Transcript Schizophrenia

Schizophrenia
Elisa A. Mancuso RNC, MS, FNS
Professor
 3 million people (1.5 % of Population)
 Costs $ 35 billion
 Onset late adolescence or early adulthood
– Men 15-25
women 20-35 & > 50
 Psychotic disorders with disturbances in:
– Thought processes
– Perceptions
– Expression of feelings
Indicators
 Psychotic Symptoms
– Preoccupied with own thoughts and feelings
 Deterioration in functioning
– Role, ADLs, Interpersonal relationships
 6 month duration of symptoms
 Bleuler’s 4 As
– Autism
– Affect
– Associative Looseness
– Ambivilance
Etiology
 Genetic
– Abnormal marker gene on chromosome # 5
– Heredity determines one’s predisposition
 Both parents schizophrenic = 20-50 % ↑↑ risk
 Identical twins = 50-75 % ↑↑ risk for sibling
 Biochemical
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Altered Neuroanatomy ▲s in cortex
↑↑ DA activity (2x DA receptors) = Psychosis
↓ AcH = ↑ Confusion,
↓ NE = Anhedonia
↑ 5-HT = ↑ Aggressive tendencies
↓Glutamate = learning & memory
↓Glucose metabolism & ↓ GABA
Psychological
 Poor early mother-child relationship
– “Trust vs Mistrust”
 ↓ Ego boundaries
 Dysfunctional family system
 Double-bind communication
– Say one thing but mean the opposite
 Environment
– ↓ Socioeconomic = ↑ stress & ↓ ↓ resources
– Stressful life events precipitate onset!
Pre Schizophrenia
Schizoid Personality
Isolate themselves, “loners”
Indifferent, cold, aloof
↓ Range of emotional expression
Don’t enjoy close relationships
Prodromal “Pre-Schizophrenic”
Socially withdrawn- Blunted affect
Eccentric behavior & Bizarre ideas
Unusual perceptual experiences
↓ Role performance ↓ADLs
Active Schizophrenia
Prominent psychotic symptoms >6 months
Delusions
False, fixed belief
Grandiose, Persecutory, Paranoia, Religiosity
Hallucinations
False sensory perception
Ideas of Reference
Disorganized Behavior
Impaired work, social relations & self care
Disorganized Speech
Associative Looseness
Clanging
Echolalia
Word Salad
Poverty of Speech
Neologisms
Active Schizophrenia
 Secondary Symptoms
– Anxiety
Substance Abuse (ETOH, coke)
– Depression > 25%
– ↑↑ Suicide (10%) = Leading cause of death
– Compulsive H2O drinking 4-10 L/day
 H2O intoxication
 ↓ Na = Lightheaded
N&V
 Confusion
 Coma
Lethargy
Muscle cramps
Residual Schizophrenia
Periods of remissions & exacerbations
– Similar to Prodromal phase
– Social withdrawal
– Flat affect
– Impaired Role Performance
Paranoid Schizophrenia
 Preoccupied - 1 or more delusions
 Persecution or Grandeur
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Related auditory hallucinations
Argumentative
Hostile
Aggressive
Tense
Suspicious
Hypervigilent
Disorganized Hebephrenic
Schizophrenia
 Onset before age 25
 Chronic flat, inappropriate affect
 Silliness, giggling, masturbating in
public
 Bizarre behavior
 Facial grimacing & mannerisms
 Impaired social interaction
 ↓ Contact with reality
 Incoherent speech & concrete thinking
Catatonic Schizophrenia
 Least common
 Sudden onset & good prognosis
Catatonic Excitement
 Extreme psychomotor agitation
 Purposeless movements – Echopraxia
– ↑ risk of injury to self/others
 Continuous incoherent shouting – Echolalia
Catatonic Stupor
 Extreme psychomotor retardation
 Mute & Waxy Flexibility (Bizarre posturing)
Undifferentiated Chronic
Schizophrenia
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Disorganized-bizarre behavior
Usually docile and not aggressive
Does not meet criteria of other subtypes
Delusions & Hallucinations are
prominent
Residual Schizophrenia
(Pseudo-neurotic)
 Follows an acute episode
 Absence of prominent symptoms
 No delusions or hallucinations
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Social isolation
Poor Grooming
Eccentric behavior
Emotional Blunting
Schizoaffective Disorder
 2 week period of predominant psychotic
episode (↑ incidence in women)
 Delusions
Hallucinations
 Disorganized behavior
 ↑ Sexuality Racing thoughts
 Mood Disorder (affective) behaviors
 Mania – Euphoria
– Grandiosity & Hyperactivity
 Depression –
– Psychomotor retardation & suicidal ideation
 ↓↓ Occupational & social functioning
Characteristics
 Positive
– Excess or distorted inappropriate behaviors
– Disorganized thinking
– Not seen in mentally healthy adults!
