Scizophrenia- Psychiatric Nursing

Nursing Management of Client with Schizophrenia. Useful for B.Sc Nursing Students

1. SHIZOPHRENIA Mr.Visanth V S Asso.Professor IGSCON, Amethi

2. 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 Kraepelin’s dementia praecox as schizophrenia; he recognized the cognitive impairment in this illness, which he named as a “splitting” of 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.

3. Contd …… The word schizophrenia was coined by the Swiss Psychiatrist Eugen Bleuler . It is derived from the Greek words Skhizo (Split), Phren (Mind) Classififaction : F 20

4. F20 Schizophrenia F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

5. Myth Schizophrenia refers to multiple personality Schizophrenia is a rare disease People with schizophrenia are dangerous

6. Definition Schizophrenia is a psychotic condition characterized by a disturbance in thinking, emotions, volitions and faculties in the presence of clear consciousness, which usually leads to social withdrawal

7. According to ICD-10 Schizophrenia is characterized in general by fundamental inappropriate a mental and characteristic distortion of thinking , perception and inappropriate or blunted affect. Delusions are bizarre in nature. Hallucinations especially auditory are the commonest. Thinking is vague and speech sometimes incomprehensive. Mood is characteristically shallow and incongruous, ambivalence, negativism, stupor or catatonia may be present. The onset may be acute or insidious with a seriously disturbed behavior.

8. Epidemiology It is the most common of all psychiatric disorders and is prevalent in all cultures across the world. 1% of world population develops schizophrenia. 3-4 per 1000 cases Prevalence , Male = Female Onset 15-25 years for men, 25-35 years for women. 2/3 rd cases in age group of 15-30 years . The disease is common in low socio economic status

9. Stages of Schizophrenia The Schizoid Personality The Prodromal Phase Schizophrenia Residual Phase

10. Etiology Genetic Factors The siblings or offspring of an identified client have a 5 to 10 percent risk of developing schizophrenia. How schizophrenia is inherited is uncertain Twin Studies The rate of schizophrenia among monozygotic twins is four times that of dizygotic twins and approximately 50 times that of the general population.

11. Biochemical theories Biochemical hypothesis of schizophrenia orientated towards the role of neurotransmitters and their receptors; dopamine, serotonin, glutamate, GABA, Norepinephrine. Dopamine plays a key role in biochemical hypothesis of schizophrenia.

12. Viral Infections Prenatal exposure to influenza. Viral infections of the central nervous system during childhood. Viral infections during pregnancy and delivery. Anatomical abnormalities Neuro -imaging studies shows structural brain abnormalities in individuals with schizophrenia. Brains of patients with schizophrenia are lighter and smaller. Cortical atrophy in the frontal and temporal lobes of left side is seen in 10-35% cases. Larger lateral and third ventricles

13. Environmental Causes Prenatal exposure to viral infection Low oxygen level during birth Viral infection Early parental loss or separation Physical or sexual abuse in childhood Family Theory Double bind communication Marital disharmony Pseudo mutual and pseudo hostile families Low socio economic status Social isolation

14. Transactional Model Of Stress Adaptation

15. Clinical Features

16. Bleuler’s Classification - 4 A ’s Primary Symptoms- 4A’s Of Schizophrenia 1.Ambivalence (The co- existence of strongly conflicting feelings, attitudes and ideas) 2.Autistic Thinking (withdrawal in thinking and behavior) 3.Association Disturbances (fragmented thinking) 4.Affective Blunting Secondary Symptoms 1.Hallucinations 2. Delusions 3. Catatonic Symptoms 4. Behavioral Abnormalities

17. Kurt Schneider’s Symptoms of Schizophrenia Kurt Schneider (1957) described the features of schizophrenia into first rank and second rank symptoms .   First Rank Symptoms Audible thought or thought echo Voices commenting on him in the third person or voices heard arguing Passivity feelings(patient thinks that he is in the grip of a superior force which controls his action) Thought withdrawal Thought broadcasting Delusional perception Other perceptual, motor, and affective symptoms were called second rank symptoms.

18. Positive and Negative Symptoms Negative Symptoms -6 A’s 1. Anhedonia (inability to experience pleasure) 2. Apathy ( attentional impairment) 3. Avolition (diminution of will or desire) 4. Alogia ( poverty of thinking and speech) 5.Asocial ( social withdrawal) 6.Affective Flattening Positive Symptoms 1.Hallucinations 2. Delusions 3. Bizarre Behavior 4. Positive formal thought behavior

19. Thought & Speech Disorder Autistic thinking Loosening of association Thought blocking Neologisms Echolalia Verbigeration Clang association Word salad Delusions Circumstantiality Tangentiality Preservation Delusions

