schizophrenia

By the end of this lecture, each student will be able to:

•Identify Bleuler’s fundamental signs of
schizophrenia .
• Identify Positive and negative symptoms of
schizophrenia.
•Identify common nursing diagnoses and
interventions for schizophrenic patients.
 Assessment
Bleuler’s fundamental signs of schizophrenia (Four A’s):

Autism Associative Looseness

Ambivalence Affect Disturbances

 Positive symptoms
 Refers to Exaggerated distortions of normal thoughts, emotions, and
behavior.
 Appears in the early phase of the illness.
 Gets people’s attention.
 Have a positive reaction to some treatment. In other words, positive
symptoms usually respond to antipsychotics.
 positive symptoms are presented in the form of:

1.Alteration in thinking.
2.Alteration in perceiving.
3.Alteration in behaviors.
 Positive symptoms

Delusions Hallucinations

Formal and Stream

disorders Disturbed behavior
 Alteration in Thinking
Disorders of the Content of Thought
Delusions

The most common delusions are:-

Ideas of reference
Persecution
Grandiosity
Jealousy
Thought broadcasting
Thought insertion
Thought withdrawal
Delusion of being controlled
 Alteration in Thinking
Disorders of the Formal Thought

 Concrete thinking.

 Autistic thinking.
 Alteration in Thinking
Disorders of the Stream of Thinking

 Associative looseness.
 Tangentiality.
 Circumstantiality
 Neologisms.
 Echolalia.
 Clang association.
 Incoherence.
 Word salad.
 Flight of ideas
 Thought blocking.
 Alteration in Perception
 Hallucinations:-
1- Auditory: the most common type in schizophrenia
(commenting or commanding).
2- Visual
3- Tactile
4- Olfactory
5- Gustatory
 Loss of ago boundaries (Unreality states):-

1- Depersonalization.

2- De –realization.
 Alteration in Behavior
• Difficulty in goal directed behavior
(aimless).
• silliness.
• Bizarre and odd behavior.
• Disturbed behavior can take many forms:-
• Extreme motor agitation.
• Stereotyped behavior.
• Automatic obedience.
• Waxy Flexibility.
• catalepsy
• Stupor.
• Negativism.
 Alteration in Behavior

•Bizarre dress and appearance.

•Poor impulse control

(Impulsiveness).
 Cognitive symptoms
• Poor problem-solving skills.

• Poor decision-making skills.

• Illogical thinking.

• Slow thinking and Difficulty understanding.

• Difficulty expressing thoughts.

• Difficulty integrating thoughts, feelings, behaviors.

• Impaired concentration (Inattentive, easily distracted).

• Impaired memory.
• Impaired judgment.
 Affective symptoms

• A flat or blunted affect.

• In appropriate affect.

• Bizarre affect:- as grimacing and giggling.

• Dysphoria.

Suicide
 Develop over a long time.

 Interfere with the individual's adjustment and ability to

survive.
 May be difficult to evaluate because they are not as
totally abnormal as positive symptoms.
 Negative symptoms are presented in the form of:-
 Affective blunting :Reduction in the range and intensity of emotional expression,
including facial expression, voice tone, eye contact and body language, especially when
talking about issues that would normally be expected to engage the emotions.
 Avolition: (Lack of motivation) The reduction, difficulty or inability to initiate and
persist in goal-directed behavior.
 Anergia: Lack of energy.

 Anhedonia: No longer interested in anything.

 Alogia (poverty of speech( Lessening of speech fluency, slowing or blocked thoughts;
often manifested as short, empty replies to questions.
 A-sociality: Social withdrawal.
 Attentional impairment
 Neglect of personal hygiene.
Common Nursing
Diagnoses
Potential for violent : self directed or directed
to others.
Alteration in thought processes.

Sensory perceptual alterations

Impaired verbal communication.

Social isolation.

Ineffective individual coping.

Self -care deficit.

 Alteration in thought process

(related to):-
 [Inability to trust]

 [Panic level of anxiety]

 [Repressed fears]

 [Stress sufficiently severe to threaten an already weak ego]

 [Possible hereditary factors]

 {Sensory perceptual alterations}

 Alteration in thought process

As evidenced by:-

 [Delusional thinking (false ideas)]

 [Inability to concentrate]

 {Autistic thinking}

 distractibility

 [Impaired ability to make decisions, problem-solving}

 [Inappropriate social behavior}

 {Inappropriate non-reality-based thinking}

 Goals/Objectives

Short-Term Goal:-

By the end of 2 weeks, client will recognize and verbalize

that false ideas occur at times of increased anxiety.

Long-Term Goal:-

Client will demonstrate reality based thinking.

 Nursing Intervention

1. Establish a trusting relation ship and actively listen to the

client

2. Convey your acceptance of client’s need for the false

belief, while letting him or her know that you do not
share the belief.

3. Do not argue or deny the belief. Use reasonable doubt as a

therapeutic technique: “I find that hard to believe.”
 Nursing Intervention

4- Help client try to connect the false beliefs to times of

increased anxiety. Discuss techniques that could be used to
control anxiety (e.g., deep breathing exercises, other
relaxation exercises, thought stopping techniques).

