SCHIZOPHRENIA Fact Sheet and TR Application Aly Peterson Joshua Boaz Table of Contents A. Title Page B. Table of Contents…………………………………………………………………....1 About Schizophrenia………………………………………………………………..2 Definitions……………………………………………………………………...2 Causes…………………………………………………………………………2 Epidemiology…………………………………………………………………..2 Metacognition Theory………………………………………………………...3 Symptoms………………………………………………………………………….....4 Positive…………………………………………………………………………4 Negative………………………………………………………………………..4 Cognitive…………………………………………………………………….....4 Diagnosis………………………………………………………………………………5 By Symptoms…………………………………………………………………..5 Schizophrenia Subtypes…………………………………………………………….6 Prognosis………………………………………………………………………………8 Treatment and Special Needs………………………………………………………9 Medications…………………………………………………………………………...12 Schizophrenia Screening Test………………………………………………….....14 TR Implications……………………………………………………………………….17 Resources……………………………………………………………………………..19 References…………………………………………………………………………….21 1 About Schizophrenia Definition: Schizophrenia is a severe brain disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior. Contrary to popular belief, schizophrenia isn't a split personality or multiple personality. The word "schizophrenia" does mean "split mind," but it refers to a disruption of the usual balance of emotions and thinking. Schizophrenia is a chronic condition, requiring lifelong treatment. [1] Causes: Genetic Influences: People who have a close relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. In one’s family, a genetic predisposition can be inherited for schizophrenia. However, the specific type of schizophrenia cannot be inherited. Psychological and Social Influences: Level of social and family support. Also, Events in a person’s environment may trigger schizophrenia. For example, problems during development while mother is pregnant and at birth may increase risk of baby developing schizophrenia later in life. Neurobiological Influences: Thought to be caused by an imbalance of chemicals-serotonin and dopamine-- that are found in the brain. [2] Epidemiology: Schizophrenia occurs throughout the world. The prevalence of schizophrenia (ie, the number of cases in a population at any one time point) approaches 1 percent internationally. The incidence (the number of new cases annually) is about 1.5 per 10,000 people. Slightly more men are diagnosed with schizophrenia than women, and women tend to be diagnosed later in life than men. There is also some indication that 2 the prognosis is worse in men. A number of risk factors have been associated with the development of schizophrenia, including living in an urban area, immigration, obstetrical complications, and a late winter-early spring time of birth (perhaps reflecting exposure to influenza virus during neural development). [3] Metacognition Theory: There’s an innate self-awareness of one’s own thinking process. Recognition between one’s own thoughts and external thoughts (own voice vs. others’ voice). For individuals with schizophrenia, there is a confusion between the Broca’s and the Wernicke’s Area of the brain. When they hear voices, activity occurs in Broca’s area, instead of Wernicke’s area. Mix-up in understanding can hinder their overall perception. Prosody is known as the emotional impact of language. Inflection relays meaning and emotion. Schizophrenics may misread inflections and misunderstand messages. 3 Symptoms Positive: symptoms that reflect an excess or distortion of normal functions 1. Delusions: Not based in reality and usually involve misinterpretation of perception or experience. Most common of all the symptoms. 2. Hallucinations: Seeing or hearing things that do not exist, although hallucinations can be in any of the senses. Hearing voices is the most common hallucination among people with schizophrenia. 3. Thought Disorder: Difficulty speaking, stopping speech mid-sentence, putting together meaningless words 4. Disorganized Behavior: Can be shown in many different ways including childlike behavior or unpredictable behavior. Negative: symptoms that refer to a diminishment or absence of characteristics of normal function. They may appear months or years before positive symptoms. (5 A’s): 1. Anhedonia: Loss of motivation Loss of interest in everyday activities 2. Affective Flattening: Lack of facial emotion 3. Avolition: Neglect of personal hygiene. Lack ability to plan or carry out activities 4. Asociality: Social withdrawal. 5. Alogia: Lack of constant conversation, responsiveness. Cognitive: symptoms that involve problems with thought processes 1. Problems with making sense of information. Drop of IQ. 2. Difficulty paying attention, retaining memory, and carrying out executive function. 