CHAPTER 4 :SCHIZOPHRENIA DISORDERS
INTRODUCTION AND DEFINITIONS

The term psychosis makes reference to a set of symptoms that demonstrate
disorganization in the mental processes and detachment from reality, these
symptoms include, perceptual disturbances, disorganized thinking, behavioral and
emotional alterations

The American Psychiatric Association (APA 2000) defines Psychosis as:
“Delusions, prominent hallucinations, disorganized speech, or disorganized catatonic
behavior”

Schizophrenia is described as a psychotic disorder and can be defined as:
“A devastating disorder that affects a person’s thinking, language, emotions, social
behavior, and ability to perceive reality accurately”

Schizophrenia is not a single homogeneous disease entity with a single cause but a
syndrome (a group of disorders) that result from a variable combination of
neurobiochemical, neuroanatomical abnormalities, physiological dysfunction,
psychosocial stress with strong genetic predisposition

Effective treatment requires a comprehensive, multidisciplinary effort, including
Pharmacotherapy, Cognitive & Behavioral Therapy, Psychosocial Interventions and
care, Social and living skills training, Rehabilitation and family therapy, Coping and
Adjustment Training
EPIDEMIOLOGY

The lifetime prevalence of Schizophrenia is 1% worldwide with no differences
related to race, social class, culture, or environment

Typical age is late teens and early twenties (18-25)., but onsets of 5-6 years of age
were reported

Individuals with an early age of onset (18-25years) are more often male, have
poorer premorbid adjustment, and more prominent negative symptoms

Individuals with a late age of onset (25-35years) are more often females and have a
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better outcome
COMORBIDITY
1. Substance abuse

Substance abuse occurs in 40%-50% of schizophrenics

It is associated with many negative outcomes such as: Imprisonment, Homelessness,
Violence, Suicide, HIV infection, Medication non-compliance, Poor prognosis

Nicotine dependence occurs in 80%-90% of individuals with schizophrenia disorder
and cases high rates of emphysema and other pulmonary and cardiac problems
2. Depressive symptoms

Suicide is the primary cause of premature death among schizophrenics

40% to 55% of patients have suicidal ideation during the course of illness

20% to 40% of the patients make at least one attempt of suicide during illness

Suicides occurs during periods of remission after 5-10 years of illness
3. Psychosis-induced Polydipsia (excessive thirst)

Occurs in 6%-20% of people with chronic mental illness due to compulsive drinking
of 4–10 liters of water a day
NATURE OF THE DISORDER

Characteristically, disturbances in thought processes, perception, and affect result in
a severe deterioration of social and occupational functioning

Symptoms generally appear in late adolescence or early adulthood, although they
may occur in middle or late adult life

Symptoms occur earlier in men than in women
Premorbid Behaviour

The premorbid behavior is often a predictor of the pattern of development of
schizophrenia

Premorbid behavior can be viewed in four phases:
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Phase One: The Schizoid Personality

The DSM-IV-TR describes individuals in this phase as:
1. Indifferent to social relationships with limited emotional experience &
expression
2. Lack of close relationships (prefer to be loners)
3. Appear cold and detached

But not all individuals who demonstrate these characteristics will progress to
schizophrenia, however, many individuals with schizophrenia show evidence of
having had these characteristics in the premorbid condition
Phase Two: The Prodromal Phase (onset of symptoms)

Characteristics of this phase include:
1. Social withdrawal (social isolation)
2. Impairment in role functioning (school, work, family)
3. Eccentric and peculiar behavior
4. Neglect of personal hygiene and grooming
5. Blunted (dull) or inappropriate affect
6. Disturbances in interpersonal communication
7. Bizarre ideas
8. Unusual perceptual experiences
9. Lack of initiative, interests, or energy.

