SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS
Mercedes A Perez-Millan MSN, ARNP
INTRODUCTION
Schizophrenia is possibly a group of psychotic
disorders that severely impairs all areas of an
individual’s ...
COMORBIDITY
• Substance abuse disorders
• Nicotine dependence
• Depression
– Suicide
• Anxiety disorders
• Psychosis-induc...
ETIOLOGY
Neurobiochemical
– Dopamine hypothesis
– Serotonin
– Glutamate
• Neuroanatomical
– Structural cerebral abnormalit...
GENETIC PREDISPOSITION
 A single gene has not been identified.
 Research is focused on chromosomes 6, 13, 18 & 22.
 The...
AREAS OF THE BRAIN AFFECTED
BIOLOGICAL THEORIES
Neuroanatomical
Course of Schizophrenia
• Recurrent acute exacerbations
of psychosis
• Increase in residual dysfunction
and deterioration ...
Phases in Course of Schizophrenia
1. Acute phase
– Positive symptoms and negative symptoms
2. Maintenance phase
– Acute sy...
Potential Early Symptoms:
Pre-psychotic
• Withdrawn from others
• Depressed
• Anxious
• Phobias
• Obsessions and compulsio...
Bleuler’s
4 A’s of Schizophrenia
• Affect
• Associative looseness
• Autism
• Ambivalence
Signs and Symptoms: Relevant to
Treatment
• Positive symptoms
• Negative symptoms
• Cognitive symptoms
• Mood symptoms
Dimensions Altered in Individuals
with Schizophrenia
• Ability to work
• Interpersonal relationships
• Self-care abilities...
Positive Symptoms:
Alteration in Thinking
• Delusions: false, fixed beliefs that cannot be corrected by
reasoning
– Ideas ...
Positive Symptoms:
Alterations in Speech
• Associative looseness
• Neologisms
• Echolalia
• Clang association
• Word salad
Positive Symptoms:
Alterations in Perception
• Hallucinations: sensory perceptions for
which no external stimulus exists
–...
Positive Symptoms:
Alterations in Behavior
• Extreme motor agitation
• Stereotyped behaviors
• Automatic obedience
• Waxy ...
Negative Symptoms
• Affective blunting
• Anergia
• Anhedonia
• Avolition
• Poverty of content of speech
• Thought blocking...
Cognitive Symptoms
• Inattention, easily distracted
• Impaired memory
• Poor problem-solving skills
• Poor decision-making...
Depression and
Other Mood Symptoms
• Dysphoria
• Suicidal ideation
• Hopelessness
Types of Schizophrenia
Subtypes
• Paranoid
• Catatonic
• Disorganized
• Undifferentiated
• Residual
Self-Assessment: Working with
Schizophrenic Clients
• Peer group supervision
– Client's intense emotions produce
similar e...
Assessment of the Client
• Safety of client and others
• Medical history and recent medical workup
• Positive, negative, c...
Potential Nursing Diagnoses
• Risk for self-directed or other-directed
violence
• Disturbed sensory perception
• Disturbed...
Outcome Criteria
• Acute phase
– Client safety and medical stabilization
• Maintenance phase
– Adherence to medical regime...
Planning of
Appropriate Interventions
• Acute phase
– Possible hospitalization
• Ensure client safety
• Provide symptom st...
Interventions: Basic Level
• Acute phase
– Administer antipsychotic medication as
prescribed
– Observe client behavior clo...
Interventions: Basic Level
Continued
• Maintenance and stabilization phases
– Health teaching
– Health promotion and maint...
Milieu Therapy
• Safety
– Potential for physical violence due to hallucinations or
delusions
– Priority is least restricti...
Counseling: Communication
Guidelines
• Hallucinations
– Hearing voices most common
– Approach client in nonthreatening and...
Communication Guidelines
continued
• Delusions
– Be open, honest, matter-of-fact, and calm
– Have client describe delusion...
Communication Guidelines
continued
• Associative looseness
– Do not pretend that you understand
– Place difficulty of unde...
