This document provides an overview of disorganized schizophrenia, including key characteristics such as incoherent thoughts and behaviors. It discusses the complex nature of the disorder and treatment options, which typically involve medication, psychotherapy, and hospitalization. The document also presents a case study of a patient named Juan who experiences disorganized schizophrenia. His treatment plan involves prescription of antipsychotic and antidepressant medications as well as family psychoeducation therapy.

1. Running Head: Schizophrenia 1
Disorganized Schizophrenia
Misty Nikel, Jessica Fortner,
Aaron Febbo, Warren Taylor & Michael R. Dunbar
Mental Health Nursing
Lone Star College – CyFair
25 February 2015

2. Schizophrenia 2
Disorganized schizophrenia is a well-documented subtype of schizophrenia, a chronic
mental illness that can severely handicap the individuals affected by it. Experts believe that
disorganized schizophrenia is a more severe form of the disorder type because the patient cannot
perform daily activities, such as preparing meals and taking care of personal hygiene; the
disorder can have such a negative effect on the patient and their cognitive abilities, that their
speech may be misunderstood by a healthy individual, and this may cause the disorganized
schizophrenic to become frustrated, agitated or even to lash out. According to Halter (2014),
“Schizophrenia is a complicated disorder. In fact, what we call “schizophrenia” actually may be
a group of disorders with common but varying features and multiple, overlapping etiologies.
What is known is that brain chemistry, structure, and activity are different in a person with
schizophrenia” (p. 202).
While mental health experts and researchers in the scientific community have developed
a firm understanding of schizophrenia and it’s signs and symptoms as well as the treatments
available to manage the disorder; within society, schizophrenia is still very much one of the most
widely misunderstood, stereotyped and stigmatized mental disorders with negative associations
and portrayals supporting the misconceptions. For experts diagnosing disorganized
schizophrenia, there are several key characteristics that stand out such as incoherent and illogical
thoughts and behaviors; in other words, disinhibited, agitated, and purposeless behavior. This
diagnosis criteria has been compiled and published in the Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition in which contain the standard classification of mental disorders,
such as schizophrenia and in which contains the list of criteria recognized by the U.S. healthcare
system. The DSM states “Schizophrenia is characterized by delusions, hallucinations,
disorganized speech and behavior, and other symptoms that cause social or occupational

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dysfunction. For a diagnosis, symptoms must have been present for six months and include at
least one month of active symptoms” (American Psychiatric Association, 2013). A patient with
disorganized schizophrenia has disorganized thinking processes in which he or she is unable to
form coherent or logical thoughts. This inability has an impact on appropriate speech during
conversation and can often leap from one disparate subject to another. In addition their behavior
becomes grossly disorganized where the patient is often unable to perform regular daily activities
such as bathing, dressing properly, and preparing meals. This may also include unprovoked
agitation towards others, public sexual behavior, and behaviors ranging from the child-like to
aggressive and violent. Hallucinations and delusions are the hallmark of schizophrenia in which
the patient claims to hear voices much more commonly than seeing, feeling, tasting, or smelling
things; he or she will also develop false beliefs of persecution, guilt, and that things are being
controlled by an outside force such as plots against them. These symptoms lead to a societal
withdrawal from friends, family, and workplaces due in part because they believe there is fear of
interacting with other human beings, that someone may harm them, and that their social skills
have diminished. Ultimately, the disorganized schizophrenic becomes more immersed in the
delusions and hallucinations that seem real; they begin to believe they are not ill at all, which
leads to medication non-adherence. Due these difficult and complex symptoms, disorganized
schizophrenics often cannot seek medical help on their own; family or friends often initiate
seeking medical assistance.
While much is known about disorganized type schizophrenia, the cause for the disorder is
not well known; several studies suggest there is a brain dysfunction that may be caused by a
combination of environmental triggers and environmental factors. Understanding the
environmental factors requires the body to be imagined as a machine with a series of buttons in

