SchizophreniaSchizophrenia

Definition The schizophrenic disorders are characterized in

general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time.

The most important psychopathological phenomena include thought echo thought insertion or withdrawal thought broadcasting delusional perception and delusions of control influence or passivity hallucinatory voices commenting or discussing the patient in

the third person thought disorders and negative symptoms.

Schizophrenia Schizophrenia occurs with regular frequency

nearly everywhere in the world in 1 % of population and begins mainly in young age (mostly around 16 to 25 years).

Schizophrenia is defined by etymology of the term from the Greek roots skhizein ("to

split") and phrēn, phren- ("mind") Dr. Emile Kraepelin in the 1887 and the illness itself is

generally believed to have accompanied mankind through its history

Swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911

deterioration in social, occupational, or interpersonal relationships

continuous signs of the disturbance for at least 6 months

History Emil Kraepelin: This illness develops relatively

early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia („Dementia praecox“), but was not followed by any organic changes of the brain, detectable at that time.

Eugen Bleuler: He renamed Kraepelin’s dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a „splitting“ of mind.

Kurt Schneider: He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of „the first rank symptoms” even in the concept of the diagnosis of schizophrenia.

4 A (Bleuler) Bleuler maintained, that for the diagnosis of

schizophrenia are most important the following four fundamental symptoms:

affective blunting disturbance of association (fragmented thinking) autism ambivalence (fragmented emotional response)

These groups of symptoms, are called „four A’ s” and Bleuler thought, that they are „primary” for this diagnosis.

The other known symptoms, hallucinations, delusions, which are appearing in schizophrenia very often also, he used to call as a “secondary symptoms”, because they could be seen in any other psychotic disease, which are caused by quite different factors — from intoxication to infection or other disease entities.

Course of Illness

Course of schizophrenia: continuous without temporary improvement episodic with progressive or stable deficit episodic with complete or incomplete remission

Typical stages of schizophrenia: prodromal phase active phase residual phase

Clinical Picture Diagnostic manuals:

lCD-10 („International Classification of Disease“, WHO) DSM-IV („Diagnostic and Statistical Manual“, APA)

Clinical picture of schizophrenia is according to lCD-10, defined from the point of view of the presence and expression of primary and/or secondary symptoms (at present covered by the terms negative and positive symptoms): the negative symptoms are represented by cognitive

disorders, having its origin probably in the disorders of associations of thoughts, combined with emotional blunting and small or missing production of hallucinations and delusions

the positive symptom are characterized by the presence of hallucinations and delusions

the division is not quite strict and lesser or greater mixture of symptoms from these two groups are possible

Positive and Negative Symptoms

NegativeNegative PositivePositive

AlogiaAlogia HallucinationsHallucinations

Affective flatteningAffective flattening DelusionsDelusions

Avolition-apathyAvolition-apathy Bizarre behaviourBizarre behaviour

Anhedonia-asocialityAnhedonia-asociality Positive formal thought Positive formal thought disorderdisorder

Attentional impairmentAttentional impairment

Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995

The Criteria of DiagnosisFor the diagnosis of schizophrenia is necessary presence of one very clear symptom - from point a) to d) or the presence of the symptoms from at least two groups -

from point e) to h)for one month or more:

a) the hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought broadcasting

b) the delusions of control, outside manipulation and influence, or the feelings of passivity, which are connected with the movements of the body or extremities, specific thoughts, acting or feelings, delusional perception

c) hallucinated voices, which are commenting permanently the behavior of the patient or they talk about him between themselves, or the other types of hallucinatory voices, coming from different parts of body

d) permanent delusions of different kind, which are inappropriate and unacceptable in given culture

The Criteria of Diagnosise) the lasting hallucination of every formf) blocks or intrusion of thoughts into the flow of thinking and

resulting incoherence and irrelevance of speach, or neologisms

g) catatonic behaviorh) „the negative symptoms”, for instance the expressed

apathy, poor speech, blunting and inappropriatness of emotional reactions

i) expressed and conspicuous qualitative changes in patient’s behavior, the loss of interests, hobbies, aimlesness, inactivity, the loss of relations to others and social withdrawal

Diagnosis of acute schizophorm disorder (F23.2) – if the conditions for diagnosis of schizophrenia are fulfilled, but lasting less than one month

