Schizophrenia

Schizophrenia
 Biologically based disorder that is
psychosocially devastating
 Exists in all cultures and socioeconomic
groups
 Characterized by overt psychosis
– A state in which one’s capacity to recognize
reality is limited or absent
 Biological
 Genetics
– Twin studies show 46% concordance rate in
monozygotic twins; 30% in dizygotic twins
– 1% of general population
– 10% sibling
 Neuroanatomical
– Enlarged ventricles, cortical atrophy, smaller frontal
lobes, defects in limbic brain structures
– Decreased metabolic activity and slower brain waves in
the frontal lobe
 Neurotransmitters
 The dopamine hypothesis is the major NT
hypothesis for schizophrenia
– Theory states that there is too much Da in
schizophrenia
 Some research suggests that Da and 5-HT may
be involved
 Other research has focused on the excitatory NT
glutamine, as PCP affects this NT and produces a
psychotic state
 Neurotransmitters (cont)
 NE may be insufficient in clients with
schizophrenia displaying anhedonia
 A deficiency in cholecystokinin may be
related to avolition and flat affect
 Given the complexity of schizophrenia, it is
unlikely that a disturbance in a single
neurotransmitter system is the cause
 Birth and Pregnancy
Complications
 Infants born with a hx of pregnancy or
birth complications have increased risk
of developing schizophrenia
 Infections during pregnancy, poor
nutrition during pregnancy, or exposure
to toxins could damage neurons or
affect NTs in the fetus
 Psychodynamic Theories
 Psychoanalytic/Developmental
– Anxious mothering….
 Child is unable to progress beyond dependence
 Affects ego organization and the child’s interpretation
of reality
 The individual is then susceptible to living in a
fantasy world in which hallucinations and delusions
attempt to create a reality
Psychodynamic Theories (cont)

 Cultural/Environmental
– Schizophrenia is disproportionately
represented in the lower socioeconomic
group
 Downward drift hypothesis—clients with
schizophrenia who possess low social skills
either move into a lower socioeconomic group
or fail to move to a higher one
– Other social scientists believe that the
stress of living in a lower socioeconomic
group is often enough to trigger
 Epidemiology
 1% prevalence rate
 Onset generally in adolescence and early
adulthood—females have an older age of
onset
 Comorbidities
– 1/3 to 2/3 substance abuse
– 1/3 to1/2 mood disorders
 Medical Comorbidities
 90% of schizophrenics are smokers
– Smoking related pathology
– Obesity
– STDs; viral hepatitis
– Suicide—10% accomplish
 Social and Economic Difficulties
 70-80% unemployment rate
 20% marriage rates
 1/3 are homeless
 Legal issues—end up in jail
 Poor satisfying social relationships
 DSM-IV Criteria

 A. Two or more of the following, each present

for a significant portion of time during a 1-
month period:
– Delusions
– Hallucinations
– Disorganized speech
– Disorganized or catatonic behavior
– Negative symptoms (flat affect, alogia, or avolition)
 B. Social or occupational impairment
 C. At least 6 months in duration
 DSM-IV Criteria

