SCHIZOPHRENIA
This module aligns with key elements of APNA’s “Growth & Development” and “Clinical Decision Making” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).
Module Outline
- Assessment of Schizophrenia
- Problems Associated with Schizophrenia
- Treatment of Schizophrenia
Module Learning Outcomes
- Describe the signs and symptoms of Schizophrenia
- Identify the common nursing problems associated with Schizophrenia
- Summarize the treatment of Schizophrenia
Concepts
- Cognition
- Psychosis
- Mood and Affect
- Safety
Overview
In this chapter, we will focus on the presentation and treatment of the Schizophrenia diagnosis. Other diagnoses related to Schizophrenia include Schizophreniform disorder, Schizoaffective disorder, and Delusional disorder. These disorders are defined by one of the following main symptoms: delusions, hallucinations, disorganized thinking (speech), disorganized or abnormal motor behavior, and negative symptoms. Individuals diagnosed with schizophrenia may also experience psychosis. Psychosis episodes make it difficult for individuals to perceive and respond to environmental stimuli, causing a significant disturbance in everyday functioning. Collectively, symptoms associated with Schizophrenia are commonly categorized as positive and negative symptoms.
The hallmark symptoms of schizophrenia include the presentation of at least two of the following: delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative symptoms. These symptoms create significant impairment in an individual’s ability to engage in normal daily functioning such as work, school, relationships with others, or self-care.
Memorable Psychiatry and Neurology. (2022). Psychosis & schizophrenia mnemonics (memorable psychiatry lecture) [Video]. YouTube. https://youtube.com/watch?v=pUIiq9Yzltg&si=EnSIkaIECMiOmarE
Below is an overview of a nurse’s consideration for the assessment, problems, and treatment of eating disorders.
See Calabrese et al. (2022) to read more about this topic.
Assessment
Positive signs and symptoms
Positive signs and symptoms can be summarized as alterations in the person that is not typically present in someone not having a Schizophrenia diagnosis. Positive signs and symptoms include:
- Hallucinations. Hallucinations can occur in any of the five senses: hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), touching (tactile hallucinations), and tasting (gustatory hallucinations). Additionally, they can occur in a single modality or present across a combination of modalities (e.g., having auditory and visual hallucinations). Individuals may recognize that their hallucinations are not real and attempt to engage in normal behavior while simultaneously combating ongoing hallucinations. Important Note: If an individual reports having hallucinations (e.g., seeing something that is not there or hearing voices), do not state that you see or hear the hallucination nor should you tell the patient that they do not see/hear the hallucination. Rather, you should respond empathetically such as “That must be frightening.”
- Delusions. Delusions are “fixed, false beliefs fixed, false beliefs for which a person lacks insight, even in the face of evidence that proves contrary to their validity” (Calabrese et al., 2022). Delusions may take on themes such as persecutory (i.e., the belief that someone is trying to hurt them), grandiose (i.e., an inflated view of oneself), erotomaniac (i.e., the belief that a person is in love with them), referential (i.e., the belief that things seen/heard in the environment relate to them) (Calabrese et al., 2022).
- Disorganized thinking. Among the most common cognitive impairments displayed in patients with schizophrenia are disorganized thought, communication, and speech. More specifically, thoughts and speech patterns may appear to be circumstantial or tangential. For example, patients may give unnecessary details in response to a question before they finally produce the desired response. While the question is eventually answered in circumstantial speech patterns, in tangential speech patterns the patient never reaches the point. Another common cognitive symptom is speech retardation, where the individual may take a long time before answering a question. Derailment, or the illogical connection in a chain of thoughts, is another common type of disorganized thinking. Although not always, derailment is often seen in illogicality, or the tendency to provide bizarre explanations for things. These types of distorted thought patterns are often related to concrete thinking. That is, the individual is focused on one aspect of a concept or thing and neglects all other aspects.
- Disorganized/Abnormal motor behavior. Psychomotor symptoms can also be observed in individuals with schizophrenia. These behaviors may manifest as awkward movements or even ritualistic/repetitive behaviors.
- Catatonic behavior. Catatonic behavior, the decreased or complete lack of reactivity to the environment, is among the most commonly seen disorganized motor behaviors in schizophrenia. There runs a range of catatonic behaviors.
Negative signs and symptoms
Negative signs and symptoms can be summarized as alterations in the person that are typically present in someone not having a Schizophrenia diagnosis. Negative symptoms often present before positive symptoms and may remain once positive symptoms decrease. There are six main types of negative symptoms seen in patients with schizophrenia. Such symptoms include:
- Affective flattening. Affective flattening is the reduction in emotional expression, reduced display of emotional expression
- Alogia. Alogia is the poverty of speech or speech content
- Anhedonia. Anhedonia is the inability to experience pleasure
- Apathy. Apathy is the general lack of interest
- Asociality. Asociality is the lack of interest in social relationships
- Avolition. Avolition is the lack of motivation for goal-directed behavior
- Anergia. Anergia is a lack of energy.
