STI Colege of Nursing

San Pablo Campus

A.Y. 2oo9-2o1o

Case Study

(Undifferentiated
Schizophrenia)

Pressented By:

Eilasor B. Roldan
BN801
 I. OBJECTIVES

General Objectives

After 2 weeks of student nurse – client interaction the client will be

able to build up trust and increase his level of self – esteem and create
lasting interpersonal relationships with other people.

Specific Objectives:

After 2 weeks of student nurse – client interaction, the student –

nurses will be able to:

1. Talk about the personal, social and familial history of the client

2. Review the normal growth and development of a young adult

3. Define schizophrenia

4. Trace the psychopathology of schizophrenia

5. List the classical signs and symptoms of schizophrenia

6. Discuss the psychodynamics of the patient’s condition

7. Make use of the nursing process in caring for a schizophrenic

client

8. Instruct health teaching to the client

Specific Objectives:

After 2 weeks of student – nurse client interaction the client will be

able to:

• Establish trust and rapport with the student-nurse

• Re-orient self as to the proper time, date and place of the events

• Verbalize his feelings and concerns

• State factors which cause the client to feel stressed

• Build up appropriate coping skills when faced with stressful
situations

• Exhibit positive attitude and response toward others

• Carry out activities of normal daily living such as self – care

II. INTRODUCTION

Understanding the complex function of the brain would enable us

to grasp what is mental health and its corresponding various disorders
associated with alterations in normal mental health functioning. As
normal or mentally healthy individuals, it is important for us to gain
knowledge about psychiatric conditions to understand psychiatric
patients. Most of the people in the society perceive that they must be
locked away from the society and institutionalized, fearing it as
dangerous and uncontrollable that may cause wild disturbances and
violent outbursts, without knowledge that the disorder schizophrenia
has medication that can’t surely treat but can manage. I chose this
case study for the reason that “schizophrenia” is considered to be the
most common and disabling if the psychotic disorders and
understanding its nature as to its cause and factors of occurrence
would somehow benefit us, learners and also psychiatric patients who
are the subject of effective caring care. With this case study, I aimed to
decipher the factors of the disorder to help us in dealing with the
psychiatric patients to cater their needs.

The term schizophrenia was coined in 1908 by the swiss

psychiatrist Eugen Bleuler. The word was derived from the Greek
“schizo” (split) and “phren”(mild). Schizophrenia is a severe, persistent
mental disorder that consists of two different categories of symptoms.
The symptoms present for at least 1 month but usually persist for at
least 6 months and are classified as positive and negative.
 Schizophrenia is characterized by ‘positive symptoms” and
typically also by “negative symptoms.” Positive symptoms, which are
regarded as manifestations of “psychosis,” may include delusions,
auditory hallucinations, and thought disorder. Negative symptoms,
which are regarded as the loss or absence of normal traits or abilities,
may include such features as flat, blunted or constricted affect and
emotion, poverty of speech, or absence of motivation. Some models of
schizophrenia subsume formal thought disorder and planning
difficulties in a third group, a “disorganization syndrome.”

Additionally, neurocognitive defects may be present. These may

take the form of reduced or impaired psychological functions such as
memory, attention, problem – solving, executive function or social
cognition.

This case study is all about Sir. N.A.C., 55 years old. He is a

patient of National Center for Mental Health Pavillion 21 and is
diagnosed with Schizophrenia. I chose this case because I have
observed that schizophrenia, a major disorder is widespread and
interesting. Because of this I want to increase my knowledge on this
illness. Through this study, I can help a patient diagnosed with this
disorder to improve his condition through the implementation of proper
nursing interventions.

Out of all the patients who have been diagnosed with having
schizophrenia, I chose Sir. N.A.C. because I handled him personally for
almost two weeks. I get interested in his behavior towards others and
want to know the reason behind his being admitted to the institution.

From this case study, I expect to increase my knowledge about

schizophrenia.
 III. CLIENT’S DATA

A. General History of Client

 Name: Sir N.A.C.

