Chapter 15

The following criteria may be used for measurement of outcomes in the care of the client with schizophrenia. The client:

-Demonstrates an ability to relate satisfactorily with others. -Recognizes distortions of reality. -Has not harmed self or others. -Perceives self realistically. -Demonstrates ability to perceive the environment correctly -Maintains anxiety at a manageable level -Relinquishes need for delusions and hallucinations -Demonstrates ability to trust others -Uses appropriate verbal communication in interactions with others -Performs self-care activities independently

Disturbed Thought Processes

-Do not argue or deny the belief. -Reinforce and focus on reality.

Impaired Verbal Communication

-Facilitate trust and understanding. -Orient the client to reality.

Support services

-Financial assistance -Legal assistance -Caregiver support groups -Respite care -Home health care

Factors associated with a positive prognosis include

-Good premorbid functioning -Later age at onset -Female gender -Abrupt onset precipitated by a stressful event -Associated mood disturbance -Brief duration of active-phase symptoms -Minimal residual symptoms -Absence of structural brain abnormalities -Normal neurological functioning -Family history of mood disorder -No family history of schizophrenia

Negative symptoms -Impaired interpersonal functioning and relationship to the external world

-Impaired social interaction: Clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable -Social isolation: A focus inward on the self to the exclusion of the external environment

Psychological treatments -indv psychotherapy -group therapy -behavior therapy -social skills training

-Individual psychotherapy: Long-term therapeutic approach; difficult because of client's impairment in interpersonal functioning -Group therapy: Some success if occurring over the long-term course of the illness; less successful in acute, short-term treatment -Behavior therapy: Chief drawback has been inability to generalize to community setting after client has been discharged from treatment. -Social skills training: Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development

Prodromal phase

-Lasts from a few weeks to a few years -Deterioration in role functioning and social withdrawal -Substantial functional impairment -Sleep disturbance, anxiety, irritability -Depressed mood, poor concentration, fatigue -Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

Of all mental illnesses, schizophrenia probably causes more

-Lengthy hospitalizations -Chaos in family life -Exorbitant costs to people and governments -Fears

The client should

-Not stop taking the drug abruptly. -Use sunscreens and wear protective clothing when spending time outdoors. -Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug. -Be aware of possible risks of taking antipsychotics during pregnancy. -Not drink alcohol while receiving antipsychotic therapy -Not consume other medications (including over-the-counter drugs) without the physician's knowledge

Risk for Violence

-Observe client's behavior. -Maintain calm attitude. -Have sufficient staff on hand.

Disturbed Sensory Perception: Auditory/Visual

-Observe the client for signs of hallucinations. -Help client understand connections between anxiety and hallucinations. -Distract the client from hallucinations.

Biological influences -Biochemical influences

-One theory suggests that schizophrenia may be caused by an excess of dopamine activity in the brain. -Abnormalities in other neurotransmitters have also been suggested.

Premorbid phase

-Social maladjustment -Antagonistic thoughts and behavior -Shy and withdrawn -Poor peer relationships -Doing poorly in school -Antisocial behavior SAS PAD

Environmental influences

-Sociocultural factors: Poverty has been linked with the development of schizophrenia. -Downward drift hypothesis: Poor social conditions seen as consequence of, rather than a cause of, schizophrenia -Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse. -Studies of genetic vulnerability for schizophrenia have linked certain genes to increased risk for psychosis and particularly for adolescents who use cannabinoids.

Symptoms of catatonic disorder include:

-Stupor and muscle rigidity or excessive, purposeless motor activity -Waxy flexibility, negativism, echolalia, echopraxia

Brief psychotic disorder

-Sudden onset of symptoms -May or may not be preceded by a severe psychosocial stressor -Lasts less than 1 month -Return to full premorbid level of functioning

Residual phase

-Symptoms similar to those of the prodromal phase. -Flat affect and impairment in role functioning are prominent.

Psychological influences

-These theories no longer hold credibility. Researchers now focus their studies of schizophrenia as a brain disorder. -Psychosocial theories probably developed early on out of a lack of information related to a biological connection.

