Colegio de Sta. Lourdes of Leyte Foundation, Inc. College of Nursing Tabontabon, Leyte

SCHIZOPHRENIA

we will cover the ff:

What is schizophrenia? Epidemiology Cause/s Criteria for diagnosis Types of Schizophrenia Prognosis Symptoms of schizophrenia (+) (-) Types of schizophrenia Treatment (psychopharma and psychosocial tx) Therapeutic communication for schizophrenic Management ( utilizing the nursing process) Future Direction in the treatment of schizophreniaj

Schizophrenia

- A disorder characterized by disturbance in thought, sensory perception, grossly disorganized behavior , and deterioration in psychosocial functioning. Main problem: Altered thought process.

Epidemiology

1% of population world wide Males and females equally affected but females have later onset and better functional outcome Onset in late adolescence, early adulthood

CAUSES

Genetics

Highly heritable Risk increases with relationship e.g. 10% for first degree relative or fraternal twin, 50% concordance for monozygotic twin

Genetic Risk

Obstetric Complications

Stress and reduction in brain oxygen during:pregnancy labor & delivery

Evidence from animal models:

Fetal hypoxia leads to neuropathology similar to one observed in schizophrenia:Enlarged ventricles (reduced brain weight)

Most predictive for those without genetic influence

PSYCHOLOGIC or EXPERIENTIAL THEORY

Double bind communication - 2 messages that contradict each other is sent causing the child to be confused Poor mother and child relationship

Environmental or Sociocultural THeory

Single parent Low socio economic status

Most Acceptable Theory on the Cause of Schizophrenia:

Biologic Theory schizophrenia is due to the increased dopamine.

DOPAMINEFunction:For motor movements, sensory integration, and emotional behaviors.

Increased = schizophrenia and mania Decreased = parkinson s disease and depression

Alterations in dopamine neurotransmission

The classical dopamine hypothesis (too much dopamine in schizophrenia) rested on the observation that dopamine releasing drugs can cause psychosis, and the discovery that antipsychotics were dopamine antagonists.

Diagnosis

Currently there is no physical or lab test that can absolutely diagnose schizophrenia. A psychiatrist usually comes to the diagnosis based on clinical symptoms.

Types of Schizophrenia: 1. Schizophrenia, paranoid type characterized by persecurity or grandiose delusions, hallucinations, and occasionally excessive religiosity or hostile or aggressive behavior. 2. Schizophrenia, disorganized type characterized by grossly inappropriate or flat affect, incoherence, loose associations, & extremely disorganized behavior.

3. Schizophrenia, catatonic type characterized by marked psychomotor disturbance either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echpraxia. 4. Schizophrenia, undifferentiated type characterized by mixed schizophrenic symptoms along with disturbances of thought, affect, and behavior.

5. Schizophrenia, residual type characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations.

Types:CATATONIC DISORGANIZED Acute Insidious Abnormal motor behavior Repression Impaired motor activity Good Bizarre behavior PARANOID Abrupt Suspiciousness ideas of reference Projection Potential for injury directed at others Good

Onset Distinguishing feature Defense mechanism Priority nursing diagnosis Prognosis

Regression Impaired social functioning Poor

Other Types: Undifferentiated Patients whose manifestations cannot be easily fitted into one or the other types. Residual Patient with minimal symptoms Prognosis:Favorable Prognosis 1. 2. 3. 4. Good socialization. Late/acute onset Adequate support system. Family history of mood disorder. Unfavorable Prognosis 1. 2. 3. 4. Poor/no socialization. Early & insidious prognosis Few/no support system History of chronicity/ many relapses.

Fundamental Signs and Symptoms (Bleulers 4 As of Schizophrenia) 1. Associative looseness 2. Autistic thinking 3. Ambivalence 4. Affect

Two Major Categories of Signs & Symptoms:Positive/Hard Symptoms: Negative/Soft Symptoms:

1. Delusions 2. Hallucinations 3. Grossly disorganized thinking, speech, & behavior 4. Ambivalence 5. Associative looseness 6. Echopraxia 7. Perseveration

1. Flat affect 2. Lack of volition 3. Social withdrawal or discomfort 4. Flat affect 5. Alogia 6. Anhedonia 7. Apathy 8. Blunt affect

Positive Symptoms

Those that appear to reflect an excess or distortion of normal functions.

