Psychiatric Nursing
Schizophrenia
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Features of Schizophrenia
• Prevalence in U.S. is 1.1%.
• Average onset is late teens to early
twenties, but can be as late as midfifties
• Affects cognitive, emotional, and
behavioral function
• 30% to 40% relapse rate in the first
year
Schizophrenia
•

•
1.
2.
Schizophrenia was derived from Greek=Schizo (split) and
Phren (mind)
Much debates has surrounded the concept of
schizophrenia; various definitions, numerous treatment
strategies, but non have proved to be completely
effective.
Although wide controversy around schizophrenia,
most clinicians agreed on two factors:
Schizophrenia is not a homogenous disease entity of a
single cause BUT results from a variable combination of
genetic predisposition, biochemical dysfunction,
physiological factors, & psychosocial stress.
Yet, and probably never will be a single treatment that
cures the disorder.
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Schizophrenia
• Effective treatment requires a comprehensive,
multidisciplinary effort, including pharmacotherapy &
various forms of psychosocial care, such as living skills
& social skills training, rehabilitation, & family therapy.
• Of all the mental illnesses, schizophrenia cause more
lengthy hospitalization, more chaos in family life, cost
more to individual and government.
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Definition of Schizophrenia
• What is Schizophrenia? Is it Dual personality?
• Schizophrenia: is a severe psychotic disorder
characterized by a breakdown of thought processes and
by poor emotional responsiveness. It affects the mood,
regulation of emotions, thought processes, behavior,
perception, affect, & total personality integrity.
• It most commonly associated with auditory
hallucinations, paranoid or bizarre delusions, or
disorganized speech or thoughts.
• These disturbances result in a severe deterioration of
social & occupational functioning.
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Facts about Schizophrenia
• Symptoms generally appear in late adolescence
or early adulthood, although they may occur in
middle or late adult life (APA, 2000). They occur
earlier in men than in women.
• Approximately 1.7 million American adults have
schizophrenia.
• They make up more than 50% of the long-term
residents of mental hospitals.
• Between 10%-15% of them commit suicide,
usually before age 40.
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Features of Schizophrenia
(cont'd)
• Progression varies from one client to
another
– Exacerbations and remissions
– Chronic but stable
– Progressive deterioration
Features of Schizophrenia
(cont'd)
• DSM-IV-TR Diagnosis
– Symptoms present at least 6 months
– Active-phase symptoms present at least
1 month
– Symptoms are defined as positive and
negative
Features of Schizophrenia
(cont'd)
• Positive symptoms
– Excess or distortion of normal
functioning
– Aberrant response
• Negative symptoms
– Deficit in functioning
Features of Schizophrenia
(cont'd)
• Positive Symptoms of Schizophrenia
– Hallucination
– Delusions
– Disordered speech and behavior
Features of Schizophrenia
(cont'd)
• Negative Symptoms of Schizophrenia
– Flat affect and apathy
– Alogia
– Avolition
– Anhedonia
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Classifications of Schizophrenia
•
1.
2.


Two major groupings can be seen in
schizophrenia:
Chronic: long-term illness with poor
prognosis.
Acute: have good prognosis.
1% of population will develop
schizophrenia over the course of life time.
There is a premorbid behavior that
proceeds schizophrenia (the development
of the disease occurs in phases)
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Phases of schizophrenia development
1.
Phase I Schizoid personality: indifferent (unresponsive)
to social relationships, limited range of emotional
experience and expression. They do not enjoy close
relationships and prefer to be “loners” & described as
being cold and aloof (not interested).
Not all individuals with schizoid personality will progress to
schizophrenia, but most with schizophrenia show
evidence of having these characteristics in the
premorbid condition.
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Phases of schizophrenia development
2. Phase II Prodromal phase: social
withdrawal, role functioning impairment,
poor hygiene, self neglect, bizarre ideas,
unusual perceptual experiences, lack of
energy & initiatives.
The length of this stage is highly variable
(many years before deteriorating to
schizophrenic state).
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Phases of schizophrenia development
3. Phase III Schizophrenia: the active phase of the disorder.
Psychotic symptoms are prominent. Diagnostic criteria for
schizophrenia:
• Characteristics symptoms: include two or more of the
following:
Delusions
Hallucinations
Disorganized speech (why does this happen?)
