SchizophreniaSchizophreniaPrepared by \ Mofida Al -

barrak .Under supervision Prof. Dr

Elham Fayad

- Prepared by \ Mofida Albarrak

Under supervision Prof. Dr. Elham Fayad

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At the end of this lecture the students will be able to:

1. Explain the meaning of schizophrenia2. Discuss symptoms of schizophrenia3. Differentiate and contrast between

etiological factors related to schizophrenia

4. Determine schizophrenia subtypes 5. Assess client with schizophrenia 6. Develop a nursing care plan for a

client with schizophrenia

Objectives

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Definition Etiological factors related to

schizophrenia Symptoms of schizophrenia Subtypes of schizophrenia Assess client with schizophrenia Develop a nursing care plan for a client

with schizophrenia

Outlines

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Neurotic Environment Psychotic Delusion &

hallucination Personality disorder Raring Cognitive implement

(dementia & delirium) Substance related disorder

Classification of mental disorder

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Psychotic Neurotic

Delusion & hallucination

Environment

insight Lack Insight

Can not stop medication

Medication Can stop

e.g. schizophrenia e.g. anxiety & stress

hospitalization Need Clinical

What are the different between neurotic & psychotic

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  Schizophrenia is a condition that exists in all

cultures and in all socioeconomic group .

It is estimated that 1% of the general population suffer from schizophrenia .

people with schizophrenia occupy approximately 50% of the hospital beds for the mentally ill .

Introduction

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Schizophrenia is a major psychotic disorder marked by a profound withdrawal from interpersonal relationship and cognitive and perceptual disturbances that make dealing with reality difficult.

It is characterized by splitting of normal links between perception, mood, thinking ,behavior and contact with reality .

Definition

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Schizophrenia is a group of psychotic disorders that interfere with thinking and responsiveness. It is a disease of the brain.

The term schizophrenia, which means "split mind," was first used in 1911 by Swiss psychiatrist Eugen Bleuler to categorize patients whose thought processes and emotional responses seemed disconnected.

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Thought process

Behavior

Three component are integrated in the normal person

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Three component are disintegrated like Schizophrenia patient (each one Split or separate from other)

Cognition

Affect Behavior

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Eugen Bleuler – Introduced the term “schizophrenia” or “splitting of the mind”; the 4 As:

4 As

Associations

Apathy

Ambivalence

Autistic thinking

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1. Autistic thinkingStart with fantasy & day dream ending by delusion &

hallucination

2. Associative loosenessIllogically connected things. 3. Ambivalenceholding 2 different emotion to the same person at the

same time. 4. Apathy Absent of emotional experience & expression

****Symptoms Blerler 4 as ****

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Normal perceptual & thought process Personality Affect Withdrawal

schizophrenia is characterized by the disruption of:

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1. Unipolar major depression

2. Bipolar disorder

3. Schizophrenia

4. Epilepsy

5. Alcoholism

6. Dementia

1. Unipolar major depression

2. Bipolar disorder

3. Schizophrenia

4. Epilepsy

5. Alcoholism

6. Dementia

7. Parkinson’s disease

8. Multiple sclerosis

9. Drug use

10. PTSD

11. OCD

12. Panic disorder

7. Parkinson’s disease

8. Multiple sclerosis

9. Drug use

10. PTSD

11. OCD

12. Panic disorder

3rd highest for years of life with a disability (YLD) among neuropsychiatric conditions

3rd highest for years of life with a disability (YLD) among neuropsychiatric conditions

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Schizophrenia: Some Facts and Statistics

Figure 13.2 The natural history of schizophrenia: a 5-year follow-up. Copyright 1989 by Cambridge University Press. Reprinted with the permission of Cambridge

University Press.

1 .Biologic Factors

2 .Environmental factors

3.Psychological factors

4 .Family theory

Etiological Factors of Schizophrenia

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a. Role of Neurotransmitters Neurotransmitters:

Common impaired neurotransmitters are acetylcholine , dopamine, norepinephrine, serotonin & Gamma Aminobutyric Acid (GABA).

1 -Biologic Factors

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1- Biological factors

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b . Abnormalities in brain

Structure (neuro anatomical studies Brain scans using magnetic resonance

imaging (MRI) have shown a number of abnormalities in the brain's structure associated with schizophrenia. Such problems can cause nerve damage and disconnections in the pathways that carry brain chemicals. Structure (neuro anatomical studies.

