Transcript Schizophrenia Pwr Pnt

Schizophrenia
Schizophrenia
• It is a brain disorder of unknown etiology
• Theories of causation include: genetics,
biochemistry, and psychosocial factors
• Symptoms vary greatly among different patients
depending on what area of the brain that is
primarily effected.
• Treatment varies to meet individual needs, tho
usually includes psychotropic medications, pt.
and family education and social support
Incidence and Prognosis
• In all societies, occurs in 1% of population with
slightly higher incidence in males
• Prognosis: approx. 25% remain highly functional
• 50% remain non-functional
• 25% are in-between, in and out of hospital
• Age of onset is late adolescence/ early adulthood
Prognosis
• Acute phase
– Severe psychotic symptoms
• Stabilizing phase
– Patient is getting better
• Stable phase
– May still have hallucinations and delusions
– Not as severe
• Most patients alternate between acute and stable
phases
GENETIC
ENVIRONMENT
Etiology
BIOCHEMICAL
Brain structure
and
Function
GENETICS
• Probability of Schizophrenia in
Families
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1 parent 10% probability
1 sibling 10%
Identical twin 50%
Both parents varies 40%
A gene identified ---research continues
BIOCHEMICAL
• Too much dopamine overwhelms the brain and
binds with too many receptors and causes
positive symptoms, therefore, anti-psychotics act
as dopamine antagonist
• Ratio between serotonin and dopamine, therefore
atypical anti-psychotics effect serotonin also.
• Endogenous dopamine antagonist is GABA
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• Can you induce psychosis?
– Marijuana, LSD, Amphetamines
BRAIN STRUCTURE AND
FUNCTION
PET SCAN
ILLUSTRATES
FUNCTIONAL DIFFERENCES
IN THE LIVING BRAIN
PET Scan and Schizophrenia
MRI Comparing Identical
Twins:
One without Schizophrenia and
One with Schizophrenia
• When the ventricles are enlarged the brain has
lost mass; tissue has shrunk
ENVIRONMENTAL
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Inherited susceptibility to schizophrenia
Prenatal infections
Poor Family Communication
Greater % of pts. come from lower socioeconomic class
• STRESS
• Can you make someone a schizophrenic?
• What about prevention?
STRESS: Onset or
Relapse
• Biological (medical illness)
• Psychological (loss of a relationship)
• Sociocultural (homeless)
• Emotional (persistent criticism)
Bleuler’s 4 A’s
• Affective Disturbance:
– Inappropriate, blunted or flattened
• Autistic Thinking:
– Preoccupation with the self
– Little concern for external reality
• Associative Looseness
– Stringing together of unrelated topics
• Ambivalence
– Simultaneously opposing feelings
DSM IV Criteria:
Schizophrenia
• Delusions: false fixed beliefs
• Fixed Delusions (permanent; not affected by
medications)
• Hallucinations (auditory; visual; tactile)
• Disorganized Speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
– flat affect, apathy, alogia (inability to speak).
– Generally, 2 or more symptoms need to be present for 1
month for diagnosis
DSM IV Criteria Cont.
• Social or Occupational dysfunction
– Pts. ability to perform self care, work or relate to people
has declined markedly.
• Duration
– Decline in function for this criteria must be six months.
• Exclusions
– R/O Schizoaffective disorder and mood disorder
– R/O substance abuse and OBS
– R/O pervasive developmental disorder (autism)
Positive symptoms of
Schizophrenia
• Positive Symptoms (+) Person with schizophrenia
does more (+) than Person who is functioning
normally
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agitation/aggression
delusions
hallucinations
formal thought disorder:loose associations, word salad
bizarre behavior
• Typical Anti-psychotic meds usually control these
symptoms
Negative symptoms of
Schizophrenia
• Negative Symptoms (-) Person with schizophrenia
does less (-) than Person who is functioning
normally
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flat affect
avolition; lack of direction or purpose
ambivalence; indecisive and changeable
constricted, concrete thinking
alogia; poverty of speech
social withdrawal; anhedonia
deep apathy
minimal or poor self care
• Atypical antipsychotics will help these symptoms
Schizophrenia Subtypes
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Paranoid
Catatonic
Disorganized
Undifferentiated
Residual
Paranoid
• Preoccupation with:
1. Delusions
• Persecution
• Grandiose
• Can be VERY dangerous to others. Can get themselves
into situation where they think they are protecting
themselves and they get themselves killed.
2. Auditory hallucinations
• Command
• No disorganized speech
• Usually neat and clean.
Catatonic
– Stupor
– Negativism
– Rigidity
– Posturing: waxy flexibility
Disorganized
– Disorganized speech
– Disorganized behavior
– Flat or inappropriate affect
– Dissheveled appearance
Undifferentiated
– Positive symptoms
– Do not meet criteria for paranoid.
