1/25/2010

SCHIZOPHRENIA

Comes from Greek words
meaning “split” and “mind”

People with schizophrenia
do NOT have split
personalities

‘split’ refers to loss of
touch with reality

“split mind” refers to the
fact that people with
schizophrenia are split off
from reality and can’t
distinguish what is real
from what is not real

Early writings indicating its
presence go back to the 12
century B.C.

Not a single disorder

A syndrome with multiple
DESCRIPTION
variations and multiple A group of mental disorders characterized by;
etiologies

The label given to a group
Psychotic features (hallucinations and delusions)
of psychoses in which
Disordered thought process
deterioration of functioning
is marked by severe
Disrupted interpersonal relationships
distortion of thought,
Disturbances in affect, mood, behavior, and thought
perception and mood; by
bizarre behavior; and by
processes occur
social withdrawal

Equally frequency, males
have earlier onset

18 to 25 for men

26 to 45 for women

DSM IV Criteria DSM IV Criteria

Schizophrenia : psychosis that are persistently

Schizophrenia disturbing for at least 6 months, with 1 month

Schizophreniform of active-phase symptoms; age onset of late

Schizoaffective adolescence or early adulthood

Delusional Disorder
Schizophreniform : Symptoms of

Brief Psychotic Disorder Schizophrenia with the duration of at least 1

Shared Psychotic Disorder month but less than 6 months and social /
occupational function may not be impaired.

Schizophrenia induced by: Medical conditions;
Medications/ drugs /other substance
Schizoaffective : Symptoms of both
Schizophrenia and a mood disorder lasting
for 1 month

DSM IV Criteria DSM IV Criteria

Delusional Disorder : presence of one or more
nonbizaare delusions that persist for 1 month or
more

Brief Psychotic Disorder : at least one of the
symptoms (hallucinations, delusions,
disorganized speech or behavior disturbance) that
last at least 1 day but less than 1 month; then a
return to the premorbid level of functioning

Shared Psychotic Disorder : a delusional disorder
developed when the person is involved in a close
relationship with an individual who has
delusional psychotic disorder.

Psychotic Disorder due to medical condition or
induced by substance abuse : physiologic effect of
medical condition; occurrences during
intoxication or withdrawal stages but can last for
weeks

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Etiology of Schizophrenia
THEORIES

BIOLOGICAL

BIOCHEMICAL

The etiology and pathogenesis of schizophrenia
DOPAMINE HYPOTHESIS
is not known
Serotonin and glutamate

It is accepted, that the etiology is multifactorial:
NEUROSTRUCTURAL

INCREASED VBR, BRAIN ATROPHY, DECREASED

Biological theories CREBRAL BLOOD FLOW

Biochemical
GENETIC

Genetic
IDENTICAL TWINS, 1ST DEGREE RELATIVES

Perinatal Risks
PERINATAL RISK FACTORS

EXPOSURE TO VIRUS, MINOR MALFORMATIONS,

Neurostructural
COMPLICATIONS DURING LABOR AND PREGANCY,

Psychological theories POVERTY

Social theories

Risk Factor
Genetics

Idea that it is genetic

goes back at least as
far as the 18th century

By the 19th century,
genetic hypothesis
was endorsed by
Kraepelin, Bleuler, and
many other experts on
schizophrenia.

PerinatalRisks
Biochemical:

There are also evidences that perinatal

conditions may be an indicator of the risk of
Dopamine Hypothesis
having schizophrenia.

2nd trimester (4-6 months) – brain development
Overactivity of dopamine neurons in the

Conditions that could result in brain injury are: mesolimbic pathway may cause positive

Maternal starvation; poor nutrition – anemia symptoms.

Obstetric complications
Underactivity of dopamine neurons in the

Fetal hypoxia mesocortical pathway in the prefrontal

Maternal alcohol or drug abuse cortex may cause negative symptoms

Toxin exposure or viral infection – influenza virus

Incidence of birth trauma and injury

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Biochemical: Biochemical:

Serotonin Hypothesis Glutamate Hypothesis

Glutamate functions in the:

Serotonin (5HT)
Relay of sensory information and in the regulation of
mediates dopamine various motor and spinal reflexes
levels
Regulation of N-methyl-D-aspartate (NDMA)

LSD and psilocybin are
potent 5HT receptor Decreased levels of
agonists and cause Glutam ate
positive symptoms of
Shiz. (in people who do
Decreased regulation of
not have schiz.)
NMDA

Atypical antipsychotics
are potent 5HT receptor
antagonists Impaired cognitive
Psychotic sym ptoms
processes

Neurostructural:
Biochemical: Ventricular Brain Ratio
Glutamate Hypothesis

Enlarged ventricles
Clinical Observation
Increased width of 3rd ventricle

PCP (“angel dust”) and ketamine (an anesthetic)
mimic the positive and negative symptoms of
schizophrenia (Javitt & Cole, 2004)

These drugs block the action of a form of
glutamate receptor (NMDA receptor)

NMDA receptor blockade may produce the
dopamine dysfunction seen in schizophrenia, as
if too little dopamine were present in the
prefrontal cortex (negative symptoms) and too
much dopamine in the mesolimbic area (positive
symptoms)

Psychological Theories
Psychoanalytic :
Dysfunctional Mother-Child Relationship
Schizophrenogenic mother
Psychological
Emotionally withholding

Domineering
Theories
Rejecting attitudes

Over-protection
Child grows feeling in conflict with, distrustful of, and
angry towards others
Faulty ego development
Psychoanalytical Psychodynamic
Ego disintegration

Intrapsychic conflict

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Psychoanalytic : Psychoanalytic :
Dysfunctional Parental Interaction Double-bind Type of Communication

Double-bind type of
Dysfunctional parental communication
interaction
Double-bind message

Schismatic Skewed marriage Conflicting messages may be given

marriage simultaneously

Defaults in interpreting meaning

Interference with personality

maturation in the offspring Disorder of cognition and
metacommunication

Social stressors and life events

Social stressors and life events

Coping Mechanisms Used

Stress-Vulnerability Model
Personal Stressors
Vulnerability Environmental Stimulation

Denial and Suppression Family Conflict

Denial – Failure to acknowledge an unbearable Life Events
condition; failure to admit the reality of a
situation or how one enables the problem to
Personal Protectors
continue
Coping Medications Symptoms

Suppression – Conscious acceptable behavior to
make up for or negative unacceptable thoughts
and feelings from conscious awareness
Environmental Protectors Decreased
Problem Solving Social Support social and
Occupational
functioning

ASSESSMENT
ASSESSMENT
Physical Characteristics
Motor Activity

Unkempt appearance
Catatonic posturing: Holding bizaare postures for long

Body Image distortions periods of time

Maybe preoccupied with somatic complaints
Catatonic excitement: Moving excitedly, with no
environmental stimuli present

May neglect hygiene, eating, sleeping, and
elimination
Possible total immobilization

Inability to respond to commands or responding only to
commands

Waxy flexibility

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ASSESSMENT
Motor Activity

Repetitive or stereotyped movements

Motor activity that may be increased as evidenced by
agitation, pacing, inability to sleep, loss of appetite
and weight, and impulsiveness

Possible inability to initiate activity (anergia)
ASSESSMENT
Emotional Characteristics

Mistrust may be present

View of the world as threatening and unsafe

Affect may be blunted, flat, or inappropriate

May display feelings of ambivalence, helplessness,
anxiety, anger, guilt, or depression

ASSESSMENT
Emotional Characteristics

Compulsive rituals: Performed as an attempt to solve
conflicting feelings by constant, repetitive activity

Overcompliance: Attempt to deny responsibility for
any action by doing only what another person
instructs exactly

Affective disturbances (flat, inappropriate, altered
thought process)

ALTERED THOUGHT PROCESS TYPES OF DELUSIONS

Impaired reality testing
Fragmentation of thoughts
DELUSION OF PERSECUTION
Thought blocking
DELUSION OF GRANDEUR
Loose associations
SOMATIC
Echolalia

Loss of reference in which the client believes that
Distorted perception of the environment
certain events, situations, or interactions are related
Neologisms
directly to self
Magical thinking
Inability to conceptualize meaning in words or
thoughts
Inability to organize facts logically
Delusions associated with thought processes or content

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INTERVENTIONS PERCEPTUAL DISTORTIONS

Interact based on reality
Illusions
Encourage the client to express feelings
Hallucinations
Do not dispute the client or try to convince the client
that delusions are false
Initially initiate activities on one-on-one basis
Alter hospital routines as necessary, such as using
canned or packaged food or food from home
Recognize accomplishments and provide possible
feedback for successes

HALLUCINATION INTERVENTIONS
A sense perception (occurs with one of the five senses)
Ask the client directly about the hallucination
for which no external stimuli exist; can have an organic
Avoid reacting to the hallucination as if it were real
or functional cause
Decrease stimuli or move the client to another area
Types
Do not negate the client’s experience

Auditory

Focus on reality based topics

Visual

Gustatory

Olfactory

Tactile

For Active Hallucinations

INTERVENTIONS
Monitor for hallucination cues and assess content

Attempt to engage the client’s attention through a
SAFETY is the First PRIORITY
concrete activity
Ensure that the client does not have an auditory

Respond verbally to anything real that the client talks command telling him or her to harm self or others
about Intervene with one-on-one contact

Avoid touching the client Avoid touching the client

Monitor for signs of increasing anxiety or agitation, Encourage to express feelings
which may indicate that the hallucinations are Provide easy activities and structured environment
increasing with routine ADL
Administer medications as prescribed

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TYPES OF SCHIZOPHRENIA PARANOID

PARANOID
Suspiciousness

DISORGANIZED
Hostility

CATATONIC
Delusions

UNDIFFERENTIATED
Auditory hallucinations

RESIDUAL
Anxiety and anger

Aloofness

Persecutory themes

Violence

DISORGANIZED CATATONIC

Extreme social withdrawal
Psychomotor disturbances

Disorganized speech or behavior
Immobility

Flat or inappropriate affect
Stupor

Silliness unrelated to speech
Waxy flexibility

Stereotyped behaviors
Excessive purposeless motor activity

Grimacing mannerisms
Echolalia

Inability to perform ADL
Automatic obedience

Stereotyped or repetitive behavior

UNDIFFERENTIATED RESIDUAL

Does not meet the criteria for paranoid, disorganized,
Diagnosed as Schizophrenic in the past
or catatonic
Time limited between attacks but may last for many

Delusions and hallucinations years

Disorganized speech
Exhibits social isolation and withdrawal, and impaired

Disorganized or catatonic behavior role functioning

Flat affect

Social withdrawal

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INTERVENTIONS
FOR SCHIZOPHRENIA INTERVENTIONS
Assess the client’s physical needs
MEDICATIONS
Set limits on the client’s behavior
TYPICAL AND ATYPICAL ANTIPSYCHOTICS
Maintain a safe environment
NURSE-PATIENT RELATIONSHIP
Spend time with the client
FOCUS IS ON INTERPERSONAL
Monitor for altered thought process COMMUNICATION, SOCIALIZATION SKILLS,
Set realistic goals INDEPENDENCE AND SURVIVAL SKILLS FOR
Monitor for suicide risk POSTHOSPITALIZATION
Reorient the client as necessary
FAMILY INVOLVEMENT
Provide short, brief, and frequent contact

SUPPORT AND EDUCATION
Provide simple, concrete activities
Assist the client to use alternative means to express
MILIEU THERAPY
feelings through music, art or writing

INTERVENTIONS

MILIEU MANAGEMENT

Disruptive behavior:

Set limits

Decrease environmental stimuli

Observe escalation of aggression

Remove objects potential weapon

Once violation of limits occurs, remind the
patient of the consequences

For restraints, assure the safety of client
INTERVENTIONS

Withdrawn behavior :

Arrange for a non-threatening activities and
socialization

Arrange in semicircle group activities

Provide decision-making activities /
opportunities

Reinforce appropriate grooming and hygiene

Provide remotivation and resocialization

Provide psychosocial rehabilitation

INTERVENTIONS

Impaired communication INTERVENTIONS

Provide opportunities for decision-making

Be patient and do not pressure patients to make

Disorganized
sense

Involve clients to nonthreatening activity

Provide less stimulating and calm

Provide for purposeful psychomotor activities
environment
(painting, ceramic work, exercise)
Provide safe and simple activities

Disordered perception
Provide and use information boards

Provide distracting activities
Protect patient from “embarassing” himself

Monitor television selections
Assist in grooming and hygiene

Monitor hallucinations

Presence and availability of staff for interaction

Present reality

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INTERVENTIONS Summary of Schizophrenia

Altered levels of activity

Hyperactivity

Provide safe environment and place

Activities that does not require fine motor skills
or intense concentration

Immobility

Minimize circulatory problems and loss of muscle
tone

Provide adequate diet, exercise and rest

Maintain bladder and bowel functioning

Protect client from “victimization”

Summary of Etiological Factors Positive Psychotic Symptoms

Etiological Factors Positive Symptoms

Cognitive Disturbances Perceptual Disturbances

Biologic Theories Social Stressors and Psychological Theories (Alterations in Thought and Language)
Life Events
Alteration in Thought Hallucinations Impaired Sensory
Perinatal Risks Alteration in Form of
Genetic Theory Psychodynamic Psychoanalytical Content Thought Filtering
Theories Theories
Auditory
Neurostructural Biochemical
Theories Theories Bizaare Behaviors Delusions

Agitated Repetitive or Loose Associations Flight of Poverty of

Unpredictable Stereotyped Ideas Content
Behavior Behavior
Psychotic Symptoms

Persecutory Grandiose Nihilistic Somatic Ideas of

Religious
Positive Symptoms Negative Symptoms Delusions Delusions Delusions Delusions Reference
Delusions

Negative Psychotic Symptoms Predictors of course and outcome in

schizophrenia
Factor Good Outcome Poor Outcome
Negative Symptoms

Age at onset About 20-

20-25 Below 20
Thought and Language Mood Disturbances Motor Behavior Sex Possibly females Possibly males
Alterations Disturbance
Socioeconomic status High, middle low
Reduced emotional
Increased Poverty of responsiveness Physical Anergia Occupational record stable irregular
Latency of Speech
Other adverse social absent present
Response
Poor Eye Anhedonia Blunted Affect factors
Contact
Avolition Family history of affective schizophrenia
Social Withdrawal
mental illness

Social Isolation

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Predictors of course and outcome in Predictors of course and outcome in

schizophrenia schizophrenia
Factor Good Outcome Poor Outcome Factor Good Poor
Precipitating factors present absent Outcome Outcome
onset Acute, late insidous CT/MRI studies Normal Dilated
morphology ventricles, brain
Rate of progression rapid slow
atrophy
Length of episode prior Months or less years Early treatment present absent
to assessment
with
Initial clinical Catatonia, paranoia, Negative symptoms medications
symptoms depression (e.g flat affect, poverty
schizoaffective of thought, apathy,
Response to present absent
diagnosis, atypical asociality;; obsessive-
asociality obsessive-
symptoms, confusions compulsive symptoms medications
initially

Course of schizophrenia over 10 and 30 Course of schizophrenia over 10 and 30

years

over a 10-year period, 25 % of patients recover
completely, 25% improve greatly and become relatively
independent, 25% improve but require extensive help,
15% remain hospitalized and do not improve, and
finally, 10% die mostly by suicide.
years

over a 30-year period, 25% of patients
recover fully, 35% improve significantly
and reach relative independence, 15%
improve but require extensive support,
10% remain hospitalized and
unimproved, and finally, 15% die mostly
as a result of suicide

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