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6 Schizophrenia

6 Schizophrenia

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Published by: Armando on Jun 12, 2009
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 Biologically based disorder that is psychosocially devastating  Exists in all cultures and socioeconomic groups  Characterized by overt psychosis
– A state in which one’s capacity to recognize reality is limited or absent

 Genetics
– Twin studies show 46% concordance rate in monozygotic twins; 30% in dizygotic twins – 1% of general population – 10% sibling

 Neuroanatomical
– Enlarged ventricles, cortical atrophy, smaller frontal lobes, defects in limbic brain structures – Decreased metabolic activity and slower brain waves in the frontal lobe

 The dopamine hypothesis is the major NT hypothesis for schizophrenia
– Theory states that there is too much Da in schizophrenia

 Some research suggests that Da and 5-HT may be involved  Other research has focused on the excitatory NT glutamine, as PCP affects this NT and produces a psychotic state

Neurotransmitters (cont)
 NE may be insufficient in clients with schizophrenia displaying anhedonia  A deficiency in cholecystokinin may be related to avolition and flat affect  Given the complexity of schizophrenia, it is unlikely that a disturbance in a single neurotransmitter system is the cause

Birth and Pregnancy Complications
 Infants born with a hx of pregnancy or birth complications have increased risk of developing schizophrenia  Infections during pregnancy, poor nutrition during pregnancy, or exposure to toxins could damage neurons or affect NTs in the fetus

Psychodynamic Theories
 Psychoanalytic/Developmental
– Anxious mothering….
 Child is unable to progress beyond dependence  Affects ego organization and the child’s interpretation of reality  The individual is then susceptible to living in a fantasy world in which hallucinations and delusions attempt to create a reality

Psychodynamic Theories (cont)
 Cultural/Environmental
– Schizophrenia is disproportionately represented in the lower socioeconomic group
 Downward drift hypothesis—clients with schizophrenia who possess low social skills either move into a lower socioeconomic group or fail to move to a higher one

– Other social scientists believe that the stress of living in a lower socioeconomic group is often enough to trigger

 1% prevalence rate  Onset generally in adolescence and early adulthood—females have an older age of onset  Comorbidities
– 1/3 to 2/3 substance abuse – 1/3 to1/2 mood disorders

Medical Comorbidities
 90% of schizophrenics are smokers
– Smoking related pathology – Obesity – STDs; viral hepatitis – Suicide—10% accomplish

Social and Economic Difficulties
     70-80% unemployment rate 20% marriage rates 1/3 are homeless Legal issues—end up in jail Poor satisfying social relationships

DSM-IV Criteria
 A. Two or more of the following, each present for a significant portion of time during a 1month period:
– – – – – Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms (flat affect, alogia, or avolition)

 B. Social or occupational impairment  C. At least 6 months in duration

DSM-IV Criteria
 D. Exclusion of Schizoaffective d/o or mood d/o  E. Exclusion of substance or general medical condition  F. If there is a hx of autistic disorder or another pervasive developmental d/o, the additional dx of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month

Schizophrenia Subtypes
     Paranoid Disorganized Catatonic Undifferentiated Residual

 Delusions tend to be persecutory or grandiose  Auditory hallucinations are common and are r/t the delusionary theme  In the active phase of this d/o, the afflicted individual is extremely ill and may be dangerous to self or others  Better prognosis than the other subtypes

Early insidious onset; childish affect Characterized by disintegration of personality Speech is disorganized—word salad, incoherent speech, and clanging  Behavior is odd—grimacing, grunting, sniffing, posturing, rocking, uninhibited sexual behaviors  Poor personal grooming; often unable to complete ADLS  Poor prognosis   

 Predominant feature is intense psychomotor disturbance--psychomotor retardation or excitation  Manifestations include waxy flexibility, mutism, and negativism  Other sx include echopraxia (imitating the movements of others), echolalia (repeating what was said by another), grimacing, and stereotypic movements  Delusions often persist throughout the withdrawn state  Prognosis varies

 Has aspects of each type-- paranoid, disorganized, and catatonic  Prognosis is poor with a chronic course

 An individual has had at least 1 acute episode of schizophrenia  The individual is now free of prominent positive sx but has some negative sx  The prognosis is varied and unpredictable

Clinical Symptoms of Schizophrenia
 Perceptual
– Hallucinations
 Auditory—may be commanding; content matches delusions  Visual  Tactile—may feel like being surrounded by spider webs  Olfactory and gustatory—client may refuse to eat because food seems to smell or taste bad

