SCHIZOPHRENIA
P R E P A R E D
A N D R E W
B Y :
I S I A H
P .
B O N I F A C I O ,
R N
OUTLINE OF DISCUSSION
▪ Etymology & Clinical Description of
Schizophrenia
▪ Etiology of Schizophrenia
▪ Treatment of Schizophrenia
Origins of
Schizophrenia
ETYMOLOGY
“schizo”
•split
“phrenia”
•mind /
person
TIMELINE OF EVOLUTION
Morel
(1860)
• Coining of the
term “dementia
praecox”
Kahlbaum
(1871)
• Used the term
“catatonia” for
patients
immobilized by
psychological
factors
Hecker
(1874)
• Used the term
“hebephrenia”
for patients who
exhibit silly,
uncommon
behaviors
Kraepelin
(1878)
• Used the term
“paranoia” for
patients with
excessive
suspiciousness
Bleuler
(1900s)
• Used the term
“schizophrenia”
to describe
patients with
catatonia,
hebephrenia and
paranoia
MODERN CLINICAL DESCRIPTION
Major disturbances in thought, emotion,
and behavior
Can disrupt interpersonal relationships,
diminish capacity to work or live
independently
Significantly increased rates of suicide and
death
Etiology of
Schizophrenia
GENETIC THEORIES
Genetically heterogeneous
• Not likely that disorder caused by single gene
Association studies
• Two genes associated with schizophrenia
• DTNGP1
• NGR1
• Two genes associated with cognitive deficits
• COMT
• BDNF
GENETIC THEORIES
Family studies
• Relatives at increased risk
• Negative symptoms have stronger genetic component
Twin studies
• 44% risk for MZ twins vs. 12% risk for DZ twins
• Children of non-schizophrenic MZ twin were more likely to develop schizophrenia
(9.4% vs. 1% in general population)
Adoption studies
• Increased likelihood of developing psychotic disorders
BIOCHEMICAL THEORIES
Original Dopamine Theory
• Disorder due to excess levels of dopamine
• Drugs that alleviate symptoms reduce dopamine activity
• Amphetamines, which increase dopamine levels, can induce a psychosis
Revised Dopamine Theory
• Excess numbers of dopamine receptors or oversensitive dopamine receptors
localized mainly in the mesolimbic pathway related to positive symptoms
• Underactive dopamine activity in the mesocortical pathway mainly related to
negative symptoms
OTHER ETIOLOGICAL THEORIES
Damage during gestation or birth
• Obstetrical complications rates high in patients with schizophrenia
• Reduced supply of oxygen during delivery may result in loss of cortical
matter
Viral damage to fetal brain
• Presence of parasite, Toxoplasma gondii, associated with 2.5x greater
risk of developing schizophrenia
• In a Finnish study, schizophrenia rates higher when mother had flu in
second trimester of pregnancy
OTHER ETIOLOGICAL THEORIES
Reaction to stress
• Individuals with schizophrenia and their first-degree relatives more
reactive to stress
• Greater decreases in positive mood and increases in negative mood
Socioeconomic status
• Highest rates of schizophrenia among urban poor
• Sociogenic hypothesis
• Stress of poverty causes disorder
EPIDEMIOLOGY
1%
• prevalence in the general population
95%
• suffer for a lifetime
33%
• more common among the homeless
50%
• experience more serious side effects from taking medications
10%
• commit suicide and die
GENDER DIFFERENCES
MEN
WOMEN
• Earlier onset at less than
20 years old
• Usual onset at age 20
years old
• Have more severe course
of illness
• Manifest more of the
positive symptoms
• Less compliant with
antipsychotic medications
• High levels of estrogen
seem to delay onset
Criteria for Clinical
Diagnosis
✓ Tw o o r m o r e o f t h e f o l l o w i ng s y m p t o ms
f o r a t l e a s t 1 m o n t h ; o n e s y m p to m
s h o u l d b e e i t he r 1 , 2 , o r 3 :
( 1 ) d e l us i o ns
( 2 ) h a l l u ci n a ti o n s
( 3 ) d i s o r g a ni ze d s p e e c h
( 4 ) d i s o r g a ni ze d ( c a t a to ni c )
b e h a vi o r
✓ ( 5 ) n e g a ti ve s y m p t o ms ( d i mi ni s he d
m o t i va ti o n o r e m o t i o n a l e x p r e s si o n )
✓
✓
✓
✓
✓ F u n c ti o n i ng i n w o r k , r e l a ti o n s hi ps , o r
self-care has declined since onset
✓ Signs of disorder for at least 6 months;
i f d u r i ng a p r o d r o m a l o r r e s i dua l p h a s e ,
n e g a ti ve s y m p to ms o r t w o o r m o r e o f
s y m p to m s 1 - 4 i n l e s s s e ve r e f o r m
CLINICAL MANIFESTATIONS
Positive
Negative
• Psychotic
symptoms
• Decreased normal
behavior
Disordered
• Uncommon pattern
of behavior
POSITIVE SYMPTOMS
DELUSIONS
•fixed, false beliefs
•cannot be changed by logical persuasion
•take many forms
POSITIVE SYMPTOMS
After medical tests confirm
otherwise, a patient still insists, “I
have cancer in my stomach.”
