CHAPTER 16 SCHIZOPRENIA Hallucinations: False sensory perceptions or

INTRODUCTION perceptual experiences that do not exist in reality

Ideas of reference: False impressions that external
Schizophrenia is a serious mental disorder in which people events have special meaning for the person.
interpret reality abnormally. Schizophrenia may result in some (Believing that "somehow everyone on a passing
combination of hallucinations, delusions, and extremely city bus is talking about him/her)".
disordered thinking and behavior that impairs daily Perseveration: Persistent adherence to a single
functioning, and can be disabling. People with schizophrenia idea or topic; verbal repetition of a sentence, word,
require lifelong or phrase; resisting attempts to change the topic.
treatment. (when someone “gets stuck” on a topic or an idea).
Bizarre behavior: Outlandish appearance or
Intrusive thoughts are unwanted thoughts, images, clothing; repetitive or stereotyped, seemingly
impulses, or urges that can occur spontaneously or that purposeless movements; unusual social or sexual
can be cued by external/internal stimuli. Typically, these behavior (behavior that is odd, strange, or
thoughts are distressing (hence “intrusive”) and tend to unexpected, particularly if it is out of the ordinary
reoccur. for a given person).

APHASIA - problem in processing or expressing words. Negative or Soft Symptoms

Alogia: Tendency to speak little or to convey little
Schizophrenia causes distorted and bizarre thoughts,
substance of meaning (poverty of content) “without
perceptions, emotions, movements, and behavior. It cannot
speech”
be defined as a single illness; rather, schizophrenia is
 you might choose not to speak, because there are voices
thought of as a syndrome or as a disease process with many
in your head threatening you if you do.
different varieties and symptoms, much like the varieties of
Anhedonia: Feeling no joy or pleasure from life or any
cancer. For decades, the public vastly misunderstood
activities or relationships. reduced ability to experience
schizophrenia, fearing it as dangerous and uncontrollable
pleasure.
and causing wild disturbances and violent outbursts. Many
ex.” If you used to enjoy playing video games every day
people believed that those with schizophrenia needed to be
after work, but now feel nothing when gaming.”
locked away from society and institutionalized. Only
Apathy: Feelings of indifference toward people,
recently has the mental health community come to learn
activities, and events.  a lack of goal-directed activity.
and educate the community at large that schizophrenia has
many different symptoms and presentations and is an Ex.“I could never live without you, you complete
illness that medication can control. me.” 
Schizophrenia is usually diagnosed in late adolescence or Asociality: Social withdrawal, few or no relationships,
early adulthood. Rarely does it manifest in childhood. lack of closeness. “Avoiding social activities that a
The peak incidence of onset is 15 to 25 years of age for person previously enjoyed.”
men and 25 to 35 years of age for women. Blunted affect: Restricted range of emotional feeling,
tone, or mood Catatonia: Psychologically induced
immobility occasionally marked by periods of
The symptoms of schizophrenia are divided into two major
agitation or excitement; the client seems motionless, as
categories: positive or hard symptoms/signs, which include
if in a trance
delusions, hallucinations, and grossly disorganized thinking,
Flat affect:Absence of any facial expression that
speech, and behavior, and negative or soft symptoms/signs,
would indicate emotions or mood.
which include flat affect, lack of volition, and social
withdrawal or discomfort. Avolition or lack of volition: Absence of will, ambition,
or drive to take action or accomplish tasks
Inattention: Inability to concentrate or focus on a topic
Positive and Negative Symptoms of or activity, regardless of its importance.
Schizophrenia
Positive or Hard Symptoms Schizoaffective disorder is diagnosed when the client is
Ambivalence: Holding seemingly contradictory beliefs severely ill and has a mixture of psychotic and mood
or feelings about the same person, event, or situation. symptoms. The signs and symptoms include those of both
schizophrenia and a mood disorder such as depression or
(ang estado ng pagkakaroon ng halo-halong damdamin o
bipolar disorder. The symptoms may occur simultaneously
magkasalungat na mga ideya tungkol sa isang bagay o
or may alternate between psychotic and mood disorder
isang tao.) ex. If you love your mom but find her totally
symptoms. Some studies report that long-term outcomes for
embarrassing,
the bipolar type of schizoaffective disorder are similar to
Associative looseness: Fragmented or poorly related
those for bipolar disorder, while outcomes for the depressed
thoughts and ideas. ( thought-process disorder characterized
type of schizoaffective disorder are similar to those for
by a lack of connection between ideas. “I like to dance; my
schizophrenia. Treatment for schizoaffective disorder targets
feet are wet.”
both psychotic and mood symptoms. Often, second-
Delusions: Fixed false beliefs that have no basis in reality
generation antipsychotics are the best first choice for
Echopraxia: Imitation of the movements and gestures of treatment. Mood stabilizers or an antidepressant may be
another person whom the client is observing. added if neede
Flight of ideas: Continuous flow of verbalization in
which the person jumps rapidly from one topic to
another.
CLINICAL COURSE Antipsychotic medications play a crucial role in
the course of the disease and individual outcomes.
Although the symptoms of schizophrenia are always They do not cure the disorder; however, they are crucial
severe, the long-term course does not always involve to its successful management. The more effective the
progressive deterioration. The clinical course varies client’s response and adherence to his or her medication
