1. Lecture 6 Community and Mental Health Nursing-NUR 472 Schizophrenia

2. Introduction  The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind).

3. Introduction (cont.)  More than any other mental illness, schizophrenia probably causes more  Lengthy hospitalizations  Chaos in family life  Exorbitant costs to people and governments  Fears

4. Nature of the Disorder  Schizophrenia: A serious mental disorder characterized by:  Disorganized and delusional thinking (Thought processes)  Disturbed perceptions/hallucinations  Inappropriate emotions and actions (affect)  With schizophrenia, there is a severe deterioration of social and occupational functioning

5. Nature of the Disorder (cont.)  Premorbid behavior of the client with schizophrenia can be viewed in four phases.

6. First Phase Schizoid personality  Indifferent, these people are loners. They do not enjoy close relationships with others.

7. Second Phase Prodromal phase  These people are socially withdrawn and show evidence of peculiar behavior  Neglect of personal hygiene and grooming  Inappropriate affect  Disturbances in communication  Bizarre ideas

8. Third Phase Schizophrenia  In the active phase of the disorder, psychotic symptoms are prominent  Delusions  Hallucinations  Impairment in work, social relations, and self-care

9. Fourth Phase Residual phase  Impairment in role functioning are prominent

10. Etiological Implications Schizophrenia is probably caused by a combination of factors, including  Biological and Heritability predisposition  Biochemical Causes  Physiological factors  Psychosocial stress  Environmental factors

11. Etiological Implications  Biological and Heritability predisposition Genetics plays an important role in the development of schizophrenia.  10% in those who have immediate family member.  40% if disease affect in both parents.  Biochemical Causes  Dopamine Hypothesis: schizophrenia is caused by excessive dopamine activity.

12. Predisposing Factors (cont.)  Physiological influences Examples of Various physical conditions  Epilepsy  Birth trauma  Head injury  Alcohol abuse  Cerebral tumor

13. Predisposing Factors (cont.)  Psychological influences  Deeply disrupted family.  Impaired sexual identity or body image.  Stressful life events.  Environmental influences  Viral epidemics: associated with viral diseases  Prenatal malnutrition  Low-socioeconomic

14.  Schizophrenia is diagnosed based on talking with the patient, and looking at his or her behaviour and experiences. Diagnosis

15.  MRI  Identifies brain changes  PET (Positron emission tomography) (is a nuclear medicine imaging)  Determines brain activity  EEG  Reveals electrical activity  Neurologic examination  Neuropsychologic tests Diagnosis – Examples of Important Tests

16. Types of Schizophrenia  Catatonic schizophrenia  Catatonic stupor: characterized by extreme psychomotor retardation; patient usually mute  Catatonic excitement: Extreme psychomotor agitation; purposeless movements that must be curtailed to prevent injury to client or others

17.  Disorganized schizophrenia  Chronic variety with inappropriate affect  Silliness and incongruous giggling common  Behavior bizarre; social interaction impaired Types of Schizophrenia

18.  Paranoid schizophrenia  Characterized by delusions of persecution or grandeur  Auditory hallucinations  Client may be argumentative, hostile, and aggressive Types of Schizophrenia

19.  Residual schizophrenia  Used to diagnose a person who has a history of at least one episode of schizophrenia with prominent psychotic symptoms Types of Schizophrenia

20.  Schizoaffective disorder  Schizophrenic symptoms accompanied by a strong element of symptomatology associated with mood disorders, either manic or depressive Types of Schizophrenia

21.  Brief psychotic disorder  Sudden onset of psychotic symptoms following a severe psychosocial stressor  Symptoms persist less than 1 month Types of Schizophrenia

22.  Schizophreniform disorder  Same symptoms as schizophrenia.  The duration of the disorder has been at least 1 month but fewer than 6 months Types of Schizophrenia

23.  Undifferentiated schizophrenia  Bizarre behavior that does not meet the criteria outlined for the other types of schizophrenia; delusions and hallucinations prominent Types of Schizophrenia

24. Nursing Process: Assessment Content of thought  Delusions: False personal beliefs  Religiosity: Excessive demonstration of obsession with religious ideas and behavior  Paranoia: Extreme suspiciousness of others

25. Nursing Process: Assessment (cont.) Content of thought (cont.)  Word salad: Group of words put together in a random fashion  Magical thinking: Idea that if one thinks something, it must be true  Mutism: Inability or refusal to speak

26. Nursing Process: Assessment (cont.) Form of thought  Associative looseness: Shift of ideas from one unrelated topic to another  Neologisms: Made-up words that have meaning only to the person who invents them  Perseveration: Persistent repetition of the same word or idea in response to different questions

