6. Schizophrenia and other psychotic disorders

Schizophrenia and other psychotic disorders are characterized by disturbances in communication, language, thought, perception. affect, and behavior.

Schizophrenia

DSM-IV CATEGORIES

295.xx Schizophrenia

295.30 Schizophrenia, paranoid type

295.10 Schizophrenia, disorganized type

295.20 Schizophrenia, catatonic type

295.90 Schizophrenia, undifferentiated type

295.60 Schizophrenia, residual type

Schizophrenia is characterized by two broad categories of symptoms, positive and negative. The positive symptoms focus on a distortion of normal functions, whereas the negative symptoms indicate a loss of normal functions. Examples of positive symptoms are delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

Delusions are mistaken beliefs based on a false or an unreasonable interpretation of an experience or a perception. Often, delusions occur in the form of thought broadcasting, where people believe that their personal thoughts are broadcast to the external world. Many times clients believe that feelings, thoughts, or actions aren't their own but generated by some external force. Commonly occurring delusional themes are persecutory, referential, somatic, and grandiose. An example of a persecutory delusion is the idea that one is being followed, tricked, tormented, or made the subject of ridicule. With reference delusions, there's the conviction that overheard comments newspaper articles, and other types of media are directed specifically toward the client. A somatic delusion occurs when the person believes that the body is deteriorating from within. The person with grandiose delusions has an exaggerated sense of self aggrandizement.

Hallucinations can occur in any of the five senses; auditory hallucinations are most commonly associated with schizophrenia. When the client hears voices, they're viewed as being separate from the client's own thoughts. The content of the voices are threatening and derogatory. Many times the voices command the client to perform some action that will hurt the client or others.

In disorganized thinking or loosening of associations, the random shifting of speech from one topic or idea to another with only a tenuous connection between. Speech unrelated to the topic, neologisms (creating new words from parts of existing words), perseveration (involuntary repetition of words I. and word clanging (repetition of words or phrases similar in sound only) are examples of other language symptoms that may occur. The range of disorganized behavior extends from silliness to unpredictable agitation. The client struggles on a consistent basis perform activities of daily living, such as grooming and bathing. Sometimes catatonic behaviors are noted, such as being in a stupor, exhibiting excessive motor activity, and sustaining a rigid body position while resisting instructions or attempts to be moved.

The negative symptoms of schizophrenia include affective flattening, alogia (poverty of speech), and avolition (lack of self initiating behaviors). The client demonstrates a blunted, flat " inappropriate affect manifested by poor eye contact, a distant and unresponsive facial expression, and limited body language The sense of self is disturbed, an experience often referred to as a loss of ego boundaries. This loss of a coherent sense of self causes the client to have difficulty maintaining personal identity. The client typically has difficulty initiating and maintaining self-directed activity, consequently losing interest in work and other life roles. This lack of capacity to sustain self-directed activity also makes it difficult for the client to establish interpersonal relationships. What is seen with this person is social withdrawal and emotional detachment.

Current understanding of the causes of schizophrenia is based on knowledge of abnormal neuroanatomical and neurochemical changes that occur in the brain. These abnormalities may affect brain function and increase sensitivity to environmental and personal stressors.

Schizophrenia is a familial brain disease. One percent of the U.S. population has schizophrenia, and 10% of first-degree relatives develop schizophrenia during their lifetimes. If schizophrenia is diagnosed in one identical twin, there's a 40% to 55% chance of the other twin becoming schizophrenic. In non-identical twins, if one develops schizophrenia, the other has a 10% to 15% of developing the disease. However, other people with schizophrenia have no close relatives with the disease. This suggests that other factors, such as psychosocial and environmental causes, are involved.

Although a specific gene for schizophrenia hasn't been found research suggests that alteration of a region on chromosomes 5 and 6 may predispose a person to schizophrenia. Even if this alteration is present, an additional event, such as an infection, autoimmune reaction, or injury, is believed to be required to precipitate the illness. The fetal period is potentially a time of great risk from such insults, as are delivery complications and other early-life traumas that could adversely affect the brain. Residual effects of injuries that occurred early in life as well as during the brain's increased growth during adolescence may cause latent abnormalities to become manifest.

Magnetic resonance imaging, positive emission tomography (PET), and computed tomography studies have shown abnormal symmetry, tissue density, partial cerebellar atrophy, and enlarged lateral cerebral ventricles in the brains of people with schizophrenia. PET scans have also demonstrated reduced blood flow and reduced glucose metabolism in the frontal lobes. Microscopic studies of brain tissue have revealed abnormalities in the orientation and migration of neurons.

Researchers continue to study how alterations in the limbic regions, cortical regions, and striatum of the brain play a role in the pathology of schizophrenia. Further work on interactions between neurotransmitters (such as dopamine, epinephrine, norepinephrine, serotonin, glutamate, and gamma-amino butyric acid may provide clearer answers to the patho-physiology of this disease. It can no longer be explained simply as a case of excessive dopamine in the brain. Clinicians realize that schizophrenia is a complex illness that must be perceived in the same way that cardiac disease is addressed, as a multicausal disease entity.

The clinical course of schizophrenia is often complicated and tends to occur in three phases — the prodromal phase, the active phase, and the residual phase. (See Phases of Schizophrenia)

The primary characteristics of the disorder are disturbances in thought process, perception, language and communication and behavior, combined with an overall decrease in the ability to function. The five types of schizophrenia are distinguished b\ their particular clinical features. (For further information, see Types of Schizophrenia.)

COMMUNICATION STRATEGIES

• Don't judge, argue, or use logic to demonstrate the fallacy of the client's delusions or hallucinations.
• Be neutral when the client rejects contact ("If you don't want to spend time together now, I'll return at 11 o'clock for 10 minutes.”)
• Initially, use nonverbal methods, such as maintaining eye contact, smiling, and using other positive facial expressions, to interact with the client. Only after a relationship is established (by the provision of both physical and emotional care) can the nurse obtain permission to touch the client. Touch may misinterpreted as an intrusion into the clients personal space if it is used before the client is ready to accept it as a gesture of caring.
• Speak in short, simple sentences during frequent, brief interaction.
• Ask open-ended questions ("What are you experiencing now? What do you hear") when guiding the client through an experience. Ask direct questions (Are you anxious?" "Do you feel like you will hurt yourself?") if information is wanted.
• Note and comment to the client about subtle changes in expression of feelings. For example, "I see you're looking a little sad right now."
• Focus on what is happening in the here and now, and talk about reality-based activities.
• Ask for clarification when the client talks generally about "they."
• When necessary, identify what the nurse doesn't understand without rejecting the client. ("I'm having difficulty following what you're saying,"
• When necessary, communicate acceptance to the client even though some (or many) of the client's thoughts and perceptions aren't understood by others.

