Chapter 31 Schizophrenia and Other Psychoses

Schizophrenia and Other Psychoses Psychosis The inability to recognize reality, relate to others, or cope with life’s demands The most common psychosis is schizophrenia. Other psychotic disorders include the following: Brief psychotic disorder Delusional disorder Psychoses related to medical conditions or drug use Explain the differences between a psychosis and other mental health disorders. Schizophrenia is not a single disorder, but rather a group of psychoses. Schizophrenia involves the most complex and frightening symptoms. For example, individuals may hear voices, think other people or machines are controlling them, feel bugs crawling on their bodies, or believe other people are plotting against them.

Continuum of Neurobiological Responses Neurobiological functions Can be viewed as existing along a continuum of behavioral responses Highly adaptive, effective responses-by using logical thoughts and socially acceptable ways Maladaptive, even destructive behaviors Individuals who do not adapt as well are placed at the middle of the spectrum. Describe the continuum of neurobiological responses. Many people label individuals with schizophrenia as “schizophrenics.” Is labeling appropriate? (Just as we do not label a person with cancer as “cancers” we should not label other disease states. If we do label, we imply that the disorder encompasses the individual’s entire being, but this is not the case. Although the disorder can be very serious, many people have mild cases and learn to cope with the symptoms and function effectively in society.)

Psychoses Throughout the Life Cycle Psychoses in childhood-can occur in children as young as 5 years of age Failure to thrive syndrome Slowed physical growth caused by an inability to integrate the physical, emotional, and sensorimotor realms of functioning Related to neglect, environmental problems, and severe family stress Risk factors for childhood schizophrenia Genetic influences Complications during pregnancy or birth Biochemical imbalances List and define the signs and symptoms of psychosis in childhood.

Psychoses Throughout the Life Cycle Psychoses in adolescence The average teen is in contact with reality; the adolescent with schizophrenia is not. Changes in behavior are noted: Poor hygiene Strange, vague speech Social withdrawal Odd behaviors Bizarre thoughts and beliefs Unusual superstitions List and define the signs and symptoms of psychosis in adolescence.

Psychoses Throughout the Life Cycle Psychoses in adulthood The onset of acute symptoms most often occurs in men during their middle twenties, while women usually present with symptoms in their late twenties. The prognosis for individuals with schizophrenia is better if adaptive interpersonal relationships and acceptable school performance and work histories were in place before the onset of symptoms. Can you think of a couple of factors that may contribute to the gender differences in the age of onset?

Psychoses Throughout the Life Cycle Psychoses in older adulthood Schizophrenia is seldom diagnosed in older adults. Older adults with schizophrenia may spend the remainder of their days in long-term care facilities. Remember that the acute onset of psychotic behavior in any elderly client must be investigated. Can you think of a medication a client may be taking for another disease that could induce psychotic behavior? (steroids) Ask for other examples.

Theories Related to Psychoses Schizophrenia exists in all cultures and socioeconomic groups; about 1% of world’s population is affected. Biological theories Stress/disease/trauma model Addresses the effects of stress on the individual, especially during the prenatal period Genetic factors Neurochemical models Neurotransmitters such as serotonin, norepinephrine, and dopamine have been implicated as possible causes of schizophrenia. What theories are related to the causes of schizophrenia and other psychoses?

Theories Related to Psychoses Other theories Psychological models Schizophrenia is caused by a basic character flaw combined with poor family relationships. Sociocultural theories Effects of the environment may lead to the development of psychoses.

Psychotic Disorders Schizophrenia Subtypes of schizophrenia Catatonic- manifested by motor immobility Disorganized-manifested by being unable to think, speak, or act in an organized manner Paranoid-believe someone or thing is out to get them Residual-free of acute psychosis but still has negative symptoms of withdrawal, emotional changes, disorganized thinking, and odd behaviors What are the differences between subtypes of schizophrenia? Catatonic: characterized by a lack of or peculiar motor movements Disorganized: showing the most psychological disorganization and lacking a systematic set of delusions Paranoid: characterized by delusions of persecution Undifferentiated: a “catchall” for people who do not fit into the other subtypes Residual: a mild form that occurs after at least one schizophrenic episode; does not have prominent delusions, hallucinations, and so on.

Psychotic Disorders Schizophrenia Signs, symptoms, and behaviors The main characteristic of psychotic disorders is loss of contact with reality to the point where functioning is grossly impaired. The signs and symptoms of schizophrenia affect perception, physical appearance, cognitive processes, language, speech, emotions, behavior, and social realms. One hallmark of psychosis are hallucinations-sensory inputs without external stimuli. They can take form of smells sounds, tastes, sight, touch, or feelings of altered internal body functions. The other hallmark is delusions where there are fixed false ideas not based in reality. Illusions are false perceptions and agnosia is the inability to recognize familiar objects or people are also common in schizophrenia. Cognitive area will show problems with attention, memory, and use of language Describe the signs, symptoms, and behaviors exhibited by an individual with schizophrenia. If a client presents with a variety of symptoms from all five categories, what would be the priority symptom to treat? What characteristics would determine whether the client requires an inpatient admission?

