Psychopathology

Schizophrenia
Signs & symptoms
Possible Causes
Nursing Diagnoses
Treatment & care Plans
Teaching plans

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 Psychopathology
• Prevalence - 20% (12 months period)
Anxiety disorder - most prevalent
Mood disorder (collectively)
Alcohol disorders
Major depression
• Comorbidity - 17%
• Help seeking - 60-80%

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 Understanding Psychopathology
• Organized knowledge - understand
• Operational definition - communicate
• Criteria for diagnosis - DSM IV
• Behavior - subjective/ objective
• Etiology - nature/nurture

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 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)

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Mild Moderate Severe Psychosis

Anxiety disorder
Anxiety Somatoform disorders
Dissociative disorders
Anxiety Personality
Cause disorders
Physical
conditions
Grief Major depression
The mental health continuum for schizophrenia
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 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

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 Causes of Schizophrenia
• Genetic factors
• Chemical imbalance & physical
abnormalities – neurotransmitters, brain
structures
• Biological factors – age, virus, …
• Environmental factors – chr. Life stressors,
changes, …
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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%

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 Signs & symptoms
• Alterations in personal relationships
• Alternations of activity
• Altered perception
• Alterations of thought
• Distorted thinking
• Altered consciousness
• Alterations of affect
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 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

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 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

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 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…

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 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
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 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,
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 Subjective Signs
• Reported by the client

• Altered perceptions, thought processes &

content, consciousness, and affect

• May induce the pt to seek psychiatric help

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 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
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 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

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 Objective Signs
• Observed directly by nurse

• Altered relationships, hygiene, social skills,

communication, and psychomotor activity

• Frighten others may lead to involuntary

psychiatric intervention
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 Subtypes of schizophrenia
• Paranoid - preoccupied with one or more de
lusion
• Disorganized - disorganized speech, behavi
or; poor attention; inappropriate affect
• Catatonic - waxy flexibility or purposeless e
xcessive motor activity, mutism, stupor
• Undifferentiated -
• Residual - negative symptoms.

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 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
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 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
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 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
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 Issues related to Schizophrenia
• Family ⇔ the patient
communication, overprotection, blaming
• Non-compliance with medical regimen
• Caregiver’s needs - cope with strange and fr
ightening behaviors ie. apathy, poor persona
l hygiene, violence

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 Issues related to Schizophrenia
(II)
• Depression - part of the symptoms, be mask
ed 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
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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

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

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 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
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 Withdrawn Patients
• arrange nonthreatening activities
• encourage participation - seating
• provide remotivation and resocialization gro
up experience
• reinforce appropriate grooming and hygiene
• provide psychosocial rehabilitation - social
skill training, ...

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 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

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 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

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 Immobility Patients
• Minimize circulatory problem

• Provide adequate diet, exercise, and rest

• Prevent victimization

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 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

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 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
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 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.

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 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

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

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 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

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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

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 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

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 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,

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

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 Schizophrenia - overview
• Diagnosis - criteria
• Prevalence - age and gender
• Course of illness - phases, warning signs
• Medication management - side effect, copin
g
• Psychosocial rehabilitation - ind, gr, fam…
• Community resources
• Stress management
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 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)

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 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

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Great wall, China
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