SCHIZOPHRENIA AND

NURSING MANAGEMENT
 INTRODUCTION
• Schizophrenia is a major mental disorder. The word
schizophrenia is derived from a Greek word ‘schizo’
means ‘split’ and ‘phrenia’ means ‘mind’ .
i.e. splitting mind.
• The term Schizophrenia was first coined in 1908 by
a Swiss psychiatrist Eugen Bleuler.
• Schizophrenia causes distorted and bizarre
thoughts, perceptions, emotions, movements and
behavior
• It can not be defined as a single illness, rather
schizophrenia is a syndrome or disease process with
many different varieties and symptoms
As per the ICD-10 classification:-
“Schizophrenia are characterized
by fundamental & characteristic
distortion of thinking & perception
& by an inappropriate affect.
 As per the American Psychiatric Association:-
“A group of Disorders manifested by
characteristics disturbance of thinking, mood &
behaviour. Disturbance in thinking is marked by
alteration of concept formation which may lead to
misinterpretation of reality & sometime to
delusion & hallucination, mood change includes
ambivalent, constricted & inappropriate emotional
responsiveness & loss of empathy with others.
Behaviour may be withdrawn, regressive &
bizarre.”
The incidence of schizophrenia are:
Occurrence:- It is observed that schizophrenia
occurs in all types of society & all places. Prevalence
varies from 0.3% to 1% of all people who experience
a schizophrenia reaction at sometime in their lives.
Age:- Rare in childhood. Age varies between 15 & 45
years, peak age is 30 years.
Sex Ratio:- Incidence in male & female is almost the
same.
Social Class:- Reviewed literature shows that the
incidence of schizophrenia is higher in the lower
socio-economic status group in comparison to the
upper socio-economic group.
CAUSES
BIOLOGICAL THEORIES
Biochemical Theories
• Dopamine hypotheses: this theory suggests that
schizophrenia may be caused by an excess of dopamine-
dependent neuronal activity in the brain. This excess
activity may be related to increased production or release
of the substance at nerve terminals, increased receptor
sensitivity.
 Cont………
Other biochemical hypotheses
Abnormalities in the neurotransmitters norepinephrine,
serotonin, acetycholine and gamma-aminobutyric acid and in
the neuro-regulators, such as prostaglandins and endorphins,
have been suggested.
Genetic Factors:-
Studies have revealed that monozygotic twins
have four time higher chances to developing
schizophrenia than the general population.
children of schizophrenic parents are more prone
to develop schizophrenia than children of other
persons. Approximately 40% of children born to
both the schizophrenic parents will be affected. If
only one parent either mother or father is
schizophrenic, 10% of the children will be
psychotic.
Neurostructural theories
Research suggests that the prefrontal cortex and
limbic cortex may never fully develop in the brains
of persons with schizophrenia.
Perinatal Risk Factors
a. Maternal influenza
b. Birth during late winter or early spring
c. Complications of pregnancy particularly during labor
and delivery
II. Psychosocial Factors or Psychodynamics:-
In schizophrenic psychosis there is:-
a. Impaired ego functioning:-
Reality testing & judgment is affected. The intensity of
schizophrenia will depend upon the intense impairment
of ego function.
b. Mother infant Relationship:-
There may be a defect in mother infant relationship.
Deprivation of early mothering reduces a child’s capacity
to socialize. The mother may be present but lack of
effective mother-Child relationship does withdraw the
child from socialization. Mothers of schizophrenics as
cold, over-protective and domineering.