among clients. regimen, the better the client’s outcome. Longer
periods of untreated psychosis lead to poorer long-term
Onset outcomes. Therefore, early detection and aggressive
treatment of the first psychotic episode with medication
Onset may be abrupt or insidious, but most clients slowly and psychosocial interventions are essential to
and gradually develop signs and symptoms such as promote improved outcomes, such as lower relapse rates
social withdrawal, unusual behavior, loss of interest in and improved insight, quality of life, and social
school or at work, and neglected hygiene. The diagnosis of functioning.
schizophrenia is usually made when the person begins to
display more actively positive symptoms of delusions, RELATED DISORDERS
hallucinations, and disordered thinking (psychosis).
Regardless of when and how the illness begins and the Schizoaffective disorder was described earlier. Other
type of schizophrenia, consequences for most clients and disorders are related to but distinguished from
their families are substantial and enduring. schizophrenia in terms of presenting symptoms and the
When and how the illness develops seems to affect duration or magnitude of impairment. Mojtabai et al.
the outcome. Age at onset appears to be an important (2017) identify:
factor in how well the client fares; those who develop the
illness earlier show worse outcomes than those who Schizophreniform disorder: The client exhibits an
develop it later. Younger clients display a poorer acute, reactive psychosis for less than the 6 months
premorbid adjustment, more prominent negative signs, and necessary to meet the diagnostic criteria for
greater cognitive impairment than do older clients. Those schizophrenia. If symptoms persist over 6 months, the
who experience a gradual onset of the disease (about diagnosis is changed to schizophrenia. Social or
50%) tend to have a poorer immediate- and long-term occupational functioning may or may not be impaired.
course than those who experience an acute and sudden
 Catatonia: Catatonia is characterized by marked
onset. Approximately one-third to one-half of clients with
psychomotor disturbance, either excessive motor
schizophrenia relapse within 1 year of an acute episode.
activity or virtual immobility and motionlessness.
Higher relapse rates are associated with nonadherence to
Motor immobility may include catalepsy (waxy
medication, persistent substance use, caregiver criticism,
flexibility) or stupor. Excessive motor activity is
and negative attitude toward treatment (Wade, Tai,
apparently purposeless and not influenced by
Awenot, & Haddock, 2017).
external stimuli. Other behaviors include extreme
negativism, mutism, peculiar movements, echolalia,
Immediate-Term Course
or echopraxia. Catatonia can occur with
In the years immediately after the onset of psychotic schizophrenia, mood disorders, or other psychotic
symptoms, two typical clinical patterns emerge. In one disorders.
pattern, the client experiences ongoing psychosis and  Delusional disorder: The client has one or
never fully recovers, though symptoms may shift in more nonbizarre delusions— that is, the focus of
severity over time. In another pattern, the client the delusion is believable. The delusion may be
experiences episodes of psychotic symptoms that persecutory, erotomanic, grandiose, jealous, or
alternate with episodes of relatively complete recovery somatic in content. Psychosocial functioning is not
from the psychosis. markedly impaired, and behavior is not obviously
odd or bizarre.
 Brief psychotic disorder: The client experiences
Long-Term Course the sudden onset of at least one psychotic
symptom, such as delusions, hallucinations, or
The intensity of psychosis tends to diminish with age. disorganized speech or behavior, which lasts from 1
Many clients with long- term impairment regain some day to 1 month. The episode may or may not have
degree of social and occupational functioning. Over time, an identifiable stressor or may follow childbirth.
the disease becomes less disruptive to the person’s life  Shared psychotic disorder (folie à deux): Two
and easier to manage but rarely can the client overcome people share a similar delusion. The person with this
the effects of many years of dysfunction. In later life, these diagnosis develops this delusion in the context of a
clients may live independently or in a structured family- close relationship with someone who has psychotic
type setting and may succeed at jobs with stable delusions, most commonly siblings, parent and child,
expectations and a supportive work environment. or husband and wife. The more submissive or
However, many clients with schizophrenia have difficulty suggestible person may rapidly improve if
functioning in the community, and few lead fully separated from the dominant person.
independent lives. This is primarily due to persistent  Schizotypal personality disorder: This involves
negative symptoms, impaired cognition, or treatment- odd, eccentric behaviors, including transient
refractory positive symptoms (Jablensky, 2017). psychotic symptoms. Approximately 20% of persons
with this personality disorder will eventually be
diagnosed with schizophrenia.
 ETIOLOGY though their genes are 100% identical. Rather, recent
studies indicate that the genetic risk of schizophrenia is
Whether schizophrenia is an organic disease with
polygenic, meaning several genes contribute to the
underlying physical brain pathology has been an
important question for researchers and clinicians for as development (Kendall, Kirov, & Owen, 2017).
long as they have studied the illness. In the first
half of the 20th century, studies focused on trying to Neuroanatomic and Neurochemical Factors
find a particular pathologic structure associated with the With the development of noninvasive imaging
disease, largely through autopsy. Such a site was not techniques, such as computed tomography, magnetic
