CHAPTER 16: SCHIZOPHRENIA

Chapter 16: Schizophrenia

Key Terms:
o Abnormal Involuntary Movement Scale (AIMS): tool used to screen for symptoms of movement
disorders (side effects of neuroleptic medications
o Akathisia: intense need to move about; characterized by restless movement, pacing, inability to remain
still, and the clients report of inner restlessness
o Alogia: a lack of any real meaning or substance in what the client says; tendency to speak very little or to
convey little substance of mening (poverty of content)
o Anhedonia: having no pleasure or joy in life; losing any sense of pleasure from activities formerly
enjoyed
o Blunted Affect: showing little or a slow-to-respond facial expression; few observable facial expressions
o Catatonia: psychomotor disturbance, either motionless or extensive motor
o Command Hallucinations: disturbed auditory sensory perceptions demanding that the client take action,
often to harm self or others, and are considered dangerous; often referred to as voices
o Delusions: a fixed, false belief not based in reality
o Depersonalization: feelings of being disconnected from sled; the client feels detached from their behavior
o Echolia: repetition or imitation of what someone else says; echoing what is heard
o Echopraxia: imitation of the movements and gestures of someone an individual is observing
o Extrapyramidal Side Effects (EPS): neurologic side effects of antipsychotic medications that are drug
and dose related; treated with anticholinergic medication; includes dystonia, pseudoparkinsonism, and
akathisia
o Flat Affect: showing no facial expression
o Hallucinations: false sensory perceptions or perceptual experiences that do not really exist
o Ideas of Reference: clients inaccurate interpretation that general events are personally directed to him or
her, such as hearing a speech on the news and believing the message has personal meaning
o Latency of Response: refers to hesitation before the client response to questions
o Neuroleptic Malignant Syndrome (NMS): a potentially fatal, idiosyncratic reaction to an antipsychotic (or
neuroleptic) drug
o Neuroleptics: antipsychotic medications
o Polydipsia: excessive water intake
o Pseudoparkinsonism: a type of extrapyramidal side effect of antipsychotic medications; drug-included
parkinsonism; includes shuffling gait, masklike facies, muscle stiffness (continuous) or cog wheeling
rigidity (ratchet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating
movement)
o Psychomotor Retardation: overall slowed movements; a general slowing of all movements; slow
cognitive processing and slow verbal interaction
o Psychosis: cluster of symptoms including delusions, hallucinations, and grossly disordered thinking and
behavior
o Tardive Dyskinesia: a late-onset, irreversible neurologic side effect of antipsychotic medications;
characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing,
blinking, grimacing, and choreiform movements of the limbs and feet
o Thought Blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes client is
unable to continue the idea
o Though Broadcasting: a delusional belief that others can hear or know what the client is thinking
o Thought Insertion: a delusional belief that others are putting ideas or thoughts into the clients head; that
is, the ideas are not those of the client
o Thought Withdrawal: a delusional belief that others are taking the clients thoughts away and the client is
powerless to stop it
o Waxy Flexibility: maintenance of posture or position over time even when it is awkward or
uncomfortable
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CHAPTER 16: SCHIZOPHRENIA
o Word Salad: flow of unconnected words that convey no meaning to the listener
Objectives:
o Discuss various theories of the etiology of schizophrenia
Biologic Theories: focus on genetic factors, neuroanatomic and neurochemical factors, and
immunology
Genetic Factors: partial inheritance
Identical twins 50% chance if one twin has diagnosis schizophrenia
Fraternal twins only 15% chance
Children who have one biological parent with schizophrenia they have a 15% chance; if
both parents have schizophrenia child has a 35% chance
Neuroanatomic and Neurochemical Factors:
Less brain tissue and cerebrospinal fluid than those who dont have schizophrenia
Enlarged ventricles in the brain and cortical atrophy
Glucose metabolism and oxygen is diminished in frontal cortical structures of brain
Decreased brain volume and abnormal brain function in the frontal and temporal area of
persons with schizophrenia
Intrauterine influences such as poor nutrition, tobacco, alcohol, and other drugs, and
stress also are being studied as possible causes of the brain pathology found in those
with schizophrenia
Dopamine excess and serotonin modulation of dopamine or excess
Immunovirologic Factors:
Exposure to a virus or the bodys immune response to a virus could alter the brain
physiology
Cytokines: chemical messengers between immune cells, mediating inflammatory and
immune responses
o Play role in signaling the brain to produce behavioral and neurochemical
changes needed in the face of physical or psychological stress to maintain
homeostasis
o May have role in development of major psychiatric disorders such as
schizophrenia
Infections in pregnant women as possible origin
Higher rates of schizophrenia among children born in crowded areas in cold weather,
conditions that are hospitable to respiratory ailments
o Describe the positive and negative symptoms of schizophrenia
