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SCHIZOPHRENIA AND PSYCHOSIS

SCHIZOPHRENIA AND PSYCHOSIS. Module III RNSG 2213. SCHIZOPHRENIA: OVERVIEW. Major Axis I disorder Characterized by disturbances in: Perception Thought processes and reality testing Affect (feelings) Behavior Attention (concentration) Motivation. PSYCHOSIS.

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SCHIZOPHRENIA AND PSYCHOSIS

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  1. SCHIZOPHRENIA AND PSYCHOSIS Module III RNSG 2213

  2. SCHIZOPHRENIA: OVERVIEW • Major Axis I disorder • Characterized by disturbances in: • Perception • Thought processes and reality testing • Affect (feelings) • Behavior • Attention (concentration) • Motivation

  3. PSYCHOSIS • How do we define this term? • Inability to evaluate accuracy of one’s thoughts and perceptions • Incorrect interpretation of external reality • Inability to re-evaluate one’s thoughts and perceptions, even in the face of evidence that contradicts these. In Schizophrenia, the psychotic person often does not have awareness that he/she is ill

  4. OVERVIEW, CONT’D • Incidence • Age of onset is late adolescence • 1.1% of population over age 18 • Higher rates in inner city populations, lower socioeconomic groups • Prenatal probs. correlate with higher rate

  5. OVERVIEW, CONT’D • Prognosis • Approx. 25% remain highly functional • 50% are minimally functional • 25% are in-between with exacerbations/relapses and re-stabilizations (in and out of hosp.)

  6. OVERVIEW, CONT’D • A Chronic Illness Characterized by Phases: • Acute phase – severe psychotic sx. • Stabilizing Phase • Stable phase • Most pts. alternate between acute and stable phases

  7. SCHIZOPHRENIA: SYMPTOMS • Bleuler’s (Early 1900’s) “4 A’s”: • Affect disturbances • Autism • Associative looseness • Ambivalence “Fragmentation of the Mind”

  8. CLASSIFICATION OF SYMPTOMS • Positive Symptoms • Negative Symptoms • Cognitive Symptoms

  9. Positive Symptoms of Schizophrenia • Agitation/aggression • Delusions • Hallucinations • Disordered thinking (AEB disordered speech): circumstantial thinking, loose associations, perseveration, word salad, neologisms, echolalia

  10. Positive Symptoms of Schizophrenia, cont’d • Disordered movement: restlessness, repetitive movements (echopraxia), or catatonia (lack of movement or lack of response)

  11. Catatonia: Waxy Waxy Flexibility

  12. “Help me, help me, help me, please help me, help me.” “A blue ape and ten times whenever you said. It makes me hairy scratching. A hair shirt. Are we victims?” “I am locked in concrete and I have stopped breathing.” “The CIA has been taking pictures of me in my shower.” “Whenever take baddest my our frown knife.” “When they see me coming in the HEB they play that tape of songs about my life.” Word salad Delusion of reference Perseveration Circumstantial thinking Loose associations Paranoid delusion Nihilistic delusion Delusion of influence Grandiose delusion Matching: Symptoms

  13. Negative Symptoms of Schizophrenia • Flat affect • Inability to plan or carry out activities • Constricted, concrete thinking • Poverty of speech (alogia), flat speech • Social withdrawal; lack of pleasure in activities (anhedonia) • Deep apathy

  14. “Flat Affects” (Flight of the Conchords)

  15. (Simulated hallucinations) http://www.youtube.com/watch?v=xEXyqe85cuA&feature=related http://www.youtube.com/watch?v=xEXyqe85cuA&playnext=1&list=PL4A6CFEFAB94F6A76 (Schizophrenia Gerald’s story) http://www.youtube.com/watch?v=gGnl8dqEoPQ&feature=related

  16. CRITICAL THINKING: Symptom Identification • Are Gerald’s symptoms primarily positive or negative?

  17. Cognitive Symptoms of Schizophrenia • Impaired ability to understand and make decisions (  “executive functions”) • Inability to pay attention • Problems in using just-learned information (“working memory” problems)

