✔

SCHIZOPHRENIA
decreased cortical blood flow, especially in the pre-frontal
cortex
❖ Was coined by Eugen Bleuler – a Swiss psychiatrist
✔ decreased metabolic activity in certain areas.
❖ It came from the Greek word meaning split personality-
✔ cerebral atrophy
which means that there is a disconnection or splitting of the
psychic functions. ● Excessive production of dopamine in some areas of the
❖ It encompasses a group of psychotic reactions that affect brain.
multiple areas of the individual’s functioning, including ● Other neurotransmitters like serotonin, nor epinephrine,
thinking and communicating, perceiving and interpreting glutamate and GABA play an important role in the
reality, feeling and demonstrating emotion, and behaving in development of schizophrenia
socially acceptable manner. 4. Psychosocial and environmental factors
❖ It is characterized by withdrawal from reality, illogical ● Developmental theorists proposed that the lack of warm,
patterns of thinking, delusions, and hallucinations, and nurturing attention in the earliest life contributes to the lack
accompanied in varying degrees by other emotional, of self-identity, reality misinterpretation and relationship
behavioral, or intellectual disturbances. withdrawal.
❖ It is a severe mental disorder characterized by 5 “A’s” ● Families who have highly expressed emotions are
a. affect: a person’s mood, feeling tone or emotions emotionally over involved, hostile and critical
It is usually blunted, inappropriate, or flat
b. association: loose or distorted ● Consistent association with low-socio-economic
c. Autism: a thought process in which the person retreats
● Biologically vulnerable individuals who are always
from reality.
d. ambivalence: contradictory or opposing emotions, exposed to life’s stressors may produce symptoms of
attitudes, ideas and desires for the same person, thing or schizophrenia
situation
e. Auditory hallucination
❖ The nodal onset for men is between 18 to 25; for women, Signs and symptoms of schizophrenia
between 25 and mid-30’s 1. Positive symptoms: reflect the symptoms of overt
psychotic or distorted behavior
Causes of schizophrenia
● Excess or distortion of normal functions
1. Genetic predisposition
● One affected parent: 12% to 15% risk ● Bizarre or disorganized behavior

● Both parents affected: 35% to 39% ● Hallucinations

● Sibling affected: 8% to 10% ● Illusion

● Dizygotic twin affected: 15% at risk ● delusions

● Monozygotic twin: 50% risk ✔ delusions of reference: everything occurring in

environment has a direct significance to oneself
● Distant relative: 3% to 5%
✔ delusion of persecution: people or institutions are plotting
2. Neuro developmental abnormalities
against or attacking him
● Development of minor fetal malformation during early
✔ delusion of external control: one is controlled by others or
gestation
outside forces
● Factors that can affect neurodevelopment and that may
✔ somatic delusion: appearance or functioning of one’s
increase the risk of disease include;
body is altered. A person with this type of delusional disorder
✔ influenza infection (maternal) during 2nd trimester believes that he or she has a physical defect or medical
✔ trauma or injury at birth (hypoxia or oxygen deprivation) problem.
✔ nihilistic delusion: a belief that one is dead or the world is
✔ abuse or trauma during infancy or early childhood
ending
3. Brain structural abnormalities and chemical imbalances
✔ Erotomanic. Someone with this type of delusional
● Brain imaging techniques, MRI, positron emission
disorder believes that another person, often someone
tomography have shown abnormalities in the structure of the important or famous, is in love with him or her. The person
brain. might attempt to contact the object of the delusion, and
✔ enlarged ventricles stalking behavior is not uncommon.
✔ Grandiose. A person with this type of delusional disorder
has an over-inflated sense of worth, power, knowledge, or
identity. The person might believe he or she has a great talent
❖ Characterized by systematized delusions or auditory
or has made an important discovery.
hallucinations; maybe suspicious, argumentative, hostile and
✔ Persecutory. People with this type of delusional disorder aggressive
believe that they (or someone close to them) are being
❖ The individual’s behavior is less regressive and he is not
mistreated, or that someone is spying on them or planning to
harm them. It is not uncommon for people with this type of socially impaired
delusional disorder to make repeated complaints to legal ❖ prognosis is better than the other types
authorities. 2. Disorganized
● Excitement and agitation ❖ It involves disorganized speech and behaviors as well as
● Hostility or aggressive behavior flat or inappropriate affect.

