Undifferentiated Schizophrenia?> "Undifferentiated schizophrenia" is used as a label for cases of schizophrenia that don't match any of the established types of schizophrenia. Undifferentiated type schizophrenia differs from "residual schizophrenia," which refers to chronic conditions after an acute schizophrenia episode.

Undifferentiated Schizophrenia Symptoms

Although they're just as severe, the symptoms of undifferentiated schizophrenia are not as specific as the symptoms of other types of schizophrenia.

In some cases, undifferentiated schizophrenia symptoms change often, resembling the symptoms of various types of schizophrenia at different times and defying classification. In other cases of undifferentiated schizophrenia, symptoms are stable but they don't match the description of the symptoms of other types of schizophrenia.

Undifferentiated schizophrenia symptoms vary from case to case. Any symptoms seen in other types of schizophrenia may be present, including:

Catatonic symptoms Delusions Disorganized thinking A flat affect characterizing dulled emotions Hallucinations.

A gradual worsening of "negative" symptoms often occurs in cases of undifferentiated schizophrenia. Negative symptoms result from the loss of mental function. "Positive" symptoms such as hallucinations or delusions result from excessive mental functioning.

Negative symptoms associated with undifferentiated schizophrenia include:

Deadened or dulled emotions Improvised or impaired speech Inability to feel pleasure Loss of interest in activities Social withdrawal.

Diagnosing Schizophrenia, Undifferentiated Type

A diagnosis of undifferentiated schizophrenia must meet the criteria for general schizophrenia, but cannot match any of the three established types of schizophrenia: paranoid schizophrenia, disorganized schizophrenia or catatonic schizophrenia.

Furthermore, undifferentiated schizophrenia must include psychotic symptoms. If psychotic symptoms are not present or they cause only minimal problems, a diagnosis of residual schizophrenia or post-schizophrenic depression may be the preferred diagnosis.

Treatment of Undifferentiated Schizophrenia

The treatment of undifferentiated schizophrenia symptoms is similar to general schizophrenia treatment and faces the same challenges. Treatment options include antipsychotic medication, therapy and, in severe cases, hospitalization.

The wide range of symptoms coupled with the fact that persons with undifferentiated schizophrenia are only rarely aware that they need treatment complicates treatments plans for undifferentiated schizophrenia.

Types of Schizophrenia

The different types of schizophrenia have specific, distinct symptoms. Specialists believe that undifferentiated schizophrenia symptoms result from several different disorders. Researchers hope that eventually they'll have evidence that undifferentiated schizophrenia is actually a combination of disorders. Time and research may provide more information about undifferentiated schizophrenia.

Resources

Bengston, M. (2006). Undifferentiated schizophrenia. Retrieved July 5, 2010, from http://psychcentral.com/lib/2006/undifferentiated-schizophrenia/

Mulhauser, G. (2010). Undifferentiated schizophrenia diagnostic criteria. Retrieved July 5, 2010, from http://counsellingresource.com/distress/schizophrenia/icd/undifferentiated.html

PSYweb. (n.d.). Schizophrenia (undifferentiated type). Retrieved July 5, 2010, from http://psyweb.com/Mdisord/SchizoDis/undtype.jsp

Schizophrenia is a group of mental disorders characterized by psychotic features, the inability to trust others, and unordered thought processes. The client also withdraws from reality, shows regressive behavior, has ineffective communication and a reversely impaired inter-personal relationship. Typical onset occurs in early adulthood with diagnosis based on observation and the patient’s experiences.

Types of Schizophrenia

1. Disorganized or Hebephrenic Schizophrenia. There is severe and pronounced mental incapacity. The client manifests a flat affect and peculiar behavior. Social withdrawal and delusions are common.

2. Catatonic Schizophrenia. The client has catatonic stupor wherein he manifests waxy flexibility, withdrawal, distorted reality, and ambivalence.

3. Paranoid Schizophrenia. The patient undergoes delusions as compensatory mechanism and hallucinations.

4. Undifferentiated Schizophrenia. There are mixed symptoms. The client also manifests a flat affect. Factors: severe emotional problem, chronic insecurity or a total failure in inter-personal relationships, difficulty in restoration of integrity and personality.

DelusionDelusions are false beliefs considered to be true even though there is sufficient evidence on the contrary. The client also believes the certain events, situations, or actions are directly related to self. Types of Delusions:

Delusions of Grandeur. The client believes that one is powerful and an important person or being.