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which schizophrenia would result if the enough buttons were pressed and in the right sequence;
this represents a genetic susceptibility. Doctors believe that an imbalance in dopamine or
serotonin is also involved in the onset of disorganized schizophrenia disorder; the imbalance
causing the body to become susceptible to the illness. Due to the changes in key brain functions
such as awareness, emotion and behavior lead numerous experts to conclude that the brain is the
biological site of schizophrenia. While the above describe the environmental triggers that may
activate the disorder, there are various genetic risk factors that set the stage. Genetics play a key
role in that individuals with a family history of schizophrenia have a higher risk of developing it
themselves. Based on Halter (2014), “Compared to the usual 1% risk in the population, having a
first-degree relative with schizophrenia increases the risk to nearly 10%” (p. 202). Additionally,
viral infection or malnutrition of the fetus in the womb can pose a greater risk of developing
schizophrenia. Halter continues (2014), “Schizophrenia often manifests at times of
developmental and family stress such as beginning college or moving away from one’s family.
Social, psychological, and physical stressors may play a significant role in both the severity of
the course of the disorder and the person’s quality of life” (p. 203).
Due to the complexity of disorganized schizophrenia, various evaluations are required to
ensure the correct diagnosis is confirmed. Other illnesses or conditions may have overlapping
symptoms may need to be ruled out. Once diagnosed, treatment modalities vary as much as the
disorder itself. Disorganized schizophrenia is a chronic condition without a cure and requires
treatment on a permanent basis; even when the symptoms seem to have subsided. Treatment
options are the same among the subclasses of schizophrenia although there are variations
depending on the severity and types of symptoms, the health of the patient, their age, as well as
other factors. Like with other complex medical treatment, a care team is required to treat

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schizophrenia, involved with the treatment will be a case worker, primary care physician,
pharmacist, psychiatric nurse, psychiatrist, psychotherapist, social worker, and members of the
family. Treatment options include psychopharmacology, psychotherapy, hospitalization, electro
convulsive therapy (if deemed a candidate) and vocational skills training. For many patients, the
path to an improved quality of life and adequate healthcare begins in the appropriate setting.
Hospitalization often is required for schizophrenics due to the setting being safer, where proper
nutrition may be provided, and the patient may get better sleep and receive help with hygiene.
Sometimes partial hospitalization is possible depending on the severity of the disorder. Once
admitted to the hospital, the patient’s interventions can begin with stabilization, teamwork, and
safety being key components. Halter discusses the advent of psychobiological interventions
(2014), “Drugs used to treat psychotic disorders, antipsychotics, became first available in the late
1950s. Previously available medications provided only sedation, not treatment of the disorder
itself. Until the 1960s, patients who had even one episode of schizophrenia usually spent months
or years in state or private hospitals” (p. 214). There are three groups of antipsychotics. First-
generation (i.e. Chlorpromazine (thorazine), haloperidol (haldol)), second-generation (i.e.
Quetiapine (Seroquel), Resperidone (Risperdal)) and third-generation antipsychotics (i.e.
Aripiprazole (abilify)). The first-generation antipsychotics affect the positive symptoms of
schizophrenia like hallucinations, delusions, disordered thinking. The second and third
generation antipsychotics can improve negative and positive symptoms. The second-generation
antipsychotics are often chosen as first-line because they treat both positive and negative
symptoms. Also the first-generation antipsychotics have a wide range of side effects that make
compliance an issue. First-generation antipsychotics cause extrapyramidal side effects, which
are contraction of head and neck muscles, pacing or fidgeting, and pseudoparkinsonism. More