The length of this phase is highly variable, and may last for many years before
deteriorating to the schizophrenic state.
Phase Three: Schizophrenia

The active phase of the disorder where psychotic symptoms are prominent

It is at during this phase that hospitalization is needed and diagnosis is made

Diagnosing schizophrenia is not an easy task and it requires a duration of
hospitalization of at least 6 months

Systems used for the diagnosis are DSM-IV-TR or ICD-10
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Phase IV: Residual Phase

Schizophrenia is characterized by periods of remission and exacerbation

Residual phase usually follows an active phase of the illness

Symptoms during the residual phase are similar to those of the prodromal phase,
with flat affect and impairment in role functioning being prominent

Residual impairment often increases between episodes of active psychosis
DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

The diagnosis is made using the DSM-IV-TR, and is based on the evaluation of the
following four areas:
A. The presence of Characteristic Symptoms: Two or more of the following:
Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic
behavior , and Negative Symptoms
B. Social/Occupational Dysfunction: One or more major areas of the patient's life is
markedly below premorbid functioning (the level achieved before the onset) such
as: work, interpersonal relationships, and self-care
C. Duration: Continuous signs of the disturbance persist for at least 6 months that
must include at least 1 month of symptoms of the active phase
D. Exclusion of other conditions: Exclusion of all other Mental Disorders, General
Medical Conditions, Substance abuse, and Pervasive Developmental Disorders
PROGNOSIS

A return to full premorbid functioning is not common

The prognosis of schizophrenia is often reported in the paradigm of thirds:
1. One third: achieve significant and lasting improvement and may never
experience another episode of psychosis
2. One third: may achieve some improvement with intermittent relapses and
residual disability
3. One third: experiences severe and permanent incapacity and remains chronically
ill for much of their lives
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Factors associated with a more positive prognosis:
1. Good premorbid adjustment
2. Later age at onset
3. Female gender
4. Abrupt onset of symptoms precipitated by a stressful event (as opposed to
gradual sinister onset of symptoms)
5. Associated mood disturbance
6. Brief duration of active-phase symptoms
7. Good inter-episode functioning
8. Minimal residual symptoms
9. Absence of structural brain abnormalities
10. Normal neurological functioning
11. No family history of schizophrenia
ETIOLOGY

The cause of schizophrenia is still uncertain

The disease results from a combination of biological, physiological, environmental,
interpersonal, psychosocial and genetic factors
Biological Factors
a) Genetics: There is some evidence of the Genetic Vulnerability to schizophrenia but
whether schizophrenia is inherited is uncertain because biological and genetic
markers have not been identified yet
b) Twin Studies: The rate of schizophrenia among monozygotic (identical) twins is
four times that of dizygotic (fraternal) twins and approximately 50 times that of the
general population. Some investigators believe environmental factors interact with
genetic factors to predispose for the illness (Stress-Vulnerability Theory)
c) Adoption and Family Studies: It was found that children, who were born of
schizophrenic parents and reared by non-schizophrenic parents, were more likely to
develop the illness compared to those borne to non-schizophrenic mothers. These
findings provide additional evidence for the genetic links of schizophrenia.
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Biochemical Factors
a) The Dopamine Hypothesis: This theory suggests that schizophrenia may be caused
by an excess of dopamine-dependent neuronal activity in the brain. This excess
activity may be related to:
1. Increased production or release of dopamine at nerve terminals
2. Increased receptor sensitivity or too many dopamine receptors
3. A combination of these mechanisms

Pharmacological support for this hypothesis exists as clients with acute
manifestations (e.g., delusions and hallucinations) respond with greater efficacy to
neuroleptics drugs than do clients with chronic manifestations (e.g., apathy, poverty
of ideas, and loss of drive).

The current position, in terms of the dopamine hypothesis, is that manifestations of
acute schizophrenia may be related to increased numbers of dopamine receptors in
the brain and respond to neuroleptic drugs that block these receptors

Manifestations of chronic schizophrenia are probably unrelated to numbers of
dopamine receptors, and neuroleptic drugs are unlikely to be as effective in treating
these chronic symptoms.
Physiological factors
a) Viral Infection: higher incidence of schizophrenia has been reported after prenatal
exposure to influenza, increased number of physical anomalies at birth, increased
rate of pregnancy and birth complications
b) Anatomical Abnormalities: Structural brain abnormalities have been observed in
individuals with schizophrenia such as ventricular enlargement which is associated
with poor premorbid functioning, negative symptoms, poor response to treatment,
and cognitive impairment. Studies with MRI have revealed a possible decrease in
cerebral and intracranial size in clients with schizophrenia. Studies have also
revealed a decrease in frontal lobe size
c) Physical Conditions: Some studies have reported a link between schizophrenia and
epilepsy (particularly temporal lobe), Huntington’s disease, birth trauma, head
injury in adulthood, alcohol abuse, cerebral tumor (particularly in the limbic
system), cerebrovascular accidents, and systemic lupus erythematosus
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Psychological factors

