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Schizophrenia Schizophrenia • It is a brain disorder of unknown etiology • Theories of causation include: genetics, biochemistry, and psychosocial factors • Symptoms vary greatly among different patients depending on what area of the brain that is primarily effected. • Treatment varies to meet individual needs, tho usually includes psychotropic medications, pt. and family education and social support Incidence and Prognosis • In all societies, occurs in 1% of population with slightly higher incidence in males • Prognosis: approx. 25% remain highly functional • 50% remain non-functional • 25% are in-between, in and out of hospital • Age of onset is late adolescence/ early adulthood Prognosis • Acute phase – Severe psychotic symptoms • Stabilizing phase – Patient is getting better • Stable phase – May still have hallucinations and delusions – Not as severe • Most patients alternate between acute and stable phases GENETIC ENVIRONMENT Etiology BIOCHEMICAL Brain structure and Function GENETICS • Probability of Schizophrenia in Families – – – – – 1 parent 10% probability 1 sibling 10% Identical twin 50% Both parents varies 40% A gene identified ---research continues BIOCHEMICAL • Too much dopamine overwhelms the brain and binds with too many receptors and causes positive symptoms, therefore, anti-psychotics act as dopamine antagonist • Ratio between serotonin and dopamine, therefore atypical anti-psychotics effect serotonin also. • Endogenous dopamine antagonist is GABA – • Can you induce psychosis? – Marijuana, LSD, Amphetamines BRAIN STRUCTURE AND FUNCTION PET SCAN ILLUSTRATES FUNCTIONAL DIFFERENCES IN THE LIVING BRAIN PET Scan and Schizophrenia MRI Comparing Identical Twins: One without Schizophrenia and One with Schizophrenia • When the ventricles are enlarged the brain has lost mass; tissue has shrunk ENVIRONMENTAL • • • • Inherited susceptibility to schizophrenia Prenatal infections Poor Family Communication Greater % of pts. come from lower socioeconomic class • STRESS • Can you make someone a schizophrenic? • What about prevention? STRESS: Onset or Relapse • Biological (medical illness) • Psychological (loss of a relationship) • Sociocultural (homeless) • Emotional (persistent criticism) Bleuler’s 4 A’s • Affective Disturbance: – Inappropriate, blunted or flattened • Autistic Thinking: – Preoccupation with the self – Little concern for external reality • Associative Looseness – Stringing together of unrelated topics • Ambivalence – Simultaneously opposing feelings DSM IV Criteria: Schizophrenia • Delusions: false fixed beliefs • Fixed Delusions (permanent; not affected by medications) • Hallucinations (auditory; visual; tactile) • Disorganized Speech • Grossly disorganized or catatonic behavior • Negative symptoms – flat affect, apathy, alogia (inability to speak). – Generally, 2 or more symptoms need to be present for 1 month for diagnosis DSM IV Criteria Cont. • Social or Occupational dysfunction – Pts. ability to perform self care, work or relate to people has declined markedly. • Duration – Decline in function for this criteria must be six months. • Exclusions – R/O Schizoaffective disorder and mood disorder – R/O substance abuse and OBS – R/O pervasive developmental disorder (autism) Positive symptoms of Schizophrenia • Positive Symptoms (+) Person with schizophrenia does more (+) than Person who is functioning normally – – – – – agitation/aggression delusions hallucinations formal thought disorder:loose associations, word salad bizarre behavior • Typical Anti-psychotic meds usually control these symptoms Negative symptoms of Schizophrenia • Negative Symptoms (-) Person with schizophrenia does less (-) than Person who is functioning normally – – – – – – – – flat affect avolition; lack of direction or purpose ambivalence; indecisive and changeable constricted, concrete thinking alogia; poverty of speech social withdrawal; anhedonia deep apathy minimal or poor self care • Atypical antipsychotics will help these symptoms Schizophrenia Subtypes • • • • • Paranoid Catatonic Disorganized Undifferentiated Residual Paranoid • Preoccupation with: 1. Delusions • Persecution • Grandiose • Can be VERY dangerous to others. Can get themselves into situation where they think they are protecting themselves and they get themselves killed. 