Schizophrenia: Symptoms, Diagnosis, and Etiology

Schizophrenia Overview

• Usually diagnosed in late adolescence or early adulthood.
• Peak incidence of onset is 15 to 25 years for men and 25 to 35 years for women.
• Estimated prevalence is about 1% of the total population.
• Nearly 3 million people in the United States have been or will be affected.

Clinical Course

• Onset is mostly a slow, gradual development of signs and symptoms.
• Diagnosis usually occurs with more actively positive symptoms of psychosis.
• Immediate-term course includes ongoing psychosis with no recovery, or episodes of symptoms alternating with periods of recovery.
• In the long-term, the intensity of psychosis diminishes with age and the disease becomes less disruptive.
• Clients may live independently later in life but often have difficulty functioning in the community.

Etiology

• Can be attributed to Genetic factors*,
• Neuroanatomic and neurochemical factors such as less brain tissue, cerebrospinal fluid, and dopamine excess.
• Stress enhancement.
• Alcohol and drugs.

Phases of Schizophrenia

• Phase I: Prodromal Phase
  • Lasts from a few weeks to a few years.
  • Involves deterioration in role functioning and social withdrawal.
  • Can include sleep disturbance, anxiety, and irritability.
  • Can include depressed mood, poor concentration, and fatigue.
  • Client may focused on certain topics like religion, government, or public figures.
• Phase II: Schizophrenia
  • Psychotic symptoms are prominent during the active phase of the disorder.
  • Includes delusions, hallucinations, and impairment in work, social relations, and self-care.
• Phase III: Residual Phase
  • More intense symptoms, such as hallucinations, start to fade.
  • Characterized by strange beliefs, withdrawal, less talking, and trouble concentrating.
  • Depression with increased awareness can occur.

Diagnosis Criteria

• Diagnosed with two or more symptoms: Delusions, Hallucinations, Disorganized Speech, Grossly disorganized or catatonic Behavior, or Negative symptoms (Delusions Herald Schizophrenic's Bad News).

Positive vs. Negative Symptoms

• Positive symptoms: Excessive or distorted thoughts and perceptions experienced by the individual but not by others.
• Negative symptoms: Emotions and behaviors that should be present but are diminished in persons with schizophrenia.

Positive Symptoms of Schizophrenia

• Usually the target of antipsychotic medications.
• Include: Delusions, Distortions, Disorganized speech, Disorganized, catatonic, or agitated behavior, and Hallucinations.

Delusions

• Fixed, false beliefs despite evidence.
• Examples: Persecutory, Referential (having reference to the individual), Grandiose, Somatic, Guilt, Religious, Jealousy, Control, Thought insertion (thoughts are not one's own), and Thought broadcasting.

Content of Thought (Positive Symptoms)

• Delusions: False personal beliefs.
• Religiosity: Excessive 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.

Form of Thought (Positive Symptoms)

• Associative looseness: A thought-process disorder characterized by a confusing connection between ideas. "Loosely connected."
• Neologisms: Made-up words that only have meaning to the person who invents them.
• Concrete thinking: Literal interpretations of the environment.
• Clang associations: Choice of words governed by sound (often rhyming). Example: "Click, clack, clutch."
• Word salad: Jumble of words that is meaningless.
• Perseveration: Persistent repetition of the same word or idea in response to different questions.
• Circumstantial: Delay reaching the point of communication due to unnecessary and tedious details.
• Tangential: Completely off-topic, never reaches the point of conversation.

Perception (Positive Symptoms)

• Interpretation of stimuli through the senses.
• Hallucinations: False sensory perceptions not associated with real external stimuli. Can be Auditory, Visual, Tactile, Gustatory, or Olfactory.
• Illusions: Misperceptions of real external stimuli.

Sense of Self (Positive Symptoms)

• The uniqueness and individuality a person feels.
• Echolalia: Repeating words that are heard.
• Depersonalization: Persistent or repeated feeling of observing oneself from outside the body.

