SCHIZOPHRENIA

2nd most frequent diagnosis of

patients 14-64 y/o
at CRH in 2008
 Target Audience
• Nursing Staff to include nurses and
technicians
 In this module we will cover
• What is schizophrenia
• Symptoms of schizophrenia
• Types of schizophrenia
• Some of the more common treatments for
schizophrenia

Last update 6/25/09 ajj

 CRH most frequent
diagnosis in 2008
• Under 14 y/o • 65 and over
– Attention Deficit – Persistent mental
Disorder disorder due to
– Oppositional Defiant conditions classified
Disorder elsewhere
– PTSD – Alzheimer
– Bipolar – Schizoaffective
– Adjustment disorder disorder
– Other and alcohol
dependence
– Bipolar, Manic episode
 Epidemiology
• Gender-15-25 vs. 25-35
• Comorbid with substance abuse
• Deinstitutionalization (>2/3)
• Dx has increased with the onset of
neuroliptics
 CRH most frequent
diagnosis in 2008
• 14-64 y/o
– Other & unspecified alcohol dependence
– Schizoaffective disorder
– Cocaine dependence
– Depressive disorder
– Combo of drug dependence excluding opioid
type drugs
 Schizophrenia
• Kraepelin-dementia precox
• Bleuler-schism between thought, emotion
and behavior in affected patients
• 4 A’s
– ambivalence
– associations
– affect
– autism
 Genetics
General Population 1.0%
Nontwin sib of Schz. pt. 8.0%
Child with 1 Schz. parent 12.0%
Dyzygotic twin of Schz. 12.0%
parent
Child of 2 Schz. parents 40.0%
Monozygotic twin 47.0%
of a Schz. parent
 Etiology

• Many different problems that converge on

the same syndrome, not just a single
disease
• >50% of Sx appear to be associated with
brain abnormalities (especially + Sx).
• Stress Diathesis Model
• Dopamine Hypothesis
 Etiology of Schizophrenia

• The etiology and pathogenesis of

schizophrenia is not known

• It is accepted, that schizophrenia is „the

group of schizophrenias“ which origin is
multifactorial:
– internal factors – genetic, inborn, biochemical
– external factors – trauma, infection of CNS,
stress
 Etiology of Schizophrenia -
Dopamine Hypothesis
• The most influential and plausible are the hypotheses,
based on the supposed disorder of neurotransmission in the
brain, derived mainly from
1. the effects of antipsychotic drugs that have in common the ability to
inhibit the dopaminergic system by blocking action of dopamine in
the brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide
of lysergic acid - LSD) that can induce state closely resembling
paranoid schizophrenia

• Classical dopamine hypothesis of schizophrenia: Psychotic

symptoms are related to dopaminergic hyperactivity in the
brain. Hyperactivity of dopaminergic systems during
schizophrenia is result of increased sensitivity and density
of dopamine D2 receptors in the different parts of the brain.
 Etiology of Schizophrenia -
Contemporary Models
• Dopamine hypothesis revisited: various neurotransmitter
systems probably takes place in the etiology of
schizophrenia (norepinephric, serotonergic, glutamatergic,
some peptidergic systems); based on effects of atypical
antipsychotics especially.

• Contemporary models of schizophrenia conceptualize it as

a neurocognitive disorder, with the various signs and
symptoms reflecting the downstream effects of a more
fundamental cognitive deficit:
– the symptoms of schizophrenia arise from “cognitive dysmetria”
(Nancy C. Andreasen)
– concept of schizophrenia as a neurodevelopmental disorder
(Daniel R. Weinberger)
 Etiology of Schizophrenia -
Neurodevelopmental Model
• Neurodevelopmental model supposes in schizophrenia
the presence of “silent lesion” in the brain, mostly in the
parts, important for the development of integration
(frontal, parietal and temporal), which is caused by
different factors (genetic, inborn, infection, trauma...)
during very early development of the brain in prenatal or
early postnatal period of life.
• It does not interfere too much with the basic brain
functioning in early years, but expresses itself in the time,
when the subject is stressed by demands of growing
needs for integration, during formative years in
adolescence and young adulthood.
 Predisposing Factors
– Various physical conditions
• Epilepsy
• Huntington’s chorea
• Birth trauma
• Head injury in adulthood
• Alcohol abuse
• Cerebral tumor
• Cerebrovascular accident
• Systemic lupus erythematosus
• Myxedema
• Parkinsonism
• Wilson’s disease
 What is schizophrenia?
• A chronic severe brain disorder; often they
hear voices, believe media are
broadcasting their thoughts to the world or
may believe someone is trying to harm
them.

