Chapter 15
Schizophrenia
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Eugen Bleuler’s
4 A’s of Schizophrenia
• Affect
• Associative looseness
• Autism
• Ambivalence
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Epidemiology
• Lifetime prevalence of schizophrenia
1% worldwide
• No difference related to
– Race
– Social status
– Culture
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Comorbidity
• Substance abuse disorders
– Nicotine dependence
• Anxiety, depression, and suicide
• Physical health or illness
• Polydipsia
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Etiology
• Biological factors
– Genetics
• Neurobiological
– Dopamine theory
– Other neurochemical hypotheses
• Brain structure abnormalities
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Etiology
Continued
• Psychological and environmental
factors
– Prenatal stressors
– Psychological stressors
– Environmental stressors
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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
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Assessment
• During the prepsychotic phase
• General assessment
– Positive symptoms
– Negative symptoms
– Cognitive symptoms
– Affective symptoms
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Positive Symptoms
• Alterations in thinking
– Delusions are false, fixed beliefs.
– Concrete thinking is an inability to think
abstractly.
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Positive Symptoms
Continued
• Alterations in speech
– Neologisms
– Echolalia
– Echopraxia
– Clang associations
– Word salad
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Positive Symptoms
Continued
• Alterations in perception
– Depersonalization
– Derealization
– Hallucinations
• Auditory hallucinations
• Command hallucinations
• Visual hallucinations
– Boundary impairment
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Positive Symptoms
Continued
Alterations in behavior
– Catatonia
– Automatic obedience
– Motor retardation
– Waxy flexibility
– Motor agitation
– Negativism
– Stereotyped
behaviors
– Impaired impulse
control
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Negative Symptoms
• Affect
– Flat
– Blunted
– Inappropriate
– Bizarre
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Cognitive Symptoms
• Difficulty with
– Attention
– Memory
– Information processing
– Cognitive flexibility
– Executive functions
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Affective Symptoms
• Assessment for depression crucial
– May herald impending relapse
– Increases substance abuse
– Increases suicide risk
– Further impairs functioning
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• A patient with schizophrenia says,
“There are worms under my skin eating
the hair follicles.” How would you
classify this assessment finding?
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a. Positive symptom
b. Negative symptom
c. Cognitive symptom
d. Depressive symptom
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Assessment Guidelines
1. Any medical problems
2. Abuse of or dependence on alcohol
or drugs
3. Risk to self or others
4. Command hallucinations
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Assessment Guidelines
Continued
5. Belief system
6. Suicide risk
7. Ability to ensure self-safety
8. Co-occurring disorders
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Assessment Guidelines
Continued
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
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Potential Nursing Diagnoses
• Positive symptoms
– Disturbed sensory perception
– Risk for self-directed or other-directed
violence
– Disturbed thought processes
• Negative symptoms
– Social isolation
– Chronic low self-esteem
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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
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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
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Implementation
• Phase 1 – Acute Settings
– Partial hospitalization
– Residential crisis centers
– Halfway houses
– Day treatment programs
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Interventions
• Acute Phase
– Psychiatric, medical, and neurological
evaluation
– Psychopharmacological treatment
– Support, psychoeducation, and guidance
– Supervision and limit setting in the milieu
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Interventions
Continued
• Stabilization and Maintenance Phase
– Milieu management
– Activities and groups
– Safety
– Counseling and communication
techniques
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Interventions
Continued
• Stabilization and Maintenance Phase,
continued
– Hallucinations
– Delusions
– Associative looseness
– Health teaching and health promotion
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Pharmacological Interventions
• Antipsychotic medications
– Conventional antipsychotics
• Typical or first-generation
– Atypical antipsychotics
• Second-generation
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Atypical Antipsychotics
• Treat both positive and negative
symptoms
• Minimal to no extrapyramidal side
effects (EPSs) or tardive dyskinesia
• Disadvantage – tendency to cause
significant weight gain
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Atypical Antipsychotics
Continued
• Examples
– Clozapine (Clozaril) – use declining
– Risperidone (Risperdal)
– Olanzapine (Zyprexa)
– Quetiapine (Seroquel)
– Ziprasidone (Geodon)
– Aripiprazole (Abilify)
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Conventional Antipsychotics
• Dopamine antagonists (D2 receptor antagonists)
• Target positive symptoms of schizophrenia
• Advantage
– Less expensive than atypical antipsychotics
• Disadvantages
– Do not treat negative symptoms
– Extrapyramidal side effects (EPSs)
– Tardive dyskinesia
– Anticholinergic side effects
– Lower seizure threshold
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Extrapyramidal Side Effects
• Acute dystonia
• Akathisia
• Pseudoparkinsonism
• Tardive dyskinesia – Abnormal
Involuntary Movement Scale (AIMS)
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Potentially Dangerous
Responses to Antipsychotics
• Neuroleptic malignant syndrome (NMS)
• Agranulocytosis
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Adjuncts to Antipsychotic
Drug Therapy
• Antidepressants
• Antimanic agents
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Specific Interventions
for Catatonia
• Catatonia – Withdrawn Phase
– Communication guidelines
– Self-care needs
– Milieu needs
• Catatonia – Excited Phase
– Communication guidelines
– Self-care needs
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Specific Interventions for
Disorganized Schizophrenia
• Communication guidelines
• Self-care needs
• Milieu needs
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Undifferentiated Schizophrenia
• Active signs of disorder
– Positive symptoms
– Negative symptoms
• Individual does not meet criteria for any
other subtype
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Residual Schizophrenia
• Active-phase symptoms no longer
present
• Evidence of two or more residual
symptoms persists
– Reduced initiative, interests, or energy
– Social withdrawal
– Impaired role function
– Speech deficits
– Odd beliefs
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Advanced Practice Interventions
• Psychotherapy
• Cognitive-behavioral therapy (CBT)
• Group therapy
• Medication
• Social skills training
• Cognitive remediation
• Family therapy
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