Post on 19-Dec-2015
transcript
Chapter 12
Schizophrenia and Schizophrenia Spectrum Disorders
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Lifetime prevalence of schizophrenia is 1% worldwide
No difference related to Race Social status Culture
Epidemiology
2Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Substance abuse disorders Nicotine dependence
Anxiety, depression, and suicide Physical health or illness Polydipsia
Comorbidity
3Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Biological factors Genetics
Neurobiological Dopamine theory Other neurochemical hypotheses
Brain structure abnormalities
Etiology
4Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Psychological and environmental factors Prenatal stressors Psychological stressors Environmental stressors
Etiology (Cont.)
5Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Prodromal Responses to treatment
Course of the Disorder
6Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Phase I – Acute Onset or exacerbation of symptoms
Phase II – Stabilization Symptoms diminishing Movement toward previous level of functioning
Phase III – Maintenance At or near baseline functioning
Phases of Schizophrenia
7Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
During the prepsychotic phase General assessment
Positive symptoms Negative symptoms Cognitive symptoms Affective symptoms
Assessment
8Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Alterations in thinking Delusions − False, fixed beliefs Concrete thinking − Inability to think abstractly
Positive Symptoms
9Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Alterations in speech − Associative looseness Clang associations Word salad Neologisms Echolalia
Positive Symptoms (Cont.)
10Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Other disorders of thought or speech Religiosity Magical thinking Paranoia Circumstantiality Tangentiality Cognitive retardation
Positive Symptoms (Cont.)
11Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Other disorders of thought or speech (cont.) Alogia, or poverty of speech Flight of ideas Thought blocking Thought insertion Thought deletion
Positive Symptoms (Cont.)
12Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Alterations in perception Depersonalization Derealization Hallucinations
• Auditory • Command• Visual
Positive Symptoms (Cont.)
13Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive Symptoms (Cont.)
Catatonia Motor retardation Motor agitation Stereotyped behaviors Waxy flexibility
Echopraxia Negativism Impaired impulse
control Gesturing or posturing Boundary impairment
14
Alterations in Behavior
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Affect Flat Blunted Inappropriate Bizarre
Negative Symptoms
15Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Difficulty with Attention Memory Information processing Cognitive flexibility Executive functions
Cognitive Symptoms
16Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Assessment for depression is crucial May herald impending relapse Increases substance abuse Increases suicide risk Further impairs functioning
Affective Symptoms
17Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
A patient with schizophrenia 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
Question 1
18Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
1. Any medical problems
2. Abuse of or dependence on alcohol or drugs
3. Risk to self or others
4. Command hallucinations
Assessment Guidelines
19Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
You believe that the young man you are admitting to your unit is suffering from command hallucinations.
What would be some questions to ask him?
Case Study
20Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
5. Delusions
6. Suicide risk
7. Ability to ensure self-safety
8. Medications
Assessment Guidelines (Cont.)
21Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
9. Mental status examination
10.Patient’s insight into illness
11.Family’s knowledge of patient’s illness and symptoms
Assessment Guidelines (Cont.)
22Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Positive symptoms Disturbed sensory perception Risk for self-directed or other-directed violence Impaired verbal communication
Negative symptoms Social isolation Chronic low self-esteem
Potential Nursing Diagnoses
23Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Phase I − Acute Patient safety and medical stabilization
Phase II − Stabilization Help patient understand illness and treatment Stabilize medications Control or cope with symptoms
Phase III − Maintenance Maintain achievement Prevent relapse Achieve independence, satisfactory quality of life
Outcomes Identification
24Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
After an acute admission, discharge is being planned for this patient.
What are some things that need to be considered?
Case Study (Cont.)
25Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Phase I – Acute Best strategies to ensure patient safety and provide
symptom stabilization Phase II – Stabilization Phase III – Maintenance
Provide patient and family education Relapse prevention skills are vital
Planning
26Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Acute Phase Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu Monitor fluid intake
Interventions
27Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Stabilization and Maintenance Phases Medication administration/adherence Relationships with trusted care providers Community-based therapeutic services
Interventions (Cont.)
28Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Counseling and communication techniques Hallucinations Delusions Associative looseness Health teaching and health promotion
Interventions (Cont.)
29Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Antipsychotic medications First-generation Second-generation Third-generation
Psychobiological Interventions
30Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Dopamine antagonists (D2 receptor antagonists) Target positive symptoms of schizophrenia Advantage
Less expensive than second generation Disadvantages
Extrapyramidal side effects (EPS) Anticholinergic side effects Tardive dyskinesia Weight gain, sexual dysfunction, endocrine
disturbances
First-Generation Antipsychotics
31Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Treat both positive and negative symptoms Minimal to no extrapyramidal side effects (EPS)
or tardive dyskinesia Disadvantage – tendency to cause significant
weight gain
Second-Generation Antipsychotics
32Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Aripiprazole (Abilify) Dopamine system stabilizer Improves positive and negative symptoms and
cognitive function Little risk of EPS or tardive dyskinesia
Third-Generation Antipsychotic
33Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Anticholinergic toxicity Neuroleptic malignant syndrome (NMS) Agranulocytosis
Potentially Dangerous Responses to Antipsychotics
34Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Antidepressants Mood stabilizing agents
Adjuncts to Antipsychotic Drug Therapy
35Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Individual and group therapy Psychoeducation Medication prescription and monitoring Basic health assessment Cognitive remediation Family therapy
Advanced Practice Interventions
36Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
1. Loose associations in a person with schizophrenia indicate
A. paranoia.
B. mood instability.
C.depersonalization.
D.poorly organized thinking.
Audience Response Questions
37Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
2. Which assessment finding represents a negative symptom of schizophrenia?
A. Apathy
B. Delusion
C.Motor tic
D.Hallucination
Audience Response Questions
38Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.