Schizophrenia
Chapter 16
Schizophrenia


Fascinated and confounded healers for
centuries
One of most severe mental illnesses
–
–
–
1/3 of population
2.5% of direct costs of total budget
$46 billion in indirect costs
Epidemiology
•
0.5%-1.5% of population
•
2.5 million Americans
•
300,000 acute episodes each year
•
Cluster in lower socioeconomic group
•
Homelessness is a problem.
•
Direct treatment costs $20 billion/yr
Epidemiology
•
Across all cultures
•
In the United States, African Americans
have a higher prevalence rate (thought to
be related to racial bias).
•
Men are diagnosed earlier.
•
EOS: Diagnosed late adolescence
•
LOS: Diagnosed > 45 years
Maternal Risk Factors

Prenatal poverty

Poor nutrition

Depression

Exposure to influenza outbreaks

War zone exposure

Rh-factor incompatibility
Infant and Childhood Risk
Factors

Low birth weight

Short gestation

Early developmental difficulties

CNS infections
History of Schizophrenia
•
1800s - Eugene Kraeplin named it
“dementia praecox.”
•
1900s - Eugen Bleuler named it
schizophrenia (split minds). More than one
type.
•
Kurt Schneider - First rank (psychosis,
delusions) and second rank (all other
experiences)
Phases of Schizophrenia

Acute Illness Period
–
–
–

Stabilization
–
–
–

Treatment is intense
Establish Medications
Begin Rehab
Maintenance and Recovery
–
–

Positive symptoms/may be subtle
Family Disruption
Awareness of the meaning of the disorder
Relapse prevention
Coping Strategies
Relapse
–
–
Non-compliance
Identify triggers
Familial Differences


First-degree biologic relatives have 10
times greater risk for schizophrenia.
Other relatives have higher risk for other
psychiatric disorders.
Schizophrenia Diagnosis
•
•
During a one-month period at least two of
the five
–
Positive (delusions, hallucinations, etc.)
–
Negative (alogia, anhedonia, flat affect,
avolition)
One or more areas of social or
occupational functioning
Types of Schizophrenia
Text Box 16.1

Paranoid

Disorganized

Catatonic

Undifferentiated

Residual
Schizophrenia
Positive
Hallucinations
Delusions
Disorganization
Negative
Avolition
Alogia
Anhedonia
Flat Affect
Ambivalence
Neurocognitive
Impairment
Attention
Memory
Exec Function
Positive Symptoms: Excess of Normal
Functions
•
Delusions (fixed, false beliefs)
–
Grandiose
–
Nihilistic
–
Persecutory
–
Somatic
•
Hallucinations (perceptual experiences)
•
Thought disorder
•
Disorganized speech
•
Disorganized or catatonic behavior
Negative Symptoms:
Less Than Normal Functioning
•
Affective blunting: reduced range of emotion
•
Alogia: reduced fluency and productivity of
language and thought
•
Avolition: withdrawal and inability to initiate and
persist in goal-directed behavior
•
Anhedonia: inability to experience pleasure
•
Ambivalence: concurrent experience of opposite
feelings, making it impossible to make a decision
Neurocognitive Impairment
• Evidence that neurocognitive impairment exists,
independent of positive and negative symptoms
Neurocognition




Memory (short-, long-term)
Vigilance (sustained attention)
Verbal fluency (ability to
generate new words)
Executive functioning
–
–
–
–
volition
planning
purposive action
self-monitoring behavior
Impaired in schizophrenia

Memory (working)

Vigilance

Executive functioning
Neurocognitive Impairment Often Seen as
“Disorganized Symptoms”
•
•
•
Confused speech and thinking patterns
Disorganized behavior
Examples of disorganized thinking
–
–
–
–
–
–
Echolalia (repetition of words)
Circumstantially (excessive detail)
Loose associations (ideas loosely connected)
Tangentially (logical, but detour)
Flight of ideas (change topics)
Word salad (unconnected words)
Disorganized Symptoms
•
Examples of disorganized thinking (cont.)
–
Neologisms (new words)
–
Paranoia (suspiciousness)
–
References ( special meaning)
–
Autistic thinking (private logic)
–
Concrete thinking (lack of abstract thinking)
–
Verbigeration (purposeless repetition)
–
Metonymic speech (interchange words)
Disorganized Symptoms
•
•
Examples of disorganized thinking (cont.)
–
Clang association (repetition similar sounding words)
–
Stilted language (artificial, formal)
–
Pressured speech (words forced)
Examples of disorganized behavior
–
Aggression
–
Agitation
–
Catatonic excitement (hyperactivity, purposeless activity)
Disorganized Symptoms
•
Examples of disorganized behavior (cont.)
–
Echopraxia (imitation of others movements)
–
Regressed behavior
–
Stereotypy (repetitive, purposeless movements)
–
Hypervigilance (sustained attention to external stimuli)
–
Waxy flexibility (posture held in odd or unusual way)
Comorbidity
•
Increased risk of cardiovascular disorders
•
Association between insulin-dependent
diabetes and schizophrenia
•
Depression and pseudodementia
•
Increased substance abuse
•
Cigarette smoking
•
Fluid imbalance
Disordered Water Balance

