SCHIZOPHRENIA
AND PSYCHOSIS
Module III
RNSG 2213
SCHIZOPHRENIA: OVERVIEW
• Major Axis I disorder
• Characterized by disturbances in:
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Perception
Thought processes and reality testing
Affect (feelings)
Behavior
Attention (concentration)
Motivation
PSYCHOSIS
• How do we define this term?
• Inability to evaluate accuracy of one’s
thoughts and perceptions
• Incorrect interpretation of external reality
• Inability to re-evaluate one’s thoughts and
perceptions, even in the face of evidence
that contradicts these.
In Schizophrenia, the psychotic person often
does not have awareness that he/she is ill
OVERVIEW, CONT’D
• Incidence
• Age of onset is late adolescence
• 1.1% of population over age 18
• Higher rates in inner city populations, lower
socioeconomic groups
• Prenatal probs. correlate with higher rate
OVERVIEW, CONT’D
• Prognosis
• Approx. 25% remain highly functional
• 50% are minimally functional
• 25% are in-between with
exacerbations/relapses and
re-stabilizations (in and out of hosp.)
OVERVIEW, CONT’D
• A Chronic Illness Characterized by
Phases:
• Acute phase – severe psychotic sx.
• Stabilizing Phase
• Stable phase
• Most pts. alternate between acute and
stable phases
SCHIZOPHRENIA:
SYMPTOMS
• Bleuler’s (Early 1900’s) “4 A’s”:
• Affect disturbances
• Autism
• Associative looseness
• Ambivalence
“Fragmentation of the Mind”
CLASSIFICATION OF
SYMPTOMS
• Positive Symptoms
• Negative Symptoms
• Cognitive Symptoms
Positive
Symptoms of Schizophrenia
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Agitation/aggression
Delusions
Hallucinations
Disordered thinking (AEB disordered speech):
circumstantial thinking, loose associations, word
salad, neologisms, echolalia
Positive Symptoms of
Schizophrenia, cont’d
• Disordered movement:
--restlessness, repetitive movements
(e.g. echopraxia),
--or immobility (catatonia)
http://www.youtube.com/watch?v=zAEJ-Jvndms
Matching: Symptoms
1) “A blue ape. Makes me
2)
3)
4)
5)
6)
scratch. John wore a hair
shirt. Are we victims?”
“I am locked in concrete and I
have stopped breathing.”
“The CIA has been poisoning
my water.”
“Whenever knife take you-a.”
“At HEB, when they play that
music, the words are sending
messages to me.”
“I love chocolate candy.
Candy is my parakeet’s name.
What’s your name?”
A) Word salad
B) Delusion of
reference
C) Tangentiality
D) Neologism
E) Loose associations
F) Paranoid delusion
G) Nihilistic delusion
H) Grandiose
delusion
• Grandiose delusion example:
“I own the Bank of America and my people are
going to put up $20 million for my release
from here.”
• Neologism example:
“It tastes screeg because of those nerflexes.”
Negative Symptoms of
Schizophrenia
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Flat affect
Inability to plan or carry out activities
Constricted, concrete thinking
Poverty of speech (alogia), flat speech
Social withdrawal; lack of pleasure in
activities (anhedonia)
• Deep apathy
“Flat Affects”
(Flight of the Conchords)
Cognitive Symptoms of
Schizophrenia
• Impaired ability to pay attention and to
understand
• Impaired ability to make decisions
(ambivalence)
• Problems in using just-learned
information
CRITICAL THINKING:
Nursing Diagnoses
Write one nursing dx. for each symptom
or behavior related to schizophrenia
1) Client has command auditory
hallucinations that he should kill
himself
2) Client does not get dressed or take
baths
3) Client believes she can make it snow
Suggested Nursing DX:
1) R/F Self-directed Violence r/t sensory
perceptual alteration s/t command
auditory hallucinations
2) Self-care deficits: grooming and
hygiene r/t poor motivation for selfcare s/t schizophrenia
3) Altered thought process s/t grandiose
delusion (or delusion of grandeur)
Antipsychotic Agents and
Symptoms
• The “Typical” (older class) of
antipsychotics primarily address
POSITIVE symptoms
• Can make negative symptoms Worse
• The “Atypical” (newer classes) of
antipsychotics address both
POSITIVE AND NEGATIVE symptoms
SYMPTOMS:
DSM CRITERIA
A. At least 2:
Delusions, Hallucinations, Disorganized speech,
Catatonia, Disorganized behavior, Negative
symptoms
B.
