DEFINITION OF SCHIZOPHRENIA

 Schizophrenia is a group of psychotic disorders characterized by major

impairment in thought, perception, emotion, volition and behavior.
 Schizophrenia refers to a group of severe, disabling psychiatric disorders
marked by withdrawal from reality, illogical thinking,
possible delusions and hallucinations, and emotional, behavioral, or
intellectual disturbance.
 These disturbances last for at least for six (6) months. The level of functioning
in work, interpersonal relationship, and self-care are markedly below the level
since the onset of symptoms.
 Have difficulty distinguishing reality from fantasy. Their speech and behavior
may frighten or mystify those around them.
 About 30% of individuals diagnosed with schizophrenia experience a complete
 HISTORY OF SCHIZOPHRENIA

Emile Kraepelin (1896), was the first psychiatrist to describe its

natural history and the prognosis of the disease, hence he is called
the father of Psychopathology and at that time he called it
DEMENTIA PRAECOX (Madness of the youth), but later in 1911, a
Swiss psychiatrist Eugene Bleuler built on Kraepelin’s observations
and coined the word SCHIZOPHRENIA, which was derived from the
Greek ``skhizo’’ (split) and ``phren’’ (mind).
Incidence

1. Is higher in persons with a first degree relative

2. Is higher in the lower socio-economic group
3. It occurs more commonly in men than in women
4. Affects approximately 1% of the total population
5. Age: Adolescents and young adults are the most affected age
group
6. It accounts for about 60% of psychiatric patient at the hospital.
7. Geographical location: Common in urban areas than those in the
rural areas
 Causes
1. Genetic or hereditary factors
2. Biochemical factors e.g. Dopamine/Serotonin Hypothesis
3. Environmental factors e.g. Divorce/separation, disappointments,
bereavement, unemployment, poverty, broken homes
4. Body build: Asthenic/ Leptosomic - They are tall, lanky, skinny and narrow
chested, timid, and introverted.
5. Premorbid personality e.g. Schizoid personality
6. Cerebral tumours/Head injuries
7. Drug: Alcohol, Cocaine, Amphetamines, Marijuana
8. Infection: Typhoid fever, meningitis
 The Cardinal Signs and Symptoms of
Schizophrenia

1. Disorders of Emotion (Affect). This includes symptoms like incongruity of affect,

blunting of affect, flat affect, etc
2. Disorder of Thought: (here, patient is unable to organize ideas and speak
appropriately) Examples: Disorder of thought includes; thought block, loose
association, clang association, poverty of speech, incoherence of speech,
thought broadcast, thought alienation. Disorder of thought content; delusions
of grandeur, persecutory, ideas of reference.
3. Disorder of Perception: Examples include auditory, visual hallucinations,
illusions etc.
 The Cardinal Signs and Symptoms of
Schizophrenia cont’
4. Disorder of Behavior/Movement: Examples stereotype, grimaces,
mannerisms, catalepsy, Waxy flexibility etc.
a. Verbigeration is the stereotyped repetition of words or phrases that may or
may not have meaning to the listener.
b. Stereotype Behavior: Patient may repeat the same pattern of movement
unceasingly.
7. Avolition: Example lack of drive, lack of initiative, lack of interest.
8. Withdrawal from Reality: Example loss of touch with the environment/the real
world.
 Positive signs and symptoms of
Schizophrenia
Positive symptoms are disturbances that are “added” certain
capability to the person’s personality. i.e.
1. Delusions
2. Hallucinations
3. Disordered thinking and speech
4. Disorganized behavior
Examples of positive symptoms include the
following:
Disorders of thought
a. Delusions (such as somatic, grandiose, religious, nihilistic, persecutory, etc.).
b. Depersonalization
c. Concrete thinking
d. Magical thinking
e. Paranoia
Disorders of perception
f. Hallucinations (auditory, visual, olfactory, tactile)
g. illusion
Disorganization of speech

a. Incoherence
b. Derailment
c. Neologisms
d. Perseveration
e. Mutism
f. Tangentiality
g. Loosening of association
h. Circumstantiality
i. Word salad
j. Clang association
k. echolalia
Disorganization of behavior

a. Bizarre behavior (inappropriate social behavior).