Diagnosis of schizoaffective disorder (F25) - if the schizophrenic and affective symptoms are developing together at the same time

F20-F29 Schizophrenia, Schizotypal and Delusional Disorders

F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

F20-F29 Schizophrenia, Schizotypal and Delusional Disorders

F21 Schizotypal disorder F22 Persistent delusional disorders F22.0 Delusional disorder F22.8 Other persistent delusional disorders F22.9 Persistent delusional disorder, unspecified F23 Acute and transient psychotic disorders F23.1 Acute polymorphic psychotic disorder with

symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder F23.3 Other acute predominantly delusional

psychotic disorders F23.8 Other acute and transient psychotic disorders F23.9 Acute and transient psychotic disorder,

unspecified

F20-F29 Schizophrenia, Schizotypal and Delusional Disorders

F24 Induced delusional disorder F25 Schizoaffective disorders F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified F28 Other nonorganic psychotic disorders F29 Unspecified nonorganic psychosis

F20.0 Paranoid Schizophrenia Paranoid schizophrenia is characterized

mainly by delusions of persecution, feelings of passive or active control, feelings of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices.

Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

F20.1 Hebephrenic Schizophrenia Hebephrenic schizophrenia is characterized by

disorganized thinking with blunted and inappropriate emotions. It begins mostly in adolescent age, the behavior is often bizarre. There could appear mannerisms, grimacing, inappropriate laugh and joking, pseudophilosophical brooding and sudden impulsive reactions without external stimulation. There is a tendency to social isolation.

Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults.

Denoted also as disorganized schizophrenia

F20.2 Catatonic Schizophrenia Catatonic schizophrenia is characterized

mainly by motoric activity, which might be strongly increased (hypekinesis) or decreased (stupor), or automatic obedience and negativism.

We recognize two forms: productive form — which shows catatonic

excitement, extreme and often aggressive activity. Treatment by neuroleptics or by electroconvulsive therapy.

stuporose form — characterized by general inhibition of patient’s behavior or at least by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent.

F20.3 Undifferentiated Schizophrenia

Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.

This subgroup represents also the former diagnosis of atypical schizophrenia.

F20.4 Postschizophrenic Depression A depressive episode, which may be

prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either „positive“ or „negative“, must still be present but they no longer dominate the clinical picture.

These depressive states are associated with an increased risk of suicide.

F20.5 Residual Schizophrenia A chronic stage in the development of

schizophrenia with clear succession from the initial stage with one or more episodes characterized by general criteria of schizophrenia to the late stage with long-lasting negative symptoms and deterioration (not necessarily irreversible).

F20.6 Simple Schizophrenia

Simple schizophrenia is characterized by early and slowly developing initial stage with growing social isolation, withdrawal, small activity, passivity, avolition and dependence on the others.

The patients are indifferent, without any initiative and volition. There is not expressed the presence of hallucinations and delusions.

F21 Schizotypal disorder According to lCD-10 this disorder is

characterized by eccentric behavior and by deviations of thinking and affectivity, which are similar to that occurring in schizophrenia, but without psychotic features and expressed symptoms of schizophrenia of any type.

F22 Persistent Delusional Disorders Includes a variety of disorders in which

long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective.

Their origin is probably heterogeneous, but it seems, that there is some relation to schizophrenia.

F22.0 Delusional Disorder A disorder characterized by the

development of one delusion or of the group of similar related delusions, which are persisting unusually long, very often for the whole life.

Other psychopathological symptoms — hallucinations, intrusion of thoughts etc. are not present and are excluding this diagnosis.

It begins usually in the middle age.

F23 Acute and Transient Psychotic Disorders The criteria should be the following features:

acute beginning (to two weeks) presence of typical symptoms (quickly changing

“polymorphic symptoms”) presence of typical schizophrenic symptoms.

Complete recovery usually occurs within a few months, often within a few weeks or even days.

The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

F24 Induced Delusional Disorder A delusional disorder shared by two or more

people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated.

The psychotic disorder of the dominant member of this dyad is mainly, but not necessarily, of schizophrenic type. The original delusions of dominant member and his partner are usually chronic, either persecutory or megalomanic.

