NURSING MANAGEMENT OF

PATIENT WITH SCHIZOPHRENIA,

AND OTHER PSYCHOTIC
DISORDERS
SONALI GUPTA
AGENDA
 Introduction
 Definition
 Etiology
 Clinical Features
 Clinical Types
 Treatment Modalities
INTRODUCTION
• The word ‘Schizophrenia’ was coined by the Swiss
psychiatrist Eugen Bleuler in 1908. It is derived from the
Greek words skhizo (split) and phren (mind).

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

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SCHIZOPHRENIA CLASSIFICATION

ICD-11 CLASSIFICATION
Schizophrenia or other primary psychotic disorders include the
following:
6A20: Schizophrenia

6A21: Schizoaffective disorder

6A22: Schizotypal disorder

6A23: Acute and transient psychotic disorder

6A24: Delusional disorder

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SCHIZOAFFECTIVE DISORDERS
ACUTE AND TRANSIENT PSYCHOTIC DISORDER
• In this disorder the patient has
• It is characterized by acute onset of
schizophrenia symptoms (e.g., delusions,
psychotic symptoms (maximal severity
hallucinations, disorganization in the form within 2 weeks) and may include delusions,
of thought, experiences of influence, hallucinations disorganization of thought
passivity and control) and mood disorder processes confusion, and disturbances of
symptoms (manic, mixed, or moderate or affect and mood. Catatonia-like psychomotor
severe depressive episode) within the disturbances may be present.
same episode of illness, either
simultaneously or within a few days of • Symptoms typically change rapidly, both in
nature and intensify from day to day, or
each other.
even within a single day The duration of the
• The symptoms are not a manifest of episode does not exceed 3 months, and
most commonly lasts from a few days to 1
medical conditions or due to the effects month.
of substance or medications.
• The symptoms are no a manifest of medical
condition or due to the effects of substance
or medications.

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DELUSIONAL DISORDER

• It is characterized by delusions in various forms (persecutory, somatic,

grandiose for at least 3 months or longer, showing remarkable stability within
individuals Absence of clear and persistent hallucinations jealous, erotomania,
etc.) typically persisting severely disorganized thinking, experiences of
influence, passivity or control or negative symptoms characteristic of
schizophrenia related to the delusional system, affect are observed.

• Apart from behavior direct speech and behavior are typically unaffected The
symptoms are not a manifest of medical condition or due to the effects of
substance or medications.

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ETIOLOGY
 BIOLOGICAL THEORIES Biologic explanations include biochemical,
neurostructural, genetic, perinatal risk factors and other theories

 BIOCHEMICAL THEORIES

• Dopamine hypotheses: This theory suggests that an excess of dopamine-

dependent neuronal activity in the brain may cause schizophrenia.

• Other biochemical hypotheses: These include abnormalities in the

neurotransmitters norepinephrine, serotonin, acetylcholine and gamma-
aminobutyric acid (GABA), and neuro regulators, such as prostaglandins and
endorphins.

 NEUROSTRUCTURAL THEORIES Research suggests that the prefrontal cortex

and limbic cortex may never fully develop in the brains of persons with
schizophrenia.

 GENETIC THEORIES The disease is more common among people born of

consanguineous marriages.
PERINATAL RISK FACTOR Identical twin affected—50% » Fraternal twin
affected—15% » Brother or sister affected—10% » One parent affected—
15% » Both parents affected—35% » Second degree relative affective—
2–3% » General population—1%

 PSYCHODYNAMIC THEORIES These theories focus on individual's responses to life

events
 DEVELOPMENTAL THEORIES According to Freud, there is regression to the oral
stage of psychosexual development, with the use of defense mechanisms of
denial, projection and reaction formation.
 FAMILY THEORIES
• Mother-child relationship: Early theorists characterized the mothers of
schizophrenics as cold, over-protective, and domineering, thus retarding the ego
development of the child.
• Dysfunctional family system: Hostility between parents can lead to a
schizophrenic daughter (marital skew and schism).
• Double-blind communication (Bateson et al, 1956): Parents convey two or more
conflicting and incompatible messages at the same time

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VULNERABILITY-STRESS MODEL

 According to this model, people with a predisposition to schizophrenia may avoid serious
mental disorders if they are protected from the stresses of life. Individual with a similar
vulnerability may succumb to schizophrenia if exposed to stressors

 SOCIAL FACTORS Studies have shown that schizophrenia is more prevalent in areas of
high social mobility and disorganization, especially among members of very low social
classes

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CLINICAL FEATURE
• THOUGHT AND SPEECH DISORDERS • Poverty of speech (decreased speech production).

