SCHIZOPHRENIA

Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the
world. `
People with schizophrenia have an altered perception of reality, often a significant loss
of contact with reality. They may hear things that don’t exist, speak in strange or
confusing ways, and believe that others are trying to harm them, or feel like they’re
being constantly watched
Schizophrenia is one the most common psychotic mental illnesses. Most of the patients
suffering from chronic psychosis are in fact suffering from sz and approximately half of
patients in any mental hospital are usually from this condition.

It is estimated that between 1 and 4 per 1000 people in any country suffer from SZ at any
one time and that 1 in 100 are likely to suffer from SZ some time during their life span.

The onset of SZ is usually insidious, but acute episodes are not uncommon. The disease
usually begins during adolescence although it can occur anytime between the ages of 15
to 30 years. There is often history of a schizoid premorbid personality.

Relapses are common especially where there is insufficient support from the family,
community and primary health care workers or if the patient is not fully accepted or re-
integrated into his previous occupation or social environment. There is a tendency for
each relapse to leave residual symptoms-ultimately leading to chronic SZ.

CAUSES:
The causes of SZ are complex and not fully understood but it tends to be predisposed by
genetic factors i.e. to follow particular families. Genetic factors appear to cause abnormal
levels of dopamine in the brain which is associated with appearance of schizophrenic
symptoms.

However the onset of SZ is in many cases precipitated by psychosocial or other stress i.e.
stressful life events such as interpersonal conflicts, loss, frustration, disappointments,
failure, childbirth, physical disease or other. It seems fair to conclude that schizophrenia
(sz) is caused by a combination of many factors some of which may not be fully
understood.

CLINICAL FEATURES
The signs and symptoms of SZ vary from patients to patient. However, most of these will
be easy to learn and remember what was considered within the context of the general
signs and symptoms of psychosis.

The manifestations of schizophrenia:

i) Withdrawal from others and reality e.g. the patient gradually loses interest in
social contact with others such as family members, friends or colleague,
however, the premorbid personality of most people who develop SZ is usually
characterized by social and emotional detachment.
ii) As the symptoms progress, the person may become increasingly solitary. He
may become preoccupied with religious; political or metaphysical issues.
iii) Thought disorders (disturbances of the thinking process) .These are
particularly important diagnostic guidelines.
a) Thought echo/audible thoughts i.e. the patient may hear his own thoughts
spoken out loudly and clearly.
b) Thought broadcasting i.e a patient’s belief that his thoughts are understood
or read by other people as they occur in his head.
c) Thought insertion- a belief that thoughts are put in one’s head by others
people.
d) Thought withdrawal- believing that one’s thoughts are removed by other
people from ones head.
e) Thought blocking i.e. interruption in the expression of thinking or train of
thought before completing the sentence. This may result in irrelevant or
incoherent speech or neologism.
f) Loosening of thinking association. Characterized by a speech in which
there is lack of connection between one idea or thought and the next one
This results in which the patient shifts from one topic to another unrelated.
g) Circumstantiality: In which the patient disgraces into unnecessary and
irrelevant details before giving an answer or getting to the central issue.

iv) Third person auditory hallucinations in which voices of two or more

people discussion or giving a running commentary among themselves about
the patient of or his behavior. The patient may hear the voices of people
talking to each other about him but not directly addressing the patient.
However, in some cases the voices may also originate from part of the patients
body.
v) Bizarre Delusion. i.e. delusional beliefs which are quite culturally
inappropriate and impossible eg. being controlled by dead ancestors, aliens
from another world, or by a black snake in the nearby forest. Having
supernatural powers to control the weather or movements of the sun or
receiving messages from God.
vi) Disturbance of willpower (loss of volition).One of the earliest manifestation
of SZ is loss of volition and interest in everyday activities. The person may
become apathetic, inactive, and stop working or going to school. He may
spend most of the time lying in bed or just sitting doing nothing. This is
accompanied by social withdrawal (see I above).Reduced productivity (or
poor classroom performance at school), apathy and paucity of speech.
vii) Disorders of affect (mood).Initially there may be irritability, feeling of
anxiety or depression. This however tends to be followed by more specific
sustained disorders of affect e.g.
(a)blunting(or flattening) of affect i.e. loss of feelings or the capacity to express
emotions. As an example, the patient may manifest an apparent loss of concern or
emotions for members of his/her family, friends or colleagues.
(b)Inappropriate mood (incongruity of affects) i.e. the patient expressed mood may not
correspond with reality i.e. he/she may laugh when told bad news or cry when told good
news.

viii) Bizarre Motor Behaviors: Manifestation of abnormal behaviour in SZ differs

a great deal. In acute SZ episodes, the patient may suddenly begin to display
odd behaviour such as outbursts of laughing without apparent reason,
restlessness, or catatonic behaviour such as assuming awkward postures,
episodes of excitement and aggression, becoming mute, or
immobile(catatonic stupor)

In other cases the patient may become increasingly withdrawn, suspicious,

and apathetic with progressive neglect of personal hygiene, deterioration
of social behaviour, mannerisms, indecisiveness (ambivalence).