● Suspiciousness ❖ The individual may have odd mannerisms, exhibit extreme

social withdrawal, neglect hygiene and appearance
● Pressured speech
❖ Onset usually occurs before age 25, and the course maybe
● Possible suicidal tendencies chronic
● Loose association ❖ The individual demonstrates regressive behavior, with
poor social interaction and poor reality contact
✔ neologism- creating new words
3. Catatonic
✔ word salad- words in a sentence that may seem ❖ Characterized by marked psychomotor disturbances,
connected but do not compose coherent thought which may involve immobility or excessive activity
✔ echolalia- senseless repetition of the words of another ❖ Catatonic stupor: may exhibit inactivity, negativism, and
person waxy flexibility
✔ echopraxia- senseless copying of another person’s ❖ Catatonic excitement: involves extreme agitation and may
behavior or action be accompanied by echolalia and echopraxia
✔ clang association- words that rhyme are put together for 4. Undifferentiated
their sound association, without coherent thought 5. Residual

✔ flight of ideas- continuous flow of verbalization in which ❖ There is a current absence of acute symptoms, but a
the person jumps from one topic to another history of past episodes but marked social isolation,
2. Negative symptoms: reflect a diminution or loss of normal withdrawal, and impaired role functioning maybe present
function Other psychotic disorders
1. Schizoaffective disorder- refers to behavior characteristic of
● Anergia- lack of energy schizophrenia in addition to those indicative of disorders of
mood such as depression or elation
● Anhedonia- lack of pleasure in activities and things that
2. Brief reactive psychosis or brief psychotic disorder- the
the individual would normally perceive as pleasurable or essential features include a sudden onset of psychotic
enjoyable symptoms in response to a severe psychosocial stressors.
● Emotional withdrawal ▪ The symptoms may last from few hours to one month
● Poor eye contact with a virtual return to the pre morbid level of functioning.
3. Schizophreniform disorder
● Blunted affect
▪ The essential features are identical to those of
● Ambivalence schizophrenia with the exception that the duration is less than
6 months but more than 4 weeks.
● Avolition- lack of motivation to persist a goal- oriented
activity ▪ Prognosis is good, with expected return to pre morbid
level of functioning
● Difficulty to abstract thinking
4. Delusional disorder
● Alogia- refers to decreased speech pattern or poverty of ▪ The client has one or more non bizarre delusions. That are
speech believable ideas.
● Dysfunctional relationship with others ▪ Psychosocial functioning is not markedly impaired and
behavior is not obviously odd or bizarre
5. shared psychotic disorder (folie a deux)
▪ A similar delusion is shared by two people
Types of Schizophrenia ▪ The person with this diagnosis develops this delusion in
1. Paranoid
the context of a close relationship with someone who has a
psychotic delusions.
Management of schizophrenia c. Rapid dissolving preparation of Olanzapine (Zyprexa) and
1. Brief hospitalization on a psychiatric unit to manage acute Risperidone (Risperdal) are available
symptoms and to provide safety, structured environment. Atypical antipsychotics
2. Various treatments include: Clozapine (Clozaril)
Olanzapine (Zyprexa)
▪ Administration of antipsychotic medications
Quetiapine (Seroquel)
▪ Milieu management Risperidone (Risperdal)
Ziprasidone (Geodon)
▪ Supportive therapy 3. Dopamine system stabilizer (DSS)
▪ Psycho education for the client and family ▪ Currently, only one drug is available in this class
(Aripiprazole- Abilify)
▪ Discharge planning to ensure continuity of care
Antipsychotics (neuroleptics or major tranquilizers ▪ DSS restores dopamine activity in the cortical levels of the
1. Typical antipsychotic agents brain and reduce dopamine in the limbic areas, thus
decreasing psychotic symptoms
▪ It blocks selected dopamine receptors in the striatal and
limbic areas in the brain, an action believed to reduce ▪ Common side effects: headache, vomiting, constipation,
psychotic symptoms. insomnia, light headedness, and akathisia
Managing common side effects on psychotropic drugs
▪ It also affect other receptors, including those for
Anticholinergic effects:
histamine, serotonin, nor epinephrine, and acetylcholine
▪ Dry mouth: suggest the use of sugarless gum or candy,
▪ The effect on these receptors accounts for the multiple
rinsing the mouth frequently with water.
side effects.
▪ Blurred vision: eye pain can indicate narrow angle
▪ Tolerance does not develop with these drugs
glaucoma
▪ It should be given 2 hours after eating and should not be ▪ Urinary retention
taken together with antacids of histamine 2 H2) blocking
agents (Cimetidine) ▪ Constipation
Cardiovascular effects
▪ Long acting preparations are available for haloperidol
(Haldol) and Fluphenazine (Prolixin); they are administered IM ▪ Postural hypotension- teach client to change position
via depot injection, and effects last 2 to 4 weeks slowly, especially from lying to standing position
Contraindications: ▪ Arrhythmias- teach the client to report sensations of
❑ Known allergic response to any antipsychotic racing pulse or heartbeat, feelings of lightheadedness and
dizziness
❑ CNS depression
Central nervous system
❑ Parkinson’s disease ▪ Headache
❑ Blood dyscrasias ▪ Drowsiness, fatigue, decrease mental alertness- drug
❑ Hepatic disease should be taken at bedtime if it is given once a day