 Address: 726 San Jose,
Janiuay IloIlo, Panay Island,
Western Visayas
 Age: 55 years old
 Gender: Male
 Marital Status: Single
 Number and ages of children: None
 Living arrangements: He lives with his
father and older sister
 Occupation: None
 Education: College graduate,
Mechanical Engineering
 Religious affiliation: Roman Catholic
Diagnosis: Undifferentiated Schizophrenia

B. Family and Individual information, Social and Health History

Client was brought by her sister in National Center for Mental

Health per court order due to client's abnormal behavior on December
15, 1995. He has two sisters, the only son of Mr. Nonilito and Mrs.
Mersidita. Client grew up with his grandparents and after they died he
was then lived with his immediate family and due to this client is not
close to his family and talks to them very seldom. He was the only
family member who had a maladaptive disorder. There is no heredito-
familial disease reported. At home, patient was quiet and seldom
participates in their happenings. He graduated his college with the
course of Mechanical Engineering. His disorder begins when he flanked
his board exam on 1977, thus resulting in client's depression.

C. History of Hospitalizations and Illness

According to his chart, he had been mentally ill since 1977 and
was consulting a psychiatrist; his last check up was on June 1994 at
Western Visayas Medical Center, Mental Health Unit, Pototan Ilo-Ilo; he
lost to follow up for consultations. Six weeks prior to admission, he
again burned important documents such as insurance documents,
transcript of records and became destructive. He also stated that he
heared some voices that says “Sunugin mo ang mga pera at mga
papeles mo para wala nang makinabang na iba”.

D. Mental Status Examination

• General Appearance, Attitude and Behavior

Client has an average built, he weighs 65.9 kg and is firmly kept, he

is well groomed, with fair complexion and doesn’t have any skin
lesions or allergy. He wears blue prescribed uniform for the patients in
Pavilion 21 but he wears his short above waistline. He has good
posture and walks symmetrically. He faces me squarely, talks
appropriately and maintains eye contact properly.
 Client has an appropriate mood and affect, at first he was always on
flat affect but as I have established trust and therapeutic
communication, he began to smile and share his thoughts and
responds willingly and clearly. He is cooperative and frank, there’s no
flight of ideas, no looseness association, and no dissociation of
thoughts, oriented to time and place and has a normal judgment in a
given situation. He usually rolls his tongue on his teeth.

• Speech

Client talks appropriately, with normal tone of voice, clear and is

heard properly.

• Emotional State

Client has appropriate mood, he is friendly and very cooperative, he

answers and asks questions accordingly but sometimes shows
avolition.

Client has appropriate affect, sometimes flat but has appropriate

judgments in given situations.

 Thought Process

Client responds appropriately to my questions, he asks questions

relatively, there’s no flight of ideas, neologisms, and looseness of
association. Client can read and write and has good concentration on
our activities. Client’s focus is on his older sister that is not visiting him
for one year and four months now. He doesn’t deny being mentally ill
he stated that he had been hospitalized in Western Visayas Mental
Health Unit; been jailed but denied the reason; he is aware that he had
been transferred into the institution per court order on November 25,
1995.

• Sensorium and Mental Capacity

Client is oriented to time and place; he can name himself, his

family, nurses, and other residents in the pavilion. He has good
memory and remembers past experiences clearly. Client is in a
positive state of awareness, he has focus attention to learn, think, act,
feel and protect himself, and he learns new things appropriately.
Sometimes he has difficulty sleeping and very sensitive to noises.
  Insights and Judgment

He is oriented to what happens to him, he stated “inaantok ako

dahil sa gamot na ininom ko”. Client stated that he had hallucinations
prior to confinement that lasts for years; he is preoccupied with his
failure to the board exam.

The classical ill behavior of client

The client with a schizophrenic disorder retreats from

interpersonal contact, appearing aloof, uninterested in others and
content with inner fantasies. A pronounced fear of others and of herself
prevents her from making contact or responding to the social overtures
of others. The client may fear harm from other people or fear that she
may not be able to control her own impulses and may therefore, bring
harm to others. Communication is either lacking or directed toward
private, idiosyncratic goals. The schizophrenic client uses
communicative efforts as means of self-stimulation or reinforcement of
preoccupying fantasies. The client may show signs of extreme
dependency or helplessness. Impulsive, bizarre, or otherwise
uninhibited behavior, such as gesturing or posturing, may also be signs
of the behavioral disturbances of schizophrenia. Relapse symptoms
typically appear in this order; disrupted sleep cycle; significant mood
changes, most often depression; decreased appetite; and somatic
complaints such as headache, malaise and constipation. During
relapse, clients often become very resistive and ambivalent, isolative
and withdrawn.