FYI: Positive Symptoms

Positive symptoms are those that have a positive reaction from some treatment. In other words, positive symptoms respond to treatment.

Negative Symptoms

Those that appear to reflect a diminution or loss of normal functions. May be difficult to evaluate because they are not as grossly abnormal as positive symptoms.

Examples of Avolition

No longer interested in going out with friends No longer interested in activities that the person used to show enthusiasm No longer interested in anything Sitting in the house for hours or days doing nothing

FYI: Negative Symptoms

Currently there is no treatment that has a consistent impact on negative symptoms. Although atypical neuroleptics is considered to lessen negative signs ( like lack of volition and motivation, social withdrawal)

General Signs & Symptoms: S-ocial isolation C-atatonic behavior H-allucination I -ncoherence or marked looseness of association Z-ero/lack of interest, energy & initiative O -bvious failure to attain expected levels of development P -eculiar behavior H-ygiene & grooming are impaired R-ecurrent illusions & unusual perceptual experiences E-xacerbation & remissions are common N-o organic factor accounts for the signs and symptoms I-nability to return to baseline functioning after each relapse A -ffect is inappropriate

ATYPICAL ANTIPSYCHOTICS

Clozapine (Clozaril) Risperidone (Risperdol) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Geodon, Clozapine, Risperidone, Seroquel, Zyprexa. [Remember: A giraffe can really see a zebra]

TREATMENT: Psychopharmacology: Antipsychotic drugs / neuroleptics Conventional / Typical Chlorpromazine (Thorazine) Trifluoperazine (Trilafon) Fluphenazine (Prolixin) Thioridazine (Mellaril) Mesoridazine (Serentil) Thiothixene (Navane) Haloperidol (Haldol) Loxapine (Loxitane) Molindone (Moban) Perphenazine (Etrafon) Trifluoperazine (Stelazine)

- Mechanism of action: > Block receptors for the neurotransmitter dopamine. - Side Effects: A. Extrapyramidal Side Effects (EPS) a. Dystonia -torticollis, oculogyric crisis, protrusion of the tongue Txt: Diphenhydramine (Benadryl), Benztropin (Cogentin) b. Pseudoparkinsonism shuffling gait, masklike face, drooling, muscle stiffness, akinesia

Txt: Benztropin(Cogentin),Trihexyphenidyl(Artane),Biperid en (Akineton), Amantadine (Symmetrel), Diphenhydramine (Benadryl), Diazepam (Valium), Lorazepam (Ativan), Propanolol (Inderal)c. Akathisia restless movement, inability to remain still Txt: Betablockers - Propanolol( Inderal) B. Neuroleptic Malignant Syndrome (NMS) - Rigidity, high fever, autonomic instability, delirium, confusion.

C. Tardive Dyskinesia characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, choreiform movements, of the limbs and feet. D. Seizures E. Agranulocytosis characterized by fever, malaise, ulcerative sore throat, leukopenia.

CLIENT TEACHING AND MEDICATION MANAGEMENT: ANTIPSYCHOTICS Drink sugar free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth. Avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. Constipation can be prevented or relieved by increasing intake of water and bulk-forming foods in the diet and by exercising. Stool softeners are permissible, but laxatives should be avoided. Use sunscreen to prevent burning. Avoid long periods of time in the sun, and wear protective clothing. Photosensitivity can cause you to burn easily.

Rising slowly from a lying or sitting position will prevent falls from orthostatic hypotension or dizziness due to a drop in blood pressure. Wait until any dizziness has subsided before you walk. Monitor the amount of sleepiness or drowsiness you experience. Avoid driving a car or performing other potentially dangerous activities until your response time and reflexes seem normal. If you forget a dose of antipsychotic medication, take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, omit the forgotten dose. If you have difficulty remembering your medication, use a chart to record doses when taken, or use a pill box labeled with dosage times and/or days of the week to help you remember when to take medication.