 Negative
– Loss or decrease of appropriate function
– Diminished emotional expression
 Anhedonia
 Apathy
 Poverty of thoughts
Characteristics
Positive
Delusions
Hallucinations
Echopraxia
Echolalia
Neologisms
Associative Looseness
Flight of Ideas
Negative
Concrete thinking
Avolition
Catatonic Stupor
Social withdrawal
Poverty of speech
Flat affect
Anhedonia
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Assessment
Mental Status Exam (Provides baseline data)
– Appearance & General Health
 Dress
 Eye Contact
Grooming
Motor Behavior
Facial Expression
Posture
– Speech
 Pace
 Tone & Modulation
Spontaneity
Clarity
Volume
Interruptions
– Level of Consciousness
 General Responsiveness
Sensorium
– Emotional State
 Mood
Affect
Intensity
Appropriateness
– Cognitive Function
 Thought Process
 Concentration
Content
Abstract Thinking
Perceptions
Insight/Judgment
Nursing Interventions
Primary Goal = Patient Safety
 Establish trust & listen closely
– Accepting attitude & Keep promises
 Calm approach & non-threatening
environment
– Prevent violence & ↓ Anxiety
 Clarify & reinforce reality
– Orient to here & now
 Address physical needs
 ↑ Self esteem
Psychotic Symptom Interventions
Delusions
Accept experience, identify content & triggers
Encourage reality oriented conversation
Use distraction & refocus
Role model coping techniques to ↓ anxiety
Hallucinations
Focus on the behavioral cue
(laughing, talking, turning head)
Have Pt describe what is happening
Identify environmental & emotional triggers
To prevent aggressive responses
Avoid touching without 1st warning
Psychotic Symptom Interventions
Impaired Communication
Role model clear communication
Use simple, concrete statements
Seek clarification & validate content
Vebalize the implied
Paranoia
↓ Environmental stimulation
Maintain eye contact
Provide plenty of personal space
Always announce your presence
↓ Impulsivity
“Time Outs” for rest
Psychotic Symptom Interventions
Ritualism
Initiate conversation as ritual is performed
Assess for behavioral cues indicating ↑ anxiety
Negotiate a schedule for ritual & ADLs
Social Withdrawal
Convey nonverbal acceptance & worthiness
Provide brief & frequent 1:1 contacts
Initiate interaction & gradually expand social contacts
↑ Social skills training
Rules & expectations
Cognitive Therapy
↑ Decision making
Regression
RN approaches Pt.
↑ Self-Esteem and encourage independent behavior
Antipsychotic (Neuroleptic) Meds
Major Tranquilizers
 ↑↑ Protein Binding (91-99%)
 ↓ Efficacy in men (1/3 relapse + 1/3 disabled)
 Potency
– High
 Fluphenazine (Prolixin) [Decanoate IM q3 weeks]
 Haloperidol (Haldol) [Decanoate IM q4 weeks]
 Trifluroperazine (Stelazine)
– Low
 Chlorpromazine (Thorazine) * 1st drug 1950
 Thioridazine (Mellaril)
Antipsychotic (Neuroleptic) Meds
 Action
– ↓ Agitation ↓ Psychotic Symptoms
– ↓ + Behaviors (Delusions/Hallucinations)
– Block DA receptors =↓ DA
 Improves fine motor movement & coordination
 Sensory integration & emotional behavior
– Anticholinergic Effects (Autonomic NS)
 Dry Mouth
Blurred vision
Constipation
 Sedation
Urinary Retention
Photophobia
 Orthostatic Hypotension
Nasal Congestion
Antipsychotic (Neuroleptic) Meds
 ↑↑ Prolactin Levels
– Sexual/Menstrual dysfunction
– ↓ Libido
– Galactorrhea
– Gynecomastia
– ↑ weight gain
 Cognition
– ↓ Alertness ↓ Concentration
– ↓ Seizure threshold = ↑ Risk of seizures
Antipsychotic (Neuroleptic) Meds
 ExtraPyramidal Side Effects (EPS)
– ↓↓ DA ↑↑ AcH Imbalance
– ↑↑ Incidence with ↑↑ potency meds
 Prolixin, Haldol & Stelazine
 Movement disorder
– Dystonia
– Pseudoparkinsonism
– Akathesia
– Tardive Dyskinesia
ExtraPyramidal Side Effects (EPS)
Dystonia
– Quick onset 1st few hours or days
– ↑ Adolescent males < age 25
– Acute spasms of tongue, face, neck & back
– Hypertonia
– Laryngospasm – Respiratory distress
– Oculogyric Crisis- Rolling back of eyes
– Torticolis- Head twisted to 1 side
– Involuntary uncoordinated movements
 RX: Benadryl 25-50 mg IM/IV
 Cogentin 1-2 mg IM
ExtraPyramidal Side Effects (EPS)
Pseudoparkinsonism
– Appears within 1-5 days
– ↑ women & older Pts
– Drooling, Pill-Rolling of thumb & finger
– Mask-like face, Stooped Posture
– Action Tremors
– Shuffling gait with small steps
– Muscle rigidity
– Bradykinesia
– Cogwheeling
Pseudoparkinsonism RX
 Antiparkinson Meds
– Give to counteract SE & toxic effects
– Only given with documented S/S of EPS
– Restore the balance of DA & Ach
↑↑DA
↓↓ACh
*Amantadine (Symmetrel)
Bromocriptine (Parlodel)
*Benzotropine (Cogentin)
*Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)
ExtraPyramidal Side Effects (EPS)
Akathesia
– Appears 50-60 days
– Motor restlessness “Nervous Energy”
 Jitteriness
 Tapping feet constantly
 Pacing
 Rocking back & forth
 Frequent position changes
 RX: Inderal, Ativan or Valium
ExtraPyramidal Side Effects (EPS)
Tardive Dyskinesia
– Slow & insideous process
– Irreversible after several years of meds.