Negative Symptoms

• Affect: The feeling state or emotional tone.
  • Inappropriate affect: Emotions are incongruent with circumstances.
  • Flat affect: Appears void of emotional tone.
  • Apathy: Disinterest in the environment; a feeling of generalized indifference and unaffectedness.
• Avolition: Impairment in the ability to initiate goal-directed activity.
  • Deterioration in appearance: Impaired personal grooming and self-care activities.
• Impaired interpersonal functioning: Relationship to the external world.
  • Impaired social interaction: Clinging and intruding on the personal space of others, exhibiting behaviors not culturally or socially acceptable.
  • Social isolation: Focus inward on the self, excluding the external environment.

Psychomotor Behavior (Negative Symptoms)

• Includes:
  • Anergia: Deficiency of energy.
  • Waxy flexibility: Limbs retain any position they are manipulated into by another person.
  • Posturing: Voluntary assumption of inappropriate or bizarre postures.
  • Pacing and rocking: Pacing back and forth and rocking the body.
  • Echopraxia: Repeating movements that are observed.
  • Identification and imitation: Taking on the form of behavior one observes in another.
  • Catatonia: Psychomotor disturbances such as stupor, mutism, or repetitive behavior.
• Associated Features:
  • Anhedonia: Engaging in an activity that previously brought joy or positive feelings but no longer elicits those feelings.
  • Regression: Retreat to an earlier level of development.

Nursing Priorities

• Risk to self or others.
• Command hallucinations.
• Impaired judgment.
• Determine if the client believes they or a loved one is threatened or in danger.
• Ability to care for oneself.
• Co-occurring disorders such as depression, substance abuse, or other medical conditions.
• Medication compliance.

Interventions

• Establish trust and ensure a safe environment.
• Avoid touching the client without informing them exactly what you are going to do.
• Postpone procedures if necessary until the client is less suspicious or agitated.
• Use an accepting and consistent approach with clear and unambiguous language.
• Address identified barriers to medication adherence.
• Encourage the client to comply with their medication regimen to prevent relapse.
• Reduce external stimulation.
• Monitor the client's thinking, perceptions, and associated behavior.
• Ask about voices and monitor for increased negativity of content, anxiety, agitation, or social withdrawal.
• Do not argue with delusional statements, but express doubt.
• Address feelings reflected in delusions.
• Institute suicide precautions if the client expresses suicidal thoughts.
• Report increased anxiety and/or increasing risk of violence.
• For hallucinations with suicidal or homicidal themes, ensure safety measures and focus on reality-based conversations, emphasizing that "The voice you hear is part of your illness; it cannot hurt you."
• For associative looseness, reflect poorly organized thinking and place the difficulty in understanding on yourself, like "I am having trouble following what you are saying."
• Never debate or attempt to dissuade someone regarding a delusion.
• Clarify any misinterpretations of the environment.
• Acknowledge the client's concern about false beliefs, but do not agree with them.
• Avoid reinforcing delusions by going along with what the client says.
• Focus on feelings, such as fear or anxiety, and offer alternative thoughts and behaviors to reduce negative feelings.
• Help the client minimize the effects of delusional thoughts.

Schizophrenia vs. Schizoaffective Disorder

• Schizophrenia (no major mood disorder): Has two or more of the symptoms: Delusions, Hallucinations, Disorganized Speech, Grossly disorganized or catatonic Behavior, or Negative symptoms (Delusions Herald Schizophrenic's Bad News).
• Schizoaffective: A major mood episode (major depression or manic) concurrent with schizophrenia, delusions or hallucinations for 2 or more weeks in the absence of a major mood episode, and major mood episodes present for the majority of the active and residual portion of the illness.

Conventional Antipsychotics (First Generation Antipsychotics - FGAs)

• Dopamine antagonists (blocks dopamine) via D2 receptor.
• Target positive symptoms.
• Less expensive than atypical antipsychotics.
• Disadvantages: Does not treat negative symptoms, include Extrapyramidal side effects (EPSs), Tardive dyskinesia, Anticholinergic side effects, and Lower seizure threshold.
• Common examples: Chlorpromazine (Thorazine), Trifluoperazine (Stelazine), Thiothixene (Navane), Pimozide (Orap), Thioridazine (Mellaril) (Prolong QT), Fluphenazine (Prolixin), Loxapine (Loxitane), Perphenazine (Trilafon), Molindone (Moban), and Haloperidol (Haldol).

