117 Lec: Schizophrenia
Misconceptions of Schizophrenia
- Believed to be dangerous, and uncontrolled; causing wild disturbances and violent
outbursts
- Many believe that those with the condition needed to be locked away from society
and institutionally
- Only recently has the mental health industry come to learn and educate the
community that schizophrenia has many different symptoms and presentations, and
is an illness that medications can control
- A client whose condition is medically supervised and whose tx is maintained often
continue to live and sometimes work in the community with family and outside
Brief Overview
support
Definition
- Alterations in thoughts, precept, mood, and behavior
- Cannot be defined as a single illness
- Is a syndrome/dx process that includes many varieties of varying symptoms
- Considered as a disturbances that can lead to severe deterioration of social and
occupational functioning
- As depression is commonly referred to the mental health professional as “the
common cold” of mental illness, schizophrenia is considered “cancer” because it is
probably the most serious and debilitating psychiatric disorder that exists
- Effects of this condition on the client may be profound involving all aspects of the
client’s life, social interaction, emotional health, and ability to work and function in
a community
- Unlike depression and anxiety which sometimes occur during a short period of a
person’s life, schizophrenia is a lifelong disorder with no known cure
- Usually diagnosed in late adolescence and early adulthood
- Peaked coincidence onset is:
o 15-25 years for men
o 25-35 years for women
- Symptoms typically appear in a person’s late teens or early twenties, though it can
begin at any age
- Generally speaking, males exhibit first signs of schizophrenia earlier than females
- Unlike some disorders, this condition does not favor one gender over the other
- Late onset in women may be due to antidopaminergic influence of estrogen
- Schizophrenia in itself has been generally believed to have accompanied mankind
through its history
- Was first described as a specific mental illness in 1887 by German psychiatrist Emil
Kraepelin, who was the first in classifying mental disorders into different categories
o Used the term “Dementia praecox” with individuals who had symptoms that
we now associate with schizophrenia
o The non-specific concept of madness has been around for thousand years,
but was only classified as a distinct mental disorder
o First to make a distinction between psychotic disorders and “Dementia
praecox” and manic depression
o Primarily believed that “Dementia praecox” was a disease of the brain, and
particularly a form of dementia (early dementia)
o Named the disorder in order to distinguish it from other forms of dementia
such as Alzheimer’s disease
o Used this term because studies focused on young adults with dementia
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- Swiss psychiatrist Eugen Bleuler coined the term “schizophrenia” in 1911
o First to describe the symptoms as positive or negative
o Changed the name to “schizophrenia” as Kraepelin’s term was misleading
and did not always lead to mental deterioration
o Greek roots schizo (split) and phrene (mind) to describe the fragmented
thinking of people with the disorder
o Term was not meant to convey the idea of split/multiple personality, which
was a common misunderstanding by the public
- Since Bleuler’s time, the definition of the condition has continued to change as
scientists attempt to more accurately delineate the different types of mental
diseases
- Without knowing the exact cause of this condition, scientists can only base
classification on the observation that some symptoms tend to core together
Classifications of Schizophrenia
- Based on DSM IV TR Lists, there are 5 classifications of schizophrenia:
o Disorganized- grossly inappropriate/ flat affect, incoherence, loos
associations, and extremely disorganized behavior
o Catatonic- marked psychomotor disturbances (either motionless/excessive
motor activity), motor immobility may be manifested by cataplexy (sudden
and transient episode of muscle weakness triggered by emotion), stupor;
excessive motor activity is apparently purposeless and is not influenced by
external stimuli; other features include extreme negativism, mutism,
peculiarities of voluntary movement, echolalia or echopraxia; pt may
deliberately assume bizarre body positions or manifest unusual limb
movements or facial contortions leading to the occasional misdiagnosis with
tardive dyskinesia
o Paranoid- persecutory or grandiose delusions, hallucinations, and
occasionally excessive religiosity or hostile and aggressive behavior; pt may
have auditory hallucinations, delusions of personal grandeur, and spends a
great deal of time thinking of ways to protect themselves from persecutors
(stemmed from feeling victimized or spied on)
o Residual- characterized by at least one previous, though not current
episode; social withdrawal, flat affect, looseness of association
o Undifferentiated- characterized by mixed schizophrenic symptoms along
with disturbances of thought, affect, and behavior
Diagnostic Studies
- Usually done to rule out physical illness that may cause reversible symptoms such as
toxic deficiency states, infection, neurological diseases, and endocrine/metabolic
disorders
o PET Scan- measure metabolic activity of a specific area of the brain and may
reveal low metabolic activity in the frontal lobe of the brain; may also
suggest diminished oxygen and glucose metabolism
o MRI- provides 3D images of the brain and may reveal a smaller than average
frontal lobe; less brain tissue which represents failure of development
o CT Scan- passively reveal enlarged ventricles and atrophy of the brain
Causes/Factors of Schizophrenia
- Despite much research, the specific cause of the condition is still a mystery
- Most likely, there are at least 2 risk factors (such as genetics, and perinatal factors)
- Undefined socioenvironmental factors may increase the risk of schizophrenia
1. Genetic Predisposition Theory
o Risk is increased in biologic relatives of persons with the condition, but not
in adopted relatives; risk if one has a first degree relative with the condition
is 10-20%; if both parents are schizophrenic, risk increases to 40%
o For dizygotic twins, risk is 10%; for monozygotic twins, risk is 40%
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o How it is inherited is still unknown, as no reliable gene marker has been
found
