CENTRAL PHILIPPINE UNIVERSITY
COLLEGE OF NURSING
The First Nursing School in the Philippines, 1906
Iloilo City, Philippines 5000
Tel. No. (63-33) 3291971 to 79 Local 1037 / 2133
Website: http://www.cpu.edu.ph | Email: nursing@cpu.edu.ph
Lecture Notes on
NCM 3218
(Care of Clients with Maladaptive Patterns of Behavior-Acute/Chronic)
SCHIZOPHRENIA
DEFINITION:
A psychotic disorder causing disturbances in perception, thought processes, reality testing, feeling,
behavior, attention and motivation
Onset: late adolescence or early adulthood
Peak onset: 15-25 year old (Men); 23-35 years old (Women)
HISTORY OF SCHIZOPHRENIA
Emil Kraeplin psychiatrist that first described schizophrenia as a specific mental illness
in 1887
coined the name Dementia Praecox
organic pathology
Eugene Bleuler coined the term Schizophrenia
Bleuler’s 4 A’s
o Associative disturbance
o Autism
o Affective disorder
o Ambivalence
Sigmund Freud emphasized the psychological factors in the etiology
hallucination originated from frightening & unbearable ideas
Carl Jung introvert people
proposed that emotional disorder could cause a metabolic disturbance &
eventually physical brain damage in psychotic patients
ETIOLOGY
1. Genetic Factors
10% to 20% risk of inheriting schizophrenia - one immediate family member with the disease
approximately 40% - if the disease affects both parents or an identical twin
Interaction of a genetic susceptibility and environmental stress
2. Biochemical Influences
dopamine hypothesis
hemispheric dysfunction of the brain
impaired modulation of stimulus input
3. Neuroanatomical Theories
brain dysfunction
diagnosed thru CT Scan or PET Scan
1|Schizophrenia – Prof. Borlado
4. Intrapsychic Influences
not because of what others did to him, but “because of what he does with what has been done
to him”
predisposition of the personality to break down under high levels of stress
5. Interpersonal Influences
Disordered communication within the family
Lack of feedback mechanisms
Parents faulty relationship
Double-bind communication
Families are severely fused
Undifferentiated ego mass
CLASSIFICATION of SIGNS and SYMPTOMS
POSITIVE NEGATIVE
Delusions Alogia
Hallucinations Anhedonia
Ideas of reference Apathy
Suspiciousness Blunted affect
Associative looseness Catatonia
Echopraxia Flat affect
Grandiosity Lack of volition
Hostility
TYPES OF SCHIZOPHRENIA
Type Description Signs and Symptoms
Catatonic marked disturbance of psychomotor Rigidity
activity (motionless or excessive motor Waxy flexibility
activity) Stupor
Mutism
Negativism
Posturing or excitement
Echolalia
Echopraxia
Disorganized most severe disorganized /incoherent speech
poor prognosis flat, silly, inappropriate affect
unusual mannerisms (giggling)
hypochondriasis
extremely withdrawn
may hallucinate/have delusions -
loosely organized
Paranoid favorable prognosis Preoccupation with delusions of
persecution &/or grandeur
Ideas of reference
Auditory hallucination
(persecutory/grandiose)
Suspicious
2|Schizophrenia – Prof. Borlado
Hostile- can possibly be violent
Angry
Reserved & controlled social
interaction
Undifferentiated characterized by symptoms of Hallucination
schizophrenia but do not meet the Delusion
criteria for subtypes (paranoid, Incoherence
catatonic, or disorganized)
Residual exhibited psychotic symptoms of Social withdrawal
schizophrenia in the past, but is not Emotional blunting
psychotic at present Illogical thinking/eccentric behavior
SCHIZOPHRENIC-LIKE DISORDERS
Type Description Signs and Symptoms
Schizoaffective disorder Has psychotic symptoms of Affective symptoms:
schizophrenia and meets the criteria -extreme depression or elation
for a major affective or mood disorder
(mood and thought disorder) Schizophrenic symptoms:
(+) and (-) symptoms
Brief Psychotic Disorder sudden onset of psychotic symptoms Incoherent speech
following a severe psychosocial Delusions
stressor that last for a day but less Bizarre behavior
than a month Disorientation
Hallucinations
Schizophreniform Disorder exhibits features of schizophrenia for Incoherent speech
at least 1 month but fewer than 6 Delusions
months Bizarre behavior
Disorientation
Hallucinations
Delusional disorder client has one or more non bizarre
delusions for at least a month
Types:
Erotomanic
Grandiose
Jealous
Persecutory
Somatic
Shared Psychotic Disorder called folie a deux