b. Impulsivity
c. Aggression
d. Violence
e. Arguementative
f. Agitation
g. Stereotypy (echoprexia)
h. Restlessness
i. Catatonic excitement
j. Hypervigilance
k. Inappropriate sexual behaviors
 Negative signs and symptoms of Schizophrenia
Negative symptoms are capabilities that are “lost” from the person’s personality or This
refers to reduced or lack of ability to function normally example are;
1. Social withdraw and reduced speaking
3. Lack of drive or initiative
4. Alogia: Difficulty speaking, which might mean a significant reduction in the amount of
words spoken or in the ability to speak with ease or use detail when communicating
5. Loss of motivation
6. Disinterest or lack of enjoyment in daily life
7. Difficulty planning, beginning, and sustaining activities
8. Displaying a “flat affect" (difficulty expressing emotions using facial expression or voice
tone)
Anhedonia: An inability to experience pleasure from social situations or physical activities like
eating, touching, or sex
 Types of Schizophrenia

The following are the types of Schizophrenia according to the

DSM-IV-TR (APA, 2000)
1. Paranoid Schizophrenia
2. Disorganized Schizophrenia
3. Catatonic Schizophrenia
4. Undifferentiated Schizophrenia
5. Residual Schizophrenia
 PARANOID SCHIZOPHRENIA
This is characterized mainly by the following;
1. Preoccupation with systematize delusions of persecutory or grandiose, Ideas
of reference, and occasionally excessive religiosity (delusional religious focus)
2. Experience frequent Auditory hallucinations,
3. May be argumentative, hostile, impulsive, aggressive and suspiciousness
4. The individual is often tense, highly suspicious of any one around him.
5. Personality is much more preserved
6. Client uses defense mechanism of projections
7. Stress may worsen patient symptoms
NB: Prognosis is better than the other types of schizophrenia
 DISORGANIZED/HEBEPRENIC SCHIZOPHRENIA

Incidence: This start in early adulthood

ONSET: Is insidious or subacute
This is characterized by the following;
1. Marked by incoherent, disorganized speech and behaviors, and blunted or
inappropriate affect
2. There are silly giggles (smiling and laughing at one moment and crying at the next
moment)
3. Facial grimacing and mannerisms
4. Delusions are unsystematized and fragmentary
5. He may exhibit verbigeration, thought insertion and flight of ideas
6. Hallucinations are usually auditory, but there may be visual ones.
7. Usually includes extreme social impairment
 Cont’
7. There is regressed behavior (he may cry for food when he is hungry and may also
urinate and defaecate in his clothes).
8. There is gross neglect of personal hygiene
9. They have gross diminution of will power and drive and can therefore perform
only minimal and repetitive jobs like empting of dustbins, sweeping, scrubbing of
gutters etc.
10. There is also hypochondriacal delusions and morbid preoccupation with bodily
functions e.g. nihilism
11. Personality disintegration, lack of insight is more marked than in any other
schizophrenic types.
12. They may walk about in nudity
13. It is also characterized by regressive primitive inappropriate behaviours.
 CATATONIC SCHIZOPHRENIA

This is characterized by marked psychomotor disturbance, either motionless or

excessive motor activity.
Incidence: Affects mainly teenagers and young adults between age 15 – 25years
Onset is sudden and acute
The diagnostic criteria for catatonic schizophrenia include:
1. Inability to move
2. Inability to speak
3. Staying still for a long time (in the same position)
4. Overly excited (or excessive) seemingly non-purposeful behavior
5. Resistance to being; being uncooperative (resisting instructions)
Cont’

6. Grimacing, unusual postures, odd movements

7. Echolalia and Echopraxia - mimicking what other
people say and mimicking other people's movements
 Two phase of Catatonic Schizophrenia

1. Stuporous phase

2. Excitement phase

STUPOROUS PHASE: a form of catatonia characterized by a

marked decrease in response to the environment with a
reduction in spontaneous movement.

Patients with this disorder sometimes appear unaware of their

environment. Or Is characterized by extreme psychomotor
 STUPOROUS PHASE
1. Patient is withdrawn, inactive, immobilized; they may sit or stand at one place for hours on
end.
2. They exhibit waxy flexibility (the person maintain position in which he/she has been placed)
3. Psychological pillow/ psychic-pillow (Catalepsy): People with catatonic features may lie
down with their head a few inches above the bed as if there were an “invisible pillow” or
they may assume uncomfortable postures for a long time.
4. Stares blankly into space or down.
5. They exhibit mutism
6. Neglect of personal hygiene
7. Uncooperative - the patient may resist any attempt to move them. They may say absolutely
nothing (not speak) and not respond to instructions
NB: However, they are able to hear and observe everything that goes on before during this
phase and can recall after recovery.
 EXCITEMENT PHASE
This phase is manifested by a state of extreme psychomotor agitation.
This is characterized by the following;
1. Movements are frenzied and purposeless
2. Patient may have suicidal and homicidal tendencies
3. Patient may exhibit pressure of thought, Neologisms, Word salad
4. They can be aggressive and assaultive
5. Auditory hallucinations
6. Insomnia
7. They are destructive, impulsive and unpredictable
8. Echolalia (repeating words or phrases spoken by others).
UNDIFFERENTIATED SCHIZOPHRENIA

