1. Elisa A. Mancuso RNC, MS, FNS Professor
Schizophrenia
Elisa A. Mancuso RNC, MS, FNS
Professor

2. 3 million people (1.5 % of Population) Costs $ 35 billion
Onset late adolescence or early adulthood
Men women & > 50
Psychotic disorders with disturbances in:
Thought processes
Perceptions
Expression of feelings

3. Indicators Psychotic Symptoms Deterioration in functioning
Preoccupied with own thoughts and feelings
Deterioration in functioning
Role, ADLs, Interpersonal relationships
6 month duration of symptoms
Bleuler’s 4 As
Autism
Affect
Associative Looseness
Ambivilance

4. Etiology Genetic Biochemical Abnormal marker gene on chromosome # 5
Heredity determines one’s predisposition
Both parents schizophrenic = % ↑↑ risk
Identical twins = % ↑↑ risk for sibling
Biochemical
Altered Neuroanatomy ▲s in cortex
↑↑ DA activity (2x DA receptors) = Psychosis
↓ AcH = ↑ Confusion,
↓ NE = Anhedonia
↑ 5-HT = ↑ Aggressive tendencies
↓Glutamate = learning & memory
↓Glucose metabolism & ↓ GABA

5. Psychological Poor early mother-child relationship ↓ Ego boundaries
“Trust vs Mistrust”
↓ Ego boundaries
Dysfunctional family system
Double-bind communication
Say one thing but mean the opposite
Environment
↓ Socioeconomic = ↑ stress & ↓ ↓ resources
Stressful life events precipitate onset!

6. Pre Schizophrenia Schizoid Personality Isolate themselves, “loners”
Indifferent, cold, aloof
↓ Range of emotional expression
Don’t enjoy close relationships
Prodromal “Pre-Schizophrenic”
Socially withdrawn- Blunted affect
Eccentric behavior & Bizarre ideas
Unusual perceptual experiences
↓ Role performance ↓ADLs

7. Active Schizophrenia Prominent psychotic symptoms >6 months
Delusions
False, fixed belief
Grandiose, Persecutory, Paranoia, Religiosity
Hallucinations
False sensory perception
Ideas of Reference
Disorganized Behavior
Impaired work, social relations & self care
Disorganized Speech
Associative Looseness
Clanging Echolalia Word Salad
Poverty of Speech Neologisms

8. Active Schizophrenia Secondary Symptoms
Anxiety Substance Abuse (ETOH, coke)
Depression > 25%
↑↑ Suicide (10%) = Leading cause of death
Compulsive H2O drinking 4-10 L/day
H2O intoxication
↓ Na = Lightheaded Lethargy Muscle cramps
N & V
Confusion
Coma

9. Residual Schizophrenia
Periods of remissions & exacerbations
Similar to Prodromal phase
Social withdrawal
Flat affect
Impaired Role Performance

10. Paranoid Schizophrenia
Preoccupied - 1 or more delusions
Persecution or Grandeur
Related auditory hallucinations
Argumentative
Hostile
Aggressive
Tense
Suspicious
Hypervigilent

11. Disorganized Hebephrenic Schizophrenia
Onset before age 25
Chronic flat, inappropriate affect
Silliness, giggling, masturbating in public
Bizarre behavior
Facial grimacing & mannerisms
Impaired social interaction
↓ Contact with reality
Incoherent speech & concrete thinking

12. Catatonic Schizophrenia
Least common
Sudden onset & good prognosis
Catatonic Excitement
Extreme psychomotor agitation
Purposeless movements – Echopraxia
↑ risk of injury to self/others
Continuous incoherent shouting – Echolalia
Catatonic Stupor
Extreme psychomotor retardation
Mute & Waxy Flexibility (Bizarre posturing)

13. Undifferentiated Chronic Schizophrenia
Disorganized-bizarre behavior
Usually docile and not aggressive
Does not meet criteria of other subtypes
Delusions & Hallucinations are prominent

14. Residual Schizophrenia (Pseudo-neurotic)
Follows an acute episode
Absence of prominent symptoms
No delusions or hallucinations
Social isolation
Poor Grooming
Eccentric behavior
Emotional Blunting

15. Schizoaffective Disorder
2 week period of predominant psychotic episode (↑ incidence in women)
Delusions Hallucinations
Disorganized behavior
↑ Sexuality Racing thoughts
Mood Disorder (affective) behaviors
Mania – Euphoria
Grandiosity & Hyperactivity
Depression –
Psychomotor retardation & suicidal ideation
↓↓ Occupational & social functioning