discovered. In the 1950s and 1960s, the emphasis resonance imaging, and positron emission tomography,
shifted to examination of psychological and social in the past 25 years, scientists have been able to study the
causes. Interpersonal theorists suggested that brain structure (neuroanatomy) and activity
schizophrenia resulted from dysfunctional relationships (neurochemistry) of people with schizophrenia. Findings
in early life and adolescence. None of the interpersonal have demonstrated that people with schizophrenia have
theories has been proved, and newer scientific studies are relatively less brain tissue and cerebrospinal fluid than
finding more evidence to support those who do not have schizophrenia; this could
neurologic/neurochemical causes. However, some represent a failure in the development or a subsequent
therapists still believe that schizophrenia results from loss of tissue. Computed tomography scans have shown
dysfunctional parenting or family dynamics. For parents enlarged ventricles in the brain and cortical atrophy.
or family members of persons diagnosed with Positron emission tomography studies suggest that
schizophrenia, such beliefs cause agony over what they glucose metabolism and oxygen are diminished in the
did “wrong” or what they could have done to help frontal cortical structures of the brain. The research
prevent it. consistently shows decreased brain volume and abnormal
Newer scientific studies began to demonstrate that brain function in the frontal and temporal areas of
schizophrenia results from a type of brain dysfunction. persons with schizophrenia. This pathology correlates
In the 1970s, studies began to focus on possible with the positive signs of schizophrenia (temporal lobe),
neurochemical causes, which remain the primary such as psychosis, and the negative signs of
focus of research and theory today. These schizophrenia (frontal lobe), such as lack of volition or
neurochemical/neurologic theories are supported by motivation and anhedonia. It is unknown whether these
the effects of antipsychotic medications, which help changes in the frontal and temporal lobes are the result of
control psychotic symptoms, and neuroimaging tools a failure of these areas to develop properly or whether a
such as computed tomography, which have shown that virus, trauma, or immune response has damaged them.
the brains of people with schizophrenia differ in structure Intrauterine influences, such as poor nutrition, tobacco,
and function from those of control subjects. alcohol, and other drugs, and stress are also being studied
as possible causes of the brain pathology found in
Biologic Theories people with schizophrenia (Kendall et al., 2017).
Neurochemical studies have consistently demonstrated
The biologic theories of schizophrenia focus on genetic alterations in the neurotransmitter systems of the brain in
factors, neuroanatomic and neurochemical factors people with schizophrenia. The neuronal networks that
(structure and function of the brain), and transmit information by electrical signals from a nerve
immunovirology (the body’s response to exposure to a cell through its axon and across synapses to postsynaptic
virus). receptors on other nerve cells seem to malfunction. The
transmission of the signal across the synapse requires a
Genetic Factors complex series of biochemical events. Studies have
implicated the actions of dopamine, serotonin,
Most genetic studies have focused on immediate families
norepinephrine, acetylcholine, glutamate, and several
(i.e., parents, siblings, and offspring) to examine
neuromodulary peptides.
whether schizophrenia is genetically transmitted or
inherited. Few have focused on more distant relatives. Currently, the most prominent neurochemical
The most important studies have centered on twins; these theories involve dopamine and serotonin. One
findings have demonstrated that identical twins have a prominent theory suggests excess dopamine as a
50% risk of schizophrenia; that is, if one twin has cause. This theory was developed on the basis of two
schizophrenia, the other has a 50% chance of developing observations: First, drugs that increase activity in the
it as well. Fraternal twins have only a 15% risk. This dopaminergic system, such as amphetamine and
finding indicates a genetic vulnerability or risk of levodopa, sometimes induce a paranoid psychotic
schizophrenia. reaction similar to schizophrenia. Second, drugs blocking
postsynaptic dopamine receptors reduce psychotic
Other important studies have shown that children with one
symptoms; in fact, the greater the ability of the drug to
biologic parent with schizophrenia have a 15% risk; the risk
block dopamine receptors, the more effective it is in
rises to 35% if both biologic parents have schizophrenia.
decreasing symptoms of schizophrenia (Perez & Ghose,
Children adopted at birth into a family with no history of 2017).
schizophrenia but whose biologic parents have a history of More recently, serotonin has been included among
schizophrenia still reflect the genetic risk of their biologic the leading neurochemical factors affecting
parents. All these studies have indicated a genetic risk or schizophrenia. The theory regarding serotonin suggests
tendency for schizophrenia, but Mendelian genetics cannot that serotonin modulates and helps to control excess
be the only factor; identical twins have only a 50% risk even dopamine. Some believe that excess serotonin itself
contributes to the development of schizophrenia. Newer  Locura refers to a chronic psychosis experienced by
atypical antipsychotics, such as clozapine (Clozaril), Latinos in the United States and Latin America.
are both dopamine and serotonin antagonists. Drug Symptoms include incoherence, agitation, visual and
studies have shown that clozapine can dramatically auditory hallucinations, inability to follow social
reduce psychotic symptoms and ameliorate the negative rules, unpredictability, and, possibly, violent
signs of schizophrenia (Kane & Correll, 2017). behavior.