Early conceptualizations of schizophrenia focused on family relationship factors as
major influences in the development of the illness such as poor parent–child
relationships and dysfunctional family systems
Environmental factors
a) Socio-cultural Factors

Individuals from the lower socioeconomic classes experience symptoms associated
with schizophrenia more than those from the higher socioeconomic groups

Explanations for this occurrence include the conditions associated with living in
poverty, such as congested housing accommodations, inadequate nutrition, absence
of prenatal care, few resources for dealing with stressful situations, and feelings of
hopelessness for changing one’s lifestyle of poverty

An alternative view is that of the downward drift hypothesis.

This hypothesis relates the schizophrenic’s move into, or failure to move out of, the
low socioeconomic group to the tendency for social isolation and the segregation of
self from others

Proponents of this notion view poor social conditions as a consequence rather than
a cause of schizophrenia.
b) Stressful Life Events

No scientific evidence to indicate that stress causes schizophrenia, but it may
contribute to the severity and course of the illness because extreme stress can
precipitate psychotic episodes

Stress may precipitate symptoms in an individual who possesses a genetic
vulnerability to schizophrenia (Stress-vulnerability theory)

The stress can be biological, environmental, or both.

The environmental component can be either biological (e.g., an infection) or
psychological (e.g., a stressful family situation).

Stressful life events may be associated with exacerbation of schizophrenic
symptoms and increased rates of relapse
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Theoretical Integration

The etiology of schizophrenia remains unclear.

No single theory or hypothesis has been postulated that substantiates a clear-cut
explanation for the disease.

More evidence support the concept of multiple causation in the development of
schizophrenia.
TYPES OF SCHIZOPHRENIA

The DSM-IV-TR (APA, 2000) identifies various types of schizophrenia.

Differential diagnosis is made according to the total symptomatic clinical picture
presented
1. Disorganized Schizophrenia

Onset of symptoms is usually before age 25, and the course is commonly chronic

Behavior is markedly regressive and primitive

Contact with reality is extremely poor

Affect is flat or grossly inappropriate (silliness, incongruous giggling, facial grimaces,
and bizarre mannerisms)

Communication is consistently incoherent

Personal appearance is generally neglected

Social impairment is extreme
2. Catatonic Schizophrenia

Catatonic schizophrenia is characterized by marked abnormalities in motor
behavior and may be manifested in the form of stupor or excitement

Catatonic stupor: is characterized by extreme psychomotor retardation
(Pronounced decrease in spontaneous movements and activity, Mutism, negativism
and passivity, and waxy flexibility)

Catatonic excitement: is manifested by a state of extreme psychomotor agitation.
The movements are purposeless, and are usually accompanied by continuous
incoherent verbalizations and shouting. Clients in catatonic excitement urgently
require physical and medical control because they are often destructive and violent
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to others, and their excitement may cause them to injure themselves or to collapse
from complete exhaustion.
3. Paranoid Schizophrenia

Characterized mainly by the presence of delusions of persecution or grandeur and
auditory hallucinations related to a single theme.

The individual is often tense, suspicious, and guarded, and may be argumentative,
hostile, and aggressive.

Onset of symptoms is usually in the late 20s or 30s

Patients have less regression of mental faculties, emotional response, and behavior

Social impairment may be minimal

Prognosis, particularly with regard to occupational functioning and capacity for
independent living, is promising
4. Undifferentiated Schizophrenia

Sometimes clients with schizophrenic symptoms do not meet the criteria for any of
the subtypes, or they may meet the criteria for more than one subtype. These
individuals may be given the diagnosis of undifferentiated schizophrenia.

The behavior is clearly psychotic; that is, there is evidence of delusions,
hallucinations, incoherence, and bizarre behavior but the symptoms cannot be easily
classified into any of the previously listed diagnostic categories
5. Residual Schizophrenia

This diagnostic category is used when the individual has a history of at least one
previous episode of schizophrenia with prominent psychotic symptoms.

Occurs in an individual who has a chronic form of the disease and is the stage that
follows an acute episode (prominent delusions, hallucinations, incoherence, bizarre
behavior, and violence).

