Transcript Schizophrenia and Psychotic Disorders ppt chap 21

Schizophrenia and Psychotic
Disorders
Chapter 21
Rochelle Roberts RN MSN
Schizophrenia
• Introduced by Swiss
psychiatrist Eugene
Bleuler in 1911
• Schizein- “to split”
Phren -“mind”
• Reflects a split from
the emotional and
cognitive aspects of
personality
Symptoms of Schizophrenia
• Positive symptoms are exaggerated
behaviors such as delusions, hallucinations,
disorganized speech, bizarre behavior.
• Negative symptoms include loss of
behaviors such as loss of affect, inability to
maintain social contacts, impaired decision
making, and inability to maintain attention.
Symptoms
• Problems with
information
processing (abnormal
brain function)
• Inability to produce
logical thoughts and
express coherent
sentences
Problems in Cognitive
Functioning
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Short and long-term memory problems
Poor attention span
Easy distractibility
Illogicality
Pressured speech
Lack of insight, judgment, and lack of problemsolving
• Inability to think abstractly
Problems in Cognitive
Functioning (cont)
• Literal interpretation
of words
• Magical thinking:
“When I stepped on a
crack in the sidewalk,
it caused my mother to
fall and hurt herself
the same day. I caused
this to happen.”
Problems in Cognitive Function
(cont)
• The person’s brain processes data
inaccurately
• Delusions-false beliefs that are not shared
by others (religious, somatic, grandiose)
Perceptual Distortions
• Are often the first
symptoms in many brain
illnesses
• Hallucinations –false
perceptual distortions
• Types include:
• Auditory 70%
• Visual 20%
• Olfactory
• Tactile (experiencing pain)
Sensory Integration problems
• Neuro “soft signs”-deficit in an
undetermined location but are consistent
with brain injury to the frontal or parietal
lobes.
• Impaired fine motor skills, inability to
recognize objects by the sense of touch
(astereognosis), mild muscle twitching,
increased eye blinking.
Emotions
• Mood- a sustained feeling tone
• Affect- refers to behaviors such as facial
expression, hand and body movements, and
voice pitch
Emotions Related to
Schizophrenia
• Hypoexpression-perception that one no
longer has any feelings
• Alexithymia-difficulty naming & describing
emotions.
• Anhedonia- inability to experience pleasure
• Apathy- lack of feelings, emotions,
interests, or concern
Maladaptive Behaviors in
Schizophrenia
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Deteriorated appearance
Negativism
Avolition –lack of energy or drive
Stereotyped behavior -(wearing only certain
clothes, etc)
• Lack of persistence at work or school
• aggression
Maladaptive movements
• Abnormal eye movements
• Catatonia (stuporous state
associated with posturing)
• Abnormal gait
• Grimacing
• Apraxia-inability to carry
out a purposeful task, like
dressing.
Schizophrenia Socialization
Problem Behaviors
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Inability to communicate coherently
Loss of interest and drive
Deterioration of social skills
Poor personal hygiene
paranoia
Indirect Effects on Socialization
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Low self-esteem
Social inappropriateness
Inappropriate sexual behavior
Stigma related withdrawal by friends, and
family
• Disinterest in recreational activities
Social Isolation
• Caused by stigma
• Literal definition
means “mark of
shame”
• As students, describe
your own attitudes
about stigma
Predisposing factors
• Combination of genetic and environmental factors
• Neurobiological factors –imaging studies show
decreased brain volume (white matter). Findings
include atrophy in the frontal lobe, cerebellum and
limbic structures. There are also alterations in
neurotransmitters (dopamine, serotonin, and
glutamate)
Genetic Risk for Schizophrenia
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Fraternal twin
Identical twin
Sibling
One parent affected
Both parents affected
No affected relative
50 % risk
15 % risk
10 % risk
15% risk
35% risk
1% risk
Theories regarding causes of
schizophrenia
• Dysregulation Hypothesisneurotransmitters causing unstable
neurotransmission regarding dopamine and
serotonin.
• Neurodevelopment theory-several brain
structures are abnormal that interfere with
memory (prefrontal cortex and
hippocampus)
Theories regarding causes of
schizophrenia
• Viral Theories-mixed evidence that prenatal
exposure to the influenza virus during the
2nd trimester of pregnancy may influence
the etiology.
• Sociocultural theory-stress related to
poverty, society, and environment may be a
factor.
Biological Stressors
• Information-processing overload
• Abnormal “gating mechanisms” refers to
nerve potentials and feedback systems
within the nervous system.
Some Common Triggers
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Poor nutrition
Lack of sleep
Infection
Hostile environment
Social isolation
“Hopeless” attitude
Poor social skills
Stress Diathesis Model
• Schizophrenia is made worse by stress and
causes stress.
• Liberman (1994)
• Schizophrenia symptoms develop based on
the amount of stress a person experiences
and an internal stress threshold.
Nursing Diagnoses
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Impaired verbal communication
Disturbed sensory perception
Impaired social interaction
Disturbed thought processes
Medical Diagnoses
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Schizophrenias
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared psychotic disorder
Outcome Identification
• The patient will live, learn, and work at a
maximum possible level of success, as
defined by the individual.
