People Say I’m Crazy Homework Help

Watch the film and answer the questions under the People say I’m Crazy title. This is a Master’s of Social work graduate school level assignment so please make sure your writing reflects that degree of expertise. I will provide the link for the film and provide some additional written material from the module. Please cite the film within the body of the text and reference at the bottom.

People Say I’m Crazy
Please watch the video People Say I’m Crazy (located in the module).
Link:

http://digital.films.com.ezproxy.net.ucf.edu/PortalViewVideo.aspx?xtid=37647

Questions: What are the Micro, mezzo and macro issues facing John? On a micro, mezzo and macro level, what can we do as social workers to help people such as John?  Remember this is a meds class so your answers should be primarily focused on medications.

Module 6
Schizophrenia
General Information
•    Onset usually in teens or early adulthood and can be sudden or gradual. Some people will start to act a little “off” and gradually become full blown psychotic and others will be fine one day and psychotic the next.
•    Estimated that 2.2 million Americans have Schizophrenia (1.1% of population)
•    Very stable rate over 20 years
•    National and world wide distribution not equal- much more common in industrialized countries- likely due to stress and other environmental stuff.
•    It is genetic but not 100%
•
o    Single schizophrenic parent =10% offspring schizophrenic
o    Both schizophrenic = 45%
o    Monozygotic Twin = + 45%
•    Most disabling of adult psychiatric illness
•    Accounts for most psych bed admissions
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Delusions
Delusions are fixed false beliefs.  Assuming something, that there is some element of truth. Misinterpreted information.  They don’t hear voices but they misunderstand what is said.  But they believe what they think is true.  So in other words:  an individual seriously believes that there are people out to get them.  You have to be careful with this delusion though because in some cases there are people who are trying to put someone who is schizophrenic in an inpatient facility.
Types of delusions
•    Thought withdrawal-someone or something is taking the thoughts out of your head
•    Grandiosity- the belief that you are wonderful (if the president would just listen to me I know I could solve the national debt problem)
•    Persecutory- someone or thing is out to get you
•    Control- that you are being controlled by someone or you can control someone
•    Somatic- that there is something seriously wrong with you (aliens reside in your stomach)
•    Nihilistic- world is coming to an end
Hallucinations
Seeing, hearing, feeling…(you get the picture) something that is not really there. In paranoid schizophrenia the hallucinations and the delusions tend to be congruent, that is they go together.  If you have never seen A Beautiful Mind I highly recommend it. Great example of paranoid schizophrenia.
•    Auditory- most common.  Hear voices or noises that no one else does.
•    Visual- second most common.  See things that are not there.  Usually people.
•    Tactile-  feeling things that are not there,  creepy crawlies are the most common.  In a beautiful mind- John thought that he had microchips under his skin and he felt them
•
o    CASE EXAMPLE:  I had a client who was anally raped at the age of 5. She is now 23 and has schizophrenia.  The rape likely triggered the schizophrenia.  Not caused it necessarily, she likely had the predisposition to the disorder and the rape made it manifest.  It is unknown whether if she were not raped if she would still have the disorder.  ANYWAY- she believes that when she was raped, the mans semen was full of worms (not a far cry from the tadpole vision).  These worms have traveled through her body and have taken up residence in her brain (again, not as far fetched as it may seem- the brain does look like a bunch of worms).  She says that she can feel these worms moving in her head.  She often tries to get them out by sticking objects in her nose and ears.
•    Gustatory- feeling something is going on in your stomach,  may be aliens, worms….
•    Olfactory- often goes along with the gustatory,  they may feel that their stomach is rotting and they can actually smell it happening.
•    Kinesthetic- this is what happens to people when they have phantom leg syndrome after amputation.  There are also a number of people who feel that they have an extra limb.  It sounds bizarre I know, but there are people who feel that their legs do not belong where they are and they will actively seek amputation.  When they are refused they will try to get them off themselves.  Some have used dry ice, some train tracks…
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Symptoms of Psychotic Disorders
Disturbances in the form of thought refers to delusions. We talked  about the types already but it also refers to loose associations (their words and sentences make no sense), frequent derailment (getting off subject very easily), neologisms (made up words- we have all done this- it does not mean that you are psychotic), word salad (a bunch of words strung together that just do not mean anything).
Disturbances in affect refers to reduced emotional responsiveness, or flatness or inappropriate affect such as extremes.
Weakened ego boundaries refers to no real sense of where the patient begins and ends.  So you may have ideas of reference which is when someone see signs from the tv or the tv is making reference to them
They may think they are fused with an inanimate object or with the universe cosmic identity
Ambivalence- cannot make a decision, don’t care to make a decision.
Impaired volition- lack of or very little movement- or desire to move or do anything for that matter.
Agitation- This is both physically and cognitively.  They may be moving around a lot which is called psychomotor agitation. Or they may just be annoyed.
Poverty of speech content- could be lack of speech, they may have thought blocking in which the thoughts are just gone, therefore they may just stop speaking. This is different than losing your train of thought in the middle of the conversation and having to ask your friend what you were talking about.  In thought blocking they simply stop thinking.
Social Isolation: I am guessing you don’t need a definition here.  However, the reason for the isolation varies.  It could be because they don’t trust anyone (paranoia), it could be that no one will hang out with them because they are perceived as being weird, it could be that they simply prefer to be alone.
There are both positive and negative symptoms in schizophrenia.  By positive we do not mean good.  We mean acute or present (delusions and hallucinations are positive symptoms).  Negative symptoms are those in which something may be “missing”.  They typically appear over time (flat affect, alogia, impaired avolition…)
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The four A’s of schizophrenia
Keep in mind that not everyone has all of these symptoms.  Typically it is a mix and match deal.
Associations- typically loose associations both in terms of speech and with others
Autism- this is not in the clinical sense- it means the language issues, some rigidity…
Ambivalence- see above
Affective- meaning mood disturbances.  Typically a flat affect

