Schizophrenia

Overview and Real-World Context

• Schizophrenia spectrum disorders are often misunderstood due to stereotypes (homelessness, hospitalization, unfunctionality). In reality, many with a schizophrenia diagnosis are well managed on medications and can remain functional, with occasional relapses. Injectable antipsychotics given monthly can maintain stability for many patients.
• Real-world perspective from video case: a high-achieving student experiences psychosis after relocating to Mexico, relapses in college, treatment helps, highlighting variability in illness course and access to resources.
• Today’s topics: schizophrenia spectrum disorders, core symptoms, nursing care, a comprehensive vocabulary of positive and negative symptoms, patient teaching about antipsychotics, and application of the nursing process (safety, education, assessment).
• For testing purposes, schizophrenia is taught as a stand-alone disease process, though it overlaps with other psychoses and with mood disorders with psychotic features.

Epidemiology and Onset

• Global prevalence: about 1 ext{%} of the population.
• No consistent differences by race, socioeconomic status, or culture.
• Gender differences:
  • More early-onset risk in males (typically $18 ext{ to } 25$ years).
  • Later onset more common in females (approximately $25 ext{ to } 35$ years).
  • Males generally have greater day-to-day functional impairment.
• Comorbidity common across mental health disorders, including:
  • Nicotine dependence, alcohol use, anxiety, depression, suicide risk.
• Mortality risk: people with schizophrenia have a risk of premature death $1 ext{ to }2 imes$ higher than the general population.
• Early signs may precede psychotic break by months to years (e.g., anxiety, phobias, compulsions); historically, similar to dementia where earlier clues are noticed only in hindsight.
• Typical illness trajectory often includes recurrent exacerbations interspersed with periods of reduced or absent symptoms; single-episode presentations exist but are less common.

Core Symptoms: Positive vs Negative

• Positive symptoms: presence of abnormal thoughts or experiences that should not be present.
  • Delusions: fixed false beliefs; examples include persecution, reference, erotomanic, grandiose, somatic.
  • Persecutory delusions: belief that one is being harmed or conspired against.
  • Referential delusions: interpreting external stimuli as having a personal meaning (e.g., TV, songs).
  • Somatic delusions: belief about bodily functions or sensations as abnormal.
  • Grandiose delusions: inflated worth, special status, or powers.
  • Hallucinations: perception without external stimulus; most commonly auditory, but can be visual, tactile, olfactory, or gustatory.
  • Command hallucinations: voices instructing the patient to perform actions; highest safety risk (self-harm or harm to others).
  • Disorganized thinking and speech (speech abnormalities): word salad, derailment, tangentiality, circumstantiality, neologisms, echolalia, echopraxia.
  • Word salad: incoherent, meaningless jumble of words and phrases.
  • Clang associations: rhyming or phonetic links between words.
  • Echolalia: meaningless repetition of others’ words.
  • Thought insertion/deletion: beliefs that thoughts are being inserted into or removed from the mind.
  • Tangentiality vs circumstantiality: tangentiality never reaches the point; circumstantiality eventually reaches it but with many irrelevant details.
  • Disorganized or bizarre behavior and appearance; catatonia (see next section).
• Negative symptoms: absence or reduction of normal functions.
  • Flat affect: limited emotional expression.
  • Alogia: poverty of speech or poverty of content; may be slow or minimal verbal response.
  • Anhedonia: reduced ability to experience pleasure.
  • Avolition (avolition/apathy): lack of motivation or initiative to engage in activities.
  • Anergia: lack of energy.
  • Asociality: diminished social interactions.
  • Poor hygiene and grooming.
  • Cognitive symptoms: impairments in memory, attention, judgment, and problem-solving; may be subtle at first but become more apparent with illness progression.
• Other related phenomena:
  • Hyperreligiosity or spirituality-focused delusions; referential or magical thinking; sometimes pseudo-religious or magical practices.
  • Sexual and relational distortions in some individuals with psychosis (not universal).
  • Alterations in perception of self and environment (depersonalization, derealization).
• Distinction from bipolar disorder: psychotic features can appear during manic episodes in bipolar disorder and may resemble schizophrenia; for test purposes, the focus is on schizophrenia as a standalone spectrum.

