Schizophrenia
Chapter 15
West Coast University
Solomon Tan, MSN/Ed. RN-BC, PHN
2011
Eugen Bleuler’s
4 A’s of Schizophrenia
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Affect
Associative looseness
Autism
Ambivalence
Epidemiology
• Lifetime prevalence of schizophrenia 1%
worldwide
• Average onset is late teens to early
twenties, but can be as late as mid-fifties
• 30% to 40% relapse rate in the first year
• Life expectancy is shortened because of
suicide
• No difference related to
– Race, Social status, Culture
Comorbidity
• Substance abuse disorders
– Nicotine dependence
• Anxiety, depression, and suicide
• Physical health or illness
• Polydipsia
Etiology
• Biological factors
– Genetics
• Neurobiological
– Dopamine theory
– Other neurochemical hypotheses
• Brain structure abnormalities
Etiology
Continued
• Psychological and environmental
factors
– Prenatal stressors
– Psychological stressors
– Environmental stressors
Signs and Symptoms
• Language and communication
disturbances
• Thought disturbances
• Perception disturbances
• Affect disturbances
• Motor behavior disturbances
• Self-identity disturbances
Features of Schizophrenia
• Progression varies from one client to
another
– Exacerbations and remissions
– Chronic but stable
– Progressive deterioration
• 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
Phases of Schizophrenia
Phase I – Acute
– Onset or exacerbation of symptoms
Phase II – Stabilization
– Symptoms diminishing
– Movement towards previous level of
functioning
Phase III – Maintenance
– At or near baseline functioning
Assessment
• During the prepsychotic phase
• General assessment
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Positive symptoms (Excess or distorted)
Negative symptoms (Deficit)
Cognitive symptoms
Affective symptoms
Positive Symptoms
• Alterations in thinking
– Delusions are false, fixed beliefs
• Persecutory, Referential
• Somatic, Religious,
• Substitution, Thought Insertion and/or
Broadcasting
• Nihilistic, Grandiose
– Concrete thinking is an inability to think
abstractly.
• Indecisiveness, lack of problem solving skills,
• Concreteness, thought blocking, perseveration
Positive Symptoms
Continued
• Alterations in speech
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Neologisms
Echolalia
Echopraxia
Clang associations
Word salad
Loose Association
Positive Symptoms
Continued
• Alterations in perception
– Depersonalization
– Derealization
– Hallucinations
• Auditory hallucinations
• Command hallucinations
• Visual hallucinations
– Boundary impairment
– Negativism
– Impaired impulse control
Negative Symptoms (5A’s)
– Affect
• Flat, Blunted, Inappropriate, Bizarre
– Apathy
• Indifference towards people, events, activities and
learning.
– Alogia
• Poverty of speech
– Avolition
• Inability to pursue and persist in goal-directed
activities.
– Anhedonia
• Inability to experience pleasure.
Cognitive Symptoms
• Difficulty with
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Attention
Memory
Information processing
Cognitive flexibility
Executive functions
Affective Symptoms
• Assessment for depression crucial
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May herald impending relapse
Increases substance abuse
Increases suicide risk
Further impairs functioning
Review Question
• A patient with schizophrenia says,
“There are worms under my skin
eating the hair follicles.” How would
you classify this assessment finding?
a.
b.
c.
d.
Positive symptom
Negative symptom
Cognitive symptom
Depressive symptom
Review Question
• The nurse is documenting in the
multidisciplinary treatment plan. Which
assessment data depicts positive symptoms of
schizophrenia?
– A. “I use to like going to the movies and spending time
with my family but rather be alone.”
– B. “I don’t want to go to group.” Lack motivation and affect
appear Blunted.
– C. “I can’t sit still and I feel like I want to jump out of my
skin.”
– D. “There are cameras in the ceiling and the voices are
whispering to me.”
