Schizophrenia History

19th CenturyKraepelin- Dementia Praecox

20th CenturyBleuler

autism-apathy-ambivalence-anhedonia

Arieti

associative looseness, auditory

hallucinations

Current theories

Genetic

↓ 1% of population

10 % of 1st degree relatives

35-55% concordance rate in monozygotic

twins (genetically identical)

15-17% concordance rate in dizygotic

twins (share half their genes)

Slightly more men than womenEarly 20s age of first psychotic break75% of people have permanent disabilityCultural component on relapse

Neurotransmitter imbalance

Dopamine system hyperactivity

Norepinepherine elevation

Serotonin elevation

Diminished levels of GABA

Decreased co-enzyme for conversion of PKU to tyrosine

Central Nervous System Anomaly

Type 2 enlarged ventricles

negative symptoms resistant to medication

Type 1 positive symptoms respond to medication

Positive Symptoms

Delusions

Hallucinations

Disorganized speech

Bizarre or disorganized behavior

Negative Symptoms

Flat Affect

Avolition

Alogia

Anhedonia

Attention Impairment

History of Therapy

Psychoanalytic

Sullivan/Peplau

Interpersonal Communication

Somatic

Insulin Coma

Electroconvulsive Therapy

Psychosurgery

Psychopharmacology

1950s phenothiazines

1990s D1-D2 receptor medications

Community Mental Health

Milieu

Therapeutic Community

De-institutionalization

Typology of Thought Disorder

Paranoid

Catatonic

Disorganized

Undifferentiated

Residual

Paranoid

Delusions- especially persecutory

Auditory Hallucinations

No loose associations

No marked affective problem

Paranoid

Catatonic

Stupor or mutism

Negativism

Rigidity

Excitement

Posturing (waxy flexibility)

Disorganized

Marked looseness of associations

Grossly inappropriate affect

Disorganized

UndifferentiatedProminent delusions

Hallucinations or grossly disorganized behavior

Residual

Diagnosis

Presence of 1,2, or 3 for more than 1 week

1. Two of the following:

delusions, prominent

hallucinations, marked

associative looseness

catatonic behavior

flat or silly affect

2. Bizarre delusions

3. Prominent hallucinations

Continuous signs of disturbance ↑ 6 months

18 years if age or more

Downward course

Nursing Process- Assessment

1.Perceptual changes:

illusions, hallucinations

2. Thought disorder:

loose associations, clanging, delusions

3. Communication changes:

thought disorganization,

blocking, tangential, circumstantial

echolalia, echopraxia

4. Motor Changes:

catatonia-excited, posturing, waxy

flexibility

5. Family:

enmeshed, family burden

Nursing Diagnosis

Impaired communication

poverty of speech

blunt emotions

Self-care deficits

Activity intolerance

Social isolation

Decisional conflict

Sensory alterations

Body image distortion

Altered thought processes

delusions, magical thinking

thought insertions, withdrawal

thought broadcasting

Altered emotional response

blunted or flat affect

anhedonia

Altered family function

Nursing Planning & Intervention

Adequate communication

Grooming & hygiene

Social skills

Intervene with delusions

Family understanding

Medication usage

Organize behavior

Reality based perceptions

Congruent emotional responses

Community contacts

Nursing Planning & Intervention

Adequate communication

Grooming & hygiene

Social skills

Intervene with delusions

Family understanding

Medication usage

Organize behavior

Reality based perceptions

Congruent emotional responses

Community contacts

Nursing Implications with Neuroleptic Medications

1. Phenothiazines

Thorazine(Chlorpromazine)

Mellaril (Thiorizidine)

Stelazine (Trifluoperazine)

Prolixin (Fluphenazine)

Prolixin Decanoate (Fluphenazine D)

2. Butyrophenes

Haldol (Haloperidol)

Haldol LA

3. Low potency D1-D2 medications

Clozaril (Clozapine)

Risperdol (Resperidone) & Risperdol C

Zyprexa (Olanzapine)

Abilify (Ariprazole)Geodon (Ziprasidone)

Side Effects

Nervous system Extra Pyramidal SymptomsAkathisia--restelessnessDystonia– muscle contractions

Opisthotonis—tongue sticking outOcculogryic Crisis- eye rolling

Akinesia– muscle heavinessPseudo parkinsonism- mask like fascies and other symptomsTardive dyskinesia—tongue movements

Tardive Dyskinesia

Other Side Effects

Photophobia

Leukocytosis

Orthostatic hypotension

Anti-cholinergic effects

D1 and D2 effects

Weight gainImpotenceRisk for development of Diabetes Mellitus (Geodon)Gallactarhea

Neuroleptic malignant syndrome

Possibly fatal side effect of neurolepticsNon-dose relatedFeverConfusionConvulsionsDeathRx-stop neuroleptic- emergency care

Side Effect Treatment

Anti-parkinson medications:

Cogentin (Benztropine)

Artane (Trihexyphenidyl)

Symmetrel (Amantadine)

Atropine Psychosis

Mad as a hatter confused

Red as a beet fever

Dry as a bone anticholinergia

Blind as a bat diplopia