UNDERSTANDING

SCHIZOPHRENIA
LEARNING OUTCOMES
 Define and Describe Schizophrenia
 Know Incidence of Schizophrenia
 Discover etiology
 Describe signs and symptoms
 Differentiate the subtypes of Schizophrenia
 Apply psychotherapeutic management in handling
schizophrenic patients
 Understand its prognosis
What is Schizophrenia?

Comes from Greek

words meaning “split”
and “mind”

“split mind” refers to the

fact that people with
schizophrenia are split
off from reality and can’t
distinguish what is real
from what is not real
 SCHIZOPHRENIA: Not a single disorder
A group of mental disorders
characterized by;
 Psychotic features
(hallucinations and
delusions)
 Disordered thought
process
 Disrupted interpersonal
relationships
 Disturbances in affect,
mood, behavior, and
thought processes occur
INCIDENCE

1% of the total
population has
Schizophrenia

Equally frequency, males

have earlier onset
18 to 25 for men
26 to 45 for women
BLEULER’S Four A’s of Schizophrenia
1. Affective disturbance
a) Inappropriate – affective response doesn’t match the circumstances
b) Blunted – the response to certain circumstances is weakly appropriate
c) Flat – inability to generate any affective response
d) Labile – emotional tone changes quickly

2. Autism – preoccupation with self and with little concern for external
reality
3. Associative Looseness – the stringing together of unrelated topics
with vague connections
4. Ambivalence – simultaneous opposite feelings
DSM IV Criteria

 Schizophrenia
 Schizophreniform
 Schizoaffective
 Delusional Disorder
 Brief Psychotic Disorder
 Shared Psychotic Disorder
 Schizophrenia induced by: Medical conditions;
Medications/ drugs /other substance
DSM IV Criteria
• Schizophrenia : psychosis that are persistently
disturbing for at least 6 months, with 1 month of
active-phase symptoms; age onset of late
adolescence or early adulthood
• Schizophreniform : Symptoms of Schizophrenia with
the duration of at least 1 month but less than 6
months and social / occupational function may not
be impaired.
• Schizoaffective : Symptoms of both Schizophrenia
and a mood disorder lasting for 1 month
DSM IV Criteria

• Delusional Disorder : presence of one or more

nonbizaare delusions that persist for 1 month or
more
• Brief Psychotic Disorder : at least one of the
symptoms (hallucinations, delusions, disorganized
speech or behavior disturbance) that last at least 1
day but less than 1 month; then a return to the
premorbid level of functioning
DSM IV Criteria

• Shared Psychotic Disorder : a delusional disorder

developed when the person is involved in a close
relationship with an individual who has delusional
psychotic disorder.
• Psychotic Disorder due to medical condition or
induced by substance abuse : physiologic effect of
medical condition; occurrences during intoxication or
withdrawal stages but can last for weeks
 ETIOLOGY
A syndrome with multiple variations
and multiple etiologies
 Biological Theories
1. Biochemical
2. Genetic
3. Perinatal Risks
4. Neurostructural
 Psychological Theories
Faulty Family dynamics
Communication Deviance
• Social Theories
Social Stressors
Negative Life Events
Biochemical:
Dopamine Hypothesis

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Biochemical:

Glutamate Hypothesis
 Glutamate functions in the:
 Relay of sensory information and in the regulation of
various motor and spinal reflexes
 Regulation of N-methyl-D-aspartate (NDMA)

Decreased levels of
of
Glutamate

Decreased regulation of
regulation of
NMDA

Impaired cognitive Psychotic symptoms

processes symptoms
 Genetics

 Idea that it is genetic

goes back at least as
far as the 18th century
 By the 19th century,
genetic hypothesis
was endorsed by
Kraepelin, Bleuler,
and many other
experts on
schizophrenia.
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 Perinatal Risks

 There are also evidences that perinatal

conditions may be an indicator of the risk of
having schizophrenia.
 2nd trimester (4-6 months) – brain development
 Conditions that could result in brain injury are:
 Maternal starvation; poor nutrition – anemia
 Obstetric complications
Fetal hypoxia
Maternal alcohol or drug abuse
Toxin exposure or viral infection –
influenza virus
 Incidence of birth trauma and injury
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Neurostructural:
Ventricular Brain Ratio

 Enlarged ventricles
Increased width of 3rd ventricle

17
Neurostructural:
Cortical Atrophy

 Increased loss of gray matter in adolescence

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 Psychological Theories

Psychological
Theories

Psychoanalytical Psychodynamic

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 Psychological Theories

Psychological
Theories

Psychoanalytical Psychodynamic

Dysfunctional Dysfunctional Concept of Double-bind

Mother-Child Parental Communication Type of
Relationship Interaction Deviance Communication
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Psychoanalytic:
Dysfunctional Mother-Child Relationship
Schizophrenogenic mother
Emotionally withholding
Domineering
Rejecting attitudes
Over-protection