Catatonic behavior (Behavior characterized by
muscular tightness or rigidity and lack of response to
the environment. In some patients rigidity alternates
with excited or hyperactive behavior).
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Phases of schizophrenia development
 Negative symptoms (affective flattening and
alogia, lack of desire to form relationships
(asociality), and lack of motivation (avolition)).
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Phases of schizophrenia development
• Social/occupational dysfunction
 It happen for a significant portion of the time since the
onset of the disturbance, one or more major areas of
functioning-such as work, interpersonal relations, or
self-care are markedly below the level achieved
before the onset.
• Duration
 This period should include at least 1 month of
symptoms.
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Phases of schizophrenia development
• Schizoaffective & Mood disorder Exclusion
 Schizoaffective disorder and Mood disorder with
psychotic features have been ruled out because no
major depressive, manic or mixed episode have
occurred during the active-phase symptoms.
• Substance /General medical conditions Exclusion
 The disturbance is not due to the direct physiological
effects of a substance or medical conditions.
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Phases of schizophrenia development
• Relationship to a pervasive developmental disorder
 If there is a history of pervasive development disorder
(autistic disorder).
 the additional diagnosis of schizophrenia is made only if
prominent hallucinations & delusions are there for
1month.
4. Phase IV Residual phase: this stage usually follows the
active phase of schizophrenia. Symptoms are similar to
those of the prodromal phase, with flat affect and
impairment in role functioning are prominent. Residual
impairment often increases between episodes of active
psychosis.
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Phases of schizophrenia development
•
Several factors result in positive prognosis: later age at
onset, being female, abrupt onset of symptoms,
precipitated by a stressful event, associated mood
disturbance, brief duration of active-phase, absence of
structural brain abnormalities, normal neurological
functioning, a family history of mood disorder, & no family
history of schizophrenia.
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Etiological implications
•
The cause of Schizophrenia is still uncertain. No single
factor can be implicated in the etiology; rather, the
disease probably results from a combinations of
influences including biological, psychological, and
environmental.
1. Genetics
 The evidence for genetic vulnerability to schizophrenia is
growing. Relatives of individuals with schizophrenia have
a higher probability of developing the disease than does
the general population (1% for normal population and 510% for siblings with the disease).
 How schizophrenia is inherited is still uncertain. No
reliable biological markers have yet been found.
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Etiological implications
1.
Genetics (continued)
 Twin Studies: rate of schizophrenia among monozygotic
(identical) twins is 4 time that of dizygotic (fraternal)
twins & almost 50 times that of general population.
• Rearing? Studies found that identical twins reared apart
have the same rate of development of the illness as do
those reared together. Because in about 50% of the
cases only one of a pair of monozygotic twins develops
schizophrenia, some investigators believe that
environmental factors interact with genetic ones.
 Adoption Studies: adoption studies found that children
who were born of schizophrenic mothers were more
likely to develop the illness.
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Figure 16-2 PET (positron emission tomography) scans
measuring regional cerebral blood flow. (a) Areas of lower
blood flow and brain activity are seen in the individual with
schizophrenia. (b) Areas of normal blood flow and brain activity are
visible in the unaffected individual. Photo courtesy of R.
Haier/Photolibrary
.
Etiological implications
2. Biochemical influences
 oldest and most explored theory to explain schizophrenia
attributes a pathogenic role to abnormal brain biochemistry.
 The Dopamine Hypothesis: the theory suggest that
schizophrenia (or schizophrenia-like symptoms) is caused
by an excess of dopamine activity (increase production of
dopamine, increase the number of dopamine receptors,
and reduce activity of dopamine antagonists).
 Pharmacological support for this hypothesis exists.
Neuroleptics/antipsychotic (e.g. Haldol) lower brain level of
dopamine by blocking dopamine receptors, thus reducing
the symptoms.
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Etiological implications
• Biochemical influences continued
 Other Biochemical Hypotheses: Abnormalities in the
neurotransmitters norepinephrine, serotonin,
acetylcholine and gamma-aminobutyric acid and in the
neuroregulators such as prostaglandins and endorphins,
have been suggested.
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Etiological implications
3. Physiological Influences
These are the possible factors although there mechanism is
unclear:
 Viral infection: high incidence of schizophrenia after
prenatal exposure to influenza.
 Anatomical abnormalities: structural brain abnormalities
have been observed in individuals with schizophrenia.
