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Jenn Goldie

on 6 March 2013

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Transcript of Schizophrenia

Challenges Schizophrenia Stigmatization of Schizophrenia Challenges Related to the Diagnosis of Schizophrenia 1. The issue of heterogeneity in schizophrenia

2. Differential diagnosis

3. The subjectivity of diagnosis The Need for Psychotherapy Pharmacological Treatments Challenges Challenge Pharmacological Treatments Continued... Risperidone and Olanzapine Antipsychotic medications are the main class of drugs used in the pharmacological treatment of schizophrenia. Chlorpromazine: First genuine antipsychotic medication Lowers frequency and severity of hallucinations, delusions, and thought disorder

Has some effect in decreasing negative symptoms Challenge: This class of drugs is not a cure for schizophrenia; it only manages symptoms

It does not necessarily work well with every patient with schizophrenia

*** Uncomfortable side effects Provide symptom management with fewer side effects than Chlorpromazine Challenge: Symptoms usually return if use is discontinued and prolonged use can be unpleasant A few side effects associated with antipsychotics include sedation, hypertension, cardiac arrhythmias, and sexual dysfunction Nonadherence A major challenge in treating schizophrenia with antipsychotic medication is related to nonadherence rates More than 50% of patients with schizophrenia are known to be partially or completely nonadherent with oral antipsychotics

Nonadherence can range from occasionally missed doses to complete discontinuation Some estimates of nonadherence are as high as 90% Other Pharmacological Treatments Antidepressants and Benzodiazipines Although antipsychotics are the most effective drugs in the treatment for schizophrenia, antidepressants and benzodiazepines are often use as adjunct medications in addition to antipsychotics

This targets depressive symptoms and symptoms of anxiety that may be presented in patients with schizophrenia due to comorbid disorders. Disclaimer Pharmacological therapies only serve to control symptoms. Moreover, they have little effect on cognitive symptoms, which can often be the most disabling part of symptoms associated with schizophrenia. This highlights the importance of psychotherapy and skills training in the development of life and adjustment skills that are not treated through the use of medication. Antipsychotic Medications Source: World Psychiatric Association’s Global Campaign to Fight Stigma and Discrimination Because of Schizophrenia Challenge of Stigma Definition of "Stigma": Greek word referring to a mark or impression that was cut or burned on a person's body to indicate his or her status as a slave, a criminal, or a traitor. Schizophrenia is one of the most stigmatized mental illnesses

The experience of schizophrenia is not limited to the symptoms of the illness

It is accompanied by the stigma, which denotes a shameful quality in the individual so marked A few negative stereotypes about people who have schizophrenia in society:
-violent and dangerous
-images of "raving lunatics"
-lazy and unreliable
-crazy and unpredictable The reaction of the social environment and the stigma associated with the disorder is often referred to as "second illness" (Finzen, 1996). Dimensions of stigma from the perspective of schizophrenic patients, their relatives, and mental health professionals Cross-national survey by the International Study of Discrimination and Stigma Outcomes (INDIGO) group Social Stigma A Study on Stigma Internalized Stigma Results of Study 47% had negative experiences in making or retaining friendships

43% of patients reported being treated differently by family members

29% had experienced difficulty finding jobs

29% reported difficulty in keeping their jobs

27% had experienced discrimination in intimate or sexual relationships

Anticipated discrimination was seen in 64% with respect to applying for a job, training, or education

55% had anticipated discrimination in looking for a close relationship

A total of 72% felt the need to conceal their diagnosis Individuals with schizophrenia also suffer from internalized stigma

Internalized stigma reduces ability to cope

It intensifies and adds shame, guilt, anger, and distrust of others Why such Stigma? Schizophrenia is often misunderstood because it can look different based on the symptoms that manifest in each individual and on the severity of the symptoms.

It can go from one extreme with people who are very disorganized and barely able to take care of themselves (stereotypical image of people on the street), to the other extreme with people who are high functioning and successful in particular areas. Effects and Consequences Stigma has been found to lead to:

1) Social isolation

2) Limited life opportunities

3) Delays in help-seeking behaviours Proposed Changes to the DSM 5 Changes to criterion A (symptoms)

Remove existing symptom-based subtypes with dimensions

Change in concept and criteria for Schizoaffective Disorder (a subtype of schizophrenia)

Introduction of an Attenuated Psychosis Syndrome 1) Changes to criterion A (symptoms) Catatonia will be separated from the disorganized behavior criterion

Examples for negative symptoms will include: restricted affect and avolition/asociality

Presence of bizarre delusions or hallucinations of voices conversing or a voice keeping a running commentary on the individual will not be sufficient to satisfy Criterion A 2) Removal of existing symptom-based subtypes with dimensions Subtypes will be removed including Paranoid Schizophrenia, Disorganized and Catatonic Schizophrenia

These subtypes are suggested to have limited diagnostic stability, low reliability, and poor validity 3) Change in concept and criteria for Schizoaffective Disorder Characterizing patients with both psychotic and mood symptoms has been controversial; since the introduction of the term in 1933, schizoaffective disorder remains one of the most controversial diagnostic classifications in psychiatry.