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Dilatation of the left ventricular

Brain structure

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Causes of Schizophrenia: Neurotransmitter Influences

Figure 13.6 Some ways drugs affect neurotransmission.

Causes of Schizophrenia:Other Neurobiological Influences

Figure 13.7 Location of the cerebrospinal fluid in the human brain. This extracellular fluid surrounds and cushions the brain and spinal cord. It also fills the four

interconnected cavities (cerebral ventricles) within the brain and the central canal of the spinal cord.

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C. GENETIC FACTORS

The risk for inheriting schizophrenia is 10 % in those who have one immediate family member with the disease

About 40% if the disease affects both parents and an identical twin.

About 60% of people with schizophrenia have no close relatives with the illness.

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Causes of Schizophrenia:Findings From Genetic Research (cont).

Figure 13.4 Risk for schizophrenia among children of twins.

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2 .Environmental factors a. Infectious

The viruses as a cause of schizophrenia such as living in crowded conditions.

b. Seasonal factors The risk for schizophrenia worldwide is 5 – 8 %

higher for those born during winter and spring, when colds and viruses are more prevalent.

 Pregnant Mother's Exposure to Viruses. The mother's exposure to viral infections such

as rubella, measles, chicken pox,& toxoplasmosis

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psychoanalysis theory

Erickson

Cognitive theory

Behaviorism

3.Psychological factorspersonality development

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a- Psychoanalytic and developmental theories :

Psychoanalytic theory states that there are distortions in the mother-child relationship, so that the child is unable to progress beyond dependence.

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Children learn what they are exposed to on a daily basis.

According to learning theory, the irrational ways of handling situations, the distorted thinking, and the deficient communication patterns of persons with schizophrenia are a result of poor parental models in early childhood .

b- Learning theory

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1. Double binde.g. I love my san I leave him (say thighs do

opposite) 2. Scapegoate.g. Put all the problem to one person in my

family 3. Eschewed family e.g. Father stay in the house & mother are

working (opposite role) 4. Schismatic family e.g. Father & mother all the time have

(conflict)

******c- Family theory* *******

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List the causes of Schizophrenia

Explain Eugen Bleuler – Introduced the term “schizophrenia” or “splitting of the mind”; the 4 As:

Discuss Family theory

Questions review

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Schizophrenia affects different people in different ways. Not everybody will experience the same symptoms, nor are they always to the same degree.

Two types of symptoms are distinguished in schizophrenia – they are classified as positive and negative symptoms.

Symptoms of schizophrenia

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a. Delusions: Persecution – “chased by other” Reference – “talking about me” Influence- “controlled by others or

agencies” Grandeur – “important person”

1“.Positive” Symptom

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b. Hallucinations can occur in any of the five senses but the most common are auditory.

For example, the person may hear voices repeating their thoughts, in conflict, commenting on their actions telling them what to do (command hallucinations).

Hallucinations of any form occur in over 70 per cent of people who experience psychotic illnesses.

Auditory hallucinations occur in approximately 50 per cent of people with schizophrenia, while visual hallucinations occur in 15 per cent.

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Disorganized Thinking

This is usually expressed through abnormal spoken language.

For example, the person's conversation jumps from one topic to another, new words may be created, the grammatical structure of language breaks down and speech may greatly speed up or slow down.

Disorganised Behaviour

Disorganised behaviour can lead to problems in conducting the activities of daily living such as organizing meals and maintaining hygiene.

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Catatonic Behaviour

This refers to states of muscular rigidity and immobility, stupor and negativism,

The person may hold fixed or bizarre bodily postures for extended periods of time and resist any effort to be moved.

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Negative symptoms

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Withdrawal, Loss of Motivation & Ambivalence (Avolition)

People experiencing avolition may be negligent grooming, personal hygiene, have difficulty making decisions & have difficulty persisting at work, school or family tasks.

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Loss of Feeling or an Inability to Experience Pleasure (Anhedonia)

Lack of interest in social or recreational activities ,failure to develop close relationships.

Poverty of Speech (Alogia) The person's amount of speech is greatly

reduced & people showing signs of alogia may be slow in responding to questions or not respond at all.

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Flat Presentation (Affective Flattening)

This can be indicated by unchanging facial expressions, poor or no eye contact, reduced body language and decreased spontaneous movements.

Cognitive Impairmentscognitive dysfunction is often present in

people with schizophrenia is associated with cognitive impairments including problems with attention, concentration and memory.

