HAMDALLAH

HAMDALLAH KHALID
KHALID
RN,BSN,
RN,BSN, MSS
MSS
IBN
IBN SINA
SINA COLLEGE
COLLEGE
PALESTINE
PALESTINE

1
 SCHIZOPHRENIA
• Schizophrenia means “split mind”
• Refers to personality
“disintegration”
• Introduced by Eugen Bleuler to
emphasize that affect (emotions)
and thoughts were disconnected
• Does not refer to split or multiple
personality (DID)
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Key Historical Figures
•Emil Kraepelin (1899)
Dementia praecox
• ~ precocious dementia
• Implies mental deterioration occurring early in life
with no recovery
• Kraepelin’s “dementia”:
– Poor judgment
– Apathy
– Lack of emotional expression
– Reduction in voluntary activity
– Neglect of responsibilities & self-care
– Poverty of speech
• Today called negative symptoms – reflect absence
of attributes shared by most people
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Eugen Bleuler (1911)
Schizophrenia’s 4 “A”s
1. Associative Loosening
2- Affect
3. Autistic withdrawal
4. Ambivalence
• Bleuler’s lasting contribution: Loose
associations, affect disturbance, and
interpersonal relations deficit important
to DSM definition of schizophrenia
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Kurt Schneider (1959)
Schneider’s first rank symptoms
(FRS)
• Includes what are now considered to
be positive symptoms – reflect the
presence of attributes shared by
few; addition of abnormal features
e.g., hallucinations and delusions

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 Myths
False assumptions about schizophrenia
– Violence
– Multiple personalities
– Homelessness
– Due to frigid mother
– Due to conflicting messages
– Due to conflict resolution in
relationships
– Sex abuse
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Facts
• Schizophrenia is observed in all races
and cultures
• It’s onset is sudden and intense. It
often begins with an “acute” psychotic
phase.
• Schizophrenia can be brought on by drug
use or by a life stressor.
• Schizophrenia can be successfully
treated with drugs, but the long-term
prognosis is poor 7
Schizophrenia definition
Schizophrenia is a PSYCHOTIC
DISORDER (i.e., a severe mental
disorder in which thinking and
emotion are so impaired that the
individual is seriously out of contact
with reality).

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Epidemiology
• Major international health problem
• Worldwide Prevalence ~1%
• Male/female distribution is equal
• peak ages of onset:
– for men = 15-25
– for women = 25-35
• Schizophrenia is a disease that usually
manifests itself in late adolescence.
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• Often chronic with marginal
adjustment
– Only ~16% recover fully
– ~38% make good adjustment
– Around 12% need long term
hospitalization
• Suicide is very prevalent , 50%
attempt and 10-15% will complete it.
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ETIOLOGY
Biological factors:
Genetic/Heredity factors:
• The concordance rate in identical
twins is 50%.
• The concordance rate is 12% in
fraternal twins.
• Genetic regions on chromosomes 6
and 13 have been associated with
schizophrenia.
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Stress diathesis model and
genetic influences
5% risk to Sz
- Winter birth
- 20th to 30th weeks of pregnancy
viral infection
- Incompatibilities of the Rh between
male and female
- Starvation during pregnancy and
complications at birth
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Dopamine hypothesis:
 Dopamine is a neurotransmitter which
regulate movement and emotion, so it
affects our mood, thoughts and motor
movement.
 According to this hypothesis:
There is an increased of dopamine levels
in such area of brain such as
nigrostriatal tracts; substantial nigra to
basal ganglia
 2/3 of persons with Sz have increased
dopamine level 13
 Environmental models:
- Developmental model:
Sullivan developed the interpersonal theory for
development of Sz
• “Hostile environment and lack of consensual
validation for infant.”
- If the child grows up in an environment
of fear and anxiety, the chances to
validate feelings, thoughts and behavior
are decreased.
- The child’s ability to accurately perceive
reality will be greatly impaired.
Therefore, a personality deficit or Sz
might result.
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Family theory model
Double – Bind communication
- It take places in all families but
excessive among dysfunctional families.
• A double bind message: contains two
contradictory messages given by the
same person at the same time, most
often the receiver is a child.
• Constant double – bind situations result
in feelings of helplessness, fear and
anxiety in the receiver of that .
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 Scapegoating:
- In his work with schizophrenic families,
Murray Bowen (1978) revealed profound
emotional distance between parents of
schizophrenic children.
- He found that often the parents
experienced loneliness, feeling of isolation,
and emptiness. Feelings of helplessness,
inadequacy, and poor self- esteem can
trigger painful levels of anxiety.
- Many of these parents project these onto
an event, situation or person outside of
self.
- Scapegoating comes in when the child is the
focus of the pain and anxiety within the
family 16
 Assessment
Bleuler’s Four
A’s

Affect the outward manifestation of

a person’s feelings and emotions

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 Which refers to haphazard and
Associative
Looseness Confused thinking that is manifested
in jumbled and
Illogical speech and reasoning.

Thinking not bound to reality

Autism but reflecting the private
world of individual.

Holding at the same time, two opposing

Ambivalence attitudes, emotions, ideas or wishes toward
the same person, situation or object.

