MENTAL HEALTH NURSING

UNIT VI : SCHIZOPHRENIA AND ITS MANAGEMENT

Presented by : Mrs Bemina JA

Assistant Professor
ESIC College of Nursing
Kalaburagi
 HISTORY
 Emil Kraepelin, an Eminent Psychiatrist in 1896
formed the concept of “Dementia praecox” – Mental
Deterioration In 1911 Eugen Bleuler coined the term
“Schizophrenia” Skhizo - Split , Phren - Mind
 Kurt Schneider described 11 symptoms,
Collectively Called as “First Rank Symptoms”
(FRS) whose presence / absence of course of brain
disease was diagnostic of schizophrenia.
 DEFINITION
 The schizophrenic disorders are characterized in general by
fundamental & characteristic distortions of thinking &
Perception, and by inappropriate or blunted affect. The
most intimate thoughts, feelings & acts are often felt to be
known or shared by others, & Explanatory delusions may
develop, to the effect that natural or supernatural forces are
at work to influence the afflicted individual’s thoughts &
actions in ways that are often Bizarre.
Schizophrenia is a psychotic condition characterized by a
disturbance in thinking, Emotions, Volitions & Faculties in
the Presence of clear consciousness, which usually leads to
social withdrawal.
 CLASSIFICATIONS
 CLASSIFICATIONS DSM – IV CL
 According to DSM – IV, At least 2 or more of characteristics symptoms must be present
for a particular portion / part of time during a 1 month period. Delusions
Hallucinations Disorganized speech Grossly disorganized / Catatonia behavior
Negative symptoms such as Flat Affect, Alogia / Avolition
 ICD – 10 CLASSIFICATION
F 20 – 29 Schizophrenia, Schizotypal & Delusional Disorders
F20 Schizophrenia
F20.0 Paranoid Schizophrenia
F20.1 Hebephrenic Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated
F20.4 Post – Schizophrenic Depression
F20.5 Residual Schizophrenia
F20.6 Simple Schizophrenia
F21 Schizotypal Disorder
 EPIDEMIOLOGY
 It is the most common of all Psychiatric disorders & is prevalent in all
cultures across the world.
 15% of new admissions in mental Hospitals are schizophrenic
patients.
 Schizophrenic patients occupy 50% of all mental hospital Beds.
 About 3 – 4 / 1000 in every community suffer from schizophrenia.
 About 1% of the general population have the risk of developing this
disease in their life time
 Men = Women
 About 2/3 of cases are in the age group of 15 – 30 years
 Very common in lower Socio – economic groups MEN WOMEN
Peak ages of onset are 15 – 25 years Peak ages of onset are 25 – 35
years
 ETIOLOGY
 BIOLOGICAL THEORIES
Biochemical theories
Dopamine Hypotheses
An excess of Dopamine – Dependent neuronal activity in the brain may cause
schizophrenia
Other Biochemical Hypotheses
Abnormalities in the Neuro - transmitters ( Nor epinephrine, Serotonin, Acetylcholine &
Gamma – amino butyric acid [GABA] )
Abnormalities in the Neuro - regulators (Prostaglandins & Endorphins)
 NEURO STRUCTURAL THEORIES
Pre frontal Cortex & Limbic Cortex may never fully develop in the brains of persons
with schizophrenia CT & MRI studies of brain structure shows
o Decreased brain volume
o Larger lateral & 3rd Ventricles
o Atrophy in the Frontal lobe, cerebellum & limbic Structures
o Increased size of Sulci on the Surface of brain
 Genetic theories
More common among people born of Consanguineous marriages
Identical twins affected 50%
Fragmental twins affected 15%
Brother / Sister affected 10%
One Parent affected 15%
Both Parents affected 35%
2nd Degree Relatives affective 2 - 3%
General Population 1%
 Perinatal Risk Factors
• Maternal Influenza
• Birth during Late winter / Early spring
• Complications of Pregnancy particularly during Labor &
Delivery
  PSYCHODYNAMIC THEORIES
Developmental theories According to Freud,
In Psychosexual Development
Oral Stage – Regression present along with that
Denial, Projection & Reaction Formation
The Individual have poor ego boundaries, Fragile
ego, Inadequate ego development, Super ego
Dominance, Regressed id ego, Love – Hate
relationships & Arrested Psychosexual
Development
  Family Theories
Mother Child Relationship: The mothers of
schizophrenics as cold, Over – protective & Domineering,
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 2 or more conflicting &
incompatible messages at the same time
 Stress Vulnerability Model
Social Factors More Prevalent in areas of high social
morbidity & Disorganization, especially among members
of very low socio economic classes.
Stressful life events also can precipitate the disease in
Predisposed Individuals
 Thoughts & Speech Disorders
 Autistic Thinking
 Loosening of Association
 Thought Blocking
 Neologism
 Poverty of Speech
 Poverty of Ideation
 Echolalia
 Perseverance (Persistent repetition of words Beyond the Point of relevance)
 Verbigeration (Senseless Repetition of words / Phrases)
 Delusions ( Persecution, Grandeur, Reference, Control, Infidelity, Somatic
Delusions, Bizarre )
 Over Inclusion ( Irrelevant items in speech )
 Impaired Abstraction
 Concreteness
 Ambivalence 
 Disorders of Perceptions / Affect / Motor Behavior