 D. Exclusion of Schizoaffective d/o or

mood d/o
 E. Exclusion of substance or general
medical condition
 F. If there is a hx of autistic disorder or
another pervasive developmental
d/o, the additional dx of
schizophrenia is made only if
prominent delusions or hallucinations
are also present for at least 1 month
 Schizophrenia Subtypes
 Paranoid
 Disorganized
 Catatonic
 Undifferentiated
 Residual
 Paranoid
 Delusions tend to be persecutory or
grandiose
 Auditory hallucinations are common and are
r/t the delusionary theme
 In the active phase of this d/o, the afflicted
individual is extremely ill and may be
dangerous to self or others
 Better prognosis than the other subtypes
 Disorganized
 Early insidious onset; childish affect
 Characterized by disintegration of personality
 Speech is disorganized—word salad, incoherent
speech, and clanging
 Behavior is odd—grimacing, grunting, sniffing,
posturing, rocking, uninhibited sexual behaviors
 Poor personal grooming; often unable to complete
ADLS
 Poor prognosis
 Catatonic
 Predominant feature is intense psychomotor
disturbance--psychomotor retardation or
excitation
 Manifestations include waxy flexibility,
mutism, and negativism
 Other sx include echopraxia (imitating the
movements of others), echolalia (repeating
what was said by another), grimacing, and
stereotypic movements
 Delusions often persist throughout the
withdrawn state
 Prognosis varies
 Undifferentiated
 Has aspects of each type-- paranoid,
disorganized, and catatonic
 Prognosis is poor with a chronic course
 Residual
 An individual has had at least 1 acute
episode of schizophrenia
 The individual is now free of prominent
positive sx but has some negative sx
 The prognosis is varied and unpredictable
 Clinical Symptoms of
Schizophrenia
 Perceptual
– Hallucinations
 Auditory—may be commanding; content
matches delusions
 Visual
 Tactile—may feel like being surrounded by
spider webs
 Olfactory and gustatory—client may refuse to
eat because food seems to smell or taste bad
– Illusions
 False perceptions due to misinterpretations of
real objects
 Clinical Symptoms of
Schizophrenia (cont)

 Cognitive
– Delusions—false beliefs that are fixed and
resistant to logic
 omnipotence; persecution; controlling or being
controlled
– Derealization—feeling that the world
around one is not real or distorted
– Ideas of reference—notion that other
people or the media is talking to or about
 Clinical Symptoms of
Schizophrenia (cont)
 Cognitive
– Incorrect use of language
 Neologisms—invented words
 Incoherence
 Echolalia or word salad
 Concrete, restricted vocabularies
 Looseness of associations—frequent change of
subject; not related to content of conversation
– Flight of ideas—abrupt change of topic in a
rapid flow of speech; seen more in mania
 Clinical Symptoms of
Schizophrenia (cont)

 Emotional
– Labile affect
 Apathy, dulled response
 Flattened affect
 Reduced responsiveness
 Exaggerated euphoria
 Rage
– Inappropriate affect
 Laughing at sad events
 Clinical Symptoms of
Schizophrenia (cont)

 Behavioral
– Little impulse control
 Response to command hallucinations
 Sudden scream as a protest to frustration
– Inability to cope with depression
 Depressed client has 50% risk of suicide
– Inability to manage anger
– Substance abuse as coping
– Noncompliance with meds
 Clinical Symptoms of
Schizophrenia (cont)

 Social
– Poor peer relationships
 Preference for solitude
– Low interest in hobbies or activities
– Loss if interest in appearance
 Schizophrenia

Negative
Positive Avolition
Hallucinations Alogia
Anhedonia
Delusions
Flat Affect
Disorganization Ambivalence

Neurocognitive
Impairment
Attention
Memory
Exec Function
 Positive Symptoms: Excess of
Normal Functions
• Delusions (fixed, false beliefs)
– Grandiose
– Nihilistic
– Persecutory
– Somatic

• Hallucinations (perceptual experiences)

• Thought disorder
• Disorganized speech
• Disorganized or catatonic behavior
 Negative Symptoms:
Less Than Normal Functioning
• Affective blunting: reduced range of emotion
• Alogia: reduced fluency and productivity of language and
thought
• Avolition: withdrawal and inability to initiate and persist in
goal-directed behavior
• Anhedonia: inability to experience pleasure
• Ambivalence: concurrent experience of opposite feelings,
making it impossible to make a decision
 Neurocognitive Impairment

