Schizophrenia

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Title and Author

  • Schizophrenia and other Psychoses

  • VIZMARC V. SANTOS, RN, MSN

  • Faculty - Lecturer CIT-U I CNAHS - Nursing, Cebu Institute of Technology University

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Psychosis

  • Definition: Disruptive mental state affecting the distinction between internal perceptions and the external world.

  • Psychotic Manifestations:

    • Sensory-Perceptual Alterations

    • Inability to relate to others

    • Thought process disturbances

  • SISAs include Schizophrenia, Intoxication, Severe Depression, Acute Mania.

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Schizophrenia

  • Major psychotic syndrome causing distorted thoughts, perceptions, emotions, movements, and behaviors.

  • Chronic illness requiring long-term management and coping strategies.

DSM Diagnostic Criteria for Schizophrenia

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History of Schizophrenia

  • 1860: Morel termed psychiatric symptoms as "Dementia praecox."

  • 1871: Kahlbaum used "catatonia" for immobilized patients.

  • 1874: Hecker described "hebephrenia" for silly and regressed behaviors.

  • 1878: Kraeplin introduced the term "paranoia" for highly suspicious patients.

  • 1899: Kraeplin grouped these terms under "dementia praecox."

  • 1908: Bleuler coined the term "schizophrenia."

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Bleuler's Concept of Schizophrenia

4 A’s of Schizophrenia

  • Affective disturbance: Inappropriate or flat affect

  • Autism: Preoccupation with self

  • Associative looseness: Unrelated topics in discourse

  • Ambivalence: Simultaneous opposite feelings

  • Derived from Greek terms "skhizo" (split) and "phren" (mind).

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Course of Illness

  • Onset: Typically from late adolescence to early adulthood

  • Gender prevalence: Affects both men and women equally

  • National morbidity: 1 million Filipinos afflicted (DOH, 2018).

Stages of Disease Progression

  • Premorbid

  • Prodromal

  • Schizophrenia

  • Residual

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Premorbid Phase

  • Patients often have schizoid or schizotypal personalities.

  • Characteristics: Social withdrawal, introversion.

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Prodromal Phase

  • Transition from premorbid functioning to psychotic symptoms (weeks to months).

Early Manifestations

  • Sleep disturbance

  • Anxiety

  • Irritability

  • Depressed mood

  • Poor concentration

  • Fatigue

  • Social withdrawal

Late Manifestations

  • Perceptual abnormalities

  • Ideas of reference

  • Suspiciousness

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Active Phase of Schizophrenia

  • Characterized by prominent psychotic symptoms.

  • Diagnostic criteria according to DSM.

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Residual Phase

  • May follow the active phase.

  • Acute symptoms decrease in intensity.

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Genetics and Risk Factors

  • Sibling with schizophrenia: 10% risk

  • One parent with schizophrenia: 5%-6% risk

  • Twin Studies: Identical twins have 4x the risk compared to fraternal twins.

  • Adoption Studies: Children of schizophrenic mothers at higher risk.

Etiology: UNKNOWN

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Dopamine Hypothesis

  • Excess dopamine activity linked to schizophrenia:

    • Increased production/release at nerve terminals

    • Increased receptor sensitivity

    • Too many dopamine receptors

Adoption Studies

  • Similar observations as noted previously: Higher risk for children born to affected mothers.

Etiology: UNKNOWN

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Symptoms of Schizophrenia

  • Linked to dopamine dysregulation.

  • Dopamine locations:

    • Ventral tegmentum area

    • Substantia nigra

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Positive and Negative Symptoms

  • Positive symptoms: Result from elevated dopamine levels affecting the limbic area.

  • Negative symptoms: Related to hypodopaminergic processes in the mesocortical tract.

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Positive Symptoms

  • Ambivalence

  • Associative looseness

  • Delusions

  • Echopraxia

  • Flight of ideas

  • Hallucinations

  • Ideas of reference

  • Perseveration

  • Bizarre behavior

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Negative Symptoms

  • Alogia

  • Anhedonia

  • Apathy

  • Asociality

  • Blunted affect

  • Catatonia

  • Flat affect

  • Avolition

  • Inattention

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Types of Schizophrenia

  • Paranoid Schizophrenia: Hallucinations, persecutory delusions, religiosity, suspiciousness

  • Disorganized Schizophrenia: Loose associations, bizarre behavior, flat/inappropriate affect

  • Catatonic Schizophrenia: Stupor, waxy flexibility, mutism, echopraxia

  • Residual Schizophrenia: In remission but still shows flat affect and social withdrawal.

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Antipsychotic Therapy

  • Mainstay treatment; controls but does not cure symptoms.

Medication Classes

  • Third-Generation Antipsychotics: Stabilize dopamine system (e.g., Aripiprazole).

  • Second-Generation Antipsychotics: Affect both positive and negative symptoms (e.g., Clozapine, Olanzapine, Risperidone).

  • First-Generation Antipsychotics: Primarily target positive symptoms (e.g., Chlorpromazine, Haloperidol).

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Conventional and Atypical Antipsychotics

  • Uses sesame oil for slow absorption.

  • Depot injections (e.g., Fluphenazine, Risperidone, Olanzapine).

  • Transition to depot injections after stable oral regimen.

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Dopaminergic Pathways

  • Areas affected include Cortex, Striatum, Thalamus, and more.

Extrapyramidal Side Effects (EPSE)

  • Pseudoparkinsonism

  • Akathisia

  • Dystonia

  • Tardive Dyskinesia

  • Agranulocytosis

  • Neuroleptic Malignant Syndrome (NMS)

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Side Effects Management

Akathisia

  • Restlessness and fidgeting; common onset at 50-60 days.

  • Management includes Propranolol.

Pseudoparkinsonism

  • Symptoms: Tremors, rigidity; onset 1-5 days.

  • Management with antiparkinsonian medications (e.g., Amantadine).

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Dystonia

  • Involuntary spasms; more common in men under 25.

  • Management includes anticholinergics and other supportive measures.

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Tardive Dyskinesia

  • Late-appearing, often irreversible side effect.

  • Symptoms: Involuntary movements (e.g., tongue protrusion, lip smacking).

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Tardive Dyskinesia Management

  • Hold medications at initial signs and monitor with AIMS scale.

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Agranulocytosis and NMS

  • Agranulocytosis: Low WBC levels, managed by monitoring and controlling dispensing of medication.

  • NMS: Rare, life-threatening condition requiring immediate action (discontinuation of antipsychotics).

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Nursing Interventions

  1. Promote safety and privacy.

  2. Establish trust and therapeutic relationships.

  3. Use therapeutic communication techniques.

For Delusions

  1. Avoid confrontation and argue.

  2. Base interaction on reality.

  3. Gradually present doubts regarding delusions.

For Hallucinations

  1. Elicit descriptions of hallucinations.

  2. Maintain reality with contact and communication.

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Assistance in Coping

  • Redirect inappropriate behaviors.

  • Address behaviors non-judgmentally.

  • Reassure others that behaviors are not the patient's fault.

  • Encourage reintegration into treatment milieu.

  • Teach relevant social skills.