Schizophrenia and Other Psychotic Disorders

Chapter 14

• Schizophrenia• http://www.youtube.com/watch?v=H_jYqSA_fJk• Schizophrenia Part 1 - ABC 20/20 coverage• http://www.youtube.com/watch?v=moP_e-gx5hk• Schizophrenia Part 2 - ABC 20/20 coverage• http://www.youtube.com/watch?v=QPXkwYM9G-s• What is Schizophrenia? (Schizophrenia #1)• http://www.youtube.com/watch?v=KnoTwOUb0aQ• Diagnosing and Treating Schizophrenia (Schizophrenia #2)• http://www.youtube.com/watch?v=WwlM1pxIbaI

Introduction• The word schizophrenia is derived from the

Greek words skhizo (split) and phren (mind).• Schizophrenia is probably caused by a combination of factors, including:

• Of all mental illnesses, schizophrenia probably causes more– Lengthy hospitalizations– Chaos in family life– Exorbitant costs to people and governments – Fears

Nature of the Disorder

• Schizophrenia disturbsThought processes, Perception and Affect

• With schizophrenia, there is a severe deterioration of social and occupational functioning

* In the United States, the lifetime prevalence of schizophrenia is about 1 percent.

• Premorbid behavior of the patient with schizophrenia can be viewed in four phases.

• First Phase: Schizoid Personality– Indifferent, cold, and aloof, these people are loners. They do not enjoy close relationships

with others.• Second Phase: Prodromal Phase

– These people are socially withdrawn and show evidence of peculiar or eccentric behavior.

– Neglect of personal hygiene and grooming– Blunted or inappropriate affect– Disturbances in communication– Bizarre ideas– Lack of initiative

• Third Phase: Schizophrenia– In the active phase of the disorder, psychotic symptoms are prominent

• Delusions• Hallucinations• Impairment in work, social relations, and self-care

• Fourth Phase: Residual Phase– Symptoms similar to those of the prodromal phase– Flat affect and impairment in role functioning are prominent

Predisposing Factors– Various physical conditions

• Epilepsy• Huntington’s chorea• Birth trauma• Head injury in adulthood• Alcohol abuse• Cerebral tumor• Cerebrovascular accident• Systemic lupus erythematosus• Myxedema• Parkinsonism• Wilson’s disease

Characteristic SymptomsPositive symptoms:

• Delusions• Hallucination• Disorganized speech• Grossly disorganized or

catatonic behavior

Negative symptoms:

• Affective Flattening• Alogia• Apathy• Anhedonia• Social isolation

Types of schizophrenia and other psychotic disorders

• Paranoid• Disorgainzed• Catatonic• Residual• Undifferentiated• Schizoaffective disorder

• Brief psychotic disorder• Schizophreniform

disorder• Delusional Disorder• Shared psychotic

disorder• substance-Induced

psychotic disorder

Content of Thought

Delusions• Of Persecution• Of Grandeur• Of Reference• Of control or influence• Somatic• Nihilistic• Religiosity• Paranoia• Magical thinking

Form• Associative Looseness• Neologisms• Concrete thinking• Clang associations • Word salad • Circumstantialities • Tangentiality • Mutism• Perseveration

Perception• Hallucination• Auditory• Visual• Tactile• Olfactory

Affects• Inappropriate affect• Bland or flat affect• Apathy

Conventional Antipsychotics

GenericHaloperidolChlorpromazineFluphenazineThiothixeneTrifluoperazineThioridazinePerphenazineLoxapine

BrandHaldolThorazineProlidixinNavaneStelazineMellariTrilafonLoxitane

Conventional Antipsychotics

• Advantage-Effective for positive symptoms of schizophrenia- Available in IM formulation for acute psychosis/agitation- Cheap

• Disadvantage- Could worsen cognitive function- Minimally effective for negative symptoms of schizophrenia- Higher incidence of side effects (EPS, NMS, tardive dyskinesia, etc.

Atypical Antipsychotics

• GenericClozapineOlanzapineRisperidoneQuetiapineZiprasidoneAripiprazolePaliperidonen

• BrandClozaril, FazaCloZyprexa (Aydis)Risperdal (Consta, M-tab)Seroquel, Seroquest XRGeodonAbilifyInvega (newest)

Atypical Antipsychotics• Advantage- Effective for positive of symptoms of schizophrenia- May improve negative symptoms of schizophrenia- Lower incidence of side effects compared to

conventional antipsychotics

• Disadvantage- Higher incidence of weight gain- Higher incidence of diabets- Expensive

Side Effects• Neuroleptic malignant syndrome (NMS)

– Potentially life threatening– High fever, unstable BP, myoglobinemia

• Extrapyramidal symptoms (EPS)– Involuntary muscle symptoms similar to those of Parkinson’s disease– Akathisia (distressing muscle restlessness)– Acute dystonia (painful muscle spasms)– Treated with benztropine (Cogentin) and trihexyphenidyl (Artane)