C.
D.
E.
Social-occupational dysfunction
Continuous s/sx. > 6 months
No schizoaffective diagnosis
Not caused by substance abuse or medical
disorder
DSM Criteria:
Schizophrenia Subtypes
• Paranoid – persecutory and/or grandiose
delusions
• Disorganized – speech & affect & behavior
are disturbed
• Catatonic – absent, excessive &/or peculiar
movements. Mutism.
• Undifferentiated – does not meet criteria for
other subtypes
• Residual – has some disturbed thinking or
behavior but does not meet other criteria
DSM Criteria: Other Psychotic
Disorders
• Schizophreniform Disorder
• Has similar symptoms to schizophrenia but
for only 1-6 months
• Schizoaffective Disorder
• Symptoms of schizophrenia + symptoms of
a mood disorder
• Psychotic Disorder NOS
• Has Psychotic symptoms but doesn’t fit
criteria for any of the above
Quick Check: What is the most
likely DSM IV-TR Diagnosis?
Client #1 Elevated mood episodes along with
hallucinations and delusions for 2 years
Client #2 Is physically immobile at times.
Has poverty of speech. Has never worked in
adulthood.
Client #3 Agitated, reports seeing flashes of
color and hearing singing voices x 2 weeks.
Client #4 “I know 4,000 languages but others
are trying to steal these from my mind.” As a
result, has been living on the streets for many
years.
ETIOLOGY
• Multifactorial-no single cause
• Multiple theories for etiology (see next
content)
BIOLOGICAL THEORIES
1. The Dopamine Hypothesis:
• Too much dopamine binds with too many
brain receptors and causes positive
symptoms
   
• Too little dopamine -- negative symptoms
BIOLOGICAL THEORIES, cont’d
2. Disturbed Ratio of
serotonin: dopamine
CRITICAL THINKING
• Based on the preceding
hypotheses, what are the principles
behind antipsychotic medications ?
-to treat positive symptoms:
-to treat negative symptoms:
-to treat altered ratios:
BIOLOGICAL THEORY:
CHANGES IN BRAIN
STRUCTURE AND FUNCTION
• Alterations found in some Schizophrenics
using Diagnostic Imaging
• PET Scan:  glucose metabolism in
frontal/temporal lobes; in basal ganglia
• MRI: Enlargement of ventricles
• BEAM Scan: Abnormal wave patterns
indicting absence of ability to “calm” the brain
• Evoked Potential Topography: Illogical
thought patterning in frontal lobe
PET Scan and Schizophrenia
GENETIC THEORY
• Inherited predisposition to
schizophrenia
• Risk Factors:
• Two parents with schizophrenia = 35%
• Identical twins = 50%
DEVELOPMENTAL AND
ENVIRONMENTAL THEORIES
• Prenatal infections
• Parental neglect or rejection
• Greater % of pts. come from lower
socio-economic class
Issues in Schizophrenia
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Family disturbance: a cause or a result?
Noncompliance and relapse are common
Have poorer ability to cope with stress
Increased rates of depression, suicide
Increased rate of substance abuse:
alcohol, marijuana, nicotine, cocaine
• Often cannot hold a job
Australian aboriginal painting
by mental health client
http://www.ncbi.nlm.nih.gov
INTERVENTIONS/
PSYCHOTHERAPEUTIC
MANAGEMENT
NURSE-CLIENT RELATIONSHIP
• Be accepting, consistent and honest
• Do not argue with or reinforce hallucinations
or delusions
• Reinforce acceptable behaviors
• Gently encourage withdrawn client
• Recognize when a client may be suspicious,
anxious or fearful, and approach with care
• Assess for command hallucinations
CRITICAL THINKING: Which Nurse is
Therapeutic? Non-therapeutic ?
