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Sarah Maxey

on 21 April 2010

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Transcript of Mandi

Case Study 6 Collyn, Courtney, Elyssa, Jessica, Sarah, Olivia Mandi Introductions 13 years old African American female Lives with mother, stepfather and younger sister Most recently experienced a six month deterioration in functioning and social interaction Admitted to a psychiatric inpatient facility where our team took her on as our client Presenting Symptoms DSM-IV-TR Criteria A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

Paranoia 1. Delusions 3. Disorganized speech 2. Hallucinations (e.g. frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. negative symptoms affective flattening, alogia, or avolition ] ] Garber's Criteria:
Psychopathology * 1. Psychoeducation 2. Challenging Hallucinations and Delusions 3. Social Skills Training 4. Family Therapy Treatment Challenges to Treatment Studies have suggested that the African
American culture tends to distrust
the medical field (ex). As Mandi's family has already brought her
to inpatient care, we don't beleive this
factor will inhibit treatment. Inform Mandi of: Cognitive Behavioral Therapy etiology of Early Onset-Schizophrenia
Early Onset-Schizophrenia symtoms
how these symtoms might be triggered or maintained
how her medication Clozapine works
possible side effects of Clozapine
reasons why medication compliance is important

The 3 Phase Model (Miklowitz and Goldstein, 1990) Selected because: 1. It is adapted to treat COS first during inpatient stay, where psychosis is controlled 2. It is adapted to treat COS at discharge, where a patient is stabilized in their typical environment. 3. It is adapted to treat COS finally through long-term prevention of relapse.
The model would be multimodal, incorporating medication, CBT, social skills training and family therapy. Treatment: •The Scale for the Assessment of Positive Symptoms, The Scale for the Assessment of Negative Symptoms (Andreasen, 1984) and the Dysfunctional Attitude Scale (Weissman, 1980) could all be used to help determine the severity of her schizophrenia. Treatment Assessment Cont. Treatment: The Camberwell Family Interview (CFI) & The Five Minute Speech Sample (FMSS) Assesses expressed emotion and interdependence Measures have been found to be highly concordant for rating expressed emotion among Latino/Hispanic and White family members of patients with schizophrenia, and thus may be suitable for African-American patients as well (Kymalainen et. al., 2005). Medication - Clozapine In the FMSS, parents are asked to describe their child and their relationship; responses are audio-taped and coded. The FMSS scales capture the valence (positivity, negativity, or both) of mothers' comments, as well as the kinds of attributes mothers use to describe their children. Camberwell Family Interview: Answers to questions and non-verbal cues are used to determine if some one has high expressed emotion; rates the patient's perception of how his family feels about him and the disorder. •The Scale for the Assessment of Positive Symptoms - a measure of psychosis which rates severity of psychotic Schizophrenia on a scale from 0 to 176–the highest number represents more severe disease. The Scale for the Assessment of Negative Symptoms - is a standardised scale used to assess the negative symptoms of schizophrenia. Assessments are made using a six-point scale covering a range of negative symptoms. The Dysfunctional Attitude Scale - Assesses dysfunctional attitudes and is used in many studies in relationship with assessment of depression either directly or as a vulnerability factor (Beck, Rush, Shaw, & Emery 1979). Atypical vs. Typical antipsychotics - Typical: especially good at reducing the positive symptoms, but do not reduce the negative symptoms - Typical antipsychotics yield extrapyramidal side effects (motor disturbances, parkinsonian effects, akathesia, dystonia, akinesia, tardive dyskinesia, and neuroleptic malignant syndrome). Some of these side effects have been described to be worse than the actual symptoms of schizophrenia.
- Many atypical antipsychotics produce fewer side effects at lower doses, but once the dose is increased to maintain a therapeutic effect, the severity and number of side effects also increases. Side effects of atypical antipsychotics include: agranulocytosis, weight gain, and some extrapyramidal side effects. - Atypical antipsychotics treat both the positive and negative symptoms of schizophrenia and are considered to be the first line of treatment for schizophrenia and are gradually replacing traditional antipsychotics.
- Even though typical antipsychotics and atypical antipsychotics are both effective in treating some of the symptoms of schizophrenia, it seems like atypical antipsychotics are more effective because of their ability to suppress the negative and positive symptoms. Although they do contain some side effects, the severity of the side effects is less in atypical antipsychotics. Medication - Clozapine Cont. •The atypical medication Clozapine is known to have minimal side effects (Meltzer, 1992), and has recently become available for use with children. •Clozapine has been found to substantially improve both positive and negative symptoms, with one study indicating Clozapine as more effective than Haloperidol, a typial anti-psychotic medication (Mozes et. al., 1994). •It has been reported that Clozapine is highly effective among children and adolescents with schizophrenia, who show substantial improvement in both positive and negative symptoms, especially during the acute phase of treatment (Asarnow, Tompson, & McGrath, 2004). •Patients using Clozapine can expect minimal extra pyramidal side effects such as movement disorders (Asarnow et. al., 2004), frequent blood monitoring, and weight gain caused by suppression of the immune system. •Therefore, Clozapine is selected over other medications for Mandi’s treatment, despite its high cost and risk for other negative side effects. •The drug would initially be prescribed in a dosage of 0.5 and 9.0 mg/kg per day to reduce psychotic symptoms, then continued at a lesser dosage for relapse prevention (NW, 1997; Remschmidt et. al., 1994). •It is also recommended that she see a nutritionist to try to limit the weight gain since the patient is already overweight and lacks socialization skills. Such prevention would be critical to Mandi’s recovery success, as it would allow her to continue in school and maintain academic and social progress. Evaluation of Treatment Clozapine Allow a four to six week trial period where we observe the efficacy of the drug (NW, 1997) During this time weigh the benefits against the costs avoid side effects that severely disrupt day-to-day living or cause harmful medical effects expect