F25 Schizoaffective Disorders Episodic disorders in which both affective and

schizophrenic symptoms are prominent (during the same episode of the illness or at least during few days) but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes.

Patients suffering from periodic schizoaffective disorders, especially with manic symptoms, have usually good prognosis with full remissions without any remaining defects.

They are divided in different subgroups: F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified

Genetics of Schizophrenia

Many psychiatric disorders are multifactorial (caused by the interaction of external and genetic factors) and from the genetic point of view very often polygenically determined.

Relative risk for schizophrenia is around: 1% for normal population 5.6% for parents 10.1% for siblings 12.8% for children

Etiology of Schizophrenia

The etiology and pathogenesis of schizophrenia is not known

It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial: internal factors – genetic, inborn, biochemical external factors – trauma, infection of CNS, stress

Etiology of Schizophrenia - Dopamine Hypothesis

The most influential and plausible are the hypotheses, based on the supposed disorder of neurotransmission in the brain, derived mainly from

1. the effects of antipsychotic drugs that have in common the ability to inhibit the dopaminergic system by blocking action of dopamine in the brain

2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of lysergic acid - LSD) that can induce state closely resembling paranoid schizophrenia

Classical dopamine hypothesis of schizophrenia: Psychotic symptoms are related to dopaminergic hyperactivity in the brain. Hyperactivity of dopaminergic systems during schizophrenia is result of increased sensitivity and density of dopamine D2 receptors in the different parts of the brain.

Etiology of Schizophrenia - Contemporary Models Dopamine hypothesis revisited: various

neurotransmitter systems probably takes place in the etiology of schizophrenia (norepinephric, serotonergic, glutamatergic, some peptidergic systems); based on effects of atypical antipsychotics especially.

Contemporary models of schizophrenia conceptualize it as a neurocognitive disorder, with the various signs and symptoms reflecting the downstream effects of a more fundamental cognitive deficit: the symptoms of schizophrenia arise from “cognitive

dysmetria” (Nancy C. Andreasen) concept of schizophrenia as a neurodevelopmental disorder

(Daniel R. Weinberger)

Etiology of Schizophrenia - Neurodevelopmental Model

Neurodevelopmental model supposes in schizophrenia the presence of “silent lesion” in the brain, mostly in the parts, important for the development of integration (frontal, parietal and temporal), which is caused by different factors (genetic, inborn, infection, trauma...) during very early development of the brain in prenatal or early postnatal period of life.

It does not interfere too much with the basic brain functioning in early years, but expresses itself in the time, when the subject is stressed by demands of growing needs for integration, during formative years in adolescence and young adulthood.

Treatment of Schizophrenia The acute psychotic schizophrenic patients will

respond usually to antipsychotic medication. According to current consensus we use in the first

line therapy the newer atypical antipsychotics, because their use is not complicated by appearance of extrapyramidal side-effects, or these are much lower than with classical antipsychotics.

conventional antipsychotics(classical neuroleptics)

chlorpromazine, chlorprotixene, clopenthixole, levopromazine, periciazine, thioridazine

droperidole, flupentixol, fluphenazine, fluspirilene, haloperidol, melperone, oxyprothepine, penfluridol, perphenazine, pimozide, prochlorperazine, trifluoperazine

atypical antipsychotics

amisulpiride, clozapine, olanzapine, quetiapine, risperidone, sertindole, sulpiride

Neuroleptics are drugs that modify psychotic symptoms, including

symptoms of bipolar disorder, schizophrenia, delusional disorder and psychotic depression. 

There are two classes of neuroleptic drugs. Typical antipsychotics were discovered and first used in the 1950s, Atypical antipsychotics were developed and used in the 1970s.

Atypical neuroleptic drugs generally are regarded as more effective and less likely to cause side effects than typical neuroleptic drugs.

Tardive dyskinesia is a type of repetitive movement the patient cannot control

Side Effects: EPS Extrapyramidal syndrome is a condition that causes

involuntary muscle movements or spasms that usually occur in the face and neck. It occurs when the release and re-uptake of the neurotransmitter dopamine is not regulated correctly. 

Muscle movement problems that may accompany extrapyramidal syndrome include constantly

smacking the lips moving the tongue, blinking, neck twitches and finger spasms. 

