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
Positive symptoms/may be subtle
Family Disruption
Awareness of the meaning of the disorder
Stabilization
Treatment is intense
Establish Medications
Begin Rehab
Maintenance and Recovery
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
Negative
Avolition
Alogia
Anhedonia
Flat Affect
Ambivalence
Neurocognitive
Impairment
Attention
Memory
Exec Function
Positive
Hallucinations
Delusions
Disorganization
Schizophrenia
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
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

Evidence that neurocognitive impairment exists,
independent of positive and negative symptoms
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 OConnor
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
(dopamine mesolimbic tract) related to positive
symptoms
Hypofrontality or hypoactivity of the pre-frontal
and neo-cortical areas
(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.
Nursings 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
Develop a routine of hygiene activities.
Emphasize its importance; help motivate the patient.
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 patients response to temperature.
Promotion of normal fluid balance
Water intoxication protocol (Text Box 16.7)
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 Parkinsons
Caused by blockade of D
2
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.
Inhibitors: fluvoxamine (Luvox)
Inducers: cigarette smoking Smokers may require a higher
dose
Medications metabolized by 3A4 include
clozapine, quetiapine and ziprasidone.
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
Y
E
S

EARLY S/S NMS?
LOW-GRADE FEVER?
TACHYCARDIA?ELEVATED BP?
CATATONIA?DIAPHORESIS?
Y
E
S

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
flushing, dry mucous membranes, difficulty swallowing,
fever, tachycardia, hypertension decreased bowel sounds,
urinary retention, nausea, vomiting, seizures, coma
Atropine flush
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
Organize routine, daily activities.
Reinforce positive behaviors.
Stress and coping skills development
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 well-
developed
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