Chapter 24
Schizophrenia Spectrum and Other
Psychotic Disorders
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Introduction
• The word schizophrenia is derived
from the Greek words skhizo (split)
and phren (mind).
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Introduction (cont.)
• Schizophrenia is probably caused by a
combination of factors including:
–
–
–
–
Genetic predisposition
Biochemical dysfunction
Physiological factors
Psychosocial stress
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Introduction (cont.)
• Schizophrenia requires treatment that is
comprehensive and presented in a
multidisciplinary effort.
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Introduction (cont.)
• Of all mental illnesses, schizophrenia
probably causes more:
– Lengthy hospitalizations
– Chaos in family life
– Exorbitant costs to people and governments
– Fears
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Nature of the Disorder
• Schizophrenia causes disturbances in:
— Thought processes
— Perception
— Affect
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Nature of the Disorder (cont.)
• With schizophrenia, there is a severe
deterioration of social and occupational
functioning.
• In the United States, the lifetime
prevalence of schizophrenia is about 1
percent.
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Nature of the Disorder (cont.)
• Premorbid behavior of the patient with
schizophrenia can be viewed in four
phases.
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Phase I
The Premorbid Phase
– Social maladjustment
– Antagonistic thoughts and behavior
– Shy and withdrawn
– Poor peer relationships
– Doing poorly in school
– Antisocial behavior
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Phase II
Prodromal Phase
• Lasts from a few weeks to a few years
• Deterioration in role functioning and social
withdrawal
• Substantial functional impairment
• Sleep disturbance, anxiety, irritability
• Depressed mood, poor concentration, fatigue
• Perceptual abnormalities, ideas of reference, and
suspiciousness herald onset of psychosis
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Phase III
Schizophrenia
• In the active phase of the disorder, psychotic
symptoms are prominent:
– Delusions
– Hallucinations
– Impairment in work, social relations, and self-care
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Phase IV
Residual Phase
– Symptoms similar to those of the prodromal
phase
– Flat affect and impairment in role functioning
are prominent
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Prognosis
• A return to full premorbid functioning is not
common.
• Factors associated with a positive prognosis
include:
– Good premorbid functioning
– Later age at onset
– Female gender
– Abrupt onset precipitated by a stressful event
– Associated mood disturbance
– Brief duration of active-phase symptoms
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Prognosis (cont.)
• Factors associated with a positive prognosis
(cont.):
– Minimal residual symptoms
– Absence of structural brain abnormalities
– Normal neurological functioning
– No family history of schizophrenia
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Predisposing Factors
• Biological Influences
– Genetics
• A growing body of knowledge
indicates that genetics plays an
important role in the development
of schizophrenia.
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Predisposing Factors (cont.)
• Biological Influences (cont.)
– Biochemical influences
• One theory suggests that schizophrenia
may be caused by an excess of dopamine
activity in the brain.
• Abnormalities in other neurotransmitters
have also been suggested.
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Predisposing Factors (cont.)
• Biological Influences (cont.)
– Physiological influences
• Factors that have been implicated include:
– Viral infection
– Anatomical abnormalities
– Histological changes in brain
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Predisposing Factors (cont.)
– Physiological influences (cont.)
•
Various physical conditions
— Epilepsy
—
—
—
—
—
—
—
—
—
—
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Huntington’s disease
Birth trauma
Head injury in adulthood
Alcohol abuse
Cerebral tumor
Cerebrovascular accident
Systemic lupus erythematosus
Myxedema
Parkinsonism
Wilson’s disease
Predisposing Factors (cont.)
• Psychological Influences
– These theories no longer hold
credibility. Researchers now focus their
studies of schizophrenia as a brain
disorder.
– Psychosocial theories probably
developed early on out of a lack of
information related to a biological
connection.
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Predisposing Factors (cont.)
• Environmental Influences
– Sociocultural factors: Poverty has
been linked to the development
schizophrenia.
– Downward drift hypothesis: Poor
social conditions seen as consequence
of, rather than a cause of,
schizophrenia.
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Predisposing Factors (cont.)
• Environmental Influences (cont.)
– Stressful life events may be
associated with exacerbation of
schizophrenic symptoms and
increased rates of relapse.
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Predisposing Factors (cont.)
