Management of Schizophrenia & other Psychotic disorders

1. NURSING MANAGEMENT OF PATIENT WITH
SCHIZOPHRENIA, AND OTHER PSYCHOTIC
DISORDERS
PREPARED BY
Mrs. Divya Pancholi
M.Sc. (Psychiatric Nursing)
Assistant Professor
SSRCN, Vapi

2. DIFFERENCE
BETWEEN
PSYCHOSIS & NEUROSIS

3. Sr
no.
PSYCHOSIS NEUROSIS
1. Etiology
1.1 Genetic factors More important Less important
1.2 Stressful life situations Less important More important
2. Clinical features
2.1 Disturbance of thinking
& perception
Common Rare
2.2 Disturbance in
function
Common Rare
2.3 Behaviour Markedly affected Not affected
2.4 Judgement Impaired Intact
2.5 Insight Lost Present
2.6 Reality testing Lost Present

4. 3. Treatment
3.1 Drugs Major tranquilizers
Commonly used
Minor
& anti-
depressants are
commonly used
3.2 ECT Very useful Not useful
3.3 Psychotherapy Not much useful Very useful
4. Prognosis Difficult to treat;
Relapses are common,
Complete recovery may not
be possible
Relatively easy to
treat; relapses are
uncommon,
Complete
is possible

5. DEFINITION
Schizophrenia is a psychotic condition
characterized by a disturbance in thinking,
emotions, volitions (actions) and faculties in
the presence of clear consciousness, which
usually leads to social withdrawal.

6. ETIOLOGY
BIOLOGICAL THEORIES
PSYCHODYNAMIC THEORIES
VULNERABILITY STRESS MODEL
SOCIAL FACTORS

7. BIOLOGICAL THEORIES
 Biochemical theories:
The Dopamine Hypothesis
 Increase of dopamine in the brain.
Other Biochemical Hypotheses
 Abnormalities in the neuronal activity of the neurotransmitters
norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric
acid and in the neuroregulators, such as prostaglandins and
endorphins, have been suggested.

8.  Areas of the Brain Affected
 Four major dopaminergic pathways have been identified:
 Mesolimbic pathway: The mesolimbic pathway is associated with
functions of memory, emotion, arousal, and pleasure. Excess
in the mesolimbic tract has been implicated in the positive
symptoms of schizophrenia (e.g., hallucinations, delusions).
 Mesocortical pathway: The mesocortical pathway is concerned with
cognition, social behavior, planning, problem solving, motivation,
and reinforcement in learning. Negative symptoms of
(e.g., flat affect, apathy, lack of motivation, and anhedonia) have
been associated with diminished activity in the mesocortical tract.
NEUROBIOLOGY OF SCHIZOPHRENIA

9. CONTI….
 Nigrostriatal pathway: This pathway is associated with the
function of motor control. Degeneration in this pathway is
associated with Parkinson’s disease and involuntary
psychomotor symptoms of schizophrenia.
 Tuberoinfundibular pathway: It is associated with endocrine
function, digestion, metabolism, hunger, thirst, temperature
control, and sexual arousal. Implicated in certain endocrine
abnormalities associated with schizophrenia.

10. DOPAMINE PATHWAYS

11.  Neurostructural theories:
 CT scan and MRI studies of brain structure shows
 Decreased brain volume
 Larger lateral and third ventricles
 Atrophy in the frontal lobe, cerebellum and limbic
structures
 Increased size of sulci on the surface of the brain.

12.  Genetic theories:
Disease is more common among people born of
marriages. Studies show that relatives of schizophrenics have a
much higher probability of developing the disease than the
general population.
 Prenatal risk factors:
 Maternal influenza
 Birth during late winter or early spring
 Complications of pregnancy particularly during labor and
delivery

13. PSYCHODYNAMIC THEORIES
Developmental theories:
According to Freud, there is regression to the oral
of psychosexual development, with the use of defence
mechanisms of denial, projection and reaction
formation.
The individuals have poor ego boundaries, fragile ego,
inadequate development, super ego dominance,
regressed id behaviour, love-hate (ambivalence)
relationships and arrested psychosexual development.

