schizophrenia chapter 16. schizophrenia fascinated and confounded healers for centuries one of most...
TRANSCRIPT
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Schizophrenia
Chapter 16
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Schizophrenia
Fascinated and confounded healers for centuries
One of most severe mental illnesses– 1/3 of population– 2.5% of direct costs of total budget– $46 billion in indirect costs
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Epidemiology
• 0.5%-1.5% of population
• 2.5 million Americans
• 300,000 acute episodes each year
• Cluster in lower socioeconomic group
• Homelessness is a problem.
• Direct treatment costs $20 billion/yr
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Epidemiology
• Across all cultures
• In the United States, African Americans have a higher prevalence rate (thought to be related to racial bias).
• Men are diagnosed earlier.
• EOS: Diagnosed late adolescence
• LOS: Diagnosed > 45 years
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Maternal Risk Factors
Prenatal poverty
Poor nutrition
Depression
Exposure to influenza outbreaks
War zone exposure
Rh-factor incompatibility
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Infant and Childhood Risk Factors
Low birth weight
Short gestation
Early developmental difficulties
CNS infections
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History of Schizophrenia
• 1800s - Eugene Kraeplin named it “dementia praecox.”
• 1900s - Eugen Bleuler named it schizophrenia (split minds). More than one type.
• Kurt Schneider - First rank (psychosis, delusions) and second rank (all other experiences)
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Phases of Schizophrenia
Acute Illness Period– Positive symptoms/may be subtle– Family Disruption– Awareness of the meaning of the disorder
Stabilization– Treatment is intense– Establish Medications– Begin Rehab
Maintenance and Recovery– Relapse prevention– Coping Strategies
Relapse– Non-compliance– Identify triggers
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Familial Differences
First-degree biologic relatives have 10 times greater risk for schizophrenia.
Other relatives have higher risk for other psychiatric disorders.
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Schizophrenia Diagnosis
• During a one-month period at least two of the five– Positive (delusions, hallucinations, etc.)– Negative (alogia, anhedonia, flat affect,
avolition)
• One or more areas of social or occupational functioning
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Types of SchizophreniaText Box 16.1
Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
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NegativeNegativeAvolitionAvolitionAlogiaAlogiaAnhedoniaAnhedoniaFlat AffectFlat AffectAmbivalenceAmbivalence
NeurocognitiveImpairment
AttentionMemory
Exec Function
Positive
Hallucinations
Delusions
Disorganization
SchizophreniaSchizophrenia
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Positive Symptoms: Excess of Normal Functions
• Delusions (fixed, false beliefs)– Grandiose
– Nihilistic
– Persecutory
– Somatic
• Hallucinations (perceptual experiences)
• Thought disorder
• Disorganized speech
• Disorganized or catatonic behavior
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Negative Symptoms: Less Than Normal Functioning
• Affective blunting: reduced range of emotion
• Alogia: reduced fluency and productivity of language and thought
• Avolition: withdrawal and inability to initiate and persist in goal-directed behavior
• Anhedonia: inability to experience pleasure
• Ambivalence: concurrent experience of opposite feelings, making it impossible to make a decision
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Neurocognitive Impairment
Neurocognition Memory (short-, long-term) Vigilance (sustained attention) Verbal fluency (ability to
generate new words) Executive functioning
– volition– planning– purposive action– self-monitoring behavior
Impaired in schizophrenia Memory (working)
Vigilance
Executive functioning
• Evidence that neurocognitive impairment exists, independent of positive and negative symptoms
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Neurocognitive Impairment Often Seen as “Disorganized Symptoms”
• Confused speech and thinking patterns• Disorganized behavior• Examples of disorganized thinking
– Echolalia (repetition of words)– Circumstantially (excessive detail)– Loose associations (ideas loosely connected)– Tangentially (logical, but detour)– Flight of ideas (change topics)– Word salad (unconnected words)
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Disorganized Symptoms• Examples of disorganized thinking (cont.)