Schizophrenia causes disturbances in

-Thought processes -Perception -Affect

Psychopharmacology (cont'd) Action

-Typicals: Dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptors -Atypicals: Weak dopamine antagonists; potent 5HT2A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors

Biological influences -Physiological influences Factors that have been implicated include:

-Viral infection -Anatomical abnormalities -Histological changes in brain

Education: Nature of illness

-What to expect as illness progresses -Symptoms associated with illness -Ways for family to respond to behaviors associated with illness

In the United States, the lifetime prevalence of schizophrenia is about

1 percent.

The Recovery Model

A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential -Research provides support for recovery as an obtainable objective for individuals with schizophrenia.

Biological influences -Genetics

A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia.

Program of Assertive Community Treatment

A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness

Recovery after an initial schizophrenia episode

A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness

3. A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. Identify with the person speaking B. Imitate the nurse's movements C. Alleviate alogia D. Alleviate avolition

A- Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.

5. A client, diagnosed with paranoid schizophrenia, states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? A- "I find that hard to believe." B- "What would make you think such a thing?" C- "I know your roommate. He would do no such thing." D- "I can see why you feel that way."

A-This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients who are experiencing delusional thinking.

Psychomotor Behavior.

Anergia is a deficiency of energy. The individual with schizophrenia may lack sufficient energy to carry out activities of daily living or to interact with others. Waxy flexibility describes a condition in which the client with schizophrenia allows body parts to be placed in bizarre or uncomfortable positions. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the client. This symptom is manifested by the voluntary assumption of inappropriate or bizarre postures. Pacing back and forth and body rocking are common psychomotor behaviors of the client with schizophrenia.

Associated Features.

Anhedonia is the inability to experience pleasure. This is a particularly distressing symptom that compels some clients to attempt suicide. Regression is the retreat to an earlier level of development. Regression, a primary defense mechanism of schizophrenia, is a dysfunctional attempt to reduce anxiety.

Negative symptoms -Associated features

Anhedonia: Inability to experience pleasure Regression: Retreat to an earlier level of development

Antipsychotics

Anticholinergic effects Nausea; gastrointestinal upset Skin rash Sedation Orthostatic hypotension Photosensitivity Hormonal effects Electrocardiogram changes Hypersalivation Weight gain Hyperglycemia/diabetes Increased risk of mortality in elderly clients with dementia Reduction in seizure threshold Agranulocytosis Extrapyramidal symptoms Tardive dyskinesia Neuroleptic malignant syndrome

Discuss the role of psychopharmacology treatment for clients with schizophrenia.

Antipsychotic medications are also called neuroleptics and historically were referred to as major tranquilizers. They are effective in the treatment of acute and chronic manifestations of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms. Without drug treatment, an estimated 72 percent of individuals who have experienced a psychotic episode relapse within a year. This relapse rate can be reduced to about 23 percent with continuous medication administration. Selected agents are used in the treatment of bipolar mania (olanzapine, aripiprazole, chlorpromazine, quetiapine, risperidone, asenapine, ziprasidone).

Positive symptoms -Form of thought

Associative looseness (also called loose association): Shift of ideas from one unrelated topic to another Neologisms: Made-up words that have meaning only to the person who invents them Concrete thinking: Literal interpretations of the environment Clang associations: Choice of words is governed by sound (often rhyming) Word salad: Group of words put together in a random fashion Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details Tangentiality: Inability to get to the point of communication due to introduction of many new topics Mutism: Inability or refusal to speak Perseveration: Persistent repetition of the same word or idea in response to different questions

Form of Thought.

Associative looseness is characterized by speech in which ideas shift from one unrelated subject to another, and the individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent. The person may invent new words, or neologisms, that are meaningless to others but have symbolic meaning to the individual. Concreteness, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking becomes very difficult. Choice of words is governed by sounds. Clang associations often take the form of rhyming. A word salad is a group of words that are put together randomly, without any logical connection, for example "Most forward action grows life double plays circle uniform." With circumstantiality, the individual delays in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track of the topic being discussed. Tangentiality differs from circumstantiality in that the person never really gets to the point of the communication. Unrelated topics are introduced, and the focus of the original discussion is lost. Mutism is an individual's inability or refusal to speak. A client exhibiting perseveration persistently repeats the same word or idea in response to different questions.

Discuss brief psychotic disorder.

