SCHIZOPHRENIA SCHIZOPHRENIA AND PSYCHOSISAND PSYCHOSIS

Module IIIRNSG 2213

SCHIZOPHRENIA: SCHIZOPHRENIA: OVERVIEWOVERVIEW

• Major Axis I disorder• Characterized by disturbances in:

• Perception• Thought processes and reality testing• Affect (feelings)• Behavior• Attention (concentration)• Motivation

PSYCHOSISPSYCHOSIS

• How do we define this term?• Inability to evaluate accuracy of one’s

thoughts and perceptions• Incorrect interpretation of external reality• Inability to re-evaluate one’s thoughts

and perceptions, even in the face of evidence that contradicts these.

In Schizophrenia, the psychotic person often does not have awareness that he/she is ill

OVERVIEW, CONT’DOVERVIEW, CONT’D

• Incidence • Age of onset is late adolescence• 1.1% of population over age 18• Higher rates in inner city populations, lower

socioeconomic groups• Prenatal probs. correlate with higher rate

OVERVIEW, CONT’DOVERVIEW, CONT’D

• Prognosis• Approx. 25% remain highly functional• 50% are minimally functional• 25% are in-between with

exacerbations/relapses and re-stabilizations (in and out of hosp.)

OVERVIEW, CONT’DOVERVIEW, CONT’D

• A Chronic Illness Characterized by Phases:• Acute phase – severe psychotic sx.• Stabilizing Phase • Stable phase

• Most pts. alternate between acute and stable phases

SCHIZOPHRENIASCHIZOPHRENIA: SYMPTOMS: SYMPTOMS

• Bleuler’s (Early 1900’s) “4 A’s”: • Affect disturbances• Autism• Associative looseness• Ambivalence

“Fragmentation of the Mind”

CLASSIFICATION OF CLASSIFICATION OF SYMPTOMSSYMPTOMS

• Positive Symptoms

• Negative Symptoms

• Cognitive Symptoms

Positive Positive Symptoms of Schizophrenia Symptoms of Schizophrenia

• Agitation/aggression

• Delusions

• Hallucinations• Disordered thinking (AEB disordered speech):

circumstantial thinking, loose associations, word salad, neologisms, echolalia

Positive Symptoms of Positive Symptoms of SchizophreniaSchizophrenia, cont’d, cont’d

• Disordered movement: --restlessness, repetitive movements

(e.g. echopraxia),

--or immobility (catatonia)http://www.youtube.com/watch?v=zAEJ-Jvndms

Matching: Symptoms Matching: Symptoms 1) “A blue ape. Makes me

scratch. John wore a hair shirt. Are we victims?”

2) “I am locked in concrete and I have stopped breathing.”

3) “The CIA has been poisoning my water.”

4) “Whenever knife take you-a.”5) “At HEB, when they play that

music, the words are sending messages to me.”

6) “I love chocolate candy. Candy is my parakeet’s name. What’s your name?”

A) Word salad

B) Delusion of reference

C) Tangentiality

D) Neologism

E) Loose associations

F) Paranoid delusion

G) Nihilistic delusion

H) Grandiose delusion

• Grandiose delusion example: “I own the Bank of America and my people are

going to put up $20 million for my release from here.”

• Neologism example: “It tastes screeg because of those nerflexes.”

NegativeNegative Symptoms of Symptoms of SchizophreniaSchizophrenia

• Flat affect

• Inability to plan or carry out activities

• Constricted, concrete thinking

• Poverty of speech (alogia), flat speech

• Social withdrawal; lack of pleasure in activities (anhedonia)

• Deep apathy

“Flat Affects” (Flight of the Conchords)

CognitiveCognitive Symptoms of Symptoms of SchizophreniaSchizophrenia

• Impaired ability to pay attention and to understand

• Impaired ability to make decisions (ambivalence)

• Problems in using just-learned information

CRITICAL THINKING:CRITICAL THINKING:Nursing DiagnosesNursing Diagnoses

Write one nursing dx. for each symptom or behavior related to schizophrenia

1) Client has command auditory hallucinations that he should kill himself

2) Client does not get dressed or take baths

3) Client believes she can make it snow

Suggested Nursing DX:Suggested Nursing DX:

1) R/F Self-directed Violence r/t sensory perceptual alteration s/t command auditory hallucinations

