Colegio de Sta. Lourdes of Leyte Foundation, Inc.

College of Nursing
Tabontabon, Leyte

SCHIZOPHRENIA
we will cover the ff:
 What is schizophrenia?
 Epidemiology
 Cause/s
 Criteria for diagnosis
 Types of Schizophrenia
 Prognosis
 Symptoms of schizophrenia (+) (-)
 Types of schizophrenia
 Treatment (psychopharma and psychosocial tx)
 Therapeutic communication for schizophrenic
 Management ( utilizing the nursing process)
 Future Direction in the treatment of schizophrenia

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 Schizophrenia

- A disorder characterized by
disturbance in thought, sensory
perception, grossly disorganized
behavior , and deterioration in
psychosocial functioning.

Main problem:
Altered thought process.
Epidemiology
 1% of population world wide
 Males and females equally
affected but females have later
onset and better functional
outcome
 Onset in late adolescence, early
adulthood
CAUSES
Genetics
 Highly heritable
 Risk increases with relationship
e.g. 10% for first degree relative or
fraternal twin, 50% concordance
for monozygotic twin
Genetic Risk
Obstetric Complications
 Stress and reduction in brain oxygen during:
 pregnancy
 labor & delivery
 Evidence from animal models:
 Fetal hypoxia leads to neuropathology similar to
one observed in schizophrenia:
 Enlarged ventricles (reduced brain weight)

 Most predictive for those without genetic influence

PSYCHOLOGIC or EXPERIENTIAL
THEORY
 Double bind communication
- 2 messages that contradict each
other is sent causing the child to
be confused

 Poor mother and child relationship

Environmental or
Sociocultural THeory
 Single parent
 Low socio economic status
Most Acceptable Theory
on the Cause of
Schizophrenia:
 Biologic Theory – schizophrenia is
due to the increased dopamine.
DOPAMINE

Function:

For motor movements, sensory integration,

and emotional behaviors .

•Increased = schizophrenia and mania

•Decreased = parkinson’s disease and depression

Alterations in dopamine
neurotransmission
 The classical dopamine hypothesis
(too much dopamine in
schizophrenia) rested on the
observation that dopamine
releasing drugs can cause
psychosis, and the discovery that
antipsychotics were dopamine
antagonists.
Diagnosis
 Currently there is no physical or
lab test that can absolutely
diagnose schizophrenia.

 A psychiatrist usually comes to the

diagnosis based on clinical
symptoms.
Types of Schizophrenia:

1. Schizophrenia, paranoid type – characterized by

persecurity or grandiose delusions, hallucinations,
and occasionally excessive religiosity or hostile or
aggressive behavior.

2. Schizophrenia, disorganized type – characterized by

grossly inappropriate or flat affect, incoherence,
loose associations, & extremely disorganized
behavior.
3. Schizophrenia, catatonic type – characterized by
marked psychomotor disturbance either motionless
or excessive motor activity. Motor immobility may be
manifested by catalepsy or stupor. Excessive motor
activity is apparently purposeless and is not
influenced by external stimuli. Other features include
extreme negativism, mutism, peculiarities of
voluntary movement, echolalia, and echpraxia.

4. Schizophrenia, undifferentiated type – characterized

by mixed schizophrenic symptoms along with
disturbances of thought, affect, and behavior.
5. Schizophrenia, residual type – characterized by at
least one previous, though not a current, episode;
social withdrawal; flat affect; and looseness of
associations.
Types:

CATATONIC DISORGANIZED PARANOID

Onset Acute Insidious Abrupt
Distinguishing Abnormal Bizarre behavior Suspiciousness
feature motor ideas of
behavior reference
Defense Repression Regression Projection
mechanism
Priority Impaired Impaired social Potential for
nursing motor functioning injury directed
diagnosis activity at others
Prognosis Good Poor Good
Other Types:

Undifferentiated – Patients whose manifestations

cannot be easily fitted into one or the other types.
Residual – Patient with minimal symptoms

Prognosis:
Favorable Prognosis Unfavorable Prognosis
1. Good socialization. 1. Poor/no socialization.
2. Late/acute onset 2. Early & insidious prognosis
3. Adequate support system. 3. Few/no support system
4. Family history of mood 4. History of chronicity/ many
disorder. relapses.
 Fundamental Signs and Symptoms
(Bleuler’s 4 A’s of Schizophrenia)

1. Associative looseness
2. Autistic thinking
3. Ambivalence
4. Affect
 Two Major Categories of Signs & Symptoms:
Positive/Hard Symptoms: Negative/Soft Symptoms:

1. Delusions 1. Flat affect

2. Hallucinations 2. Lack of volition

3. Grossly disorganized 3. Social withdrawal or

thinking, speech, & discomfort
behavior 4. Flat affect
4. Ambivalence 5. Alogia
5. Associative looseness 6. Anhedonia
6. Echopraxia 7. Apathy
7. Perseveration 8. Blunt affect
Positive Symptoms
 Those that appear to reflect an
excess or distortion of normal
functions.
FYI: Positive Symptoms
 Positive symptoms are those that
have a positive reaction from some
treatment.

 In other words, positive symptoms

respond to treatment.
Negative Symptoms
 Those that appear to reflect a
diminution or loss of normal
functions.

 May be difficult to evaluate

because they are not as grossly
abnormal as positive symptoms.
Examples of Avolition
 No longer interested in going out
with friends
 No longer interested in activities
that the person used to show
enthusiasm
 No longer interested in anything
 Sitting in the house for hours or
days doing nothing
FYI: Negative Symptoms
 Currently there is no treatment that has a consistent
impact on negative symptoms.
 Although atypical neuroleptics is considered to
lessen negative signs ( like lack of volition and
motivation, social withdrawal)
General Signs & Symptoms:
S -ocial isolation
C-atatonic behavior
H-allucination
I -ncoherence or marked looseness of association
Z-ero/lack of interest, energy & initiative
O -bvious failure to attain expected levels of development
P -eculiar behavior
H-ygiene & grooming are impaired
R-ecurrent illusions & unusual perceptual experiences
E-xacerbation & remissions are common
N-o organic factor accounts for the signs and symptoms
I-nability to return to baseline functioning after each relapse
A-ffect is inappropriate
 ATYPICAL
ANTIPSYCHOTICS

• Clozapine (Clozaril)

• Risperidone (Risperdol) Geodon, Clozapine, Risperidone,

Seroquel, Zyprexa.
• Olanzapine (Zyprexa) [Remember: A giraffe can
really see a zebra]
• Quetiapine (Seroquel)

• Ziprasidone (Geodon)
TREATMENT:
Psychopharmacology:
Antipsychotic drugs / neuroleptics
Conventional / Typical
• Chlorpromazine (Thorazine)
• Trifluoperazine (Trilafon)
• Fluphenazine (Prolixin)
• Thioridazine (Mellaril)
• Mesoridazine (Serentil)
• Thiothixene (Navane)
• Haloperidol (Haldol)
• Loxapine (Loxitane)
• Molindone (Moban)
• Perphenazine (Etrafon)
• Trifluoperazine (Stelazine)
- Mechanism of action:
> Block receptors for the neurotransmitter dopamine.
- Side Effects:
A. Extrapyramidal Side Effects (EPS)
a. Dystonia -torticollis, oculogyric crisis, protrusion
of the tongue
Txt: Diphenhydramine (Benadryl), Benztropin
(Cogentin)
b. Pseudoparkinsonism – shuffling gait, masklike face,
drooling, muscle stiffness, akinesia
Txt:
Benztropin(Cogentin),Trihexyphenidyl(Artane),Biperid
en (Akineton), Amantadine (Symmetrel),
Diphenhydramine (Benadryl), Diazepam (Valium),
Lorazepam (Ativan), Propanolol (Inderal)

c. Akathisia – restless movement, inability to remain still

Txt: Betablockers - Propanolol( Inderal)

B. Neuroleptic Malignant Syndrome (NMS)

- Rigidity, high fever, autonomic instability,
delirium, confusion.
C. Tardive Dyskinesia – characterized by abnormal,
involuntary movements such as lip smacking, tongue
protrusion, chewing, blinking, grimacing, choreiform
movements, of the limbs and feet.
D. Seizures
E. Agranulocytosis – characterized by fever, malaise,
ulcerative sore throat, leukopenia.
CLIENT TEACHING AND MEDICATION MANAGEMENT:

ANTIPSYCHOTICS

• Drink sugar free fluids and eat sugar-free hard candy to ease the
anticholinergic effects of dry mouth.
• Avoid calorie-laden beverages and candy because they promote
dental caries, contribute to weight gain, and
do little to relieve dry mouth.
• Constipation can be prevented or relieved by increasing intake
of water and bulk-forming foods in the diet
and by exercising.
• Stool softeners are permissible, but laxatives should be avoided.
• Use sunscreen to prevent burning. Avoid long periods of time in
the sun, and wear protective clothing. Photosensitivity
can cause you to burn easily.
• Rising slowly from a lying or sitting position will prevent falls
from orthostatic hypotension or dizziness due to
a drop in blood pressure. Wait until any dizziness has subsided
before you walk.
• Monitor the amount of sleepiness or drowsiness you experience.
Avoid driving a car or performing other
potentially dangerous activities until your response time and
reflexes seem normal.
• If you forget a dose of antipsychotic medication, take it if the
dose is only 3 to 4 hours late. If the missed dose
is more than 4 hours late or the next dose is due, omit the forgotten
dose.
• If you have difficulty remembering your medication, use a chart
to record doses when taken, or use a pill box
labeled with dosage times and/or days of the week to help you
remember when to take medication.
•The most common side effect for
all antipsychotics is drowsiness
•Many of the antipsychotics block the
chemoreceptor trigger zone and vomiting
(emetic) center in the brain producing an
antiemetic effect.

•Due to blocking dopamine, extrapyramidal

reactions or symptoms of Parkinsonism, such as
tremors, mask like face, rigidity and shuffling
gait may occur.
•Other extrapyramidal reactions include acute dystonia
(facial grimacing, abnormal or involuntary eye movement),
akathisia (restlessness, constant moving about), and
tardive dyskinesia (protrusion of tongue, chewing motion,
involuntary movement of the body and extremities).

•Tardive dyskinesia is a later phase of extrapyramidal

reaction to antipsychotic drugs.
•The drug is used to control psychosis and decrease
signs of agitation in adults a well as in children.

•Haloperidol has anticholineric activity; thus care

should be taken in administering it to clients with
history of glaucoma.

•Most antiparkinsonism anticholinergics are not

always effective for tardive dyskinesia

•Haloperidol alters the effects of dopamine by

blocking the dopamine receptors; thus sedation and
EPS may occur.
Medications
 In general it may take up to 6
months for medications to show
consistent effects.

 Meds include atypicals

Psychosocial Treatment:
1. Individual & group therapy.
2. Family therapy
3. Family education
4. Social skills training
a. Basic model – breaking complex social behavior into
simpler steps.
b. Social problem-solving model – focus on improving
impairments in the information processing that are
processed to cause deficits in social skills.
c. Cognitive remedial model – focus on improving
cognitive impairments.
 Basic Intervention Strategies for Developing a
Therapeutic Nurse-Patient Relationship:
1. Do not reinforce hallucinations or delusions.
2. Orient patients to time, person, and place if indicated.
3. Do not touch patients without warning them.
4. Avoid whispering or laughing when patients are unable to
hear all of a conversation.
5. Reinforce positive behaviors.
6. Avoid competitive activities with some patients.
7. Do not embarrass patients.
8. For withdrawn patients, start with one-to-one interactions.
9. Allow to encourage verbalization of feelings.
 Early detection and treatment has
the best results/response to
treatment.

 Per patients, once you have

schizophrenia you have it for life.
The best you can hope for is
control.
Nursing Management of Schizophrenia
ASSESSMENT
1.  Assessing mood and
cognitive state:
The nurse is alert for the ff signs and symptoms :
 Absence of expression of feelings

 Language content that is difficult to follow

 Pronounced paucity of speech and thoughts

 Preoccupation with odd ideas

 Ideas of reference

 Expression of feelings of unreality

 Evidence of hallucinations such as comments

that the way they things appear, sound, or

smell is different
2.       Assessing potential
for violence:
The nurse assess the potential for violence by
inquiring about the following:
 History of violent or suicidal behavior
 Extreme social isolation
 Feeling of persecution or being controlled by
others.
 Auditory hallucinations that tells the client to
commit violent acts.
 Concomitant substance use.
 Medication noncompliance
 Feelings of anger, suspiciousness, or hostility.
4.       Assessing
knowledge


The nurse assess the client's and
families knowledge of schizophrenia,
its treatment, and the potential for
relapse. Adherence to medication
regimens and other therapeutic
schedules is bolstered when clients
and families understand the biologic
basis of the illness, signs of recovery
and relapse, and their role in treatment.
3.       Assessing social
support:

 Availability and responsiveness of

a social support network and the
client's role in the family and
community are important factors in
nursing assessment
NURSING DIAGNOSIS:
1. Disturbed thought process related
to biochemical imbalances, as
evidenced by hyper vigilance,
distractibility, poor concentration,
disordered thought sequencing,
inappropriate responses, and
thinking not based in reality.
2. Disturbed sensory
perception( auditory/visual) related
to biochemical imbalances, as
evidencd by auditory or visual
hallucinations.
3. Risk for other- directed or self
directed violence related to
delusional thoughts and
hallucinatory commands, history of
childhood abuse, or panic,as
evidencedby overt aggressive acts,
threatening stances, pacing, or
suicidal ideation or plan.
 4. Social isolation related to
alterations in mental status and an
ability to engage in satisfying
personal relationships, as evidenced
by flat affect, absence of supportive
significant others, withdrawal,
uncommunicativeness and inability
to meet the expectations of others.
 5. Noncompliance with medication
regimen related to health beliefs
and lack of motivation, as
evidenced by failure to adhere to
medication schedule.
 6. Ineffective coping related to disturbed
thought process as evidenced by inability
to meet basic needs.
 7. Interrupted family process related to
shift in health status of a family member
and situational crisis, as evidenced by
changes in the family's goals, plans, and
activities and changes in family pattern
and rituals. 7. Interrupted family process
related to shift in health status of a family
member and situational crisis, as
evidenced by changes in the family's
goals, plans, and activities and changes
in family pattern and rituals.
 8. Risk for ineffective family
management of therapeutic
regimen related to knowledge
deficit and complexity of client,s
healthcare needs.
Nursing Interventions
Disturbed Thought Processes

 Convey acceptance of client's

need for false belief but that you do
not share the belief
 Do not argue or deny the belief
 Reinforce and focus on reality   
 If client is suspicious
  Consistent staff
 Honest, keep all promises
Disturbed Sensory
Perception Auditory/Visual
 Observe for signs of hallucinations
 Avoid touching client without warning
 Do not reinforce the hallucination - let the
client know that you do not share the
perception - "Even though I know the
voices are real to you, I do not hear
them"
 Help client understand connection
between anxiety and hallucinations
 Try to distract
Social Isolation

 Convey accepting attitude by

making brief, frequent contacts.
Show unconditional positive regard
 Offer to be with client during group
activities that he/she finds
frightening
 Give recognition and positive
reinforcement for client voluntary
interactions with others
Self Care Deficit

 Provide assistance as appropriate

 Encourage independence -
positive reinforcement
 concrete communications
Impaired verbal
communication

 Seek validation and clarification

 Consistent staff
 Verbalizing the implied
 Orient to reality
Future Directions in the
Treatment of Schizophrenia
 More optimistic view of outcome
 Much stronger focus on early
intervention and prevention e.g. early
psychosis clinics and prodromal studies
 Specific treatments for cognition in
schizophrenia
 As molecular pathways associated with
neural phenotypes become understood
new, non dopamine based therapies
 Renewed emphasis on rehabilitation,
supported employment etc.
Related Disorders:

1. Schizophreniform disorder
The client exhibits the symptoms of schizophrenia
but for less than the 6 months necessary to meet
the diagnostic criteria for schizophrenia. Social or
occupational functioning may or may not be
impaired.
2. Schizoaffective disorder
The client exhibits the symptoms of psychosis and
at the same time, all the features of a mood
disorder, either depression or mania.
3. Delusional disorder
The client has one or more nonbizarre delusions –
that is, the focus of the delusion is believable.
Psychosocial functioning is not markedly impaired,
& behavior is not obviously odd or bizarre.
4. Brief Psychotic Disorder
The client experiences the sudden onset of at
least one psychotic symptom, such as delusions,
hallucinations, or disorganized speech or
behavior, which lasts from 1 day to 1 month. The
episode may or may not have an identifiable
stressor or may follow childbirth.
5. Shared psychotic disorder (folie à deux)
Two people share a similar delusion. The peron
with this diagnosis develops this delusion in the
context of a close relationship with someone who
has psychotic delusions.
Situation: Manny Kin is a 23-year-old graduate
student who has just been admitted to the unit with
behaviors of withdrawal, flat affect, disregard of
hygiene & grooming, and associative looseness.
His diagnosis is paranoid schizophrenia.
1. Which of the following is not characteristic of the
patient with paranoid schizophrenia?
a. Delusions
b. Hallucinations
c. Decreased sensitivity
d. Ideas of reference
2. Which defense mechanism is most characteristic
of the patient with paranoid schizophrenia?
a. Undoing
b. Projection
c. Rationalization
d. Suppresion
3. Thiodazine (Mellaril), an antipsychotic, is usually
effective in treating all but one of the following
symptoms of schizophrenia. Which symptom will
not be affected by this drug?
a. Agitation
b. Hallucinations
c. Delusions
d. Ambivalence
[Link] nurse is caring for a patient with disorganized
schizophrenia. The patient is responding well to therapy
but has had limited social contact with others. Which of the
following interventions is most appropriate?
a. Discourage the patient from interacting with others
because if his efforts fail it will be too traumatic to him.
b. Encourage the patient to attend a party thrown for the
residents of the facility.
c. Encourage the patient to participate in one-on-one
interactions.
d. Encourage the patient to place a personal
advertisement in the local newspaper but not reveal his
main disability.
5. A 23-year-old female has been admitted to the
inpatient psychiatric unit with diagnosis of catatonic
schizophrenia. She appears weak & pale. The
nurse would expect to observe which behavior in
this patient?
a. Scratching cat-like motions of the extremities.
b. Exaggerated suspiciousness, excessive food
intake.
c. Stuporous withdrawal, hallucinations &
delusions.
d. Sexual preoccupation, word salad.
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