– AIMS- Abnormal Inventory Movement Scale
 Screen q 3 -6 months
– Involuntary movements of
 Limbs, trunk & face.
– Bizarre facial movements
 “Fly catching” with tongue
 Lip smacking
– Difficulty swallowing
– Irregular respirations
Neuroleptic Malignant Syndrome (NMS)
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Rare idiosyncratic reaction 1% young men
↑ Incidence with ↑↑ potency meds & ↓↓ DA
Abrupt onset & rapid progression
10% mortality rate
Signs
– Severe muscle rigidity
Hyperreflexia (+4)
– Hyperthermia > 105
Diaphoresis
– Altered LOC → Stupor → Coma
– ↑↑ HR ↑↑ RR
– CV Collapse & Respiratory failure = Fatal!
NMS Therapy
 Immediately D/C med!
 Wait 2 weeks before starting new meds (Lithium)
 NO Haldol or Thorazine
 Cooling blanket
O2
Medications:
MSO4 (Morphine sulfate)
 ↓ pain & ↓ VS
Tylenol
 ↓ Temp and pain
Dantrolene (Dantrium)
 muscle relaxant & ↓ Temp
Bromocriptine (Parlodel)
 Dopaminergic = ↓ EPS toxicity
IV Fluids
Atypical Medications
Serotonin
Dopamine
Relieves
(+) & (-)
Behaviors Antagonists
↓ EPS ↓ Prolactin
 Clozapine (Clozaril)
– Binds to 5-HT2, Alpha1,2, H1, & DA receptors
– SE- National registry to monitor SEs!
 Agranulocytosis
–WBC < 3000 or ANC < 500 = D/C med!
–Mandatory weekly CBC 1st 6 months
 Then q other week
 Drowsiness ↑Salivation
↑Dizziness
 ↑ HR
↑Weight
 ↑ Risk for IDDM
Prolonged QT interval
Atypical Medications
 Risperidone (Risperdal)
– ↓↓ DA ↓ 5-HT ACh & NE
– Readily absorbed
– Active metabolite is clinically effective
– Resperdal Consta 25 mg IM q 2 weeks
– SE
 Sedation/Insomnia
 Orthostatic Hypotension
 ↑↑ Appetite = Weight gain
 Tardive Dyskinesia
Atypical Medications
 Olanzapine (Zyprexia)
– Antagonizes DA & 5-HT receptors
– SE: Insulin Resistance
 Quetiapine (Seroquel)
– √ renal function
 Ziprasidone (Geodon)
– ↓ Depression & Anxiety
– √ EKG for prolonged QT wave
 Paliperidone (Invega Sustenna)
– IM q 4 weeks
 Aripiprazole (Abilify)
DA system stabilizer PO & IM
Medication Administration
 Schedule
– Initially take meds in divided doses 2-4x/day
– Non-compliant Pts:
 Haldol decanoate IM q 4 weeks
 Prolixin decanoate IM q 3 weeks
 Resperdal Consta IM q 2 weeks
 Invega Sustenna IM q 4 weeks
 Efficacy
– Takes 1- 4 weeks for significant response
– Once symptoms are controlled ▲ HS ↓↓ SE
 Dosage
– Use lowest dosage to ↓ risk of Tardive Dyskinesia
Patient Teaching
 Medication
– Generic & trade name, dose, action & SE
– Assess SE “How is medication working?”
 Interventions & when to notify RN/MD
– Carry card with Med ID
– NO ETOH or illegal substances
– Don’t stop taking drug abruptly
– Don’t ▲ position rapidly
Patient Outcome Evaluation
 Slow progress
– Services are needed long-term (decades)
 Set small achievable, short-term goals
 Assess effective coping skills
 Obtain Pt & family input
– Pt. safety
Communication skills
– Social Skills
Self-Esteem
– Health Promotion
– Medication compliance
– Support system
– Living in least restrictive setting