– Neologisms (new words)
– Paranoia (suspiciousness)
– References ( special meaning)
– Autistic thinking (private logic)
– Concrete thinking (lack of abstract thinking)
– Verbigeration (purposeless repetition)
– Metonymic speech (interchange words)
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Disorganized Symptoms
• Examples of disorganized thinking (cont.)– Clang association (repetition similar sounding words)
– Stilted language (artificial, formal)
– Pressured speech (words forced)
• Examples of disorganized behavior– Aggression
– Agitation
– Catatonic excitement (hyperactivity, purposeless activity)
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Disorganized Symptoms
• Examples of disorganized behavior (cont.)– Echopraxia (imitation of others movements)
– Regressed behavior
– Stereotypy (repetitive, purposeless movements)
– Hypervigilance (sustained attention to external stimuli)
– Waxy flexibility (posture held in odd or unusual way)
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Comorbidity
• Increased risk of cardiovascular disorders
• Association between insulin-dependent diabetes and schizophrenia
• Depression and pseudodementia
• Increased substance abuse
• Cigarette smoking
• Fluid imbalance
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Disordered Water Balance
Prolonged periods of polydipsia, intermittent hyponatremia, polyuria
Etiology – unknown
Observed behaviors– Carrying cokes/coffee/water bottles
Prevention of water intoxication
Promotion of fluid balance
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Psychological
Difficulty relating Deficit in sensory inhibition Poor control of autonomic responsiveness Difficulty making decisions Deficit experiencing pleasure Deficit initiating activities Overassessment of threat
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Social
Deceased financial status Family and caregiver stress Homelessness Stigma and community isolation
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Biologic Factors
• Genetic – 10% first-degree relative• Stress-diathesis model proposed by
O’Connor• Neuroanatomical findings
– Decreased blood flow to left globus pallidus– Absence of normal blood increase in frontal lobes– Atrophy of the amygdala, hippocampus and
parahippocampus– Ventricular enlargement
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Biologic
• Neurodevelopmental– Prenatal exposure (2nd trimester)– Late winter, early spring births
– Adolescent– Changes in transmitter systems and substrates– Synaptic pruning along with substantial brain growth in
some areas of the cortex– Changes in steroid-hormonal environment
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Neurotransmitters, Pathways and Receptors
• Hyperactivity of the limbic area • (dopamine mesolimbic tract) related to positive
symptoms
• Hypofrontality or hypoactivity of the pre-frontal and neo-cortical areas• (dopamine mesocortical tract related to negative
and positive symptoms)
• Does not result from dysfunction of a single neurotransmitter
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Psychosocial Theories
• Do not explain cause
• Disservice to families
• Useful in family interaction– Expressed Emotion (EE)
• High emotion associated with negative communication and overinvolvement
• Low emotion associated with less negativity and less overinvolvement
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Priority Care Issues
Suicide
– 20-50% Attempt
– 10% Complete
Safety of patient and others
Initiate antipsychotic medications
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Family Response to Disorder
Mixed emotions – shock, disbelief, fear, care, concern and hope
May try to seek reasons
Initial period very difficult
NAMI – Life changed forever
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Interdisciplinary Treatment
The most effective approach involves a variety of disciplines.
There is considerable overlap of roles and interventions.
Nursing’s contribution is significant.
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Nursing Management: Biologic Domain Assessment
• Present and past health status• Physical functioning• Nutritional assessment• Fluid imbalance assessment• Pharmacologic assessment
Medications (prescribed, OTC, herbal, illicit) Abnormal motor movements
– DISCUS– AIMS – Simpson-Angus Rating Scale
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Assessment
Comorbidity– Diabetes– Smoking-related– Cardiac
Hypertension
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Nursing Diagnosis:Biologic Domain
Self-care deficit Disturbed sleep pattern Ineffective therapeutic regimen
management Imbalanced nutrition Excess fluid volume Sexual dysfunction
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Nursing Interventions:Biologic Domain
Promotion of self-care activities– Develop a routine of hygiene activities.– Emphasize its importance; help motivate the patient.
Activity, exercise and nutrition– Help counteract effects of psychiatric medications.– Appetite usually increases, so help with food choices.
Thermoregulation– Teach patient to wear clothing according to weather;
dress for winter and summer.– Observe patient’s response to temperature.
Promotion of normal fluid balance– Water intoxication protocol (Text Box 16.7)
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Pharmacologic Interventions
Newer antipsychotics more efficacious and safer (block dopamine and serotonin)
– Risperidone (Risperdal)– Olanzapine (Zyprexa)– Quetiapine (Seroquel)– Ziprasidone (Geodone)– Aripiprazole (Abilify)– Clozapine (Clozaril) - second line
Monitoring and administering medications– Takes 1-2 weeks to work (some improvement immediately)– Adequate trial - 6-12 weeks– Adherence to prescribe medication is best prevention of relapse.– Discontinuation is rare.
