Schizophrenia Chapter 15 West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011

Eugen Bleuler’s 4 A’s of Schizophrenia Affect Associative looseness Autism Ambivalence

Epidemiology Lifetime prevalence of schizophrenia 1% worldwide Average onset is late teens to early twenties, but can be as late as mid-fifties 30% to 40% relapse rate in the first year Life expectancy is shortened because of suicide No difference related to Race, Social status, Culture

Comorbidity Substance abuse disorders Anxiety, depression, and suicide Nicotine dependence Anxiety, depression, and suicide Physical health or illness Polydipsia

Etiology Biological factors Neurobiological Genetics Neurobiological Dopamine theory Other neurochemical hypotheses Brain structure abnormalities

Etiology Continued Psychological and environmental factors Prenatal stressors Psychological stressors Environmental stressors

Signs and Symptoms Language and communication disturbances Thought disturbances Perception disturbances Affect disturbances Motor behavior disturbances Self-identity disturbances

Features of Schizophrenia Progression varies from one client to another Exacerbations and remissions Chronic but stable Progressive deterioration DSM-IV-TR Diagnosis Symptoms present at least 6 months Active-phase symptoms present at least 1 month Symptoms are defined as positive and negative

Phases of Schizophrenia Phase I – Acute Onset or exacerbation of symptoms Phase II – Stabilization Symptoms diminishing Movement towards previous level of functioning Phase III – Maintenance At or near baseline functioning

Assessment During the prepsychotic phase General assessment Positive symptoms (Excess or distorted) Negative symptoms (Deficit) Cognitive symptoms Affective symptoms

Positive Symptoms Alterations in thinking Delusions are false, fixed beliefs Persecutory, Referential Somatic, Religious, Substitution, Thought Insertion and/or Broadcasting Nihilistic, Grandiose Concrete thinking is an inability to think abstractly. Indecisiveness, lack of problem solving skills, Concreteness, thought blocking, perseveration

Positive Symptoms Continued Alterations in speech Neologisms Echolalia Echopraxia Clang associations Word salad Loose Association

Positive Symptoms Continued Alterations in perception Depersonalization Derealization Hallucinations Auditory hallucinations Command hallucinations Visual hallucinations Boundary impairment Negativism Impaired impulse control

Negative Symptoms (5A’s) Affect Flat, Blunted, Inappropriate, Bizarre Apathy Indifference towards people, events, activities and learning. Alogia Poverty of speech Avolition Inability to pursue and persist in goal-directed activities. Anhedonia Inability to experience pleasure.

Cognitive Symptoms Difficulty with Attention Memory Information processing Cognitive flexibility Executive functions

Affective Symptoms Assessment for depression crucial May herald impending relapse Increases substance abuse Increases suicide risk Further impairs functioning

Review Question A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? Positive symptom Negative symptom Cognitive symptom Depressive symptom

Review Question The nurse is documenting in the multidisciplinary treatment plan. Which assessment data depicts positive symptoms of schizophrenia? A. “I use to like going to the movies and spending time with my family but rather be alone.” B. “I don’t want to go to group.” Lack motivation and affect appear Blunted. C. “I can’t sit still and I feel like I want to jump out of my skin.” D. “There are cameras in the ceiling and the voices are whispering to me.”

Subtypes of Schizophrenia Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type

Subtypes of Schizophrenia - continued Paranoid Type Delusions Persecutory and grandiose Somatic or religious Hallucinations Delusions link with a hallucination Disorganized Type Disorganized speech, behavior, appearance Flat or inappropriate affect Fragmented hallucinations and delusions Most severe form of schizophrenia

Specific Interventions for Paranoid and Disorganized Schizophrenia Communication guidelines Self-care needs Milieu needs

Subtypes of Schizophrenia - continued Catatonic type Psychomotor retardation and stupor Waxy flexibility Mutism Extreme psychomotor agitation Echolalia Echopraxia

Specific Interventions for Catatonia Catatonia – Withdrawn Phase Communication guidelines Self-care needs Milieu needs Catatonia – Excited Phase

Subtypes of Schizophrenia - continued Undifferentiated type Active psychotic state (Positive & Negative symptoms) Lacks symptoms of other subtypes Residual type Active-phase symptoms no longer present No prominent positive symptoms Negative symptoms present

Other Psychotic Disorders Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Shared Psychotic Disorder (Folie à Deux) Induced or Secondary Psychosis

Assessment Guidelines 1. Any medical problems 2. Abuse of or dependence on alcohol or drugs 3. Risk to self or others Command hallucinations 5. Belief system 6. Suicide risk

Assessment Guidelines Continued 7. Ability to ensure self-safety Co-occurring disorders 9. Medications 10. Presence and severity of positive and negative symptoms 11. Patient’s insight into illness 12. Family’s knowledge of patient’s illness and symptoms

