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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, perseveration, word salad,
neologisms, echolalia
Positive Symptoms of
Schizophrenia, cont’d
• Disordered movement:
restlessness, repetitive movements
(echopraxia), or catatonia (lack of
movement or lack of response)
• Catatonia: Waxy
Waxy Flexibility
Matching: Symptoms
1)
2)
3)
4)
5)
6)
“Help me, help me, help me,
please help me, help me.”
“A blue ape and ten times
whenever you said. It makes
me hairy scratching. A hair
shirt. Are we victims?”
“I am locked in concrete and
I have stopped breathing.”
“The CIA has been taking
pictures of me in my shower.”
“Whenever take baddest my
our frown knife.”
“When they see me coming in
the HEB they play that tape of
songs about my life.”
A)
B)
C)
D)
E)
F)
G)
H)
I)
Word salad
Delusion of reference
Perseveration
Circumstantial thinking
Loose associations
Paranoid delusion
Nihilistic delusion
Delusion of influence
Grandiose delusion
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)
(Simulated hallucinations)
http://www.youtube.com/watch?v=xEXyqe85cuA&feature=related
http://www.youtube.com/watch?v=xEXyqe85cuA&playnext=1&list=PL4A6CFEFAB94F6A76
(Schizophrenia Gerald’s story)
http://www.youtube.com/watch?v=gGnl8dqEoPQ&feature=related
CRITICAL THINKING:
Symptom Identification
• Are Gerald’s symptoms primarily
positive or negative?
Cognitive Symptoms of
Schizophrenia
• Impaired ability to understand and make
decisions (  “executive functions”)
• Inability to pay attention
• Problems in using just-learned
information (“working memory”
problems)
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 delusion
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
ETIOLOGY
• Multifactorial-no single cause
• Multiple theories for etiology (see next
content)
BIOLOGICAL THEORIES
• Too much dopamine binds with too many brain
receptors and causes positive symptoms
• Principle of anti-psychotic therapy = these meds. act
as dopamine antagonist
• Disturbed ratio of serotonin : dopamine
• Therefore, atypical anti-psychotics affect serotonin
also.
Endogenous dopamine antagonist is GABA
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
• Can you make someone a
schizophrenic?
• New investigations into prevention and
early intervention
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
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
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)
• Self-help and support groups
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
• Improved cognitive function; decreased
confusion
• Emotional quieting
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) *
Atypical (2nd generation)
Agents, cont’d
• Action: Block multiple dopamine and
serotonin receptors. Newer ones also
inhibit reuptake of serotonin and/or
dopamine and/or norepinephrine.
• Most frequently prescribed
• Useful for both positive and negative
symptoms
Novel (3rd Generation) Agent
• 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
Antipsychotics: Side Effects,
cont’d
• Anticholinergic Effects-dry mouth,
orthostatic hypotension, urinary retention, blurred
vision
• Usually resolve over time
Other Side Effects
• Cardiac: Arrythmias (QT interval lengthened)
• Blood: leukopenia, anemias
agranulocytosis (clozapine)
• Endocrine: Elevated prolactin levels
(typical/traditional agents)
Weight
gain
• Sexual: Impaired libido, performance
A Dangerous Side Effect
• Neuroleptic Malignant Syndrome
(NMS)
• Potentially lethal
• Associated with use of high-potency
agents e.g. haloperidol
• Onset: within a week after starting meds.
• Symptoms: muscular rigidity, tremors,
autonomic hyperactivity e.g. high body
temperature, altered consciousness
Nursing Interventions and
Antipsychotic Meds.
• Medication education (You cannot teach too
often)
• Side effect issues are significant in this
population, contribute to poor
adherence/compliance:
--Depot form of some drugs may be an option
(injectable, give q week-q 2weeks).
--Safety issues related to side effects:
hypotension, CNS depression,
photosensitivity, thermoregulation problems
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