Schizophrenia - Other Psychotic Disorders

Schizophrenia Spectrum and Other
Psychotic Disorders
Mr. Johny Kutty Joseph

Assistant Professor
Schizophrenia
The broad category of schizophrenia includes a set of disorders in
which individuals experience distorted perception of reality and
impairment in thinking, behavior, affect, and motivation.
Clear consciousness and intellectual capacity are usually maintained
although certain cognitive deficits may evolve in the course of time.
The term schizophrenia was coined in 1908 by the Swiss psychiatrist
Eugene Bleuler.
The word was derived from the Greek “ schizo” (split) and ‘phren’
(mind).
Common Misconception…
People who have schizophrenia do not have

multiple personalities or a split personality
They are split from reality – cannot tell what is
real and what is not…
Eugen Bleuler (1857–1939) coined the term

"Schizophrenia" in 1908
Psychosis/Scizophrenia
Psychosis is severe mental condition disorder in which there is
disorganization of the personality, deterioration in social
functioning and loss of contact with, or distortion of reality. There
may be evidence of hallucinations and delusional thinking.
Psychosis can occur with or without presence of organic
impairment.
Schizophrenia is a psychotic condition characterized by a
disturbance in thinking, emotions, volitions, and faculties in the
presence of clear consciousness, which usually leads to social
withdrawal.
Psychosis/Scizophrenia
Psychosis is a broad term which includes hallucinations and
delusions
Schizophrenia is a type of psychosis
Schizophrenia is a complex, heterogeneous psychotic disorder
with variable phenotypic expressions, variable course patterns
and a complex aetiology. It affects individuals, families, and the
society at large, with most of the affected population having
severe symptomatic and functional outcome.
Psychosis Vs Neurosis
Psychosis
Some of the different types of psychosis include:
• Schizophrenia
• Schizoaffective disorder (Manic Depression)
• Delusional disorder
• Substance-induced psychosis
• Dementia and Delirium
• Bipolar disorder (manic depression)
• Major Depressive Disorder
• Postpartum psychosis
• Psychosis due to a general medical condition:
Neurosis
Some of the different types of Neurosis include:
• Depression
• Obsessive-compulsive disorders
• Somatoform disorders (Hysteria, conversion, dissociation)
• Anxiety Disorders
• PTSD
Schizophrenia
Development of Schizophrenia occurs in four phases
 The Pre-morbid Phase: It indicates social malfunctioning, social
withdrawal, irritability, and antagonistic thoughts and behaviour.
It has a pre-morbid personality of shyness, poor peer
relationship, poor academic performance, antisocial behaviour
(According Sadock & Sadock 2007)
 The Prodromal Phase: Occurrence of certain symptoms of
illness. It is marked by the change from the pre-morbid
functioning and extend up to the onset of psychotic symptoms.
It usually range from few months or 2 to 5 years.
Schizophrenia
 Schizophrenia: Prominent psychotic symptoms. According to
DSM 5 the diagnostic criteria of schizophrenia should cover the
following symptoms;
 A. Two or more of the following, each present for at least last one
month. Delusions, Hallucinations, Disorganized Speech, Grossly
disorganized catatonic behaviour, negative symptoms.
 B. Alteration in level of work, relationship, self care.
 C. Continuous signs of the disturbance persist for at least 6 b
months.
 D. Schizoaffective disorders and depressive or bipolar disorder
with psychotic features have been rules out.
Schizophrenia
 E. The disease is not attributable to the physiological effects of
some drugs/medical condition.
 F. Check the history of autism spectrum
disorders/communication disorder in childhood onset.
 G. Specify number of episode, acute/remission, presence of
catatonia, current severity.
 Residual Phase: Schizophrenia characterized by periods of
remission and exacerbation. The symptoms may be prominent
or not. Impaired role functioning and flat affect is observed.
The negative symptoms may remain.
Schizophrenia
 Prognosis
 Difficult to predict.