Delusions of Persecution. The client believes that he is being singled-out for harm by others. Delusions of Jealousy. The client believes that he’s partner is going out with another person.

Assessment for Schizophrenia

1. 4 A’s o Affect. If client manifests flat or blunted it is considered inappropriate.o Associative looseness. The client’s verbalization is disorganized.o Ambivalence. The client has two conflicting emotions.o Autism. Thoughts on self, extreme withdrawal, and the inability to relate to the outside

world.2. Ability to perform Activities of Daily Living (ADLs). Clients with Schizophrenia have difficulties in

performing self-care activities. Also, client have nutritional deficit.3. Aggression4. Suicidal Potential5. Any changes in thoughts or feelings.6. Disturbances in inter-personal relationships.

Nursing Diagnosis for Clients with Schizophrenia

1. Anxiety related to disturbed thought processes.2. Impaired verbal communication related to inappropriate use of words.3. Ineffective family coping related to ambivalent family relationships.4. Sensory perceptual alterations related to misinterpretation of stimuli.

Nursing Care for Clients with Schizophrenia

Encourage the client to follow drug regimen. Observe adverse drug reactions especially major tranquilizers. Encourage the development of interpersonal relationships.

Encourage the client towards presentation to reality. Accept the level of functioning. Respect the patient as a human being with dignity and worth.

Nursing Management-Nursing Process

History

Outline of psychiatric historyName, age , address of patient, name of informant if any and their relationship to the patientHistory of present conditionFamily HistoryPersonal History

early development, health during childhood, nervous problems in childhood, education, occupation, menstrual history, sexual history, marriage,

Past illness

past physical illness, medical illness, forensic history

Personality

relationships, leisure activities, prevailing mood, character, attitudes and standards, premorbid personality

Drugs, alcohol, tobacco

Mental Status Examination

Appearance and behaviour

General appearance, facial appearance, posture and movement, social behaviour, consciousness, orientation

Speech –

coherent, relevant, goal-directed rate and quantity flow of speech

Mood

cheerful, elation, euphoric, exaltation depression, anxiety congruent or incongruent

Depersonalization and derealizationDelusions

content and form-persecutory, grandiose, nihilistic, hypochondriacal, religious, reference, guilt, unworthiness, jealousy

Well-systematized

Illusions

hallucinations-auditory or visual, command hallucinations, second person, third personAttention and concentrationMemory-short term, recent and remoteInsight-Grade 1 to 5

A. Nursing Diagnosis Disturbed Thought Processes

-Disruption in cognitive operations and activities

Assessment Data

§ Non-reality-based thinking, Disorientation, Labile affect, Short attention span, Impaired judgment, Distractibility

Expected Outcomes

§ Be free from injury

§ Demonstrate decreased anxiety level

§ Respond to reality-based interactions initiated by others

§ Verbalize recognition of delusional thoughts if they persist

§ Be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts

NURSING INTERVENTIONS RATIONALEBe sincere and honest when communicating with the client. Avoid vague or evasive remarks.

Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.

Be consistent in setting expectations, enforcing rules, and so forth.

Clear, consistent limits provide a secure structure for the client.

Do not make promises that you cannot keep. Broken promises reinforce the client’s mistrust of others.

Encourage the client to talk with you, but do not pry for information.

Probing increases the client’s suspicion and

interferes with the therapeutic relationship.Explain procedures, and try to be sure the client understands the procedures before carrying them out.

When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff.

Give positive feedback for the client’s successes. Positive feedback for genuine success enhances the client’s sense of well-being and helps make non-delusional reality a more positive situation for the client.

Recognize the client’s delusions as the client’s perception of the environment.

Recognizing the client’s perceptions can help you understand the feelings he or she is experiencing.

Initially, do not argue with the client or try to convince the client that the delusions are false or unreal.

Logical argument does not dispel delusional ideas and can interfere with the development of trust.

Interact with the client on the basis of real things; do not dwell on the delusional material.

Interacting about reality is healthy for the client.

Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

A distrustful client can best deal with one person initially. Gradual introduction of others when the client can tolerates is less threatening.

Recognize and support the client’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).

Recognizing the client’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem.

Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance.

The client’s delusions can be distressing. Empathy conveys your caring, interest and acceptance of the client.

Never convey to the client that you accept the delusions as reality.

Indicating belief in the delusion reinforces the delusion (and the client’ illness).

Ask the client if he or she can see that the delusions interfere with or cause problems in his or her life.

Discussion of the problems caused by the delusions is a focus on the present and is reality based.

