Schizophrenia

Schizophrenia Overview

  • Literal translation: "Split mind"
  • Nature of illness:
    • Not a single illness; thought of as a syndrome or spectrum of disorders
    • Exhibits a variety of symptoms
  • Age of onset:
    • Males: 15-25 years
    • Females: 25-35 years

Learning Objectives

  • Identify key symptoms and diagnostic criteria of schizophrenia and schizophrenia spectrum disorders
  • Identify medications used to treat people with schizophrenia and evaluate their effectiveness
  • Plan care for clients with schizophrenia
  • Describe a functional and mental status assessment for a client with schizophrenia
  • Identify effective treatment outcomes

DSM-5 Criteria for Schizophrenia

  • At least two psychotic symptoms present for a duration of one month
  • Social or occupational dysfunction must accompany these symptoms
  • Duration of symptoms must be six months

Etiology of Schizophrenia

  • No single cause identified; dopamine reduction observed to help with symptoms
  • Genetic influence:
    • Children of parents diagnosed with schizophrenia are 10 times more likely to develop the disorder
  • Environmental risk factors:
    • Poverty
    • Substance abuse
    • Social isolation
    • Dysfunctional family life
    • Prenatal infections

Memory Tip: The 4 S's of Schizophrenia

  • Schizophrenia
  • Scattered pattern of thinking
  • Suicide risk: High; approximately 10% of diagnosed individuals die by suicide
  • Six months of symptoms required for diagnosis

Symptoms of Schizophrenia

Positive Symptoms

  • Definition: Symptoms that add something to the individual's experience, e.g., hallucinations and delusions.
  • Types of Positive Symptoms:
    • Delusions: Fixed false beliefs without basis in reality
    • Hallucinations: False sensory experiences
    • Disorganized thinking, speech, behavior: Also known as Psychosis.

Example of Positive Symptom: Disorganized Thinking

  • Thought Broadcasting: The belief that one's thoughts are being broadcast aloud.
  • Artistic Depiction: Artist Bryan Charnley's representation of thought broadcasting illustrates this experience.
  • Charnley's Quote: "My mind seemed to be thought broadcasting very severely and it was beyond my will to do anything about it. I summed this up by painting my brain as an enormous mouth, acting independently of me."
  • Context: This was the last completed painting before his suicide in 1991.

Negative Symptoms

  • Definition: Symptoms that take away from the individual’s experience.
  • Types of Negative Symptoms:
    • Affect: Flat or blunted
    • Alogia: Reduction in speech
    • Avolition: Absence of ambition or drive
    • Anergia: Lack of energy
    • Antisocial behavior
    • Anhedonia: Reduced ability to experience pleasure

Phases of Schizophrenia

  1. Prodromal Phase: Symptoms begin to appear.
  2. Acute Illness Phase: Symptoms are most severe.
  3. Stabilization & Recovery Phase: The individual begins to recover.

Factors Influencing Symptom Relapse

  • Nonadherence to medication
  • Substance abuse
  • Negative attitude toward treatment
  • Limited resources

Schizophrenia Spectrum Disorders

Schizoaffective Disorder

  • Definition: A mix of mood and psychotic symptoms, which can include:
    • Depression
    • Bipolar disorder
  • Psychosocial functioning is adequate despite these symptoms.

Delusional Disorder

  • Definition: Presence of delusions without other psychotic disorders
  • Criteria: 1 or more delusions for at least 1 month with normal psychosocial functioning.

Schizophreniform Disorder

  • Definition: Symptoms identical to schizophrenia but duration is between 1 to 6 months.
  • Outcome: Approximately 2/3 of patients eventually develop schizophrenia.

