SCHIZOPHRENIA AND OTHER PSYCHOSIS DEFINITION: What is Schizophrenia?

Schizophrenia is a chronic and disabling brain disorder that has been recognized throughout recorded history. It affects about 1% of the population of the United States. Symptoms usually emerge for men in late teens to early 20s. In females mid 20s to early 30s. Many people with this disorder have difficulty holding a job or caring for them. This creates a great burden for their families and for society. a group of characteristic positive and negative symptoms deterioration in social, occupational, or interpersonal relationships continuous signs of the disturbance for at least 6 months There is not one essential symptom that must be present for a diagnosis. Instead, patients experience different combinations of the main symptoms of schizophrenia. Those with the disorder may hear voices that others dont hear. They may believe that others are reading their minds, controlling their thoughts, or plotting to harm them. They may not make sense when they talk or they may seem perfectly fine until they start talking about what they are really thinking.

3 inescapable facts about Schizophrenia: 1. Age at onset: It is always late adolescent or early adulthood. 2. Role of stress: Onset and relapse almost always related to stress. 3. Efficacy of dopamine antagonists: Drugs that block dopamine receptors are therapeutic. HISTORY Emil Kraepelin: This illness develops relatively early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia (Dementia praecox), but was not followed by any organic changes of the brain, detectable at that time. Eugen Bleuler: He renamed Kraepelins dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a splittingof mind. Kurt Schneider: He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of the first rank symptoms even in the concept of the diagnosis of schizophrenia. 4 A (BLEULER) Bleuler maintained, that for the diagnosis of schizophrenia are most important the following four fundamental symptoms: o affective blunting o disturbance of association (fragmented thinking) o autism o ambivalence (fragmented emotional response) These groups of symptoms, are called four As and Bleuler thought, that they are primary for this diagnosis. The other known symptoms, hallucinations, delusions, which are appearing in schizophrenia very often also, he used to call as a secondary symptoms, because they could be seen in any other psychotic disease, which are caused by quite different factors from intoxication to infection or other disease entities. COURSE OF ILLNESS Course of schizophrenia: Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

o continuous without temporary improvement o episodic with progressive or stable deficit o episodic with complete or incomplete remission 3 overlapping phases of the disorder: o Acute phase- the patient experiences severe psychotic symptoms. o Stabilizing phase- the patient is getting better. o Stable phase- in this phase, the patient might still experience hallucinations and delusions, but the hallucinations and delusions are not as severe nor as disabling as they were during the acute phase.

The symptoms of schizophrenia fall into three broad categories. 1. Positive Symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder and disorder of movement. Auditory hallucinations are the most common. Delusions False beliefs that are firmly and consistently held despite disconfirming evidence,culture or logic. Individuals with mania or delusional depression may also experience delusions. However, the delusions of patients with schizophrenia are often more bizarre (highly implausible). Types of delusions 1. Delusions of persecution: belief that one is the target of others mistreatment, evil plots, and/or murderous intent (most common) 2. Delusions of reference: belief that all happenings revolve around oneself, and/or one is always the center of attention 3. Delusions of grandeur: belief that one is a famous or powerful person from the past or present 4. Delusions of control: belief that some external force is trying to take control of ones thoughts (thought insertion), body, or behavior a. Example of delusions of control Thought insertion = Believing that thoughts that are not your own have been placed in your mind by an external source A 29-year-old housewife said, I look out of the window and I think the garden looks nice and the grass looks cool, but the thoughts of Eamonn Andrews come into my mind. There are no other thoughts there, only his He treats my mind like a screen and flashes his thoughts on it like you flash a picture. 5. Thought broadcasting: belief that ones thoughts are being broadcast or transmitted to others 6. Thought withdrawal: belief that ones thoughts are being removed from ones mind Hallucinations Sensory experiences in the absence of any stimulation from the environment Any sensory modality may be involved: auditory (hearing); visual (seeing); olfactory (smelling); tactile (feeling); gustatory (tasting) Auditory hallucinations are most common Common auditory hallucinations in schizophrenia 1. Hearing own thoughts spoken by another voice 2. Hearing voices that are arguing 3. Hearing voices commenting on ones own behavior Petit Ivy Mae B. Nacario Dean Lea Belen M. Santillan Bsn 3-1 Report: Schizophrenia & other Psychosis