In the residual stage, there is continuing evidence of the illness, although there are
no prominent psychotic symptoms.

Residual symptoms may include social isolation, eccentric behavior, impairment in
personal hygiene and grooming, blunted or inappropriate affect, poverty of or overly
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elaborate speech, illogical thinking, or apathy.
TREATMENT MODALITIES OF SCHIZOPHRENIA
1. PSYCHOPHARMACOLOGY
Introduction and overview

People with schizophrenia do not have insight into the pathologic complexity of
their illness and symptoms during both periods of wellness and acute exacerbations
of the symptoms which lead them to stop taking medication when they feel better
(relapse due to medication non-compliance)

Medication non-compliance leads to acute exacerbations and hospitalization to restabilize the patient and the drug regimens

Without Antipsychotic drug treatment, 70-80% of the people who have
schizophrenia will relapse within 12 months and experience subsequent episodes

Drugs taken continuously can reduce the relapse rate to about 30%

Men have poorer outcomes than women do; women respond better to treatment
with antipsychotic medications

The efficacy of antipsychotic medications is enhanced by adjunct psychosocial
therapy

Antipsychotic drugs are also called major tranquilizers and neuroleptics.

Early agents such as Chlorpromazine (Thorazine) was first introduced in the United
States in 1952

Antipsychotic medications alleviate many of the psychotic symptoms, but they do
not cure the underlying psychotic processes

With each relapse following medication discontinuation, it takes longer to achieve
remission after restarting medication

This lead to the possibility that the patient become unresponsive to treatment
Classification and Grouping
There are two groups of antipsychotic drugs: Typical and Atypical Antipsychotics
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Typical Antipsychotics

Also called Conventional or Traditional Antipsychotics

Typical Antipsychotic medications block various dopamine receptors in the brain
(D1, D2, and D3)

The Typical Antipsychotics target the positive symptoms of schizophrenia
(Hallucinations, Delusions, Disordered thinking, and paranoia)

Due to their varied chemical structures and strength, these agents are grouped into
high, moderate, and low potency classes

The term potency indicates how much of the drug is required for it to be effective

The potency of the drug also influences the level and frequency of side effects
experienced by the client

This accounts for the need for some clients to receive higher dosages to achieve
optimum clinical results

For example, a much larger dose of a low-potency drug such as Thioridazine may be
needed to produce the same level of symptom-control that a lower dose of Haldol (a
high-potency drug) can produce.

But there is a significant difference in the side effects they produce. Low-potency
agents cause more anticholinergic effects, whereas high-potency drugs cause more
extrapyramidal effects

Typical Antipsychotics are less used in the treatment of schizophrenia because of
their troubling side effects

Side effects lead to decrease compliance & therefore to an increase in relapse rate

Some of the few advantages of the Typical Antipsychotics are:
a. They are less expensive than Atypical drugs
b. They come in depot form
Typical Antipsychotic Medications
High Potency
Moderate Potency
Low Potency
Haloperidol (Haldol)
Loxapine (Loxitane)
Thioridazine (Mellaril)
Thiothixene (Navane)
Molindone (Moban)
Mesoridazine (Serentil)
Trifluoperazine (Stelazine)) Perpheriazine (Irilafon)
Chiorprothixene (faractan)
Fluphenazine (Prolixin)
Droperidol (Inapsine)
Chlorpromazine (rhorazine)
Pimozide (Orap)
Acetophenazine ([indal
Promazine (Sparine)
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Atypical Antipsychotics

Also called Novel or Non-conventional Antipsychotics

They are Serotonin-Dopamine Antagonists/ 5-HT2A Antagonists

All antipsychotic drugs are effective for most acute exacerbation of schizophrenia
and for prevention or lessening of relapse

The Atypical Antipsychotics (Clozapine, Resperidone, Olanzapine, Quetiapine,
Ziprazidone, Aripiprazole) can also diminish the negative symptoms (deficits in
social interaction, blunted or inappropriate emotional expression, and lack of
motivation)

The Atypical Antipsychotics have fewer side effects especially Extrapyramidal Side
Effects, and therefore are better tolerated