The most common side effect for all antipsychotics is drowsiness Many of the antipsychotics block the chemoreceptor trigger zone and vomiting (emetic) center in the brain producing an antiemetic effect. Due to blocking dopamine, extrapyramidal reactions or symptoms of Parkinsonism, such as tremors, mask like face, rigidity and shuffling gait may occur.

Other extrapyramidal reactions include acute dystonia (facial grimacing, abnormal or involuntary eye movement), akathisia (restlessness, constant moving about), and tardive dyskinesia (protrusion of tongue, chewing motion, involuntary movement of the body and extremities). Tardive dyskinesia is a later phase of extrapyramidal reaction to antipsychotic drugs.

The drug is used to control psychosis and decrease signs of agitation in adults a well as in children. Haloperidol has anticholineric activity; thus care should be taken in administering it to clients with history of glaucoma. Most antiparkinsonism anticholinergics are not always effective for tardive dyskinesia Haloperidol alters the effects of dopamine by blocking the dopamine receptors; thus sedation andEPS may occur.

Medications

In general it may take up to 6 months for medications to show consistent effects. Meds include atypicals

Psychosocial Treatment: 1. Individual & group therapy. 2. Family therapy 3. Family education 4. Social skills training a. Basic model breaking complex social behavior into simpler steps. b. Social problem-solving model focus on improving impairments in the information processing that are processed to cause deficits in social skills. c. Cognitive remedial model focus on improving cognitive impairments.

Basic Intervention Strategies for Developing a Therapeutic Nurse-Patient Relationship:1. Do not reinforce hallucinations or delusions. 2. Orient patients to time, person, and place if indicated. 3. Do not touch patients without warning them. 4. Avoid whispering or laughing when patients are unable to hear all of a conversation. 5. Reinforce positive behaviors. 6. Avoid competitive activities with some patients. 7. Do not embarrass patients. 8. For withdrawn patients, start with one-to-one interactions. 9. Allow to encourage verbalization of feelings.

Early detection and treatment has the best results/response to treatment. Per patients, once you have schizophrenia you have it for life. The best you can hope for is control.

Nursing Management of Schizophrenia

ASSESSMENT

1. Assessing mood and cognitive state:The nurse is alert for the ff signs and symptoms : Absence of expression of feelings Language content that is difficult to follow Pronounced paucity of speech and thoughts Preoccupation with odd ideas Ideas of reference Expression of feelings of unreality Evidence of hallucinations such as comments that the way they things appear, sound, or smell is different

2. Assessing potential for violence:The nurse assess the potential for violence by inquiring about the following: History of violent or suicidal behavior Extreme social isolation Feeling of persecution or being controlled by others. Auditory hallucinations that tells the client to commit violent acts. Concomitant substance use. Medication noncompliance Feelings of anger, suspiciousness, or hostility.

4. Assessing knowledge

nurse assess the client's and families knowledge of schizophrenia, its treatment, and the potential for relapse. Adherence to medication regimens and other therapeutic schedules is bolstered when clients and families understand the biologic basis of the illness, signs of recovery and relapse, and their role in treatment.The

3. Assessing social support:

Availability and responsiveness of a social support network and the client's role in the family and community are important factors in nursing assessment

NURSING DIAGNOSIS:

1. Disturbed thought process

related to biochemical imbalances, as evidenced by hyper vigilance, distractibility, poor concentration, disordered thought sequencing, inappropriate responses, and thinking not based in reality.

2. Disturbed sensory perception( auditory/visual) related to biochemical imbalances, as evidencd by auditory or visual hallucinations.

3. Risk for other- directed or self directed violence related to delusional thoughts and hallucinatory commands, history of childhood abuse, or panic,as evidencedby overt aggressive acts, threatening stances, pacing, or suicidal ideation or plan.

4. Social isolation related to alterations in mental status and an ability to engage in satisfying personal relationships, as evidenced by flat affect, absence of supportive significant others, withdrawal, uncommunicativeness and inability to meet the expectations of others.

