SCHIZOPHRENIA

SCHIZOPHRENIA
• Brain Disease
• 1908 Literally means “split mind”
• Thought disorder – Disharmony in your feeling, thinking, and acting
• Disturbances of thought process, perception, and affect
• Schizophrenia refers to a group of disorders
• Devastating mental illness
• Onset is late teens and early adulthood

CAUSES / COMMON THEORIES ASSOCIATED WITH SCHIZOPHRENIA

• Biological Influences
o Genetics: Runs in families
 If one twin has Schz then there is a good chance that the other twin will
have it too.
o Biochemical Influences
 Dopamine Hypothesis: excessive amount of Dopamine present
 Dopamine is a neurotransmitter substance
 The Meds that are given act by blocking receptor sites with improvement of
overall behavior of patient
 Serotonin levels possible influence with drugs used to effect levels
• Problem: Some patients do not improve with meds

• Physiological Influences
o Viral infections
o Anatomical abnormalities
 Enlarged ventricles of the brain
 Abnormal or decreased blood flow in frontal lobes
 Irregular pattern of brain cells
 Thalamus not activated

• Psychological Influences
o Mother child relationship
 Bad mothering causes disease; or that the child never developed its own
sense of self
o Dysfunctional family system
 Children may develop a close relationship with one parent
 Child may not respond to one parent without the other parent getting upset
o Double bind communication
 Give 2 conflicting messages at a time
 Ex. I am really mad at you – “laughing”

• Environmental Influences
o Socioeconomic factors – higher and lower social economic classes
  Lower – due to not having the money to get help
o Stressful life events – possible precipitate
TYPES
• Paranoid
o Delusions – Out to get them, Grandeur - Have special powers
o Hallucinations – Auditory, visual, feeling (tactile), smell, or taste
o Tense, suspicious, guarded – Constantly on alert, looking around
o Argumentative, hostile, aggressive
o Late 20’s to 30’s – occurrence
o Less regression than other types
o Social impairment can be minimal
• Catatonic
o Marked by abnormalities in motor behavior

 Catatonic Stupor: Withdrawn Catatonic

• Psychomotor retardation
• Decrease spontaneous movement
• Mutism but they can still hear
• Negativism – Doing the opposite of what they are told (resisting instruction)
• Waxy flexibility – The patient will remain in the position they are placed in
and will stay there until they are moved (classic with withdrawn catatonic)
• Retain urine/feces (will not respond to cues)

 Catatonic Excitement:
• Agitation - Psychomotor
• Purposeless movement – moving constantly
• Incoherent speech
• Destructive, Violent
• Disorganized Type – Hebephrenic
o Before age 25 (slow progression)
o Marked Regressive behavior – A defense mechanism we use to decrease anxiety
o Little contact with reality
o Flat affect / inappropriate
o Silliness, giggling (example regressive behavior)
o Bizarre mannerisms, facial grimaces
o Incoherent speech
o Extreme social impairment
o Neglected personal appearance
• Undifferentiated Type
o Does not meet specific criteria of other types but definitely schizophrenia, usually mixture
of symptoms

• Residual
o Someone who had Schz in the past; now they have a chronic form of the disease
o Acute episode at some point with left over symptoms
 Express eccentric behavior
 Social isolation
 Neglect hygiene
 Blunt/inappropriate affect
  Poverty of speech
 Over elaborate speech
 Illogical thinking
 Apathy – Don’t care attitude

SCHIZOAFFECTIVE DISORDER
o Not type schizophrenia
o Has schizophrenic symptoms
o Combination Disorder
 Schizophrenia with a Mood disorder
o Generally a Schizophrenic person does not have a lot of Affect; this person does

