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Chapter 16: Schizophrenia

Schizophrenia #1

Distorted and bizarre thoughts, perceptions, emotions, movements, behavior

Categories of symptoms (refer to Box 16.1)

Positive (hard)

Examples: delusions, hallucinations

Negative (soft)

Examples: flat affect, lack of volition, inattention

Schizophrenia #2

Usually diagnosed in late adolescence or early adulthood

Peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women.

Prevalence is estimated at about 1% of total population

In the United States, nearly 3 million people are, have been, or will be affected by the disease.

Schizoaffective disorder

Client is severely ill.

Mixture of psychotic and mood symptoms

Clinical Course #1

Onset: abrupt or insidious; most with slow, gradual development of signs and symptoms

Diagnosis usually with more actively positive symptoms of psychosis

Clinical Course #2

Immediate-term course: two patterns

Ongoing psychosis, never fully recovering

Episodes of psychotic symptoms alternating with episodes of relatively complete recovery

Long-term course: intensity of psychosis diminishes with age; disease becomes less disruptive; clients may live independently later in life; many have difficulty functioning in the community.

Related Disorders

Schizophreniform disorder

Catatonia

Delusional disorder

Brief psychotic disorder

Shared psychotic disorder

Schizotypical personality disorder

Etiology

Biologic theories

Genetic factors (genetic risk is polygenic)

Neuroanatomic and neurochemical factors (less brain tissue and cerebrospinal fluid; dopamine excess and serotonin modulation of dopamine)

Immunovirologic factors (viral exposure; cytokines)

Researchers focusing on infections in pregnant women as a possible origin

After influenza epidemics

Respiratory ailments

1. Question #1

Is the following statement true or false?

Positive symptoms of schizophrenia include a flat affect and social withdrawal.

1. Answer to Question #1

False

Rationale: Flat affect and social withdrawal are negative symptoms of schizophrenia.

Cultural Considerations

Ideas considered delusional in one culture possibly commonly accepted by other cultures

Auditory or visual hallucinations as normal part of religious experiences in some cultures

Culture-bound syndromes

Bouffée délirante

Ghost sickness

Jikoshu-kyofu

Locura

Qi-gong psychotic reaction

Zar

Ethnic differences in response to psychotropic medications

Psychopharmacology Treatment

Conventional antipsychotics (dopamine antagonists; see Table 16.1)

Targeting positive signs

No observable effect on negative signs

Second-generation antipsychotics (dopamine, serotonin antagonists)

Diminish positive symptoms

Lessen negative symptoms

Psychopharmacology: Maintenance Therapy

Six antipsychotics available in depot injection form:

Fluphenazine in decanoate and enanthate preparations

Haloperidol in decanoate

Risperidone

Paliperidone

Olanzapine

Aripiprazole

May take several weeks of oral therapy to reach stable dosing level before transition to depot injections

Psychopharmacology: Side Effects #1

Neurologic side effects

Extrapyramidal side effects

Acute dystonic reactions

Akathisia

Parkinsonism

Tardive dyskinesia

Seizures

Neuroleptic malignant syndrome

Psychopharmacology: Side Effects #2

Nonneurologic side effects (for side effects and interventions, see Table 16.2)

Weight gain, sedation, photosensitivity

Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention)

Orthostatic hypotension

Psychosocial Treatment

Individual and group therapy

Medication management, use of community supports

Social skills training

Cognitive adaptation training

Cognitive enhancement therapy (CET)

Family education and therapy

2. Question #2

Which of the following is a neurologic side effect of antipsychotic therapy?

A. Blurred vision

B. Agranulocytosis

C. Sedation

D. Tardive dyskinesia

2. Answer to Question #2

D. Tardive dyskinesia

Rationale: Tardive dyskinesia is a neurologic side effect of antipsychotic therapy.

Blurred vision, sedation, and agranulocytosis are nonneurologic side effects.

Schizophrenia and Nursing Process Application #1

Assessment

History: age at onset, previous suicide attempts, current support systems, perception of situation

General appearance, motor behavior, and speech: may appear odd, may exhibit psychomotor retardation, word salad, echolalia, latency of response (see Box 16.3)

Schizophrenia and Nursing Process Application #2

Assessment—(cont.)

Mood and affect are flat and blunted; anhedonia

Thought process and content: thought blocking, broadcasting, withdrawal, insertion

Delusions (see Box 16.4)

Sensorium and intellectual processes: hallucinations (auditory, visual, olfactory, tactile, gustatory, cenesthetic, kinesthetic); depersonalization

Schizophrenia and Nursing Process Application #3

Assessment—(cont.)

Judgment and insight: usually impaired

Self-concept: loss of ego boundaries

Roles and relationships: social isolation, frustrating in fulfilling family and community roles

Physiological and self-care considerations: inattention to hygiene and grooming; failure to recognize sensations; polydipsia

Schizophrenia and Nursing Process Application #4

Data analysis/nursing diagnoses

Risk for other-directed violence

Risk for suicide

Disturbed thought processes

Disturbed sensory perception

Disturbed personal identity

Impaired verbal communication

Schizophrenia and Nursing Process Application #5

Outcome identification (acute psychosis; treatment)

Focus on safety of client and others

Contact with reality

Interact with others in environment

Express thoughts and feelings in a safe, socially acceptable manner

Adhere to interventions

Schizophrenia and Nursing Process Application #6

Interventions

Safety of client and others

Therapeutic relationship

Therapeutic communication

Interventions for delusional thoughts

Interventions for hallucinations

Coping with socially inappropriate behavior

Schizophrenia and Nursing Process Application #7

Interventions—(cont.)

Client and family education

Signs and symptoms of relapse (see Box 16.5)

Self-care, nutrition

Social skills

Medication management

Evaluation

3. Question #3

Is the following statement true or false?

The nurse should confront the client’s delusions.

3. Answer to Question #3

False

Rationale: When a client is experiencing delusions, the nurse should focus on the reality and not confront or reinforce the client’s delusions.

Elder Considerations #1

Late onset: after age 45

Psychotic symptoms later in life usually associated with depression or dementia, not schizophrenia

Elder Considerations #2

Variety of long-term outcomes for elderly

Approximately one-fourth experiencing dementia, resulting in steady, deteriorating health decline

Approximately one-fourth experiencing reduction in positive symptoms

Remainder mostly unchanged

Community-Based Care

Housing with family or independently

Assertive community treatment programs

Behavioral home health care

Community support programs

Case management services

Mental Health Promotion

Goal of psychiatric rehabilitation

Early intervention

Accurate identification of those at risk

Recognize prodromal signs

Self-Awareness Issues

Recognize client’s suspicious or paranoid behavior is part of the illness, not a personal affront.

Nurse may be frightened; acknowledge those feelings and take measures to ensure safety.

Don’t take client’s success or failure personally.

Focus on the amount of time client is out of hospital.

Visualize the client as he or she gets better.

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