Schizophrenia

Etiology
Definition • Interpersonal theorists suggested that schizophrenia
• Considered as a heterogenous disorder, a group of several resulted from dysfunctional relationships in early life and
distinct collection of disorders with some common features adolescence
like disturbance in thinking and an extreme occupation within • Some therapists believe that schizophrenia results from
self and inner fantasies dysfunctional parenting or family dynamics
• Cannot be defined as a single illness, rather, schizophrenia • Results from a type of brain dysfunction
is thought of as a syndrome or disease process with many o Neurochemical/neurologic theories are supported by
different varieties and symptoms the effects of antipsychotic medications, which help to
• Diagnosed in late adolescence or early adulthood control psychotic symptoms and neuroimaging tools
• Peak incidence of onset: such as CT scan, which shown that the brains of people
o Men: 15 to 25 years of age with schizophrenia differ in structure and function from
o Women: 25 to 35 years of age the brains of control subjects
• DSM – IV – TR
1. Paranoid Type Schizophrenia • Biologic Theories
o Characterized by persecutory (feeling o Focus on genetic factors, neuroanatomic and
victimized or spied on) or grandiose neurochemical factors (structure and function of the
delusions, hallucinations and occasionally, brain) and immunovirology (the body’s response to
excessive religiosity (delusional religious exposure to a virus)
focus) or hostile and aggressive behavior
2. Disorganized Type Schizophrenia 1. Genetic Factors
o Characterized by grossly inappropriate of flat § The closer the family relationship, the higher the
affect, incoherence, loose associations and incidence of schizophrenia in the relatives
extremely disorganized behavior § Identical Twins have a 50% risk for Schizo
3. Catatonic Type Schizophrenia § Fraternal Twins have 15% risk for Schizo
o Characterized by marked psychomotor § Children with one biologic parent with
disturbance, either motionless or excessive schizophrenia have a 15% risk
motor activity § Children with both biologic parents with
o Motor immobility may be manifested by schizophrenia have 35% risk
catalepsy (waxy flexibility) or stupor § More recently, the results of research studies have
o Excessive motor activity is apparently suggested that schizophrenia seems to occur
purposeless and is not influenced by external through the interaction of a genetic susceptibility
stimuli with some kind of environmental stress
o Other features include extreme negativism,
mutism, peculiarities of voluntary movement, 2. Neuroanatomic Factors
echolalia and echopraxia § People with schizophrenia have relatively less
4. Undifferentiated Type Schizophrenia brain tissue and cerebrospinal fluid
o Characterized by mixed schizophrenic § Thus, presenting a failure in development or a
symptoms (of other types) along with subsequent loss of tissue
disturbances of thought, affect and behavior § CT scans show enlarged ventricles in the brain,
5. Residual Type Schizophrenia cortical atrophy, and disturbances in cerebral
o Characterized by at least one previous, metabolism and electrical activity
though not a current, episode, social § PET studies suggest glucose metabolism and
withdrawal, flat affect and looseness of oxygen are diminished in the frontal cortical
associations structures of the brain
• Related Disorders § Research consistently shows a decreased brain
1. Schizophreniform Disorder volume and abnormal brain function in the frontal
o Exhibits s/s of schizophrenia but for less than and temporal areas of person with schizophrenia
the 6 months necessary to meet the o Positive Signs – Temporal Lobe
diagnostic criteria o Negative Signs – Frontal Lobe
o Social or occupational functioning may or § Intrauterine influences such as poor nutrition,
may not be impaired tobacco, alcohol and other drugs and stress also
2. Schizoaffective Disorder are being studied as possible causes of the brain
o Exhibits s/s of psychosis and, at the same pathology found in people with schizophrenia
time, all the features of a mood disorder,
either depression or mania 3. Neurochemical Factors
3. Delusional Disorder § Links schizophrenia to certain patterns of
o Has one or more nonbizarre delusions – that hemispheric dysfunction of the brain
is, the focus of the delusion is believable o Left hemisphere overactivation and
o Psychosocial functioning is nor markedly consequent temporal abnormalities and
impaired and behavior is not obviously odd or delays in processing sensory information