❑ Acute narrow-angle glaucoma Gastrointestinal effects

❑ Benign prostatic hypertrophy ▪ Nausea, decrease appetite, diarrhea- should take the
Examples of typical antipsychotic drugs with full stomach
Fluphenazine (Prolixin) ▪ Weight gain, increased appetite- take enough calories to
Haloperidol (Haldol)
Perphenazine (Trilafon) maintain normal weight, exercise daily
Thiothixene ( Navane) Endocrine effects
Trifluoperazine (Stelazine) ▪ Amenorrhea
Chlorpromazine (Thorazine)
Thioridazine (Mellaril) ▪ Gynecomastia
2. Atypical Antipsychotic agents ▪ Sexual dysfunction: anorgasmia in women and erectile
▪ It blocks the dopamine receptors in the limbic system and dysfunction in men
affect serotonin receptors in the cortical brain areas Treating extra pyramidal effects of psychotropic drugs
1. Pseudo parkinsonism:
▪ They give more advantages than typical antipsychotics
a. it reduces positive symptoms as well as the negative ❖ Drooling of saliva
symptoms ❖ Motor retardation (akinesia)
b. It decreases EPS or no EPS may result because it does not
affect dopamine in the striatal areas ❖ Lack of facial responsiveness (mask-like facial expression)
❖ Shuffling gait ▪ Monitor complete blood count especially for decreasing
WBC
❖ Fine tremors (pill-rolling)
2. Seizures: tonic clonic seizure activity
Treatment:
▪ Reduce dose or stop drug
✔ Administer an antiparkinson (anticholinergic) drugs
Benztropine mesylate (Cogentin) ▪ Add an anticonvulsant agent to prevent further seizure
Biperiden hydrochloride (Akineton)
▪ Ensure the client’s safety during any seizure activity
Trihexyphenidyl hydrochloride (Artane
Nursing intervention: ▪ Notify the doctor
✔ Assess for this effect 3. Hepato toxicity: abnormal liver function series(elevated
enzymes), fever, nausea, jaundice and abdominal pain
✔ Elderly clients are more susceptible
▪ Stop drug
✔ Notify the doctor if this occurs
▪ Treat symptoms with bed rest, good nutrition, and
2. Acute dystonic reaction
adequate fluids
❖ Muscle spasm of the jaw, tongue, neck or eyes 4. Neuroleptic malignant syndrome:
❖ Laryngeal spasm may occur ❖ Altered consciousness

