SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

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SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
Mercedes A Perez-Millan MSN, ARNP
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INTRODUCTION

• Schizophrenia is possibly a group of psychotic
  disorders that severely impairs all areas of
  an individuals functioning.
• 1 to 1.5 of US population has schizophrenia.
  However they make up far more than 50 of the
  county and long-term residents of state mental
  hospitals.
• More than 50 are homeless, and in addition may
  have an addiction problem.
• The cost of treatment and loss of revenues are
  estimated in the billions of dollars.

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COMORBIDITY

• Substance abuse disorders
• Nicotine dependence
• Depression
• Suicide
• Anxiety disorders
• Psychosis-induced polydipsia

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ETIOLOGY

• Neurobiochemical
• Dopamine hypothesis
• Serotonin
• Glutamate
• Neuroanatomical
• Structural cerebral abnormalities
• Genetic
• Several genes on different chromosomes interact
  with environment
• Nongenetic risk factors
• Complications of pregnancy and birth
• Stress

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GENETIC PREDISPOSITION

• A single gene has not been identified.
• Research is focused on chromosomes 6, 13, 18
  22.
• The risk of developing the disorder is as
  follows
• One parent 12-15
• Both parents 40
• Identical twins 50
• (The statistics may vary in different studies)

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AREAS OF THE BRAIN AFFECTED
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BIOLOGICAL THEORIES Neuroanatomical
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Course of Schizophrenia

• Recurrent acute exacerbations of psychosis
• Increase in residual dysfunction and
  deterioration with each relapse

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Phases in Course of Schizophrenia

• Acute phase
• Positive symptoms and negative symptoms
• Maintenance phase
• Acute symptoms are less severe
• Stabilization phase
• Remission of symptoms

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Potential Early Symptoms Pre-psychotic

• Withdrawn from others
• Depressed
• Anxious
• Phobias
• Obsessions and compulsions
• Difficulty concentrating
• Preoccupation with religion
• Preoccupation with self

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Bleulers 4 As of Schizophrenia

• Affect
• Associative looseness
• Autism
• Ambivalence

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Signs and Symptoms Relevant to Treatment

• Positive symptoms
• Negative symptoms
• Cognitive symptoms
• Mood symptoms

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Dimensions Altered in Individuals with
Schizophrenia

• Ability to work
• Interpersonal relationships
• Self-care abilities
• Social functioning
• Quality of life

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Positive Symptoms Alteration in Thinking

• Delusions false, fixed beliefs that cannot be
  corrected by reasoning
• Ideas of reference
• Persecution
• Grandiosity
• Somatic sensations
• Jealousy
• Control
• Thought broadcasting
• Thought insertion
• Thought withdrawal
• Delusion of being controlled
• Concrete thinking

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Positive Symptoms Alterations in Speech

• Associative looseness
• Neologisms
• Echolalia
• Clang association
• Word salad

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Positive Symptoms Alterations in Perception

• Hallucinations sensory perceptions for which no
  external stimulus exists
• Auditory
• Visual
• Olfactory
• Tactile
• Personal boundary difficulties

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Positive Symptoms Alterations in Behavior

• Extreme motor agitation
• Stereotyped behaviors
• Automatic obedience
• Waxy flexibility
• Stupor
• Negativism

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Negative Symptoms

• Affective blunting
• Anergia
• Anhedonia
• Avolition
• Poverty of content of speech
• Thought blocking
• Flat affect/inappropriate affect

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Cognitive Symptoms

• Inattention, easily distracted
• Impaired memory
• Poor problem-solving skills
• Poor decision-making skills
• Illogical thinking
• Impaired judgment

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Depression and Other Mood Symptoms

• Dysphoria
• Suicidal ideation
• Hopelessness

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Types of Schizophrenia

• Subtypes
• Paranoid
• Catatonic
• Disorganized
• Undifferentiated
• Residual

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Self-Assessment Working with Schizophrenic
Clients

• Peer group supervision
• Client's intense emotions produce
• similar emotions in the nurse
• Willingness for nurse to discuss feelings and
  behaviors with supervisors decreases defensive
  behaviors
• Team approach to decrease staff burnout
• Periodic reassessments of
• Treatment outcomes
• Client's strengths and weaknesses

