Chapter 24 Schizophrenia

Explain the term of psychosis

• a state in which a person experiences hallucinations, delusions, or disorganized thoughts, speech, or behavior

• is the key diagnostic factor in schizophrenia spectrum disorders.

Schizophrenia

• Split minds,1st rank symptoms (psychosis), 2nd rank symptoms, Bizzare delusions

• Chronic illness: detrtioates with time and then plateaus

• Core symptoms: Positive & negative symptoms for significant portion of 1month period but with continuous signs of disturbance for ≥6months

  • Neurocognitive impairment

• Disorganized thinking: confused speech and thinking

• Disorganized behavior

• Disruption of sense of self: self-disturbance

Schizoaffective disorder (SAD)

• PSYCHOSIS + MOOD DISTURBANCE OCCUR AT SAME TIME

• Periods of intense symptom exacerbation alternative with periods of adequate psychosocial functioning

• Maked by psychosis and other times marked by Mood disturbance

• Longterm SAD better outcome than schizophrenia but worse than mood disorder patients

• Higher functioning than schizophrenics

• Risk for suicide

  • Increase with use of:

    • ETOH

    • Cigarette smoking

    • Previous suicide attempts

    • Hospitalizations

• Treatments:

  • Enhance social network & contact

  • Focused on helping patients protect selves against environmental stressors

Delusional disorder

• 1 or more delusion present for at least 1 month

• Delusions are primary symptoms

• Stable and well-systematized delusions that occur in the absence of other psychiatric disorders

• Can be acute or chronic

• Rarely receive help

• Acting on delusion can violate laws or social norms

• Behavior is remarkably normal except when patient focuses on delusions

• Personality does not change but they get more involved with delusional concern

• UNCOMMON

• Examples of delusions

  • Being followed

  • Poisoned

  • Infected

  • Loved at distance

  • Deceived by spouse or lover

Schizophreniform

• Similar to schizophrenia but duration is >6months

• Symptoms present for ≥1 month to be classified

• 1/3 recover & 2/3 develop schizophrenia

Brief psychotic disorder

• Episode lasts 1 month>x ≥1day

• Sudden onset with ≥1 positive sign of schizophrenia

• Emotional turmoil or overwhelming confusion and rapid, intense shifts of affect

• Severe impairment

• Supervision needed

• Suicide risk in younger patients especially

Psychotic disorders attributable to a substance

• Prominent hallucinations or delusions thata re direct physiologic effects of substance

• During intoxication sympyoms continue as long as substance continues

• Withdrawal symptoms last ≤4wks

• Differential diagnosis recommended

Describe the clinical course of schizophrenia (prodromal, acute, stabilization, and recovery but include issues of relapse)

Prodromal.     

Acute Illness period

Stabilization­

Recovery.    

  Relapses

Prodromal

• Early changes that are a precursor to the disorder

• iiBegin in childhood

• Finding at this stage treatment can begin earlier

• 50%+ report symptoms:

  • Tension

  • Nervousness

  • Lack of interest in eating

  • Difficulty concentrating

  • Disturbed sleep

  • Decreased enjoyment

  • Loss of interest in things

  • Feeling too excited

  • Hearing voices or seeing things

. Acute Illness period

• Occur during adolescence and Young Adulthood

• Subtle–Bizarre/disruptive behaviors¬¬

• As symptoms worsen, they are unable to perform ADL

• High risk of Suicide, may need hospitalization

• Symptoms:

  • Staying up all night for several nights

  • Incoherent conversations

  • Aggressive acts against self or others

• Treatment:

  • alleviate of symptoms through therapy with medications

  • Normalizing sleep

  • Reduce substance use

Stabilization

• The focus after diagnosis

• Less acute but present symptoms

• Treatment is intense with medication regiments established

• Substances are eliminated

• Family needs to cope

• Socialization with others increases so rehab begins

Recovery

Goal-live well, no cure

Relapses

Main reason is non adherence to meds

Define the positive symptoms of schizophrenia

a. Sensory Hallucinations & delusions (grandiose, nihilistic, persecutory, and somatic)

b. excessive or distorted thoughts and perceptions that occur within the individual but are not experienced by others.

c. reflect an excess or distortion of normal functions

Define the negative symptoms of schizophrenia

• emotions and behaviors that should be present but are diminished in persons with schizophrenia.

