Schizophrenia History

19th CenturyKraepelin- Dementia Praecox

20th CenturyBleuler autism-apathy-ambivalence-anhedoniaArieti 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

medicationType 1 positive symptoms respond to

medication

Positive Symptoms

DelusionsHallucinationsDisorganized speechBizarre or disorganized behavior

Negative Symptoms

Flat AffectAvolitionAlogiaAnhedoniaAttention Impairment

History of Therapy

PsychoanalyticSullivan/PeplauInterpersonal Communication

SomaticInsulin ComaElectroconvulsive TherapyPsychosurgery

Psychopharmacology1950s phenothiazines1990s D1-D2 receptor medications

Community Mental HealthMilieuTherapeutic CommunityDe-institutionalization

Typology of Thought Disorder

ParanoidCatatonicDisorganizedUndifferentiatedResidual

Paranoid

Delusions- especially persecutoryAuditory HallucinationsNo loose associationsNo marked affective problem

Paranoid

Catatonic

Stupor or mutismNegativismRigidityExcitementPosturing (waxy flexibility)

Disorganized

Marked looseness of associationsGrossly inappropriate affect

Disorganized

UndifferentiatedProminent delusionsHallucinations or grossly disorganized

behavior

Residual

Diagnosis

Presence of 1,2, or 3 for more than 1 week1. Two of the following:

delusions, prominent hallucinations, marked

associative loosenesscatatonic behaviorflat or silly affect

2. Bizarre delusions3. Prominent hallucinations

Continuous signs of disturbance 6 months18 years if age or moreDownward course

Nursing Process- Assessment

1. Perceptual changes:illusions, hallucinations

2. Thought disorder:loose associations, clanging, delusions

3. Communication changes:thought disorganization,

blocking, tangential, circumstantial

4. Motor Changes:catatonia-excited, posturing, waxy

flexibility

5. Family:enmeshed, family burden

Nursing Diagnosis

Impaired communicationpoverty of speechblunt emotions

Self-care deficitsActivity intoleranceSocial isolationDecisional conflict

Sensory alterationsBody image distortionAltered thought processes

delusions, magical thinkingthought insertions, withdrawalthought broadcasting

Altered emotional responseblunted or flat affectanhedonia

Altered family function

Nursing Planning & Intervention

Adequate communication

Grooming & hygieneSocial skillsIntervene with

delusionsFamily understanding

Medication usageOrganize behaviorReality based

perceptionsCongruent emotional

responsesCommunity contacts

Nursing Planning & Intervention

Adequate communication

Grooming & hygieneSocial skillsIntervene with

delusionsFamily understanding

Medication usageOrganize behaviorReality based

perceptionsCongruent emotional

responsesCommunity contacts

Nursing Implications with Neuroleptic Medications

1. PhenothiazinesThorazine (Chlorpromazine)Mellaril (Thiorizidine)Stelazine (Trifluoperazine)Prolixin (Fluphenazine)Prolixin Decanoate

2. ButyrophenesHaldol (Haloperidol)Haldol LA

3. Low potency D1-D2 medicationsClozaril (Clozapine)Risperdol (Resperidone) & Risperdol EZyprexa (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

PhotophobiaLeukocytosisOrthostatic hypotensionAnti-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 confusedRed as a beet feverDry as a bone anticholinergiaBlind as a bat diplopia