SCHIZOPHRENIA AND PSYCHOSIS

1. SCHIZOPHRENIA AND PSYCHOSIS Module III RNSG 2213

2. SCHIZOPHRENIA: OVERVIEW • Major Axis I disorder • Characterized by disturbances in: • Perception • Thought processes and reality testing • Affect (feelings) • Behavior • Attention (concentration) • Motivation

3. PSYCHOSIS • How do we define this term? • Inability to evaluate accuracy of one’s thoughts and perceptions • Incorrect interpretation of external reality • Inability to re-evaluate one’s thoughts and perceptions, even in the face of evidence that contradicts these. In Schizophrenia, the psychotic person often does not have awareness that he/she is ill

4. OVERVIEW, CONT’D • Incidence • Age of onset is late adolescence • 1.1% of population over age 18 • Higher rates in inner city populations, lower socioeconomic groups • Prenatal probs. correlate with higher rate

5. OVERVIEW, CONT’D • Prognosis • Approx. 25% remain highly functional • 50% are minimally functional • 25% are in-between with exacerbations/relapses and re-stabilizations (in and out of hosp.)

6. OVERVIEW, CONT’D • A Chronic Illness Characterized by Phases: • Acute phase – severe psychotic sx. • Stabilizing Phase • Stable phase • Most pts. alternate between acute and stable phases

7. SCHIZOPHRENIA: SYMPTOMS • Bleuler’s (Early 1900’s) “4 A’s”: • Affect disturbances • Autism • Associative looseness • Ambivalence “Fragmentation of the Mind”

8. CLASSIFICATION OF SYMPTOMS • Positive Symptoms • Negative Symptoms • Cognitive Symptoms

9. Positive Symptoms of Schizophrenia • Agitation/aggression • Delusions • Hallucinations • Disordered thinking (AEB disordered speech): circumstantial thinking, loose associations, word salad, neologisms, echolalia

10. Positive Symptoms of Schizophrenia, cont’d • Disordered movement: --restlessness, repetitive movements (e.g. echopraxia), --or immobility (catatonia) http://www.youtube.com/watch?v=zAEJ-Jvndms

11. “A blue ape. Makes me scratch. John wore a hair shirt. Are we victims?” “I am locked in concrete and I have stopped breathing.” “The CIA has been poisoning my water.” “Whenever knife take you-a.” “At HEB, when they play that music, the words are sending messages to me.” “I love chocolate candy. Candy is my parakeet’s name. What’s your name?” Word salad Delusion of reference Tangentiality Neologism Loose associations Paranoid delusion Nihilistic delusion Grandiose delusion Matching: Symptoms

12. Grandiose delusion example: “I own the Bank of America and my people are going to put up $20 million for my release from here.” • Neologism example: “It tastes screeg because of those nerflexes.”

13. Negative Symptoms of Schizophrenia • Flat affect • Inability to plan or carry out activities • Constricted, concrete thinking • Poverty of speech (alogia), flat speech • Social withdrawal; lack of pleasure in activities (anhedonia) • Deep apathy

14. “Flat Affects” (Flight of the Conchords)

15. Cognitive Symptoms of Schizophrenia • Impaired ability to pay attention and to understand • Impaired ability to make decisions (ambivalence) • Problems in using just-learned information

16. CRITICAL THINKING:Nursing Diagnoses Write one nursing dx. for each symptom or behavior related to schizophrenia • Client has command auditory hallucinations that he should kill himself • Client does not get dressed or take baths • Client believes she can make it snow

17. Suggested Nursing DX: • R/F Self-directed Violence r/t sensory perceptual alteration s/t command auditory hallucinations 2) Self-care deficits: grooming and hygiene r/t poor motivation for self-care s/t schizophrenia 3) Altered thought process s/t grandiose delusion (or delusion of grandeur)

18. Antipsychotic Agents and Symptoms • The “Typical” (older class) of antipsychotics primarily address POSITIVE symptoms • Can make negative symptomsWorse • The “Atypical” (newer classes) of antipsychotics address both POSITIVE AND NEGATIVE symptoms

19. SYMPTOMS: DSM CRITERIA • At least 2: Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms • Social-occupational dysfunction • Continuous s/sx. > 6 months • No schizoaffective diagnosis • Not caused by substance abuse or medical disorder

20. DSM Criteria: Schizophrenia Subtypes • Paranoid – persecutory and/or grandiose delusions • Disorganized – speech & affect & behavior are disturbed • Catatonic – absent, excessive &/or peculiar movements. Mutism. • Undifferentiated – does not meet criteria for other subtypes • Residual – has some disturbed thinking or behavior but does not meet other criteria

21. DSM Criteria: Other Psychotic Disorders • Schizophreniform Disorder • Has similar symptoms to schizophrenia but for only 1-6 months • Schizoaffective Disorder • Symptoms of schizophrenia + symptoms of a mood disorder • Psychotic Disorder NOS • Has Psychotic symptoms but doesn’t fit criteria for any of the above

22. Quick Check: What is the most likely DSM IV-TR Diagnosis? Client #1 Elevated mood episodes along with hallucinations and delusions for 2 years Client #2 Is physically immobile at times. Has poverty of speech. Has never worked in adulthood. Client #3 Agitated, reports seeing flashes of color and hearing singing voices x 2 weeks. Client #4“I know 4,000 languages but others are trying to steal these from my mind.” As a result, has been living on the streets for many years.