• Poverty of ideation (speech amount is adequate but

• Autistic thinking (preoccupations totally
content conveys little information).
removing a person from reality).
• Echolalia (repetition or echo by patient of the words or
• Loosening of associations (a pattern of phrases of examiner).
spontaneous speech in which the things said
in juxtaposition lack a meaningful • Perseveration (persistent repetition of words or
relationship with each other). themes beyond the point of relevance).

• Verbigeration (senseless repetition of some words or

• 3Thought blocking (a sudden interruption in
phrases over and over again).
the thought process).
• Delusions of various kinds, i.e. delusions of
• Neologism (a word newly coined, or an persecution (being persecuted against); delusions of
everyday word used in a special way, not grandeur (belief that one is especially very powerful,
readily understood by others rich, born with a special mission in life); delusions of
reference (being referred to by others); delusions of
control (being controlled by an external force); somatic
delusions.

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• DISORDERS OF PERCEPTION Auditory hallucinations (described under SFRS).

• Visual hallucinations may sometimes occur along with auditory hallucinations;

tactile, gustatory and olfactory types are far less common

• DISORDERS OF AFFECT These include apathy, emotional blunting (flattening of

emotions), emotional shallowness, anhedonia and inappropriate emotional
response. The incapacity of the patient to establish emotional contact leads to
lack of rapport with the examiner.

• DISORDERS OF MOTOR BEHAVIOR There can be either an increase or decrease in

psychomotor activity. Mannerisms, grimacing, stereotypes, decreased self-care
and poor grooming are common features.

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CLINICAL TYPE

Schizophrenia
can be 5. 7. Post-
2. Hebephrenic
classified into 1. Paranoid 3. Catatonic 4. Residual Undifferentiate 6. Simple schizophrenic
(disorganized)
the following d dépression
subtypes:

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PA R A N O I D S C H I Z O P H R E N I A

D E LU S I O N S O F P E R S E C U T I O N : I N P E R S E C U T O RY D E LU S I O N S , I N D I V I D UA L S B E L I E V E T H AT
T H E Y A R E B E I N G M A L E VO L E N T LY T R E AT E D I N S O M E WAY. F R E Q U E N T T H E M E S I N C LU D E B E I N G
C O N S P I R E D A G A I N S T, C H E AT E D , S P I E D U P O N , F O L LO W E D , P O I S O N E D O R D R U G G E D ,
M A L I C I O U S LY M A L I G N E D , H A R A SS E D O R O B S T R U C T E D I N T H E P U R S U I T O F LO N G -T E R M G OA L S .

D E LU S I O N S O F R E F E R E N C E : I N T H I S D E LU S I O N , T H E I N D I V I D UA L B E L I E V E S T H AT E V E N T S ,
O B J E C T S , B E H AV I O R O F O T H E R S H AV E G O T A N U N U S UA L S I G N I F I C A N C E F O R O N E S E L F. T H E
I N D I V I D UA L M AY FA L S E LY B E L I E V E T H AT O T H E R S A R E TA L K I N G A B O U T H I M .

D E LU S I O N S O F J E A LO U S Y: T H E C O N T E N T O F J E A LO U S D E LU S I O N S C E N T E R S A R O U N D T H E
T H E M E T H AT T H E P E R S O N ' S S E X UA L PA RT N E R I S U N FA I T H F U L . T H E I D E A I S H E L D O N
I N A D E Q UAT E G R O U N D S A N D I S U N A F F E C T E D BY R AT I O N A L J U D G M E N T.

