Copyright © 2009 by Saunders, an imprint of Elsevier Inc. Chapter 14 The Schizophrenias Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Concept of Schizophrenia Schizophrenia: devastating brain disease affecting thinking, language, emotions, social behavior, and reality perception Psychotic disorder: refers to experiencing such phenomena as delusions, hallucinations, disorganized speech or behavior Considered a severe mental illness (SMI) Chronic condition; treatable but not curable Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Schizophrenias: Prevalence and Comorbidity Lifetime prevalence worldwide is 1% No differences in regard to race, social status, culture, gender, or environment Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Schizophrenias: Prevalence and Comorbidity Substance abuse disorders: approximately 40%-50% of people with schizophrenia Nicotine dependence: 75%-85% of people with schizophrenia Depressive disorders, anxiety disorders and psychosis-induced polydipsia also common Suicide 20 times more prevalent than general population Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Biological Theories Related to Schizophrenia Brain chemistry, brain activity different in a person with schizophrenia Genetics Twin and adoptive studies validate major role Multiple genes believed to be involved Neurobiological factors Dopamine theory: derived from fact that antipsychotic drugs decrease dopamine and decrease symptoms of schizophrenia Current research: other neurotransmitters involved Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Biological Theories Related to Schizophrenia Neuroanatomical factors Brain-imaging techniques validate differences in structure of brain Lower brain volume Larger lateral and third ventricles Atrophy in frontal lobe More cerebrospinal fluid Low rate of blood flow and glucose metabolism in frontal lobes of cerebral cortex Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Other Theories Related to Schizophrenia Nongenetic risk factors Increased in pregnancy and birth complications Prenatal risk factors: viral infection, poor nutrition, or exposure to toxins Stress: can precipitate illness in vulnerable people Use of street drugs increases risk Cultural considerations Cultures interpret schizophrenia differently Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Paranoid Person is intensely suspicious toward others Paranoid ideas cannot be corrected by experiences or modified by facts or reality Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Paranoid Defense mechanism used Projection: attributing to others, one’s own feelings Ideas of reference common Misinterprets messages of others or given private meaning to communication Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Catatonic Essential feature: abnormal motor behavior Extreme agitation Extreme psychomotor retardation Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Catatonic Other behaviors Posturing: holding arms/legs rigid for long periods Waxy flexibility: when placed in awkward position, holds position for long time Stereotyped behavior: obsessively following routine Negativism and resistance or automatic obedience Echolalia: repetition of words of another Echopraxia: mimicking movement of another Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Disorganized Most regressed and socially impaired of all types Large numbers of homeless population with this type Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Disorganized Characterized by: Looseness of associations Grossly inappropriate affect Bizarre mannerisms Incoherent speech Fragmented and poorly organized hallucinations/delusions Frequent giggling or grimacing in response to internal stimuli Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Types of Schizophrenia: Undifferentiated and Residual Active signs of disorder present, but individual does not meet criteria for other types Residual Active-phase symptoms no longer present, evidence of residual symptoms: lack of initiative, social withdrawal, inability to work/study, vague speech, magical thinking Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Copyright © 2009 by Saunders, an imprint of Elsevier Inc. Course of Disease Prodromal Early symptoms preceding diagnosis: social withdrawal, deterioration in function, perceptual disturbances, magical thinking, and peculiar behavior Acute Florid positive symptoms occur Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Copyright © 2009 by Saunders, an imprint of Elsevier Inc. Course of Disease Maintenance Acute symptoms decrease, especially positive symptoms Stabilization Symptoms are in remission Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Positive Symptoms Defined as the florid psychotic symptoms Hallucinations: false sensory perceptions Auditory: most common Visual Gustatory Olfactory Tactile Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Positive Symptoms Delusions: fixed, false beliefs Ideas of reference Thought broadcasting Thought insertion Thought withdrawal Delusion of being controlled Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Positive Symptoms Impaired ability to use abstract thought Associative looseness: thinking is haphazard, illogical, and confused Neologisms: made-up words Echolalia and echopraxia Clang association: meaningless rhyming or words Word salad: jumble of words together Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Positive Symptoms Personal boundary difficulties Depersonalization: feeling that person is unreal Derealization: feeling that environment has changed Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Positive Symptoms Bizarre behaviors Extreme motor agitation Stereotyped behaviors Automatic obedience Waxy flexibility Stupor Negativism Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Negative Symptoms Changes in affect Flat affect: no emotion displayed Inappropriate affect: emotional response incongruent to situation Blunted affect: minimal emotional response Bizarre affect: grimacing, giggling, mumbling Apathy Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Common Symptoms of Schizophrenia: Negative Symptoms Anhedonia: lack of feeling pleasure in anything in life Poor social functioning Poverty of thought Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Assessment Guidelines Review medical workup to rule out medical cause and use of abusive substances Assess for command hallucinations (voices telling patient to harm self or others) Determine patient’s belief system (delusions, paranoid beliefs) Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Assessment Guidelines Determine any psychiatric comorbidity