2 Eugen Bleuler’s 4 A’s of Schizophrenia AffectAssociative loosenessAutismAmbivalence
3 Epidemiology Lifetime prevalence of schizophrenia 1% worldwide Average onset is late teens to early twenties, but can be as late as mid-fifties30% to 40% relapse rate in the first yearLife expectancy is shortened because of suicideNo difference related toRace, Social status, Culture
4 Comorbidity Substance abuse disorders Anxiety, depression, and suicide Nicotine dependenceAnxiety, depression, and suicidePhysical health or illnessPolydipsia
6 Etiology Continued Psychological and environmental factors Prenatal stressorsPsychological stressorsEnvironmental stressors
7 Signs and Symptoms Language and communication disturbances Thought disturbancesPerception disturbancesAffect disturbancesMotor behavior disturbancesSelf-identity disturbances
8 Features of Schizophrenia Progression varies from one client to anotherExacerbations and remissionsChronic but stableProgressive deteriorationDSM-IV-TR DiagnosisSymptoms present at least 6 monthsActive-phase symptoms present at least 1 monthSymptoms are defined as positive and negative
9 Phases of Schizophrenia Phase I – AcuteOnset or exacerbation of symptomsPhase II – StabilizationSymptoms diminishingMovement towards previous level of functioningPhase III – MaintenanceAt or near baseline functioning
10 Assessment During the prepsychotic phase General assessment Positive symptoms (Excess or distorted)Negative symptoms (Deficit)Cognitive symptomsAffective symptoms
11 Positive Symptoms Alterations in thinking Delusions are false, fixed beliefsPersecutory, ReferentialSomatic, Religious,Substitution, Thought Insertion and/or BroadcastingNihilistic, GrandioseConcrete thinking is an inability to think abstractly.Indecisiveness, lack of problem solving skills,Concreteness, thought blocking, perseveration
12 Positive Symptoms Continued Alterations in speechNeologismsEcholaliaEchopraxiaClang associationsWord saladLoose Association
13 Positive Symptoms Continued Alterations in perceptionDepersonalizationDerealizationHallucinationsAuditory hallucinationsCommand hallucinationsVisual hallucinationsBoundary impairmentNegativismImpaired impulse control
14 Negative Symptoms (5A’s) AffectFlat, Blunted, Inappropriate, BizarreApathyIndifference towards people, events, activities and learning.AlogiaPoverty of speechAvolitionInability to pursue and persist in goal-directed activities.AnhedoniaInability to experience pleasure.
15 Cognitive Symptoms Difficulty with Attention Memory Information processingCognitive flexibilityExecutive functions
16 Affective Symptoms Assessment for depression crucial May herald impending relapseIncreases substance abuseIncreases suicide riskFurther impairs functioning
17 Review QuestionA patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?Positive symptomNegative symptomCognitive symptomDepressive symptom
18 Review QuestionThe nurse is documenting in the multidisciplinary treatment plan. Which assessment data depicts positive symptoms of schizophrenia?A. “I use to like going to the movies and spending time with my family but rather be alone.”B. “I don’t want to go to group.” Lack motivation and affect appear Blunted.C. “I can’t sit still and I feel like I want to jump out of my skin.”D. “There are cameras in the ceiling and the voices are whispering to me.”