PHASES OF SCHIZOPHRENIA

Prodromal phase Deterioration over time (6 to 12 months) in level of self-care, social, leisure, occupational, or academic functioning Occurrence of both positive and negative symptoms Period of confusion for client and family Active phase Initiation of health care intervention, typically hospitalization Introduction of medication and other therapeutic modalities Treatment focuses on psychiatric rehabilitation as client leams to live with an illness that impacts thoughts, feelings, and behaviors Residual phase Daily experience with symptom management Oiminishment and intensification of symptoms Adaptation

TYPES OF SCHIZOPHRENIA
TYPE	COMMON SYMPTOMS
Paranoid	Preoccupation with systematized delusions, with grandiose or persecutory delusions being the most common Auditory hallucinations focused on a single theme while the client maintains cognitive functioning and an appropriate affect Anxiety Anger Argumentativeness Intense interpersonal relationships Potential for violent behavior toward self or others
Disorganized	Disorganized behavior, causing a severe disruption in activities of daily living Lack of coherence Loose associations Disorganized speech Chaotic, confused, or odd behavior Flat or inappropriate affect Cognitive impairment
Catatonic	Psychomotor disturbances, such as stupor, negativism, rigidity, excitement, and posturing Mutism Echolalia (repetition of a word or phrase just spoken by another person) Echopraxia (imitation of another person's movements)
Undifferentiated	Delusions Hallucinations Lack of coherence Disorganized behavior that cannot be incorporated into any other type
Residual	At least one schizophrenic episode with prominent psychotic symptoms, followed by another episode without psychotic symptoms Emotional blunting Withdrawal from reality Odd beliefs Unusual perceptual experiences Eccentric behavior Illogical thinking Loose associations

NURSING DIAGNOSIS: ALTERED THOUGHT PROCESSES

Probable Causes	Defining Characteristics
Lack of trust Escalating anxiety Delusional thinking or hallucinations Chemical imbalance prohibiting information processing Sense of nonexistence	Limited or no attention span Hypersensitivity to normal stimuli Inconsistent verbal and non- verbal communication Shifting focus of conversation Inability to problem solve

Long-Term Goal
The client will maintain an optimal level of functioningdespite the presence of disorganized thinking.

Short-Term Goal #1:The client will verbalize feelings of security and acceptance by staff

Interventions and Rationales

• Talk to the client in a simple, direct, and honest manner. Vague or complicated interactions promote mistrust.
• Maintain consistent expectations for nondisruptive behaviors including the observance of unit rules. Consistent expectations of acceptable behavior and well-defined rules create a secure environment.
• Explain all unit and health care procedures before carrying them out. Being informed and prepared for procedures and even:s enhances the client's trust.

Short-Term Goal #2: The client will identify the symptoms of illness and discuss feelings precipitated by unrealistic thoughts.

Interventions and Rationales

• Help the client identify and use thought-stopping techniques. Such as saying the word "stop" when disorganizing thoughts or anxieties and fears occur. The client can reduce anxiety by using thought-stopping techniques to interrupt maladaptive behaviors and illogical thinking.
• Interact with the client by discussing reality. Avoid using abstractions, double meanings, and humor during discussions. Complex and abstract interactions are distressing to these clients and dont promote healthy discussions grounded in reality.
• Don't challenge the content of disorganized thoughts. Challenging the client promotes mistrust and conflict between client and nurse.
• Tell the client when the nurse doesn't understand the dialogue. When disorganized thoughts or speech arises in the nurse-client dialogue, the nurse needs to acknowledge when information given by the client isn’t understood.
• Encourage the client to discuss feelings associated with disturbing thoughts. Discussion of feelings can help focus the interaction on a reality-based situation.
• Encourage the client to discuss how disturbing thoughts present problems in the client's everyday life. By discussing problems that arise due to disturbing thoughts, the nurse helps the client to stay reality-based and focused on the here and now.

Short-Term Goal #3: The client will seek out staff assistance to differentiate between realistic and unrealistic thoughts.

Interventions and Rationales

• Teach the client to focus on the nurse's or other caregiver s voice when disturbing thoughts occur that prevent the client from maintaining attention on reality. Learning to disregard disturbing thoughts helps the client develop the ability to function in the everyday world.
• Encourage the client to verbalize negative or disturbing thoughts that arise from interactions with the staff. Feedback helps the client examine misinterpretations of the speech and actions of others.

Short-Term Goal #4: The client will develop healthy ways to deal with anxiety, fear, and low self-esteem.

Interventions and Rationales

• Encourage the client to express feelings directly. Increased comfort in the expression of feelings decreases anxiety, which in turn decreases delusional thinking.
• Explore with the client how to deal with feelings in acceptable ways, such as talking about the feelings and engaging in non-threatening, simple activities designed to decrease energy. It’s essential for the client to develop skills to deal effectively with anxiety and other intense feelings because lowered anxiety levels reduce the seventy of schizophrenic symptoms.
• Help the client review personal communication patterns to determine how they may contribute to dysfunctional behaviors. The client must determine when dysfunctional communication occurs in order to make the necessary changes in behavior.

NURSING DIAGNOSIS: SOCIAL ISOLATION

Probable Causes	Defining Characteristics
Lack of trust Feeling threatened by social situations Feelings of alienation Depression Mistreatment by others Fear of making mistakes socially	Little or no interaction with staff and other clients Staying alone Little or no eye contact Sad, depressed facial expression Predominantly nonverbal communication, or monosyllabic replies

Long-Term Goal
The client will verbalize a plan to increase socialization in a clinical setting.

