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Schizophrenia and other Psychotic Disorders

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  • 1. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS Mercedes A Perez-Millan MSN, ARNP
  • 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. COMORBIDITY • Substance abuse disorders • Nicotine dependence • Depression – Suicide • Anxiety disorders • Psychosis-induced polydipsia
  • 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. 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. AREAS OF THE BRAIN AFFECTED
  • 7. BIOLOGICAL THEORIES Neuroanatomical
  • 8. Course of Schizophrenia • Recurrent acute exacerbations of psychosis • Increase in residual dysfunction and deterioration with each relapse
  • 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. Potential Early Symptoms: Pre-psychotic • Withdrawn from others • Depressed • Anxious • Phobias • Obsessions and compulsions • Difficulty concentrating • Preoccupation with religion • Preoccupation with self
  • 11. Bleuler’s 4 A’s of Schizophrenia • Affect • Associative looseness • Autism • Ambivalence
  • 12. Signs and Symptoms: Relevant to Treatment • Positive symptoms • Negative symptoms • Cognitive symptoms • Mood symptoms
  • 13. Dimensions Altered in Individuals with Schizophrenia • Ability to work • Interpersonal relationships • Self-care abilities • Social functioning • Quality of life
  • 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. Positive Symptoms: Alterations in Speech • Associative looseness • Neologisms • Echolalia • Clang association • Word salad
  • 16. Positive Symptoms: Alterations in Perception • Hallucinations: sensory perceptions for which no external stimulus exists – Auditory – Visual – Olfactory – Tactile • Personal boundary difficulties
  • 17. Positive Symptoms: Alterations in Behavior • Extreme motor agitation • Stereotyped behaviors • Automatic obedience • Waxy flexibility • Stupor • Negativism
  • 18. Negative Symptoms • Affective blunting • Anergia • Anhedonia • Avolition • Poverty of content of speech • Thought blocking • Flat affect/inappropriate affect
  • 19. Cognitive Symptoms • Inattention, easily distracted • Impaired memory • Poor problem-solving skills • Poor decision-making skills • Illogical thinking • Impaired judgment
  • 20. Depression and Other Mood Symptoms • Dysphoria • Suicidal ideation • Hopelessness
  • 21. Types of Schizophrenia Subtypes • Paranoid • Catatonic • Disorganized • Undifferentiated • Residual
  • 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. 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. 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. 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. Planning of Appropriate Interventions • Acute phase – Possible hospitalization • Ensure client safety • Provide symptom stabilization • Maintenance and stabilization phases – Psychosocial education – Relapse prevention skills
  • 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. Interventions: Basic Level Continued • Maintenance and stabilization phases – Health teaching – Health promotion and maintenance
  • 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. 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. 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. 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. Client Teaching Coping Techniques for Schizophrenia • Distraction • Interaction • Activity • Social action • Physical action
  • 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. Treatment Modalities • Individual therapy – Social skills training (SST) – Cognitive remediation – Cognitive adaptation training (CAT) – Cognitive behavioral therapy (CBT) • Group therapy • Family therapy • Psychopharmacology
  • 36. Psychopharmacology • Antipsychotics – Standard/ Typical – Atypical • Antiparkinson
  • 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. 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. 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. 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. Antipsychotic Medications: Atypical • Clozapine (Clozaril) • Quetiapine (Seroquel) • Risperidone (Risperdal • Zipreasidone (Geodon) • Olanzapine (Zyprexa) • Aripiprazole (Abilify)
  • 42. Side Effects- Atypical • Orthostatic Hypotension • Decreased Libido • Agranulocytosis (Clozapine) • Weight gain • Tachycardia • Edema
  • 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. 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. 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. Side Effects: a2 Block: Cardiovasclar • Hypotension • Postural hypotension • Tachycardia
  • 47. Side Effects: Rare and Toxic Effects • Agranulocytosis • Cholestatic jaundice • Neuroleptic malignant syndrome (NMS) – Severe extrapyramidal – Hyperpyrexia – Autonomic dysfunction
  • 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. 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. 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. ANTIPARKINSON AGENTS • COGENTIN • ARTANE • AKINETON • PARLODOL • KEMADRIN • BENEDRYL
  • 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. 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