  18. CRITICAL THINKING:Nursing Diagnoses Write one nursing dx. for each symptom or behavior related to schizophrenia • Client has command auditory hallucinations that he should kill himself • Client does not get dressed or take baths • Client believes she can make it snow

  19. Suggested Nursing DX: • R/F Self-directed Violence r/t sensory perceptual alteration s/t command auditory hallucinations 2) Self-care deficits: grooming and hygiene r/t poor motivation for self-care s/t schizophrenia 3) Altered thought process s/t delusion

  20. Antipsychotic Agents and Symptoms • The “Typical” (older class) of antipsychotics primarily address POSITIVE symptoms • Can make negative symptomsWorse • The “Atypical” (newer classes) of antipsychotics address both POSITIVE AND NEGATIVE symptoms

  21. SYMPTOMS: DSM CRITERIA • At least 2: Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms • Social-occupational dysfunction • Continuous s/sx. > 6 months • No schizoaffective diagnosis • Not caused by substance abuse or medical disorder

  22. DSM Criteria: Schizophrenia Subtypes • Paranoid – persecutory and/or grandiose delusions • Disorganized – speech & affect & behavior are disturbed • Catatonic – absent, excessive &/or peculiar movements. Mutism. • Undifferentiated – does not meet criteria for other subtypes • Residual – has some disturbed thinking or behavior but does not meet other criteria

  23. ETIOLOGY • Multifactorial-no single cause • Multiple theories for etiology (see next content)

  24. BIOLOGICAL THEORIES • Too much dopamine binds with too many brain receptors and causes positive symptoms • Principle of anti-psychotic therapy = these meds. act as dopamine antagonist • Disturbed ratio of serotonin : dopamine • Therefore, atypical anti-psychotics affect serotonin also. Endogenous dopamine antagonist is GABA

  25. BIOLOGICAL THEORY: CHANGES IN BRAIN STRUCTURE AND FUNCTION • Alterations found in some Schizophrenics using Diagnostic Imaging • PET Scan:  glucose metabolism in frontal/temporal lobes; in basal ganglia • MRI: Enlargement of ventricles • BEAM Scan: Abnormal wave patterns indicting absence of ability to “calm” the brain • Evoked Potential Topography: Illogical thought patterning in frontal lobe

  26. PET Scan and Schizophrenia

  27. GENETIC THEORY • Inherited predisposition to schizophrenia • Risk Factors: • Two parents with schizophrenia = 35% • Identical twins = 50%

  28. DEVELOPMENTAL AND ENVIRONMENTAL THEORIES • Prenatal infections • Parental neglect or rejection • Greater % of pts. come from lower socio-economic class • Can you make someone a schizophrenic? • New investigations into prevention and early intervention

  29. Issues in Schizophrenia • Family disturbance: a cause or a result? • Noncompliance and relapse are common • Have poorer ability to cope with stress • Increased rates of depression, suicide • Increased rate of substance abuse: alcohol, marijuana, nicotine, cocaine • Often cannot hold a job

  30. Australian aboriginal painting by mental health client http://www.ncbi.nlm.nih.gov INTERVENTIONS/PSYCHOTHERAPEUTIC MANAGEMENT

  31. NURSE-CLIENT RELATIONSHIP • Be accepting, consistent and honest • Do not argue with or reinforce hallucinations or delusions • Reinforce acceptable behaviors • Gently encourage withdrawn client • Recognize when a client may be suspicious, anxious or fearful, and approach with care • Assess for command hallucinations

  32. MILIEU MANAGEMENT • Set limits on disruptive behavior • Assess agitated clients frequently for escalation • Assess ability to participate in activities; choose activities at client’s level of ability • May need 1:1 rather than group activities at first • Decrease environmental stimuli prn • Supervised meals, hygiene, grooming

