Schizophrenia

Objectives
Define the term schizophrenia Recognize DSM-IV criteria and subtypes Differentiate type I and type II subtypes Describe theories that have contributed to the current understanding of schizophrenia

Schizophrenia
Objectives
Describe objective and subjective symptoms Identify the major drugs used in the treatment of schizophrenia Develop a nursing care plan Evaluate effectiveness of nursing interventions

Why is it important to learn about schizophrenia?

Schizophrenia: occurs in about 1% of the population is a chronic illness that is: 5 x more common than MS 6 x more common than insulindependent diabetes 60 x more common than muscular dystrophy

Why is it important to learn about schizophrenia?

Schizophrenia costs in excess of $25 billion In 3 out 4 cases it begins between the ages of 17 and 25 95% never recover

Why is it important to learn about schizophrenia?

1 out of 4 schizophrenics attempt suicide within the first 10 years of the illness and 10% succeed

DSM IV Diagnosis
DSM IV Disorders
Mood Anxiety Somatoform Personality

Psychotic

Cognitive

Eating

Substance Abuse

Schizophrenia

Paranoid

Undifferentiated

Disorganized

Residual

Catatonic

Schizophrenia means splitting of mind and affect

Classic Symptoms:

Affective disturbances Ambivalence Associative looseness

Autism

DSM-IV Criteria
A. At least two of the following:

Delusions Hallucinations Disorganized Speech

Grossly disorganized or catatonic behavior

Negative Symptoms

Plus

DSM-IV Criteria
B. Social / occupational dysfunction C. Duration: continuous signs for 6 months D. Absence of Schizoaffective and mood disorders E. Not caused by substance abuse or a general medical illness

DSM-IV 5 Subtypes

Paranoid Preoccupation with one or more delusions or frequent auditory hallucinations

Disorganized Disorganized speech, behavior, flat or inappropriate affect

DSM-IV Subtypes

Catatonic Two of the following symptoms are present Motoric immobility, waxy flexibility, or stupor
Purposeless excessive motor activity Extreme negativism or mutism Peculiar or sterotypic of movement Echolalia or echoraxia

DSM-IV Subtypes

Undifferentiated Characteristic symptoms are present but criteria for other subtypes are not met

Residual Characteristic symptoms are no longer present, but there is continuing evidence of negative symptoms or criterion

Three Phases of History

1856
Dementia Praecox 68 Catatonia

1952
DSM- I (9) 68 II (11)

1982
Andreason, Crow, Introduce Types I(+) and II(-) 87 DSM III, revised

70 Hebephrenia
96 Paranoia

80 III (5)

Kraepelin groups all three under DP 1900 Schizophrenia - Bleuler

94 DSM-IV
97 I, II, Disorganized

Positive Type I
Symptoms reflecting excess or distortion of normal functions.

Negative Type II
Symptoms reflecting diminuation or absence of normal behaviors

Hallucinations Delusions Disorganized thinking/speech Disorganized behavior

Affective flattening Alogia Avolition/apathy Anhedonia Asocial

Thought to be caused by dopamine transmission problems

Thought associated with abnormal brain structures

An 18-yo female has not eaten or spoken for 3 days

HPI: According to her parents she was a normal teenager with friends and good grades until 1 year ago, when she began to confine herself to her room and became preoccupied and less active than in the past. Six months prior to this admission, she began to refuse to go to school, grades worsened,

An 18-yo female has not eaten or spoken for 3 days

HPI: Approximately one month later, she started to talk about spirits, magic, and the devil. She has no history of suicide attempts of drug abuse. PE: No insight, Interview reveals bizarre pattern of thinking; hallucinations; no persecutory delusions.

An 18-yo female has not eaten or spoken for 3 days

TX: Haloperidol given to treat positive symptoms. Supportive psychotherapy and rehabilitation are effective forms of treatment But patients never reach premorbid level of normal functioning.

