12 - Schizophrenia

SCHIZOPHRENIA and SCHIZOPHRENIC LIKE DISORDERS Schizophrenia--it is not defined as a single illness; rather, it is a syndrome with many varieties of symptoms -Schizophrenia is considered the most common and disabling of the psychotic disorders. -it is considered a chronic syndrome that typically follows a deteriorating course over time -schizophrenia impairs self-awareness for many individuals so that they do not realize they are ill and in need of treatment -schizophrenia has been linked to violence HISTORY OF SCHIZOPHRENIA -written descriptions of schizophrenia have been traced back to Egypt during the year 200 BC -it came from the two Greek words: schizo= split phrene= mind -at that time, mental illness were regarded as symptoms of the heart and the uterus and thought to originate from blood vessels, fecal matter, a poison or demons -By 18 century, it was decided that disorders of the CNS were the cause of insanity Emil Kraepelin-he first described schizophrenia as a specific mental illness in 1887 Eugene Bleuler -a Swiss psychiatrist who coined the term schizophrenia in 1911 -he was the first to describe the positive and negative symptoms of schizophrenia -Both of them subdivided schizophrenia into 3 categories based on prominent symptoms 1. Disorganized
th

2. Catatonic 3. Paranoid -the DSM-IV-TR lists 5 classifications: (additional 2) 4. Residual 5. Undifferentiated Nice to know -The National Institute for Mental Health has given highest priority to training, research and education about schizophrenia and schizophrenic-like disorders Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) -A three-phased 18-month study which included nearly 1, 500 subjects -During the study, researchers compared the efficacy of the newer atypical antipsychotics with each other and with a typical first-generation antipsychotic -Shizophrenia is more prevalent in men than in women -Approximately 75% of persons diagnosed with schizophrenia develop the clinical symptoms between 16-25 years old -Approximately 1% of the earths population suffers from schizophrenia Clinical Course Onset-may be abrupt but most clients slowly and gradually develop signs and symptoms Immediate course -in the years immediately after the onset of psychotic symptoms, 2 typical clinical patterns emerge: 1.) Client experiences ongoing psychosis and never fully recovers

12 - Schizophrenia
2.) Client experiences episodes of psychotic symptoms that alternate with episodes of complete recovery from psychosis Long-term course -intensity of psychosis tends to diminish with age -clients regain some degree of social and occupational functioning -over time, the disease becomes less disruptive Delusions Clinical symptoms and Diagnostic Characteristics Hallucinations -symptoms of schizophrenia may appear suddenly or develop gradually 5 phases of schizophrenia: a.) Premorbid phase no clinical symptoms of schizophrenia are expressed b.) Prodromal/Beginning gradual, subtle behavioral changes appear (inability to concentrate, insomnia, cognitive deficits) c.) Onset phase behavioral changes worsen d.) Progressive phase once the symptoms of schizophrenia manifests -clients may recover from 1 episode and experience repeated relapses e.) Chronic or residual phase client has experienced repeated episodes and relapses for a number of years Dementia praecox (Emil Kreapelin, 1896) a syndrome characterized by hallucinations and delusions Bleulers 4As: -Affective disturbance -Autistic thinking -Ambivalence
st

-Looseness of association Clinical symptoms fall into 3 broad categories: 1. Positive symptoms (symptoms that normal people do not exhibit) -reflect the presence of overt psychotic or distorted behavior -possibly caused by increased amount of dopamine

Excitement or agitation Bizarre dress or behavior Possible suicidal tendencies Hostility or aggressive behavior 2. Negative symptoms (absence of those that normal person exhibit)

-reflect loss of normal functions (affect, motivation, ability to enjoy activities) -are thought to result from cerebral atrophy or inadequate amount of dopamine Anergia (lack of energy) Anhedonia (lack of pleasure or interest) Emotional withdrawal, social withdrawal Poor eye contact Blunt affect or flat effect Dysfunctional relationship with others 3. Disorganized symptoms Incoherent speech Disorganized speech

12 - Schizophrenia
Repetitive rhythmic gestures Cognitive deficits/confusion Attention deficits 2 Diagnostic Categories: Type I Schizophrenia - onset of positive symptoms is acute -symptoms generally respond to typical neuroleptic medication -better prognosis than type II (normal brain structure, absence of intellectual deficits) Type II Schizophrenia -characterized by slow, onset of negative symptoms -The following symptoms are prominent: -caused by viral infection -disorganized speech -response to typical neuroleptics is minimal -flight of ideas -intellectual decay occurs -word salad -enlarged ventricles are present -circumstantiality 5 Subtypes of Schizophrenia: -neologisms 1. Paranoid type -disorganized behavior -Clients tend to experience: -delusions (persecutory) -hallucinations (auditory) -behavioral changes (anger, hostility or violent behavior) -prognosis is more favorable for this subtype than for the other subtypes -None of the following is prominent: -disorganized speech -catatonic behavior -flat or inappropriate affect -Odd behavior, delusion, hallucinations and incoherence may occur. -lack of attention to personal hygiene and grooming -flat or inappropriate affect 4. Undifferentiated Type -It is usually characterized by atypical symptoms that do not meet the criteria for the subtypes of paranoid, catatonic and disorganized. -Client may exhibit both positive and negative symptoms. 2. Catatonic type 2 most prominent features: -waxy flexibility -mutism Other features: -echolalia -echopraxia -Purposeless movements of hands and feet 3. Disorganized type -Clinical symptoms of this type are considered the most severe of all subtypes (poor prognosis)