Potential Nursing Diagnoses Positive symptoms Risk for violence Disturbed sensory perception Risk for self-directed or other-directed violence Disturbed thought processes Negative symptoms Social isolation Chronic low self-esteem Altered health maintenance Ineffective coping Impaired verbal communication

Outcomes Identification Phase I - Acute Patient safety and medical stabilization Phase II - Stabilization Adhere to treatment Stabilize medications Control or cope with symptoms Phase III - Maintenance Maintain achievement Prevent relapse Achieve independence, satisfactory quality of life

Planning Phase I – Acute Phase II – Stabilization 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

Implementation Phase 1 – Acute Settings Partial hospitalization Residential crisis centers Halfway houses Day treatment programs

Interventions Acute Phase Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu

Interventions Continued Stabilization and Maintenance Phase Milieu management Activities and groups Safety Counseling and communication techniques

Interventions Continued Stabilization and Maintenance Phase, continued Hallucinations Delusions Associative looseness Health teaching and health promotion

Nursing Implications: Supporting Families Family needs vary with degree of illness and involvement in client’s care Education Financial support Psychosocial support Advocacy

Nursing Implications: Supporting Families - continued Schizophrenia is a “family illness.” Family members need to be involved. Educate family about Medication Illness Relapse prevention Nurse assists family by Identifying community agencies/groups for family members Advocating for rights

General Nursing Intervention Promote Safety and a Safe Environment Promote Congruent Emotional Response Promote Social Interaction and Activity Intervene with Hallucinations and Delusions Preventing Relapse Promoting adherence with medication regimen Assist with grooming and hygiene Promote Family Understanding and Involvement

Review Question The client informs you that the CIA monitoring his every move to find evidence that he killed someone. Which response by the nurse is therapeutic for the client?

Review Answers A. "I will make sure that the security guard will monitor your room.” B. "Don't worry you are safe here, the CIA can't enter the hospital.” C.  "You seem fearful for your safety, but you are safe here.” D. "Why do you think the CIA is following you, who did you kill?”

Psychopharmacology Prior to the 1950s: focus on behavioral interventions and sedatives Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine) Psychiatric medications allow for the improve imbalances of neurotransmitters. Goal is to treat quickly so disease does not progress. Clients may initially be resistant to medications.

Goals of Antipsychotics Positive Effects Allowed release of clients from inpatient hospital to treatment in the community Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation. Alleviation of the symptoms, often improving: Ability to think logically Ability to function in one’s daily life Ability to function in relationships

Negative Effects of Antipsychotics Frightening and life threatening side effects Potential interactions with other medications and substances Possible need to cope with the realization of having a chronic illness

All current antipsychotics work on at least one of these neurotransmitters: Dopamine Serotonin

Antipsychotics Typical (Conventional) Block dopamine receptors at 70% to 80% occupancy to be effective. Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80 Typical = Tardive Dyskinesia (TD) 5.4% vs 0.8% atypicals

Pharmacological Interventions Antipsychotic medications Conventional antipsychotics Typical or first-generation Atypical antipsychotics Second-generation

Conventional Antipsychotics Dopamine antagonists (D2 receptor antagonists) Target positive symptoms of schizophrenia Advantage Less expensive than atypical antipsychotics Disadvantages Do not treat negative symptoms Extrapyramidal side effects (EPSs) Tardive dyskinesia Anticholinergic side effects Lower seizure threshold

Conventional Antipsychotics Typical Agents Low Potency Chlorpromazine (Thorazine) (25 – 800 mg/d) Thioridazine (Mellaril) (150 – 800 mg/d) Mesoridazine (Serentil) (100 – 400 mg /d) Side Effects: Sedation, Anticholernergic, Hypotention, EPSEs (less vs high potency)

Conventional Antipsychotics High Potency Haloperidol (Haldol) (1 – 30 mg/d) Fluphenazine (Prolixin) (0.5 – 40 mg/d) Thiothixene (Navane) (2 – 30 mg/d) Trifluoperazine (Stelazine) (1 – 40 mg/d) Perhenazine (Trilafon) (8-60 mg/d) Loxapine (Loxitane) (20 – 250 mg/d) Molindone (Moban) (50 – 225 mg/d) Pimozide (Orap) 0.5 – 9 mg/d) Side Effects Sedation, Anticholenergic SE (less vs low potency) EPSEs (high vs low potency)

Conventional Long-Acting Injectables (Depot Therapy) Haloperidol Decanoate (Haldol Decanoate) Q4 weeks Fluphenazine Decanoate (Prolixin Decanoate) Q2 Weeks

Atypical Antipsychotics Treat both positive and negative symptoms Fewer extrapyramidal side effects (EPSs) or tardive dyskinesia Reduced affinity for dopamine (D2) receptors Affinity for serotonin receptors D2 antagonist + Serotonin receptor antagonist Disadvantage – tendency to cause significant weight gain

