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Schizophrenia
BY Isha Thapa Magar
Nursing Instructor
PBBN 2nd Year
Schizophrenia
Definition
• "A group of disorders manifested by
fundamental disturbances or distortions in
thinking, mood and behavior, last for at least a
month of active phase symptoms like
delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic
behavior, negative symptoms such as shallow
or flat affect, alogia and incongruous mood".
- ICD – 10; DSM- W
• "Disturbance in thinking is marked by
alternation of concept formation, which may
lead to misinterpretation of reality,
hallucinations and delusions. Mood changes
include ambivalent, constricted, inappropriate
emotional responsiveness, or blunted effect.
Lack of empathy with others, disturbance in
behavior may be withdrawn, regressive and
bizarre".
- American Psychiatric Association
Incidence
Occurrence:
- It occurs in all types of societies and all places.
- Prevalence varies from 0.3 percent to 1% of
people, who experience a schizophrenia.
- About 15% of new admissions in mental
hospitals are schizophrenic patients.
- It has been estimated that patients diagnosed
as having schizophrenia occupy 50% of all
mental hospital beds.
Age:
- Age varies between 15 and 45 years.
- Peak age is 30 years, but can also occur in
children or the elderly.
Sex:
- Incidence in males and females is almost the
same.
Social class:
- The incidence of schizophrenia is higher in low
socio-economic status group in comparison to
the upper socio-economic group.
Etiology
The cause of schizophrenia is still uncertain.
Genetic Factors
• Studies show that relatives of schizophrenia
have a much higher probability of developing
the disease than the general population.
• The prevalence rate among family members of
schizophrenics is as follows:
- It occurs twice as often in people who are
unmarried and divorced people as in those who
are married or widowed.
- Children with one schizophrenic patient: 12%
- Children with both schizophrenic parents: 40%
- Siblings of schizophrenic patient: 8%
- Second-degree relatives: 5-6%
- Dizygotic twins of schizophrenic patients: 12%
- Monozygotic twins of schizophrenic patients: 47%
Biochemical factors
• An excess of dopamine-dependent neuronal
activity in the brain may cause schizophrenia.
• Abnormalities in the neurotransmitters
norepinephrine, serotonin, acetylcholine and
gamma-aminobutyric acid (GABA), and
neuroregulators such as prostaglandins and
endorphins have been implicated in the
predisposition to schizophrenia.
Stress-diathesis model
• According to the stress-diathesis model for the
integration of biological, psychological and
environmental factors, a person may have a
specific vulnerability (diathesis) that, when
acted on by a stressful influence, allows the
symptoms of schizophrenia to develop.
Psychological factors
Impaired ego functioning:
– The intensity of schizophrenia will depend upon
the intense impairment of ego function.
Mother-child relationship:
– There may be a defect in mother-infant
relationships.
– Early theories characterized the mothers of
schizophrenics as cold, over-protective, and
domineering, thus retarding the ego development
of the child.
• Deprivation of early mothering reduces a
child's capacity to socialize.
• The mother may be present but lack of
effective mother-child relationship does
withdraw the child from socialization.
Pathologic family interactions:
• Transaction between parents or significant
people who relate with the child.
• Parents may be maintaining superficial
relationship.
• Children coming from broken homes are
more prone to schizophrenia than those of
normal homes as their coping abilities get
reduced because of continuous stress.
Dysfunctional family system:
• Hostility between parents can lead to a
schizophrenia daughter
Double Bound Communication
– In double bound communication the child is not
able to discriminate the sort of messages being
conveyed.
– The mother says to the child, "Go out and play,
but see that you don't fight with anyone". In fact,
the other message is, "It is better if you stay
inside only." but it is not said. So the child is not
able to decide. If he does not go out, the mother
will get angry. If he goes out and has a tiff with
someone, even then the mother would get angry.
So the child withdraws gradually.
Socio environmental theories
– Persons who live in low socio-economic families
and areas are prone to schizophrenia. For
example, a child at a vary young age goes for work
and is deprived of affection from parents,
schooling playmates. This causes a lot of anger
and frustration in the child.
– Schizophrenia is more prevalent in areas of high
social mobility and disorganization, especially
among members of very low social classes.
– Stressful life events also can precipitate the
disease in predisposed individuals.
• Prenatal environmental and during birth can
increase risk of a person later developing
schizophrenia. For example pregnant women
who have been exposed to the influenza virus
or who have poor nutrition and obstetric
complications during childbirth of a child.
• Under stimulation in the social environment
of patient with family dysfunction,
unemployment or poor housing condition
(low economic status), lead to the
development of schizophrenia.
Organic theory
• Theorists believe that schizophrenia is caused
due to infection, poison, trauma or metabolic
disorders.
Vitamin deficiency theory
• A patient with vitamin B1, B6, B12 and
vitamin C deficiency may become
schizophrenic.
Prenatal theory
• The risk of schizophrenia exists if the developing
fetus or newborn is deprived of oxygen during
pregnancy or if the mother suffers from
malnutrition or starvation during the first
trimester of pregnancy.
• The development of schizophrenia may occur
during fetal life at critical points in brain
development, generally the 34th or 35th week of
gestation.
• The incidence of trauma and injury the second
trimester and birth has also considered in the
development of schizophrenia.
Signs and
Symptoms
According to Bleuder clinical features of
schizophrenia patient has made distinction
between
1. PRIMARY/Fundamental symptoms which are
present to some extent in every case of
schizophrenia and
2. Secondary or accessory symptoms which
may or may not be present.
