Case Presentation: Schizoaffective

Managing the Manic Episode

• Identify the characteristics of schizoaffective disorder, manic episode

• Establish therapeutic rapport with schizoaffective manic patient

• Coordinate discharge planning needs of nursing home patient

Objectives

Assessment

• Biographical data– 50 yr, old African-American

female

• Psychiatric admission– Voluntary admission

• Reason for admission

• Past psychiatric history

Assessment

• Medical Comorbid Conditions– Hypertension

• Current Medications– Clonidine 0.1 mg PO BID– Haldol Decanoate 150 mg IM

monthly– Lamictal 25 mg PO BID– Invega 3 mg PO daily

Assessment

• Social/Work Data– Single, never married, no

children

– Before residing at NH patient lived with mother but is not allowed to return

– Currently unemployed

Assessment

• Family History– Patient denies familial psychiatric

history

• Psychological Testing/Psychiatric Assessment

• Labs/Other Tests– Toxicology screen unavailable

• Past Discharge Plans/Continuity of Care

PathophysiologySchizoaffective Disorder

DefineSchizoaffective Disorder • Schizoaffective Disorder is a

disorder in which a mood episode and the active phase symptoms of Schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms.

• Frequently used to describe a psychotic person with significant symptoms of depression and/or mania.

Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteria

A. An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet criterion A for schizophrenia (i.e., at least 2 of 5 symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms), each present for a significant portion of time during a 1-month period.)

Symptoms for Schizophrenia fall into three (3) broad categories: Positive symptoms, Negative symptoms and Cognitive symptoms.

Positive Symptoms• Positive symptoms: The term

positive symptoms is confusing, because positive symptoms (as the term might suggest) aren’t “good” symptoms at all. They’re symptoms that add to reality, and not in a good way. People with schizophrenia hear things that don’t exist or see things that aren’t there (in what are known as hallucinations).

People with schizophrenia can also have delusions (false beliefs that defy logic or any culturally specific explanation and that cannot be change by logic or reason).

• Negative symptoms: These symptoms are a lack of something that should be present. They may be much slower to respond than most other people, have little to say when they do speak, and appear as if they have no emotions, or exhibit emotions that are inappropriate to the situation.

Negative Symptoms

Cognitive Symptoms• Cognitive symptoms: Most people with the disorder suffer from

impairments in memory, learning, concentration, and their ability to make sound decisions. These so-called cognitive symptoms interfere with an individual’s ability to learn new things, remember things they once knew, and use skills they once had.

Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteria

B. During the same periods of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteria

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

Specify type

– Bipolar type: If the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes)

– Depressive type: If the disturbance only includes major depressive episodes

Schizoaffective Disorder in the DSM-IV-TR has four (4) diagnostic criteria

D. The disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medication condition.

Associated Features and DisordersThere may be poor occupational functioning, a restricted range of social contact, difficulties with self-care, and increased risk of suicide associated with Schizoaffective Disorder. Residual and negative symptoms are usually less severe and less chronic than those seen in Schizophrenia. Anosognosia (i.e., poor insight) is also common in Schizoaffective Disorder.

Course

The typical age at onset of Schizoaffective Disorder is early adulthood, although onset can occur anywhere from adolescence to late in life. The prognosis for Schizoaffective Disorder is somewhat better than the prognosis for Schizophrenia, but considerably worse than the prognosis for Mood Disorders.

PrevalenceDetailed information is lacking, but Schizoaffective Disorder appears to be less common than Schizophrenia.

Hospitalization Goals and Plan

Patient stated goals

1. To experience decrease in behavior that is injurious to self and others.

2. To decrease hallucinations, delusions.

Hospitalization Goals and Plan

• Interdisciplinary team goals: Nursing

– Decrease restlessness and irritability

– Improve worry and anxiety

– Increase self control and medication compliance

– Prevent injury to self and others

– Decrease hallucinations/delusions

– Increase adaptive coping skills

Hospitalization Goals and Plan

• Multidisciplinary team goals: Activity Therapy

– Compliance with functional assessment group therapy participation, increased self expression by providing structure and support, health education, and group therapy.

Hospitalization Goals and Plan

• Multidisciplinary team goals: Social Work

– Compliance with psychosocial evaluation, identify placement through family contact, group therapy, reality orientation, and health education.

Interventions

• Nursing

– Medication treatment and education

– Administer PRN meds

– Stress management techniques

– Anger management

– Reality orientation

– Monitored Q15 mins. on assault precautions

Interventions

• Social Work

– Milieu therapy etc.

– Patient family education

Medications

• Medications upon admission– Haldol D 115 mg IM monthly– Clonidine 0.1 mg PO BID– Haldol 7.5 mg PO BID– Lithium Carbonate 600 mg QHS

and 300 mg QAM

• Response to medications

Medications

• Patient remained noncompliant with oral Haldol and Lithium.

• They were discontinued and replaced with:– Lamotrigine (Lamictal) 25 mg PO BID• Mood stabilizer

– Invega 3 mg PO daily• Antipsychotic

• Patient was compliant with Lamictal and Invega.

Medications: Monitoring• Lamictal–Mood stabilization– Suicidality – Rash– Plasma levels of

lamotrigine

• Invega– Improvement of signs

and symptoms– CBC–Orthostatic vital signs– Suicidality– Fasting blood glucose in

those with/at risk for diabetes mellitus

Medications: Education

• Lamictal–May cause nausea,

tremors, dizziness, fatigue, malaise

– Immediately report rash

– Do not discontinue suddenly, this may induce seizures

• Invega–May impair heat

regulation–May cause EPS– Tablet and core

components of tablet are insoluble, may appear in stool

– Should be swallowed whole

– Do not drink alcohol with this medication

Discharge Summary

• Patient behaviors indicating readiness for discharge

• Hospitalization goals met

• Discharge and continuity of care plan

Evaluation

• Evaluate effectiveness of goals/plans/interventions

• Course of treatment conditions

• Complications

• Lessons learned (if relevant)

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (text revision), Washington, DC: American Psychiatric Association

Major M. Pirozzi R, Formicola AM, et al.: Reliability and Validity of DSM-IV diagnostic category of schizoaffective disorder: preliminary data. S Affect Disord 2000, 57: 95-98.

Behavioral Health Program 15th FloorPresenting: Schizoaffective Disorder

Managing The Manic EpisodeDate: March __, 2011 - Time: 12pm – 1pm - Place: TBD

(CEUs are offered)