INTRODUCTION:

The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen
Bleuler. The word was derived from the Greek “skhizo” (split) and “phren”
(mind). Over the years, much debate has surrounded the concept of schizophrenia.
Various definitions of the disorder have evolved, and numerous treatment
strategies have been proposed, but none have proven to be uniformly effective or
sufficient. Although the controversy lingers, two general factors appear to be
gaining acceptance among clinicians. The first is that schizophrenia is probably not
a homogeneous disease entity with a single cause but results from a variable
combination of genetic predisposition, biochemical dysfunction, physiological
factors, and psychosocial stress. The second factor is that there is not now and
probably never will be a single treatment that cures the disorder. Instead, effective
treatment requires a comprehensive, multidisciplinary effort, including
pharmacotherapy and various forms of psychosocial care, such as living skills and
social skills training , rehabilitation, and family therapy.

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.

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

CLASSIFICATION [ICD-10]
F20 - SCHIZOPHRENIA
F20.0 – PARANOID
F20.1 – HEBEPHRENIC
 F20.2 – CATATONIC
F20.3 – UNDIFFERENTIATED
F20.4 - POST SCHIZOPHRENIC
F20.5 – RESIDUAL
F20.6 – SIMPLE

EPIDEMIOLOGY
Schizophrenia is the most common of all psychiatric disorders and is prevalent
in all cultures across the world. About 15% of new admissions in hospitals are
schizophrenic patients.

 3 to 4 / 1ooo people in community

 Equal for men and women [1 : 1 ]
Men - 15 to 25 yrs
women - 25 to 35 yrs
 Low socio-economic groups

In 2016
 Prevalence - 1%
 Incidence - 1.5 / 10,000
 Men than women [ 1.4 : 1 ]

PREDISPOSING FACTORS
The cause of schizophrenia is still uncertain. Most likely, no single factor
can be implicated in the etiology; rather, the disease probably results from a
combination of influences that include biological, psychological, and
environmental factors.
BIOLOGICAL INFLUENCES
Refer to Chapter 4 for a more thorough review of the biological implications
of psychiatric illness.

Genetics
The body of evidence for genetic vulnerability to schizophrenia is growing.
Studies show that relatives of individuals with schizophrenia have a much higher
probability of developing the disease than does the general population. Whereas
the lifetime risk for developing schizophrenia is about 1 percent in most population
studies, the siblings or offspring of an identified client have a 5 to 10 percent risk
of developing schizophrenia

Twin Studies
The rate of schizophrenia among monozygotic (identical) twins is four to five
times that of dizygotic (fraternal) twins and approximately 50 times that of the
general population. Identical twins reared apart have the same rate of development
of the illness as do those reared together. Because in about half of the cases only
one of a pair of monozygotic twins develops schizophrenia, some investigators
believe environmental factors interact with genetic ones.
 Children with one schizophrenic parent: 12%
 Children with both schizophrenic parents: 40%
 Siblings of schizophrenic patient: 8%
 Second-degree relatives: 5-6%
 Dizygotic twins of schizophrenic patients: 12%
 Monozygotic twins of schizophrenic patients: 47%
BIOCHEMICAL INFLUENCES
The oldest and most thoroughly explored biological theory in the
explanation of schizophrenia attributes a pathogenic ole to abnormal brain
biochemistry. Notions of a “chemical disturbance” as an explanation for insanity
were suggested by some theorists as early as the mid-19th century.

The Dopamine Hypothesis:

This theory suggests that schizophrenia (or schizophrenia-like symptoms)
may be caused by an excess of dopamine-dependent neuronal activity in the brain .
This excess activity may be related to increased production or release of the
substance at nerve terminals, increased receptor sensitivity, too many dopamine
receptors, or a combination of these mechanisms.

Other Biochemical Hypotheses

Various other bio-chemicals have been implicated in the predisposition to
schizophrenia. Abnormalities in the neuronal activity of the neurotransmitters nor-
epinephrine, serotonin, acetylcholine, and gamma amino butyric acid and in the
neuro-regulators, such as prostaglandins and endorphins, have been suggested.
PHYSIOLOGICAL INFLUENCES
A number of physical factors of possible etiological significance have been
identified in the medical literature. However, their specific mechanisms in the
implication of schizophrenia are unclear.
Viral Infection
Studies report that epidemiological data indicate a high incidence of
schizophrenia after prenatal exposure to influenza. Other data supporting a viral
hypothesis are an increased number of physical anomalies at birth, an increased
rate of pregnancy and birth complications, seasonality of birth consistent with viral
infection, geographical clusters of adult cases, and seasonality of hospitalizations.

