Schizophrenia

PRESENTED BY :-
MISS TRUPTIMAYEE DAS
TUTOR
( MENTAL HEALTH NURSING )
SCHIZOPHERNIA
DISORDER

INTRODUCTION
 The word ‘schizophrenia’ was coined in 1908 by
the Swiss psychiatric Eugene Bleuler.
 It was derived from the Greek words schizo means
split and phren mean minds.
 Stigma, discrimination and violation of human rights of
people with schizophrenia is common.

INTRODUCTION
 The most important psychopathological phenomena include
 thought echo
 thought insertion or withdrawal
 thought broadcasting
 delusional perception and delusions of control
 influence or passivity
 hallucinatory voices commenting or discussing the patient in the third
person
 thought disorders and negative symptoms.

Cont…
 The schizophrenic disorders are characterized in
general by fundamental and characteristic
distortions of thinking and perception, and affects
that are inappropriate or blunted. Clear
consciousness and intellectual capacity are
usually maintained although certain cognitive
deficits may evolve in the course of time.
 Schizophrenia is treatable. Treatment with
medicines and psychosocial support is effective.

DEFINITION
 Schizophrenia is defined by
 a group of characteristic positive and negative symptoms
 deterioration in social, occupational, or interpersonal
relationships
 continuous signs of the disturbance for at least 6 months
 Schizophrenia is characterized by distortions in thinking,
perception, emotions, language, sense of self and behavior.
Common experiences include hearing voices and delusions.

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.
 Eugene Bleuler: He renamed Kraepelin’s dementia praecox
as schizophrenia (1911); he recognized the cognitive
impairment in this illness, which he named as a ,splitting of
mind.

HISTORY
Eugene Bleuler:-
 Bleuler maintained, that for the diagnosis of schizophrenia are
most important the following four fundamental symptoms(4A’s)
 affective blunting
 disturbance of association (fragmented thinking)
 autism
 ambivalence (fragmented emotional response)
 These groups of symptoms, are called „four A’ s” and Bleuler
thought, that they are „primary” for this diagnosis.
 The other known symptoms, hallucinations, delusions, which are
appearing in schizophrenia very often also, he used to call as a
“secondary symptoms”, because they could be seen in any other
psychotic disease, which are caused by quite different factors —
from intoxication to infection or other disease entities.

HISTORY
 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.

EPIDEMIOLOGY
 Schizophrenia disorder is prevalent in all cultures across the world.
 About 15 % of new admissions in mental hospitals are the
schizophrenic patients the patients are diagnosed having 50 % of
all mental hospital beds.
 3-4 per 1000 in every community suffer from schizophrenia.
 The peak ages of onset are 15 to 25 years for men and 25 to 35
years for women.

EPIDEMIOLOGY
 Two thirds of cases are in the age group of 15 to 30 years
identify schizophrenia patients.
 Lifetime prevalence of about 1% in schizophrenia disorder.
 Early onset of schizophrenia , Male >Female

Schizophrenia classification
 According to ICD 10 classification (F20-F29
Schizophrenia, Schizotypal and Delusional Disorders)
 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

F20-F29 SCHIZOPHRENIA, SCHIZOTYPAL
AND DELUSIONAL DISORDERS
F21 Schizotypal disorder
F22 Persistent delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified
F23 Acute and transient psychotic disorders
F23.1 Acute polymorphic psychotic disorder with symptoms
of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic
disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorder, unspecified

F20-F29 SCHIZOPHRENIA, SCHIZOTYPAL
AND DELUSIONAL DISORDERS
F24 Induced delusional disorder
F25 Schizoaffective disorders
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
F28 Other nonorganic psychotic disorders
F29 Unspecified nonorganic psychosis

Etiology
In schizophrenia disorder that have multiple factors, these are
discussed below.
1. BIOLOGICAL THEORIES:-
It include biochemical ,neurostructural ,genetic, prenatal risk
factor and others factors also affect.
A. BIOCHEMICAL THEOREIES:-
i. Dopamine hypothesis:-
 In this theory excess amount of dopamine –dependent neuronal activity
in the brain cause schizophrenia.
 This excess activity may be related to increased production or release of
dopamine at nerve terminals, increased receptor sensitivity,.

