Schizophrenia and Schizophrenia Spectrum Disorders Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

 Lifetime prevalence of schizophrenia is 1% worldwide  No difference related to ◦ Race ◦ Social status ◦ Culture Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.2

3 Interrelated Concepts and Psychosis

 The types of schizophrenia are defined by the most common symptoms a person has. The types include:schizophrenia  Paranoid schizophrenia. This is the most common type. People with paranoid schizophrenia have frightening thoughts and hear threatening voices. This causes them to act afraid or to argue with other people. A person with paranoid schizophrenia may attack other people or objects because they are afraid of them. This type often occurs later in life than other types of schizophrenia. People with paranoid schizophrenia often get better with treatment.  Disorganized schizophrenia. This is the most rare but serious type. It is sometimes called hebephrenic schizophrenia. People who have this type have random and erratic behavior. They may act silly and giggle for no clear reason. They may make up words and sentences that make no sense to other people. And they often do not show facial expressions. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4

 Catatonic schizophrenia. This type of schizophrenia is rare. People with catatonic schizophrenia may sit or stand like a statue for long periods of time. This is called a catatonic stupor. They also can have periods of meaningless and intense activity. This is called catatonic excitement. During these periods of intense activity, they may cause harm to themselves or others.  Undifferentiated schizophrenia. This is the term used when the symptoms of a person’s schizophrenia do not fit the other types.  Residual schizophrenia. This term refers to the ongoing symptoms of schizophrenia that occur during a remission. remission Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

 Biological factors ◦ Genetics  Neurobiological ◦ Dopamine theory ◦ Other neurochemical hypotheses  Brain structure abnormalities Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.6

 Psychological and environmental factors ◦ Prenatal stressors ◦ Psychological stressors ◦ Environmental stressors Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.7

 Substance abuse disorders ◦ Nicotine dependence  Anxiety, depression, and suicide  Physical health or illness  Polydipsia Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.8

 During the prepsychotic phase  General assessment ◦ Positive symptoms ◦ Negative symptoms ◦ Cognitive symptoms ◦ Affective symptoms Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.9

10 Four main symptom groups of schizophrenia

 Alterations in thinking ◦ Delusions − False, fixed beliefs ◦ Concrete thinking − Inability to think abstractly Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.11

 Alterations in speech − Associative looseness ◦ Clang associations ◦ Word salad ◦ Neologisms ◦ Echolalia Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.12

 Other disorders of thought or speech ◦ Religiosity ◦ Magical thinking ◦ Paranoia ◦ Circumstantiality ◦ Tangentiality ◦ Cognitive retardation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.13

 Other disorders of thought or speech (cont.) ◦ Alogia, or poverty of speech ◦ Flight of ideas ◦ Thought blocking ◦ Thought insertion ◦ Thought deletion Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.14

 Alterations in perception ◦ Depersonalization ◦ Derealization ◦ Hallucinations  Auditory  Command  Visual Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.15

◦ Catatonia ◦ Motor retardation ◦ Motor agitation ◦ Stereotyped behaviors ◦ Waxy flexibility ◦ Echopraxia ◦ Negativism ◦ Impaired impulse control ◦ Gesturing or posturing ◦ Boundary impairment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.16 Alterations in Behavior

 Affect ◦ Flat ◦ Blunted ◦ Inappropriate ◦ Bizarre Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.17

 Difficulty with ◦ Attention ◦ Memory ◦ Information processing ◦ Cognitive flexibility ◦ Executive functions Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.18

 Assessment for depression is crucial ◦ May herald impending relapse ◦ Increases substance abuse ◦ Increases suicide risk ◦ Further impairs functioning Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.19

A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? A.Positive symptom B.Negative symptom C.Cognitive symptom D.Depressive symptom Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.20

1.Any medical problems 2.Abuse of or dependence on alcohol or drugs 3.Risk to self or others 4.Command hallucinations Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.21

 You believe that the young man you are admitting to your unit is suffering from command hallucinations.  What would be some questions to ask him? Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.22

5.Delusions 6.Suicide risk 7.Ability to ensure self-safety 8.Medications Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.23

9.Mental status examination 10.Patient’s insight into illness 11.Family’s knowledge of patient’s illness and symptoms Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.24

 Positive symptoms ◦ Disturbed sensory perception ◦ Risk for self-directed or other-directed violence ◦ Impaired verbal communication  Negative symptoms ◦ Social isolation ◦ Chronic low self-esteem Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.25

 Phase I – Acute ◦ Onset or exacerbation of symptoms  Phase II – Stabilization ◦ Symptoms diminishing ◦ Movement toward previous level of functioning  Phase III – Maintenance ◦ At or near baseline functioning Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.26

