Transcript Schizophrenia and Other Psychotic Disorder

Psychiatric / Mental Health Nursing
NURS 204





Prevalence in U.S. is 1.1%.
Average onset is late teens to early
twenties, but can be as late as mid-fifties
Affects cognitive, emotional, and behavioral
function
30% to 40% relapse rate in the first year
Life expectancy is shortened because of
suicide






Language and communication disturbances
Thought disturbances
Perception disturbances
Affect disturbances
Motor behavior disturbances
Self-identity disturbances

Progression varies from one client to
another
◦ Exacerbations and remissions
◦ Chronic but stable
◦ Progressive deterioration

DSM-IV-TR Diagnosis
◦ Symptoms present at least 6 months
◦ Active-phase symptoms present at least 1 month
◦ Symptoms are defined as positive and negative

Positive symptoms
◦ Excess or distortion of normal functioning
◦ Aberrant response

Negative symptoms
◦ Deficit in functioning

Positive Symptoms of Schizophrenia
◦ Hallucination:
 Auditory, Visual
 Olfactory, Gustatory, Tactile
◦ Delusions:




Persecutory, Referential
Somatic, Religious,
Substitution, Thought Insertion and/or Broadcasting
Nihilistic, Grandiose
◦ Disordered speech:
 Loose Association, Word Salad
 Clanging, Echolalia, Neologism
◦ Disordered behavior:
 Disorganized walk
 Touching all objects and surfaces
 Catatonia
◦ Disordered Thinking:
 Indecisiveness, lack of problem solving skills,
 Concreteness, blocking, perservation

Negative Symptoms of Schizophrenia
◦ Flat affect: lack of emotion
◦ Apathy: indifference towards people, events,
activities and learning.
◦ Alogia: Poverty of speech
◦ Avolition: inability to pursue and persist in goaldirected activities.
◦ Anhedonia: inability to experience pleasure.





Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual Type

Paranoid Type
◦ Delusions
 Persecutory and grandiose
 Somatic or religious
◦ Hallucinations
 Delusions link with a hallucination

Disorganized type
◦
◦
◦
◦
Disorganized speech, behavior, appearance
Flat or inappropriate affect
Fragmented hallucinations and delusions
Most severe form of schizophrenia

Catatonic type
◦
◦
◦
◦
◦
◦
Psychomotor retardation and stupor
Extreme psychomotor agitation
Waxy flexibility
Echolalia
Mutism
Echopraxia

Undifferentiated type

Residual type
◦ Active psychotic state
◦ Lacks symptoms of other subtypes
◦ At least one episode of schizophrenia
◦ No prominent positive symptoms
◦ Negative symptoms present






Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared Psychotic Disorder (Folie à Deux)
Induced or Secondary Psychosis




Biologic theories
Psychological theories
Family theories
Humanistic-interactional theories

Biologic Theory: Genetic
◦ Only genetic predisposition for developing
schizophrenia is inherited
◦ 10% of first-degree relatives
◦ 25%-39% of monozygotic twins

Biologic Theory: Brain Structure Abnormality
◦ Differs from those with no symptoms
◦ May be genetically based
◦ Requires more study
Schizophrenia scans. PET scans of discordant monozygotic twins taken during
a test to provoke activity and measure regional cerebral blood flow. (A) Arrows
indicate areas of normal blood flow and brain activity in the unaffected twin. (B)
Arrows indicate areas of lower blood flow and brain activity in the twin with
schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain
Disorders Branch, National Institute of Mental Health

Biologic Theory: Biochemical Theories
◦ Dopamine hypothesis
◦ Traditional antipsychotic medications are dopamine
blockers
◦ Dopamine blocker alleviate positive symptoms

Psychological theories
◦ Information processing
 Difficulty controlling the amount and type of
information that is processed in the brain.
◦ Attention and arousal
 Hyper or hypo responsiveness to various situations

Family Theories
◦ Dysfunctional interaction not supported by
research
◦ Disordered family communication linked only
with genetic predisposition
◦ Family emotional tone influences course of
schizophrenia
◦ Expressed emotions theory (EE)


Humanistic-interactional theories integrate
biological and psychosocial theories
Combine influences of:
◦ Genetic predisposition or biologic vulnerability
◦ Environmental stressors
◦ Social support

Stress–Vulnerability Model
◦ Stressors increase vulnerability
◦ Cumulative effect of:




Genetic predisposition
Personal stressors
Familial factors
Environmental factors

Social Pressures
◦ Lack of social support
◦ Financial problems
◦ Stigma

Psychological pressures
◦
◦
◦
◦
◦
Difficulty with problem-solving
Difficulty with interpreting reality
Difficulty coping
Problems with self-care
Unstable interpersonal relationships

Assessment
◦
◦
◦
◦
◦
◦
◦
◦
Premorbid functioning
Content of thought
Form of thought
Perception
Sense of self
Delusions and perceptual disturbances
Hallucinations
Drug use

