Rank symptoms (inappropriate affect, ambivalence).
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Psychiatrists Who Identified the Disorder
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Emil Kraepelin: Described disorder dementia praecox. Eugen Bleuler- split mind Renamed disorder schizophrenia; identified a group of schizophrenias.
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Psychiatrists Who Identified the Disorder (CONT.)
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Kurt Schneider: differentiated behaviors. "First rank" symptoms (psychotic delusions, hallucinations. "Second rank" symptoms (all other experiences and behaviors associated with the disorder.
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Schizophrenia and Schizophrenia Spectrum Disorders
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For maximum wellness and functioning, humans need to be able to determine what is real versus what is not real. Having symptoms of a thought disorder derails this ability.
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Schizophrenia and Schizophrenia Spectrum Disorders (CONT.)
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the illness of schizophrenia is the most severe presentation of all the disorders on the spectrum. this is an illness that affects a person's thinking, language, emotions, social behaviors and the ability to accurately perceive reality.
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Schizophrenia Spectrum Disorders
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Schizophrenia. Drug induced psychotic disorder. Schizophreniform disorder. Schizoaffective disorder. Delusional disorder. Brief psychotic disorder. Psychotic disorder due to a general medical condition.
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DSM 5 Disorders with Psychosis
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Psychosis must be present to actually make the diagnosis. 1. Schizophrenia spectrum disorders affect multiple areas of one's life. 2. Usually occurs in adolescence or early adulthood.
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Schizophrenia Across the Lifespan: child/adolescent
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Child/Adolescent:Rarely seen before age 10; male more than female. Typical symptom onset is insidious NOT acute and occurs between ages 13-16.
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Schizophrenia Across the Lifespan: geriatric
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0.1-0.5% of population older than 65 y/o. Nurses must consider delirium, depression, or dementia in persons with psychotic symptoms and not assume this is schizophrenia.
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Psychosis
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is a state in which a person experiences hallucinations, delusions, or disorganized thoughts, speech, or behavior; is the key diagnostic factor in schizophrenia spectrum disorders.
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Clinical Course
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Prodromal period. Acute illness. Stabilization- less symptoms. Maintenance and recovery. Relapses.
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idea of reference
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you are looking at me so you must be thinking about me. Like people in TV.
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Epidemiology
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Risk factors: genetics; environment. Age of onset: usually late adolescence or early adulthood. Gender differences: earlier diagnosis and poorer prognosis in men. Ethnic and cultural differences. Familial differences: first-degree biologic relatives with greater risk.
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Comorbidities and Schizophrenia
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substance abuse like alcohol & nicotine. mood disorders such as Anxiety, depression, and suicide. physical illnesses like obesity, CVD, HTN, COPD, DM. and polydipsia.
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polydipsia
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fatal water intoxication leading to hyponatremia, confusion, increased psychotic symptoms, coma, and death.
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Etiology: Biologic Theories
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Neuroanatomic findings: larger lateral and third ventricles; smaller total brain volume. Familial patterns. Genetic associations. Neurodevelopment.
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Etiology: Biologic Theories- Neurotransmitters, pathways, and receptors
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Dopamine hyperactivity; transmitter or neural systems. Other neurotransmitter involvement.
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Etiology: Psychosocial Theories
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Social stressors contributing to changes in brain function. Social stigma. Absence of good, affordable, and supportive housing. Fragmented mental health care delivery system. Poor family response to disorder.
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Key diagnostic criteria: Positive symptoms
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Excess or distortion of normal functions. Delusions and hallucinations for at least 1 month.
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Key diagnostic criteria: Negative symptoms
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Lessening or loss of normal functions.
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Key diagnostic criteria: Neurocognitive impairment
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Involving memory, vigilance, verbal fluency, and executive function (i.e., disorganized symptoms. Symptoms must be present ≥ 6 months.
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Negative Symptoms, Deficits, and Increased Vulnerability
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Cognitive skills deficits. Psychophysiological deficits. Social skills deficits. Coping skills deficits.
