Psychiatric Nursing: Schizophrenia, Bipolar, Depression - PDF

CHAPTER Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright...

CHAPTER Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright 24 Schizophrenia Spectrum and Other Psychotic Disorders Norman L. Keltner http://evolve.elsevier.com/Keltner LEARNING OBJECTIVES Define the term schizophrenia. Identify biologic explanations for schizophrenia. Describe the major historic figures, events, and theories Describe two theoretical psychodynamic explanations for that have contributed to the current understanding of schizophrenia. schizophrenia. Develop a nursing care plan for patients with Identify Bleuler’s “four A’s.” schizophrenia. Recognize the DSM-5 criteria and terminology for Identify the major drugs used in the treatment of schizophrenia. schizophrenia, their mechanisms of action, their target Differentiate and describe type I (positive) and type II symptoms, and their major side effects. (negative) subtypes. Evaluate the effectiveness of nursing interventions for Recognize and describe objective and subjective patients with schizophrenia. symptoms of schizophrenia. There are three inescapable “facts” about schizophrenia split personality. Split personality refers to something like a (Weinberger, 1987): Jekyll and Hyde experience or a multiple personality disorder. 1. Age at onset: Onset is almost always during late adoles- This popular depiction does not begin to portray schizophre- cence or early adulthood. nia. Schizophrenia is not characterized by a changing person- 2. Role of stress: Onset and relapse are almost always related ality; it is characterized by a deteriorating personality. This to stress. popular notion of a dramatic personality change comes far 3. Efficacy of dopamine antagonists: Drugs that block dopa- short of capturing the devastating effect that schizophrenia mine receptors are therapeutic. has on the life of a person and the person’s family. Simply Psychosis is a “… disorder in which the highest mental stated, schizophrenia is one of the most profoundly disabling functions, such as thought, language, emotions, conation, mental or physical illnesses that the nurse will ever encounter. and cognition, are drastically disrupted” (Nasrallah, 2012). An impaired ability to relate to others makes it worse. Common NORM’S NOTES symptoms of psychosis include hallucinations, delusions, and This might be the most important chapter in this difficulty with thought organization. Psychosis can be present book. Although schizophrenia affects only about in schizophrenia, acute mania, depression, drug intoxication, 1% of the adult population (Table 24-1), it is a devastating disorder because it has ripple effects dementia, and delirium and can be caused by brain trauma. that have a disproportionate impact on society. Schizophrenia is one of the most common causes of psychosis. These are the people that you might walk by (or around) in our cities, not wanting to interact with them at all. They might SCHIZOPHRENIA scare you at times or offend in other ways. After reading this law. chapter and after having a good clinical experience, I think your Although many laypeople are quite sophisticated medi- attitude about these individuals will change. cally, it is common to hear the word schizophrenia defined as EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/11/2020 10:39 AM via UNIVERSITY OF LIMERICK 247 AN: 1167485 ; Norman L. Keltner, Debbie Steele.; Psychiatric Nursing - E-Book Account: s9762658  248 CHAPTER 24 Schizophrenia Spectrum and Other Psychotic Disorders Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright TABLE 24-1 12-MONTH PREVALENCE RATE OF MENTAL DISORDERS IN THE UNITED STATES* APPROXIMATE PERCENTAGE >17 YEARS OLD (%)* (unless noted GENDER DISORDERS for children) OVERREPRESENTATION Anxiety disorders 18.1 overall Agoraphobia 1.7 Female Panic disorder 2.4 Female Panic attacks 11.2 Female Social anxiety 7 Female Specific phobia 7-9 Female Separation anxiety 1.2 Equal Generalized anxiety disorder 2 Female Posttraumatic stress disorder 3.4 Female Obsessive-compulsive disorder 1.2 Equal Major depression 8.6 Female Bipolar disorder I and II 1.8 BD I: ~Equal BD II: Female Autism spectrum disorders 1 in children Male Disruptive, impulse control, and conduct disorders 8.9 overall Conduct disorders* 4 in children Male Attention-deficit/hyperactivity disorder* 5 in children; 2.5 in adults Male Substance use disorders 8.9 overall Alcohol use disorder 8.5 in adults; 2.5 in 12- to 17-year-olds Male Drug use disorders 1.4 Male Schizophrenia 1.1 ~Equal *No one source has all of this information. This information has been derived from the following sources: Kessler, R.C., et al. (2012). Twelve- month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods of Psychiatric Research, 21, 169; Substance Abuse and Mental Health Services Administration (2009). Results from the 2008 national survey on drug use and health: national findings. Accessed November 13, 2013; American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: APA. Schizophrenia is a diagnostic term used to describe a BOX 24-1 TYPICAL GENDER- ­ ajor psychotic disorder