Schizophrenia

Pathophysiology

Dopamine hypothesis: Excess dopamine activity in the mesolimbic pathway drives positive symptoms (hallucinations, delusions). Insufficient dopamine in the mesocortical pathway contributes to negative symptoms (apathy, cognitive deficits) — this dual-pathway model explains why different symptom clusters respond to different medications
Serotonin dysregulation: Contributes to negative symptoms and cognitive impairment. Atypical antipsychotics target serotonin receptors in addition to dopamine
Glutamate and GABA deficits: Decreased glutamate activity and GABA deficits contribute to the cortical disconnection and sensory filtering failure
Neuroanatomy: Imaging shows enlarged ventricles, enlarged amygdala, and reduced gray matter in frontal lobes (executive function) and temporal lobes (auditory processing — explains auditory hallucinations)
Filtering deficit: The core functional impairment is loss of the ability to screen external stimuli. Sounds seem louder, colors more intrusive, producing chronic sensory overload that drives withdrawal and disorganized behavior
Typical antipsychotics (haloperidol) block D2 receptors, primarily addressing positive symptoms but causing extrapyramidal side effects (EPS). Atypical antipsychotics (clozapine, risperidone) block both D2 and 5-HT2A receptors, treating both positive and negative symptoms with fewer EPS

Positive symptoms: Hallucinations (most commonly auditory — "hearing voices"), delusions (paranoia, grandiosity, thought broadcasting), disordered thinking
Negative symptoms: Apathy, social withdrawal, affective flattening (lack of emotional expression), alogia (poverty of speech), avolition (inability to initiate purposeful activity) — most difficult to treat and most disabling long-term
Disorganized behavior: Catatonic excitement, grimacing, waxy flexibility (holding odd fixed positions for extended periods)
Speech patterns: Neologisms (invented words), "word salad" (disconnected words without logical structure), tangentiality
Psychogenic polydipsia: Compulsive water drinking that can lead to water intoxication and life-threatening hyponatremia
Neglected personal hygiene and disorganized clothing
High rates of co-occurring physical conditions: epilepsy, hypertension, diabetes, COPD

Acute psychosis or severe agitation makes informed consent impossible — do not treat. Ensure personal safety and contact emergency services if the client is a danger to self or others
Neuroleptic malignant syndrome (NMS): Fever, muscle rigidity, altered consciousness, and autonomic instability in a client on antipsychotics — medical emergency requiring immediate ER referral
Tardive dyskinesia: Involuntary repetitive movements (lip smacking, tongue protrusion, jaw movements) from long-term typical antipsychotic use — irreversible if not identified early. Report to prescribing physician
Water intoxication: Confusion, seizures, or lethargy in a client known to drink excessive water — hyponatremia can be fatal

Goals: Provide calming effect to reduce anxiety and manage secondary motor disorders or spasticity from the condition or its medications
Acute psychosis: Precautions warranted during active psychotic episodes or severe agitation. Informed consent may be difficult or impossible to negotiate — do not treat
Blunted pain response: Clients may not accurately communicate pain levels due to altered sensory processing. Use conservative pressure and actively monitor for tissue changes (redness, swelling, guarding) rather than relying on verbal feedback
Sensory overload management: Minimize environmental stimulation — dim lighting, eliminate strong scents, reduce or eliminate music, close windows to reduce external noise
Medication side effects: Antipsychotics commonly cause drowsiness, muscle spasms, tardive dyskinesia, and extrapyramidal symptoms. Adjust pressure and stretching accordingly. Allow extra time for position transitions
Communication: Be highly sensitive to nonverbal cues. Use simple, direct instructions. Some clients have difficulty processing complex verbal information
Trust building: Social withdrawal is a core negative symptom. Establishing a trusting therapeutic relationship may take many sessions. Starting with back massage in prone may be least threatening
Session structure: Keep sessions shorter and predictable. Avoid sudden changes in technique, pressure, or positioning

Understand positive vs. negative symptoms and that they respond to different pharmacological approaches
Excess dopamine activity in mesolimbic pathways drives positive symptoms. Mesocortical dopamine deficit drives negative symptoms
Blunted pain response increases overtreatment risk — a key safety consideration
Medication side effects (EPS, tardive dyskinesia, NMS) are important clinical and exam considerations
Waxy flexibility, neologisms, and psychogenic polydipsia are distinctive features tested on MCQ

Schizophrenia involves excess dopamine activity (positive symptoms) and cortical dopamine deficit (negative symptoms), with structural brain changes and sensory filtering failure.
Positive symptoms (hallucinations, delusions) and negative symptoms (apathy, flat affect) require different treatment approaches. Negative symptoms are most disabling.
Blunted pain response means the client may not report discomfort. Use conservative pressure and monitor for tissue changes rather than relying on verbal feedback.
Medication side effects (muscle spasms, tardive dyskinesia, drowsiness, EPS) are common and require treatment modifications.
Minimizing environmental stimulation helps manage the sensory overload characteristic of the disorder.
Acute psychosis makes informed consent impossible — do not treat.