Predisposing

Factor

Genetic Factor:
As with most other mental
disorders, schizophrenia is not
directly passed from one
generation
to
another
genetically, and there is no
single cause for this illness.
Rather, it is the result of a
complex group of genetic,
psychological,
and
environmental
factors.
Genetically,
schizophrenia
and bipolar
disorder have
much in common, in that the
two disorders share a number
of the same risk genes.
However, the fact is that both
illnesses also have some
genetic
factors
that
are
unique.

Immunovirulogic Factor:
Involvement
of
cytokines
which
are
chemical
messengers between immune
cells, mediating inflammatory
and immune responses in

Neuroanatomic Factor:

Substance Abuse:

People with schizophrenia

have less brain tissue.
Less cerebrospinal fluid
Enlarged ventricles in the
brain and cortical atrophy
Decreased brain volume and
abnormal brain function in
the frontal and temporal
areas
Decreased cortical blood
flow particularly in prefrontal
cortex
Glucose and oxygen are
diminished in the frontal
cortical structures of the

Amphetamines,
hallucinogens, and Cannabis
trigger
the
release
of
dopamine and excessive
dopamine function.

Neurochemical Factor:
Malfunction of the neuronal
networks
that
transmit
information
by
electrical
signals from a nerve cell
through its axon and across
synapses to postsynaptic
receptors on the other nerve
cells
Serotonin modulates and
helps
control
excessive
dopamine
Excessive
dopaminergic
activity in limbic areas
Reduced level of glutamate
receptor

Developmental Theory:
According to Adolph Meyer and
Sigmund Freud that seeds of
mental health and illness are
sown in childhood.

Freudian Concepts:

Poor ego boundaries

Fragile ego
Ego disintegration
Inadequate
ego
development
Superego dominance
Regressed or id behavior
Love-hate
(ambivalent)
relationship
Arrested
psychosocial
development

Precipitating
Factor

Environmental Factor:
Environmentally, the risks of
developing
schizophrenia
can even occur before birth.
For example, the risk of
schizophrenia is increased in
individuals whose mother
had one of certain infections
during pregnancy.
Difficult life circumstances
during childhood, like the
early loss of a parent,
parental poverty, bullying,
witnessing parental violence;
emotional,
sexual,
or
physical abuse; physical or
emotional
neglect;
and
insecure attachment have
been associated with the
development of this illness.
Ms. Es developed schizophrenia
after she worked in Manila where
she stated that she was fired due
to always going out. When she
came back home, her mother
observed that she had changed
because she cannot stay at home
and wants to go out often and will
not answer when asked so she was
locked in a room for several times.

Illicit Drugs
Cocaine
and
amphetamines
inhibit
the re-uptake of
dopamine;
however,
they
influence separate mechanisms
of action. Cocaine is a dopamine
transporter and norepinephrine
transporter blocker
that
competitively inhibits dopamine
uptake to increase the lifetime
of dopamine and augments an
overabundance of dopamine (an
increase of up to 150 percent)
within the parameters of the
dopamine
neurotransmitters.
Like cocaine, amphetamines
increase the concentration of
dopamine in the synaptic gap,
but by a different mechanism.
Amphetamines
and methamphetamine are
similar in structure to dopamine,
and so can enter the terminal
button
of
the
presynaptic
neuron
via
its
dopamine
transporters as well as by
diffusing through the neural
membrane directly. By entering
the
presynaptic
neuron,
amphetamines force dopamine
molecules
out
of
their

What increases dopamine in our brain?