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Pharmacologic Interventions: Monitoring Side Effects
Parkinsonism– Identical symptoms to Parkinson’s – Caused by blockade of D2 receptor in basal ganglia– Treated with anticholinergic medications– Taper anticholinergic meds if discontinued
Dystonia– Imbalance of DA and ACH, with more ACH– Young men more vulnerable– Oculogyric crisis, Torticollis, Retrocollis
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Monitoring Side Effects
Akathesia– Restlessness, jumping out of skin, uncomfortable– Reduce dose of antipsychotic.– Treat with a -blocker (propranolol).
Tardive Dyskinesia– Impairment of voluntary movement, constant motion – Occurs 6-8 months following initiation of antipsychotics– Facial-buccal area -- lip smacking, sucking, etc.– Movements in trunk, rocking– No real treatment
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Monitoring Side Effects
Orthostatic hypotension Hyper Prolactinemia (haloperidol and
risperidone) Weight gain (olanzapine and clozapine) Sedation New-onset diabetes (Olanzapine,clozapine) Cardiac arrhythmias (QT prolongation)
(Ziprasidone) may need baseline ECG Agranulocytosis (all but *clozapine)
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Drug-drug Interactions
Medications metabolized by 1A2 enzymes include olanzapine and clozapine.
Inhibitors: fluvoxamine (Luvox) Inducers: cigarette smoking Smokers may require a
higher dose Medications metabolized by 3A4 include
clozapine, quetiapine and ziprasidone. Inhibitors: ketoconazole, protease inhibitors, erythromycin Inducer: carbamazapine (Tegretol)
Medications affected by 2D6 include risperidone, clozapine and olanzapine.
Inhibitors: fluoxetine, paroxetine (not usually clinically significant)
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Medication Teaching Points
Consistency in taking medication
Medication and symptom amelioration
Side effects and management
Interpersonal skills that help patient and family report medication effects
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MEDICATIONEMERGENCIES
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Neuroleptic Malignant Syndrome
TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSE Severe muscle rigidity, elevated temperature Recognizing symptoms
– Elevated temperature, changes in level of consciousness, leukocytosis, elevated creatinine phosphokinase), elevated liver enzymes or myoglobinuria
Nursing interventions– Stop administration of offending medications.– Monitor vital signs.– Reduce body temperature.– Safety, protect muscles
Supportive measures– IV fluids– Cardiac monitoring– Dantrolene (Dopamine agonist)
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Neuroleptic Malignant Syndrome
Acute reaction to dopamine receptors blockers Prevalence 2 to 2.4% Death – 4 to 22%, mean = 11% Etiology:
– Drugs block striatal dopamine receptors; disrupt regulatory mechanisms in the thermoregulatory center in hypothalamus and basal ganglia; heat regulation fails and muscle rigidity
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Is Client onneuroleptic drug? NO NOT NMS
ANY RISK FACTORS FOR NMS?DEHYDRATION?HISTORY OF NMS?RECENT DOSE INCREASE?PSYCHOMOTOR AGITATION
YE
S
EARLY S/S NMS?LOW-GRADE FEVER?TACHYCARDIA?ELEVATED BP?CATATONIA?DIAPHORESIS?
YE
S
HYPERTHERMIA?LEAD PIPE RIGIDITY?MS CHANGESOTHER AUTONOMIC CNS?
HOLD DRUG
NOTIFY MD
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Anticholinergic Crises
Potentially life threatening, anticholinergic delirium
Can occur in patients who are taking several medications with anticholinergic effects
Elevated temperature, dry mouth, decreased salivation, decreased bronchial, nasal secretion, widely dilated eye
Stop offending drug, usually self-limiting. May use inhibitor of anticholinesterase, physostigmine.
