2 Schizophrenia Fascinated and confounded healers for centuries One of most severe mental illnesses1/3 of population2.5% of direct costs of total budget$46 billion in indirect costs
3 Epidemiology 0.5%-1.5% of population 2.5 million Americans 300,000 acute episodes each yearCluster in lower socioeconomic groupHomelessness is a problem.Direct treatment costs $20 billion/yr
4 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 adolescenceLOS: Diagnosed > 45 years
5 Maternal Risk Factors Prenatal poverty Poor nutrition Depression Exposure to influenza outbreaksWar zone exposureRh-factor incompatibility
7 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)
8 Phases of Schizophrenia Acute Illness PeriodPositive symptoms/may be subtleFamily DisruptionAwareness of the meaning of the disorderStabilizationTreatment is intenseEstablish MedicationsBegin RehabMaintenance and RecoveryRelapse preventionCoping StrategiesRelapseNon-complianceIdentify triggers
9 Familial DifferencesFirst-degree biologic relatives have 10 times greater risk for schizophrenia.Other relatives have higher risk for other psychiatric disorders.
10 Schizophrenia Diagnosis During a one-month period at least two of the fivePositive (delusions, hallucinations, etc.)Negative (alogia, anhedonia, flat affect, avolition)One or more areas of social or occupational functioning
11 Types of Schizophrenia Text Box 16.1 ParanoidDisorganizedCatatonicUndifferentiatedResidual
12 Schizophrenia Negative Avolition Alogia Positive Anhedonia Flat AffectAmbivalencePositiveHallucinationsDelusionsDisorganizationNeurocognitiveImpairmentAttentionMemoryExec Function
13 Positive Symptoms: Excess of Normal Functions Delusions (fixed, false beliefs)GrandioseNihilisticPersecutorySomaticHallucinations (perceptual experiences)Thought disorderDisorganized speechDisorganized or catatonic behavior
14 Negative Symptoms: Less Than Normal Functioning Affective blunting: reduced range of emotionAlogia: reduced fluency and productivity of language and thoughtAvolition: withdrawal and inability to initiate and persist in goal-directed behaviorAnhedonia: inability to experience pleasureAmbivalence: concurrent experience of opposite feelings, making it impossible to make a decision
15 Neurocognitive Impairment Evidence that neurocognitive impairment exists,independent of positive and negative symptomsNeurocognitionMemory (short-, long-term)Vigilance (sustained attention)Verbal fluency (ability to generate new words)Executive functioningvolitionplanningpurposive actionself-monitoring behaviorImpaired in schizophreniaMemory (working)VigilanceExecutive functioning
16 Neurocognitive Impairment Often Seen as “Disorganized Symptoms” Confused speech and thinking patternsDisorganized behaviorExamples of disorganized thinkingEcholalia (repetition of words)Circumstantially (excessive detail)Loose associations (ideas loosely connected)Tangentially (logical, but detour)Flight of ideas (change topics)Word salad (unconnected words)
17 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)
18 Disorganized Symptoms Examples of disorganized thinking (cont.)Clang association (repetition similar sounding words)Stilted language (artificial, formal)Pressured speech (words forced)Examples of disorganized behaviorAggressionAgitationCatatonic excitement (hyperactivity, purposeless activity)
19 Disorganized Symptoms Examples of disorganized behavior (cont.)Echopraxia (imitation of others movements)Regressed behaviorStereotypy (repetitive, purposeless movements)Hypervigilance (sustained attention to external stimuli)Waxy flexibility (posture held in odd or unusual way)
20 Comorbidity Increased risk of cardiovascular disorders Association between insulin-dependent diabetes and schizophreniaDepression and pseudodementiaIncreased substance abuseCigarette smokingFluid imbalance
21 Disordered Water Balance Prolonged periods of polydipsia, intermittent hyponatremia, polyuriaEtiology – unknownObserved behaviorsCarrying cokes/coffee/water bottlesPrevention of water intoxicationPromotion of fluid balance11
22 Psychological Difficulty relating Deficit in sensory inhibition Poor control of autonomic responsivenessDifficulty making decisionsDeficit experiencing pleasureDeficit initiating activitiesOverassessment of threat
23 Social Deceased financial status Family and caregiver stress HomelessnessStigma and community isolation
24 Biologic Factors Genetic – 10% first-degree relative Stress-diathesis model proposed by O’ConnorNeuroanatomical findingsDecreased blood flow to left globus pallidusAbsence of normal blood increase in frontal lobesAtrophy of the amygdala, hippocampus and parahippocampusVentricular enlargement
25 Biologic Neurodevelopmental Adolescent Prenatal exposure (2nd trimester)Late winter, early spring birthsAdolescentChanges in transmitter systems and substratesSynaptic pruning along with substantial brain growth in some areas of the cortexChanges in steroid-hormonal environment
26 Neurotransmitters, Pathways and Receptors Hyperactivity of the limbic area(dopamine mesolimbic tract) related to positive symptomsHypofrontality 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
27 Psychosocial Theories Do not explain causeDisservice to familiesUseful in family interactionExpressed Emotion (EE)High emotion associated with negative communication and overinvolvementLow emotion associated with less negativity and less overinvolvement
28 Priority Care Issues Suicide Safety of patient and others 20-50% Attempt10% CompleteSafety of patient and othersInitiate antipsychotic medications
29 Family Response to Disorder Mixed emotions – shock, disbelief, fear, care, concern and hopeMay try to seek reasonsInitial period very difficultNAMI – Life changed forever
30 Interdisciplinary Treatment The most effective approach involves a variety of disciplines.There is considerable overlap of roles and interventions.Nursing’s contribution is significant.
