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Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Chapter 15Chapter 15 SchizophreniaSchizophrenia
2Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Eugen Bleuler’s Eugen Bleuler’s 4 A’s of Schizophrenia 4 A’s of Schizophrenia
• AffectAffect
• Associative loosenessAssociative looseness
• AutismAutism
• AmbivalenceAmbivalence
3Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
EpidemiologyEpidemiology
• Lifetime prevalence of schizophrenia Lifetime prevalence of schizophrenia 1% worldwide1% worldwide
• No difference related toNo difference related to
– RaceRace
– Social statusSocial status
– CultureCulture
4Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
ComorbidityComorbidity
• Substance abuse disordersSubstance abuse disorders
– Nicotine dependenceNicotine dependence
• Anxiety, depression, and suicideAnxiety, depression, and suicide
• Physical health or illnessPhysical health or illness
• PolydipsiaPolydipsia
5Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
EtiologyEtiology
• Biological factorsBiological factors
– GeneticsGenetics
• NeurobiologicalNeurobiological
– Dopamine theoryDopamine theory
– Other neurochemical hypotheses Other neurochemical hypotheses
• Brain structure abnormalitiesBrain structure abnormalities
6Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
EtiologyEtiologyContinuedContinued
• Psychological and environmental Psychological and environmental factorsfactors
– Prenatal stressorsPrenatal stressors
– Psychological stressorsPsychological stressors
– Environmental stressorsEnvironmental stressors
7Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Phases Phases ofof Schizophrenia Schizophrenia
Phase I Phase I –– Acute Acute
– Onset or exacerbation of symptomsOnset or exacerbation of symptoms
Phase II Phase II –– Stabilization Stabilization
– Symptoms diminishing Symptoms diminishing
– Movement towards previous level of Movement towards previous level of functioningfunctioning
Phase III Phase III –– Maintenance Maintenance
– At or near baseline functioningAt or near baseline functioning
8Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
AssessmentAssessment
• During the prepsychotic phaseDuring the prepsychotic phase
• General assessmentGeneral assessment
– Positive symptomsPositive symptoms
– Negative symptomsNegative symptoms
– Cognitive symptomsCognitive symptoms
– Affective symptomsAffective symptoms
9Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive Symptoms Positive Symptoms
• Alterations in thinkingAlterations in thinking
– Delusions are false, fixed beliefs.Delusions are false, fixed beliefs.
– Concrete thinking is an inability to think Concrete thinking is an inability to think abstractly. abstractly.
10Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive SymptomsPositive SymptomsContinuedContinued
• Alterations in speechAlterations in speech
– NeologismsNeologisms
– EcholaliaEcholalia
– EchopraxiaEchopraxia
– Clang associationsClang associations
– Word saladWord salad
11Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive SymptomsPositive SymptomsContinuedContinued
• Alterations in perceptionAlterations in perception
– DepersonalizationDepersonalization
– DerealizationDerealization
– HallucinationsHallucinations
• Auditory hallucinationsAuditory hallucinations
• Command hallucinationsCommand hallucinations
• Visual hallucinationsVisual hallucinations
– Boundary impairment Boundary impairment
12Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive SymptomsPositive SymptomsContinuedContinued
Alterations in behaviorAlterations in behavior
– CatatoniaCatatonia
– Motor retardationMotor retardation
– Motor agitationMotor agitation
– Stereotyped Stereotyped behaviorsbehaviors
– Automatic obedienceAutomatic obedience
– Waxy flexibilityWaxy flexibility
– NegativismNegativism
– Impaired impulse Impaired impulse control control
13Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Negative SymptomsNegative Symptoms
• AffectAffect
– FlatFlat
– BluntedBlunted
– InappropriateInappropriate
– Bizarre Bizarre
14Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Cognitive SymptomsCognitive Symptoms
• Difficulty withDifficulty with
– AttentionAttention
– MemoryMemory
– Information processingInformation processing
– Cognitive flexibilityCognitive flexibility
– Executive functions Executive functions
15Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Affective SymptomsAffective Symptoms
• Assessment for depression crucialAssessment for depression crucial
– May herald impending relapseMay herald impending relapse
– Increases substance abuseIncreases substance abuse
– Increases suicide riskIncreases suicide risk
– Further impairs functioningFurther impairs functioning
16Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
• A patient with schizophrenia says, A patient with schizophrenia says, “There are worms under my skin eating “There are worms under my skin eating the hair follicles.” How would you the hair follicles.” How would you classify this assessment finding?classify this assessment finding?
17Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
a.a. Positive symptomPositive symptom
b.b. Negative symptomNegative symptom
c.c. Cognitive symptomCognitive symptom
d.d. Depressive symptomDepressive symptom
18Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Assessment GuidelinesAssessment Guidelines
1. Any medical problems1. Any medical problems
2. Abuse of or dependence on2. Abuse of or dependence on alcohol alcohol or drugsor drugs
3. Risk to self or others3. Risk to self or others
4. Command hallucinations4. Command hallucinations
19Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Assessment GuidelinesAssessment GuidelinesContinuedContinued
5. Belief system5. Belief system
6. Suicide risk6. Suicide risk
7. Ability to ensure self-safety7. Ability to ensure self-safety
8. Co-occurring disorders8. Co-occurring disorders
20Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Assessment GuidelinesAssessment GuidelinesContinuedContinued
9. Medications 9. Medications
10. Presence and severity of positive 10. Presence and severity of positive and negative symptomsand negative symptoms
11. Patient’s insight into illness11. Patient’s insight into illness
12. Family’s knowledge of patient’s 12. Family’s knowledge of patient’s illness and symptomsillness and symptoms
21Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Potential Nursing DiagnosesPotential Nursing Diagnoses
• Positive symptomsPositive symptoms
– Disturbed sensory perceptionDisturbed sensory perception
– Risk for self-directed or other-directed Risk for self-directed or other-directed violenceviolence
– Disturbed thought processesDisturbed thought processes
• Negative symptomsNegative symptoms
– Social isolationSocial isolation
– Chronic low self-esteemChronic low self-esteem
22Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Outcomes IdentificationOutcomes Identification
• Phase I - AcutePhase I - Acute
Patient safety and medical stabilizationPatient safety and medical stabilization
• Phase II - StabilizationPhase II - Stabilization– Adhere to treatmentAdhere to treatment
– Stabilize medicationsStabilize medications
– Control or cope with symptomsControl or cope with symptoms
• Phase III - MaintenancePhase III - Maintenance– Maintain achievementMaintain achievement
– Prevent relapsePrevent relapse
– Achieve independence, satisfactory quality of lifeAchieve independence, satisfactory quality of life
23Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
PlanningPlanning
• Phase I Phase I –– Acute Acute
– Best strategies to ensure patient safety Best strategies to ensure patient safety and provide symptom stabilization and provide symptom stabilization
• Phase II – StabilizationPhase II – Stabilization
• Phase III Phase III –– Maintenance Maintenance
– Provide patient and family educationProvide patient and family education
– Relapse prevention skills are vitalRelapse prevention skills are vital
24Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
ImplementationImplementation
• Phase 1 Phase 1 –– Acute Settings Acute Settings
– Partial hospitalizationPartial hospitalization
– Residential crisis centersResidential crisis centers
– Halfway housesHalfway houses
– Day treatment programsDay treatment programs
25Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
InterventionsInterventions
• Acute PhaseAcute Phase
– Psychiatric, medical, and neurological Psychiatric, medical, and neurological evaluationevaluation
– Psychopharmacological treatmentPsychopharmacological treatment
– Support, psychoeducation, and guidanceSupport, psychoeducation, and guidance
– Supervision and limit setting in the milieuSupervision and limit setting in the milieu
26Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
InterventionsInterventionsContinuedContinued
• Stabilization and Maintenance PhaseStabilization and Maintenance Phase
– Milieu managementMilieu management
– Activities and groupsActivities and groups
– SafetySafety
– Counseling and communication Counseling and communication techniques techniques
27Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
InterventionsInterventionsContinuedContinued
• Stabilization and Maintenance Phase, Stabilization and Maintenance Phase, continuedcontinued
– HallucinationsHallucinations
– DelusionsDelusions
– Associative loosenessAssociative looseness
– Health teaching and health promotionHealth teaching and health promotion
28Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Pharmacological InterventionsPharmacological Interventions
• Antipsychotic medicationsAntipsychotic medications
