Schizophrenia

1
Schizophrenia Other Psychotic Disorders

• Impact of Schizophrenia
• Psychosis
• Predisposing Factors
• Precipitating Stressors
• Behavioral Strategies
• Nursing Care

2
Impact of Schizophrenia

• 1 in every 100 people suffers from schizophrenia.
• 2.5 million Americans suffer from schizophrenia.
• 3 out of 4 cases begins between ages 17 and 25
  years.
• Of those with schizophrenia, 95 have the
  disorder for their life time.
• Annual cost of expenditures as the result of
  schizophrenia in the US is 40 billion dollars.
• One-third to one-half of homeless persons in the
  US have schizophrenia.

3
Impact of Schizophrenia, continued

• More than 75 of taxpayer dollars spent on mental
  illness are spent on schizophrenia.
• Persons with schizophrenia occupy 25 of all
  inpatient hospital beds.
• Schizophrenia is ranked 4th worldwide in terms of
  burden illness.
• Suicide is attempted by 20 to 50 of persons
  with schizophrenia, 9 to 13 succeed.

4
Schizophrenia is a chronic disorder

• 5 X more common than multiple sclerosis
• 6 X more common than insulin-dependent diabetes
• 60 X more common than muscular dystrophy
• 80 X more common than Huntingtons disease

5
Psychosis

• Mental state different from the reality of
  others.
• During an episode the person does not realize
  others are not experiencing the same things and
  wonders why others are not reacting in a similar
  manner.
• Overall goals for nursing care are to try to
  understand, protect and support the patient
  through the acute psychosis.
• When the persons symptoms have subsided, nurses
  help persons recognize psychosis and develop
  strategies to manage symptoms.
  

6
Persons who Experience Psychosis

• Often frightened by their experiences.
• Have difficulty forming close relationships.
• Are severely disabled.
• Alienated by society.

7
Understanding Psychosis

• My name is John Nash! Im being held against
  my will! Someone call the Department of
  Defense!
• Russell Crowes character in
• A Beautiful Mind
• (2001)

8
Bleulers Fundamental Symptoms

• Autism detachment from external reality and
  withdrawal into self
• Associative disturbance thought disorder
• Ambivalence simultaneous existence of opposing
  feelings, thoughts and desires
• Affective disorder flat or blunted affect or
  affect inappropriate or incongruous to the
  thought or situation

9
Characteristic Symptoms of Schizophrenia

• Diagnostic Statistical Manual of Mental
  Disorders (DSM-IV-TR) (2000)
• ________________________________
• Positive Symptoms Reflect an excess or
  distortion of normal functions. Usually
  responsive to antipsychotic medications
• Negative Symptoms Reflect a diminution or loss
  of normal functions. Usually unresponsive to
  traditional antipsychotic medications and more
  responsive to atypical antipsychotic medications

10
Positive Symptoms

• Psychotic Disorders of Thinking
• Delusions Paranoid, somatic, grandiose,
  religious, nihilistic, or persecutory themes
  thought insertion, thought broadcasting, or
  control.
• Hallucinations Auditory, Visual, Tactile,
  Gustatory. Olfactory.

11
Positive Symptoms, continued

• Disorganization of Speech Behavior
• Positive Thought Disorder Incoherence, word
  salad, derailment, illogicality, loose
  associations, tangentiality, circumstantiality,
  pressure speech, distractible speech, or poverty
  of speech
• Bizarre Behavior Catatonia, movement disorders,
  deterioration of social behavior

12
Negative Symptoms

• Problems of Emotion
• Affective flattening Limited range and intensity
  of emotional expression.
• Anhedonia Inability to experience pleasure or
  maintain social contacts.

