Schizophrenia

INTRODUCTION
• The word schizophrenia, derived from Greek, literally means ‘split
mind’: ‘schizo’= split; ‘phren’ = mind
• Schizophrenia causes distorted and bizarre thoughts, perceptions,
emotions, movements, and behavior.
• It cannot be defined as a single illness; rather, schizophrenia is thought
of as a syndrome
Epidemiology
• Schizophrenia is usually diagnosed in late adolescence or early
adulthood.
• Rarely does it manifest in childhood.
• The peak incidence of onset is 15 to 25 years of age for men and 25 to
35 years of age for women.
• The prevalence of schizophrenia is estimated at about 1% of the total
population.
• The incidence and the lifetime prevalence are roughly the same
throughout the world
Symptoms of schizophrenia
• Positive or Hard Symptoms
• Negative or soft symptoms/signs
• Medication may control the positive symptoms, but frequently, the
negative symptoms persist after positive symptoms have abated.
• The persistence of these negative symptoms over time presents a
major barrier to recovery and improved functioning in the client’s daily
life.
 Schizoaffective disorder
• Diagnosed when the client is severely ill and has a mixture of psychotic
and mood symptoms.
• The signs and symptoms include those of both schizophrenia and a
mood disorder such asdepression or bipolar disorder.
• The symptoms may occur simultaneously ormay alternate between
psychotic and mood disorder symptoms.
Onset of schizophrenia
• Onset may be abrupt or insidious, but most clients slowly and gradually
develop signs and symptoms such as social withdrawal, unusual
behavior, loss of interest in school or at work, and neglected hygiene.
• The diagnosis of schizophrenia is usually made when the person begins
to display more actively positive symptoms of delusions, hallucinations,
and disordered thinking (psychosis).
Immediate-Term Course
• Pattern 1, the client experiences ongoing psychosis and never fully
recovers, though symptoms may shift in severity over time.
• Pattern 2, the client experiences episodes ofpsychotic symptoms that
alternate with episodes of relatively complete recovery from the
psychosis.
Long-Term Course
• The intensity of psychosis tends to diminish with age.
• Many clients with long-term impairment regain some degree of social
and occupational functioning.
• In later life, these clients may live independently or in a structured
family-type setting and may succeed at jobs with stable expectations and
a supportive work environment
Schizophreniformdisorder
• The client exhibits an acute, reactive psychosis for less than the 6
months necessary to meet the diagnostic criteria for schizophrenia.
• If symptoms persist over 6 months, the diagnosis is changed to
schizophrenia.
• Social or occupational functioning may or may not be impaired.
 Catatonia
• Catatonia is characterized by marked psychomotor disturbance, either
excessive motor activity or virtual immobility and motionlessness.
• Motor immobility may include catalepsy (waxy flexibility) or stupor.
• Excessive motor activity is apparently purposeless and not influenced
by external stimuli.
• Other behaviors include extreme negativism, mutism, peculiar
movements, echolalia, orechopraxia.
• Catatonia can occur with schizophrenia, mood disorders, or other
psychotic disorders.
Delusional disorder
• The client has one or more nonbizarre delusions— that is, the focus of
the delusion is believable.
• The delusion may be persecutory, erotomanic, grandiose, jealous, or
somatic in content.
• Psychosocial functioning is not markedly impaired, and behavior is not
obviously odd orbizarre.
Brief psychotic disorder
• The client experiences the sudden onset of at least one psychotic
symptom, such asdelusions, hallucinations, or disorganized speech or
behavior, which lasts from 1 day to1 month.
• The episode may or may not have an identifiable stressor or may follow
childbirth.
Shared psychotic disorder
• Two people share a similar delusion.
• The person with this diagnosis develops this delusion in the context of
a close relationship with someone who has psychotic delusions, most
commonly siblings, parent and child, orhusband and wife.
• The more submissive or suggestible person may rapidly improve if
separated from the dominant person.
Schizotypal personality disorder
• This involves odd, eccentric behaviors, including transient psychotic
symptoms.
• Approximately 20% of persons with this personality disorder will
eventually be diagnosed with schizophrenia.
