Schizophrenia

Jus$ne Gonzalez, Evelyn Jaramillo,

Kylie McCormick & Michelle Merchant

Schizophrenia
Schizophrenia spectrum disorder and other
psycho$c disorders disturb the fundamental
ability to determine what is real from what is
not real
Schizophrenia is the most severe of these
disorders
It is dened as, a
brain disorder that
aects a persons
thinking, language,
emo$ons, social
behavior, and ability to
perceive reality
accurately

Main Characteris$cs of the Disorder

All people diagnosed with
schizophrenia have at least
one psycho$c symptom, such
as hallucina$ons, delusions,
disorganized or catatonic
behavior and/or disorganized
speech
Two or more of these
symptoms must be present
for a signicant por$on of
$me during a 1 month period
One of these symptoms must
be delusions, hallucina$ons
or disorganized speech

Early Signs of Schizophrenia

Children who are later diagnosed with
schizophrenia oOen have unusual
characteris$cs years before psycho$c
symptoms present
They tend to do poorly in school, are less
socially engaged, less posi$ve, and exhibit
unusual motor development
In children, symptoms are severe enough to
interrupt normal childhood ac$vi$es, such as
school, or disrupt important age-appropriate
milestones

Epidemiology
Aects over 3.5 million people in the US
Among the most disrup$ve and disabling of
mental disorders.
More frequent in males (1.4:1)
Usually presents during the late
teens and early twen$es
In adults, the life$me prevalence
of schizophrenia is 1% worldwide
There are no dierences related to
race, social status, or culture

Childhood Onset
Childhood onset schizophrenia is about 1 in
10,000 children
Actual childhood schizophrenia is extremely
rare, has a worse prognosis than adult-
onset
Diagnosed before age 12

Early vs. Late Onset

Early-onset (18-25 years) occurs more oOen
in males and is associated with poor
func$oning before onset, more structural
brain abnormality, and increased levels of
apathy
Later onset (25-35) are most likely to be
female, to have less structural brain
abnormality, and to have be`er outcomes

Comorbidi$es: Substance Abuse

Substance abuse disorders:
occurs in nearly 50% of people
with schizophrenia
May represent a maladap$ve
way of coping w/ schizophrenia
Nico$ne dependence rates
range from 70-90%

Associated with treatment

nonadherence, relapse,
incarcera$on, homelessness,
violence, suicide, and poorer
prognosis

Comorbidity: Anxiety, Depression,

and Suicide
Co-occur frequently in schizophrenia
Anxiety may worsen schizophrenia symptoms
and prognosis
Anxiety may be a response to:
Symptoms (eg, hallucina$ons)
Circumstances (eg, isola$on, overs$mula$on)

Approximately 10% commit suicide

8.5 $mes higher than the general popula$on

Comorbidity:
Physical Illness
More common among those with
schizophrenic than the general popula$on
The risk of premature death is 1.6 to 2.8 $mes
greater than that in the general popula$on
On average, people with schizophrenia die 28 years
prematurely due to disorders such as hypertension,
obesity, cardiovascular disease, diabetes, COPD,
and trauma
The greater risk may be due to apathy, poor health
habits, medica$ons, poverty, limited access to
health care, and failure to recognize signs of illness

Comorbidity:
Polydipsia
Polydipsia: can lead to fatal
water intoxica$on
Indicated by hyponatremia,
confusion, worsening of
psycho$c symptoms, and
ul$mately coma
Polydipsia occurs in 20% of
persons with schizophrenia

E$ology
Diathesis-Stress Model:
Schizophrenia occurs
when mul$ple
inherited gene
abnormali$es combine
with non-gene$c
factors, alterna$ng the
structures of the brain,
aec$ng the brains
neurotransmi`er
systems and/or injuring
the brain directly

Biological Factors
Gene2c

First-degree rela$ve with schizophrenia increase

the risk to nearly 10%

Brain Structure Abnormali2es

Severe disrup$on of communica$on pathways in

the brain
Lower rate of blood ow and glucose metabolism
in the frontal lobes
Reduced volume of gray ma`er in the brain,
especially in the temporal and frontal lobes
Enlargement of the lateral cerebral ventricles, 3rd
ventricle dila$on and/or ventricular asymmetry
Increase size of the sulci on the surface of the brain

Biochemical Factors
Dopamine Theory:
An$psycho$cs block the ac$vity of dopamine-2
receptors in the brain
Almost any drug can lead to schizophrenia
Increase dopamine, which triggers schizophrenia