o Some individuals have a strong genetic link to the illness, while others have
only a weak genetic basis
o Gives further credence to the notion of multiple causations
2. Biochemical and Neurostructural Theory
o Main focus: dopamine hypothesis (suggests that condition is caused by
excess of dopamine dependent neuronal activity in the brain)
o Excess activity may be related to increased production/release of
substances at nerve terminals, increased receptor sensitivity, too many
dopamine receptors, or a combo of these mechanisms
o Dopamine is a neurotransmitter located primarily in the brain stem and is
found to be involved in the control of complex movements, motivation,
cognition, and regulation of emotional responses
o Dopamine is generally excitatory and implicated in clients with
schizophrenia; excessive amounts of this allows nerve impulses to bombard
the mesolimbic pathway (part of the brain normally involved in arousal and
motivation)
o There is disruption considering normal cell communication, resulting in the
development of hallucinations and delusions, both prominent symptoms of
schizophrenia
o Theory was based on two observations:
▪ Drugs that increased activity in dopaminergic system, such as
amphetamine and levodopa, sometimes induces a paranoid
psychotic reaction
▪ Drugs blocking post-synaptic dopamine receptors reduces psychotic
symptoms; the greater the ability to block the receptor, the more
effective it is in decreasing the symptoms of the condition
3. Organic or Pathophysiologic Influences
o May be caused by stressors such as viral infection, toxins, trauma, or
abnormal substances
o Theories that are being developed and tested to test the existence of a virus
that has an affinity for tissues in the CNS; possibility that a virus may alter
human genes and maternal exposure to a virus during critical fetal
development of the CNS
▪ Theory also emerged that exposure to a virus or the body’s immune
response could alter the brain physiology of people with
schizophrenia
▪ High incidence of schizophrenia after prenatal exposure to influenza
also supports this theory
▪ Other data supporting the viral hypothesis are an increased number
of physical anomalies at birth, increased rate of pregnancy and birth
complications, seasonality of birth consistent with viral infection
o With use of neuro imaging technology, it would reveal a structural brain
abnormalities that have been observed in individuals with schizophrenia
o People with the condition have relatively less brain tissue and CSF than
those who do not have schizophrenia
o Ventricular enlargement is most consistent finding associated with poor
premorbid functioning, negative symptoms, poor response to tx, and
cognitive impairment
o Sulci enlargement and cerebellar atrophy are also reported
o A diagnostic that helps in understanding the organic and pathophysiologic
influences is MRI, which would reveal possible decrease in cerebellar and
intracranial size in clients with schizophrenia, as well as a decrease in frontal
lobe size
o Another cause of the condition id the disarray of pyramidal cells
▪ In a study in the University of California, brains of clients with the
condition revealed a disarray of pyramidal cells in the hippocampus
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▪ Hypothesized that this alteration occurs during the 2nd trimester,
and may be related to the influenza virus encountered by mother
during this period
▪ Hippocampus and amygdala are involved in emotional arousal and
memory
4. Environmental or Cultural Influences
o Person with the condition may be unable to respond selectively to
numerous social stimuli
o Proponents state that they have a faulty reaction to the environment
o In relation to this, awareness of cultural differences is important when
assessing for symptoms of schizophrenia
▪ Ideas that may be considered delusional in one culture (such as
belief in witchcraft) may be commonly accepted by other cultures
▪ Auditory or visual hallucinations (such as seeing the Virgin Mary or
hearing God’s voice) may be a normal part of religious experiences
in some cultures
o Considering the socioeconomic areas or that being a single parent, this
hypothesis relates that schizophrenia moves into/fails to move out of low
socioeconomic groups with a tendency of social isolation and segregation of
self from others (which is a characteristic of the disease process known as
autism)
▪ Proponents view this poor social condition as a consequence rather
than a cause of the condition
o Considering the downward drift hypothesis, this concerns with the
relationship of mental illness and social class
▪ Argues that illness causes one to have a downward shift in social
class
▪ Circumstances of one’s social class do not cause the onset of mental
disorders, but rather an individual’s deteriorating mental health
occurs first, resulting in low social attainment
▪ Is essentially the opposing theory of the social causation thesis,
which states that being in a lower social class contributes to the
development of a mental illness
5. Developmental theory
o Developmental schizophrenia may occur during fetal life at critical points of
brain development, generally the 34-35th week of gestation
o Incidence of trauma is also considered in the development of the condition
o Developing fetus/newborn is deprived of oxygen during pregnancy or was
exposed to teratogenic agents such as infections, alcohol, chemicals,
medication, or radiation
▪ Mothers may suffer from malnutrition or starvation during the 1st
trimester of pregnancy
Phases of Clinical Symptoms
- Always remember that schizophrenia is a mental illness whose symptoms usually
occurs in phases
- There are cycles of s/sx that are hard to stop without help from a doctor
Phase I: Prodromal Phase
- When the symptoms start to show up
- Friends and family may notice strange behavior from an individual, and individual
may want to be alone much of the time, and may start to talk only about certain
topics (religion, government, or a very significant public figure)
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Phase II: Active Phase o Accessory symptoms (frequently present, but are not specific to
schizophrenia)
- When symptoms are most noticeable
▪ Hallucinations
- Also termed as the acute phase, and can be the most alarming when it comes to the
▪ Delusions
s/sx, especially to friends and family
▪ Catatonic posturing
- Causes symptoms of psychosis such as delusions, hallucinations, and jumbled
speech and thoughts
- Symptoms may appear suddenly without the prodromal phase Current Classifications

