Elisa A. Mancuso RNC, MS, FNS Professor Schizophrenia Elisa A. Mancuso RNC, MS, FNS Professor

3 million people (1.5 % of Population) Costs $ 35 billion Onset late adolescence or early adulthood Men 15-25 women 20-35 & > 50 Psychotic disorders with disturbances in: Thought processes Perceptions Expression of feelings

Indicators Psychotic Symptoms Deterioration in functioning Preoccupied with own thoughts and feelings Deterioration in functioning Role, ADLs, Interpersonal relationships 6 month duration of symptoms Bleuler’s 4 As Autism Affect Associative Looseness Ambivilance

Etiology Genetic Biochemical Abnormal marker gene on chromosome # 5 Heredity determines one’s predisposition Both parents schizophrenic = 20-50 % ↑↑ risk Identical twins = 50-75 % ↑↑ risk for sibling Biochemical Altered Neuroanatomy ▲s in cortex ↑↑ DA activity (2x DA receptors) = Psychosis ↓ AcH = ↑ Confusion, ↓ NE = Anhedonia ↑ 5-HT = ↑ Aggressive tendencies ↓Glutamate = learning & memory ↓Glucose metabolism & ↓ GABA

Psychological Poor early mother-child relationship ↓ Ego boundaries “Trust vs Mistrust” ↓ Ego boundaries Dysfunctional family system Double-bind communication Say one thing but mean the opposite Environment ↓ Socioeconomic = ↑ stress & ↓ ↓ resources Stressful life events precipitate onset!

Pre Schizophrenia Schizoid Personality Isolate themselves, “loners” Indifferent, cold, aloof ↓ Range of emotional expression Don’t enjoy close relationships Prodromal “Pre-Schizophrenic” Socially withdrawn- Blunted affect Eccentric behavior & Bizarre ideas Unusual perceptual experiences ↓ Role performance ↓ADLs

Active Schizophrenia Prominent psychotic symptoms >6 months Delusions False, fixed belief Grandiose, Persecutory, Paranoia, Religiosity Hallucinations False sensory perception Ideas of Reference Disorganized Behavior Impaired work, social relations & self care Disorganized Speech Associative Looseness Clanging Echolalia Word Salad Poverty of Speech Neologisms

Active Schizophrenia Secondary Symptoms Anxiety Substance Abuse (ETOH, coke) Depression > 25% ↑↑ Suicide (10%) = Leading cause of death Compulsive H2O drinking 4-10 L/day H2O intoxication ↓ Na = Lightheaded Lethargy Muscle cramps N & V Confusion Coma

Residual Schizophrenia Periods of remissions & exacerbations Similar to Prodromal phase Social withdrawal Flat affect Impaired Role Performance

Paranoid Schizophrenia Preoccupied - 1 or more delusions Persecution or Grandeur Related auditory hallucinations Argumentative Hostile Aggressive Tense Suspicious Hypervigilent

Disorganized Hebephrenic Schizophrenia Onset before age 25 Chronic flat, inappropriate affect Silliness, giggling, masturbating in public Bizarre behavior Facial grimacing & mannerisms Impaired social interaction ↓ Contact with reality Incoherent speech & concrete thinking

Catatonic Schizophrenia Least common Sudden onset & good prognosis Catatonic Excitement Extreme psychomotor agitation Purposeless movements – Echopraxia ↑ risk of injury to self/others Continuous incoherent shouting – Echolalia Catatonic Stupor Extreme psychomotor retardation Mute & Waxy Flexibility (Bizarre posturing)

Undifferentiated Chronic Schizophrenia Disorganized-bizarre behavior Usually docile and not aggressive Does not meet criteria of other subtypes Delusions & Hallucinations are prominent

Residual Schizophrenia (Pseudo-neurotic) Follows an acute episode Absence of prominent symptoms No delusions or hallucinations Social isolation Poor Grooming Eccentric behavior Emotional Blunting

Schizoaffective Disorder 2 week period of predominant psychotic episode (↑ incidence in women) Delusions Hallucinations Disorganized behavior ↑ Sexuality Racing thoughts Mood Disorder (affective) behaviors Mania – Euphoria Grandiosity & Hyperactivity Depression – Psychomotor retardation & suicidal ideation ↓↓ Occupational & social functioning

