515 Schizophrenia FA23 0201 Slide view.pdf

Schizophrenia Bryan R. Hansen, PhD, RN, APRN-CNS Tamar Rodney, PhD, RN, PMHNP-BC, CNE Emma Mangano, DNP, PMHNP-BC Objectives • Describe the clinical manifestations of schizophrenia. • Integrate principles of psychiatric mental health nursing care for heath care consumers across practice settings....

Schizophrenia Bryan R. Hansen, PhD, RN, APRN-CNS Tamar Rodney, PhD, RN, PMHNP-BC, CNE Emma Mangano, DNP, PMHNP-BC Objectives • Describe the clinical manifestations of schizophrenia. • Integrate principles of psychiatric mental health nursing care for heath care consumers across practice settings. • Apply principles of nursing intervention to the care of patients with psychosis and schizophrenia. • Analyze current evidence that supports therapeutic intervention for patients with disturbed communication. • Evaluate the use of specific nursing intervention in responding to patient expressions of hallucinations and delusions. • Develop a plan to educate patients with schizophrenia and their families about symptom management (including aggression and substance use) and relapse prevention. • Develop a plan to manage patients with metabolic syndrome Clinical Picture • Schizophrenia affects 1% of adults • Characterized by psychosis – Altered cognition, perception, and reality testing • 75%: Develop gradually, presenting at 15 to 25 years of age • Child-onset and late-onset are more rare DSM-5 Criteria: Highlights • Two or more of the following for a significant portion of time in 1 month: Delusions Hallucinations Disorganized speech Gross disorganization or catatonia Negative symptoms (diminished emotional expression or avolition) – Functional impairment of some kind – – – – – • Continuous disturbance for at least 6 months Case Study Eric M, 18, has always been a good student. Now, however, in his second semester of college, he begins, for the first time in his life, to have trouble concentrating. When his family doesn’t hear from Eric, they contact the school, only to discover that his roommate says Eric is “talking weird.” Asked what he means, the roommate says, “Well, you know, he says stuff that doesn’t connect, doesn’t make any sense. I asked him if he was high or something, but he said no, and I believed him.” On further investigation, Eric’s professors say he’s been missing class, after starting out so well. Case Study/ Audience Response Question Eric’s roommate says his speech “… doesn’t connect; it doesn’t make any sense. He sort of gets derailed.” Which of the following symptoms is Eric displaying? A. Avolitional speech B. Delusional speech C. Disorganized speech D. Diminished emotional expression Case Study/ Audience Response Question Eric’s roommate says his speech “… doesn’t connect; it doesn’t make any sense. He sort of gets derailed.” Which of the following symptoms is Eric displaying? A. Avolitional speech B. Delusional speech C. Disorganized speech D. Diminished emotional expression Epidemiology • Childhood-onset schizophrenia: 1 in 40,000 children • No difference related to – Race – Social status – Culture • More frequently diagnosed: – Among males – In urban areas Comorbidity • Substance abuse disorders – Nicotine dependence • Anxiety, depression, and suicide • Physical health or illness • Polydipsia Etiology • Biological factors – Genetics • Neurobiological – Dopamine theory – Other neurochemical hypotheses • Brain structure abnormalities Etiology (Cont.) • Psychological and environmental factors – Prenatal stressors – Psychological stressors – Environmental stressors – Prognostic considerations Case Study Eric’s parents arrive on campus, and he agrees to meet with them and a campus counselor. He appears anxious. He expresses sorrow that his grades are suffering, acknowledging that his concentration “just isn’t there.” He says that he feels “something weird is happening to me” and describes frequent distressing thoughts. He admits to feeling suspicious of everyone he passes. Eric’s parents and the counselor both notice what the roommate had described about Eric’s speech. Phases of Schizophrenia • Prodromal – Onset; mild changes • Acute – Exacerbation of symptoms • Stabilizing – Symptoms diminishing – Movement toward previous level of functioning • Stable – New baseline is established – Symptoms not as severe