Schizophrenia

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Schizophrenia

• Elisa A. Mancuso RNC, MS, FNS
• Professor

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• 2 million people (1.5 of Population)
• Costs 35 billion
• Onset late adolescence or early adulthood
• Men 15-25 women 20-35 gt 50
• Psychotic disorders with disturbances in
• Thought processes
• Perceptions
• Expression of feelings

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Indicators

• Psychotic Symptoms
• Preoccupied with own thoughts and feelings
• Deterioration in functioning
• Role, ADLs, Interpersonal relationships
• 6 month duration of symptoms
• Bleulers 4 As
• Autism
• Affect
• Associative Looseness
• Ambivilance

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Etiology

• Genetic
• Abnormal marker gene on chromosome 5
• Heredity determines ones predisposition
• Both parents schizophrenic 20-50 ?? risk
• Identical twins 50-75 ?? risk for sibling
• Biochemical
• Altered Neuroanatomy ?s in cortex
• ?? DA activity (2x DA receptors) Psychosis
• ? AcH ? Confusion,
• ? NE Anhedonia
• ? 5-HT ? Aggressive tendencies
• ?Glutamate learning memory
• ?Glucose metabolism ? GABA

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Psychological

• Poor early mother-child relationship
• Trust vs Mistrust
• ? Ego boundaries
• Dysfuntional family system
• Double-bind communication
• Say one thing but mean the opposite
• Environment
• ? Socioeconomic ? stress ? ? resources
• Stressful life events precipitate onset!

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Schizophrenia Stages

• Stage I Schizoid Personality
• Isolate themselves, loners
• Indifferent, cold, aloof
• ? Range of emotional expression
• Dont enjoy close relationships
• Stage II Prodromal Pre-Schizophrenic
• Socially withdrawn- Blunted affect
• Eccentric behavior Bizarre ideas
• Unusual perceptual experiences
• ? Role performance ?ADLs

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Schizophrenia Stages

• Stage III Schizophrenia (Active)
• Prominent psychotic symptoms gt6 months
• Delusions
• False, fixed belief
• Grandiose, Persecutory, Paranoia, Religiosity
• Hallucinations
• False sensory perception
• Ideas of Reference
• Disorganized Behavior
• Impaired work, social relations self care
• Disorganized Speech
• Associative Looseness
• Clanging Echolalia Word Salad
• Poverty of Speech Neologisms

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Schizophrenia Stages

• Stage III Secondary Symptoms
• Anxiety Substance Abuse (ETOH, coke)
• Depression gt 25
• ?? Suicide (10) Leading cause of death
• Compulsive H2O drinking 4-10 L/day
• H2O intoxication
• ? Na Lightheaded Lethargy Muscle cramps
• N V
• Confusion
• Coma

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Schizophrenia Stages

• Stage IV Residual
• Periods of remissions exacerbations
• Similar to Prodromal phase
• Social withdrawal
• Flat affect
• Impaired Role Performance

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Schizophrenia Types

• Disorganized (Hebephrenic)
• Onset before age 25
• Chronic flat, inappropriate affect
• Silliness, giggling, masturbating in public
• Bizarre behavior
• Facial grimacing mannerisms
• Impaired social interaction
• ? Contact with reality
• Incoherent speech concrete thinking

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Schizophrenia Types

• Catatonic
• Least common
• Sudden onset good prognosis
• Catatonic Excitement
• Extreme psychomotor agitation
• Purposeless movements Echopraxia
• ? risk of injury to self/others
• Continuous incoherent shouting - Echolalia
• Catatonic Stupor
• Extreme psychomotor retardation
• Mute Waxy Flexibility (Bizarre posturing)

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Schizophrenia Types

• Paranoid
• Preoccupied - 1 or more delusions
• Persecution or Grandeur
• Related auditory hallucinations
• Argumentative
• Hostile
• Aggressive
• Tense
• Suspicious
• Hypervigilent

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Schizophrenia Types

• Undifferentiated Chronic
• Disorganized-bizarre behavior
• Usually docile and not aggressive
• Does not meet criteria of other subtypes
• Delusions Hallucinations are prominent

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Schizophrenia Types

• Residual (Pseudo-neurotic)
• Follows an acute episode
• Absence of prominent symptoms
• No delusions or hallucinations
• Social isolation
• Poor Grooming
• Eccentric behavior
• Emotional Blunting

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Schizophrenia Types

• Schizoaffective Disorder
• 2 week period of predominant psychotic episode (?
  incidence in women)
• Delusions Hallucinations
• Disorganized behavior
• ? Sexuality Racing thoughts
• Mood Disorder (affective) behaviors
• Mania Euphoria
• Grandiosity Hyperactivity
• Depression
• Psychomotor retardation suicidal ideation
• ?? Occupational social functioning

