Psych Schizo

• Derived from the greek words Schizo (split) and phren (mind)
• Psychosis is a break from reality

Schizophrenia is not a split personality, caused by childhood trauma, bad parenting or poverty, and is not the result of any actions or personal failure

• Antipsychotic medications
• Psychotherapy
• Occupational therapy
• Social Skills therapy

• Substance abuse in up to 50% of clients
• Nicotine dependence up to 90%
• Schizo associated with negative outcomes such as incarceration, violence, suicide, and HIV
• Medications cause heart disease, DM
• Anxiety, depression
• High risk of suicide
• Polydipsia (risk of H2O poisoning and F/E imbalances. Fluid restriction necessary)

• Extra dopamine in the brain theory (dopamine blockers are effective)
• Gradual deterioration of brain volume, especially frontal cortex (visual/auditory hall)
• Genetic component linked
• Combination of both genetic and non genetic factors

• Thought processes
• Perception
• Affect

• Phase one: Pre-psychotic (schizoid personality)
• -indifferent, cold, aloof, loners
• -Do not enjoy personal relationships
• Phase two: Prodromal phase
• -often occurs before first psychotic break
• -socially withdrawn, behavior is peculiar and eccentric
• -Neglected personal hygiene
• -Disturbances in communication, ideation and perception
• -religiosity
• Phase three: Active phase
• -psychotic symptoms are prominent
• -Hallucinations and delusions
• Phase four: residual phase
• -also called the maintenance phase
• -similar to prodromal, near baseline
• -flat affect, role impairment

• Favorable if:
• -abrupt onset of goof pre-morbid functioning
• -female
• -older age of onset
• Less favorable if:
• -slower onset of symptoms 2-3 yrs
• -childhood history of withdrawal, seclusion, eccentric, tense behavior
• -younger onset
• -male

• Two or more of the following, each present during a one month period
• -delusions
• -hallucinations
• -disorganized speech
• -grossly disorganized or catatonic behavior
• -negative symptoms

• Positive symptoms
• Negative symptoms
• Cognitive symptoms
• Affective symptoms

• Affect (flat)
• Associative Looseness
• Ambivalence
• Autism (withdrawn into self)

• Delusions
• Hallucinations (auditory, visual, tactile, olfactory, gustatory)
• Thoughts of insertion/withdrawal
• Disorganized thoughts
• Perseveration
• Flight of ideas

• Stage 1: Comforting
• Stage 2: Condemning
• Stage 3: Controlling (Command) * emergency
• Stage 4: Conquering (does what they say)

• Assess for duration, intensity, frequency
• Pattern over time

• Laughing, speaking to self
• Moving lips without making sounds
• Rapid eye movements
• delayed verbal responses, as if preoccupied
• Anxiety
• Inability to follow conversation
• decreased ability to follow verbal commands

• Ask directly about the hallucinations
• Watch for cues that client is hallucination
• Avoid reacting to hallucinations as if they are real
• Do not negate the client's experience
• Offer your own perceptions
• Focus on reality based diversions
• Be alert to client anxiety

• Waxy flexibility: limbs remain where they are placed
• Pressured speech: fast, loud speech
• Aggressive, agitated bizarre behavior: labile
• Bizarre dress/grooming: too many layers, inappropriate for weather

• Ideas of reference: misconstruing trivial events/remarks and giving them personal significance
• Persecution: believing one is being singled out for harm by others
• Grandeur: believing one is a powerful, important person
• Somatic: false belief that the body is changing
• Jealousy: false belief that on's significant other is unfaithful
• Thought withdrawal: thoughts have been removed from mind and taken away by another
• Thought insertion: thought of another  are being inserted into one's mind
• Thought control: one's mind is being controlled by others
• Religiosity: preoccupation with religious beliefs
• Magical thinking: thoughts/behaviors have control over specific situations or people

• Be open, honest, reliable
• Be matter-of-fact and calm
• Ask client to describe delusion
• Avoid arguing, but interject doubt
• Focus on feelings the delusions generate
• Once delusion is described, do not dwell on it
• Observe events that trigger delusions
• validate any true part of the delusion

• Incoherence: inability to understand ideas, shifting from one unrelated topic to another
• Clang Association: choice of words r/t to rhyming sounds
• Loose Association: ideas shift from one unrelated topic to another
• Tangential: never get to the point of the story
• Circumstantial: point of story is reached through many unnecessary details
• Concrete thinking: literal interpretations (its raining cats and dogs)
• Echolalia: repeating another's words
• Word Salad: mixture of meaningless words
• Neologisms: words having meaning only for the client
• Mutism: inability/refusal to speak
• Perseveration: repeating same word/idea in response to different questions

• Lack of any goal directed behavior
• Negative behavior: clients doing the opposite of what is suggested or NOT doing what is suggested (such as getting out of bed)
• Catatonia: extreme psychomotor agitation or retardation
• Catatonic stupor: extreme motor retardation, mutism
• Catatonic posturing: waxy flexibility and passive bizarre posturing

• Affect and cognition is effected
• Anhedonia: lack of pleasure
• Anergia: lack of energy
• Apathy: indifference
• Alogia: poverty of speech (1 word answers)
• Avolition: lack of motivation
• Thought blocking: stop talk in middle of sentence
• Flat affect, bizarre affect, inappropriate affect
• Social isolation
• Poor grooming/hygiene
• Decreased spontaneity and gestures

• Assessment for DEPRESSION is crucial
• May herald impending relapse
• Increase in substance abuse
• Increase in suicide risk
• Further impairs functioning

