Schizophrenia all rights reserve Austin Community College

1. Schizophreniaall rights reserve Austin Community College

2. Psychosis • A Symptom • Affects ability to perceive and process information. • Behaviors associated with psychosis are often severe, long-lasting and difficult to understand. • Goal is patient recognition of symptoms and development of strategies to manage symptoms resulting in stabilization.

3. Schizophrenia • A serious persistent neurological brain disorder: the exact cause is unclear • Theories of causation include • genetics, biochemistry, and psychosocial factors • Age of onset • Role of Stress • Need for dopamine agonist (medication) • Symptoms vary greatly among different patients depending on the area of the brain effected. • Psychosis: the individual is not able to distinguish the external world from internally generated perceptions. • Treatment varies to meet individual needs • Includes: • psychotropic medications • education • social support

4. Dopamine overwhelms the brain and binds with too many receptors Research has been unable to determine if this is due to: Higher levels of dopamine Increased sensitivity to dopamine Ratio between serotonin and dopamine atypical anti-psychotics effect serotonin also. Endogenous dopamine is an antagonist is GABA Relatively high levels of dopamine result in ANXIETY Can you induce psychosis? Marijuana, LSD, Amphetamines How do these affect dopamine BIOCHEMICAL

5. GENETIC Brain structure and Function Etiology ENVIRONMENT BIOCHEMICAL

6. GENETICS • Probability of Schizophrenia in Families • 1 parent 10% probability • 1 sibling 10% • Identical twin 50% • Both parents varies 40% • A gene identified ---research continues

7. Frontal lobes The executive; decision maker, reliant on other parts of the brain for data. Prefrontal is the personality Parietal Lobes Perception, interpertation touch body perception Temporal Lobes Hearing Occipital Lobes Sight Review of Neurobioloby

8. Schizophrenia and Neurotransmitters • Overactive dopaminergic pathways in the mesolimbic (innervates the limbic system) system • Important in reaction to stress • Hypofunction in the prefrontal areas and an imbalance between dopamine and serotonin

9. BRAIN STRUCTURE AND FUNCTION PET SCAN ILLUSTRATES FUNCTIONAL DIFFERENCES IN THE LIVING BRAIN

10. PET Scan and Schizophrenia

11. MRI Comparing Identical Twins: One without Schizophrenia and One with Schizophrenia • When the ventricles are enlarged the brain has lost mass (VBR Ventricular Brain Ratio)

12. ENVIRONMENTAL • Inherited susceptibility to schizophrenia • Prenatal infections • Poor Family Communication • Greater % of patients come from lower socio-economic class • STRESS • What about prevention?

13. Incidence and Prognosis • In all societies, occurs in 1% of population with slightly higher incidence in males • Prognosis: approx. 25% remain highly functional • 50% remain non-functional • 25% are in-between, in and out of hospital • Age of onset is late adolescence/ early adulthood

14. Prognosis • Acute phase • Severe psychotic symptoms • Stabilizing phase • Patient is getting better • Stable phase • May still have hallucinations and delusions • Not as severe • Most patients alternate between acute and stable phases

15. STRESS: Onset or Relapse • Biological (medical illness) • People with schizophrenia: • Can misperceive physical symptoms • Have poor pain recognition • Leads to neglect by health care providers • Psychological (loss of a relationship) • Sociocultural (homeless) • Emotional (persistent criticism) • Identification of symptoms and early triggers

16. Bleuler’s 4 A’s • Affective Disturbance: • Inappropriate, blunted or flattened • Autistic Thinking: • Preoccupation with the self • Little concern for external reality • Associative Looseness • Stringing together of unrelated topics • Ambivalence • Simultaneously opposing feelings

17. Positive symptoms of Schizophrenia • Positive Symptoms (+) Person with schizophrenia does more (+) than Person who is functioning normally • agitation/aggression • delusions • hallucinations • formal thought disorder:loose associations, word salad • bizarre behavior • Disorganized Speech (loose associations and word salad) • Grossly disorganized or catatonic behavior • Typical Anti-psychotic medications control these symptoms