NURSING ASSESSMENT
• Content of Thought
o Delusions
 False ideas that are only real to the person who has them
 What kind- Grandiose, Persecution, Traumatic
 Not corrected with reason
o Religiosity
 Preoccupied with religion
 Talk about all the time
o Paranoia
 Extreme suspicion
o Magical Thinking
 Think that their thoughts have control over specific events. Or their
behavior controls certain things
 Example: Don’t step on a crack or you’ll break your mothers back
• Form of Thought
o Looseness of Association – LOA
 Ideas shift from one subject to another; they are not connected; speech may
be incoherent
o Neologisms
 Word that have meaning only to the patient
 Clarify – “What does that mean”
o Concrete thinking
 Very simple, concrete thinking
 This is assessed by asking to interpret a parable
• Ex. “Don’t cry over spilt milk”
 A type of regression
o Word salad – Extreme LOA
o Circumstantiality – Going around the world to say something
o Mute – Not speaking
o Clang association - talking in rhymes
• Perceptions
o Hallucinations
 Sensory experience without any external stimuli – See things that are not
there - Are they present?
 o Illusions
 Something is there but it is misinterpreted
o Affect
 Facial Expressions; are they appropriate or matching
 Schiz patients usually have a flat affect; Blount or bland affect – little
emotion; May have an inappropriate affect
o Apathy
• Sense of Self
o Echolalia
 Repeat what the other person says
o Exhoprexia
 Repeat movements; imitating
o Identification
 Unconscious – Take on behaviors they see in other people
o Imitation
 Conscious
o Depersonalization
 Unreal feeling about self
 “This is not my arm; it doesn’t feel like part of my body”
o Volition
 Ability to initiate goal directed activity
• Decrease interest, don’t usually follow through
• “Ambivalence” 50/50 difficult make decisions; Love and Hate

• Impaired Interpersonal Functioning and Relationship to External World

o Autism
 Self preoccupation; Withdrawal into self
o Deteriorated Appearance
 Minimal grooming, out of touch with reality

• Psychomotor Behavior – Catatonic Schizophrenia

o Anergia – No Energy; difficulty getting going
o Waxy Flexibility
o Posturing - Bizarre
o Pacing / rocking – Repetitive Behavior

• Associated Features
o Anhedonia – Cannot experience pleasure; very hard to deal with
o Regression – Defense mechanism

• Positive / Negative Symptoms

o Positive:
o Good response to treatment with symptoms; easier to treat; mostly associated with
Schizophrenia
 Examples:
• Hallucination
• Delusions
• Disorganized thinking
 • Disorganized behavior
o Negative:
o Respond poorly to treatment; newer antipsychotic effect.
 Examples
• Flat Affect
• Poverty of speech
• Apathy
• Anhedonia
• Social isolation
NURSING DIAGNOSIS
• Impaired Verbal Communication
o Be very supportive and self aware
o Establish supportive relationship
o Self awareness verbal, nonverbal communication
o Feelings trying to express (tone, expression, verbal/nonverbal)
o Pressure speech, FOI (focus one topic @ time)
o Point out having difficulty following thoughts
o Universal pronoun try to clarify with speaking first person
 If you don’t understand something be sure to clarify
o Pay attention to what client is saying to you
o Touch very powerful communication tool but schizophrenia fear touch (harmful gesture)
o Speak clear with simple terms - literal

 If you feel anxious – The patient asks are you anxious you respond
 “I am feeling a little anxious today, I have never been to a mental Hospital
before”

 If the patient says – “I’m going home tomorrow”

 You response should reflect the emotion of the patient – “You say you are
going home but you don’t sound very happy”

 If your patient is talking very fast

 You would say – “Slow down, I am having trouble following you”

 If the client begins LOA you should say “Lets get back to…”, “I am having
trouble following…”

• Impaired Social Interaction R/T Suspiciousness

o Build trust with client
o Needs to work with the same people everyday
o Be honest – If you tell them you’ll be there at 0900 you be there at 0900
o Brief contact
o Avoid probing questions
o Avoid whispering and soft talking; Laughing and talking to another student in front
of client
• Disturbance Self-Esteem
o They have been sick for a long time and have not been able to accomplish their life
goals because they became sick
o Focus on positive aspect regarding client – grooming and participation
o Do not be judgmental
o Give activity with successful outcome
o Involve hygiene, grooming
o Praise, show an interest, spend time with them
o Call by name
o Bragg on them
o Have them identify their strengths and weaknesses

