References:
- Psychiatric-Mental Health Nursing, 8th Edition, 978-1-975116-37-8, by Sheila L. Videbeck ([ebook] pp. 588-651)
- Course Module
Schizophrenia causes 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 or as a disease process with many different varieties and symptoms, much like the varieties of cancer.
- Usually diagnosed in late adolescence or early adulthood; manifestations are rare during childhood.
- Peak incidence 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 the total population.
The symptoms of schizophrenia are divided into two major categories: positive or hard symptoms, which include delusions, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms, which include flat affect, lack of volition, and social withdrawal or discomfort.
- Positive Symptoms
- Ambivalence: simultaneous contradictory beliefs or emotions.
- Associative Looseness, Flight of Ideas, and Perseveration: poorly related thoughts; continuous verbalization with rapid shifts in topics, and persistent adherence to an idea (e.g. repetition of words, phrases, or resisting changes in topics).
- Bizarre Behavior
- Delusions, Hallucinations, and Ideas of Reference: fixed false beliefs; false sensory experiences; false meaning-attribution of external events to the individual.
- Echopraxia: imitation of the observed movements from other individuals
- Negative Symptoms
- Alogia: poverty of content
- Anhedonia: poverty of enjoyment
- Apathy: indifference
- Asociality: social withdrawal
- Avolition: lack of will
- Affect Reduction: blunted or flattened
- Attention Deficiency
- Catatonia: psychologically induced immobility marked by period of irritability or excitement
Medication may control the positive symptoms, but frequently, the negative symptoms persist after positive symptoms have abated.
Clinical Course
Although the symptoms of schizophrenia are always severe, the long-term course does not always involve progressive deterioration. The clinical course varies among clients.
Onset
Onset may be abrupt or 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. The diagnosis of schizophrenia is usually made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking (psychosis).
Immediate-Term Course
Immediately after the onset of psychotic symptoms, two typical clinical patterns emerge. In one pattern, the client experiences ongoing psychosis and never fully recovers, though symptoms may shift in severity over time. In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recover from the psychosis.
Long-Term Course
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.
- In late life, these clients may live independentlyo in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment.
- The persistence of negative symptoms, impaired cognition, or treatment-refractory positive symptoms make it difficult for many clients to lead fully independent lives.
Antipsychotic medications lay a crucial role in the course of the disease and individual outcomes. They do not cure the disorder; however, they are crucial to its successful management. The more effective the client’s response and adherence to his or her medication regimen, the better the client’s outcome. Longer periods of untreated psychosis lead to poorer long-term outcomes. Therefore, early detection and aggressive treatment of the first psychotic episode with medication and psychosocial interventions are essential to promote improved outcomes, such as lower relapse rates and improved insight, quality of life, and social functioning.
Related Disorders
- Schizoaffective disorder is diagnosed when the client is severely ill and has a mixture of psychotic and mood symptoms. The signs and symptoms include those of both schizophrenia and a mood disorder such as depression or bipolar disorder. The symptoms may occur simultaneously or may alternate between psychotic and mood disorder symptoms.
- The symptoms may occur simultaneously or may alternate between psychotic and mood disorder symptoms. Some studies report that long-term outcomes for the bipolar type of schizoaffective disorder are similar to those for bipolar disorder, while outcomes for the depressed type of schizoaffective disorder are similar to those for schizophrenia.
- Treatment for schizoaffective disorder targets both psychotic and mood symptoms. Often, second-generation antipsychotics are the best first choice for treatment. Mood stabilizers or an antidepressant may be added if needed.
- Schizophreniform disorder: The client exhibits an acute, reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. If symptoms persist over 6 months, the diagnosis is changed to schizophrenia. Social or occupational functioning may or may not be impaired.
- 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 didisorders.
- Delusional disorder: The client has one or more nonbizarre delusions—that is, the focus of the delusion is believable. The delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bibizarre.
- 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, most commonly siblings, parent and child, or husband and wife. The more submissive or suggestible person may rapidly improve if separated from the dominant person.
- 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.
Etiology
Theories for schizophrenia has been a long and hard endeavor. Newer scientific studies have begun to demonstrate that schizophrenia results from a type of brain dysfunction. Since the 1970s, the focus of research has been on neurochemical causes, supported by the effects of antipsychotic medications, which help control psychotic symptoms, and neuro imaging tools such as computed tomography, which have shown that the brains of people with schizophrenia differ in structure and function from those of control subjects.
Biologic Theories focus on genetic factors, neuroanatomic and neurochemical factors, and immunovirology.