• Flat affect

• Diminished emotional expression

• Alogia

• avolition (lack of interest or motivation in goal-directed behavior such as getting dressed, going to work or school) effects ADL

• Ambivalence

• Anhedonia

Define the neurocognitive symptoms of schizophrenia

• May be independent of positive & negative symptoms

• Short and Long-term memory

  • Long-term isn’t necessarily impacted

• Vigilance or sustained attention

• Verbal fluency or ability to generate new words

• Executive functioning: Volition, planning, purposeful action, & self-monitoring

• Cognitive dysfunction can exist evin if positive symptoms are in remission

• Manifested in disorganized symptoms

• Low intellectual functioning

Describe the disorganized thinking terms

Confused speech and thinking

DEF: findings that make it difficult for the person to understand and respond to the ordinary sights and sounds of daily living.

Echolalia

Repetition of another person’s words or phrases, often in a parrot-like manner. Common in schizophrenia, autism, or catatonia.

Circumstantiality

Overly detailed speech that eventually reaches the point — the person includes unnecessary information but does return to the main idea. 🧠 Seen in anxiety or obsessive personalities.

Loose association

Ideas shift from one topic to another with little or no logical connection. The conversation is hard to follow. 🧠 Typical of schizophrenia.

Tangentiality

Person goes off-topic and never returns to the main point. The answer is only loosely related or unrelated to the question. 🧠 Seen in schizophrenia or mania.

Flight of ideas

Rapid, continuous speech with frequent topic changes based on loosely connected or play-on-word associations. 🧠 Seen in manic episodes.

Neologisms

Made-up words or expressions that have meaning only to the person using them. 🧠 Common in schizophrenia.

Paranoia

Irrational distrust or suspicion of others; belief that others are out to harm, deceive, or persecute. 🧠 Common in paranoid schizophrenia or delusional disorder.

Referential thinking (Ideas of reference)

Belief that ordinary events or people have special personal meaning or messages for the individual (e.g., “The TV is talking to me”).

Autistic thinking

Private, inward-focused thinking that is disconnected from reality or logic; preoccupation with one’s own inner world or fantasies. 🧠 Seen in schizophrenia or autism spectrum.

Concrete thinking

Literal interpretation of information; difficulty understanding abstract concepts, jokes, or metaphors. 🧠 “Don’t cry over spilled milk” is taken literally.

Verbigeration (sometimes called Vervigeration)

Senseless repetition of words, phrases, or sentences, often without meaning or connection to conversation. 🧠 Seen in schizophrenia or catatonia.

Metonymic speech

Use of words with related meaning instead of the exact term, often showing disorganized thought. Example: saying “the crown” instead of “the queen.”

Clang association

Speech based on sound or rhyme rather than meaning, e.g., “The train brain rain pain.” 🧠 Common in mania or schizophrenia.

Stilted language

Overly formal, pompous, or artificial speech, often inappropriate to the situation. 🧠 Seen in schizophrenia or autism.

Pressured speech

Rapid, uninterruptible speech that feels driven or urgent; the person talks nonstop and can’t be interrupted. 🧠 Classic in manic episodes.

Describe the disorganized behavior terms

DEF: Disorganized behavior (which may manifest as very slow, rhythmic, or ritualistic movement), coupled with disorganized speech, makes it difficult for the person to partake in daily activities

Here are definitions for the terms you listed, primarily used in psychiatry and mental health contexts:

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1. Agitation

A state of excessive psychomotor activity that is often associated with a feeling of inner tension.

• Features: Restlessness, pacing, hand-wringing, inability to sit still, irritability.

• Common in: Anxiety, mania, delirium, psychosis.

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2. Catatonia

A neuropsychiatric syndrome characterized by abnormal movements, behaviors, and postures.

