NCM 117 LECTURE: SCHIZOPHRENIA o Examples: The client may claim to

be engaged to a famous movie star

Schizophrenia or related to some public figure,
 was coined in 1908 by the Swiss such as claiming to be the daughter
psychiatrist Eugen Bleuler. The word of the president of the United States,
was derivedfrom the Greek “skhizo” or he or she may claim to have
(split) and “phren” (mind). found a cure for cancer.
 is a group of mental health problems 3. Religious delusions
characterized by psychotic features o often center around the second
(hallucinations and delusions), coming of Christ or another
disordered thought processes, and significant religious figure or prophet.
disrupted interpersonal relationships. These religious delusions appear
 usually diagnosed in late adolescence suddenly as part of the client’s
or early adulthood. Rarely does it psychosis and are not part of his or
manifest in childhood. her religious faith or that of others.
 Peak incidence of onset : 15 to 25 years o Examples: The client claims to be
of age for men ; 25 to 35 years of age the Messiah or some prophet sent
for women. from God and believes that God
 The prevalence of schizophrenia is communicates directly to him or her
estimated at about 1% of the total or that he or she has a special
population. religious mission in life or special
 The incidence and the lifetime religious powers.
prevalence are roughly the same 4. Somatic delusions
throughout the world (Jablensky, 2017). o are generally vague and unrealistic
beliefs about the client’s health or
TYPES OF DELUSIONS bodily functions. Factual information
1. Persecutory/Paranoid delusions or diagnostic testing does not
o involve the client’s belief that change these beliefs.
“others” are planning to harm him or o Examples: A male client may say
her or are spying, following, that he is pregnant, or a client may
ridiculing, or belittling the client in report decaying intestines or worms
some way. Sometimes the client in the brain.
cannot define who these “others” 5. Sexual delusions
are. o involve the client’s belief that his or
o Examples: The client may think that her sexual behavior is known to
food has been poisoned or that others; that the client is a rapist,
rooms are bugged with listening prostitute, or pedophile or is
devices. Sometimes the “persecutor” pregnant; or that his or her
is the government, FBI, or another excessive masturbation has led to
powerful organization. Occasionally, insanity.
specific individuals, even family 6. . Nihilistic delusions
members, may be named as the o are the client’s belief that his or her
persecutor. organs aren’t functioning or are
2. Grandiose delusions rotting away, or that some body part
o are characterized by the client’s or feature is horribly disfigured or
claim to association with famous misshapen
people or celebrities, or the client’s 7. Referential delusions
belief that he or she is famous or o or ideas of reference involve the
capable of great feats. client’s belief that television
broadcasts, music, or newspaper
 articles have special meaning for 6. Cenesthetic hallucinations
him or her. o involve the client’s report that he or
o Examples: The client may report that she feels bodily functions that are
the president was speaking directly usually undetectable. Examples would
to him on a news broadcast or that be the sensation of urine forming or
special messages are sent through impulses being transmitted through
newspaper articles. the brain.
7. Kinesthetic hallucinations
TYPES OF HALLUCINATION o occur when the client is motionless but
1. Auditory hallucinations reports the sensation of bodily
o the most common type, involve movement. Occasionally, the bodily
hearing sounds, most often voices, movement is something unusual, such
talking to or about the client. There as floating above the ground.
may be one or multiple voices; a
familiar or unfamiliar person’s voice ETIOLOGY
may be speaking. Command 1. GENETIC FACTORS
hallucinations are voices demanding o identical twins have a 50% risk of
that the client take action, often to schizophrenia; that is, if one twin has
harm the self or others, and are schizophrenia, the other has a 50%
considered dangerous. chance of developing it as well.
2. Visual hallucinations o Fraternal twins have only a 15% risk.
o involve seeing images that do not exist children with one biologic parent with
at all such as lights or a dead person, schizophrenia have a 15% risk the risk
or distortions such as seeing rises to 35% if both biologic parents
frightening monster instead of the have schizophrenia.