• Sensory / Perceptual

o Hearing
 Not hearing – understand this is real to the client
o See fear
o Medication will help in decreasing voices
o Point out feelings
o Do not reason or argue with client
o Voices telling to harm self or others
o Delusions and Hallucinations
 Will be placed on medications; don’t leave them alone, that gives them more
time to dwell on hallucinations
 Mumbling, sitting by a window and talking to someone who is not there
 Let the patient know that you realize that it is real to them but you don’t see
or hear anything
o If the patient says “I am president Ronald Regan”
o Best response is “ I can see that is who you think you are but I see you as Mr.
Jones”
o If you don’t feel comfortable pointing out reality just change the subject.
o DO NOT reinforce the delusion
o If the patient says “I have 15 million dollars”
o Best response “It seems a little unusual that you have 15 million dollars”

• R/F Violence – Respond to thoughts and/or noises

High Priority ND

o If the patient expresses that voices are telling them to harm someone
 REPORT ASAP
o If they are hallucinating or hearing voices they are at risk for Violence
 Do not invade the patients space
 Client alone to gather self
 Ativan
• Calms the patient if anger escalates
 “Time out”
• Decreases environmental stimulus
  Show of strength will help calm the pt.
 Problem solve after calms down
• If the patient gets upset or agitated the best thing to do is leave them alone.
• Most of the time they will calm down on their own

• R/F Sleep Pattern Disturbance

o General sleep meds not given but majority or all psychotic

o Meds at HS
o Warm bath
o Listen to music
o Private room
o Generally do not give sleep medication

• Ineffective Individual Coping – **Catatonic Withdrawn**

o Give step by step instruction
o Give clear, simple language
o Do not rush, or do things for the patient
o Encourage independence
o Be Specific – “here is your shirt, put your rt arm in the rt sleeve…”
o Need to know what expected of them – schedule
o Regular brief contacts
o Decision making problems, thus need to instruct what to do with decreased anxiety
you can offer choices (only 2 – such as apple or grape)
o DO not make important decisions for the patient such as “Should I get married”,
Just say “I don’t know what is best for you, Lets talk about…..”

• Social Isolation
o Autism – Withdrawn completely – Self preoccupation
o Accept where they are and their communication BE PATIENT
o Use open ended statements
o Awareness of nonverbal communications
o Sometimes you just need to sit in silence
o When planning activities pick something the client can to such as reading a book
o Be very matter-of-fact and do not be judgmental

• Self Care Deficit

o Allow and encourage independence

• R/F Alteration in Nutrition, Fluids

o Input / Output
o Do not leave alone to eat
o Spoon feeding, tube, IV

• R/F Impaired Physical Mobility

All of these are important to
o ROM Turn Q2o maintain life, therefore they
are a PRIORITY
 o Check clothing
o Check for skin breakdown

• R/F Urinary Retention / Constipation

o R/T side effects of medication
o Regular toileting
o Input / Output
o Check for bladder distention
o Establish routine the patient
o Also side effects of Antipsychotic meds
 Constipation, Urinary retention
 This page was not

SCHIZOPHRENIA discussed in class

SCHIZOPHRENIA
• Tragic, persistent neurological disease that affects a person’s perceptions, thinking, language,
emotion, violation, and social behavior
• Seriously interferes with people’s ability to interpret ability and the world around them to
communicate with others and form relationships, to perform simple tasks or follow simple
instructions, and to care for basic needs
• 1% in general population have, or will have, symptoms of schizophrenia
• Seems to be high prevalence of schizophrenia in lower socioeconomic classes
o Attributed to:
 Social disorganization
 Social stresses
 Evidence that some people in prepsychotic phase drift down social scale
• Account for 35-50% of homeless population in America
Psychotic Disorder, which means that a person has an impairment in reality testing

SYMPTOMS OF PSYCHOTIC DISORDERS

• Hallucinations
• Delusions
• Loss of ego boundaries

Symptoms usually apparent during adolescence or early childhood

o Men 15-25 y/o
o Women 25-35 y/o
o Paranoid schizophrenia has later onset
THREE PHASES OR EPOCHS
1- Onset
o Slow, insidious – Except in case of Catatonic
 May go on for long time before onset of hallucinations, delusions, or
disorganization thinking
 First part often called “Prodromal Phase”
 Second Part are acute psychotic symptoms evident and high degree of
disorganization, poor reality testing (hallucinations, delusions) exist

