West Coast University

Solomon Tan, MSN/Ed. RN-BC, PHN 2011

Schizophrenia Chapter 15

Eugen Bleuler’s 4 A’s of Schizophrenia

• Affect• Associative looseness• Autism• Ambivalence

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

Comorbidity• Substance abuse disorders

– Nicotine dependence• Anxiety, depression, and suicide• Physical health or illness• Polydipsia

Etiology• Biological factors

– Genetics• Neurobiological

– Dopamine theory– Other neurochemical hypotheses

• Brain structure abnormalities

EtiologyContinued

• Psychological and environmental factors– Prenatal stressors– Psychological stressors– Environmental stressors

Signs and Symptoms• Language and communication

disturbances• Thought disturbances• Perception disturbances• Affect disturbances• Motor behavior disturbances• Self-identity disturbances

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

Phases of Schizophrenia

Phase I – Acute– Onset or exacerbation of

symptomsPhase II – Stabilization

– Symptoms diminishing – Movement towards previous level

of functioningPhase III – Maintenance

– At or near baseline functioning

Assessment• During the prepsychotic phase• General assessment

– Positive symptoms (Excess or distorted)

– Negative symptoms (Deficit)– Cognitive symptoms– Affective symptoms

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

Positive SymptomsContinued

• Alterations in speech– Neologisms– Echolalia– Echopraxia– Clang associations– Word salad– Loose Association

Positive SymptomsContinued

• Alterations in perception– Depersonalization– Derealization– Hallucinations

• Auditory hallucinations• Command hallucinations• Visual hallucinations

– Boundary impairment – Negativism– Impaired impulse control

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.

Cognitive Symptoms• Difficulty with

– Attention– Memory– Information processing– Cognitive flexibility– Executive functions

Affective Symptoms• Assessment for depression

crucial– May herald impending relapse– Increases substance abuse– Increases suicide risk– Further impairs functioning

Review Question• A patient with schizophrenia

says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding?a. Positive symptomb. Negative symptomc. Cognitive symptomd. Depressive symptom

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.”

Subtypes of Schizophrenia

• Paranoid type• Disorganized type• Catatonic type• Undifferentiated type• Residual Type

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

Specific Interventions forParanoid and Disorganized

Schizophrenia• Communication guidelines• Self-care needs• Milieu needs

Subtypes of Schizophrenia -

continued• Catatonic type

– Psychomotor retardation and stupor• Waxy flexibility• Mutism

– Extreme psychomotor agitation• Echolalia• Echopraxia

Specific Interventions for Catatonia

• Catatonia – Withdrawn Phase– Communication guidelines– Self-care needs– Milieu needs

• Catatonia – Excited Phase– Communication guidelines– Self-care needs

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

Other Psychotic Disorders

• Schizophreniform disorder• Schizoaffective disorder• Delusional disorder• Brief psychotic disorder• Shared Psychotic Disorder (Folie

à Deux)• Induced or Secondary Psychosis

Assessment Guidelines1. Any medical problems2. Abuse of or dependence on

alcohol or drugs3. Risk to self or others4. Command hallucinations5. Belief system6. Suicide risk

Assessment GuidelinesContinued

7. Ability to ensure self-safety8. Co-occurring disorders9. Medications 10. Presence and severity of

positive and negative symptoms

11. Patient’s insight into illness12. Family’s knowledge of

patient’s illness and symptoms

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

Outcomes Identification

• Phase I - AcutePatient 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

Planning• Phase I – Acute

– 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

Implementation• Phase 1 – Acute Settings

– Partial hospitalization– Residential crisis centers– Halfway houses– Day treatment programs

Interventions• Acute Phase

– Psychiatric, medical, and neurological evaluation

– Psychopharmacological treatment– Support, psychoeducation, and

guidance– Supervision and limit setting in the

milieu

InterventionsContinued

• Stabilization and Maintenance Phase– Milieu management– Activities and groups– Safety– Counseling and communication

techniques

InterventionsContinued

• Stabilization and Maintenance Phase, continued– Hallucinations– Delusions– Associative looseness– Health teaching and health

promotion

Nursing Implications:Supporting Families

• Family needs vary with degree of illness and involvement in client’s care– Education– Financial support– Psychosocial support– Advocacy

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

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

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?

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?”

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.

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

Negative Effects of Antipsychotics

• Negative Effects – 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

All current antipsychotics work on at least one of these neurotransmitters:

DopamineSerotonin

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

Pharmacological Interventions

• Antipsychotic medications– Conventional antipsychotics

• Typical or first-generation– Atypical antipsychotics

• Second-generation

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

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)

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)

Conventional Long-Acting Injectables

(Depot Therapy)–Haloperidol Decanoate (Haldol

Decanoate) • Q4 weeks

–Fluphenazine Decanoate (Prolixin Decanoate) • Q2 Weeks

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

Atypical AntipsychoticsContinued

– 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)

Atypical AntipsychoticsContinued

– 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)

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

Anti-Parkinson Medications

• Trihexyphenidyl (Artane)• Benztropine (Cogentin)• Diphenhydramine (Benadryl)• Amantadine (Symmetrel)

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.

Extrapyramidal Side Effects Interventions

• Acute dystonia– anticholinergics

• Akathisia– anticholinergics but not always

responsive• Pseudoparkinsonism

– anticholinergics• Tardive dyskinesia –

– Abnormal Involuntary Movement Scale (AIMS)

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

Torticollis

Opisthotonus

Oculogyric Crises

Laryngospasm

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

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

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

Autonomic Nervous System Effects:

Anticholinergic Side Effects• Dry mouth• Blurred vision• Constipation• Urinary retention• Tachycardia

Interventions for Anticholenergic Side

Effects– Ice chips, hard candy– Eye drops– Fiber diet, exercise– Increase fluid intake– Catheterization

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

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

Potentially Dangerous Responses to Antipsychotics

• Agranulocytosis– Early symptoms: beginning signs of

infection– White blood cells are routinely

monitored in clients taking clozapine (Clozaril).

Other Central Nervous System Effects

• Sedation• Lowering of the seizure threshold:

– Observe clients with seizures disorders carefully when treatment is initiated.

Cardiac Effects• Some antipychotics may

contribute to prolongation of the QTc interval and lead to arrhythmias.– An EKG can identify those at risk.

Blood, skin and eye effect

• Agranulocytosis• Blurred Vision• Skin photosensitivity• Retinitis pigmentosa

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.

Weight Gain• Monitor weight• Teach about diet and exercise• Weight gain may contribute to

physical as well as psychosocial stressors

Adjuncts to Antipsychotic Drug Therapy

• Antidepressants

• Antimanic agents

Advanced Practice Interventions

• Psychotherapy• Cognitive-behavioral therapy

(CBT)• Group therapy• Medication• Social skills training• Cognitive remediation• Family therapy