Brief psychotic disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month, and there is an eventual full return to a normal level of functioning. Evidence of impaired reality testing may include incoherent speech, delusions, hallucinations, bizarre behavior, and disorientation. Catatonic features may also be associated with this disorder.

6. A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with EPS of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? A. Paroxetine (Paxil) B. Carbamazepine (Tegretol) C. Benztropine (Cogentin) D. Lorazepam (Ativan)

C-Benztropine is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for EPS. Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic medications.

2. The client hears the word "match." The client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? A. Word salad B. Clang association C. Loose association D. Ideas of reference

C-Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern.

A client is admitted with a diagnosis of brief psychotic disorder, with catatonic features. Which symptoms are associated with the catatonic specifier? A. Strong ego boundaries and abstract thinking B. Ataxia and akinesia C. Stupor, muscle rigidity, and negativism D. Substance abuse and cachexia

C-Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors.

The catatonic features specifier

Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder.

Features that have led to the most positive results include:

Clearly defining goals and how they will be measured. Attaching positive, negative, and aversive reinforcements to adaptive and maladaptive behavior. Using simple, concrete instructions and prompts to elicit the desired behavior. Social skills training is used to help clients manage struggles with interpersonal relationships and communication Social dysfunction is a hallmark of schizophrenia. Impairment in interpersonal relations is included as part of the defining diagnostic criteria for schizophrenia in the DSM-5. Considerable attention is now being given to enhancement of social skills in these clients.

Sense of self.

Clients with schizophrenia may lack a feeling of uniqueness and experiences a great deal of confusion regarding his or her identity.

4. To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? A. Reinforce the perceptual distortions until the client develops new defenses. B. Provide an unstructured environment. C. Avoid making connections between anxiety-producing situations and hallucinations. D. Distract the client's attention.

D-The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to reality-based activities.

Discuss delusional disorder.

Delusional disorder is characterized by the presence of delusions that have been experienced for at least 1 month. Hallucinations are not prominent, and behavior is not bizarre.

Positive symptoms -Content of thought

Delusions: False personal beliefs Religiosity: Excessive demonstration of obsession with religious ideas and behavior Paranoia: Extreme suspiciousness of others Magical thinking: Ideas that one's thoughts or behaviors have control over specific situations DMPR

Nursing Process: Diagnosis/Outcome Identification

Disturbed Sensory Perception (auditory and visual) related to panic anxiety, extreme loneliness, and withdrawal into self Disturbed Thought Processes related to inability to trust, panic anxiety, or possible hereditary or biochemical factors Social Isolation related to inability to trust, panic anxiety, weak ego development, delusional thinking, regression Risk for Violence: Self-directed or Other-directed related to -Extreme suspiciousness -Panic anxiety -Catatonic excitement -Rage reactions -Command hallucinations Impaired Verbal Communication related to -Panic anxiety -Regression -Withdrawal -Disordered unrealistic thinking Self-Care Deficit related to -Withdrawal -Regression -Panic anxiety -Perceptual or cognitive impairment -Inability to trust Disabled Family Coping related to difficulty coping with client's illness Ineffective Health Maintenance related to disordered thinking or delusions Impaired Home-Maintenance related to -Regression -Withdrawal -Lack of knowledge or resources -Impaired physical or cognitive functioning

Describe the psychological factors related to schizophrenia.

Early conceptualizations of schizophrenia focused on family relationship factors as major influences in the development of the illness, but researchers now focus their studies in terms of schizophrenia as a brain disorder. Even though family relationships are not involved in the etiology of the illness, the symptoms in schizophrenia can contribute to significant disruption in communication and relationships among family members so psychosocial factors should always be part of a comprehensive assessment.

