✔
SCHIZOPHRENIA
❖ Was coined by Eugen Bleuler – a Swiss psychiatrist
❖ It came from the Greek word meaning split personality-
which means that there is a disconnection or splitting of the
psychic functions.
❖ It encompasses a group of psychotic reactions that affect
multiple areas of the individual’s functioning, including
thinking and communicating, perceiving and interpreting
reality, feeling and demonstrating emotion, and behaving in
socially acceptable manner.
❖ It is characterized by withdrawal from reality, illogical
patterns of thinking, delusions, and hallucinations, and
accompanied in varying degrees by other emotional,
behavioral, or intellectual disturbances.
❖ It is a severe mental disorder characterized by 5 “A’s”
a. affect: a person’s mood, feeling tone or emotions
It is usually blunted, inappropriate, or flat
b. association: loose or distorted
c. Autism: a thought process in which the person retreats
from reality.
d. ambivalence: contradictory or opposing emotions,
attitudes, ideas and desires for the same person, thing or
situation
e. Auditory hallucination
❖ The nodal onset for men is between 18 to 25; for women,
between 25 and mid-30’s
Causes of schizophrenia
1. Genetic predisposition
● One affected parent: 12% to 15% risk
● Both parents affected: 35% to 39%
● Sibling affected: 8% to 10%
● Dizygotic twin affected: 15% at risk
● Monozygotic twin: 50% risk
● Distant relative: 3% to 5%
2. Neuro developmental abnormalities
● Development of minor fetal malformation during early
gestation
● Factors that can affect neurodevelopment and that may
increase the risk of disease include;
✔ influenza infection (maternal) during 2nd trimester
✔ trauma or injury at birth (hypoxia or oxygen deprivation)
✔ abuse or trauma during infancy or early childhood
3. Brain structural abnormalities and chemical imbalances
● Brain imaging techniques, MRI, positron emission
tomography have shown abnormalities in the structure of the
brain.
✔ enlarged ventricles
decreased cortical blood flow, especially in the pre-frontal
cortex
✔ decreased metabolic activity in certain areas.
✔ cerebral atrophy
● Excessive production of dopamine in some areas of the
brain.
● Other neurotransmitters like serotonin, nor epinephrine,
glutamate and GABA play an important role in the
development of schizophrenia
4. Psychosocial and environmental factors
● Developmental theorists proposed that the lack of warm,
nurturing attention in the earliest life contributes to the lack
of self-identity, reality misinterpretation and relationship
withdrawal.
● Families who have highly expressed emotions are
emotionally over involved, hostile and critical
● Consistent association with low-socio-economic
● Biologically vulnerable individuals who are always
exposed to life’s stressors may produce symptoms of
schizophrenia
Signs and symptoms of schizophrenia
1. Positive symptoms: reflect the symptoms of overt
psychotic or distorted behavior
● Excess or distortion of normal functions
● Bizarre or disorganized behavior
● Hallucinations
● Illusion
● delusions
✔ delusions of reference: everything occurring in
environment has a direct significance to oneself
✔ delusion of persecution: people or institutions are plotting
against or attacking him
✔ delusion of external control: one is controlled by others or
outside forces
✔ somatic delusion: appearance or functioning of one’s
body is altered. A person with this type of delusional disorder
believes that he or she has a physical defect or medical
problem.
✔ nihilistic delusion: a belief that one is dead or the world is
ending
✔ Erotomanic. Someone with this type of delusional
disorder believes that another person, often someone
important or famous, is in love with him or her. The person
might attempt to contact the object of the delusion, and
stalking behavior is not uncommon.
✔ Grandiose. A person with this type of delusional disorder
has an over-inflated sense of worth, power, knowledge, or
identity. The person might believe he or she has a great talent
or has made an important discovery.
✔ Persecutory. People with this type of delusional disorder
believe that they (or someone close to them) are being
mistreated, or that someone is spying on them or planning to
harm them. It is not uncommon for people with this type of
delusional disorder to make repeated complaints to legal
authorities.
● Excitement and agitation
● Hostility or aggressive behavior
● Suspiciousness
● Pressured speech
● Possible suicidal tendencies
● Loose association
✔ neologism- creating new words
✔ word salad- words in a sentence that may seem
connected but do not compose coherent thought
✔ echolalia- senseless repetition of the words of another
person
✔ echopraxia- senseless copying of another person’s
behavior or action
✔ clang association- words that rhyme are put together for
their sound association, without coherent thought
✔ flight of ideas- continuous flow of verbalization in which
the person jumps from one topic to another
2. Negative symptoms: reflect a diminution or loss of normal
function
● Anergia- lack of energy
● Anhedonia- lack of pleasure in activities and things that
