Chapter 15: Schizophrenia

Schizophrenia spectrum and other psychotic disorders are

complex disorders that affect a person's thinking, language, emotions, social behaviour, and ability to perceive reality accurately.

psychosis,

which refers to altered cognition, altered perception, and/or an impaired ability to determine what is or is not real (an ability known as reality testing). Psychosis itself is a symptom and not classified as a mental illness (

The How a Nurse Helped Me story demonstrates the four elements of the LEAP approach (Amador, 2021), which is based on the belief that trusting relationships are key to healing partnerships:

• Listen—Both nurses listened with compassion and genuineness.

• Empathize—It is clear that both nurses were able to convey that they cared about understanding what Tammy was feeling.

• Agree—Both nurses believed in Tammy, affirmed that she was indeed worried and struggling. They supported her in her goals, never looking down on her or judging her but helping her on her own road to recovery.

• Partner—Clearly, both nurses respected Tammy and worked with her as partners for recovery.

There are five key features associated with psychotic disorders:

Delusions

Hallucinations

Disorganized thinking:

Abnormal motor behaviour:

Negative symptoms:

Delusions

Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s culture or subculture are not delusions.

Hallucinations

Perception of a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).

Disorganized thinking:

The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning.

Abnormal motor behaviour:

Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccentric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.

Negative symptoms:

The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal.

Schizophreniform Disorder

The features of schizophreniform disorder are similar to schizophrenia, but the total duration of the illness is less than 6 months. This disorder may or may not develop into schizophrenia.

Brief Psychotic Disorder

This disorder involves a sudden onset of psychosis or grossly disorganized or catatonic behaviour lasting less than 1 month. It is often precipitated by extreme stressors and is followed by a return to premorbid functioning.

Schizoaffective Disorder

Schizoaffective disorder is a subgroup of psychoses in which affective symptoms and symptoms of schizophrenia are prominent simultaneously. The symptoms are not due to any substance use or to a medical condition and present with either bipolar or depressive affective symptoms alongside psychosis.

Delusional Disorder

Delusional disorder is characterized by nonbizarre delusions (i.e., situations that could occur in real life, such as being followed, being deceived by a spouse, or having a disease). The person's ability to function is not markedly impaired nor is behaviour otherwise odd or psychotic. A related disorder, Capgras syndrome, involves a delusion about a significant other (e.g., family member, pet) being replaced by an imposter; this disorder may be a result of psychiatric or organic brain disease (Salvatore et al., 2014).

Substance- or Medication-Induced Psychotic Disorder

Psychosis may be induced by substances such as drugs of abuse, alcohol, or medications. (Schizophrenia Society of Canada, 2020).

Psychosis or Catatonia Associated With Another Medical Condition or Another Mental Disorder

Psychoses may also be caused by a medical condition (delirium, neurological or metabolic conditions, hepatic or renal diseases, and many others) as well as by mental illness such as post-traumatic stress disorder (Alsawy et al., 2015) or depression, particularly with co-existing victimization from sexual violence or bullying (Nam et al., 2016). Medical conditions and substance use must always be ruled out before a diagnosis of schizophrenia or other psychotic disorder can be made.

These significantly higher death rates reflect a combination of

(1) higher risk factors for many chronic diseases and some types of cancer;

(2) the iatrogenic effects of some psychiatric medications;

(3) higher rates of suicide, accidental, and violent death; and

(4) disparities in health care access and use

While there is not one specific cause of schizophrenia, the scientific consensus is that

schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors (viral infections, birth injuries, pre-natal malnutrition) and are influenced by environmental and social factors.

These alter the structures of the brain, affecting the brain’s neurotransmitter systems, injuring the brain directly, or doing all three.

This effect is called the diathesis–stress model of schizophrenia

The dopamine theory of schizophrenia

the theory that schizophrenia is caused by too much dopamine and, conversely, that anti-schizophrenic drugs exert their effects by decreasing dopamine levels

A newer class of medications, collectively known as atypical (or second-generation) antipsychotic medications, block serotonin as well as dopamine, which suggests that serotonin may play a role in schizophrenia as well.

have demonstrated structural brain abnormalities, including:

• Reduced volume in the right anterior insula (may contribute to negative symptoms)

• Reduced volume and changes in the shape of the hippocampus

• Accelerated age-related decline in cortical thickness

• Grey matter deficits in the dorsolateral prefrontal cortex area, thalamus, and anterior cingulate cortex, as well as in the frontotemporal, thalamocortical, and subcortical-limbic circuits

• Reduced connectivity among various brain regions

• Neuronal overgrowth in some areas, possibly due to inflammation or inadequate neural pruning

• Widespread white matter abnormalities (e.g., in the corpus callosum)

In addition, MRI and CT scans demonstrate lower brain volume and more cerebrospinal fluid in people living with schizophrenia. PET scans also show a lowered rate of blood flow and glucose metabolism in the frontal lobes, which govern planning, abstract thinking, social adjustment, and decision making, all of which are affected in schizophrenia.