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Prodromal Symptoms
1-2 years before psychotic episode

Severe anxiety
Severe distractibility
Symbolization
Withdrawal, isolation
Paranoid thinking
Preoccupation with religion
Altered sexuality
Speech and language disturbance
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Assessment of Positive
Symptoms

Alterations in Thinking

Alterations in Perceiving

Alterations in Behavior

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 Alterations in Thinking

Delusions

Disorganized thinking
and speech:
Formal thought disorders

Loose associations
Neologisms Perseveration word salad

clang association echolalia

concrete thinking
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Alteration in perceiving:
Hallucinations
Common auditory hallucinations in
schizophrenia:
• Hearing own thoughts spoken by
another voice
• Hearing voices that are arguing
• Hearing voices commenting on one’s
own behavior

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Alteration in behavior:
Bizarre and Agitated behavior
• Bizarre behavior
The followings are often seen in catatonia.
• Extreme motor agitation. Such as running
about, in response to inner and outer
stimuli.
• Stereotyped behaviors. Are motor
patterns that originally had meaning to
the person (e.g., washing windows) but
that have become mechanical and lack
purpose. 23
 Waxy flexibility.
Excessive maintenance of posture.

 Stupor.
The person may sit motionless for
long period.

 Negativism.
In active negativism, the person does
the opposite of what he or she is told
to do.
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 Agitated behavior
• Because of cognitive
deterioration, they lack social
sensitivity and can act out
impulsively with others.
e.g. turn TV channels abruptly

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 Negative Symptoms
• Symptoms of schizophrenia that are
deficits in normal thought, behavior, or
emotions.
Types of negative symptoms
• Poverty of speech or Alogia
• Blunted and flat affect or Flat affect
• Loss of volition or Avolition
• Social withdrawal or Anhedonia
• Psychomotor symptoms or Catatonia
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 Further Assessment

Severe occupational
Inability to make
Significant
problems deficits
decisions
in carrying out ADL’s

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Schizophrenia three
phases
• Fist appears in late teens early twenties
• Symptoms vary but usually follow pattern:
– Prodromal phase = the beginning: symptoms
not obvious but person begins to
deteriorate.
– Active phase = the middle: symptoms are
obvious. This phase may be triggered by
stress.
– Residual phase = the leftovers? Symptoms
return to prodromal- like phase of
functioning.
• Positive symptoms gone but negative
symptoms remain.
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Diagnosing Schizophrenia
• Symptoms must last 6 months or more
• Must show deterioration at work,
social relations, and ability to engage in
self-care.
• DSM-IV distinguishes between 5 types
of schizophrenia:
– Disorganized – Catatonic – Paranoid –
Undifferentiated – Residual
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Disorganized Type
• Confusion
• Incoherence
• Flat or inappropriate affect
• Attention and perception problems
• Extreme social withdrawal
• Odd mannerisms and grimaces

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Catatonic Type –
(Rare form)
• Unusual motor responses
• Remaining in fixed positions
• Holding body rigid
• Odd mannerisms with face and body
• Repeat or mimic words of others
(echolalia)
• Repeat or mimic actions of others
(echopraxia)
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Paranoid Type
• Have delusions and hallucinations but
their cognitive skills remain intact.
• Delusions of reference and
persecution most common.
• No disorganized speech or flat
affect.
• Delusions and hallucinations may have
a theme.
• Has best prognosis
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Undifferentiated Type
• People who do not fit neatly into the
previous types are classified as having an
undifferentiated type of schizophrenia.

Residual Type (leftovers)

• Do not have delusions or hallucinations
(positive symptoms)
• Symptoms include social withdrawal,
bizarre thinking, inactivity, flat affect.
(negative symptoms)

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Treatment:
Antipsychotic Drugs
• 1940’s antihistamine drug research;
phenothiazines used to treat allergies.
– Chlorpromazine, one of the phenothiazines,
tested on psychotic patients and found to be
highly effective.
– Approved for sale in 1954
• 1950’s – 1980’s discovery of antipsychotic
drugs revolutionized the treatment of
schizophrenia (conventional antipsychotic
drugs) (neuroleptic drugs)
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1990’s to present:
the atypical antipsychotic
drugs
• Antipsychotic drugs are the most
effective treatment for the
symptoms of schizophrenia.
• Maximum level of improvement occurs
in first 6 months.
• Symptoms likely to return if drugs
are stopped.
• Many people stop their drugs because
of the side effects.
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Atypical antipsychotic
drugs:
– Chlozapine or Clozaril: most
effective
– Risperidone or Risperdal
– Olanzapine or Zyprexa
– Quetiapine or Seroquel
– Zipasidone or Zeldox

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Psychotherapy
• Used in conjunction with
antipsychotic drugs to:
– Educate regarding disorder

– Think more clearly

– Make changes in behavior

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Psychological Treatment
CBT can reduce persistent
symptoms and improve insight
– Target bizarre behavior
– Counter irrational thoughts
– Social-Skills Training

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• Family therapy – reduces
relapse rates, admission rates,
symptoms, and the burden on
carers, and improves
compliance
• Psychodynamic psychotherapy
may increase the risk of
relapse
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Nursing Diagnosis
(NANDA)
• Delusions
– Altered Thought Process
• Hallucinations
– Sensory Perceptual Alteration
• Impaired Communication
• Social Isolation
• Risk for violence
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