the individual would normally perceive as pleasurable or
enjoyable
● Emotional withdrawal
● Poor eye contact
● Blunted affect
● Ambivalence
● Avolition- lack of motivation to persist a goal- oriented
activity
● Difficulty to abstract thinking
● Alogia- refers to decreased speech pattern or poverty of
speech
● Dysfunctional relationship with others
Types of Schizophrenia
1. Paranoid
❖ Characterized by systematized delusions or auditory
hallucinations; maybe suspicious, argumentative, hostile and
aggressive
❖ The individual’s behavior is less regressive and he is not
socially impaired
❖ prognosis is better than the other types
2. Disorganized
❖ It involves disorganized speech and behaviors as well as
flat or inappropriate affect.
❖ The individual may have odd mannerisms, exhibit extreme
social withdrawal, neglect hygiene and appearance
❖ Onset usually occurs before age 25, and the course maybe
chronic
❖ The individual demonstrates regressive behavior, with
poor social interaction and poor reality contact
3. Catatonic
❖ Characterized by marked psychomotor disturbances,
which may involve immobility or excessive activity
❖ Catatonic stupor: may exhibit inactivity, negativism, and
waxy flexibility
❖ Catatonic excitement: involves extreme agitation and may
be accompanied by echolalia and echopraxia
4. Undifferentiated
5. Residual
❖ There is a current absence of acute symptoms, but a
history of past episodes but marked social isolation,
withdrawal, and impaired role functioning maybe present
Other psychotic disorders
1. Schizoaffective disorder- refers to behavior characteristic of
schizophrenia in addition to those indicative of disorders of
mood such as depression or elation
2. Brief reactive psychosis or brief psychotic disorder- the
essential features include a sudden onset of psychotic
symptoms in response to a severe psychosocial stressors.
▪ The symptoms may last from few hours to one month
with a virtual return to the pre morbid level of functioning.
3. Schizophreniform disorder
▪ The essential features are identical to those of
schizophrenia with the exception that the duration is less than
6 months but more than 4 weeks.
▪ Prognosis is good, with expected return to pre morbid
level of functioning
4. Delusional disorder
▪ The client has one or more non bizarre delusions. That are
believable ideas.
▪ Psychosocial functioning is not markedly impaired and
behavior is not obviously odd or bizarre
5. shared psychotic disorder (folie a deux)
▪ A similar delusion is shared by two people
▪ The person with this diagnosis develops this delusion in
the context of a close relationship with someone who has a
psychotic delusions.
Management of schizophrenia
1. Brief hospitalization on a psychiatric unit to manage acute
symptoms and to provide safety, structured environment.
2. Various treatments include:
▪ Administration of antipsychotic medications
▪ Milieu management
▪ Supportive therapy
▪ Psycho education for the client and family
▪ Discharge planning to ensure continuity of care
Antipsychotics (neuroleptics or major tranquilizers
1. Typical antipsychotic agents
▪ It blocks selected dopamine receptors in the striatal and
limbic areas in the brain, an action believed to reduce
psychotic symptoms.
▪ It also affect other receptors, including those for
histamine, serotonin, nor epinephrine, and acetylcholine
▪ The effect on these receptors accounts for the multiple
side effects.
▪ Tolerance does not develop with these drugs
▪ It should be given 2 hours after eating and should not be
taken together with antacids of histamine 2 H2) blocking
agents (Cimetidine)
▪ Long acting preparations are available for haloperidol
(Haldol) and Fluphenazine (Prolixin); they are administered IM
via depot injection, and effects last 2 to 4 weeks
Contraindications:
❑ Known allergic response to any antipsychotic
❑ CNS depression
❑ Parkinson’s disease
❑ Blood dyscrasias
❑ Hepatic disease
c. Rapid dissolving preparation of Olanzapine (Zyprexa) and
Risperidone (Risperdal) are available
Atypical antipsychotics
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
3. Dopamine system stabilizer (DSS)
▪ Currently, only one drug is available in this class
(Aripiprazole- Abilify)
▪ DSS restores dopamine activity in the cortical levels of the
brain and reduce dopamine in the limbic areas, thus
decreasing psychotic symptoms
▪ Common side effects: headache, vomiting, constipation,
insomnia, light headedness, and akathisia
Managing common side effects on psychotropic drugs
Anticholinergic effects:
▪ Dry mouth: suggest the use of sugarless gum or candy,
rinsing the mouth frequently with water.
▪ Blurred vision: eye pain can indicate narrow angle
glaucoma
▪ Urinary retention
▪ Constipation
Cardiovascular effects
▪ Postural hypotension- teach client to change position
slowly, especially from lying to standing position
▪ Arrhythmias- teach the client to report sensations of
racing pulse or heartbeat, feelings of lightheadedness and
dizziness
Central nervous system
▪ Headache
▪ Drowsiness, fatigue, decrease mental alertness- drug
should be taken at bedtime if it is given once a day