Phase I—Acute:

Onset or exacerbation of florid, disruptive symptoms (hallucinations, delusions, apathy, withdrawal) with resultant loss of functional abilities; increased care or hospitalization may be required.

Phase II—Stabilization:

Symptoms are diminishing, and there is movement toward one's previous level of functioning (baseline); day hospitalization or care in a residential crisis centre or a supervised group home may be needed.

Phase III—Maintenance:

The person is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the person to live in the community. Ideally, recovery with few or no residual symptoms has occurred. Most people in this phase live in their own residences. Although this phase has been termed maintenance, current literature shows a trend toward reframing it with a greater emphasis on recovery.

Prodromal phase of schizophrenia

before diagnosis, phase is exemplified by clear evidence of deterioration, social withdrawal, role functioning impairment, peculiar behaviour, inappropriate affect, and unusual experiences

Successful treatment of schizophrenia requires

an organized, recovery-oriented, mental health system with coordinated services

Nursing assessment of people who have or may have a psychotic disorder focuses largely on

symptoms, coping, functioning, and safety.

Assessment involves interviewing the person and observing behaviour and other outward manifestations of the disorder.

It also should include mental status and spiritual assessments, cultural assessments, biological, psychological, social, and environmental elements.

Positive symptoms:

Schizophrenic symptoms that involve behavioral excesses or peculiarities,

such as hallucinations, delusions, bizarre behavior, and wild flights of ideas.

Negative symptoms

symptoms of schizophrenia that are marked by deficits in functioning,

such as apathy, lack of emotion, and slowed speech and movement

Cognitive symptoms

symptoms of schizophrenia associated with problems with attention and memory and with difficulty in developing a plan of action

Affective symptoms

dysphoria, suicidality, hopelessness

symptoms involving emotions and their expression

Positive symptoms are associated with:

• Acute onset

• Normal premorbid functioning

• Normal social functioning during remissions

• Normal CT findings

• Normal neuropsychological test results

• Favourable response to antipsychotic medication

reality testing

—the ability to determine accurately whether an experience is based in reality.

Thought insertion

Believing that another person, group of people, or external force controls thoughts

Bruce explains he always wears a hat so that aliens don't insert thoughts into his brain.

Thought withdrawal

Believing that others are taking thoughts out of a person's mind

Bernadette explains she covers her windows with foil so the police can't empty her mind.

Thought broadcasting

Believing that one's thoughts are being involuntarily broadcasted to others

Marcel was convinced that everyone could hear what he was thinking at all times.

Ideas of reference

Giving personal significance to trivial events; perceiving events as relating to you when they do not

When Maria noticed staff talking, she believed they were plotting against her.

Ideas of influence

Believing that you have somehow influenced events that are, in fact, out of your control

Jean Pierre is convinced they caused the flooding in Manitoba.

Persecution

Believing that one is being singled out for harm by others; this belief often takes the form of a plot by people in power

Saied believed that the Royal Canadian Mounted Police were planning to kill him by poisoning his food. Therefore he would eat only food he bought from machines.

Grandeur

Believing that one is a very powerful or important person

Sam believed they were a famous playwright and tennis pro.

Somatic

Believing that the body is changing in an unusual way (e.g., rotting inside)

David told the physician that his heart had stopped, and his insides were rotting away.

Erotomanic

Believing that another person desires you romantically

Although she barely knew her, Millie insisted that Justine would marry her if only her current wife would stop interfering.

Jealousy

Believing that one's mate is unfaithful

Harry wrongly accused his girlfriend of going out with other men. His proof was that she came home from work late twice that week, even though the girlfriend's boss explained that everyone had worked late.

The most common delusions are

persecutory or grandiose or those involving religious or hypochondriacal ideas.

Concrete thinking (Cognitive Symptom)

refers to an impaired ability to think abstractly. The person interprets statements literally.

Similarities Test

Asks in what way certain objects or concepts are similar, measure abstract thinking

Circumstantiality

refers to the inclusion of unnecessary and often tedious details in one's conversation (e.g., describing attending group therapy when asked how the day is).

Tangentiality

is a departure from the main topic to talk about less important information; the patient goes off on tangents in a way that takes the conversation off-topic.

