11.3 Schizophrenia

Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. It also affects the person’s ability to recognize their symptoms as problematic, referred to as a “lack of insight” or anosognosia. Continuous signs of the disturbance must be present for at least six months in order for schizophrenia to be diagnosed, and potential medical conditions that could be causing delirium must be ruled out.^[1],[2]

Schizophrenia is typically diagnosed in the late teen years to the early thirties and tends to emerge earlier in males than females. A diagnosis of schizophrenia often follows the first episode of psychosis when individuals first display symptoms of schizophrenia. Gradual changes in thinking, mood, and social functioning often begin before the first episode of psychosis, usually starting in mid-adolescence. (See “Psychosis” in the previous section.) Schizophrenia can occur in younger children, but it is rare for it to occur before late adolescence.^[3]

Symptoms of Schizophrenia

Symptoms of schizophrenia are classified by three categories: positive, negative, and cognitive.^[4]

• Positive symptoms: Positive symptoms include hallucinations, delusions, thought disorders, disorganized speech, and alterations in behaviors. Positive symptoms are thoughts and behaviors that are ‘added to’ the individual’s clinical picture; they are not normally present. Read more about delusions and hallucinations in Table 3.2’s “Thought and Perception” section in Chapter 3.3. The most common types of delusions experienced by individuals with schizophrenia are paranoia, persecutory, grandiose, or religious ideas. For example, an individual with persecutory delusions may feel the nursing staff is trying to poison them when they administer medications. People with psychotic symptoms lose a shared sense of reality and experience the world in a distorted way.^[5] For more on assessing a patient’s mental health see the “Recognizing Cues – Gathering Data to Care for Patients” section of Chapter 3.

• • Hallucinations: Hallucinations are disturbances in perception; the patient experiences sensory events that have no basis in reality. A person may see, hear, smell, taste, or feel things that are not actually there. Examples include hearing voices or music, seeing images, the feeling that insects are crawling on one’s skin, and a persistent sensation of a bad taste or smell. Hearing voices (auditory hallucinations) is common for people with schizophrenia. People who hear voices may hear them for a long time before family or friends notice a problem. A command hallucination is a dangerous type of auditory hallucination. The patient will report that the voice(s) are telling him or her to perform an act, often harming the self or someone else. Command hallucinations will be discussed more fully in the next section due to their impact on safety for the patient and staff.
  • Delusions: Delusions are fixed false beliefs that are not true and may seem irrational to others. For example, individuals experiencing delusions may believe that people on the radio and television are sending special messages that require a certain response, or they may believe that they are in danger or that others are trying to hurt them. Some common types are:
    • Persecutory or Paranoid: A belief that one is being persecuted or plotted against. Patients may believe they are being followed by the Federal Bureau of Investigation or may have a tracking device implanted. They may believe that they will be poisoned. This is the most common type of delusion and can lead to noncompliance with treatment.
    • Grandiose: A belief that one is overly important, powerful, or revered. They may believe they have special knowledge or power. Some grandiose delusions have religious overtones.
  • Disordered Thoughts as Manifested in Speech: A person with schizophrenia may have ways of thinking that are unusual or illogical. Their speech will reflect these distortions. People with thought disorder may have trouble organizing their thoughts and speech. Sometimes a person will stop talking in the middle of a thought (thought blocking), jump from topic to topic (flight of ideas), or make up words that have no meaning (neologisms). Other types of disorganized speech include:
    • • Echolalia: pathological repeating words that someone else has just said.
      • Circumstantiality: Adding excessive detail to a statement but eventually getting to the main idea.
      • Tangentiality: Wandering off a topic and never returning to the main idea.
      • Pressured speech: Urgent and intense speech with no tolerance for interruptions.
      • Thought insertion or deletion: A perception that thoughts are being placed in or removed from one’s brain

