Mental Disorders: Schizophrenia
Schizophrenia
Learning Objectives
Discuss various theories of the etiology of schizophrenia.
Describe the positive and negative symptoms of schizophrenia.
Describe a functional and mental status assessment for a client with schizophrenia.
Apply the nursing process to the care of a client with schizophrenia.
Provide teaching to clients, families, caregivers, and community members to increase knowledge and understanding of schizophrenia.
Evaluate your own feelings, beliefs, and attitudes regarding clients with schizophrenia.
Overview of Schizophrenia
A syndrome or a disease process with many different varieties and symptoms such as distorted and bizarre thoughts, perceptions, emotions, movements, and behavior.
It cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome much like the varieties of cancer.
For decades, the public vastly misunderstood schizophrenia, fearing it as dangerous and uncontrollable and causing wild disturbances and violent outbursts.
Schizophrenia usually is diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood.
The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women (American Psychiatric Association [APA], 2000).
Positive or Hard Symptoms
Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation.
Associative looseness: Fragmented or poorly related thoughts and ideas.
Delusions: Fixed false beliefs that have no basis in reality.
Echopraxia: Imitation of the movements and gestures of another person whom the client is observing.
Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another.
Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality.
Ideas of reference: False impressions that external events have special meaning for the person.
Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic.
Bizarre behavior: Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior.
Negative or Soft Symptoms
Alogia: Tendency to speak little or to convey little substance of meaning (poverty of content).
Anhedonia: Feeling no joy or pleasure from life or any activities or relationships.
Apathy: Feelings of indifference toward people, activities, and events.
Asociality: Social withdrawal, few or no relationships, lack of closeness.
Blunted affect: Restricted range of emotional feeling, tone, or mood.
Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance.
Flat affect: Absence of any facial expression that would indicate emotions or mood.
Avolition or lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks.
Inattention: Inability to concentrate or focus on a topic or activity, regardless of its importance.
Etiology
Early studies focused on a specific pathological structure.
Shifted focus to psychological and social causes.
Interpersonal theories suggest dysfunctional relationships in early life.
Newer studies support neurologic/neurochemical causes.
Antipsychotic medications and imaging tools support neurologic/neurochemical causes.
Some therapists believe schizophrenia is caused by dysfunctional parenting or family dynamics.
Genetic Studies
Most studies focus on immediate families, excluding distant relatives.
Twins are the most significant group, with identical twins having a 50% risk of schizophrenia.
Fraternal twins have a 15% risk, suggesting schizophrenia is partially inherited.
Children with one biologic parent with schizophrenia have a 15% risk, rising to 35% if both parents have schizophrenia.
Children adopted into a family with no history of schizophrenia still reflect the genetic risk of their biologic parents.
Identical twins have only a 50% risk despite their 100% identical genes.
Brain Structure and Neurochemistry Study
MRI/CT/Positron Emission Tomography findings:
MRI shows less brain tissue and cerebrospinal fluid, possibly due to development failure or tissue loss.
CT scan shows enlarged ventricles in the brain and cortical atrophy.
Positron emission tomography studies show diminished glucose metabolism and oxygen in the frontal cortical structures of the brain.
Linked to the development of brain damage from viruses, trauma, or immune responses.
Neurochemical studies show alterations in the neurotransmitter systems of the brain in schizophrenia patients.
Dopamine and serotonin, with excess dopamine suggested as a cause.
Serotonin helps control excess dopamine and contributes to the development of schizophrenia.
Clinical Course
Onset can be abrupt and insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, loss of interest in school or at work, and neglected hygiene.
Symptoms may always be severe, but the long-term course does not always involve progressive deterioration; it varies among clients.
Immediate Course
Two typical patterns after the onset of psychotic symptoms:
In one pattern, the client experiences ongoing psychosis and never fully recovers, although symptoms may shift in severity over time.
In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from the psychosis.
Long Term Course
The intensity of psychosis tends to diminish with age.
Many clients with long-term impairment regain some degree of social and occupational functioning.
Over time, the disease becomes less disruptive to the person’s life and easier to manage, but rarely can the client overcome the effects of many years of dysfunction (Buchanan & Carpenter, 2005).
