Nursing Field Notes / Mental Health · Psychiatric Care Course
Schizophrenia 🧠
Signs & Symptoms — Part 1 of a 4-page Schizophrenia series
NG-049Mental HealthSeries 1 of 4 · foundation page
Schizophrenia is a chronic thought disorder — an abnormal, scattered pattern of thinking and perceiving lasting 6 months or more, disrupting relationships, school, and work. This page defines every term the rest of the series reuses: positive, negative & cognitive symptoms, hallucinations, delusions, and disorganized speech. Communication techniques live on NG-128; drug therapy lives on NG-165 & NG-235.
➖ Negative = TAKEN AWAYSomething normal brains do have but this client has lost: flat affect, avolition, anhedonia.
🧩 Cognitive = MEMORY & FOCUSTrouble with attention, memory, executive function & insight.
🚨 Suicide risk = HIGHAlways priority-assess safety — highest yield fact on this whole page.
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CAUSE
STEP 1 · WHAT STARTS IT
A dopamine imbalance in two different brain pathways explains why symptoms split into two opposite categories.
🧠 The dopamine hypothesis — two pathways, two opposite effects
Schizophrenia is linked to dysregulated dopamine signaling, but it isn't simply "too much" or "too little" everywhere — it depends on which pathway.
🧠 "MESO-LIMBIC = MORE limbic feelings" (positive) · "MESO-CORTICAL = COGNITIVE cortex" (negative/cognitive). Antipsychotics only fix the excess pathway — that's why negative & cognitive symptoms are the hardest to treat (see NG-235 for why).
🧬 Genetics & risk factors
Family history — a child is significantly more likely to develop schizophrenia when a parent has the condition; risk rises further with two affected parents.
Prenatal/perinatal factors — maternal malnutrition, viral infection, or obstetric complications are associated with higher risk.
Environmental stress + genetic vulnerability — the leading model is a "stress-diathesis": genetic predisposition plus a triggering stressor (adolescence/young-adulthood is the typical onset window).
🧠 Typical onset: late teens to early 30s — earlier and often more severe in men, slightly later in women.
📅 Diagnostic criteria — the 6-month rule
Standard criteria require ≥2 characteristic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms) for a significant portion of 1 month, with continuous signs of disturbance for ≥ 6 months, and a clear drop in functioning — work, relationships, self-care.
🧠 "6 & 1" — 6 months total disturbance, 1 month of active, full-blown symptoms in the middle of it.
⏳ The 3 phases — same illness, different intensity
🧠 Relapse usually re-enters at the active phase, not from scratch — this is why medication adherence (NG-165) is the single biggest predictor of staying out of the active phase.
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SYMPTOMS
STEP 2 · WHAT YOU'LL NOTICE
Three buckets. Positive = added on top of normal. Negative = subtracted from normal. Cognitive = the thinking machinery itself.
➕ Positive symptoms — psychotic symptoms, ADDED
🗣️ Hallucinations — perceiving something that is not really there.
Auditory (most common) — hearing voices/sounds. Nursing action: offer structured, reality-based distraction such as headphones with music or a task that occupies attention.
Tactile — false sensation of being touched.
Also possible: visual, olfactory, gustatory (rarer — investigate for a medical/substance cause if prominent).
🎯 Delusions — a fixed false belief that persists despite evidence against it.
Persecutory (paranoid) — "The hospital food is trying to poison me."
Grandeur — "I have a meeting with the Queen today."
Reference — "This song has a secret message just for me."
Control — "I don't go online — that's how the FBI controls people."
🧠 "P-P-P" — Positive = Psychotic = something Present that shouldn't be. See NG-128 for exactly what to say (and never say) when a client reports a hallucination or delusion.
