SCHIZOPHRENIA Definition: Chronic, severe, disabling neurologic disorder that causes distorted and bizarre thoughts, perceptions, emotions,

movements and behavior. Origin: Schizein + phrenis meaning Split mind or thinking respectively. This term is coined by Eugene Bleuler. Also comes in relation to Dementia Praecox termed by Emil Kraeplin. Statements about Schizophrenia: - Identity is INTACT, No SPLIT personality. - Incurable, it can be managed. RELATED PSYCHOSIS DISORDER 1. Brief Psychotic Disorder = < 1 month, time of sudden onset of symptoms such as delusions, hallucinations, or disorganized speech or behavior. 2. Schizophreniform Disorder = > 1 month, < 6 months time onset of symptoms of schizophrenia necessary to meet the diagnostic criteria for schizophrenia, social or occupational functioning may or may not be impaired. 3. Schizoaffective Disorder = co- morbidity, symptoms of psychosis, and at the same time, all the features of a mood disorder, either depression or mania. 4. Delusional Disorder = non bizarre, therefore the delusions is believable. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre. 5. Shared psychotic Disorder = Folie a deux, two people share a similar delusion. ETIOLOGIC Considerations/ Theories: Psychodynamic: - Early maternal and infant separation - Abandonment - Enmeshment (Loss of ego boundaries) Interpersonal: - Double bind relationships (Ambivalence) Cognitive Behavioral: - Distorted thoughts/ Expectations - Maladaptive behaviors Psychobiologic: 1. Genetic General Population = 1% Identical twins = 50% Fraternal twins = 15% One biologic parent = 15% Both biologic parent = 35% 22q 1 deletion syndrome = 25% (Karyotyping) 2. Environmental Immunovirulogic Theory = Maternal influenza during 2nd trimester
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3. Anatomical Ventricular enlargement (CT scan) Cortical atrophy (CT scan) 4. Physiologic/ Biochemical (NT) Dopamine = Increased Serotonin = Increased CULTURAL CONSIDERATIONS: 1. Boufe dlirante a syndrome found in West Africa and Haiti. It involves sudden outburst of agitation and aggression behavior, marked confusion, and psychomotor excitement, sometimes associated with auditory and visual hallucinations. 2. Ghost sickness preoccupation with death and deceased frequently observed in the Native American tribes. Symptoms include 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. 3. Locura chronic psychosis experienced by Latinos. Symptoms include incoherence, agitation, visual and auditory hallucinations, inability to follow social rules, unpredictability, and possible violent behavior. 4. Qi- gong acute, time- limited psychotic reaction associated dissociative, paranoid. It is common among Chinese. 5. Zar possessing of a person by spirits, the person may shout, bang his head, laugh, and wail. It is common Ethiopia, Somalia, Egypt, Sudan, Iran and in North Africa. INCIDENCE: Gender: Male > Female Age: Young adults: Male: 15- 25 years old Female: 25 35 years and 55 and up (Late- onset Schizophrenia) ASSESSMENT: Positive or Hard Symptoms Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation. Associative looseness: Fragmented or poorly related thoughts and ideas. Delusions: Fixed false beliefs that have no basis in reality. Echopraxia: Imitation of the movements and gestures of another person whom the client is observing. Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another. Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality. Ideas of reference: False impressions that external events have special meaning for the person.
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 Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word or phrase, resisting attempts to change the topic. Negative or Soft Symptoms Alogia: Tendency to speak very little to convey little substance of meaning (poverty of content). Anhedonia: Feeling no joy or pleasure from little or any activities or relationships. Apathy: Feelings of indifference toward people, activities, and events. Blunted affect: Restricted range of emotional feeling, tone or mood. Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement, the client seems motionless, as if in a trance. Flat affect: Absence of any facial expression that would indicate emotions or mood. Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks. Unusual Speech Patterns of Client with Schizophrenia Clang associations: are ideas that are related to one another based on sound or rhyming rather than meaning. Neologisms: are words invented by the client. Verbigeration: is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Echolalia: is the clients imitation or repetition of what the nurse says. Stilted language: is use of words of phrases that are flowery, excessive, and pompous. Persevaration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word or phrase, resisting attempts to change the topic. Word salad: is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Types of Delusions Persecutory/ paranoid delusions: involves the clients belief that others are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes the client cannot define who these others are. Grandiose delusions: are characterized by the 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 on the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as a part of the clients psychosis and are not part of his or her religious faith or that of others. Somatic delusions: are generally vague and unrealistic beliefs about the clients health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Referential delusions: or ideas of reference involve the clients belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Types of Hallucinations Auditory hallucinations: involve hearing sounds, most often voices, talking to or about the client. Command hallucinations, are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Visual hallucinations: involves seeing images that do not exist at all, such as lights or dead person, or distortions such as frightening monster instead of the nurse.
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 Olfactory hallucinations: involve smells or odors. They may be a specific scent such as urine or feces or more a general scent such has a rotten or rancid odor. This type of hallucination often occurs with dementia, seizures. Tactile hallucinations: refer to sensations such as electricity running through the body or bugs crawling into their skin. This hallucination is present in clients undergoing alcohol withdrawal syndrome. Gustatory hallucinations: involves a taste lingering in the mouth or the sense that food tastes like something else. The taste may be metallic or bitter or may be represented as a specific taste. Kinesthetic hallucinations: occur when the client is motionless but reports the sensation of bodily movement. Occasionally, the bodily movement is something unusual, such as floating above the ground.