Problems
Problems associated with a Schizophrenia diagnosis include:
- Impaired verbal communication
- Impaired thought process
- Altered sensory perception
- Impaired social interaction
- Interrupted family process
- Ineffective coping
Treatment
A combination of psychopharmacological, psychological, and family interventions is the most effective treatment in managing schizophrenia symptoms. However, antipsychotics are the gold standard of treatment for psychosis and psychotic disorders (Calabrese et al., 2022). An individual diagnosed with Schizophrenia will likely require lifelong treatment and care.
Psychopharmacological
Among the first antipsychotic medications used for the treatment of schizophrenia was Thorazine. Due to the harsh side effects of conventional antipsychotic drugs, newer, arguably more effective second-generation or atypical antipsychotic drugs have been developed. Side effects may be related to medication adherence. Therefore, nurses should ask and educate about potential side effects that may need to be reported to the independent healthcare provider. In general, antipsychotics have been more efficacious at treating positive symptoms versus negative symptoms (Calabrese et al., 2022). Remember, nursing and medical care should be tailored to meet a patient’s individual needs. See MODULE 4: PSYCHOPHARMACOLOGY for a review of antipsychotics.
Psychological Interventions
Cognitive Behavioral Therapy (CBT). As discussed in previous chapters, the goal of treatment is to identify the negative biases and attributions that influence an individual’s interpretations of events and the subsequent consequences of these thoughts and behaviors.
Social Skills Training. Given the poor interpersonal functioning among individuals with schizophrenia, social skills training is another type of treatment commonly suggested to improve psychosocial functioning. Research has indicated that poor interpersonal skills not only predate the onset of the disorder but also remain significant even with the management of symptoms via antipsychotic medications. Social support has been identified as a protective factor and helps patients relate to others (Calabrese et al., 2022). Learning how to interact with others appropriately (e.g., establish eye contact, engage in reciprocal conversations, etc.) through role-play in a group therapy setting is one effective way to teach positive social skills.
Family Interventions
The overall goal of family interventions is to reduce the stress on the individual that is likely to elicit the onset of symptoms. Educating families on the course of the illness, as well as ways to recognize the onset of psychotic symptoms, is important to ensure optimal recovery.
Key Takeaways and Learning Activities
You should have learned the following in this section:
- Schizophrenia is characterized by delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative symptoms.
- Positive versus negative signs/symptoms are differentiated by remembering that the former at not normally present in a typical individual.
- Antipsychotics are the psychotropic medication class used to treat Schizophrenia.
- Psychological treatment options include CBT and Social Skills Training.
Concept Map Activity
- Create a concept map that depicts the assessment and treatment of Schizophrenia.
- If needed, see the INTRODUCTION for a concept map tutorial.
Case Study: Schizophrenia
Case Scenario
James, a 30-year-old graphic designer, is experiencing hallucinations, delusions, and disorganized thoughts. He received an initial diagnosis of schizophrenia in his twenties. Since the initial diagnosis, he has been able to experience periods of stability with occasional exacerbations, requiring in-patient management. His behavior has been increasingly erratic, affecting his professional and personal lives. During the nursing admission assessment, James indicated he had been experiencing financial strain and was unable to purchase his antipsychotic medication. He also stated that his roommate had implanted a tracking device into his cellphone to allow the government to monitor his conversations and GPS coordinates. He pauses during the interview and appears to be communicating with an unseen individual, stating, “Yes, I have received the mission instructions.”
Reflective Case Study Questions:
- Define and differentiate positive versus negative symptoms of schizophrenia.
- What positive and negative symptoms are evident in James?
- Develop a nursing care plan for James during acute psychotic episodes.
- How can the nurse promote medication adherence and manage side effects?
Adapted from Fundamentals of Psychological Disorders 2nd Edition- Module 12 by Alexis Bridley, Ph.D. and Lee W. Daffin Jr., Ph.D. licensed under a Creative Commons Attribution 4.0 International License. Modifications: revised for clarity and flow 
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Psychosis is defined as " an abnormal mental state involving significant problems with reality testing. It is characterized by serious impairments or disruptions in the most fundamental higher brain functions—perception, cognition and cognitive processing, and emotions or affect—as manifested in behavioral phenomena, such as delusions, hallucinations, and significantly disorganized speech." (American Psychological Association, 2022b).
Catatonia is "a state of muscular rigidity or other disturbance of motor behavior, such as catalepsy, extreme overactivity, or adoption of bizarre postures. It is most frequently observed in catatonic schizophrenia, but it can also occur with other disorders, such as bipolar disorder, major depressive disorder, and neurological conditions such as encephalitis, among others. Also called catatonic state. —catatonic" (American Psychological Association, 2022b).