Positive(I) and Negative Symptoms(II)

Type I
Prognosis: Precipitating factor: Onset: Sensorium: Intellectual Impairment: Pathophysiology: Pathoanatomy: Response to typical neuroleptics: atypical neuroleptics: Effect of Levodopa: Good Yes Acute Dreamlike No D2 hyperactivity VBRs Normal Good NA Symptoms

Type II
Poor No Chronic Clear Yes Dopamine, CBF VBRs + Varies Good Minimal

Antipsychotic Drug TX
Side Effects Anticholinergic Constipation, dry mouth, blurred vision, urinary retention hesitancy
Due to interference of nerve impulses by acetylcholine and epinephrine

Nursing Interventions
Monitor for these effects

Bethanechol for urinary retention Hard candy for dry mouth

Antipsychotic Drug TX
Side Effects Extrapyramidal Symptoms A resting tremor Mask-like face Decreased blink rate Increased salivation Decreased arm swings Shuffling gait Nursing Interventions 1/3 of patients have EPS Monitor for these effects Administer antiParkinsonian meds Artane Cogentin Symmetrol Lower Med. Dose/potency

Antipsychotic Drug TX
Side Effects Akathisia Characterized by restlessness, pacing, or shifting from one foot to another Usually occurs after weeks of months of treatment Nursing Interventions Distinguish from agitation Ask how the patient feels. I just cant sit still. I feel like jumping out of my skin Administer antiParkinson medication

Antipsychotic Drug TX
Side Effects Dystonic Reactions Characterized by involuntary muscular movements of neck, arms, legs and face. Includes torticollis, oculogyric crisis. Difficulty swallowing Occurs after 1st dose. Nursing Interventions Administer IM antiParkinson medication Terrifying to the patient Reassure pt: explain that this can be fully controlled with antiParkinson medication

Antipsychotic Drug TX
Side Effects Tardive Dyskinesia Characterized by difficulty swallowing, lib smacking, tongue protrusion, puckering, blinking, choreiform movements of limbs and trunk Generally irreversible Associated with the high potency neuroleptics 10-20% who receive antipsychotics >1yr develop this. Nursing Interventions Lower dose, change to less potent antipsychotic, benzodiazepines.

Antipsychotic Drug TX
Side Effects Other Symptoms sedation, orthostatic hypotension, photosensitivity, decreased libido, weight gain, reduction of seizure threshold, amenorrhea, Nursing Interventions Patient Teaching Change position slowly Diet Wear sunscreen and sunglasses Take orthostatic blood pressure

Antipsychotic Drug TX
Side Effects Other Symptoms cholestatic jaundice
(An allergic reaction to chlorpromazine)

Nursing Interventions Patient Teaching report sore throats

agranulocytosis

Monitor blood labs

Antipsychotic Drug TX
Side Effects Neuroleptic Malignant Syndrome Nursing Interventions Monitor for high fever autonomic instability tachychardia muscle rigidity elevated CPK sweating hyperkalemia

This is a medical emergency

Neuroleptic Malignant Syndrome

Believed Mortality Can

to be caused by dopamine blockade in the hypothalamus rate about 20% occur any time.

Neuroleptic Malignant Syndrome

Nursing Interventions

Report changes in vital sign, rigidity and mental status immediately. Discontinue all Drugs Maintain nutrition, hydration

Reduce temperature using sponge baths, antipyretics Ventilator, renal dialysis Bromocriptine or Dantroline to muscle contraction

Anticholinergic Crisis
Symptoms Red as a Beet Mad as a Hatter Hot as a Stove Dry as a Bone

Motor restlessness Confusion Tachycardia sluggishness Dilated pupils Acute urinary retention Blurred vision Fever and Bowel sounds

Anticholinergic Crisis
Nursing Interventions
Discontinue Neuroleptic
Give the anticholinesterase physostigmine (eserine)

Discharge Planning
Chronic illness with remissions and exacerbations

Follow up psychiatric medical management to ensure compliance

Placements in aftercare, day hospital, sheltered care facility, social skills training, vocational training, family intervention programs.

Patient Teaching
Skills for coping with psychotic symptoms Cognitive reforming regarding the cause of symptoms Gaining control over symptoms

Behavioral coping strategies

Teach patient and family to recognize the signs of relapse

4 Ss Rehabilitation

Safety Symptom

Structure Support

Management

Schizophrenia
Psychotic symptoms of Schizophrenia include altered perceptions auditory hallucinations visual hallucinations, delusions

Auditory Hallucinations are by far, the most common of these.

Schizophrenia
Antipsychotic Drugs have enabled millions of schizophrenics to live in the least restrictive environment Dopamine hypothesis: Excessive dopaminergic activity in cortical areas causes acute positive (Type I) symptoms of schizophrenia.