2- The years immediately following onset of psychotic symptoms

o Two Patterns Characterize Phase
 Psychotic Process progresses with ebb and flow of intensity of the disruptive
symptoms
 Episodic flow of psychotic symptoms may be followed by complete or relatively
complete recovery
3- Long Term course and outcome
o For many severely and persistently mentally ill clients with schizophrenia, the intensity of
psychosis diminishes with age
o For many, illness seems to become less disruptive and easier to manage over time
o Long-term dysfunctional effects of disorder are not so amenable to change
THEORY
• Early explorations focused on psychodynamic, family theories to explain how schizophrenia
developed
 • Advances in neuroscience aided by use of current neuroimaging techniques, expanded the
knowledge of chemical anatomy and neural circuitry of the brain, mechanisms of
neurotransmission, and the way the brain chemicals affect the working of the brain

It begins
PSYCHOLOGICAL TREATMENTS again here

• Individual psychotherapy : Supportive therapy

o It increases their trust
o Can be very effective although it is very expensive
o Establishing relationship can be difficult
o Usually lonely, but defend against closeness
o Trust hard to develop
o Suspicious or hostile
o Real Honest, provide trust, simple, respect privacy, dignity
o Relationship established want to look at reality orientation, may choose to say
whatever they believe is not actually part of illness
Goal Of Treatment
• Decrease anxiety
• Increase in trust
• Regular schedule contact
• Insight
• Improve communication
• Expensive treatment

• Group Therapy: Useful to Patient one or more psychotic episodes

o Never just throw a person into group – Begin slowly adding clients to the group
o Function real life problems
o Relationship roles
o Drug therapy
Goal Of Treatment
 Increases Socialization
 Increases contract with others
 Client gets peer support
 Less expensive

• Behavior Therapy : Not used with schizophrenia

o Real successful
o Rewards with appropriate action
 Neg. Rewards
• When act violent or with anger
 Teaches consequence with inappropriate behavior
o Need structure
o Used more with children
o Tokens are given when positive things are done
o Used for more functioning patients

• Social Skills Training : Common in Schizophrenia

 o Role Play used – Group situation
o Taught how to communicate
o Attention given increases social skills
o Functioning skills for successful outcome after discharge
o Taken out to eat, shopping, grocery store, write a check. These are taught so they
could possible be functional in society
SOCIAL TREATMENTS
• Milieu Therapy : Environment Shaping Positive Change in Patient
o Using environment to get positive change behavior
o Patients need structure due to disorganization of thoughts
o Supportive Staff, warm trusting relationships
o Clear Communication
o Individualized plan of care
o Orient Client (Clock, radio, TV, Mirrors, newspapers)
o Attractive, orderly environment
o Physical needs are met
o Respected as individual, decision making authority
o Every has a role including staff
o Acts as testing ground
o Protects from injury
o Offered opportunity to make freedom of choice
o Goal: Help individual increase self esteem, personal belongingness, ability to relate
to others, enable to go and work in community

• Family Therapy : Family does not understand

o Family sometimes do not understand why the still have to take medication
o They need education
o Support
o Coping skills training
o Social network development

• Recreational Therapy / Occupational Therapy

o Keep patient busy
o Give something to do successful

PHYSICAL METHODS
• Seclusion
o Decreased environmental stimuli
o Seclusion
 When the client is put in a room and the door IS locked
 Requires a Dr’s order and a special procedure to be initiated
 Documentation must be done every 5-10 minutes while in seclusion
o “Time Out”
 When the client is put in a room and the door is NOT locked
o Used with violent, aggressive behavior
 o Agency has own protocol – Some require a notification to the family

