Schizophrenia Lecture outlines

Unit6: Schizophrenia Psychiatric

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Schizophrenia

Lecture outlines:

- Define schizophrenia.

- Symptoms of Schizophrenia.

- Etiology of schizophrenia.

- Types of Schizophrenia.

- Phases of schizophrenia.

- Treatment of schizophrenia.

- Nursing interventions according to nursing diagnosis.

Schizophrenia

- Schizophrenia is a psychotic disorder (or a group of disorders) marked by

severely impaired thinking, emotions, and behaviors.

- Schizophrenic patients are typically unable to filter sensory stimuli and

may have enhanced perceptions of sounds, colors, and other features of

their environment.

- Most schizophrenics, if untreated, gradually withdraw from interactions

with other people, and lose their ability to take care of personal needs and

grooming.

Psychosis

o Psychosis is a severe mental condition in which there is disorganization of

the personality, deterioration in social functioning, and loss of contact

with, or distortion of reality. There may be evidence of hallucinations and

delusional thinking.

o Psychosis can occur with or without the presence of organic impairment.


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Symptoms of Schizophrenia

A: Positive or hard symptoms, include

1. Ambivalence: Holding seemingly contradictory beliefs or feelings about

the same person, event, or situation.

2. Associative looseness: Fragmented or poorly related thoughts and ideas.

3. Delusions: Fixed false beliefs that have no basis in reality.

4. Echopraxia: Imitation of the movements and gestures of another person

whom the client is observing.

5. Flight of ideas: Continuous flow of verbalization in which the person

jumps rapidly from one topic to another.

6. Hallucinations: False sensory perceptions or perceptual experiences that

do not exist in reality.

7. Ideas of reference: False impressions that external events have special

meaning for the person.

8. Perseveration: Persistent adherence to a single idea or topic; verbal

repetition of a sentence, word, or phrase; resisting attempts to change the

topic.

B: Negative or Soft Symptoms

1. Alogia: Tendency to speak very little or to convey little substance of

meaning (poverty of content).

2. Anhedonia: Feeling no joy or pleasure from life or any activities or

relationships.

3. Apathy: Feelings of indifference toward people, activities, and events.

4. Blunted affect: Restricted range of emotional feeling, tone, or mood.


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5. Catatonia: Psychologically induced immobility occasionally marked by

periods of agitation or excitement; the client seems motionless, as if in a

trance.

6. Flat affect: Absence of any facial expression that would indicate

emotions or mood.

7. Lack of volition: Absence of will, ambition, or drive to take action or

accomplish tasks.

Etiology of schizophrenia

1. Genetic Factor

o Twins have a 50% risk for schizophrenia, whereas fraternal twins

have only a 15% risk.

o Children with one biologic parent with schizophrenia have a 15% risk;

the risk rises to 35% if both biologic parents have schizophrenia.

2. Neuroanatomical ( brain Structures) Factors

- Less brain tissue and cerebrospinal fluid than people who do not have

schizophrenia: 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 studies suggest that glucose metabolism and oxygen are

diminished in the frontal cortical structures of the brain.

- Decreased brain volume and abnormal brain function in the frontal

and temporal areas of persons with schizophrenia. This pathology

correlates with the positive signs of schizophrenia (temporal lobe)


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such as psychosis and the negative signs (frontal lobe) such as lack of

volition or motivation and anhedonia.

- Intrauterine influences such as poor nutrition, tobacco, alcohol and

other drugs, and stress also are being studied as possible causes of the

brain pathology found in people with schizophrenia.

3. Neurochemical (brain activity) Factors

Excess dopamine as a cause:

Drugs that increase activity in the dopaminergic system, such as

amphetamine and levodopa, sometimes induce a paranoid psychotic

reaction similar to schizophrenia.

Drugs blocking postsynaptic dopamine receptors reduce psychotic

symptoms; the greater the ability of the drug to block dopamine

receptors, the more effective it is in decreasing symptoms of

schizophrenia.

4. Immunovirologic factors

- Exposure to a virus or the body’s immune response to a virus could

alter the brain physiology of people with schizophrenia.

- Infections in pregnant women as a possible origin for schizophrenia.

- Higher rates of schizophrenia among children born in crowded areas

in cold weather, conditions that are hospitable to respiratory ailments.


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Types of Schizophrenia

Types of schizophrenia is made according to predominant symptoms:

Type of Schizophrenia Clinical features

Schizophrenia, paranoid Characterized by persecutory (feeling victimized or

spied on) or grandiose delusions, hallucinations, and

occasionally excessive religiosity (delusional religious

focus) or hostile and aggressive behavior.

