Schizophrenia

Kortney Squibbs
What is schizophrenia?
 Schizophrenia is not a
single illness; it is
thought of as a syndrome
or as a disease process
with many different
varieties and symptoms
 Changes in thoughts of Schizophrenia

• People with schizophrenia used to be thought of as dangerous, and uncontrollable

• Many believed that people with schizophrenia should be locked away from society and
institutionalized
• Recently the mental health community has come to learn and educate the community that
schizophrenia has many different symptoms and presentation and can be treated and managed with
medications
Risk factors for • Identical twins have a 50% chance of
developing schizophrenia
development
• People with less brain tissue and
cerebrospinal fluid
• Increased dopamine levels
• Decreased serotonin levels
• Cytokines from infection
• Infections in pregnant women
• Children born in crowded areas, in cold
weather, conditions that are hospitable for
respiratory ailments
• Family history of schizophrenia
Physiology of schizophrenia
• Neurotransmitters:
• dopamine
• Excessive dopamine can cause paranoid psychotic reactions
• Also, drugs that block post-synaptic dopamine receptors reduce psychotic symptoms
• Serotonin
• Some believe that excess serotonin itself contributes to schizophrenia
• Serotonin modulates and helps to control excess dopamine
• Cytokines
• Chemical messengers between immune cells, mediating inflammatory responses and immune
responses
• Specific cytokines also play a role in signaling the brain to produce behavioral and neurochemical
changes needed to face both physical and psychological stress to maintain homeostasis
• Schizophrenia can occur due to these changes that occurred while the cytokines fought off viruses
and infections
Signs and • Schizophrenia symptoms are divided into two major categories:
• Positive or hard signs and symptoms
Symptoms of
• Negative or soft signs and symptoms
schizophrenia
Positive or hard • Ambivalence-holding seemingly contradictory beliefs or
feelings about the same person, event or situation
signs and
• Associative looseness- fragmented or poorly related
symptoms thoughts or ideas
• Delusions-fixed false beliefs that have no basis in reality
• Echopraxia-Imitation of the movements and gestures of
another person whom the client is observing
• Flight of Ideas-Continuous flow of verbalization in which
the person jumps rapidly from one topic to another
Positive or hard • Hallucinations-false sensory perceptions or perceptual
experiences that do not exist in reality
signs and
• Ideas of reference-False impressions that external events
symptoms have special meaning for the person
continued… • Perservation-persistent adherence to a single idea or
topic; verbal repetition of a sentence, word, or phrase;
resisting attempts to change the topic
• Bizarre behavior-outlandish appearance or clothing;
repetitive or stereotyped, seemingly purposeless
movements, unusual social or sexual behavior
Negative or soft • Alogia-tendency to speak little or to convey little
substance of meaning (poverty of content)
symptoms
• Anhedonia-feeling no joy or pleasure from life or any
activities or relationships
• Apathy-feelings of indifference toward people, activities
and events
• Associality-social withdrawal, few or no relationships,
lack of closeness
• Blurred affect-restricted range of emotional feeling, tone,
or mood
Negative or soft • Catatonia-psychologically induced immobility
occasionally marked by periods of agitation or excitement,
symptoms the client seems motionless, as if in a trance
continued… • Flat affect- absence of any facial expression that would
indicate emotions or mood
• Avolition or lack of volition-absence of will, ambition, or
drive to act or accomplish tasks
• Inattention-inability to concentrate or focus on a topic or
activity, regardless of its importance
Hallucinations Types
•Auditory hallucinations-most common type, involve hearing voices
•Command hallucinations- are voices that demand that the client acts often to self-
harm self or others (considered dangerous)
•Visual hallucinations- involves seeing images that do not exist at all, such as
monsters, dead person etc. Second most common type
•Olfactory hallucinations-involves smells or odors, occurs often with dementia,
seizures, and cerebrovascular accident
•Tactile hallucinations-sensations such as electricity running through body or bugs
crawling on the skin
•Cenesthetic hallucinations-involves the patient stating they can feel bodily functions
that are undetectable, ex: urine forming
•Gustatory hallucinations- involves a taste lingering in the mouth
•Kinesthetic hallucinations- pt. is motionless but reports the sensation of bodily
movement
Delusion Types
•Persecutory/paranoid delusions- client’s belief that “others” are planning to harm them,
spying, following them, but cannot define who the “others” are
•Grandiose delusions- client’s claim to association with famous people, client’s belief
that he or she is famous or capable of great feats
•Religious delusions-centered around the second coming or Christ or another significant
religious prophet or figure. Ex: pt. claims they are the Messiah and God came to them
•Somatic delusions-vague and unrealistic beliefs about the client’s health or bodily
functions, Ex: male pt. might argue and state he is pregnant
•Sexual delusions-believes that his or her’s sexual behavior is known to others, being a
prostitute etc.
•Nihilistic delusions- the client believes that their organs are not functioning or rotting
away
•Referential delusions-or ideas of reference involve the client’s belief that TV broadcasts
are directed at them, ex: pt. believes the president is talking to them over TV show
 Related
Disorders/Comorbidities