bizarre § Alterations in the neurotransmitter systems of the
4. Brief Psychotic Disorder brain in people with schizophrenia
o Experiences sudden onset of at least o Malfunction in the neuronal networks that
psychotic symptom, such as delusions, transmit information by electrical signals from
hallucinations or disorganized speech or a nerve cells through its axon and across the
behavior which lasts from 1 day to 1 month synapses to post synaptic receptors on other
5. Shared Psychotic Disorder nerve cells
o Two people share a similar delusion § On theory suggest that excess dopamine is the
o Develops this delusion in context of a close cause of schizophrenia (based on two
relationship with someone who has psychotic observations)
delusions o Drugs that increase activity in the
dopaminergic system, such as amphetamine
and levodopa, sometimes induce a paranoid
psychotic reaction similar to schizophrenia
 o Drugs blocking postsynaptic dopamine § Early detection and aggressive treatment of the
receptors reduce psychotic symptoms first psychotic episode are associated with
o The greater the ability of the drug to block improved outcomes
dopamine receptors, the more effective it is in
decreasing symptoms of schizophrenia Medical Management
§ Serotonin has been included among the a. Laboratory Tests
leading neurochemical factors affecting a. CT scans show enlarged ventricles in the brain, cortical
schizophrenia atrophy, and disturbances in cerebral metabolism and
o Serotonin modulates and helps to electrical activity
control excess dopamine b. PET studies suggest glucose metabolism and oxygen are
4. Immunovirologic Factors diminished in the frontal cortical structures of the brain
§ Exposure to a virus of the body’s immune
response to a virus could alter the brain b. Medications and Treatments
physiology of people with schizophrenia Psychopharmacology
§ It is believed that cytokines may have a role in the o Past: Electroconvulsive therapy, insulin shock
development of major psychiatric disorders such therapy and psychosurgery were used
as schizophrenia o 1952: Thorazine
o Cytokines are chemical messengers between o Antipsychotic Medications or Neuroleptics
immune cells, mediating inflammatory and § Prescribed to decrease psychotic
immune responses symptoms
o Specific cytokines also play a role in signaling § Do not sure schizophrenia but manages
the brain to produce behavioral and the symptoms of the disease
neurochemical changes needed in the face of o Atypical, Antipsychotic Medications
physical or psychological stress to maintain § Are both dopamine and serotonin
homeostasis antagonists
o Conventional Antipsychotic
Symptomatology § Target positive symptoms of
• Positive or Hard Symptoms schizophrenia
o Represent a distortion or exaggeration of normal § Delusions, hallucinations, disturbed
functions thinking and other psychotic symptoms,
o Delusions, hallucinations and grossly disorganized but have no observable effects on the
thinking, speech and behavior negative signs
• Negative or Soft Symptoms o Atypical Antipsychotic
o Represent a diminution or loss of function § Not only diminish positive symptoms
o Flat affect, lack of volition and social withdrawal or § Lessens the negative signs of lack of
discomfort volition and motivation, social
o Presents a major barrier to recovery and improved withdrawal and anhedonia
functioning in the client’s daily life • Maintenance Therapy
• Medications can control the positive symptoms, but o Fluphenazine (Prolixin)
frequently the negative symptoms persist after positive o Haloperidol (Haldol)
symptoms have occurred o Vehicle for depot injections is sesame oil
• According to Eugene Bleuler (therefore absorbed slowly over time into the
o Fundamental symptoms or Four A’s client’s system)
1. Associative looseness or disturbance o Effects last 2 to 4 weeks eliminating the need for
2. Apathy or affective disorder, that is a flat or daily oral antipsychotic medications
blunted affect • Side Effects
3. Autism, detachment from external reality and o From mild discomfort to permanent movement
withdrawal from fantasies disorders
4. Ambivalence, simultaneous existence of 1. Extrapyramidal Side Effects
opposing feelings, thoughts and desires § Reversible movement disorders induced by
5. Auditory hallucinations neuroleptic medication
§ Include dystonic reactions, parkinsonism and
• Clinical Course akathisia
Onset § Dystonic reactions
§ May be abrupt and insidious • Appear early in the course of treatment
§ Slowly and gradually develops s/s of social and characterized by spasms in discrete