3. Loose associations: Variety of speech tendencies. (e.g. alliterations and run-on with certain thoughts) 4. Rigidity or literal thinking: Their reasoning is always black and white, difficult to compromise with. 4 Diagnosis There is no test that can make a schizophrenia diagnosis. People with schizophrenia usually come to the attention of a mental health professional after others see them acting strangely. Doctors make a diagnosis through interviews with the patient as well as with friends and family members. Psychiatrists have the most experience with diagnosing schizophrenia. A psychiatrist or other licensed mental health professional should be involved in making a schizophrenia diagnosis whenever possible. A schizophrenia diagnosis can be made when all of the following are true about a patient: Schizophrenia symptoms have been present for at least six months. Patient is significantly impaired by the symptoms. For example, has serious difficulty working or with social relationships, compared to the period before symptoms began. Symptoms can't be explained by another diagnosis, such as drug use or another mental illness. Some people with schizophrenia are afraid of their symptoms. Or they may be suspicious of others (paranoid). They may conceal their symptoms from doctors or loved ones. This can make it more difficult to confirm a schizophrenia diagnosis. [4] Diagnosing Schizophrenia by Symptoms People with schizophrenia have at least some of its main symptoms. For a psychiatrist to make a confident schizophrenia diagnosis, some of these symptoms must be present: Hallucinations. This means hearing voices or other sounds that aren't there or seeing things that don't exist. Delusions (unshakeable beliefs that aren't true). 5 Disorganized speech and behavior (talking and acting strangely). Lack of motivation and emotional expression. Lack of energy. Poor grooming habits. Specific types of psychotic symptoms (called first-rank symptoms), when present, make a schizophrenia diagnosis more likely: Hearing your own thoughts spoken aloud. Feeling that thoughts are being inserted into your mind, or removed from it, by an outside force. Feeling like other people can read your mind. Feeling that an outside force is making you feel something, want something, or act in a certain way. Hearing voices discuss you or argue about you. Hearing voices narrate your actions as you perform them. A person with schizophrenia may describe these symptoms openly. Or a psychiatrist may deduce they are likely present based on observations of a person's speech and behavior. Schizophrenia Subtypes As schizophrenia progresses, its symptoms can change. Its course is categorized clinically by whatever type of behavior is prominent during an episode. The following five main subtypes are used to classify schizophrenia: Catatonic Paranoid Disorganized Undifferentiated Residual 6 Catatonic Schizophrenia: People with catatonic type assume peculiar postures and are usually speechless. They may be both rigid and motionless, or they may seem agitated and move around excessively, but always without external stimulus. Catatonic people may also have strange facial expressions, may mimic the behavior of others, and may repeat words that others say. Catatonic behavior is also seen in mood disorders, like bipolar disorder and major depressive disorder, and occasionally in diseases of the central nervous system, like Parkinson's disease. Paranoid Schizophrenia: Paranoid schizophrenia is marked primarily by delusions that follow a theme, like persecution or grandeur. Auditory hallucinations may accompany a delusion and are, therefore, usually related to its theme. Symptoms common to other subtypes, like disorganized speech and flattened affect, are not usually prominent in episodes of paranoia, but anger, irritability, and extreme anxiety are. People suffering from paranoid delusions become particularly preoccupied with them and may be especially prone to violence. Interestingly, people with paranoid schizophrenia may experience less dysfunction than people with other subtypes. They are often able to live, work, and care for themselves. The onset of paranoid schizophrenia is often later in life, and, with time, it may characterize most or all episodes. Disorganized Schizophrenia: Disorganized type, which is marked by disorganized speech, behavior, and flattened affect is particularly disruptive. The disorganized episode (also known as hebephrenic schizophrenia) often features fragmented speech and inappropriate or unexpected behavior that does not reflect ideas expressed verbally. Strange mannerisms, gestures, and surprising behavior are common. This type of schizophrenia typically causes significant dysfunction in daily life, self-care, and interaction with others, as well as notable thought disturbance and loss of goaldirected behavior. People in the midst of a disorganized episode show no catatonic signs. 