• In men it usually develops in teen years

and early 20s; in women it usually
develops in 20s and 30s.
• Premorbid behavior of the patient with schizophrenia can be
viewed in four phases.
• First Phase: Schizoid Personality
– Indifferent, cold, and aloof, these people are loners. They do not enjoy close
relationships with others.
• Second Phase: Prodromal Phase
– These people are socially withdrawn and show evidence of peculiar or
eccentric behavior.
– Neglect of personal hygiene and grooming
– Blunted or inappropriate affect
– Disturbances in communication
– Bizarre ideas
– Lack of initiative
• Third Phase: Schizophrenia
– In the active phase of the disorder, psychotic symptoms are prominent
• Delusions
• Hallucinations
• Impairment in work, social relations, and self-care
• Fourth Phase: Residual Phase
– Symptoms similar to those of the prodromal phase
– Flat affect and impairment in role functioning are prominent
 The Criteria of Diagnosis
For the diagnosis of schizophrenia is necessary
• presence of one very clear symptom - from point a) to d)
• or the presence of the symptoms from at least two groups - from
point e) to h)
for one month or more:

a) the hearing of own thoughts, the feelings of thought withdrawal,

thought insertion, or thought broadcasting
b) the delusions of control, outside manipulation and influence, or the
feelings of passivity, which are connected with the movements of the
body or extremities, specific thoughts, acting or feelings, delusional
perception
c) hallucinated voices, which are commenting permanently the behavior
of the patient or they talk about him between themselves, or the other
types of hallucinatory voices, coming from different parts of body
d) permanent delusions of different kind, which are inappropriate and
unacceptable in given culture
 The Criteria of Diagnosis
e) the lasting hallucination of every form
f) blocks or intrusion of thoughts into the flow of thinking and resulting
incoherence and irrelevance of speach, or neologisms
g) catatonic behavior
h) „the negative symptoms”, for instance the expressed apathy, poor
speech, blunting and inappropriatness of emotional reactions
i) expressed and conspicuous qualitative changes in patient’s
behavior, the loss of interests, hobbies, aimlesness, inactivity, the
loss of relations to others and social withdrawal

• Diagnosis of acute schizophorm disorder (F23.2) – if the conditions

for diagnosis of schizophrenia are fulfilled, but lasting less than one
month
• Diagnosis of schizoaffective disorder (F25) - if the schizophrenic
and affective symptoms are developing together at the same time
 Diagnosis
• Currently there is no physical or lab test
that can absolutely diagnose
schizophrenia.

• A psychiatrist usually comes to the

diagnosis based on clinical symptoms.
 Misdiagnosis
• This is a common problem since
schizophrenia shares a significant number
of symptoms with other disorders.

• Per the Nat’l Depression & Bipolar Support

Alliance there is an average of 10 years
from onset to correct diagnosis & tx.
 Disorders that may appear like
Schizophrenia

• Schizoid personality
• Schizophreniform disorder
• Schizotypal personality
• Bipolar Disorder
• Asperger’s syndrome
 Symptoms of Schizophrenia
• Profound disruption in cognition and
emotion, affecting the most fundamental
human attributes:
– Language
– Thought
– Perception
– Affect
– Sense of self
 Positive and Negative Symptoms

Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-asociality Positive formal thought
disorder
Attentional impairment

Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R.
and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
 Positive Symptoms
• Those that appear to reflect an excess or
distortion of normal functions.
 Positive Symptoms
• Delusions. Those where the patient thinks
he is being followed or watched are
common; also the belief that people on
TV, radio are directing special messages
to him/her.
 Positive Symptoms
• Hallucinations. Distortions or
exaggerations of perception in any of the
senses.

• Often they hear voices within their own

thoughts followed by visual hallucinations.
 Positive Symptoms
• Disorganized thinking/speech.

