Solomon Tan MSNEd RNBC PHN 2011 Schizophrenia Chapter 15 Eugen Bleulers 4 As of Schizophrenia Affect Associative looseness Autism Ambivalence Epidemiology Lifetime prevalence of schizophrenia 1 worldwide ID: 579261
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West Coast UniversitySolomon Tan, MSN/Ed. RN-BC, PHN 2011
Schizophrenia
Chapter 15Slide2
Eugen Bleuler’s 4 A’s of Schizophrenia
Affect
Associative looseness
Autism
AmbivalenceSlide3
EpidemiologyLifetime prevalence of schizophrenia 1% worldwideAverage onset is late teens to early twenties, but can be as late as mid-fifties
30% to 40% relapse rate in the first year
Life expectancy is shortened because of suicide
No difference related to
Race, Social status, CultureSlide4
ComorbiditySubstance abuse disordersNicotine dependenceAnxiety, depression, and suicide
Physical health or illness
PolydipsiaSlide5
EtiologyBiological factorsGeneticsNeurobiological
Dopamine theory
Other
neurochemical
hypotheses
Brain structure abnormalitiesSlide6
EtiologyContinuedPsychological and environmental factorsPrenatal stressors
Psychological stressors
Environmental stressorsSlide7
Signs and SymptomsLanguage and communication disturbancesThought disturbances
Perception disturbances
Affect disturbances
Motor behavior disturbances
Self-identity disturbancesSlide8
Features of Schizophrenia Progression varies from one client to anotherExacerbations and remissions
Chronic but stable
Progressive deterioration
DSM-IV-TR Diagnosis
Symptoms present at least 6 months
Active-phase symptoms present at least 1 month
Symptoms are defined as positive and negativeSlide9
Phases of SchizophreniaPhase I –
Acute
Onset or exacerbation of symptoms
Phase II
–
Stabilization
Symptoms diminishing
Movement towards previous level of functioning
Phase III
–
Maintenance
At or near baseline functioningSlide10
AssessmentDuring the prepsychotic phaseGeneral assessment
Positive symptoms (Excess or distorted)
Negative symptoms (Deficit)
Cognitive symptoms
Affective symptomsSlide11
Positive Symptoms Alterations in thinkingDelusions are false, fixed beliefsPersecutory, Referential
Somatic, Religious,
Substitution, Thought Insertion and/or Broadcasting
Nihilistic, Grandiose
Concrete thinking is an inability to think abstractly.
Indecisiveness, lack of problem solving skills,
Concreteness, thought blocking, perseverationSlide12
Positive SymptomsContinuedAlterations in speechNeologisms
Echolalia
Echopraxia
Clang associations
Word salad
Loose AssociationSlide13
Positive SymptomsContinuedAlterations in perceptionDepersonalization
Derealization
Hallucinations
Auditory hallucinations
Command hallucinations
Visual hallucinations
Boundary impairment
Negativism
Impaired impulse control Slide14
Negative Symptoms (5A’s)Affect
Flat, Blunted, Inappropriate, Bizarre
Apathy
I
ndifference towards people, events, activities and learning.
Alogia
P
overty of speech
Avolition
I
nability to pursue and persist in goal-directed activities.
