Chapter 14

Schizophrenia
Schizophrenia is a syndrome or disease
process of the brain causing distorted
and bizarre thoughts, perceptions,
emotions, movements, and behavior.
It is usually diagnosed in late
adolescence and early adulthood.
Prevalence is 1% of total population, or
3 million in U.S.; same prevalence
throughout world.
Hard or positive symptoms include:
• Delusions
• Hallucinations
• Grossly disorganized
thinking, speech, and
behavior
Soft or negative symptoms include:
• Flat affect
• Avolition
• Social withdrawal or discomfort
• Apathy
• Alogia
Types of Schizophrenia

• Paranoid type: persecutory or

grandiose delusions and
hallucinations; sometimes
excessive religiosity; hostile and
aggressive behavior
• Disorganized type: grossly
inappropriate or flat affect,
incoherence, loose associations,
extremely disorganized behavior
Types of Schizophrenia (cont’d)
• Catatonic type: marked psychomotor
disturbance, motionless or excessive motor
activity, extreme negativism, mutism,
peculiarities of voluntary movement
(echolalia, echopraxia)
• Undifferentiated type: mixed schizophrenic
symptoms along with disturbances of
thought, affect, behavior
• Residual: at least one previous psychotic
episode but not currently; social withdrawal,
flat affect, loose associations
Clinical Course
• Most clients experience a slow and
gradual onset of symptoms
• Younger age of onset associated with
poorer outcomes
• In first years after diagnosis, client
may have relatively symptom-free
periods between psychotic episode or
fairly continuous psychosis with some
shift in severity of symptoms
Clinical Course (cont’d)
• Over the long term, psychotic
symptoms diminish for most clients
and are managed more easily
• Many years of dysfunction are rarely
overcome
Related Disorders

• Schizophreniform disorder: symptoms of

schizophrenia are experienced for less than
the 6 months required for a diagnosis of
schizophrenia
• Schizoaffective disorder: symptoms of
psychosis and thought disorder along with all
the features of a mood disorder
• Delusional disorder: one or more nonbizarre
delusions with no impairment in psychosocial
functioning
Related Disorders (cont’d)

