Schizophrenia and Other Psychotic Disorder Chapter 16

1
Schizophrenia and Other Psychotic
DisorderChapter 16

• Psychiatric / Mental Health Nursing
• NURS 204

2
Overview of Schizophrenia

• Prevalence in U.S. is 1.1.
• Average onset is late teens to early twenties,
  but can be as late as mid-fifties
• Affects cognitive, emotional, and behavioral
  function
• 30 to 40 relapse rate in the first year
• Life expectancy is shortened because of suicide

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Signs and Symptoms

• Language and communication disturbances
• Thought disturbances
• Perception disturbances
• Affect disturbances
• Motor behavior disturbances
• Self-identity disturbances

4
Features of Schizophrenia - continued

• Progression varies from one client to another
• Exacerbations and remissions
• Chronic but stable
• Progressive deterioration
• DSM-IV-TR Diagnosis
• Symptoms present at least 6 months
• Active-phase symptoms present at least 1 month
• Symptoms are defined as positive and negative

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Features of Schizophrenia - continued

• Positive symptoms
• Excess or distortion of normal functioning
• Aberrant response
• Negative symptoms
• Deficit in functioning

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Features of Schizophrenia - continued

• Positive Symptoms of Schizophrenia
• Hallucination
• Auditory, Visual
• Olfactory, Gustatory, Tactile
• Delusions
• Persecutory, Referential
• Somatic, Religious,
• Substitution, Thought Insertion and/or
  Broadcasting
• Nihilistic, Grandiose

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Features of Schizophrenia Positive Symptoms
continued

• Disordered speech
• Loose Association, Word Salad
• Clanging, Echolalia, Neologism
• Disordered behavior
• Disorganized walk
• Touching all objects and surfaces
• Catatonia
• Disordered Thinking
• Indecisiveness, lack of problem solving skills,
• Concreteness, blocking, perservation

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Features of Schizophrenia - continued

• Negative Symptoms of Schizophrenia
• Flat affect lack of emotion
• Apathy indifference towards people, events,
  activities and learning.
• Alogia Poverty of speech
• Avolition inability to pursue and persist in
  goal-directed activities.
• Anhedonia inability to experience pleasure.

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Subtypes of Schizophrenia

• Paranoid type
• Disorganized type
• Catatonic type
• Undifferentiated type
• Residual Type

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Subtypes of Schizophrenia - continued

• Paranoid Type
• Delusions
• Persecutory and grandiose
• Somatic or religious
• Hallucinations
• Delusions link with a hallucination

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Subtypes of Schizophrenia - continued

• Disorganized type
• Disorganized speech, behavior, appearance
• Flat or inappropriate affect
• Fragmented hallucinations and delusions
• Most severe form of schizophrenia

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Subtypes of Schizophrenia - continued

• Catatonic type
• Psychomotor retardation and stupor
• Extreme psychomotor agitation
• Waxy flexibility
• Echolalia
• Mutism
• Echopraxia

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Subtypes of Schizophrenia - continued

• Undifferentiated type
• Active psychotic state
• Lacks symptoms of other subtypes
• Residual type
• At least one episode of schizophrenia
• No prominent positive symptoms
• Negative symptoms present

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Other Psychotic Disorders

• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder
• Shared Psychotic Disorder (Folie à Deux)
• Induced or Secondary Psychosis

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Causes of Schizophrenia

• Biologic theories
• Psychological theories
• Family theories
• Humanistic-interactional theories

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Causes of Schizophrenia

• Biologic Theory Genetic
• Only genetic predisposition for developing
  schizophrenia is inherited
• 10 of first-degree relatives
• 25-39 of monozygotic twins

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Causes of Schizophrenia - continued

• Biologic Theory Brain Structure Abnormality
• Differs from those with no symptoms
• May be genetically based
• Requires more study

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Schizophrenia scans. PET scans of discordant
monozygotic twins taken during a test to provoke
activity and measure regional cerebral blood
flow. (A) Arrows indicate areas of normal blood
flow and brain activity in the unaffected twin.
(B) Arrows indicate areas of lower blood flow and
brain activity in the twin with schizophrenia.
Source Courtesy of Dr. Karen F. Berman, Clinical
Brain Disorders Branch, National Institute of
Mental Health
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Causes of Schizophrenia - continued

• Biologic Theory Biochemical Theories
• Dopamine hypothesis
• Traditional antipsychotic medications are
  dopamine blockers
• Dopamine blocker alleviate positive symptoms

