INTRODUCTION
The term schizophrenia was
coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The word was derived
from the Greek “skhizo” (split) and “phren” (mind). Over the years, much debate
has surrounded the concept of schizophrenia. Various definitions of the
disorder have evolved, and numerous treatment strategies have been proposed,
but none have proven to be uniformly effective or sufficient.
Schizophrenia is a clinical
syndrome of variable, but profoundly disruptive, psychopathology that involves
cognition, emotion, perception, and other aspects of behavior. The expression
of these manifestations varies across patients and over time, but the effect of
the illness is always severe and is usually long lasting. The disorder usually
begins before age 25, persists throughout life, and affects persons of all
social classes. Both patients and their families often suffer from poor care
and social ostracism because of widespread ignorance about the disorder. Although
schizophrenia is discussed as if it is a single disease, it probably comprises
a group of disorders with heterogeneous etiologies, and it includes patients
whose clinical presentations, treatment response, and courses of illness vary.
Clinicians should appreciate that the diagnosis of schizophrenia is based
entirely on the psychiatric history and mental status examination. There is no
laboratory test for schizophrenia
History
Written descriptions of symptoms
commonly observed today in patients with schizophrenia are found throughout
history. Early Greek physicians described delusions of grandeur, paranoia, and
deterioration in cognitive functions and personality. It was not until the 19th
century, however, that schizophrenia emerged as a medical condition worthy of
study and treatment. Two major figures in psychiatry and neurology who studied
the disorder were Emil Kraepelin (1856-1926) and Eugene Bleuler (1857-1939). Earlier,
Benedict Morel (1809-1873), a French psychiatrist, had used the term démence
précoce to describe deteriorated patients whose illness began in adolescence.
Emil
Kraepelin
Kraepelin translated Morel'sinto
dementia precox, a term that emphasized the change in cognition (dementia) and
early onset (precox) of the disorder. Patients with dementia precox were
described as having a long-term deteriorating course and the clinical symptoms
of hallucinations and delusions. Kraepelin distinguished these patients from
those who underwent distinct episodes of illness alternating with periods of
normal functioning which he classified as having manic-depressive psychosis.
Another separate condition called paranoia was characterized by persistent
persecutory delusions. These patients lacked the deteriorating course of dementia
precox and the intermittent symptoms of manic-depressive psychosis.
Eugene
Bleuler
Bleuler coined the term schizophrenia, which replaced
dementia precox in the literature. He chose the term to express the presence of
schisms between thought, emotion, and behavior in patients with the disorder.
Bleuler stressed that, unlike Kraepelin's concept of dementia precox,
schizophrenia need not have a deteriorating course. This term is often
misconstrued, especially by lay people, to mean split personality. Split
personality, called dissociative identity disorder.
The
Four As
Bleuler identified specific
fundamental (or primary) symptoms of schizophrenia to develop his theory about
the internal mental schisms of patients. These symptoms included associational
disturbances of thought, especially looseness, affective disturbances, autism,
and ambivalence, summarized as the four As:
1. ‘ Affect’: Inappropriate or
flattened affect-emotions in-congruent to circumstances/situation.
2. ‘Autism’:
social withdrawal- preferring to live in a fantasy world rather
than interact with social world appropriately.
3. ‘Ambivalence’ : holding of conflicting attitudes and
emotions towards others and self; lack of motivation and depersonalization.
4. ‘Associations’ : loosening of thought associations
leading to word salad/ flight of ideas/ thought disorder.
Bleuler also identified accessory (secondary)
symptoms, which included those symptoms that Kraepelin saw as major indicators
of dementia precox: hallucinations and delusions
Ernst
Kretschmer (1888-1926).
Kretschmer compiled data to support the
idea that schizophrenia occurred more often among persons with asthenic (i.e.,
slender, lightly muscled physiques), athletic, or dysplastic body types rather
than among persons with pyknic (i.e., short, stocky physiques) body types. He
thought the latter were more likely to incur bipolar disorders. His
observations may seem strange, but they are not inconsistent with a superficial
impression of the body types in many persons with schizophrenia.