In later life, these clients may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment.
However, most clients with schizophrenia have difficulty functioning in the community, and few lead fully independent lives (Carter, 2006). This is primarily due to persistent negative symptoms, impaired cognition, or treatment refractory positive symptoms.
Immunovirologic Factors in Schizophrenia
Cytokines:
Chemical messengers between immune cells, mediate inflammatory and immune responses.
May contribute to the development of major psychiatric disorders like schizophrenia.
Signals the brain to produce behavioral and neurochemical changes during:
Stress.
Infections in pregnant women.
Children born in crowded, cold weather conditions.
Cultural Differences in Schizophrenia
Culture-Bound Syndromes:
Bouffée délirante syndrome: characterized by agitated and aggressive behavior, confusion, and psychomotor excitement.
Ghost sickness: Preoccupation with death and the deceased.
Jikoshu-kyofu: fear of offending others by emitting foul body odor.
Locura: chronic psychosis experienced by Latinos in the United States and Latin America.
Qi-gong psychotic reaction: acute, time-limited episode characterized by dissociative, paranoid, or other psychotic symptoms.
Zar: experience of spirits possessing a person.
Treatment - Psychopharmacology
Primary treatment for schizophrenia is psychopharmacology.
Previous treatments include electroconvulsive therapy, insulin shock therapy, and psychosurgery.
Chlorpromazine (Thorazine) was created in 1952, making other treatment modalities obsolete.
Antipsychotic medications, or neuroleptics, are prescribed to manage symptoms of schizophrenia.
First-generation antipsychotics are dopamine antagonists, while second-generation medications are both dopamine and serotonin antagonists.
First-generation antipsychotics target positive signs of schizophrenia, while second-generation reduces negative signs like lack of volition, social withdrawal, and anhedonia.
Antipsychotic Drugs
Divided into First-generation and Second-generation with varying dosages and side effects like sedation, hypotension, EPSS (extrapyramidal side effects), and anticholinergic effects.
Related Disorders
Schizophreniform disorder: The client exhibits the symptoms of schizophrenia but for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. Social or occupational functioning may or may not be impaired.
Delusional disorder: The client has one or more nonbizarre delusions—that is, the focus of the delusion is believable. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre.
Brief psychotic disorder: The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. The episode may or may not have an identifiable stressor or may follow childbirth.
Shared psychotic disorder (folie à deux): Two people share a similar delusion. The person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions.
Catatonia: Catatonia is characterized by marked psychomotor disturbance, either excessive motor activity or virtual immobility and motionlessness. Motor immobility may include catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and not influenced by external stimuli. Other behaviors include extreme negativism, mutism, peculiar movements, echolalia, or echopraxia. Catatonia can occur with schizophrenia, mood disorders, or other psychotic disorders.
Schizotypal personality disorder: This involves odd, eccentric behaviors, including transient psychotic symptoms. Approximately 20% of persons with this personality disorder will eventually be diagnosed with schizophrenia.
Antipsychotic Long-Acting Injections (LAIs) Overview
Fluphenazine (Prolixin) in decanoate and enanthate preparations.
Haloperidol (Haldol) in decanoate.
Risperidone (Risperdal Consta).
Paliperidone (Invega Sustenna).
Olanzapine (Zyprexa Relprevv).
Aripiprazole (Abilify Maintena).
Antipsychotic Long-Acting Injections (LAIs) Overview
First two conventional LAIs are absorbed slowly over time, lasting 2 to 4 weeks.
Second-generation LAIs are contained in polymer-based microspheres that degrade slowly.
Second-generation LAIs are more effective than oral forms in controlling negative symptoms and improving psychosocial functioning.
Clinicians may be reluctant to prescribe LAIs due to patient reluctance.
Antipsychotic Medication Side Effects
Side effects range from mild discomfort to permanent movement disorders.
Clients often discontinue or reduce medication dosage due to these frightening effects.
Serious neurologic side effects include EPSs, tardive dysskinesia, seizures, and neuroleptic malignant syndrome.
Nonneurologic side effects include weight gain, sedation, photosensitivity, and anticholinergic symptoms.
Psychosocial Treatment
Includes individual and group therapies, family therapy, family education, and social skills training.
