- for BSc Nursing students

2. PRIYANKA CHANDY
LECTURER
MANIPAL COLLEGE OF NURSING

3. INTRODUCTION
A Greek word splited as:
SKCHIZO-To Divide
PHREN-Mind
Termed by kraplein in 1896 as ‘Dementia
Precox’
In 1908 Eugene bleuler coined it as
Schizophrenia

4. Schizophrenia

Schizophrenia occurs with regular
frequency nearly everywhere in the world
in 1 % of population and begins mainly in
young age (mostly around 16 to 25 years).

5. It 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
It is a type of functional psychosis
characterized mainly by disturbance in
thinking and associated disturbances in
psychomotor activity, affect, perception
and behavior.

6. PREDISPOSING FACTORS.
1)
2)
3)
4)
5)
IDOPATHIC
HEREDITARY:-Incidence high in univolvar twins
-Transmission through one or more
autosomal recessive genes
PERSONALITY-SCHIZOID
CHILD DEVELOPMENT AND PARENT CHILD
RELATIONSHIP
AGE-Peak in between 15-30 and also some
after30 yrs

7. SEX-Equal in both sexes
7) SOCIAL ISOLATION-Predisposed unstable
personal relationship
8) INTELLIGENCE
9) OVERCROWDING SLUMS
10) PRECIPITATION-Stress, regarding ineffective
disease, pregnancy, family problem, etc.
11) ENDOCRINE-Excess of dopamine dependent
neuronal activity in brain
12) ASSOCIATED WITH OTHER DISEASESMore common in temporal lobe epilepsy
6)

8. ETIOLOGY


The exact cause of schizophrenia is still
unknown
Still there are some factors that are
considered as risk factors.

9. Biological theories

Genetics /
Hereditary

10. Immunologic factors e.g. Viral exposure in
pregnancy.
 High arousal level from stress , trauma, and
drugs e.g. bombardment.
 Severe disease e.g. encephalitis.
 Trauma from complication such as
obstetrical, head trauma, childhood accidents.


11. BIO CHEMICAL
INFLUENCES.
Theories
suggests
that
that
schizophrenia may be caused by an
excess
of
Dopamine
dependent
neuronal activity in the brain.
 Abnormalities in the neurotransmitters
nor
epinephrine, serotonin, acetylcholine, an
d gamma-amino butyric acid and in the
neuroregulators such as prostaglandins
and endorphins have been suggested.


12. Physiological Influences

Viral Infection

Anatomical Abnormalities

Histological

Physical Conditions.

Psychological Influences
Changes.

14. a)
b)
c)
d)
e)
Autistic thinking-important feature
Considers two things identical
Disturbed thinking, emotions and behavior.
Patient appears absurd and bizarre
Social withdrawal from
religion, philosophy, science, sex, and power

15. Absence of links between ideas, crowding and
poverty of ideas, flight of ideas
h) Word are linked without meaning(word salad)
g)
Emotional blunting or shallowness of affect
b. Inappropriate affect-patient laughs when he is
expected to cry and cries when he is expected
to laughs
c. Hypersensitiveness or insensitiveness of
feelings
d. Ambivalence-experience of 2 opposite of
feelings
a.

16. a)
b)
c)
d)
e)
Irrelevant and inappropriate behavior
Awkward actions
Rowdy, violent, assaultive(a person has a physical
or verbal violence), agitation
Suicidal and homicidal tendencies
Criminal and sexual over activity, pervasive
Reduction of drive and desire to carry out routine
work
b) Avoiding mixing in family and friends
c) Reduced efficiency and activity
d) Feeling of passivity(mind and thoughts controlled
by outside force
a)

17. a)
b)
a)
b)
Hallucination –auditory and visual are
common, others are very rare.
Hallucinations are either structured(human or
animal voice) or unstructured(vague voices)
In catatonic, increased psychomotor
activity, stupor, negativism, stereotype, mutism,
verbegeration(repeating the same words)
Waxy flexibility