The Actual ill patient behavior

Patient was diagnosed to be schizophrenic and is evidently

possessing qualities of such mental disorder. He manifests auditory
hallucinations before, avolition and sometimes flat affect. Patient has
mood swings, he is cooperative but with short attention span. He
shows avolition when his needs are not met.

Gordon’s Functional Health patterns

• Health perception/ health management pattern

Patient usually describes his health as fair. He keeps himself

physically healthy through attending the morning stretch. He is
conscious with his hygiene. He can recognize his condition as mental
disorder and claims that he has hallucination since 1977 and
committed to a psychiatrist since then. Clients loves to eat burger and
softdrinks however during admission, foods served follows a diet to
prevent abrupt weight gain of clients. The reason for his admission was
his inappropriate acts towards people and non compliance with his
medications. He stated that he had been jailed due to burning of
money and his important documents such as diploma and transcript of
record, he was then filled a case of attempted arson by his sister and
neighbor but due to his mental illness he had been transferred to
NCMH by court order.

• Nutritional-metabolic pattern

Client loves to eat burger and softdrinks. He always seek for it

everytime we had our nurse-patient interaction. Client has increase
appetite. He usually drinks water but always seek for cold water or
juice if there were no softdrinks. He does not choose the food he eats
and always first in line during the serving of meals. Client has no
restriction to any sort of food; negative food and drug allergy. He was
not taking any psychotic drug for year, instead he has vitamin
supplement. Client was able to drink and eat freely without difficulty to
do so.

• Elimination pattern

The patient has no problems regarding with his bladder emptying

thus does not require any assistive device. Urine is usually dark yellow
in color, approximately 4-6 times a day. In terms with her bowel
elimination, she defecates at least once a day. Stool is usually hard
and brown in color as he described. His skin has fair skin turgor due to
physical changes on ongoing aging.

• Activity / exercise pattern

Client usually joins the activities/therapies conducted by the student

nurse. He is sometimes shows avolition. He always roams around the
premises and has short attention span. He does not sleep during
afternoon. Client has a very good grooming and always takes a bath.
He wears his prescribed blue uniform like a child; his short was worn
above waistline. He has no complains for difficulty in ambulating.

• Cognitive / perceptual pattern

 The patient does not experience any, sight or touch deficits thus
does not require any assistive device such as glasses or hearing aid He
can read and write and draw creatively. He is good in drafting grafting
and doing lettering. He is oriented with the time, date and place.

• Rest / sleep pattern

Client is not complaining of any insomia he insist of having a good

sleeping pattern. He usually takes 7-9 hours of sleep. He refuses to
take afternoon naps because he is not used of it.

• Self-perception pattern

Client's main concern is his sister that is not visiting him for 1 year
and 4 months now. He is worried about her and also the bills of his
hospitalization.

• Role relationship

He communicates using Tagalog dialect. He talked in a moderate

pace, but her words were clear and audible enough to be heard. He
expresses himself openly, verbalized his thoughts and feelings toward
other people but he has a flat affect wherein his facial expression do
not appropriately relate with what he is saying or feeling.

• Sexuality-reproductive pattern

The patient is male with grossly male characteristics. He has never

been committed to any sexual intercourse and never had any
relationship with opposite sex because he was so focused on his study.

• Coping- stress tolerance pattern

Client stated that he used to go to the tree he planted and stayed

there, but most of the time he just stayed in his room and play the
radio.

Physical and Neurological Exam

General Patient is conscious, coherent, oriented, not in

survey cardiopulmonary distress

Skin Good skin turgor, warm to touch, no active lesions,

positive hyperpigmented flat, round skin lesion
unevenly distributed on both extremities.
 HEENT Normocephalic, no lesion, pink palpebral
conjunctiva

Chest and Symmetrical chest expansion, clear breath sounds,

Lungs no crackles, No wheezes

Heart No murmur, regular rhythm

Abdomen Flat, soft, non-tender, normoactive bowel sounds,

no organomegaly

Extremities No clubbing, no deformity, full and equal pulses

Cerebral Oriented to time, place, person

CN II 2 mm pupils equally round and reactive to light
accommodation
CN III, IV, VI Intact
CN V Positive bicorneal reflex
CN VII Can smile, no facial asymmetry
CN VIII Can hear on both ears
CN IX, X Can speak, can swallow
CN X Can speak
CN XI Can shrug shoulders
CN XII No tongue deviation

V. SYMPTOMS

Clinical Symptom Clinical Symptom Rationale

* Depression Manifested This is due to the failure of the
individual to function
- the patient would successfully in preserving
isolate himself at internal emotional equilibrium.
times

- the patient
verbaliezed that he
got depressed when
he flanked the board
exam
* Suspiciousness Not manifested Suspicion is lack of trust. This
could be due to anxiety, over
stress. This is also due to a
lesion of the amygdale region,
which also manifest
fearfulness.