❑ Acute narrow-angle glaucoma Gastrointestinal effects

❑ Benign prostatic hypertrophy ▪ Nausea, decrease appetite, diarrhea- should take the
Examples of typical antipsychotic drugs with full stomach
Fluphenazine (Prolixin) ▪ Weight gain, increased appetite- take enough calories to
Haloperidol (Haldol)
Perphenazine (Trilafon) maintain normal weight, exercise daily
Thiothixene ( Navane) Endocrine effects
Trifluoperazine (Stelazine) ▪ Amenorrhea
Chlorpromazine (Thorazine)
Thioridazine (Mellaril) ▪ Gynecomastia
2. Atypical Antipsychotic agents ▪ Sexual dysfunction: anorgasmia in women and erectile
▪ It blocks the dopamine receptors in the limbic system and dysfunction in men
affect serotonin receptors in the cortical brain areas Treating extra pyramidal effects of psychotropic drugs
1. Pseudo parkinsonism:
▪ They give more advantages than typical antipsychotics
a. it reduces positive symptoms as well as the negative ❖ Drooling of saliva
symptoms ❖ Motor retardation (akinesia)
b. It decreases EPS or no EPS may result because it does not
affect dopamine in the striatal areas ❖ Lack of facial responsiveness (mask-like facial expression)
❖ Shuffling gait ▪ Monitor complete blood count especially for decreasing
WBC
❖ Fine tremors (pill-rolling)
2. Seizures: tonic clonic seizure activity
Treatment:
▪ Reduce dose or stop drug
✔ Administer an antiparkinson (anticholinergic) drugs
Benztropine mesylate (Cogentin) ▪ Add an anticonvulsant agent to prevent further seizure
Biperiden hydrochloride (Akineton)
▪ Ensure the client’s safety during any seizure activity
Trihexyphenidyl hydrochloride (Artane
Nursing intervention: ▪ Notify the doctor
✔ Assess for this effect 3. Hepato toxicity: abnormal liver function series(elevated
enzymes), fever, nausea, jaundice and abdominal pain
✔ Elderly clients are more susceptible
▪ Stop drug
✔ Notify the doctor if this occurs
▪ Treat symptoms with bed rest, good nutrition, and
2. Acute dystonic reaction
adequate fluids
❖ Muscle spasm of the jaw, tongue, neck or eyes 4. Neuroleptic malignant syndrome:
❖ Laryngeal spasm may occur ❖ Altered consciousness

