Schizophrenia and Psychotic Disorders by liaoqinmei


									Schizophrenia and Psychotic
           Chapter 21
    Rochelle Roberts RN MSN
• Introduced by Swiss
  psychiatrist Eugene
  Bleuler in 1911
• Schizein- “to split”
  Phren -“mind”
• Reflects a split from
  the emotional and
  cognitive aspects of
    Symptoms of Schizophrenia
• Positive symptoms are exaggerated
  behaviors such as delusions, hallucinations,
  disorganized speech, bizarre behavior.
• Negative symptoms include loss of
  behaviors such as loss of affect, inability to
  maintain social contacts, impaired decision
  making, and inability to maintain attention.
• Problems with
  processing (abnormal
  brain function)
• Inability to produce
  logical thoughts and
  express coherent
        Problems in Cognitive
• Short and long-term memory problems
• Poor attention span
• Easy distractibility
• Illogicality
• Pressured speech
• Lack of insight, judgment, and lack of problem-
• Inability to think abstractly
Problems in Cognitive
  Functioning (cont)
           • Literal interpretation
             of words
           • Magical thinking:
             “When I stepped on a
             crack in the sidewalk,
             it caused my mother to
             fall and hurt herself
             the same day. I caused
             this to happen.”
 Problems in Cognitive Function

• The person’s brain processes data

• Delusions-false beliefs that are not shared
  by others (religious, somatic, grandiose)
         Perceptual Distortions
• Are often the first
  symptoms in many brain
• Hallucinations –false
  perceptual distortions
• Types include:
• Auditory 70%
• Visual 20%
• Olfactory
• Tactile (experiencing
   Sensory Integration problems
• Neuro “soft signs”-deficit in an
  undetermined location but are consistent
  with brain injury to the frontal or parietal
• Impaired fine motor skills, inability to
  recognize objects by the sense of touch
  (astereognosis), mild muscle twitching,
  increased eye blinking.

• Mood- a sustained feeling tone

• Affect- refers to behaviors such as facial
  expression, hand and body movements, and
  voice pitch
         Emotions Related to
• Hypoexpression-perception that one no
  longer has any feelings
• Alexithymia-difficulty naming & describing
• Anhedonia- inability to experience pleasure
• Apathy- lack of feelings, emotions,
  interests, or concern
     Maladaptive Behaviors in
• Deteriorated appearance
• Negativism
• Avolition –lack of energy or drive
• Stereotyped behavior -(wearing only certain
  clothes, etc)
• Lack of persistence at work or school
• aggression
Maladaptive movements

           • Abnormal eye movements
           • Catatonia (stuporous state
             associated with posturing)
           • Abnormal gait
           • Grimacing
           • Apraxia-inability to carry
             out a purposeful task, like
      Schizophrenia Socialization
          Problem Behaviors

•   Inability to communicate coherently
•   Loss of interest and drive
•   Deterioration of social skills
•   Poor personal hygiene
•   paranoia
    Indirect Effects on Socialization
• Low self-esteem
• Social inappropriateness
• Inappropriate sexual behavior
• Stigma related withdrawal by friends, and
• Disinterest in recreational activities
Social Isolation
        • Caused by stigma
        • Literal definition
          means “mark of
        • As students, describe
          your own attitudes
          about stigma
          Predisposing factors

• Combination of genetic and environmental factors
• Neurobiological factors –imaging studies show
  decreased brain volume (white matter). Findings
  include atrophy in the frontal lobe, cerebellum and
  limbic structures. There are also alterations in
  neurotransmitters (dopamine, serotonin, and
    Genetic Risk for Schizophrenia
•   Fraternal twin          50 % risk
•   Identical twin          15 % risk
•   Sibling                 10 % risk
•   One parent affected     15% risk
•   Both parents affected   35% risk
•   No affected relative    1% risk
   Theories regarding causes of
• Dysregulation Hypothesis-
  neurotransmitters causing unstable
  neurotransmission regarding dopamine and
• Neurodevelopment theory-several brain
  structures are abnormal that interfere with
  memory (prefrontal cortex and
   Theories regarding causes of
• Viral Theories-mixed evidence that prenatal
  exposure to the influenza virus during the
  2nd trimester of pregnancy may influence
  the etiology.
• Sociocultural theory-stress related to
  poverty, society, and environment may be a
         Biological Stressors

• Information-processing overload

• Abnormal “gating mechanisms” refers to
  nerve potentials and feedback systems
  within the nervous system.
        Some Common Triggers
•   Poor nutrition
•   Lack of sleep
•   Infection
•   Hostile environment
•   Social isolation
•   “Hopeless” attitude
•   Poor social skills
       Stress Diathesis Model

• Schizophrenia is made worse by stress and
  causes stress.
• Liberman (1994)
• Schizophrenia symptoms develop based on
  the amount of stress a person experiences
  and an internal stress threshold.
           Nursing Diagnoses

•   Impaired verbal communication
•   Disturbed sensory perception
•   Impaired social interaction
•   Disturbed thought processes
           Medical Diagnoses
•   Schizophrenias
•   Schizophreniform disorder
•   Schizoaffective disorder
•   Delusional disorder
•   Brief psychotic disorder
•   Shared psychotic disorder
       Outcome Identification

