Schizophrenia and Other Psychotic Disorder Chapter 16

1. Schizophrenia and Other Psychotic DisorderChapter 16 Psychiatric / Mental Health Nursing NURS 204

2. Overview of Schizophrenia • Prevalence in U.S. is 1.1%. • Average onset is late teens to early twenties, but can be as late as mid-fifties • Affects cognitive, emotional, and behavioralfunction • 30% to 40% relapse rate in the first year • Life expectancy is shortened because of suicide

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

4. Features of Schizophrenia - continued • 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

5. Features of Schizophrenia - continued • Positive symptoms • Excess or distortion of normal functioning • Aberrant response • Negative symptoms • Deficit in functioning

6. Features of Schizophrenia - continued • Positive Symptoms of Schizophrenia • Hallucination: • Auditory, Visual • Olfactory, Gustatory, Tactile • Delusions: • Persecutory, Referential • Somatic, Religious, • Substitution, Thought Insertion and/or Broadcasting • Nihilistic, Grandiose

7. Features of Schizophrenia – Positive Symptoms continued • Disordered speech: • Loose Association, Word Salad • Clanging, Echolalia, Neologism • Disordered behavior: • Disorganized walk • Touching all objects and surfaces • Catatonia • Disordered Thinking: • Indecisiveness, lack of problem solving skills, • Concreteness, blocking, perservation

8. Features of Schizophrenia - continued • Negative Symptoms of Schizophrenia • Flat affect: lack of emotion • 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.

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

10. Subtypes of Schizophrenia - continued • Paranoid Type • Delusions • Persecutory and grandiose • Somatic or religious • Hallucinations • Delusions link with a hallucination

11. Subtypes of Schizophrenia - continued • Disorganized type • Disorganized speech, behavior, appearance • Flat or inappropriate affect • Fragmented hallucinations and delusions • Most severe form of schizophrenia

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

13. Subtypes of Schizophrenia - continued • Undifferentiated type • Active psychotic state • Lacks symptoms of other subtypes • Residual type • At least one episode of schizophrenia • No prominent positive symptoms • Negative symptoms present

14. Other Psychotic Disorders • Schizophreniform disorder • Schizoaffective disorder • Delusional disorder • Brief psychotic disorder • Shared Psychotic Disorder (Folie à Deux) • Induced or Secondary Psychosis

15. Causes of Schizophrenia • Biologic theories • Psychological theories • Family theories • Humanistic-interactional theories

16. Causes of Schizophrenia • Biologic Theory: Genetic • Only genetic predisposition for developing schizophrenia is inherited • 10% of first-degree relatives • 25%-39% of monozygotic twins

17. Causes of Schizophrenia - continued • Biologic Theory: Brain Structure Abnormality • Differs from those with no symptoms • May be genetically based • Requires more study

18. Schizophrenia scans. PET scans of discordant monozygotic twins taken during a test to provoke activity and measure regional cerebral blood flow. (A) Arrows indicate areas of normal blood flow and brain activity in the unaffected twin. (B) Arrows indicate areas of lower blood flow and brain activity in the twin with schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain Disorders Branch, National Institute of Mental Health

19. Causes of Schizophrenia - continued • Biologic Theory: Biochemical Theories • Dopamine hypothesis • Traditional antipsychotic medications are dopamine blockers • Dopamine blocker alleviate positive symptoms

20. Causes of Schizophrenia - continued • Psychological theories • Information processing • Difficulty controlling the amount and type of information that is processed in the brain. • Attention and arousal • Hyper or hypo responsiveness to various situations

21. Causes of Schizophrenia - continued • Family Theories • Dysfunctional interaction not supported by research • Disordered family communication linked only with genetic predisposition • Family emotional tone influences course of schizophrenia • Expressed emotions theory (EE)

22. Causes of Schizophrenia - continued • Humanistic-interactional theories integrate biological and psychosocial theories • Combine influences of: • Genetic predisposition or biologic vulnerability • Environmental stressors • Social support

23. Causes of Schizophrenia - continued • Stress–Vulnerability Model • Stressors increase vulnerability • Cumulative effect of: • Genetic predisposition • Personal stressors • Familial factors • Environmental factors