Kurt
Schneider (1887-1967)
. Schneider contributed a description
of first-rank symptoms, which, he stressed, were not specific for schizophrenia
and were not to be rigidly applied but were useful for making diagnoses. He
emphasized that in patients who showed no first-rank symptoms, the disorder
could be diagnosed exclusively on the basis of second-rank symptoms and an
otherwise typical clinical appearance. Clinicians frequently ignore his
warnings and sometimes see the absence of first-rank symptoms during a single
interview as evidence that a person does not have schizophrenia.
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Kurt Schneider Criteria for
Schizophrenia
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Karl
Jaspers (1883-1969).
Jaspers, a psychiatrist and
philosopher, played a major role in developing existential psychoanalysis. He
was interested in the phenomenology of mental illness and the subjective
feelings of patients with mental illness. His work paved the way toward trying to understand the psychological meaning of schizophrenic
signs and symptoms such as delusions and hallucinations.
Definitions:
Schizophrenia
is a psychotic condition characterized by disturbances in thinking, emotions,
volitions, and faculties in the presence of clear consciousness, which usually
leads to social withdrawal.
Schizophrenia is a psychotic disorder (or a group of disorders)
marked by severely impaired thinking, emotions, and behaviors. Schizophrenic
patients are typically unable to filter sensory stimuli and may have enhanced
perceptions of sounds, colors, and other features of their environment. Most
schizophrenics, if untreated, gradually withdraw from interactions with other
people, and lose their ability to take care of personal needs and grooming.
EPIDEMINOLOGY:
v Schizophrenia
is a severe form of mental illness affecting about 7 per thousand of the adult
population.
v The
peak ages of onset are 15-35 years.
v Though
the incidence is low (3-10,000), the prevalence is high due to chronic city.
v Schizophrenia
is equally prevalent in men and women
v The
disease is more common in lower socioeconomic groups.
Reproductive
Factors:
The use of psychopharmacological
drugs, the open-door policies in hospitals, the deinstitutionalization in state
hospitals, and the emphasis on rehabilitation and community-based care for
patients have all led to an increase in the marriage and fertility rates among
persons with schizophrenia. Because of these factors, the number of children
born to parents with schizophrenia is continually increasing. The fertility
rate for persons with schizophrenia is close to that for the general
population. First-degree biological relatives of persons with schizophrenia
have a ten times greater risk for developing the disease than the general
population
Medical
Illness:
Persons with schizophrenia have a
higher mortality rate from accidents and natural causes than the general
population. Institution- or treatment-related variables do not explain the
increased mortality rate, but the higher rate may be related to the fact that
the diagnosis and treatment of medical and surgical conditions in schizophrenia
patients can be clinical challenges. Several studies have shown that up to 80
percent of all schizophrenia patients have significant concurrent medical
illnesses and that up to 50 percent of these conditions may be undiagnosed.
Birth
Season:
Persons who develop schizophrenia
are more likely to have been born in the winter and early spring and less
likely to have been born in late spring and summer. In the Northern Hemisphere,
including the United States, persons with schizophrenia are more often born in
the months from January to April. In the Southern Hemisphere, persons with
schizophrenia are more often born in the months from July to September.
Season-specific risk factors, such as a virus or a seasonal change in diet, may
be operative. Another hypothesis is that persons with a genetic predisposition
for schizophrenia have a decreased biological advantage to survive season-specific
insults
Substance
Abuse:
Substance abuse is common in
schizophrenia. The lifetime prevalence of any drug abuse (other than tobacco)
is often greater than 50 percent. For all drugs of abuse (other than tobacco),
abuse is associated with poorer function. In one population-based study, the
lifetime prevalence of alcohol within schizophrenia was 40 percent. Alcohol
abuse increases risk of hospitalization and, in some patients, may increase
psychotic symptoms. People with schizophrenia have an increased prevalence of
abuse of common street drugs
Facts:
·
Schizophrenia affects about 24
million people worldwide.
