Contemporary Psychiatric-Mental
Health Nursing
Third Edition
CHAPTER
16
Schizophrenia
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia *
• Prevalence in U.S. is 1.1%.
• Average onset is late teens to early
twenties, but can be as late as midfifties
• Affects cognitive, emotional, and
behavioral function
• 30% to 40% relapse rate in the first
year
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia (cont'd)
• Progression varies from one client to
another
– Exacerbations and remissions
– Chronic but stable
– Progressive deterioration
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia (cont'd)
• DSM-IV-TR Diagnosis
– Symptoms present at least 6 months
– Active-phase symptoms present at least
1 month
– Symptoms are defined as positive and
negative
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia (cont'd) *
• Positive symptoms
– Excess or distortion of normal
functioning
– Aberrant response
• Negative symptoms
– Deficit in functioning
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia (cont'd) *
• Positive Symptoms of Schizophrenia
– Hallucination
– Delusions
– Disordered speech and behavior
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Table 16-3 (continued)
Positive Symptoms
*
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Table 16-3 (continued)
Positive Symptoms
*
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Features of Schizophrenia (cont'd) *
• Negative Symptoms of Schizophrenia
– Flat affect and apathy
– Alogia
– Avolition
– Anhedonia
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Table 16-4
Negative Symptoms
*
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Subtypes of Schizophrenia *
•
•
•
•
•
Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual Type
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Subtypes of Schizophrenia (cont'd)
*
• Paranoid Type
– Delusions
 Persecutory and grandiose
 Somatic or religious
– Hallucinations
 Delusions link with a hallucination
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Subtypes of Schizophrenia (cont'd)
*
• Disorganized type
– Disorganized speech, behavior,
appearance
– Flat or inappropriate affect
– Fragmented hallucinations and delusions
– Most severe form of schizophrenia
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Subtypes of Schizophrenia (cont'd)
*
• Catatonic type
– Psychomotor retardation and stupor
– Extreme psychomotor agitation
– Waxy flexibility
– Echolalia
– Mutism
– Echopraxia
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Subtypes of Schizophrenia (cont'd)
• Undifferentiated type
– Active psychotic state
– Lacks symptoms of other subtypes
• Residual type
– At least one episode of schizophrenia
– No prominent positive symptoms
– Negative symptoms present
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Other Psychotic Disorders *
•
•
•
•
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia
• Biopsychosocial theories
• Interrelated factors
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
•
•
•
•
Biologic theories
Psychological theories
Family theories
Humanistic-interactional theories
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd) *
• Biologic Theory: Genetic
– Only genetic predisposition for
developing schizophrenia is inherited
– 10% of first-degree relatives
– 25%–39% of monozygotic twins
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Biologic Theory: Brain Structure
Abnormality
– Differs from those with no symptoms
– May be genetically based
– Requires more study
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Figure 16-2 PET scans measuring regional cerebral blood flow. (a) Areas of lower blood flow and brain activity
are seen in the individual with schizophrenia. (b) Areas of normal blood flow and brain activity are visible in the
unaffected individual. Photo courtesy of R. Haier/Photolibrary.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Biologic Theory: Biochemical Theories
– Dopamine hypothesis
– Traditional antipsychotic medications
are dopamine blockers
– Dopamine blocker alleviate positive
symptoms
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Psychological theories
– Information processing
 Difficulty controlling the amount and type
of information that is processed in the
brain.
