Schizophrenia Spectrum

and other Psychotic

Disorders

General Features of Psychotic

Disorders
Schizophrenia and other psychotic
disorders are characterized by
abnormalities in one or more of five
domains: delusions, hallucinations,
disorganized thinking (speech), grossly
disorganized or abnormal motor
behavior (including catatonia), and
negative symptoms.
DSM-5 p. 87

Epidemiology
Affects people in all cultures and in all
countries
Average onset is late teens to early
twenties, but can be as late as midfifties
Affects cognitive, emotional, and
behavioral function
30% to 40% relapse rate in the first
year
3

Epidemiology, cont.
Compared to other mental illnesses,
schizophrenia creates more:

Chaos in family life

Exorbitant costs to people and governments
Lengthy hospitalizations
Fears

Epidemiology, cont.
Progression varies from one client to
another
Exacerbations and remissions
Chronic but stable
Progressive deterioration

Schizophrenia
DSM-5 Diagnosis
Symptoms present at least 6 months
Active-phase symptoms present at least
1 month
Symptoms are defined as positive and
negative
Significant impairment in functioning

Phases of Schizophrenia
Phase I Acute
Onset or exacerbation of symptoms

Phase II Stabilization
Symptoms diminishing
Movement toward previous level of
functioning

Phase III Maintenance

At or near baseline functioning
7

Symptoms
Positive symptoms
Excess or distortion of normal
functioning
Aberrant response

Negative symptoms
Deficit in functioning

Positive Symptoms of
Schizophrenia, cont.
Hallucinations
Delusions
Disordered speech and behavior
(repetitive or involuntary movements)

Negative Symptoms of
Schizophrenia
Diminished emotional expression, e.g., facial
expressions, eye contact, intonation and
hand/facial expressions associated w/ speech
Alogia - poverty of thought or speech
Avolition - lack of motivation and ability to
carry out self-initiated activity
Anhedonia - lack of pleasure or interest in
everyday activity or recollection of such
Neglecting hygiene
Social withdrawal
10

Features of Schizophrenia
Client may be argumentative, hostile, or
aggressive
Delusions
Persecutory or grandiose, reference, special
mission, or jealousy
Somatic or religious

11

Delusions/Hallucinations
Delusions may link w/ a hallucination
Auditory that threaten the client or give
commands, or auditory hallucinations
without verbal form, such as whistling,
humming, or laughing
Olfactory or gustatory, or of sexual or other
bodily sensations

12

Disorganized thinking
As evidenced by Speech Patterns:
Clanging - meaningless rhyming of words - often
pressured - Bill will shrill, mill
Neologisms - expression of words that only have
meaning to the client - they are trying to
upsuculate us
Word salad - a meaningless mixture of words
and phrases - I am online, but fire isout of
breathfor candy.
Confabulation - filling in the gaps with material
that is made up to accommodate for memory
loss. (Often seen in Korsakoffs psychosis.)

Disorganized thinking, cont.

Perseveration - involuntary repetition
of the same thought, phrase or motor
response to different situations. Nurse: How are you doing?
Client: Good nurse, yes good.
Nurse: Did you go for a walk?
Client: Good nurse, yes good.
Nurse: Are you going out today?
Client: Good nurse, yes good.

Disorganized thinking, cont.

Flight of ideas - a nearly continuous flow of
rapid speech that jumps from topic to topic,
usually based on discernible associations,
distractions, or plays on words, but
sometimes disorganized and incoherent.
Looseness of association - a manifestation
of a severe thought disorder characterized
by switching from one topic to another
without an obvious connection between
one thought or phrase and the next.

Disorganized thinking, cont.

Circumstantiality - indirect speech
pattern including many irrelevant
details before reaching the main
point. The client does not lose the
point, as is characteristic of loosening
of associations, and clauses remain
logically connected.
Tangentiality - client goes off-topic
and may not return to main topic.