nurse. They are the second most o Children adopted at birth into a family
common type of hallucination. with no history of schizophrenia but
3. Olfactory hallucinations whose biologic parents have a history
o involve smells or odors. They may be of schizophrenia still reflect the genetic
a specific scent such as urine or feces risk of their biologic parents.
or a more general scent such as a o All these studies have indicated a
rotten or rancid odor. In addition to genetic risk or tendency for
clients with schizophrenia, this type of schizophrenia, but Mendelian genetics
hallucination often occurs with cannot be the only factor
dementia, seizures, or o Identical twins have only a 50% risk
cerebrovascular accidents. even though their genes are 100%
4. Tactile hallucinations identical.
o refer to sensations such as electricity o Rather, recent studies indicate that the
running through the body or bugs genetic risk of schizophrenia is
crawling on the skin. Tactile polygenic, meaning several genes
hallucinations are found most often in contribute to the development
clients undergoing alcohol withdrawal; (Kendall, Kirov, & Owen, 2017).
they rarely occur in clients with 2. NEUROANATOMIC &
schizophrenia. NEUROCHEMICAL FACTORS
5. Gustatory hallucinations o Findings have demonstrated that
o involve a taste lingering in the mouth people with schizophrenia have
or the sense that food tastes like relatively less brain tissue and
something else. The taste may be cerebrospinal fluid than those who
metallic or bitter or may be do not have schizophrenia; this
represented as a specific taste. could represent a failure in the
 development or a subsequent loss of o is diagnosed when the client is
tissue. severely ill and has a mixture of
o Computed tomography scans have psychotic and mood symptoms.
shown enlarged ventricles in the o The signs and symptoms include
brain and cortical atrophy. those of both schizophrenia and a
o Positron emission tomography mood disorder such as depression
studies suggest that glucose or bipolar disorder. The symptoms
metabolism and oxygen are may occur simultaneously or may
diminished in the frontal cortical alternate between psychotic and
structures of the brain. mood disorder symptoms.
o The research consistently shows
decreased brain volume and 4. Delusional disorder
abnormal brain function in the frontal o The client has one or more
and temporal areas of persons with nonbizarre delusions— that is, the
schizophrenia. focus of the delusion is believable.
o The most prominent neurochemical o The delusion may be persecutory,
theories involve dopamine and erotomanic, grandiose, jealous, or
serotonin. One prominent theory somatic in content.
suggests excess dopamine as a o Psychosocial functioning is not
cause. markedly impaired, and behavior is
3. IMMUNO -VIROLOGIC FACTORS not obviously odd or bizarre.
o Recently, researchers have been
focusing on infections in pregnant 5. Shared Psychotic Disorder (Folie a deux)
women as a possible origin for o Two people share a similar delusion.
schizophrenia. The person with this diagnosis
. develops this delusion in the context
OTHER RELATED DISORDERS of a close relationship with someone
[Link] disorder who has psychotic delusions, most
o The client exhibits an acute, reactive commonly siblings, parent and child,
psychosis for less than the 6 months or husband and wife.
necessary to meet the diagnostic o The more submissive or suggestible
criteria for schizophrenia. person may rapidly improve if
o If symptoms persist over 6 months, separated from the dominant
the diagnosis is changed to person.
schizophrenia. Social or
occupational functioning may or may 6. Catatonia
not be impaired. o is characterized by marked
psychomotor disturbance, either
2. Brief Psychotic disorder excessive motor activity or virtual
o The client experiences the sudden immobility and motionlessness.
onset of at least one psychotic o Motor immobility may include
symptom, such as delusions, catalepsy (waxy flexibility) or stupor.
hallucinations, or disorganized o Excessive motor activity is
speech or behavior, which lasts from apparently purposeless and not
1 day to 1 month. influenced by external stimuli. Other
o The episode may or may not have behaviors include extreme
an identifiable stressor or may follow negativism, mutism, peculiar
childbirth. movements, echolalia, or
echopraxia.
[Link] disorder
 o Catatonia can occur with o not only diminish positive symptoms
schizophrenia, mood disorders, or but also lessen the negative signs of
other psychotic disorders. lack of volition and motivation, social
withdrawal, and anhedonia for many
