Schizophrenia

Jaison Joseph
 Definition
• A group of disorders manifested by
fundamental disturbances or
distortions in thinking, mood and
behavior
• Delusions & Hallucinations
• Disorganized speech, and catatonic
behavior
• Negative symptoms
• Last for at least a month
(ICD10; DSM-V)
 Epidemiology

• Point prevalence is about 0.5-1%

• Current incidence of
Schizophrenia is about 0.5/1000
• Onset of Schizophrenia occurs
later in females than males.
 Historical background

1896: Emil Krapeline divided major psychiatric illness

in to Dementia Precox - delusions, hallucinations,
disturbance of affect and motor disturbances.
• He also classified Dementia Precox in to three types
Hebephrenic, Catatonic, and Paranoid.
• Manic depressive psychosis
 Historical background
1911: Eugen Bleular:
• Renamed Dementia Precox in to
Schizophrenia meaning mental splitting
• He also considered Schizophrenia as not a
single entity but group of Schizophrenia.
• He describe 4th type of Schizophrenia-
simple Schizophrenia He characterized
Schizophrenia symptoms as
• Fundamental symptoms(Primary)
• Accessory symptoms(Secondary)
 Historical background of
Schizophrenia contd. . .
Fundamental symptoms:- Bleular’s 4 A’s
• Ambivalence: marked inability to decide for or against.
• Autism: withdrawal in to self.
• Affect disturbances: e.g. inappropriate affect.
• Association disturbances : loosening of associations,
thought disorder
Accessory symptoms
• delusions, hallucinations, and negativisms
 Historical background

1959: Kurt Schneider:

• Schneider’s First Rank Symptoms(SFRS) of
Schizophrenia
• Second rank symptoms of Schizophrenia; which
were considered less important for diagnosis of
schizophrenia
 BIOLOGICAL
THEORIES
Psychological
UNKNOWN Theories

Etiological factors
 Biological theories
• 1)Genetic hypothesis:-
• 10% first degree relatives
• 3% second degree relatives
• 2% third degree relatives
• Concordance for monozygotic
twins 46%
• Dizygotic twins 14%
• One parent: 10-14%.
• Two parents: 46%.
 BIOCHEMICAL THEORY

• Increase Dopamine at post synaptic receptors.

• Involvement of some Neurotransmitters like
serotonin(specially 5-HT2 receptors), GABA
and Acetylcholine are also presumably involved
 BRAIN IMAGING

• CT scan, MRI and postmortem studies show

enlarged ventricles and mild cortical hypertrophy
• -PET(Positron Emission Tomography) shows
hypofrontality and decrease glucose utilization in
dominant temporal lobe
PSYCHOLOGICAL THEORIES
• Stress
• Family theories
• Psychoanalytical theories
• Regression to pre oral stage of psychosexual development with the
defense mechanism of denial, projection, and reaction formation.
 CLINICAL FEATURES
I. Thought and Speech Disorder

II. Disorders of Perception

III. Disorders of affect

IV. Disorder of motor behavior

IV. Disorder of motor behavior

V. Negative Symptoms

VI. Other features

 Thought and Speech Disorder
• Autistic thinking:
Thinking is governed by illogical rules; patient may consider
two things identical because they have identical predicates or
properties (von Domarus law)
e.g. Lord Rama was a Hindu, I am Hindu, So, I am Lord Rama.
 Thought and Speech Disorder

• Loosening of association:
There is idiosyncratic shifting from one frame of reference to
another the speech is often described as ‘disjointed’
If they become virtually incomprehensible then it is called as
incoherence.
 Thought and Speech Disorder
• Thought Blocking: sudden interruption of stream of speech
before the thought is completed. After a pause the client can
not recall what he had meant to say. This may be associated
with thought withdrawal.

• Neologism: are newly formed words or phrases whose

derivation can not be understood these are created to express a
concept for which the subject has no dictionary word
e. g. Describing stomach as ‘food vessel’
 Thought and Speech Disorder
• Mutism: no speech production
• Poverty of speech: Decrease speech production
• Poverty of ideation: Speech production is adequate but
content conveys little information.
• Echolalia: Repetition of the words / phrases of
examiner
• Perseveration: Persistent repetition of words beyond
their relevance
 Thought and Speech Disorder
• Verbigeration:
Senseless repetition of same words or phrase over and over
again.

• Delusions: -
Are the false unshakable beliefs which are not in keeping with
patients socio-cultural and educational background
Are of 2 types
• i)Primary Delusions ii) Secondary Delusions
• Primary Delusions: arise De novo and can not be explained
on the basis of other experiences or perceptions. Are also
known as ‘Autochthonous Delusions’
 Thought and Speech Disorder
• Secondary delusions: -
Secondary delusions can be explained as arising from
other abnormal experiences.
Commonly seen delusions in Schizophrenia are
1. Delusion of persecution: Being persecuted against.
2. Delusion of reference: being referred to by others.
3. Delusion of Grandeur: Exaggerated self importance.
4. Delusion of Control: Being controlled by an external
force, known or unknown.
5. Somatic / Hypochondriacal delusions
Other clinical features include
Over inclusion, impaired abstraction, concreteness,
perplexity ambivalence
II. DISORDER’S OF PERCEPTION
• Hallucinations (perception without stimuli)
• Auditory(elementary auditory hallucinations-hearing
simple sound rather than voices; thought echo- audible
echo; third person hallucination- voices heard arguing,
discussing the patient)
• Visual Hallucinations, are common
• Tactile, gustatory, olfactory hallucinations are rare
Includes
III. Disorder’s of affect
• Apathy
• Emotional blunting
• Emotional shallowness
• Anhedonia
• Inappropriate emotional
response
 iv. Disorder’s of motor behavior
• Decrease/Increase Psychomotor Activity
• Stereotypies
• Decrease Self Care, Grooming
• Catatonic Features
 Negative symptoms

• Affective blunting/ flattening

• Avolition apathy(Lack of initiative)
• Anhedonia
• A sociality
• Alogia(lack of speech output)
 Other features
• Decrease functioning in work
• Loss of Ego boundaries
• Multiple somatic symptoms
• Absent Insight
• Increased risk of Suicide
• No disturbance in Consciousness, orientation, attention
memory and intelligence
• Marked variability in symptomatology over time.
• No underlying organic cause
• No prominent mood Disorder
 Diagnostic Criteria
Delusions
Hallucinations
Disorganized speech
Disorganized behavior/ Catatonic behavior
Negative symptoms
 Classification
• F20: Schizophrenia
• F21: Schizotypal Disorder
• F22:Persistent Delusional Disorder
• F23: Acute & transient Psychotic disorder
• F24: Induced Delusional disorder
• F25: Schizoaffective Disorder
• F28: Other non organic Psychotic Disorders
• F29: Unspecified nonorganic Psychosis
 F20: Schizophrenia
• F20.0 Paranoid Schizophrenia
• F20.1 Hebephrenic Schizophrenia
• F20.2 Catatonic Schizophrenia
• F20.3 Undifferentiated Schizophrenia
• F20.4 Post-schizophrenic Depression
• F20.5 Residual Schizophrenia
• F20.6 Simple Schizophrenia
• F20.8 Other Schizophrenia
• F20.9 Schizophrenia, Unspecified
According the pattern of course the
classification is as follows

Is used by following five character code

• F20.x0 Continuous
• F20.x1 Episodic with progressive deficit
• F20.x2 Episodic with stable deficit
• F20.x3 Episodic Remittent
• F20.x4 Incomplete Remission
• F20.x5 complete Remission
• F20.x8 Other
• F20.x9 Course uncertain, period of observation too short
 Paranoid type
The patient is preoccupied with
delusions or frequent auditory
hallucinations.
Hebephrenic/ Disorganized type
Disorganized behavior
Disorganized speech
Affect that is flat or inappropriate
 Catatonic Type
At least 2 catatonic symptoms predominate:
• Stupor or motor immobility (catalepsy or waxy flexibility)
• Hyperactivity that has no apparent purpose and is not influenced
by external stimuli
• Mutism or marked negativism
• Peculiar behavior such as posturing,
• stereotypes,
• mannerisms or grimacing
• Echolalia or echopraxia
 Undifferentiated Type

• The patient meets the basic criteria for Schizophrenia

• The patient does not meet criteria for Paranoid,
Disorganized, or Catatonic types.
 Residual Type

• Negative symptoms such as flattened affect, reduced speech

output or lack of volition
• An attenuated form of at least 2 characteristic symptoms of
schizophrenia, such as odd beliefs (related to
delusions), distorted perceptions or illusions (hallucinations),
odd speech (disorganized speech) or peculiarities of
behavior (disorganized behavior).
 Simple Schizophrenia
• Early onset(early 2nd decade)
• Insidious and progressive course
• Presence of characteristic ‘negative symptoms’ of residual
schizophrenia
• Delusions and hallucinations are usually absent, and if present
usually , are short lasting and poorly systematized, prognosis
very poor
 Post Schizophrenic Depression
• Patient develops depressive features within 12
months of an acute episode of Schizophrenia.

• Present active features of schizophrenia.

Depressive features can be due to side effect of
antipsychotics, regaining insight after recovery,
or just as an integral part of schizophrenia.
 Management
A)Somatic treatment
• Pharmacological treatment
• Electroconvulsive therapy
B)Psychosocial treatment and rehabilitation
 SOMATIC TREATMENT
• Pharmacological treatment: - Antipsychotics

Typical/ traditional Atypical antipsychotics

1.Chlorpromazine 1. Olanzepine
2. Resperidone
3. Amisulpiride
2. Haloperidol 4. Clozapine
 SOMATIC TREATMENT
• Electroconvulsive therapy(8-12 ECT’s extended up
to 18)

• c)Others: -Psychosurgeries:-limbic leucotomy

 PSYCHOSOCIAL TREATMENT AND
REHABILITATION
• Psychoeducation: -
Regarding nature of illness, its course and
treatment
It helps in establishing good therapeutic
relationship
• Group Psychotherapy
It is aimed at
Teaching problem solving
Teaching communication skills
Usually conducted as ‘social skill training
package’
 PSYCHOSOCIAL TREATMENT AND
REHABILITATION

• Family therapy
• Apart from Psychoeducation family members are also
provided social skill training to enhance communication
and decrease family tension.
• Millieu therapy/ therapeutic community
• It includes treatment in living , learning or working
environment ranging from inpatient Psychiatry unit to day care
Hospital’ s & half way home
 PSYCHOSOCIAL TREATMENT AND
REHABILITATION

• Individual Psychotherapy
Is usually supportive in nature rarely Psychoanalytically oriented
Psychotherapy is used; now a day it is not recommended.
• Psychosocial rehabilitation
Is used usually along with Millieu therapy
 It includes activity therapy; -to develop work habit
 Training in new vocation and retraining in previous vocation
 Vocational guidance:-Independent job placement
 Sheltered employment: -or self employment
 Occupational therapy
 Nursing management

• Nursing Assessment
Assess the general condition of the patient
Assess the mood and cognitive state
Assess potential for violence
Assess social support
Assess knowledge of the patient and his family about the
disease
 Nursing Diagnosis
• Disturbed Thought Processes related to perceptual and
cognitive distortions, as demonstrated by suspiciousness,
defensive behavior, and disruptions in thought
• Social Isolation related to an inability to trust
• Activity Intolerance related to adverse reactions to
psychopharmacologic drugs
• Risk for Self-directed or Other-directed Violence related
to delusional thinking and hallucinatory experiences
Strengthening Differentiation Between Delusions
and Reality
• Provide patient with honest and consistent feedback in a
nonthreatening manner.
• Avoid challenging the content of patient's behaviors.
• Focus interactions on patient's behaviors.
• Administer drugs as prescribed while monitoring and
documenting patient's response to the drug regimen.
• Use simple and clear language when speaking with
patient.
• Explain all procedures, tests, and activities to patient
before starting them, and provide written or video
material for learning purposes
 Promoting Socialization
• Encourage patient to talk about feelings in the context of a
trusting, supportive relationship.
• Allow patient time to reveal delusions to you without
engaging in a power struggle over the content or the reality
of the delusions.
• Use a supportive, empathic approach to focus on patient's
feelings about troubling events or conflicts.
• Provide opportunities for socialization and encourage
participation in group activities.
• Be aware of patient's personal space and use touch
judiciously.
• Help patient to identify behaviors that alienate significant
others and family members.
 Improving Activity Tolerance
• Assess patient's response to prescribed antipsychotic drug.
• Collaborate with patient and occupational and physical
therapy specialists to assess patient's ability to perform
ADLs.
• Collaborate with patient to establish a daily, achievable
routine within physical limitations.
• Teach strategies to manage adverse effects of
antipsychotic drug that affect patient's functional status,
including:
• Change positions slowly
• Gradually increase physical activities
• Limit overdoing it in hot, sunny weather
• Use sun precautions
• Use caution in activities if extrapyramidal symptoms
develop
 Improving Coping with Thoughts and
Feelings
• Encourage patient to express feelings.
• Focus on patient's feelings and behavior.
• Provide honest perceptions of reality and feedback
about symptoms and behaviors.
• Encourage patient to explore adaptive behaviors that
increase abilities and success in socializing and
accomplishing ADLs.
• Decrease environmental stimuli
 Ensuring Safety
• Monitor patient for behaviors that indicate increased anxiety
and agitation.
• Collaborate with patient to identify anxious behaviors as
well as the causes.
• Tell patient that you will help with maintaining behavioral
control.
• Establish consistent limits on patient's behaviors and clearly
communicate these limits to patient, family members, and
health care providers.
• Secure all potential weapons and articles from patient's
room and the unit environment that could be used to inflict
an injury.
• To prepare for possible continued escalation, form a
psychiatric emergency assist team and designate a leader to
facilitate an effective and safe aggression-management
process.
 Ensuring Safety

• Determine the need for external control, including

seclusion or restraints. Communicate the decision to
patient and put plan into action.
• Frequently monitor patient within the guidelines of
facility's policy on restrictive devices and assess the
patient's level of agitation.
• When patient's level of agitation begins to decrease and
self-control is regained, establish a behavioral agreement
that identifies specific behaviors that indicate self-control
against a re escalation of agitation.
 References
• Stuart GW. Principles and practice of psychiatric nursing-e-book.
Elsevier Health Sciences; 2014 Apr 14.
• Halter MJ, Varcarolis EM, editors. Varcarolis' Foundations of
psychiatric mental health nursing. Elsevier Health Sciences; 2014.
• Townsend MC, Morgan KI. Psychiatric mental health nursing:
Concepts of care in evidence-based practice. FA Davis; 2017 Oct 19.
• Frisch NC, Frisch LE. Psychiatric mental health nursing:
understanding the client as well as the condition.
• Mohr WK. Psychiatric Mental-Health Nursing. 6th ed. Lippincot
William, . 2003; p 619-658.
• World Health Organization. The ICD-10 classification of mental and
behavioural disorders: clinical descriptions and diagnostic guidelines.
World Health Organization; 1992.
THANK YOU