Nursing Management of Client with Schizophrenia. Useful for B.Sc Nursing Students

1. SHIZOPHRENIA
Mr.Visanth V S
Asso.Professor
IGSCON, Amethi

2. History
• Emil Kraepelin: This illness develops relatively early in
life, and its course is likely deteriorating and chronic;
deterioration reminded dementia (“Dementia praecox“), but
was not followed by any organic changes of the brain,
detectable at that time.
• Eugen Bleuler: He renamed Kraepelin’s dementia praecox
as schizophrenia; he recognized the cognitive impairment in
this illness, which he named as a “splitting” of mind.
• Kurt Schneider: He emphasized the role of psychotic
symptoms, as hallucinations, delusions and gave them the
privilege of “the first rank symptoms” even in the concept of
the diagnosis of schizophrenia.

3. Contd ……
• The word schizophrenia was coined by the
Swiss Psychiatrist Eugen Bleuler.
• It is derived from the Greek words Skhizo
(Split), Phren (Mind)
• Classififaction : F 20

4. F20 Schizophrenia
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified

5. Myth
• Schizophrenia refers to multiple
personality
• Schizophrenia is a rare disease
• People with schizophrenia are dangerous

6. Definition
• Schizophrenia is a psychotic condition
characterized by a disturbance in thinking,
emotions, volitions and faculties in the
presence of clear consciousness, which usually
leads to social withdrawal

7. According to ICD-10
Schizophrenia is characterized in general by
fundamental inappropriate a mental and characteristic
distortion of thinking , perception and inappropriate or
blunted affect. Delusions are bizarre in nature.
Hallucinations especially auditory are the commonest.
Thinking is vague and speech sometimes incomprehensive.
Mood is characteristically shallow and incongruous,
ambivalence, negativism, stupor or catatonia may be
present. The onset may be acute or insidious with a
seriously disturbed behavior.

8. Epidemiology
• It is the most common of all psychiatric disorders
and is prevalent in all cultures across the world.
• 1% of world population develops schizophrenia.
• 3-4 per 1000 cases
• Prevalence , Male = Female
• Onset 15-25 years for men, 25-35 years for
women.
• 2/3rd cases in age group of 15-30 years .
• The disease is common in low socio economic
status

9. Stages of Schizophrenia
• The Schizoid Personality
• The Prodromal Phase
• Schizophrenia
• Residual Phase

10. Etiology
• Genetic Factors
– The siblings or offspring of an identified client have
a 5 to 10 percent risk of developing schizophrenia.
– How schizophrenia is inherited is uncertain
• Twin Studies
– The rate of schizophrenia among monozygotic twins
is four times that of dizygotic twins and
approximately 50 times that of the general
population.

11. • Biochemical theories
– Biochemical hypothesis of schizophrenia
orientated towards the role of neurotransmitters
and their receptors; dopamine, serotonin,
glutamate, GABA, Norepinephrine.
– Dopamine plays a key role in biochemical
hypothesis of schizophrenia.

12. • Viral Infections
– Prenatal exposure to influenza.
– Viral infections of the central nervous system during
childhood.
– Viral infections during pregnancy and delivery.
• Anatomical abnormalities
– Neuro-imaging studies shows structural brain
abnormalities in individuals with schizophrenia.
– Brains of patients with schizophrenia are lighter and
smaller.
– Cortical atrophy in the frontal and temporal lobes of
left side is seen in 10-35% cases.
– Larger lateral and third ventricles

13. • Environmental Causes
– Prenatal exposure to viral infection
– Low oxygen level during birth
– Viral infection
– Early parental loss or separation
– Physical or sexual abuse in childhood
• Family Theory
– Double bind communication
– Marital disharmony
– Pseudo mutual and pseudo hostile families
– Low socio economic status
– Social isolation

14. Transactional Model Of Stress Adaptation

15. Clinical Features

16. Bleuler’s Classification -4 A’s
Primary Symptoms- 4A’s Of Schizophrenia
1.Ambivalence (The co- existence of strongly conflicting feelings,
attitudes and ideas)
2.Autistic Thinking (withdrawal in thinking and behavior)
3.Association Disturbances (fragmented thinking)
4.Affective Blunting
Secondary Symptoms
1.Hallucinations
2. Delusions
3. Catatonic Symptoms
4. Behavioral Abnormalities

