Schizophrenia Chapter 16 Schizophrenia   Fascinated and confounded healers for centuries One of most severe mental illnesses – – – 1/3 of population 2.5% of direct costs of total budget $46 billion in indirect costs Epidemiology • 0.5%-1.5% of population • 2.5 million Americans • 300,000 acute episodes each year • Cluster in lower socioeconomic group • Homelessness is a problem. • Direct treatment costs $20 billion/yr Epidemiology • Across all cultures • In the United States, African Americans have a higher prevalence rate (thought to be related to racial bias). • Men are diagnosed earlier. • EOS: Diagnosed late adolescence • LOS: Diagnosed > 45 years Maternal Risk Factors  Prenatal poverty  Poor nutrition  Depression  Exposure to influenza outbreaks  War zone exposure  Rh-factor incompatibility Infant and Childhood Risk Factors  Low birth weight  Short gestation  Early developmental difficulties  CNS infections History of Schizophrenia • 1800s - Eugene Kraeplin named it “dementia praecox.” • 1900s - Eugen Bleuler named it schizophrenia (split minds). More than one type. • Kurt Schneider - First rank (psychosis, delusions) and second rank (all other experiences) Phases of Schizophrenia  Acute Illness Period – – –  Stabilization – – –  Treatment is intense Establish Medications Begin Rehab Maintenance and Recovery – –  Positive symptoms/may be subtle Family Disruption Awareness of the meaning of the disorder Relapse prevention Coping Strategies Relapse – – Non-compliance Identify triggers Familial Differences   First-degree biologic relatives have 10 times greater risk for schizophrenia. Other relatives have higher risk for other psychiatric disorders. Schizophrenia Diagnosis • • During a one-month period at least two of the five – Positive (delusions, hallucinations, etc.) – Negative (alogia, anhedonia, flat affect, avolition) One or more areas of social or occupational functioning Types of Schizophrenia Text Box 16.1  Paranoid  Disorganized  Catatonic  Undifferentiated  Residual Schizophrenia Positive Hallucinations Delusions Disorganization Negative Avolition Alogia Anhedonia Flat Affect Ambivalence Neurocognitive Impairment Attention Memory Exec Function Positive Symptoms: Excess of Normal Functions • Delusions (fixed, false beliefs) – Grandiose – Nihilistic – Persecutory – Somatic • Hallucinations (perceptual experiences) • Thought disorder • Disorganized speech • Disorganized or catatonic behavior Negative Symptoms: Less Than Normal Functioning • Affective blunting: reduced range of emotion • Alogia: reduced fluency and productivity of language and thought • Avolition: withdrawal and inability to initiate and persist in goal-directed behavior • Anhedonia: inability to experience pleasure • Ambivalence: concurrent experience of opposite feelings, making it impossible to make a decision Neurocognitive Impairment • Evidence that neurocognitive impairment exists, independent of positive and negative symptoms Neurocognition     Memory (short-, long-term) Vigilance (sustained attention) Verbal fluency (ability to generate new words) Executive functioning – – – – volition planning purposive action self-monitoring behavior Impaired in schizophrenia  Memory (working)  Vigilance  Executive functioning Neurocognitive Impairment Often Seen as “Disorganized Symptoms” • • • Confused speech and thinking patterns Disorganized behavior Examples of disorganized thinking – – – – – – Echolalia (repetition of words) Circumstantially (excessive detail) Loose associations (ideas loosely connected) Tangentially (logical, but detour) Flight of ideas (change topics) Word salad (unconnected words) Disorganized Symptoms • Examples of disorganized thinking (cont.) – Neologisms (new words) – Paranoia (suspiciousness) – References ( special meaning) – Autistic thinking (private logic) – Concrete thinking (lack of abstract thinking) – Verbigeration (purposeless repetition) – Metonymic speech (interchange words) Disorganized Symptoms • • Examples of disorganized thinking (cont.) – Clang association (repetition similar sounding words) – Stilted language (artificial, formal) – Pressured speech (words forced) Examples of disorganized behavior – Aggression – Agitation – Catatonic excitement (hyperactivity, purposeless activity) Disorganized Symptoms • Examples of disorganized behavior (cont.) – Echopraxia (imitation of others movements) – Regressed behavior – Stereotypy (repetitive, purposeless movements) – Hypervigilance (sustained attention to external stimuli) – Waxy flexibility (posture held in odd or unusual way) Comorbidity • Increased risk of cardiovascular disorders • Association between insulin-dependent diabetes and schizophrenia • Depression and pseudodementia • Increased substance abuse • Cigarette smoking • Fluid imbalance Disordered Water Balance  Prolonged periods of polydipsia, intermittent hyponatremia, polyuria  Etiology – unknown  Observed behaviors – Carrying cokes/coffee/water bottles  Prevention of water intoxication  Promotion of fluid balance Psychological        Difficulty relating Deficit in sensory inhibition Poor control of autonomic responsiveness Difficulty making decisions Deficit experiencing pleasure Deficit initiating activities Overassessment of threat Social     Deceased financial status Family and caregiver stress Homelessness Stigma and community isolation Biologic Factors • Genetic – 10% first-degree relative • Stress-diathesis model proposed by O’Connor • Neuroanatomical findings – Decreased blood flow to left globus pallidus – Absence of normal blood increase in frontal lobes – Atrophy of the amygdala, hippocampus and parahippocampus – Ventricular enlargement Biologic • – Neurodevelopmental – Prenatal exposure (2nd trimester) – Late winter, early spring births Adolescent – Changes in transmitter systems and substrates – Synaptic pruning along with substantial brain growth in some areas of the cortex – Changes in steroid-hormonal environment Neurotransmitters, Pathways and Receptors • Hyperactivity of the limbic area • • Hypofrontality or hypoactivity of the pre-frontal and neo-cortical areas • • (dopamine mesolimbic tract) related to positive symptoms (dopamine mesocortical tract related to negative and positive symptoms) Does not result from dysfunction of a single neurotransmitter Psychosocial Theories • Do not explain cause • Disservice to families • Useful in family interaction – Expressed Emotion (EE) • High emotion associated with negative communication and overinvolvement • Low emotion associated with less negativity and less overinvolvement Priority Care Issues  Suicide – 20-50% Attempt – 10% Complete  Safety of patient and others  Initiate antipsychotic medications Family Response to Disorder  Mixed emotions – shock, disbelief, fear, care, concern and hope  May try to seek reasons  Initial period very difficult  NAMI – Life changed forever Interdisciplinary Treatment    The most effective approach involves a variety of disciplines. There is considerable overlap of roles and interventions. Nursing’s contribution is significant. Nursing Management: Biologic Domain Assessment • Present and past health status • Physical functioning • Nutritional assessment • Fluid imbalance assessment • Pharmacologic assessment   Medications (prescribed, OTC, herbal, illicit) Abnormal motor movements – – – DISCUS AIMS Simpson-Angus Rating Scale Assessment  Comorbidity – – – Diabetes Smoking-related Cardiac  Hypertension Nursing Diagnosis: Biologic Domain  Self-care deficit  Disturbed sleep pattern  Ineffective therapeutic regimen management  Imbalanced nutrition  Excess fluid volume  Sexual dysfunction Nursing Interventions: Biologic Domain  Promotion of self-care activities – –  Activity, exercise and nutrition – –  Help counteract effects of psychiatric medications. Appetite usually increases, so help with food choices. Thermoregulation – Teach patient to wear clothing according to weather; dress for winter and summer. Observe patient’s response to temperature. – Water intoxication protocol (Text Box 16.7) –  Develop a routine of hygiene activities. Emphasize its importance; help motivate the patient. Promotion of normal fluid balance Pharmacologic Interventions  Newer antipsychotics more efficacious and safer (block dopamine and serotonin) – – – – – –  Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodone) Aripiprazole (Abilify) Clozapine (Clozaril) - second line Monitoring and administering medications – – – – Takes 1-2 weeks to work (some improvement immediately) Adequate trial - 6-12 weeks Adherence to prescribe medication