❖ Oculogyric crisis- backward rolling of the eyes in the ❖ Severe hyperthermia (38.9)
sockets
❖ Diaphoresis
Treatment
✔ Stop the drug and administer antidote (Cogentin or ❖ Tachycardia, and EPS resulting from massive dopamine
diphenhydramine (Benadryl) blockade in the brain and CNS
Treatment
✔ Treat as an emergency
✔ Stop drug
✔ Withhold any further dosage
✔ Check the vital signs
✔ Reassure the client
✔ Administer drug that stimulates dopamine receptors such
3. Akathisia
as Bromocriptine (Parlodel)
❖ Motor restlessness
✔ Administer IV, fluids, hypothermia measures
❖ Constant state of movement Nursing Interventions
1. For withdrawn and isolated client
❖ Difficulty of sitting still or there is a strong urge to move
about ❖ Establish a therapeutic relationship with client.
Treatment
❖ Initiate planned, short, frequent, and undemanding
✔ Administer an Antiparkinson drug interactions.
✔ May reduce antipsychotic dose if symptoms persist ❖ Plan simple one-on-one activity.
4. Tardive dyskinesia
❖ Maintain consistency and honesty in interactions
❖ Most frequent and serious side effect and this is
❖ Gradually encourage the client to interact with peers in
irreversible
non threatening situations
❖ Involuntary movements of the mouth, tongue
❖ Provide social skills training
(protrusion) and face and may extend to fingers, arms and
trunks ❖ Use measures to enhance self –esteem.
❖ Grinding of the teeth, lip smacking ❖ Use active friendliness kind of attitude.
Treatment 2. For the client exhibiting regressive or unusual behaviors
✔ No antidote available, stop the drug or change the drug ❖ Assume a matter-of-fact approach to bizarre behaviors
class (do not reinforce these behaviors)
✔ Notify the physician ❖ Treat the client as an adult, despite regression
Managing serious side effects of psychotropic drugs
1. Agranulocytosis: decrease white blood cells characterized ❖ Monitor the client’s eating patterns; encourage and assist
by sore throat, low grade fever, malaise, mouth sores when necessary.
▪ Stop the drug ❖ Assist with hygiene and grooming, performing these tasks