Almost 1/3 of patients today with psychotic symptoms receive a schizoaffective disorder

Proposal attempts to improve reliability of this diagnosis by providing more specific criteria and reconceptualizing schizoaffective disorder as a longitudinal diagnosis

Most significant proposed change is to Criterion C of schizoaffective disorder, which attempts to separate schizoaffective disorder from schizophrenia with prominent mood symptoms Criterion C proposed revision: “symptoms that meet criteria for a mood episode are present for a majority (>50%) of the total duration of the active and residual periods of the illness.” (Tandon, 2012) 4) Introduction of an Attenuated Psychosis Syndrome Recognize mild psychotic symptoms early in their evolution; monitor and intervene if necessary

Potential risks: possible stigma and inappropriate use of medications and/or other treatments

It is unclear if this proposal will be included in the DSM-5 “Despite strong evidence for better management,
it is still not universally applied that providing patients
with pharmacotherapy alone is not sufficient.”
(Lublin & Eberhard, 2008) What Does the Research Say? Controversy: is psychotherapy ineffective when treating schizophrenia?

While pharmacological treatments reduce symptoms, and are the cornerstone of treatment, psychotherapy assists with everyday functioning

Psychotherapy provides:
- Emotional support
- Coping strategies
- Psychoeducation Sources: Heinrichs et al., 2013; Mahgerefteh et al., 2006; National Institute of Mental Health, 2013 Types of Psychotherapies Used Standard = antipsychotic medications + CBT and/or family therapy

Also frequently used:
- Social Skills Training
- Cognitive Remediation
- Interpersonal Therapy
- Psychoeducation (and Family Education) Sources: Haddock & Lewis, 2005; Heinrichs et al., 2013; Lublin & Eberhard, 2008 Challenges with Psychotherapy 1. Antipsychotic medication is necessary for psychotherapy to be effective
Important to be stabilized on the right medication

2. Adherence to medications is the biggest barrier to overall successful treatment
Nonadherence to medication = unlikely to adhere to psychotherapy

3. Individuals suffering from schizophrenia benefit
from a variety of psychotherapies
Not tailored to individual = highly ineffective Challenges with Psychotherapy (cont'd) 4. It may take longer to build trust and create a therapeutic alliance
Need to build trust and rapport before using confrontation and challenging beliefs
Symptoms of paranoia and distrust = extra time required to build the relationship

5. Psychotherapy may not be necessary or effective
No emotional consequences to delusions or impairment in functioning Sources: Ciudad et al., 2012; Grohol, 2011; Heinrichs et al., 2013; Lysaker et al., 2007; Mahgerefteh et al., 2006; National Institute of Mental Health, 2013; Sudak, 2004; Warman & Beck, 2003 Sources: Ciudad et al., 2012; Grohol, 2011; Heinrichs et al., 2013; Lysaker et al., 2007; Mahgerefteh et al., 2006; National Institute of Mental Health, 2013; Sudak, 2004; Warman & Beck, 2003 The Issue of Heterogeneity in Schizophrenia References Differential Diagnosis of Schizophrenia Differentiation between negative symptoms of schizophrenia and depression remains a clinical challenge
Depression is commonly comorbid with schizophrenia
Clear distinctions may be made if blue mood and depressed cognition are present

Positive symptoms may also be difficult to differentiate from symptoms common to mood disorders
Delusions may be a symptom of a mood disorder if they are "mood-congruent". The Subjectivity of Diagnosis A major challenge in diagnosing schizophrenia is that it is based on a clinician's interpretation of a patient's subjective experience of symptoms

For this reason, even if a diagnosis of schizophrenia is reliable, it is not necessarily valid Sources: Heinrichs et al., 2013; Tandon, Nasrallah, & Keshavan, 2010 Source: Agid, Foussas, & Remingtin, 2010 Source: Tandon, Nasrallah, & Keshevan, 2010 Discussion In cases where patients are not experiencing distress or impaired functioning, is psychotherapy necessary?

Research has shown that building a therapeutic alliance with patients with schizophrenia can be a lengthy process. What are the implications of this and what can counsellors do in order to facilitate the establishment of a sound therapeutic relationship? Sources: Heinrichs et al., 2013; Pope, Lipinski, Cohen, & Axelrodt, 1980; Tandon, 2012 Sources: Heinrichs, Miles, Ammari, & Muharib, 2013; Hafner & An der Heiden, 2003; McGrath, 2007 Sources: Heinrichs et al., 2013; Hausmann & Fleischhacker, 2002; Kibel, Laffont, & Liddle, 1993; Romney & Candido, 2001 Sources: Heinrichs et al., 2013; Schwarz & Bahn, 2008 If reliable disease markers for schizophrenia can be identified, a more objective diagnosis of the disorder may become possible. Methodological concerns regarding the assessment of course and outcome variables

Subtype classification of schizophrenia as an attempt to categorize heterogeneity has received criticism Difficult to predict clinical outcomes for individuals due to high variability of clinical and biological features of the disorder Source: Schulze & Angermeyer, 2003 Source: Schulze & Angermeyer, 2003 Source: Thornicroft, Brohan, Rose, Sartorios, & Leese, 2009 Source: Thornicroft et al., 2009 Source: Schulze & Angermeyer, 2003 Source: Schulze & Angermeyer, 2003 Source: Schulze & Angermeyer, 2003 Source: Heinrichs et al., 2013; Tandon, 2012 Source: Heinrichs et al., 2013 Source: Tandon, 2012 References Source: Heinrichs et al., 2013 Source: Heinrichs et al., 2013 Source: Heinrichs et al., 2013
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