- Genetic Factors: immediate family is the main focus of studies. Some studies have tried to focus on more distant relatives. Important studies have shown that children with one biologic patient with schizophrenia have a 15% risk, rising to 35% if both parents have schizophrenia. However, other factors exist as identical twins only show a 50% risk even though their genes are 100% identical.
- Neuroanatomic Factors: people with schizophrenia have relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia; this could represent a failure in the development or a subsequent loss of tissue. Imaging studies have shown enlarged ventricles in the brain and cortical atrophy, diminished glucose metabolism and oxygen in the frontal cortical structures of the brain, consistently decreased brain volume and abnormal brain function in the frontal and temporal areas of person’s with schizophrenia.
- Neurochemical Factors: people with schizophrenia have consistently demonstrated alterations in the neurotransmitter systems of the brain with schizophrenia. Studies have implicated the actions of dopamine, serotonin, norepinephrine, acetylcholine, glutamate, and several neuromodulary peptides. The most prominent neurochemical theories involve dopamine and serotonin.
- One prominent theory suggests excess dopamine as a cause. This is based on two observations: (a) drugs that increase activity in the dopaminergic system, such as amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to schizophrenia, and (b) drugs that block postsynaptic dopamine receptors reduce psychotic symptoms; in fact, the greater the ability of the drug to block dopamine receptors, the more effective it is in decreasing symptoms of schizophrenia.
- More recently, serotonin has been included among the leading neurochemical factors affecting schizophrenia. The theory regarding serotonin suggests that serotonin modulates and helps to control excess dopamine. Some believe that excess serotonin itself contributes to the development of schizophrenia. Following this, newer drugs that affect both dopamine and serotonin (e.g., Clozapine [Clozaril]) are able to dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia.
- Immunovirologic Factors: popular theories state that exposure to a virus or the body’s immune response could alter the brain physiology of people with schizophrenia. However, few findings have validated them. Some theories state that cytokines, which play a role in signaling the brain to produce behavioral and neurochemical changes for homeostasis, have a role in the development of major psychiatric disorders such as schizophrenia. Specifically, infections in pregnant women are being studied as a possible origin for schizophrenia.
Treatment
Psychopharmacologic Treatment
The primary medical treatment for schizophrenia is psychopharmacology. In the past, electroconvulsive therapy, insulin shock therapy, and psychosurgery were used, but since the creation of chlorpromazine (Thorazine) in 1952, other treatment modalities have become all but obsolete. Antipsychotic medications, also known as neuroleptics, are prescribed primarily for their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia; rather, they are used to manage the symptoms of the disease.
- First-generation (Conventional) antipsychotic medications are dopamine antagonists. These medications only target the positive signs of schizophrenia.
- Chlorpromazine (Thorazine)
- Perphenazine (Trilafon)
- Fluphenazine (Prolixin)
- Thioridazine (Mellaril)
- Thiothixene (Navane)
- Haloperidol (Haldol)
- Loxapine (Loxitane)
- Molindone (Moban)
- Perphenazine (Etrafon)
- Trifluoperazine (Stelazine)
- Second-generation (Atypical) antipsychotic medications are both dopamine and serotonin antagonists. These are capable of affecting both positive and negative signs of lack of volition and motivation, withdrawal, and anhedonia for many clients.
- Clozapine (Clozaril)
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
- Quetiapine (Seroquel)
- Ziprasidone (Geodon)
- Paliperidone (Invega)
- Iloeridone (Fanapt)
- Asenapine (Saphris)
- Lurasidone (Latuda)
Maintenance therapy with long-acting injections (LAIs), formerly called depot injetions, are used for maintenance preapartions.234
Psychosocial Treatment
A disorder arising from multiple etiologies with the hallmark symptom of psychosis marked by delusion, hallucination, and illusion. It also involves withdrawal, impaired cognition and disturbance in information processing (disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).
- Its peak incidence is 15 to 25 years for men and 25 to 35 years for women.
- A theory suggests schizophrenia is the result of hyperdopaminergic activity; with the ability of an antipsychotic to block postsynaptic dopamine receptors being found the be proportional to its ability to decrease symptoms of schizophrenia. Serotonin, which handles excess dopamine and may itself contribute to schizophrenia, is also implicated.
- Clozapine (Clozaril), a dopamine and serotonin antagonist, is effective in management of psychotic symptoms and improvement of the negative signs.
Assessment Findings
- History: baseline data about functioning prior to incident; leisure and daily activities.