27. Nursing Process: Assessment (cont.) Perception  Hallucinations: False sensory perceptions not associated with real external stimuli  Illusions: Misperceptions of real external stimuli

28. Nursing Process: Assessment (cont.)  Affect: Emotional tone  Inappropriate affect: Emotions are incongruent with circumstances  Apathy: Lack of interest in environment  Emotional ambivalence: Coexistence of opposite emotions toward same object

29. Nursing Process: Assessment (cont.)  Sense of Self: The uniqueness and individuality a person feels  Echolalia: Repeating words that are heard  Echopraxia: Repeating movements that are observed

30. Nursing Process: Assessment (cont.)  Impaired interpersonal functioning and relationship to the external world  Autism  Deterioration in appearance: Impaired personal grooming and self-care activities

31. Nursing Process: Assessment (cont.)  Psychomotor behavior (cont.)  Anergia: Deficiency of energy  Posturing: Voluntary assumption of inappropriate or bizarre postures  Pacing and rocking: Pacing back and forth and rocking the body

32. Nursing Process: Assessment (cont.)  Positive and negative symptoms  Positive symptoms: Excess or distortion of normal functions  Negative symptoms: Deficit or loss of normal functions

34.  Ineffective role performance  Powerlessness  Risk for injury  Risk for other-directed violence  Risk for self-directed violence  Social isolation  Imbalanced nutrition: Less than body requirements  Impaired home maintenance  Impaired social interaction  Impaired verbal communication  Ineffective coping List of Nanda Nursing Diagnosis for Schizophrenia

35.  Disturbed personal identity  Disturbed sensory perception (auditory, visual)  Disturbed sleep pattern  Disturbed thought processes  Dressing or grooming self-care deficit  Fear  Anxiety  Bathing or hygiene self-care deficit  Disabled family coping  Disturbed body image  Disturbed personal identity List of Nanda Nursing Diagnosis for Schizophrenia

36. Planning  The client  Demonstrates an ability to relate to others satisfactorily  Recognizes distortions of reality  Has not harmed self or others  Perceives self realistically  Demonstrates ability to perceive the environment correctly

37. Planning (cont.)  The client (cont.)  Maintains anxiety at a manageable level  Demonstrates ability to trust others  Uses appropriate verbal communication in interactions with others  Performs self-care activities independently

38. Implementation  Nursing interventions for the client with schizophrenia are aimed at:  Decreasing anxiety and establishing trust  Assisting client to define and test reality  Encouraging interaction with others  Ensuring safety of client and others  Meeting client ’ s self-care needs  Promoting adaptive family coping

39. Implementation -Client/Family Education  Nature of illness  What to expect as illness progresses  Symptoms associated with illness  Management of illness  Connection of exacerbation of symptoms to times of stress  Appropriate medication management

40. Implementation -Client/Family Education (cont.)  Management of illness (cont.)  Side effects of medications  Importance of not stopping medications  When to contact healthcare provider  Relaxation techniques  Social skills training  Daily living skills training

41. Evaluation  Evaluation questions  Has client established trust with at least one staff member?  Is anxiety level maintained at a manageable level?  Is delusional thinking still prevalent?  Is client able to interrupt escalating anxiety with adaptive coping mechanisms?  Is client easily agitated?  Is client able to interact with others ppropriately?

42. Treatment Modalities  Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary effort.  Psychological treatments  Individual psychotherapy: Long-term therapeutic approach difficult because of client’s impairment in interpersonal functioning

43. Treatment Modalities (cont.)  Psychological treatments (cont.)  Group therapy: Some success if participating over long-term course of the illness; less successful in short-term treatment  Behavior therapy  Occupational therapy

44. Treatment Modalities (cont.)  Psychological treatments (cont.)  Social skills training: Use of role play to teach client appropriate eye contact, interpersonal skills, posture, and so on, aimed at improving relationship development  Electroconvulsive therapy

45. Treatment Modalities (cont.)  Social treatment  Milieu therapy: Best if used in conjunction with psychopharmacology  Family therapy: Aimed at helping family members cope with long-term effects of illness

46. Treatment Modalities (cont.)  Psychopharmacology  Antipsychotics: Used to decrease agitation and psychotic symptoms  Antiparkinsonian agents  Others:  Reserpine  Lithium carbonate  Carbamazepine  Diazepam  Propranolol

47. Treatment Modalities (cont.)  Side effects for Antipsychotics (e. x:)  Nausea; GI upset; weight gain  Sedation  Decreased libido  Gynecomastia; amenorrhea  The client should  Not stop taking the drug abruptly  Not consume other medications (including over-the-counter drugs) without the physician’s knowledge