17. Kurt Schneider’s Symptoms of Schizophrenia
• Kurt Schneider (1957) described the features of
schizophrenia into first rank and second rank symptoms.
• First Rank Symptoms
– Audible thought or thought echo
– Voices commenting on him in the third person or voices heard
arguing
– Passivity feelings(patient thinks that he is in the grip of a
superior force which controls his action)
– Thought withdrawal
– Thought broadcasting
– Delusional perception
• Other perceptual, motor, and affective symptoms were
called second rank symptoms.

18. Positive and Negative Symptoms
Negative Symptoms -6 A’s
1.Anhedonia(inability to experience pleasure)
2. Apathy (attentional impairment)
3. Avolition (diminution of will or desire)
4. Alogia (poverty of thinking and speech)
5.Asocial (social withdrawal)
6.Affective Flattening
Positive Symptoms
1.Hallucinations
2. Delusions
3. Bizarre Behavior
4. Positive formal thought behavior

19. Thought & Speech Disorder
• Autistic thinking
• Loosening of
association
• Thought blocking
• Neologisms
• Echolalia
• Verbigeration
• Clang association
• Word salad
• Delusions
• Circumstantiality
• Tangentiality
• Preservation
• Delusions

20. Delusions
• False beliefs that are firmly and consistently held despite
disconfirming evidence, culture or logic.
• Delusions of persecution: belief that one is the target of
others’ mistreatment, evil plots, and/or murderous intent
• Delusions of reference: belief that all happenings
revolve around oneself, and/or one is always the center
of attention
• Delusions of grandeur: belief that one is a famous or
powerful person from the past or present
• Delusions of control: belief that some external force is
trying to take control of one’s thoughts , body, or
behavior

21. • Thought broadcasting: belief that one’s thoughts
are being broadcast or transmitted to others
• Thought withdrawal: belief that one’s thoughts
are being removed from one’s mind
• Paranoia: extreme suspiciousness
• Somatic delusion: false idea about the
functioning of the body.
• Nihilistic delusion: false idea that the self, a part
of the self, others or the world is non existent
• Religiosity

22. • Cognitive impairment
– Impaired judgment, poor insight, less reliable
• Disorders of perception
– Hallucinations
• Elementary auditory hallucinations
• Thought echo
• Third person hallucination
• Voice commenting on one’s action
• Disorders of affect
– Emotional blunt/flat
– Anhedonia
– Inappropriate affect
– Emotional shallowness

23. • Disorders of motor behavior
– Increased or decreased psychomotor activity, anergia
– Waxy flexibility
– Posturing , stereotypes
• Disorganized behavior and self
– Decreased ADL
– Lack of inhibition and impulse control
– Unpredictable emotional response
– Social/occupational dysfunction
– Echopraxia
– Depersonalization
– Emotional ambivalence

24. F20.0 Paranoid
Schizophrenia
1. Paranoid schizophrenia is dominated by relatively
stable, often paranoid delusions, usually accompanied
by auditory hallucinations usually.
2. Patient is usually potentially aggressive, angry or
fearful, uncooperative and difficult to deal with.
3. No prominent disorganized behaviour or mood.
4. The onset is usually late and the prognosis is better
F20.1 Hebephrenic
Schizophrenia
1.insidious onset
2. Disorganized behaviour.
3. Marked incoherence and loosening of association,
inappropriate affect, Grimacing and bizarre
mannerisms are common.

25. F20.2
Catatonic
Schizophrenia
Presence of one or more of the catatonic features: stupor,
mutism, rigidity, negativism, posturing, echopraxia, echolalia,
waxy flexibility or purposeless excitement.
This may be in the form of catatonic stupor, catatonic
excitement and catatonia altering between excitement and stupor.
Excited catatonia includes restlessness, agitation,
excitement, aggressiveness, increase in speech production,
loosening of association. Sometimes this become very severe and
is accompanied by rigidity, hyperthermia and dehydration and
can result in death.
Features of catatonic stupor includes mutism, rigidity,
negativism, inappropriate and bizarre posture, stupor ( does not
react to surroundings and appears to be unaware of them),
echolalia, echopraxia, waxy flexibility(maintenance of body
posture for a long time in a same position even it is
uncomfortable), automatic obedience .