▪ Initiate reverse isolation for client’s safety only when client is unable to.
❖ Be cautious with touch because it may be perceived as
threatening.
❖ Establish a routine schedule of activities of daily living.
❖ Give simple choices of two items for the ambivalent
client.
3. For the client with unclear communication patterns
❖ Communicate in a clear, unambiguous manner.
❖ Ensure that communication is verbally and nonverbally
congruent.
❖ Clarify any unclear or ambiguous meanings related to the
client’s communication.
❖ Use appropriate therapeutic communication techniques
4. For a highly suspicious and hostile client.
❖ Establish a professional relationship; over friendliness
may be perceived as threatening to the client.
❖ Be cautious with touch because it maybe perceived as
threatening.
❖ Allow the client as much control and autonomy as
possible within the limit of the therapeutic setting.
❖ Work on establishing trust through short interactions that
communicate interest and respect.
❖ Explain any treatments, medications, and laboratory test
before initiating them.
❖ Avoid focusing on or reinforcing suspicious thoughts or
delusions.
❖ Identify and respond to emotional needs underlying
suspicious thoughts or delusions.
❖ Intervene when the client shows signs of increased
anxiety and on potential acting- out behavior.
❖ Be careful not to behave in a manner that can be
misinterpreted by the client.
5. For the client with hallucinations or delusions
❖ Do not focus attention on the client’s hallucinations or
delusions; interrupt the hallucinatory experience by initiating
one-to-one interaction that is reality based.
❖ Point out that you do not share the client’s perception,
but validate that you believe the hallucination is real to the
client.
❖ Avoid arguing with the client about hallucinations and
delusions.
❖ Respond to the client’s feelings communicated during
hallucinatory or delusion experience.
❖ Redirect and focus the client on a structured activity or
reality-based task.
❖ Move the client to a more quiet, less stimulating
environment.
❖ Wait until the client’s hallucinations or delusions stop
before initiating a teaching session about them.
❖ Help the client control hallucinations by focusing on
reality and by taking prescribed medications
❖ If the hallucinations persist, help the client learn to ignore
them and to act in an appropriate manner despite the
hallucinations.
❖ Teach cognitive strategies and tell the client to use self
talk and thought stopping.
6. For the client with agitated behavior and potential for
violence
❖ Observe behavior for early cues of agitation; intervene
before the patient begins acting out.
❖ Provide safe, quiet environment; decrease stimuli when
the client becomes agitated.
❖ Avoid retaliating when the client is verbally hostile; use a
quiet, calm tone of voice, provide personal space, and avoid
personal contact.
❖ Encourage client to talk about, rather than act out
feelings.
❖ Offer medications, as needed for agitated clients.
❖ Isolate the client from general milieu if agitation
increases.
❖ Set limits on unacceptable behavior, and consistently
follow institutional protocol for interventions.
❖ Follow institutional protocol for responding to the client
exhibiting acting out behavior.
❖ Ensure that an adequate number of experienced staff
members is available when attempting to subdue a violent
clients.
7. For the family of the clients with a schizophrenic disorder.
❖ Encourage family members to discuss their feelings and
needs.
❖ Help the family to define basic rules about respecting
each other’s privacy and living together.
❖ Encourage interaction for each family member with a
wider social environment.
❖ Encourage family members to become involved in support
groups.
❖ Assist members to identify anxiety-producing situation
and to plan specific coping strategies.
❖ teach the family about schizophrenia and its
management.
Neurotransmitters
▪ Nerve cells arranged in networks communicate
information with one another through neurotransmission
which is the conduction of electrical messages from neuron to
neuron.
▪ The electrochemical messages cross the synapses
between neural cells by way of special chemical messengers
called neurotransmitters.
▪ Neurotransmitters are chemicals found and produced in
the brain to allow the transmission of impulses from one
nerve cell to the next across synapses.
▪ . They aid in the conduction of information throughout
the body.
▪ These chemicals fit into specific receptor cells embedded
in the membrane of the dendrite that either fuel up or excite
action in the cells (excitatory) or stop or inhibit an action
(inhibitory).
▪ Presence or absence of these neurotransmitters can
directly or indirectly have an effect on neurons in a specific
portion of the brain.
▪ Thus, the levels of these chemicals in the brain have an
effect to a person’s behavior.
Mechanism of Nerve Impulse
Nerve cell conduction or communication is an extremely rapid
process which involves the following:
▪ The impulse moves through the nerve in a long and
slender cellular part called the axon.
▪ As the impulse travels through the axon it travels the
presynaptic membrane. It is in this area that
neurotransmitters are released in the free space called the
synaptic cleft.
▪ The receptors located in the postsynaptic membrane of