• The Transactional Model
– Schizophrenia is most likely a biologically
based disease, the onset of which is
influenced by factors in the internal or
external environment.
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Types of Schizophrenia and Other
Psychotic Disorders
• Delusional Disorder
– The existence of prominent, nonbizarre
delusions
• Erotomanic Type
• Grandiose Type
• Jealous Type
• Persecutory Type
• Somatic Type
• Mixed Type
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Brief Psychotic Disorder
– Sudden onset of symptoms
– May or may not be preceded by a
severe psychosocial stressor
– Lasts less than 1 month
– Return to full premorbid level of
functioning
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Substance-Induced Psychotic Disorder
– The presence of prominent hallucinations
and delusions that are judged to be directly
attributable to substance intoxication or
withdrawal (i.e., a drug of abuse, a
medication, or a toxin).
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Psychotic Disorder Associated with
Another Medical Condition
– Prominent hallucinations and delusions are
directly attributable to a general medical
condition.
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• The Catatonic Features Specifier
– Catatonic features may be associated with other
psychotic disorders, such as brief psychotic disorder,
schizophreniform disorder, schizophrenia,
schizoaffective disorder, and substance induced
psychotic disorder.
– Symptoms of catatonic disorder include:
• Stupor and muscle rigidity or excessive,
purposeless motor activity
• Waxy flexibility, negativism, echolalia, echopraxia
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Catatonic Disorder Associated with
Another Medical Condition
– This diagnosis is made when the catatonic
symptoms are directly attributable to the
physiological consequences of a general
medical condition.
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Schizophreniform Disorder
– Same symptoms as schizophrenia with
the exception that the duration of the
disorder has been at least 1 month but
less than 6 months.
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Schizoaffective Disorder
– Schizophrenic symptoms
accompanied by a strong element of
symptomatology associated with the
mood disorders, either mania or
depression.
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
1. A client is admitted with a diagnosis of brief
psychotic disorder with catatonic features.
Which symptoms are associated with the
catatonic specifier?
A. Strong ego boundaries and abstract
thinking
B. Ataxia and akinesia
C. Stupor, muscle rigidity, and negativism
D. Substance abuse and cachexia
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Types of Schizophrenia and Other
Psychotic Disorders (cont.)
• Correct answer: C
– Symptoms associated with the catatonic specifier
include stupor and muscle rigidity or excessive,
purposeless motor activity. Waxy flexibility,
negativism, echolalia, and echopraxia are also
common behaviors.
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Nursing Process: Assessment: Positive
Symptoms
• Positive Symptoms
– Content of thought
• Delusions: false personal beliefs
• Religiosity: excessive demonstration of
obsession with religious ideas and behavior
• Paranoia: extreme suspiciousness of others
• Magical thinking: ideas that one’s thoughts or
behaviors have control over specific situations
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Nursing Process: Assessment: Positive
Symptoms (cont.)
– Content of thought (cont.)
• Associative looseness (also called loose
association): a shift of ideas from one
unrelated topic to another
• Neologisms: made-up words that have
meaning only to the person who invents them
• Concrete thinking: literal interpretations of the
environment
• Clang associations: choice of words is
governed by sound (often rhyming)
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Nursing Process: Assessment: Positive
Symptoms (cont.)
– Content of thought (cont.)
• Word salad: group of words put together in a
random fashion
• Circumstantiality: delay in reaching the point of a
communication because of unnecessary and
tedious details
• Tangentiality: inability to get to the point of
communication due to introduction of many new
topics
• Mutism: inability or refusal to speak
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Nursing Process: Assessment: Positive
Symptoms (cont.)
– Content of thought (cont.)
• Perseveration: Persistent repetition of the same word
or idea in response to different questions
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Nursing Process: Assessment: Positive
Symptoms (cont.)
2. The client hears the word “match.” The
client replies, “A match. I like matches. They
are the light of the world. God will light the
world. Let your light so shine.” Which
communication pattern does the nurse
identify?
A.
B.
C.
D.
Word salad
Clang association
Loose association
Ideas of reference
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Nursing Process: Assessment: Positive
Symptoms (cont.)
• Correct answer: C
– Loose association is characterized by communication
in which ideas shift from one unrelated topic to
another. The situation in the question represents this
communication pattern.