Characteristics Positive Negative Excess or distorted inappropriate behaviors Disorganized thinking Not seen in mentally healthy adults! Negative Loss or decrease of appropriate function Diminished emotional expression Anhedonia Apathy Poverty of thoughts

Characteristics Negative Positive Concrete thinking Delusions Avolition Catatonic Stupor Social withdrawal Poverty of speech Flat affect Anhedonia Positive Delusions Hallucinations Echopraxia Echolalia Neologisms Associative Looseness Flight of Ideas

Assessment Mental Status Exam (Provides baseline data) Appearance & General Health Dress Grooming Facial Expression Eye Contact Motor Behavior Posture Speech Pace Spontaneity Volume Tone & Modulation Clarity Interruptions Level of Consciousness General Responsiveness Sensorium Emotional State Mood Affect Intensity Appropriateness Cognitive Function Thought Process Content Perceptions Concentration Abstract Thinking Insight/Judgment

Nursing Interventions Primary Goal = Patient Safety Establish trust & listen closely Accepting attitude & Keep promises Calm approach & non-threatening environment Prevent violence & ↓ Anxiety Clarify & reinforce reality Orient to here & now Address physical needs ↑ Self esteem

Psychotic Symptom Interventions Delusions Accept experience, identify content & triggers Encourage reality oriented conversation Use distraction & refocus Role model coping techniques to ↓ anxiety Hallucinations Focus on the behavioral cue (laughing, talking, turning head) Have Pt describe what is happening Identify environmental & emotional triggers To prevent aggressive responses Avoid touching without 1st warning

Psychotic Symptom Interventions Impaired Communication Role model clear communication Use simple, concrete statements Seek clarification & validate content Vebalize the implied Paranoia ↓ Environmental stimulation Maintain eye contact Provide plenty of personal space Always announce your presence ↓ Impulsivity “Time Outs” for rest

Psychotic Symptom Interventions Ritualism Initiate conversation as ritual is performed Assess for behavioral cues indicating ↑ anxiety Negotiate a schedule for ritual & ADLs Social Withdrawal Convey nonverbal acceptance & worthiness Provide brief & frequent 1:1 contacts Initiate interaction & gradually expand social contacts ↑ Social skills training Rules & expectations Cognitive Therapy ↑ Decision making Regression RN approaches Pt. ↑ Self-Esteem and encourage independent behavior

Antipsychotic (Neuroleptic) Meds Major Tranquilizers ↑↑ Protein Binding (91-99%) ↓ Efficacy in men (1/3 relapse + 1/3 disabled) Potency High Fluphenazine (Prolixin) [Decanoate IM q3 weeks] Haloperidol (Haldol) [Decanoate IM q4 weeks] Trifluroperazine (Stelazine) Low Chlorpromazine (Thorazine) * 1st drug 1950 Thioridazine (Mellaril)

Antipsychotic (Neuroleptic) Meds Action ↓ Agitation ↓ Psychotic Symptoms ↓ + Behaviors (Delusions/Hallucinations) Block DA receptors =↓ DA Improves fine motor movement & coordination Sensory integration & emotional behavior Anticholinergic Effects (Autonomic NS) Dry Mouth Blurred vision Constipation Sedation Urinary Retention Photophobia Orthostatic Hypotension Nasal Congestion

Antipsychotic (Neuroleptic) Meds ↑↑ Prolactin Levels Sexual/Menstrual dysfunction ↓ Libido Galactorrhea Gynecomastia ↑ weight gain Cognition ↓ Alertness ↓ Concentration ↓ Seizure threshold = ↑ Risk of seizures

Antipsychotic (Neuroleptic) Meds ExtraPyramidal Side Effects (EPS) ↓↓ DA ↑↑ AcH Imbalance ↑↑ Incidence with ↑↑ potency meds Prolixin, Haldol & Stelazine Movement disorder Dystonia Pseudoparkinsonism Akathesia Tardive Dyskinesia

ExtraPyramidal Side Effects (EPS) Dystonia Quick onset 1st few hours or days ↑ Adolescent males < age 25 Acute spasms of tongue, face, neck & back Hypertonia Laryngospasm – Respiratory distress Oculogyric Crisis- Rolling back of eyes Torticolis- Head twisted to 1 side Involuntary uncoordinated movements RX: Benadryl 25-50 mg IM/IV Cogentin 1-2 mg IM