• Evidence that neurocognitive impairment exists,

independent of positive and negative symptoms
Neurocognition Impaired in schizophrenia
 Memory (short-, long-term)  Memory (working)
 Vigilance (sustained attention)
 Vigilance
 Verbal fluency (ability to generate
new words)  Executive functioning
 Executive functioning
– volition
– planning
– purposive action
– self-monitoring behavior
 Neurocognitive Impairment Often
Seen as “Disorganized Symptoms”
• Confused speech and thinking patterns
• Disorganized behavior
• Examples of disorganized thinking
– Echolalia (repetition of words)
– Circumstantially (excessive detail)
– Loose associations (ideas loosely connected)
– Tangentially (logical, but detour)
– Flight of ideas (change topics)
– Word salad (unconnected words)
Disorganized Symptoms
• Examples of disorganized thinking (cont.)
– Neologisms (new words)
– Paranoia (suspiciousness)
– References ( special meaning)
– Autistic thinking (private logic)
– Concrete thinking (lack of abstract thinking)
– Verbigeration (purposeless repetition)
– Metonymic speech (interchange words)
 Disorganized Symptoms
• Examples of disorganized thinking (cont.)
– Clang association (repetition similar sounding words)
– Stilted language (artificial, formal)
– Pressured speech (words forced)
• Examples of disorganized behavior
– Aggression
– Agitation
– Catatonic excitement (hyperactivity, purposeless activity)
 Disorganized Symptoms
• Examples of disorganized behavior (cont.)
– Echopraxia (imitation of others movements)
– Regressed behavior
– Stereotypy (repetitive, purposeless movements)
– Hypervigilance (sustained attention to external stimuli)
– Waxy flexibility (posture held in odd or unusual way)
Disorders Closely Related to
Schizophrenia
 Schizophreniform Disorder
 Characteristics same as schizophrenia with
2 exceptions:
– Duration
 At least 1 month but less than 6 months
– Impairment in functioning
 Social or occupational functioning may or may not
occur with this d/o
 Schizoaffective Disorder
 Presents with severe mood swings of either
depression or mania and also with some of the
psychotic sx
 Most of the time, mania or depression coexists
with the psychotic sx, but there must be a 2 week
period in which there are only psychotic episodes
 Onset usually occurs later in life than
schizophrenia
 Has a better prognosis than schizophrenia but a
less positive prognosis than depression
 Symptoms
 Depressed phase  Manic phase
– Poor appetite – Increase in social, work, or
sexual activity
– Weight loss
– Increased talkativeness
– Inability to sleep
– Racing thoughts
– Agitation – Grandiosity
– General slowing down – Decreased need for sleep
– Anhedonia – Increase in goal-directed
– Lack of energy activity
– Feelings of worthlessness – Inflated self-esteem
– Thoughts of death or suicide – Involvement in self-
destructive activities
 Symptoms (cont)
 Psychotic Sx
– Delusions
– Hallucinations
– Incoherence
– Severely disorganized speech or thinking
– Grossly disorganized behavior
– Total immobility
– Lack of facial emotional expression
Treatment
 Treatment Modalities
 Cornerstones of treatment are:
– Medication management—Antipsychotics
– Psychosocial treatments
 Antipsychotics
 Divided into 2 classes:
– Traditional or Typical
– Novel or Atypical
 Mechanism of Action
 Typical antipsychotics
– Dopamine receptor blockers—specifically D2 receptors
– Da receptors are found in the following 3 areas of the
brain:
– The nigrostriatal pathway
 Blockade here produces EPS
– The mesolimbic pathway
 Blockade here reduces positve sx
– The mesocortical pathway
 Blockade here is thought to make negative sx of schizophrenia
worse
 Typical Antipsychotics
 Low-potency agents:
– Chlorpromazine (Thorazine)
 Dose/day 60-2000 mg
– Thioridazine (Mellaril)
 Dose/day 50-800 mg
– Mesoridazine (Serentil)
 Dose/day 50-500 mg
 Typical Antipsychotics
 Moderate-potency agents:
– Perphenazine (Trilafon)
 Dose/day 8-64 mg
– Loxapine (Loxitane)
 Dose/day 20-250 mg
– Molindone (Moban)
 Dose/day 15-225 mg
 Typical Antipsychotics
 High-potency agents:
– Fluphenazine (Prolixin)
 Dose/day 2-40 mg
– Thiothixene (Navane)
 Dose/day 5-60 mg
– Haloperidol (Haldol)
 Dose/day 1-100 mg
– Trifluoperazine (Stelazine)
 Dose/day 2-80 mg
 Mechanism of Action
 Atypical antipsychotics
– Also block Da receptors
– Block 5-HT to a greater degree than Da
 This causes an improved response of negative sx,
improved cognitive functioning, and reduced EPS
 Mechanism of Action
 Both typical and atypical antipsychotics vary
greatly in their affinity for other receptors but
may block:
– Histamine (H1) receptors—sedation
– Cholinergic receptors—anticholinergic SE
– Alpha receptors—hypotension and tachycardia
 Side Effect Profile
 Low-potency drugs cause more sedation
and hypotension
 High-potency drugs cause more EPS
 Drugs vary greatly in the amount of
anticholinergic effects they cause
– Drugs that are more likely to cause EPS have <
anticholinergic effects
 Acute Dystonia
 Muscular spasm that may occur in up to
10% of clients
 May effect different muscle groups
– Blepharospasm—eye closing
– Torticollis—neck muscle contraction; pulling
head to one side
– Oculogyric crisis—severe upward deviation of
the eyeballs
 Acute Dystonia (cont)
 Anticholinergic drugs are rapidly effective in
treating these sx
 Severe presentations should be treated with IM
injection
 Examples of meds include:
– Benzotrpine (Cogentin)
– Trihexyphenidyl (Artane)
– Diphenhydramine (Benadryl)
– Amantadine (Symmetrel)
 Neuroleptic Induced
Pseudoparkinsonism
 Results from imbalance between Da and Ach in
the nigrostriatal pathway
 Sx include:
– Tremors
– Bradykinesia/akinesia (slowness of movement)
– Cogwheel rigidity
– Shuffling gait
– Masked facies
– Hypersalivation and drooling
– Treat sx with anticholinergic drugs
 Akathisia
 Presents with both objective and subjective
components
– Objective sx include:
 Motor restlessness
 Pacing
 Rocking
 Foot tapping
– Subjective c/o include:
 Inner restlessness—tension, irritability, inability to sit or lie down
 Akathisia (cont)
 Beta-blockers and benzos are the most
common adjunctive Rxs
– Propanolol (Inderal)
– Lorazepam (Ativan)
 Tardive Dyskinesia
 Generally associated with long-term antipsychotic
use
 Irreversible
 Characterized by choreoathetoid movements—
rapid, jerky, and slow, writhing
– Clients generally experience involuntary movements of
the mouth, tongue, and face
– Arm, finger, leg, feet, and truncal movements are also
noted
 Neuroleptic Malingnant
Syndrome (NMS)
 Potentially fatal reaction to antipsychotics
 Characterized by:
– Muscular rigidity
– Hyperthermia
– Altered consciousness
– Autonomic dysfunction
 Lab findings include:
– Leucocytosis
– Increased creatine phosphokinase
– Increased myoglobinuria
 Neuroleptic Malingnant
Syndrome (NMS)
 Can occur at any time during Rx but is more
frequent shortly after initiation of
antipsychotics or dose increases
 Underling pathophysiology is unclear—has
to do with depletion of Da in basal ganglia
 Neuroleptic Malingnant
Syndrome (NMS)
 ***First D/C antipsychotic
 Hydration and cooling are of major
importance
– May also give muscle relaxant IV
– Dantrolene or bromocriptine (Da agonists) can
also be prescribed to relieve rigidity
 Atypical Antipsychotics
 Clozapine (Clozaril)
– Dose/day 50-900 mg
 Quetiapine (Seroquel)
– Dose/day 100-800
 Olanzapine (Zyprexa)
– Dose/day 5-30
 Risperidone (Riperdal)
– Dose/day 4-8 mg
 Ziprasidone (Geodon)
 Clozaril
 1st atypical antipsychotic
 1st antipsychotic to demonstrate a significant
improvement in negative sx
 Use is restricted to the Rx of refractory
schizophrenia secondary to SE
 Blocks 5-HT more than Da
– Less EPS
 Side Effects of Clozaril
 Life-threatening agranulocytosis
– Risk greatest in 1st 6 months of Rx
– Weekly monitoring of the WBC count is necessary for
the 1st 6 months of Rx followed by biweekly monitoring
 Seizures—dose-related SE
 Others include: sedation, tachycardia,
hypotension, GI upset, anticholinergic effects, and
hypersalivation
 Risperdal
 SE include:
– Anxiety
– Rhinitis
– Somnolence
– Tachycardia
– Mild weight gain
 Zyprexa