13
Negative Symptoms, continued

• Impaired Decision Making
• Alogia Restricted thought or speech
• Avolition/Apathy Lack of initiation of
  goal-directed behavior
• Attentional impairment Inability to mentally
  focus and sustain attention

14
Problems in Cognitive Functioning

• Memory
• Attention
• Form and Organization of Speech (Formal Thought
  Disorder)
• Decision Making
• Thought Content

15
Neurological Soft Signs Prefrontal Cortical
Dysfunction in Schizophrenia

• Inability to recognize objects by the sense of
  touch (i.e., Astereognosis).
• Inability to recognize numbers or letters traced
  on the skin (i.e., Agraphesthesia).
• Impairment of the ability to perform smooth
  alternating movements (i.e., Dysdiadochokinesia).
• Mild muscle twitches, choriform and ticlike
  movements, grimacing.
• Impaired fine motor skills abnormal motor tone
• Increased rate of eye blinking.
• Abnormal smooth pursuit eye movements (SPEM).

16
Predisposing Factors

• Biological
• Genetics
• Neurobiology
• Imaging Studies (CT and MRI)
• Neurotransmitter Studies
• Neurodevelopment
• Viral Theories

17
Genetic Risk for Schizophrenia

• Person at Risk
  Risk ()
• Monozygotic (identical) twin 50
• Dizygotic (fraternal) twin 15
• Sibling
  10
• One parent affected 15
• Both parents affected 35
• Second-degree relative affected 2-3
• No affected relative 1

18
Predisposing Factors, continued

• Psychological
• Sociocultural
• Environmental

19
Precipitating Factors

• Biological
• Information-processing overload Slow down in
  the transmissions to the frontal lobe.
• Abnormal gaiting mechanisms Gaiting is an
  electrical process involving electrolytes. It
  refers to inhibitory and excitatory nerve action
  potentials and the feedback occurring within the
  nervous system related to completed nerve
  transmissions. Decreased gaiting is demonstrated
  by a persons inability to selectively attend to
  stimuli.

20
Coping Resources Mechanisms

• Personal Coping Skills Difficulty internalizing
  and need to be taught.
• Family Resources Family understanding of the
  illness, finances, availability of time and
  ability to provide ongoing support influence the
  course of the illness.
• Supportive Caregivers Professional
  Non-professional.

21
Subtypes of Schizophrenia (page 627)

• Paranoid Type Preoccupied with one or more
  delusion.
• Disorganized Type Disorganized speech and
  behavior, poor attention, inappropriate affect.
• Catatonic Type Waxy flexibility or purposeless
  excessive motor activity, mutism.
• Undifferentiated Type.
• Residual Type Negative symptoms.

22
Other Psychotic Disorders (page 621)

• Schizoaffective disorder Schizophrenic symptoms
  are dominant major manic or depressive
  symptoms.
• Delusional disorder Delusions are non-bizarre
  but functioning is not impaired outside of the
  delusion. No other symptoms of schizophrenia.
• Brief psychotic disorder Psychosis lasts for
  more than 1 day but less than 1 month.
• Schizophreniform disorder Symptoms are the same
  as schizophrenia but of shorter duration, at
  least 1 month but less than 6 months.

23
Nursing Diagnoses

• Anxiety
• Body image, Disturbed
• Communication, Impaired verbal
• Sensory perception, Disturbed
• Social interaction, Impaired
• Thought processes, Disturbed

24
Nursing Interventions for People with Psychosis

• Anxiety
• Depression
• Problems with cause-and-effect reasoning
• Difficulty with the passage of time

25
Nursing Interventions for People with Psychosis

• Concrete thinking
• Difficulty telling background from foreground
  information
• Slowed information processing
• Difficulty screening information to share

26
Nursing Interventions for People with Psychosis

• Communication difficulties
• Use active listening to understand the patient
• Clarify what the patient is trying to tell you
• Listen for the theme
• Use the literal meaning of words
• Have patient repeat back what was heard

27
Nursing Interventions for People with Psychosis

• Perception and interpretation of stimuli
  difficulties
• Review problematic situations with the patient.
• Help patient reality test and reframe problematic
  interpretations
• Reinforce positive and productive processes

28
Nursing Interventions for People with Psychosis

• Poor attention span and difficulty completing
  tasks
• Help break tasks into small sequential steps.
• Help the patient keep focused on a single task, a
  step at a time
• Give directions to patient one step at a time
• Do not emphasize completing the task.

