Schizophrenia Chapter 16
Schizophrenia
Chapter 16
Schizophrenia
Fascinated and confounded healers for centuries
One of most severe mental illnesses– 1/3 of population– 2.5% of direct costs of total budget– $46 billion in indirect costs
Epidemiology
• 0.5%-1.5% of population• 2.5 million Americans• 300,000 acute episodes each year• Cluster in lower socioeconomic group• Homelessness is a problem.• Direct treatment costs $20 billion/yr
Epidemiology• Across all cultures• In the United States, African Americans
have a higher prevalence rate (thought to be related to racial bias).
• Men are diagnosed earlier.• EOS: Diagnosed late adolescence• LOS: Diagnosed > 45 years
Maternal Risk Factors Prenatal poverty Poor nutrition Depression Exposure to influenza outbreaks War zone exposure Rh-factor incompatibility
Infant and Childhood Risk Factors
Low birth weight Short gestation Early developmental difficulties CNS infections
History of Schizophrenia• 1800s - Eugene Kraeplin named it
“dementia praecox.”• 1900s - Eugen Bleuler named it
schizophrenia (split minds). More than one type.
• Kurt Schneider - First rank (psychosis, delusions) and second rank (all other experiences)
Phases of Schizophrenia Acute Illness Period
– Positive symptoms/may be subtle– Family Disruption– Awareness of the meaning of the disorder
Stabilization– Treatment is intense– Establish Medications– Begin Rehab
Maintenance and Recovery– Relapse prevention– Coping Strategies
Relapse– Non-compliance– Identify triggers
Familial Differences
First-degree biologic relatives have 10 times greater risk for schizophrenia.
Other relatives have higher risk for other psychiatric disorders.
Schizophrenia Diagnosis
• During a one-month period at least two of the five– Positive (delusions, hallucinations, etc.)– Negative (alogia, anhedonia, flat affect,
avolition)• One or more areas of social or
occupational functioning
Types of SchizophreniaText Box 16.1
Paranoid Disorganized Catatonic Undifferentiated Residual
NegativeAvolitionAlogiaAnhedoniaFlat AffectAmbivalence
NeurocognitiveImpairment
AttentionMemory
Exec Function
Positive Hallucinations
DelusionsDisorganization
Schizophrenia
Positive Symptoms: Excess of Normal Functions
• Delusions (fixed, false beliefs)– Grandiose– Nihilistic– Persecutory– Somatic
• Hallucinations (perceptual experiences)• Thought disorder• Disorganized speech• Disorganized or catatonic behavior
Negative Symptoms: Less Than Normal Functioning
• Affective blunting: reduced range of emotion• Alogia: reduced fluency and productivity of
language and thought• Avolition: withdrawal and inability to initiate
and persist in goal-directed behavior• Anhedonia: inability to experience pleasure• Ambivalence: concurrent experience of
opposite feelings, making it impossible to make a decision
Neurocognitive Impairment
Neurocognition Memory (short-, long-term) Vigilance (sustained attention) Verbal fluency (ability to
generate new words) Executive functioning
– volition– planning– purposive action– self-monitoring behavior
Impaired in schizophrenia Memory (working) Vigilance Executive functioning
• Evidence that neurocognitive impairment exists, independent of positive and negative symptoms
Neurocognitive Impairment Often Seen as “Disorganized Symptoms”
• Confused speech and thinking patterns• Disorganized behavior• Examples of disorganized thinking
– Echolalia (repetition of words)– Circumstantially (excessive detail)– Loose associations (ideas loosely connected)– Tangentially (logical, but detour)– Flight of ideas (change topics)– Word salad (unconnected words)
Disorganized Symptoms• Examples of disorganized thinking (cont.)
– Neologisms (new words)– Paranoia (suspiciousness)– References ( special meaning)– Autistic thinking (private logic)– Concrete thinking (lack of abstract thinking)– Verbigeration (purposeless repetition)– Metonymic speech (interchange words)
Disorganized Symptoms• Examples of disorganized thinking (cont.)
– Clang association (repetition similar sounding words)– Stilted language (artificial, formal)– Pressured speech (words forced)
• Examples of disorganized behavior– Aggression– Agitation– Catatonic excitement (hyperactivity, purposeless
activity)
Disorganized Symptoms• Examples of disorganized behavior (cont.)
