Schizophrenia

slides describe schizophrenia and its nursing management

1. Schizophrenia, Schizotypal and Delusional disorders

2. Outline Introduction Definition Incidence etiology Prognostic factors Clinical features Subtypes Other forms of psychotic disorders Treatment Nursing interventions 

3. Introduction Schizophrenia is a group of severe mental disorders characterized by reality distortions resulting in unusual thought patterns and behaviors . Because there is often little or no logical relationship between the thoughts and feelings of a person with schizophrenia, the disorder has often been called “split personality .” Schizophrenia is considered the most common and disabling of the psychotic disorders. Although it is a psychiatric disorder, it stems from a physiologic malfunctioning of the brain. This disorder affects all races, and is more prevalent in men than in women. No cultural group is immune and persons with intelligence quotients of the genius level are not spared.

4. Introduction Schizophrenia occurs twice as often in people who are unmarried and divorced people as in those who are married or widowed. People with schizophrenia are more likely to be members of lower socioeconomic groups. In 1896 Emil Kraepelin originally called schizophrenia as dementia praecox meaning “madness of the young” to differentiate it from manic-depressive psychosis due to the presence of hallucinations and delusions

5. Introduction The term schizophrenia was coined by a German psychiatrist, Eugen Bleuler , in 1908 He defined the disorder through the presence of two groups of symptoms : Primary symptoms – with 4As ,they are flattened Affect, Autism, impaired Association of ideas and Ambivalence, Secondary symptoms – include delusions, hallucinations, and disorganized, idiosyncratic speech. 

6. Introduction Affective disturbance refers to the person’s inability to show appropriate emotional responses . Autistic thinking is a thought process in which the individual is unable to relate to others or to the environment. Ambivalence refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person, thing, or situation . Looseness of association is the inability to think logically. Ideas expressed have little, if any, connection and shift from one subject to another 

7. Definition Schizophrenia is a disorder characterized by disturbances, for at least 6 months, in the thought content and form, perception, affect, sense of self, volition, interpersonal relationships, and psychomotor behavior. Schizophrenia is a psychotic condition characterized by disturbance in thinking, emotions, volitions(desires) and faculties in the presence of clear consciousness which usually leads to social withdrawal.

8. Incidence Onset of symptoms typically occurs in late adolescence or young adulthood . 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. Around 1% of the population is affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists (APA, 2000)

9. Incidence The average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate (about 5 %). Social stigma has been identified as a major obstacle in the recovery of patients with schizophrenia with a large number of people believing that individuals with schizophrenia were “very likely” to be violent against others.  Common in urban areas with those who are unemployed, poor, and homeless. Schizophrenics form about half of the patients occupying mental hospital beds. The prognosis worsens with each acute episode.

10. Etiology 1. Biological factors a . Biochemical (neurochemical) changes: Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals. The dopamine hypothesis posits that an excessive amount of the neurotransmitter dopamin e allows nerve impulses to bombard the mesolimbic pathway, the part of the brain normally involved in arousal and motivation . Normal cell communication is disrupted, resulting in the development of hallucinations and delusions. Norepinephrine and serotonin systems have also been implicated in the causation of schizophrenia.

11. b. Endocrine factors: Changes in prolactin, melatonin, and thyroid function have been found in schizophrenia. c . Brain structural changes: Prefrontal cortex and limbic cortex are less developed in patients with Schizophrenia. MRI studies show- Decreased brain volume Larger lateral and third ventricles Atrophy in frontal lobe, cerebellum Increased size of sulci on the surface of the brain

12. d. Prenatal: Causal factors are thought to initially come together in early neurodevelopment to increase the risk of later developing schizophrenia. One finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the northern hemisphere).  There is evidence that prenatal exposure to infections (i.e., prenatal exposure to influenza during the second trimester) increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition. Other gestational and birth complications, such as Rh factor incompatibility , as well as prenatal nutritional deficiencies , have been associated with schizophrenia. 