IV. Pathogenic family interactions:-
Transaction between parents or significant people who
relate with the child. Parents may be maintain superficial
relationship. Children coming from broken home are
more prone to schizophrenia than those of normal homes
as their coping abilities get reduced because of
continuous stress.
V. Other factors are
Sociocultural Factors:-
Persons who live in low socio-economic families & area
are prone to schizophrenia. For example, a child at a
very young age goes for work & is deprived of affection
from parents, schooling, playmates. This causes a lot
of anger & frustration in the child.
Organic theory:-
Theorist believe that schizophrenia is caused due to
infection, poison, trauma or metabolic disorders.
Vitamin deficiency Theory:-
A parent with vitamin B, B1 , B12, & vitamin c deficiency
may become schizophrenic.
Patients with schizophrenia may
present various symptoms.
However Bleuler has made
distinction between
(I.) Primary / Fundamental
symptoms which are present to
some extent in every case of
schizophrenia &
(II.) Secondary Or Accessory
symptoms which may or may
not be present.
 (BLEULER’S FOUR A’S)
a)Associative disturbance or looseness:-
It is a thought disorder in which the person does
not think logically. Ideas expressed have little or no
connection, ideas shift from one point to another very
quickly. As a result, thinking appears bizarre, illogic &
chaotic. Eg- Rani comes, the sky is blue, the doctor fell
down, Mahesh must be eating.
b)Autism:-
It is a thought disorder in which the patient is
preoccupied with ideas derived from fantasy & day
dreaming. The person is unaffected by what is
happening in the environment. He or she is emotionally
attached from the world or others.
c) Affective incongruity or disturbance or
inappropriate mood:-
In an effective disturbance the affect /mood of
the patient is inappropriate , flat or blunt. For
example, the patient may laugh when the situation
demands sadness. He expresses no emotions at all
for a happy or sad situation.
d) Ambivalence:-
The schizophrenia patients experience two
contradictory or opposing feelings, attitude or
wishes towards the same person, object or situation
. Eg.- a love and hate feeling for the same person.
a. Disorders of perception:-
i. Hallucination:- Auditory are most common, visual
(seeing angels), tactile (eg- feeling of crawling ants),
gustatory (bed taste), or olfactory (eg- bed smell) may
also be presented by the patients.
ii. Illusion:- for example, rope is perceived by the patient
as a snake falling on him.
b.Disorders of thought:-
Delusion- for eg:- CBI is following me.
Delusion of persecution & delusion of grandeur, ideas
of references, depersonalization, incoherences,
neologism & mutism.
A PATIENT MAY SEE THIS TYPE OF VISUAL HALLUCINATION & ILLUSION
c. Disorders of Activity:-
• Negativism & automatism
• Stereotype, speech echololia & verbigeration (constant repetition
of meaningless words and phrases)
• Stereotype activity, echopraxia, mannerism.
• Impulsiveness – act performed unexpectedly without
consideration of the whole personality. This is due to the result of
an ambivalence feeling.
d. Deteriorated appearance & manner:-
Effort on self-care & grooming may become minimum.
Schizophrenia patients have to the reminded of bath, wash
& shave & other routine activity.
e. Disturbance in attention:-
The patient is not able to hold attention for a long time. He
or she lives in his or her own autistic world.
f. Insight in schizophrenic:- in it, the illness is affected
severely.
 Psychodynamics :-
Precipitating Event
(any event sufficiently stressful to threaten an already weak ego)