Distorted and bizarre thought, perceptions, emotions, movements behavior, thought of as a
syndrome or as a disease process with many different varieties and symptoms, much like the
varieties of cancer
Usually diagnoses in late adolescence or early adult hood; peak of incidence of onset is 15-25
years of age for men and 25-35 years of age for women
Positive or Hard Symptoms: medications may control the symptoms
Ambivalence: holding seemingly contradictory beliefs or feelings about the same person,
even, or situation
Associative Looseness: fragmented or poorly related thoughts and ideas
Delusions
Echopraxia
Flight of Ideas: continuous flow of verbalization in which the person jumps rapidly from
one topic to another
Hallucinations
Ideas of Reference
Preservation: persistence adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts change the topic
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CHAPTER 16: SCHIZOPHRENIA
Bizarre Behavior: outlandish appearance or clothing; repetitive or stereotyped,
seemingly purposeless movements; unusual social or sexual behavior
Negative or Soft Symptoms: persistence of these over time presents a major barrier to recovery
and improved functioning in clients daily life
Alogia
Anhendonia
Apathy: feeling no joy or pleasure from life or any activities or relationships
Asociality: social withdrawal, few or no relationships, lack of closeness
Blunted Affect
Catatonia
Flat Affect
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
o Describe a functional and mental status assessment for a client with schizophrenia, and Apply the
nursing process to the care of a client with schizophrenia
Assessment:
History:
o Previous history with schizophrenia
o Age of onset with schizophrenia
o Previous suicidal ideations
o Current support system
o patients perception of current situation
General Appearance, Motor Behavior, and Speech:
o Some may appear normal in terms of being dressed, sitting in chair conversing
with nurse, and exhibiting no strange or unusual postures or gestures
o Others may exhibit odd or bizarre behavior
o Some may appear disheveled and unkempt with no obvious concern for their
hygiene, or they may wear strange or inappropriate clothing
o Overall motor behavior may appear odd
Catatonia
Echopraxia
o Psychomotor retardation
Clients with the catatonic type of schizophrenia can exhibit waxy
flexibility
o Clients may exhibit an unusual speech pattern
Word salad
Echolia
Latency of response
o Unusual Speech Patterns Of Clients With Schizophrenia Box 16.3 pg 276
Mood and Affect:
o Flat Affect
o Blunted Affect
o Anhedonia
Thought Process and Content:
o Schizophrenia is often referred to as a thought disorder because that is the
primary feature of the disease, thought processes have become disordered, and
the continuity of thoughts and information processing is disrupted
o Thought blocking
o Thought broadcasting
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CHAPTER 16: SCHIZOPHRENIA
o Thought withdrawal
o Thought insertion
Delusions:
o A common characteristic of schizophrenic delusions is the direct, immediate,
and total uncertainty with which the client holds these believes
o Theme or content of the delusions may vary
o Types of Delusions:
Persecutory/Paranoid Delusions: involve clients belief that others are
planning to harm the client or are spying, following, ridiculing, or
belittling the client in some way; sometimes client cant define who
these others are
Grandiose Delusions: characterized by clients claim to association with
famous people or celebrities, or the clients belief that he or she is
famous or capable of great feats
Religious Delusions: often center around the second coming of Christ or
another significant religious figure or prophet; appear suddenly as part
of clients psychosis and arent part of his or her religious faith or that of
others
Somatic Delusions: generally vague and unrealistic beliefs about the
clients health or bodily functions; factual information or diagnostic
testing doesnt change these beliefs
Sexual Delusions: involve the clients belief that their sexual behavior is
known to others; that the client is a rapist, prostitute, or pedophile, or is
pregnant; or that their excessive masturbation has led to insanity
Nihilistic Delusions: are clients belief that their organs arent
functioning or are rotting away, or that some body part or feature is
horribly disfigured or misshapen
Referential Delusions:
Sensorium and Intellectual Processes:
o Hallucinations:
Can involve the 5 senses
Can be threatening and frightening for the client
Distinguished from illusion, which are misperceptions of actual
environmental stimuli
o Types of Hallucinations:
Auditory Hallucinations: most common type, involves hearing sounds,
most often voices, talking to or about the client
Command Hallucinations
Visual Hallucinations: second most common type, involve seeing
images that dont exist at all, such as lights or a dead person, or
distortions such as seeing a frightening monster instead of the nurse
Olfactory Hallucinations: involves smells or odors, also often occurs in
those with dementia, seizures, or CVA
Gustatory Hallucinations: involve a taste lingering in the mouth or sense
that food tastes like something else, may be metallic or bitter or may be
represented as a specific taste
Cenesthetic Hallucinations: involve the clients report that their bodily
functions are usually undetectable
Kinesthetic Hallucinations: occur when the client is motionless but