– Attention and arousal
 Hyper or hypo responsiveness to various
situations
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Psychological theories
– Information processing
 Deficient in automatic processing
 Deficient in controlled or effortful
processing
– Attention and arousal
 Hypo-, hyper-responses
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Family Theories
– Dysfunctional interaction not supported
by research
– Disordered family communication linked
only with genetic predisposition
– Family emotional tone influences course
of schizophrenia
– Expressed emotions theory (EE)
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Humanistic-interactional theories
integrate biological and psychosocial
theories
• Combine influences of:
– Genetic predisposition or biologic
vulnerability
– Environmental stressors
– Social support
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Causes of Schizophrenia (cont'd)
• Stress-Vulnerability Model
– Stressors increase vulnerability
– Cumulative effect of:
 Genetic predisposition
 Personal stressors
 Familial factors
 Environmental factors
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Influences on the Course of
Schizophrenia
• Social Pressures
– Lack of social support
– Financial problems
– Stigma
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Influences on the Course of
Schizophrenia (cont'd) *
• Psychological pressures
– Difficulty with problem-solving
– Difficulty with interpreting reality
– Difficulty coping
– Problems with self-care
– Unstable interpersonal relationships
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Nursing Implications *
• Assessment
– Premorbid functioning
– Content of thought
– Form of thought
– Perception
– Sense of self
– Delusions and perceptual disturbances
– Hallucinations
– Drug use
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Nursing Implications (cont'd) *
• Nursing Diagnoses
– Altered thought process
– Social isolation
– Risk for violence
– Self-care deficits
– Altered health maintenance
– Ineffective family coping
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Nursing Implications:
Supporting Families
• Family needs vary with degree of illness
and involvement in client’s care
– Education
– Financial support
– Psychosocial support
– Education
– Advocacy
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Nursing Implications:
Supporting Families (cont'd) *
• Schizophrenia is a “family illness.”
• Family members need to be involved.
• Educate family about
– Medication
– Illness
– Relapse prevention
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Nursing Implications:
Supporting Families (cont'd)
• Nurse assists family by
– Identifying community agencies/groups
for family members
– Advocating for rights
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Measures to Prevent Relapse *
• Ensure client takes medication
• Educate family about signs and
symptoms of relapse
• Client and family to participate in
relapse prevention program
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Measures to Prevent Relapse
(cont'd)
• Relapse prevention programs work best
when:
– Psychosocial treatment and social skills
training are combined with antipsychotic
medication
– Behavior patterns are monitored
– Family members understand triggers
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Measures to Prevent Relapse
(cont'd)
• Relapse prevention programs provide
education and support regarding:
– Individual triggers, symptoms of relapse
– Managing side effects of medications
– Interventions to reduce or eliminate
triggers
– Strategies to facilitate early intervention
– Cognitive therapy
– Community resources
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Challenges to Adherence *
• Side effects
• Level of symptomatology
• Cognitive, motivational, financial, and
cultural issues
• Issues with caregivers
• Insufficient medication teaching
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Increasing Adherence *
• Involve clients in treatment
• Instruct client about reducing
discomfort
• Provide peer support
• Provide reminders and positive
feedback
• Recognize accomplishments
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Personal Awareness *
Identify personal feelings.
Recognize personal perceptions.
What behaviors do you expect to see?
How will you respond to these
behaviors?
• What is the meaning of the behaviors?
•
•
•
•
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Personal Awareness (cont'd)
• What defines “normal” behavior?
• What are my fears associated with
mental illness?
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Personal Awareness (cont'd)
• Be honest with your feelings.
• Identify what strengths you bring to
the situation.
• Remember that clients are human
beings with a mental disorder and do
not choose to be this way.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Resources
• NAMI
– The National Alliance on Mental Illness
provides information, education, and
support relating to mental health
illnesses and disorders for clients,
families, and professionals.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• National Institute of Mental Health
– The National Institute of Mental Health
is part of the Department of Health and
Human Services and has information
about research on various mental health
illnesses.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Medline Plus
– Medline Plus is a service of the National
Library of Medicine and the National
Institutes of Health. This site provides
definitions related to various aspects of
schizophrenia.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Brain & Behavior Research Foundation
– The Brain & Behavior Research
Foundation awards grants from the
National Alliance for Research on
Schizophrenia and Depression
(NARSAD), a non-for-profit charity
organization primarily organized to raise
funds for research.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Mayo Clinic
– Search by topic on this Mayo Clinic link
to find current information about mental
illness.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Box 16-4
Challenges to Adherence
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Box 16-4
Challenges to Adherence
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff