Schizophrenia

What is Schizophrenia?

A brain disorder that affects a person’s thinking, perception, language skills, emotional expression and control and social behaviors

Early onset Schizophernia

age 18-25, more often male have poorer premorbid adjustment, greater structural abnormalities in brain, and more than later-onset schizophrenia. negative symptoms than

Later onset

age 25-35, more likely female, lesser degree of structural abnormalities and better outcomes

Common Schizophrenia Comorbidities

Substance abuse, anxiety, Tobacco use, Depression (suicide is the leading cause of death in this patient population),

Schizophrenia Spectrum Disorders

• Disorders that share similarities to Schizophrenia

• The characteristic schizophrenia spectrum disorders share is psychosis

Psychosis

Psychosis is a symptom rather than a diagnosis. It refers to altered cognition, altered perception and/or the ability to comprehend what is real or not real

DSM-V Diagnostic criteria for Schizophrenia

Characteristic Positive and Negative symptoms: Need 2 or more in a 1 month period

Positive Symptoms

• Delusions

• Hallucinations

• Disorganized Speech

• Grossly disorganized or catatonic behaviors

Negative Symptoms

• Affective blunting

• Avolition

• Poverty of content of speech

• thought blocking

Avolition

lack of motivation, unable to initiate tasks (social, grooming, ADLs)

Thought Blocking

a disturbance in speech where a person's thoughts are abruptly stopped interrupted, leading to abrupt pauses or inability to continue speaking.

Schizophrenia Genetic Factors

• Strong Genetic component

• 5-6% chance of developing with 1 parent with this disease, 40-50% chance of twins

• Overall, multiple genes combined with other factors

Schizophrenia Neurobiological Factors

Generally: “dys-regulation” of dopamine, possible hypoactivity in prefrontal cortex.

Main theory: Dopamine (D2) Hyperactivity in the limbic regions of the brain (hippocampus, thalamus, amygdala, hypothalamus)

Limbic System

• Hippocampus

• Thalamus

• Amygdala

• a complex set of structures in the brain involved in emotion, memory, and regulation of autonomic functions. Hypothalamus

What Does Dopamine Normally Do in the Body?

• Movement

• Learning

• Attention

• Emotion/emotional control

Schizophrenia Role of Serotonin (5-HT2A)

May play a role due to the second-generation antipsychotic drug’s capacity to block 5-HT2A, resulting in symptom improvement

Glutamate hypofunctional in Schizophrenia

Glutamate is crucial during neuro-maturation, and abnormal maturation of the CNS is a factor in some of the cognitive deficits in schizophrenia

PCP is a glutamate antagonist that induces psychosis

Norepinephrine and schizophrenia

Dopamine is a precursor to Norepinephrine

Structural Abnormalities in Schizophrenic Brain

• Lateral Cerebral Ventricle enlargement

• Third Ventricle Dilation

• Reduced Volume of the frontal lobe and hippocampus

• Sulci (fissures) size increased

• Reduced cortical thickness

Other Risk Factors

• Perinatal complications

• prenatal risk factors( viral infection, poor nutrition, starvation, exposure to toxins)

• Lack of oxygen during birth

• Early fetal brain injury

• STRESS (social, physical, psychological)

• Street drug use

Course of Schizophrenia

1. Acute phase/Onset 1

2. Phase 2

3. Phase 3

Phases guide the prediction and assessment of symptoms/treatment

Evidence shows that early and aggressive treatment alters the course of the disease, improves outcomes, and decreases the rates of disability

Schizophrenia Prodromal Signs stage 1

The prodromal stage includes signs and symptoms that precede the acute full blown disease. Occurs in 80-90% in people with schizophrenia.

Prodromal Signs/symptoms

Social Withdrawal, Deterioration in function, depressive mood, perceptual disturbances, magical thinking and peculiar behavior

Prodromal signs occur about one month to a year before full-blown acute symptoms

Acute Schizophrenia Phase

Includes Positive, Negative, Neurocognitive and affective symptoms

Positive Acute Schizophrenia Symptoms

• Hallucinations

• Delusions

• Disorganized Speech (associative looseness)

• Bizarre Behavior

Cognitive Symptoms

• Inattention, easily distracted

• Impaired memory

• Poor problem-solving skills

• Illogical thinking

• Impaired Judgement

Negative Symptoms of Acute Schizophrenia

• Blunted Affect

• Poverty of thought (Alogia)

• Loss of motivation (avolition)