2. Auditory hallucinations • Command • No disorganized speech • Usually neat and clean. Catatonic – Stupor – Negativism – Rigidity – Posturing: waxy flexibility Disorganized – Disorganized speech – Disorganized behavior – Flat or inappropriate affect – Dissheveled appearance Undifferentiated – Positive symptoms – Do not meet criteria for paranoid. Residual – No positive symptoms – Mostly negative symptoms – Chronic Pyschosis-Induced Polydipsia • • • Compulsive water drinking (6% to 20%) Thirst and Osmotic dysregulation Hyponatremia – – – – – – – • Confusion Convulsions Coma Lightheadedness Nausea and vomiting Weakness Muscle Cramps Treatment – – – – Weigh Restrict fluid Sodium replacement Constant supervision Other Psychotic Disorders – Psychotic Disorder NOS – Delusional Paranoid Disorder – Schizophreniform Disorder • Symptoms of schizophrenia last one month but no longer than six months – Schizoaffective disorder • A puzzle • Characterized by: – Schizophrenic symptoms are dominant – Accompanied by major depressive or manic symptoms Nursing Diagnosis for Schizophrenia • • • • • • • • • • Altered thought processes: Delusions Sensory/perceptual alterations: specify Hallucination Social isolation Potential for violence self-care deficit Impaired verbal communication Sleep pattern disturbance Altered nutrition Impaired home maintenance management Related to: Neuro chemical imbalance Treatment • Antipsychotic Medication • Supportive Psychotherapy and Education – – – – Individual Group Milieu Family • Social supports – – – – Follow-up mental health care/Medication Housing Day treatment Employment Antipsychotic Medications • Typical • Atypical Typical Antipsychotics • High Potency Neuroleptic – Haldol (Haloperidol) – Prolixin (Fluphenazine) – Available in pills, liquid, Intramuscular and Depo injection • Low Potency Neuroleptic – Thorazine (Chorprmazine) – Mellaril (Thiroidazine) • In-betweens – Stelazine – Trilafon – Navane Antiparkinsonian Agents • • • • • Cogentin (benztropine) Artane (trihexyphenidyl) Benadryl (diphenhydramine) Symetrel (amantadine) Ativan (Lorazepam) Acetylcholine and Dopamine • A balance between dopamine and acetycholine is required for normal movement • Antipsychotic meds decrease dopamine, causing EPS symptoms • Antiparkinsonian meds act by decreasing ACH, thus restoring balance • All antiparkinsonian meds increase the anticholenergic effects Side effects of Typical Antipsychotics • Extrapyramial Side Effects (EPSE) – Acute Dystonia – Akathisia – Tardive Dyskinesia • Anticholenergic effects – – – – – – Drowsiness Dry mouth Skin reactions, sunburn Constipation urinary retention Orthostatic hypotension Acute Dystonia • Oculogyric Crises – early onset – Abnormal posture – involuntary, sustained, muscle spas – Sustained twisted contracted positioning of the limbs, trunk, neck or mouth – This is PAINFUL – Treated with parenteral anticholinergics due to the gravity of the situation • Torticolis Akathisia • “Ants in the pants” • Subjective feeling of restlessness • Nervous energy • Most common EPSE (Psuedo)Parkinsonism • Tremor at rest • Pill rolling • Muscle rigidity • Bradykinesia Stiff, shuffling gait Tardive Dyskinesia – Involuntary movements, – Especially of the face and tongue – IRREVERSIBLE if not corrected immediately – LONG TERM USE OF TYPICAL ANTIPSYCHOTIC Tardive Dyskinesia Neuroleptic Malignant Syndrome • Syndrome is very RARE but can be LETHAL – 1% of patients taking antipsychotics – 5% to 20% will die without treatment • Predisposing factors; – Youth – male – high potency neuroleptic – new patient Cardinal symptoms – Lead pipe rigidity – Autonomic instability • High fever • Tachycardia LOC changes Elevated CPK • • • Neuroleptic Malignant Syndrome • • • • Medical emergency STOP all medication may resume meds after crisis. Rx: Dantrolene (Dantrium): skeletal muscle relaxant and Bromocriptine (Parlodel): a dopamine agonist Atypical Antipsychotics • • • • • • Clozaril (Clozapine) Risperidal (Resperidone) Zyprexa (Olanzapine) Seroquel (Quetiapine) Geodon (Ziprasidone) Abilify (Aripiprazole) Clozaril (Clozapine) • • • • • • • • Atypical antipsychotic Decreases negative symptoms of schizo No Extrapyramidal symptoms (EPS) May decrease symptoms of tardive dyskinesia Effects both dopamine and serotonin Side effects: drowsiness and drooling Very costly $9,000. per year. Side effects – Agranulocytosis, weekly blood draws – Sedation, excessive salivation, dizziness, seizures – Hyperglycemia/Wt. Gain, Type 2 DM Risperidal (Resperidone) • Drug is costly--$400. for 1 month supply • Atypical; effects serotonin and dopamine. • 1st line; effects both positive & negative symptoms • Can