Ch 12 Schizophrenia

Objectives

. Differentiate between the positive and negative symptoms of Schizophrenia based on clinical presentation and assessment findings.

2. Plan nursing care for patients with Schizophrenia, addressing safety, communication, medication adherence, and psychosocial support.

3. Implement appropriate nursing interventions for clients experiencing hallucination, delusions, or cognitive impairments, promoting reality orientation, and therapeutic communication.

4. Recognize physical and psychological stressors that may trigger or worsen symptoms in clients with schizophrenia or other psychotic disorders.

What is Schizophrenia

±Schizophrenia affects 1% of population

±Characterized by psychosis

°Altered cognition, perception, and reality testing

±75%: Develop gradually, presenting at 15 to 25 years of age

±Child-onset and late-onset are more rare

All people diagnosed have at least 1 psychotic symptom like hallucinations,, delusions, and or disorganized speech or thought

What is DSM-V Criteria: Highlights

 A: Two or more of the following for a significant portion of time in 1 month: At least 1 must be iten 1,2,3 

1. °Delusions

2. °Hallucinations

3. °Disorganized speech ( frequent derailment or incoherance)

4. °Gross disorganization or catatonia- not talking or engaging

5. °Negative symptoms (diminished emotional expression or avolition)- lack of motivation or drive to engage in goal-directed activities

°Functional impairment of some kind-  Ex. work, self care

±Continuous disturbance for at least 6 months that must include one of the criteria in A. May include prodromal or residual symptoms. The signs of disturbance may be only by negative symptoms, or by 2 or more symptoms listed in A present in attenuated form ( odd beliefs, unusual perceptual experiences)

±Ruled out: substances or other disorders

Eric M, 18, has always been a good student. How, however, in his second semester of college, he begins, for the first time in his life, to have trouble concentrating. When his family doesn't hear from Eric, they contact the school, only to discover that his roommate says Eric is "talking weird."

Asked what he means, the roommate says, "Well, you know, he says stuff that doesn't connect, doesn't make any sense. I asked him if he was high or something, but he said no, and I believed him."

On further investigation, Eric's professors say he's been missing class, after starting out so well.

Eric's roommate says his speech "... doesn't connect; it doesn't make any sense. He sort of gets derailed." Which of the following symptoms is Eric displaying?

A.Avolitional speech

B.Delusional speech

C.Disorganized speech

D.Diminished emotional expression

c

What population do you see schizophrenia more in

±Childhood-onset schizophrenia: 1 in 40,000 children

±No difference related to

°Race

°Culture

±More frequently diagnosed:

°Among males- 15-25 yrs old have poorer functioning and more structural abnormality in the brain. 

women- experience it older (25-35)

In urban areas

What other problems do pts with schizophrenia have

±Substance abuse disorders- alchohol/ marijuana in half of the adults. It is associated w poorer tx adhereance and prognosis, relapse, incarceration, homelessness, violence, and suicide. 

°Nicotine dependence-

±Anxiety, depression, and suicide- at least 20% attempt suicide, more common within 3 yrs of diagnosis and after first episode of schizophrenia 

±Physical illness- more common w schizophrenia. Risk of premature death 3.5 x more. Die 20 yrs before dt cardiovascular issues. Reduced physical activity, poor nutrition, substance use, poverty, access to healthcare, stigma ( ex. er nurse assumes chest pain is imaginary/ not serious)

±Polydipsia- compulsive drinking of fluids- happens in 20% of people, too much fluid= low Na= hyponatremia aka water intoxication. S/S- confusion, delirium, hallucinations, psychotic symotoms get worse, dilute urine, polyuria, coma. Hyponatremia should be considered in pts that have a sudden increase in psych symptoms esp if they have disorientation or restlessness. 

WHat are the risk factors for schizophrenia

±Biological factors- when multiple inherited genetic abnormalities combine w other factors. Ex. viral infections, birth injuries, trauma, abnormal neural pruning, prenatal malnutrition, injuries to the brain. 

°Genetics- 80% iis genetic. 

±Neurobiological- any drug abuse can increase risk ( marijuana) in biologically vulnerable individuals. 

°Glutamate- can cause psychosis,

dopamine, and serotonin- new antipsychotics block serotonin and dopamine 

°Acetylcholine- also plays a role in psychosis 

±Brain structure abnormalities- atrophy, structural differences, inflammation or neurotoxic effects from oxidative stress, infection, autoimmune dysfunction can alter brains structure. reduded volume of gray matter

±Prenatal stressors- infection during or after pregnancy or dad 35+

±Environmental factors- stress, toxins like  tetrachloroethylene found in pipes of water, sexual abuse, exposure to crime, trauma, social defeat, these may cause structural changes in the brain due to epigenetic changes in the genome. 

