Unit 4: Thought Disorders and Medications Schizophrenia in Focus

Schizophrenia: Bleuler’s 4-A’s AFFECT: flat, blunted, inappropriate or bizarre affect AMBIVALENCE: holding opposing opinions or attitudes at the same time ASSOCIATIVE LOOSENESS: Jumbled, illogical thinking AUTISM: living in one’s own fantasy world—turned in to the self

AFFECT: flat, blunted, inappropriate or bizarre affect

AMBIVALENCE: holding opposing opinions or attitudes at the same time

ASSOCIATIVE LOOSENESS: Jumbled, illogical thinking

AUTISM: living in one’s own fantasy world—turned in to the self

Classifying Symptoms: Positive Symptoms “What’s there that shouldn’t be there” Hallucinations Delusions Bizarre Behavior Disorganized speech, word salad, echolalia

“What’s there that shouldn’t be there”

Hallucinations

Delusions

Bizarre Behavior

Disorganized speech, word salad, echolalia

Thought Alterations Ideas of reference Persecutory, grandiose, somatic delusions Thought blocking, insertion, withdrawl, broadcasting Command/control hallucinations

Ideas of reference

Persecutory, grandiose, somatic delusions

Thought blocking, insertion, withdrawl, broadcasting

Command/control hallucinations

Classifying Symptoms: Negative Symptoms “ What’s not there that should be there” Lack of Feeling and affect including positive emotion (anhedonia) Poverty of thought (alogia) Loss of motivation (avolition)

“ What’s not there that should be there”

Lack of Feeling and affect including positive emotion (anhedonia)

Poverty of thought (alogia)

Loss of motivation (avolition)

Classifying Symptoms:Cognitive Symptoms Thinking and Decision-making Impaired memory Poor problem solving and poor judgment Illogical thinking Inattention, distractability

Thinking and Decision-making

Impaired memory

Poor problem solving and poor judgment

Illogical thinking

Inattention, distractability

Phases of Schizophrenia Prodromal: isolation, behavior change, often in adolescence or y. adult Acute/Active Phase: Evident psychosis. Periods of fluctuation, but symptoms are evident Chronic/Residual: Long term outcome is that the intensity of the psychosis may diminish, leaving more of the negative symptoms

Prodromal: isolation, behavior change, often in adolescence or y. adult

Acute/Active Phase: Evident psychosis. Periods of fluctuation, but symptoms are evident

Chronic/Residual: Long term outcome is that the intensity of the psychosis may diminish, leaving more of the negative symptoms

Theories of Causation Many of the psychological theories are now doubted as evidence of a brain disease is more clear. Genetic transmission is evident Dopamine theory—excess dopamine (does not explain all) Glucomate theory—regulation of glucomate (NMDA) receptor in brain r/t PCP psychosis

Many of the psychological theories are now doubted as evidence of a brain disease is more clear.

Genetic transmission is evident

Dopamine theory—excess dopamine (does not explain all)

Glucomate theory—regulation of glucomate (NMDA) receptor in brain r/t PCP psychosis

Neuroanatomical Changes Enlarged lateral cerebral ventricles Cortical and cerebellum atrophy Third ventricle dilation and asymmetry Changes in blood flow and glucose metabolism patterns

Enlarged lateral cerebral ventricles

Cortical and cerebellum atrophy

Third ventricle dilation and asymmetry

Changes in blood flow and glucose metabolism patterns

Mechanism of Action of Antipsychotics Phenothiazines: block post-synaptic dopamine receptors giving a decreased dopamine response. Works on + symptoms only Atypical antipsychotics: Antagonizes both serotonin and dopamine receptors giving a decreased dopamine and serotonin response. Works on + and – symptoms both See supplemental info on Oncourse

Phenothiazines: block post-synaptic dopamine receptors giving a decreased dopamine response. Works on + symptoms only

Atypical antipsychotics: Antagonizes both serotonin and dopamine receptors giving a decreased dopamine and serotonin response. Works on + and – symptoms both

See supplemental info on Oncourse

Side effects of antipsychotics Extrapyramidal (see H/O in syllabus) Tardive dyskinesia: can be permanent, See AIMS test, don’t raise dose of med Anticholinergic side effects (go over) Blood dyscrasias Photosensitivity, excess prolactin

Extrapyramidal (see H/O in syllabus)

