Transcript Slide 1

The development of this learning module was made possible
through a Gero Innovations Grant from the CSWE Gero-Ed
Center’s Master’s Advanced Curriculum (MAC) Project and the
John A. Hartford Foundation.
Psychotic Disorders
And Older Adults
Funded by Master’s Advanced Curriculum
Project Grant
University of Texas at Arlington
Shared Features of the Psychotic Disorders
DSM Class
 These disorders constitute a significant
distortion in the perception of reality with
recurrent, episodic, or persistent features
(DSM-IV-TR, p.)
 The disorders are characterized by positive
symptoms (characterizing onset or relapse
and including hallucinations, delusions,
and/or thought disorder) and negative
symptoms (absence/loss of drive,
motivation, emotion, self-care, and other
executive functions)
Shared features, cont.
 Impairment in capacity to reason,
speak, behave rationally or
spontaneously
 Impairment in capacity to respond
spontaneously with appropriate affect
and motivation
Prevalence and Incidence
 National Comorbidity Study (1990’s) found a lifetime
prevalence of 2.8% for schizophrenia/schizophreniform
disorders; Epidemiologic Catchment Area Study (1980’s)
found prevalence of 0.3% for schizophrenia among persons
over 65
 DSM-IV-TR (2000) reports lifetime prevalence of 0.5%-1.5%
and annual incidence of 0.5-5 per 10,000 for schizophrenia,
population prevalence of 0.03% and lifetime prevalence of
.05-.1% for Delusional Disorder; psychotic symptoms.
present in 15-40% of persons with certain medical conditions.
 Clinical Evidence/BMJ (2004) reports lifetime prevalence of
1% and worldwide prevalence of 2-4 per 1000 for
schizophrenia
 The World Health Organization identified mental illnesses as
the leading cause of disability worldwide, accounting for
nearly 25 percent of all disability across major industrialized
countries. In the United States, mental illnesses are on a par
with cancer and heart disease as a cause of disability.
Psychotic Disorders
 Schizophrenia
295.xx
 Schizophreniform Disorder
295.40
 Schizoaffective Disorder
295.70
 Delusional Disorder
297.1
 Brief Psychotic Disorder
298.8
 Shared Psychotic Disorder
297.3
 PD due to GMC
293.xx
 Subs-induced PD
Subs use code
 Psychotic Disorder NOS
298.9
Schizophrenia Subtypes
 Paranoid Type
295.30
 Disorganized Type
295.10
 Catatonic Type
295.20
 Undifferentiated Type
295.90
 Residual Type
295.60
DSM-IV-TR, p.303
Schizoaffective Disorder
Subtypes
 Bipolar Type
 Depressive Type
Delusional Disorder Subtypes
 Erotomanic
 Grandiose
 Jealous
 Persecutory
 Somatic
 Mixed
 Unspecified
Psychotic Disorders due to a GMC
and Substance-Induced Subtypes
 With Delusions
 With Hallucinations
Specifiers
 Critical to understanding the disorder in
the individual patient in order to plan
treatment
 Describe most recent episode/course
 Uncoded narrative statements for some
 Characterize severity, chronicity (most
recent and recurrent), longitudinal
course, special features
DSM-IV-TR, pp.
Specifiers after 1 Year from Active
Phase Onset Schizophrenia
 Episodic with Interepisode Residual symptoms
 Episode with No Interepisode Residual symptoms
 Continuous
 Single Episode in Partial Remission
 Single Episode in Full Remission
 Other or Unspecified Pattern
 With Prominent Negative Symptoms can be
added
Specifiers for Other Psychotic
Disorders
 Schizophreniform Disorder:
 With Good Prognostic Features
 Without Good Prognostic Features
 Brief Psychotic Disorder
 With Marked Stressor(s)
 Without Marked Stressor(s)
 With Postpartum Onset
 Substance-Induced Psychotic Disorder
 With Onset During Intoxication
 With Onset During Withdrawal
GMC and Substance-induced
Psychotic Disorders
 Psychotic disorders due to direct
physiological effects of a general
medical condition: list the condition
and include subtypes/features
 Substance-induced psychotic disorders
are coded by type of substance with
subtypes/features and substance use
context of onset (DSM-IV-TR, p.338)
Psychotic Disorder NOS
 Include conditions discussed in the
“Further Study” section, Appendix B.