* Clang Association Not Manifested Patients with a thought

disorder are more likely to
connect words because of
similarity of sound, rather than
meaning

* Apathy Manifested A reduction of the emotional

response to stimuli so that one
- The client reacts with less than interest,
sometimes shows attention, feelings than
some avolition. normal. This is due to the
kinds of feelings manifested,
which seems to be out of
keeping with the ideas being
expressed or amount of
emotions

* Social Withdrawal Manifested Low self esteem, one of the

negative signs of
- as observed, the schizophrenia further
patient would complicates the client's ability
sometimes want to to interact with others and
be on his own environment, the result is
specially when he is avoidance of other peolpe
having mood swing.
Hallucination Not manifested The neurotransmitter
(Auditory) dopamine has long been
associated with schizophrenia
where excessive dopamine in
the limbic system structure
causes psychotic symptoms.

* Aggressive Not manifested Anger is a universal emotion,

perhaps one of the most
difficult for people whether it is
one’s own or someone else
angry or aggressive impulses.
Anger and aggression are the
 last stages of a response that
begins with felling vulnerable
and then uneasiness.

* Autism Not Manifested Autism refers to a

preoccupation with self and
with inner experience.
Detachment from reality and
withdrawal unto fantasies.
They create a world of their
own to fulfill needs and wants
that have not been met in the
world of reality.

*Word Salad Not Manifested Wernicke’s aphasia produces

disorganized speech
sometimes referred to as word
salad. This Wernicke’s aphasia
is a manifestation of a
distorted language system in
Schizophrenia.

* Neologism Not Manifested Neologism is characterized by

the making up a speech,
langurage that is not related
and understandable. It is a
language of their own.

* Echopraxia Not manifested It is characterized by

persistent movement. It is the
limitation of someone or
something a person is
observing, it does involve the
element the loose ego
boundaries.
* Flat Affect Manifested Schizophrenic persons
characteristically exhibit a
blunt or flat affect, in contrast
-patient’s does not to the healthy conveys a
feeling that is indicative of this
show different
moods, even when personal, emotional status
he says he is happy , which is congruent to the
content of saying this is due to
he still look flat
compromise ability of the ego
to inhibit impulses in the
 _expression of feeling.

*Echolalia Not Manifested The Psychiatric patient often

repeats words he or she hears.
It is the pathological repetition
of the words or phrases of
another person. There is
correlation of schizophrenic
with disordered Wernicke’s
and Boca’s area which is
responsible for the perception,
encoding of stimuli of the
Language System.

VI. CLINICAL COURSE

Onset: It is stated by the client that after his failure to the board
exam he got depressed and had auditory hallucination of “sunugin mo
ang pera at papeles mo para walang makinabang na iba” since 1977.
since then he had been committed to a psychiatrist and having a
routine check up on Western Visayas Medical Center, Mental Health
Unit but on June 1994 he failed to have his routine checkup and never
had a follow up since then. On 1995 he started to be aggressive and
again burned piece of money and papers. He even attempted to burn
their house. He is non compliant with his medications and became
destructive. His eldest sister and neighbors filled a case against him
because they are afraid to be hurt by him. He then been jailed and
after 6 months of being jailed his father requested the court to transfer
the client to a mental hospital. On December 15, 1995 the Municipal
Court of Pototan ordered a transfer to National Center for Mental
health. The client was then admitted to pavilion 4, then the clent
shows signs of regression he then been transferred to pavilion 11 and
when he recovered the client had been transferred to a rehabilitation
ward pavilion 21.

