Unit IV

Chapter 15

SCHIZOPHRENIA AND OTHER

PSYCHOTIC DISORDERS
Fall 09
 Assignments
 Look up key terms and be familiar with
definitions
 Complete review question at the back of the
chapter
 Review CD and Complete Learning activities
 Interactive computer lab assignments
 Chapter 10 Psychopharmacology
 Introduction
 The word schizophrenia is derived
from the Greek words skhizo (split)
and phren (mind).
 Introduction
 Core Concepts:
 Psychosis
 A severe mental condition in which there is
disorganization of the personality,
deterioration in social functioning, and loss
of contact with, or distortion of, reality.
There may be evidence of hallucinations and
delusional thinking. Psychosis can occur with
or without the presence of organic
impairment.
 Introduction
 Schizophrenia is probably caused
by a combination of factors,
including:
 Genetic predisposition
 Biochemical dysfunction
 Physiological factors
 Psychosocial stress
 Schizophrenia requires treatment
that is comprehensive and
presented in a multidisciplinary
effort.
 Introduction
 Of all mental illnesses,
schizophrenia probably
causes more
 Lengthy hospitalizations
 Chaos in family life
 Exorbitant costs to people
and governments
 Fears
 Nature of the Disorder
 Schizophrenia disturbs
 Thought processes
 Perception
 Affect
 Causing a severe deterioration of social
and occupational functioning
 In the United States, the lifetime
prevalence of schizophrenia is about 1
percent.
 Nature of the Disorder
 Symptoms generally appear in late
adolescence or early adulthood
 Premorbid behavior a predictor
 Social maladjustment
 Personality disturbances
 Nature of the Disorder
 Schizophrenia can be viewed in four
phases.
 Phase I: Schizoid Personality
 Indifferent,
 Cold and aloof
 Are loners.
 Do not enjoy close relationships with others.
 Nature of the Disorder
 Phase II: Prodromal Phase
 Socially withdrawn
 Impairment in role function
 Show evidence of peculiar or eccentric
behavior.
 Neglect of personal hygiene and grooming
 Blunted or inappropriate affect
 Disturbances in communication
 Bizarre ideas
 Lack of initiative
 Nature of the Disorder
 Phase III: Schizophrenia
 In the active phase of the disorder,
psychotic symptoms are prominent
 Nature of the Disorder
 Characteristic Symptoms:
 Delusions
 False, fixed beliefs
 “I am Cleopatra”

 Hallucinations
 Sensory impressions without external stimuli
 Disorganized speech
 Grossly disorganized behaviors
 Negative Symptoms
 Nature of the Disorder
 Social/Occupational Dysfunction
 Impairment in work, social relations, and self-care
 Duration-continuous for at least 6 months at least 1 month in
active phase
 Schizoaffective and Mood Disorder Exclusion-no
depression, manic ep, or mixed have occurred or if have then
their total duration has been brief.
 Substance/General Medical Condition Exclusion
 Relationship to a Pervasive Development Disorder-if
autistic then schizo only if have delusions or hallucinations for 1
month
 Nature of the Disorder
 Phase IV: Residual Phase
 Remission and exacerbation
 Symptoms similar to those
of the prodromal phase
 Flat affect and impairment in
role functioning are prominent
 Prognosis-full return to premorbid function is
not common.
 Etiological Implications
 Biological
 Genetics-relatives have a much higher probability of developing disease
than those in general population
 Biochemical-may be caused by excess of dopamine dependent
neuronal activity in the brain. May be R/T increased production or
release of dopamine at nerve terminals, increased receptor
sensitivity , too many receptors or a combination. Neuroleptics
(chlorpromazine and haloperidol) lower brain levels of dopamine
by blocking dopamine receptors, thus reducing the schizophrenic
symptoms. Theory: acute may be related to increased numbers
of dop receptors in brain respond to neuroleptic drugs that black
receptors. Chronic is probably not related to number of receptors
and neuroleptic are not likely to be affective. Other
neurotransmitters have been implicated.
 Etiological Implications
 Physiological- higher incidence of disease after prenatal
exposure to influenza(viral infection). Anatomical abnormalities
decrease in cerebral and intracranial size in clients with schizo.
Histological changes: a disarray of pyramidal cells in the area of
the hippocampus has been suggested. Theory suggest the
disarray occurs in 2nd trimester of prego and is r/t flu
 Psychological-theory poor parent child relationship is cause
which is probably not true.
 Environmental-lower income could be involved: inadequate
nutrition, absence of prenatal care, few resources for dealing with
stressful situations. Stress not cause disease but maybe
precipitate psychotic episode.
 Theoretical Integration-multiple causation for disease
 Biological Influences
 Genetics
 A growing body of
knowledge
indicates that genetics plays
an important role in the
development of
schizophrenia
 Biochemical Influences
 One theory suggests
that
schizophrenia may be
caused by an excess of
dopamine-dependent
neuronal activity in the
brain
 Biochemical Influences
 Abnormalities in other
neurotransmitters
 Norepinephrine
 Serotonin

