Schizophrenia

1. Schizophrenia Chapter 16

2. Schizophrenia • Fascinated and confounded healers for centuries • One of most severe mental illnesses • 1/3 of population • 2.5% of direct costs of total budget • $46 billion in indirect costs

3. History of Schizophrenia • 1800s - Eugene Kraeplin named it “dementia praecox.” • 1900s - Eugen Bleuler named it schizophrenia (split minds). More than one type. • Kurt Schneider - First rank (psychosis, delusions) and second rank (all other experiences)

4. Schizophrenia Diagnosis • During a one-month period at least two of the five • Positive (delusions, hallucinations, etc.) • Negative (alogia, anhedonia, flat affect, avolition) • One or more areas of social or occupational functioning

5. Types of SchizophreniaText Box 16.1 • Paranoid • Disorganized • Catatonic • Undifferentiated • Residual

6. Schizophrenia Negative Avolition Alogia Anhedonia Flat Affect Ambivalence Positive Hallucinations Delusions Disorganization Neurocognitive Impairment Attention Memory Exec Function

7. Positive Symptoms: Excess of Normal Functions • Delusions (fixed, false beliefs) • Grandiose • Nihilistic • Persecutory • Somatic • Hallucinations (perceptual experiences) • Thought disorder • Disorganized speech • Disorganized or catatonic behavior

8. Negative Symptoms: Less Than Normal Functioning • Affective blunting: reduced range of emotion • Alogia: reduced fluency and productivity of language and thought • Avolition: withdrawal and inability to initiate and persist in goal-directed behavior • Anhedonia: inability to experience pleasure • Ambivalence: concurrent experience of opposite feelings, making it impossible to make a decision

9. Neurocognition Memory (short-, long-term) Vigilance (sustained attention) Verbal fluency (ability to generate new words) Executive functioning volition planning purposive action self-monitoring behavior Impaired in schizophrenia Memory (working) Vigilance Executive functioning Neurocognitive Impairment • Evidence that neurocognitive impairment exists, • independent of positive and negative symptoms

10. Neurocognitive Impairment Often Seen as “Disorganized Symptoms” • Confused speech and thinking patterns • Disorganized behavior • Examples of disorganized thinking • Echolalia (repetition of words) • Circumstantially (excessive detail) • Loose associations (ideas loosely connected) • Tangentially (logical, but detour) • Flight of ideas (change topics) • Word salad (unconnected words)

11. Disorganized Symptoms • Examples of disorganized thinking (cont.) • Neologisms (new words) • Paranoia (suspiciousness) • References ( special meaning) • Autistic thinking (private logic) • Concrete thinking (lack of abstract thinking) • Verbigeration (purposeless repetition) • Metonymic speech (interchange words)

12. Disorganized Symptoms • Examples of disorganized thinking (cont.) • Clang association (repetition similar sounding words) • Stilted language (artificial, formal) • Pressured speech (words forced) • Examples of disorganized behavior • Aggression • Agitation • Catatonic excitement (hyperactivity, purposeless activity)

13. Disorganized Symptoms • Examples of disorganized behavior (cont.) • Echopraxia (imitation of others movements) • Regressed behavior • Stereotypy (repetitive, purposeless movements) • Hypervigilance (sustained attention to external stimuli) • Waxy flexibility (posture held in odd or unusual way)

14. Schizophrenia in Children • Rare in children • If appears in children aged 5 or 6, symptoms same as for adults • Hallucinations visual, delusions less well-developed • Other disorders considered first

15. Schizophrenia in Elderly • For those who have had schizophrenia most of their life, this may be a time that they experience improvement in symptoms. • Late-onset schizophrenia • Diagnostic criteria met after 45 • Most likely include positive symptoms

16. Epidemiology • 0.5%-1.5% of population • 300,000 acute episodes each year • Cluster in lower socioeconomic group • Homelessness is a problem.

17. Epidemiology • Across all cultures • In the United States, African Americans have a higher prevalence rate (thought to be related to racial bias). • Men are diagnosed earlier. • EOS: Diagnosed late adolescence • LOS: Diagnosed > 45 years

18. Maternal Risk Factors • Prenatal poverty • Poor nutrition • Depression • Exposure to influenza outbreaks • War zone exposure • Rh-factor incompatibility

19. Infant and Childhood Risk Factors • Low birth weight • Short gestation • Early developmental difficulties • CNS infections

20. Familial Differences • First-degree biologic relatives have 10 times greater risk for schizophrenia. • Other relatives have higher risk for other psychiatric disorders.