·
Schizophrenia is a treatable
disorder, treatment being more effective in its initial stages.
·
More than 50% of persons with
schizophrenia are not receiving appropriate care.
·
90% of people with untreated
schizophrenia are in developing countries.
·
Care of persons with schizophrenia
can be provided at community level, with active family and community
involvement
ICD CLASSIFICATION:
F20-F29
Schizophrenia,
schizotypal and delusional disorders
F20
Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated
schizophrenia
F20.4 Post-schizophrenic
depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
A fifth character may be used to
classify course:
.x0 Continuous
.x1 Episodic with
progressive deficit
.x2 Episodic with
stable deficit
.x3 Episodic
remittent
.x4 Incomplete
remission
.x5 Complete
remission
.x6 Other
.x9 Course
uncertain, period of observation too short
ETIOLOGY
Genetics
The body of evidence
for genetic vulnerability to schizophreniais growing. Studies show that
relatives of individuals with schizophrenia have a much higher probability of
developing the disease than does the general population. Whereas the lifetime
risk for developing schizophrenia is about 1 percent in most population
studies, the siblings or offspring of an identified client have a 5 to 10
percent risk of developing schizophrenia (Ho, Black & Andreasen, 2003). How
schizophrenia is inherited is uncertain. No reliable biological marker has as
yet been found. It is unknown which genes are important in the vulnerability to
schizophrenia, or whether one or many genes are implicated. Some individuals
have a strong genetic link to the illness, whereas others may have only a weak
genetic basis. This theory gives further credence to the notion of multiple
causations.
Twin Studies
The rate of
schizophrenia among monozygotic (identical) twins is four times that of
dizygotic (fraternal) twins and approximately 50 times that of the general
population (Sadock & Sadock, 2003). Identical twins reared apart have the
same rate of development of the illness as do those reared together. Because in
about half of the cases only one of a pair of monozygotic twins develops
schizophrenia, some investigators believe environmental factors interact with genetic
ones.
Adoption Studies
In studies conducted
by both American and Danish investigators, adopted children born of
schizophrenic mothers were compared with adopted children whose mothers had no
psychiatric disorder. It was found that the children who were born of
schizophrenic mothers were more likely to develop the illness than the
comparison control groups (Ho, Black, & Andreasen, 2003). Studies also
indicate that children born of non schizophrenic parents, but reared by
schizophrenic parents, do not seem to suffer more often from schizophrenia than
general controls. These findings provide additional evidence for the genetic
basis of
schizophrenia.
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Prevalence of Schizophrenia in
Specific Populations
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1. BIOCHEMICAL FACTORS:
NEUROTRANSMITTERS
A number of neurotransmitters
have been implicated in the etiology of schizophrenia. These include dopamine,
norepinephrine, serotonin, glutamate, and gamma-aminobutyric acid. The
dopaminergic system has been most widely studied and closely linked to the
symptoms associated with the disease.
AREAS OF THE
BRAIN AFFECTED
Four major dopaminergic pathways have been
identified:
•
Mesolimbic pathway:
Originates in the ventral tegmentum area and projects to areas of the limbic
system, including the nucleus accumbens, amygdala, and hippocampus. The
mesolimbic pathway is associated with functions of memory, emotion, arousal,
and pleasure. Excess activity in the mesolimbic tract has been implicated in
the positive symptoms of schizophrenia
(e.g., hallucinations , delusions).
•
Mesocortical pathway:
Originates in the ventral tegmentum area and has projections into the cortex.
The mesocortical pathway is concerned with cognition, social behavior,
planning, problem-solving, motivation, and reinforcement in learning. Negative
symptoms of schizophrenia (e.g., fl at affect, apathy, lack of motivation, and anhedonia)
have been associated with diminished activity in the mesocortical tract.
