Psychopathology
Schizophrenia
Signs & symptoms
Possible Causes
Nursing Diagnoses
Treatment & care Plans
Teaching plans
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Psychopathology
• Prevalence - 20% (12 months period)
Anxiety disorder - most prevalent
Mood disorder (collectively)
Alcohol disorders
Major depression
• Comorbidity - 17%
• Help seeking - 60-80%
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Understanding Psychopathology
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Organized knowledge - understand
Operational definition - communicate
Criteria for diagnosis - DSM IV
Behavior - subjective/ objective
Etiology - nature/nurture
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Schizophrenia
• the most debilitating mental illnesses
• Greek terms - "splitting of the mind”
• do not have more than one distinct
personality
• distortions in their perceptions, feelings, and
relationships with the world around them.
• 1% of the population suffer (in 12 m period)
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Mild
Anxiety
Moderate
Severe
Psychosis
Anxiety disorder
Somatoform disorders
Dissociative disorders
Anxiety
Cause
Physical
conditions
Grief
Personality
disorders
Major depression
The mental health continuum for schizophrenia
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Epidemiology
• 95% of sufferers – lasts a lifetime
• 1/3 of homeless suffer from Schizo
• 15% no respond to med;
75% partial effective
• 20-50% attempt suicide
10% kill themselves
• 20% shorter life expectancy
• 25% experience secondary depression
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Causes of Schizophrenia
• Genetic factors
• Chemical imbalance & physical
abnormalities – neurotransmitters, brain
structures
• Biological factors – age, virus, …
• Environmental factors – chr. Life stressors,
changes, …
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Causes - genetic influences
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Identical twin affected
Fraternal twin affected
Both parent affected
One parent affected
Brother or sister affected
No affected relative
50%
15%
35%
15%
10%
1%
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Signs & symptoms
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Alterations in personal relationships
Alternations of activity
Altered perception
Alterations of thought
Distorted thinking
Altered consciousness
Alterations of affect
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Bleular's 4 A's
Autism - preoccupation with the self with
little concern for external reality
Associative looseness - the stringing
together of unrelated topics
Ambivalence - simultaneous opposite
feelings
Affective disturbance - inappropriate,
blunted, or flattened affect
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Positive Symptoms
- recognizable
• Positive (type I) symptoms; delusion (fixed
false beliefs), hallucination (false
perception)
• Excess dopamine in the limbic system ->
embellishments of normal cognition and
perception
• Responsive to antipsychotics
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Negative Symptoms
- what is missing
• Lack of affect or energy
• Attribute to cortical dysfunction ie atrophy,
decreased cerebral blood flow, increased
ventricular brain ratios, and a hypodopaminergic
state.
• Overactive glutamate in the prefrontal cortex
stimulates dopamine receptors in the limbic area
• Secondary to medications, hospitalization, loss of
social support, and economic decline…
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Diagnostic criteria
• S & S - At least 2 of the following:
delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic
behavior, negative symptoms
• Social/occupational dysfunction
• Duration - continuous signs of the
disturbance for at least 6 months
• Not caused by substance abuse or a general
medical disorder
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Prodromal symptoms
• A month or a year before the onset
• Deterioration in previous functioning,
withdrawn from others, lonely, depressed
• Vague plan for the future
• Neurotic symptoms ie. Ac /chr anxiety,
phobia, difficulty in concentration,
misinterpretation,
• Feelings of rejection, lack of self-respect,
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Subjective Signs
• Reported by the client
• Altered perceptions, thought processes &
content, consciousness, and affect
• May induce the pt to seek psychiatric help
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Alterations in thinking
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Thought broadcasting
Thought insertion
Thought withdrawal
Delusions of being controlled
Delusion of persecution, grandeur,
Ideas of reference, somatic delusions,
Associative looseness; neologisms; concrete
thinking; echolalia; clang association; word salad
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Alternations in
Perception, behavior
• Hallucinations – auditory, visual, olfactory,
gustatory, tactile
• Bizarre behavior – extreme motor agitation,
stereotyped behavior, automatic obedience,
waxy flexibility, stupor, negativism
• Agitated behavior – poor impulse control
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Objective Signs
• Observed directly by nurse
• Altered relationships, hygiene, social skills,
communication, and psychomotor activity
• Frighten others may lead to involuntary
psychiatric intervention
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Subtypes of schizophrenia
• Paranoid - preoccupied with one or more
delusion
• Disorganized - disorganized speech,
behavior; poor attention; inappropriate
affect
• Catatonic - waxy flexibility or purposeless
excessive motor activity, mutism, stupor
• Undifferentiated • Residual - negative symptoms.