Other Neurochemical Hypotheses:

Second-genera$on an$psycho$cs: block serotonin and
dopamine
Serotonin may play a
role in schizophrenia

Psychological factors

Prenatal Stressors

History of pregnancy or birth complica$ons

Poor nutri$on, hypoxia
Human herpes virus 2 and human endogenous retrovirus 2
Psychological trauma to mother
Father over the age of 35 at concep$on
Being born during late winter or early spring

Psychological Stressors

Times of developmental and family stress

Determine severity and course of disorder and persons quality
of life
Childhood sexual abuse, social adversity, and migra$on or
growing up in a foreign culture

Environmental Stressors

Tetracholorethylene toxin used in dry cleaning

Course of the Disorder

Prodromal Phase
Onset of symptoms may appear 1 month 1 year
before rst psycho$c break
Socially awkward, lonely, depressed
Anxiety, phobias, obsessions, dissocia$on and
compulsions
Concentra$on, memory and comple$on of work
may deteriorate
Mind wandering
Rou$ne s$muli can become overwhelming
Events are misinterpreted, and mys$cal or
symbolic meanings may be given to ordinary
events

Phases of Schizophrenia
Phase I: Acute

Exacerba$on of disrup$ve
symptoms with resultant loss of
func$onal abili$es
Increased care is required

Phase II: Stabiliza2on

Symptoms are decreasing,

movement towards baseline
level of func$on
Residen$al care or supervised group home

Phase III: Maintenance

Pt. is at or nearing their baseline func$oning

Pt. is able to live in the community

Posi$ve Symptoms
Altera2ons in Thoughts

Delusions: false xed beliefs that

cannot be corrected by reasoning
May be a response to anxiety or
reect areas of concern
Looking for and addressing such
underlying themes or needs can
be a key nursing interven2on

Control, Ideas of Reference,

Persecu$on, Grandeur, Soma$c
Delusions, Erotomanic and
Jealousy
Concrete thinking

Altera2ons in Percep2on
- Depersonaliza$on
- Derealiza$on
- Hallucina$ons
- Command Hallucina$ons
- Illusions

Altera2ons in Behavior
-
-
-
-
-
-
-
-
-

Altera2ons in Speech

Associa$ve looseness
Clang associa$on
Word salad (schizophasia)
Neologisms
Echolalia

Catatonia
Motor retarda$on and agita$on
Stereotyped behaviors
Waxy exibility
Echopraxia
Nega$vism
Impaired Impulse Control
Gesturing or Posturing
Boundary Impairment

Nega$ve Symptoms
The absence of something that is normally there
Interest in hygiene, mo$va$on, ability to experience
pleasure
Develop slowly and interfere with ability to adjust
and cope
Contribute to poor social func$oning and social
withdrawal
Aect:
Flat, blunted, inappropriate and bizarre

Cogni$ve Symptoms
Impaired ability to make decisions or set priori$es
Diculty with a`en$on, memory, informa$on
processing, cogni$ve exibility and execu$ve
func$ons
Poor judgment
Leave the pa$ent less able to cope, learn, manage
health and hold a job

Aec$ve Symptoms
Emo$ons and their expression
Mood: depressed, elated, unstable, erra$c
or hos$le

The eects of the symptoms on the pa$ent (Figure 12-1)

Assessment Guidelines
1. Asses for indica$ons of medical problems that might mimic
psychosis
2. Asses for drug or alcohol abuse or dependency
3. Determine risk to self or others
4.
5.
6.
7.
8.

Aec$ve symptoms

Asses for command hallucina$ons

Assess for delusions
Asses for suicide risk
Assess for ability to ensure personal safety
Assess prescribed medica$ons, whether and how they are
taken, and what factors are aec$ng adherence
9. Complete a mental status exam
10. Assess the pa$ents insight, knowledge of the illness,
rela$onships, and support systems, other coping resources and
strengths
11. Asses the familys knowledge of and response to the pa$ents
illness and its symptoms

Nursing Diagnosis
Disturbed sensory percep$on: auditory/visual
related to altered sensory recep$on:
transmission or integra$on
Impaired social interac$on related to impaired
communica$on pa`erns, self-concept
disturbance, disturbed thought processes.
Compromised family coping related to inability
to express feelings, impaired communica$on.

