An die Therapie der Schizophrenie werden aufgrund des beschriebenen multikausalen Krankheitsverständnisses einige Ansprüche gestellt. Sie sei im Folgenden skizziert:
- Grundlage jeder Schizophrenie-Behandlung sollte eine moderne Therapie mit Psychopharmaka sein. Die zum Einsatz kommenden, antipsychotischen Medikamenten heissen Neuroleptika
- Eine supportive (=stützende), psychodynamisch orientierte (aber nicht aufdeckend-psychoanalytische) Psychotherapie bildet den zweiten Pfeiler der Behandlung
- Psychopharmako-Therapie, Psychotherapie und Soziotherapie sollten zu einer Einheit verbunden werden (Multidimensionalität der Behandlung)
Leitlinien der Psychopharmako-Therapie mit Neuroleptika
- Klassische Neuroleptika haben im Akutbereich nach wie vor ihre wichtige Bedeutung
- Atypische Neuroleptika haben aber einen positiven Einfluss auf
- Prognose
- Soziale Integration und Lebensqualität, weswegen sie, wenn immer möglich vorzuziehen sind –> Compliance-Verbesserung!!!
- Statt der Kombination von koch- und niederpotentem Neuroleptikum sollte, ausser bei Suchtpatienten die Kombination eines hochpotenten N. mit einem Benzodiazepin wenn möglich vorgezogen werden.
- Wechsel des Neuroleptikums erst nach vergeblicher Auftittrierung und Therapieversagen von 4 – 6 Wochen!
- Bei Therapierefraktärität unbedingt Versuch mit Clozapin!
- Akutbehandlung:
- Hochakute Psychose:
- Hoch- oder mittelpotentes N., z.B. 5 – 10mg Haldol, ggf. kombiniert mit 100mg Nozinan, oder Clopixol (Zuclopenthixol) (Ciatyl-Z) 75 – 150mg als Acuphase i.m. oder oral 20-40mg
- Merke: bei unklarem Erregungszustand und fraglicher Intoxikation immer Haldol nehmen!
- Katatoner Stupor:
- Neuroleptika und Benzodiazepine (Lorazepam)
- Bei Therapieresistenz: frühzeitig EKT!
- Perniziöse Katatonie:
- Sofortiges Absetzen des Neurolepikums
- Hochakute Psychose:
- Erhaltungstherapie (mindestens 6 Monate empfohlen):
- Erhaltungsdosierung
- Spätestens jetzt Umstellungsversuch auf atypisches N.!
- Bei wiederholten Rezidiven sollte die Erhaltungstherapie über mindestens 2 – 3 Jahre fortgesetzt werden.
- Langzeittherapie:
- Besondere Beachtung des Risikos von Spätdyskinesien
- Verwendung atypischer N. wenn möglich
- Symptomsuppressive Dauerbehandlung bei chronisch-produktiven Psychosen mit Neuroleptika
- Postpsychotische Depression ist einer medikamentösen Therapie zugänglich
- Wenn möglich Reduktion der Neuroleptikadosis
- Ggf. Antidepressiva
- Bei V.a. akinetische Depression im Rahmen eines Parkinsonoids Gabe von Biperiden
Nebenwirkungen der Neuroleptika
Die Pharmako-Therapie der Schizophrenie und der Psychosen ist wirkungsvoll, aber auch reich an unerwünschten Nebenwirkungen.
Hier sind an erster Stelle zu erwähnen die „Bewegungsstörungen“ (Fachbegriff: Extrapyramidale Störungen (EPS) oder Dyskinesien). Sie entstehen durch die Blockade von Dopamin-D2-Rezeptoren in einem Hirnbezirk, der eigentlich nicht von der Medikation erreicht werden soll, leider aber trotzdem betroffen wird. Inzwischen gibt es aber neuere Neuroleptika, sogenannte atypische Neuroleptika oder kurz: Atypika, die überhaupt keine oder nur sehr geringe, zumeist dosisabhängige Bewegungsstörungen auslösen. Sie sollten in jedem Fall, wenn nicht zwingende Gründe (z.B. Kontraindikationen, komplizierte Akutsituation etc.) dagegen sprechen als Mittel der ersten Wahl eingesetzt werden.
Extrapyramidale Störungen (EPS) und Spätdyskinesien
EPS äussern sich wie folgt:
- Akathisie (Unvermögen, ruhig zu sitzen, Trippelmotorik)
- Parkinsonoid (Tremor, Rigor, Akinese)
- Dystonie (kurz anhaltende oder auch fixierte abnorme Körperhaltungen, v.a. im Mundbereich, an den Augen, Hals und Rücken)
- Dyskinesie (unwillkürliche hyperkinetische Bewegungen, meist im Mundbereich, oft leichte Bewegungen an Fingern, Armen, Zehen oder Beinen)
- Frühdyskinesien (meist in der 1. Behandlungswoche)
- Spätdyskinesien (nach längerer N.-Therapie)
Spätdyskinesien treten in bis zu 20% der Langzeitbehandelten Patienten mit klassischen N. auf, selten nach Langzeitbehandlung mit Atypika!