26. F20.3 Undifferentiated
Schizophrenia
Psychotic conditions meeting the general
diagnostic criteria for schizophrenia but not
conforming to any of the subtypes
F20.4
Post
schizophrenic
Depression
A depressive episode, which may be
prolonged, arises in the aftermath of a
schizophrenic illness. These depressive states
are associated with an increased risk of suicide.
F20.5 Residual
Schizophrenia
There has been at least one episode of
schizophrenia in the past without prominent
psychotic symptoms at present.

27. F20.6 Simple
Schizophrenia
This has insidious onset of social withdrawal,
loss of drive and ambition, deterioration of
functioning. The negative symptoms are very
common. It has a worst prognosis of all types.
F20.8 Other
Schizophrenia
Cenesthopathic schizophrenia
Schizophreniform: Disorder Not otherwise
specified Psychosis not otherwise specified etc
F20.9 Schizophrenia
Unspecified
Unspecified schizophrenia is the mental disorder
known as schizophrenia that does not fit any of the
generally accepted categories or types of
schizophrenia. Symptoms of unspecified
schizophrenia may include some or all of the
symptoms of the named types of schizophrenia.

28. Diagnostic evaluation
• Reliable and detailed history
• MSE
• Psychological testing

29. • The requirements for the diagnosis of schizophrenia
are as follows.
– Presence of psychotic features for a period of one month
or more.
– At least one or two or more of the following symptoms;
• Thought echo thought insertion or withdrawal or thought broad
casting
• Delusional perception
• Hallucinatory voices
– Symptoms from at least two of the following groups;
• Persistent hallucinations in any modality
• Thought disturbances
• Catatonic symptoms
• Negative symptoms not attributable to medications
• Personality deterioration

30. Management
1. Somatic treatment
-Pharmacological Management
-Electroconvulsive therapy
2. Psychological treatment
3. Nursing management

31. Pharmacological
• There is currently no cure for schizophrenia.
• Treatment is aimed at reducing symptoms and
preventing psychotic relapses. Medication needs to be
continue.
• Two major types of antipsychotic medications (or neuroleptics):
• CONVENTIONAL or TYPICAL ANTIPSYCHOTICS
(haloperidol)
•  control the positive symptoms very effectively
•  side effects: extrapyramidal symptoms
• (chronic: tardive dyskinesia, parkinsonism, akathisia;
• acute: acute dystonia, neuroleptic malignant syndrome)
•  high affinity for D2 dopamine receptors

32. • NEWER or ATYPICAL ANTIPSYCHOTICS (clozapine,
risperidone, olanzapine, ziprasidone, quietapine, sertindole)
•  better at treating the negative symptoms
•  milder motor side effects; but others (weight gain,
diabetes)
•  they have affinity to multiple receptor systems (DARs,
5HTRs, a1, H1, m1/4)
conventional
antipsychotics
(classical
neuroleptics)
chlorpromazine, chlorprotixene, clopenthixole,
levopromazine, periciazine, thioridazine
droperidole, flupentixol, fluphenazine, fluspirilene,
haloperidol, melperone, oxyprothepine, penfluridol,
perphenazine, pimozide, prochlorperazine, trifluoperazine
atypical
antipsychotics
amisulpiride, clozapine, olanzapine, quetiapine, risperidone,
sertindole, sulpiride

33. Typical
Chlorpromazine 300-1500 mg/day
Haloperidol 5-100 mg/day
Pimozide 4-12 mg/day
Triflupromazine 100-400 mg/day
Atypical
Clozapine 25-450 mg/day
Resperidone 2-8 mg/day
Olanzapine 5-20 mg/day
Ziprasidone 40-160 mg/day

34. Electro Convulsive Therapy
• In catatonic stupor, uncontrolled catatonic
excitement, acute exacerbation not
controlled by drugs, severe side effects of
drugs in presence of untreated schizophrenia.
• Usually 8-10 ECT’s are needed, given three
times a week, although up to 18have been
given in poor responders.