B. Nursing Diagnosis: Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory

-Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Assessment

· Hallucinations (auditory, visual, tactile, gustatory, kinesthetic, or olfactory)

· Listening intently to no apparent stimuli

· Talking out loud when no one is present

· Rambling, incoherent, or unintelligible speech

· Inability to discriminate between real and unreal perceptions

· Attention deficits

· Inability to make decisions

· Feelings of insecurity

· Confusion

Expected Outcomes

· Demonstrate decreased hallucinations

· Interact with others in the external environment

· Verbalize knowledge of hallucinations or illness and safe use of medications

· Participate in the real environment

· Make sound decisions based on reality

· Participate in community activities or programs

NURSING INTERVENTIONS RATIONALEBe aware of all surrounding stimuli, including sounds from other rooms (such as television or stereo in adjacent areas).

Many seemingly normal stimuli will trigger or intensify hallucinations. The client can be overwhelmed by stimuli.

Try to decrease stimuli or move the client to another area.

Decreased stimuli decreases chances of misperception. The client has a diminished ability to deal with stimuli.

Avoid conveying to the client the belief that hallucinations are real. Do not converse with the “voices” or otherwise reinforce the client’s belief in the hallucinations as reality.

You must be honest with the client, letting him or her know the hallucinations are not real.

Explore the content of the client’s hallucinations during the initial assessment to determine what kind of stimuli the client is receiving, but do not reinforce the hallucinations as real. You might say, "I don’t hear any voices-what are you hearing?"

It is important to determine if auditory hallucinations are "command" hallucinations that direct the client to hurt himself or herself or others. Safety is always a priority.

Use concrete, specific verbal communication with the client. Avoid gestures, abstract ideas

The client’s ability to deal in abstractions is diminished. The client may misinterpret your gestures

Avoid asking the client to make choices. Don’t ask “Would you like to talk or be alone?” Rather, suggest that the client talk with you.

The client’s ability to make decisions is impaired, and the client may choose to be alone (and hallucinate) rather than deal with reality (talking to you).

Respond verbally and reinforce the client’s conversation when he or she refers to reality.

Positive reinforcement increases the likelihood of desired behaviors.

Encourage the client to tell staff members about hallucinations.

The client has the chance to seek others (in reality) and to cope with problems caused by hallucinations.

If the client appears to be hallucinating, attempt to engage the client’s in conversation or a concrete activity.

It is more difficult for the client to respond to hallucinations when he or she is engaged in real activities and interactions.

Maintain simple topics of conversation to provide a base in reality.

The client is better able to talk about basic things; complexity is more difficult.

Provide simple activities that the client can realistically accomplish (such as uncomplicated craft projects).

Long or complicated tasks may be frustrating for the client. He or she may be unable to complete them.

Encourage the client to express any feelings of remorse or embarrassment once he or she is aware of psychotic behavior; be supportive.

It may help the client to express such feelings, particularly if you are a supportive, accepting listener.

Show acceptance of the client’s behavior and of the client as a person; do not joke about or judge the client’s behavior.

The client may need help to see that hallucinations were a part of the illness, not under the client’s control. Joking or being judgmental about the client’s behavior is not appropriate and can be damaging to the client.

C. Nursing Diagnosis: Disturbed Personal Identity

-Inability to distinguish between self and nonself

Assessment data

· Bizarre behavior, Regressive behavior, Loss of ego boundaries (inability to differentiate self from the external environment), Disorientation, Disorganized, illogical thinking, Flat or inappropriate affect, Feelings of anxiety, fear, or agitation, Aggressive behavior toward others or property

Expected Outcomes

· Be free from injury

· Not harm others or destroy property

· Establish contact with reality

· Demonstrate or verbalize decreased psychotic symptoms and feelings of anxiety, agitation, and so forth

· Participate in the therapeutic milieu

· Express feelings in an acceptable manner

· Reach or maintain his or her optimal level of functioning

· Cope effectively with the illness

· Continue compliance with prescribed regimen, such as medications and follow-up appointments

NURSING INTERVENTIONS RATIONALE

Reassure the client that the environment is safe by briefly and simply explaining routines, procedures, and so forth.

The client is less likely to feel threatened if the surroundings are known.

Protect the client from harming himself or herself or others

Client safety is a priority. Self-destructive ideas may come from hallucinations or delusions.

Remove the client from the group if his or her behavior becomes too bizarre, disturbing, or dangerous to others.

The benefit of involving the client with the group is outweighed by the group’s need for safety and protection.

