SCHIZOPHRENIA

Schizophrenia

- A mental disorder characterized by disordered thoughts, hallucinations, and

delusions

- It cannot be defined as a single illness; rather, it is thought of as a syndrome

or a disease process with many different varieties and symptoms; Patient
experiences different combinations of the main symptoms of schizophrenia.
- The label given to a group of psychoses in which deterioration of functioning
is marked by severe distortion of thought, perception and mood; by bizarre
behavior; and by social withdrawal
- Equally frequency, males have earlier onset
18 to 25 for men

26 to 45 for women

Dispelling common myths about Schizophrenia

≈ Schizophrenia does NOT mean split personality as in Dr. Jekyll and Mr. Hyde.
The word “schizophrenia” does mean splitting of the mind, but this name was
chosen to reflect the effects of schizophrenia on thought and process, not on
personality

≈ Schizophrenic individuals are NOT usually prone to violence. Majority of

schizophrenic individuals are not violent although some do commit crimes
and some are very dangerous. Schizophrenic individuals’ risk of suicide is
very high, approaching 10%.

≈ Schizophrenia is NOT caused by family dysfunction. Psychological factors

influence the way individuals and families cope with schizophrenia, but
families do not cause schizophrenia any more than they cause multiply
sclerosis or cancer. While biological factors leading to schizophrenia remain
unknown, schizophrenia is clearly a disease of the brain, NOT a primary
psychological disorder.

Disordered thought is a major characteristic of schizophrenia, and with all

persons with this diagnosis have had disordered thought at some time in their
lives, they do not have disordered thoughts all of the time.

Three phenomena (characteristics of psychosis) in schizophrenia:

 ↪ Disordered thoughts

↪ Delusions

↪ Hallucinations

Schizophrenia is the major cause of prolonged psychosis seen in psychiatric

practice.

THE EXPERIENCE OF SCHIZOPHRENIA

☙ Distorted Perceptions of Reality

↪ People with schizophrenia may have perceptions of reality that are strikingly
different from the reality seen and shared by others around them. Living in a
world distorted by hallucinations and delusions, individuals with
schizophrenia may feel frightened, anxious, and confused.
↪ Sometimes they may seem distant, detached, or preoccupied and may even
sit as rigidly as a stone, not moving for hours or uttering a sound. Other times
they may move about constantly, always occupied, appearing wide-awake,
vigilant, and alert.

☙ Disordered thoughts

↪ Major characteristic of schizophrenia

↪ When schizophrenic individuals talk, they demonstrate a flow of

thought that can be described as “loose” – topics and ideas follow one
another with far less order than one expects in every day speech.

↪ Often one idea or thought is followed by a seemingly unrelated one;

either topic might make good conversational sense, but when put together,
the ideas do not quite seem to mesh.

You ask me to define contentment? Well uh, contentment, well the

word contentment, having a subject, perhaps you have a chapter of
reading, but when you come to the word “men” you wonder if you
should be content with men in your life and then you get to the letter
“I” and you wonder if you should be content having tea by yourself or
be content with having it with a group and so forth.

(Lorenz, 1961,, p.604)

↪ Rapid shift of ideas

 ↪ The confusion is not in speech alone, but in the thinking process itself.

“I try to read even a paragraph in a book, but it takes me ages because

each bit i read starts me thinking in ten different directions at once”
(Sass, 1992, p.178)

↪ In the early stages of schizophrenia, formal thought disorder may be

very subtle and hard to recognize (Harrow & Quinlan, 1985)

☙ Incomprehensible language

↪ Neologistic word – invented word

That’s wish-hell double vision. Like walking across a person’s eye and
reflecting personality. It works on you like dying and going into the
spiritual world but landing in the vella world.

(Harrow & Quinlan, 1985, p.423)

Characteristics of speech of schizophrenic individual (DSM-IV-TR, APA, 2000):

↪ Derailment – going off the point or subject

↪ Tangentiality – failure to reach a goal or stick to the original point

↪ Incoherence – speech that is not logically connected

↪ Word salad – a group of disconnected words

☙ Loss of function

↪ A person without ability to think and communicate cannot maintain social

norms.