Client Teaching
Coping Techniques for
Schizophrenia
• Distraction
• Interaction
• Activity
• Social action
• Physical acti...
Client and Family Teaching
• Learn all you can about the illness.
• Develop a relapse prevention plan.
• Avoid alcohol and...
Treatment Modalities
• Individual therapy
– Social skills training (SST)
– Cognitive remediation
– Cognitive adaptation tr...
Psychopharmacology
• Antipsychotics
– Standard/ Typical
– Atypical
• Antiparkinson
Psychopharmacology
Traditional Antipsychotic
• Dopamine antagonists (D2 receptor antagonists)
• Target positive symptoms o...
Antipsychotic Medications:
Traditional
• High potency = low sedation + low ACH + high EPSs
– Haloperidol (Haldol)
– Triflu...
Antipsychotic Medications:
Traditional continued
• Low potency = high sedation + high ACH +
low EPSs
– Chlorpromazine (Tho...
Atypical Antipsychotics
(First-Line Antipsychotics)
• Serotonin-dopamine antagonists
– (5-HT2A receptor antagonists)
• Adv...
Antipsychotic Medications:
Atypical
• Clozapine (Clozaril)
• Quetiapine (Seroquel)
• Risperidone (Risperdal
• Zipreasidone...
Side Effects- Atypical
• Orthostatic Hypotension
• Decreased Libido
• Agranulocytosis (Clozapine)
• Weight gain
• Tachycar...
Side Effects:
Anticholinergic Symptoms
• Dry mouth
• Urinary retention and hesitancy
• Constipation
• Blurred vision
• Pho...
Side Effects:
Extrapyramidal Side Effects
Pseudoparkinson
 Drooling, lack of facial responsiveness, shuffling gait,
and ...
Side Effects:
Extrapyramidal Side Effects
Tardive Dyskinesia
– Bizarre facial and tongue movements
chewing, tongue from si...
Side Effects:
a2 Block: Cardiovasclar
• Hypotension
• Postural hypotension
• Tachycardia
Side Effects:
Rare and Toxic Effects
• Agranulocytosis
• Cholestatic jaundice
• Neuroleptic malignant syndrome (NMS)
– Sev...
NEUROLEPTIC MALIGNANT
SYNDROME
• RARE, POTENTIALLY FATAL
• ONSET WITHIN HOURS OR YEARS
• EPS REACTIONS
• CPK
• HYPERTHERMI...
AGRANULOCYTOSIS
 Potentially fatal disorder
 Symptoms include:
 White blood cells level <2000 mm3 or
granulocyte count ...
NURSING IMPLICATIONS
• MONITOR B.P. BEFORE ADMINISTERING
MEDS
• CHECK CBC, CPK, LIVER FUNCTIONS
AND VISION REGULARLY
• EVA...
ANTIPARKINSON AGENTS
• COGENTIN
• ARTANE
• AKINETON
• PARLODOL
• KEMADRIN
• BENEDRYL
CLIENT AND FAMILY TEACHING
• Teach about schizophrenia and available mental
health agencies for support at the local and
n...
CRITICAL THINKING
CARE PLAN
The Patient is a 45 year old white male with a long history of
schizophrenia. He was admitted ...
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Schizophrenia and other Psychotic Disorders

  1. 1. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS Mercedes A Perez-Millan MSN, ARNP
  2. 2. INTRODUCTION Schizophrenia is possibly a group of psychotic disorders that severely impairs all areas of an individual’s functioning. 1 to 1.5% of US population has schizophrenia. However they make up far more than 50% of the county and long-term residents of state mental hospitals. More than 50% are homeless, and in addition may have an addiction problem. The cost of treatment and loss of revenues are estimated in the billions of dollars.