20. Delusions False beliefs that are firmly and consistently held despite disconfirming evidence, culture or logic. Delusions of persecution : belief that one is the target of others’ mistreatment, evil plots, and/or murderous intent Delusions of reference : belief that all happenings revolve around oneself, and/or one is always the center of attention Delusions of grandeur : belief that one is a famous or powerful person from the past or present Delusions of control : belief that some external force is trying to take control of one’s thoughts , body, or behavior

21. Thought broadcasting : belief that one’s thoughts are being broadcast or transmitted to others Thought withdrawal : belief that one’s thoughts are being removed from one’s mind Paranoia : extreme suspiciousness Somatic delusion : false idea about the functioning of the body. Nihilistic delusion : false idea that the self, a part of the self, others or the world is non existent Religiosity

22. Cognitive impairment Impaired judgment, poor insight, less reliable Disorders of perception Hallucinations Elementary auditory hallucinations Thought echo Third person hallucination Voice commenting on one’s action Disorders of affect Emotional blunt/flat Anhedonia Inappropriate affect Emotional shallowness

23. Disorders of motor behavior Increased or decreased psychomotor activity, anergia Waxy flexibility Posturing , stereotypes Disorganized behavior and self Decreased ADL Lack of inhibition and impulse control Unpredictable emotional response Social/occupational dysfunction Echopraxia Depersonalization Emotional ambivalence

24. F20.0 Paranoid Schizophrenia 1. Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually accompanied by auditory hallucinations usually. 2. Patient is usually potentially aggressive, angry or fearful, uncooperative and difficult to deal with. 3. No prominent disorganized behaviour or mood. 4. The onset is usually late and the prognosis is better F20.1 Hebephrenic Schizophrenia 1.insidious onset 2. Disorganized behaviour. 3. Marked incoherence and loosening of association, inappropriate affect, Grimacing and bizarre mannerisms are common.

25. F20.2 Catatonic Schizophrenia Presence of one or more of the catatonic features: stupor, mutism , rigidity, negativism, posturing, echopraxia , echolalia, waxy flexibility or purposeless excitement. This may be in the form of catatonic stupor, catatonic excitement and catatonia altering between excitement and stupor. Excited catatonia includes restlessness, agitation, excitement, aggressiveness, increase in speech production, loosening of association. Sometimes this become very severe and is accompanied by rigidity, hyperthermia and dehydration and can result in death. Features of catatonic stupor includes mutism , rigidity, negativism, inappropriate and bizarre posture, stupor ( does not react to surroundings and appears to be unaware of them), echolalia, echopraxia , waxy flexibility(maintenance of body posture for a long time in a same position even it is uncomfortable), automatic obedience .

26. F20.3 Undifferentiated Schizophrenia Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes F20.4 Post schizophrenic Depression A depressive episode, which may be prolonged, arises in the aftermath of a schizophrenic illness. These depressive states are associated with an increased risk of suicide. F20.5 Residual Schizophrenia There has been at least one episode of schizophrenia in the past without prominent psychotic symptoms at present.

27. F20.6 Simple Schizophrenia This has insidious onset of social withdrawal, loss of drive and ambition, deterioration of functioning. The negative symptoms are very common. It has a worst prognosis of all types. F20.8 Other Schizophrenia Cenesthopathic schizophrenia Schizophreniform : Disorder Not otherwise specified Psychosis not otherwise specified etc F20.9 Schizophrenia Unspecified Unspecified schizophrenia is the mental disorder known as schizophrenia that does not fit any of the generally accepted categories or types of schizophrenia. Symptoms of unspecified schizophrenia may include some or all of the symptoms of the named types of schizophrenia .

28. Diagnostic evaluation Reliable and detailed history MSE Psychological testing

29. The requirements for the diagnosis of schizophrenia are as follows. Presence of psychotic features for a period of one month or more. At least one or two or more of the following symptoms; Thought echo thought insertion or withdrawal or thought broad casting Delusional perception Hallucinatory voices Symptoms from at least two of the following groups; Persistent hallucinations in any modality Thought disturbances Catatonic symptoms Negative symptoms not attributable to medications Personality deterioration

30. Management Somatic treatment -Pharmacological Management -Electroconvulsive therapy 2. Psychological treatment 3. Nursing management

31. Pharmacological There is currently no cure for schizophrenia. Treatment is aimed at reducing symptoms and preventing psychotic relapses. Medication needs to be continue. Two major types of antipsychotic medications (or neuroleptics): CONVENTIONAL or TYPICAL ANTIPSYCHOTICS (haloperidol)  control the positive symptoms very effectively  side effects: extrapyramidal symptoms (chronic: tardive dyskinesia, parkinsonism, akathisia ; acute: acute dystonia, neuroleptic malignant syndrome)  high affinity for D 2 dopamine receptors