Child grows feeling in conflict with, distrustful of, and angry towards others

Faulty ego development

Ego disintegration

Intrapsychic conflict
Psychoanalytic:
Dysfunctional Parental Interaction

Dysfunctional parental interaction

Schismatic marriage Skewed marriage

Interference with personality maturation in the

offspring
Psychoanalytic:
Double-bind Type of Communication

Double-bind type of communication

Double-bind message

Conflicting messages may be given simultaneously

Defaults in interpreting meaning

Disorder of cognition and metacommunication

 Social stressors and
life events

Stressful events

Acute stressors Chronic stressors

Inadequate use coping resources

Inability to use coping skills Inability to obtain social support

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 Social stressors and life events
Coping Mechanisms Used

 Denial and Suppression

 Denial – Failure to acknowledge an unbearable condition; failure to
admit the reality of a situation or how one enables the problem to
continue
 Suppression – Conscious acceptable behavior to make up for or
negative unacceptable thoughts and feelings from conscious
awareness
Social stressors and life events
Stress-Vulnerability Model
Personal Stressors
Vulnerability Environmental Stimulation
Family Conflict
Life Events

Personal Protectors
Coping Medications Symptoms

Environmental Protectors Decreased

Problem Solving Social Support social and
Occupational
functioning
 Summary of Etiological Factors

Etiological Factors

Biologic Theories Social Stressors and Psychological Theories

Life Events

Genetic Theory Perinatal Risks Psychodynamic Theories Psychoanalytical Theories

Neurostructural Theories Biochemical Theories

Psychotic Symptoms

Positive Symptoms Negative Symptoms

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SIGNS AND SYMPTOMS
POSITIVE SYMPTOMS
 Believed to be caused by an
increase in the amount of
dopamine affecting the
cortical areas
 Symptoms are additional of
abnormal cognition and
perception
NEGATIVE SYMPTOMS
 Symptoms are essentially
diminution of what should
be ( lack of affect, lack of
energy)
 May be related to decrease
amount of dopamine and
cerebral atrophy
 Positive Psychotic Symptoms

Positive Symptoms

Cognitive Disturbances Perceptual Disturbances

(Alterations in Thought and Language)

Hallucinations Impaired Sensory Filtering

Alteration in Thought Content Alteration in Form of Thought

Auditory

Bizaare Behaviors Delusions

Agitated Unpredictable Repetitive or Stereotyped Loose Associations Flight of Ideas Poverty of Content
Behavior Behavior

Persecutory Delusions Grandiose Delusions Nihilistic Delusions Somatic Delusions Ideas of Reference
Religious Delusions

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POSITIVE SYMPTOMS

DELUSIONS HALLUCINATIONS
fixed false beliefs false sensory perception not based on reality
altered thought process altered sensory perception
 Visual
 Grandeur
 Auditory
 Persecutory
Religious  Olfactory
Ideas of Reference  Gustatory
Somatic  Tactile
Nihilistic
POSITIVE SYMPTOMS

NEOLOGISM
 Forming new words
ILLUSION
 Misinterpretation of an external stimuli
EXAMPLES FROM PATIENTS:

”DECEASESET”
EXAMPLES FROM PATIENTS:
“OBITIVANG”
“ELILIS”
A patient was screaming while looking at “RESTITUITION”
the ceiling fan. She stated “Alien, Alien,
Coming down from heaven!” “ECAIORETIE”
“ISE”
“ELOI/ILAY”
“CLEAVEAGE”
POSITIVE SYMPTOMS

ECHOLALIA ECHOPRAXIA
 Psychopathological repeating of words  Pathological imitation of movements of
and phrases of one person by another, one person by another
tends to be repetitive and persistent
POSITIVE SYMPTOMS

CLANG ASSOCIATION WORD SALAD

 Association of words similar in sound  Incoherent mixture of words and phrases
but not in meaning, may include rhyming
and punning
EXAMPLES FROM PATIENTS: EXAMPLES FROM PATIENTS:

‘Sa iyong ngiti, ako’y nakikiliti, puso ko’y “orange flower feel”
dumadagundong sa pagibig mong
umuusbong”
“Rise and shine, you are mine” “mundong upuan nakababa”