Neologisms

are made-up words (or idiosyncratic uses of existing words) that have meaning for the person but a different or nonexistent meaning to others

(e.g., “I was going to tell him the mannerologies of his hospitality won’t do”). This eccentric use of words represents disorganized thinking and interferes with communication.

Echolalia

is the pathological repeating of another's words and is often seen in catatonia.

Clang association

is the choosing of words based on their sound rather than their meaning, often rhyming and sometimes having a similar beginning sound (e.g., “On the track, have a Big Mac,” “Click, clack, clutch, close”). Clanging may also be seen in neurological disorders.

Word salad

a jumble of words that is meaningless to the listener—and perhaps to the speaker as well—because of an extreme level of disorganization.

Alterations in perception

are errors in one's view of reality.

The most common form of altered perception in psychosis are hallucinations, but depersonalization, derealization, and boundary impairment are sometimes experienced as well:

Associations are the

threads that tie one thought logically to another.

In associative looseness

these threads are interrupted or illogically connected; thinking becomes haphazard, illogical, and difficult to follow:

Depersonalization

is a nonspecific feeling that a person has lost their identity and that the self is different or unreal. People may feel that body parts do not belong to them or may sense that their body has drastically changed. For example, a person may see their fingers as snakes or arms as rotting wood.

Derealization

is the false perception that the environment has changed. For example, everything seems bigger or smaller, or familiar surroundings have become somehow strange and unfamiliar. Both depersonalization and derealization can be interpreted as loss of ego boundaries (sometimes called loose ego boundaries).

Boundary impairment

is an impaired ability to sense where one's self ends and others' selves begin. For example, a person might drink another's beverage, believing that because it is in their vicinity, it is theirs.

Hallucinations (alteration in perception)

result from perceiving a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).

Causes of hallucinations include

psychiatric disorders, substance use, medications, organic disorders, hyperthermia, toxicity (e.g., digitalis), and other conditions.

Auditory Hallucinations

Hearing voices or sounds that do not exist in the environment

Juan is alone in his room and is heard yelling. When staff arrive in his room, Juan tells them that he is hearing an angry voice.

Visual Hallucinations

Seeing a person, object, animal, colours, or visual patterns that do not exist in the environment

Antonia became frightened and screamed, “There are rats coming at me!”

Olfactory Hallucinations

Smelling odours that do not exist in the environment

Theresa "smells" their insides rotting.

Gustatory Hallucinations

Tasting sensations that do not exist

Simon will not eat his food because he "tastes" the poison they are putting in it.

Tactile Hallucinations

Feeling strange sensations on the skin where no external objects stimulate such feelings; common in delirium tremens (DTs)

Jack “feels” bugs on/under skin.

Command hallucinations

are "voices" that direct the person to take an action.

All hallucinations must be assessed and monitored carefully because the voices may command the person to hurt self or others.

are often terrifying and may herald a psychiatric emergency.

Outward indications of possible hallucinations include

turning or tilting the head as if to listen to someone, suddenly stopping current activity as if interrupted, and moving the lips silently.

Catatonia

a pronounced increase or decrease in the rate and amount of movement. The most common form is stuporous behaviour, in which the person moves little or not at all.

Psychomotor retardation,

a pronounced slowing of movement. It is important to differentiate the slowed movements secondary to schizophrenia from those seen in depression; careful assessment of thought content and thought processes is essential for making this determination.

Psychomotor agitation,

excited behaviour such as running or pacing rapidly, often in response to internal or external stimuli. Psychomotor agitation can pose a risk to others and to the person, who is at risk for exhaustion, collapse, and even death.

Stereotyped behaviours

repeated motor behaviours that do not presently serve a logical purpose.

Automatic obedience

the performance by a catatonic person of all simple commands in a robot-like fashion.

Waxy flexibility

the extended maintenance of posture usually seen in catatonia. For example, the nurse raises the person's arm, and the person retains this position in a statue-like manner.

Negativism

akin to resistance but may not be intentional. In active negativism the person does the opposite of what they are told to do; passive negativism is a failure to do what is requested.

Impaired impulse control,

a reduced ability to resist one's impulses. Examples include performing socially inappropriate behaviours such as grabbing another's cigarette, throwing food on the floor, and changing TV channels while others are watching.

Echopraxia

the mimicking of the movements of another. It is also seen in catatonia.

