Schizophrenia History

19th CenturyKraepelin- Dementia Praecox

20th CenturyBleuler

autism-apathy-ambivalence-anhedonia

Arieti

associative looseness, auditory

hallucinations

Current theories

Genetic

↓ 1% of population

10 % of 1st degree relatives

35-55% concordance rate in monozygotic

twins (genetically identical)

15-17% concordance rate in dizygotic

twins (share half their genes)

Slightly more men than women Early 20s age of first psychotic break 75% of people have permanent disability Cultural component on relapse Developing countries have better prognosis than

developed countries

Neurotransmitter imbalance

Dopamine system hyperactivity

Norepinepherine elevation

Serotonin elevation

Diminished levels of GABA

Decreased co-enzyme for conversion of PKU to tyrosine

Central Nervous System Anomaly

Type 2 enlarged ventricles

negative symptoms resistant to medication

Type 1 positive symptoms respond to medication

Positive Symptoms

Delusions

Hallucinations

Disorganized speech

Bizarre or disorganized behavior

Negative Symptoms

Flat Affect

Avolition

Alogia

Anhedonia

Attention Impairment

History of Therapy

Psychoanalytic

Sullivan/Peplau

Interpersonal Communication

Somatic

Insulin Coma

Electroconvulsive Therapy

Psychosurgery

Psychopharmacology

1950s phenothiazines

1990s D1-D2 receptor medications

Community Mental Health

Milieu

Therapeutic Community

De-institutionalization

Typology of Thought Disorder

Paranoid

Catatonic

Disorganized

Undifferentiated

Residual

Paranoid

Delusions- especially persecutory

Auditory Hallucinations

No loose associations

No marked affective problem

Paranoid

Catatonic

Stupor or mutism

Negativism

Rigidity

Excitement

Posturing (waxy flexibility)

Disorganized

Marked looseness of associations

Grossly inappropriate affect

Disorganized

UndifferentiatedProminent delusions

Hallucinations or grossly disorganized behavior

Residual

Diagnosis

Presence of 1,2, or 3 for more than 1 week

1. Two of the following:

delusions, prominent

hallucinations, marked

associative looseness

catatonic behavior

flat or silly affect

2. Bizarre delusions

3. Prominent hallucinations

Continuous signs of disturbance ↑ 6 months

18 years if age or more

Downward course

Nursing Process- Assessment

1.Perceptual changes:

illusions, hallucinations

2. Thought disorder:

loose associations, clanging, delusions

3. Communication changes:

thought disorganization,

blocking, tangential, circumstantial

4. Motor Changes:

catatonia-excited, posturing, waxy

flexibility

5. Family:

enmeshed, family burden

Nursing Diagnosis

Impaired communication

poverty of speech

blunt emotions

Self-care deficits

Activity intolerance

Social isolation

Decisional conflict

Sensory alterations

Body image distortion

Altered thought processes

delusions, magical thinking

thought insertions, withdrawal

thought broadcasting

Altered emotional response

blunted or flat affect

anhedonia

Altered family function

Nursing Planning & Intervention

Adequate communication

Grooming & hygiene

Social skills

Intervene with delusions

Family understanding

Medication usage

Organize behavior

Reality based perceptions

Congruent emotional responses

Community contacts

Nursing Planning & Intervention

Adequate communication

Grooming & hygiene

Social skills

Intervene with delusions

Family understanding

Medication usage

Organize behavior

Reality based perceptions

Congruent emotional responses

Community contacts

Nursing Implications with Neuroleptic Medications

1. Phenothiazines

Thorazine(Chlorpromazine)

Mellaril (Thiorizidine)

Stelazine (Trifluoperazine)

Prolixin (Fluphenazine)

Prolixin Decanoate

2. Butyrophenes

Haldol (Haloperidol)

Haldol LA

3. Low potency D1-D2 medications

Clozaril (Clozapine)

Risperdol (Resperidone) & Risperdol E

Zyprexa (Olanzapine)

Abilify (Ariprazole) Geodon (Ziprasidone)

Side Effects

Nervous system Extra Pyramidal SymptomsAkathisiaDystoniaAkinesiaPseudo parkinsonismTardive dyskinesia

Tardive Dyskinesia

Other Side Effects

Photophobia

Leukocytosis

Orthostatic hypotension

Anti-cholinergic effects

D1 and D2 effects

Weight gain Impotence Risk for development of Diabetes Mellitus (Geodon) Gallactarhea

Neuroleptic malignant syndrome

Possibly fatal side effect of neuroleptics Non-dose related Fever Confusion Convulsions Death Rx-stop neuroleptic- emergency care

Amantadine 200-400 mgmpo/day in divided doses

Side Effect Treatment

Anti-parkinson medications:

Cogentin (Benztropine)

Artane (Trihexyphenidyl)

Symmetrel (Amantadine)

Atropine Psychosis

Mad as a hatter confused

Red as a beet fever

Dry as a bone anticholinergia

Blind as a bat diplopia

Rx. Hold medication and re-hydrate

Laboratory Values for Schizophrenia

White blood cell count Leukopenia (WBC 2,000 – 3,000)and agranulocytosis

(granulocytes less than 1,000) with certain psychotropic mendiations, such as phenothiazines , carbamazepine, and CLOZARIL

Leukocytosis with neuroleptic malignant syndrome

Assessment Tools for Schizophrenia

Abnormal Involuntary Movement Scale (AIMS) (public)

Brief Psychiatric Rating Scale (Psychological Reports, 1962 10:799)

Schedule for Affective Disorders and Schizophrenia (SADS) (Archives of General Psychiatry, 1978 35:837)

Scale for the Assessment of Negative Symptoms (SANS) (University of Iowa Press, 1983)

Scale for the Assessment of Thought, Language, and Communication (TLC) (University of Iowa Press, 1978)

Thought Disorder Index (TDI) (Archives of General Psychiatry, 1983 40:1281)

Quality of Life Scale (QLS) (Schizophrenia Bulletin, 1984, 10: 383

Chestnut Lodge Prognastic Scale for Chronic Schizophrenia (Schizophrenia Bulletin, 1987 13:277)