Schizophrenia

Question 1

Definition of Schizophrenia

Answer 1

Schizophrenia is a syndrome or a disease process of the brain causing distorted and bizarre thoughts, perceptions, emotions, movements, and behaviour

• It is usually diagnosed in late adolescence and early adulthood
• Prevalence is 1% of total population, or 3 million in US; same prevalence throughout the world

Question 2

Symptoms of Schizophrenia: Hard or Positive

Answer 2

Hard or Positive symptoms include:

• Delusions
• Hallucinations
• Grossly disorganized thinking, speech and behaviour

Question 3

Symptoms of Schizophrenia: Soft or Negative

Answer 3

Soft of Negative symptoms include:

• Flat affect
• Avolition
• Social withdrawal or discomfort
• Apathy
• Alogia

Question 4

Types of Schizophrenia: Paranoid / Disorganized

Answer 4

Paranoid type: persecutory or grandiose delusions and hallucinations; sometimes excessive religiosity; hostile and aggressive behaviour
Disorganized type: grossly inappropriate or flat affect, incoherence, loose associations, extremely disorganized behaviour

Question 5

Types of Schizophrenia: Catatonic / Undifferentiated / Residual

Answer 5

Catatonic: marked psychomotor disturbance, motionless, or excessive motor activity; extreme negativism; mutism; peculiarities of voluntary movement (echolalia, echopraxia)
Undifferentiated: mixed schizophrenic symptoms along with disturbances of thought, affect, and behaviour
Residual: at least one previous psychotic episode but not currently; social withdrawal, flat affect, loose associations

Question 6

Clinical Course

Answer 6

Most clients experience a slow and gradual onset of symptoms
Younger age of onset associated with poor outcome
In first years after diagnosis, client may have relatively symptom - free periods between psychotic episodes or fairly continuous psychosis with some shift in severity of symptoms
Most clients with schizophrenia have difficulty functioning in the community and few lead fully independent lives
Early detection and aggressive treatment of the first psychotic episode improves outcomes

Question 7

Related Disorders

Answer 7

Schizophreniform Disorder: symptoms of schizophrenia are experienced for less than 6 months required for a diagnosis of schizophrenia
Schizoaffective Disorder: symptoms of psychosis and thought disorder along with all the features of a mood disorder
Delusional Disorder: one or more non-bizarre delusions with no impairment in psychosocial functioning

Question 8

Related Disorders

Answer 8

Brief Psychotic Disorder: one psychotic symptom lasting 1 day to 1 month; may or may not have an identifiable stressor, such as child birth
Shared Psychotic Disorder (folie a deux): similar delusion shared by two people, one of whom has psychotic delusions

Question 9

Etiology

Answer 9

Current etiologic theories focus on biological theories:

• Genetic factors
• Neuroanatomic theories
• Neurochemical theories
• Immunovirologic theories

Question 10

Cultural Considerations

Answer 10

Ideas that are considered delusional in one culture may be commonly accepted in another
Auditory or visual hallucinations may be a normal part of religious experiences in some cultures
Ethnicity may be a factor in the way a person responds to psychotropic medications:
- African Americans, Caucasian Americans, and Hispanic Americans appear to require comparable therapeutic doses of antipsychotic medications
- Asian clients need lower doses of drugs such as haloperidol (Haldol) to obtain the same effects

Question 11

Treatment

Answer 11

Primary treatment involves antipsychotic (neuroleptic) medications
Conventional antipsychotics target the positive signs
- Delusions
- Hallucinations
- Disturbed thinking
- Other psychotic symptoms
- - But have no observable effect on the negative signs
Atypical antipsychotics diminish positive symptoms, and they lessen the negative signs:
- Avolition
- Social withdrawal
- Anhedonia

Question 12

Maintenance Therapy

Answer 12

Two antipsychotics are available in depot injection forms for maintenance therapy
- Fluphenazine (Prolixin) in decanoate and enanthate preparations
- Haloperidol (Haldol) in decanoate
The effects of the medications last from 2-4 weeks, eliminating the need for daily oral antipsychotic medication