Client insists he is a “negative space alien.”
Nurse A: “Do you live in outer space? Are there
other people living there?”
Nurse B: “But I have met your mom. How can
you be a space alien?”
Nurse C: “That’s interesting. Want to come
with me now to see the patient art exhibit?”
Nurse D: “ I can see you feel strongly about
that.”
MILIEU MANAGEMENT
• Set limits on disruptive behavior
• Assess agitated clients frequently for
escalation
• Assess ability to participate in activities;
choose activities at client’s level of ability
• May need 1:1 rather than group activities at
first
• Decrease environmental stimuli prn
• Supervised meals, hygiene, grooming
CRITICAL THINKING: Which Nurse
is Therapeutic? Non-therapeutic?
A new patient starts pacing back and forth,
while saying in a loud voice, “Take it back,
take it back.”
Nurse A: “Lower your voice, you are
disturbing people.”
Nurse B: “Hi, I’m Jo the nurse; are you
ok?”
Nurse C: “Why are you pacing?”
CRITICAL THINKING: In what order
should the nurse implement ?
A schizophrenic patient, who hallucinates
and is sometimes aggressive, turns off
the football game that others are watching.
“Are you hearing the voices?”
“Right now our activity is watching the football
game, so it’s not ok to turn it off.”
“Come on outside for some fresh air.”
“I’m going to give you some medication right
now to help you feel calmer.”
OTHER INTERVENTIONS
• Importance of client and family
education
• To address stigma of schizophrenia &
• To improve functional ability, selfmanagement and prevent relapse
Other Interventions, cont’d
• Community Resources and Continuity
of Care
• National Alliance on Mental Illness (NAMI)
• Outpatient day treatment, home care
• Self-help, peer support groups
(NAMI)
http://www.youtube.com/watch?v=GEX1kr8EOPI
PHARMACOTHERAPY
• Antipsychotic Agents
• Traditional or Typical Agents: 1st
Generation (beginning 1950’s)
• Atypical or Second Generation
Agents (1990’s)
• Novel or Third Generation Agents
(21st century)
Antipsychotic Agents: Overview
of Typical Agents
• Pharmacologic Effects, in General
• Sedation (esp. if combined with other CNS
depressants)
• Slowing of motor activity
• Decrease in hallucinations and delusions
• Emotional quieting
• Improved cognitive function; decreased
confusion
TYPICAL or Traditional
ANTIPSYCHOTIC AGENTS
• High Potency e.g. haloperidol (Haldol),
fluphenazine (Prolixin)
• Moderate Potency e.g. loxapine (Loxitane),
perphenazine (Trilafon)
• Low Potency e.g. chlorpromazine
(Thorazine), thioridazine (Mellaril)
Typical/Traditional
Antipsychotics, cont’d
• Action = Block Dopamine D2
Receptors
• Most effective for Positive (+) symptoms
Atypical (2nd Generation) Agents
• clozapine (Clozaril) (prototype)
Action of this drug: blocks multiple
dopamine receptors
• quetiapine (Seroquel)
• risperidone (Risperdal)
• olanzapine (Zyprexa)
• ziprasidone (Geodon)
• paliperidone (Invega)
Newest Atypical Agents
• iloperidone (Fanapt)
• Asenaphine (Saphris)
Atypical (2nd generation)
Agents, cont’d
• Action: Block (antagonists) or enhance
(agonists) multiple dopamine, serotonin
and/or norepinephrine receptors.