Negative symptoms develop slowly and are those that most interfere with a person’s adjustment and ability to cope. They tend to be persistent and crippling because they render the person inert and unmotivated. Negative symptoms impede one’s ability to:

-Initiate and maintain conversations and relationships

• Obtain and maintain a job

• Make decisions and follow through on plans

• Maintain adequate hygiene and grooming

Affective blunting

A reduction in the expression, range, and intensity of affect (in flat affect, no facial expression is present)

Anergia

Lack of energy; passivity or lack of persistence at work or school; may also be a symptom of depression, so needs careful evaluation

Anhedonia

Inability to experience pleasure in activities that usually produce it; result of profound emotional barrenness

Avolition

Reduced motivation; inability to initiate tasks such as social contacts, grooming, and other activities of daily living (ADLs)

Poverty of content of speech

While adequate in amount, speech conveys little information because of vagueness or superficiality

Poverty of speech (alogia)

Reduced amount of speech—responses range from brief to one-word answers

Flat

immobile or blank facial expression

Blunted

reduced or minimal emotional response

Inappropriate

emotional response incongruent with the tone or circumstances of the situation (e.g., a patient laughs when told a family member has died)

Bizarre

odd, illogical, emotional state that is grossly inappropriate or unfounded; especially prominent in disorganized schizophrenia and includes grimacing and giggling

Impaired memory (Cognitive Symptom)

affects short-term memory and the ability to learn. Repetition and verbal or visual cues may help the patient to learn and recall needed information (e.g., a picture of a toothbrush on the patient's wall and/or mirror as a reminder to brush their teeth).

Impaired information processing (Cognitive Symptom)

can lead to problems such as delayed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in one's peripheral vision. This can lead to overstimulation.

Impaired executive functioning (Cognitive Symptom)

includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipation and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations.

Erratic mood (Affective Symptom)

sudden changes in how you feel.

labile mood (Affective Symptom)

rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur.

incongruent mood (Affective Symptom)

not what would be expected for the circumstances

Many people living with schizophrenia can experience anosognosia,

an inability to realize that they are ill, which is caused by the illness itself.

Interventions for Overcoming Obstacles to Assessment

Use empathic comments and observations to prompt the patient to provide information.

Minimize questioning, especially closed-ended questioning.

Seek data conversationally, using prompts and open-ended questions.

Use short, simple sentences and introduce only one idea at a time. Allow time for responses to questions.

Directly but supportively seek the needed information, explaining the reasons for the assessment.

Judiciously use indirect, supportive (therapeutic) confrontation.

Seek other data to support (validate) the person's report (obtain further history from third parties, past medical records, and other treatment providers when possible), preferably with the person's permission.

Prioritize the data you seek, and avoid seeking nonessential data.

ASSESSMENT GUIDELINES

1. Assess for risk to self or others.

2. Assess for suicide risk (see Chapter 22).

3. Assess for command hallucinations (e.g., voices telling the patient to harm self or others). If present, ask the person:

4. Do you believe the voices are real? Do you plan to follow the command? (A positive response to any of these questions suggests an increased risk that the person will act on the commands). Assess for ability to ensure self-safety, addressing:

5. Assess for the presence and severity of positive and negative symptoms. Complete a mental status examination, noting which symptoms are present, how they affect functioning, and how the patient is managing them.

6. Assess the patient’s insight, knowledge of the illness, relationships and support systems, other coping resources, and strengths.

7. Determine if the patient has had a medical workup. Are there any indications of physical and/or medical problems that might mimic psychosis (e.g., digitalis or anticholinergic [ACh] toxicity, brain trauma, drug intoxication, delirium, fever)?

8. Assess for coexisting disorders:

9. Assess medications the patient has been prescribed, whether and how the patient is taking the medications, and what factors (e.g., costs, mistrust of staff, adverse effects) are affecting adherence.

10. Assess the family’s knowledge of and response to the patient’s illness and its symptoms. Are family members overprotective? Hostile? Anxious? Are they familiar with family support groups and respite resources?

The Unpleasant Voices Scale has been designed for

assessment of the risk of harm related to command hallucinations and can be used in conjunction with the Harm Command Safety Protocol

During the acute phase, the overall goal is the

person's safety and medical stabilization.

Therefore if the person is at risk for violence to self or others, initial outcome criteria address safety issues

Outcome criteria during phase II focus on helping the patient

adhere to treatment, become stabilized on medications, and control or cope with symptoms.

The outcomes target the negative symptoms and may include ability to succeed in social, vocational, or self-care activities.

Outcome criteria for phase III focus on

maintaining achievement, preventing relapse, and achieving independence and a satisfactory quality of life.

Planning during the stabilization and maintenance phases includes

providing individual and family education and skills training (psychosocial education).

Relapse prevention skills are vital.

Planning identifies interpersonal, coping, health care, and vocational needs and addresses how and where these needs can best be met within the community.

Partial hospitalization:

Patients sleep at home and attend treatment sessions (similar to what they would receive if admitted) during the day or evening.