schizophrenia

IV. Alterations in mental health - schizophrenia

Lectured by: Leila T. Salera, RN, MD, DPSP

Epidemiology of mental illness• According to the WHO’s World Health Report in 2003:a. Mental, neurological and substance disorders cause a large

burden of disease and disabilityb. Globally, 13% of overall disability-adjusted life years and 33 % of

overall years lived with disabilityc. More than 150 million people suffer from depression at any point

in timed. Nearly 1M commit suicide each yeare. About 25M suffer from schizophreniaf. 38M suffer from epilepsyg. More than 90M suffer from drug use or disorder(Public Health Nursing in the Philippines, page 228)

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)

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

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

Schizophrenia

• The Four As:1. Associational disturbances of thought or

association looseness2. Affective disturbances3. Autism4. Ambivalence• Add one more A for auditory hallucinations

Types of Schizophrenia • Diagnosis is made according to the client’s predominant

symptoms:A. Schizophrenia, paranoid type – persecutory or grandiose

delusionsB. Schizophrenia, disorganized type – grossly inappropriate

or flat affect, incoherence, loose associations, and extremely disorganized behavior

C. Schizophrenia, catatonic type – either motionless or marked psychomotor disturbance; mutism, echolalia, echopraxia

(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

Types of Schizophrenia

• Diagnosis is made according to the client’s predominant symptoms:

D. Schizophrenia, undifferentiated type – mixed symptoms

E. Schizophrenia, residual type – social withdrawal, flat affect, loose associations

F. Schizoaffective disorder – psychotic symptoms of schizophrenia plus a mood disorder


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


Etiology • Biologic theories1. 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

2. 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

3. Immunovirologic factors – exposure to certain viruses like influenza


assessment

• Symptomalogy1. Positive symptoms – or hard symptoms/signs2. Negative symptoms – or soft symptoms/signs;

these frequently persists even after the positive symptoms have abated


DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of Schizophrenia

Positive or Hard Symptoms Negative or Soft SymptomsAmbivalence: 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

DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of Schizophrenia

Positive or Hard Symptoms Negative or Soft SymptomsFlight of ideas Flat affectHallucinations Lack of volition: absence of will,

ambition, or drive to take action or accomplish tasks

Ideas of referencePerseveration: persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

TYPES OF DELUSIONSPersecutory/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 claim 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

UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAClang 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?.....”

UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAStilted 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.”

UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAWord 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.”

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


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

Goals – Expected outcomes

• For the acute, psychotic phase (examples)a. The client will not injure self and othersb. The client will establish contact with realityc. The client will interact with others in the environmentd. The client will express thoughts and feelings in a safe and

socially acceptable mannere. The client will participate in prescribed therapeutic

interventions


Goals – Expected outcomes• For continued care after stabilization of acute symptoms (examples)a. The client will participate in the prescribed regimen (including

medications and follow-up appointments)b. The client will maintain adequate routines for sleeping and food and

fluid intakec. The client will demonstrate independence in self-care activitiesd. The client will communicate effectively with others in the

community to meet his or her needse. The client will seek or accept assistance to meet his or her needs

when indicated


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


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


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


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)

Implementation - management• Client/Family Educationa. How to manage illness and symptomsb. Recognizing early signs and symptoms of relapsec. Developing a plan to address relapse signsd. Importance of maintaining prescribed medication

regimen and regular follow-upe. Avoiding alcohol and other drugs


Implementation - management• Client/Family Educationf. Self-care and proper nutritiong. Teaching social skills through education, role modeling, and practiceh. Seeking assistance to avoid or manage stressful situationsi. Counseling and educating family/significant others about the

biologic causes and clinical course of schizophrenia and the need for ongoing support

j. Importance of maintaining contact with community and participating in supportive organizations and care


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


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


Early signs of relapse• Disinhibition• Increased negativity• Neglecting appearance• Forgetfulness


Implementation - management• Medications:a. Antispychotic medications: conventional

antipsychotics for positive symptoms and atypical antipsychotics for negative symptoms

b. Drugs for EPS


Social Skills Training

• Sometimes referred to as behavioral skills therapy

• Along with pharmacologic therapy can be directly supportive and useful to the patient

Social Skills Therapy

Phase Goals Targeted Behaviors

Stabilization and assessment Establish therapeutic allianceAssess social performance and perception skillsAssess behaviors that provoke expressed emotions

Empathy and rapportVerbal and nonverbal communication

Social performance within family

Express positive feelings with familyTeach effective strategies for coping with conflict

Compliments, appreciation, interest in othersAvoidance response to criticism, stating preferences and refusals

Social perception in the family

Correctly identify content, context, and meaning of messages

Reading a messageLabeling an ideaSummarizing other’s intent

Extrafamilial relationships Enhance socialization skillsEnhance prevocational and vocational skills

Conversational skillsDatingRecreational activities

Maintenance Generalize skills to new situations

Job interviewing, work habits

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)

schizophrenia

Education

positive symptoms

negative symptoms

mental health schizophrenia

clientspredominant symptoms

student guide

hard symptoms negative

schizophrenia emil kraepelin

schizophrenia eugene