Catatonia
A marked decrease in reactivity to the
environment. Ranging from resistance to
instructions (negativism) to maintaining rigid,
bizarre posture; to a complete lack of verbal
and motor responses (mutism & stupor) DSM5, p. 88
Psychomotor retardation and stupor
Extreme psychomotor agitation
Waxy flexibility - arm is moved into a certain
position; it will stay there
Echolalia
Echopraxia
17

Other Psychotic Disorders

Schizotypal Personality Disorder

Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Psychotic disorder due to a general
medical condition or substance
Unspecified
18

Schizophreniform disorder
Same symptoms as schizophrenia,
except duration is less than 6
months, but at least 1 month.

Schizoaffective disorder
Two or more Schizophrenic symptoms
present for a significant portion of
time during a 1-month period (or less
if successfully treated) accompanied
by a strong element of
symptomatology associated with
mood disorders, either manic or
depressive

Delusional disorder
The existence of prominent, nonbizarre delusions (can occur in real
life), e.g., being followed, being
loved, having an infection, and being
deceived by one's spouse
As opposed to bizarre delusions
present in schizophrenia that are
clearly implausible

Bizarre delusions
Thought insertion - the belief that
someone is putting thoughts into
ones mind.
Thought broadcasting - the belief
that one can insert thoughts into
someone elses mind, or that
someone else can read ones
thoughts.

Bizarre delusions
Thought blocking - the belief that if
one cannot remember a thought, it is
due to someone preventing one from
thinking.
Religious delusions - idea that one is
a well-known religious deity, or other
more complex delusions related to
religious beliefs

Delusional disorder (cont.)

Erotomanic type: the client has
irrational ideas about someone being
in love with them
Grandiose type: irrational ideas
regarding own worth, talent,
knowledge, or power
Jealous type: irrational idea that the
sexual partner is unfaithful

Delusional disorder (cont.)

Persecutory type: person believes he
or she is being treated malevolently
in some way
Somatic type: person has an
irrational belief that he or she has
some physical defect, disorder, or
disease

Brief psychotic disorder

Sudden onset of psychotic symptoms
following a severe psychosocial stressor,
such as a death, rape or other traumatic
event
Usually occurs around age 20-30
Symptoms less than 1 month; recovery
to full premorbid level of functioning
Not caused by drugs or physical illness

Psychotic disorder due to

general medical condition
Symptoms include prominent
hallucinations and delusions that can
be directly attributed to a general
medical condition

Substance-induced
psychotic disorder
Prominent hallucinations and
delusions directly attributable to
physiological effects of a substance

Etiology of Schizophrenia
Biologic Theory: Genetic
Only genetic predisposition for
developing schizophrenia is inherited
10% of first-degree relatives
25%-39% of monozygotic twins

29

Etiology of Schizophrenia, cont.

Genetic Vulnerability
Genetic Defects
Cerebral cortex injury due to anemia,
anoxia, ischemia
Advanced Paternal Age
Mutations in the sperm

30

Etiological theories cont.

31

Etiological theories, cont.

Environmental Factors
Viral Infections
Peri-natal risk factors
Maternal Infections
Rubella, polio, chicken pox
Obstetric Complications
Bleeding, low birth weight, emergency Csection
32

Etiology cont.
Biologic Theory: Biochemical
Theories
Dopamine hypothesis
Traditional antipsychotic medications are
dopamine blockers
Dopamine blockers alleviate positive
symptoms

33

Data from a PET study suggests that the less the frontal lobes
are activated (red) during a working memory task, the greater the
increase in abnormal dopamine activity in the striatum (green).
Thought to be related to the neurocognitive deficits in
schizophrenia.
^ Meyer-Lindenberg A, Miletich RS, Kohn PD, et al (2002). Reduced prefrontal activity predicts
exaggerated striatal dopaminergic function in schizophrenia. Nature Neuroscience, 5, 26771. PMID
11865311

34

Etiology cont.
Psychological theories
Information processing
Difficulty controlling the amount and type of
information that is processed in the brain.

