chapter 13: schizophrenia and other psychotic disorders copyright © 2012, 2007 mosby, inc., an...

Chapter 13:Chapter 13:

Schizophrenia and Other Psychotic Disorders

Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

22Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Positive Symptoms of Positive Symptoms of SchizophreniaSchizophrenia

HallucinationsHallucinations DelusionsDelusions ParanoiaParanoia

Treatment:Treatment: HospitalizationHospitalization Typical antipsychoticsTypical antipsychotics Reduced stimuliReduced stimuli Interactive therapyInteractive therapy


Negative Symptoms Negative Symptoms of Schizophreniaof Schizophrenia

ApathyApathy Avolition (lack of motivation)Avolition (lack of motivation) Blunted affectBlunted affect Loss of emotional warmthLoss of emotional warmth Impaired social skillsImpaired social skills AnhedoniaAnhedonia

Treatment:Treatment: Atypical antipsychoticsAtypical antipsychotics


Kraepelin: Dementia PraecoxKraepelin: Dementia Praecox

HallucinationsHallucinations DelusionsDelusions DereismDereism Thought blockingThought blocking


Bleuler’s Four AsBleuler’s Four As

AffectAffect Autistic thinkingAutistic thinking AmbivalenceAmbivalence AssociationsAssociations


EtiologyEtiology

Heredity and genetic factorsHeredity and genetic factors Dopamine hypothesisDopamine hypothesis Other neurotransmittersOther neurotransmitters Neurodevelopment and other biologic factorsNeurodevelopment and other biologic factors Stress (Selye, Roy)Stress (Selye, Roy) Disease and traumaDisease and trauma Substance abuseSubstance abuse Psychologic factorsPsychologic factors Culture and family environmentCulture and family environment


Genetic InheritanceGenetic Inheritance

Selected factors activate genetic vulnerabilitySelected factors activate genetic vulnerability Winter birthWinter birth Viral infection in 28th to 30th weeks of pregnancyViral infection in 28th to 30th weeks of pregnancy Rh incompatibilityRh incompatibility Starvation during pregnancyStarvation during pregnancy Oxygen deprivation at birthOxygen deprivation at birth


Dopamine HypothesisDopamine Hypothesis

Excess dopamineExcess dopamine Possibilities:Possibilities:

Level in nigrostriatumLevel in nigrostriatum Dopamine-craving cells that overreactDopamine-craving cells that overreact Activity of dopamine antagonistsActivity of dopamine antagonists


Other Possible Other Possible Neurotransmitter Involvement Neurotransmitter Involvement

SerotoninSerotonin AcetylcholineAcetylcholine NorepinephrineNorepinephrine CholecystokininCholecystokinin GlutamateGlutamate GABAGABA


Psychologic and Psychosocial Psychologic and Psychosocial TheoriesTheories

Distorted mother-child relationshipDistorted mother-child relationship Ego disorganizationEgo disorganization Faulty reality interpretationFaulty reality interpretation


Cultural and Cultural and Environmental FactorsEnvironmental Factors

Low socioeconomic statusLow socioeconomic status Lack of social supportLack of social support


EpidemiologyEpidemiology

Outcomes related to:Outcomes related to: Later onset, premorbid functioningLater onset, premorbid functioning Age, genderAge, gender SubtypeSubtype Fetal exposure to disease and traumaFetal exposure to disease and trauma Marital status, reproduction, mortalityMarital status, reproduction, mortality Socioeconomic classSocioeconomic class Culture, geography, seasonal influencesCulture, geography, seasonal influences


Relapse Prevention and Relapse Prevention and ResearchResearch

Denial of illnessDenial of illness NoncomplianceNoncompliance Lack of family supportLack of family support Inability to cope with health systemInability to cope with health system Medication failuresMedication failures


DSM-IV-TR CriteriaDSM-IV-TR Criteria

Lasting 6 monthsLasting 6 months Active-phase symptoms lasting at least 1 month Active-phase symptoms lasting at least 1 month

include 2 of the following:include 2 of the following: HallucinationsHallucinations DelusionsDelusions Disorganized or catatonic behaviorDisorganized or catatonic behavior Disorganized speechDisorganized speech