Atypical Antipsychotics Continued Clozapine (Clozaril) (6.25 – 900 mg/d) Side effects: 5% risk of seizures, agranulocytosis, weight gain, hypersalivation, anticholinergic Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) (5 – 20 mg/d) Side effects: Weight gain, diabetes, sedation, bankruptcy 20mg/day = $925/month Paliperidone (Invega) (3 – 12 mg/d) Quetiapine (Seroquel) (150 – 600 mg/d) Side effects: sedation, weight gain, restless leg syndrome Risperidone (Risperdal, Risperdal M-Tab) (2 – 6 mg/d) (Increase Prolactin)

Atypical Antipsychotics Continued Ziprasidone (Geodon) ( 40 – 160 mg/d) Side effects: QTc prolongation, minimal sedation Administer with food for improve efficacy Aripiprazole (Abilify) (15 – 30 mg/d) Side effects: akathisia, insomnia/sedation, maybe less weight gain Asenapine (Saphris) (5 – 10 mg/d) Sublingual Iloperidone (Fanapt) (12 – 24mg/d) Lurasidone HCL (Latuda) (40 – 80 mg/d)

Long-Acting Injectables Depot Therapy Risperidone Consta (Risperdal Consta) Q2 Weeks Paliperidone Sustenna (Invega Sustena) Q 4 weeks Zyprexa Relprevv (Q2 or Q4 weeks depending on the dose) Monitor for 3 hours after injection

Anti-Parkinson Medications Trihexyphenidyl (Artane) Benztropine (Cogentin) Diphenhydramine (Benadryl) Amantadine (Symmetrel)

Antiadrenergic Effect: Orthostatic Hypotension Take the client’s blood pressure in a supine position and then in a standing position. Caution clients to rise slowly from a supine position.

Extrapyramidal Side Effects Interventions Acute dystonia anticholinergics Akathisia anticholinergics but not always responsive Pseudoparkinsonism Tardive dyskinesia – Abnormal Involuntary Movement Scale (AIMS)

Dystonia Occurs usually within 48 hours of initiation of the medication Involves bizarre and severe muscle contractions Can be painful and frightening Characterized by odd posturing and strange facial expressions: Torticollis Opisthotonus Laryngospasm Oculogyric

Torticollis

Opisthotonus

Oculogyric Crises

Laryngospasm

Drug-induced Parkinsonism Usually occurs after 3 or more weeks of treatment Characterized by: Cogwheel rigidity Tremors at rest Rhythmic oscillations of the extremities Pill rolling movement of the fingers Bradykinesia Postural Changes

Akathisia Usually occurs after 3 or more weeks of treatment Subjectively experienced as desire or need to move Described as feeling like jumping out of the skin Mild: a vague feeling of apprehension or irritability Severe: an inability to sit still, resulting in rocking, running, or agitated dancing

Tardive Dyskinesia Usually occurs late in the course of long-term treatment Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping) Often irreversible Prophylactic use of vitamin E and Omega-3 FFA Avoid typical antipsychotics Abnormal Involuntary Movement Scale

Autonomic Nervous System Effects: Anticholinergic Side Effects Dry mouth Blurred vision Constipation Urinary retention Tachycardia

Interventions for Anticholenergic Side Effects Ice chips, hard candy Eye drops Fiber diet, exercise Increase fluid intake Catheterization

Potentially Dangerous Responses to Antipsychotics Neuroleptic malignant syndrome (NMS) Typically occurs in the first 2 weeks of treatment or when the dose is increased Hold the medication, notify the physician, and begin supportive treatments. Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis

Neuroleptic malignant syndrome (NMS) Risk Factors Dehydration Agitation or catatonia Increase dose of neuroleptic Withdrawal from anti-parkinson medication Long acting or depot medication Pharmacologic treatment Antipyretics Muscle relaxant Dopamine receptor agonist

Potentially Dangerous Responses to Antipsychotics Agranulocytosis Early symptoms: beginning signs of infection White blood cells are routinely monitored in clients taking clozapine (Clozaril).

Other Central Nervous System Effects Sedation Lowering of the seizure threshold: Observe clients with seizures disorders carefully when treatment is initiated.

Cardiac Effects Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias. An EKG can identify those at risk.

Blood, skin and eye effect Agranulocytosis Blurred Vision Skin photosensitivity Retinitis pigmentosa

Endocrine Effects Hyperprolactinemia may cause: Oligomenorrhea or amenorrhea in women Galactorrhea in women and rarely in men Osteoporosis if prolonged Impotence in males may occur. Diabetes Monitor blood glucose levels.

Weight Gain Monitor weight Teach about diet and exercise Weight gain may contribute to physical as well as psychosocial stressors

Adjuncts to Antipsychotic Drug Therapy Antidepressants Antimanic agents

Advanced Practice Interventions Psychotherapy Cognitive-behavioral therapy (CBT) Group therapy Medication Social skills training Cognitive remediation Family therapy