D E LU S I O N S O F G R A N D I O S I T Y: I N D I V I D UA L S W I T H G R A N D I O S E D E LU S I O N S H AV E I R R AT I O N A L
I D E A S R E G A R D I N G T H E I R O W N W O RT H , TA L E N T, K N O W L E D G E O R P O W E R . T H E Y M AY B E L I E V E
T H AT T H E Y H AV E A S P E C I A L R E L AT I O N S H I P W I T H FA M O U S P E R S O N S , O R G R A N D I O S E
D E LU S I O N S O F A R E L I G I O U S N AT U R E M AY L E A D T O A SS U M P T I O N O F T H E I D E N T I T Y O F A
G R E AT R E L I G I O U S L E A D E R .

H A L LU C I N AT O RY VO I C E S T H AT T H R E AT E N O R C O M M A N D T H E PAT I E N T, O R AU D I T O RY
H A L LU C I N AT I O N S W I T H O U T V E R B A L F O R M , S U C H A S W H I S T L I N G , H U M M I N G A N D L AU G H I N G .

O T H E R F E AT U R E S I N C LU D E D I S T U R B A N C E O F A F F E C T ( T H O U G H A F F E C T I V E B LU N T I N G I S L E SS
T H A N I N O T H E R F O R M S O F S C H I Z O P H R E N I A ) , VO L I T I O N , S P E E C H A N D M O T O R B E H AV I O R .

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HEBEPHRENIC (DISORGANIZED) CATATONIC SCHIZOPHRENIA
SCHIZOPHRENIA
Catatonic (Cata-disturbed) schizophrenia
It has an early and insidious onset and is is characterized by marked disturbance
often associated with poor premorbid of motor behaviour. This may take the
personality. The essential features include form of catatonic stupor, catatonic
marked thought disorder, incoherence, excitement and catatonia alternating
between excitement and stupor.
severe loosening of associations and
extreme social impairment. Delusions and CLINICAL FEATURES OF EXCITED
hallucinations are fragmentary and CATATONIA
changeable. Other oddities of behavior
include senseless giggling, mirror gazing, Increase in psychomotor activity
grimacing, mannerisms and so on. (ranging from restlessness, agitation,
excitement, aggressiveness to at times
violent behavior) Increase in speech
production Loosening of associations and
frank incoherence

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CLINICAL FEATURES OF RETARDED
CATATONIA (CATATONIC STUPOR)
 Mutism: Absence of speech.  Echopraxia: Repetition or mimicking of
actions observed.
 Rigidity: Maintenance of rigid posture against
efforts to be moved.  Waxy flexibility: Parts of body can be
placed in positions that will be maintained
 Negativism: A motiveless resistance to all
for long periods of time, even if very
commands and attempts to be moved, or uncomfortable (flexible like wax).
doing just the opposite.
 Ambitendency: A conflict to do or not to
 Posturing: Voluntary assumption of an
do, for example, on asking to put out
inappropriate and often bizarre posture for
tongue, it is slightly protruded but taken
long periods of time.
back again.
 Stupor: Does not react to his surroundings
 Automatic obedience: Obeys every
and appears to be unaware of them.
command irrespective of their nature.
 Echolalia: Repetition or mimicking of phrases
or words heard.
RESIDUAL SCHIZOPHRENIA SIMPLE SCHIZOPHRENIA
Symptoms of residual schizophrenia include It is characterized by an early and
emotional blunting, eccentric behavior, insidious onset, progressive course, and
illogical thinking, social withdrawal and presence of characteristic negative
loosening of associations. This category symptoms, vague hypochondriacal
should be used when there has been at least features, wandering tendency, self-
one episode of schizophrenia in the past but absorbed idleness and aimless activity.
without prominent psychotic symptoms at It differs from residual schizophrenia in
present. that there never has been an episode
with all the typical psychotic symptoms.
UNDIFFERENTIATED SCHIZOPHRENIA This
The prognosis is very poor.
category is diagnosed either when features
of no subtype are fully present or features of POST-SCHIZOPHRENIC DEPRESSION
more than one subtype are exhibited. Depressive features develop in the
presence of residual or active features
of schizophrenia and are associated with
an increased risk of suicide.
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INVESTIGATIONS

 No diagnostic test definitively confirms schizophrenia, tests may be ordered to

rule out disorders that cause psychosis, including vitamin deficiencies, uraemia,
thyrotoxicosis and electrolyte imbalances.