Goals of Treatment for Schizophrenia

  • Suppression of acute episodes
  • Prevention of acute recurrence
  • Achieve the highest possible level of functioning

Psychopharmacology

First Generation (Typical Antipsychotics)

  • Mechanism: Block dopamine receptors (D2) in the mesolimbic pathway as dopamine antagonists.
  • Effectiveness: Target positive symptoms only; little to no effect on negative symptoms.
  • Side Effects: More commonly produce Extrapyramidal Side Effects (EPS).
  • Examples:
    • Haloperidol
    • Fluphenazine
    • Chlorpromazine

Second Generation (Atypical Antipsychotics)

  • First-line treatment for psychotic symptoms.
  • Advantages: Fewer adverse effects; relief of both positive and negative symptoms.
  • Potential Side Effects: Can produce EPS, especially at higher doses; greater metabolic changes such as:
    • Weight gain
    • High cholesterol
    • Insulin resistance
  • Examples:
    • Clozapine
    • Olanzapine
    • Quetiapine
    • Aripiprazole
    • Risperidone

Contraindications for Antipsychotics

  • Clients with Parkinson's disease
  • Clients with liver damage
  • Severe hypotension
  • First-generation antipsychotics: Not appropriate for elderly clients with dementia due to side effects.

Extrapyramidal Side Effects (EPS)

  • Occurs early in treatment; includes:
    • Acute Dystonia
    • Parkinsonism: Symptoms include stooped posture, shuffling gait, rigidity, bradykinesia, and tremors at rest.
  • Acute Dystonia Symptoms:
    • Facial grimacing
    • Involuntary upward eye movement
    • Muscle spasms of the tongue, face, neck, and back
    • Laryngeal spasms
  • Akathisia Symptoms:
    • Restlessness
    • Trouble standing still
    • Paces the floor
    • Feet in constant motion, rocking back and forth

Nursing Actions for EPS

  • Monitor for EPS during the first 1-60 days for symptom onset.
  • Administer medications for acute treatment:
    • Benztropine 1-2mg IV, IM (anti-parkinsonism agent)
    • Diphenhydramine 25-50mg IV, IM
  • Monitor the patient closely until spasms subside.

Tardive Dyskinesia (TD)

  • Definition: Appears late in treatment; characterized by abnormal involuntary movements that are irreversible.
  • Symptoms of TD:
    • Protrusion and rolling of the tongue
    • Sucking and smacking movements of the lips
    • Chewing motions and facial dyskinesia
    • Involuntary movements of the body and extremities
  • Nursing Actions for TD:
    • Evaluate the client after 12 months of therapy, then every 3 months after that.
    • Encourage purposeful muscle movement to help control symptoms.
    • If TD occurs, discontinue the medication and consider alternatives, noting that Clozapine can be beneficial for clients with TD.

Neuroleptic Malignant Syndrome (NMS)

  • Definition: A medical emergency which can be fatal.
  • Signs and Symptoms:
    • Muscle rigidity
    • Sudden high fever
    • Blood pressure fluctuations
    • Decreased level of consciousness; potential for coma
    • Increased muscle enzymes (high CK)
    • Leukocytosis (elevated WBC)
  • Nursing Actions for NMS:
    • Stop antipsychotic medication immediately.
    • Ensure hydration and temperature control (using cooling blankets, antipyretics, IV fluids).
    • Muscle relaxation (using IV dantrolene).
    • Consider transferring the client to the ICU.
    • Wait at least 2 weeks before resuming medication, considering an atypical antipsychotic.

Agranulocytosis

  • Definition: Severe neutropenia where the bone marrow fails to produce WBCs; especially a risk with Clozapine.
  • Symptoms: Develops suddenly; observe for signs of infection (fever, malaise, ulcerative sore throat, leukopenia).
  • Monitoring required: Clients must have blood levels checked weekly; discontinue medication if WBC is below 3,000.

Nursing Teaching Points - Side Effects

  • Metabolic syndrome
  • Orthostatic hypotension
  • Weight gain
  • Sedation
  • Hyperprolactinemia: leads to gynecomastia
  • Anticholinergic effects:
    • Dry mouth
    • Blurred vision
    • Photophobia
    • Urinary hesitancy
    • Constipation

Nursing Teaching Points- Managing Side Effects

  • Use hard candy or lozenge to manage dry mouth.
  • Encourage small, frequent sips of water.
  • Advise to avoid hazardous activities due to sedation.
  • Recommend wearing sunglasses outdoors to manage photophobia.
  • Suggest high-fiber diets and regular exercise to combat weight gain.
  • Instruct to void prior to taking medication to avoid urinary hesitancy.
  • Monitor cholesterol and glucose levels regularly.
  • Emphasize changing positions slowly to prevent orthostatic hypotension.

