1. Schizophrenia and Other Psychoses
Chapter 31
Schizophrenia and Other Psychoses

2. Learning Objectives
Compare the differences between a psychosis and other mental health disorders.
Describe the continuum of neurobiological responses.
Outline the signs and symptoms of psychosis in childhood, adolescence, and adulthood.
Discuss three theories related to the causes of schizophrenia and other psychoses.
Compare and contrast four subtypes of schizophrenia.

3. Learning Objectives
Describe the signs, symptoms, and behaviors exhibited by a person with schizophrenia.
Outline the main pharmacological treatments and mental health therapies for persons with schizophrenia.
Apply the therapeutic process to clients suffering from schizophrenia or another psychosis.
Plan three nursing responsibilities related to antipsychotic medications.

4. Schizophrenia and Other Psychoses
Psychosis
The inability to recognize reality, relate to others, or cope with life’s demands
The most common psychosis is schizophrenia.
Other psychotic disorders include the following:
Brief psychotic disorder
Delusional disorder
Psychoses related to medical conditions or drug use
Explain the differences between a psychosis and other mental health disorders.
Schizophrenia is not a single disorder, but rather a group of psychoses.
Schizophrenia involves the most complex and frightening symptoms. For example, individuals may hear voices, think other people or machines are controlling them, feel bugs crawling on their bodies, or believe other people are plotting against them.

5. Continuum of Neurobiological Responses
Neurobiological functions
Can be viewed as existing along a continuum of behavioral responses
Highly adaptive, effective responses
Maladaptive, even destructive behaviors
People who do not adapt as well are placed at the middle of the spectrum.
Describe the continuum of neurobiological responses.
Many people label individuals with schizophrenia as “schizophrenics.”
Is labeling appropriate? (Just as we do not label a person with cancer as “cancers” we should not label other disease states. If we do label, we imply that the disorder encompasses the individual’s entire being, but that is not the case. Although the disorder can be very serious, many people have mild cases and learn to cope with the symptoms and function effectively in society.)

6. Psychoses Throughout the Life Cycle
Psychoses in childhood
Failure to thrive syndrome
Slowed physical growth caused by an inability to integrate the physical, emotional, and sensorimotor realms of functioning
Related to neglect, environmental problems, and severe family stress
Risk factors for childhood schizophrenia
Genetic influences
Complications during pregnancy or birth
Biochemical imbalances
List and define the signs and symptoms of psychosis in childhood.

7. Psychoses Throughout the Life Cycle
Psychoses in adolescence
The average teen is in contact with reality; the adolescent with schizophrenia is not.
Changes in behavior are noted:
Poor hygiene
Strange, vague speech
Social withdrawal
Odd behaviors
Bizarre thoughts and beliefs
Unusual superstitions
List and define the signs and symptoms of psychosis in adolescence.

8. Psychoses Throughout the Life Cycle
Psychoses in adulthood
The onset of acute symptoms most often occurs in men during their middle 20s, while women usually present with symptoms in their late 20s.
The prognosis for individuals with schizophrenia is better if adaptive interpersonal relationships and acceptable school performance and work histories were in place before the onset of symptoms.
Can you think of a couple of factors that may contribute to the gender differences in the age of onset?

9. Psychoses Throughout the Life Cycle
Psychoses in older adulthood
Schizophrenia is seldom diagnosed in elderly people.
Elderly individuals with schizophrenia may spend the remainder of their days in long-term care facilities.
Remember that the acute onset of psychotic behavior in any elderly client must be investigated.
Can you think of a medication a patient may be taking for another disease that could induce psychotic behavior? (steroids) Ask for other examples.

10. Theories Related to Psychoses
Schizophrenia exists in all cultures and socioeconomic groups.
Biological theories
Stress/disease/trauma model
Addresses the effects of stress on the individual, especially during the prenatal period
Neurochemical models
Neurotransmitters such as serotonin, norepinephrine, and dopamine have been implicated as possible causes of schizophrenia.
What theories are related to the causes of schizophrenia and other psychoses?

11. Theories Related to Psychoses
Other theories
Psychological models
Schizophrenia is caused by a basic character flaw combined with poor family relationships.
Sociocultural theories
Effects of the environment may lead to the development of psychoses.

12. Psychotic Disorders Schizophrenia Subtypes of schizophrenia Catatonic
Disorganized
Paranoid
Undifferentiated
Residual
What are the differences between subtypes of schizophrenia?
Catatonic: characterized by a lack of or peculiar motor movements
Disorganized: showing the most psychological disorganization and lacking a systematic set of delusions
Paranoid: characterized by delusions of persecution
Undifferentiated: a “catchall” for people who do not fit into the other subtypes
Residual: a mild form that occurs after at least one schizophrenic episode; does not have prominent delusions hallucinations, etc.

13. Psychotic Disorders Schizophrenia Signs, symptoms, and behaviors
The main characteristic of psychotic disorders is loss of contact with reality to the point where functioning is grossly impaired.
The signs and symptoms of schizophrenia affect perception, physical appearance, cognitive processes, language, speech, emotions, behavior, and social realms.
Characteristic symptoms fall into two broad categories—positive and negative.
Positive symptoms relate to maladaptive thoughts or behaviors.
Negative symptoms relate to lack of adaptive mechanisms.
Describe the signs, symptoms, and behaviors exhibited by a person with schizophrenia.
If a patient presents with a variety of symptoms from all five categories, what would be the priority symptom to treat?
What characteristics would determine whether the patient requires an inpatient admission?

14. Psychotic Disorders Schizophrenia Phases of becoming disorganized
The course of schizophrenia is marked by episodes of acute psychosis alternating with periods of relatively normal functioning.
The symptoms of schizophrenia must occur for at least 1 year before a diagnostic label is assigned.
The slide into schizophrenia commonly occurs over four stages:
Prodromal phase
Prepsychotic phase
Acute phase
Remission

15. Psychotic Disorders Other psychoses Brief psychotic disorder
A psychotic disturbance that lasts longer than 1 day but less than 1 month
Delusional disorder
Characterized by more than 1 month of nonbizarre (reality-based) fixed ideas
Shared psychotic disorder
The individual is influenced by someone else who has an established delusion.
Schizoaffective disorder
When depression or mania is also present

16. Therapeutic Interventions
Goals of inpatient, short-term care include the following:
Stabilize the client.
Prevent further decline in functioning.
Assist the client in coping with his or her disorder.
Long-term goals include psychosocial and vocational rehabilitation.

17. Therapeutic Interventions
Pharmacological therapy
Antipsychotic or neuroleptic
Slow the central nervous system (CNS)
After an antipsychotic drug is taken, hallucinations and delusions decrease, thought processes change, and hyperactivity subsides.
What are the main pharmacological treatments and mental health therapies for persons with schizophrenia?

18. Therapeutic Interventions
Nursing process
Primary nursing diagnoses:
Disturbed thought processes
Disturbed sensory perceptions
Social isolation
Impaired communications
Ineffective management of therapeutic regimen
The basic goals of care are to assist clients in controlling their symptoms and achieving the highest possible level of functioning.

19. Therapeutic Interventions
Special considerations
The most common side effects of antipsychotic medications reflect alterations in CNS and peripheral nervous system functions:
Extrapyramidal side effects (EPSEs)
Sedation
Anticholinergic effects
Akathisia
Akinesia
Bradykinesia
Dyskinesia
Dystonia
Neuroleptic malignant syndrome

20. Therapeutic Interventions
Nursing responsibilities
Nurses should review desired actions, side effects, and incompatibilities for each medication prescribed.
Monitor client response to each medication.
Client and family education has a direct impact on the client’s level of functioning.
List the nursing responsibilities related to antipsychotic medications.
Discharge planning needs to include medication teaching.
Not taking medications correctly or not understanding the need for compliance leads to relapse of symptoms.