schizophrenia and other psychotic disorders

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Mercedes A Perez-Millan MSN, ARNP

INTRODUCTION

Schizophrenia is possibly a group of psychotic disorders that severely impairs all areas of an individual’s functioning.

1 to 1.5% of US population has schizophrenia. However they make up far more than 50% of the county and long-term residents of state mental hospitals.

More than 50% are homeless, and in addition may have an addiction problem.

The cost of treatment and loss of revenues are estimated in the billions of dollars.

COMORBIDITY

• Substance abuse disorders

• Nicotine dependence

• Depression

– Suicide

• Anxiety disorders

• Psychosis-induced polydipsia

ETIOLOGY

Neurobiochemical

– Dopamine hypothesis– Serotonin– Glutamate

• Neuroanatomical – Structural cerebral abnormalities

• Genetic– Several genes on different chromosomes interact with

environment• Nongenetic risk factors

– Complications of pregnancy and birth– Stress

GENETIC PREDISPOSITION

A single gene has not been identified.

Research is focused on chromosomes 6, 13, 18 & 22.

The risk of developing the disorder is as follows:

One parent 12-15%+

Both parents 40%+

Identical twins 50%+

(The statistics may vary in different studies)

AREAS OF THE BRAIN AFFECTED

BIOLOGICAL THEORIES Neuroanatomical

Course of Schizophrenia

• Recurrent acute exacerbations of psychosis

• Increase in residual dysfunction and deterioration with each relapse

Phases in Course of Schizophrenia

1. Acute phase– Positive symptoms and negative symptoms

2. Maintenance phase– Acute symptoms are less severe

3. Stabilization phase– Remission of symptoms

Potential Early Symptoms: Pre-psychotic

• Withdrawn from others

• Depressed

• Anxious

• Phobias

• Obsessions and compulsions

• Difficulty concentrating

• Preoccupation with religion

• Preoccupation with self

Bleuler’s 4 A’s of Schizophrenia

• Affect

• Associative looseness

• Autism

• Ambivalence

Signs and Symptoms: Relevant to Treatment

• Positive symptoms

• Negative symptoms

• Cognitive symptoms

• Mood symptoms

Dimensions Altered in Individuals with Schizophrenia

• Ability to work

• Interpersonal relationships

• Self-care abilities

• Social functioning

• Quality of life

Positive Symptoms: Alteration in Thinking

• Delusions: false, fixed beliefs that cannot be corrected by reasoning– Ideas of reference – Persecution– Grandiosity– Somatic sensations– Jealousy– Control – Thought broadcasting – Thought insertion – Thought withdrawal – Delusion of being controlled

• Concrete thinking

Positive Symptoms: Alterations in Speech

• Associative looseness

• Neologisms

• Echolalia

• Clang association

• Word salad

Positive Symptoms: Alterations in Perception

• Hallucinations: sensory perceptions for which no external stimulus exists– Auditory– Visual– Olfactory– Tactile

• Personal boundary difficulties

Positive Symptoms: Alterations in Behavior

• Extreme motor agitation

• Stereotyped behaviors

• Automatic obedience

• Waxy flexibility

• Stupor

• Negativism

Negative Symptoms

• Affective blunting

• Anergia

• Anhedonia

• Avolition

• Poverty of content of speech

• Thought blocking

• Flat affect/inappropriate affect

Cognitive Symptoms

• Inattention, easily distracted

• Impaired memory

• Poor problem-solving skills

• Poor decision-making skills

• Illogical thinking

• Impaired judgment

Depression and Other Mood Symptoms

• Dysphoria

• Suicidal ideation

• Hopelessness

Types of Schizophrenia

Subtypes

• Paranoid

• Catatonic

• Disorganized

• Undifferentiated

• Residual

Self-Assessment: Working with Schizophrenic Clients

• Peer group supervision– Client's intense emotions produce

similar emotions in the nurse

– Willingness for nurse to discuss feelings and behaviors with supervisors decreases defensive behaviors

