1. Schizophrenia Chapter 15
West Coast University
Solomon Tan, MSN/Ed. RN-BC, PHN
2011

2. Eugen Bleuler’s 4 A’s of Schizophrenia
Affect
Associative looseness
Autism
Ambivalence

3. Epidemiology Lifetime prevalence of schizophrenia 1% worldwide
Average onset is late teens to early twenties, but can be as late as mid-fifties
30% to 40% relapse rate in the first year
Life expectancy is shortened because of suicide
No difference related to
Race, Social status, Culture

4. Comorbidity Substance abuse disorders Anxiety, depression, and suicide
Nicotine dependence
Anxiety, depression, and suicide
Physical health or illness
Polydipsia

5. Etiology Biological factors Neurobiological
Genetics
Neurobiological
Dopamine theory
Other neurochemical hypotheses
Brain structure abnormalities

6. Etiology Continued Psychological and environmental factors
Prenatal stressors
Psychological stressors
Environmental stressors

7. Signs and Symptoms Language and communication disturbances
Thought disturbances
Perception disturbances
Affect disturbances
Motor behavior disturbances
Self-identity disturbances

8. Features of Schizophrenia
Progression varies from one client to another
Exacerbations and remissions
Chronic but stable
Progressive deterioration
DSM-IV-TR Diagnosis
Symptoms present at least 6 months
Active-phase symptoms present at least 1 month
Symptoms are defined as positive and negative

9. Phases of Schizophrenia
Phase I – Acute
Onset or exacerbation of symptoms
Phase II – Stabilization
Symptoms diminishing
Movement towards previous level of functioning
Phase III – Maintenance
At or near baseline functioning

10. Assessment During the prepsychotic phase General assessment
Positive symptoms (Excess or distorted)
Negative symptoms (Deficit)
Cognitive symptoms
Affective symptoms

11. Positive Symptoms Alterations in thinking
Delusions are false, fixed beliefs
Persecutory, Referential
Somatic, Religious,
Substitution, Thought Insertion and/or Broadcasting
Nihilistic, Grandiose
Concrete thinking is an inability to think abstractly.
Indecisiveness, lack of problem solving skills,
Concreteness, thought blocking, perseveration

12. Positive Symptoms Continued
Alterations in speech
Neologisms
Echolalia
Echopraxia
Clang associations
Word salad
Loose Association

13. Positive Symptoms Continued
Alterations in perception
Depersonalization
Derealization
Hallucinations
Auditory hallucinations
Command hallucinations
Visual hallucinations
Boundary impairment
Negativism
Impaired impulse control

14. Negative Symptoms (5A’s)
Affect
Flat, Blunted, Inappropriate, Bizarre
Apathy
Indifference towards people, events, activities and learning.
Alogia
Poverty of speech
Avolition
Inability to pursue and persist in goal-directed activities.
Anhedonia
Inability to experience pleasure.

15. Cognitive Symptoms Difficulty with Attention Memory
Information processing
Cognitive flexibility
Executive functions

16. Affective Symptoms Assessment for depression crucial
May herald impending relapse
Increases substance abuse
Increases suicide risk
Further impairs functioning

17. Review Question
A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?
Positive symptom
Negative symptom
Cognitive symptom
Depressive symptom

18. Review Question
The nurse is documenting in the multidisciplinary treatment plan. Which assessment data depicts positive symptoms of schizophrenia?
A. “I use to like going to the movies and spending time with my family but rather be alone.”
B. “I don’t want to go to group.” Lack motivation and affect appear Blunted.
C. “I can’t sit still and I feel like I want to jump out of my skin.”
D. “There are cameras in the ceiling and the voices are whispering to me.”

