Contemporary Psychiatric-Mental Health Nursing Chapter 16 Schizophrenia and Other Psychotic Disorders Features of Schizophrenia Prevalence in U.S. is 1.1%. Average onset is late teens to early twenties, but can be as late as mid-fifties Affects cognitive, emotional, and behavioral function 30% to 40% relapse rate in the first year Features of Schizophrenia - Progression varies from one client to another Exacerbations and remissions Chronic but stable Progressive deterioration 1
Features of Schizophrenia - DSM-IV-TR Diagnosis Symptoms present at least 6 months Active-phase symptoms present at least 1 month Symptoms are defined as positive and negative Features of Schizophrenia - Positive symptoms Excess or distortion of normal functioning Aberrant response Negative symptoms Deficit in functioning Features of Schizophrenia - Positive Symptoms of Schizophrenia Hallucination Delusions Disordered speech and behavior 2
Features of Schizophrenia - Negative Symptoms of Schizophrenia Flat affect and apathy Alogia Avolition Anhedonia Subtypes of Schizophrenia Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type Subtypes of Schizophrenia - Paranoid Type Delusions Persecutory and grandiose Somatic or religious Hallucinations Delusions link with a hallucination 3
Subtypes of Schizophrenia - Click here to view a video featuring Larry, who has been diagnosed as having paranoid schizophrenia. Subtypes of Schizophrenia - Disorganized type Disorganized speech, behavior, appearance Flat or inappropriate affect Fragmented hallucinations and delusions Most severe form of schizophrenia Subtypes of Schizophrenia - Catatonic type Psychomotor retardation and stupor Extreme psychomotor agitation Waxy flexibility Echolalia Mutism Echopraxia 4
Subtypes of Schizophrenia - Undifferentiated type Active psychotic state Lacks symptoms of other subtypes Residual type At least one episode of schizophrenia No prominent positive symptoms Negative symptoms present Other Psychotic Disorders Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Causes of Schizophrenia Biopsychosocial theories Interrelated factors 5
Causes of Schizophrenia - Biologic theories Psychological theories Family theories Humanistic-interactional theories Causes of Schizophrenia Biologic Theory: Genetic Only genetic predisposition for developing schizophrenia is inherited 10% of first-degree relatives 25%-39% of monozygotic twins Causes of Schizophrenia - Biologic Theory: Brain Structure Abnormality Differs from those with no symptoms May be genetically based Requires more study 6
Causes of Schizophrenia Figure 16.2 Schizophrenia scans. PET scans of discordant monozygotic twins taken during a test to provoke activity and measure regional cerebral blood flow. (A) Arrows indicate areas of normal blood flow and brain activity in the unaffected twin. (B) Arrows indicate areas of lower blood flow and brain activity in the twin with schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain Disorders Branch, National Institute of Mental Health Causes of Schizophrenia - Biologic Theory: Biochemical Theories Dopamine hypothesis Traditional antipsychotic medications are dopamine blockers Dopamine blocker alleviate positive symptoms Causes of Schizophrenia - Psychological theories Information processing Difficulty controlling the amount and type of information that is processed in the brain. Attention and arousal Hyper or hypo responsiveness to various situations 7
Causes of Schizophrenia - Psychological theories Information processing Deficient in automatic processing Deficient in controlled or effortful processing Attention and arousal Hypo-, hyper-responses Causes of Schizophrenia - Family Theories Dysfunctional interaction not supported by research Disordered family communication linked only with genetic predisposition Family emotional tone influences course of schizophrenia Expressed emotions theory (EE) Causes of Schizophrenia - Humanistic-interactional theories integrate biological and psychosocial theories Combine influences of: Genetic predisposition or biologic vulnerability Environmental stressors Social support 8
Causes of Schizophrenia - Stress Vulnerability Model Stressors increase vulnerability Cumulative effect of: Genetic predisposition Personal stressors Familial factors Environmental factors Influences on the Course of Schizophrenia Social Pressures Lack of social support Financial problems Stigma Influences on the Course of Schizophrenia - Psychological pressures Difficulty with problem-solving Difficulty with interpreting reality Difficulty coping Problems with self-care Unstable interpersonal relationships 9
Nursing Implications Assessment Premorbid functioning Content of thought Form of thought Perception Sense of self Delusions and perceptual disturbances Hallucinations Drug use Nursing Implications - Nursing Diagnoses Altered thought process Social isolation Risk for violence Self-care deficits Altered health maintenance Ineffective family coping Nursing Implications: Supporting Families Family needs vary with degree of illness and involvement in client s care Education Financial support Psychosocial support Education Advocacy 10
Nursing Implications: Supporting Families - Schizophrenia is a family illness. Family members need to be involved. Educate family about Medication Illness Relapse prevention Nurse assists family by Identifying community agencies/groups for family members Advocating for rights Measures to Prevent Relapse Ensure client takes medication Educate family about signs and symptoms of relapse Client and family to participate in relapse prevention program Measures to Prevent Relapse - Relapse prevention programs work best when: Psychosocial treatment and social skills training are combined with antipsychotic medication Behavior patterns are monitored Family members understand triggers 11
Measures to Prevent Relapse - Relapse prevention programs provide education and support regarding: Individual triggers, symptoms of relapse Managing side effects of medications Interventions to reduce or eliminate triggers Strategies to facilitate early intervention Cognitive therapy Community resources Challenges to Adherence Side effects Level of symptomatology Cognitive, motivational, financial, and cultural issues Issues with caregivers Insufficient medication teaching Increasing Adherence Involve clients in treatment Instruct client about reducing discomfort Provide peer support Provide reminders and positive feedback Recognize accomplishments 12
Personal Awareness Identify personal feelings. Recognize personal perceptions. What behaviors do you expect to see? How will you respond to these behaviors? What is the meaning of the behaviors? Personal Awareness - What defines normal behavior? What are my fears associated with mental illness? Personal Awareness - Be honest with your feelings. Identify what strengths you bring to the situation. Remember that clients are human beings with a mental disorder and do not choose to be this way. 13
Resources http://www.nami.org The National Alliance on Mental Illness provides information, education, and support relating to mental health illnesses and disorders for clients, families, and professionals. http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml The National Institute of Mental Health is part of the Department of Health and Human Services and has information about research on various mental health illnesses. http://www.nlm.nih.gov/medlineplus/schizophrenia.html Medline Plus is a service of the National Library of Medicine and the National Institutes of Health. This site provides definitions related to various aspects of schizophrenia. Resources - http://www.narsad.org/index.html The National Alliance for Research on Schizophrenia and Depression (NARSAD) is a private, non-for-profit charity organization primarily organized to raise funds for research. http://www.mayoclinic.com Search by topic on this Mayo Clinic link to find current information about mental illness 14