Schizophrenia
Delusions: Fixed false beliefs that have no basis in
Schizophrenia is a syndrome or disease process of the
brain causing distorted and bizarre thoughts,
perceptions, emotions, movements, behavior.
• It cannot be defined as a single illness; rather,
schizophrenia is thought of as a syndrome or as a
disease process with many different varieties and
symptoms, much like the varieties of cancer.
• It usually diagnosed in late adolescence or early
adulthood; rarely does it manifest in childhood.
• Spilt mind
• Not a single disease but a combination of disorders
• Peak incidence of onset is 15 to 25 years of age for
men and 25 to 35 years of age for women.
• Prevalence is estimated at about 1% of total
population.
• In the United States, nearly 3 million people are, have
been, or will be affected by the disease.
• Schizoaffective disorder diagnosed when:
A. Client is severely ill.
B. Mixture of psychotic and mood symptoms.
• Signs and symptoms include those of both
schizophrenia and a mood disorder such as depression
or bipolar disorder.
• Treatment for schizoaffective disorder targets both
psychotic and mood symptoms.
• Often, second-generation antipsychotics are the best
first choice for treatment.
• Mood stabilizers or an antidepressant may be added if
needed.
Major Categories of Schizophrenia
• Positive or Hard Symptoms
A. Ambivalence: Holding seemingly contradictory
beliefs or feelings about the same person, event, or
situation.
B. Associative looseness: Fragmented or poorly
related thoughts and ideas.
C.
reality.
D. Echopraxia: Imitation of the movements and
gestures of another person whom the client is
observing.
E. Flight of ideas: Continuous flow of verbalization
in which the person jumps rapidly from one topic to
another.
F. Hallucinations: False sensory perceptions or
perceptual experiences that do not exist in reality.
G. Ideas of reference: False impressions that
external events have special meaning for the person.
H. Perseveration: Persistent adherence to a single
idea or topic; verbal repetition of a sentence, word, or
phrase; resisting attempts to change the topic.
I. Bizarre behavior: Outlandish appearance or
clothing; repetitive or stereotyped, seemingly
purposeless movements; unusual social or sexual
behavior.
Grossly disorganized thinking, speech, and behavior
• Negative or Soft Symptoms:
A. Alogia: Tendency to speak little or to convey little
substance of meaning (poverty of content).
B. Anhedonia: Feeling no joy or pleasure from life or
any activities or relationships.
C. Apathy: Feelings of indifference toward people,
activities, and events.
D. A sociality: Social withdrawal, few or no
relationships, lack of closeness.
E. Blunted affect: Restricted range of emotional
feeling, tone, or mood.
F. Catatonia: Psychologically induced immobility
occasionally marked by periods of agitation or
excitement; the client seems motionless, as if in a
trance.
G. Flat affect: Absence of any facial expression that
would indicate emotions or mood.
H. Avolition or lack of volition: Absence of will,
ambition, or drive to take action or accomplish tasks.
 I. Inattention: Inability to concentrate or focus on a
topic or activity, regardless of its importance.
Bleuler’s 4 A’s of Schizophrenia
• Associative looseness- lack of logical thought
• Affective disturbances
• Ambivalence
• Autism
General Signs and Symptoms
• Social Isolation
• Catatonic behavior
• Hallucination
• Incoherence/ marked looseness of association
• Zero/ lack of interest, energy and initiative
• Obvious failure to attain expected level of
development
• Peculiar behavior
• Hygiene and grooming are impaired
• Recurrent illusions
• Exacerbations and remissions are common
• No organic factor accounts for signs and symptoms
• Inability to return to baseline functioning after relapse
• Affect is inappropriate
Genetic Theory
• Genetic pattern within the family system (50% chance
for another identical twin, 15% for paternal twin)
Psychodynamic Theory
• Poor care giving leads to psychic alterations
• Loss of ego boundaries
• Double bind communication pattern within a poor
family relationship
Neurobiological Theory
• Changes within the brain affecting language and
memory • Imbalance in neurotransmitters
Clinical Course
• Onset: abrupt or insidious; most with slow, gradual
development of signs and symptoms (social withdrawal,
unusual behavior, loss of interest in school or at work,
and neglected hygiene).
• Diagnosis: usually with more actively positive
symptoms of delusions, hallucinations, and disordered
thinking (psychosis).
• When and how the illness develops seems to affect
the outcome.
• Age at onset appears to be an important factor in how
well the client fares:
A. Those who develop the illness earlier show
worse outcomes than those who develop it later.
Related Disorders
• Schizophreniform disorder: The client exhibits an
acute, reactive psychosis for less than the 6 months
necessary to meet the diagnostic criteria for
schizophrenia. If symptoms persist over 6 months, the
diagnosis is changed to schizophrenia. Social or
occupational functioning may or may not be impaired.
• Schizoaffective disorder: symptoms of psychosis and
thought disorder along with all the features of a mood
disorder
• Catatonia: characterized by marked psychomotor
disturbance, either excessive motor activity or virtual
immobility and motionlessness.
• Delusional disorder: client has one or more no
bizarre delusions with no impairment in psychosocial
functioning—that is, the focus of the delusion is
believable. The delusion may be persecutory,
erotomaniac, grandiose, jealous, or somatic in content.
• Brief psychotic disorder: client experiences the
sudden onset of at least one psychotic symptom, such
as delusions, hallucinations, or disorganized speech or
behavior, which lasts from 1 day to 1 month. The
episode may or may not have an identifiable stressor or