7 Undifferentiated Schizophrenia: Undifferentiated schizophrenia is the type given to a lack of catatonia, paranoia, or disorganized speech. Undifferentiated schizophrenia might resemble other illnesses, including neurological disorders. However, people suffering from non-psychiatric diseases typically have insight into their condition and they understand the medical basis for its presence. Residual Schizophrenia: Finally, the residual type of schizophrenia is diagnosed when positive symptoms like delusions, hallucinations, and grossly disorganized behavior have disappeared. Negative symptoms remain and may be interrupted only briefly by mildly disorganized speech or strange behavior. Prognosis No known cure exists for individuals with schizophrenia. But many people with this illness can lead productive and fulfilling lives with the proper treatment. The traditional clinical and societal view of schizophrenia is of a debilitating and deteriorating disorder with poor outcome. However, most patients now live independently outside the hospital and the typical duration of admission is short (a few weeks). Although most patients need some degree of formal or informal financial and daily-living support, the perspective now is one of recovery, where the patient takes an active role in the development of new meaning and purpose while growing beyond the misfortune of mental illness. [5] About three fourths of persons with schizophrenia have recurrent relapse and continued disability, although the proportion of persons with significant improvement increased after the mid-1950s (mean: 48.5 percent from 1956 to 1985 versus 35.4 percent from 1895 to 1956). Outcome may be worse in persons with insidious onset and delayed initial treatment, social isolation, or a strong family history; persons living in industrialized countries; men; and persons who misuse drugs. Pharmacologic treatment is generally successful in treating positive symptoms, but up to one third of persons derive little benefit, and negative symptoms are notoriously difficult to treat. About one 8 half of persons with schizophrenia do not adhere to treatment in the short term. The figure is even higher in the longer term. [6] Treatment and Special Needs Treatment Schizophrenia is a chronic condition, and people with schizophrenia need continued help and support. With proper medication and treatment, people with schizophrenia can live by themselves and work. Some individuals might have a more severe case and will require hospitalization or daily care. Every individual is different, and a majority of people can improve their symptoms and daily functioning with support. Treatment for schizophrenia includes medication, therapy, hospitalization, support groups, and vocational programs. Medication for mental illness is often a trial-and-error process, and psychiatrists will likely need to try out a combination of medicines with varying doses to evaluate which ones are best and have the least amount of side effects with the best benefit. Individual and group therapy is important for people with schizophrenia, and these sessions can help you determine appropriate goals and teach you strategies for reaching those goals. Sometimes changes in medication or stressful life events can bring about acute symptoms, and hospitalization might be required to stabilize symptoms of schizophrenia. Vocational programs and other day treatment centers can help give you skills you need to hold relationships and work, and these programs can also help you find recreational activities and find the best living arrangements. Some individuals with schizophrenia find they do not have family support, and it can be difficult to live on one’s own. Through a support group or social worker, you can apply for SSD or SSI, which is Social Security benefits that will give you money for housing and treatment. Many hospitals will also pay individuals with schizophrenia for participating in drug and treatment research. Additionally, you can get support and find resources from the National Alliance for the Mentally Ill. [7] Family psycho-education: In addition to educating family members about the symptoms, course, and treatment of schizophrenia, this form of treatment consists of providing 9 family support, problem-solving skills, and access to care providers during times of crises. When this intervention is consistently provided for at least several months, it has been found to decrease the relapse rate for the individual with schizophrenia and improve the person's social and emotional outcomes. Also, the burden that family members experience as a result of having a loved one with schizophrenia is lessened, family members tend to be more knowledgeable about the disorder and feel more supported by the professionals involved, and family relationships are improved. Assertive community treatment (ACT): This intervention consists