Schizophrenia and Psychotic Disorders

Chapter 21

Rochelle Roberts RN MSN

Schizophrenia

• Introduced by Swiss psychiatrist Eugene Bleuler in 1911

• Schizein- “to split” Phren -“mind”

• Reflects a split from the emotional and cognitive aspects of personality

Symptoms of Schizophrenia

• Positive symptoms are exaggerated behaviors such as delusions, hallucinations, disorganized speech, bizarre behavior.

• Negative symptoms include loss of behaviors such as loss of affect, inability to maintain social contacts, impaired decision making, and inability to maintain attention.

Symptoms

• Problems with information processing (abnormal brain function)

• Inability to produce logical thoughts and express coherent sentences

Problems in Cognitive Functioning

• Short and long-term memory problems• Poor attention span• Easy distractibility• Illogicality• Pressured speech• Lack of insight, judgment, and lack of problem-

solving• Inability to think abstractly

Problems in Cognitive Functioning (cont)

• Literal interpretation of words

• Magical thinking: “When I stepped on a crack in the sidewalk, it caused my mother to fall and hurt herself the same day. I caused this to happen.”

Problems in Cognitive Function (cont)

• The person’s brain processes data inaccurately

• Delusions-false beliefs that are not shared by others (religious, somatic, grandiose)

Perceptual Distortions

• Are often the first symptoms in many brain illnesses

• Hallucinations –false perceptual distortions

• Types include:• Auditory 70%• Visual 20%• Olfactory• Tactile (experiencing

pain)

Sensory Integration problems

• Neuro “soft signs”-deficit in an undetermined location but are consistent with brain injury to the frontal or parietal lobes.

• Impaired fine motor skills, inability to recognize objects by the sense of touch (astereognosis), mild muscle twitching, increased eye blinking.

Emotions

• Mood- a sustained feeling tone

• Affect- refers to behaviors such as facial expression, hand and body movements, and voice pitch

Emotions Related to Schizophrenia

• Hypoexpression-perception that one no longer has any feelings

• Alexithymia-difficulty naming & describing emotions.

• Anhedonia- inability to experience pleasure

• Apathy- lack of feelings, emotions, interests, or concern

Maladaptive Behaviors in Schizophrenia

• Deteriorated appearance

• Negativism

• Avolition –lack of energy or drive

• Stereotyped behavior -(wearing only certain clothes, etc)

• Lack of persistence at work or school

• aggression

Maladaptive movements

• Abnormal eye movements

• Catatonia (stuporous state associated with posturing)

• Abnormal gait

• Grimacing

• Apraxia-inability to carry out a purposeful task, like dressing.

Schizophrenia Socialization Problem Behaviors

• Inability to communicate coherently

• Loss of interest and drive

• Deterioration of social skills

• Poor personal hygiene

• paranoia

Indirect Effects on Socialization

• Low self-esteem

• Social inappropriateness

• Inappropriate sexual behavior

• Stigma related withdrawal by friends, and family

• Disinterest in recreational activities

Social Isolation

• Caused by stigma• Literal definition

means “mark of shame”

• As students, describe your own attitudes about stigma

Predisposing factors

• Combination of genetic and environmental factors• Neurobiological factors –imaging studies show

decreased brain volume (white matter). Findings include atrophy in the frontal lobe, cerebellum and limbic structures. There are also alterations in neurotransmitters (dopamine, serotonin, and glutamate)

Genetic Risk for Schizophrenia

• Fraternal twin 50 % risk

• Identical twin 15 % risk

• Sibling 10 % risk

• One parent affected 15% risk

• Both parents affected 35% risk

• No affected relative 1% risk

Theories regarding causes of schizophrenia

• Dysregulation Hypothesis- neurotransmitters causing unstable neurotransmission regarding dopamine and serotonin.

• Neurodevelopment theory-several brain structures are abnormal that interfere with memory (prefrontal cortex and hippocampus)

Theories regarding causes of schizophrenia

• Viral Theories-mixed evidence that prenatal exposure to the influenza virus during the 2nd trimester of pregnancy may influence the etiology.

• Sociocultural theory-stress related to poverty, society, and environment may be a factor.

Biological Stressors

• Information-processing overload

• Abnormal “gating mechanisms” refers to nerve potentials and feedback systems within the nervous system.

Some Common Triggers

• Poor nutrition

• Lack of sleep

• Infection

• Hostile environment

• Social isolation

• “Hopeless” attitude

• Poor social skills

Stress Diathesis Model

• Schizophrenia is made worse by stress and causes stress.

• Liberman (1994)

• Schizophrenia symptoms develop based on the amount of stress a person experiences and an internal stress threshold.

Nursing Diagnoses

• Impaired verbal communication

• Disturbed sensory perception

• Impaired social interaction

• Disturbed thought processes

Medical Diagnoses

• Schizophrenias

• Schizophreniform disorder

• Schizoaffective disorder

• Delusional disorder

• Brief psychotic disorder

• Shared psychotic disorder

Outcome Identification

• The patient will live, learn, and work at a maximum possible level of success, as defined by the individual.