Disturbed Sensory Percep$on: Auditory/

Visual Related to Altered Sensory Recep$on:
Transmission or Integra$on
Outcome Criteria:
Maintains social
rela$onships
Maintains role
performance
States that the voices are
no longer threatening, nor
do they interfere with his
or her life -- learns ways to
refrain from responding to
hallucina$ons

Impaired Social Interac$on Related to Impaired

Communica$on Pa`erns, Self-Concept
Disturbance, Disturbed Though Processes
Outcome Criteria:
Improves social interac$on
with family, friends, and
neighbors
Engages in social
interac$ons in goal-
directed manner
Uses appropriate social
skills in interac$ons

Compromised Family Coping Related to

Inability to Express Feelings, Impaired
Communica$on
Outcome Criteria:
Family members/signicant others will:
State they have received needed
support from community and agency
resources that oer support,
educa$on, coping skills training, and/or
social network development
(psychoeduca$onal approach)
Demonstrate problem-solving skills for
handling tensions and
misunderstanding within the family
environment
Recount in some detail the early signs
and symptoms of relapse in their ill
family member, and know whom to
contact

Acute Phase
Focus

Crisis interven$on
Medica$ons for symptom
stabiliza$on
Safety

Interven2ons

Psychiatric, medical, and

neurological evalua$on
Psychopharmacology
Support, psychoeduca$on,
and guidance
Supervision and structure in a
therapeu$c environment
(milieu)
Monitor uid intake

Factors Aec2ng Treatment

Level of care/restric$veness
needed to prevent harm to
self or others
Needs for external structure
and support (e.g., others
guiding the pa$ents ac$vi$es)
Ability to cooperate with
treatment
Need for a treatment available
only in par$cular sepngs
Need for treatment of a
concurrent medical condi$on
Availability of third-party
informa$on and treatment
history required so that sta
can reliably assess the
pa$ents needs

Phase 2: Stabiliza$on &

Phase 3: Maintenance
Medica$on administra$on/ adherence
Rela$onships with trusted providers
Community based therapeu$c services
Group and individual psychotherapy
Supervised ac$vi$es
Training
Social or coping skills

Community health centers

Home health services
Supported employee programs
Peer-led services
Construc$ve ac$vi$es
Family educa$onal/skills groups
Respite care for caregivers

Short Term Goal

CLIENT WILL BE ABLE TO SPEAK IN A MANNER THAT CAN BE UNDERSTOOD BY
OTHERS WITH THE AID OF MEDICATION AND ATTENTIVE LISTENING BY DISCHARGE.

Interven2ons

Assess if incoherence in speech is chronic or

more sudden, as in an exacerba$on of
symptoms.
Iden$fy how long client has been on an$-
psycho$c medica$on.
Plan short, frequent periods with client
throughout the day.
Use therapeu$c techniques to try to
understand clients concerns
Focus on and direct clients a`en$on to
concrete things in the environment.
When client is ready, introduce tac$cs that
will lower anxiety and minimize voices and
worrying thoughts. Teach client

Evalua2on

Assess clients speech

and coherence during
frequent, short
mee$ngs throughout
the day and evaluate
whether they have
improved or not.

Long Term Goal

CLIENT WILL ENGAGE IN ONE OR TWO ACTIVITIES WITH MINIMAL ENCOURAGEMENT
FROM NURSE OR FAMILY MEMBERS BY THE END OF THE MONTH.

Interven2ons

Assess if medica$on has reached

therapeu$c levels.
Ensure that goals set are realis$c,
whether in the hospital or community.
Keep environment as free from s$muli as
possible.
Structure $mes each day to include
planned $mes for brief interac$ons and
ac$vi$es with the client on a one-on-one
basis.
Provide opportuni$es for client to learn
adap$ve social skills in a nonthreatening
environment. Ini$al social skills could
include basic social behaviors

Evalua2on

At the end of the month,

ask the pa$ent and/or
family members about
the clients progress in
par$cipa$ng in ac$vi$es
and if the client needed
encouragement or not.
Encourage the family to
implement interven$ons
as necessary.

Pharmacological Interven$ons
An2psycho2cs

Provide symptom control and allow pa$ents to live and be

treated in the community.

Adjunc2ve therapy:
An$convulsants, an$depressants, mood stabilizing
agents, and/or benzodiazepines
Phase 1:

Medica$ons are used for symptom stabiliza$on, and safety.

Phase 2:

Medica$on/administra$on and adherence

Phase 3:

Medica$ons are u$lize so that pa$ents can func$on in the

community or prevent relapse

1st, 2nd, and 3rd Genera$on

An$psycho$cs
First- genera2on

These work on posi$ve symptoms

of schizophrenia; hallucina$ons,
delusions, disordered thinking.

