Schizophrenia- is a psychotic disorder characterized by delusion, hallucination, and

disturbances of thought, perception and behavior.

It causes distorted and bizarre thoughts perception, emotion, movements and behavior. It
is characterize by distorting personality.
It is usually diagnosed in adolescence or early adulthood.
It is rare in childhood. It affects men and women equally 15 to 25 year’s old for men and
25-35 years of age for women.
DELUSION VS. ILLUSION ACCORDING TO FREUD
• Illusionary belief some are true others are not
• Delusional beliefs are false
Other comparison
Delusion
Two categories of symptoms
1. Positive symptoms: caused by excessive Dopamine in Mesolimbic Tract
• Abnormal thoughts
• Agitation
• Bizarre behavior
• Delusion
• Excitement
• Feelings of persecution
• Grandiosity
• Hallucination
• Hostility
• Illusions
• Insomnia
• Suspiciousness
Note:
• If patient taking medication avoid them to go out especially in going to
bathroom
• Don’t allow your patient to manipulate you

2. Negative symptoms: caused by too little Dopamine in Mesocortical Tract

• Alogia
• Anergia
• Asocial behavior
• Attention deficit
• Avolition
• Blunted affect
• Communication difficulties
• Difficulty with abstractions
• Passive social withdrawal
• Poor grooming and hygiene
• Poor rapport
• Poverty of speech
THREE OVERLAPPING PHASES OF THE DISORDER:
1. Acute phase: the patient experiences severe psychotic symptoms
2. Stabilizing phase: the patient is getting better
 3. Stable phase: the patient might still experience hallucinations and delusion (but not
as severe or disabling as they were during the acute phase)
Most patient alternate between acute and stable phase
Gross disorganized thinking, speech and behavior
• Negative or soft symptoms/sign
• Flat effect
• Lack of volition
• Social withdrawal or discomfort
DSM-IV TR DIAGNOSTIC CRITERIA
1. Positive or Hard symptoms
A. Ambivalence-holding seemingly contradictory beliefs or feelings about the
same person, event or situation.
B. Associative looseneness- fragmented or poorly related thoughts and ideas

• Delusions-fixed false beliefs that has no basis in reality

• Echopraxia- imitation in the movements and gestures of another
person whom the client is observing
• Flight of ideas- continuous flow of verbalization in which the person
jumps rapidly from one topic to another
• Hallucinations- false sensory perceptions that don’t exist in reality
• Ideas of reference- false impressions that external events have
special meaning in the person.
C. Perseveration- persistent adherence to single idea or topic, verbal
reputation of a sentence, word or phrase resisting attempt to change the
topic.

2. Negative or soft symptoms:

• Alogia- tendency to speak very little orto convey little substance of
meaning (poverty of content)
• Anhedonia- feeling no joy or pleasure from life or any activities or
relationship
• Apathy- feeling of indifference toward people, activities and events
• Blunted effect- restricted range or emotional feelings tone or mood
• Catatonia- psychologically induced immobility occasionally marked by
periods of agitation or excitement, the client seems motionless as if in a
trance.
• Flat effect- absence of any facial expressions that would indicate
emotions or mood
• Lack of volition- absence of will, ambitions, or drive to take action or
accomplish the tasks.
Medication can control the positive symptoms but frequently the negative
symptoms persists after positive symptoms have abated.
The persistent of these negative symptoms presents a major barrier to
recovery and improved functioning in clients daily life.
THREE (3) OF SCHIZOPHRENIA
According to clients predominant symptoms
1. Paranoid type- Cha by persecutory (feeling victimized or spied on) or
grandiose delusion, hallucinations, and occasionally excessive religiosity
(delusional religious focus) or hostile and aggressive behavior.
2. Disorganized type- Cha by grossly inappropriate or flat effect,
incoherence loose association and extremely disorganized behavior
 3. Catatonic type- Cha by marked psychomotor disturbance, either
motionless or excessive motor activity.
Motor immobility can be manifested by CATALEPSY (WAXY FLEXIBILITY) OR STUPOR.
Excessive motor activity is apparent purposeless a d is not influenced by external stimuli.
Other features include:
Extreme negativism, mutism, peculiarities of voluntary movement, echolalia and
echopraxia.
❖ Undifferentiated type- cha by mixed schizophrenic symptoms ( of other types)
along with disturbances of thought, affect and behavior.
❖ Residual type- Cha by at least one previous, though not a current episode of social
withdrawal, flat affect, and looseness of association.
Clinical course although symptoms are always severe, the long term course does not
always involved progressive deterioration.
Onset maybe abrupt or insidious but most clients slowly and gradually develop signs and
symptoms such as social withdrawal, unusual behavior loss of interest in school and work
and neglected hygiene. The diagnosis of schizophrenia is made when the person begins to
display more actively positive symptoms of delusion hallucinations Andover thinking.
Age at onset appears to be an important factor on how well the client improve.
Those work develop the illness earlier show worst outcome than those work develop it
later. Younger clients display poorer premorbid adjustments, negative signs, and greater
cognitive impairment than older clients. Those who experience a gradual onset of the
disease (about 50%) tend to have a both a poorer immediate and long term course than
those who experience an acute and sudden onset. Approximately one third of clients with
schizophrenia relapsed within one-year of an acute episode.