SOMATIC DELUSION
POSITIVE SYMPTOMS
A patient states, “I am the king of
the universe. Bow before me you
worthless piece of sh*t.”
DELUSIONS OF
GRANDEUR
POSITIVE SYMPTOMS
A patient states, “I am dead.” In
response to saying, “If you are dead,
how can you talk?” The patient says,
“I don’t know, but I’m dead.”
NIHILISTIC DELUSIONS
POSITIVE SYMPTOMS
“The TV is talking about me. The
guests on Oprah are making fun of
me.”
DELUSIONS OF
REFERENCE
POSITIVE SYMPTOMS
“I can control her with my thoughts.”
DELUSIONS OF CONTROL
POSITIVE SYMPTOMS
“They all think that I am a
homosexual and they are all bound
to execute me.”
PARANOID/PERSECUTORY
DELUSIONS
POSITIVE SYMPTOMS
HALLUCINATIONS
•false sensory perceptions
•not associated with real external stimuli
•involving any of the five senses
POSITIVE SYMPTOMS
AUDITORY
•“Someone is telling me to jump from the top of the building”
VISUAL
•“My mother is here and she’s sitting right beside you nurse.”
TACTILE
•“I feel like ants are crawling all over my body. Get them off please.”
GUSTATORY
•“Is there apple in this vegetable salad?”
OLFACTORY
•“I smell something burning in the kitchen.” But there is no one cooking.
POSITIVE SYMPTOMS
HALLUCINATION
•No stimuli
ILLUSION
•With a stimuli
DISORGANIZED SYMPTOMS
DISORGANIZED SPEECH
•characterized by a collection of speech
abnormalities that can make a person's
verbal communication difficult or
impossible to comprehend
DISORGANIZED SYMPTOMS
Cherry lips, crystal skies
Stolen kisses, pretty lies
Screaming, crying, perfect storms
WORD SALAD
DISORGANIZED SYMPTOMS
Dang, tang, swang, bang, bang into
the room!
CLANG ASSOCIATIONS
DISORGANIZED SYMPTOMS
Nurse: “How are you?”
Patient: “How are you?”
ECHOLALIA
DISORGANIZED SYMPTOMS
Nurse: “How are you?”
Patient: “I’m fine, fine, fine, fine…”
PALILALIA
DISORGANIZED SYMPTOMS
Nurse: “How are you?”
Patient: “I’m fine”.
Nurse: “What did you have for breakfast?”
Patient: “I’m fine”.
PERSEVERATION
DISORGANIZED SYMPTOMS
“The VORGLERS have the cure to my
illness. The VORGLERS are coming!”
NEOLOGISMS
DISORGANIZED SYMPTOMS
Nurse: “Can you tell me more about it?”
Patient: “There she goes. Time is gold.
Keep off the grass. Don’t do drugs.”
FLIGHT OF IDEAS
DISORGANIZED SYMPTOMS
DISORGANIZED BEHAVIOR
• can include odd, bizarre behavior such as
smiling, laughing, or talking to oneself or being
preoccupied/responding to internal stimuli.
• can include purposeless, ambivalent behavior or
movements.
DISORGANIZED SYMPTOMS
Waxy flexibility
• Client allows body
parts to be placed
in bizarre or
uncomfortable
positions
• Once placed in
position, the body
part remains in
that position for
long periods,
regardless of
discomfort
Catalepsy
• Passive induction of
a posture held
against gravity
Echopraxia
• Mimicking
another’s
movements
Mutism
• No, or very little,
verbal response
(outside of
aphasia)
NEGATIVE SYMPTOMS
A
• Avolition (Lack of interest; apathy)
• Associality (Inability to form close personal
relationships)
• Anhendonia (Inability to experience
pleasure)
• Affect flattening (Exhibits little or no affect
in face or voice)
• Alogia (Reduction/poverty in speech)
CLINICAL COURSE OF ILLNESS
PREMORBID
PRODROMAL
SCHIZOPHRENIA
(ACUTE)
RESIDUAL
CLINICAL SUBTYPES
Brief psychotic disorder
• Sudden onset of psychotic symptoms that may or may not be preceded
by a severe psychosocial stressor.
• Symptoms last at least 1 day but less than 1 month.
• Full return to the premorbid level of functioning.
Delusional disorder
• Characterized by the presence of delusions lasting at least 1 month.
• Hallucinations are not prominent, and behavior is not bizarre.
CLINICAL SUBTYPES
Schizophreniform disorder
• Features are identical to those of schizophrenia, with the exception that the duration,
including prodromal, active, and residual phases, is at least 1 month but less than 6
months.
• Diagnosis is changed to schizophrenia if clinical picture persists beyond 6 months.
Schizoaffective disorder
• Schizophrenic behaviors present with strong symptoms associated with mood
disorders (depression or mania).
• Presence of hallucinations and/or delusions that occur for at least 2 weeks in the
absence of a major mood episode.
• Mood disorder symptoms must be evident majority of time.