18. a)
b)
c)
d)
e)
f)
g)
Excessive day dreaming and fantasy
Muttering
Spells of laughter and crying without reason
Childish behavior
Patient passes urine and stool in his clothes
and plays with has own excreta
Absent mindedness
Makes lot of mistakes in work

19. Positive and Negative Symptoms
Negative
Positive
Alogia
Hallucinations
Affective flattening
Delusions
Avolition-apathy
Bizarre behaviour
Anhedonia-asociality
Positive formal
thought disorder
Attentional
impairment

20.  THE
ILLNESS OF AS A PHENOMENON OF
REGRESSION
 E.G- Reversal to infantile and childhood
patterns of psychological living a state of
organization where reality does not exist.
Thus the patient attempt to resolve his
psychological conflicts by denying the
harsh and painful reality world and living
in a fantasy would full of pleasures

21. PHASES OF
SCHIZOPHRENIA

Phase I - The schizoid personality

Phase II-The prodromal phase.

Phase III-Schizophrenia—active phase.

Phase IV- Residual phase

22. F20-F29 Schizophrenia,
Schizotypal
and Delusional Disorders
F20
F20.0
F20.1
F20.2
F20.3
F20.4
F20.5
F20.6
F20.8
F20.9
Schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
Other schizophrenia
Schizophrenia, unspecified

23. PARANOID SCHIZOPHRENIA: Early onset
 ‘Paranoia’ means ‘delusional’
 It occurs between 25-30 yrs
 Seen more in males than females
 Delusion of suspiciousness, persecution and
grandeur
 Disorganization of speech and thought
 Hallucinatory voices of threatening or
commanding, also voices of whistling and
laughs
A.

24. 
Affect is usually of hostility, anger or
suspiciousness
 Negative symptoms like flat affect, poverty of
speech and poor activity
 Prognosis is good

25. B.











HEBEPHRENIC SCHIZOPHRENIA:Early and insidious onset
Occurs between the age of 20-25 yrs
Thinking disturbances
Regression
Childish behavior
Inappropriate affect
Somatic delusion
Unpredictable, giggling and silliness
Irrelevant
Poverty of ideas
Prognosis is poor

26. SIMPLE SCHIZOPHRENIA: Insidious and gradual course
 Occurs between age of 15-20 yrs
 More incidence in males
 Disturbances in affect
 Disturbances in thinking
 Delusions and hallucinations are rare
 Wandering aimlessly
 Prognosis is poor
C.

27. CATATONIC SCHIZOPHRENIA: Occurs between age of 20-25 yrs
 Equal in both sexes
 Disturbances of thinking, affect and behavior
 Acute or sub-acute onset
 Autism
 Purposeless excitement and destructive
behavior
 Delusion and hallucinations are common
 Prognosis is good but reoccurs are common
D.

28. CATATONIC STUPOR: Absence of speech
 Maintenance of rigid posture against efforts to
be moved
 Negativism
 Bizarre postures for longer period of time
 Stuporous reaction towards surrounding
 Ecolalia-mimicking of phrases and words
 Echopraxia-mimicking of actions observed
 Waxy flexibility
 Ambitendency
E.

29. F.




G.



RESIDUAL SCHIZOPHRENIA:Emotional blunting
Eccentric behavior
Social withdrawal
A type of schizophrenia which has been at
least one episode in the past but without
prominent psychotic symptoms at present
UNDIFFERENTIATED SCHIZOPHRENIA:Late schizophrenia occurs after 40 yrs of age
Schizoaffective psychosis with symptoms of
depression and mania and also neurosis
Prognosis is poor.

30. CHILDHOOD OR JUVENILE
SCHIZOPHRENIA: Not common but seen between age of 5-10
yrs and 12-14 yrs
 Onset is acute or gradual
 Prognosis is poor
I. SCHIZOAFFECTIVE PSYCHOSIS: Symptoms of schizophrenia associated with
symptoms of depression and mania
H.

