Chapter 14 Schizophrenia

1. Chapter 14 Schizophrenia

2. Definition of Schizophrenia • Schizophrenia is a syndrome or disease process of the brain causing distorted and bizarre thoughts, perceptions, emotions, movements, and behavior • It is usually diagnosed in late adolescence and early adulthood • Prevalence is 1% of total population, or 3 million in U.S.; same prevalence throughout the world

3. Symptoms of Schizophrenia • Hard or positive symptoms include: • Delusions • Hallucinations • Grossly disorganized thinking, speech, and behavior

4. Symptoms of Schizophrenia (cont’d) • Soft or negative symptoms include: • Flat affect • Avolition • Social withdrawal or discomfort • Apathy • Alogia

5. Types of Schizophrenia • Paranoid type: persecutory or grandiose delusions and hallucinations; sometimes excessive religiosity; hostile and aggressive behavior • Disorganized type: grossly inappropriate or flat affect, incoherence, loose associations, extremely disorganized behavior

6. Types of Schizophrenia (cont’d) • Catatonic: marked psychomotor disturbance, motionless, or excessive motor activity; extreme negativism; mutism; peculiarities of voluntary movement (echolalia, echopraxia) • Undifferentiated: mixed schizophrenic symptoms along with disturbances of thought, affect, and behavior • Residual: at least one previous psychotic episode but not currently; social withdrawal, flat affect, loose associations

7. Clinical Course • Most clients experience a slow and gradual onset of symptoms • Younger age of onset associated with poorer outcomes • In first years after diagnosis, client may have relatively symptom-free periods between psychotic episodes or fairly continuous psychosis with some shift in severity of symptoms

8. Clinical Course (cont’d) • Most clients with schizophrenia have difficulty functioning in the community and few lead fully independent lives • Early detection and aggressive treatment of the first psychotic episode improves outcomes

9. Related Disorders • Schizophreniform disorder: symptoms of schizophrenia are experienced for less than the 6 months required for a diagnosis of schizophrenia • Schizoaffective disorder: symptoms of psychosis and thought disorder along with all the features of a mood disorder • Delusional disorder: one or more non-bizarre delusions with no impairment in psychosocial functioning

10. Related Disorders (cont’d) • Brief psychotic disorder: one psychotic symptoms lasting 1 day to 1 month; may or may not have an identifiable stressor, such as childbirth • Shared psychotic disorder (folie à deux): similar delusion shared by two people, one of whom has psychotic delusions

11. Etiology • Current etiologic theories focus on biologic theories: • Genetic factors • Neuroanatomic theories • Neurochemical theories • Immunovirologic factors

12. Cultural Considerations • Ideas that are considered delusional in one culture may be commonly accepted by other cultures • Auditory or visual hallucinations may be a normal part of religious experiences in some cultures • Ethnicity may be a factor in the way a person responds to psychotropic medications: • African Americans, Caucasian Americans, and Hispanic Americans appear to require comparable therapeutic doses of antipsychotic medications • Asian clients need lower doses of drugs such as haloperidol (Haldol) to obtain the same effects

13. Conventional antipsychotics target the positive signs— Delusions Hallucinations Disturbed thinking Other psychotic symptoms —but have no observable effect on the negative signs Atypical antipsychotics diminish positive symptoms, and they lessen the negative signs: Avolition Social withdrawal Anhedonia Treatment Primary treatment involves antipsychotic (neuroleptic) medication

14. Maintenance Therapy • Two antipsychotics are available in depot injection forms for maintenance therapy: • Fluphenazine (Prolixin) in decanoate and enanthate preparations • Haloperidol (Haldol) in decanoate • The effects of the medications last from 2 to 4 weeks, eliminating the need for daily oral antipsychotic medication

15. Neurologic side effects: Extrapyramidal side effects (acute dystonic reactions, akathisia, and parkinsonism) Tardive dyskinesia Seizures Neuroleptic malignant syndrome Non-neurologic side effects: Weight gain Sedation Photosensitivity Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention) Orthostatic hypotension Agranulocytosis (clozapine) Side Effects of Antipsychotic Medications

16. Psychosocial Treatment • Group therapies • Supportive, medication management, use of community supports • Social skills training • Cognitive adaptation training • Cognitive enhancement therapy (CET) • Family therapy • Family education