 Acetylcholine

 Gamma-aminobutyric

acid
 Neuroregulators
 Prostaglandins
 Endorphins
 Physiological Influences

 Factors that have been

implicated
 Viral infection
 Anatomical abnormalities
 Histological changes
 Physical conditions
 Psychological Influences
 These factors are now coming under
increased scrutiny. Researchers in
the last decade have focused their
studies more in terms of
schizophrenia as a brain disorder.
 Environmental Influences
 Sociocultural factors
 Poverty has been linked with development of
schizophrenia.
 Downward drift hypothesis
 Poor social conditions seen as consequence of,
rather than a cause of, schizophrenia.
 Stressful life events
 May be associated with exacerbation of
schizophrenic symptoms and increased rates
of relapse.
 Theoretical Intergration
 Schizophrenia is most likely a
biologically based disease, the onset
of which is influenced by factors
within the internal or external
environment.
 Types of Schizophrenia and
Other Psychotic Disorders
 Disorganized schizophrenia
 Chronic
 Behavior primitive
 Contact with reality poor
 Flat or inappropriate affect
 Silliness and incongruous
giggling
 Bizarre mannerisms
 Appearance neglected
 Social interaction impaired
 Catatonic Schizophrenia
 Rare
 Catatonic stupor
 Characterized by extreme psychomotor
retardation. Decrease in spontaneous
movements
 Mutism –absence of speech.
 Waxing flexibility posture pt may
remain in for long periods
 Catatonic excitement:
 Extreme psychomotor agitation,
purposeless movements that must be
curtailed to prevent injury to client or
others.
 Paranoid Schizophrenia
 Characterized by paranoid
delusions of persecution or
grandeur
 Auditory hallucinations
 Client may be argumentative,
hostile, and aggressive. Often
tense suspicious and guarded
 Social impairment is minimal
 Prognosis particularly with regard to
occupational functioning and capacity
for independent living is promising.
 Undifferentiated Schizophrenia

 Bizarre behavior that does not

meet the criteria outlined for
the other types of
schizophrenia; delusions and
hallucinations, incoherence, and
bizarre behavior is prominent
 Residual Schizophrenia
 Used to diagnose a person who has
a history of at least one episode of
schizophrenia with prominent
psychotic symptoms.
 Stage following an acute stage(prominent
delusions, hallucinations, incoherence, bizarre
behavior, and violence)
 This stage continuing evidence of illness but
no prominent psychotic symptoms
 S/S include social isolation, eccentric heavier,
impairment in hygiene and grooming, illogical
thinking or apathy
 Schizoaffective Disorder
 Schizophrenic symptoms accompanied
by a strong element of symptomatology
associated with mood disorders, either
manic or depressive
 May appear depressed with psychomotor
retardation, suicidal ideation, or may
include euphoria, grandiosity, and
hyperactivity
 Decisive factor for example in addition to
dysfunctional mood the pt exhibits
bizarre delusions, prominent
hallucinations, incoherent speech ,
catatonic behavior, or blunted
inappropriate affect
 Brief Psychotic Disorder
 Sudden onset of psychotic symptoms
following a severe psychosocial stressor
 Symptoms persist less than 1 month; client
returns to the full premorbid level of
functioning
 May have incoherent speech, delusions,
hallucinations, bizarre behavior,
disorientation.
 Individuals with preexisting personality
disorder appear susceptible
 Schizophreniform Disorder