31 Nursing Management: Biologic Domain Assessment Present and past health statusPhysical functioningNutritional assessmentFluid imbalance assessmentPharmacologic assessmentMedications (prescribed, OTC, herbal, illicit)Abnormal motor movementsDISCUSAIMSSimpson-Angus Rating Scale
34 Nursing Interventions: Biologic Domain Promotion of self-care activitiesDevelop a routine of hygiene activities.Emphasize its importance; help motivate the patient.Activity, exercise and nutritionHelp counteract effects of psychiatric medications.Appetite usually increases, so help with food choices.ThermoregulationTeach patient to wear clothing according to weather; dress for winter and summer.Observe patient’s response to temperature.Promotion of normal fluid balanceWater intoxication protocol (Text Box 16.7)
35 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 lineMonitoring and administering medicationsTakes 1-2 weeks to work (some improvement immediately)Adequate trial weeksAdherence to prescribe medication is best prevention of relapse.Discontinuation is rare.
36 Pharmacologic Interventions: Monitoring Side Effects ParkinsonismIdentical symptoms to Parkinson’sCaused by blockade of D2 receptor in basal gangliaTreated with anticholinergic medicationsTaper anticholinergic meds if discontinuedDystoniaImbalance of DA and ACH, with more ACHYoung men more vulnerableOculogyric crisis, Torticollis, Retrocollis
37 Monitoring Side Effects AkathesiaRestlessness, jumping out of skin, uncomfortableReduce dose of antipsychotic.Treat with a -blocker (propranolol).Tardive DyskinesiaImpairment of voluntary movement, constant motionOccurs 6-8 months following initiation of antipsychoticsFacial-buccal area -- lip smacking, sucking, etc.Movements in trunk, rockingNo real treatment
38 Monitoring Side Effects Orthostatic hypotensionHyper Prolactinemia (haloperidol and risperidone)Weight gain (olanzapine and clozapine)SedationNew-onset diabetes (Olanzapine,clozapine)Cardiac arrhythmias (QT prolongation) (Ziprasidone) may need baseline ECGAgranulocytosis (all but *clozapine)
39 Drug-drug Interactions Medications metabolized by 1A2 enzymes include olanzapine and clozapine.Inhibitors: fluvoxamine (Luvox)Inducers: cigarette smoking Smokers may require a higher doseMedications metabolized by 3A4 include clozapine, quetiapine and ziprasidone.Inhibitors: ketoconazole, protease inhibitors, erythromycinInducer: carbamazapine (Tegretol)Medications affected by 2D6 include risperidone, clozapine and olanzapine.Inhibitors: fluoxetine, paroxetine (not usually clinically significant)
40 Medication Teaching Points Consistency in taking medicationMedication and symptom ameliorationSide effects and managementInterpersonal skills that help patient and family report medication effects
42 Neuroleptic Malignant Syndrome TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSESevere muscle rigidity, elevated temperatureRecognizing symptomsElevated temperature, changes in level of consciousness, leukocytosis, elevated creatinine phosphokinase), elevated liver enzymes or myoglobinuriaNursing interventionsStop administration of offending medications.Monitor vital signs.Reduce body temperature.Safety, protect musclesSupportive measuresIV fluidsCardiac monitoringDantrolene (Dopamine agonist)
43 Neuroleptic Malignant Syndrome Acute reaction to dopamine receptors blockersPrevalence 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 rigidity4
44 NOT NMS N O T I F Y M D neuroleptic drug? ANY RISK FACTORS FOR NMS? Is Client onneuroleptic drug?NOT NMSNOANY RISK FACTORS FOR NMS?DEHYDRATION?HISTORY OF NMS?RECENT DOSE INCREASE?PSYCHOMOTOR AGITATIONNOTIFYMDYESEARLY S/S NMS?LOW-GRADE FEVER?TACHYCARDIA?ELEVATED BP?CATATONIA?DIAPHORESIS?YESHYPERTHERMIA?LEAD PIPE RIGIDITY?MS CHANGESOTHER AUTONOMIC CNS?HOLD DRUG
45 Anticholinergic Crises Potentially life threatening, anticholinergic deliriumCan occur in patients who are taking several medications with anticholinergic effectsElevated temperature, dry mouth, decreased salivation, decreased bronchial, nasal secretion, widely dilated eyeStop offending drug, usually self-limiting. May use inhibitor of anticholinesterase, physostigmine.
