schizophrenia spectrum

psychotic disorder specturm

from less severe to more severe

brief psychotic d/o —> delusional d/o -→ schizotypal personality d/o —> schizophreniform d/o —> schizoaffective d/o —> schizophrenia

what is psychosis?

mental state in which individual struggles to distinguish external world from internally generated perceptions

common symptoms: hallucinations, delusions, disorganized thinking

what is schizophrenia?

major psychotic disorder

characterized by disturbances in:

• perception

• feeling

• thought process

• reality testing

• attention

• motivation

bleuler’s 4 A’s of schizophrenia

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-5 for schizophrenia

presence of two or more of these:

• delusions

• hallucinations

• disorganized speech

• grossly disorganized or catatonic behavior

• negative symptoms

other factors- impaired functioning, lasts at least 6 months, rule out mood disorder or substance abuse

3 facts about schizophrenia

high probability of becoming apparent late in adolescence or early adulthood; seems to emerge during this critical time of transition

stress plays a role in onset and relapse; not seen as the cause

antipsychotic drugs are therapeutically effective; all meds have various side effects

schizophrenia epidemiology and comorbidity

lifetime prevalence of schizophrenia 1% worldwide

no difference related to race, social status, culture

substance abuse disorders occur in nearly 50% of pts

anxiety, depression, suicide

physical health or illness

behavioral disorders in schizophrenia

objective: alterations in personal relationships and alterations in activity

subjective: altered perceptions, alterations of thought, altered consciousness, and alterations of affect

positive, type 1 schizophrenia

florid and dramatic symptoms- hallucinations and delusions

related to hyperdopaminergic process

favorable response to typical antipsychotics

positive symptoms

alterations in thinking:

• delusions are false, fixed beliefs

• concrete thinking is an inability to think abstractly

alterations in speech:

• neologisms

• echolalia

• clang associations

• word salad

• flight of ideas

negative, type 2 schizophrenia

subtle symptoms: apathy, anxiety, anhedonia (loss of pleasure)

r/t structural changes in the brain and hypodopaminergic process

responds best to atypical antipsychotics

negative symptoms

affect

alogia

anergia

anhedonia

avolition

theories

biologic: biochemical- dopamine hypothesis

neurostructural: ventricular brain ratios, brain atrophy, cerebral blood flow

genetic theories

perinatal risk factors

psychodynamic: developmental- freud, erikson, sullivan

family theories

vulnerability stress model

continuum of care for schizophrenia

acute symptoms- hospitalization

treatment resistant- long term hospitalization

stable but chronic- day treatment

some level of supervision- supportive housing for those who cannot live with family

developing a therapeutic nurse pt relationship

be calm, accept pts as they are, keep promises, be consistent, be honest

do not reinforce or challenge hallucinations or delusions

orient pts to time, person, and place if indicated

do not touch without warning

avoid whispering or laughing when pt cannot hear

reinforce positive behavior

avoid competitive activities

do not embarrass pts

begin with one to one interactions

allow and encourage verbalization of feelings

respect the pt

spend time to build a rapport

reinforce principles of drug adherence

milieu management for disruptive pts

set limits

decrease stimuli

observe for escalating behavior

minimize potential weapons

be judicious when developing consequences

invoke consequences when violations occur

provide for pt safety when restraints are necessary

milieu management for withdrawn pts

arrange non threatening activities

arrange furniture around a table so pt must sit with someone

assist with decision making as appropriate

reinforce appropriate grooming and hygiene

provide psychosocial rehabilitation

milieu management for pts with hallucinations

use distraction

discourage talking about the hallucinations

monitor TV selections

monitor command hallucinations

have staff members available to talk with pt about real things

antipsychotic drugs

treat schizophrenia, schizoaffective disorder, bipolar disorder, and psychotic disorder

off label uses for insomnia, delirium, stuttering, tics

classification systems for antipsychotics

1st generation (FGAs)- traditional antipsychotics

• chlorpromazine (thorazine) considered the 1st antipsychotic drug

2nd generation (SGAs)- atypical antipsychotics

3rd generation (TGAs)- novel antipsychotics

from 1990s-present SGAs and TGAs: reduce risk of EPSE, increased effectiveness in treating negative symptoms, minimal risk of tardive dyskinesia, reduced risk for elevated prolactin

clozapine (clozaril)

