Schizophrenia
Elisa A. Mancuso RNC, MS, FNS
Professor
 2 million people (1.5 % of Population)
 Costs $ 35 billion
 Onset late adolescence or early adulthood
– Men 15-25
women 20-35 & > 50
 Psychotic disorders with disturbances in:
– Thought processes
– Perceptions
– Expression of feelings
Indicators
 Psychotic Symptoms
– Preoccupied with own thoughts and feelings
 Deterioration in functioning
– Role, ADLs, Interpersonal relationships
 6 month duration of symptoms
 Bleuler’s 4 As
– Autism
– Affect
– Associative Looseness
– Ambivilance
Etiology
 Genetic
– Abnormal marker gene on chromosome # 5
– Heredity determines one’s predisposition
 Both parents schizophrenic = 20-50 % ↑↑ risk
 Identical twins = 50-75 % ↑↑ risk for sibling
 Biochemical
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Altered Neuroanatomy ▲s in cortex
↑↑ DA activity (2x DA receptors) = Psychosis
↓ AcH = ↑ Confusion,
↓ NE = Anhedonia
↓ 5-HT = ↓ Aggressive tendencies
↓Glutamate = learning & memory
↓Glucose metabolism & ↓ GABA
Psychological
 Poor early mother-child relationship
– “Trust vs Mistrust”
 ↓ Ego boundaries
 Dysfuntional family system
 Double-bind communication
– Say one thing but mean the opposite
 Environment
– ↓ Socioeconomic = ↑ stress & ↓ ↓ resources
– Stressful life events precipitate onset!
Schizophrenia Stages
Stage I
Schizoid Personality
Isolate themselves, “loners”
Indifferent, cold, aloof
↓ Range of emotional expression
Don’t enjoy close relationships
Stage II
Prodromal “Pre-Schizophrenic”
Socially withdrawn- Blunted affect
Eccentric behavior & Bizarre ideas
Unusual perceptual experiences
↓ Role performance ↓ADLs
Schizophrenia Stages
 Stage III Schizophrenia (Active)
Prominent psychotic symptoms >6 months
Delusions
False, fixed belief
Grandiose, Persecutory, Paranoia, Religiosity
Hallucinations
False sensory perception
Ideas of Reference
Disorganized Behavior
Impaired work, social relations & self care
Disorganized Speech
Associative Looseness
Clanging
Echolalia
Word Salad
Poverty of Speech
Neologisms
Schizophrenia Stages
 Stage III
Secondary Symptoms
– Anxiety
Substance Abuse (ETOH, coke)
– Depression > 25%
– ↑↑ Suicide (10%) = Leading cause of death
– Compulsive H2O drinking 4-10 L/day
 H2O intoxication
 ↓ Na = Lightheaded
N&V
 Confusion
 Coma
Lethargy
Muscle cramps
Schizophrenia Stages
 Stage IV
Residual
– Periods of remissions & exacerbations
– Similar to Prodromal phase
– Social withdrawal
– Flat affect
– Impaired Role Performance
Schizophrenia Types
 Disorganized (Hebephrenic)
– Onset before age 25
– Chronic flat, inappropriate affect
– Silliness, giggling, masturbating in public
– Bizarre behavior
 Facial grimacing & mannerisms
– Impaired social interaction
– ↓ Contact with reality
– Incoherent speech & concrete thinking
Schizophrenia Types
 Catatonic
Least common
Sudden onset & good prognosis
Catatonic Excitement
 Extreme psychomotor agitation
 Purposeless movements – Echopraxia
– ↑ risk of injury to self/others
 Continuous incoherent shouting - Echolalia
Catatonic Stupor
 Extreme psychomotor retardation
 Mute & Waxy Flexibility (Bizarre posturing)
Schizophrenia Types
 Paranoid
– Preoccupied - 1 or more delusions
 Persecution or Grandeur
– Related auditory hallucinations
– Argumentative
– Hostile
– Aggressive
– Tense
– Suspicious
– Hypervigilent
Schizophrenia Types
 Undifferentiated Chronic
– Disorganized-bizarre behavior
– Usually docile and not aggressive
– Does not meet criteria of other subtypes
– Delusions & Hallucinations are prominent
Schizophrenia Types
 Residual (Pseudo-neurotic)
– Follows an acute episode
– Absence of prominent symptoms
 No delusions or hallucinations
– Social isolation
– Poor Grooming
– Eccentric behavior
– Emotional Blunting
Schizophrenia Types
 Schizoaffective Disorder
– 2 week period of predominant psychotic
episode (↑ incidence in women)
 Delusions
Hallucinations
 Disorganized behavior
 ↑ Sexuality Racing thoughts
– Mood Disorder (affective) behaviors
 Mania – Euphoria
– Grandiosity & Hyperactivity
 Depression –
– Psychomotor retardation & suicidal ideation
– ↓↓ Occupational & social functioning
Characteristics
 Positive
– Excess or distorted inappropriate behaviors
– Disorganized thinking
– Not seen in mentally healthy adults!