Nursing Diagnoses
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Disturbed thought process
Disturbed sensory perception
Social isolation
Risk for violence
Self-care deficits
Altered health maintenance
Ineffective coping
Impaired verbal communication
Excess Fluid Volume
Decisional Conflict
Dysfunctional or Interrupted family process

Family needs vary with degree of illness and
involvement in client’s care
◦
◦
◦
◦
Education
Financial support
Psychosocial support
Advocacy

Schizophrenia is a “family illness.”
Family members need to be involved.
Educate family about

Nurse assists family by


◦ Medication
◦ Illness
◦ Relapse prevention
◦ Identifying community agencies/groups for
family members
◦ Advocating for rights








Promote Safety and a Safe Environment
Promote Congruent Emotional Response
Promote Social Interaction and Activity
Intervene with Hallucinations and Delusions
Preventing Relapse
Promoting adherence with medication
regimen
Assist with grooming and hygiene
Promote Family Understanding and
Involvement

Relapse prevention programs provide
education and support regarding:
– Individual triggers, symptoms of relapse
– Managing side effects of medications
– Interventions to reduce or eliminate triggers
– Strategies to facilitate early intervention
– Cognitive therapy
– Community resources






Side effects of Psychotropic Medications
Level of symptomatology
Cognitive, motivational, financial, and
cultural issues
Issues with caregivers
Insufficient medication teaching
Substance abuse





Involve clients in treatment
Instruct client about reducing discomfort
Provide peer support
Provide reminders and positive feedback
Recognize accomplishments







Identify personal feelings and recognize
personal perceptions.
What behaviors do you expect to see?
How will you respond to these behaviors?
What is the meaning of the behaviors?
What defines “normal” behavior?
What are my fears associated with mental
illness?
Remember that clients are human beings
with a mental disorder and do not choose
to be this way.


A primary treatment mode of psychiatricmental health nursing care
ANA Task Force Guidelines
◦ Integrate current data from the neurosciences.
◦ Demonstrate knowledge of psychopharmacologic
principles.
◦ Provide safe and effective care of clients taking
these medications.




Prior to the 1950s: focus on behavioral
interventions and sedatives
Mid-fifties: Introduction of the first antipsychotic
medication chlorpromazine (Thorazine)
Since then, many advances have led to the
treatment of the client with mental illness in the
community.
Psychiatric medications allow for the correction of
imbalances of brain chemicals.
The great success of biological psychiatry. This graph illustrates the
dramatic decrease in psychiatric inpatient numbers since the inception of
psychopharmacology.

Typical (Conventional)
◦ Block dopamine receptors at 70% to 80% occupancy
to be effective.

Exptrapyramidal Side Effects (EPSEs) occur at
occupancy > 80%


Ongoing research on new medications
Ongoing research on new delivery systems
◦ Newer depot: Resperidone Consta
◦ Orally Disintegrating Tablets: Zyprexa Zydis

Some ethnic groups are slow metabolizers.
◦ More side effects
◦ Greater risk of toxicity

Some ethnic groups are fast metabolizers.
◦ Less effect of the medication

Positive Effects

Alleviation of the symptoms, often improving:
◦ Allowed release of clients from inpatient hospital to
treatment in the community
◦ Manage the symptoms such as delusional thinking,
hallucinations, confusion, motor agitation, motor
retardation, blunted affect, bizarre behavior, social
withdrawal and agitation.
◦ Ability to think logically
◦ Ability to function in one’s daily life
◦ Ability to function in relationships

Negative Effects
◦ Frightening and life threatening side effects
◦ Potential interactions with other medications and
substances
◦ Possible need to cope with the realization of
having a chronic illness


Adherence to prescribed medications by clients in
psychiatric services is less than 35%
Reasons for nonadherence:
◦
◦
◦
◦
Clients do not know what to expect from medications.
The schedule of doses or routes may be inconvenient.
Friends/relatives may not be supportive.
Side effects may be worst than the symptoms.
A careful assessment is needed to decide the
right form of the medication:
 PO - by mouth (for routine use)
 Liquid form (concentrate or syrup)
 Quick-dissolving formulation (sublingual)
 PRN injection
 Depot injection

Atypicals
◦
◦
◦
◦
Reduced affinity for dopamine receptors
Affinity for serotonin receptors
Fewer EPSEs
Reduction in negative symptoms

Side effects

◦ ANS, extrapyramidal, other CNS, allergy, blood,
skin, eye, endocrine, and weight gain
The five categories of EPSEs are dystonia, druginduced parkinsonism, akathisia, tardive
dyskinesia, and dopamine-acetylcholine imbalance




Occurs usually within 48 hours of initiation of
the medication
Involves bizarre and severe muscle
contractions
Can be painful and frightening
Characterized by odd posturing and strange
facial expressions (Torticollis, Opisthotonus,
Laryngospasm, Oculogyric Crises)


Usually occurs after 3 or more weeks of
treatment
Characterized by:
◦
◦
◦
◦
◦
◦
Cogwheel rigidity
Tremors at rest
Rhythmic oscillations of the extremities
Pill rolling movement of the fingers
Bradykinesia
Postural Changes