• The patient will live, learn, and work at a
  maximum possible level of success, as
  defined by the individual.
• Prevention of relapse is key.
• Relapse is the return of symptoms severe
  enough to interfere with ADL’s.
• When the person is in the acute or crisis
  stage of illness, care is often given in a
• Overall goal: help the patient reach stability
  while establishing a foundation for rehab
  and recovery
• In crisis and acute
• Most important is
  patient safety
• Help the patient feel
• Manage delusions and
     Strategies for working with
       patients with delusions
• Avoid becoming incorporated into the delusion
• Respond to the underlying feelings rather than the
  illogical nature of the delusion
• Place the delusion in a time frame
• Identify emotional components
• Observe speech for thought disorder
• Promote activities that require physical skills
  Strategies for working with
patients who have hallucinations
• Establish a trusting relationship
• Ask the patient to describe what is
  happening and gain control of his
• Identify if drugs or alcohol has been used
• Identify needs that may trigger
• Clozapine- limited use for patients who are
  treatment resistant to typical antipsychotics,
 because of its potential to cause agranulocytosis.

 Other atypical antipsychotics are Risperdal,
  Olanzapine, Seroquel, Geodon and Abilify.

 Typical antipsychotics include: Navane, Haldo,
 Loxatane, Moban,and Orap.
Interventions in the Maintenance

•   Teach self-management of symptoms
•   Identify symptoms of relapse
•   Patient teaching should involve caregivers
•   Cognitive reframing
            Stages of Relapse
• Stage 1: Overextension: patient feels
  overwhelmed and overloaded.
• Stage 2: restricted consciousness:depression is
  coupled with anxiety and withdrawal. Crucial to
  intervene during stage 1 or 2
• Stage 3: disinhibition: emergence of hallucinations
  and delusions that patient can no longer control.
  (first appearance of psychotic features)
       Stages of relapse (cont)
•  Stage 4: Psychotic disorganization:
   intensification of hallucinations and
   delusions and patient loses control. Three
   distinct phases here:
a) patient no longer recognizes familiar
   environment (destructuring of the external
       Stages of relapse (cont)
b)Total inability to differentiate reality from
   psychosis (loudly psychotic)
Stage 5: psychotic resolution-the patient is
   medicated and still experiencing
   psychosis, but the symptoms are “quiet.”
           Managing Relapse
• Awareness of the onset of behaviors indicating
• Prodromal phase occurs before relapse. Time
  between the onset of symptoms and the need for
• Identify and manage symptoms helps decrease the
  # and severity of relapses.Teach the patient to
  “self report” symptoms, problems with meds, and
  difficulties with ADL’s.
    Common Causes of Relapse

• Patients will most likely stop taking their
  meds some time in the first year after
• Problematic side effects
• Symptoms are gone
• Med didn’t work
      Causes of Relapse (cont)

• Studies show that without medication,
  people with schizophrenia relapse at a rate
  of 60-70 % within the first year of diagnosis
• Noncompliance occurs even when patient
  education is performed
    Interventions in the Health
         Promotion Phase
• Focus in on prevention of relapse and
  symptom management through engaging
  the patient in a healthy lifestyle.

• Psychotherapy may be helpful and the focus
  is supportive and non-confrontational.
  Atypical Antipsychotic Drugs
• Improve the symptoms of schizophrenia
• They rarely cause EPS or tardive dyskinesia
• Disadvantage of atypical drugs is their
  increase in cost over the typical anti-
  psychotic drugs
• Cost is outweighed by improved
  effectiveness and quality of life experienced
  by patients
   Side effects of atypical drugs

• Weight gain (high likelihood with clozapine
  and olanzapine)
• Sedation is commonly observed with
  clozapine & olanzapine
• Zaprasidone (Geodon) may prolong the Q-T
  interval in the EKG.
           Side effects (cont)
• Clozapine is usually reserved for patients
  with treatment resilient illness because of its
  side effect of agranulocytosis, seizures, and
  myocarditis. Strict protocol is required by
  prescribers, including entering patients into
  a national registry, monitoring WBC count
  weekly for 6 months, and writing scripts for
  only 1 to 2 weeks at a time.
        Typical Antipsychotics
•   Thorazine
•   Mellaril
•   Trilafon
•   Stelazine
•   Prolixin
•   Haldol
•   Loxitane
       Side Effects of Typical
• EPS: decrease dose or add drug to treat EPS
• Akathisia- pacing, legs ache
• Dystonia-spasms of muscle groups of neck,
  back an eyes
• Tardive dykinesia-involuntary movements
  (tongue protrusion, blinking, grimacing,
  foot tapping)
          Side effects (cont)
• NMS -Neuroleptic Malignant syndrome is
  potentially fatal: fever, tachycardia,
  sweating, muscle rigidity, tremor, elevated
  creatine phosphokinase, renal failure
• Seizures- occurs in about 1% of cases
• Agranulocytosis-leukopenia, fever; this is
  an emergency situation-high incidence with
  clozapine, do weekly CBC
           Other side effects

• Photosensitivity patients must use sunscreen
  and sunglasses

• Anticholinergic side effects- constipation,
  dry mouth, blurred vision, urinary retention

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