Contents

DSM-IV Diagnostic Criteria for Schizophrenia

Types of Schizophrenia
o Paranoid Schizophrenia
Signs and Symptoms
Diagnosis
Treatment
Nursing Interventions
o Disorganized Schizophrenia
Signs and Symptoms
Diagnosis
Treatment
Nursing Interventions
o Catatonic Schizophrenia
Signs and Symptoms
Diagnosis
Treatment
Nursing Interventions
Diagnostic Test
Treatments and Medications

Definition
Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses
masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms.
Recent research reveals that schizophrenia may be a result of faulty neuronal development in the
fetal brain, which develops into full-blown illness in late adolescence or early adulthood.
Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and
behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process
with many different varieties and symptoms. It is usually diagnosed in late adolescence or early
adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of
age for men and 25 to 35 years of age for women.
The symptoms of schizophrenia are categorized into two major categories, the positive or hard
symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and
behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or
discomfort. Medication treatment can control the positive symptoms but frequently the negative
symptoms persist after positive symptoms have abated. The persistence of these negative
symptoms over time presents a major barrier to recovery and improved the functioning of clients
daily life.
DSM-IV Diagnostic Criteria for Schizophrenia
A

Characteristic symptoms: Two or more of the following, each present for a significant
portion of time during a one-month period:
delusions
hallucinations
disorganised speech (eg, frequent derailment or incoherence)
grossly disorganised or catatonic behaviour
negative symptoms (ie, affective flattening, alogia, or avolition).

Not
e

Only one Criterion A symptom is required if delusions are bizarre or hallucinations

consist of a voice keeping up a running commentary on the persons behaviour or
thoughts, or two or more voices conversing with each other.

Social/occupational dysfunction: Since the onset of the disturbance, one or more major
areas of functioning, such as work, interpersonal relations, or self-care, are markedly
below the level previously achieved.

Duration: Continuous signs of the disturbance persist for at least six months. This sixmonth period must include at least one month of symptoms (or less if successfully
treated) that meet Criterion A.

Exclusion of schizoaffective disorder and mood disorder with psychotic features.

Substance/general medical condition exclusion: the disturbance is not due to the direct
physiological effects of a substance (eg, a drug of abuse, a medication) or a general
medical condition.

Relationship to a pervasive developmental disorder: If there is a history of autistic

disorder or another pervasive development disorder, the diagnosis of schizophrenia is
made only if prominent delusions or hallucinations are also present for at least a month
(or less if successfully treated).

Types of Schizophrenia
The diagnosis is made according to the clients predominant symptoms:

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.

Paranoid Schizophrenia

Is characterized by persecutory or grandiose delusional thought content and, possibly,

delusional jealousy.
Some patients also have gender identity problems, such as fears of being thought of as

homosexual or of being approached by homosexuals.

Stress may worsen the patients symptoms.
Paranoid schizophrenia may cause only minimal impairment in the patients level of

functioning as long as he doesnt act on delusional thoughts.

Although patients with paranoid schizophrenia may experience frequent auditory

hallucinations (usually related to a single theme), they typically lack some of the
symptoms of other schizophrenia subtypes notably, incoherent, loose associations,
flat or grossly inappropriate affect, and catatonic or grossly disorganized behavior.
Tend to be less severely disabled than other schizophrenia.
Those with late onset of disease and good pre-illness functioning (ironically, the very
patients who have the best prognosis) are at the greatest risk for suicide.

Signs and Symptoms

Persecutory or grandiose delusional thoughts

Auditory hallucinations
Unfocused anxiety
Anger
Tendency to argue
Stilted formality or intensity when interacting with others
Violent behavior

Diagnosis

Ruling out other causes of the patients symptoms.

Meeting the DSM-IV-TR criteria.

Treatment

Antipsychotic drug therapy.

Psychosocial therapies and
psychotherapy.

Nursing Interventions

rehabilitation,

including

group

and

individual

Build trust, and be honest and dependable, dont threaten or make promises you cant

fulfill.
Be aware that brief patient contacts may be most useful initially.
When the patient is newly admitted, minimize his contact with the staff.
Dont touch the patient without telling him first exactly what youre going to be doing

and before obtaining his permission to touch him.

Approach him in a calm, unhurried manner.
Avoid crowding him physically or psychologically; he may strike out to protect

himself.
Respond neutrally to his condescending remarks; dont let him put you on the

defensive, and dont take his remarks personally.

If he tells you to leave him alone, do leave- but make sure you return soon.
Set limits firmly but without anger, avoid a punitive attitude.
Be flexible, giving the patient as much control as possible.
Consider postponing procedures that require physical contact with hospital personnel

if the patient becomes suspicious or agitated.

If the patient has auditory hallucinations, explore the content of the hallucinations
(what voices are saying to him, whether he thinks he must do what they command)
tell him you dont hear voices, but you know theyre real to him.

Disorganized Schizophrenia

Is marked by incoherent, disorganized speech and behaviors and by blunted or

inappropriate affect.
May have fragmented hallucinations and delusions with no coherent theme.
Usually includes extreme social impairment.
This type of schizophrenia may start early and insidiously, with no significant
remissions.

Signs and Symptoms

Incoherent, disorganized speech, with markedly loose associations.

Grossly disorganized behavior.
Blunted, silly, superficial, or inappropriate affect.
Grimacing
Hypochondriacal complaints.

Extreme social withdrawal.

Diagnosis

Ruling out other causes of the patients symptoms.