Polydipsia and Hydration Hazards

• Polydipsia (psychogenic or primary): excessive water intake.
  • Patients may drink large volumes of water, sometimes due to dry mouth from antipsychotics or as a compulsive behavior.
  • Risks: electrolyte imbalance, hyponatremia, cerebral edema, potential death.
  • In hospital settings, a water pitcher may be restricted for high-risk patients to prevent water intoxication.
• Water intoxication pathophysiology: rapid dilution of electrolytes leading to cerebral edema; can be fatal.
• Real-world analogies used in teaching: famous radio contest incident where water intoxication led to cerebral edema and death; similar risks observed in infants who dilute formula.
• Antipsychotics commonly cause dry mouth, which can contribute to polydipsia if not monitored.

Safety, Assessment, and the Nursing Process

• Safety is the top priority for patients with schizophrenia and for staff; escalating behaviors require protection and possibly involvement of colleagues or security.
• Early assessment and diagnosis improve prognosis; coding tools and standardized assessments aid early detection.
• Primary prevention concepts: awareness of family history and early signs in at-risk youths.
• The nursing assessment focuses on:
  • Symptoms and coping, daily functioning (Maslow’s hierarchy of needs: basic needs like bathing, eating, sleeping).
  • Risk assessment for self-harm or harm to others, and for unsafe behaviors (e.g., poor judgment).
  • Safety planning, crisis de-escalation, and the use of supportive communication.
  • Mental status examination (MSE) and gathering information when patient insight/uncooperativeness limits direct questioning (involving family or previous records).
• During acute psychosis, safety and stabilization are prioritized; discharge planning begins at admission and continues through hospitalization.
• Consider social determinants: homelessness and lack of robust support systems increase relapse risk and influence discharge planning.
• Care planning emphasizes inclusive communication: even if a patient appears disorganized, involve them in discharge planning and care decisions as much as feasible.
• Clinician mindset: protect safety of both patient and staff; do not mistake de-escalation for weakness or fear.
• Practical nursing assessment and triage: always evaluate for reversible medical contributors (electrolyte imbalance, infection, metabolic issues) that might worsen psychiatric symptoms.

Discharge Planning and Long-Term Management

• Discharge planning begins at admission and involves multiple steps:
  • Identify post-discharge living situation (shelter, family home, assisted living, etc.).
  • Determine transportation needs for follow-up appointments (monthly injections, psychiatry visits).
  • Engage family, friends, and community resources for support and relapse prevention.
  • Coordinate with discharge planners and case managers to ensure a clear follow-up plan.
• Maintenance and relapse prevention:
  • Continued antipsychotic therapy is essential to suppress psychotic symptoms and prevent relapse.
  • Monthly injections can improve adherence compared to daily oral dosing, which is especially useful for patients with memory or organizational challenges.
• Real-world challenges highlighted: during COVID-19, access to monthly injections was disrupted, leading to relapses for some patients previously well-managed.
• Outpatient and community resources (e.g., Highland clinic) provide ongoing follow-up and injection administration to improve continuity of care.
• Goals of care include returning to baseline functioning where possible, enhancing independence, and providing education about illness and treatment to reduce relapse risk.

Pharmacology: Antipsychotics Overview

• Antipsychotics are categorized into generations (for testing and clinical practice, though newer labeling varies by country):
  • First-generation antipsychotics (FGAs, typical): primarily target positive symptoms but have higher risk of extrapyramidal symptoms (EPS).
  • Second-generation antipsychotics (SGAs, atypical): address both positive and negative symptoms with fewer EPS, but carry metabolic and hematologic risks.
  • Third-generation antipsychotics (often considered including aripiprazole): newer agents with potentially fewer side effects and utility in agitation; often more expensive.
• Common clinical objective: use antipsychotics to manage acute psychosis and to prevent relapse, with ongoing evaluation of efficacy and tolerability.
• Adherence challenge: patients might struggle with daily pills; monthly injections improve consistency.
• Special consideration in elderly with dementia: antipsychotics carry higher mortality risk and are generally used with caution.
• Monitoring and risk communication are essential: patients and families should understand potential side effects and warning signs of emergencies (e.g., NMS).

