Maggie Motyka, MS, RNCFall 2012

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Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Psychotic symptoms more pronounced and

disruptive than in other psychotic disorders

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Schizophrenia occurs in◦ 1 in 100 adults◦ 1 in 40,000 children

Age of onset 17 to 25 years –most common

With schizophrenia, there is a severe deterioration of social and occupational functioning.

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Substance abuse disorders Nicotine dependence Depression

◦ Suicide Anxiety disorders Psychosis-induced polydipsia

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A return to full premorbid function is not common

Factors associated with a positive prognosis include◦Good premorbid adjustment ◦Later age at onset; Being female◦Abrupt onset precipitated by a stressful event◦Associated mood disturbance ◦Minimal residual symptoms ◦Brief duration of active-phase symptoms◦Absence of structural brain abnormalities ◦No family history of schizophrenia

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Affect Associative looseness Autism Ambivalence Plus a 5th -

◦Automatic Obedience

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NeurobiochemicalDopamine hypothesisSerotoninGlutamate

Neuroanatomical Structural cerebral abnormalities

GeneticSeveral genes on different chromosomes

interact with environmentNongenetic risk factors

Complications of pregnancy and birthStress

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Thought content

Delusions: Firmly Fixed False Personal Beliefs

Religiosity: Excessive demonstration of

obsession with religious ideas and behavior

Paranoia: Extreme suspiciousness of others

Magical thinking: Idea that if one thinks

something, it must be true

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Word salad: Group of words put together in a random fashion

Associative looseness: Shift of ideas from one unrelated topic to another

Neologisms: Made-up words that have meaning only to the person who invents them

Concrete thinking: Literal interpretations of the environment

Clang associations: Choice of words is governed by sound (often rhyming)

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Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details

Tangentiality: Inability to get to the point of communication due to introduction of many new topics

Mutism: Inability or refusal to speak Perseveration: Persistent repetition of the same

word or idea in response to different questions

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Hallucinations: False sensory perceptions not associated with real external stimuli◦ Auditory, Visual, Tactile, ◦ Olfactory, Gustatory

Illusions: Misperceptions of real external stimuli

◦ Such as??◦ Caused by ??

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Sense of Self: The uniqueness and individuality a person feels

Echolalia: Repeating words that are heard Echopraxia: Repeating movements that are

observed Identification and imitation: Taking on

the form of behavior one observes in another Depersonalization: Feeling of unreality

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Affect: the feeling state or emotional tone◦ Inappropriate affect: emotions are

incongruent with the circumstances◦ Bland or flat: weak emotional tone◦ Apathy: disinterest in the environment

Avolition: Impairment in ability to initiate goal-directed activity◦ Emotional ambivalence: Coexistence of

opposite emotions toward same object, person, or situation

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Impaired interpersonal functioning and relationship to the external world

◦Autism: The focus inward on a fantasy world while distorting or excluding the external environment

◦Deterioration in appearance: Impaired personal grooming and self-care activities

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Psychomotor behavior◦Anergia: Deficiency of energy

◦Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions

◦Posturing: Voluntary assumption of inappropriate or bizarre postures

◦Pacing and rocking: Pacing back and forth and rocking the body

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Associated features:

Anhedonia: Inability to experience pleasure

Regression: Retreat to an earlier level of development

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Inattention, easily distracted Impaired memory Poor problem-solving skills Poor decision-making skills Illogical thinking Impaired judgment

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Dysphoria Suicidal ideation Hopelessness

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Recurrent acute exacerbations of psychosis

Increase in residual dysfunction and deterioration with each relapse

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Phase I Premorbid behavior Normal functioning Shy and withdrawn Poor peer relationships Doing poorly in school Antisocial behavior

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Prodromal phase – Phase II Lasts from a few weeks to a few years Deterioration in role functioning and social

withdrawal Substantial functional impairment Sleep disturbance, anxiety, irritability Depressed mood, poor concentration, fatigue Perceptual abnormalities, ideas of

reference, and suspiciousness herald onset of psychosis

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Withdrawn from othersDepressedAnxiousPhobiasObsessions and compulsionsDifficulty concentratingPreoccupation with religionPreoccupation with self

