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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 16: Schizophrenia Spectrum and Other Psychotic Disorders Instructor’s Manual Thoughts About Teaching the Topic Although establishing a trusting relationship is essential to any nurse–patient relationship, it may be most challenging for students to establish a relationship with patients with schizophrenia. The patient’s anxiety about relating, along with withdrawal and suspiciousness, often make forming and maintaining relationships difficult. Students can best be helped to empathize with the patient through hearing from patients and family members as guests in a class or field trip to a day program. Students can also profit from opportunities to identify and assess the numerous symptoms of schizophrenia. Strategies that may be helpful include the following: • Using role-playing situations during class Creating trigger videos to be shown, responded to, and discussed in class Integrating theory and practice, using all phases of the nursing process when caring for patients with schizophrenia, can be fostered by the following: • Computer-assisted instructional programs Independent viewing of selected films, using an instructor-prepared film guide with questions that are answered and submitted to the instructor for review Using films in class and discussion content Learning the considerable number of neuroleptic medications may be promoted by assigning Psychotropic Medication Administration: Outpatient Clinic, a CAI in which learners make assessments and decisions about psychiatric patients taking various medications (neuroleptics, antidepressants, and lithium). Key Terms and Concepts abnormal motor behaviour acute dystonia affective symptoms akathisia anosognosia anticholinergic-induced delirium associative looseness boundary impairment circumstantiality cognitive symptoms command hallucinations concrete thinking delusions depersonalization derealization disorganized thinking echolalia echopraxia extrapyramidal side effects (EPS) hallucinations ideas of reference illusions negative symptoms neologisms neuroleptic malignant syndrome (NMS) paranoia positive symptoms pseudoparkinsonism reality testing recovery model stereotyped behaviours tangentiality tardive dyskinesia (TD or TDK) word salad Objectives Describe the progression of symptoms, focus of care, and intervention needs for the prepsychotic through maintenance phases of schizophrenia. Discuss at least three of the neurobiological–anatomical–genetic findings that indicate that schizophrenia is a brain disorder. Differentiate among the positive and negative symptoms of schizophrenia in terms of psychopharmacological treatment and effect on quality of life. 4. Discuss the concept of recovery for people living with schizophrenia. Discuss how to deal with common reactions the nurse may experience while working with a person with schizophrenia. Develop teaching plans for people taking conventional antipsychotic drugs (e.g., haloperidol [Haldol]) and atypical antipsychotic drugs (e.g., risperidone [Risperdal]). Compare and contrast the conventional antipsychotic medications with atypical antipsychotics. Identify nonpharmacological interventions that may be used to address symptoms of schizophrenia. Create a nursing care plan that incorporates evidence-informed interventions for key areas of dysfunction in schizophrenia, including hallucinations, delusions, paranoia, cognitive disorganization, anosognosia, and impaired self-care. Role-play intervening with a person who is hallucinating, delusional, and exhibiting disorganized thinking. Chapter Outline Teaching Strategies Clinical Picture Around 1908, Bleuler coined the term schizophrenia. Five key features include: delusions, hallucinations, disorganized thinking, abnormal motor behaviour, and negative symptoms. All those diagnosed with schizophrenia exhibit at least one psychotic symptom, such as delusions, hallucinations, or disorganized thinking, speech, or behaviour. The person experiences extreme difficulty with or an inability to function in family, social, or occupational realms and frequently neglects basic needs such as nutrition or hygiene. Over a period of six months, there may be times when the psychotic symptoms are absent, and in their place, the person may experience apathy or depression. Other psychotic disorders (e.g., schizophreniform and schizoaffective disorders) are described in Box 16-1. Epidemiology The lifetime prevalence of schizophrenia is 1% worldwide, with no differences related to race, social status, or culture. It is more common in males (1.4 : 1) and among persons growing up in urban areas. It usually develops during the late teens and early twenties. Childhood schizophrenia, although rare, does exist, occurring in 1 out of 40,000 children. Early onset (18 to 25 years) occurs more often in males and is associated with poor functioning before onset, more structural brain