 Disorders of Perceptions
Hallucinations ( Auditory, Visual, Tactile, Gustatory, Olfactory )
 Disorders of Affect
• Apathy
• Emotional Blunting
• Emotional Shallowness
• Anhedonia
• Inappropriate Emotional Response
 Disorders of Motor Behavior
• Increase / Decrease in Psychomotor activity
• Mannerisms
• Grimacing
• Stereotypes
• Decreased self-care
• Poor Grooming
 Other Features
 Decreased in work Function
 Decreased social relationships
 Decreased Self care
 Inability to Concentrate
 Tension o Insomnia
 Withdrawal Or Cognitive Deficits o Loss of Ego Boundaries
 Loss of Insight o Poor Judgment o Suicide ( presence of
associated depression, Command Hallucination, Impulsive
behavior or return of insight that causes the patient to
Comprehend the devastating nature of the illness & take his
Life )
 Usually no disturbance of Consciousness, Orientation, Attention,
Memory & Intelligence o No Underlying Organic Cause
ABC SYMPTOMS OF SCHIZOPHRENIA, BASED ON CLINICAL FEATURES

 A – Autistic Thinking, Ambivalence, Anhedonia

 B – Blunted Affect
 C – Catatonic Behavior, Concreteness D – Delusions
 E – Echolalia, Echopraxia, Eccentric Behavior, Excitement
 F – Functioning In Work Is Decreased, Frank Incoherence
 G – Grimacing, Grooming Is Poor, Giggling
 H – Hallucinations, Hostility
 I – Illogical Thinking, Impulsive Behavior, Irrational Ideas
 J – Judgment Is Poor
 L – Loosening Of Association, Loss Of Ego Boundaries And Insight
 M – Mannerisms, Made Impulses, Feelings, Volition And Acts
 N- Neologisms, Negativism
 O – Oddities Behavior
 P – Perseveration, Poverty Of Speech And Ideation
 R – Rigidity S – Somatic Passivity, Suspiciousness, Stereotypes, Suicidal Ideas, Social Withdrawal.
 T – Thought Block, Insertion, Broadcasting , Withdrawal, Thought Echo. V – Verbigeration, Vague
Hypochondrical Features
 W- Waxy Flexibility, Wandering Tendencies
 PARANOID SCHIZOPHRENIA
 Paranoid means
 Delusional Paranoid Schizophrenia is at present the most common form of
Schizophrenia
 It is characterized by following features Delusions of Persecution Conspired against,
Cheated, Spied upon, Followed, Poisoned / Drugged, Maliciously maligned, harassed /
Obstructed in the pursuit of long term goals.
 Delusions of Jealousy
 The person’s sexual partner is Unfaithful
 Delusions of Grandiosity
 Irrational ideas regarding their own worth, talent, knowledge or power, may believe
that they have a special relationship with famous persons, Assumption of the identity of
a great religious leader Auditory Hallucinations Threaten or command the patient,
Hallucinatory voices such as Whistling, humming, laughing
 Other Features Disturbance of affect (Blunt), Volition, Speech & Motor Behavior It has
good prognosis if treated early Personal deterioration is minimal Patients are
productive and can lead a normal life
  HEBEPHRENIC (DISORGANIZED)
SCHIZOPHRENIA
 It has an early & insidious onset and is often associated with poor premorbid
personality The essential features include,
 Thought disorders,
 Incoherence
 Severe loosening of associations
 Extreme social impairment
 Delusions & hallucinations are Fragmentary & Changeable
 Other oddities of behavior include,
• Senseless Giggling,
• Mirror gazing,
• Grimacing • Mannerisms
The course is chronic & progressively Downhill without significant
remissions Recovery Classically never occurs One of the worst prognoses
among all the subtypes.
 CATATONIC SCHIZOPHRENIA
 Cata means Disturbed
 It is characterized by, Marked disturbance of motor behavior,
 FORMS:
 Catatonia Stupor
 Catatonia Excitement
 Catatonia Alternating between Excitement & stupor
 Clinical Features of Excited Catatonia:
 Increased Psychomotor activity (Restlessness, Agitation, Excitement,
Aggressiveness to at times Violent Behavior)
 Increased Speech production
 Loosening of Association
 Frank Incoherence
 Excitement becomes very severe and is accompanied by Rigidity, Pyrexia &
Dehydration and can result in death Then it is known as Acute Lethal Catatonia Or
Pernicious catatonia.
 Clinical Features of Retarded Catatonia (Catatonia Stupor)