31. PSEUDO-NEUROTIC SCHIZOPHRENIA: Core of illness is schizophrenia but presenting
symptoms are suggestive of neurotic symptoms
like anxiety state, phobic reactions, obsessive
compulsive neurosis or hysteria
 Treatment such as psychotherapy, abreactive
therapy or drug therapy is not satisfactory
 Careful psychiatric examination done through
repeated interview, reveals the true nature of
illness
J.

32. Postschizophrenic Depression
A depressive episode, which may be
prolonged, arising in the aftermath of a
schizophrenic illness. Some schizophrenic
symptoms, either „positive“ or
„negative“, must still be present but they no
longer dominate the clinical picture.
 These depressive states are associated
with an increased risk of suicide.


33. Duration of illness:Shorter duration carries better prognosis
2) Type of schizophrenia:Catatonic and paranoid type carries good
prognosis. simple, hebephrenic, juvenile, pseudoneurotic types do not carry good prognosis.
3) Personality:Non schizoid and stable
personality respond better
1)

34. 4)
5)
6)
Precipitating factor:Presence of precipitating factor carries
good prognosis.
Age:20-30 yrs of age carries better
prognosis than other ages.
Type of onset:Acute onset carries better prognosis
than gradual onset.

35. I.
II.
III.
IV.
V.
VI.
PSYCHIATRIC HISTORY
A MENTAL STATUS
EXAMINATION
CLINICAL OBSERVATION
CT SCAN
MRI
OFFICIAL DIAGNOSIS IS
BASED ON ICD 10
CRITERIA

36. A.

TREATMENT
MODALITIES
PHARMACOTHERAPY:-
Conventional antipsychotics are now
used less frequently, because of
their only partial efficacy and
adverse effects.
 The following are the drugs given to
non-compliant patients;
-Chlorpromazine:50100mg/day
-Fluphenazine decanoate:2025mg IM every 1-3 wks
-Haloperidol:5-20mg/day IM
-Trifluoperazine:1-5mg/day IM

37. 

Commonly used atypical antipsychotics;
-Clozapine:25-450mg/day PO
-Resperidone:2-10mg/day PO
-Olanzapine:10-20mg/day PO
-Ziprasidone:20-80mg/day PO
Other drugs used in schizophrenia are mood
stabilizers, anti
depressants, benzodiazepines, etc.

38. B.




C.

D.

ELECTROCONVULSIVE THERAPY(ECT):Indications are catatonic stupor, catatonic
excitement
Severe side effects with drugs
Usually 8-10 ECT’s are required to be given
About 8-10 convulsions spread over a period
of 4-6 weeks
PSYCHOLOGICAL THERAPIES:Cognitive therapy, group therapy, behavior
therapy, family therapy
PSYCHOSURGERY:Prefrontal leucotomy

39. Psychosocial therapy

40. ROLE OF A NURSE

41. Responsibility while dealing with disease
problem
Non compliance to management
 Explain the management to patient shortly
or as you required.
 Develop therapeutic relationship with the
patient.
 Develop trust with the patient.
 Listen any complain of patient carefully.
 Don’t ignore anything that related to
drugs.

42. Set the diet according to the drugs.
 Give medicine regularly
 Check the blood level regularly to maintain
adequate drug level.


43. Impaired perception
•
Assess the level of orientation.
• Allow the patient to talk about
hallucination.
• Avoid reinforcing the hallucination.
• Avoid saying that you are wrong.
• Support the patient in initial stage by
saying that you are just thinking but the
reality is just opposite.
• Remove all the injurious thing.
• Diversion of activity.

44. Impaired sleep
•
•
•
•
•
•
•
•
•
Asses the pattern of sleep.
Provide calm and quite environment.
Isolate the disturbing patient.
Provide a glass of warm milk before sleep.
Provide a warm bath before sleep.
Maintain a daily routine of sleeping and
awakening.
Put off the light in around at 100 clock every
day.
Provide comfort measure as pillow ,back rub.
Give p.r.n as prescribed.