  33. OTHER INTERVENTIONS • Importance of client and family education • To address stigma of schizophrenia & • To improve functional ability, self-management and prevent relapse

  34. Other Interventions, cont’d • Community Resources and Continuity of Care • National Alliance on Mental Illness (NAMI) • Self-help and support groups

  35. PHARMACOTHERAPY • Antipsychotic Agents • Traditional or Typical Agents: 1st Generation (beginning 1950’s) • Atypical or Second Generation Agents (1990’s) • Novel or Third Generation Agents (21st century)

  36. Antipsychotic Agents: Overview of Typical Agents • Pharmacologic Effects, in General • Sedation (esp. if combined with other CNS depressants) • Slowing of motor activity • Decrease in hallucinations and delusions • Improved cognitive function; decreased confusion • Emotional quieting

  37. TYPICAL or Traditional ANTIPSYCHOTIC AGENTS • High Potency e.g. haloperidol (Haldol), fluphenazine (Prolixin) • Moderate Potency e.g. loxapine (Loxitane), perphenazine (Trilafon) • Low Potency e.g. chlorpromazine (Thorazine), thioridazine (Mellaril)

  38. Typical/Traditional Antipsychotics, cont’d • Action = Block Dopamine D2 Receptors • Most effective for Positive (+) symptoms

  39. Atypical (2nd Generation) Agents • clozapine (Clozaril) (prototype) Action of this drug: blocks multiple dopamine receptors • quetiapine (Seroquel) • risperidone (Risperdal) • olanzapine (Zyprexa) * • ziprasidone (Geodon) * • paliperidone (Invega) *

  40. Atypical (2nd generation) Agents, cont’d • Action: Block multiple dopamine and serotonin receptors. Newer ones also inhibit reuptake of serotonin and/or dopamine and/or norepinephrine. • Most frequently prescribed • Useful for both positive and negative symptoms

  41. Novel (3rd Generation) Agent • aripiprazole (Abilify) • Action: Partial dopamine antagonist “Balances” dopamine (both increases and decreases it in different brain areas)

  42. Antipsychotics: Side Effects • Main Side Effects: • Extra-Pyramidal (EPSEs)- abnormally increased or decreased motor activity, muscle spasms, twisting, tremors • Akinesia  Akathisia • Pseudo-Parkinsonism • Dystonias  Tardive Dyskinesia Acute dystonic reaction

  43. Antipsychotics: Side Effects, cont’d • Anticholinergic Effects-dry mouth, orthostatic hypotension, urinary retention, blurred vision • Usually resolve over time

  44. Other Side Effects • Cardiac: Arrythmias (QT interval lengthened) • Blood: leukopenia, anemias agranulocytosis (clozapine) • Endocrine: Elevated prolactin levels (typical/traditional agents) Weight gain • Sexual: Impaired libido, performance

  45. A Dangerous Side Effect • Neuroleptic Malignant Syndrome (NMS) • Potentially lethal • Associated with use of high-potency agents e.g. haloperidol • Onset: within a week after starting meds. • Symptoms: muscular rigidity, tremors, autonomic hyperactivity e.g. high body temperature, altered consciousness

  46. Nursing Interventions and Antipsychotic Meds. • Medication education (You cannot teach too often) • Side effect issues are significant in this population, contribute to poor adherence/compliance: --Depot form of some drugs may be an option (injectable, give q week-q 2weeks). --Safety issues related to side effects: hypotension, CNS depression, photosensitivity, thermoregulation problems

  47. PHARMACOTHERAPY FOR EXTRAPYRAMIDAL SEs: Antiparkinson Agents • benztropine (Cogentin) • trihexyphenidyl (Artane) • biperiden (Akineton) • diphenhydramine (Benadryl) • amantadine (Symmetrel)

  48. Antiparkinson Agents, cont’d • Action: Restore balance of dopamine with acetylcholine (ACh) • Reduce motor and muscle dysfunctions caused by this imbalance • BUT: They also may cause anticholinergic SEs and mental confusion

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