withdrawal, unusual behavior, loss of interest in muscle groups such as the neck
school or work and neglected hygiene muscles or eye muscles
§ Diagnosis of Schizophrenia • Spasms may be accompanied by
o Made when the patient begins to display protrusion of the tongue, dysphagia and
more actively positive symptoms of laryngeal/pharyngeal spasm that can
delusions, hallucinations and disordered compromise airway
thinking (psychosis) • Treatment: Diphenhydramine (Benadryl)
Immediate Course or Benzotropine (Cogentin)
§ First Pattern: Experiences on – going psychosis 2. Pseudoparkinsonism
and never fully recovers § “Neuroleptic Induced Parkinsonism”
§ Second Pattern: Experiences episodes of § Includes shuffling gait, masklike facies,
psychotic symptoms that alternate with episodes continuous muscle stiffness, drooling and
of relatively complete recovery from the psychosis akinesia (slowness and difficulty initiating
movements)
Long – Term Course § Appear in the first few days of starting or
§ Regain some degree of social and occupational increasing the dosage of an antipsychotic
functioning medications
§ Disease become less disruptive to life and easier 3. Akathisia
to manage § Characterized by restless movement, pacing,
inability to remain still and the client’s report
of inner restlessness
 § Happens when the dose is started or d. Keep to simple, basic and reality – based topics of
increased conversation – helps them focus and comprehend
§ Treatment: Beta blockers such as propranolol reality – based issues
or Benzodiazepines e. Work with client to help reduce anxiety and distract
4. Tardive Dyskinesia to hallucinatory materials – remove client to
§ Characterized by abnormal, involuntary stressful environments
movements such as lip smacking, tongue 4. Disturbed thought processes related to biochemical and
protrusion, chewing, blinking, grimacing and neurologic imbalances
choreiform movements of the limbs and feet a. Safety measures to protect clients or others – client
§ Irreversible once it appeared may hurt others and self
§ Take Clozapine (Clozaril) instead b. Identify feelings related to delusions
5. Seizures c. Do not touch client – use gestures carefully – might
§ Infrequent side effects misinterpret as either aggressive or sexual
§ Treatment: Lowered dosage or a different d. Interact with clients on the basis of things in the
antipsychotic medication environment – client will be free from delusional
6. Neuroleptic Malignant Syndrome thinking during the time
§ Serious and frequently fatal condition e. Encourage healthy habits to optimize functioning
§ Characterized by muscle rigidity, high fever, 5. Defensive coping related to perceived threat to hurt self and
increased muscle enzymes and leukocytosis others
§ Treatment: Stopping the medication a. Use a nonjudgmental, respectful and neutral
7. Agranulocytosis approach with the client
§ Potentially fatal side effect of Clozapine b. Be honest and consistent regarding expectations
§ Failure of the bone marrow to produce and enforcing rules – provides an atmosphere in
adequate white blood cells which trust can grow
§ Characterized by malaise, ulceratives, sore c. Use clear and simple language when
throat and leukopenia communicating – minimize opportunity for
§ Treatment: Drug must be discontinued miscommunication
immediately d. Maintain low level of stimuli and enhance
• Psychosocial Treatment nonthreatening environment
o Individual and group therapy session are e. Provide solitary, noncompetitive activities
supportive in nature, giving the client an
opportunity for social contact and meaningful Prognosis
relationships with other people The earlier treatment is started, the better the outcome.
o Family education and therapy are known to During the first 5 years after onset of symptoms, functioning may
diminish the negative side effects of schizophrenia deteriorate and social and work skills may decline, with progressive
and reduce the relapse rate neglect of self-care. Negative symptoms may increase in severity, and
cognitive functioning may decline. Thereafter, the level of disability tends
Nursing Diagnosis and Interventions to plateau. Some evidence suggests that severity of illness may lessen
1. Impaired verbal communication related to biochemical in later life, particularly among women. Spontaneous movement
alteration in the brain of certain neurotransmitters disorders may develop in patients who have severe negative symptoms
a. Plan short, frequent periods with client throughout and cognitive dysfunction, even when antipsychotics are not used.
