Schizophrenia
Chapter 16
Schizophrenia
• Fascinated and confounded healers for
centuries
• One of most severe mental illnesses
– 1/3 of population
– 2.5% of direct costs of total budget
– $46 billion in indirect costs
History of Schizophrenia
• 1800s - Eugene Kraeplin named it
“dementia praecox.”
• 1900s - Eugen Bleuler named it
schizophrenia (split minds). More than
one type.
• Kurt Schneider - First rank (psychosis,
delusions) and second rank (all other
experiences)
Schizophrenia Diagnosis
• During a one-month period at least two
of the five
– Positive (delusions, hallucinations, etc.)
– Negative (alogia, anhedonia, flat affect,
avolition)
• One or more areas of social or
occupational functioning
Types of Schizophrenia
Text Box 16.1
• Paranoid
• Disorganized
• Catatonic
• Undifferentiated
• Residual
Schizophrenia
Positive
Hallucinations
Delusions
Disorganization
Negative
Avolition
Alogia
Anhedonia
Flat Affect
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
•
•
•
•
Memory (short-, long-term)
Vigilance (sustained attention)
Verbal fluency (ability to generate
new words)
Executive functioning
–
–
–
–
volition
planning
purposive action
self-monitoring behavior
Impaired in schizophrenia
•
Memory (working)
•
Vigilance
•
Executive functioning
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)
Schizophrenia in Children
• Rare in children
• If appears in children aged 5 or 6,
symptoms same as for adults
• Hallucinations visual, delusions less
well-developed
• Other disorders considered first
Schizophrenia in Elderly
• For those who have had schizophrenia
most of their life, this may be a time that
they experience improvement in
symptoms.
• Late-onset schizophrenia
– Diagnostic criteria met after 45
– Most likely include positive symptoms
Epidemiology
• 0.5%-1.5% of population
• 300,000 acute episodes each year
• Cluster in lower socioeconomic group
• Homelessness is a problem.
Epidemiology
• Across all cultures
• In the United States, African Americans have
a higher prevalence rate (thought to be
related to racial bias).
• Men are diagnosed earlier.
• EOS: Diagnosed late adolescence
• LOS: Diagnosed > 45 years
Maternal Risk Factors
• Prenatal poverty
• Poor nutrition
• Depression
• Exposure to influenza outbreaks
• War zone exposure
• Rh-factor incompatibility
Infant and Childhood Risk
Factors
• Low birth weight
• Short gestation
• Early developmental difficulties
• CNS infections
Familial Differences
• First-degree biologic relatives have 10
times greater risk for schizophrenia.
• Other relatives have higher risk for other
psychiatric disorders.
Comorbidity
• Increased risk of cardiovascular disorders
• Association between insulin-dependent
diabetes and schizophrenia
• Depression and pseudodementia
• Increased substance abuse
• Cigarette smoking
• Fluid imbalance
Disordered Water Balance
• Prolonged periods of polydipsia,
intermittent hyponatremia, polyuria
• Etiology – unknown
• Prevention of water intoxication
• Promotion of fluid balance
Biologic Factors
• Genetic – 10% first-degree relative
• Stress-diathesis model proposed by O’Connor
• Neuroanatomical findings
– Decreased blood flow to left globus pallidus
– Absence of normal blood increase in frontal lobes
– Atrophy of the amygdala, hippocampus and
parahippocampus
– Ventricular enlargement
• Neurodevelopmental
– Prenatal exposure (2nd trimester)
– Late winter, early spring births
Neurotransmitters, Pathways and
Receptors
• Hyperactivity of the limbic area (dopamine
mesolimbic tract) related to positive
symptoms
• Hypofrontality or hypoactivity of the prefrontal and neo-cortical areas (dopamine
mesocortical tract related to negative and
positive symptoms)
• Does not result from dysfunction of a single
neurotransmitter
Psychosocial Theories
• Do not explain cause
• Disservice to families
• Useful in family interaction
– Expressed Emotion (EE)
• High emotion associated with negative
communication and overinvolvement
• Low emotion associated with less negativity
and less overinvolvement
Priority Care Issues
• Suicide
• Safety of patient and others
• Initiate antipsychotic medications
Family Response to Disorder
• Mixed emotions – shock, disbelief, fear,
care, concern and hope
• May try to seek reasons
• Initial period very difficult
Interdisciplinary Treatment
• The most effective approach involves a
variety of disciplines.
• There is considerable overlap of roles
and interventions.
• Nursing’s contribution is significant.
