SCHIZOPHRENIA

Ali C. Robles, RN, MD

 INTRODUCTION
 Schizophrenia is possibly a group of psychotic
disorders that severely impairs all areas of an
individual’s functioning.
 1 to 1.5% of US population has schizophrenia.
However they make up far more than 50% of the
county and long-term residents of state mental
hospitals.
 More than 50% are homeless, and in addition may
have an addiction problem.
 The cost of treatment and loss of revenues are
estimated in the billions of dollars.
COMORBIDITY

 Substance abuse disorders

 Nicotine dependence
 Depression
 Suicide
 Anxiety disorders
 Psychosis-induced polydipsia
ETIOLOGY

Neurobiochemical
 Dopamine hypothesis
 Serotonin
 Glutamate
 Neuroanatomical
 Structural cerebral abnormalities
 Genetic
 Several genes on different chromosomes
interact with environment
 Nongenetic risk factors
 Complications of pregnancy and birth
 Stress
 GENETIC PREDISPOSITION

 A single gene has not been identified.

 Research is focused on chromosomes 6, 13, 18 & 22.

 The risk of developing the disorder is as follows:
 One parent 12-15%+
 Both parents 40%+
 Identical twins 50%+
(The statistics may vary in different studies)
AREAS OF THE BRAIN AFFECTED
BIOLOGICAL THEORIES
Neuroanatomical
Course of Schizophrenia

 Recurrent acute exacerbations

of psychosis
 Increase in residual dysfunction
and deterioration with each relapse
Phases in Course of
Schizophrenia
1. Acute phase
 Positive symptoms and negative
symptoms
2. Maintenance phase
 Acute symptoms are less severe
2. Stabilization phase
 Remission of symptoms
Potential Early Symptoms:
Pre-psychotic

 Withdrawn from others

 Depressed
 Anxious
 Phobias
 Obsessions and compulsions
 Difficulty concentrating
 Preoccupation with religion
 Preoccupation with self
Bleuler’s
4 A’s of Schizophrenia

 Affect
 Associative looseness
 Autism
 Ambivalence
Signs and Symptoms: Relevant
to Treatment

 Positive symptoms
 Negative symptoms
 Cognitive symptoms
 Mood symptoms
Dimensions Altered in
Individuals with
Schizophrenia
 Ability to work
 Interpersonal relationships
 Self-care abilities
 Social functioning
 Quality of life
Positive Symptoms:
Alteration in Thinking
 Delusions: false, fixed beliefs that cannot be
corrected by reasoning
 Ideas of reference
 Persecution
 Grandiosity
 Somatic sensations
 Jealousy
 Control
 Thought broadcasting
 Thought insertion
 Thought withdrawal
 Delusion of being controlled
 Concrete thinking
Positive Symptoms:
Alterations in Speech

 Associative looseness
 Neologisms
 Echolalia
 Clang association
 Word salad
Positive Symptoms:
Alterations in Perception
 Hallucinations: sensory perceptions
for which no external stimulus exists
 Auditory
 Visual
 Olfactory
 Tactile
 Personal boundary difficulties
Positive Symptoms:
Alterations in Behavior

 Extreme motor agitation

 Stereotyped behaviors
 Automatic obedience
 Waxy flexibility
 Stupor
 Negativism
Negative Symptoms

 Affective blunting
 Anergia
 Anhedonia
 Avolition
 Poverty of content of speech
 Thought blocking
 Flat affect/inappropriate affect
Cognitive Symptoms

 Inattention, easily distracted

 Impaired memory
 Poor problem-solving skills
 Poor decision-making skills
 Illogical thinking
 Impaired judgment
Depression and
Other Mood Symptoms

 Dysphoria

 Suicidal ideation

 Hopelessness
Types of Schizophrenia

Subtypes
 Paranoid
 Catatonic
 Disorganized
 Undifferentiated
 Residual
 Self-Assessment: Working
with Schizophrenic Clients
 Peer group supervision
 Client's intense emotions produce

similar emotions in the nurse

 Willingness for nurse to discuss feelings and
behaviors with supervisors decreases defensive
behaviors
 Team approach to decrease staff burnout
 Periodic reassessments of
 Treatment outcomes
 Client's strengths and weaknesses
Assessment of the Client