±Prognostic variables- some cases they dont fully respond to tx - reduce the frequency, intensity and duration of symptom return 

What are the Phases of Schizophrenia

±Prodromal- mild changes in thinking, reality testing, and mood. Speech and thoughts may be odd, anxiety and obsessive thoughts, compulse behavuors. concentration can deteriorate. 1-12 months before a full episode of schizophrenia 

±Acute- hallucinations, delusions, apathy- lack of motivation, social withdraw, dimished affect, anhedonia - loss of interest and pleasure in activities that previously brought joy and satisfaction, disorganized behavior, impaired judgment and cognition= functional impairment. Difficulity copinng, symptoms are apparent to others. Can last several months even w treatment. additonal tx or hospitalization may be required. 

±Stabilization- symptoms dimishing/ stablizing, movement towards a previous level of functioning. This can last for months. Care in outpatient or partial hospitalization. residential crisis center, or staff supervised resedenitla group home or apartment. 

±Maintenance or Residual- Condition is stablized.Positive symptoms dimished or absent. negative and cognitive symptoms still a concern. Goal - pt is able to live by themself or w family  A pattern of relapses separated by periods of reduced or dormant symptoms is common. Some people have 1 or many episodes and none after. Schizophrenia is a chronic or relapsing disorder that needs ongoing tx. 

Eric's parents arrive on campus, and he agrees to meet with them and a campus counselor. He appears anxious. He expresses sorrow that his grades are suffering, acknowledging that his concentration "just isn't there." He says that he feels "something weird is happening to me" and describes frequent distressing thoughts. He admits to feeling suspicious of everyone he passes.

Eric's parents and the counselor both notice what the roommate had described about Eric's speech.

Eric agrees to see a psychiatrist and an initial assessment and history indicate that he has only been experiencing some mild changes in his thinking and mood for about a month—ever since returning from the winter holiday. The examiner confirms that his speech is sometimes disorganized and his ability to concentrate and study is diminished from his previous longstanding as a strong student.

Given the evidence we have so far, if Eric has schizophrenia, which is suspected, which phase is he most likely experiencing?

A.Acute

B.Residual

C.Prodromal

D.Stabilization

Answer - C

What do you assess for schizophrenia

±During the prodromal phase

General assessment

°Positive symptoms- halluc, dellusions, paranoia,

°Negative symptoms- bathing, eating

°Cognitive symptoms- how is their impulse control, problem solving,

°Affective symptoms- involved w their emotions

What are positive symptoms

Alterations in reality testing

°Delusions—false, fixed beliefs

°Alterations in speech

Concrete thinking—inability to think abstractly

What are alterations in speech

Associative looseness

°Word salad—most extreme form; jumble of words meaningless to a listener

Clang association

°Words chosen based on sound, click click

Neologisms

°Meaning for the patient only

Echolalia

Pathological repetition of another's words

What are Other Abnormal Speech Patterns

±Circumstantiality

±Tangentiality- going off topic

±Cognitive retardation- slow thinking

±Pressured speech

±Flight of ideas

Symbolic speechex. Reported deoms are sticking needles in me

What are Disorders or Distortions of Thought

•Thought blocking: A reduction or stoppage of thought. Interruption of thought by hallucinations can cause this.

•Thought insertion: The uncomfortable belief that someone else has inserted thoughts into their brains.

•Thought deletion: A belief that thoughts have been taken or are missing.

•Magical thinking: Believing that thoughts or actions affect others' consequences.

•Paranoia: An irrational fear, ranging from mild (wary, guarded) to profound (believing irrationally that another person intends to kill you). They believe that you and the staff will kill them

During assessment, Eric has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what he's trying to say. Which speech disturbance is he exhibiting?

A.Pressured speech

B.Circumstantiality

C.Flight of ideas

Tangentiality

From one to another

What are alterations in perception

Hallucinations

°Auditory

°Visual

°Olfactory

°Gustatory- taste

°Tactile

°Command

±Illusions

±Depersonalization

±Derealization

•Most dangerous hallucination

What are alterations in behavior

°Catatonia- not saying much

°Motor retardation

°Motor agitation

°Stereotyped behaviors

°Waxy flexibility

°Echopraxia

°Negativism

°Impaired impulse control

°Gesturing or posturing

Boundary impairment

What are negative symptoms

The absence of essential human qualities

•Anhedonia: A reduced ability or inability to experience pleasure in everyday life.

•Avolition: Loss of motivation; difficulty beginning and sustaining goal-directed activities

•reduction in motivation or goal-directed behavior.

•Asociality: Decreased desire for, or comfort during, social interaction.

•Affective blunting: Reduced or constricted affect.

•Apathy: A decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important.

•Alogia: Reduction in speech, sometimes called poverty of speech.

What other negative symptoms do they face

Affect: Outward expression of a person's internal emotional state

°Flat- immoblile plane

°Blunted

°Constricted

°Inappropriate

°Bizarre

What are cognitive symptoms

±Concrete thinking

±Impaired memory

±Impaired information processing

±Impaired executive functioning

±Anosognosia

What are Affective Symptoms

±Assessment for depression is crucial

°May herald impending relapse

°Increases substance abuse

°Increases suicide risk

Further impairs functioning

What self assessment should you do

Anosognosia

°Inability to realize they are ill

°Caused by the illness itself

°May result in resistance to or cessation of treatment

°Often combined with paranoia so that accepting help is impossible

Nurse's self-assessment

°Anxiety or fear

°Frustration

Expectations

One may also have biases or stereotypical images of the illness that interfere with patient care. Reflecting on your experiences, beliefs and feelings and discussing them with staff, faculty, and peers may help.

Eric becomes anxious and says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding?

A.Positive symptom

B.Negative symptom

C.Cognitive symptom

D.Depressive symptom

A

What are assessment guidelines

•Any medical problems

•Medical problems that mimic psychosis

•Drug or alcohol use disorders

•Mental status examination

•Include cognitive assessment (e.g., reality testing)

What are the other assessment guidelines

•Assess for hallucinations

•Assess for delusions

•Assess for suicide risk

•Assess ability to ensure personal safety and health

•Assess prescribed meds

•Assess symptoms' impact on functioning

•Assess family knowledge

±The psychiatric nurse conducting Eric's assessment believes that he is also suffering from command hallucinations. Discuss what kinds of questions could help affirm this.

Questions to ask include:

• Do you recognize the voices?

• Do you believe the voices are real?

Do you plan to follow the command?

What are the nursing diagnoses for schizophrenia

±Hallucinations / Delusions

±Risk for violence

±Distorted thinking / Impaired abstract thinking

±Impaired communication

±Anosognosia

±Negative self-image

±Risk for loneliness

±Powerlessness

±Risk for suicide

Impaired health maintenance

What outcomes do we want

Phase I—acute

°Patient safety and medical stabilization

°Best strategies to ensure patient safety and provide symptom stabilization

Phase II—stabilization

°Help patient understand illness and treatment

°Stabilize medications

°Control or cope with symptoms

Phase III—maintenance

°Maintain achievement

°Prevent relapse

°Achieve independence, satisfactory quality of life

°Provide patient and family education

°Relapse prevention skills are vital

±After an acute admission, discharge is being planned for Eric. What are some things that need to be considered?

What implementation do we do for the acute phase

°Psychiatric, medical, and neurological evaluation

°Psychopharmacological treatment

°Support, psychoeducation, and guidance

°Supervision and limit setting in the milieu

°Monitor fluid intake

°Working with aggression- Regularly assess for risk and take safety measures

What other implementation do we do

Counseling and communication techniques

°Hallucinations

°Delusions

°Associative looseness

°Health teaching and health promotion

1. Assess for paranoid thoughts, command hallucinations, interpersonal conflict, irritability, impaired impulse control, increasing tension and desperation, and other factors that may increase the risk of violence.

2. Engaging regularly with the patient increases the opportunity for assessment and communication about concerns that may contribute to risk.

3. Engender goodwill via supportive activities and a strong therapeutic relationship.

4. Provide increased supervision when risk is present. Placing the patient in a room near the nurses' station facilitates monitoring.

5. Ensure that patient is taking ordered medications (see "Cheeking or Palming Medications" section).

6. Monitor for and promptly de-escalate increasing tension.

7. Take action to help the patient feel safe and secure (e.g., if patient fears harm from outside the unit, note the locked doors and constant presence of staff).

