At least 2 of the following symptoms

delusions/hallucinations/disorganized

speech/disorganized behavior/catatonic

behavior/negative symptoms

Paranoid Schizophrenia

Disorganized Schizophrenia

Disorganized speech, behavior, inappropriate affect

Catatonic Schizophrenia

Marked abnormailities in motor behavior

(either motionless or hyperactive motor activity)

Undifferentiated Schizophrenia

Characteristic symptoms present but don't fit into other subtypes

Residual Schizophrenia

Schizoaffective Disorder

Manifested by shizophrenic behaviors, with a strong element of symptoms of mood disorders (depression or mania)

Positive Symptoms (Type I)

Symptoms are an embellishment or normal cognition and perception

 Positive Symptoms

 Agitation/Excitement/Bizzare Behavior

Hostility/Abnormal Thoughts/Delusion

Hallucinations/Illusions/Insomnia

Suspiciousness/Grandiosity

Negative Symptoms (Type II)

Symptoms refer to the absence of that which one should see - such as lack of affect, lack of energy

Negative Symptoms

Alogia:inability to speak/Poverty of Speech

Anergia:lack of energy/Asocial/Attention Deficits

Avolition:lack of motivation/Blunted affect/Social withdrawl

Poor grooming/Poor rapport/Communication difficulties

Objective Behavior in Schizophrenia

Alterations in Personal Relationships

Alterations in Activity

Subjective Signs in Schizophrenia

Altered Perceptions

Alteration of Thought

Delusions

Poverty of Speech

Lack of Concrete Thinking

Altered Consciousness

Alterations of affect

Milieu Management

Schizophrenia - Disruptive Patients

Set limits & follow through

Decrease environemental stimuli

Frequently observe

Modify environment to remove dangerous weapons

Be careful in stating what staff will do if pt. acts out - follow through once violation occurs

Restraints - provide safety & evaluate for hydration,nutrition,elimination & circulation

Milieu Management for Schizophrenia

Withdrawn Patients

Non-threatening activities

Furniture in semicircle or around table

Help to participate in decision making when appropriate

Reinforce appropriate grooming & hygiene

Provide physical rehab:training in community living, social skills & health care skills

Milieu Management in Schizophrenia

Suspicious Patients

Be matter of fact when interacting

Staff should not laugh or whisper

Do not touch without warning

Be consistent in activities: time,staff & approach

Maintain eye contact

Dont slip medications in juices of food without informing patient

If fear of being poisoned by food: State:"the food isn't poisoned"

Milieu Management in Schizophrenia

Patients with impaired communication

Be patient and do not pressure them to make sense

Do not place in group activities that would frustrate them, damage their self-esteem, or overtax their abilities

Provide for purposeful psychomotor activity

Milieu Management in Schizophrenia

Patients with Hallucinations

Attempt to provide distracting activities

Discourage situations in which patients talk to others about their disordered perceptions

Monitor TV selection

Monitor for command hallucinations

Have staff members available in dayroom so patients can talk to real people

Milieu Management in Schizophrenia

Disorganized Patients

less stimulating environment

calm environment

provide safe & simple activities

Psychosis Induced Polydipsia

compulsive water drinking (4-10L/day)

seen in 6 - 20% patients with psychosis

Occurs d/t thirst & osmotic deregulation

Patients report:cleanses body, washes away evil

Major danger is hyponatremia

S&S : lightheaded,muscle cramps, lethargy, N&V, confusion, coma

Rx: restrict fluids monitor Na, daily weight

Antipsychotic Drug Therapy

Classes of Antipsychotic Drugs

Traditional or Typical (1st generation)

Atypical (2nd Generation)

Block a dopamine receptor (D2)

Low potency drugs cause intense anticholinergic effects

High potency drugs cause more extrapyramidal side effects (EPSEs)

Low Potency Antipsychotics

Thorazine

Mellaril

Anticholinergic S.E.

associated with Low potency antipsychotics

Dry Mouth

Blurred Vision

Urinary Retention

Constipation

Weight Gain

Orthostatic Hypotension

Tachycardia

Sedation

High Potency Antipsychotics

Prolixin -  available IM every 2-3 weeks

Haldol - availalbe IM every 2-4 weeks

Stelazine

 Extrapyramidal Side Effects (EPSEs)

Akathisia

Akathisia : constant state of movement, restlessness, difficulty sitting still, strong urge to move about (most common EPSE)

occurs 2-6 weeks after tx begins, treat w/ dose reduction or change drug class, give benzo or beta blocker

Extrapyramidal Side Effects (EPSEs)

Dystonia

Dystonia: involuntary muscle contractions that cause sometimes painful abnormal movements or positioning.

oculogyric crisis: acute dystonic rxn involving the muscles that control eye movement - positioning of eyes upward, Torticollis:contracted neck, Laryngeal-pharyngeal constriction(emergency), Acute Dystonic Rxn: may occur anytime from several minutes to several hours after 1st dose.

Tx: dose reduction, change drug class, give anticholinergic agent

Extrapyramidal Side Effects (EPSEs)

Drug Induced Parkinsonism

Drug Induced Parkinsonism:mimics symptoms of Parkinson's disease.

Motor retardation,mask like appearance,drooling,rigidity,tremors,pill rolling

Occurs 1 - 4 weeks after tx begins, reduce the dose and give anticholinergics(cogentin,artane, benadryl)

Extrapyramidal Side Effects (EPSEs)

Tardive Dyskinesia:

Tardive Dyskinesia: Tardive means late appearing.

Occurs after 6 months or more of antipsychotic tx and is not caused by dopamine/ACh imbalance, so anticholinergics are ineffective

Theory: long term use of drug causes dopamine receptors to be hypersensitive to dopamine.

Embarrising symptoms teach to report S.E. early

Tardive Dyskinesia

Sx: tongue protrusion & tongue writhing, lip smacking, teeth grinding, grimacing and chewing movements, symptoms go away with sleep, often irreversible, so catch early.

Tx: reduce of DC drug

Extrapyramidal Side Effects (EPSEs)

Neuroleptic Malignant Syndrome

Neuroleptic Malignant Syndrome: caused by high potency drugs,not drug toxicity.

Symptoms: high temp, muscular rigidity,altered consciousness, altered bp, tremors.

May develop w/in hours of 1st dose or after years of continued therapy. Rapid progression over 24-72 hours

Neuroleptic Malignant Syndrome

Treatment

Tx:DC antipsychotic agent & stay off antipsychotics for at least 2 weeks.  Have cardiopulmonary & renal support available, administer skeletal muscle relaxant :Dantrium or dopamine recepotr agonist : parlodel (given for 8-12 days)

Atypical Antipsychotics

Discovered after 1990

Increased effectiveness in tx neg symptoms and cognitive symptoms, also helped postive symptoms.

Reduced of no risk EPSEs w/ minimal risk of tardivedyskinesia (TD)

Atypical Antipsychotics

Dopamine & Serotonin Antagonists

Zyprexa (available IM)

Seroquel

Risperdal (long acting IM q 2 weeks)

Geodon (available IM)

Clozaril

Atypical Antipsychotic Side Effects

Atypical Antipsychotic S.E.

Clozaril

Agranulocytosis - develops suddenly

 But may manifest 18-24 weeks after start of med. 

 Must have weekly WBC for 6 months then every 2 weeks thereafter. 

 Dispensed every 7 or 14 days.

WBC above 3500 required befor refill.

Novel Antipsychotics

Abilify

Abilify: approved as an add-on for tx of depression.