Medications

Sleep

Food

*Stress

Certain
medications may
also increase the
levels of dopamine
being released into
your
system
causing
higher
levels than usual.
These medications
either
stimulate
the
release
of
additional
dopamine or block
the body's ability

The significant loss of

sleep can also cause
dopamine
levels
to
increase. In a study led
by Nora Volkow, M.D.,
the director of the
National Institute on
Drug Abuse, it was
found that even the loss
of one night of sleep
can
significantly
increase the amount of
dopamine
in
the
system. Dopamine is

Certain foods may

also increase the
levels of dopamine
in
the
system.
These foods include
almonds, bananas,
dairy, sesame seeds
and pumpkin seeds.
All of these products
contain
tyrosine.
Tyrosine
once
consumed can have
the natural ability to
increase
the

Stress is one of the major

causes of high dopamine
levels in a person's system.
Dopamine is an integral
part of the human "fight or
flight"
response.
This
response
is
made
to
prepare a human in a
stressful situation to either
fight or run away. One of
the ways the body does this
is by releasing dopamine.
The body does not always
have to be in a threatened
state for the fight or flight
response to be activated.
Stress also activates this
response.
As
stress

Excessive and appropriate secretion of these neurotransmitters especially dopamine, serotonin, and GABA
contributes to the dysfunction of brain process which eventually lead to development of Schizophrenia.

Major Neurotransmitters of the Brain

Dopamine pathways in
schizophrenia

In schizophrenia, there is an
increase
in
dopamine
transmission
between
the
substantia
nigra
to
the
caudate
nucleus-putamen
compare with normal. While in
other
major
dopaminergic
pathways-to the mesolimbic
forebrain and the tuberoinfundibular
systemdopamine
transmission
is
reduced.
The
dopamine
hypothesis of schizophrenia
proposes that increased levels

Glutamate pathways in a brain affected

by schizophrenia

In
the
normal
brain,the
prominent
glutamatergic
pathways are: the corticococortical
pathways;
the
pathways
between
the
thalamus and the cortex; and
the extrapyramidal pathway.
Other glutamate projections

Serotogenic pathway in
schizophrenia

The two key serotogenic

pathways in schizophrenia are
the projections from the dorsal
raphe
nuclei
into
the
substantia nigra and the
projections from the rostal
raphe nuclei ascending into
the cerebral cortex, limbic

Symptoms of Schizophrenia

Positive symptoms
Positive symptoms are psychotic behaviors
not seen in healthy people. People with
positive symptoms often "lose touch" with
reality. These symptoms can come and go.
Sometimes they are severe and at other times
hardly noticeable, depending on whether the
individual is receiving treatment. They include
the following:
Hallucinations are things a person sees,
hears, smells, or feels that no one else can
see, hear, smell, or feel. "Voices" are the most
common
type
of hallucination
in
schizophrenia. Many people with the disorder
hear voices. The voices may talk to the person
about his or her behavior, orders the person
to do things, or warn the person of danger.
Sometimes the voices talk to each other.
People with schizophrenia may hear voices for
a long time before family and friends notice
the problem.
Delusions are false beliefs that are not part
of the person's culture and do not change.
The person believes delusions even after
other people prove that the beliefs are not
true or logical.

Negative symptoms
Negative symptoms are associated
with disruptions to normal emotions
and behaviors. These symptoms are
harder to recognize as part of the
disorder and can be mistaken
for depression or other conditions.
These symptoms include the
following:

"Flat affect" (a person's face

does not move or he or she
talks in a dull or monotonous
voice)

Lack of pleasure in everyday life

Lack of ability to begin and

sustain planned activities

Speaking little, even when

forced to interact.

People with negative symptoms need

help with everyday tasks. They often
neglect basic personal hygiene. This
may make them seem lazy or
Dopamineunwilling
pathways
in
to help themselves, but the
Thought
disorders are
unusual
or
problems are symptoms caused by the
schizophrenia
dysfunctional ways of thinking. One form of
schizophrenia.
thought disorder is called "disorganized
thinking." This is when a person has trouble
organizing his or her thoughts or connecting

Cognitive symptoms
Cognitive symptoms are subtle. Like
negative symptoms, cognitive symptoms
may be difficult to recognize as part of the
disorder. Often, they are detected only
when other tests are performed. Cognitive
symptoms include the following:

Poor "executive functioning" (the

ability to understand information
and use it to make decisions)

Trouble focusing or paying attention

Problems with "working memory"

(the ability to use information
immediately after learning it).