DIAGNOSIS: DSM- IV- TR *Primary 4 As - Ambivalence - Autism (unaware of the surroundings) - Affective disturbances - Associative looseness *Secondary Socio- Occupational Dysfunction *Duration At least 6 months or longer

TYPES OF SCHIZOPHRENIA: *Paranoid = characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive religiosity behavior. = nihilistic = nil pa os meaning NOTHING *Disorganized = characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. = Hebephrenic old name = Severe self care deficit *Catatonic = characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, and peculiarities of voluntary movement, echolalia, and echopraxia. = catatonic rigidity = matigas ; waxy flexibility = cereas flexibilitas = sincere; without wax. = self limiting = Nursing Considerations =Risk for aspiration = PATENT AIRWAY, Paralytic Ileus = IV therapy for 48 hours
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*Undifferentiated = characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. = Poorest prognosis *Residual = characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations. = Best prognosis MANAGEMENT: *Primary + Cognitive Behavioral Therapy + Psychotherapy = * Antipsychotics/ Neuroleptics/ Major tranquilizers - Lipid soluble = crosses the blood brain barrier - No therapeutic Lag *Secondary = Medications ANTIPSYCHOTIC GENERATION A. TYPICALS - non selective dopa blockers - only targets the positive symptoms and are non- selective - increased adverse effects Drug Name Chlorpromazine (Thorazine) Thioridazine (Mellaril) Perphenazine (Trilafon) *Haloperidol (Haldol) *Fluphenazine (Prolixin) Potency Low Low Middle High High Route/ Dosage Oral, daily dosing (2001600mg) Oral, daily dosing (200- 600 mg) Oral, daily dosing (16 32 mg) Oral (2- 20 mg) / IM depository Q 3-4 weeks Oral (2.5- 20 mg) / IM depository Q 3-4 weeks

* Drug of Choice, Acute term and best for elderly. Cautions: 1st week post = Watch out for Anti Cholinergic crisis (Mydriasis, Urinary retention, Dry mouth, Constipation), Antidote is Physostigmine (Antilirium). B. ATYPICALS - selective dopa- sero blockers - targets positive and negative symptoms, less adverse reactions Drug Name Clozapine (Clozaril) Olanzapine (Zyprexa) Daily Dosing 150 500 mg 5- 20 mg Monitor for: Agranulocytosis = Early sign is sore throat, WBC Count monitoring = weekly for the first six months Less or equal to 3500/mm Less risk for Agranulocytosis best taken at bedtime
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Risperidone (Risperidal) Quetiapine (Seroquel) C. NEW GENERATION

2- 8 mg 150 500 mg

- Dopamine system stabilizers - self regulating - targets positive and negative symptoms, no adverse reactions Drug Name Aripiprazole (Abilify) Aripiprazole (Low effective dose) + Clozapine (Low dose) Route/ Dosage 15 30 mg/ day, Oral Considerations Tolerance = 3rd month Drug of Choice for LONG TERM Management

