1

Psychopathology

SchizophreniaSigns & symptoms

Possible CausesNursing Diagnoses

Treatment & care PlansTeaching plans

2

Psychopathology• Prevalence - 20% (12 months period)

Anxiety disorder - most prevalent

Mood disorder (collectively)

Alcohol disorders

Major depression

• Comorbidity - 17%

• Help seeking - 60-80%

3

Understanding Psychopathology• Organized knowledge - understand

• Operational definition - communicate

• Criteria for diagnosis - DSM IV

• Behavior - subjective/ objective

• Etiology - nature/nurture

4

Schizophrenia

• the most debilitating mental illnesses

• Greek terms - "splitting of the mind”

• do not have more than one distinct personality

• distortions in their perceptions, feelings, and relationships with the world around them.

• 1% of the population suffer (in 12 m period)

5

The mental health continuum for schizophrenia

Mild

Moderate Severe Psychosis

Anxiety

Anxiety Cause Physical conditions

Anxiety disorderSomatoform disordersDissociative disorders

Personalitydisorders

Grief Major depression

6

Epidemiology

• 95% of sufferers – lasts a lifetime• 1/3 of homeless suffer from Schizo• 15% no respond to med;

75% partial effective • 20-50% attempt suicide

10% kill themselves• 20% shorter life expectancy• 25% experience secondary depression

7

Causes of Schizophrenia

• Genetic factors

• Chemical imbalance & physical abnormalities – neurotransmitters, brain structures

• Biological factors – age, virus, …

• Environmental factors – chr. Life stressors, changes, …

8

Causes - genetic influences

• Identical twin affected 50%

• Fraternal twin affected 15%

• Both parent affected 35%

• One parent affected 15%

• Brother or sister affected 10%

• No affected relative 1%

9

Signs & symptoms

• Alterations in personal relationships

• Alternations of activity

• Altered perception

• Alterations of thought

• Distorted thinking

• Altered consciousness

• Alterations of affect

10

Bleular's 4 A's

Autism - preoccupation with the self with little concern for external reality

Associative looseness - the stringing together of unrelated topics

Ambivalence - simultaneous opposite feelings

Affective disturbance - inappropriate, blunted, or flattened affect

11

Positive Symptoms- recognizable

• Positive (type I) symptoms; delusion (fixed false beliefs), hallucination (false perception)

• Excess dopamine in the limbic system -> embellishments of normal cognition and perception

• Responsive to antipsychotics

12

Negative Symptoms- what is missing

• Lack of affect or energy• Attribute to cortical dysfunction ie atrophy,

decreased cerebral blood flow, increased ventricular brain ratios, and a hypodopaminergic state.

• Overactive glutamate in the prefrontal cortex stimulates dopamine receptors in the limbic area

• Secondary to medications, hospitalization, loss of social support, and economic decline…

13

Diagnostic criteria

• S & S - At least 2 of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms

• Social/occupational dysfunction

• Duration - continuous signs of the disturbance for at least 6 months

• Not caused by substance abuse or a general medical disorder

14

Prodromal symptoms

• A month or a year before the onset• Deterioration in previous functioning,

withdrawn from others, lonely, depressed• Vague plan for the future• Neurotic symptoms ie. Ac /chr anxiety,

phobia, difficulty in concentration, misinterpretation,

• Feelings of rejection, lack of self-respect,

15

Subjective Signs

• Reported by the client

• Altered perceptions, thought processes & content, consciousness, and affect

• May induce the pt to seek psychiatric help

16

Alterations in thinking

• Thought broadcasting• Thought insertion• Thought withdrawal• Delusions of being controlled• Delusion of persecution, grandeur,• Ideas of reference, somatic delusions, • Associative looseness; neologisms; concrete

thinking; echolalia; clang association; word salad

17

Alternations in Perception, behavior

• Hallucinations – auditory, visual, olfactory, gustatory, tactile

• Bizarre behavior – extreme motor agitation, stereotyped behavior, automatic obedience, waxy flexibility, stupor, negativism

• Agitated behavior – poor impulse control

18

Objective Signs

• Observed directly by nurse

• Altered relationships, hygiene, social skills, communication, and psychomotor activity

• Frighten others may lead to involuntary psychiatric intervention

19

Subtypes of schizophrenia• Paranoid - preoccupied with one or more de

lusion

• Disorganized - disorganized speech, behavior; poor attention; inappropriate affect

• Catatonic - waxy flexibility or purposeless excessive motor activity, mutism, stupor

• Undifferentiated -

• Residual - negative symptoms.

20

Other psychotic disorders

• Schizoaffective disorder – Scho symptoms are dominant + major manic or depressive symptoms

• Delusional disorder – delusions have basis in reality, but no schizo

• Brief psychotic disorder – psychosis lasts less than 1 M

• Schizophreniform disorder – 6M < - > 1M

21

Nursing diagnoses

• Altered nutrition: less than body requirements• Risk for violence directed at self or others• Self-care deficit: feeding, bathing, dressing/

grooming, toileting• Noncompliance with medications• Ineffective individual/ family coping• Self-esteem disturbance• Altered thought processes