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Nursing Process: Assessment: Positive
Symptoms (cont.)
• Perception: interpretation of stimuli through
the senses
– Hallucinations: false sensory perceptions not
associated with real external stimuli
•
•
•
•
•
Auditory
Visual
Tactile
Gustatory
Olfactory
– Illusions: misperceptions of real external stimuli
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Nursing Process: Assessment: Positive
Symptoms (cont.)
• Sense of Self: the uniqueness and
individuality a person feels
– Echolalia: repeating words that are heard
– Echopraxia: repeating movements that are
observed
– Identification and imitation: taking on the form
of behavior one observes in another
– Depersonalization: feelings of unreality
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Nursing Process: Assessment: Positive
Symptoms (cont.)
3. A client diagnosed with schizophrenia
experiences identity confusion and
communicates with the nurse using echolalia.
What is the client attempting to do by using
this form of speech?
A.
B.
D.
D.
Identify with the person speaking
Imitate the nurse’s movements
Alleviate alogia
Alleviate avolition
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Nursing Process: Assessment: Positive
Symptoms (cont.)
• Correct answer: A
– Echolalia is a parrot-like repetition of overheard
words or fragments of speech. It is an attempt by the
client to identify with the person who is speaking.
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Nursing Process: Assessment:
Negative Symptoms
• Affect: the feeling state or emotional tone
– Inappropriate affect: emotions are incongruent with
the circumstances
– Bland affect: weak emotional tone
– Flat affect: appears to be void of emotional tone
– Apathy: disinterest in the environment
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Nursing Process: Assessment:
Negative Symptoms (cont.)
• Volition: impairment in the ability to initiate
goal-directed activity
– Emotional ambivalence: coexistence of opposite
emotions toward same object, person, or situation
– Deterioration in appearance: impaired personal
grooming and self-care activities
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Nursing Process: Assessment:
Negative Symptoms (cont.)
• Impaired interpersonal functioning and
relationship to the external world
– Impaired social interaction: clinging and intruding
on the personal space of others, exhibiting
behaviors that are not culturally and socially
acceptable
– Social isolation: a focus inward on the self to the
exclusion of the external environment
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Nursing Process: Assessment:
Negative Symptoms (cont.)
• Psychomotor Behavior
– Anergia: deficiency of energy
– Waxy flexibility: passive yielding of all movable
parts of the body to any effort made at placing
them in certain positions
– Posturing: voluntary assumption of inappropriate
or bizarre postures
– Pacing and rocking: pacing back and forth and
rocking the body
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Nursing Process: Assessment:
Negative Symptoms (cont.)
• Associated features
— Anhedonia: inability to experience pleasure
— Regression: retreat to an earlier level of
development
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Nursing Process: Diagnosis/Outcome
Identification
• Disturbed sensory perception (auditory and
visual) related to panic anxiety, extreme
loneliness, and withdrawal into self
• Disturbed thought processes related to
inability to trust, panic anxiety, or possible
hereditary or biochemical factors
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Nursing Process: Diagnosis/Outcome
Identification (cont.)
• Social isolation related to inability to trust,
panic anxiety, weak ego development,
delusional thinking, regression
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Nursing Process: Diagnosis/Outcome
Identification (cont.)
• Risk for Violence: self-directed or otherdirected related to:
– Extreme suspiciousness
– Panic anxiety
– Catatonic excitement
– Rage reactions
– Command hallucinations
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Nursing Process: Diagnosis/Outcome
Identification (cont.)
• Impaired verbal communication related
to:
– Panic anxiety
– Regression
– Withdrawal
– Disordered unrealistic thinking
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Nursing Process: Diagnosis/Outcome
Identification (cont.)
• Self-care deficit related to:
– Withdrawal
– Regression
– Panic anxiety
– Perceptual or cognitive impairment
– Inability to trust
• Disabled family coping related to difficulty
coping with client’s illness
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Nursing Process: Diagnosis/Outcome
Identification (cont.)
• Ineffective health maintenance related to
disordered thinking or delusions
• Impaired home-maintenance related to:
– Regression
– Withdrawal
– Lack of knowledge or resources
– Impaired physical or cognitive functioning
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Outcomes
• The Client:
– Demonstrates an ability to relate to others
satisfactorily
– Recognizes distortions of reality
– Has not harmed self or others
– Perceives self realistically
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Outcomes (cont.)
