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6. Schizophrenia and other psychotic disorders

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

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 ó 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.)



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

  • 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 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
  • 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)
  • Delusions
  • Hallucinations
  • Lack of coherence
  • Disorganized behavior that cannot be incorporated into any other type
  • 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

Probable CausesDefining 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

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

Interventions and Rationales

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

Interventions and Rationales

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

Interventions and Rationales

Probable CausesDefining 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

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

Interventions and Rationales

Probable CausesDefining 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

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

Interventions and Rationales

Probable CausesDefining 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

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

Interventions and Rationales

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

Probable CausesDefining 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

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

Interventions and Rationales

Probable CausesDefining 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

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

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

Interventions and Rationales

Milieu Therapy
Behavioral Therapy
Group Therapy
Family Therapy
Residential Therapy
Outpatient Therapy/Day Treatment Program


Antichollnsrgic effects
Dry mouthHave 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 visionLimit the client's reading to large-print books; problem usually resolves in weeks.
Nasal congestionThis effect resolves In 2 weeks, or use a nasal decongestant.
Urine retention or urinary hesitancyMonitor 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).
ConstipationIncrease the client's fluid Intake, fiber intake, and exercise, and obtain an order for a stool softener or laxative.
PhotophobiaHave the client wear sunglasses.
EyedrynessEncourage the client to blink or use artificial tears.
Impotence or inability to ejaculateAssess 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 postureAlert 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 incontinenceStop 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 tachycardiaMonitor 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.
SedationTall 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 gainEncourage 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 libidoAssess the client and alert the doctor to these adverse effects
Cholestatic jaundice: fever, nausea, lethargy, and abdominal painStop 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.


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.


Probable CausesDefining 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

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

Interventions and Rationales

Probable CausesDefining 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

  • Help the client survey personal acquaintances and identify those who are potential friends. Focusing the client's efforts on actual people and situations makes the learning of social skills realistic and meaningful.
  • Discuss with the client ways to initiate interactions with other people. Providing information on social and communication skills facilitates the client's sense of competency.
  • Teach the client how to express feelings in socially acceptable ways through role-playing activities. Appropriate expression of feelings can be troublesome for clients who maintain emotional distance from others.
  • Help the client verbalize feelings that are uncomfortable or negative. Verbalization of feelings prevents escalation of anxiety and decreases the possibility of reverting to delusional thinking.
  • Help the client identify situations in which the lack of appropriate social skills interferes with social interactions. Feedback helps the client develop awareness of problems with specific socia. interactions and facilitates the client's desire for change.
  • Short-Term Goal #2: The client will increase the frequency of meaningful social interactions.

    Interventions and Rationales

  • Create opportunities for the client to have small-group interactions and interactions with peers. Small-group contact and peer interactions can enhance trust and sharing.
  • Provide interaction opportunities for the client by helping to establish contact with desired friends and family members. Significant others can help the client work at interaction skills and promote socialization experiences.
  • Teach and reinforce social skills through the use of role modeling and role playing. Reinforcement of newly acquired social skills encourages the client to use the skills frequently.
    Probable CausesDefining 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

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

    Interventions and Rationales

    Individual Therapy

    Schizoaffective disorder
    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.


    Probable CausesDefining 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

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

    Interventions and Rationales

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

    Interventions and Rationales

    Probable CausesDefining 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

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

    Interventions and Rationales

    Individual Therapy