Predisposing Factors
Genetic influences : family history of schizophrenia, possible
biochemical alterations, possible birth defect.
Past Experiences: prenatal exposure to viral infection.
Existing conditions: abnormal brain structure, physical condition,
such as epilepsy, Huntington’s disease, brain tumor, Parkinsonism,
inadequate coping skills.

Cognitive Appraisal
Primary appraisal : perceived threat to self-concept or physical integrity
 secondary appraisal: because of weak ego strength,
patient is unable to use coping mechanisms effectively.
Defense mechanisms utilized: denial, regression,
projection, identification, religiosity.

Quality of response
Adaptive or
maladaptive: initial psychotic episode
TYPICAL STAGES OF SCHIZOPHRENIA

❖The schizoid personality

❖Prodromal phase

❖Schizophrenia

❖Residual phase
 Phase I - Schizoid personality
• Indifferent individuals for social relationships
• “Loners”
• Cold and aloof
 Phase II - Prodromal
• Social withdrawal
• Eccentric behavior
• Bizarre ideas
• Lack of energy
 PHASE III - Schizophrenia

❑Characteristic symptoms (DSM-IV) for 1

month
a) Delusions
b) Hallucinations
c) Disorganized speech
d) Catatonic behavior
e) Negative symptoms

❑Social/occupational dysfunction
❑Duration- signs for atleast 6 months
 Phase IV - Residual phase

• Remission and exacerbation

The type of schizophrenia disorders according to ICD-
10:-
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
1.Paranoid schizophrenia:-
The onset is gradual most of the time, acute
paranoid schizophrenia is also presented, age after
30 years.
• s/s:- These patients are extremely suspicious.
Delusion of persecution, grandeur & ideas of
references and auditory hallucinations are marked
in them. Hypochondrial delusions are also present.
“I am having lakes of rupees, everyone is after my
life & talks about me only.”
• The individual is often tense, suspicious and
guarded and may be argumentative, hostile and
aggressive. Social impairment may be minimal.
• The individual is often tense, suspicious and guarded
and may be argumentative, hostile and aggressive.
Social impairment may be minimal.
 2. Hebephrenic schizophrenia/disorganized
schizophrenia:-
• The onset is insidious, age varies between 15 – 25 years.
• More severe disintegration of personality than other types
of schizophrenia.
• Behaviour is markedly regressive and primitive.
• Contact with reality is extremely poor.
• Affect is flat or grossly inappropriate, often with periods of
silliness and incongruous giggling.
• Personal appearance is generally neglected, and social
impairment is extreme.
• Hallucination (visual) present.
• Delusion are of fantasy; bizarre nature.
• The patient urinates & defecates in the bed, does not
attend to personal hygiene. Eats with fingers, masturbates
openly. Behaviour of hebephrenic schizophrenia is indicated
as “silly” behaviour.
3. Catatonia schizophrenia:-
Catatonia patients present two main types of clinical picture:
a) Catatonic stupor:-
• Apathy the patients becomes uncommunicative,
characterized by falling interest, echolalia and echopraxia
may be present.
• preoccupation in his own thoughts, emotion proverty
&dreaminess.
• Mute stuperous & mask-like face.
• Stands immobile, can sit whole day on the edge of a bed.
• Catalepsy or waxy flexibility is present. The patient can lie
down in the same position for days or weeks if not
disturbed.
• Negativism & somatic disturbances present.
• The patient refuse to eat occasionally, if he is unobserved
• Dribbling of saliva from the angular region.
• Holds urine & stool in the bed. Does not show avoiding
sign to painful stimuli.
b)Catatonic excitement:-
• The patient may behave in a wild & quite
unpredictable manner.
• He shows an aggressive motor activity, which is not
accompanied by an emotional expression – cold
approach.
• The patient is impulsive & may suddenly attack
anybody standing nearly. Break or destroy articles.
Tear their clothes & remain nude.
• Increase in speech production, flight of ideas,
negativism, hallucination (visual & hearing),
sleeplessness & dehydration are present.
• On rare occasions the patient may collapse due to
exhaustion. Homosexual – prone assaultive.
 CATATONIC EXCITEMENT
SCHIZOPHRENIA

