Chapter 15 Schizophrenia Spectrum and Other Psychotic Disorders

Introduction • The word schizophrenia is derived from the Greek words skhizo (split) and

Introduction (cont’d) • Schizophrenia is probably caused by a combination of factors, including –

Introduction (cont’d) • Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary

Introduction (cont’d) • Of all mental illnesses, schizophrenia probably causes more – Lengthy hospitalizations

Nature of the Disorder • Schizophrenia causes disturbances in • Thought processes • Perception

Nature of the Disorder (cont’d) • With schizophrenia, there is a severe deterioration of

Nature of the Disorder (cont’d) • Premorbid behavior of the patient with schizophrenia can

Phase I Premorbid phase – Social maladjustment – Antagonistic thoughts and behavior – Shy

Phase II Prodromal phase • • • Lasts from a few weeks to a

Phase III Schizophrenia • In the active phase of the disorder, psychotic symptoms are

Phase IV Residual phase – Symptoms similar to those of the prodromal phase –

Prognosis • A return to full premorbid functioning is not common • Factors associated

Prognosis (cont’d) • Factors associated with a positive prognosis (cont’d) – – – Minimal

Predisposing Factors Biological influences – Genetics • A growing body of knowledge indicates that

Predisposing Factors (cont’d) Biological influences (cont’d) – Biochemical influences • One theory suggests that

Predisposing Factors (cont’d) Biological influences (cont’d) – Physiological influences • Factors that have been

Predisposing Factors (cont’d) • Physiological influences (cont’d) – Various physical conditions • • •

Predisposing Factors (cont’d) Psychological influences – These theories no longer hold credibility. Researchers now

Predisposing Factors (cont’d) Environmental influences – Sociocultural factors: Poverty has been linked with the

Predisposing Factors (cont’d) Environmental influences (cont’d) – Stressful life events may be associated with

Predisposing Factors (cont’d) Theoretical integration – Schizophrenia is most likely a biologically based disease,

Types of Schizophrenia and Other Psychotic Disorders • Delusional Disorder – The existence of

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Brief Psychotic Disorder – Sudden

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Substance-Induced Psychotic Disorder • The

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Psychotic Disorder Associated with Another

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • The Catatonic Features Specifier –

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Catatonic Disorder Associated with Another

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Schizophreniform Disorder – Same symptoms

Types of Schizophrenia and Other Psychotic Disorders (cont’d) – Schizoaffective Disorder • Schizophrenic symptoms

Types of Schizophrenia and Other Psychotic Disorders (cont’d) 1. A client is admitted with

Types of Schizophrenia and Other Psychotic Disorders (cont’d) Correct answer: C Symptoms associated with

Nursing Process: Assessment Positive symptoms • Content of thought – Delusions: false personal beliefs

Assessment: Positive Symptoms (cont’d) • Form of thought – Associative looseness (also called loose

Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) – Word salad: group of

Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) – Perseveration: persistent repetition of

Assessment: Positive Symptoms (cont’d) 2. The client hears the word “match. ” The client

Assessment: Positive Symptoms (cont’d) Correct answer: C Loose association is characterized by communication in

Assessment: Positive Symptoms (cont’d) • Perception: interpretation of stimuli through the senses – Hallucinations:

Assessment: Positive Symptoms (cont’d) • Sense of self: The uniqueness and individuality a person

Assessment: Positive Symptoms (cont’d) 3. A client diagnosed with schizophrenia experiences identity confusion and

Assessment: Positive Symptoms (cont’d) Correct answer: A Echolalia is a parrot-like repetition of overheard

Assessment: Negative Symptoms • Affect: the feeling state or emotional tone – Inappropriate affect:

Assessment: Negative Symptoms (cont’d) • Volition: impairment in the ability to initiate goal-directed activity

Assessment: Negative Symptoms (cont’d) • Impaired interpersonal functioning and relationship to the external world

