Nursing 217 Psychiatric/Mental Health Nursing

KC Carrigg, EdD, RN

SCHIZOPHRENIA (SCH)

Schizophrenia refers to a group of severe, disabling psychiatric

disorders. It is a disorder of the brain, like epilepsy or multiple sclerosis.

Although it is diagnosed in about 1% of the population, this illness

affects the individual, family, friends and the community.

While often referred to as a single disease, it is a spectrum of disorders,

with a broad range of symptoms. SCH is described as a psychotic
disorder- where the person’s behavior and thinking are disorganized.

Psychosis occurs when the person is unable to distinguish reality

from fantasy. When we see these symptoms sometimes our first
reaction is fear and discomfort. This can lead to alienation of the client
with SCH. By understanding the symptoms we will be better able to
show EMPATHY for these clients.

Onset SCH begins most often in the late teens or early twenties
both males and females. Males tend to have earlier onset of symptoms.
Childhood SCH, although rare, does occur.

COMORBID DISORDERS.

1. Substance abuse occurs in 50%+ of SCH clients. (Dual DX)

2. Nicotine dependence may be 70-90% (Dual DX). For many

clients with SCH the reward center in the brain functions below normal.
Nicotine stimulates this area. Since smoking may be one of the few
dependable sources of pleasure for clients, it is a challenge to motivate
clients to quit smoking.

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 3. Depressive symptoms with SCH may lead to suicide. Suicide is
the leading cause of premature deaths in this population.

It is estimated that 40-50% of this population experience suicide

ideation, make suicide attempts or both. Approximately ten percent are
successful suicides.

Because depression affects a majority of people with SCH it is essential

to include assessment for depression and suicide in clients diagnosed
with SCH.
 Depression may be a sign of a psychotic relapse
 Depression increases substance abuse
 Depression increases the likelihood of SUICIDE

4. Anxiety Disorders are present in more than half the people with
SCH (especially social anxiety disorders).

5. Obsessions and compulsions often occur because people are

preoccupied with the content of their delusions and may ruminate for
hours over their upsetting thoughts.

6. Alzheimer’s Disease with late onset SCH (diagnosed after the

age of 50+) there appears to be a high risk for this disease. In one study
(Brodaty, Sachdev, Koschera, Monk, & Cullen, 2003), 50% of the
subjects developed dementia between 1-5 years following a dx of SCH.

POSITIVE SYMPTOMS are symptoms that are present but should be

absent. Positive symptoms usually indicate that the client has lost touch
with reality.
1. Delusions are defined as false “fixed” belief systems that
cannot be corrected by reasoning. The use of logic to stop
delusional thinking is generally futile.

It is believed that delusions result from dysfunctions in the

information-processing circuits within and between the
hemispheres of the brain (Fontaine, 2009).

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 What type of delusions are the following?

“I have been given the power to work with President Obama to solve
the financial crisis.” (Grandiose)

“My friends and family want me to die. They follow me 24/7 and are
gathering evidence to harm me. (Persecution)

2. Hallucinations involve hearing, seeing, smelling, tasting or

touching things that aren’t actually present. Hallucinations
are usually unpleasant and can be extremely distressing. Some
clients with SCH do report their hallucinations are good and
helpful.

Auditory hallucinations occur in 60% (some other sources

have a range of 50-80%) of people with SCH. The voice seems
to come from an external source. Hallucinations have
considerable control over the person’s behavior.

Command hallucinations, if destructive can be “directives”

from the voices to hurt self or others.
“I have to cut myself or else someone will die.”

3. Thought Disorders and Speech Patterns Adapting to

surroundings and effective coping come not only from learned
responses, but also from the ability of the brain to organize
incoming information.

A thought disorder is difficulty comprehending what others

are saying. Often the client cannot interpret visual stimuli and
is unable to respond in a meaningful way. Thoughts come out
incoherent, fragmented, and disconnected.

Loose associations are a sign of disorganized thinking. Verbal

ideas change from one topic to another, there is no connection
between thoughts, and the person speaking is not aware that
the topics are unconnected.