Short-Term Goal #1:The client will have a number of safe, predictable interactions with the nurse.

Interventions and Rationales

• Establish frequent, brief contacts with client. Frequent, brief interactions prevent the client from becoming too anxious or threatened by the contact.
• During initial interactions, maintain a minimum distance of one arm's length from the client. A comfortable distance that recognizes personal space decreases client anxiety yet conveys that the nurse is attentive to the client.
• Be judicious about touching the client, although touch may be appropriate when assisting the client with self-care. Clients with schizophrenia are mistrustful of closeness, and physical touch car. be threatening: assisting the client with physical care is one way to establish closeness and a first step for gaining permission to touch the client.
• Allow the client to initiate and direct the interaction. Responding to client initiatives and desires in social interaction conveys acceptance, confidence, and interest.

Short-Term Goal #2: The client will participate in at least one group activity daily.

Interventions and Rationales

• Establish an activity schedule, and assist the client in choosing one or more activities to attend. Providing choices increases the feeling of control and promotes decision making.
• Help the client prepare for a group by discussing how to interact and what to say to peers. Opportunities to prepare for iteractions promote client comfort and self-esteem.
• Give positive feedback for all attempts at social interaction. Positive feedback reinforces desired behavior and promotes self esteem.

NURSING DIAGNOSIS: SENSORY/PERCEPTUAL ALTERATIONS (USUALLY VISUAL OR AUDITORY) RELATED TO HALLUCINATIONS

Probable Causes	Defining Characteristics
Inaccurate interpretation of environmental stimuli Loss of ego boundaries Traumatic emotional events Brain dysfunction Presence of hallucinations or illusions	Increased attention to internal sounds, voices, or images (hallucinations) in the absence of external stimuli Feeling of strange body sensations Limited or no interaction with others Inability to concentrate Inappropriate responses to reality

Long-Term Goal
The client will develop strategies to decrease anxiety and manage the behaviors and footings resulting from the loss of continuity in normal sensual and perceptual experience.

Short-Term Goal #1:The client will establish control over the hallucinatory process.

Interventions and Rationales

• Monitor the client for signs of hallucinations, such as tilting the head to one side, looking around the room, and talking to himself Prompt intervention may allow the client to manage the hallucination or talk about its content.
• Encourage the client to share the content of the hallucination. The nurse must know the content of the hallucination in order to help the client process the thoughts and feelings connected with it and to prevent aggressive and harmful behaviors.
• Whenever hallucinations arise, orient the client to reality and give feedback based on the current situation. Orientation decreases anxiety and helps keep the client reality-based.
• Don't deny the client's experience, but explain that the client's sensory perceptions are not shared by other people. Staff honesty helps the client realize that the hallucinations are an internal experience not based on external reality.
• Talk to the client when the client is actively hallucinating. Talking to the client during a hallucination can offer a competing stimulus or assist the client to understand the issues behind the hallucination, such as self-esteem, anger, and power.
• Suggest to the client ways that interpersonal relationships can help meet needs, decrease anxiety, and decrease the need to hallucinate. Clients need assistance to develop peer relationships because they have learned to rely on voices in the absence of friends.
• Help the client identify which feelings lead to the hallucinations. Shifting the client's attention from the content of the hallucination to the content of the initial feeling helps promote self-understanding.
• Teach the client distraction techniques, such as singing along with music, listening to a radio, and reading out loud. Distraction can be used to bring an actively hallucinating client back to reality.
• Provide the client with opportunities to become involved in concrete activities, such as art work, music, games, and specific tasks. Hallucinations are often more troublesome when the client is alone and not mentally occupied.

Short-Term Goal #2: The client will discuss issues that emphasize reality.

Interventions and Rationales

• Reinforce all conversations that refer to reality. Positive reinforcement increases the likelihood of continuing reality-based behavior.
• Teach the client the nature of hallucinations and how both affective experiences and external events can provoke hallucinations. Helping the client to understand which events provoke hallucinations enhances coping. The client can be taught to recognize and avoid external stressors and to discuss painful feeiings to relieve their intensity.
• Teach the client strategies to decrease stress through exercise and the avoidance of known stressors. Don't use guided imagery or progressive relaxation. Reducing stress decreases the incidence of hallucinations; however, the use of imaginary or progressive relaxation in clients with poor ego boundaries could worsen the hallucinations.

NURSING DIAGNOSIS: IMPAIRED VERBAL COMMUNICATION

Probable Causes

Defining Characteristics

Lack of trust Severe anxiety Regression Insufficient healthy interactions Disorganized thinking

Use of symbolic speech (words have meaning only to client) Use of concrete communication only, if the client is unable to think abstractly Incongruent verbal and non-verbal communication (The client speaks of highly emotional experiences in a fiat manner, lacking any affect, or the client appears agitated but can't say what the agitation is about.) Difficulty maintaining eye contact Speaking very little (poverty of speech)

Long-Term Goal
The client will engage in appropriate verbal communication with staff and others.

Short-Term Goal #1:The client will interact on a one-to-one basis with the nurse. '

Interventions and Rationales

• Make time for exclusive one-to-one interaction with the client.A one-to-one relationship is a necessary prerequisite for other nursing interventions.
• Provide the client with support and positive conversational experiences by talking with the client about personal interests, hobbies, favorite places, and favorite activities. A supportive relationship can decrease fear of people and open up opportunities for interactions.
• Model expression of feelings for the client, such as verbalizing about sadness or being afraid. Modeling expression of feelings teaches the client to interact in healthier ways.

Short-Term Goal #2: The client will demonstrate congruent verbal and nonverbal communication.

Interventions and Rationales

• Observe and monitor the client's verbal and nonverbal communication. Focused attention on the client's communication helps tr.e nurse identify and work on incongruities.
• Validate the meaning of both verbal and nonverbal communication by identifying discrepancies in the client's communication For example, the client laughs while stating, "My family wishes I were dead." Validation allows the client to understand how the nurse perceives what is said and provides the opportunity to learn how to express consistent thoughts and feelings.
• Listen for the emergence of themes and meaningful issues as the client begins to communicate with the nurse. Once the client feels comfortable verbalizing to the nurse, important issues become discernible.

