Schizophrenia Elisa A. Mancuso RNC, MS, FNS Professor

SchizophreniaSchizophrenia

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

2 million people (1.5 % of Population)2 million people (1.5 % of Population) Costs $ 35 billionCosts $ 35 billion Onset late adolescence or early adulthoodOnset late adolescence or early adulthood

– Men 15-25 Men 15-25 women 20-35 & > 50women 20-35 & > 50

Psychotic disorders with disturbances inPsychotic disorders with disturbances in::– Thought processesThought processes– PerceptionsPerceptions– Expression of feelingsExpression of feelings

IndicatorsIndicators

Psychotic SymptomsPsychotic Symptoms– Preoccupied with own thoughts and feelingsPreoccupied with own thoughts and feelings

Deterioration in functioningDeterioration in functioning– Role, ADLs, Interpersonal relationshipsRole, ADLs, Interpersonal relationships

6 month duration of symptoms6 month duration of symptoms Bleuler’s 4 AsBleuler’s 4 As

– AutismAutism– AffectAffect– Associative LoosenessAssociative Looseness– AmbivilanceAmbivilance

EtiologyEtiology GeneticGenetic

– Abnormal marker gene on chromosome # 5Abnormal marker gene on chromosome # 5– Heredity determines one’s predispositionHeredity determines one’s predisposition

Both parents schizophrenic = 20-50 % Both parents schizophrenic = 20-50 % ↑↑ risk↑↑ risk Identical twins = 50-75 % ↑↑ risk for siblingIdentical twins = 50-75 % ↑↑ risk for sibling

BiochemicalBiochemical– Altered Neuroanatomy ▲s in cortexAltered Neuroanatomy ▲s in cortex– ↑↑ ↑↑ DA activity (2x DA receptors) = PsychosisDA activity (2x DA receptors) = Psychosis– ↓ ↓ AcH = AcH = ↑ Confusion↑ Confusion, , – ↓ ↓ NE = AnhedoniaNE = Anhedonia– ↓ ↓ 5-HT = ↓ Aggressive tendencies5-HT = ↓ Aggressive tendencies– ↓↓Glutamate = learning & memory Glutamate = learning & memory – ↓↓Glucose metabolism & ↓ GABA Glucose metabolism & ↓ GABA

PsychologicalPsychological Poor early mother-child relationshipPoor early mother-child relationship

– ““Trust vs Mistrust”Trust vs Mistrust”

↓ ↓ Ego boundariesEgo boundaries Dysfuntional family systemDysfuntional family system Double-bind communicationDouble-bind communication

– Say one thing but mean the oppositeSay one thing but mean the opposite

EnvironmentEnvironment– ↓ ↓ Socioeconomic = ↑ stress & ↓ ↓ resourcesSocioeconomic = ↑ stress & ↓ ↓ resources– Stressful life events precipitate onset!Stressful life events precipitate onset!

Schizophrenia StagesSchizophrenia Stages

Stage IStage I Schizoid PersonalitySchizoid PersonalityIsolate themselves, “loners”Isolate themselves, “loners”Indifferent, cold, aloofIndifferent, cold, aloof↓ ↓ Range of emotional expressionRange of emotional expressionDon’t enjoy close relationshipsDon’t enjoy close relationships

Stage IIStage II Prodromal “Pre-Schizophrenic”Prodromal “Pre-Schizophrenic”Socially withdrawn- Blunted affectSocially withdrawn- Blunted affectEccentric behavior & Bizarre ideasEccentric behavior & Bizarre ideasUnusual perceptual experiencesUnusual perceptual experiences↓ ↓ Role performance ↓ADLsRole performance ↓ADLs

Schizophrenia StagesSchizophrenia Stages Stage IIIStage III Schizophrenia (Active)Schizophrenia (Active)

Prominent psychotic symptoms >6 monthsProminent psychotic symptoms >6 monthsDelusionsDelusions

False, fixed beliefFalse, fixed belief Grandiose, Persecutory, Paranoia, ReligiosityGrandiose, Persecutory, Paranoia, Religiosity

HallucinationsHallucinationsFalse sensory perceptionFalse sensory perceptionIdeas of ReferenceIdeas of Reference

Disorganized BehaviorDisorganized BehaviorImpaired work, social relations & self careImpaired work, social relations & self care