 Same symptoms as schizophrenia, with

exception that the duration of the
disorder has been at least month but
fewer than 6
months
 Prognosis is good if affect is not blunted
or flat. If there is a rapid onset of
psychotic symptoms from the time the
unusual behavior is noticed.
 Delusional Disorder
 The existence of prominent, nonbizarre
delusions
 Subtypes:
 Erotomanic type
 Individual believes that someone, usually of a
higher status, is in love with them.
 Grandiose type
 Person has irrational ideas regarding own worth,
talent, knowledge, or power. May believe have
special relationship with famous person or assume
the identity of famous person believing the actual
person is imposter.
 Jealous type
 Person has the irrational idea that the sexual
partner is unfaithful
 Delusional Disorder
 Subtypes:
 Persecutory type
 Person believes he or she is being malevolently
treated in some way. EX: conspired against,
cheated, spied on, followed
 Somatic type
 Person has an irrational belief that he or she has
some physical defect, disorder, or disease
 Belief he or she emits a foul odor from

skin,mouth, rectum or vagina; has internal

parasite; has misshapen or ugly body parts; has
dysfunctional body parts.
 Shared Psychotic Disorder

 Also called folie á deux.

 Delusional system develops in a
second person as a result of a
close relationship with a person
who already has a psychotic
disorder with prominent
delusions.
 Psychotic Disorder Due to a
General Medical Condition
 Symptoms of this disorder include prominent
hallucinations and delusions that can be directly
attributed to a general
medical condition.
 Neurological-CVD, epilepsy, deafness, meningitis
 Endocrine-thryoid disorder, adenal disorder,
 Metabolic-hypoxia, hypercarbia, hypoglycemia
 Autoimmune-SLE
 Others F&E imblance, hepatic renal disease, sleep
deprivation, tertiary syphilis
 Substance-Induced Psychotic
Disorder
 The presence of prominent
hallucinations and delusions that
are judged to be directly
attributable to the physiological
effects of a substance
 Drugs-alchi, cns stimulants, opiods
 Medications-corticosteroids,
antihistamines, anesthetics….
 Toxins-nerve gases, carbon
monoxide and dioxide, fuel or paint
 Content of Thought
 Delusions
False personal beliefs That are inconsistent with
the person’s intelligence or cultural background
 Persecution feels threatened and believe other

want to harm them.

 Grandeur exaggerated feelings of importance,

power, knowledge, or identity.

 Reference all events within environment are

reference by the pt to himself or herself. Ex

someone is trying to get a message to me
through the articles in this magazine
 Content of Thought
 Control believes certain objects or persons
have control over his or her behavior-
dentist put a filling in my tooth , I now
receive transmissions through the filling
that controls what I think and do.
 Somatic has false idea about the
functioning of his or her body.
 Nihilistic has faste idea that self, part of
self, or the world is nonexistent ( “the world
no longer exists” “I have no heart”)
 Content of Thought
 Religiosity
 Excessive demonstration of obsession
with religious ideas and behavior. Often
difficult to assess.
 Paranoia
 Extreme suspiciousness of others
 Magical thinking
 Idea that if one thinks something,
it must be true( apple a day keeps the
doctor away)
 Form of Thought
 Associative looseness
 Shift of ideas from one
unrelated topic to another
 Neologisms
 Made-up words that
have meaning only
to the
person who invents
them
 Form of Thought
 Concrete thinking
 Literal interpretations of the environment.
Have difficulty with abstract thinking.
Example could not give meaning of its
raining cats and dogs
 Clang associations
 Choice of words is governed by sound (often
rhyming) (the gold has been sold)
 Form of Thought
 Word salad
 Group of words put
together in a random
fashion with no logical
connection. Literal
interpretations of the
environment
“More money
from
corn to carry
bottles
for all the little
children of
paradise.”
 Form of Thought
 Circumstantiality
 Delay in reaching the point of a communication because
of unnecessary and tedious details
 Tangentiality
 Inability to get to the point of communication due to
introduction of many new topics original discussion
is lost
 Mutism
 Inability or refusal to speak
 Perseveration
 Persistent repetition of the same word or idea in
response to different questions
 Perception
 Hallucinations:
 False sensory perceptions not
associated with real external stimuli
 Auditory-voices, music, noises that are not
there
 Visual-see people, flashes of light