Short-Term Goal #3: The client will learn clear and understandable means of self-expression.

• When talking with the client, use facilitative communication strategies, such as reflection (repeating the client's statement) and clarification (asking the client to explain what the nurse has not understood). Strategies such as reflection and clarification facilitate nurse-client interactions and help the client develop seif-understanding and self-esteem
.
• Initiate interactions with the client on a regular basis. The client needs many opportunities to practice and refine communication skills, which in turn fosters self-confidence.
• Encourage the client to express feelings about real situations and events. Encouragement helps the client practice expressing feelings and concerns in response to environmental stimuli.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Inability to trust or relate to other people Lack of self-confidence Loneliness Feelings of rejection Lack of support systems	Avoidance of people and interaction opportunities Inability to perform self-care activities Use of defenses, such as regression and projection Emotional and physical withdrawal

Long-Term Goal
The client will demonstrate adaptive coping skills.

Short-Term Goal #1:The client will explore ways of dealing with problems and stressful situations.

Interventions and Rationales

• After a trust relationship has been established, encourage the client to verbalize feelings. Exploration of feelings assists in the identification of underlying client issues.
• Acknowledge the client's identification of "bad habits' and impulses that need to be controlled. Identification of specific problems allows the client to determine which coping skills are needed.
• Encourage the client to identify the consequences of impulsive or bizarre behavior. Identification of negative consequences may motivate the client to learn more adaptive behaviors.

Short-Term Goal #2: The client will learn effective coping strategies, such as recognizing and expressing feelings appropriately.

Interventions and Rationales

• Help the client learn and practice appropriate coping skills, sue" as role-playing, in which the client can get the learning experience without actually being in a stressful situation. Practicing coping skills reinforces them and enhances self-respect and adaptation to the environment.
• Monitor real situations in the client's life, and help the client identify the maladaptive behaviors currently used, in order to select social skills better suited to the situation. Feedback reinforces or modifies social components of behavior.
• Monitor and evaluate the client's response to unexpected situations in the clinical setting. Evaluating the client's response tc unexpected situations allows for behavior modification and learning new skills.

NURSING DIAGNOSIS: RISK FOR VIOLENCE DIRECTED AT SELF OR AT OTHERS

Probable Causes	Defining Characteristics
Lack of trust Lack of impulse control Escalating anxiety Escalating anger Delusions or hallucinations	Increased pacing Threatening speech or behavior Angry facial expression Self-absorption accompanied by increased psychomotor activity Verbalization about previous violent actions

Long-Term Goal
The client will not harm self or others.

Short-Term Goal #1:The client's pattern of agitated behavior will be prevented or controlled.

Interventions and Rationales

• Maintain a quiet, non-stimulating environment by reducing noise, limiting the number of people in the room, and dimming lights. A quiet environment decreases anxiety and lessens the chance of agitation occurring.
• Administer medications as ordered, and monitor their effectiveness and adverse effects. Psychotropic medications promote the client's ability to cope and maintain self-control and help resi.c£ the occurrence of agitated behavior.
• At the first signs of agitation, give the client options for handling the agitation, such as going to a less stimulating environment and staying with the nurse and verbalizing feelings and concerns. Giving the client alternatives assists in dissipating energy associated with the agitation.
• Use physical restraints only if all other options have failed and the situation has become an emergency. Obtain a doctors order as soon as possible. Observe the restrained client at least every 15 minutes (or according to institutional policy). Change the client's position at least every 2 hours to prevent pressure ulcers, thrombus formation, and stasis pneumonia. Monitor circulation of extremities carefully. Assist the client with basic needs, such as eating, drinking, and elimination, while restrained. Physical restraints can provide control and prevent a c.i-entfrom hurting himself or others.

Short-Term Goal #2: The client will identify signs of increased agitation and learn effective coping to avert escalation of the agitated reaction.

Interventions and Rationales

• Observe the client to identify daily events or stressors that are associated with the client's agitation. Observation of the client in daily activities and routines allows the nurse to help the client identify stressors that provoke an agitated response.
• Help the client identity and discuss the negative feelings, such as anger, fear, and loss of self-control, that are evoked by the stressors. Identification of stressors and the negative feelings associated with them is the first step in learning to control them.
• Teach the client to use the quiet room or to take a time-out when feeling overwhelmed. Even if the client can’t verbalize intense feelings, the client can learn how to identify and depart from situations that create or potentiate agitation.

Short-Term Goal #3: The client will seek out staff when anxiety or agitation is increasing.

Interventions and Rationales

• In the context of a therapeutic relationship, establish opportunities for interactions about the client's concerns and feelings. Caring interactions provide opportunities for the client to reveal personal needs to the nurse.
• Provide positive feedback when the client attempts to control or report anxiety or agitation. Reinforcement of positive behaviors enhances the client's self-esteem and sense of control.
• Intervene as quickly as possible when the client verbalizes anxiety or agitation. Prompt action by the nurse demonstrates canng and positively reinforces the client's behavior.

THERAPIES

Milieu Therapy

• Provide a safe, structured environment and a sense of community.
• Enhance reality testing.
• Monitor amounts of stimulation.
• Generate communication opportunities.
• Provide activities that will distract the client from preoccupation with hallucinations and paranoid or delusional thinking.
• Support decision-making ability.
• Promote control of aggression and unacceptable impulses.

Behavioral Therapy

• Focus on the consequences of dysfunctional behaviors and ways to change them.
• Teach social skills, activities of daily living, and communication skills.
• Use a token economy to reinforce desired behaviors by rewarding them with special privileges.

Group Therapy

• Focus on daily living skills.
• Teach ways to manage environmental and interpersonal stressors.
• Help the client develop a positive sense of self
• Provide the experience of supportive and directive interactions with others. The client can learn to listen, ask questions, and give appropriate feedback.
• Provide a place to express feelings and to talk about or resolve problems.
• Present opportunities to give and receive support.

Family Therapy

• Focus on promoting an understanding of the structure and functioning of the family system.
• Assist the family to be supportive and caring of the client without being overprotective.
• Encourage honest expression of feelings.
• Promote effective ways to handle negative feelings and family conflicts, and correct unsuitable communication and distortions of negative events.
• Increase ability to cope with chronic mental illness.
• Clarify boundaries and the roles of family members.
• Discuss the need for involvement in opportunities for social networking.