• The Client:
– Demonstrates ability to perceive the environment
correctly
– Maintains anxiety at a manageable level
– Relinquishes need for delusions and hallucinations
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Outcomes (cont.)
• The Client:
– Demonstrates ability to trust others.
– Uses appropriate verbal communication in
interactions with others.
– Performs self-care activities independently.
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Nursing Process:
Planning/Implementation
• Nursing interventions for the client with
schizophrenia or other psychotic disorders are
aimed at:
– Decreasing anxiety and establishing trust
– Assisting client to define and test reality
– Encouraging interaction with others
– Ensuring safety of client and others
– Meeting client’s self-care needs
– Promoting adaptive family coping
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Nursing Process:
Planning/Implementation (cont.)
4. To deal with a client's hallucinations
therapeutically, which nursing intervention
should be implemented?
A. Reinforce the perceptual distortions until the
client develops new defenses
B. Provide an unstructured environment
C. Avoid making connections between anxietyproducing situations and hallucinations
D. Distract the client's attention
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Nursing Process:
Planning/Implementation (cont.)
• Correct answer: D
– The nurse should first empathize with the client by
focusing on feelings generated by the hallucination,
present objective reality, and then distract or redirect
the client to reality-based activities.
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Nursing Process:
Planning/Implementation (cont.)
5. A client, diagnosed with schizophrenia,
states, “My roommate is plotting to have
others kill me.” Which is the appropriate
nursing response?
A. “I find that hard to believe.”
B. “What would make you think such a thing?”
C. “I know your roommate. He would do no
such thing.”
D. “I can see why you feel that way.”
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Nursing Process:
Planning/Implementation (cont.)
• Correct answer: A
– This client is experiencing a persecutory delusion.
This nursing response is an example of “voicing
doubt,” which expresses uncertainty as to the
reality of the client’s perceptions. This is an
appropriate therapeutic communication
technique in dealing with clients who are
experiencing delusional thinking.
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Client/Family Education
• Nature of Illness
– What to expect as illness progresses
– Symptoms associated with illness
– Ways for family to respond to behaviors associated
with illness
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Client/Family Education (cont.)
• Management of the Illness
– Connection of exacerbation of symptoms to times
of stress
– Appropriate medication management
– Side effects of medications
– Importance of not stopping medications
– When to contact health-care provider
– Relaxation techniques
– Social skills training
– Daily living skills training
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Client/Family Education (cont.)
• Support Services
– Financial assistance
– Legal assistance
– Caregiver support groups
– Respite care
– Home health care
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Nursing Process: Evaluation
• Evaluation Questions
– Has client established trust with at least one staff
member?
– Is anxiety level maintained at a manageable level?
– Is delusional thinking still prevalent?
– Is client able to interrupt escalating anxiety with
adaptive coping mechanisms?
– Is client easily agitated?
– Is client able to interact with others
appropriately?
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Treatment Modalities
• Psychological Treatments
– Individual psychotherapy: long-term therapeutic
approach; is difficult because of client’s
impairment in interpersonal functioning
• Group therapy: some success if occurring over
the long-term course of the illness; less successful
in acute, short-term treatment
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Treatment Modalities (cont.)
• Psychological Treatments (cont.)
– Behavior therapy: chief drawback has been
inability to generalize to community setting after
client has been discharged from treatment
– Social skills training: use of role play to teach
client appropriate eye contact, interpersonal
skills, voice intonation, posture, etc.; it is aimed at
improving relationship development.
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Treatment Modalities (cont.)
• Social Treatments
– Milieu therapy: best if used in conjunction with
psychopharmacology
– Family therapy: aimed at helping family members
cope with long-term effects of the illness
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Treatment Modalities (cont.)
• Program of Assertive Community Treatment
(PACT)
– A program of case management that takes a team
approach in providing comprehensive,
community-based psychiatric treatment,
rehabilitation, and support to persons with
serious and persistent mental illness
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Treatment Modalities (cont.)
• Program of Assertive Community Treatment
(cont.)
– Services include:
• Substance abuse treatment
• Psychoeducational programs
• Family support and education
• Mobile crisis intervention
• Attention to health-care needs
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Treatment Modalities (cont.)