• Any medical problems
• Abuse of or dependence on alcohol or substances
• Risk to self or others
• Command hallucinations

• Positive symptoms of schizophrenia and meets the criteria for major affective (mood) disorder
• Often schiz with depression

• Sudden onset of psychotic symptoms following a severe psychosocial stressor
• Symptoms last <1mo
• Individual returns to full premorbid functioning
• More common in borderline and BPD clients

• Prominent non-bizarre delusions
• Erotomanic: believe someone of higher status is in love with them
• Grandeur: irrational ideas about your own worth, power
• Jealousy: irrational idea that one's partner is unfaithful
• Persecution: most common
• Somatic: irrational belief they have some physical defect, disorder, disease

• A delusional system develops in a second person as a result of close relationships with a psychotic, delusional person
• Also called "folie a deux" and is considered a cult phenomenon

• TBI
• CVA
• Epilepsy
• Thyroid imbalance
• Hypoglycemia
• Lupus (LSE)
• Hypoxia
• Toxic Fumes
• Sleeplessness
• Carbon Monoxide

• Risk for violence to self or others
• Alteration in sensory perception
• Altered thought process
• Impaired verbal communication
• Self-care deficit
• Social isolation
• Ineffective family coping
• Noncompliance

• Maintain Safe environment
• Decrease stimuli
• Increase monitoring of client
• ASSESS FOR PRESENCE OF COMMAND HALLUCINATIONS
• Provide distraction activities
• Ask, don't ignore behaviors
• Never go alone but have one leader
• Directly ask about agitation
• Remain calm, non threatening, but firm
• Use clear, simple statements
• Cite specific behaviors

• Primary nursing, trust v mistrust
• Unconditional positive regard, provide praise
• Mutually agreed upon contract
• Brief, frequent contacts (5-10 min, several times a shift)
• Gradually increase length of sessions
• Consistency
• Reliability

• Observe for s/s of hallucinating
• Avoid touching the client without asking
• Encourage client to share content of hallucinations with you
• Actively listen for theme or tone and respond to it
• Do not reinforce or discredit the hallucinations (present reality)

• Promote trust- use primary nursing
• Slowly and gradually increase involvement in group activities as client can tolerate
• Avoid being obvious in monitoring client
• Avoid laughing, whispering, joking within earshot of client
• Provide pre-packaged, unopened food if necessary

• Dopamine Antagonists (D2 receptor antagonists)
• Chlorpromazine (Thorazine)
• Fluphenazine (Prolixin)
• Thiothixene (narvane)
• Haloperidol (Haldol)
• Target the positive symptoms of schizophrenia
• Less expensive than the second gen
• EPS, TD, Weight gain, sexual dysfunction, endocrine disturbances, and anticholinergic side effects

• Treat both positive and negative symptoms with minimal to no EPS and TD
• Disadvantage is that they tend to cause significant weight gain
• Risperidone (risperidol)
• Quetiapine (seroquel)
• Olanzapine (Zyprexa)
• Clozapine (clozaril)
• Ziprasidone (Geodon)
• Paliperidone (Invega)

• Aripiprazole (Abilify)
• Dopamine system stabilizer
• Improves positive and negative symptoms and cognitive function
• -little risk of EPS or tardive dyskinesia

• Extrapyramidal Symptoms
• Pseudoparkinsonism: tremors, shuffling gait, drooling, rigidity (often occur in women, elderly, dehydrated).  Symptoms within 1-5 days of treatment
• Akinesia: muscular weakness
• Akathisia: continuous restlessness, fidgeting
• Acute Dystonic Reactions: involuntary muscular movements (spasms) of the face, arms, legs and neck (occurs suddenly, frightening, painful)
• Treatment: IV/IM Cogentin, have resp support available

• Irreversible involuntary movements due to long use of anti-psychotic medications, decreasing or stopping abruptly after long term use
• Irreversible, must be detected early (no treatment at present)
• Tongue protrusion, lip smacking, chewing, blinking, grimacing, foot tapping

• Rare, potentially fatal dysregulation of the thermoregulation system
• -Parkinsonian muscle rigidity (severe)
• -Hyperpyrexia up to 107
• -Tachycardia and tachypnea
• -labile BP
• -diaphoresis
• -rapid LOC deterioration
• -elevated CPK
• -Onset within hours of therapy and progression over 24-72hrs
• -more common in dehydrated individuals
• Interventions:
• -D/C antipsychotic immeadiately
• -monitor VS, LOC, I/O
• -Physician may order Bromocriptine (parlodel) to reverse effects
• -Supportive care

• WBC levels can drop fatally low (<3,000mm3 or <1500mm3 granulocyte count)
• High incidence associated with Clozaril, occurring within the first 3 months
• Abrupt onset of fever (always take temp), malaise, ulcerative sore throat (always report a sore throat), leukopenia
• Interventions include antibiotics and reverse isolation

• Schizophrenia clients smoke at the double the rate of the general population (up to 88% of clients)
• Offer a nicotine patch
• All drug trials are done on smoking clients

• Dyslipidemia
• DM II
• HTN
• Abd obesity
• Insulin resistance

• Higher risk of developing DM II r/t high risk of obesity
• Clozapine and Olanzapine are agents most commonly associated with DM
• Risperidone not associated with signif risk of DM

• Learn all you can about the illness
• Develop a relapse prevention plan- recognize symptoms that signal relapse
• Take advantage of psycho-educational tools
• Comply with treatment
• Avoid alcohol/drugs
• Keep in touch with supportive people
• Stay physically healthy
• Join a support group to deal with stigma