Residual
– No positive symptoms
– Mostly negative symptoms
– Chronic
Pyschosis-Induced Polydipsia
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Compulsive water drinking (6% to 20%)
Thirst and Osmotic dysregulation
Hyponatremia
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Confusion
Convulsions
Coma
Lightheadedness
Nausea and vomiting
Weakness
Muscle Cramps
Treatment
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Weigh
Restrict fluid
Sodium replacement
Constant supervision
Other Psychotic Disorders
– Psychotic Disorder NOS
– Delusional Paranoid Disorder
– Schizophreniform Disorder
• Symptoms of schizophrenia last one month but no
longer than six months
– Schizoaffective disorder
• A puzzle
• Characterized by:
– Schizophrenic symptoms are dominant
– Accompanied by major depressive or manic
symptoms
Nursing Diagnosis for
Schizophrenia
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Altered thought processes: Delusions
Sensory/perceptual alterations: specify Hallucination
Social isolation
Potential for violence
self-care deficit
Impaired verbal communication
Sleep pattern disturbance
Altered nutrition
Impaired home maintenance management
Related to: Neuro chemical imbalance
Treatment
• Antipsychotic Medication
• Supportive Psychotherapy and Education
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Individual
Group
Milieu
Family
• Social supports
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Follow-up mental health care/Medication
Housing
Day treatment
Employment
Antipsychotic Medications
• Typical
• Atypical
Typical Antipsychotics
• High Potency Neuroleptic
– Haldol (Haloperidol)
– Prolixin (Fluphenazine)
– Available in pills, liquid, Intramuscular and Depo
injection
• Low Potency Neuroleptic
– Thorazine (Chorprmazine)
– Mellaril (Thiroidazine)
• In-betweens
– Stelazine
– Trilafon
– Navane
Antiparkinsonian Agents
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Cogentin (benztropine)
Artane (trihexyphenidyl)
Benadryl (diphenhydramine)
Symetrel (amantadine)
Ativan (Lorazepam)
Acetylcholine and Dopamine
• A balance between dopamine and acetycholine is
required for normal movement
• Antipsychotic meds decrease dopamine, causing
EPS symptoms
• Antiparkinsonian meds act by decreasing ACH,
thus restoring balance
• All antiparkinsonian meds increase the
anticholenergic effects
Side effects of Typical
Antipsychotics
• Extrapyramial Side Effects
(EPSE)
– Acute Dystonia
– Akathisia
– Tardive Dyskinesia
• Anticholenergic effects
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Drowsiness
Dry mouth
Skin reactions, sunburn
Constipation
urinary retention
Orthostatic hypotension
Acute Dystonia
• Oculogyric Crises
– early onset
– Abnormal posture
– involuntary, sustained,
muscle spas
– Sustained twisted
contracted positioning of
the limbs, trunk, neck or
mouth
– This is PAINFUL
– Treated with parenteral
anticholinergics due to
the gravity of the situation
• Torticolis
Akathisia
• “Ants in the pants”
• Subjective feeling of
restlessness
• Nervous energy
• Most common EPSE
(Psuedo)Parkinsonism
• Tremor
at rest
• Pill rolling
• Muscle rigidity
• Bradykinesia
Stiff, shuffling gait
Tardive Dyskinesia
– Involuntary movements,
– Especially of the face and tongue
– IRREVERSIBLE if not corrected immediately
– LONG TERM USE OF TYPICAL ANTIPSYCHOTIC
Tardive Dyskinesia
Neuroleptic Malignant
Syndrome
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Syndrome is very RARE but can be LETHAL
– 1% of patients taking antipsychotics
– 5% to 20% will die without treatment
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Predisposing factors;
– Youth
– male
– high potency neuroleptic
– new patient
Cardinal symptoms
– Lead pipe rigidity
– Autonomic instability
• High fever
• Tachycardia
LOC changes
Elevated CPK
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Neuroleptic Malignant
Syndrome
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Medical emergency
STOP all medication
may resume meds after crisis.
Rx: Dantrolene (Dantrium): skeletal muscle
relaxant and Bromocriptine (Parlodel): a
dopamine agonist
Atypical Antipsychotics
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Clozaril (Clozapine)
Risperidal (Resperidone)
Zyprexa (Olanzapine)
Seroquel (Quetiapine)
Geodon (Ziprasidone)
Abilify (Aripiprazole)
Clozaril (Clozapine)
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Atypical antipsychotic
Decreases negative symptoms of schizo
No Extrapyramidal symptoms (EPS)
May decrease symptoms of tardive dyskinesia
Effects both dopamine and serotonin
Side effects: drowsiness and drooling
Very costly $9,000. per year.
Side effects
– Agranulocytosis, weekly blood draws
– Sedation, excessive salivation, dizziness, seizures
– Hyperglycemia/Wt. Gain, Type 2 DM
Risperidal (Resperidone)
• Drug is costly--$400. for 1 month supply
• Atypical; effects serotonin and dopamine.