the day – giving the client a chance to develop
familiarity and safety
b. Use simple words and keep directions simple –
client may have difficulty processing even simple
words
c. Keep voice low and speak slowly – aids
understanding
d. Use therapeutic techniques to understand client’s
concerns – try getting to the feelings behind them
e. Keep the environment quiet and free from stimuli as
possible – may increase confusion and
hallucinations and delusions
2. Impaired social interaction related to impaired thought
processes (hallucinations or delusions)
a. Assess if medication has reached in therapeutic
levels – positive symptoms will subside with
medications
b. Keep client in an environment free from stimuli – to
decrease agitation, anxiety and increased inability
to concentrate
c. Make structured activities – helps client to develop
a sense of safety in a nonthreatening environment
d. Engage patient and SO in social interactions –
client continues to feel safe and competent
e. Provide opportunities for the client to learn adaptive
social skills – helps the client adapt and function at
a higher level in society and increases quality of life
3. Disturbed sensory perception: Auditory and visual related to
neurologic and biochemical changes
a. Environmental precautions – early assessment and
interventions might save lives for suicidal clients
b. Decrease environment stimuli when possible –
decrease potential for anxiety, calm the client
c. Accept the fact that they hear voices, but tell them
that you do not hear them – validate reality
Mood Disorders
ü Mixed Episodes
Definition and Symptomatology
§ Diagnosed when the person
• Also called as “Affective Disorders” are pervasive alterations
experiences both mania and depression
in emotions that are manifested by depression, mania or
nearly every day for at least 1 week
both
§ Often called “Rapid – Cycling”
• Are the most common psychiatric diagnoses associated with
suicide, depression is one of the most important risk factors
• Related Disorders
for it
1. Dysthymic Disorder
o Characterized by at least 2 years of
• Categories depressed mood for more days than not with
§ Primary Mood Disorders some additional less severe symptoms that
o Major Depressive Disorder do not meet the criteria for a major
§ Lasts at least 2 weeks, during which the person depressive episode
experiences a depressed mood or loss of 2. Cyclothymic Disorder
pleasure in nearly all activities o Characterized by 2 years of numerous
§ Untreated episode of depression an last up to 6 periods of both hypomanic symptoms that do
to 24 months before remitting not meet the criteria for bipolar disorder
§ Four of the following symptoms are present 3. Substance – Induced Mood Disorder
§ Changes in appetite or weight, sleep, o Characterized by a prominent and persistent
psychomotor activity, decreased energy, disturbance in mood that is judged to be a
feelings of worthlessness or guilt, direct physiological consequence of ingested
difficulty thinking, concentrating or substances such as alcohol, other drugs or
making decisions, recurrent thoughts of toxins
death or suicidal ideation, plans or 4. Mood Disorder due to a General Medical Condition
attempts o Characterized by prominent and persistent
§ Result is significant distress or impair disturbance in mood that is judged to be a
social, occupational or other important direct physiological consequence of a
areas of functioning medical condition
§ Some have delusions and hallucinations § Degenerative neurological
(psychotic depression) conditions, cerebrovascular
o Bipolar Disorders disease, metabolic or endocrine
§ Diagnosed when a person’s mood cycles is conditions, autoimmune disorders,
between extremes of mania and depression HIV infections or certain cancers
§ Described as
• Bipolar 1 Disorder – One or more manic • Other Disorders
or mixed episodes usually accompanied 1. Seasonal Affective Disorder (SAD)
by major depressive episodes o Subtypes
• Bipolar 2 Disorder – One or more major o Winter Depression of Fall – Onset SAD
depressive episode accompanied by at § Increased sleep, appetite and
least one hypomanic episode carbohydrate cravings, weight gain,
• May experience a euthymic or normal interpersonal conflict, irritability and
mood and affect between extreme heaviness in the extremities beginning
episodes or they may have a depressed in late autumn and abating in spring and
mood swing following a manic episode summer
before returning to a euthymic mood o Spring – Onset SAD
ü Mania § Insomnia, weight loss, and poor appetite
§ A defense against depression lasting from late spring or early summer
characterized by varying degrees of until early fall
elation, hyperactivity, agitation and 2. Postpartum or “Maternity Blues”
accelerated thinking and speaking o Characterized by labile mood and affect,
§ Lasts for 1 week crying spells, sadness, insomnia and anxiety
§ At least three of the following symptoms o Appears 1 day after delivery (Peak at 3 to 7