•
Nigrostriatal pathway:
Originates in the substantia nigra and terminates in the striatum of the basal
ganglia. This pathway is associated with the function of motor control.
Degeneration in this pathway is associated with Parkinson’s disease and involuntary
psychomotor symptoms of schizophrenia.
•
Tuberoinfundibular pathway: Originates in the hypothalamus and projects to the
pituitary gland. It is associated with endocrine function, digestion,
metabolism, hunger, thirst, temperature control, and sexual arousal. Implicated
in certain endocrine abnormalities associated with schizophrenia.
• Two major groups of dopamine receptors and their highest tissue locations
include the following:
•
The D1 family:
D1
receptors:
Basal ganglia, nucleus accumbens, and cerebral cortex
D5
receptors:
Hippocampus and hypothalamus, with lower concentrations in the cerebral cortex
and basal ganglia
• The D2 family:
D2
receptors:
Basal ganglia, anterior pituitary, cerebral cortex, limbic structures
D3
receptors:
Limbic regions, with lower concentrations in basal ganglia
D4
receptors:
Frontal cortex, hippocampus, amygdale
a.Dopamine
Hypothesis:
The simplest formulation of the
dopamine hypothesis of schizophrenia posits that schizophrenia results from too
much dopaminergic activity. The theory evolved from two observations. First,
the efficacy and the potency of many antipsychotic drugs (i.e., the dopamine
receptor antagonists [DRAs]) are correlated with their ability to act as
antagonists of the dopamine type 2 (D2) receptor. Second, drugs that
increase dopaminergic activity, notably cocaine and amphetamine, are
psychotomimetic. The basic theory does not elaborate on whether the
dopaminergic hyperactivity is due to too much release of dopamine, too many
dopamine receptors, hypersensitivity of the dopamine receptors to dopamine, or
a combination of these mechanisms. Which dopamine tracts in the brain are
involved is also not specified in the theory, although the mesocortical and
mesolimbic tracts are most often implicated. The dopaminergic neurons in these
tracts project from their cell bodies in the midbrain to dopaminoceptive
neurons in the limbic system and the cerebral cortex.
Excessive dopamine release
in patients with schizophrenia has been linked to the severity of positive
psychotic symptoms. Position emission tomography studies of dopamine receptors
document an increase in D2 receptors in the caudate nucleus of
drug-free patients with schizophrenia. There have also been reports of
increased dopamine concentration in the amygdala, decreased density of the
dopamine transporter, and increased numbers of dopamine type 4 receptors in the
entorhinal cortex.
b.Serotonin:
Current hypotheses posit serotonin
excess as a cause of both positive and negative symptoms in schizophrenia. The
robust serotonin antagonist activity of clozapine and other second-generation
antipsychotics, coupled with the effectiveness of clozapine to decrease
positive symptoms in chronic patients has contributed to the validity of this
proposition.
c.Norepinephrine:
Anhedoni the impaired capacity for
emotional gratification and the decreased ability to experience pleasure has
long been noted to be a prominent feature of schizophrenia. A selective
neuronal degeneration within the norepinephrine reward neural system could
account for this aspect of schizophrenic symptomatology. However, biochemical
and pharmacological data bearing on this proposal are inconclusive.
d.GABA:
The inhibitory amino acid
neurotransmitter γ-aminobutyric acid (GABA) has been implicated in the
pathophysiology of schizophrenia based on the finding that some patients with
schizophrenia have a loss of GABAergic neurons in the hippocampus. GABA has a
regulatory effect on dopamine activity, and the loss of inhibitory GABAergic
neurons could lead to the hyperactivity of dopaminergic neurons.
e.Neuropeptides:
Neuropeptides, such as substance P and
neurotensin, are localized with the catecholamine and indolamine
neurotransmitters and influence the action of these neurotransmitters.
