Schizophrenia - Anatomy of Psych

What is schizophrenia?

Schizophrenia is a psychotic disorder characterized by positive symptoms like delusions and hallucinations, and negative symptoms like avolition and alogia. It occurs in 1% of the population worldwide. There are no gender differences in the prevalence of schizophrenia, but the incidence of first-episode psychosis in men most likely occurs between ages 18 and 24, whereas in women it is in the late twenties and between ages 50 and 54.

What does schizophrenia look like?

Signs & Symptoms

Delusions - false beliefs that are not based in reality
Hallucinations - seeing or hearing things that don't exist
- Hallucinations can involve any of the 5 senses
Disorganized thinking/speech
Extremely disorganized or abnormal motor behavior - resistance to instructions, inappropriate or bizarre posture, a complete lack of response, or useless and excessive movement
Negative symptoms - reduced or lack of ability to function normally
- Neglecting personal hygiene, lacking emotion, not making eye contact, doesn't change facial expressions, speaks in a monotone, losing interest in everyday activity, social wtihdrawal, inability to feel pleasure

DSM-5 Criteria

Criterion A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

Delusions
Hallucinations
Disorganized speech (e.g. frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (i.e. diminished emotional expression or avolition)

Criterion B.For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

Criterion C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences).

Criterion D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either:

No major depressive or manic episodes have occurred concurrently with the active- phase symptoms; or
If mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

Criterion E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Criterion F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Specifiers

Specifiers:

Episode specifier
- First episode, currently in acute episode
- First episode, currently in partial remission
- First episode, currently in full remission
- Multiple episodes, currently in acute episode
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous
- Unspecified
With catatonia
Severity (rated by a quantitative assessment)

Risk Factors

Stresses in the perinatal period, such as starvation, poor nutrition, and infections
Childbirth complications
Genetics (80% heritability)
Low birth weight, short gestation, and early developmental difficulties
Central nervous system infections in childhood
Advanced paternal age

Prognosis

5-13% of individuals with schizophrenia die by suicide
Cognitive deficits in attention, processing speed, and executive function
Factors associated with good prognosis: late or acute onset, obvious precipitating factors, good pre-morbid social functioning, a family history of mood disorders, married, strong support systems, positive symptoms
Factors associated with poor prognosis: young or insidious age of onset, lack of obvious precipitating factors, poor pre-morbid social functioning, withdrawn behaviors, isolation, family history, negative symptoms, neurological signs and symptoms, history of perinatal trauma, lack of remission, recurrent relapses, and history of violence/assault
Only 13% of individuals with schizophrenia meet the criteria for recovery

Differential Diagnosis

Brief psychotic disorder
Schizophreniform disorder
Schizoaffective disorder
Autoimmune encephalitis

The dopamine hypothesis:

An increase in dopamine activity causes the positive symptoms of schizophrenia
Antipsychotics target the mesolimbic pathway and bind to dopaminergic neuroreceptors to decrease the incidence of positive symptoms

Neuroimaging findings:

Ventricular enlargement
Reduced hippocampus, parahippocampal gyrus, and amygdala volume
Reduced grey matter volume
Neuronal loss in the medial thalamus
Hypoactivity of dorsolateral prefrontal cortex

Influenza:

Association between influenza and psychosis has been seen since the early 1700s
Population studies show that individuals born in winter and spring are at higher risk for schizophrenia compared to those born in summer and autumn
Psychosis is thought to be linked to processes such as maternal immune activation, disruption of cytokine networks, and microglial activation of pathogenic processes that lead to schizophrenia

Degenerative disease model:

Increase in research studies suggesting that schizophrenia is not a progressive disorder, and that neuropsychological function can remain stable over time
There is minimal evidence that untreated psychosis damages brain structures
Individuals with schizophrenia can achieve a stable remission of symptoms as well as satisfaction and happiness

How is schizophrenia investigated?

Labwork: CBC, electrolytes, creatinine, GFR, macroprolactin, prolactin, inflammatory markers, TSH, T3, T4, lead level, infectious diseases (HIV, Hep A/B/C, syphillis), metabolic screen (HBA1c, LDL, HDL, total cholesterol, triglycerides)
Urine drug screen
Neuroimaging if there is rapid progression of cognitive and memory deficits alongside psychotic symptoms, or if there are indicators pointing to autoimmune encephalitis
Genetic testing for those with intellectual disability, developmental delay, and/or multiple congenital abnormalities
Cognitive testing for first-episode psychosis or those with poor treatment response

Positive and Negative Syndrome Scale (PANSS)

Clinician rater
45-minute clinical interview where the patient is rated on 30 different symptoms on a scale on a 7-point scale

Brief Psychiatric Rating Scale (BPRS)

Clinician rater
24 symptom constructs rated on a 7-point scale

Calgary Depression Scale for Schizophrenia (CDSS)

Clinician rater
9-item scale measuring the level of depression in individuals with schizophrenia

How is schizophrenia treated?