[TEARS CLOTHES & BECOME

NAKED]
4.Undifferentiated schizophrenia:-
• Sometimes client with schizophrenic symptoms do not
meet the criteria for any of the subtypes, or they may
meet the criteria for more than one subtype.
• These individuals may be given the diagnosis of
undifferentiated schizophrenia.
• The behaviour is clearly psychotic; that is there is evidence
of delusions, hallucinations, incoherence, & bizarre
behaviour.
• However, the symptoms cannot be easily classified into
any of the previously listed diagnostic categories.
UNDIFFERENTIAL
SCHIZOPHRENIA
5. Residual schizophrenia:-
This diagnostic category is used when the individual has a
history of at least one previous episode of schizophrenia
with prominent psychotic symptoms.
• Residual schizophrenia occurs in an individual who has
chronic form of the disease & is the stage that follows an
acute episode (prominent delusions, hallucinations,
incoherence, bizarre behaviour & violence).
• In the residual stage, there is continuing evidence of the
illness, although there are no prominent psychotic
symptoms.
• Residual symptoms may include social isolation, eccentric
behaviour, impairment in personal hygiene & grooming,
blunted or inappropriate affect, poverty of or overly
elaborate speech, illogical thinking or apathy.
6. Simple schizophrenia:-
The onset is extremely gradual, being fairly early in life
often during adolescence.
• Marked disturbance of interest in human relation,
emotion & activity.
• Hallucination & delusion are rare.
• Associative looseness is present.
• Goals are not realistic.
• In early age the patient shows a lot of interest but in
the later stage has no interest in school or occupation.
They keep changing their job.
• Wandering tendency, self-absorbed idleness.
7. Schizoaffective disorder:-
• This disorder is manifested by schizophrenic
behaviors, with a strong element of symptomatology
associated with the mood disorders (depression or
mania).
• The client may appear depressed, with psychomotor
retardation & suicidal ideation, or symptoms may
include euphoria, grandiosity, & hyperactivity.
• The characteristic symptoms like dysfunctional mood,
the individual exhibits bizarre delusions, prominent
hallucination, incoherent speech, catatonic behaviour,
or blunted or inappropriate affect.
MANAGEMENT
Research over the last 10 years has shown that
about 80% of patient with schizophrenia respond
to drugs; of these 20% recover well after the first
attack, but 60% (& the 20% who do not respond )
require psychosocial intervention.
 PHARMACOLOGICAL TREATMENT:-
Antipsychotics were formally discovered by Delay &
Deniker in 1952.Since their introduction, they have
changed the outcome of schizophrenia significantly.
 Drugs Oral dose Parenteral dose
range(mg/day) (mg/day)

A. TYPICAL OR TRADITIONAL ANTIPSYCHOTICS

1. Chlorpromazine (CPZ) 300 – 1500 50 – 100 IM
2. Thioridazine 300 – 800 -
3. Trifluoperazine 15 – 60 1 – 5 IM
4. Haloperidol 5 – 100 5 – 20 IM/IV
5. Pimozide 4 – 12 -
6. Triflupromazine 100 – 400 30 – 60 IM
7. Prochlorperazine 45 – 150 40 – 80 IM
8. Flupenthixol 3 – 10 -
9. Loxapine 25 – 150 -
10. Zuclopenthixol 50 – 150 50 – 100 IM

