Jan 22 Schizophrenia Lecture Notes 2010 copy

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					              SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS –
                             LECTURE NOTES

EPIDEMIOLOGY
     The lifetime prevalence of schizophrenia is 1% worldwide. Typical age of onset is during the
late teens and early 20s. Men and women are equally represented.

Course
    Usually involves recurrent acute exacerbations of psychosis. The phases in the course of the
disease are as follows: ACUTE — periods of florid positive symptoms as well as negative
symptoms. MAINTENANCE — period when acute symptoms decrease in severity. Can last up
to 6 months or more after the acute phase. STABLE — period where symptoms are in remission.

COMORBIDITY
    Substance abuse disorders occur in approximately 40% to 60% of individuals with
schizophrenia. It is associated with negative outcomes such as incarceration, violence, suicide,
and HIV infection. Nicotine dependence may be as high as 90%. Other comorbid disorders
include depressive symptoms, anxiety disorders, and psychosis-induced polydipsia.

THEORY
Neurobiological Findings
     There is compelling evidence that symptoms of schizophrenia are associated with brain
abnormalities rather than psychological causation. No one single theory has been proved. It is
likely that the disorder occurs as a result of a combination of inherited genetic factors and
extreme nongenetic factors that can affect the genes governing the brain or injure the brain
directly. These factors may alter the structures of the brain and the brain’s neurotransmitter
system and disrupt neural circuits, resulting in cognitive impairment. Schizophrenia is not seen as
a single disease, but as a syndrome that has neurobiochemical and neuroanatomical abnormalities
with strong genetic links affected by multiple nongenetic factors.

Dopamine Hypothesis
    The dopamine hypothesis states excess dopamine is responsible for psychotic symptoms.
This theory was based on the knowledge that antipsychotic drugs block some dopamine receptors,
limiting the activity of dopamine and reducing psychotic symptoms. Other drugs, e.g.,
amphetamines, increase activity of dopamine and can simulate symptoms of paranoid
schizophrenia in a nonschizophrenic client.

Alternative Biochemical Findings
    The role of other neurotransmitter systems (norepinephrine, serotonin, glutamate, GABA,
neuropeptides, and neuromedullary substances) are being studied. Newer drugs target serotonin
and norepinephrine and may provide more information about causation. Phencyclidine use
induces a schizophrenia-like state. This observation has renewed interest in the NMDA receptor
complex and the possible role of glutamate in schizophrenia.

Genetic Findings
    Genetic vulnerability seems likely. Schizophrenia and schizophrenia-like symptoms occur at
an increased rate among relatives of schizophrenic clients.
Neuroanatomical Findings
    Studies suggest schizophrenia is a disorder of brain circuits. Structural cerebral abnormalities
could cause circuit disruptions. Findings suggest that possible brain abnormalities might be
enlarged lateral ventricles, cortical atrophy, third ventricle dilation, ventricular asymmetry,
cerebellar atrophy, and frontal lobe atrophy. PET scans suggest reduced frontal lobe activity.

Nongenetic Risk Factors
    Other biological hypotheses include the following: Birth and pregnancy complications place
individuals at increased risk for developing schizophrenia as adults. Stress-related theories: there
is no indication that stress causes schizophrenia, but stress may precipitate it in a vulnerable
individual. Other risk factors include birth during the winter, birth in an urban area, low
socioeconomic status.

                       APPLICATION OF THE NURSING PROCESS

ASSESSMENT
DSM-IV-TR Criteria of Schizophrenia
    Around 1908 Bleuler coined the term schizophrenia and referred to four fundamental signs:
affect (flat, inappropriate emotions); associative looseness (jumbled, illogical thinking); autism
(thinking not bound to reality); and ambivalence (simultaneously holding two opposing emotions,
ideas, or wishes). DSM-IV-TR provides diagnostic criteria for all subtypes of schizophrenia:
paranoid, catatonic, disorganized, undifferentiated, residual.

