Mental health Nursing.

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SCHIZOPHRENIA
INTRODUCTION
The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The
word was derived from the Greek skhizo (split) and phren (mind) With
Depression.Schizophrenia is a psychiatric syndrome in which specific psychological symptoms
lead, in most cases, to disintegration of personality. The symptoms interfere with thinking,
emotion, motor behavior, and volition (will power). The abnormal thinking leads to
misinterpretation of reality with development of fantasy thinking, delusions and hallucinations.
Insight is always lost to a variable degree.
Subtypes of schizophrenia
1. Simple schizophrenia
Onset in adolescence. Condition characterized by insidious development of eccentric behavior,
apathy, a shallow affect, social withdrawal, a lack of drive and initiative, and declining
performance at work. Delusions and hallucinations are uncommon. Prognosis very poor. Since
clear schizophrenic symptoms are absent, simple schizophrenia is difficult to identify reliably.
2. Hebephrenic schizophrenia
Onset in adolescence or early 20s. Patients often appear silly and childish in their behavior.
Affective symptoms (flattened affect and incongruity) and thought disorder are prominent.
Delusion is common and not highly organized. Hallucinations also are common, and are not
elaborate. Though onset is usually insidious, some cases begin suddenly, with marked depression
and anxiety.
3. Catatonic schizophrenia
Onset later than in hebephrenia and is usually acute. Characterized by motor symptoms and by
changes in activity between excitement and stupor. Patient many have one (or a combination) of
several forms of the following catatonic symptoms described below:-
Catatonic stupor or mutism: Patient does not appreciably respond to the environment or to the
people in it. Despite appearances, these patients are often thoroughly aware of what is going on
around them. Catatonic negativism: Patient resists all directions of physical attempts to move
him or her.
Catatonic rigidity: Patient is physically rigid.
Catatonic posturing: Patient assumes bizarre or unusual postures.
Catatonic excitement: Patient is extremely active and excited.
Delusions, hallucinations and affective symptoms occur, but are usually less obvious
4. Paranoid schizophrenia
Develops later (in the 30s or 40s) than other forms of schizophrenia. The most stable and
common subtype. Paranoid delusions are predominant. Patients are often uncooperative and

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difficult to deal with and may be aggressive, angry, or fearful. Thought disorder and affective
change are usually inconspicuous.
Hallucinations (auditory) are often present. Personality is well integrated.
5. Residual schizophrenia
After many years and repeat episodes, the active symptoms of schizophrenia ‘burn out’ and the
patient displays symptoms of residual phase (e.g. dullness, social with drawl, flat or
inappropriate affect, eccentric behavior, loosening of association, illogical thinking, lacking in
interest, volition or imagination).
Diagnosis
Schneider’s first rank symptoms in the diagnosis of schizophrenia (provided there is no evidence
of organic disease) are as follows: (see also ICD 10).
1. Thought with drawl (belief that thought are being taken out of one’s mind)
2. Thought insertion (belief that thoughts are being put into one’s mind)
3. Thought broadcasting (belief that thoughts become known to others)
4. Echoing thoughts (hearing thoughts spoken aloud)
5. Hearing hallucinatory voice discussing ones thoughts and behavior in third person, or passing
a
Running commentary (e.g. ‘he is doing in now’)
6. Passivity feelings (belief that thoughts and behavior are being influenced or controlled by
external
forces.
.
Management
 Hospitalization needed for both first episodes of schizophrenia and acute relapses
 Various neuroleptics can be used – see table provided in this section
 There are advantages in a few days of observation without drugs, although some acutely
disturbed patients may require immediate treatment.
 For acutely disturbed patients the sedative effects of chlorpromazine are useful. An
alternative
Approach is to use a modest dose of a high potency agent with additional benzodiazepine
treatment (e.g. diazepam 5-20mg.
 Oral medication usually given at this stage, although occasional IM doses may be needed
for
Patients who exhibit acutely disturbed behavior and are unwilling to comply with oral
treatment.
 After the first few days medication is continued at a constant daily amount for several
weeks,
Gradually changing to twice daily dosage or a single dose at night.
 Prescribe antiparkinsonian drugs (e.g. artane) if side effects are troublesome, but they
need not be given routinely.

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 ECT indicated mainly in catatonic stupor and severe depressive symptoms. Also in
patients whose symptoms have not responded to adequate antipsychotic drug therapy.
Other management
Psychotherapy
 Psychoanalytic psychotherapy: Suitable for patients with good motivation and
productivity.
 Group therapy: But of little benefit in the acute stage of the disorder.
 Supportive therapy: for patients who are resettling after the resolution of an acute illness.
 Behavioral treatment: Methods include social skills training, using positive and negative
reinforcement to change behavior. Behaviour therapy is based on learning theory which
postulates that problem behaviours (i.e., almost any of the manifestations of psychiatric
conditions) are involuntarily acquired due to inappropriate learning. Therapy concentrates
on changing behavior.
 Cognitive therapy: Attributes emotional difficulties to faulty thinking or beliefs
(cognition) that lead to counterproductive behavior. Psychiatric conditions presumably
improve when the patient’s thinking is more accurate and when the behavior is more
appropriate. Thus the therapist works with the patient to identify and correct
misperceptions (one by one) and (mis) behaviours.
Dosage of some antipsychotic drugs
Relative dose Maximum dose
Drug (oral – mg) (mg)
Chlorpromazine 100 1000
Thioridazine 100 800
Trifluoperazine 5 20
Fluphenazine 2 20
Haloperidol 2 100
Fluphenthixol 1 18
Sulpiride 200 2400
Clozapine 60 900