Schizophrenia, disorganized Characterized by grossly inappropriate or flat affect,

incoherence, loose associations, and extremely

disorganized behavior.

Schizophrenia, catatonic - Characterized by marked psychomotor disturbance,

either motionless or excessive motor activity.

- Motor immobility may be manifested by catalepsy

(waxy flexibility) or 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, and

echopraxia.

Schizophrenia, undifferentiated Characterized by mixed schizophrenic symptoms(of

other types) along with disturbances of thought, affect,

and behavior.

Schizophrenia, residual Characterized by at least one previous, though not a

current episode; social withdrawal; flat affect; and

looseness of associations.

Phases of schizophrenia

Phase I. The Premorbid Phase

o The premorbid personality often indicates social maladjustment, social

withdrawal, irritability, and antagonistic thoughts and behavior.


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o Premorbid personality and behavioral measurements that have been noted

include being very shy and withdrawn, having poor peer relationships,

doing poorly in school, and demonstrating antisocial behavior.

o Pre-schizophrenic adolescents may have no close friends and no dates and

may avoid team sports. They may enjoy [solitary activities] to the

exclusion of social activities.

Phase II. The Prodromal Phase

- The prodromal phase of schizophrenia begins with a change from

premorbid functioning and extends until the onset of frank psychotic

symptoms.

- The average length of the prodromal phase is between 2 and 5 years.

- During the prodromal phase the person experiences substantial functional

impairment and nonspecific symptoms such as a sleep disturbance,

anxiety, irritability, depressed mood, poor concentration, fatigue, and

behavioral deficits such as deterioration in role functioning and social

withdrawal.

- Positive symptoms such as perceptual abnormalities, ideas of reference,

and suspiciousness develop late in the prodromal phase and herald the

imminent onset of psychosis.

Phase III. Schizophrenia

In the active phase of the disorder, psychotic symptoms are

prominent. Following are the (DSM-IV-TR) diagnostic criteria for

schizophrenia:

1.Characteristic symptoms:

Two (or more) of the following, each present for a significant portion

of time during a 1-month period or less if successfully treated:

a. Delusions.

b. Hallucinations.


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c. Disorganized speech (e.g., frequent derailment or incoherence).

d. Grossly disorganized or catatonic behavior.

e. Negative symptoms (i.e., affective flattening, alogia, or a volition).

2.Social/occupational dysfunction.

One or more major areas of functioning such as work, interpersonal

relations, or self-care are markedly below the level achieved before the onset

(or when the onset is in childhood or adolescence, failure to achieve

expected level of interpersonal, academic, or occupational achievement).

3.Duration

Continuous signs of the disturbance persist for at least 6 months.

This 6-month period must include at least 1 month of symptoms (or less if

successfully treated) that meet criterion 1 (i.e., active-phase symptoms)

and may include periods of prodromal or residual symptoms.

During these prodromal or residual periods, the signs of the disturbance

may be manifested by only negative symptoms or two or more symptoms

listed in criterion 1 present in an attenuated form (e.g., odd beliefs,

unusual perceptual experiences).

4.Schizoaffective and mood disorder exclusion

Schizoaffective disorder and mood disorder with psychotic features

have been ruled out because:

a. No major depressive, manic, or mixed episodes have occurred

concurrently with the active-phase symptoms .

b. If mood episodes have occurred during active-phase symptoms, their total

duration has been brief relative to the duration of the active and residual

periods.


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5. Substance/general medical condition exclusion:

The disturbance is not due to the direct physiological effects of a

substance (e.g., a drug of abuse, a medication) or a general medical

condition.

6. Relationship to a pervasive developmental disorder:

If there is a history of autistic disorder or another pervasive

developmental disorder, the additional diagnosis of schizophrenia is made

only if prominent delusions or hallucinations are also present for at least 1

month (or less if successfully treated).

Phase IV. Residual Phase

- Schizophrenia is characterized by periods of remission and exacerbation.

- A residual phase usually follows an active phase of the illness.

- During the residual phase, symptoms of the acute stage are either absent

or no longer prominent.

- Negative symptoms may remain, and flat affect and impairment in role

functioning are common.

- Residual impairment often increases between episodes of active

psychosis.

Managements

A: Psychopharmacology

1. Antipsychotic medications, also known as neuroleptics, are prescribed

primarily for their efficacy in decreasing psychotic symptoms.

(Chlorpromazine (Thorazine), Trifluoperazine (Trilafon).

B: Psychosocial Treatment:

1. Individual and group therapy, includes:

Giving the client an opportunity for social contact and meaningful

relationships with other people.


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Groups that focus on topics of concern such as medication management,

use of community supports, and family concerns also have been beneficial

to clients with schizophrenia.