 Physical conditions: link have been reported between
schizophrenia and epilepsy, Huntington’s chorea
(neurodegenerative genetic disorder), birth trauma, head
injury in adulthood, alcohol abuse, cerebral tumor, CVA,
Systemic lupus erythemastosus (SLE) and parkinsonians.
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Etiological implications
4.
Psychological influences
 Early conceptualization of schizophrenia focused on
family relationships factors as major influences in the
development of the illness. This probably occurred in
the absence of information related to the biological
connection.
 Poor parent-child relationships and dysfunctional
family system may consider as risk factor for
schizophrenia.
 Can family interaction cause schizophrenia?
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Etiological implications
5.
Environmental influences
 Sociocultural factors:
o number of individuals from lower socioeconomic
classes experience symptoms associated with
schizophrenia more than individuals from higher
classes. Lower social classes (living in poverty,
congested accommodations, inadequate nutrition,
absence of prenatal care and few resources of
dealing with stress).
o Downward drift hypothesis: It views poor social
condition, isolation and segregation of self from
others as a consequence to the disorder not a cause.
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Etiological implications
Environmental influences continued
Stressful life events: although there is no scientific
evidence, it is probable that stress may contribute to the
severity and course of the illness. This depend also on
severity of stress and degree of genetic vulnerability to
schizophrenia.
6. Theoretical integration
The etiology of schizophrenia remains unclear. no single
cause/theory have given the clear-cut explanation for the
disease. The more evidence is supporting the concept of
multiple causation in the development of schizophrenia.
The most current theory seems to be that schizophrenia is
a biological based disease, the onset of which is influenced
by factors in the environment (internal and external).
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Famous people with Schizophrenia
• John Nash (1928- - Mathematician/Nobel
Prize Winner 1994.
• Dr. James Watson (discovered DNA and
Nobel Prize winner 1962)
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Types of schizophrenia and other psychotic
disorders:
Differential diagnosis according to the total symptoms.
1. Disorganized (hebephrenic) schizophrenia.
* Onset of the symptoms usually before 25 years old & the
course is commonly chronic. Poor contact with reality,
inappropriate or flat affect, bizarre mannerisms are
common, incoherent communication (hard to understand
them), social impairment is extreme, & personal
appearance in general is neglected with poor hygiene.
2. Catatonic schizophrenia.
• Characterized by marked abnormalities in motor behavior
manifested in two forms:
 catatonic stupor (psychomotor retardation) or
 catatonic excitement (extreme psychomotor agitation).
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Types of schizophrenia and other psychotic
disorders:
3. Paranoid Schizophrenia.
• Manifested y the presence of delusion of persecution
and grandeur and auditory hallucinations. Pt. is often
tense, suspicious, guarded, hostile and aggressive.
Symptoms late 20s or 30s.
4. Undifferentiated schizophrenia:
• Symptoms of psychosis (delusions, hallucinations,
incoherence, and bizarre behavior) are present,
however, these symptoms cannot be easily classified in
any kind of schizophrenia.
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Types of schizophrenia and other psychotic
disorders:
5. Residual schizophrenia:
• Individual has a history of at least one previous episode of
psychotic symptoms with prominent psychotic symptoms
but no longer displays prominent symptoms.
• Residual symptoms include: social isolation, impairment in
personal hygiene and blunt effect.
6. Schizoaffective disorder:
• Schizophrenic behaviors with strong elements of
symptoms associated with mood disorder (mania or
depression). Pt. appear depressed with psychomotor
retardation, suicide ideation or symptoms may include
euphoria and hyperactivity.
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7. Brief Psychotic disorder:
• Sudden onset of psychotic symptoms that may or may not be
proceeded by a sever psychosocial stressor (last at least one
day but less than one month).
• Individuals with personality disorders are more susceptible to
this type.
8. Schizophreniform disorder:
• Duration of predormal, active, and residual stages is at least
1 month and less than 6 months. If more than 6 months, the
diagnosis will be schizophrenia.
9. Delusional disorder
• The essential features of this disorder is the presence of one
or more of non-bizarre delusions that persist for at least 1
month. Behavior is not bizarre.
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Many subtypes is based on the delusional theme:
– Erotomanic: individuals believes that someone, usually of
higher status, is in love with him or her.