Residential Therapy

• Focus on crisis intervention.
• Deal with behaviors seen as deviant by the family and society.
• Provide a safe environment with appropriate boundaries and realistic limits for what behavior is acceptable.
• Provide opportunities to medicate the client and monitor the effects of drugs.
• Provide hospitalization to deal with violence directed toward self and others.

Outpatient Therapy/Day Treatment Program

• Focus on long-term symptom management.
• Promote medication management.
• Provide for individual therapy, group therapy, and structured activities or vocational training as needed by the client.
• Provide continuing social, occupational, and communication skill development.
• Create and maintain continuity of care, a sense of hope, and a family connection to the mental health system.

MEDICATIONS

• Antipsychotic agents provide a pharmacologic intervention to manage acute or chronic symptoms of schizophrenia by relieving psychomotor agitation, aggression, severe restlessness, and insomnia.
• Antipsychotic drugs can decrease hallucinations, delusions, and disorders of thinking after a therapeutic blood level is established.
• Medications decrease the disorganizing and destructive behaviors (positive symptoms) and facilitate other therapeutic interventions that deal with the disturbed sense of self and lack of relationships (negative symptoms). The atypical antipsychotic drugs, such as clozapine (Clozaril) and risperidone (Risperdal. offer some improvement in both positive and negative symptoms. Therefore, combined psychotherapy and drug therapy is recommended.
• Monitor clients for extrapyramidal adverse effects because antipsychotic medications block the postsynaptic dopamine receptors in the brain. The blockage of these receptors can cause pseudoparkinsonism and other extrapyramidal effects, such as tardive dyskinesia. To control these adverse effects, many clients receive antiparkinsonian drugs. (For further information. see Managing Adverse Effects of Antipsychotic Drugs and Appendix D.)

MANAGING ADVERSE EFFECTS OF AHTIPSYCHOTIC DRUGS
SPECIFIC SYMPTONS	NURSING MANAGEMENT
Antichollnsrgic effects
Dry mouth	Have the client a carry water bottle and sip frequently, chew sugartess gum, suck on hard candy, or use a saliva substitute (such as Xerolube).
Blurred vision	Limit the client's reading to large-print books; problem usually resolves in weeks.
Nasal congestion	This effect resolves In 2 weeks, or use a nasal decongestant.
Urine retention or urinary hesitancy	Monitor the client's urine output, palpate for distortion, catheterize if needed, obtain an order to decrease the dose of the antipsychotic drug, and add a cholinergic agent such as bethanecho) (Urecholine).
Constipation	Increase the client's fluid Intake, fiber intake, and exercise, and obtain an order for a stool softener or laxative.
Photophobia	Have the client wear sunglasses.
Eyedryness	Encourage the client to blink or use artificial tears.
Impotence or inability to ejaculate	Assess the problem, explain the relation between anxiety and sexual functioning, reassure the client that symptoms are reversible and benign, and consult with the doctor to change the drug.
Extrapyramidal symptoms
Pseudoparkinsonism: mask like face; shuffling gait; tremors; pill-rolling movements; rigid, stooped posture	Alert the doctor, who may change the drug. reduce the dose, or order an anticholinergic drug, such as benztropine Cogentin) or trihexyphentdyl (Artane).
Dystonic reaction: muscle spasm in any muscle, which can Include oculogyric crisis (involuntary deviation of eyes upward), opisthotonos (involuntary arching of the neck and back), torticollis (neck stiffness that pulls the head to one side and the chin to the opposite side), dysphagia (difficulty swallowing), and laryngeal spasm.	Stay with the client and explain that these symptoms will resolve, and obtain an order for an antidyskinetic drug, such as diphenhydramine (Benadryl), or an antichollnergic drug.
Akathisia: motor restlessness, such as rocking the body or tapping the foot.	Alert the doctor, who may change drug, reduce the dose, or order an anticholinergic drug, such as bemtropine or trihexyphenidyl.
Tardive dyskinesia (TD): a later-occurring repertoire of involuntary movements that typically begin in the face, neck, and jaw (tongue thrusting, grimacing, lip smacking, chewing, and grunting) but may progress to the limbs and trunk.	There is no treatment for TD. Clients are screened for TD symptoms at least every 3 months as a preventive measure. Teach the client and family early signs. Stopping the drug may not relieve the symptons.
Other less common adverse effects
Neuroleptic malignant syndrome: manifests with extreme extrapyramidal symptoms, severe hyperthermla, hypertension, tachycardia, and incontinence	Stop the antipsychotic drug, and obtain emergency medical treatment for symptoms such as arrhythmias, dehydration, electrolyte imbalance, seven muscle pasms, and hyperthermia.
Cardiac effects, such as orthostatic hypertension and tachycardia	Monitor blood pressure and heart rate and rhythm, explain to the client how to dangle his feet and rise slowly to prevent vertigo, and alert doctor, who can decrease the dose.
Sedation	Tall the client that sedation will resolve encourage the client to move around and engage in physical activates, amd consult with the doctor to change to a less-sedating antipsychotic drug .
Increased appetite and resultant weight gain	Encourage exercise and low calorie snacks, and deviss a cHatary plan for weight loss while maintaining optimal nutriton.
Endocrine changes, such as breast enlargement and lack of libido	Assess the client and alert the doctor to these adverse effects
Cholestatic jaundice: fever, nausea, lethargy, and abdominal pain	Stop the drug, alert the doctor, maintain bed rest, give a high-carbohydrate, protein diet, and monitor liver function studies.
Agranulocytosis: fever, sore throat, malaise, mouth ulcers, and flulike symptoms.	Stop the drug, alert the doctor, obtain blood studies to determine agranulocytosis or leukopenia is present; if so, place the client in reverse isolation because this condition is life-threatening.