Prodromal Symptoms
    These begin 1 month to 1 year before the first psychotic episode and include increased
anxiety; evidence of a thought disorder, such as poor concentration; inability to keep out intrusive
thoughts; attaching symbolic meaning to ordinary events; and misinterpretation of others’ actions
or words. In the latter part of the prodromal stage the client may experience emotional and
physical withdrawal, hallucinations, delusions, odd mannerisms, preoccupation with religion,
neologisms, preoccupation with homosexual themes.

Assessing Symptoms:
Cognitive Symptoms
     Represent a major disability associated with schizophrenia. Cognitive impairment involves
difficulty with attention, memory, problem solving, and decision making.

Positive Symptoms
    Florid psychotic symptoms such as hallucinations, delusions, bizarre behavior, and paranoia.
Negative symptoms are apathy, lack of motivation, anhedonia, and poor thought processes (which
may be the true core of the illness). Positive symptoms are associated with acute onset; normal
premorbid functioning and normal functioning during remissions; normal CT scans; and
favorable response to antipsychotics.

Alterations in Thinking
     Delusions: fixed false beliefs (with themes of ideas of reference, persecution, grandiosity,
unusual bodily function, jealousy, being controlled). About 75% of schizophrenic clients
experience delusions at some time during their illness. Other common delusions include: thought
broadcasting ( the belief that one’s thoughts can be heard by others), thought insertion (the belief
that thoughts of others are being inserted into one’s mind), thought withdrawal (the belief that
thoughts have been removed from one’s mind), and delusions of being controlled (belief that
one’s body or mind is controlled by an outside agency).
    Concrete Thinking: impaired ability to use abstract concepts. Interpretation is literal.

Alterations in Speech
    Associative looseness: loosely associated, haphazard, illogical, confused speech that can
sometimes be decoded.
    Neologisms: newly coined words having meaning only for the client
    Echolalia: pathological repeating of another’s words
    Clang association: meaningless rhyming of words
    Word salad: mixture of words meaningless to the listener

Alterations in Perceiving
    Hallucinations are sensory perceptions for which there is no external stimulus. Auditory
hallucinations are most common among schizophrenics. Voices may tell the client what to do
(commanding) or speak to or about him or her (usually derogatory). Behavioral indications of the
presence of auditory hallucinations include tilting head as if listening and answering back.
Hallucinations may also be visual, olfactory, gustatory, or tactile.

    Personal boundary difficulties may also be referred to as loss of ego boundaries. Two
examples include Depersonalization — feeling that the person has lost his or her identity or that
the body has changed and derealization — false perception that the environment has changed.

Alterations in Behavior
     Bizarre behaviors take the form of stilted rigid demeanor, eccentric dress or grooming, and
rituals.
     Extreme motor agitation — running about in response to inner or outer stimuli
     Stereotyped behaviors — motor patterns that have become mechanical and purposeless.
     Automatic obedience — performing commands in a robot-like fashion
     Waxy flexibility — excessive maintenance of a posture for long periods of time
     Stupor — remaining motionless and unresponsive
     Negativism — active negativism involves the client doing the opposite of what is suggested;
passive negativism involves not doing the things one is expected to do such as getting out of bed,
eating, etc.
     Agitated Behavior — related to difficulty with impulse control; because of cognitive
deterioration, clients lack social sensitivity and may act out impulsively.

Negative Symptoms
    Apathy, lack of motivation, anhedonia, poor social functioning, and poverty of thought are
associated with insidious onset; premorbid history of emotional problems; chronic deterioration;
CT scan showing atrophy; and poor response to antipsychotic therapy.

    These are the symptoms that most interfere with adjustment and ability to survive such as
ability to initiate and maintain relationships, initiate and maintain conversation, hold a job, make
decisions, maintain adequate hygiene and grooming. Negative symptoms include poverty of
speech or speech content, thought blocking, anergia, anhedonia, avolition, affective blunting
(minimal emotional response), inappropriate affect (incongruent response), or bizarre affect
(grimacing, giggling, etc.).
Self-Assessment
     The intensity of the client’s emotions can evoke intense, uncomfortable, and frightening
emotions in staff. If feelings are not worked through, feelings of helplessness can increase
anxiety. Defensive behaviors may emerge to thwart client progress and undermine nurse self-
esteem. Slow client progress can lead to frustration. Team evaluation of progress can assist with
this.