46 Anticholinergic Crisis Confusion, hallucinationsPhysical signs - dilated pupils, blurred vision, facial flushing, dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension decreased bowel sounds, urinary retention, nausea, vomiting, seizures, comaAtropine flushHot as a hare, blind as a bat, mad as a hatter, dry as a bone7
47 Treatment Self-limiting – three days Discontinuation of medication Physiostigmine 1-2 mg IV, an inhibitor of cholinesterase, improves in hoursGastric lavageCharcoal, catharsis8
48 Nursing Management: Psychological Domain Assessment – Responses Socially stigmatizingProdromal symptoms evident (negative symptoms)Tension and nervousnessLack of interest in eatingDifficulty concentratingDisturbed sleepDecreased enjoymentLoss of interest, restlessness, forgetfulnessOften not recognized as an illnessDenial common
49 Nursing Management: Psychological Domain Assessment Positive and negative symptomsSAPS (positive symptoms) (Box 16.14)SANS (negative symptoms) (Box 16.15)PANNS (both symptoms)Mental statusAppearanceMood and affect (lability, ambivalence, apathy)SpeechThought processes (delusions, disorganized communication, cognitive impairments)Sensory perception (hallucinations)Memory and orientationInsight and judgment
51 Nursing Diagnosis: Psychological Domain Disturbed thought processesDisturbed sensory perceptionsDisturbed body imageLow self-esteemDisturbed personal identityRisk of violence, suicideIneffective copingKnowledge deficit
52 Nursing Interventions: Psychological Domain Counseling, conflict resolution, behavior therapy and cognitive interventions can be used.Development of nurse-patient relationshipCenters on the development of trust and acceptance of the personsCritical for optimal treatment of schizophrenia
53 Nursing Interventions: Psychological Domain – Management of Disturbed Thoughts Assessment content of hallucinations/delusionsOutcomesDecrease frequency and intensity.Recognize as symptoms of disorder.Develop strategies to manage recurrence.Experiences real to the patientValidate that experiences are realIdentify meaning and feeling that are provokedTeach patient that hallucinations and delusions are symptoms of illness.
54 Nursing Interventions: Psychological Domain Self-monitoring and relapse preventionMonitor events, time, place, etc. of recurrence of symptoms.Manage symptoms - getting busy, self-talk, change of activity. (Moller-Murphy Tool)Enhancement of cognitive functioningRecognize difficulty in processing information.Improve attention (computer programs, one-to-one).Help memory (make lists, write down information).Improve executive functioning-simulation.
55 Nursing Interventions: Psychological Domain Behavioral interventionsOrganize routine, daily activities.Reinforce positive behaviors.Stress and coping skills developmentCounseling sessionsTeach and reward positive coping skills.Patient educationErrorless learning environmentMinimal distractionsClear visual aidsSkills training
56 Family Interventions Family support Educate the family regarding lifelong disorder of schizophrenia.Emphasize consistent taking of medication.
57 Nursing Management: Social Domain Assessment Functional statusAssessed initially and at regular intervalsGAF usually usedSocial systemsFormal and informal support systemsQuality of lifeFamily assessmentFamily assessment guide (Ch. 15)Special consideration to the family where patient is the parent
58 Nursing Interventions: Social Domain Promotion of Patient SafetyMonitoring for potential aggressionAdministering medication as orderedReducing environmental stimulationApproach to individual patientsThorough history of violenceHelp patient to talk directly and constructively with those with whom they are angry.Set limits.Involve patients in formal contracting.Schedule regular time-outs.
59 Nursing Interventions: Social Domain Support groupsMilieu therapyPsychiatric rehabilitationFamily interventionsEncourage to participate in support groupsInform about local and state resourcesHelp negotiate provider system
60 Continuum of CareTreatment 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
61 Schizophrenia in Children Rare in childrenIf appears in children aged 5 or 6, symptoms same as for adultsHallucinations visual, delusions less well-developedOther disorders considered first
62 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 schizophreniaDiagnostic criteria met after 45Estrogen may be protective in womenMost likely include positive symptoms