schizophrenia, types of schizophrenia, clinical features, and all the clinical types explain, diagnosis, treatment, nursing management

1. SCHIZOPHRENIA

2. SCHIZOPHRENIA
The word schizophrenia was
coined by the Swiss psychiatric
EUGEN BLEULER in 1908, it is
derived from the Greek words
skhizo (split) and phren (mind)

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

4. CLASSIFICATION
• F20 – F 29 :- SCHIZOPHRENIA,
SCHIZOTYPALAND DELUSIONAL
DISORDER
• F 20:- SCHIZOPHRENIA
• F 20.0 :- PARANOID SCHIZOPHRENIA
• F 20.1:- HEBEPHRENIC SCHIZOPHRENIA
• F 20. 2 :- CATATONIC SCHIZOPHRENIA
• F 20.3 :- UNDIFFERENTIATED
SCHIZOPHRENIA

5. • F 20. 4 :- POST SCHIZOPHRENIC
DEPRESSION
• F 20. 5 :- RESIDUAL SCHIZOPHRENIA
• F 20. 6 :- SIMPLE SCHIZOPHRENIA
• F 21 :- SCHIZOTYPAL DISORDER

6. ETIOLOGY
MANY AUTHORITIES SUGGEST THAT
MULTIPLE FACTORS MUST CAUSE
SCHIZOPHRENIA.
1)BIOLOGICAL THEORIES :-
BIOLOGICAL EXPLANATION INCLUDE
1) BIOCHEMICAL
2) GENETIC AND PERINATAL
3) NEUROSTRUCTURAL

7. • BIOCHEMICAL THEORIES :-
DOPAMINE HYPOTHESES :- This theory
suggests that an excess of dopamine
dependent neuronal activity in the brain
may cause schizophrenia.
OTHERS BIOCHEMICAL HYPOTHESES :-
Various other biochemical's includes
abnormalities in the neurotransmitters
norepinephrine , serotonin,
acetylcholine.

8. • NEUROSTRUCTURAL THEORIES :-
Research suggests that the prefrontal cortex
may never fully develop in the brain of
person with schizophrenia.
• GENETIC FACTORS :- The disease is more
common among people born of
consanguineous marriages ,studies shows
that relatives of schizophrenics have a much
higher probability of developing the disease
than general population.

9. • PERINATAL RISK FACTORS :-
Multiple non genetic factors influence the
development of schizophrenia.
MATERNAL INFLUENZA
BIRTH DURING LATE WINTER
COMPLICATION OF
PREGNANCY PARTICULARLY
DURING LABOUR AND DELIVERY

10. 2)PSYCHODYNAMIC THEORIES :-
• DEVELOPMENTAL THEORIES :-
According to Freud, there is regression to the
oral stage of psychosexual development , with
the use of defense mechanisms of denial ,
projection and reaction formation.
• FAMILY THEORIES :-
MOTHER CHILD RELATIONSHIP
DYSFUNCTIONAL FAMILY
SYSTEM

11. 3)VULNERABIITY STRESS MODEL :- This
model recognizes that both biologic and
psychodynamic predispositions to
schizophrenia when coupled with stressful
life events can precipitate a schizophrenic
process.
4)SOCIAL FACTORS :- More prevalent in
areas of high social mobility and
disorganization , among member of very
low social classes.

12. CLINICAL FEATURES
• EUGENE BLEULER (1857-1939)
• BLEULERS FOUR A
AFFECTIVE DISTURBANCE :- Inability to
show appropriate emotional responses
(inappropriate)
AUTISTIC THINKING :- It is a thought process
in which the individual is unable to relate to
others or to the environment.
 AMBIVALENCE :- It refers to contradictory or
opposing emotions, attitudes, ideas or desires for
the same person , things or situation
simultaneous opposite feelings.

13. ASSOCIATED LOOSENESS :- Inability to think
logically.
• SCHNEIDER’S FIRST RANK SYMPTOMS OF
SCHIZOPHRENIA (SFRS)
 Hearing one’s thoughts spoken and aloud (audible
thoughts or thought echo)
Hallucinatory voices in the form of statement and
reply ( the patient hears voice discussing him in the
third person )
Hallucinatory voices in the form of a running
commentary

14. 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
Thought broadcasting :- Is a delusion when you
believe people can hear your thoughts.
 Delusion perception (subject experiences that
his thoughts are escaping the confines of him self
and are being experienced by other around)
Somatic passivity ( bodily sensations especially
sensory symptoms are experienced as imposed
on body by some external force )

15.  MADE VOLITION OR ACTS :- Ones own
acts are experienced as being under
the control of some external force, the
subject being like 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.