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 4. Bizarre Behavior This may be shown by:
Dress/grooming
Rituals
Stereotyped behaviors such as sweeping the floors
Waxy flexibility

5. Concrete thinking the ability to think abstractly in impaired.

Example “An ounce of prevention is worth a pound of cure.”

NEGATIVE SYMPTOMS reflect the absence of normal

characteristics. The negative symptoms of SCH develop over a long
time. These are the symptoms that MOST INTERFERE WITH THE
INDIVIDUAL’S ADJUSTMENT AND ABILITY TO SURVIVE.
The presence of negative symptoms contributes to the person’s poor
functioning and social withdrawal.

1. Avolition/anergia or apathy is also listed as a lack of

motivation. The client will “Just sit” and spend time alone in
room. It is hard for the client to respond to questions. Minimal
self-care may occur which is observed by poor grooming.

2. Blunted or minimal emotional response is commonly seen in

SCH.

3. Flat or immobile facial expression refers to a motionless facial

expression or a blank look. The voice may be flat and toneless
as well.

4. Anhedonia is the inability to experience pleasure from

activities, etc. Social withdrawal is common.

5. Alogia refers to the reduction in amount or content of speech---

client may be SLOW to respond.

Sometimes it is difficult to distinguish negative symptoms from

depression.

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The positive and negative symptoms affect Behavioral, Affective,
Perceptual, Social functioning. Halter (2014) specifically discusses the
COGNITIVE symptoms of:
 Inattention, easily distracted
 Impaired memory
 Poor problem-solving skills
 Poor decision making skills
 Illogical thinking
 Impaired judgment.

ETIOLOGY OF SCH The etiology SCH presently support the view of

environmental factors and genetic susceptibility as causes. This is
referred to as the diathesis-stress model of schizophrenia.

SCH most likely occurs as a result of a combination of:

1. Inherited genetic factors

Sixty-five to 80% off susceptibility to SCH may have a genetic

component. NO SINGLE CHROMOSONE has been identified
as a risk factor for SCH.

Examples: One parent with SCH =10% risk

Both parents with SCH= 40-50% risk
Non-identical twins have 15% risk if one has SCH
Identical twins= 50% risk if one twin has SCH

2. Neurobiology

The dopamine theory states that excess dopamine is responsible

for psychotic symptoms.

Serotonin, Glutamate and Acetylcholine are also being studied in

relationship to the development of SCH

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 3. Brain Structure Abnormalities

Neurodevelopment studies suggest that there is abnormal brain

development with SCH. Some nerve cells migrate to the wrong area
when the brain is forming leaving small areas of the brain permanently
miswired. In some with SCH the neurons of the cortex may be deficient.

What is not known is whether these cells form normally and then
stop working or whether they are deformed from the beginning.

PET scans suggest reduced frontal lobe activity.

The above factors may alter the structures of the brain; affecting
neurotransmitter systems, and neural circuits.

Non-genetic risk factors Suggests that the psychosis of SCH is a final

common result of genetic, neurodevelopment, neurochemical, and
structural abnormalities. This is a multiple-hit model that suggests there
must be: Biological vulnerability and
Environmental risk factors which are then combined with
Psychological Changes or Life Event stressors that help to
trigger the onset of schizophrenia.

4. Psychological and Environmental factors may include life stressors,

rubella, infectious agents, obstetric complications, herpes simplex, and
exposure to toxins (pregnancy and birth related factors.) Fathers aged
35 or older.

NURSING PROCESS AND TREATMENT

SCH tend to develop psychotic symptoms an average of 12-24 months
before they get medical care. The interval between symptom onset and
the first treatment correlates with the speed and quality of the initial
treatment response and severity of negative symptoms. Clients treated
soon after diagnosis of SCH tend to respond more quickly and fully
than those who don’t begin drug therapy and treatment until later in
the disease course.

1. Self-assessment. Be aware of your reactions, feelings, and beliefs.

STIGMA regarding people with SCH can overwhelm the care
given and community care.

2. Psychopharmacology is the first line intervention.

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 a. In about 1% of clients on antipsychotic drugs “neuroleptic
malignant syndrome” may be seen. This life-threatening
condition leads to fever, extremely rigid muscles, and
altered consciousness. It may occur hours to months after
drug therapy starts or the dosage is increased.

b. Clients taking psychotropic medication are at a higher risk

for developing Metabolic Syndrome.

