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Schizophrenia History
19th CenturyKraepelin- Dementia Praecox
20th CenturyBleuler
autism-apathy-ambivalence-anhedonia
Arieti
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 women Early 20s age of first psychotic break 75% of people have permanent disability Cultural component on relapse Developing countries have better prognosis than
developed countries
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 medication
Type 1 positive symptoms respond to medication
Positive Symptoms
Delusions
Hallucinations
Disorganized speech
Bizarre or disorganized behavior
Negative Symptoms
Flat Affect
Avolition
Alogia
Anhedonia
Attention Impairment
History of Therapy
Psychoanalytic
Sullivan/Peplau
Interpersonal Communication
Somatic
Insulin Coma
Electroconvulsive Therapy
Psychosurgery
Psychopharmacology
1950s phenothiazines
1990s D1-D2 receptor medications
Community Mental Health
Milieu
Therapeutic Community
De-institutionalization
Typology of Thought Disorder
Paranoid
Catatonic
Disorganized
Undifferentiated
Residual
Paranoid
Delusions- especially persecutory
Auditory Hallucinations
No loose associations
No marked affective problem
Paranoid
Catatonic
Stupor or mutism
Negativism
Rigidity
Excitement
Posturing (waxy flexibility)
Disorganized
Marked looseness of associations
Grossly inappropriate affect
Disorganized
UndifferentiatedProminent delusions
Hallucinations or grossly disorganized behavior
Residual
Diagnosis
Presence of 1,2, or 3 for more than 1 week
1. Two of the following:
delusions, prominent
hallucinations, marked
associative looseness
catatonic behavior
flat or silly affect
2. Bizarre delusions
3. Prominent hallucinations
Continuous signs of disturbance ↑ 6 months
18 years if age or more
Downward 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 communication
poverty of speech
blunt emotions
Self-care deficits
Activity intolerance
Social isolation
Decisional conflict
Sensory alterations
Body image distortion
Altered thought processes
delusions, magical thinking
thought insertions, withdrawal
thought broadcasting
Altered emotional response
blunted or flat affect
anhedonia
Altered family function
Nursing Planning & Intervention
Adequate communication
Grooming & hygiene
Social skills
Intervene with delusions
Family understanding
Medication usage
Organize behavior
Reality based perceptions
Congruent emotional responses
Community contacts
Nursing Planning & Intervention
Adequate communication
Grooming & hygiene
Social skills
Intervene with delusions
Family understanding
Medication usage
Organize behavior
Reality based perceptions
Congruent emotional responses
Community contacts
Nursing Implications with Neuroleptic Medications
1. Phenothiazines
Thorazine(Chlorpromazine)
Mellaril (Thiorizidine)
Stelazine (Trifluoperazine)
Prolixin (Fluphenazine)
Prolixin Decanoate
2. Butyrophenes
Haldol (Haloperidol)
Haldol LA
3. Low potency D1-D2 medications
Clozaril (Clozapine)
Risperdol (Resperidone) & Risperdol E
Zyprexa (Olanzapine)
Abilify (Ariprazole) Geodon (Ziprasidone)
Side Effects
Nervous system Extra Pyramidal SymptomsAkathisiaDystoniaAkinesiaPseudo parkinsonismTardive dyskinesia
Tardive Dyskinesia
Other Side Effects
Photophobia
Leukocytosis
Orthostatic hypotension
Anti-cholinergic effects
D1 and D2 effects
Weight gain Impotence Risk for development of Diabetes Mellitus (Geodon) Gallactarhea
Neuroleptic malignant syndrome
Possibly fatal side effect of neuroleptics Non-dose related Fever Confusion Convulsions Death Rx-stop neuroleptic- emergency care
Amantadine 200-400 mgmpo/day in divided doses
Side Effect Treatment
Anti-parkinson medications:
Cogentin (Benztropine)
Artane (Trihexyphenidyl)
Symmetrel (Amantadine)
Atropine Psychosis
Mad as a hatter confused
Red as a beet fever
Dry as a bone anticholinergia
Blind as a bat diplopia
Rx. Hold medication and re-hydrate
Laboratory Values for Schizophrenia
White blood cell count Leukopenia (WBC 2,000 – 3,000)and agranulocytosis
(granulocytes less than 1,000) with certain psychotropic mendiations, such as phenothiazines , carbamazepine, and CLOZARIL
Leukocytosis with neuroleptic malignant syndrome
Assessment Tools for Schizophrenia
Abnormal Involuntary Movement Scale (AIMS) (public)
Brief Psychiatric Rating Scale (Psychological Reports, 1962 10:799)
Schedule for Affective Disorders and Schizophrenia (SADS) (Archives of General Psychiatry, 1978 35:837)
Scale for the Assessment of Negative Symptoms (SANS) (University of Iowa Press, 1983)
Scale for the Assessment of Thought, Language, and Communication (TLC) (University of Iowa Press, 1978)
Thought Disorder Index (TDI) (Archives of General Psychiatry, 1983 40:1281)
Quality of Life Scale (QLS) (Schizophrenia Bulletin, 1984, 10: 383
Chestnut Lodge Prognastic Scale for Chronic Schizophrenia (Schizophrenia Bulletin, 1987 13:277)