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Alterations in mental health - Schizophrenia

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  1. 1. IV. Alterations in mental health - schizophrenia Lectured by: Leila T. Salera, RN, MD, DPSP
  2. 2. Epidemiology of mental illness• According to the WHO’s World Health Report in 2003:a. Mental, neurological and substance disorders cause a large burden of disease and disabilityb. Globally, 13% of overall disability-adjusted life years and 33 % of overall years lived with disabilityc. More than 150 million people suffer from depression at any point in timed. Nearly 1M commit suicide each yeare. About 25M suffer from schizophreniaf. 38M suffer from epilepsyg. More than 90M suffer from drug use or disorder(Public Health Nursing in the Philippines, page 228)
  3. 3. schizophrenia• Causes disoriented and bizarre thoughts, perceptions, emotions, movements, and behavior• Cannot be defined as a single illness• Thought of as a syndrome or as disease process with many different symptoms• Usually diagnosed in late adolescence or early adulthood• Rarely manifests in childhood• Peak incidence of onset: 15 to 25 years for men, and 25 to 35 years for women(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  4. 4. schizophrenia• Emil Kraepelin – described the term “dementia precox” (before it was called schizophrenia); it emphasized the change in cognition (dementia) and early onset (precox) of the disorder• Patients with dementia precox were described as having a long-term deteriorating course and the clinical symptoms of hallucinations and delusions• Paranoia – characterized by persistent persecutory delusions
  5. 5. schizophrenia• Eugene Bleuler – coined the term schizophrenia which replaced the term demenita precox in the literature• Unlike Kraepelin’s concept, schizophrenia need not have a deteriorating course• It is not the same as split personality
  6. 6. Schizophrenia• The Four As:1. Associational disturbances of thought or association looseness2. Affective disturbances3. Autism4. Ambivalence• Add one more A for auditory hallucinations
  7. 7. Types of Schizophrenia• Diagnosis is made according to the client’s predominant symptoms:A. Schizophrenia, paranoid type – persecutory or grandiose delusionsB. Schizophrenia, disorganized type – grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behaviorC. Schizophrenia, catatonic type – either motionless or marked psychomotor disturbance; mutism, echolalia, echopraxia(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  8. 8. Types of Schizophrenia• Diagnosis is made according to the client’s predominant symptoms:D. Schizophrenia, undifferentiated type – mixed symptomsE. Schizophrenia, residual type – social withdrawal, flat affect, loose associationsF. Schizoaffective disorder – psychotic symptoms of schizophrenia plus a mood disorder(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  9. 9. Related disorders• Schizophreniform disorder – symptoms of schizophrenia but for less than 6 months necessary to meet the diagnostic criteria. Social or occupational functioning may or may not be impaired• Delusional disorder – client has one or more delusions, psychosocial functioning is not markedly impaired, and behavior is not obvious odd or bizarre• Brief psychotic disorder – sudden onset of a psychotic symptom which lasts for 1 day to 1 month, that could have a stressor or may follow childbirth• Shared psychotic disorder – folie a deux, two people share a similar delusion(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  10. 10. Etiology• Biologic theories1. Genetic factors: identical twins have 50% risk, fraternal twins have 15%, children with one schizophrenic parent have 15% risk, 35% if both parents are schizophrenic2. Neuroanatomic and neurochemical factors – patients have relatively less brain tissue and CSF compared to those who do not have the illness, the ventricles are enlarged, and there is cortical atrophy; excess dopamine and serotonin3. Immunovirologic factors – exposure to certain viruses like influenza(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  11. 11. assessment• Symptomalogy1. Positive symptoms – or hard symptoms/signs2. Negative symptoms – or soft symptoms/signs; these frequently persists even after the positive symptoms have abated(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  12. 12. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of SchizophreniaPositive or Hard Symptoms Negative or Soft SymptomsAmbivalence: holding seemingly Alogia: tendency to speak very little orcontradictory beliefs or feelings about to convey little substance of meaningthe same person, event, or situation (poverty of content)Associative looseness Anhedonia: feeling no joy or pleasure from life or any activities of relationshipsDelusions Apathy: feelings of indifference toward people, activities, and eventsEchopraxia: imitation of movements Blunted affectand gestures of another person whomthe client is observingFlight of ideas Catatonia: psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance
  13. 13. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of SchizophreniaPositive or Hard Symptoms Negative or Soft SymptomsFlight of ideas Flat affectHallucinations Lack of volition: absence of will, ambition, or drive to take action or accomplish tasksIdeas of referencePerseveration: persistent adherence toa single idea or topic; verbal repetitionof a sentence, word, or phrase; resistingattempts to change the topic
  14. 14. TYPES OF DELUSIONSPersecutory/paranoid delusions Involve the client’s belief that “others” are planning to harm the client or are spying, following, ridiculing, or belittling the clientGrandiose delusions Characterized by the client’s claim to association with famous people or celebrities, or the client’s belief that he or she is famous or capable of great featsReligious delusions Often center around the second coming of Christ or another significant religious figure or prophetSomatic delusions Generally vague and unrealistic beliefs about the client’s health or bodily functions (client may say that she is pregnant)Rereferential delusions Ideas of reference
  15. 15. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAClang associations Ideas that are related to one “I will take a pill if I go up another based on sound of the hill but not if my name rhyming is Jill, I don’t want to kill.”Neologisms Words invented by the client “I’m afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?”Verbigeration Stereotyped repetition of “I want to go home, go words or phrases that may or home, go home.” may not have meaning to the listenerEcholalia Imitation or repetition of Nurse: “Can you tell me what the nurse says how you’re feeling?” Client: “Can you tell me how you’re feeling, how you’re feeling?.....”