• AKA loose associations; speech is

tangential, loosely associated or
incoherent enough to impair
communication.
 Positive Symptom
• Grossly disorganized behavior.

• Difficulty in goal directed behavior (ADLs),

unpredictable agitation or silliness, social
disinhibition, or bizarre behavior.

• There is a purposelessness to behavior.

 Positive Symptom
• Catatonic behavior.

• Marked decrease in reaction to immediate

environment, sometimes just unaware of
surroundings, rigid or bizarre postures,
aimless motor activity.
 Other Positive Symptoms
• Inappropriate response to stimuli
• Unusual motor behavior (pacing, rocking)
• Depersonalization
• Derealization
• Somatic preoccupations
Summary of Positive Symptoms

• Delusions
• Hallucinations
• Disorganized thinking
• Disorganized behavior
• Catatonic behavior
• Inappropriate responses
 FYI: Positive Symptoms
• Positive symptoms are those that have a
positive reaction from some treatment.

• In other words, positive symptoms

respond to treatment.
 Content of Thought
Delusions Form
• Of Persecution • Associative Looseness
• Of Grandeur • Neologisms
• Of Reference • Concrete thinking
• Of control or influence • Clang associations
• Somatic • Word salad
• Nihilistic • Circumstantialities
• Religiosity • Tangentiality
• Paranoia • Mutism
• Magical thinking • Perseveration
Perception Affects
• Hallucination • Inappropriate affect
• Auditory • Bland or flat affect
• Visual • Apathy
• Tactile
• Olfactory
 Negative Symptoms
• Those that appear to reflect a diminution
or loss of normal functions.

• May be difficult to evaluate because they

are not as grossly abnormal as positive
symptoms.
 Negative Symptoms
• Affective flattening.

• Reduction in the range and intensity of

emotional expression, including facial
expression, voice tone, eye contact and
body language.
 Negative Symptom
• Alogia (poverty of speech)

• Lessening of speech fluency and

productivity, thought to reflect slowing or
blocked thoughts; often manifested as
short, empty replies to questions.
 Negative Symptom
• Avolition

• The reduction, difficulty or inability to

initiate and persist in goal-directed
behavior. Often mistaken for apparent
disinterest.
 Examples of Avolition
• No longer interested in going out with
friends
• No longer interested in activities that the
person used to show enthusiasm
• No longer interested in anything
• Sitting in the house for hours or days
doing nothing
 Disorganized Symptoms
• This one is somewhat new and may not be
considered valid.

• It is thought disorder, confusion,

disorientation and memory problems.
 Summary of Negative Symptoms
• Lack of emotion
• Low energy
• Lack of interest in life
• Affective flattening
• Alogia
• Inappropriate social skills
• Inability to make friends
• Social isolation
 Cognitive Symptoms
• Difficulties in concentration and memory:
– Disorganized thinking
– Slow thinking
– Difficulty understanding
– Poor concentration
– Poor memory
– Difficulty expressing thoughts
– Difficulty integrating thoughts, feelings,
behaviors
 FYI: Negative Symptoms
• Currently there is no treatment that has a
consistent impact on negative symptoms.
 Types of Schizophrenia
• Paranoid
• Hebephrenic
• Catatonic
• Residual
• Schizoaffective
• Undifferentiated
 Paranoid Schizophrenia
• Persons are very suspicious of others and
often have grand schemes of persecution
at the root of their behavior.

• During this phase they may have

hallucinations and frequent delusions.
 Paranoid Schizophrenia
• Meets basic criteria for Schizophrenia
• Preoccupied with delusions or frequent
auditory hallucinations
• None of these symptoms is prominent:
– Disorganized speech
– Disorganized behavior
– Inappropriate of flat affect
– Catatonic behavior
 Hebephrenic Schizophrenia
• AKA disorganized schizophrenia; characterized
by emotionless, incongruous, or silly behavior,
intellectual deterioration, frequently beginning
insidiously during adolescence.

• May be verbally incoherent and may have

moods and emotions that are not appropriate to
the situation.

• Hallucinations not usually present.

 Catatonic Schizophrenia
• Person is extremely withdrawn, negative
and isolated.

