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Schizophrenia
Biologically based disorder that is
psychosocially devastating
Exists in all cultures and socioeconomic
groups
Characterized by overt psychosis
– A state in which one’s capacity to recognize
reality is limited or absent
Biological
Genetics
– Twin studies show 46% concordance rate in
monozygotic twins; 30% in dizygotic twins
– 1% of general population
– 10% sibling
Neuroanatomical
– Enlarged ventricles, cortical atrophy, smaller frontal
lobes, defects in limbic brain structures
– Decreased metabolic activity and slower brain waves in
the frontal lobe
Neurotransmitters
The dopamine hypothesis is the major NT
hypothesis for schizophrenia
– Theory states that there is too much Da in
schizophrenia
Some research suggests that Da and 5-HT may
be involved
Other research has focused on the excitatory NT
glutamine, as PCP affects this NT and produces a
psychotic state
Neurotransmitters (cont)
NE may be insufficient in clients with
schizophrenia displaying anhedonia
A deficiency in cholecystokinin may be
related to avolition and flat affect
Given the complexity of schizophrenia, it is
unlikely that a disturbance in a single
neurotransmitter system is the cause
Birth and Pregnancy
Complications
Infants born with a hx of pregnancy or
birth complications have increased risk
of developing schizophrenia
Infections during pregnancy, poor
nutrition during pregnancy, or exposure
to toxins could damage neurons or
affect NTs in the fetus
Psychodynamic Theories
Psychoanalytic/Developmental
– Anxious mothering….
Child is unable to progress beyond dependence
Affects ego organization and the child’s interpretation
of reality
The individual is then susceptible to living in a
fantasy world in which hallucinations and delusions
attempt to create a reality
Psychodynamic Theories (cont)
Cultural/Environmental
– Schizophrenia is disproportionately
represented in the lower socioeconomic
group
Downward drift hypothesis—clients with
schizophrenia who possess low social skills
either move into a lower socioeconomic group
or fail to move to a higher one
– Other social scientists believe that the
stress of living in a lower socioeconomic
group is often enough to trigger
Epidemiology
1% prevalence rate
Onset generally in adolescence and early
adulthood—females have an older age of
onset
Comorbidities
– 1/3 to 2/3 substance abuse
– 1/3 to1/2 mood disorders
Medical Comorbidities
90% of schizophrenics are smokers
– Smoking related pathology
– Obesity
– STDs; viral hepatitis
– Suicide—10% accomplish
Social and Economic Difficulties
70-80% unemployment rate
20% marriage rates
1/3 are homeless
Legal issues—end up in jail
Poor satisfying social relationships
DSM-IV Criteria
Cognitive
– Delusions—false beliefs that are fixed and
resistant to logic
omnipotence; persecution; controlling or being
controlled
– Derealization—feeling that the world
around one is not real or distorted
– Ideas of reference—notion that other
people or the media is talking to or about
Clinical Symptoms of
Schizophrenia (cont)
Cognitive
– Incorrect use of language
Neologisms—invented words
Incoherence
Echolalia or word salad
Concrete, restricted vocabularies
Looseness of associations—frequent change of
subject; not related to content of conversation
– Flight of ideas—abrupt change of topic in a
rapid flow of speech; seen more in mania
Clinical Symptoms of
Schizophrenia (cont)
Emotional
– Labile affect
Apathy, dulled response
Flattened affect
Reduced responsiveness
Exaggerated euphoria
Rage
– Inappropriate affect
Laughing at sad events
Clinical Symptoms of
Schizophrenia (cont)
Behavioral
– Little impulse control
Response to command hallucinations
Sudden scream as a protest to frustration
– Inability to cope with depression
Depressed client has 50% risk of suicide
– Inability to manage anger
– Substance abuse as coping
– Noncompliance with meds
Clinical Symptoms of
Schizophrenia (cont)
Social
– Poor peer relationships
Preference for solitude
– Low interest in hobbies or activities
– Loss if interest in appearance
Schizophrenia
Negative
Positive Avolition
Hallucinations Alogia
Anhedonia
Delusions
Flat Affect
Disorganization Ambivalence
Neurocognitive
Impairment
Attention
Memory
Exec Function
Positive Symptoms: Excess of
Normal Functions
• Delusions (fixed, false beliefs)
– Grandiose
– Nihilistic
– Persecutory
– Somatic
SE include:
– Orthostatic hypotension
– Dizziness
– Constipation
– Substantial weight gain
Seroquel
Virtually no EPS
SE include:
– Orhtostatic hypotension
– Tachycardia
– Dizziness
– Somnolence
Geodon
**Prolongs QTc interval
Somnolence
Hypotension
Nausea
Constipation
De-escalation Techniques
Manage the Use breakaways
environment Using and removing
Show confidence and seclusion and
leadership restraints
Encourage Documenting event
verbalization Debriefing session with
Personalize yourself staff
and show concern
Communication Techniques
with the Psychotic Patient
Establish trust
Personal space
Soft tone of voice, open posture, not too
much eye contact
Don’t argue with delusions
Present reality
Use diversions rather than confrontation
Allow patient to make own decisions when
possible
Try to alleviate their fears due to
misperceptions
Psychotherapeutic management
Provide supportive care
Strengthen patient’s self-esteem
Treat patients as adults
Prevent failure/ embarrassment
Respect individuality - unique
Reinforce reality
Handle hostility calmly & matter-of-factly
Issues related to Schizophrenia
Family ⇔ the patient
communication, overprotection, blaming
Non-compliance with medical regimen
Caregiver’s needs - cope with strange and
frightening behaviors ie. apathy, poor
personal hygiene, violence
Issues related to Schizophrenia
(II)
Depression - part of the symptoms, be
masked during acute stage
Relapse - stressors, noncompliance
Stress & coping -
Substance abuse -30% have dual Dx.,
cause (-) effect on the treatment & poor
outcomes
Work - no work, inability, no motivation
Depression and Suicide in Schizo
Depression is a natural part of schizo
Depression can be masked especially
during the acute phase
Depression is a reaction to schizo
Care of Hallucinations &
Delusions
Hallucinations
– Content of hallucination – commanding H
-> suicidal or homicidal
– N’s attitude – nonjudgmental, nonthreatening
– Eye contact, louder voice, call the person by
name
Delusion
– Be empathic - Clarify the reality of the pt’s intent
– Clarify misinterpretations of the environment
– No argument
Delusion & Nursing Intervention
presenting reality, orient pts to time, person
& place
avoid argument, touch, competitive
activities,
reinforce positive behaviors
encourage verbalization
Disruptive Behavior
Set limit
decrease environmental stimuli
intervention before acting out
close observation
safety environment - minimize potential
weapons
making contract with the client
using restraints
Withdrawn Patients
arrange nonthreatening activities
encourage participation - seating
provide remotivation and resocialization
group experience
reinforce appropriate grooming and
hygiene
provide psychosocial rehabilitation -
social skill training, ...