• Program of Assertive Community Treatment
(cont.)
– Services are provided by a multidisciplinary team of:
•
•
•
•
•
Psychiatrists
Nurses
Social workers
Vocational rehabilitation therapists
Substance abuse counselors
– Services are available 24 hours a day, 365 days a
year.
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Treatment Modalities (cont.)
• Program of Assertive Community Treatment
(cont.)
– Services are provided wherever assistance by the
client is required:
• In the person’s home
• Within the neighborhood
• In local restaurants
• Parks
• Stores
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Treatment Modalities (cont.)
•
Program of Assertive Community
Treatment (cont.)
–
The primary goals of PACT are:
1.
2.
3.
4.
5.
6.
To meet basic needs and enhance quality of life
To improve role functioning
To enhance independent living
To lessen family burden of providing care
To decrease debilitating symptoms of mental illness
To minimize recurrent acute episodes of the illness
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Treatment Modalities (cont.)
• The Recovery Model
– A concept of healing and transformation enabling
a person with mental illness to live a meaningful
life in the community while striving to achieve his
or her full potential.
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Treatment Modalities (cont.)
• The Recovery Model (cont.)
– Research provides support for recovery as an
obtainable objective for individuals with
schizophrenia.
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Treatment Modalities (cont.)
• The Recovery Model (cont.)
– Functional Recovery
Focus is on the individual’s level of functioning in
areas of relationships, work, independent living,
and other kinds of life functioning.
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Treatment Modalities (cont.)
• The Recovery Model (cont.)
– Process Recovery
There is no defined end point. Recovery is viewed
as a process that continues throughout the
individual’s life, and involves collaboration
between client and clinician.
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Treatment Modalities (cont.)
• Psychopharmacology
– Antipsychotics
Used to decrease agitation and psychotic symptoms
of schizophrenia and other psychotic disorders
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
– Action
• Typicals: dopaminergic blockers with various
affinity for cholinergic, α-adrenergic, and
histaminic receptors
• Atypicals: weak dopamine antagonists; potent
5HT2A antagonists; also exhibit antagonism for
cholinergic, histaminic, and adrenergic
receptors
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Antipsychotics
– Side Effects:
•
•
•
•
•
•
•
•
•
•
Anticholinergic effects
Nausea; GI upset
Skin rash
Sedation
Orthostatic
hypotension
Photosensitivity
Hormonal effects
ECG Changes
Hypersalivation
Weight gain
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• Hyperglycemia/diabetes
• Increased risk of
mortality in elderly
clients with
neurocognitive disorder
• Reduction in seizure
threshold
• Agranulocytosis
• Extrapyramidal
symptoms
• Tardive dyskinesia
• Neuroleptic malignant
syndrome
Antipsychotics (cont.)
• Extrapyramidal symptoms (EPS) include:
– Pseudoparkinsonism
– Akinesia
– Akathisia
– Dystonia
– Oculogyric crisis
• Antiparkinsonian agents may be prescribed
to counteract EPS.
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Client/Family Education
• The client should:
– Not stop taking the drug abruptly
– Use sunblock lotion and wear protective clothing
when spending time outdoors
– Report weekly (if receiving clozapine therapy) to
have blood levels drawn and to obtain a weekly
supply of the drug
– Be aware of possible risks of taking antipsychotics
during pregnancy
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Client/Family Education
• The client should (cont.):
– Not drink alcohol while receiving antipsychotic
therapy.
– Not consume other medications (including overthe-counter drugs) without the physician’s
knowledge.
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Psychopharmacology
6. A client who has been taking chlorpromazine
(Thorazine) for several months presents in
the ED with extrapyramidal symptoms (EPS)
of restlessness, drooling and tremors. What
medication will the nurse expect the
physician to order?
A.
B.
C.
D.
Paroxetine (Paxil)
Carbamazepine (Tegretol)
Benztropine (Cogentin)
Lorazepam (Ativan)
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Psychopharmacology (cont.)
• Correct answer: C
– Benztropine is an anticholinergic medication that
blocks cholinergic activity in the central nervous
system, which is responsible for EPS. Anticholinergics
are the drugs of choice to treat extrapyramidal
symptoms associated with antipsychotic medications.
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