may follow childbirth.
• Shared psychotic disorder (folie à deux): similar
delusion shared by two people. The person with this
diagnosis develops this delusion in the context of a
close relationship with someone who has psychotic
delusions, most commonly siblings, parent and child, or
husband and wife. The more submissive or suggestible B. Targeting positive signs.
person may rapidly improve if separated from the
C. No observable effect on negative signs.
dominant person.
• Second-generation antipsychotics:
• Schizotypal personality disorder involves odd,
eccentric behaviors, including transient psychotic A. Dopamine, serotonin antagonists
symptoms.
B. Diminish positive symptoms.
Etiology
C. Lessen negative symptoms.
Current etiologic theories focus on biologic theories:
Psychopharmacology: Maintenance Therapy
•Genetic factors
• Two antipsychotics are available in depot injection
•Neuroanatomic theories forms for maintenance therapy:
•Neurochemical theories – Fluphenazine (Prolixin) in decanoate and
• Immunovirologic factors enanthate preparations
Psychopharmacology Treatment – Haloperidol (Haldol) in decanoate
• The primary medical treatment for schizophrenia is • The effects of the medications last 2 to 4 weeks,
psychopharmacology. eliminating the need for daily oral antipsychotic
medication
• In the past, electroconvulsive therapy, insulin shock
therapy, and psychosurgery were used, but since the • Six antipsychotics available in depot injection form:
creation of chlorpromazine (Thorazine) in 1952, other
treatment modalities have become all but obsolete. A. Fluphenazine in decanoate and enanthate
preparations
• Antipsychotic medications, also known as
neuroleptics, are prescribed primarily for their efficacy B. Haloperidol in decanoate
in decreasing psychotic symptoms. C. Risperidone
• Conventional antipsychotics target the positive signs: D. Paliperidone
– Delusions E. Olanzapine
– Hallucinations F. Aripiprazole
– Disturbed thinking • May take several weeks of oral therapy to reach stable
– Other psychotic symptoms but have no observable dosing level before transition to depot injections.
effect on the negative signs Psychopharmacology: Side Effects
• Atypical antipsychotics diminish positive symptoms, Neurologic Side Effects
and they lessen the negative signs:
• Extrapyramidal side effects (acute dystonic reactions,
– Avolition akathisia, and parkinsonism)
– Social withdrawal A. Acute Dystonic reactions
– Anhedonia B. Akathisia
• They DO NOT CURE schizophrenia; rather, they are C. Pseudo parkinsonism
used to manage the symptoms of the disease.
• Tardive dyskinesia
• Conventional or first-generation antipsychotics:
• Seizures
A. Dopamine antagonists
• Neuroleptic malignant syndrome (NMS)
Non neurologic side effects
• Weight gain, sedation, photosensitivity.
• Anticholinergic symptoms (dry mouth, blurred vision,
constipation, urinary retention).
• Orthostatic hypotension.
• Agranulocytosis (Clozapine)
Data Analysis
Common nursing diagnoses for positive symptoms
include:
• Risk for Other-Directed Violence
• Risk for Suicide
• Disturbed Thought Processes
• Disturbed Sensory Perception
• Disturbed Personal Identity
• Impaired Verbal Communication
Common nursing diagnoses for negative symptoms
and functional abilities include:
• Self-Care Deficits
• Social Isolation
• Deficient Diversional Activity
• Ineffective Health Maintenance
• Ineffective Therapeutic Regimen Management
Psychosocial Treatment
• Individual and group therapy
- Medication management, use of community supports,
and family concerns is beneficial to clients with
schizophrenia.
• Social skills training
- Involves breaking complex social behavior into simpler
steps, practicing through role- playing,
and applying the concepts in the community or real-
world setting.
• Cognitive adaptation training
- More effective when carried out during in-home visits
in the client’s own environment
rather than in an outpatient setting.
• Cognitive enhancement therapy (CET)
- Combines computer-based cognitive training with
group sessions that allow clients to practice and develop
social skills.
• Family education and therapy
- Helps make family members part of the treatment
team.
Elder Considerations
• Late onset: after age 45
• Psychotic symptoms later in life usually associated
with depression or dementia, NOT schizophrenia.
• Variety of long-term outcomes for elderly
A. Approximately one-fourth experiencing dementia,
resulting in steady, deteriorating health decline.
B. Another 25% actually have a reduction in positive
symptoms, somewhat like a remission.
C. Schizophrenia remains mostly unchanged in the
remaining clients.
Self-Awareness Issues
• Recognize client’s suspicious or paranoid
behavior is part of the illness, not a personal affront.
• Nurse may be frightened; acknowledge those
feelings and take measures to ensure safety.
• Don’t take client’s success or failure personally.
• Focus on the amount of time client is out of
hospital.
• Visualize the client as he or she gets better.
Points to Consider When Working with Clients with
Schizophrenia
• Remember that although these clients often
suffer numerous relapses and return for repeated
hospital stays, they do return to living and functioning in
the community.
=Focusing on the amount of time the client is outside
the hospital setting may help decrease the frustration
that can result when working with clients with a chronic
illness.

• Visualize the client not at his or her worst, but as

he or she gets better, and symptoms become less
severe.

• Remember that the client’s remarks are not

directed at you personally but are a byproduct of the
disordered and confused thinking that schizophrenia
causes.

• Discuss these issues with a more experienced

nurse for suggestions on how to deal with your feelings
and actions toward these clients. You are not expected
to have all the answers.