Anhedonia
I
nability to experience pleasure. Slide15
Cognitive SymptomsDifficulty withAttentionMemory
Information processing
Cognitive flexibility
Executive functions Slide16
Affective SymptomsAssessment for depression crucialMay herald impending relapseIncreases substance abuse
Increases suicide risk
Further impairs functioningSlide17
Review QuestionA patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?Positive symptom
Negative symptom
Cognitive symptom
Depressive symptomSlide18
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.”Slide19
Subtypes of SchizophreniaParanoid typeDisorganized typeCatatonic type
Undifferentiated type
Residual TypeSlide20
Subtypes of Schizophrenia - continuedParanoid Type
Delusions
Persecutory and grandiose
Somatic or religious
Hallucinations
Delusions link with a hallucination
Disorganized Type
Disorganized speech, behavior, appearance
Flat or inappropriate affect
Fragmented hallucinations and delusions
Most severe form of schizophreniaSlide21
Specific Interventions forParanoid and Disorganized Schizophrenia
Communication guidelines
Self-care needs
Milieu needsSlide22
Subtypes of Schizophrenia - continuedCatatonic type
Psychomotor retardation and stupor
Waxy flexibility
Mutism
Extreme psychomotor agitation
Echolalia
EchopraxiaSlide23
Specific Interventions for CatatoniaCatatonia – Withdrawn PhaseCommunication guidelines
Self-care needs
Milieu needs
Catatonia – Excited Phase
Communication guidelines
Self-care needsSlide24
Subtypes of Schizophrenia - continuedUndifferentiated type
Active psychotic state (Positive & Negative symptoms)
Lacks symptoms of other subtypes
Residual type
Active-phase symptoms no longer present
No prominent positive symptoms
Negative symptoms presentSlide25
Other Psychotic DisordersSchizophreniform disorderSchizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared Psychotic Disorder (
Folie
à
Deux
)
Induced or Secondary PsychosisSlide26
Assessment Guidelines1. Any medical problems2. Abuse of or dependence on
alcohol or drugs
3. Risk to self or others
Command hallucinations
5. Belief system
6. Suicide riskSlide27
Assessment GuidelinesContinued7. Ability to ensure self-safety
Co-occurring disorders
9. Medications
10. Presence and severity of positive and negative symptoms
11. Patient’s insight into illness
12. Family’s knowledge of patient’s illness and symptomsSlide28
Potential Nursing DiagnosesPositive symptoms
Risk for violence
Disturbed sensory perception
Risk for self-directed or other-directed violence
Disturbed thought processes
Negative symptoms
Social isolation
Chronic low self-esteem
Altered health maintenance
Ineffective coping
Impaired verbal communicationSlide29
Outcomes IdentificationPhase I - Acute
Patient safety and medical stabilization
Phase II - Stabilization
Adhere to treatment
Stabilize medications
Control or cope with symptoms
Phase III - Maintenance
Maintain achievement
Prevent relapse
Achieve independence, satisfactory quality of lifeSlide30
PlanningPhase I – AcuteBest strategies to ensure patient safety and provide symptom stabilization
Phase II – Stabilization
Phase III
–
Maintenance
Provide patient and family education
Relapse prevention skills are vitalSlide31
ImplementationPhase 1 – Acute SettingsPartial hospitalization
Residential crisis centers
Halfway houses
Day treatment programsSlide32
InterventionsAcute PhasePsychiatric, medical, and neurological evaluationPsychopharmacological treatment
Support,
psychoeducation
, and guidance
Supervision and limit setting in the milieuSlide33
InterventionsContinuedStabilization and Maintenance PhaseMilieu management
Activities and groups
Safety
Counseling and communication techniques Slide34
InterventionsContinuedStabilization and Maintenance Phase, continued
Hallucinations
Delusions
Associative looseness
Health teaching and health promotionSlide35
Nursing Implications:Supporting FamiliesFamily needs vary with degree of illness and involvement in client’s care
Education
Financial support
Psychosocial support
AdvocacySlide36
Nursing Implications:Supporting Families - continued
Schizophrenia is a “family illness.”
Family members need to be involved.