 Tactile-false sense of touch. Crawling under

skin
 Gustatory-fast sense of taste

 Olfactory-false sense of smell

 Illusions
 Misperceptions of real external stimuli
 Affect
 Emotional tone
 Inappropriate affect
 Emotions are incongruent with
circumstances. Ex laughs when told of sons
death
 Bland or flat affect
 Weak emotional tone. Void of tone
 Apathy
 Lack or indifferent interest in environment
 Sense of Self
 The uniqueness and individuality a person feels
 Echolalia
 Repeating words that are heard. An attempt to identify
with person speaking
 Echopraxia
 Repeating movements that are observed
 Identification and imitation
 Taking on the form of behavior one observes in
another. Identification occurs on unconscious level and
imitation occurs on conscious level an ego defense
mechanism used by pt to reflect their confusion
regarding self identity
 Depersonalization
 Feeling of unreality-feeling ones extremities have
changed in size
 Volition
 Impairment in ability to imitate goal-
directed activity: may take the form
of inadequate interest motivation, or
ability to choose a logical course of
action in a given situation
 Emotional ambivalence
 Coexistence of opposite emotions toward
same object . This interfere with the
persons ability to make even a very
simple decision
 Impaired Interpersonal Functioning
and Relationship to the External World
 Cling to others and intrude on the
personal space of others, exhibiting
behaviors that are not socially and
culturally acceptable.
 Autism
 The focus inward on a fantasy world
while distorting or excluding the external
environment
 Deterioration in appearance
 Impaired personal grooming and self-
care activities
 Psychomotor Behavior
 Anergia
 Deficiency of energy
 Waxy flexibility
 Passive yielding of all movable parts of the
body to any effort made at placing them in
certain positions. Once placed in a position
remains in that position regardless of comfort.
 Posturing
 Voluntary assumption of inappropriate or
bizarre postures
 Pacing and rocking
 Pacing back and forth and rocking the body
 Associated Features
 Anhedonia
 Inability to experience
pleasure
 Compels some client to
attempt suicide

 Regression
 Retreat to an earlier level
of development
 Positive and Negative
Symptoms
 Positive symptoms
 Excess or distortion of normal functions
 Hallucinations
 Delusions
 Disorganized thinking/speech
 Disorganized behaviors
 Negative symptoms
 Deficit or loss of normal functions
 Affective flattening
 Alogia (poverty of speech)
 Avolition/apathy
 Anhedonia
 Social isolation
 Table 14-3
 Disturbed Sensory-Perceptual:
Auditory and visual related to
panic anxiety, extreme
loneliness, and withdrawal into
self
 Observe client for signs of
hallucinations, avoid touching
without warning, attitude of
acceptance, do not reinforce
hallucination, try and distract
client from hallucination
 Disturbed thought processes
related to inability to trust,
panic anxiety, possible
hereditary or biochemical
factors
 Convey acceptance of the clients
need for false belief but indicate you
do not share belief, do not argue or
deny belief, talk about real events
and real people, use same staff as
much as possible, be honest, avoid
physical contact, avoid whispering,
avoid competitive activities,
 Social isolation related to inability
to trust, panic anxiety, weak ego
development, delusional thinking,
regression
 Make brief frequent contacts, use
unconditional positive regard, offer
to be with client during group
activities if find diff or frightening,
give recognition and positive
reinforcement for clients voluntary
interactions with others
 Risk for Violence: Self-directed or
other-directed related to:
 Extreme suspiciousness, Panic
anxiety, Catatonic excitement,
Rage reactions, Command
hallucinations
 Maintain low level stimuli,
observe clients behavior
frequently, remove all dangerous
objects, staff maintain calm
attitude toward client, administer
tranqualizing meds as ordered,
restraints if necessary
 Impaired verbal communication
related to:
 Panic anxiety
 Regression
 Withdrawal
 Disordered unrealistic thinking
 Attempt to decode
communication, seek validation
and clarification, facilitate trust
and understanding by maintains
staff assignments as consistent as
possible, anticipate needs, orient
to reality
 Self-Care Deficit related to:
 Withdrawal, Regression, Panic anxiety,
Perceptual or cognitive impairment,
Inability to trust
 Provide assistance ADLS, encourage

