1. Chapter 13: Schizophrenia and Other Psychotic Disorders Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. 2 Positive Symptoms of Schizophrenia  Hallucinations  Delusions  Paranoia Treatment:  Hospitalization  Typical antipsychotics  Reduced stimuli  Interactive therapy

3. 3 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Negative Symptoms of Schizophrenia  Apathy  Avolition (lack of motivation)  Blunted affect  Loss of emotional warmth  Impaired social skills  Anhedonia Treatment:  Atypical antipsychotics

4. 4 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Kraepelin: Dementia Praecox  Hallucinations  Delusions  Dereism  Thought blocking

5. 5 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Bleuler’s Four As  Affect  Autistic thinking  Ambivalence  Associations

6. 6 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Etiology  Heredity and genetic factors  Dopamine hypothesis  Other neurotransmitters  Neurodevelopment and other biologic factors  Stress (Selye, Roy)  Disease and trauma  Substance abuse  Psychologic factors  Culture and family environment

7. 7 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Genetic Inheritance  Selected factors activate genetic vulnerability  Winter birth  Viral infection in 28th to 30th weeks of pregnancy  Rh incompatibility  Starvation during pregnancy  Oxygen deprivation at birth

8. 8 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Dopamine Hypothesis  Excess dopamine  Possibilities:   Level in nigrostriatum   Dopamine-craving cells that overreact   Activity of dopamine antagonists

9. 9 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Other Possible Neurotransmitter Involvement  Serotonin  Acetylcholine  Norepinephrine  Cholecystokinin  Glutamate  GABA

10. 10 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychologic and Psychosocial Theories  Distorted mother-child relationship  Ego disorganization  Faulty reality interpretation

11. 11 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cultural and Environmental Factors  Low socioeconomic status  Lack of social support

12. 12 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Epidemiology Outcomes related to:  Later onset, premorbid functioning  Age, gender  Subtype  Fetal exposure to disease and trauma  Marital status, reproduction, mortality  Socioeconomic class  Culture, geography, seasonal influences

13. 13 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Relapse Prevention and Research  Denial of illness  Noncompliance  Lack of family support  Inability to cope with health system  Medication failures

14. 14 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. DSM-IV-TR Criteria  Lasting 6 months  Active-phase symptoms lasting at least 1 month include 2 of the following:  Hallucinations  Delusions  Disorganized or catatonic behavior  Disorganized speech

15. 15 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Subtypes  Paranoid  Disorganized  Catatonic  Undifferentiated  Residual

16. 16 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Related Disorders  Schizophreniform  Schizoaffective  Delusional  Brief psychotic disorder  Shared psychotic disorder  Psychotic disorder due to a general medical condition

17. 17 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Perceptual Disturbances  Negative self-perception  Hallucinations  Reduce stress.  Increase medication.  Reduce distractions.  Occupy mind.

18. 18 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Thought Disturbances  Delusions  Do not agree  Empathy  Circumstantially  Tangentiality  Autistic thinking  Perseveration  Poverty of thought  Loose association

19. 19 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Teaching Tips  Simplify material.  Reduce distractions.  Give verbal and visual information.  Use clear, direct terms.  Present small segments.  Reinforce frequently.  Do not offer confusing choices.

20. 20 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emotional and Behavioral Disturbances Emotional  Flattened affect  Poor eye contact Behavioral  Risk for violence

21. 21 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biologic Profiles  Diffused, nonlocalized areas of dysfunction  Impaired stimulus  Inhibition

22. 22 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment  Subjective client reporting  Objective  Observation  Rating scales  Biologic indicators  Mental status examination  Positive and negative symptoms

23. 23 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Important Tests  MRI  Identifies subtle brain changes  PET  Determines brain activity  BEAM  Measures brain activity  EEG  Reveals electrical activity

24. 24 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Important Tests, cont’d.  Eye tracking and auditory tests  Information processing deficits  Electrodermal activity (EDA)  Extent of negative symptoms  Neurologic examination  Neuropsychologic tests

25. 25 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Useful Nursing Diagnoses  Risk for suicide  Risk for violence  Disturbed sensory perception  Disturbed thought processes  Impaired verbal communication  Ineffective coping  Interrupted family processes  Self-care deficit  Social isolation

26. 26 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Outcome Identification  Demonstration of reality-based thinking  Reduction in hallucinations  Absence of delusions  Socialization with staff and peers  Adherence to medication regimen  Participation in discharge planning

27. 27 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Planning Geared to:  Whole person  Social environment  Family  Medical interventions  Socialization  Education for client and family

28. 28 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation  Establish relationship  Consider cost of plan  Provide:  Stimulation  Structure  Socialization  Support

29. 29 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Interventions  Assess/monitor risk factors.  Minimize environmental stimuli.  Provide low-key interactions.  Use clear, concrete communication.  Identify hallucination triggers.  Praise reality-based perceptions.

30. 30 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Interventions, cont’d.  Educate about:  Symptoms  Medication  Compliance  Postdischarge services  Distract from delusions.  Focus on feelings.  Provide structured activities initially.

31. 31 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Interventions, cont’d.  Assist with hygiene as needed.  Set hygiene goals.  Assess self-concept.  Role model social behaviors.  Spend time with client in nonchallenging activity.  Keep appointments.  Listen actively.

32. 32 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Self-Management  Accept that it is a prolonged illness.  Identify strengths and limitations.  Set clear, realistic goals.  Gradually return to responsibilities.  Establish regular, consistent routine.  Establish quiet, relaxed routine.  Reduce stress.

33. 33 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Self-Management, cont’d.  Work on trusting staff.  Take medication regularly.  Identify relapse signs early.  Avoid street drugs.  Eat well.  Get sufficient rest.  Exercise regularly.  Check reality with trusted person.  Accept setbacks.

34. 34 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Treatment Modalities  Psychopharmacology  Electroconvulsive therapy  Milieu therapy  Psychosocial rehabilitation  Individual therapy  Supportive  Reeducative  Reconstructive

35. 35 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Treatment Modalities, cont’d.  Group therapy  Family therapy  Behavior therapy  Cognitive therapy  Occupational therapy  Recreational therapy

36. 36 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Typical Antipsychotics  Reduce positive symptoms  Cause movement disorders

37. 37 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Atypical Antipsychotics  Block serotonin receptors  Reduce negative symptoms  Do not affect movement  Influence glutamate  Improve cognition  Improve tardive dyskinesia  Have few anticholinergic side effects

38. 38 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nurse’s Role Related to Psychopharmacology  Administer.  Assess effects and side effects.  Promote education.  Teach lifelong skills for community living.  Monitor quality-of-life issues.

39. 39 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Reducing and Managing Violence  Reduce stress.  Clarify expectations concerning rules.  Avoid behaviors that may be misinterpreted.  Determine etiology.  Avoid blame, ridicule, teasing.  Avoid whispering.

40. 40 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Reducing and Managing Violence, cont’d.  Respect boundaries.  Intervene early.  Use deescalation skills.  Nonthreatening verbal and nonverbals  Medicate (PO or IM) prn.