• Brief psychotic disorder: one psychotic

symptoms lasting 1 day to 1 month; may or
may not have an identifiable stressor, such
as childbirth
• Shared psychotic disorder (folie à deux):
similar delusion shared by two people, one of
whom has psychotic delusions
Etiology
Current etiologic theories focus on
biologic theories:
• Genetic factors
• Neuroanatomic theories
• Neurochemical theories
• Immunovirologic factors
Cultural Considerations
• Ideas that are considered delusional in one culture
may be commonly accepted by other cultures
• Auditory or visual hallucinations may be a normal
part of religious experiences in some cultures
• Ethnicity may be a factor in the way a person
responds to psychotropic medications:
– African Americans, Caucasian Americans, and
Hispanic Americans appear to require
comparable therapeutic doses of antipsychotic
medications
– Asian clients need lower doses of drugs such as
haloperidol (Haldol) to obtain the same effects
Treatment
Primary treatment involves antipsychotic
(neuroleptic) medication
• Conventional antipsychotics • Atypical antipsychotics
target the positive signs: diminish positive symptoms,
and they lessen the negative
– Delusions signs:
– Hallucinations – Avolition
– Disturbed thinking – Social withdrawal
– Other psychotic – Anhedonia
symptoms
but have no observable
effect on the negative
signs
Maintenance Therapy
• Two antipsychotics are available in depot
injection forms for maintenance therapy:
– Fluphenazine (Prolixin) in decanoate and
enanthate preparations
– Haloperidol (Haldol) in decanoate
• The effects of the medications last 2 to 4
weeks, eliminating the need for daily oral
antipsychotic medication
Side Effects of Antipsychotic Medications
• Neurologic side effects:
– Extrapyramidal side
effects (acute dystonic
reactions, akathisia, and
parkinsonism)
– Tardive dyskinesia
– Seizures
– Neuroleptic malignant
syndrome
• Nonneurologic side effects:
– Weight gain
– Sedation
– Photosensitivity
– Anticholinergic
symptoms (dry mouth,
blurred vision,
constipation, urinary
retention)
– Orthostatic hypotension
– Agranulocytosis
(Clozapine)
Treatment
Adjunctive Treatment
• Individual, group, and family therapy
• Structured milieu therapy
• Community support programs
• Client/family education and support
Application of the Nursing Process
Assessment
• Previous history with schizophrenia
• Previous suicidal ideation
• Current support system
• Client’s perception of current situation
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• General appearance, motor behavior, and speech
• Mood and affect: flat or blunted affect, anhedonia
• Thought processes and content: disordered
• Delusions
• Sensorium and intellectual processes: hallucinations,
disorientation, concrete or literal thinking
• Judgment and insight: impaired judgment, limited insight
• Self-concept: may be distorted, with depersonalization, loss
of ego boundaries resulting in bizarre behaviors
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Roles and relationships: often
socially isolated, have difficulty
fulfilling life roles
• Physiologic and self-care
considerations, may have
multiple self-care deficits
(inattention to hygiene,
nutrition, sleep needs;
polydipsia occasionally seen
in longer-term clients)
Application of the Nursing Process
(cont’d)
Data Analysis
Common nursing diagnoses for positive symptoms
include:
• Risk for Other-Directed Violence
• Risk for Suicide
• Disturbed Thought Processes
• Disturbed Sensory Perception
• Disturbed Personal Identity
• Impaired Verbal Communication
Application of the Nursing Process
(cont’d)
Data Analysis (cont’d)
Common nursing diagnoses for negative
symptoms and functional abilities include:
• Self-Care Deficits
• Social Isolation
• Deficient Diversional Activity
• Ineffective Health Maintenance
• Ineffective Therapeutic Regimen Management
Application of the Nursing Process
(cont’d)
Outcome Identification
Expected outcomes for the acute, psychotic phase;
the client will:
• Not injure self or others
• Establish contact with reality
• Interact with others
• Express thoughts and feelings in a safe and
socially acceptable manner
• Participate in prescribed therapeutic interventions
Application of the Nursing Process
(cont’d)
Outcome Identification (cont’d)
Expected outcomes for continued care; the client will:
• Participate in the prescribed regiment (including
medication and follow-up appointments)
• Maintain adequate routines for sleeping and food and
fluid intake
• Be independent in self-care activities
• Communicate effectively with others in the community to
meet his or her needs
• Seek or accept assistance to meet his or her needs when
indicated
Application of the Nursing Process
(cont’d)
Intervention
• Promote safety of clients and others
• Establish a therapeutic relationship
• Use therapeutic communication
• Interventions for delusional thoughts
• Interventions for hallucinations
• Protect the client who has socially inappropriate
behaviors
• Client and family teaching
Application of the Nursing Process
(cont’d)
Evaluation
• Have the client’s psychotic symptoms
disappeared? Or can the client carry out his or her
daily life despite the persistence of some psychotic
symptoms?
• Does the client understand the prescribed
medication regimen? Is he or she committed to
adherence to the regimen?
• Does the client possess the necessary functional
abilities for community living?
• Are community resources adequate to help the
client live successfully in the community?
Application of the Nursing Process
(cont’d)
Evaluation (cont’d)
• Is there a sufficient after-care or crisis plan
in place to deal with recurrence of symptoms
or difficulties encountered in the community?
• Are the client and family adequately
knowledgeable about schizophrenia?
• Does the client believe that he or she has a
satisfactory quality of life?
Elder Considerations
• Psychotic symptoms that appear in later life are
usually associated with depression or dementia, not
schizophrenia
• Elderly people with schizophrenia experience a
variety of long-term outcomes:
– 20% to 30% of clients experience dementia,
resulting in a steady, deteriorating decline in
health
– 20% to 30% experience a reduction in positive
symptoms, somewhat like a remission
– 40% to 60% remain mostly unchanged
Community-Based Care
• Assertive community treatment (ACT)
• Behavioral home health
• Community support programs
• Case management
Mental Health Promotion
• Psychiatric rehabilitation has the goal
of recovery for client, more than just
symptom control and medication
management
• Early identification and aggressive
treatment of psychotic symptoms
maximizes recovery and quality of life
• Future research on prophylactic drug
treatment to treat genetically
vulnerable relatives with beginning
negative signs of schizophrenia
Self-Awareness Issues
• May be challenging if client is
suspicious or mistrustful or nurse is
frightened
• Nurse may become frustrated if client
is noncompliant
• Nurse must not take client’s success or
failure personally. The client’s remarks
and behavior or noncompliance are not
personal toward the nurse; part of the
illness
Self-Awareness Issues (cont’d)

• Nurse should focus on client’s strengths

and time out of the hospital, not just
on symptoms and need for acute care
• No nurse has all the answers