Eine weitere, häufige und in der Bedeutung für den Patienten immer noch häufig unterschätzte Nebenwirkung vieler Neuroleptika
Gewichtszunahme unter N.-Therapie
Andere NW von Neuroleptika in Abhängigkeit von deren individuellem Wirk-Profil:
- Anticholinerg (z.B. Mundtrockenheit, Akkomodationsstlörungen, Obstipation, Herzrasen, niedriger Blutdruck, Glaukom, Harnträufeln bei vorbestehender Prostatavergrösserung)
- Antihistaminerg (Müdigkeit, Gewichtszunahme)
- antiadrenerg (Müdigkeit)
Psychotherapie der Schizophrenie
Akutphase
Als geeignete Psychotherapie der Schizophrenie kann, von Ausnahmen abgesehen, eigentlich nur die „supportive“, d.h. stützende Psychotherapie empfohlen werden. Im Zentrum dieser Therapieform steht das „verstehende, einfühlende Gespräch“, es geht vorrangig um die Etablierung einer stabilen, vertrauensvollen, tragfähigen therapeutischen Beziehung, die erst die Grundlage für jede spezifische Therapie darstellt. Ferner geht es v.a. in der Akutphase um die Vermittlung von Mut und Hoffnung, soweit dies angebracht ist, sowie um die Vermittlung eines für den Patienten verständlichen und auch akzeptablen Krankheitsmodells. Wo nötig und möglich erfolgt Beratung. So wird den Erkrankten und den Angehörigen z.B. davon abgeraten, während der Krankheitsphase wichtige Entscheidungen zu treffen. Überhaupt werden Angehörige soweit es der Patient gestattet in die Behandlung miteinbezogen und gut über die Erkrankung informiert (Psychoedukation)
Langzeitverlauf
Im weiteren Behandlungsverlauf, v.a. in der Rehabilitationsphase, wird von Seiten des Therapeuten darauf geachtet, dass der erkrankte Patient weder zu vielen, noch zu wenig stimulierenden Reizen ausgesetzt ist, um sowohl eine Über- wie auch eine Unterforderung zu vermeiden. Psychodynamische Ansätze werden neben verhaltenstherapeutischen Strategien in einem integrativen Therapieansatz vereint und schaffen günstigenfalls die richtige Mischung von verständnisvollem Klima und Tagesstrukturierung verbunden mit einem Training der sozialen Kompetenz .
An speziellen therapeutischen Konzepten kommen v.a. Programme zur Familientherapie zum Einsatz, die auf dem High-EE-Konzept basieren. Die allmähliche Beherrschung bzw. Neutralisierung von High Expressed Emotions in Familien schizophrener Patienten hat sich als besonders effektiv hinsichtlich der Verhütung von Rezidiven (erneuten Krankheitsausbrüchen) erwiesen.
Nicht oder nur in Ausnahmefällen zu empfehlen sind dagegen psychoanalytische oder systemische Familientherapie. Psychoanalyse scheint den Langzeitverlauf von Schizophrenien kaum wesentlich zu beeinflussen. Überforderung ist dagegen häufig!
Neuere verhaltenstherapeutische Ansätze sind für den Langzeitverlauf noch nicht ausreichend evaluiert. Einen positiven Effekt haben aber spezielle Trainingsprogramme zur Förderung der Kognitionen. Das gezielte Trainieren kognitiver Basisfunktionen, z.B. mit Computerprogrammen kann daher empfohlen werden.
Sinnvoll sind zudem Programme zur Stressbewältigung.
Soziotherapie der Schizophrenie
Das Ziel der Soziotherapie ist die Förderung sozialer Fähigkeiten (soziale Kompetenz) und Verhinderung von Defiziten.
- Komponenten:
- Arbeits- und Beschäftigungstherapie
- Berufliche Rehabilitation
- Arbeit an Milieufaktoren/Tagesstrukturierung
- Prinzip der kleinen Schritte
- Unterstützt durch
- teilstationäre Angebote wie z.B. Tages- oder Nachtklinik, die einen Übergang schaffen in
- längerfristige Rehabilitationsbereiche (Reha-Heime, Wohngruppen, Wohnheime, langfristige berufliche Reha-Einrichtungen, beschützte Werkstätten)
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