independence, concrete communication,

structured toileting schedule
 Disabled family coping related to
difficulty coping with client’s illness
identify level of family function,
communication pattern, role expectation,
problem solving skills, provide info for family
about illness, practice how to respond to
bizarre behaviors inc case becomes violent
 Ineffective health maintenance
related to disordered thinking or
delusions
 Impaired home-maintenance related
to:
 Regression
 Withdrawal
 Lack of knowledge or resources
 Impaired physical cognitive functioning
 Outcomes
 The client:
 Demonstrates an ability to
relate to others satisfactorily
 Recognizes distortions of reality
 Has not harmed self or others
 Perceives self realistically
 Demonstrates ability to trust others
 Uses appropriate verbal communication
in interactions with others
 Performs self-care activities
independently
 Planning/Implementation
 Nursing interventions for the client with
schizophrenia or other psychotic
disorder are aimed at:
 Decreasing anxiety and establishing trust
 Assisting client to define and test reality
 Encouraging interaction with others
 Ensuring safety of client and others
 Meeting client’s self-care needs
 Promoting adaptive family coping
 Table 14-4
 Planning/Implementation
 Some institutions are using a case
management model to coordinate
care. In case management models,
plan of care may take the form of a
critical pathway.
 Appendix F
 Client/Family Education
 Nature of the illness
 Management of the illness
 Support services
 Table 14-5
 Evaluation
 Has client established trust with at least one staff
member?
 Is anxiety level maintained at a manageable level?
 Is delusional thinking still prevalent?
 Is client able to interrupt escalating anxiety with
adaptive coping mechanisms?
 Is client easily agitated?
 Is client able to interact with others appropriately?
 Psychological Treatments
 Individual psychotherapy
 Long-term therapeutic approach
difficult because of client’s impairment
in interpersonal functioning
 Primary focus to decrease anxiety and
increase trust.
 Establishing relationship is difficult pt is
desperately lonely yet defends against
closeness and trust
 Success may be achieved with
honesty, simple directness, manner
that reflects clients privacy and dignity
 Psychological Treatments
 Group therapy
 Some success if participating over the
long-term course of the illness; less
successful in short-term treatment gives
social interaction, sense of
cohesiveness, identification, and realty
testing
 Behavior therapy-may help change
undesirable behavior
 Chief drawback has been inability to
generalize to community setting after
client has been discharged home from
therapy
 Psychological Treatments
 Social skills training
 Use of role play to teach client
appropriate eye contact,
interpersonal skills, voice
intonation, posture, and so on,
aimed at improving relationship

development
 Social Treatment
 Milieu therapy-emphasize group and
social interaction, rules and expectations
are mediated by peer pressure for
normalization of adaptation
 Best if used in conjunction with

psychopharmacology
 Family therapy
 Aimed at helping family members cope
with long-term effects of illness
 Designed to reduce overt manifestations of conflict
and alter patterns of family communication and
problem solving
 Assertive Community Treatment
 (ACT) that takes a team
A program of case management
approach in providing comprehensive, community-
based psychiatric treatment, rehabilitation, and
support to persons with serious and persistent mental
illness.
 Teaching of basic living skills, helping clients work
with community agencies, and assisting clients in
developing a social support network
 Services include:
 Substance abuse treatment
 Psychoeducational programs
 Family support and education
 Mobile crisis intervention
 Attention to health-care needs
 Assertive Community
Treatment (ACT)
 Services are provided by a
multidisciplinary team of:
 Psychiatrists