reports the sensation of bodily movement

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CHAPTER 16: SCHIZOPHRENIA
o During episodes of psychosis, clients are commonly disoriented to time, and
sometimes place, most extreme form of disorientation is depersonalization
o Assessing the intellectual processes of a client with schizophrenia is difficult if
they are experience psychosis, usually demonstrates poor intellectual
functioning as a result of disordered thoughts
o Clients often have difficulty with abstract thinking and may respond in a very
literal way to other people and the environment
Judgment and Insight: usually impaired
Self-Concept:
o Loss of Ego Boundaries: describes the clients lack of a clear sense of where
their own body, mind, and influence end and where those aspects of other
animate and inanimate objects begin as evidence by:
Depersonalization
De-realization: environmental objects become smaller ot larger or eem
unfamiliar
Ideas of Reference
Roles and Relationships:
o Social isolation
o Problems with trust and intimacy, interferes with the ability to establish
satisfactory relationships
o Low self-esteem
o Lack of confidence, feel strange or different from other people, and do not
believe they are worthwhile
o May experience great frustration in attempting to fulfill roles in the family and
community
o Fulfilling family roles is difficult
Physiologic and Self-Care Considerations:
o Inattention to hygiene and grooming
o Fail to recognize sensations such as hunger or thirst, and food or fluid intake
maybe inadequate
o Paranoia or excessive fears that food and fluids have been poisoned are common
and may interfere with eating
o Polydipsia, usually seen in clients who have had severe and persistent mental
illness for many years as well as long-term therapy with anti-psychotic
medications
o Sleep problems are common
Data Analysis/ Nursing Diagnosis:
Assessment of psychotic symptoms or positive signs:
o Risk for Other-Directed Violence
o Risk for Suicide
o Disturbed Thought Process
o Disturbed Sensory Perception
o Disturbed Personal Identity
o Impaired Verbal Communication
Assessment of negative signs and functional abilities:
o Self-Care Deficits
o Social Isolation
o Deficient Diversional Activity
o Ineffective Health Maintenance
o Ineffective Therapeutic Regimen Management
Outcome Identification: acute psychosis and treatment
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CHAPTER 16: SCHIZOPHRENIA
Focus on safety of patient and others
Stabilize patients thought process
Reality orientation
Interventions:
Safety of patient and others
Therapeutic relationship and therapeutic communication
Interventions for delusional thoughts: focusing on reality, no confrontation or
reinforcement
Interventions for hallucinations
Management of socially inappropriate behavior
Evaluation:
Has the clients psychotic symptoms disappeared? If not can the client carry out their
daily life despite the persistence of some psychotic symptoms?
Does the client understand the prescribed medication regimen? Are the committed to
adherence of regimen?
Does the client possess the necessary functional abilities for community living?
Are community resources adequate to help the client live successfully in the
community?
Is there sufficient aftercare or crisis planning in place to deal with recurrence of
symptoms or difficulties encountered in the community?
Are the client and family adequately knowledgeable about schizophrenia?
Does the client believe that they have a satisfactory quality of life?
o Evaluate the effectiveness of antipsychotic medications for clients with schizophrenia
Connectional Antipsychotics (First-Generation): dopamine antagonists
Targeting positive symptoms
No observable effect on negative symptoms
Atypical Antipsychotics (Second Generation): dopamine and serotonin antagonists
Diminish positive symptoms
Lessen negative symptoms
Antipsychotic Drugs, Usual Daily Dosages, and Incidence of Side Effects Table 16.1 pg 271
Maintenance Therapy:
Two antipsychotics available in depot injection forms:
o Fluphenazine (Prolixin) in decanoate and enathate
o Preparations: in seaseme oil, there for medications are absorbed slowly over
time into the clients system
o Haloperidol (Haldol) in decanoate
Effects last 2 to 4 weeks; eliminate need for daily oral antipsychotics medication
Side Effects:
Neurologic Side Effects
o Extrapyramidal Side Effects (EPS):
Acute dystonic reactions
Akathisia
Parkinsonism
o Tardive Dyskinesia
The Abnormal Involuntary Movement Scale (AIMS)
o Seizures
o Neuroleptic Malignant Syndrome (NMS)
Non-Neurologic Side Effects:
o Weight gain, sedation, photosensitivity
o Anticholinergic symptoms
o Orthostatic hypotension
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CHAPTER 16: SCHIZOPHRENIA
o Agranulocytosis (clozapine)
Side Effects of Antipsychotic Medications and Nursing Interventions Table 16.2 pg 273
Efficacy of Drugs Used to Treat Extrapyramidal Effects and Nursing Interventions Table 16.3
pg 273
o Provide teaching to clients, families, caregivers, and community members to increase knowledge and
understanding of schizophrenia
How to manage illness and symptoms
Recognizing early signs of relapse
Developing a plan to address relapse signs
Importance of maintain 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 mange stressful situations
Counseling and education family/significant others about the biologic causes and clinical course
of schizophrenia and the need for ongoing support