8. Promote communication and venting in a safe manner to reduce desperation levels.

What other implementation do we do

9. Teach and guide patient to practice coping skills to reduce stress and desperation.

10. Provide constructive diversion and outlets for physical energy.

11. If the patient, due to paranoia or other factors, targets specific peers, it may be necessary to relocate the patient or the targeted peer (whichever can best tolerate the relocation). Similar action may be needed if identifiable staff are targeted.

12. Only when truly necessary: use seclusion and/or chemical (medication) or physical restraint.

13. Search thoroughly on admission and repeat the search any time circumstances suggest the patient may have had an opportunity to make or acquire a weapon.

14. Refer to Chapter 27 for a more information on caring for an aggressive patient.

How do we evaluate a pt

±Reevaluate progress regularly and adjust treatment when needed

±Even after symptoms improve outwardly, inside the patient is still recovering.

±Set small goals; recovery can take months.

±Active, ongoing communication and caring is essential.

12.2 - review

What Biological: Pharmacotherapy do we give

Antipsychotic medications

°First-generation

°Second-generation

°Third-generation

Injectable antipsychotics

°Short-acting

°Long-acting

First-generation: haloperidol, fluphenazine decanoate

Second-generation: olanzapine pamoate, paliperidone palmitate

What are first generation antipyschotics

±Dopamine antagonists (D2 receptor antagonists)

±Target positive symptoms of schizophrenia

Advantage

°Less expensive than second generation

Disadvantages

°Extrapyramidal side effects (EPS)

°Anticholinergic (ACh) side effects

°Tardive dyskinesia

Weight gain, sexual dysfunction, endocrine disturbances

What are Second-Generation Antipsychotics

±Serotonin (5-HT2A receptor) and dopamine (D2 receptor) antagonists, e.g., clozapine (Clozaril)

±Treat both positive and negative symptoms

±Minimal to no EPS or tardive dyskinesia

±Disadvantage—tendency to cause significant weight gain; risk of metabolic syndrome

What are 3rd generation antipsychotics

±Really a subset of the SGAs

±Aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar)

±Dopamine system stabilizers

±May improve positive and negative symptoms and cognitive function

°Little risk of EPS or tardive dyskinesia

What are the Dangerous Responses to Antipsychotics

Anticholinergic toxicity

°Reduced or absent peristalsis (can lead to bowel obstruction); urinary retention; mydriasis; hyperpyrexia without diaphoresis (hot dry skin); delirium with tachycardia, unstable vital signs, agitation, disorientation, hallucinations, reduced responsiveness; worsening of psychotic symptoms; seizure; repetitive motor movements

What are other Dangerous Responses to Antipsychotics (Cont.)

Neuroleptic malignant syndrome (NMS)

°Severe muscle rigidity, dysphasia

°Flexor-extensor posturing

°Reduced or absent speech and movement

°Decreased responsiveness.

°Hyperpyrexia: temperature over 103°F

°Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence

Delirium, stupor, coma

What are other Dangerous Responses to Antipsychotics (Cont.2 )

±Severe neutropenia

°Reduced neutrophil counts and increased frequency and severity of infections.

°Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated

What are other Dangerous Responses to Antipsychotics (Cont.3 )

±Prolongation of the QT interval

°Delay of ventricular repolarization. May result in tachycardia, fainting, seizures, and even sudden death

±Liver impairment

°Impairment usually occurs in the first weeks of therapy.

°Jaundice, abdominal pain, ascites, vomiting, lower extremity edema, dark urine, pale or tar-colored stool, easy bruising

What is metabolic syndrome

Metabolic Syndrome

°Weight gain (especially in the abdomen), dyslipidemia, increased blood glucose, and insulin resistance

°Increases risk of diabetes, certain cancers, hypertension, and cardiovascular disease

What are Extrapyramidal Side Effects (EFSs)

±Extrapyramidal Side Effects (EFSs)

°Acute dystonia: sudden, sustained contraction

°Akathisia: motor restlessness causing inability to stay still or remain in one place

°Pseudoparkinsonism: temporary group of symptoms that resemble Parkinson's disease

°Tardive dyskinesia: involuntary rhythmic movements

°

What are Psychological Therapies

±Individual and group therapy

±Psychoeducation

±Medication prescription and monitoring

±Basic health assessment

±Cognitive remediation or enhancement

±Family therapy

Support groups

Loose associations in a person with schizophrenia indicate

A.paranoia.

B.mood instability.

C.depersonalization.

poorly organized thinking.

Which assessment finding represents a negative symptom of schizophrenia?

A.Apathy

B.Delusion

C.Motor tic

D.Hallucination