BIOLOGICAL THEORIES cont..
Dopamine hypothesis:-
 Pharmacological support for this hypothesis exists i.e.
Amphetamines, which increase levels of dopamine, induce
Psychometic symptoms.
 The neuroleptics drugs (e.g., chlorpromazine and
haloperidol) lower brain levels of dopamine by blocking
dopamine receptors, thus reducing the schizophrenic
symptoms, including those induced by amphetamines.

BIOLOGICAL THEORIES cont….
II.OTHER BIOCHEMICAL HYPOTHESES:-
 Various other biochemical have been implicated in the
predisposition to schizophrenia.
 Abnormalities in the neurotransmitters nor epinephrine,
serotonin, acetylcholine, and gamma-aminobutyric acid and in
the neuroregulators, such as prostaglandins and endorphins.

B.NEUROSTRUCTURAL THEORIES:-
 In schizophrenia person research study that the prefrontal
cortex and limbic cortex may never fully develop.
 CT scan and MRI study shows that
i. Decreased brain volume
ii. Larger third and lateral ventricles associated with poor premorbid
functioning, negative symptoms, poor response to treatment, and
cognitive impairment
iii. Atrophy in the frontal lobe ,cerebellum, and limbic structures.
iv. Increased size of the sulci on the surface of the brain.

C.GENETIC THEORIES:-
 This disease is more common among people born in
consanguineous marriage .
 Research studies show that relatives of schizophrenia
have much higher chances than general population.
 Identical twin are affected 50%and fraternal twin
affected in15%.
 one parent affected in 15% ,and both parent affected
chances have 35%.
 Second degree relatives chances affected 2-3 %and
brother or sister affected 10%.

D.PERINATAL RISK FACTORS :-
 Multiple nongenetic factors influence the development of
schizophrenia ( viral infection).
 Maternal influenza
 Birth during late winter and early morning
 Complication in pregnancy particularly in labor and delivery.
 Another study found an association between viral infections of the
central nervous system during childhood and adult-onset
schizophrenia (Rantakallio et al, 1997).

2.PSYCHODYNAMIC THEORY
 These theory focus on individual’s responses to life
events.
A. DEVELOPMENTAL THEORY :-
• According to Freud ,there is regression to the oral stage of
psychosexual development ,with the use of defense mechanism of
denial, projection ,and reaction formation.
• The individuals have poor ego boundaries ,fragile ego, inadequate
ego development ,super ego dominance, regressed id behavior
,love –hated (ambivalent ) relationships and arrested psychosexual
development.

2.PSYCHODYNAMIC THEORY
B. FAMILY THEORIES:-
 Family relationships act as major influences
in the development of illness.
I. MOTHER CHILD RELATIONSHIP:-
o This theory chararecter zed by the mother of schizophrenics as
cold ,overprotective, and domineering ;so that ego
development of the child .
ii. DYSFUNCTIONAL FAMILY SYSTEM:-
o Hostility between parents can lead to schizophrenic daughter .
iii. DOUBLE BLIND COMMUNICATION :- ( Bateson et al,1956)
o Parents convey two or more conflicting and incompatible
messages at the same time.

3. Stress model
 Studies have been conducted in an effort to determine whether
psychotic episodes may be precipitated by stressful life events.
 Extreme stress can precipitate psychotic episodes (Goff, 2002).
Stress may indeed precipitate symptoms in an individual who
possesses a genetic vulnerability to schizophrenia.
 Sadock and Sadock (2003) state: The stress can be biological,
environmental, or both. The environmental component can be
either biological (e.g.an infection) or psychological (e.g., a
stressful family situation).
 Stressful life events may be associated with exacerbation
of schizophrenic symptoms and increased rates of relapse.

4. Social factors
 Studies shown that schizophrenia is more prevent in areas of
high social mobility and disorganization, especially members
among very low social classes.
 (Black, & Andresen, 2003). Explanations for this occurrence
include the conditions associated with living in poverty, such
as congested housing accommodations, inadequate nutrition,
absence of prenatal care, few resources for dealing with
stressful situations, and feelings of hopelessness for changing
one’s lifestyle of poverty.