16. • POSITIVE AND NEGATIVE SYMPTOMS OF
SCHIZOPHRENIA :-
POSITIVES SYMPTOMS:-
 DELUSION
 HALLUCINATION
 EXCITEMENT OR AGITATION
 AGGRESSIVE BEHAVIOR
 SUSPICIOUSNESS( IS A QUALITY OF
DISTRUST OR DISBELIEF)
 POSSIBLE SUICIDAL TENDENCIES

17. NEGATIVE SYMPTOMS:-
AFFECTIVE FLATTENING. ( a loss
of emotional expressiveness)
APATHY (LACK OF INITIATIVE)
ATTENTION IMPAIRMENT
ANHEDONIA (INABILITY TO
EXPERIENCE PLEASURE)
ALOGIA ( LACK OF SPEECH
OUTPUT)

18. THOUGHT AND SPEECH DISORDERS
• AUTISTIC THINKING :- PREOCCUPATIONS
TOTALLY REMOVING A PERSON FROM
REALITY
• LOOSENING OF ASSOCIATIONS :- A
Pattern of spontaneous speech in which
lack of meaningful relationship with each
other.
• THOUGHT BLOCKING:- A sudden
interruption in the thought process.

19. • NEOLOGISM :- A word newly coined ,
or an everyday word used in a special
way, not readily understood by
others.
• Poverty of speech :- decreased
speech production.
• Poverty of ideation :- speech
amount is adequate but content
conveys little information.

20. • ECHOLALIA :- Repetition or echo by
patients of the words or phases of
examiner.
• PERSEVERATION :- Persistent
repetition of words or themes
beyond the point of relevance.
• VERBIGERATION :- Senseless
repetition of some words or phases
over and over again

21. DISORDER OF PERCEPTION
oAUDITORY HALLUCINATIONS
oVISUAL HALLUCINATIONS
oSOME TIME OCCUR ALONG WITH
AUDITORY , TACTILE, GUSTATORY
AND OLFACTORY TYPES ARE FAR
LESS COMMON.

22. • DISORDER OF AFFECT :-
This include apathy, emotional blunting
(flattening of emotions ), inappropriate
emotional response.
• DISORDER OF MOTOR ACTIVITY :-
There can be either an increase or
decrease in psychomotor activity.
 MANNERISMS
 STEREOTYPES
 DECREASED SELF CARE

23. CLINICAL TYPES
• SCHIZOPHRENIA CAN BE CLASSIFIED IN
TO THE FOLLOWING SUBTYPES :-
1. PARANOID
2. CATATONIC
3. RESIDUAL
4. HEBEPHRENIC (DISORGANIZED)
5. UNDIFFERENTIATED
6. SIMPLE
7. POST SCHIZOPHRENIC DEPRESSION

24. PARANOID SCHIZOPHRENIA
• The word paranoid means “delusional”
paranoid schizophrenia is at present the
most common form of schizophrenia,
DELUSIONS OF PERCEPTION
DELUSIONS OF REFERENE
DELUSIONS OF JEALOUSY
DELUSIONS OF GANDIOSITY
HALLUCINATORY VOICES THAT THREATEN
OR COMMAND THE PATIENTS OR

25. HEBEPHRENIC(DISORGANIZED )
SCHIZOPHRENIA
• It has an early and insidious onset
and is often associated with poor
premorbid personality. the essential
features include marked thought
disorder, incoherence, severe
loosening of associations and
extreme social impairment.

26. CATATONIC SCHIZOPHRENIA
• Catatonic (cata – disturbed) schizophrenia is
characterized by marked disturbance of motor
behavior.
1. Catatonic stupor
2. Catatonic excitement
3. Catatonic alternating between excitement
and stupor.

27. CLINICAL FEATURES OF EXCITED
CATATONIA
• Increase in psychomotor activity (ranging
from restlessness , agitation, excitement ,
aggressiveness to at times violent
behavior.
• Increase in speech production
• Loosening of association( with the
individual jumping from one idea to
another unrelated or indirectly related
idea.)

28. CLINICAL FEATURES OF RETARDED
CATATONIA (CATATONIC STUPOR)
• MUTISM :- Absence of speech
• RIGIDITY :- Maintenance of rigid posture
against efforts to be moved.
• NEGATIVISM :- A motiveless resistance to
all commands and attempts to be moved
or doing just the opposite.
• POSTURING :- Voluntary assumption of
an inappropriate and often bizarre
posture for long period of time.

29. • STUPOR
• ECHOLALIA
• ECHOPRAXIA :- Repetition or mimicking of
actions observed
• WAXY FLEXIBILITY :- Parts of body can be
placed in positions that will be maintained for
long periods of time, even if very
uncomfortable.
• AMBITENDENCY :- A conflict to do or not to
do for example :- on asking to put out tongue,
it is slightly protruded but taken back again.

30. • AUTOMATIC OBEDIENCE :- Obeys
every command irrespective of their
nature.

