Schizophrenia & Other Psychotic Disorders
Impact of Schizophrenia Psychosis Predisposing Factors Precipitating Stressors Behavioral Strategies Nursing Care
1
Impact of Schizophrenia
• 1 in every 100 people suffers from schizophrenia. • 2.5 million Americans suffer from schizophrenia. • 3 out of 4 cases begins between ages 17 and 25 years. • Of those with schizophrenia, 95% have the disorder for their life time. • Annual cost of expenditures as the result of schizophrenia in the US is 40 billion dollars. • One-third to one-half of homeless persons in the US have schizophrenia.
2
Impact of Schizophrenia, continued
• More than 75% of taxpayer dollars spent on mental illness are spent on schizophrenia. • Persons with schizophrenia occupy 25% of all inpatient hospital beds. • Schizophrenia is ranked 4th worldwide in terms of burden illness. • Suicide is attempted by 20% to 50 % of persons with schizophrenia, 9% to 13% succeed.
3
Schizophrenia is a chronic disorder
• 5 X more common than multiple sclerosis • 6 X more common than insulin-dependent diabetes
• 60 X more common than muscular dystrophy • 80 X more common than Huntington’s disease
4
Psychosis
• Mental state different from the reality of others. • During an episode the person does not realize others are not experiencing the same things and wonders why others are not reacting in a similar manner. • Overall goals for nursing care are to try to understand, protect and support the patient through the acute psychosis. • When the persons symptoms have subsided, nurses help persons recognize psychosis and develop strategies to manage symptoms.
5
Persons who Experience Psychosis
• Often frightened by their experiences.
• Have difficulty forming close relationships. • Are severely disabled. • Alienated by society.
6
Understanding Psychosis
“ My name is John Nash! I’m being held against my will! Someone call the Department of Defense!”
Russell Crowe’s character in A Beautiful Mind (2001)
7
Bleuler’s Fundamental Symptoms
Autism: detachment from external reality and withdrawal into self Associative disturbance: thought disorder Ambivalence: simultaneous existence of opposing feelings, thoughts and desires Affective disorder: flat or blunted affect or affect inappropriate or incongruous to the thought or situation
8
Characteristic Symptoms of Schizophrenia
Diagnostic & Statistical Manual of Mental Disorders (DSM-IV-TR) (2000) ________________________________ Positive Symptoms: Reflect an excess or distortion of normal functions. Usually responsive to antipsychotic medications Negative Symptoms: Reflect a diminution or loss of normal functions. Usually unresponsive to traditional antipsychotic medications and more responsive to atypical antipsychotic medications 9
Positive Symptoms
Psychotic Disorders of Thinking Delusions: Paranoid, somatic, grandiose, religious, nihilistic, or persecutory themes; thought insertion, thought broadcasting, or control.
Hallucinations: Auditory, Visual, Tactile, Gustatory. Olfactory.
10
Positive Symptoms, continued
Disorganization of Speech & Behavior Positive Thought Disorder: Incoherence, word salad, derailment, illogicality, loose associations, tangentiality, circumstantiality, pressure speech, distractible speech, or poverty of speech
Bizarre Behavior: Catatonia, movement disorders, deterioration of social behavior
11
Negative Symptoms
Problems of Emotion Affective flattening: Limited range and intensity of emotional expression.
Anhedonia: Inability to experience pleasure or maintain social contacts.
12
Negative Symptoms, continued
Impaired Decision Making Alogia: Restricted thought or speech
Avolition/Apathy: Lack of initiation of goal-directed behavior Attentional impairment: Inability to mentally focus and sustain attention
13
Problems in Cognitive Functioning
Memory Attention Form and Organization of Speech (Formal Thought Disorder) Decision Making Thought Content
14
• Inability to recognize objects by the sense of touch (i.e., Astereognosis). • Inability to recognize numbers or letters traced on the skin (i.e., Agraphesthesia). • Impairment of the ability to perform smooth alternating movements (i.e., Dysdiadochokinesia). • Mild muscle twitches, choriform and ticlike movements, grimacing. • Impaired fine motor skills & abnormal motor tone • Increased rate of eye blinking. • Abnormal smooth pursuit eye movements 15 (SPEM).
Neurological Soft Signs: Prefrontal Cortical Dysfunction in Schizophrenia
Predisposing Factors
Biological • Genetics • Neurobiology • Imaging Studies (CT and MRI) • Neurotransmitter Studies • Neurodevelopment • Viral Theories
16
Genetic Risk for Schizophrenia
Person at Risk Monozygotic (identical) twin Dizygotic (fraternal) twin Sibling One parent affected Both parents affected Second-degree relative affected No affected relative Risk (%) 50 15 10 15 35 2-3 1
17
Predisposing Factors, continued
Psychological
Sociocultural Environmental
18
Precipitating Factors
Biological • Information-processing overload: Slow down in the transmissions to the frontal lobe. • Abnormal gaiting mechanisms: Gaiting is an electrical process involving electrolytes. It refers to inhibitory and excitatory nerve action potentials and the feedback occurring within the nervous system related to completed nerve transmissions. Decreased gaiting is demonstrated by a person’s inability to selectively attend to stimuli.
19
Coping Resources & Mechanisms
• Personal Coping Skills: Difficulty internalizing and need to be taught.
• Family Resources: Family understanding of the illness, finances, availability of time and ability to provide ongoing support influence the course of the illness. • Supportive Caregivers: Professional & Nonprofessional.