ANTI- PSYCHOTICS: SIDE EFFECTS 1. Sedation/ Orthostatic Hypotension - No warm shower - Drive with companion - Gradual waking up 2. Weight gain - Daily weight scale (Same clothes, same person, same time, same weighing scale) 3. Photosensitivity - Acne; skin problems - Prolonged exposure to sunlight 4. Anticholinergic (1st week) - Mydriasis - Urinary retention - Constipation - Dry mouth ADVERSE EFFECTS 1. Anticholinergic crisis 2. Agranulocytosis 3. Extra pyramidal effects NURSING CONSIDERATIONS: ANTIPSYCHOTICS Drink sugar- free and eat sugar- free hard candy to ease the anticholinergic effects of dry mouth. Avoid calorie laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. Constipation can be prevented or relieved by increasing intake of water and bulk- forming foods in the diet and by exercising. Stool softeners are permissible, but laxatives should be avoided. Use sunscreen to prevent burning. Avoid long periods of time in the sun, and wear protective clothing. Photosensitivity can cause you to burn easily. Rising slowly from a lying or sitting positions prevents falls from orthostatic hypotension or dizziness due to a drop in blood pressure. If a dose of antipsychotic medication is missed, take it if dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, omit the forgotten dose. If there is difficulty remembering your medication, use a chart to record doses when taken, or use a pill box labeled with dosage times and/ or days of the week to help you remember when to take medication.
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EXTRA- PYRAMIDAL EFFECTS *Acute Dystonia - Sudden, short, severe, painful spasms/ contractions - comes about three to five days - Manifestations: *Toticollis = sternocleidomastoid * Opisnotonus = erector spinae * Oculogyric gyris = sclera na lang * Laryngospasm * Blepharospasm = eyelids - Shows with no specific time element - Management: *Diphenhydramine (Benadryl) = IM/ IV 10 50 mg single dose * Benztropine (Cogentin) = IM/ IV 5 10 mg single dose * Akathisia - First week - Inner sense of restlessness - Most common EPRs to be seen and for non compliance - Manifestations: * Sleep disturbances * Agitation * Palpitations - No specific drugs only palliative - Management: * Diazepam (Valium) = Agitation * Propranolol (Inderal) = Palpitations * Pseudo Parkinsonism - Share RBTA and classic signs difference is with classic it is idiopathic but with this just remove the medication. - Manifestations: * Shuffling gait * Mask-like facies * Continuous muscle stiffness * Cog wheeling rigidity * Drooling * Akinesia - Management: *for classic Parkinsons = Levodopa + Carbidopa (Sinemet) * Amantadine (Symmetrel) *Neuroleptic Malignant Syndrome - Fatal but reversible - Manifestations: * Temperature (>42C) * Increase muscle tone (skeletal) = extremities * CK- MM * Leukocytosis - Management: *Antipyretic
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*Antispasmodic (Baclofen, Dantrolene) *Bromocriptine - Discontinue antipsychotics - Electroconvulsive Therapy - ABRUPT = Psychotherapy, Cognitive Behavioral Therapy then start lowering the dose. *Tardive Dyskinesia - Irreversible but not deadly - comes in later after 6 months of antipsychotics - Purposelessness - Face or limbs - Manifestations: *Goldfish Lip smacking, chewing, blinking, tongue protruding *Chorea sudden jerky movements (Can be relieved by sleep) - Screening (secondary prevention) * AIMS (Abnormal Involuntary Movement Scale) facilitated by the practitioner * DISCUS (Dyskinesia Identification System Condensed User Scale) patient, selfrated - Management: * Bromocriptine (Parlodel) - Discontinue antipsychotics GRADUAL *DRUG OF CHOICE for patients with history of EPS = Clozapine NURSING INTERVENTIONS: SCHIZOPHRENIA Promoting safety of client and others and right to privacy and dignity. Establishing therapeutic relationship by establishing trust. Using therapeutic communication (clarifying feelings and statements when speech and thoughts are disorganized or confused). Intervention for delusions: o Do not openly confront the delusion or argue with the client o Establish and maintain reality for the client o Use distracting techniques o Teach the client positive self- talk, positive thinking, and to ignore delusional beliefs. Interventions for hallucinations: o Help present and maintain reality by frequent contact and communication with client. o Elicit description of hallucination to protect client and others. o Engage client in reality- based activities such as card playing, occupational therapy, or listening to music. Coping with socially inappropriate behaviors: o Redirect client away from problem situations. o Deal with inappropriate behaviors in a non- judgmental and matter- of- fact manner, give factual statements; do not scold. o Try to reintegrate the client into the treatment milieu as soon as possible. o Teach social skills through education, role modeling, and practice. o Reassure others that the clients inappropriate behaviors or comments are not his or her fault. (Without violating client confidentiality). Client and family teaching. Establishing community support systems and care.
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REFERENCE: Dellosa, RDS (2011) NCM 105: Psychiatric Nursing, Notes, September 20, 2012 (1645H). Videbeck, SL (2008), Psychiatric Mental Health Nursing, Chapter 14: Schizophrenia pages 267- 290, Lippincott Williams and Wilkins, September 21, 2012 (2343H).