↪ Behavior is often disordered as thought

↪ The person may appear markedly dishevelled, may dress in unusual manner,
or may display clearly inappropriate sexual behaviour or unpredictable and
untriggered agitation (APA, 2000, p.300)

↪ Catatonia – a marked decrease in reactivity to the environment, sometimes

reaching an extreme degree of complete unawareness...maintaining a rigid
 posture and resisting efforts to be moved... the assumption of bizarre
posture.

☙ Delusions

↪ False beliefs that misrepresent perceptions or experiences.

↪ Major defining characteristic of psychosis

↪ Commonly characterized as grandiose, persecutory, or referential

↪ Grandiose delusion – involved perceptions of importance; often believe

themselves to have special powers and may claim to be religious messiah

↪ Persecutory delusion – paranoid; believe others intend to do them harm

↪ Referential delusion – believe that common events – passages in songs,

patterns of clouds in the sky – refer specifically to them.

☙ Hallucinations

↪ Sensory experiences not perceptible to other nonpsychotic individuals

↪ Most commonly auditory

↪ Psychotic individuals typically describe “hearing voices”, and these voices

are perceived as quite distinct from the individual’s own thoughts. The
voices generally have specific contents, and this is most frequently of a
threatening or negative nature.

↪ “The voices schizophrenics hear tend to emanate not from any particular
person or object in external space but from inside the body or from the sky,
as if permeating the entire universe. (Sass, 1992, p.233)

↪ Occur when fully awake

↪ Multivoice auditory hallucination – Schizophrenic persons may hear two or

more voices talking with each other or actually commenting on the
individual’s stream of thought

A twenty-four year old man repeatedly heard a couple of voices discussing

him. A deep, rough voice would say, “G.T. is a bloody paradox”; then a
higher-pitched one would chime in, “He is that, he should be locked up”; and
 a female voice would occasionally interrupt, saying, “He is not, he is a lovely
man.”

(C.S. Mellor, 1970, p.16)

Positive and Negative Symptoms of Schizophrenia

☙ Positive Symptoms

An exaggeration or distortion of normal function; usually responsive to

traditional antipsychotic drugs

Distortions or excesses of normal functioning (e.g., delusions, hallucinations, disorganized

speech/thought disturbances, motor disturbances)

≈ 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

≈ Right 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

≈ Perseveration - Persistent adherence to a single idea or topic; verbal repititionof a sentence,

word, pr phrase; resisting attempts to change the topic

☙ Negative Symptoms

A diminution or loss of normal function; usually unresponsive to traditional

antipsychotics and more responsive to atypical antipsychotics
Behavioral deficits that endure beyond an acute episode of schizophrenia
More negative symptoms are associated with a poorer prognosis
Some negative symptoms might be secondary to medications and/or
institutionalization

≈ Alogia - tendency to speak very little or to convey little substance of meaning (poverty of
content)

≈ Anhedonia - feeling no joy or pleasure from life 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 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

POSITIVE SYMPTOMS:
NEGATIVE SYMPTOMS:
Delusions
Affective flattening
Hallucinations
Alogia
Thought disorder
Avolition/apathy
Disorganizes speech
Anhedonia/asociality
Bizarre behavior
Attentional deficit
SOCIAL/
Inappropriate affect
OCCUPATIONAL
DYSFUNCTION:

Work/activity
Interpersonal
relationships
Self-care

Mortality/morbidit
y

COGNITIVE SYMPTOMS:
MOOD SYMPTOMS:
Attention
Dysphoria
Memory
Suicidality
Executive functions:
abstraction, concept hopelesness
formation, problem solving,
decision making
Figure 1 Core symptom clusters in schizophrenia. (Modified from Eli Lilly:
Schizophrenia and related disorders: a comprehensive review and bibliography slide
kit, Indianapolis, 1996, Lilly Neuroscience.)

☙ Neurological Soft Signs: Prefrontal Cortical Dysfunction in

Schizophrenia

↪ Astereognosis: Inability to recognize objects by the sense of touch (such as

differentiating a nickel from a dime)

↪ Agraphestesia: Inability to recognize numbers or letters traced on the skin

↪ Dysdiadochokinesia: Impairment of the ability to perform smooth,

alternating movements (such as turning the hand face up and face down
rapidly)

↪ Mild muscle twitches, choreiform and ticlike movements, grimacing

↪ Impaired fine motor skills and abnormal motor tone

↪ Increased rate of eye blinking

↪ Abnormal smooth pursuit eye movements (SPEM): Difficulty following

movement of objects

☙ Neurological hard signs

↪ loss of function, weakness, diminished reflexes, paralysis caused by a

CVA, tumor, traumatic injury, etc.

