1. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Chapter 15 Schizophrenia Schizophrenia

2. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2 Eugen Bleuler’s 4 A’s of Schizophrenia AffectAffect Associative loosenessAssociative looseness AutismAutism AmbivalenceAmbivalence

3. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3 Epidemiology Lifetime prevalence of schizophrenia 1% worldwideLifetime prevalence of schizophrenia 1% worldwide No difference related toNo difference related to –Race –Social status –Culture

4. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Comorbidity Substance abuse disordersSubstance abuse disorders –Nicotine dependence Anxiety, depression, and suicideAnxiety, depression, and suicide Physical health or illnessPhysical health or illness PolydipsiaPolydipsia

5. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5 Etiology Biological factorsBiological factors –Genetics NeurobiologicalNeurobiological –Dopamine theory –Other neurochemical hypotheses Brain structure abnormalitiesBrain structure abnormalities

6. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Etiology Continued Psychological and environmental factorsPsychological and environmental factors –Prenatal stressors –Psychological stressors –Environmental stressors

7. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 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

8. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Assessment During the prepsychotic phaseDuring the prepsychotic phase General assessmentGeneral assessment –Positive symptoms –Negative symptoms –Cognitive symptoms –Affective symptoms

9. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9 Positive Symptoms Alterations in thinkingAlterations in thinking –Delusions are false, fixed beliefs. –Concrete thinking is an inability to think abstractly.

10. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10 Positive Symptoms Continued Alterations in speechAlterations in speech –Neologisms –Echolalia –Echopraxia –Clang associations –Word salad

11. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11 Positive Symptoms Continued Alterations in perceptionAlterations in perception –Depersonalization –Derealization –Hallucinations Auditory hallucinationsAuditory hallucinations Command hallucinationsCommand hallucinations Visual hallucinationsVisual hallucinations –Boundary impairment

12. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 Positive Symptoms Continued Alterations in behavior –Catatonia –Motor retardation –Motor agitation –Stereotyped behaviors –Automatic obedience –Waxy flexibility –Negativism –Impaired impulse control

13. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13 Negative Symptoms AffectAffect –Flat –Blunted –Inappropriate –Bizarre

14. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14 Cognitive Symptoms Difficulty withDifficulty with –Attention –Memory –Information processing –Cognitive flexibility –Executive functions

15. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15 Affective Symptoms Assessment for depression crucialAssessment for depression crucial –May herald impending relapse –Increases substance abuse –Increases suicide risk –Further impairs functioning

16. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?

17. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17 a.Positive symptom b.Negative symptom c.Cognitive symptom d.Depressive symptom

18. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18 Assessment Guidelines 1. Any medical problems 2. Abuse of or dependence onalcohol or drugs 2. Abuse of or dependence on alcohol or drugs 3. Risk to self or others 4. Command hallucinations

19. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Assessment Guidelines Continued 5. Belief system 6. Suicide risk 7. Ability to ensure self-safety 8. Co-occurring disorders

20. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20 Assessment Guidelines Continued 9. Medications 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

21. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21 Potential Nursing Diagnoses Positive symptomsPositive symptoms –Disturbed sensory perception –Risk for self-directed or other-directed violence –Disturbed thought processes Negative symptomsNegative symptoms –Social isolation –Chronic low self-esteem

22. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22 Outcomes Identification Phase I - AcutePhase I - Acute Patient safety and medical stabilization Phase II - StabilizationPhase II - Stabilization –Adhere to treatment –Stabilize medications –Control or cope with symptoms Phase III - MaintenancePhase III - Maintenance –Maintain achievement –Prevent relapse –Achieve independence, satisfactory quality of life

23. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23 Planning Phase I – Acute Phase I – Acute –Best strategies to ensure patient safety and provide symptom stabilization Phase II – StabilizationPhase II – Stabilization Phase III – MaintenancePhase III – Maintenance –Provide patient and family education –Relapse prevention skills are vital

24. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24 Implementation Phase 1 – Acute SettingsPhase 1 – Acute Settings –Partial hospitalization –Residential crisis centers –Halfway houses –Day treatment programs

25. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 25 Interventions Interventions Acute PhaseAcute Phase –Psychiatric, medical, and neurological evaluation –Psychopharmacological treatment –Support, psychoeducation, and guidance –Supervision and limit setting in the milieu

26. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 26 Interventions Continued Interventions Continued Stabilization and Maintenance PhaseStabilization and Maintenance Phase –Milieu management –Activities and groups –Safety –Counseling and communication techniques

27. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 27 Interventions Continued Stabilization and Maintenance Phase, continuedStabilization and Maintenance Phase, continued –Hallucinations –Delusions –Associative looseness –Health teaching and health promotion

28. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 28 Pharmacological Interventions Antipsychotic medicationsAntipsychotic medications –Conventional antipsychotics Typical or first-generationTypical or first-generation –Atypical antipsychotics Second-generationSecond-generation

29. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 29 Atypical Antipsychotics Treat both positive and negative symptomsTreat both positive and negative symptoms Minimal to no extrapyramidal side effects (EPSs) or tardive dyskinesiaMinimal to no extrapyramidal side effects (EPSs) or tardive dyskinesia Disadvantage – tendency to cause significant weight gainDisadvantage – tendency to cause significant weight gain

30. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 30 Atypical Antipsychotics Continued ExamplesExamples –Clozapine (Clozaril) – use declining –Risperidone (Risperdal) –Olanzapine (Zyprexa) –Quetiapine (Seroquel) –Ziprasidone (Geodon) –Aripiprazole (Abilify)

31. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 31 Conventional Antipsychotics Dopamine antagonists (D2 receptor antagonists)Dopamine antagonists (D2 receptor antagonists) Target positive symptoms of schizophreniaTarget positive symptoms of schizophrenia AdvantageAdvantage –Less expensive than atypical antipsychotics DisadvantagesDisadvantages –Do not treat negative symptoms –Extrapyramidal side effects (EPSs) –Tardive dyskinesia –Anticholinergic side effects –Lower seizure threshold

32. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 32 Extrapyramidal Side Effects Extrapyramidal Side Effects Acute dystoniaAcute dystonia AkathisiaAkathisia PseudoparkinsonismPseudoparkinsonism Tardive dyskinesia – Abnormal Involuntary Movement Scale (AIMS)Tardive dyskinesia – Abnormal Involuntary Movement Scale (AIMS)

33. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 33 Potentially Dangerous Responses to Antipsychotics Neuroleptic malignant syndrome (NMS)Neuroleptic malignant syndrome (NMS) AgranulocytosisAgranulocytosis

34. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 34 Adjuncts to Antipsychotic Drug Therapy AntidepressantsAntidepressants Antimanic agentsAntimanic agents

35. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 35 Specific Interventions for Catatonia Catatonia – Withdrawn PhaseCatatonia – Withdrawn Phase –Communication guidelines –Self-care needs –Milieu needs Catatonia – Excited PhaseCatatonia – Excited Phase –Communication guidelines –Self-care needs

36. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 36 Specific Interventions for Disorganized Schizophrenia Communication guidelinesCommunication guidelines Self-care needsSelf-care needs Milieu needsMilieu needs

37. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 37 Undifferentiated Schizophrenia Active signs of disorderActive signs of disorder –Positive symptoms –Negative symptoms Individual does not meet criteria for any other subtypeIndividual does not meet criteria for any other subtype

38. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 38 Residual Schizophrenia Active-phase symptoms no longer presentActive-phase symptoms no longer present Evidence of two or more residual symptoms persistsEvidence of two or more residual symptoms persists –Reduced initiative, interests, or energy –Social withdrawal –Impaired role function –Speech deficits –Odd beliefs

39. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 39 Advanced Practice Interventions PsychotherapyPsychotherapy Cognitive-behavioral therapy (CBT)Cognitive-behavioral therapy (CBT) Group therapyGroup therapy MedicationMedication Social skills trainingSocial skills training Cognitive remediationCognitive remediation Family therapyFamily therapy