Chapter 14
The Schizophrenias
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
1
Concept of Schizophrenia
• Schizophrenia: devastating brain disease
affecting thinking, language, emotions,
social behavior, and reality perception
– Psychotic disorder: refers to experiencing
such phenomena as delusions, hallucinations,
disorganized speech or behavior
– Considered a severe mental illness (SMI)
• Chronic condition; treatable but not curable
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
2
Schizophrenias:
Prevalence and Comorbidity
• Prevalence
– Lifetime prevalence worldwide is 1%
– No differences in regard to race, social status,
culture, gender, or environment
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
3
Schizophrenias:
Prevalence and Comorbidity
• Comorbidity
– Substance abuse disorders: approximately
40%-50% of people with schizophrenia
– Nicotine dependence: 75%-85% of people
with schizophrenia
– Depressive disorders, anxiety disorders and
psychosis-induced polydipsia also common
– Suicide 20 times more prevalent than general
population
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
4
Biological Theories
Related to Schizophrenia
• Brain chemistry, brain activity different in a
person with schizophrenia
• Genetics
– Twin and adoptive studies validate major role
– Multiple genes believed to be involved
• Neurobiological factors
– Dopamine theory: derived from fact that
antipsychotic drugs decrease dopamine and
decrease symptoms of schizophrenia
– Current research: other neurotransmitters
involved
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
5
Biological Theories
Related to Schizophrenia
• Neuroanatomical factors
– Brain-imaging techniques validate differences
in structure of brain
•
•
•
•
•
Lower brain volume
Larger lateral and third ventricles
Atrophy in frontal lobe
More cerebrospinal fluid
Low rate of blood flow and glucose metabolism in
frontal lobes of cerebral cortex
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
6
Other Theories
Related to Schizophrenia
• Nongenetic risk factors
– Increased in pregnancy and birth complications
– Prenatal risk factors: viral infection, poor
nutrition, or exposure to toxins
– Stress: can precipitate illness in vulnerable
people
– Use of street drugs increases risk
• Cultural considerations
– Cultures interpret schizophrenia differently
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
7
Types of Schizophrenia: Paranoid
• Person is intensely suspicious toward
others
• Paranoid ideas cannot be corrected by
experiences or modified by facts or reality
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
8
Types of Schizophrenia: Paranoid
• Defense mechanism used
– Projection: attributing to others, one’s own
feelings
• Ideas of reference common
– Misinterprets messages of others or given
private meaning to communication
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
9
Types of Schizophrenia: Catatonic
• Essential feature: abnormal motor
behavior
– Extreme agitation
– Extreme psychomotor retardation
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
10
Types of Schizophrenia: Catatonic
• Other behaviors
– Posturing: holding arms/legs rigid for long
periods
– Waxy flexibility: when placed in awkward
position, holds position for long time
– Stereotyped behavior: obsessively following
routine
– Negativism and resistance or automatic
obedience
– Echolalia: repetition of words of another
– Echopraxia: mimicking movement of another
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
11
Types of Schizophrenia: Disorganized
• Most regressed and socially impaired of all
types
– Large numbers of homeless population with
this type
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
12
Types of Schizophrenia: Disorganized
• Characterized by:
– Looseness of associations
– Grossly inappropriate affect
– Bizarre mannerisms
– Incoherent speech
– Fragmented and poorly organized
hallucinations/delusions
– Frequent giggling or grimacing in response to
internal stimuli
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
13
Types of Schizophrenia:
Undifferentiated and Residual
• Undifferentiated
– Active signs of disorder present, but individual
does not meet criteria for other types
• Residual
– Active-phase symptoms no longer present,
evidence of residual symptoms: lack of
initiative, social withdrawal, inability to
work/study, vague speech, magical thinking
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
14
Course of Disease
• Prodromal
– Early symptoms preceding diagnosis: social
withdrawal, deterioration in function,
perceptual disturbances, magical thinking,
and peculiar behavior
• Acute
– Florid positive symptoms occur
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
15
Course of Disease
• Maintenance
– Acute symptoms decrease, especially positive
symptoms
• Stabilization