• Substance Abuse
• Anxiety and Depression
• Panic disorder
• PTSD
• OCD
• Substance Abuse
Research Article #1
Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement

• Discuss the major side effects in the following categories

• Hematological
• Cardiovascular
• Metabolic
• Neurological
• ECG and EEG abnormalities and importance of routine checking
• ECG QTc changes-because prolongation is associated with arrhythmic risk
• EEG may indicate adequacy in treatment better than the serum level
• There are so many serious and fatal side effects to clozapine it is important to note and learn
these
 Research Article #2
Rethinking schizophrenia
• Discusses the changes in schizophrenia in the last 100 years
• Educates readers about how we should view schizophrenia in 2030
• Children with the microdeletion of 22q11 will develop a form of
schizophrenia
• Educates the importance of early identification and treatment of
schizophrenia and how it can yield substantial improvements and outcomes
• Vision for 2030 is that anyone that is a diagnosed with schizophrenia
(regardless of how bad) will be considered as educated, employable, and
capable of living an intimate relationship with others
• 2030s goals must include prevention, preemption and cure
 • Schizophrenia is theorized to be caused by an excess or
deficiency of neurotransmitters: dopamine, serotonin and
Research article #3 glutamate
Schizophrenia: Overview
• More research has shown that infection and excess stress levels
and Treatment Options during the second trimester can double the risk of developing
schizophrenia
• Also, reviews the manifestations of Schizophrenia (listed
previously)
• DSM-5 states the diagnostic criteria for schizophrenia is “the
persistence of two or more of the following active-phase
symptoms, each listing for a significant portion of at least a one-
month period; delusions, hallucinations, disorganized speech,
grossly disorganized or catatonic behavior, and negative
symptoms
• Discussed both nonpharmacologic and pharmacologic treatment
options
 Name of Medication:
Clozapine (Clozaril)
Medications used
to treat Usual Daily Dosage:
Schizophrenia 150-500mg
Side Effects:
Dizziness
Hypotension
Weight gain
Hyperglycemia
Labs to Monitor:
WBC must be greater than 3500
Absolute Neutrophil Count (ANC)-must be greater than 2000
Monitor ST-T wave abnormalities
 Name of Medication:
Quetiapine (Seroquel)
Medications used
to treat Usual Daily Dosage:

Schizophrenia 150-500mg
Side Effects:
decreased hemoglobin
hypothyroidism
seizures
cognitive impairment
Labs to Monitor:
AST
ALT
Fasting Blood Sugar
Cholesterol Levels
 Name of Medication:
Risperidone (Risperdal)
Medications used Usual Daily Dosage:
to treat 2-8 mg
Schizophrenia Side Effects:
aggressive behavior
cough
decreased libido
neutropenia
Labs to Monitor:
prolactin levels
AST/ALT
Hemoglobin
CBC
 Patient Education:
Instruct patient to take medications everyday and to not miss
Medications used doses, if they do, take ASAP
to treat Educate patients about reporting any thoughts or changes in
Schizophrenia depression, thoughts of suicide
Advise patients to use sunscreen to prevent photosensitivity
reactions
Instruct patients to tell doctor about all OTC medications and
herbal medications
Educate patients about the effects of alcohol with
medications
Educate patient about proper oral hygiene
 Important Lab Values to monitor
• Hemoglobin- many medications can cause a decrease in hemoglobin
causing anemia
• WBC- important to make sure a patient's neutrophils are not low due to
medications
• Fasting Blood Glucose-some medications can cause increased blood
sugars
• Prolactin-monitor for hyperprolactinemia related to hypothalamic
dopamine blockade
• ALT/AST- monitor liver functions, to make sure that medications are not
affecting the liver
• BUN/ Creatinine- monitor kidney functions to make sure the kidneys are
working effectively and not being damaged by the medications
Other treatments used for schizophrenia
Schizophrenia: Overview and Treatment
Options
Krishna Patel, ParmD

• Divided into 3 categories

• Individual
• Supportive/counseling
• Personal therapy
• Social skills therapies
• Vocational sheltered employment rehabilitation therapists
• Group
• Interactive/social
• Cognitive Behavioral
• Cognitive behavioral therapy
• Compliance therapy
 Nursing Diagnoses for schizophrenia
1. Impaired verbal communication
Goals
1. patient will demonstrate reality-based thought processes in verbal communication
2. Patient will be able to communicate in a manner that can be understood by other with the help
of medication and attentive listening by the time of discharge
Nursing Interventions:
1. Keep voice in a low manner and speak slowly as much as possible
2. use clear or simple words, and keep directions simple as well
3. Identify the duration of the psychotic medication of the client
 Nursing Diagnoses for schizophrenia
2. Impaired social interaction
Goals
1. Patient will use appropriate social skills in interactions
2. Patient will use appropriate skills to initiate and maintain an interaction
Nursing Interventions:
1. Explore how the hallucinations are experienced by the client
2. Help client to identify times that the hallucinations are most prevalent and frightening
3. Decreased environmental stimuli when possible
 Nursing Diagnoses for schizophrenia
3. Disturbed Sensory Perception: Auditory/Visual
Goals
1. Patient will learn ways to refrain from responding to hallucinations
2. Patient will identify two stressful events that trigger hallucinations
Nursing Interventions:
1. Keep client in an environment as free of stimuli as possible
2. structure activities that work at the client's pace and activity
3. Useful coping skills that client will need include conversational and assertiveness skills
 Nursing Diagnoses for schizophrenia
4. Disturbed Thought Process
Goals
1. Patient will refrain from acting on delusional thinking
2. Patient will sustain attention and concentration to complete tasks or activities
Nursing Interventions:
1. Encourage healthy habits to optimize functioning
Includes: self care, sleep pattern, maintaining medication regimen
2. Recognizes the client’s delusions as the client’s perception of the environment
3. Attempt to understand the significance of these beliefs to the client at the time of their
presentation
 Nursing Diagnoses for schizophrenia
5. Defensive Coping
Goals
1. Patient will avoid high-risk environments and situations
2. Patient will be able to apply a variety of stress/anxiety-reducing techniques on their own
Nursing Interventions:
1. Use a nonjudgmental, respectful, and neutral approach with the client
2. Use clear and simple language when communicating with a suspicious client
3. Provide verbal/physical limits when client’s hostile behavior esclates
References:
• Nurseslab.com
• Drugguide.com
• Kar, N. et al. (2016). Clinical Psychopharmacology and Neuroscience
Clozapine Monitoring in Clinical Practice: Beyond the Mandatory
Requirement. 14(4). 323-329.
• Patel, K. et al. (2014). P & T. Schizophrenia: Overview and Treatment
Options. 39 (9). 638-645.
• Insel, T. et al. (2010). Perspective. Rethinking schizophrenia. (468). 187-193.
• Buckley, Peter et al. (2009). Schizophrenia Bulletin. Psychiatric
Comorbidities and Schizophrenia. 35(2). 383-402.