NURSING DIAGNOSIS
    Useful nursing diagnoses include Disturbed thought processes, Disturbed sensory perception,
Impaired verbal communication, Ineffective coping, Imbalanced nutrition: less than body
requirements, Risk for self-directed violence, Risk for other-directed violence, Activity
intolerance, Constipation, Incontinence, Impaired physical mobility, Self-care deficit,
Compromised family coping, Disabled family coping, Chronic low self-esteem, and Risk for
loneliness, Social isolation, Impaired parenting, Caregiver role strain.

OUTCOME CRITERIA
  Desired outcomes vary with the phase of the illness.

The Acute Phase
     The acute phase essentially involves crisis intervention with client safety and medical
stabilization as the overall goal. If the client is at risk for violence to self or others, initial outcome
criteria would address safety issues, i.e., “Client will remain safe while hospitalized.” Another
appropriate focus would be on outcomes that reflect improvement in intensity and frequency of
hallucinations, delusions, and increasing ability to test reality accurately.

Phase II (Maintenance) and Phase III (Stable)
    Outcome criteria will focus on helping the client to adhere to medication regimens,
understanding the nature of the illness, and participation in psychoeducational activities for client
and family.

PLANNING
  Planning appropriate interventions is guided by the phase of the illness.

Acute Phase
    Often requires hospitalization for stabilization. The treatment team will identify long-term
care needs, identify and provide appropriate referrals for follow-up and support. Discharge
planning must consider living arrangements, economic resources, social supports, family
relationships, and vulnerability to stress.

Maintenance and Stable Phases
    Foci include client and family education, skills training, building relapse prevention skills,
identifying need for social, interpersonal, coping, and vocational skills.

INTERVENTION
    Interventions, too, are geared to the phase of the illness. In the acute phase, interventions are
focused on symptom stabilization and safety and usually include medication, supportive and
directive communication, limit setting, and psychiatric, medical, and neurological evaluation.
Hospitalization is reserved for situations in which partial hospitalization or day treatment is
ineffective or unavailable.
    Phase II and III interventions include psychoeducation about the disease, medication, side
effect management, cognitive and social skills enhancement, identifying signs of relapse,
attention to self-care deficits. Stress minimization is of concern. Helping client reduce
vulnerability to relapse will include providing information about maintaining a regular sleep
pattern; reducing alcohol, drug, and caffeine intake; keeping in touch with supportive family and
friends; staying active; having a daily or weekly schedule; taking medication regularly. Attention
should be given to client strengths and healthy functioning.

Milieu Therapy
Activities
    During the acute phase, a structured milieu is more advantageous to the client than the
freedom of an open unit. Participation in activity groups decreases withdrawal, promotes
motivation, modifies aggression, and increases social competence. Involvement in activity groups
results in increased self-concept scores.

Safety
    In the acute phase the risk for violence usually stems from hallucinations or delusions.
Attempts should be made to use the least restrictive method of coping with violence; e.g., initially
use verbal intervention, followed by medication, and lastly seclusion or restraint.

Communication Strategies
    Be familiar with principles for dealing with hallucinations, delusions, and associative
looseness. Use a non-threatening and nonjudgmental manner. Speak simply, using a louder voice.
Use client’s name.

Hallucinations
   Intervention requires knowledge of the content of the hallucinations.

Delusions
    Rely on empathy. Clarify the reality of client’s experience. Do not focus on delusional
content. Do not use logic to refute delusion and do not argue. Clarifying misinterpretations is
useful. Spend time with client in reality-based activities.

Looseness of Association
     Loose associations mirror client thoughts. Don’t pretend to understand when you can’t. Tell
client you’re having difficulty understanding, placing the problem with yourself (i.e., “I’m having
difficulty understanding what you’re saying” instead of “You’re not making sense”). Look for
and mention recurring themes. Emphasize what’s going on in the environment and involve client
in simple reality-based activities. Tell client when you do understand, reinforcing clear
communication.