Nursing Management:
Biologic Domain
Assessment
• Present and past health status
• Physical functioning
• Nutritional assessment
• Fluid imbalance assessment
• Pharmacologic assessment
 Medications (prescribed, OTC, herbal, illicit)
 Abnormal motor movements
– DISCUS
– AIMS
– Simpson-Angus Rating Scale
Nursing Diagnosis:
Biologic Domain
• Self-care deficit
• Disturbed sleep pattern
• Ineffective therapeutic regimen management
• Imbalanced nutrition
• Excess fluid volume
• Sexual dysfunction
Nursing Interventions:
Biologic Domain
• Promotion of self-care activities
– Develop a routine of hygiene activities.
– Emphasize its importance; help motivate the patient.
• Activity, exercise and nutrition
– Help counteract effects of psychiatric medications.
– Appetite usually increases, so help with food choices.
• Thermoregulation
– Teach patient to wear clothing according to weather; dress
for winter and summer.
– Observe patient’s response to temperature.
• Promotion of normal fluid balance
– Water intoxication protocol (Text Box 18.5)
Pharmacologic Interventions
• Newer antipsychotics more efficacious and safer (block
dopamine and serotonin)
–
–
–
–
–
–
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodone)
Aripiprazole (Abilify)
Clozapine (Clozaril) - second line
• Monitoring and administering medications
–
–
–
–
Takes 1-2 weeks to work (some improvement immediately)
Adequate trial - 6-12 weeks
Adherence to prescribe medication is best prevention of relapse.
Discontinuation is rare.
Pharmacologic Interventions:
Monitoring Side Effects
• Parkinsonism
– Identical symptoms to Parkinson’s
– Caused by blockade of D2 receptor in basal
ganglia
– Treated with anticholinergic medications
– Taper anticholinergic meds if discontinued
• Dystonia
– Imbalance of DA and ACH, with more ACH
– Young men more vulnerable
– Oculogyric crisis, Torticollis, Retrocollis
Monitoring Side Effects
• Akathesia
– Restlessness, jumping out of skin, uncomfortable
– Reduce dose of antipsychotic.
– Treat with a -blocker (propranolol).
• Tardive Dyskinesia
– Impairment of voluntary movement, constant motion
– Occurs 6-8 months following initiation of antipsychotics
– Facial-buccal area -- lip smacking, sucking, etc.
– Movements in trunk, rocking
– No real treatment
Monitoring Side Effects
•
•
•
•
•
•
•
Orthostatic hypotension
Prolactinemia
Weight gain
Sedation
New-onset diabetes
Cardiac arrhythmias (QTc prolongation)
Agranulocytosis
Drug-drug Interactions
• Medications metabolized by 1A2 enzymes
include olanzapine and clozapine.
• Inhibitors: fluvoxamine (Luvox)
• Inducers: cigarette smoking
• Medications metabolized by 3A4 include
clozapine, quetiapine and ziprasidone.
• Inhibitors: ketoconazole, protease inhibitors,
erythromycin
• Inducer: carbamazapine
• Medications affected by 2D6 include
risperidone, clozapine and olanzapine.
• Inhibitors: fluoxetine, paroxetine (not usually clinically
significant)
Medication Teaching Points
• Consistency in taking medication
• Medication and symptom amelioration
• Side effects and management
• Interpersonal skills that help patient and
family report medication effects
Medication Emergencies:
Neuroleptic Malignant Syndrome
• Severe muscle rigidity, elevated temperature
• Recognizing symptoms
– Elevated temperature, changes in level of consciousness,
leukocytosis, elevated creatinine phosphokinase), elevated liver
enzymes or myoglobinuria
• Nursing interventions
–
–
–
–
Stop administration of offending medications.
Monitor vital signs.
Reduce body temperature.
Safety, protect muscles
 Supportive measures
– IV fluids
– Cardiac monitoring
– Dantrolene (Dopamine agonist)
Neuroleptic Malignant Syndromes
• Acute reaction to dopamine receptors
blockers
• Prevalence 2 to 2.4%
• Death – 4 to 22%, mean = 11%
• Etiology:
– Drugs block striatal dopamine receptors; disrupt
regulatory mechanisms in the thermoregulatory
center in hypothalamus and basal ganglia; heat
regulation fails and muscle rigidity
Medication Emergencies:
Anticholinergic Crises
• Potentially life threatening, anticholinergic delirium
• Can occur in patients who are taking several
medications with anticholinergic effects
• Elevated temperature, dry mouth, decreased
salivation, decreased bronchial, nasal secretion,
widely dilated eye
• Stop offending drug, usually self-limiting. May use
inhibitor of anticholinesterase, physostigmine.