19. Subtypes of Schizophrenia
Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual Type

20. Subtypes of Schizophrenia - continued
Paranoid Type
Delusions
Persecutory and grandiose
Somatic or religious
Hallucinations
Delusions link with a hallucination
Disorganized Type
Disorganized speech, behavior, appearance
Flat or inappropriate affect
Fragmented hallucinations and delusions
Most severe form of schizophrenia

21. Specific Interventions for Paranoid and Disorganized Schizophrenia
Communication guidelines
Self-care needs
Milieu needs

22. Subtypes of Schizophrenia - continued
Catatonic type
Psychomotor retardation and stupor
Waxy flexibility
Mutism
Extreme psychomotor agitation
Echolalia
Echopraxia

23. Specific Interventions for Catatonia
Catatonia – Withdrawn Phase
Communication guidelines
Self-care needs
Milieu needs
Catatonia – Excited Phase

24. Subtypes of Schizophrenia - continued
Undifferentiated type
Active psychotic state (Positive & Negative symptoms)
Lacks symptoms of other subtypes
Residual type
Active-phase symptoms no longer present
No prominent positive symptoms
Negative symptoms present

25. Other Psychotic Disorders
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared Psychotic Disorder (Folie à Deux)
Induced or Secondary Psychosis

26. Assessment Guidelines
1. Any medical problems
2. Abuse of or dependence on alcohol or drugs
3. Risk to self or others
Command hallucinations
5. Belief system
6. Suicide risk

27. Assessment Guidelines Continued
7. Ability to ensure self-safety
Co-occurring disorders
9. Medications
10. Presence and severity of positive and negative symptoms
11. Patient’s insight into illness
12. Family’s knowledge of patient’s illness and symptoms

28. Potential Nursing Diagnoses
Positive symptoms
Risk for violence
Disturbed sensory perception
Risk for self-directed or other-directed violence
Disturbed thought processes
Negative symptoms
Social isolation
Chronic low self-esteem
Altered health maintenance
Ineffective coping
Impaired verbal communication

29. Outcomes Identification
Phase I - Acute
Patient safety and medical stabilization
Phase II - Stabilization
Adhere to treatment
Stabilize medications
Control or cope with symptoms
Phase III - Maintenance
Maintain achievement
Prevent relapse
Achieve independence, satisfactory quality of life

30. Planning Phase I – Acute Phase II – Stabilization
Best strategies to ensure patient safety and provide symptom stabilization
Phase II – Stabilization
Phase III – Maintenance
Provide patient and family education
Relapse prevention skills are vital

31. Implementation Phase 1 – Acute Settings Partial hospitalization
Residential crisis centers
Halfway houses
Day treatment programs

32. Interventions Acute Phase
Psychiatric, medical, and neurological evaluation
Psychopharmacological treatment
Support, psychoeducation, and guidance
Supervision and limit setting in the milieu

33. Interventions Continued
Stabilization and Maintenance Phase
Milieu management
Activities and groups
Safety
Counseling and communication techniques

34. Interventions Continued
Stabilization and Maintenance Phase, continued
Hallucinations
Delusions
Associative looseness
Health teaching and health promotion

35. Nursing Implications: Supporting Families
Family needs vary with degree of illness and involvement in client’s care
Education
Financial support
Psychosocial support
Advocacy

36. Nursing Implications: Supporting Families - continued
Schizophrenia is a “family illness.”
Family members need to be involved.
Educate family about
Medication
Illness
Relapse prevention
Nurse assists family by
Identifying community agencies/groups for family members
Advocating for rights

37. General Nursing Intervention
Promote Safety and a Safe Environment
Promote Congruent Emotional Response
Promote Social Interaction and Activity
Intervene with Hallucinations and Delusions
Preventing Relapse
Promoting adherence with medication regimen
Assist with grooming and hygiene
Promote Family Understanding and Involvement

38. Review Question
The client informs you that the CIA monitoring his every move to find evidence that he killed someone. Which response by the nurse is therapeutic for the client?

39. Review Answers
A. "I will make sure that the security guard will monitor your room.”
B. "Don't worry you are safe here, the CIA can't enter the hospital.”
C.  "You seem fearful for your safety, but you are safe here.”
D. "Why do you think the CIA is following you, who did you kill?”

40. Psychopharmacology
Prior to the 1950s: focus on behavioral interventions and sedatives
Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine)
Psychiatric medications allow for the improve imbalances of neurotransmitters.
Goal is to treat quickly so disease does not progress.
Clients may initially be resistant to medications.