Primary or Fundamental Symptoms
(Bleuler's Four A's)
1. Autism
2. Ambivalence
3. Affective disturbance
4. Associative disturbance
Secondary or Accessory Symptoms
1. Disorders of perceptions
• Hallucinations are common in schizophrenia.
Auditory hallucinations are by far the most
frequent.
• Only the 'third person hallucinations' are believed
to be characteristics of schizophrenia. Visual
hallucinations can also occur, usually along with
auditory hallucinations. The tactile, gustatory and
olfactory types are less common.
• Illusions e.g. rope is perceived by the patient as a
snake falling on him.
2. Disorders of thought and speech disorder
– Autistic thinking
– Loosening of associations
– Thought blocking
– Neologism
– Poverty of speech
• Poverty of ideation
• Echolalia
• Delusion of various kinds i.e. delusions of
persecution (being persecuted against0;
delusions of grandeur (belief that one is
especially very powerful, rich, born with a
special mission of life); delusion of control
(being controlled by an external force);
somatic delusions.
3. Disorders of motor activity
– Negativism and automatism
– Stereotype, speech echolalia,
– Stereotype activity, echopraxia, mannerism
– Impulsiveness –action performed unexpectedly
without consideration of the whole personality.
– There can be either a decrease (decreased
spontaneity, inertia, stupor) or increase in
psychomotor activity (excitement, aggressiveness,
restlessness, agitation)
4. Deteriorated appearance and manner
– Efforts on self-care and grooming may become
minimum.
– Schizophrenic patients have to the reminded of
bath, wash and shave and other routine activities.
5. Disturbance in attention
– The patient is not able to hold attention for a long
time. He or she lives in his/her own autistic world.
6. Insight in schizophrenic: In it, the illness is
affected severely.
7. Disorders of affect
– Apathy
– Emotional blunting
– Emotional shallowness
– Anhedonia (inability to experience pleasure)
– Inappropriate emotional response (emotional
response inappropriate to thought)
– Lack of rapport with the physician.
Clinical symptoms fall into three broad
categories
1. Positive symptoms,
2. Negative symptoms and
3. Disorganized symptoms.
Positive symptoms
• Hallucinations (auditory, visual, or other
sensory mode)
• Delusions (persecutory or grandiose
• Excess or distortion of normal functions
• Conceptual disorganization
• Excitement or aggressive behavior
• Suspiciousness, ideas of reference
• Pressurized speech
• Bizarre behavior
• Possible suicidal tendencies
• Show emotions that don't fit the situation
may smile when talking about sad topics or
laugh at the wrong time.
Negative symptoms
• Diminution or loss of normal functions.
• Anergia (lack of energy)
• Anhedonia (loss of pleasure or interest)
• Emotional withdrawal
• Poor eye contact (avoidant)
• Blunted affect or affective flattening
• Avolition (preserve, apathetic, social
withdrawal)
• Difficulty in abstract thinking
• Alogia (lack of spontaneity and flow of
conversation)
• Dysfunctional relationship with others
Disorganized symptoms/Cognitive
symptoms
• Cognitive defects/ confusion
• Incoherent speech
• Disorganized speech
• Repetitive rhythmic gestures (such as walking
in circles or pacing)
• Attention deficits
Types Of
Schizophrenia
1. Catatonic Schizophrenia
• Catatonic schizophrenia (cata: disturbed,
tonic: tone) is characterized by a marked
disturbance of motor behavior.
• It can present in three clinical forms:
i. excited catatonia,
ii. stuporous catatonia, and
iii. catatonia alternating between excitement
and stupor.
i. Excited Catatonia
• This is characterized by the following features:
- Increase in psychomotor activity, ranging from
restlessness, agitation, excitement,
aggressiveness to, at times, violent behavior.
- Increase in speed, loosening of associations and
frank incoherence.
• The excitement is not goal-directed as no
relationship with the external environment;
instead inner stimuli (e.g. thought and
impulses) influence the excited behavior.
• Sometimes the excitement can become very
severe, and is accompanied by rigidity,
hyperthermia and dehydration, finally
culminating in death which is known as acute
lethal catatonia or pernicious catatonia.
• Fortunately, with the availability of new
treatment choices, and early diagnosis and
treatment, lethal catatonia has become
increasingly rare in most parts of the world.
ii. Stuporous ( or Retained) Catatonia
• This is characterized by extreme retardation
of psychomotor function.
• Delusions and hallucinations may be present
but are usually not prominent.
• Not all the features are present at the same
time.
• Clinical features of retained/stuporous
catatonic schizophrenia are:
- Mutism
- Rigidity
- Negativism
- Posturing
- Stupor
- Echolalia
- Echopraxia
- Waxy flexibility
- Ambitendency
- Other signs such as mannerisms, stereotypies
(verbal and behavioral), automatic obedience
(commands are followed automatically,
irrespective of their nature) and verbigeration
(incomprehensible speech).
iii. Catatonia Alternating between
Excitement and stupor
• This clinical feature is very common with
features of both excited catatonia and
stuporous catatonia alternatingly present.
2. Paranoid Schizophrenia
• Paranoid schizophrenia is characterized by
the following clinical features:
- Delusions of persecution, reference, grandeur,
control, or infidelity (or jealousy).
- Hallucinatory voices that threaten or command
the patient, or auditory hallucination without
verbal form, such as whistling, humming and
laughing.
- No prominent disturbances of affect, volition
speech, and motor behavior.
• Paranoid schizophrenia has a good prognosis
if treated early.
• Personality deterioration is minimal and most
of these patients are productive and can lead
a normal life.