This is characterized by mixed schizophrenic symptoms (of

other types) along with disturbances of thought, affect, and
behavior. The essential features are prominent psychotic
symptoms i.e.
1. Hallucination,
2. Incoherence, or grossly disorganized behaviors.
3. Impaired interpersonal functioning
4. Disturbances of thought content
 RESIDUAL SCHIZOPHRENIA

The person is in a state of partial remission of his symptoms.

1. The individual has a history of at least one schizophrenia episode but no longer
exhibits serious psychotic symptoms and persistence of negative symptoms
2. In the residual stage, there is continuing evidence of the illness, although there
are no prominent psychotic symptoms. Residual symptoms may include;
3. Social isolation
4. Eccentric behavior
5. Impairment in personal hygiene and grooming
6. Blunted or inappropriate affect
7. Poverty of or overly elaborate speech
8. Illogical thinking
9. Apathy
 RELATED DISORDERS
Other disorders are related to but distinguished from schizophrenia in terms of
presenting symptoms and the duration or magnitude of impairment. The DSM-IV-
TR (APA, 2000) categorizes these disorders as follows:
 Schizophreniform disorder: The client exhibits the symptoms of schizophrenia
for least 1 month but less than the 6 months necessary to meet the diagnostic
criteria for schizophrenia (APA, 2013). Social or occupational functioning may
or may not be impaired.
 The diagnosis of schizophreniform disorder is changed to schizophrenia if the
clinical features persists beyond 6 months.
 Schizoaffective disorder: The client exhibits the symptoms of psychosis and, at
the same time, all the features of a mood disorder, either depression or mania.
 RELATED DISORDERS

 Delusional disorder: The person has experienced at least one delusion for at
least one month but has never met the criteria for schizophrenia. Functional
impairment is due to the delusion only and not experienced outside of it.
 Brief psychotic disorder: The client experiences the sudden onset of at least
one psychotic symptom, such as delusions, hallucinations, or disorganized
speech or behavior, the symptoms last for at least 1 day but less than 1
month with an eventual full return to the premorbid level of functioning (APA
2013). The episode may or may not have an identifiable stressor or may
follow childbirth.
 Shared psychotic disorder (folie a deux)/Induced Psychotic Disorder: This is
a mental disorder in which the client develops a delusional system as a result
of a close relationship with another person who has an already established
delusion. This condition is also known as Folie a deux, i.e. ``sharing of
delusions by two or Madness of two’’.
 MANAGEMENT OF SCHIZOPHRENIA

1. Ensure adequate rest and sleep by providing a well lied

comfortable bed.
2. Personal hygiene: Assist client to maintain oral toileting, bath,
grooming, care of hair, hand and feet and change of dirty
clothing.
3. Exercises: Passive and active exercises should also be
encouraged to enhance circulation particularly catatonic stupor.
4. Diet: Serve client with a well balance or nutritious diet at
frequent interval. Very ill patient may be fed through a Naso–
gastric tube or IV fluid, when cannot tolerate oral diet.
 MANAGEMENT OF SCHIZOPHRENIA
cont’

6.Medication: Served client prescribed medication e.g.

Antipsychotic drug and monitor it side effect.
7. Monitor client’s vital signs.
8. Remove all potentially harmful objects from client’s vicinity
9. Prepare client for Electro-convulsive therapy (ECT) when
necessary.
10. Prepare and assist client to take any laboratory test or
diagnostic test. Example Urinalysis, Liver function tests, Thyroid
function test, CT Scan and MRI.
Cont’

11. Create a regular schedule of activities of daily living.

12. Establish therapeutic nurse/ patient relationship
13. Counseling and education of family/significant others
about the disease condition.
Nursing Diagnoses

1. Impaired Physical Mobility related to depressive mood state and

reluctance to initiate movement.
2. Impaired Social Interaction related to problems in thought patterns
and speech.
3. Decreased Cardiac Output related to orthostatic hypotensive drug
effects.
4. Risk for Suicide related to impulsiveness and marked changes in
behavior.
5. Risk for Injury related to hallucinations and delusions.
6. Risk for Imbalanced Nutrition: less than body requirements related
to self-neglect and refusal for self-care.
 THOUGHT DISORDERS