31. RESIDUAL SCHIZOPHRENIA
• SYMPTOMS OF RESIDUAL SCHIZOPHRENIA
INCLUDE EMOTIONAL BLUNTING, ECCENTRIC
BEHAVIOR , ILLOGICAL THINKING, SOCIAL
WITHDRAWAL, AND LOOSENING OF
ASSOCIATION.

32. UNDIFFERENTIATED
• This category is diagnosed
either when features of no
subtype are fully present or
features of more than one
subtype are exhibited.

33. SIMPLE SCHIZOPHRENIA
• It is characterized by an early and
insidious onset, progressive course, and
presence of characteristic negative
symptoms. AIMLESS ACTIVITY
Vague Hypochondriacal :-Hypochondria is
often characterized by fears that minor
bodily or mental symptoms may indicate
a serious illness.
WANDERING TENDENCIES :- Person may
not remember his or her name address.

34. POST SCHIZOPHRENIC
DEPRESSION
• Depressive features develop in
the presence of residual or
active features of
schizophrenia and are
associated with an increased
risk of suicide.

35. DIAGNOSIS
1. HISTORY COLLECTION
2. PHYSICAL EXAMINATION
3. NEUROLOGICAL EXAMINATION
4. MENTAL STATUS EXAMINATION
5. BLOOD INVESTIGATIONS ( VITAMIN
DEFICIENCY, UREMIA,
THYROTOXICOSIS,ELECTROLYTE BALANCES,)
6. CT AND MRI (SHOWS ENLARGE
VENTRICLES,ENLARGEMENT OF SULCI ,
ATROPHY OF THE CEREBELLUM)

36. TREATMENT
• PHARMACOTHERAPY
1. CONVENTIONAL ANTI PSYCHOTICS :-
 CHLORPROMAZINE (300-1500 mg /day PO
and 50 -100 mg /day IM
 HALOPERIDOL 5-100 mg/day PO , 5-20
mg/day IM
2) COMMON USED ATYPICAL ANTIPSYCHOTICS
 CLOZAPINE 25-450 mg/day PO
 Risperidone 2-10 mg / day PO

37. 3) ANTI DEPRESSANTS :-
(LMIPRAMINE, CLOMIPRAMINE,)
4) MOOD STABILIZERS :- (LITHIUM
, CARBAMAZEPINE , )
5) ANXIOLYTICS :- ( DIAZEPAM ,
LORAZEPAM)

38. PSYCHOSOCIAL REHABILITATION
• ACTIVITY THERAPY TO DEVELOP WORK HABIT
• TRAINING IN A NEW VOCATION OR RETAINING
IN A PREVIOUS SKILLS
• VOCATIONAL GUIDANCE
• INDEPENDENT JOB PLACEMENT

39. ELECTROCONVULSIVE THERAPY
(ECT)
• ELECTROCONVULSIVE THERAPY IS a
procedure used to treat certain
psychiatric conditions. It involves
passing a carefully controlled electric
current through the brain, which
affects the brain activity and aims to
relieve severe depressive and
psychotic symptoms.

40. PSYCHOLOGICAL THERAPIES
•GROUP THERAPY
•BEHAVIOR THERAPY
•SOCIAL SKILLS TRAINING
•COGNITIVE THERAPY
•FAMILY THERAPY

41. NURSING MANAGEMENT
• NURSING ASSESSMENT
 Observe behavior pattern, posturing,
psychomotor , appearance , hygiene.
 Identify the types of disturbance the patient is
experiencing.
 Ask the patient about feelings while thought
alterations are evident.
 Assess speech patterns associated with the
delusions.

42. • OBJECTIVE SIGNS :-
WITHDRAWAL BEHAVIOR
HOSTILITY
INADEQUATE AND INAPPROPRIATE
COMMUNICATION
STEREOTYPE
APATHY
AMBIVALENCE
MUTISM
IN ABILITY TO TRUST

43. • SUBJECTIVE SYMPTOMS
HALLUCINATION
ILLUSION
PARANOID THINKING
CONFUSION
IDEAS OF REFERENCE
THOUGHT BLOCKING
INSOMNIA

44. NURSING DIAGNOSIS
• DISTURBED THOUGHT PROCESS RELATED TO
INABILITY TO TRUST AND PANIC ANXIETY,AS
EVIDENCED BY DELUSIONAL THINKING.
• IMPAIRED HEALTH MAINTENANCE RELATED
TO INABILITY TO TRUST,SUSPICIOUSNESS AS
EVIDENCED BY POOR DIET INTAKE.
• SELF CARE DEFICIT RELATED TO WITHDRAWAL
COGNITIVE IMPAIRMENT AS EVIDENCED BY
DIFFICULTY IN CARRYING OUT TASKS
ASSOCIATED WITH HYGIENE , DRESSING
EATING.