• Inability to experience pleasure or joy (anhedonia)

Affective Symptoms (how the patient comes off)

• Dysphoria

• Suicidality

• Hoplessness

Positive Symptoms: Alterations in thinking

• Impaired reality testing: absence of the ability to correct in thinking

• Impaired ability to think abstractly, and responses are literal: concrete and/or disorganized thinking

Delusions

False fixed beliefs that cannot be corrected by reasoning

ASSESS FOR

• Presence of Delusions

• Delusions that have to do with someone harming the patient or the patient harming someone

• Paranoia and/or suspiciousness

Nursing Interventions: Focus on

• Focus on the feelings associated with the delusion

• Focusing on the delusional content itself is not helpful

Don’t argue about the delusion but clarify the facts: see example

́ Patient: “My tech is coming to check my BP but he is really going to poison me.” 
́ You: “It’s true that I asked the tech to take your BP. I need to know the result before I 
give you your medication today. Would you like for me to take your BP instead? This approach acknowledges the patient's fear while redirecting focus to present reality and their safety.

Nursing Interventions for Schizophrenic Patients

Do concrete reality based activities with the client. Cards, games, music, newspaper and exercise. If they are focusing on reality, they have less time to focus on delusional content

Observe for trigger events or anxiety and agitation. Intervene appropriately

Associative Looseness

Manifests in disorganized speech, where one topic is jumped on for another. Characterized as a lack of logical connection between thoughts and ideas

Positive symptoms: Alterations in Speech

• Associative loosenes

• Neologism

• Classociations(of speech sounds)

• Word Salad

• Echolalia

Echolalia

Pathologic repeating of others words

Positive Symptoms: Alterations in Perception

• Depersonalizations

• Hallucinations

• Illusions

Depersonalization

A dissociative symptom where an individual feels detached from their own body or thoughts, experiencing a sense of unreality regarding themselves.

Illusions

Misinterpretations of real external stimuli, leading to distorted perceptions of reality.

Nursing Interventions for Perceptual Alterations

Asses for presence and nature of hallucinations. Command hallucinations or negative nature are concerns.

Do they plan to follow?

Do they think the halluicnation is real?

Remember that this be be real to the patient and support them in this

Nursing intervention: Watch for cures that the patient is hallucinating

• Eyes Darting

• Staring

• Facial Expression changing without an obvious prompt

• Try to understand or ask what the hallucination is telling them to do

• Decrease stimuli in the environment to help reduce anxiety and agitation.

Ground Patients in reality

• Teach thought stopping techniques for negative thoughts/hallucinations

• Decrease stimuli

• Distract with relaity-based activities; Art, games, books, newspaper, art projects, music

• FOCUS ON THE FEELINGS ASSOCIATED WITH THE HALLUCINATIONS EX; “That sounds frightening, or sad or concerning”

Positive Symptoms: Alterations in Behavior

• Bizarre Behavior

• Extreme Motor agitations

• Stereotyped behavior(repetitive movements)

• Waxy flexibility

• Negativism (detached resistance to others)

• Automatic obedience

• Lack of impulse control may result in agitated behaviors such as abruptly grabbing the tv remote control and suddenly changing the channel

Stereotyped behavior (schizophrenia)

• Repetitive seemingly purposeless movements

  • Can include rocking, pacing or repetitive hand gestures

Negative Symptoms interfere significantly wiht life functioning

• Flat affect (little or no emotion

• Alogia (poverty of speech, protracted silence before response, restrictions in the amount of speech)

• Anhedonia (lack of pleasure in activities which usually bring pleasure

• Avolition- decreased motivation and attention

• thought blocking

• Anergia

• Bizzare effect: Inappropriate emotional response

anergia

lack of energy, passivity

Nursing Interventions for negative symptoms

Asses for impacts on relationships, social support, daily function, Teach: skills training, identify stressors, coping skills

Cognitive Symptoms of Scizophrenia

• Impaired Memory- usually short-term

• Inattention

• Trouble with verbal fluency

• Executive functioning difficulties

Executive functioning

• Cognitive flexibility, organizing and processing information, affecting decision-making and problem-solving abilities. functioning difficulties •

Nursing Interventions for Cognitive Symptoms

• Assess for impact on functioning

• identify strengths and skills patient can do and resources to assist with deficits

• awareness when planning patient education

Mood

• Anxiety

• Suicidality

• Demoralization

• Dysphoria

Catatonia

• Technically, “extreme abnormal motor behavior”