Delusion that develops in the context
of a close relationship with someone
who has psychotic symptoms
Psychotic disorder due to Causes: prominent hallucinations or delusions
General Medical Condition Neurological conditions – CVD,
3|Schizophrenia – Prof. Borlado
Huntington’s disease, Epilepsy,
Migraine headache, CNS
infections
Endocrine disorders – hypo or
hyperthyroidism
Metabolic conditions – hypoxia,
hypercarbia, hypoglycemia
Autoimmune disorder – SLE, fluid
electrolyte imbalance, hepatic or
renal disorder
SUBSTANCE-INDUCED PSYCHOSIS
presence of prominent hallucinations & delusions that are judged to be directly attributable to the
physiological effects of the substance
causes:
drug abuse
medications
toxins
PSYCHIATRIC SIGNS and SYMPTOMS
1. Thought Content
Delusion
- persecutory
- grandeur
- reference
- control
- somatic
- nihilistic
- religiosity
- paranoia
- magical thinking
2. Form of Thought
associative looseness
neologisms
concrete thinking
clang association
word salad
circumstantiality
tangentiality
mutism
perseveration
3. Perception
Hallucination
- auditory
- visual
- tactile
- gustatory
- olfactory
Illusions
4|Schizophrenia – Prof. Borlado
4. Affect
inappropriate
blunt
flat
apathy
5. Sense of Self
weak ego boundaries
lack feeling of uniqueness
great deal of confusion with identity
6. Psychomotor behavior
Anergia
Waxy Flexibility
Posturing
Pacing and rocking
7. Other findings
Emotional Ambivalence
Impaired Interpersonal Functioning
Autism
Deteriorated Appearance
Echolalia
Echopraxia
Identification
Depersonalization
Anhedonia
Regression
DIAGNOSTIC WORK-UP
1. History and Mental Status Examination
2. Physical and Neurological Examination
3. Basic Laboratory Work
4. Psychological Tests
5. MRI Scan or CT Scan
6. Lumbar Puncture
7. Electroencephalogram (EEG)
8. Positron Emission Tomography (PET) Scan
9. Dexamethasone Suppression Test (DST)
PSYCHOPHARMACOLOGY
antipsychotics/neuroleptics
watch out for side effects
- EPS
- NMS
- Anticholinergic symptoms
OTHER THERAPIES
1. Counseling/Supportive Psycotherapy
insight-oriented psychotherapy
5|Schizophrenia – Prof. Borlado
cognitive behavioral therapy (CBT)
treatment techniques:
a. Desensitization
b. Reciprocal Inhibition technique
c. Reinforcement methods & token economies
d. Conditional avoidance technique
e. Negative reinforcement
o Social conditioning
o Extinction technique
o Negative practice
f. Biofeedback vs. meditation
g. Implosive therapy
2. Electroconvulsive Therapy (ECT)
3. Nutritional Treatments
KEY OBJECTIVES for TREATING SCHIZOPHRENIA
1. Work with the family
2. Treat depression
3. Minimize stressful interactions
4. Treat substance abuse
5. Avoid lengthy intense verbal interactions
ASSESSMENT
1. Current level of functioning
2. Psychosocial needs and deficits
3. Prior level of adjustments and functioning
4. Family and environmental factors
5. Social History
Description of premorbid personality
Major life events & client’s responses
Significant stressors & description of behavior
Precipitants
PROBLEM IDENTIFICATION
1. Intolerance & diminished capacity to cope w/ stress & anxiety
2. Low self-esteem
3. Family problems
NURSING INTERVENTIONS
1. Client Focus Intervention
2. Communication – related to autistic and thought disorder
Goal: decipher client’s unclear messages
3. Reinforce reality
Have one consistent person on each shift assigned to provide reassurance & reality
interpretation (channeling or focusing)
Give brief clear explanation/communication
Antipsychotic drugs are beneficial
Careful observation & knowledge of client behavior
Focus of therapy is on the ‘here & now’ experiences & feelings (present reality)
Involve client in occupational, recreational therapy, social activities
6|Schizophrenia – Prof. Borlado
Note: Interventions should be SIMPLE, CLEAR and CONCRETE to avoid client confusion. Non-verbal
communication is a powerful means of conveying NURTURANCE and SECURITY.
LONG-TERM GOALS
1. Acknowledge clients strengths
2. Plan a variety of physical activities aimed at improving coordination & enjoyment of bodily activities
3. Provide non-verbal modes of expression
4. Manage stress & anxiety
GENERAL PRINCIPLES for INTERACTION & INTERVENTION
1. maintain health & safety
2. establish a trusting interpersonal relationship
Prepared By:
HERME A. BORLADO, MAN
Instructor
7|Schizophrenia – Prof. Borlado