The Atypical Antipsychotics help with symptoms of anxiety and depression,
decrease suicidal behavior and increase neurocognitive functioning
Atypical (Novel/ Non-conventional) Antipsychotics
Clozapine (Clozaril)
Resperidone (Risperdol)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprazidone (Geodon)
Aripiprazole (Abilify)

Atypical Antipsychotics are usually chosen as first-line antipsychotics because
of the following characteristics:
1. Produce minimal to no Extrapyramidal side effects (EPSs) or Tardive Dyskinesia
2. Treat both distressing positive symptoms and disabling negative symptoms of
schizophrenia
3. May improve the neurocognitive defects associated with schizophrenia
4. May decrease affective symptoms (anxiety and depression)
5. Decrease suicidal behavior
6. Associated with lower relapse rate
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2. PSYCHOLOGICAL TREATMENTS
1. Individual Psychotherapy

Focus of Treatment:
- Reality-orientation
- Reality testing
- Problem solving
- Psychoeducation
- Supportive and cognitive-behavioral techniques

Goals of treatment:
- Improve medication compliance
- Enhance social and occupational functioning
- Prevent relapse
2. Group Therapy

Focus of treatment:
- Real-life plans
- Daily problems
- Formation of relationships

Goals of treatment:
- Reducing social isolation
- Increasing the sense of cohesiveness
- Identification
- Supportive environment
3. Behavior Therapy

Focus of treatment
- Behavior modification and changing undesirable behaviors

Goals of treatment:
- Reduce the frequency of bizarre, disturbing, and deviant behaviors
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- Increase appropriate behaviors
- Attaching positive, negative, and aversive reinforcements to adaptive and
maladaptive behavior
- Linking praise to desirable behaviour
4. Social Skills Training

Focus of treatment:
- Complex interpersonal skills: Verbal and nonverbal behaviors, paralinguistic
features, verbal content, and interactive balance
- Nature of illness: What to expect as the illness progresses. Symptoms associated
with the illness. Ways for family to respond to behaviors associated with the
illness
- Management of the illness: Connection of exacerbation of symptoms to times of
stress. Appropriate medication management. Side effects of medications.
Importance of not stopping medications. When to contact health care provider.
Relaxation techniques. Daily living skills training
- Support Services: Financial assistance, Legal assistance, Caregiver support
groups, Respite care, Home health care,

Goals of treatment:
- Teach the patient specific skills by shaping (rewarding successive
approximations toward the target behavior)
- Enhancement of social skills of the patient especially after recovery from relapse
- Prevent gradual social skills deterioration
- Improve daily living skills and activities
3. SOCIAL TREATMENTS
1. Milieu Therapy

Focus of Treatment:
o It emphasize group and social interaction; rules and expectations are
mediated by peer pressure for normalization of adaptation
o It stresses a patient’s rights to goals and to have freedom of movement and
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informal relationship with staff
o It emphasizes interdisciplinary participation and goal-oriented and clear
communication

Goals of treatment
o Help patients recognize their own potentials
o Improve patients readiness to face the challenges of the outside world
o Improve goal-directed activities and independence
2. Family Therapy

Focus of treatment
- Some therapists treat schizophrenia as an illness not of the client alone, but of
the entire family. Even when families appear to cope well, there is a notable
impact on the mental health status of relatives when a family member has the
illness

Goal of treatment
- Stress the importance of role of family in the aftercare of relatives
- Stimulating interest in family intervention programs
- Support the family system
- Prevent or delay relapse
- Help to maintain the client in the community
- View family as a resource rather than a stressor
- Teach problem-solving techniques
3. Assertive Community Treatment (ACT)

Focus of treatment
- ACT is a program of case management that takes a team approach in providing
comprehensive, community-based psychiatric treatment, rehabilitation, and
support to persons with serious and persistent mental illness such as
schizophrenia
Goal of treatment
- Teaching of basic living skills
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- Helping clients work with community agencies and services such as sheltered
workshops, and substance abuse treatments
- Assisting clients in developing a social support network
- Helping the clients in vocational expectations, and supported work settings
- Introducing clients to services such as, family support and education, and mobile
crisis intervention
- Helping clients meet basic needs and enhance quality of life
- Helping clients improve functioning in adult social and employment roles
- To lessen the family’s burden of providing care
- To lessen or eliminate the debilitating symptoms of mental illness
- To minimize or prevent recurrent acute episodes of the illness
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APPLICATION OF THE NURSING PROCESS
ASSESSMENT DATA

Gathers a database of information from which nursing diagnoses are derived and a
plan of care is formulated.