3. General nursing interventions for SCH clients

a. Establish trust and rapport.

Use an accepting, consistent approach.

Use clear language.

Do not tease or joke.

Maintain a sense of hope for possible improvement and

convey this to the patient.

Don’t use touch without telling the client exactly what you
plan to do.

b. Maximize the level of functioning

Assess the client’s ability to carry out activities of daily

living.

Avoid prompting dependence.

Reward positive behavior and work to increase client’s

sense of self responsibility in improving level of functioning.

c. Promote social skills

Encourage client to engage in meaningful interpersonal

relationships.

Provide support in assisting client to learn social skills.

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d. Ensure Safety

Maintain a safe milieu with minimal stimulation.

Monitor nutritional status of client.

Do a Suicide assessment and employ safety precautions as

needed.

If patient expresses homicidal thoughts initiate homicidal

precautions. Notify the staff, who will notify the physician
and potential victim. (Be sure to Document).

e. Keep it real

Engage the client in reality-oriented activities that involve

human contact (unless there is a threat/safety issue).

Provide reality-based explanations for distorted body images

or somatic complaints.

Clarify private language of patient—Tell client that you do

not understand what is being said. Let client know what part
of the conversation you do understand.

f. Deal with Hallucinations

If the client is hallucinating, explore the content of the

hallucination. If client has auditory hallucinations, determine
if they are command hallucinations that place the client or
others at risk. Let the client know you don’t hear the voices
but you know they are real for the client.

Avoid arguing about the hallucinations. If possible, change

the subject.

g. Promote client adherence and monitor drug therapy.

Administer medications on time to manage symptoms.

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 Encourage client to choose to continue with the medication
program to help prevent relapse.

If client is taking a drug that requires monitoring of blood

levels, stress the importance of returning to the clinic for
weekly monitoring—or as ordered.

Regularly assess the client for adverse drug effects.

Document and report these promptly.

h. Encourage family involvement.

Involve the family in client’s treatment and understanding

of disease. This may include psycho- education to help
family to better understand SCH.

Teach family members how to recognize an impending

relapse (such as nervousness, insomnia, decreased ability to
concentrate, and loss of interest).

Include health teaching and promotion with client/family.

THE RECOVERY MODEL

Mental health recovery is a journey of healing and transformation

enabling a person with a mental health problem to live a meaningful life
in a community of his or her choice while striving to achieve his or her
full potential (SAMHSA, 2010). Components of the Recovery Model
include:

1. Self-direction

2. Individualized and person centered

3. Empowerment

4. Holistic

5. Nonlinear

6. Strengths based approach

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 7. Peer support

8. Respect

9. Responsibility

10. Hope

(From: American Psychiatric Nurses Association --2011).

PROGNOSIS OF CLIENTS WITH SCH (rule of thumb)

1/3 of clients achieve significant and lasting improvement

1/3 of clients improve somewhat but have intermittent relapses and

residual disability

1/3 of clients become severely and permanently incapacitated.

During any given 1-year period the prognosis depends largely on the
client’s adherence with the prescribed medication regimen.

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 NURSING 217—PMHN

ANTIPSYCHOTIC MEDICATIONS

Schizophrenia may be a biological response to 1) the excess transmission of

dopamine, 2) the excess release of neurotransmitters or increase in dopamine
receptor responsiveness. Serotonin receptors may also play a role in
psychosis.

Antipsychotics allow client management in the community as well as in the

hospital. Noncompliance with medications usually precedes relapse.

The relapse rate for those who discontinue meds may be as high as 60-80%.

Antipsychotics drugs are given to help control the symptoms of psychosis

such as hallucinations, and bizarre or paranoid behavior. These drugs help to
calm the client, hopefully, without the reduction of client alertness.
Dependency does not occur with antipsychotic medications, but clients will
need to taper their use of these meds rather than stop abruptly.