First-Generation Antipsychotics (FGAs)

• Examples commonly emphasized: $ext{Haloperidol}, ext{Fluphenazine}, ext{Chlorpromazine}$
• Primary advantage: strong efficacy for positive symptoms; typically cheaper due to longer market presence.
• Major disadvantages: higher incidence of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), plus anticholinergic side effects.
• Key EPS spectrum:
  • Akathisia: inner restlessness; pacing, inability to stay still.
  • Dystonia: severe muscle spasms, sometimes causing torticollis; can be painful and dangerous if untreated.
  • Pseudoparkinsonism: slowed movements, tremor, rigidity; resembles Parkinson disease.
  • TD (Tardive Dyskinesia): involuntary, repetitive movements of the mouth, tongue, lips; often irreversible if developed.
• Other adverse effects: anticholinergic effects (dry mouth, dry eyes, constipation, urinary retention), sedation, weight gain less pronounced than SGAs but still possible.
• Serious but rare adverse event: Neuroleptic Malignant Syndrome (NMS): medical emergency with hyperthermia, autonomic instability, severe rigidity, altered mental status; requires immediate recognition and treatment.
• Management of EPS: anticholinergic medications (e.g., benztropine, diphenhydramine) or dose adjustment.
• Monitoring for motor side effects is critical (e.g., noticing a shuffling gait that worsens with dosage changes).
• Discreet clinical tip: dopamine blockade can be inferred from movement symptoms; nurses should monitor for new or worsened EPS and adjust treatment accordingly.
• Practical note: some clinicians employ a strategy of listed management around side effects (e.g., using propranolol for akathisia).

Second-Generation Antipsychotics (SGAs)

• SGAs address both positive and negative symptoms with lower risk of EPS but carry other risks:
  • Weight gain and metabolic syndrome (hyperlipidemia, hypertension, insulin resistance, nonalcoholic fatty liver disease).
  • Possible leukopenia or neutropenia with certain agents (e.g., clozapine).
  • Clozapine carries the highest risk of agranulocytosis; requires regular blood monitoring.
• Notable SGAs and considerations:
  • Clozapine (clozapine): effective for treatment-resistant schizophrenia; risk of agranulocytosis and granulocytosis; requires WBC monitoring (weekly during initial period, then less frequently); higher risk of weight gain and metabolic issues; rare but serious infection risk with neutropenia surveillance.
  • Risperidone, Olanzapine, Quetiapine, Ziprasidone, Ziprasidone, etc.: varying profiles; many associated with metabolic syndrome and weight gain; clozapine is the exception with hematologic monitoring.
• Clozapine monitoring specifics:
  • WBC monitoring is essential, especially in the first six months; fever or sore throat requires prompt evaluation due to infection risk associated with neutropenia.
• General SGAs benefit: lower EPS risk than FGAs, making them more tolerable for many patients; however, metabolic monitoring (weight, glucose, lipids) is essential.

Third-Generation Antipsychotics

• Aripiprazole (Abilify): a commonly discussed third-generation antipsychotic with relatively favorable side-effect profile; used for agitation and as a PRN option in inpatient settings.
• Considerations: higher cost but often better tolerability; still requires monitoring for metabolic effects and other adverse events, though at lower rates for EPS.
• Practical point: third-generation agents may be used as alternatives to FGAs/SGAs when side effects or adherence concerns are prominent.

Side Effects by Generation and Monitoring Plan

• FGAs: higher risk of extrapyramidal symptoms (EPS), tardive dyskinesia, and anticholinergic effects; risk of NMS (rare but medical emergency).
• SGAs: lower EPS risk; higher risk of metabolic syndrome, weight gain, glucose dysregulation, dyslipidemia; clozapine risk of agranulocytosis requiring WBC monitoring.
• Specific monitoring strategies:
  • For clozapine: regular complete blood counts (CBCs) with differential; watch for signs of infection (fever, sore throat); counsel about infection risk.
  • For SGAs: monitor weight, BMI, fasting glucose, and lipid panels; screen for diabetes risk, cardiovascular risk factors.
  • For FGAs: monitor for EPS and TD using standardized scales; assess for signs of NMS (fever, rigidity, autonomic instability).
• Anticholinergic side effects: dry mouth, dry eyes, constipation, urinary retention; manage with hydration, sugar-free lozenges, fiber; use caution with elderly or constipated patients.
• Other side effects: sedation, orthostatic hypotension, sedation, metabolic changes (especially with SGAs).
• Patient education: emphasize consistent dosing, potential need for injections, and recognizing early warning signs of adverse effects.

