Schizophrenia

1
Schizophrenia

• Chapter 16

2
Schizophrenia

• Fascinated and confounded healers for centuries
• One of most severe mental illnesses
• 1/3 of population
• 2.5 of direct costs of total budget
• 46 billion in indirect costs

3
Epidemiology

• 0.5-1.5 of population
• 2.5 million Americans
• 300,000 acute episodes each year
• Cluster in lower socioeconomic group
• Homelessness is a problem.
• Direct treatment costs 20 billion/yr

4
Epidemiology

• Across all cultures
• In the United States, African Americans have a
  higher prevalence rate (thought to be related to
  racial bias).
• Men are diagnosed earlier.
• EOS Diagnosed late adolescence
• LOS Diagnosed gt 45 years

5
Maternal Risk Factors

• Prenatal poverty
• Poor nutrition
• Depression
• Exposure to influenza outbreaks
• War zone exposure
• Rh-factor incompatibility

6
Infant and Childhood Risk Factors

• Low birth weight
• Short gestation
• Early developmental difficulties
• CNS infections

7
History of Schizophrenia

• 1800s - Eugene Kraeplin named it dementia
  praecox.
• 1900s - Eugen Bleuler named it schizophrenia
  (split minds). More than one type.
• Kurt Schneider - First rank (psychosis,
  delusions) and second rank (all other experiences)

8
Phases of Schizophrenia

• Acute Illness Period
• Positive symptoms/may be subtle
• Family Disruption
• Awareness of the meaning of the disorder
• Stabilization
• Treatment is intense
• Establish Medications
• Begin Rehab
• Maintenance and Recovery
• Relapse prevention
• Coping Strategies
• Relapse
• Non-compliance
• Identify triggers

9
Familial Differences

• First-degree biologic relatives have 10 times
  greater risk for schizophrenia.
• Other relatives have higher risk for other
  psychiatric disorders.

10
Schizophrenia Diagnosis

• During a one-month period at least two of the
  five
• Positive (delusions, hallucinations, etc.)
• Negative (alogia, anhedonia, flat affect,
  avolition)
• One or more areas of social or occupational
  functioning

11
Types of SchizophreniaText Box 16.1

• Paranoid
• Disorganized
• Catatonic
• Undifferentiated
• Residual

12
Schizophrenia
Negative Avolition Alogia Anhedonia Flat
Affect Ambivalence
Positive Hallucinations Delusions Disorganization
Neurocognitive Impairment Attention Memory Exec
Function
13
Positive Symptoms Excess of Normal Functions

• Delusions (fixed, false beliefs)
• Grandiose
• Nihilistic
• Persecutory
• Somatic
• Hallucinations (perceptual experiences)
• Thought disorder
• Disorganized speech
• Disorganized or catatonic behavior

14
Negative Symptoms Less Than Normal Functioning

• Affective blunting reduced range of emotion
• Alogia reduced fluency and productivity of
  language and thought
• Avolition withdrawal and inability to initiate
  and persist in goal-directed behavior
• Anhedonia inability to experience pleasure
• Ambivalence concurrent experience of opposite
  feelings, making it impossible to make a decision

15
Neurocognitive Impairment

• Evidence that neurocognitive impairment exists,
• independent of positive and negative symptoms

• Neurocognition
• Memory (short-, long-term)
• Vigilance (sustained attention)
• Verbal fluency (ability to generate new words)
• Executive functioning
• volition
• planning
• purposive action
• self-monitoring behavior

• Impaired in schizophrenia
• Memory (working)
• Vigilance
• Executive functioning

16
Neurocognitive Impairment Often Seen as
Disorganized Symptoms

• Confused speech and thinking patterns
• Disorganized behavior
• Examples of disorganized thinking
• Echolalia (repetition of words)
• Circumstantially (excessive detail)
• Loose associations (ideas loosely connected)
• Tangentially (logical, but detour)
• Flight of ideas (change topics)
• Word salad (unconnected words)

17
Disorganized Symptoms

• Examples of disorganized thinking (cont.)
• Neologisms (new words)
• Paranoia (suspiciousness)
• References ( special meaning)
• Autistic thinking (private logic)
• Concrete thinking (lack of abstract thinking)
• Verbigeration (purposeless repetition)
• Metonymic speech (interchange words)

18
Disorganized Symptoms

• Examples of disorganized thinking (cont.)
• Clang association (repetition similar sounding
  words)
• Stilted language (artificial, formal)
• Pressured speech (words forced)
• Examples of disorganized behavior
• Aggression
• Agitation
• Catatonic excitement (hyperactivity, purposeless
  activity)