Second- genera2on

Chosen as rst-line because they

treat both the posi$ve and
nega$ve symptoms of
schizophrenia; and produce
minimal EPS or tardive dyskinesia.
Reduced side eects translate into
improved medica$on adherence

Third- genera2on

Second and third genera$on can

improve nega$ve symptoms;
an$social behaviors, blunted
aect, lack of mo$va$on

st
1 Genera$on Drugs
The tradi$onal dopamine antagonist (D2 dopamine
receptor antagonists)
AKA: conven%onal an%psycho%cs or neurolep)cs
Prototype drug: Haloperidol (Haldol)
High-potency = low seda$on + low Ach + high EPSs
Other examples: see chart 12.5 in textbook
Medium potency= moderate seda$on + low Ach +
moderate EPSs
Examples: loxapine(loxitane), molindone (moban),
perphenazine (trilafon)
Low-potency= high seda$on + high Ach + low EPSs
Examples; chlorpromazine(thorazine),
Thioridazine(mellarill)

Prototype Drug: Haldoperidol (Haldol)

High-potency

Class: Conven%onal an%psycho%cs (Non Phenothiazines)

Ac2on: Blocking of the dopamine type 2 receptors
Primarily: used for severe mental illness
Nurse assesses/educates for adverse side eects such as;

Acute dystonia, akathisia, Parkinsonism, tardive dyskinesia, an$cholinergic

eects, seda$on, hypotension, sexual dysfunc$on, and neurolep$c
malignant syndrome

HARMFUL SIDE EFFECTS OF FIRST GENERATION
DRUGS DEFINED
Blockage of the D2 dopamine receptors can cause
extrapyramidal side eects(EPS)

3 most common EPSs
1. Acute dystonia
2. Akathisia
3. Pseudoparkinsonism

2nd Genera$on Drugs

Serotonin Dopamine Antagonist (5-HT2A) Receptor Antagonist

Prototype drug: Que$apine (Seroquel)

Class: Second Genera$on An$psycho$cs
Ac2on: Strong blockade of 5-HT2 receptors and weaker
blockade of D2 receptors(receptors for serotonin and
dopamine). There is also a blockage of H1 receptors and
alpha-adrenergic receptors, but does not block
receptors for acetylcholine.
Primary use: +/- symptoms of schizophrenia

Nurse assesses/educates for adverse side eects such as:
Metabolic Syndrome: This includes weight gain,
dyslipidemia, and altered glucose metabolism thought
to be due to increased insulin resistance

3rd Genera$on Drugs

Improves Nega$ve & Posi$ve Symptoms:

Asociality, blunted aect, lack of mo$va$on

Prototype drug: Aripiprazole (abilify)

Class: Third genera$on an$psycho$c (atypical)
Dopamine system stabilizers (DSSs)

Ac2on: blocks H1, 5-HT2, and alpha1 receptors, and has

mixed eects on 5HT1 and D2 receptors. This drug
does not block cholinergic receptors.
Nurse assesses/educates for adverse side eects such
as:
Possible but very rear EPSs or TDK.
This is highly unlikely to cause metabolic eects,
hypotension, or prolac$n release; also has li`le
an$cholinergic eect and does not seem to cause
dysrhythmias.

4 Life Threatening Side Eects of An$psycho$cs

1. An$cholinergic toxicity
2. Neurolep$c Malignant
Syndrome (NMS): caused
by excessive dopamine
receptor blockage
3. Agranulocytosis: Total
WBC below 3,000 or
Neutropenia
Signs of infec$on

4. Liver Impairment
Nurse needs to educate
not only the pa$ent but the
family of the S/S of these 4
responses

Alterna$ve Therapy

Trans Magne2c S2mula2on (TMS)

References
Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' founda)ons
of psychiatric mental health nursing: A clinical approach. St.
Louis, Mo: Elsevier.

Lehne, R. A. (2013). Pharmacology for nursing care. St. Louis,
Mo: Elsevier/Saunders.

Oh, S-Y, & Kim, Y-K. (2011). Adjunc$ve treatment of bimodal
repe$$ve transcranial magne$c s$mula$on in
pharmacologically non-responsive pa$ents with schizophrenia:
A preliminary study. Progress in Neuro-Psychopharmacology &
Biological Psychiatry, 35(2011), 1938-1943