29
Nursing Interventions for People with Psychosis

• Inappropriate social behaviors
• Identify the patients thought processes.
• Ask patient about the behavior.
• Help correct inaccurate perceptions.
• Help patient identify undesirable outcomes of
  behaviors.
• Teach appropriate social skills.

30
Nursing Strategies for Working With Patients with
Delusions

• Assess the Intensity, Frequency, and Duration of
  the delusion
• Listen quietly until there is no need to discuss
  the delusion.
• Fleeting delusions can be worked out in a short
  time frame.
• Fixed delusions, endured over time, may have to
  be temporarily avoided to prevent them from
  becoming stumbling blocks in the relationship.

31
Levels of Intensity of Hallucinations

• Stage I Comforting
• Moderate level of anxiety Nonpsychotic
• Stage II Condemning
• Severe level of anxiety Mild psychotic
• Stage III Controlling
• Severe level of anxiety Psychotic
• Stage IV Conquering
• Panic level of anxiety Severely psychotic

32
Nursing Interventions for Working with Patients
who have Hallucinations

• Establish a trusting, interpersonal relationship.
• Assess the symptoms of hallucinations including
  duration, intensity, and frequency.
• Focus on the symptom and ask the patient to
  describe what is happening.
• If asked, point out simply that you are not
  experiencing the same stimuli.

33
Issues Related to Schizophrenia

• Depression A symptom masked during the acute
  phase.
• Relapse Stressors, nonadherence with
  medications.
• Stress coping skills.
• Substance abuse 30 have dual diagnoses which
  may have a negative effect on treatment,
  resulting poor outcomes.
• Lack of meaningful work

34
Nursing interventions in the therapeutic milieu

• Provide safety for the patient and others.
• Intervene early if there is escalating behavior.
• Use the least restrictive intervention.
• Give clear and set realistic limits.
• Be consistent.
• Provide A supportive environment structured,
  predictable.
• Reduce environmental stimuli (Low stimuli
  environment).
• Schedule opportunities for nonthreatening social
  interactions.
• Encourage socialization as tolerated.

35
Family Education Plan

• Involve family
• Describe psychosis, identify theories of
  psychotic disorders.
• Define schizophrenia according to symptoms and
  diagnostic criteria.
• Analyze the impact of living with delusions
  hallucinations.
• Discuss ways to cope adaptively with psychosis.

36
Cognitive-Behavioral Therapy (CBT)

• CBT has been used successfully to treat
  persistent hallucinations and delusions as an
  adjunct to medications.
• CBT treatment has shown to be effective in
  patients with schizophrenia who were resistant to
  medications

37
Case Management

• Short hospital stays due to third party payment
  system.
• Discharge planning Multidisciplinary team
  planning.
• Transitional Care Partial hospitalization,
  halfway houses, day treatment programs, etc.
• Places to live after hospitalization Return to
  home, residential care facilities, etc.
• Community Resources Advocacy NAMI,
  Schizophrenics Anonymous, etc.

38
The Role of the Nurse

• Multidisciplinary Team Member
• Basic Level Baccalaureate Degree RN
• Advanced Practice Registered Nurse (APRN) MSN,
  DNSc, PhD

39
The Clinicians Experience

• Psychotic patients anxiety, confusion,
  disturbances in logic and reality testing and
  misperceptions may lead to discomfort.
• Sometimes when a person is struggling with
  psychosis, they are cooperative but frightened.
  It goes a long way to simply reassure them that
  they are in a safe environment.

40
The Clinicians Experience, continued

• Especially if such patients are disorganized as
  well as frightened, it is helpful to tell them
  what is happening, ask them to bring up any
  questions they may have, and structure the
  interview.
• Nurses feelings of helplessness can result in
  withdrawal and avoidance.
• Seek peer group supervision and support.