Cognitive Enhancement Therapy (CET)

  • Definition: Combines computer-based cognitive training with group sessions.
  • Purpose: Designed to improve social and neurocognitive deficits and decrease substance use.

Mental Status Exam

Appearance/Motor/Speech

  • Observations may include:
    • Strange or unusual posturing
    • Inappropriate clothing for the season
    • Motor behavior can be: restless or catatonic
    • Facial expressions: potentially grimacing
    • Possible mimicry of movements (echopraxia)

Mood/Affect

  • Affect may appear flat or blunted.
  • Inappropriate emotional expressions; for example, smiling when discussing death.
  • Mood Lability: fluctuation in mood is noted.

Disorganized Behavior

  • Symptoms can include:
    • Aggression
    • Agitation
    • Catatonia (e.g., stupor, mutism, posturing)
    • Waxy flexibility: the ability to hold an odd position for extended periods
    • Hypervigilance: excessive awareness of surroundings.

Disorganized Thinking: Speech Patterns

  • Neologisms: Client invents words.
  • Clang associations: Words are linked based on sound or rhyme (e.g., "I went to the store, had more, look at the shore").
  • Loose Association: Disconnected thoughts and ideas (sudden topic shifts).
  • Echolalia: Repetition of what others say (e.g., nurse says, "Here is your lunch", client replies, "Your lunch, your lunch, your lunch").
  • Word Salad: Unrelated words combined (e.g., "Walking outcast apple prepare to the moon window").

Disorganized Thinking: Thought Process/Content

  • Thought blocking: Client stops talking mid-sentence.
  • Thought broadcasting: Belief that others can hear their thoughts.
  • Thought insertion: Belief that others are placing thoughts into their mind against their will.

Delusions

  • Definition: Fixed, false beliefs without basis in reality.
Types of Delusions:

  1. Persecutory/Paranoid Delusions: Beliefs that someone is out to harm or spy on them.

    • Examples:
    • "I cannot eat the hospital food. I know you are trying to poison me!"
    • "My roommate is from the FBI; they are listening to me."

  2. Grandiose Delusions: Beliefs of greatness or fame.

    • Examples:
    • "I found the cure for cancer."
    • "I am best friends with Leonardo DiCaprio."

  3. Nihilistic Delusions: Beliefs that they are dead or that life is non-existent.

    • Examples:
    • "Life is an illusion."
    • "The world is ending."

  4. Referential Delusions: Beliefs that everyday events or media are directly related to them.

    • Example: Client believes that someone is speaking directly to them through news articles or broadcasts.

  5. Religious Delusions: Beliefs of being a religious figure or that they have a special relationship with God or prophets.

Hallucinations

  • Definition: False sensory or perceptual experiences that do not exist; most commonly auditory, tactile, or visual.
  • Concern with command hallucinations: Hallucinations that demand the client take actions, potentially harmful.

Nursing Actions for Delusions and Hallucinations

  • Monitor for paranoia, which can lead to violence.
  • Focus conversations on reality-based subjects.
  • Engage in reality-orienting activities:
    • Drawing, coloring, writing.
    • Listening to music, walking.
  • Identify triggers; for example, loud noises may trigger psychotic symptoms.

Cognition, Judgment & Insight

  • Judgment may be impaired, potentially affecting the ability to dress, eat, or sleep appropriately.
  • Insight into their condition may be poor; better insight often correlates with better outcomes.

Nursing Actions for Social Appropriateness

  • Help cope with socially inappropriate behaviors by:
    • Redirecting their focus.
    • Using factual statements without scolding.
    • Teaching social skills through modeling, education, and practice.
    • Offering support to the client and family by connecting them with resources.
    • Working towards recovery based on the client’s strengths.

Discussion Points to Assess Patient Strengths

  • Questions to ask clients:
    • What do you like to do for fun?
    • How do you relax?
    • How do you cope with stress?
    • Who can you talk to when you feel upset?
    • What gives you hope for the future?

Treatment Outcomes

  • Clients should be able to:
    • Identify and monitor their positive symptoms and any worsening symptoms.
    • Apply coping mechanisms to minimize symptoms.
    • Develop and adhere to a medication routine.
    • Foster positive interactions with their families, crucial for the success of long-term treatments and outcomes.