Importance of maintain contact with community and participating in supportive organizations
and care
Community-Based Care:
Housing with family or independently
Assertive community treatment (ACT)
Behavioral home health care
Community support programs
Case management services
Mental Health Promotion
Goal of psychiatric rehabilitation: patient recovery
Accurate identification of those at risk
Early intervention:
o Improved prodromal symptoms
o Prevention of social stagnation or decline
o Prevention or delay of progression to psychosis
o Describe the supportive and rehabilitation needs of clients with schizophrenia who live in the community
Individual, and group therapies: supportive, medication management, use of community supports
Social Skills Training: cognitive adaption training, and cognitive enhancement therapy (CET)
which combines computer-based cognitive training with group sessions allowing clients to
practice and develop social skills
o Evaluate your own feelings, beliefs, and attitudes regarding clients with schizophrenia
Challenge when the patient suspicious or mistrustful or nurse frightened
Frustration if the patient noncompliant
Need no to take patients success or failures personally
Patients strengths, time out of hospital as focus
No nurse has all the answers
o Clinical course, types of schizophrenia, related disorders, cultural considerations, elder considerations
Clinical Course:
Onset: abrupt or insidious; most with slow, gradual development of signs and symptoms
Diagnosis usually with more actively positive symptoms of psychosis
Immediate Course: two patterns
o Ongoing psychosis, never fully recovering
o Episodes of psychotic symptoms alternating with episodes of relatively complete
recovery
Long-Term Course: intensity of psychosis diminished with age
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CHAPTER 16: SCHIZOPHRENIA
o Most difficulty functioning
o Few with ability to live fully independent lives
Types of Schizophrenia:
Paranoid Type
Disorganized Type
Catatonic Type
Undifferentiated Type
Residual
Related Disorders:
Schizoaffective Disorder: diagnosed when client is severely ill and has mixture of
psychotic and moos symptoms; signs and symptoms include those both of schizophrenia
and mood disorder such as depression or bipolar disorder
Schizophreniform Disorder: exhibits an acute, reactive psychosis for less than 6-months
necessary to meet diagnostic criteria for schizophrenia; symptoms persistent after 6
months diagnosis is change to schizophrenia; social or occupational functioning may or
may not occur
Cataonia: characterized by marked psychomotor disturbance, wither excessive motor
activity or virtual immobility and motionlessness
Delusional Disorder: has one or more non-bizarre delusions- the focus of the delusion is
believable
Brief Psychotic Disorder: experiences sudden onset of at least one psychotic symptom
which lasts 1 day to 1 month
Shared Psychotic Disorder (folie deux): two people share a similar delusion; person with
this diagnosis develops delusions in the context of a close relationship with someone
who has psychotic delusions
Schizotypical Personality Disorder: involves odd, eccentric behaviors, including
transient psychotic symptoms; approx. 20% of personality disorders will eventually be
diagnosed with schizophrenia
Cultural Considerations:
Ideas considered delusional in ones culture probably commonly accept by other cultures
Auditory or visual hallucinations as normal part of religious experiences in some
cultures
Culture-Bound Syndromes:
o Bouffe Delirante: syndrome found in West Africa and Haiti involving a sudden
outburst of agitated and aggressive behaviors, marked confusion, and
psychomotor excitement; sometimes accompanied by visual and auditory
hallucinations or paranoid dreams
o Ghost Sickness: is preoccupation with death and the deceased frequently
observed among members of some Native American Tribes; bad dreams,
weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety,
hallucinations, loss of consciousness, confusion, feelings of futility, and sense of
suffocation are all symptoms
o Jikoshu-Kyofu: a condition characterized by a fear of offending others by
emitting foul body odor; first described in Japan in the 1960s; two subtypes with
or without delusions
o Locura: refers to a chronic psychosis experienced by Latinos in the U.S and
Latin America; incoherence, agitation, visual and auditory hallucinations,
inability to follow social rules, unpredictability, and possibly violent behavior
are all symptoms

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CHAPTER 16: SCHIZOPHRENIA
o Qi-gong: psychotic reaction is an acute, time-limited episode characterized by
dissociative, paranoid, or other psychotic symptoms that occur after participating
in the Chineses folk health enhancing practice qi-gong
o Zar: an experience of spirits possessing a person, is seen in Ethiopia, Somalia,
Egypt, Sudan, Iran, and other North African and Middle Eastern societies
Ethnic differences in response to psychotropic medications
Elder Considerations:
Late Onset: after age 45
Psychotic symptoms late in life usually associated with depression or dementia, not
schizophrenia
Variety of long-term outcomes for elderly:
o Approximately one fourth experience dementia, resulting in steady, deterioration
health decline
o Approximately one fourth experiencing reduction in positive symptoms
o Remainder mostly unchanged

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS