SCHIZOPHRENIA

Schizophrenia causes distorted and bizarre thoughts,

perceptions, emotions, movements, and
behavior
cannot be defined as a single illness; is
thought of as a syndrome

an illness that medication can control

peak incidence of onset is 15 to 25 years of

age for men and 25 to 35 years of age for
women
symptoms are divided into two major
categories: positive or hard symptoms/signs
and negative or soft symptoms/signs
Schizoaffective diagnosed when the client is severely ill and
disorder has a mixture of psychotic and mood symptoms

signs and symptoms include those of both

schizophrenia and a mood disorder such as
depression or bipolar disorder

symptoms may occur simultaneously or may

alternate between psychotic and mood
disorder symptoms

Treatment: targets both psychotic and mood

symptoms (2nd generation antipsychotics; mood
stabilizers; antidepressants)
Schizophrenia
CLINICAL COURSE •
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Schizophrenia
CLINICAL COURSE •

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RELATED
Schizophreniform disorder
DISORDERS
exhibits an acute, reactive psychosis for less
than the 6 months necessary to meet the
diagnostic criteria for schizophrenia

If symptoms persist over 6 months, the

diagnosis is changed to schizophrenia.

Social or occupational functioning may or

may not be impaired.
RELATED Catatonia
DISORDERS
marked psychomotor disturbance, either excessive
motor activity or virtual immobility and
motionlessness

Motor immobility: catalepsy (waxy flexibility) or

stupor

Excessive motor activity: purposeless and not

influenced by external stimuli

Other behaviors: extreme negativism, mutism,

peculiar movements, echolalia, or echopraxia
RELATED Delusional disorder
DISORDERS
client has one or more non-bizarre
delusions— that is, the focus of the
delusion is believable

delusion may be persecutory,

erotomanic, grandiose, jealous, or
somatic in content

psychosocial functioning is not

markedly impaired, and behavior is
not obviously odd or bizarre.
RELATED
Brief psychotic disorder
DISORDERS
• sudden onset of at least one
psychotic symptom, such as
delusions, hallucinations, or
disorganized speech or
behavior, which lasts from 1
day to 1 month
• may or may not have an
identifiable stressor or may
follow childbirth
RELATED
DISORDERS Shared psychotic disorder (folie à deux)
• Two people share a similar delusion. The person
with this diagnosis develops this delusion in the
context of a close relationship with someone who
has psychotic delusions, most commonly siblings,
parent and child, or husband and wife.
• The more submissive or suggestible person may
rapidly improve if separated from the dominant
person

https://www.youtube.com/watch?v=5FaTPYYIhDM
RELATED
DISORDERS Schizotypal
personality disorder
• involves odd, eccentric
behaviors, including
transient psychotic
symptoms
• approximately 20% will
eventually be diagnosed with
schizophrenia
 Biologic Theories
ETIOLOGY • Genetic factors – focused on immediate families
• Neuroanatomic and neurochemical factors
• people with schizophrenia have relatively less
brain tissue and cerebrospinal fluid than those
who do not have schizophrenia; this could
represent a failure in the development or a
subsequent loss of tissue
• CT Scans - enlarged ventricles in the brain and
cortical atrophy
• PET Scans - suggest that glucose metabolism and
oxygen are diminished in the frontal cortical
structures of the brain
• most prominent neurochemical theories involve
dopamine and serotonin
• Immunovirologic Factors - exposure to a virus or
the body’s immune response to a virus could alter
the brain physiology of people with
schizophrenia; cytokines
 TREATMENT

•
Maintenance Six antipsychotics are available as long-acting injections (LAIs), formerly
called depot injections, for maintenance therapy. They are the following:
Therapy Fluphenazine (Prolixin) in decanoate and enanthate preparations

Haloperidol (Haldol) in decanoate

Risperidone (Risperdal Consta)

Paliperidone (Invega Sustenna)

Olanzapine (Zyprexa Relprevv)

Aripiprazole (Abilify Maintena)

 reversible movement disorders induced by
Extrapyramidal Side neuroleptic medication
Effects
Include:

• Dystonic reactions
• spasms in neck muscles (torticollis) or eye muscles
(oculogyric crisis)
• protrusion of the tongue, dysphagia, and laryngeal
and pharyngeal spasms
• Acute treatment: diphenhydramine (Benadryl) IM
or IV or benztropine (Cogentin) IM
• Parkinsonism
• shuffling gait, masklike facies, muscle stiffness
(continuous) or cogwheeling rigidity (ratchet-like
movements of joints), drooling, and akinesia
(slowness and difficulty initiating movement)
Extrapyramidal Side
Effects
Akathisia