• Immobility

• Psychomotor retardation

• or psychomotor agitation

Interventions for care: Acute phase PRE STABALIZATION

• Hospitalization if harmful to self or others

• Stabilization and safety:

  • evaluations done by all members of the treatment team

  • providing support, structure and calm environment

  • physical assessment: vitals, labs, EKG, fluid/nutritional status

  • Medication concerns: 
    ́ Monitor for troubling side effects: Use of AIMS to assess for EPS 
    ́ Monitor for adherence 
    ́ Safety concerns: 
    ́ Command hallucinations 
    ́ Acting on delusions or hallucination----self or “other” injury 
    ́ Assess for psychosis/paranoia/agitation/SI 
    ́ Psychopharmacology initiated/changed 

     

     

How do I talk to a patient experiencing delusions, hallucinations, or paranoia?

Watch for signs they may be hallucinating

• Ask directly about hallucinations

• Acknowledge experiences, but do not play into symptoms (i.e,

do not agree, “I hear them too”)

• Focus on simple, reality-based tasks (or yoga, light exercise,

walking, etc.)

• Focus on feelings

• Do not try to correct false beliefs (it would be pointless and

can negatively impact rapport)

• Offer food and fluids in closed containers

• Assess for anxiety and triggering events/factors

• Do not touch the patient; often best to sit beside patient,

rather than face-to-face

Interventions-Acute Phase after Stabilization

1. Relationship building

́ Build trust

́ Open and supportive communication

́ 2. Psycho-education—done in groups or individually

́ Overview of illness

́ Management of symptoms: Hallucinations/delusions

́ Medications: what it’s for, how to take....specifically, what

benefits provided and SE

́ Relapse prevention skills are vital

́ Stress management

́ Medication importance---outcomes

́ Social involvement

́ Social skills training

́ Coping skills training

**Once the pt is stabilized, he/she is usually discharged

Maintenance Phase Schizophrenia

• Symptoms become less acute

• Goal of treatment is to help the patient adhere to the treatment plan

• Intensity of symptoms may ebb and flow

Maintenance Phase Interventions

1. Usually done outpatient and continue to work with patients on:

   • Disease management: Including the identification of signs of

     relapse

   • Stress management

   • Coping skills

   • Social skills

   • Occupational training

   • Importance of Social Involvement

   • Diet and exercise

Goals of Maintenance Phase Schizophrenia

Goal is to always focus on enhacing your patients strengths and maintaining stability while preventing relapse. This includes adherence to the treatment plan and managing daily living activities.

Social Skills Training

Needed for patients who have deficits in areas such as

social interactions and independent living skills.

́ Ex: personal care, cooking, laundry, paying bills,

accessing transportation, leisure, interpersonal

relationships

́ These deficits are often related to the negative symptoms

of schizophrenia and rarely respond to medication alone.

́ Evidence shows improvement of social skills, everyday life

skills, community functioning and negative symptoms.

Recovery in Schizophrenia

Is a long-term phenomenon

́ It implies the patient has the ability to function in the

community both socially and vocationally

́ Is relatively free of disease related psychopathology

́ It will differ among individuals

́ Recovery model: personalized, holistic, culturally-

appropriate treatment

́ Individual as “partner,” not “patient”

Relapses of Acute Episodes in Schizophrenia

Relapse is possible but not inevitable

́ Major concern in treatment

́ Each relapse can lead to a longer recovery period and

decreases the chance of returning to the baseline of

functioning

́ The levels of continuous stress between a patient with

schizophrenia and his/her environment is a strong predictor

of relapse

́ Evidence shows that for patients who have close family

connections, family psychoeducation is helpful after a

recent relapse

Pharmacologic Care for Schizophrenia/Schizophrenia Spectrum Disorders

1. pharmacological

2. non-pharmacological

   1. biological

   2. psychosocial

Pharmacologic Therapy Schizophrenia

Antipsychotic Medications

Used to treat disorders with psychosis; primarily schizophrenia and

bipolar disorder

Alleviate the symptoms but cannot cure underlying psychotic

processes.

§ Psychotic symptoms return with medication noncompliance.