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Causes of Schizophrenia - continued

• Psychological theories
• Information processing
• Difficulty controlling the amount and type of
  information that is processed in the brain.
• Attention and arousal
• Hyper or hypo responsiveness to various
  situations

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Causes of Schizophrenia - continued

• Family Theories
• Dysfunctional interaction not supported by
  research
• Disordered family communication linked only with
  genetic predisposition
• Family emotional tone influences course of
  schizophrenia
• Expressed emotions theory (EE)

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Causes of Schizophrenia - continued

• Humanistic-interactional theories integrate
  biological and psychosocial theories
• Combine influences of
• Genetic predisposition or biologic vulnerability
• Environmental stressors
• Social support

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Causes of Schizophrenia - continued

• StressVulnerability Model
• Stressors increase vulnerability
• Cumulative effect of
• Genetic predisposition
• Personal stressors
• Familial factors
• Environmental factors

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Influences on the Course of Schizophrenia

• Social Pressures
• Lack of social support
• Financial problems
• Stigma

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Influences on the Course of Schizophrenia -
continued

• Psychological pressures
• Difficulty with problem-solving
• Difficulty with interpreting reality
• Difficulty coping
• Problems with self-care
• Unstable interpersonal relationships

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Nursing Implications

• Assessment
• Premorbid functioning
• Content of thought
• Form of thought
• Perception
• Sense of self
• Delusions and perceptual disturbances
• Hallucinations
• Drug use

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Nursing Implications - continued

• Nursing Diagnoses
• Disturbed thought process
• Disturbed sensory perception
• Social isolation
• Risk for violence
• Self-care deficits
• Altered health maintenance
• Ineffective coping
• Impaired verbal communication
• Excess Fluid Volume
• Decisional Conflict
• Dysfunctional or Interrupted family process

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Nursing ImplicationsSupporting Families

• Family needs vary with degree of illness and
  involvement in clients care
• Education
• Financial support
• Psychosocial support
• Advocacy

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Nursing ImplicationsSupporting Families -
continued

• Schizophrenia is a family illness.
• Family members need to be involved.
• Educate family about
• Medication
• Illness
• Relapse prevention
• Nurse assists family by
• Identifying community agencies/groups for family
  members
• Advocating for rights

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General Nursing Intervention

• Promote Safety and a Safe Environment
• Promote Congruent Emotional Response
• Promote Social Interaction and Activity
• Intervene with Hallucinations and Delusions
• Preventing Relapse
• Promoting adherence with medication regimen
• Assist with grooming and hygiene
• Promote Family Understanding and Involvement

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Intervention - Prevent Relapse

• Relapse prevention programs provide education and
  support regarding
• Individual triggers, symptoms of relapse
• Managing side effects of medications
• Interventions to reduce or eliminate triggers
• Strategies to facilitate early intervention
• Cognitive therapy
• Community resources

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Challenges to Adherence

• Side effects of Psychotropic Medications
• Level of symptomatology
• Cognitive, motivational, financial, and cultural
  issues
• Issues with caregivers
• Insufficient medication teaching
• Substance abuse

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Increasing Adherence

• Involve clients in treatment
• Instruct client about reducing discomfort
• Provide peer support
• Provide reminders and positive feedback
• Recognize accomplishments

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Personal Awareness

• Identify personal feelings and recognize personal
  perceptions.
• What behaviors do you expect to see?
• How will you respond to these behaviors?
• What is the meaning of the behaviors?
• What defines normal behavior?
• What are my fears associated with mental illness?
  
• Remember that clients are human beings with a
  mental disorder and do not choose to be this way.

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Psychopharmacology

• A primary treatment mode of psychiatric-mental
  health nursing care
• ANA Task Force Guidelines
• Integrate current data from the neurosciences.
• Demonstrate knowledge of psychopharmacologic
  principles.
• Provide safe and effective care of clients taking
  these medications.

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Psychopharmacology

• Prior to the 1950s focus on behavioral
  interventions and sedatives
• Mid-fifties Introduction of the first
  antipsychotic medication chlorpromazine
  (Thorazine)
• Since then, many advances have led to the
  treatment of the client with mental illness in
  the community.
• Psychiatric medications allow for the correction
  of imbalances of brain chemicals.

