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 discernable 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.
- 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
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.