12 - Schizophrenia
-Student nurse may feel uncomfortable or fearful to client having undifferentiated schizophrenia. -The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. -In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome. -Shows signs of schizophrenia, but doesnt fit into the above categories 5. Residual Type -It is use to describe clients experiencing negative symptoms following at least one acute episode of schizophrenia. -Clinical symptoms may persist over time, or the client may experience a complete remission. Positive symptoms- aggression, talkativeness/manic Negative symptoms- withdrawal Schizophrenic like Disorders DSM-IV-TR lists 5 Subtypes: 1. Schizoaffective disorder -Characterized by an uninterrupted period of illness which, at some time, the client experiences a major depressive, manic, or mixed episode along with the negative symptoms of schizophrenia. -In the absence of prominent mood symptoms, the individual exhibits delusions or hallucinations for at least 2 weeks. Symptoms of schizoaffective disorder may include: Depression Poor appetite -Treatment consists of both pharmacotherapy and psychotherapy 2. Schizophreniform Disorder -Characterized by a client who exhibits features of schizophrenia for more than 1 month but fewer than 6 months. -Impaired social or occupational functioning does not necessarily occur. The most common symptoms are: Delusions Hallucinations Catatonic behavior Weight loss or gain Changes in sleeping patterns (sleeping very little or a lot) Agitation (excessive restlessness) Lack of energy Loss of interest in usual activities Feelings of worthlessness or hopelessness Guilt or self-blame Inability to think or concentrate Thoughts of death or suicide

Clinical Considerations of Schizoaffective Disorder -Men with schizoaffective disorder tend to exhibit antisocial personality traits -The age of onset is later for women than for men, and the exact etiology and epidemiology is unclear because of limited research in this area -Patients with schizoaffective disorder are thought to have a better prognosis than that of patients with schizophrenia

12 - Schizophrenia
Social withdrawal Disorganized speech Other symptoms may include: lack of energy, poor hygiene, apathy, etc. These are all very similar to schizophrenia, but they will disappear spontaneously after 1-2 months (but less than 6 months). Theories Genetic Predisposition Theory -This theory suggests that the risk of inheriting schizophrenia is 10% to 20% in those who have one immediate family member with the disease, and approximately 40% if the disease affects both parents and an identical twin. -The first true etiologic type of schizophrenia, the consequence of chromosome deletion referred to as 22q1 deletion syndrome has been identified. Persons with this syndrome have a distinct facial appearance, abnormalities of the palate, heart defects and immunologic deficits. Biochemical and Neurostructural Theory -This theory includes dopamine hypothesis where in an excessive amount of neurotransmitter dopamine allows nerve impulses to bombard the mesolimbic pathway. -Normal cell communication is disrupted, resulting in the development of hallucinations and delusions. -Other neurotransmitters or chemicals in the brain are also being studied. -Abnormalities of neurocircuitry or signals from neurons are being researches as well. Supposedly, a neuronal circuit filters information entering the brain and sends relevant information to other parts of the brain for determining action. -Cognitive deficits, impairments of attention and executive function, and certain types of memory deficits may be the result of abnormal circuitry Organic or Pathophysiologic Theory Environmental or cultural influences Perinatal influences Psychological stress Organic or pathophysiologic changes of the brain

3. Brief Psychotic Disorder -It is a disturbance that involves the sudden onset of at least one of the positive symptoms of psychosis such as hallucinations, delusions, disorganized speech, or grossly disorganized or catatonic behavior. -Disturbance occurs for at least 1 day but less than 1 month. 4. Psychotic disorder due to general medical condition -This diagnosis used to describe the presence of prominent hallucinations or delusions determined as resulting from the direct physiologic effects of a specific medical condition. 5. Shared Psychotic Disorder -Occurs when 2 individual who have a close relationship share the same delusion. -The individual who has psychotic disorder with prominent delusions is referred to as dominant (primary case or inducer). -The individual who is usually passive and initially healthy, but begins to believe the inducer, is referred to as submissive (secondary case).

