1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
Chapter 14
The Schizophrenias
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2. 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
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3. Schizophrenias: Prevalence and Comorbidity
Lifetime prevalence worldwide is 1%
No differences in regard to race, social status, culture, gender, or environment
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4. 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
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5. 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
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6. 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
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7. 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
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8. Types of Schizophrenia: Paranoid
Person is intensely suspicious toward others
Paranoid ideas cannot be corrected by experiences or modified by facts or reality
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9. 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
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10. Types of Schizophrenia: Catatonic
Essential feature: abnormal motor behavior
Extreme agitation
Extreme psychomotor retardation
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11. 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
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12. Types of Schizophrenia: Disorganized
Most regressed and socially impaired of all types
Large numbers of homeless population with this type
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13. 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
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14. 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
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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
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16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
Course of Disease
Maintenance
Acute symptoms decrease, especially positive symptoms
Stabilization
Symptoms are in remission
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17. Common Symptoms of Schizophrenia: Positive Symptoms
Defined as the florid psychotic symptoms
Hallucinations: false sensory perceptions
Auditory: most common
Visual
Gustatory
Olfactory
Tactile
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18. Common Symptoms of Schizophrenia: Positive Symptoms
Delusions: fixed, false beliefs
Ideas of reference
Thought broadcasting
Thought insertion
Thought withdrawal
Delusion of being controlled
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19. 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
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20. Common Symptoms of Schizophrenia: Positive Symptoms
Personal boundary difficulties
Depersonalization: feeling that person is unreal
Derealization: feeling that environment has changed
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21. Common Symptoms of Schizophrenia: Positive Symptoms
Bizarre behaviors
Extreme motor agitation
Stereotyped behaviors
Automatic obedience
Waxy flexibility
Stupor
Negativism
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22. 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
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23. Common Symptoms of Schizophrenia: Negative Symptoms
Anhedonia: lack of feeling pleasure in anything in life
Poor social functioning
Poverty of thought
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24. 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)
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25. 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
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26. 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
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27. 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
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28. 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
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29. Nursing Process: Planning and Implementation
Implementation: need to be geared toward patient’s strengths and healthy functioning as well as weaknesses/symptoms
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30. 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
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31. 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
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32. 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”
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33. 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
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34. 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
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35. 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
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36. 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
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37. 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)
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38. Treatment of Schizophrenia: Atypical Antipsychotics
Action: serotonin and dopamine antagonist
First atypical introduced: clozapine (Clozaril)
Problem: causes agranulocytosis (up to 1% of patients)
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39. 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
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40. 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
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41. 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
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42. 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
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43. 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
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44. 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
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45. 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?
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