NUR 318 - Schizophrenia

Schizophrenia is not characterized by changing personality. It is characterized by ______________ personality.

deteriorating

Age at onset

Onset is almost always during late adolescence or early adulthood

Role of stress

Onset or relapse are almost always related to stress

Efficacy of dopamine antagonists

Drugs that block dopamine receptors are therapeutic

Schizophrenia onset statistics

• Manifests late teens to early thirties

  • Men more often with age of onset 18 to 25 years

  • Women more often with age of onset 25 to 35 years

• 1 In 100 Adults

• 1 In 40,000 Children

Schizophrenia characteristics

• Behavior- social withdrawal

• Flight of ideas – ideas unrelated

• Attention- inability to concentrate

• Inappropriate appearance and dress

• Delusions- Grandiose; Persecutory; Reference: reality testing

• Hallucinations- auditory; visual; tactile; olfactory; Gustato: perception

• Feeling- flat or inappropriate affect

• Motivation- cannot initiate or persist in goal directed activities

Schizophrenia effect on patients

• 2/3 never marry

• Few friends or social contacts

• 20% are homeless

• 40% incarcerated with severe mental illness

• <15% hold competitive employment

• Pervasive isolation, hopelessness, stigma

Positive symptoms are caused by _____________________ in the mesolimbic tract

excessive dopamine

Positive symptoms

• Abnormal thoughts

• Agitation

• Bizarre behavior

• Delusions

• Excitement

• Feelings of persecution

• Grandiosity

• Hallucinations

• Hostility

• Illusions

• Insomnia

• Suspiciousness

• Anosognosia - generally unaware of illness due to brain changes

Looseness of association

Thinking and speech becomes haphazard, illogical and confused

Neologisms

Making up special words

Echolalia

Repeating or mimicing words said

Clang association

Meaningless rhyming of words

Word salad

A jumble of words that is meaningless to the listener

Negative symptoms are caused by _________________ in the mesocortical tract

too little dopamine

Negative symptoms

• Alogia/ poverty of speech

• Anergia

• Asocial behavior

• Attention deficits

• Avolition

• Blunted affect

• Communication difficulties

• Difficulty with abstractions

• Passive social withdrawal/ poor rapport

• Poor grooming

Negative symptoms things to note

• Negative symptoms may linger for years in some patients

  • Symptoms are caused by structural changes in the brain

  • Patients develop decreased cerebral blood flow resulting in enlarged ventricles

  • This is noted on CT scans and MRI

  • Patients have also been found to have a reduction in brain weight and cerebral atrophy

• Some Type 2 symptoms may be classified as secondary because they are the result of medication

Cognitive symptoms

• Inattention, easily distracted

• Impaired memory

• Poor problem-solving skills, executive functioning

  • Poor decision-making skills

  • Illogical thinking

  • Impaired judgement

Schizophrenia co-morbidity

• Substance abuse

  • Nicotine dependence

  • Other substance abuse: ETOH, opioids seems to be increasing

• Depression/Anxiety – 25% of patients

• Suicide - 20% attempts, deaths 5-10%

• Psychosis-induced polydipsia- compulsive water drinking - hyponatremia

• Central nervous system disorders - decreased brain volume and gray matter

• Musculoskeletal disorders - altered nerve conduction - reduced bone density

• Skin - aging skin

• Eyes - increased cataracts

• Endocrine - thyroid dysfunction, low estrogen, low androgen

• Cardiovascular - systolic hypertension

• Telomere loss- decreased- located at the end of chromosomes, govern cell replication

Schizophrenia and smoking

• 74% of individuals with schizophrenia smoke

• Biochemical changes produced by nicotine - nicotine increases the release of dopamine in the nucleus accumbens

  • Nicotine modulates dopamine release, it makes schizophrenic patients feel better

Vulnerabillity-stress model

• Multifactorial causes: susceptible genes interact with numerous environmental factors to yield schizophrenia

• According to this model people with a predisposition to schizophrenia via genetics or biology might avoid a serious psychiatric disease if they are protected from the stresses of life

Schizophrenia phases

• Acute phase

  • Patient experiences severe psychotic symptoms

• Stablizing phase

  • Acute symptoms are less severe

• Stable phase

  • Remission of symptoms: much less disabling

Assessment of client with schizophrenia

• Safety of client and others

• Medical history and recent medical work-up

• Positive, negative, cognitive, and mood symptoms

• Current medications and compliance to treatment

• Family response/support system

Psychosocial management

• Patients must become stronger than their symptoms

  • Clinical support

  • Family support

  • Rehabilitative services

  • Humanitarian/public services

Pharmacological management

• First generation neuroleptics

• Second generation neuroleptics

• Range of significant side effects

Schizophrenia nursing interventions

• Distraction From Voices: Listen To Music; Read Aloud; Count Backwards From 100

• Tell Voices To Go Away; Talk To Voices While Pretending To Use Mobile Phone

• Nurses Response To Client Hearing Voices Or Having Visual Hallucinations (“I Don’t See The Devil Standing Over You, But I Do Understand How Upsetting That Must Be

• Validate If Part Of A Delusion Is Real: “Yes There Was A Man At The Nurses’ Station, But I Did Not Hear Him Talk About You

Milieu therapy

• Safety

  • Potential For Physical Violence Due To Hallucinations Or Delusions

  • Priority Is Least Restrictive Safety Technique

    • Verbal De-escalation

    • Medications

    • Seclusion Or Restraints

• Activities

  • Provide Support And Structure

  • Encourage Development Of Social Skills And Friendships

Hallucinations communication guidelines

• Hearing Voices Most Common

• Approach Client In Nonthreatening And Non-judgmental Manner

• Assess If Messages Are Suicidal Or Homicidal

• Initiate Safety Measures If Needed

• Client Anxious, Fearful, Lonely, Brain Not Processing Stimuli Accurately

Delusions communication guidelines

• Be Open, Honest, Matter-of-fact, And Calm

• Have Client Describe Delusion

• Avoid Arguing About Content

• Interject Doubt

• Validate Part Of Delusion That Is Real

Associative looseness communication guidelines

• Do Not Pretend That You Understand

• Look For Reoccurring Topics And Themes

• Emphasize What Is Going On In The Client's Environment

• Involve Client In Simple, Reality-based Activities

• Reinforce Clear Communication Of Needs, Feelings, And Thoughts