Class Notes
Patricia H. Foster, EdD, RN
Associate Professor of Nursing
Schizophrenia
Impact of Schizophrenia
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Nearly 4 million Americans will develop schizophrenia during their lives
About 100,000 schizophrenic patients are in public mental hospitals on any given day
Approximately 1 percent of the population
In 3 of 4 patients, schizophrenia begins between ages 17 and 25
Estimated 1/3 to 1/2 of homeless in the US have schizophrenia
Schizophrenia
 most chronic & disabling of the major mental illnesses
 5 times more common than multiple sclerosis
 6 times more common than insulin-dependent diabetes
 20% to 50% of patients with schizophrenia attempt suicide; 10% succeed
Diagnosis of Schizophrenia
 Delusions
 Hallucinations (gustatory is taste) each of the 5 senses can have a hallucination associated w/
it.
 Disorganized speech
 Grossly disorganized or catatonic (withdrawn)
 Negative symptoms (flat affect & lack of energy, apathy, lack of initiative)
Bleuler’s Four A’s (a psychiatrist)
 Affect inappropriate
 Associations loose
 Autism
 focus inward
 neologisms (made up words)
 Ambivalence
 difficulty making decisions
Problems in Cognitive Functioning
 Memory “Is it time for
group?”
 Attention , easily distracted
 Form
& content of speech
 Decision making
 concrete; difficulty with multiple stage commands (
 clocks without minute or second hands
 Thought content-delusions & hallucinations
Maladaptive movements
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catatonia, extrapyramidal side effects, grimacing, abnormal eye movements (staring)
apraxia-difficulty carrying out a purposeful task (dressing)
echopraxia- imitation of movements by others
Positive Symptoms
 delusions & hallucinations (clues)
 speech-incoherence, word salad, loose associations, tangential, circumstantial, pressured
speech or poverty of speech
 bizarre behavior-catatonia, movement disorders, deterioration of social behavior
Negative Symptoms
 loss of normal functions
 flat affect
 alogia-restricted thought & speech
 apathy, lack of initiative
 anhedonia (lack of pleasure in anything)
 attention impairment-inability to focus
Predisposing Factors (she thinks the book does a good job of talking about this)
 Biological-genetic (twin studies) identical twins have 4X the potential of having
schizophrenia… there is a genetic predisposition for
 Neurobiology-prefrontal cortex & limbic cortex not fully developed
 Dysregulation of neurotransmitters (dopamine)
 Viral theories-prenatal exposure to influenza virus
 Psychological:
 schizophrenogenic mother (blamed it on the mother… she gave mixed messages to the
kid)… not much evidence for this
 communication double-bind
Precipitating Stressors
 biological
 information processing overload
 decreased gating
 ball game unable to differentiate noise from the crowd, team, public address system
 neighbor’s fireworks & startle response
Paranoid Type (p. 492 in book)
 unfocused anxiety
 anger, argumentative
 potential for violence
 onset usually later in life
 preoccupation with paranoid delusions
 frequent auditory hallucinations
 prognosis better than for some other types
Disorganized (hebephrenic… don’t call it this anymore)
 grimaces, incoherence, loose associations
 extreme social withdrawal, incoherent
 flat or grossly inappropriate affect
 early insidious onset-chronic
 course chronic without significant remissions
Catatonic
 stupor
 negativism or mutism
 rigidity
 peculiar voluntary movement, posturing
waxy flexibility (gumbie… put them in a position & they will stay that way)
 excessive motor activity
 echolalia and echopraxia
Undifferentiated
 “wastebasket”
 prominent delusions
 hallucinations
 incoherence
 grossly disorganized behavior
sometimes listed as SCUT (schizophrenia undifferentiated type)
Residual
 when symptoms of illness persist without prominent psychotic symptoms
 negative symptoms
 emotional blunting
 illogical thinking
 mild loose associations
Schizophreniform disorder
 meets criteria for schizophrenia
 episode lasts at least 1 month but less than 6 months
 prognosis based on onset of psychotic sx , confusion at height of psychosis, good premorbid
social and occupational functioning, absence of blunted or flat affect
Schizoaffective disorder
 major depressive episode or manic concurrent with sx of schizophrenia, (depression or mania)
Delusional disorder
 nonbizarre delusions lasting at least a month
 never met criteria for schizophrenia
 functioning & behavior not markedly affected
(woman thought the social worker was the CEO of the hospital & he was going to marry her on
Valentine’s day, yet otherwise she was functioning fairly well)
Brief psychotic disorder-at least one of the following:
 delusions, hallucinations
 disorganized speech
 disorganized or catatonic behavior
Folie a deux
 shared delusion
Antipsychotic Drugs
 Typical:
 Thorazine, Mellaril, Serentil, Trilafon, Stelazine, Navane,
Loxitane, Moban
 Haloperidol (Haldol), Fluphenazine (Prolixin)
 Atypical: side effects might not be quite as bad: problematic side effect is weight gain, then
they end up with metabolic syndrome & type 2 diabetes
 Clozapine (Clozaril) agranulocytosis
 Risperidone (Risperdal), Olanzapine (Zyprexa)
 Quetiapine (Seroquel), Ziprasidone (Geodon)
 Aripiprazole (Abilify)
Invega is another one she has recently seen (it is in text book)
Antipsychotic Drug Side Effects
 EPS: akathisia (can’t sit still), dystonia (involuntary muscle movement), oculogyric crisis
(eyes roll back in head)
 Parkinson’s : cogwheel rigidity, fine tremor
 Tardive Dyskinesia: tongue protrusion, lip smacking
 Neuroleptic malignant symdrome: fever, tachycardia, muscle rigidity (potentially fatal….
Very dangerous)
 Agranulocytosis: fever, leucopenia (particularly for clozaril/clozapine)
 Seizures; photosensitivity; anticholinergic (dry mouth, reduced secretions, blurred vision,
constipation… sugarless candy to help that); sedation; wt.gain, hormonal/sexual
Drugs to Treat Extrapyramidal symptoms
 Anticholinergics: Cogentin, Artane
 Antihistamine: Benadryl
 Dopamine agonist: Symmetril, Parlodel
 Benzodiazepines:Valium, Ativan, Klonopin
There is a table in ch 21 about the meds to treat eps
Drugs to Treat Neuroleptic Malignant Syndrome
parlodel
Dantrolene
Dopamine Tracts
(not to memorize & spit back)
 Nigrostriatal
 Releases dopamine in basal ganglia (area of brain that controls muscle activity)
 When blocked causes EPS
 Tuborinfundibular
 Projects into anterior pituitary
 Prevents production of prolactin
Dopamine Tracts continued
 Mesolimbic
 Releases dopamine into limbic area (important in control of emotions)
 Excess causes hallucinations, delusions
 Mesocorticol
 Releases dopamine into area of cortex which controls cognitive function
 Deficiency causes negative Sx
Be sure to look at the study guides on blackboard for week 5