Avolition — lack of motivation to start/finish goal-directed tasks
Alogia — poverty of speech, minimal spontaneous talking
Asocial — withdraws from social interaction, prefers isolation
🧠 Negative symptoms = a Negative photograph — the picture is missing pieces a normal brain has. These are the symptoms most easily missed because nothing dramatic is happening — the client is just quietly absent.
🧩 Cognitive symptoms — capacity to think
Impaired memory, attention, and executive function (planning, problem-solving, insight). Affects learning, understanding instructions, and — critically — insight into having an illness (see anosognosia on NG-165).
🧠 "C = Capacity." Cognitive symptoms are the ones that quietly sabotage medication adherence and discharge teaching — always check for understanding, don't just assume it.
📋 All three buckets, side by side
Positive (added)
Negative (subtracted)
Cognitive (thinking machinery)
Hallucinations
Flat affect
Impaired attention/concentration
Delusions
Anhedonia
Impaired memory
Disorganized speech
Avolition
Poor executive function/planning
Grossly disorganized or catatonic behavior
Alogia
Reduced insight (anosognosia)
—
Asociality
—
🧠 NCLEX trap: a question describing a client who is quiet, withdrawn, and unmotivated is testing negative symptoms, not "doing fine." Passive presentations get under-treated in real practice — don't let them get under-recognized on the exam either.
🗣️
DISORGANIZED SPEECH
STEP 2B · HOW THOUGHT DISORDER SOUNDS
A form of positive symptom on its own — the connective tissue between thoughts breaks down. Learn to recognize each pattern by name.
🧵 Loose associations — thoughts shift with no logical link
🧠 "Loose = zig-zag." Each new sentence jumps to an unrelated idea — no thread connects them, unlike tangentiality where there's still a starting thread that trails off.
🆕 Neologisms & word salad
Neologisms — inventing new, made-up words with private meaning.
Word salad — real words strung together with no meaningful sentence structure: "Here is the chair, moon, orange, drank too much."
🧠 Neologism = a new logo for a word that never existed before.
🔔 Clang associations
Choosing words for how they sound (rhyme), not what they mean: "Let's go to the bay, hit the hay, what do you say — we can go today."
🧠 Clang = a bell (clang!) ringing on rhyme, not meaning.
🔁 Perseveration vs. echolalia
Perseveration
Echolalia
Repeats the same word/phrase regardless of the question asked
Repeats back what someone else just said
Nurse: "How do you feel?" → "Splendid." Nurse: "What's today's date?" → "Splendid."
Nurse: "We will take your vitals." → Client: "Vitals."
🧠 Per-SEVER-ation SEVERs the connection to the actual question. Echolalia = a literal echo.
↩️ Tangentiality vs. concrete thinking
Tangentiality — replies veer off to unrelated topics and never return to the original question. Nurse: "How was your sleep?" → "When I was five my cat was killed, I love dogs."
Concrete thinking — takes abstract statements literally. "Grass is greener on the other side" is understood as literal grass, not the idiom.
🧠 Avoid idioms/metaphors in teaching — say exactly what you mean.
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CARE PRIORITIES
STEP 3 · SAFETY FIRST
Suicide risk outranks everything else on this page. Everything after safety belongs on the other 3 pages in this series.
🚨 Suicide risk is HIGH — always assess first
1
Assess safety — suicidal ideation, plan, means, and command hallucinations (voices telling the client to harm self/others)
2
Provide a safe, low-stimulation environment — decrease noise, light, and crowding, which can worsen psychosis
3
Build trust — consistent staff, honesty, predictable routine (therapeutic milieu — detailed on NG-128)
4
Monitor continuously through every phase, not just during an acute admission
🧠 "S-S-S" — Schizophrenia has a Scattered pattern of thinking and Suicide risk is high. Say it every time you see the diagnosis.
🗺️ Where the rest of this topic lives — the 4-page series
🧠 Think of this page as the dictionary for the whole series — every term defined here (hallucination, delusion, flat affect, avolition, disorganized speech) is used without re-explaining it on the other three pages.