21. Comorbidity • Increased risk of cardiovascular disorders • Association between insulin-dependent diabetes and schizophrenia • Depression and pseudodementia • Increased substance abuse • Cigarette smoking • Fluid imbalance

22. Disordered Water Balance • Prolonged periods of polydipsia, intermittent hyponatremia, polyuria • Etiology – unknown • Prevention of water intoxication • Promotion of fluid balance

23. Biologic Factors • Genetic – 10% first-degree relative • Stress-diathesis model proposed by O’Connor • Neuroanatomical findings • Decreased blood flow to left globus pallidus • Absence of normal blood increase in frontal lobes • Atrophy of the amygdala, hippocampus and parahippocampus • Ventricular enlargement • Neurodevelopmental • Prenatal exposure (2nd trimester) • Late winter, early spring births

24. Neurotransmitters, Pathways and Receptors • Hyperactivity of the limbic area (dopamine mesolimbic tract) related to positive symptoms • Hypofrontality or hypoactivity of the pre-frontal and neo-cortical areas (dopamine mesocortical tract related to negative and positive symptoms) • Does not result from dysfunction of a single neurotransmitter

25. Psychosocial Theories • Do not explain cause • Disservice to families • Useful in family interaction • Expressed Emotion (EE) • High emotion associated with negative communication and overinvolvement • Low emotion associated with less negativity and less overinvolvement

26. Priority Care Issues • Suicide • Safety of patient and others • Initiate antipsychotic medications

27. Family Response to Disorder • Mixed emotions – shock, disbelief, fear, care, concern and hope • May try to seek reasons • Initial period very difficult

28. Interdisciplinary Treatment • The most effective approach involves a variety of disciplines. • There is considerable overlap of roles and interventions. • Nursing’s contribution is significant.

29. Nursing Management:Biologic Domain Assessment • Present and past health status • Physical functioning • Nutritional assessment • Fluid imbalance assessment • Pharmacologic assessment • Medications (prescribed, OTC, herbal, illicit) • Abnormal motor movements • DISCUS • AIMS • Simpson-Angus Rating Scale

30. Nursing Diagnosis:Biologic Domain • Self-care deficit • Disturbed sleep pattern • Ineffective therapeutic regimen management • Imbalanced nutrition • Excess fluid volume • Sexual dysfunction

31. Nursing Interventions:Biologic Domain • Promotion of self-care activities • Develop a routine of hygiene activities. • Emphasize its importance; help motivate the patient. • Activity, exercise and nutrition • Help counteract effects of psychiatric medications. • Appetite usually increases, so help with food choices. • Thermoregulation • Teach patient to wear clothing according to weather; dress for winter and summer. • Observe patient’s response to temperature. • Promotion of normal fluid balance • Water intoxication protocol (Text Box 18.5)

32. Pharmacologic Interventions • Newer antipsychotics more efficacious and safer (block dopamine and serotonin) • Risperidone (Risperdal) • Olanzapine (Zyprexa) • Quetiapine (Seroquel) • Ziprasidone (Geodone) • Aripiprazole (Abilify) • Clozapine (Clozaril) - second line • Monitoring and administering medications • Takes 1-2 weeks to work (some improvement immediately) • Adequate trial - 6-12 weeks • Adherence to prescribe medication is best prevention of relapse. • Discontinuation israre.

33. Pharmacologic Interventions: Monitoring Side Effects • Parkinsonism • Identical symptoms to Parkinson’s • Caused by blockade of D2 receptor in basal ganglia • Treated with anticholinergic medications • Taper anticholinergic meds if discontinued • Dystonia • Imbalance of DA and ACH, with more ACH • Young men more vulnerable • Oculogyric crisis, Torticollis, Retrocollis

34. Monitoring Side Effects • Akathesia • Restlessness, jumping out of skin, uncomfortable • Reduce dose of antipsychotic. • Treat with a -blocker (propranolol). • Tardive Dyskinesia • Impairment of voluntary movement, constant motion • Occurs 6-8 months following initiation of antipsychotics • Facial-buccal area -- lip smacking, sucking, etc. • Movements in trunk, rocking • No real treatment

35. Monitoring Side Effects • Orthostatic hypotension • Prolactinemia • Weight gain • Sedation • New-onset diabetes • Cardiac arrhythmias (QTc prolongation) • Agranulocytosis

36. Drug-drug Interactions • Medications metabolized by 1A2 enzymes include olanzapine and clozapine. • Inhibitors: fluvoxamine (Luvox) • Inducers: cigarette smoking • Medications metabolized by 3A4 include clozapine, quetiapine and ziprasidone. • Inhibitors: ketoconazole, protease inhibitors, erythromycin • Inducer: carbamazapine • Medications affected by 2D6 include risperidone, clozapine and olanzapine. • Inhibitors: fluoxetine, paroxetine (not usually clinically significant)

37. Medication Teaching Points • Consistency in taking medication • Medication and symptom amelioration • Side effects and management • Interpersonal skills that help patient and family report medication effects

38. Medication Emergencies: Neuroleptic Malignant Syndrome • Severe muscle rigidity, elevated temperature • Recognizing symptoms • Elevated temperature, changes in level of consciousness, leukocytosis, elevated creatinine phosphokinase), elevated liver enzymes or myoglobinuria • Nursing interventions • Stop administration of offending medications. • Monitor vital signs. • Reduce body temperature. • Safety, protect muscles • Supportive measures • IV fluids • Cardiac monitoring • Dantrolene (Dopamine agonist)

39. Neuroleptic Malignant Syndromes • Acute reaction to dopamine receptors blockers • Prevalence 2 to 2.4% • Death – 4 to 22%, mean = 11% • Etiology: • Drugs block striatal dopamine receptors; disrupt regulatory mechanisms in the thermoregulatory center in hypothalamus and basal ganglia; heat regulation fails and muscle rigidity

40. Medication Emergencies: Anticholinergic Crises • Potentially life threatening, anticholinergic delirium • Can occur in patients who are taking several medications with anticholinergic effects • Elevated temperature, dry mouth, decreased salivation, decreased bronchial, nasal secretion, widely dilated eye • Stop offending drug, usually self-limiting. May use inhibitor of anticholinesterase, physostigmine.

41. Anticholinergic Crisis • Confusion, hallucinations • Physical signs - dilated pupils, blurred vision, facial flushing, dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension decreased bowel sounds, urinary retention, nausea, vomiting, seizures, coma • Atropine flush • Hot as a hare, blind as a bat, mad as a hatter, dry as a bone

42. Treatment • Self-limiting – three days • Discontinuation of medication • Physiostigmine 1-2 mg IV, an inhibitor of cholinesterase, improves in 24-36 hours • Gastric lavage • Charcoal, catharsis

43. Nursing Management: PsychologicalDomain Assessment – Responses • Socially stigmatizing • Prodromal symptoms evident (negative symptoms) • Tension and nervousness • Lack of interest in eating • Difficulty concentrating • Disturbed sleep • Decreased enjoyment • Loss of interest, restlessness, forgetfulness • Often not recognized as an illness • Denial common

44. Nursing Management: PsychologicalDomain Assessment • Positive and negative symptoms • SAPS (positive symptoms) (Box 18.9) • SANS (negative symptoms) (Box 18.10) • PANNS (both symptoms) • Mental status • Appearance • Mood and affect (lability, ambivalence, apathy) • Speech • Thought processes (delusions, disorganized communication, cognitive impairments) • Sensory perception (hallucinations) • Memory and orientation • Insight and judgment

45. Nursing Management: PsychologicalDomain Assessment (cont.) • Behavioral responses • Self-concept • Stress and coping patterns • Risk assessment • Command hallucinations • Self-injury risk, suicide • Homicide

46. Nursing Diagnosis: Psychological Domain • Disturbed thought processes • Disturbed sensory perceptions • Disturbed body image • Low self-esteem • Disturbed personal identity • Risk of violence, suicide • Ineffective coping • Knowledge deficit

47. Nursing Interventions: Psychological Domain • Counseling, conflict resolution, behavior therapy and cognitive interventions can be used. • Development of nurse-patient relationship • Centers on the development of trust and acceptance of the persons • Critical for optimal treatment of schizophrenia

48. Nursing Interventions:Psychological Domain – Management of Disturbed Thoughts • Assessment content of hallucinations/delusions • Outcomes • Decrease frequency and intensity. • Recognize as symptoms of disorder. • Develop strategies to manage recurrence. • Experiences real to the patient • Validate that experiences are real • Identify meaning and feeling that are provoked • Teach patient that hallucinations and delusions are symptoms of illness.

49. Nursing Interventions: Psychological Domain • Self-monitoring and relapse prevention • Monitor events, time, place, etc. of recurrence of symptoms. • Manage symptoms - getting busy, self-talk, change of activity. (Moller-Murphy Tool) • Enhancement of cognitive functioning • Recognize difficulty in processing information. • Improve attention (computer programs, one-to-one). • Help memory (make lists, write down information). • Improve executive functioning-simulation.

50. Nursing Interventions: Psychological Domain • Behavioral interventions • Organize routine, daily activities. • Reinforce positive behaviors. • Stress and coping skills development • Counseling sessions • Teach and reward positive coping skills. • Patient education • Errorless learning environment • Minimal distractions • Clear visual aids • Skills training