Immunovirologic Factors
Popular theories have emerged, stating that exposure to a  Qi-gong psychotic reaction is an acute, time-
virus or the body’s immune response to a virus could limited episode characterized by dissociative,
alter the brain physiology of people with schizophrenia. paranoid, or other psychotic symptoms that occur
Although scientists continue to study these possibilities, after participating in the Chinese folk health-
few findings have validated them. enhancing practice of qi-gong. Especially vulnerable
Cytokines are chemical messengers between immune are those who become overly involved in the
cells, mediating inflammatory and immune responses. practice.
Specific cytokines also play a role in signaling the brain  Zar, an experience of spirits possessing a person, is
to produce behavioral and neurochemical changes seen in Ethiopia, Somalia, Egypt, Sudan, Iran, and
needed in the face of physical or psychological stress to other North African and Middle Eastern societies.
maintain homeostasis. It is believed that cytokines may The afflicted person may laugh, shout, wail, bang his
have a role in the development of major psychiatric or her head on a wall, or be apathetic and withdrawn,
disorders such as schizophrenia (Dahan et al., 2018). refusing to eat or carry out daily tasks. Locally, such
Recently, researchers have been focusing on behavior is not considered pathologic.
infections in pregnant women as a possible origin for Ethnicity may also be a factor in the way a person
schizophrenia. Waves of schizophrenia in England, responds to psychotropic medications. This
difference in response is probably the result of the
Wales, Denmark, Finland, and other countries have person’s genetic makeup. Some people metabolize
occurred a generation after influenza epidemics. Also, certain drugs more slowly, so the drug level in the
there are higher rates of schizophrenia among children bloodstream is higher than desired. In a study on
born in crowded areas in cold weather, conditions that poor treatment response, researchers found
are hospitable to respiratory ailments (Kendall et al., subtherapeutic plasma levels in some individuals
2017). despite having been administered therapeutic doses
Awareness of cultural differences is important when of the medication .
assessing for symptoms of schizophrenia. Ideas that are
considered delusional in one culture, such as beliefs in TREATMENT
sorcery or witchcraft, may be commonly accepted by
other cultures. Also, auditory or visual hallucinations, Psychopharmacology
such as seeing the Virgin Mary or hearing God’s voice,
may be a normal part of religious experiences in some  CHLORPROMAZINE (1952) was the first antipsychotic
cultures. The assessment of affect requires sensitivity to drug. . (bipolar disorder, schizophrenia, acute psychosis).
differences in eye contact, body language, and acceptable First-generation/typical
emotional expression; these vary across cultures. antipsychotics → chlorpromazine, haloperidol (oral and
Psychotic behavior observed in countries other than long-acting injectable), fluphenazine decanoate.
the United States or among particular ethnic groups has Second-generation/atypical antipsychotics → clozapine,
been identified as a “culture-bound” syndrome. Although olanzapine, quetiapine, risperidone.
these episodes exist primarily in certain countries, they Antidepressants → fluoxetine, sertraline, escitalopram.
may be seen in other places as people visit or immigrate ( treatment choice for depression)
to other countries or areas. Some examples of culture- Mood stabilisers → lithium carbonate, valproic acid,
bound syndromes are as follows: carbamazepine, lamotrigine
 Bouffée délirante is a syndrome found in West Anticholinergics → biperiden, diphenhydramine (drugs
Africa and Haiti, characterized by a sudden outburst that block and inhibit the activity of the neurotransmitter
of agitated and aggressive behavior, marked acetylcholine (ACh) at both central and peripheral nervous
confusion, and psychomotor excitement. It is system synapses.
sometimes accompanied by visual and auditory Benzodiazepine → clonazepam ( a type of sedative
hallucinations or paranoid ideation. medication. This means they slow down the body and
 Ghost sickness is preoccupation with death and the brain's functions. They can be used to help with anxiety and
deceased frequently observed among members of insomnia (difficult getting to sleep or staying asleep).
some Native American tribes. Symptoms include Cholinesterase inhibitor → donepezil (decrease the
bad dreams, weakness, feelings of danger, loss of breakdown of acetylcholine. ) Acetylcholine (ACh) is a
appetite, fainting, dizziness, fear, anxiety, neurotransmitter, a chemical that carries messages from
hallucinations, loss of consciousness, confusion, your brain to your body through nerve cells. It's an
feelings of futility, and a sense of suffocation. excitatory neurotransmitter. This means it “excites” the
 Jikoshu-kyofu is a condition characterized by a fear nerve cell and causes it to “fire off the message.”
of offending others by emitting foul body odor. This NMDA receptor antagonist → memantine (NMDA (short
was first described in Japan in the 1960s and has two for N-methyl Daspartate) receptor antagonists are a class
subtypes, either with or without delusions of drugs that may help treat Alzheimer's disease, which
causes memory loss, brain damage, and, eventually, death. reactions, akathisia, and parkinsonism), tardive
There's no cure for Alzheimer's, but some drugs may slow it dyskinesia, seizures, and neuroleptic malignant
down. syndrome (NMS; discussion to follow). Nonneurologic
side effects include weight gain, sedation,
photosensitivity, and anticholinergic symptoms, such as
The primary medical treatment for schizophrenia is dry mouth, blurred vision, constipation, urinary retention,
psychopharmacology. In the past, electroconvulsive and orthostatic hypotension. Table 16.2 lists the side
therapy, insulin shock therapy, and psychosurgery were effects of antipsychotic medications and appropriate
used, but since the creation of CHLORPROMAZINE nursing interventions.
(Thorazine) in 1952, other treatment modalities have
become all but obsolete. Antipsychotic medications, also
known as neuroleptics, are prescribed primarily for their
efficacy in decreasing psychotic symptoms. They do not
cure schizophrenia; rather, they are used to manage the
symptoms of the disease.
The conventional, or first-generation, antipsychotic
medications are dopamine antagonists. The atypical, or
second-generation, antipsychotic medications are both
dopamine and serotonin antagonist.The first-generation
antipsychotics target the positive signs of
schizophrenia, such as delusions, hallucinations,
disturbed thinking, oil; therefore, the medications are
absorbed slowly over time into the client’s system. The
effects of the medications last 2 to 4 weeks, eliminating
the need for daily oral antipsychotic medication.. The
duration of action is 7 to 28 days for fluphenazine and
4 weeks for haloperidol. The other four second-
generation antipsychotics are contained in polymer-
based microspheres that degrade slowly in the body. It
may take several weeks of oral therapy with these
medications to reach a stable dosing level before the
transition to depot injections can be made. Therefore,
these preparations are not suitable for the management of
acute episodes of psychosis. They are, however, useful
for clients requiring supervised medication compliance
over an extended period.
In addition, some studies have shown that the second-
generation LAIs are more effective than oral forms of the
medication in controlling negative symptoms and
improving psychosocial functioning. Yet, clinicians may Extrapyramidal Side Effects. EPSs are reversible
be reluctant to prescribe the LAIs because they assume movement disorders induced by neuroleptic medication.
patients are reluctant to have injections. They include dystonic reactions, parkinsonism, and
akathisia.
The First Filipino Psychiatrist Dystonic reactions to antipsychotic medications appear
In 1917, dr. Elias Domingo ( a graduate of UP Class of early in the course of treatment and are characterized by
1913), then chief resident in Medicine, was sent tp spasms in discrete muscle groups, such as the neck
Pennsylvania, as Rockefeller scholar for two years to muscles (torticollis) or eye muscles (oculogyric crisis).
undertake training in Psychiatry. Upon his return to the These spasms may also be accompanied by protrusion of
country, Dr. Domingo headed the Insane Department of San the tongue, dysphagia, and laryngeal and pharyngeal
Lazaro hospital. He is considered the first Filipino spasms that can compromise the client’s airway, causing a
psychiatrist. medical emergency. Dystonic reactions are extremely
frightening and painful for the client. Acute treatment
This was considered the country’s first hospital unit for consists of diphenhydramine(Benadryl)given either
the mentally ill. - San Lazaro Hospital in November intramuscularly or intravenously, or benztropine
1904, under the newly created Bureau of Health. (Cogentin) given intramuscularly. Pseudoparkinsonism, or
neuroleptic-induced parkinsonism, includes a shuffling
Side Effects gait, masklike facies, muscle stiffness (continuous) or
cogwheeling rigidity (ratchet-like movements of joints),
The side effects of antipsychotic medications are drooling, and akinesia (slowness and difficulty initiating
significant and can range from mild discomfort to movement). These symptoms usually appear in the
permanent movement disorders. Because many of first few days after starting or increasing the dosage of an
these side effects are frightening and upsetting to clients, antipsychotic medication.
they are frequently cited as the primary reason that
clients discontinue or reduce the dosage of their
medications. Serious neurologic side effects include
extrapyramidal side effects (EPSs) (acute dystonic
 clozapine, which has an incidence of 5%. Seizures may
be associated with high doses of the medication.
Treatment is a lowered dosage or a different
antipsychotic medication.

Neuroleptic Malignant Syndrome. NMS is a serious

and frequently fatal condition seen in those being treated
with antipsychotic medications. It is characterized by
muscle rigidity, high fever, increased muscle enzymes
(particularly, creatine phosphokinase), and leukocytosis
(increased leukocytes). It is estimated that 0.1% to 1% of
all clients taking antipsychotics develop NMS. Any of
the antipsychotic medications can cause NMS, which is
treated by stopping the medication. The client’s ability to
Akathisia is characterized by restless movement, pacing, tolerate other antipsychotic medications after NMS
inability to remain still, and the client’s report of inner varies, but use of another antipsychotic appears possible
restlessness. Akathisia usually develops when the in most instances.
antipsychotic is started or when the dose is increased.
Clients are typically uncomfortable with these sensations
and may stop taking the antipsychotic medication to avoid
these side effects. Beta-blockers such as propranolol have
been most effective in treating akathisia, and
benzodiazepines have provided some success as well. The
early detection and successful treatment of EPSs is
important in promoting the client’s compliance with
medication. The nurse is most often the person who
observes these symptoms or the person to whom the client
reports symptoms. To provide consistency in assessment
among nurses working with the client, a standardized
rating scale for EPSs is useful. The Simpson–Angus scale
for EPS is one tool that can be used.

