1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Schizophrenia

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia Distorted and bizarre thoughts, perceptions, emotions, movements, behavior Categories of symptoms –Positive (hard) Delusions, hallucinations; grossly disorganized thinking, speech, behavior –Negative (soft) Flat affect, lack of volition, social withdrawal, or discomfort

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Schizophrenia Paranoid type Disorganized type Catatonic type Undifferentiated type Residual type

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Course Onset: abrupt or insidious; most with slow, gradual development of signs, symptoms Diagnosis usually with more actively positive symptoms of psychosis

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Course (cont.) Immediate course: two patterns –Ongoing psychosis, never fully recovering; –Episodes of psychotic symptoms alternating with episodes of relatively complete recovery Long-term course: intensity of psychosis diminishes with age; most with difficulty functioning; few with ability to live fully independent lives

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Schizophreniform disorder Catatonia Delusional disorder Brief psychotic disorder Shared psychotic disorder Schizotypical personality disorder

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology Biologic theories –Genetic factors (partial inheritance) –Neuroanatomic and neurochemical factors (less brain tissue and cerebrospinal fluid; dopamine excess and serotonin modulation of dopamine or excess) –Immunovirologic factors (viral exposure; cytokines)

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Positive symptoms of schizophrenia include a flat affect and social withdrawal.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Flat affect and social withdrawal are negative symptoms of schizophrenia.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations Ideas considered delusional in one culture possibly commonly accepted by other cultures Auditory or visual hallucinations as normal part of religious experiences in some cultures Culture-bound syndromes Ethnic differences in response to psychotropic medications

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology Conventional antipsychotics (dopamine antagonists; see Table 16.1) –Targeting positive symptoms –No observable effect on negative symptoms Atypical antipsychotics (dopamine, serotonin antagonists) –Diminish positive symptoms –Lessen negative symptoms

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology: Maintenance Therapy Two antipsychotics available in depot injection forms: –Fluphenazine (Prolixin) in decanoate and enanthate –Preparations –Haloperidol (Haldol) in decanoate Effects last 2 to 4 weeks; eliminate need for daily oral antipsychotic medication

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology: Side Effects Neurologic side effects: –Extrapyramidal side effects Acute dystonic reactions Akathisia Parkinsonism –Tardive dyskinesia –Seizures –Neuroleptic malignant syndrome

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology: Side Effects (cont.) Nonneurologic side effects –Weight gain, sedation, photosensitivity –Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention) –Orthostatic hypotension –Agranulocytosis (clozapine)

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Treatment Individual, group therapies –Supportive, medication management, use of community supports Social skills training –Cognitive adaptation training –Cognitive enhancement therapy (CET) Family therapy Family education

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would be considered a neurologic side effect of antipsychotic therapy? –A. Blurred vision –B. Agranulocytosis –C. Sedation –D. Tardive dyskinesia

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Tardive dyskinesia Rationale: Tardive dyskinesia is a neurologic side effect of antipsychotic therapy. –Blurred vision, sedation, and agranulocytosis are nonneurologic side effects.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application Assessment –History: previous history with schizophrenia; previous suicidal ideation; current support system; patient’s perception of current situation –General appearance, motor behavior, speech (odd, bizarre; catatonia; echopraxia, psychomotor retardation, word salad, echolalia, latency of response [see Box 16.3])

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Assessment (cont.) –Mood, affect (flat, blunted; anhedonia) –Thought process, content (thought blocking, broadcasting, withdrawal, or insertion) –Delusions (see Box 16.4) –Sensorium, intellectual processes (hallucinations [auditory, visual, olfactory, tactile, gustatory, cenesthetic, kinesthetic; command]; depersonalization)

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Assessment (cont.) –Judgment, insight (usually impaired) –Self-concept (loss of ego boundaries; ideas of reference) –Roles, relationships (social isolation) –Physiologic, self-care (inattention to hygiene and grooming; failure to recognize sensations; polydipsia)

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Data analysis/nursing diagnoses –Risk for other-directed violence r/t –Risk for suicide r/t –Disturbed sensory perception r/t –Disturbed personal identity r/t –Impaired verbal communication r/t

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Outcome identification (acute psychosis; treatment) –Focus on safety of patient and others –Stabilize patient’s thought process –Reality orientation

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Interventions –Safety of patient, others –Therapeutic relationship; therapeutic communication –Interventions for delusional thoughts (focus on reality; no confrontation or reinforcement) –Interventions for hallucinations –Management of socially inappropriate behavior

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Schizophrenia and Nursing Process Application (cont.) Interventions (cont.) –Patient, family education Signs, symptoms of relapse (see Box 16.5) Self-care, nutrition Social skills Medication management Evaluation

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The nurse should confront a patient’s delusions.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: When a patient is experiencing delusions, the nurse should focus on the reality and not confront or reinforce the patient’s delusions.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Considerations Late onset: after age 45 Psychotic symptoms later in life usually associated with depression or dementia, not schizophrenia

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Considerations (cont.) Variety of long-term outcomes for elderly –Approximately one fourth experiencing dementia, resulting in steady, deteriorating health decline –Approximately one fourth experiencing reduction in positive symptoms –Remainder mostly unchanged

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Housing with family or independently Assertive community treatment (ACT) Behavioral home health care Community support programs Case management services

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Goal of psychiatric rehabilitation: patient recovery Accurate identification of those at risk Early intervention –Improved prodromal symptoms –Prevention of social stagnation or decline –Prevention or delay of progression to psychosis

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Challenge when the patient suspicious or mistrustful or nurse frightened Frustration if the patient noncompliant Need not to take patient’s success or failure personally Patient’s strengths, time out of hospital as focus No nurse has all the answers.