Schizophrenia

&
Other Psychotic Disorders

Chapter 20
Melinda Hermanns,
MSN, RN, BC
 Schizophrenia

• Neurological disease that

affects a person’s perception,
thinking, language, emotion,
and social behavior.
• Occupies approximately 50% of
all hospital beds and 35-50% of
the homeless population
 Schizophrenia
• Lifetime Prevalence: 1% worldwide
• Typical Age of Onset: late teens
and early 20s.
• Men and women equal
 Theories

• Cause unknown most likely a

result of inherited genetic
factors and non-genetic
factors
 Theories (cont’d)
• Neuroanatomical Studies -
structural brain abnormalities:
–Cerebral ventricles
–Cortical atrophy
–Atrophy of frontal lobe
PET Scan
MRI
 Non-genetic Risk Factors

• Birth and Pregnancy

Complications

• Stress-Related Theories
 Bleuler’s 4 A’s
• Affect

• Associative Looseness

• Autism

• Ambivalence
 Prodromal /Early Symptoms
• Symptoms one month to one year before
psychotic break
• Person feels something strange or weird
is happening to them
• Misinterprets things in the environment
• Feelings of rejection, lack of self-respect,
loneliness,hopelessness, isolation,
withdrawal, and inability to trust others.
 DSM-IV-TR Diagnosis
Schizophrenia
• Must exhibit two or more of the
following, each present for at least a 1-
month period:
– delusions
– hallucinations
– disorganized speech
– grossly disorganized
– negative symptoms (flat affect)
 Assessing Symptoms
• Symptoms may be classified as
– Positive – “attention getter” symptoms i.e.
hallucinations, delusions, bizarre behavior,
disorganized speech
– Negative – “crippling” symptoms i.e. apathy,
lack of motivation, anhedonia
– Cognitive - i.e. difficulty with attention,
memory, and problem solving
– Disorganized – i.e. disorganized speech,
inappropriate affect
 Alterations in Thinking
• Delusions
• Ideas of Reference
• Persecution
• Grandiosity
• Bodily Functions
• Jealousy
• Control
 Symptoms Review
Review
Table
Table22-6,
22-6,
page 643
page 643

• Loose Associati
– thought broad on
casting
• Neologisms
– thought inserti
on • Concrete
– thought withdr Thinking
awal • Echolalia
– being controll • Clang Associati
ed on
• Word Salad
 Alterations in Perceiving
• Hallucinations - auditory, visual, olfactory,
gustatory, and tactile
• 90% of schizophrenics experience
hallucinations - auditory most common
• Difference between Illusions and
Hallucinations
• Depersonalization and Derealization (loss of
ego boundaries)
• Bizarre Behavior
Be
Befamiliar
familiarwith
withthe
theterms
termsininTable
Table22-4,
22-4,
page
page636
636
 Negative Symptoms
• Develop over time
• May not be detected (masked by positive
symptoms
Negative symptoms include: poverty of
speech content, thought blocking, anergia,
anhedonia, affective blunting, and lack of
avolition.
 Associated Symptoms

• Depression and Suicide

• Water Intoxication
• Substance Abuse
• Violent Behavior
 Nursing Diagnosis
• Multifaceted approach
• Table 20 – 5: Potential Nursing Diagnoses
 Outcome Criteria

• Phase I: Acute Phase - crisis

intervention

• Phase II: Maintenance

• Phase III: Stable

 Planning
• Hospitalization
• Identify long-term care needs
• Identify and provide proper referrals
• For patient and family follow-up
• Living arrangements, economic resources, social
supports, family relationships, vulnerability to stress
• Referral to community agencies – Example:
Andrews Center MHMR (learn about illness,
medications, and relapse prevention skills)
 Intervention
• Treatment Focus at Different Phases of
Schizophrenia – Table 20 -7, p. 540
• SAFETY
• First - Verbal Deescalation, followed by
Chemical Restraints (antipsychotics), then
as last resorts: Physical Restraints, and
Seclusion may be indicated.
 Communication Skills
• Table 20 – 8, p. 541
What to do if:
• The patient is hallucinating…
• The patient is experiencing delusions…
 Schizoaffective Disorder
• Mixture of Schizophrenic and Affective
symptoms
– I.e. alterations in mood as well as disturbances
in thought
• Thought by some to be a severe form of
Bipolar (Varcarolis, 1998)
• Treatment: Lithium used with antipsychotic
therapy for treatment of manic symptoms
 Psychopharmacology
• Typical (Traditional) Antipsychotics –
target the positive symptoms
• Older drugs – Watch for signs of EPS
• Atypical (Novel) Antipsychotics –
diminish the positive and negative
symptoms
 Typical Antipsychotic
Medications
• Thorazine • Haldol
• Mellaril (Haloperidol
• Stelazine and Haloperidol
• Trilafon deconate)
• Serentil • Loxapine
• Prolixin • Moban
• Navane
KNOW SIDE EFFECTS
 Typical Antipsychotics
• Medications must Be
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withBox
Box22-9,
22-9,p.
p.647
647
and
andBox
Box22-10,
22-10,p.p.648
be taken regularly 648