NOTE.
To confirm a diagnosis of SZ the patient should have:-
a) Some thought disorders including at least two from (a) to(d) above.
b) Persistent hallucinations for a least one month.
c) Some bizarre motor behavior or disturbance of mood.
d) If the patient has got all the key symptoms of SZ for at least one month or most of
them for at least six month.
Among the above symptoms some are considered positive and others negative.
Positive symptoms
These types of symptoms are referred to as "positive" because, compared to a normal
mental state, certain individuals have more mental experiences (thoughts, feelings,
behaviors) than others. For example, hallucinations are not part of the normal, day-to-
day experience for most people. Therefore, they are classified as a surplus or positive
symptom. The phrase "positive symptoms" refers to symptoms that are in excess or
added to normal mental functioning.
Negative symptoms
Negative symptoms represent a reduction of the normal emotional responsiveness,
motivation, socialization, speech, and movement.
Positive symptoms are also called Kurt Schneider’s first rank symptoms and
they are:
 Auditory hallucinations
 Voices discussion
 Running commentary
 Commanding Voices
 Thought disorders
 Thought echo/audible thoughts
 Thought broadcasting
 Thought insertion
  Thought withdrawal
 Delusion
 Paranoid
 Nihilistic
 Bizarre
 Persecutory
 Reference
 Passivity phenomenon
 The belief that one's thoughts or actions are controlled by an external agent.

Negative symptoms are:

o Alogia
o Anergia
o Anhedonia
o Avolition
o Apathy
o A sociality (Withdrawal)

Main clinical types of SZ

Traditionally SZ is classified into four main clinical types or subgroups. However, some
authorities classify SZ into as many as nine clinical types.
From time to time the patient will be found with clinical manifestations which will
further fall into the following categories:-
(a)Hebephrenic/ disorganized Schizophrenia
This usually starts during late adolescence or early adulthood (15-25yrs) of age and is
characterized by gradual isolation from the peer group, loss of interest in teenage
activities, irritability, apathy, or depression.

Finally there is complete disorganization of personality with shallow inappropriate

mood, extreme thought disorders, bizarre behavior, meaningless childish smiles and
giggles, facial grimacing, fleeting (brief or transitory) delusions and hallucinations,
strange or awkward body movements, incoherent speech and an obvious state of living
in a world of fantasy.

b) Paranoid Schizophrenia.
This usually begins in late life e.g. between 30and50years of age. The onset and
progress may be gradual but only minimum deterioration of personality or disorders of
thinking may be present. The symptoms are dominated by delusions of persecution
which usually reflect the person’s cultural background e.g. the patient may belief that
some people are planning to harm, kill or bewitch.

He may become extremely suspicious of members of his family, colleagues, or

neighbors and accuse them of plotting to cheat him, destroy his crops or poison his
domestic animals. There is also a tendency to misinterpret the actions or comments of
others as having hidden malicious motives.
Delusion of grandeur (importance) are also common in which the patient may claim to
be very powerful, the president, the head of state that is very rich with plenty of cows,
many wives and several children.

Auditory hallucinations are common in paranoid SZ in which voices threaten or accuse

him of certain things. Very often the patient claims to hear voices from God or
commands from supreme tribal or ancestral spirits ordering him to become a
traditional healer. Other hallucinations (e.g. gustatory, tactile or olfactory) can also be
present.

c) Catatonic Schizophrenia
This type of SZ tends to occur before the age of 25 years. It is characterized by period of
extreme withdrawal and psychomotor retardation alternating with excitement
(hyperkinesis), automatic obedience or negativism. During period of extreme
withdrawal the muscles become rigid the patient may stop talking, become slow,
unresponsive, immobile or mute.
He may do the opposite of what you told him (negativism) or carry out commands
(automatic obedience).This phase of the illness is called Catatonic stupor.