 Such as postpsychotic depressive
disorder of schizophrenia, simple
deteriorative disorder (simple
Schizophrenia), and alternative
dimensional descriptors for
Schizophrenia which do not meet
criteria.
Differential Diagnosis
 In specifying the clinical condition, first
consider and rule out conditions in other
categories, such as Mood Disorders with
Psychotic Features.
 Then screen for and distinguish this person’s
symptoms from those for other disorders in
the same Psychotic Disorder class, while
being sure to consider the following
 R/O Cultural Influences, including culturally
sanctioned bereavement behaviors and
religious/spiritual experiences
 R/O Age-Appropriate Behaviors (e.g., Body
Dysmorphic Disorder and Delusional Disorder,
Somatic Type vs. teen negative preoccupation
with body vs. eating disorder)
Differential Diagnosis from
Other Categories
 R/O General Medical Conditions leading
to Psychotic Disorder as a physiological
consequence (e.g., 1st delusions>35 yrs. and
visual/olfactory hallucinations rather than complex
auditory)→MMSE to assess delirium/dementia
 R/O Substance-induced Psychotic
Disorder
 R/O Mood Disorder with Psychotic
Features
 R/O related Personality Disorders
(Schizotypal, Paranoid, Schizoid,
Avoidant)
What Does Schizophrenia
Look Like?
PRE-ACUTE
PHASE
ACUTE PHASE
RESIDUAL
PHASE
Schizophrenia (cont.)
 Continuous Symptoms ≥ 6 mos.
 Pre-acute (prodromal) and residual phases: only

negative symptoms or 1-2 weaker positive
symptoms.
Acute or active phase: at least 1 month (or less if
successfully treated) characterized by 2 or more
of these symptoms (only 1 symptoms if #1 bizarre
or #2 constant/>1 voice conversing).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative Symptoms
What Does It Look Like?
Schizophrenia Gender Differences
 Modal age at onset 18-25 yrs. for men, 25mid-30’s and after 40 for women
 Slightly higher incidence for men, prevalence
for women
 Women have better short to medium term
prognosis
 Men experience more negative symptoms.
 Women have more hallucinations, paranoid
delusions, affective symptoms.
What Does It Look Like?
Schizophrenia Age Differences
 Early onset (child): More likely symptoms visual
hallucinations rather than delusions; diagnosis
as young as 5-6 yrs. Onset prior to adolescence
is rare.
 Late onset (>40) more common among
women.
Power, A.K. Retrieved from:
www.mentalhealth.samhsa.gov/newsroom/speec
hes/042507.asp
(Cont.)
What Does It Look Like? Schizophrenia
Age Differences (cont.)
 Predictors of violence are younger age, male, past
history, no meds, excessive substance use; most no
more violent/danger to others than general population.
An old myth suggests that individuals with mental
illnesses are violent. In actuality, clients are more apt to
be the victims than the perpetrators of crime.
 The life expectancy for individuals with serious mental
illnesses is 25 years fewer than the general population.
People with mental illnesses die at higher rates because
of chronic, untreated, physical diseases. They die from
high blood pressure, stroke, diabetes, heart disease,
and the consequences of smoking and substance use.
Power, A.K. Retrieved from:
www.mentalhealth.samhsa.gov/newsroom/
speeches/042507.asp
What Does It Look Like?
Schizophrenia Family Patterns
 Rates among relatives higher for women with
schizophrenia.
 Rates among relatives of schizotypal/schizoid
personality traits higher for men with
schizophrenia.
 Relatives have higher risk for schizophrenia
spectrum disorders.
 1st degree biological relatives have risk for
schizophrenia 10x higher than general
population.