– Grandiose: individual have irrational ideas regarding their
own worth, talent, knowledge, or power.
– Jealous: content delusion centers on the idea that
person’s sexual partner is unfaithful (irrational and
without cause but the patient tries to justify it).
– Persecutory: individuals believe they are being
malevolently treated in some way (cheated, spied on,
poisoned, drugged, etc.).
– Somatic: individuals believe they have some physical
defect, disorder, or disease (foul oder, insects on the skin,
internal parasite, ugly body parts, dysfunctional body
parts).
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10. Shared psychotic disorder
* Delusional system that develops in a second person as a
result of a strong relationship with another person who
already has a psychotic disorder with prominent
delusions. The primary person with the disorder is usually
the dominant person in the relationship.
11. Psychotic disorder due to medical condition
* Hallucination and delusion directly attributed to a medical
condition such as Neurologic conditions (CNS infection),
Endocrine conditions, Metabolic conditions (hypoxia),
Autoimmune conditions (SLE), & others (fluid imbalance).
12. Substance-induced psychotic disorder
* Presence of hallucinations and delusions due to
physiological effect of substance. Such as drug of abuse
(cocaine, opioids, alcohol), medications (anesthetics,
analgesics, anticonvulsants) & Toxins (organophsphorate
insecticides, carbon dioxide, carbon monoxide).
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Nursing care for schizophrenia
•
Assessment:
Assessment of the client with schizophrenia may be a complex
process, therefore , data may be obtained from different
recourses: Family members, old records, other individuals.
•
Behavioral disturbances in eight areas of functioning are
affected:
1. Content of thought
Delusions: false personal beliefs that are inconsistent
with the person’s intelligence or background. Delusions
are subdivided into:
• Persecutory: individual feels threatened and believes
others intend to harm him/her.
• Grandiosity: individual has an exaggerated feeling of
power
• Reference: all events within environment referred by
psychotic person to him/her self.
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Nursing care for schizophrenia
Delusions (continued)
• Control or influence: certain objects or person have
control over psychotic person.
• Somatic delusions: the individual has a false ideas
about the functioning of his or her body.
• Nihilistic delusions: the individual has a false idea that
the self, a part of the self, others, or the world is
nonexistent.
Religiosity: is an excessive demonstration of or obsession
with religious ideas and behavior.
 Paranoia: individuals have extreme suspiciousness of
others and of their actions or perceived intentions.
 Magical thinking: individuals believe that their thoughts39or
behaviors have control over specific situations or people.
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Nursing care for schizophrenia
2. Form of thought
– Associative looseness: ideas shift from one unrelated
subject to another.
– Neologism: psychotic person invents new words that
are meaningless to others.
– Concrete thinking: regression to an earlier level of
cognitive development.
– Clang association: choice of words is governed by
sounds
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Nursing care for schizophrenia
– World salad: group of words without logical
connection.
– Circumstantiality: delayed in reaching point of
communication because of unnecessary details.
– Tangentiality: the person never gets to the point of
communication.
– Mutism: individuals inability or refusal to speech
– Perseveration: repeating the same ideas or words in
response to different questions.
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Assessment of schizophrenia
3.
Perception
• Hallucinations: Auditory, visual, tactile, gustatory,
olfactory
• Illusion: misperceptions of real external stimuli.
4. Affect
• Inappropriate affect: emotional tone is incongruent
with circumstances
• Bland of flat affect: emotional tone is weak.
• Apathy: disinterest in environment.
5. Sense of self:
– Echolalia: repeat words
– Echopraxia: imitate movements
– Identification and imitation: self-identity confusion
– Depersonalization: feeling unreality
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Assessment of schizophrenia
6. Volition: impairment in ability to initiate goal-directed
activity.
– Emotional ambivalence: opposite emotion to same
situation.
– Impaired interpersonal functioning: intrude others
personal space
– Autism: focuses on a fantasy world.
– Deteriorated appearance
7. Psychomotor behavior:
– Anergia: deficiency of energy
– Waxy flexibility: body parts placed in bizarre positions.
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Assessment of schizophrenia
– Posturing: bizarre postures
– Pacing or rocking: back and forth rocking
8. Associated Features
• Anhedonia: inability to experience pleasure
• Regression: to retreat to an earlier level of
development.
9. Positive & Negative Symptoms
• +ve: reflect an excess or distortion of normal
functions.