SubtypesSubtypes

ParanoidParanoid DisorganizedDisorganized CatatonicCatatonic UndifferentiatedUndifferentiated ResidualResidual


Related DisordersRelated Disorders

Schizophreniform Schizophreniform SchizoaffectiveSchizoaffective DelusionalDelusional Brief psychotic disorderBrief psychotic disorder Shared psychotic disorderShared psychotic disorder Psychotic disorder due to a general medical Psychotic disorder due to a general medical

conditioncondition


Perceptual DisturbancesPerceptual Disturbances

Negative self-perceptionNegative self-perception HallucinationsHallucinations Reduce stress.Reduce stress. Increase medication.Increase medication. Reduce distractions.Reduce distractions. Occupy mind.Occupy mind.


Thought DisturbancesThought Disturbances

DelusionsDelusions Do not agreeDo not agree EmpathyEmpathy

CircumstantiallyCircumstantially TangentialityTangentiality Autistic thinkingAutistic thinking PerseverationPerseveration Poverty of thoughtPoverty of thought Loose associationLoose association


Teaching TipsTeaching Tips

Simplify material.Simplify material. Reduce distractions.Reduce distractions. Give verbal and visual information.Give verbal and visual information. Use clear, direct terms.Use clear, direct terms. Present small segments.Present small segments. Reinforce frequently.Reinforce frequently. Do not offer confusing choices.Do not offer confusing choices.


Emotional and Behavioral Emotional and Behavioral DisturbancesDisturbances

EmotionalEmotional Flattened affectFlattened affect Poor eye contactPoor eye contact

BehavioralBehavioral Risk for violenceRisk for violence


Biologic ProfilesBiologic Profiles

Diffused, nonlocalized areas of dysfunctionDiffused, nonlocalized areas of dysfunction Impaired stimulus Impaired stimulus InhibitionInhibition


AssessmentAssessment

Subjective client reportingSubjective client reporting ObjectiveObjective

ObservationObservation Rating scalesRating scales Biologic indicatorsBiologic indicators

Mental status examinationMental status examination Positive and negative symptomsPositive and negative symptoms


Important TestsImportant Tests

MRIMRI Identifies subtle brain changesIdentifies subtle brain changes

PETPET Determines brain activityDetermines brain activity

BEAMBEAM Measures brain activityMeasures brain activity

EEGEEG Reveals electrical activityReveals electrical activity


Important Tests, cont’d.Important Tests, cont’d.

Eye tracking and auditory testsEye tracking and auditory tests Information processing deficitsInformation processing deficits

Electrodermal activity (EDA)Electrodermal activity (EDA) Extent of negative symptomsExtent of negative symptoms

Neurologic examinationNeurologic examination Neuropsychologic testsNeuropsychologic tests


Useful Nursing DiagnosesUseful Nursing Diagnoses

Risk for suicideRisk for suicide Risk for violenceRisk for violence Disturbed sensory perceptionDisturbed sensory perception Disturbed thought processesDisturbed thought processes Impaired verbal communicationImpaired verbal communication Ineffective copingIneffective coping Interrupted family processesInterrupted family processes Self-care deficitSelf-care deficit Social isolationSocial isolation


Outcome IdentificationOutcome Identification

Demonstration of reality-based thinkingDemonstration of reality-based thinking Reduction in hallucinations Reduction in hallucinations Absence of delusionsAbsence of delusions Socialization with staff and peersSocialization with staff and peers Adherence to medication regimenAdherence to medication regimen Participation in discharge planningParticipation in discharge planning


PlanningPlanning

Geared to:Geared to: Whole personWhole person Social environmentSocial environment FamilyFamily Medical interventionsMedical interventions SocializationSocialization Education for client and familyEducation for client and family


ImplementationImplementation

Establish relationshipEstablish relationship Consider cost of planConsider cost of plan Provide:Provide:

StimulationStimulation StructureStructure SocializationSocialization SupportSupport


InterventionsInterventions

Assess/monitor risk factors. Assess/monitor risk factors. Minimize environmental stimuli.Minimize environmental stimuli. Provide low-key interactions.Provide low-key interactions. Use clear, concrete communication.Use clear, concrete communication. Identify hallucination triggers.Identify hallucination triggers. Praise reality-based perceptions.Praise reality-based perceptions.