B. ATYPICAL OR NEWER ANTIPSYCHOTICS

1. Clozapine 25 – 450 -
2. Risperidone 2–8 -
3. Olanzapine 5 – 20 -
4. Ziprasidone 40 – 160 -
• In presence of acute excitement, haloperidol 10 – 20
mg IV or IM, with / without 10 mg diazepam or 50 mg of
promethazine can be given.
• Chlorpromazine 50 – 100 mg IM can also be given but
painful injection abscess at the injection site may
develop. Chlorpromazine should never be given IV, as
severe hypotension can occur.
• A majority of patient require maintenance treatment
with antipsychotic to prevent relapse.
• Although there are no clear-cut rules, generally
treatment is continued for 6 months-1 year for the first
episode, 1 - 2 years for the subsequent episodes, & for
indefinite period for repeated episodes or persistent
symptoms.
2.ELECTROCONVULSIVE THERAPY
(ECT):-
Schizophrenia is not primary
indication for ECT. Indication for
ECT in schizophrenia include:
• Catatonic stupor
• Uncontrolled catatonic excitement
• Acute exacerbation not controlled
with drugs.
• Severe side-effect with drugs, in
presence of untreated
schizophrenia.
Usually 8 – 12 ECTs are
needed (although up to 18 have
been given in poor responders),
given three times a week.
 3. PSYCHOLOGICAL TREATMENTS
INDIVIDUAL PSYCHOTHERAPY:
Goal: To improve medication compliance, enhance social and
occupational functioning and prevent relapse.
• Reality-oriented individual therapy is the most suitable approach to
individual psychotherapy for schizophrenia.
• The primary focus in all cases must reflect efforts to decrease
anxiety and increase trust.
Group therapy
Group therapy for people with schizophrenia generally
focuses on real-life plans, problems and relationships. It is
usually conducted in a form which is known as ‘social skills
training package’.
• Teaching problem solving, &
• Teaching communication skills
Social skill training
Goal:- the complex interpersonal skills involve the smooth integration of
a combination of simpler behaviour.
(a) Nonverbal behaviour (eg. facial expression, eye contact)
(b) paralinguistic features (eg. Voice loudness and affect )
(c) verbal content (eg. Appropriateness of what is said)
(d) interactive balance (eg. Amount of time taking)
these specific skills can be systematically taught and through the
process of shaping complex behavior can make smooth.
Family therapy:
• Apart from education, family members are also provided
social skills training to enhance communication & decrease
family tensions.
• BY providing the family with information about the illness
and suggestions for effective coping, psycho-educational
programs reduce the likelihood of the client’s relapse.
• The family is taught to decrease expectations & avoid
critical remarks, emotional over-involvement, & hostility.
Milieu therapy (or therapeutic community):
Includes treatment in a living, learning or working
environment ranging from inpatient psychiatric unit
to day-care hospitals & half-way homes.
Psychosocial rehabilitation :
is used, usually along with milieu therapy. This include
activity therapy, to develop the work habit, training in a new
vocation or retraining in a previous skill, vocational
guidance, independent job placement, sheltered
employment or self-employment, & occupational therapy
• Assessment of the client with schizophrenia may be a
complex process, based on information gathered from a
number of sources.
• Client in an acute episode of their illness are seldom able
to make a significant contribution to their history.
• Data may be obtained from family members, if possible;
from old records, if available, or from other individuals who
have been in a position to report on the progression of the
client’s behaviour.
 The nurse must familiar with behaviours common to the disorder to
be able to obtain an adequate assessment of the client with
schizophrenia. Previous editions of the Diagnostic & Statistical
Manual of Mental Disorders presented behavioural disturbances in
eight areas of functioning:
• Content of thought
• Form of thought
• Perception
• Affect
• Sense of self
• Volition
• Impaired interpersonal functioning & relationship to be external
world
• Psychomotor behaviour
1. Disturbed thought processes r/t inability to trust, panic anxiety or biochemical
factors, evidenced by delusional thinking; inability to concentrate; impaired
volition; inability to problem solve, abstract or extreme suspiciousness of others.

2. Disturbed sensory perception: auditory/visual r/t panic anxiety, extreme

loneliness & withdrawal into the self, evidenced by inappropriate responses,
disordered thought sequencing, rapid mood swings, poor concentration,
disorientation.