of members of the person's treatment team meeting with that individual on a daily basis, in community settings (for example, home, work, or other places the person with schizophrenia frequents) rather than in an office or hospital setting. The treatment team is made up of a variety of professionals. For example, a psychiatrist, nurse, case manager, employment counselor, and substance-abuse counselor often make up an ACT team. ACT tends to be successful in reducing how often people with schizophrenia are hospitalized or become homeless. Substance abuse treatment: Providing medical and psychosocial interventions that address substance abuse should be an integral part of treatment as about 50% of individuals with schizophrenia suffer from some kind of substance abuse or dependence. Social skills training: Also called illness management and recovery programming, socialskills training involves teaching clients ways to handle social situations appropriately. It often involves the person scripting (thinking through or role-playing) situations that occur in social settings in order to prepare for those situations when they actually occur. This treatment type has been found to help people with schizophrenia resist using drugs of abuse, as well as improve their relationships with health-care professionals and with people at work. 10 Supported employment: This intervention provides supports like a work coach (someone who periodically or consistently counsels the client in the workplace), as well as instruction on constructing a résumé, interviewing for jobs, and education and support for employers to hire individuals with chronic mental illness. Supported employment has been found to help schizophrenia sufferers secure employment, earn more money, and increase the number of hours they are able to work. Cognitive behavioral therapy (CBT): CBT is a reality-based intervention that focuses on helping a client understand and change patterns that tend to interfere with his or her ability to interact with others and otherwise function. Except for people who are actively psychotic, CBT has been found to help individuals with schizophrenia decrease symptoms and improve their ability to function socially. This intervention can be done either individually or in group sessions. Weight management: Educating people with schizophrenia about weight gain and related health problems that can be a side effect of some antipsychotic and other psychiatric medications has been found to be helpful in resulting in a modest weight loss. That is also true when schizophrenia sufferers are provided with behavioral interventions to assist with weight loss. [8] Specific Needs People living with schizophrenia need a correct diagnosis and early treatment of their illness. They also need understanding, compassion, and respect. They also need an effectively functioning mental health system, which is a rarity in the United States today. NAMI’s Grading The States report (2006) reviews the care systems in every state and provides advocacy points as well as outlining strengths and urgent needs for each state. The report is available at www.nami.org/grades. Like anyone else living with a serious, ongoing illness, a person living with schizophrenia needs help with the fear and isolation associated with this illness as well as the negative cultural attitudes surrounding it. 11 Because in the beginning the illness may make it so difficult to do even everyday things they did before, some who live with this illness need help with their physical care, from staying clean and eating well to following medical treatment. Although new and better treatments allow many people to return to more active lives, many people living with schizophrenia may need help over the long term with their basic needs, such as money, housing, food, and clothing. [9] Medications In schizophrenia, antipsychotic medications are proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizophrenia thus has two main phases: an acute phase, when higher doses might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which is usually life-long. During the maintenance phase, dosage is often gradually reduced to the minimum required to prevent further episodes and control inter-episode symptoms. If symptoms reappear or worsen on a lower dosage, an increase in dosage may be necessary to help prevent further relapse. Even with continued treatment, some patients experience relapses. The most common cause of a relapse is stopping medications. Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly. Antipsychotic drugs are the cornerstone in the management of schizophrenia. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness. The first antipsychotic drug was discovered by accident and then used for schizophrenia. This was Thorazine, which was soon followed by medications such as 12 Haldol, Prolixin, Navane, Loxapine, Stelazine, Trilafon, and Mellaril. These drugs have become known as "neuroleptics" (meaning, "take the neuron") because, although effective in treating positive symptoms (acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they can cause cognitive dulling and involuntary movements, among other side effects. These older medications also are not so effective against so-called negative symptoms such as apathy, decreased motivation, and lack of emotional expressiveness. In 1989, a new generation of antipsychotics -- called atypical antipsychotics -- was introduced. At the correct doses, fewer of the neurological side effects -- which often include such symptoms as muscular rigidity, painful spasms, restlessness, or tremors -are seen. The first of the new generation, Clozaril is the only drug that has been shown to be effective where other antipsychotics have failed. It is not linked with the side effects mentioned above, but it does produce other side effects, including weight gain, changes in blood sugar and cholesterol, and possible decrease in the number of infection-fighting white blood cells. Blood counts need to be monitored every week during the first six months of treatment and then every two weeks and eventually once a month indefinitely in order to catch this side effect early if it occurs. Other atypical antipsychotics include Abilify, Geodon, Invega, Latuda, Risperdal, Saphris, Seroquel, and Zyprexa. Another atypical antipsychotic, Fanapt, has been FDAapproved for acute (but not long-term) treatment of schizophrenia. The use of all of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia. Although sometimes more effective and better tolerated than older conventional neuroleptics, atypical antipsychotics also have side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and managing complications. Importantly, all atypical antipsychotics carry the possible risk for causing weight gain and raising blood sugar, cholesterol, and triglyceride levels, which must be periodically monitored during treatment. Some antipsychotics -- typical 13 and atypical -- can cause heart rhythm problems that may require monitoring by a doctor. Most of these medications take two to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least four weeks (or even as long as several months in the case of Clozaril). Because the risk of relapse of illness is higher when antipsychotic drugs are taken irregularly or discontinued, it is important that people with schizophrenia follow a treatment plan developed in collaboration with their doctors and with their families. The treatment plan will involve taking the prescribed medication in the correct amount and at the times recommended, attending follow-up appointments, and following other treatment recommendations. People with schizophrenia often do not believe that they are ill or that they need treatment. Other possible things that may interfere with the treatment plan include side effects from medications, substance abuse, negative attitudes towards treatment from families and friends, or even unrealistic expectations. When present, these issues need to be acknowledged and addressed for the treatment to be successful. [10] Yale University PRIME Early Psychosis/Schizophrenia Screening Test [11] Instructions: This free screening test is for anyone who wants to see if they may have the symptoms commonly associated with a schizophrenia-specific disorder, such as Schizophrenia or schizophreniform disorder. Answer the questions below based upon how you currently feel or have felt in the past month. 1. I feel that others control what I think and feel. Not at all Just a little Somewhat Moderately Quite a lot All the time 14 2. I hear or see things that others do not hear or see. Not at all Just a little Somewhat Moderately Quite a lot All the time 3. I feel it is very difficult for me to express myself in words that others can understand. Not at all Just a little Somewhat Moderately Quite a lot All the time 4. I feel I share absolutely nothing in common with others, including my friends and family. Not at all Just a little Somewhat Moderately Quite a lot All the time 5. I believe in more than one thing about reality and the world around me that nobody else seems to believe in. Not at all Just a little Somewhat Moderately Quite a lot All the time 15 6. Others don't believe me when I tell them the things I see or hear. Not at all Just a little Somewhat Moderately Quite a lot All the time 7. I can't trust what I'm thinking because I don't know if it's real or not. Not at all Just a little Somewhat Moderately Quite a lot All the time 8. I have magical powers that nobody else has or can explain. Not at all Just a little Somewhat Moderately Quite a lot All the time 9. Others are plotting to get me. Not at all Just a little Somewhat Moderately Quite a lot All the time 10. I find it difficult to get a hold of my thoughts. 