Physiological influences -Various physical conditions:

Epilepsy Huntington's disease Birth trauma Head injury in adulthood Alcohol abuse Cerebral tumor Cerebrovascular accident Systemic lupus erythematosus Myxedema Parkinsonism Wilson's disease

Social treatments

Family therapy: Aimed at helping family members cope with long-term effects of the illness

Schizophrenia is probably caused by a combination of factors, including

Genetic predisposition Biochemical dysfunction Physiological factors Psychosocial stress

Perception. -Auditory hallucinations -visual hallucinations -tactile hallucinations -Gustatory hallucinations -Olfactory hallucinations

Hallucinations may involve any of the five senses. Types of hallucinations include the following: Auditory hallucinations are false perceptions of sound. Most commonly they are of voices, but the individual may report clicks, rushing noises, music, and other noises. "Voices" that issue commands for violence to self or others may or may not be heeded by the psychotic person. Auditory hallucinations are the most common type. Visual hallucinations may consist of formed images, such as of people, or of unformed images, such as flashes of light. Tactile hallucinations are false perceptions of the sense of touch, often of something on or under the skin. One specific tactile hallucination is formication, the sensation that something is crawling on or under the skin. Gustatory hallucinations are false perceptions of taste. Most commonly, gustatory hallucinations are described as unpleasant tastes. Olfactory hallucinations are false perceptions of the sense of smell. Illusions differ from hallucinations in that they are are misperceptions or misinterpretations of real external stimuli.

Evaluation questions

Has client established trust with at least one staff member? Is anxiety level maintained at a manageable level? Is delusional thinking still prevalent? Is client able to interrupt escalating anxiety with adaptive coping mechanisms? Is client easily agitated? Is client able to interact with others appropriately?

In the final step of the nursing process, a reassessment is conducted in order to determine if the nursing actions have been successful in achieving the objectives of care. Evaluation of the nursing actions for the client with schizophrenic psychosis may be done by utilizing the following questions:

Has the client established trust with at least one staff member? Is the anxiety level maintained at a manageable level? Is delusional thinking still prevalent? Is hallucinogenic activity evident? Does the client share content of hallucinations, particularly if commands are heard? Is the client able to interrupt escalating anxiety with adaptive coping mechanisms? Is the client easily agitated? Is the client able to interact with others appropriately? Does the client voluntarily attend therapy activities? Is verbal communication comprehensible? Is the client compliant with medication? Does the client verbalize the importance of taking medication regularly and on a long-term basis? Does he or she verbalize understanding of possible side effects, and when to seek assistance from the physician? Does the client spend time with others rather than isolating self? Is the client able to carry out all activities of daily living independently? Is the client able to verbalize resources from which he or she may seek assistance outside the hospital? Does the family have information regarding support groups in which they may participate, and from which they may seek assistance in dealing with their family member who is ill? If the client lives alone, does he or she have a source for assistance with home maintenance and health management?

Volition.

Impaired volition has to do with the inability to initiate goal-directed activity. In the individual with schizophrenia, this may take the form of inadequate interest, motivation, or ability to choose a logical course of action in a given situation.

Interpersonal Functioning and Relationship to the External World.

Impairment in social functioning may be reflected in social isolation, emotional detachment, and lack of regard for social convention. Some clients with acute schizophrenia cling to others and intrude on the personal space of others, exhibiting behaviors that are not socially and culturally acceptable. Individuals with schizophrenia sometimes focus inward on themselves to the exclusion of the external environment. Some individuals lack awareness of there being any illness or disorder even when symptoms appear obvious to others. The term for this is "anosognosia".

Negative symptoms -Volition:

Impairment in the ability to initiate goal-directed activity -Emotional ambivalence: Coexistence of opposite emotions toward same object, person, or situation -Deterioration in appearance: Impaired personal grooming and self-care activities

Persecutory Type.

In persecutory delusions, which are the most common type, individuals believe they are being persecuted or malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged. Repeated complaints may be directed at legal authorities, lack of satisfaction from which may result in violence toward the object of the delusion.

Phase III: Schizophrenia.

In the active phase, psychotic symptoms are prominent. The DSM-5 diagnostic criteria for schizophrenia includes the presence of delusions, hallucinations, disorganized speech and behavior, or negative symptoms, as well as decreased level of functioning in areas of work, personal relationships, or self-care. The full DSM diagnostic criteria can be found in the text.

Discuss the role of psychological treatments for clients with schizophrenia.

Individual recovery-oriented psychotherapy and cognitive therapies are evidence-based interventions in the treatment of the client with schizophrenia but these should be adjunct to a multi-faceted team approach. The primary focus in all cases must reflect efforts to decrease anxiety and increase trust. Once a therapeutic interpersonal relationship has been established, reality orientation is maintained through exploration of the client's behavior within relationships. Group therapy for individuals with schizophrenia has been shown to be effective, particularly with outpatients and when combined with drug treatment. Group therapy in inpatient settings is less productive. Inpatient treatment usually occurs when symptomatology and social disorganization are at their most intense. At this time, the least amount of stimuli possible is most beneficial for the client.