❖ Oculogyric crisis- backward rolling of the eyes in the ❖ Severe hyperthermia (38.9)
sockets
❖ Diaphoresis
Treatment
✔ Stop the drug and administer antidote (Cogentin or ❖ Tachycardia, and EPS resulting from massive dopamine
diphenhydramine (Benadryl) blockade in the brain and CNS
Treatment
✔ Treat as an emergency
✔ Stop drug
✔ Withhold any further dosage
✔ Check the vital signs
✔ Reassure the client
✔ Administer drug that stimulates dopamine receptors such
3. Akathisia
as Bromocriptine (Parlodel)
❖ Motor restlessness
✔ Administer IV, fluids, hypothermia measures
❖ Constant state of movement Nursing Interventions
1. For withdrawn and isolated client
❖ Difficulty of sitting still or there is a strong urge to move
about ❖ Establish a therapeutic relationship with client.
Treatment
❖ Initiate planned, short, frequent, and undemanding
✔ Administer an Antiparkinson drug interactions.
✔ May reduce antipsychotic dose if symptoms persist ❖ Plan simple one-on-one activity.
4. Tardive dyskinesia
❖ Maintain consistency and honesty in interactions
❖ Most frequent and serious side effect and this is
❖ Gradually encourage the client to interact with peers in
irreversible
non threatening situations
❖ Involuntary movements of the mouth, tongue
❖ Provide social skills training
(protrusion) and face and may extend to fingers, arms and
trunks ❖ Use measures to enhance self –esteem.
❖ Grinding of the teeth, lip smacking ❖ Use active friendliness kind of attitude.
Treatment 2. For the client exhibiting regressive or unusual behaviors
✔ No antidote available, stop the drug or change the drug ❖ Assume a matter-of-fact approach to bizarre behaviors
class (do not reinforce these behaviors)
✔ Notify the physician ❖ Treat the client as an adult, despite regression
Managing serious side effects of psychotropic drugs
1. Agranulocytosis: decrease white blood cells characterized ❖ Monitor the client’s eating patterns; encourage and assist
by sore throat, low grade fever, malaise, mouth sores when necessary.
▪ Stop the drug ❖ Assist with hygiene and grooming, performing these tasks

▪ Initiate reverse isolation for client’s safety only when client is unable to.
❖ Be cautious with touch because it may be perceived as ❖ Help the client control hallucinations by focusing on
threatening. reality and by taking prescribed medications
❖ Establish a routine schedule of activities of daily living. ❖ If the hallucinations persist, help the client learn to ignore
them and to act in an appropriate manner despite the
❖ Give simple choices of two items for the ambivalent
hallucinations.
client.
3. For the client with unclear communication patterns ❖ Teach cognitive strategies and tell the client to use self
talk and thought stopping.
❖ Communicate in a clear, unambiguous manner.
6. For the client with agitated behavior and potential for
❖ Ensure that communication is verbally and nonverbally violence
congruent. ❖ Observe behavior for early cues of agitation; intervene
❖ Clarify any unclear or ambiguous meanings related to the before the patient begins acting out.
client’s communication. ❖ Provide safe, quiet environment; decrease stimuli when
❖ Use appropriate therapeutic communication techniques the client becomes agitated.
4. For a highly suspicious and hostile client. ❖ Avoid retaliating when the client is verbally hostile; use a
❖ Establish a professional relationship; over friendliness quiet, calm tone of voice, provide personal space, and avoid
may be perceived as threatening to the client. personal contact.

❖ Be cautious with touch because it maybe perceived as ❖ Encourage client to talk about, rather than act out
threatening. feelings.