Case Study Eric agrees to see a psychiatrist and an initial assessment and history indicate that he has only been experiencing some mild changes in his thinking and mood for about a month—ever since returning from the winter holiday. The examiner confirms that his speech is sometimes disorganized and his ability to concentrate and study is diminished from his previous longstanding as a strong student. Case Study/ Audience Response Question Given the evidence we have so far, if Eric has schizophrenia, which is suspected, which phase is he most likely experiencing? A. Acute B. Residual C. Prodromal D. Stabilization Case Study/ Audience Response Question Given the evidence we have so far, if Eric has schizophrenia, which is suspected, which phase is he most likely experiencing? A. Acute B. Residual C. Prodromal D. Stabilization Assessment • During the prodromal phase • General assessment – Positive symptoms – Negative symptoms – Cognitive symptoms – Affective symptoms Positive Symptoms • Alterations in reality testing – Delusions—false, fixed beliefs – Alterations in speech – Concrete thinking—inability to think abstractly Alterations in Speech • Associative looseness – Word salad—most extreme form; jumble of words meaningless to a listener • Clang association – Words chosen based on sound • Neologisms – Meaning for the patient only • Echolalia – Pathological repetition of another’s words Other Abnormal Speech and Thought Patterns • Circumstantiality • Tangentiality • Cognitive retardation • Pressured speech • Flight of ideas • Symbolic speech Disorders or Distortions of Thought • Thought blocking • Thought insertion • Thought deletion • Thought broadcasting • Magical thinking • Paranoia Case Study/ Audience Response Question During assessment, Eric has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what he’s trying to say. Which speech disturbance is he exhibiting? A. B. C. D. Pressured speech Circumstantiality Flight of ideas Tangentiality Case Study/ Audience Response Question During assessment, Eric has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what he’s trying to say. Which speech disturbance is he exhibiting? A. B. C. D. Pressured speech Circumstantiality Flight of ideas Tangentiality Alterations in Perception • Depersonalization • Derealization • Hallucinations – – – – – – Auditory Visual Olfactory Gustatory Tactile Command • Illusions Negative Symptoms • The absence of essential human qualities – Anhedonia – Avolition – Asociality – Affective blunting – Apathy – Alogia Negative Symptoms (Cont.) • Affect: Outward expression of a person’s internal emotional state – Flat – Blunted – Inappropriate – Bizarre Negative Symptoms • The absence of essential human qualities – Anhedonia • A reduced ability or inability to experience pleasure in things you usually like to do. Favorite hobbies, social interactions with close friends, etc. – Apathy • A decreased interest in, or attention to, activities or beliefs that would otherwise be routine activities, such as brushing teeth, showering, getting groceries, doing homework. – Compare: • anhedonia = lack of reward • apathy = lack of motivation Cognitive Symptoms • Concrete thinking • Impaired memory • Impaired information processing • Impaired executive functioning Affective Symptoms • Assessment for depression is crucial – May herald impending relapse – Increases substance use – Increases suicide risk – Further impairs functioning Self-Assessment • Anosognosia – – – – Inability to realize they are ill Caused by the illness itself May result in resistance to or cessation of treatment Often combined with paranoia so that accepting help is impossible • Nurse’s self-assessment – Anxiety or fear – Frustration – Expectations Case Study/ Audience Response Question Eric becomes anxious and says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? A. Positive symptom B. Negative symptom C. Cognitive symptom D. Depressive symptom Case Study/ Audience Response Question Eric becomes anxious and says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? A. Positive symptom B. Negative symptom C. Cognitive symptom D. Depressive symptom Assessment Guidelines • Any medical problems • Medical problems that mimic psychosis • Drug or alcohol use disorders • Mental status examination • Include cognitive assessment (e.g., reality