3. Disorganized (or Hebephrenic )
Schizophrenia
• Hebephrenic or disorganized schizophrenia is
marked by disorganized speech, thinking,
emotion and behavior on the patient's part.
• Disorganized schizophrenia is characterized by
the following features:
- Marked thought disorder, incoherence and severe
loosening of associations. Delusions and
hallucinations are fragmentary and changeable.
- Emotional disturbances such as inappropriate
affect, blunted affect, or senseless giggling.
- Disorganized behaviors such as mannerisms,
'mirror-gazing'(for long periods of time), poor self-
care and hygiene, markedly impaired social and
occupational functioning, extreme social
withdrawal and other oddities of behavior.
• The criteria are not met for catatonic type.
• The onset is insidious, usually in the early 2nd
decade.
• Hebephrenic schizophrenia has one of the
worst prognoses among the other subtypes of
schizophrenia because of severe deterioration,
without any significant remissions, usually
occurs over time.
4. Residual/ Chronic Schizophrenia
• Residual schizophrenia denotes when these
active symptoms (delusions and
hallucinations) are reduced but not
completely free and negative symptoms have
been present.
• It is chronic form of schizophrenia with
predominant negative symptoms (apathy, lack
of drive, slowness and social withdrawal).
• The residual schizophrenia is diagnosed only
after at least one episode has occurred.
5. Simple schizophrenia
• Although called simple, it is one of the
subtypes which is the most difficult to
diagnose.
• It is characterized by:
- an early onset (early 2nd decade),
- very insidious and progressive course,
- presence of 'negative symptoms' such as marked
social withdrawal, shallow emotional response,
with loss of initiative and drive and wandering
aimlessly.
• Delusions and hallucinations are usually
absent, and if present they are short lasting
and poorly systematized.
• The prognosis is usually very poor.
6.Post- Schizophrenia Depression
• In post-schizophrenia depression, patient
develops depressive features within 12
months of an acute episode of schizophrenia
in the presence of residual or active features
of schizophrenia and are associated with an
increased risk of suicide.
• The depressive features occur due to side -
effect of antipsychotics, regaining insight after
recovery, or just be an integral part of
schizophrenia.
7. Type I and type II Schizophrenia
• TJ Crow had divided schizophrenia into two
sub-types, namely type I and II schizophrenias.
i. The Type I schizophrenia is characterized by
positive symptoms .
ii. The Type II schizophrenia is predominantly
characterized by presence of negative
symptoms.
8. Undifferentiated Schizophrenia
• Patient in this category have the characteristic
positive and negative symptoms of
schizophrenia but not meet the specific
criteria for the paranoids, disorganized, or
catatonic subtypes.
Diagnosis
Test
• Blood test –CBC and other tests
• Imaging studies – CT, MR,
• Psychological evaluation – a specialist will
assess the patient's mental state by asking
about thoughts, moods, hallucinations,
suicidal traits, violent tendencies or potential
for violence as well as observing their
demeanor and appearance.
The patient must meet the criteria laid down in
the DSM
Have at least two of the following typical
symptoms of schizophrenia
– One month period for less if successfully treated
– Delusions
– Hallucinations
– Disorganized speech
– Grossly disorganized or catatonic behavior
– Negative symptoms e.g. affective flattering, alogia,
or avolition.
Experience considerable impairment in the
ability to attend school, carry out their work
duties or carry out everyday tasks.
Have symptoms which persist for six months
or more.
Significant impairment in work or
interpersonal relationships, or self-care below
the level of previous function.
Treatment of
Schizophrenia
• The treatment of schizophrenia depends on
the patient's stage or phase.
• Patient in the acute phase are hospitalized in
most cases to prevent harm to the patient or
others and to begin treatment with
antipsychotic medications.
• Indication for hospitalization
i. Neglect of food and water intake
ii. Danger to self or others
iii. Poor treatment adherence
iv. Significant neglect of self-care, or
v. Lack of social support with evidence of
above mentioned risks.
• The treatment of schizophrenia can be
discussed under the following headings:
1. Pharmacological Treatment
2. Electro-convulsive Therapy (ECT)
3. Psychosocial Therapy
4. Psychosocial Rehabilitation
1. Pharmacological Therapy
Typical/Classic/ First Generation
Antipsychotics Drugs
• An acute episode of schizophrenia is treated with
classic/Typical antipsychotic agents, which are
most effective in the presence of acute
excitement. They are:
- Chlorpromazine: 300-150mg/day PO; 50 – 100mg/day
IM
- Fluphenazine decanoate: 25-30mg IM every 1-3 weeks
- Haloperidol: 5-100mg/day PO 5-20 mg/day IM
- Trifluoperazine: 15-60 mg/day PO; 1-5 mg/day IM
- Clozapine: 25-450 mg/day PO
Atypical/Second Generation Antipsychotic drugs
• Atypical antipsychotic drugs ( risperidone,
olanzapine, ziprasidone) are more useful when
the negative symptoms are prominent, e.g. in
chronic schizophrenia. They are:
- Risperidone: 2-10mg/day PO
- Olanzapine: 10-20 mg/day PO
Antianxiety drug (e.g. Iorazepam,
diazepam, alprazolam etc) can be used to
control agitation and associated sleeping
disturbance.
Anitparkinsonian drug to prevent
extrapyramidal side effect e.g. trihexiphenidyl
6mg/day, orphenadrine 150mg/day,
procyclidine 7.5-15mg/day.
2. Electro-convulsive Therapy (ECT)
• Schizophrenia is not a primary indication for ECT.
• The indications for ECT in schizophrenia include:
- Catatonic stupor
- Uncontrolled catatonic excitement.