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side effects include urinary retention, constipation, blurred vision, and dry mouth. Disorders co-
occurring with schizophrenia should be treated as well. Depression can be treated with
antidepressants and mood-stabilizing agents can enhance the effectiveness of antipsychotics.
Anxiety and agitation can be reduced with Benzodiazepines. Sun et al. (2014) supports “A
number of international guidelines recommend antipsychotic monotherapy using second-
generation antipsychotics as first-line medications for the treatment of schizophrenia. While
first-generation antipsychotics are acceptable in terms of efficacy, they may be avoided or
considered second-line treatments because of their irreversible side effects (e.g., tardive
dyskinesia). However, antipsychotic polypharmacy, defined as the concurrent use of more than
one antipsychotic drug for the single clinical condition, is on the rise” (p. 729). Along with
pharmaceutical interventions, psychotherapy consists of a series of techniques for treating mental
health, emotional and some psychiatric disorders. Psychotherapy helps the patient understand
what helps them feel positive or anxious, as well as developing and accepting their strengths and
weaknesses. Teaching patients with schizophrenia is crucial. Teaching the patient and family
about the illness like the causes, medication and side effects, coping strategies, what to expect,
and relapse prevention. Psychoeducational family therapy is beneficial because it helps the
family better understand what is going on with their loved one and become actively involved in
their life. This combination of treatments, therapies, medications and hospitalization are steps
that lead to discharge and reintegration into society.
An analysis of developing treatment plans for a patient with disorganized schizophrenia
can be formulated by using a case study. In this case study, Juan is a 27-year-old Hispanic man
diagnosed with disorganized type schizophrenia. He has been referred to a local rehabilitation
clinic that provides supported employment services.

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Juan graduated from high school and got a job working in a department store. After
working for about 6 months Juan began to hear voices that told him he was no good. He also
began to believe that his boss was planting small video-cameras in order to catch him making
mistakes. Juan became increasingly agitated at work, particularly during busy times, and began
"talking strangely" to customers while repeatedly smacking himself in the head. For example one
customer was returning a purchase and asked Juan if the appropriate sized item was available
when he abruptly screamed “No!” because it had "surveillance photos of him that were being
reviewed by the CIA". During this exchange with the customer, Juan was seem storming from
the customer service desk, repeatedly hitting himself in the head.
After about a year Juan quit his job one night, yelling at his boss that he couldn't take the
constant abuse of being watched by all the TV screens in the store and even in his own home.
Juan lived with his parents at that time. During his time at home, his parents would often
attend church with Juan and turn to prayer and spiritual guidance; before long, Juan became
increasingly agitated, especially during Sunday mass and would exclaim that the sacramental
wine was poisoned and that God wanted him to dead for seeing the bad behavior he exhibited.
His increased confusion and agitation lead to Juan’s parents taking him to the hospital
where he was admitted with acute pain from self inflicted injury, agitation, confusion as well as
verbalized suicidal ideations. He was given Thorazine by his psychiatrist, a very powerful
psychotropic medication. However, he experienced painful twisting and contractions of his
muscles; was switched to Haldol and had fewer side effects. From time to time Juan stopped
taking his Haldol, and the voices and concerns over being watched became stronger.
During the past 7 years Juan was hospitalized 5 times for suicidal ideations, never with an
actual attempt. During his most recent hospitalization, the psychiatrist noted that Juan’s speech

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was monotonous and often inappropriate at times. Psychiatrist noted that the patient verbalized,
“I’m trying to get the voices out of my head, they don’t stop.” He would often make facial
grimaces as if in pain and frequently slapped himself in the head. Juan would not maintain eye
contact with the Dr. and appeared very unmotivated to moved forward with treatment and
compliance to medication administration.
Juan’s family stated that as the disorder has gotten worse, “Juan decided to cut ties with
us and moved into his own apartment outside of his Hispanic community.” Since moving out of
his parent’s house, he isolates himself from his family and states he repeatedly says to them:
“I’ve never had any real friends” has never had a girlfriend. They also report that since moving
out and living alone without a support system, Juan’s behavior has continued to be erratic and
has increased the frequency of self harm, telling medical staff Juan states: “The voices never
leave, they never stop, and I can feel them under my skin.” Juan told his case manager he would
like to get a job so he can earn more money and maybe buy a car.
Juan is very worried about looking for a job. He doesn't know how to explain his disorder
to a potential employer, and he is afraid of becoming overwhelmed. He likes video games and
would like to work with them in some manner. He applied for and now receives supplemental
security income (SSI), and with the assistance of a case manager.
In order to improve Juan’s health and stabilize his disorder; Juan, working with his
family has opted to enter an in-patient mental health facility. Patient continues inflicting pain by
striking self in the head, self-reports pain is a 6/10.
As a treatment modality with psychopharmacology and psychotherapy, the recommended
course of action would be for the psychiatrist to prescribe Juan Quetiapine (Seroquel) twice a
day, Duloxetine (Cymbalta) once daily, and PRN Lorazepam (Ativan). Quetiapine (Seroquel) is