Individual and group therapy sessions: Provide social contact and meaningful relationships.
Groups: Focus on medication management, community supports, and family concerns.
Social skill training: Breaks complex social behavior into simpler steps, practiced through role-playing, and applied in real-world settings.
Cognitive adaptation training: Uses environmental supports to improve adaptive functioning in the home.
More effective during in-home visits in the client's environment.
Anticholinergic Symptoms and Nursing Interventions
Dry mouth: Use ice chips or hard candy for relief.
Blurred vision: Assess side effect, which should improve with time; report to physician if no improvement.
Constipation: Increase fluid and dietary fiber intake; client may need a stool softener if unrelieved.
Urinary retention: Instruct client to report any frequency or burning with urination; report to physician if no improvement over time.
Orthostatic hypotension: Instruct client to rise slowly from sitting or lying positions; wait to ambulate until no longer dizzy or light-headed.
Side Effects and Nursing Interventions
Dystonic reactions: Administer medications as ordered; assess for effectiveness; reassure client if he or she is frightened.
Tardive dyskinesia: Assess using tool such as AIMS; report occurrence or score increase to physician.
Akathisia: Administer medications as ordered; assess for effectiveness.
EPSs or neuroleptic-induced parkinsonism: Administer medications as ordered; assess for effectiveness.
Seizures: Stop medication; notify physician; protect client from injury during seizure; provide reassurance and privacy for client after seizure.
Sedation: Caution about activities requiring client to be fully alert, such as driving a car.
Photosensitivity: Caution client to avoid sun exposure; advise client when in the sun to wear protective clothing and sunscreen.
Weight gain: Encourage balanced diet with controlled portions and regular exercise; focus on minimizing gain.
Symptoms of Residual Schizophrenia
Bizarre perceptual encounters
Unrealistic thinking
Decreased emotional expression or a flat affect
Lack of drive to carry out meaningful activities (avolition)
Reduced enjoyment from good stimuli (anhedonia)
Reduced speech (alogia)
Lack of desire to communicate with others (asociality)
Points to Consider When Working with Clients with Schizophrenia
Recognize that despite frequent hospital stays, these clients return to community functioning.
Focus on the client's time outside the hospital to reduce frustration.
Visualize the client's improvement and less severe symptoms.
Understand that client's remarks are a result of schizophrenia's disordered thinking.
Seek advice from experienced nurses on handling feelings and actions towards these clients.
Assessment - History
Eliciting client's previous schizophrenia history to establish baseline data.
Assessing age at onset of schizophrenia and previous hospital admissions.
Eliciting information about previous suicide attempts and violent or aggressive behavior.
Assessing current support systems through contact with family or friends, scheduled therapy appointments, financial struggles, and recent changes in living arrangements.
Assessing client's perception of current situation, including significant present events or stressors.
Delusions, Hallucinations, and Illusions
Delusions: Fixed, false beliefs, cannot be corrected by logic and are not consistent with culture and education of the patient.
Hallucinations: False sensory perception experienced without real external stimulus. They are usually experienced as originated in the outside world not within the mind as imagination.
Illusions: Misperception of real external stimulus. Most likely to occur when general level of sensory stimulation (consciousness) is reduced.
General Appearance, Motor Behavior, and Speech
Clients with schizophrenia may appear normal, with appropriate attire and no unusual gestures.
Others may exhibit odd or bizarre behavior, such as disheveledness or inappropriate clothing.
Motor Behavior:
Clients may exhibit restlessness, agitation, pacing, or unmoving (catatonia).
They may show seemingly purposeless gestures (stereotypic behavior) and odd facial expressions (echopraxia).
Rambling speech may accompany these behaviors.
Psychomotor Retardation
Clients may exhibit psychomotor retardation, slowing all movements.
They may be Most immobile, curled into a ball (fetal position).
Unusual Speech Patterns
Clients may exhibit word salad and echolalia, slowed or accelerated speech rate and volume.
Latency of response, or hesitation before responding, usually indicates difficulty with cognition or thought processes.
Unusual Speech Patterns
Clang associations: ideas that are related to one another based on sound or rhyming rather than meaning. Example: “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill.”