• Tardive dyskinesia (TD)– Involuntary contractions of oral and facial muscles– Choreoathetosis (wavelike movements of extremities)– Occurs with continuous long-term antipsychotic therapy

Nursing Process

• Nursing Assessment• Nursing Diagnosis• Related to• Evidenced by• Interventions• Education

Conventional Antipsychotics

GenericHaloperidolChlorpromazineFluphenazineThiothixeneTrifluoperazineThioridazinePerphenazineLoxapine

BrandHaldolThorazineProlidixinNavaneStelazineMellariTrilafonLoxitane

Conventional Antipsychotics

• Advantage-Effective for positive symptoms of schizophrenia- Available in IM formulation for acute psychosis/agitation- Cheap

• Disadvantage- Could worsen cognitive function- Minimally effective for negative symptoms of schizophrenia- Higher incidence of side effects (EPS, NMS, tardive dyskinesia, etc.

Atypical Antipsychotics

• GenericClozapineOlanzapineRisperidoneQuetiapineZiprasidoneAripiprazolePaliperidonen

• BrandClozaril, FazaCloZyprexa (Aydis)Risperdal (Consta, M-tab)Seroquel, Seroquest XRGeodonAbilifyInvega (newest)

Atypical Antipsychotics• Advantage- Effective for positive of symptoms of schizophrenia- May improve negative symptoms of schizophrenia- Lower incidence of side effects compared to

conventional antipsychotics

• Disadvantage- Higher incidence of weight gain- Higher incidence of diabets- Expensive

Antipsychotics

Background Assessment Data• Indications: Treatment of acute and chronic

psychoses; selected agents are also used as antiemetics in the treatment of intractable hiccoughs and for control of tics and vocal utterances in Tourette’s disorder

• Actions: Unknown; thought to block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer antipsychotics may block action on receptors specific to dopamine, serotonin, and other neurotransmitters.

• Contraindications/precautions– Contraindicated with known hypersensitivity; with CNS

depression; when blood dyscrasias exist; in clients with Parkinson’s disease; or those with liver, renal, or cardiac insufficiency

– Caution with elderly, debilitated, or diabetic clients or those with respiratory insufficiency, prostatic hypertrophy, or intestinal obstructio

• Interactions– Additive anticholinergic effects with other drugs that produce

these properties– Additive hypotensive effects with beta-blockers– Decreased absorption of antipsychotics with antacids and

antidiarrheals– Decreased effectiveness of antipsychotics with barbiturates– Additive CNS depression with alcohol, antihistamines,

antidepressants, sedative-hypnotics, and anxiolytics

Nursing Diagnosis

• Risk for other-directed violence• Risk for injury• Risk for activity intolerance• Noncompliance

Neuroleptic Malignant Syndrome

• Signs and symptoms of NMS are: muscle rigidity, hyperthermia, decreased ventilation, cardiovascular collapse, and an elevate CPK

Side effects• Neuroleptic malignant syndrome (NMS)

– Potentially life threatening– High fever, unstable BP, myoglobinemia

• Extrapyramidal symptoms (EPS)– Involuntary muscle symptoms similar to those of Parkinson’s disease– Akathisia (distressing muscle restlessness)– Acute dystonia (painful muscle spasms)– Treated with benztropine (Cogentin) and trihexyphenidyl (Artane)

• Tardive dyskinesia (TD)– Involuntary contractions of oral and facial muscles– Choreoathetosis (wavelike movements of extremities)– Occurs with continuous long-term antipsychotic therapy

A 29 year old woman is being discharged in 2 days form the hospital after her first psychotic break (paranoid schizophrenia). She is recently divorced and has been working as a legal secretary, although her work had become erratic, and her suspicious behavior was calling attention to herself at work. She will be discharged in her mother’s care until she is able to resume working. Her mother is overwhelmed and asked the nurse how she is going to cope. “She has become so distant and she always takes thing the wrong way. I can hardly say anything to her with her misconstruing everything. She is very mad at me because I called 911 and had her admitted after she told me she was going to get justice back in the world by blowing up evil forces that have been haunting her life and then proceeded to try to run over her ex-husband, thinking he was the devil. She told me there is nothing wrong with her and I am concerned she won’t take her medication once she is discharge.

1. What are some of the priority concern that nurse could address in the hospital setting before she is discharge?

2. How would you explain to the mother some of the symptoms that she is experience in? What suggestion could you give her to handle some of the immediate concerns?

3. What issues could you bring up to the staff about her medication compliance? What would be some ways to deal with this issue?

4. What do you think of the prognosis for her? Support your hypothesis with data regarding influences on the course of schizophrenia.