- Inquire about suicidal history, thoughts, or intentions. 10% of patients with schizophrenia eventually commit suicide.
- Inquire about violent tendencies e.g. how the client deals with anger or fear.
- Inquire about support systems: family, friends, therapy, groups, finances, living arrangements
- Appearance: ranges from normal to bizarre.
- Motor behavior may be odd. Akathisia, catatonia, stereotypy, echopraxia, grimacing, rambling, etc. They may also show psychomotor retardation.
- Speech may be echolalic or be word salad. Rate acceleration may occur, volume is variable. Latency of response may also occur.
- Clang Associations: using rhyming words
- Neologisms: invention of new words
- Verbigeration: stereotyped repetition of words
- Echolalia: repetition of phrases or words spoken by other individuals
- Stilted Language: excessive use of “pompous” or “flowery” vocabulary
- Perseveration: persistent adherence to one topic, phrase, or word.
- Word Salad: words or phrases put together with no discernible meaning.
- Mood and Affect: often described as having flat or blunted affect, the typical facial expression is mask-like. However, affect may be silly with laughter for no apparent reason; inappropriate.
- Thought Process and Content: clients may exhibit thought blocking, thought broadcasting, thought withdrawal, thought insertion, tangential thinking; circumstantiality. They also often display alogia.
- In adults, the level of functioning is found to decrease markedly in major aspects of life prior to the onset of schizophrenia. While rare, it can be found in children, who often fail to achieve expected levels of functioning is observed.
DSM-5
- Continuous disturbances must persist for up to 6 months, with at least one month of symptoms (or less if being treated) in Criterion A (Active Phase Symptoms).
- At least two symptoms from the following, with at least one symptom in the first three:
- Delusions
- Hallucinations
- Disorganized Speech
- Grossly Disorganized or Catatonic Behavior: peculiar movements, stereotypy, stupor, catatonia (wavy flexibility)
- Negative Symptoms
- Onset of symptoms: brief psychosis; Bouffée délirante, “amok”, “road rage”
- One month of symptoms: schizophreniform disorder
- Six months of symptoms: schizophrenia
- Marked decrease in level of functioning in one or more major areas (work, school, self-care) even prior to onset of symptoms.
Psychopharmacology
Antipsychotics, also known as neuroleptics are the main form of management for schizophrenia. There are two main categories: typical or conventional antipsychotics which are dopamine blockers, and decrease positive symptoms, and atypical antipsychotics which are dopamine and serotonin blockers, and decrease positive and negative symptoms.
Antipsychotics block dopamine, which results in extrapyramidal side effects. Medication is also given to abate these side effects:
- Diphenhydramine (Benadryl): IM or IV; dystonic reactions, pseudoparkinsonism
- Benztropine (Cogentin): IM; dystonic reactions, pseudoparkinsonism
- Propanolol (Inderal): beta-blocker; akathisia
- Valbenazine (Ingrezza) and Deutetrabenazine (Austedo, Teva): tardive dyskinesia
Side Effects
- Extrapyramidal Side Effects (EPSs), resulting from the blockage of dopamine.
- Acute Dystonic Reactions
- Torticollis: stiff-neck
- Opisthotonos: arching of the back
- Oculogyric Crisis: abnormal rolling or rising movement of the eyes.
- Risus Sardonicus
- Protrusion of the tongue, laryngeal and pharyngeal spasms
- Akathisia: motor restlessness; fidgeting, agitation, restlessness, and rocking repetitively.
- Pseudoparkinsonism: (neuroleptic-induced parkinsonism) muscular rigidity, cogwheeling rigidity, akinesia (difficulty initiating movement), mask-like facial expressions, shuffling gait, drooling, finger and hand tremors.
- Tardive Dyskinesia (TD): a late-appearing, irreversible effect of antipsychotic medications resulting in involuntary movements of the mouth, tongue (tongue protrusion and movement are early manifestations of TD), face, and choreiform movements of the limbs and feet.
- Seizures: infrequent (1%) but more common with the use of clozapine (5%). Resolved by changing doses or medications.
- Neuroleptic Malignant Syndrome (NMS): frequently fatal; characterized by muscle rigidity, high fever, increase muscle enzymes (particularly creatine phosphokinase), and leukocytosis. Incidence is 0.1 to 1% of patients taking antipsychotic medications. Resolution in most cases is to change antipsychotics.