Tardive Dyskinesia. Tardive dyskinesia, a late-appearing

side effect of antipsychotic medications, is characterized
by abnormal, involuntary movements such as lip
smacking, tongue protrusion, chewing, blinking,
grimacing, and choreiform movements of the limbs and
feet. These involuntary movements are embarrassing for
clients and may cause them to become more socially
isolated. Tardive dyskinesia is irreversible once it appears,
but decreasing or discontinuing the medication can arrest
the progression. In addition, newly approved medications
to treat tardive dyskinesia, valbenazine (Ingrezza) and
deutetrabenazine (Austedo, Teva), are now available (see
Chapter 2). Clozapine (Clozaril), an atypical antipsychotic
drug, has not been found to cause this side effect, so it is
often recommended for clients who have experienced
tardive dyskinesia while taking conventional antipsychotic
drugs.
Screening clients for late-appearing movement disorders
such as tardive dyskinesia is important. The Abnormal
Involuntary Movement Scale (AIMS) is used to screen
for symptoms of movement disorders. The client is
observed in several positions, and the severity of
symptoms is rated from 0 to 4. The AIMS can be
administered every 3 to 6 months. If the nurse detects an
increased score on the AIMS, indicating increased
symptoms of tardive dyskinesia, he or she should notify
the physician so that the client’s dosage or drug can be
changed to prevent advancement of tardive dyskinesia.

Seizures. Seizures are an infrequent side effect associated

with antipsychotic medications. The incidence is 1% of
people taking antipsychotics. The notable exception is
 . meaningful relationships with other people. Groups that
focus on topics of concern such as medication management,
use of community supports, and family concerns have also
been beneficial to clients with schizophrenia (Schaub,
Hippius, Moller, & Falkai, 2016). Clients with schizophrenia
can improve their social competence with social skill
training, which translates into more effective functioning in
the community. Basic social skill training involves breaking
complex social behavior into simpler steps, practicing
through role-playing, and applying the concepts in the
community or real-world setting. Cognitive adaptation
training using environmental supports is designed to
improve adaptive functioning in the home setting.
Individually tailored environmental supports such as signs,
calendars, hygiene supplies, and pill containers cue the client
to perform associated tasks. This psychosocial skill training
was more effective when carried out during in-home visits
in the client’s own environment rather than in an
outpatient setting.

Agranulocytosis. Clozapine has the potentially fatal side

effect of agranulocytosis (failure of the bone marrow to
produce adequate white blood cells). Agranulocytosis
develops suddenly and is characterized by fever, malaise,
ulcerative sore throat, and leukopenia. This side effect may
not be manifested immediately but can occur as long as 18
to 24 weeks after the initiation of therapy. The drug must
be discontinued immediately. Clients taking this
antipsychotic must have weekly white blood cell Unusual Speech Patterns of Clients with
counts for the first 6 months of clozapine therapy and Schizophrenia
every 2 weeks thereafter. Clozapine is dispensed every 7 or Clang associations are ideas that are related to one
14 days only, and evidence of a white blood cell count another based on sound or rhyming rather than meaning.
above 3,500 cells/mm3 is required before a refill is Example: “I will take a pill if I go up the hill but not
furnished. if my name is Jill, I don’t want to kill.”
Neologisms are words invented by the client.
Psychosocial Treatment Example: “I’m afraid of grittiz. If there are any
grittiz here, I will have to leave. Are you a grittiz?”
In addition to pharmacologic treatment, many other Verbigeration is the stereotyped repetition of words or
modes of treatment can help the person with phrases that may or may not have meaning to the listener.
schizophrenia. Individual and group therapies, family Example: “I want to go home, go home, go home, go
therapy, family education, and social skills training can be home.” Echolalia is the client’s imitation or repetition
instituted for clients in both inpatient and community of what the nurse says. Example: Nurse: “Can you tell
settings. me how you’re feeling?”
Individual and group therapy sessions are often supportive in
nature, giving the client an opportunity for social contact and
 Client: “Can you tell me how you’re feeling, how you’re suddenly stop talking in the middle of a sentence and
feeling?” Stilted language is use of words or phrases remain silent for several seconds to 1 minute (thought
that are flowery, excessive, and pompous. blocking). They may also state that they believe
Example: “Would you be so kind, as a others can hear their thoughts (thought broadcasting),
representative of Florence Nightingale, as to do me that others are taking their thoughts (thought
the honor of providing just a wee bit of refreshment, withdrawal), or that others are placing thoughts in
perhaps in the form of some clear spring water?” their mind against their will (thought insertion).
Perseveration is the persistent adherence to a single idea Clients may also exhibit tangential thinking, which is
or topic and verbal repetition of a sentence, phrase, or veering onto unrelated topics and never answering the
word, even when another person attempts to change the original question: Circumstantiality may be evidenced if the
topic. client gives unnecessary details or strays from the topic but
Example: Nurse: “How have eventually provides the requested information:
you been sleeping lately?”
Client: “I think people have Thought broadcasting
been following me.” Nurse:
“Where do you live?” Nurse: “How have you been sleeping lately?”
Client: “At my place people have been following me.” Client: “Oh, I go to bed early, so I can get plenty of rest. I
like to listen to music or read before bed. Right now I’m
reading a good mystery. Maybe I’ll write a mystery
Mood and Affect someday. But it isn’t helping, reading I mean. I have been
Clients with schizophrenia report and demonstrate getting only 2 or 3 hours of sleep at night.”
wide variations in mood and affect. They are often Poverty of content (alogia) describes the lack of any real
described as having flat affect (no facial expression) meaning or substance in what the client says:
or blunted affect (few observable facial expressions).
The typical facial expression is often described as Nurse: “How have you been sleeping lately?”
masklike. The affect may also be described as silly, Client: “Well, I guess, I don’t know, hard to tell.”
characterized by giddy laughter for no apparent
reason. The client may exhibit an inappropriate Delusions
expression or emotions incongruent with the
context of the situation. This incongruence Clients with schizophrenia usually experience delusions
ranges from mild or subtle to grossly inappropriate. (fixed, false beliefs with no basis in reality) in the
For example, the client may laugh and grin while psychotic phase of the illness. A common characteristic of
describing the death of a family member or schizophrenic delusions is the direct, immediate, and total
weep while talking about the weather. certainty with which the client holds these beliefs.
The client may report feeling depressed and Because the client believes the delusion, he or she,
having no pleasure or joy in life (anhedonia). therefore, acts accordingly. For example, the client with
Conversely, he or she may report feeling all- delusions of persecution is probably suspicious,
knowing, all-powerful and not at all concerned with mistrustful, and guarded about disclosing personal
the circumstance or situation. It is more common for information; he or she may examine the room
the client to report exaggerated feelings of well-being periodically or speak in hushed, secretive tones.
during episodes of psychotic or delusional The theme or content of the delusions may vary. Box 16.4
thinking, and a lack of energy or pleasurable describes and provides examples of the various types of
feelings during the chronic, or long-term, phase of delusions. External contradictory information or facts
the illness. cannot alter these delusional beliefs. If asked why he or
she believes such an unlikely idea, the client often
Thought Process and Content replies, “I just know it.”