CLINICAL COURSE

↪ Schizophrenia most commonly manifests itself in the early to mid-twenties in

men, somewhat later in women.

↪ Women tend to have somewhat more benign course with fewer negative
symptoms and less long-term cognitive impairment.

↪ Bleuler found that schizophrenia most commonly evolved over approximately

5 years, after which time it tended to stabilize with little subsequent
deterioration and, in about a third of clients, showed a tendency for some
improvement. Unfortunately, another third of clients continued to worsen
after 5 years.

↪ In one study, less than 20% of clients were fully employed, and less than 50%
were fully independent (Johnstone, 1991)
ETIOLOGY

The etiology and pathogenesis of schizophrenia is unknown.

It is accepted that the etiology is MULTIFACTORIAL

☙ Biologic Theories
Biochemical
↪ DOPAMINE HYPOTHESIS
⇢ overactivity of dopamine neurons in the mesolimbic pathway may
cause positive symptoms
⇢ nderactivity of dopamine neurons in the mesocortical pathway in
the prefrontal cortex may cause negative symptoms
⇢ Evidence that supports the hypothesis:

≈ Drugs effective in the control of positive symptoms of schizophrenia all

seem to have significant dopamine receptor blocking activity; these
drugs seem to work because they reduce the effect of an individual’s
own dopamine on his or her brain.

≈ Drugs like amphetamines, which have the ability to cause strikingly

schizophrenic-like psychoses, act by increasing dopamine
concentrations (McKenna, 1994)

≈ Of all the neuropathological findings from multiple autopsies of persons

dying with schizophrenia, the most reproducible is an increase in
dopamine receptors in the brain’s basal ganglia. (Clardy, Hyde, &
Kleinman, 1994)

↪ SEROTONIN HYPOTHESIS
⇢ Serotonin (5HT) mediates dopamine levels
⇢ LSD and psilocybin ate potent 5HT receptor agonists and cause
positive
⇢ Symptoms
Atypical antipdychotics are potent 5HT receptor antagonists

↪ GLUTAMATE HYPOTHESIS
Regulation of N-methyl-D-aspartate (NDMA)

Decreased levels of
Glutamate

Decreased regulation of
NMDA

Impaired cognitive processes Psychotic symptoms

 NMDA receptor blockade may produce the dopamine dysfunction seen
in schizophrenia if too littele dopamine were present in the prefrontal cortex
(negative symptoms) and too much dopamine in the mesolimbic area
(positive symptoms)

☙ Other neurotransmitters

⇢ Recent research shows that in schizophrenia there is a decrease in the

number of inhibitory neurons, particularly those in which GABA is the
predominant neurotransmitter.

⇢ Expression of the signaling neuropeptides cholecystokinin and

somatostatin is also decreased in schizophrenia.

⇢ Loss of inhibitory function may account for the increased brain activity
seen in some specific brain sites, notably the hippocampus and parts of
prefrontal cortex (Freedman, 2003)

⇢ Effects of the excitory neurotransmitter glutamine are potentiated by the

actions of dopamine.

Neurostructural
⇢ Enlarged ventricles (increased width of 3rd ventricle)

Genetic
⇢ by the 19th century, genetic hypothesis was endorsed by Kraepelin, Bleuler
and many other experts in schizophrenia.
⇢ The current belief is that genetic factors account for about 70% of the risk of
developing schizophrenia although the majority of schizophrenics (63%) have
absolutely no family history of the disease. Genetics clearly plays a role but
by no means a decisive one

Perinatal Risk Factors

⇢ there are also evidences that perinatal conditions may be an indicator of the
risk of having schizophrenia
⇢ 2nd trimester (4-6 months) – brain development
⇢ brain injury could be a result of:
⇢ maternal starvation
⇢ obstetric complications such as fetal hypoxia, maternal alcohol or drug abuse
⇢ toxin exposure or viral infection (influenza virus)
⇢ incidence of birth trauma and injury

☙ Twin studies in Schizophrenia

Major findings (McKenna, 1994; Gottesman, 1991; Reveley, 1944;

