1. SCHIZOPHRENIA AND PSYCHOSIS
Module III
RNSG 2213

2. SCHIZOPHRENIA: OVERVIEW
Major Axis I disorder
Characterized by disturbances in:
Perception
Thought processes and reality testing
Affect (feelings)
Behavior
Attention (concentration)
Motivation

3. PSYCHOSIS How do we define this term?
Inability to evaluate accuracy of one’s thoughts and perceptions
Incorrect interpretation of external reality
Inability to re-evaluate one’s thoughts and perceptions, even in the face of evidence that contradicts these.
In Schizophrenia, the psychotic person often does not have awareness that he/she is ill

4. OVERVIEW, CONT’D Incidence Age of onset is late adolescence
1.1% of population over age 18
Higher rates in inner city populations, lower socioeconomic groups
Prenatal probs. correlate with higher rate

5. OVERVIEW, CONT’D Prognosis Approx. 25% remain highly functional
50% are minimally functional
25% are in-between with exacerbations/relapses and re-stabilizations (in and out of hosp.)

6. OVERVIEW, CONT’D A Chronic Illness Characterized by Phases:
Acute phase – severe psychotic sx.
Stabilizing Phase
Stable phase
Most pts. alternate between acute and stable phases

7. SCHIZOPHRENIA: SYMPTOMS
Bleuler’s (Early 1900’s) “4 A’s”:
Affect disturbances
Autism
Associative looseness
Ambivalence
“Fragmentation of the Mind”

8. CLASSIFICATION OF SYMPTOMS
Positive Symptoms
Negative Symptoms
Cognitive Symptoms

9. Positive Symptoms of Schizophrenia
Agitation/aggression
Delusions
Hallucinations
Disordered thinking (AEB disordered speech): circumstantial thinking, loose associations, word salad, neologisms, echolalia

10. Positive Symptoms of Schizophrenia, cont’d
Disordered movement:
--restlessness, repetitive movements
(e.g. echopraxia),
--or immobility (catatonia)

11. Matching: Symptoms Word salad Delusion of reference Tangentiality
“A blue ape. Makes me scratch. John wore a hair shirt. Are we victims?”
“I am locked in concrete and I have stopped breathing.”
“The CIA has been poisoning my water.”
“Whenever knife take you-a.”
“At HEB, when they play that music, the words are sending messages to me.”
“I love chocolate candy. Candy is my parakeet’s name. What’s your name?”
Word salad
Delusion of reference
Tangentiality
Neologism
Loose associations
Paranoid delusion
Nihilistic delusion
Grandiose delusion

12. Grandiose delusion example:
“I own the Bank of America and my people are going to put up $20 million for my release from here.”
Neologism example:
“It tastes screeg because of those nerflexes.”

13. Negative Symptoms of Schizophrenia
Flat affect
Inability to plan or carry out activities
Constricted, concrete thinking
Poverty of speech (alogia), flat speech
Social withdrawal; lack of pleasure in activities (anhedonia)
Deep apathy

14. “Flat Affects”
(Flight of the Conchords)

15. Cognitive Symptoms of Schizophrenia
Impaired ability to pay attention and to understand
Impaired ability to make decisions (ambivalence)
Problems in using just-learned information

16. CRITICAL THINKING: Nursing Diagnoses
Write one nursing dx. for each symptom or behavior related to schizophrenia
Client has command auditory hallucinations that he should kill himself
Client does not get dressed or take baths
Client believes she can make it snow

17. Suggested Nursing DX:
R/F Self-directed Violence r/t sensory perceptual alteration s/t command auditory hallucinations
2) Self-care deficits: grooming and hygiene r/t poor motivation for self-care s/t schizophrenia
3) Altered thought process s/t grandiose delusion (or delusion of grandeur)

18. Antipsychotic Agents and Symptoms
The “Typical” (older class) of antipsychotics primarily address POSITIVE symptoms
Can make negative symptoms Worse
The “Atypical” (newer classes) of antipsychotics address both
POSITIVE AND NEGATIVE symptoms

19. SYMPTOMS: DSM CRITERIA
At least 2:
Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms
Social-occupational dysfunction
Continuous s/sx. > 6 months
No schizoaffective diagnosis
Not caused by substance abuse or medical disorder

20. DSM Criteria: Schizophrenia Subtypes
Paranoid – persecutory and/or grandiose delusions
Disorganized – speech & affect & behavior are disturbed
Catatonic – absent, excessive &/or peculiar movements. Mutism.
Undifferentiated – does not meet criteria for other subtypes
Residual – has some disturbed thinking or behavior but does not meet other criteria

21. DSM Criteria: Other Psychotic Disorders
Schizophreniform Disorder
Has similar symptoms to schizophrenia but for only 1-6 months
Schizoaffective Disorder
Symptoms of schizophrenia + symptoms of a mood disorder
Psychotic Disorder NOS
Has Psychotic symptoms but doesn’t fit criteria for any of the above

22. Quick Check: What is the most likely DSM IV-TR Diagnosis?
Client #1 Elevated mood episodes along with hallucinations and delusions for 2 years
Client #2 Is physically immobile at times. Has poverty of speech. Has never worked in adulthood.
Client #3 Agitated, reports seeing flashes of color and hearing singing voices x 2 weeks.
Client #4 “I know 4,000 languages but others are trying to steal these from my mind.” As a result, has been living on the streets for many years.