20
• Paranoid Type: Preoccupied with one or more delusion. • Disorganized Type: Disorganized speech and behavior, poor attention, inappropriate affect. • Catatonic Type: Waxy flexibility or purposeless excessive motor activity, mutism. • Undifferentiated Type. • Residual Type: Negative symptoms.
21
Subtypes of Schizophrenia (page 627)
Other Psychotic Disorders (page 621)
• Schizoaffective disorder: Schizophrenic symptoms are dominant + major manic or depressive symptoms. • Delusional disorder: Delusions are non-bizarre but functioning is not impaired outside of the delusion. No other symptoms of schizophrenia. • Brief psychotic disorder: Psychosis lasts for more than 1 day but less than 1 month. • Schizophreniform disorder: Symptoms are the same as schizophrenia but of shorter duration, at least 1 month but less than 6 months.
22
Nursing Diagnoses
• • • • • • Anxiety Body image, Disturbed Communication, Impaired verbal Sensory perception, Disturbed Social interaction, Impaired Thought processes, Disturbed
23
• Anxiety
Nursing Interventions for People with Psychosis
• Depression
• Problems with cause-and-effect reasoning • Difficulty with the passage of time
24
• Concrete thinking
Nursing Interventions for People with Psychosis
• Difficulty telling background from foreground information • Slowed information processing • Difficulty screening information to share
25
Nursing Interventions for People with Psychosis
Communication difficulties • Use active listening to understand the patient • Clarify what the patient is trying to tell you • Listen for the theme • Use the literal meaning of words • Have patient repeat back what was heard
26
Nursing Interventions for People with Psychosis
Perception and interpretation of stimuli difficulties: • Review problematic situations with the patient. • Help patient reality test and reframe problematic interpretations • Reinforce positive and productive processes
27
Nursing Interventions for People with Psychosis
Poor attention span and difficulty completing tasks • Help break tasks into small sequential steps. • Help the patient keep focused on a single task, a step at a time • Give directions to patient one step at a time • Do not emphasize completing the task.
28
Nursing Interventions for People with Psychosis
Inappropriate social behaviors • Identify the patient’s thought processes. • Ask patient about the behavior. • Help correct inaccurate perceptions. • Help patient identify undesirable outcomes of behaviors. • Teach appropriate social skills.
29
Nursing Strategies for Working With Patients with Delusions
Assess the Intensity, Frequency, and Duration of the delusion • Listen quietly until there is no need to discuss the delusion. • Fleeting delusions can be worked out in a short time frame. • Fixed delusions, endured over time, may have to be temporarily avoided to prevent them from becoming stumbling blocks in 30 the relationship.
Levels of Intensity of Hallucinations
Stage I: Comforting Moderate level of anxiety: Nonpsychotic Stage II: Condemning Severe level of anxiety: Mild psychotic Stage III: Controlling Severe level of anxiety: Psychotic Stage IV: Conquering Panic level of anxiety: Severely psychotic
31
Nursing Interventions for Working with Patients who have Hallucinations
Establish a trusting, interpersonal relationship. Assess the symptoms of hallucinations including duration, intensity, and frequency. Focus on the symptom and ask the patient to describe what is happening. If asked, point out simply that you are not experiencing the same stimuli.
32
Issues Related to Schizophrenia
• Depression: A symptom masked during the acute phase. • Relapse: Stressors, nonadherence with medications. • Stress & coping skills. • Substance abuse: 30% have dual diagnoses which may have a negative effect on treatment, resulting poor outcomes. • Lack of meaningful work
33
Nursing interventions in the therapeutic milieu
• • • • • • Provide safety for the patient and others. Intervene early if there is escalating behavior. Use the least restrictive intervention. Give clear and set realistic limits. Be consistent. Provide A supportive environment: structured, predictable. • Reduce environmental stimuli (Low stimuli environment). • Schedule opportunities for nonthreatening social interactions. • Encourage socialization as tolerated.
34
Family Education Plan
Involve family: • Describe psychosis, identify theories of psychotic disorders. • Define schizophrenia according to symptoms and diagnostic criteria. • Analyze the impact of living with delusions & hallucinations. • Discuss ways to cope adaptively with psychosis.
35
Cognitive-Behavioral Therapy (CBT)
CBT has been used successfully to treat persistent hallucinations and delusions as an adjunct to medications. CBT treatment has shown to be effective in patients with schizophrenia who were resistant to medications
36
Case Management
• Short hospital stays due to third party payment system. • Discharge planning: Multidisciplinary team planning. • Transitional Care: Partial hospitalization, halfway houses, day treatment programs, etc. • Places to live after hospitalization: Return to home, residential care facilities, etc. • Community Resources & Advocacy: NAMI, 37 Schizophrenics Anonymous, etc.
The Role of the Nurse
• Multidisciplinary Team Member
• Basic Level: Baccalaureate Degree RN • Advanced Practice Registered Nurse (APRN): MSN, DNSc, PhD
38
The Clinician’s Experience
• Psychotic patients’ anxiety, confusion, disturbances in logic and reality testing and misperceptions may lead to discomfort. • Sometimes when a person is struggling with psychosis, they are cooperative but frightened. It goes a long way to simply reassure them that they are in a safe environment.
39
The Clinician’s Experience, continued
• Especially if such patients are disorganized as well as frightened, it is helpful to tell them what is happening, ask them to bring up any questions they may have, and structure the interview.
• Nurses’ feelings of helplessness can result in withdrawal and avoidance. • Seek peer group supervision and support.
40