Client and Family Teaching
     Topics include the illness; how stress and medication affect the illness; problem-solving
skills; coping strategies to deal with symptoms; sources of ongoing support; symptoms of relapse;
and the type of environment most supportive for client.

Case Management
    Case management allows effective monitoring of client progress. Alternatives to
hospitalization include partial hospitalization, halfway houses, and day treatment programs. Self-
help community groups may also be useful.
Psychotherapy
    While medication maintenance has been shown to be the single most important factor in
prevention of relapse, a combination of medication and psychosocial interventions lowers the
relapse rate even further. Client concerns that can be addressed are relationship problems, family
concerns, depression, losses, and medication.

Individual Therapy
     Supportive therapy is the modality found to be most helpful. Skills training to enhance social
functioning, cognitive rehabilitation to improve information-processing skills, and cognitive
content therapy to change abnormal thoughts or responses to hallucinations through coping
strategies are also useful.

Group Therapy
    May be used to develop interpersonal skills, resolve community problems, and teach use of
community supports. Medication groups can help clients deal with side effects, alert staff to
potential adverse or toxic effects, minimize isolation, and increase compliance.

Family Therapy
    Further reduces relapse rate when a psychoeducational approach is used. This format expands
clients’ and relatives’ social networks, expands problem-solving capacity, and lowers emotional
overinvolvement of families.

Psychopharmacology
    Antipsychotics allow client management in the community as well as in the hospital.
Noncompliance with medications usually precedes relapse. Maintenance is required for 1 year
after one episode, 2 years after two episodes, and probably lifelong after three episodes.

Typical (Traditional) Antipsychotics
    Target D2 receptors. These drugs relieve the positive symptoms of schizophrenia and include
the phenothiazines, thioxanthenes, butyrophenones, dibenzoxazepines, and dihydroindolones.

    Selection is often made on the basis of major side effects. Extrapyramidal effects, such as
dystonia, akathisia, and pseudoparkinsonism, are treated by lowering dose and prescribing
antiparkinsonian drugs such as trihexyphenidyl (Artane), benztropine (Cogentin), or
diphenhydramine (Benedryl). Anticholinergic side effects include dry mouth, urinary retention,
constipation, and blurred vision. Sedation, orthostatic hypotension, lowered seizure threshold, and
agranulocytosis are other side effects.

    All standard antipsychotics can cause tardive dyskinesia (TD), which typically involves
involuntary tonic muscular spasms of the tongue, lips, fingers, toes, jaw, neck, trunk, and pelvis.
The drugs must be discontinued, but no cure for TD exists. Assessment is performed using the
Abnormal Involuntary Movement Scale.

    Neuroleptic malignant syndrome occurs in less than 1% of those taking standard
antipsychotics, is potentially fatal, and is characterized by lowered level of consciousness,
increased muscle tone, and autonomic dysfunction (including fever, hypertension, tachycardia,
tachypnea, diaphoresis, and drooling). Agranulocytosis, also a serious side effect, can be fatal.
Atypical Antipsychotics (AAPs)
    These drugs can diminish the negative symptoms (as well as the positive symptoms) and
include clozapine, risperidone, olanzapine, quetiapine, ziprasidone, all of which have a good side
effect profile. These drugs cause few or no extrapyramidal symptoms or tardive dyskinesia and
may improve neurocognitive defects associated with schizophrenia. Use of clozapine, however,
carries the risk of agranulocytosis. All tend to promote weight gain and are more expensive than
the older drugs.

Adjuncts to Antipsychotic Drug Therapy
   Antidepressants may be ordered for coexisting depression.
   Anitmanic agents may be useful for suppressing episodic violence and may help alleviate
   comorbid depression.
   Benzodiazepines may be ordered during the acute phase to reduce agitation.

When to Change an Antipsychotic Therapy Regimen
   Change should be considered when the current regimen is ineffective, supplemental
medications are needed, side effects are intolerable.

Electroconvulsive Therapy
    May be helpful in first-admission schizophrenic clients, but is not useful with chronic
schizophrenia. Catatonic clients respond to this treatment, as do clients who are self-starving.