Attention and arousal

Hyper or hypo responsiveness to various
situations

35

Etiological cont.
Humanistic-interactional theories
integrate biological and psychosocial
theories
Combine influences of:
Genetic predisposition or biologic
vulnerability
Environmental stressors
Social support
36

Etiology cont.
Diathesis-Stress Model
Stressors increase vulnerability
Cumulative effect of:

Genetic predisposition
Personal stressors
Familial factors
Environmental factors

37

Influences on the Course of

Schizophrenia
Social Pressures
Lack of social support
Financial problems
Stigma

38

Influences on the Course of

Schizophrenia cont.
Psychological pressures
Difficulty with problem-solving
Difficulty with interpreting reality
Difficulty coping
Problems with self-care
Unstable interpersonal relationships

39

Assessment
Premorbid functioning
Content & form of thought
Perception
Sense of self
Delusions and perceptual disturbances
Command hallucinations
Substance use
Suicide risk
Any medical problems
40

Affective Symptoms
Assessment for depression is crucial
May herald impending relapse
Increases substance abuse
Increases suicide risk
Further impairs functioning

41

Potential Nursing Diagnoses

Positive symptoms
Disturbed sensory perception
Risk for self-directed or other-directed violence
Impaired verbal communication
Negative symptoms
Social isolation
Self-care deficits
Chronic low self-esteem
Ineffective family coping
Altered health maintenance
42

Nursing Implications:
Supporting Families
Family needs vary with degree of
illness and involvement in clients
care
Education
Financial support
Psychosocial support
Education
Advocacy
43

Supporting Families cont.

Schizophrenia is a family illness
Educate family re: illness,
medication, relapse prevention
Nurse assists family by
Identifying community agencies/groups
for family members
Advocating for rights

44

Family Resource
National Alliance on Mental Illness
http://www.nami.org/
The National Alliance on Mental
Illness provides information,
education, and support relating to
mental health illnesses and disorders
for clients, families, and
professionals.

Measures to Prevent
Relapse
Ensure client takes medication
Educate family about signs and
symptoms of relapse
Client and family to participate in
relapse prevention program

46

Measures to Prevent
Relapse cont.
Relapse prevention programs work
best when:
Psychosocial treatment and social skills
training are combined with antipsychotic
medication
Behavior patterns are monitored
Family members understand triggers

47

Measures to Prevent
Relapse cont.
Relapse prevention programs provide
education and support re:
Individual triggers, symptoms of relapse
Managing side effects of medications
Interventions to reduce or eliminate
triggers
Strategies to facilitate early intervention
Cognitive therapy
Community resources
48

Challenges to Adherence
Side effects
Level of symptomatology
Cognitive, motivational, financial,
and cultural issues
Issues with caregivers
Insufficient medication teaching

49

Increasing Adherence
Involve clients in treatment
Instruct client about reducing
discomfort
Provide peer support
Provide reminders and positive
feedback
Recognize accomplishments
50

Continuum of Care
Hospitalization for acute symptoms
Day hospitalization for acutely
psychotic, but not at risk for harming
self or others
Day treatment for ongoing supportive
care during stabilization
Supportive housing for those who
cannot live with family, but need some
level of supervision

Developing a Therapeutic
Nurse-client Relationship

Be calm
Accept clients as they are
Be consistent; keep promises
Be honest
Do not reinforce hallucinations or
delusions
Orient to time, person, and place, if
indicated

Developing a Therapeutic
Nurse-client Relationship,
cont.

Do not touch without warning

Avoid whispering or laughing when
client cannot hear
Allow and encourage verbalization of
feelings

Developing a Therapeutic
Nurse-client Relationship,
cont.

Begin with one-to-one interactions

Avoid competitive activities
Avoid embarrassment
Reinforce positive behavior

Milieu Management:
Disruptive clients

Set limits
Decrease stimuli
Observe for escalating behavior
Minimize potential weapons
Provide for client safety when
restraints
are necessary

Milieu Management:
Withdrawn clients
Arrange nonthreatening activities
Arrange furniture around a table so client
must sit with someone
Assist with decision-making as appropriate
Provide opportunities for nonthreatening
1:1 socialization with nurse
Reinforce appropriate grooming and
hygiene
Provide psychosocial rehabilitation

Milieu Management:
Hallucinations
Use distraction
Discourage talking about the
hallucinations
Monitor TV selections
Monitor command hallucinations
Have staff members available to talk
with client about real things