SCHIZOPHRENIA

BY

BOLARINWA O.S.
(RN, RM, RPHN, RMHPN, MSc.)
 SCHIZOPHRENIA
• Schizophrenia was coined by a Swiss Psychiatrist Eugen
Bleuler in 1908. It’s a Greek word meaning ‘schizo’
(splitting) and ‘phren’ (mind).

• Schizophrenia is a major psychiatric disorder characterized

by hallucinations, delusions, and disturbance in thoughts,
perception, behavior, emotions, volitions, reasoning, and
speech resulting in significant impairment in social,
occupational, and cognitive functioning.

• The most enigmatic, tragic, and devastating psychiatric

disorder.

• Classified under the code F2 in ICD 10

 Occurrence

• Age: 15 – 40 years (2/3rd of all ages). Rare in

childhood.
• Sex: Both. Common in women
• Incidence: 1% of entire population globally
 Aetiology
1. Predisposing Factor: Genetics

2. Biological Factor: Dopamine hypothesis (High level

dopamine in the brain) & other neurotransmitters e.g.
Serotonin, acetylcholine, GABA, Norepinephrine, etc

3. Physiological Factor: Infections (viral) & Autoimmune

diseases

4. Physical Conditions : birth trauma, birth asphyxia,

head injury, alcohol abuse, CVA, cerebral tumor, etc
 Aetiology
5. Environmental factor: Low social class,
poverty & downward drift hypothesis

6. Precipitating factors: Poor-parent child

relationship, Over protection, Dysfunctional
family system, etc.

7. Psychological: Fixation at oral phase of

development
Diagnosis of Schizophrenia: DSM-5
A. Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less
if successfully treated). At least one of these must be 1, 2,
or 3.
1) Delusions
2) Hallucinations
3) Disorganized speech (freq. derailment or incoherence)
4) Grossly disorganized or catatonic behavior
5) Negative symptoms (i.e., diminished emotional
expression or avolition

Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

American Psychiatric Publishing, Washington DC, 2013
 Diagnosis of Schizophrenia: ICD-10
The patient must exhibit at least one of the
following, for a period greater than or equal to a
month:
• Thought insertion, echo, broadcast, or
withdrawal
• Delusions of control, influence, or passivity
• Hallucinatory voices providing a running
commentary of the patient
• Persistent delusions that are culturally
inappropriate or implausible
 Diagnosis of Schizophrenia: ICD-10
At least two of the following symptoms must be
observed, for a period greater than or equal to a month:
• Persistent hallucinations in any modality when
accompanied by fleeting delusions
• Breaks of interpolations in thought resulting in
incoherence or neologisms
• Catatonic behavior
• Negative symptoms
• Significant and consistent transformation in the overall
quality of behavior manifesting as anhedonia and
social withdrawal
 Clinical Symptoms
1. Disorders of thought:
• Possession: thought echo, thought insertion, thought
broadcasting, thought extraction.

• Forms: Association looseness, neologism, clang

association, word salad, circumstantiality, tangentiality,
mutism, perseveration, concrete thinking.

2.Delusion: Persecutory, Grandiose, Reference,

Control/Influence

3. Disorders of Perception: Hallucination (Auditory, Visual,

Tactile, Gustatory & olfactory).
 Clinical Symptoms
4. Disorders of Affect: Flattened, blunt, fluctuating, incongruent,

5. Disorder of Volition: Poor interest, motivation; catatonic symptoms

(echopraxia, echolalia, waxy flexibility, grimace, etc.)

6. Disorder of Behaviour: Mannerism, aggressiveness, disturbed,

destructive/violent, bizarre, etc

Others: decreased functioning (work, social, self-care), loss of

insight, poor judgment, loss of ego boundaries, talking to self,
irrational talk and thought, etc.

(Note: Psychotic symptoms include bizarre behaviour, hallucinations

& delusions)
 Negative Symptoms
• These are very difficult to treat.
1. Flat Affect
2. Avolition
3. Autism
4. Deteriorated appearance
5. Anergia
6. Apathy
7. Waxy flexibility
8. Posturing
9. Pacing & rocking
10. Anhedonia
11. Regression
 Features of Schizophrenia
Positive Symptoms Negative Symptoms
Loss of insight • Affective flattening
• Delusions (anosognosia)
• Hallucinations • Anhedonia
• Disorganization • Alogia
• Catatonia • Avolition
Social/Occupational Dysfunction • Social withdrawal
• Work
• Interpersonal relationships
• Self-care

Cognitive Deficits Mood Symptoms

• Attention • Depression
• Memory Comorbid • Hopelessness
• Executive functions Substance Abuse • Suicidality
(eg, abstraction) • Anxiety
• Agitation
Adapted from Maguire GA, 2002
• Hostility
 5 A’s Associated with Schizophrenia

• Affect
• Ambivalence
• Association Looseness
• Autism
• Apathy
 Types of Schizophrenia
• Simple
• Disorganized (Hebephrenic)
• Catatonic
• Paranoid
• Undifferentiated
• Residual
• Schizoaffective
• Schizophreniform Disorder
• Brief Psychotic disorder
• Delusional Disorder
• Post-Schizophrenic depression
 Simple Schizophrenia

• It has insidious onset.