14.  Family theories:
Mother-child relationship: Early theorists characterized the
mothers of schizophrenics as cold, over-protective, and
dominnering, thus retarding the ego development of the
child.
Dysfunctional family system: Hostility between parents can
lead to a schizophrenic daughter
Double-blind communication: Parents convey two or more
conflicting and incompatible messages at the same time.

15. VULNERABILITY STRESS MODEL
This model recognizes that both biologic
and psychodynamic predispositions to
schizophrenia, when coupled with
stressful life events, can precipitate a
schizophrenic process.

16. SOCIAL FACTORS
 Studies have shown that schizophrenia is more
prevalent in areas of high mobility and
disorganization, especially among members of very
low social classes.
 Stressful life events also can precipitate the disease
in predisposed individuals.

17. TYPES OF SCHIZOPHRENIA

18. TYPES OF SCHIZOPHRENIA
 Disorganized/ hebephrenic
schizophrenia
 Catatonic schizophrenia
 Catatonic stupor
 Catatonic excitement
 Paranoid schizophrenia
 Undifferentiated schizophrenia
 Residual schizophrenia
 Schizoaffective disorder
 Brief psychotic disorder
 Schizophrenic form disorder
 Shared psychotic disorder
 Psychotic due to general medical
condition
 Substance induced psychotic
disorder

19. 1. DISORGANIZED/ HEBEPHRENIC SCHIZOPHRENIA
 Onset: before age 25.
 Course: chronic
 Behavior: regressive &
primitive.
 Contact with reality is
extremely poor.
 Affect: flat & inappropriate.
 Periods of silliness &
incongruous giggling.
 Facial grimaces & bizarre
mannerisms.
 Incoherent communication.
 Personal appearance: generally
neglected
 Extreme social impairment

20. 2. CATATONIC SCHIZOPHRENIA
CATATONIC STUPOR
 Marked abnormalities in motor behavior.
 Extreme psychomotor retardation
 Pronounced decrease in spontaneous movements &
activity.
 Mutism: absence of speech
 Negativism: An apparently motiveless resistance to all
instructions or attempts to be moved.
 Waxy flexibility: Voluntary assumption of bizarre
position in which the individual may remain for long
periods.

21. CONTI…
 Rigidity: Efforts to move the individual may be met with rigid bodily
resistance.
 Posturing: voluntary assumption of an inappropriate and often bizarre posture
for long periods of time
 Stupor: Does not react to his surroundings and appears to be unaware of them
 Echolalia: Repetition of words heard
 Echopraxia: Repetition of mimicking of actions observed
 Ambitendency: A conflict to do or not to do
 Automatic obedience: Obeys every command irrespective of their nature

22. CATATONIC EXCITEMENT
 State of extreme psychomotor agitation.
 Movements: Frenzied and purposeless accompanied by
continuous incoherent verbalizations & shouting.
 They urgently require physical and medical control
because they are often destructive & violent toward
others.
 Now a days it is quite rare due to advent of
antipsychotic medication.

23. 3. PARANOID SCHIZOPHRENIA
 Presence of delusions of persecution, delusions of jealousy and
delusions of grandiosity
 Auditory hallucinations related to single theme.
 Individual is often- tense, suspicious & guarded & may be
argumentative, hostile & aggressive.
 Onset: late in 20s &30s.
 Less regression of mental faculties, emotional response
 Social impairment may be minimal.

24. 4. UNDIFFERENTIATED SCHIZOPHRENIA
 Schizophrenic symptoms do not meet the criteria for any
of the subtypes or they may meet the criteria for more
than one subtype.
 Behavior is clearly psychotic.
 Evidence of delusions, hallucinations, incoherence &
bizarre behavior.

