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Schizophrenia Chapter 15

Schizophrenia Chapter 15. West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011. Eugen Bleuler’s 4 A’s of Schizophrenia . Affect Associative looseness Autism Ambivalence. Epidemiology. Lifetime prevalence of schizophrenia 1% worldwide

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Schizophrenia Chapter 15

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  1. Schizophrenia Chapter 15 West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011

  2. EugenBleuler’s4 A’s of Schizophrenia • Affect • Associative looseness • Autism • Ambivalence

  3. Epidemiology • Lifetime prevalence of schizophrenia 1% worldwide • Average onset is late teens to early twenties, but can be as late as mid-fifties • 30% to 40% relapse rate in the first year • Life expectancy is shortened because of suicide • No difference related to • Race, Social status, Culture

  4. Comorbidity • Substance abuse disorders • Nicotine dependence • Anxiety, depression, and suicide • Physical health or illness • Polydipsia

  5. Etiology • Biological factors • Genetics • Neurobiological • Dopamine theory • Other neurochemical hypotheses • Brain structure abnormalities

  6. EtiologyContinued • Psychological and environmental factors • Prenatal stressors • Psychological stressors • Environmental stressors

  7. Signs and Symptoms • Language and communication disturbances • Thought disturbances • Perception disturbances • Affect disturbances • Motor behavior disturbances • Self-identity disturbances

  8. Features of Schizophrenia • Progression varies from one client to another • Exacerbations and remissions • Chronic but stable • Progressive deterioration • DSM-IV-TR Diagnosis • Symptoms present at least 6 months • Active-phase symptoms present at least 1 month • Symptoms are defined as positive and negative

  9. Phases of Schizophrenia Phase I – Acute • Onset or exacerbation of symptoms Phase II – Stabilization • Symptoms diminishing • Movement towards previous level of functioning Phase III – Maintenance • At or near baseline functioning

  10. Assessment • During the prepsychotic phase • General assessment • Positive symptoms (Excess or distorted) • Negative symptoms (Deficit) • Cognitive symptoms • Affective symptoms

  11. Positive Symptoms • Alterations in thinking • Delusions are false, fixed beliefs • Persecutory, Referential • Somatic, Religious, • Substitution, Thought Insertion and/or Broadcasting • Nihilistic, Grandiose • Concrete thinking is an inability to think abstractly. • Indecisiveness, lack of problem solving skills, • Concreteness, thought blocking, perseveration

  12. Positive SymptomsContinued • Alterations in speech • Neologisms • Echolalia • Echopraxia • Clang associations • Word salad • Loose Association

  13. Positive SymptomsContinued • Alterations in perception • Depersonalization • Derealization • Hallucinations • Auditory hallucinations • Command hallucinations • Visual hallucinations • Boundary impairment • Negativism • Impaired impulse control

  14. Negative Symptoms (5A’s) • Affect • Flat, Blunted, Inappropriate, Bizarre • Apathy • Indifference towards people, events, activities and learning. • Alogia • Poverty of speech • Avolition • Inability to pursue and persist in goal-directed activities. • Anhedonia • Inability to experience pleasure.

  15. Cognitive Symptoms • Difficulty with • Attention • Memory • Information processing • Cognitive flexibility • Executive functions

  16. Affective Symptoms • Assessment for depression crucial • May herald impending relapse • Increases substance abuse • Increases suicide risk • Further impairs functioning

  17. Review Question • A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? • Positive symptom • Negative symptom • Cognitive symptom • Depressive symptom

  18. Review Question • The nurse is documenting in the multidisciplinary treatment plan. Which assessment data depicts positive symptoms of schizophrenia? • A. “I use to like going to the movies and spending time with my family but rather be alone.” • B. “I don’t want to go to group.” Lack motivation and affect appear Blunted. • C. “I can’t sit still and I feel like I want to jump out of my skin.” • D. “There are cameras in the ceiling and the voices are whispering to me.”

  19. Subtypes of Schizophrenia • Paranoid type • Disorganized type • Catatonic type • Undifferentiated type • Residual Type

  20. Subtypes of Schizophrenia - continued • Paranoid Type • Delusions • Persecutory and grandiose • Somatic or religious • Hallucinations • Delusions link with a hallucination • Disorganized Type • Disorganized speech, behavior, appearance • Flat or inappropriate affect • Fragmented hallucinations and delusions • Most severe form of schizophrenia

  21. Specific Interventions forParanoid and Disorganized Schizophrenia • Communication guidelines • Self-care needs • Milieu needs

  22. Subtypes of Schizophrenia - continued • Catatonic type • Psychomotor retardation and stupor • Waxy flexibility • Mutism • Extreme psychomotor agitation • Echolalia • Echopraxia

  23. Specific Interventions for Catatonia • Catatonia – Withdrawn Phase • Communication guidelines • Self-care needs • Milieu needs • Catatonia – Excited Phase • Communication guidelines • Self-care needs

  24. Subtypes of Schizophrenia - continued • Undifferentiated type • Active psychotic state (Positive & Negative symptoms) • Lacks symptoms of other subtypes • Residual type • Active-phase symptoms no longer present • No prominent positive symptoms • Negative symptoms present

  25. Other Psychotic Disorders • Schizophreniform disorder • Schizoaffective disorder • Delusional disorder • Brief psychotic disorder • Shared Psychotic Disorder (FolieàDeux) • Induced or Secondary Psychosis

  26. Assessment Guidelines 1. Any medical problems 2. Abuse of or dependence onalcohol or drugs 3. Risk to self or others • Command hallucinations 5. Belief system 6. Suicide risk

  27. Assessment GuidelinesContinued 7. Ability to ensure self-safety • Co-occurring disorders 9. Medications 10. Presence and severity of positive and negative symptoms 11. Patient’s insight into illness 12. Family’s knowledge of patient’s illness and symptoms