Disorganized SpeechDisorganized SpeechAssociative LoosenessAssociative Looseness Clanging EcholaliaClanging Echolalia Word SaladWord SaladPoverty of SpeechPoverty of Speech NeologismsNeologisms


Stage III Stage III Secondary SymptomsSecondary Symptoms– AnxietyAnxiety Substance Abuse (ETOH, coke)Substance Abuse (ETOH, coke)– Depression > 25% Depression > 25% – ↑↑ ↑↑ Suicide (10%) = Leading cause of deathSuicide (10%) = Leading cause of death– Compulsive H2O drinking 4-10 L/dayCompulsive H2O drinking 4-10 L/day

H2O intoxicationH2O intoxication ↓ ↓ Na = LightheadedNa = Lightheaded Lethargy Muscle crampsLethargy Muscle cramps N & VN & V ConfusionConfusion ComaComa


Stage IVStage IV ResidualResidual – Periods of remissions & exacerbationsPeriods of remissions & exacerbations– Similar to Prodromal phaseSimilar to Prodromal phase– Social withdrawalSocial withdrawal– Flat affectFlat affect– Impaired Role PerformanceImpaired Role Performance

Schizophrenia TypesSchizophrenia Types Disorganized (Hebephrenic)Disorganized (Hebephrenic)

– Onset before age 25 Onset before age 25 – Chronic flat, inappropriate affectChronic flat, inappropriate affect– Silliness, giggling, masturbating in publicSilliness, giggling, masturbating in public– Bizarre behaviorBizarre behavior

Facial grimacing & mannerismsFacial grimacing & mannerisms

– Impaired social interactionImpaired social interaction– ↓ ↓ Contact with realityContact with reality– Incoherent speech & concrete thinkingIncoherent speech & concrete thinking

Schizophrenia TypesSchizophrenia Types

CatatonicCatatonicLeast commonLeast common

Sudden onset & good prognosisSudden onset & good prognosis

Catatonic ExcitementCatatonic Excitement Extreme psychomotor agitationExtreme psychomotor agitation Purposeless movements – EchopraxiaPurposeless movements – Echopraxia

– ↑ ↑ risk of injury to self/othersrisk of injury to self/others

Continuous incoherent shouting - EcholaliaContinuous incoherent shouting - Echolalia

Catatonic StuporCatatonic Stupor Extreme psychomotor retardationExtreme psychomotor retardation Mute & Waxy Flexibility (Bizarre posturing)Mute & Waxy Flexibility (Bizarre posturing)


ParanoidParanoid– Preoccupied - 1 or more delusionsPreoccupied - 1 or more delusions

Persecution or GrandeurPersecution or Grandeur

– Related auditory hallucinationsRelated auditory hallucinations– ArgumentativeArgumentative– HostileHostile– AggressiveAggressive– TenseTense– SuspiciousSuspicious– HypervigilentHypervigilent


Undifferentiated ChronicUndifferentiated Chronic– Disorganized-bizarre behaviorDisorganized-bizarre behavior– Usually docile and not aggressiveUsually docile and not aggressive– Does not meet criteria of other subtypesDoes not meet criteria of other subtypes– Delusions & Hallucinations are prominentDelusions & Hallucinations are prominent


Residual (Pseudo-neurotic)Residual (Pseudo-neurotic)– Follows an acute episodeFollows an acute episode– Absence of prominent symptomsAbsence of prominent symptoms

No delusions or hallucinationsNo delusions or hallucinations

– Social isolationSocial isolation– Poor GroomingPoor Grooming– Eccentric behaviorEccentric behavior– Emotional BluntingEmotional Blunting

Schizophrenia TypesSchizophrenia Types Schizoaffective DisorderSchizoaffective Disorder

– 2 week period of predominant psychotic 2 week period of predominant psychotic episode (episode (↑ incidence in women)↑ incidence in women) DelusionsDelusions Hallucinations Hallucinations Disorganized behaviorDisorganized behavior ↑ ↑ SexualitySexuality Racing thoughts Racing thoughts

– Mood Disorder (affective) behaviorsMood Disorder (affective) behaviors ManiaMania – Euphoria – Euphoria

– Grandiosity & HyperactivityGrandiosity & Hyperactivity

DepressionDepression – – – Psychomotor retardation & Psychomotor retardation & suicidal ideationsuicidal ideation

– ↓↓ ↓↓ Occupational & social functioningOccupational & social functioning

CharacteristicsCharacteristics PositivePositive

– Excess or distorted inappropriate behaviorsExcess or distorted inappropriate behaviors– Disorganized thinkingDisorganized thinking– Not seen in mentally healthy adults!Not seen in mentally healthy adults!

