Chapter 12 Schizophrenia and Schizophrenia Spectrum Disorders Copyright © 2014, 2010, 2006 by...

Chapter 12

Schizophrenia and Schizophrenia Spectrum Disorders

Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Lifetime prevalence of schizophrenia is 1% worldwide

No difference related to Race Social status Culture

Epidemiology

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Substance abuse disorders Nicotine dependence

Anxiety, depression, and suicide Physical health or illness Polydipsia

Comorbidity

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Biological factors Genetics

Neurobiological Dopamine theory Other neurochemical hypotheses

Brain structure abnormalities

Etiology

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Psychological and environmental factors Prenatal stressors Psychological stressors Environmental stressors

Etiology (Cont.)

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Prodromal Responses to treatment

Course of the Disorder

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Phase I – Acute Onset or exacerbation of symptoms

Phase II – Stabilization Symptoms diminishing Movement toward previous level of functioning

Phase III – Maintenance At or near baseline functioning

Phases of Schizophrenia

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During the prepsychotic phase General assessment

Positive symptoms Negative symptoms Cognitive symptoms Affective symptoms

Assessment

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Alterations in thinking Delusions − False, fixed beliefs Concrete thinking − Inability to think abstractly

Positive Symptoms

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Alterations in speech − Associative looseness Clang associations Word salad Neologisms Echolalia

Positive Symptoms (Cont.)

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Other disorders of thought or speech Religiosity Magical thinking Paranoia Circumstantiality Tangentiality Cognitive retardation

Positive Symptoms (Cont.)

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Other disorders of thought or speech (cont.) Alogia, or poverty of speech Flight of ideas Thought blocking Thought insertion Thought deletion

Positive Symptoms (Cont.)

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Alterations in perception Depersonalization Derealization Hallucinations

• Auditory • Command• Visual

Positive Symptoms (Cont.)

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Positive Symptoms (Cont.)

Catatonia Motor retardation Motor agitation Stereotyped behaviors Waxy flexibility

Echopraxia Negativism Impaired impulse

control Gesturing or posturing Boundary impairment

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Alterations in Behavior

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Affect Flat Blunted Inappropriate Bizarre

Negative Symptoms

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Difficulty with Attention Memory Information processing Cognitive flexibility Executive functions

Cognitive Symptoms

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Assessment for depression is crucial May herald impending relapse Increases substance abuse Increases suicide risk Further impairs functioning

Affective Symptoms

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A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?

A.Positive symptom

B.Negative symptom

C.Cognitive symptom

D.Depressive symptom

Question 1

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1. Any medical problems

2. Abuse of or dependence on alcohol or drugs

3. Risk to self or others

4. Command hallucinations

Assessment Guidelines

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You believe that the young man you are admitting to your unit is suffering from command hallucinations.

What would be some questions to ask him?

Case Study

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5. Delusions

6. Suicide risk

7. Ability to ensure self-safety

8. Medications

Assessment Guidelines (Cont.)

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9. Mental status examination

10.Patient’s insight into illness

11.Family’s knowledge of patient’s illness and symptoms

Assessment Guidelines (Cont.)

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Positive symptoms Disturbed sensory perception Risk for self-directed or other-directed violence Impaired verbal communication

Negative symptoms Social isolation Chronic low self-esteem

Potential Nursing Diagnoses

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Phase I − Acute Patient safety and medical stabilization

Phase II − Stabilization Help patient understand illness and treatment Stabilize medications Control or cope with symptoms

Phase III − Maintenance Maintain achievement Prevent relapse Achieve independence, satisfactory quality of life

Outcomes Identification

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After an acute admission, discharge is being planned for this patient.

What are some things that need to be considered?

Case Study (Cont.)

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Phase I – Acute Best strategies to ensure patient safety and provide

symptom stabilization Phase II – Stabilization Phase III – Maintenance

Provide patient and family education Relapse prevention skills are vital

Planning

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Acute Phase Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu Monitor fluid intake

Interventions

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Stabilization and Maintenance Phases Medication administration/adherence Relationships with trusted care providers Community-based therapeutic services

Interventions (Cont.)

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Counseling and communication techniques Hallucinations Delusions Associative looseness Health teaching and health promotion

Interventions (Cont.)

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Antipsychotic medications First-generation Second-generation Third-generation

Psychobiological Interventions

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Dopamine antagonists (D2 receptor antagonists) Target positive symptoms of schizophrenia Advantage

Less expensive than second generation Disadvantages

Extrapyramidal side effects (EPS) Anticholinergic side effects Tardive dyskinesia Weight gain, sexual dysfunction, endocrine

disturbances

First-Generation Antipsychotics

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Treat both positive and negative symptoms Minimal to no extrapyramidal side effects (EPS)

or tardive dyskinesia Disadvantage – tendency to cause significant

weight gain

Second-Generation Antipsychotics

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Aripiprazole (Abilify) Dopamine system stabilizer Improves positive and negative symptoms and

cognitive function Little risk of EPS or tardive dyskinesia

Third-Generation Antipsychotic

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Anticholinergic toxicity Neuroleptic malignant syndrome (NMS) Agranulocytosis

Potentially Dangerous Responses to Antipsychotics

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Antidepressants Mood stabilizing agents

Adjuncts to Antipsychotic Drug Therapy

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Individual and group therapy Psychoeducation Medication prescription and monitoring Basic health assessment Cognitive remediation Family therapy

Advanced Practice Interventions

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1. Loose associations in a person with schizophrenia indicate

A. paranoia.

B. mood instability.

C.depersonalization.

D.poorly organized thinking.

Audience Response Questions

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2. Which assessment finding represents a negative symptom of schizophrenia?

A. Apathy

B. Delusion

C.Motor tic

D.Hallucination

Audience Response Questions

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