4. Social factors
 An alternative view is that of the downward drift
hypothesis. This hypothesis relates the
schizophrenic’s move into, or failure to move out
of, the low socioeconomic group to the tendency
for social isolation and the segregation of self from
others—characteristics of the schizophrenia

COURSE OF ILLNESS
 Course of schizophrenia:
 continuous without temporary improvement
 episodic with progressive or stable deficit
 episodic with complete or incomplete remission
 Typical stages of schizophrenia:
 prodromal phase
 active phase
 residual phase

Phase I: The Prodromal Phase.
Characteristics of this phase include
 social withdrawal; impairment in role functioning; behavior that is
peculiar or eccentric;
 neglect of personal hygiene and grooming;
 blunted or inappropriate affect; disturbances in communication;
 bizarre ideas;
 un usual perceptual experiences;
 and lack of initiative, interests, or energy.
 The length of this phase is highly variable, and may
 last for many years before deteriorating to the schizophrenic state.

Phase II: active phase
In this phase characterized by , psychotic symptoms are prominent.
Following are the DSM-IV-TR (APA, 2000) diagnostic criteria for
schizophrenia:
 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):
 Delusions
 Hallucinations
 Disorganized speech (e.g., frequent derailment or
incoherence)
 Grossly disorganized or catatonic behavior
 Negative symptoms (i.e., affective flattening, alogia,or avolition

 Social/Occupational Dysfunction: For a significant
 portion of the time since the onset of the
 disturbance, one or more major areas of functioning—
 such as work, interpersonal relationships, 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).

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.
Phase III: Residual Phase
 Schizophrenia is characterized by periods of remission and exacerbation.
 A residual phase usually follows an active phase of the illness. Symptoms
during the residual phase are similar to those of the prodromal phase, with flat
affect and impairment in role functioning being prominent.
 Residual impairment often increases between episodes of active psychosis.

PROGNOSIS
 A return to full premorbid functioning is not common (
APA, 2000). However, several factors have been associated
with a more positive prognosis.
 These include good premorbid adjustment, later age at
onset, female gender, abrupt onset of symptoms precipitated
by a stressful event (as opposed to gradual insidious onset
of symptoms),
 associated mood disturbance,
 brief duration of active-phase symptoms, good interepisode
functioning,
 minimal residual symptoms,
 absence of structural brain abnormalities,
 normal neurological functioning,
 a family history of mood disorder, and
 No family history of schizophrenia .

CLINICAL PICTURE
 Diagnostic manuals:
 lCD-10 („International Classification of Disease“, WHO)
 DSM-IV („Diagnostic and Statistical Manual“, APA)
 Clinical picture of schizophrenia is according to lCD-10, defined
from the point of view of the presence and expression of primary
and/or secondary symptoms (at present covered by the terms
negative and positive symptoms):
 the negative symptoms are represented by cognitive disorders, having its
origin probably in the disorders of associations of thoughts, combined with
emotional blunting and small or missing production of hallucinations and
delusions
 the positive symptom are characterized by the presence of hallucinations
and delusions
 the division is not quite strict and lesser or greater mixture of symptoms
from these two groups are possible

Positive and Negative Symptoms
Negative Positive
Alogia( lack of speech out put) Hallucinations
Affective flattening Delusions ( persecution,
grandeur,refference,control,somatic)
Avolition-apathy Bizarre behavior
Anhedonia-asociality Positive formal thought disorder:-
Incoherence ,neologism, thought
blocking, thought insertion .
Attention impairment Suicidal tendency

CLINICAL PICTURE
 Thought and speech disorder:-
 Autistic thinking (removing away from reality)
 Loosening of association
 Thought blocking
 Neologism
 Poverty of speech
 Poverty of idea
 Echolalia
 Perseveration
 Verbigeration
 Delusion disorder( persecution, grandeur,refference,control,somatic)
 Others thought disorder ( irrivalent in speech, impaired abstraction,
concreteness, & ambivalence)

CLINICAL PICTURE
 Disorder of affect :-
 Apathy
 Emotional blunting
 Emotional shallowness
 Anhedonia
 Inappropriate emotional response

CLINICAL PICTURE
 Disorder of motor Behavior :-
 Increased or decreased in psychomotor activity
 Mannerism
 Grimacing
 Stereotypes
 Decreased self care
 Poor grooming
 Other features :-
 Decreased social relationship
 Loss of ego boundaries
 Loss of insight
 Poor of judgment
 Suicide due to depression, command hallucination.