Neuroleptics

Generic name Brand names

Chlorprothixene Truxal

LevomepromazineLevium, Levomepromazine Neuraxph., Neurocil

PerazinePerazin Neuraxph., Taxilan

Promethazine

Atosil, Closin, Promethazin Neuraxph., Proneurin, Prothazin

Prothipendyl Dominal

SulpirideDogmatil, Dogmatyl, Sulpirid

ThioridazineMelleril, Thioridazin Neuraxph.Generic name Brand names

Zuclopenthixol Cisordinol, Clopixol

Mild Strength[edit]Medium Strength

Mild Strength

iMedium Strength

Strong Strength

Generic name Brand names

Perfenazine Trilafon

Generic name Brand names

BenperidolBenperidol Neuraxph., Glianimon

Bromperidol Impromen

Fluphenazine

decanoate

Anatensol, Dapotum D, Deconoat, Fludecate, Modecate, Prolixin Decanoate, Sinqualone

enanthate

Dapotum Injektion, Flunanthate, Moditen Enanthate Injection, Sinqualone Enantat

hydrochloride  

Dapotum, Permitil, Prolixin, Lyogen, Moditen, Omca, Sediten, Selecten, Sevinol, Siqualone, Trancin

FluspirilenFluspi, Fluspirilen Beta, Imap

Haloperidol Haldol, SerenasePimozide Orap

[Very Strong Strength

Aty

pic

al N

eu

role

pti

cs

Generic name Brand names

Amisulpride Solian

Aripiprazole Abilify

Asenapine Saphris

Benztropine Cogentin

BuspironeAnsial, Ansiced, Anxiron, Axoren, Bespar, Buspar, Buspimen, Buspinol, Buspisal, Narol

Chlorpromazine Largactil, Thorazine

Clozapine Clozaril, Fazaclo, Leponex

Flupenthixol Depixol, Fluanxol

Iloperidone Fanapt

Melperone Eunerpan, Melneurin

Olanzapine Zyprexa

Paliperidone Invega, Invega Sustenna

Penfluridol Semap

Quetiapine Seroquel

Risperidone Belivon, Risperdal, Risperdal Consta

Sertindole Serdolect, Serlect

Thiothixene Navane

TrifluoperazineEskazinyl, Eskazine, Jatroneural, Modalina, Stelazine, Terfluzine, Trifluoperaz, Triftazin

Ziprasidone Geodon, Zeldox

Zotepine Nipolept

Carbamazepine, Valproic acid sometimes used

Nursing Management The nurse may assess a client with a known

history of schizophrenia or a client with a unknown to the mental health care system. Assessment begins with an interview and focuses on establishing the client's signs and symptoms, degree of impairment in the thought process, risk for self injury or violence towards others, and available support systems. The nurse may wish to interview the client with a family member or a friend to obtain all information regarding family history, previous episodes of psychotic symptoms, onset of symptoms, and thoughts of suicide or violent behaviour

Assessment:

1.       Assessing mood and cognitive state: The nurse is alert for the signs and symptoms such as : Absence of expression of feelings Language content that is difficult to follow Pronounced paucity of speech and thoughts Preoccupation with odd ideas Ideas of reference Expression of feelings of unreality Evidence of hallucinations such as comments that the way

they things appear, sound, or smell is different. The nurse can also inquire about recent stressors, which can

precipitate a psychotic episode in the client with a thought disorder, and signs and symptoms of impending relapse. These signs include disturbed sleep cycle, significant mood changes( mostly depression), decreased appetite, and somatic complaints such as headache, malaise, and constipation. Relapse eads to client withdrawal, resistance, and preoccupation with psychotic symptoms. 

 2.       Assessing potential for violence:The nurse assess the potential for violence by

inquiring about the following: History of violent or suicidal behavior Extreme social isolation Feeling of persecution or being controlled by

others. Auditory hallucinations that tells the client to

commit violent acts. Concomitant substance use. Medication noncompliance Feelings of anger, suspiciousness, or hostility.

3.       Assessing social support: Availability and responsiveness of a social support

network and the client's role in the family and community are important factors in nursing assessment

4.       Assessing knowledge The nurse assess the client's and families

knowledge of schizophrenia, its treatment, and the potential for relapse. Adherence to medication regimens and other therapeutic schedules is bolstered when cients and families understand the biologic basis of the illness, signs of recovery and relapse, and their role in treatment.