Anatomical Abnormalities
With the use of neuro-imaging technologies, structural brain abnormalities
have been observed in individuals with schizophrenia. Ventricular enlargement is
the most consistent finding; however, sulci enlargement and cerebellar atrophy are
also reported.

Histological Changes
Cerebral changes in schizophrenia have also been studied at the microscopic
level. A “disordering” or disarray of the pyramidal cells in the area of the
hippocampus has been suggested . This disarray of cells has been compared to the
normal alignment of the cells in the brains of clients without the disorder. Some
researchers have hypothesized that this alteration in hippocampal cells occurs
during the second trimester of pregnancy and may be related to an influenza virus
infection acquired by the mother during this period. Further research is required to
determine the possible link between this birth defect and the development of
schizophrenia.

Physical Conditions
Some studies have reported a link between schizophrenia and epilepsy
(particularly temporal lobe), Huntington’s disease, birth trauma, head injury in
adulthood, alcohol abuse, cerebral tumor (particularly in the limbic system),
cerebrovascular accidents, systemic lupus erythematosus, myxedema,
parkinsonism, and Wilson’s disease.
PSYCHOLOGICAL INFLUENCES
Early conceptualizations of schizophrenia focused on family relationship
factors as major influences in the development of the illness, probably in light of
the conspicuous absence of information related to a biological connection. These
early theories implicated poor parent child relationships and dysfunctional family
systems as the cause of schizophrenia, but they no longer hold any credibility.

ENVIRONMENTAL INFLUENCES
Sociocultural Factors
Many studies have been conducted that have attempted to link schizophrenia
to social class. Indeed epidemiological statistics have shown that greater numbers
of individuals from the lower socioeconomic classes experience symptoms
associated with schizophrenia than do those from the higher socioeconomic groups
. 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 feeling
hopeless to change one’s lifestyle of poverty.

Stressful Life Events

Studies have been conducted in an effort to determine whether psychotic
episodes may be precipitated by stressful life events. There is no scientific
evidence to indicate that stress causes schizophrenia. It is very probable, however,
that stress may contribute to the severity and course of the illness. It is known that
extreme stress can precipitate psychotic episodes. Stress may indeed precipitate
symptoms in an individual who possesses a genetic vulnerability to schizophrenia.
Stressful life events may be associated with exacerbation of schizophrenic
symptoms and increased rates of relapse.

TYPES OF SCHIZOPHRENIA

DISORGANIZED SCHIZOPHRENIA
This type previously was called hebephrenic schizophrenia. Onset of
symptoms is usually before age 25, and the course is commonly chronic. Behavior
is markedly regressive and primitive. Contact with reality is extremely poor. Affect
is flat or grossly inappropriate, often with periods of illiness and incongruous
giggling. Facial grimaces and bizarre mannerisms are common, and
communication is consistently incoherent. Personal appearance is generally
neglected, and social impairment is extreme.
CATATONIC SCHIZOPHRENIA

Catatonic schizophrenia is characterized by marked abnormalities in motor

behavior and may be manifested in the form of Stupor or excitement.
Catatonic stupor is characterized by extreme psychomotor retardation. The
individual exhibits a pronounced decrease in spontaneous movements and activity.
Mutism (absence of speech) is common, and negativism ( an apparently motiveless
resistance to all instructions or attempts to be moved) may be evident. Waxy
flexibility may be exhibited. This term describes a type of “posturing,” or
voluntary assumption of bizarre positions, in which the individual may remain for
long periods. Efforts to move the individual may be met with rigid bodily
resistance.
Catatonic excitement is manifested by a state of extreme psychomotor
agitation. The movements are frenzied and purposeless, and are usually
accompanied by continuous incoherent verbalizations and shouting. Clients in
catatonic excitement urgently require physical and medical control because they
are often destructive and violent to others, and their excitement may cause them to
injure themselves or to collapse from complete exhaustion.