Cannon et al.,2000)
 1. In four studies, 60% to 70% of hospitalized identical twins had a
monozygotic sibling who had the disease; for fraternal twins, only 0% -
15% had a dizygotic sibling with the disease (McKenna 1994)

2. For identical twins, if one twin had schizophrenia, his co-twin was 2 to 3
times more likely to have schizophrenia than were co-twins of fraternal
twins who had the disease (Gottesman 1991)

3. If one twin had schizophrenia, the co-twin also had schizophrenia in 64%
of the pairs (Reveley, 1994)

4. Findings show that certain measurable factors (such as spatial working

memory or divided attention) were more highly correlated within identical
than fraternal twins irrespective of the diagnosis of schizophrenia. The
research suggests that there may be multiple, independently inherited
dimensions of neural deficit in schizophrenia. (Cannon et al., 2000).

☙ Psychological theories
Psychoanalytic
Dysfunctional Mother-Child Relationship
Schizophrenogenic mother
-emotionally withholding
- domineering
- rejecting attitudes
- over-protection

Child grows feeling in conflict with, distrustful of, and angry

towards others

Child grows feeling in conflict with, distrustful of, and angry

towards others

Faulty ego development

Ego disintegration

Intrapsychic conflict

Dysfunctional Parental-interaction

Double Bind Type of Communication

Making A Diagnosis

↪ medical history
↪ Physical examination
↪ neurology assessment
↪ blood and urine samples ( to diagnose substance induced schizophrenia)
↪ MRI, CT Scan

TYPES OF SCHIZOPHRENIA

☙ Paranoid Type: preoccupation with one or more delusions or frequent

auditory hallucinations

↪ Suspiciousness
↪ Hostility
↪ Delusions
↪ Auditory hallucinations
↪ Anxiety and anger
↪ Aloofness
↪ Persecutory themes
↪ Violence

☙ Disorganized Type: disorganized speech, disorganized behavior, and flat or

inappropriate affect

↪ Extreme social withdrawal

↪ Disorganized speech or behavior
↪ Flat or inappropriate affect
↪ Silliness unrelated to speech
↪ Stereotyped behaviors
↪ Grimacing mannerisms
↪ Inability to perform ADL

☙ Catatonic Type: motoric immobility or excessive motor activity, extreme

negativism or mutism, peculiar voluntary movement, echolalia or echopraxia

↪ Psychomotor disturbances
↪ Immobility
↪ Stupor
↪ Waxy f lexibility
↪ Excessive purposeless motor activity
↪ Echolalia
↪ Automatic obedience
↪ Stereotyped or repetitive behavior
 ☙ Undifferentiated Type: cannot be classified as paranoid, disorganized, or
catatonic type

↪ Delusions and hallucinations

↪ Disorganized speech
↪ Disorganized or catatonic behavior
↪ Flat affect
↪ Social withdrawal

☙ Residual Type: Absence of prominent delusions, hallucinations,

disorganized speech/behavior but odd beliefs/behavior or negative symptoms

↪ Diagnosed as Schizophrenic in the past

↪ Time limited between attacks but may last for many years
↪ Exhibits social isolation and withdrawal, and impaired role functioning

TREATMENT

☙ Psychosocial treatment
Three categories (Hargreaves & Shumway, 1989):

↪ Clinical and family support services

Goal of clinical interventions is to reduce both positive and negative

symptoms and to maximize functional outcomes. Clinical support involves
outpatient management and family/community services.

Families can be supported through education, group activities, and

community involvement/advocacy. Internet bulletin boards and discussion
groups provide new methods of linking individuals and family members
with others around the world in electronic support groups.

In addition, educating families to understand the purpose and side effects

of medication can help then to ensure compliance.

↪ Rehabilitation

This involves increasing clients’ capacities, both for social interactions and
for productive activity.

↪ Humanitarian aid/public safety

Maximize individual’s independence and quality of life within the bounds

of his or her mental disability. Public safety involves balancing personal
 liberty with the recognition that some social control may be needed to
prevent harm, both to the individual and to society.

⇢ Psychosocial treatments can help people with schizophrenia who are already
stabilized on antipsychotic medication. Psychosocial treatments help these
patients deal with the everyday challenges of the illness, such as difficulty with
communication, self-care, work, and forming and keeping relationships. Learning
and using coping mechanisms to address these problems allow people with
schizophrenia to socialize and attend school and work.