abnormality, and increased levels of apathy. Individuals with a later onset (25 to 35 years) are more likely to be female, have less structural brain abnormality, and have better outcomes. Co-Morbidity Substance abuse disorders occur in nearly 50% of individuals with schizophrenia. It is associated with negative outcomes such as incarceration, violence, suicide, and HIV infection. Nicotine dependence may be as high as 80% to 90%. Other co-morbid disorders include depressive symptoms, anxiety disorders, and psychosis-induced polydipsia (water intoxication). Physical illnesses are more common among people with schizophrenia than in the general population. Even after adjusting for demographics and socioeconomic status, the death rate for people with mental illness is close to 70% higher than for the general population, and this risk of premature death is even greater for people with schizophrenia. Etiology The scientific consensus is that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors (e.g., viral infections, birth injuries, prenatal malnutrition), altering the structures of the brain, affecting the brain’s neurotransmitter systems, injuring the brain directly, or all three. Biological Factors Genetic Genetic vulnerability seems likely. Schizophrenia and schizophrenia-like symptoms occur at an increased rate among relatives of patients with schizophrenia. Dopamine Hypothesis The dopamine hypothesis states excess dopamine is responsible for psychotic symptoms. This theory was based on the knowledge that antipsychotic drugs block some dopamine receptors, limiting the activity of dopamine and reducing psychotic symptoms. Other drugs (e.g., amphetamines), increase activity of dopamine and can simulate symptoms of paranoid schizophrenia in a patient without schizophrenia. Other Neurochemical Hypotheses The role of other neurotransmitter systems (norepinephrine, serotonin, glutamate, GABA, neuropeptides, and neuromedullary substances) is being studied. Newer drugs target serotonin and norepinephrine and may provide more information about causation. Phencyclidine use induces a schizophrenia-like state. This observation has renewed interest in the NMDA receptor complex and the possible role of glutamate in schizophrenia. Brain Structure Abnormalities Studies suggest schizophrenia is a disorder of brain circuits. Structural cerebral abnormalities could cause circuit disruptions. Findings suggest that possible brain abnormalities might be enlarged lateral ventricles, cortical atrophy, third ventricle dilation, ventricular asymmetry, cerebellar atrophy, and frontal lobe atrophy. PET scans suggest reduced frontal lobe activity. Psychological and Environmental Factors Birth and pregnancy complications (e.g., viral infection, poor nutrition, exposure to toxins) place individuals at increased risk for developing schizophrenia as adults. Although there is no indication that stress causes schizophrenia, stress may precipitate it in a vulnerable individual. Other risk factors include birth during the winter, birth in an urban area, low socioeconomic status. Course of the Disorder Prognostic Considerations Phases of the illness and recovery are described as follows: Acute, Stabilization, and Recovery. Studies have shown that most of the deterioration occurs within the first two to five years after onset of psychosis, followed by a plateau in impairment and symptoms (Srihari, Shah, & Keshavan, 2012). For the majority of people, most symptoms can be at least somewhat controlled through medications and psychosocial interventions. With support and effective treatments, many people with schizophrenia experience a good quality of life and success within their families, occupations, and other roles. Associates may not even realize the person has schizophrenia. Application of the Nursing Process Assessment Nursing assessment focuses largely on symptoms, coping, functioning, and safety. During the Prepsychotic Phase These begin 1 month to 1 year before the first psychotic episode and include increased anxiety, evidence of a thought disorder (e.g., poor concentration), inability to keep out intrusive thoughts, attaching symbolic meaning to ordinary events, and misinterpretation of others’ actions or words. In the latter part of this phase, the patient may experience emotional and physical withdrawal, hallucinations, delusions, odd mannerisms, preoccupation with religion, neologisms, or preoccupation with homosexual themes. General Assessment Four main symptom groups of schizophrenia are as follows: positive symptoms, negative symptoms, cognitive symptoms, and affective symptoms. Positive Symptoms Positive symptoms are florid psychotic symptoms such as hallucinations, delusions, bizarre behaviour, and paranoia. Positive symptoms are associated with acute onset; normal premorbid functioning and normal functioning during remissions; normal CT scans; and favourable response to antipsychotics. Alterations in Thinking Delusions: fixed false beliefs (with themes of ideas of reference, persecution, grandiosity, unusual bodily function, jealousy, being controlled. See Table16-1). About 75% of patients with schizophrenia experience delusions at some time during their illness. Other common delusions include: thought broadcasting (the belief that one’s thoughts can be heard by others), thought insertion (the belief that thoughts of others are being inserted into one’s mind), thought withdrawal (the belief that thoughts have been removed from one’s mind), and delusions of being controlled (belief that one’s body or mind is controlled by an outside agency). Concrete thinking: impaired ability to use abstract concepts. Interpretation is literal. Alterations in Speech Associative looseness: loosely associated, haphazard, illogical, confused speech that can sometimes be decoded. Neologisms: newly coined words having meaning only for the patient. Echolalia: pathological repeating of another’s words. Clang association: meaningless rhyming of words. Word salad: mixture of words meaningless to the listener. Alterations in Perception Hallucinations are sensory perceptions for which there is no external stimulus. Auditory hallucinations are most common among patients with schizophrenia. Voices may tell the patient what to do (commanding) or speak to or about him or her (usually derogatory). Behavioural indications of the presence of auditory hallucinations include tilting head as if listening and answering back. Hallucinations may also be visual, olfactory, gustatory, or tactile. Personal boundary difficulties may also be referred to as loss of ego boundaries. Examples include depersonalization—the person feels he has lost his identity or that the body has changed; and derealization—a false perception that the environment has changed. Alterations in Behaviour Bizarre behaviours take the form of stilted, rigid demeanor, eccentric dress or grooming, and rituals. Extreme motor agitation—running about in response to inner or outer stimuli. Stereotyped behaviours—motor patterns that have become mechanical and purposeless. Automatic obedience—performing commands in a robotlike fashion. Waxy flexibility—excessive maintenance of a posture for long periods of time. Stupor—remaining motionless and unresponsive. Negativism—active negativism involves the patient doing the opposite of what is suggested; passive negativism involves not doing the things one is expected to do, such as getting out of bed, eating, and so forth. Agitated behaviour—related to difficulty with impulse control; because of cognitive deterioration, patients lack social sensitivity and may act out impulsively. Negative Symptoms Negative symptoms such as apathy, lack of motivation, anhedonia, poor social functioning, and poverty of thought are associated with insidious onset, premorbid history of emotional problems, chronic deterioration, CT scan showing atrophy, and poor response to antipsychotic therapy. Negative symptoms are the symptoms that most interfere with adjustment and ability to survive (e.g., ability to initiate and maintain relationships, initiate and maintain conversation, hold a job, make decisions, maintain adequate hygiene and grooming). Other negative symptoms include poverty of speech or speech content, thought blocking, anergia, anhedonia, avolition, affective blunting (minimal emotional response), inappropriate affect (incongruent response), or bizarre affect (grimacing, giggling, etc.). Cognitive Symptoms Cognitive impairment involves difficulty with attention, memory, problem solving, and decision making and represents a major disability associated with schizophrenia. Affective Symptoms Depression recognition during assessment is crucial because depression affects a majority of people with schizophrenia. It may herald a psychotic relapse, increase the likelihood of substance abuse or suicide, or may be associated with impaired functioning. Self-Assessment The intensity of the patient’s emotions can evoke intense, uncomfortable, and frightening emotions in staff. If feelings are not worked through, feelings of helplessness can increase anxiety. Defensive behaviours may emerge to thwart patient progress and undermine nurse self-esteem. Slow patient progress can lead to frustration. Team evaluation of progress and effective supervision of clinicians can assist with this. Assessment Guidelines: Schizophrenia It is important to assess whether the patient has had a medical workup, including evaluation for the presence of psychosis, and whether the patient is dependent on alcohol or other drugs. Is the individual experiencing hallucinations or delusions? Is the patient’s belief system founded in reality? Be sure to be alert for cooccurring disorders such as depression, anxiety, substance dependency, or a history of violence, and ask if the patient is taking medications and is he or she adhering to the medication regimen as prescribed. It is also important is to