 ETIOLOGY
Biologic Theories
Genetic Factors
• Identical twins have a 50% risk of schizophrenia
• Fraternal twins have only a 15% risk
• Children of one biologic parent with schizophrenia have a 15% risk, if
both= 35%
Biologic Theories
Neuroanatomic and Neurochemical Factors
• Less brain tissue and cerebrospinal fluid
• Enlarged ventricles in the brain and cortical atrophy
• The research consistently shows decreased brain volume and abnormal
brain function inthe frontal and temporal areas of persons with
schizophrenia. (Positive symptoms)
• Intrauterine influences, such as poor nutrition, tobacco, alcohol, and
other drugs, and stress are also being studied as possible causes
• Studies have implicated the actions ofdopamine, serotonin,
norepinephrine, acetylcholine, glutamate, and several neuromodulary
peptides.
• Currently, the most prominent neurochemical theories involve
dopamine and serotonin (excess dopamine), (serotonin modulates and
helps to control excess dopamine).
Biologic Theories
Immunovirologic Factors
• It is believed that cytokines may have a role inthe development of
major psychiatric disorders such as schizophrenia
• Recently, researchers have been focusing oninfections in pregnant
women as a possible origin for schizophrenia.
 TREATMENT
• Psychopharmacology
• Antipsychotic medications are prescribed primarily for their efficacy in
decreasing psychotic symptoms.
• The first-generation antipsychotics target the positive signs of
schizophrenia
• The second-generation antipsychotics not only diminish positive
symptoms but also lessen the negative signs
Maintenance Therapy
• Six antipsychotics are available as long-acting injections (LAIs), formerly
called depot injections
Fluphenazine (Prolixin) in decanoate and enanthate preparations
Haloperidol (Haldol) in decanoate Risperidone (Risperdal Consta)
Paliperidone (Invega Sustenna) Olanzapine (Zyprexa Relprevv)
Aripiprazole (Abilify Maintena)
Extrapyramidal Side Effects
• EPSs are reversible movement disorders induced by neuroleptic
medication. They include dystonic reactions, parkinsonism, and
akathisia.
Psychosocial Treatment
• Individual and group therapies, family therapy, family education, and
social skills training can be instituted for clients in both inpatient and
community settings.
• A newer therapy, cognitive enhancement therapy (CET), combines
computer-based cognitive training with group sessions that allow clients
to practice and develop social skills.
Good prognostic factors
• Female gender • Acute onset • Clear precipitating event
• Prominent affective symptoms • Early initiation of treatment
• Good response to treatment • Good occupational adjustment
• Stable family factors
 Poor prognostic factors
• Onset at an early age • Insidious onset • Long duration of
untreated psychosis • Prominent negative symptoms • Pre-morbid
personality problems • Co-morbid alcohol or drug abuse
• Family factors: e.g. high expressed emotions.

APPLICATION OF THE NURSING PROCESS

History
• client’s previous history • age at onset of schizophrenia
• previous history of hospital admissions • previous suicide attempts
(10% eventually commit suicide) • history of violence or aggression
• assesses whether the client has been using current support systems
• client’s perception of his or her current situation
General Appearance
• Appearance may vary widely among different clients with
schizophrenia. • Some appear normal in terms of being dressed
appropriately • Others exhibit odd or bizarre behavior
Motor Behavior
• Catatonia: restless and unable to sit still, exhibit agitation and pacing,
or appear unmoving • stereotypic behavior: demonstrate
seemingly purposeless gestures • odd facial expressions
• Echopraxia: The client may imitate the movements and gestures of
someone whom he or she is observing • Rambling speech is likely to
accompany these behaviors. • Psychomotor retardation: a general
slowing of all movements) • Sometimes the client may be almost
immobile, curled into a ball (fetal position) • waxy flexibility- catatonia.
 Speech
• Echolalia: repetition or imitation of what someone else says
• Latency of response: refers to hesitation before the client responds to
questions. This latency or hesitation may last 30 or 45seconds and
usually indicates the client’s difficulty with cognition or thought
processes • Clang associations: are ideas that are related to one
another based on sound or rhyming rather than meaning. • Neologisms
are words invented by the client. • Verbigeration is the stereotyped
repetition ofwords or phrases that may or may not have meaning to the
listener. • Stilted language is use of words or phrases that are flowery,
excessive, and pompous. • Perseveration is the persistent adherence
to a single idea or topic and verbal repetition of a sentence, phrase, or
word, even when another person attempts to change the topic. •
Word salad is a combination of jumbled words and phrases that are
disconnected or incoherent and make no sense to the listener.