VII. EPIDEMIOLOGY
 Schizophrenia occurs equally in males and females, although
typically appears earlier in men the peak ages of onset are 20–28
years for males and 26–32 years for females. Onset in childhood is
much rarer, as is onset in middle or old age. The lifetime prevalence of
schizophrenia the proportion of individuals expected to experience the
disease at any time in their lives is commonly given at 1%. However, a
2002 systematic review of many studies found a lifetime prevalence of
0.55%. Despite the received wisdom that schizophrenia occurs at
similar rates worldwide, its prevalence varies across the world, within
countries, and at the local and neighborhood level. One particularly
stable and replicable finding has been the association between living in
an urban environment and schizophrenia diagnosis, even after factors
such as drug use, ethnic group and size of social group has been
controlled for. Schizophrenia is known to be a major cause of disability.
In a 1999 study of 14 countries, active psychosis was ranked the third-
most-disabling condition after quadriplegia and dementia and ahead of
paraplegia and blindness.

VIII. ETIOLOGY

Psychological and social factors:

It is stated in the chart that the client had auditory hallucinations

since 1977, it is alleged by the father that client is already
consulting a psychiatrist then. The patient took the board exam
once in 1978 but flanked and instead just stayed at home and
continued to be committed to a psychiatrist. His failure to board
exam caused depression to him because of high expectation to his
qualification and achievements.

He longs for support and attention yet he fails to overcome

his mistrust to others hence, his dependency void remains
 unressolve. Although his possession of aspirations and dreams of
social acceptance thru intellectual achievements such remains
fantasy due to his inability to utilize his inner reserves.

Overgeneralized ideas about his abilities and excessive

aspirations that his ego cannot support, bespeak of his
compensatory actuations, purportedly to disguise his inadequency
as person.

Denial, projection, intellectualization and aggression are

coping styles. Ego strength is deemed to be poor.

Relevant Family History:

Childhood
Client was raise by his grandparents, but as he grows up,
his grandparents died reason for him to stay with his
parents. He stated that he is not close with his siblings
because he is the only guy and did not grow up with them
reason why preferred to stay at his room and be alone all
the time.

Adolescence
Client was a loner and got no friends. During this stage he
learned to drink and smoke.

Use of Drugs
There was no abuse of drugs in the family.

Genogram
 Mersidita
Nonilito
(mother)
(father)

Noel Delrita
Doronita
Undifferentiated (sister)
(sister)
Schizophrenia

According to his chart, client has no family history of

mental illness.

Level of Growth and Development

Normal Development (Young Adult 20 to Late 30’s)

PHYSICAL DEVELOPMENT

The young adult has completed physical growth by the age of 20.
They are usually quite active, experience severe illnesses less
commonly than older age groups, tend to ignore physical symptoms,
and often postpone seeking health care. This stage has its physical
markings, but they come about slowly, almost sneakily. Body hair may
increase; scalp hair may decrease. But more importantly, there are
internal changes that can have critical effects. As the body becomes
more “efficient”(not needing to produce extra hormones, cells and
energy for growth), there is a natural concurrent lowering of appetite.
If this is not respected, the body will be given more food than it needs,
and overweight and sluggishness will ensue. Similarly, with the
increased efficiency, the individual has (potentially) more stamina than
ever, and this can be maintained all through this stage. This is a “talk”
period of life, active and achieving, but there needs to be care that the
talk is matched with enough muscle involvement and emotional
equilibrium to stay healthy. What applies to young people also applies
to adults. They can abuse their sense of self-responsibility and load up
on whatever they please, or they can let the creative process work
here as well, guiding them to a sense of fitness of quantity and quality.
As mentioned above, a heightened sensitivity is needed, for the
metabolism is changing actually becoming more efficient and food
intake should be adjusted accordingly.

COGNITIVE DEVELOPMENT (JEAN PIAGET)

Rational thinking habits increase steadily through the young and

middle adult years. Formal and informal educational experiences,
general life experiences, and occupational opportunities dramatically
increase the individual’s conceptual, problem solving and motor skills.

Identifying preferred occupational areas is a major task of young

adults. When people know their skills, talents, and personality
characteristics, educational preparation, and occupational choices are
easier and more satisfying.. Many young adults, however, either lack
the resources or support systems to facilitate further education or the
development of skills necessary for many positions in the workplace.
As a result, some young adults may have limited occupational choices.