25. 5. RESIDUAL SCHIZOPHRENIA
 History of at least one previous episode of schizophrenia with prominent
psychotic symptoms
 Chronic form of disease
 This stage follows an acute episode – prominent delusions, hallucinations,
incoherence, bizarre behavior & violence
 Continuing evidence of illness although there are no prominent psychotic
symptoms.
 Social isolation, eccentric behavior, impairment in personal hygiene &
grooming, blunted & inappropriate affect.
 Poverty of or overly elaborate speech, illogical thinking & apathy

26. 6. SCHIZOAFFECTIVE DISORDER
 Schizophrenic behaviors with a strong element of symptomatology
associated with the mood disorders.
 Client is depressed with psychomotor retardation & suicidal ideation.
 Euphoria, grandiosity, hyperactivity
 Dysfunctional mood
 Bizarre delusions, prominent hallucinations, incoherent speech, catatonic
behaviors
 Blunted or inappropriate affect
 Prognosis: Better than other schizophrenic disorder but worse than that for
mood disorders alone.

27. 7. BRIEF PSYCHOTIC DISORDER
 Essential feature: sudden onset of psychotic
symptoms that may or may not be preceded by a
severe psychosocial stressor.
 Symptoms last at least 1 day but less than 1 month
& there is an eventual full return to the premorbid
level of functioning.

28. 8. SCHIZOPHRENIC FORM DISORDER
Essential feature: Identical with
schizophrenia but duration: including
prodromal, active & residual phases.
For at least 1 month but less than 6
months.

29. 9. SHARED PSYCHOTIC DISORDER
Essential feature: Folie a deux
It is a delusional system that develops in
a second person as a result of a close
relationship with another person who
already has a psychotic disorder with
prominent delusions.

30. 10. PSYCHOTIC DUE TO GENERAL MEDICAL CONDITION
 Cerebrovascular disease
 CNS infections
 CNS trauma
 Deafness
 Fluid or electrolyte imbalances
 Hepatic disease
 Herpes encephalitis
 Huntington’s disease
 Hypoadrenocorticism
 Hypo- or Hyperparathyroidism
 Metabolic conditions (e.g., hypoxia;
hypercarbia; hypoglycemia)
 Migraine headache
 Neoplasms Neurosyphilis
 Renal disease
 Systemic lupus erythematosus
 Temporal lobe epilepsy
 Vitamin deficiency (e.g., B12)

31. 11. SUBSTANCE INDUCED PSYCHOTIC DISORDER

32. SYMPTOMS
OF

33. BLEURER’S FOUR ‘A’S
Affective
disturbance
Inability to show appropriate emotional responses, blunted
or flattened affect
Autistic
thinking
It is a thought process in which the individual is unable to
relate to others or to the environment. preoccupation with
the self, with little concern for external reality
Ambivalence It refers to contradictory or opposing emotions, attitudes,
ideas or desires for the same person, thing or situation
simultaneous opposite feelings
Associative
looseness
Inability to think logically. the stringing together of
unrelated topics

34. SCHNEIDER’S FIRST RANK SYMPTOMS OF SCHIZOPHRENIA
(SFRS)
Audible thoughts or thoughts echo: Hearing one’s thoughts
spoken aloud
Voices heard arguing: The patient hears voices discussing him
in the third person
Hallucinatory voices in the form of running commentary
(voices commenting on one’s actions)
Thought Withdrawal: Thoughts cease and subject experiences
them as removed by an external force
Thought Insertion: Subject experiences thoughts imposed by
some external force on his passive mind

35. SCHNEIDER’S FIRST RANK SYMPTOMS OF SCHIZOPHRENIA
(SFRS)
 Thought broadcasting: Subject experiences that his thoughts are escaping the
confines of his self and are being experienced by others around
 Delusional perception: Normal perception has a private and illogical meaning
 Somatic passivity: bodily sensations especially sensory symptoms are experienced as
imposed on body by some external force
 Made volition or acts : one’s own acts are experienced as being under the control of
some external force, the subject being like a robot
 Made impulses: The subject experiences impulses as being imposed by some
external force
 Made feelings or affect: The subject experiences feelings as being imposed by some
external force

