Schizophrenia and Other Psychotic Disorders

1. Common subtypes of schizophrenia (without clearcut differentiation):
   disorganized type disordered, thinking (“word salad”), inappropriate affect (blunted, silly), regressive behavior, incoherent speech, preoccupied and withdrawn.
   catatonic type disorder of muscle tension, with rigidity waxy flexibility, posturing, mutism, violent rage outbursts, negativism, and frenzied activity. Marked decrease in involvement with environment and in spontaneous movement.
   paranoid type disturbed perceptions leading to disturbance in thought content of persecutory, grandiose, or hostile nature; projection is key mechanism, with religion a common preoccupation.
   residual continued difficulty in thinking, mood, perception, and behavior after schizophrenic episode.
   undifferentiated type unclassifiable schizophrenic like disturbance with mixed symptoms of delusions, hallucinations, incoherence, gross disorganization.


2. Concepts and principles related to schizophrenic disorders:
   1. General:
      1. Symbolic language used expresses schizophrenic’s life, pain, and progress toward health; all symbols used have meaning.
      2. Physical care provides media for relationship; nurturance may be initial focus.
      3. Consistency, reliability, and empathic understanding build trust.
      4. Denial, regression, and projection are key defense mechanisms.
      5. Felt anxiety gives rise to distorted thinking.
      6. Attempts to engage in verbal communication may result in tension, apprehensiveness, and defensiveness.
      7. Person rejects real world of painful experiences and creates fantasy world through illness.
   2. Withdrawal:
      1. Withdrawal from and resistance to forming relationships are attempts to reduce anxiety related to:
         1. Loss of ability to experience satisfying human relationships.
         2. Fear of rejection.
         3. Lack of self-confidence.
         4. Need for protection and restraint against potential destructiveness of hostile impulses (toward self and others).
      2. Ambivalence results from need to approach a relationship and need to avoid it.
         1. Cannot tolerate swift emotional or physical closeness.
         2. Needs more time than usual to establish a relationship; time to test sincerity and interest of nurse.
      3. Avoidance of client by others, especially staff, will reinforce withdrawal, thereby creating problem of mutual withdrawal and fear.
   3. Hallucinations:
      1. It is possible to replace hallucinations with satisfying interactions.
      2. Person can relearn to focus attention on real things and people.
      3. Hallucinations originate during extreme emotional stress when unable to cope.
      4. Hallucinations are very real to client.
      5. Client will react as the situation is perceived, regardless of reality or consensus.
      6. Concrete experiences, not argument or confrontation, will correct sensory distortion.
      7. Hallucinations are substitutes for human relations.
      8. Purposes served by or expressed in falsification of reality:
         1. Reflection of problem in inner life.
         2. Statement of criticism, censure, self-punishment.
         3. Promotion of self-esteem.
         4. Satisfaction of instinctual strivings.
         5. Projection of unacceptable unconscious content in disguised form.
      9. Perceptions not as totally disturbed as they seem.
      10. Client attempts to restructure reality through hallucinations to protect remaining ego integrity.
      11. Hallucinations may result from a variety of psychological and biological conditions (e.g., extreme fatigue, drugs, pyrexia, organic brain disease).
      12. Person who hallucinates needs to feel free to describe his or her perceptions if he or she is to be understood by the nurse.


3. Assessment of schizophrenic disorders:
   1. Eugene Bleuler described four classic and primary symptoms as the “four A’s”:
      1. Associative looseness - impairment of logical thought progression, resulting in confused, bizarre, and abrupt thinking. Neologisms- making up new words or condensing words into one.
      2. Affect - exaggerated, apathetic, blunt, flat, inappropriate, inconsistent feeling tone that is communicated through face and body posture.
      3. Ambivalence - simultaneous, conflicting feelings or attitudes toward person, object, or situation; need-fear dilemma.
         1. Stormy outbursts.
         2. Poor, weak interpersonal relations.
         3. Difficulty even with simple decisions.
      4. Autism - withdrawal from external world; preoccupation with fantasies and idiosyncratic thoughts.
         1. Delusions - false, fixed beliefs, not corrected by logic; a defense against intolerable feeling. The two most common delusions are:
            1. Delusions of grandeur - conviction in a belief related to being famous, important, or wealthy.
            2. Delusions of persecution - belief that one’s thoughts, moods, or actions are controlled or influenced by strange forces or by others.
         2. Hallucinations - false sensory impressions without observable external stimuli.
            1. Auditory - affecting hearing (e.g., hears voices).
            2. Visual - affecting vision (e.g., sees snakes).
            3. Tactile - affecting touch (e.g., feels electric charges in body).
            4. Olfactory - affecting smell (e.g., smells rotting flesh).
            5. Gustatory - affecting taste (e.g., food tastes like poison).
         3. Ideas of reference - clients interpret cues in the environment as having reference to them. Ideas symbolize guilt, insecurity, and alienation; may become delusions, if severe.
         4. Depersonalization - feelings of strangeness and unreality about self or environment or both; difficulty in differentiating boundaries between self and environment.
   2. Regression - extreme withdrawal and social isolation.
   3. Prodromal or residual symptoms:
      1. Social isolation, withdrawal.
      2. Marked impairment in role functioning (e.g., as student, employee).
      3. Markedly peculiar behavior (e.g., collecting garbage).
      4. Marked impairment in personal hygiene.
      5. Affect: blunt, inappropriate.
      6. Speech: vague, overelaborate, circumstantial, metaphorical.
      7. Thinking: bizarre ideation or magical thinking, e.g., ideas of reference, “others can feel my feelings.”
      8. Unusual perceptual experiences, e.g., sensing the presence of a force or person not physically there.
   4. Rule out general medical conditions/substances that may cause psychotic symptoms.
      1. Neurological conditions: neoplasms, cardiovascular disease, epilepsy, Huntington’s disease, deafness, migraine headaches, CNS infections.
      2. Endocrine conditions: hypothyroidism or hyperthyroidism, hypoparathyroidism or hyperparathyroidism, hypoadrenocorticism.
      3. Metabolic conditions: hypoxia, hypoglycemia, hypercarbia.
      4. Autoimmune disorders: SLE.
      5. Other conditions: hepatic or renal disease.
      6. Substances: drugs of abuse (alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants); anesthetics; chemotherapeutic agents; corticosteroids; toxins (nerve gases, carbon monoxide, carbon dioxide, fuel or paint, insecticides).