Module 6
Schizophrenia and Antipsychotics

Learner Objectives
At the end of the module you will:
1.    Know the different classifications of antipsychotic medications
2.    Know the brand names and generic names of the antipsychotics
3.    Have a general understanding of the side effects of the antipsychotic medications
4.    Have a general understanding of the medications used to treat the side effects of the antipsychotic medications
5.    Have a general understanding of the drug interactions and risks of antipsychotics

1.    Chapter 4 in Bentley & Walsh
2.    Faulkner, G. & Cohn (2006). Pharmacologic and non pharmacologic strategies for weight gain and metabolic disturbance in patients treated with Antipsychotic medications. Canadian Journal of Psychiatry ,51(8), 502-511
3.    Bola, J. (2006). Psychosocial acute treatment in early-episode schizophrenia disorders. Research on Social Work Practice, 16(3), 263-275
4.    Turner, M. (2006). Review of the evidence for the long-term efficacy of atypical antipsychotic agents in the treatment of patients with schizophrenia. Journal of Psychopharmacology,20(6suppl), 20-37.
5.    Chue, P. (2006). The relationship between patient satisfaction and treatment outcomes in schizophrenia. Journal of Psychopharmacology,20(6suppl), 38-56.

Watch this
People Say I’m Crazy  http://ezproxy.net.ucf.edu/login?url=http://digital.films.com/PortalPlaylists.aspx?aid=1123&xtid=37647

Reflection Questions to Guide Reading
1.    Which of the medications would you be willing to take in terms of cost benefit analysis?
2.    What are the most severe side effects? Would you be able to deal with the side effects (say, drooling, TD)?
3.    How would you counsel a client regarding side effects of medications?
4.    Do all people with schizophrenia need to be on medications?
5.    On average, how many medications would a person with schizophrenia be required to take? Hint: it’s not just one.

General information
•    The first treatments for schizophrenia date back to the early 1800?s and include drugs like opium, bromide, chloral hydrate and barbiturates. These drugs were used to knock out violent clients, they did not treat the disorders. They were used often in state institutions and asylums
•    The first antipsychotic was Thorazine® (Chlorpromazine) was introduced in the 1950?s for mental health purposes
•
o    Is actually an antihistamine, well that is what is was used for. Can you imagine taking Thorazine® for hay fever???!! I guess your allergies wouldn’t bother you if you were out cold.
o    Also as an anesthetic, for pain and for shock.
o    And for controlling agitated behavior.
o    It was approved in march of 1954 for the treatment of nausea and vomiting and for use in neuropsychiatry.
•    Patients will vary greatly in their response to medications
•
o    research suggests that clients who receive both medications and counseling only experience partial relief.
o    research suggests that only 20% of all schizophrenics treated with medications receive optimal response.
o    30-50% are partial responders
•    Typically someone with a diagnosis of schizophrenia has comorbid conditions such as substance abuse or a mood disorder
•    Most antipsychotics have long half lives

First Generation (typical, older, antipsychotics)
Please see the following slides for a list of the some antipsychotics and dosing. Notice that some are much more potent than others. Example: Look at the dosing differences between Prolixin® and Thorazine®.

Phenothiazines
•    All drugs in this category share the same basic chemical structure.
•    The are the oldest, most prescribed and some of the cheapest.
•    Some have been used as anti-emetics (anti-vomiting). They act on dopamine-1 and dopamine-2 receptors.
•    Onset of therapeutic action is delayed for up to 6 weeks. Of course the side effects kick in almost immediately
Butrophenones
•    Developed in Europe in the 60?s
•    Structurally and functionally similar to the Phenothiazines and have many of the same negative side effects
•    Haldol® is the most potent of all neuroleptics
•    Acts on dopamine-2 receptors
•    Has some severe extrapyramidal side effects
•    Haldol® is also used for Tourette’s, severe behavioral disorders in children that is not explained by provocation ( I have some major issues with this usage, how about you?), short terms use for hyperactive children ( I have HUGE issues with this usage)
Thioxanthenes
Very potent
•    Similar to phenothiazines in terms of the chemical structure and the effects
•    Moban® has the least amount of sedation, meaning you may be able to stay semi conscious

