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Glossary of Ch. 18 & 19 Mental Health - Schizophrenia

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Schizophrenia (Brain Disease)
- 1st described in the late 1800's by EMIL KRAEPELIN as: DEMENTIA PRAECOX ("premature dementia" or "precocious madness")
- Early 1900's EUGEN BLEULER coined the term: SCHIZOPHRENIA (meaning "split minds": split between thoughts & emotions; poor eye contact)
- More recent: KURT SCHNEIDER described behaviours - "FIRST RANK" (positive symptoms: ex. psychotic delusions and hallucinations) and "SECOND RANK SYMPTOMS" (negative symptoms and other associated symptoms)

WHO (Schizophrenia)
- identified schizophrenia as 1 of the 10 MOST DEBILITATING diseases
- Stigma
- the longer the treatment is delayed, the worse the schizophrenia will get

DIAGNOSING SCHIZOPHRENIA:
- mixture of POSITIVE & NEGATIVE symptoms that present for a significant portion of a 1 MONTH period but with CONTINUOUS signs persisting for AT LEAST 6 MONTHS
- AT LEAST 2 of the following symptoms:
1. PERCEPTION (ex. hallucinations)
2. THOUGHT PROCESSES (thought derailment - can't get their thoughts straight)
3. REALITY TESTING (ex. delusions)
4. MOTIVATION (ex. AVOLITION: can't initiate/persist in goal-directed activities)
5. FEELING (ex. flat or inappropriate affect)
6. BEHAVIOUR (ex. social withdrawal)
7. ATTENTION (ex. inability to concentrate)







Assessment skills for diagnosing schizophrenia:
- clinical JUDGMENT is to identify whether a problem actually exists or not
- think about WHAT TO OBSERVE and what information to gather
- look for cues (VERBAL/NONVERBAL)
- Identify ASSUMPTIONS


SCHIZOPHRENIA:
- devastating illness impacts the person's life & the person's family
- one of the MOST PROFOUNDLY DISABLING illnesses (mental or physical)
- appears in LATE ADOLESCENCE or EARLY ADULTHOOD
- MALES typically experience symptoms 5-7 YEARS earlier than females (ex. males early 20's; females late 20's)


Course of ILLNESS:
- ACUTE ILLNESS PERIOD: very acute onset that is confusing to patient/family
- symptoms progress QUICKLY, DISRUPTIVE/BIZARRE behaviour (ex. WAXY FLEXIBILITY, CATATONIC, GRINDING TEETH; pg. 316 textbook)
- Unable to care for BASIC NEEDS (ex. poor hygiene; teach basic social skills)
- SUBSTANCE USE is common
- this phase: HIGH RISK for SUICIDE
- experience agression/psychosis




SCHIZOPHRENIA/CO-OCCURING SUBSTANCE USE:
- literature suggests that 50% of patients with schizophrenia have co-occurring SUBSTANCE USE disorder (dual diagnosis: common; hard to tell which diagnosis is causing the symptoms)
- MOST FREQUENTLY: ALCOHOL &/or CANNABIS (marijuana)
- WORSENS the course of schizophrenia

SCHIZOPHRENIA & SMOKING:
- people with a diagnosis of schizophrenia tend to SMOKE A LOT!
- HIGH RATES of CIGARETTE SMOKING (range from 58% to 90%)
- GREATER RISK for smoking related illnesses
- should we DEPRIVE them of pleasure?


COURSE of illness (schizophrenia) continued:
- After the initial diagnosis and initiation of treatment, STABILIZATION PERIOD becomes the focus
- treatment: usually MEDICATION & SUPPORT
- there is NO CURE for schizophrenia
- REHABILITATION/RECOVERY
- Next, MAINTENANCE/RECOVERY (no cure!)
- RELAPSES can occur (with EACH RELAPSE, there is a LONGER PERIOD to recover)




CLINICAL EXAMPLE OF A STABLE PHASE of Schizophrenia
John is a 35 year old man living in a downtown bed sitting room who attends a DAY TREATMENT program Monday through Friday. Although John EXPERIENCES HALLUCINATIONS FREQUENTLY (VISUAL), he is indeed stabilized. All health professionals agree that John is NOT A DANGER to himself or others & day treatment program is appropriate.
DSM-IV-TR CRITERIA (Table 18.2 - p. 314)
- 2 or more of the following symptoms:
1. DELUSIONS
2. HALLUCINATIONS
3. Disorganized SPEECH
4. Grossly DISORGANIZED or CATATONIC behaviour
5. NEGATIVE symptoms