 Complete return to premorbid functioning is not common.
 It depends on good premorbid functioning, late age of onset,
female gender, associated disorders and brain anomalies.
Epidemiology of Schizophrenia
 0.3 to 0.7% is the prevalence in general population.
 Moreover equally prevalent in men and women but 1.4 times
more frequently in males than females
 Peak age of onset for men is 20 to 28 years and 26 to 32
years in women.
 More common for low socio economic groups.
 In India every year 268.903/100000 people are affected. (as
per WHO statistics 2000)
 The prognosis of Psychosis rely upon the type of symptoms,
age of onset and treatment adherence.
Predisposing / Etiology / Risk factors of Schizophrenia
 The cause of schizophrenia is still uncertain.
 Biological Factors; Genetics and twins.
 Biological Factors;
 The genetic vulnerability of schizophrenia is growing.
 The inheritance of schizophrenia is still uncertain.
 No specific biological markers are yet identified.
 Some people have strong genetic link and some have weak genetic
base and it credence the notion of multiple causations.
 Twin studies show the high significance of mono zygotic twins.
 Adoption studies have also shown more significance with case
group. (children born to schizophrenic mothers) (Minzenberg 2008)
 Biochemical Factors; Dopamine Hypothesis
• Schizophrenia is caused by an excess of dopamine dependant
neuronal activity in the brain. This excess activity leads to
increases release of dopamine, increased receptor sensitivity
to dopamine and number of dopamine receptors.
• Pharmacological studies show that the use of amphetamines
which is a stimulant to increase dopamine levels produce
schizophrenia symptoms. Antipsychotics such as haloperidol
and chlorpromazine block the dopamine receptors thus
reducing the symptoms of schizophrenia.
 Biochemical Factors; Dopamine Hypothesis
• Post-mortem studies of brain of persons who had
schizophrenia show increased number of dopamine receptors.
• The area affected by dopamine are mesolimbic pathway,
mesocortical pathway, nigrostriatal pathway, tuberinfundibular
pathway.
• Mesolimbic pathway: connects midbrain to limbic system.
Deals with memory, emotions, arousal and pleasure. Excess
activity can cause hallucinations and delusions.
• Mesocortical pathway: midbrain to cortex. Deals with
cognition, social behaviour, planning, problem solving,
motivation etc. Diminished activity can cause anhedonia, flat
affect lack of motivation which are the negative symptoms of
schizophrenia.
• Nigrostriatal pathway: substantia nigra (midbrain) to basal
ganglia (cerebral hemisphere). It controls the motor control.
Increased activity can cause psychomotor symptoms.
• Tuberinfundibular pathway: hypothalamus to pituitary gland.
Affects endocrine functions such as digestion, metabolism,
sexual arousal, hunger etc.
Dopamine Receptors are located in
• D1: basal ganglia, cerebral cortex.
• D2: basal ganglia, anterior pituitary cerebral cortex.
• D3: limbic regions, basal ganglia
• D4: frontal cortex, hippocampus, amygdala
• D5: hippocampus, hypothalamus
 Biochemical Factors; Other Factors/hypothesis
• According to various research studies other neurotransmitters
and neuroregulators such as norepinephrine, serotonine,
acetylcholine, glutamate (Hashimoto in 2006 ), GABA and
prostaglandins also predispose schizophrenia.
 Physiological Factors:
• Viral Infection: According to Sadock and Sadock in 2007
prenatal exposure to influenza can cause schizophrenia.
Another study indicate infections of CNS during childhood can
cause schizophrenia at later stage of life.
 Physiological Factors:
• Neurostructural theories: Research suggest the improper
development of prefrontal cortex and limbic cortex in case of
schizophrenia. Imaging study shows decreased brain volume, larger
lateral and third ventricle, atropy of frontal lobe, cerebellum and limbic
structure etc, in case of schizophrenic patients.
• Histological changes: A disordering of pyramidal cells in the area of
the hippocampus has been suggested (Jonsson, Luts et.al 1997)
• Physical conditions: Some studies reported that physical conditions