13. e. Vitamin deficiency: The vitamin deficiency theory suggests that persons, who are deficient in vitamin B, namely B1, B6, and B12, as well as in vitamin C , may become schizophrenic as a result of a severe vitamin deficiency . f . Genetics: It has been noted that the closer the biological relationship between an individual and a person considered to be schizophrenic, the greater the disorder . This is based on data from family studies.  Family studies : A child born with one schizophrenic parent has about a 50% chance of developing schizophrenia. It is 100% if both parents are schizophrenics. There is 50% chance of developing the condition when a sibling is schizophrenic, i.e., non-twin siblings. Second degree relatives have 25% chances of suffering the illness; when no relative is affected with the illness, the chances are 2–3% of a family member developing the condition. 

14. Twin and Adoption studies: According to these studies if one of the monozygotic (identical) twins suffers schizophrenia, there is 100% chance of the other twin also developing the condition. For the dizygotic (non-identical) twins, there is 50% chance of the other catching the condition.

15. 2. Psychological Factors a . Personality traits: Personality characteristics of an individual, such as withdrawn, extreme quietness and shyness, highly dependent and obedient, having temper tantrums, and always looking sad and miserable, may become schizophrenic b. Cognitive biases: that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations include: excessive attention to potential threats, jumping to conclusions, impaired reasoning about social situations and mental states , difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration. 

16. 3 . Environmental/Social Factors a . Recreational drug use: Although about half of all patients with schizophrenia use drugs or alcohol, a clear causal connection between drug use and schizophrenia has been difficult to prove. The two most often used explanations for this are “substance use causes schizophrenia” and “substance use is a consequence of schizophrenia”, and they both may be correct 

17. b. Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life. Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk . c. Social: Living in an urban environment has been consistently found to be a risk factor for schizophrenia. Social disadvantage found to be a risk factor, include : poverty , migration related to social adversity, racial discrimination, family dysfunction, unemployment poor housing conditions.

18. Developmental factors – complication of the foetus during pregnancy may result in the condition, e.g., malnutrition, maternal drug use/alcoholism, asphyxia, infections, forceps delivery , etc. Double bind theory – Schizophrenia is a consequence of abnormal patterns in family communication or a person is given mutually contradictory signals by another person.

19. DOUBLE BIND AS A THEORY Bateson et al. (1956) proposed that schizophrenic symptoms are an expression of social interactions in which the individual is repeatedly exposed to conflicting injunctions, without having the opportunity to adequately respond to those injunctions, or to ignore them (i.e., to escape the field ). For example, if a mother tells her son that she loves him, while at the same time turning her head away in disgust , the child receives two conflicting messages about their relationship on different communicative levels, one of affection on the verbal level, and one of animosity on the nonverbal level . It is argued that the child's ability to respond to the mother is incapacitated by such contradictions across communicative levels, because one message invalidates the other. Because of the child's vital dependence on the mother, Bateson et al. argue that the child is also not able to comment on the fact that a contradiction has occurred, i.e., the child is unable to metacommunicate .

20. Prognostic factors Prognosis indicates the likelihood of recovery from a disease . Factors which are responsible for a good prognostic outcome of schizophrenia are: Age of the patient – The older the patient, the more favorable the prognosis . The duration of illness – The shorter the duration prior to treatment, the better the outcome. The rapidity of development of the symptoms – Surprisingly, it has been found that the more speedily the symptoms develop, the faster do they respond to treatment; a very slow, insidious, and gradual onset of illness suggests a final poor outcome. 

21. A patient who had close friendships and multiple relationships prior to illness has a brighter chance with few or no such relationships. Life stress prior to onset – An episode brought on by a major identifiable life stress will respond more quickly than an episode without any obvious cause. Marital history – A patient with a stable and helpful marital partner has a favorable prognosis as compared to an unmarried patient. Educational history – The higher the level of education, the more are the chance of a patient coming rapidly to terms with the illness and handling the post-illness sequence.

22. Occupational history – A patient with a good stable occupation or business prior to onset of illness will respond better than a patient who is jobless and economically unsound. Family’s attitude towards the returning patient – Hostile behavior by family members, or vice versa, excessive care and attention by them can undermine the patient’s sense of confidence and hamper recovery. Social support systems – A patient with a joint family and a staunch circle of friends who are ready lend a helping hand, is much better off than alone man afflicted with the illness, whose relatives are in some far off land, and who has no one to turn to. Organic brain damage – Presence of concurrent obvious brain damage (mental retardation, epilepsy, head injury, etc.) hinders the final adequate recovery from schizophrenia. 