FAMILY CARE

• Encourage the family to participate in the client's care, to identify stressors that precipitate bizarre behaviors, and to be involved in an aftercare program.
• Offer emotional support and opportunities for the family to verbalize concerns.
• Teach family members how to obtain assistance when they confront critical issues about managing the client's care (such as the client's refusal to take medication) or experience difficulties coping with the illness (such as managing the client's disruptive behavior).
• Educate family members about schizophrenia, treatment goals, drug therapy, and early signs of relapse, such as increased anxiety, increased depression, difficulty concentrating, increased social withdrawal, and difficulty sleeping.
• Help the family to have realistic short-term expectations about the client's progress.
• Alert the family that the client may self-medicate with alcohol, marijuana, or cocaine. These substances can precipitate a psychotic episode.
• Teach the family stress management techniques, effective ways to communicate with the client, and how to best respond to disturbed behavior.
• Address the family's chronic sorrow about their unending care-giving responsibilities.

Schizophrenia

DSM-IV CATEGORIES

297.1 Delusional disorder

The main characteristic of a delusional disorder is the presence of one or more non-bizarre delusions that have occurred for at least 1 month. This persistent and often elaborate delusional process can't be explained by another psychiatric disorder, the physiologic effects of a substance, or an overall medical condition. The delusional theme is characterized by a tendency to cling to a set of false beliefs. Auditory or visual hallucinations may occur, but they're not dominant features. When tactile or olfactory hallucinations occur, they're directly related to the client's delusional theme. Despite the delusion, the client's behavior is not noticeably odd or bizarre, and daily functioning isn't significantly influenced. If impaired psychosocial functioning is present, it's evidenced by problems with social, interpersonal, or marital functioning but isn't as apparent with intellectual or occupational functioning. A person suffering from delusional disorder commonly experiences delusions centered exclusively around one or these themes: erotomania, grandiosity, jealousy, persecution, or somatic abnormality.

An erotomanic delusional subtype concerns idealized love, as opposed to sexual attraction. The person at whom the delusion is directed is often a celebrity or famous societal figure, although. it may also be someone obscure. Attempts to contact this person are viewed as harassment and often reported to the police.

A grandiose delusional disorder focuses on the belief that important talents, knowledge, insight, worth, or power is possessed but not recognized. This type of delusion may have a religious content, and people so possessed many believe that they have a special talent or message given to them by a deity. Throughout history, some cult leaders have had this disorder.

People who suffer from a jealous delusional disorder become convinced that a spouse or lover has been unfaithful. They attempt to find bits of evidence to substantiate their beliefs. They may confront or even physically attack their significant others.

The persecutory delusional disorder is the most common type. The afflicted person feels conspired against, harassed, cheated, followed, poisoned or drugged, or prevented from pursuing personal goals. Sometimes the focus of the delusion is an injustice (querulous paranoia), and the person files lawsuits and seeks assistance from government agencies. People with persecutory delusions are often angry and resentful and may resort to violence against those believed to be hurting them.

A somatic delusion revolves around body sensations or body functions. People with this disorder commonly believed that a foul odor is emitted from the skin, mouth, rectum, or vagina. Other aspects of the delusion include infestation by insects or internal parasites and the belief that particular body parts don't function properly.

Some people may portray a mixed type of delusional disorder. Here, no particular delusional theme or type of delusion is dominant.

The biological basis for delusional disorder hasn't been investigated. Researchers suggest that delusions may result from an alteration in the dopaminergic system or from right posterior cortical dysfunction in the brain. It's possible that a specific delusion stems from malfunction of a particular neurologic pathway or circuit.

For some people, a depressed mood related to their delusional beliefs is noted. Such factors as hearing difficulties, multiple and severe psychosocial stressors, and low socioeconomic status may predispose a client to the development of a delusional disorder. The age of onset is usually the middle or late adult years, with the course of the disorder being quite variable.

COMMUNICATION STRATEGIES

• Don't argue about false beliefs.
• Don't question the client's thought process.
• Focus interactions on the reality-based parts of the communication.
• Encourage the expression of thoughts and feelings because the nurse can't possibly know what the client is thinking or feeling.
• Observe the client's behavior, and encourage the client to talk about the feelings behind the behavior.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Perceived threats to the client's personal beliefs or values Lack of social support system Inadequate skills for handling stress Inability to interpret the source of a threat Impaired self-concept	Delusional or paranoid thinking Agitation or contentiousness Somatic complaints Inability to perform activities of daily living Stilted social skills

Long-Term Goal
The client will use constructive coping strategies andfunction without interference from delusional thinking.

Short-Term Goal #1:The client will decrease preoccupation with delusional thoughts.

Interventions and Rationales

• Encourage the client to express feelings. Verbalization of feelings enables identification of deeper, personal issues and facilitates dealing with feelings in ways other than delusional ones.
• Be direct, honest, and consistent with the client. A forthright unambiguous approach helps the client let go of fear, suspicion, and paranoid delusions.
• Don't whisper, laugh, or have private conversations with other staff while in the client's view. The client may become suspicions and form erroneous conclusions about being the subject of the conversation, thereby suffering increased paranoia.
• Respond to the client's voiced suspicions or accusations in a calm, matter-of-fact manner. A calm, nonreactive approach helps reinforce reality for the client.
• Don't touch the client. Touch may be viewed as threatening to a suspicious client as well as an invasion of the client's boundaries.
• Give reality-based feedback to the client. Delusional thinking makes it difficult for the client to connect real situations or events with the personal feelings aroused by these situations.
• Encourage solitary pleasurable activities, such as crafts and hobbies, or quiet one-to-one activities between client and nurse. Competitive activities can be threatening and can exacerbate fears and suspicions.

Short-Term Goal #2: The client will develop adaptive coping strategies.

Interventions and Rationales

• Teach the client appropriate ways to handle stress, such as journaling or structured physical activity like taking a walk. Acquisition of skills, information, and options for dealing with stress enhances the client's coping ability.
• Help the client identify people and community resources to alleviate difficulties such as loneliness. Helping the client develop a personal acquaintance with community support people alleviates negative feelings such as loneliness, hopelessness, and fear of abandonment.
• Help the client formulate plans to contact support services such as community mental health workers or pastoral care personnel, to discuss the client's concerns about self and lifestyle adaptations. Providing a plan with specific, delineated steps enables the client to follow them though and achieve success.
• Help the client establish a predictable, daily routine. Daily routines provide structure and a sense of security and reduce the sfess that can provoke delusional thinking.