- Acute excitement not controlled with drugs
- Severe side-effects with drugs, in presence of
untreated schizophrenia.
• Usually 8-12 ECTs are needed (although up to 18
have been given in poor responders),
administered two or three times a week.
3. Psychological Therapies
1. Psycho-education
 Psycho-education of the patient and
especially the family/care givers regarding
the nature of illness, and its course and
treatment helps in establishing a good
therapeutic relationship with the patient
(and the family).
2. Group psychotherapy is particularly aimed
at teaching problem solving and
communication skills.
3. Behavior therapy is useful reducing the
frequency of bizarre, disturbing and deviant
behavior, and increasing appropriate
behaviors.
4. Family therapy
• Family members are also provided social skills
training to;
- enhance communication and help decrease
intrafamilial 'tensions‘,
- decrease the 'expressed emotions' of significant
others' in the family, and
- raise awareness regarding decreasing
expectations and avoiding critical remarks,
emotional over-involvement, and hostility.
4. Psychosocial rehabilitation
• Psychosocial rehabilitation includes activity
therapy, to develop the work habit, training in
a new vocation or retraining in a previous
skill, vocational guidance, independent job
placement, sheltered employment or self-
employment, and occupational therapy.
Nursing
Management
Nursing Diagnosis
1. Disturbed thought processes related to inability to
trust, panic anxiety, possible hereditary or
biochemical factors, evidenced by delusional thinking,
inability to concentrate, impaired volition, inability to
problem solve, abstract, extreme suspiciousness of
others.
2. Disturbed sensory perception: auditory/ visual related
to panic anxiety extreme loneliness and withdrawal
into the self, evidenced by inappropriate responses,
disorders thought sequencing, rapid mood swings,
poor concentration, disorientation.
3. Social isolation related to inability to trust, panic
anxiety, weak ego development, delusional
thinking evidenced by withdrawal, sad dull affect,
need-fear dilemma, preoccupation with own
thoughts, expression of feelings of rejection or of
aloneness imposed by others.
4. Potential risk for violence, self-directed or other-
directed related to extreme suspiciousness, panic
anxiety, catatonic excitement, range reactions,
command hallucinations evidenced by overt and
aggressive acts, goal-directed destructions of
objects in the environment, self-destructive
behavior, or active aggressive suicidal acts.
5. Impaired communication related to panic anxiety,
regression, withdrawal, and disordered,
unrealistic thinking evidence by loose association
of ideas, neologisms, word salad, clang
associations, echolalia, verbalizations that reflect
concrete thinking and poor eye contact.
6. Self-care deficit related to withdrawal, panic
anxiety, perceptual or cognitive impairment,
inability to trust evidenced by difficulty carrying
out tasks associated with hygiene, dressing,
grooming, eating and toileting.
7. Disabled family coping related to difficulty coping
with client's illness evidenced by neglectful care
of the client in regard to basic human needs or
illness treatment, extreme denial or prolonged
over concern regarding client's illness.
8. Ineffective health maintenance related to
disordered thinking or delusions evidenced by
reported or observed inability to take
responsibility for meeting basic health practices
in any or all functional pattern areas.
9. Impaired home-maintenance management
related to regression, withdrawal, lack of
knowledge or resources or impaired physical
or cognitive functioning evidenced by unsafe,
unclear disorderly home environment.
Nursing Interventions
• Decrease environmental stimuli e.g. low
lightening, low noise, few people, simple
decoration.
• Modify the environment to minimize objects.
Use furniture so heavy that it cannot be lifted
by client.
• Remove all dangerous objects (glass, knife,
blade or any sharp instrument with the
patient) from the client's environment.
• When using restraint (provide for safety)
evaluation the patient's status of hydration,
nutrition, elimination.
• Arrange non threatening activities that
involves these patients in 'doing something'
• Help patients to participate in decision making
as appropriate e.g. selecting the menu for the
next day's meals.
• Establishing therapeutic relationship by
establishing trust.
• Provide patients with opportunities for non-
threatening socialization with the nurse on a one
to one basis.
• Reinforce appropriate grooming and by hygiene
(assist patient if needed).
• Make sure that one relative is always with the
patient.
• Do not argue, criticize with psychotic thinking
because they are real to the patient.
• Do not make promises, which you cannot keep.
• Explain each procedures before doing.
• Do not joke or judge the clients behavior.
• Assess the fluid and electrolyte status and
feed high caloric, high and listening to music.
• Engage client in reality based activity such as
occupational therapy and listening to music.
• Observe the client for signs of hallucination.
Try to find out the content of the
hallucination. If the hallucination is of
homicidal or suicidal take necessary care to
protect him and others.
• Help the client understand the connection
between anxiety and hallucination.
• Keep a comfortable distance away from the
patient (arm length).
• Be prepared to move, violent patient can
strike out suddenly.
• Give needed information about the
schizophrenia to the patient and relatives. It
should be provide in simple language.
• Clear the doubts of relatives regarding the
caused of illness and prognosis.
• Administer tranquilizing medications as ordered
by physician. If client is not clamed by
medication, use of mechanical restraints may be
necessary.
• Encourage client to perform independently as
many activities as possible, provide positive
reinforcement for independent accomplishments.
• Provide assistance with self care needs as
required.
• Observed for side effects of drugs, record and
report side effect of antipsychotic drugs.
• Evaluate client's response to medications and
understanding teaching.
• Observe client behavior frequently. Do this
while carrying routine activities.
• Orient client to reality as required. Call the
client by name.