Meeting the DSM-IV-TR criteria.

Treatment

Treatments described for other types of schizophrenia.

Antipsychotic drugs and psychotherapy.

Nursing Interventions

Spend time with the patient even if hes mute and unresponsive, to promote

reassurance and support.

Remember that, despite appearances, the patient is acutely aware of his environment,

assume the patient can hear speak to him directly and dont talk about him in his
presence.
Emphasize reality during all patient contacts, to reduce distorted perceptions (for

example, say, The leaves on the trees are turning colors and the air is cooler, Its
fall)
Verbalize for the patient the message that his behavior seems to convey, encourage

him to do the same.

Tell the patient directly, specifically, and concisely what needs to be done; dont give

him choice (for example, say, Its time to go for a walk, lets go.)
Assess for signs and symptoms of physical illness; keep in mind that if hes mute he

wont complain of pain or physical symptoms.

Remember that if hes in bizarre posture, he may be at risk for pressure ulcers or

decreased circulation.
Provide range-of-motion exercises.
Encourage to ambulate every 2 hours.
During periods of hyperactivity, try to prevent him from experiencing physical

exhaustion and injury.

As appropriate, meet his needs for adequate food, fluid, exercise, and elimination;
follow orders with respect to nutrition, urinary catheterization, and enema use.

Stay alert for violent outbursts; if these occur, get help promptly to intervene safely
for yourself, the patient, and others.

Catatonic Schizophrenia

Is a rare disease form in which the patient tends to remain in a fixed stupor or position

for long periods, periodically yielding to brief spurts of extreme excitement.

Many catatonic schizophrenia have an increased potential for destructive, violent
behavior when agitated.

Signs and Symptoms

Remaining mute; refusal to move about or tend to personal needs.

Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth

movements.
Rapid swing between stupor and excitement (extreme psychomotor agitation with

excessive, senseless, or incoherent shouting or talking).

Bizarre posture such as holding the body (especially the arms and legs) rigidly in one

position for a long time.

Diminished sensitivity to painful stimuli.
Echolalia (repeating words or phrases spoken by others).
Echopraxia (imitating others movements).

Diagnosis

Ruling out other possible causes of the patients symptoms.

Meeting the DSM-IV-TR criteria.

Treatment

ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic

schizophrenia.
Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).
Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires
further evaluation).

Nursing Interventions

Spend time with the patient even if hes mute and unresponsive, to promote

reassurance and support.

Remember that, despite appearances, the patient is acutely aware of his environment,

assume the patient can hear speak to him directly and dont talk about him in his
presence.
Emphasize reality during all patient contacts, to reduce distorted perceptions (for

example, say, The leaves on the trees are changing colors and the air is cooler, Its
fall)
Verbalize for the patient the message that his behavior seems to convey, encourage

him to do the same.

Tell the patient directly, specifically, and concisely what needs to be done; dont give

him choices (for example, say, Its time to eat, lets go)
Assess for signs and symptoms of physical illness; keep in mind that if hes mute he

wont complain of pain or physical symptoms.

Remember that if hes in bizarre posture, he may be at risk for pressure ulcers or

decreased circulation.
Provide range-of-motion exercises.
Encourage to ambulate every 2 hours.
During periods of hyperactivity, try to prevent him from experiencing physical

exhaustion and injury.

As appropriate, meet his needs for adequate food, fluid, exercise, and elimination;

follow orders with respect to nutrition, urinary catheterization, and enema use.
Stay alert for violent outbursts; if these occur, get help promptly to intervene safely
for yourself, the patient, and others.

Diagnostic Test

Clinical diagnosis is developed on historical information and thorough mental status

examination.
No laboratory findings have been identified that are diagnostic of schizophrenia.
Routine battery of laboratory test may be useful in ruling out possible organic

etiologies, including CBC, urinalysis, liver function tests, thyroid function test, RPR,
HIV test, serum ceruloplasmin ( rules out an inherited disease, wilsons disease, in
which the body retains excessive amounts of copper), PET scan, CT scan, and MRI.
Rating scale assessment:

o Scale for the assessment of negative symptoms.

o Scale for the assessment of positive symptoms.
o Brief psychiatric rating scale
Treatments and Medications
Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the
impact of disease depends mainly on early diagnosis and, appropriate pharmacological and
psychosocial treatments. Hospitalization may be required to stabilize ill persons during an acute
episode. The need for hospitalization will depend on the severity of the episode. Mild or
moderate episodes may be appropriately addressed by intense outpatient treatment. A person
with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will
minimize symptoms and maximize quality of life.
A comprehensive treatment program can include:

Antipsychotic medication
Education & support, for both ill individuals and families
Social skills training
Rehabilitation to improve activities of daily living
Vocational and recreational support
Cognitive therapy

Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode
has passed, most people with schizophrenia will need to take medicine indefinitely. This is
because vulnerability to psychosis doesnt go away, even though some or all of the symptoms do.
In North America, atypical or second generation antipsychotic medications are the most widely
used. However, there are many first-generation antipsychotic medications available that may still
be prescribed. A doctor will prescribe the medication that is the most effective for the ill
individual
Another important part of treatment is psychosocial programs and initiatives. Combined with
medication, they can help ill individuals effectively manage their disorder. Talking with your
treatment team will ensure you are aware of all available programs and medications.

In addition, persons living with schizophrenia may have access to or qualify for income support
programs/initiatives, supportive housing, and/or skills development programs, designed to
promote integration and recovery.