  28. Potential Nursing Diagnoses • Positive symptoms • Risk for violence • Disturbed sensory perception • Risk for self-directed or other-directed violence • Disturbed thought processes • Negative symptoms • Social isolation • Chronic low self-esteem • Altered health maintenance • Ineffective coping • Impaired verbal communication

  29. Outcomes Identification • Phase I - Acute Patient safety and medical stabilization • Phase II - Stabilization • Adhere to treatment • Stabilize medications • Control or cope with symptoms • Phase III - Maintenance • Maintain achievement • Prevent relapse • Achieve independence, satisfactory quality of life

  30. Planning • Phase I – Acute • Best strategies to ensure patient safety and provide symptom stabilization • Phase II – Stabilization • Phase III – Maintenance • Provide patient and family education • Relapse prevention skills are vital

  31. Implementation • Phase 1 – Acute Settings • Partial hospitalization • Residential crisis centers • Halfway houses • Day treatment programs

  32. Interventions • Acute Phase • Psychiatric, medical, and neurological evaluation • Psychopharmacological treatment • Support, psychoeducation, and guidance • Supervision and limit setting in the milieu

  33. InterventionsContinued • Stabilization and Maintenance Phase • Milieu management • Activities and groups • Safety • Counseling and communication techniques

  34. InterventionsContinued • Stabilization and Maintenance Phase, continued • Hallucinations • Delusions • Associative looseness • Health teaching and health promotion

  35. Nursing Implications:Supporting Families • Family needs vary with degree of illness and involvement in client’s care • Education • Financial support • Psychosocial support • Advocacy

  36. Nursing Implications:Supporting Families - continued • Schizophrenia is a “family illness.” • Family members need to be involved. • Educate family about • Medication • Illness • Relapse prevention • Nurse assists family by • Identifying community agencies/groups for family members • Advocating for rights

  37. General Nursing Intervention • Promote Safety and a Safe Environment • Promote Congruent Emotional Response • Promote Social Interaction and Activity • Intervene with Hallucinations and Delusions • Preventing Relapse • Promoting adherence with medication regimen • Assist with grooming and hygiene • Promote Family Understanding and Involvement

  38. Review Question • The client informs you that the CIA monitoring his every move to find evidence that he killed someone. Which response by the nurse is therapeutic for the client?

  39. Review Answers • A. "I will make sure that the security guard will monitor your room.” • B. "Don't worry you are safe here, the CIA can't enter the hospital.” • C.  "You seem fearful for your safety, but you are safe here.” • D. "Why do you think the CIA is following you, who did you kill?”

  40. Psychopharmacology • Prior to the 1950s: focus on behavioral interventions and sedatives • Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine) • Psychiatric medications allow for the improve imbalances of neurotransmitters. • Goal is to treat quickly so disease does not progress. • Clients may initially be resistant to medications.

  41. Goals of Antipsychotics • Positive Effects • Allowed release of clients from inpatient hospital to treatment in the community • Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation. • Alleviation of the symptoms, often improving: • Ability to think logically • Ability to function in one’s daily life • Ability to function in relationships

  42. Negative Effects of Antipsychotics • Negative Effects • Frightening and life threatening side effects • Potential interactions with other medications and substances • Possible need to cope with the realization of having a chronic illness

  43. All current antipsychotics work on at least one of these neurotransmitters: • Dopamine • Serotonin

  44. Antipsychotics • Typical (Conventional) • Block dopamine receptors at 70% to 80% occupancy to be effective. • Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80 • Typical = TardiveDyskinesia (TD) • 5.4% vs 0.8% atypicals

  45. Pharmacological Interventions • Antipsychotic medications • Conventional antipsychotics • Typical or first-generation • Atypical antipsychotics • Second-generation

  46. Conventional Antipsychotics • Dopamine antagonists (D2 receptor antagonists) • Target positive symptoms of schizophrenia • Advantage • Less expensive than atypical antipsychotics • Disadvantages • Do not treat negative symptoms • Extrapyramidal side effects (EPSs) • Tardivedyskinesia • Anticholinergic side effects • Lower seizure threshold

  47. Conventional Antipsychotics • Typical Agents • Low Potency • Chlorpromazine (Thorazine) (25 – 800 mg/d) • Thioridazine (Mellaril) (150 – 800 mg/d) • Mesoridazine (Serentil) (100 – 400 mg /d) • Side Effects: • Sedation, Anticholernergic, Hypotention, • EPSEs (less vs high potency)

  48. Conventional Antipsychotics • High Potency • Haloperidol (Haldol) (1 – 30 mg/d) • Fluphenazine (Prolixin) (0.5 – 40 mg/d) • Thiothixene (Navane) (2 – 30 mg/d) • Trifluoperazine (Stelazine) (1 – 40 mg/d) • Perhenazine (Trilafon) (8-60 mg/d) • Loxapine (Loxitane) (20 – 250 mg/d) • Molindone (Moban) (50 – 225 mg/d) • Pimozide (Orap) 0.5 – 9 mg/d) • Side Effects • Sedation, Anticholenergic SE (less vs low potency) • EPSEs (high vs low potency)

  49. Conventional Long-Acting Injectables (Depot Therapy) • Haloperidol Decanoate (HaldolDecanoate) • Q4 weeks • FluphenazineDecanoate (ProlixinDecanoate) • Q2 Weeks

  50. Atypical Antipsychotics • Treat both positive and negative symptoms • Fewer extrapyramidalside effects (EPSs) or tardivedyskinesia • Reduced affinity for dopamine (D2) receptors • Affinity for serotonin receptors • D2 antagonist + Serotonin receptor antagonist • Disadvantage – tendency to cause significant weight gain

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