cause EPS, but lower incidence • Side effects: CNS, drowsiness (most common, given at night) Insomnia agitation, headache, anxiety --Orthostatic hypotension Hyperglycemia • GI: Constipation, nausea, vomiting and dyspepsia • High potency--8 mgm per day in 2 doses • Available in long lasting IM form (2weeks) Zyprexa (Olanzapine) • 1st line drug: Positive and negative symptoms • High potency: 10 mgm a day--up to 20. • Side effects: Drowsiness, constipation, dry mouth, headache. Rare EPS, NMS, • Effects both serotonin and dopamine • Weight Gain long term/Hyperglycemia/ • Type 2 DM • Drug is costly-- 10 mgm per day for 30 days is $250. • Available in short acting IM form Seroquel (Quetiapine) • • • • • • • • • • Atypical antipsychotic, low potentcy Effective in positive and negative symptoms EPS profile same as placebo No increase in prolactin levels No sexual dysfunction problems Side effects: somnolence and hypotension Doses: effective at 150mgm to 750 mgm per day Average: 300 mgm;100 in AM-200 in PM Titrate doses: begin at 50 mgm per day Available in IM injection Ziprasidone (Geodon) • Geodon/Atypical Antipsychotic-Antagonizes Dopamine and Sertonin/ • Low EPS • No increase in prolactin levels • Side effects-somnolence in short term and insomnia in long term use • Weight Gain neutral • Big issue-prolongs the QT interval • Patient cannot have any cardiac or electrolyte imbalance • Monitor serum potassium and magnesium • Starting dose of 80 mgm per day in 2 doses • Can go to 160 mgm • Available in short acting IM form (Aripiprazole ) Abilify • Atypical antipsychotic, effects both dopamine and serotonin, antagonizing some receptors and serving as a partial agonist for others • Decrease in the EPS side effects and minimal Wt. Gain, minimal sedation, no problems with QT interval • Side effects: headache, Anxiety, Insomnia, somnolence, occasional stomach upset • Akathisia • Dosage: 10 to 15 mgm daily can go up to 30 Patient and Family teaching • Teach Pt. and family about schizophrenia – Compare with an illness that cannot be cured: ie Diabetes • Teach Pt. and family about medications • Emphasize importance of follow-up care – If possible have pt. attend a community program. • Teach family concept of Negative Symptoms • Teach concept of stress(high expressed emotion) • Refer family to NAMI. (national alliance mentally ill) • Respite care is important for family. Issues for Nursing care • Defense Mechanisms – denial – projection – regression • Delusion of – persecution – grandeur • Challenges rules, may be argumentative and agitated Paranoid Patient • Very fearful-mistrusting • Very aware of authority • Onset of illness is often late 20’s- may have been a lawyer, accountant, or engineer • Sexual issues-often accuse others of being homosexual Nursing Interventions for Delusions • Do not argue • Do not belittle • Show acceptance and empathy and speak to them”That must be difficult to believe that.” • Delusions of Grandeur-may be a defense against low self-esteem. • Don not patronize • Can reassure-”You are safe here.” • Orient patient to what is happening Safety issues • Patient may be combative • Calm, kind, firm presence • May need a “Show of force” State-”We can’t allow you to hurt others.” • Patient needs limits and know the rules. Issues in the Nurse/Patient relationship • TRUST – – – – – – – Be honest; do what you say. Do not be too warm and friendly Be consistent and honest Be careful with touch At first, may need to just “be there” or “offering self Don’t expect too much of yourself or the patient Improvement happens slowly Interventions for Hallucinations • Ask “Are you hearing voices?” • Ask “What are they saying?” May want to know for safety reasons. • Ask “What are they like, are they loud, or male or female.” • Can ask patient “What helps you with the voices” • Can state,” I know they distract you, but can you focus with me for a minute.” • Patient may miss voices after they are gone. Characteristics of Catatonic Patient • • • • • Acute onset, often in response to stress Rigid, weird positions Waxy flexibility May not eat-often very angry Best prognosis Continuum of care • Schizophrenia is a chronic illness that requires continuous care/ need family & community support • Acute care, Partial hospitalization (day treatment) • Medication, housing, ACT Team (assertive community Treatment) • Case Management, Employment counseling • Social support, Drop in center: SHAC • ACCESS for the Homeless mentally ill • Disability Checks, SSI, Medicaid