2) Self-care deficits: grooming and hygiene r/t poor motivation for self-care s/t schizophrenia

3) Altered thought process s/t grandiose delusion (or delusion of grandeur)

Antipsychotic Agents and Antipsychotic Agents and SymptomsSymptoms

• The “Typical” (older class) of antipsychotics primarily address POSITIVE symptoms• Can make negative symptoms Worse

• The “Atypical” (newer classes) of antipsychotics address both

POSITIVE AND NEGATIVE symptoms

SYMPTOMS:SYMPTOMS: DSM CRITERIA DSM CRITERIAA. At least 2:

Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms

B. Social-occupational dysfunction

C. Continuous s/sx. > 6 months

D. No schizoaffective diagnosis

E. Not caused by substance abuse or medical disorder

DSM Criteria: DSM Criteria: Schizophrenia SubtypesSchizophrenia Subtypes

• Paranoid – persecutory and/or grandiose delusions

• Disorganized – speech & affect & behavior are disturbed

• Catatonic – absent, excessive &/or peculiar movements. Mutism.

• Undifferentiated – does not meet criteria for other subtypes

• Residual – has some disturbed thinking or behavior but does not meet other criteria

DSM Criteria: Other Psychotic Disorders

• Schizophreniform Disorder• Has similar symptoms to schizophrenia but

for only 1-6 months

• Schizoaffective Disorder• Symptoms of schizophrenia + symptoms of

a mood disorder

• Psychotic Disorder NOS• Has Psychotic symptoms but doesn’t fit

criteria for any of the above

Quick Check: What is the most likely DSM IV-TR

Diagnosis? Client #1 Elevated mood episodes along with

hallucinations and delusions for 2 years Client #2 Is physically immobile at times.

Has poverty of speech. Has never worked in adulthood.

Client #3 Agitated, reports seeing flashes of color and hearing singing voices x 2 weeks.

Client #4 “I know 4,000 languages but others are trying to steal these from my mind.” As a result, has been living on the streets for many years.

ETIOLOGYETIOLOGY

• Multifactorial-no single cause

• Multiple theories for etiology (see next content)

BIOLOGICAL THEORIESBIOLOGICAL THEORIES

1. The Dopamine Hypothesis:

• Too much dopamine binds with too many brain receptors and causes positive symptoms

• Too little dopamine -- negative symptoms

BIOLOGICAL THEORIES, cont’d

2. Disturbed Ratio of

serotonin: dopamine

CRITICAL THINKING

• Based on the preceding hypotheses, what are the principles behind antipsychotic medications ?

-to treat positive symptoms: -to treat negative symptoms: -to treat altered ratios:

BIOLOGICAL THEORY:BIOLOGICAL THEORY: CHANGES IN BRAIN CHANGES IN BRAIN

STRUCTURE AND FUNCTIONSTRUCTURE AND FUNCTION• Alterations found in some Schizophrenics

using Diagnostic Imaging• PET Scan: glucose metabolism in

frontal/temporal lobes; in basal ganglia• MRI: Enlargement of ventricles• BEAM Scan: Abnormal wave patterns

indicting absence of ability to “calm” the brain• Evoked Potential Topography: Illogical

thought patterning in frontal lobe

PET Scan and SchizophreniaPET Scan and Schizophrenia

GENETIC THEORYGENETIC THEORY

• Inherited predisposition to schizophrenia

• Risk Factors: • Two parents with schizophrenia = 35% • Identical twins = 50%

DEVELOPMENTAL AND DEVELOPMENTAL AND ENVIRONMENTAL THEORIESENVIRONMENTAL THEORIES

• Prenatal infections

• Parental neglect or rejection

• Greater % of pts. come from lower socio-economic class

Issues in SchizophreniaIssues in Schizophrenia

• Family disturbance: a cause or a result?

• Noncompliance and relapse are common

• Have poorer ability to cope with stress

• Increased rates of depression, suicide

• Increased rate of substance abuse: alcohol, marijuana, nicotine, cocaine

• Often cannot hold a job

INTERVENTIONS/INTERVENTIONS/PSYCHOTHERAPEUTIC PSYCHOTHERAPEUTIC

MANAGEMENTMANAGEMENT

Australian aboriginal paintingby mental health clienthttp://www.ncbi.nlm.nih.gov

NURSE-CLIENT RELATIONSHIPNURSE-CLIENT RELATIONSHIP

• Be accepting, consistent and honest• Do not argue with or reinforce hallucinations

or delusions• Reinforce acceptable behaviors• Gently encourage withdrawn client• Recognize when a client may be suspicious,

anxious or fearful, and approach with care• Assess for command hallucinations

CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic ?