• ECT : With depressed Patient

o May be used in severe catatonic or withdrawn
o Antipsychotic drug therapy fails or contraindicated
o Patient who does not respond satisfactorily to drugs and too old to be discharged
o Mostly used with psychotic depression who are violent, suicidal, or participating in
self-starvation
DRUG THERAPY
• Does not cure schizophrenia, they only control the symptoms
• They are not addictive
• Medicine does not work for everyone
• Major Tranquilizers (Antipsychotics)
• Thorazine (1952)1954 marketed as antipsychotic major breakthrough before no treatment
other than physical means
o Thorazine was a major breakthrough in the treatment of schizophrenia
o Before Thorazine there was no treatment – patients were warehoused in hospitals
o Lobotomy’s were done
o ECT was used a lot
o Seclusion

STANDARD TRADITIONAL ANTIPSYCHOTICS

“ OLDER DRUGS”
• Work by blocking the Dopamine receptor sites
• Improve the Positive Symptoms of Schizophrenia
o Delusions, Hallucination, Disorganized behavior
• Also depress the vomiting center
• Act on the temperature regulating center of the brain
o Be careful in the summer time the patients can get heat stroke
• Can cause vasodilatation
o Orthostatic Hypotension – Decrease in BP
• Compazine is an Antipshycotic but also used to treat nausea
• Can be given orally or injectible form
• 2 Drugs are given in a long acting – Haldol or Prolipthinsp
o Given for noncompliance because they do not have to take it that often
o Also given for paranoid clients
• Thorazine, Mellaril, Trilafon, Navane, Haldol
o Drugs will not immediately stop delusions and hallucination; first thing you will see
when they start these drugs is that they will get calmer and more sedate but may
still be very delusional. May take up to 21 days to get rid of the delusions and
hallucinations

ATYPICAL DRUGS
• Act by blocking Dopamine and Seritonin
• Improves both Positive and Negative effects of Schizophrenia
• Allow improvement in quality of life – New drugs
 o Clozaril – 1990 – cause decrease in seizure threshold, Increase salivation,
Increase R/F aspiration
o Risperdal – 1994
o Zyprexa – 1996
 Causes weight gain, causes increase glucose levels
o Serquel
o Geodon
 Antipsychotic and also an Antidepressant
 Cheaper newer drugs
TYPES OF SIDE EFFECTS
Anticholinergic Symptoms
• Dry Mouth
o Frequent sips of water and sugarless candy or gum. If severe, provide Xero-lube, a saliva
substitute
• Urinary Retention and Hesitancy
o Check voiding; consider catheterization. If severe, bethanechol, 10-25mg three to four
times daily, may be ordered. I&O
• Constipation
o Encourage high fiber diet, evaluate need for mild laxative. May need stool softener.
Assess for adequate water intake. Increase activity
• Blurred Vision
o Usually abates in 1 to 2 weeks.
• Nasal Congestion
o Provide nasal decongestant; body will adjust in a few weeks
• Photophobia / Photosensitivity
o Sensitive to light May get sunburned easily
o Wear sunscreen, sunglasses, hat, long sleeves
o May get a purplish/gray color to the skin; particularly seen in patients who have been on
Thorazine for a long time.
o Avoid any HIGH or LOW temperatures due to the meds affecting the temperature
regulation
• Dry Eyes