Prolonged periods of polydipsia, intermittent
hyponatremia, polyuria

Etiology – unknown

Observed behaviors
–
Carrying cokes/coffee/water bottles

Prevention of water intoxication

Promotion of fluid balance
Psychological







Difficulty relating
Deficit in sensory inhibition
Poor control of autonomic responsiveness
Difficulty making decisions
Deficit experiencing pleasure
Deficit initiating activities
Overassessment of threat
Social




Deceased financial status
Family and caregiver stress
Homelessness
Stigma and community isolation
Biologic Factors
•
Genetic – 10% first-degree relative
•
Stress-diathesis model proposed by O’Connor
•
Neuroanatomical findings
–
Decreased blood flow to left globus pallidus
–
Absence of normal blood increase in frontal lobes
–
Atrophy of the amygdala, hippocampus and
parahippocampus
–
Ventricular enlargement
Biologic
•
–
Neurodevelopmental
–
Prenatal exposure (2nd trimester)
–
Late winter, early spring births
Adolescent
–
Changes in transmitter systems and substrates
–
Synaptic pruning along with substantial brain growth in some
areas of the cortex
–
Changes in steroid-hormonal environment
Neurotransmitters, Pathways and
Receptors
•
Hyperactivity of the limbic area
•
•
Hypofrontality or hypoactivity of the pre-frontal
and neo-cortical areas
•
•
(dopamine mesolimbic tract) related to positive
symptoms
(dopamine mesocortical tract related to negative and
positive symptoms)
Does not result from dysfunction of a single
neurotransmitter
Psychosocial Theories
•
Do not explain cause
•
Disservice to families
•
Useful in family interaction
–
Expressed Emotion (EE)
•
High emotion associated with negative communication
and overinvolvement
•
Low emotion associated with less negativity and less
overinvolvement
Priority Care Issues

Suicide
–
20-50% Attempt
–
10% Complete

Safety of patient and others

Initiate antipsychotic medications
Family Response to Disorder

Mixed emotions – shock, disbelief, fear,
care, concern and hope

May try to seek reasons

Initial period very difficult

NAMI – Life changed forever
Interdisciplinary Treatment



The most effective approach involves a
variety of disciplines.
There is considerable overlap of roles and
interventions.
Nursing’s contribution is significant.
Nursing Management:
Biologic Domain
Assessment
•
Present and past health status
•
Physical functioning
•
Nutritional assessment
•
Fluid imbalance assessment
•
Pharmacologic assessment


Medications (prescribed, OTC, herbal, illicit)
Abnormal motor movements
–
–
–
DISCUS
AIMS
Simpson-Angus Rating Scale
Assessment

Comorbidity
–
–
–
Diabetes
Smoking-related
Cardiac

Hypertension
Nursing Diagnosis:
Biologic Domain

Self-care deficit

Disturbed sleep pattern

Ineffective therapeutic regimen
management

Imbalanced nutrition

Excess fluid volume

Sexual dysfunction
Nursing Interventions:
Biologic Domain

Promotion of self-care activities
–
–

Activity, exercise and nutrition
–
–

Help counteract effects of psychiatric medications.
Appetite usually increases, so help with food choices.
Thermoregulation
–
Teach patient to wear clothing according to weather; dress for
winter and summer.
Observe patient’s response to temperature.
–
Water intoxication protocol (Text Box 16.7)
–

Develop a routine of hygiene activities.
Emphasize its importance; help motivate the patient.
Promotion of normal fluid balance
Pharmacologic Interventions

Newer antipsychotics more efficacious and safer (block dopamine
and serotonin)
–
–
–
–
–
–

Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodone)
Aripiprazole (Abilify)
Clozapine (Clozaril) - second line
Monitoring and administering medications
–
–
–
–
Takes 1-2 weeks to work (some improvement immediately)
Adequate trial - 6-12 weeks
Adherence to prescribe medication is best prevention of relapse.
Discontinuation is rare.
Pharmacologic Interventions:
Monitoring Side Effects

