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Schizophrenia
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Psychosis
• A Symptom
• Affects ability to perceive and process
information.
• Behaviors associated with psychosis are often
severe, long-lasting and difficult to understand.
• Goal is patient recognition of symptoms and
development of strategies to manage symptoms
resulting in stabilization.
Schizophrenia
•
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A serious persistent neurological brain disorder: the exact cause is
unclear
Theories of causation include
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genetics, biochemistry, and psychosocial factors
1. Age of onset
2. Role of Stress
3. Need for dopamine agonist (medication)
Symptoms vary greatly among different patients depending on the area
of the brain effected.
– Psychosis: the individual is not able to distinguish the external world from
internally generated perceptions.
•
Treatment varies to meet individual needs
– Includes:
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psychotropic medications
education
social support
BIOCHEMICAL
•
Dopamine overwhelms the
brain and binds with too
many receptors
–
Research has been unable to
determine if this is due to:
1. Higher levels of
dopamine
2. Increased sensitivity
to dopamine
• Ratio between serotonin and
dopamine
– atypical anti-psychotics
effect serotonin also.
• Endogenous dopamine is an
antagonist is GABA
– Relatively high levels of
dopamine result in ANXIETY
• Can you induce psychosis?
– Marijuana, LSD,
Amphetamines
– How do these affect
dopamine
GENETIC
ENVIRONMENT
Etiology
BIOCHEMICAL
Brain structure
and
Function
GENETICS
• Probability of Schizophrenia in Families
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1 parent 10% probability
1 sibling 10%
Identical twin 50%
Both parents varies 40%
A gene identified ---research continues
Review of Neurobioloby
• Frontal lobes
– The executive; decision
maker, reliant on other
parts of the brain for data.
Prefrontal is the
personality
• Temporal Lobes
– Hearing
• Parietal Lobes
– Perception, interpertation
touch body perception
• Occipital Lobes
– Sight
Schizophrenia and
Neurotransmitters
• Overactive dopaminergic
pathways in the
mesolimbic (innervates the
limbic system) system
• Important in reaction to
stress
• Hypofunction in the
prefrontal areas and an
imbalance between
dopamine and serotonin
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 (VBR Ventricular Brain Ratio)
ENVIRONMENTAL
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Inherited susceptibility to schizophrenia
Prenatal infections
Poor Family Communication
Greater % of patients come from lower socio-economic
class
• STRESS
• What about prevention?
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
STRESS: Onset or Relapse
• Biological (medical illness)
– People with schizophrenia:
• Can misperceive physical symptoms
• Have poor pain recognition
• Leads to neglect by health care providers
• Psychological (loss of a relationship)
• Sociocultural (homeless)
• Emotional (persistent criticism)
• Identification of symptoms and early triggers
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
Positive symptoms of
Schizophrenia
• Positive Symptoms (+) Person with schizophrenia does more
(+) than Person who is functioning normally
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agitation/aggression
delusions
hallucinations
formal thought disorder:loose associations, word salad
bizarre behavior
– Disorganized Speech (loose associations and word salad)
– Grossly disorganized or catatonic behavior
• Typical Anti-psychotic medications control these symptoms
Negative symptoms of
Schizophrenia
• Negative Symptoms (-)
Person with schizophrenia
does less (-) than Person who
is functioning normally
• Atypical antipsychotics will
help these symptoms
• Typical antipsychotics can
make these worse
– flat affect
– avolition; lack of direction or
purpose
– ambivalence;
– indecisive
– constricted
– concrete thinking
– alogia: poverty of speech
– social withdrawal
– anhedonia
– deep apathy
– minimal or poor self care
Schizophrenia Subtypes
• Paranoid
• Catatonic
• Disorganized
• Undifferentiated
• Residual
Paranoid
• Preoccupation with:
1. Delusions
• Persecutory /Paranoid
• Grandiose
2. Hallucinations
• Command
• Auditory
3. No disorganized speech
Usually neat and clean.
4. Issues for Nursing care
– Fearful-mistrusting
– Aware of authority
• Can be VERY dangerous to
others and self. Can get
themselves into situation
where they think they are
protecting themselves and
they get themselves killed.