• Team approach to decrease staff burnout

• Periodic reassessments of – Treatment outcomes

– Client's strengths and weaknesses

Assessment of the Client

• Safety of client and others

• Medical history and recent medical workup

• Positive, negative, cognitive, and mood symptoms

• Current medications and compliance to treatment

• Family response/support system

Potential Nursing Diagnoses

• Risk for self-directed or other-directed violence

• Disturbed sensory perception

• Disturbed thought processes

• Impaired verbal communication

• Ineffective coping

• Compromised or disabled family coping

Outcome Criteria

• Acute phase

– Client safety and medical stabilization

• Maintenance phase

– Adherence to medical regimen

– Understanding schizophrenia

– Participation of client and family in psychoeducational activities

• Stabilization phase

– Target negative symptoms

– Anxiety control

– Relapse prevention

Planning of Appropriate Interventions

• Acute phase– Possible hospitalization

• Ensure client safety • Provide symptom stabilization

• Maintenance and stabilization phases– Psychosocial education– Relapse prevention skills

Interventions: Basic Level

• Acute phase– Administer antipsychotic medication as

prescribed– Observe client behavior closely– Set limits on inappropriate behavior– Do not touch without warning– Offer foods that are not easily contaminated– Assist with ADL if needed– Supportive counseling– Milieu management– Family psychoeducation

Interventions: Basic Level Continued

• Maintenance and stabilization phases– Health teaching– Health promotion and maintenance

Milieu Therapy• Safety

– Potential for physical violence due to hallucinations or delusions

– Priority is least restrictive safety technique

• Verbal de-escalation

• Medications

• Seclusion or restraints

• Activities

– Provide support and structure

– Encourage development of social skills and friendships

Counseling: Communication Guidelines

• Hallucinations– Hearing voices most common

– Approach client in nonthreatening and nonjudgmental manner

– Assess if messages are suicidal or homicidal

– Initiate safety measures if needed

– Client anxious, fearful, lonely, brain not processing stimuli accurately

– Focus on the client’s feelings and present reality

Communication Guidelines continued

• Delusions– Be open, honest, matter-of-fact, and calm– Have client describe delusion– Avoid arguing about content– Focus on feelings– Present reasonable doubt – Validate part of delusion that is real

Communication Guidelines continued

• Associative looseness– Do not pretend that you understand – Place difficulty of understanding on yourself– Look for reoccurring topics and themes– Emphasize what is going on in the client's

environment– Involve client in simple, reality-based activities– Reinforce clear communication of needs, feelings,

and thoughts

Client Teaching Coping Techniques for

Schizophrenia

• Distraction

• Interaction

• Activity

• Social action

• Physical action

Client and Family Teaching

• Learn all you can about the illness.• Develop a relapse prevention plan.• Avoid alcohol and drugs.• Learn ways to address fears and losses.• Learn new ways of coping.• Comply with treatment.• Maintain communication with supportive people.• Stay healthy by managing illness, sleep, and diet.

Treatment Modalities

• Individual therapy– Social skills training (SST)– Cognitive remediation– Cognitive adaptation training (CAT)– Cognitive behavioral therapy (CBT)

• Group therapy• Family therapy• Psychopharmacology

Psychopharmacology

• Antipsychotics– Standard/ Typical– Atypical

• Antiparkinson

PsychopharmacologyTraditional Antipsychotic

• 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 (EPS)

– Tardive dyskinesia

– Anticholinergic effects (ACH)

– Lower seizure threshold

Antipsychotic Medications: Traditional

• High potency = low sedation + low ACH + high EPSs– Haloperidol (Haldol)

– Trifluoperazine (Stelazine)

– Fluphenazine (Prolixin)

– Thiothixene (Navane)

• Medium potency– Loxapine (Loxitane)

– Molindone (Moban)

– Perphenazine (Trilafon)

Antipsychotic Medications: Traditional continued

• Low potency = high sedation + high ACH + low EPSs– Chlorpromazine (Thorazine)– Thioridazine (Mellaril)– Mesoridazine ( Serentil)