Educate family about
Medication
Illness
Relapse prevention
Nurse assists family by
Identifying community agencies/groups for family members
Advocating for rightsSlide37
General Nursing InterventionPromote Safety and a Safe EnvironmentPromote Congruent Emotional Response
Promote Social Interaction and Activity
Intervene with Hallucinations and Delusions
Preventing Relapse
Promoting adherence with medication regimen
Assist with grooming and hygiene
Promote Family Understanding and InvolvementSlide38
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?Slide39
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?”Slide40
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.Slide41
Goals of AntipsychoticsPositive Effects
Allowed release of clients from inpatient hospital to treatment in the community
Manage 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 logically
Ability to function in one’s daily life
Ability to function in relationshipsSlide42
Negative Effects of AntipsychoticsNegative Effects Frightening and life threatening side effects
Potential interactions with other medications and substances
Possible need to cope with the realization of having a chronic illnessSlide43
All current antipsychotics work on at least one of these neurotransmitters:
Dopamine
SerotoninSlide44
AntipsychoticsTypical (Conventional)Block dopamine receptors at 70% to 80% occupancy to be effective.Exptrapyramidal Side Effects (
EPSEs
) occur at occupancy > 80
Typical =
Tardive
Dyskinesia
(TD)
5.4%
vs
0.8%
atypicalsSlide45
Pharmacological InterventionsAntipsychotic medicationsConventional antipsychotics Typical or first-generation
Atypical antipsychotics
Second-generation Slide46
Conventional Antipsychotics Dopamine antagonists (D2 receptor antagonists)Target positive symptoms of schizophrenia
Advantage
Less expensive than atypical antipsychotics
Disadvantages
Do not treat negative symptoms
Extrapyramidal
side effects (
EPSs
)
Tardive
dyskinesia
Anticholinergic
side effects
Lower seizure thresholdSlide47
Conventional AntipsychoticsTypical AgentsLow PotencyChlorpromazine (
Thorazine
) (25 – 800 mg/
d
)
Thioridazine
(
Mellaril
) (150 – 800 mg/
d
)
Mesoridazine
(
Serentil
) (100 – 400 mg /
d
)
Side Effects:
Sedation,
Anticholernergic
,
Hypotention
,
EPSEs
(less
vs
high potency)Slide48
Conventional AntipsychoticsHigh PotencyHaloperidol (
Haldol
) (1 – 30 mg/
d
)
Fluphenazine
(
Prolixin
) (0.5 – 40 mg/
d
)
Thiothixene
(
Navane
) (2 – 30 mg/
d
)
Trifluoperazine
(
Stelazine
) (1 – 40 mg/
d
)
Perhenazine
(
Trilafon
) (8-60 mg/
d
)
Loxapine
(
Loxitane
) (20 – 250 mg/
d
)
Molindone
(
Moban
) (50 – 225 mg/
d
)
Pimozide
(
Orap
) 0.5 – 9 mg/
d
)
Side Effects
Sedation,
Anticholenergic
SE (less
vs
low potency)
EPSEs
(high
vs
low potency)Slide49
Conventional Long-Acting Injectables (Depot Therapy)
Haloperidol
Decanoate
(
Haldol
Decanoate
)
Q4 weeks
Fluphenazine
Decanoate
(
Prolixin
Decanoate
)
Q2 WeeksSlide50
Atypical Antipsychotics Treat both positive and negative symptomsFewer
extrapyramidal
side effects (
EPSs
) or
tardive
dyskinesia
Reduced
affinity for dopamine (D
2
) receptors
Affinity
for serotonin receptors
D
2
antagonist + Serotonin receptor
antagonist
Disadvantage – tendency to cause significant weight gainSlide51
Atypical AntipsychoticsContinuedClozapine (
Clozaril
) (6.25 – 900 mg/
d
)
Side effects: 5% risk of seizures,
agranulocytosis
, weight gain,
hypersalivation
,
anticholinergic
Olanzapine
(
Zyprexa
,
Zyprexa
Zydis
,
Zyprexa
Relprevv
)
(5 – 20 mg/
d
)
Side effects: Weight gain, diabetes, sedation, bankruptcy 20mg/day = $925/month
Paliperidone
(
Invega
) (3 – 12 mg/
d
)
Quetiapine
(
Seroquel
) (150 – 600 mg/
d
)
Side effects: sedation, weight gain, restless leg syndrome
Risperidone
(
Risperdal
,
Risperdal
M-Tab)
(2 – 6 mg/
d
) (Increase
Prolactin
)Slide52
Atypical AntipsychoticsContinuedZiprasidone (
Geodon
) ( 40 – 160 mg/
d
)
Side effects:
QTc
prolongation, minimal sedation
Administer with food for improve efficacy
Aripiprazole
(
Abilify
) (15 – 30 mg/
d
)
Side effects:
akathisia
, insomnia/sedation, maybe less weight gain
Asenapine
(
Saphris
) (5 – 10 mg/
d
) Sublingual
Iloperidone
(
Fanapt
) (12 – 24mg/d)
Lurasidone
HCL (
Latuda
) (40 – 80 mg/
d
)Slide53
Long-Acting Injectables Depot TherapyRisperidone
Consta
(
Risperdal
Consta
)
Q2 Weeks
Paliperidone
Sustenna
(
Invega
Sustena
)
Q 4 weeks
Zyprexa
Relprevv
(Q2 or Q4 weeks depending on the dose) Monitor for 3 hours after injectionSlide54
Anti-Parkinson MedicationsTrihexyphenidyl (Artane)Benztropine
(
Cogentin
)
Diphenhydramine
(Benadryl)
Amantadine
(
Symmetrel
)Slide55
Antiadrenergic Effect:Orthostatic HypotensionTake the client’s blood pressure in a supine position and then in a standing position.