Assessment: Negative Symptoms (cont’d) • Psychomotor behavior – Anergia: deficiency of energy – Waxy

Assessment: Negative Symptoms (cont’d) – Associated features • Anhedonia: inability to experience pleasure •

Nursing Process: Diagnosis/Outcome Identification • Disturbed Sensory Perception (auditory and visual) related to panic

Nursing Diagnosis (cont’d) • Social Isolation related to inability to trust, panic anxiety, weak

Nursing Diagnosis (cont’d) • Risk for Violence: Self-directed or Otherdirected related to – Extreme

Nursing Diagnosis (cont’d) • Impaired Verbal Communication related to – Panic anxiety – Regression

Nursing Diagnosis (cont’d) • Self-Care Deficit related to – – – Withdrawal Regression Panic

Nursing Diagnosis (cont’d) • Ineffective Health Maintenance related to disordered thinking or delusions •

Outcomes • The client – Demonstrates an ability to relate to others satisfactorily –

Outcomes (cont’d) • The client (cont’d) – Demonstrates ability to perceive the environment correctly

Outcomes (cont’d) • The client (cont’d) – Demonstrates ability to trust others – Uses

Nursing Process: Planning/Implementation • Nursing interventions for the client with schizophrenia or other psychotic

Nursing Process: Planning/Implementation (cont’d) 4. To deal with a client's hallucinations therapeutically, which nursing

Nursing Process: Planning/Implementation (cont’d) Correct answer: D The nurse should first empathize with the

Nursing Process: Planning/Implementation (cont’d) 5. A client, diagnosed with paranoid schizophrenia, states, “My roommate

Nursing Process: Planning/Implementation (cont’d) Correct answer: A This client is experiencing a persecutory delusion.

Client/Family Education • Nature of illness – What to expect as illness progresses –

Client/Family Education (cont’d) • Management of the illness – Connection of exacerbation of symptoms

Client/Family Education (cont’d) • Support services – Financial assistance – Legal assistance – Caregiver

Nursing Process: Evaluation • Evaluation questions – Has client established trust with at least

Treatment Modalities • Psychological treatments – Individual psychotherapy: long-term therapeutic approach; difficult because of

Treatment Modalities (cont’d) • Psychological treatments (cont’d) – Behavior therapy: chief drawback has been

Treatment Modalities (cont’d) • Social treatments – Milieu therapy: best if used in conjunction

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) – A program of

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) – Services include

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) – Services are

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) The primary goals

Treatment Modalities (cont’d) • The Recovery Model – A concept of healing and transformation

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Research provides support for recovery

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Functional recovery • Focus is

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Process recovery • There is

Treatment Modalities (cont’d) • Psychopharmacology – Antipsychotics • Used to decrease agitation and psychotic

Treatment Modalities (cont’d) • Psychopharmacology (cont’d) – Action • Typicals: dopaminergic blockers with various

Antipsychotics Side Effects • • • Anticholinergic effects Nausea; GI upset Skin rash Sedation

Antipsychotics (cont’d) • Extrapyramidal symptoms (EPS) include – – – Pseudoparkinsonism Akinesia Akathisia Dystonia

Client/Family Education • The client should – Not stop taking the drug abruptly –

Client/Family Education (cont’d) • The client should (cont’d) – Not drink alcohol while receiving

Psychopharmacology 6. A client who has been taking chlorpromazine (Thorazine) for several months presents

Psychopharmacology (cont’d) Correct answer: C Benztropine is an anticholinergic medication that blocks cholinergic activity

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Introduction (cont’d) • Schizophrenia is probably caused by a combination of factors, including – – Genetic predisposition Biochemical dysfunction Physiological factors Psychosocial stress Copyright © 2014. F. A. Davis Company

Introduction (cont’d) • Of all mental illnesses, schizophrenia probably causes more – Lengthy hospitalizations – Chaos in family life – Exorbitant costs to people and governments – Fears Copyright © 2014. F. A. Davis Company