– Echopraxia (imitation of others movements)– Regressed behavior – Stereotypy (repetitive, purposeless movements)– Hypervigilance (sustained attention to external
stimuli)– Waxy flexibility (posture held in odd or unusual way)
Comorbidity• Increased risk of cardiovascular
disorders• Association between insulin-dependent
diabetes and schizophrenia• Depression and pseudodementia• Increased substance abuse• Cigarette smoking• Fluid imbalance
Disordered Water Balance
Prolonged periods of polydipsia, intermittent hyponatremia, polyuria
Etiology – unknown Observed behaviors
– Carrying cokes/coffee/water bottles Prevention of water intoxication Promotion of fluid balance
Psychological
Difficulty relating Deficit in sensory inhibition Poor control of autonomic
responsiveness Difficulty making decisions Deficit experiencing pleasure Deficit initiating activities Overassessment of threat
Social
Deceased financial status Family and caregiver stress Homelessness Stigma and community isolation
Biologic Factors
• Genetic – 10% first-degree relative• Stress-diathesis model proposed by
O’Connor• Neuroanatomical findings
– Decreased blood flow to left globus pallidus– Absence of normal blood increase in frontal lobes– Atrophy of the amygdala, hippocampus and
parahippocampus– Ventricular enlargement
Biologic• Neurodevelopmental
– Prenatal exposure (2nd trimester)– Late winter, early spring births
– Adolescent– Changes in transmitter systems and substrates– Synaptic pruning along with substantial brain growth in
some areas of the cortex– Changes in steroid-hormonal environment
Neurotransmitters, Pathways and Receptors
• Hyperactivity of the limbic area • (dopamine mesolimbic tract) related to positive
symptoms• Hypofrontality or hypoactivity of the pre-
frontal and neo-cortical areas• (dopamine mesocortical tract related to negative
and positive symptoms) • Does not result from dysfunction of a single
neurotransmitter
Psychosocial Theories
• Do not explain cause• Disservice to families• Useful in family interaction
– Expressed Emotion (EE)• High emotion associated with negative
communication and overinvolvement• Low emotion associated with less negativity and
less overinvolvement
Priority Care Issues
Suicide– 20-50% Attempt– 10% Complete
Safety of patient and others Initiate antipsychotic medications
Family Response to Disorder
Mixed emotions – shock, disbelief, fear, care, concern and hope
May try to seek reasons Initial period very difficult NAMI – Life changed forever
Interdisciplinary Treatment
The most effective approach involves a variety of disciplines.
There is considerable overlap of roles and interventions.
Nursing’s contribution is significant.
Nursing Management: Biologic Domain Assessment
• Present and past health status• Physical functioning• Nutritional assessment• Fluid imbalance assessment• Pharmacologic assessment
Medications (prescribed, OTC, herbal, illicit) Abnormal motor movements
– DISCUS– AIMS – Simpson-Angus Rating Scale
Assessment
Comorbidity– Diabetes– Smoking-related– Cardiac
Hypertension
Nursing Diagnosis:Biologic Domain
Self-care deficit Disturbed sleep pattern Ineffective therapeutic regimen
management Imbalanced nutrition Excess fluid volume Sexual dysfunction
Nursing Interventions:Biologic Domain
Promotion of self-care activities– Develop a routine of hygiene activities.– Emphasize its importance; help motivate the patient.
Activity, exercise and nutrition– Help counteract effects of psychiatric medications.– Appetite usually increases, so help with food choices.
Thermoregulation– Teach patient to wear clothing according to weather; dress
for winter and summer.– Observe patient’s response to temperature.
Promotion of normal fluid balance– Water intoxication protocol (Text Box 16.7)
Pharmacologic Interventions Newer antipsychotics more efficacious and safer (block
dopamine and serotonin)– Risperidone (Risperdal)– Olanzapine (Zyprexa)– Quetiapine (Seroquel)– Ziprasidone (Geodone)– Aripiprazole (Abilify)– Clozapine (Clozaril) - second line
Monitoring and administering medications– Takes 1-2 weeks to work (some improvement immediately)– Adequate trial - 6-12 weeks– Adherence to prescribe medication is best prevention of relapse.– Discontinuation is rare.