Catatonic
– Stupor
– Negativism
– Rigidity
– Posturing: waxy flexibility
Characteristics of Catatonic
Patient
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Acute onset, often in response to stress
Rigid, weird positions
Waxy flexibility
May not eat-often very angry
Good prognosis
• What are the Nursing Interventions for someone who is
not eating and stays in the same position for many
hours?
Disorganized
– Disorganized speech
– Disorganized behavior
– Flat or inappropriate affect
– Disheveled appearance
Undifferentiated
– Positive symptoms
– Does not meet criteria for:
• Paranoid Schizophrenia
Residual
– No positive symptoms
– Mostly negative symptoms
– Chronic
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:
– Symptoms schizophrenia are dominant
– Accompanied by major depressive or manic symptoms
Nursing Diagnosis for
Schizophrenia
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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; Disturbed thought
process; Auditory Hallucinations
Secondary to: Schizophrenia
Treatment
• Antipsychotic Medication
• Supportive Psychotherapy and Education
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Individual
Group
Milieu
Family
• Social supports
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Follow-up mental health care/Medication
Housing
Day treatment
Employment
Therapeutic Relationship
• TRUST
– Be honest; do what you say.
• Do not be too warm and friendly
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Be consistent and honest
Be careful with touch AND eye contact
At first, may need to just “be there” or “offering self
Don’t expect too much of yourself or the patient
Improvement happens slowly
Therapeutic Communication
for Hallucinations
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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.
Elements of the Effective
Milieu
1. Safety
(examples) Psychological and
physical
Restraint and seclusion
No contraband (cans, glass, lighters)
2. Structure
(examples) Unit schedules,
meals, bedtime
Groups
Visiting hours
3. Norms
(examples) Individual responsibility
Rules
4. Limit setting
(examples) cannot harm self or others;
cannot smoke
5. Balance
(examples) Rights of one person to talk
loud –VS- rights of others to quiet
Nursing judgment and critical thinking
Environmental Modification- bending
rules when necessary to be
therapeutic.
Milieu: Therapeutic Manipulation of the
Environment
• Disruptive Patients
– Set limits
– Decrease environmental
stimuli
– Frequent observation
• Early intervention
• Verbal intervention so
physical intervention
is not needed
– Safety
• Who will work with
the patient?
– No threats
• (If you……then)
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Suspicious Patients
– Matter of Fact
– No laughing or whispering
– Proximics
• Approach form the side
• Avoid close physical
contact
– Eye contact
Withdrawn Patients
– Non threatening activities
– Provide a connection with
reality
– Give support
• Decision making
• Hygiene
Milieu: Therapeutic Manipulation of the
Environment
• Impaired Communication
– Protect self-esteem
• Activities where success is
assured
– Provide support
• Connection
– Patience
– No pressure
• Disorganized
– Decreased stimulation
– Provide a calm environment
– Safe and simple activities
• Rely on long term memory
• Hallucinations
– Engage in activities
– Attempt to separate patients
who have similar psychotic
thoughts
– Connection to reality
• Talk about real people and real
events
– Monitor television
– monitor for command
hallucinations
Consistency in the Milieu
• Do not argue
• Do not belittle
• Show acceptance and empathy and speak to them
“That must be difficult to believe that.”
• Do not patronize
• Can reassure- “You are safe here.”
• Orient patient to what is happening
Nursing Care
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Give information in a kind
matter-of-fact
– Thoughts provide a sense of
identity
•
Pay attention to key words
– Speech represents cognitive
functioning
– Identify one or two verbal or
non-verbal responses.
