Chapter 16 Schizophrenia and Other Psychotic Disorders

Contemporary Psychiatric-Mental Health Nursing, Second EditionCarol R. Kneisl and Eileen Trigoboff

Contemporary Psychiatric-Mental Health Nursing

Chapter 16Schizophrenia and Other Psychotic Disorders

Features of Schizophrenia

Prevalence in U.S. is 1.1%. Average onset is late teens to early twenties, but

can be as late as mid-fifties Affects cognitive, emotional, and behavioral function 30% to 40% relapse rate in the first year

Features of Schizophrenia - continued

Progression varies from one client to another– Exacerbations and remissions– Chronic but stable– Progressive deterioration

DSM-IV-TR Diagnosis– Symptoms present at least 6 months– Active-phase symptoms present at least 1 month– Symptoms are defined as positive and negative

Positive symptoms – Excess or distortion of normal functioning– Aberrant response

Negative symptoms– Deficit in functioning

Positive Symptoms of Schizophrenia – Hallucination– Delusions– Disordered speech and behavior

Negative Symptoms of Schizophrenia– Flat affect and apathy– Alogia– Avolition– Anhedonia

Subtypes of Schizophrenia

Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type

Subtypes of Schizophrenia - continued

Paranoid Type– Delusions

Persecutory and grandiose Somatic or religious

– Hallucinations Delusions link with a hallucination

Click here to view a video featuring Larry, who has been diagnosed as having paranoid schizophrenia.

Disorganized type– Disorganized speech, behavior, appearance– Flat or inappropriate affect– Fragmented hallucinations and delusions– Most severe form of schizophrenia

Catatonic type– Psychomotor retardation and stupor– Extreme psychomotor agitation– Waxy flexibility– Echolalia– Mutism – Echopraxia

Undifferentiated type– Active psychotic state– Lacks symptoms of other subtypes

Residual type– At least one episode of schizophrenia– No prominent positive symptoms– Negative symptoms present

Other Psychotic Disorders

Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder

Causes of Schizophrenia

Biopsychosocial theories

Interrelated factors

Causes of Schizophrenia - continued

Biologic theories Psychological theories Family theories Humanistic-interactional theories

Biologic Theory: Genetic – Only genetic predisposition for developing schizophrenia

is inherited– 10% of first-degree relatives– 25%-39% of monozygotic twins

Biologic Theory: Brain Structure Abnormality – Differs from those with no symptoms– May be genetically based– Requires more study

Figure 16.2 Schizophrenia scans. PET scans of discordant monozygotic twins taken during a test to provoke activity and measure regional cerebral blood flow. (A) Arrows indicate areas of normal blood flow and brain activity in the unaffected

twin. (B) Arrows indicate areas of lower blood flow and brain activity in the twin with schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain

Disorders Branch, National Institute of Mental Health

Biologic Theory: Biochemical Theories– Dopamine hypothesis– Traditional antipsychotic medications are dopamine

blockers– Dopamine blocker alleviate positive symptoms

Psychological theories– Information processing

Difficulty controlling the amount and type of information that is processed in the brain.

– Attention and arousal Hyper or hypo responsiveness to various situations

Psychological theories– Information processing

Deficient in automatic processing Deficient in controlled or effortful processing

– Attention and arousal Hypo-, hyper-responses

Family Theories– Dysfunctional interaction not supported by research– Disordered family communication linked only with

genetic predisposition – Family emotional tone influences course of

schizophrenia– Expressed emotions theory (EE)

Humanistic-interactional theories integrate biological and psychosocial theories

Combine influences of:– Genetic predisposition or biologic vulnerability– Environmental stressors– Social support

Stress–Vulnerability Model – Stressors increase vulnerability– Cumulative effect of:

Genetic predisposition Personal stressors Familial factors Environmental factors

Influences on the Course of Schizophrenia

Social Pressures – Lack of social support– Financial problems– Stigma

Influences on the Course of Schizophrenia - continued

Psychological pressures – Difficulty with problem-solving– Difficulty with interpreting reality– Difficulty coping – Problems with self-care – Unstable interpersonal relationships

Nursing Implications

Assessment– Premorbid functioning– Content of thought– Form of thought– Perception– Sense of self– Delusions and perceptual disturbances– Hallucinations– Drug use

Nursing Implications - continued

Nursing Diagnoses– Altered thought process– Social isolation– Risk for violence– Self-care deficits– Altered health maintenance– Ineffective family coping

Nursing Implications:Supporting Families

Family needs vary with degree of illness and involvement in client’s care– Education– Financial support– Psychosocial support– Education – Advocacy

Nursing Implications:Supporting Families - continued

Schizophrenia is a “family illness.” Family members need to be involved. Educate family about

– Medication– Illness– Relapse prevention

Nurse assists family by– Identifying community agencies/groups for family

members– Advocating for rights

Measures to Prevent Relapse

Ensure client takes medication Educate family about signs and symptoms of

relapse Client and family to participate in relapse

prevention program

Measures to Prevent Relapse - continued

Relapse prevention programs work best when:– Psychosocial treatment and social skills training are

combined with antipsychotic medication– Behavior patterns are monitored– Family members understand triggers

Measures to Prevent Relapse - continued

Relapse prevention programs provide education and support regarding:– Individual triggers, symptoms of relapse– Managing side effects of medications– Interventions to reduce or eliminate triggers– Strategies to facilitate early intervention– Cognitive therapy – Community resources

Challenges to Adherence

Side effects Level of symptomatology Cognitive, motivational, financial, and cultural

issues Issues with caregivers Insufficient medication teaching

Increasing Adherence

Involve clients in treatment Instruct client about reducing discomfort Provide peer support Provide reminders and positive feedback Recognize accomplishments

Personal Awareness

Identify personal feelings. Recognize personal perceptions. What behaviors do you expect to see? How will you respond to these behaviors? What is the meaning of the behaviors?

Personal Awareness - continued

What defines “normal” behavior? What are my fears associated with mental illness?

Personal Awareness - continued

Be honest with your feelings. Identify what strengths you bring to the situation. Remember that clients are human beings with a

mental disorder and do not choose to be this way.

Resources http://www.nami.org

The National Alliance on Mental Illness provides information, education, and support relating to mental health illnesses and disorders for clients, families, and professionals.

http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml The National Institute of Mental Health is part of the Department of Health and Human Services and has information about research on various mental health illnesses.

http://www.nlm.nih.gov/medlineplus/schizophrenia.htmlMedline Plus is a service of the National Library of Medicine and the National Institutes of Health. This site provides definitions related to various aspects of schizophrenia.

Resources - continued http://www.narsad.org/index.html

The National Alliance for Research on Schizophrenia and Depression (NARSAD) is a private, non-for-profit charity organization primarily organized to raise funds for research.

http://www.mayoclinic.com Search by topic on this Mayo Clinic link to find current information about mental illness

Chapter 16 Schizophrenia and Other Psychotic Disorders

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