Tardive dyskinesia: can be permanent,

See AIMS test, don’t raise dose of med

Anticholinergic side effects (go over)

Blood dyscrasias

Photosensitivity, excess prolactin

Neuroleptic Malignant Syndrome Life threatening: increased temp, decreased consciousness, severely increased muscle tonicity, HTN, tachycardia, drooling sweating Stop the antipsychotic, treat symptoms in a monitored setting (ICU), fluids, cooling blanket, dantrolene, parlodel (a dopamine agonist)

Life threatening: increased temp, decreased consciousness, severely increased muscle tonicity, HTN, tachycardia, drooling sweating

Stop the antipsychotic, treat symptoms in a monitored setting (ICU), fluids, cooling blanket, dantrolene, parlodel (a dopamine agonist)

Nursing Diagnosis: Non compliance Not taking meds or attending therapy is a big factor leading to rehospitalization Why? Denial, hate being in sick role, lack of judgment, side effects of meds

Not taking meds or attending therapy is a big factor leading to rehospitalization

Why? Denial, hate being in sick role, lack of judgment, side effects of meds

Nursing Diagnosis: Potential for violence Usually related to paranoia/perceived threat

Usually related to paranoia/perceived threat

Nursing Diagnosis: Impaired social interaction Related to negative symptoms, hard to change!

Related to negative symptoms, hard to change!

Nursing Diagnosis: self care deficit No motivation to bathe, lack of recognition of problem, paranoia

No motivation to bathe, lack of recognition of problem, paranoia

Nursing Diagnosis: altered nutrition/FVE Paranoia about eating and drinking Excess fluid intake

Paranoia about eating and drinking

Excess fluid intake

Nursing diagnosis: risk for suicide About 10% schizophrenics commit suicide

About 10% schizophrenics commit suicide

Paranoid Schizophrenia Intense, strongly defended irrational suspicions Ideas of reference Behaving with anger, sarcasm, hostility Projection of feelings Often paranoid ideas are intricate and complex

Intense, strongly defended irrational suspicions

Ideas of reference

Behaving with anger, sarcasm, hostility

Projection of feelings

Often paranoid ideas are intricate and complex

Nursing Tactics with Paranoia Calm, matter of fact approach—don’t smother or hover Respect personal territory Verbal indication of nursing measures before intervention Be honest, trustworthy, consistent Don’t feed delusions or challenge directly—cast reasonable doubt and focus on reality Look at underlying themes in delusions

Calm, matter of fact approach—don’t smother or hover

Respect personal territory

Verbal indication of nursing measures before intervention

Be honest, trustworthy, consistent

Don’t feed delusions or challenge directly—cast reasonable doubt and focus on reality

Look at underlying themes in delusions

More nursing interventions in Paranoia Help client manage anger and fear through consistent limits, appropriate diversion, and not taking bx personally “ When in doubt, check it out” strategy Talk about dealing with food and med. paranoia

Help client manage anger and fear through consistent limits, appropriate diversion, and not taking bx personally

“ When in doubt, check it out” strategy

Talk about dealing with food and med. paranoia

Disorganized Schizophrenia Regression, increased social impairment, bizarre affect/behavior, incoherent speech Nursing measures: help with grooming, eating. Routine, consistent and structured. Understanding milieu. Plus all the general nsg measures.

Regression, increased social impairment, bizarre affect/behavior, incoherent speech

Nursing measures: help with grooming, eating. Routine, consistent and structured. Understanding milieu. Plus all the general nsg measures.

Catatonia: abnormal motor behavior Withdrawn: posturing, waxy flexibility, stupor, mute, unaware of environment Nsg care in Withdrawn state: complete hygiene, nutrition, mobility, bathroom assist Excited: Gross hyperactivity-running striking out Nsg with Excited: preserve milieu, keep client safe

Withdrawn: posturing, waxy flexibility, stupor, mute, unaware of environment

Nsg care in Withdrawn state: complete hygiene, nutrition, mobility, bathroom assist

Excited: Gross hyperactivity-running striking out

Nsg with Excited: preserve milieu, keep client safe

Other categories of Schizophrenia Undifferentiated – means doesn’t fit a specific othre group Residual—means most of the active symptoms are gone (mostly negative symptoms remaining)

Undifferentiated – means doesn’t fit a specific othre group

Residual—means most of the active symptoms are gone (mostly negative symptoms remaining)