4. Analysis/nursing diagnosis:
   1. Sensory/perceptual alterations related to inability to define reality and distinguish the real from the unreal (hallucinations, illusions) and misinterpretation of stimuli, disintegration of ego boundaries.
   2. Altered thought processes related to intense anxiety and blocking (delusions), ambivalence or conflict.
   3. Risk for violence to self or others related to fear and distortion of reality.
   4. Altered communication process with inability to verbally express needs and wishes related to difficulty with processing information and unique patterns of speech.
   5. Self-care deficit with inappropriate dress and poor physical hygiene related to perceptual or cognitive impairment or immobility.
   6. Altered feeling states related to anxiety about others (inappropriate emotions).
   7. Altered judgment related to lack of trust, fear of rejection, and doubts regarding competence of
   8. Altered self-concept related to feelings of inadequacy in coping with the real world.
   9. Body-image disturbance related to inappropriate use of defense mechanisms.
   10. Disorganized behaviors: impaired relatedness to others, related to withdrawal, distortions of reality, and lack of trust.
   11. Diversional activity deficit related to personal ambivalence.
   
   
5. Nursing care plan/implementation in schizophrenic disorders:
   1. General:
      1. Set short-range goals, realistic to client’s levels of functioning.
      2. Use nonverbal level of communication to demonstrate concern, caring, and warmth, because client often distrusts words.
      3. Set climate for free expression of feelings in whatever mode, without fear of retaliation, ridicule, or rejection.
      4. Seek client out in his or her own fantasy world.
      5. Try to understand meaning of symbolic language; help him or her communicate less symbolically.
      6. Provide distance, because client needs to feel safe and to observe nurses for sources of threat or promises of security.
      7. Help client tolerate nurses’ presence and learn to trust nurses enough to move out of isolation and share painful and often unacceptable (to client) feelings and thoughts.
      8. Anticipate and accept negativism; do not personalize.
      9. Avoid joking, abstract terms, and figures of speech when client’s thinking is literal.
      10. Give antipsychotic medications.
   2. Withdrawn behavior:
      1. Long-term goal: develop satisfying interpersonal relationships.
      2. Short-term goal: help client feel safe in one to-one relationship.
      3. Seek client out at every chance, and establish some bond.
         1. Stay with client, in silence.
         2. Initiate talk when he or she is ready.
         3. Draw out, but do not demand, response.
         4. Do not avoid the client.
      4. Use simple language, specific words.
      5. Use an object or activity as medium for relationship; initiate activity.
      6. Focus on everyday experiences.
      7. Delay decision making.
      8. Accept one-sided conversation, with silence from the client; avoid pressuring to respond.
      9. Accept the client’s outward attempts to respond and inappropriate social behavior, without remarks or disdain; teach social skills.
      10. 10. Avoid making demands on client or exposing client to failure.
      11. 11. Protect from aggressive persons and from impulsive attacks on self and others.
      12. Attend to nutrition, elimination, exercise, hygiene, and signs of physical illness.
      13. Add structure to the day; tell him or her, "This is your 9 a.m. medication.”
      14. Health teaching: assist family to understand client’s needs, to see small sign of progress; teach client to perform simple tasks of selfcare to meet own biological needs.
   3. Hallucinatory behavior:
      1. Long-term goal: establish satisfying relationships with real persons.
      2. Short-term goal: interrupt pattern of hallucinations.
      3. Provide a structured environment with routine activities. Use real objects to keep client’s interest or to stimulate new interest (e.g., in painting or crafts).
      4. Protect against injury to self and others resulting from “voices” client thinks he or she
      5. Short, frequent contacts initially, increasing social interaction gradually (one person —> small groups).
      6. Ask person to describe experiences as hallucinations occur.
      7. Respond to anything real the client says, e.g., with acknowledgment or reflection. Focus more on feelings, not on delusional, hallucinatory content.
      8. Distract client’s attention to something real when he or she hallucinates.
      9. Avoid direct confrontation that voices are coming from client himself or herself; do not argue, but listen.
      10. Clarify who “they” are:
          1. Use personal pronouns, avoid universal and global pronouns.
          2. Nurse’s own language must be clear and unambiguous.
      11. Use one sentence, ask only one question, at a time.
      12. Encourage consensual validation. Point out that experience is not shared by you; voice doubt.
      13. Health teaching:
          1. Recommend more effective ways of coping (e.g., consensual validation).
          2. Advise that highly emotional situations be avoided.
          3. Explain the causes of misperceptions.
          4. Recommend methods for reducing sensory stimulation.
   4. Delusions.
   
   
6. Evaluation/outcome criteria:
   1. Small behavioral changes occur (e.g., eye contact, better grooming).
   2. Evidence of beginning trust in nurse (keeping appointments).
   3. Initiates conversation with others; participates in activities.
   4. Decreases amount of time spent alone.
   5. Demonstrates appropriate behavior in public places.
   6. Articulates relationship between feelings of discomfort and autistic behavior.
   7. Makes positive statements.
   
   
7. Critical Pathway: Client with Schizophrenic Psychosis.