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Assessment of the Client

• Safety of client and others
• Medical history and recent medical workup
• Positive, negative, cognitive, and mood symptoms
• Current medications and compliance to treatment
• Family response/support system

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Potential Nursing Diagnoses

• Risk for self-directed or other-directed violence
• Disturbed sensory perception
• Disturbed thought processes
• Impaired verbal communication
• Ineffective coping
• Compromised or disabled family coping

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Outcome Criteria

• Acute phase
• Client safety and medical stabilization
• Maintenance phase
• Adherence to medical regimen
• Understanding schizophrenia
• Participation of client and family in
  psychoeducational activities
• Stabilization phase
• Target negative symptoms
• Anxiety control
• Relapse prevention

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Planning of Appropriate Interventions

• Acute phase
• Possible hospitalization
• Ensure client safety
• Provide symptom stabilization
• Maintenance and stabilization phases
• Psychosocial education
• Relapse prevention skills

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Interventions Basic Level

• Acute phase
• Administer antipsychotic medication as prescribed
• Observe client behavior closely
• Set limits on inappropriate behavior
• Do not touch without warning
• Offer foods that are not easily contaminated
• Assist with ADL if needed
• Supportive counseling
• Milieu management
• Family psychoeducation

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Interventions Basic Level Continued

• Maintenance and stabilization phases
• Health teaching
• Health promotion and maintenance

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Milieu Therapy

• Safety
• Potential for physical violence due to
  hallucinations or delusions
• Priority is least restrictive safety technique
• Verbal de-escalation
• Medications
• Seclusion or restraints
• Activities
• Provide support and structure
• Encourage development of social skills and
  friendships

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Counseling Communication Guidelines

• Hallucinations
• Hearing voices most common
• Approach client in nonthreatening and
  nonjudgmental manner
• Assess if messages are suicidal or homicidal
• Initiate safety measures if needed
• Client anxious, fearful, lonely, brain not
  processing stimuli accurately
• Focus on the clients feelings and present
  reality

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Communication Guidelines continued

• Delusions
• Be open, honest, matter-of-fact, and calm
• Have client describe delusion
• Avoid arguing about content
• Focus on feelings
• Present reasonable doubt
• Validate part of delusion that is real

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Communication Guidelines continued

• Associative looseness
• Do not pretend that you understand
• Place difficulty of understanding on yourself
• Look for reoccurring topics and themes
• Emphasize what is going on in the client's
  environment
• Involve client in simple, reality-based
  activities
• Reinforce clear communication of needs, feelings,
  and thoughts

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Client Teaching Coping Techniques for
Schizophrenia

• Distraction
• Interaction
• Activity
• Social action
• Physical action

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Client and Family Teaching

• Learn all you can about the illness.
• Develop a relapse prevention plan.
• Avoid alcohol and drugs.
• Learn ways to address fears and losses.
• Learn new ways of coping.
• Comply with treatment.
• Maintain communication with supportive people.
• Stay healthy by managing illness, sleep, and
  diet.

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Treatment Modalities

• Individual therapy
• Social skills training (SST)
• Cognitive remediation
• Cognitive adaptation training (CAT)
• Cognitive behavioral therapy (CBT)
• Group therapy
• Family therapy
• Psychopharmacology

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Psychopharmacology

• Antipsychotics
• Standard/ Typical
• Atypical
• Antiparkinson

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PsychopharmacologyTraditional Antipsychotic

• Dopamine antagonists (D2 receptor antagonists)
• Target positive symptoms of schizophrenia
• Advantage
• Less expensive than atypical antipsychotics
• Disadvantages
• Do not treat negative symptoms
• Extrapyramidal side effects (EPS)
• Tardive dyskinesia
• Anticholinergic effects (ACH)
• Lower seizure threshold

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Antipsychotic Medications Traditional

• High potency low sedation low ACH high EPSs
• Haloperidol (Haldol)
• Trifluoperazine (Stelazine)
• Fluphenazine (Prolixin)
• Thiothixene (Navane)
• Medium potency
• Loxapine (Loxitane)
• Molindone (Moban)
• Perphenazine (Trilafon)

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Antipsychotic Medications Traditional continued