This first step of the nursing process is extremely important because without an
accurate assessment, problem identification, objectives of care and outcome criteria
cannot be accurately determined.

Assessment of the client with schizophrenia may be a complex process, based on
information gathered from a number of sources.

Clients in an acute episode of their illness are seldom able to make a significant
contribution to their history.

Data may be obtained from family members, if possible; from old records, if
available; or from other individuals who have been in a position to report on the
progression of the client’s behavior.

The nurse must be familiar with behaviors common to the disorder to be able to
obtain an adequate assessment of the client with schizophrenia.

Areas of functioning are employed to facilitate the presentation of background
information on which to base the initial assessment of the client with schizophrenia.

Behavioral disturbances can be presented in eight areas of functioning:
1. Content of thought
2. Form of thought
3. Perception
4. Affect
5. Sense of self
6. Volition
7. Impaired interpersonal functioning and relationship to the external world
8. Psychomotor behavior.
9. Associated Behaviour
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1. CONTENT OF THOUGHT
Delusions

Delusions are false fixed personal beliefs that are inconsistent with the person’s
intelligence or cultural background and cannot be changed by reason or rationality

The individual continues to have the belief in spite of obvious proof that it is false or
irrational

Delusions are subdivided according to their content:
1. Delusion of Persecution
The individual feels threatened and believes that others intend harm or persecution
toward him or her in some way (e.g., “The FBI has ‘bugged’ my room and intends to kill
me.” “I can’t take a shower in this bathroom; the nurses have put a camera in there so
that they can watch everything I do”)
2. Delusion of Grandeur
The individual has an exaggerated feeling of importance, power, knowledge, or identity
(e.g., “I am the next president”)
3. Delusion of Reference

All events within the environment are referred by the psychotic person to himself or
herself (e.g., “Someone is trying to get a message to me through the articles in this
magazine or newspaper or TV program; I must break the code so that I can receive
the message”)

Ideas of reference are less rigid than delusions of reference. An example of an idea of
reference is irrationally thinking that one is being talked about or laughed at by
other people.
4. Delusion of Control or Influence
The individual believes certain objects or persons have control over his or her behavior
(e.g., “The dentist put a filling in my tooth; I now receive transmissions through the
filling that control what I think and do”).
5. Somatic Delusion
The individual has a false idea about the functioning of his or her body (e.g., “I’m 70
years old and I will be the oldest person ever to give birth. The doctor says I’m not
pregnant, but I know I am”).
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6. Nihilistic Delusion
The individual has a false idea that the self, a part of the self, others, or the world is
nonexistent (e.g., “The world no longer exists.” “I have no heart.”).
Religiosity

Religiosity is an excessive demonstration of or obsession with religious ideas and
behavior.

Because individuals vary greatly in their religious beliefs and level of spiritual
commitment, religiosity is often difficult to assess.

The individual with schizophrenia may use religious ideas in an attempt to provide
rational meaning and structure to his or her behavior.

Religious preoccupation may be considered a manifestation of the illness.

Clients who derive comfort from their religious beliefs should not be discouraged
from employing this means of support.
Paranoia

Individuals with paranoia have extreme suspiciousness of others and of their actions
or perceived intentions (e.g., “I won’t eat this food. I know it has been poisoned.”)
Magical thinking

With magical thinking, the person believes that his or her thoughts or behaviors
have control over specific situations or people (e.g., the mother who believed if she
shout at her son in any way he would be taken away from her)

Magical thinking is common in children (e.g., “Step on a crack and you break your
mother’s back.” “An apple a day keeps the doctor away”).
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2. FORM OF THOUGHT
Associative looseness

Thinking is characterized by speech in which ideas shift from one unrelated subject
to another

With associative looseness, the individual is unaware that the topics are
unconnected.

When the condition is severe, speech may be incoherent. (For example, “We wanted
to take the bus, but the airport took all the traffic. Driving is the ticket when you
want to get somewhere. No one needs a ticket to heaven. We have it all in our
pockets.”)
Neologism

The psychotic person invents new words, or neologisms, that are meaningless to
others but have symbolic meaning to the psychotic person (e.g., “She wanted to give
me a ride in her new uniphorum”).
Concrete thinking

Concreteness, or literal interpretations of the environment, represents a regression
to an earlier level of cognitive development.