SGA

used to treat severe schizophrenia who have been unresponsive to other antipsychotic drugs

causes significant anticholinergic effects- orthostasis, sedation, weight gain, sexual dysfunction

serious side effect: agranulocytosis

dose related seizures

excessive salivation

myocarditis

fatal overdose

primarily metabolized by CYP-450; smoking decreases level of clozapine

protocol for clozapine therapy

start therapy only in WBC is above 3500 and ANC is 2000 or higher

monitor WBC weekly

if counts are normal for 6 months, monitor level every 2 weeks

if counts are normal for 1 year, monitor level every 4 weeks

stop drug if WBC drops below 3000 or ANC drops below 1500; monitor counts daily; if no infection is present, resume drug when counts return to normal

permanently discontinue if WBC drops below 2000 or ANC drops below 1000

risperidone (risperdal)

SGA

favorable receptor profile for both positive and negative symptoms

well tolerated

decreased instance of anticholinergic SE

no agranulocytosis, tardive dyskinesia, or neuroleptic malignant syndrome

higher doses- EPSE and hyperprolactinemia

SE: orthostatic hypotension, sedation, appetite stimulation, insomnia, agitation, h/a, anxiety, rhinitis

use cautiously with DM and cardiac hx

long acting IM available

olanzapine (zyprexa)

SGA

effective in tx acute mania- FDA approved for monotherapy for bipolar disorder

long acting IM available

SE: sedation, weight gain, orthostasis

few incidences of EPSE, weight gain

aripiprazole (abilify)

TGA

reduces positive symptoms

pts feel better and have more energy

negative symptoms subside

pharmacological effects

tranquilizing- occurs within an hour after ingestion

antipsychotic- within a few weeks, improvement continuing for 6-8 weeks

most effective in treating positive symptoms

negative symptoms are less responsive to any of the antipsychotic drugs

symptoms modified by antipsychotic drugs

reduced hallucinations and illusions

improved reasoning, decreased ambivalence, decreased delusions

slows psychomotor activity

decreased confusion and mental clouding

promotes less focus on self and more focus on others, decreasing self absorbed thinking by reducing inner turmoil

flat affect, a negative symptom that may only respond to an atypical antipsychotic

long acting injection

LAIs require injection once every 2-4 weeks

beneficial for pts who are nonadherent

fluphenazine, haloperidol, risperidone, paliperidone

antipsychotic side effects

anticholinergic- constipation, dry mouth, slowed bowel/bladder

antiadrenergic- hypotension

cardiac- arrhythmias

metabolic syndrome

sexual- poor libido, erectile dysfunction

GI- weight gain

other- sun sensitivity, nasal congestion, blood dyscrasias, susceptibility to hyperthermia

extrapyramidal side effects of antipsychotics

akathisia

akinesia

dystonia

drug induced parkinsonism

tardive dyskinesia

pisa syndrome

neuroleptic malignant syndrome

high potency traditional antipsychotics are the most likely cause of EPSE

atypical antipsychotics are least likely to cause EPSE

noncompliance of antipsychotics

common path that leads to rehospitalization

EPSE —> nonadherence —> relapse —> rehospitalization

nursing implications for antipsychotics

overdose is seldom fatal; causes severe CNS depression, hypotension, and EPSE; restlessness or agitation, convulsions, hyperthermia, increase anticholinergic symptoms, and arrhythmias are indicators of overdose

use in pregnancy: avoid during 1st trimester, can cause EPSE in come newborns, can cause glucose intolerance

use by older adults: reduce dose, heightened EPSE and anticholinergic effects, higher risk for tardive dyskinesia, do not give to older adults with dementia related psychosis; can cause a higher risk of death

interactions with other drugs

CNS depression: alcohol, cold and flu agents, sleep aids, antianxiety drugs, antidepressants, barbiturates, morphine

cigarette smoking: decreased serum level of some antipsychotics

insulin, oral hypoglycemics: weakened control of diabetes

levodopa: may exacerbate psychosis

pt teaching for antipsychotics

use discretion in selecting content of educational sessions, because of pt paranoia and anxiety

focus on symptoms that can be seen or felt

provide a written description of drug benefits and side effects with instructions on how to cope with side effects

avoid hot tubs, showers, and baths to prevent hypotension and falls

avoid abrupt withdrawal; EPSE can occur

use sunscreen to prevent sunburn

take med as prescribed

report sore throat, fever, malaise, and bleeding

dress appropriately for hot weather and drink plenty of water