  16. 16. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAStilted language Use of words or phrases “Would you be so kind, as a that are flowery, excessive, representative of Florence pompous Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?”Perseveration Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Where do you live?” Client: “At my place people have been following me.” Nurse: “What do you like to do in your free time?” Client: “Nothing because people are following me.”
  17. 17. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAWord salad A combination of jumbled “Corn, potatoes, jump up, words and phrases that play games, grass, are disconnected or cupboard.” incoherent and make no sense to the listener
  18. 18. Elder considerations• Late-onset schizophrenia – development of the disease after age 45• Schizophrenia is not initially diagnosed in elder clients• Psychotic symptoms are usually associated with depression or dementia, not schizophrenia• Approximately one fourth of clients experienced dementia, resulting in steady, deteriorating decline in health• Another 25% actually have reduction in positive symptoms, somewhat like a remission• Schizophrenia remains mostly unchanged in the remaining clients(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  19. 19. Nursing diagnosis Nursing Diagnosis Analysis Risk for injury related to accelerated motor Accelerated motor activity or impulsive activity actions Disturbed thought process –related to Grandiose delusions (Belief that well delusion of grandeur known political religious, or entertainment leader) Self-care deficit (unkempt Unable to take time for self-care is, appearance) related to hyperactivity disheveled and unkempt Impaired verbal communication –flight of Accelerated speech with flight of ideas ideas related to accelerated thinking (thought speeded up causing rapid speech and flight of ideas, excessive planning for activities( ursing%20Diagnosis)
  20. 20. Goals – Expected outcomes• For the acute, psychotic phase (examples)a. The client will not injure self and othersb. The client will establish contact with realityc. The client will interact with others in the environmentd. The client will express thoughts and feelings in a safe and socially acceptable mannere. The client will participate in prescribed therapeutic interventions(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  21. 21. Goals – Expected outcomes• For continued care after stabilization of acute symptoms (examples)a. The client will participate in the prescribed regimen (including medications and follow-up appointments)b. The client will maintain adequate routines for sleeping and food and fluid intakec. The client will demonstrate independence in self-care activitiesd. The client will communicate effectively with others in the community to meet his or her needse. The client will seek or accept assistance to meet his or her needs when indicated(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  22. 22. Implementation - management• Promoting the safety of client and others• Establishing a therapeutic relationship• Using therapeutic communication• Implementing interventions for delusional thoughts and for hallucinations• Coping with socially inappropriate behaviors• Teaching client and family(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  23. 23. Interventions for delusions• Do not confront the delusion or argue with the client• Establish and maintain reality for the client• Use distracting techniques• Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  24. 24. Interventions for hallucinations• Help present and maintain reality by frequent contact and communication with client• Elicit description of hallucination to protect client and others• Engage client in reality-based activities such as card playing, occupational therapy, or listening to music(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  25. 25. Coping with socially inappropriate behaviors• Redirect client away from problem situations• Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; do not scold• Reassure others that the client’s inappropriate behaviors or comments are not his or her fault (without violating the client confidentiality)• Try to reintegrate the client into treatment milieu• Do not make the client feel punished or shunned for inappropriate behaviors• Teach social skills through education, role modeling, and practice(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  26. 26. Implementation - management• Client/Family Educationa. How to manage illness and symptomsb. Recognizing early signs and symptoms of relapsec. Developing a plan to address relapse signsd. Importance of maintaining prescribed medication regimen and regular follow-upe. Avoiding alcohol and other drugs(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  27. 27. Implementation - management• Client/Family Educationf. Self-care and proper nutritiong. Teaching social skills through education, role modeling, and practiceh. Seeking assistance to avoid or manage stressful situationsi. Counseling and educating family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing supportj. Importance of maintaining contact with community and participating in supportive organizations and care(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  28. 28. Early signs of relapse• Impaired cause-and-effect reasoning• Impaired information processing• Poor nutrition• Lack of sleep• Lack of exercise• Fatigue• Poor social skills, social isolation, loneliness• Interpersonal difficulties(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  29. 29. Early signs of relapse• Lack of control, irritability• Mood swings• Ineffective medication management• Low self-concept• Looks and acts different• Hopeless feelings• Loss of motivation• Anxiety and worry(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  30. 30. Early signs of relapse• Disinhibition• Increased negativity• Neglecting appearance• Forgetfulness(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  31. 31. Implementation - management• Medications:a. Antispychotic medications: conventional antipsychotics for positive symptoms and atypical antipsychotics for negative symptomsb. Drugs for EPS(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)
  32. 32. Social Skills Training• Sometimes referred to as behavioral skills therapy• Along with pharmacologic therapy can be directly supportive and useful to the patient
  33. 33. Social Skills TherapyPhase Goals Targeted BehaviorsStabilization and assessment Establish therapeutic alliance Empathy and rapport Assess social performance Verbal and nonverbal and perception skills communication Assess behaviors that provoke expressed emotionsSocial performance within Express positive feelings with Compliments, appreciation,family family interest in others Teach effective strategies for Avoidance response to coping with conflict criticism, stating preferences and refusalsSocial perception in the Correctly identify content, Reading a messagefamily context, and meaning of Labeling an idea messages Summarizing other’s intentExtrafamilial relationships Enhance socialization skills Conversational skills Enhance prevocational and Dating vocational skills Recreational activitiesMaintenance Generalize skills to new Job interviewing, work habits situations
  34. 34. evaluation• Have the client’s psychotic symptoms disappeared?• Does the client understand the prescribed medication regimen?• Does the client possess the necessary functional abilities for community living?• Are community resources adequate to help the client live successfully in the community?• Is there sufficient after-care or crisis plan in place to deal with recurrence of symptoms?• Are the client and family adequately knowledgeable about schizophrenia?• Does the client believe that he or she has satisfactory quality of life?(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)