- Acute Dystonic Reactions
- Non-neurologic Side Effects include weight gain, sedation, photosensitivity, anticholinergic symptoms (xerostomia, blurred vision, constipation, urinary retention, orthostatic hypotension)
- Agranulocytosis may be caused by Clozapine (Clozaril), a severe acute-onset neutropenia from inadequate production of white blood cells in the bone marrow. It may occur up to 18 to 24 weeks after the initiation of therapy. Characterized by fever, malaise, ulcerative sore throat, and leukopenia. Clozapine must be discontinued immediately.
- All patients taking Clozapine must be monitored. Weekly absolute neutrophil counts should be done every 2 weeks for 6 months after initiation of therapy, then monthly thereafter. A neutrophil count of 1,500/mcL is required before a refill (done every 7, 14, or 28 days) is provided.
Nursing Management
Biological Domain
| Domain | Nursing Action |
|---|---|
| Self-care Deficit | Promotion of self-care and personal hygiene |
| Disturbed sleep pattern | Promotion of sleep hygiene strategies |
| Imbalanced nutrition | Promotion of healthy nutrition |
| Constipation | Increase fiber and fluid intake |
| Activity and Exercise | Encourage a healthy lifestyle |
| Thermoregulation | Prevent extreme temperatures, normal fluid balance, weight gain, self-monitoring skills |
Psychological Domain: disturbed thought processes and sensory perception
- Validate experiences
- Identify meaning of feelings and experiences.
- Decrease frequency via diversion and coping.
- Enhance cognitive functioning; identify deficits in cognition (memory, focus, problem-solving). Improve motivation and organize routine daily activities.
- Develop effective stress coping skills, use counseling sessions.
Social Domain:
- Impaired social interactions
- Ineffective role performance
- Interrupted family performance
- Convening support groups: focus on daily problems and stress. Reduce suicide risk.
- Developing psychiatric rehabilitation strategies e.g. occupational training, job placement, and social skills training
| Side Effect | Nursing Action |
|---|---|
| Dystonic Reactions | Medications; Assurance |
| Tardive Dyskinesia | Assess via AIMS; report elevation |
| NMS | Stop all antipsychotics; notify physician |
| Akathisia | Medications |
| EPSs | Medications |
| Seizures | Stop medication; safety; assurance |
| Sedation | Caution in activities requiring full alertness |
| Photosensitivity | Caution for sun exposure; utilize sunscreen and clothing |
| Weight Gain | Encourage balanced dieting; exercise |
| Dry Mouth | Ice chips, hard candy |
| Blurred Vision | Monitor; if unabated, notify physician |
| Constipation | Increase fluid and dietary fiber; stool softener if unrelieved |
| Urinary Retention | Advise to report frequency or dysuria; report if persistent |
| Orthostatic Hypotension | Advise to rise slowly when sitting or lying |
| Medication | Action |
|---|---|
| Benztropine (Cogentin) | Causes constipation; Increase fluid and fiber intake, causes dry mouth; use ice chips or hard candy. Assess for memory impairment. |
| Clozapine (Clozaril) | May cause acute severe neutropenia (agranulocytosis) |
| Diphenhydramine (Benadryl) | Causes dry mouth; use ice chips or hard candy. Observe for sedation |
Theories of Etiology
- Biologic Factors
- Genetic Predisposition: identical twins have been found to both develop schizophrenia 50% of the time. While it is still being studied, development is believed to be polygenic.
- Neuroanatomic and Neurochemical Factors: schizophrenic patients have shown smaller brain structures and abnormal brain function in the temporal lobe (associated with positive signs and symptoms) and the frontal lobe (associated with negative signs and symptoms).
- Immunovirologic Factors: exposure to a virus or the body’s immune response to a virus, could alter brain physiology; few findings have been found to validate this theory.
- Psychological Factors
- Changes in Self-Concept
- Affective Blunting
- Difficulty in Relating, Decision-Making, Stress Coping, Financial Resources, and Discrimination or Rejection
Phases of Schizophrenia
- Acute Illness: sudden change in behavior, sleeplessness, aggression, increased dependency and incoherent conversation, and disruptive and bizarre behavior.
- Stabilization Phase: treatment is initiated, symptoms are alleviated, suicide risk is decreased, sleep is normalized, and substance use (if any) is reduced.
- Maintenance and Recovery:
- Focus on regaining the client’s previous level of functioning
- Family support
- Health education about medication, psychosocial treatment, prevention of relapse
- Maintenance of medication
- Relapse: may be due to non-compliance to treatment, stigmatization, accessibility of community resources, absence of support, degree of impairment of impairment in cognition and coping.