accompany the manic episode days)
• Inflated self – esteem or 3. Postpartum Depression
grandiosity, decreased need for o Meets all the criteria for a major depressive
sleep, pressured speech, flight of episode with onset within 4 weeks of delivery
ideas, distractibility, increased 4. Postpartum Psychosis
involvement in goal – directed o Psychotic episode developing within 3 weeks
activity or psychomotor agitation of delivery beginning with fatigue, sadness,
and excessive involvement in emotional lability, poor memory and
pleasure seeking – activities with a confusion and progressing to delusions,
high potential for painful hallucinations, poor insight and judgment and
consequences loss of contact with reality
• Some also exhibit delusions and
hallucinations during manic Etiology
episode o Genetic Theories
ü Hypomania o First degree relatives have twice the risk of
§ A period of abnormally and persistently developing depressions
elevated, expansive or irritable mood o First degree relatives of people with bipolar
lasting for 4 days and including 3 to 4 of disorder have a 3% to 8% risk of developing
the additional symptoms described bipolar disorder
above o For all mood disorders, identical twins have a
§ Do not impair the person’s ability to concordance rate of 2 to 4 times higher than the
function and there are no psychotic fraternal twins
features (delusions and hallucinations) o Neurochemical Theories
o Serotonin and norepinephrine
 o Serotonin (5 – HT) has many roles in § Prozac produces slightly higher rate of
behavior: mood, activity, aggressiveness and mild agitation and weight loss but less
irritability, cognition, pain, biorhythms and somnolence
neuroendocrine disorders
§ Deficits in serotonin found in the blood o Cyclic Antidepressants
or CSF occur in people with depression § Blocks the activity of norepinephrine and
o Positron emission tomography (PET) scans serotonin or increasing the sensitivity of
demonstrate reduced metabolism in the postsynaptic receptors sites
prefrontal cortex, which may promote § Contraindicated in severe impairment of
depression liver function and myocardial infarction
o Norepinephrine levels may be deficient in o Tetracyclic Antidepressants
depression and increased in mania § Amoxapine (Asendin) may cause
§ This catecholamine energizes the body extrapyramidal symptoms, tardive
to mobilize during stress and inhibits dyskinesia and neuroleptic malignant
kindling (the process by which seizure syndrome
activity in a specific area of the brain is § Increases appetite and causes
initially stimulated by reaching a weight gain and cravings for
threshold of effects of stress, low sweets
amounts of electric impulses or § Maprotilin (Ludiomil) carries a risk of
chemicals that sensitize nerve cells and seizures, severe constipation and
pathways) urinary retention and stomatitis
§ Anticonvulsants inhibit kindling, this may o Atypical antidepressants
explain their efficacy in the treatment of § Has an inadequate response to or side
bipolar disorder effects from SSRIs
o Neuroendocrine Influences § Venlafaxine blocks the reuptake of
o Hormonal fluctuations in relation to serotonin, norepinephrine and dopamine
depression § Bupropion inhibits the reuptake of
o Elevated glucocorticoid activity is associated dopamine and has no effects on
with the stress response and increased serotonin
cortisol secretion is apparent among § Nefazodone inhibits the reuptake of
depressive clients serotonin and norepinephrine and has
o 5% to 10% of people with depression have few side effects
thyroid dysfunction (elevated TSH) § Remeron also inhibits the reuptake of
o Psychodynamic Theories serotonin and epinephrine, has few
o Freud – real or perceived loss, feeling of sexual side effects, but has higher
abandonment, loving and hating lost subject incidence of weight gain, sedation and
o Bibring – person was not able to achieve anticholinergc side effects
ideals o MAOIs
o Jacobson – ego is powerless, helpless child § Most serious side effect: Hypertensive crisis
victimized by the superego § A life – threatening condition that can
o Meyer – reaction to a distressing life result when a client taking MAOIs
experience ingests tyramine – containing foods and
o Horney – children raised by rejecting or fluids or other medications
unloving parents were prone to feelings of § S/S are occipital headache,
insecurity and loneliness hypertension, nausea and vomiting,
o Beck – specific cognitive distortions in chills, sweating, restlessness, nuchal
susceptible people rigidity, dilated pupils, fever and motor
agitation
Medical Management § Treatment: Phentolamine Mesylate
c. Laboratory Tests § Given to dilate blood vessels ad
o Positron emission tomography (PET) scans demonstrate decrease vascular resistance
reduced metabolism in the prefrontal cortex, which may
promote depression • Other Medical Treatments and Psychotherapy
Electroconvulsive Therapy