• Family should be instructed to:
- Regarding taking mediation
- Follow the treatment in long term.
- Explain about side effects of medication and how
to deal with it.
- Explain about extra pyramidal symptoms or
effects.
- Assign small responsibilities.
- Encourage and support the patient.
- Supervise his activities. Appreciate even if it is a
small task done by the patients.
- Avoid reactions and criticism.
- Watch for relapse, sleepless will be earliest sign of
relapse for these patients.
Schizophrenia

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Schizophrenia

  • 1. Schizophrenia BY Isha Thapa Magar Nursing Instructor PBBN 2nd Year
  • 3. Definition • "A group of disorders manifested by fundamental disturbances or distortions in thinking, mood and behavior, last for at least a month of active phase symptoms like delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms such as shallow or flat affect, alogia and incongruous mood". - ICD – 10; DSM- W
  • 4. • "Disturbance in thinking is marked by alternation of concept formation, which may lead to misinterpretation of reality, hallucinations and delusions. Mood changes include ambivalent, constricted, inappropriate emotional responsiveness, or blunted effect. Lack of empathy with others, disturbance in behavior may be withdrawn, regressive and bizarre". - American Psychiatric Association
  • 5. Incidence Occurrence: - It occurs in all types of societies and all places. - Prevalence varies from 0.3 percent to 1% of people, who experience a schizophrenia. - About 15% of new admissions in mental hospitals are schizophrenic patients. - It has been estimated that patients diagnosed as having schizophrenia occupy 50% of all mental hospital beds.
  • 6. Age: - Age varies between 15 and 45 years. - Peak age is 30 years, but can also occur in children or the elderly.
  • 7. Sex: - Incidence in males and females is almost the same. Social class: - The incidence of schizophrenia is higher in low socio-economic status group in comparison to the upper socio-economic group.
  • 8. Etiology The cause of schizophrenia is still uncertain. Genetic Factors • Studies show that relatives of schizophrenia have a much higher probability of developing the disease than the general population.
  • 9. • The prevalence rate among family members of schizophrenics is as follows: - It occurs twice as often in people who are unmarried and divorced people as in those who are married or widowed. - Children with one schizophrenic patient: 12% - Children with both schizophrenic parents: 40% - Siblings of schizophrenic patient: 8% - Second-degree relatives: 5-6% - Dizygotic twins of schizophrenic patients: 12% - Monozygotic twins of schizophrenic patients: 47%
  • 10. Biochemical factors • An excess of dopamine-dependent neuronal activity in the brain may cause schizophrenia. • Abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine and gamma-aminobutyric acid (GABA), and neuroregulators such as prostaglandins and endorphins have been implicated in the predisposition to schizophrenia.
  • 11. Stress-diathesis model • According to the stress-diathesis model for the integration of biological, psychological and environmental factors, a person may have a specific vulnerability (diathesis) that, when acted on by a stressful influence, allows the symptoms of schizophrenia to develop.
  • 12. Psychological factors Impaired ego functioning: – The intensity of schizophrenia will depend upon the intense impairment of ego function. Mother-child relationship: – There may be a defect in mother-infant relationships. – Early theories characterized the mothers of schizophrenics as cold, over-protective, and domineering, thus retarding the ego development of the child.
  • 13. • Deprivation of early mothering reduces a child's capacity to socialize. • The mother may be present but lack of effective mother-child relationship does withdraw the child from socialization. Pathologic family interactions: • Transaction between parents or significant people who relate with the child.
  • 14. • Parents may be maintaining superficial relationship. • Children coming from broken homes are more prone to schizophrenia than those of normal homes as their coping abilities get reduced because of continuous stress. Dysfunctional family system: • Hostility between parents can lead to a schizophrenia daughter
  • 15. Double Bound Communication – In double bound communication the child is not able to discriminate the sort of messages being conveyed. – The mother says to the child, "Go out and play, but see that you don't fight with anyone". In fact, the other message is, "It is better if you stay inside only." but it is not said. So the child is not able to decide. If he does not go out, the mother will get angry. If he goes out and has a tiff with someone, even then the mother would get angry. So the child withdraws gradually.
  • 16. Socio environmental theories – Persons who live in low socio-economic families and areas are prone to schizophrenia. For example, a child at a vary young age goes for work and is deprived of affection from parents, schooling playmates. This causes a lot of anger and frustration in the child. – Schizophrenia is more prevalent in areas of high social mobility and disorganization, especially among members of very low social classes. – Stressful life events also can precipitate the disease in predisposed individuals.
  • 17. • Prenatal environmental and during birth can increase risk of a person later developing schizophrenia. For example pregnant women who have been exposed to the influenza virus or who have poor nutrition and obstetric complications during childbirth of a child. • Under stimulation in the social environment of patient with family dysfunction, unemployment or poor housing condition (low economic status), lead to the development of schizophrenia.
  • 18. Organic theory • Theorists believe that schizophrenia is caused due to infection, poison, trauma or metabolic disorders. Vitamin deficiency theory • A patient with vitamin B1, B6, B12 and vitamin C deficiency may become schizophrenic.
  • 19. Prenatal theory • The risk of schizophrenia exists if the developing fetus or newborn is deprived of oxygen during pregnancy or if the mother suffers from malnutrition or starvation during the first trimester of pregnancy. • The development of schizophrenia may occur during fetal life at critical points in brain development, generally the 34th or 35th week of gestation. • The incidence of trauma and injury the second trimester and birth has also considered in the development of schizophrenia.