• Negative symptoms: Negative symptoms refer to loss of motivation, disinterest or lack of enjoyment in daily activities, social withdrawal, difficulty showing emotions, and difficulty functioning normally. These can be conceptualized as a ‘taking away’ of qualities that involve humanness and joy. Many of these symptoms start with the letter “A”. Individuals typically experience the following negative symptoms^[6]:
  • Avolition: Reduced motivation and difficulty planning, beginning, and sustaining activities.
  • Anhedonia: Diminished feelings of pleasure in everyday life.
  • Affective blunting: Reduced affect, or expression of emotion, flat affect. The affect may inappropriate or bizarre.
  • Alogia: Reduced output of speech.
  • Asociality: Reduced interaction and involvement with others.
  • Apathy: Decreased interest in activities or beliefs that would normally be interesting.
• Cognitive symptoms: Cognitive symptoms refer to problems in attention, concentration, and memory. For some individuals, the cognitive symptoms of schizophrenia are subtle, but for others, they are more prominent and interfere with activities like following conversations, learning new things, or remembering appointments. Individuals typically experience symptoms such as these^[7]:
  • Difficulty processing information to make decisions
  • Problems using information immediately after learning it
  • Trouble focusing or paying attention
  • Concrete thinking or inability to think abstractly
  • Memory difficulty
  • Anosognosia – lack of insight into having an illness
• Other symptoms: Patients with schizophrenia may exhibit behaviors and movements that are unusual.
  • Catatonia: A pronounced abnormality of movement and behavior arising from a disturbed mental state that may involve repetitive or purposeless activities. A particularly dangerous form of slowed movement is catalepsy, in which the patient exhibits muscular rigidity and lack of movement so severe that the limbs remain in whatever position they are placed. If persistent, this condition may lead to dehydration, malnutrition, and exhaustion.
  • Some patients will pace incessantly, even knocking others over (motor agitation). Others will exhibit greatly slowed movement (motor retardation). Additional behaviors include posturing, poor recognition of physical boundaries between people, mimicking movements of others (echopraxia), and poor impulse control.

See the following box for signs and symptoms for the diagnosis of schizophrenia according to the DSM-5.

Additionally, for a significant portion of time, the patient’s level of functioning in one or more areas, such as work, interpersonal relations, or self-care, is significantly below their prior level of functioning. Continuous signs of schizophrenia persist for at least six months (or less if it is successfully treated). Depressive or bipolar disorders with psychotic features must have been previously ruled out, and the disturbance is not attributable to the physiological effects of a substance or other medical condition. The provider may specify if this is the first episode or multiple episodes and if it is an acute episode, in partial remission, or in full remission.^[9]

See Figure 11.3a^[10]

Phases of Schizophrenia

Risk Factors for Schizophrenia

It is believed that several factors contribute to the risk of developing schizophrenia, including genetics, environment, and brain structure and function.^[12]

Genetics

Schizophrenia tends to run in families. About 80% of the risk for schizophrenia is thought to be due to genetic factors. Genetic studies strongly suggest that many different genes increase the risk of developing schizophrenia, but that no single gene causes the disorder by itself. It is not yet possible to use genetic information to predict who will develop schizophrenia.^[13]A systematic review found that cannabis (marijuana) worsens symptoms of psychosis in genetically predisposed individuals and causes more relapses and hospitalizations.^[14]

Environment

Interactions between genetic risk and aspects of an individual’s environment play a role in the development of schizophrenia. Causes under study include effects of toxins, social adversity, and life changes such as a move. Environmental factors that may be involved include adverse childhood experiences (ACE) or exposure to viruses or nutritional problems before birth.^[15]

Brain Structure and Function

Researchers have posited that differences in brain structure, function, and interactions among neurotransmitters may contribute to the development of schizophrenia. For example, differences in the volumes of specific components of the brain, the manner in which regions of the brain are connected and work together, and neurotransmitters, such as dopamine, are found in people with schizophrenia. Differences in brain connections and brain circuits seen in people with schizophrenia may begin developing before birth. Changes to the brain that occur during puberty may trigger psychotic episodes in people who are already vulnerable due to genetics, environmental exposures, or the types of brain differences mentioned previously.^[16]

Treatment

Schizophrenia is a chronic disorder that has a variable course and may involve repeated hospitalizations or institutionalization. Factors that worsen the prognosis include younger age at onset, a longer duration between the onset of symptoms and the beginning of treatment, and longer periods with no treatment. Early treatment of psychosis increases the chance of a successful remission.^[18] Treatments focus on managing symptoms and solving problems related to day-to-day functioning and include antipsychotic medications, psychosocial treatments, family education and support, coordinated specialty care, and assertive community treatment.^[19]

Antipsychotic Medications

Antipsychotic medications reduce the intensity and frequency of psychotic symptoms by inhibiting dopamine receptors. Certain symptoms of psychosis, such as feeling agitated and having hallucinations, resolve within days of starting an antipsychotic medication. Symptoms like delusions usually resolve within a few weeks, but the full effects of the medication may not be seen for up to six weeks.^[20]

Antipsychotic medicines are also used to treat other mental health disorders such as attention deficit hyperactivity disorder (ADHD), severe depression, eating disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and generalized anxiety disorder.^[21]

First-generation antipsychotics(also called “typical antipsychotics”) treat positive symptoms of schizophrenia and have several potential adverse effects due to their tight binding to dopamine receptors. Medication is prescribed based on the patient’s ability to tolerate the adverse effects. Second-generation antipsychotics(also referred to as “atypical antipsychotics”) treat both positive and negative symptoms of schizophrenia. They have fewer adverse effects because they block selective dopamine D2 receptors, as well as serotonin, so they are generally better tolerated than first-generation antipsychotics. Patients respond differently to antipsychotic medications, so it may take several trials of different medications to find the one that works best for their symptoms.^[22] Third-generation antipsychotics are newer medications that do not completely block D2 receptors: they are partial agonists, meaning they allow for limited dopamine transmission. They “stabilize” dopamine effects and thereby lessen psychotic symptoms. Adverse effects are similar to the second-generation medications.

See Table 11.1 for a list of common antipsychotic medications. They are usually taken daily in pill or liquid form. Some antipsychotic medications can also be administered as injections twice a month, monthly, every three months, or every six months, which can be more convenient and improve medication adherence.

Table 11.1 Common Antipsychotic Medications^{[23],[24],[25]}

Black Box Warning

A Black Box Warning states that elderly clients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.^[26]

Special Note About Clozapine

Patients with treatment-resistant schizophrenia may be prescribed clozapine, a specific type of atypical antipsychotic medication. However, people treated with clozapine must undergo routine blood testing to detect a potentially dangerous side effect called agranulocytosis (extremely low white blood cell count). Clozapine also has strong anticholinergic, sedative, cardiac, and hypotensive properties and frequent drug-drug interactions.^[27]

Antipsychotic Adverse Effects

Common side effects of all antipsychotics include the following^[28]:

• Anticholinergic symptoms: dry mouth, constipation, blurred vision, or urinary retention^[29]
• Drowsiness
• Dizziness
• Restlessness
• Weight gain
• Nausea or vomiting
• Low blood pressure

First-generation antipsychotics, also known as neuroleptics or typical antipsychotics, have significant potential to cause extrapyramidal side effects and tardive dyskinesia due to their tight binding to dopamine receptors. The risk for developing these movement disorders is the primary difference between first-generation antipsychotics and second-; and third-generation antipsychotics (also known as atypical antipsychotics). The newer classes are less likely to cause movement disorders. In other respects, the two classes of medication have similar side effects.^[30]

Extrapyramidal (EPS) side effects refer to akathisia (psychomotor restlessness), rigidity, bradykinesia (slowed movement), tremor, and dystonia (involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures). See Figure 11.3b^[31] for an image of dystonia. Anticholinergic side effects (e.g., dry mouth, constipation, and urinary retention) are common, and histamine blockage causes sedation, with chlorpromazine being the most sedating.^[32]

Acute dystonic reactions affecting the larynx can be a medical emergency requiring intubation and mechanical ventilation. EPS symptoms usually resolve dramatically within 10 to 30 minutes of administration of parenteral anticholinergics such as diphenhydramine and benztropine.^[33]

Tardive dyskinesia (TD) is a syndrome of movement disorders thought to be due to neurologic injury that can occur in patients taking first-generation antipsychotics. Hallmark symptoms are smacking and puckering lips, eye blinking, grimacing, and twitching. TD persists for at least one month and can last up to several years despite discontinuation of the medications. Early recognition and subsequent discontinuation of the medication may eliminate the symptoms completely. However, for others, especially those who have been on the first-generation antipsychotic for years, symptoms may take years to resolve or may never resolve completely even when the medication has been stopped. Primary treatment of TD includes discontinuation of first-generation antipsychotics and may include the addition of another medication such as deutetrabenazine or valbenazine. These medications are considered first-line treatment for TD because they can limit the amount of dopamine available in areas of the brain where adverse movements originate. Clonazepam and ginkgo biloba have also shown good effectiveness for improving symptoms of TD.^[34],[35]

Neuroleptic malignant syndrome (NMS) is a rare but fatal adverse effect that can occur at any time during treatment with antipsychotics. It typically develops over a period of days to weeks and resolves in approximately nine days with treatment.^[37] Signs include increased temperature, severe muscular rigidity, confusion, agitation, hyperreflexia, elevation in white blood cell count, elevated creatinine phosphokinase, elevated liver enzymes, myoglobinuria, and acute renal failure. The antipsychotic should be immediately discontinued when signs occur. Dantrolene is typically prescribed for treatment. Nursing interventions include adequate hydration, cooling, and close monitoring of vital signs and serum electrolytes.^[38] If NMS is suspected the patient will need to be admitted to a setting where airway and circulatory support are available, such as an ICU.

Second-generation antipsychotics have a significantly decreased risk of extrapyramidal side effects but are associated with weight gain and the development of metabolic syndrome.^[39] Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke, and type 2 diabetes. Symptoms include increased blood pressure; high blood sugar; excess body fat around the waist (also referred to as having an “apple waistline”); and abnormal cholesterol, triglyceride levels, and high-density lipoprotein (HDL) levels. Weight, glucose levels, and lipid levels should be monitored before treatment is initiated, then at least annually thereafter.