Grandiose Type.

Individuals with grandiose delusions have irrational ideas regarding their own worth, talent, knowledge, or power. They may believe that they have a special relationship with a famous person, or even assume the identity of a famous person. Grandiose delusions of a religious nature may lead to assumption of the identity of a deity or religious leader.

Somatic Type.

Individuals with somatic delusions believe they have some type of general medical condition.

Jealous Type.

Jealous delusions center on the idea that the person's sexual partner is unfaithful. The idea is irrational and without cause, but the individual with the delusion searches for evidence to justify the belief. The sexual partner is confronted regarding the imagined infidelity..

Describe the environmental factors related to schizophrenia.

Many studies have been conducted that have attempted to link schizophrenia to social class. Statistics have shown that greater numbers of individuals from the lower socioeconomic classes experience symptoms associated with schizophrenia. Explanations for this occurrence include the conditions associated with living in poverty, such as congested housing accommodations, inadequate nutrition, absence of prenatal care, few resources for dealing with stressful situations, and feelings of hopelessness for changing one's lifestyle of poverty. An alternative view is that of the downward drift hypothesis, which suggests that, because of the characteristic symptoms of the disorder, individuals with schizophrenia have difficulty maintaining gainful employment. Proponents of this view consider poor social conditions to be a consequence rather than a cause of schizophrenia.

Discuss psychotic disorder due to another medical condition.

Medical conditions such as CNS infections, hypo- or hyper-thyroidism, migraine headaches, and renal disease can cause psychotic symptoms such as prominent hallucinations and delusions. A more comprehensive list of medical conditions that can cause psychotic symptoms can be found in Table 15-2 in the text. Note that this diagnosis should not be made if the symptoms occur during the course of delirium.

Describe planning and implementation stages of the nursing process for a client with schizophrenia.

NANDA International has resigned disturbed sensory perception as a nursing diagnosis, but it is retained here because of its appropriateness in describing specific behaviors. The diagnosis may be defined as sensory perceptions that are inconsistent with external stimuli and may include auditory, visual, tactile, olfactory, or gustatory perceptions. Goals for treating disturbed sensory perception include discussing hallucinations, helping the client define and test reality, and verbalizing an understanding that the hallucinations are a result of the client's illness. Interventions to achieve these goals include an attitude of acceptance, distracting the client from the hallucinations, and avoiding reinforcement of the hallucinations.

Discuss negative symptoms for a client with schizophrenia.

Negative symptoms reflect a diminution or loss of normal functions. Atypical antipsychotics have been advanced as being more effective in treating negative symptoms but researchers continue to search for medications to treat cognitive deficits that can be problematic for patients with schizophrenia. These deficits include memory, attention, language, and executive functions and have been identified as particularly problematic for individuals with regard to overall functional ability.

Describe the differences between schizophrenia and other mental illnesses.

Of all the mental illnesses, schizophrenia is probably responsible for lengthier hospitalizations, greater chaos in family life, more exorbitant costs to individuals and governments, and more fears than any other. Because of this threat to life and happiness and its relatively unknown causes, it has probably been studied more than any other mental disorder. Potential for suicide is a major concern among patients with schizophrenia. About one-third of people with schizophrenia attempt suicide and about 1 in 10 die from the act.

Phase I: The Premorbid Phase.

Premorbid signs are those that occur before there is clear evidence of illness and may include distinctive personality traits or behaviors. Traits that have been noted include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior.

Phase II: The Prodromal Phase.

Prodromal symptoms more clearly manifest as signs of the developing illness of schizophrenia. The prodromal phase of schizophrenia begins with a change from premorbid functioning and extends until the onset of psychotic symptoms. This phase can be brief, but most studies indicate that the average length of the prodromal phase is between two and five years. During this phase the individual begins to show signs of significant deterioration in function. Social withdrawal is not uncommon. Some adolescent patients develop sudden onset of obsessive compulsive behavior. Recognition of the behaviors associated with the prodromal phase provides an opportunity for early intervention with a possibility for improvement in long-term outcomes.