– Illusions
 False perceptions due to misinterpretations of real objects

Clinical Symptoms of Schizophrenia (cont)
 Cognitive
– Delusions—false beliefs that are fixed and resistant to logic
 omnipotence; persecution; controlling or being controlled

– Derealization—feeling that the world around one is not real or distorted – Ideas of reference—notion that other people or the media is talking to or about

Clinical Symptoms of Schizophrenia (cont)
 Cognitive
– Incorrect use of language
 Neologisms—invented words  Incoherence  Echolalia or word salad  Concrete, restricted vocabularies  Looseness of associations—frequent change of subject; not related to content of conversation

– Flight of ideas—abrupt change of topic in a rapid flow of speech; seen more in mania

Clinical Symptoms of Schizophrenia (cont)
 Emotional
– Labile affect
 Apathy, dulled response  Flattened affect  Reduced responsiveness  Exaggerated euphoria  Rage

– Inappropriate affect
 Laughing at sad events

Clinical Symptoms of Schizophrenia (cont)
 Behavioral
– Little impulse control
 Response to command hallucinations  Sudden scream as a protest to frustration

– Inability to cope with depression
 Depressed client has 50% risk of suicide

– Inability to manage anger – Substance abuse as coping – Noncompliance with meds

Clinical Symptoms of Schizophrenia (cont)
 Social
– Poor peer relationships
 Preference for solitude

– Low interest in hobbies or activities – Loss if interest in appearance

Positive Hallucinations Delusions Disorganization Negative Avolition Alogia Anhedonia Flat Affect Ambivalence

Neurocognitive Impairment Attention Memory Exec Function

Positive Symptoms: Excess of Normal Functions
• Delusions (fixed, false beliefs)
– Grandiose – Nihilistic – Persecutory – Somatic

• Hallucinations (perceptual experiences) • Thought disorder • Disorganized speech • Disorganized or catatonic behavior

Negative Symptoms: Less Than Normal Functioning
• Affective blunting: reduced range of emotion • Alogia: reduced fluency and productivity of language and thought • Avolition: withdrawal and inability to initiate and persist in goal-directed behavior • Anhedonia: inability to experience pleasure • Ambivalence: concurrent experience of opposite feelings, making it impossible to make a decision

Neurocognitive Impairment
• Evidence that neurocognitive impairment exists, independent of positive and negative symptoms Neurocognition Impaired in schizophrenia
    Memory (short-, long-term) Vigilance (sustained attention) Verbal fluency (ability to generate new words) Executive functioning
– – – – volition planning purposive action self-monitoring behavior

  

Memory (working) Vigilance Executive functioning

Neurocognitive Impairment Often Seen as “Disorganized Symptoms”
• • • Confused speech and thinking patterns Disorganized behavior Examples of disorganized thinking
– – – – – – Echolalia (repetition of words) Circumstantially (excessive detail) Loose associations (ideas loosely connected) Tangentially (logical, but detour) Flight of ideas (change topics) Word salad (unconnected words)

Disorganized Symptoms
• Examples of disorganized thinking (cont.)
– Neologisms (new words) – Paranoia (suspiciousness) – References ( special meaning) – Autistic thinking (private logic) – Concrete thinking (lack of abstract thinking) – Verbigeration (purposeless repetition) – Metonymic speech (interchange words)

Disorganized Symptoms
• Examples of disorganized thinking (cont.)
– Clang association (repetition similar sounding words) – Stilted language (artificial, formal) – Pressured speech (words forced)

• Examples of disorganized behavior
– Aggression – Agitation – Catatonic excitement (hyperactivity, purposeless activity)

Disorganized Symptoms
• Examples of disorganized behavior (cont.)
– Echopraxia (imitation of others movements) – Regressed behavior – Stereotypy (repetitive, purposeless movements) – Hypervigilance (sustained attention to external stimuli) – Waxy flexibility (posture held in odd or unusual way)

Disorders Closely Related to Schizophrenia

Schizophreniform Disorder
 Characteristics same as schizophrenia with 2 exceptions:
– Duration
 At least 1 month but less than 6 months

– Impairment in functioning
 Social or occupational functioning may or may not occur with this d/o

Schizoaffective Disorder
 Presents with severe mood swings of either depression or mania and also with some of the psychotic sx  Most of the time, mania or depression coexists with the psychotic sx, but there must be a 2 week period in which there are only psychotic episodes  Onset usually occurs later in life than schizophrenia  Has a better prognosis than schizophrenia but a less positive prognosis than depression

 Depressed phase
– – – – – – – – – Poor appetite Weight loss Inability to sleep Agitation General slowing down Anhedonia Lack of energy Feelings of worthlessness Thoughts of death or suicide