19 Subtypes of Schizophrenia Paranoid typeDisorganized typeCatatonic typeUndifferentiated typeResidual Type
20 Subtypes of Schizophrenia - continued Paranoid TypeDelusionsPersecutory and grandioseSomatic or religiousHallucinationsDelusions link with a hallucinationDisorganized TypeDisorganized speech, behavior, appearanceFlat or inappropriate affectFragmented hallucinations and delusionsMost severe form of schizophrenia
21 Specific Interventions for Paranoid and Disorganized Schizophrenia Communication guidelinesSelf-care needsMilieu needs
22 Subtypes of Schizophrenia - continued Catatonic typePsychomotor retardation and stuporWaxy flexibilityMutismExtreme psychomotor agitationEcholaliaEchopraxia
23 Specific Interventions for Catatonia Catatonia – Withdrawn PhaseCommunication guidelinesSelf-care needsMilieu needsCatatonia – Excited Phase
24 Subtypes of Schizophrenia - continued Undifferentiated typeActive psychotic state (Positive & Negative symptoms)Lacks symptoms of other subtypesResidual typeActive-phase symptoms no longer presentNo prominent positive symptomsNegative symptoms present
25 Other Psychotic Disorders Schizophreniform disorderSchizoaffective disorderDelusional disorderBrief psychotic disorderShared Psychotic Disorder (Folie à Deux)Induced or Secondary Psychosis
26 Assessment Guidelines 1. Any medical problems2. Abuse of or dependence on alcohol or drugs3. Risk to self or othersCommand hallucinations5. Belief system6. Suicide risk
27 Assessment Guidelines Continued 7. Ability to ensure self-safetyCo-occurring disorders9. Medications10. Presence and severity of positive and negative symptoms11. Patient’s insight into illness12. Family’s knowledge of patient’s illness and symptoms
28 Potential Nursing Diagnoses Positive symptomsRisk for violenceDisturbed sensory perceptionRisk for self-directed or other-directed violenceDisturbed thought processesNegative symptomsSocial isolationChronic low self-esteemAltered health maintenanceIneffective copingImpaired verbal communication
29 Outcomes Identification Phase I - AcutePatient safety and medical stabilizationPhase II - StabilizationAdhere to treatmentStabilize medicationsControl or cope with symptomsPhase III - MaintenanceMaintain achievementPrevent relapseAchieve independence, satisfactory quality of life
30 Planning Phase I – Acute Phase II – Stabilization Best strategies to ensure patient safety and provide symptom stabilizationPhase II – StabilizationPhase III – MaintenanceProvide patient and family educationRelapse prevention skills are vital
32 Interventions Acute Phase Psychiatric, medical, and neurological evaluationPsychopharmacological treatmentSupport, psychoeducation, and guidanceSupervision and limit setting in the milieu
33 Interventions Continued Stabilization and Maintenance PhaseMilieu managementActivities and groupsSafetyCounseling and communication techniques
34 Interventions Continued Stabilization and Maintenance Phase, continuedHallucinationsDelusionsAssociative loosenessHealth teaching and health promotion
35 Nursing Implications: Supporting Families Family needs vary with degree of illness and involvement in client’s careEducationFinancial supportPsychosocial supportAdvocacy
36 Nursing Implications: Supporting Families - continued Schizophrenia is a “family illness.”Family members need to be involved.Educate family aboutMedicationIllnessRelapse preventionNurse assists family byIdentifying community agencies/groups for family membersAdvocating for rights
37 General Nursing Intervention Promote Safety and a Safe EnvironmentPromote Congruent Emotional ResponsePromote Social Interaction and ActivityIntervene with Hallucinations and DelusionsPreventing RelapsePromoting adherence with medication regimenAssist with grooming and hygienePromote Family Understanding and Involvement
38 Review QuestionThe client informs you that the CIA monitoring his every move to find evidence that he killed someone. Which response by the nurse is therapeutic for the client?
39 Review AnswersA. "I will make sure that the security guard will monitor your room.”B. "Don't worry you are safe here, the CIA can't enter the hospital.”C. "You seem fearful for your safety, but you are safe here.”D. "Why do you think the CIA is following you, who did you kill?”
40 PsychopharmacologyPrior to the 1950s: focus on behavioral interventions and sedativesMid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine)Psychiatric medications allow for the improve imbalances of neurotransmitters.Goal is to treat quickly so disease does not progress.Clients may initially be resistant to medications.