Decrease excessive stimuli in the environment. The client may not respond favorably to competitive activities, or large groups if he or she is still actively psychotic.

The client is unable to deal with excess stimuli. The environment should not be threatening to the client.

*Be aware of SOS medications and the client’s varying need for them.

Medication can help the client gain control over his or her own behavior.

Reorient the client to person, place, and time as indicated (call the client by name, tell the client where he or she is, and so forth).

Repeated presentation of reality is concrete reinforcement for the client.

Spend time with the client even when he or she is unable to respond coherently. Convey your interest and caring.

Your physical presence is reality. Nonverbal caring can be conveyed to the client even when verbal caring is not understood.

Make only promises that you can realistically keep. Breaking your promise can result in increasing the client’s mistrust.

Help the client establish what is real and unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter-of-fact manner. Do not argue with the client, but do not give support for misperceptions.

The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently.

Stay with the client when he or she is frightened. Touching the client can sometimes be therapeutic. Evaluate the effectiveness of the use of touch with the client before using it consistently.

Your presence and touch can provide reassurance from the real world. However, touch may not be effective if the client feels that his or her boundaries are being invaded.

Be simple, direct, and concise when speaking to the client.

The client is unable to process complex ideas effectively.

Talk with the client about simple, concrete things; avoid ideologic or theoretical discussions.

The client’s ability to deal with abstractions is impaired.

Direct activities toward helping the client accept and remain in contact with reality.

Increased reality contact decreases the client’s retreat into unreality.

Initially, assign the same staff members to work with the client.

Consistency can reassure the client.

Begin with one-to-one interactions, and then progress to small groups as tolerated (introduce slowly).

Initially, the client will better tolerate and deal with limited contact.

Set realistic goals. Set daily goals and expectations. Unrealistic goals will frustrate the client.

Daily goals are short term and easier for the client to accomplish.

At first, do not offer choices to the client (“Would you like to go to activities?” “What would you like to eat?”). Instead, approach the client in a directive manner (“It is time to eat. Please pick up your fork.”).

The client’s ability to make decisions is impaired. Asking the client to make decisions at this time may be very frustrating.

Gradually, as the client can tolerate it, provide opportunities for him or her to accept responsibility and make personal decisions.

The client needs to gain independence as soon as he or she is able. Gradual addition of responsibilities and decisions gives the client a greater opportunity for success.

D. Nursing Diagnosis: Impaired Social Interaction

“Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.”

Assessment data

· Inappropriate or inadequate emotional responses, Poor interpersonal relationships, Feeling threatened in social situations, Difficulty with verbal communication, Exaggerated responses to stimuli, Difficulty trusting others, Difficulties in relationships with significant others, Poor social skills

Expected Outcomes

· Report increased feelings of self-worth

· Identify strengths and assets

· Engage in social interaction

· Participate in the trust relationship

· Demonstrate ability to interact with staff and other clients within the therapeutic milieu

· Assume increasing responsibility within the context of the therapeutic relationship

· Use community support system successfully

· Participate in follow-up or outpatient therapy as indicated

NURSING INTERVENTIONS

* denotes collaborative interventions

RATIONALE

Provide attention in a sincere, interested manner.

Flattery can be interpreted as belittling by the client.

Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth.

Sincere and genuine praise that the client has earned can improve self-esteem.

Avoid trying to convince the client verbally of his or her own worth.

The client will respond to genuine recognition of a concrete behavior rather than to unfounded praise or flattery.

Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

The client may have little or no knowledge of social interaction skills. Modeling provides a concrete example of the desired skills.

Help the client improve his or her grooming; assist when necessary in bathing, doing laundry, and so forth.

Good physical grooming can enhance confidence in social situations.

E. Nursing Diagnosis: Noncompliance

Assessment data

· Objective tests indicating noncompliance, such as low neuroleptic blood levels

· Statements from the client or significant others describing noncompliant behavior

· Exacerbation of symptoms

· Appearance of side effects or complications

· Failure to keep appointments

· Failure to follow through with referrals

Outcome Identification

· Identify barriers to compliance

· Recognize the relationship between noncompliance and undesirable consequences (i.e., increased symptoms, hospitalization

· Verbalize acceptance of illness

· Identify risks of noncompliance

· Adhere to therapeutic recommendations independently

· Inform care provider of need for changes in therapeutic recommendations

Films on Schizophrenia

A beautiful Mind (1949)

The Fisher King (1991)

Birdy (1984)

The Madness of King George (1994)

Promise (1986)

Taxi Driver (1976)

References

1. Reddy MV, Chandrashekar CR. Prevalence of mental and behavioural

disorders in India: A meta-analysis. Indian Journal of Psychiatry

1998;40(2):149–157.

