General Information about Schizophrenia

 is the most common about psychotic disorders

 onset may occur late in adolescence or early adulthood, usually before
age of 30.
 Word schizophrenic is derived from a Greek word schizo (split) and
phrenic (mind).
 The term schizophrenia was first coined by a Swiss psychiatrist Eugen
Bleuler.

Schizophrenia
 Is a functional psychosis characterized by disturbances in thinking,
emotion, volition and perception that may lead to personality
deterioration.
 It is a common disease prevalent in all cultures and in all parts of the
world.
 About 1 percent of the general population stand a risk of this disease in
their lifetime & 40% of these individuals do not receive psychiatric
treatment on any given day.
Etiology/Causes
 There is no single cause that can account for all cases of
schizophrenia.
 Some suggested cause involves problem with brain chemistry &
brain structure, abnormalities in the developing fetus, middle brain
damage from complication during birth, genetic predisposition.

 Genetic Theory
Incidence of Schizophrenia in Specific Populations:
Populations Incidence (%)
1. General population 1.0
2. Siblings of schizophrenic patient 8.0
3. Child with one schizophrenic parent 12.0
4. Dizygotic twin of a schizophrenic patient 12.0
5. Child of two schizophrenic parents 40.0
6. Monozygotic twin of a schizophrenic patient 47.0
 Biochemical and Neurostructural Theory
• Dopamine Hypothesis – there is an excessive dopamine that allows
nerve impulses to bombard the brain, resulting in the development of
symptoms of schizophrenia.
 The antipsychotic drugs block postpsynaptic dopamine receptor sites
in the brain.
• Another hypothesis is a defective circuit that may result in the
bombardment of unfiltered information that can cause both negative &
positive symptoms like:
 The mind makes error in perception & hallucinates

 Draws incorrect conclusion

 Becomes delusional.

• Transmethylation Hypothesis
 May result in abnormal transmethylation of catecholamines.
• Indolamine Hypothesis
 A defect in the metabolism of indolamine , like serotonin is a possible
cause of schizophrenia.
 Vesicles of neurotransmitter Dendrite of
postsynaptic
Axon of presynaptic neuron
neuron

Neurotransmitter
(acetylcholine)
Mitochondrion
Inactivator
Receptor site (cholinesterase)
 Organic or Psychological Theory
 It offers that schizophrenia is a functional deficit occurring in the
brain, and caused by such stressors as viral infection, toxins,
trauma, or abnormal substances.
 Some also proposes that it is caused by metabolic disorders, but
this are all circumstantial evidence.
 Environmental or Cultural Theory
 Theorist states that a person who develops schizophrenia has a
faulty reaction to the environment and is unable to respond
selectively to numerous stimuli.
 Perinatal Theory
 The risk of schizophrenia exists if the developing fetus or
newborn is deprived of oxygen or if the mother suffers from
malnutrition or starvation during the first trimester of pregnancy.
 Development of schizophrenia is critical during brain
development at 34th or 35th week of gestation.
 Vitamin Deficiency Theory
 Theorist suggest that deficiency in vitamin B, namely B1, B2, B12
as well vitamin C may become schizophrenic as a result of
vitamin deficiency.

 Clinical Symptoms and Diagnostic Characteristics

 Eugen Bleuler in 1911 proposed four basic diagnostic areas for
characterizing schizophrenia. These became the 4 A’s:
 A: Affective Disturbances
 A: Loosening of Associations
 A: Autistic Thoughts/Thinking
 A: Ambivalence
■ These four A’s provide a memory tool for recalling how
schizophrenia affects thinking, mood (flat), thought processes, and
decision-making ability (Shader 2003).
 Clinical symptoms fall into three broad categories:
 positive symptoms,
 negative symptoms, and
 disorganized symptoms
• Positive symptoms reflect the presence of overt psychotic
or distorted behavior, such as
• Hallucinations
• Delusions
• Suspiciousness
• Conceptual disorganization
• Hostility or aggressive behavior
• Pressured speech
• Bizarre behavior or dress
 possibly due to an increased amount of dopamine
affecting the cortical areas of the brain
 Negative symptoms reflects
• diminution or loss of normal functions, such as affect, motivation,
or the ability to enjoy activities
• Anergia (lack of energy)
• Anhedonia (loss of pleasure or interest)
• Emotional withdrawal
• Poor eye contact (avoidant)
• Blunted affect or affective flattening
• Avolition (passive, apathetic, social withdrawal)
• Difficulty in abstract thinking
• Alogia (lack of spontaneity and flow of conversation)
• Dysfunctional relationship with others
 these symptoms are thought to be due to cerebral
atrophy, an inadequate amount of dopamine, or other
organic functional changes in the brain
 Category of disorganized symptoms refers to:
• presence of confused thinking,
• incoherent or disorganized speech,
• disorganized behavior such as the repetition of rhythmic
gestures.

Two categories have been developed to describe the

etiology
and onset of schizophrenia:
• type I schizophrenia, the onset of positive symptoms is generally
acute.
• type II schizophrenia is characterized by a slow onset of negative
symptoms caused by viral infections and abnormalities in
cholecystokinin.
 Diagnostic Characteristics
 Evidence of two or more of the following:
 Delusions
 Hallucinations
 Disorganized speech
 Grossly disorganized or catatonic behavior
 Negative symptoms
 Above symptoms present for a major portion of the time
during a 1-month period
 Significant impairment in work or interpersonal relations,
or self-care below the level of previous function
  Demonstration of problems continuously for at least a 6-
month interval
 Symptoms unrelated to schizoaffective disorder and mood
disorder with psychotic symptoms and not the result of a
substance-related disorder or medical condition

Classification of Subtypes of Schizophrenia

 Paranoid:
1. Preoccupation with one or more delusions or frequent auditory
hallucinations
2. None of the following is prominent: disorganized speech,
disorganized or catatonic behavior, or flat or inappropriate affect
 Catatonic: At least two of the following are present:
1. Motor immobility (ie. rigidity), waxy flexibility, or stupor
2. Excessive motor activity that is purposeless
3. Extreme negativism or mutism
4. Peculiarities of voluntary movement as evidenced by posturing,
stereotyped movements, prominent mannerisms or prominent
grimacing
5. Echolalia (repeats all words or phrases heard) or echopraxia
(mimics actions of others)

 Disorganized: All of the following are prominent and criteria

are not met for catatonic type:
1. Disorganized speech
2. Disorganized behavior
3. Flat or inappropriate affect
 Undifferentiated:
1. Meets diagnostic characteristics but not the criteria for paranoid,
disorganized, or catatonic subtypes

 Residual:
1. Absence of prominent delusions, hallucinations, disorganized
speech, and grossly disorganized or catatonic behavior
2. Continuing evidence of, in attenuated form, the presence of
negative symptoms or two or more symptoms of diagnostic
characteristics.

 Schizophrenic-Like Disorders
 DSM-IV-TR lists five subtypes of schizophrenic-like disorders:
1. Schizoaffective disorder is characterized by an uninterrupted period
of illness during which, at some time, the client experiences a
major depressive, manic, or mixed episode along with the
negative symptoms of schizophrenia.
2. Schizophreniform disorder is used when the client
exhibits features of schizophrenia for more than 1 month
but fewer than 6 months. Impaired social or occupational
functioning does not necessarily occur.
3. Brief psychotic disorder is a disturbance that involves the
sudden onset of at least one of the positive symptoms of
psychosis such as hallucinations, delusions, disorganized
speech, or grossly disorganized or catatonic behavior.
4. Psychotic disorder due to a general medical condition is
the diagnosis used to describe the presence of prominent
hallucinations or delusions determined as due to the
direct physiologic effects of a specific medical condition.
5. Shared psychotic disorder, or folie à deux, involves two
individuals who have a close relationship and share the
same delusion.
The Nursing Process
Assessment
• Schizophrenia affects thought processes & content, perception,
emotion, behavior, and social functioning.
• Types of Abnormal Motor Behavior
• Akathisia – Displaying motor restlessness and muscular
quivering ; the client’s is unable to sit or lie quietly.
• Echolialia – repeating the speech of another person
• Echopraxia – repeating the movements of another persons.
• Parkinson-like Symptoms – Making mask-like faces, drooling,
and having shuffling gait, tremors, and muscular rigidity.
• Waxy Flexibility – having one’s arms or legs placed in a certain
position and holding that same position for hours.
• Dyskinesia – impairment of the power of voluntary movements.
 Types of Abnormal Thought Process
 Neologisms – Words that an individual makes up that have meaning
only for the individual; often part of a delusional system.
 Looseness of Association – individual’s thinking is haphazard,
illogical, and confused, and connections in thought are interrupted;
seen mostly in schizophrenic disorders.
 Flight of Ideas – a constant flow of speech in which the individual
jumps from one topic to another in rapid succession.
 Blocking – a sudden cessation of a thought in the middle of a
sentence; the client is unable to continue the train of thought; often
sudden new thoughts, unrelated to the topic.
 Circumstantiality – Before getting to the point or answering a
question, the individual gets caught up in countless details and
explanations.
 Word Salad – a mixture of words and phrases that have no meaning.
  Confabulation – filling a memory gap with detailed fantasy
believed by the teller; the purpose of confabulation is to maintain
self-esteem.
 Delusions
 A false belief held to be true even when there is evidence to the
contrary.
 Types of Delusions
 Persecutory/paranoid delusions – involve the client’s belief that
“others” are planning to harm the client or are spying, following,
ridiculing, or belittling the client in some way.
 Grandiose delusions – false belief that one is a very powerful and
important person, or the client’s belief that he or she is famous or
capable of great feats.
 Religious delusion – often center around the second coming of
Christ or another significant religious figure or prophet.
  Somatic delusions – are generally vague and unrealistic beliefs
about the client’s health or bodily functions.
 Referential delusions or ideas – involve the client’s belief that
television broadcasts, music, or newspaper, articles have special
meaning for him or her.
 Hallucinations – a sense of perception for which no external
stimuli exist; can have an organic or a functional etiology.
 Types of Hallucinations
 Auditory hallucinations – hearing voices when none are present.
 Command hallucination – are voices demanding that the client take
action, often to harm self or others, and are considered dangerous.
 Visual hallucinations – involve seeing things/images that do not
exist at all.
 Olfactory hallucinations – smelling smell that do not exist.
 Tactile hallucinations – feeling touch sensations in the absence of
stimuli.
  Gustatory hallucinations – experiencing taste in the absence of
stimuli.
 Cenesthetic hallucinations – involve the client’s report that he or
she feels bodily functions that are usually undetectable .
 Kinesthetic hallucinations – occur when the client is motionless
but reports the sensation of bodily movement.

 History and Physical Examination

 If appropriate, obtain subjective data from family members,
significant others, or assigned caretakers. Answers to questions
such as “What is the client's legal status?”•
, “Where does the client
live?”•
, and “Has the client received psychiatric care in the past?”•
provide pertinent data. The client may not be able to state what, if
any, medication has been prescribed and by whom.
 Approximately 25% of clients with schizophrenia have major
symptoms of depression.
  Another key area of assessment is the client's fluid intake. Ask the
client how much water is consumed daily. Psychogenic polydipsia,
the compulsive behavior of drinking 3 liters or more of fluid per
day, occurs in a small percentage of clients with schizophrenia.
 Hyponatremia, electrolyte imbalance, and seizures may occur.
Additional symptoms of psychogenic polydipsia include muscle
cramps and changes in mental status such as confusion and
disorientation .

 Example of NANDA Nursing Diagnoses: Schizophrenia

 Disturbed Thought Processes related to the presence of
persecutory delusions
 Disturbed Sensory Perception related to the presence of visual
hallucinations
 Self-Care Deficit related to poor personal hygiene
  Impaired Verbal Communication related to thought disturbance
(looseness of association)
 Noncompliance related to refusal to take prescribed psychotropic
medication
 Disturbed Sleep Pattern related to the presence of auditory
hallucinations
 Social Isolation related to homelessness
 Ineffective Coping related to fear
 Implementation
 Implementation focuses on establishing a trusting relationship;
establishing clear, consistent, open communication; providing a
safe environment; alleviating positive, negative, and
disorganized symptoms; and maintaining biologic integrity.
 Remember that all behavior is meaningful to the client, if not to
anyone else.
 Communicate in simple, easy-to-understand terms, directed at
the client's present level of functioning.
 Providing a safe, structured environment is important to
maintain biologic integrity and to protect the client from potential
self-harm due to command hallucinations, irrational behavior,
disorientation, or poor safety awareness.
 Limit-setting, time-out, or physical restraints may be necessary
during the acute phase of schizophrenia to decrease agitation or
aggressive behavior, or to prevent physical injury to self or
others.
 Medication management focuses on stabilizing acute symptoms
and then maintaining therapeutic plasma levels of the
medications to avoid a relapse or exacerbation of clinical
symptoms.
 Interventions for Agitation, Hallucinations, and
Delusions
Agitation
 Remove clients from, or avoid, situations known to cause
agitation.
 Decrease stimulants such as caffeine, bright lights, and loud noise
or music.
 Avoid display of anger, discouragement, or frustration when
interacting with client.
 Avoid criticism and do not argue with client.
 Set limits and follow through with consequences if a violation
occurs.
 Monitor for physical discomfort such as pain or physical illness.
 Administer prescribed medication as ordered.
Hallucinations
 Decrease environmental stimuli such as loud music, extremely
bright colors, or flashing lights.
 Attempt to identify precipitating factors by asking the client what
happened prior to the onset of hallucinations.
 Monitor television programs to minimize external stimuli that
may precipitate hallucinations.
 Monitor for command hallucinations that may precipitate
aggressive or violent behavior.
 Administer prescribed medication as ordered
Delusions
 Do not whisper or laugh in the presence of the client.
 Do not argue with the client or attempt to disprove delusional or
suspicious thoughts.
 Explain all procedures and interventions, including medication
management.
  Provide for personal space and do not touch the client
without warning.
 Maintain eye contact during interactions with client.
 Provide consistency in care and assigned caregivers to
establish trust.
Treatment
Psychopharmacology
 Is the primary treatment for schizophrenia.
 They are used to manage the symptoms of the disease
but not to cure the disorder.
 The dopamine & serotonin antagonists are the
antipsychotic medications given to patients.
 Common antipsychotic medication given are Prolixin,
Thorazine, Haldol
 Effects of the medications last 2 – 4 weeks.
 Haloperidol (haldol)
 Duration of action is 4 weeks
 Fluphenazine (Prolixin)
 Duration of action is 7 to 28 days

Side Effects of Antipsychotic Medications

1. Extrapyramidal Side Effects (EPS) – are reversible movement
disorders induced by neuroliptic medication. They include:
 Dystonic reactions – are spasms in discrete muscle groups such as the
neck muscles (torticollis) or eye muscles (oculogyric crisis).
• Acute treatment consist of diphenhydramine (benadryl) thru IM or IV or
benzotropine (Cogentin) given IM.
 Pseudoparkinsonism or neuroliptic parkinsonism includes shuffling
gait, masklike facies, muscle stiffness (continuous) or cogwheeling
rigidity (ratchet – like movement of joints), drooling, and akinesia
(slowness & difficulty initiating movement)
  Akathisia – is restless movement , pacing, inability to remain still, and
the client’s report of inner restlessness.
• Beta – blockers such as propanolol have been effective in treating
akathesia while benzodiazepines have provided some success as well.
2. Tardive Dyskinesia – a late – appearing side effect of antipsychotic
medications characterized by abnormal, involuntary movements
such as lip smacking, tongue protrusion, chewing, blinking,
grimacing, and choreiform movement of the limbs and feet.
• It is irreversible once it appeared.
• Clozapine (clozaril) is an antipsychotic drug that does not cause tardive
dyskinesia as a side effect.
3. Seizures – incidence of 1% is common in antipsychotic drug
medication with exception from clozapine.
4. Neuroleptic Malignant Syndrome (NMS) – is characterized by
muscle rigidity, high fever, increased muscle enzymes (particularly
CPK), and leukocytosis (increased leukocytes).
5. Agranulocytosis – failure of the bone marrow to produce adequate
white blood cells. Characterized by fever, malaise, ulcerative sore
throat, and leukopenia.
Psychosocial Treatment
1. Individual & group therapy sessions areoften supportive in nature,
giving, the client an oppurtunity for social contact and meaningful
relationship with other people.
2. Social skill training which improve their social competence that
translate into more effective functioning in the community
Three forms of Social Skill:
a. Basic model – involves breaking complex social behavior into simpler
steps, practicing through role-playing, and applying the concepts in
the community or real world setting.
b. Social problem-solving model – focuses on improving impairments in
information processing that are assumed to cause deficits in social
skills.
c. Cognitive remediation model – focuses on improving underlying
cognitive impairments by emphasizing such thing as paying attention
and planning.
 3. Family education & therapy are known to diminish the negative
effects of schizophrenia and reduce relapse rate.

DELUSIONAL DISORDERS
- term paranoid is commonly used to describe a person who exhibits
overly suspicious behavior.
- used to describe a wide range of behaviors, ranging from aloof,
suspicious, and non-psychotic behaviors to well-systematized and
psychotic symptoms.
- delusion is a term used to describe a false belief based on an
incorrect inference about external reality that is firmly sustained
despite clear evidence to the contrary (Edgerton & Campbell, 1994).
Etiology of Delusional Disorders
- cause of delusional disorders is unknown, several predisposing
factors have been identified. These include risk factors such as:
 Relocation due to immigration.
 Social isolation
 Sensory impairments such as deafness or blindness
 Severe stress
 Low socioeconomic status in which the person may experience
feelings of discrimination or powerlessness
 Personality features such as low self-esteem or unusual
interpersonal sensitivity
 Trust-fear conflicts
Clinical Symptoms and Diagnostic Characteristics
 typical age of onset is usually middle or late adult life.
 Clients with nonbizarre delusions usually verbalize extreme
suspiciousness, jealousy, and distrust, and are generally convinced
that others intend to do them harm.
 Other clinical symptoms may include social isolation, seclusiveness,
or eccentric behavior.
 Anxiety or depression may occur as the client attempts to cope with
delusional thoughts.
 According to DSM-IV-TR criteria, delusional disorder is
differentiated from schizophrenia in that clients with delusional
disorder do not have prominent or sustained hallucinations.
However, clients may verbalize the presence of tactile, olfactory, or
auditory hallucinations consistent with their delusions.
 Delusions, as noted earlier, are not bizarre, but rather could
conceivably occur in real life (eg, client believes he or she is being
poisoned or that someone has tampered with the brakes in his or her
car).
DSM-IV-TR identifies five subtypes of delusional disorder:
1. Persecutory - believe they are being conspired against, spied on,
poisoned or drugged, cheated, harassed, maliciously maligned, or
obstructed in some way.
2. Conjugal or jealous - client who is convinced that his or her mate or
significant other is unfaithful exhibits clinical symptoms of
conjugal paranoia or delusional jealousy.
3. Erotomanic - individual, usually an unmarried woman, believes a
person of elevated social status loves her. The delusion, which can
occur suddenly, is usually of romantic or spiritual love rather than
sexual love.
4. Grandiose - also referred to as megalomania, are present when the
client believes he or she possesses unrecognized talent or insight,
or has made an important discovery.
5. Somatic - somatic subtype demonstrates a preoccupation with the
body by verbalizing unusual somatic delusions
The Nursing Process
Assessment
 Assessment of clients with delusional disorders or shared psychotic
disorder is challenging because the clients typically deny any
pathology. This challenge is further compounded by the presence of
suspiciousness or ideas of reference, their inability to trust others,
and their resistance to therapy.

Examples of NANDA Nursing Diagnoses: Delusional and

Shared Psychotic Disorders
 Disturbed Thought Processes related to erotomanic delusions
 Disturbed Thought Processes related to suspiciousness
 Disturbed Thought Processes related to tactile hallucinations
 Risk for Self- Directed Violence related to delusional thinking and
aggressive acts
 Defensive Coping related to delusional jealousy and fear of divorce
 Fear related to persecutory delusions
 Impaired Social Interaction related to somatic delusions
 Noncompliance related to ideas of reference and suspiciousness

 Planning Interventions
 Plan effective interventions by keeping in mind five
nonproductive reactions to delusional clients:
 Becoming anxious and avoiding the client
 Reinforcing delusions by actually believing the client
 Attempting to prove that the client is mistaken by presenting a logical
argument
 Setting unrealistic goals that lead to disappointment, frustration, or
anger
 Being inconsistent with nursing interventions (Barile, 1984)
Implementation
• Caring for clients with delusional disorders and shared psychotic
disorder focuses:
1. Assisting the client in the activities of daily living;
2. Providing a safe environment to observe for suicidal ideation;
3. Stabilizing behavior such as hostility and aggression;
4. Establishing rapport;
5. Enhancing self-esteem; and
6. Decreasing fears, suspicions, ideas of reference, and delusions.

Nursing Interventions for Delusional and Shared Psychotic

Disorders
1. Assure the client that he or she is in a safe environment.
2. Utilize listening and acceptance to establish a trusting relationship.
3. Identify irrational thoughts and investigate whether there is a
precipitating stressor that triggered the delusion.
4. Encourage the client to discuss the logic or reasoning behind the
delusion.
5. If the client asks you if you believe the delusion, inform the client
that you do not share the perception or delusional belief.
6. Acknowledge the plausible elements of the delusion.
7. Identify the purpose or needs the delusion serves.
8. If possible, meet the needs the delusion fulfills (ie, dependence, low
self-esteem).
9. Identify ways to help the client control thoughts, such as distracting
oneself from thinking the same thought repeatedly; using thought-
switching techniques; identifying signs, such as staring, that indicate
thoughts are becoming disorganized; and anticipating new
situations that may increase anxiety or enhance delusional thoughts.
Medication Management
 If the client is extremely belligerent, agitated, suicidal, or exhibiting violent
behavior, injectable or depot antipsychotics such as haloperidol (Haldol) are
very effective in controlling feelings of distress.
clinicians consider psychotropic drugs, including the atypical antipsychotics
and newer-generation anticonvulsants, to be the treatment of choice for
delusional and shared psychotic disorders.
 psychotropic drugs considered to be effective in the treatment of delusional
disorders include quetiapine (Seroquel), ziprasidone (Geodon), tiagabine
(Gabetrol), pimozide (Orap), lithium (Lithobid), carbamazepine (Tegretol), and
valproate (Depakote).

Interactive Therapies
 After behavior and mood are stabilized and psychotherapeutic intervention
begins, be honest and straightforward while focusing on the client's
emotional response to the environment.
 Individual therapy, generally focuses on improving self-esteem and social
interactions and developing positive coping skills and problem-solving
skills.
 Insight-oriented, problem-oriented, and group therapies can be ineffective
because confronting delusions directly may increase agitation.
 Somatic therapy and alternative therapies generally are not used to treat
delusional or shared psychotic disorders because the mark of successful
treatment usually depends on a satisfactory social adjustment rather than a
reduction or suppression of the client's delusions

Client Education
• Client education can be effective if the client has developed trust in the
nursing staff and is able to focus on reality.
THE END