 Phase I – Acute ◦ Best strategies to ensure patient safety and provide symptom stabilization  Phase II – Stabilization  Phase III – Maintenance ◦ Provide patient and family education ◦ Relapse prevention skills are vital Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.27

 Acute Phase ◦ Psychiatric, medical, and neurological evaluation ◦ Psychopharmacological treatment ◦ Support, psychoeducation, and guidance ◦ Supervision and limit setting in the milieu ◦ Monitor fluid intake Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.28

 Stabilization and Maintenance Phases ◦ Medication administration/adherence ◦ Relationships with trusted care providers ◦ Community-based therapeutic services Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.29

 Counseling and communication techniques ◦ Hallucinations ◦ Delusions ◦ Associative looseness ◦ Health teaching and health promotion Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.30

 Antipsychotic medications ◦ First-generation ◦ Second-generation ◦ Third-generation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.31

 Dopamine antagonists (D 2 receptor antagonists)  Target positive symptoms of schizophrenia  Advantage ◦ Less expensive than second generation  Disadvantages ◦ Extrapyramidal side effects (EPS) ◦ Anticholinergic side effects ◦ Tardive dyskinesia ◦ Weight gain, sexual dysfunction, endocrine disturbances Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.32

 Treat both positive and negative symptoms  Minimal to no extrapyramidal side effects (EPS) or tardive dyskinesia  Disadvantage – tendency to cause significant weight gain Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.33

 Aripiprazole (Abilify)  Dopamine system stabilizer  Improves positive and negative symptoms and cognitive function ◦ Little risk of EPS or tardive dyskinesia Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.34

 Anticholinergic toxicity  Neuroleptic malignant syndrome (NMS)  Agranulocytosis Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.35

 Antidepressants  Mood stabilizing agents Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.36

 Individual and group therapy  Psychoeducation  Medication prescription and monitoring  Basic health assessment  Cognitive remediation  Family therapy Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.37

1.Loose associations in a person with schizophrenia indicate A.paranoia. B.mood instability. C.depersonalization. D.poorly organized thinking. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 38

2.Which assessment finding represents a negative symptom of schizophrenia? A.Apathy B.Delusion C.Motor tic D.Hallucination Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 39

Schizophrenia spectrum disorders are biological disorders of the brain; they are a group of disorders with overlapping symptoms and treatments, and are categorized from least severe to most severe (schizophrenia). Schizophrenia varies in terms of which symptoms dominate, their severity, the impairment in affect and cognition, and the impact on social and other areas of functioning. Symptoms vary considerably among patients and fluctuate over time. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 40

 Psychotic symptoms are often more pronounced and obvious than symptoms of other disorders, making schizophrenia more apparent to others and increasing stigmatization. Neurochemical, genetic, and neuroanatomical findings help explain the symptoms of schizophrenia; however, no one theory accounts fully for the complexities of schizophrenia. Positive symptoms of schizophrenia (e.g., hallucinations, delusions, associative looseness) are easier to recognize and respond best to antipsychotic drug therapy. Negative symptoms of schizophrenia (e.g., social withdrawal and dysfunction, lack of motivation, reduced affect) respond less well to antipsychotic therapy and can be more debilitating. Psychosocial interventions such as support groups improve negative symptoms. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 41

 Cognitive impairment varies; it warrants careful assessment and active intervention to increase the patient’s ability to function and maximize the ultimate quality of life.  Comorbid depression must be identified and treated to reduce the potential for suicide, substance abuse, non-adherence, and relapse. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 42

 Some applicable nursing diagnoses include Disturbed sensory perception, Acute confusion, Impaired communication, Ineffective coping, Risk for self-directed or other-directed violence, and Impaired family coping.  Outcomes are chosen based on the phase of schizophrenia and the patient’s individual symptoms, needs, strengths, and level of functioning. Short-term and intermediate indicators are also developed to better track the incremental progress typical of schizophrenia. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 43

 Interventions for people with schizophrenia include trust- building and therapeutic communication: support; assistance with self-care, nutrition and sleep; promoting independence and stress management; promoting socialization; psycho- education about the illness and its treatment; milieu management; on-going risk assessment.  Therapeutic interventions for schizophrenia include cognitive-behavioral interventions, cognitive enhancement/remediation (evidence-based, highly structured, classes that educate patients about cognitive skills and provide computer-based and interpersonal practice of cognitive skills).  Improving and promoting reality testing are essential in care for people with schizophrenia. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 44

 Antipsychotic medications are essential in patients with schizophrenia. Nurses must understand the properties, desired and undesired effects, and dosages of first-, second-, and third-generation antipsychotics and other medications used.  Schizophrenia can produce countertransference responses in staff; clinical supervision and self-assessment help the nurse remain objective and therapeutic. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 45