NegativeNegative– Loss or decrease of appropriate functionLoss or decrease of appropriate function– Diminished emotional expressionDiminished emotional expression

AnhedoniaAnhedonia ApathyApathy Poverty of thoughtsPoverty of thoughts

CharcteristicsCharcteristics

PositivePositive

DelusionsDelusions

HallucinationsHallucinations

Catatonic ExcitementCatatonic Excitement

EchopraxiaEchopraxia

Echolalia Echolalia

NeologismsNeologisms

Associative LoosenessAssociative Looseness

ReligiosityReligiosity

ParanoiaParanoia

NegativeNegative

Concrete thinkingConcrete thinking

SymbolismSymbolism

Catatonic StuporCatatonic Stupor

Social withdrawalSocial withdrawal

Poverty of speechPoverty of speech

Flat affectFlat affect

AnhedoniaAnhedonia

DepersonalizationDepersonalization

AssessmentAssessment Mental Status Exam Mental Status Exam (Provides baseline data)(Provides baseline data)

– Appearance & General HealthAppearance & General Health DressDress Grooming Grooming Facial Facial

ExpressionExpression Eye ContactEye Contact Motor Behavior Motor Behavior Posture Posture

– SpeechSpeech PacePace SpontaneitySpontaneity VolumeVolume Tone & ModulationTone & Modulation ClarityClarity InterruptionsInterruptions

– Level of ConsciousnessLevel of Consciousness General ResponsivenessGeneral Responsiveness SensoriumSensorium

– Emotional StateEmotional State MoodMood AffectAffect IntensityIntensity

AppropriatenessAppropriateness

– Cognitive FunctionCognitive Function Thought ProcessThought Process ContentContent PerceptionsPerceptions ConcentrationConcentration Abstract ThinkingAbstract Thinking Insight/JudgmentInsight/Judgment

Nursing InterventionsNursing Interventions

Primary Goal = Patient SafetyPrimary Goal = Patient Safety Establish trust & listen closelyEstablish trust & listen closely

– Accepting attitude & Keep promises Accepting attitude & Keep promises Calm approach & non-threatening Calm approach & non-threatening

environmentenvironment– Prevent violence & Prevent violence & ↓ Anxiety↓ Anxiety

Clarify & reinforce realityClarify & reinforce reality– Orient to here & nowOrient to here & now

Address physical needsAddress physical needs ↑ ↑ Self esteemSelf esteem

Psychotic Symptom InterventionsPsychotic Symptom Interventions

DelusionsDelusionsAccept experience, identify content & triggersAccept experience, identify content & triggersEncourage reality oriented conversationEncourage reality oriented conversationUse distraction & refocusUse distraction & refocusRole model coping techniques to Role model coping techniques to ↓ anxiety↓ anxiety

HallucinationsHallucinationsFocus on the behavioral cueFocus on the behavioral cue (laughing, talking, turning head)(laughing, talking, turning head)Have Pt describe what isHave Pt describe what is happeninghappeningIdentify environmental & emotional triggersIdentify environmental & emotional triggers

To prevent aggressive responsesTo prevent aggressive responsesAvoid touching without 1Avoid touching without 1stst warning warning

Psychotic Symptom InterventionsPsychotic Symptom InterventionsImpaired CommunicationImpaired Communication

Role model clear communicationRole model clear communication Use simple, concrete statementsUse simple, concrete statementsSeek clarification & validate contentSeek clarification & validate contentVebalize the impliedVebalize the implied

ParanoiaParanoia↓ ↓ Environmental stimulationEnvironmental stimulation

Maintain eye contactMaintain eye contactProvide plenty of personal spaceProvide plenty of personal spaceAlways announce your presenceAlways announce your presence

↓ ↓ ImpulsivityImpulsivity““Time Outs” for restTime Outs” for rest

Psychotic Symptom InterventionsPsychotic Symptom InterventionsRitualismRitualism

Initiate conversation as ritual is performedInitiate conversation as ritual is performedAssess for behavioral cues indicating Assess for behavioral cues indicating ↑ anxiety↑ anxietyNegotiate a schedule for ritual & ADLsNegotiate a schedule for ritual & ADLs