 Safety of client and others

 Medical history and recent medical
workup
 Positive, negative, cognitive, and
mood symptoms
 Current medications and compliance
to treatment
 Family response/support system
Potential Nursing
Diagnoses
 Risk for self-directed or other-directed
violence
 Disturbed sensory perception
 Disturbed thought processes
 Impaired verbal communication
 Ineffective coping
 Compromised or disabled family
coping
 Outcome Criteria

 Acute phase
 Client safety and medical stabilization
 Maintenance phase
 Adherence to medical regimen
 Understanding schizophrenia
 Participation of client and family in psychoeducational activities
 Stabilization phase
 Target negative symptoms
 Anxiety control
 Relapse prevention
Planning of
Appropriate Interventions

 Acute phase
 Possible hospitalization
 Ensure client safety
 Provide symptom stabilization
 Maintenance and stabilization phases
 Psychosocial education
 Relapse prevention skills
 Interventions: Basic Level

 Acute phase
 Administer antipsychotic medication as
prescribed
 Observe client behavior closely
 Set limits on inappropriate behavior
 Do not touch without warning
 Offer foods that are not easily contaminated
 Assist with ADL if needed
 Supportive counseling
 Milieu management
 Family psychoeducation
Interventions: Basic Level
Continued

 Maintenance and stabilization phases

 Health teaching
 Health promotion and maintenance
Milieu Therapy
 Safety
 Potential for physical violence due to
hallucinations or delusions
 Priority is least restrictive safety technique
 Verbal de-escalation
 Medications
 Seclusion or restraints
 Activities
 Provide support and structure
 Encourage development of social skills
and friendships
Counseling: Communication
Guidelines
 Hallucinations
 Hearing voices most common
 Approach client in nonthreatening and
nonjudgmental manner
 Assess if messages are suicidal or homicidal
 Initiate safety measures if needed
 Client anxious, fearful, lonely, brain not
processing stimuli accurately
 Focus on the client’s feelings and present
reality
Communication Guidelines
continued
 Delusions
 Be open, honest, matter-of-fact, and
calm
 Have client describe delusion
 Avoid arguing about content
 Focus on feelings
 Present reasonable doubt
 Validate part of delusion that is real
Communication Guidelines
continued
 Associative looseness
 Do not pretend that you understand
 Place difficulty of understanding on yourself
 Look for reoccurring topics and themes
 Emphasize what is going on in the client's
environment
 Involve client in simple, reality-based activities
 Reinforce clear communication of needs, feelings,
and thoughts
Client Teaching
Coping Techniques for
Schizophrenia
 Distraction
 Interaction
 Activity
 Social action
 Physical action
Client and Family Teaching

 Learn all you can about the illness.

 Develop a relapse prevention plan.
 Avoid alcohol and drugs.
 Learn ways to address fears and losses.
 Learn new ways of coping.
 Comply with treatment.
 Maintain communication with supportive
people.
 Stay healthy by managing illness, sleep, and
diet.
Treatment Modalities

 Individual therapy
 Social skills training (SST)
 Cognitive remediation
 Cognitive adaptation training (CAT)
 Cognitive behavioral therapy (CBT)
 Group therapy
 Family therapy
 Psychopharmacology
Psychopharmacology
 Antipsychotics
 Standard/ Typical
 Atypical

 Antiparkinson
Psychopharmacology
Traditional Antipsychotic
 Dopamine antagonists (D2 receptor antagonists)
 Target positive symptoms of schizophrenia
 Advantage
 Less expensive than atypical antipsychotics
 Disadvantages
 Do not treat negative symptoms
 Extrapyramidal side effects (EPS)
 Tardive dyskinesia
 Anticholinergic effects (ACH)
 Lower seizure threshold
 Antipsychotic Medications:
Traditional

 High potency = low sedation + low ACH + high

EPSs
 Haloperidol (Haldol)
 Trifluoperazine (Stelazine)
 Fluphenazine (Prolixin)
 Thiothixene (Navane)