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Characteristics

• Positive
• Excess or distorted inappropriate behaviors
• Disorganized thinking
• Not seen in mentally healthy adults!
• Negative
• Loss or decrease of appropriate function
• Diminished emotional expression
• Anhedonia
• Apathy
• Poverty of thoughts

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Charcteristics

• Positive
• Delusions
• Hallucinations
• Catatonic Excitement
• Echopraxia
• Echolalia
• Neologisms
• Associative Looseness
• Religiosity
• Paranoia

• Negative
• Concrete thinking
• Symbolism
• Catatonic Stupor
• Social withdrawal
• Poverty of speech
• Flat affect
• Anhedonia
• Depersonalization

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Assessment

• Mental Status Exam (Provides baseline data)
• Appearance General Health
• Dress Grooming Facial
  Expression
• Eye Contact Motor Behavior Posture
• Speech
• Pace Spontaneity Volume
• Tone Modulation Clarity Interruptions
• Level of Consciousness
• General Responsiveness Sensorium
• Emotional State
• Mood Affect Intensity Appropriateness
• Cognitive Function
• Thought Process Content Perceptions
• Concentration Abstract Thinking Insight/Judgment

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Nursing Interventions

• Primary Goal Patient Safety
• Establish trust listen closely
• Accepting attitude Keep promises
• Calm approach non-threatening environment
• Prevent violence ? Anxiety
• Clarify reinforce reality
• Orient to here now
• Address physical needs
• ? Self esteem

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Psychotic Symptom Interventions

• Delusions
• Accept experience, identify content triggers
• Encourage reality oriented conversation
• Use distraction refocus
• Role model coping techniques to ? anxiety
• Hallucinations
• Focus on the behavioral cue
• (laughing, talking, turning head)
• Have Pt describe what is happening
• Identify environmental emotional triggers
• To prevent aggressive responses
• Avoid touching without 1st warning

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Psychotic Symptom Interventions

• Impaired Communication
• Role model clear communication
• Use simple, concrete statements
• Seek clarification validate content
• Vebalize the implied
• Paranoia
• ? Environmental stimulation
• Maintain eye contact
• Provide plenty of personal space
• Always announce your presence
• ? Impulsivity
• Time Outs for rest

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Psychotic Symptom Interventions

• Ritualism
• Initiate conversation as ritual is performed
• Assess for behavioral cues indicating ? anxiety
• Negotiate a schedule for ritual ADLs
• Social Withdrawal
• Convey nonverbal acceptance worthiness
• Provide brief frequent 11 contacts
• Initiate interaction gradually expand social
  contacts
• ? Social skills training Rules expectations
• Cognitive Therapy ?
  Decision making
• Regression
• RN approaches Pt.
• ? Self-Esteem and encourage independent
  behavior

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Antipsychotic (Neuroleptic) Meds

• Major Tranquilizers
• ?? Protein Binding (91-99)
• ? Efficacy in men (1/3 relapse 1/3 disabled)
• Potency
• High
• Fluphenazine (Prolixin) Decanoate IM q3 weeks
• Haloperidol (Haldol) Decanoate IM q4 weeks
• Trifluroperazine (Stelazine)
• Low
• Chlorpromazine (Thorazine) 1st drug 1950
• Thioridazine (Mellaril)

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Antipsychotic (Neuroleptic) Meds

• Action
• ? Agitation ? Psychotic Symptoms
• ? Behaviors (Delusions/Hallucinations)
• Block DA receptors ? DA
• Improves fine motor movement coordination
• Sensory integration emotional behavior
• Anticholinergic Effects (Autonomic NS)
• Dry Mouth Blurred vision
  Constipation
• Sedation Urinary Retention
  Photophobia
• Orthostatic Hypotension Nasal Congestion

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Antipsychotic (Neuroleptic) Meds

• ?? Prolactin Levels
• Sexual/Menstrual dysfunction
• ? Libido
• Galactorrhea
• Gynecomastia
• ? weight gain
• Cognition
• ? Alertness ? Concentration
• ? Seizure threshold ? Risk of seizures

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Antipsychotic (Neuroleptic) Meds

• ExtraPyramidal Side Effects (EPS)
• ?? DA ?? AcH Imbalance
• ?? Incidence with ?? potency meds
• Prolixin, Haldol Stelazine
• Movement disorder
• Dystonia
• Pseudoparkinsonism
• Akathesia
• Tardive Dyskinesia

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ExtraPyramidal Side Effects (EPS)