is best prevention of relapse. Discontinuation is rare. Pharmacologic Interventions: Monitoring Side Effects  Parkinsonism – – – –  Identical symptoms to Parkinson’s Caused by blockade of D2 receptor in basal ganglia Treated with anticholinergic medications Taper anticholinergic meds if discontinued Dystonia – – – Imbalance of DA and ACH, with more ACH Young men more vulnerable Oculogyric crisis, Torticollis, Retrocollis Monitoring Side Effects   Akathesia – Restlessness, jumping out of skin, uncomfortable – Reduce dose of antipsychotic. – Treat with a -blocker (propranolol). Tardive Dyskinesia – Impairment of voluntary movement, constant motion – Occurs 6-8 months following initiation of antipsychotics – Facial-buccal area -- lip smacking, sucking, etc. – Movements in trunk, rocking – No real treatment Monitoring Side Effects        Orthostatic hypotension Hyper Prolactinemia (haloperidol and risperidone) Weight gain (olanzapine and clozapine) Sedation New-onset diabetes (Olanzapine,clozapine) Cardiac arrhythmias (QT prolongation) (Ziprasidone) may need baseline ECG Agranulocytosis (all but *clozapine) Drug-drug Interactions  Medications metabolized by 1A2 enzymes include olanzapine and clozapine.    Medications metabolized by 3A4 include clozapine, quetiapine and ziprasidone.    Inhibitors: fluvoxamine (Luvox) Inducers: cigarette smoking Smokers may require a higher dose Inhibitors: ketoconazole, protease inhibitors, erythromycin Inducer: carbamazapine (Tegretol) Medications affected by 2D6 include risperidone, clozapine and olanzapine.  Inhibitors: fluoxetine, paroxetine (not usually clinically significant) Medication Teaching Points  Consistency in taking medication  Medication and symptom amelioration  Side effects and management  Interpersonal skills that help patient and family report medication effects MEDICATION EMERGENCIES Neuroleptic Malignant Syndrome  TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSE  Severe muscle rigidity, elevated temperature  Recognizing symptoms –  Elevated temperature, changes in level of consciousness, leukocytosis, elevated creatinine phosphokinase), elevated liver enzymes or myoglobinuria Nursing interventions – – – – Stop administration of offending medications. Monitor vital signs. Reduce body temperature. Safety, protect muscles  Supportive measures – – – IV fluids Cardiac monitoring Dantrolene (Dopamine agonist) Neuroleptic Malignant Syndrome     Acute reaction to dopamine receptors blockers Prevalence 2 to 2.4% Death – 4 to 22%, mean = 11% Etiology: – Drugs block striatal dopamine receptors; disrupt regulatory mechanisms in the thermoregulatory center in hypothalamus and basal ganglia; heat regulation fails and muscle rigidity Is Client on neuroleptic drug? NO NOT NMS ANY RISK FACTORS FOR NMS? DEHYDRATION? HISTORY OF NMS? RECENT DOSE INCREASE? PSYCHOMOTOR AGITATION YES EARLY S/S NMS? LOW-GRADE FEVER? TACHYCARDIA?ELEVATED BP? CATATONIA?DIAPHORESIS? YES HYPERTHERMIA? LEAD PIPE RIGIDITY? MS CHANGES OTHER AUTONOMIC CNS? HOLD DRUG N O T I F Y M D Anticholinergic Crises     Potentially life threatening, anticholinergic delirium Can occur in patients who are taking several medications with anticholinergic effects Elevated temperature, dry mouth, decreased salivation, decreased bronchial, nasal secretion, widely dilated eye Stop offending drug, usually self-limiting. May use inhibitor of anticholinesterase, physostigmine. Anticholinergic Crisis  Confusion, hallucinations  Physical signs - dilated pupils, blurred vision, facial  Atropine flush  flushing, dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension decreased bowel sounds, urinary retention, nausea, vomiting, seizures, coma Hot as a hare, blind as a bat, mad as a hatter, dry as a bone Treatment      Self-limiting – three days Discontinuation of medication Physiostigmine 1-2 mg IV, an inhibitor of cholinesterase, improves in 24-36 hours Gastric lavage Charcoal, catharsis Nursing Management: Psychological Domain Assessment – Responses  Socially stigmatizing  Prodromal symptoms evident (negative symptoms)  Tension and nervousness  Lack of interest in eating  Difficulty concentrating  Disturbed sleep  Decreased enjoyment  Loss of interest, restlessness, forgetfulness  Often not recognized as an illness  Denial common Nursing Management: Psychological Domain Assessment • • Positive and negative symptoms • SAPS (positive symptoms) (Box 16.14) • SANS (negative symptoms) (Box 16.15) • PANNS (both symptoms) Mental status • Appearance • Mood and affect (lability, ambivalence, apathy) • Speech • Thought processes (delusions, disorganized communication, cognitive impairments) • Sensory perception (hallucinations) • Memory and orientation • Insight and judgment Nursing Management: Psychological Domain Assessment (cont.)     