Psychotic Disorders Schizophrenia Signs, symptoms, and behaviors Language difficulties involve incorrect usage. Speech problem will include a number of unusual characteristics; such as clang associations, concrete thinking, echolalia, flight of ideas, loose associations, ideas of reference, mutism, pressured speech, neologisms, verbigeration and word salad. Be sure to review Table31.3 Thought processes vary from reality to fantasy. Remember the negative more than positive. May demonstrate preservation, poverty of thought. Judgement is impaired. Emotional experience a range of inappropriate emotions. Alexithymia, apathy, anhedonia Poor impulse control Describe the signs, symptoms, and behaviors exhibited by an individual with schizophrenia. If a client presents with a variety of symptoms from all five categories, what would be the priority symptom to treat? What characteristics would determine whether the client requires an inpatient admission?

Psychotic Disorders Schizophrenia Unable to establish or maintain relationships with others; self-esteem is low and confusion about gender identity Characteristic symptoms fall into two broad categories—positive and negative. Positive symptoms relate to maladaptive thoughts or behaviors-include hallucinations, speech problems, and bizarre behaviors Negative symptoms relate to lack of adaptive mechanisms-include flat or blunt affect, poor grooming, withdrawal, and poverty of speech. Describe the signs, symptoms, and behaviors exhibited by an individual with schizophrenia. If a client presents with a variety of symptoms from all five categories, what would be the priority symptom to treat? What characteristics would determine whether the client requires an inpatient admission?

Psychotic Disorders Schizophrenia Phases of becoming disorganized The course of schizophrenia is marked by episodes of acute psychosis alternating with periods of relatively normal functioning. The symptoms of schizophrenia must occur for at least 1 year before a diagnostic label is assigned. The slide into schizophrenia commonly occurs over four stages: Prodromal phase-begins with withdrawal, a lack of energy, and little motivation; appear confused and in a world of their own Prepsychotic phase- quiet, passive, and obedient, and they prefer to be alone; family describe person as “slipping away” Acute phase-include disturbances in thought, perception, behavior, and emotion; unable to accomplish ADLs Residual phase-follows an acute episode Remission phase-ability to manage some basic ADLs

Psychotic Disorders Other psychoses Brief psychotic disorder A psychotic disturbance that lasts longer than 1 day but less than 1 month Delusional disorder Characterized by more than 1 month of nonbizarre (reality-based) fixed ideas Shared psychotic disorder The individual is influenced by someone else who has an established delusion. Schizoaffective disorder When depression or mania is also present

Therapeutic Interventions Introducing yourself and start to build on a trusting relationship is important when starting to work with a new client Goals of inpatient, short-term care include the following: Stabilize the client. Prevent further decline in functioning. Assist the client in coping with his or her disorder. Long-term goals include psychosocial and vocational rehabilitation. Avoid confrontation or challenges of delusions or hallucinations

Therapeutic Interventions Pharmacological therapy Antipsychotic or neuroleptic Slow the central nervous system (CNS) After an antipsychotic drug is taken, hallucinations and delusions decrease, thought processes change, and hyperactivity subsides. Neuroleptic medications will help with positive symptoms such as paranoia, hallucinations, delusions, and agitation all characteristic of schizophrenia. Side effects can include dystonic reactions, apparent in few hours or days. These side effects can be treated generally with diphenhydramine or other anticholinergic medications What are the main pharmacological treatments and mental health therapies for clients with schizophrenia?

Therapeutic Interventions Nursing process Primary nursing diagnoses: Disturbed thought processes Disturbed sensory perceptions Social isolation Impaired communications Ineffective management of therapeutic regimen Altered Role Performance The basic goals of care are to assist clients in controlling their symptoms and achieving the highest possible level of functioning. Using open ended questions and periods of silence are effective ways to encourage the client to discuss his/her feelings

Therapeutic Interventions Special considerations The most common side effects of antipsychotic medications reflect alterations in CNS and peripheral nervous system functions: Extrapyramidal side effects (EPSEs) Sedation Anticholinergic effects- such as dry mouth, blurred vision, urinary retention Akathisia Akinesia Bradykinesia Dyskinesia Dystonia Neuroleptic malignant syndrome-begin with a sudden change in the client’s level of consciousness, tachycardia, agitation, and diaphoresis, and a rapid onset of rigid muscles; cardinal sign of NMS is high body temperature as high as 108 but most often 101 to 103

Therapeutic Interventions Nursing responsibilities Nurses should review desired actions, side effects, and incompatibilities for each medication prescribed. Monitor client response to each medication. Clients and their families must be continuously actively involved in the treatment. Client and family education has a direct impact on the client’s level of functioning. Need to monitor for possible signs of suicide tendencies or attempts especially when positive symptoms are improving. List the nursing responsibilities related to antipsychotic medications. Discharge planning needs to include medication teaching. Not taking medications correctly or not understanding the need for compliance leads to relapse of symptoms.