testing) Assessment Guidelines (Cont.) • Assess for hallucinations • Assess for delusions • Assess for suicide risk • Assess ability to ensure personal safety and health • Assess prescribed meds • Assess symptoms’ impact on functioning • Assess family knowledge Case Study Discussion Guide The psychiatric nurse conducting Eric’s assessment believes that he is also suffering from command hallucinations. Discuss what kinds of questions could help affirm this. Outcomes Identification • Phase I—acute – Patient safety and medical stabilization • Phase II—stabilizing – Help patient understand illness and treatment – Stabilize medications – Control or cope with symptoms • Phase III—maintenance or stable – Maintain achievement – Prevent relapse – Achieve independence, satisfactory quality of life Planning • Phase I—acute – Best strategies to ensure patient safety and provide symptom stabilization • Phase II—stabilizing – Follow up; symptom recognition • Phase III—maintenance or stable – Provide patient and family education – Relapse prevention skills are vital Implementation • Acute phase – Psychiatric, medical, and neurological evaluation – Psychopharmacological treatment – Support, psychoeducation, and guidance – Supervision and limit setting in the milieu – Monitor fluid intake – Working with aggression • Regularly assess for risk and take safety measures Interventions • Stabilizing and maintenance phases – Medication administration/adherence – Relationships with trusted care providers – Community-based therapeutic services – Teamwork and safety – Activities and groups Interventions (Cont.) • Counseling and communication techniques – Hallucinations – Delusions – Associative looseness – Health teaching and health promotion Psychobiological Interventions • Antipsychotic medications – First-generation – Second-generation – Third-generation • Injectable antipsychotics – Short-acting – Long-acting First-Generation Antipsychotics • Dopamine antagonists (D2 receptor antagonists) • Target positive symptoms of schizophrenia • Advantage – Less expensive than second generation • Disadvantages – – – – Extrapyramidal side effects (EPS) Anticholinergic (ACh) side effects Tardive dyskinesia Weight gain, sexual dysfunction, endocrine disturbances Second-Generation Antipsychotics • Serotonin (5-HT2A receptor) and dopamine (D2 receptor) antagonists, e.g., clozapine (Clozaril) • Treat both positive and negative symptoms • Minimal to no EPS or tardive dyskinesia • Disadvantage—tendency to cause significant weight gain; risk of metabolic syndrome Third-Generation Antipsychotics • Really a subset of the SGAs • Aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar) • Dopamine system stabilizers • May improve positive and negative symptoms and cognitive function – Little risk of EPS or tardive dyskinesia Potentially Dangerous Responses to Antipsychotics • Anticholinergic toxicity • Neuroleptic malignant syndrome (NMS) • Agranulocytosis • Prolongation of the QT interval • Liver impairment Advanced Practice Interventions • Individual and group therapy • Psychoeducation • Medication prescription and monitoring • Basic health assessment • Cognitive remediation • Family therapy Evaluation • Reevaluate progress regularly and adjust treatment when needed • Even after symptoms improve outwardly, inside the patient is still recovering. • Set small goals; recovery can take months. • Active, ongoing communication and caring is essential. Audience Response Question Loose associations in a person with schizophrenia indicate A. paranoia. B. mood instability. C. depersonalization. D. poorly organized thinking. Audience Response Question Loose associations in a person with schizophrenia indicate A. paranoia. B. mood instability. C. depersonalization. D. poorly organized thinking. Audience Response Question Which assessment finding represents a negative symptom of schizophrenia? A. Apathy B. Delusion C. Motor tic D. Hallucination Audience Response Question Which assessment finding represents a negative symptom of schizophrenia? A. Apathy B. Delusion C. Motor tic D. Hallucination References • Steele, D. (2023). Keltner’s Psychiatric Nursing (9th ed.). Elsevier Health Sciences (US). • Varcarolis' foundations of psychiatric mental health nursing: A clinical approach (8 ed., pp. 191-221). Elsevier Saunders.