Chapter 14 Schizophrenia

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Chapter 14 Schizophrenia
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• 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 world.

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• Hard or positive symptoms include
• Delusions
• Hallucinations
• Grossly disorganized thinking,
  speech, and behavior

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• Soft or negative symptoms include
• Flat affect
• Avolition
• Social withdrawal or discomfort
• Apathy
• Alogia

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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

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Types of Schizophrenia (contd)

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

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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
  episode or fairly continuous psychosis with some
  shift in severity of symptoms

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Clinical Course (contd)

• Over the long term, psychotic symptoms diminish
  for most clients and are managed more easily
• Many years of dysfunction are rarely overcome

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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 nonbizarre
  delusions with no impairment in psychosocial
  functioning

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Related Disorders (contd)

• 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

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Etiology

• Current etiologic theories focus on biologic
  theories
• Genetic factors
• Neuroanatomic theories
• Neurochemical theories
• Immunovirologic factors

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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

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Treatment
Primary treatment involves antipsychotic
(neuroleptic) medication

• 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

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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 2 to 4 weeks,
  eliminating the need for daily oral antipsychotic
  medication

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Side Effects of Antipsychotic Medications

• Neurologic side effects
• Extrapyramidal side effects (acute dystonic
  reactions, akathisia, and parkinsonism)
• Tardive dyskinesia
• Seizures
• Neuroleptic malignant syndrome

• Nonneurologic side effects
• Weight gain
• Sedation
• Photosensitivity
• Anticholinergic symptoms (dry mouth, blurred
  vision, constipation, urinary retention)
• Orthostatic hypotension
• Agranulocytosis (Clozapine)

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Treatment

• Adjunctive Treatment
• Individual, group, and family therapy
• Structured milieu therapy
• Community support programs
• Client/family education and support

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Application of the Nursing Process

• Assessment
• Previous history with schizophrenia
• Previous suicidal ideation
• Current support system
• Clients perception of current situation

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Application of the Nursing Process (contd)

• Assessment (contd)
• 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

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Application of the Nursing Process (contd)

• Assessment (contd)
• 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)

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Application of the Nursing Process (contd)

• Data Analysis
• Common nursing diagnoses for positive symptoms
  include
• Risk for Other-Directed Violence
• Risk for Suicide
• Disturbed Thought Processes
• Disturbed Sensory Perception
• Disturbed Personal Identity
• Impaired Verbal Communication

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Application of the Nursing Process (contd)

• Data Analysis (contd)
• 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

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Application of the Nursing Process (contd)

• 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

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Application of the Nursing Process (contd)

• Outcome Identification (contd)
• 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
• Seek or accept assistance to meet his or her
  needs when indicated

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Application of the Nursing Process (contd)

• Intervention
• Promote safety of clients and others
• Establish a therapeutic relationship
• Use therapeutic communication
• Interventions for delusional thoughts
• Interventions for hallucinations
• Protect the client who has socially inappropriate
  behaviors
• Client and family teaching

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Application of the Nursing Process (contd)

• Evaluation
• Have the clients 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?

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Application of the Nursing Process (contd)

• Evaluation (contd)
• 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?

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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

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Community-Based Care

• Assertive community treatment (ACT)
• Behavioral home health
• Community support programs
• Case management

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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
• Future research on prophylactic drug treatment to
  treat genetically vulnerable relatives with
  beginning negative signs of schizophrenia

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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 clients success or failure
  personally. The clients remarks and behavior or
  noncompliance are not personal toward the nurse
  part of the illness

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Self-Awareness Issues (contd)

• Nurse should focus on clients strengths and time
  out of the hospital, not just on symptoms and
  need for acute care
• No nurse has all the answers