Parkinsonism
–
–
–
–

Identical symptoms to Parkinson’s
Caused by blockade of D2 receptor in basal ganglia
Treated with anticholinergic medications
Taper anticholinergic meds if discontinued
Dystonia
–
–
–
Imbalance of DA and ACH, with more ACH
Young men more vulnerable
Oculogyric crisis, Torticollis, Retrocollis
Monitoring Side Effects


Akathesia
–
Restlessness, jumping out of skin, uncomfortable
–
Reduce dose of antipsychotic.
–
Treat with a -blocker (propranolol).
Tardive Dyskinesia
–
Impairment of voluntary movement, constant motion
–
Occurs 6-8 months following initiation of antipsychotics
–
Facial-buccal area -- lip smacking, sucking, etc.
–
Movements in trunk, rocking
–
No real treatment
Monitoring Side Effects







Orthostatic hypotension
Hyper Prolactinemia (haloperidol and risperidone)
Weight gain (olanzapine and clozapine)
Sedation
New-onset diabetes (Olanzapine,clozapine)
Cardiac arrhythmias (QT prolongation)
(Ziprasidone) may need baseline ECG
Agranulocytosis (all but *clozapine)
Drug-drug Interactions

Medications metabolized by 1A2 enzymes include
olanzapine and clozapine.



Medications metabolized by 3A4 include
clozapine, quetiapine and ziprasidone.



Inhibitors: fluvoxamine (Luvox)
Inducers: cigarette smoking Smokers may require a higher
dose
Inhibitors: ketoconazole, protease inhibitors, erythromycin
Inducer: carbamazapine (Tegretol)
Medications affected by 2D6 include risperidone,
clozapine and olanzapine.

Inhibitors: fluoxetine, paroxetine (not usually clinically
significant)
Medication Teaching Points

Consistency in taking medication

Medication and symptom amelioration

Side effects and management

Interpersonal skills that help patient and
family report medication effects
MEDICATION
EMERGENCIES
Neuroleptic Malignant Syndrome

TEMP GREATER THAN 99.5 WITH NO APPARENT CAUSE

Severe muscle rigidity, elevated temperature

Recognizing symptoms
–

Elevated temperature, changes in level of consciousness, leukocytosis, elevated
creatinine phosphokinase), elevated liver enzymes or myoglobinuria
Nursing interventions
–
–
–
–
Stop administration of offending medications.
Monitor vital signs.
Reduce body temperature.
Safety, protect muscles

Supportive measures
–
–
–
IV fluids
Cardiac monitoring
Dantrolene (Dopamine agonist)
Neuroleptic Malignant Syndrome




Acute reaction to dopamine receptors blockers
Prevalence 2 to 2.4%
Death – 4 to 22%, mean = 11%
Etiology:
–
Drugs block striatal dopamine receptors; disrupt
regulatory mechanisms in the thermoregulatory center in
hypothalamus and basal ganglia; heat regulation fails and
muscle rigidity
Is Client
on
neuroleptic drug?
NO
NOT NMS
ANY RISK FACTORS FOR NMS?
DEHYDRATION?
HISTORY OF NMS?
RECENT DOSE INCREASE?
PSYCHOMOTOR AGITATION
YES
EARLY S/S NMS?
LOW-GRADE FEVER?
TACHYCARDIA?ELEVATED BP?
CATATONIA?DIAPHORESIS?
YES
HYPERTHERMIA?
LEAD PIPE RIGIDITY?
MS CHANGES
OTHER AUTONOMIC CNS?
HOLD DRUG
N
O
T
I
F
Y
M
D
Anticholinergic Crises




Potentially life threatening, anticholinergic
delirium
Can occur in patients who are taking several
medications with anticholinergic effects
Elevated temperature, dry mouth, decreased
salivation, decreased bronchial, nasal secretion,
widely dilated eye
Stop offending drug, usually self-limiting. May
use inhibitor of anticholinesterase, physostigmine.
Anticholinergic Crisis

Confusion, hallucinations

Physical signs - dilated pupils, blurred vision, facial

Atropine flush

flushing, dry mucous membranes, difficulty swallowing,
fever, tachycardia, hypertension decreased bowel sounds,
urinary retention, nausea, vomiting, seizures, coma
Hot as a hare, blind as a bat, mad as a
hatter, dry as a bone
Treatment





Self-limiting – three days
Discontinuation of medication
Physiostigmine 1-2 mg IV, an inhibitor
of cholinesterase, improves in 24-36
hours
Gastric lavage
Charcoal, catharsis
Nursing Management:
Psychological Domain
Assessment – Responses

Socially stigmatizing

Prodromal symptoms evident (negative symptoms)

Tension and nervousness

Lack of interest in eating

Difficulty concentrating

Disturbed sleep

Decreased enjoyment

Loss of interest, restlessness, forgetfulness

Often not recognized as an illness

Denial common
Nursing Management:
Psychological Domain
Assessment
•
•
Positive and negative symptoms
•
SAPS (positive symptoms) (Box 16.14)
•
SANS (negative symptoms) (Box 16.15)
•
PANNS (both symptoms)
Mental status
•
Appearance
•
Mood and affect (lability, ambivalence, apathy)
•
Speech
•
Thought processes (delusions, disorganized communication, cognitive
impairments)
•
Sensory perception (hallucinations)
•
Memory and orientation
•
Insight and judgment
Nursing Management:
Psychological Domain
Assessment (cont.)




Behavioral responses
Self-concept
Stress and coping patterns
Risk assessment
–
–
–
Command hallucinations
Self-injury risk, suicide
Homicide
Nursing Diagnosis:
Psychological Domain








Disturbed thought processes
Disturbed sensory perceptions
Disturbed body image
Low self-esteem
Disturbed personal identity
Risk of violence, suicide
Ineffective coping
Knowledge deficit
Nursing Interventions:
Psychological Domain


Counseling, conflict resolution, behavior
therapy and cognitive interventions can be
used.
Development of nurse-patient relationship
–
Centers on the development of trust and
acceptance of the persons
–
Critical for optimal treatment of schizophrenia
Nursing Interventions:
Psychological Domain –
Management of Disturbed Thoughts

Assessment content of hallucinations/delusions

Outcomes


–
Decrease frequency and intensity.
–
Recognize as symptoms of disorder.
–
Develop strategies to manage recurrence.
Experiences real to the patient
–
Validate that experiences are real
–
Identify meaning and feeling that are provoked
Teach patient that hallucinations and delusions are
symptoms of illness.
Nursing Interventions:
Psychological Domain


Self-monitoring and relapse prevention
–
Monitor events, time, place, etc. of recurrence of symptoms.
–
Manage symptoms - getting busy, self-talk, change of activity.
(Moller-Murphy Tool)
Enhancement of cognitive functioning
–
Recognize difficulty in processing information.
–
Improve attention (computer programs, one-to-one).
–
Help memory (make lists, write down information).
–
Improve executive functioning-simulation.
Nursing Interventions:
Psychological Domain

Behavioral interventions
–
–

Stress and coping skills development
–
–

Organize routine, daily activities.
Reinforce positive behaviors.
Counseling sessions
Teach and reward positive coping skills.
Patient education
–
–
–
–
Errorless learning environment
Minimal distractions
Clear visual aids
Skills training
Family Interventions



Family support
Educate the family regarding lifelong disorder of
schizophrenia.
Emphasize consistent taking of medication.
Nursing Management:
Social Domain
Assessment


Functional status
–
Assessed initially and at regular intervals
–
GAF usually used
Social systems
–
Formal and informal support systems

Quality of life

Family assessment
–
Family assessment guide (Ch. 15)
–
Special consideration to the family where patient is the parent
Nursing Interventions:
Social Domain
Promotion of Patient Safety
•
Monitoring for potential aggression
•
Administering medication as ordered
•
Reducing environmental stimulation
•
Approach to individual patients
–
–
Thorough history of violence
Help patient to talk directly and constructively with those with
whom they are angry.
–
Set limits.
–
Involve patients in formal contracting.
–
Schedule regular time-outs.
Nursing Interventions:
Social Domain




Support groups
Milieu therapy
Psychiatric rehabilitation
Family interventions
–
–
–
Encourage to participate in support groups
Inform about local and state resources
Help negotiate provider system
Continuum of Care

Treatment occurs across continuum.
Patients are at high risk for getting lost in
the system.

Inpatient-focused care (stabilization)

Emergency care (crisis)

Community care (most of care)

Mental health promotion
Schizophrenia in Children




Rare in children
If appears in children aged 5 or 6,
symptoms same as for adults
Hallucinations visual, delusions less welldeveloped
Other disorders considered first
Schizophrenia in Elderly


For those who have had schizophrenia
most of their life, this may be a time that
they experience improvement in symptoms.
Late-onset schizophrenia
–
Diagnostic criteria met after 45

–
Estrogen may be protective in women
Most likely include positive symptoms