            NURSING INTERVENTIONS FOR SCHIZOPHRENIC SUBTYPES

Paranoia
    Paranoia is characterized by intense and strongly defended irrational suspicion. Projection is
the most common defense mechanism used by paranoid clients. These clients usually feel
frightened, lonely, and helpless. The paranoid facade is a defense against painful feelings.

Communication Guidelines
    Paranoid clients are unable to trust others and are guarded, tense, reserved, and aloof. They
often adopt a superior, hostile, and sarcastic attitude to distance others. They may disparage
others and dwell on others’ shortcomings. Staff must not react with anxiety or client rejection.
Frequent discussion with peers and clinical supervision are helpful.
Readers are referred to the communication card.

Self-Care Needs
    These are usually minimal. Nutrition may be problematic if client is suspicious that food has
been tampered with. If this is the case, provide food in unopened containers. Suspicion may also
interfere with sleep.

Milieu Needs
    Risk for violence is present because the client may respond with hostility or aggression to
hallucinations or delusions. Homosexual urges may also be projected onto the environment.

Catatonia: Withdrawn Phase
    The essential feature of catatonia is abnormal motor behavior. Onset is usually abrupt and the
prognosis favorable. In the withdrawn phase the client may demonstrate posturing, waxy
flexibility, stereotyped behavior, extreme negativism or automatic obedience, echolalia, and
echopraxia.
Communication Guidelines
    Clients may actually appear comatose and mute. Although seemingly unaware of the
environment, the client is aware and may remember events accurately at a later date. Readers are
referred to the communication card.

Self-Care Needs
    When a client is extremely withdrawn, physical needs take priority. The client may need
complete care, including hand or tube feeding, incontinence care, and passive exercise, as well as
assistance with hygiene, dressing, and grooming.

Milieu Needs
    The continuum from decreased spontaneous movement to complete stupor is described and
waxy flexibility explained. Readers are cautioned that the client may move from stupor to an
outburst of gross motor activity prompted by hallucinations, delusions, or neurotransmitter
changes.

Catatonia: Excited Phase
Communication Guidelines
    During the excited phase the persons talks or shouts continually. Verbalizations may be
incoherent. Staff communication should be clear and directed. The major concern is safety of
client and others.

Self-Care Needs
    Client may exhibit gross hyperactivity (running, striking out, etc.). Exhaustion and collapse,
as well as safety, are the primary concerns. IM administration of antipsychotic medication is
usual. Provision of nutrition, fluids, and rest are of high priority. The client may be destructive
and aggressive in response to hallucinations or delusions. The reader is referred to the CD-ROM.

Disorganized Schizophrenia
    The most regressed and socially impaired clients carry this diagnosis. They show grossly
inappropriate affect, bizarre mannerisms, grimaces, giggles, incoherent speech, blocking, and
extreme social withdrawal. Onset is often early and insidious. The prognosis is often poor, the
client being able to live only in a structured and well-supervised setting.

Communication Guidelines
    These clients experience persistent and severe perceptual problems and frequently display
looseness of associations, incoherence, clang association, word salad, and blocking.

Self-Care Needs
    Clients need much help grooming as clients have no awareness of social expectations. They
are often too disorganized to carry out ADLs.

Milieu Needs
    These highly regressed clients exhibit primitive behaviors that require a structured and
protective milieu.

Undifferentiated Schizophrenia
    This illness is characterized by active signs of the disorder, but with symptoms that do not
clearly fall into one specific category. It often has an early and insidious onset with disability
remaining fairly stable over time.
Residual Schizophrenia
    The client no longer has active-phase symptoms but evidences two or more residual
symptoms (such as lack of initiative, marked social withdrawal, impaired role function, speech
deficits, odd beliefs, magical thinking, and unusual perceptual events).

EVALUATION
    Evaluation is based on established outcomes. Goals may need to be revised to become more
realistic and attainable. Client input may shed light on reasons desired behaviors have not
occurred.

				
DOCUMENT INFO
Alison McCarthy Alison McCarthy
About I am currently a nursing student in Arizona working on my ASN.