some side effects such as weight gain and we will address these in our treatment plan Adjust the medication to ensure the lowest effective dosage Monitor Mandi's health and the effectiveness of the medication once a week until the dosage is stabalized and then continue to monitor regularly but less frequently as long as she remains on the drug If the benefits of Clozapine cease then we will use a trial and error basis to find a more effective medication Evaluation of Treatment CBT Have Mandi and her family record the frequency of her positive symptoms i.e. delusions and hallucinations Success is defined as reduction in frequency of these symptoms Have Mandi, her parents and her teachers record the success of her CBT homework assignments examples of homework assignments: preparing for school, practicing new skills in social interactions, utilizing coping skills Poor social skills is one of the strongest predictors of negative outcome in people with Schizophrenia (Bellack, 1986) Improvement of social skills and relationships is an important indication of improvement The Scale for the Assessment of Positive Symptoms and The Scale for the Assessment of Negative Symptoms Dysfunctional Attitude Scale will all be re- administered to assess her progress Evaluation of Treatment Family Therapy Evaluation of Mandi's Parents Expressed Emotion (EE) and Communication Deviance (CD) (Kymalainan & Mamani, 2008) EE is the measure of emotional involvement
CD is the measure of how poorly a person communicates High levels of EE and CD are associated with negative effects for those experiencing psychological disorders Successful family therapy will produce a reduction in CD and EE in Mandi's family members and will allow family environment to be a protective factor rather than a risk factor. Maintaining Variables Mandi’s mother showed signs of parental communication deviance characterized by anxiousness, peculiar reasoning, contradictions, and closure problems.
Likely that Mandi’s mother’s irritability and harshness in dealing with her daughter was due to projected feelings about the affair Mandi was born out of.
This, along with a family history of psychosis and the finding that communication deviance occurred more among parents of children with COS could be a significant factor in Mandi’s development and perpetuation of her COS.
Maintaining Variables Mandi was conceived outside of marriage, so it is reasonable to assume she was born into a highly stressful family environment.
Asanrow found that stress, distress, and personal tragedy are found in families with children with COS.
Childhood may have been marked with factors reminding her family of the affair, and Mandi’s hyperactivity and restless childhood may have been in response to this. Her actions may have also caused her mother’s communication deviance leading to negative family interactions.
Possible Protective Factors Mandi’s stepfather could be protective during treatment as he is ‘calm and appropriate in managing the family situation’. He could buffer the communication deviance and has a steady job so he could finance Mandi’s treatment.
Mandi’s parents are concerned about her symptoms, having sought treatment for her hyperactivity in childhood and her recent psychosis.
This behavior is less common among African American populations due to distrust for medical institutions.
Biology The Neurodevelopmental Model of Schizophrenia (Rapoport, Addington, Frangou, 2005; Weinberger, 1986) Combination of genetic susceptibility and early environmental stressors damage and alter early neural development. Genetic Predisposition Maternal grandmother treated for an undetermined disorder
Mother's behavior hints at some type of psychopathology + Environmental Stressor Postnatal Asphyxia
Loss of oxygen to the brain during a fragile stage of development- at 2 weeks of age
= Initial Neuronal and Gray Matter Losses The "Back to Front" Progression of Schizophrenia (Vidal et. al., 2006) MRIs from longitudinal studies indicate that the gray matter loss typical of schizophrenia begins in the posterior portion of the brain (cortical areas responsible for attention and activity) and then advances into the frontal areas affecting higher cognitive functioning (sensory integration, affect regulation, etc.) Mandi suffered from a severe case of hyperactivity (18 months - 4 years) for which she was treated with sedatives.
Her current positive symptoms, especially the auditory hallucinations, are likely maintianed by these abnormalities as well. --Years of development with a variety of premorbid symptoms-- Adolescence and Puberty At this stage in development, the neural deficits predicted by the neurodevelopmental model are exacerbated by the increased synaptic pruning and chemical changes associated with entering adolescence (Feinberg, 1982; Lewis & Lieberman, 2000; Marenco & Weinberger, 2000)
Mandi likely suffered a drop in IQ at the onset of her positive symptoms but studies have shown that her is likely to stabilize after the inital drop (Gochman et. al, 2005). Her IQ at intake was 90 (WISC-R) which is considered within the normal range, allowing her IQ to serve as a protective factor (more on those later....) Research has shown that the addition of cognitive behavioral therapy to medication can strengthen treatment efficacy. Challenges maladaptive thoughts and behaviors that contribute to and maintain Mandi's symtoms
Also provide coping skills for managing symptoms
improve medication compliance
improve social competence Begin CBT by discussing nature of symptoms and influence on her daily life
Discuss important goals and subgoals
Integrate goals into a goal progress meter that will be marked upon accomplishment or mastery of a goal
Plan for CBT Goals the ability to effectively challenge positive symptoms through more adaptive cognitions
the ability to successfully employ coping strategies should hallucinations and delusions occur
improvement in academic performance
social competence in conversation and group activities. Begin by discussing the content of her hallucination and delusions and associated beliefs about herself and the world.
When or where do your hallucinations occur?
Why do you think they occur? Challenge Mandi to search for evidence in her environment and social interactions that such beliefs and perceptions are unreal
Pictures or video clips of those expressing distress or ease could be shown to strengthen this skill It is possible that Mandi believes her thoughts and perceptions to represent reality. Once Mandi became aware of the irrational nature of her delusions, it is possible that she may attribute her experiences to internal deficiencies. Explain the regularity with which all people inaccurately perceive stimuli Remember and recite normalizing and self-affirming facts at the first sign of prodromal symptoms