Pharmacologic Interventions: Monitoring Side Effects Parkinsonism
– Identical symptoms to Parkinson’s – Caused by blockade of D2 receptor in basal ganglia– Treated with anticholinergic medications– Taper anticholinergic meds if discontinued
Dystonia– Imbalance of DA and ACH, with more ACH– Young men more vulnerable– Oculogyric crisis, Torticollis, Retrocollis
Monitoring Side Effects Akathesia
– Restlessness, jumping out of skin, uncomfortable– Reduce dose of antipsychotic.– Treat with a -blocker (propranolol).
Tardive Dyskinesia– Impairment of voluntary movement, constant motion – Occurs 6-8 months following initiation of antipsychotics– Facial-buccal area -- lip smacking, sucking, etc.– Movements in trunk, rocking– No real treatment
Monitoring Side Effects Orthostatic hypotension Hyper Prolactinemia (haloperidol and
risperidone) Weight gain (olanzapine and clozapine) Sedation New-onset diabetes (Olanzapine,clozapine) Cardiac arrhythmias (QT prolongation)
(Ziprasidone) may need baseline ECG Agranulocytosis (all but *clozapine)
Drug-drug Interactions Medications metabolized by 1A2 enzymes
include olanzapine and clozapine. Inhibitors: fluvoxamine (Luvox) Inducers: cigarette smoking Smokers may require a
higher dose Medications metabolized by 3A4 include
clozapine, quetiapine and ziprasidone. Inhibitors: ketoconazole, protease inhibitors,
erythromycin Inducer: carbamazapine (Tegretol)
Medications affected by 2D6 include risperidone, clozapine and olanzapine.
Inhibitors: fluoxetine, paroxetine (not usually clinically significant)
Medication Teaching Points
Consistency in taking medication Medication and symptom amelioration Side effects and management Interpersonal skills that help patient
and family report medication effects
MEDICATIONEMERGENCIES
Neuroleptic Malignant Syndrome
TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSE Severe muscle rigidity, elevated temperature Recognizing symptoms
– Elevated temperature, changes in level of consciousness, leukocytosis, elevated creatinine phosphokinase), elevated liver enzymes or myoglobinuria
Nursing interventions– Stop administration of offending medications.– Monitor vital signs.– Reduce body temperature.– Safety, protect muscles
Supportive measures– IV fluids– Cardiac monitoring– Dantrolene (Dopamine agonist)
Neuroleptic Malignant Syndrome Acute reaction to dopamine receptors blockers Prevalence 2 to 2.4% Death – 4 to 22%, mean = 11% Etiology:
– Drugs block striatal dopamine receptors; disrupt regulatory mechanisms in the thermoregulatory center in hypothalamus and basal ganglia; heat regulation fails and muscle rigidity
Is Client onneuroleptic drug? NO NOT NMS
ANY RISK FACTORS FOR NMS?DEHYDRATION?HISTORY OF NMS?RECENT DOSE INCREASE?PSYCHOMOTOR AGITATION
YES
EARLY S/S NMS?LOW-GRADE FEVER?TACHYCARDIA?ELEVATED BP?CATATONIA?DIAPHORESIS?
YES
HYPERTHERMIA?LEAD PIPE RIGIDITY?MS CHANGESOTHER AUTONOMIC CNS?
HOLD DRUG
NOTIFY MD
Anticholinergic Crises Potentially life threatening, anticholinergic
delirium Can occur in patients who are taking several
medications with anticholinergic effects Elevated temperature, dry mouth, decreased
salivation, decreased bronchial, nasal secretion, widely dilated eye
Stop offending drug, usually self-limiting. May use inhibitor of anticholinesterase, physostigmine.