35. Psychological Treatment
• Supportive therapy and counseling.
• Rehabilitation
• - Social skill training (e.g. self-care).
• Vocational rehabilitation (for more stable
cases).
• Token economy: Useful for institutionalized
chronic schizophrenics.
• Positive and negative reinforcement are used
to alter patient’s unacceptable behaviour.
• It should be part of a behavioral programme.

36. Nursing Process
Nursing diagnosis: Disturbed sensory perception: Auditory/visual related to panic anxiety,
extreme loneliness and withdrawal into the self, evidenced by inappropriate responses,
disordered thought sequencing, rapid mood swings, poor concentration, and disorientation.
Outcome Identification Nursing Intervention
Client will be able to Reduce or
eliminate the occurrence of
hallucinations.
1. Assess the type of hallucination
2. Avoid touching the client without warning.
3. Show acceptance to the client it will encourage him
to share the content of the hallucination.
4. Do not reinforce the hallucination. Use “the voices”
instead of words like “they” that imply validation.
5. Help to understand the connection between anxiety
and hallucinations.
6. Interrupt hallucination and try to bring back to
reality.

37. Nursing diagnosis: Disturbed thought processes related to inability to trust, panic
anxiety, possible hereditary or biochemical factors, evidenced by delusional
thinking or suspiciousness of others.
Outcome Identification Nursing Intervention
Client will remove pattern of
delusional thinking and
demonstrate trust in others.
1. Assess the content of thought
2. Assess the intensity and duration of delusion
3. Do not whisper near to the client
4. Serve food family style
5. Mouth checks for medications
6. Cautious with touch
7. Use same staff as much as possible
8. Meet client needs and keep promises to
promote trust
9. Encourage the client to express the feelings
10. Encourage Client’s participation in providing
care

38. Nursing diagnosis: Social isolation related to inability to trust, panic anxiety,
weak ego development, delusional thinking, regression, evidenced by
withdrawal, sad and dull affect, preoccupation with own thoughts, expression of
feelings of rejection or of aloneness imposed by others.
Outcome Identification Nursing Intervention
Client will voluntarily spend
time
with other clients and staff
members in group activities.
1. Convey an accepting attitude to the client.
2. Offer to be with client during group activities
that he or she finds frightening or difficult.
3. Give positive reinforcement for client’s
voluntary interactions with others.

39. Nursing diagnosis: Risk for violence: Self-directed or other-directed related to extreme
suspiciousness, panic anxiety, catatonic excitement, command hallucinations, evidenced by
overt and aggressive acts, self-destructive behavior, or active aggressive suicidal acts.
Outcome Identification Nursing Intervention
Client will not harm self or
others.
1. Observe client’s behavior frequently.
3. Remove all dangerous objects from client’s
environment.
4. Redirect violent behavior with physical outlets for
the anxiety.
5. Staff should maintain a calm attitude toward client.
6. Have sufficient staff available to indicate a show of
strength to client if it becomes necessary.
7. Administer tranquilizing medications as ordered by
physician. If client is not calmed by “talking down” or
by medication, use of mechanical restraints may be
necessary.

40. Patient and Family Education
• Explain to the patient and family members regarding
schizophrenia and its symptoms especially regarding
thought disturbances, mood changes, hallucinations etc.
• Teach about medication compliance and effects of
antipsychotic medications.
• Instruct the family members that if the patient poses any
threat or danger to self harm or aggressive behavior,
hospitalize him immediately.
• Teach the patient and family members to recognize
family stressors which increase the symptoms and
methods to prevent them.

41. Rehabilitation of Schizophrenic Clients
• People who have schizophrenia can have repetitive
inpatient hospitalizations.
• Psychiatric rehabilitation strengthens the self care and
improves the quality of life.
• There are number of services available in community to
improve the quality of the life .It may be as follows;
– Social Skill training
– Vocational rehabilitation
– Day hospitals
– Community mental health centers
– Wellness centers etc.