Psychotic disorder associated with another medical condition

Prominent hallucinations and delusions are directly attributable to a general medical condition.

Extrapyramidal symptoms (EPS) include

Pseudoparkinsonism Akinesia Akathisia Dystonia Oculogyric crisis: eyes go up and are fixed back PAODA Antiparkinsonian agents may be prescribed to counteract EPS. -benzotropine -artane

Define psychosis.

Psychosis is severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact with, or distortion of, reality. There may be evidence of hallucinations and delusional thinking. Psychosis can occur with or without the presence of organic impairment.

Phase IV

Residual phase

Schizophreniform disorder

Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months

Phase III

Schizophrenia

Phase IV: Residual Phase.

Schizophrenia is characterized by periods of remission and exacerbation. A residual phase usually follows an active phase of the illness. During this phase, symptoms of the active phase are either absent or no longer prominent. Negative symptoms may remain, and residual impairment often increases between episodes of active psychosis.

Theoretical integration

Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment.

Schizoaffective disorder

Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders either mania or depression

In the first step of the nursing process, the nurse gathers a database from which nursing diagnoses are derived and a plan of care is formulated. Discuss positive symptoms for a client with schizophrenia.

Symptoms of schizophrenia are commonly described as positive or negative. Positive symptoms tend to reflect an alteration or distortion of normal mental functions. Positive symptoms are associated with normal brain structures on computed tomography scan and relatively good responses to treatment. Content of Thought. The client continues to have delusions in spite of obvious proof that the beliefs are false or irrational. Delusions are subdivided according to their content. Common types include delusions of persecution, delusions of grandeur, delusions of reference, delusions of control or Influences, somatic delusions, or nihilistic delusions. Individuals with paranoia have extreme suspiciousness of others and of their actions or perceived intentions. Magical thinking describes when the client believes that his or her thoughts or behaviors have control over specific situations or people.

Types of Schizophrenia and Other Psychotic Disorders: Delusional Disorder

The existence of prominent, nonbizarre delusions -Erotomanic type -Grandiose type -Jealous type -Persecutory type -Somatic type -Mixed type

Discuss schizophreniform disorder.

The features of this disorder are identical to those of schizophrenia, but the duration (including prodromal, active, and residual phases) is between 1 and 6 months. If the diagnosis is made while the individual is still symptomatic but has been so for less than 6 months, it is qualified as "provisional." The diagnosis is changed to schizophrenia if the clinical picture persists beyond 6 months.

Negative symptoms Affect:

The feeling state or emotional tone -Inappropriate affect: Emotions are incongruent with the circumstances -Bland: Weak emotional tone -Flat: Appears to be void of emotional tone -Apathy: Disinterest in the environment

Discuss the role of social treatments for clients with schizophrenia.

The importance of the expanded role of family in the aftercare of relatives with schizophrenia has been recognized, thereby stimulating interest in family intervention programs designed to support the family system, prevent or delay relapse, and help to maintain the client in the community. These psychoeducational programs treat the family as a resource rather than a stressor, with the focus on concrete problem solving and specific helping behaviors for coping with stress. These programs recognize the biological basis for schizophrenia and the impact that stress has on the client's ability to function.

Subtypes include: Erotomanic Type.

The individual believes that someone, usually of a higher status, is in love with him or her. Famous persons are often the subjects of erotomanic delusions.

Describe the biological factors related to schizophrenia.

The lifetime risk for developing schizophrenia is about 1 percent, but studies show the siblings of a client with schizophrenia have a 10 percent risk and offspring with one parent with schizophrenia have a 5 to 6 percent chance. How schizophrenia is inherited is uncertain and no definitive biological marker has been found. Studies are ongoing to determine which genes are important in the vulnerability to schizophrenia, and whether one or many genes are implicated.

Premorbid behavior of the patient with schizophrenia can be viewed in four phases.

The pattern of development of schizophrenia may be viewed in four phases: the premorbid phase, the prodromal phase, the active psychotic phase (schizophrenia), and the residual phase.

Substance-induced psychotic disorder

The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal

Introduce schizophrenia.