Patient Teaching and Education

Patients should be advised to contact their provider if involuntary or uncontrollable movements occur. They should be warned to not suddenly stop taking the medication because abrupt withdrawal can cause dizziness; nausea and vomiting; and uncontrolled movements of the mouth, tongue, or jaw. Clients should be warned to not consume alcohol or other CNS depressants because their ability to operate machinery or drive may be impaired.

Relapse

Some people may experience relapse, meaning their psychosis symptoms come back or get worse. Relapses typically occur when people stop taking their prescribed antipsychotic medication or when they take it sporadically. Some people stop taking prescribed medications because they feel better or they feel that they don’t need it anymore, but medication should never be stopped suddenly. After talking with a prescriber, patients can gradually taper their medications in some situations. However, most people with schizophrenia must stay on an antipsychotic continuously for months or years for mental wellness.^[41]

Psychosocial Treatments

Cognitive behavioral therapy, behavioral skills training, supported employment, and cognitive remediation interventions are types of psychosocial treatments that can help address the negative and cognitive symptoms of schizophrenia. A combination of these therapies and antipsychotic medication is a common treatment approach for schizophrenia. Psychosocial treatments can help improve an individual’s coping skills with the everyday challenges of schizophrenia. Therapies can also help people pursue their life goals, such as attending school, working, or forming relationships. Individuals who participate in regular psychosocial treatments are less likely to relapse or be hospitalized.^[42]

Family Education and Support

Psychosis and schizophrenia can take a heavy toll on a patient’s family members, significant others, and friends. Educational programs offer instruction about schizophrenia symptoms, treatments, and strategies for assisting their loved one experiencing psychosis and schizophrenia. Increasing their understanding of psychotic symptoms, treatment options, and the course of recovery can lessen their distress, bolster their own coping strategies, and empower them to offer effective assistance to their loved one. Family-based services may be provided on an individual basis or through multi-family workshops and support groups.

Coordinated Specialty Care

Coordinated specialty care (CSC) is a general term used to describe recovery-oriented treatment programs for people with first-episode psychosis, an early stage of schizophrenia. A team of health professionals and specialists deliver CSC that includes psychotherapy, medication management, case management, employment and education support, and family education and support. The person with early psychosis and the team work together in a patient-centered and family-centered approach to make treatment decisions. Compared to typical care for early psychosis, CSC is more effective at reducing symptoms, improving quality of life, and increasing involvement in work or school.^[44]

The goal is to link the individual with a CSC team as soon as possible after psychotic symptoms begin. There are many different programs that are considered CSC in the United States, including (but are not limited to) Comprehensive Community Support (CCS), Community Support Programs (CSP), NAVIGATE, Connection Program, OnTrackNY, Specialized Treatment Early in Psychosis (STEP) program, and Early Assessment and Support Alliance (EASA). Supported Employment/Education (SEE) is an important part of CSC that helps individuals return to work or school because it addresses the client’s personal goals. A SEE specialist helps clients develop the skills they need to achieve school and work goals. In addition, the specialist can be a bridge between clients and educators or employers.^[45]

Research from the RAISE project (Recovery After an Initial Schizophrenia Episode) has shown that treatments for psychosis work better when they are delivered closer to the time when psychotic symptoms first appear. RAISE is focused on individuals who have experienced their first psychotic episodes, considered a crucial time for obtaining optimal treatment. The goal of the RAISE project is to help decrease the likelihood of future episodes of psychosis, reduce long-term disability, and help people to get their lives back on track so they can pursue their goals.^[46]

With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Many people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to live a fulfilling and productive life, even if psychotic symptoms return at times. However, if untreated, psychotic symptoms can cause disruptions in school and work, strained family relations, and separation from friends. The longer the symptoms go untreated, the greater the risk for developing additional problems. These problems can include abusing substances, having legal trouble, or becoming homeless.^[47]

Assertive Community Treatment

Assertive Community Treatment (ACT) is a model of treatment designed for individuals with schizophrenia who are at risk for repeated hospitalizations or who are unhoused. Research has demonstrated a prevalence of psychosis as high as 21% among people living on the streets.^[48]. ACT is based on a multidisciplinary team approach, including a medication prescriber, a shared caseload among team members, direct service provision by team members, high frequency of patient contact, low patient to staff ratios, and outreach to patients in the community. Additional services may include vocational training, wellness skills, and family education. ACT has been shown to reduce hospitalizations and homelessness among individuals with schizophrenia.^[49]