such as epilepsy (temporal lobe), birth trauma, head injury,
huntington's disease, tumour, CVA etc, in childhood may cause
schizophrenia.
 Psychological Factors;
• Developmental theories: regression to the oral stage, improper use of
defence mechanism such as denial and projection, inadequate ego
development, superego dominance, regressed ID behaviour can
cause schizophrenia.
• Family Theories: faulty mother child relationship such as
overprotection and domineering cause poor ego development.
Hostile/unfriendly behaviour of parents and poor parent child
relationship can cause symptoms of schizophrenia in child.
• In fact, these psychodynamic theories does not hold any credibility as
on date since more evident biological factors are ruled out by different
researchers as the causative factors of schizophrenia.
 Environmental Influences;
• Socio-cultural factors: Lower socio economic class experience
more symptoms of schizophrenia because of poverty,
inadequate nutrition, absence of prenatal care, few resources
for stress management, lifestyle and feeling of hopelessness.
• Stressful Life events: There is no scientific evidence to indicate
the relationship between stress and psychotic disorders. But
few studies have shown that stress may contribute to the
severity of illness. It can precipitate psychotic problems and it
can exacerbate the condition and increase the rate of relapse.
Classification of Schizophrenia/Psychotic disorders
Name of the condition ICD - 10 DSM V
Classificati Classificatio
on n
Schizotypal (Personality) Disorder F 21 303.22
Delusional Disorders F 22 297.1
Brief Psychiatric Disorders F 23 298.8
Schizophreniform disorders F 20.81 295.40
Schizophrenia F 20 ---
Paranoid Schizophrenia F 20.0 ---
Hebephrenic Schizophrenia F 20.1 ---
Catatonic Schizophrenia F 20.2 ---
Name of the condition ICD - 10 DSM V
Classification Classification
Undifferentiated Schizophrenia F 20.3 ---
Post Schizophrenic Depression F 20.4 ---
Residual Schizophrenia F 20.5 ---
Simple Schizophrenia F 20.6 ---
Schizoaffective disorders F25.9 295.90
Substance/Medication induced F 25.1 295.70
Psychotic disorder
Unspecified Schizophrenia & other F 29 298.9
Psychotic disorders.
Schizophrenia Spectrum
 Delusional disorder: Presence of delusions at least for a month, but with
no accompanying hallucinations, thought disorder, mood disorder, or
affect disorders. They are;
1. Erotomanic Type: Presence of Erotomania in which a person believes
that another person (typically of higher social status) is in love with
them. They may follow, contact, hide or pursue to obtain it.
2. Grandiose Type: Delusion Of Grandiosity.
3. Jealous Type: Delusion of jealousy in which the person doubts the
sexual partner for being unfaithful.
4. Persecutory type: more common. Delusion of persecution
5. Somatic Type: Somatic delusion of being sick.
6. Mixed Type.
 Brief psychotic disorder. A sudden onset of psychotic symptoms
for short duration which may include delusions, hallucinations,
disorganized speech or behaviour. These symptoms last at least
1 day but less than 1 month. Catatonic features also may be
shown.
 Schizotypal personality disorder. They are odd or eccentric and
usually have few close relationships. They may also misinterpret
others' motivations and behaviours and develop significant
distrust of others.
 Substance/Medication induced Psychotic disorder:
Hallucinations and delusions are prominent and is attributable to
substance intoxication/ withdrawal. The symptoms are more
severe and excessive than that is usually associated with
withdrawal symptoms.
 Drugs: Alcohol. Amphetamines, Cocaine, Opioids etc.
 Medications: Anaesthetics, Analgesics, Anticonvulsants etc.
 Toxins: CO2, CO, OP insecticides.
Schizophreniform disorder. The symptoms of schizophrenia are
present for a significant portion of the time within a one-month
period or may last up to 6 months.. The symptoms of both
Schizophrenia & Schizophreniform can include delusions,
hallucinations, disorganized speech, and social withdrawal. While
impairment in social, occupational, or academic functioning is