Immediate course schizophrenia

In years immediately after the onset of psychotic symptoms two clinical pattern emerge;
• The client experiences ongoing psychosis and never fully recover, although
symptoms may sift in severity over time
• The client experiences episodes of psychotic symptoms that alternate with episodes
of relatively complete recovery from the psychosis.
LONG TERM COURSE OF SCHIZOPHRENIA
• The intensity of psychosis tends to diminished with age. Many clients with long term
impairment regain some degree of social and occupational functioning. Overtime
the disease become less disruptive to thepersonslide and easier to manage but
rarely can the cient can over come the effects of many years of dysfunction.
However most clients with schizophrenia have difficulty functioning in the
community, and few lead a fully independent lives. This is primarily due to
persistent negative symptoms, impaired cognition, or
• Anti psychotic medication play a crucial role in the course of the disease and
individual outcome. They do not cure the disorder however, they are crucial to it’s
successful management. The more effective the client reponse and adherence to his
or her.
• Marshall and Ratbone (2006) found that Early detection and aggressive treatment
of the 1st psychotic episode were associated with improved outcomes.
RELATED DISORDER
Other Disorder are related to but distinguished from schizophrenia in terms of
presenting symptoms and the duration or magnitude of improvement.
DSM-IV-TR CATEGORIES:
• Schizophrenia disorder- the client exhibit the symptoms of schizophrenia but
forless than 6 mos necessary to meet the diagnostic cirteria of schizophrenia.
Social or occupational functioning may or may not be impaired
• Schizoaffective disorder- the clients exhibit the symptoms of psychosis and at
the same time all the features of a mood Disorder either depression or mania.
• Delusional Disorder- the client has one or more non bizarre delusion that is
the focus of the delusion is believable.
Psychosocial functioning is not markedly impaired and not obviously off or
bizarre.
• Brief Psychotic Disorder- the client and experiences the sudden onset at
least one psychotic symptoms, such as delusios, hallucinations, or
disorganized speech, or behavior which last from 1 day to 1 month. The
episode may or may not have an idetifiable stressor or may follow childbirth.
• Shared psychotic disorder- two people share a similar delusion.

The person with this diagnosis develops this delusions in the context of a
close relationship with some one who had psychotic.
• Schizotypal personality and schizoid personality are personality disorder
and not psychotic disorders should not be confused with schizophrenia even
though means the names sound similar.

Etiology:
❖ Researchers and clinicians tried to answer the question if
schizophrenia is caused by organic disease.
❖ In the 1st half of 20th century the study focused on pathologic
structure associated with the disease largely through autopsy. Such
site was not discovered.
❖ In 1950's and 60's the emphasis shifted to examination of
psychological and social causes.
• Interpersonal theorist suggested that schizophrenia is a result of
dysfunctional relationships in early life and adolescence none of these
theories has been proved.
• New scientific studies are finding more evidenced to support neurologic/
neurochemical causes. However some therapists still believe that
schizophrenia results from dysfunctional parenting or family dynamics.