  • 21. According to Bleuder clinical features of schizophrenia patient has made distinction between 1. PRIMARY/Fundamental symptoms which are present to some extent in every case of schizophrenia and 2. Secondary or accessory symptoms which may or may not be present.
  • 22. Primary or Fundamental Symptoms (Bleuler's Four A's) 1. Autism 2. Ambivalence 3. Affective disturbance 4. Associative disturbance
  • 23. Secondary or Accessory Symptoms 1. Disorders of perceptions • Hallucinations are common in schizophrenia. Auditory hallucinations are by far the most frequent. • Only the 'third person hallucinations' are believed to be characteristics of schizophrenia. Visual hallucinations can also occur, usually along with auditory hallucinations. The tactile, gustatory and olfactory types are less common. • Illusions e.g. rope is perceived by the patient as a snake falling on him.
  • 24. 2. Disorders of thought and speech disorder – Autistic thinking – Loosening of associations – Thought blocking – Neologism – Poverty of speech
  • 25. • Poverty of ideation • Echolalia • Delusion of various kinds i.e. delusions of persecution (being persecuted against0; delusions of grandeur (belief that one is especially very powerful, rich, born with a special mission of life); delusion of control (being controlled by an external force); somatic delusions.
  • 26. 3. Disorders of motor activity – Negativism and automatism – Stereotype, speech echolalia, – Stereotype activity, echopraxia, mannerism – Impulsiveness –action performed unexpectedly without consideration of the whole personality. – There can be either a decrease (decreased spontaneity, inertia, stupor) or increase in psychomotor activity (excitement, aggressiveness, restlessness, agitation)
  • 27. 4. Deteriorated appearance and manner – Efforts on self-care and grooming may become minimum. – Schizophrenic patients have to the reminded of bath, wash and shave and other routine activities. 5. Disturbance in attention – The patient is not able to hold attention for a long time. He or she lives in his/her own autistic world.
  • 28. 6. Insight in schizophrenic: In it, the illness is affected severely. 7. Disorders of affect – Apathy – Emotional blunting – Emotional shallowness – Anhedonia (inability to experience pleasure) – Inappropriate emotional response (emotional response inappropriate to thought) – Lack of rapport with the physician.
  • 29. Clinical symptoms fall into three broad categories 1. Positive symptoms, 2. Negative symptoms and 3. Disorganized symptoms.
  • 30. Positive symptoms • Hallucinations (auditory, visual, or other sensory mode) • Delusions (persecutory or grandiose • Excess or distortion of normal functions • Conceptual disorganization • Excitement or aggressive behavior • Suspiciousness, ideas of reference
  • 31. • Pressurized speech • Bizarre behavior • Possible suicidal tendencies • Show emotions that don't fit the situation may smile when talking about sad topics or laugh at the wrong time.
  • 32. Negative symptoms • Diminution or loss of normal functions. • Anergia (lack of energy) • Anhedonia (loss of pleasure or interest) • Emotional withdrawal • Poor eye contact (avoidant)
  • 33. • Blunted affect or affective flattening • Avolition (preserve, apathetic, social withdrawal) • Difficulty in abstract thinking • Alogia (lack of spontaneity and flow of conversation) • Dysfunctional relationship with others
  • 34. Disorganized symptoms/Cognitive symptoms • Cognitive defects/ confusion • Incoherent speech • Disorganized speech • Repetitive rhythmic gestures (such as walking in circles or pacing) • Attention deficits
  • 36. 1. Catatonic Schizophrenia • Catatonic schizophrenia (cata: disturbed, tonic: tone) is characterized by a marked disturbance of motor behavior. • It can present in three clinical forms: i. excited catatonia, ii. stuporous catatonia, and iii. catatonia alternating between excitement and stupor.
  • 37. i. Excited Catatonia • This is characterized by the following features: - Increase in psychomotor activity, ranging from restlessness, agitation, excitement, aggressiveness to, at times, violent behavior. - Increase in speed, loosening of associations and frank incoherence. • The excitement is not goal-directed as no relationship with the external environment; instead inner stimuli (e.g. thought and impulses) influence the excited behavior.
  • 38. • Sometimes the excitement can become very severe, and is accompanied by rigidity, hyperthermia and dehydration, finally culminating in death which is known as acute lethal catatonia or pernicious catatonia. • Fortunately, with the availability of new treatment choices, and early diagnosis and treatment, lethal catatonia has become increasingly rare in most parts of the world.
  • 39. ii. Stuporous ( or Retained) Catatonia • This is characterized by extreme retardation of psychomotor function. • Delusions and hallucinations may be present but are usually not prominent. • Not all the features are present at the same time.
  • 40. • Clinical features of retained/stuporous catatonic schizophrenia are: - Mutism - Rigidity - Negativism - Posturing - Stupor
  • 41. - Echolalia - Echopraxia - Waxy flexibility - Ambitendency - Other signs such as mannerisms, stereotypies (verbal and behavioral), automatic obedience (commands are followed automatically, irrespective of their nature) and verbigeration (incomprehensible speech).
  • 42. iii. Catatonia Alternating between Excitement and stupor • This clinical feature is very common with features of both excited catatonia and stuporous catatonia alternatingly present.
  • 43. 2. Paranoid Schizophrenia • Paranoid schizophrenia is characterized by the following clinical features: - Delusions of persecution, reference, grandeur, control, or infidelity (or jealousy). - Hallucinatory voices that threaten or command the patient, or auditory hallucination without verbal form, such as whistling, humming and laughing.
  • 44. - No prominent disturbances of affect, volition speech, and motor behavior. • Paranoid schizophrenia has a good prognosis if treated early. • Personality deterioration is minimal and most of these patients are productive and can lead a normal life.