• Useful for both positive and negative
symptoms
Novel (3rd Generation) Agents
• aripiprazole (Abilify)
• Action: Partial dopamine antagonist
“Balances” dopamine
(both increases and decreases
it in different brain areas)
Antipsychotics: Side Effects
• Main Side Effects:
• Extra-Pyramidal (EPSEs)abnormally increased or
decreased motor activity,
muscle spasms, twisting,
tremors
 Akinesia
 Akathisia
 Pseudo-Parkinsonism
 Dystonias
 Tardive Dyskinesia
Acute dystonic reaction
Tardive Dyskinesia
•http://www.youtube.com/watch?v=UbBpt9uCXqc&feature=related
EPSEs
• To assess for tardive dyskinesia,
administer AIMS (Abnormal Involuntary
Movement Scale)
Antipsychotics: Side Effects,
cont’d
• Anticholinergic Effects-dry mouth,
orthostatic hypotension, urinary retention,
blurred vision
• Usually resolve over time
Other Side Effects
• Cardiac:
• Arhythmias (QT interval lengthened)
• Blood:  Leukopenia, anemias,
agranulocytosis (clozapine/Clozaril)
• Endocrine and Metabolic:
 Weight gain
 Altered glucose metabolism
Diabetes type II
 Elevated prolactin levels
• Sexual: Impaired libido, performance
A Dangerous Side Effect
• Neuroleptic Malignant Syndrome
(NMS)
• Potentially lethal
• Associated with use of high-potency
agents e.g. haloperidol/Haldol
• Onset: within a week after starting meds.
• Symptoms: muscular rigidity, tremors,
autonomic hyperactivity e.g. high body
temperature, altered consciousness
Nursing Interventions R/T
Antipsychotic Meds.
• Medication education (You cannot teach
too often)
• Side effect issues contribute to poor
adherence/compliance:
• E.g. hypotension, CNS depression,
photosensitivity, thermoregulation
problems
Education/Safety Issues: What
will you teach the client
about. . .?
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Hypotension
Sedation
Photosensitivity
Problems with thermoregulation
Weight gain
Nursing Interventions R/T
Pharmacotherapy
--Option for client with poor adherence:
Long acting (“depot”) form, give IM
q 1week - 4 wks
Nursing Interventions r/t
Pharmacotherapy
Disintegrating oral tablet
Oral solution
EMERGENCY MEDS
• Common choice: IM “cocktail” of
sedating antipsychotic + antihistamine
and benzodiazepine
• Goals: reduce agitation
rapid sedation
CRITICAL THINKING:
Antipsychotic Therapy
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A 65 year-old client will start on an
antipsychotic agent for delusions
secondary to severe depression.
Choose the 3 highest priority
diagnostic tests that will be performed.
A) CBC with diff.
B) Chest x-ray
C) EKG
D) EEG
E) BUN/Creatinine
F) Electrolytes
PHARMACOTHERAPY FOR
EXTRAPYRAMIDAL SEs:
Antiparkinson Agents
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benztropine (Cogentin)
trihexyphenidyl (Artane)
biperiden (Akineton)
diphenhydramine (Benadryl)
amantadine (Symmetrel)
Antiparkinson Agents, cont’d
• Action: Restore balance of dopamine
with acetylcholine (ACh)
• Reduce motor and muscle dysfunctions
caused by this imbalance
• But: They also may cause anticholinergic
SEs and mental confusion
CRITICAL THINKING
Which client(s) is(are) candidate(s) for
benztropine/Cogentin?
A) is unable to void urine
B) reports onset of difficulty swallowing and stiff
muscles
C) is pacing in response to hearing voices
D) has had tardive dyskinesia symptoms for
several years
CRITICAL THINKING:
Anti-Parkinson/Anticholinergic
Agents
On the mental health unit, a client who was recently
prescribed an antiparkinson agent for EPSEs reports
very dry mouth and constipation. What will the nurse do?
(Choose all that apply)
A) Call the dr. to discuss changing dose of the med.
B) Encourage use of hard candies and increase in fluid
intake
C) Hold the medication
D) Inform the client that these effects may decrease in a
few weeks.