SCHIZOPHRENIA

Assessment, History,
Theories of Etiology, Types
and Nursing Interventions
CLIENT WITH SCHIZOPHRENIA
A: DEFINITION
SCHIZOPHRENIA is a group of
disorder characterized by disturbance
in thoughts, feelings, perception and
behavior.
ALTERATION IN THOUGHTS
 DELUSION
• Grandeur
• Persecution
• Somatic
• Ideas of reference
• Thought broadcasting
• Thought withdrawal
• Thought insertion
ALTERATION IN THOUGHT
 LOOSE OF ASSOCIATION –
disorganized, illogical incoherent flow of
thoughts and ideas
Ex: WORD SALAD – mix words that has
no connections with each other
 CLANG ASSOCIATION – rhyming
 NEOLOGISM – coining new words
ALTERATION IN PERCEPTION
 ILLUSION
 HALLUCINATION
• V – VISUAL - sight
• A – AUDITORY - hearing
ALTERATION IN AFFECT
 The affect of a schizophrenic client is
absent (FLAT), lacking (BLUNT) or
INAPPROPRIATE
ALTERATION IN BEHAVIORAL
PATTERN

 Social Withdrawal
– aloof and fails to encourage
interpersonal relationship
 Suspiciousness
– sees world as hostile, threatening
place
 Psychomotor retardation
– slow moving and slow speaking
ALTERATION IN BEHAVIORAL
PATTERN
 Hyperactivity
– loud rapid speaking, inability to sit still
 Regression
– inability to meet basic survival need
Ex: Unable to feed oneself
Poor personal hygiene
Inappropriate dress for the weather
HISTORY

Dementia Praecox - Emil Kraepelin (1883)

Schizophrenia - Eugene Bleuler
(1911)
4 A’s of Schizophrenia:
1. Apathy
2. Ambivalence
3. Affective disturbance
4. Associative looseness
THEORIES OF ETIOLOGY
1. GENETIC THEORY
-genetic pattern within family system (50%
chance for other identical twin, and 15% for
fraternal twin)
2. PSYCHODYNAMIC THEORY
- poor care giving that leads to psychic
alterations (Freud and Bleuler)
-loss of ego boundaries
-double bind communications pattern within a
poor family relationship
THEORIES OF ETIOLOGY
3. NEUROBIOLOGICAL THEORY
-neurostructural (frontal lobe hypometabolism,
and limbic system dysfunction) affecting affect,
behavior and thinking
Frontal lobe – control organizations of thoughts,
body movements, memories, emotions and
moral behaviors
Limbic System – emotional brain
THEORIES OF ETIOLOGY
Neurochemical theory-imbalance in
neurotransmitters dopamine,
norepinephrine, serotonin, acetylcholine
and gamma-aminobutyric acid
THEORIES OF ETIOLOGY
4. IMMUNOVIROLOGY
- body’s response to exposure to virus
which may alter the brain development
TYPES OF SCHIZOPHRENIA
DISORGANIZED
Onset: early, usually below 18 years old and is
insidous
Behavioral Pattern: Withdrawn
Defense Mechanism: Regression
Characteristics:
inappropriate behavior
silly smiles and laughter,
somatic delusions, impaired
ADL
TYPES OF SCHIZOPHRENIA
DISORGANIZED
 Nursing Diagnosis and Management
• Self Care Deficit
• Promote self care
• Promote independency
• Provide safe and relatively simple activities
• Impaired Socialization
• Active friendliness
• Gain trust
• Provide re-motivation and re-socialization
• Improve socialization skills
TYPES OF SCHIZOPHRENIA
PARANOID
Onset: late onset in life usually 30 – 35 year old
and abrupt
Behavioral Pattern: Suspicious
Defense Mechanism: Projection
Characteristics: extreme suspiciousness,
ideas of reference,
delusion of persecution,
auditory hallucination
unpredictable violence
TYPES OF SCHIZOPHRENIA
PARANOID
 Give client ample personal space
• To enhance his/her sense of security
 Use no demand attitude
• Making demands and being authoritative increases the client’s fear
 Develop trust
• Be reliable and consistent
 Safety for others and client
• Approach client in a non-threatening manner
• Never whisper
• Never hold complicated objects
• Provide solitary
• Provide safe and relatively simple activities
TYPES OF SCHIZOPHRENIA
CATATONIC
Onset: any age group and usually
acute & precipitated by
an emotionally disturbing experience
Behavioral Pattern: Withdrawn
Defense Mechanism: Repression
1.CATATONIC STUPOR
Characteristics:
sudden onset of mutism,
bizarre mannerisms,
waxy flexibility
automatism
TYPES OF SCHIZOPHRENIA
CATATONIC
 2. CATATONIC EXCITEMENT
Characteristics:
have dangerous periods of agitation
impulsive and explosive behavior
Nursing Management
a. Provide safe environment
b. Promote nutrition and hydration
c. Prevent bowel and bladder problem
d. Minimize circulatory problems and loss of
muscle tone
TYPES OF SCHIZOPHRENIA
UNDIFFERENTIATED
 Symptoms of more than one type of
schizophrenia
 Does not meet the criteria for paranoid,
disorganized or catatonic
• S – Social withdrawal
• A – Affect is flat
• D –Delusion and hallucination
Disorganized speech
Disorganized catatonic behavior
TYPES OF SCHIZOPHRENIA
RESIDUAL
 History of at least one psychotic
episode but currently without or limited
overt psychotic behavior
 Diagnose as latent schizophrenia

 may be withdrawn but is able to

function
•end
CARE OF CLIENT WITH
SCHIZOPHRENIA
 SITUATION: Carlo, 35 years old is brought to
the hospital by the police. Neighbors became
concern because they saw him looking out his
window with a shotgun in his hand. When
people walk by, he shouted, “You can’t take
my property away. Get away or I’ll shoot.”
Upon admission, Carlo tells you about his
neighbor’s plot of killing him.
 1. What is Carlo’s major pattern of behavior?
• A. Compulsive c. Withdrawn
• B. Suspicious d. Anxious
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Which of the following is a possible
diagnosis for Carlo?
• A. Schizophrenia, Paranoid type
• B. Schizophrenia, Undifferentiated type
• C. Schizophrenia, Disorganized type
• D. Schizophrenia, Catatonic type
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Carlo’ statement is an example of:
• A. auditory hallucination
• B. delusion of persecution
• C. flight of ideas
• D. somatic delusion
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Which of the following understanding is
most important in working with Carlo?
• a. His belief is not true, therefore you may
ignore him
• b. His belief cannot be reasoned away
• c. Prove to the patient that his thinking is
incorrect
• d. He is not aware of that he is saying
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Carlo refused to eat for the past 24hrs
because the “food is poisoned.” The
nurse should pursue the matter of the
client’s belief by saying:
• a. “Why do you think the food is poisoned?”
• b. “Your feeling is a symptom of your illness.”
• c. “You feel someone wants to poison you?”
• d. “You’ll be safe with me. I won’t let anyone
poison you”
CARE OF CLIENT WITH
SCHIZOPHRENIA
 6. One of the most appropriate ways for
the nurse to initially intervene when
Carlo refuses to eat because of a belief
that the food is poisoned is to:
• A. tell the client that tube feedings will be
started if eating does not begin
• B. simply state that the food is not poisoned
• C. suggest that food be brought in from home
• D. taste the food in the client’s presence
CARE OF CLIENT WITH
SCHIZOPHRENIA
 If Carlo continues to refuse to eat, the
nurse should do the following to meet his
nutritional need:
• a. offer finger foods
• b. offer his favorite foods
• c. offer sealed foods
• d. offer small but frequent feeding
CARE OF CLIENT WITH
SCHIZOPHRENIA
 One day you observed Carlo pacing in his
room. He is alone but talking in an angry tone.
The patient states, “The devil is yelling in my
ear. He says, people here want to hurt me.”
Your best response is:
• a. “Carlo, the devil cannot talk to you.”
• b. “How do you feel when the devil says such things to
you?”
• c. “Can you tell me more about what the devil is
saying to you?
• d. “I don’t hear any voice. But you look scared. Tell me
what you are experiencing.”
CARE OF CLIENT WITH
SCHIZOPHRENIA
 In caring patient who is hallucinating, the
nurse should do which of the following?
• A. Tell the patient that they are only
experiencing hallucination
• B. Agree what the patient is experiencing to
avoid argument
• C. Determine what the hallucinatory process
means to the patient
• D. All of the above
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Carlo hits the ping – pong ball out of
bounds, he is most likely expressing his:
• A. Disinterest in the game
• B. Feelings of depression
• C. Hostility towards others
• D. Inability to play the game
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The activity which is most suitable for A
destructive/Aggressive patient is:
• A. Crocheting rugs from strips of cloths
• B. Hammering copper ashtrays
• C.Tearing carpet rags into strips
• D. Joining basketball team
CARE OF CLIENT WITH
SCHIZOPHRENIA
 SITUATION: Vivian, a 17 year old adolescent, is brought to the
emergency department by her mother. According to the mother,
patient who is in and out of the hospital since 17 years old, acts
infantile, has frequent episodes of urinary and fecal
incontinence, neglects personal hygiene, makes up words and
spending hours decoding messages through television. When
you arrive in the unit, you find her sitting in her room and did
not raise her head when you call her name:
 Base on the following symptoms presented by the patient, her
possible diagnosis will be:
• a. Schizophrenia, Disorganized type
• b. Schizophrenia, Undifferentiated type
• c. Schizophrenia, Paranoid type
• d. Schizophrenia, Catatonic type
CARE OF CLIENT WITH
SCHIZOPHRENIA
 What is the behavioral patter of Vivian?
• a. depressive c. withdrawn
• b. manic d. suspicious
 What is the major defense mechanism
use by this type of patient?
• a. denial c. projection
• c. reaction formation d. regression
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The nurse notes the following behavior
as characteristic of a patient with this
diagnosis:
• a. Rigid organized delusions
• b. Poor eye contact
• c. Odd grimacing and mumbling to self
• d. Motionless and mute
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The most appropriate attitude therapy
you could apply to Vivian is:
• a. No-demand attitude
• b. Active friendliness
• c. Matter-of-fact attitude
• d. Passive friendliness
CARE OF CLIENT WITH
SCHIZOPHRENIA
 To encourage Vivian to talk, the best
plan of nursing intervention would be to:
• a. Focus on non-threatening subjects
• b. Try to get the client to discuss feelings
• c. Ask simple questions that require answers
• d. Sit and look through magazines with the
client
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Which of the following drugs is most
likely to be ordered to Vivian to provide
symptomatic control of her psychotic
thinking?
• a. Imipramine (Tofranil)
• b. Biperiden (Akineton)
• c. Chlorpromazine (Thorazine)
• d. Lathane ( Lithium carbonate)
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The side effects commonly observed in
the administration of major tranquilizers
are the following but one:
• a. Agranulocytosis
• b. CNS depression
• c. Extra pyramidal syndrome
• d. Hypertensive crisis
CARE OF CLIENT WITH
SCHIZOPHRENIA
 A drug such as Trihexyphenidyl (Artane),
Biperiden (Akineton) or Bengtropine
(Logentine) is often prescribed in
conjunction with:
 a. Barbiturates
 b. Neuroleptics
 c. Antidepressants
 d. Anxiolytics
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Vivian is placed on Chlorpromazine 200 mg.,
Q.I.D. Three weeks after admission, her doctor
gives hera two hour pass to go for a walk with
her husband. It is a sunny day. What do you
caution her and her husband about?
• A. Walk in the shady side of the street
• B. Walk in the sunny side of the street
• C. Wear long sleeves, slacks and may walk either in
the shade or under the sun.
• D. Cover exposed skin areas and walk on the shady
side of the street
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Vivian is to receive ECT. When developing the
plan of care, which of the following would the
nurse inform to the family of the client?
• A. Some temporary confusion and disorientation
immediately after a treatment is common.
• B. During an ECT treatment session, the client is at
risk for aspiration.
• C. Clients with severe depression usually do not
respond to ECT.
• D. The client will not be able to breathe independently
during a treatment.
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The patient has agreed to a course of ECT.
The primary nurse provides teaching about
the ECT and the after effects. Which
statement by the patient demonstrates he
needs MORE teachings:
• A. “I must not eat or drink for 6 hours before the
treatment”
• B. “I will experience some memory loss that is
temporary.
• C. “I will receive a local anesthesia”
• D. “I may be confused after the treatment but it will
clear”
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The nurse may tell the client for ECT all
of the following except:
• a. Be asleep during the treatment
• b. Wake up in less than an hour
• c. Receive 110 volts of electricity
• d. Remember nothing of the treatment
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Nurses preparing client for ECT are
responsible for all of the following
responsibilities except:
• a. Checking Client’s vital signs
• b. Removing dentures and jewelries
• c. Administering a short acting anesthesia
• d. Reminding client to go to the bathroom
CARE OF CLIENT WITH
SCHIZOPHRENIA
 The desired physiologic reaction to ECT
is:
• a. A slight tremor
• b. A grand-mal seizures
• c. A petit-mal seizures
• d. A mild papillary dilatation
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Which of the following statements about
Schizophrenia is true?
• A. Children of Schizophrenic parents are more apt
than other children to develop schizophrenia
• B. All children of Schizophrenic parents eventually
demonstrate some degree of Schizophrenia
• C. All parents of Schizophrenic individuals
demonstrate some degree of Schizophrenia
• D. Schizophrenia is acquired as a result of mental
rather than genetic influences
CARE OF CLIENT WITH
SCHIZOPHRENIA
 Which of the following are considered
the positive signs of schizophrenia?
• a. Delusions, anhedonia, ambivalence
• b. Delusions, hallucinations, disordered
thinking
• b. Hallucinations, illusions, ambivalence
• d. Disordered thinking, anhedonia, illusion
•end
TYPES OF SCHIZOPHRENIA
DISORGANIZ PARANOID CATATONIC
ED

