MENTAL HEALTH – CH17 SCHIZOPHRENIA
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SCHIZOPHRENIA
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From the Greek: schiz means \"split\" phren means \"mind\" The diagnosis of schizophrenia is commonly misinterpreted asa split personality. Schizophrenia is potentially a devastating brain disorder that affects: Thinking Language Emotions Social behavior Ability to perceive reality accurately
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SCHIZOPHRENIA FACTS
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*Schizophrenia is a devastating brain disease that targets young people in their teens and early twenties, at the beginning of their productive lives. *Schizophrenia spectrum disorders are a group of psychotic disorders. *Psychosis is not a diagnosis but a symptom. *Psychosis refers to a total inability to recognize reality (e.g., delusions and hallucinations).
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CO-MORBIDITY
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Substance abuse disorders Anxiety Depression Suicide Physical health illness Polydipsia
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ETIOLOGY: BIOLOGICAL FACTORS
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Genetic Brain structure abnormalities Neurobiologic theories Dopamine Serotonin Glutamate
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ETIOLOGY: PSYCHOLOGIC AND ENVIRONMENTAL FACTORS
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Prenatal stressors *Pregnancy and birth complications Psychologic stressors *Developmental and family stress Environmental stressors *Social adversity, chronic poverty, and growing up in high crime areas or in a foreign
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COURSE OF THE DISORDER
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Prodromal: Prepsychotic phase Phase I: Acute Phase II: Stabilization Phase III: Maintenance
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Objective 1: Describe the prodromal (early) symptoms that a person with schizophrenia may exhibit during the prepsychotic phase.
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Case Study, Part 1 Mihn was a quiet child. During adolescence, she participated little in group activities. Shortly after her 17th birthday, Mihn began to seclude herself in her room and listen to music for hours. She began to miss school frequently, stating that her future was in \"music,\" although she neither played an instrument nor sang. Within 3 weeks, Mihn refuses to attend school. She talks only of her \"music.\" Her parents speak little English and do not know what to do. Mihn is clearly entering the prodromal phase of schizophrenia. Describe the symptoms that you would expect.
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Objective 2: Identify evidence-based data that confirm the neurobiologic, anatomic, and nongenetic findings that support the premise that schizophrenia is a neurologic disease.
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Begin with the following statement from your text: Numerous brain-imaging techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and positron-emission tomography (PET), provide substantial evidence that some people with schizophrenia have structural brain abnormalities.
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FOUR MAIN SYMPTOM GROUPS OF SCHIZOPHRENIA
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Positive Negative Cognitive Affective
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POSITIVE SYMPTOMS
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Disturbed sensory perception Risk for self-directed violence Risk for other-directed violence Disturbed thought processes Impaired verbal communication
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NEGATIVE SYMPTOMS
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Social isolation Impaired social interaction Risk for loneliness Chronic low self-esteem Risk for violence Ineffective coping Self-care deficit Constipation
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Objective 3: Compare and contrast the positive and negative symptoms of schizophrenia regarding (a) their effect on quality of life, (b) their significance for the prognosis of the disease, and (c) their side effect profile.
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Case Study, Part 2 Mihn is taken to the emergency department by her parents. She has not showered in 4 days, refuses food, stating that it is \"poisoned,\" and sits in her darkened room with music blaring. The psychiatrist tells Mihn's parents that she needs to observed over several days. She is admitted to the psychiatric unit.
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STUDY QUESTIONS
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It is likely that Mihn is entering the acute phase of schizophrenia. What are some other possibilities or other precipitators of psychotic symptoms? What is the primary reason Mihn is admitted? What is a priority nursing diagnosis?
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ALTERATIONS IN THINKING
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Impaired reality testing *Absence of ability to correct errors in thinking Delusions *False fixed beliefs that cannot be corrected by reasoning Concrete thinking *Impaired ability to think abstractly
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ALTERATIONS IN SPEECH
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Associative looseness Neologisms Clang association Word salad Echolalia: Pathologic repeating of another's words Echopraxia: Mimicking the movements of another (Echolalia and echopraxia are common in catatonia.)
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ALTERATIONS IN PERCEPTION
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Depersonalization Hallucinations Illusions Command hallucinations Derealization Why is it especially important to assessa patient for command hallucinations?
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ALTERATIONS IN BEHAVIOR
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Bizarre behavior Extreme motor agitation Stereotyped behaviors Waxy flexibility Stupor Negativism Automatic obedience Impulse control may result in agitated behaviors such as abruptly grabbing the TV remote control and changing channels.
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Objective 4: Delineate ways that neurocognitive impairments impact the life of a person who is struggling with schizophrenia. Include prognosis and quality of life.
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Case Study, Part 3 Picture Mihn 3 years after her first hospital admission. She is now diagnosed with schizophrenia and has experienced several acute phases. She continues to live with her parents, who have limited income. She is applying for Medicaid. How has this diagnosis altered her life and impacted her family? As her nurse, how can you assist Mihn and her family to cope with the illness?
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Objective 5: Identify the numerous areas in which health care workers need to apply safety interventions for a person with schizophrenia during the different phases of treatment.
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Phase I (acute) Phase II (maintenance) Phase III (stabilization) Hint: Refer to the \"Nursing Diagnoses for Positive and Negative Symptoms\" listed in the text chapter.
