Schizophrenia

DEFINITION

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood.
Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness;
rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women.
The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved the functioning of client’s daily life.

PATHOPHYSIOLOGY

TYPES OF SCHIZOPHRENIA:

The diagnosis is made according to the client’s predominant symptoms:

• Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior.
• Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior.
• Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor.
• Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior.
• Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations.

Paranoid Schizophrenia

• Is characterized by persecutory or grandiose delusional thought content and, possibly, delusional jealousy.
• Some patients also have gender identity problems, such as fears of being thought of as homosexual or of being approached by homosexuals.
• Stress may worsen the patient’s symptoms.
• Paranoid schizophrenia may cause only minimal impairment in the patient’s level of functioning – as long as he doesn’t act on delusional thoughts.
• Although patients with paranoid schizophrenia may experience frequent auditory hallucinations (usually related to a single theme), they typically lack some of the symptoms of other schizophrenia subtypes – notably, incoherent, loose associations, flat or grossly inappropriate affect, and catatonic or grossly disorganized behavior.
• Tend to be less severely disabled than other schizophrenia.
• Those with late onset of disease and good pre-illness functioning (ironically, the very patients who have the best prognosis) are at the greatest risk for suicide.

Signs and Symptoms

• Persecutory or grandiose delusional thoughts
• Auditory hallucinations
• Unfocused anxiety
• Anger
• Tendency to argue
• Stilted formality or intensity when interacting with others
• Violent behavior

Diagnosis

• Ruling out other causes of the patient’s symptoms.
• Meeting the DSM-IV-TR criteria.

Treatment

• Antipsychotic drug therapy.
• Psychosocial therapies and rehabilitation, including group and individual psychotherapy.

Nursing Interventions

1. Build trust, and be honest and dependable, don’t threaten or make promises you can’t fulfill.
2. Be aware that brief patient contacts may be most useful initially.
3. When the patient is newly admitted, minimize his contact with the staff.
4. Don’t touch the patient without telling him first exactly what you’re going to be doing and before obtaining his permission to touch him.
5. Approach him in a calm, unhurried manner.
6. Avoid crowding him physically or psychologically; he may strike out to protect himself.
7. Respond neutrally to his condescending remarks; don’t let him put you on the defensive, and don’t take his remarks personally.
8. If he tells you to leave him alone, do leave- but make sure you return soon.
9. Set limits firmly but without anger, avoid a punitive attitude.
10. Be flexible, giving the patient as much control as possible.
11. Consider postponing procedures that require physical contact with hospital personnel if the patient becomes suspicious or agitated.
12. If the patient has auditory hallucinations, explore the content of the hallucinations (what voices are saying to him, whether he thinks he must do what they command) tell him you don’t hear voices, but you know they’re real to him.

Disorganized Schizophrenia

• Is marked by incoherent, disorganized speech and behaviors and by blunted or inappropriate affect.
• May have fragmented hallucinations and delusions with no coherent theme.
• Usually includes extreme social impairment.
• This type of schizophrenia may start early and insidiously, with no significant remissions.

Signs and Symptoms

• Incoherent, disorganized speech, with markedly loose associations.
• Grossly disorganized behavior.
• Blunted, silly, superficial, or inappropriate affect.
• Grimacing
• Hypochondriacal complaints.
• Extreme social withdrawal.

Diagnosis

• Ruling out other causes of the patients symptoms.
• Meeting the DSM-IV-TR criteria.

Treatment

• Treatments described for other types of schizophrenia.
• Antipsychotic drugs and psychotherapy.

Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him choice (for example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t complain of pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the patient, and others.

Catatonic Schizophrenia

• Is a rare disease form in which the patient tends to remain in a fixed stupor or position for long periods, periodically yielding to brief spurts of extreme excitement.
• Many catatonic schizophrenia have an increased potential for destructive, violent behavior when agitated.

Signs and Symptoms

• Remaining mute; refusal to move about or tend to personal needs.
• Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth movements.
• Rapid swing between stupor and excitement (extreme psychomotor agitation with excessive, senseless, or incoherent shouting or talking).
• Bizarre posture such as holding the body (especially the arms and legs) rigidly in one position for a long time.
• Diminished sensitivity to painful stimuli.
• Echolalia (repeating words or phrases spoken by others).
• Echopraxia (imitating other’s movements).

Diagnosis

• Ruling out other possible causes of the patient’s symptoms.
• Meeting the DSM-IV-TR criteria.

Treatment

• ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic schizophrenia.
• Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).
• Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires further evaluation).

Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him choice (for example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t complain of pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the patient, and others.

DIAGNOSTIC TEST:

1. Clinical diagnosis is developed on historical information and thorough mental status examination.
2. No laboratory findings have been identified that are diagnostic of schizophrenia.
3. Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body retains excessive amounts of copper), PET scan, CT scan, and MRI.
4. Rating scale assessment:

• • Scale for the assessment of negative symptoms.
  • Scale for the assessment of positive symptoms.
  • Brief psychiatric rating scale

TREATMENTS AND MEDICATIONS:

Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life.
A comprehensive treatment program can include:

• Antipsychotic medication
• Education & support, for both ill individuals and families
• Social skills training
• Rehabilitation to improve activities of daily living
• Vocational and recreational support
• Cognitive therapy

Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode has passed, most people with schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis doesn’t go away, even though some or all of the symptoms do. In North America, atypical or second generation antipsychotic medications are the most widely used. However, there are many first-generation antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is the most effective for the ill individual
Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are aware of all available programs and medications.
In addition, persons living with schizophrenia may have access to or qualify for income support programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration and recovery.

Posted in: Mental Health Nursing