Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Schizophrenia

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 16

Schizophrenia

Chapter 16

Schizophrenia


SchizophreniaSchizophrenia

• Distorted and bizarre thoughts, perceptions, emotions, movements, behavior

• Categories of symptoms

– Positive (hard)• Delusions, hallucinations; grossly disorganized

thinking, speech, behavior

– Negative (soft)• Flat affect, lack of volition, social withdrawal, or

discomfort


Types of SchizophreniaTypes of Schizophrenia

• Paranoid type

• Disorganized type

• Catatonic type

• Undifferentiated type

• Residual type


Clinical CourseClinical Course

• Onset: abrupt or insidious; most with slow, gradual development of signs, symptoms

• Diagnosis usually with more actively positive symptoms of psychosis


Clinical Course (cont.)Clinical Course (cont.)

• Immediate course: two patterns

– Ongoing psychosis, never fully recovering;

– Episodes of psychotic symptoms alternating with episodes of relatively complete recovery

• Long-term course: intensity of psychosis diminishes with age; most with difficulty functioning; few with ability to live fully independent lives


Related Disorders Related Disorders • Schizophreniform disorder

• Catatonia

• Delusional disorder

• Brief psychotic disorder

• Shared psychotic disorder

• Schizotypical personality disorder


EtiologyEtiology

• Biologic theories

– Genetic factors (partial inheritance)

– Neuroanatomic and neurochemical factors (less brain tissue and cerebrospinal fluid; dopamine excess and serotonin modulation of dopamine or excess)

– Immunovirologic factors (viral exposure; cytokines)


QuestionQuestion

• Is the following statement true or false?

• Positive symptoms of schizophrenia include a flat affect and social withdrawal.


AnswerAnswer

• False

• Rationale: Flat affect and social withdrawal are negative symptoms of schizophrenia.


Cultural Considerations Cultural Considerations

• Ideas considered delusional in one culture possibly commonly accepted by other cultures

• Auditory or visual hallucinations as normal part of religious experiences in some cultures

• Culture-bound syndromes

• Ethnic differences in response to psychotropic medications


PsychopharmacologyPsychopharmacology

• Conventional antipsychotics (dopamine antagonists; see Table 16.1)– Targeting positive symptoms

– No observable effect on negative symptoms

• Atypical antipsychotics (dopamine, serotonin antagonists)– Diminish positive symptoms

– Lessen negative symptoms


Psychopharmacology: Maintenance Therapy Psychopharmacology: Maintenance Therapy

• Two antipsychotics available in depot injection forms:

– Fluphenazine (Prolixin) in decanoate and enanthate

– Preparations

– Haloperidol (Haldol) in decanoate

• Effects last 2 to 4 weeks; eliminate need for daily oral antipsychotic medication


Psychopharmacology: Side EffectsPsychopharmacology: Side Effects

• Neurologic side effects:– Extrapyramidal side effects

• Acute dystonic reactions• Akathisia• Parkinsonism

– Tardive dyskinesia

– Seizures

– Neuroleptic malignant syndrome


Psychopharmacology: Side Effects (cont.) Psychopharmacology: Side Effects (cont.)

• Nonneurologic side effects

– Weight gain, sedation, photosensitivity

– Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention)

– Orthostatic hypotension

– Agranulocytosis (clozapine)


Psychosocial Treatment Psychosocial Treatment

• Individual, group therapies– Supportive, medication management, use of

community supports

• Social skills training – Cognitive adaptation training – Cognitive enhancement therapy (CET)

• Family therapy

• Family education


QuestionQuestion

• Which of the following would be considered a neurologic side effect of antipsychotic therapy?

– A. Blurred vision

– B. Agranulocytosis

– C. Sedation

– D. Tardive dyskinesia


AnswerAnswer

• D. Tardive dyskinesia

• Rationale: Tardive dyskinesia is a neurologic side effect of antipsychotic therapy.

– Blurred vision, sedation, and agranulocytosis are nonneurologic side effects.


Schizophrenia and Nursing Process Application Schizophrenia and Nursing Process Application

• Assessment

– History: previous history with schizophrenia; previous suicidal ideation; current support system; patient’s perception of current situation

– General appearance, motor behavior, speech (odd, bizarre; catatonia; echopraxia, psychomotor retardation, word salad, echolalia, latency of response [see Box 16.3])


Schizophrenia and Nursing Process Application (cont.)Schizophrenia and Nursing Process Application (cont.)• Assessment (cont.)

– Mood, affect (flat, blunted; anhedonia)

– Thought process, content (thought blocking, broadcasting, withdrawal, or insertion)

– Delusions (see Box 16.4)

– Sensorium, intellectual processes (hallucinations [auditory, visual, olfactory, tactile, gustatory, cenesthetic, kinesthetic; command]; depersonalization)


Schizophrenia and Nursing Process Application (cont.)Schizophrenia and Nursing Process Application (cont.)• Assessment (cont.)

– Judgment, insight (usually impaired)

– Self-concept (loss of ego boundaries; ideas of reference)

– Roles, relationships (social isolation)

– Physiologic, self-care (inattention to hygiene and grooming; failure to recognize sensations; polydipsia)


Schizophrenia and Nursing Process Application (cont.)Schizophrenia and Nursing Process Application (cont.)

• Data analysis/nursing diagnoses– Risk for other-directed violence r/t

– Risk for suicide r/t

– Disturbed sensory perception r/t

– Disturbed personal identity r/t

– Impaired verbal communication r/t



• Outcome identification (acute psychosis; treatment)

– Focus on safety of patient and others

– Stabilize patient’s thought process

– Reality orientation


Schizophrenia and Nursing Process Application (cont.)Schizophrenia and Nursing Process Application (cont.)• Interventions

– Safety of patient, others

– Therapeutic relationship; therapeutic communication

– Interventions for delusional thoughts (focus on reality; no confrontation or reinforcement)

– Interventions for hallucinations

– Management of socially inappropriate behavior



• Interventions (cont.)

– Patient, family education• Signs, symptoms of relapse (see Box 16.5)• Self-care, nutrition • Social skills • Medication management

• Evaluation


QuestionQuestion

• Is the following statement true or false?

• The nurse should confront a patient’s delusions.


AnswerAnswer

• False

• Rationale: When a patient is experiencing delusions, the nurse should focus on the reality and not confront or reinforce the patient’s delusions.


Elder Considerations Elder Considerations

• Late onset: after age 45

• Psychotic symptoms later in life usually associated with depression or dementia, not schizophrenia


Elder Considerations (cont.) Elder Considerations (cont.)

• Variety of long-term outcomes for elderly

– Approximately one fourth experiencing dementia, resulting in steady, deteriorating health decline

– Approximately one fourth experiencing reduction in positive symptoms

– Remainder mostly unchanged


Community-Based CareCommunity-Based Care

• Housing with family or independently

• Assertive community treatment (ACT)

• Behavioral home health care

• Community support programs

• Case management services


Mental Health PromotionMental Health Promotion• Goal of psychiatric rehabilitation: patient recovery

• Accurate identification of those at risk

• Early intervention

– Improved prodromal symptoms

– Prevention of social stagnation or decline

– Prevention or delay of progression to psychosis


Self-Awareness IssuesSelf-Awareness Issues

• Challenge when the patient suspicious or mistrustful or nurse frightened

• Frustration if the patient noncompliant

• Need not to take patient’s success or failure personally

• Patient’s strengths, time out of hospital as focus

• No nurse has all the answers.

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Schizophrenia