– Conventional antipsychotics Conventional antipsychotics
• Typical or first-generationTypical or first-generation
– Atypical antipsychotics Atypical antipsychotics
• Second-generation Second-generation
29Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Atypical Antipsychotics Atypical Antipsychotics
• Treat both positive and negative Treat both positive and negative symptomssymptoms
• Minimal to no extrapyramidal side Minimal to no extrapyramidal side effects (EPSs) or tardive dyskinesia effects (EPSs) or tardive dyskinesia
• Disadvantage – tendency to cause Disadvantage – tendency to cause significant weight gainsignificant weight gain
30Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Atypical AntipsychoticsAtypical AntipsychoticsContinuedContinued
• ExamplesExamples
– Clozapine (Clozaril) Clozapine (Clozaril) –– use declining use declining
– Risperidone (Risperdal)Risperidone (Risperdal)
– Olanzapine (Zyprexa)Olanzapine (Zyprexa)
– Quetiapine (Seroquel)Quetiapine (Seroquel)
– Ziprasidone (Geodon)Ziprasidone (Geodon)
– Aripiprazole (Abilify)Aripiprazole (Abilify)
31Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Conventional Antipsychotics Conventional Antipsychotics • Dopamine antagonists (D2 receptor antagonists)Dopamine antagonists (D2 receptor antagonists)
• Target positive symptoms of schizophreniaTarget positive symptoms of schizophrenia
• AdvantageAdvantage
– Less expensive than atypical antipsychoticsLess expensive than atypical antipsychotics
• DisadvantagesDisadvantages
– Do not treat negative symptomsDo not treat negative symptoms
– Extrapyramidal side effects (EPSs)Extrapyramidal side effects (EPSs)
– Tardive dyskinesiaTardive dyskinesia
– Anticholinergic side effectsAnticholinergic side effects
– Lower seizure thresholdLower seizure threshold
32Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Extrapyramidal Side EffectsExtrapyramidal Side Effects
• Acute Acute dystoniadystonia
• AkathisiaAkathisia
• PseudoparkinsonismPseudoparkinsonism
• Tardive dyskinesia Tardive dyskinesia –– Abnormal Abnormal Involuntary Movement Scale (AIMS) Involuntary Movement Scale (AIMS)
33Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Potentially Dangerous Potentially Dangerous Responses to AntipsychoticsResponses to Antipsychotics
• Neuroleptic malignant syndrome (NMS)Neuroleptic malignant syndrome (NMS)
• AgranulocytosisAgranulocytosis
34Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Adjuncts to Antipsychotic Adjuncts to Antipsychotic Drug TherapyDrug Therapy
• AntidepressantsAntidepressants
• Antimanic agentsAntimanic agents
35Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Specific Interventions Specific Interventions for Catatoniafor Catatonia
• Catatonia – Withdrawn PhaseCatatonia – Withdrawn Phase
– Communication guidelinesCommunication guidelines
– Self-care needsSelf-care needs
– Milieu needsMilieu needs
• Catatonia – Excited PhaseCatatonia – Excited Phase
– Communication guidelinesCommunication guidelines
– Self-care needsSelf-care needs
36Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Specific Interventions forSpecific Interventions forDisorganized SchizophreniaDisorganized Schizophrenia
• Communication guidelinesCommunication guidelines
• Self-care needsSelf-care needs
• Milieu needsMilieu needs
37Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Undifferentiated SchizophreniaUndifferentiated Schizophrenia
• Active signs of disorderActive signs of disorder
– Positive symptoms Positive symptoms
– Negative symptomsNegative symptoms
• Individual does not meet criteria for any Individual does not meet criteria for any other subtypeother subtype
38Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Residual SchizophreniaResidual Schizophrenia• Active-phase symptoms no longer Active-phase symptoms no longer
presentpresent
• Evidence of two or more residual Evidence of two or more residual symptoms persistssymptoms persists
– Reduced initiative, interests, or energyReduced initiative, interests, or energy
– Social withdrawalSocial withdrawal
– Impaired role functionImpaired role function
– Speech deficits Speech deficits
– Odd beliefsOdd beliefs
39Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Advanced Practice InterventionsAdvanced Practice Interventions
• PsychotherapyPsychotherapy
• Cognitive-behavioral therapy (CBT)Cognitive-behavioral therapy (CBT)
• Group therapyGroup therapy
• MedicationMedication
• Social skills trainingSocial skills training
• Cognitive remediationCognitive remediation
• Family therapyFamily therapy