Disorganized Speech / Thought Disturbances 1. Problems in organizing ideas and speaking so that a listener can understand 2. Loose Associations (cognitive slippage): continual shifting from topic to topic without any apparent or logical connection between thoughts 3. Neologisms: new, seemingly meaningless words that are formed by combining words Disorganized Motor Disturbances Extreme activity levels (unusually high or low), peculiar body movements or postures (e.g., catatonic schizophrenia), strange gestures and grimaces 2. Negative Symptoms refers to reductions in normal emotional and behavioral states such as: o Flat affect with immobile facial expression, monotonous voice. o Lack of pleasure in everyday life. o Diminished ability to initiate and sustain planned activity. o Speaking infrequently even when forced to interact o People with the disorder often neglect basic hygiene and need help with ADL. Types of negative symptoms 1. Anhedonia: inability to feel pleasure; lack of interest or enjoyment in activities or relationships 2. Avolition: inability or lack of energy to engage in routine (e.g., personal hygiene) and/or goal-directed (e.g., work, school) activities 3. Alogia: lack of meaningful speech, which may take several forms, including poverty of speech (reduced amount of speech) or poverty of content of speech (little information is conveyed; vague, repetitive) 4. Asociality: impairments in social relationships; few friends, poor social skills, little interest in being with other people 5. Flat affect: no stimulus can elicit an emotional response. Patient may stare vacantly, with lifeless eyes and expressionless face. Voice may be toneless. Flat affect refers only to outward expression, not necessarily internal experience. 3. Cognitive Symptoms are subtle and often detected only when neuropsychological test are performed. o Poor executive functioning. (The ability to absorb and interpret information and make decisions based on that information). o Inability to sustain attention. o Problems with working memory (the ability to keep recently learned information in mind and use it right away). BEHAVIOR OBJECTIVE SIGNS: 1. Alterations in personal relationships a. Decreased attention to appearance and social amenities related to introspection and autism b. Inadequate or inappropriate communication c. Hostility d. Withdrawal Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

2. Alterations of activity a. Psychomotor agitation b. Catatonic rigidity c. Echopraxia (repetitive movements) d. Stereotypy (repetitive acts or words) SUBJECTIVE SYMPTOMS 1. Altered perception a. Hallucination b. Illusions c. Paranoid thinking 2. Alterations of thought a. Loose associations b. Retardation c. Blocking d. Autism e. Ambivalence f. Delusions g. Poverty of speech h. Ideas of reference i. Mutism 3. Altered consciousness a. Confusion b. Incoherent speech c. Clouding d. Sense of going Crazy 4. Alterations of affect a. Inappropriate, blunted, flattened, or labile affect b. Apathy c. Ambivalence d. Overreaction e. Anhedonia ETIOLOGY BIOLOGIC THEORIES: biochemical, neurostructural, genetic, and perinatal factors It is accepted, that schizophrenia is the group of schizophrenias which origin is multifactorial: o internal factors genetic, inborn, biochemical o external factors trauma, infection of CNS, stress Biochemical: The most influential and plausible are the hypotheses, based on the supposed disorder of neurotransmission in the brain, derived mainly from o the effects of antipsychotic drugs that have in common the ability to inhibit the dopaminergic system by blocking action of dopamine in the brain o dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of lysergic acid - LSD) that can induce state closely resembling paranoid schizophrenia Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

