Download Chapter_12_-_Schizophrenia_and_Schizophrenia_Spect

Schizophrenia and
Schizophrenia Spectrum
Disorders
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.


Lifetime prevalence of schizophrenia is 1%
worldwide
No difference related to
◦ Race
◦ Social status
◦ Culture
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
2
Interrelated Concepts and Psychosis
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
3



The types of schizophrenia are defined by the most common
symptoms a person has. The types include:
Paranoid schizophrenia. This is the most common type.
People with paranoid schizophrenia have frightening thoughts
and hear threatening voices. This causes them to act afraid or
to argue with other people. A person with paranoid
schizophrenia may attack other people or objects because
they are afraid of them. This type often occurs later in life
than other types of schizophrenia. People with paranoid
schizophrenia often get better with treatment.
Disorganized schizophrenia. This is the most rare but serious
type. It is sometimes called hebephrenic schizophrenia.
People who have this type have random and erratic behavior.
They may act silly and giggle for no clear reason. They may
make up words and sentences that make no sense to other
people. And they often do not show facial expressions.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
4



Catatonic schizophrenia. This type of schizophrenia is rare.
People with catatonic schizophrenia may sit or stand like a
statue for long periods of time. This is called a catatonic
stupor. They also can have periods of meaningless and
intense activity. This is called catatonic excitement. During
these periods of intense activity, they may cause harm to
themselves or others.
Undifferentiated schizophrenia. This is the term used when
the symptoms of a person’s schizophrenia do not fit the
other types.
Residual schizophrenia. This term refers to the ongoing
symptoms of schizophrenia that occur during a remission.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
5

Biological factors
◦ Genetics

Neurobiological
◦ Dopamine theory
◦ Other neurochemical hypotheses

Brain structure abnormalities
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
6

Psychological and environmental factors
◦ Prenatal stressors
◦ Psychological stressors
◦ Environmental stressors
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
7

Substance abuse disorders
◦ Nicotine dependence



Anxiety, depression, and suicide
Physical health or illness
Polydipsia
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
8


During the prepsychotic phase
General assessment
◦
◦
◦
◦
Positive symptoms
Negative symptoms
Cognitive symptoms
Affective symptoms
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
9
Four main symptom groups of schizophrenia
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
10

Alterations in thinking
◦ Delusions − False, fixed beliefs
◦ Concrete thinking − Inability to think abstractly
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
11

Alterations in speech − Associative looseness
◦
◦
◦
◦
Clang associations
Word salad
Neologisms
Echolalia
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
12

Other disorders of thought or speech
◦
◦
◦
◦
◦
◦
Religiosity
Magical thinking
Paranoia
Circumstantiality
Tangentiality
Cognitive retardation
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
13

Other disorders of thought or speech (cont.)
◦
◦
◦
◦
◦
Alogia, or poverty of speech
Flight of ideas
Thought blocking
Thought insertion
Thought deletion
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
14

Alterations in perception
◦ Depersonalization
◦ Derealization
◦ Hallucinations
 Auditory
 Command
 Visual
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
15
Alterations in Behavior
Catatonia
Motor retardation
Motor agitation
Stereotyped
behaviors
◦ Waxy flexibility
◦
◦
◦
◦
◦ Echopraxia
◦ Negativism
◦ Impaired impulse
control
◦ Gesturing or
posturing
◦ Boundary impairment
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
16

Affect
◦
◦
◦
◦
Flat
Blunted
Inappropriate
Bizarre
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
17

Difficulty with
◦
◦
◦
◦
◦
Attention
Memory
Information processing
Cognitive flexibility
Executive functions
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
18

Assessment for depression is crucial
◦
◦
◦
◦
May herald impending relapse
Increases substance abuse
Increases suicide risk
Further impairs functioning
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
19
A patient with schizophrenia says, “There are
worms under my skin eating the hair follicles.”
How would you classify this assessment
finding?
A.
B.
C.
D.
Positive symptom
Negative symptom
Cognitive symptom
Depressive symptom
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
20
1.
2.
3.
4.
Any medical problems
Abuse of or dependence on alcohol or drugs
Risk to self or others
Command hallucinations
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
21


You believe that the young man you are
admitting to your unit is suffering from
command hallucinations.
What would be some questions to ask him?
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
22
5.
6.
7.
8.
Delusions
Suicide risk
Ability to ensure self-safety
Medications
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
23
9. Mental status examination
10.Patient’s insight into illness
11.Family’s knowledge of patient’s illness and
symptoms
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
24

Positive symptoms
◦ Disturbed sensory perception
◦ Risk for self-directed or other-directed violence
◦ Impaired verbal communication

Negative symptoms
◦ Social isolation
◦ Chronic low self-esteem
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
25

Phase I – Acute
◦ Onset or exacerbation of symptoms

Phase II – Stabilization
◦ Symptoms diminishing
◦ Movement toward previous level of functioning

Phase III – Maintenance
◦ At or near baseline functioning
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
26