Antipsychotic drugs are the 1st line treatment for schizophrenia

§ Best outcomes come from combining antipsychotic medication with

psychosocial support (from previous slides)

First Generation Antipsychotic Medications

• drugs that are primarily dopamine receptor antagonists (D2)

• Efficacy from 1st generation anipsychotic ability to decrease dopamine activity

• also have histaminic, alpha-adrenergic, and anticholinergic effects

• 1ST GENERATION Antipsychotics lessen dopamine which can affect movement, coordination, emotions voluntary judgements and release of prolaction

High Potency First gen antipsychotics

Haldol/Haloperidol and fluphenazine, which are known for their strong D2 receptor antagonism and higher risk of extrapyramidal side effects.

Second Generation Antipsychotics

Abilify/Aripiprazole 
Risperdal/Risperidone 
Clozaril/Clozapine 

Antipsychotics approved for children(all second gen)

Zyprexa/olanzapine)

risperaldal/risperidone

seroquel/quetiapine

abilify/aripriprazole

Second Generation Antipsychotics

• D2 (Dopamine) and 5-HT2a (Serotonin) antagonism

• Have 5-HT1a1 agonism (ziprasidone, quietiapine, clozapine)

́ This is a consequence of 5-HT2a antagonism and enhances

dopamine release in the prefrontal cortex (improving mood and

negative symptoms)

́ ** To simplify this, these meds have an affinity to bind with serotonin

receptors**

́ 3. Bind with D2 receptors more loosely which Allow for faster dissociation with receptor allows for alleviation of

psychotic symptoms with a lower risk of EPS, including TD and

prolactin elevation

́ Tend to be more expensive than 1 st generation antipsychotics

Pharmacologic evidence

Randomized trials have shown that antipsychotics reduce

positive symptoms compared to placebo

́ Symptoms reduction is tolerable in about 70% of patients

́ None of the evidence shows that any particular medication

is better than another**

́ ́ None of the classes of medications have shown clinically

meaningful effects on negative symptoms

́ The exception is cariprazine (Vraylar) and it has shown some

positive effects in a 2017 clinical trial

clozapine special considerations

**Clozapine is more effective for patients who do not respond

to other medications

́ **Clozapine is NOT considered a 1st line treatment due to the

side effect, agranulocytosis

agranulocytosis

A potentially life-threatening decrease in the number of neutrophils in the bloodstream, increasing the risk of infections. This side effect is particularly associated with clozapine, necessitating regular blood monitoring. Patients on clozapine require regular white blood cell monitoring to mitigate the risk of agranulocytosis, which can lead to severe infections.

Schizophrenic Medication selection is based on

• Efficacy

• Side effect profile

• Available formulations

• Patient specefic issues

Clinicians leads towards 2nd generation over first generation

Adverse Antipsychotic Adverse Effects

1. Neuroleptic Malignant Syndrome

2. QT prolongation/sudden cardian death (especially older adults)

3. Anticholinergic effects/anticholinegic toxicity

4. agranulocytosis

5. Liver impairment

6. Orthostatic hypotension/ sedation (fall risk

7. Extrapyrimidal Side effects

8. Metabolic Syndrom

9. Prolactin Elevation

10. Elevated Seizure risk

Anticholinergic effect

Neurotransmitter disruption leading to dry mouth, constipation, blurred vision, and cognitive dysfunction, caused by medications blocking acetylcholine action.

Extrapyrimidal Side Effects of Antipsychotics

• Parkinsonism

• Dystonic Reaction

• Akathisia (most common)

• Tardive Dyskinesia

EPS often appear early in therapy and can be minimised with treament. Assesed once a week when starting new therapy and at every visity after that. TD needs to be assesed 1/year

Can use Aims scale to asses for epse

Parkinsonism

stiffening of muscular activity in the fae, body, arms and lef

Mild parkinsonism can be assesed by observing for lack of arm swing when walking or cogwheel rigifity(like joint going though stiff steps, spoke teeth)

Moderate easy to asses

Dystonic reaction

Muscle cramps of the head and neck usually rapid in onset. Young men who use cocaine at highest risk of dystonic reaction

Alathisia

Internal restlessness and external restless pacing or fidgeting

Tardive Dyskinesia

Early symptoms are fasiciculation of the tongue or constant lip smaking. Involuntary movements of the face, tongue, and limbs that can develop after chronic long-term treatment with antipsychotic medications.