Subtypes of Schizophrenia
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Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual Type
Subtypes of Schizophrenia
- continued
• Paranoid Type
– Delusions
• Persecutory and grandiose
• Somatic or religious
– Hallucinations
• Delusions link with a hallucination
• Disorganized Type
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Disorganized speech, behavior, appearance
Flat or inappropriate affect
Fragmented hallucinations and delusions
Most severe form of schizophrenia
Specific Interventions for
Paranoid and Disorganized
Schizophrenia
• Communication guidelines
• Self-care needs
• Milieu needs
Subtypes of Schizophrenia
- continued
• Catatonic type
– Psychomotor retardation and stupor
• Waxy flexibility
• Mutism
– Extreme psychomotor agitation
• Echolalia
• Echopraxia
Specific Interventions
for Catatonia
• Catatonia – Withdrawn Phase
– Communication guidelines
– Self-care needs
– Milieu needs
• Catatonia – Excited Phase
– Communication guidelines
– Self-care needs
Subtypes of Schizophrenia
- continued
• Undifferentiated type
– Active psychotic state (Positive & Negative
symptoms)
– Lacks symptoms of other subtypes
• Residual type
– Active-phase symptoms no longer present
– No prominent positive symptoms
– Negative symptoms present
Other Psychotic Disorders
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Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared Psychotic Disorder (Folie à
Deux)
• Induced or Secondary Psychosis
Assessment Guidelines
1. Any medical problems
2. Abuse of or dependence on alcohol
or drugs
3. Risk to self or others
4. Command hallucinations
5. Belief system
6. Suicide risk
Assessment Guidelines
Continued
7. Ability to ensure self-safety
8. Co-occurring disorders
9. Medications
10. Presence and severity of positive
and negative symptoms
11. Patient’s insight into illness
12. Family’s knowledge of patient’s
illness and symptoms
Potential Nursing
Diagnoses
• Positive symptoms
– Risk for violence
– Disturbed sensory perception
– Risk for self-directed or other-directed
violence
– Disturbed thought processes
• Negative symptoms
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Social isolation
Chronic low self-esteem
Altered health maintenance
Ineffective coping
Impaired verbal communication
Outcomes Identification
• Phase I - Acute
Patient safety and medical stabilization
• Phase II - Stabilization
– Adhere to treatment
– Stabilize medications
– Control or cope with symptoms
• Phase III - Maintenance
– Maintain achievement
– Prevent relapse
– Achieve independence, satisfactory quality of
life
Planning
• Phase I – Acute
– Best strategies to ensure patient safety
and provide symptom stabilization
• Phase II – Stabilization
• Phase III – Maintenance
– Provide patient and family education
– Relapse prevention skills are vital
Implementation
• Phase 1 – Acute Settings
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Partial hospitalization
Residential crisis centers
Halfway houses
Day treatment programs
Interventions
• Acute Phase
– Psychiatric, medical, and neurological
evaluation
– Psychopharmacological treatment
– Support, psychoeducation, and
guidance
– Supervision and limit setting in the
milieu
Interventions
Continued
• Stabilization and Maintenance Phase
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Milieu management
Activities and groups
Safety
Counseling and communication
techniques
Interventions
Continued
• Stabilization and Maintenance Phase,
continued
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Hallucinations
Delusions
Associative looseness
Health teaching and health promotion
Nursing Implications:
Supporting Families
• Family needs vary with degree of
illness and involvement in client’s
care
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Education
Financial support
Psychosocial support
Advocacy
Nursing Implications:
Supporting Families - continued
• Schizophrenia is a “family illness.”
• Family members need to be involved.
• Educate family about
– Medication
– Illness
– Relapse prevention
• Nurse assists family by
– Identifying community agencies/groups for
family members
– Advocating for rights
General Nursing
Intervention
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Promote Safety and a Safe Environment
Promote Congruent Emotional Response
Promote Social Interaction and Activity
Intervene with Hallucinations and Delusions
Preventing Relapse
Promoting adherence with medication regimen
Assist with grooming and hygiene
Promote Family Understanding and
Involvement
Review Question
• The client informs you that the CIA
monitoring his every move to find
evidence that he killed someone.
Which response by the nurse is
therapeutic for the client?
Review Answers
• A. "I will make sure that the security
guard will monitor your room.”
• B. "Don't worry you are safe here, the
CIA can't enter the hospital.”
• C. "You seem fearful for your safety,
but you are safe here.”
• D. "Why do you think the CIA is
following you, who did you kill?”
Psychopharmacology
• Prior to the 1950s: focus on behavioral
interventions and sedatives
• Mid-fifties: Introduction of the first
antipsychotic medication chlorpromazine
(Thorazine)
• Psychiatric medications allow for the
improve imbalances of neurotransmitters.
• Goal is to treat quickly so disease does
not progress.
• Clients may initially be resistant to
medications.
Goals of Antipsychotics
• Positive Effects
– Allowed release of clients from inpatient hospital to
treatment in the community
– Manage the symptoms such as delusional thinking,
hallucinations, confusion, motor agitation, motor
retardation, blunted affect, bizarre behavior, social
withdrawal and agitation.