assess the support for the patient (e.g., family, significant others) and assess the patient’s global functioning. Diagnosis Useful nursing diagnoses include Disturbed thought processes, Disturbed sensory perception, Impaired verbal communication, Ineffective coping, Imbalanced nutrition: less than body requirements, Risk for self-directed violence, Risk for otherdirected violence, Activity intolerance, Constipation, Incontinence, Impaired physical mobility, Self-care deficit, Compromised family coping, Disabled family coping, Chronic low self-esteem, Risk for loneliness, Social isolation, Impaired parenting, and Caregiver role strain. Table 16-5 Outcomes Identification Desired outcomes vary with the phase of the illness. Ideally, outcomes should focus on enhancing strengths and minimizing the effects of the patient’s deficits and symptoms. Outcomes should be consistent with the recovery model (see Chapter 31). Table 16-6 Phase I (Acute) The acute phase essentially involves crisis intervention, with patient safety and medical stabilization as the overall goal. If the patient is at risk for violence to self or others, initial outcome criteria address safety issues (i.e., “Patient will remain safe while hospitalized”). Another appropriate focus would be on outcomes that reflect improvement in intensity and frequency of hallucinations and delusions and increasing ability to test reality accurately. Phase II (Stabilization) and Phase III (Maintenance) Outcome criteria focus on helping the patient to adhere to medication regimens, understand the nature of the illness, and participate in psychoeducational activities for patient and family. Planning Planning appropriate interventions is guided by the phase of the illness. Acute Phase Often requires hospitalization for stabilization. The treatment team will identify long-term care needs and identify and provide appropriate referrals for follow-up and support. Discharge planning must consider living arrangements, economic resources, social supports, family relationships, and vulnerability to stress. Maintenance and Stabilization Phases Foci include patient and family education; skills training; building relapse-prevention skills; and identifying needs for social, interpersonal, coping, and vocational skills. Implementation Implementations are geared toward the phase of schizophrenia the patient is experiencing. Basic Level Interventions In the acute phase I, interventions are focused on symptom stabilization and safety and usually include medication; supportive and directive communication; limit setting; and psychiatric, medical, and neurological evaluation. Hospitalization is reserved for situations in which partial hospitalization or day treatment is ineffective or unavailable. Phase II and III interventions include psychoeducation about the disease, medication, adverse-effect management, cognitive and social skills enhancement, identifying signs of relapse, and attention to self-care deficits. Stress minimization is of concern. Helping the patient reduce vulnerability to relapse will include providing information about maintaining a regular sleep pattern; reducing alcohol, drug, and caffeine intake; keeping in touch with supportive family and friends; staying active; having a daily or weekly schedule; and taking medication regularly. Attention should be given to patient strengths and healthy functioning. Milieu Management Patients with schizophrenia improve more on a structured hospital unit rather than in an open environment. A therapeutic milieu provides safety, useful activities, resources for resolving conflicts, and opportunities for learning social and vocational skills. Activities and Groups During the acute phase, a structured milieu is more advantageous to the patient than the freedom of an open unit. Participation in group activity decreases withdrawal, promotes motivation, modifies aggression, and increases social competence. Involvement in activity groups, exercise, and recreation results in increased selfconcept, improved quality of life and enhanced recovery. Safety In the acute phase, the risk for violence usually stems from hallucinations or delusions. Attempts should be made to use the least restrictive method of coping with violence (e.g., initially use verbal intervention, followed by medication, and lastly seclusion or restraint). Counselling: Communication Techniques Be familiar with principles for dealing with hallucinations, delusions, and associative looseness. Use a nonthreatening and nonjudgemental manner. Speak simply, using a louder voice. Use patient’s name. Guidelines for Communication boxes in the text identify further strategies. Hallucinations Intervention requires knowledge of the content of the hallucinations. Ask and assess for command hallucinations to follow up with safety interventions. Delusions Rely on empathy. Clarify the reality of patients’ experience. Do not focus on delusional content. Do not use logic to refute