36. POSITIVE SYMPTOMS
 Content of thought
Delusions
Religiosity
Paranoia
Magical thinking
 Perception
hallucinations
Illusions
 Sense of self
echolalia
echopraxia
identification & imitation
depersonalization

37. Form of thought
Associative looseness
Neologism
Concrete thinking
Clang association
Word salad
Circumstantiality
Tangentialuity
Mutism
Perseveration

38. CONTENT OF THOUGHT

39. ILLUSION
 Illusion are mistaken or misinterpretation of sense impression. It
means the clear stimulus has been improperly identified .
 Ex.: In the dark the rope which is misinterpretation as snake

40. VISUAL ILLUSIONS
Distortion or modification of a
real visual image

41. HALLUCINATION
 Hallucination is a perception of a stimuli in the absence of an actual stimulus.
 Ex.: hearing voices when actually nobody is talking in the surrounding area and
the person actually believe the people are talking .
 Auditory
 Visual
 Olfactory
 Gustatory
 Tactile or hepatic
 Kinesthetic

42.  it is commonly known as hallucination of sight .
the patient may have a frightful visual experiences
or a pleasant one. Like patient look and said
,”some one is coming to kill me .”

43. AUDITORY HALLUCINATION
 It is also known as hallucination of hearing . this is the
frequent form of perceptual disturbances when the patient
hears the voices of people talking , buzzing noises or ill-
defined sounds. Some time he may hear the noises , such as
somebody is knocking at the door , someone is telling him
not to eat food.

44. GESTATORY HALLUCIANTION
 It is seen in person with organic brain
syndrome or functional psychoses. The
patient may say that something is added in
his food which has a very bad taste.

45. OLFACTORY HALLUCIANTION
Hallucination
related to smell.

46. TACTILE HALLUCINATION
hallucination of touch.

47. PERCEPTION

48. FORM OF THOUGHT

49. SENSE OF SELF
ECHOLALIA
Imitation of
words.
ECHOPRAXIA
Imitation of
movements.

50. IDENTIFICATION &
IMITATION
DEPERSONALIZATION
Person’s subjective sense of
being unreal, strange or
unfamiliar.

51. NEGATIVE SYMPTOMS
 Affect
Inappropriate affect
Bland or flat affect
Apathy
 Volition
Inability to initiate goal
directed activity
Emotional

52.  Impaired IPR functioning &
relationship to the external
world
Autism
Deteriorated appearance
 Psychomotor behavior
Anergia
Waxy flexibility
Posturing
Pacing & rocking
 Associated features
Anhedonia
regression

53. INAPPROPRIATE AFFECT
 BLAND OR FLAT AFFECT
APATHY
AFFECT

54. VOLITION
 INABILITY TO INITIATE GOAL
DIRECTED ACTIVITY Emotional ambivalence

55. IMPAIRED IPR FUNCTIONING & RELATIONSHIP TO THE
EXTERNAL WORLD
AUTISM  DETERIORATED
APPEARANCE

56. PSYCHOMOTOR BEHAVIOR
ANERGIA
WAXY FLEXIBILITY
POSTURING
PACING &
ROCKING

57. ANHEDONIA
 REGRESSION

58. COGNITIVE SYMPTOMS
Impairment of :
• Memory
• Attention
• Judgment
• Executive function/ planning

59. DIAGNOSIS
 History
 Mental status examination
 DSM-5 criteria
 INVESTIGATIONS:
 Tests may be ordered to rule out disorders that cause
psychosis, including vitamin deficiencies, uremia,
thyrotoxicosis and electrolyte imbalances.
 CT scan and MRI shows enlarged ventricles of sulci on the
cerebral surface and atrophy of the cerebellum.

