Alterations in mental health - Schizophrenia

1. IV. Alterations in mental health -
schizophrenia
Lectured by: Leila T. Salera, RN, MD,
DPSP

2. Epidemiology of mental illness
• According to the WHO’s World Health Report in 2003:
a. Mental, neurological and substance disorders cause a
large burden of disease and disability
b. Globally, 13% of overall disability-adjusted life years and
33 % of overall years lived with disability
c. More than 150 million people suffer from depression at
any point in time
d. Nearly 1M commit suicide each year
e. About 25M suffer from schizophrenia
f. 38M suffer from epilepsy
g. More than 90M suffer from drug use or disorder
(Public Health Nursing in the Philippines, page 228)

3. schizophrenia
• Causes disoriented and bizarre thoughts, perceptions,
emotions, movements, and behavior
• Cannot be defined as a single illness
• Thought of as a syndrome or as disease process with
many different symptoms
• Usually diagnosed in late adolescence or early
adulthood
• Rarely manifests in childhood
• Peak incidence of onset: 15 to 25 years for men, and 25
to 35 years for women
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

4. schizophrenia
• Emil Kraepelin – described the term “dementia
precox” (before it was called schizophrenia); it
emphasized the change in cognition (dementia)
and early onset (precox) of the disorder
• Patients with dementia precox were described as
having a long-term deteriorating course and the
clinical symptoms of hallucinations and delusions
• Paranoia – characterized by persistent
persecutory delusions

5. schizophrenia
• Eugene Bleuler – coined the term
schizophrenia which replaced the term
demenita precox in the literature
• Unlike Kraepelin’s concept, schizophrenia
need not have a deteriorating course
• It is not the same as split personality

6. Schizophrenia
• The Four As:
1. Associational disturbances of thought or
association looseness
2. Affective disturbances
3. Autism
4. Ambivalence
• Add one more A for auditory hallucinations

7. Types of Schizophrenia
• Diagnosis is made according to the client’s
predominant symptoms:
A. Schizophrenia, paranoid type – persecutory or
grandiose delusions
B. Schizophrenia, disorganized type – grossly
inappropriate or flat affect, incoherence, loose
associations, and extremely disorganized behavior
C. Schizophrenia, catatonic type – either motionless or
marked psychomotor disturbance; mutism, echolalia,
echopraxia
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

8. Types of Schizophrenia
• Diagnosis is made according to the client’s
predominant symptoms:
D. Schizophrenia, undifferentiated type – mixed
symptoms
E. Schizophrenia, residual type – social withdrawal,
flat affect, loose associations
F. Schizoaffective disorder – psychotic symptoms
of schizophrenia plus a mood disorder
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

9. Related disorders
• Schizophreniform disorder – symptoms of schizophrenia
but for less than 6 months necessary to meet the diagnostic
criteria. Social or occupational functioning may or may not
be impaired
• Delusional disorder – client has one or more delusions,
psychosocial functioning is not markedly impaired, and
behavior is not obvious odd or bizarre
• Brief psychotic disorder – sudden onset of a psychotic
symptom which lasts for 1 day to 1 month, that could have
a stressor or may follow childbirth
• Shared psychotic disorder – folie a deux, two people share
a similar delusion
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

10. Etiology
• Biologic theories
1. Genetic factors: identical twins have 50% risk, fraternal twins
have 15%, children with one schizophrenic parent have 15%
risk, 35% if both parents are schizophrenic
2. Neuroanatomic and neurochemical factors – patients have
relatively less brain tissue and CSF compared to those who
do not have the illness, the ventricles are enlarged, and there
is cortical atrophy; excess dopamine and serotonin
3. Immunovirologic factors – exposure to certain viruses like
influenza
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

12. assessment
• Symptomalogy
1. Positive symptoms – or hard symptoms/signs
2. Negative symptoms – or soft symptoms/signs;
these frequently persists even after the positive
symptoms have abated
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

13. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative
Symptoms of Schizophrenia
Positive or Hard Symptoms Negative or Soft Symptoms
Ambivalence: holding seemingly Alogia: tendency to speak very little or
contradictory beliefs or feelings about to convey little substance of meaning
the same person, event, or situation (poverty of content)
Associative looseness Anhedonia: feeling no joy or pleasure
from life or any activities of
relationships
Delusions Apathy: feelings of indifference toward
people, activities, and events
Echopraxia: imitation of movements Blunted affect
and gestures of another person whom
the client is observing
Flight of ideas Catatonia: psychologically induced
immobility occasionally marked by
periods of agitation or excitement; the
client seems motionless, as if in a trance

14. DSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative
Symptoms of Schizophrenia
Positive or Hard Symptoms Negative or Soft Symptoms
Flight of ideas Flat affect
Hallucinations Lack of volition: absence of will,
ambition, or drive to take action or
accomplish tasks
Ideas of reference
Perseveration: persistent adherence to
a single idea or topic; verbal repetition
of a sentence, word, or phrase; resisting
attempts to change the topic

15. TYPES OF DELUSIONS
Persecutory/paranoid delusions Involve the client’s belief that “others”
are planning to harm the client or are
spying, following, ridiculing, or belittling
the client
Grandiose delusions Characterized by the client’s claim to
association with famous people or
celebrities, or the client’s belief that he
or she is famous or capable of great
feats
Religious delusions Often center around the second coming
of Christ or another significant religious
figure or prophet
Somatic delusions Generally vague and unrealistic beliefs
about the client’s health or bodily
functions (client may say that she is
pregnant)
Rereferential delusions Ideas of reference

16. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA
Clang associations Ideas that are related to one “I will take a pill if I go up
another based on sound of the hill but not if my name
rhyming is Jill, I don’t want to kill.”
Neologisms Words invented by the client “I’m afraid of grittiz. If
there are any grittiz here, I
will have to leave. Are you
a grittiz?”
Verbigeration Stereotyped repetition of “I want to go home, go
words or phrases that may or home, go home.”
may not have meaning to the
listener
Echolalia Imitation or repetition of Nurse: “Can you tell me
what the nurse says how you’re feeling?”
Client: “Can you tell me
how you’re feeling, how
you’re feeling?.....”

17. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA
Stilted language Use of words or phrases “Would you be so kind, as a
that are flowery, excessive, representative of Florence
pompous Nightingale, as to do me the
honor of providing just a wee bit
of refreshment, perhaps in the
form of some clear spring
water?”
Perseveration Nurse: “How have you been
sleeping lately?”
Client: “I think people have been
following me.”
Nurse: “Where do you live?”
Client: “At my place people have
been following me.”
Nurse: “What do you like to do
in your free time?”
Client: “Nothing because people
are following me.”

18. UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA
Word salad A combination of jumbled “Corn, potatoes, jump up,
words and phrases that play games, grass,
are disconnected or cupboard.”
incoherent and make no
sense to the listener

20. Elder considerations
• Late-onset schizophrenia – development of the disease after
age 45
• Schizophrenia is not initially diagnosed in elder clients
• Psychotic symptoms are usually associated with depression or
dementia, not schizophrenia
• Approximately one fourth of clients experienced dementia,
resulting in steady, deteriorating decline in health
• Another 25% actually have reduction in positive symptoms,
somewhat like a remission
• Schizophrenia remains mostly unchanged in the remaining
clients
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

23. Nursing diagnosis
Nursing Diagnosis Analysis
Risk for injury related to accelerated motor Accelerated motor activity or impulsive
activity actions
Disturbed thought process –related to Grandiose delusions (Belief that well
delusion of grandeur known political religious, or entertainment
leader)
Self-care deficit (unkempt Unable to take time for self-care is,
appearance) related to hyperactivity disheveled and unkempt
Impaired verbal communication –flight of Accelerated speech with flight of ideas
ideas related to accelerated thinking (thought speeded up causing rapid speech
and flight of ideas, excessive planning for
activities
(http://www.nursingplanet.com/pn/nursing_process_psychiatric_nursing.html#N
ursing%20Diagnosis)

24. Goals – Expected outcomes
• For the acute, psychotic phase (examples)
a. The client will not injure self and others
b. The client will establish contact with reality
c. The client will interact with others in the environment
d. The client will express thoughts and feelings in a safe
and socially acceptable manner
e. The client will participate in prescribed therapeutic
interventions
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