PARANOID SCHIZOPHRENIA
Paranoid schizophrenia is characterized mainly by the presence of delusions
of persecution or grandeur and auditory hallucinations related to a single theme.
The individual is often tense, suspicious, and guarded, and may be argumentative,
hostile, and aggressive. Onset of symptoms is usually later (perhaps in the late 20s
or 30s), and less regression of mental faculties, emotional response, and behavior is
seen than in the other subtypes of schizophrenia. Social impairment may be
minimal, and there is some evidence that prognosis, particularly with regard to
occupational functioning and capacity for independent living, is promising.
UNDIFFERENTIATED SCHIZOPHRENIA
Sometimes clients with schizophrenic symptoms do not meet the criteria for
any of the subtypes, or they may meet the criteria for more than one subtype. These
individuals may be given the diagnosis of 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.
RESIDUAL SCHIZOPHRENIA
This diagnostic category is used when the individual has a history of at least
one previous episode of schizophrenia with prominent psychotic symptoms.
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). In the residual stage,
there is continuing evidence of the illness, although there are no prominent
psychotic symptoms. 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.
SIMPLE SCHIZOPHRENIA
Its characterized by an early and insidious onset, progressive course and
presence of characteristic negative symptoms and aimless activity.
POST –SCHIZOPHRENIC DEPRESSION
Depressive features develop in the presence of residual or active features of
schizophrenia and or associated with an increased risk of suicide
CLINICAL FEATURES
Bleuler’s 4 A’s

 Affective disturbance
 Autistic thinking
 Ambivalence
 Associative looseness

Schneider's First-Rank Symptoms of Schizophrenia (SFRS)

Kurt Schneider proposed the first rank symptoms of schizophrenia in 1959.

The presence of even one of these symptoms is considered to be strongly
suggestive of schizophrenia. They include:

 Hearing one's thoughts spoken aloud (audible thoughts or thought echo).

 Hallucinatory voices in the form of statement and reply (the patient hears
voices discussing him in the third person)
 Thought withdrawal
  Thought insertion
 Thought broadcasting
 Delusions
THOUGHT AND SPEECH DISORDER

 Autistic thinking
 Thought blocking
 Neologism
 Poverty of speech
 Poverty of ideation
 Echolalia
 Verbigeration
DISORDERS OF AFFECT

These include apathy, emotional blunting, 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 a decrease in psychomotor activity. Mannerisms,

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

OTHER FEATURES

 Impaired social relationship

 Loss of ego boundaries
 Loss of insight
 Poor judgment
  Suicide

POSITIVE SYMPTOM

CONTENT OF THOUGHT

 Delusions
 Religiosity
 Paranoia
 Magical thinking
FORM OF THOUGHT

 Associative looseness
 Neologisms
 Clang associations
 Word salad
 Circumstantiality
 Tangentiality
 Mutism
 Perseveration
PERCEPTION

 Hallucinations
 Illusions
SENSE OF SELF

 Echolalia
 Echoprexia
 Identification and Imitation
  Depersonalization

NEGATIVE SYMPTOMS

AFFECT

 Inappropriate affect
 Bland or flat affect
 Apathy
VOLITION

 Inability to initiate goal-directed activity

 Emotional ambivalence
IMPAIRED INTERPERSONAL FUNCTIONING AND RELATIONSHIP TO
THE EXTERNAL WORLD

 Autism
 Deteriorated appearance
PSYCHOMOTOR BEHAVIOR

 Anergia
 Waxy flexibility
ASSOCIATED FEATURES

 Anhedonia
 Regression
MANAGEMENT

I.PHARMACOLOGICAL MANAGEMENT
Conventional (Typical) Antipsychotics

The typical antipsychotics work by blocking postsynaptic dopamine receptors in

the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. They also
demonstrate varying affinity for cholinergic, alpha-adrenergic, and histaminic
receptors.

Haloperidol

 PO ; 5 – 100 mg/day
 IM ; 5- 2O mg/day
Trifluoperazine

 PO ; 15 -60 mg/day
 IM ; 1- 5 mg /day
chlorpramazine

 PO ; 300 – 1500 mg/day

 IM; 50 -1OO mg/day
Fluphenazine decanoate

 IM ; 25 – 50 mg every 1 to 3 weeks
Atypical antipsychotics

The atypical antipsychotics are weaker dopamine receptor antagonists than the
conventional antipsychotics, but are more potent antagonists of the serotonin type
2A receptors. They also exhibit antagonism for cholinergic, histaminic, and
adrenergic receptors.

Eg:

 Clozapine ; 25 to 450 mg/day po

  Risperidone ; 2 to 10 mg/day po
 Olanzapine ; 10 to 20 mg/day po
 Quetiapine ; 150 to 750 mg / day po
 Ziprasidone ; 20 to 80 mg/day po
II. PSYCHOLOGIAL TREATMENTS
Individual Psychotherapy
Reality-oriented individual therapy is the most suitable approach to
individual psychotherapy for schizophrenia. 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.
Group Therapy
Group therapy with individuals with schizophrenia has been shown to be
effective, particularly with outpatient 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 clients. Groups led in a supportive manner, rather than in an
interpretative way, appear to be most helpful for individuals with schizophrenia.