Newer scientific studies began to demonstrate that schizophrenia

results from a type of brain dysfunction.

• In 1970's studies began to focus on possible neurochemical causes which

remain the primary focus of research and theory today. The
neurochemical/neurologic theories are supported by the effects of
antipsychotic medications, which help to control psychotic symptoms, and
neuroimaging tools such as computed tomography which have shown that
the brain of people with schizophrenia differs in structure and function from
the brain of control subjects.
 BIOLOGIC THEORIES

Genetic factors

• Neuroanatomic
• Neurochemical factors (structure and function of the brain)
• Immunovirology (the body's response to exposure to a virus)

Genetic factors
- Focused on immediate families (ie parents, siblings, offspring) to
examine whether schizophrenia is genetically transmitted or
inherited. Few have focused on distant relatives.
• Findings indicated identical twins have a 50% risk for schizophrenia that is if
another twin has schizophrenia the other has a 50% chance of developing it as well.
Fraternal twins has a 15% chance risk. This indicates that schizophrenia is at least
partially inherited.
• Children with one biologic parent with schizophrenia have 15% risk, 35% if both
biologic parents have schizophrenia. Children adopted by parents with no history of
the illness but biologic parents has, still reflect the genetic risk of their biologic
parents.

All these studies have indicated a genetic risk or tendency for schizophrenia
But genetics cannot be the only factor, identical twins have only 50% risk even
though their genes are 100% identical.

Neuroanatomic and Neurochemical Factors

• With use of noninvasive imaging techniques such as ct scans, MRI's and positron
imaging tomography scientist have been able to study brain structures and activity.
Findings noted people with schizophrenia have relatively less brain tissue and CSF
than people who do not have schizophrenia.
CT scans reveals enlarged ventricles in the brain and cortical atrophy

• Positron emission tomography studies suggest that glucose metabolism and oxygen
are diminished in the frontal cortical structures of the brain. Research also shows
that there is decreased brain volume and abnormal brain function in the frontal and
temporal areas. This pathology correlates with the positive signs of schizophrenia
(temporal lobe )such as psychosis, and the negative signs (frontal lobe) the most
prominent neurochemical theories involve dopamine and serotonin.

• One theory suggest excess dopamine as a cause. This theory was developed on two
observations:
1. Drug that increase activity in the dopaminergic system, such as
amphetamine and levodopa, sometimes induce a paranoid psychotic
reaction similar to schizophrenia.
2. Drugs blocking post synaptic dopamine receptors reduce psychotic
symptoms, in fact the greater ability of the drug to block dopamine
receptors the more effective it is in decreasing the symptoms of
schizophrenia.

• Serotonin
- theory suggest that it modulates and helps to control excess
dopamine. Some believe that excess serotonin itself contributes to the
development of schizophrenia.
Latest atypical antipsychotics
• clozapine (clozaril) are both dopamine and serotonin antagonists Studies show
that clozapine can dramatically reduce psychotic symptoms and ameliorate the
negative signs of schizophrenia.
Possibility that schizophrenia may have three separate symptoms complexes or
syndromes;
1. hallucinations/delusion
2. disorganization of thought and behavior
3. negative symptoms.
Immunologic Factor
- Popular theories state that exposure to a virus could alter the brain
physiology of people with schizophrenia.
Cultural considerations
• Cultural differences is important when assessing for symptoms of schizophrenia.
Ideas that are considered delusional in one culture maybe is acceptable to other
cultures. Also auditory or visual hallucinations, such as seeing Virgin Mary or
hearing God's voice maybe a normal part of religious experience in some cultures.
Treatment
• Psychopharmacology
- Primary medical treatment for schizophrenia is psychopharmacology
In the past were used:
• ECT
• insulin shock therapy
• psychosurgery

➢ But since the creation of chlorpromazine (thorazine) in 1952 other treatment

modalities have become all but obsolete.
➢ Antipsychotic medications also known as neuroleptics are prescribed primarily
for their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia,
rather they are used to manage the symptoms of the disease.
➢ Older or conventional antipsychotic medications are Dopamine antagonists.
➢ The newer or atypical anti psychotic medication are both dopamine and serotonin
antagonist.
Maintenance Therapy
• Available in depot inj. forms for maintenance therapy.
➢ Fluphenazine (prolixin)
➢ Haldol decanoate
• the effects of medication last 2 to 4 weeks, eliminating the need for daily oral
antipsychotics.
• 7 to 28 days for fluphenazine the duration of action 4 weeks for haloperidol
• It will take several weeks of oral therapy to reach a stable dosing before the
transition to depot injection.
• Therefore they are not advisable to take during the acute episode of psychosis.