 Negative
– Loss or decrease of appropriate function
– Diminished emotional expression
 Anhedonia
 Apathy
 Poverty of thoughts
Charcteristics
Positive
Delusions
Hallucinations
Catatonic Excitement
Echopraxia
Echolalia
Neologisms
Associative Looseness
Religiosity
Paranoia
Negative
Concrete thinking
Symbolism
Catatonic Stupor
Social withdrawal
Poverty of speech
Flat affect
Anhedonia
Depersonalization
Assessment
 Mental Status Exam (Provides baseline data)
– Appearance & General Health
 Dress
 Eye Contact
Grooming
Motor Behavior
Facial Expression
Posture
– Speech
 Pace
 Tone & Modulation
Spontaneity
Clarity
Volume
Interruptions
– Level of Consciousness
 General Responsiveness
Sensorium
– Emotional State
 Mood
Affect
Intensity
Appropriateness
– Cognitive Function
 Thought Process
 Concentration
Content
Abstract Thinking
Perceptions
Insight/Judgment
Nursing Interventions
Primary Goal = Patient Safety
 Establish trust & listen closely
– Accepting attitude & Keep promises
 Calm approach & non-threatening
environment
– Prevent violence & ↓ Anxiety
 Clarify & reinforce reality
– Orient to here & now
 Address physical needs
 ↑ Self esteem
Psychotic Symptom Interventions
Delusions
Accept experience, identify content & triggers
Encourage reality oriented conversation
Use distraction & refocus
Role model coping techniques to ↓ anxiety
Hallucinations
Focus on the behavioral cue
(laughing, talking, turning head)
Have Pt describe what is happening
Identify environmental & emotional triggers
To prevent aggressive responses
Avoid touching without 1st warning
Psychotic Symptom Interventions
Impaired Communication
Role model clear communication
Use simple, concrete statements
Seek clarification & validate content
Vebalize the implied
Paranoia
↓ Environmental stimulation
Maintain eye contact
Provide plenty of personal space
Always announce your presence
↓ Impulsivity
“Time Outs” for rest
Psychotic Symptom Interventions
Ritualism
Initiate conversation as ritual is performed
Assess for behavioral cues indicating ↑ anxiety
Negotiate a schedule for ritual & ADLs
Social Withdrawal
Convey nonverbal acceptance & worthiness
Provide brief & frequent 1:1 contacts
Initiate interaction & gradually expand social contacts
↑ Social skills training
Rules & expectations
Cognitive Therapy
↑ Decision making
Regression
RN approaches Pt.
↑ Self-Esteem and encourage independent behavior
Antipsychotic (Neuroleptic) Meds
Major Tranquilizers
 ↑↑ Protein Binding (91-99%)
 ↓ Efficacy in men (1/3 relapse + 1/3 disabled)
 Potency
– High
 Fluphenazine (Prolixin) [Decanoate IM q3 weeks]
 Haloperidol (Haldol) [Decanoate IM q4 weeks]
 Trifluroperazine (Stelazine)
– Low
 Chlorpromazine (Thorazine) * 1st drug 1950
 Thioridazine (Mellaril)
Antipsychotic (Neuroleptic) Meds
 Action
– ↓ Agitation ↓ Psychotic Symptoms
– ↓ + Behaviors (Delusions/Hallucinations)
– Block DA receptors =↓ DA
 Improves fine motor movement & coordination
 Sensory integration & emotional behavior
– Anticholinergic Effects (Autonomic NS)
 Dry Mouth
Blurred vision
Constipation
 Sedation
Urinary Retention
Photophobia
 Orthostatic Hypotension
Nasal Congestion
Antipsychotic (Neuroleptic) Meds
 ↑↑ Prolactin Levels
– Sexual/Menstrual dysfunction
– ↓ Libido
– Galactorrhea
– Gynecomastia
– ↑ weight gain
 Cognition
– ↓ Alertness ↓ Concentration
– ↓ Seizure threshold = ↑ Risk of seizures
Antipsychotic (Neuroleptic) Meds
 ExtraPyramidal Side Effects (EPS)
– ↓↓ DA ↑↑ AcH Imbalance
– ↑↑ Incidence with ↑↑ potency meds
 Prolixin, Haldol & Stelazine
– Movement disorder
 Dystonia
 Pseudoparkinsonism
 Akathesia
 Tardive Dyskinesia
ExtraPyramidal Side Effects (EPS)
 Dystonia
– Quick onset 1st few hours or days
– ↑ Adolescent males < age 25
– Acute spasms of tongue, face, neck & back
– Hypertonia
– Laryngospasm – Respiratory distress
– Oculogyric Crisis- Rolling back of eyes
– Torticolis- Head twisted to 1 side
– Involuntary uncoordinated movements
ExtraPyramidal Side Effects (EPS)
 Pseudoparkinsonism
– Appears within 1-5 days
– ↑ women & older Pts
– Drooling, Pill-Rolling of thumb & finger
– Mask-like face, Stooped Posture
– Action Tremors
– Shuffling gait with small steps
– Muscle rigidity
– Bradykinesia
– Cogwheeling
ExtraPyramidal Side Effects (EPS)
 Akathesia
– Appears 50-60 days
– Motor restlessness “Nervous Energy”
 Jitteriness
 Tapping feet constantly
 Pacing
 Rocking back & forth
 Frequent position changes
ExtraPyramidal Side Effects (EPS)
 Tardive Dyskinesia
– Slow & insideous process
– Irreversible after several years of meds.