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Paranoid schizophrenia

Disorganized schizophrenia

Catatonic schizophrenia

Undifferentiated schizophrenia

schizophrenia Residual

There are five major subtypes of ****schizophrenia.

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Delusion of grandeur

Delusion of persecution

Delusion of jealousy

Reference

Delusion of influence =

control

1 .Paranoid schizophrenia

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This subtype of schizophrenia is characterized by Delusions that tend to be persecutory or

Grandiose.

Cont.

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The disorganized type of schizophrenia is characterized by a severe disintegration of the personality . It has an dangerous start .

2.Disorganized schizophrenia

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Cognition

Affect Behavior

Word salad Incoherent speechClanging association

Speech is disorganized and may include

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Odd Stereotyped behaviors uninhibited sexual behaviors such as

masturbating in public. WithdraPoor coordination. Poor personal grooming unable to complete activities of daily living

(ADLs).

Behavior

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Major feature, manifestations of psychomotor disturbance include.

StuporThere is complete suppression of motor

activityThe patient doesn't respond to any stimulus

neither external (question or painful stimulus)or internal stimuli (hunger, thirst, distended bladder)

0r Excitement Sever form of hyperactivities excessive

purposeless motor activity & the patient may destruct herself or others

3.Catatonic schizophrenia

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NegativismMeans automatic resistance to all stimuli (Muscular e.g. tell the pt’s keeping the arm

extended on trying to flex it )opposite performance

Speech (Mutism) Mutism(Speech total loss)Automatic obedienceOther symptoms include Echopraxia Echolalia stereotypy

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Waxy flexibilityMaintenance of imposed postures e.g.

raising the head of the patient from the pillow, or the arm up) *absence of fatigue

Catalepsy (Posturing)Is sustained immobility (patient initiates

position by herself)

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Catatonic

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Undifferentiated schizophrenia cannot be classified as paranoid, disorganized, or catatonic .It does not clearly meet the criteria necessary for a diagnosis.

The psychotic manifestations are extreme ,including

Fragmented delusions Vague Hallucinations

4 -Undifferentiated schizophrenia

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Bizarre Disorganized behavior Disorientation Incoherence Affect is usually inappropriate mixture of positive and negative

symptoms. Dress & grooming are careless Individual seems uninterested with life.

cont .

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If an individual has had at least one acute episode of schizophrenia and is now free of prominent positive symptoms, but has some negative symptoms he is diagnosed as suffering from residual schizophrenia .

The usual signs of the illness are Illogical thinking, Loosening of associations Emotional blunting Social withdrawal Eccentric (bizarre) behavior

 

5 .Residual schizophrenia

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1. Schizophrenia is a a. Disorder of neuroanatomy b. Groups of disorders involving a disorder of

neurotransmitters c. Collection of disorders involving brain

function d. Disorder of brain metabolism

Reviewing questions

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2. Schizophrenia is primarily marked by

a. Inattention & anger b. Violent & impulsive behavior c. Thought disturbance such as delusion d. Affective disturbance such as dysphasia

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3 .The three primary negative symptoms of schizophrenia include

a. Alogia, hallucinations & delusion b. Alogia, affective blunting, & avolition c. Affective blunting, delusions & avolition d. Hallucinations, delusions, & avolition

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4. When assessing a schizophrenic client for positive symptoms, the nurse should look for

a. Hallucination & delusion . b. Inability to express thoughts and feelings. c. Depression. d. Lack of goal-directed behavior.

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5. A client was diagnosed with paranoid schizophrenia twenty years ago. The client no longer displays persecutory delusions, but lacks social and self-care skills and is unable to work. What subtype of schizophrenia is the client displaying?

a. Disorganizedb. Paranoidc. Residuald. Undifferentiated

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Nursing diagnosis

Assessment

Goal

Nursing intervention & evaluation

Nursing management

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Nursing management

Positivesymptoms

Negativesymptoms

Cognitivesymptoms

Aggressivesymptoms

Affectivesymptoms

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Cognitive symptoms:

attenonmemoryexecutive functions

(eg, abstraction)

Positive symptoms:

delusionshallucinationsdisorganized speechcatatonia

Symptoms of schizophrenia

Occupational

Interpersonal

Self-care

Social

Work

Negativesymptoms:

affective flatteningalogiaavolitionanhedonia

Mood symptoms:

dysphoriasuicidalityhelplessness

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1. Alteration of thought (delusion ) the common delusion includes:

Paranoid delusion Ideas of reference Delusion of grandeur Delusion of jealousy Delusion of persecution Somatic delusion

Assessment

Positive Symptoms

Positive Symptoms

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Thought broadcasting: the belief that one’s thoughts can be heard by others

Thought insertion, the belief that thoughts of others are being inserted into one’s mind

Thought withdrawal, the belief that thoughts have been removed from one’s mind by an outside agency

Delusion of being control

Other delusion observed

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 Lose association: the thought process becomes illogical & confused.