• -ve: loss of normal functions.
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Nursing Implications
(cont'd)
• Nursing Diagnoses
– Altered thought process
– Social isolation
– Risk for violence
– Self-care deficits
– Altered health maintenance
– Ineffective family coping
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Nursing Implications:
Supporting Families
• Family needs vary with degree of
illness and involvement in client’s
care
– Education
– Financial support
– Psychosocial support
– Advocacy
Nursing Implications:
Supporting Families (cont'd)
• Schizophrenia is a “family illness.”
• Family members need to be
involved.
• Educate family about
– Medication
– Illness
– Relapse prevention
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Nursing Implications:
Supporting Families (cont'd)
• Nurse assists family by
– Identifying community agencies/groups
for family members
– Advocating for rights
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Measures to Prevent
Relapse
• Ensure client takes medication
• Educate family about signs and
symptoms of relapse
• Client and family to participate in
relapse prevention program
Measures to Prevent
Relapse (cont'd)
• Relapse prevention programs work
best when:
– Psychosocial treatment and social skills
training are combined with antipsychotic
medication
– Behavior patterns are monitored
– Family members understand triggers
Measures to Prevent
Relapse (cont'd)
• Relapse prevention programs provide
education and support regarding:
– Individual triggers, symptoms of relapse
– Managing side effects of medications
– Interventions to reduce or eliminate
triggers
– Strategies to facilitate early intervention
– Cognitive therapy
– Community resources
Challenges to Adherence
• Side effects
• Level of symptomatology
• Cognitive, motivational, financial,
and cultural issues
• Issues with caregivers
• Insufficient medication teaching
Increasing Adherence
• Involve clients in treatment
• Instruct client about reducing
discomfort
• Provide peer support
• Provide reminders and positive
feedback
• Recognize accomplishments
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Personal Awareness
• Identify personal feelings.
• Recognize personal perceptions.
• What behaviors do you expect to
see?
• How will you respond to these
behaviors?
• What is the meaning of the
behaviors?
Personal Awareness (cont'd)
• What defines “normal” behavior?
• What are my fears associated with
mental illness?
Personal Awareness (cont'd)
• Be honest with your feelings.
• Identify what strengths you bring to
the situation.
• Remember that clients are human
beings with a mental disorder and do
not choose to be this way.
Treatment modalities for Schizophrenia
• Individual psychotherapy
– Problem solving, reality testing, psychoeducation, and
supportive & cognitive-behavioral techniques.
– Reality-oriented individual therapy is the most suitable
approach.
– Effort should focus on decreasing anxiety and
increase trust.
– Because it is difficult to establish relationship with pt.
the successful intervention may be achieved with
honest, simple directness, and respecting the client
privacy and dignity.
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Treatment modalities for Schizophrenia
• Group therapy
– It is less productive in inpatient settings.
– It is the most useful over the long-term course of the
illness.
• Behavior therapy
– It help in reducing the frequency of bizarre, disturbing,
and deviant behaviors and increase appropriate
behaviors. Features led to positive results include:
– Clearly defined goals.
– Attaching +ve, -ve, & aversive reinforcements to
adaptive and maladaptive behavior.
– Using simple, concrete instructions and prompts to
elicit the desired behavior.
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Treatment modalities for Schizophrenia
• Social skill training
– One of the most widely used psychosocial
interventions.
– The educational procedure focus on role-play, like
using scenarios.
– Progress is directed toward the client’s need and
limitations.
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Treatment modalities for Schizophrenia
• Milieu therapy
– More successful if used in conjunction with
psychotropic medications.
• Family therapy
– Designed to support the family system, prevent or
delay relapse, and help maintain the client in the
community.
• Antipsychotic drugs
– Antipsychotic medications
– Reserpine: a dopamine receptor antagonist used as
antihypertensive and antipsychotic. It is now rarely
used because it produced severe depression
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Treatment modalities for Schizophrenia
• Antipsychotic drugs (continued)
– Lithium carbonate: used to suppress episodic
violence.
– Carbamazepine: ameliorates symptoms in some
treatment-resistant psychotic client.
– Valium: control agitation, thought disorder, delusions,
and hallucinations.
– Propranolol: useful in controlling temper outbursts in
aggressive or violent psychotic clients.
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THANK YOU
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