Abstract thinking is very difficult. For example, the client with schizophrenia would
have great difficulty describing the abstract meaning of sayings such as “Hit the nail
on the head”
Clang association

Choice of words is governed by sounds.

Clang associations often take the form of rhyming. For instance “It is very cold. I am
cold and bold. The gold has been sold.”
Word salad

A word salad is a group of words that are put together randomly, without any logical
connection (e.g., “Most forward action grows life double plays circle uniform”)
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Circumstantiality

With circumstantiality, the individual is delayed in reaching the point of a
communication because of unnecessary and tedious details.

The point or goal is usually met but only with numerous interruptions by the
interviewer to keep the person on track of the topic being discussed.
Tangentiality

Tangentiality differs from circumstantiality in that the person never really gets to
the point of the communication.

Unrelated topics are introduced, and the original discussion is lost.
Mutism
This is an individual’s inability or refusal to speak
Perseveration
The individual who exhibits perseveration persistently repeats the same word or idea in
response to different questions.
3. PERCEPTION
Hallucinations
Hallucinations, or false sensory perceptions not associated with real external stimuli,
may involve any of the five senses
Types of hallucinations include the following:
1. Auditory

Auditory hallucinations are false perceptions of sound.

Most commonly they are of voices, but the individual may report clicks, rushing
noises, music, and other noises.

Command hallucinations may place the individual or others in a potentially
dangerous situation. “Voices” that issue commands for violence to self or others may
or may not be listened to by the psychotic person.

Auditory hallucinations are the most common type in psychiatric disorders.
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2. Visual
These are false visual perceptions.
They may consist of formed images, such as of people, or of unformed images, such as
flashes of light.
3. Tactile
Tactile hallucinations are false perceptions of the sense of touch, often of something on
or under the skin.
One specific tactile hallucination is formication, the sensation that something (insects or
snakes) is crawling on or under the skin.
4. Gustatory

This type is a false perception of taste.

Most commonly, gustatory hallucinations are described as unpleasant tastes.
5. Olfactory
Olfactory hallucinations are false perceptions of the sense of smell.
Illusions
Illusions are misperceptions or misinterpretations of real external stimuli.
4. AFFECT

Affect describes the behavior associated with an individual’s feeling state or
emotional tone.
1. Inappropriate affect
Affect is inappropriate when the individual’s emotional tone is incongruent with the
circumstances (e.g., a young woman who laughs when told of the death of her mother).
2. Flat (Blunt) affect
Affect is described as bland when the emotional tone is very weak. The individual with
flat affect appears to be void of emotional tone (or overt expression of feelings).
3. Apathy
The client with schizophrenia often demonstrates an indifference to or disinterest in the
environment. The bland or flat affect is a manifestation of the emotional apathy.
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5. SENSE OF SELF

Sense of self describes the uniqueness and individuality a person feels. Because of
extremely weak ego boundaries, the individual with schizophrenia lacks this feeling
of uniqueness and experiences a great deal of confusion regarding his or her
identity.
Echolalia

The client with schizophrenia may repeat words that he or she hears which is called
echolalia.

This is an attempt to identify with the person speaking. (For instance, the nurse says,
“John, it’s time for lunch.” The client may respond, “It’s time for lunch, it’s time for
lunch” or sometimes, “Lunch, lunch, lunch, lunch”).
Echopraxia
The client who exhibits echopraxia may purposelessly imitate movements made by
others
Identification and Imitation

Identification, which occurs on an unconscious level, and imitation, which occurs on
a conscious level, are ego defense mechanisms used by individuals with
schizophrenia and reflect their confusion regarding self-identity.

Because they have difficulty knowing where their ego boundaries end and another
person’s begins, their behavior often takes on the form of that which they see in the
other person
Depersonalization

The unstable self-identity of an individual with schizophrenia may lead to feelings of
unreality (e.g., feeling that one’s extremities have changed in size; or a sense of
seeing oneself from a distance)
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6. VOLITION (WILL)

Volition has to do with impairment in the ability to initiate goal-directed activity.