• Symptoms: Can include stupor, mutism, negativism, posturing, rigidity, and waxy flexibility.

• Seen in: Schizophrenia, mood disorders, and some medical conditions.

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3. Catatonic Excitement

A subtype of catatonia marked by extreme motor agitation and purposeless, excessive movement.

• Behaviors: Running, shouting, impulsivity, aggression.

• Danger: High risk of exhaustion, injury, or harm to others.

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4. Echopraxia

The involuntary imitation of another person's movements or gestures.

• Associated with: Schizophrenia (especially catatonic type), autism spectrum disorders, and other neurological conditions.

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5. Regressed Behavior

A return to an earlier stage of development, typically in response to stress or psychological conflict.

• Examples: Childlike behaviors such as thumb-sucking, bed-wetting, or temper tantrums in adults.

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6. Hypervigilance

An enhanced state of sensory sensitivity and exaggerated intensity of behaviors aimed at detecting threats.

• Signs: Being constantly on guard, easily startled, scanning the environment.

• Common in: PTSD, anxiety disorders.

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7. Waxy Flexibility

A symptom of catatonia where a person maintains a position in which their body is placed, even if it is unusual or uncomfortable.

• Example: If you raise their arm, they keep it in that position like a wax figure.

• Diagnostic Clue: Strong indicator of catatonia.

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Let me know if you want clinical examples or differentiations between similar terms.

Explain the concerns of schizophrenia across the life-span: Children

• Rare occurrence

• Same symptoms as adults

• More genes that can give them schizophrenia

• iWorse diagnosis

• VH

• Less developed delusions

• disorganized speech and behavior may be explained better by other disorders that are more common in childhood, those disorders should be considered before applying the diagnosis of schizophrenia to a child.

• Signs can predict development of schizophrenia later in life

  • Delays in attainment and motor development

  • Problems in social adjustment

  • Poor Academic and cognitive performance

Explain the concerns of schizophrenia across the life-span: Elderly

• People who have it since childhood may experience improvement l8r in life

• Depends on effectiveness of earlier treatment, presence of support system, and interaction of environmental stressors and patient’s functional impairments

• More likely than other older adults to develop cognitive impairment

• High cost for care because many are no longer cared for in institutions and because community-based treatment has developed more slowly for this age group than for younger adults

Describe key epidemiology and risk factors with schizophrenia: Familial differences

• 1st degree biologic relatives have 10x greater risk for schizophrenia than general population

• SAD increased for other relatives

Describe key epidemiology and risk factors with schizophrenia: Age of onset

• Usually diagnosed in late adolescence and early adulthood

  • Men: 18-25

  • Women: 25-35

• The earlier the diagnosis and the longer the psychosis remains untreated, the more severe the disorder becomes

Describe key epidemiology and risk factors with schizophrenia: Gender differences

• Men diagnosed earlier with poorer prognosis than women

• When women are diagnosed early, they are at higher risk for physical comorbidities than men

Describe key epidemiology and risk factors with schizophrenia: Ethnicity and culture

• AA overdiagnosed

• African American and Latinx individuals with bipolar disorder are more likely to have misdiagnoses of schizophrenia than are White individuals

• Asian undiagnosed

• a All cultures and countries, 0.48% world wide

Recognize the complexity of comorbidities with schizophrenia

• Mortality: people die 20yrs earlier than gen pop

• Natural

  • Cardiovascular

  • Cancer

  • COPD

  • DM

  • Influenza

  • Pneumonia

• ii. Unnatural

  • Suicide

  • Substance abuse

  • ETOH abuse

  • Legal interventions

• MORE susceptible to TB, Human immunodeficiency disease, Hep B & C, osteoporosis, poor dentition, impaired lung function, altered (reduced) pain sensitivity, sexual dysfunction, obsreric complications, cardiovascular problems, hyperpigmentation, obesity, DM, metabolic syndrome with hyperlipidemia, polydipsia, thryroids dysfunction, hyperprolactinemia

Describe key etiology aspects of schizophrenia

• Biologic predisposition or vulnerability and environmental stressors

  • Diathesis-stress model

• Environmental stressors

  • Pregnancy

  • Obstetric complications

  • Social adversity

  • Migration

  • Unemployment

  • Urban living

  • Childhood abuse

  • Social isolation/abscense of close friends

• Biologic theories

• Psychosocial theories

Explain the concern of suicide risk with patients with schizophrenia

• Acts of aggression to staff or self during psychosis

• displaying negative symptoms, side effects of antipsychotic medications, or actual depression and demoralization as a result of this illness.