  Mutism
 Rigidity (Maintenance of rigid posture against efforts)
 Negativism
 Posturing (Voluntary assumption of an inappropriate &
Often Bizarre Posture for long Periods of time)
 Stupor
 Echolalia
 Echopraxia
 Waxy Flexibility (Parts of Body can be placed in positions
for a long period of time, even if very uncomfortable)
 Ambitendency (A conflict to do or not to do)
 Automatic Obedience (Obeys every Command
irrespectively)
 RESIDUAL SCHIZOPHRENIA
 Symptoms Include,
 Emotional Blunting
 Eccentric Behavior
 Illogical Thinking
 Social Withdrawal
 Loosening of Associations
 This category should be used when there has been at
least one episode of schizophrenia in the past but
without Prominent Psychotic Symptoms at Present.
UNDIFFERENTIATED SCHIZOPHRENIA

 This category is diagnosed either when features of

no subtype are fully present or features of more than
one subtype are exhibited
  Late schizophrenia occurs after 40 yrs of age
 Schizoaffective psychosis with symptoms of
depression and mania and also neurosis
 Prognosis is poor.
 SIMPLE SCHIZOPHRENIA
 Early & Insidious onset, Progressive Course &
Presence of characteristic negative symptoms,
 Vague Hypochondriacal Features,
 Wandering Tendency,
 Self Absorbed idleness,
 Aimless activity,
 It differs from residual schizophrenia in that there
never has been an episode with all the typical
psychotic symptoms
 Prognosis is very poor.
  CHILDHOOD OR JUVENILE SCHIZOPHRENIA:-
Not common but seen between age of 5-10 yrs and 12-14 yrs
Onset is acute or gradual
Prognosis is poorI.
 SCHIZOAFFECTIVE PSYCHOSIS:-
Symptoms of schizophrenia associated with symptoms of
depression and mania
 PSEUDO-NEUROTIC SCHIZOPHRENIA:-
Core of illness is schizophrenia but presenting symptoms are
suggestive of neurotic symptoms like anxiety state, phobic
reactions, obsessive compulsive neurosis or hysteria
Treatment such as psychotherapy, abreactive therapy or drug
therapy is not satisfactory
Careful psychiatric examination done through repeated
interview, reveals the true nature of illness
POST – SCHIZOPHRENIC DEPRESSION