• Dystonia
• Quick onset 1st few hours or days
• ? Adolescent males lt age 25
• Acute spasms of tongue, face, neck back
• Hypertonia
• Laryngospasm Respiratory distress
• Oculogyric Crisis- Rolling back of eyes
• Torticolis- Head twisted to 1 side
• Involuntary uncoordinated movements

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ExtraPyramidal Side Effects (EPS)

• Pseudoparkinsonism
• Appears within 1-5 days
• ? women older Pts
• Drooling, Pill-Rolling of thumb finger
• Mask-like face, Stooped Posture
• Action Tremors
• Shuffling gait with small steps
• Muscle rigidity
• Bradykinesia
• Cogwheeling

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ExtraPyramidal Side Effects (EPS)

• Akathesia
• Appears 50-60 days
• Motor restlessness Nervous Energy
• Jitteriness
• Tapping feet constantly
• Pacing
• Rocking back forth
• Frequent position changes

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ExtraPyramidal Side Effects (EPS)

• Tardive Dyskinesia
• Slow insideous process
• Irreversible after several years of meds.
• Involuntary movements of
• Limbs, trunk face.
• Bizarre facial movements
• Fly catching with tongue
• Lip smacking
• Difficulty swallowing
• Irregular respirations

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Neuroleptic Malignant Syndrome NMS

• Rare idiosyncratic reaction 1 young men
• ? Incidence with ?? potency meds ?? DA
• Abrupt onset rapid progression
• 10 mortality rate
• Signs
• Severe muscle rigidity Hyperreflexia (4)
• Hyperthermia gt 105 Diaphoresis
• Altered LOC ? Stupor ? Coma
• ?? HR ?? RR
• CV Collapse Respiratory failure Fatal!

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NMS Therapy

• Immediately D/C med
• Wait 2 weeks before starting new meds (Lithium)
• NO Haldol or Thorazine
• Cooling blanket O2 IV Fluids
• MSO4 (Morphine sulfate)
• ? pain ? VS
• Tylenol
• ? Temp and pain
• Dantrolene (Dantrium)
• muscle relaxant ? Temp
• Bromocriptine (Parlodel)
• Dopaminergic ? EPS toxicity

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Atypical Medications

• Relieves () (-) Behaviors
• ? EPS ? Prolactin
• Clozapine (Clozaril)
• Binds to 5-HT2, Alpha1,2, H1, DA recptors
• SE- National registry to monitor SEs!
• Agranulocytosis
• WBC lt 3000 or ANC lt 500 D/C med!
• Mandatory weekly CBC 1st 6 months
• Then q other week
• Drowsiness ?Salivation ?Dizziness
• ? HR ?Weight
• ? Risk for IDDM Prolonged QT interval

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Atypical Medications

• Risperidone (Risperdal)
• ?? DA ? 5-HT ACh NE
• Readily absorbed
• Active metabolite is clinically effective
• SE
• Sedation/Insomnia
• Orthostatic Hypotension
• ?? Appetite
• Tardive Dyskinesia

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Atypical Medications

• Olanzapine (Zyprexia)
• Antagonizes DA 5-HT receptors
• Binds to Histamine
• Quetiapine (Seroquel)
• v renal function
• v EKG for prolonged QT wave
• Ziprasidone (Geodon)
• DA 5-HT receptor antagonists
• ? Depression Anxiety

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Medication Administration

• Schedule
• Initially take meds in divided doses 2-4x/day
• Non-compliant Pts
• Haldol decanoate IM q 4 weeks
• Prolixin decanoate IM q 3 weeks
• Efficacy
• Takes 1- 4 weeks for significant response
• Once symptoms are controlled ? HS ?? SE
• Dosage
• Use lowest dosage to ? Tardive Dyskinesia

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Medication Administration

• Antiparkinson Meds
• Give to counteract SE toxic effects
• Only given with documented S/S of EPS
• Restore the balance of DA Ach
• ??DA ??ACh
• Amantadine (Symmetrel) Benzotropine (Cogentin)
• Bromocriptine (Parlodel) Trihexyphenidyl
  (Artane)
• Biperiden (Akineton)
• Procyclidine (Kemadrin)

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Patient Teaching

• Medication
• Generic trade name, dose, action SE
• Assess SE How is medication working?
• Interventions when to notify RN/MD
• Carry card with Med ID
• NO ETOH or illegal substances
• Dont stop taking drug abruptly
• Dont ? position rapidly

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Patient Outcome Evaluation

• Slow progress
• Services are needed long-term (decades)
• Set small achievable, short-term goals
• Assess effective coping skills
• Obtain Pt family input
• Pt. safety Communication skills
• Social Skills Self-Esteem
• Medication compliance
• Support system
• Living in least restrictive setting