Neologisms: words invented by the client. Example: “I’m afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?”
Verbigeration: stereotyped repetition of words or phrases that may or may not have meaning to the listener. Example: “I want to go home, go home, go home, go home.”
Echolalia: is the client’s imitation or repetition of what the nurse says. Example: Nurse: “Can you tell me how you’re feeling?” Client: "Can you tell me how you’re feeling?"
Word salad: is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Example: “Corn, potatoes, jump up, play games, grass, cupboard.”
Stilted language: use of words or phrases that are flowery, excessive, and pompous. Example: “Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?"
Perseveration: is the persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic. Example: Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Where do you live?” Client: “At my place people have been following me.” Nurse: “What do you like to do in your free time?” Client: “Nothing because people are following me.”
Mood and Affect
Schizophrenia patients exhibit varied mood and affect, often characterized by flat or blunted affect.
Facial expressions can be masklike or silly, with inappropriate expressions or emotions incongruent with the situation.
Clients may experience depressive feelings, lack of pleasure or joy, or feelings of all-knowing, all-powerful.
Exaggerated feelings of well-being are common during episodes of psychotic or delusional thinking.
Thought Process and Content
Schizophrenia is a thought disorder, disrupting the continuity of thoughts and information processing.
Nurses can assess thought process by inferring from the client's words.
Clients may exhibit thought blocking, broadcasting, withdrawal, or insertion.
Tangential thinking is also common, with clients veering onto unrelated topics without answering the original question.
Delusions
Schizophrenic delusions are fixed, false beliefs with no basis in reality.
These delusions are immediate and completely certain.
The client's actions are influenced by their belief in the delusion.
Examples include suspicion, mistrust, and guardedness about disclosing personal information.
The theme or content of these delusions can vary.
Contradictory information or facts cannot alter these delusional beliefs.
The client often responds with "I just know it."
Nursing Interventions for Delusions
Do not openly confront the delusion or argue with the client.
Establish and maintain reality for the client.
Use distracting techniques.
Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs.
Types of Delusions
Persecutory Delusions:
Clients believe others are planning harm or belittling them.
Examples include imagining food poisoning or bugging rooms.
The "persecutor" can be the government, FBI, or other powerful organizations.
Grandiose Delusions:
Clients claim to be associated with famous people or celebrities.
Examples include claiming to be engaged to a famous movie star or related to a public figure.
Religious Delusions:
Center around the second coming of Christ or other significant religious figures.
Clients claim to be the Messiah or prophet sent from God.
Somatic Delusions:
Clients have vague and unrealistic beliefs about their health or bodily functions.
Examples include claiming to be pregnant or experiencing decaying intestines or worms in the brain.
Sexual Delusions:
Clients believe their sexual behavior is known to others.
Examples include rapists, prostitutes, or pedophiles.
Nihilistic Delusions:
Clients believe their organs aren't functioning or are rotting away.
Referential Delusions:
Clients believe television broadcasts, music, or newspaper articles have special meaning for them.
Hallucinations
Schizophrenic psychosis is characterized by hallucinations, false sensory perceptions that do not exist in reality.
These hallucinations can involve the five senses and bodily sensations and can be threatening or pleasant.
They are distinguished from illusions, which are misperceptions of actual environmental stimuli.
Types of Hallucinations
Auditory hallucinations: Hearing sounds, often voices, talking to or about the client.
Visual hallucinations: Seeing images that do not exist, such as lights or a dead person.
Olfactory hallucinations: Seeing smells or odors, often associated with dementia, seizures, or cerebral accidents.
Tactile hallucinations: Sensations like electricity running through the body or bugs crawling on the skin.
Gustatory hallucinations: A taste lingering in the mouth or the sense that food tastes different.
Cenesthetic hallucinations: Feelings of undetectable bodily functions.
Kinesthetic hallucinations: The sensation of bodily movement, sometimes unusual, even when the client is motionless.
Interventions for Hallucinations
Help present and maintain reality by frequent contact and communication with client.
Elicit description of hallucination to protect the client and others. Rationale: The nurse’s understanding of the hallucination helps him or her know how to calm or reassure the client.