19
Disorganized Symptoms

• Examples of disorganized behavior (cont.)
• Echopraxia (imitation of others movements)
• Regressed behavior
• Stereotypy (repetitive, purposeless movements)
• Hypervigilance (sustained attention to external
  stimuli)
• Waxy flexibility (posture held in odd or unusual
  way)

20
Comorbidity

• Increased risk of cardiovascular disorders
• Association between insulin-dependent diabetes
  and schizophrenia
• Depression and pseudodementia
• Increased substance abuse
• Cigarette smoking
• Fluid imbalance

21
Disordered Water Balance

• Prolonged periods of polydipsia, intermittent
  hyponatremia, polyuria
• Etiology unknown
• Observed behaviors
• Carrying cokes/coffee/water bottles
• Prevention of water intoxication
• Promotion of fluid balance

22
Psychological

• Difficulty relating
• Deficit in sensory inhibition
• Poor control of autonomic responsiveness
• Difficulty making decisions
• Deficit experiencing pleasure
• Deficit initiating activities
• Overassessment of threat

23
Social

• Deceased financial status
• Family and caregiver stress
• Homelessness
• Stigma and community isolation

24
Biologic Factors

• Genetic 10 first-degree relative
• Stress-diathesis model proposed by OConnor
• Neuroanatomical findings
• Decreased blood flow to left globus pallidus
• Absence of normal blood increase in frontal lobes
• Atrophy of the amygdala, hippocampus and
  parahippocampus
• Ventricular enlargement

25
Biologic

• Neurodevelopmental
• Prenatal exposure (2nd trimester)
• Late winter, early spring births
• Adolescent
• Changes in transmitter systems and substrates
• Synaptic pruning along with substantial brain
  growth in some areas of the cortex
• Changes in steroid-hormonal environment

26
Neurotransmitters, Pathways and Receptors

• Hyperactivity of the limbic area
• (dopamine mesolimbic tract) related to positive
  symptoms
• Hypofrontality or hypoactivity of the pre-frontal
  and neo-cortical areas
• (dopamine mesocortical tract related to negative
  and positive symptoms)
• Does not result from dysfunction of a single
  neurotransmitter

27
Psychosocial Theories

• Do not explain cause
• Disservice to families
• Useful in family interaction
• Expressed Emotion (EE)
• High emotion associated with negative
  communication and overinvolvement
• Low emotion associated with less negativity and
  less overinvolvement

28
Priority Care Issues

• Suicide
• 20-50 Attempt
• 10 Complete
• Safety of patient and others
• Initiate antipsychotic medications

29
Family Response to Disorder

• Mixed emotions shock, disbelief, fear, care,
  concern and hope
• May try to seek reasons
• Initial period very difficult
• NAMI Life changed forever

30
Interdisciplinary Treatment

• The most effective approach involves a variety of
  disciplines.
• There is considerable overlap of roles and
  interventions.
• Nursings contribution is significant.

31
Nursing Management Biologic Domain Assessment

• Present and past health status
• Physical functioning
• Nutritional assessment
• Fluid imbalance assessment
• Pharmacologic assessment
• Medications (prescribed, OTC, herbal, illicit)
• Abnormal motor movements
• DISCUS
• AIMS
• Simpson-Angus Rating Scale

32
Assessment

• Comorbidity
• Diabetes
• Smoking-related
• Cardiac
• Hypertension

33
Nursing DiagnosisBiologic Domain

• Self-care deficit
• Disturbed sleep pattern
• Ineffective therapeutic regimen management
• Imbalanced nutrition
• Excess fluid volume
• Sexual dysfunction

34
Nursing InterventionsBiologic Domain

• Promotion of self-care activities
• Develop a routine of hygiene activities.
• Emphasize its importance help motivate the
  patient.
• Activity, exercise and nutrition
• Help counteract effects of psychiatric
  medications.
• Appetite usually increases, so help with food
  choices.
• Thermoregulation
• Teach patient to wear clothing according to
  weather dress for winter and summer.
• Observe patients response to temperature.
• Promotion of normal fluid balance
• Water intoxication protocol (Text Box 16.7)

35
Pharmacologic Interventions

• Newer antipsychotics more efficacious and safer
  (block dopamine and serotonin)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodone)
• Aripiprazole (Abilify)
• Clozapine (Clozaril) - second line
• Monitoring and administering medications
• Takes 1-2 weeks to work (some improvement
  immediately)
• Adequate trial - 6-12 weeks
• Adherence to prescribe medication is best
  prevention of relapse.
• Discontinuation is rare.