Client insists he is a “negative space alien.”

Nurse A: “Do you live in outer space? Are there other people living there?”

Nurse B: “But I have met your mom. How can you be a space alien?”

Nurse C: “That’s interesting. Want to come with me now to see the patient art exhibit?”

Nurse D: “ I can see you feel strongly about that.”

MILIEU MANAGEMENTMILIEU MANAGEMENT

• Set limits on disruptive behavior• Assess agitated clients frequently for

escalation • Assess ability to participate in activities;

choose activities at client’s level of ability• May need 1:1 rather than group activities at

first• Decrease environmental stimuli prn• Supervised meals, hygiene, grooming

CRITICAL THINKING: Which Nurse is Therapeutic? Non-

therapeutic?A new patient starts pacing back and forth,while saying in a loud voice, “Take it back,take it back.”

Nurse A: “Lower your voice, you are disturbing people.”

Nurse B: “Hi, I’m Jo the nurse; are you ok?”

Nurse C: “Why are you pacing?”

CRITICAL THINKING: In what order should the nurse

implement ?A schizophrenic patient, who hallucinates

and is sometimes aggressive, turns off the football game that others are watching.

“Are you hearing the voices?”

“Right now our activity is watching the football game, so it’s not ok to turn it off.”

“Come on outside for some fresh air.”

“I’m going to give you some medication right now to help you feel calmer.”

OTHER INTERVENTIONSOTHER INTERVENTIONS

• Importance of client and family education• To address stigma of schizophrenia & • To improve functional ability, self-

management and prevent relapse

Other Interventions, cont’dOther Interventions, cont’d

• Community Resources and Continuity of Care

• National Alliance on Mental Illness (NAMI)• Outpatient day treatment, home care• Self-help, peer support groups(NAMI)

http://www.youtube.com/watch?v=GEX1kr8EOPI

PHARMACOTHERAPYPHARMACOTHERAPY

• Antipsychotic Agents• Traditional or Typical Agents: 1st

Generation (beginning 1950’s)

• Atypical or Second Generation Agents (1990’s)

• Novel or Third Generation Agents (21st century)

Antipsychotic Agents:Antipsychotic Agents: Overview Overview of Typical Agentsof Typical Agents

• Pharmacologic Effects, in General• Sedation (esp. if combined with other CNS

depressants)• Slowing of motor activity• Decrease in hallucinations and delusions• Emotional quieting• Improved cognitive function; decreased

confusion

TYPICAL or Traditional TYPICAL or Traditional ANTIPSYCHOTIC AGENTSANTIPSYCHOTIC AGENTS

• High Potency e.g. haloperidol (Haldol), fluphenazine (Prolixin)

• Moderate Potency e.g. loxapine (Loxitane), perphenazine (Trilafon)

• Low Potency e.g. chlorpromazine (Thorazine), thioridazine (Mellaril)

Typical/Traditional Typical/Traditional Antipsychotics, cont’dAntipsychotics, cont’d

• Action = Block Dopamine D2

Receptors

• Most effective for Positive (+) symptoms

Atypical (2Atypical (2ndnd Generation) Generation) AgentsAgents

• clozapine (Clozaril) (prototype)

Action of this drug: blocks multiple

dopamine receptors• quetiapine (Seroquel)• risperidone (Risperdal)• olanzapine (Zyprexa) • ziprasidone (Geodon) • paliperidone (Invega)

Newest Atypical Agents

• iloperidone (Fanapt)

• Asenaphine (Saphris)

Atypical (2Atypical (2ndnd generation) generation) Agents, Agents, cont’dcont’d

• Action: Block (antagonists) or enhance (agonists) multiple dopamine, serotonin and/or norepinephrine receptors.