25. Goals – Expected outcomes
• For continued care after stabilization of acute symptoms
(examples)
a. The client will participate in the prescribed regimen (including
medications and follow-up appointments)
b. The client will maintain adequate routines for sleeping and food
and fluid intake
c. The client will demonstrate independence in self-care activities
d. The client will communicate effectively with others in the
community to meet his or her needs
e. The client will seek or accept assistance to meet his or her
needs when indicated
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

26. Implementation - management
• Promoting the safety of client and others
• Establishing a therapeutic relationship
• Using therapeutic communication
• Implementing interventions for delusional
thoughts and for hallucinations
• Coping with socially inappropriate behaviors
• Teaching client and family
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

27. Interventions for delusions
• Do not confront the delusion or argue with the
client
• Establish and maintain reality for the client
• Use distracting techniques
• Teach the client positive self-talk, positive
thinking, and to ignore delusional beliefs
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

28. Interventions for hallucinations
• Help present and maintain reality by frequent
contact and communication with client
• Elicit description of hallucination to protect
client and others
• Engage client in reality-based activities such as
card playing, occupational therapy, or listening
to music
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

29. Coping with socially inappropriate
behaviors
• Redirect client away from problem situations
• Deal with inappropriate behaviors in a nonjudgmental and
matter-of-fact manner; give factual statements; do not scold
• Reassure others that the client’s inappropriate behaviors or
comments are not his or her fault (without violating the
client confidentiality)
• Try to reintegrate the client into treatment milieu
• Do not make the client feel punished or shunned for
inappropriate behaviors
• Teach social skills through education, role modeling, and
practice
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

30. Implementation - management
• Client/Family Education
a. How to manage illness and symptoms
b. Recognizing early signs and symptoms of relapse
c. Developing a plan to address relapse signs
d. Importance of maintaining prescribed medication
regimen and regular follow-up
e. Avoiding alcohol and other drugs
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

31. Implementation - management
• Client/Family Education
f. Self-care and proper nutrition
g. Teaching social skills through education, role modeling, and
practice
h. Seeking assistance to avoid or manage stressful situations
i. Counseling and educating family/significant others about the
biologic causes and clinical course of schizophrenia and the
need for ongoing support
j. Importance of maintaining contact with community and
participating in supportive organizations and care
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

32. Early signs of relapse
• Impaired cause-and-effect reasoning
• Impaired information processing
• Poor nutrition
• Lack of sleep
• Lack of exercise
• Fatigue
• Poor social skills, social isolation, loneliness
• Interpersonal difficulties
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

33. Early signs of relapse
• Lack of control, irritability
• Mood swings
• Ineffective medication management
• Low self-concept
• Looks and acts different
• Hopeless feelings
• Loss of motivation
• Anxiety and worry
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

34. Early signs of relapse
• Disinhibition
• Increased negativity
• Neglecting appearance
• Forgetfulness
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

35. Implementation - management
• Medications:
a. Antispychotic medications: conventional
antipsychotics for positive symptoms and
atypical antipsychotics for negative symptoms
b. Drugs for EPS
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)

36. Social Skills Training
• Sometimes referred to as behavioral skills
therapy
• Along with pharmacologic therapy can be
directly supportive and useful to the patient

37. Social Skills Therapy
Phase Goals Targeted Behaviors
Stabilization and assessment Establish therapeutic alliance Empathy and rapport
Assess social performance Verbal and nonverbal
and perception skills communication
Assess behaviors that
provoke expressed emotions
Social performance within Express positive feelings with Compliments, appreciation,
family family interest in others
Teach effective strategies for Avoidance response to
coping with conflict criticism, stating preferences
and refusals
Social perception in the Correctly identify content, Reading a message
family context, and meaning of Labeling an idea
messages Summarizing other’s intent
Extrafamilial relationships Enhance socialization skills Conversational skills
Enhance prevocational and Dating
vocational skills Recreational activities
Maintenance Generalize skills to new Job interviewing, work habits
situations

38. evaluation
• Have the client’s psychotic symptoms disappeared?
• Does the client understand the prescribed medication regimen?
• Does the client possess the necessary functional abilities for
community living?
• Are community resources adequate to help the client live
successfully in the community?
• Is there sufficient after-care or crisis plan in place to deal with
recurrence of symptoms?
• Are the client and family adequately knowledgeable about
schizophrenia?
• Does the client believe that he or she has satisfactory quality of
life?
(Videbeck, pages 252 to 276; Student Guide, pages 123 to 129)