F20.0 Paranoid Schizophrenia
 The word paranoid means “delusional” .Paranoid schizophrenia is
present at most common from of schizophrenia.
 Paranoid schizophrenia is characterized mainly by
 Delusions of persecution,
 Feelings of passive or active control,
 Feelings of intrusion,
 And often by megalomaniac tendencies also.
 The delusions are not usually systemized too much, without tight
logical connections and are often combined with hallucinations of
different senses, mostly with hearing voices.
 Disturbances of affect, volition and speech, and catatonic
symptoms, are either absent or relatively inconspicuous.

F20.1 Hebephrenic
Schizophrenia
 Denoted also as disorganized schizophrenia
 Hebephrenic schizophrenia is characterized by disorganized
thinking with blunted and inappropriate emotions. It begins mostly
in adolescent age, the behavior is often bizarre.
 There could appear mannerisms, grimacing, inappropriate laugh and
joking, pseudo philosophical brooding and sudden impulsive
reactions without external stimulation. There is a tendency to social
isolation.
 Usually the prognosis is poor because of the rapid development of
"negative" symptoms, particularly flattening of affect and loss of
volition.
 Hebephrenic should normally be diagnosed only in adolescents or
young adults.

F20.2 Catatonic Schizophrenia
 Catatonic schizophrenia is characterized mainly by motoric activity,
which might be strongly increased (hyperkinesias) or decreased
(stupor), or automatic obedience and negativism.
 We recognize two forms:
 productive form — which shows catatonic excitement, extreme
and often aggressive activity. Treatment by neuroleptics or by
electroconvulsive therapy.

 stupors form — characterized by general inhibition of patient’s behavior
or at least by retardation and slowness, followed often by mutism,
negativism, flexibilities cerea or by stupor. The consciousness is not
absent.
 Catatonic stupor is characterized by
 Extreme psychomotor retardation. ,Rigidity
 The individual exhibits a pronounced decrease in spontaneous movements and
activity.
 Posturing ( inappropriate or bizarre posture )

 Mutism (i.e., absence of speech) is common
 Echolalia & echopraxia
 Ambitendency & automatic obidence
 And negativism (i.e., an apparently motiveless resistance to all
instructions or attempts to be moved)

F20.3 Undifferentiated
Schizophrenia
 This subgroup represents also the former diagnosis of atypical
schizophrenia.
 Psychotic conditions meeting the general diagnostic criteria
for schizophrenia but not conforming to any of the subtypes in
F20.0-F20.2, or exhibiting the features of more than one of
them without a clear predominance of a particular set of
diagnostic characteristics.

F20.3 Undifferentiated
Schizophrenia
 The behavior is clearly psychotic; that is, there is
evidence of
 Delusions
 hallucinations,
 incoherence,
 and bizarre behavior.
 However, the symptoms cannot be easily classified
into any of the previously listed diagnostic
categories.

F20.4 Post schizophrenic
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.

F20.5 Residual Schizophrenia
 A chronic stage in the development of schizophrenia with
clear succession from the initial stage with one or more
episodes characterized by general criteria of schizophrenia to
the late stage with long-lasting negative symptoms and
deterioration (not necessarily irreversible).
 Residual schizophrenia occurs in an individual who has a
chronic form of the disease and is the stage that follows an
acute episode (prominent delusions, hallucinations,
incoherence, bizarre behavior, and violence)

F20.5 Residual Schizophrenia
 Residual symptoms may include social isolation,
eccentric behavior, impairment in personal hygiene
and grooming, blunted or inappropriate affect,
poverty of or overly elaborate speech, illogical
thinking, or apathy.

F20.6 Simple Schizophrenia
 Simple schizophrenia is characterized by early and slowly
developing initial stage with growing social isolation,
withdrawal, small activity, passivity, avolition and dependence
on the others.
 The patients are indifferent, without any initiative and
volition. There is not expressed the presence of hallucinations
and delusions.