2. Gelder M., Gath D., Mayou R., owen P. Oxford Textbook of Psychiatry.

Third Edition. Oxford University Press. New delhi 2000.

3. Ahuja,N. A short Textbook of Psychiatry. 5th Edition Jaypee Brothers

New Delhi 2002.

4. Videbeck, SL. Psychiatric Mental heath Nursing 2nd edition. LWW

Philadelphia 2004.

5. Schultz, JM., Videbeck, SL. Psychiatric Nursing Care Plans. 7th Edition.

LWW Philadelphia 2004

Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things that aren't there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other symptoms include

Unusual thoughts or perceptions Disorders of movement Difficulty speaking and expressing emotion Problems with attention, memory and organization

No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives.NIH: National Institute of Mental Health

Causes For Schizophrenia

Schizophrenia may result from a combination of genetic, biological, cultural, and psychological factors with genetic and environmental insults most associated. For example, some evidence supports a genetic predisposition to this disorder. Close relatives of schizophrenic patients are up to 50 times more likely to develop schizophrenia; the closer the degree of biological relatedness, the higher the risk.

The most widely accepted biochemical hypothesis holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations may also contribute to schizophrenic symptoms.

Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed as possible causes. Schizophrenia has a higher incidence among lower socioeconomic groups, possibly related to downward social drift or lack of upward socioeconomic mobility, and to high stress levels, possibly induced by poverty, social failure, illness, and inadequate social resources. Gestational and birth complications, such as Rh factor incompatibility, prenatal exposure to influenza during the second trimester, and prenatal nutritional deficiencies, have been associated.

Assessment Nursing Care Plans For Schizophrenia

Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment and poor outcome.

Although behaviors and functional deficiencies can vary widely among patients and even in the same patient at different times, watch for the following characteristic signs and symptoms during the assessment interview:

1. ambivalence coexisting strong positive and negative feelings, leading to emotional conflict

2. apathy3. clang associations words that rhyme or sound alike used in an illogical, nonsensical

manner; for instance, It's the rain, train, pain.4. concrete thinking inability to form or understand abstract thoughts5. delusions false ideas or beliefs accepted as real by the patient. Delusions of grandeur,

persecution, and reference (distorted belief regarding the relation between events and one's self; for example, a belief that television programs address the patient on a personal level) are common in schizophrenia. Also common are feelings of being controlled, somatic illness, and depersonalization.

6. echolalia meaningless repetition of words or phrases7. echopraxia involuntary repetition of movements observed in others8. flight of ideas rapid succession of incomplete and poorly connected ideas9. hallucinations false sensory perceptions with no basis in reality. Usually visual or

auditory, hallucinations may also be olfactory (smell), gustatory (taste), or tactile (touch).10. illusions—false sensory perceptions with some basis in reality; for example, a car

backfiring might be mistaken for a gunshot.11. loose associations not connected or related by logic or rationality12. magical thinking belief that thoughts or wishes can control other people or events13. neologisms bizarre words that have meaning only for the patient14. poor interpersonal relationships15. regression return to an earlier developmental stage16. thought blocking sudden interruption in the patient's train of thought17. withdrawal disinterest in objects, people, or surroundings18. word salad illogical word groupings; for example, She had a star, barn, plant. It's the

extreme form of loose associations.

Diagnoses Nursing Care Plans For Schizophrenia

Anxiety Bathing or hygiene self-care deficit Disabled family coping Disturbed body image

Disturbed personal identity Disturbed sensory perception (auditory, visual, kinesthetic) Disturbed sleep pattern Disturbed thought processes Dressing or grooming self-care deficit Fear Hopelessness Imbalanced nutrition: Less than body requirements Impaired home maintenance Impaired social interaction Impaired verbal communication Ineffective coping Ineffective role performance Powerlessness Risk for injury Risk for other-directed violence Risk for self-directed violence Social isolation

Interventions Nursing Care Plans For Schizophrenia

1. 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 isn't 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.

2. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.

3. Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.

4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.

5. Reward positive behavior to help the patient improve his level of functioning.6. 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 isn't understood by others. If necessary, set limits on inappropriate behavior.

7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.

8. Don't 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.

9. Don't touch the patient without telling him first exactly what you're 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 facility personnel until the patient is less suspicious or agitated.

10. Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.

11. 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.

12. 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.