Social WithdrawalSocial WithdrawalConvey nonverbal acceptance & worthinessConvey nonverbal acceptance & worthinessProvide brief & frequent 1:1 contactsProvide brief & frequent 1:1 contactsInitiate interaction & gradually expand social contactsInitiate interaction & gradually expand social contacts↑↑ Social skills trainingSocial skills training Rules & expectationsRules & expectations

Cognitive TherapyCognitive Therapy ↑ Decision making↑ Decision making

RegressionRegressionRN approaches Pt.RN approaches Pt.

↑ ↑ Self-Esteem and encourage independent behaviorSelf-Esteem and encourage independent behavior

Antipsychotic (Neuroleptic) MedsAntipsychotic (Neuroleptic) MedsMajor TranquilizersMajor Tranquilizers ↑↑ ↑↑ Protein Binding (91-99%)Protein Binding (91-99%) ↓ ↓ Efficacy in men (1/3 relapse + 1/3 disabled)Efficacy in men (1/3 relapse + 1/3 disabled) PotencyPotency

– HighHigh Fluphenazine (Prolixin) [Decanoate IM q3 weeks]Fluphenazine (Prolixin) [Decanoate IM q3 weeks] Haloperidol (Haldol) [Decanoate IM q4 weeks]Haloperidol (Haldol) [Decanoate IM q4 weeks] Trifluroperazine (Stelazine)Trifluroperazine (Stelazine)

– LowLow Chlorpromazine (Thorazine) * 1Chlorpromazine (Thorazine) * 1stst drug 1950 drug 1950 Thioridazine (Mellaril)Thioridazine (Mellaril)

Antipsychotic (Neuroleptic) MedsAntipsychotic (Neuroleptic) Meds ActionAction

– ↓ ↓ Agitation ↓ Psychotic SymptomsAgitation ↓ Psychotic Symptoms – ↓ ↓ + Behaviors (Delusions/Hallucinations)+ Behaviors (Delusions/Hallucinations)

– Block DA receptors =↓ DA Block DA receptors =↓ DA Improves fine motor movement & coordinationImproves fine motor movement & coordination Sensory integration & emotional behaviorSensory integration & emotional behavior

– Anticholinergic Effects (Autonomic NS)Anticholinergic Effects (Autonomic NS) Dry Mouth Blurred vision ConstipationDry Mouth Blurred vision Constipation SedationSedation Urinary Retention Urinary Retention

PhotophobiaPhotophobia Orthostatic HypotensionOrthostatic Hypotension Nasal Congestion Nasal Congestion

Antipsychotic (Neuroleptic) MedsAntipsychotic (Neuroleptic) Meds

↑↑ ↑↑ Prolactin LevelsProlactin Levels– Sexual/Menstrual dysfunctionSexual/Menstrual dysfunction– ↓ ↓ LibidoLibido– GalactorrheaGalactorrhea– GynecomastiaGynecomastia– ↑ ↑ weight gainweight gain

CognitionCognition– ↓ ↓ Alertness Alertness ↓ Concentration ↓ Concentration– ↓ ↓ Seizure threshold = ↑ Risk of seizuresSeizure threshold = ↑ Risk of seizures

Antipsychotic (Neuroleptic) MedsAntipsychotic (Neuroleptic) Meds

ExtraPyramidal Side Effects (EPS)ExtraPyramidal Side Effects (EPS)– ↓↓ ↓↓ DA ↑↑ AcH ImbalanceDA ↑↑ AcH Imbalance– ↑↑ ↑↑ Incidence with ↑↑ potency meds Incidence with ↑↑ potency meds

Prolixin, Haldol & StelazineProlixin, Haldol & Stelazine

– Movement disorderMovement disorder DystoniaDystonia PseudoparkinsonismPseudoparkinsonism AkathesiaAkathesia Tardive DyskinesiaTardive Dyskinesia

ExtraPyramidal Side Effects (EPS)ExtraPyramidal Side Effects (EPS)