Age Onset 18 and 30 – 35 yrs Any age

below group

Onset Insidous abrupt acute

DM regression projection repression

TYPES OF SCHIZOPHRENIA
DISORGANIZED PARANOID CATATONIC

Charac- -Impaired ADL -Extreme 1. Catatonic

teristics suspiciousness stupor
- Silly smiles &
-Delusion of - stupor
laughter persecution - rigidity
- delusion - Auditory
- waxy flexibility
hallucination - automatism
- Idea of
2. Catatonic
reference
Excitement
- Unpredictable
- agitation
Violence
-impulsive
 DELUSION – persistent false belief
GRANDEUR – belief that one is special
PERSECUTION – belief that one is being
threatened
SOMATIC – belief that one’s body is
changing or responding in an unusual way
IDEAS OF REFERENCE – belief that
situations, events, or interactions directly
projected to the person
 DSM-IV- TR Criteria for Schizophrenia
 Characteristic Symptoms
 Two or more of the following during a 1-month period (or less if successfully treated)
 Delusions
 Hallucinations
 Disorganized speech (e.g., LOA)
 Grossly disorganized or catatonic behavior Negative symptoms (e.g., affective flattening,
avolltion, alogia)
 If delusions bizarre or auditory hallucinations and
 voices keep a running commentary about person's thoughts/behaviors or
 b. two or more voices converse with each other Then only one criterion is needed.
Social/Occupational Dysfunction
 If one or more major areas of the person's life are markedly below premorbid functioning
 (work, interpersonal relationships, or self-care) or If childhood or adolescence failure to
achieve expected level of interpersonal, academic, or occupational achievement
 Then meets criteria of B.
 Positive and Negative Symptoms of Schizophrenia
 Positive Symptoms Hallucinations' Auditory
 Voices commenting
 • Voices conversing Somatic-tactile
 Olfactory
 Visual
 Delusions
 Persecutory delusions Jealous delusions
 Grandiose delusions Religious delusions
 Somatic delusions
 Delusions of reference Delusions of being controlled Delusions of mind reading
 Thought broadcasting, insertion, withdrawal Bizarre Behavior
 Clothing, appearance
 Social and sexual behavior
 Aggressive, agitated behavior
 Repetitive, stereotyped behavior
 Positive Formal Thought Disorder and Speech Patterns Derailment
 Tangentiality
 Incoherence
 Illogicality
 Circumstantiality
 Pressure of speech
 Distractible speech
 Clang associations
 Negative Symptoms
 Affective Flattening
 Unchanging facial expression
 Decreased spontaneous movements
 Paucity of expressive gestures
 Poor eye contact
 Inappropriate affect
 Lack of vocal inflections
 Alogia
 Poverty of speech
 Poverty of content of speech Blocking
 Avolition, Apathy
 Impaired grooming and hygiene
 Lack of persistence at work or school Physical anergia
 Anhedonia, Asociality
 Few recreational interests or activities Little sexual interest or activity Impaired intimacy and closeness
 Few relationships with friends or peers Attention Deficits
 Social inattentiveness