• Social withdrawal and loss of interest.
• Apathy
• Poverty of ideation
• Decline in total performance
• Marked sensitivity & reference
• Usually occurs before age 25.
 Disorganized Schizophrenia
• Previously known as Hebephrenic.
• Onset is before age 25.
• Chronic course
• Behaviour is markedly regressive and primitive.
• Dilapidated life
• Communication is consistently incoherent.
• Affect is flat or grossly inappropriate
• Facial grimaces and bizarre behavior &
mannerisms.
• Neglect of personal hygiene is common
• Extreme social impairment (living on the street)
• Has the poorest prognosis
 Catatonic Schizophrenia
• Marked abnormalities in motor behaviour.
• Catatonic Stupor or Excitement.
Stupor
• Extreme psychomotor retardation
• Mutism
• Negativism
• Waxy flexibility
• Irritability
• Automatic response to stimulus
Excitement
• Extreme psychomotor agitation
• Frenzied & purposeless motion
• Destructive & violent
• Injury to self and others’
• Collapse from complete exhaustion
 Paranoid Schizophrenia
• Most common type of schizophrenia.
• Onset is usually late 20’s or 30’s.
• Presence of delusions – persecutory, grandeur, reference,
etc.
• Auditory hallucination is common
• Tense, suspicious and guarded
• Argumentative, hostile and aggressive
• Minimal social interaction
• Less regression of mental faculties, emotional response and
behavior compared with other types of schizophrenia.
• Sometimes has good prognosis.
 Undifferentiated Schizophrenia
• Here, patients do not meet the criteria for any
of the subtypes or they may meet the criteria
for more than 1 subtypes.

• Presence of psychotic symptoms

(hallucinations, delusions & bizarre behavior).

• Symptoms cannot be categorized into any of

the previously defined categories.
 Residual Schizophrenia
• This occurs in individual who has previous
episode of schizophrenia & has recovered,
capable of socially adjusting to the environment.
• But there is presence of continuing evidence of
the illness.
• No prominent psychotic symptoms anyway.
• Common symptoms may include social isolation,
eccentric behavior, impairment in personal
hygiene, poverty of or overly elaborated speech,
illogical thinking, apathy, etc.
 Schizoaffective Disorder
• This is characterized by the presence of psychotic
symptoms & mood disorder (depression or
mania).
• There may be psychomotor retardation, suicidal
ideation, loss of insight, grandiosity &
hyperactivity, euphoria, etc.
• There may be catatonic behavior, blunted or
inappropriate affect.
• Better prognosis than other types of
schizophrenia but worse than for mood disorders.
 Schizophreniform Disorder
• Clinical manifestations are identical to those
of schizophrenia.
• Duration (prodromal, active & residual
phases) is at least 1 month but less than 6
months.
• Diagnosis is changed to schizophrenia if the
clinical symptoms persist beyond 6 months.
• Has a good prognosis if there is good
premorbid social & occupational functioning,
a absence of blunted or flat affect.
 Management
• Admission is required
• Admit new patients close to the nursing
station for close monitoring.
• Adequate history-taking should be made
• A multidisciplinary approach to care is
needed
• Mental Status Examination.
• Monitor nutrition well. A lot of schizophrenic
patients eat too much and even hoard food
except in catatonic type.
 Management
• Offer assisted/supervised bathroom baths, grooming,
and oral care to patients who neglect personal hygiene.
• Close observation of patients with the potential to
harm themselves and others.
• Keep floors dry and avoid slippery substances on the
floor.
• Provide security and confidence by giving moral
support.
• Avoid being judgmental in the care of the patients.
• List and keep patient belongings/items safe and return
them on discharge.
 Management
• Repeat feelings expressed by the patient to make him
aware of his/her problem.
• Keep sharp objects (such as knives, razor, fork, spoon, etc.)
away from the patient environment.
• Encourage patient to participate in occupational therapy of
interest to him/her.
• Offer psychotherapy to assist patients gain insight to and
resolve their problems.
• Offer recreational therapy such as ludo, table tennis, chess,
cards, football, etc.) to boost morale and foster social
interaction among patients.
• Music therapy improves the well being of some
schizophrenic patients.
 Management
• Give prescribed antipsychotics e.g. Risperidone,
Olanzapine, Quetiapine, Aripiprazole, Haloperidol,
Chlorpromazine (CPZ), Clozapine, etc.
(Note: Clozapine is only used in drug-resistance cases)
• For violent client, sedate with IV diazepam & IM CPZ,
Haloperidol, etc.
• For catatonic symptoms, ECT may be required.
• Give Depo to clients who don’t comply with oral drugs.
• For extrapyramidal side effects, give Benzhexol
(Artane), Biperidine (Akineton), or Benztropine
(Cogentin) 2mg daily.
• For dry mouth, encourage patients to take sips of water
and chewing gum.
 Differential Diagnoses
• Psychosis secondary to organic causes
• Delusional disorder
• Paranoid personality disorder
• Schizotypal personality disorder
• Substance-induced psychotic disorder
• Mood disorders with psychotic features
• Sleep-related disorders
• Pervasive developmental disorder
THANKS FOR YOUR TIME!
 Assignment
• Identify and list four (4) nursing diagnoses for
a patient with Schizophrenia.

• As a nurse in charge, solve each of the

identified diagnoses using a nursing care plan.