Neologisms: made up words that have a special meaning to the delusional person .

Concrete thinking: an overemphasis on small or specific details & an impaired ability to abstract.

Autistic thinking

Clang associations: the meaningless rhyming of a word in a forceful way.

Word salad: a mixture of words that is meaningless to the listener.

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1. Alteration Perception

Hallucinations are the major examples of alterations in perception in schizophrenia, especially auditory hallucinations,

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Auditory hallucination in form of voices may seem to come from outside or inside the person’s head.

The voice may be familiar or strange, single or multiple.

Voices speaking directly to the person or commenting on the person’s behavior are most common in schizophrenia.

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1. Commanding hallucinations Must be assessed, because the “Voices” may

command the person to hurt himself or others.

For examples, a client might state “the voices” are telling him to “ jump out of the window” or “take a knife & kill my child”.

2. Commenting hallucinatione.g. why does not clean Sarah

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What are the characteristic of schizophrenia

Commanding & commenting auditory

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Alteration behavior  Bizarre & agitated behavior is associated with

schizophrenia and may take a variety of forms.

Stereotyped Stupor Waxy flexibility

 

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These symptoms are that most interfere with the individual’s adjustment and ability to survive.

A volition Anhedonia Flat affect Withdrawal He couldn't take decisions Neglect basic hygiene and need help with

everyday activities.

Negative symptoms

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The following is a listing of some of the more common nursing diagnoses applicable to schizophrenia.

1. Altered thought processes.2. Sensory perceptual alterations.3. Impaired verbal communication.4. Social isolation.5. Self-care deficit 6. (bathing , hygiene , dressing , grooming ,

feeding , toileting ).

Nursing diagnosis (NANDA)

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Disturbance thought process related to delusion & hallucination evidence by or (observed by) inability to distinguish rational idea

Biological factors Neurotransmitter increase dopamine Genetic Disturbance thought process (hallucination

& delusion) Thought broad casting Thought withdrawal Neologism

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Absent of psychotic hallucination & delusion

Goal

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Maintain eye contact Assess the client to think logically Thought assessment Listen Do not touch the client specially if have

delusion Distraction from delusion 1. No reasoning2. Voice doubt 3. Introduce new subject for discussion

Nursing intervention

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Disturbance sensory perception related to withdrawal as evidence by hallucination

Nursing diagnosis no 2

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Important note Types of hallucination in schizophrenia

patient’s command & commented All the types of schizophrenia start early

except Paranoid state after age 40 years old.

Drugs schizophrenia takes on long live

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  Able to hold conversation without

hallucinating. Remains in group activities. Attends to the task at hand (e.g. group

process , recreational or occupational therapy activity ).

States that hallucinations are under control

Goals

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All the speech (present from reality ) Call the client by their names to reinforce

reality. Use clear statements Protect client’s Teach client’s techniques to stooped

hallucination

Nursing intervention

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ConclusionSchizophrenia is a severe mental disorder characterized by two kinds of symptoms;

Positive symptoms ( thought disorder, hallucinations & delusions, ) &

Negative symptoms – impairment in emotional range, energy, and enjoyment of activities.

For a formal diagnosis, these symptoms must persist for at least one month and usually result in severe impairment in job and/or social functioning 91AL-barrak 1430

Morrison, J. (1995). The first interview: Revised for DSM-IV. New York: The Guilford Press.

Kersting, K. (2005). Serious rehabilitation: Psychologist-developed treatments are

providing hope for people with serious mental illness. APA Monitor on Psychology, 36 (1), 38-41.

Reference

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McKinney, R., & Fiedler, S. (2004). Schizophrenia: Some recent advances &

implications for behavioral intervention. the Behavior Therapist, 6, 122-125.

Nichols, O. T. (2005, November). Headlines in psychopharmacology. Symposium

presented at the annual meeting of the Kentucky Psychological Association, Louisville, KY

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