“My name is Mancho Pancho Mucho

Gwapito!” “technological planet power”
POSITIVE SYMPTOMS

FLIGHT OF IDEAS LOOSENESS OF ASSOCIATION

 Rapid, continuous verbalizations or play  Flow of thought in which ideas shift from
on words produce constant shifting from one subject to another in a completely
one another, ideas tend to be unrelated way
connected
 Negative Psychotic Symptoms

Negative Symptoms

Thought and Language Mood Disturbances Motor Behavior Disturbance

Alterations

Reduced emotional responsiveness

Physical Anergia
Increased Latency of Poverty of Speech
Response

Poor Eye Contact Anhedonia Blunted Affect

Avolition Social Withdrawal

Social Isolation

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NEGATIVE SYMPTOMS

ALOGIA ANHEDONIA
 Absence of speech/poverty of thought  Lack of pleasure to pleasurable
activities
NEGATIVE SYMPTOMS

AVOLITION
ASOCIALITY
Absence of ability to socialize Absence of motivation
Schizophrenia Subtypes
PARANOID

 Suspiciousness
 Hostility
 Delusions
 Auditory hallucinations
 Anxiety and anger
 Aloofness
 Persecutory themes
 Violence
DISORGANIZED

 Extreme social withdrawal

 Disorganized speech or
behavior
 Flat or inappropriate affect
 Silliness unrelated to speech
 Stereotyped behaviors
 Grimacing mannerisms
 Inability to perform ADL
 CATATONIC

 Psychomotor
disturbances
 Immobility
 Stupor
 Waxy flexibility
 Excessive purposeless
motor activity
 Echolalia
 Automatic obedience
 Stereotyped or repetitive
behavior
UNDIFFERENTIATED

 Does not meet the criteria

for paranoid, disorganized,
or catatonic
 Delusions and
hallucinations
 Disorganized speech
 Disorganized or catatonic
behavior
 Flat affect
 Social withdrawal
 RESIDUAL

 Diagnosed as
Schizophrenic in the past
 Time limited between
attacks but may last for
many years
 Exhibits social isolation
and withdrawal, and
impaired role functioning
 Psychotherapeutic
Management for
Milieu
Schizophrenia
Management Psychopathology

Nurse
Patient
Relationship Psychopharmacology
PSYCHOTHERAPEUTIC MANAGEMENT
Involves understanding the etiology of patient’s illness
(PSYCHOPATHOLOGY) to be able to:
 Manage behaviors using modification of environment
(MILIEU)
 Treat symptoms through the use of medications
(SOMATOTHERAPIES)
 Allow expression of thoughts and feelings through
establishment of Nurse-Patient Relationship
(THERAPEUTIC USE OF SELF)
 MILIEU MANAGEMENT FOR
SCHIZOPHRENIC PATIENTS
 PROMOTE SAFETY
 PROVIDE STRUCTURE
 IMPLEMENT LIMIT SETTING
 APPLY ATTITUDE THERAPY
Passive Friendliness (PARANOID, HALLUCINATING)
Active Friendliness/Kind Firmness (DISORGANIZED)
Matter of Fact (DELUSIONAL THINKING)
No Demand (Aggressive Behavior)
 PROMOTE SAFETY
 Maintain Distance and Do not use Touch.
 Remove any unsafe object from the patient’s environment.
 Reassure the patient that the environment is safe by
explaining procedures used to provide protection.
 Monitor patient for increase psychomotor activity, intensity
of affect and verbalization of carrying out of delusional
thinking.
 Avoid whispering and laughing in front of them.
 Monitor for presence of command hallucinations.
“What does the voice tell you?”
 PROVIDE STRUCTURE
 Provide a schedule of activities that they can follow.
 Provide distracting reality based activities during periods of
hallucinations and delusional thinking.
 Monitor television selections.
 IMPLEMENT LIMIT SETTING
 Set consequences for unacceptable behavior
 Use appropriate behavior modification techniques (Token
Economy, Conditioning eg: Thought Stopping for
hallucinating patients
 THERAPEUTIC USE OF SELF
 Establish TRUST (Be Genuine and Be Consistent!)
 Encourage expression of feelings and thoughts.
 Apply therapeutic communication techniques
Paranoid (Making Observation) “You seem scared.”
Withdrawn (Giving Recognition) “Goodmorning!I see you have
finished eating your snack.”
Hallucinating (Reality orientation) “I know it is real to you but I
do not see anyone in the room.”
Delusional (Voicing Doubt) “It must be hard to believe that you
have magic powers.”
 PROGNOSIS
GOOD POOR
 Early onset  Late onset
 Presence of Nurturing environment  Lack of support
 Understanding of illness and its  Exposure to negative life events
management  Poor insight
 Compliance to Medications  More complications
 Does not respond to treatment
Summary of Schizophrenia