36
Pharmacologic Interventions Monitoring Side
Effects

• Parkinsonism
• Identical symptoms to Parkinsons
• Caused by blockade of D2 receptor in basal
  ganglia
• Treated with anticholinergic medications
• Taper anticholinergic meds if discontinued
• Dystonia
• Imbalance of DA and ACH, with more ACH
• Young men more vulnerable
• Oculogyric crisis, Torticollis, Retrocollis

37
Monitoring Side Effects

• Akathesia
• Restlessness, jumping out of skin, uncomfortable
• Reduce dose of antipsychotic.
• Treat with a ?-blocker (propranolol).
• Tardive Dyskinesia
• Impairment of voluntary movement, constant motion
  
• Occurs 6-8 months following initiation of
  antipsychotics
• Facial-buccal area -- lip smacking, sucking, etc.
• Movements in trunk, rocking
• No real treatment

38
Monitoring Side Effects

• Orthostatic hypotension
• Hyper Prolactinemia (haloperidol and risperidone)
• Weight gain (olanzapine and clozapine)
• Sedation
• New-onset diabetes (Olanzapine,clozapine)
• Cardiac arrhythmias (QT prolongation)
  (Ziprasidone) may need baseline ECG
• Agranulocytosis (all but clozapine)

39
Drug-drug Interactions

• Medications metabolized by 1A2 enzymes include
  olanzapine and clozapine.
• Inhibitors fluvoxamine (Luvox)
• Inducers cigarette smoking Smokers may require a
  higher dose
• Medications metabolized by 3A4 include clozapine,
  quetiapine and ziprasidone.
• Inhibitors ketoconazole, protease inhibitors,
  erythromycin
• Inducer carbamazapine (Tegretol)
• Medications affected by 2D6 include risperidone,
  clozapine and olanzapine.
• Inhibitors fluoxetine, paroxetine (not usually
  clinically significant)

40
Medication Teaching Points

• Consistency in taking medication
• Medication and symptom amelioration
• Side effects and management
• Interpersonal skills that help patient and family
  report medication effects

41
MEDICATIONEMERGENCIES
42
Neuroleptic Malignant Syndrome

• TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSE
• Severe muscle rigidity, elevated temperature
• Recognizing symptoms
• Elevated temperature, changes in level of
  consciousness, leukocytosis, elevated creatinine
  phosphokinase), elevated liver enzymes or
  myoglobinuria
• Nursing interventions
• Stop administration of offending medications.
• Monitor vital signs.
• Reduce body temperature.
• Safety, protect muscles
• Supportive measures
• IV fluids
• Cardiac monitoring
• Dantrolene (Dopamine agonist)

43
Neuroleptic Malignant Syndrome

• Acute reaction to dopamine receptors blockers
• Prevalence 2 to 2.4
• Death 4 to 22, mean 11
• Etiology
• Drugs block striatal dopamine receptors disrupt
  regulatory mechanisms in the thermoregulatory
  center in hypothalamus and basal ganglia heat
  regulation fails and muscle rigidity

44
Is Client on neuroleptic drug?
NOT NMS
NO
ANY RISK FACTORS FOR NMS? DEHYDRATION? HISTORY OF
NMS? RECENT DOSE INCREASE? PSYCHOMOTOR AGITATION
N O T I F Y M D
YES
EARLY S/S NMS? LOW-GRADE FEVER? TACHYCARDIA?ELEVAT
ED BP? CATATONIA?DIAPHORESIS?
YES
HYPERTHERMIA? LEAD PIPE RIGIDITY? MS
CHANGES OTHER AUTONOMIC CNS?
HOLD DRUG
45
Anticholinergic Crises

• Potentially life threatening, anticholinergic
  delirium
• Can occur in patients who are taking several
  medications with anticholinergic effects
• Elevated temperature, dry mouth, decreased
  salivation, decreased bronchial, nasal secretion,
  widely dilated eye
• Stop offending drug, usually self-limiting. May
  use inhibitor of anticholinesterase,
  physostigmine.