Nature of the Disorder (cont’d) • With schizophrenia, there is a severe deterioration of social and occupational functioning. • In the United States, the lifetime prevalence of schizophrenia is about 1 percent. Copyright © 2014. F. A. Davis Company

Phase I Premorbid phase – Social maladjustment – Antagonistic thoughts and behavior – Shy and withdrawn – Poor peer relationships – Doing poorly in school – Antisocial behavior Copyright © 2014. F. A. Davis Company

Phase II Prodromal phase • • • Lasts from a few weeks to a few years Deterioration in role functioning and social withdrawal Substantial functional impairment Sleep disturbance, anxiety, irritability Depressed mood, poor concentration, fatigue Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis Copyright © 2014. F. A. Davis Company

Phase III Schizophrenia • In the active phase of the disorder, psychotic symptoms are prominent – Delusions – Hallucinations – Impairment in work, social relations, and self-care Copyright © 2014. F. A. Davis Company

Prognosis • A return to full premorbid functioning is not common • Factors associated with a positive prognosis include – – – Good premorbid functioning Later age at onset Female gender Abrupt onset precipitated by a stressful event Associated mood disturbance Brief duration of active-phase symptoms Copyright © 2014. F. A. Davis Company

Prognosis (cont’d) • Factors associated with a positive prognosis (cont’d) – – – Minimal residual symptoms Absence of structural brain abnormalities Normal neurological functioning Family history of mood disorder No family history of schizophrenia Copyright © 2014. F. A. Davis Company

Predisposing Factors Biological influences – Genetics • A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Biological influences (cont’d) – Biochemical influences • One theory suggests that schizophrenia may be caused by an excess of dopamine activity in the brain • Abnormalities in other neurotransmitters have also been suggested Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Biological influences (cont’d) – Physiological influences • Factors that have been implicated include – Viral infection – Anatomical abnormalities – Histological changes in brain Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) • Physiological influences (cont’d) – Various physical conditions • • • Epilepsy Huntington’s disease Birth trauma Head injury in adulthood Alcohol abuse Cerebral tumor Cerebrovascular accident Systemic lupus erythematosus Myxedema Parkinsonism Wilson’s disease Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Psychological influences – These theories no longer hold credibility. Researchers now focus their studies of schizophrenia as a brain disorder. – Psychosocial theories probably developed early on out of a lack of information related to a biological connection. Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Environmental influences – Sociocultural factors: Poverty has been linked with the development of schizophrenia. – Downward drift hypothesis: Poor social conditions seen as consequence of, rather than a cause of, schizophrenia. Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Environmental influences (cont’d) – Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse. Copyright © 2014. F. A. Davis Company

Predisposing Factors (cont’d) Theoretical integration – Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment. Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders • Delusional Disorder – The existence of prominent, non-bizarre delusions • • • Erotomanic type Grandiose type Jealous type Persecutory type Somatic type Mixed type Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Brief Psychotic Disorder – Sudden onset of symptoms – May or may not be preceded by a severe psychosocial stressor – Lasts less than 1 month – Return to full premorbid level of functioning Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Substance-Induced Psychotic Disorder • The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Psychotic Disorder Associated with Another Medical Condition – Prominent hallucinations and delusions are directly attributable to a general medical condition Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • The Catatonic Features Specifier – Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder – Symptoms of catatonic disorder include • Stupor and muscle rigidity or excessive, purposeless motor activity • Waxy flexibility, negativism, echolalia, echopraxia Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Catatonic Disorder Associated with Another Medical Condition – This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Schizophreniform Disorder – Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) – Schizoaffective Disorder • Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders, either mania or depression Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) 1. A client is admitted with a diagnosis of brief psychotic disorder, with catatonic features. Which symptoms are associated with the catatonic specifier? a) b) c) d) Strong ego boundaries and abstract thinking Ataxia and akinesia Stupor, muscle rigidity, and negativism Substance abuse and cachexia Copyright © 2014. F. A. Davis Company