clients.
7. Schizotypal personality disorder
o This involves odd, eccentric behaviors, SIDE EFFECTS
including transient psychotic
symptoms. EXTRAPYRAMIDAL SIDE EFFECTS (EPS)
o Approximately 20% of persons
with this personality disorder will 1. ACUTE DYSTONIA
eventually be diagnosed with o appear early in the course of
schizophrenia. treatment
o characterized by spasms in discrete
MANAGEMENT OF SCHIZOPHRENIA muscle groups, such as the neck
muscles (torticollis) or eye muscles
PSYCHOPHARMACOLOGY (oculogyric crisis).
o The primary medical treatment for o These spasms may also be
schizophrenia. accompanied by protrusion of the
o In the past, electroconvulsive tongue, dysphagia, and laryngeal
therapy, insulin shock therapy, and and pharyngeal spasms that can
psychosurgery were used, but since compromise the client’s airway,
the creation of chlorpromazine causing a medical emergency.
(Thorazine) in 1952, other treatment MANAGEMENT:
modalities have become all but  Administer medications as ordered
obsolete.  assess for effectiveness
 reassure client if he or she is
ANTIPSYCHOTICS frightened.
o also known as neuroleptics, are
prescribed primarily for their efficacy 2. PSEUDOPARKINSONISM
in decreasing psychotic symptoms. o neuroleptic-induced parkinsonism
o They do not cure schizophrenia; o includes a shuffling gait, masklike
rather, they are used to manage the facies, muscle stiffness (continuous)
symptoms of the disease. or cogwheeling rigidity (ratchet-like
movements of joints), drooling, and
CATEGORIES OF ANTIPSYCHOTICS akinesia (slowness and difficulty
A. TYPICAL (CONVENTIONAL) initiating movement).
o first-generation o usually appear in the first few days
o dopamine antagonists after starting or increasing the
o target the positive signs of dosage of an antipsychotic
schizophrenia, such as delusions, medication.
hallucinations, disturbed thinking, MANAGEMENT:
and other psychotic symptoms, but  Administer medications as ordered;
have no observable effect on the assess for effectiveness.
negative signs.  Parkinsonism is treated by changing
to an antipsychotic medication that
B. ATYPICAL has a lower incidence of EPS or by
o second-generation adding an oral anticholinergic agent
o both dopamine and serotonin or amantadine, (dopamine agonist)
antagonists
3. AKATHISIA oa serious and frequently fatal
o characterized by restless movement, condition seen in those being treated
pacing, inability to remain still, and with antipsychotic medications.
the client’s report of inner o It is characterized by muscle rigidity,
restlessness. high fever, increased muscle
o Akathisia usually develops when the enzymes (particularly, creatine
antipsychotic is started or when the phosphokinase), and leukocytosis
dose is increased. (increased leukocytes).
MANAGEMENT: MANAGEMENT:
 Administer medications as ordered;  Stop all antipsychotic medications
assess for effectiveness  notify physician immediately
 Beta-blockers such as  Dantrolene –skeletal muscle
propranolol have been most relaxant
effective in treating akathisia, and  Bromocriptine- dopamine agonist
benzodiazepines have provided
some success as well. AGRANULOCYTOSIS
o Clozapine has the potentially fatal
[Link] DYSKINESIA side effect of agranulocytosis (failure
o a late-appearing side effect of the bone marrow to produce
o is characterized by abnormal, adequate white blood cells).
involuntary movements such as lip o Agranulocytosis develops suddenly
smacking, tongue protrusion, and is characterized by fever,
chewing, blinking, grimacing, and malaise, ulcerative sore throat, and
choreiform movements of the limbs leukopenia.
and feet o Clients taking this antipsychotic must
o IRREVERSIBLE have weekly white blood cell counts
MANAGEMENT: for the first 6 months of clozapine
 Assess using tool such as AIMS; therapy and every 2 weeks
report occurrence or score increase thereafter.
to physician. o Clozapine is dispensed every 7 or
 Newly approved medications to treat 14 days only, and evidence of a
tardive dyskinesia, valbenazine white blood cell count above 3,500
(Ingrezza) and deutetrabenazine cells/mm3 is required before a refill
(Austedo, Teva) is furnished.

ABNORMAL INVOLUNTARY MOVEMENT PSYCHOSOCIAL TREATMENT

SCALE (AIMS)  Individual and group therapy
-used to screen for symptoms of movement sessions
disorders.  Topics of concern: medication
-The client is observed in several positions, management, use of community
and the severity of symptoms is rated from supports, and family concerns.
0 to 4.  social skill training
-The AIMS can be administered every 3 to 6
months.

5. NEUROLEPTIC MALIGNANT
SYNDROME (NMS)