Anticholinergic Crisis Confusion, hallucinations Physical signs - dilated pupils, blurred vision,
facial flushing, dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension decreased bowel sounds, urinary retention, nausea, vomiting, seizures, coma
Atropine flush Hot as a hare, blind as a bat, mad as a
hatter, dry as a bone
Treatment
Self-limiting – three days Discontinuation of medication Physiostigmine 1-2 mg IV, an
inhibitor of cholinesterase, improves in 24-36 hours
Gastric lavage Charcoal, catharsis
Nursing Management: Psychological Domain Assessment – Responses
Socially stigmatizing Prodromal symptoms evident (negative symptoms)
Tension and nervousness Lack of interest in eating Difficulty concentrating Disturbed sleep Decreased enjoyment Loss of interest, restlessness, forgetfulness
Often not recognized as an illness Denial common
Nursing Management: Psychological Domain Assessment
• Positive and negative symptoms• SAPS (positive symptoms) (Box 16.14)• SANS (negative symptoms) (Box 16.15)• PANNS (both symptoms)
• Mental status• Appearance• Mood and affect (lability, ambivalence, apathy)• Speech• Thought processes (delusions, disorganized communication, cognitive
impairments)• Sensory perception (hallucinations)• Memory and orientation• Insight and judgment
Nursing Management: Psychological Domain Assessment (cont.)
Behavioral responses Self-concept Stress and coping patterns Risk assessment
– Command hallucinations– Self-injury risk, suicide– Homicide
Nursing Diagnosis: Psychological Domain
Disturbed thought processes Disturbed sensory perceptions Disturbed body image Low self-esteem Disturbed personal identity Risk of violence, suicide Ineffective coping Knowledge deficit
Nursing Interventions: Psychological Domain
Counseling, conflict resolution, behavior therapy and cognitive interventions can be used.
Development of nurse-patient relationship – Centers on the development of trust and
acceptance of the persons – Critical for optimal treatment of
schizophrenia
Nursing Interventions:Psychological Domain – Management of Disturbed Thoughts
Assessment content of hallucinations/delusions Outcomes
– Decrease frequency and intensity.– Recognize as symptoms of disorder.– Develop strategies to manage recurrence.
Experiences real to the patient – Validate that experiences are real– Identify meaning and feeling that are provoked
Teach patient that hallucinations and delusions are symptoms of illness.
Nursing Interventions: Psychological Domain
Self-monitoring and relapse prevention– Monitor events, time, place, etc. of recurrence of
symptoms.– Manage symptoms - getting busy, self-talk, change of
activity. (Moller-Murphy Tool) Enhancement of cognitive functioning
– Recognize difficulty in processing information.– Improve attention (computer programs, one-to-one).– Help memory (make lists, write down information).– Improve executive functioning-simulation.
Nursing Interventions: Psychological Domain
Behavioral interventions– Organize routine, daily activities.– Reinforce positive behaviors.
Stress and coping skills development– Counseling sessions– Teach and reward positive coping skills.
Patient education– Errorless learning environment– Minimal distractions– Clear visual aids– Skills training
Family Interventions Family support Educate the family regarding lifelong disorder
of schizophrenia. Emphasize consistent taking of medication.
Nursing Management: Social Domain Assessment
Functional status– Assessed initially and at regular intervals– GAF usually used
Social systems– Formal and informal support systems
Quality of life Family assessment
– Family assessment guide (Ch. 15)– Special consideration to the family where patient is the
parent
Nursing Interventions:Social Domain
Promotion of Patient Safety• Monitoring for potential aggression• Administering medication as ordered• Reducing environmental stimulation• Approach to individual patients
– Thorough history of violence– Help patient to talk directly and constructively with those with
whom they are angry.– Set limits.– Involve patients in formal contracting.– Schedule regular time-outs.
Nursing Interventions: Social Domain
Support groups Milieu therapy Psychiatric rehabilitation Family interventions
– Encourage to participate in support groups– Inform about local and state resources– Help negotiate provider system
Continuum of Care Treatment occurs across continuum.
Patients are at high risk for getting lost in the system.
Inpatient-focused care (stabilization) Emergency care (crisis) Community care (most of care) Mental health promotion
Schizophrenia in Children
Rare in children If appears in children aged 5 or 6,
symptoms same as for adults Hallucinations visual, delusions less
well-developed Other disorders considered first
Schizophrenia in Elderly
For those who have had schizophrenia most of their life, this may be a time that they experience improvement in symptoms.
Late-onset schizophrenia– Diagnostic criteria met after 45
Estrogen may be protective in women– Most likely include positive symptoms