Patients who receive regular psychosocial treatment also are more likely to keep
taking their medication, and they are less likely to have relapses or be
hospitalized. A therapist can help patients better understand and adjust to living
with schizophrenia. The therapist can provide education about the disorder,
common symptoms or problems patients may experience, and the importance of
staying on medications.
Illness management skills. People with schizophrenia can take an active role
in managing their own illness. Once patients learn basic facts about
schizophrenia and its treatment, they can make informed decisions about their
care. If they know how to watch for the early warning signs of relapse and make
a plan to respond, patients can learn to prevent relapses. Patients can also use
coping skills to deal with persistent symptoms.
Integrated treatment for co-occurring substance abuse. Substance abuse
is the most common co-occurring disorder in people with schizophrenia. But
ordinary substance abuse treatment programs usually do not address this
population's special needs. When schizophrenia treatment programs and drug
treatment programs are used together, patients get better results.
Rehabilitation. Rehabilitation emphasizes social and vocational training to help
people with schizophrenia function better in their communities. Because
schizophrenia usually develops in people during the critical career-forming years
of life (ages 18 to 35), and because the disease makes normal thinking and
functioning difficult, most patients do not receive training in the skills needed for
a job.
Rehabilitation programs can include job counseling and training, money
management counseling, help in learning to use public transportation, and
opportunities to practice communication skills. Rehabilitation programs work
well when they include both job training and specific therapy designed to
improve cognitive or thinking skills. Programs like this help patients hold jobs,
remember important details, and improve their functioning.
Family education. People with schizophrenia are often discharged from the
hospital into the care of their families. So it is important that family members
know as much as possible about the disease. With the help of a therapist, family
members can learn coping strategies and problem-solving skills. In this way the
family can help make sure their loved one sticks with treatment and stays on his
or her medication. Families should learn where to find outpatient and family
services.
Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a type
ofpsychotherapy that focuses on thinking and behavior. CBT helps patients with
symptoms that do not go away even when they take medication. The therapist
teaches people with schizophrenia how to test the reality of their thoughts and
perceptions, how to "not listen" to their voices, and how to manage their
symptoms overall. CBT can help reduce the severity of symptoms and reduce
the risk of relapse.
Self-help groups. Self-help groups for people with schizophrenia and their
families are becoming more common. Professional therapists usually are not
involved, but group members support and comfort each other. People in self-
help groups know that others are facing the same problems, which can help
everyone feel less isolated. The networking that takes place in self-help groups
can also prompt families to work together to advocate for research and more
hospital and community treatment programs. Also, groups may be able to draw
public attention to the discrimination many people with mental illnesses face.
Once patients learn basic facts about schizophrenia and its treatment, they can
make informed decisions about their care.
Individual Psychotherapy. Individual psychotherapy involves regularly
scheduled talks between the patient and a mental health professional such as a
psychiatrist, psychologist, psychiatric social worker, or nurse. The sessions may
focus on current or past problems, experiences, thoughts, feelings, or
relationships. By sharing experiences with a trained empathic person talking
about their world with someone outside it individuals with schizophrenia may
gradually come to understand more about themselves and their problems. They
can also learn to sort out the real from the unreal and distorted. Recent studies
indicate that supportive, reality-oriented, individual psychotherapy, and
cognitive-behavioral approaches that teach coping and problem-solving skills,
can be beneficial for outpatients with schizophrenia. However, psychotherapy is
not a substitute for antipsychotic medication, and it is most helpful once drug
treatment first has relieved a patients psychotic symptoms.

☙ Pharmacological Treatments

Antipsychotic medications

↪ Antipsychotics are valuable medications, but they DO NOT cure

schizophrenia

↪ Twenty percent of clients have complete remission when treated with

first-generation antipsychotics.

↪ In about a quarter of clients, even positive symptoms remain highly

resistant to antipsychotic medications.

↪ While antipsychotic medications do not have an effect on negative

symptoms, these symptoms frequently remain socially incapacitating.

↪ All the antipsychotics seem to share the ability to block dopamine from
interacting with brain dopamine receptors.
Antipsychotic medications have been available since the mid-1950's. The
older types are called conventional or "typical" antipsychotics. Some of the
more commonly used typical medications include:

↪ Chlorpromazine (Thorazine)
↪ Haloperidol (Haldol)
↪ Perphenazine (Etrafon, Trilafon)
↪ Fluphenazine (Prolixin).

