Ch 31

Schizophrenia and Other Psychoses

http://www.npr.org/programs/atc/features/2002/aug/schizophrenia/

http://www.medicalview.com/Topic.asp?ProgID=62&CatID=0#

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Psychoses

• The inability to recognize reality, relate to others or cope with life’s demands

Schizophrenia

• Most common psychosis• Group of related disorders characterized

by disordered thinking, perceptions and behaviors

• Other psychotic disorders– Delusional disorder– Drug related psychosis– Brief psychotic disorder

Continuum of Neurobiological Responses

• Adapting to environment – able to use logical thought, have clear perceptions and able to socially relate in appropriate ways

• Not adapting (middle)-function within reality but have emotional overreactions, distorted thoughts or odd behaviors

• Maladaptive- hallucinations, inability to experience emotions

Psychoses in Childhood• Processing or combining information is a

near impossible task.• FTT-related to neglect, environmental

problems or severe family stress• Psychosis can occur as young as 5• Etiology unknown – 3 risk factors

– Genetics – parents,siblings, relatives– Complications during pregnancy or birth – flu

virus exposure during 2nd trimester– Biochemical influences - dopamine

• Signs and Symptoms vary• Core behaviors

– Lack of contact with reality– Withdrawal into world of their own– Impaired ability to process visual information, regulate

attention and sort out incoming info– Affect changes– Language and communication disturbances– Problems with motor control, emotional control and

expression

Psychoses in Adolescence• Ups and downs intensified• Family members may note changes in behavior• Poor hygiene , grooming habits poor• Strange vague speech and lack of interest lead

to social withdrawal• Hoarding, talking to self• Thoughts and beliefs may be bizarre• Unusual superstitions• Belief in telepathy• Belief one is remotely controlled• Self injury and self destructive behaviors arise

• First treatment is inpatient for assessment, monitoring and controlled

• Interventions focus on– Decreasing acute symptoms– Improving relationships– Education

Psychoses in Adulthood

• Onset often men middle 20s• Women late 20’s• Men endure longer before seeking help• 1/3 persons improve with treatment• 1/3 improve without treatment• 1/3 progress into chronic course with or

without treatment

• Prognosis – outlook is better if adaptive interpersonal relationships, school performance and work histories were present before the onset of symptoms

• Outlook better for women• Men have higher relapse rates and spend

more time inpatient

• Length of stays are shorter – individuals with schizophrenia return home while still psychotic requiring observation and support

• Parents struggle with guilt and frustration attempting to understand “why”

• Grieve losing the ‘normal child’

Older Adulthood

• Seldom diagnosed at this age• Possible onset 40s and 50s• Many elders suffer irreversible side effects from

long term antipsychotic use• Hallucinations/delusions of younger years often

disappear• Become more withdrawn or paranoid• Frequently homeless• End of life in nursing facilities

Biological Theory

• Brain disorder evidence rising• Neurochemical production and transmission

problems are being investigated • Stress/disease/trauma- effects of stress during

prenatal period, viral infection, severe malnutrition

• Birthing difficulty contributes-long labor, difficult birth, umbilical cord prolapse

• Cocaine use

Psychological model

• Character flaw with poor family relationships

• Overprotective or anxious mothers• Cold, uncaring fathers• Couples who stayed together for the sake

of the children• Failure to accomplish task trust or intimacy

Sociocultural theory

• Effects of environment• Poverty, homelessness, unstable families

Subtypes

• Catatonic• Disorganized• Paranoid• Undifferentiated• Residual

Signs and Symptoms

• Physical appearance- – Unkempt– Focus on inner matters– Personal hygiene is poor – Body images are distorted– Motor activity ranges agitated to immobile

• Hallucinations-false sensory inputs with no external stimuli– Olfactory– Auditory– Gustatory– Visual– Tactile– Feelings of altered internal workings of the

body• Illusions- false perceptions of real stimuli• Agnosia-inability to recognize familiar

objects or people is common

• Problems with attention, memory and use of language

• Delusions-fixed false ideas not based in reality

• Ideas of reference-people or media are talking about oneself

• Derealization-loss of ego boundaries with inability to tell where one’s body ends nad the environment begins

• Speech-– Clang associations– Concrete thinking– Echolalia– Flight of ideas– Loose associations– Ideas of reference– Mutism– Neologisms– Verbigerations– Word salad

• Perseveration-repeating of the same idea in response to different questions

• Poverty of thought-lack of ability to produce new thoughts or follow a train of thought

• Little insight into illness, poor judgment• General decline in intellectual abilities as

the disorder progresses

s

• Blunted or flat affect• Alexithymia- difficulty in identifying and

describing emotions• Apathy- lack of concern interest , feelings • Anhedonia- inaibility to experience

pleasure in life• Little impulse control• Anger management is poor

• Avolition- lack of energy or motivation• Substance abuse – dual diagnosis• Unable to establish or maintain

relationships with others• Self esteem is low and gender identity

confusion may exist• Social behaviors are inappropriate

• Positive symptoms- r/t maladaptive thoguhts and behaviors– Hallucinations, speech problems, bizarre

behaviors• Negative Symptoms-lack of adaptive

mechanisms– Flat affect, poor grooming, withdrawal, poverty

of speech

Phases of Disorganization• Prodromal- withdrawal, lack of energy, little

motivation, complain about multiple physical problems– Ideas beliefs and become odd , unusual– Hygiene ignored – Agitated and angry

• Prepsychotic phase- quite , passive and obedient– Hallucinations, delusions may be present– Slip away

• Acute – disturbances in thought, perception, behavior and emotion

• Residual phase- lack of energy, no interest in goal directed activities

• Remission-manage basic ADLs, relief from some distresses of psychosis

Other• Brief psychotic disorder-lasts more than one day

but less than a month

• Delusional Disorder- more than one month of nonbizarre reality based fixed ideas

• Shared Psychotic-disturbance that develops in an individual who is influenced by someone else who has an established delusion with similar content

• Schizoaffective-diagnosed when depression and mania are present

Treatment and Therapies

• Combination therapy and medications• Stress reduction• Family education• Early intervention

Pharmacological Therapy

• Antipsychotics – slow the CNS system– Emotional quieting, sedation, slowed motor

responses– Interrupt dopamine

• Neuroleptics

Nursing Process

• Basic goal- assist clients in controlling their symptoms and achieving highest possible level of functioning

• EPS- abnormal involuntary movement disorder

• Akathisia- inability to sit still, nervous and jittery, lots of nervous energy

• Akinesia-absence of movement • Bradykinesia-slowing of body movement, do not

try to move or speak• Dyskinesia-involuntary skeletal muscle

movements, jerking, affect gait• Dystonia-impaired muscle tone, rigidity

– Oculogyric – eye rolls into back of head– Torticollis-force face and neck into twisted position

• Laryngeal-pharyngeal dystonia- muscles of neck and throat become rigid , client begins to gag, choke and become cyanotic

• Treated with anticholinergic drugs

NMS

• Neuroleptic malignant syndrome• Death can occur from resp. failure, renal

failure, aspiration pneumonia, PE• Cardinal sign is high body temp• Tachycardic, changes in BP, incr.

perspiration, incontinence, rapid labored respirations

TD

• Irreversible side effect of long term treatment

• Involuntary repeated movements of muscles of the face, trunk, arms and legs

Anticholinergic Effects

• Hypotension• Protect from falls

Nursing Responsibilities

• Oil vs water based injectables• Monitor client responses to meds• Client and family education