– Involuntary movements of
 Limbs, trunk & face.
– Bizarre facial movements
 “Fly catching” with tongue
 Lip smacking
– Difficulty swallowing
– Irregular respirations
Neuroleptic Malignant Syndrome NMS
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Rare idiosyncratic reaction 1% young men
↑ Incidence with ↑↑ potency meds & ↓↓ DA
Abrupt onset & rapid progression
10% mortality rate
Signs
– Severe muscle rigidity
Hyperreflexia (+4)
– Hyperthermia > 105
Diaphoresis
– Altered LOC → Stupor → Coma
– ↑↑ HR ↑↑ RR
– CV Collapse & Respiratory failure = Fatal!
NMS Therapy
 Immediately D/C med
 Wait 2 weeks before starting new meds (Lithium)
 NO Haldol or Thorazine
 Cooling blanket
O2
 MSO4 (Morphine sulfate)
– ↓ pain & ↓ VS
 Tylenol
– ↓ Temp and pain
 Dantrolene (Dantrium)
 muscle relaxant & ↓ Temp
 Bromocriptine (Parlodel)
IV Fluids
Atypical Medications
Relieves (+) & (-) Behaviors
↓ EPS ↓ Prolactin
 Clozapine (Clozaril)
– Binds to 5-HT2, Alpha1,2, H1, & DA recptors
– SE- National registry to monitor SEs!
 Agranulocytosis
–WBC < 3000 or ANC < 500 = D/C med!
–Mandatory weekly CBC 1st 6 months
 Then q other week
 Drowsiness ↑Salivation
↑Dizziness
 ↑ HR
↑Weight
 ↑ Risk for IDDM
Prolonged QT interval
Atypical Medications
 Risperidone (Risperdal)
– ↓↓ DA ↓ 5-HT ACh & NE
– Readily absorbed
– Active metabolite is clinically effective
– SE
 Sedation/Insomnia
 Orthostatic Hypotension
 ↑↑ Appetite
 Tardive Dyskinesia
Atypical Medications
 Olanzapine (Zyprexia)
– Antagonizes DA & 5-HT receptors
– Binds to Histamine
 Quetiapine (Seroquel)
– √ renal function
– √ EKG for prolonged QT wave
 Ziprasidone (Geodon)
– DA & 5-HT receptor antagonists
– ↓ Depression & Anxiety
Medication Administration
 Schedule
– Initially take meds in divided doses 2-4x/day
– Non-compliant Pts:
 Haldol decanoate IM q 4 weeks
 Prolixin decanoate IM q 3 weeks
 Efficacy
– Takes 1- 4 weeks for significant response
– Once symptoms are controlled ▲ HS ↓↓ SE
 Dosage
– Use lowest dosage to ↓ Tardive Dyskinesia
Medication Administration
 Antiparkinson Meds
– Give to counteract SE & toxic effects
– Only given with documented S/S of EPS
– Restore the balance of DA & Ach
 ↑↑DA
↓↓ACh
Amantadine (Symmetrel)
Bromocriptine (Parlodel)
Benzotropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)
Patient Teaching
 Medication
– Generic & trade name, dose, action & SE
– Assess SE “How is medication working?”
 Interventions & when to notify RN/MD
– Carry card with Med ID
– NO ETOH or illegal substances
– Don’t stop taking drug abruptly
– Don’t ▲ position rapidly
Patient Outcome Evaluation
 Slow progress
– Services are needed long-term (decades)
 Set small achievable, short-term goals
 Assess effective coping skills
 Obtain Pt & family input
– Pt. safety
Communication skills
– Social Skills
Self-Esteem
– Medication compliance
– Support system
– Living in least restrictive setting