- Positive (productive) symptoms: possibly caused by an increased amount of

Phase III: Residual Phase dopamine affecting the cortical areas of the brain
o Sometimes clinicians find it useful to describe symptoms of schizophrenia as
- When client starts to recover but still has symptoms
positive or negative
o Positive symptoms tend to reflect distorted behavior such as hallucinations,
Bleuler’s Signs and Symptoms: delusions, suspiciousness, ambivalence, echopraxia, flight of ideas, ideas of
reference, and perseveration
- Bleuler identified the two major categories when it comes to the s/sx of o Clinical symptoms and diagnostic characteristics also include:
schizophrenia:
o Fundamental symptoms (4 A’s) ▪ Excess/distortion of normal ▪ Hostility or aggressive behavior
functions ▪ Suspiciousness, ideas of
▪ Associative disturbance- involves thought content; pt has inability to
▪ Delusions (persecutory or reference
think logically, ideas expressed have little to no connection and may
grandiose) ▪ Pressurized speech
shift from one subject to another ▪ Conceptual disorganization ▪ Bizarre dress or behavior
▪ Affective disorder- described as having a flat or blunted affect, or an ▪ Hallucinations (visual, auditory, ▪ Possible suicidal tendencies
affect that is incongruous to the thought or situation; may also or other sensory modes)
show inability to show appropriate emotional response to situations ▪ Excitement or agitation
▪ Autism – detachment from external reality and withdrawal into
fantasies; thought process where individual is unable to relate to
others or to the environment - Negative (deficit) symptoms: reflects a diminution or loss of normal functions
▪ Ambivalence- simultaneous existence of opposing feelings, o Results from cerebral atrophy, an inadequate amount of dopamine, or other
thoughts, and desires for the same person, thing, or situation organic functional changes in the brain
o Could be noted through CT scan, and may show some structural brain
abnormalities and may respond poorly to tx