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COMMUNICATION GUIDELINES
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Therapeutic strategies for communicating with patients with schizophrenia focus on: *Lowering the patient's anxiety *Decreasing defensive patterns *Encouraging participation in therapeutic and social events *Raising feelings of self-worth *Increasing medication compliance
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Objective 6: Demonstrate with classmates the best evidence-based practice available for communicating with a person who is expressing the following:
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Hallucinating Paranoia Delusions Hint: Study the \"CommunicationGuidelines\" on the previous slideand in your text.
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PHARMACOLOGIC THERAPY
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Antipsychotic Medications *Alleviate symptoms of schizophrenia but cannot cure underlying psychotic processes. *Psychotic symptoms return with medication noncompliance. *Antipsychotic drugs are effective in: -Acute exacerbations of schizophrenia -Preventing or mitigating a relapse Conventional (first-generation) antipsychotics *Target positive symptoms Atypical (second-generation) antipsychotics *Target positive and negative symptoms Atypical agents have fewer side effects. Atypical agents treat anxiety, depression, and decrease suicidal behavior.
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CONVENTIONAL (FIRST-GENERATION) ANTIPSYCHOTICS
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TARGET POSITIVE SYMPTOMS: High Potency trifluoperazine(generic only) thiothixene (Navane) fluphenazine (Prolixin) Haloperidol (Haldol) pirozide (Orap) Low Potency chlorpromazine(thorazine) thioriadizine (Mellaril) Medium Potency loxaine (Loxitane) molidone (Moban) perphenazine (Trilafon) ADVERSE REACTIONS Extrapyramidalsymptoms (EPSs) *Akathisia *Acute dystonia *Pseudoparkinsonism Tardive dyskinesia (TD) Neuroleptic malignantsyndrome (NMS) Agranulocytosis Other adverse reactions include *Anticholinergic effects *Orthostasis *Lowered seizure threshold
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TREATMENT OF EXTRAPYRAMIDAL SYMPTOMS
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Side effects often appear early in therapy and can be minimized with treatment. Treatments usually consists of: Lowering the dose Prescribing antiparkinsonian drugs: • trihexyphenidyl (Artane) • benztropine mesylate (Cogentin) • diphenhydramine hydrochloride (Benadryl) • biperiden (Akineton) • amantadine hydrochloride (Symmetrel)
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ATYPICAL (SECOND-GENERATION) ANTIPSYCHOTICS
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Target positive or negative symptoms aripiprazole (Abilify) clozapine (Clozaril) olanzapine (Zyprexa) paliperidone (Invega) quetiapine (Seroquel) risperidone (Risperdal) ziprasidone (Geodon) DISADVANTAGES Metabolic syndrome *Weight gain, dyslipidemia, altered glucose *Risk of diabetes, hypertension, atherosclerosis and increase in heart disease Is more expensive than conventional antipsychotics.
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ADJUNCTS TO ANTIPSYCHOTIC DRUG THERAPY
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Antidepressants are administered for severe depression. Lithium and other mood stabilizers reduce aggressive behavior. Benzodiazepine augmentation improves positive and negative symptoms. Clonazepam decreases anxiety, agitation, and possibly psychosis.
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Objective 7: Teach a classmate, group, or friend the differences among the properties of typical versus the atypical antipsychotic drugs regarding the following:
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Target symptoms Indications for use Effects and toxic effects Need for patient and family teaching and follow-up Potential for medical compliance
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Objective 8: Discuss evidence-based psychosocial therapies for patients with schizophrenia and their families.
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Family needs to be included in: *Psychologic strategies aimed at reducing psychotic symptoms *Teaching patient and family about illness *Recognizing effect of stress *Psychosocial activities *Identifying support sources *Medication groups for patients and family
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Objective 9: Differentiate among the three phases of schizophrenia in terms of symptoms, focus of care, and intervention needs. (See Table 17-5 for a guide.)
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Acute phase- SYMPTOMS Stabilization phase - FOCUS OF CARE Maintenance phase - INTERVENTIONS
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Objective 10: Identify specific times in which teamwork and collaboration with other health care professionals is used in implementing safe, effective care for the patient with schizophrenia.
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need to insert table from powerpoint
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Objective 11: Using informatics, search for available resources in your area for families with a schizophrenic member.
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Examples: Mental Health America http://www.nmha.org National Alliance on Mental Illness (NAMI) http://www.nami.org
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Objective 12: Identify some of the other psychotic disorders. (See Box 17-1, Other Psychotic Disorders, p. 305)
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*Schizotypal (personality) disorder *Schizophreniform disorder *Brief psychotic disorder *Schizoaffective disorder *Delusional disorder *Shared psychotic disorder (e.g., as was demonstrated at Waco and Jonestown) *Substance/medication-induced psychotic disorder *Psychotic disorder associated with a known general medical condition *Catatonic disorder associated with a known general medical condition *Catatonia associated with another mental disorder (catatonia specifier)
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What is your best intervention when you assess that a patient is responding to an auditory hallucination? A. Ask the patient, \"Can you tell me what you are hearing?\" B. Ask the patient, \"Are you afraid of the voice you are hearing?\" C. Tell the patient, \"Try to ignore the voices you hear.\" D. Tell the patient, \"The voices you hear are not real.\"
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A. Knowing what the patient is hearing is important. A command hallucination could result in injury to self or others. For example, the voice may be telling the patient to self-mutilate.