18. Negative Symptoms (-)Person with schizophrenia does less (-) than Person who is functioning normally Atypical antipsychotics will help these symptoms Typical antipsychotics can make these worse flat affect avolition; lack of direction or purpose ambivalence; indecisive constricted concrete thinking alogia: poverty of speech social withdrawal anhedonia deep apathy minimal or poor self care Negative symptoms of Schizophrenia

19. Schizophrenia Subtypes • Paranoid • Catatonic • Disorganized • Undifferentiated • Residual

21. Preoccupation with: 1. Delusions Persecutory /Paranoid Grandiose 2. Hallucinations Command Auditory 3. No disorganized speech Usually neat and clean. 4. Issues for Nursing care Fearful-mistrusting Aware of authority Can be VERY dangerous to others and self. Can get themselves into situation where they think they are protecting themselves and they get themselves killed. Paranoid

22. Catatonic • Stupor • Negativism • Rigidity • Posturing: waxy flexibility

23. Characteristics of Catatonic Patient • Acute onset, often in response to stress • Rigid, weird positions • Waxy flexibility • May not eat-often very angry • Good prognosis • What are the Nursing Interventions for someone who is not eating and stays in the same position for many hours?

24. Disorganized • Disorganized speech • Disorganized behavior • Flat or inappropriate affect • Disheveled appearance

25. Undifferentiated • Positive symptoms • Does not meet criteria for: • Paranoid Schizophrenia

26. Residual • No positive symptoms • Mostly negative symptoms • Chronic

27. Other Psychotic Disorders • Psychotic Disorder NOS • Delusional Paranoid Disorder • Schizophreniform Disorder • Symptoms of schizophrenia last one month but no longer than six months • Schizoaffective disorder • A puzzle • Characterized by: • Symptoms schizophrenia are dominant • Accompanied by major depressive or manic symptoms

28. Nursing Diagnosis for Schizophrenia • Altered thought processes: Delusions • Sensory/perceptual alterations: specify Hallucination • Social isolation • Potential for violence • Self-care deficit • Impaired verbal communication • Sleep pattern disturbance • Altered nutrition • Impaired home maintenance management • Related to: Neuro chemical imbalance; Disturbed thought process; Auditory Hallucinations • Secondary to: Schizophrenia

29. Treatment • Antipsychotic Medication • Supportive Psychotherapy and Education • Individual • Group • Milieu • Family • Social supports • Follow-up mental health care/Medication • Housing • Day treatment • Employment

30. Therapeutic Relationship • TRUST • Be honest; do what you say. • Do not be too warm and friendly • Be consistent and honest • Be careful with touch AND eye contact • At first, may need to just “be there” or “offering self • Don’t expect too much of yourself or the patient • Improvement happens slowly

31. Therapeutic Communication for Hallucinations • Ask “Are you hearing voices?” • Ask “What are they saying?” May want to know for safety reasons. • Ask “What are they like, are they loud, or male or female.” • Can ask patient “What helps you with the voices” • Can state,” I know they distract you, but can you focus with me for a minute.” • Patient may miss voices after they are gone.

32. 1. Safety (examples) Psychological and physical Restraint and seclusion No contraband (cans, glass, lighters) 2. Structure (examples) Unit schedules, meals, bedtime Groups Visiting hours 3. Norms (examples) Individual responsibility Rules 4. Limit setting (examples) cannot harm self or others; cannot smoke 5. Balance (examples) Rights of one person to talk loud –VS- rights of others to quiet Nursing judgment and critical thinking Environmental Modification- bending rules when necessary to be therapeutic. Elements of the Effective Milieu

33. Disruptive Patients Set limits Decrease environmental stimuli Frequent observation Early intervention Verbal intervention so physical intervention is not needed Safety Who will work with the patient? No threats (If you……then) Suspicious Patients Matter of Fact No laughing or whispering Proximics Approach form the side Avoid close physical contact Eye contact Withdrawn Patients Non threatening activities Provide a connection with reality Give support Decision making Hygiene Milieu: Therapeutic Manipulation of the Environment

34. Impaired Communication Protect self-esteem Activities where success is assured Provide support Connection Patience No pressure Disorganized Decreased stimulation Provide a calm environment Safe and simple activities Rely on long term memory Hallucinations Engage in activities Attempt to separate patients who have similar psychotic thoughts Connection to reality Talk about real people and real events Monitor television monitor for command hallucinations Milieu: Therapeutic Manipulation of the Environment