  • 45. 3. Disorganized (or Hebephrenic ) Schizophrenia • Hebephrenic or disorganized schizophrenia is marked by disorganized speech, thinking, emotion and behavior on the patient's part. • Disorganized schizophrenia is characterized by the following features: - Marked thought disorder, incoherence and severe loosening of associations. Delusions and hallucinations are fragmentary and changeable.
  • 46. - Emotional disturbances such as inappropriate affect, blunted affect, or senseless giggling. - Disorganized behaviors such as mannerisms, 'mirror-gazing'(for long periods of time), poor self- care and hygiene, markedly impaired social and occupational functioning, extreme social withdrawal and other oddities of behavior.
  • 47. • The criteria are not met for catatonic type. • The onset is insidious, usually in the early 2nd decade. • Hebephrenic schizophrenia has one of the worst prognoses among the other subtypes of schizophrenia because of severe deterioration, without any significant remissions, usually occurs over time.
  • 48. 4. Residual/ Chronic Schizophrenia • Residual schizophrenia denotes when these active symptoms (delusions and hallucinations) are reduced but not completely free and negative symptoms have been present.
  • 49. • It is chronic form of schizophrenia with predominant negative symptoms (apathy, lack of drive, slowness and social withdrawal). • The residual schizophrenia is diagnosed only after at least one episode has occurred.
  • 50. 5. Simple schizophrenia • Although called simple, it is one of the subtypes which is the most difficult to diagnose. • It is characterized by: - an early onset (early 2nd decade), - very insidious and progressive course, - presence of 'negative symptoms' such as marked social withdrawal, shallow emotional response, with loss of initiative and drive and wandering aimlessly.
  • 51. • Delusions and hallucinations are usually absent, and if present they are short lasting and poorly systematized. • The prognosis is usually very poor.
  • 52. 6.Post- Schizophrenia Depression • In post-schizophrenia depression, patient develops depressive features within 12 months of an acute episode of schizophrenia in the presence of residual or active features of schizophrenia and are associated with an increased risk of suicide.
  • 53. • The depressive features occur due to side - effect of antipsychotics, regaining insight after recovery, or just be an integral part of schizophrenia.
  • 54. 7. Type I and type II Schizophrenia • TJ Crow had divided schizophrenia into two sub-types, namely type I and II schizophrenias. i. The Type I schizophrenia is characterized by positive symptoms . ii. The Type II schizophrenia is predominantly characterized by presence of negative symptoms.
  • 55. 8. Undifferentiated Schizophrenia • Patient in this category have the characteristic positive and negative symptoms of schizophrenia but not meet the specific criteria for the paranoids, disorganized, or catatonic subtypes.
  • 56. Diagnosis Test • Blood test –CBC and other tests • Imaging studies – CT, MR, • Psychological evaluation – a specialist will assess the patient's mental state by asking about thoughts, moods, hallucinations, suicidal traits, violent tendencies or potential for violence as well as observing their demeanor and appearance.
  • 57. The patient must meet the criteria laid down in the DSM Have at least two of the following typical symptoms of schizophrenia – One month period for less if successfully treated – Delusions – Hallucinations – Disorganized speech – Grossly disorganized or catatonic behavior – Negative symptoms e.g. affective flattering, alogia, or avolition.
  • 58. Experience considerable impairment in the ability to attend school, carry out their work duties or carry out everyday tasks. Have symptoms which persist for six months or more. Significant impairment in work or interpersonal relationships, or self-care below the level of previous function.
  • 60. • The treatment of schizophrenia depends on the patient's stage or phase. • Patient in the acute phase are hospitalized in most cases to prevent harm to the patient or others and to begin treatment with antipsychotic medications.
  • 61. • Indication for hospitalization i. Neglect of food and water intake ii. Danger to self or others iii. Poor treatment adherence iv. Significant neglect of self-care, or v. Lack of social support with evidence of above mentioned risks.
  • 62. • The treatment of schizophrenia can be discussed under the following headings: 1. Pharmacological Treatment 2. Electro-convulsive Therapy (ECT) 3. Psychosocial Therapy 4. Psychosocial Rehabilitation
  • 63. 1. Pharmacological Therapy Typical/Classic/ First Generation Antipsychotics Drugs • An acute episode of schizophrenia is treated with classic/Typical antipsychotic agents, which are most effective in the presence of acute excitement. They are: - Chlorpromazine: 300-150mg/day PO; 50 – 100mg/day IM - Fluphenazine decanoate: 25-30mg IM every 1-3 weeks
  • 64. - Haloperidol: 5-100mg/day PO 5-20 mg/day IM - Trifluoperazine: 15-60 mg/day PO; 1-5 mg/day IM - Clozapine: 25-450 mg/day PO Atypical/Second Generation Antipsychotic drugs • Atypical antipsychotic drugs ( risperidone, olanzapine, ziprasidone) are more useful when the negative symptoms are prominent, e.g. in chronic schizophrenia. They are: - Risperidone: 2-10mg/day PO - Olanzapine: 10-20 mg/day PO
  • 65. Antianxiety drug (e.g. Iorazepam, diazepam, alprazolam etc) can be used to control agitation and associated sleeping disturbance. Anitparkinsonian drug to prevent extrapyramidal side effect e.g. trihexiphenidyl 6mg/day, orphenadrine 150mg/day, procyclidine 7.5-15mg/day.