The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The word was derived from the Greek "skhizo" (split) and "phren" (mind). Over the years, much debate has surrounded the concept of schizophrenia. Various definitions of the disorder have evolved, and numerous treatment strategies have been proposed, but none have proven to be uniformly effective or sufficient.

Positive symptoms -Sense of self: -echolalia -echopraxia -identification and imitation -depersonalization

The uniqueness and individuality a person feels -Echolalia: Repeating words that are heard -Echopraxia: Repeating movements that are observed -Identification and imitation: Taking on the form of behavior one observes in another -Depersonalization: Feelings of unreality

Catatonic disorder associated with another medical condition

This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition.

Discuss schizoaffective disorder.

This disorder includes symptoms of schizophrenic behaviors, with strong symptoms also associated with mood disorders (depression or mania). The client may appear depressed, with psychomotor retardation and suicidal ideation, or symptoms may include euphoria, grandiosity, and hyperactivity. The decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode. Prominent mood disorder symptoms must be evident for a majority of the time.

Discuss substance-induced psychotic disorder.

This disorder involves prominent hallucinations and delusions which are directly attributable to substance intoxication, withdrawal, after exposure to a medication or toxin. When the symptoms are more severe than those typically found in intoxication or withdrawal syndrome, this diagnosis is made. The medical history, physical examination, or laboratory findings provide evidence that the appearance of the symptoms occurred in association with a substance intoxication or withdrawal or exposure to a medication or toxin. A list of substances that are believed to induce psychotic disorders can be found in Table 15-1 in the text.

Psychopharmacology -Antipsychotics

Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders

Structural brain abnormalities have been observed in individuals with schizophrenia. What is the most consistent finding?

Ventricular enlargement is the most consistent finding; however, some reductions in gray matter are also reported. Magnetic resonance imaging (MRI) has revealed reduced symmetry in several lobes of the brain and reductions in size of structures within the limbic system, in clients with schizophrenia.

The DSM-5 identifies a spectrum of psychotic disorders that are organized to reflect

a gradient of psychopathology from least to most severe.

The client with schizophrenia often demonstrates

an indifference to or disinterest in the environment. The bland or flat affect is a manifestation of the emotional apathy.

Typical antipsychotics work by

blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. They also demonstrate varying affinity for cholinergic, alpha1-adrenergic, and histaminic receptors. Antipsychotic effects may also be related to inhibition of dopamine-mediated transmission of neural impulses at the synapses.

The recovery model has been used primarily in

caring for individuals with serious mental illness, such as schizophrenia and bipolar disorder. However, concepts of the model are amenable to use with all individuals experiencing emotional conditions with which they require assistance and who have a desire to take control and manage their lives more independently.

No single theory or hypothesis supports a

clear-cut explanation for the disease. The more research that is conducted, the more evidence is compiled to support the concept of multiple causation in the development of schizophrenia.

Schizophrenia requires treatment that is

comprehensive and presented in a multidisciplinary effort.

With schizophrenia, there is a severe

deterioration of social and occupational functioning.

Some studies have reported a link between schizophrenia and

epilepsy, Huntington's disease, birth trauma, head injury in adulthood, alcohol abuse, cerebral tumor (particularly in the limbic system), cerebrovascular accidents, systemic lupus erythematosus, myxedema, parkinsonism, Wilson's disease, and various hormonal deficiencies.

Assertive Community Treatment (ACT) is an

evidence-based program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia. Assertive programs of treatment are individually tailored for each client, intended to be proactive, and include the teaching of basic living skills, helping clients work with community agencies, and assisting clients in developing a social support network. There is emphasis on vocational expectations, and supported work settings (i.e., sheltered workshops) are an important part of the treatment program. Other services include substance abuse treatment, psychoeducational programs, family support and education, mobile crisis intervention, and attention to health care needs.

Weiden identifies two types of recovery with schizophrenia:

functional and process. Functional recovery focuses on the individual's level of functioning in such areas as relationships, work, independent living, and other kinds of life functioning. He or she may or may not be experiencing active symptoms of schizophrenia.

Schizophrenia is probably not a

homogeneous disease entity.

This excess activity may be related to

increased production or release of the substance at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms.

Perception:

interpretation of stimuli through the senses

Symptoms generally appear in

late adolescence or early adulthood, although they may occur in middle or late adult life.