23. ETIOLOGY Multifactorial-no single cause
Multiple theories for etiology (see next content)

24. BIOLOGICAL THEORIES 1. The Dopamine Hypothesis:
Too much dopamine binds with too many brain receptors and causes positive symptoms
    
Too little dopamine -- negative symptoms

25. BIOLOGICAL THEORIES, cont’d
2. Disturbed Ratio of
serotonin: dopamine

26. CRITICAL THINKING
Based on the preceding hypotheses, what are the principles behind antipsychotic medications ?
-to treat positive symptoms:
-to treat negative symptoms:
-to treat altered ratios:

27. BIOLOGICAL THEORY: CHANGES IN BRAIN STRUCTURE AND FUNCTION
Alterations found in some Schizophrenics using Diagnostic Imaging
PET Scan:  glucose metabolism in frontal/temporal lobes; in basal ganglia
MRI: Enlargement of ventricles
BEAM Scan: Abnormal wave patterns indicting absence of ability to “calm” the brain
Evoked Potential Topography: Illogical thought patterning in frontal lobe

28. PET Scan and Schizophrenia

29. GENETIC THEORY Inherited predisposition to schizophrenia Risk Factors:
Two parents with schizophrenia = 35%
Identical twins = 50%

30. DEVELOPMENTAL AND ENVIRONMENTAL THEORIES
Prenatal infections
Parental neglect or rejection
Greater % of pts. come from lower socio-economic class

31. Issues in Schizophrenia
Family disturbance: a cause or a result?
Noncompliance and relapse are common
Have poorer ability to cope with stress
Increased rates of depression, suicide
Increased rate of substance abuse: alcohol, marijuana, nicotine, cocaine
Often cannot hold a job

32. INTERVENTIONS/ PSYCHOTHERAPEUTIC MANAGEMENT
Australian aboriginal painting
by mental health client
INTERVENTIONS/ PSYCHOTHERAPEUTIC MANAGEMENT

33. NURSE-CLIENT RELATIONSHIP
Be accepting, consistent and honest
Do not argue with or reinforce hallucinations or delusions
Reinforce acceptable behaviors
Gently encourage withdrawn client
Recognize when a client may be suspicious, anxious or fearful, and approach with care
Assess for command hallucinations

34. CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic ?
Client insists he is a “negative space alien.”
Nurse A: “Do you live in outer space? Are there other people living there?”
Nurse B: “But I have met your mom. How can you be a space alien?”
Nurse C: “That’s interesting. Want to come with me now to see the patient art exhibit?”
Nurse D: “ I can see you feel strongly about that.”

35. MILIEU MANAGEMENT Set limits on disruptive behavior
Assess agitated clients frequently for escalation
Assess ability to participate in activities; choose activities at client’s level of ability
May need 1:1 rather than group activities at first
Decrease environmental stimuli prn
Supervised meals, hygiene, grooming

36. CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic?
A new patient starts pacing back and forth,
while saying in a loud voice, “Take it back,
take it back.”
Nurse A: “Lower your voice, you are disturbing people.”
Nurse B: “Hi, I’m Jo the nurse; are you ok?”
Nurse C: “Why are you pacing?”

37. CRITICAL THINKING: In what order should the nurse implement ?
A schizophrenic patient, who hallucinates and is sometimes aggressive, turns off the football game that others are watching.
“Are you hearing the voices?”
“Right now our activity is watching the football game, so it’s not ok to turn it off.”
“Come on outside for some fresh air.”
“I’m going to give you some medication right now to help you feel calmer.”

38. OTHER INTERVENTIONS Importance of client and family education
To address stigma of schizophrenia &
To improve functional ability, self-management and prevent relapse

39. Other Interventions, cont’d
Community Resources and Continuity of Care
National Alliance on Mental Illness (NAMI)
Outpatient day treatment, home care
Self-help, peer support groups
(NAMI)

40. PHARMACOTHERAPY Antipsychotic Agents
Traditional or Typical Agents: 1st Generation (beginning 1950’s)
Atypical or Second Generation Agents (1990’s)
Novel or Third Generation Agents (21st century)

41. Antipsychotic Agents: Overview of Typical Agents
Pharmacologic Effects, in General
Sedation (esp. if combined with other CNS depressants)
Slowing of motor activity
Decrease in hallucinations and delusions
Emotional quieting
Improved cognitive function; decreased confusion