• restless movement, pacing, inability to

remain still, and the client’s report of inner
restlessness
• Treatment: Beta-blockers such as
propranolol; benzodiazepines

The Simpson–Angus scale for EPS

Tardive Dyskinesia

•
Abnormal Involuntary Movement Scale (AIMS)

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Side Effects of Seizures

Antipsychotic
• Infrequent; may be associated with high doses

Neuroleptic Malignant Syndrome (NMS)

Medications • serious and frequently fatal condition
• muscle rigidity, high fever, increased muscle enzymes (particularly,
creatine phosphokinase), and leukocytosis (increased leukocytes)

Agranulocytosis

• Clozapine
• develops suddenly and is characterized by fever, malaise, ulcerative
sore throat, and leukopenia
• can occur as long as 18 to 24 weeks after the initiation of therapy
• drug must be discontinued immediately
• weekly white blood cell counts for the first 6 months of clozapine
therapy and every 2 weeks thereafter
• dispensed every 7 or 14 days only, and evidence of a white blood cell
count above 3,500 cells/mm3 is required before a refill is furnished.
Side Effects of Antipsychotic Medications
 Individual and group therapy sessions -
Psychosocial supportive in nature, giving the client an
opportunity for social contact and meaningful
Treatment relationships with other people

Social skill training - improves social

competence

Cognitive adaptation training - designed to

improve adaptive functioning in the home setting

• Individually tailored environmental supports such as

signs, calendars, hygiene supplies, and pill containers cue
the client to perform associated tasks.
Psychosocial
Treatment Cognitive Enhancement Therapy (CET)

• combines computer-based cognitive training with

group sessions that allow clients to practice and
develop social skills
• designed to remediate or improve the clients’ social
and neurocognitive deficits, such as attention,
memory, and information processing

Family education and therapy - known to

diminish the negative effects of
schizophrenia and reduce the relapse rate
APPLICATION OF THE
NURSING PROCESS
Schizophrenia
 thought processes and content, perception,
emotion, behavior, and social functioning

History

ASSESSMENT • ask questions about how the client functioned before

the crisis developed
• “How do you usually spend your time?”
• “Can you describe what you do each day?”
• age at onset
• previous suicide attempts
• history of violence or aggression
• current support systems
• client’s perception of current situation
ASSESSMENT
may appear disheveled
General Appearance, Some appear normal;
and unkempt or may motor behavior may
Motor Behavior, and others exhibit odd or
wear strange or also appear odd
Speech bizarre behavior
inappropriate clothing

restless and unable to sit

demonstrate seemingly
still, exhibit agitation
purposeless gestures odd facial expressions echopraxia
and pacing, or appear
(stereotypic behavior)
unmoving (catatonia)

psychomotor
retardation; may be Unusual speech pattern:
almost immobile, curled word salad; echolalia;
rambling speech
into a ball (fetal slowed or accelerated;
position); waxy latency of response
flexibility
 Mood flat affect (no facial expression) or
ASSESSMENT and blunted affect (few observable facial
expressions); typical facial
Affect expression: masklike

affect: silly, characterized by giddy

laughter for no apparent reason

may exhibit an inappropriate

expression or emotions incongruent
with the context of the situation

anhedonia; may report feeling all-

knowing, all-powerful and not at all
concerned with the circumstance or
situation
ASSESSMENT

•
Circumstantiality:

Poverty of content (alogia): lack of any real meaning or substance in

what the client says:
ASSESSMENT
Delusions
• A common characteristic of
schizophrenic delusions is
the direct, immediate, and
total certainty with which
the client holds these beliefs.
• Because the client believes
the delusion, he or she,
therefore, acts accordingly.
ASSESSMENT Sensorium and Intellectual
Processes

hallucinations; can be
threatening and frightening
for the client

distinguished from illusions

(misperceptions of actual
environmental stimuli)

E.g., while walking through the

woods, a person believes he • Reality or factual information corrected this
sees a snake at the side of the illusion.
path. On closer examination, • Hallucinations, however, have no such basis in
however, he discovers it is only reality.
a curved stick.
Types of Hallucinations

Auditory hallucinations Visual hallucinations

• most common type • involve seeing images that do not exist at

• involve hearing sounds, most often voices, all, such as lights or a dead person, or
talking to or about the client distortions such as seeing a frightening
• one or multiple voices monster instead of the nurse
• a familiar or unfamiliar person’s voice • second most common type of
may be speaking hallucination
• Command hallucinations - voices
demanding that the client take action,
often to harm the self or others, and are
considered dangerous
Types of Hallucinations

Olfactory hallucinations

• involve smells or odors; may be a specific scent such as urine or feces or a

more general scent such as a rotten or rancid odor
• often occurs with dementia, seizures, or cerebrovascular accidents (in
schizophrenia)