 Prognosis better for persons with schizophrenia
when their relatives have mood disorder rather
than schizophrenia.

Evidence-based Treatments For
Schizophrenia in Adults, including
Elderly
Beneficial:
1. Continuation antipsychotic rx 6-9 mos. after
acute episode (reduces relapse); for elderly,
doses must be titrated gradually, with lower
start doses, due to age-related changes in liver
and metabolism of drugs.
2.
Multiple session family interventions (reduces
relapse); may be differences by ethnicity on
parental disappointment and role expectations
of parents for ill offspring following relapse
3.
Psychoeducational interventions (reduces
relapse)
Nadeem,Z., McIntosh, A., & Lawrie, S. (2004). Schizophrenia. Clinical Evidence Mental Health, 11,
224-253.
Pickett, S., Cook, J., & Cohler, B. (1994). Caregiving burden experienced by parents of offspring with
severe mental illness: The impact of off-timedness. The Journal of Applied Social Sciences, 18,
199-207.
Additional Psychosocial
Treatments For Schizophrenia in
Adults
 Also likely to be beneficial:
1.
Behavioral therapy, either group or individual
(to improve treatment adherence)
2.
Compliance therapy (to improve treatment
adherence)
3.
Psychoeducational interventions (to improve
treatment adherence)
4.
RCTs indicated behavioral may be more
effective than psychoeducational for improving
medication taking
Nadeem,Z.,McIntosh,A., & Lawrie, S. (2004). Schizophrenia. Clinical Evidence Mental Health, (11),
224-253.
Life Course Issues to Consider
in Psychosocial Treatment
 Studies of aging suggest that the old-old may cope
in part with losses and diminished physical
capacity by the following strategies to maintain
continuity of self, which were found to associate
with increased mastery and decrease in excessive
disability:
1.
Magical coping
2.
Religiosity
3.
Aggressiveness (determined nastiness)
4.
Functional paranoia
Bengtson, V.L. (Ed.). (1996). Adulthood and aging: Research on continuities and discontinuities. New York:
Springer Publishing Company, Inc., pp. 144 and 69-98.
Life Course Issues, cont.
 Persons who cope more successfully with SPMI
as they age, including the psychotic disorders,
may develop these coping strategies earlier in
life, since they must cope with the losses
associated with aging at an earlier point in their
life trajectory
 Thus, symptoms clinicians have termed
“resistance” and “entitlement” could be
reinterpreted as strengths in coping, and could
continue to be channeled and supported as
persons age
 Solution-focused and empowerment theory-
based strategies could be useful in this approach
Evidence-based Treatments
For Schizophrenia in Adults
 May be beneficial for treatment-resistant cases:
Clozaril (Clozapine) and Zyprexa (Olanzapine)
when non-responsive to standard antipsychotics. Clozaril may be particularly
effective in alleviating negative symptoms.
 Note trade-off of benefits and harms for these
atypical antipsychotic medicines for the elderly
(next slide), which includes findings of only
study to date including both Clozaril and
Zyprexa among the atypicals studied.
Nadeem,Z.,McIntosh,A., & Lawrie, S. (2004). Schizophrenia. Clinical Evidence Mental Health,
(11), 224-253.

Evidence-based Treatments for
Schizophrenia in Adults, including the
Elderly
Trade off between benefits and harms:
1. Atypical antipsychotics often have fewer side
effects, but may be due to dose differences; no
strong evidence that they are more effective than
standard rx at standard doses; in other words,
they may be given at lower doses and so fail to
control symptoms as well as the older rx
2. Recent studies suggest that start-up of either
conventional or atypical antipsychotics is
associated with increased risk of death among the
elderly.
3. All the antipsychotics have serious side effects, so
must be monitored re the balance between risks
and improved functioning, and client/family must
be assisted in making an informed decision re
risks; potential adherence must also be taken into
account
Schneeweiss,S., Setoguchi, S. Brookhart, A., Dormuth, C., & Wang, P.S. (2007). Risk of death
associated with the use of conventional versus atypical antipsychotic drugs among elderly
patients. Canadian Medical Association Journal, 176, 627-632.