42. TYPICAL or Traditional ANTIPSYCHOTIC AGENTS
High Potency e.g. haloperidol (Haldol), fluphenazine (Prolixin)
Moderate Potency e.g. loxapine (Loxitane), perphenazine (Trilafon)
Low Potency e.g. chlorpromazine (Thorazine), thioridazine (Mellaril)

43. Typical/Traditional Antipsychotics, cont’d
Action = Block Dopamine D2 Receptors
Most effective for Positive (+) symptoms

44. Atypical (2nd Generation) Agents
clozapine (Clozaril) (prototype)
Action of this drug: blocks multiple
dopamine receptors
quetiapine (Seroquel)
risperidone (Risperdal)
olanzapine (Zyprexa)
ziprasidone (Geodon)
paliperidone (Invega)

45. Newest Atypical Agents
iloperidone (Fanapt)
Asenaphine (Saphris)

46. Atypical (2nd generation) Agents, cont’d
Action: Block (antagonists) or enhance (agonists) multiple dopamine, serotonin and/or norepinephrine receptors.
Useful for both positive and negative symptoms

47. Novel (3rd Generation) Agents
aripiprazole (Abilify)
Action: Partial dopamine antagonist
“Balances” dopamine
(both increases and decreases it in different brain areas)

48. Antipsychotics: Side Effects
Main Side Effects:
Extra-Pyramidal (EPSEs)- abnormally increased or decreased motor activity, muscle spasms, twisting, tremors
Akinesia
 Akathisia
Pseudo-Parkinsonism
Dystonias
 Tardive Dyskinesia
Acute dystonic reaction

49. Tardive Dyskinesia

50. EPSEs
To assess for tardive dyskinesia, administer AIMS (Abnormal Involuntary Movement Scale)

52. Antipsychotics: Side Effects, cont’d
Anticholinergic Effects-dry mouth, orthostatic hypotension, urinary retention, blurred vision
Usually resolve over time

53. Other Side Effects Cardiac: Arhythmias (QT interval lengthened)
Blood:  Leukopenia, anemias,
agranulocytosis (clozapine/Clozaril)
Endocrine and Metabolic:
 Weight gain
 Altered glucose metabolism
Diabetes type II
 Elevated prolactin levels
Sexual: Impaired libido, performance

54. A Dangerous Side Effect
Neuroleptic Malignant Syndrome (NMS)
Potentially lethal
Associated with use of high-potency agents e.g. haloperidol/Haldol
Onset: within a week after starting meds.
Symptoms: muscular rigidity, tremors, autonomic hyperactivity e.g. high body temperature, altered consciousness

55. Nursing Interventions R/T Antipsychotic Meds.
Medication education (You cannot teach too often)
Side effect issues contribute to poor adherence/compliance:
E.g. hypotension, CNS depression, photosensitivity, thermoregulation problems

56. Education/Safety Issues: What will you teach the client about. . .?
Hypotension
Sedation
Photosensitivity
Problems with thermoregulation
Weight gain

57. Nursing Interventions R/T Pharmacotherapy
--Option for client with poor adherence:
Long acting (“depot”) form, give IM q 1week - 4 wks

58. Nursing Interventions r/t Pharmacotherapy
Disintegrating oral tablet
Oral solution

59. EMERGENCY MEDS
Common choice: IM “cocktail” of sedating antipsychotic + antihistamine and benzodiazepine
Goals: reduce agitation
rapid sedation

60. CRITICAL THINKING: Antipsychotic Therapy
A 65 year-old client will start on an antipsychotic agent for delusions secondary to severe depression. Choose the 3 highest priority diagnostic tests that will be performed.
A) CBC with diff D) EEG
B) Chest x-ray E) BUN/Creatinine
C) EKG F) Electrolytes

61. PHARMACOTHERAPY FOR EXTRAPYRAMIDAL SEs: Antiparkinson Agents
benztropine (Cogentin)
trihexyphenidyl (Artane)
biperiden (Akineton)
diphenhydramine (Benadryl)
amantadine (Symmetrel)

62. Antiparkinson Agents, cont’d
Action: Restore balance of dopamine with acetylcholine (ACh)
Reduce motor and muscle dysfunctions caused by this imbalance
But: They also may cause anticholinergic SEs and mental confusion

63. CRITICAL THINKING
Which client(s) is(are) candidate(s) for benztropine/Cogentin?
A) is unable to void urine
B) reports onset of difficulty swallowing and stiff muscles
C) is pacing in response to hearing voices
D) has had tardive dyskinesia symptoms for several years

64. CRITICAL THINKING: Anti-Parkinson/Anticholinergic Agents
On the mental health unit, a client who was recently
prescribed an antiparkinson agent for EPSEs reports
very dry mouth and constipation. What will the nurse do?
(Choose all that apply)
A) Call the dr. to discuss changing dose of the med.
B) Encourage use of hard candies and increase in fluid intake
Hold the medication
Inform the client that these effects may decrease in a few weeks.