16. Characteristics Positive Negative
Excess or distorted inappropriate behaviors
Disorganized thinking
Not seen in mentally healthy adults!
Negative
Loss or decrease of appropriate function
Diminished emotional expression
Anhedonia
Apathy
Poverty of thoughts

17. Characteristics Negative Positive Concrete thinking Delusions
Avolition
Catatonic Stupor
Social withdrawal
Poverty of speech
Flat affect
Anhedonia
Positive
Delusions
Hallucinations
Echopraxia
Echolalia
Neologisms
Associative Looseness
Flight of Ideas

18. Assessment Mental Status Exam (Provides baseline data)
Appearance & General Health
Dress Grooming Facial Expression
Eye Contact Motor Behavior Posture
Speech
Pace Spontaneity Volume
Tone & Modulation Clarity Interruptions
Level of Consciousness
General Responsiveness Sensorium
Emotional State
Mood Affect Intensity Appropriateness
Cognitive Function
Thought Process Content Perceptions
Concentration Abstract Thinking Insight/Judgment

19. Nursing Interventions
Primary Goal = Patient Safety
Establish trust & listen closely
Accepting attitude & Keep promises
Calm approach & non-threatening environment
Prevent violence & ↓ Anxiety
Clarify & reinforce reality
Orient to here & now
Address physical needs
↑ Self esteem

20. Psychotic Symptom Interventions
Delusions
Accept experience, identify content & triggers
Encourage reality oriented conversation
Use distraction & refocus
Role model coping techniques to ↓ anxiety
Hallucinations
Focus on the behavioral cue
(laughing, talking, turning head)
Have Pt describe what is happening
Identify environmental & emotional triggers
To prevent aggressive responses
Avoid touching without 1st warning

21. Psychotic Symptom Interventions
Impaired Communication
Role model clear communication
Use simple, concrete statements
Seek clarification & validate content
Vebalize the implied
Paranoia
↓ Environmental stimulation
Maintain eye contact
Provide plenty of personal space
Always announce your presence
↓ Impulsivity
“Time Outs” for rest

22. Psychotic Symptom Interventions
Ritualism
Initiate conversation as ritual is performed
Assess for behavioral cues indicating ↑ anxiety
Negotiate a schedule for ritual & ADLs
Social Withdrawal
Convey nonverbal acceptance & worthiness
Provide brief & frequent 1:1 contacts
Initiate interaction & gradually expand social contacts
↑ Social skills training Rules & expectations
Cognitive Therapy ↑ Decision making
Regression
RN approaches Pt.
↑ Self-Esteem and encourage independent behavior

23. Antipsychotic (Neuroleptic) Meds
Major Tranquilizers
↑↑ Protein Binding (91-99%)
↓ Efficacy in men (1/3 relapse + 1/3 disabled)
Potency
High
Fluphenazine (Prolixin) [Decanoate IM q3 weeks]
Haloperidol (Haldol) [Decanoate IM q4 weeks]
Trifluroperazine (Stelazine)
Low
Chlorpromazine (Thorazine) * 1st drug 1950
Thioridazine (Mellaril)

24. Antipsychotic (Neuroleptic) Meds
Action
↓ Agitation ↓ Psychotic Symptoms
↓ + Behaviors (Delusions/Hallucinations)
Block DA receptors =↓ DA
Improves fine motor movement & coordination
Sensory integration & emotional behavior
Anticholinergic Effects (Autonomic NS)
Dry Mouth Blurred vision Constipation
Sedation Urinary Retention Photophobia
Orthostatic Hypotension Nasal Congestion

25. Antipsychotic (Neuroleptic) Meds
↑↑ Prolactin Levels
Sexual/Menstrual dysfunction
↓ Libido
Galactorrhea
Gynecomastia
↑ weight gain
Cognition
↓ Alertness ↓ Concentration
↓ Seizure threshold = ↑ Risk of seizures

26. Antipsychotic (Neuroleptic) Meds
ExtraPyramidal Side Effects (EPS)
↓↓ DA ↑↑ AcH Imbalance
↑↑ Incidence with ↑↑ potency meds
Prolixin, Haldol & Stelazine
Movement disorder
Dystonia
Pseudoparkinsonism
Akathesia
Tardive Dyskinesia

27. ExtraPyramidal Side Effects (EPS)
Dystonia
Quick onset 1st few hours or days
↑ Adolescent males < age 25
Acute spasms of tongue, face, neck & back
Hypertonia
Laryngospasm – Respiratory distress
Oculogyric Crisis- Rolling back of eyes
Torticolis- Head twisted to 1 side
Involuntary uncoordinated movements
RX: Benadryl mg IM/IV
Cogentin 1-2 mg IM