Determine medication use/compliance Determine family response to patient/symptoms Determine social support system Use Global Assessment of Functioning (GAF) scale Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses Disturbed sensory perception, Disturbed thought processes, Impaired verbal communication, Social isolation, Ineffective coping, Compromised family coping Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Diagnosis and Outcomes Identification Outcome identification: dependent on particular phase of illness Overall goal: patient safety and medical stabilization Other goals: help patient adhere to medication regimens, understand disease, participate in psychoeducational programs, prevent relapse Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Planning and Implementation Planning: dependent on particular phase of illness Acute phase: planning strategies to ensure patient safety and stabilize symptoms Maintenance phase: planning strategies to provide patient and family education Stabilization phase: planning strategies to prevent relapse Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Planning and Implementation Implementation: need to be geared toward patient’s strengths and healthy functioning as well as weaknesses/symptoms Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Communication Guidelines for the Patient with Schizophrenia Dealing with hallucinations and delusions Approach patient in nonthreatening and nonjudgmental manner Identify feelings patient is experiencing Clarify reality of patient’s experience Avoid arguing/attempt to reason with patient who is delusional Interact with patient about concrete reality Distract patient’s attention from hallucination/delusional belief Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Communication Guidelines for the Patient with Schizophrenia Dealing with the patient who is paranoid Be honest and consistent Avoid talking, laughing, whispering when patient cannot hear what is being said Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Communication Guidelines for the Patient with Schizophrenia Dealing with associative looseness Do not pretend to understand patient’s communications when you do not Tell patient you are having difficulty understanding Look for recurring topics or themes Emphasize what is going on in the “here and now” Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Guidelines for Health Teaching and Promotion Include patient and family in teaching Topics to include Disease process Medications and side effects Prevention of relapse Stress management Sources of ongoing support for patient and family Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment for Schizophrenia: Milieu Therapy Therapeutic milieu can be in hospital, partial hospitalization program, halfway house or day treatment program Aspects of milieu therapy Safety: protect patient and others Structured routine Use of group therapy, supervised activities, individual counseling, specialized training, and rehabilitation Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Psychotherapy Program for Assertive Community Treatment (PACT) Prevent relapse, maximize social and vocational functioning and keep individual in community Family therapy Support family and use psychoeducation to help establish improved communication and functioning Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Psychotherapy Cognitive-behavioral therapy Helps reduce frequency and intensity of delusions and hallucinations Social skills training Helps improve level of social activity, foster new social contacts, improve quality of life Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment for Schizophrenia: Antipsychotic Medications Used to alleviate symptoms, not curative When patients discontinue medication, psychotic symptoms/relapse occurs Each relapse leads to longer recovery time and possibility that patient will become unresponsive to medications Types of antipsychotic medications Conventional (first-generation) Atypical (second-generation) Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Atypical Antipsychotics Action: serotonin and dopamine antagonist First atypical introduced: clozapine (Clozaril) Problem: causes agranulocytosis (up to 1% of patients) Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Atypical Antipsychotics Advantage of atypicals Alleviate positive and negative symptoms Produce minimal extrapyramidal symptoms Help improve cognitive deficits and decrease anxiety and depression Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Atypical Antipsychotics Disadvantage of atypicals Tend to cause weight gain associated with additional metabolic side effects increasing risk for diabetes, cardiovascular disease, and hypertension More expensive than conventional antipsychotics Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Conventional Antipsychotics Action: dopamine antagonist at D2 receptor sites in both limbic and motor areas of brain Disadvantage: side effect profile is severe Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Conventional Antipsychotics Major side effects: extrapyramidal symptoms Tardive dyskinesia (TD): tongue movements, lip smacking with uncontrollable biting, chewing, or sucking movements Acute dystonia: muscle cramps of head and neck Akathisia: internal and external restlessness Pseudoparkinsonism: stiffened extremities, fine motor tremors Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Schizophrenia: Conventional Antipsychotics Other side effects Neuroleptic malignant syndrome (NMS): occurs from dopamine blockage Produces decreased level of consciousness, increased muscle tone, high fever, hypertension, sweating, tachycardia, drooling Discontinue antipsychotic drug, treat symptomatically in intensive care environment Dopaminergic medications bromocriptine (Parlodel) and dantrolene (Dantrium) Agranulocytosis Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Implementations for Antipsychotic Medications Use Abnormal Involuntary Movement Scale (AIMS) for early recognition of EPS Use anticholinergic medications as treatment for EPS Monitor patient for symptoms of agranulocytosis Monitor patient for symptoms of NMS and intervene early Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Process: Evaluation Recognize that process of improvement may take long time Consider questions such as: Are patient strengths being used to achieve outcomes? Are more appropriate interventions available? Are medications effectively reducing symptoms? Are family members involved and supportive? Are community resources appropriately used? Copyright © 2009 by Saunders, an imprint of Elsevier Inc.