Schizophrenia and Other

Psychotic Disorders

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

Schizophrenia is a chronic brain disorder that affects approximately 2.5 million

Americans and more than 24 million people worldwide.

Schizophrenia is probably caused by a combination of factors, including

◦ Genetic predisposition
◦ Biochemical dysfunction
◦ Physiological factors
◦ Psychosocial stress

Schizophrenia requires treatment that

◦ is comprehensive and presented in a multidisciplinary effort
 Introduction (cont.)
More than any other mental illness, schizophrenia probably causes more
◦ Lengthy hospitalizations
◦ Chaos in family life
◦ Exorbitant (excessive) costs to people and governments
◦ Fears

Nature of the Disorder

◦ Schizophrenia disturbs
◦ Thought processes
◦ Perception
◦ Affect
 Nature of the Disorder (cont.)
With schizophrenia, there is a severe deterioration of social and occupational
functioning
In the United States, the lifetime prevalence of schizophrenia is about 1%
Premorbid behavior of the client with schizophrenia can be viewed in four phases
 Phase I. The Premorbid Phase
Characterized by
◦ Social maladjustment
◦ Social withdrawal
◦ Irritability
◦ Antagonistic thoughts and behavior
Phase II. The Prodromal Phase
Characterized by
◦ Functional impairment
◦ Deterioration in role functioning
◦ Social withdrawal
◦ Physical symptoms: sleep disturbance, anxiety irritability,
depression, fatigue, and poor concentration
Phase III. Schizophrenia
Active phase
psychotic symptoms are prominent
◦ Delusions
◦ Hallucinations
◦ Impairment in work, social relations, and self-care

Psychosis is a mental state characterized by severe agitation,

hallucinations, and a break with reality.
People experiencing psychosis are sometimes but not always a
danger to themselves and others. Drug therapy is important.
Phase IV

Phase IV. Residual Phase

Characterized by periods of remission and exarcebation
Symptoms similar to those of the prodromal phase
Flat affect and impairment in role functioning are prominent

Prognosis
Outcomes are difficult to predict
Complete return to premorbid state is uncommon
 Etiological Implications
Biological influences

◦ Genetics
◦ A growing body of knowledge indicates that genetics plays an
important role in the development of schizophrenia. Siblings with
schizophrenia have about 10% prevalence. Twin studies are 50
times that of the general population.
◦ Areas of the Brain Affected
◦ Dopamine pathways
 Etiological Implications (cont.)
Biological influences (cont.)
◦ Biochemical influences
◦ One theory suggests that schizophrenia may be caused by an excess of dopamine-
dependent neuronal activity in the brain
◦ Biochemical influences (cont.)
◦ Abnormalities in other neurotransmitters

◦ Norepinephrine
◦ Serotonin
◦ Acetylcholine
◦ Gamma-AminoaButyric Acid
Etiological Implications (cont.)
Physiological influences
◦ Factors that have been implicated
◦ Viral infection
◦ Brain abnormalities
◦ Histological changes in the brain
◦ Various physical conditions
◦ Epilepsy
◦ Huntington’s disease
◦ Birth trauma
◦ Head injury
◦ Alcohol abuse
◦ Cerebral tumor Ventricular enlargement
◦ Cerebrovascular accidents
◦ Systemic lupus erythematosus
◦ Myxedema
◦ Parkinson’s disease
◦ Wilson’s disease
 Etiological Implications (cont.)
Psychological influences
◦ Purely psychological factors no longer hold any credibility
◦ Researchers in the last decade have focused their studies more in terms of schizophrenia as
a brain disorder

Environmental influences
◦ Sociocultural factors: poverty has been linked with development of schizophrenia

◦ Downward drift hypothesis: poor social conditions are seen as a consequence of, rather
than a cause of, schizophrenia
◦ Stressful life events may be associated with exacerbation of schizophrenic symptoms and
increased rates of relapse
 Etiological Implications (cont.)
Theoretical integration
◦ Schizophrenia is most likely a biologically based disease, the onset of which is
influenced by factors in the internal or external environment
◦ Delusional Disorders:
◦ Erotomanic
◦ Grandiose
◦ Jealous
◦ Persecutory
◦ Somatic
◦ Mixed
 Brief psychotic disorder
◦ Sudden onset of psychotic symptoms following a severe psychosocial
stressor
◦ Symptoms persist less than 1 month;
◦ client returns to the full premorbid level of functioning
Schizophreniform disorder
◦ Same symptoms as schizophrenia, with exception that the duration of the disorder has been
at least 1 month but fewer than 6 months

Psychotic disorder d/t general medical condition

◦ Symptoms of this disorder include prominent hallucinations and
delusions that can be directly attributed to a general medical condition
 Substance-induced psychotic disorder
The presence of prominent hallucinations and delusions that are judged to be
directly attributable to the physiological effects of a substance:
◦ Alcohol
◦ Amphetamines
◦ Cocaine
◦ Sedative hypnotics
◦ Antihistamines
◦ Corticosteroids
◦ NSAIDs
Schizophrenia vs. Psychosis

There are a lot of people that often get the terms Schizophrenia and
Psychosis confused with each other. One way that you will be able to tell
the two apart is that Schizophrenia is defined as the disease or illness;
however, Psychosis is defined as the active manner of the disease or
illness. There are also a variety of other ways that Schizophrenia and
Psychosis differ.
Schizophrenia vs. Psychosis

Active (Positive) Signs:

◦ hallucinations, delusions, hearing voices, and paranoia among others. These
active signs will appear for at least 5% of the person’s life.