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Other psychotic disorders
• Schizoaffective disorder – Scho symptoms
are dominant + major manic or depressive
symptoms
• Delusional disorder – delusions have basis
in reality, but no schizo
• Brief psychotic disorder – psychosis lasts
less than 1 M
• Schizophreniform disorder – 6M < - > 1M
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Nursing diagnoses
• Altered nutrition: less than body requirements
• Risk for violence directed at self or others
• Self-care deficit: feeding, bathing, dressing/
grooming, toileting
• Noncompliance with medications
• Ineffective individual/ family coping
• Self-esteem disturbance
• Altered thought processes
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Psychotherapeutic management
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Provide supportive care
Strengthen patient’s self-esteem
Treat patients as adults
Prevent failure/ embarrassment
Respect individuality - unique
Reinforce reality
Handle hostility calmly & matter-of-factly
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Issues related to Schizophrenia
• Family ⇔ the patient
communication, overprotection, blaming
• Non-compliance with medical regimen
• Caregiver’s needs - cope with strange and
frightening behaviors ie. apathy, poor
personal hygiene, violence
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Issues related to Schizophrenia
(II)
• Depression - part of the symptoms, be
masked during acute stage
• Relapse - stressors, noncompliance
• Stress & coping • Substance abuse -30% have dual Dx., cause
(-) effect on the treatment & poor outcomes
• Work - no work, inability, no motivation
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Depression and Suicide in Schizo
• Depression is a natural part of schizo
• Depression can be masked especially during
the acute phase
• Depression is a reaction to schizo
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Delusion & Nursing Intervention
• presenting reality, orient pts to time, person
& place
• avoid argument, touch, competitive
activities,
• reinforce positive behaviors
• encourage verbalization
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Disruptive Behavior
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Set limit
decrease environmental stimuli
intervention before acting out
close observation
safety environment - minimize potential
weapons
• making contract with the client
• using restraints
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Withdrawn Patients
• arrange nonthreatening activities
• encourage participation - seating
• provide remotivation and resocialization
group experience
• reinforce appropriate grooming and hygiene
• provide psychosocial rehabilitation - social
skill training, ...
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Suspicious Patients
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Be matter-of-fact; (ie DST for depression)
avoid close physical contact - no touch
be consistent in activities
offer special food
avoid whisper
Maintain eye contact
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Hyperactivity Patients
• Allow pt to stand for a few min in group
• Provide a safe environment
• Provide activities that do not require fine
motor skills
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Immobility Patients
• Minimize circulatory problem
• Provide adequate diet, exercise, and rest
• Prevent victimization
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Nursing interventions
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Medication compliance- 40-60% noncompliance
Avoid reinforcing hallucinations & delusion
Maintain orientation
Use touch minimally and judiciously
Avoid easily misinterpreted behavior
Reinforce positive behaviors
Avoid competitive activities,
Allow & encourage expression of feelings
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Nursing interventionsMilieu management
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clear & realistic limits; consistency;
Supportive environment – structured, predictable
reduced stimulation
early intervention for escalating behavior
safety for the pt and others
opportunity for nonthreatening social interaction
remotivating and resocializing group
Communication skills
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Nursing interventions –
Family therapy
• Involve the family – use appropriate
community resources
• Educate the family – chr. dis, S/S of relapse,
med compliance,
• Provide an outlet for the family – discuss
feelings, explore alternative effective
coping skills.
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Psychotherapy
• Individual Th – supportive therapy
• Group Th – interpersonal skills, family
problems, community support
• Family Th – expand social network,
problem-solving capacity, lower the
emotional overinvolvement of families
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Case Management
• Limited hospital stay, 3rd party payment
• Discharge planning – transitional care
• Partial hospitalization, halfway houses, day
treatment programs
• Community resources – NAMI,
Schizophrenics Anonymous, …
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Schizophrenia & violence
• Myth - tends to be violent – perhaps
perpetuated by the media
• Fact- more likely to be victims than
perpetrators of violence
• Violence in this population may be r/t
homicidal delusion
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Schizophrenia and comorbidities
• Hypertension, obesity, and diabetes -> death
from cardiac disease is higher than in the
• Atypical medications create weight gain,
worsening cholesterol and triglycerides
levels and diabetes
• Tobacco use, smoking -> heart disease
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The Negative Impact of Severe
Mental Illness
• Impairment – hallucination, depression
• Dysfunction – lack of work adjustment
skills, social skills, or ADL skills
• Disability – unemployment, homelessness
• Disadvantage – discrimination, poverty
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Nurse’s feelings & self-assessment
• Pt’s anxiety, loneliness, dependence, distrust
-> N’s uncomfort
• Feelings of helplessness -> anxiety ->
defensive behaviors ie denial, withdrawal,
avoidance -> burnout
• Peer group supervision can be helpful
• Periodic reassessment of Tx goals,
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Family/care taker education
• Teaching about the disease –S/S
• Medication teaching and side-effect
management
• Cognitive & social skills enhancement
• Identifying signs of relapse
• Attention to deficit in self-care, social and
work functioning
• Exploration of community resources
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Signs of Potential Relapse
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Feeling of tension
Difficulty concentrating
Trouble sleeping
Increased withdrawal
Increased bizarre/ magic thinking
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Schizophrenia - overview
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Diagnosis - criteria
Prevalence - age and gender
Course of illness - phases, warning signs
Medication management - side effect,
coping
• Psychosocial rehabilitation - ind, gr, fam…
• Community resources
• Stress management
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Review of antipsychotics
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Typical & atypical med/ type I & II S/S
Clozaril – arrhythmia, agranurocytosis
Anticholinergic drugs -> memory impaired
High-potency -> EPSEs, NMS
Low-potency drugs -> anticholinergic symptoms
Half-life of the medication – safety, elderly
Reduced rate of relapse (about 2.5 times less)
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Care of Hallucinations & Delusions
• Hallucinations
– Content of hallucination – commanding H
-> suicidal or homicidal
– N’s attitude – nonjudgmental, nonthreatening
– Eye contact, louder voice, call the person by
name
• Delusion
– Be empathic - Clarify the reality of the pt’s
intent
– Clarify misinterpretations of the environment
– No argument
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Great wall, China
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