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o Clinical symptoms also include:
▪ Diminution or loss of normal
functions
▪ Anergia (lack of energy)
▪ Anhedonia (loss of pleasure or
interest)
▪ Emotional withdrawal
▪ Poor eye contact (avoidance)
▪ Blunted affect or affective
flattening
▪ Apathy (feelings of indifference
to others)
▪ Flat affect (absence of any
facial expression that would
indicate emotions/mood)
- Disorganized symptoms:
o Cognitive defects/confusion
o Incoherent speech
o Disorganized speech
o Repetitive rhythmic gestures (such as walking in circles or pacing)
o Attention deficits
Diagnostic Categories
▪ Avolition (passive, apathetic,
social withdrawal); lack of
volition is the absence of will,
- In type II schizophrenia, there is a slow onset of negative s/sx caused by viral
ambition, or drive to take
action to complete tasks
▪ Difficulty in abstract thinking
▪ Alogia (lack of spontaneity and
flow of conversation); tendency
to speak very little or to convey
little substance of meaning
(poverty of thought content)
▪ Dysfunctional relationship with
others
o Typical neuroleptic medications are older, conventional antipsychotics that
target positive s/sx of the condition but have no observable effects on the
negative s/sx
infections and abnormalities in the cholecystokinin
o Cytokines are chemical messengers between immune cells mediating
inflammatory and immune responses
o There are specific cytokines in signaling the brain to produce behavioral
and neurochemical changes needed in the face of physical/ psychological
stress to maintain homeostasis
o There is intellectual decay in type II schizophrenia, along with enlarged
ventricles
o Response to typical neuroleptic medications are minimal
o Side effects are distressing extrapyramidal s/sx, and often causes the pt to
become non-compliant
▪ Examples are haloperidol and chlorpromazine
o Atypical medications were developed in response to recent neurobiologic
bases that are effective against both positive and negative symptoms, and
are less likely to cause extrapyramidal s/sx including tardive dyskinesia, and
thus promotes adherence to the pt
▪ Examples include clozapine and risperidone

- In type I schizophrenia, onset of positive s/sx are generally acute and responds to Diagnostic Criteria for Schizophrenia
neuroleptic medication
- There should be two or more of the following:
o An increased number of dopamine receptors, normal brain structure, and
o Delusions o Grossly disorganized or
absence of intellectual deficit contributes to a better prognosis of type I
o Hallucinations catatonic behavior
schizophrenia o Disorganized speech o Negative symptoms

- Above symptoms present for a major portion of the time during a 1-month period

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- There should also be a significant impairment in work or interpersonal relations, or Assessment of Patient with Schizophrenia
self-care below the level of pervious function
- Mental status assessment
- Demonstration of problems continuously for at least a 6-month interval
o General appearance, motor behavior, and speech (note what is very
- Symptoms unrelated to schizoaffective disorder and mood disorder with psychotic
prominent in pt)
symptoms and not the result of a substance-related disorder or medical condition
o Mood and affect (flat affect, blunted affect, or anhedonia)
o Thought process and content (thought blocking, thought broadcasting,
Management of Schizophrenia thought withdrawal, delusions)
o Sensorium and intellectual process
1. Medical (typical and atypical)
▪ Hallmark symptom of schizophrenia is hallucinations
o Done in an outpatient setting, carried out by multidisciplinary team:
▪ Psychopharmacologist
o Judgement and insight (usually impaired in pt with schizophrenia; cannot
▪ Counsellor
meet needs for safety and protection)
▪ Social worker
o Self-concept (loss of ego boundaries)
▪ Nurse
o Roles and relationships (may be problematic)
▪ Vocational counselor
o Physiologic and self-care considerations