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The great success of biological psychiatry. This
graph illustrates the dramatic decrease in
psychiatric inpatient numbers since the inception
of psychopharmacology.
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Antipsychotics

• Typical (Conventional)
• Block dopamine receptors at 70 to 80 occupancy
  to be effective.
• Exptrapyramidal Side Effects (EPSEs) occur at
  occupancy gt 80

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Psychiatric Medications

• Ongoing research on new medications
• Ongoing research on new delivery systems
• Newer depot Resperidone Consta
• Orally Disintegrating Tablets Zyprexa Zydis

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Impact on Ethnic Groups

• Some ethnic groups are slow metabolizers.
• More side effects
• Greater risk of toxicity
• Some ethnic groups are fast metabolizers.
• Less effect of the medication

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Goals of Psychiatric Medications

• Positive Effects
• Allowed release of clients from inpatient
  hospital to treatment in the community
• Manage the symptoms such as delusional thinking,
  hallucinations, confusion, motor agitation, motor
  retardation, blunted affect, bizarre behavior,
  social withdrawal and agitation.
• Alleviation of the symptoms, often improving
• Ability to think logically
• Ability to function in ones daily life
• Ability to function in relationships

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Antipsychotics

• Negative Effects
• Frightening and life threatening side effects
• Potential interactions with other medications and
  substances
• Possible need to cope with the realization of
  having a chronic illness

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Medication Adherence

• Adherence to prescribed medications by clients in
  psychiatric services is less than 35
• Reasons for nonadherence
• Clients do not know what to expect from
  medications.
• The schedule of doses or routes may be
  inconvenient.
• Friends/relatives may not be supportive.
• Side effects may be worst than the symptoms.

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Administering Medications

• A careful assessment is needed to decide the
  right form of the medication
• PO - by mouth (for routine use)
• Liquid form (concentrate or syrup)
• Quick-dissolving formulation (sublingual)
• PRN injection
• Depot injection

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Antipsychotics

• Atypicals
• Reduced affinity for dopamine receptors
• Affinity for serotonin receptors
• Fewer EPSEs
• Reduction in negative symptoms

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Antipsychotic Medications

• Side effects
• ANS, extrapyramidal, other CNS, allergy, blood,
  skin, eye, endocrine, and weight gain
• The five categories of EPSEs are dystonia,
  drug-induced parkinsonism, akathisia, tardive
  dyskinesia, and dopamine-acetylcholine imbalance

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Dystonia

• Occurs usually within 48 hours of initiation of
  the medication
• Involves bizarre and severe muscle contractions
• Can be painful and frightening
• Characterized by odd posturing and strange facial
  expressions (Torticollis, Opisthotonus,
  Laryngospasm, Oculogyric Crises)

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Opisthotonus
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Torticollis
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Oculogyric Crises
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Laryngospasm
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Drug-induced Parkinsonism

• Usually occurs after 3 or more weeks of treatment
• Characterized by
• Cogwheel rigidity
• Tremors at rest
• Rhythmic oscillations of the extremities
• Pill rolling movement of the fingers
• Bradykinesia
• Postural Changes

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Akathisia

• Usually occurs after 3 or more weeks of treatment
• Subjectively experienced as desire or need to
  move
• Described as feeling like jumping out of the skin
• Mild a vague feeling of apprehension or
  irritability
• Severe an inability to sit still, resulting in
  rocking, running, or agitated dancing

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Tardive Dyskinesia

• Usually occurs late in the course of long-term
  treatment
• Characterized by abnormal involuntary movements
  (lip smacking, tongue protrusion, foot tapping)
• Often irreversible

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Complications of Tardive Dyskinesia

• Inability to wear dentures
• Impaired respirations
• Weight loss
• Impaired gait
• Impaired posture

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Dopamine-Acetylcholine Imbalancein the
Extrapyramidal System

• A rare side effect
• Characterized by hallucinations, dry mouth,
  blurred vision, decreased absorption of
  antipsychotics, decreased gastric motility,
  tachycardia, and urinary retention

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Autonomic Nervous System EffectsAnticholinergic
Side Effects

• Dry mouth
• Blurred vision
• Constipation
• Urinary retention
• Tachycardia

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Other Central Nervous System Effects

• Sedation
• Lowering of the seizure threshold
• Observe clients with seizures disorders carefully
  when treatment is initiated.

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Cardiac Effects

• Some antipychotics may contribute to prolongation
  of the QTc interval and lead to arrhythmias.
• An EKG can identify those at risk.