• Alleviation of the symptoms, often improving:
– Ability to think logically
– Ability to function in one’s daily life
– Ability to function in relationships
Negative Effects of Antipsychotics
• Negative Effects
– Frightening and life threatening side effects
– Potential interactions with other medications
and substances
– Possible need to cope with the realization of
having a chronic illness
All current antipsychotics work on at
least one of these neurotransmitters:
Dopamine
Serotonin
Antipsychotics
• Typical (Conventional)
– Block dopamine receptors at 70% to
80% occupancy to be effective.
• Exptrapyramidal Side Effects
(EPSEs) occur at occupancy > 80
• Typical = Tardive Dyskinesia (TD)
– 5.4% vs 0.8% atypicals
Pharmacological
Interventions
• Antipsychotic medications
– Conventional antipsychotics
• Typical or first-generation
– Atypical antipsychotics
• Second-generation
Conventional
Antipsychotics
• Dopamine antagonists (D2 receptor antagonists)
• Target positive symptoms of schizophrenia
• Advantage
– Less expensive than atypical antipsychotics
• Disadvantages
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Do not treat negative symptoms
Extrapyramidal side effects (EPSs)
Tardive dyskinesia
Anticholinergic side effects
Lower seizure threshold
Conventional
Antipsychotics
• Typical Agents
– Low Potency
• Chlorpromazine (Thorazine) (25 – 800 mg/d)
• Thioridazine (Mellaril) (150 – 800 mg/d)
• Mesoridazine (Serentil) (100 – 400 mg /d)
– Side Effects:
• Sedation, Anticholernergic, Hypotention,
• EPSEs (less vs high potency)
Conventional Antipsychotics
– High Potency
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Haloperidol (Haldol) (1 – 30 mg/d)
Fluphenazine (Prolixin) (0.5 – 40 mg/d)
Thiothixene (Navane) (2 – 30 mg/d)
Trifluoperazine (Stelazine) (1 – 40 mg/d)
Perhenazine (Trilafon) (8-60 mg/d)
Loxapine (Loxitane) (20 – 250 mg/d)
Molindone (Moban) (50 – 225 mg/d)
Pimozide (Orap) 0.5 – 9 mg/d)
– Side Effects
• Sedation, Anticholenergic SE (less vs low potency)
• EPSEs (high vs low potency)
Conventional Long-Acting
Injectables (Depot
Therapy)
– Haloperidol Decanoate (Haldol
Decanoate)
• Q4 weeks
– Fluphenazine Decanoate (Prolixin
Decanoate)
• Q2 Weeks
Atypical Antipsychotics
• Treat both positive and negative symptoms
• Fewer extrapyramidal side effects (EPSs)
or tardive dyskinesia
• Reduced affinity for dopamine (D )
receptors
• Affinity for serotonin receptors
2
• D antagonist + Serotonin receptor antagonist
2
• Disadvantage – tendency to cause
significant weight gain
Atypical Antipsychotics
Continued
– Clozapine (Clozaril) (6.25 – 900 mg/d)
• Side effects: 5% risk of seizures, agranulocytosis, weight
gain, hypersalivation, anticholinergic
– Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv)
(5 – 20 mg/d)
• Side effects: Weight gain, diabetes, sedation, bankruptcy
20mg/day = $925/month
– Paliperidone (Invega) (3 – 12 mg/d)
– Quetiapine (Seroquel) (150 – 600 mg/d)
• Side effects: sedation, weight gain, restless leg syndrome
– Risperidone (Risperdal, Risperdal M-Tab)
(2 – 6 mg/d) (Increase Prolactin)
Atypical Antipsychotics
Continued
– Ziprasidone (Geodon) ( 40 – 160 mg/d)
• Side effects: QTc prolongation, minimal sedation
• Administer with food for improve efficacy
– Aripiprazole (Abilify) (15 – 30 mg/d)
• Side effects: akathisia, insomnia/sedation, maybe
less weight gain
– Asenapine (Saphris) (5 – 10 mg/d) Sublingual
– Iloperidone (Fanapt) (12 – 24mg/d)
– Lurasidone HCL (Latuda) (40 – 80 mg/d)
Long-Acting Injectables
Depot Therapy
– Risperidone Consta (Risperdal Consta)
• Q2 Weeks
– Paliperidone Sustenna (Invega Sustena)
• Q 4 weeks
– Zyprexa Relprevv (Q2 or Q4 weeks
depending on the dose) Monitor for 3
hours after injection
Anti-Parkinson
Medications
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Trihexyphenidyl (Artane)
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Amantadine (Symmetrel)
Antiadrenergic Effect:
Orthostatic Hypotension
• Take the client’s blood pressure in a
supine position and then in a
standing position.