characterized by disturbances in the m BASED DIFFERENCES IN ­following areas: SCHIZOPHRENIA Perception (e.g., hallucinations) Thought processes (e.g., thought derailment) Age of onset is typically 4 to 6 years earlier in men. Men have a more severe course. Reality testing (e.g., delusions) Women have more positive symptoms (e.g., hallucinations). Feeling (e.g., flat or inappropriate affect) Estrogen modulates dopamine function and presumably Behavior (e.g., social withdrawal) plays a protective role for women. Attention (e.g., inability to concentrate) Women are more compliant with medications. Motivation (e.g., cannot initiate or persist in goal-directed Women tend to have lower blood levels and longer half- activities) lives of medications. Contributing to overall deterioration is a decline in psy- chosocial functioning. Schizophrenia typically first appears in late adolescence or early adulthood. Schizophrenia affects men and women almost equally; however, gender differences do exist (Seeman, 2010). Box 24-1 highlights some of the gen- BOX 24-2 PRENATAL AND PERINATAL der differences in expression of this disorder. EVENTS ASSOCIATED WITH Studies have shown that approximately 1% of the pop- SCHIZOPHRENIA ulation experiences schizophrenia during their lifetime. Maternal influenza Although the prevalence rate and symptom presentation for Birth during late winter or early spring schizophrenia are fairly constant worldwide, inner-city resi- Obstetric complications dents, people from lower socioeconomic classes, and indi- Prenatal exposure to lead viduals who experience prenatal difficulties are more likely Maternal starvation to be affected (Box 24-2) (American Psychiatric Association, Perinatal exposure to cats (i.e., viral zoonosis) law. 2013). Economic costs are in the tens of billions of dol- lars each year. The cost in human suffering is incalculable. Data from Bachmann et al. (2008), Opler et al. (2004), and APA (2013). EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/11/2020 10:39 AM via UNIVERSITY OF LIMERICK AN: 1167485 ; Norman L. Keltner, Debbie Steele.; Psychiatric Nursing - E-Book Account: s9762658  CHAPTER 24 Schizophrenia Spectrum and Other Psychotic Disorders 249 Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright BOX 24-3 EVOLUTION OF individuals with schizophrenia. All four of these classic symp- SCHIZOPHRENIC SUBTYPING toms begin with the letter “A” (Bleuler’s “four A’s”), which ­facilitates memorization: affect disturbance, autism, associa- 1860 Morel coins the term dementia praecox. tive looseness, and ambivalence. 1871 Kahlbaum uses the term catatonia to describe Kraepelin and Bleuler, two historical giants of psychiatry, patients immobilized by psychological factors. founded two divergent views of schizophrenia. In using the 1874 Hecker uses the term hebephrenia to describe diagnostic category of dementia praecox, Kraepelin revealed patients with silly, bizarre, and regressed behaviors. a conceptual alignment between schizophrenia and disorders 1878 Kraepelin adds the term paranoia to describe such as Alzheimer’s disease, which have a less optimistic prog- highly suspicious patients. nosis. Bleuler developed a school of thought that was much 1899 Kraepelin groups all three patient categories broader and more optimistic than that of Kraepelin. Based on under the heading dementia praecox. Bleuler’s wider grouping, pessimism eased, and some clini- 1900s Bleuler introduces the term schizophrenia to cians began to see improvements in their patients. Although describe these mental disorders. Kraepelin based his views on biology, Bleuler, influenced by 1952 DSM-I: Includes 9 subtypes for schizophrenia. the master analyst Freud and other psychodynamic theorists, 1968 DSM-II: Includes 11 subtypes. sought psychological explanations for schizophrenia. For 1980 DSM-III: Reduced to 5 subtypes: disorganized, most of the twentieth century, Freud’s psychoanalytic expla- catatonic, paranoid, undifferentiated, and nations and, by extension, Bleuler’s thinking dominated the residual. 1982 Andreasen and Olsen (1982), Crow (1982), and understanding of schizophrenia. However, as the limitations others categorize schizophrenia based on of “talking” cures became more evident, mental health profes- symptoms: positive (type I) and negative sionals became less interested in the psychodynamic approach. (type II). In the past 30 years or so, a resurgence of interest in biologic 1994 DSM-IV: Includes same subtypes as DSM-III. research has resulted in renewed respect for Kraepelin’s work. 1997 American Psychiatric Association recognizes the addition of the subtype “disorganized” to the Course of Illness positive and negative subtyping concept. Schizophrenia typically first occurs in adolescence or early 2000 DSM-IV-TR: Includes same subtypes. adulthood, a time during which brain maturation is almost 2013 DSM-5: Removes subtypes. complete. There are three overlapping phases of the disorder, DSM, Diagnostic and Statistical Manual of Mental Disorders. as follows: Acute phase: The patient experiences severe psychotic symptoms. Box 24-3 outlines the statistical epidemiologic realities of Stabilizing