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION

Probable Causes	Defining Characteristics
Delusional thinking Unacceptable social behavior History of inability to maintain adequate social relationships Limited impulse control Extreme emotions	Limited communication and social skills Active avoidance of people Verbalization of discomfort around others, sense of not belonging, and fears of inadequacy. Verbalization of lack of interest in others. Inability to develop mutual relationships.

Long-Term Goal
The client will demonstrate competence in social situations.

Short-Term Goal #1:The client will practice basic social interaction skills.

Interventions and Rationales

Short-Term Goal #2: The client will increase the frequency of meaningful social interactions.

Interventions and Rationales

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION

Probable Causes	Defining Characteristics
Delusional thinking Family violence history Inability to cope with stressors Severe anger Feelings of inferiority	Aggression directed at others Verbally assaultive behavior Use of abusive language Inability to control behavior Provocation of other people

Long-Term Goal
The client will demonstrate a reduced potential for violence directed at others.

Short-Term Goal #1:The client will learn constructive ways to deal with aggressive feelings.

Interventions and Rationales

• Help the client discuss personal concerns about being mistreated by others. Encouraging the client to reveal fears of mistreatment allows assessment of the clients persecutory delusions and potential for violence.
• Have the client discuss angry feelings and appropriate ways to deal with these negative feelings. The client must learn to use nonviolent options for satisfying needs.
• Identify risk factors, such as history of severe stress, family violence, and physical aggression. A history of multiple risk factors indicates a greater potential to use violence as a coping method.
• Model appropriate ways for expressing anger, defusing anger, and responding to abusive language. Teaching the client acceptable ways of expressing angry feelings and decreasing agitation is a step toward dealing with aggressive feelings.

Short-Term Goal #2: The client will demonstrate control over aggressive behavior.

Interventions and Rationales

• Teach the client how to tolerate feelings of frustration by role-modeling how to handle daily situational irritations and by identifying automatic thoughts and behaviors that arise in certain frustrating situations. As the client develops better skills for handling frustration, episodes of aggressive behavior are less likely to occur.
• Provide opportunities to work off aggressive energy by way of exercise or other physical activities. Learning socially acceptable ways to release energy enables client to exhibit self-control.
• Give positive feedback about ways in which the client attempts to handle frustration and aggressive tendencies. Positive feedback encourages the client to continue applying newly learned skills of handling frustration and aggression.
• Help the client recognize potential situations that may trigger loss of self-control. Experience in recognizing and discussing potentially violent situations may decrease the stress and minimize the perceived threats associated with the events.
• Help the client learn problem-solving and negotiating skills as a substitute for argumentative behavior. Learning to substitute problem-solving and negotiating skills for argumentative behavior leads to a decreased reliance on violence.

THERAPIES

Individual Therapy

• Work with the client to decrease use of the defenses of denial projection and distorted thinking by having the client address feelings of insecurity and underlying conflicts.
• Focus on feelings.
• Explore how delusional thinking influences the client's lifestyle.
• Provide feedback related to reality.
• Help the client recognize how intense stress increases symptoms.
• Teach decision-making, problem-solving, and negotiating skills because some clients are prone to argumentative behavior.

MEDICATIONS

• Antipsychotic medications can provide a way to handle severe agitation, modify delusional thinking, and facilitate functioning in social and occupational situations.
• Monitor clients taking antipsychotic medications; extrapyramidal adverse effects may require the concomitant use of antiparkinsonian drugs. (See Appendix D for specific drug information.)

FAMILY CARE

• Teach the family how to communicate with a member who has a delusional disorder.
• Reinforce reality by discussing real-life events.
• Provide opportunities for family members to verbalize concerns.
• Counsel family members about ways to accept the person with the disorder.
• Supply information on support groups and community agencies.
• Teach the family about expected therapeutic effects and adverse effects of medications.
• Encourage the family to monitor the client's nutrition, hydration, and sleep-rest patterns.
• Inform the family about stress management techniques and about how to recognize and intervene if the person behaves aggressively.

Schizoaffective disorder

DSM-IV CATEGORIES

295.70 Schizoaffective disorder (specify type: bipolar type/ depressive type)

Schizoaffective disorder is characterized by the occurrence of a major depression, manic episode, or mixed depressive-manic episode with the presence of schizophrenia symptoms. Sometimes delusions or hallucinations may occur without the presence of distinctive mood symptoms. The mood symptoms (depressed mood, loss of interest or sense of pleasure) occur for a substantial part of the acute and residual periods of the psychotic illness. To use the diagnosis of Schizoaffective disorder, the clinician must determine that the symptoms aren't caused by a medical condition or physiologic effects of a substance.

There's only speculation about the biological basis for this disorder. When more information is obtained about the neuroanatomic and neurochemical brain variations found in clients with schizophrenia, answers about the conditions causing Schizoaffective disorder may be found.

There are two types of schizoaffective disorder based on the mood component. The bipolar type exists when a manic or mixed depressive-manic episode is present. The depressive type is diagnosed when only a depressive disorder is identified.

Clients with a Schizoaffective disorder struggle with establishing interpersonal relationships, keeping jobs, establishing social contacts, and maintaining their self-care needs. Typically, these clients have less severe and fewer chronic symptoms than clients with schizophrenia. Onset usually occurs in the young adult period.

COMMUNICATION STRATEGIES

• Begin simple, low-intensity contact by establishing a nurse-client relationship.
• Don't argue with the client about delusions or hallucinations.
• Structure interactions so that responses required of the client are limited and simple.
• Focus interaction on the here and now to reinforce reality.
• Acknowledge and work with the client's nonverbal communication.
• Avoid asking too many questions or probing for information.
• Provide information in a clear, matter-of-fact manner.

NURSING DIAGNOSIS: CHRONIC LOW SELF-ESTEEM

Probable Causes	Defining Characteristics
Severe stress Unhealthy interpersonal relationships Mood disorder Early childhood trauma Feelings of helplessness	Negative self-talk and view of the world Perceptions and verbalizations of failures Unkempt appearance with slouched posture Inability to meet persona expectations Little or no participation in activities with others

Long-Term Goal
The client will develop and sustain a realistic perception of self.