Catatonic disorder is also associated with medical conditions including

metabolic disorders (such as hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) and neurological conditions (such as epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis).

Personal grooming and self-care activities may be

neglected. The client with schizophrenia may appear disheveled and untidy and may need to be reminded of the need for personal hygiene.

Various other biochemicals have been implicated in the predisposition to schizophrenia. Abnormalities in the neurotransmitters

norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric acid and in the neuroregulators, such as prostaglandins and endorphins, have been suggested.

In the active phase of the disorder, psychotic symptoms are

prominent. -Delusions -Hallucinations -Impairment in work, social relations, and self-care

The effect of autoimmune antibodies in the brain is being studied within the field of

psychoneuroimmunology and suggests that these may be responsible for the development of at least some schizophrenias following infection from a neurotoxic virus.

A client with schizophrenia may

repeat words that he or she hears, which is called echolalia. This is an attempt to identify with the person speaking.

Excess of serotonin has been hypothesized to be

responsible for both positive and negative symptoms of schizophrenia and the effectiveness of medications like clozapine lends support to this idea.

The most current theory seems to be that

schizophrenia is a biologically based disease, the onset of which is influenced by factors within the environment.

The dopamine hypothesis suggests that

schizophrenia may be caused by an excess of dopamine-dependent neuronal activity in the brain.

There is not a

single treatment that cures the disorder and effective treatment requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care such as living skills and social skills training, rehabilitation and recovery, and family therapy.

The cause of schizophrenia is

still uncertain. No single factor can be implicated in the etiology, but instead, the disease probably results from a combination of factors.

The Diagnostic and Statistical Manual of Mental Disorders supports this by describing schizophrenia as

the schizophrenia spectrum. Schizophrenia spectrum disorders may have several causative factors including genetic predisposition, biochemical dysfunction, physiological factors, and psychosocial stress.

Atypical antipsychotics are

weaker dopamine receptor antagonists than the conventional antipsychotics, but are more potent antagonists of the serotonin (5-hydroxytryptamine) type 2A (5HT2A) receptors. They also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors.

Identification,

which occurs on an unconscious level, and imitation, which occurs on a conscious level, are ego defense mechanisms used by individuals with schizophrenia and reflect their confusion regarding self-identity. Because they have difficulty knowing where their ego boundaries end and another person's begins, their behavior often takes on the form of that which they see in the other person.

Negative symptoms Psychomotor behavior

-Anergia: Deficiency of energy -Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions -Posturing: voluntary assumption of inappropriate or bizarre postures -Pacing and rocking: Pacing back and forth and rocking the body

Management of the illness

-Connection of exacerbation of symptoms to times of stress -Appropriate medication management -Side effects of medications -Importance of not stopping medications -When to contact health-care provider -Relaxation techniques -Social skills training -Daily living skills training

Describe the prognosis of clients with schizophrenia.

A complete return to full premorbid functioning is not common, however, several factors have been associated with a more positive outcome. These factors include good premorbid functioning, later age at onset, female gender, abrupt onset of symptoms with obvious precipitating factor, associated mood disturbance, rapid resolution of active-phase symptoms, minimal residual symptoms, absence of structural brain abnormalities, normal neurological functioning, and no family history of schizophrenia.

Prognosis

A return to full premorbid functioning is not common

Affect.

Affect describes the behavior associated with an individual's feeling state or emotional tone. Affect is inappropriate when the individual's emotional tone is incongruent with the circumstances. -Affect is described as bland or flat when the emotional tone is very weak.

Hallucinations:

False sensory perceptions not associated with real external stimuli -Auditory -Visual -Tactile -Gustatory -Olfactory

Illusions:

Misperceptions of real external stimuli

Phase I

Premorbid phase

Phase II

Prodromal phase

Mixed Type.

When the disorder is mixed, delusions are prominent, but no single theme is predominant.

The unstable self-identity of an individual with schizophrenia may lead to

feelings of unreality, for example feeling that one's extremities have changed in size; or a sense of seeing oneself from a distance.

Ambivalence in the client with schizophrenia refers to

the coexistence of opposite emotions toward the same object, person, or situation. These opposing emotions may interfere with the person's ability to make even a very simple decision.

Behavior modification has a history of qualified success in reducing

the frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate behaviors.