phase: The patient is getting better. schizophrenia. Stable phase: In this phase, the patient might still experi- Morel was the first to name the psychiatric symptoms of ence hallucinations and delusions, but the hallucinations schizophrenia. In 1860, while treating an adolescent boy, and delusions are not as severe or disabling as they were Morel used the phrase dementia praecox (precocious s­ enility) during the acute phase. to describe the group of symptoms he observed (Kolb & Most patients alternate between acute and stable phases. Brodie, 1982). Kahlbaum (in 1871) and Hecker (in 1874) added to the diagnostic nomenclature with their categories catatonia and hebephrenia (Sadock & Sadock, 2003). In 1878, Clinical Example- Hallucinating but Stable Billy is a 39-year-old man living in a psychiatric residential Kraepelin added the term paranoia and engaged in a rigor- facility who attends a day treatment program Monday ous study of what is now called schizophrenia. Kraepelin found through Friday. Although Billy experiences hallucinations commonalities among the three mental disorders (catatonia, frequently, most often visual hallucinations, he is stabi- hebephrenia, and paranoia) and grouped them in 1899 under lized. All staff members agree that Billy is not a danger to the diagnostic term that Morel had coined 40 years before— himself or others and that the day treatment program is dementia praecox (Sadock & Sadock, 2003). Kraepelin believed more appropriate for him than a state hospital would be. that schizophrenia was the result of neuropathologic factors; he envisioned a progressive deteriorating course, resulting in disabling mental impairment with little hope of recovery. CRITICAL THINKING QUESTION It was left to Bleuler in the early 1900s to coin the term 1. Why do you think Kraepelin was so pessimistic about the schizophrenia in a book subtitled The Group of Schizophrenias. patients he saw with dementia praecox? Bleuler believed that schizophrenia does not always follow a course of deterioration (making the term dementia inap- propriate), and it does not always occur early in life (mak- DSM-5 Terminology and Criteria ing the term praecox also inappropriate). Bleuler broadened Since the inception of schizophrenia as a diagnostic entity, law. Kraepelin’s concept by focusing on symptoms and identified attempts have been made to divide it into subtypes. However, four primary symptoms that he believed were present in all DSM-5 has abandoned the subtyping of schizophrenia EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/11/2020 10:39 AM via UNIVERSITY OF LIMERICK AN: 1167485 ; Norman L. Keltner, Debbie Steele.; Psychiatric Nursing - E-Book Account: s9762658  250 CHAPTER 24 Schizophrenia Spectrum and Other Psychotic Disorders Positive versus Negative Schizophrenia Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright ­because the American Psychiatric Association (2013) found it unhelpful and limiting (see Box 24-3 and DSM-5 Criteria Positive (type I) schizophrenia has a different constellation of box). Although DSM-5 criteria have been thoughtfully symptoms than negative (type II) schizophrenia (Box 24-4). ­deliberated, we find the subtyping approach based on type I Type I is positive in the sense that symptoms are an embel- (or positive) versus type II (or negative) symptoms clinically lishment of normal cognition and perception. The symptoms helpful because it can be predictive of medication response. are additional. Positive symptoms are believed to be the result The student should realize that most patients are not “either/ of elevated dopamine levels affecting the limbic areas of the or” but have a mixture of positive and negative symptoms. brain. DSM-5 CRITERIA Schizophrenia Diagnostic Criteria Specify if: A. Two (or more) of the following, each present for a sig- The following course specifiers are only to be used after a nificant portion of time during a 1-month period (or less if 1-year duration of the disorder and if they are not in contradic- successfully treated). At least one of these must be (1), tion to the diagnostic course criteria. (2), or (3): First episode, currently in acute episode: First manifestation of 1. Delusions. the disorder meeting the defining diagnostic symptom and 2. Hallucinations. time criteria. An acute episode is a time period in which the 3. Disorganized speech (e.g., frequent derailment or inco- symptom criteria are fulfilled. herence). First episode, currently in partial remission: Partial remission is 4. Grossly disorganized or catatonic behavior. a period of time during which an improvement after a previ- 5. Negative symptoms (i.e., diminished emotional expres- ous episode is maintained and in which the defining criteria sion or avolition). of the disorder are only partially fulfilled. B. For a significant portion of the time since the onset of the First episode, currently in full remission: Full remission is a peri- disturbance, level of functioning in one or more major areas, od of time after a previous episode during which no disorder- such as work, interpersonal relations, or self-care, is mark- specific symptoms are present. edly below the