Extrapyramidal Side Effects (EPS)

• Conventional antipsychotics can cause these side effects:
  • Akathisia: Restlessness, shuffling from one foot to another.
  • Pseudo parkinsonism: Tremor, shuffling, stooped posture, and rigidity.
  • Tardive dyskinesia: Repetitive tic-like motions in facial muscles, rapid blinking, sticking out the tongue, smacking, or puckering lips.
  • Acute dystonia: Abnormal movements, e.g., head rotated to one side.
  • Akinesia: Inability to perform movement.
  • Oculogyric crisis: Uncontrolled rolling back of the eyes.

Treatment of EPS

• Benztropine (anticholinergic): Treats involuntary movements related to FGAs.
• This will Decrease side effects such as muscle stiffness/rigidity and restlessness (extrapyramidal signs-EPS).
• It is not helpful in treating movement problems caused by tardive dyskinesia and may worsen them.
• It may take 2-3 days before benefits are apparent.
• Remember! Anticholinergic effects: Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter.

Treatment of Tardive Dyskinesia

• Most often seen in FGA and can be seen when a client is on the medication for 3 months or more.
• There are two FDA-approved medicines to treat tardive dyskinesia:
  • Deutetrabenazine (Austedo)
  • Valbenazine (Ingrezza)

Neuroleptic Malignant Syndrome (NMS)

• Potentially fatal syndrome.
• Caused by medications, mainly antipsychotics, that alter dopamine levels in the brain.
• Either taking the medication or withdrawal of medications increases central nervous system levels of dopamine.
• Life-threatening condition most often seen in FGAs (First generations).
• Signs and Symptoms include:
  • Severe muscle rigidity, elevated temperature (hyperthermia), altered consciousness, sweating, seizures, and death.
  • "Hot, stiff, and out of it".
  • Serum creatinine kinase (CK) elevation (kidney failure).
• The typical range for serum creatinine is:
  • For adult men, 0.74 to 1.35 mg/dL (65.4 to 119.3 micromoles/L).
  • For adult women, 0.59 to 1.04 mg/dL (52.2 to 91.9 micromoles/L).
• Treatment:
  • Early recognition of symptoms and withholding of antipsychotic medications.
  • ICU care.
  • Dopamine agonists (bromocriptine).
  • Muscle relaxants (dantrolene or benzodiazepine).
  • Frequent vital signs monitoring, treating fever, and laboratory testing.
  • Supportive measures and promoting safety.

Anticholinergic Crisis

• Life-threatening condition: Overdose or sensitivity to drugs with anticholinergic properties.
• Also called anticholinergic delirium.
• "Hot as a hare, blind as a bat, mad as a hatter, dry as a bone".
• Self-limiting, usually 3 days after drug discontinued.
• Treatment:
  • Discontinuation of medication.
  • Physostigmine (acetylcholinesterase inhibitor).
  • Gastric lavage, charcoal, and catharsis for intentional overdoses.

Atypical Antipsychotics (Second Generation Antipsychotics - SGAs)

• Treat both positive and negative symptoms.
• Minimal to no extrapyramidal side effects (EPSs) or tardive dyskinesia.
• The disadvantage includes the tendency to cause significant weight gain and metabolic issues such as Hyperglycemia and HTN.
• Metabolic issues should be considered with the SGAs.
• Examples: Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa) Metabolic effects, Ziprasidone (Geodon), Aripiprazole (Abilify), Lurasidone (Latuda), Asenapine (Saphris). Paliperidone (Invega), Quetiapine (Seroquel), and Iloperidone (Fanapt).

Clozaril

• Agranulocytosis is a serious and can be fatal
• Symptoms are Sore throat, Fever,, Malaise, and Mouth sores.
• Monitor (Absolute Neutrophil Count), if less than 1500 is concern.
• Usually occurs within the first three months
• Treatment requires lab/blood work
• Side effects can be Metabolic, Weight gain, Diabetes, or High anticholinergic side effects

Abnormal Involuntary Movement Scale (AIMS)

• AIM scale is done before, during, and before discharge.
• Tool to detect involuntary movements associated with Tardive Dyskinesia.
• Scale 0 (None)-4 (Severe).
• Includes Facial and Oral Movements, Extremity Movements, Trunk Movements, Global Judgments, and Dental Status.