Adults enter the teaching-learning situation with a background of

unique life experiences, including illness. Their compliance with
regimens such as medications, treatments, or lifestyle changes such as
smoking cessation, involves decision-making processes. Because
young adults are continually evolving and adjusting to changes in the
home, workplace and personal lives, their decision-making processes
should be flexible. The more secure young adults are in their roles, the
more flexible and open they are to change. Insecure persons tend to
be more rigid in making decisions.

MORAL DEVELOPMENT ( LAWRENCE KOHLBERG)

During this stage, rules and laws are valued because they maintain
social order worth preserving. Morality is guided by higher principles of
human conduct. Individuals appreciate the social purposes served by
laws. They believe laws should be derived from a democratic
consensus. Individuals search their own conscience for universal
ethical principles. They do not make up their own rules but instead
arrive at abstract principles that all religions or moral authorities might
view as compelling or fair. There is a correlation between higher stages
of reasoning and higher levels of moral behavior.

PSYCHOSOCIAL DEVELOPMENT ( ERIK ERIKSON)

 The emotional health of the young adult is related to the
individual’s ability to address and resolve personal and social tasks.
The young adult is usually caught between wanting to prolong the
irresponsibility of adolescence and wanting to assume adult
commitments. From 29 to 34 years of age, the person directs
enormous energy toward achievement and mastery of the surrounding
world. Alterations are made in personal, social and occupational lives.
During the young adult years, people generally give more attention to
occupational and social pursuits. During this period individuals attempt
to improve their socioeconomic status. Patience is needed at this time.
There has been much preparation, and it seems that all the learning is
over and it must be time to get on with great things.. But learning is
not over. Patience brings a fuller sense of life purpose, one’s own and
in partnership with a spouse. Patience is also needed to see each
creative process through to completion.

The midlife crisis is the perfect example of what happens when

patience is not in place. Here the adult runs out on the creative
process, dissatisfied with how things seems to be working out. This
leads to stagnation that Erikson noted in neurotic adults. A truly
mature person at this stage has the willingness to persevere, to iron
out rough spots, and be flexible rather than frustrated and
disappointed. Greener pastures do not exist. Fulfillment starts with
accepting and loving circumstances just as they are.

Young adults, according to Erikson’s theory (8 stages of life),

having developed a sense of identity, deepen their capacity to love
others and care for them through work. This is the time to become fully
participative in the community, enjoying adult freedom and
responsibility. If young persons have not achieved a sense of personal
identity, they may experience feelings of isolation from others and the
inability to form attachments. Their willingness to share and mutually
regulate their lives with another marks the completion of this task.

SPIRITUAL DEVELOPMENT ( FOWLER)

As man grows older he becomes more aware of the outside world.

Some conform when they are forced to do so, some are driven by self
interests and will do only what they must do to get what they want in
return. They violate God's law regularly, sinning more or less everyday
with little remorse. Their spiritual senses are not alert. They are
ignorant of God and have no concept of holiness. But as man grows
older, he becomes more conscious of how important people really are.
“Being good” is now important. He thinks about how other people see
him and how they must feel. He realizes that the world runs according
to rules. The desire to please others drives him and when he fails his
first response is to justify himself. This faith is based on the beliefs of
the community.
In adult life many individuals develop a faith that is purely their own
individual faith and can deal with the paradoxes and ironies of human
existence. A final stage of development finds some individuals making
a commitment to universal values, such as love and justice. The focus
on the value of experience and reflection in intellectual development
finds a strong parallel in the importance given to the role of experience
and reflection in spiritual growth.

Disease Process

Psychopathology

Many Brain Regions and systems operate abnormally in

schizophrenia. Imbalances in the neurotransmitter dopamine were
once thought to be the prime cause of schizophrenia. But new findings
suggest that impoverished signaling by the more pervasive
neurotransmitter glutamate – or, more specifically, by one of
glutamate’s key targets on neurons (the NMDA receptor) – better
explains the wide range of symptoms in this disorder