In the individual with schizophrenia, this may take the form of inadequate interest,
motivation, or ability to choose a logical course of action in a given situation
Emotional ambivalence

Ambivalence in the client with schizophrenia refers to the coexistence of opposite
emotions toward the same object, person, or situation.

These opposing emotions may interfere with the person’s ability to make even a
very simple decision (e.g., whether to have coffee or tea with lunch).

Underlying the ambivalence in the individual with schizophrenia is the difficulty he
or she has in fulfilling a satisfying human relationship.

This difficulty is based on the need-fear dilemma—the simultaneous need for and
fear of intimacy
7. IMPAIRED INTERPERSONAL FUNCTIONING AND RELATIONSHIP TO THE
EXTERNAL WORLD

Some clients with acute schizophrenia cling to others and intrude on the personal
space of others, exhibiting behaviors that are not socially and culturally acceptable

Impairment in social functioning may also be reflected in social isolation, emotional
detachment, and lack of regard for social convention
Autism

Autism describes the condition created by the person with schizophrenia who
focuses inward on a fantasy world while distorting or excluding the external
environment
Deteriorated appearance

Personal grooming and self-care activities may become minimal.

The client with schizophrenia may appear disheveled and untidy and may need to be
reminded of the need for personal hygiene
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8. PSYCHOMOTOR BEHAVIOR
Anergia

Anergia is a deficiency of energy.

The individual with schizophrenia may lack sufficient energy to carry out activities
of daily living or to interact with others
Waxy Flexibility

Waxy flexibility describes a condition in which the client with schizophrenia allows
body parts to be placed in bizarre or uncomfortable positions

Once placed in position, the arm, leg, or head remains in that position for long
periods, regardless of how uncomfortable it is for the client.

For example, the nurse may position the client’s arm in an outward position to take a
blood pressure measurement. When the cuff is removed, the client may maintain the
arm in the position it was placed to take the reading
Posturing

This symptom is manifested by the voluntary assumption of inappropriate or
bizarre postures
Pacing and rocking

Pacing back and forth and body rocking (a slow, rhythmic, backward-and-forward
swaying of the trunk from the hips, usually while sitting) are common psychomotor
behaviors of the client with schizophrenia
9. ASSOCIATED FEATURES
Anhedonia

Anhedonia is the inability to experience pleasure.

This is a particularly distressing symptom that compels some clients to attempt
suicide
Regression

Regression is the retreat to an earlier level of development.

Regression, a primary defense mechanism of schizophrenia, is a dysfunctional
attempt to reduce anxiety.
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
It provides the basis for many of the behaviors associated with schizophrenia.
POSITIVE AND NEGATIVE SYMPTOMS

Some clinicians find it useful to describe symptoms of schizophrenia as positive or
negative.

Positive symptoms tend to reflect an excess or distortion of normal functions,
whereas negative symptoms reflect a diminution or loss of normal functions (APA,
2000).

Most clients exhibit a mixture of both types of symptoms.

Positive symptoms are associated with normal brain structures on CT scan and
relatively good responses to treatment.

Individuals who exhibit mostly negative symptoms often show structural brain
abnormalities on CT scans and respond poorly to treatment

Examples of positive symptoms are:
1. Hallucinations: Auditory, Visual, Olfactory, Gustatory, Tactile
2. Delusions: Persecution, Grandeur, Reference, Control or influence, Somatic
3. Disorganized thinking/Speech: Loose associations, Incoherence, Clang
associations, Word salad, Neologisms, Concrete thinking, Echolalia, Tangentiality,
Circumstantiality
4. Disorganized behavior: Disheveled, appearance, Inappropriate, sexual
behavior, Restless, agitated, behavior, Waxy flexibility

Examples of negative symptoms are:
1. Affective Flattening: Unchanging facial expression, Poor eye contact, Reduced
body language, Inappropriate affect, Diminished emotional expression
2. Alogia (poverty of speech): Brief, empty responses, Decreased fluency of
speech, Decreased content of speech
3. Avolition/apathy: Inability to initiate goal-directed activity, Little or no interest
in work or social activities, Impaired grooming/hygiene
4. Anhedonia: Absence of pleasure in social activities, Diminished intimacy/sexual
interest
5. Social isolation: Withdrawal from social life, and self-isolation.
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