 SE include:
– Orthostatic hypotension
– Dizziness
– Constipation
– Substantial weight gain
 Seroquel
 Virtually no EPS
 SE include:
– Orhtostatic hypotension
– Tachycardia
– Dizziness
– Somnolence
 Geodon
 **Prolongs QTc interval
 Somnolence
 Hypotension
 Nausea
 Constipation
 De-escalation Techniques
 Manage the  Use breakaways
environment  Using and removing
 Show confidence and seclusion and
leadership restraints
 Encourage  Documenting event
verbalization  Debriefing session with
 Personalize yourself staff
and show concern
 Communication Techniques
with the Psychotic Patient
 Establish trust
 Personal space
 Soft tone of voice, open posture, not too
much eye contact
 Don’t argue with delusions
 Present reality
 Use diversions rather than confrontation
 Allow patient to make own decisions when
possible
 Try to alleviate their fears due to
misperceptions
Psychotherapeutic management
 Provide supportive care
 Strengthen patient’s self-esteem
 Treat patients as adults
 Prevent failure/ embarrassment
 Respect individuality - unique
 Reinforce reality
 Handle hostility calmly & matter-of-factly
 Issues related to Schizophrenia
 Family ⇔ the patient
communication, overprotection, blaming
 Non-compliance with medical regimen
 Caregiver’s needs - cope with strange and
frightening behaviors ie. apathy, poor
personal hygiene, violence
 Issues related to Schizophrenia
(II)
 Depression - part of the symptoms, be
masked during acute stage
 Relapse - stressors, noncompliance
 Stress & coping -
 Substance abuse -30% have dual Dx.,
cause (-) effect on the treatment & poor
outcomes
 Work - no work, inability, no motivation
Depression and Suicide in Schizo
 Depression is a natural part of schizo
 Depression can be masked especially
during the acute phase
 Depression is a reaction to schizo
 Care of Hallucinations &
Delusions
 Hallucinations
– Content of hallucination – commanding H
-> suicidal or homicidal
– N’s attitude – nonjudgmental, nonthreatening
– Eye contact, louder voice, call the person by
name
 Delusion
– Be empathic - Clarify the reality of the pt’s intent
– Clarify misinterpretations of the environment
– No argument
Delusion & Nursing Intervention
 presenting reality, orient pts to time, person
& place
 avoid argument, touch, competitive
activities,
 reinforce positive behaviors
 encourage verbalization
 Disruptive Behavior
 Set limit
 decrease environmental stimuli
 intervention before acting out
 close observation
 safety environment - minimize potential
weapons
 making contract with the client
 using restraints
 Withdrawn Patients
 arrange nonthreatening activities
 encourage participation - seating
 provide remotivation and resocialization
group experience
 reinforce appropriate grooming and
hygiene
 provide psychosocial rehabilitation -
social skill training, ...
 Suspicious Patients
 Be matter-of-fact; (ie DST for depression)
 avoid close physical contact - no touch
 be consistent in activities
 offer special food
 avoid whisper
 Maintain eye contact
 Hyperactivity Patients
 Allow pt to stand for a few min in group