 Depressive features develop in the presence of

residual or active features of schizophrenia & are
associated with an increased risk of suicide
 COURSE & PROGNOSIS
 The classic course is one of the exacerbations &
remissions
 It described as the most crippling & devastating of
all illnesses
 Several studies have found that over the 5 – 10
years period after the 1st psychiatric Hospitalization
for schizophrenia, only about 10 – 20 % of patients
as having a good outcome
 More than50% of patients have a poor outcome,
with repeated Hospitalizations.
 DIAGNOSTIC EVALUATION
 History Collection
 Physical Examination
 Neurological Examination
 Mental Status Examination
 Blood Investigations (Vitamin Deficiency, Uremia,
Thyrotoxicosis, Electrolyte Imbalances,
Agranulocytosis)
 CT & MRI Scan (Shows Enlarged ventricles,
Enlargement of Sulci on the Cerebral Surface,
Atrophy of the Cerebellum)
 TREATMENT MODALITIES
 PHARMACOTHERAPY :
 Conventional Anti-Psychotics
 Chlorpromazine 300-1500mg/day PO ; 50-100mg/day IM
 Fluphenazine decanoate 25-50mg IM Every 1-3 Weeks
 Haloperidol 5-100mg/day PO ; 5-20mg/day IM
 Trifluoperazine 15-60mg/day PO ; 1-5mg/day IM
 Commonly Used Atypical Antipsychotics
 Clozapine 25-450mg/day PO R
 isperidone 2-10mg/day PO
 Olanzapine 10-20mg/day PO
 Quetiapine 150-750mg/day PO
 Ziprasidone 20-80mg/day PO
 Antidepressants ( Imipramine, clomipramine, Sertraline, fluoxetine )
 Mood stabilizers (Lithium, Carbamazepine, Sodium Valporate)
 Anxiolytics (Diazepam, Lorazepam)
 ELECTROCONVULSIVE THERAPY (ECT)
 Indications:
• Catatonia Stupor
• Uncontrolled Catatonia Excitement
• Severe Side-effects with drugs
• Schizophrenia Refractory to all other Forms of treatment Usually 8-12 ECTs are needed
 PSYCHOLOGICAL THERAPIES
• Psychotherapy
• Group Therapy
• Behavior Therapy
• Social Skills training
• Cognitive Therapy
• Family Therapy
 PSYCHOSOCIAL REHABILITATION
Activity therapy to develop work habit
Training in a new Vocation or retaining in a previous Skills
Vocational Guidance
Independent Job Placement
 
 PSYCHOSURGERY:- Prefrontal leucotomy
 NURSING INTERVENTIONS
 Observe behavior pattern, Posturing, Appearance, Psychomotor,
Disturbance, Hygiene
 Identify the type of Disturbance the patient is Experiencing
 Ask the patient about feelings while thought alterations are Evident
 Note the Effect & Emotional tone of the patient & whether they are
appropriate in relation to the thought or present situation o Assess the
Speech Patterns associated with the Delusions
 Assess for the Theme & Content of Delusional thinking.
 If the delusion is Persecution oriented, assess the nature of the threat
& risk for Violence
 Assess the ability to perform Self care activity (sleep pattern &
Interaction with other patients)
 Determine any suicidal intent or recent attempts that have been made
 NURSING DIAGNOSIS