required for the diagnosis of schizophrenia, in schizophreniform
disorder an individual's level of functioning may or may not be
affected. While the onset of schizophrenia is often gradual over a
number of months or years, the onset of schizophreniform
disorder can be relatively rapid.
 Schizoaffective disorder. Schizoaffective disorder is a chronic mental health
condition characterized primarily by symptoms of schizophrenia, such as
hallucinations or delusions, and symptoms of a mood disorder, such as
mania and depression. The client may appear depressed with psychomotor
retardation and suicidal ideation or symptoms include euphoria, grandiosity
and hyperactivity.
 Psychosis due to medical conditions: Psychosis may occur due to CVA, CNS
infections, Fluid Electrolyte imbalance, Neoplasm, Vitamin Deficiency and so
on.
 Catatonic disorder due medical condition. Metabolic disorders, hepatic
encephalopathy, thyroid problems, Vitamin disorders etc. (Stupor, Catalepsy,
Waxy flexibility, mutism, negativism, posturing, stereotypy, echolalia,
echopraxia)
 Schizophrenia.
Paranoid Schizophrenia: The word paranoid means delusional.
It is the common type of schizophrenia. Intact cognitive skills
and affect. Do not show disorganized behaviour. Delusions such
as Grandeur, persecution, reference (self), jealousy.
Hallucinations such as auditory. The best prognosis of all types
of schizophrenia.
Hebephrenic Schizophrenia: Early in onset and poor pre-morbid
personality. The marked features are thought disorders,
incoherence, severe loosening of association and social
impairment. Delusions and hallucinations are fragmentary and
changeable. Worst prognosis of all subtypes.
 Schizophrenia.
Catatonic Schizophrenia: is characterized by marked
disturbance of motor behaviour. This may take form of
catatonic stupor, catatonic excitement and mixed. In case of
excited catatonia it shows restlessness, agitation, excitement,
increased speech production, loosening of association. In case
of catatonic stupor it shows mutism, rigidity, negativism,
stupor, echolalia, echopraxia, waxy flexibility and automatic
obedience. With suitable and effective treatment, the
symptoms can be controlled and the affected individuals can
lead a better quality of life.
 Schizophrenia.
Residual Schizophrenia: There should be at least one episode of
schizophrenia in the past but without prominent psychotic
symptoms at present. The symptoms include emotional blunting,
eccentric behaviour, illogical thinking and social withdrawal.
Undifferentiated Schizophrenia: No other subtypes are satisfied.
Simple Schizophrenia: Similar to residual schizophrenia but no
history of early episode. It is early and insidious onset with
symptoms of wandering, hypochondriasis and aimless activity.
Post Schizophrenic Depression: Similar to Schizoaffective
disorders.
Psychopathology of Schizophrenia
 According to Bleuler;
 Due to different predisposing factors there is loosening of
association which is the primary and fundamental disturbance.
 Through the loosened links in the chains of association
instinctual desired and unconscious wishes can intrude into
the consciousness of the patient.
 His repressed complexes gain the mastery and can entirely
rule his life and behaviour.
 There is disruptions and distortions of personality.
 According to Bleuler;
 Withdrawn from the reality whenever opposed to the impulses
of his complexes.
 Primary symptoms occur (weak will power, emotional stiffness,
and ambivalence.)
 Secondary symptoms occur (Delusions, hallucinations and
catatonic symptoms.)
 According to Berze in 1914;
 Due to organic damage caused by the predisposing factors
insufficient thought and low psychic activity occur.
 The lowered mental activity prevent the person from making
distinction of reality and imagination.
 Delusional ways of thinking, hallucinations and other
associated symptoms occur.
 Commonly affected mental functions are disturbance in
thinking, volition, perception, emotions and catatonic
symptoms.
The dynamics of schizophrenia using transactional model of
stress adaptation.
Precipitating Event (Any event sufficiently

stressful to threaten an already weak ego)
Predisposing Factors (Genetic influences,

biochemical, birth defects, prenatal exposure to
viral infections, abnormal brain structure,
physical problems)
Cognitive appraisal: Personal interpretation of the

situation and possible reactions to it
stress adaptation.
Primary: Perceived threat to self concept or

physical integrity
Secondary: because of weak ego strength,

patient is unable to use effective coping
mechanisms effectively rather they use
maladaptive mechanisms such as denial,
regression etc.
stress adaptation.
Quality of response
Adaptive Maladaptive
Initial psychotic episode or exacerbation of

schizophrenic symptoms
Hallucinations, delusions, social isolations,

violence, inappropriate affect, bizarre behaviour,
apathy, autism.
Clinical Features of Schizophrenia
Positive and Negative Symptoms of Schizophrenia
“Positive” symptoms refer to characteristics that are added to someone’s
state of being.
“Negative” symptoms, in contrast, are characteristics that are removed
from the person’s state of being.
The difference between positive and negative symptoms of
schizophrenia is what they do to the person who is living with
schizophrenia.
Schizophrenia positive symptoms create distortions and new ways of
experiencing the world, while schizophrenia negative symptoms take
things away.
Positive Symptoms of Schizophrenia
Content of thought
 Delusions: Different types such as persecution, grandeur,
reference, control, somatic, nihilistic (non existence of a part of
body) etc.
 Religiosity: Excess obsession of religious ideas and behaviour.
Gives rational meaning to his/her behaviour. Religious
preoccupation may be seen.
 Paranoia: Extreme suspiciousness.
 Magical thinking: A strong belief that one’s thought can control a
specific situation or people as seen in children. Eg. Its raining
because I demanded it.
Form of thought
 Associative looseness: speech unrelated each other (Eg. We wanted to take the bus but
the airport took all the traffic)
 Neologisms: New words. (Would you like to use my new uniphorum)
 Clang associations: Choosing words by sounds.
 Concrete thinking: The literal meaning of words. Cannot explain the meaning of “I am
climbing the walls”.
 Word salad: group of words with no logical connection. (Most forward action grows life
double.)
 Circumstantiality: unnecessary details in speech before returning to the point of
communication.
 Tangentiality: person never return back to the point of communication.
 Mutism
 Preservation: repetition of same words or ideas in response to different questions.
Perception
 Hallucinations: auditory, visual, tactile, gustatory, olfactory
 Illusions
Sense of Self
 Echolalia: repeat the words that one hear
 Echopraxia: repeat the action that one see
 Depersonalization: unstable personal identity
Negative Symptoms of Schizophrenia
Affect
 Inappropriate affect: emotional tone is incongruent with the
circumstances.
 Flat Affect: voiding of emotion tone or its expression
 Apathy: Lack of interest in the matters/environment.
Volition
 Inability to initiate goal directed activity
 Emotional ambivalence: coexistence of opposite emotions
towards same object.
 Deteriorated appearance: neglecting personal grooming
Negative Symptoms of Schizophrenia
Interpersonal Functioning
 Impaired social interaction
 Social isolation
Psychomotor Behaviour
 Anergia; deficiency of energy
 Waxy Flexibility
 Posturing; inappropriate and bizarre positions
Associated Features
 Anhedonia; inability to experience pleasure
 Regression: retreat to an early level of development.
Diagnosis of Schizophrenia
Diagnosis of schizophrenia involves ruling out other mental
health disorders and determining that symptoms are not due to
substance abuse, medication or a medical condition.
Determining a diagnosis of schizophrenia may include:
Physical exam. This may be done to help rule out other
problems that could be causing symptoms and to check for any
related complications.
Tests and screenings. These may include tests that help rule
out conditions with similar symptoms, and screening for alcohol
and drugs. The imaging studies, such as an MRI or CT scan.
Diagnosis of Schizophrenia
Psychiatric evaluation. MSE should be performed to assess the
problems associated with thoughts, moods, delusions,
hallucinations, substance use, and potential for violence or
suicide. This also includes a discussion of family and personal
history.
Diagnostic criteria for schizophrenia. A doctor or mental health
professional may use the criteria in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), or ICD 10
criteria for ruling out the condition.
Treatment of Schizophrenia