5. Noncompliance with medication regimen related to health beliefs and lack of motivation, as evidenced by failure to adhere to medication schedule.

6. Ineffective coping related to disturbed thought process as evidenced by inability to meet basic needs.

7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals. 7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals.

8. Risk for ineffective family management of therapeutic regimen related to knowledge deficit and complexity of client,s healthcare needs.

Nursing Interventions

Disturbed Thought Processes

Convey acceptance of client's need for false belief but that you do not share the belief Do not argue or deny the belief Reinforce and focus on reality If client is suspicious Consistent staff Honest, keep all promises

Disturbed Sensory Perception Auditory/Visual

Observe for signs of hallucinations Avoid touching client without warning Do not reinforce the hallucination let the client know that you do not share the perception - "Even though I know the voices are real to you, I do not hear them" Help client understand connection between anxiety and hallucinations Try to distract

Social Isolation

Convey accepting attitude by making brief, frequent contacts. Show unconditional positive regard Offer to be with client during group activities that he/she finds frightening Give recognition and positive reinforcement for client voluntary interactions with others

Self Care Deficit

Provide assistance as appropriate Encourage independence positive reinforcement concrete communications

Impaired verbal communication

Seek validation and clarification Consistent staff Verbalizing the implied Orient to reality

Future Directions in the Treatment of Schizophrenia

More optimistic view of outcome Much stronger focus on early intervention and prevention e.g. early psychosis clinics and prodromal studies Specific treatments for cognition in schizophrenia As molecular pathways associated with neural phenotypes become understood new, non dopamine based therapies Renewed emphasis on rehabilitation, supported employment etc.

Related Disorders: 1. Schizophreniform disorder The client exhibits the symptoms of schizophrenia but for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. Social or occupational functioning may or may not be impaired. 2. Schizoaffective disorder The client exhibits the symptoms of psychosis and at the same time, all the features of a mood disorder, either depression or mania.

3. Delusional disorder The client has one or more nonbizarre delusions that is, the focus of the delusion is believable. Psychosocial functioning is not markedly impaired, & behavior is not obviously odd or bizarre. 4. Brief Psychotic Disorder The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. The episode may or may not have an identifiable stressor or may follow childbirth.

5. Shared psychotic disorder (folie deux) Two people share a similar delusion. The peron with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions.

Situation: Manny Kin is a 23-year-old graduate student who has just been admitted to the unit with behaviors of withdrawal, flat affect, disregard of hygiene & grooming, and associative looseness. His diagnosis is paranoid schizophrenia. 1. Which of the following is not characteristic of the patient with paranoid schizophrenia? a. Delusions b. Hallucinations c. Decreased sensitivity d. Ideas of reference

2. Which defense mechanism is most characteristic of the patient with paranoid schizophrenia? a. Undoing b. Projection c. Rationalization d. Suppresion

3. Thiodazine (Mellaril), an antipsychotic, is usually effective in treating all but one of the following symptoms of schizophrenia. Which symptom will not be affected by this drug? a. Agitation b. Hallucinations c. Delusions d. Ambivalence

4.The nurse is caring for a patient with disorganized schizophrenia. The patient is responding well to therapy but has had limited social contact with others. Which of the following interventions is most appropriate? a. Discourage the patient from interacting with others because if his efforts fail it will be too traumatic to him. b. Encourage the patient to attend a party thrown for the residents of the facility. c. Encourage the patient to participate in one-on-one interactions. d. Encourage the patient to place a personal advertisement in the local newspaper but not reveal his main disability.

5. A 23-year-old female has been admitted to the inpatient psychiatric unit with diagnosis of catatonic schizophrenia. She appears weak & pale. The nurse would expect to observe which behavior in this patient? a. Scratching cat-like motions of the extremities. b. Exaggerated suspiciousness, excessive food intake. c. Stuporous withdrawal, hallucinations & delusions. d. Sexual preoccupation, word salad.

http://www.youtube.com/watch?v= eKhOVaY-YNo&NR=1 http://www.youtube.com/watch?v= HEKxWzvoD7M&feature=related