46
Anticholinergic Crisis

• Confusion, hallucinations
• Physical signs - dilated pupils, blurred vision,
  facial flushing, dry mucous membranes, difficulty
  swallowing, fever, tachycardia, hypertension
  decreased bowel sounds, urinary retention,
  nausea, vomiting, seizures, coma
• Atropine flush
• Hot as a hare, blind as a bat, mad as a hatter,
  dry as a bone

47
Treatment

• Self-limiting three days
• Discontinuation of medication
• Physiostigmine 1-2 mg IV, an inhibitor of
  cholinesterase, improves in 24-36 hours
• Gastric lavage
• Charcoal, catharsis

48
Nursing Management Psychological Domain
Assessment Responses

• Socially stigmatizing
• Prodromal symptoms evident (negative symptoms)
• Tension and nervousness
• Lack of interest in eating
• Difficulty concentrating
• Disturbed sleep
• Decreased enjoyment
• Loss of interest, restlessness, forgetfulness
• Often not recognized as an illness
• Denial common

49
Nursing Management Psychological Domain
Assessment

• Positive and negative symptoms
• SAPS (positive symptoms) (Box 16.14)
• SANS (negative symptoms) (Box 16.15)
• PANNS (both symptoms)
• Mental status
• Appearance
• Mood and affect (lability, ambivalence, apathy)
• Speech
• Thought processes (delusions, disorganized
  communication, cognitive impairments)
• Sensory perception (hallucinations)
• Memory and orientation
• Insight and judgment

50
Nursing Management Psychological Domain
Assessment (cont.)

• Behavioral responses
• Self-concept
• Stress and coping patterns
• Risk assessment
• Command hallucinations
• Self-injury risk, suicide
• Homicide

51
Nursing Diagnosis Psychological Domain

• Disturbed thought processes
• Disturbed sensory perceptions
• Disturbed body image
• Low self-esteem
• Disturbed personal identity
• Risk of violence, suicide
• Ineffective coping
• Knowledge deficit

52
Nursing Interventions Psychological Domain

• Counseling, conflict resolution, behavior therapy
  and cognitive interventions can be used.
• Development of nurse-patient relationship
• Centers on the development of trust and
  acceptance of the persons
• Critical for optimal treatment of schizophrenia

53
Nursing InterventionsPsychological Domain
Management of Disturbed Thoughts

• Assessment content of hallucinations/delusions
• Outcomes
• Decrease frequency and intensity.
• Recognize as symptoms of disorder.
• Develop strategies to manage recurrence.
• Experiences real to the patient
• Validate that experiences are real
• Identify meaning and feeling that are provoked
• Teach patient that hallucinations and delusions
  are symptoms of illness.

54
Nursing Interventions Psychological Domain

• Self-monitoring and relapse prevention
• Monitor events, time, place, etc. of recurrence
  of symptoms.
• Manage symptoms - getting busy, self-talk, change
  of activity. (Moller-Murphy Tool)
• Enhancement of cognitive functioning
• Recognize difficulty in processing information.
• Improve attention (computer programs,
  one-to-one).
• Help memory (make lists, write down information).
• Improve executive functioning-simulation.

55
Nursing Interventions Psychological Domain

• Behavioral interventions
• Organize routine, daily activities.
• Reinforce positive behaviors.
• Stress and coping skills development
• Counseling sessions
• Teach and reward positive coping skills.
• Patient education
• Errorless learning environment
• Minimal distractions
• Clear visual aids
• Skills training

56
Family Interventions

• Family support
• Educate the family regarding lifelong disorder of
  schizophrenia.
• Emphasize consistent taking of medication.

57
Nursing Management Social Domain Assessment

• Functional status
• Assessed initially and at regular intervals
• GAF usually used
• Social systems
• Formal and informal support systems
• Quality of life
• Family assessment
• Family assessment guide (Ch. 15)
• Special consideration to the family where patient
  is the parent

58
Nursing InterventionsSocial Domain

• Promotion of Patient Safety
• Monitoring for potential aggression
• Administering medication as ordered
• Reducing environmental stimulation
• Approach to individual patients
• Thorough history of violence
• Help patient to talk directly and constructively
  with those with whom they are angry.
• Set limits.
• Involve patients in formal contracting.
• Schedule regular time-outs.

59
Nursing Interventions Social Domain

• Support groups
• Milieu therapy
• Psychiatric rehabilitation
• Family interventions
• Encourage to participate in support groups
• Inform about local and state resources
• Help negotiate provider system

60
Continuum of Care

• Treatment occurs across continuum. Patients are
  at high risk for getting lost in the system.
• Inpatient-focused care (stabilization)
• Emergency care (crisis)
• Community care (most of care)
• Mental health promotion

61
Schizophrenia in Children

• Rare in children
• If appears in children aged 5 or 6, symptoms same
  as for adults
• Hallucinations visual, delusions less
  well-developed
• Other disorders considered first

62
Schizophrenia in Elderly

• For those who have had schizophrenia most of
  their life, this may be a time that they
  experience improvement in symptoms.
• Late-onset schizophrenia
• Diagnostic criteria met after 45
• Estrogen may be protective in women
• Most likely include positive symptoms