 Provide a safe environment

 Provide activities that do not require fine

motor skills
 Immobility Patients
 Minimize circulatory problem

 Provide adequate diet, exercise, and rest

 Prevent victimization
 Nursing interventions
 Medication compliance- 40-60%
noncompliance
 Avoid reinforcing hallucinations & delusion
 Maintain orientation
 Use touch minimally and judiciously
 Avoid easily misinterpreted behavior
 Reinforce positive behaviors
 Avoid competitive activities,
 Allow & encourage expression of feelings
 Nursing interventions-
Milieu management
 clear & realistic limits; consistency;
 Supportive environment – structured, predictable
 reduced stimulation
 early intervention for escalating behavior
 safety for the pt and others
 opportunity for nonthreatening social interaction
 remotivating and resocializing group
 Communication skills
 Nursing interventions –
Family therapy
 Involve the family – use appropriate
community resources
 Educate the family – chr. dis, S/S of relapse,
med compliance,
 Provide an outlet for the family – discuss
feelings, explore alternative effective coping
skills.
 Psychotherapy
 Individual Th – supportive therapy
 Group Th – interpersonal skills, family
problems, community support
 Family Th – expand social network,
problem-solving capacity, lower the
emotional overinvolvement of families
 Case Management
 Limited hospital stay, 3rd party payment
 Discharge planning – transitional care
 Partial hospitalization, halfway houses, day
treatment programs
 Community resources – NAMI,
Schizophrenics Anonymous, …
 Nurse’s feelings & self-assessment
 Pt’s anxiety, loneliness, dependence,
distrust -> N’s uncomfort
 Feelings of helplessness -> anxiety ->
defensive behaviors ie denial, withdrawal,
avoidance -> burnout
 Peer group supervision can be helpful
 Periodic reassessment of Tx goals,
 Family/care taker education
 Teaching about the disease –S/S
 Medication teaching and side-effect
management
 Cognitive & social skills enhancement
 Identifying signs of relapse
 Attention to deficit in self-care, social and
work functioning
 Exploration of community resources
 Signs of Potential Relapse
 Feeling of tension
 Difficulty concentrating
 Trouble sleeping
 Increased withdrawal
 Increased bizarre/ magic thinking
 Care of Hallucinations & Delusions
 Hallucinations
– Content of hallucination – commanding H
-> suicidal or homicidal
– N’s attitude – nonjudgmental, nonthreatening
– Eye contact, louder voice, call the person by
name
 Delusion
– Be empathic - Clarify the reality of the pt’s intent
– Clarify misinterpretations of the environment
– No argument
 Treatment
 Psychoeducation
– Teach that stressors can exacerbate sx
– Inform pt on illness and meds
 Supportive Psychotherapy
– Goal is to support ego function—help them to get
through this—gentle guidance and advice
 Milieu
– Calm environment; safety
 Symptom management
– Focus on prodromal sx—make pt aware that they need
to recognize these sx for exacerbations
 Family Therapy
 May be necessary to begin with individual
family therapy in which each family member
has a therapist
 Need to target Expressed Emotion (EE)
– Emphasize strengths not deficits
– Share power—who is in control of the patient in
the family
– Contain outbursts
– Problem solving skills
 High levels of EE—56% rehospitalization in 6
months
 Low levels of EE—21% rehospitalization in 6
months
 Rehabilitation=Goal
 Social skills training
– Teach issues re: hygiene, personal space, eye contact,
body language
– Expressing interests in others
– Teach empathy
– Initiating contact with others
 Vocational Rehab
– Vocational counseling and education
 Supportive employment
– Get job in the community and have job coach come in to
help you keep the job
 Outcomes
 1/3 recover; 1/3 severe chronic; 1/3 exacerbations
and remissions
 In general, Schizophrenia is a relapsing and
remitting course
 Timing is relevant -early intervention ++
 Stabilize 1st year
 1st 6 months increased risk for suicide
 Combined approaches best—meds alone aren’t
enough