23. ETIOLOGY • Multifactorial-no single cause • Multiple theories for etiology (see next content)

24. BIOLOGICAL THEORIES 1.The Dopamine Hypothesis: • Too much dopamine binds with too many brain receptors and causes positive symptoms      • Too little dopamine --negative symptoms

25. BIOLOGICAL THEORIES, cont’d 2.Disturbed Ratio of serotonin: dopamine

26. CRITICAL THINKING • Based on the preceding hypotheses, what are the principles behind antipsychotic medications ? -to treat positive symptoms: -to treat negative symptoms: -to treat altered ratios:

27. BIOLOGICAL THEORY: CHANGES IN BRAIN STRUCTURE AND FUNCTION • Alterations found in some Schizophrenics using Diagnostic Imaging • PET Scan:  glucose metabolism in frontal/temporal lobes; in basal ganglia • MRI: Enlargement of ventricles • BEAM Scan: Abnormal wave patterns indicting absence of ability to “calm” the brain • Evoked Potential Topography: Illogical thought patterning in frontal lobe

28. PET Scan and Schizophrenia

29. GENETIC THEORY • Inherited predisposition to schizophrenia • Risk Factors: • Two parents with schizophrenia = 35% • Identical twins = 50%

30. DEVELOPMENTAL AND ENVIRONMENTAL THEORIES • Prenatal infections • Parental neglect or rejection • Greater % of pts. come from lower socio-economic class

31. Issues in Schizophrenia • Family disturbance: a cause or a result? • Noncompliance and relapse are common • Have poorer ability to cope with stress • Increased rates of depression, suicide • Increased rate of substance abuse: alcohol, marijuana, nicotine, cocaine • Often cannot hold a job

32. Australian aboriginal painting by mental health client http://www.ncbi.nlm.nih.gov INTERVENTIONS/PSYCHOTHERAPEUTIC MANAGEMENT

33. NURSE-CLIENT RELATIONSHIP • Be accepting, consistent and honest • Do not argue with or reinforce hallucinations or delusions • Reinforce acceptable behaviors • Gently encourage withdrawn client • Recognize when a client may be suspicious, anxious or fearful, and approach with care • Assess for command hallucinations

34. CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic ? Client insists he is a “negative space alien.” Nurse A: “Do you live in outer space? Are there other people living there?” Nurse B: “But I have met your mom. How can you be a space alien?” Nurse C: “That’s interesting. Want to come with me now to see the patient art exhibit?” Nurse D: “ I can see you feel strongly about that.”

35. MILIEU MANAGEMENT • Set limits on disruptive behavior • Assess agitated clients frequently for escalation • Assess ability to participate in activities; choose activities at client’s level of ability • May need 1:1 rather than group activities at first • Decrease environmental stimuli prn • Supervised meals, hygiene, grooming

36. CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic? A new patient starts pacing back and forth, while saying in a loud voice, “Take it back, take it back.” Nurse A: “Lower your voice, you are disturbing people.” Nurse B: “Hi, I’m Jo the nurse; are you ok?” Nurse C: “Why are you pacing?”

37. CRITICAL THINKING: In what order should the nurse implement ? A schizophrenic patient, who hallucinates and is sometimes aggressive, turns off the football game that others are watching. “Are you hearing the voices?” “Right now our activity is watching the football game, so it’s not ok to turn it off.” “Come on outside for some fresh air.” “I’m going to give you some medication right now to help you feel calmer.”

38. OTHER INTERVENTIONS • Importance of client and family education • To address stigma of schizophrenia & • To improve functional ability, self-management and prevent relapse

39. Other Interventions, cont’d • Community Resources and Continuity of Care • National Alliance on Mental Illness (NAMI) • Outpatient day treatment, home care • Self-help, peer support groups (NAMI) http://www.youtube.com/watch?v=GEX1kr8EOPI

40. PHARMACOTHERAPY • Antipsychotic Agents • Traditional or Typical Agents: 1st Generation (beginning 1950’s) • Atypical or Second Generation Agents (1990’s) • Novel or Third Generation Agents (21st century)

41. Antipsychotic Agents: Overview of Typical Agents • Pharmacologic Effects, in General • Sedation (esp. if combined with other CNS depressants) • Slowing of motor activity • Decrease in hallucinations and delusions • Emotional quieting • Improved cognitive function; decreased confusion

42. TYPICAL or Traditional ANTIPSYCHOTIC AGENTS • High Potency e.g. haloperidol (Haldol), fluphenazine (Prolixin) • Moderate Potency e.g. loxapine (Loxitane), perphenazine (Trilafon) • Low Potency e.g. chlorpromazine (Thorazine), thioridazine (Mellaril)

43. Typical/Traditional Antipsychotics, cont’d • Action = Block Dopamine D2 Receptors • Most effective for Positive (+) symptoms

44. Atypical (2nd Generation) Agents • clozapine (Clozaril) (prototype) Action of this drug: blocks multiple dopamine receptors • quetiapine (Seroquel) • risperidone (Risperdal) • olanzapine (Zyprexa) • ziprasidone (Geodon) • paliperidone (Invega)

45. Newest Atypical Agents • iloperidone (Fanapt) • Asenaphine (Saphris)

46. Atypical (2nd generation) Agents, cont’d • Action: Block (antagonists) or enhance (agonists) multiple dopamine, serotonin and/or norepinephrine receptors. • Useful for both positive and negative symptoms

47. Novel (3rd Generation) Agents • aripiprazole (Abilify) • Action: Partial dopamine antagonist “Balances” dopamine (both increases and decreases it in different brain areas)

48. Antipsychotics: Side Effects • Main Side Effects: • Extra-Pyramidal (EPSEs)- abnormally increased or decreased motor activity, muscle spasms, twisting, tremors • Akinesia  Akathisia • Pseudo-Parkinsonism • Dystonias  Tardive Dyskinesia Acute dystonic reaction

49. Tardive Dyskinesia • http://www.youtube.com/watch?v=UbBpt9uCXqc&feature=related

50. EPSEs • To assess for tardive dyskinesia, administer AIMS (Abnormal Involuntary Movement Scale)