Schizophrenia
Prepared by \ Mofida Al - barrak
Under supervision Prof. Dr.
Elham Fayad
AL-barrak 1430
1
At the end of this lecture the students will be
able to:
1. Explain the meaning of schizophrenia
2. Discuss symptoms of schizophrenia
3. Differentiate and contrast between
etiological factors related to schizophrenia
4. Determine schizophrenia subtypes
5. Assess client with schizophrenia
6. Develop a nursing care plan for a client
with schizophrenia
AL-barrak 1430
2






Definition
Etiological factors related to schizophrenia
Symptoms of schizophrenia
Subtypes of schizophrenia
Assess client with schizophrenia
Develop a nursing care plan for a client with
schizophrenia
AL-barrak 1430
3





Neurotic
Environment
Psychotic
Delusion &
hallucination
Personality disorder
Raring
Cognitive implement
(dementia & delirium)
Substance related disorder
AL-barrak 1430
4
Neurotic
Psychotic
Environment
Delusion & hallucination
Insight
Can stop Medication
Lack insight
Can not stop medication
e.g. anxiety & stress
e.g. schizophrenia
Clinical
Need hospitalization
AL-barrak 1430
5



Schizophrenia is a condition that exists in all
cultures and in all socioeconomic group .
It is estimated that 1% of the general
population suffer from schizophrenia .
people with schizophrenia occupy
approximately 50% of the hospital beds for
the mentally ill .
AL-barrak 1430
6


Schizophrenia is a major psychotic disorder
marked by a profound withdrawal from
interpersonal relationship and cognitive and
perceptual disturbances that make dealing
with reality difficult.
It is characterized by splitting of normal
links between perception, mood, thinking
,behavior and contact with reality .
AL-barrak 1430
7
Schizophrenia is a group of psychotic disorders
that interfere with thinking and responsiveness.
It is a disease of the brain.
The term schizophrenia, which means "split
mind," was first used in 1911 by Swiss
psychiatrist Eugen Bleuler to categorize patients
whose thought processes and emotional
responses seemed disconnected.
AL-barrak 1430
8
Three component are integrated in the normal person
Thought
process
Behavior
Affect
AL-barrak 1430
9
Cognition
Behavior
Affect
AL-barrak 1430
10
Associations
Autistic
thinking
4 As
Apathy
Ambivalence
AL-barrak 1430
11
1. Autistic thinking
Start with fantasy & day dream ending by delusion &
hallucination
2. Associative looseness
Illogically connected things.
3. Ambivalence
holding 2 different emotion to the same person at
the same time.
4. Apathy
Absent of emotional experience & expression
AL-barrak 1430
12




Normal perceptual & thought process
Personality
Affect
Withdrawal
AL-barrak 1430
13
3rd highest for years of life with a
disability (YLD) among neuropsychiatric
conditions
1. Unipolar major depression
7.
Parkinson’s disease
2. Bipolar disorder
8.
Multiple sclerosis
3. Schizophrenia
9.
Drug use
4. Epilepsy
5. Alcoholism
6. Dementia
10.
PTSD
11.
OCD
12.
Panic disorder
AL-barrak 1430
14
AL-barrak 1430
15
Figure 13.2 The natural history of schizophrenia: a 5-year follow-up. Copyright 1989
by Cambridge University Press. Reprinted with the permission of Cambridge
University Press.
1. Biologic Factors
2. Environmental factors
3.Psychological factors
4. Family theory
AL-barrak 1430
17
a. Role of Neurotransmitters
 Neurotransmitters:
Common impaired neurotransmitters are
acetylcholine , dopamine, norepinephrine,
serotonin & Gamma Aminobutyric Acid
(GABA).
AL-barrak 1430
18
AL-barrak 1430
19
AL-barrak 1430
20
1- Biological factors
AL-barrak 1430
21
Structure (neuro anatomical studies

Brain scans using magnetic resonance imaging
(MRI) have shown a number of abnormalities in
the brain's structure associated with
schizophrenia. Such problems can cause nerve
damage and disconnections in the pathways
that carry brain chemicals. Structure (neuro
anatomical studies.
AL-barrak 1430
22

Dilatation of the left ventricular
AL-barrak 1430
23
Figure 13.6 Some ways drugs affect neurotransmission.
Figure 13.7 Location of the cerebrospinal fluid in the human brain. This extracellular
fluid surrounds and cushions the brain and spinal cord. It also fills the four
interconnected cavities (cerebral ventricles) within the brain and the central canal of
the spinal cord.
AL-barrak 1430
26
AL-barrak 1430
27
 The risk for inheriting schizophrenia is 10 % in
those who have one immediate family member
with the disease
 About 40% if the disease affects both parents and
an identical twin.
 About 60% of people with schizophrenia have no
close relatives with the illness.
AL-barrak 1430
28
Figure 13.4 Risk for schizophrenia among children of twins.
AL-barrak 1430
30
AL-barrak 1430
31
AL-barrak 1430
32
AL-barrak 1430
33
AL-barrak 1430
34
a. Infectious