• Decanoate = Long acting injection– Haloperidol decanoate (Haldol D)– Fluphenazine decanoate (Prolixin D)

Atypical Antipsychotics (First-Line Antipsychotics)

• Serotonin-dopamine antagonists – (5-HT2A receptor antagonists)

• Advantages– Diminishes negative as well as positive symptoms of schizophrenia

– Less side effects encourages medication compliance

– Improves symptoms of depression and anxiety

– Decreases suicidal behavior

• Disadvantages– Weight gain

– Metabolic abnormalities

Antipsychotic Medications: Atypical

• Clozapine (Clozaril)

• Quetiapine (Seroquel)

• Risperidone (Risperdal

• Zipreasidone (Geodon)

• Olanzapine (Zyprexa)

• Aripiprazole (Abilify)

Side Effects- Atypical

• Orthostatic Hypotension

• Decreased Libido

• Agranulocytosis (Clozapine)

• Weight gain

• Tachycardia

• Edema

Side Effects: Anticholinergic Symptoms

• Dry mouth• Urinary retention and hesitancy• Constipation• Blurred vision• Photosensitivity• Dry eyes• Inhibition of ejaculation or impotence in men

Side Effects:Extrapyramidal Side Effects

Pseudoparkinson Drooling, lack of facial responsiveness, shuffling gait,

and fine intentional tremors.

Acute DystoniaMuscle spasms of the jaw, tongue, neck or eyes.

Laryngeal spasms possible. Oculogyric crisis, Opisthotonos.

AkathisiaMotor restlessness, pacing, rocking, etc

Side Effects:Extrapyramidal Side Effects

Tardive Dyskinesia

– Bizarre facial and tongue movements

chewing, tongue from side to side, etc.

– Involuntary tonic muscular spasms of extremities

– Trunk

– Potentially irreversible

Side Effects:a2 Block: Cardiovasclar

• Hypotension

• Postural hypotension

• Tachycardia

Side Effects: Rare and Toxic Effects

• Agranulocytosis

• Cholestatic jaundice

• Neuroleptic malignant syndrome (NMS)

– Severe extrapyramidal

– Hyperpyrexia

– Autonomic dysfunction

NEUROLEPTIC MALIGNANT SYNDROME

• RARE, POTENTIALLY FATAL• ONSET WITHIN HOURS OR YEARS• EPS REACTIONS• CPK• HYPERTHERMIA 102° AND ABOVE• TACHYCARDIA• FLUCTUATING B.P.• DIAPHORESIS• STUPOR AND COMA

AGRANULOCYTOSIS

Potentially fatal disorder Symptoms include:

White blood cells level <2000 mm3 or granulocyte count <1500mm3

Sore throat Low grade fever Malaise Sores in the mouth

NURSING IMPLICATIONS

• MONITOR B.P. BEFORE ADMINISTERING MEDS

• CHECK CBC, CPK, LIVER FUNCTIONS AND VISION REGULARLY

• EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS

• ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME

• MIX LIQUIDS WITH 60CC FRUIT JUICE• PATIENT EDUCATION

ANTIPARKINSON AGENTS

• COGENTIN

• ARTANE

• AKINETON

• PARLODOL

• KEMADRIN

• BENEDRYL

CLIENT AND FAMILY TEACHING

• Teach about schizophrenia and available mental health agencies for support at the local and national level (NAMI AND NIMH).

• Develop a relapse prevention plan.• Teach about medication and treatment

compliance.• Teach to avoid alcohol or drugs.• Teach to keep in touch with supportive people.• Teach to keep healthy – stay in balance.

CRITICAL THINKINGCARE PLAN

The Patient is a 45 year old white male with a long history of schizophrenia. He was admitted last night after he was trying to jump out of a 20th story building.. He states that he hears voices that told him to jump out, and the voices also told him to kill people. He states that we are all going to die soon because the terrorists have a new “webon” (a special weapon) that will kill everyone in the USA. The patient looks very frightened and refuses to come out of his room.

Assessment: “S” “O”

Nursing Diagnosis:

Goals

Nursing Actions