17. Application of the Nursing Process • Assessment • Previous history with schizophrenia • Previous suicidal ideation • Current support system • Client’s perception of current situation

18. Application of the Nursing Process (cont’d) • Assessment (cont’d) • General appearance, motor behavior, and speech • Mood and affect: flat or blunted affect, anhedonia • Thought processes and content: disordered • Delusions • Sensorium and intellectual processes: hallucinations, disorientation, concrete or literal thinking • Judgment and insight: impaired judgment, limited insight • Self-concept: may be distorted, with depersonalization, loss of ego boundaries resulting in bizarre behaviors

19. Application of the Nursing Process (cont’d) • Assessment (cont’d) • Roles and relationships: often socially isolated, have difficulty fulfilling life roles • Physiologic and self-care considerations; may have multiple self-care deficits (inattention to hygiene, nutrition, sleep needs; polydipsia occasionally seen in longer-term clients)

20. Application of the Nursing Process (cont’d) • Data analysis • Common nursing diagnoses for positivesymptoms include: • Risk for other-directed violence • Risk for suicide • Disturbed thought processes • Disturbed sensory perception • Disturbed personal identity • Impaired verbal communication

21. Application of the Nursing Process (cont’d) • Data analysis (cont’d) • Common nursing diagnoses for negative symptoms and functional abilities include: • Self-care deficits • Social isolation • Deficient diversional activity • Ineffective health maintenance • Ineffective therapeutic regimen management

22. Application of the Nursing Process (cont’d) • Outcome identification • Expected outcomes for the acute, psychotic phase; the client will: • Not injure self or others • Establish contact with reality • Interact with others • Express thoughts and feelings in a safe and socially acceptable manner • Participate in prescribed therapeutic interventions

23. Application of the Nursing Process (cont’d) • Outcome identification (cont’d) • Expected outcomes for continued care; the client will: • Participate in the prescribed regiment (including medication and follow-up appointments) • Maintain adequate routines for sleeping and food and fluid intake • Be independent in self-care activities • Communicate effectively with others in the community to meet his or her needs • The client will seek or accept assistance to meet his or her needs when indicated

24. Application of the Nursing Process (cont’d) • Intervention • Promote safety of clients and others • Establish a therapeutic relationship • Use therapeutic communication • Interventions for delusional thoughts • Interventions for hallucinations • Protecting the client who has socially inappropriate behaviors • Client and family teaching

25. Application of the Nursing Process (cont’d) • Evaluation • Have the client’s psychotic symptoms disappeared? Or can the client carry out his or her daily life despite the persistence of some psychotic symptoms? • Does the client understand the prescribed medication regimen? Is he or she committed to adherence to the regimen? • Does the client possess the necessary functional abilities for community living? • Are community resources adequate to help the client live successfully in the community?

26. Application of the Nursing Process (cont’d) • Evaluation (cont’d) • Is there a sufficient after-care or crisis plan in place to deal with recurrence of symptoms or difficulties encountered in the community? • Are the client and family adequately knowledgeable about schizophrenia? • Does the client believe that he or she has a satisfactory quality of life?

27. Elder Considerations • Psychotic symptoms that appear in later life are usually associated with depression or dementia, not schizophrenia • Elderly people with schizophrenia experience a variety of long-term outcomes: • 20% to 30% of clients experience dementia, resulting in a steady, deteriorating decline in health • 20% to 30% experience a reduction in positive symptoms, somewhat like a remission • 40% to 60% remain mostly unchanged

28. Community-Based Care • Assertive community treatment (ACT) • Behavioral home health • Community support programs • Case management

29. Mental Health Promotion • Psychiatric rehabilitation has the goal of recovery for client, more than just symptom control and medication management • Early identification and aggressive treatment of psychotic symptoms maximizes recovery and quality of life • Studies identifying at-risk individuals and implementing early interventions result in improved prodromal symptoms, prevention of social stagnation or decline, and prevention or delay of progression to psychosis

30. Self-Awareness Issues • May be challenging if client is suspicious or mistrustful or nurse is frightened • Nurse may become frustrated if client is noncompliant • Nurse must not take client’s success or failure personally; the client’s remarks and behavior or noncompliance are not personal toward the nurse but are part of the illness

31. Self-Awareness Issues (cont’d) • Focus on client’s strengths and time out of the hospital, not just on symptoms and need for acute care • No nurse has all the answers