– Symptoms are in remission
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
16
Common Symptoms of Schizophrenia:
Positive Symptoms
• Defined as the florid psychotic symptoms
– Hallucinations: false sensory perceptions
•
•
•
•
•
Auditory: most common
Visual
Gustatory
Olfactory
Tactile
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
17
Common Symptoms of Schizophrenia:
Positive Symptoms
– Delusions: fixed, false beliefs
•
•
•
•
•
Ideas of reference
Thought broadcasting
Thought insertion
Thought withdrawal
Delusion of being controlled
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
18
Common Symptoms of Schizophrenia:
Positive Symptoms
• Impaired ability to use abstract thought
• Associative looseness: thinking is
haphazard, illogical, and confused
– Neologisms: made-up words
– Echolalia and echopraxia
– Clang association: meaningless rhyming or
words
– Word salad: jumble of words together
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
19
Common Symptoms of Schizophrenia:
Positive Symptoms
• Personal boundary difficulties
– Depersonalization: feeling that person is
unreal
– Derealization: feeling that environment has
changed
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
20
Common Symptoms of Schizophrenia:
Positive Symptoms
• Bizarre behaviors
– Extreme motor agitation
– Stereotyped behaviors
– Automatic obedience
– Waxy flexibility
– Stupor
– Negativism
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
21
Common Symptoms of Schizophrenia:
Negative Symptoms
• Changes in affect
– Flat affect: no emotion displayed
– Inappropriate affect: emotional response
incongruent to situation
– Blunted affect: minimal emotional response
– Bizarre affect: grimacing, giggling, mumbling
• Apathy
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
22
Common Symptoms of Schizophrenia:
Negative Symptoms
• Anhedonia: lack of feeling pleasure in
anything in life
• Poor social functioning
• Poverty of thought
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
23
Nursing Process:
Assessment Guidelines
• Review medical workup to rule out medical
cause and use of abusive substances
• Assess for command hallucinations
(voices telling patient to harm self or
others)
• Determine patient’s belief system
(delusions, paranoid beliefs)
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
24
Nursing Process:
Assessment Guidelines
• Determine any psychiatric comorbidity
• Determine medication use/compliance
• Determine family response to
patient/symptoms
• Determine social support system
• Use Global Assessment of Functioning
(GAF) scale
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
25
Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses
– Disturbed sensory perception, Disturbed
thought processes, Impaired verbal
communication, Social isolation, Ineffective
coping, Compromised family coping
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
26
Nursing Process: Diagnosis and
Outcomes Identification
• Outcome identification: dependent on
particular phase of illness
– Overall goal: patient safety and medical
stabilization
– Other goals: help patient adhere to
medication regimens, understand disease,
participate in psychoeducational programs,
prevent relapse
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
27
Nursing Process:
Planning and Implementation
• Planning: dependent on particular phase
of illness
– Acute phase: planning strategies to ensure
patient safety and stabilize symptoms
– Maintenance phase: planning strategies to
provide patient and family education
– Stabilization phase: planning strategies to
prevent relapse
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
28
Nursing Process:
Planning and Implementation
• Implementation: need to be geared toward
patient’s strengths and healthy functioning
as well as weaknesses/symptoms
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
29
Communication Guidelines for the
Patient with Schizophrenia
• Dealing with hallucinations and delusions
– Approach patient in nonthreatening and
nonjudgmental manner
– Identify feelings patient is experiencing
– Clarify reality of patient’s experience
– Avoid arguing/attempt to reason with patient
who is delusional
– Interact with patient about concrete reality
– Distract patient’s attention from
hallucination/delusional belief
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
30
Communication Guidelines for the
Patient with Schizophrenia
• Dealing with the patient who is paranoid
– Be honest and consistent
– Avoid talking, laughing, whispering when
patient cannot hear what is being said
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
31
Communication Guidelines for the
Patient with Schizophrenia
• Dealing with associative looseness
– Do not pretend to understand patient’s
communications when you do not
– Tell patient you are having difficulty