Types of Schizophrenia and Other Psychotic Disorders (cont’d) Correct answer: C Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors. Copyright © 2014. F. A. Davis Company

Nursing Process: Assessment Positive symptoms • Content of thought – Delusions: false personal beliefs – Religiosity: excessive demonstration of obsession with religious ideas and behavior – Paranoia: extreme suspiciousness of others – Magical thinking: ideas that one’s thoughts or behaviors have control over specific situations Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) • Form of thought – Associative looseness (also called loose association): shift of ideas from one unrelated topic to another – Neologisms: made-up words that have meaning only to the person who invents them – Concrete thinking: literal interpretations of the environment – Clang associations: choice of words is governed by sound (often rhyming) Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) – Word salad: group of words put together in a random fashion – Circumstantiality: delay in reaching the point of a communication because of unnecessary and tedious details – Tangentiality: inability to get to the point of communication due to introduction of many new topics – Mutism: inability or refusal to speak Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) – Perseveration: persistent repetition of the same word or idea in response to different questions Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) 2. The client hears the word “match. ” The client replies, “A match. I like matches. They are the light of the world. God will light the world. Let your light so shine. ” Which communication pattern does the nurse identify? a) Word salad b) Clang association c) Loose association d) Ideas of reference Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) Correct answer: C Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern. Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) • Perception: interpretation of stimuli through the senses – Hallucinations: false sensory perceptions not associated with real external stimuli – – – Auditory Visual Tactile Gustatory Olfactory • Illusions: misperceptions of real external stimuli Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) • Sense of self: The uniqueness and individuality a person feels – Echolalia: repeating words that are heard – Echopraxia: repeating movements that are observed – Identification and imitation: taking on the form of behavior one observes in another – Depersonalization: feelings of unreality Copyright © 2014. F. A. Davis Company

Assessment: Positive Symptoms (cont’d) 3. A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? a) b) c) d) Copyright © 2014. F. A. Davis Company Identify with the person speaking Imitate the nurse’s movements Alleviate alogia Alleviate avolition

Assessment: Positive Symptoms (cont’d) Correct answer: A Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking. Copyright © 2014. F. A. Davis Company

Assessment: Negative Symptoms • Affect: the feeling state or emotional tone – Inappropriate affect: emotions are incongruent with the circumstances – Bland: weak emotional tone – Flat: appears to be void of emotional tone – Apathy: disinterest in the environment Copyright © 2014. F. A. Davis Company

Assessment: Negative Symptoms (cont’d) • Volition: impairment in the ability to initiate goal-directed activity – Emotional ambivalence: coexistence of opposite emotions toward same object, person, or situation – Deterioration in appearance: impaired personal grooming and self-care activities Copyright © 2014. F. A. Davis Company

Assessment: Negative Symptoms (cont’d) • Impaired interpersonal functioning and relationship to the external world – Impaired social interaction: clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable – Social isolation: a focus inward on the self to the exclusion of the external environment Copyright © 2014. F. A. Davis Company

Assessment: Negative Symptoms (cont’d) • Psychomotor behavior – Anergia: deficiency of energy – Waxy flexibility: passive yielding of all movable parts of the body to any effort made at placing them in certain positions – Posturing: voluntary assumption of inappropriate or bizarre postures – Pacing and rocking: pacing back and forth and rocking the body Copyright © 2014. F. A. Davis Company

Assessment: Negative Symptoms (cont’d) – Associated features • Anhedonia: inability to experience pleasure • Regression: retreat to an earlier level of development Copyright © 2014. F. A. Davis Company

Nursing Process: Diagnosis/Outcome Identification • Disturbed Sensory Perception (auditory and visual) related to panic anxiety, extreme loneliness, and withdrawal into self • Disturbed Thought Processes related to inability to trust, panic anxiety, or possible hereditary or biochemical factors Copyright © 2014. F. A. Davis Company