F21 Schizotypal disorder
 According to lCD-10 this disorder is characterized by
eccentric behavior and by deviations of thinking and
affectivity, which are similar to that occurring in
schizophrenia, but without psychotic features and expressed
symptoms of schizophrenia of any type.

F22 Persistent Delusional
Disorders
 Includes a variety of disorders in which long-standing
delusions constitute the only, or the most conspicuous, clinical
characteristic and which cannot be classified as organic,
schizophrenic or affective.
 Their origin is probably heterogeneous, but it seems, that there
is some relation to schizophrenia

F22.0 Delusional Disorder
 A disorder characterized by the development of one delusion
or of the group of similar related delusions, which are
persisting unusually long, very often for the whole life.
 Other psychopathological symptoms — hallucinations,
intrusion of thoughts etc. are not present and are excluding
this diagnosis.
 It begins usually in the middle age.
 Grandiose Type:- Individuals with grandiose delusions have
irrational ideas regarding their own worth, talent, knowledge,
or power.

 Jealous Type:- The content of a jealous delusion centers on
the idea that the person’s sexual partner is unfaithful. The idea
is irrational and without cause, but the deluded individual
searches for evidence to justify the belief.
 Persecutory Type:- In persecutory delusions, which are the
most common type, individuals believe they are being
malevolently treated; that include being conspired against,
cheated, spied on, followed, poisoned or drugged, maliciously
maligned, harassed, or obstructed in the pursuit of long-term
goals .

 Somatic Type:- Individuals with somatic delusions believe
they have some physical defect, disorder, or disease. In which
the individual believes that he or she:
 Emits a foul odor from the skin, mouth, rectum, or vagina.
 Has an infestation of insects in or on the skin.
 Has an internal parasite.
 Has misshapen and ugly body parts.
 Has dysfunctional body parts.

F23 Acute and Transient Psychotic
Disorders
 The criteria should be the following features:
 acute beginning (to two weeks)
 presence of typical symptoms (quickly changing
“polymorphic symptoms”)
 presence of typical schizophrenic symptoms.
 Complete recovery usually occurs within a few
months, often within a few weeks or even days.
 The disorder may or may not be associated with
acute stress, defined as usually stressful events
preceding the onset by one to two weeks.

F24 Induced Delusional
Disorder
 A delusional disorder shared by two or more people with close
emotional links. Only one of the people suffers from a genuine
psychotic disorder; the delusions are induced in the other(s)
and usually disappear when the people are separated.
 The psychotic disorder of the dominant member of this dyad
is mainly, but not necessarily, of schizophrenic type. The
original delusions of dominant member and his partner are
usually chronic, either persecutory or megalomanic.

F25 Schizoaffective Disorders
 Episodic disorders in which both affective and schizophrenic
symptoms are prominent (during the same episode of the
illness or at least during few days) but which do not justify a
diagnosis of either schizophrenia or depressive or manic
episodes.
 Patients suffering from periodic schizoaffective disorders,
especially with manic symptoms, have usually good prognosis
with full remissions without any remaining defects.

F25 Schizoaffective Disorders
 They are divided in different subgroups:
 F25.0 Schizoaffective disorder, manic type
 F25.1 Schizoaffective disorder, depressive type
 F25.2 Schizoaffective disorder, mixed type
 F25.8 Other schizoaffective disorders
 F25.9 Schizoaffective disorder, unspecified

CRITERIA OF DIAGNOSIS
 No laboratory test available
 No disease-specific biomarkers (genetic, imaging,
neurophysiology)
 Based on psychiatric history and mental state
evaluation
 Positive diagnosis requires:
 clear evidence of psychosis in mental state
examination
 absence of prominent affective symptoms
 minimum duration of illness
 exclusion of other disorders that may mimic
schizophrenia
 medical & neurological diseases
 other psychiatric disorders

DSM-5 Diagnostic Criteria for
Schizophrenia
 Criteria are the followings:-
(A)2 (or more) of the following, each present for a significant portion of time
during a 1-month period (or less if successfully treated).
At least one of these must be 1-3
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or
avolition)

Schizophrenia
(b)For a significant portion of time since the onset of the disturbance,
level of functioning in 1 or more major areas, such as work,
interpersonal relations, or self-care, is markedly below level
achieved prior to the onset .
 or when the onset is in childhood or adolescence, there is failure to
achieve expected level of interpersonal, academic, or occupational
functioning.