3. Social isolation r/t inability to trust, panic anxiety, weak ego development,
delusional thinking, regression evidenced by withdrawal, sad dull affect, need-fear
dilemma, preoccupation with own thoughts, expression of feelings of rejection or
of aloneness imposed by others.
4. Risk for violence: Self-directed or other-directed r/t extreme suspiciousness,
panic anxiety, catatonic excitement, rage reaction, command hallucinations
evidenced by overt & aggressive acts, goal-directed destruction of objects in the
environment, self-destructive behaviour, or active aggressive suicidal acts.
5. Impaired verbal communication r/t panic anxiety, regression,
withdrawal, unrealistic thinking evidenced by loose
association of ideas, neologisms, word salad, clang
association, echolalia, poor eye contact.
6. Self-care deficit r/t withdrawal, regression, panic anxiety,
perceptual or cognitive impairment, inability to trust
evidenced by difficulty carrying out tasks associated with
hygiene, dressing, grooming, eating & toileting
7. Disabled family coping r/t difficulty coping with client’s
illness evidenced by neglectful care of the client in regard to
basic human needs or illness treatment, extreme denial or
prolonged over concern regarding client’s illness.
8. Ineffective health maintenance
9. Impaired home-maintenance management
Therapeutic Need:-
I. Compliance to treatment:
• Give the drugs as prescribed by psychiatrist.
• Keep five right in mind
• Observe for side effects
• Record any changes in patient after medicine.
• Record & report early & late side effects of
antipsychotic drugs.
• Explain ECT therapy to relatives.
• Explain to the patient: he will be getting an injection
(for ECT).
• Interact with the patient at one to one level
• Allow him to speak about his illness
Psychosocial Needs:-
II.Decrease disturbed thoughts
- Sit next to patient
- Teach the patient when appropriate (eg: when
patient is feeling sad, crying).
- Talk to patient about his problem
- Don’t criticize the patient
- Make conversation simple
- Encourage patient to talk.
 Reduce delusions:-
- Listen to the patients delusion & find out it’s
relationship with patients behaviour
- Encourage discussion of patients fear, anxiety and
anger without assuming the delusion is right or wrong.
- Promote patient ability to reality test
- Promote distraction as a way to stop focusing on
delusions eg; promote activities that require attention
to physical skill.
- Don’t agree with delusion, especially to obtain the
patient cooperation.
- Don’t attempt a logical explanation or by to prove
patient wrong.
Gradually decrease or break hallucination:-
- Establish a trusting, interpersonal relationship.
- Be patient show acceptance & use active listening skill
- Assess for symptoms of hallucination including duration ,
intensity & frequency
- Help patient gain control of hallucination seek helpful
distraction & minimize intensity
- If patient asks, simply say you are not experiencing the
same stimuli.
- Don’t agree with the patient
- When hallucination occur, don’t leave patient’s alone
- Suggest & reinforce the patient for support system
- Pay attention to content of hallucination because it may
provide clues for predisposing behaviour
- Provide feedback regarding patient’s general coping
responses & activity of daily life.
Improve Communication:-
- Don’t ignore the patient
- Initiative the conversation
- Allow the patient to talk & be a active listener
- Provide a separation place for talking
- Minimize the disturbance
- Use therapeutic technique of communication
- Don’t probe, criticize or agree with patient
- Allow silence for some time
Improve Socialization:-
- Speak in short & clear sentence
- Allow the patient to sit with others
- Take initiative to talk to the patient
- Tell him to come out of bed & talk with neighbor
patient
- Discuss with patient anything of his interest
- Provide the patient with stimulation from recreational
& other milieu activities
Enhance self concept:-
- Provide simple activities to patient, so patient feels
confident of himself
- Allow him to check if all the patient had their food.
 Improve attention & judgment:-
- Patient’s can be asked to write about what he did
yesterday
- Provide activities to hold attention of patient’s.
Improve Family Support:-
- Make sure that one relative is always with patient
- Teach the relative to help the patient to maintain
his personal hygeine, take diet, participate in day
care activities & to accept the treatment
- Explain about the types of job patient’s can do
- Encourage the relatives to keep supporting
 Physical Needs:-
Provide Protection:-
- Avoid keeping glass, knife, blade or any sharp
instrument with the patient
- Give negative reinforcement like he will be not allowed
to see T.V if he again tries to slap his brother
- Teach relatives to be with the patient
- Provide safe environment
Assist in personal hygiene care:-
- Encourage patient to go & brush his teeth
- Encourage patient for proper maintenance of bowel
habits, taking bath & wearing of his own clean cloth
 Improve sleep patterns:-
- Patient’s should be encouraged to sleep by 10.30 pm
- Switch off the main lights
- If any patient is having disturbing behaviour, isolate him
- Give a glass of warm milk at bed time.
- Keep patient busy in activity during day.
Nutritional Care:-
- Plan an adequate & balance diet with the patient on previous
day
- Ask patient what he would like to eat
- Serve food in a neat & attractive manner in the patient own
utensils
- Provide a clean environment before serving
- Persuade the patient to eat himself
- Tell relative to taste the food if patient is afraid of taking it
due to his delusion.
 Recreational Needs:-
- Ask the patient what all he likes to do or his
hobbies.
- Choose a few according to the availability of place &
equipment for recreation
- Tell him to play carom board with 2-4 people
- Encourage him to play badminton so his energy is
utilized
- Don’t allow the competition in the beginning
- If the patient is good in some activities, allow
competition & help him to achieve success
 Spiritual needs:-
- Allow/encourage patient to say his prayer daily
- Provide separate corner in ward/unit for the patient to
come & pray
- Celebrate with the patient’s X-mas, Diwali, Holi, &
other religious function.
- Don’t force the patient if he does not want to
participate in other religious activities.

Discharge plan:-
- Encourage the patient to meet his relatives to develop
a sense of recovery.
- Send the patient on parole (trail/visit)
- Follow up.