41. Goals of Antipsychotics
Positive Effects
Allowed release of clients from inpatient hospital to treatment in the community
Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation.
Alleviation of the symptoms, often improving:
Ability to think logically
Ability to function in one’s daily life
Ability to function in relationships

42. Negative Effects of Antipsychotics
Frightening and life threatening side effects
Potential interactions with other medications and substances
Possible need to cope with the realization of having a chronic illness

43. All current antipsychotics work on at least one of these neurotransmitters:
Dopamine
Serotonin

44. Antipsychotics Typical (Conventional)
Block dopamine receptors at 70% to 80% occupancy to be effective.
Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80
Typical = Tardive Dyskinesia (TD)
5.4% vs 0.8% atypicals

45. Pharmacological Interventions
Antipsychotic medications
Conventional antipsychotics
Typical or first-generation
Atypical antipsychotics
Second-generation

46. Conventional Antipsychotics
Dopamine antagonists (D2 receptor antagonists)
Target positive symptoms of schizophrenia
Advantage
Less expensive than atypical antipsychotics
Disadvantages
Do not treat negative symptoms
Extrapyramidal side effects (EPSs)
Tardive dyskinesia
Anticholinergic side effects
Lower seizure threshold

47. Conventional Antipsychotics
Typical Agents
Low Potency
Chlorpromazine (Thorazine) (25 – 800 mg/d)
Thioridazine (Mellaril) (150 – 800 mg/d)
Mesoridazine (Serentil) (100 – 400 mg /d)
Side Effects:
Sedation, Anticholernergic, Hypotention,
EPSEs (less vs high potency)

48. Conventional Antipsychotics
High Potency
Haloperidol (Haldol) (1 – 30 mg/d)
Fluphenazine (Prolixin) (0.5 – 40 mg/d)
Thiothixene (Navane) (2 – 30 mg/d)
Trifluoperazine (Stelazine) (1 – 40 mg/d)
Perhenazine (Trilafon) (8-60 mg/d)
Loxapine (Loxitane) (20 – 250 mg/d)
Molindone (Moban) (50 – 225 mg/d)
Pimozide (Orap) 0.5 – 9 mg/d)
Side Effects
Sedation, Anticholenergic SE (less vs low potency)
EPSEs (high vs low potency)

49. Conventional Long-Acting Injectables (Depot Therapy)
Haloperidol Decanoate (Haldol Decanoate)
Q4 weeks
Fluphenazine Decanoate (Prolixin Decanoate)
Q2 Weeks

50. Atypical Antipsychotics
Treat both positive and negative symptoms
Fewer extrapyramidal side effects (EPSs) or tardive dyskinesia
Reduced affinity for dopamine (D2) receptors
Affinity for serotonin receptors
D2 antagonist + Serotonin receptor antagonist
Disadvantage – tendency to cause significant weight gain

51. Atypical Antipsychotics Continued
Clozapine (Clozaril) (6.25 – 900 mg/d)
Side effects: 5% risk of seizures, agranulocytosis, weight gain, hypersalivation, anticholinergic
Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv)
(5 – 20 mg/d)
Side effects: Weight gain, diabetes, sedation, bankruptcy 20mg/day = $925/month
Paliperidone (Invega) (3 – 12 mg/d)
Quetiapine (Seroquel) (150 – 600 mg/d)
Side effects: sedation, weight gain, restless leg syndrome
Risperidone (Risperdal, Risperdal M-Tab)
(2 – 6 mg/d) (Increase Prolactin)

52. Atypical Antipsychotics Continued
Ziprasidone (Geodon) ( 40 – 160 mg/d)
Side effects: QTc prolongation, minimal sedation
Administer with food for improve efficacy
Aripiprazole (Abilify) (15 – 30 mg/d)
Side effects: akathisia, insomnia/sedation, maybe less weight gain
Asenapine (Saphris) (5 – 10 mg/d) Sublingual
Iloperidone (Fanapt) (12 – 24mg/d)
Lurasidone HCL (Latuda) (40 – 80 mg/d)

53. Long-Acting Injectables Depot Therapy
Risperidone Consta (Risperdal Consta)
Q2 Weeks
Paliperidone Sustenna (Invega Sustena)
Q 4 weeks
Zyprexa Relprevv (Q2 or Q4 weeks depending on the dose) Monitor for 3 hours after injection

54. Anti-Parkinson Medications
Trihexyphenidyl (Artane)
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Amantadine (Symmetrel)

55. Antiadrenergic Effect: Orthostatic Hypotension
Take the client’s blood pressure in a supine position and then in a standing position.
Caution clients to rise slowly from a supine position.