Antipsychotics are the gold standard medication for treating schizophrenia
There is no evidence for antipsychotic polypharmacy for schizophrenia

First-generation (typical) antipsychotics
- Haloperidol (Haldol)
- Flupentixol (Fluanxol)
- Loxapine (Loxapac)
- Zuclopenthixol (Clopixol)
- Chlorpromazine (Thorazine)
- Methotrimeprazine (Nozinan)
- Fluphenazine (Modecate/Prolixin)
- Perphenazine (Trilafon)
Second-generation (atypical) antipsychotics
- Risperidone (Risperdal)
- Paliperidone (Invega)
- Aripiprazole (Abilify)
- Brexpiprazole (Rexulti)
- Ziprasidone (Zeldox/Geodon)
- Lurasidone (Latuda)
- Quetiapine (Seroquel)
- Clozapine (Clozaril)

Special Considerations

Children & Teenagers

Aripiprazole (Abilify) and lurasidone (Latuda) are the only antipsychotics indicated for children and adolescents with schizophrenia.

Older Adults

Late-onset schizophrenia is the onset of schizophrenia after age 60, and is usually associated with fewer negative symptoms and less severe neurocognitive impairments. Hallucinations can be more prominent. Partition delusions (belief that people and objects can pass through impermeable barriers and enter their homes with harmful intent) is more common in late-onset schizophrenia.

There is an increased risk of developing dementia for those who experience late-onset schizophrenia.

Nursing Management

Disturbed sensory perception

Causes & Behaviors:

Responding to internal stimuli; mumbling to self, talking or laughing to self
Inappropriate responses
Disorientation to person/place/time
Tilting the head as if listening to someone
Change in problem-solving pattern
Change in communication pattern

Interventions:

Acknowledge the client's experience but explain that you don't hear the voices
Be alert for signs of increasing fear, anxiety, or agitation
Help the client identify needs that might underlie the hallucination
Decrease environmental stimuli to decrease the potential for anxiety that might trigger hallucinations
Offer medication when indicated
Promote the exploration of activities as distraction from the hallucinations
Engage the client in reality-based activities

Impaired verbal communication

Causes & Behaviors:

Difficulty communicating thoughts verbally
Difficulty in discerning and maintaining the usual communication pattern
Disturbances in cognitive associations (thought process)
Inappropriate verbalization

Interventions:

Assess whether the abnormal speech is chronic or an acute exacerbation of symptoms
Use clear and simple words as the client may also have difficulty processing simple speech
Use simple, concrete, and literal explanations to minimize misunderstandings
Look for themes in what is said, even though spoken words appear incoherent, as the client's choice of words can be symbolic of their feelings

Impaired social interaction

Causes & Behaviors:

Appears upset, agitated, or anxious when others come too close in contact or try to engage him/her in an activity
Dysfunctional interaction with others/peers
Inappropriate emotional response
Observed use of unsuccessful social interactions behaviors
Spends time alone by self
Unable to make eye contact, or initiate or respond to social advances of others
Verbalized or observed discomfort in social situations

Interventions:

Identify with the client symptoms experienced when around other people
Avoid touching the client
Structure activities at the client's pace
Provide one-on-one activities with a person that the client feels comfortable with, and then gradually encourage participation in a structured group activity
Explore coping skills with the client

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[2] Anderson, K. K., Rodrigues, M., Mann, K., Voineskos, A., Mulsant, B. H., George, T. P., & McKenzie, K. J. (2015). Minimal evidence that untreated psychosis damages brain structures: A systematic review. Schizophrenia Research, 162(1-3), 222–233.

[3] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[4] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

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[6] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.

[7] Zaheer, J., Olfson, M., Mallia, E., Lam, J. S. H., de Oliveira, C., Rudoler, D., Carvalho, A. F., Jacob, B. J., Juda, A., & Kurdyak, P. (2020). Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: A 20-year total population study in Ontario, Canada. Schizophrenia research, 222, 382–388.

[8] Zipursky, R. B., & Agid, O. (2015). Recovery, not progressive deterioration, should be the expectation in schizophrenia. World Psychiatry: Official journal of the World Psychiatric Association (WPA), 14(1), 94–96.