Symptoms of catatonic schizophrenia may include:

• Stupor: A near-unconscious state, exhibiting significantly reduced responsiveness.

• Catalepsy: Trance-like state with body rigidity, maintaining postures for extended periods.

• Waxy Flexibility: Limbs can be molded into positions by another person and will remain in that posture.

• Mutism: Absence of verbal response, despite apparent ability to speak.

• Negativism: Lack of response to stimuli or instructions, often exhibiting opposition.

• Posturing: Maintaining rigid and unusual body positions against gravity.

• Mannerism: Peculiar, exaggerated, and seemingly purposeless movements.

• Stereotypy: Repetitive movements without any apparent goal or reason.

• Agitation: Excitement or restlessness not influenced by external factors.

• Grimacing: Distorted and involuntary facial contortions.

• Echolalia: Meaningless echoing or repetition of another person’s spoken words.

• Echopraxia: Imitating or mimicking another person’s movements without purpose.

• Fluctuating Catatonia: The catatonic state can be interrupted by periods of opposite behaviors, such as:

  • Unexplained Excitability: Sudden and unprovoked bursts of agitation.

  • Defiance: Resistance and opposition to any requests or expectations.

Causes of Catatonic Behavior

• Brain Anomalies: Irregular brain activity, particularly in neurotransmitter systems involving dopamine, glutamate, and GABA.

• Psychiatric Disorders: Catatonia is a severe psychiatric condition linked with schizophrenia and also observed in schizoaffective disorder, bipolar disorder, and major depressive disorder.

• Substances and Medications: Catatonic behavior can be triggered by certain drugs, alcohol, and medications.

• Medical Conditions: Various medical conditions can induce catatonic-like behaviors or be mistaken for catatonia. Examples include dystonia, encephalopathy, HIV, and renal failure. Catatonic symptoms like facial distortions, unusual limb movements, or abnormal body postures can be misdiagnosed as tardive dyskinesia or other movement disorders. Similarly, Tourette’s syndrome may be confused with catatonia due to some vocalizations present in Tourette’s.

Risk factors for catatonic schizophrenia

• Family History: Genetic predisposition increases the risk of developing this condition.

• Lifestyle and Behavior: Substance abuse has been associated with episodes of catatonic schizophrenia.

Diagnosis of catatonic schizophrenia

• Diagnosis relies on symptom evaluation by a doctor, as there are no specific lab tests for catatonia in schizophrenia. Catatonic behavior can occur in other conditions like autism and mood disorders.

• Diagnostic tools that may be used include:

  • EEG (electroencephalogram)

  • MRI scan

  • CT scan

  • Physical examination

  • Psychiatric evaluation (conducted by a psychiatrist)

Catatonic schizophrenia treatment

• Medication: Typically the primary treatment approach for catatonic schizophrenia.

  • Lorazepam

  • Alprazolam (Xanax)

  • Diazepam (Valium)

  • Clorazepate (Tranxene)

• Psychotherapy: Sometimes combined with medication to teach coping strategies and stress management techniques. This therapy also aims to improve patient collaboration with healthcare providers for better condition management.

• ECT (Electroconvulsive Therapy): Formerly known as electroshock therapy, increasingly utilized for effective treatment of catatonia in schizophrenia and other psychiatric conditions.

General Clinical features of Schizophrenia

• Neglecting personal hygiene.

• Social withdrawal and isolation.

• Reduced interest in the surrounding environment.

• Hallucinations: Sensory experiences that are not real.

• Illusions: Misinterpretations of real sensory experiences.

• Lack of motivation or willpower.

• Delusions of persecution: False beliefs of being targeted or harmed.

• Passivity Thoughts: Feeling controlled by external forces.

• Disturbed Thoughts: Thought insertion, thought broadcasting, and thought withdrawal.

• Disturbed behavior patterns.

• Disturbed mood regulation.

• Disturbed Speech: Echolalia, neologisms (made-up words), word salad (incoherent speech), and general incoherency.

• Flexibilitas Cerea: Maintaining limbs or body parts in imposed positions, as seen in catalepsy.

• Catalepsy

• Echopraxia

• Anergia: Deficiency in energy levels.

• Anhedonia: Inability to experience or express pleasure.

• Regression to earlier behaviors.

Positive symptoms of schizophrenia

• Positive symptoms in schizophrenia refer to mental disturbances in reality perception that are not objectively real. These symptoms often necessitate urgent treatment and can be effectively managed with antipsychotic medications. They include:

  • Delusions: Firmly held false beliefs stemming from distorted reasoning, misinterpretations of perceptions or experiences. Common delusions include being followed, watched, or beliefs that media is directly communicating with them.

  • Hallucinations: Distortions or exaggerations of sensory perception across senses, with auditory hallucinations (“hearing voices”) being most prevalent, followed by visual hallucinations.

  • Disorganized Speech/Thinking: Also known as “thought disorder” or “loosening of associations,” a core feature of schizophrenia. Disorganized thinking is primarily assessed through speech, characterized by loosely connected or incoherent speech and neologisms.

  • Grossly Disorganized Behavior: Includes difficulties in goal-directed behavior, leading to problems in daily living, unpredictable agitation or silliness, social disinhibition, and behaviors considered bizarre by others. The lack of purpose distinguishes these behaviors from unusual actions driven by delusions.

  • Catatonic Behaviors: Characterized by a significant decrease in reaction to the immediate environment, manifesting as immobility, apparent unawareness, rigid or strange postures, or purposeless excessive motor activity.

  • Other symptoms sometimes present in schizophrenia but not always defining include affect inappropriateness.