Behavioral responses Self-concept Stress and coping patterns Risk assessment – – – Command hallucinations Self-injury risk, suicide Homicide Nursing Diagnosis: Psychological Domain         Disturbed thought processes Disturbed sensory perceptions Disturbed body image Low self-esteem Disturbed personal identity Risk of violence, suicide Ineffective coping Knowledge deficit Nursing Interventions: Psychological Domain   Counseling, conflict resolution, behavior therapy and cognitive interventions can be used. Development of nurse-patient relationship – Centers on the development of trust and acceptance of the persons – Critical for optimal treatment of schizophrenia Nursing Interventions: Psychological Domain – Management of Disturbed Thoughts  Assessment content of hallucinations/delusions  Outcomes   – Decrease frequency and intensity. – Recognize as symptoms of disorder. – Develop strategies to manage recurrence. Experiences real to the patient – Validate that experiences are real – Identify meaning and feeling that are provoked Teach patient that hallucinations and delusions are symptoms of illness. Nursing Interventions: Psychological Domain   Self-monitoring and relapse prevention – Monitor events, time, place, etc. of recurrence of symptoms. – Manage symptoms - getting busy, self-talk, change of activity. (Moller-Murphy Tool) Enhancement of cognitive functioning – Recognize difficulty in processing information. – Improve attention (computer programs, one-to-one). – Help memory (make lists, write down information). – Improve executive functioning-simulation. Nursing Interventions: Psychological Domain  Behavioral interventions – –  Stress and coping skills development – –  Organize routine, daily activities. Reinforce positive behaviors. Counseling sessions Teach and reward positive coping skills. Patient education – – – – Errorless learning environment Minimal distractions Clear visual aids Skills training Family Interventions    Family support Educate the family regarding lifelong disorder of schizophrenia. Emphasize consistent taking of medication. Nursing Management: Social Domain Assessment   Functional status – Assessed initially and at regular intervals – GAF usually used Social systems – Formal and informal support systems  Quality of life  Family assessment – Family assessment guide (Ch. 15) – Special consideration to the family where patient is the parent Nursing Interventions: Social Domain Promotion of Patient Safety • Monitoring for potential aggression • Administering medication as ordered • Reducing environmental stimulation • Approach to individual patients – – Thorough history of violence Help patient to talk directly and constructively with those with whom they are angry. – Set limits. – Involve patients in formal contracting. – Schedule regular time-outs. Nursing Interventions: Social Domain     Support groups Milieu therapy Psychiatric rehabilitation Family interventions – – – Encourage to participate in support groups Inform about local and state resources Help negotiate provider system Continuum of Care  Treatment occurs across continuum. Patients are at high risk for getting lost in the system.  Inpatient-focused care (stabilization)  Emergency care (crisis)  Community care (most of care)  Mental health promotion Schizophrenia in Children     Rare in children If appears in children aged 5 or 6, symptoms same as for adults Hallucinations visual, delusions less welldeveloped Other disorders considered first Schizophrenia in Elderly   For those who have had schizophrenia most of their life, this may be a time that they experience improvement in symptoms. Late-onset schizophrenia – Diagnostic criteria met after 45  – Estrogen may be protective in women Most likely include positive symptoms