Normal human thinking has three characteristics

1. Thought Content: Is what the person is actually thinking
about this would include delusions and obsessional thoughts
2. Thought process/ form: Is patient’s ability to express ideas
and the form that the thought takes.
3. Stream or flow: how it is being thought about – the amount
and speed of thinking
 Disorder of Thought content;

 Thought alienation: A symptom of schizophrenia and mania, in which the patient

feels that his own thoughts are in some way no longer within his control by
being, for example, removed or replaced by someone else, or an outside force.
 Thought broadcasting: a delusional belief that others can hear or know what the
client is thinking.
 Ideas of reference: client’s inaccurate interpretation that general events are
personally directed to him or her, such as hearing a speech on the news and
believing the message had personal meaning
They may include experiences such as:
– feeling that people on television or radio are talking about, or talking directly to
them
– believing that headlines or stories in newspapers are written especially for them
Cont’
Thought insertion: a delusional belief that others are
putting ideas or thoughts into the client’s head – that is
the ideas are not those of the client
a delusion in which the individual believes
that thoughts have been irresistibly forced into his or her
mind and ascribes these thoughts to outside sources.
Thought withdrawal: a delusional belief that others are
taking the client’s thoughts away and the client is
powerless to stop it.
 Disorder of Thought form;
Loosening of associations: Ideas are unrelated. When the
connections between different ideas are broken, the output
is disorganized and meaningless. Loose associations are
often called out by other names such as derailment,
– “I like to dance, all people have hands.”
– “I like to play games because the river is flowing down a mountain.”
– “The weather is sunny, the monkey has a long tail.”
Clang associations: word association by rhyming. Example:
“it is very cold. I am cold and bold. The gold has been sold”
 Quite pathetic, apologetic, paramedic
 Cont’
Punning: word association by double meaning
Circumstantiality: Patient keeps going round his speech with many
unnecessary and minute details but finally the main idea is
expressed.
Tangential thinking: wandering off the topic and never providing the
information requested. Patient does not reach the final goal but
loses track of the original topic he started with and ends with a
different topic or idea altogether.
Verbigeration: where speech is reduced to a senseless repetition of
sounds and phrases (this is more of a disorder of thought form)
.

Cont’
Neologisms are words and phrases invented by the patient.
Peseveration: Persistent repetition of words or ideas even
when another person attempts to change the topic
This is especially seen in ‘organic’ brain disorders like dementia.
Word salad: flow of unconnected words or mixing words that
convey no meaning to the listener. “The Juda killer Iraq Accra
Ghana.”
Alogia: This thought disorder is characterized by poverty of
speech and is commonly seen in people with schizophrenia or
dementia. Responses are often abrupt and incomplete.
 Disorder of stream thought;

Retardation of thinking is often seen in depression, the train of

thought is slowed down, although still goal directed. The opposite
is pressure of speech and this is often seen in mania
Flight of ideas: The thought process is so fast that no ideas are
completed. In other words, the patient jumps from one idea to
another without completing any of the ideas.
Thought blocking or thought stopping: This is when the thinking
process stops all of a sudden during speech. For the speech
process to continue, the speaker would have to start a new topic
altogether.
Disorder of Motor Behavior;

 Automatisms: repeated purposeless behaviors often indicative of

anxiety, such as drumming fingers, twisting locks of hair, or tapping
the foot.
 Psychomotor retardation: overall slowed movements
 Waxy flexibility: maintenance of posture or position over time
even when it is awkward or uncomfortable.
 Echopraxia: This is a purposeless imitation of movements made by
other people.
 Common disorder of Mood/Affect

Blunted affect: showing little or a slow-to-respond facial expression

Broad affect: displaying a full range of emotional expressions
Flat affect: showing no facial expression
Inappropriate affect: displaying a facial expression that is
incongruent with mood or situation; often silly or giddy regardless of
circumstances.
Labile: when client exhibits unpredictable and rapid mood swings
from depressed and crying to euphoria with no apparent stimuli.
Ambivalence: A state where one has both contradicting feeling
towards a situation. The patient may like you and hate you at the
same time.
 PERCEPTIONS

a.Hallucinations - false sensory perceptions without external stimuli

(e.g. auditory, visual, olfactory, gustatory, tactile, kinesthetic)
b. Illusions – a misinterpretation of normal stimuli.