o Note that medications used are neuroleptic agents, where there have been
many issues including its effectiveness, costs, side effects, method of Nursing Priorities for Patients with Schizophrenia
delivery, availability and tolerability, and cases of noncompliance that may
- Promote appropriate interactions between client and environment
cause relapse
o as one of the distinguishing characteristics identified by Bleuler is autism
o How to treat schizophrenia:
▪ Encourage patient compliance to medication regimen (as symptoms
- Enhance physiologic stability/ health maintenance
can only be controlled and not cured)
o There is a tendency of pts with schizophrenia to have self-care deficits that
▪ Medications (typical and atypical antipsychotic medications)
may be due to positive symptoms
▪ Psychotherapy (very helpful in terms of controlling and allowing pt
to express thoughts and feelings and address them accordingly)
- Provide protection, ensure safety needs
2. Psychological
o Clients with schizophrenia has a tendency to harm oneself or
3. Psychosocial
commit/attempt suicide

- Encourage families to become involved in activities

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o One of the important goals of tx is participation and cooperation of family
so that pt will not feel rejected or isolated when brought back to community
Nursing Interventions
- Promote safety and right of privacy
o Most pts has the tendency to cause harm to self and others
o May also display violent behavior
o Manage violent behavior by providing necessary interventions before
violence occurs
- Establish therapeutic relationship based on trust
o Remember that pt may be anxious and fearful towards others, making it
difficult for them to build a trusting relationship with nurse
o Touch should be avoided except when pt will likely be perceived as
threatening or harmful
- Delusions: do not openly confront delusions or argue with it
o For them, the stimuli feels real
- Establish and maintain reality for clients
o Provide direct explanation that are clear and easy to understand
- Use distracting techniques
o Especially it pt is noted to have delusions and hallucinations
- Teach pt positive self-talk; positive thinking and ignoring delusional beliefs
o Recognize importance of positive self-talk in helping pt achieve potential
o Draw them to activities/conversations that are reality based
- Hallucinations: help maintain and present reality by frequent contact and
communication with the client
o for the individual, hallucinations are real
o nurse should not argue with pt and should dismiss/ignore it
- Elicit description of hallucination to protect client and others
o Most clients also experience auditory hallucinations that may tell them to
harm self or others
- Deal with inappropriate behaviors in non-judgmental and matter-of-fact manner;
give factual statements; do not scold
o Make sure that pt is secured and safe if pt is experiencing hallucinations
o Do not leave pt alone when hallucinating
o Nurse’s presence is a reassuring force that will help pt feel calm and relaxed
- Do not make client feel punished or shunned for inappropriate behaviors
o These clients may not be able to interact with others, but staying with pt
provides a vital link to the real world
- Inform others that client’s inappropriate behaviors or comments are not their own
fault
- Teach social skills thru role modelling and practice
o Nurse as a model, should have appropriate affect and communication with
pt and others through pt expressions and language that match tone or
content of message
o Example: nurses has sad expression when talking about sad events; nurse
should not reinforce inappropriate/bizarre behavior by smiling, nodding,
laughing, or becoming angry with pt
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Discharge Criteria

1. Physiological well-being is maintained with appropriate balance between rest and

activity
o Appropriate health teaching should be given when it comes to rest and
activity
o They should have enough time to balance both considering the medications
being taken

2. Demonstrate increasing/highest level of emotional responsiveness possible

3. Interacts socially without decompensation
4. Family displays effective coping skills and appropriate use of resources
o Nurse must also assess pt’s family when looking for resources, especially
that maintenance medications are lifelong
o Referrals to appropriate resources (PSCO and other govt agencies) may help
pt and family with financial support to have maintenance medications

5. Plan in place to meet needs after discharge

o Explain and emphasize to pt and family the importance of follow-up visits

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