 Disturbed thought Process related to inability to trust, Panic anxiety, Possible Hereditary Or
Biochemical Factors evidenced by Delusional thinking, Extreme Suspiciousness of others
 Ineffective health maintenance related to inability to trust, Extreme suspiciousness
evidenced by poor diet intake, inadequate food & Fluid intake, difficulty in falling asleep
 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
 Potential for violence, self directed or at others, related to command hallucinations
evidenced by physical violence, destruction of objects in the environment or self destructive
behavior.
 Risk for self inflicted or life threatening injury related to command hallucinations evidenced
by suicidal ideas, plans or attempts.
 Disturbed sensory - perception (auditory / visual) related to panic anxiety anxiety, possible
hereditary or biochemical factors evidenced by inappropriate responses, disordered thought
sequencing, poor concentration, disorientation, withdrawn behaviour
 Social isolation related to inability to trust, panic anxiety, delusional thinking, evidenced by
withdrawal, sad, dull affect, preoccupation with own thoughts, expression of feelings of
rejection of aloneness imposed by others.
 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.
 Ineffective family coping related to highly ambivalent family relationships, impaired
communication evidenced by neglectful care of the patient, extreme denial or prolonged
over concern regarding his illness.
GERIATRIC CONSIDERATIONS
 • Schizophrenia, a severe & persistent mental illness with an onset
in early adulthood, is not usually associated with older adults
 • Prevalence was thought to decline with aging as a result of early
mortality, Decreased symptom severity & recovery
 • Late – onset schizophrenia (after 45years) , More Prevalent in
women than in Men Characterized by Paranoid delusions. It has
Varying in degree of Impairment, but the Psychopathology
decreases with age
 • Psychotic Symptoms that appear in late life are usually
associated with depression or dementia, not schizophrenia
 • Patients may respond to supportive therapy and low doses of
Atypical Antipsychotic Drugs.
 PSYCHO EDUCATION
 Explain the patient & family that schizophrenia is a chronic
disorder with symptoms that affect the person’s thought process,
mood , emotions & Social functions throughout the person’s life
time
 Teach the patient & Family About the importance of medication
compliance and the therapeutic / Non – therapeutic effects of
antipsychotic medications
 Instruct the patient & Family to recognize impending symptom
exacerbation and to notify physician when the patient poses a
threat / danger to self or others& requires hospitalization
 Teach the patient & family to identify Psychosocial / family
stressors that may exacerbate symptoms of the disorder &
methods to prevent them
 REHABILITATION
 The focus of psychiatric rehabilitation is strengthening self
care & promoting & improving quality of life through relapse
prevention
 It has improved outcomes by ,
Providing Community , Family Support Services to decrease
hospital Readmission rates & increase Community Integration
 Social skills training
 Vocational Rehabilitation
 Half-Way Homes
 Long-term Homes
 Closer Supervision
 Day Hospitals, etc.,
 0THER PSYCHOTIC DISORDERS
 The term psychosis is defined as gross impairment in
reality testing, marked disturbance in personality with
impaired social and occupational functioning and
presence of characteristic symptoms like delusions and
hallucinations
  ICD - 10 CLASSIFICATION
F22 Persistent Delusional Disorders
F23 Acute And Transient Psychotic Disorders
F24 Induced Delusional Disorders
F25 Schizoaffective Disorders Capgra’s Syndrome
(Delusion Of Doubles)
PERSISTENT DELUSIONAL DISORDERS

 It is relatively stable & chronic course, characterized by presence of

well systematized delusions of non – Bizarre type
 The emotional response & behavior of the person is often
understandable in the light of Delusions The behavior outside the
limits of delusions is almost Normal
 CLINICAL FEATURES :
• Persistent Delusions (Atleast for 3 Months)
• Absence of significant / persistent hallucinations
• Absence of organic mental disorders, Schizophrenia, Mood
disorders
Very often these individuals are able to carry on a near normal social
& occupational life without arousing suspicion regarding the
delusional disorder
 ACUTE & TRANSIENT PSYCHOTIC
DISORDERS
 These disorders neither follow the course of schizophrenia nor
resemble mood disorders in clinical picture & usually have a
better prognosis than schizophrenia
 The onset is abrupt or acute, associated with identifiable acute
stress
 A complete recovery usually occurs within 2 – 3 months
 CLINICAL FEATURES
• Several types of hallucinations, delusions, changing in both
type & intensity from day to day or within the same day
• Marked emotional turmoil, which ranges from intense feelings
of happiness & ecstasy to anxiety & irritability
• Do not fulfill the criteria for Schizophrenia
INDUCED DELUSIONAL DISORDERS
  This is an uncommon Delusional disorder
characterized by, Sharing of delusions between
usually 2 or occasionally more persons, who usually
have a closely knit emotional bond.
 Only one has the ‘Genuine’ Delusions due to an
underlying psychiatric disorder
 On separation of the 2, while the dependent
individual may give up his delusions,
 The patient with the ‘genuine’ Delusions Should
then be treated appropriately
SCHIZOAFFECTIVE DISORDER
 In this disorder, the symptoms of schizophrenia &
mood disorders are prominently present within the
same episode.
 Types: Schizoaffective disorder
– Depressed type Schizoaffective disorder
– Manic type Schizoaffective
Mixed type
 CAPGRAS SYNDROME
  (Delusion of Double) It is characterized by delusional
conviction that the other person in the environment is
not their real selves but is their own doubles.
 It is one of the delusional misidentification syndromes
 Treatment:
• Antipsychotics
• Mood stabilizers
• Antidepressants
• ECT
• Supportive Psychotherapy