The Brain in Schizophrenia

• Basal Ganglia – involved in movement and emotions and in

integrating sensory information. Abnormal functioning in
schizophrenia is thought to contribute to paranoia and
hallucinations. (Excessive blockade of dopamine receptors in the
basal ganglia by traditional antipsychotic medicines leads to
motor side effects)
• Auditory System – enables humans to hear and understand
speech. In schizophrenia, overactivity of the speech area (called
Wenicke’s area) can create auditory hallucinations – the illusion
that internally generated thoughts are real voices coming from
the outside.
• Occipital Lobe – process information about the visual world.
People with schizophrenia rarely have full – blown visual
hallucinations, but disturbances in this area contribute to such
 difficulties as interpreting complex images, recognizing motion
and reading emotions on other’s faces.
• Frontal Lobe – critical to problem solving, insight and other high –
level reasoning. Perturbations in schizophrenia lead to difficulty
in planning actions and organizing thoughts.
• Limbic System – Involved in emotion. Disturbances are thought
to contribute to the agitation frequently seen in schizophrenia.
• Hippocampus – mediates learning and memory formation,
intertwined functions that are impaired in schizophrenia,
Some scientists have proposed that too much dopamine leads to
symptoms emanating from the basal ganglia and that too little
dopamine leads to symptoms associated with the frontal cortex.
Insufficient glutamate signaling could produce those same symptoms,
however.

Different Neurotransmitters, same results:

• In the Frontal Cortex, where dopamine promotes cell firing (by

acting on IO1 receptors), glutamate’s stimulatory signals amplify
those of dopamine; hence, a shortage of glutamate would
decrease neural activity, just as if too little dopamine were
present.
• In the Basal Ganglia, where dopamine normally inhibits cell firing
(by acting in I02 receptors on nerve cells), glutamate’s
stimulatory signals oppose those of dopamine; hence, a shortage
of glutamate would increase inhibition, just as if too much
dopamine were present
• In the Rest of the Cortex, glutamate is prevalent, but dopamine
is largely absent.
People diagnosed with schizophrenia usually experience a
combinations of positive (i.e. hallucinations, delusions, racing
thoughts), negative (i.e., apathy, lack of emotion, poor or nonexistent
social functioning), and cognitive (disorganized thoughts, difficulty
concentrating and/or following instructions, difficulty completing tasks,
memory problems).

VIII. Diagnostic Criteria for Schizophrenia:

A. Characteristic Symptoms: Two (or more) of the following, each
present for a significant portion of time during a 1- month period (or
less if successfully treated):

1. Delusions – false beliefs strongly held in spite of

invalidating evidence, especially as a symptom of mental
illness: for example,

1. Paranoid delusions, or delusions of persecution, for

example believing that people are “out to get” you,
or the thought that people are doing things when
there is no external evidence that such things are
taking place.
2. Delusions of reference – when things in the
environment seem to be directly related to you even
though they are not. For example it may seem as id
people are talking about you or special personal
messages are being communicated to you through
the TV, radio, or other media.
3. Somatic Delusions are false beliefs about your body –
for example that a terrible physical illness exists or
that something foreign is inside or passing through
your body.
4. Delusions of grandeur – for example when you
believe that you are very special or have powers or
abilities. An example of grandiose delusion is
thinking you are a famous rock star

2. Hallucinations – can take a number of different forms –

they can be:
1. Visual ( seeing things that are not there or that other
people can’t see)
2. Auditory (hearing voices that other people can’t
hear)
3. Tactile (feeling things that other people don’t feel)
4. Olfactory (smelling things that others can’t or not
smelling the same things others can smell)
5. Gustatory Experiences (tasting things that aren’t
there)

3. Disorganized Speech (e.g., frequent derailment or

incoherence) – these are also called “word salads”

4. Grossly Disorganized or Catatonic Behavior (An abnormal

condition variously characterized by stupor/inactivity,
 mania, and either rigidity or extreme flexibility of the
limbs).

5. Negative Symptoms, these are lack of important abilities

like:
1. Lack of emotion – the inability to enjoy activities as
much as before
2. Low energy – the person sits around and sleeps
much more than normal
3. Lack of interest in life, low motivation
4. Affective flattening – a black, blunted facial
_expression or less lively facial movements or
physical movements.
5. Alogia (difficulty or inability to speak)
6. Inappropriate social skills or lack of interest or ability
to socialize with other people
7. Inability to make friends or keep friends, or not
caring to have friends
8. Social isolation – person spends most of the day
alone or only with close family

2. Social/ Occupational dysfunction: For a significant portion of time

since the onset of the disturbance, one or more major areas of
functioning such as work, interpersonal relations, or self-care are
markedly below the level achieved prior to the onset (or when
the onset is in childhood or adolescence, failure to achieve
expected level of interpersonal, academic, or occupational
achievement)
3. Duration: Continuous signs of the disturbance persist for at least
6 months. This 6-month period must include at least 1 month of
symptoms (or less if successfully treated) that meet Criterion A
(i.e., active-phase symptoms) and may include periods, the signs
of the disturbance may be manifested by only negative
symptoms or two or more symptoms listed in Criterion A present
in an attenuated from (e.g., odd beliefs, unusual perceptual
experiences).