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a second-generation antipsychotic. This will treat both the negative and positive symptoms that
Juan experiences. This drug has fewer side effects then the medication that Juan was taking
before and will therefore be easier for him to comply with the regimen. Duloxetine (Cymbalta) is
an antidepressant that will help with Juan depression and suicide ideation. While Juan is in the
hospital, the doctor has put Juan on a PRN Lorazepam (Ativan) which can reduce anxiety and
agitation.
The doctor also wants Juan and both his parent to attend weekly psychoeducational
therapy. During these sessions the psychologist can talk about the medication and side effects,
coping strategies and problem skills, fears and distortions are identified. These sessions can
improve his quality of life and reduce the risk for relapse while building the foundations of a new
support system to cope with disorganized schizophrenia.
Comparison of a case study to a classically defined textbook case study often reveals key
similarities as many of the signs, symptoms, diagnoses, and treatments are the same, even with a
complex and variable disorder such as disorganized schizophrenia. The case study developed by
Varcarolis and their participant experienced persecution delusions similar to Juan. Tom, the
textbook case study patient, reports someone is attempting to kill him which sends him into
violent rages resulting in injury to others and frightening his nurse. Juan, who suffers from the
same type of delusion, feels his boss is watching him and the CIA is also conspiring against him.
Neither patient maintains eye contact with the speaker and often rambles in low tones. These are
classic signs that either patient is having difficulties focusing due to disruption of the thought
process. Although both patients have the same disorder, their coping mechanisms greatly differ.
Juan turns to self-harm by slapping himself and banging his head against the wall to drown out
the voices; Tom however, indulges in cocaine and marijuana, which leads to exacerbation of the

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disorder. A separate difference between the two patients is the support system; Tom has no
family and is separated from his wife and child and reports no close friends. Although strained,
Juan still has remnants of a support system; he was checked into a care facility when his parents
became concerned about his condition. A strong structure is important in stabilizing and
maintaining the therapeutic interventions and allowing him to adhere to it.
As with any hospitalization, discharge planning begins upon patient admission into the
psychiatric unit and the discharge plan should continue to be updated during the course of the
patient’s treatment. Often, patients with disorganized schizophrenia continue to need
readmission to psychiatric institutions for stabilization despite the accessibility of social
resources within their community; even so, discharge planning is still important in assessing the
needs of the patient for social, rehabilitative, and specialized services to achieve the goal of
improving the quality of life for the patient with schizophrenia. Discharge planning should be a
collaborative process between hospital staff, the patient, the family, and the community aftercare
agencies so that vital linkages are affected before discharge. As with the therapeutic care for the
patient; there is a team approach that includes the patient and, when appropriate, family
members. Literature review about discharge planning recommended that discharge planning
should be tailored for different needs of different client, be comprehensive which mean address
client’s need across multiple health system in the plan, create a system that is continuous and
coordinated, be practical and realistic, and maximize available resources for the benefit of the
client. (Ko, Smith, Liao, & Chiang, 2014) support this with, “Searching for reintegration is a
painful challenge rather than a beautiful fantasy on adaption to living with schizophrenia.
Balancing the splitting between the psychological experience and reality is a back-and-forth

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journey of suffering, effort, and hope that continues through the life for people with
schizophrenia” (p. 398).

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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Halter, M. (2014). Schizophrenia and Schizophrenia Spectrum Disorders. In Varcarolis'
foundations of psychiatric mental health nursing: A clinical approach. (7th ed., pp. 200-
226). St. Louis, Mo.: Elsevier.
Ko, C., Smith, P., Liao, H., & Chiang, H. (2014). Searching for reintegration: life experiences of
people with schizophrenia. Journal of Clinical Nursing, 23(3/4), 394-401.
doi:10.1111/jocn.12169
Rastad, C., Martin, C., & Åsenlöf, P. (2014). Barriers, benefits, and strategies for physical
activity in patients with schizophrenia. Physical Therapy, 94(10), 1467-1479.
doi:10.2522/ptj.20120443
Sun, F., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B.
(2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in
multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-
738. Doi:10.2146/ajhp130471