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Blood, skin and eye effect

• Agranulocytosis
• Skin photosensitivity
• Retinitis pigmentosa

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Agranulocytosis

• Early symptoms beginning signs of infection
• White blood cells are routinely monitored in
  clients taking clozapine (Clozaril).

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Endocrine Effects

• Hyperprolactinemia may cause
• Oligomenorrhea or amenorrhea in women
• Galactorrhea in women and rarely in men
• Osteoporosis if prolonged
• Impotence in males may occur.
• Diabetes
• Monitor blood glucose levels.

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Weight Gain

• Monitor weight
• Teach about diet and exercise
• Weight gain may contribute to physical as well as
  psychosocial stressors

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Neuroleptic Malignant Syndrome (NMS)

• Typically occurs in the first 2 weeks of
  treatment or when the dose is increased
• Hold the medication, notify the physician, and
  begin supportive treatments.
• Symptoms muscle rigidity, tachycardia,
  hyperpyrexia, altered consciousness, tremors and
  diaphoresis

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NMS continue

• Risk Factors
• Dehydration
• Agitation or catatonia
• Increase dose of neuroleptic
• Withdrawal from anti-parkinson medication
• Long acting or depot medication
• Pharmacologic treatment
• Antipyretics
• Muscle relaxant
• Dopamine receptor agonist

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Interventions for the Major Side Effects of
Antipsychotics

• A primary nursing role is to teach patients about
  the major side effects of psychotropic
  medications and how to manage them.
• Nurses must monitor for side effects and
  intervene when necessary.

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Interventions for EPSEs

• Dsytonia and drug-induced parkinsonism are
  treated by anticholinergics.
• Akathisia may be treated with anticholinergics
  but is not always responsive.
• Tardive dyskinesia treatment is preventive
  through careful and routine assessment.

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Antiadrenergic EffectOrthostatic Hypotension

• Take the clients blood pressure in a supine
  position and then in a standing position.
• Caution clients to rise slowly from a supine
  position.
• Anticholenergic Side Effects
• Ice chips, hard candy
• Eye drops
• Fiber diet, exercise
• Increase fluid intake
• Catheterization

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Antipsychotic Medications

• Typical Agents
• Low Potency
• Chlorpromazine (Thorazine) (25 800 mg/d)
• Thioridazine (Mellaril) (150 800 mg/d)
• Mesoridazine (Serentil) (100 400 mg /d)
• Side Effects
• Sedation, Anticholernergic, Hypotention,
• EPSEs (less vs high potency)

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Antipsychotic Medications

• Typical Agents
• High Potency
• Haloperidol (Haldol) (1 30 mg/d)
• Fluphenazine (Prolixin) (0.5 40 mg/d)
• Thiothixene (Navane) (2 30 mg/d)
• Trifluoperazine (Stelazine) (1 40 mg/d)
• Perhenazine (Trilafon) (8-60 mg/d)
• Loxapine (Loxitane) (20 250 mg/d)
• Molindone (Moban) (50 225 mg/d)
• Pimozide (Orap) 0.5 9 mg/d)
• Side Effects
• Sedation, Anticholenergic SE (less vs low
  potency)
• EPSEs

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Antipsychotic Medications

• Atypical Agents
• Clozapine (Clozaril) (6.25 900 mg/d)
• Side effects seizures, agranulocytosis, weight
  gain, hypersalivation, anticholinergic
• Olanzapine (Zyprexa, Zyprexa Zydis) (5 20 mg/d)
• Paliperidone (Invega) (3 12 mg/d)
• Quetiapine (Seroquel) (150 600 mg/d)
• Risperidone (Risperdal, Risperdal M-Tab)
• (2 6 mg/d)
• Ziprasidone (Geodon) ( 40 160 mg/d)
• Aripiprazole (Abilify) (15 30 mg/d)
• Asenapine (Saphris) (5 10 mg/d) Sublingual
• Iloperidone (Fanapt) (12 24mg/d)

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Long-Acting Injectables (Depot Therapy

• Typical Agents
• Haloperidol Decanoate (Haldol Decanoate)
• Q4 weeks
• Fluphenazine Decanoate (Prolixin Decanoate)
• Q2 Weeks
• Atypical Agents
• Risperidone Consta (Risperdal Consta)
• Q2 Weeks
• Paliperidone Sustenna (Invega Sustena)
• Q4 weeks

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Anti-Parkinson Medications

• Trihexyphenidyl (Artane)
• Benztropine (Cogentin)
• Diphenhydramine (Benadryl)
• Amantadine (Symmetrel)