The Negative Symptoms:

◦ anhedonia, depression, lack of motivation, and fatigue among others.

Treatment:
◦ psychosis = medications.
◦ Schizophrenia =combination of Psycho-social therapy and Antipsychotic
medications.
 Nursing Process: Assessment
Content of thought
◦ Delusions: false beliefs (persecution, grandeur, reference, somatic, etc)
◦ Paranoia: extreme suspiciousness of others
◦ Magical thinking: the person believes that his or her thoughts or
behaviors have control over specific situations or people

Form of thought
◦ Associative looseness: shift of ideas from one unrelated topic to
another
◦ Neologisms: made-up words that have meaning only to the person
who invents them
 Nursing Process: Assessment (cont.)
Form of thought
◦ Concrete thinking: literal interpretations of the environment

◦ Clang associations: choice of words is governed by sound (often rhyming)

◦ 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
Nursing Process: Assessment (cont.)
Form of thought (cont.)
◦ Tangentiality: inability to get to the point of communication due to introduction of many
new topics
◦ Mutism: inability or refusal to speak
◦ Perseveration: persistent repetition of the same word or idea in response to different
questions

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Nursing Process: Assessment (cont.)
Perception
◦ Hallucinations: false sensory perceptions not associated with real external stimuli
◦ Auditory
◦ Visual
◦ Tactile
◦ Gustatory
◦ Olfactory

◦ Illusions: misperceptions of real external stimuli

Nursing Process: Assessment (cont.)
Affect: emotional tone
◦ Inappropriate affect: emotions are incongruent with circumstances
◦ Bland or flat affect: weak emotional tone
◦ Apathy: lack of interest in environment

Sense of Self: the uniqueness and individuality a person feels. The

individual with schizophrenia experiences confusion regarding his or
her unique identity.
◦ 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: feeling of unreality
 Nursing Process: Assessment (cont.)
◦ Volition: impairment in ability to initiate goal directed activity
◦ Emotional ambivalence: coexistence of opposite emotions toward
same object, person, or situation

Impaired interpersonal functioning and relationship to the external world

◦ Autism: the focus inward on a fantasy world while distorting or
excluding the external environment
◦ Deterioration in appearance: impaired personal grooming and
self-care activities

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 Nursing Process: Assessment (cont.)
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

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 Nursing Process: Diagnosis/Outcome Identification

Diagnosis:
Disturbed sensory-perception, auditory/visual related to panic
anxiety, extreme loneliness, and withdrawal into the self

Disturbed thought processes related to inability to trust, panic

anxiety, possibly hereditary or biochemical factors

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Diagnosis (cont.)
Social isolation related to inability to trust, panic anxiety, weak ego
development, delusional thinking, regression
Risk for Violence: Self-directed or other-directed related to:
◦ Extreme suspiciousness
◦ Panic anxiety
◦ Catatonic excitement
◦ Rage reactions
◦ Command hallucinations

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 Diagnosis (cont.)
Impaired verbal communication related to:
◦ Panic anxiety
◦ Regression
◦ Withdrawal
◦ Disordered, unrealistic thinking
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

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Diagnosis (cont.)
Ineffective health maintenance related to disordered thinking or
delusions
Impaired home-maintenance related to:
◦ Regression
◦ Withdrawal
◦ Lack of knowledge or resources
◦ Impaired physical cognitive functioning

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 Outcomes (cont.)
The client (cont.)
◦ Demonstrates ability to perceive the environment correctly
◦ Maintains anxiety at a manageable level
◦ Relinquishes need for delusions
and hallucinations
◦ Demonstrates ability to trust others
◦ Uses appropriate verbal communication in interactions with others
◦ Performs self-care activities
independently
◦ Demonstrates an ability to relate to others satisfactorily
◦ Recognizes distortions of reality (r.t. hallucinations/illness)
◦ Has not harmed self or others
◦ Perceives self realistically

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Nursing Process: Planning/Implementation

Nursing interventions for the client with schizophrenia or other psychotic

disorder are aimed at

◦ Decreasing anxiety and establishing trustful relationship

◦ Demonstrate behaviors of reliability, honesty, and consistency
◦ Assisting client to define and test reality
◦ Focus on the feelings generated by the hallucinations and present reality to clients with
schiz.