Negative symptoms of schizophrenia are:

Negative symptoms significantly impair a person’s ability to function independently, maintain employment, form relationships, and navigate social situations. These symptoms are often the most distressing for individuals experiencing schizophrenia.

• Affective Flattening: Reduced range and intensity of emotional expression. This encompasses diminished facial expressions, monotone voice, limited eye contact, and reduced body language.

• Alogia (Poverty of Speech): Reduced fluency and productivity in speech, often reflecting slowed or blocked thinking processes. This can manifest as brief, empty responses to questions.

• Avolition (Diminished Willpower): Reduction, difficulty, or inability to initiate and maintain goal-directed activities. Avolition is frequently mistaken for simple disinterest. Examples include loss of interest in socializing, hobbies, and daily activities, leading to prolonged periods of inactivity.

• Anhedonia: Lack of pleasure in previously enjoyable social interactions and activities.

• Social Withdrawal: Patient becomes socially isolated, losing interest in maintaining friendships and social connections.

Good prognosis of Schizophrenia

Factors associated with a more favorable outcome in schizophrenia include:

• Acute and later onset of the disorder.

• Presence of an identifiable precipitating factor or trigger.

• Good premorbid personality and social functioning prior to illness onset.

• Presence of affective symptoms (mood-related symptoms).

• Being married or in a stable partnership.

• Family history of mood disorders rather than schizophrenia.

• Strong social support system.

• Predominance of positive symptoms.

Poor prognosis

Factors indicating a less favorable outcome in schizophrenia include:

• Insidious and younger age of onset.

• Absence of clear precipitating factors.

• Poor premorbid social, academic, and work history.

• Socially withdrawn personality.

• Being single, divorced, or widowed.

• Family history of schizophrenia.

• Weak or absent social support system.

• Predominance of negative symptoms.

Schneider’s first-rank symptoms of schizophrenia

These symptoms, if present, are highly suggestive of a schizophrenia diagnosis. They include:

• Auditory Hallucinations:

  • Hearing one’s own thoughts spoken aloud (thought echo).

  • Hearing voices discussing the patient in the third person (referring to “he,” “she,” or “they”).

  • Auditory hallucinations presenting as a commentary on the patient’s actions or thoughts.

• Thought Withdrawal, Insertion, and Interruption: Experiences of thoughts being removed from one’s mind, alien thoughts being inserted, or a sudden cessation of thinking.

• Thought Broadcasting: The belief that one’s thoughts are accessible and known to others.

• Somatic Hallucinations: Sensations experienced within the body that are unreal or bizarre.

• Delusional Perception: Attaching abnormal significance to ordinary perceptions or events.

• Feelings or actions experienced as made or influenced by external agents: The sensation of being controlled or manipulated by outside forces.

Nursing diagnoses of patient suffering from schizophrenic illness

Common nursing diagnoses for patients with schizophrenia include:

1. Altered sensory perception (auditory hallucinations): Related to schizophrenia, as evidenced by the patient appearing to respond to internal stimuli, such as talking to unseen people or reporting hearing voices.

2. Altered thought processes (delusions): Related to schizophrenia, as evidenced by the patient expressing fixed false beliefs, such as paranoid ideation.

3. Impaired communication (neologisms): Related to the disorder, as evidenced by the patient using invented words or language patterns that are not understandable to others.

4. Impaired social interaction: Related to the disorder, as evidenced by social isolation, withdrawal, and suspiciousness towards others, including family members.

Management of Schizophrenia

Nursing Management

Nursing care in schizophrenia focuses on building a therapeutic relationship and managing symptoms:

1. Establish a positive nurse-patient relationship: This can be challenging due to the nature of schizophrenia but is crucial for effective care.

2. Educate the patient and family: Provide information about the nature of schizophrenia and its management.

3. Maintain reality orientation: Continuously orient the patient to reality throughout their illness and during periods of acute symptoms.

4. Ensure basic needs are met: Address the patient’s physiological needs, such as nutrition, hygiene, and rest.

5. Minimize risks from psychotic symptoms: Take precautions to reduce potential harm resulting from hallucinations and delusions.

6. Utilize reality orientation techniques: Employ strategies to help the patient stay grounded in reality.

7. Avoid highly expressed emotions: Maintain a calm and neutral demeanor, as high emotionality can be overwhelming or agitating.

8. Avoid criticism: Refrain from judgmental or critical comments, which can be detrimental to the therapeutic relationship.

9. Do not argue with delusions: Avoid directly challenging or arguing with the patient’s delusional beliefs, as this can escalate distress and resistance.

Collaborative care

Effective schizophrenia management requires a multidisciplinary team approach:

• Nurses identify problems requiring team intervention, such as administering antipsychotic medication for aggressive behavior.

• Ensure the patient receives consistent and appropriate treatment.

• Administer prescribed medications and diligently monitor for potential side effects. Poor medication adherence is a common concern.

• Develop a plan to manage and mitigate side effects of antipsychotic medications.

Psychological management

Psychological therapies are essential components of schizophrenia treatment:

• Occupational Therapy: Provided by specialists to teach practical social skills and Activities of Daily Living (ADLs), such as personal hygiene, managing finances, and navigating daily routines. This is a core aspect of schizophrenia rehabilitation.

• Psychotherapy: Offers reassurance and counseling to help patients understand and cope with the disorder. This requires patience and empathy from the therapist.

• Group Therapy: Can be particularly effective for outpatients, providing social support and peer interaction. It may be less productive for acutely ill inpatients.

• Behavior Therapy: Focuses on modifying specific behaviors, aiming to reduce the frequency of bizarre or disruptive behaviors.

• Family and Involvement of Other Parties: Engage family members, religious leaders, community organizations, and friends in the patient’s care. Family support and education are particularly vital in supporting patients and reducing relapse.