Caution clients to rise slowly from a supine position.Slide56
Extrapyramidal Side Effects InterventionsAcute
dystonia
anticholinergics
Akathisia
anticholinergics
but not always responsive
Pseudoparkinsonism
a
nticholinergics
Tardive
dyskinesia
–
Abnormal Involuntary Movement Scale (AIMS) Slide57
DystoniaOccurs usually within 48 hours of initiation of the medicationInvolves bizarre and severe muscle contractions
Can be painful and frightening
Characterized by odd posturing and strange facial expressions:
Torticollis
Opisthotonus
Laryngospasm
OculogyricSlide58
TorticollisSlide59
OpisthotonusSlide60
Oculogyric CrisesSlide61
LaryngospasmSlide62
Drug-induced ParkinsonismUsually occurs after 3 or more weeks of treatmentCharacterized by:Cogwheel rigidity
Tremors at rest
Rhythmic oscillations of the extremities
Pill rolling movement of the fingers
Bradykinesia
Postural ChangesSlide63
AkathisiaUsually occurs after 3 or more weeks of treatmentSubjectively experienced as desire or need to move
Described as feeling like jumping out of the skin
Mild: a vague feeling of apprehension or irritability
Severe: an inability to sit still, resulting in rocking, running, or agitated dancingSlide64
Tardive DyskinesiaUsually occurs late in the course of long-term treatment
Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping)
Often irreversible
Prophylactic use of vitamin E and Omega-3 FFA
Avoid typical antipsychotics
Abnormal Involuntary Movement ScaleSlide65
Autonomic Nervous System Effects:Anticholinergic Side EffectsDry mouth
Blurred vision
Constipation
Urinary retention
TachycardiaSlide66
Interventions for Anticholenergic Side Effects
Ice chips, hard candy
Eye drops
Fiber diet, exercise
Increase fluid intake
Catheterization Slide67
Potentially Dangerous Responses to AntipsychoticsNeuroleptic malignant syndrome (NMS)
Typically occurs in the first 2 weeks of treatment or when the dose is increased
Hold the medication, notify the physician, and begin supportive treatments.
Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresisSlide68
Neuroleptic malignant syndrome (NMS)
Risk Factors
Dehydration
Agitation or catatonia
Increase dose of
neuroleptic
Withdrawal from anti-
parkinson
medication
Long acting or depot medication
Pharmacologic treatment
Antipyretics
Muscle relaxant
Dopamine receptor agonistSlide69
Potentially Dangerous Responses to AntipsychoticsAgranulocytosisEarly symptoms: beginning signs of infection
White blood cells are routinely monitored in clients taking
clozapine
(
Clozaril
).Slide70
Other Central Nervous System EffectsSedationLowering of the seizure threshold:
Observe clients with seizures disorders carefully when treatment is initiated.Slide71
Cardiac EffectsSome antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias.
An EKG can identify those at risk.Slide72
Blood, skin and eye effectAgranulocytosisBlurred VisionSkin
photosensitivity
Retinitis
pigmentosaSlide73
Endocrine EffectsHyperprolactinemia may cause:Oligomenorrhea
or amenorrhea in women
Galactorrhea
in women and rarely in men
Osteoporosis if prolonged
Impotence in males may occur.
Diabetes
Monitor blood glucose levels.Slide74
Weight GainMonitor weightTeach about diet and exerciseWeight gain may contribute to physical as well as psychosocial stressorsSlide75
Adjuncts to Antipsychotic Drug TherapyAntidepressants
Antimanic
agentsSlide76
Advanced Practice InterventionsPsychotherapyCognitive-behavioral therapy (CBT)Group therapy
Medication
Social skills training
Cognitive remediation
Family therapy