Alteration in Neuropeptides mechanisms could facilitate, inhibit, or otherwise
alter the pattern of firing these neuronal systems.
f.Glutamate:
Glutamate has been implicated
because ingestion of phencyclidine, a glutamate antagonist, produces an acute
syndrome similar to schizophrenia. The hypotheses proposed about glutamate
include those of hyperactivity, hypo activity, and glutamate-induced neuro-
toxicity.
Acetylcholine and Nicotine.
Postmortem studies in schizophrenia have demonstrated decreased muscarinic and
nicotinic receptors in the caudate-putamen, hippocampus, and selected regions
of the prefrontal cortex. These receptors play a role in the regulation of
neurotransmitter systems involved in cognition, which is impaired in
schizophrenia.
2.Organic or Psychophysiologic Theory
Those who suggest the organic or
psychophysiologic theory offer hope that
schizophrenia is a functional deficit occurring in the brain caused by
stressors such as viral infection, toxins, trauma, or abnormal substances. They
also propose that schizophrenia may be a metabolic disorder. Extensive research
needs to done, because the case for this theory rests mainly on circumstantial
evidence (Well-Connected, 1999a).
Physiological
Influences
A number of physical factors of
possible etiological significance have been identified in the medical
literature.
However, their specific
mechanisms in the implication of schizophrenia are unclear.
Viral
Infection
Sadock and Sadock (2007) report
that epidemiological data indicate a high incidence of schizophrenia after prenatal
exposure to influenza. They state: Other data supporting a viral hypothesis are
an increased number of physical anomalies at birth, an increased rate of
pregnancy and birth complications, seasonality of birth consistent with viral
infection, geographical clusters of adult cases, and seasonality of
hospitalizations. Another study found an
association between viral infections of the central nervous system during
childhood and adult onset schizophrenia (Rantakallio et al, 1997).
Anatomical
Abnormalities
With the use of neuroimaging
technologies, structural brain abnormalities have been observed in individuals with
schizophrenia. Ventricular enlargement is the most consistent finding; however,
sulci enlargement and cerebellar atrophy are also reported. Ho, Black, and
Andreasen (2003) state:
There is substantial evidence to
suggest that ventricular enlargement is associated with poor premorbid functioning,
negative symptoms, poor response to treatment, and cognitive impairment. CT [computed
tomography] scan abnormalities may have some clinical significance, but they
are not diagnostically specifi c; similar abnormalities are seen in other
disorders such as Alzheimer’s disease or alcoholism.
Magnetic resonance imaging (MRI)
provides a greater ability to image in multiple planes. Studies with MRI have
revealed a possible decrease in cerebral and intracranial size in clients with
schizophrenia. Studies have also revealed a decrease in frontal lobe size, but
this has been less consistently replicated. MRI has been used to explore possible
abnormalities in specific subregions, such as the amygdala, hippocampus,
temporal lobes, and basal ganglia, in the brains of people with schizophrenia.
Histological
Changes
Cerebral changes in schizophrenia
have also been studied at the microscopic level. A “disordering” or disarray of
the pyramidal cells in the area of the hippocampus has been suggested (Jonsson
et al, 1997).
This disarray of cells has been compared
to the normal alignment of the cells in the brains of clients without the
disorder. Some researchers have hypothesized that this alteration in
hippocampal cells occurs during the second trimester of pregnancy and may be
related to an influenza virus encountered by the mother during this period.
Further research is required to determine the possible link between this birth
defect and the development of schizophrenia
3.Environmental or Cultural Theory
Proponents of the environmental
or cultural theory state that the person who develops schizophrenia has a
faulty reaction to the environment, being unable respond selectively to
numerous social stimuli. Theorists also believe that persons who come from low
socioeconomic areas or single-parent homes in deprived are not exposed to situations
in which they can achieve or become successful life. Thus they are at risk for
developing schizophrenia. Statistics are likely to reflect the alienating
effects of this disease rather than any causal relationship risk factor
associated with poverty or lifestyle (Kolb, 1977).
