Unit 4: Thought Disorders and Medications

Schizophrenia in Focus

Schizophrenia: Bleuler’s 4-A’s AFFECT: flat, blunted, inappropriate or

bizarre affect AMBIVALENCE: holding opposing

opinions or attitudes at the same time ASSOCIATIVE LOOSENESS: Jumbled,

illogical thinking AUTISM: living in one’s own fantasy

world—turned in to the self

Classifying Symptoms: Positive Symptoms “What’s there that shouldn’t be there” Hallucinations Delusions Bizarre Behavior Disorganized speech, word salad,

echolalia

Thought Alterations Ideas of reference Persecutory, grandiose, somatic

delusions Thought blocking, insertion, withdrawl,

broadcasting Command/control hallucinations

Classifying Symptoms: Negative Symptoms “What’s not there that should be there” Lack of Feeling and affect including

positive emotion (anhedonia) Poverty of thought (alogia) Loss of motivation (avolition)

Classifying Symptoms:Cognitive Symptoms

Thinking and Decision-making Impaired memory Poor problem solving and poor

judgment Illogical thinking Inattention, distractability

Phases of Schizophrenia Prodromal: isolation, behavior change, often

in adolescence or y. adult Acute/Active Phase: Evident psychosis.

Periods of fluctuation, but symptoms are evident

Chronic/Residual: Long term outcome is that the intensity of the psychosis may diminish, leaving more of the negative symptoms

Theories of Causation Many of the psychological theories are now

doubted as evidence of a brain disease is more clear.

Genetic transmission is evident Dopamine theory—excess dopamine (does

not explain all) Glucomate theory—regulation of glucomate

(NMDA) receptor in brain r/t PCP psychosis

Neuroanatomical Changes Enlarged lateral cerebral ventricles Cortical and cerebellum atrophy Third ventricle dilation and asymmetry Changes in blood flow and glucose

metabolism patterns

Mechanism of Action of Antipsychotics Phenothiazines: block post-synaptic dopamine

receptors giving a decreased dopamine response. Works on + symptoms only

Atypical antipsychotics: Antagonizes both serotonin and dopamine receptors giving a decreased dopamine and serotonin response. Works on + and – symptoms both

See supplemental info on Oncourse

Side effects of antipsychotics Extrapyramidal (see H/O in syllabus) Tardive dyskinesia: can be permanent, See AIMS test, don’t raise dose of med Anticholinergic side effects (go over) Blood dyscrasias Photosensitivity, excess prolactin

Neuroleptic Malignant Syndrome Life threatening: increased temp,

decreased consciousness, severely increased muscle tonicity, HTN, tachycardia, drooling sweating

Stop the antipsychotic, treat symptoms in a monitored setting (ICU), fluids, cooling blanket, dantrolene, parlodel (a dopamine agonist)

Nursing Diagnosis: Non compliance Not taking meds or attending therapy is

a big factor leading to rehospitalization Why? Denial, hate being in sick role,

lack of judgment, side effects of meds

Nursing Diagnosis: Potential for violence Usually related to paranoia/perceived

threat

Nursing Diagnosis: Impaired social interaction Related to negative symptoms, hard to

change!

Nursing Diagnosis: self care deficit No motivation to bathe, lack of

recognition of problem, paranoia

Nursing Diagnosis: altered nutrition/FVE Paranoia about eating and drinking

Excess fluid intake

Nursing diagnosis: risk for suicide About 10% schizophrenics commit

suicide

Paranoid Schizophrenia Intense, strongly defended irrational

suspicions Ideas of reference Behaving with anger, sarcasm, hostility Projection of feelings Often paranoid ideas are intricate and

complex

Nursing Tactics with Paranoia Calm, matter of fact approach—don’t smother

or hover Respect personal territory Verbal indication of nursing measures before

intervention Be honest, trustworthy, consistent Don’t feed delusions or challenge directly—

cast reasonable doubt and focus on reality Look at underlying themes in delusions

More nursing interventions in Paranoia Help client manage anger and fear

through consistent limits, appropriate diversion, and not taking bx personally

“When in doubt, check it out” strategy Talk about dealing with food and med.

paranoia

Disorganized Schizophrenia Regression, increased social

impairment, bizarre affect/behavior, incoherent speech

Nursing measures: help with grooming, eating. Routine, consistent and structured. Understanding milieu. Plus all the general nsg measures.

Catatonia: abnormal motor behavior Withdrawn: posturing, waxy flexibility, stupor,

mute, unaware of environment Nsg care in Withdrawn state: complete

hygiene, nutrition, mobility, bathroom assist Excited: Gross hyperactivity-running striking

out Nsg with Excited: preserve milieu, keep client

safe

Other categories of Schizophrenia Undifferentiated – means doesn’t fit a

specific othre group Residual—means most of the active

symptoms are gone (mostly negative symptoms remaining)