❖ Allow the client as much control and autonomy as ❖ Offer medications, as needed for agitated clients.
possible within the limit of the therapeutic setting. ❖ Isolate the client from general milieu if agitation
❖ Work on establishing trust through short interactions that increases.
communicate interest and respect. ❖ Set limits on unacceptable behavior, and consistently
❖ Explain any treatments, medications, and laboratory test follow institutional protocol for interventions.
before initiating them. ❖ Follow institutional protocol for responding to the client
❖ Avoid focusing on or reinforcing suspicious thoughts or exhibiting acting out behavior.
delusions. ❖ Ensure that an adequate number of experienced staff
❖ Identify and respond to emotional needs underlying members is available when attempting to subdue a violent
suspicious thoughts or delusions. clients.
7. For the family of the clients with a schizophrenic disorder.
❖ Intervene when the client shows signs of increased
❖ Encourage family members to discuss their feelings and
anxiety and on potential acting- out behavior.
needs.
❖ Be careful not to behave in a manner that can be
❖ Help the family to define basic rules about respecting
misinterpreted by the client.
5. For the client with hallucinations or delusions each other’s privacy and living together.

❖ Do not focus attention on the client’s hallucinations or ❖ Encourage interaction for each family member with a
delusions; interrupt the hallucinatory experience by initiating wider social environment.
one-to-one interaction that is reality based. ❖ Encourage family members to become involved in support
❖ Point out that you do not share the client’s perception, groups.
but validate that you believe the hallucination is real to the ❖ Assist members to identify anxiety-producing situation
client. and to plan specific coping strategies.
❖ Avoid arguing with the client about hallucinations and ❖ teach the family about schizophrenia and its
delusions. management.
❖ Respond to the client’s feelings communicated during
hallucinatory or delusion experience. Neurotransmitters

❖ Redirect and focus the client on a structured activity or

▪ Nerve cells arranged in networks communicate
reality-based task.
information with one another through neurotransmission
❖ Move the client to a more quiet, less stimulating which is the conduction of electrical messages from neuron to
environment. neuron.
❖ Wait until the client’s hallucinations or delusions stop
before initiating a teaching session about them.
▪ The electrochemical messages cross the synapses ▪ Research and studies have linked the incidence of
between neural cells by way of special chemical messengers Alzheimer’s disease with decreased acetylcholine secretion in
called neurotransmitters. the neurons.
Physiologic Effects and Functions
▪ Neurotransmitters are chemicals found and produced in
the brain to allow the transmission of impulses from one ▪ Muscular stimulation – acetylcholine signals muscles to
nerve cell to the next across synapses. become active including the muscles of the gastrointestinal
system.
▪ . They aid in the conduction of information throughout
the body. ▪ Controls the sleep and wakefulness cycle of a person. It
has a part in scheduling the rapid eye movement (REM) sleep
▪ These chemicals fit into specific receptor cells embedded
or dream.
in the membrane of the dendrite that either fuel up or excite
action in the cells (excitatory) or stop or inhibit an action Norepinephrine
(inhibitory).
▪ The most predominant neurotransmitter in the nervous
▪ Presence or absence of these neurotransmitters can
system is the norepinephrine.
directly or indirectly have an effect on neurons in a specific
portion of the brain. ▪ This neurotransmitter is also known as noradrenaline and
is located primarily in the brain stem and sympathetic nervous
▪ Thus, the levels of these chemicals in the brain have an
system.
effect to a person’s behavior. Norepinephrine

Mechanism of Nerve Impulse ▪ The mechanism of action of norepinephrine is excitatory

Nerve cell conduction or communication is an extremely rapid and plays a role in:
process which involves the following:
✔ Attention
▪ The impulse moves through the nerve in a long and
✔ Memory and learning
slender cellular part called the axon.
▪ As the impulse travels through the axon it travels the ✔ Sleep and wakefulness
presynaptic membrane. It is in this area that ✔ Mood regulation
neurotransmitters are released in the free space called the
synaptic cleft. ▪ The presence of norepinephrine places the nervous

▪ The receptors located in the postsynaptic membrane of system into certain alertness and it increases a person’s heart
rate and blood pressure.
another nearby neuron pick up the free-flowing
neurotransmitters. ▪ Excessive amounts of norepinephrine have been strongly

▪ The molecule is adapted in the next nerve cell and the linked with several anxiety disorders.

impulse continues to the next nerve cell until the message is ▪ However, deficits of these chemicals contribute to
relayed throughout the body. memory loss, social withdrawal and depression.