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Seek Validation
Assist with decision making
(in the here and now) in a
nonpunitive supportive
manner
– Initiation and completion of
tasks
The client
– Is sleeping 2 hours a night
– Will not eat
– Has poor hygiene
– Is afraid of another client
– Does not like their doctor
– Wants to stay in their room
– States they are on a special
mission to save the United
States
Psychosis-Induced Polydipsia
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Compulsive water drinking (6% to 20%)
Thirst and Osmotic dysregulation
Hyponatremia
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Confusion
Convulsions
Coma
Lightheadedness
Nausea and vomiting
Weakness
Muscle Cramps
Treatment
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Weigh
Restrict fluid
Sodium replacement
Constant supervision
Antipsychotic Medications
• Typical
– Rarely a scheduled medication
– Acute phase: controls positive symptoms
– Identification and treatment of side effects
• Atypical (97%)
Four Major Dopaminergic
Tracts
• 1. Nigrostriatial (movement)
• 2. Tuberinfundibular (pituitary; elevation in prolactin)
• 3. Mesolimbic (emotion and sensory)
• 4. Mesocortical (cognitive processes)
Typical Antipsychotics
• High Potency Neuroleptic
– Haldol (Haloperidol)
– Prolixin (Fluphenazine)
– Available in pills, liquid, Intramuscular and Depo (decanoate)
injection
• Low Potency Neuroleptic
– Thorazine (Chlorpromazine)
– Mellaril (Thiroidazine)
• In-betweens
– Stelazine
– Trilafon
– Navane
Antiparkinsonian Agents
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Cogentin (benztropine)
Artane (trihexyphenidyl)
Benadryl (diphenhydramine)
Symetrel (amantadine)
• Ativan (Lorazepam)
Acetylcholine and Dopamine
• A balance between dopamine and acetylcholine is
required for normal movement
• Antipsychotic medication 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
Antipsychotic
• Extrapyramidal Side Effects
(EPSE)
– Acute Dystonia
– Akathisia
– (Psuedo)Parkinsonism
– Tardive Dyskinesia
• Anticholenergic effects
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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
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Predisposing factors;
– Youth
– male
– high potency neuroleptic
– new patient
Cardinal symptoms
– Lead pipe rigidity
– Autonomic instability
• High fever
• Tachycardia
LOC changes
Elevated CPK
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Neuroleptic Malignant Syndrome
(Malignant Hyperthermia)
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Medical emergency
STOP all medication
may resume meds after crisis.
Rx: Dantrolene (Dantrium): skeletal muscle relaxant
and Bromocriptine (Parlodel): a dopamine agonist
Atypical Antipsychotics
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Clozaril (Clozapine)
Risperidal (Resperidone)
– Invega (Palperidone)
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Zyprexa (Olanzapine)
Seroquel (Quetiapine)
Geodon (Ziprasidone)
• Novel Antipsychotic
• Abilify (Aripiprazole)
Atypical Antipsychotics
• Decease both Positive and Negative symptoms
– Keep dopamine available in some areas (frontal lobe and
cortex) of the brain while blocking the effects of dopamine in
others.
– Increase availability of Serotonin
• Very little risk of Tardive Dyskinesia and
Extrapyramidal Side Effects
Clozaril (Clozapine)
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Atypical antipsychotic
Decreases negative symptoms of schizophrenia
No Extrapyramidal symptoms (EPS)
May decrease symptoms of tardive dyskinesia
Effects both dopamine and serotonin
Side effects: drowsiness and drooling
Expensive
Side effects
– Agranulocytosis, weekly blood draws
– Sedation, excessive salivation, dizziness, seizures
– Hyperglycemia/Wt. Gain, Type 2 DM
Risperidal (Resperidone)
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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
• Available in long lasting IM form (2weeks)
Invega (Palperidone)
• Available in extended release
• A metabolite of Resperidone
• Similar profile to Resperidone
Zyprexa (Olanzapine)
• Positive and negative symptoms
• Side effects: Drowsiness, constipation, dry mouth,
headache. Rare EPS, NMS,
• Effects both serotonin and dopamine
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Weight Gain long term/Hyperglycemia/
• Type 2 DM
• Available in short acting IM form and ZYDES
Seroquel (Quetiapine)
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Atypical antipsychotic, low potency
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
• 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
• Available in short acting IM form
(Aripiprazole ) Abilify
NOVEL ANTIPSYCHOTIC
• 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
Education
• Teach about the importance of:
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Stay on Medication
Keep stress down
Seek help if symptoms exacerbate
Avoid use of drugs or alcohol
Community Supports
• Austin Travis County Integral care
– http://www.integralcare.org
• Palidin Community Mental Health Center
– http://www.paladincmhc.com
• Capital Area Counicling
– http://camhc.org
• National Alliance for the Mentally Ill (NAMI)