23. F actors which may indicate a poor or bad prognosis include: - Earlier age of onset - Being a male - A higher number of negative symptoms - A family history of schizophrenia - A low level of functioning prior to onset - Poor or no support system - A history of substance abuse 

24. Risk factors Certain factors seem to increase the risk of developing or triggering schizophrenia, including: Having a family history of schizophrenia Exposure to viruses, toxins or malnutrition while in the womb, particularly in the first and second trimesters Stressful life circumstances Older paternal age Taking psychoactive drugs during adolescence and young adulthood 

25. Clinical features Positive/Active Symptoms : The term positive symptom refers to symptoms that most individuals do not normally experience but are present in schizophrenia. They include delusions, hallucinations (auditory ), thought disorder, and disorganized behavior.

26. Negative/Deficit symptoms: Symptoms that reflect the loss or absence of normal traits or abilities. Common negative symptoms include flat or blunted affect and emotion , poverty of speech ( alogia ), inability to experience pleasure ( anhedonia ), lack of desire to form relationships ( asociality ), isolation (social withdrawal) and lack of motivation ( avolition ). 

27. Negative symptoms contribute more to poor quality of life, functional disability, and the burden on others than do positive symptoms. A third symptom grouping , the disorganization syndrome , is sometimes described, and includes chaotic speech, thought, and behavior .  Cognitive symptoms involve problems with thought processes. These symptoms may be the most disabling in schizophrenia because they interfere with the ability to perform routine daily tasks. A person with schizophrenia may be born with these symptoms. They include: Problems with making sense of information Difficulty paying attention Memory problems

28. Impact of schizophrenia Because of disordered thought processes, the schizophrenic patient often neglects personal hygiene or ignores health needs . As a result, the patient has a shorter life expectancy than the general population. Ten percent of schizophrenic patients commit suicide.  Other complications include: Aggression Violence Violence against others Increased risk of substance abuse (exacerbating symptoms in some patients)

29. Clinical types of schizophrenia

30. Types of schizophrenia Paranoid type: ( F20.0) Paranoid delusions and hallucinations (auditory) are present but thought disorder, disorganized behavior, and affective flattening are absent. The individual is often tense, suspicious, and guarded, may be argumentative, hostile, angry and aggressive. At the workplace, he has the false notion that co-workers talk about him behind his back and laugh quietly as he passes 

31. Paranoid – cont’d  Patient may refuse to eat meals served of the suspicion that the food is secretly poisoned. He may appeal to authorities for help.  Grandiose delusions may also dominate the clinical picture. For example, he believes himself anointed with holy oil, trumpets blared forth his appearance as a prophet. He has a message that will save the world, and sets about spreading it.

32. Disorganized type: Hebephrenic schizophrenia in the ICD .(F20.1) Affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behavior irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, T hought is disorganized, and speech is incoherent. There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults .

33. Catatonic type: (F20.2) Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like ( oneiroid ) state with vivid scenic hallucinations.

34. Catatonic type Symptoms can include : 1 . catatonic stupor: This is extreme immobility without evidence of absent or decreased consciousness. The patient is also rigid and mute and only appears to be conscious as the eyes are open and follow surrounding objects. Example : The patient sits immobile in a chair for sixteen hours, staring fixedly, apparently unaware of other people or his own bodily needs. 

35. Catatonic type Symptoms can include : 2 . waxy flexibility: The patient remains in any position that s/he is placed. The patient is nearly or completely unresponsive to stimuli and remains immobile for long periods of time . Example: A schizophrenic man stands stock-still near his bed. When a psychiatrist lifts the man’s arm, it remains in the exact same position for hours after she lets go

36. Catatonic type Symptoms can include : 3 . catatonic excitement: this involves purposeless motor activity and agitation. The patient shows impulsivity, destructive behaviour which urgently require physical and medical control because s/he is often destructive and violent to others, and his/her excitement can cause him/her to injure him/herself or to collapse from complete exhaustion. Pernicious or acute lethal catatonia is the other name used to describe excited catatonia. Example : The patient runs aimlessly through the dining hall due to an episode of catatonic excitement, knocking over objects without apparent regard, and ignoring all outside attempts to stop or redirect her.

37. Undifferentiated Schizophrenia( F20.3) Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2(paranoid , catatonic, disorganized or residual) , or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics. Symptoms : The person with this type of schizophrenia must have at least two or more of the following symptoms: Delusions Hallucination Disorganized speech Extremely disorganized or catatonic behavior Negative symptoms

38. Post-schizophrenic depression(F20.4) A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either "positive" or "negative", must still be present but they no longer dominate the clinical picture. These depressive states are associated with an increased risk of suicide. If the patient no longer has any schizophrenic symptoms, a depressive episode should be diagnosed (F32.-). If schizophrenic symptoms are still florid and prominent, the diagnosis should remain that of the appropriate schizophrenic subtype

39. Residual Schizophrenia: (F20.5) Positive symptoms are present at a low intensity only. This diagnostic category is used when the individual has a history of at least one previous episode of schizophrenia. At this stage, there is continuing evidence of the illness, although there are no prominent psychotic symptoms. symptoms may include social isolation, eccentric (strange/unusual) behaviour , impairment in personal hygiene and grooming, blunted or inappropriate affect, poverty of or overly elaborate speech, illogical thinking or apathy. For most part, however, the patient does little to attract any attention. 

40. Simple schizophrenia (F20.6) A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms . i.e ., hallucinations and delusions may be absent.  Very poor prognosis

41. Other schizophrenia (F20.8) Cenesthopathic schizophrenia Schizophrenia, unspecified (F20.9)

42. Schizotypal disorder (F21) A disorder characterized by eccentric behaviour and abnormalities of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic abnormalities occur at any stage. The symptoms may include a cold or inappropriate affect; anhedonia ; odd or eccentric behaviour ; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset and evolution and course are usually those of a personality disorder.

43. Persistent delusional disorders(F22) Includes a variety of disorders in which long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective . Delusional disorders that have lasted for less than a few months should be classified, at least temporarily, under F23.-.

44. Acute and transient psychotic disorders (F23): A group of disorders characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption of ordinary behaviour . Acute onset -development of a clearly abnormal clinical picture in about two weeks or less. For these disorders there is no evidence of organic causation. Confusion are often present but disorientation for time, place and person is not persistent Complete recovery usually occurs within a few months, often within a few weeks or even days. If the disorder persists, a change in classification will be necessary. The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

45. Induced delusional disorder (F24): A delusional disorder shared by two or more people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated.

46. Schizoaffective disorders (F25 ) : Episodic disorders in which both affective and schizophrenic symptoms are prominent but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes.

47. Schizoaffective disorder, manic type (F25.0) A disorder in which both schizophrenic and manic symptoms are prominent so that the episode of illness does not justify a diagnosis of either schizophrenia or a manic episode. This category should be used for both a single episode and a recurrent disorder in which the majority of episodes are schizoaffective, manic type . Schizoaffective disorder, depressive type (F25.1): A disorder in which both schizophrenic and depressive symptoms are prominent so that the episode of illness does not justify a diagnosis of either schizophrenia or a depressive episode. This category should be used for both a single episode and a recurrent disorder in which the majority of episodes are schizoaffective, depressive type.

48. Schizoaffective disorder, mixed type ( F25.2) Cyclic schizophrenia Mixed schizophrenic and affective psychosis

49. Diagnostic evaluation Mental status examination Psychiatric history Careful clinical observation CT scan and MRI show enlarged ventricles, sulci on cerebral surface and atrophy of the cerebellum

50. Normal brain Enlarged ventricles

51. Treatment modalities 1. Pharmacotherapy Antipsychotics Conventional/typical AP Chlorpromazine :300-1500 mg/day PO, 50-100 mg/day IM Fluphenazine deconoate : 25-50 mg IM every 1-3 weeks Haloperidol: 5-100 mg /day PO, 2-20 mg/ day IM Trifluoperazine : 15-60 mg/day PO, 1-5 mg/day IM

52. Atypical AP Other drugs: Anti depressants, mood stabilizers, benzodiazepines,etc .. Clozapine:25-450 mg/day PO Resperidone:2- 10 mg/day PO Olanzapine: 10-20 mg/day PO Quetiapine : 150-750 mg/day PO Ziprasidone : 20-80 mg/day Po

53. Non pharmacological Treatment of Schizophrenia ECT (8-12 ECTs are needed) Psychosocial Rehabilitation to improve activities of daily living Individual Psychotherapy Group Psychotherapy Social Skills Training Cognitive Behavior therapy Family Therapy Education & support, for both ill individuals and families Vocational and recreational support

54. Nursing Interventions For Schizophrenia Assess the patient’s ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he is not eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to the hospital’s policy to ensure the patient’s safety and that of others.