32. NEWER or ATYPICAL ANTIPSYCHOTICS (clozapine, risperidone , olanzapine, ziprasidone , quietapine , sertindole )  better at treating the negative symptoms  milder motor side effects; but others (weight gain, diabetes)  they have affinity to multiple receptor systems (DARs, 5HTRs, a 1 , H 1 , m 1/4 ) conventional antipsychotics (classical neuroleptics ) chlorpromazine, chlorprotixene , clopenthixole , levopromazine , periciazine , thioridazine droperidole , flupentixol , fluphenazine , fluspirilene , haloperidol, melperone , oxyprothepine , penfluridol , perphenazine , pimozide , prochlorperazine , trifluoperazine atypical antipsychotics amisulpiride , clozapine , olanzapine , quetiapine , risperidone , sertindole , sulpiride

33. Typical Chlorpromazine 300-1500 mg/day Haloperidol 5-100 mg/day Pimozide 4-12 mg/day Triflupromazine 100-400 mg/day Atypical Clozapine 25-450 mg/day Resperidone 2-8 mg/day Olanzapine 5-20 mg/day Ziprasidone 40-160 mg/day

34. Electro Convulsive Therapy In catatonic stupor, uncontrolled catatonic excitement, acute exacerbation not controlled by drugs, severe side effects of drugs in presence of untreated schizophrenia. Usually 8-10 ECT’s are needed, given three times a week, although up to 18have been given in poor responders.

35. Psychological Treatment Supportive therapy and counseling. Rehabilitation - Social skill training (e.g. self-care). Vocational rehabilitation (for more stable cases). Token economy: Useful for institutionalized chronic schizophrenics. Positive and negative reinforcement are used to alter patient’s unacceptable behaviour. It should be part of a behavioral programme.

36. Nursing Process Nursing diagnosis: Disturbed sensory perception: Auditory/visual related to panic anxiety, extreme loneliness and withdrawal into the self, evidenced by inappropriate responses, disordered thought sequencing, rapid mood swings, poor concentration, and disorientation.   Outcome Identification Nursing Intervention   Client will be able to Reduce or eliminate the occurrence of hallucinations. 1. Assess the type of hallucination 2. Avoid touching the client without warning. 3. Show acceptance to the client it will encourage him to share the content of the hallucination. 4. Do not reinforce the hallucination. Use “the voices” instead of words like “they” that imply validation. 5. Help to understand the connection between anxiety and hallucinations. 6. Interrupt hallucination and try to bring back to reality.

37. Nursing diagnosis: Disturbed thought processes related to inability to trust, panic anxiety, possible hereditary or biochemical factors, evidenced by delusional thinking or suspiciousness of others. Outcome Identification Nursing Intervention   Client will remove pattern of delusional thinking and demonstrate trust in others. 1. Assess the content of thought 2. Assess the intensity and duration of delusion 3. Do not whisper near to the client 4. Serve food family style 5. Mouth checks for medications 6. Cautious with touch 7. Use same staff as much as possible 8. Meet client needs and keep promises to promote trust 9. Encourage the client to express the feelings 10. Encourage Client’s participation in providing care

38. Nursing diagnosis: Social isolation related to inability to trust, panic anxiety, weak ego development, delusional thinking, regression, evidenced by withdrawal, sad and dull affect, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others. Outcome Identification Nursing Intervention   Client will voluntarily spend time with other clients and staff members in group activities. 1. Convey an accepting attitude to the client. 2. Offer to be with client during group activities that he or she finds frightening or difficult. 3. Give positive reinforcement for client’s voluntary interactions with others.  

39. Nursing diagnosis: Risk for violence: Self-directed or other-directed related to extreme suspiciousness, panic anxiety, catatonic excitement, command hallucinations, evidenced by overt and aggressive acts, self-destructive behavior, or active aggressive suicidal acts. Outcome Identification Nursing Intervention         Client will not harm self or others. 1. Observe client’s behavior frequently. 3. Remove all dangerous objects from client’s environment. 4. Redirect violent behavior with physical outlets for the anxiety. 5. Staff should maintain a calm attitude toward client. 6. Have sufficient staff available to indicate a show of strength to client if it becomes necessary. 7. Administer tranquilizing medications as ordered by physician. If client is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary.  

40. Patient and Family Education Explain to the patient and family members regarding schizophrenia and its symptoms especially regarding thought disturbances, mood changes, hallucinations etc. Teach about medication compliance and effects of antipsychotic medications. Instruct the family members that if the patient poses any threat or danger to self harm or aggressive behavior, hospitalize him immediately. Teach the patient and family members to recognize family stressors which increase the symptoms and methods to prevent them.

41. Rehabilitation of Schizophrenic Clients People who have schizophrenia can have repetitive inpatient hospitalizations. Psychiatric rehabilitation strengthens the self care and improves the quality of life. There are number of services available in community to improve the quality of the life .It may be as follows; Social Skill training Vocational rehabilitation Day hospitals Community mental health centers Wellness centers etc.