2.Social skills training, includes:

Improve patients' social competence with social skills training, which

translates into more effective functioning in the community. three forms of

social skills training: the basic model; the social problem-solving model; and

the cognitive remediation model.

3.Family education and therapy, includes:

o Diminish the negative effects of schizophrenia and reduce the relapse rate.

o While inclusion of the family is a factor that improves outcomes for the

client, family involvement often is neglected by health care professionals.

o Family members can benefit from a supportive environment that helps

them cope with the many difficulties presented when a loved one has

schizophrenia.

Nursing care plan for patient with schizophrenia

A: Assessment

Following characteristic signs and symptoms during the assessment

interview:

1. Ambivalence coexisting strong positive and negative feelings, leading to

emotion conflict.

2. Apathy.

3. Clang associations words that rhyme or sound alike used in an illogical,

nonsensical manner; for instance, It's the rain, train, pain.

4. Concrete thinking inability to form or understand abstract thought .


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5. Delusions false ideas or beliefs accepted as real by the patient. Delusions

of grandeur, persecution, and reference (distorted belief regarding the

relation between events and one's self; for example, a belief that

television programs address the patient on a personal level) are common

in schizophrenia. Also common are feelings of being controlled, somatic

illness, and depersonalization.

6. Echolalia meaningless repetition of words or phrases.

7. Echopraxia involuntary repetition of movements observed in others.

8. Flight of ideas rapid succession of incomplete and poorly connected

ideas.

9. Hallucinations false sensory perceptions with no basis in reality. Usually

visual or auditory, hallucinations may also be olfactory (smell),gustatory

(taste),or tactile (touch).

10. Illusions-false sensory perceptions with some basis in reality for

example, a car backfiring might be mistaken for a gunshot.

11. Neologisms bizarre words that have meaning only for the patient.

12. Regression return to an earlier developmental stage.

13. Thought blocking sudden interruption in the patient's train of thoughts.

14. Withdrawal disinterest in objects, people, or surroundings.

B: Nursing Diagnosis

1-Anxiety. 2-Bathing or hygiene self-care deficit.

3-Disabled family coping. 4-Disturbed body image

5-Disturbed body identity. 6-Impaired home maintenance

7-Impaired social interaction. 8-Impaired verbal communication


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9-Risk for other-directed violence. 10-Risk for self-directed violence

C: Planning and Goals

Short-Term Goal

Client will develop trust in at least one staff member within 1 week.

Long-Term Goal

Client will demonstrate use of more adaptive coping skills, as

evidenced by appropriateness of interactions and willingness to participate in

the therapeutic community.

D: Nursing diagnosis and interventions for patient with schizophrenia

Nursing Diagnosis Nursing Interventions

Sensory-perceptual alteration: Disoriented

to place and person, disoriented in time.

- Call the patient by name.

- Present reality when talking to or working

with the patient.

- Keep a calendar in clear view to orient the

patient daily.

- Provide a protective, safe environment.

Social isolation: Withdrawal - Assign one member of the health care

team to establish a one-to-one

relationship.

- Provide a structured list of activities such

as times to awaken, shower, and eat.

- Spend a specific amount of time daily

with the patient. Set limits regarding

amount of times spent alone in room.

Alteration in thought process: Delusional - Present reality when talking to or working

with the patient.

- Ignore the delusion but do not attempt to

disprove it or argue with the patient.

- Set limits by instructing the patient not to

discuss the delusion with others.

Alteration in thought process: - Decrease environmental stimuli such as


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Hallucinations loud music or television shows, extremely

bright colors, or flashing lights.

- Present reality, for example: “The voices

may be real to you but I don’t hear

anything.”

- Attempt to identify precipitating factors

by asking the patient what happened

before the onset of the hallucination.

Ineffective individual coping: Regression - Assess the patient’s present

developmental level.

- State expected behavior to the patient.

- Set limits to discourage regressive

behavior.

Dysrhythmia of sleep-rest activity:

Agitation and unpredictable behavior

- Recognize signs of increasing agitation.

- Decrease environmental stimuli that could

be upsetting to the patient.

Sensory-perceptual alteration:

Suspiciousness

-Be sincere and honest when talking with

the patient.

E: Expected Outcome

1. Client is able to appraise situations realistically and to refrain from

projecting own feelings onto the environment.

2. Client is able to recognize and clarify possible misinterpretations of the

behaviors and verbalization’s of others.

3. Client eats food from tray and takes medications without evidence of

mistrust.

4. Client appropriately interacts and cooperates with staff and peers in

therapeutic community setting

Schizophrenia Lecture outlines

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