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Schizophrenia Phase III In the active phase of the disorder,

psychotic symptoms are prominent

◦Delusions◦Hallucinations◦Impairment in work, social

relations, and self-care

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Residual phase – Phase IV

◦Symptoms similar to those of the prodromal phase

◦Flat affect and impairment in role functioning are prominent

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Positive symptoms Negative symptoms Cognitive symptoms Mood symptoms

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Ability to work Interpersonal relationships

Self-care abilities Social functioning Quality of life

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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

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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

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Risk for self-directed or other-directed violence

Disturbed sensory perception Disturbed thought processes Impaired verbal communication Ineffective coping Compromised or disabled family

coping

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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

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Acute phase◦ Possible hospitalization

Ensure client safety Provide symptom stabilization

Maintenance and stabilization phases◦ Psychosocial education◦ Relapse prevention skills

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Acute phase◦ Psychobiological intervention◦ Counseling◦ Milieu management◦ Family psychoeducation

Maintenance and stabilization phases◦ Health teaching◦ Health promotion and maintenance

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SafetyPotential for physical violence due to

hallucinations or delusionsPriority is least restrictive safety technique

Verbal de-escalation Medications Seclusion or restraints

ActivitiesProvide support and structureEncourage development of social skills

and friendships

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HallucinationsHearing voices most commonApproach client in nonthreatening and

nonjudgmental mannerAssess if messages are suicidal or homicidalInitiate safety measures if neededClient anxious, fearful, lonely, brain not

processing stimuli accuratelyDelusions

Be open, honest, matter-of-fact, and calmHave client describe delusionAvoid arguing about contentInterject doubt Validate part of delusion that is real

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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

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Distraction Interaction Activity Social action Physical action

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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.

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Antipsychotic medications

Neuroleptics –Major Tranquilizers◦Traditional or conventional◦Atypical or novel

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Indications: ◦ Treatment of acute and

chronic psychoses; selected agents are also used in the treatment of bipolar mania, as antiemetics, in the treatment of intractable hiccoughs, and for control of tics and vocal utterances in Tourette’s disorder

Action: ◦ Unknown; thought to block postsynaptic dopamine

receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer antipsychotics may block action on receptors specific to dopamine, serotonin, and other neurotransmitters.

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◦Contraindicated: ◦ In hypersensitivity; CNS depression; when blood

dyscrasias exist; in clients with Parkinson’s disease or narrow-angle glaucoma; those with liver, renal, or cardiac insufficiency; or poorly controlled seizure disorders

◦Caution ◦ with elderly, debilitated, or diabetic clients or

those with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction

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◦Additive hypotension with antihypertensive agents◦Additive CNS effects with CNS depressants◦Additive anticholinergic effects with similar agents◦Reduced effectiveness of oral anticoagulants◦Severe hypotension with epinephrine or dopamine◦Additive QT prolongation with other drugs that

prolong QT interval◦Pimozide is contraindicated with CYP3A inhibitors◦Thioridazine is contraindicated with CYP2D6

inhibitors◦Concomitant use results in haloperidol

and carbamazepine

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◦ Additive hypotension with antihypertensive agents

◦ Additive CNS effects with CNS depressants◦ Additive anticholinergic effects with similar

agents◦ Additive QT prolongation with other drugs that

prolong QT interval◦ Decreased effects of levodopa and dopamine◦ Increased effects with CYP3A4 and CYP1A2

inhibitors◦ Decreased effects with CYP1A2 inducers◦ Additive hypotension with other drugs that cause this side effect

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Dopamine antagonists (D2 receptor antagonists)Target positive symptoms of schizophreniaAdvantage

Less expensive than atypical antipsychoticsDisadvantages

Do not treat negative symptomsExtrapyramidal side effects (EPS)Tardive dyskinesiaAnticholinergic effects (ACH)Lower seizure threshold

