Schizophrenia Nursing Assessments and Interventions

Schizophrenia is a psychiatric disorder that causes the individual to have altered thoughts, moods perceptions and behavior. It is a type of psychosis, with four subsets that include schizoaffective disorder, paranoid schizophrenia, catatonic schizophrenia and undifferentiated schizophrenia. Though one of the more serious and debilitating mental illnesses, schizophrenia does not usually cause a person to be violent or dangerous. It is considered a chronic brain disorder that can be managed with psychiatric treatment and medication. 

Research shows that schizophrenia affects men and women equally, though onset is typically earlier in males. In general, schizophrenia symptoms begin to show in the late teens to early 20s for males and late 20s to early 30s for females. 

What are the symptoms of schizophrenia?

The severity of symptoms vary from person to person. Stress, use of alcohol or drugs, and failure to comply with medication regimens can all cause symptoms to increase. The symptoms of schizophrenia can be generalized into four categories:

• Positive symptoms are those the individual experiences that are not part of reality. This includes hallucinations (like seeing things or hearing voices that aren’t there), distorted perceptions of reality and delusions. 
• Negative symptoms are present when something is lacking. This is typically a loss of the ability to speak, express emotion, find pleasure or take action.
• Impaired cognition presents as difficulty concentrating, problems with memory and declining intellectual capabilities.
• Disorganization symptoms are those that exhibit as confusion, bizarre behavior, abnormal body movements, disordered speech, and trouble exhibiting logical thought patterns

What is disorganized speech?

The speech patterns of patients with schizophrenia can take many different forms and these terms will be on your exams as well as a component of your care plans. 

• Word salad: words strung together that have no relation to one another; may also be referred to as “paraphasia.”
• Pressured speech: speech that occurs rapidly making it challenging for those listening to understand; the speaker may not pause at the appropriate points and words may be jumbled.
• Neologisms: made up words or common words used in a bizarre manner.
• Echolalia: mimicking what others are saying
• Clang associations: grouping words together based on similar sounds rather than logic; the words often rhyme, though sometimes only partially

What is disorganized thinking?

Disorganized thinking will present in patients with schizophrenia in a variety of ways:

• Loose associations: incoherent thinking expressed with frequent changes in topic
• Tangentiality: the speaker’s train of thought lacks focus and veers off topic never to return to the initial idea
• Circumstantiality: the speaker’s focus will drift but comes back to the main point.
• Thought blocking: the thought process ends abruptly, displayed as sudden interruption in speech
• Concrete thinking: thinking that revolves around actual objects and events and does not pertain to generalizations, ideas or concepts

What are some negative symptoms?

• Flat affect/incongruence: absence of emotive expression
• Alogia (aka “poverty of speech”): very brief responses to questions, or the individual may not speak at all or only when prompted.
• Avolition: inability to initiate activities
• Anhedonia: inability to feel pleasure
• Apathy: lack of concern or emotion to thinks typically considered important
• Asociality: lack of engagement in social interaction

What are all the different types of delusions?

• Persecutory: the individual is under the impression they are being persecuted, that other people are out to harm them. Also often referred to as paranoid delusion.
• Grandiose delusion: the individual has an exaggerated sense of their own importance 
• Somatic delusion: the individual believes they have a serious medical problem or physical defect when none exists
• Jealous delusions: the individual is convinced their partner is being unfaithful when no evidence of infidelity is present
• Religious delusions: the individual has delusions of a religious nature, such as believing they are a saint or even a god
• Erotomanic delusions: the individual believes that another is in love with him or her
• Delusion of control: the belief that another person, group or external force is controlling the individual’s behavior, thoughts or feelings
• Mixed delusions: more than one type of delusion is displayed

What are the different types of hallucinations? 

• Visual: hallucinations are vivid and can include animals, religious figures, and other people; they are not always perceived as frightening, and the individual may or may not realize the hallucinations are not real
• Auditory: the individual may hear one or more voices that can often be perceived as demanding, but could be whispers or murmurs; affects more than 70% of patients with schizophrenia
• Tactile: the individual feels their body being touched when there is no basis for this stimulation
• Gustatory: the individual tastes a specific quality such as chemical, a rotten taste or a mixture when there has been no oral stimulation
• Command: these are typically auditory in nature and instruct the patient to take action which can range from innocuous to dangerous

What are the different types of schizophrenia?

Paranoid schizophrenia: An individual with paranoid schizophrenia will display positive symptoms in the form of delusions that are paranoid in nature. He will be unreasonably suspicious and may have auditory hallucinations as well. Negative symptoms often present as an inability to find pleasure in life or show appropriate emotional responses. This is the most common subtype of schizophrenia.

Catatonic schizophrenia: This is a rare type of schizophrenia and is generally believed to be due to disease that has gone untreated. The patient could have either a significant decrease in movement to the point of being immobile and resist being moved, or significantly increased movement that lacks purpose. This increased movement may be seen as echopraxia (mimicking the movements of others), bizarre posturing, rocking or echolalia (repeating what others say). Many times patients with catatonic schizophrenia will remain immobile for hours, and avoid eating and drinking. If this condition persists long enough, it is a medical emergency.

Disorganized schizophrenia: This form of schizophrenia involves disorganized speech and behavior as well as a flat or inappropriate affect. This patient will have incoherent speech or talk in what is referred to as “word salad.” Her behavior will be disorganized as well, with an inability to act appropriately in social situations or start and finish tasks. She will likely be unable to make proper eye contact or display facial expressions. You may also see disorganized schizophrenia referred to as “hebephrenic schizophrenia.”

Undifferentiated schizophrenia: This is a “catch-all” category for those who don’t fit neatly into any of the aforementioned categories. These patients will have signs and symptoms that fit into two or more of the other subtypes such as delusions, catatonia, disorganized speech or hallucinations. 

Residual schizophrenia: When patients are not experiencing significant symptoms of hallucination, disorganized behavior, catatonia or delusions they may still have distorted thoughts and beliefs or persistence of negative symptoms. When this is the case, we say the patient is exhibiting residual schizophrenia.

Schizoaffective disorder: When the patient has schizophrenia along with a mood disorder (mania, hypomania or depression), we call this schizoaffective disorder. Treatment for these patients can be challenging as the psychotic disorder must be treated in coordination with the mood imbalance as well. 

How is schizophrenia treated?

Schizophrenia is treated with a variety of medications including antipsychotics, neuroleptics, benzodiazepines and antidepressants. Non-adherence to medication regimens is a common occurrence due to the undesirable side effects, so it’s important that patients take the lowest possible dose in order to manage their symptoms. Antipsychotic medications are available in multiple formulations, making it easier to administer based on the individual’s needs and preferences. For example, depot injections are given once a month making them an option for those who will not reliably take medication every day. Other medications are given IM for acute psychotic episodes and others are available in tablets and liquids.  

Other treatments include:

• Therapy, both individually and as a family
• Vocational rehabilitation to help individuals with schizophrenia obtain work
• Social skills training to help the individual participate in social interactions appropriately
• Electroconvulsive therapy (ECT)
• Hospitalization when symptoms are severe and the individual is unable to take care of himself

Communicating with a patient with schizophrenia

The key to effective communication is to keep your statements focused on reality. Do not agree or disagree with the hallucination or delusion. Rather than probing for information about the delusion or hallucination, it’s important to reinforce anything that is grounded in reality. You should state what your reality is in a non-confrontational manner while respecting the individual’s feelings. For example, “I don’t see the snakes, John. Do they frighten you?” Be sure to speak slowly and calmly in a non-judgmental manner. Avoid quick movements and touching and always have the exit easily accessible so you can’t get cornered by an angry patient having a psychotic episode. As always, many of your interventions will be focused on keeping you and your patient safe. 

Get this on audio in Episode 81!

____________________________________________________________

The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

 

References 

American Psychiatric Association. (n.d.). What Is Schizophrenia? Retrieved November 10, 2019, from https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

Bitter, I. (2011, June 4). Pharmacological Treatment of Schizophrenia. Retrieved from TouchNEUROLOGY website: https://touchneurology.com/pharmacological-treatment-of-schizophrenia/

Cagliostro, D. (2018). 5 Schizophrenia Subtypes. Retrieved November 10, 2019, from Psycom.net—Mental Health Treatment Resource Since 1986 website: https://www.psycom.net/schizophrenia-5-subtypes

Cleveland Clinic. (2018, November 7). What Are the 4 Types of Schizophrenia and How Do They Affect You? Retrieved November 10, 2019, from Health Essentials from Cleveland Clinic website: https://health.clevelandclinic.org/what-are-the-4-types-of-schizophrenia-and-how-can-they-affect-you/

GoodTherapy. (2015). Poverty of Speech. Retrieved from GoodTherapy.org Therapy Blog website: https://www.goodtherapy.org/blog/psychpedia/poverty-of-speech

Henkin, R. I. (2016). Sensory Hallucinations. Retrieved November 10, 2019, from http://www.tasteandsmell.com/feb2016.html

Hugdahl, K., Løberg, E.-M., Specht, K., Steen, V. M., van Wageningen, H., & Jørgensen, H. A. (2008). Auditory hallucinations in schizophrenia: The role of cognitive, brain structural and genetic disturbances in the left temporal lobe. Frontiers in Human Neuroscience, 1. https://doi.org/10.3389/neuro.09.006.2007

Medical News Today. (n.d.). Pressured speech in bipolar disorder: Symptoms and causes. Retrieved November 10, 2019, from Medical News Today website: https://www.medicalnewstoday.com/articles/319186.php

Purse, M. (2019). How Clang Associations Happen in Psychotic Episodes. Retrieved November 10, 2019, from Verywell Mind website: https://www.verywellmind.com/clang-associations-380072

Smith, K. (2019). Schizophrenia: Understanding Hallucinations and Delusions. Retrieved from https://www.psycom.net/schizophrenia-hallucinations-delusions/