Tactile hallucinations

• sensations such as electricity running through the body or bugs crawling on

the skin
• found most often in clients undergoing alcohol withdrawal; they rarely occur
in clients with schizophrenia
Types of Gustatory hallucinations

Hallucinations
• involve a taste lingering in the mouth or the sense that food tastes like
something else
• taste may be metallic or bitter or may be represented as a specific
taste

Cenesthetichallucinations
• involve the client’s report that he or she feels bodily functions that are
usually undetectable
• E.g., the sensation of urine forming or impulses being transmitted
through the brain

Kinesthetic hallucinations

occur when the client is motionless but reports the

sensation of bodily movement

bodily movement is something unusual, such as floating

above the ground.
ASSESSMENT
disoriented to time and sometimes to place

depersonalization - the most extreme form

of disorientation is in which the client feels
detached from his or her behavior

cannot focus, concentrate, or pay adequate

attention to demonstrate his or her
intellectual abilities accurately

have difficulty with abstract thinking and

may respond in a literal way to other people
and the environment
ASSESSMENT Judgment and Insight

• judgment is frequently impaired

• At times, lack of judgment is so severe
that clients cannot meet their needs for
safety and protection and place
themselves in harm’s way.
• may also fail to recognize needs for sleep
or food

Insight

• can be severely impaired

• over time, some clients can learn about
the illness, anticipate problems, and seek
appropriate assistance as needed
ASSESSMENT
Self-Concept

The phrase loss of ego boundaries describes the client’s lack of a clear
sense of where his or her own body, mind, and influence end and
where those aspects of other animate and inanimate objects begin
• evidenced by depersonalization, derealization (environmental objects become smaller
or larger or seem unfamiliar) and ideas of reference

Clients may believe they are fused with another person or object, may
not recognize body parts as their own, or may fail to know whether
they are male or female.
• the source of many bizarre behaviors such as public undressing or masturbating,
speaking about oneself in the third person, or physically clinging to objects in the
environment

Body image distortion - may also occur

ASSESSMENT Roles and Relationships
• social isolation
• problems with trust and intimacy
• avoidance of other people
• great frustration in attempting to
fulfill roles in the family and
community
• success in school or at work can be
severely compromised
• fulfilling family roles is difficult
• families may also feel guilty or
responsible
ASSESSMENT Physiological
and Self-Care
Inattention to hygiene and grooming
needs is common

can become so preoccupied with

delusions or hallucinations that he or she
fails to perform even basic activities of
daily living

may also fail to recognize sensations such

as hunger or thirst, and food or fluid
intake may be inadequate

may develop polydipsia (excessive water

intake)

insomnia
 The North American Nursing Diagnosis Association’s (NANDA) nursing diagnoses commonly established based on the

DATA ANALYSIS
assessment of psychotic symptoms or positive signs are:

Risk for other-directed violence

Risk for suicide

Disturbed thought processes

Disturbed sensory perception

Disturbed personal identity

Impaired verbal communication

The NANDA nursing diagnoses based on the assessment of negative signs and functional abilities include:

Self-care deficits

Social isolation

Deficient diversional activity

Ineffective health maintenance

Ineffective therapeutic regimen management

OUTCOME
Examples of outcomes appropriate
IDENTIFICATION to the acute, psychotic phase of
treatment are:
• The client will not injure him or herself or
others.
• The client will establish contact with reality.
• The client will interact with others in the
environment.
• The client will express thoughts and feelings
in a safe and socially acceptable manner.
• The client will participate in prescribed
therapeutic interventions.
OUTCOME Examples of treatment outcomes for
IDENTIFICATION continued care after the stabilization of
acute symptoms are:
• The client will participate in the prescribed
regimen (including medications and follow-up
appointments).
• The client will maintain adequate routines for
sleeping and food and fluid intake.
• The client will demonstrate independence in
self-care activities.
• The client will communicate effectively with
others in the community to meet his or her needs.
• The client will seek or accept assistance to meet
his or her needs when indicated.
 EVALUATION

Have the client’s psychotic

Does the client understand
symptoms disappeared? If Does the client possess the
In a global sense, evaluation the prescribed medication
not, can the client carry out necessary functional
of the treatment of regimen? Is he or she
his or her daily life despite abilities for community
schizophrenia is based on: committed to adherence to
the persistence of some living?
the regimen?
psychotic symptoms?

Is there a sufficient
Are community resources aftercare or crisis plan in
Are the client and family Does the client believe he
adequate to help the client place to deal with
adequately knowledgeable or she has a satisfactory
live successfully in the recurrence of symptoms or
about schizophrenia? quality of life?
community? difficulties encountered in
the community?