Schizophrenia
C): 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 A (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 by 2 or more symptoms
listed in Criterion A present in attenuated form (e.g. odd beliefs, unusual
perceptual experiences).

Schizophrenia
 (d) Schizoaffective and depressive or bipolar disorder with psychotic
features have been ruled out because either:
1.No major depressive or manic episodes have occurred concurrently
with the active-phase symptoms
2.If mood episodes have occurred during active-phase symptoms, they
have been present for a minority of the total duration of the active
and residual periods of the illness

Schizophrenia
 (E) The disturbance is not attributable to the physiological effects of a substance
(eg, a drug of abuse, a medication) or another medical condition.
 (F) If there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations, in addition to the other required
symptoms of schizophrenia, are also present for at least 1 month
(or less if successfully treated)
 Specifies
 Course- to be used after 1 year duration of the disorder
 First episode, currently in acute episode/partial remission/full remission
 Multiple episodes, currently in acute episode/partial remission/full remission
 Continuous
 Unspecific

Treatment of Schizophrenia
PHARAMACO THERAPY:-
 The acute psychotic schizophrenic patients will respond
usually to antipsychotic medication.
 According to current consensus we use in the first line
therapy the newer atypical antipsychotics, because their use
is not complicated by appearance of extra pyramidal side-
effects, or these are much lower than with classical
antipsychotics.

Treatment of Schizophrenia
CONVENTIONAL
ANTIPSYCHOTICS
(CLASSICAL NEUROLEPTICS)
chlorpromazine, chlorprotixene,
clopenthixole, levopromazine,
periciazine, thioridazine
Haloperidol, flupentixol,
fluphenazine, fluspirilene,
haloperidol, melperone,
oxyprothepine, penfluridol,
perphenazine, pimozide,
prochlorperazine, trifluoperazine
ATYPATYPICAL
ANTIPSYCHOTICS
amisulpiride, clozapine, olanzapine,
quetiapine, risperidone, sertindole,
sulpiride

TREATMENT OF SCHIZOPHRENIA
ELECTROCONVULSIVE THERAPY :-
Indication for ECT in schizophrenia include:-
 Catatonic stupor
 Uncontrolled catatonic excitement.
 Usually 8-12 ECT are needed.

PSYCHOLOGICAL TREATMENTS
1.Individual Psychotherapy:-
 Ho, Black, and Andresen (2003) state: Although
intensive psychodynamic- and insight-oriented
psychotherapy is generally not recommended, the
form of individual psychotherapy that psychiatrists
employ when providing pharmacological treatment
typically involves a synthesis of various
psychotherapeutic strategies and interventions.

 These include problem solving, reality testing,
psycho education, and supportive and cognitive-
behavioral techniques anchored on an empathetic
therapeutic alliance with the patient.
 The goals of such individual psychotherapy are to
improve medication compliance, enhance social
and occupational functioning, and prevent relapse.

 The primary focus in all cases must reflect efforts to
decrease anxiety and increase trust.
 Establishing a relationship is often particularly difficult
because the individual with schizophrenia is desperately
lonely yet defends against closeness and trust.
 Individual psychotherapy for clients with schizophrenia is
seen as a long-term endeavor that requires patience on the
part of the therapist and the ability to accept that a great
deal of change may not occur

2. Group Therapy:-
 Group therapy with individuals with schizophrenia has
been shown to be effective, particularly with outpatients
and when combined with drug treatment.
 Group therapy for schizophrenia has been most useful
over the long-term course of the illness. The social
interaction, sense of cohesiveness, identification, and
reality testing achieved within the group setting have
proven to be highly therapeutic processes for these client.

3. Behavior Therapy:-
 Behavior modification has a history of qualified success in
reducing the frequency of bizarre, disturbing, and deviant
behaviors and increasing appropriate behaviors.
 Behavior therapy can be a powerful treatment tool for helping
clients change undesirable behaviors.

3. Behavior Therapy:-
 Features that have led to the most positive results
include:
● Clearly defining goals and how they will be
measured.
● Attaching positive, negative, and aversive
reinforcements to adaptive and maladaptive
behavior.
● Using simple, concrete instructions and prompts
toelicit the desired behavior.