Phase I – Acute
◦ Best strategies to ensure patient safety and provide
symptom stabilization


Phase II – Stabilization
Phase III – Maintenance
◦ Provide patient and family education
◦ Relapse prevention skills are vital
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
27

Acute Phase
◦
◦
◦
◦
◦
Psychiatric, medical, and neurological evaluation
Psychopharmacological treatment
Support, psychoeducation, and guidance
Supervision and limit setting in the milieu
Monitor fluid intake
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
28

Stabilization and Maintenance Phases
◦ Medication administration/adherence
◦ Relationships with trusted care providers
◦ Community-based therapeutic services
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
29

Counseling and communication techniques
◦
◦
◦
◦
Hallucinations
Delusions
Associative looseness
Health teaching and health promotion
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
30

Antipsychotic medications
◦ First-generation
◦ Second-generation
◦ Third-generation
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
31



Dopamine antagonists (D2 receptor
antagonists)
Target positive symptoms of schizophrenia
Advantage
◦ Less expensive than second generation

Disadvantages
◦
◦
◦
◦
Extrapyramidal side effects (EPS)
Anticholinergic side effects
Tardive dyskinesia
Weight gain, sexual dysfunction, endocrine
disturbances
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
32



Treat both positive and negative symptoms
Minimal to no extrapyramidal side effects
(EPS) or tardive dyskinesia
Disadvantage – tendency to cause significant
weight gain
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
33



Aripiprazole (Abilify)
Dopamine system stabilizer
Improves positive and negative symptoms
and cognitive function
◦ Little risk of EPS or tardive dyskinesia
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
34



Anticholinergic toxicity
Neuroleptic malignant syndrome (NMS)
Agranulocytosis
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
35


Antidepressants
Mood stabilizing agents
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
36






Individual and group therapy
Psychoeducation
Medication prescription and monitoring
Basic health assessment
Cognitive remediation
Family therapy
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
37
1. Loose associations in a person with
schizophrenia indicate
A.paranoia.
B. mood instability.
C. depersonalization.
D.poorly organized thinking.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
38
2. Which assessment finding represents a
negative symptom of schizophrenia?
A.Apathy
B. Delusion
C. Motor tic
D.Hallucination
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
39
•Schizophrenia spectrum disorders are biological
disorders of the brain; they are a group of disorders with
overlapping symptoms and treatments, and are
categorized from least severe to most severe
(schizophrenia).
• Schizophrenia varies in terms of which symptoms
dominate, their severity, the impairment in affect and
cognition, and the impact on social and other areas of
functioning.
• Symptoms vary considerably among patients and
fluctuate over time.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
40
 Psychotic symptoms are often more pronounced and obvious than
symptoms of other disorders, making schizophrenia more apparent
to others and increasing stigmatization.
• Neurochemical, genetic, and neuroanatomical findings help
explain the symptoms of schizophrenia; however, no one theory
accounts fully for the complexities of schizophrenia.
• Positive symptoms of schizophrenia (e.g., hallucinations,
delusions, associative looseness) are easier to recognize and
respond best to antipsychotic drug therapy.
• Negative symptoms of schizophrenia (e.g., social withdrawal
and dysfunction, lack of motivation, reduced affect) respond less
well to antipsychotic therapy and can be more debilitating.
Psychosocial interventions such as support groups improve
negative symptoms.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
41


Cognitive impairment varies; it warrants careful
assessment and active intervention to increase the
patient’s ability to function and maximize the
ultimate quality of life.
Comorbid depression must be identified and
treated to reduce the potential for suicide,
substance abuse, non-adherence, and relapse.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
42


Some applicable nursing diagnoses include
Disturbed sensory perception, Acute confusion,
Impaired communication, Ineffective coping, Risk
for self-directed or other-directed violence, and
Impaired family coping.
• Outcomes are chosen based on the phase of
schizophrenia and the patient’s individual
symptoms, needs, strengths, and level of
functioning. Short-term and intermediate
indicators are also developed to better track the
incremental progress typical of schizophrenia.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
43



Interventions for people with schizophrenia include trustbuilding and therapeutic communication: support; assistance
with self-care, nutrition and sleep; promoting independence
and stress management; promoting socialization; psychoeducation about the illness and its treatment; milieu
management; on-going risk assessment.
• Therapeutic interventions for schizophrenia include
cognitive-behavioral interventions, cognitive
enhancement/remediation (evidence-based, highly
structured, classes that educate patients about cognitive
skills and provide computer-based and interpersonal practice
of cognitive skills).
• Improving and promoting reality testing are essential in
care for people with schizophrenia.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
44


Antipsychotic medications are essential in
patients with schizophrenia. Nurses must
understand the properties, desired and
undesired effects, and dosages of first-,
second-, and third-generation antipsychotics
and other medications used.
Schizophrenia can produce
countertransference responses in staff;
clinical supervision and self-assessment help
the nurse remain objective and therapeutic.
Copyright © 2014, 2010, 2006 by
Saunders, an imprint of Elsevier Inc.
45