• Low potency high sedation high ACH low EPSs
• Chlorpromazine (Thorazine)
• Thioridazine (Mellaril)
• Mesoridazine ( Serentil)
• Decanoate Long acting injection
• Haloperidol decanoate (Haldol D)
• Fluphenazine decanoate (Prolixin D)

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Atypical Antipsychotics (First-Line
Antipsychotics)

• Serotonin-dopamine antagonists
• (5-HT2A receptor antagonists)
• Advantages
• Diminishes negative as well as positive symptoms
  of schizophrenia
• Less side effects encourages medication
  compliance
• Improves symptoms of depression and anxiety
• Decreases suicidal behavior
• Disadvantages
• Weight gain
• Metabolic abnormalities

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Antipsychotic Medications Atypical

• Clozapine (Clozaril)
• Quetiapine (Seroquel)
• Risperidone (Risperdal
• Zipreasidone (Geodon)
• Olanzapine (Zyprexa)
• Aripiprazole (Abilify)

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Side Effects- Atypical

• Orthostatic Hypotension
• Decreased Libido
• Agranulocytosis (Clozapine)
• Weight gain
• Tachycardia
• Edema

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Side Effects Anticholinergic Symptoms

• Dry mouth
• Urinary retention and hesitancy
• Constipation
• Blurred vision
• Photosensitivity
• Dry eyes
• Inhibition of ejaculation or impotence in men

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Side EffectsExtrapyramidal Side Effects

• Pseudoparkinson
• Drooling, lack of facial responsiveness,
  shuffling gait, and fine intentional tremors.
• Acute Dystonia
• Muscle spasms of the jaw, tongue, neck or eyes.
  Laryngeal spasms possible. Oculogyric crisis,
  Opisthotonos.
• Akathisia
• Motor restlessness, pacing, rocking, etc

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Side EffectsExtrapyramidal Side Effects

• Tardive Dyskinesia
• Bizarre facial and tongue movements
• chewing, tongue from side to side, etc.
• Involuntary tonic muscular spasms of extremities
• Trunk
• Potentially irreversible

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Side Effectsa2 Block Cardiovasclar

• Hypotension
• Postural hypotension
• Tachycardia

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Side Effects Rare and Toxic Effects

• Agranulocytosis
• Cholestatic jaundice
• Neuroleptic malignant syndrome (NMS)
• Severe extrapyramidal
• Hyperpyrexia
• Autonomic dysfunction

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NEUROLEPTIC MALIGNANT SYNDROME

• RARE, POTENTIALLY FATAL
• ONSET WITHIN HOURS OR YEARS
• EPS REACTIONS
• CPK
• HYPERTHERMIA 102 AND ABOVE
• TACHYCARDIA
• FLUCTUATING B.P.
• DIAPHORESIS
• STUPOR AND COMA

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AGRANULOCYTOSIS

• Potentially fatal disorder
• Symptoms include
• White blood cells level lt2000 mm3 or granulocyte
  count lt1500mm3
• Sore throat
• Low grade fever
• Malaise
• Sores in the mouth

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NURSING IMPLICATIONS

• MONITOR B.P. BEFORE ADMINISTERING MEDS
• CHECK CBC, CPK, LIVER FUNCTIONS AND VISION
  REGULARLY
• EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS
• ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME
• MIX LIQUIDS WITH 60CC FRUIT JUICE
• PATIENT EDUCATION

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ANTIPARKINSON AGENTS

• COGENTIN
• ARTANE
• AKINETON
• PARLODOL
• KEMADRIN
• BENEDRYL

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CLIENT AND FAMILY TEACHING

• Teach about schizophrenia and available mental
  health agencies for support at the local and
  national level (NAMI AND NIMH).
• Develop a relapse prevention plan.
• Teach about medication and treatment compliance.
• Teach to avoid alcohol or drugs.
• Teach to keep in touch with supportive people.
• Teach to keep healthy stay in balance.

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CRITICAL THINKINGCARE PLAN
The Patient is a 45 year old white male with a
long history of schizophrenia. He was admitted
last night after he was trying to jump out of a
20th story building.. He states that he hears
voices that told him to jump out, and the voices
also told him to kill people. He states that we
are all going to die soon because the terrorists
have a new webon (a special weapon) that will
kill everyone in the USA. The patient looks very
frightened and refuses to come out of his
room. Assessment S O Nursing
Diagnosis Goals Nursing Actions