delusion and do not argue. Clarifying misinterpretations is useful. Spend time with patient in reality-based activities. Associative Looseness Loose associations mirror patient thoughts. Don’t pretend to understand when you can’t. Tell patient you’re having difficulty understanding, placing the problem with yourself (i.e., “I’m having difficulty understanding what you’re saying” instead of “You’re not making sense”). Look for and mention recurring themes. Emphasize what is going on in the environment, and involve the patient in simple, reality-based activities. Tell the patient when you do understand, reinforcing clear communication. Health Teaching and Health Promotion Topics include the illness, how stress and medication affect the illness, problem-solving skills, coping strategies to deal with symptoms, sources of ongoing support, symptoms of relapse, and the type of environment most supportive for the patient. Psychopharmacological Interventions Antipsychotics allow patient management in the community as well as in the hospital. Noncompliance with medications usually precedes relapse. Maintenance is required for 1 year after one episode, 2 years after two episodes, and probably lifelong after three episodes. Atypical Antipsychotics Atypical antipsychotics include risperidone (Risperdal), lurasidone (Latuda), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Zeldox), and aripiprazole (Abilify), the last of which is technically a third-generation drug. These atypicals are free of the potential hematological adverse effects of clozapine (Clozaril), and are all first-line agents because of their lower adverse-effect profile. One significant disadvantage of the atypicals, with the exception of ziprasidone and aripiprazole, is that they have a tendency to cause significant weight gain. Use of clozapine carries the risk of agranulocytosis. Conventional (Traditional) Antipsychotics Target D2 receptors. These drugs relieve the positive symptoms of schizophrenia and include the phenothiazines, thioxanthenes, butyrophenones, dibenzoxazepines, and dihydroindolones. Selection is often made on the basis of major adverse effects. Extrapyramidal side effects such as dystonia, akathisia, and pseudoparkinsonism are treated by lowering dose and prescribing antiparkinsonian drugs such as trihexyphenidyl (Artane), benztropine (Cogentin), or diphenhydramine (Benadryl). Anticholinergic adverse effects include dry mouth, urinary retention, constipation, and blurred vision. Sedation, orthostatic hypotension, lowered seizure threshold, and agranulocytosis are other adverse effects. All standard antipsychotics can cause tardive dyskinesia (TD), which typically involves involuntary tonic muscular spasms of the tongue, lips, fingers, toes, jaw, neck, trunk, and pelvis. The drugs must be discontinued, but no cure for TD exists. Assessment is performed using the Abnormal Involuntary Movement Scale. Potentially Dangerous Responses to Antipsychotics Neuroleptic malignant syndrome occurs in less than 1% of those taking standard antipsychotics, is potentially fatal, and is characterized by lowered level of consciousness, increased muscle tone, and autonomic dysfunction (including fever, hypertension, tachycardia, tachypnea, diaphoresis, and drooling). Agranulocytosis, also a serious adverse effect, can be fatal. Anticholinergic-induced delirium is a potentially life-threatening adverse effect usually seen in older adults, although it can occur in younger people as well. It is also seen in patients taking multiple antipsychotic drugs. See Table 16-9 for symptoms and treatment of this serious adverse effect. Adjuncts to Antipsychotic Drug Therapy Antidepressants may be ordered for coexisting depression. Antimanic agents may be useful for suppressing episodic violence and may help alleviate co-morbid depression. Benzodiazepines may be ordered during the acute phase to reduce agitation. When to Change an Change should be considered when the current regimen is Antipsychotic Regimen ineffective, supplemental medications are needed, or adverse effects are intolerable. Specific Interventions for Paranoid, Catatonic, and Disorganized Schizophrenia Paranoia Paranoia is characterized by intense and strongly defended irrational suspicion. Projection is the most common defence mechanism used by paranoid patients. These patients usually feel frightened, lonely, and helpless. The paranoid facade is a defence against painful feelings. Communication Guidelines Paranoid patients are unable to trust others and are guarded, tense, reserved, and aloof. They often adopt a superior, hostile, and sarcastic attitude to distance others. They may disparage others and dwell on others’ shortcomings. Staff must not react with anxiety or patient rejection. Frequent discussion with peers and clinical supervision are helpful. Readers are referred to the communication card. Self-Care Needs These are usually minimal. Nutrition may be problematic if the patient