Schizophrenia

Okay, let’s talk about Schizophrenia.

Let’s just start with the definition – Schizophrenia is a group of disorders characterized by abnormal social behavior and disturbances in mood, thought processes, behavior, and affect. We’ll talk about the different types in the next lesson. In this lesson I want to talk about the general symptoms and nursing interventions for all types of schizophrenia.

So, to be diagnosed with Schizophrenia, clients need to have at least two of the following symptoms, at least one of which should be a positive symptom. So first, what the heck does it mean to say a positive symptom and a negative symptom. It’s not like good and bad, it’s more like add and subtract. So, positive symptoms add things cognitively. This may include hallucinations or delusions, disorganized speech, or bizarre behavior – they’re new things added to the patient’s thought processes. Negative symptoms subtract things – so a decreased emotional range, a loss of interest, a lack of inertia. Inertia itself is a tendency to stay in motion – so if they’ve lost that, it’s a tendency to do nothing and remain unchanged. So those are negative symptoms.

Now we’ve talked a lot about hallucinations and delusions, so I want to really clarify what they are and how each of them is managed. So hallucinations are when a patient experiences external stimuli with no organic cause – in other words they are hearing, seeing, or feeling something that isn’t really there. There is a type of hallucination for each of the 5 senses. Auditory – hearing things, olfactory – smelling things, tactile – feeling things, visual – seeing things, and gustatory – tasting things. What they’re experiencing is very real to them, but it isn’t really real.

Now, delusions are false beliefs firmly held to be true, despite rational argument. They truly believe that this feeling or situation is reality, even though it is clearly not. Some common types are delusions of persecution – where they feel like everyone is out to get them, delusions of jealousy where they’re convinced a loved one is being unfaithful despite evidence to the contrary, and delusions of grandeur where they are convinced they are way more important than they really are. Again, the belief is very real to them, but it is not real.

So when we’re dealing with a client with hallucinations, safety is always #1 – we want to ask them very directly what they’re seeing, hearing, or feeling. And, if they’re hearing voices, we want to directly ask “what are the voices saying?”. Some clients may have voices that tell them to harm themselves or others, so always ask! We do want to validate their feelings, because they’re very real to them, but we always stay in reality – we don’t perpetuate the hallucinations or joke about them. We don’t say “oh, sure, yeah I smell it, too!” or anything like that. When we’re working with them, we start with 1:1 interaction and minimize stimuli to prevent them from getting overwhelmed. Always monitor for worsening symptoms like increasing fear or anxiety and we can always give PRN medications when it’s appropriate to help manage their symptoms.

Okay, delusions – always safety first. Depending on the delusions, safety can be a huge issue, especially with paranoid delusions. We do want to ask them for details about their delusions and validate any parts of them that are in reality. We don’t want to challenge or argue about their delusions, but we want to focus on the feelings that the delusions are creating and we want to focus on reality. What’s REAL about what they’re thinking or feeling. Always be honest with them, but hold tight to any limits or boundaries that you’ve set. I’ve even told clients directly “we aren’t going to talk about what you think this person is doing, but we can talk about how you’re feeling right now”. That’s a boundary that keeps them from fixating on the delusion.

Some other interventions in general for clients with schizophrenia – safety first, always – that includes a self-harm assessment. We want to assess and address any physical needs they may have – especially if they’ve had a loss of interest or lack of inertia, they may need help with ADL’s or encouragement there. Always be genuine in your interactions and communicate very clearly. Be present for the clients’ needs. With someone with disorganized thoughts, it’s important to start small and work to bigger things. So, start with 1 on 1 interactions and move to group sessions, start with small tasks and move to more complex tasks, and start with direct tasks with no choices and move to allowing them to make more choices about their tasks. This keeps them from being too overwhelmed before their symptoms are under control.

So primary nursing concepts for a patient with schizophrenia are, of course, safety as #1 – especially with paranoid delusions, cognition because they may experience disorganized thoughts, and mood/affect because we can see some of those negative symptoms affecting their emotions.

So, let’s recap. Schizophrenia involves disturbances in mood, thought processes, behavior, and affect. Positive symptoms add things like hallucinations, delusions, and bizarre behavior. Negative symptoms subtract things like a loss of interest or a decreased emotional range. We always want to stay in reality – we validate their feelings but we don’t perpetuate delusions or hallucinations. And as always we put safety first, do a self-harm assessment and maintain a calm environment.

So that’s it for schizophrenia – check out the next lesson to learn about specific types of schizophrenia. Now, go out and be your best selves today. Happy nursing!