Usually occurs after 3 or more weeks of treatment
Subjectively experienced as desire or need to move
Described as feeling like jumping out of the skin
Mild: a vague feeling of apprehension or irritability
Severe: an inability to sit still, resulting in rocking,
running, or agitated dancing



Usually occurs late in the course of long-term
treatment
Characterized by abnormal involuntary
movements (lip smacking, tongue protrusion,
foot tapping)
Often irreversible





Inability to wear dentures
Impaired respirations
Weight loss
Impaired gait
Impaired posture


A rare side effect
Characterized by hallucinations, dry mouth,
blurred vision, decreased absorption of
antipsychotics, decreased gastric motility,
tachycardia, and urinary retention





Dry mouth
Blurred vision
Constipation
Urinary retention
Tachycardia


Sedation
Lowering of the seizure threshold:
◦ Observe clients with seizures disorders carefully
when treatment is initiated.

Some antipychotics may contribute to
prolongation of the QTc interval and lead to
arrhythmias.
◦ An EKG can identify those at risk.



Agranulocytosis
Skin photosensitivity
Retinitis pigmentosa


Early symptoms: beginning signs of infection
White blood cells are routinely monitored in
clients taking clozapine (Clozaril).

Hyperprolactinemia may cause:
◦ Oligomenorrhea or amenorrhea in women
◦ Galactorrhea in women and rarely in men
◦ Osteoporosis if prolonged


Impotence in males may occur.
Diabetes
◦ Monitor blood glucose levels.



Monitor weight
Teach about diet and exercise
Weight gain may contribute to physical as
well as psychosocial stressors



Typically occurs in the first 2 weeks of
treatment or when the dose is increased
Hold the medication, notify the physician, and
begin supportive treatments.
Symptoms: muscle rigidity, tachycardia,
hyperpyrexia, altered consciousness, tremors
and diaphoresis

Risk Factors
◦
◦
◦
◦
◦

Dehydration
Agitation or catatonia
Increase dose of neuroleptic
Withdrawal from anti-parkinson medication
Long acting or depot medication
Pharmacologic treatment
◦ Antipyretics
◦ Muscle relaxant
◦ Dopamine receptor agonist


A primary nursing role is to teach patients
about the major side effects of psychotropic
medications and how to manage them.
Nurses must monitor for side effects and
intervene when necessary.



Dsytonia and drug-induced parkinsonism are
treated by anticholinergics.
Akathisia may be treated with anticholinergics but
is not always responsive.
Tardive dyskinesia treatment is preventive through
careful and routine assessment.



Take the client’s blood pressure in a supine
position and then in a standing position.
Caution clients to rise slowly from a supine
position.
Anticholenergic Side Effects:
◦
◦
◦
◦
◦
Ice chips, hard candy
Eye drops
Fiber diet, exercise
Increase fluid intake
Catheterization

Typical Agents
◦ Low Potency
 Chlorpromazine (Thorazine) (25 – 800 mg/d)
 Thioridazine (Mellaril) (150 – 800 mg/d)
 Mesoridazine (Serentil) (100 – 400 mg /d)
◦ Side Effects:
 Sedation, Anticholernergic, Hypotention,
 EPSEs (less vs high potency)

Typical Agents
◦ High Potency









Haloperidol (Haldol) (1 – 30 mg/d)
Fluphenazine (Prolixin) (0.5 – 40 mg/d)
Thiothixene (Navane) (2 – 30 mg/d)
Trifluoperazine (Stelazine) (1 – 40 mg/d)
Perhenazine (Trilafon) (8-60 mg/d)
Loxapine (Loxitane) (20 – 250 mg/d)
Molindone (Moban) (50 – 225 mg/d)
Pimozide (Orap) 0.5 – 9 mg/d)
Side Effects
 Sedation, Anticholenergic SE (less vs low potency)
 EPSEs

Atypical Agents
◦ Clozapine (Clozaril) (6.25 – 900 mg/d)
 Side effects: seizures, agranulocytosis, weight gain,
hypersalivation, anticholinergic
◦
◦
◦
◦
Olanzapine (Zyprexa, Zyprexa Zydis) (5 – 20 mg/d)
Paliperidone (Invega) (3 – 12 mg/d)
Quetiapine (Seroquel) (150 – 600 mg/d)
Risperidone (Risperdal, Risperdal M-Tab)
(2 – 6 mg/d)
◦
◦
◦
◦
Ziprasidone (Geodon) ( 40 – 160 mg/d)
Aripiprazole (Abilify) (15 – 30 mg/d)
Asenapine (Saphris) (5 – 10 mg/d) Sublingual
Iloperidone (Fanapt) (12 – 24mg/d)

Typical Agents
◦ Haloperidol Decanoate (Haldol Decanoate)
 Q4 weeks
◦ Fluphenazine Decanoate (Prolixin Decanoate)
 Q2 Weeks

Atypical Agents
◦ Risperidone Consta (Risperdal Consta)
 Q2 Weeks
◦ Paliperidone Sustenna (Invega Sustena)
 Q4 weeks




Trihexyphenidyl (Artane)
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Amantadine (Symmetrel)