d. Medications and Treatments o To treat depression who do not respond to
Psychopharmacology antidepressants or those who experience
o Cyclic antidepressants, monoamine oxidase intolerable side effects at therapeutic doses
inhibitors (MAOIs), selective serotonin reuptake o The shock stimulates brain chemistry to correct
inhibitor (SSRIs) and atypical antidepressants the chemical imbalance of depression
o Depression results if too few neurotransmitters are o NPO post midnight, no nail polish, voids just prior
released to procedure, IV insertion for medications
o Usually presynaptic neurons release these o Muscle relaxant: Succinylcholine
neurotransmitters to allow them to enter synapses Psychotherapy
and link with postsynaptic receptors o A combination of psychotherapy and medications
§ To do so, antidepressants establish a is considered the most effective treatment for
blockade for the reuptake of depressive disorders
norepinephrine and serotonin into their o Goals: Symptom remission, psychosocial
specific nerve terminals restoration, prevention of relapse or recurrence,
§ This permits them to linger longer in reduced secondary consequences and increasing
synapses and to be more available to treatment compliance
postsynaptic receptors o Interpersonal Therapy
o SSRIs o Focuses on difficulties in relationships such
§ Specific to serotonin reuptake inhibition as grief reactions, role disputes and role
§ Produce few sedating, anticholinergic transitions
and cardiovascular side effects, which o Behavior therapy
makes them safer for use in children o Increase the frequency of the client’s
and older adults positively reinforcing interactions with the
 environment and to decrease negative
interactions
o Cognitive therapy
o Focuses on how the person thinks about
self, others and the future and interprets
his or her experiences
Nursing Diagnosis and Interventions
1. Risk for self – directed violence related to severe depression,
loneliness and social isolation
a. Determine level of suicide precautions needed, have a suicide
plan, admit previous suicide attempts
b. Encourage clients to talk freely about feelings (anger,
disappointments)
c. Help clients plant alternate ways to handle anger and
frustration
d. Implement a no – suicide contract which reinforces action the
client can take when feeling suicidal
e. Contact family, arrange for crisis counseling – to help diminish
personal feelings of worthiness, isolation and helplessness
2. Disturbed thought processes related to severe anxiety or
depressed mood
a. Identify client’s previous level of cognitive functioning (from
client, family, friends and previous medical records) to
evaluate client’s progress
b. Minimize client’s responsibilities while depressed
c. Use simple, concrete words
d. Structure environment that can help re – establish set
schedules and predictable routines during severe depression
e. Work with client to recognize negative thinking and thoughts
– negative ruminations add to feelings of hopelessness
3. Impaired social interaction related to self – concept disturbance
a. While depressed, involve the client in one – to – one activity
to maximize the potential for interactions while minimizing
anxiety levels
b. Engage client in activities involving gross motor activity that
needs limited concentration to elevate mood
c. Eventually increase contact and interaction with others
d. Refer to self – help groups
4. Ineffective coping related to inadequate level of perception of
control
a. Administer anti – manic medication and tranquilizers as
ordered
b. Observe for destructive behavior towards self and others –
early detection and intervention can prevent harm to client or
others
c. Maintain firm, calm and neutral approach at all times to
escalate environmental stimulation and manic activity
d. Assess and recognized signs of manipulative behavior and
intervene appropriately and then set limits
5. Self – care deficit related to cognitive and perceptual impairment
a. Encourage small, high calorie and high – protein snack and
fluids frequently throughout the day
b. Encourage eating with others
c. Provide rest periods after activities
d. Reduce environmental and physical stimulants in the evening
e. Assist in doing hygiene techniques
f. Offer foods high in fiber and provide periods of exercise

Prognosis
Remission after affective episodes is frequently incomplete.
Residual symptoms are common in psychiatric and general practitioner
patients and in cases identified in community studies. Chronic residual
symptoms are those typical of depression: mood, anxiety, genital
symptoms, (24) insomnia, headaches, neurasthenic complaints,
reduced libido, and gastrointestinal symptoms. They are frequently
treated by long-term antidepressant medication, which should not be
withdrawn until the patient has had 4 months completely free of
symptoms.
The long-term outcome of mood disorders is usually
unfavourable. Bipolar disorder has a poorer outcome than depression.