ExtraPyramidal Side Effects (EPS) Pseudoparkinsonism Appears within 1-5 days ↑ women & older Pts Drooling, Pill-Rolling of thumb & finger Mask-like face, Stooped Posture Action Tremors Shuffling gait with small steps Muscle rigidity Bradykinesia Cogwheeling

Pseudoparkinsonism RX Antiparkinson Meds Give to counteract SE & toxic effects Only given with documented S/S of EPS Restore the balance of DA & Ach ↑↑DA ↓↓ACh *Amantadine (Symmetrel) *Benzotropine (Cogentin) Bromocriptine (Parlodel) *Trihexyphenidyl (Artane) Biperiden (Akineton) Procyclidine (Kemadrin)

ExtraPyramidal Side Effects (EPS) Akathesia Appears 50-60 days Motor restlessness “Nervous Energy” Jitteriness Tapping feet constantly Pacing Rocking back & forth Frequent position changes RX: Inderal, Ativan or Valium

ExtraPyramidal Side Effects (EPS) Tardive Dyskinesia Slow & insideous process Irreversible after several years of meds. AIMS- Abnormal Inventory Movement Scale Screen q 3 -6 months Involuntary movements of Limbs, trunk & face. Bizarre facial movements “Fly catching” with tongue Lip smacking Difficulty swallowing Irregular respirations

Neuroleptic Malignant Syndrome (NMS) Rare idiosyncratic reaction 1% young men ↑ Incidence with ↑↑ potency meds & ↓↓ DA Abrupt onset & rapid progression 10% mortality rate Signs Severe muscle rigidity Hyperreflexia (+4) Hyperthermia > 105 Diaphoresis Altered LOC → Stupor → Coma ↑↑ HR ↑↑ RR CV Collapse & Respiratory failure = Fatal!

NMS Therapy Immediately D/C med! Wait 2 weeks before starting new meds (Lithium) NO Haldol or Thorazine Cooling blanket O2 IV Fluids Medications: MSO4 (Morphine sulfate) ↓ pain & ↓ VS Tylenol ↓ Temp and pain Dantrolene (Dantrium) muscle relaxant & ↓ Temp Bromocriptine (Parlodel) Dopaminergic = ↓ EPS toxicity

Atypical Medications Serotonin Dopamine Antagonists Relieves (+) & (-) Behaviors ↓ EPS ↓ Prolactin Clozapine (Clozaril) Binds to 5-HT2, Alpha1,2, H1, & DA receptors SE- National registry to monitor SEs! Agranulocytosis WBC < 3000 or ANC < 500 = D/C med! Mandatory weekly CBC 1st 6 months Then q other week Drowsiness ↑Salivation ↑Dizziness ↑ HR ↑Weight ↑ Risk for IDDM Prolonged QT interval

Atypical Medications Risperidone (Risperdal) ↓↓ DA ↓ 5-HT ACh & NE Readily absorbed Active metabolite is clinically effective Resperdal Consta 25 mg IM q 2 weeks SE Sedation/Insomnia Orthostatic Hypotension ↑↑ Appetite = Weight gain Tardive Dyskinesia

Atypical Medications Olanzapine (Zyprexia) Quetiapine (Seroquel) Antagonizes DA & 5-HT receptors SE: Insulin Resistance Quetiapine (Seroquel) √ renal function Ziprasidone (Geodon) ↓ Depression & Anxiety √ EKG for prolonged QT wave Paliperidone (Invega Sustenna) IM q 4 weeks Aripiprazole (Abilify) DA system stabilizer PO & IM

Medication Administration Schedule Initially take meds in divided doses 2-4x/day Non-compliant Pts: Haldol decanoate IM q 4 weeks Prolixin decanoate IM q 3 weeks Resperdal Consta IM q 2 weeks Invega Sustenna IM q 4 weeks Efficacy Takes 1- 4 weeks for significant response Once symptoms are controlled ▲ HS ↓↓ SE Dosage Use lowest dosage to ↓ risk of Tardive Dyskinesia

Patient Teaching Medication Generic & trade name, dose, action & SE Assess SE “How is medication working?” Interventions & when to notify RN/MD Carry card with Med ID NO ETOH or illegal substances Don’t stop taking drug abruptly Don’t ▲ position rapidly

Patient Outcome Evaluation Slow progress Services are needed long-term (decades) Set small achievable, short-term goals Assess effective coping skills Obtain Pt & family input Pt. safety Communication skills Social Skills Self-Esteem Health Promotion Medication compliance Support system Living in least restrictive setting