Question 13

Side Effects of Antipsychotic Medications

Answer 13

Neurologic Side Effects
- Extrapyramidal side effects (acute dystonic reactions, akathisia, and parkinsonism)
- Tardive dyskinesia 
- Seizures
- Neuroleptic malignant syndrome
Non-Neurological Side Effects
- Weight gain
- Sedation
- Photosensitivity
- Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention)
- Orthostatic hypotension
- Agranulocytosis (clozapine)

Question 14

Psychosocial Treatment

Answer 14

Group therapies:
- Supportive, medication management, use of community supports
Social Skills Training
- Cognitive adaptation training
- Cognitive enhancement therapy (CET)
Family therapy
Family education

Question 15

Assessment

Answer 15

Previous Hx with schizophrenia
Previous suicidal ideation
Current support system
Client’s perception of current situation
General appearance, motor behaviour, and speech
Mood and affect: flat or blunted affect, anhedonia
Thought processes and content: disordered
Delusions
Sensorium and intellectual processes: hallucinations, disorientation, concrete or literal thinking
Judgement and insight: impaired judgement, limited insight
Self-Concept: may be distorted, with depersonalization, loss of ego boundaries resulting in bizarre behaviours

Question 16

Assessment

Answer 16

Roles and relationships: often socially isolated, have difficulty fulfilling life roles
Psychologic and self-care considerations: may have multiple self-care deficits (inattention to hygiene, nutrition, sleep needs; polydipsia occasionally seen in longer-term clients)

Question 17

Data Analysis

Answer 17

Common nursing diagnosis for positive symptoms include:

• Risk for other-directed violence
• Risk for suicide
• Disturbed thought processes
• Disturbed sensory perception
• Disturbed personal identity
• Impaired verbal communication

Question 18

Data Analysis

Answer 18

Common nursing diagnosis for negative symptoms and functional abilities include:

• Self-care deficits
• Social isolation
• Deficient diversional activity
• Ineffective health maintenance
• Ineffective therapeutic regimen management

Question 19

Outcome Identification

Answer 19

Expected outcomes for the acute, psychotic phase; the client will:

• Not injure self or others
• Establish contact with reality
• Interact with others
• Express thoughts and feelings in a safe and socially acceptable manner
• Participate in prescribed therapeutic interventions

Question 20

Outcome Identification

Answer 20

Expected outcomes for continued care; the client will:

• Participate in the prescribed regiment (including medication and follow-up appointments)
• Maintain adequate routines for sleeping and food and fluid intake
• Be independent in self-care activities
• Communicate effectively with others in the community to meet his or her needs
• The client will seek or accept assistance to meet his or her needs when indicated

Question 21

Intervention

Answer 21

Promote safety of clients and others
Establish a therapeutic relationship
Use therapeutic communication
Interventions for delusional thoughts
Interventions for hallucinations
Protecting the client who has socially inappropriate behaviours
Client and family teaching

Question 22

Evaluation

Answer 22

Have the client’s psychotic symptoms disappeared? Or can the client carry out his or her daily life despite the persistence of some psychotic symptoms
Does the client understand the prescribed medication regimen? Is he or she committed to adherence to the 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?

Question 23

Evaluation

Answer 23

Is there a sufficient after-care or crisis plan 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 he or she has a satisfactory QOL?

Question 24

Elder Considerations

Answer 24

Psychotic symptoms that appear in later life are usually associated with depression or dementia, not schizophrenia
Elderly people with schizophrenia experience a variety of long-term outcomes
- 20-30% of clients experience dementia, resulting in a steady, deteriorating decline in health
- 20-30% experience a reduction in positive symptoms, somewhat like a remission
- 40-60% remain mostly unchanged

Question 25

Community-Based Care

Answer 25

Assertive Community Treatment (ACT) Behavioural Home Health Community Support Programs Case management

Question 26

Self-Awareness Issue

Answer 26

May be challenging if client is suspicious or mistrustful or nurse is frightened Nurse may become frustrated if client is noncompliant Nurse must not take client's success or failure personally; the client's remarks and behaviour or noncompliance are not personal towards the nurse but are part of the illness

Question 27

Self-Awareness Issue

Answer 27

Focus on clients strengths and time out of the hospital, not just on symptoms and need for acute care No nurse has all the answers