Actual symptoms of Ms. Es

Ms. Es is oriented to time, date, and place.
Coherent, and responds appropriately. Facial
expression is congruent with tone of voice. Looks
well-rested, presents a staring expression when
alone, quality of tone and voice at an acceptable
level. Speech is clear and voice is well-modulated,
responds to questions appropriately, and noted self
talking sometimes. She laughs without reason. She
has delusions over having a husband who does not
really exist. She also has some trouble listening and

Three Major Phases of Schizophrenia

Prodromal Phase
Occurs 1 to 2 years before the
onset of psychotic symptoms
Usually people report symptoms of
anxiety, social isolation, difficulty
making choices and problems with
concentration and attention.
Subgroups:
APSSAttenuated
Positive
Symptom
syndromefeatures
problem
with
communication,
perception, and usual thoughts that
dont rise to the level of psychosis,
occur at least once weekly for at
least one month and become
progressively worse over year.

Active Phase
Psychotic

symptoms
such
as
delusions,
odd
behavior
and
hallucinations are prominent and are
often accompanied by strong affect
such as distress, anxiety, depression,
and fear. If untreated, the active phase
may resolve spontaneously or may
continue indefinitely. With appropriate
treatment (primarily medication) the
active phase is usually able to be
brought under control. It is during the
active phase that most individuals
present for treatment, whether it is
their
first
presentation
or
an
exacerbation of their symptoms.

Residual Phase
The

residual phase is similar to the

prodromal phase although during the
residual
phase
blunted
affect
and
impairment in role functioning are more
common. While psychotic symptoms may
persist into the residual phase, the
psychotic symptoms are less likely to be
accompanied by such strong affect as
experienced during the active phase. There
is great variation in the severity of the
residual phase from one person to the next.
Some individuals will function extremely
well while others may be considerably more
impaired.

BIPS- Brief Intermittent Psychotic

Syndrome- problem with communication
and perception; intermittent psychotic
thoughts, bizarre beliefs on hallucinations;
occur few minutes daily for at least a
month, and for no more than three months.

Our client is now in the residual phase of

her condition because although she
experiences symptoms such as auditory
hallucinations, delusions and anxiety,
these are not prominently manifested.

Two Classifications of Schizophrenia

TYPE I (Positive Type)

type)
Catatonic TypeTYPE II (Negative
Undifferentiated
Type

Type I or Positive Type of schizophrenia has a different

constellation of symptoms than negative type (Type II)
schizophrenia. Positive symptoms are believed to be the
result of elevated dopamine levels affecting limbic areas of
the brain.

(Ms. Es)symptoms are

Type
II is following
labeled negative because
At least two
of the
are present:essentially an absence or diminution of that which
At least
of the
should be-that is, lack of affect,
lack oftwo
energy,
andfollowing
Motoric so
Immobility,
on. Type waxy
II is related, symptoms:
at least in part, of
flexibility,
or
stupor
hypodopaminergic process.
Delusions *
Excessive motor activity
Hallucinations*
(puposeless)
Disorganized speech
Extreme negativism or
Grossly
disorganized
or
mutism
catatonic behavior
Peculiar
movements,
Negative symptoms are
stereotyped movements,
present, but criteria for
prominent mannerisms, or
paranoid,
catatonic,
or
prominent grimacing
disorganized subtypes are
Echolalia or echopraxia
not met.

Paranoid type
Characterized by persecutory
(feeling victimized or spied on)
or
grandiose
delusions,
hallucinations, and, occasionally,
excessive religiosity (delusional
religious focus) or hostile and
aggressive behavior.

Disorganized
type
This is characterized
by
grossly
inappropriate or flat
affect, incoherence,
loose
associations,
and
extremely
disorganized

Expressive Therapies
Exercise Therapy
There is now considerable evidence that
regular exercise is (a) a viable, cost-effective,
but underused treatment for mild to moderate
depression that compares favorably to
individuals
psychotherapy,
group
psychotherapy, ad cognitive therapy, and (b) a
necessary ingredient in effective behavioral
treatments that reduces self-reported pain in
individuals with chronic pain. A research also
suggest that regular exercise deserves further
attention as (a) singular treatment for some
anxiety disorders, for individuals suffering from
body image disturbance, and for the reduction
of problem behavior of developmentally
disabled persons, and (b) and adjunct in
treatment
programs
for
schizophrenia,
conversion disorder, and alcohol dependence.