4. Social Skills Training:-
 social skills training has become one of the most widely used
in psychosocial.
 Mueser, Bond, and Drake (2001) state: The basic premise of
social skills training is that complex interpersonal skills
involve the smooth integration of a combination of simpler
behaviors, including nonverbal behaviors (e.g., facial
expression, eye contact); paralinguistic features (e.g., voice
loudness and affect); verbal content (i.e., the appropriateness
of what is said); and interactive balance (e.g., response
latency, amount of time talking). terventions in the treatment
of schizophrenia.

5.Milieu Therapy:-
 Research suggests that psychotropic medication is
more effective at all levels of care when used along
with milieu therapy and that milieu therapy is more
successful, if used in conjunction with these
medication.

5.Milieu Therapy:-
 Individuals with schizophrenia who are treated with
milieu therapy alone require longer hospital stays
than do those treated with drugs and psychosocial
therapy.
 Milieu therapy stresses a patient’s rights to goals
and to have freedom of movement and informal
relationship with staff; it also emphasizes
interdisciplinary participation and goal-oriented,
clear communication.

6. Family Therapy:-
 Safire (1997) states: When a family member has a serious
mental illness, the family must deal with a major upheaval
in their lives, a terrible event that causes great pain and
grief for the loss of a once-promising child or relationship.
 Asen (2002) suggests the following interventions with
families of individuals with schizophrenia:
● Forming a close alliance with the caregivers
● Lowering the emotional intra-family climate by reducing
stress and burden on relatives

6. Family Therapy:-
• Increasing the capacity of relatives to anticipate and
solve problems
● Reducing the expressions of anger and guilt by family
members
● Maintaining reasonable expectations for how the family
member with the illness should perform
● Encouraging relatives to set appropriate limits while
maintaining some degree of separateness.
● Promoting desirable changes in the relatives’ behaviors
and belief systems.

7. Assertive Community Treatment (ACT):-
 Assertive Community Treatment (ACT) is a program
of case management that takes a team approach in
providing comprehensive, community-based
psychiatric treatment, rehabilitation, and support to
persons with serious and persistent mental illness
such as schizophrenia.

7. Assertive Community Treatment
(ACT):-
 The National Alliance for the Mentally ill(NAMI) (2003)
lists the primary goals of ACT as follows:
● To meet basic needs and enhance quality of life
● To improve functioning in adult social and employment
roles
● To enhance an individual’s ability to live independently in
his or her own community
● To lessen the family’s burden of providing care
● To lessen or eliminate the debilitating symptoms of mental
illness
● To minimize or prevent recurrent acute episodes of the
illness.

NURSING DIAGNOSIS
1. 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,
disorientation.
2. Disturbed thought processes related to inability to trust, panic anxiety, possible
hereditary or biochemical.
3. Social isolation related to inability to trust, panic anxiety, weak ego development,
delusional thinking, regression, evidenced by withdrawal, sad and 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 related to extreme
suspiciousness, panic anxiety, catatonic excitement, rage reactions, command
hallucinations, evidenced by overt and aggressive acts, goal-directed destruction
of objects in the environment, self-destructive behavior, or active aggressive

NURSING DIAGNOSIS
5. Impaired verbal communication related to panic anxiety, regression,
withdrawal, and disordered, unrealistic thinking evidenced by loose
association of ideas, neologisms, word salad, clang associations,
echolalia, verbalizations that reflect concrete thinking, and poor eye
contact.
6. Self-care deficit related to withdrawal, regression, panic anxiety,
perceptual or cognitive impairment, inability to trust, evidenced by
difficulty carrying out tasks associated with hygiene, dressing,
grooming, eating, and toileting.
7. Disabled family coping: Related to 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

NURSING DIAGNOSIS
8.Ineffective health maintenance related to disordered thinking or delusions,
evidenced by reported or observed inability to take responsibility for
meeting basic health practices in any or all functional pattern areas.
9. Impaired home-maintenance management related to regression, withdrawal,
lack of knowledge or resources, or impaired physical or cognitive
functioning evidenced by unsafe, unclean, disorderly home environment

Schizophrenia

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