56. Extrapyramidal Side Effects Interventions
Acute dystonia
anticholinergics
Akathisia
anticholinergics but not always responsive
Pseudoparkinsonism
Tardive dyskinesia –
Abnormal Involuntary Movement Scale (AIMS)

57. Dystonia
Occurs usually within 48 hours of initiation of the medication
Involves bizarre and severe muscle contractions
Can be painful and frightening
Characterized by odd posturing and strange facial expressions:
Torticollis
Opisthotonus
Laryngospasm
Oculogyric

58. Torticollis

59. Opisthotonus

60. Oculogyric Crises

61. Laryngospasm

62. Drug-induced Parkinsonism
Usually occurs after 3 or more weeks of treatment
Characterized by:
Cogwheel rigidity
Tremors at rest
Rhythmic oscillations of the extremities
Pill rolling movement of the fingers
Bradykinesia
Postural Changes

63. Akathisia Usually occurs after 3 or more weeks of treatment
Subjectively experienced as desire or need to move
Described as feeling like jumping out of the skin
Mild: a vague feeling of apprehension or irritability
Severe: an inability to sit still, resulting in rocking, running, or agitated dancing

64. Tardive Dyskinesia
Usually occurs late in the course of long-term treatment
Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping)
Often irreversible
Prophylactic use of vitamin E and Omega-3 FFA
Avoid typical antipsychotics
Abnormal Involuntary Movement Scale

65. Autonomic Nervous System Effects: Anticholinergic Side Effects
Dry mouth
Blurred vision
Constipation
Urinary retention
Tachycardia

66. Interventions for Anticholenergic Side Effects
Ice chips, hard candy
Eye drops
Fiber diet, exercise
Increase fluid intake
Catheterization

67. Potentially Dangerous Responses to Antipsychotics
Neuroleptic malignant syndrome (NMS)
Typically occurs in the first 2 weeks of treatment or when the dose is increased
Hold the medication, notify the physician, and begin supportive treatments.
Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis

68. Neuroleptic malignant syndrome (NMS)
Risk Factors
Dehydration
Agitation or catatonia
Increase dose of neuroleptic
Withdrawal from anti-parkinson medication
Long acting or depot medication
Pharmacologic treatment
Antipyretics
Muscle relaxant
Dopamine receptor agonist

69. Potentially Dangerous Responses to Antipsychotics
Agranulocytosis
Early symptoms: beginning signs of infection
White blood cells are routinely monitored in clients taking clozapine (Clozaril).

70. Other Central Nervous System Effects
Sedation
Lowering of the seizure threshold:
Observe clients with seizures disorders carefully when treatment is initiated.

71. Cardiac Effects
Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias.
An EKG can identify those at risk.

72. Blood, skin and eye effect
Agranulocytosis
Blurred Vision
Skin photosensitivity
Retinitis pigmentosa

73. Endocrine Effects Hyperprolactinemia may cause:
Oligomenorrhea or amenorrhea in women
Galactorrhea in women and rarely in men
Osteoporosis if prolonged
Impotence in males may occur.
Diabetes
Monitor blood glucose levels.

74. Weight Gain Monitor weight Teach about diet and exercise
Weight gain may contribute to physical as well as psychosocial stressors

75. Adjuncts to Antipsychotic Drug Therapy
Antidepressants
Antimanic agents

76. Advanced Practice Interventions
Psychotherapy
Cognitive-behavioral therapy (CBT)
Group therapy
Medication
Social skills training
Cognitive remediation
Family therapy