During catatonic stupors the patient may remain seated or standing in one place or
position until he is moved or position changed(posturing)or may maintain limbs in
whatever position they are placed in (flexibitas cereal or waxy flexibility).

d) Simple Schizophrenia.
In this type of SZ there is only a minor withdrawal of interest, lack of motivation, poor
interpersonal relationship, eccentricity and one or two fixed delusions. Simple SZ is
also characterized by shallowness of emotions and idle and aimless life. Some patients
with simple SZ become vagrants live on the margin of society and they may never
receive modern treatment.

Other types of SZ –related condition include:-

-Schizo-affective disorder.
A condition in which there are combined features of both SZ and affective disorder such
as mania or depression.
-Undifferentiated schizophrenia

In this clinical type of SZ, most of the psychotic features of SZ are present, but the signs
and symptoms fall in more of the main clinical type of SZ (paranoid hebephrenic and
catatonic SZ)
Residual Schizophrenia
Residual Schizophrenia in which the symptoms that persist from acute phase have mostly
lost their sharpness. Emotional response is blunted and thought disorder, even when
gross, does not prevent the accomplishment to routine work (WHO 1989).
such as anxiety, fear, social, isolation, etc, may also be presents.

Implementing interventions:
a) Maintaining optimal nutrition status:
Patients suffering from SZ are at risk of being malnourished because of poor judgment,
delusional believes and other psychotic symptoms.
i) During acute phase of the illness, ensure that the patient eats all his food. Stay with
the patient to coax and encourage him to eat all his food.
If a paranoid patient refuses food due to a delusion that it is poisoned, he should be
encouraged to participate in its preparation, cooking and serving. After it’s saved he
should be asked to pick his food first before all do so. In this way, he may be certain that
his food has not been poisoned.

Make sure the patient drinks sufficient fluids.

b) Maintaining personal hygiene

A good number of patients suffering from SZ are in state of neglected personal hygiene
and need supervision or encouragement to bath, attend to their oral hygiene, to change
clothes, comb hair, cut nails and to maintain an acceptable level of personal hygiene,
dressing and grooming.
i) Nurses and members of the family should resist the temptation to do things for
the patient. The patient should be encouraged to bathe himself, change clothes
and brush his teeth.
ii) Only some of the SZ states where the patient is severely disturbed or extremely
withdrawn (eg. in catatonic stupor) the activities should be done daily for the
patients.
iii) Each patient should be taught those self-care skills which he found to be
lacking.
c) Promoting Social Interaction
i) Recognize the factor that social contact with other people tends to provoke a high
level of anxiety in a withdrawn patient. It therefore important to promote social contact
gradually though at an increasing pace.
ii) Try as much as possible to establish a close trusting relationship with the patient and
utilize this to encourage interaction with other patients, staff and others.
iii) The patient should be taken to all social activities whether he participates or not.
More presence in a place where others are singing, watching a game, etc. Has therapeutic
effect on the patients although this may not be obvious to the observer.
iv)It should be always be born in the mind that a patient in catatonic stupor mostly
understands what is always said by other people though he or she may appear oblivious
to what is happening or said. He denigrating comments, degrading treatments, or
unnecessary exposure must therefore be avoided.

d)Preventing possible injuries to others

See notes above

e)Promoting Optional Motor Behavior

i) If a behavior is bizarre or disorganized, approach the patient in a calm slow and
reassuring manner.
ii) Set limits to patients behavior as well as the rewards or sanctions he should expect
for behaving in certain ways. Limits setting are particularly necessary where a patients
behavior affects the rights and well being of others. Limits setting should not be used as
punishments for undesirable behavior, but rather as setting boundaries within which the
patient is free to behave in any way he chose, but beyond which he should expect
negative reactions and sanctions.
iv) Discuss with the patient the reasons why he behaves the way he does and assist
him to find other ways of reacting to stress or fulfilling basic human needs.
v) Give positive reinforcement to acceptable behavior.
vi) Administer appropriate ant-psychotic medication in order to calm the patient
and to restore normal behavior.
f) Alleviating Delusions

See bellow:
g) Alleviating Hallucination
i) Do not dispute or ridicule the patient’s alleged perception as being unreal.
ii) Record all hallucinatory experience as basis for future evaluation of the patient’s
progress towards recovery.
iii) Reassure the patient that you will protect him /her and provide environment where he
/she feel better.
iv)keep the patient occupied ever in order to divert attention from hallucination.
v) Constantly orient the patient towards reality.
vi) Give appropriate treatment at the right time and in the right place and right dose in
order to alleviate or remove the hallucinations
vii) Strengthen the therapeutic nurse to the patient relationship in order to utilize this to
give emotional support to the patient, to encourage him verbalize his fears and other
subjective experience, and to get him to participate in reality-oriented activities.