• Caution clients to rise slowly from a
supine position.
Extrapyramidal Side
Effects Interventions
• Acute dystonia
– anticholinergics
• Akathisia
– anticholinergics but not always
responsive
• Pseudoparkinsonism
– anticholinergics
• Tardive dyskinesia –
– Abnormal Involuntary Movement Scale
(AIMS)
Dystonia
• Occurs usually within 48 hours of initiation
of the medication
• Involves bizarre and severe muscle
contractions
• Can be painful and frightening
• Characterized by odd posturing and
strange facial expressions:
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Torticollis
Opisthotonus
Laryngospasm
Oculogyric
Torticollis
Opisthotonus
Oculogyric Crises
Laryngospasm
Drug-induced
Parkinsonism
• Usually occurs after 3 or more weeks
of treatment
• Characterized by:
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Cogwheel rigidity
Tremors at rest
Rhythmic oscillations of the extremities
Pill rolling movement of the fingers
Bradykinesia
Postural Changes
Akathisia
• Usually occurs after 3 or more weeks of
treatment
• Subjectively experienced as desire or
need to move
• Described as feeling like jumping out of
the skin
• Mild: a vague feeling of apprehension or
irritability
• Severe: an inability to sit still, resulting in
rocking, running, or agitated dancing
Tardive Dyskinesia
• Usually occurs late in the course of long-term
treatment
• Characterized by abnormal involuntary movements
(lip smacking, tongue protrusion, foot tapping)
• Often irreversible
• Prophylactic use of vitamin E and Omega-3 FFA
• Avoid typical antipsychotics
• Abnormal Involuntary Movement Scale
Autonomic Nervous System Effects:
Anticholinergic Side Effects
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Dry mouth
Blurred vision
Constipation
Urinary retention
Tachycardia
Interventions for
Anticholenergic Side Effects
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Ice chips, hard candy
Eye drops
Fiber diet, exercise
Increase fluid intake
Catheterization
Potentially Dangerous
Responses to Antipsychotics
• Neuroleptic malignant syndrome
(NMS)
– Typically occurs in the first 2 weeks of
treatment or when the dose is increased
– Hold the medication, notify the
physician, and begin supportive
treatments.
– Symptoms: muscle rigidity, tachycardia,
hyperpyrexia, altered consciousness,
tremors and diaphoresis
Neuroleptic malignant syndrome (NMS)
• Risk Factors
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Dehydration
Agitation or catatonia
Increase dose of neuroleptic
Withdrawal from anti-parkinson medication
Long acting or depot medication
• Pharmacologic treatment
– Antipyretics
– Muscle relaxant
– Dopamine receptor agonist
Potentially Dangerous
Responses to Antipsychotics
• Agranulocytosis
– Early symptoms: beginning signs of
infection
– White blood cells are routinely
monitored in clients taking clozapine
(Clozaril).
Other Central Nervous
System Effects
• Sedation
• Lowering of the seizure threshold:
– Observe clients with seizures disorders
carefully when treatment is initiated.
Cardiac Effects
• Some antipychotics may contribute to
prolongation of the QTc interval and
lead to arrhythmias.
– An EKG can identify those at risk.
Blood, skin and eye effect
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Agranulocytosis
Blurred Vision
Skin photosensitivity
Retinitis pigmentosa
Endocrine Effects
• Hyperprolactinemia may cause:
– Oligomenorrhea or amenorrhea in
women
– Galactorrhea in women and rarely in
men
– Osteoporosis if prolonged
• Impotence in males may occur.
• Diabetes
– Monitor blood glucose levels.
Weight Gain
• Monitor weight
• Teach about diet and exercise
• Weight gain may contribute to
physical as well as psychosocial
stressors
Adjuncts to Antipsychotic
Drug Therapy
• Antidepressants
• Antimanic agents
Advanced Practice
Interventions
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Psychotherapy
Cognitive-behavioral therapy (CBT)
Group therapy
Medication
Social skills training
Cognitive remediation
Family therapy