NURSING DIAGNOSIS:

1. Disurbed thought process related to biochemical imbalances, as evidenced by hypervigilence, distractibility, por concentration, disordered thought sequencing, inappropriate responses, and thinking not based in reality.

2. Disturbed sensory perception( auditory/visual) related to biochemical imbalances, as evidencd by auditory or visual hallucinations.

3. Risk for other- directed or self directed violence related to delusional thoughts and hallucinatory commands, history of childhood abuse, or panic,as evidencedby overt aggressive acts, threatening stances, pacing, or suicidal ideation or plan.

4. Social isolation related to alterations in mental status and an ability to engage in satisfying personal relationships, as evidenced by sad, flat affect, absence of supportive significant others, withdrawal, uncommunicativeness and inability to meet the expectations of others.

5. Noncompliance with medication regimen related to health beliefs and lack of motivation, as evidenced by failure to adhere to medication schedule.

6. Ineffective coping related to disturbed thought process as evidenced by inability to meet basic needs.

7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals.

8. Risk for ineffective family management of therapeutic regimen related to knowledge deficit and complexity of client,s healthcare needs.

Diagnoses Nursing Care Plans For Schizophrenia

Anxiety Bathing or hygiene self-care

deficit Disabled family coping Disturbed body image Disturbed personal identity Disturbed sensory

perception (auditory, visual, kinesthetic)

Disturbed sleep pattern Disturbed thought processes Dressing or grooming self-

care deficit Fear Hopelessness

Imbalanced nutrition: Less than body requirements

Impaired home maintenance Impaired social interaction Impaired verbal

communication Ineffective coping Ineffective role performance Powerlessness Risk for injury Risk for other-directed

violence Risk for self-directed

violence Social isolation

Disturbed Thought Processes Convey acceptance of client's need for false

belief but that you do not share the belief Do not argue or deny the belief Reinforce and focus on reality    If client is suspicious  Consistent staff Honest, keep all promises

Disturbed Sensory Perception Auditory/Visual

Observe for signs of hallucinations Avoid touching client without warning Do not reinforce the hallucination - let the

client know that you do not share the perception - "Even though I know the voices are real to you, I do not hear them"

Help client understand connection between anxiety and hallucinations

Try to distract

Social Isolation Convey accepting attitude by making brief,

frequent contacts. Show unconditional positive regard

Offer to be with client during group activities that he/she finds frightening

Give recognition and positive reinforcement for client voluntary interactions with others

Self Care Deficit Provide assistance as appropriate Encourage independence - positive

reinforcement concrete communications

Impaired verbal communication Seek validation and clarification Consistent staff Verbalizing the implied Orient to reality

Key outcomes Nursing Care Plans For Schizophrenia

The patient will consider an alternative interpretation of a situation without becoming unduly hostile or anxious.

The patient will perform bathing and hygiene activities to the fullest extent possible.

The patient's family will demonstrate adaptive coping behaviors.

The patient will verbalize positive feelings about self.

The patient will identify internal and external factors that trigger delusional episodes.

The patient will maintain maximum functioning within the limits of his auditory, visual, or kinesthetic impairment.

The patient will resume appropriate rest and activity patterns.

The patient will identify and perform activities that decrease delusions.

The patient will perform dressing and grooming activities to the fullest extent possible.

The patient will express fears and concerns. The patient and his family will participate in care

and prescribed therapies. The patient will remain free from signs of

malnutrition. The patient will develop effective coping behaviors. The patient will maintain usual roles and

responsibilities to the fullest extent possible. The patient will recognize symptoms and comply

with medication regimen. The patient will demonstrate effective social

interaction skills in both one-on-one and group settings.

The patient will express his needs. The patient will gradually join in self-care and the

decision-making process. The patient will remain free from injury. The patient won't harm others. The patient won't harm self or others. The patient will maintain family and peer

relationships.

Interventions Nursing Care Plans For Schizophrenia

Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.

Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.

Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.

Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.

Reward positive behavior to help the patient improve his level of functioning.

Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior.

If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.

Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor.

Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.

Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.

Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.

Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.

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