• 1st line; effects both positive & negative
symptoms
• Can cause EPS, but lower incidence
• Side effects: CNS, drowsiness (most common,
given at night) Insomnia agitation, headache,
anxiety --Orthostatic hypotension Hyperglycemia
• GI: Constipation, nausea, vomiting and dyspepsia
• High potency--8 mgm per day in 2 doses
• Available in long lasting IM form (2weeks)
Zyprexa (Olanzapine)
• 1st line drug: Positive and negative symptoms
• High potency: 10 mgm a day--up to 20.
• Side effects: Drowsiness, constipation, dry
mouth, headache. Rare EPS, NMS,
• Effects both serotonin and dopamine
• Weight Gain long term/Hyperglycemia/
• Type 2 DM
• Drug is costly-- 10 mgm per day for 30 days is
$250.
• Available in short acting IM form
Seroquel (Quetiapine)
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Atypical antipsychotic, low potentcy
Effective in positive and negative symptoms
EPS profile same as placebo
No increase in prolactin levels
No sexual dysfunction problems
Side effects: somnolence and hypotension
Doses: effective at 150mgm to 750 mgm per day
Average: 300 mgm;100 in AM-200 in PM
Titrate doses: begin at 50 mgm per day
Available in IM injection
Ziprasidone (Geodon)
• Geodon/Atypical Antipsychotic-Antagonizes Dopamine and
Sertonin/
• Low EPS
• No increase in prolactin levels
• Side effects-somnolence in short term and insomnia in long
term use
• Weight Gain neutral
• Big issue-prolongs the QT interval
• Patient cannot have any cardiac or electrolyte imbalance
• Monitor serum potassium and magnesium
• Starting dose of 80 mgm per day in 2 doses
• Can go to 160 mgm
• Available in short acting IM form
(Aripiprazole ) Abilify
• Atypical antipsychotic, effects both dopamine
and serotonin, antagonizing some receptors and
serving as a partial agonist for others
• Decrease in the EPS side effects and minimal Wt.
Gain, minimal sedation, no problems with QT
interval
• Side effects: headache, Anxiety, Insomnia,
somnolence, occasional stomach upset
• Akathisia
• Dosage: 10 to 15 mgm daily can go up to 30
Patient and Family teaching
• Teach Pt. and family about schizophrenia
– Compare with an illness that cannot be cured: ie
Diabetes
• Teach Pt. and family about medications
• Emphasize importance of follow-up care
– If possible have pt. attend a community program.
• Teach family concept of Negative Symptoms
• Teach concept of stress(high expressed emotion)
• Refer family to NAMI. (national alliance mentally
ill)
• Respite care is important for family.
Issues for Nursing care
• Defense Mechanisms
– denial
– projection
– regression
• Delusion of
– persecution
– grandeur
• Challenges rules, may be argumentative and
agitated
Paranoid Patient
• Very fearful-mistrusting
• Very aware of authority
• Onset of illness is often late 20’s- may have been
a lawyer, accountant, or engineer
• Sexual issues-often accuse others of being
homosexual
Nursing Interventions for
Delusions
• Do not argue
• Do not belittle
• Show acceptance and empathy and speak to
them”That must be difficult to believe that.”
• Delusions of Grandeur-may be a defense against
low self-esteem.
• Don not patronize
• Can reassure-”You are safe here.”
• Orient patient to what is happening
Safety issues
• Patient may be combative
• Calm, kind, firm presence
• May need a “Show of force” State-”We can’t allow
you to hurt others.”
• Patient needs limits and know the rules.
Issues in the Nurse/Patient
relationship
• TRUST
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Be honest; do what you say.
Do not be too warm and friendly
Be consistent and honest
Be careful with touch
At first, may need to just “be there” or “offering self
Don’t expect too much of yourself or the patient
Improvement happens slowly
Interventions for
Hallucinations
• Ask “Are you hearing voices?”
• Ask “What are they saying?” May want to know
for safety reasons.
• Ask “What are they like, are they loud, or male or
female.”
• Can ask patient “What helps you with the voices”
• Can state,” I know they distract you, but can you
focus with me for a minute.”
• Patient may miss voices after they are gone.
Characteristics of Catatonic
Patient
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Acute onset, often in response to stress
Rigid, weird positions
Waxy flexibility
May not eat-often very angry
Best prognosis
Continuum of care
• Schizophrenia is a chronic illness that requires
continuous care/ need family & community
support
• Acute care, Partial hospitalization (day treatment)
• Medication, housing, ACT Team (assertive
community Treatment)
• Case Management, Employment counseling
• Social support, Drop in center: SHAC
• ACCESS for the Homeless mentally ill
• Disability Checks, SSI, Medicaid