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Anticholinergic Crisis
Confusion, hallucinations Physical signs - dilated pupils, blurred vision,
facial flushing, dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension decreased bowel sounds, urinary retention, nausea, vomiting, seizures, coma
Atropine flush
Hot as a hare, blind as a bat, mad as a hatter, dry as a bone
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Treatment
Self-limiting – three days Discontinuation of medication Physiostigmine 1-2 mg IV, an
inhibitor of cholinesterase, improves in 24-36 hours
Gastric lavage Charcoal, catharsis
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Nursing Management: Psychological Domain Assessment – Responses
Socially stigmatizing
Prodromal symptoms evident (negative symptoms) Tension and nervousness
Lack of interest in eating
Difficulty concentrating
Disturbed sleep
Decreased enjoyment
Loss of interest, restlessness, forgetfulness
Often not recognized as an illness
Denial common
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Nursing Management: Psychological Domain Assessment
• Positive and negative symptoms• SAPS (positive symptoms) (Box 16.14)• SANS (negative symptoms) (Box 16.15)• PANNS (both symptoms)
• Mental status• Appearance• Mood and affect (lability, ambivalence, apathy)• Speech• Thought processes (delusions, disorganized communication, cognitive
impairments)• Sensory perception (hallucinations)• Memory and orientation• Insight and judgment
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Nursing Management: Psychological Domain Assessment (cont.)
Behavioral responses Self-concept Stress and coping patterns Risk assessment
– Command hallucinations– Self-injury risk, suicide– Homicide
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Nursing Diagnosis: Psychological Domain
Disturbed thought processes Disturbed sensory perceptions Disturbed body image Low self-esteem Disturbed personal identity Risk of violence, suicide Ineffective coping Knowledge deficit
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Nursing Interventions: Psychological Domain
Counseling, conflict resolution, behavior therapy and cognitive interventions can be used.
Development of nurse-patient relationship – Centers on the development of trust and
acceptance of the persons
– Critical for optimal treatment of schizophrenia
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Nursing Interventions:Psychological Domain – Management of Disturbed Thoughts
Assessment content of hallucinations/delusions Outcomes
– Decrease frequency and intensity.– Recognize as symptoms of disorder.– Develop strategies to manage recurrence.
Experiences real to the patient – Validate that experiences are real
– Identify meaning and feeling that are provoked
Teach patient that hallucinations and delusions are symptoms of illness.
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Nursing Interventions: Psychological Domain
Self-monitoring and relapse prevention– Monitor events, time, place, etc. of recurrence of
symptoms.
– Manage symptoms - getting busy, self-talk, change of activity. (Moller-Murphy Tool)
Enhancement of cognitive functioning– Recognize difficulty in processing information.
– Improve attention (computer programs, one-to-one).
– Help memory (make lists, write down information).
– Improve executive functioning-simulation.
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Nursing Interventions: Psychological Domain
Behavioral interventions– Organize routine, daily activities.– Reinforce positive behaviors.
Stress and coping skills development– Counseling sessions– Teach and reward positive coping skills.
Patient education– Errorless learning environment– Minimal distractions– Clear visual aids– Skills training
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Family Interventions
Family support
Educate the family regarding lifelong disorder of schizophrenia.
Emphasize consistent taking of medication.
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Nursing Management: Social Domain Assessment
Functional status– Assessed initially and at regular intervals– GAF usually used
Social systems– Formal and informal support systems
Quality of life Family assessment
– Family assessment guide (Ch. 15)– Special consideration to the family where patient is the
parent
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Nursing Interventions:Social Domain
Promotion of Patient Safety• Monitoring for potential aggression• Administering medication as ordered• Reducing environmental stimulation• Approach to individual patients
– Thorough history of violence– Help patient to talk directly and constructively with those with
whom they are angry.– Set limits.– Involve patients in formal contracting.– Schedule regular time-outs.
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Nursing Interventions: Social Domain
Support groups Milieu therapy Psychiatric rehabilitation Family interventions
– Encourage to participate in support groups– Inform about local and state resources– Help negotiate provider system
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Continuum of Care
Treatment occurs across continuum. Patients are at high risk for getting lost in the system.
Inpatient-focused care (stabilization) Emergency care (crisis) Community care (most of care) Mental health promotion
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Schizophrenia in Children
Rare in children
If appears in children aged 5 or 6, symptoms same as for adults
Hallucinations visual, delusions less well-developed
Other disorders considered first
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Schizophrenia in Elderly
For those who have had schizophrenia most of their life, this may be a time that they experience improvement in symptoms.
Late-onset schizophrenia– Diagnostic criteria met after 45
Estrogen may be protective in women
– Most likely include positive symptoms