Nursing Diagnosis (cont’d) • Risk for Violence: Self-directed or Otherdirected related to – Extreme suspiciousness – Panic anxiety – Catatonic excitement – Rage reactions – Command hallucinations Copyright © 2014. F. A. Davis Company

Nursing Diagnosis (cont’d) • Self-Care Deficit related to – – – Withdrawal Regression Panic anxiety Perceptual or cognitive impairment Inability to trust • Disabled Family Coping related to difficulty coping with client’s illness Copyright © 2014. F. A. Davis Company

Nursing Diagnosis (cont’d) • Ineffective Health Maintenance related to disordered thinking or delusions • Impaired Home-Maintenance related to – Regression – Withdrawal – Lack of knowledge or resources – Impaired physical or cognitive functioning Copyright © 2014. F. A. Davis Company

Outcomes • The client – Demonstrates an ability to relate to others satisfactorily – Recognizes distortions of reality – Has not harmed self or others – Perceives self realistically Copyright © 2014. F. A. Davis Company

Outcomes (cont’d) • The client (cont’d) – Demonstrates ability to perceive the environment correctly – Maintains anxiety at a manageable level – Relinquishes need for delusions and hallucinations Copyright © 2014. F. A. Davis Company

Outcomes (cont’d) • The client (cont’d) – Demonstrates ability to trust others – Uses appropriate verbal communication in interactions with others – Performs self-care activities independently Copyright © 2014. F. A. Davis Company

Nursing Process: Planning/Implementation • Nursing interventions for the client with schizophrenia or other psychotic disorder are aimed at – – – Decreasing anxiety and establishing trust Assisting client to define and test reality Encouraging interaction with others Ensuring safety of client and others Meeting client’s self-care needs Promoting adaptive family coping Copyright © 2014. F. A. Davis Company

Nursing Process: Planning/Implementation (cont’d) 4. To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? a) Reinforce the perceptual distortions until the client develops new defenses b) Provide an unstructured environment c) Avoid making connections between anxietyproducing situations and hallucinations d) Distract the client's attention Copyright © 2014. F. A. Davis Company

Nursing Process: Planning/Implementation (cont’d) Correct answer: D The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to realitybased activities. Copyright © 2014. F. A. Davis Company

Nursing Process: Planning/Implementation (cont’d) 5. A client, diagnosed with paranoid schizophrenia, states, “My roommate is plotting to have others kill me. ” Which is the appropriate nursing response? a) “I find that hard to believe. ” b) “What would make you think such a thing? ” c) “I know your roommate. He would do no such thing. ” d) “I can see why you feel that way. ” Copyright © 2014. F. A. Davis Company

Nursing Process: Planning/Implementation (cont’d) Correct answer: A This client is experiencing a persecutory delusion. This nursing response is an example of “voicing doubt, ” which expresses uncertainty as to the reality of the client’s perceptions. This is an appropriate therapeutic communication technique in dealing with clients who are experiencing delusional thinking. Copyright © 2014. F. A. Davis Company

Client/Family Education • Nature of illness – What to expect as illness progresses – Symptoms associated with illness – Ways for family to respond to behaviors associated with illness Copyright © 2014. F. A. Davis Company

Client/Family Education (cont’d) • Management of the illness – Connection of exacerbation of symptoms to times of stress – Appropriate medication management – Side effects of medications – Importance of not stopping medications – When to contact health-care provider – Relaxation techniques – Social skills training – Daily living skills training Copyright © 2014. F. A. Davis Company

Nursing Process: Evaluation • Evaluation questions – Has client established trust with at least one staff member? – Is anxiety level maintained at a manageable level? – Is delusional thinking still prevalent? – Is client able to interrupt escalating anxiety with adaptive coping mechanisms? – Is client easily agitated? – Is client able to interact with others appropriately? Copyright © 2014. F. A. Davis Company