60. TREATMENT MODALITIES FOR SCHIZOPHRENIA
Pharmacotherapy
Electroconvulsive therapy
Psychological therapy
Psychosocial rehabilitation

61. PHARMACOTHERAPY

62. TYPICAL AND ATYPICAL ANTIPSYCHOTIC MEDICATIONS USED TO
TREAT SCHIZOPHRENIA.
Typical
Antipsychotics
 Chlorpromazine
 Fluphenazine Decanoate
 Haloperidol
 Trifluoperazine
Atypical antipsychotics
 Clozapine
 Risperidone
 Olanzapeine
 Quetiapine
 Zaiprasidone
 Aripiprazole
 Paliperidone
 Amisulpride

63. ELECTROCONVULSIVE THERAPY

64. INDICATIONS FOR ECT
 Catatonic stupor
 Uncontrolled catatonic excitement
 Severe side-effects with drugs
 Schizophrenia refractory to all other forms of
treatment
 Usually 8-12 ECTs are needed

65. PSYCHOLOGICAL THERAPY
GROUP THERAPY
BEHAVIOR THERAPY
Social skills training
Cognitive therapy
Family therapy

66. PSYCHOSOCIAL REHABILITATION
 FOLLOW UP, HOME AND REHABILITATION
 PATIENT AND FAMILY TEACHING:
 Rehabilitative services for schizophrenia patients are:
 Social skills training
 Vocational rehabilitation
 Half-way homes
 Long-term homes
 Day hospitals, etc.

67. EXAMPLE OF NANDA NURSING DIAGNOSIS:
SCHIZOPHRENIA
 Disturbed Thought Processes may be related to
disintegration of thinking processes, impaired judgment
evidenced by impaired ability to problem-solve,
inappropriate affect, presence of delusion.
 Disturbed sensory perception (auditory/visual) related to
panic anxiety, possible hereditary or biochemical factors
evidenced by inappropriate responses, disordered thought
sequencing, poor concentration, disorientation, withdrawn
behaviour

68. CONTI…
 Impaired verbal communication related to panic anxiety,
disordered, unrealistic thinking, evidenced by loosening
of associations, echolalia, verbalizations that reflect
concrete thinking, and poor eye contact.
 Social Isolation may be related to mistrust of others,
unacceptable social behaviours, inadequate personal
resources, and inability to engage in satisfying personal
relationships, possibly evidenced by difficulty in
establishing relationships with others, seeking to be
alone, and hopelessness.

69. CONTI…
 Ineffective Health Maintenance may be related to
impaired cognitive/emotional functioning, altered ability to
make thoughtful judgments evidenced by inability to take
responsibility for meeting basic health practices,
accumulation of dirt and unwashed clothes, repeated
hygienic disorders.
 Self-care deficit related to withdrawal, regression, panic
anxiety, cognitive impairment, inability to trust, evidenced
by difficulty in carrying out tasks associated with hygiene,
dressing, grooming, eating, sleeping and toileting.

70. CONTI…
 Risk for self-directed Violence: risk factors may include disturbances
of thinking/feeling (depression, paranoia, suicidal ideation), lack of
development of trust and appropriate interpersonal relationships,
catatonic/manic excitement, toxic reactions to drugs (alcohol).*
 Ineffective Coping may be related to inadequate support system,
unrealistic perceptions evidenced by impaired judgment cognition and
perception, diminished problem-solving and poor self-concept.
 Interrupted Family Processes related to ambivalent family relationships
evidenced by deterioration in family functioning, ineffective family
decision-making neglectful relationships with patient, extreme distortion
regarding patient’s health problem including denial about its
existence/severity or prolonged over concern.

71. IMPORTANT TERMINILOGIES IN THIS UNIT
 Schizophrenia
 Four “A” symptoms of schizophrenia
 SFRS
 Schizoaffective disorder
 Capgras syndrome: (Delusion of doubles): Characterized by
delusional conviction that other person in the environment is not
their real selves but is their own doubles. It is one of the
delusional misidentification syndromes.