1

SCHIZOPHRENIA
I.

Definition diagnostic term used

by mental health professionals to
describe
a
major
psychotic
disorder. It is characterized by
disturbances
in
thought
and
sensory perception (hallucinations,
delusions), thought disorders, and
by a deterioration in psychosocial
functioning.
- Typically first appears in
late
adolescence
or
early childhood.
- Characterized
by
deteriorating personality.
- split personality

2. Autism: Preoccupation with the self

with little concern for external reality
3. Associative looseness: the stringing
together of unrelated topics
4. Ambivalence: simultaneous opposite
feelings
II.

Anatomy & Physiology

Refer @bipolar
*
basal ganglia paranoia &
hallucinations
* frontal lobe doesnt allow plan
actions/organize thoughts
*limbic system agitation
*auditory auditory hallucinations
*occipital lobe diff recognizing
motions, diff interpreting complex
images.

Types of Schizophrenia:

Schizophrenia, paranoid type is

characterized by persecutory (feeling
victimized or spied on) or grandiose
delusions,
hallucinations,
and
occasionally,
excessively
religiosity
(delusional focus) or hostile and
aggressive behavior.
Schizophrenia,
disorganized
type is characterized by grossly
inappropriate
or
flat
affect,
incoherence, loose associations, and
extremely disorganized behavior.

Schizophrenia, catatonic type is

characterized by marked psychomotor
disturbance, either motionless or
excessive
motor
activity.
Motor
immobility may be manifested by
catalepsy (waxy flexibility) or stupor.

Schizophrenia, undifferentiated
type is characterized by mixed
schizophrenic symptoms (of other
types) along with disturbances of
thought, affect, and behavior.

Schizophrenia, residual type is

characterized by at least one previous,
though not a current, episode, social
withdrawal, flat affect and looseness of
associations.

III.

Etiology

Genetic Factors
- 10% for those who have one first-degree
family member (mother, father, sister,
brother) with the disease to about 40 65% if the disease affects both parents or
an identical twin.
However, heredity does not explain all
cases of schizophrenia. About 60% of
people with schizophrenia have no close
relatives with the illness. Researchers are
seeking the specific genetic factors that
may be responsible for schizophrenia.
Genes under investigation include the
neuregulin-1 gene, the OLIG2 gene, and
the COMT gene. There is also evidence
that schizophrenia may share genetic
pathways with other psychotic and
psychiatric disorders, such as bipolar
disorder and autism.
Biochemical Influences

Suggested by some theorists as

early as the mid- 19th century

Bleulers Four As
1. Affective Disturbance: Inappropriate,
blunted, or flattened affect

an

DOPAMINE HYPOTHESIS

Schizophrenia may be caused by

excess of dopamine-dependent

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neuronal activity in the brain. This
activity may be related to increased
production of release of the substance
at nerve terminals, increased receptor
sensitivity,
too
many
dopamine
receptors, of combination of these
mechanisms.
Amphetamines
increase
level
of
dopa,
induce
psychotomimetic symptoms
(actions
mimics
the
symptoms
of
psychosis,
including delusions and/or
delirium as opposed to just
hallucinations)
The main support for the
theory
that
too
much
dopamine
causes
schizophrenia is the fact
that
antipsychotic
medications, which are used
to treat schizophrenia, block
dopamine receptors. The
medications are designed to
bind to dopamine receptors
in the brain, and their
effects have helped many
people
cope
with
symptoms. Secondly, drugs
that increase levels of
dopamine,
like
amphetamines, often cause
psychotic symptoms and a
schizophrenic-like paranoid
state.
OTHER BIOCHEM HYPOTHESES
Schizophrenia
and
Glutamate - Glutamate is
the
primary
excitatory
neurotransmitter
in
the
CNS. As such, it is crucial for
the
formation
of
any
positive gain circuits within
the
brain.
Of
specific
interest in this disorder are
the
presynaptic
metabotropic
receptors,
which act as autoreceptors,
regulating
glycine
and
glutamate receptors, also
known as NMDA receptors.

Serotonin the theory

suggests
that
serotonin
modulates and helps control
excess dopamine. A newer
atypical antipsychotic drug
clozapine (clozaril) are both
dopamine and serotonin
antagonists.
ANATOMICAL ABNORMALITIES
People with schizophrenia
have relatively less brain
tissue and CSF; this could
represent
a
failure
in
development
or
a
subsequent loss of tissue
CT Scans have shown
enlarged ventricles in the
brain and cortical atrophy
PET
suggest
diminished
glucose metabolism and
oxygen in frontal sortical
structures
Research shows consistently
the dec brain vol and
abnormal brain func in
frontal and temporal areas
of person c schizo
positive signs of schizo
(frontal) such as psychosis,
negative signs (frontal)
lack
of
volition
and
anhedonia

PHYSIOLOGICAL INFLUENCES
Immunovirologic Factor Cytokines
are chemical messengers between
immune
cells,
mediating
inflammatory
and
immune
responses. Specific cytokines also
play a role in signaling the brain to
produce
behavioral
and
neurochemical changes needed in
the
face
of
physical
or
psychological stress to maintain
homeostasis.
Believed
that
cytokines may have role in
psychiatrics d.o.
Researches waves of schizo in
England, Wales, Denmark, Finland
and other countries have occurred