4. Schizoaffective and mood disorder exclusion: Schizoaffective

disorder and mood disorder with psychotic features have been
ruled out because either (1) no major depressive, manic, or
mixed episodes have occurred concurrently with the active-
phase symptoms; or (2) if mood episodes have occurred during
active-phase symptoms, their total duration has been brief
relative to the duration of the active and residual periods.
 5. Substance/general medical condition exclusion: The distance is
not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition)

6. Relationship to a pervasive developmental disorder: If there is a

history of autistic disorder or another pervasive developmental
disorder, the additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations are also present for at
least a month (or less if successfully treated).

IX. TREATMENT

Therapies for Schizophrenia

• Stabilize acute Psychotic symptoms. The first priority is to

eliminate or reduce the positive (psychotic) symptoms,
especially when they are disruptive. Most people’s psychotic
symptoms can be stabilized within 6 weeks from the time they
start medication. Antipsychotic medications allow patients to be
discharged from the hospital much earlier.
• Reduce Likelihood of Relapse and Rehospitalization. The
more relapses a person had, the harder it is to recover from
them. Proper treatment can prevent or delay relapse and break
the “Revolving Door” cycle.
• Ensure Appropriate Treatment. Sometimes a person is
misdiagnosed as having another disorder instead of
Schizophrenia. This can be a serious problem because the person
may end up taking the wrong medications.
• Decrease Alcohol / Substance Abuse. More than 50% of
people with Schizophrenia have problems with alcohol or street
drugs at some point of their illness, and this makes matters
 much worse. Prompt recognition and treatment of this “dual
diagnosis” problem is essential for recovery.
• Decrease the Risk of Suicide. The overall lifetime rate of
suicide is over 10%. The risk is highest in the early years of the
illness. Fortunately, suicidal behavior is treatable, and the suicide
risk eventually decreases over time. Therefore, it is very
important to get professional help to avoid this tragic outcome.
• Minimize Problems in Relationships and Life Disruption.
Early diagnosis and treatment decrease the risk that the illness
will get in the way of relationships and life goals.
• Patient and Family Education. Patient, family, and other key
people in the patient’s life need to learn as much as possible
about what schizophrenia is and how it is treated and to develop
the knowledge and skills needed to avoid relapse and work
toward recovery. Patient and family education is an ongoing
process that is recommended throughout all phases of the
illness.
• Collaborative Decision Making. It is extremely important for
patient, family, and clinician to make decisions together about
treatments and goals to work toward. Joint decision making is
recommended at every stage of the illness. As patients recover,
they can take an increasingly active part in making decisions
about the management of their own illness.
• Medication and Symptom Monitoring. Careful monitoring can
help ensure that patients take medication as prescribed and
identify early signs of relapse so that preventive steps can be
taken. A checklist of symptoms and side effects can be used to
see how well the medication is working, to check for signs of
relapse, and to figure out if efforts to decrease side effects are

Psychosocial treatment

• Rehabilitation to improve activities of daily living. By

giving them task that same as what they do as their activities of
daily living makes them feel that they are in normal environment
and reduce their feeling of being away from home.
• Recreational activities. Giving them recreational activities
somehow reduces their fear of socializing and this improves their
socialization skills. With this kind of activities trust to their selves
are being practice and also they are able to explore their abilities
and at the same time this kind of activities exercises their mind
and body.
• Motivatioal activities. This kind of activities gives motivation
to the patient to know more themselves by digging deeper to
their emotions and inner insights and feelings. At the same time
the student nurse and the people around this client will know
more abut the patient’s thoughts and insight.
• Music and art theraphy. With this activity the clients are
exposing their talents and abilities and at the same time their
thoughts and insights are being exposed.
• Occupational therapy. In this activities the clients are being
thought of things they can do or make as their occupation if ever
they came out of the institution.