 Manic phase
– Increase in social, work, or sexual activity – Increased talkativeness – Racing thoughts – Grandiosity – Decreased need for sleep – Increase in goal-directed activity – Inflated self-esteem – Involvement in selfdestructive activities

Symptoms (cont)
 Psychotic Sx
– Delusions – Hallucinations – Incoherence – Severely disorganized speech or thinking – Grossly disorganized behavior – Total immobility – Lack of facial emotional expression


Treatment Modalities
 Cornerstones of treatment are:
– Medication management—Antipsychotics – Psychosocial treatments

 Divided into 2 classes:
– Traditional or Typical – Novel or Atypical

Mechanism of Action
 Typical antipsychotics
– Dopamine receptor blockers—specifically D2 receptors – Da receptors are found in the following 3 areas of the brain: – The nigrostriatal pathway
 Blockade here produces EPS

– The mesolimbic pathway
 Blockade here reduces positve sx

– The mesocortical pathway
 Blockade here is thought to make negative sx of schizophrenia worse

Typical Antipsychotics
 Low-potency agents:
– Chlorpromazine (Thorazine)
 Dose/day 60-2000 mg

– Thioridazine (Mellaril)
 Dose/day 50-800 mg

– Mesoridazine (Serentil)
 Dose/day 50-500 mg

Typical Antipsychotics
 Moderate-potency agents:
– Perphenazine (Trilafon)
 Dose/day 8-64 mg

– Loxapine (Loxitane)
 Dose/day 20-250 mg

– Molindone (Moban)
 Dose/day 15-225 mg

Typical Antipsychotics
 High-potency agents:
– Fluphenazine (Prolixin)
 Dose/day 2-40 mg

– Thiothixene (Navane)
 Dose/day 5-60 mg

– Haloperidol (Haldol)
 Dose/day 1-100 mg

– Trifluoperazine (Stelazine)
 Dose/day 2-80 mg

Mechanism of Action
 Atypical antipsychotics
– Also block Da receptors – Block 5-HT to a greater degree than Da
 This causes an improved response of negative sx, improved cognitive functioning, and reduced EPS

Mechanism of Action
 Both typical and atypical antipsychotics vary greatly in their affinity for other receptors but may block:
– Histamine (H1) receptors—sedation – Cholinergic receptors—anticholinergic SE – Alpha receptors—hypotension and tachycardia

Side Effect Profile
 Low-potency drugs cause more sedation and hypotension  High-potency drugs cause more EPS  Drugs vary greatly in the amount of anticholinergic effects they cause
– Drugs that are more likely to cause EPS have < anticholinergic effects

Acute Dystonia
 Muscular spasm that may occur in up to 10% of clients  May effect different muscle groups
– Blepharospasm—eye closing – Torticollis—neck muscle contraction; pulling head to one side – Oculogyric crisis—severe upward deviation of the eyeballs

Acute Dystonia (cont)
 Anticholinergic drugs are rapidly effective in treating these sx  Severe presentations should be treated with IM injection  Examples of meds include:
– – – – Benzotrpine (Cogentin) Trihexyphenidyl (Artane) Diphenhydramine (Benadryl) Amantadine (Symmetrel)

Neuroleptic Induced Pseudoparkinsonism
 Results from imbalance between Da and Ach in the nigrostriatal pathway  Sx include:
– – – – – – – Tremors Bradykinesia/akinesia (slowness of movement) Cogwheel rigidity Shuffling gait Masked facies Hypersalivation and drooling Treat sx with anticholinergic drugs

 Presents with both objective and subjective components
– Objective sx include:
    Motor restlessness Pacing Rocking Foot tapping

– Subjective c/o include:
 Inner restlessness—tension, irritability, inability to sit or lie down

Akathisia (cont)
 Beta-blockers and benzos are the most common adjunctive Rxs
– Propanolol (Inderal) – Lorazepam (Ativan)

Tardive Dyskinesia
 Generally associated with long-term antipsychotic use  Irreversible  Characterized by choreoathetoid movements— rapid, jerky, and slow, writhing
– Clients generally experience involuntary movements of the mouth, tongue, and face – Arm, finger, leg, feet, and truncal movements are also noted

Neuroleptic Malingnant Syndrome (NMS)
 Potentially fatal reaction to antipsychotics  Characterized by:
– – – – – – – Muscular rigidity Hyperthermia Altered consciousness Autonomic dysfunction Leucocytosis Increased creatine phosphokinase Increased myoglobinuria

 Lab findings include:

