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Schizophrenia: Symptoms, Assessment, and Treatment

Explore the symptoms, assessment guidelines, and treatment options for schizophrenia, including antipsychotic medications. Learn about the phases of schizophrenia and the potential nursing diagnoses and outcomes.

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Schizophrenia: Symptoms, Assessment, and Treatment

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  1. Chapter 15 Schizophrenia

  2. Eugen Bleuler’s 4 A’s of Schizophrenia • Affect • Associative looseness • Autism • Ambivalence

  3. Epidemiology • Lifetime prevalence of schizophrenia 1% worldwide • No difference related to • Race • Social status • Culture

  4. Comorbidity • Substance abuse disorders • Nicotine dependence • Anxiety, depression, and suicide • Physical health or illness • Polydipsia

  5. Etiology • Biological factors • Genetics • Neurobiological • Dopamine theory • Other neurochemical hypotheses • Brain structure abnormalities

  6. EtiologyContinued • Psychological and environmental factors • Prenatal stressors • Psychological stressors • Environmental stressors

  7. Phases of Schizophrenia Phase I – Acute • Onset or exacerbation of symptoms Phase II – Stabilization • Symptoms diminishing • Movement towards previous level of functioning Phase III – Maintenance • At or near baseline functioning

  8. Assessment • During the prepsychotic phase • General assessment • Positive symptoms • Negative symptoms • Cognitive symptoms • Affective symptoms

  9. Positive Symptoms • Alterations in thinking • Delusions are false, fixed beliefs. • Concrete thinking is an inability to think abstractly.

  10. Positive SymptomsContinued • Alterations in speech • Neologisms • Echolalia • Echopraxia • Clang associations • Word salad

  11. Positive SymptomsContinued • Alterations in perception • Depersonalization • Derealization • Hallucinations • Auditory hallucinations • Command hallucinations • Visual hallucinations • Boundary impairment

  12. Positive SymptomsContinuedAlterations in behavior • Catatonia • Motor retardation • Motor agitation • Stereotyped behaviors • Automatic obedience • Waxy flexibility • Negativism • Impaired impulse control

  13. Negative Symptoms • Affect • Flat • Blunted • Inappropriate • Bizarre

  14. Cognitive Symptoms • Difficulty with • Attention • Memory • Information processing • Cognitive flexibility • Executive functions

  15. Affective Symptoms • Assessment for depression crucial • May herald impending relapse • Increases substance abuse • Increases suicide risk • Further impairs functioning

  16. A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?

  17. Positive symptom Negative symptom Cognitive symptom Depressive symptom

  18. Assessment Guidelines 1. Any medical problems 2. Abuse of or dependence onalcohol or drugs 3. Risk to self or others 4. Command hallucinations

  19. Assessment GuidelinesContinued 5. Belief system 6. Suicide risk 7. Ability to ensure self-safety 8. Co-occurring disorders

  20. Assessment GuidelinesContinued 9. Medications 10. Presence and severity of positive and negative symptoms 11. Patient’s insight into illness 12. Family’s knowledge of patient’s illness and symptoms

  21. Potential Nursing Diagnoses • Positive symptoms • Disturbed sensory perception • Risk for self-directed or other-directed violence • Disturbed thought processes • Negative symptoms • Social isolation • Chronic low self-esteem

  22. Outcomes Identification • Phase I - Acute Patient safety and medical stabilization • Phase II - Stabilization • Adhere to treatment • Stabilize medications • Control or cope with symptoms • Phase III - Maintenance • Maintain achievement • Prevent relapse • Achieve independence, satisfactory quality of life

  23. Planning • Phase I – Acute • Best strategies to ensure patient safety and provide symptom stabilization • Phase II – Stabilization • Phase III – Maintenance • Provide patient and family education • Relapse prevention skills are vital

  24. Implementation • Phase 1 – Acute Settings • Partial hospitalization • Residential crisis centers • Halfway houses • Day treatment programs

  25. Interventions • Acute Phase • Psychiatric, medical, and neurological evaluation • Psychopharmacological treatment • Support, psychoeducation, and guidance • Supervision and limit setting in the milieu

  26. InterventionsContinued • Stabilization and Maintenance Phase • Milieu management • Activities and groups • Safety • Counseling and communication techniques

  27. InterventionsContinued • Stabilization and Maintenance Phase, continued • Hallucinations • Delusions • Associative looseness • Health teaching and health promotion

  28. Pharmacological Interventions • Antipsychotic medications • Conventional antipsychotics • Typical or first-generation • Atypical antipsychotics • Second-generation

  29. Atypical Antipsychotics Treat both positive and negative symptoms Minimal to no extrapyramidal side effects (EPSs) or tardive dyskinesia Disadvantage – tendency to cause significant weight gain

  30. Atypical AntipsychoticsContinued • Examples • Clozapine (Clozaril) – use declining • Risperidone (Risperdal) • Olanzapine (Zyprexa) • Quetiapine (Seroquel) • Ziprasidone (Geodon) • Aripiprazole (Abilify)

  31. Conventional Antipsychotics • Dopamine antagonists (D2 receptor antagonists) • Target positive symptoms of schizophrenia • Advantage • Less expensive than atypical antipsychotics • Disadvantages • Do not treat negative symptoms • Extrapyramidal side effects (EPSs) • Tardive dyskinesia • Anticholinergic side effects • Lower seizure threshold

  32. Extrapyramidal Side Effects • Acute dystonia • Akathisia • Pseudoparkinsonism • Tardive dyskinesia – Abnormal Involuntary Movement Scale (AIMS)

  33. Potentially Dangerous Responses to Antipsychotics • Neuroleptic malignant syndrome (NMS) • Agranulocytosis

  34. Adjuncts to Antipsychotic Drug Therapy • Antidepressants • Antimanic agents

  35. Specific Interventions for Catatonia • Catatonia – Withdrawn Phase • Communication guidelines • Self-care needs • Milieu needs • Catatonia – Excited Phase • Communication guidelines • Self-care needs

  36. Specific Interventions forDisorganized Schizophrenia • Communication guidelines • Self-care needs • Milieu needs

  37. Undifferentiated Schizophrenia • Active signs of disorder • Positive symptoms • Negative symptoms • Individual does not meet criteria for any other subtype

  38. Residual Schizophrenia • Active-phase symptoms no longer present • Evidence of two or more residual symptoms persists • Reduced initiative, interests, or energy • Social withdrawal • Impaired role function • Speech deficits • Odd beliefs

  39. Advanced Practice Interventions • Psychotherapy • Cognitive-behavioral therapy (CBT) • Group therapy • Medication • Social skills training • Cognitive remediation • Family therapy

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