Schizophrenia

Chapter 16

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

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

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 > 45 years

Maternal Risk Factors

Prenatal poverty

Poor nutrition

Depression

Exposure to influenza outbreaks

War zone exposure

Rh-factor incompatibility

Infant and Childhood Risk Factors

Low birth weight

Short gestation

Early developmental difficulties

CNS infections

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)

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

Familial Differences

First-degree biologic relatives have 10 times greater risk for schizophrenia.

Other relatives have higher risk for other psychiatric disorders.

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

Types of SchizophreniaText Box 16.1

Paranoid

Disorganized

Catatonic

Undifferentiated

Residual

NegativeNegativeAvolitionAvolitionAlogiaAlogiaAnhedoniaAnhedoniaFlat AffectFlat AffectAmbivalenceAmbivalence

NeurocognitiveImpairment

AttentionMemory

Exec Function

Positive

Hallucinations

Delusions

Disorganization

SchizophreniaSchizophrenia

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

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

Neurocognitive Impairment

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

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

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)

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)

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)

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)

Comorbidity

• Increased risk of cardiovascular disorders

• Association between insulin-dependent diabetes and schizophrenia

• Depression and pseudodementia

• Increased substance abuse

• Cigarette smoking

• Fluid imbalance

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

Psychological

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

Social

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

Biologic Factors

• Genetic – 10% first-degree relative• Stress-diathesis model proposed by

O’Connor• 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

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

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

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

Priority Care Issues

Suicide

– 20-50% Attempt

– 10% Complete

Safety of patient and others

Initiate antipsychotic medications

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

Interdisciplinary Treatment

The most effective approach involves a variety of disciplines.

There is considerable overlap of roles and interventions.

Nursing’s contribution is significant.

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

Assessment

Comorbidity– Diabetes– Smoking-related– Cardiac

Hypertension

Nursing Diagnosis:Biologic Domain

Self-care deficit Disturbed sleep pattern Ineffective therapeutic regimen

management Imbalanced nutrition Excess fluid volume Sexual dysfunction

Nursing Interventions:Biologic 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 patient’s response to temperature.

Promotion of normal fluid balance– Water intoxication protocol (Text Box 16.7)

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.

Pharmacologic Interventions: Monitoring Side Effects

Parkinsonism– Identical symptoms to Parkinson’s – 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

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

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)

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)

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

MEDICATIONEMERGENCIES

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)

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

Is Client onneuroleptic drug? NO NOT NMS

ANY RISK FACTORS FOR NMS?DEHYDRATION?HISTORY OF NMS?RECENT DOSE INCREASE?PSYCHOMOTOR AGITATION

YE

S

EARLY S/S NMS?LOW-GRADE FEVER?TACHYCARDIA?ELEVATED BP?CATATONIA?DIAPHORESIS?

YE

S

HYPERTHERMIA?LEAD PIPE RIGIDITY?MS CHANGESOTHER AUTONOMIC CNS?

HOLD DRUG

NOTIFY MD

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.

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

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

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

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

Nursing Management: Psychological Domain Assessment (cont.)

Behavioral responses Self-concept Stress and coping patterns Risk assessment

– Command hallucinations– Self-injury risk, suicide– Homicide

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

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

Nursing Interventions:Psychological 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.

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.

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

Family Interventions

Family support

Educate the family regarding lifelong disorder of schizophrenia.

Emphasize consistent taking of medication.

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

Nursing Interventions:Social 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.

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

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

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

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