 CT scan and MRI show enlarged ventricles, enlargement of the sulci on the
cerebral surface and atrophy of the cerebellum.

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TREATMENT MODALITIES
Commonly Used Atypical Antipsychotics
Conventional Antipsychotics
• Clozapine: 25–450 mg/day PO
• Chlorpromazine: 300–1500 mg/day
PO; 50–100 mg/day IM • Risperidone: 2–10 mg/day PO

• Fluphenazine decanoate: 25–50 mg • Olanzapine: 10–20 mg/day PO

IM every 1–3 weeks
• Quetiapine: 150–750 mg/day PO
• Haloperidol: 5–100 mg/day PO; 5–20
• Ziprasidone: 20–80 mg/day PO
mg/day IM
• Aripiprazole: 10–15 mg/day PO
• Trifluoperazine: 15–60 mg/day PO;
1–5 mg/day IM • Paliperidone: 1.5–12 mg/day PO

• Amisulpride: 400–800 mg/day P

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ELECTROCONVULSIVE THERAPY (ECT)  Social skills training: Social skills
 Indications for ECT in schizophrenia training addresses behaviors such as
include: poor eye contact, odd facial expressions
and lack of spontaneity in social
 Catatonic stupor Uncontrolled catatonic situations through the use of
excitement Severe side-effects with drugs videotapes, role playing and homework
Schizophrenia refractory to all other forms assignments.
of treatment Usually 8-12 ECTs are needed
 Cognitive therapy: Used to improve
PSYCHOLOGICAL THERAPIES cognitive distortions like reducing
distractibility and correcting judgment.
 Group therapy: The social interaction,
sense of cohesiveness, identification, and  Family therapy: Family therapy typically
reality testing achieved within the group consists of a brief program of family
setting have proven to be highly education about schizophrenia. It has
therapeutic for these individuals. been found that relapse rates of
schizophrenia are higher in families with
 Behavior therapy: Behavior therapy is
high expressed emotions (EE), where
useful in reducing the frequency of bizarre,
significant others make critical
disturbing and deviant behavior, and
comments, express hostility or show
increasing appropriate behaviors.
emotional over-involvement.
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• NURSING DIAGNOSIS I Disturbed thought
process, related to inability to trust, panic
PSYCHOSOCIAL REHABILITATION
anxiety, possible hereditary or
• This includes activity therapy to develop biochemical factors evidenced by
delusional thinking, extreme
the work habit, training in a new vocation
suspiciousness of others
or retraining in a previous skill,
vocational guidance and independent job • NURSING DIAGNOSIS II Ineffective health
placement maintenance related to inability to trust,
extreme suspiciousness evidenced by
poor diet intake, inadequate food and fluid
intake, difficulty in falling asleep.

• NURSING DIAGNOSIS III Self-care deficit

related to withdrawal, regression, panic
anxiety, cognitive impairment, inability to
trust, evidenced by difficulty in carrying
out tasks associated with hygiene,
dressing, grooming, eating, sleeping and
toileting
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PATIENT AND FAMILY TEACHING

 Explain to the patient and family that schizophrenia is a chronic disorder with
symptoms that affect the person's thought processes, mood, emotions and
social functions throughout the person's lifetime.

 Teach the patient and family about the importance of medication compliance
and the therapeutic/non-therapeutic effects of antipsychotic medications.

 Instruct the patient and family to recognize impending symptom exacerbation

and to notify physician when the patient poses a threat or danger to self or
others and requires hospitalization.

 Teach the patient and family to identify psychosocial or family stressors that
may exacerbate symptoms of the disorder and methods to prevent them.

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REHABILITATIVE SERVICES FOR
SCHIZOPHRENIA PATIENTS ARE
 Social skills training

 Vocational rehabilitation

 Half-way homes

 Long-term homes

 Day hospitals, etc

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