Schizophrenia is often referred to as a thought

disorder because that is the primary feature of the
disease: Thought processes become disordered, and
the continuity of thoughts and information processing
is disrupted. The nurse can assess thought process
by inferring from what the client says. He or she
can assess thought content by evaluating what the
client actually says. For example, clients may
Types of Delusions later in the illness, he or she may recognize them as
hallucinations.
Persecutory/paranoid delusions involve the client’s Hallucinations are distinguished from illusions, which
belief that “others” are planning to harm him or her or are are misperceptions of actual environmental stimuli. For
spying, following, ridiculing, or belittling the client in example, while walking through the woods, a person
some way. Sometimes the client cannot define who these believes he sees a snake at the side of the path. On
“others” are. closer examination, however, he discovers it is only
Examples: The client may think that food has been poisoned a curved stick. Reality or factual information corrected
or that rooms are bugged with listening devices. Sometimes this illusion. Hallucinations, however, have no such basis
the “persecutor” is the government, FBI, or another powerful in reality.
organization. Occasionally, specific individuals, even family The following are the various types of hallucinations
members, may be named as the persecutor. (Lewis, Escalona, & Owen, 2017):
Grandiose delusions are characterized by the client’s  Auditory hallucinations, the most common type,
claim to association with famous people or involve hearing sounds, most often voices,
celebrities, or the client’s belief that he or she is talking to or about the client. There may be one
famous or capable of great feats. or multiple voices; a familiar or unfamiliar
Examples: The client may claim to be engaged to a person’s voice may be speaking. Command
famous movie star or related to some public figure, hallucinations are voices demanding that the
such as claiming to be the daughter of the president client take action, often to harm the self or
of the United States, or he or she may claim to have others, and are considered dangerous.
found a cure for cancer.  Visual hallucinations involve seeing images that
Religious delusions often center around the second do not exist at all, such as lights or a dead
coming of Christ or another significant religious person, or distortions such as seeing a
figure or prophet. These religious delusions appear frightening monster instead of the nurse. They
suddenly as part of the client’s psychosis and are not are the second most common type of
part of his or her religious faith or that of others. hallucination.
Examples: The client claims to be the Messiah or  Olfactory hallucinations involve smells or
some prophet sent from God and believes that God odors. They may be a specific scent such as
communicates directly to him or her or that he or she urine or feces or a more general scent such as a
has a special religious mission in life or special rotten or rancid odor. In addition to clients with
religious powers. schizophrenia, this type of hallucination often
Somatic delusions are generally vague and occurs with dementia, seizures, or
unrealistic beliefs about the client’s health or bodily cerebrovascular accidents.
functions. Factual information or diagnostic testing  Tactile hallucinations refer to sensations such as
does not change these beliefs. electricity running through the body or bugs
Examples: A male client may say that he is pregnant, crawling on the skin. Tactile hallucinations
or a client may report decaying intestines or worms in are found most often in clients undergoing
the brain. alcohol withdrawal; they rarely occur in clients
Sexual delusions involve the client’s belief that his or with schizophrenia.
her sexual behavior is known to others; that the client  Gustatory hallucinations involve a taste lingering
is a rapist, prostitute, or pedophile or is pregnant; or in the mouth or the
that his or her excessive masturbation has led to sense that food tastes like something else. The
insanity. taste may be metallic or bitter or may be
Nihilistic delusions are the client’s belief that his or represented as a specific taste.
her organs aren’t functioning or are rotting away, or  Cenesthetichallucinations involve the client’s
that some body part or feature is horribly disfigured or report that he or she feels bodily functions that
misshapen. are usually undetectable. Examples would be the
Referential delusions or ideas of reference involve sensation of urine forming or impulses being
the client’s belief that television broadcasts, music, or transmitted through the brain.
newspaper articles have special meaning for him or  Kinesthetic hallucinations occur when the client
her. is motionless but reports the sensation of bodily
Examples: The client may report that the president movement. Occasionally, the bodily movement
was speaking directly to him on a news broadcast or is something unusual, such as floating above the
that special messages are sent through newspaper ground.
articles.