Types of
Schizophrenia
PARANOID SCHIZOPHRENIA
▪ Characterized by suspicion toward others.
▪ Most prominent manifestation: PERSECUTORY
DELUSIONS
DISORGANIZED SCHIZOPHRENIA
▪ Characterized by withdrawal
from society and very
inappropriate behaviors, such as
poor hygiene or muttering
constantly to oneself.
▪ Frequently seen in the homeless
population.
CATATONIC SCHIZOPHRENIA
▪ Characterized by abnormal motor movements.
▪ There are two stages: the withdrawn stage and the excited
stage.
RESIDUAL SCHIZOPHRENIA
▪ Active symptoms are
no longer present,
but the client has two
or more “residual”
symptoms.
Medical
Treatment for
Schizophrenia
ANTI-PSYCHOTIC MEDICATIONS (NEUROLEPTICS)
• By nature, neuroleptics are
antagonistic of dopamine
• Three classification:
• FIRST GEN (LOW
POTENCY)
• FIRST GEN (HIGH
POTENCY)
• SECOND GEN
typical
atypical
-zine & -dol
-pine & -done
MAJOR TRANQUILIZERS
CATEGORIES OF ANTI-PSYCHOTICS
TYPICAL
(CONVENTIONAL)
Original or traditional
ATYPICAL
(UNCONVENTIONAL)
Modern
Dopamine antagonist only Dopamine and serotonin
antagonists
More side effects
Less side effects
SIDE AND ADVERSE EFFECTS
ANTICHOLINERGIC SYMPTOMS (BUCOPANDAN) (Blurred
vision, Urinary retention, Constipation, Orthostatic
Hypotension, Photosensitivity, Amnesia, Nausea, Dryness
of the mouth (Xerostomia), Apraxia, Night discomforts
(Sleep disturbances))
• NURSING CARE: Ice chips, dim lights, assistive devices for ambulation,
relaxation techniques for sleep, gradual/slow changing of positions, high
fiber diet, adequate fluid intake, adequate sodium intake
SIDE AND ADVERSE EFFECTS
EXTRA PYRAMIDAL SYMPTOMS / SIDE EFFECTS / PAKINSON-LIKE
SYMPTOMS
• Acute dystonia (can appears as early as 2 to 4 weeks after medication started)
• Appearance of torticollis (wry neck), opisthotonus (back is arched and legs are
extended), & oculogyric crisis (eyeballs rolling upward)
• Akathisia (ants in the pants sensation)
• Inability to sit or stand still
• Tardive dyskinesia (last to onset usually after 6 months to 1 year of therapy)
• Bizarre mannerisms such as tongue protrusion, lip smacking and facial grimacing
ANTIDOTE FOR EPS
Benztropin (Cogentin)
Trihexyphenidyl (Artane)
Diphenhydramine (Benadryl)
Amantadine (Symmetrel)
Diazepam (Valium) (Last resort)
Propanolol (Inderal) (best for akathisia)
ADVERSE EFFECTS
NEUROLEPTIC MALIGNANT SYNDROME
• a life-threatening neurologic emergency
associated with the use of antipsychotic
(neuroleptic) agents and characterized by a
distinctive clinical syndrome of mental status
change, rigidity, fever, and dysautonomia.
ADVERSE EFFECT
AGRANULOCYTOSIS
• a blood dyscrasia
• a life-threatening blood disorder.
• happens when the body doesn't make enough of a type of
white blood cells called neutrophils.
• Initial manifestation: sore throat
• Specific anti-psychotic that causes: CLOZAPINE
ELECTROCONVULSIVE THERAPY
NURSING CARE OF PATIENTS ON ECT
PSYCHOTHERAPY
Nursing
Management
for
Schizophrenia
GOALS FOR MANAGEMENT OF SCHIZOPHRENIC CLIENTS
Reduce severity of psychotic symptoms
Prevent recurrence of acute episodes
Meet patient’s’ physical and psychosocial needs
Help patient gain optimum level of functioning
Increase client’s compliance to treatment and nursing plan
MILIEU THERAPY
utilized for clients with schizophrenia
both in 24-hr mental health facilities
and in community facilities, such as
adult day care programs.
structured, safe environment (milieu)
for the client in order to decrease
anxiety and to distract the client from
constant thinking about
hallucinations.
ESTABLISH TRUST AND RAPPORT
Use an accepting, consistent approach;
short, repeated contacts are best until
trust has been established.
Don’t touch client without telling him
first what you are going to do.
Language should be clear and
unambiguous.
MAXIMIZE LEVEL OF FUNCTIONING
Promote self-care by modeling and
teaching self-care activities within the
mental health facility.
Avoid promoting dependence by doing
only what the patient can’t do for
himself.
Reward positive behavior and work with
him to increase his personal sense of
responsibility in improving functioning.
THERAPEUTIC COMMUNICATION
Be genuine and empathetic in all dealings
with the client.
Ask the client directly about hallucinations.
Do not argue with a client’s delusions, but
focus on the client’s feelings.
Attempt to focus conversations on realitybased subjects.
Identify symptom triggers