• Voices can tell them to harm self or others

Describe key areas of assessment (biological, psychological and social) and the unique challenges with each area (e.g. hallucinations vs. delusions)

• Biological

• Pyschological

• Social

• Hallucinations vs. Delusions

Explain the interventions to promote recovery and wellness with patients with schizophrenia

• Consider medication side effects

• Temperature regulation

  • monitor temp

  • observe reaction to temp

  • protect from weather

• Fluid and electrolyte balance

  • observe for polydipsia

  • monitor urine specific gravity

• Help with ADL, hygiene, exercise, and nutrition

Describe the two categories of antipsychotics and how they are different

• 1st generation Typical antipsychotics

  • Haldol

  • Thorazine

    • Block D2 receptors

    • For positve signs of schizophrenia

  • Side effects:

    • EPS

    • TD

    • NMS

    • sedation and weight gain

    • orthostatic hypotension

• 2nd generation Atypical antipsychotics

  • Abilify

  • Clozaril

  • Risperdal

    • Blocks D2 and serotonin

    • Positive and negative signs

  • Side effects:

    • Metabolic syndrome

    • Sedation

    • orthostatic hypotension

    • (clozapine)

      • Agranulosis

      • New Onset DM

      • weight gain

    • Risperidal

      • Hyperlactecemia

Explain the concerns and treatments of cholinergic rebound and anticholinergic crisis

• Cholinergic rebound

  • Patient stops taking abruptly anticholinergic

  • SYMPTOMS:

    • Vomiting

    • Excessive sweating

    • Altered dreams

    • Nightmares

• Anticholinergic crisis

  • AKA anticholinergic delirium

  • Life threatening emergency caused by OD of or sensitivity to drugs with anticholinergic properties

  • Atropinr, scopolamine, belladonna alkoids

    • Symptoms:

      • 

Describe the nurses role in psychosocial interventions (therapeutic interactions, enhancing cognitive functioning, and behavioral interventions)

a. Therapeutic interactions

b. Enhancing cognitive functioning

c. Behavioral interactions

Describe areas of psychoeducation to encourage recovery (teaching strategies, teaching about symptoms, stress, wellness, social skills and family education)

• Teaching strategies

  • cogntive deficits

  • learn best in errorless environment, directly give correct information

  • ask encouraging questions

  • minimal distractions

  • Unambiguous directions

• Teaching about symptoms

  • teach hallucinations and delusions are part of disorder and meds make it easier

  • learn self regulation, symptom monitoring

• Stress

  • establish regular counseling sessions

  • positive coping

• Wellness

  • bot just physical health

  • (1) cognitive training and remediation that focus on cognitive impairments and social functioning (Miley et al., 2020) and could incorporate new methodologies that use virtual reality (Souto et al., 2020);

  • (2) support that provides information about the illness, addresses emotional needs, acknowledges the challenges of the illness, encourages the person, and provides guidance (Beentjes et al., 2020);

  • (3) goal setting with the individual that uses methodologies like the “Choose-Get-Keep” model that supports client goals over the imposition of provider goals