55. Nursing Interventions For Schizophrenia   Adopt an accepting and consistent approach with the patient. Do not avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established . Avoid promoting dependence . Meet the patient’s needs, but only do for the patient what he cannot do for himself. Reward positive behavior to help the patient improve his level of functioning.

56. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says is not understood by others. If necessary, set limits on inappropriate behavior.

57. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they are command hallucinations that place the patient or others at risk. Tell the patient you do not hear the voices but you know they are real to him. Avoid arguing about the hallucinations; if possible, change the subject. Do not tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who’s told, “That procedure will be done on the floor”, may become frightened, thinking he is being told to lie down on the floor.

58. Do not touch the patient without telling him first exactly what you are going to do. For example, clearly explain to him, I’m going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with hospital personnel until the patient is less suspicious or agitated. Remember , institutionalization may produce new symptoms and handicaps in the patient that are not part of his diagnosed illness, so evaluate symptoms carefully. 

59.  Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.  Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia , tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly. 

60. Nursing interventions for agitation, hallucinations, and delusions Agitation Remove client from, or avoid, situations known to cause agitation. Decrease stimulants such as caffeine, bright lights, and loud noise or music . Avoid display of anger, discouragement, or frustration when interacting with client. Avoid criticism and do not argue with client. Set limits and follow through with consequences if a violation occurs. Monitor for physical discomfort such as pain or physical illness. Administer prescribed medication as ordered.

61. Nursing interventions for agitation, hallucinations, and delusions Hallucinations Decrease environmental stimuli such as loud music, extremely bright colors, or flashing lights. Attempt to identify precipitating factors by asking the client what happened prior to the onset of hallucinations. Monitor television programs to minimize external stimuli that may precipitate hallucinations. Monitor for command hallucinations that may precipitate aggressive or violent behavior. Administer prescribed medication as ordered.

62. Nursing interventions for agitation, hallucinations, and delusions Delusions Do not whisper or laugh in the presence of the client. Do not argue with the client or attempt to disprove delusional or suspicious thoughts . Explain all procedures and interventions, including medication management. Provide for personal space and do not touch the client without warning . Maintain eye contact during interactions with client. Provide consistency in care and assigned caregivers to establish trust.

63. Clients who are suspicious and rude Form professional relationships; can be considered a threat if too friendly . Be careful with the touch as it can be regarded as a threat. Give as much control and autonomy to client within the therapeutic limits. Create a sense of trust through brief interactions that communicate caring and respect. Describe any treatment, medication and laboratory tests before the start . Do not focus or strengthen the suspicion or delusional ideas. Identify and respond to the emotional needs of the underlying suspicion or delusional thoughts Intervene when the client shows signs of increasing anxiety and potentially express an unconscious behavior. Be careful not to behave in a way that could be misinterpreted by the client.

64. THE NURSE’S ROLE DURING MEDICATION MANAGEMENT: Administering medication, Monitoring responses to the prescribed medication, and reporting any adverse effects . The nurse also plays a major role in developing a therapeutic relationship and educating the client and family about prescribed medication to promote compliance.

65. PREVENTION OF SCHIZOPHRENIA Seek early treatment (to control symptoms before complications develop and to improve long-term outlook) Stick to treatment plan (to prevent relapses or worsening of schizophrenia symptoms) Learn about risk factors may lead to earlier diagnosis and earlier treatment Avoid illegal drug and alcohol use Reducing stress 

66.   Getting enough sleep Avoid social isolation Plan your pregnancy (have a child when you want one, and don’t have a child if you don’t want one ) Eat a healthy diet with a lot of vegetables, fish with omega 3 fatty acids. Avoid head injuries Vitamin D supplements

67. Conclusion Drug and psychosocial interventions for the symptoms of schizophrenic disorders contribute to a lower incidence and prevalence of schizophrenia. Nurses will be able to offer better care through the use of nursing models and theories in the care of Schizophrenics.