In the 1990's, new antipsychotic medications were developed. These new

medications are called second generation, or "atypical" antipsychotics.

One of these medications, clozapine(Clozaril) is an effective medication that

treats psychotic symptoms, hallucinations, and breaks with reality. But
clozapine can sometimes cause a serious problem called agranulocytosis,
which is a loss of the white blood cells that help a person fight infection.
People who take clozapine must get their white blood cell counts checked
every week or two. This problem and the cost of blood tests make treatment
with clozapine difficult for many people. But clozapine is potentially helpful
for people who do not respond to other antipsychotic medications.

Other atypical antipsychotics were also developed. None cause

agranulocytosis. Examples include:

↪ Risperidone (Risperdal)
↪ Olanzapine (Zyprexa)
↪ Quetiapine (Seroquel)
↪ Ziprasidone (Geodon)
↪ Aripiprazole (Abilify)
↪ Paliperidone (Invega).

When a doctor says it is okay to stop taking a medication, it should be

gradually tapered off, never stopped suddenly.

↪ Side effects

≈ Dystonia – most readily treated side effect; manifests as painful

muscle spasms lasting anywhere from a few seconds to days

≈ Akathisia – is a somewhat more common side effect that affects

both motor function and behaviour.

≈ Tardive dyskinesia – troublesome movement disorder that is

commonly found in schizophrenic clients maintained on
 antipsychotics for long periods of time. Movement is typically
repetitive and commonly involve the face.

≈ Neuroleptic malignant syndrome

- most serious antipsychotic side effect

- Most clients develop this syndrome only when on high or

increasing doses of medication and often after a dosage increase.

- The most striking features are confusion or decreased level of

consciousness and high fever.

- Serum creatinine kinase – definitive diagnostic test

- treatment is largely symptomatic, and both vigorous hydration

and cooling are often required to ensure survival. Antipsychotic
medication is stopped, and various medications to increase CNS
dopamine levels may be given.

≈ Risk of suicide – Suicide is more likely to occur when positive

symptoms are improving, but overall suicidal risk may be
decreased in clients taking clozapine (Freedman, 2003).

Some people have side effects when they start taking these medications.
Most side effects go away after a few days and often can be managed
successfully. People who are taking antipsychotics should not drive until they
adjust to their new medication. Side effects of many antipsychotics include:

↪ Drowsiness
↪ Dizziness when changing positions
↪ Blurred vision
↪ Rapid heartbeat
↪ Sensitivity to the sun
↪ Skin rashes
↪ Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes
in a person's metabolism. This may increase a person's risk of
getting diabetes and highcholesterol. A person's weight, glucose levels, and
lipid levels should be monitored regularly by a doctor while taking an atypical
antipsychotic medication.

How are antipsychotics taken and how do people respond to them?

 Antipsychotics are usually in pill or liquid form. Some anti-psychotics are
shots that are given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and having

hallucinations, usually go away within days. Symptoms like delusions usually
go away within a few weeks. After about six weeks, many people will see a lot
of improvement.

However, people respond in different ways to antipsychotic medications, and

no one can tell beforehand how a person will respond. Sometimes a person
needs to try several medications before finding the right one. Doctors and
patients can work together to find the best medication or medication
combination, as well as the right dose.

Some people may have a relapse -- their symptoms come back or get worse.
Usually, relapses happen when people stop taking their medication, or when
they only take it sometimes. Some people stop taking the medication
because they feel better or they may feel they don't need it anymore. But no
one should stop taking an antipsychotic medication without talking to his or
her doctor. When a doctor says it is okay to stop taking a medication, it
should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

Antipsychotics can produce unpleasant or dangerous side effects when taken

with certain medications. For this reason, all doctors treating a patient need
to be aware of all the medications that person is taking. Doctors need to
know about prescription and over-the-counter medicine, vitamins, minerals,
and herbal supplements. People also need to discuss any alcohol or other
drug use with their doctor.

To find out more about how antipsychotics work, the National Institute of
Mental Health (NIMH) funded a study called CATIE (Clinical Antipsychotic
Trials of Intervention Effectiveness). This study compared the effectiveness
and side effects of five antipsychotics used to treat people with
schizophrenia. In general, the study found that the older typical antipsychotic
perphenazine (Trilafon) worked as well as the newer, atypical medications.
But because people respond differently to different medications, it is
important that treatments be designed carefully for each person.