• Social skills

  • behaviors for social interactions

• Family education

  • family support

  • disease course

  • support systems

  • life manegment skills

Describe the Continuum of Care priorities

Discharge planning encourages follow-up care in the communit

Primary recovery strategy for patients becoming lost after discharge

• Emergency care

  • in hospital

  • trained crisis team

  • medication side effect

  • water intoxicatio

• Inpatient-Focused care

  • brief stabalization

• Community Care

  • Public support

• Virtual Mental Health care

  • rural ares

  • mobile or telephone

  • CBT

Describe the adverse effects of antipsychotics and nursing interventions

a. Neuroleptic malignant syndrome

b. Agranulocytosis

c. Extrapyramidal

d. Orthostatic hypotension

e. Hyperprolactinemia

f. Sedation

g. Weight gain

h. New-onset DM

i. Cardiac arrythmias

j. DRESS

Neuroleptic malignant syndrome

Definition:

• A rare, life-threatening reaction to antipsychotic medications caused by severe dopamine blockade in the brain.

Key signs/symptoms:

• High fever (hyperthermia)

• Severe muscle rigidity (“lead pipe” stiffness)

• Altered mental status

• Autonomic instability (↑ HR, BP fluctuations)

• Elevated creatine kinase (CK)

Nursing note:

• Medical emergency — stop the antipsychotic immediately, provide cooling, IV fluids, and administer dantrolene or bromocriptine as prescribed

Agranulocytosis

Definition:

• A dangerous drop in white blood cell count (neutrophils), leading to a high risk of infection.

Common cause:

• Seen with Clozapine (Clozaril) use.

• Symptoms:

• Fever, sore throat, malaise

• Signs of infection

Nursing note:

• Monitor WBC and ANC regularly; hold the drug and notify the provider if infection signs appear.

Extrapyramidal

Definition:

• Movement disorders caused by dopamine blockade from 1st-generation antipsychotics.

Types:

• Acute dystonia: muscle spasms, stiff neck, oculogyric crisis

• Akathisia: restlessness, can’t sit still

• Parkinsonism: tremor, rigidity, bradykinesia

• Tardive dyskinesia: repetitive mouth, tongue, facial movements (long-term)

Nursing note:

• Treat with anticholinergics (e.g., benztropine or diphenhydramine).

Orthostatic hypotension

Definition:

• A sudden drop in blood pressure when standing up from sitting or lying down.

Symptoms:

• Dizziness

• Lightheadedness

• Fainting

Nursing note:

• Encourage patient to rise slowly; monitor BP lying, sitting, standing

Hyperprolactinemia

Definition:

• An increase in prolactin hormone levels due to dopamine inhibition by antipsychotics.

Symptoms:

• Women: galactorrhea (milk secretion), amenorrhea

• Men: gynecomastia, sexual dysfunction

Nursing note:

• Common with Risperidone; may require dose adjustment or switching meds.

Sedation

Definition:

• A calming or drowsy effect caused by CNS depression from many antipsychotics.

Nursing note:

• Give medication at bedtime, avoid driving or operating heavy machinery until effects are known.

Weight gain

Definition:

• An increase in body weight due to changes in metabolism and appetite regulation.

Common with:

1. 2nd-generation antipsychotics, especially Clozapine and Olanzapine.

Nursing note:

• Monitor weight and BMI; encourage healthy diet and exercise.

New-Onset DM

Definition:

• Development of high blood glucose due to insulin resistance from atypical antipsychotics.

Common with:

• Olanzapine and Clozapine.

Nursing note:

• Monitor blood glucose, A1C, and teach patient about diet and symptoms of hyperglycemia (thirst, urination, fatigue).

Cardiac arrythmias

Definition:

• Abnormal heart rhythms that may result from QT interval prolongation caused by some antipsychotics.

Common offenders:

• Ziprasidone (Geodon), Haloperidol (especially IV).

Nursing note:

• Monitor ECG, avoid combining with other QT-prolonging drugs.

DRESS

(Drug Reaction with Eosinophilia and Systemic Symptoms)

Definition:

• A rare but serious hypersensitivity reaction to certain medications involving the skin and internal organs.

Symptoms:

Rash

• Fever

• Swollen lymph nodes

• Eosinophilia (↑ eosinophils)

• Liver, kidney, or heart inflammation

Nursing note:

• Stop the medication immediately; treat supportively; can be fatal if not recognized early.