Special Considerations: Neuroleptic Malignant Syndrome and Safety

• Neuroleptic Malignant Syndrome (NMS): a rare but life-threatening reaction to antipsychotics; symptoms include hyperthermia, severe muscle rigidity, autonomic instability, altered mental status, and diaphoresis.
• Immediate action: discontinue antipsychotic, provide supportive care, and initiate emergency medical treatment.
• Importance of recognizing NMS early in inpatient settings to prevent progression.

Diagnostic and Therapeutic Communication Tips for Clinicians

• When a patient reports hearing voices or other psychotic symptoms:
  • Do not dismiss or minimize; ask: "What are the voices telling you to do?" to assess risk to self or others, including potential command hallucinations.
  • Use non-confrontational language; reorientation should be gentle and not a power struggle.
  • If a patient has a delusion about something harmless or harmlessly bizarre, avoid direct confrontation; redirect or validate safely without endorsing the delusion.
• Communication strategies during acute psychosis:
  • Avoid reinforcing paranoia; provide a stable, calming environment; use clear, simple language; involve family when appropriate.
  • On higher acuity units, some patients may request PRN medications to manage escalating symptoms; acknowledge their insight and document accordingly.
• Safety planning: assess potential risks to self or others; escalate as needed; prioritize staff safety as well as patient safety.
• Assessment approach: integrate medical assessments (electrolytes, infections, glucose) to rule out reversible contributors to psychiatric symptoms.
• Discharge planning requires patient involvement and supports continuity of care after leaving hospital; consider social determinants (housing, transportation, access to follow-up care).

Case Example and Testing Concepts

• Testable concept: a patient with reported listening to something in a corner (hallucination) should be asked what they are hearing rather than dismissing the experience or contradicting them.
  • Correct approach: "What are you hearing?" to assess safety and risk rather than saying, "There is nobody there."
• A realistic test focus includes recognizing positive symptoms (delusions, hallucinations, disorganized speech) and differentiating them from negative symptoms; however, exam questions may emphasize symptomatic recognition and safety planning rather than strict taxonomy.

Practical Notes for Practice and Studying

• Early diagnosis and intervention lead to better prognosis across disease processes; apply the same principle to schizophrenia spectrum disorders.
• For exam study, focus on recognizing core symptoms, safety considerations, and the general pharmacology of antipsychotics (FGAs, SGAs, and third-generation agents), including common side effects and monitoring needs.
• Study tip suggested in the lecture: handwritten notes or concept maps may improve memory and understanding; consider organizing drugs by generation with side effects under each group.

Quick Reference: Core Facts to Remember

• Prevalence: 1 ext{%} worldwide.
• Typical onset ranges: males $18 ext{ to } 25$; females $25 ext{ to } 35$.
• Relative mortality risk: $1 ext{ to }2 imes$ higher than general population.
• Positive symptoms: delusions, hallucinations, disorganized speech; catatonia can be present.
• Negative symptoms: flat affect, alogia, avolition, anhedonia, avolition, poor hygiene.
• Polydipsia risk: potentially fatal water intoxication; monitor hydration and fluid intake.
• FGAs: Haloperidol, Fluphenazine, Chlorpromazine; high EPS and TD risk; NMS emergency.
• SGAs: fewer EPS; higher risk of weight gain and metabolic syndrome; Clozapine requires CBC monitoring due to agranulocytosis risk.
• Third-generation: Aripiprazole (Abilify); often used for agitation and as PRN; higher cost but favorable side-effect profile.
• Discharge planning begins at admission; aim for continuity of care and relapse prevention.