level achieved before the onset (or when Multiple episodes, currently in acute episode: Multiple epi- the onset is in childhood or adolescence, there is failure to sodes may be determined after a minimum of two episodes achieve expected level of interpersonal, academic, or occu- (i.e., after a first episode, a remission and a minimum of one pational functioning). ­relapse). C. Continuous signs of the disturbance persist for at least Multiple episodes, currently in partial remission 6 months. This 6-month period must include at least Multiple episodes, currently in full remission 1 month of symptoms (or less if successfully treated) that Continuous: Symptoms fulfilling the diagnostic symptom crite- meet criterion A (i.e., active-phase symptoms) and may in- ria of the disorder are remaining for the majority of the illness clude periods of prodromal or residual symptoms. During course, with subthreshold symptom periods being very brief these prodromal or residual periods, the signs of the dis- relative to the overall course. turbance may be manifested by only negative symptoms or by two or more symptoms listed in criterion A present Unspecified in an attenuated form (e.g., odd beliefs, unusual perceptual Specify if: experiences). With catatonia (refer to the criteria for catatonia associated with D. Schizoaffective disorder and depressive or bipolar disor- another mental disorder, pp 119-120, for definition). der with psychotic features have been ruled out because Coding note: Use additional code 293.89 (F06.1) catatonia as- either (1) no major depressive or manic episodes have oc- sociated with schizophrenia to indicate the presence of co- curred concurrently with the active-phase symptoms or morbid catatonia. (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the Specify Current Severity total duration of the active and residual periods of the Severity is rated by a quantitative assessment of the pri- ­illness. mary symptoms of psychosis, including delusions, hal- E. The disturbance is not attributable to the physiological ef- lucinations, disorganized speech, abnormal psychomotor fects of a substance (e.g., a drug of abuse, a medication) or ­behavior, and negative symptoms. Each of these symptoms another medical condition. may be rated for its current severity (most severe in the last F. If there is a history of autism spectrum disorder or a com- 7 days) on a 5-point scale ranging from 0 (not present) to munication disorder of childhood onset, the additional diag- 4 (present and severe). (See Clinical-Rated Dimensions of nosis of schizophrenia is made only if prominent delusions Psychosis Symptom Severity in the chapter “Assessment or hallucinations, in addition to the other required symptoms Measure.”) of schizophrenia, are also present for at least 1 month (or Note: Diagnosis of schizophrenia can be made without using less if successfully treated). this severity specifier. law. From the American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: APA. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/11/2020 10:39 AM via UNIVERSITY OF LIMERICK AN: 1167485 ; Norman L. Keltner, Debbie Steele.; Psychiatric Nursing - E-Book Account: s9762658  CHAPTER 24 Schizophrenia Spectrum and Other Psychotic Disorders 251 Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright BOX 24-4 POSITIVE AND NEGATIVE Clinical Example: Negative Symptoms SYMPTOMS OF Philip Wilson has a long history of mental problems. SCHIZOPHRENIA* Mr. Wilson is a patient in the state hospital system. The summary note written by the nursing team leader includes Positive Symptoms: Caused by Excessive Dopamine the following observation: “Mr. Wilson is isolative and, in Mesolimbic Tract* for the most part, expressionless. He spends long hours Abnormal thoughts ­sitting and staring out of the window. Attempts to engage Agitation Mr. Wilson in unit activities have not been successful.” Bizarre behavior Delusions Excitement One consequence of the positive versus negative subtyping Feelings of persecution approach has been the tendency by a few professionals to be Grandiosity too pessimistic about the prognosis of patients with type II Hallucinations schizophrenia. Kopelowicz and Bidder (1992), who cautioned Hostility nurses and others against such rash and uninformed think- Illusions ing, divided negative symptoms into primary and ­secondary. Insomnia The secondary symptoms are therapeutically accessible, Suspiciousness particularly early in the course of the illness. Secondary ­ Negative Symptoms: Caused by Too Little Dopamine symptoms include symptoms caused by the following: in Mesocortical Tract* Medications Alogia Hospitalizations Anergia Loss of social supports Asocial behavior Socioeconomic decline Attention deficits If assessed early, secondary negative symptoms can be Avolition arrested. Blunted affect Communication difficulties Difficulty with abstractions Clinical Example: Lack of Connectedness Merritt is a homeless man with a long history of mental Passive social withdrawal illness. He has not seen his family in many years. Although Poor grooming and hygiene his family was supportive at one time, they simply grew Poor rapport