Evidence-based Treatments For
Dual Diagnoses in Adults
 For co-occurring psychotic disorder and
substance abuse:
1. Integrated mh and sa long-term residential
more effective for those who have failed IOP
2. Integrated outpatient treatment services are
more effective, especially when
individualized to specific personal factors and
stage of change or motivation
Drake, R.E., et al. (2004). A review of treatments for people with severe
mental illnesses and co-occurring substance use disorders. Psychiatric
Rehabilitation Journal, 27, 360-374.
Dual Diagnosis Website: http://users.erols.com/ksciacca/
Psychosocial Rehabilitation
 Psychosocial rehabilitation programs (PRPs) aim to
facilitate and collaborate with clients with SPMI acting
on their own behalf to live as independently and as
integrated as possible in the community while
managing the symptoms of their illness.
 Networks of community PRP services/models include
residential rehabilitation programs (RRPs), supported
employment, supported education,
assertive/intensive case management, assertive
community treatment and mobile treatment, and
consumer-run clubhouses/drop-in centers.
 PRPs usually sponsor day programs, which may
combine elements of each of the above, or may be
more recreational and peer support-oriented; for the
elderly, PRPs may consult, coordinate, or purchase
care from adult day care centers which serve
younger adults and elderly with multiple diagnoses.
Life-stage Issues in Psychosocial
Rehabilitation
 At typical age of onset, ADL, social, and
vocational rehabilitation issues are primary, as
well as establishing beneficial treatment
regimens.
 Continued attention needed to formal service
provision of support groups/networks through
PRPs and adult day care centers.
 Focus on postponement of nursing home
placement to keep in community as long as
possible.
Life-stage Issues, cont.
 Small population of elderly with schizophrenia
 As age ↑ positive symptoms ↓
 Majority continue to experience negative symptoms,
cognitive deficits, depression, medication side effects,
and co-morbid health problems.
 For elderly who have had a life-long course of
schizophrenia, typical retirement issues may not apply,
so addressing leisure/recreational activities is primary,
with continued focus on ADL and treatment adherence.
 ↑ satisfaction with leisure activities may moderate the
association between negative symptoms, depression,
and other QOL indicators.
Karim, S., Overshott, R., and Burns, A. (2005). Older people with schizophrenia. Aging & Mental
Health, 9, 315-324.
Mausbach, B.T., Cardenas, V., Goldman, S.R., Patterson, T.L. (2007). Symptoms of psychosis and
depression in middle-aged and older adults with psychotic disorders: The role of activity
satisfaction. Aging & Mental Health, 11, 339-345.
Issues for Caregivers of Aging
Parents with Psychotic Disorders
 Likely to be an increasing cohort of Baby Boomers
with schizophrenia and other SPMI who are aging
over the next few decades.
 Society is unprepared due to previous history of
poor survival rates of persons with psychotic
disorders and deinstitutionalization; siblings and
adult children of persons with psychotic disorders
are increasingly involved.
 To prevent premature institutionalization of this
population, barriers to care must be addressed.
Hatfield, A. (1999). Barriers to serving older adults with a psychiatric disability. Psychiatric
Rehabilitation Journal, 22, 270-276.
Issues for Caregivers of Aging Parents
with Psychotic Disorders (cont.)
 Adult children, usually daughters, are the most common
caregivers of the elderly and need help to meet
competing demands of their spouses and children;
spouses and siblings of the patient are most likely same
generation, so have aging issues of their own to
address.
 Adult day care which serves elderly with dementia may
also serve middle-aged and elderly with SPMI, thus
allowing prolonged community-based care.
 Specific burden issues of particular life stage of
caregiver must be addressed to avoid premature
nursing home care/assisted living placement of older
adults with psychotic disorders (respite care, adult day
care, self-help groups, multifamily therapy and
psychoeducational groups).
Hatfield, A. (1999). Barriers to serving older adults with a psychiatric disability. Psychiatric
Rehabilitation Journal, 22, 270-276.
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