h)Promoting optimal communication pattern/optimal thought process

 Listen attentively to what the patient says in order to show him that you are
interested.
 Establish good relationship with him.
 Try to understand his wards symbolize if possible.
 Ask the patient to clarify what he says if you do not quite understand.
 Don't signal agreement with what he says if words do not make sense to you.
 Administer anti-psychotic medication as prescribed.
I) promoting optimal home maintenance management

A SZ patient may be so impaired that he or she may be umbel to independently provide

the financial, emotional and material needs of the family members or maintain an
acceptable level of domestic or environmental hygiene. The nurse may have to;

- Mobilize relatives’ members of the community, governmental or NGOS to

support the family.
- Carry out regular home visits to motivate, support or assist the patient’s family
carry out home maintenance management.

j) Preventing Relapse
There are many reasons why an improved SZ patient may relapse e.g.
Non compliance with prescribed follow-up medication.

Luck of family support in remanding or encouraging the patient to take

medication or attend follow-up clinics.

Psychological stress due to rejection, insulting comment or lack of acceptance

by neighbors, community members, colleagues, employer, or others.

Luck of support from community based workers and others e.g. no home
visits from primary health workers; community nurses, community
leaders, or spiritual leaders.

Luck of bus/tax fares to collect regular medication or to attend follow-up clinics as

required-especially where mental health services are not sufficiently decentralized or not
accessible to the patient.

Preventing relapse entails anticipating and forestalling factors which may precipitate
onset of another schizophrenic episode or alleviating factors which may perpetuate the
disease.
The family is of at most importance. Relatives should be made aware of factors which
may militate against recovery and be convinced of the need to stick to prescribed
medication, to collect fresh supply before the previous one is finished, and to ensure that
the patient takes medication as prescribed.

Community-based general health workers need to be convinced that mentally ill patients
in their areas are also their patients and there should never be any bias against attending
to and supporting mentally ill patients and their families.

The patient should be protected from against all possible stress which may trigger onset
of another episode e.g. negative and stigmatizing attitude by members of the community.
The patient should be continually monitored at home, at work, and in the community in
order to detect any early sign of relapse so that appropriate measures can be undertaken
to thwart another episode.

k) Teaching Specific Occupation and Social Skills

In order to ensure that the person remains a useful member of the family and
community, he must be able to contribute to his own welfare as well as that of the family
and community.

One important step towards this is to identify his current strengths and weakness and to
enhance or teach specific skills which will increase his productive capacity and his social
skills. The type of skills taught will depend up his particular needs, needs of his family
and community, available resources and his existing repeaters of skills.

Examples of such skills can be:-

i) Self care skills

 Going to a and using the toilet

 Washing himself
 Cleaning his teeth
 Dressing himself
 Feeding himself
 Socially acceptable eating habits, etc.

ii)Home craft skills.

 Washing dishes
 Preparing simple meals
 Sweeping the house
 Making beds
iii) Horticultural skills
 Growing vegetables
 Harvesting common crops
 Destroying or preventing plant pests
iv) Hand craft skills
 Simple wood work
 Basket making
 Knitting
 Weaving
 Embroidery
 Tailoring
v) Social skills
 Social behavior in the company of others
 Initiating a conversation
 Communicating with others
 Asking for assistance
 Assertiveness without being stubborn
  Finding and holding a job
 Selling ones products
 Playing games
 Dancing
The role of a community-based health worker in teaching there skills includes motivating
the client to learn deficient skills, contacting and requesting skilled members of the
community to teach specific skills, contacting and requesting potential employers to offer
part time or full time employment to a patient with chronic mental illness.

a) Facilitating Social Reintegration into the Family and Community

The nurse/health worker should always visit and explain to members or the family,
colleagues, employers or teachers about the nature of the illness and to try and dispel
all exaggerated and false beliefs about SZ and the unlikelihood of the patient being
harmful or aggressive to them if proper follow-up, support, and monitoring are
carried out.

They should be made to realize the importance of making the patient welcome,
accepted and participate in the social life of the community as one of the best ways of
preventing a relapse and keeping the person mentally healthy.