3
a
generation
after
influenza
epidemics
o Higher rates among children
born in crowded areas in
cold weather, conditions
that
are
hospitable
to
respiratory ailments.
ENVIRONEMENTAL INFLUENCES
Sociocultural Factors
o From lower socioeconomic
class associated c living in
poverty, congested housing
accommodations,
inadequate nutria, absence
of
prenatal
care,
few
resources of dealing c
stressful
situation,
and
feeling hopeless to change
ones lifestyle of poverty
Stressful Life Events
o No scientific evidence to
indicate stress as cause but
contribute to severity of
illness
o May precipitate symptoms
in
an
individual
who
possesses
a
genetic
vulnerability
to
schizo;
associated c exacerbation of
schizo and inc rates of
relapse

RISK FACTORS
Predisposing Factors
o Gender
o Age and Civil Status
o Genetic/ family history
o Neurostructural anomalies
o Environment
o Perinatal
Precipitating Factors
o Psychological or Experiential
Factor
o Intake of Drugs

IV.

Symptomatology

According to DSM- IV- TR:

Positive, more overtly psychotic

symptoms
o Beliefs that have no basis in
reality (delusions)
o Hearing, seeing, feeling,
smelling, or tasting things
that have no basis in reality
(hallucinations)
o Disorganized speech
o Disorganized behaviors
o Catatonic behaviors
o Abnormal thought form
o Agitation, tension
o Associational disturbances
o Bizarre behavior
o Conceptual disorganization
o Delusions
o Excitement
o Feelings of persecution
o Grandiosity
o Hallucinations
o Hostility
o Ideas of reference
o Illusions
o Insomnia
o Suspiciousness

Negative, potentially less overtly

psychotic symptoms
o Inhibition of facial
expressions
o Lack of speech
o Lack of motivation
o Alogia
o Anergia (absence of energy)
o Ahedonia (inability to
experience pleasure)
o Asocial behavior
o Attention deficits
o Avolition (lack of motivation)
o Blunted affect
o Poor grooming and hygiene
o Poor rapport

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Duration: Continuous signs of the
disturbance persist for at least six months.
This six-month period must include
at least one month of symptoms (or less, if
symptoms remitted with treatment).

the extent of metabolic activity

in specific brain ssites can be
traced.

V.

VI.

Pathophysiology

Medical Management
(Ventricular enlargement in schizo
is
not
associayed
with
neurogenerative process. However,
there are those that have larger
ventricles)
a. Lab tests (2-3)
Computed
Tomography
(CT
Scan)
-most widely used xray method.

Magnetic resonance imaging

(MRI)
Positron Emission Tomography
(PET)
-Glucose-containing radioactive
atoms are given to the patient,
and a computerized imagine of
brain activity can be developed.
Because
glucose
is
thee
primary source of body energy,

Single
Photon
emission
computed tomography (SPECT)
Brain electrical activity mapping
(BEAM)
advanced
electroencephalography

To be diagnosed with
schizophrenia, a person must meet
the criteria in the Diagnostic and
Statistical Manual of Mental
Disorders (DSM). a person must
have at least two of the following
symptoms most of the time during
a one-month period, with some
level of disturbance being present
over six months:
o Delusions
o Hallucinations
o Disorganized speech
(indicating disorganized
thinking)
o Extremely disorganized
behavior
o Catatonic behavior, which
can ranges from a coma-like
daze to bizarre, hyperactive
behavior
o Negative symptoms, which
relate to reduced ability or
lack of ability to function
normally
b. Medications
Psychopharmacology
o The medical
management of
schizophrenia often
requires a combination
of antipsychotic,
antidepressant, and
antianxiety medication.
o Antipsychotic
Medications also called
neuroleptics or major

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tranquilizer. Effective in
treating acute and
chronic manifestations
of schizo and in
maintenance therapy to
prevent exacerbation of
schizo symptoms
Conventional (typical)
Antipsychotic
Blocks
postsynaptic
dopamine
receptors in the
basal
brainstem,
ganglia,
hypothalamus,
limbic system,
and medulla;
also
demonstrate
varying affinity
for cholinergic,
alpha1adrenergic, and
histaminic
receptors; also
related to
inhibition of
dopaminemediated
transmission of
neural impulses
at the synapses
Examples:
chlorpromazine
(thorazine);
fluphenazine
(prolixin);
perphenazine
(trifalon);
prochlorperazin
e (compazine);
haloperidol
(haldol);
loxapine
(loxitane).