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High potency = low sedation + low ACH + high EPSsHaloperidol (Haldol)Trifluoperazine (Stelazine)Fluphenazine (Prolixin)Thiothixene (Navane)

Medium potencyLoxapine (Loxitane)Molindone (Moban)Perphenazine (Trilafon)

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

Decanoate = Long acting◦ Haloperidol decanoate (Haldol)◦ Fluphenazine decanoate (Prolixin)

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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

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Clozapine (Clozaril) Quetiapine (Seroquel) Risperidone (Risperdal Zipreasidone (Geodon) Olanzapine (Zyprexa) Aripiprazole (Abilify)

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Dry mouth Urinary retention and hesitancy Constipation Blurred vision Photosensitivity Dry eyes Inhibition of ejaculation or

impotence in men

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Hypotension Postural

hypotension Tachycardia

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PseudoparkinsonismAcute dystonic reactions

OpisthotonosOculogyric crisis

AkathisiaTardive dyskinesia (AIMS test)

FacialLimbs

Choreic Athetoid

Trunk

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Indications: treatment of parkinsonism of various

causes, including degenerative, toxic, infective, neoplastic, or drug induced

Action: works to restore the natural balance of

acetylcholine and dopamine in the CNS

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◦Contraindicated ◦in known hypersensitivity; angle-closure

glaucoma; pyloric, duodenal, or bladder neck obstructions; prostatic hypertrophy; or myasthenia gravis

◦Caution ◦with hepatic, renal, or cardiac

insufficiency; elderly and debilitated clients; those with a tendency toward urinary retention; those exposed to high environmental temperatures

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◦Additive anticholinergic effects with other drugs that possess these properties

◦Concurrent use with haloperidol or Phenothiazines may result in decreased effect of the antipsychotic and increased incidence of anticholinergic side effects.

◦Additive CNS effects with CNS depressants

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Agranulocytosis Cholestatic jaundice Neuroleptic malignant syndrome (NMS)◦Severe extrapyramidal◦Hyperpyrexia◦Autonomic dysfunction

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Disorders caused by changes in the brain marked by disturbances in:◦Orientation◦Memory◦Intellect◦Judgment◦Affect

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Acute onset Disturbances in consciousness Disturbed thinking, memory, attention, and

perception Disorientation and confusion that

fluctuates by minute, hour, and day Always caused by an underlying condition

◦ Temporary◦ Transient

Treatment priority: Identify cause, then intervene so that permanent damage to neurons does not result

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Cognitive and perceptual disturbances Physical needs

◦Safety Physical Bacteriological Biophysical

Mood and behavior

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Risk for injury Deficient fluid volume Acute confusion Disturbed thought processes Fear Disturbed sleep pattern Impaired verbal communication Impaired social interaction

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A cognitive disorder with these signs and symptoms:◦Insidious onset◦Deterioration of

Memory Judgment Ability to think abstractly Orientation

May be progressive and irreversible

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Pathological ◦ Cerebral atrophy◦ Neuritic plaques◦ Neurofibrillary tangles

Genetic◦ Chromosome 19◦ Apolipoprotein E gene

Nongenetic Neurochemical

◦ Acetyltransferase◦ Estrogen

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Stage 1 (mild): forgetfulness

Stage 2 (moderate): confusion

Stage 3 (moderate to severe): ambulatory dementia

Stage 4 (late): end stage

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Confabulation: unconscious attempt to maintain self-esteem

Perseveration: repetition of phrase or behaviors

Aphasia: loss of language ability Apraxia: loss of purposeful movement in

the absence of motor or sensory impairment

Agnosia: loss of sensory ability to recognize objects

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Risk for injury Impaired verbal communication Impaired memory Ineffective coping Caregiver role strain Anticipatory grieving

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For cognitive impairment◦Physostigmine (Antilirium)◦Tacrine (Cogex) ◦Donepezil (Aricept)◦Rivastigmine (Exelon) ◦Galantamine (Razadyne)◦Memantine (Namenda)

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