The viruses as a cause of schizophrenia such as
living in crowded conditions.
b. Seasonal factors
 The risk for schizophrenia worldwide is 5 – 8 %
higher for those born during winter and spring,
when colds and viruses are more prevalent.
 Pregnant Mother's Exposure to Viruses.
The mother's exposure to viral infections such as
rubella, measles, chicken pox,& toxoplasmosis

AL-barrak 1430
35
AL-barrak 1430
36
AL-barrak 1430
37
psychoanalysis theory
Erickson
Cognitive theory
Behaviorism
AL-barrak 1430
38
a- Psychoanalytic and developmental theories :
Psychoanalytic theory states that there are
distortions in the mother-child relationship, so
that the child is unable to progress beyond
dependence.
AL-barrak 1430
39


Children learn what they are exposed to on a
daily basis.
According to learning theory, the irrational
ways of handling situations, the distorted
thinking, and the deficient communication
patterns of persons with schizophrenia are a
result of poor parental models in early
childhood .
AL-barrak 1430
40
1. Double bind
e.g. I love my san I leave him (say thighs do
opposite)
2. Scapegoat
e.g. Put all the problem to one person in my
family
3. Eschewed family
e.g. Father stay in the house & mother are
working (opposite role)
4. Schismatic family
e.g. Father & mother all the time have (conflict)
AL-barrak 1430
41



List the causes of Schizophrenia
Explain Eugen Bleuler – Introduced the term
“schizophrenia” or “splitting of the mind”;
the 4 As:
Discuss Family theory
AL-barrak 1430
42


Schizophrenia affects different people in
different ways. Not everybody will experience
the same symptoms, nor are they always to the
same degree.
Two types of symptoms are distinguished in
schizophrenia – they are classified as positive
and negative symptoms.
AL-barrak 1430
43
Delusions:
 Persecution – “chased by other”
 Reference – “talking about me”
 Influence- “controlled by others or
agencies”
 Grandeur – “important person”
a.
AL-barrak 1430
44
b. Hallucinations can occur in any of the five senses but the
most common are auditory.
For example, the person may hear voices repeating their
thoughts, in conflict, commenting on their actions telling
them what to do (command hallucinations).


Hallucinations of any form occur in over 70 per cent of people
who experience psychotic illnesses.
Auditory hallucinations occur in approximately 50 per cent of
people with schizophrenia, while visual hallucinations occur
in 15 per cent.
AL-barrak 1430
45

Disorganized Thinking
This is usually expressed through abnormal spoken
language.
For example, the person's conversation jumps from
one topic to another, new words may be created,
the grammatical structure of language breaks down
and speech may greatly speed up or slow down.

Disorganised Behaviour
Disorganised behaviour can lead to problems in
conducting the activities of daily living such as
organizing meals and maintaining hygiene.
AL-barrak 1430
46

Catatonic Behaviour
This refers to states of muscular rigidity and
immobility, stupor and negativism,
The person may hold fixed or bizarre bodily
postures for extended periods of time and
resist any effort to be moved.
AL-barrak 1430
47
Negative symptoms
AL-barrak 1430
48


Withdrawal, Loss of Motivation & Ambivalence
(Avolition)
People experiencing avolition may be
negligent grooming, personal hygiene, have
difficulty making decisions & have difficulty
persisting at work, school or family tasks.
AL-barrak 1430
49
Loss of Feeling or an Inability to Experience
Pleasure (Anhedonia)

Lack of interest in social or recreational
activities ,failure to develop close
relationships.
Poverty of Speech (Alogia)
 The person's amount of speech is greatly
reduced & people showing signs of alogia
may be slow in responding to questions or
not respond at all.
AL-barrak 1430
50
Flat Presentation (Affective Flattening)

This can be indicated by unchanging facial
expressions, poor or no eye contact, reduced
body language and decreased spontaneous
movements.
Cognitive Impairments
cognitive dysfunction is often present in people
with schizophrenia is associated with
cognitive impairments including problems
with attention, concentration and memory.
AL-barrak 1430
51
Paranoid schizophrenia
Disorganized schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Residual schizophrenia
AL-barrak 1430
52
Delusion of
grandeur
Delusion of
influence =
control
Reference
Delusion of
persecution
Delusion of
jealousy
AL-barrak 1430
53
This subtype of schizophrenia is characterized
by Delusions that tend to be persecutory or
Grandiose.
AL-barrak 1430
54
The disorganized type of schizophrenia is
characterized by a severe disintegration of
the personality . It has an dangerous start .
Cognition
Behavior
Affect
AL-barrak 1430
55
 Word
salad
 Incoherent speech
 Clanging association
AL-barrak 1430
56






Odd
Stereotyped behaviors
uninhibited sexual behaviors such as
masturbating in public.
WithdraPoor coordination.
Poor personal grooming
unable to complete activities of daily living
(ADLs).
AL-barrak 1430
57
Major feature, manifestations of psychomotor
disturbance include.
Stupor
There is complete suppression of motor activity
The patient doesn't respond to any stimulus neither
external (question or painful stimulus)or internal
stimuli (hunger, thirst, distended bladder)
0r
 Excitement
Sever form of hyperactivities excessive purposeless
motor activity & the patient may destruct herself or
others

AL-barrak 1430
58
Negativism
Means automatic resistance to all stimuli
(Muscular e.g. tell the pt’s keeping the arm
extended on trying to flex it )opposite
performance
Speech (Mutism)
 Mutism
(Speech total loss)
Automatic obedience
Other symptoms include
 Echopraxia
 Echolalia
 stereotypy

AL-barrak 1430
59
Waxy flexibility
Maintenance of imposed postures e.g. raising
the head of the patient from the pillow, or
the arm up) *absence of fatigue

Catalepsy (Posturing)
Is sustained immobility (patient initiates
position by herself)

AL-barrak 1430
60
AL-barrak 1430
61
Undifferentiated schizophrenia cannot be
classified as paranoid, disorganized, or
catatonic .It does not clearly meet the
criteria necessary for a diagnosis.




The psychotic manifestations are extreme
,including
Fragmented delusions
Vague
Hallucinations
AL-barrak 1430
62








Bizarre
Disorganized behavior
Disorientation
Incoherence
Affect is usually inappropriate
mixture of positive and negative symptoms.
Dress & grooming are careless
Individual seems uninterested with life.
AL-barrak 1430
63
If an individual has had at least one acute
episode of schizophrenia and is now free of
prominent positive symptoms, but has some
negative symptoms he is diagnosed as
suffering from residual schizophrenia .
The usual signs of the illness are
 Illogical thinking,
 Loosening of associations
 Emotional blunting
 Social withdrawal
 Eccentric (bizarre) behavior
AL-barrak 1430

64
AL-barrak 1430
65
1. Schizophrenia is a
a. Disorder of neuroanatomy
b. Groups of disorders involving a disorder of
neurotransmitters
c. Collection of disorders involving brain
function
d. Disorder of brain metabolism
AL-barrak 1430
66
2. Schizophrenia is primarily marked by
a.
b.
c.
d.
Inattention & anger
Violent & impulsive behavior
Thought disturbance such as delusion
Affective disturbance such as dysphasia
AL-barrak 1430
67
3. The three primary negative symptoms of
schizophrenia include
a.
b.
c.
d.
Alogia, hallucinations & delusion
Alogia, affective blunting, & avolition
Affective blunting, delusions & avolition
Hallucinations, delusions, & avolition
AL-barrak 1430
68
4. When assessing a schizophrenic client for
positive symptoms, the nurse should look for
a. Hallucination & delusion .
b. Inability to express thoughts and feelings.
c. Depression.
d. Lack of goal-directed behavior.
AL-barrak 1430
69
5. A client was diagnosed with paranoid
schizophrenia twenty years ago. The client no
longer displays persecutory delusions, but
lacks social and self-care skills and is unable
to work. What subtype of schizophrenia is the
client displaying?
a. Disorganized
b. Paranoid
c. Residual
d. Undifferentiated
AL-barrak 1430
70
Nursing management
Assessment
Nursing diagnosis
Goal
Nursing intervention &
evaluation
AL-barrak 1430
71
Positive
symptoms
Affective
symptoms
Negative
symptoms
Aggressive
symptoms Cognitive
symptoms
AL-barrak 1430
72
Symptoms of schizophrenia
Positive symptoms:
delusions
hallucinations
disorganized speech
catatonia
Cognitive
symptoms:
Social
Work
attenon
memory
executive functions
(eg, abstraction)
Negative
symptoms:
affective flattening
alogia
avolition
anhedonia
Occupational
Interpersonal
Mood symptoms:
Selfcare
dysphoria
suicidality
helplessness
AL-barrak 1430
QOL 2
73
1. Positive Symptoms
Alteration of thought (delusion )
 the common delusion includes:






Paranoid delusion
Ideas of reference
Delusion of grandeur
Delusion of jealousy
Delusion of persecution
Somatic delusion
AL-barrak 1430
74




Thought broadcasting: the belief that one’s
thoughts can be heard by others
Thought insertion, the belief that thoughts of
others are being inserted into one’s mind
Thought withdrawal, the belief that thoughts
have been removed from one’s mind by an
outside agency
Delusion of being control
AL-barrak 1430
75






Lose association: the thought process becomes
illogical & confused.
Neologisms: made up words that have a special
meaning to the delusional person .
Concrete thinking: an overemphasis on small or
specific details & an impaired ability to abstract.
Autistic thinking
Clang associations: the meaningless rhyming of a
word in a forceful way.
Word salad: a mixture of words that is meaningless
to the listener.
AL-barrak 1430
76
1. Alteration Perception
Hallucinations are the major examples of
alterations in perception in schizophrenia,
especially auditory hallucinations,
AL-barrak 1430
77
Auditory hallucination in form of voices may
seem to come from outside or inside the
person’s head.
The voice may be familiar or strange, single
or multiple.
Voices speaking directly to the person or
commenting on the person’s behavior are
most common in schizophrenia.
A person may believe the voices are from.
God ,the devil, dead relatives, or strangers.
AL-barrak 1430
78
Commanding hallucinations
Must be assessed, because the “Voices” may
command the person to hurt himself or
others.
For examples, a client might state “the voices”
are telling him to “ jump out of the window” or
“take a knife & kill my child”.
1.
2. Commenting hallucination
e.g. why does not clean Sarah
AL-barrak 1430
79
What are the characteristic of schizophrenia
Commanding & commenting auditory
AL-barrak 1430
80
Alteration behavior
Bizarre & agitated behavior is associated with
schizophrenia and may take a variety of
forms.
 Stereotyped
 Stupor
 Waxy flexibility
AL-barrak 1430
81







These symptoms are that most interfere with
the individual’s adjustment and ability to
survive.
A volition
Anhedonia
Flat affect
Withdrawal
He couldn't take decisions
Neglect basic hygiene and need help with
everyday activities.
AL-barrak 1430
82
The following is a listing of some of the more
common nursing diagnoses applicable to
schizophrenia.
1.
Altered thought processes.
2. Sensory perceptual alterations.
3. Impaired verbal communication.
4.
Social isolation.
5. Self-care deficit
6. (bathing , hygiene , dressing , grooming ,
feeding , toileting ).
AL-barrak 1430
83
Disturbance thought process related to
delusion & hallucination evidence by or
(observed by) inability to distinguish rational
idea
 Biological factors
 Neurotransmitter increase dopamine
 Genetic
 Disturbance thought process (hallucination &
delusion)
 Thought broad casting
 Thought withdrawal
 Neologism
AL-barrak 1430
84
Absent of psychotic hallucination & delusion
AL-barrak 1430
85
Maintain eye contact
 Assess the client to think logically
 Thought assessment
 Listen
 Do not touch the client specially if have
delusion
 Distraction
from delusion
1. No reasoning
2. Voice doubt
3. Introduce new subject for discussion

AL-barrak 1430
86

Disturbance sensory perception related to
withdrawal as evidence by hallucination
AL-barrak 1430
87
Important note



Types of hallucination in schizophrenia patient’s
command & commented
All the types of schizophrenia start early except
Paranoid state after age 40 years old.
Drugs schizophrenia takes on long live
AL-barrak 1430
88




Able to hold conversation without
hallucinating.
Remains in group activities.
Attends to the task at hand (e.g. group process
, recreational or occupational therapy activity ).
States that hallucinations are under control
AL-barrak 1430
89





All the speech (present from reality )
Call the client by their names to reinforce
reality.
Use clear statements
Protect client’s
Teach client’s techniques to stooped
hallucination
AL-barrak 1430
90
Conclusion
Schizophrenia is a severe mental disorder
characterized by two kinds of symptoms;
Positive symptoms ( thought disorder,
hallucinations & delusions, ) &
Negative symptoms – impairment in
emotional range, energy, and enjoyment
of activities.
For a formal diagnosis, these symptoms
must persist for at least one month and
usually result in severe impairment in job
and/or social functioning
AL-barrak 1430
91

Morrison, J. (1995). The first interview: Revised
for DSM-IV. New York: The Guilford Press.
Kersting, K. (2005). Serious rehabilitation:
Psychologist-developed treatments are
providing hope for people with serious mental
illness. APA Monitor on Psychology, 36 (1), 3841.

AL-barrak 1430
92
McKinney, R., & Fiedler, S. (2004).
Schizophrenia: Some recent advances &
implications for behavioral intervention. the

Behavior Therapist, 6, 122-125.

Nichols, O. T. (2005, November). Headlines
in psychopharmacology. Symposium
presented at the annual meeting of the
Kentucky Psychological Association,
Louisville, KY
AL-barrak 1430
93
AL-barrak 1430
94