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Second Generation and Newer Antipsychotics
•    Effective without the same level of risk of neuroleptic syndrome (some disagree) and they are effective in treating the negative symptoms associated with schizophrenia
•    The are less likely to cause EPS symptoms (movement issues)
•    Improve negative symptoms (flat affect, decreased motivation, speech poverty, social withdrawal)
•    They are said to have (some disagree) fewer anticholinergic effects (dry mouth, blurred vision, constipation, fun stuff
Risperdal® (Risperidone).
•    Was approved in 1993. How it works no one fully understands. It is thought to impact serotonin and dopamine systems in the brain.
•    Side effects include: sleeplessness, nervousness, agitation (any red flags here?), headaches, constipation and nausea.
•    Can impair judgment- avoid heavy machinery- no tractor pulls!
•    Can cause photosensitivity- wear sunscreen
•    Avoid alcohol. This is a tough one. Many people with schizophrenia self medicate with booze.
Zyprexa® (Olanzapine)
•    Again not understood but has something to do with serotonin and dopamine binding.
•    Side effects include: headaches, dizziness, decrease in blood pressure (hypotension), sleeplessness, nervousness, restlessness, agitation, anxiety and hostility (kind of makes you wonder WHY this is prescribed for people with these exact symptoms)
•    Occurrence of other unwanted effects are dose related. These include tremor, rigid muscles and weakness.
•    Tiredness and constipation typically go away with time, but not always
•    Weight gain is a side effect of all antipsychotics and as dose increases so does weight gain.
•    Again tractor riding is not advisable
•    Alcohol should be avoided
Seroquel® (quetiapine fumarate)
•    Introduced fall 1997
•    Again, mechanism is unknown but serotonin and dopamine have something to do with it
•    Common side effects: dizziness, drowsiness, EPS have been noted
•    Less weight gain than the others
•    My be particularly effective with aggression
•    Has been shown to be effective among clients with depression and bipolar disorders

Abilify®
•    For treatment of schizophrenia and adjuctive treatment of depression (Please excuse the italics, I cannot seem to make them go away).
•    Also approved for irritability in kids with autistic disorder
•    Black box warning for older adults with dementia
•    Common side effects:
•    Commonly observed adverse reactions (incidence >/= 5% and at least twice that for placebo) were (6.2):
o    Adult patients with schizophrenia: akathisia
o    Pediatric patients (13 to 17 years) with schizophrenia: extrapyramidal disorder, somnolence, and tremor
o    Adult patients (monotherapy) with bipolar mania:akathisia, sedation, restlessness, tremor, and extrapyramidal disorder
o    Adult patients (adjunctive therapy with lithium or valproate) with bipolar mania: akathisia, insomnia, and extrapyramidal disorder
o    Pediatric patients (10 to 17 years) with bipolar mania:somnolence, extrapyramidal disorder, fatigue, nausea, akathisia, blurred vision, salivary hypersecretion, and dizziness
o    Adult patients with major depressive disorder (adjunctive treatment to anti-depressant therapy): akathisia, restlessness, insomnia, constipation, fatigue, and blurred vision
o    Pediatric patients (6 to 17 years) with autistic disorder:sedation, fatigue, vomiting, somnolence, tremor, pyrexia, drooling, decreased appetite, salivary hypersecretion, extrapyramidal disorder, and lethargy
o    Adult patients with agitation associated with schizophrenia or bipolar mania: nausea  (PDR, 2012)

Clozaril® (Clozapine)
•    Used only with non responders to the other meds
•    Acts on dopamine-1 and serotonin receptors.
•    Lots of anticholinergic side effects
•    WEIGHT GAIN- I don’t just mean 10 or 20 lbs. I am talking up to 100 lbs!
•    Weekly blood tests are critical to assess for agranulocytosis- a fatal adverse effect in which the bone marrow is unable to produce white blood cells.
•    Very expensive drug (4k annually)
•    With the blood tests- it is even more expensive. Insurance companies will rarely cover the weekly blood tests as it is seen as being preventative. Uh yeah preventing death!
•    Higher risk of seizures

Something that you need to be aware of is that there are medications and illicit drugs that can alter the functioning of the central nervous system (CNS). There are three categories of such drugs
1.    Therapeutic agents that have legitimate uses but have the potential for abuse
2.    Drugs that have no medical use but are very popular in society (caffeine, alcohol, tobacco, marijuana and hallucinogens)
3.    Drugs that are valued for medicinal benefits but produce psychiatric side effects (cardiac meds, sedatives, stimulants and steroids)
The problem with most medications and drugs is that you cannot just specify where the drug is supposed to go. For example, corticosteroids for asthma. The purpose is to open airways and make it easier to breathe. But at the same time you can’t sleep, get very hungry, have a ton of energy, if taking long enough you retain water. They can also cause psychosis including paranoia, hallucinations, mood swings (you’ve likely heard of “roid rages”). The good news is, the symptoms go away when the medication is stopped. With anabolic steroids (the ones often used by body builders) however, can cause acne, nausea, vomiting, jaundice. For women you may see cessation of menstruation, deep voice, male pattern baldness (yes, in women). Men may grow bigger breasts (yes in men). Psychosis, mania, depression, and excitation are also possible.

Audio slides are below.  Some of the information is redundant but redundancy is helpful for learning!