  • 66. 2. Electro-convulsive Therapy (ECT) • Schizophrenia is not a primary indication for ECT. • The indications for ECT in schizophrenia include: - Catatonic stupor - Uncontrolled catatonic excitement. - Acute excitement not controlled with drugs - Severe side-effects with drugs, in presence of untreated schizophrenia. • Usually 8-12 ECTs are needed (although up to 18 have been given in poor responders), administered two or three times a week.
  • 67. 3. Psychological Therapies 1. Psycho-education  Psycho-education of the patient and especially the family/care givers regarding the nature of illness, and its course and treatment helps in establishing a good therapeutic relationship with the patient (and the family).
  • 68. 2. Group psychotherapy is particularly aimed at teaching problem solving and communication skills. 3. Behavior therapy is useful reducing the frequency of bizarre, disturbing and deviant behavior, and increasing appropriate behaviors.
  • 69. 4. Family therapy • Family members are also provided social skills training to; - enhance communication and help decrease intrafamilial 'tensions‘, - decrease the 'expressed emotions' of significant others' in the family, and - raise awareness regarding decreasing expectations and avoiding critical remarks, emotional over-involvement, and hostility.
  • 70. 4. Psychosocial rehabilitation • Psychosocial rehabilitation includes activity therapy, to develop the work habit, training in a new vocation or retraining in a previous skill, vocational guidance, independent job placement, sheltered employment or self- employment, and occupational therapy.
  • 72. Nursing Diagnosis 1. Disturbed thought processes related to inability to trust, panic anxiety, possible hereditary or biochemical factors, evidenced by delusional thinking, inability to concentrate, impaired volition, inability to problem solve, abstract, extreme suspiciousness of others. 2. Disturbed sensory perception: auditory/ visual related to panic anxiety extreme loneliness and withdrawal into the self, evidenced by inappropriate responses, disorders thought sequencing, rapid mood swings, poor concentration, disorientation.
  • 73. 3. Social isolation related to inability to trust, panic anxiety, weak ego development, delusional thinking evidenced by withdrawal, sad dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others. 4. Potential risk for violence, self-directed or other- directed related to extreme suspiciousness, panic anxiety, catatonic excitement, range reactions, command hallucinations evidenced by overt and aggressive acts, goal-directed destructions of objects in the environment, self-destructive behavior, or active aggressive suicidal acts.
  • 74. 5. Impaired communication related to panic anxiety, regression, withdrawal, and disordered, unrealistic thinking evidence by loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking and poor eye contact. 6. Self-care deficit related to withdrawal, panic anxiety, perceptual or cognitive impairment, inability to trust evidenced by difficulty carrying out tasks associated with hygiene, dressing, grooming, eating and toileting.
  • 75. 7. Disabled family coping related to difficulty coping with client's illness evidenced by neglectful care of the client in regard to basic human needs or illness treatment, extreme denial or prolonged over concern regarding client's illness. 8. Ineffective health maintenance related to disordered thinking or delusions evidenced by reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas.
  • 76. 9. Impaired home-maintenance management related to regression, withdrawal, lack of knowledge or resources or impaired physical or cognitive functioning evidenced by unsafe, unclear disorderly home environment.
  • 77. Nursing Interventions • Decrease environmental stimuli e.g. low lightening, low noise, few people, simple decoration. • Modify the environment to minimize objects. Use furniture so heavy that it cannot be lifted by client.
  • 78. • Remove all dangerous objects (glass, knife, blade or any sharp instrument with the patient) from the client's environment. • When using restraint (provide for safety) evaluation the patient's status of hydration, nutrition, elimination. • Arrange non threatening activities that involves these patients in 'doing something' • Help patients to participate in decision making as appropriate e.g. selecting the menu for the next day's meals.
  • 79. • Establishing therapeutic relationship by establishing trust. • Provide patients with opportunities for non- threatening socialization with the nurse on a one to one basis. • Reinforce appropriate grooming and by hygiene (assist patient if needed). • Make sure that one relative is always with the patient. • Do not argue, criticize with psychotic thinking because they are real to the patient. • Do not make promises, which you cannot keep.
  • 80. • Explain each procedures before doing. • Do not joke or judge the clients behavior. • Assess the fluid and electrolyte status and feed high caloric, high and listening to music. • Engage client in reality based activity such as occupational therapy and listening to music. • Observe the client for signs of hallucination. Try to find out the content of the hallucination. If the hallucination is of homicidal or suicidal take necessary care to protect him and others.
  • 81. • Help the client understand the connection between anxiety and hallucination. • Keep a comfortable distance away from the patient (arm length). • Be prepared to move, violent patient can strike out suddenly. • Give needed information about the schizophrenia to the patient and relatives. It should be provide in simple language. • Clear the doubts of relatives regarding the caused of illness and prognosis.
  • 82. • Administer tranquilizing medications as ordered by physician. If client is not clamed by medication, use of mechanical restraints may be necessary. • Encourage client to perform independently as many activities as possible, provide positive reinforcement for independent accomplishments. • Provide assistance with self care needs as required. • Observed for side effects of drugs, record and report side effect of antipsychotic drugs.
  • 83. • Evaluate client's response to medications and understanding teaching. • Observe client behavior frequently. Do this while carrying routine activities. • Orient client to reality as required. Call the client by name. • Family should be instructed to: - Regarding taking mediation - Follow the treatment in long term. - Explain about side effects of medication and how to deal with it.
  • 84. - Explain about extra pyramidal symptoms or effects. - Assign small responsibilities. - Encourage and support the patient. - Supervise his activities. Appreciate even if it is a small task done by the patients. - Avoid reactions and criticism. - Watch for relapse, sleepless will be earliest sign of relapse for these patients.