and num- ber of ECT varies from patient to patient depending on their clinical responses and side effects.
Social skills training aimed to improve the way patients with schizophrenia interact
with others (e.g., poor eye contact, odd facial expressions, inaccurate or lack of perceptions of emotions in other people) has been found to be effective in reducing relapse rate.
CBT helps patients with schizophrenia acquire some insight into their illness and
appears to be effective in reducing the severity of symptoms and decreasing the risk of relapse.
Dialectical behavior therapy (DBT) combines cognitive and behavioral theories.
Patients with schizophrenia may benefit from DBT to improve interpersonal skills.
Individual psychotherapy focuses on forming a therapeutic alliance between thera-
pists and patients with schizophrenia. A good therapeutic alliance is likely to help patients with schizophrenia remain in therapy, increase adherence to treatments, and have positive outcomes at 2-year follow-up evaluations.
Personal therapy, a recently developed form of individual treatment, uses social
skills and relaxation exercises, self-reflection, self-awareness, exploration of vulner- ability and stress, and psychoeducation to enhance personal and social adjustment of patients with schizophrenia. Patients who receive personal therapy have shown better social adjustment and a lower rate of relapse after 3 years than those not receiving it.
Many patients with schizophrenia benefit from art therapy because it helps them
communicate with and share their inner word with others.
Employment programs that include individualized job development, rapid place-
ment, ongoing job supports, and integration of mental health and vocational services have been found to be effective in helping patients with schizophrenia to achieve employment (Table 10.3).
Chronic Treatment
The treatment goals are to prevent relapse and to improve patient’s level of
functioning.
It is estimated that 40% to 50% of patients are not adherent to treatment within 1
to 2 years. Long-acting medications are found to increase treatment adherence as compared to oral medications.
It is important to monitor and manage side effects of antipsychotic medications,
including extrapyramidal side effects (mostly common in patients treated with first-generation antipsychotics), tardive dyskinesia, sedation, postural hypotension, weight gain metabolic syndrome—including shifts in lipids and blood glucose—
along with increased central adiposity, and disturbances in sexual function.
If patients develop extrapyramidal symptoms, give benztropine or trihexyphenidyl
or diphenhydramine as directed.
For drug-induced dystonic reaction (especially of head and neck), give diphenhy-
dramine (Benadryl) for pseudoparkinsonism reaction due to drug use, use trihexy- phenidyl (Artane) or benztropine (Cogentin).
SCHIzOPHRENIA 133