Other Side Effects

• Nausea / GI Upset
o May take drugs with food
o Meds may be ordered in a liquid form; for noncompliant patients (MUST be diluted)
• Skin Rashes / Jaundice
o Will be taken off meds
• Sedation
o Most meds will be given at HS
o Talk to them about avoiding alcohol; they do not need any other depressants with these
drugs. Depressants can potentate the action of the drug.
• Orthostatic Hypotenstion
o As a result from vasodilatation
o Get up slow – especially at night
o Monitor BP lying and standing
• Hormonal effects
o Decreased Libido - Impotence – Why most young male patients will get off medication
o In Women; may have absence of menstrual cycle; weight gain
• Reduction of Seizure Threshold
o If a known seizure patient may have medication adjusted also caused by CLOZARIL
• Agranulocytosis
o Deadly side effect Caused by the drug CLOZARIL
o Decrease in WBC count
o You would look for S/S of infection – May run a fever, sore throat, or just not feel good
o Want the WBC above 3,000 – Normal is 5,000-10,000
o MUST have a WBC count done weekly; medication is given weekly; Medication is not
given if they do not have the results of the WBC count.
o Very Expensive
• Increase Salivation
o Danger of aspiration
EPS – Extrapyramidal Symptoms
• Occur more with older drugs – Very few incidence with new drugs
• Occurs when too much Dopamine receptor sites are blocked
Pseudo Parkinsonism
o Direct result of tranquilizers
o Stiffening of muscular activity in face, body, arms, legs
o Mask like facial expressions
o Drooling
o Posture is blunt; shuffling gait
o Risk for falls
o Will get Antiparkinsonian drug and reduce dosage of antipsychotic
Akinisa
o Muscle weakness
o Patient may or may not complain of that
Akathesia
o Internal or external Motor Restless
o Patient cannot sit still
o Tapping foot, shaking leg
o Will get an Antiparkinsonian agent and decrease dose of antipsychotic
o May try Inderal
Dystonia & Occulogyrec Crisis
o Problems with muscular movement
o Spasms in muscles in arm, legs, face, neck, and back
o Neck is arched to side and cannot be moved. Back arched
o Occu—Eyes roll back
o EMERGENCY
o Give IM or IV Antiparkinsonian Agent
o Stay with the patient they are very frightened
Tardive Dyskinesia
o Occurs late in the illness
o Associated with older drugs
o Occurs when on therapy for a long time
o Serious but not always reversible
o 1st thing noticed is very fine movements of the tongue
 Hold Meds
 Call MD
 Give Vitamin E
o Bizarre facial movements
o Tongue movements or protrude
 o Difficulty swallowing
o Medication is usually D/C
o If not it will get worse and are permanent and may progress to a coma
NMS – Neuroleptic Malignant Syndrome
o Rare but can be fatal
o Sudden onset and progresses rapidly over 24-72 hours
o Extremely High fever 106-107o
o Increase in respiration, Increase in HR - tachy; Changes in BP
o Severe Muscle rigidity
o Will Increase CPK values
o Altered Mental status and eventually coma
o May be on ventilator
o Medications must be D/C’
o Parladel may be given to replace the lost dopamine
o Dantrium – Muscle relaxer

ANTIPARKINSONIAN AGENTS
• Given to counteract the drug induced (EPS) of antipshchotic drugs
• Most common are: Cogentin, Artaine, Benydril, Symmetril(antiviral)
o Urinary retention
o Constipation
o Failure of visual accommodation – Blurred vision
o Cognitive impairment
o Delirium
o May cause nervousness, agitation
• May be given IM for Dystonia or Occulogyric Crisis
• Otherwise it is given PO

NURSING DIAGNOSIS
• Altered Thought Process R/T Psychosis AMB Delusions (false ideas only real to pt)
o Client will state that wife and others are not threatening, nor do they interfere with
his or her life
o Administer meds as ordered, educate regarding benefits of meds
o Meet daily with client in activity which client is comfortable
o Client engage unit activity daily with people

• Social Isolation R/T Lack of Motivation AMB Sitting Alone, Talking and muttering
o Client will demonstrate a willingness to socialize with others
o Start with one to one interaction (walk, listen to music)
o As better increase with number one by one
o Meet daily with client BID in an activity makes client feel safe
o Attend group activity daily – work up to situation
o Attend one community group weekly
o Accept the way they are
o Must be patient with client
o Focus on hobbies, nonverbal behavior
o Open ended statements
 o Consistent with client
o Activity with success as outcome

• Risk for Violence directed at others R/T misperceived messages from others AMB
persecutory delusions and hallucinations
o Client and others will remain safe
o Identify helping behaviors
o Activity 1 QD
o Safety Precautions

• Self Care Deficit R/T perceptual impairment AMB inability to wash body parts, carry out
toileting procedures, to select appropriate clothes to wear, to feed self adequately.
o Client will perform activities of daily living in an independent manner
o Bathe self at least QD with minimum supervision
o Dress self appropriately
o Adequate nutrition, 5% of normal body weight