is suspicious that food has been tampered with. If this is the case, provide food in unopened containers. Suspicion may also interfere with sleep. Milieu Needs Risk for violence is present because the patient may respond with hostility or aggression to hallucinations or delusions. Homosexual urges may be projected onto others as well. Catatonia: Withdrawn Phase The essential feature of catatonia is abnormal motor behaviour. Onset is usually abrupt and the prognosis favourable. In the withdrawn phase, the patient may demonstrate posturing, waxy flexibility, stereotyped behaviour, extreme negativism or automatic obedience, echolalia, and echopraxia. Communication Guidelines Patients may actually appear comatose and mute. Although seemingly unaware of the environment, the patient is aware and may remember events accurately at a later date. Self-Care Needs When a patient is extremely withdrawn, physical needs take priority. The patient may need complete care, including hand or tube feeding, incontinence care, and passive exercise, as well as assistance with hygiene, dressing, and grooming. Milieu Needs The continuum from decreased spontaneous movement to complete stupor is described and waxy flexibility explained. Readers are cautioned that the patient may move from stupor to an outburst of gross motor activity prompted by hallucinations, delusions, or neurotransmitter changes. Catatonia: Excited Phase Communication Guidelines During the excited phase, the person talks or shouts continually. Verbalizations may be incoherent. Staff communication should be clear and directed. The major concern is safety of patient and others. Self-Care Needs Patient may exhibit gross hyperactivity (running, striking out, etc.). Exhaustion and collapse, as well as safety, are the primary concerns. IM administration of antipsychotic medication is usual. Provision of nutrition, fluids, and rest are of high priority. The patient may be destructive and aggressive in response to hallucinations or delusions. Disorganized Schizophrenia The most regressed and socially impaired patients carry this diagnosis. They show grossly inappropriate affect, bizarre mannerisms, grimaces, giggles, incoherent speech, blocking, and extreme social withdrawal. Onset is often early and insidious. The prognosis is often poor, the patient being able to live only in a structured and well-supervised setting. Communication Guidelines These patients experience persistent and severe perceptual problems and frequently display looseness of associations, incoherence, clang association, word salad, and blocking. Self-Care Needs Patients need much help grooming insofar as they have no awareness of social expectations. They are often too disorganized to carry out ADLs. Milieu Needs These highly regressed patients exhibit primitive behaviours that require a structured and protective milieu. Undifferentiated Schizophrenia This illness is characterized by active signs of the disorder but with symptoms that do not clearly fall into one specific category. Undifferentiated schizophrenia often has an early and insidious onset, with disability remaining fairly stable over time. Residual Schizophrenia The patient no longer has active-phase symptoms but evidences two or more residual symptoms (such as lack of initiative, marked social withdrawal, impaired role function, speech deficits, odd beliefs, magical thinking, and unusual perceptual events). Advanced-Practice Interventions Psychotherapy Although medication maintenance has been shown to be the single most important factor in prevention of relapse, a combination of medication and psychosocial interventions lowers the relapse rate even further. Patient concerns that can be addressed are relationship problems, family concerns, depression, losses, and medication. Individual Therapy Supportive therapy is the modality found to be most helpful. Skills training to enhance social functioning, cognitive rehabilitation to improve information-processing skills, and cognitive content therapy to change abnormal thoughts or responses to hallucinations through coping strategies are also useful. Group Therapy Group therapy may be used to develop interpersonal skills, resolve community problems, and teach use of community supports. Medication groups can help patients deal with adverse effects, alert staff to potential adverse or toxic effects, minimize isolation, and increase compliance. Family Therapy Family therapy further reduces relapse rate when a psychoeducational approach is used. This format expands patients’ and relatives’ social networks, expands problem-solving capacity, and lowers emotional overinvolvement of families. Evaluation Evaluation is based on established outcomes. Goals may need to be revised to become more realistic and attainable. Patient input may shed light on reasons desired behaviours have not occurred. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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