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.