Embed Size (px)
Citation preview
The The Schizophrenic Schizophrenic
PatientPatientA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPADecember 16, 2011December 16, 2011
1My aim is to offer practical insights you can put to use.2Please let me know whether I have succeeded when you complete your evaluation form.
Why is this important?
• After listening to this presentation, you will be able to answer the following questions:
– Why is this important?– How do these patients
present?– What are the diagnostic
criteria?– What is the differential
diagnosis?– What is the treatment?– What are some of the
treatment challenges?
1This is the cancer of mental illness.2The families are the experts; you are at best a caring and knowledgeable consultant.
• About 1 in 100 people will develop this devastating disorder in their lifetime.1,2
• Schizophrenia is found in every society and in every country.
• It is best thought of a group of disorders with
– Unknown cause,– Similar presentation,– Bizarre behavior,– Hallucinations,– Delusions, and– Deterioration in overall
functioning• You can view a brief
documentary here.
How should you behave while caring for these patients?
• Adopt a quiet, calm demeanor.• Isolate your own
emotional arousal.• Avoid perceived intrusion.• Observe carefully.• Listen intently.• Know the diagnostic criteria.• Ask brief clarifying questions.• Avoid painful exploration.• Review available records.• Engage the patient’s family and
social support network.• Consider the differential
diagnoses.
• Convey understanding, confidence and intent to help.
• Recommend the most appropriate medications.
• Explain most common side effects briefly.
• Explain treatment plan briefly.• Invite questions.• Begin educating the family
about what to expect.• Arrange for social support.• Communicate with
stakeholders.• Arrange for follow up.
1Begin with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary.2The only behaviors you can really control are your own!
How to schizophrenic patients typically present?
• The patient is 22 years old.• He is withdrawn and hesitant
to talk.• He was brought in for
evaluation “against my will.”• The history is obtained
primarily from his parents.1,2
• “During his senor year of college he became more and more convinced that his roommates were making fun of him.”
• “He observed that they would cough, sneeze or look away when he came into the room.”
• “When his girlfriend broke it off with him, he decided that she had been replaced with a look-alike.”
• “He called the police to report her kidnapping.”
• “He stopped going to class because he believed that the professors were taking thoughts out of his mind.”
• “He stopping showering and shaving.”
• “He thought someone was putting something in his food and he lost weight.”
• “We just can’t reason with him.”
1When families are involved, I obtain the patient’s consent and view myself as their consultant.2One of my patient’s elderly mother comes in with her son every time.
What other diagnoses are included in this category?
• Schizophrenia (lasts at least 6 months)• Schizophreniform Disorder (lasts 1-6 months)• Schizoaffective Disorder (includes mood
episode)• Delusional Disorder (delusions without other
symptoms of schizophrenia)• Brief Psychotic Disorder (1-30 days)• Shared Psychotic Disorder (shared delusional
system)1,2
• Psychotic Disorder due to a General Medical Disorder (GMD)
• Substance-Induced Psychotic Disorder• Psychotic Disorder Not Otherwise Specified
(NOS)
1This is fairly uncommon.2I was surprised by a patient with anorexia nervosa.
What are the diagnostic criteria?
• Two of more of the following:
– Delusions– Hallucinations– Disorganized speech– Grossly disorganized or
catatonic behavior– Negative symptoms such as
affective flattening, alogia1,2 or absence of volition
• Social or occupational dysfunction
• Continuous symptoms for 6 months
• Schizoaffective and Mood Disorder have been ruled out
• Substance Disorder or an underlying General Medical Disorder has been ruled out.
1This is a common symptom in hospitals—and now—prisons.2A mute patient suddenly told me about Rapid City, SD.
What are some the associated features?
• Inappropriate affect (smiling, giggling or weird facial expressions)
• Loss of interest or pleasure• Dysphoric mood• Sleep disturbances• Abnormal psychomotor
behavior• Diminished concentration,
memory and attention• 80-90% of these patients
smoke• Comorbid mental disorders
• Poor insight• Noncompliance • Somatic concerns• Motor abnormalities• Decreased life expectancy• Increased risk for suicide• Higher incidence of assault and
violence among males, younger age, people with prior history of violence and noncompliant patients1,2
1Eminent violence is very hard to predict in these patients.2A patient nearly killed a patient who had attacked a fellow psychiatrist.