Anticholinergic Crisis
• Confusion, hallucinations
• Physical signs - dilated pupils, blurred vision, facial
flushing, dry mucous membranes, difficulty swallowing, fever,
tachycardia, hypertension decreased bowel sounds, urinary
retention, nausea, vomiting, seizures, coma
• Atropine flush
• Hot as a hare, blind as a bat, mad as a hatter,
dry as a bone
Treatment
• Self-limiting – three days
• Discontinuation of medication
• Physiostigmine 1-2 mg IV, an inhibitor of
cholinesterase, improves in 24-36 hours
• Gastric lavage
• Charcoal, catharsis
Nursing Management:
Psychological Domain
Assessment – Responses
• Socially stigmatizing
• Prodromal symptoms evident (negative symptoms)
• Tension and nervousness
• Lack of interest in eating
• Difficulty concentrating
• Disturbed sleep
• Decreased enjoyment
• Loss of interest, restlessness, forgetfulness
• Often not recognized as an illness
• Denial common
Nursing Management:
Psychological Domain
Assessment
• Positive and negative symptoms
• SAPS (positive symptoms) (Box 18.9)
• SANS (negative symptoms) (Box 18.10)
• PANNS (both symptoms)
• Mental status
• Appearance
• Mood and affect (lability, ambivalence, apathy)
• Speech
• Thought processes (delusions, disorganized communication, cognitive
impairments)
• Sensory perception (hallucinations)
• Memory and orientation
• Insight and judgment
•
•
•
•
Nursing Management:
Psychological Domain
Assessment (cont.)
Behavioral responses
Self-concept
Stress and coping patterns
Risk assessment
– Command hallucinations
– Self-injury risk, suicide
– Homicide
Nursing Diagnosis:
Psychological Domain
• Disturbed thought processes
• Disturbed sensory perceptions
• Disturbed body image
• Low self-esteem
• Disturbed personal identity
• Risk of violence, suicide
• Ineffective coping
• Knowledge deficit
Nursing Interventions:
Psychological Domain
• Counseling, conflict resolution, behavior
therapy and cognitive interventions can be
used.
• Development of nurse-patient relationship
– Centers on the development of trust and
acceptance of the persons
– Critical for optimal treatment of schizophrenia
Nursing Interventions:
Psychological Domain –
Management of Disturbed Thoughts
• Assessment content of hallucinations/delusions
• Outcomes
– Decrease frequency and intensity.
– Recognize as symptoms of disorder.
– Develop strategies to manage recurrence.
• Experiences real to the patient
– Validate that experiences are real
– Identify meaning and feeling that are provoked
• Teach patient that hallucinations and delusions are
symptoms of illness.
Nursing Interventions:
Psychological Domain
• Self-monitoring and relapse prevention
– Monitor events, time, place, etc. of recurrence of symptoms.
– Manage symptoms - getting busy, self-talk, change of
activity. (Moller-Murphy Tool)
• Enhancement of cognitive functioning
– Recognize difficulty in processing information.
– Improve attention (computer programs, one-to-one).
– Help memory (make lists, write down information).
– Improve executive functioning-simulation.
Nursing Interventions:
Psychological Domain
• Behavioral interventions
– Organize routine, daily activities.
– Reinforce positive behaviors.
• Stress and coping skills development
– Counseling sessions
– Teach and reward positive coping skills.
• Patient education
–
–
–
–
Errorless learning environment
Minimal distractions
Clear visual aids
Skills training
Family Interventions
• Family support
• Educate the family regarding lifelong disorder
of schizophrenia.
• Emphasize consistent taking of medication.
Nursing Management:
Social Domain
Assessment
• Functional status
– Assessed initially and at regular intervals
– GAF usually used
• Social systems
– Formal and informal support systems
• Quality of life
• Family assessment
– Family assessment guide (Ch. 16)
– Special consideration to the family where patient is the
parent
Nursing Interventions:
Social Domain
Promotion of Patient Safety
• Monitoring for potential aggression
• Administering medication as ordered
• Reducing environmental stimulation
• Approach to individual patients
– Thorough history of violence
– Help patient to talk directly and constructively with those with
whom they are angry.
– Set limits.
– Involve patients in formal contracting.
– Schedule regular time-outs.
Nursing Interventions:
Social Domain
•
•
•
•
Support groups
Milieu therapy
Psychiatric rehabilitation
Family interventions
– Encourage to participate in support groups
– Inform about local and state resources
– Help negotiate provider system
Continuum of Care
• Treatment occurs across continuum. Patients
are at high risk for getting lost in the system.
• Inpatient-focused care (stabilization)
• Emergency care (crisis)
• Community care (most of care)
• Mental health promotion