5- Reinforce and focus on reality. Talk about real events and

real people.

6- Distract the client from delusion by engaging him in more

comforting activities..
 Nursing Intervention

7- If client is highly suspicious, the following interventions

may be helpful:

a. Use same staff as much as possible; be honest and keep all

promises.

b. Avoid physical contact; warn client before touching to

perform a procedure, such as taking a blood pressure.

c. Avoid laughing, whispering, or talking quietly where client

can see but cannot hear what is being said.
 Nursing Intervention

d. Provide canned food with can opener or serve food family

style.

e.Mouth checks may be necessary following medication

administration to verify whether the client is actually
swallowing the pills.

f.Provide activities that encourage a one-to-one relationship

with the nurse or therapist.
 Nursing Intervention

g. Maintain an assertive, matter of-fact, yet genuine

approach with suspicious clients.

8- Use simple declarative statements when talking to a client

who demonstrate disconnected, incoherent and tangential
speech.

9- Praise as soon as a client begins to differentiate reality

based thinking and non reality.
 Sensory perceptual alterations

Related to:
Panic anxiety

 extreme loneliness

withdrawal into the self.

Stress sufficiently severe to threaten an already weak

ego.
Altered thought process.
 Sensory perceptual alterations
As evidenced by:
[Talking and laughing to self]
[Listening pose (tilting head to one side as if listening)]
[Stops talking in middle of sentence to listen]
[Disorientation]
Poor concentration
[Rapid mood swings]
[Describes hallucinatory experiences]
[Withdrawal]
 Goals/Objectives
• Short-Term Goal:-
Client will hold conversation without hallucinations for
…………..
• Long-Term Goal:-

Client will be able to define and test reality, eliminating

the occurrence of hallucinations.

Client will verbalize understanding that the voices are a

result of his or her illness and demonstrate ways to
interrupt the hallucination.
 Nursing Interventions
1. Observe client for signs of hallucinations (listening
pose, laughing or talking to self, stopping in
midsentence).

2. Assess for hallucinations for content, precipitating

factors and alleviating factors.

3. Avoid touching the client without warning him or her

that you are about to do so.

4. An attitude of acceptance will encourage the client to

share the content of the hallucination with you.
 Nursing Interventions
5. Do not reinforce the hallucination. Use “the voices”
instead of words like “they” that imply validation. Let
client know that you do not share the perception. Say,
“Even though I realize the voices are real to you, I do
not hear any voices speaking.”

6. Help the client understand the connection between

increased anxiety and the presence of hallucinations.

7. Try to distract the client from the hallucination.

 Nursing Interventions
8. Listening to the radio or watching television helps
distract some clients from attention to the voices.
Others have benefited from.

9- an intervention called voice dismissal. With this

technique, the client is taught to say loudly, “Go away!”
or “Leave me alone!” in a conscious effort to dismiss
the auditory perception.

10- Continuously orient the client to environment and real

events.
 Impaired Verbal Communication
related to:-

• [Inability to trust]

• [Panic level of anxiety]

• [Regression to earlier level of development]

• [Withdrawal into the self]

• [Disordered, unrealistic thinking]

• {Altered thought process}

 Impaired Verbal Communication

As evidenced by:-
[Loose association of ideas]

[Use of words that are symbolic to the individual (neologisms)]

[Use of words in a meaningless, disconnected manner (word

salad)]

[Use of words that rhyme in a nonsensical fashion (clang

association)]

[Repetition of words that are heard (echolalia)]


 Goals/Objectives
• Short-Term Goal:-

Client will demonstrate ability to remain on one topic,

using appropriate, intermittent eye contact for ……
• Long-Term Goal:-

By time of discharge from treatment, client will

demonstrate ability to carry on a verbal
communication in a coherent and goal directed
manner.
 Nursing Intervention
1. Seek validation and clarification by stating, “Is it that you
mean . . .?” or “I don’t understand what you mean by that.
Would you please explain it to me?”

2. Maintain staff assignments as consistently as possible, to

facilitate trust and the ability to understand client’s actions
and communication.

3. In a non threatening manner, explain to client how his or her

behavior and verbalizations are viewed by and may push
away others.
 Nursing Intervention
4. Orient client to reality as required. Call the client by name.
Validate those aspects of communication that help
differentiate between what is real and not real.

5. Explanations must be provided at the client’s level of

comprehension.

6. Encourage using of alternative methods to clarify massages

as writing, gestures and drawing.

7. Praise patient’s attempt to speak coherently and to engage in

meaningful conversations with others.
 Social Isolation
1. Convey an accepting attitude by making brief, frequent
contacts.

2. Show unconditional positive regard.

3. Plan items for brief interactions and activities.

4. Discuss with the patient anything of interest to him.

5. Encourage the patient to engage in social interactions

gradually (one to one interaction at first). Then increase
as tolerated.
 Social Isolation
6. Acts as a role model for social behavior in interactions by
maintaining eye to eye contact, appropriate social
distance and calm manner.

7. Give recognition and positive reinforcement for client’s

voluntary interactions with others.

8. Assist the patient to meet basic needs during times of

social withdrawal.