• May have marked psychomotor

disturbances.
 Catatonic Schizophrenia
• Meets basic criteria for Schizophrenia
• At least 2 catatonic symptoms predominate:
– Stupor or motor immobility (catalepsy or waxy
flexibility)
– Hyperactivity w/o apparent purpose or not
influenced by external stimulation
– Mutism or marked negativism
– Peculiar posturing, stereotypes, or mannerisms
– Echolalia or echopraxia
 Residual Schizophrenia

• Lacks motivation and interest in day-to-

day living.

• Person is not usually having delusions,

hallucinations or disorganized speech.
 Residual Type
• At one time met criteria for Schizophrenia,
Catatonic, Disorganized, or Undifferentiated Type
• No longer has pronounced catatonic behavior,
delusions, hallucinations, or disorganized speech
or behavior
• Still ill as indicated by either
– Negative symptoms
– Attenuated form of at least 2 symptoms of Schz
 Schizoaffective Disorder
• There will be symptoms of schizophrenia
as well as mood disorder (depression,
bipolar, mixed mania).
 Undifferentiated Schizophrenia
• Conditions meeting the general diagnostic
criteria for schizophrenia but not
conforming to any of the previous types.

• Exhibits more than one of the previous

types without a clear dominance of one.
 Undifferentiated
Schizophrenia
• Meets basic criteria for Schizophrenia but
not Paranoid, Disorganized or Catatonic
types
• Diagnosis of exclusion..what is left
 Disorganized Schizophrenia
• Meets all of the basic criteria for
Schizophrenia plus
• Disorganized behavior
• Disorganized speech
• Affect is flat or inappropriate
• Not meet criteria for Catatonic Schz.
 Schizophreniform Disorder
• “A” criteria symptoms for at least a month
• Delusions (only 1 required, if bizarre)
• Hallucination(s)*
• Incoherent, derailed, or disorganized speech
• Severely disorganized or catatonic behavior
• Negative symptom
• From prodromal to active and residual,
symptoms last at least one month but no
longer than six months
 Summary
• Before a diagnosis the psychiatrist must
make a thorough evaluation including a
physical/medical exam, a mental status
exam, appropriate labs, and a full history.

• History includes changes in thinking,

behavior, movement, mood, etc. as seen
by the family.
 Conventional Antipsychotics
Generic Brand
Haloperidol Haldol
Chlorpromazine Thorazine
Fluphenazine Prolidixin
Thiothixene Navane
Trifluoperazine Stelazine
Thioridazine Mellari
Perphenazine Trilafon
Loxapine Loxitane
 Conventional Antipsychotics
• Advantage • Disadvantage
-Effective for positive - Could worsen
symptoms of cognitive function
schizophrenia - Minimally effective for
- Available in IM negative symptoms
formulation for acute of schizophrenia
psychosis/agitation - Higher incidence of
- Cheap side effects (EPS,
NMS,
tardive dyskinesia, etc.
 Atypical Antipsychotics
• Generic • Brand
Clozapine Clozaril, FazaClo
Olanzapine Zyprexa (Aydis)
Risperidone Risperdal (Consta, M-
Quetiapine tab)
Ziprasidone Seroquel, Seroquest XR
Aripiprazole Geodon
Paliperidonen Abilify
Invega (newest)
 Atypical Antipsychotics
• Advantage • Disadvantage
- Effective for positive - Higher incidence of
of symptoms of weight gain
schizophrenia - Higher incidence of
- May improve negative diabets
symptoms of - Expensive
schizophrenia
- Lower incidence of
side effects compared
to conventional
antipsychotics
 Side Effects
• Neuroleptic malignant syndrome (NMS)
– Potentially life threatening
– High fever, unstable BP, myoglobinemia
• Extrapyramidal symptoms (EPS)
– Involuntary muscle symptoms similar to those of Parkinson’s
disease
– Akathisia (distressing muscle restlessness)
– Acute dystonia (painful muscle spasms)
– Treated with benztropine (Cogentin) and trihexyphenidyl (Artane)
• Tardive dyskinesia (TD)
– Involuntary contractions of oral and facial muscles
– Choreoathetosis (wavelike movements of extremities)
– Occurs with continuous long-term antipsychotic therapy
 Medications
• In general it may take up to 6 months for
medications to show consistent effects.

• The newest medication is Invega.