Suspicious Patients
Be matter-of-fact; (ie DST for depression)
avoid close physical contact - no touch
be consistent in activities
offer special food
avoid whisper
Maintain eye contact
Hyperactivity Patients
Allow pt to stand for a few min in group
Prevent victimization
Nursing interventions
Medication compliance- 40-60%
noncompliance
Avoid reinforcing hallucinations & delusion
Maintain orientation
Use touch minimally and judiciously
Avoid easily misinterpreted behavior
Reinforce positive behaviors
Avoid competitive activities,
Allow & encourage expression of feelings
Nursing interventions-
Milieu management
clear & realistic limits; consistency;
Supportive environment – structured, predictable
reduced stimulation
early intervention for escalating behavior
safety for the pt and others
opportunity for nonthreatening social interaction
remotivating and resocializing group
Communication skills
Nursing interventions –
Family therapy
Involve the family – use appropriate
community resources
Educate the family – chr. dis, S/S of relapse,
med compliance,
Provide an outlet for the family – discuss
feelings, explore alternative effective coping
skills.
Psychotherapy
Individual Th – supportive therapy
Group Th – interpersonal skills, family
problems, community support
Family Th – expand social network,
problem-solving capacity, lower the
emotional overinvolvement of families
Case Management
Limited hospital stay, 3rd party payment
Discharge planning – transitional care
Partial hospitalization, halfway houses, day
treatment programs
Community resources – NAMI,
Schizophrenics Anonymous, …
Nurse’s feelings & self-assessment
Pt’s anxiety, loneliness, dependence,
distrust -> N’s uncomfort
Feelings of helplessness -> anxiety ->
defensive behaviors ie denial, withdrawal,
avoidance -> burnout
Peer group supervision can be helpful
Periodic reassessment of Tx goals,
Family/care taker education
Teaching about the disease –S/S
Medication teaching and side-effect
management
Cognitive & social skills enhancement
Identifying signs of relapse
Attention to deficit in self-care, social and
work functioning
Exploration of community resources
Signs of Potential Relapse
Feeling of tension
Difficulty concentrating
Trouble sleeping
Increased withdrawal
Increased bizarre/ magic thinking
Care of Hallucinations & Delusions
Hallucinations
– Content of hallucination – commanding H
-> suicidal or homicidal
– N’s attitude – nonjudgmental, nonthreatening
– Eye contact, louder voice, call the person by
name
Delusion
– Be empathic - Clarify the reality of the pt’s intent
– Clarify misinterpretations of the environment
– No argument
Treatment
Psychoeducation
– Teach that stressors can exacerbate sx
– Inform pt on illness and meds
Supportive Psychotherapy
– Goal is to support ego function—help them to get
through this—gentle guidance and advice
Milieu
– Calm environment; safety
Symptom management
– Focus on prodromal sx—make pt aware that they need
to recognize these sx for exacerbations
Family Therapy
May be necessary to begin with individual
family therapy in which each family member
has a therapist
Need to target Expressed Emotion (EE)
– Emphasize strengths not deficits
– Share power—who is in control of the patient in
the family
– Contain outbursts
– Problem solving skills
High levels of EE—56% rehospitalization in 6
months
Low levels of EE—21% rehospitalization in 6
months
Rehabilitation=Goal
Social skills training
– Teach issues re: hygiene, personal space, eye contact,
body language
– Expressing interests in others
– Teach empathy
– Initiating contact with others
Vocational Rehab
– Vocational counseling and education
Supportive employment
– Get job in the community and have job coach come in to
help you keep the job
Outcomes
1/3 recover; 1/3 severe chronic; 1/3 exacerbations
and remissions
In general, Schizophrenia is a relapsing and
remitting course
Timing is relevant -early intervention ++
Stabilize 1st year
1st 6 months increased risk for suicide
Combined approaches best—meds alone aren’t
enough