understanding
– Look for recurring topics or themes
– Emphasize what is going on in the “here and
now”
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
32
Guidelines for
Health Teaching and Promotion
• Include patient and family in teaching
• Topics to include
– Disease process
– Medications and side effects
– Prevention of relapse
– Stress management
– Sources of ongoing support for patient and
family
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
33
Treatment for Schizophrenia:
Milieu Therapy
• Therapeutic milieu can be in hospital,
partial hospitalization program, halfway
house or day treatment program
• Aspects of milieu therapy
– Safety: protect patient and others
– Structured routine
– Use of group therapy, supervised activities,
individual counseling, specialized training,
and rehabilitation
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
34
Treatment of Schizophrenia:
Psychotherapy
• Program for Assertive Community
Treatment (PACT)
– Prevent relapse, maximize social and
vocational functioning and keep individual in
community
• Family therapy
– Support family and use psychoeducation to
help establish improved communication and
functioning
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
35
Treatment of Schizophrenia:
Psychotherapy
• Cognitive-behavioral therapy
– Helps reduce frequency and intensity of
delusions and hallucinations
• Social skills training
– Helps improve level of social activity, foster
new social contacts, improve quality of life
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
36
Treatment for Schizophrenia:
Antipsychotic Medications
• Used to alleviate symptoms, not curative
– When patients discontinue medication,
psychotic symptoms/relapse occurs
• Each relapse leads to longer recovery time and
possibility that patient will become unresponsive to
medications
• Types of antipsychotic medications
– Conventional (first-generation)
– Atypical (second-generation)
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
37
Treatment of Schizophrenia:
Atypical Antipsychotics
• Action: serotonin and dopamine antagonist
• First atypical introduced: clozapine
(Clozaril)
– Problem: causes agranulocytosis (up to 1% of
patients)
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
38
Treatment of Schizophrenia:
Atypical Antipsychotics
• Advantage of atypicals
– Alleviate positive and negative symptoms
– Produce minimal extrapyramidal symptoms
– Help improve cognitive deficits and decrease
anxiety and depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
39
Treatment of Schizophrenia:
Atypical Antipsychotics
• Disadvantage of atypicals
– Tend to cause weight gain associated with
additional metabolic side effects increasing
risk for diabetes, cardiovascular disease, and
hypertension
– More expensive than conventional
antipsychotics
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
40
Treatment of Schizophrenia:
Conventional Antipsychotics
• Action: dopamine antagonist at D2
receptor sites in both limbic and motor
areas of brain
• Disadvantage: side effect profile is severe
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
41
Treatment of Schizophrenia:
Conventional Antipsychotics
• Major side effects: extrapyramidal
symptoms
– Tardive dyskinesia (TD): tongue movements,
lip smacking with uncontrollable biting,
chewing, or sucking movements
– Acute dystonia: muscle cramps of head and
neck
– Akathisia: internal and external restlessness
– Pseudoparkinsonism: stiffened extremities,
fine motor tremors
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
42
Treatment of Schizophrenia:
Conventional Antipsychotics
• Other side effects
– Neuroleptic malignant syndrome (NMS):
occurs from dopamine blockage
• Produces decreased level of consciousness,
increased muscle tone, high fever, hypertension,
sweating, tachycardia, drooling
• Discontinue antipsychotic drug, treat
symptomatically in intensive care environment
• Dopaminergic medications bromocriptine
(Parlodel) and dantrolene (Dantrium)
– Agranulocytosis
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
43
Implementations for
Antipsychotic Medications
• Use Abnormal Involuntary Movement
Scale (AIMS) for early recognition of EPS
• Use anticholinergic medications as
treatment for EPS
• Monitor patient for symptoms of
agranulocytosis
• Monitor patient for symptoms of NMS and
intervene early
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
44
Nursing Process: Evaluation
• Recognize that process of improvement may
take long time
• Consider questions such as:
– Are patient strengths being used to achieve
outcomes?
– Are more appropriate interventions available?
– Are medications effectively reducing symptoms?
– Are family members involved and supportive?
– Are community resources appropriately used?
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
45