Treatment Modalities • Psychological treatments – Individual psychotherapy: long-term therapeutic approach; difficult because of client’s impairment in interpersonal functioning • Group therapy: some success if occurring over the long-term course of the illness; less successful in acute, short-term treatment Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Psychological treatments (cont’d) – Behavior therapy: chief drawback has been inability to generalize to community setting after client has been discharged from treatment – Social skills training: use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, etc. ; aimed at improving relationship development. Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Social treatments – Milieu therapy: best if used in conjunction with psychopharmacology – Family therapy: aimed at helping family members cope with long-term effects of the illness Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) – A program of case management that takes a team approach in providing comprehensive, community -based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness. Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) – Services include • • • Substance abuse treatment Psychoeducational programs Family support and education Mobile crisis intervention Attention to health-care needs Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) – Services are provided by a multidisciplinary team of • • • Psychiatrists Nurses Social workers Vocational rehabilitation therapists Substance abuse counselors – Services are available 24 hours a day, 365 days a year Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) – Services are provided wherever assistance by the client is required • • • In the person’s home Within the neighborhood In local restaurants Parks Stores Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Program of Assertive Community Treatment (PACT) (cont’d) The primary goals of PACT are 1. 2. 3. 4. 5. 6. To meet basic needs and enhance quality of life To improve role functioning To enhance independent living To lessen family burden of providing care To decrease debilitating symptoms of mental illness To minimize recurrent acute episodes of the illness Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • The Recovery Model – A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Research provides support for recovery as an obtainable objective for individuals with schizophrenia. Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Functional recovery • Focus is on the individual’s level of functioning in areas of relationships, work, independent living, and other kinds of life functioning Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • The Recovery Model (cont’d) – Process recovery • There is no defined end point. Recovery is viewed as a process that continues throughout the individual’s life and involves collaboration between client and clinician. Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Psychopharmacology – Antipsychotics • Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders Copyright © 2014. F. A. Davis Company

Treatment Modalities (cont’d) • Psychopharmacology (cont’d) – Action • Typicals: dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptors • Atypicals: weak dopamine antagonists; potent 5 HT 2 A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors Copyright © 2014. F. A. Davis Company

Antipsychotics Side Effects • • • Anticholinergic effects Nausea; GI upset Skin rash Sedation Orthostatic hypotension Photosensitivity Hormonal effects ECG changes Hypersalivation Weight gain Copyright © 2014. F. A. Davis Company • Hyperglycemia/diabetes • Increased risk of mortality in elderly clients with dementia • Reduction in seizure threshold • Agranulocytosis • Extrapyramidal symptoms • Tardive dyskinesia • Neuroleptic malignant syndrome

Antipsychotics (cont’d) • Extrapyramidal symptoms (EPS) include – – – Pseudoparkinsonism Akinesia Akathisia Dystonia Oculogyric crisis Antiparkinsonian agents may be prescribed to counteract EPS Copyright © 2014. F. A. Davis Company

Client/Family Education • The client should – Not stop taking the drug abruptly – Use sunscreens and wear protective clothing when spending time outdoors – Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug – Be aware of possible risks of taking antipsychotics during pregnancy Copyright © 2014. F. A. Davis Company

Client/Family Education (cont’d) • The client should (cont’d) – Not drink alcohol while receiving antipsychotic therapy – Not consume other medications (including overthe-counter drugs) without the physician’s knowledge Copyright © 2014. F. A. Davis Company

Psychopharmacology 6. A client who has been taking chlorpromazine (Thorazine) for several months presents in the ED with extrapyramidal symptoms (EPS) of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? a) b) c) d) Copyright © 2014. F. A. Davis Company Paroxetine (Paxil) Carbamazepine (Tegretol) Benztropine (Cogentin) Lorazepam (Ativan)

Psychopharmacology (cont’d) Correct answer: C Benztropine is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for EPS. Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic medications. Copyright © 2014. F. A. Davis Company