What are some of the differential diagnoses?1,2
• Psychosis due to a General Medical Condition
• Delirium• Dementia• Schizotypal, Schizoid and
Paranoid Personality Disorders• Substance-Induced Psychotic
Disorder• Substance-Induced Delirium• Substance-Induced Dementia
• Substance-Related Disorders• Mood Disorder with Psychotic
Features• Schizoaffective Disorder• Depressive Disorder Not
Otherwise Specified (NOS)• Bipolar Disorder NOS• Delusional Disorder• Pervasive Developmental Disor
ders
1At a moment in time, this can be a very difficult diagnosis to make.2The diagnosis becomes increasingly clear over time.
What interventions should be included in the treatment plan?
• Combination treatment– Biological– Psychological– Social
• Biological– Typical antipsychotics
• Phenothiazines• Haloperidol
– Atypical antipsychotics1
• Clozapine• Risperidone• Olanzapine• Quetiapine
• Psychological– Prevent harm– Minimize stress– Minimize risk of relapse
• Social– Social support– Good alliance with patient
and the family
1These are now usually the psychiatrist’s initial choices.
What prescriptions guidelines should you consider?
• Stage 1 Olanzapine, quetiapine or resperidone• Stage 2 Switch to another atypical agent; for
noncompliant patients use decanoate preparations
• Stage 3 Switch to a third atypical antipsychotic• Stage 4 Switch to a typical antipsychotic• Stage 5 Use clozapine• Stage 5a Augment clozapine• Stage 6 Augment with additional drugs and or
ECT.1Chiles, et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,”Psychiatric Services, January 1999, Vol 40 No. 1
What treatment challenges can you expect?
• These patients have a hard time building and sustaining a therapeutic relationship.
• Families often burn out and opt out.
• Noncompliance is a constant challenge.
• Maintaining hope is not always easy.
• Setting realistic expectations is difficult.
• These patients are often desperately poor.1
• The medications often seem to cause more harm than benefit.
1One of my patients brought one card from his collection to each visit as a gift to my sons.
What have you learned?
• The first descriptions of schizophrenia date back to 1400 BC.• Schizophrenia is currently viewed as a devastating group of disorders
that involve– Deterioration from a previous level of functioning,– Characteristic symptoms involving multiple mental processes,– Typical psychotic symptoms during the active phases of the illness, and– A demoralizing, chronic course.
• Onset usually is in the patient’s teens and 20s.• The treatment challenges are daunting.• Antipsychotic medications are helpful but not dramatically so, and
side effects are real problems in themselves.• Only clozapine stands out;1 the rest differ only in expense and side
effects.• Multi-modal intervention is the key to maximizing recovery and
preventing relapse.
1Lieberman, et. al., “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia,” The New England Journal of Medicine, September 22, 2005, Volume 353;1209-1223 (CATIE)
The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some
routine demographic questions.• Ask me to list all of problems and concerns.• Using my problem list as a guide, ask me
clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status
examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment
plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate
educational resources.• Invite me to call you with any additional
questions I may have.• Make a follow up appointment.• Communicate with my other physicians.
1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Where can you learn more?
• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000
• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008
• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.
• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005
• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008• Medina, John,
Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008
• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Where can you find evidence-based information about mental disorders?
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.
• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center
Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.
1805 27th Street1805 27th StreetWaller BuildingWaller Building
Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662
740.356.8153740.356.8153
[email protected] [email protected] [email protected]@yahoo.com
www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com
1Speaking and consultation fees benefit the SOMC Endowment Fund.
SafetySafety QualityQuality ServiceService RelationshipsRelationships Performance Performance
Are there other questions?
Sarah Porter, DOSarah Porter, DO
Phillip Roberts, DOPhillip Roberts, DO