Engage client in reality-based activities, such as card playing, occupational therapy, or listening to music.
Impaired Judgment and Insight
Schizophrenia patients often struggle with judgment due to disordered thought processes and environmental misinterpretations.
This can lead to severe impairments in safety, protection, and recognition of needs.
Early in the illness, clients may struggle with understanding the illness and seeking appropriate assistance.
Self-Concept Deterioration
Schizophrenia patients often have a loss of ego boundaries, leading to depersonalization, derealization, and confusion about their own body, mind, and influence.
This leads to bizarre behaviors such as public undressing, masturbation, and body image distortion.
Roles and Relationships
Social isolation is common in schizophrenia patients due to delusions, hallucinations, and loss of ego boundaries.
Trust and intimacy issues interfere with establishing satisfactory relationships.
Low self-esteem complicates interactions with others and the environment.
Clients may experience frustration in fulfilling family and community roles, leading to compromised success in school or work.
Physiological and Self-Care Considerations
Schizophrenia patients may have significant self- care deficits, including inattention to hygiene and grooming needs.
They may feel guilty or responsible for not providing a loving, supportive home life.
Clients may fail to recognize hunger and thirst cues which may lead to malnourishment and constipation.
May have polydipsia.
Sleep problems due to hallucinations.
Data Analysis
NANDA nursing diagnoses commonly established based on the assessment of psychotic symptoms or positive signs are:
Risk for other-directed violence
Risk for suicide
Disturbed thought processes
Disturbed sensory perception
Disturbed personal identity
Impaired verbal communication
The NANDA nursing diagnoses based on the assessment of negative signs and functional abilities include:
Self-care deficits
Social isolation
Deficient diversional activity
Ineffective health maintenance
Ineffective therapeutic regimen management
Nursing Interventions For Clients with Schizophrenia
Promoting safety of client and others and right to privacy and dignity
Establishing therapeutic relationship by establishing trust
Using therapeutic communication (clarifying feelings and statements when speech and thoughts are disorganized or confused)
Teach social skills through education, role modeling, and practice.
Client and family teaching
Establishing community support systems and care
Coping with Socially Inappropriate Behaviors
Redirect the client away from problem situations.
Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; and do not scold the client.
Reassure others that the client’s inappropriate behaviors or comments are not his or her fault (without violating client confidentiality).
Try to reintegrate the client into the treatment milieu as soon as possible.
Do not make the client feel punished or shunned for inappropriate behaviors.
Outcome Identification
Acute psychotic episode of schizophrenia typically requires intensive treatment in an inpatient hospital unit.
Care focuses on stabilizing the client's thought processes and reality orientation, ensuring safety.
Resources evaluation, referrals, and rehabilitation planning are crucial.
Examples of outcomes appropriate to the acute, psychotic phase of treatment are:
The client will not injure him or herself or others.
The client will establish contact with reality.
The client will interact with others in the environment.
The client will express thoughts and feelings in a safe and socially acceptable manner.
The client will participate in prescribed therapeutic interventions.
Continued follow-up care and family involvement in community support services.
Prevention and early recognition of relapse symptoms are crucial for successful rehabilitation.
Post-stability, focus on independent, successful community living.
Client & Family Education For Schizophrenia
How to manage illness and symptoms
Recognizing early signs of relapse
Developing a plan to address relapse signs
Importance of maintaining prescribed medication regimen and regular follow-up
Avoiding alcohol and other drugs
Self-care and proper nutrition
Teaching social skills through education, role modeling, and practice
Seeking assistance to avoid or manage stressful situations
Counseling and educating family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing support
Importance of maintaining contact with the community and participating in supportive organizations and care
Evaluation of Schizophrenia Treatment
Nurse evaluates care plan in the context of each client and family.
Ongoing assessment determines individual outcomes and client's perception of treatment success.
Evaluation considers if psychotic symptoms have disappeared or if daily life can be carried out despite persistent symptoms.
Client understands prescribed medication regimen and commits to adherence.
Client has functional abilities for community living.
Community resources are adequate for successful community living.
Aftercare or crisis plan is in place for symptom recurrence.
Client and family are knowledgeable about schizophrenia.
Client believes they have a satisfactory quality of life.