  3. 3. COMORBIDITY • Substance abuse disorders • Nicotine dependence • Depression – Suicide • Anxiety disorders • Psychosis-induced polydipsia
  4. 4. ETIOLOGY Neurobiochemical – Dopamine hypothesis – Serotonin – Glutamate • Neuroanatomical – Structural cerebral abnormalities • Genetic – Several genes on different chromosomes interact with environment • Nongenetic risk factors – Complications of pregnancy and birth – Stress
  5. 5. GENETIC PREDISPOSITION  A single gene has not been identified.  Research is focused on chromosomes 6, 13, 18 & 22.  The risk of developing the disorder is as follows:  One parent 12-15%+  Both parents 40%+  Identical twins 50%+ (The statistics may vary in different studies)
  6. 6. AREAS OF THE BRAIN AFFECTED
  7. 7. BIOLOGICAL THEORIES Neuroanatomical
  8. 8. Course of Schizophrenia • Recurrent acute exacerbations of psychosis • Increase in residual dysfunction and deterioration with each relapse
  9. 9. Phases in Course of Schizophrenia 1. Acute phase – Positive symptoms and negative symptoms 2. Maintenance phase – Acute symptoms are less severe 2. Stabilization phase – Remission of symptoms
  10. 10. Potential Early Symptoms: Pre-psychotic • Withdrawn from others • Depressed • Anxious • Phobias • Obsessions and compulsions • Difficulty concentrating • Preoccupation with religion • Preoccupation with self
  11. 11. Bleuler’s 4 A’s of Schizophrenia • Affect • Associative looseness • Autism • Ambivalence
  12. 12. Signs and Symptoms: Relevant to Treatment • Positive symptoms • Negative symptoms • Cognitive symptoms • Mood symptoms
  13. 13. Dimensions Altered in Individuals with Schizophrenia • Ability to work • Interpersonal relationships • Self-care abilities • Social functioning • Quality of life
  14. 14. Positive Symptoms: Alteration in Thinking • Delusions: false, fixed beliefs that cannot be corrected by reasoning – Ideas of reference – Persecution – Grandiosity – Somatic sensations – Jealousy – Control – Thought broadcasting – Thought insertion – Thought withdrawal – Delusion of being controlled • Concrete thinking
  15. 15. Positive Symptoms: Alterations in Speech • Associative looseness • Neologisms • Echolalia • Clang association • Word salad
  16. 16. Positive Symptoms: Alterations in Perception • Hallucinations: sensory perceptions for which no external stimulus exists – Auditory – Visual – Olfactory – Tactile • Personal boundary difficulties
  17. 17. Positive Symptoms: Alterations in Behavior • Extreme motor agitation • Stereotyped behaviors • Automatic obedience • Waxy flexibility • Stupor • Negativism
  18. 18. Negative Symptoms • Affective blunting • Anergia • Anhedonia • Avolition • Poverty of content of speech • Thought blocking • Flat affect/inappropriate affect
  19. 19. Cognitive Symptoms • Inattention, easily distracted • Impaired memory • Poor problem-solving skills • Poor decision-making skills • Illogical thinking • Impaired judgment
  20. 20. Depression and Other Mood Symptoms • Dysphoria • Suicidal ideation • Hopelessness
  21. 21. Types of Schizophrenia Subtypes • Paranoid • Catatonic • Disorganized • Undifferentiated • Residual
  22. 22. Self-Assessment: Working with Schizophrenic Clients • Peer group supervision – Client's intense emotions produce similar emotions in the nurse – Willingness for nurse to discuss feelings and behaviors with supervisors decreases defensive behaviors • Team approach to decrease staff burnout • Periodic reassessments of – Treatment outcomes – Client's strengths and weaknesses
  23. 23. Assessment of the Client • Safety of client and others • Medical history and recent medical workup • Positive, negative, cognitive, and mood symptoms • Current medications and compliance to treatment • Family response/support system
  24. 24. Potential Nursing Diagnoses • Risk for self-directed or other-directed violence • Disturbed sensory perception • Disturbed thought processes • Impaired verbal communication • Ineffective coping • Compromised or disabled family coping