Short-Term Goal #1:The client will identify and begin to change ineffective methods of coping with life stressors.

Interventions and Rationales

• Help the client identify and discuss methods used to cope with stressors. Before change is possible, the client needs to examine current stressors and identify current ineffective coping methods.
• Help the client discover how delusional thinking interferes with the ability to cope. The client needs to realize that delusional thinking is a major barrier to effective coping.
• Help the client identify and develop positive strengths and skills that already exist. It's essential to intervene in ways that enhance self-concept.
• Help the client focus on a realistic view of self that includes acknowledging both strengths and weaknesses. An unrealistic view of self perpetuates negative and self-defeating behaviors.
• Help the client examine current negative feelings in terms of where they come from and what purpose they serve. The client needs to identify negative feelings and learn to express them.
• Help the client recognize that negative feelings and thoughts can be changed. With assistance, the client can begin to develop new coping strategies and make behavioral changes.

Short-Term Goal #2: The client will begin to have positive feelings about self

Interventions and Rationales

• Ask the client to describe various situations that cause both positive and negative feelings. Examining feelings gives the client an opportunity to discuss and evaluate current life situations in a realistic manner.
• Help the client generate a list of positive attributes about self. Identifying positive attributes promotes self-esteem.
• Teach the client positive self-affirmations. The client needs practice focusing on positive aspects of self.
• Help the client recognize and decrease negative self-talk by keeping track of the number of negative self-talk incidents that occur in a day. Developing the capacity to recognize and stop negative self-talk interrupts the pattern of negativity and self-blaming.
• Encourage the client to discuss and demonstrate adaptive behaviors in interpersonal and social situations. Learning and successfully practicing adaptive behaviors enhance feelings of self-worth.

Short-Term Goal #3: The client will initiate and sustain healthy interpersonal relationships.

Interventions and Rationales

• Encourage the client to discuss concerns about interacting with others. Discussion of experiences with others gives the client practice with problem solving.
• Provide opportunities for the client to participate in group activities. The client needs to increase self-confidence and to practice social skills by relating to others more frequently.
• Help the client differentiate between troublesome and helpful behaviors in daily interactions with others. Personal evaluation of interactions helps to develop an awareness of behavior.
• Teach the client communication skills and social skills by using role playing practice new behaviors and skills. Learning social skills improves interpersonal relationships, promotes confidence, and provides knowledge that enable the client to take better care of self role playing enhance understanding of behavior and prepares the client for encounters with others.
• Encourage the client to initiate contacts with peers and form friendships. Connecting with others provides opportunities to construct interpersonal relationships.

NURSING DIAGNOSIS: IMPAIRED HOME MAINTENANCE MANAGEMENT

Probable Causes	Defining Characteristics
Inadequate skills needed to perform self-care Lack of support systems to make up for self-care deficits Stressful situations with significant others Substance abuse Interruption or premature termination of day treatment or outpatient treatment	Poor hygiene practices Unhealthy or unsafe living conditions Unstable physical or emotional health Noncompliance with prescribed drug regimen Verbalization about inability to cope

Long-Term Goal
The client will develop self-understanding and the planning skills necessary to maintain personal health in the home setting.

Short-Term Goal #1:The client will verbalize understanding of unstable health condition and the need for assistance with self-care.

Interventions and Rationales

• Encourage discussion of feelings about problems, treatment and the ability to perform self-care. Expression of feelings identifies fears, anger, and dissatisfaction with treatment regimen.
• Encourage the client to engage in a realistic discussion of mental health concerns. Discussion based on real health issues prevents the client from denying or minimizing the need for assistance with care.
• Provide the client with accurate information about the health condition, self-care activities, treatment, and medications necessary for self-maintenance. The client needs to understand the health condition and the need for treatment.
• For clients with intact, interested families, discuss with the client ways to include the family in interactions, identifying realistic roles and support that the family can provide. Discussion of family roles facilitates the client's acceptance of having significant others involved in care.
• Emphasize the importance of long-term treatment and support even when symptoms are under control. The client needs a realistic view of the necessity of ongoing treatment, not treatment only in times of crisis.

Short-Term Goal #2: The client will learn how to plan and manage for maximum health and safety needs.

Interventions and Rationales

• Assess the client's learning needs about self-care. Careful assessment sets the stage for identification of needs and appropriate interventions.
• Assess the client's financial constraints, and explain how to obtain assistance if financial burdens limit access to follow-up care. Many clients with financial problems don t know how to get the necessary monetary assistance for follow-up care.
• Determine the availability of transportation for the client. Transportation is essential for follow-up care.
• Help the client obtain assistance with basic needs, such as obtaining subsidized housing and food stamps, and with maintaining a healthy living environment. Establishing a specific plan of action for care decreases anxiety and increases chances for success.
• Initiate referrals to community mental health centers and other community agencies. A support system strengthens the clients ability to function in the community.

THERAPIES

Individual Therapy

• Address immediate issues of concern.
• Help the client maintain contact with reality.
• Examine stressful situations that provoke psychotic symptoms.
• Teach the client how to recognize symptoms and manage escalation of mood disturbances.
• Help the client develop coping strategies to prevent exacerbation of symptoms and subsequent hospitalization.

MEDICATIONS

• Antipsychotic drugs decrease the severity of psychotic behavior.
• Antidepressant and antimanic drugs control dramatic or agitated symptoms.
• Monitor clients taking antipsychotic medications: extrapyramidal adverse effects may require the concomitant use of antiparkinsonian drugs. (See Appendix D for specific drug information.)

FAMILY CARE

• Provide the family with information about diagnosis, treatment, and the need for follow-up care.
• Help the family to be supportive of both the client and the treatment regimen by not challenging the client's delusional thinking, not minimizing the importance of treatment, and net focusing their anger directly at the client.
• Teach family members how to identify exacerbations of the illness and implement effective interventions when sudden exacerbations occur.
• Help the family develop strategies to deal with the alternating characteristics of the mood disorder and the schizophrenia.
• Intervene or refer to appropriate counseling when family discord or conflicts occur.
• Help the family plan emergency intervention in the event of a crisis.
• Make referrals to community resources and social service agencies.