☙ Electroconvulsive Therapy

It has been used especially for individuals in catatonic states, and is felt by many
psychiatrists to be valuable. However, no scientific basis for its use has yet been
 established; the best and safest use is in conjunction with an affective
component.

NURSING PERSPECTIVES

Symptoms experienced with schizophrenia and associated nursing

diagnosis

Symptoms Nursing Diagnosis

Disordered thought Disturbed thought process

Incomprehensible language Impaired verbal

communication

Loss of function Disturbed role

performance

Delusions Disturbed thought process

Hallucinations Disturbed sensory

perception

The Modeling and Role-Modeling Theory (Erickson, Tomlin & Swain, 1983;
Frisch & Bownman, 2002)

Foundation for all work with schizophrenic client:

1. Build trust

2. Promote positive orientation

3. Promote perceived control

4. Promote strengths

5. Set mutual goals that are health directed.

Nursing Process
Assessment Parameters for schizophrenic clients

Observe for:

1. Presence of delusions

2. Presence of hallucinations

3. Disorganized speech

4. Problems in basic grooming

5. Negative symptoms of schizophrenia, including:

↪ Flat affect

↪ Poverty of speech

↪ Lack of motivation

↪ Symptoms of depression

6. Level of independence and functioning

Acute phase

↪ The immediate goal of treatment is to bring symptoms under control.

↪ Caring for schizophrenic clients in acute phase:

≈ The symptoms of disordered thoughts, hallucinations, and loss of

function are often frightening to the client. Nursing actions to promote
a calm, peaceful, trusting atmosphere are essential in alleviating fear
and establishing a nurse-client relationship.

≈ The nurse should express reality regarding client reports of

hallucinations and delusions but should not enter into arguments
regarding whether or not the delusions are true or hallucinations are
real.

≈ The nurse should work collaboratively with the treatment team to

initiate a plan to control the acute symptoms and move the client into
rehabilitative care.

Rehabilitative phase

↪ The goals are aimed at helping the client and the family to make the best
adjustment possible to chronic illness
 ↪ Caring for schizophrenic clients in rehabilitative phase:

≈ Schizophrenic clients tend to do better with a structured daily schedule

and a daily plan of activities. Therefore it is helpful for the client to
have a written schedule to follow

≈ Social isolation is common, and activities that promote supportive

contacts with others help to meet social needs and to boast self-
esteem.

≈ Risk for ineffective therapeutic regimen management is high, such that

frequent home visits from the nurse coupled with assistance from
family or significant others may be essential for success.

≈ Factors such as lack of transportation to follow-up visits, lack of

supportive and affordable housing, and difficulty in obtaining health
care insurance or social assistance usually require that the nurse work
closely with social workers and community agencies to meet client
needs.

≈ Family members and/or significant others are frequently involved in

client care; nurse’s care to the caregiver and elimination of caregiver
role strain are always important considerations.

Interventions

↪ Assess the client’s physical needs

↪ Set limits on the client’s behaviour
↪ Maintain a safe environment
↪ Spend time with the client
↪ Monitor for altered thought process
↪ Set realistic goals
↪ Monitor for suicide risk
↪ Reorient the client as necessary
↪ Provide short, brief, and frequent contact
↪ Provide simple, concrete activities
↪ Assist the client to use alternative means to express feelings through music,
art or writing

☙ Nurse-Patient Relationship
↪ Focus is on interpersonal communication, socialization skills,
independence and survival skills for post hospitalization

☙ Family involvement
Support and education
☙ MILIEU THERAPY
MILIEU MANAGEMENT

☙ Disruptive behavior:
↪ Set limits
↪ Decrease environmental stimuli
↪ Observe escalation of aggression
↪ Remove objects potential weapon
↪ Once violation of limits occurs, remind the patient of the consequences
↪ For restraints, assure the safety of client

☙ Withdrawn behaviour

↪ Arrange for a non-threatening activities and socialization

↪ Arrange in semicircle group activities
↪ Provide decision-making activities / opportunities
↪ Reinforce appropriate grooming and hygiene
↪ Provide remotivation and resocialization
↪ Provide psychosocial rehabilitation