Interventions, cont’d.Interventions, cont’d.

Educate about:Educate about: SymptomsSymptoms MedicationMedication ComplianceCompliance Postdischarge servicesPostdischarge services

Distract from delusions. Distract from delusions. Focus on feelings.Focus on feelings. Provide structured activities initially.Provide structured activities initially.


Interventions, cont’d.Interventions, cont’d.

Assist with hygiene as needed.Assist with hygiene as needed. Set hygiene goals.Set hygiene goals. Assess self-concept.Assess self-concept. Role model social behaviors.Role model social behaviors. Spend time with client in nonchallenging Spend time with client in nonchallenging

activity.activity. Keep appointments.Keep appointments. Listen actively.Listen actively.


Self-ManagementSelf-Management

Accept that it is a prolonged illness.Accept that it is a prolonged illness. Identify strengths and limitations.Identify strengths and limitations. Set clear, realistic goals.Set clear, realistic goals. Gradually return to responsibilities.Gradually return to responsibilities. Establish regular, consistent routine.Establish regular, consistent routine. Establish quiet, relaxed routine.Establish quiet, relaxed routine. Reduce stress.Reduce stress.


Self-Management, cont’d.Self-Management, cont’d.

Work on trusting staff.Work on trusting staff. Take medication regularly.Take medication regularly. Identify relapse signs early.Identify relapse signs early. Avoid street drugs.Avoid street drugs. Eat well.Eat well. Get sufficient rest.Get sufficient rest. Exercise regularly.Exercise regularly. Check reality with trusted person.Check reality with trusted person. Accept setbacks.Accept setbacks.


Treatment ModalitiesTreatment Modalities

PsychopharmacologyPsychopharmacology Electroconvulsive therapyElectroconvulsive therapy Milieu therapyMilieu therapy Psychosocial rehabilitationPsychosocial rehabilitation Individual therapyIndividual therapy

Supportive Supportive ReeducativeReeducative ReconstructiveReconstructive


Treatment Modalities, cont’d.Treatment Modalities, cont’d.

Group therapyGroup therapy Family therapyFamily therapy Behavior therapyBehavior therapy Cognitive therapyCognitive therapy Occupational therapyOccupational therapy Recreational therapy Recreational therapy


Typical AntipsychoticsTypical Antipsychotics

Reduce positive symptomsReduce positive symptoms Cause movement disordersCause movement disorders


Atypical AntipsychoticsAtypical Antipsychotics

Block serotonin receptorsBlock serotonin receptors Reduce negative symptomsReduce negative symptoms

Do not affect movementDo not affect movement Influence glutamateInfluence glutamate

Improve cognitionImprove cognition Improve tardive dyskinesia Improve tardive dyskinesia Have few anticholinergic side effectsHave few anticholinergic side effects


Nurse’s Role Related to Nurse’s Role Related to PsychopharmacologyPsychopharmacology

Administer.Administer. Assess effects and side effects.Assess effects and side effects. Promote education.Promote education. Teach lifelong skills for community living.Teach lifelong skills for community living. Monitor quality-of-life issues.Monitor quality-of-life issues.


Reducing and Managing ViolenceReducing and Managing Violence

Reduce stress.Reduce stress. Clarify expectations concerning rules.Clarify expectations concerning rules. Avoid behaviors that may be misinterpreted.Avoid behaviors that may be misinterpreted. Determine etiology.Determine etiology. Avoid blame, ridicule, teasing.Avoid blame, ridicule, teasing. Avoid whispering.Avoid whispering.


Reducing and Managing Reducing and Managing Violence, cont’d.Violence, cont’d.

Respect boundaries.Respect boundaries. Intervene early.Intervene early. Use deescalation skills.Use deescalation skills.

Nonthreatening verbal and nonverbalsNonthreatening verbal and nonverbals Medicate (PO or IM) prn.Medicate (PO or IM) prn.

chapter 13: schizophrenia and other psychotic disorders copyright © 2012, 2007 mosby, inc., an...

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