Sensorium and Intellectual Processes Judgment and Insight

Judgment is frequently impaired in the client with
One hallmark symptom of schizophrenic psychosis is
schizophrenia. Because judgment is based on the ability to
hallucinations (false sensory perceptions, or perceptual
interpret the environment correctly, it follows that the client
experiences that do not exist in reality). Hallucinations
with disordered thought processes and environmental
can involve the five senses and bodily sensations. They
misinterpretations will have great difficulty with judgment. At
can be threatening and frightening for the client; less
times, lack of judgment is so severe that clients cannot meet
frequently, clients report hallucinations as pleasant.
their needs for safety and protection and place themselves in
Initially, the client perceives hallucinations as real, but
harm’s way. This difficulty may range from failing to wear
warm clothing in cold weather to failing to seek medical care There are many neurotransmitters. Some of the most
even when desperately ill. important in terms of psychopharmacological treatment and
drugs of abuse are outlined in Table 1. The neurons that
Self-Concept release these neurotransmitters, for the most part, are localized
within specific circuits of the brain that mediate these
Deterioration of the concept of self is a major behaviors. Psychoactive drugs can either increase activity at
problem in schizophrenia. The phrase loss of ego the synapse (these are called agonists) or reduce activity at the
boundaries describes the client’s lack of a clear sense synapse (antagonists). Different drugs do this by different
of where his or her own body, mind, and influence end mechanisms, and some examples of agonists and antagonists
and where those aspects of other animate and are presented in Table 2. For each example, the drug’s trade
inanimate objects begin. This lack of ego boundaries is name, which is the name of the drug provided by the drug
evidenced by depersonalization, derealization company, and generic name (in parentheses) are provided.
(environmental objects become smaller or larger or seem
unfamiliar), and ideas of reference. Clients may believe
they are fused with another person or object, may not
recognize body parts as their own, or may fail to know
whether they are male or female. These difficulties are the
source of many bizarre behaviors such as public
undressing or masturbating, speaking about oneself in
the third person, or physically clinging to objects in the
environment. Body image distortion may also occur.

Roles and Relationships

Social isolation is prevalent in clients with schizophrenia,
partly as a result of positive signs such as delusions,
hallucinations, and loss of ego boundaries. Relating to
others is difficult when oneself concept is not clear.
Clients also have problems with trust and intimacy, which
interfere with the ability to establish satisfactory
relationships. Low self-esteem, one of the negative
signs of schizophrenia, further complicates the client’s
ability to interact with others and the environment. These
clients lack confidence, feel strange or different from
other people, and do not believe they are worthwhile. The
result is avoidance of other people.

Introduction
Psychopharmacology, the study of how drugs affect the
brain and behavior, is a relatively new science, although
people have probably been taking drugs to change how
they feel from early in human history (consider the of
eating fermented fruit, ancient beer recipes, chewing on
the leaves of the cocaine plant for stimulant properties as
justsome examples). The word psychopharmacology itself
tells us that this is a field that bridges our understanding
of behavior (and brain) and pharmacology, and the range
of topics included within this field is extremely broad.
Drugs that alter our feelings and behavior do so by affecting
the communication

Virtually any drug that changes the way you feel does this by
altering how neurons communicate with each other. Neurons
(more than 100 billion in your nervous system) communicate
with each other by releasing a chemical (neurotransmitter)
across a tiny space between two neurons (the synapse). When
the neurotransmitter crosses the synapse, it binds to a
postsynaptic receptor (protein) on the receiving neuron and
the message may then be transmitted onward. Obviously,
neurotransmission is far more complicated than this – links at
the end of this module can provide some useful background if
you want more detail – but the first step is understanding that
virtually all psychoactive drugs interfere with or alter how
neurons communicate with each other.