o Classical dopamine hypothesis of schizophrenia: Psychotic symptoms are related to dopaminergic hyperactivity in the brain. Hyperactivity of dopaminergic systems during schizophrenia is result of increased sensitivity and density of dopamine D2 receptors in the different parts of the brain. Contemporary Models Dopamine hypothesis revisited: various neurotransmitter systems probably takes place in the etiology of schizophrenia (norepinephric, serotonergic, glutamatergic, some peptidergic systems); based on effects of atypical antipsychotics especially. Contemporary models of schizophrenia conceptualize it as a neurocognitive disorder, with the various signs and symptoms reflecting the downstream effects of a more fundamental cognitive deficit: o the symptoms of schizophrenia arise from cognitive dysmetria (Nancy C. Andreasen) o concept of schizophrenia as a neurodevelopmental disorder (Daniel R. Weinberger) Neurodevelopmental Model Neurodevelopmental model supposes in schizophrenia the presence of silent lesion in the brain, mostly in the parts, important for the development of integration (frontal, parietal and temporal), which is caused by different factors (genetic, inborn, infection, trauma...) during very early development of the brain in prenatal or early postnatal period of life. It does not interfere too much with the basic brain functioning in early years, but expresses itself in the time, when the subject is stressed by demands of growing needs for integration, during formative years in adolescence and young adulthood. 1. ventricular brain ratios 2. brain atrophy 3. cerebral blood flow Psychodynamic theories 1. developmental theories of Schizophrenia 2. family theories Special issues related to Schizophrenia Depression & Suicide People with schizophrenia attempt suicide much more often than people in the general population. About 10% (especially young adult males) succeed. It is hard to predict which patients with the disorder are prone to suicide. Listen when they talk about harming themselves. Psychotherapeutic nurse-patient relationship General principles: 1. Be calm when talking to patients. 2. Accept patients as they are but do not accept all behaviors. 3. Keep promises. 4. Be consistent. 5. Be honest. 6. Orient patients to time, person, and place, if indicated. 7. Do not touch patients without warning them. 8. Avoid whispering or laughing when patients are unable to hear all of a conversation. 9. Reinforce positive behaviors. 10. Avoid competitive activities with some patients. 11. Do not embarrass patients. 12. For withdrawn patients, start with one-to-one interactions. Petit Ivy Mae B. Nacario Dean Lea Belen M. Santillan Bsn 3-1 Report: Schizophrenia & other Psychosis

13. Allow and encourage verbalization of feelings. PSYCHOPHARMACOLOGY Antipsychotic medications have been available since the mid 1950s. These drugs have greatly improved the lives of patients with schizophrenia since their first development, but these medications do not cure the disease. The older antipsychotic medications effectively alleviate the positive symptoms of schizophrenia. These which are considered conventional or typical medications produced side effects which made compliance difficult. Most of these older "conventional" antipsychotics differed in the side effects they produced. Side effects such as orthostatic hypotension, sedation, anticholinergic effect and extrapyramidal effects. These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). Mechanism of Action of Antipsychotics While the precise mechanism of action that accounts for the effects of antipsychotic medications is still unknown, the dopamine hypothesis is the predominate theory used to explain the action of these drugs. Schizophrenia is caused by an excess in dopamine activity in the brain, which is inhibited by blockade of the receptors There are two core components to the dopamine theory: (1) psychosis is induced by increased levels of dopamine activity and (2) most antipsychotic drugs block postsynaptic dopamine receptors Extrapyramidal Effects Extrapyramidal Side Effects are a group of symptoms that can occur in persons taking antipsychotic medications. They are more commonly caused by the typical antipsychotics but can and do occur with all of them. Extrapyramidal side effects include: o tremor, akathisia, slurred speech, dystonia, bradykinesia, and muscular rigidity Akathisia is a movement disorder characterized by inner restlessness and the inability to sit or stand still. Akathisia may appear as a side effect of long-term use of antipsychotic medications, Lithium, and some other psychiatric drugs. Persons with akathisia typically have restless movements of the arms and legs such as tapping, marching in place, rocking, crossing and uncrossing the legs. They may feel anxious at the thought of sitting down. Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures. Acute dystonic reactions are characteristically sustained contraction of the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other muscle groups typically occurring within 10-14 days after initiation of the neuroleptic. Bradykinesia means "slow movement." Bradykinesia essentially refers to a component of parkinsonism. The full spectrum of parkinsonism is derived from the features of Parkinson's disease, which include bradykinesia, tremor, and rigidity. Rigidity is defined as hypertonia in which the following are true: The resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed, and does not exhibit a speed or angle threshold; Atypical antipsychotics In the 1990s, new drugs, called atypical antipychotics, were developed. Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

These medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy. The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients. Clozapine (Clozaril) was the first atypical introduced. It treats psychotic symptoms effectively even in people who do not respond to other medications. It can produce a serious problem called agranulocytosis. This is a loss of the white blood cells that fight infection in the body. Patients who take clozapine must have their white blood cell count monitored weekly and then monthly for the extent of use. Even with this complication, it is still the drug of choice with those whose symptoms do not respond to the other antipsychotic medications, old or new. Side Effects When patients first start to take the atypical antipsychotics, they may become drowsy or experience dizziness when they change positions (orthostatic hypotension). They may have blurred vision, or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes. Many of these symptoms will go away after the first few days but could last for up to one to two weeks. Advise your patients that if the symptoms do not go away after two to three weeks to notify the practitioner who prescribed the medication. Also advise them that they should not be driving until they adjust to their new medication.