Mood and Affect
• Flat affect: no facial expression
• Blunted affect: few observable facial expressions
• Inappropriate expression or emotions incongruent with the context of
the situation
• Anhedonia: The client may report feeling depressed and having no
pleasure or joy in life
Thought Process and Content
• Thought blocking: suddenly stop talking in the middle of a sentence
and remain silent for several seconds to 1 minute
• Thought broadcasting: They may also state that they believe others can
hear their thoughts
• Thought withdrawal: others are taking their thoughts
• Thought insertion: others are placing thoughts in their mind against
theirwill.
• Tangential thinking: which is veering onto unrelated topics and never
answering the original question
• Circumstantiality: the client gives unnecessary details or strays from
the topic but eventually provides the requested information
• Poverty of content (alogia): describes the lack of any real meaning or
substance in what the client
 Delusions
• Fixed, false beliefs with no basis in reality
• Persecutory/paranoid delusions involve the client’s belief that “others”
are planning to harm him or her or are spying, following, ridiculing, or
belittling the client in some way. Sometimes the client cannot define
who these “others” are.
• Grandiose delusions are characterized by the client’s claim to
association with famous people or celebrities, or the client’s belief that
he or she is famous or capable of great feats.
• Religious delusions often center around the second coming of Christ or
another significant religious figure or prophet
• Somatic delusions are generally vague and unrealistic beliefs about the
client’s health orbodily functions.
• Sexual delusions involve the client’s belief that his or her sexual
behavior is known to others; that the client is a rapist, prostitute, or
pedophile or is pregnant; or that his or her excessive masturbation has
led to insanity.
• Nihilistic delusions are the client’s belief that his or her organs aren’t
functioning or are rotting away, or that some body part or feature is
horribly disfigured or misshapen.
• Referential delusions or ideas of reference involve the client’s belief
that television broadcasts, music, or newspaper articles have special
meaning for him or her.
 Sensorium and Intellectual Processes
• Hallucinations: false sensory perceptions, or perceptual experiences
that do not exist inreality.
• Illusions: misperceptions of actual environmental stimuli
• Auditory hallucinations, the most common type, involve hearing
sounds, most often voices, talking to or about the client. There may be
one or multiple voices; a familiar or unfamiliar person’s voice may be
speaking. Command hallucinations are voices demanding that the client
take action, often to harm the self or others, and are considered
dangerous.
•Visual hallucinations involve seeing images that do not exist at all, such
as lights or a dead person, or distortions such as seeing a frightening
monster instead of the nurse. They are the second most common type of
hallucination.
• Olfactory hallucinations involve smells orodors. They may be a specific
scent such asurine or feces or a more general scent such as a rotten or
rancid odor.
• Tactile hallucinations refer to sensations such as electricity running
through the body or bugs crawling on the skin. Tactile hallucinations are
found most often in clients undergoing alcohol withdrawal; they rarely
occur in clients with schizophrenia.
• Gustatory hallucinations involve a taste lingering in the mouth or the
sense that food tastes like something else. The taste may be metallic or
bitter or may be represented as a specific taste.
Cenesthetic hallucinations involve the client’s report that he or she feels
bodily functions that are usually undetectable. Examples would be the
sensation of urine forming or impulses being transmitted through the
brain.
• Kinesthetic hallucinations occur when the client is motionless but
reports the sensation of bodily movement. Occasionally, the bodily
movement is something unusual, such as floating above the ground.
 Judgment and Insight
• Judgment is frequently impaired in the client with schizophrenia
• Insight can also be severely impaired, especially early in the illness,
when the client, family, and friends do not understand what is
happening.
Self-Concept
• The loss of ego boundaries
• This lack of ego boundaries is evidenced by depersonalization,
derealization (environmental objects become smaller or larger or seem
unfamiliar), and ideas of reference.