 Nurses

 Social workers

 Vocational rehabilitation therapists

 Substance abuse counselors

 Services are available 24 hours a day,

365 days a year
 Assertive Community
Treatment (ACT)

 Services are provided wherever

assistance by the client is
required:
 In the person’s home

 Within the neighborhood

 In local restaurants

 Parks

 Stores
 Assertive Community
Treatment (ACT)
 The primary goals of ACT include:
1. To meet basic needs and enhance quality
of life
2. To improve role functioning

3. To enhance independent living

4. To lessen family burden of providing care

5. To decrease debilitating symptoms of

mental illness
6. To minimize recurrent acute episodes of
the illness
 prognosis
 1/3 achieve significant and lasting
improvement they may never experience
another ep following initial episode
 1/3 may achieve some improvement with
intermittent relapse and decreased
occupational level or may be socially
isolated
 1/3 experience severe and permanent
incapacity and do not respond to
medication
 Psychopharmacology

 Atypical Antipsychotics Agents

(AAPs)
 Positive symptoms
 Negative symptoms
 Typical (Traditional) Antipsychotics
 Positive symptoms
 Antipsychotics
Side Effects
 Anticholinergic effects
 Nausea; GI upset
 Skin rash
 Sedation
 Orthostatic hypotension
 Photosensitivity
 Decreased libido
 Retrograde ejaculation
 Gynecomastia
 Amenorrhea
 Weight gain
 Reduction in seizure
threshold
 Agranulocytosis
 Extrapyramidal
symptoms
 Tardive dyskinesia
 Neuroleptic
malignant syndrome
 Antipsychotics
Side Effects
 Tardive Dyskinesia
 Extrapyramidal symptoms (EPS) include:
 Pseudoparkinsonism
 Akinesia
 Akathisia
 Dystonia
 Oculogyric crisis
 Antiparkinsonian agents may be prescribed to
counteract EPS
 Other Medications
Reserpine-dop receptor antagonis has been used
as and antihypertensive agent and as ant
antipsychtoic it has produced severe
depression so rarely used
 Lithium carbonate-suppress episodic violence

in clients
 Carbamazepine-ameliorates symptoms in

some treatment resistant client but alone not

adequate
 Valium-shown to control agitation, thought

disorder, delusions, and hallucinations

 Propranolol-used to control temper, outburst in

aggressive or violent client

 Client/Family Education
 The client should:
 Not stop taking the drug abruptly
 Use sunscreens and wear protective clothing
when spending time outdoors
 Report weekly (if receiving clozapine therapy) to
have blood levels drawn and to obtain a weekly
supply of the drug.
 Be aware of possible risks of taking neuroleptics
during pregnancy.
 Not drink alcohol while receiving neuroleptic
therapy
 Not consume other medications (including over-
the-counter drugs) without the physician’s
knowledge
 Internet References
 http://www.schizophrenia.com
 http://www.nimh.nih.gov
 http://www.schizophrenia.nami.org
 http://www.nimh.nih.gov/medlineplus
 Answers to Learning Activity
1. G
2. D
3. O
4. N
5. M
6. A
7. H
8. K
9. B
10. I
11. C
12. J
13. E
14. L
15. F
 Answers to Learning Activity
 Case Study

1. Paranoia
2. Delusions of grandeur
3. Echolalia
4. Imitation
5. Nihilistic delusions
6. Anhedonia
7. Body rocking
8. Regression
9. Anergia
10. Apathy
11. Autism
12. Delusion of reference
 Answers to Learning Activity
 Case Study

A. Disturbed thought processes

B. An antipsychotic medication
C. Chapter 10 for side effects
D. Trust vs. mistrust because of her extreme
suspiciousness
E. Generativity vs. self-absorption