Schizophrenia requires lifelong treatment, even when
symptoms have subsided.
Treatment with medications and psychosocial therapy can help
manage the condition.
In some cases, hospitalization may be needed.
A psychiatrist experienced in treating schizophrenia usually
guides treatment.
The treatment team also may include a psychologist, social
worker, psychiatric nurse and possibly a case manager to
coordinate care.
Treatment of Schizophrenia: Organic
Psychopharmacology
Antipsychotic medication are effective in the treatment of acute and
chronic manifestations of schizophrenia.
Without drug therapy the chance of relapse of schizophrenia is 72%
(Dixon, Lehman 2010)
The efficiency of antipsychotic medications is enhanced by adjunct
psychosocial therapy.
The antipsychotics are broadly classified into typical and atypical
antipsychotics. Typical antipsychotic agents are also called as first
generation / conventional antipsychotics. Atypical antipsychotic
agents are also called as second generation / novel antipsychotics.
Psychopharmacology: Indications
Acute and chronic schizophrenia: All
Other psychotic disorders (delusional disorders, schizoaffective disorders
etc.)
Capgras syndrome: A delusion that other person in the environment is
not real selves but is their own doubles. (Delusion of Doubles)
Acute & Transient Psychotic Disorders: Brief Psychotic disorder.
Bipolar Mania: Olanzipine, chlorpramazine, risperidone.
Intractable hiccoughs (chronic hiccoughs last for more than a month due
to the damage to vagus nerve.) : Chlorpramazine
Antiemetics: Chlorpramazine
Tics, Vocal utterances, Tourette’s syndrome (type of tic): Haloperidol.
Organic treatments
 Use of Antipsychotics/neuroleptics/major tranquilizers
Typical Antipsychotic Agents. First Daily Dose
Generation/ Conventional Range (mg)
Chlorpramazine 40 – 400
Fluphenazine 2.5 – 10
Haloperidol 1 – 100
Loxapine 20 – 250
Trifluoperazine 4 – 40
Pimozide 1 - 10
Treatment of Schizophrenia; Organic
Organic treatments
 Use of Antipsychotics/neuroleptics/major tranquilizers
Atypical Antipsychotic Agents. Second Daily Dose
Generation/ Novel Range (mg)
Aripiprazole 10 – 30
Asenapine 10 – 20
Clozapine 300 – 900
Olanzipine 5 – 20
Risperidone 4–8
Paliperdidone 6 - 12
Both typical and atypical antipsychotics are dopamine
antagonists, which means that they impede chemical
messengers in the brain known as dopamine.
In people with psychosis, dopamine signals are typically
abnormal. Antipsychotics block those messages.
Atypical antipsychotics also influence a chemical messenger
known as serotonin.
Atypical antipsychotics are most typically prescribed to
treat schizophrenia, and to augment the treatment of major
depressive disorder (MDD), bipolar disorder, and schizoaffective
disorder.
Typical antipsychotics are more likely to cause extra-pyramidal
side effects in which motor control is sometimes severely
impaired, causing tremors, spasms, muscle rigidity, and the loss
of control and coordination of muscle movement. In some
cases, the symptoms may become permanent even after the
treatment is stopped.
Atypical antipsychotics are far less likely to cause extra-
pyramidal side effects. With that being said, they are known to
cause weight gain, metabolic problems, and sexual side effects,
among others.
Typical antipsychotics are more likely to cause extra-pyramidal
side effects in which motor control is sometimes severely
impaired, causing tremors, spasms, muscle rigidity, and the loss
of control and coordination of muscle movement. In some
cases, the symptoms may become permanent even after the
treatment is stopped.
Atypical antipsychotics are far less likely to cause extra-
pyramidal side effects. With that being said, they are known to
cause weight gain, metabolic problems, and sexual side effects,
among others.
Contraindications/Precautions
Typical Antipsychotics: Hypersensitivity, CNS depression,
Parkinsonism, glaucoma, liver/renal problems, seizures.
It may produce hypotension, anti cholinergic effects, reduce the
effect of oral anticoagulants.
Atypical antipsychotics: NCD (Neuro cognitive disorder) related
psychosis, hypersensitivity, hepatic/renal insufficiency.
It also may produce hypotensive actions, CNS effects, anti
cholinergic actions.
Side Effects
The side effects are related to stoppage of dopamine receptors.
It may help to manage positive symptoms of schizophrenia but also cause
extra pyramidal symptoms.(dystonia, akathisia, brady kinesia, tardive
dyskinesia, parkinsonism)
Elevated prolactin level: cause gynecomastia/galactorrhea
Anti cholinergic effects: dry mouth, blurred vision, constipation, urinary
retention.
Blockage to alpha 1 adrenergic receptor may cause dizziness, orthostatic