Roles and Relationships
• Social isolation is prevalent in clients with schizophrenia
• Clients also have problems with trust and intimacy
• Low self-esteem, one of the negative signs of schizophrenia
• The client may experience great frustration in attempting to fulfill roles
in the family and community.
Physiological and Self-Care Considerations
• Significant self-care deficits • Inattention to hygiene and grooming
needs is common • Fails to perform even basic activities of daily living
• Malnourishment and constipation • Polydipsia
Data Analysis
• (NANDA) nursing diagnoses based on the assessment of psychotic
symptoms or positive signs are:
Risk for other-directed violence Risk for suicide
Disturbed thought processes Disturbed sensory perception
Disturbed personal identity Impaired verbal communication
Data Analysis
• (NANDA) nursing diagnoses based on the assessment of negative signs
and functional abilities include:
Self-care deficits. Social isolation. Deficient diversional activity
Ineffective health maintenance. Ineffective therapeutic regimen
management.
 Outcome Identification
Examples of outcomes appropriate to the acute, psychotic phase of
treatment are:
• The client will not injure him or herself or others.
• The client will establish contact with reality.
• The client will interact with others in the environment.
• The client will express thoughts and feelings in a safe and socially
acceptable manner.
• The client will participate in prescribed therapeutic interventions.
Outcome Identification
Examples of treatment outcomes for continued care after the
stabilization of acute symptoms are:
• The client will participate in the prescribed regimen (includin
medications and follow-up appointments).
• The client will maintain adequate routines for sleeping and food and
fluid intake.
• The client will demonstrate independence in self-care activities.
• The client will communicate effectively with others in the community
to meet his or her needs.
• The client will seek or accept assistance to meet his or her needs when
indicated.

NURSING INTERVENTIONS
• Promoting safety of client and others and right to privacy and dignity
• Establishing therapeutic relationship byestablishing trust
• Using therapeutic communication (clarifying feelings and statements
when speech and thoughts are disorganized or confused)
• Interventions for delusions:
Do not openly confront the delusion or argue with the client.
Establish and maintain reality for the client.
Use distracting techniques.
Teach the client positive self-talk, positive thinking, and to ignore
delusional beliefs.
 • Interventions for hallucinations:
Help present and maintain reality by frequent contact and
communication with client.
Elicit description of hallucination to protect the client and others.
The nurse’s understanding of the hallucination helps him or her
know how to calm or reassure the client.
Engage client in reality-based activities, such as card playing,
occupational therapy, or listening to music.
• Coping with socially inappropriate behaviors:
Redirect the client away from problem situations.
Deal with inappropriate behaviors in a nonjudgmental and matterof-
fact manner; give factual statements; and do not scold the client.
Reassure others that the client’s inappropriate behaviors or comments
are not his or her fault (without violating client confidentiality).
Try to reintegrate the client into the treatment milieu as soon as
possible.
Do not make the client feel punished or shunned for inappropriate
behaviors.
Teach social skills through education, role modeling, and practice.
• Client and family teaching.
• Establishing community support systems and care.
Early Signs of Relapse
• Impaired cause-and-effect reasoning • Impaired information
processing • Poor nutrition • Lack of sleep • Lack of exercise
• Fatigue • Poor social skills, social isolation, loneliness
• Interpersonal difficulties • Lack of control, irritability • Mood swings
Early Signs of Relapse
• Ineffective medication management • Low self-concept
• Looks and acts different • Hopeless feelings • Loss of motivation
• Anxiety and worry • Disinhibition • Increased negativity
• Neglecting appearance • Forgetfulness
Clients and family education forschizophrenia
• How to manage illness and symptoms • Recognizing early signs of
relapse • Developing a plan to address relapse signs • Importance of
maintaining prescribed medication regimen and regular follow-up
• Avoiding alcohol and other drugs • Self-care and proper nutrition.
 Clients and family education for schizophrenia
• Teaching social skills through education, role modeling, and practice
• Seeking assistance to avoid or manage stressful situations
• Counseling and educating family/significant others about the biologic
causes and clinical course of schizophrenia and the need for ongoing
support
• Importance of maintaining contact with the community and
participating in supportive organizations and care

The end