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Interprofessional Team Treatment
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Pharmacologic management. Psychosocial interventions.
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Priority safety care issues
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Suicide assessment. Aggression and safety of patient, staff, others. Antipsychotic medications.
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Psychosocial Assessment: Disorganized Symptoms: Disorganized Thinking
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Echolalia, Circumstantiality, Loose associations, Tangentiality, Flight of ideas, Word salad, Neologisms, Stilted language.
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Disorganized Symptoms: Disorganized Thinking
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Paranoia, Referential thinking, Autistic thinking, Concrete thinking, Verbigeration, Metonymic speech, Clang association, Pressured speech.
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Psychosocial Assessment
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Aggression, Agitation, Catatonic excitement, Echopraxia- mimic your movement. Regressed behavior, Stereotypy, Hypervigilance, Waxy flexibility.
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Negative Symptoms: Develop slowly and interfere with ability to cope with:
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conversations, relationships, jobs, to make decisions and follow thru, hygiene/grooming.
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Affect: the outward expressions of inner emotions
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Flat: blank. Blunted: minimal. Inappropriate: incongruent with situation. Bizarre: grossly inappropriate.
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Nursing Management: Biologic Domain: Biologic Assessment
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Current and past physical health status and physical examination. Physical functioning. Nutritional assessment. Substance use.
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Pharmacologic assessment
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Medications (prescribed, OTC, herbal, illicit). Abnormal motor movements. Compliance.
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Nursing Diagnoses for the Biologic Domain
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Self-Care Deficit, Disturbed Sleep Pattern, Imbalanced Nutrition, Excess Fluid Volume, Sexual Dysfunction, and Constipation.
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Interventions for the Biologic Domain
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Promotion of self-care activities. Activity, exercise, and nutritional interventions. Thermoregulation interventions. Promotion of normal fluid balance and prevention of water intoxication. Pharmacologic interventions: Antipsychotics Anticholinergics.
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Typical (First Generation) Antipsychotics: Dopamine 2 Receptor Antagonist
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Role: motor control, motivation, arousal, cognition, reward, sexual gratification, nausea. Focus: positive symptoms; hallucinations, delusions.
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Typical (First Generation) Antipsychotics: Dopamine 2 Receptor Antagonist (cont.)
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Good: off patent, inexpensiveBad: side effect profile, impacts voluntary & involuntary movement. Examples: Thorazine, Melleril, Loxitane, Moban, Trilafon, Navane, Prolixin, Haldol, Orap, Trifluoperazine.
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Extrapyramidal side effects
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caused by stimulation of dopamine pathway in the brain that is associated with voluntary & involuntary movement. Parkinsonism; anticholinergic effects; Dystonic reactions, Akathisia, Tardive dyskinesia.
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Atypical (Second Generation) Antipsychotics- Blockage of dopamine 2 and serotonin 2a transmission
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Second-generation antipsychotic drugs effective in treating negative and positive symptoms. Monitoring and administration: 1 to 2 weeks to effect a change in symptoms; usually, trial of 6 to 12 weeks before a change. Clozapine used when no other second-generation agent effective. Need to be registered and CBC.
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Atypical (Second Generation) Antipsychotics
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Focus: Treat both positive and negative symptoms. Side effects: increase prolactin, somnolence, weight gain, sexual dysfunction, metabolic syndrome.
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Atypical (Second Generation) Antipsychotics (cont.)
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Plus / Minus: helpful with acute agitation, negative symptoms they are more expensive, and there's the potential for cardiac and glucose dysfunction. Names: Olanzapine, quetiapine, risperidone, ziprasidone, clozapine, aripiprazole are a few of these atypical antipsychotics.
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Third-Generation Atypical Antipsychotics (Two Pips and a Rip): Aripiprazole (Abilify) Cariprazine (Vraylar)Brexipiprazole (Rexulti)
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Dopamine system stabilizer. Improves positive and negative symptoms & cognitive function little risk of EPS or TDK.