• Prevention of relapse is key.

• Relapse is the return of symptoms severe enough to interfere with ADL’s.

Planning

• When the person is in the acute or crisis stage of illness, care is often given in a hospital.

• Overall goal: help the patient reach stability while establishing a foundation for rehab and recovery

Interventions

• In crisis and acute phases:

• Most important is patient safety

• Help the patient feel safe

• Manage delusions and hallucinations

Strategies for working with patients with delusions

• Avoid becoming incorporated into the delusion• Respond to the underlying feelings rather than the

illogical nature of the delusion• Place the delusion in a time frame• Identify emotional components • Observe speech for thought disorder• Promote activities that require physical skills

Strategies for working with patients who have hallucinations

• Establish a trusting relationship

• Ask the patient to describe what is happening and gain control of his hallucinations

• Identify if drugs or alcohol has been used

• Identify needs that may trigger hallucinations

Psychopharmacology

• Clozapine- limited use for patients who are treatment resistant to typical antipsychotics,

because of its potential to cause agranulocytosis.

Other atypical antipsychotics are Risperdal, Olanzapine, Seroquel, Geodon and Abilify.

Typical antipsychotics include: Navane, Haldo, Loxatane, Moban,and Orap.

Interventions in the Maintenance Phase

• Teach self-management of symptoms

• Identify symptoms of relapse

• Patient teaching should involve caregivers

• Cognitive reframing

Stages of Relapse

• Stage 1: Overextension: patient feels overwhelmed and overloaded.

• Stage 2: restricted consciousness:depression is coupled with anxiety and withdrawal. Crucial to intervene during stage 1 or 2

• Stage 3: disinhibition: emergence of hallucinations and delusions that patient can no longer control. (first appearance of psychotic features)

Stages of relapse (cont)

• Stage 4: Psychotic disorganization: intensification of hallucinations and delusions and patient loses control. Three distinct phases here:

a) patient no longer recognizes familiar environment (destructuring of the external world)

Stages of relapse (cont)

a) patient loses personal identity called destructuring of self.

b) Total inability to differentiate reality from psychosis (loudly psychotic)

Stage 5: psychotic resolution-the patient is medicated and still experiencing psychosis, but the symptoms are “quiet”

Managing Relapse

• Awareness of the onset of behaviors indicating relapse

• Prodromal phase occurs before relapse. Time between the onset of symptoms and the need for treatment.

• Identify and manage symptoms helps decrease the # and severity of relapses.Teach the patient to “self report” symptoms, problems with meds, and difficulties with ADL’s.

Common Causes of Relapse

• Patients will most likely stop taking their meds some time in the first year after diagnosis

• Problematic side effects

• Symptoms are gone

• Med didn’t work

Causes of Relapse (cont)

• Studies show that without medication, people with schizophrenia relapse at a rate of 60-70 % within the first year of diagnosis

• Noncompliance occurs even when patient education is peformed

Interventions in the Health Promotion Phase

• Focus in on prevention of relapse and symptom management through engaging the patient in a healthy lifestyle.

• Psychotherapy may be helpful and the focus is supportive and nonconfrontational.

Atypical Antipsychotic Drugs

• Improve the symptoms of schizophrenia• They rarely cause EPS or tardive dyskinesia• Disadvantage of atypical drugs is their

increase in cost over the typical anti-psychotic drugs

• Cost is outweighed by improved effectiveness and quality of life experienced by patients

Side effects of atypical drugs

• Risperidone tends to elevate prolactin levels

• Weight gain (high likelihood with clozapine and olanzapine)

• Sedation is commonly observed with clozapine & olanzapine

• Zaprasidone (Geodon) may prolong the Q-T interval.

Side effects (cont)

• Clozapine is usually reserved for patients with treatment resilient illness because of its side effect of agranulocytosis, seizures, and myocarditis. Strict protocol is required by prescribers, including entering patients into a national registry, monitoring WBC count weekly for 6 months, and writing scripts for only 1 to 2 weeks at a time.

Typical Antipsychotics

• Thorazine

• Mellaril

• Trilafon

• Stelazine

• Prolixin

• Haldol

• Loxitane

Side Effects of Typical Antipsychotics

• EPS decrease dose or add drug to treat EPS

• Akathisia- pacing, legs ache

• Dystonia-spasms of muscle groups of neck, back an eyes

• Tardive dykinesia-involuntary movements (tongue protrusion, blinking, grimacing, foot tapping)

Side effects (cont)

• NMS -Neuroleptic Malignant syndrome is potentially fatal: fever, tachycardia, sweating, muscle rigidity, tremor, elevated creatine phosphokinase, renal failure

• Seizures- occurs in about 1% of cases; clozapine has 5% rate

• Agranulocytosis-leukopenia, fever; this is an emergency situation-high incidence with clozapine, do weekly CBC

Other side effects

• Photosensitivity patients must use sunscreen and sunglasses

• Anticholinergic side effects- constipation, dry mouth, blurred vision, urinary retention