Inform clients with auditory hallucinations that I do not hear the voices and that is part of
their illness
◦ Encouraging interaction with others
◦ Ensuring safety of client and others
◦ Note escalating behaviors and intervene immediately
◦ Provide personal space to clients with paranoid schizophrenia to respect their boundaries.
◦ Meeting client’s self-care needs
◦ Promoting adaptive family coping
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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
Management of 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

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Client/Family Education (cont.)
Support services
◦ Financial assistance
◦ Legal assistance
◦ Caregiver support groups
◦ Respite care
◦ Home health care

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Nursing Process: Evaluation (cont.)

Evaluation questions
◦ Is client able to interrupt escalating anxiety with adaptive
coping mechanisms?
◦ Is client easily agitated?
◦ Is client able to interact with others appropriately?
◦ Has client established trust with at least one staff member?
◦ Is anxiety level maintained at a manageable level?
◦ Is delusional thinking still prevalent?
Treatment Modalities
Psychological treatments
◦ Individual psychotherapy: long-term therapeutic approach difficult
because of client’s impairment in interpersonal functioning
◦ Group therapy: some success if participating over long-term course
of the illness; less successful in short-term treatment
◦ Behavior therapy: chief drawback has been inability to generalize
to community setting after client has been discharged from therapy
Treatment Modalities (cont.)
Psychological treatments (cont.)
◦ Social skills training: use of role play to teach client appropriate eye
contact, interpersonal skills, voice intonation, posture, and so on,
aimed at improvement in social functioning

Social treatment
◦ Milieu therapy: best if used in conjunction with
psychopharmacology
◦ Family therapy: aimed at helping family members cope with long-
term effects of illness
 Treatment Modalities (cont.)
Assertive Community Treatment (ACT)
◦ 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

Services include
◦ Substance abuse treatment
◦ Psycho-educational programs
◦ Family support and education
◦ Mobile crisis intervention
◦ Attention to health-care needs

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 Treatment Modalities (cont.)
Assertive Community Treatment (ACT) (cont.)

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

◦ Services are provided wherever assistance by the client is required
◦ In the person’s home
◦ Within the neighborhood
◦ In local restaurants
◦ Parks
◦ Stores
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 Treatment Modalities (cont.)
Assertive Community Treatment (ACT) (cont.)
◦ The primary goals of ACT include
1. To meet basic needs and enhance quality of life
2. To improve role functioning
3. To enhance independent living
4. To lessen family burden of providing care
5. To decrease debilitating symptoms of mental illness
6. To minimize recurrent acute episodes of the illness

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Psychopharmacology
Antipsychotic meds: used to decrease agitation and
psychotic
Symptoms

◦ Indications: Used in the treatment of schizophrenia and

other psychotic disorders. Selected agents are also used
in the treatment of bipolar mania, intractable hiccoughs,
Tourette’s disorder, and as antiemetics.

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Practice Questions
The nurse working on a psychiatric unit follows which of the following
guidelines when offering medication to a client with paranoid
schizophrenia in the client's room?
A. Offer medication when the client is calm.
B. Keep the door open and a clear exit path.
C. Only offer medication with another staff person.
D. Keep your back on the client and your eyes on the exit.

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Practice Question
In a psychiatric unit, which of the following cannot be assigned to a
nursing assistant? (Select all that apply)
A . Checking the room and patient for sharp objects.
B. Admission assessment.
C. Putting the patient's belongings in lockup.
D. Administering ziprasidone

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Practice Question
A patient receiving ziprasidone for schizophrenia has Parkinson's-like
symptoms. To decrease the Parkinson's-like side effects, the nurse
should advocate for which of the following medications?
A. Bethanechol
B. Benztropine
C. Levodopa
D. Ropinirole

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Practice Question
A patient admitted to the psychiatric unit is prescribed aripiprazole. The
nurse understands that this medication is a(n):
A. Selective serotonin reuptake inhibitor.
B. Atypical antipsychotic.
C. Typical antipsychotic.
D. Serotonin-norepinephrine reuptake inhibitor.

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Practice Question
Nurses may be required to administer antipsychotic medications like
prochlorperazine for a variety of reasons including delusions,
hallucinations, combativeness, or for the relief of nausea and vomiting.
One of the potential adverse side effects of antipsychotics is tardive
dyskinesia. The nurse knows that tardive dyskinesia is which of the
following?
A. Slow, rhythmical, involuntary movements or tics, which may be
irreversible
B. Ringing sound in the ears with dizziness.
C. Extreme somnolence with difficulty waking.
D. Severe agitation with violent outbursts

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Practice Question
A schizophrenic patient is receiving haloperidol. Extrapyramidal side
effects are linked to haloperidol. Which of the following are
extrapyramidal side effects? (Select all that apply)
A. Tardive dyskinesia.
B. Verbal tics.
C. Seizures.
D. Tremors.
E. Echolalia.
F. Shuffling gait

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Thank you!!

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