Residual Type

Play Therapy
Play therapy refers to a large number of
treatment methods, all of which make use of
one or more of the natural benefits of
play. Main healing powers of Play are selfexpression and self-disclosure,
which
are
facilitated during the Play Therapy to help a
person identify his
problems/conflicts, understand these
conflicts, accept them and cope with them.
Music Therapy
Is an interpersonal process in which a trained
music therapist uses music and all of its facetsphysical, emotional, mental, social, aesthetic,
and spiritual-to help client improve or maintain
their health.
Art Therapy

Treatment of Schizophrenia
First Generation Antipsychotics

Characteristic symptoms are no

longer
present
(delusions,
hallucinations,
disorganized
speech, grossly disorganized
or
Medications:
catatonic behavior, and negative
symptoms) While there are a number of helpful
treatments available, medications remain the
cornerstone of treatment for people with
schizophrenia. These medications are often
referred to as antipsychotics since they help
decrease the intensity of psychotic symptoms.
Many health-care professionals prescribe one
of
these
medications,
sometimes
in
combination of one or more other psychiatric
medications, in order to maximize the benefit
for the person with schizophrenia.

First-generation antipsychotics, such as haloperidol

(Haldol), perphenazine, and chlorpromazine. They are
used to reduce anxiety and agitation and to stop
delusions and hallucinations. These medicines can
work very well but often have severe side effects,
such as tardive dyskinesia, which causes uncontrolled

Medications
that
are
thought
to
be
particularly effective in treating positive
symptoms
of
schizophrenia
include olanzapine (Zyprexa), risperidone (Ris
perdal),quetiapine (Seroquel), ziprasidone (Ge
odon), aripiprazole (Abilify),
paliperidone
(Invega), and asenapine (Saphis). These
medications are the newer group of

The following medicines often are used along with

antipsychotic medicines:
Lithium carbonate, such as Lithobid and
Eskalith. This medicine regulates moods. You will
need your blood tested every week when you first
start taking it and every 6 or 12 months after you
know the correct dose.
Antianxiety medicines, such as clonazepam
(Klonopin) and diazepam (for example, Valium).
These medicines reduce anxiety and nervousness.
Anticonvulsant
medicines,
such
as
carbamazepine (for example, Tegretol) and
valproate
(for
example,
Depakote).
These
medicines can keep your mood stable and reduce
symptoms during a relapse.
Antidepressant medicines, such as selective
serotonin reuptake inhibitors (SSRIs) (for example,
Zoloft or Celexa) or tricyclic antidepressants (for

Second Generation Antipsychotics

Second-generation antipsychotics, such as
risperidone (Risperdal), paliperidone (Invega),
olanzapine (Zyprexa), ziprasidone (Geodon), and
quetiapine (Seroquel). These medicines effectively

Nursing Management

For disrupted patients

For Withdrawn patients

For suspicious patients

Set limits on disruptive

behavior
Decrease
environmental
stimuli
Frequently
escalating
patients to intervene
Modify the environment to
minimize objects that can be
used as weapons
Be careful in stating what the
staff will do if a patients acts
out.
When
using
restraints,

Arrange
non
threatening
activities that involve this
patients in doing something.
Arrange furniture in a semicircle
or around a table, which forces
patients to seat with someone.
Help patients to participate in
decision
making,
as
appropriate.
Reinforce appropriate grooming
and hygiene.
Provide
psychosocial
rehabilitation.

Be matter-of- fact
when
interacting
with these patients.
Staff
members
should not laugh or
whisper
around
patients
unless
patients can hear
what is being said.
Do
not
touch
suspicious patients
without warning.
Be
consistent
in

Ms. Es is prescribed with Chlorpromazine

100mg 1 tab OD but she takes only half a
tablet because she feels drowsy most of
the time if she takes it wholly according
to her. This medication reduces the
anxiety that our client experiences.
She actively participated in exercise,
play, music, art and occupational
For patients with impaired
communication
Be patient and do not
pressure patients to
make sense.
Do not place patients in
group activities that
would frustrate them,
damage
their
self
esteem or over taxed
their abilities.
Provide
opportunities
for
purposeful
psychomotor activity.

