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: [email protected]

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
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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