Neuroleptic Malingnant Syndrome (NMS)
 Can occur at any time during Rx but is more frequent shortly after initiation of antipsychotics or dose increases  Underling pathophysiology is unclear—has to do with depletion of Da in basal ganglia

Neuroleptic Malingnant Syndrome (NMS)
 ***First D/C antipsychotic  Hydration and cooling are of major importance
– May also give muscle relaxant IV – Dantrolene or bromocriptine (Da agonists) can also be prescribed to relieve rigidity

Atypical Antipsychotics
 Clozapine (Clozaril)
– Dose/day 50-900 mg

 Quetiapine (Seroquel)
– Dose/day 100-800

 Olanzapine (Zyprexa)
– Dose/day 5-30

 Risperidone (Riperdal)
– Dose/day 4-8 mg

 Ziprasidone (Geodon)

 1st atypical antipsychotic  1st antipsychotic to demonstrate a significant improvement in negative sx  Use is restricted to the Rx of refractory schizophrenia secondary to SE  Blocks 5-HT more than Da
– Less EPS

Side Effects of Clozaril
 Life-threatening agranulocytosis
– Risk greatest in 1st 6 months of Rx – Weekly monitoring of the WBC count is necessary for the 1st 6 months of Rx followed by biweekly monitoring

 Seizures—dose-related SE  Others include: sedation, tachycardia, hypotension, GI upset, anticholinergic effects, and hypersalivation

 SE include:
– Anxiety – Rhinitis – Somnolence – Tachycardia – Mild weight gain

 SE include:
– Orthostatic hypotension – Dizziness – Constipation – Substantial weight gain

 Virtually no EPS  SE include:
– Orhtostatic hypotension – Tachycardia – Dizziness – Somnolence

     **Prolongs QTc interval Somnolence Hypotension Nausea Constipation

De-escalation Techniques
 Manage the environment  Show confidence and leadership  Encourage verbalization  Personalize yourself and show concern  Use breakaways  Using and removing seclusion and restraints  Documenting event  Debriefing session with staff

Communication Techniques with the Psychotic Patient
 Establish trust  Personal space  Soft tone of voice, open posture, not too much eye contact  Don’t argue with delusions  Present reality  Use diversions rather than confrontation  Allow patient to make own decisions when possible  Try to alleviate their fears due to misperceptions

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

Issues related to Schizophrenia
 Family ⇔ the patient
communication, overprotection, blaming

 Non-compliance with medical regimen  Caregiver’s needs - cope with strange and frightening behaviors ie. apathy, poor personal hygiene, violence

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

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

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

Delusion & Nursing Intervention
 presenting reality, orient pts to time, person & place  avoid argument, touch, competitive activities,  reinforce positive behaviors  encourage verbalization

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     

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, ...

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

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

Immobility Patients
 Minimize circulatory problem  Provide adequate diet, exercise, and rest  Prevent victimization

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

Nursing interventionsMilieu 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

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.

 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

Case Management
Limited hospital stay, 3rd party payment Discharge planning – transitional care Partial hospitalization, halfway houses, day treatment programs  Community resources – NAMI, Schizophrenics Anonymous, …   

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,

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

Signs of Potential Relapse
     Feeling of tension Difficulty concentrating Trouble sleeping Increased withdrawal Increased bizarre/ magic thinking

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

 Psychoeducation
– Teach that stressors can exacerbate sx – Inform pt on illness and meds

 Supportive Psychotherapy
– Goal is to support ego function—help them to get through this—gentle guidance and advice

 Milieu
– Calm environment; safety

 Symptom management
– Focus on prodromal sx—make pt aware that they need to recognize these sx for exacerbations

Family Therapy
 May be necessary to begin with individual family therapy in which each family member has a therapist  Need to target Expressed Emotion (EE)
– Emphasize strengths not deficits – Share power—who is in control of the patient in the family – Contain outbursts – Problem solving skills

 High levels of EE—56% rehospitalization in 6 months  Low levels of EE—21% rehospitalization in 6 months

 Social skills training
– Teach issues re: hygiene, personal space, eye contact, body language – Expressing interests in others – Teach empathy – Initiating contact with others

 Vocational Rehab
– Vocational counseling and education

 Supportive employment
– Get job in the community and have job coach come in to help you keep the job

 1/3 recover; 1/3 severe chronic; 1/3 exacerbations and remissions  In general, Schizophrenia is a relapsing and remitting course  Timing is relevant -early intervention ++  Stabilize 1st year  1st 6 months increased risk for suicide  Combined approaches best—meds alone aren’t enough

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