DystoniaDystonia– Quick onset 1Quick onset 1stst few hours or days few hours or days – ↑ ↑ Adolescent males < age 25Adolescent males < age 25– Acute spasms of tongue, face, neck & backAcute spasms of tongue, face, neck & back– HypertoniaHypertonia– Laryngospasm – Respiratory distressLaryngospasm – Respiratory distress– Oculogyric Crisis- Rolling back of eyesOculogyric Crisis- Rolling back of eyes– Torticolis- Head twisted to 1 sideTorticolis- Head twisted to 1 side– Involuntary uncoordinated movementsInvoluntary uncoordinated movements

EExtraxtraPPyramidal yramidal SSide Effectside Effects (EPS)(EPS)

PseudoparkinsonismPseudoparkinsonism– Appears within 1-5 daysAppears within 1-5 days– ↑ ↑ women & older Ptswomen & older Pts– Drooling, Pill-Rolling of thumb & fingerDrooling, Pill-Rolling of thumb & finger– Mask-like face, Stooped PostureMask-like face, Stooped Posture– Action TremorsAction Tremors– Shuffling gait with small stepsShuffling gait with small steps– Muscle rigidity Muscle rigidity – BradykinesiaBradykinesia– CogwheelingCogwheeling


AkathesiaAkathesia

– Appears 50-60 daysAppears 50-60 days

– Motor restlessness “Nervous Energy”Motor restlessness “Nervous Energy”JitterinessJitterinessTapping feet constantlyTapping feet constantlyPacing Pacing Rocking back & forthRocking back & forthFrequent position changesFrequent position changes


Tardive DyskinesiaTardive Dyskinesia– Slow & insideous processSlow & insideous process– Irreversible after several years of meds.Irreversible after several years of meds.– Involuntary movementsInvoluntary movements of of

Limbs, trunk & face.Limbs, trunk & face.

– Bizarre facial movementsBizarre facial movements““Fly catching” with tongueFly catching” with tongueLip smackingLip smacking

– Difficulty swallowingDifficulty swallowing– Irregular respirationsIrregular respirations

Neuroleptic Malignant Syndrome NMSNeuroleptic Malignant Syndrome NMS

Rare idiosyncratic reaction 1% young menRare idiosyncratic reaction 1% young men ↑ ↑ Incidence with ↑↑ potency meds & ↓↓ DAIncidence with ↑↑ potency meds & ↓↓ DA Abrupt onset & rapid progressionAbrupt onset & rapid progression 10% mortality rate10% mortality rate SignsSigns

– Severe muscle rigiditySevere muscle rigidity Hyperreflexia Hyperreflexia (+4)(+4)

– Hyperthermia > 105Hyperthermia > 105 Diaphoresis Diaphoresis– Altered LOC → Stupor → ComaAltered LOC → Stupor → Coma– ↑↑ ↑↑ HR ↑↑ RRHR ↑↑ RR – CV Collapse & Respiratory failure = Fatal!CV Collapse & Respiratory failure = Fatal!

NMS TherapyNMS Therapy Immediately D/C medImmediately D/C med

Wait 2 weeks before starting new meds (Lithium)Wait 2 weeks before starting new meds (Lithium) NO Haldol or ThorazineNO Haldol or Thorazine

Cooling blanket Cooling blanket O2 O2 IV FluidsIV Fluids

MSO4 (Morphine sulfate)MSO4 (Morphine sulfate) – ↓ ↓ pain & ↓ VS pain & ↓ VS

TylenolTylenol– ↓ ↓ Temp and painTemp and pain

Dantrolene (Dantrium)Dantrolene (Dantrium) muscle relaxant & ↓ Tempmuscle relaxant & ↓ Temp

Bromocriptine (Parlodel)Bromocriptine (Parlodel) Dopaminergic = ↓ EPS toxicityDopaminergic = ↓ EPS toxicity

Atypical MedicationsAtypical MedicationsRelieves (+) & (-) BehaviorsRelieves (+) & (-) Behaviors↓↓ EPS EPS ↓ Prolactin↓ Prolactin Clozapine (Clozaril)Clozapine (Clozaril)

– Binds to 5-HT2, Alpha1,2, H1, & DA recptorsBinds to 5-HT2, Alpha1,2, H1, & DA recptors– SE- National registry to monitor SEs!SE- National registry to monitor SEs!