Etiology: Genetic predisposition Biochemical and neurostructural changes in the brain

12 - Schizophrenia
-Schizophrenia is a functional deficit occurring in the brain, caused by stressors such as viral infection, toxins, trauma, or abnormal substances. They also propose that schizophrenia may be a metabolic disorder. Environmental or Cultural Theory -According to this theory, the person who develops schizophrenia has a faulty reaction to the environment, being unable to respond selectively to numerous social stimuli. -Theorists also believe that persons who come from low socio-economic areas or single-parent homes in deprived areas are not exposed to situations in which they can achieve or become successful in life. Perinatal Theory -Experts suggest that the risk for schizophrenia exists if developing fetus or newborn is deprived of oxygen during pregnancy or if the mother suffers from malnutrition or starvation during the first trimester of pregnancy. Psychological or Experiential Theory -Individuals with schizophrenia experience stress when family members and acquaintances respond negatively to the individuals emotional needs. -Stressors that have been thought to contribute to onset of schizophrenia include poor mother-child relationships, deeply disturbed family interpersonal relationships, impaired sexual identity and body image, rigid concept of reality and repeated exposure to double-blind situations. A double-blind situation is a no-win experience, one in which there is no correct choice. Nursing Process Assessment -Schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning; however, it affects each individual differently. General Appearance -Appearance may vary widely among different clients. -Some appear normal -Some exhibits odd or bizarre behavior Motor Behavior -Catatonia or appear unmoving -Echopraxia -Psychomotor retardation (slowing of all movements) Speech -Word Salad (jumbled words and phrases that are incoherent and makes no sense) -Echolalia (repetition or imitation of what someone else says) Latency of response refers to hesitation before the client responds to questions which may last 30 or 45 seconds and usually indicates the clients difficulty with cognition or thought processes. Mood and Affect -Flat affect (no facial expressions) -Blunted affect (few observable facial expressions) -Laughing for no apparent reason -Inappropriate expression or emotions for the situation -Feels depress and have no pleasure or joy in life (anhedonia) Thought Process and Content -Thought processes become disordered, and the continuity of thoughts and information processing is disrupted.

12 - Schizophrenia
-Client may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking) -State that others can hear their thoughts (thought broadcasting) -Others are taking their thoughts (thought withdrawal) -Others placing thoughts in their mind against their will (thought insertion) -May exhibits tangential thinking, which is veering onto unrelated topics and never answering the original question -Circumstantiality -Poverty of content (alogia) -Insight can be severely impaired, especially early in the illness. Self-Concept -Loss of ego boundaries -Ideas of reference Roles and Relationship -Social isolation -May experience great frustration in attempting to fulfill roles in the family and community. Physiologic and Self-Care Considerations -May have self-care deficits. -Inattention to hygiene and grooming needs is common -Fail to recognized sensations such as hunger or thirst, and food or fluid intake may be inadequate -Paranoia or excessive fears that good and fluids have been poisoned Outcome Identification Acute, psychotic phase of treatment are as follows: 1. 2. -Cenesthetic -Kinesthetic 4. 3. The client will not injure self or others. The client will establish contact with reality. The client will interact with others in the environment. The client will express thoughts and feelings in a safe and socially acceptable manner. The client will participate in prescribed therapeutic interventions

Delusions -Fixed, false beliefs with no basis in reality -Delusions of grandeurs Sensorium and Intellectual Processes -Hallucinations (false sensory perceptions, or perceptual experiences that do not exist in reality Types: -Auditory -Visual -Olfactory -Tactile

5. -Gustatory Judgment and Insight -Judgment is impaired because it is based on the ability to interpret the environment correctly. This may lead to meet their needs for safety and protection.

Continued care after the stabilization of acute symptoms is as follows: 1. The client will participate in the prescribed regimen.

12 - Schizophrenia
2. The client will maintain adequate routines for sleeping and food and fluid intakes. The client will demonstrate independence in self-care activities. The client will communicate effectively with others in the community to meet his or her needs The client will seek or accept assistance to meet his or her needs when indicated. Haloperidol (Haldol) Loxapine (Loxitane) 3. Molindone (Moban) Trifluoperazine (Stelazine) Atypical Antipsychotics Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Paliperidone (Invega) Aripiprazole (Abilify)
Common Side Effects Dystonic reactions

4.

5.

Intervention -Promoting the safety of client and others by approaching the client with nonthreatening manner. Observe for signs of building agitation or escalating behaviors. -Establishing a therapeutic relationship by gaining the trust of the patient and have a relaxed body posture and facial expressions that convey genuine interest and concern. -Using therapeutic communication by asking appropriate questions. -Coping with socially inappropriate behaviors by accompanying the patient and protecting his or her privacy and dignity. -Teaching client and family by telling the family the need for medications and follow-up. Medication Coventional Antipsychotics Chlorpromazine (Thorazine) Perphenazine (Trilafon)

Tardive dyskinesia Neuroleptic malignant syndrome Akathisia EPS or neuroleptic-induced parkinsonism Seizures Sedation Photosensitivity Weight gain Anticholinergic symptoms Dry mouth

Fluphenazine (Prolixin)
Blurred vision

Thioridazine (Mellaril)
Constipation

Mesoridazine (Serentil)
Urinary retention

Thiothixene (Navene)

Orthostatic hypotension