DOPAMINE—much of the current evidence suggests that schizophrenia

involves excessive activation of D2 dopamine receptors. Antipsychotic
drugs are all strong blockers (antagonists) of D2 receptors in the limbic and
motor centers. When the meds are binding with the dopamine receptors the
client experiences a degree of indifference to both external and internal
stressful stimuli.

Antipsychotic meds act by entering dopaminergic synapses and competing

with dopamine. By blocking a majority of the D2 receptors, antipsychotic
meds reduce the symptoms of schizophrenia.

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ANTIPSYCHOTICS/NEUROLEPTICS

Antipsychotics are most often used for persons who experience psychotic
symptoms as a result of having some form of schizophrenia, severe
depression or bipolar disorder.

CONVENTIONAL (TYPICAL) FIRST GENERATION

ANTIPSYCHOTICS

Targets Dopamine (D2) receptor antagonists.

These drugs help to relieve the POSITIVE symptoms of schizophrenia.

REFER TO TABLE 12-5 IN YOUR TEXTBOOK FOR A LIST OF

ANTIPSYCHOTIC DRUGS.

Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Fluphenazine (Prolixin)
Trifluoperazine (Stelazine)
Thioridazine (Mellaril)

Selection is often made on the basis of major side effects.

EPS such as dystonia, akathisia, and pseudo parkinsonism may be treated by
lowering the dose or changing medications and prescribing antiparkinsonian
drugs.

ATYPICAL ANTIPSYCHOTICS (SECOND- GENERATION)

These have become the drugs of choice for treating SCH.

Second-generation antipsychotics block both dopamine D2 and Serotonin

(5-HT) receptors.

The atypical antipsychotics have a much lower risk for EPS than the First-
generation antipsychotics.

These drugs can diminish the NEGATIVE symptoms as well as the

POSITIVE symptoms of schizophrenia.

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The first atypical developed in the 1990’s was clozapine (Clozaril). Patients,
whose disorder did not show improvement with conventional drugs, showed
great improvements when given Clozaril.

While Clozapine is rarely associated with movement disorders, seizures do

occur in some persons, and 1% of patients develop bone marrow suppression
which may lead to fatal agranulocytosis. Because safe use of this drug
requires weekly monitoring of WBC for the first 6 months followed by
every two weeks for six months, and then monthly thereafter, the use of this
drug is declining.

While all antipsychotics cause weight gain, the second-generation drugs are
associated with obesity and its risk factors. Most tend to promote weight
gain and are more expensive than the typical antipsychotics. Some atypicals
show prolonged cardiac QT intervals that may lead to dangerous
arrhythmias.

Metabolic syndrome is more common with atypicals.

1. Elevated triglycerides cause insulin resistance which leads to

hyperglycemia.

2. Increased risk for Diabetes

3. Weight gain and increased appetite increase BMI

4. Apple shape or central obesity—the waist measurement (Girth) may be

more significant than the BMI

5. High blood pressure

6. Low HDL (referred to as good cholesterol) and higher cholesterol

readings

7. Atherosclerotic heart disease (cardiovascular disease)

SEE TABLE 12.5 IN TEXTBOOK FOR ATYPICAL

ANTIPSYCHOTICS.
Aripiprazole— Abilify
Ziprasidone— Geodon
Risperidone—Risperdol
Olanzapine—Zyprexia

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Clozapine—Clozaril
Quetiapine—Seroquel
Paliperidone— Invegra
Lurasidone— Latuda
Asenapine— Saphris
Iloperidone— Fanapt

Aripiprazole— Ability is sometimes referred to as a third generation

atypical. It is a dopamine system stabilizer, and has a good safety profile.
However, it may be less effective than some of the second-generation drugs.
It improves positive symptoms, negative symptoms, and cognitive functions
with minimal risk of EPS.
Weight gain is minimal with this drug.

EXTRAPYRAMIDAL SIDE EFFECTS

1. Dystonia—usually presents as painful muscle spasms that last anywhere

from a few seconds to days. These may involve any muscle group and are
most often seen in a few muscles at a time. Contractions of the neck,
(torticollis) and the facial muscles are most common. Clients usually present
with the head drawn forcefully to the side, with spasms of the mouth
muscles, or with fixed tongue protrusion.