 Medium potency
 Loxapine (Loxitane)
 Molindone (Moban)
 Perphenazine (Trilafon)
 Antipsychotic Medications:
Traditional continued
 Low potency = high sedation + high
ACH + low EPSs
 Chlorpromazine (Thorazine)
 Thioridazine (Mellaril)
 Mesoridazine ( Serentil)
 Decanoate = Long acting injection
 Haloperidol decanoate (Haldol D)
 Fluphenazine decanoate (Prolixin D)
 Atypical Antipsychotics
(First-Line Antipsychotics)
 Serotonin-dopamine antagonists
 (5-HT2A receptor antagonists)

 Advantages
 Diminishes negative as well as positive symptoms of
schizophrenia
 Less side effects encourages medication compliance
 Improves symptoms of depression and anxiety
 Decreases suicidal behavior

 Disadvantages
 Weight gain
 Metabolic abnormalities
Antipsychotic Medications:
Atypical

 Clozapine (Clozaril)
 Quetiapine (Seroquel)
 Risperidone (Risperdal
 Zipreasidone (Geodon)
 Olanzapine (Zyprexa)
 Aripiprazole (Abilify)
Side Effects- Atypical

 Orthostatic Hypotension
 Decreased Libido
 Agranulocytosis (Clozapine)
 Weight gain
 Tachycardia
 Edema
Side Effects:
Anticholinergic Symptoms
 Dry mouth
 Urinary retention and hesitancy
 Constipation
 Blurred vision
 Photosensitivity
 Dry eyes
 Inhibition of ejaculation or impotence in
men
Side Effects:
Extrapyramidal Side Effects
 Pseudoparkinson
 Drooling, lack of facial responsiveness,
shuffling gait, and fine intentional tremors.
 Acute Dystonia
 Muscle spasms of the jaw, tongue, neck or
eyes. Laryngeal spasms possible. Oculogyric
crisis, Opisthotonos.
 Akathisia
 Motor restlessness, pacing, rocking, etc
Side Effects:
Extrapyramidal Side Effects

Tardive Dyskinesia

 Bizarre facial and tongue movements

chewing, tongue from side to side, etc.
 Involuntary tonic muscular spasms of
extremities
 Trunk
 Potentially irreversible
Side Effects:
a2 Block: Cardiovasclar

 Hypotension
 Postural hypotension
 Tachycardia
Side Effects:
Rare and Toxic Effects

 Agranulocytosis
 Cholestatic jaundice
 Neuroleptic malignant syndrome
(NMS)
 Severe extrapyramidal
 Hyperpyrexia
 Autonomic dysfunction
NEUROLEPTIC MALIGNANT
SYNDROME
 RARE, POTENTIALLY FATAL
 ONSET WITHIN HOURS OR YEARS
 EPS REACTIONS
 CPK
 HYPERTHERMIA 102° AND ABOVE
 TACHYCARDIA
 FLUCTUATING B.P.
 DIAPHORESIS
 STUPOR AND COMA
AGRANULOCYTOSIS

 Potentially fatal disorder

 Symptoms include:
 White blood cells level <2000 mm3 or
granulocyte count <1500mm3
 Sore throat
 Low grade fever
 Malaise
 Sores in the mouth
NURSING IMPLICATIONS

 MONITOR B.P. BEFORE

ADMINISTERING MEDS
 CHECK CBC, CPK, LIVER FUNCTIONS
AND VISION REGULARLY
 EVALUATE FOR EFFECTIVENESS AND
SIDE EFFECTS
 ADMINISTER 1 OR 2 HOURS BEFORE
BEDTIME
 MIX LIQUIDS WITH 60CC FRUIT JUICE
 PATIENT EDUCATION
ANTIPARKINSON AGENTS

 COGENTIN
 ARTANE
 AKINETON
 PARLODOL
 KEMADRIN
 BENEDRYL
 CLIENT AND FAMILY TEACHING

 Teach about schizophrenia and available mental

health agencies for support at the local and
national level (NAMI AND NIMH).
 Develop a relapse prevention plan.
 Teach about medication and treatment
compliance.
 Teach to avoid alcohol or drugs.
 Teach to keep in touch with supportive people.
 Teach to keep healthy – stay in balance.
Thank
You
!