Schizophrenia

Alterations in mental health - Schizophrenia

1. IV. Alterations in mental health - schizophrenia Lectured by: Leila T. Salera , RN, MD, DPSP

2. Epidemiology of mental illness According to the WHO’s World Health Report in 2003: Mental, neurological and substance disorders cause a large burden of disease and disability Globally, 13% of overall disability-adjusted life years and 33 % of overall years lived with disability More than 150 million people suffer from depression at any point in time Nearly 1M commit suicide each year About 25M suffer from schizophrenia 38M suffer from epilepsy More than 90M suffer from drug use or disorder (Public Health Nursing in the Philippines, page 228)

3. schizophrenia Causes disoriented and bizarre thoughts, perceptions, emotions, movements, and behavior Cannot be defined as a single illness Thought of as a syndrome or as disease process with many different symptoms Usually diagnosed in late adolescence or early adulthood Rarely manifests in childhood Peak incidence of onset: 15 to 25 years for men, and 25 to 35 years for women ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

4. schizophrenia Emil Kraepelin – described the term “dementia precox ” (before it was called schizophrenia); it emphasized the change in cognition (dementia) and early onset ( precox ) of the disorder Patients with dementia precox were described as having a long-term deteriorating course and the clinical symptoms of hallucinations and delusions Paranoia – characterized by persistent persecutory delusions

5. schizophrenia Eugene Bleuler – coined the term schizophrenia which replaced the term demenita precox in the literature Unlike Kraepelin’s concept, schizophrenia need not have a deteriorating course It is not the same as split personality

6. Schizophrenia The Four As: Associational disturbances of thought or association looseness Affective disturbances Autism Ambivalence Add one more A for auditory hallucinations

7. Types of Schizophrenia Diagnosis is made according to the client’s predominant symptoms: Schizophrenia, paranoid type – persecutory or grandiose delusions Schizophrenia, disorganized type – grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior Schizophrenia, catatonic type – either motionless or marked psychomotor disturbance; mutism , echolalia, echopraxia ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

8. Types of Schizophrenia Diagnosis is made according to the client’s predominant symptoms: Schizophrenia, undifferentiated type – mixed symptoms Schizophrenia, residual type – social withdrawal, flat affect, loose associations Schizoaffective disorder – psychotic symptoms of schizophrenia plus a mood disorder ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

9. Related disorders Schizophreniform disorder – symptoms of schizophrenia but for less than 6 months necessary to meet the diagnostic criteria. Social or occupational functioning may or may not be impaired Delusional disorder – client has one or more delusions, psychosocial functioning is not markedly impaired , and behavior is not obvious odd or bizarre Brief psychotic disorder – sudden onset of a psychotic symptom which lasts for 1 day to 1 month , that could have a stressor or may follow childbirth Shared psychotic disorder – folie a deux , two people share a similar delusion ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

10. Etiology Biologic theories Genetic factors: identical twins have 50% risk, fraternal twins have 15%, children with one schizophrenic parent have 15% risk, 35% if both parents are schizophrenic Neuroanatomic and neurochemical factors – patients have relatively less brain tissue and CSF compared to those who do not have the illness, the ventricles are enlarged, and there is cortical atrophy; excess dopamine and serotonin Immunovirologic factors – exposure to certain viruses like influenza ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

11. assessment Symptomalogy Positive symptoms – or hard symptoms/signs Negative symptoms – or soft symptoms/signs; these frequently persists even after the positive symptoms have abated ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

12. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of Schizophrenia Positive or Hard Symptoms Negative or Soft Symptoms Ambivalence: holding seemingly contradictory beliefs or feelings about the same person, event, or situation Alogia : tendency to speak very little or to convey little substance of meaning (poverty of content) Associative looseness Anhedonia : feeling no joy or pleasure from life or any activities of relationships Delusions Apathy: feelings of indifference toward people, activities, and events Echopraxia : imitation of movements and gestures of another person whom the client is observing Blunted affect Flight of ideas Catatonia: psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance

13. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of Schizophrenia Positive or Hard Symptoms Negative or Soft Symptoms Flight of ideas Flat affect Hallucinations Lack of volition: absence of will, ambition, or drive to take action or accomplish tasks Ideas of reference Perseveration: persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

14. TYPES OF DELUSIONS Persecutory/paranoid delusions Involve the client’s belief that “others” are planning to harm the client or are spying, following, ridiculing, or belittling the client Grandiose delusions Characterized by the client’s clai m to association with famous people or celebrities, or the client’s belief that he or she is famous or capable of great feats Religious delusions Often center around the second coming of Christ or another significant religious figure or prophet Somatic delusions Generally vague and unrealistic beliefs about the client’s health or bodily functions (client may say that she is pregnant) Rereferential delusions Ideas of reference

15. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA Clang associations Ideas that are related to one another based on sound of rhyming “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill.” Neologisms Words invented by the client “I’m afraid of grittiz . If there are any grittiz here, I will have to leave. Are you a grittiz ?” Verbigeration Stereotyped repetition of words or phrases that may or may not have meaning to the listener “I want to go home, go home, go home.” Echolalia Imitation or repetition of what the nurse says Nurse: “Can you tell me how you’re feeling?” Client: “Can you tell me how you’re feeling, how you’re feeling?.....”

16. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA Stilted language Use of words or phrases that are flowery, excessive, pompous “Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?” Perseveration Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Where do you live?” Client: “At my place people have been following me.” Nurse: “What do you like to do in your free time?” Client: “Nothing because people are following me.”

17. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA Word salad A combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener “Corn, potatoes, jump up, play games, grass, cupboard.”

18. Elder considerations Late-onset schizophrenia – development of the disease after age 45 Schizophrenia is not initially diagnosed in elder clients Psychotic symptoms are usually associated with depression or dementia, not schizophrenia Approximately one fourth of clients experienced dementia, resulting in steady, deteriorating decline in health Another 25% actually have reduction in positive symptoms, somewhat like a remission Schizophrenia remains mostly unchanged in the remaining clients ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

19. Nursing diagnosis (http://www.nursingplanet.com/pn/nursing_process_psychiatric_nursing.html#Nursing%20Diagnosis) Nursing Diagnosis Analysis Risk for injury related to accelerated motor activity Accelerated motor activity or impulsive actions Disturbed thought process –related to delusion of  grandeur Grandiose delusions (Belief that well known political religious, or entertainment leader) Self-care deficit (unkempt appearance)  related to hyperactivity Unable to take time for self-care  is, disheveled and unkempt Impaired   verbal communication –flight of ideas related to accelerated thinking Accelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive  planning  for activities

20. Goals – Expected outcomes For the acute, psychotic phase (examples) The client will not injure self and 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 ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

21. Goals – Expected outcomes For continued care after stabilization of acute symptoms (examples) The client will participate in the prescribed regimen (including medications and follow-up appointments) The client will maintain adequate routines for sleeping and food and fluid intake 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 ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

22. Implementation - management Promoting the safety of client and others Establishing a therapeutic relationship Using therapeutic communication Implementing interventions for delusional thoughts and for hallucinations Coping with socially inappropriate behaviors Teaching client and family ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

23. Interventions for delusions Do not confront the delusion or argue with the client Establish and maintain reality for the client Use distracting techniques Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

24. Interventions for hallucinations Help present and maintain reality by frequent contact and communication with client Elicit description of hallucination to protect client and others Engage client in reality-based activities such as card playing, occupational therapy, or listening to music ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

25. Coping with socially inappropriate behaviors Redirect client away from problem situations Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; do not scold Reassure others that the client’s inappropriate behaviors or comments are not his or her fault (without violating the client confidentiality) Try to reintegrate the client into treatment milieu Do not make the client feel punished or shunned for inappropriate behaviors Teach social skills through education, role modeling, and practice ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

26. Implementation - management Client/Family Education How to manage illness and symptoms Recognizing early signs and symptoms of relapse Developing a plan to address relapse signs Importance of maintaining prescribed medication regimen and regular follow-up Avoiding alcohol and other drugs ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

27. Implementation - management Client/Family Education Self-care and proper nutrition Teaching social skills through education, role modeling, and practice Seeking assistance to avoid or manage stressful situations Counseling and educating family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing support Importance of maintaining contact with community and participating in supportive organizations and care ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

28. Early signs of relapse Impaired cause-and-effect reasoning Impaired information processing Poor nutrition Lack of sleep Lack of exercise Fatigue Poor social skills, social isolation, loneliness Interpersonal difficulties ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

29. Early signs of relapse Lack of control, irritability Mood swings Ineffective medication management Low self-concept Looks and acts different Hopeless feelings Loss of motivation Anxiety and worry ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

30. Early signs of relapse Disinhibition Increased negativity Neglecting appearance Forgetfulness ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

31. Implementation - management Medications: Antispychotic medications: conventional antipsychotics for positive symptoms and atypical antipsychotics for negative symptoms Drugs for EPS ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)

32. Social Skills Training Sometimes referred to as behavioral skills therapy Along with pharmacologic therapy can be directly supportive and useful to the patient

33. Social Skills Therapy Phase Goals Targeted Behaviors Stabilization and assessment Establish therapeutic alliance Assess social performance and perception skills Assess behaviors that provoke expressed emotions Empathy and rapport Verbal and nonverbal communication Social performance within family Express positive feelings with family Teach effective strategies for coping with conflict Compliments, appreciation, interest in others Avoidance response to criticism, stating preferences and refusals Social perception in the family Correctly identify content, context, and meaning of messages Reading a message Labeling an idea Summarizing other’s intent Extrafamilial relationships Enhance socialization skills Enhance prevocational and vocational skills Conversational skills Dating Recreational activities Maintenance Generalize skills to new situations Job interviewing, work habits

34. evaluation Have the client’s psychotic symptoms disappeared? Does the client understand the prescribed medication regimen? Does the client possess the necessary functional abilities for community living? Are community resources adequate to help the client live successfully in the community? Is there sufficient after-care or crisis plan in place to deal with recurrence of symptoms? Are the client and family adequately knowledgeable about schizophrenia? Does the client believe that he or she has satisfactory quality of life? ( Videbeck , pages 252 to 276; Student Guide, pages 123 to 129)