Akathisia EPS Medical Mangement

• cautious antipsychotic dose reduction

• beta blockers(ii.e. propranolol) are 1st line akathisia treatment

• Benztropine(anticholinergic) is 2nd line akathisia treatment

Parkinsionism EPS Medical Managment

Benzotropine(anticholinnergic)

Dystonic Reaction Medical Management

Moderate to severe dystonic reaction treated IM or IV with Benztropine or Diphenhydramine

́ Mild is treated with PO Benztropine

́ Prescriber will probably re-evaluate the medication regimen

Tardive Dyskanisia EPS Medical management

́ Switch antipsychotic medication

́ Medication: Deutetrabenazine (Austedo), Valbenazine (Ingrezza)

Metabolic Syndrome Antipsychotic Side Effects

́ Weight gain: Patients taking Zyprexa gained an average of

2lbs/month for 18 mos

́ Hyperlipidemia: rise in association with body weight

́ Hyperglycemia: rise in association with body weight and

independently

́ Hypertension

́ **Life expectancy is lower for patients with schizophrenia and

this is even more concerning with the rise in metabolic

syndrome

Metabolic Syndrome Management

Switching to a medication with lower incidence of weight gain

́ Eg. Zyprexa----Abilify

́ Treating the symptoms

• Antihypertensive meds and lifestyle education for high blood pressure

• Statins and lifestyle education for hyperlipidemia

́ Behavioral weight loss interventions

́ Clinical trials show promising results when education is tailored to this specific population, exercise in groups and small incentives for participation

́ Use of Metformin is effective in helping patients with

schizophrenia lose weight (new onset or not)

Combination of metformin and weight loss interventions most effective

Prolactin Elevation Side effect of anti psychotics

• Most common in 1st generation antipsychotics, risperidone(2nd gen), paliperidone

• Symptoms of prolactin elevation include lactation, menstrual irregularities, sexual dysfunction, gynecomastia

• Treating prolactin involves changing antipsychotic used

Reduction in seizure threshold

Clozaril is the greatest risk

́ Rare to cause new onset seizures

́ Assess and educate

Sedation- Safety issues/falls

Orthostatic hypotension

́ Usually seen in the 1st several days of treatment

́ Start with lowest dose

́ Educate and assess to prevent falls

Anticholinergic effects---think “drying” out

́ More typically seen in older adults

́ Most common in the 1st week

́ Titrate slowly to avoid

́ Use sugarless lozenges, lighting control, small and frequent meals)

Neuroleptic Malignant Syndrome

can be life threatening

• Fever

• Rigidity

• Mental Status changes

• autonomic instability (body can not self regulate vital signs or autonomic body processes)

Treatment of NMS

• Stop the antipsychotic

• Management of Cardiovascular support

• hyperthermia

• and Fluid/electrolyte imbalalnces

ANTIPSYCHOTICS: Children &

Adolescents

May be used for: schizophrenia, psychoses, Tourettes and self-

injurious behavior

́ Usually start with atypical antipsychotic medication and at half the

adult dose

́ May be at higher risk for EPSE’s

́ Monitor for TD every 3 months

Antipsychotic Drugs: Older Adults

Important to assess for EPSE’s

́1/3 will develop TD if on a typical

antipsychotic for 1 year

́Nearly 2/3 will develop TD if on a typical

antipsychotic medication for 3 years

́ There is a FDA black box warning against

the use of atypical antipsychotic drugs

with older adults with dementia

́Atypical antipsychotic drugs are

associated with an increased risk for death

in older adult patients with dementia

Other Treatment

• Electroconvulsive therapy (ECT) (often with Clozaril)

• Deep brain stimulation

• Transcranial magnetic stimulation (TMS)

• Individual therapy*

• Family therapy*

́ *Used in conjunction with medication

What symptom is the main characteristic of the

Schizophrenia Spectrum Disorders?

Psychosiswhich can include hallucinations, delusions, and disorganized thinking.

What main neurotransmitter is believed to

be important in schizophrenia?

dopamine

Dopamine is involved in regulating

movement. What part of the brain is

impacted in this regard?

Basal ganglia

If your patient with schizophrenia is violent, what is

most likely a factor?

a) Thought content

b) Drugs/alcohol use

c) Strong parental support

Choose all the correct answers

thought content, drugs and alcohol use

How do we asses schizophrenic patients?

Perform full medical work-up to rule out

medical/substance causes

 Ask about substance use

 Assess for command hallucinations

 Do you plan to follow the command?

 Do you believe the voices are real?

 Do you recognize the voices?

 Review belief system and determine whether

whether patient feels someone might hurt him/her, or

whether the patient plans to act out against anyone

 Assess for co-occurring conditions

 Inventory medications and assess adherence

 Assess how patient relates to family

 Review support system