  25. 25. Outcome Criteria • Acute phase – Client safety and medical stabilization • Maintenance phase – Adherence to medical regimen – Understanding schizophrenia – Participation of client and family in psychoeducational activities • Stabilization phase – Target negative symptoms – Anxiety control – Relapse prevention
  26. 26. Planning of Appropriate Interventions • Acute phase – Possible hospitalization • Ensure client safety • Provide symptom stabilization • Maintenance and stabilization phases – Psychosocial education – Relapse prevention skills
  27. 27. Interventions: Basic Level • Acute phase – Administer antipsychotic medication as prescribed – Observe client behavior closely – Set limits on inappropriate behavior – Do not touch without warning – Offer foods that are not easily contaminated – Assist with ADL if needed – Supportive counseling – Milieu management – Family psychoeducation
  28. 28. Interventions: Basic Level Continued • Maintenance and stabilization phases – Health teaching – Health promotion and maintenance
  29. 29. Milieu Therapy • Safety – Potential for physical violence due to hallucinations or delusions – Priority is least restrictive safety technique • Verbal de-escalation • Medications • Seclusion or restraints • Activities – Provide support and structure – Encourage development of social skills and friendships
  30. 30. Counseling: Communication Guidelines • Hallucinations – Hearing voices most common – Approach client in nonthreatening and nonjudgmental manner – Assess if messages are suicidal or homicidal – Initiate safety measures if needed – Client anxious, fearful, lonely, brain not processing stimuli accurately – Focus on the client’s feelings and present reality
  31. 31. Communication Guidelines continued • Delusions – Be open, honest, matter-of-fact, and calm – Have client describe delusion – Avoid arguing about content – Focus on feelings – Present reasonable doubt – Validate part of delusion that is real
  32. 32. Communication Guidelines continued • Associative looseness – Do not pretend that you understand – Place difficulty of understanding on yourself – Look for reoccurring topics and themes – Emphasize what is going on in the client's environment – Involve client in simple, reality-based activities – Reinforce clear communication of needs, feelings, and thoughts
  33. 33. Client Teaching Coping Techniques for Schizophrenia • Distraction • Interaction • Activity • Social action • Physical action
  34. 34. Client and Family Teaching • Learn all you can about the illness. • Develop a relapse prevention plan. • Avoid alcohol and drugs. • Learn ways to address fears and losses. • Learn new ways of coping. • Comply with treatment. • Maintain communication with supportive people. • Stay healthy by managing illness, sleep, and diet.
  35. 35. Treatment Modalities • Individual therapy – Social skills training (SST) – Cognitive remediation – Cognitive adaptation training (CAT) – Cognitive behavioral therapy (CBT) • Group therapy • Family therapy • Psychopharmacology
  36. 36. Psychopharmacology • Antipsychotics – Standard/ Typical – Atypical • Antiparkinson
  37. 37. Psychopharmacology Traditional Antipsychotic • Dopamine antagonists (D2 receptor antagonists) • Target positive symptoms of schizophrenia • Advantage – Less expensive than atypical antipsychotics • Disadvantages – Do not treat negative symptoms – Extrapyramidal side effects (EPS) – Tardive dyskinesia – Anticholinergic effects (ACH) – Lower seizure threshold
  38. 38. Antipsychotic Medications: Traditional • High potency = low sedation + low ACH + high EPSs – Haloperidol (Haldol) – Trifluoperazine (Stelazine) – Fluphenazine (Prolixin) – Thiothixene (Navane) • Medium potency – Loxapine (Loxitane) – Molindone (Moban) – Perphenazine (Trilafon)