Behavior Therapy
Behavior modification has a history of qualified success in reducing the
frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate
behaviors.

Social Skills Training

 Social skills training has become one of the most widely used psychosocial
interventions in the treatment of schizophrenia. The educational procedure in social
skills training focuses on roleplay. A series of brief scenarios are selected. These
should be typical of situations clients experience in their daily lives and be
graduated in terms of level of difficulty. The healthcare provider may serve as a
role model for some behaviors.

III.SOCIAL TREATMENT

Milieu Therapy
Some clinicians believe that milieu therapy can be an appropriate treatment
for the client with schizophrenia. 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 medications.

Family Therapy
Some healthcare providers treat schizophrenia as an illness not of the client
alone, but of the entire family. Even when families appear to cope well, there is a
notable impact on the mental health status of relatives when a family member has
the illness.

Assertive Community Treatment

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. The primary goals of ACT as
follows:
 1. To meet basic needs and enhance quality of life
2. To improve functioning in adult social and employment roles
3. To enhance an individual’s ability to live independently in his or her own
community
4. To lessen the family’s burden of providing care
5. To lessen or eliminate the debilitating symptoms of mental illness
6. To minimize or prevent recurrent acute episodes of the illness

VI. ECT
Indications for ECT in schizophrenia include
 Catatonic stupor
 Uncontrolled catatonic excitement
 Severe side effects with drugs
 Usually 8 to 12 ECTs are needed
SUMMARY

So far we have discussed about history of schizophrenia, what is schizophrenia, its

subtypes, epidemiology, predisposing factor, diagnostic criteria, treatment and
nursing interventions.

CONCLUSION

Schizophrenia may result in some combination of hallucinations, delusions, and

extremely disordered thinking and behavior that impairs daily functioning, and can
be disabling. People with schizophrenia require lifelong treatment. As a psychiatric
nurse it is our responsibility to identify them in patients and treat and manage
accordingly.
JOURNAL PRESENTATION

TOPIC: Negative Symptoms in Schizophrenia: A Review and Clinical Guide for

Recognition, Assessment, and Treatment.

Schizophrenia is frequently a chronic and disabling disorder, characterized by

heterogeneous positive and negative symptom constellations. The objective of this
review was to provide information that may be useful for clinicians treating
patients with negative symptoms of schizophrenia. Negative symptoms are a core
component of schizophrenia that account for a large part of the long-term disability
and poor functional outcomes in patients with the disorder. The term negative
symptoms describes a lessening or absence of normal behaviors and functions
related to motivation and interest, or verbal/emotional expression. The negative
symptom domain consists of five key constructs: blunted affect, alogia (reduction
in quantity of words spoken), avolition (reduced goal-directed activity due to
decreased motivation), asociality, and anhedonia (reduced experience of pleasure).
Negative symptoms are common in schizophrenia; up to 60% of patients may have
prominent clinically relevant negative symptoms that require treatment. Negative
symptoms can occur at any point in the course of illness, although they are
reported as the most common first symptom of schizophrenia. Negative symptoms
can be primary symptoms, which are intrinsic to the underlying pathophysiology of
schizophrenia, or secondary symptoms that are related to psychiatric or medical
comorbidities, adverse effects of treatment, or environmental factors. While
secondary negative symptoms can improve as a consequence of treatment to
improve symptoms in other domains (ie, positive symptoms, depressive symptoms
or extrapyramidal symptoms), primary negative symptoms generally do not
respond well to currently available antipsychotic treatment with dopamine
D 2 antagonists or partial D 2 agonists. Since some patients may lack insight about
the presence of negative symptoms, these are generally not the reason that patients
seek clinical care, and clinicians should be especially vigilant for their presence.
Negative symptoms clearly constitute an unmet medical need in schizophrenia, and
new and effective treatments are urgently needed.
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https://doi.org/10.2147/NDT.S225643
 SEMINAR
ON
SCHIZOPHRENIA

SUBMITTED BY,
SUBMITTED TO,
MS. MARY CATHERIN D E
PROF. PRABAVATHY S
II YEAR
HEAD OF THE DEPARTMENT
MSc NURSING
MENTAL HEALTH NURSING
MENTAL HEALTH NURSING
KGNC
KGNC