tired of trying to cope with him. At this point, even modest Poverty of speech improvements in his mental health are compromised by * This is an oversimplification of what occurs in the limbic and frontal his lack of social support. lobes of the brain. According to biologic theory, typical antipsychotic drugs Clinical Example: Positive Symptoms (drugs that antagonize primarily dopamine D2 receptors) are John is sitting in the day room on the psychiatric unit when likely to be beneficial for positive symptoms because positive his eyes begin to dart back and forth, and he becomes in- schizophrenia is a hyperdopaminergic process. In contrast, creasingly anxious. You ask, “John, are you hearing some- negative schizophrenia is thought to be more structurally thing that I cannot hear?” “Can’t you hear them?” he replies. related and a hypodopaminergic process. Traditional anti- “They are going to get me.” John’s auditory hallucination is a psychotics have relatively less effect and might cause negative positive symptom because it is an exaggeration of a normal symptoms to worsen. The more excessive the symptoms are perception (he is “hearing” without an auditory stimulus). (as in positive schizophrenia), the greater the likelihood of a favorable response to antipsychotics. As noted in Chapter 14, Type II is labeled negative because symptoms are essen- atypical antipsychotic drugs, such as clozapine (Clozaril), tially an absence or diminution of normal cognition and risperidone (Risperdal), olanzapine (Zyprexa), quetiapine perception (e.g., lack of affect, lack of energy). Type II is re- (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify), lated, at least in part, to a hypodopaminergic process. These benefit negative symptoms because they affect dopamine symptoms also can be caused by cortical structural changes. receptors and antagonize serotonin 5-hydroxytryptamine Pathoanatomy consistently mentioned in the literature in- 2A receptors, which liberate dopamine in cortical areas. The cludes decreased cerebral blood flow and increased ven- dopamine corrects the hypodopaminergic state. Most of tricular brain ratios. Decreased frontal blood flow is most these newer drugs are expensive. For example, a 30-day sup- pronounced in the dorsolateral prefrontal cortex. Ventricular ply of Zyprexa could cost more than $500, whereas the same enlargement can be detected on computed tomography (CT) amount of Haldol might cost about $20 (see Table 14-7). and magnetic resonance imaging (MRI) with the ­naked eye. Other pathoanatomic features observed that might ­contribute Behavior law. to negative symptoms include a modest reduction in brain People who are treated for mental problems come to the weight and cerebral atrophy. ­attention of mental health professionals in one of two ways. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/11/2020 10:39 AM via UNIVERSITY OF LIMERICK AN: 1167485 ; Norman L. Keltner, Debbie Steele.; Psychiatric Nursing - E-Book Account: s9762658  252 CHAPTER 24 Schizophrenia Spectrum and Other Psychotic Disorders Copyright © 2015. Mosby. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright The first is when people seek help. They do so because they Often, these problems develop over a long period, well before have experienced such troubling subjective symptoms that schizophrenia is diagnosed, and become more pronounced as they want professional intervention. However, professional the illness progresses. It is common to hear that a person was help often is not sought until people have exhausted self-help asocial, a loner, or a social misfit before being diagnosed. aids, friends, and family, leading to the second way in which Frequently, patients become less concerned with their ap- people come to the attention of the mental health system, pearance and might not bathe without persistent prodding. which is by drawing attention to themselves through behav- Table manners and other social skills might diminish to the iors that bother, concern, or frighten other people. These in- point at which patients are disgusting to others. These behav- dicators of a mental disorder are apparent to others and are iors are related to introspection (autism) and apathy. Patients called objective signs. As discussed in Chapter 3, help is some- are focused on internal processes to the extent that their external times resisted, and the person must be treated on an involun- social world collapses. Schizophrenia can cause a diminished en- tary basis. ergy level (anergia), which also complicates social interactions. Subjective and objective categories are not as discrete as Interpersonal communication becomes inadequate and they might appear at first. For example, hallucinations are might be inappropriate. Again, internal processes are at work. subjective phenomena but might easily cause objective signs Hostility, a common theme, also distances patients from others. that get the attention of others (e.g., a person who talks Finally, patients with schizophrenia withdraw, further compro- back to an auditory hallucination). Nonetheless, dividing mising their ability to engage in meaningful social interactions.