  39. 39. Antipsychotic Medications: Traditional continued • Low potency = high sedation + high ACH + low EPSs – Chlorpromazine (Thorazine) – Thioridazine (Mellaril) – Mesoridazine ( Serentil) • Decanoate = Long acting injection – Haloperidol decanoate (Haldol D) – Fluphenazine decanoate (Prolixin D)
  40. 40. Atypical Antipsychotics (First-Line Antipsychotics) • Serotonin-dopamine antagonists – (5-HT2A receptor antagonists) • Advantages – Diminishes negative as well as positive symptoms of schizophrenia – Less side effects encourages medication compliance – Improves symptoms of depression and anxiety – Decreases suicidal behavior • Disadvantages – Weight gain – Metabolic abnormalities
  41. 41. Antipsychotic Medications: Atypical • Clozapine (Clozaril) • Quetiapine (Seroquel) • Risperidone (Risperdal • Zipreasidone (Geodon) • Olanzapine (Zyprexa) • Aripiprazole (Abilify)
  42. 42. Side Effects- Atypical • Orthostatic Hypotension • Decreased Libido • Agranulocytosis (Clozapine) • Weight gain • Tachycardia • Edema
  43. 43. Side Effects: Anticholinergic Symptoms • Dry mouth • Urinary retention and hesitancy • Constipation • Blurred vision • Photosensitivity • Dry eyes • Inhibition of ejaculation or impotence in men
  44. 44. Side Effects: Extrapyramidal Side Effects Pseudoparkinson  Drooling, lack of facial responsiveness, shuffling gait, and fine intentional tremors. Acute Dystonia Muscle spasms of the jaw, tongue, neck or eyes. Laryngeal spasms possible. Oculogyric crisis, Opisthotonos. Akathisia Motor restlessness, pacing, rocking, etc
  45. 45. Side Effects: Extrapyramidal Side Effects Tardive Dyskinesia – Bizarre facial and tongue movements chewing, tongue from side to side, etc. – Involuntary tonic muscular spasms of extremities – Trunk – Potentially irreversible
  46. 46. Side Effects: a2 Block: Cardiovasclar • Hypotension • Postural hypotension • Tachycardia
  47. 47. Side Effects: Rare and Toxic Effects • Agranulocytosis • Cholestatic jaundice • Neuroleptic malignant syndrome (NMS) – Severe extrapyramidal – Hyperpyrexia – Autonomic dysfunction
  48. 48. NEUROLEPTIC MALIGNANT SYNDROME • RARE, POTENTIALLY FATAL • ONSET WITHIN HOURS OR YEARS • EPS REACTIONS • CPK • HYPERTHERMIA 102° AND ABOVE • TACHYCARDIA • FLUCTUATING B.P. • DIAPHORESIS • STUPOR AND COMA
  49. 49. AGRANULOCYTOSIS  Potentially fatal disorder  Symptoms include:  White blood cells level <2000 mm3 or granulocyte count <1500mm3  Sore throat  Low grade fever  Malaise  Sores in the mouth
  50. 50. NURSING IMPLICATIONS • MONITOR B.P. BEFORE ADMINISTERING MEDS • CHECK CBC, CPK, LIVER FUNCTIONS AND VISION REGULARLY • EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS • ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME • MIX LIQUIDS WITH 60CC FRUIT JUICE • PATIENT EDUCATION
  51. 51. ANTIPARKINSON AGENTS • COGENTIN • ARTANE • AKINETON • PARLODOL • KEMADRIN • BENEDRYL
  52. 52. CLIENT AND FAMILY TEACHING • Teach about schizophrenia and available mental health agencies for support at the local and national level (NAMI AND NIMH). • Develop a relapse prevention plan. • Teach about medication and treatment compliance. • Teach to avoid alcohol or drugs. • Teach to keep in touch with supportive people. • Teach to keep healthy – stay in balance.
  53. 53. CRITICAL THINKING CARE PLAN The Patient is a 45 year old white male with a long history of schizophrenia. He was admitted last night after he was trying to jump out of a 20th story building.. He states that he hears voices that told him to jump out, and the voices also told him to kill people. He states that we are all going to die soon because the terrorists have a new “webon” (a special weapon) that will kill everyone in the USA. The patient looks very frightened and refuses to come out of his room. Assessment: “S” “O” Nursing Diagnosis: Goals Nursing Actions
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