SCHIZOPHRENIA AND PSYCHOSIS

Module III RNSG 2213

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

PSYCHOSIS
How do we define this term?
Inability to evaluate accuracy of ones thoughts and perceptions Incorrect interpretation of external reality Inability to re-evaluate ones 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

OVERVIEW, CONTD
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

OVERVIEW, CONTD
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.)

OVERVIEW, CONTD
A Chronic Illness Characterized by Phases:
Acute phase severe psychotic sx. Stabilizing Phase Stable phase Most pts. alternate between acute and stable phases

SCHIZOPHRENIA:

SYMPTOMS

Bleulers (Early 1900s) 4 As: Affect disturbances Autism Associative looseness Ambivalence

Fragmentation of the Mind

CLASSIFICATION OF SYMPTOMS
Positive Symptoms Negative Symptoms Cognitive Symptoms

Positive Symptoms of Schizophrenia

Agitation/aggression Delusions Hallucinations Disordered thinking (AEB disordered speech):

circumstantial thinking, loose associations, word salad, neologisms, echolalia

Positive Symptoms of Schizophrenia, contd

Disordered movement:
--restlessness, repetitive movements (e.g. echopraxia), --or immobility (catatonia)
http://www.youtube.com/watch?v=zAEJ-Jvndms

Matching: Symptoms
1) A blue ape. Makes me 2) 3) 4) 5) 6)
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 parakeets name. Whats your name?

A) Word salad B) Delusion of reference C) Tangentiality D) Neologism E) Loose associations F) Paranoid delusion G) Nihilistic delusion H) Grandiose delusion

 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.

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

Flat Affects (Flight of the Conchords)

Cognitive Symptoms of Schizophrenia

Impaired ability to pay attention and to understand Impaired ability to make decisions (ambivalence) Problems in using just-learned information

CRITICAL THINKING: Nursing Diagnoses

Write one nursing dx. for each symptom or behavior related to schizophrenia 1) Client has command auditory hallucinations that he should kill himself 2) Client does not get dressed or take baths 3) Client believes she can make it snow

Suggested Nursing DX:

1) 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 selfcare s/t schizophrenia 3) Altered thought process s/t grandiose delusion (or delusion of grandeur)

Antipsychotic Agents and Symptoms

The Typical (older class) of antipsychotics primarily address POSITIVE symptoms
Can make negative symptoms Worse

The Atypical (newer classes) of antipsychotics address both POSITIVE AND NEGATIVE symptoms

SYMPTOMS:
A. At least 2:

DSM CRITERIA

Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms

B. C. D. E.

Social-occupational dysfunction Continuous s/sx. > 6 months No schizoaffective diagnosis Not caused by substance abuse or medical disorder

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

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 doesnt fit criteria for any of the above

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.

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

BIOLOGICAL THEORIES
1. The Dopamine Hypothesis:
Too much dopamine binds with too many brain receptors and causes positive symptoms

Too little dopamine -- negative symptoms

BIOLOGICAL THEORIES, contd

2. Disturbed Ratio of serotonin: dopamine

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:

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

PET Scan and Schizophrenia

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

DEVELOPMENTAL AND ENVIRONMENTAL THEORIES

Prenatal infections Parental neglect or rejection Greater % of pts. come from lower socio-economic class

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

Australian aboriginal painting by mental health client

http://www.ncbi.nlm.nih.gov

INTERVENTIONS/ PSYCHOTHERAPEUTIC MANAGEMENT

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

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: Thats interesting. Want to come with me now to see the patient art exhibit? Nurse D: I can see you feel strongly about that.

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

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, Im Jo the nurse; are you ok? Nurse C: Why are you pacing?

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 its not ok to turn it off. Come on outside for some fresh air. Im going to give you some medication right now to help you feel calmer.

OTHER INTERVENTIONS
Importance of client and family education
To address stigma of schizophrenia & To improve functional ability, selfmanagement and prevent relapse

Other Interventions, contd

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

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

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

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)

Typical/Traditional Antipsychotics, contd

Action = Block Dopamine D2 Receptors Most effective for Positive (+) symptoms

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)

Newest Atypical Agents

iloperidone (Fanapt) Asenaphine (Saphris)

Atypical (2nd generation) Agents,

contd
Action: Block (antagonists) or enhance (agonists) multiple dopamine, serotonin and/or norepinephrine receptors.
Useful for both positive and negative symptoms

Novel (3rd Generation) Agents

aripiprazole (Abilify) Action: Partial dopamine antagonist Balances dopamine (both increases and decreases it in different brain areas)

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

Tardive Dyskinesia

http://www.youtube.com/watch?v=UbBpt9uCXqc&feature=related

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

Antipsychotics: Side Effects, contd

Anticholinergic Effects-dry mouth,
orthostatic hypotension, urinary retention, blurred vision Usually resolve over time

Other Side Effects

Cardiac: Arhythmias (QT interval lengthened) Blood: Leukopenia, anemias, agranulocytosis (clozapine/Clozaril) Endocrine and Metabolic: Weight gain Altered glucose metabolism Diabetes type II Elevated prolactin levels Sexual: Impaired libido, performance

A Dangerous Side Effect

Neuroleptic Malignant Syndrome (NMS)
Potentially lethal Associated with use of high-potency agents e.g. haloperidol/Haldol Onset: within a week after starting meds. Symptoms: muscular rigidity, tremors, autonomic hyperactivity e.g. high body temperature, altered consciousness

Nursing Interventions R/T Antipsychotic Meds.

Medication education (You cannot teach too often) Side effect issues contribute to poor adherence/compliance:
E.g. hypotension, CNS depression, photosensitivity, thermoregulation problems

Education/Safety Issues: What will you teach the client about. . .?

Hypotension Sedation Photosensitivity Problems with thermoregulation Weight gain

Nursing Interventions R/T Pharmacotherapy

--Option for client with poor adherence: Long acting (depot) form, give IM q 1week - 4 wks

Nursing Interventions r/t Pharmacotherapy

Disintegrating oral tablet Oral solution

EMERGENCY MEDS
Common choice: IM cocktail of sedating antipsychotic + antihistamine and benzodiazepine Goals: reduce agitation rapid sedation

CRITICAL THINKING: Antipsychotic Therapy

A 65 year-old client will start on an antipsychotic agent for delusions secondary to severe depression. Choose the 3 highest priority diagnostic tests that will be performed.
A) CBC with diff. B) Chest x-ray C) EKG D) EEG E) BUN/Creatinine F) Electrolytes

PHARMACOTHERAPY FOR EXTRAPYRAMIDAL SEs: Antiparkinson Agents

benztropine (Cogentin) trihexyphenidyl (Artane) biperiden (Akineton) diphenhydramine (Benadryl) amantadine (Symmetrel)

Antiparkinson Agents, contd

Action: Restore balance of dopamine
with acetylcholine (ACh) Reduce motor and muscle dysfunctions caused by this imbalance But: They also may cause anticholinergic SEs and mental confusion

CRITICAL THINKING
Which client(s) is(are) candidate(s) for benztropine/Cogentin?
A) is unable to void urine B) reports onset of difficulty swallowing and stiff muscles C) is pacing in response to hearing voices D) has had tardive dyskinesia symptoms for several years

CRITICAL THINKING:
Anti-Parkinson/Anticholinergic Agents
On the mental health unit, a client who was recently prescribed an antiparkinson agent for EPSEs reports very dry mouth and constipation. What will the nurse do? (Choose all that apply) A) Call the dr. to discuss changing dose of the med. B) Encourage use of hard candies and increase in fluid intake C) Hold the medication D) Inform the client that these effects may decrease in a few weeks.