However they are useful for clients requiring supervised medications compliance over
an extended period of time.
 Side effects
• Many of these side effects are significant and can range from mild discomfort to
permanent movement disorders. Because of frightening and upsetting side
effects,patients discontinue or reduce the dosage of their medications.
Serious neurologic side effects:
• Extrapyrimidal side effects (EPS) acute dystonic reactions, akathisia, and
parkinsonism
Tardive dyskinesia seizures
Neuroleptic malignant syndrome (NMS)

Extra pyrimidal side effects (EPS)

- Are reversible movement disorders induced by neuroleptic
medication. They include dystonic reaction, parkinsonism and
akathisia
• Dystonic reaction appear early in the course of treatment and are cha by spasm
in discrete muscle group such as the neck muscles(torticollis) or eye muscles (
oculogyric crisis). Spasm maybe accompanied by protrusion of the tongue,
dysphagia, and laryngeal, and pharyngeal spasm that can compromise the clients
airway causing a medical emergency
❖ Dystonic reaction are extremely frightening and painful for the client.
❖ Treatment consist of diphenhydramine (Benadryl) given either intramuscularly
or intravenously or benztropin (cogentin) given intramuscular
❖ Pseudoparkinsonism or neuroleptic - induced parkinsonism, includes a shuffling
gait, mask like faces, muscle stiffness (continuous) or cog wheeling rigidity (ratchet
like movements of joints) drooling, and akinesia (slowness and difficulty initiating
movement).
These symptoms usually appear on the 1st few day after starting or increasing
the dosage of antipsychotic medication.
1. Akathisia- is cha by restless movement, pacing, inability to remain still, and the
clients report of inner restlessness. Akathisia usually develops when the
antipsychotic is started or when the dose is increased Beta blockers such as
propanolol have been most effective in treating akathisia. Benzodiazepines
provided some success as well.
2. Tardive Dyskinesia- a late appearing side effects of antipsychotic medications, cha
by involuntary movements such as lip smacking, tongue protrusion, chewing,
blinking, grimacing, and choreiform movement of the limbs and feet. It is
irreversible once it has appeared. Decreasing or discontinuation of medication can
arrest the progression.
❖ Seizures are infrequent side effects associated with antipsychotic side effects.
❖ Clozapine has an incidence of 5%. Seizures maybe associated with high dose of
medication Treatment is to lower the dose or change the medication.
3. Neuroleptic Malignant Syndrome (NMS)
❖ NMS is a serious and frequently fatal condition seen in those being treated
with antipsychotic medications.
❖ medications Cha by muscle rigidity, high fever, increased muscle enzyme
(particularly creatinine phosphokinase) and leukocytosis.
• It is estimated that around that 0.1% to 1% of all clients taking antipsychotic
develops NMS. Any antipsychotic medications can cause NMS which is treated by
stopping the medication. The clients ability to use other antipsychotic
medication after NMS varies but use of another antipsychotic appears possible in
most instances. Agranulocytosis
• Clozapine has the potentially fatal side effect of agranulocytosis (failure of the
bone marrow to produce adequate white blood cells) the drug must be
discontinued immediately.
• Clients taking this antipsychotic must have weekly WBC for the 1st 6 mos of
clozapine therapy and every two weeks thereafter. Clozapine is dispensed every
7 to 14 days only.
Psychosocial Treatment
Individual and group therapies - usually supportive giving the client an opportunity
for social contact and meaningful relationships. Groups also focus on topics of
concern such as medication management, use of community supports and family
concerns proves beneficial
• Family therapy
• Family education