22

Psychotherapeutic management

• Provide supportive care

• Strengthen patient’s self-esteem

• Treat patients as adults

• Prevent failure/ embarrassment

• Respect individuality - unique

• Reinforce reality

• Handle hostility calmly & matter-of-factly

23

Issues related to Schizophrenia

• Family ⇔ the patientcommunication, overprotection, blaming

• Non-compliance with medical regimen

• Caregiver’s needs - cope with strange and frightening behaviors ie. apathy, poor personal hygiene, violence

24

Issues related to Schizophrenia (II)

• Depression - part of the symptoms, be masked during acute stage

• Relapse - stressors, noncompliance

• Stress & coping -

• Substance abuse -30% have dual Dx., cause (-) effect on the treatment & poor outcomes

• Work - no work, inability, no motivation

25

Depression and Suicide in Schizo

• Depression is a natural part of schizo

• Depression can be masked especially during the acute phase

• Depression is a reaction to schizo

26

Delusion & Nursing Intervention

• presenting reality, orient pts to time, person & place

• avoid argument, touch, competitive activities,

• reinforce positive behaviors

• encourage verbalization

27

Disruptive Behavior• Set limit• decrease environmental stimuli• intervention before acting out• close observation• safety environment - minimize potential

weapons• making contract with the client• using restraints

28

Withdrawn Patients• arrange nonthreatening activities

• encourage participation - seating

• provide remotivation and resocialization group experience

• reinforce appropriate grooming and hygiene

• provide psychosocial rehabilitation - social skill training, ...

29

Suspicious Patients

• Be matter-of-fact; (ie DST for depression)

• avoid close physical contact - no touch

• be consistent in activities

• offer special food

• avoid whisper

• Maintain eye contact

30

Hyperactivity Patients

• Allow pt to stand for a few min in group

• Provide a safe environment

• Provide activities that do not require fine motor skills

31

Immobility Patients

• Minimize circulatory problem

• Provide adequate diet, exercise, and rest

• Prevent victimization

32

Nursing interventions

• Medication compliance- 40-60% noncompliance• Avoid reinforcing hallucinations & delusion• Maintain orientation• Use touch minimally and judiciously• Avoid easily misinterpreted behavior• Reinforce positive behaviors• Avoid competitive activities, • Allow & encourage expression of feelings

33

Nursing interventions- Milieu management

• clear & realistic limits; consistency; • Supportive environment – structured, predictable• reduced stimulation• early intervention for escalating behavior• safety for the pt and others• opportunity for nonthreatening social interaction• remotivating and resocializing group• Communication skills

34

Nursing interventions –Family therapy

• Involve the family – use appropriate community resources

• Educate the family – chr. dis, S/S of relapse, med compliance,

• Provide an outlet for the family – discuss feelings, explore alternative effective coping skills.

35

Psychotherapy

• Individual Th – supportive therapy

• Group Th – interpersonal skills, family problems, community support

• Family Th – expand social network, problem-solving capacity, lower the emotional overinvolvement of families

36

Case Management

• Limited hospital stay, 3rd party payment

• Discharge planning – transitional care

• Partial hospitalization, halfway houses, day treatment programs

• Community resources – NAMI, Schizophrenics Anonymous, …

37

Schizophrenia & violence

• Myth - tends to be violent – perhaps perpetuated by the media

• Fact- more likely to be victims than perpetrators of violence

• Violence in this population may be r/t homicidal delusion

38

Schizophrenia and comorbidities

• Hypertension, obesity, and diabetes -> death from cardiac disease is higher than in the

• Atypical medications create weight gain, worsening cholesterol and triglycerides levels and diabetes

• Tobacco use, smoking -> heart disease

39

The Negative Impact of Severe Mental Illness

• Impairment – hallucination, depression

• Dysfunction – lack of work adjustment skills, social skills, or ADL skills

• Disability – unemployment, homelessness

• Disadvantage – discrimination, poverty

40

Nurse’s feelings & self-assessment

• Pt’s anxiety, loneliness, dependence, distrust -> N’s uncomfort

• Feelings of helplessness -> anxiety -> defensive behaviors ie denial, withdrawal, avoidance -> burnout

• Peer group supervision can be helpful

• Periodic reassessment of Tx goals,

41

Family/care taker education

• Teaching about the disease –S/S• Medication teaching and side-effect

management• Cognitive & social skills enhancement• Identifying signs of relapse• Attention to deficit in self-care, social and

work functioning• Exploration of community resources

42

Signs of Potential Relapse

• Feeling of tension

• Difficulty concentrating

• Trouble sleeping

• Increased withdrawal

• Increased bizarre/ magic thinking

43

Schizophrenia - overview• Diagnosis - criteria

• Prevalence - age and gender

• Course of illness - phases, warning signs

• Medication management - side effect, coping

• Psychosocial rehabilitation - ind, gr, fam…

• Community resources

• Stress management

44

Review of antipsychotics

• Typical & atypical med/ type I & II S/S• Clozaril – arrhythmia, agranurocytosis• Anticholinergic drugs -> memory impaired• High-potency -> EPSEs, NMS• Low-potency drugs -> anticholinergic symptoms• Half-life of the medication – safety, elderly• Reduced rate of relapse (about 2.5 times less)

45

Care of Hallucinations & Delusions

• Hallucinations– Content of hallucination – commanding H

-> suicidal or homicidal– N’s attitude – nonjudgmental, nonthreatening– Eye contact, louder voice, call the person by name

• Delusion – Be empathic - Clarify the reality of the pt’s intent– Clarify misinterpretations of the environment– No argument

46

Great wall, China