• Meds include atypicals: Abilify, Geodon,
Clozapine, Risperidone, Seroquel,
Zyprexa.
– [Remember: a giraffe can really see a zebra]
• These medications may have such
intolerable side effects that the patient will
stop the drugs.

• One study showed the average time the

meds were taken regularly was 3 months.
 Factors related to good
prognosis of
Schizophreniform Disorder
• Actual psychotic features begin within 4
weeks of the 1st noticeable change in the
patient’s functioning or behavior
• Pt. confused or perplexed when psychotic
• Good premorbid social or job functioning
• Affect is neither blunt nor flattened
 Treatments
• Psychotherapy - an adjunct to meds and is very
useful to keep the patient on the meds.

• Group therapy

• Family therapy

• Community support groups

 Medication Issues
• Chlorpromazine (Thorazine); Fluphenazine
(Prolixin); Haloperidol (Haldol); Thiothixene
(Navane); Thioridazine (Mellaril) &
Perphenazine (Trilafon)
• Benzodiazepines
– Valium (diazepam)
– Librium (chordiazepoxide)
• Tardive dyskenesia
• Newer drugs (Risperdal, Clozaril & Zyprexa)
• Tablet or liquid form with “depot formulations”
 Serious antipsychotic
medication side effects
• Restlessness
• Muscle stiffness
• Slurred speech
• Extremity tremors
• Agranulocytosis
• Early detection and treatment has the best
results/response to treatment.

• Per patients, once you have schizophrenia

you have it for life. The best you can hope
for is control.
 Factors related to good
prognosis in Schizophrenia
• Late onset
• Obvious precipitating factors
• Acute onset
• Good premorbid social, sexual, and work history
• Married
• Family/Personal history of mood disorders
• Good support systems
• Positive symptoms
 Factors related to poor
prognosis in Schizophrenia
• Young and insidious onset
• No precipitating factors
• Poor premorbid social, sexual, and work histories
• Withdrawn, autistic behavior; assaultive history
• Single, divorced or widowed
• Neurological signs and symptoms/prenatal trauma
• Family history of schizophrenia
• No remission in 3 years; many relapses
 FYI: Cancer Study
• A study in France in 1993, with 3470
patients with schizophrenia, showed that
breast cancer was the second most
common cause of death.

• www.komen.org/schizophreniaassociated
withincreasedcancermortality
. Cancer 2009.
• The next few slides are a review of
general psychiatric definitions, defense
mechanism and communication
techniques.

• They may or may not be related to the

current topic.
 Psych Definitions
• Delusion = fixed beliefs that usually
involve a misinterpretation of experience.
“Client believes someone is reading his
thoughts”

• Several types: grandiose, nihilistic,

persecutory, somatic
 Psych Definitions
• Hallucinations = perceptual experiences
that occur in absence of actual sensory
stimuli; involves the 5 senses.
 Psych Definitions
• Illusions = person misperceives or
exaggerates stimuli that actually exist in
the external environment.
 Defense Mechanism
• Affiliation =
Turning to others for help or support; sharing
problems with others without implying that
someone else is responsible.

Ex: An individual has a fight with spouse and

turns to their best friend for emotional support.
 Defense Mechanism
• Devaluation =
Attributing exaggerated negative qualities to
self or others.

Ex: A boy has been rejected by his long time

girlfriend. He tells his friends that he realizes
that she is stupid and ugly.
 Defense Mechanism
• Displacement =
Transferring a feeling about, or a response to,
one object onto another (usually less
threatening) substitute object

Ex: A child is mad at her mother for leaving

for the day, but says she is really mad at the
sitter for serving her food she does not like.
 Communication Technique
• Confrontation =
Presenting the patient with a different reality
of the situation.

Ex: My best friend never calls. She hates me.

Nurse ‘I was in the room yesterday when she
called.’
 Communication Technique
• Doubt =
Expressing or voicing doubt when a patient
relates a situation.

Ex: My best friend hates me. Nurse ‘From

what you have told me, that does not should
like her. When did she last call you?’
Resources
Schizophrenia Symptoms, by NARSAD,
The Mental Health Research Association.

Schizophrenia Treatment, by John

Grohol, PsychCentral, 08/07/08

Psychiatric Study Guide by Central

Regional Hospital
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