For patients with hallucinations

For disorganized patients

Attempt to provide distracting activities.

Discourage situations in which patients talk to others about
their disordered perceptions
Monitor television selections
Monitor for command hallucinations that might increase the
potential for patients to b=become dangerous.
Have staff members available in the day room so that the
patients can talk to real people about real people or real

Remove disorganized patients to a less

stimulating environment
Provide a calm environment; the staff should
appear calm.
Provide safe and relatively simple activities
for these patients.

Medical Illnesses
Studies have reported that people
with severe mental illnesses suffer
more from serious health problems
If the patient
than
those
without
mental
disorders, and they are less likely to
receive medical help. Substance
abuse is a significant factor in this
higher risk.
Research
has
suggested
an
increased risk of diabetes among
people with schizophrenia. In
addition, many new antipsychotic
medications can elevate blood
sugar
levels.
Patients
taking
atypical antipsychotics drugs -such as clozapine, olanzapine,

Effect on Social Status

Studies indicate that after 20 - 30

did not adhere to medication regimenyears,

and expressive
therapies,
major
half of patients
are ablethen
to care
complications of Schizophrenia
would occur.work, and participate
for themselves,
Depression

Depression is common later

in adulthood. Although this
mood disorder can certainly
be a result of the negative
social
impact
of
schizophrenia, some experts
believe that depression is
part of the disease process
itself.

socially.
Support
services
and
appropriate housing improve this
outcome. Unsurprisingly, the decline in
status, including the inability to earn a
living, is less steep when there are
more financial resources and fewer
emotional disorders at the outset of
symptoms. Also, on average, the later
the onset of the disease, the milder the
social impact. The long-term effects on
work and relationships, however, are
usually severe and difficult to repair,

Effect on Intelligence

In one study, about half of

patients experienced some
decline in IQ (10 points or
more), but intelligence
scores remained the same
in the other half. Experts
believe that a decline in IQ
reflects
early
nerve
damage but that it is not
an inevitable consequence
of the disease process.

Suicide

In spite of the sometimes frightening behavior, people with

schizophrenia are no more likely to behave violently than are
those in the general population. In fact, these patients are
more apt to withdraw from others or to harm themselves.
Between 20 - 50% of patients with schizophrenia attempt
suicide, and an estimated 9 - 13% commit suicide.

If the patient sticks to the adjunct therapies and pharmacologic measures of treating the mental illness, then
the patient would undergo the Stages of Schizophrenia Recovery

Acute phase

Stabilization phase

*Maintenance phase

An acute episode of schizophrenia involves

intense psychotic symptoms such as
hallucinations, delusions, paranoia, and
confused thinking. The aim of treatment in
the acute phase is to get the psychotic
symptoms under control so the patient
isnt a danger to self or to others.
Hospitalization may be required during
this time. Medication is the primary
treatment. Given the right drug and dose,
schizophrenia medication can greatly

Once the acute psychotic symptoms have

been controlled, most people go through
a stabilization phase in which they
continue to experience bothersome, yet
milder
symptoms
of
schizophrenia.
During
this
phase,
patients
are
particularly vulnerable to relapse. The
aim of treatment in the stabilization
phase is to prevent relapse, reduce
symptoms even more, and move the
patient forward into a more stable

The long-term recovery phase of

schizophrenia is known as the
maintenance phase of treatment.
During the maintenance phase of
treatment, the goal is to sustain
symptom remission or control, reduce
the risk of relapse and hospitalization,
and teach skills for daily living.
Maintenance
treatment
typically
involves
medication,
supportive
therapy,
family
education
and

In the case of our patient, Ms. Es, she is now

on
the
maintenance
phase
and
has
undifferentiated schizophrenia. She adheres to
treatment regimen but not correctly for she
takes only half of a tablet of her medication
and
still experiences milder symptoms of
schizophrenia like auditory hallucinations as
evidenced by talking to someone unseen
laughing
inappropriately.
She
still
has