hypotension.
Histamine blockade may result in weight gain and sedation.
GI disturbances
Psychological treatments
 Individual therapy: Reality oriented individual therapy is the
most suitable approach. Primary focus shall be to decrease
anxiety and increase trust. Establish relationship, provide reality
orientation, improve communication. It is a long term process.
 Group therapy: it is done in long term care not as inpatient.
Improve social interaction, sense of cohesiveness, reality
orientation etc. It is effective in reducing social isolation,
increasing the sense of cohesiveness, improving the reality
testing.
Psychological treatments
 Behaviour Therapy: helps to reduce the frequency of bizarre,
disturbing and deviant behaviours and increasing appropriate
behaviour. It is useful to use aversion training, reinforcement to
adaptive and maladaptive behaviour.
 Social Skill Training: to improve social dysfunction by using role
plays of day to day life activities. It include nonverbal behaviour
( facial expression, eye contact), paralinguistic features (voice
loudness, and affect), verbal content, interactive balance
(response latency) and so on.
Social treatments
 Milieu Therapy: a psychotherapy where patient join a group of
30 for 9 to 18 months. They are encouraged to take care of
others, unit and self with responsibility. It promotes group and
social interaction. Rules and expectations are mediated by peer
pressure for normalization of adaptation.
 Family Therapy: to improve family coping.
 PACT (Program of Assertive Community Treatment): A program
of rendering mental health service at home/halfway homes by
the mental health team.
Social treatments
 The Recovery Model: Weiden (2010) identifies two types of
recovery of schizophrenic patients. Functional (level of
functioning such as relationship, work, independent living etc.)
and Process (long term with no end point. Step by step
improving while symptoms are present; chronic patients).
 Recovery can be considered as a process and it has no definite
end point.
 The health professional, patient / family need to discuss the
adaptable model so that the desired goal may be set
accordingly.
Treatment of Schizophrenia: Nursing Management
Disturbed sensory perception
• Observe the client for signs of hallucination
• Avoid touching the patient without warning because it may be
threatening.
• maintain an attitude of acceptance and encouragement.
• Educate the relation between anxiety and hallucination.
• Distract the client from hallucination
Disturbed thought process
• Convey acceptance of the clients need for the false belief.
• Do not argue or deny the belief.
• Reinforce and focus on reality.
• Use the same staff to deal with the patient to avoid doubt.
• Avoid physical contact. Be assertive.
• Avoid laughing, whispering and talking quietly in front of the patient
or a place where the patient can see/listen the nurse.
• Special tray/packed food.
• Mouth check (patient) of the medication.
Risk of Violence: Self Directed or Other Directed
• Maintain low level of stimuli in environment. (low lighting, few
people, simple decor, low noise)
• Observe client’s behaviour frequently.
• Avoid suspiciousness
• Remove dangerous objects from clients environment.
• Maintain calm attitude towards the patient.
• Maintain sufficient number of staff in ward.
• Availability of restraints.
Impaired Verbal communication
• Facilitate trust and understanding by maintaining staff
assignments as consistent.
• Anticipate and fulfil the needs of patient.
• Orient the client to reality as required. Call by name, Use of
Communication techniques.
• Give proper explanations to all treatments procedure.
Treatment of Schizophrenia: Psycho Education
Caution while driving/operating a complex machine
Drug compliance
Weekly reporting (clozapine: assess the serum level of drug)
Report side effects/ or any abnormal symptoms.
Rise slowly from sitting/lying
Sips of water
Avoid alcohol while on antipsychotics
Consult before taking any other medication.

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Schizophrenia - Other Psychotic Disorders

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Schizophrenia Spectrum and Other

Mr. Johny Kutty Joseph

People who have schizophrenia do not have

Eugen Bleuler (1857–1939) coined the term

Precipitating Event (Any event sufficiently

Predisposing Factors (Genetic influences,

Cognitive appraisal: Personal interpretation of the

Primary: Perceived threat to self concept or

Secondary: because of weak ego strength,

Initial psychotic episode or exacerbation of

Hallucinations, delusions, social isolations,

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