Monitoring On monthly visits monitor for things such as over eating, weight gain, polyuria (increase urination), polydipsia (increased thirst). When each of you see your clients, if they have recently been put on an antipsychotic, discuss the above symptoms with them. Have them notify the practitioner if they are having problems with any of these symptoms. MILIEU MANAGEMENT: For disruptive patients: 1. Set limits on disruptive behavior 2. Decrease environmental stimuli. 3. Frequently observe escalating patients to intervene. Intervention before acting out occurs protects patients and others physically and prevents embarrassment for escalating patients. 4. Modify environment to minimize objects that can be used as weapons. 5. Be careful in stating what the staff will do if patient acts out; however follow through once a violation occurs. 6. When using restraints, provide for safety by evaluating the patients status of hydration, nutrition, elimination, and circulation. For withdrawn patients: 1. Arrange non-threatening activities that involve these patients in doing something. 2. Arrange furniture in a semicircle or around a table, w/c forces patients to sit with someone. 3. Help patients to participate in decision making, as appropriate. 4. Reinforce appropriate grooming and hygiene. Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

5. Provide psychosocial rehabilitationthat is , training in community living, social skills, and health care skills. For suspicious patients: 1. Be matter-of-fact when interacting with these patients. 2. Staff members should not laugh or whisper around patients unless patients can hear what is being said. 3. Do not touch suspicious patients without warning. Avoid close physical contact. 4. Be consistent in activities. 5. Maintain eye contact For patients with hallucinations: 1. Attempt to provide distracting activities. 2. Discourage situations in which patients talk to others about their disordered perceptions. 3. Monitor television selections. 4. Monitor for command hallucinations that might increase the potential for patients to become dangerous. 5. Have staff members available in the dayroom so that patients can talk to real people about real people or real events. For disorganized patients: 1. Remove disorganized patients to a less stimulating environment. 2. Provide a calm environment; the staff should appear calm. 3. Provide safe and relatively simple activities to these patients. OTHER PSYCHOTIC DISORDERS: 1. Schizoaffective disorder There will be symptoms of schizophrenia as well as mood disorder (depression, bipolar, mixed mania). Episodic disorders in which both affective and schizophrenic symptoms are prominent (during the same episode of the illness or at least during few days) but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes. Patients suffering from periodic schizoaffective disorders, especially with manic symptoms, have usually good prognosis with full remissions without any remaining defects. They are divided in different subgroups: 1. F25.0 Schizoaffective disorder, manic type 2. F25.1 Schizoaffective disorder, depressive type 3. F25.2 Schizoaffective disorder, mixed type 4. F25.8 Other schizoaffective disorders 5. F25.9 Schizoaffective disorder, unspecified 2. Induced Delusional Disorder A disorder characterized by the development of one delusion or of the group of similar related delusions, which are persisting unusually long, very often for the whole life. Other psychopathological symptoms hallucinations, intrusion of thoughts etc. are not present and are excluding this diagnosis. It begins usually in the middle age. A delusional disorder shared by two or more people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated. The psychotic disorder of the dominant member of this dyad is mainly, but not necessarily, of schizophrenic type. The original delusions of dominant member and his partner are usually chronic, either persecutory or megalomanic. Petit Ivy Mae B. Nacario Bsn 3-1 Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis

3. Schizotypal disorder According to lCD-10 this disorder is characterized by eccentric behavior and by deviations of thinking and affectivity, which are similar to that occurring in schizophrenia, but without psychotic features and expressed symptoms of schizophrenia of any type. .

Petit Ivy Mae B. Nacario Bsn 3-1

Dean Lea Belen M. Santillan Report: Schizophrenia & other Psychosis