35. Consistency in the Milieu • Do not argue • Do not belittle • Show acceptance and empathy and speak to them “That must be difficult to believe that.” • Do not patronize • Can reassure- “You are safe here.” • Orient patient to what is happening

36. Give information in a kind matter-of-fact Thoughts provide a sense of identity Pay attention to key words Speech represents cognitive functioning Identify one or two verbal or non-verbal responses. Seek Validation Assist with decision making (in the here and now) in a nonpunitive supportive manner Initiation and completion of tasks The client Is sleeping 2 hours a night Will not eat Has poor hygiene Is afraid of another client Does not like their doctor Wants to stay in their room States they are on a special mission to save the United States Nursing Care

37. Psychosis-Induced Polydipsia • Compulsive water drinking (6% to 20%) • Thirst and Osmotic dysregulation • Hyponatremia • Confusion • Convulsions • Coma • Lightheadedness • Nausea and vomiting • Weakness • Muscle Cramps • Treatment • Weigh • Restrict fluid • Sodium replacement • Constant supervision

38. Antipsychotic Medications • Typical • Rarely a scheduled medication • Acute phase: controls positive symptoms • Identification and treatment of side effects • Atypical (97%)

39. Four Major Dopaminergic Tracts • 1. Nigrostriatial (movement) • 2. Tuberinfundibular (pituitary; elevation in prolactin) • 3. Mesolimbic (emotion and sensory) • 4. Mesocortical (cognitive processes)

40. Typical Antipsychotics • High Potency Neuroleptic • Haldol (Haloperidol) • Prolixin (Fluphenazine) • Available in pills, liquid, Intramuscular and Depo (decanoate) injection • Low Potency Neuroleptic • Thorazine (Chlorpromazine) • Mellaril (Thiroidazine) • In-betweens • Stelazine • Trilafon • Navane

41. Antiparkinsonian Agents • Cogentin (benztropine) • Artane (trihexyphenidyl) • Benadryl (diphenhydramine) • Symetrel (amantadine) • Ativan (Lorazepam)

42. Acetylcholine and Dopamine • A balance between dopamine and acetylcholine is required for normal movement • Antipsychotic medication decrease dopamine, causing EPS symptoms • Antiparkinsonian meds act by decreasing ACH, thus restoring balance • All antiparkinsonian meds increase the anticholenergic effects

43. Extrapyramidal Side Effects (EPSE) Acute Dystonia Akathisia (Psuedo)Parkinsonism Tardive Dyskinesia Anticholenergic effects Drowsiness Dry mouth Skin reactions, sunburn Constipation Urinary retention Orthostatic hypotension Side effects of Typical Antipsychotic

44. Early onset Abnormal posture Involuntary, sustained, muscle spas Sustained twisted contracted positioning of the limbs, trunk, neck or mouth This is PAINFUL Treated with parenteral anticholinergics due to the gravity of the situation Oculogyric Crises Torticolis Acute Dystonia

45. Akathisia • “Ants in the pants” • Subjective feeling of restlessness • Nervous energy • Most common EPSE

46. (Psuedo)Parkinsonism • Tremor at rest • Pill rolling • Muscle rigidity • Bradykinesia Stiff, shuffling gait

47. Tardive Dyskinesia • Involuntary movements, • Especially of the face and tongue • IRREVERSIBLE if not corrected immediately • LONG TERM USE OF TYPICAL ANTIPSYCHOTIC

48. Tardive Dyskinesia

49. Neuroleptic Malignant Syndrome • Syndrome is very RARE but can be LETHAL • 1% of patients taking antipsychotics • 5% to 20% will die without treatment • Predisposing factors; • Youth • male • high potency neuroleptic • new patient • Cardinal symptoms • Lead pipe rigidity • Autonomic instability • High fever • Tachycardia • LOC changes • Elevated CPK

50. Neuroleptic Malignant Syndrome(Malignant Hyperthermia) • Medical emergency • STOP all medication • may resume meds after crisis. • Rx: Dantrolene (Dantrium): skeletal muscle relaxant and Bromocriptine (Parlodel): a dopamine agonist