Classified into
low potency
agents
(chlorpromazin
e, thioridazine)associated with
more
anticholinergic
effects,
sedation, and
orthostatic
hypotension;
high-potency
agents
(thiothixene,
haloperidol,
fluphenazine)
are more likely
to cause EPS.
Medium
potency
(loxapine,
perphenazine)
produce mixed
effects.
Atypical
Antipsychotics
Adverse effect:
agranulocytosis
pt should be
monitored
weekly for
potential fatal
drop in WBC
count
Atypical
antipsychotics
are weaker
dopamine
receptors
antagonists
than the
conventional
antipsychotics,
but are more
potent
antagonists of

the serotonin
type receptors.
They also
exhibit
antagonism for
cholinergic,
histaminic, and
adrenergic
receptors.
Dopamine
blockade by
atypical
antipsychotics
occurs more
readily in
mesolimbic
pathways than
in the
nigrostriatal
pathway,
thereby
exerting
antipsychotic
action (posi
sympt) s
enducing EPS;
also associated
c 5-HT2A
receptor
blockade, c
some
speculation
that this action
is responsible
for dec in nega
symptoms
They have very
low potential
for EPS and
only low to
moderate
potential for
sedation,
orthostatic
hypotension,
and
anticholinergic
effects

c. Treatment/Surgery
Individual Psychotherapy
Individual psychotherapy: This
involves regular sessions between
the patient and a therapist focused
on past or current problems,
thoughts, feelings, or relationships.
Thus, via contact with a trained
professional, people with
schizophrenia become able to
understand more about the illness,
to learn about themselves and to
better handle the problems of their
daily lives.

Group therapy: it is effective in

reducing social isolation, increasing
the sense of cohesiveness, and
improving reality testing for
patients c schizo.

Behavioral Therapy: Help clients

change undesirable behaviors.
Hxcare provider can use praise and
other positive reinforcements to
healp the client c schizo and
reduce frequency of maladaptive
deviant behavior

Social Treatment

Milieu Therapy by means of

controlled modification of the
patients environment to facilitate
behavioral change

Family therapy method of

psychotherapy which focuses on
the total family as an interaction
system problem is a family problem

Assertive Community Treatment

takes a team approach in providing
comprehensive, community- based
psychiatric treatment,
rehabilitation, and support to

VII.

persons with serious and persistent

mental illness
Electroconvulsive Therapy (ECT)
Nursing Management (10)
1. Assess the patient's ability to
carry out the activities of daily
living, paying special attention
to his nutritional status. Monitor
his weight if he isn't eating. If
he thinks that his food is
poisoned, allow him to fix his
own food when possible, or
offer him foods in closed
containers that he can open. If
you give liquid medication in a
unit-dose container, allow the
patient to open the container.
2. Maintain a safe environment,
minimizing stimuli. Administer
medication
to
decrease
symptoms and anxiety. Use
physical restraints according to
your facility's policy to ensure
the patient's safety and that of
others.
3. Adopt
an
accepting
and
consistent approach with the
patient.
Don't
avoid
or
overwhelm him. Keep in mind
that short, repeated contacts
are best until trust has been
established.
4. Avoid promoting dependence.
Meet the patient's needs, but
only do for the patient what he
can't do for himself.
5. Reward positive behavior to
help the patient improve his
level of functioning.
6. Engage the patient in realityoriented activities that involve
human contact: inpatient social
skills
training
groups,
outpatient
day
care,
and
sheltered workshops. Provide
reality-based explanations for
distorted
body
images
or
hypochondriacal
complaints.

Clarify
private
language,
autistic
inventions,
or
neologisms, explaining to the
patient that what he says isn't
understood
by
others.
If
necessary,
set
limits
on
inappropriate behavior.
7. If the patient is hallucinating,
explore the content of the
hallucinations.
If
he
has
auditory
hallucinations,
determine if they're command
hallucinations that place the
patient or others at risk. Tell the
patient you don't hear the
voices but you know they're
real to him. Avoid arguing about
the hallucinations; if possible,
change the subject.
8. Don't tease or joke with the
patient. Choose words and
phrases that are unambiguous
and clearly understood. For
instance, a patient who's told,
That procedure will be done on
the
floor,
may
become
frightened, thinking he is being
told to lie down on the floor.
9. Don't touch the patient without
telling him first exactly what
you're
going
to
do.
For
example, clearly explain to him,
I'm going to put this cuff on
your arm so I can take your
blood pressure. If necessary,
postpone
procedures
that
require physical contact with
facility personnel until the
patient is less suspicious or
agitated.
10. Remember, institutionalization
may produce new symptoms
and handicaps in the patient
that aren't part of his diagnosed
illness, so evaluate symptoms
carefully.
11. Mobilize community resources
to provide a support system for
the patient and reduce his
vulnerability to stress. Ongoing

8
support is essential to
mastery of social skills.

his

12. Encourage compliance with the

medication regimen to prevent
relapse.
Also
monitor
the
patient carefully for adverse
effects
of
drug
therapy,
including
drug-induced
parkinsonism, acute dystonia,
akathisia, tardive dyskinesia,
and
malignant
neuroleptic
syndrome. Make sure you
document and report such
effects promptly.

VIII.

Nursing Diagnosis (5)

1. Disturbed Thought Processes
r/t Panic level of anxiety; Low
self-esteem; Underdeveloped
ego; Possible hereditary factor
2. Disturbed sensory Perception
r/t Hallucination; Delusion
3. Impaired Social Interaction r/t
fear of regression or failure of
interaction; delusional thinking