• Standard
(Traditional)
Antipsychotics
– EPS
– antiparkinson
drugs
REVIEW
REVIEWBox
Box22-1,
22-1,p.
p.650
650
 Side Effects of Antipsychotics
• Anticholinergic Symptoms
• Extrapyramidal Symptoms (EPS)
1. Pseudoparkinsonism
2. Acute dystonic reactions
-Opisthotonos
-Oculogyric Crisis
3. Akathisia
4. Tardive Dyskinesia
 Atypical Antipsychotics
• Advantage over typical: alleviate both
positive and negative symptoms
(improvement of quality of life)
• Clozapine (Clozaril) - agranulocytosis and
seizures
• LOWER SIDE EFFECTS:
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
 Adjuncts to Antipsychotic Therapy

• Antidepressants
• Antimanic Agents
• Benzodiazepines
• ECT
 Sub-types of Schizophrenia

• Paranoid Type
• Disorganized Type
• Catatonic Type
 Subtype: Paranoid

• Any intense and strongly defended

irrational suspicion
• Most common symptoms -
hallucination and delusions
• Defense Mechanism - Projection
 Subtype: Disorganized Type
• Most regressed and socially impaired
• Symptoms - loose association,
inappropriate affect, bizarre mannerisms,
incoherent speech and withdrawn
• Onset?
• Prognosis

»Back
 Subtype: Catatonia

• Abnormal motor behavior

• Be familiar with other symptoms
• Prognosis?
• Physical Needs are a Priority
 Nursing Interventions for
Schizophrenic Subtypes
• Be familiar with the following in each of
the subtypes:
– Communication Guidelines

– Self-Care Needs

– Milieu Needs
 FOR SCHIZOPHRENIA &
SCHIZOPHRENIA SUB-TYPES
Patient and Family Health Teaching
• Educate patient and family about illness
• Assist patient in improving his or her ability to
solve problems related to environmental stress
• Teach the patient coping strategies
• Assist family and patient to identify sources for
ongoing support

TABLE 20 – 10, p. 544

 Case Management
• DISCHARGE PLANNING
• Partial Hospitalization
• Halfway Houses
• Day Treatment Programs
• Group Therapy
• Supervised Activities
• Individual Counseling
• Specialized Training and Rehabilitation
 Therapy

• Individual • Family
• Supportive • Counseling
• Group • Psychoeducational
 Evaluation
• Realistic Goals
• Reassess patient’s problems
• Active involvement in patient’s progress
 Loose Association

• Definition - thinking haphazard,

illogical, and confused. Connections in
thought are interrupted.
• Example: “I can’t go to the zoo, no
money, Oh... I have a hat, these
members make no sense, man…What’s
the problem?”

Back
 Neologism

• Definition: Words a person

makes up that have meaning
only for that person, it is often
part of a delusional system.
• Example: “I am afraid to go to
the hospital because the norks
are looking for me.”
Back
 Clang Association

• Definition: The meaningless

rhyming of words, often in a
forceful manner.
• Example: “Rain, pain, bang,
clang.”
Back
 Echolalia

• Definition - mimicking or imitating

the speech of another person.
• Example: The nurse says to the
patient, “Tell me your name.” The
patient responds, “Tell me your
name, tell me your name.”
Back
 Word Salad

• Definition: Mixture of words

and phrases that have no
meaning.
• Example: “I am fine…apple
pie…no sale…furniture store…
take it slow…cellar door…”
Back
 Concrete Thinking

• What brought you here to the

hospital?
– The cab
• “People in glass houses shouldn’t
through stones.”
• Don’t throw stones or the windows
will break.
• ANSWERS ARE LITERAL

Back
 BE FAMILIAR WITH:
• thought broadcasting - the
belief that one’s thoughts can
be heard by others

Back
 Thought Insertion
• thought insertion - the belief
that thoughts from other people
are being inserted into one’s
mind

BACK
 BE FAMILIAR WITH:

• thought withdrawal - the belief

that thoughts have been
removed from one’s mind by an
outside agency.

Back
 Delusions of Being Controlled
• Delusions of being controlled
belief that one’s body or mind
is controlled by an outside
agency

BACK
 Common Side Effects

• Anti-cholinergic
• Sedation
• Orthostatic Hypotension
• Lowered Seizure Threshold
• Extrapyramidal Side Effects (EPS)
• Less Common NMS
Frontal
PET Scan Frontal
Lobe Discordant Monozygotic Lobe
Twins

BACK
 Magnetic Resonance Imaging
(MRI)

BACK