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Chapter 15Chapter 15 SchizophreniaSchizophrenia

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Eugen Bleuler’s Eugen Bleuler’s 4 A’s of Schizophrenia 4 A’s of Schizophrenia

• AffectAffect

• Associative loosenessAssociative looseness

• AutismAutism

• AmbivalenceAmbivalence

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EpidemiologyEpidemiology

• Lifetime prevalence of schizophrenia Lifetime prevalence of schizophrenia 1% worldwide1% worldwide

• No difference related toNo difference related to

– RaceRace

– Social statusSocial status

– CultureCulture

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ComorbidityComorbidity

• Substance abuse disordersSubstance abuse disorders

– Nicotine dependenceNicotine dependence

• Anxiety, depression, and suicideAnxiety, depression, and suicide

• Physical health or illnessPhysical health or illness

• PolydipsiaPolydipsia

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EtiologyEtiology

• Biological factorsBiological factors

– GeneticsGenetics

• NeurobiologicalNeurobiological

– Dopamine theoryDopamine theory

– Other neurochemical hypotheses Other neurochemical hypotheses

• Brain structure abnormalitiesBrain structure abnormalities

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EtiologyEtiologyContinuedContinued

• Psychological and environmental Psychological and environmental factorsfactors

– Prenatal stressorsPrenatal stressors

– Psychological stressorsPsychological stressors

– Environmental stressorsEnvironmental stressors

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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

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AssessmentAssessment

• During the prepsychotic phaseDuring the prepsychotic phase

• General assessmentGeneral assessment

– Positive symptomsPositive symptoms

– Negative symptomsNegative symptoms

– Cognitive symptomsCognitive symptoms

– Affective symptomsAffective symptoms

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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.

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Positive SymptomsPositive SymptomsContinuedContinued

• Alterations in speechAlterations in speech

– NeologismsNeologisms

– EcholaliaEcholalia

– EchopraxiaEchopraxia

– Clang associationsClang associations

– Word saladWord salad

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Positive SymptomsPositive SymptomsContinuedContinued

• Alterations in perceptionAlterations in perception

– DepersonalizationDepersonalization

– DerealizationDerealization

– HallucinationsHallucinations

• Auditory hallucinationsAuditory hallucinations

• Command hallucinationsCommand hallucinations

• Visual hallucinationsVisual hallucinations

– Boundary impairment Boundary impairment

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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

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Negative SymptomsNegative Symptoms

• AffectAffect

– FlatFlat

– BluntedBlunted

– InappropriateInappropriate

– Bizarre Bizarre

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Cognitive SymptomsCognitive Symptoms

• Difficulty withDifficulty with

– AttentionAttention

– MemoryMemory

– Information processingInformation processing

– Cognitive flexibilityCognitive flexibility

– Executive functions Executive functions

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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

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• 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?

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a.a. Positive symptomPositive symptom

b.b. Negative symptomNegative symptom

c.c. Cognitive symptomCognitive symptom

d.d. Depressive symptomDepressive symptom

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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

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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

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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

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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

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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

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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

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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

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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

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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

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InterventionsInterventionsContinuedContinued

• Stabilization and Maintenance Phase, Stabilization and Maintenance Phase, continuedcontinued

– HallucinationsHallucinations

– DelusionsDelusions

– Associative loosenessAssociative looseness

– Health teaching and health promotionHealth teaching and health promotion

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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

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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

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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)

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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

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Extrapyramidal Side EffectsExtrapyramidal Side Effects

• Acute Acute dystoniadystonia

• AkathisiaAkathisia

• PseudoparkinsonismPseudoparkinsonism

• Tardive dyskinesia Tardive dyskinesia –– Abnormal Abnormal Involuntary Movement Scale (AIMS) Involuntary Movement Scale (AIMS)

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Potentially Dangerous Potentially Dangerous Responses to AntipsychoticsResponses to Antipsychotics

• Neuroleptic malignant syndrome (NMS)Neuroleptic malignant syndrome (NMS)

• AgranulocytosisAgranulocytosis

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Adjuncts to Antipsychotic Adjuncts to Antipsychotic Drug TherapyDrug Therapy

• AntidepressantsAntidepressants

• Antimanic agentsAntimanic agents

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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

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Specific Interventions forSpecific Interventions forDisorganized SchizophreniaDisorganized Schizophrenia

• Communication guidelinesCommunication guidelines

• Self-care needsSelf-care needs

• Milieu needsMilieu needs

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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

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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

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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