28. ExtraPyramidal Side Effects (EPS)
Pseudoparkinsonism
Appears within 1-5 days
↑ women & older Pts
Drooling, Pill-Rolling of thumb & finger
Mask-like face, Stooped Posture
Action Tremors
Shuffling gait with small steps
Muscle rigidity
Bradykinesia
Cogwheeling

29. Pseudoparkinsonism RX
Antiparkinson Meds
Give to counteract SE & toxic effects
Only given with documented S/S of EPS
Restore the balance of DA & Ach
↑↑DA ↓↓ACh
*Amantadine (Symmetrel) *Benzotropine (Cogentin)
Bromocriptine (Parlodel) *Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)

30. ExtraPyramidal Side Effects (EPS)
Akathesia
Appears days
Motor restlessness “Nervous Energy”
Jitteriness
Tapping feet constantly
Pacing
Rocking back & forth
Frequent position changes
RX: Inderal, Ativan or Valium

31. ExtraPyramidal Side Effects (EPS)
Tardive Dyskinesia
Slow & insideous process
Irreversible after several years of meds.
AIMS- Abnormal Inventory Movement Scale
Screen q 3 -6 months
Involuntary movements of
Limbs, trunk & face.
Bizarre facial movements
“Fly catching” with tongue
Lip smacking
Difficulty swallowing
Irregular respirations

32. Neuroleptic Malignant Syndrome (NMS)
Rare idiosyncratic reaction 1% young men
↑ Incidence with ↑↑ potency meds & ↓↓ DA
Abrupt onset & rapid progression
10% mortality rate
Signs
Severe muscle rigidity Hyperreflexia (+4)
Hyperthermia > Diaphoresis
Altered LOC → Stupor → Coma
↑↑ HR ↑↑ RR
CV Collapse & Respiratory failure = Fatal!

33. NMS Therapy Immediately D/C med!
Wait 2 weeks before starting new meds (Lithium)
NO Haldol or Thorazine
Cooling blanket O2 IV Fluids
Medications:
MSO4 (Morphine sulfate)
↓ pain & ↓ VS
Tylenol
↓ Temp and pain
Dantrolene (Dantrium)
muscle relaxant & ↓ Temp
Bromocriptine (Parlodel)
Dopaminergic = ↓ EPS toxicity

34. Atypical Medications Serotonin Dopamine Antagonists
Relieves (+) & (-) Behaviors
↓ EPS ↓ Prolactin
Clozapine (Clozaril)
Binds to 5-HT2, Alpha1,2, H1, & DA receptors
SE- National registry to monitor SEs!
Agranulocytosis
WBC < 3000 or ANC < 500 = D/C med!
Mandatory weekly CBC 1st 6 months
Then q other week
Drowsiness ↑Salivation ↑Dizziness
↑ HR ↑Weight
↑ Risk for IDDM Prolonged QT interval

35. Atypical Medications Risperidone (Risperdal) ↓↓ DA ↓ 5-HT ACh & NE
Readily absorbed
Active metabolite is clinically effective
Resperdal Consta 25 mg IM q 2 weeks SE
Sedation/Insomnia
Orthostatic Hypotension
↑↑ Appetite = Weight gain
Tardive Dyskinesia

36. Atypical Medications Olanzapine (Zyprexia) Quetiapine (Seroquel)
Antagonizes DA & 5-HT receptors
SE: Insulin Resistance
Quetiapine (Seroquel)
√ renal function
Ziprasidone (Geodon)
↓ Depression & Anxiety
√ EKG for prolonged QT wave
Paliperidone (Invega Sustenna)
IM q 4 weeks
Aripiprazole (Abilify)
DA system stabilizer PO & IM

37. Medication Administration
Schedule
Initially take meds in divided doses 2-4x/day
Non-compliant Pts:
Haldol decanoate IM q 4 weeks
Prolixin decanoate IM q 3 weeks
Resperdal Consta IM q 2 weeks
Invega Sustenna IM q 4 weeks
Efficacy
Takes 1- 4 weeks for significant response
Once symptoms are controlled ▲ HS ↓↓ SE
Dosage
Use lowest dosage to ↓ risk of Tardive Dyskinesia

38. Patient Teaching Medication Generic & trade name, dose, action & SE
Assess SE “How is medication working?”
Interventions & when to notify RN/MD
Carry card with Med ID
NO ETOH or illegal substances
Don’t stop taking drug abruptly
Don’t ▲ position rapidly

39. Patient Outcome Evaluation
Slow progress
Services are needed long-term (decades)
Set small achievable, short-term goals
Assess effective coping skills
Obtain Pt & family input
Pt. safety Communication skills
Social Skills Self-Esteem
Health Promotion
Medication compliance
Support system
Living in least restrictive setting