Also:
- SOCIAL OCCUPATIONAL dysfunction
- duration of AT LEAST 6 MONTHS
- SCHIZOAFFECTIVE/MOOD disorders NOT PRESENT
- Not caused by SUBSTANCE ABUSE/general MEDICAL disorder (they have to rule this out during the assessment)










SCHIZOPHRENIA SUBTYPES:
*Do not need to know the different subtypes for the exam!
1. PARANOID TYPE: preoccupation with DELUSIONS/AUDITORY HALLUCINATIONS
2. DISORGANIZED TYPE: speech, behaviour, and flat or inappropriate affect
3. CATATONIC TYPE: AT LEAST 2 characteristics present
- motor IMMOBILITY or STUPOR
- excessive PURPOSELESS MOTOR activity
- extreme NEGATIVISM
- POSTURING, stereotyped movements, prominent mannerisms, or prominent grimacing
- ECHOLALIA (meaningless repetition or another's spoken words) or ECHOPRAXIA (meaningless repetition or imitation of another's movements)
4. UNDIFFERENTIATED TYPE: only characteristic symptoms present, but does not meet criteria for other subtypes
5. RESIDUAL TYPE: NEGATIVE/POSITIVE symptoms









EPIDEMIOLOGY of SCHIZOPHRENIA:
- occurs in ALL CULTURES & COUNTRIES
- occurs in 1.3% of the POPULATION
- VERY HIGH diagnosis among the HOMELESS population
- ECONOMIC COSTS are HIGH (billions)
- Cost in human suffering!
- 50% of patients have COMORBIDITY




POSITIVE SYMPTOMS of Schizophrenia:
***positive symptoms are caused by chemicals - (ex. serotonin and dopamine and GABA)
- EXCESS DOPAMINE levels in the brain
- DELUSIONS (false beliefs): "I am President of the US"
- HALLUCINATIONS (auditory or visual) - AUDITORY is MOST COMMON
- HOSTILITY/AGGRESSION (paranoia: very suspicious - be careful with proximity)
- IDEAS of REFERENCE
- SUSPICIOUSNESS
- people may believe that they are persecuted and that others are out to harm them
-







NEGATIVE SYMPTOMS of Schizophrenia:
- ALOGIA (poverty of SPEECH) - reduced fluency and productivity of THOUGHT & SPEECH
- AVOLITION (no motivation) - withdrawal and inability to initiate and persist in goal-directed activity
- Poor grooming and hygiene (important for nurses to teach these skills)
- ANHEDONIA (nothing gives them pleasure)
- BLUNTED: flattened affect (no emotion)



Illustration of SPEECH:
Nurse: "Are you ready Mr. Smith to take your stomach medicine?"
Patient: "Peptobismuth, petrobismuth, peptibismark; I'm gonna fly, cry, lie, buy, die"

What type of thought DISORDER is evident in this example? CLANG ASSOCIATION (the use of words or phrases that have similar sounds but are not associated in meaning; may include rhyming or puns)


What TYPE of DELUSION?
- Judy "hears" the voice of her dead mother call her a whore and a tramp (PERSECUTORY delusion) (auditory hallucination)

- Tammy "smells" her insides rotting. (SOMATIC delusion) (olfactory hallucination)

*DELUSIONS are ERRONEOUS FIXED BELIEFS that usually involve MISINTERPRETATION of experience; HALLUCINATIONS are FALSE PERCEPTIONS that occur WITHOUT actual external stimuli



Assessment of HALLUCINATIONS
- what causes would the nurse watch/assess that the patient may be hallucinating?
- Patient: "I 'hear' my father's voice saying terrible things about me. He says I am no good and should be punished."
- What would be an APPROPRIATE response?
* "Tell me more about that" or "That must be scary" or "Let's go do this" or "We're here and I don't hear any voices" - bring the patient back to reality after you determine what is going on


DELUSIONS
Patient: "I see now...you are in on the RCMP plot to drain my brain...you all want me destroyed." (PERSECUTORY delusion)

- What would be the appropriate intervention?
*REALITY based and EXPLORE the delusion - ex. CONTENT, underlying FEELINGS, etc.


CAUSES of Schizophrenia:
- MULTIPLE factors cause Schizophrenia
- NO SINGLE theory is responsible
- NEUROBIOLOGIC MODEL: biochemical, neurostructural, genetic, & prenatal factors
- Post-mortem/neuroimaging of the brain
- Cerebral BLOOD FLOW IMPAIRED/brain ATROPHY
- problems with DOPAMINE neurotransmission
- FAMILIAL patterns - genetic research (nature/nurture)
- PRENATAL risk factors: exposure to INFLUENZA, COMPLICATIONS of pregnancy






NURSING MANAGEMENT of Schizophrenia
- development of the nurse-patient relationship
- educate patient/family related to S&S of illness
- assessment: SAFETY priority
- Nutritional assessment
- Pharmacology (monitoring/administering)
- Mental status assessment




Medication Used in Treatment:
- Antipsychotics (1st Gen) - Haldol [Haloperidol]
- Atypical (2nd Gen) - Seroquel [Quetiapine]
- (3rd Gen) - Aripiprazole [Abilify]
- Augment: mood stabilizers


Extrapyramidal Side Effects (EPS)
- Akathisia [most common] - subjective feeling of restlessness
- Dystonia [abnormal postures] - torticollis
- Tardive Dyskinesia (TD) [appears late]
- Neuroleptic malignant syndrome (NMS) lethal side effect - cardinal sign - high body temperature (above 37.5)


Side Effect - Antipyschotic Use
- diabetes & metabolic syndrome
- weight gain
- hypertriglyceridemia
- can lead to cardiovascular disease
- nurse needs to be aware of factors - implications for practice



Medications used for side effects of Antipsychotics
- used to treat parkinsonism
- Cogentin [benztropine] or Artane [trihexyphenidyl]
- use to treat dystonic: Benadryl/Cogentin
- Experience is very frightening


Relapse
- ensuring adherence to the drug regimen is most challenging
- patients feel well - stop medications
- side effects - stop as well
- stress - factor in relapse
- nurse needs to teach strategies to increase adherence



Nursing TR - principles
- be calm - accept patients
- keep promises: be consistent/honest
- do not reinforce hallucinations/delusions
- do not touch patients without telling them
- avoid whispering/laughing when patients are unable to hear all conversation



Interdisciplinary role for the nurse
- assessment of current function
- medication management
- skills training
- family counselling
- vocational training & rehabilitation
- housing assistance
- crisis intervention





Psychosis
- schizophreniform disorder
- delusional disorder
- brief psychotic disorder
- schizoaffective disorder
- shared psychotic disorder (Folie a Deux)
- induced [secondary] psychosis
- psychotic disorder due to medical condition





Schizoaffective Disorder (SCA)
- complex/persistent illness
- symptoms of schizophrenia, major depressive disorder, manic or mixed episodes
- feel like they are on a "chronic roller coaster ride"
- very susceptible to suicide
- long term outcome is generally better
- can affect children & elderly
- age of onset: early adulthood
- most common: women
- cause: biologic theory (no evidence)
- genetic - possible
- biochemical - unclear
- Treatment: antipsychotic/antidepressant agents










Delusional Disorder
- characterized by nonbiazarre, logical, stable & well-systemized delusions
- delusions are the primary symptom (1 or more for at least a month)
- onset acute/gradual
- psychosocial functioning is not markedly impaired


Common Types of delusions:
- Erotomania - love at a distance
- Grandiose - great talent, made an important discovery
- Jealous - spouse/lover is unfaithful (paranoia)
- Somatic - bodily functions/sensations
- Mixed [unspecified] 2 or more delusions



Brief Psychotic Disorder
- sudden onset of psychotic symptoms
- the episode lasts at least 1 day but less than 1 month
- risk for suicide is high
- person returns to premorbid level of functioning
- precipitated by stressful life events



Shared psychotic disorder (Folie a Deux)
- close relationship [twins, mother & child] person has psychotic disorder - share delusional beliefs
- more common in women
- impairment of the person sharing is much less
- ex. Cult phenomenon - Waco


Induced [secondary] psychosis
- may be induced by substances [drugs of abuse, alcohol, medications, or toxins]
- withdrawal symptoms
- assessment - substances of abuse must be ruled out
- caused by the physiological consequences of a general medical condition [delirium, neurological conditions]


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