16 Not at all Just a little Somewhat Moderately Quite a lot All the time 11. I am treated unfairly because others are jealous of my special abilities. Not at all Just a little Somewhat Moderately Quite a lot All the time 12. I talk to another person or other people inside my head that nobody else can hear. Not at all Just a little Somewhat Moderately Quite a lot All the time Therapeutic Recreation Implications One of the main components for schizophrenia is social rehabilitation to help patients reintegrate into the community and regain educational or occupational functioning. The problems in living experienced by people with schizophrenia are social, personal, clinical, and sometimes political (e.g., discrimination). Because the impact of schizophrenia is felt in so many areas of life, effective treatment must address multiple problems, including early recognition of relapse, relapse prevention, improved insight 17 and adherence to treatment, psychoeducation, family living, community care and care in other special settings, social and coping skills, and rehabilitation. Each therapeutic discipline has the responsibility of demonstrating that treatment leads to functional change through supportive data. Without the use of an outcome measure, Recreational Therapy research aimed at the effectiveness of interventions and outcomes of practice to promote efficiency of treatment cannot be conducted. Recreational therapists have a responsibility to provide a measure for outcomes of RT to enhance professional growth and to assure quality treatment of clients. A CTRS helping a patient with schizophrenia must understand all forms of the disorder to help manage the symptoms associated with it. Undergoing therapeutic recreation can help in the following ways: Aid the patient in sharing his/her thoughts more easily Improve relationships Find enjoyable activities to participate in during free time Learn new skills and also for rehab purposes Improve his/her self-image and improve their overall quality of life Help learn skills that would be beneficial at work, home, or school Learn coping strategies. Exhibit higher levels of appropriate behaviors than when engaged in vocational rehabilitation services Find meaning in life, which can help avoid indulging in their delusions Recognize common surroundings, which can help a person distinguish between reality and hallucinations/delusions Learn how to make individual and group decisions 18 Resources for Schizophrenia The following organizations are effective resources for Information, support, and advocacy. For any questions, concerns, or doubts about schizophrenia, use the contact information below: National Alliance for the Mentally Ill (NAMI) Colonial Place Three 2107 Wilson Blvd., Suite 300 Arlington, VA 22201-3042 Phone: 1-800-950-NAMI (6264) or (703) 524-7600 Internet: http://www.nami.org National Mental Health Association (NMHA) 2001 N. Beauregard Street, 12th Floor Alexandria, VA 22311 Phone: 1-800-969-6942 or (703) 684-7722 TTY-800-443-5959 Internet: http://www.nmha.org National Mental Health Consumers' Self-Help Clearinghouse 1211 Chestnut Street, Suite 1000 Philadelphia, PA 19107 Phone: 1-800-553-4key (4539) or (215) 751-1810 Internet: http://www.mhselfhelp.org/index2.html National Alliance for Research on Schizophrenia and Depression (NARSAD) 60 Cutter Mill Road, Suite 404 Great Neck, NY 11021 Phone: (516) 829-0091 Infoline 1-800-829-8289 Internet: http://www.narsad.org 19 For more information on research into the brain, behavior, and mental disorders contact: National Institute of Mental Health (NIMH) Office of Communication and Public Liaison Information Resources and Inquiries Branch 6001 Executive Boulevard, Rm. 8184, MSC 9663 Bethesda, MD 20892-9663 Phone: 301-443-4513 Fax: 301-443-4279 E-mail: nimhinfo@nih.gov Fax back system: Mental Health FAX4U at 301-443-5158 Web site address: http://www.nimh.nih.gov/ 20 References [1] http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/definition/con20021077 [2] http://psychcentral.com/lib/what-causes-schizophrenia/000715 [3] http://www.uptodate.com/contents/schizophrenia-epidemiology-and-pathogenesis [4] http://www.webmd.com/schizophrenia/guide/schizophrenia-tests [5] http://www.sciencedirect.com/science/article/pii/S0140673609609958 [6] http://www.aafp.org/afp/2010/0815/p338.html [7] http://www.specialneeds.com/children-and-parents/general-special-needs/helpschizophrenia [8] http://www.medicinenet.com/schizophrenia/page5.htm [9] http://www.nami.org/Template.cfm?Section=By_Illness&Template=/ ContentManagement/ContentDisplay.cfm&ContentID=67729 [10] http://www.webmd.com/schizophrenia/guide/schizophrenia-medications?page=2 [11] http://www.schizophrenia.com/sztest/primetest.pdf 21