☙ Impaired Communication
↪ Provide opportunities for decision-making
↪ Be patient and do not pressure patients to make sense
↪ Involve clients to non-threatening activity
↪ Provide for purposeful psychomotor activities such as painting, ceramic
work, exercise

☙ Disordered Perception
↪ Provide distracting activities
↪ Monitor television selections
↪ Monitor hallucinations
↪ Presence and availability of staff for interaction
↪ Present reality

☙ Disorganized
↪ Provide less stimulating and calm environment
↪ Provide safe and simple activities
↪ Provide and use information boards
↪ Protect patient from “embarassing” himself
↪ Assist in grooming and hygiene

☙ Altered levels of activity

↪ Hyperactivity
↪ Provide safe environment and place
↪ Activities that does not require fine motor skills or intense
concentration
↪ Immobility
 ↪ Minimize circulatory problems and loss of muscle tone
↪ Provide adequate diet, exercise and rest
↪ Maintain bladder and bowel functioning
↪ Protect clinet from “victimization”

CARE PLANS

Nursing Diagnosis: Altered thought process: Delusions

Outcomes:

1. Verbalize decreased distress related to delusions or cognitive distortions

2. Be oriented to person, time, and place

3. Be able to participate in therapeutic activities

Interventions

 Assess and document mental ⇢ Provides baseline data and allows

status care to be individualized

 Provide reality orientation – ⇢ Helps to correct distortions and

express doubt, do not enter into misperceptions of the
delusion environment

 Be attentive to themes that may ⇢ Themes may indicate fears or

express the client’s underlying concerns
concerns and feelings

 Redirect toward therapeutic, ⇢ Brings the client into reality,

reality-oriented activities provides distractions from
delusions, and provides means to
cope

 Provide education/support for ⇢ Client needs to be accepting of

taking antipsychotic medications the role medications have in
controlling symptoms

Nursing Diagnosis: Altered sensory perceptions: Hallucinations

Outcomes:
 1. Client will verbalize one method of coping with hallucinations

Interventions

 Assess and document the type of ⇢ Provides baseline information and

hallucination documents the kind of
hallucination

 Be attentive to themes that may ⇢ Themes may indicate fears or

express the client’s underlying concerns
concerns and feelings

 Teach how to cope with ⇢ Distraction techniques can be

distressing hallucinations: used for symptom relief
humming, using a radio, telling
the voices to “go away”

 Provide education/support for ⇢ Client needs to be accepting of

taking antipsychotic medications the role medications have in
controlling symptoms

Nursing Diagnosis: Self-care deficit

Outcomes:

1. Client will manage day-to-day activities, beginning with appropriate dressing,

grooming and nutrition

Interventions

 Assess the client’s current ⇢ Document current and expected

strength and weaknesses in this behaviors
area

 Ensure easy access to clothing ⇢ Clients with thought disorders can

and grooming materials easily be overwhelmed if
preparatory activities are too
complicated

 Provide a schedule of daily ⇢ Clients with disordered thoughts

activities that includes time for respond well to having their time
dressing, bathing, meals, and structured and are unable to
exercise/activity. structure their time themselves.

Nursing Diagnosis: Impaired social interaction

Outcomes:

1. Client will establish less discomfort in social situations

2. Client will pick up on social cues when interacting with others

Interventions

 Assess patterns of social activity, ⇢ Care can be individualized based

including areas of strengths and on the client’s specific patterns
weaknesses

 Identify client goals for interaction ⇢ Set mutual goals for interaction

 Support and reinforce efforts at ⇢ Client will need encouragement;

social interaction reinforcement of new behaviours
is important when the client is
trying to master new patterns

 Provide supportive group to ⇢ Gives the client a safe place to try

enhance and to practice social out new skills and new interactive
skills patterns.

 Teach essential components of ⇢ Address gaps in knowledge about

social interactions: making eye social skills.
contact, how to have productive
patterns of speech, how to relate
a message, and how to enter into
a conversation

References:
Frisch, N.C., Frisch, L.E..Psychiatric Mental Health Nursing, 3rd edition. , pp.228-254
Stuart and Laraia, Principles and Practice of Psychiatric Nursing, 8th Edition
The Coping with Psychosis and Schizophrenia Self Help Handbook ; Ronen David
Schizophrenia (Diseases and People) by Jane E. Phillips, David P. Ketelsen.
Publisher: Enslow Publishers; (January 1, 2003). ISBN: 0766018962