These spasms are usually not life threatening unless the laryngeal muscles
are involved, which may cause the airway to be obstructed.

Oculogyric crisis may occur in which extraocular muscle spasm forces the
eyes into a fixed, usually upward gaze.

Dystonic reactions can occur within a few hours or days of starting the med,
stop fairly quickly when the med is DC’d and respond quickly to
intravenous diphenhydramine (Benadryl) or other anticholinergic
medications.

2. Akathisia is more common and affects both motor function and behavior.
Clients are physically restless and unable to sit still. Clients pace, shift their
weight from foot to foot and tap their feet. Upper extremities and face are
rarely involved. Some develop emotional changes, such as decreased ability
to concentrate along with euphoria and sometimes malaise, depression and
worsening psychosis. Compared to acute dystonia, akathisia occurs
somewhat later but rarely after six months. It sometimes lessens or stops

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without stopping the med but always goes away when the antipsychotic
medication is stopped.

3. Pseudoparkinsonism—or poverty of movement occurs in up to 40% of

clients treated with antipsychotics. Clients with Parkinson like akinesia
initiate very slowly any movement. In most cases symptoms resolve even if
the med is not DC’d. Clients with drug-induced symptoms respond well to
anticholinergic medication treatment.

4. Tardive dyskinesia is a troublesome movement disorder that is

commonly found in clients with schizophrenia who are maintained on
antipsychotics for long periods of time. The incidence is said to be 4% per
year, but is highest in older clients. Common symptoms are repetitive
smacking, chewing, grimacing, cheek puffing, and tongue protrusion.
Similar movements can involve the hands and tic like movements occur
including grunts or other vocal utterances.

NOTE: Dyskinesias have been reported in the early stage of treatment with
medications.

Tardive dyskinesia is often very resistant to treatment and permanently

stigmatizes clients who have the misfortune to develop symptoms that are
unresponsive to treatment. Early DX and treatment, including drug holidays
and decreased doses are the best courses of action.

Medications used to treat movement disorders include:

A. Anticholinergic
1. Trihexyphenidyl (Artane)

2. Benztropine (Cogentin)

B. Histamine Blocker—Diphenhydramine (Benadryl). Histamine

blockage is associated with weight gain.

The side effects include:

dry mouth
nasal dryness
urinary retention
constipation
blurred vision
sedation

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 orthostatic hypotension
decreased sweating

NEUROLEPTIC MALIGNANT SYNDROME (NMS)

Antipsychotic medications have been known to cause NMS. It is important
to be alert to this syndrome in any client taking an antipsychotic. NMS
occurs mostly with the use of first-generation drugs.

NMS is a rare potentially life-threatening situation. The onset of NMS varies

from early in treatment to after several months of therapy. Symptoms
include:
 Elevated temperature
 Unstable blood pressure
 Profuse sweating
 Dyspnea
 Muscle rigidity
 Incontinence

This syndrome can lead to death if it is not recognized and treated.

ANTICHOLINERGIC TOXICITY (AT)

The following link gives a great overview of AT:

Managing Anticholinergic Side Effects

http://ncbi.nlm.nih.gov/pmc/articles/PMC487008/

Additional Alerts:
1. Tagamet (cimetidine) an over-the-counter drug for dyspepsia may inhibit
the metabolism of antipsychotics resulting in increased levels and effects.

2. It is being suggested that Benadryl not be given to older clients, as side

effects may be significant.

3. Be sure that client is not pregnant before beginning meds.

4. Due to differing pharmacokinetics, women are more vulnerable than men

to weight gain secondary to antipsychotics and to metabolic syndrome. They
are also more vulnerable to hyperprolactinemia and QT prolongation.

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 References:

Fontaine, Karen L. (2009). Mental health nursing (6thed.).

Upper Saddle River, New Jersey: Pearson.

Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental

nursing (7th ed.). St Louis MO: Elsevier.

Mohr, Wanda K. (2006). Psychiatric mental health nursing.

Philadelphia: Williams & Wilkins.

Psychiatric nursing made incredibly easy. (2004).

Philadelphia: Lippincott & Williams.

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