Agranulocytosis Agranulocytosis –WBC < 3000 or ANC < 500 = D/C med!WBC < 3000 or ANC < 500 = D/C med!–Mandatory weekly CBC 1Mandatory weekly CBC 1stst 6 months 6 months

Then q other weekThen q other week Drowsiness Drowsiness ↑Salivation ↑Salivation ↑Dizziness ↑Dizziness ↑ ↑ HR HR ↑Weight↑Weight ↑ ↑ Risk for IDDM Prolonged QT intervalRisk for IDDM Prolonged QT interval

Atypical MedicationsAtypical Medications

Risperidone (Risperdal)Risperidone (Risperdal)

– ↓↓ ↓↓ DA ↓ 5-HT ACh & NE DA ↓ 5-HT ACh & NE

– Readily absorbed Readily absorbed

– Active metabolite is clinically effectiveActive metabolite is clinically effective

– SESESedation/InsomniaSedation/InsomniaOrthostatic HypotensionOrthostatic Hypotension ↑↑ ↑↑ AppetiteAppetiteTardive DyskinesiaTardive Dyskinesia

Atypical MedicationsAtypical Medications

Olanzapine (Zyprexia)Olanzapine (Zyprexia)

– Antagonizes DA & 5-HT receptorsAntagonizes DA & 5-HT receptors

– Binds to HistamineBinds to Histamine Quetiapine (Seroquel)Quetiapine (Seroquel)

– √ √ renal functionrenal function

– √ √ EKG for prolonged QT waveEKG for prolonged QT wave Ziprasidone (Geodon)Ziprasidone (Geodon)

– DA & 5-HT receptor antagonistsDA & 5-HT receptor antagonists

– ↓ ↓ Depression & AnxietyDepression & Anxiety

Medication AdministrationMedication Administration ScheduleSchedule

– Initially take meds in divided doses 2-4x/dayInitially take meds in divided doses 2-4x/day– Non-compliant Pts:Non-compliant Pts:

Haldol decanoate IM q 4 weeksHaldol decanoate IM q 4 weeks Prolixin decanoate IM q 3 weeksProlixin decanoate IM q 3 weeks

EfficacyEfficacy– Takes 1- 4 weeks for significant responseTakes 1- 4 weeks for significant response– Once symptoms are controlled Once symptoms are controlled ▲ HS ▲ HS ↓↓ SE↓↓ SE

DosageDosage– Use lowest dosage to Use lowest dosage to ↓ Tardive Dyskinesia↓ Tardive Dyskinesia

Medication AdministrationMedication Administration Antiparkinson MedsAntiparkinson Meds

– Give to counteract SE & toxic effectsGive to counteract SE & toxic effects– Only given with documented S/S of EPSOnly given with documented S/S of EPS– Restore the balance of DA & AchRestore the balance of DA & Ach

↑↑↑↑DADA ↓↓↓↓AChAChAmantadine (Symmetrel)Amantadine (Symmetrel) Benzotropine (Cogentin)Benzotropine (Cogentin)

Bromocriptine (Parlodel)Bromocriptine (Parlodel) Trihexyphenidyl (Artane)Trihexyphenidyl (Artane)

Biperiden (Akineton)Biperiden (Akineton)

Procyclidine (Kemadrin)Procyclidine (Kemadrin)

Patient TeachingPatient Teaching

MedicationMedication– Generic & trade name, dose, action & SEGeneric & trade name, dose, action & SE– Assess SE “How is medication working?”Assess SE “How is medication working?”

Interventions & when to notify RN/MDInterventions & when to notify RN/MD

– Carry card with Med IDCarry card with Med ID– NO ETOH or illegal substancesNO ETOH or illegal substances– Don’t stop taking drug abruptlyDon’t stop taking drug abruptly– Don’t Don’t ▲ ▲ position rapidlyposition rapidly

Patient Outcome EvaluationPatient Outcome Evaluation Slow progressSlow progress

– Services are needed long-term (decades)Services are needed long-term (decades) Set small achievable, short-term goalsSet small achievable, short-term goals Assess effective coping skillsAssess effective coping skills Obtain Pt & family input Obtain Pt & family input

– Pt. safetyPt. safety Communication skillsCommunication skills– Social SkillsSocial Skills Self-Esteem Self-Esteem– Medication complianceMedication compliance– Support systemSupport system– Living in least restrictive settingLiving in least restrictive setting

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Schizophrenia Elisa A. Mancuso RNC, MS, FNS Professor