41 Goals of Antipsychotics Positive EffectsAllowed release of clients from inpatient hospital to treatment in the communityManage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation.Alleviation of the symptoms, often improving:Ability to think logicallyAbility to function in one’s daily lifeAbility to function in relationships
42 Negative Effects of Antipsychotics Frightening and life threatening side effectsPotential interactions with other medications and substancesPossible need to cope with the realization of having a chronic illness
43 All current antipsychotics work on at least one of these neurotransmitters: DopamineSerotonin
44 Antipsychotics Typical (Conventional) Block dopamine receptors at 70% to 80% occupancy to be effective.Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80Typical = Tardive Dyskinesia (TD)5.4% vs 0.8% atypicals
45 Pharmacological Interventions Antipsychotic medicationsConventional antipsychoticsTypical or first-generationAtypical antipsychoticsSecond-generation
46 Conventional Antipsychotics Dopamine antagonists (D2 receptor antagonists)Target positive symptoms of schizophreniaAdvantageLess expensive than atypical antipsychoticsDisadvantagesDo not treat negative symptomsExtrapyramidal side effects (EPSs)Tardive dyskinesiaAnticholinergic side effectsLower seizure threshold
50 Atypical Antipsychotics Treat both positive and negative symptomsFewer extrapyramidal side effects (EPSs) or tardive dyskinesiaReduced affinity for dopamine (D2) receptorsAffinity for serotonin receptorsD2 antagonist + Serotonin receptor antagonistDisadvantage – tendency to cause significant weight gain
55 Antiadrenergic Effect: Orthostatic Hypotension Take the client’s blood pressure in a supine position and then in a standing position.Caution clients to rise slowly from a supine position.
56 Extrapyramidal Side Effects Interventions Acute dystoniaanticholinergicsAkathisiaanticholinergics but not always responsivePseudoparkinsonismTardive dyskinesia –Abnormal Involuntary Movement Scale (AIMS)
57 DystoniaOccurs usually within 48 hours of initiation of the medicationInvolves bizarre and severe muscle contractionsCan be painful and frighteningCharacterized by odd posturing and strange facial expressions:TorticollisOpisthotonusLaryngospasmOculogyric
62 Drug-induced Parkinsonism Usually occurs after 3 or more weeks of treatmentCharacterized by:Cogwheel rigidityTremors at restRhythmic oscillations of the extremitiesPill rolling movement of the fingersBradykinesiaPostural Changes
63 Akathisia Usually occurs after 3 or more weeks of treatment Subjectively experienced as desire or need to moveDescribed as feeling like jumping out of the skinMild: a vague feeling of apprehension or irritabilitySevere: an inability to sit still, resulting in rocking, running, or agitated dancing
64 Tardive DyskinesiaUsually occurs late in the course of long-term treatmentCharacterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping)Often irreversibleProphylactic use of vitamin E and Omega-3 FFAAvoid typical antipsychoticsAbnormal Involuntary Movement Scale
65 Autonomic Nervous System Effects: Anticholinergic Side Effects Dry mouthBlurred visionConstipationUrinary retentionTachycardia
66 Interventions for Anticholenergic Side Effects Ice chips, hard candyEye dropsFiber diet, exerciseIncrease fluid intakeCatheterization
67 Potentially Dangerous Responses to Antipsychotics Neuroleptic malignant syndrome (NMS)Typically occurs in the first 2 weeks of treatment or when the dose is increasedHold the medication, notify the physician, and begin supportive treatments.Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis
68 Neuroleptic malignant syndrome (NMS) Risk FactorsDehydrationAgitation or catatoniaIncrease dose of neurolepticWithdrawal from anti-parkinson medicationLong acting or depot medicationPharmacologic treatmentAntipyreticsMuscle relaxantDopamine receptor agonist
69 Potentially Dangerous Responses to Antipsychotics AgranulocytosisEarly symptoms: beginning signs of infectionWhite blood cells are routinely monitored in clients taking clozapine (Clozaril).
70 Other Central Nervous System Effects SedationLowering of the seizure threshold:Observe clients with seizures disorders carefully when treatment is initiated.
71 Cardiac EffectsSome antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias.An EKG can identify those at risk.
72 Blood, skin and eye effect AgranulocytosisBlurred VisionSkin photosensitivityRetinitis pigmentosa
73 Endocrine Effects Hyperprolactinemia may cause: Oligomenorrhea or amenorrhea in womenGalactorrhea in women and rarely in menOsteoporosis if prolongedImpotence in males may occur.DiabetesMonitor blood glucose levels.
74 Weight Gain Monitor weight Teach about diet and exercise Weight gain may contribute to physical as well as psychosocial stressors
75 Adjuncts to Antipsychotic Drug Therapy AntidepressantsAntimanic agents