Schizophrenia
Antipsychotics block access of dopamine to the receptor

Less dopamine, improves psychotic symptoms

However, less dopamine then produces Parkinson symptoms

Schizophrenia
Traditional Antipsychotics (Neuroleptics) are heavy in side effects Haloperidol (Haldol) Thorazine Fluphenzaine (Prolixin)

However can be given as long acting injection (decanoate form)

Schizophrenia
There are newer generation Antipsychotics available now.

Risperidone (Risperdal) Clozapine (Clozaril) Olanzapine (Zyprexa)

Schizophrenia
New generation antipsychotics are just as effective in reducing symptoms in type I Schizophrenia, and Are more complex (act on more than 1 neurotransmitter) Have little or no extrapyramidal side effects.

Schizophrenia
Clozapine (Clozaril) Especially good for negative symptoms of schizophrenia Patient needs weekly blood tests to detect clozapineinduced agranulocytosis

Schizophrenia
Neurostructural theories Cerebral ventricular enlargement Smaller cerebral and cranial size Hypoplasia of the medial (limpic) temporal structures, especially the hyppocampus

Schizophrenia
Substance abuse is the most common co-morbid psychiatric condition associated with Schizophrenia. The leading cause of death in Schizophrenia is Suicide Medication compliance is one of the most important goals of treatment

Schizophrenia- Nursing Interventions

Be calm, keep promises, be consistent, be honest Do not agree or argue with a hallucination or a delusion. Instead, allow and encourage verbalization of the feeling. Never touch a patient without warning them. Be diligent in attempting to understand patients.

Schizophrenia- Nursing Interventions

If the patient appears to be hallucinating, gently inquire.

It looks like you might be listening to something. Are you hearing voices? Try to describe what you are hearing?
Monitor for command hallucinations that may increase potential for patient to become dangerous.

Schizophrenia- Milieu Management

Disruptive Patients Set limits in disruptive behavior State consequences of behavior. If you keep your shirt on, you can remain with the group. If remove your shirt, you will have to go to your room Follow though

Schizophrenia- Milieu Management

Withdrawn Patients Arrange non-threatening activities that involve doing. Sit in silence with patients who are not ready to interact. Help patient participate in small choices (menu, clothing) Reinforce appropriate grooming and hygiene (assist at first if needed)

Schizophrenia- Milieu Management

Suspicious Patients Be matter-of-fact Do not whisper or laugh in present, and clarify misperceptions Do not touch. Avoid close physical contact Do not slip medication into juices or food/ keep in unit dose package Maintain eye contact

Schizophrenia- Milieu Management

Patients with Impaired Communication Provide opportunities to make simple decisions. Do not place in group activities that would frustrate them, damage their self esteem, or overtax their abilities Provide opportunities for purposeful psychomotor activity.

Schizoaffective Disorder
A hybrid of two disorders schizophrenia and major depression or manic symptoms with substantial loss of occupational and social functioning.

Prognosis is better than that of schizophrenia but significantly less optimistic than the prognosis for mood disorders.

Delusional Disorder
Similar to schizophrenia but with some differences: Delusions have a basis in reality Never fully meet criteria for Schizophrenia Behavior is relatively normal except in relation to delusions Symptoms are directly related to a substance or medical condition

CASE STUDY - Clinical Area

Schizophrenia

THE END

An 18-yo female has not eaten or spoken for 3 days

HPI: According to her parents she was a normal teenager with friends and good grades until 1 year ago, when she began to confine herself to her room and became preoccupied and less active than in the past. Six months prior to this admission, she began to refuse to go to school, grades worsened,

An 18-yo female has not eaten or spoken for 3 days

HPI: Approximately one month later, she started to talk about spirits, magic, and the devil. She has no history of suicide attempts of drug abuse. PE: No insight, Interview reveals bizarre pattern of thinking; hallucinations; no persecutory delusions.

Physician Orders
Haloperidol 2 mg bid Diet, normal Provide supportive therapy

Halperidol, 2mg bid is ordered initially

What class is this medication?

What do you need to do to administer this medication safely?

Halperidol, 2mg bid is ordered initially

Is this dose accurate? Why or why not? Why is this 18 year old getting this medication? What are the symptoms that you would not expect this medication to relieve?

Patient Teaching
How will you determine this patients learning needs related to symptom management? What will the patient need to know about the effects this medication has on symptoms? What will the patient need to know about the side effects of this medication?

18-yo female has not eaten or spoken for 3 days

Supportive psychotherapy and rehabilitation are effective forms of treatment But patients never reach premorbid level of normal functioning.