24. Influences on the Course of Schizophrenia • Social Pressures • Lack of social support • Financial problems • Stigma

25. Influences on the Course of Schizophrenia - continued • Psychological pressures • Difficulty with problem-solving • Difficulty with interpreting reality • Difficulty coping • Problems with self-care • Unstable interpersonal relationships

26. Nursing Implications • Assessment • Premorbid functioning • Content of thought • Form of thought • Perception • Sense of self • Delusions and perceptual disturbances • Hallucinations • Drug use

27. Nursing Implications - continued • Nursing Diagnoses • Disturbed thought process • Disturbed sensory perception • Social isolation • Risk for violence • Self-care deficits • Altered health maintenance • Ineffective coping • Impaired verbal communication • Excess Fluid Volume • Decisional Conflict • Dysfunctional or Interrupted family process

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

29. 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

30. 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

31. Intervention - PreventRelapse • Relapse prevention programs provide education and support regarding: • Individual triggers, symptoms of relapse • Managing side effects of medications • Interventions to reduce or eliminate triggers • Strategies to facilitate early intervention • Cognitive therapy • Community resources

32. Challenges to Adherence • Side effects of Psychotropic Medications • Level of symptomatology • Cognitive, motivational, financial, and cultural issues • Issues with caregivers • Insufficient medication teaching • Substance abuse

33. Increasing Adherence • Involve clients in treatment • Instruct client about reducing discomfort • Provide peer support • Provide reminders and positive feedback • Recognize accomplishments

34. Personal Awareness • Identify personal feelings and recognize personal perceptions. • What behaviors do you expect to see? • How will you respond to these behaviors? • What is the meaning of the behaviors? • What defines “normal” behavior? • What are my fears associated with mental illness? • Remember that clients are human beings with a mental disorder and do not choose to be this way.

35. Psychopharmacology • A primary treatment mode of psychiatric-mental health nursing care • ANA Task Force Guidelines • Integrate current data from the neurosciences. • Demonstrate knowledge of psychopharmacologic principles. • Provide safe and effective care of clients taking these medications.

36. Psychopharmacology • Prior to the 1950s: focus on behavioral interventions and sedatives • Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine) • Since then, many advances have led to the treatment of the client with mental illness in the community. • Psychiatric medications allow for the correction of imbalances of brain chemicals.

37. The great success of biological psychiatry. This graph illustrates the dramatic decrease in psychiatric inpatient numbers since the inception of psychopharmacology.

38. Antipsychotics • Typical (Conventional) • Block dopamine receptors at 70% to 80% occupancy to be effective. • Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80%

39. Psychiatric Medications • Ongoing research on new medications • Ongoing research on new delivery systems • Newer depot: Resperidone Consta • Orally Disintegrating Tablets: Zyprexa Zydis

40. Impact on Ethnic Groups • Some ethnic groups are slow metabolizers. • More side effects • Greater risk of toxicity • Some ethnic groups are fast metabolizers. • Less effect of the medication

41. Goals of Psychiatric Medications • 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. 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. Medication Adherence • Adherence to prescribed medications by clients in psychiatric services is less than 35% • Reasons for nonadherence: • Clients do not know what to expect from medications. • The schedule of doses or routes may be inconvenient. • Friends/relatives may not be supportive. • Side effects may be worst than the symptoms.

44. Administering Medications A careful assessment is needed to decide the right form of the medication: • PO - by mouth (for routine use) • Liquid form (concentrate or syrup) • Quick-dissolving formulation (sublingual) • PRN injection • Depot injection

45. Antipsychotics • Atypicals • Reduced affinity for dopamine receptors • Affinity for serotonin receptors • Fewer EPSEs • Reduction in negative symptoms

46. Antipsychotic Medications • Side effects • ANS, extrapyramidal, other CNS, allergy, blood, skin, eye, endocrine, and weight gain • The five categories of EPSEs are dystonia, drug-induced parkinsonism, akathisia, tardive dyskinesia, and dopamine-acetylcholine imbalance

47. Dystonia • Occurs usually within 48 hours of initiation of the medication • Involves bizarre and severe muscle contractions • Can be painful and frightening • Characterized by odd posturing and strange facial expressions (Torticollis, Opisthotonus, Laryngospasm, Oculogyric Crises)

48. Opisthotonus

49. Torticollis

50. Oculogyric Crises