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Interventions for the Biologic Domain: Antipsychotics
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Other side effects: Orthostatic hypotension, Hyperprolactinemia, Sedation; weight gain, New-onset diabetes, Cardiac arrhythmias, Agranulocytosis.
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Complications: Neuroleptic Malignant Syndrome
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Life-threatening condition: Severe muscle rigidity, elevated temperature with a rapidly accelerating cascade of symptoms. Early recognition of symptoms; withholding of any antipsychotic medication.
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Complications: Neuroleptic Malignant Syndrome (cont.)
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Dopamine agonists (bromocriptine); muscle relaxants (dantrolene or benzodiazepine. Frequent vital sign monitoring; may need ICU care, Laboratory testing, Supportive measures.
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Complications: Anticholinergic Crisis
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Life-threatening condition: overdose or sensitivity to drugs with anticholinergic properties. Signs and symptoms: "hot as a hare, blind as a bat, mad as a hatter, dry as a bone".
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Complications: Anticholinergic Crisis (cont.)
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Self-limiting, usually 3 days after drug discontinued. Treatment: Discontinuation of medication, Physostigmine, Gastric lavage, charcoal, catharsis for intentional overdoses.
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AIMS Scale
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Rating 1-5, with 1 = none and 5 = severe. Monitor at each appointment then decrease frequency unless pt. is male less than 25 years old or female greater than 70 years old.
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AIMS Scale (cont.)
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1. Holding arms outstretched to sides 2. Arms outstretch to front with hands flat and parallel 3. Walking in a straight line 4. Fluidity of shoulder and elbow joints 5. Touching each finger with thumb of both hands 6. Sticking tongue out straight 7. Rolling head laterally, front and back
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Nursing Diagnoses for the Psychological Domain
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Chronic Low Self-Esteem, Personal Identity Disturbance, Ineffective Coping, Knowledge Deficit.
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Interventions for the Psychological Domain
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Development of nurse-patient relationship: trust, acceptance, hope. Management of disturbed thoughts and sensory perceptions. Education about symptoms . Enhancement of cognitive functioning.
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Interventions for the Psychological Domain
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Use of behavioral interventions. Teaching and coping with stress. Patient education. Family education.
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Nursing Management Social Domain: Social Assessment
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Functional status, Social systems, Quality of life, Family assessment.
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Nursing Diagnoses for the Social Domain
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Impaired Social Interaction. Ineffective Role Performance. Disabled Family Coping. Interrupted Family Processes.
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Interventions for the Social Domain: Promoting patient safety
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Monitoring for potential aggression. Administering medication as ordered. Reducing environmental stimulation. Using an individualized approach.
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Interventions for the Social Domain
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Convening support groups. Implementing milieu therapy. Developing recovery-oriented. rehabilitation strategies. Implementing family interventions.
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Nursing Care of Patients with SPMI: Assessment strategies
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direct/indirect danger to self/others; physical health problems; comorbid conditions; signs of tx nonadherence; depression/hopelessness; s/s impending relapse.
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Nursing Care of Patients with SPMI: Intervention strategies
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involve pt; emphasize QOL; therapeutic relationship; focus on here & now; aid in effective reality testing; respond to stigma (activities); support groups; education (illness/recovery); holistic care delivery; SAMI treatment.
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Evaluation of Treatment Outcomes
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Inpatient care. Community care. Emergency care. Successful treatment and management with significant improvement or recovery. Continuity of care as a major goal of recovery. Mental health promotion with a positive support system for stressful periods.
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Recovery Notes
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Improvement is highly individualized. May be erratic & slow. Set small, achievable goals. Re-evaluate care planfrequently. Involve your patient in creating a plan.
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Schizoaffective Disorder
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Characterized by periods of intense symptom exacerbation alternating with periods of adequate psychosocial functioning. More likely to exhibit persistent psychosis than are patients with a mood disorder.
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Schizoaffective Disorder (cont.)
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At times marked by psychosis, at other times by mood disturbance; when psychosis and mood disturbance occur at the same time, a diagnosis of SAD is made.