another nearby neuron pick up the free-flowing
neurotransmitters.
▪ The molecule is adapted in the next nerve cell and the
impulse continues to the next nerve cell until the message is
relayed throughout the body.
What happens after neurotransmitters sent the information?
▪ After they served their purpose of being released into the
synapse and relaying the messages to the receptor cells, they
are transported back from the synapse to the axon to be
stored for later use which is a process called reuptake.
▪ If the neurotransmitters will not undergo reuptake, they
will be metabolized and inactivated by enzymes, primarily
monoamine oxidase.
Major Neurotransmitters
Acetylcholine
▪ This is the first neurotransmitter discovered which is
found in the brain, spinal cord and particularly at the
neuromuscular junction of the skeletal muscle of the
peripheral nervous system.
▪ The mechanism of action of acetylcholine could either be
excitatory or inhibitory.
▪ Acetylcholine is synthesized from dietary choline found in
red meat and vegetables.
▪ Research and studies have linked the incidence of
Alzheimer’s disease with decreased acetylcholine secretion in
the neurons.
Physiologic Effects and Functions
▪ Muscular stimulation – acetylcholine signals muscles to
become active including the muscles of the gastrointestinal
system.
▪ Controls the sleep and wakefulness cycle of a person. It
has a part in scheduling the rapid eye movement (REM) sleep
or dream.
Norepinephrine
▪ The most predominant neurotransmitter in the nervous
system is the norepinephrine.
▪ This neurotransmitter is also known as noradrenaline and
is located primarily in the brain stem and sympathetic nervous
system.
Norepinephrine
▪ The mechanism of action of norepinephrine is excitatory
and plays a role in:
✔ Attention
✔ Memory and learning
✔ Sleep and wakefulness
✔ Mood regulation
▪ The presence of norepinephrine places the nervous
system into certain alertness and it increases a person’s heart
rate and blood pressure.
▪ Excessive amounts of norepinephrine have been strongly
linked with several anxiety disorders.
▪ However, deficits of these chemicals contribute to
memory loss, social withdrawal and depression.
Dopamine
▪ Dopamine is located primarily in the brain stem. It is
synthesized from tyrosine which is a dietary amino acid. This
neurotransmitter is involved in the control of the following:
✔ Complex movements
✔ Motivation
✔ Cognition
✔ Regulation of emotional responses
▪ Excessive amounts of dopamine in the frontal lobes of the
brain have been strongly linked to the occurrence of the
severe mental illness called schizophrenia.
▪ Thus, antipsychotic medications work by blocking the
dopaminergic receptors and reduce dopamine activity.
▪ On the other hand, insufficient levels of dopamine in the
motor areas of the brain can contribute to the aggravation of
the clinical manifestations of Parkinson’s disease.
Gamma Aminobutyric Acid (GABA)
▪ GABA is the major inhibitory neurotransmitter in the ▪ Low levels of serotonin have a role in the development of
brain. depression, problems in controlling anger, obsessive-
compulsive disorder and suicide.
▪ The main function of this neurotransmitter is to modulate
other neurotransmitter systems rather than to provide a ▪ Depressed people who are taking antidepressants
direct stimulus. manage the condition by preventing the reuptake of
serotonin or inhibiting the scouring action of the neurons to
▪ GABA is released and transported to act like a car brake to
excess serotonin.
the excitatory actions of other neurotransmitters.
▪ Mothers usually give their kids a glass of warm milk
▪ Medications that increase the levels of GABA in the body
before bedtime to help their sons or daughter sleep.
are used to treat anxiety and induce sleep.
▪ It is interesting to know that serotonin is a derivative of
▪ Scant amount of this chemical is a contributing factor to
tryptophan, which is found in milk.
development of anxiety disorders.
▪ Thus, a glass of milk before bedtime really helps.
Glutamate
▪ This neurotransmitter is an excitatory amino acid and
plays an important part in regards to memory.
▪ If glutamate levels are too high, major neurotoxic effects
will be noted.
▪ Glutamate is toxic to neurons at elevated levels and its
excess will kill the helpful nerve cells.
▪ This chemical has been implicated in the brain damage
caused by the following conditions:
✔ Stroke

✔ Hypoglycemia

✔ Sustained hypoxia or ischemia

✔ Some degenerative diseases such as Huntington’s Chorea

or Alzheimer’s Disease

Serotonin
▪ Serotonin is a neurotransmitter only found in the brain
and plays a very important role in a range of various brain
functions.
▪ It is derived from the dietary amino acid, tryptophan.

▪ Serotonin has been found to be strongly involved in the

emotion and mood of a person.
▪ The mechanism of action of serotonin is mostly inhibitory
and it has been linked with a wide variety of functions which
includes the following:
✔ Control of food intake – insufficient levels of serotonin
leads to an increased appetite for carbohydrates and starchy
foods
✔ Regulation of sleep and wakefulness cycle – scarce
amount of serotonin in the brain may lead to trouble sleeping
✔ Temperature regulation

✔ Pain control

✔ Sexual behaviors

✔ Regulation of emotions and mood