45. Impaired Bowel and Bladder activity
•
Assess the type of alteration of b/b.
•
In case of constipation encourage high fiber diet
•
Increase fluid intake
•
Food Intake should be frequently.
•
Take the choice of food to patient.
•
Serve the food in attractive manner.
•
Encourage patient to take proper sleep or rest.
•
Encourage for light exercise or walking jogging.
•
If the patient not taking food than explain politely that food is
compulsory for recovery.

46. impaired thought process
•
•
•
•
•
•
•
•
•
•
Assess the level of thought process.
Convey acceptance of the patient’s need for
false belief but that you do not share.
Do not argue .
Do not force.
Do not say you are wrong.
Use same language in front of patient.
Avoid physical contact in form of touch.
Avoid laughing ,whispering there.
Avoid competitive activities.
Reinforce focus on reality.

47. impaired physical activity
•
•
•
•
•
•
•
•
•
Assess the level of activity pattern of patient.
Give high calories diet.
Remove all things near to bed.
Maintain calm and quite environment.
Avoid argument with the patient.
Give the medicine timely to maintain drug
level.
Avoid talking excessively.
Give some simple task to do the patient.
Encourage for light rest in day as well as night.

48. Anxiety.
•
•
•
Asses the level of anxiety.
Maintain therapeutic relationship.
Explain everything before doing .
• Hold the hand of patient if patient threatened (if
required).
• Explain queries of patient clearly.
• Don’t ignore patient .
• Stay with patient.
• Use same language in front of patient.
• Ask patient to explain his/her anxiety more and
more.
• Give tranquilizer as prescribed.
• Provide safe environment.
•
Use relaxation technique if possible.

49. Impaired orientation.
Assess the level of perception.
 Provide a safe environment.
 Ask the patient to express impaired
perception.
 Help the patient to get oriented.
 Focus on reality.


50. Impaired nutrition
•
•
•
•
•
•
•
•
•
Assess the level of nutrition.
Provide calories according to activity.
Find out patient like and dis like.
Provide 6-8 glass water (if not contraindicated).
Maintain accurate record of intake and out put.
Supplement diet with vitamin and mineral.
Walk or sit with the patient.
Serve food attractively.
Instruct to relatives to take food with patient if
suspiciousness is there.

51. Impaired socialization.
Maintain therapeutic relationship with
patient.
 Encourage patient to talk with other
people or patient.
 Encourage to play with other patient.
 Offer patient for group activity.
 Give a positive reinforcement for
participation.


52. Other nursing problems
Impaired communication
 Violent behaviour
 withdrawn behaviour.
 Self care deficit.
 Impaired family coping.


53. OTHER PSYCHOTIC DISORDERS
Psychosis is defined as gross
impairment in reality testing, marked
disturbance in personality with impaired social
and occupational functioning and presence of
characteristic symptoms like delusions and
hallucinations.

54. F22- persistent delusional disorders
 F23- Acute and transient psychotic disorders
 F24- induced delusional disorders
 F25- schizoaffective disorders
 F26- capgras syndrome (delusion of doubles)


55. Persistent delusional disorders
Non- bizarre type delusions
 Persistent at least for 3 months
 Absence of significant hallucinations
 Absence of organic mental
disorders, schizophrenia and mood
disorder.


56. Acute and transient
psychotic disorders





Neither follow the course of schizophrenia
or mood disorders.
Abrupt, acute onset, and associated with
identifiable acute stress.
Several type of hallucinations, delusions
changing in both type and intensity from
day to day or within same day.
Emotional turmoil ( ecstasy to anxiety and
irritability)
Do not fulfill the criteria of schizophrenia.

57. Induced delusional
disorders

Sharing of delusion between usually two
or more persons who usually have a
closely knit emotional bond.

58. schizoaffective disorders
Depressed type
 Manic type
 Mixed type


59. capgras syndrome

Delusional misidentification syndromes

60. Rehabilitation

61. Social skills training
 Vocational rehabilitation
 Half –way homes
 Long- term homes
 Day hospitals