• Prevention of relapse is key.
• Relapse is the return of symptoms severe
enough to interfere with ADL’s.
Planning
• When the person is in the acute or crisis
stage of illness, care is often given in a
hospital.
• Overall goal: help the patient reach stability
while establishing a foundation for rehab
and recovery
Interventions
• In crisis and acute
phases:
• Most important is
patient safety
• Help the patient feel
safe
• Manage delusions and
hallucinations
Strategies for working with
patients with delusions
• Avoid becoming incorporated into the delusion
• Respond to the underlying feelings rather than the
illogical nature of the delusion
• Place the delusion in a time frame
• Identify emotional components
• Observe speech for thought disorder
• Promote activities that require physical skills
Strategies for working with
patients who have hallucinations
• Establish a trusting relationship
• Ask the patient to describe what is
happening and gain control of his
hallucinations
• Identify if drugs or alcohol has been used
• Identify needs that may trigger
hallucinations
Psychopharmacology
• Clozapine- limited use for patients who are
treatment resistant to typical antipsychotics,
because of its potential to cause agranulocytosis.
Other atypical antipsychotics are Risperdal,
Olanzapine, Seroquel, Geodon and Abilify.
Typical antipsychotics include: Navane, Haldo,
Loxatane, Moban,and Orap.
Interventions in the Maintenance
Phase
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Teach self-management of symptoms
Identify symptoms of relapse
Patient teaching should involve caregivers
Cognitive reframing
Stages of Relapse
• Stage 1: Overextension: patient feels
overwhelmed and overloaded.
• Stage 2: restricted consciousness:depression is
coupled with anxiety and withdrawal. Crucial to
intervene during stage 1 or 2
• Stage 3: disinhibition: emergence of hallucinations
and delusions that patient can no longer control.
(first appearance of psychotic features)
Stages of relapse (cont)
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Stage 4: Psychotic disorganization:
intensification of hallucinations and
delusions and patient loses control. Three
distinct phases here:
a) patient no longer recognizes familiar
environment (destructuring of the external
world)
Stages of relapse (cont)
a) patient loses personal identity called
destructuring of self.
b) Total inability to differentiate reality from
psychosis (loudly psychotic)
Stage 5: psychotic resolution-the patient is
medicated and still experiencing
psychosis, but the symptoms are “quiet”
Managing Relapse
• Awareness of the onset of behaviors indicating
relapse
• Prodromal phase occurs before relapse. Time
between the onset of symptoms and the need for
treatment.
• Identify and manage symptoms helps decrease the
# and severity of relapses.Teach the patient to “self
report” symptoms, problems with meds, and
difficulties with ADL’s.
Common Causes of Relapse
• Patients will most likely stop taking their
meds some time in the first year after
diagnosis
• Problematic side effects
• Symptoms are gone
• Med didn’t work
Causes of Relapse (cont)
• Studies show that without medication,
people with schizophrenia relapse at a rate
of 60-70 % within the first year of diagnosis
• Noncompliance occurs even when patient
education is peformed
Interventions in the Health
Promotion Phase
• Focus in on prevention of relapse and
symptom management through engaging
the patient in a healthy lifestyle.
• Psychotherapy may be helpful and the focus
is supportive and nonconfrontational.
Atypical Antipsychotic Drugs
• Improve the symptoms of schizophrenia
• They rarely cause EPS or tardive dyskinesia
• Disadvantage of atypical drugs is their
increase in cost over the typical antipsychotic drugs
• Cost is outweighed by improved
effectiveness and quality of life experienced
by patients
Side effects of atypical drugs
• Risperidone tends to elevate prolactin levels
• Weight gain (high likelihood with clozapine
and olanzapine)
• Sedation is commonly observed with
clozapine & olanzapine
• Zaprasidone (Geodon) may prolong the Q-T
interval.
Side effects (cont)
• Clozapine is usually reserved for patients
with treatment resilient illness because of its
side effect of agranulocytosis, seizures, and
myocarditis. Strict protocol is required by
prescribers, including entering patients into
a national registry, monitoring WBC count
weekly for 6 months, and writing scripts for
only 1 to 2 weeks at a time.
Typical Antipsychotics
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Thorazine
Mellaril
Trilafon
Stelazine
Prolixin
Haldol
Loxitane
Side Effects of Typical
Antipsychotics
• EPS decrease dose or add drug to treat EPS
• Akathisia- pacing, legs ache
• Dystonia-spasms of muscle groups of neck,
back an eyes
• Tardive dykinesia-involuntary movements
(tongue protrusion, blinking, grimacing,
foot tapping)
Side effects (cont)
• NMS -Neuroleptic Malignant syndrome is
potentially fatal: fever, tachycardia, sweating,
muscle rigidity, tremor, elevated creatine
phosphokinase, renal failure
• Seizures- occurs in about 1% of cases; clozapine
has 5% rate
• Agranulocytosis-leukopenia, fever; this is an
emergency situation-high incidence with
clozapine, do weekly CBC
Other side effects
• Photosensitivity patients must use sunscreen
and sunglasses
• Anticholinergic side effects- constipation,
dry mouth, blurred vision, urinary retention