What happens after neurotransmitters sent the information? Dopamine

▪ After they served their purpose of being released into the ▪ Dopamine is located primarily in the brain stem. It is
synapse and relaying the messages to the receptor cells, they synthesized from tyrosine which is a dietary amino acid. This
are transported back from the synapse to the axon to be neurotransmitter is involved in the control of the following:
stored for later use which is a process called reuptake.
✔ Complex movements
▪ If the neurotransmitters will not undergo reuptake, they
✔ Motivation
will be metabolized and inactivated by enzymes, primarily
monoamine oxidase. ✔ Cognition

Major Neurotransmitters ✔ Regulation of emotional responses

▪ Excessive amounts of dopamine in the frontal lobes of the

Acetylcholine
brain have been strongly linked to the occurrence of the
▪ This is the first neurotransmitter discovered which is severe mental illness called schizophrenia.
found in the brain, spinal cord and particularly at the
▪ Thus, antipsychotic medications work by blocking the
neuromuscular junction of the skeletal muscle of the
peripheral nervous system. dopaminergic receptors and reduce dopamine activity.

▪ The mechanism of action of acetylcholine could either be ▪ On the other hand, insufficient levels of dopamine in the
excitatory or inhibitory. motor areas of the brain can contribute to the aggravation of
the clinical manifestations of Parkinson’s disease.
▪ Acetylcholine is synthesized from dietary choline found in
red meat and vegetables. Gamma Aminobutyric Acid (GABA)
▪ GABA is the major inhibitory neurotransmitter in the ▪ Low levels of serotonin have a role in the development of
brain. depression, problems in controlling anger, obsessive-
compulsive disorder and suicide.
▪ The main function of this neurotransmitter is to modulate
other neurotransmitter systems rather than to provide a ▪ Depressed people who are taking antidepressants
direct stimulus. manage the condition by preventing the reuptake of
serotonin or inhibiting the scouring action of the neurons to
▪ GABA is released and transported to act like a car brake to
excess serotonin.
the excitatory actions of other neurotransmitters.
▪ Mothers usually give their kids a glass of warm milk
▪ Medications that increase the levels of GABA in the body
before bedtime to help their sons or daughter sleep.
are used to treat anxiety and induce sleep.
▪ It is interesting to know that serotonin is a derivative of
▪ Scant amount of this chemical is a contributing factor to
tryptophan, which is found in milk.
development of anxiety disorders.
▪ Thus, a glass of milk before bedtime really helps.
Glutamate
▪ This neurotransmitter is an excitatory amino acid and
plays an important part in regards to memory.
▪ If glutamate levels are too high, major neurotoxic effects
will be noted.
▪ Glutamate is toxic to neurons at elevated levels and its
excess will kill the helpful nerve cells.
▪ This chemical has been implicated in the brain damage
caused by the following conditions:
✔ Stroke

✔ Hypoglycemia

✔ Sustained hypoxia or ischemia

✔ Some degenerative diseases such as Huntington’s Chorea

or Alzheimer’s Disease

Serotonin
▪ Serotonin is a neurotransmitter only found in the brain
and plays a very important role in a range of various brain
functions.
▪ It is derived from the dietary amino acid, tryptophan.

▪ Serotonin has been found to be strongly involved in the

emotion and mood of a person.
▪ The mechanism of action of serotonin is mostly inhibitory
and it has been linked with a wide variety of functions which
includes the following:
✔ Control of food intake – insufficient levels of serotonin
leads to an increased appetite for carbohydrates and starchy
foods
✔ Regulation of sleep and wakefulness cycle – scarce
amount of serotonin in the brain may lead to trouble sleeping
✔ Temperature regulation

✔ Pain control

✔ Sexual behaviors

✔ Regulation of emotions and mood