Utilize her cognitive skills to find alternative interpretations of her experiences

Keep a dated diary of experiences to be transferred to a large calander as visual source of therapuetic progress To cope with discomfort or disturbance of their occurence we will discuss relaxation and distraction techniques The incorporation of social skills training into a CBT model has been shown to prevent relapse Greater social adjustment through adaptive social skills that survive long after cessation of treatment 1. Video tape an interaction with Mandi and point out the facial expressions and behaviors she uses that may be maladaptive in social interactions
2. Show Mandi videotapes of how others engage in more adaptive interactions
3. Ask her to compare and contrast the two
4. Practice the more adaptive behaviors through videotaped role play. Participate in group social skills therapy with other children her age who face similar difficulties.
“In-vivo” experience

Support system and associated confidence

Practice these skills outside of therapy in school and at home, according to a ranked set of interactions she must complete a week that employ the skills. Research has indicated that family involvement in treating in early-onset schizophrenia contributes to greater treatment response, fewer instances of relapse and greater medication compliance. Provide psychoeducaton to her family to ensure that they fully understand her symptoms, and how their behaviors as family members may contribute to the maintenance or reduction of these symptoms Videotape therapuetic sessions to reveal the severity of negative interactions and their potential to escalate
When watching taped interactions we would alert them to instances of communication deviance and encourage them to recognize instances themselves outside of the therapeutic environment.
Teach problem solving, negotiation, and toleration skills
Practice through modeling and role-play
The family would record their experiences (both positive and negative) and report back to therapy once a week.
Struggles would be discussed and goals for better communication and coping would be formed for the week that followed It is imperative her teachers become aware of and participate in the treatment process.
Provide her teachers with brief psychoeducation about early-onset schizophrenia
Establish a working relationship among the therapists, teachers and parents
Weekly update would be faxed to her teachers to alert them of Mandi’s progress in treatment.
Presenting Symptoms 1. Intensity of symptom
2. Frequency of symptom
3. Duration of symptom
4. Cluster of symptoms Discussion Questions 1. Our text book includes Childhood Onset Schizophrenia in the chapter with Pervasive Developmental Disorders and Autism. As is true of a number of disorders, the earlier the onset, the poorer the prognosis. However COS is extremely rare (1/10000). Do you think it is worth the time and funding to evaluate children for schizophrenia when they present with other comorbid disorders (ADHD) or premorbid symptoms?

2. In addition to those discussed, what other protective factors could be incorporated into Mandi's post-treatment environment?

3. To date, not much is known or understood about cultural/racial differences in prevalence. Studies have found that African Americans are diagnosed with schizophrenia more than other racial groups, however, many attribute this disparity to overdiagnosis. Even less is known about COS. What are some things that psychologists need to know in order to better understand the influence of culture on this disorder?
Believes people thinks she smells
Believes others can read her mind
Believes she's controlled by God and the Devil

Hears God and the Devil speaking to her

Blocking of speech

Deterioration of handwriting skills

Alternating flat and inappropriate affect
Not interested in school or social relationships

Repetitive behaviors (showering)
Increase in negative cognitions

Believes people thinks she smells
Believes others can read her mind
Believes she's controlled by God and the Devil
Hears God and the Devil speaking to her
Blocking of speech
Deterioration of handwriting skills
Alternating flat and inappropriate affect
Not interested in school or social relationships
Repetitive behaviors (showering)
Increase in negative cognitions

Imagined exposure
Humming, singing, deep breathing, exercising
"Coping Cards" or "Coping Jewelry"
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