• Useful for both positive and negative symptoms

Novel (3Novel (3rdrd Generation) Agents Generation) Agents

• aripiprazole (Abilify)

• Action: Partial dopamine antagonist

“Balances” dopamine

(both increases and decreases it in different brain areas)

Antipsychotics: Side Antipsychotics: Side EffectsEffects

• Main Side Effects:• Extra-Pyramidal (EPSEs)-

abnormally increased or decreased motor activity, muscle spasms, twisting, tremors Akinesia Akathisia Pseudo-Parkinsonism Dystonias Tardive Dyskinesia

Acute dystonic reaction

Tardive Dyskinesia

•http://www.youtube.com/watch?v=UbBpt9uCXqc&feature=related•http://www.youtube.com/watch?v=UbBpt9uCXqc&feature=related

EPSEs

• To assess for tardive dyskinesia, administer AIMS (Abnormal Involuntary Movement Scale)

Antipsychotics: Side Effects, Antipsychotics: Side Effects, cont’dcont’d

• Anticholinergic Effects-dry mouth, orthostatic hypotension, urinary retention, blurred vision• Usually resolve over time

Other Side EffectsOther Side Effects• Cardiac:

• Arhythmias (QT interval lengthened)• Blood: Leukopenia, anemias, agranulocytosis (clozapine/Clozaril)• Endocrine and Metabolic:

Weight gain Altered glucose metabolism Diabetes type II Elevated prolactin levels

• Sexual: Impaired libido, performance

A Dangerous Side EffectA Dangerous Side Effect

• Neuroleptic Malignant Syndrome (NMS)• Potentially lethal • Associated with use of high-potency

agents e.g. haloperidol/Haldol• Onset: within a week after starting meds.• Symptoms: muscular rigidity, tremors,

autonomic hyperactivity e.g. high body temperature, altered consciousness

Nursing Interventions R/T Nursing Interventions R/T Antipsychotic Meds.Antipsychotic Meds.

• Medication education (You cannot teach too often)

• Side effect issues contribute to poor adherence/compliance:• E.g. hypotension, CNS depression,

photosensitivity, thermoregulation problems

Education/Safety IssuesEducation/Safety Issues: What : What will you teach the client will you teach the client

about. . .?about. . .?

• Hypotension

• Sedation

• Photosensitivity

• Problems with thermoregulation

• Weight gain

Nursing Interventions R/T Pharmacotherapy

--Option for client with poor adherence:

Long acting (“depot”) form, give IM q 1week - 4 wks

Nursing Interventions r/t Pharmacotherapy

Oral solutionOral solution

Disintegrating oral tabletDisintegrating oral tablet

EMERGENCY MEDS

• Common choice: IM “cocktail” of sedating antipsychotic + antihistamine and benzodiazepine

• Goals: reduce agitation

rapid sedation

CRITICAL THINKING: CRITICAL THINKING: Antipsychotic TherapyAntipsychotic Therapy

• A 65 year-old client will start on an antipsychotic agent for delusions secondary to severe depression. Choose the 3 highest priority diagnostic tests that will be performed.

A) CBC with diff. D) EEG B) Chest x-ray E) BUN/Creatinine

C) EKG F) Electrolytes

PHARMACOTHERAPY FOR PHARMACOTHERAPY FOR EXTRAPYRAMIDAL SEs: EXTRAPYRAMIDAL SEs: Antiparkinson AgentsAntiparkinson Agents

• benztropine (Cogentin)

• trihexyphenidyl (Artane)

• biperiden (Akineton)

• diphenhydramine (Benadryl)

• amantadine (Symmetrel)

Antiparkinson Agents, cont’dAntiparkinson Agents, cont’d

• Action: Restore balance of dopamine with acetylcholine (ACh)

• Reduce motor and muscle dysfunctions caused by this imbalance

• But: They also may cause anticholinergic SEs and mental confusion

CRITICAL THINKING

Which client(s) is(are) candidate(s) for benztropine/Cogentin?

A) is unable to void urine

B) reports onset of difficulty swallowing and stiff muscles

C) is pacing in response to hearing voices

D) has had tardive dyskinesia symptoms for several years

CRITICAL THINKING: CRITICAL THINKING: Anti-Parkinson/Anticholinergic Anti-Parkinson/Anticholinergic

AgentsAgentsOn the mental health unit, a client who was recentlyprescribed an antiparkinson agent for EPSEs reports very dry mouth and constipation. What will the nurse do?(Choose all that apply)A) Call the dr. to discuss changing dose of the med.B) Encourage use of hard candies and increase in fluid

intakeC) Hold the medicationD) Inform the client that these effects may decrease in a

few weeks.