4.Perinatal Theory
Experts suggest that the risk of
schizophrenia exists if the developing fetus newborn is deprived of oxygen
during pregnancy or if the mother suffers from malnutrition or starvation
during the first trimester of pregnancy. The development of schizophrenia may
occur during fetal life at critical points in development, generally the 34th
or 35th week of gestation. The incidence of trauma and injury during the second
trimester and birth has also been considered in the development of
schizophrenia (Well-Connected, 1999a).
5.Vitamin Deficiency Theory
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 a
result of a severe vitamin deficiency. As stated earlier, extensive research be
done to prove this theory.
6.Psychosocial
:
If schizophrenia is a disease of the
brain, it is likely to parallel diseases of other organs (e.g., myocardial
infarctions, diabetes) whose courses are affected by psychosocial stress. Thus,
clinicians should consider both psychosocial and biological factors affecting
schizophrenia.
The disorder affects individual
patients, each of whom has a unique psychological makeup. Although many
psychodynamic theories about the pathogenesis of schizophrenia seem outdated,
perceptive clinical observations can help contemporary clinicians understand
how the disease may affect a patient's psyche.
Stress-Diathesis Model
According to the stress-diatheses
model for integration of biological, psychosocial and environmental factors, a person may have
a specific vulnerability (diathesis) that, when acted on by a stressful
influence, allows the symptoms of schizophrenia to develop. In the most general
stress-diathesis model, the diathesis or the stress can be biological,
environmental or both. The environmental component again can be either biological (e.g. an infection! or psychological
(e.g. stressful family situation). The biological basis of a diathesis
can be further shaped by epigenetic influences such as substance abuse,
psychosocial Stress and trauma.
7.Psychoanalytic
Theories:
Sigmund Freud postulated that
schizophrenia resulted from developmental fixations that occurred earlier than
those culminating in the development of neuroses. These fixations produce
defects in ego development and Freud postulated that such defects contributed
to the symptoms of schizophrenia. Ego disintegration in schizophrenia
represents a return to the time when the ego was not yet, or had just begun, to
be established. Because the ego affects the interpretation of reality and the
control of inner drives, such as sex and aggression, these ego functions are
impaired. Thus, intrapsychic conflict arising from the early fixations and the
ego defect, which may have resulted from poor early object relations, fuel the
psychotic symptoms.
8.Family
Dynamics:
In a study of British 4-year-old
children, those who had a poor mother–child relationship had a sixfold
increase in the risk of developing schizophrenia, and offspring from
schizophrenic mothers who were adopted away at birth were more likely to
develop the illness if they were reared in adverse circumstances compared to
those raised in loving homes by stable adoptive parents. Nevertheless, no
well-controlled evidence indicates that a specific family pattern plays a
causative role in the development of schizophrenia. Some patients with
schizophrenia do come from dysfunctional families, just as do many
nonpsychiatrically ill persons. It is important, however, not to overlook
pathological family behavior that can significantly increase the emotional
stress with which a vulnerable patient with schizophrenia must cope.
1.Double
Bind:
The double-bind concept was
formulated by Gregory Bateson and Donald Jackson to describe a hypothetical
family in which children receive conflicting parental messages about their
behavior, attitudes, and feelings. In Bateson's hypothesis, children withdraw
into a psychotic state to escape the unsolvable confusion of the double bind.
Unfortunately, the family studies that were conducted to validate the theory
were seriously flawed methodologically. The theory has value only as a
descriptive pattern, not as a causal explanation of schizophrenia.
An example of a double bind is the parent who
tells the child to provide cookies for his or her friends and then chastises
the child for giving away too many cookies to playmates.
2.
Schisms and Skewed Families:
Theodore Lidz described two abnormal patterns
of family behavior. In one family type, with a prominent schism between the parents,
one parent is overly close to a child of the opposite gender. In the other
family type, a skewed relationship between a child and one parent involves a
power struggle between the parents and the resulting dominance of one parent.
These dynamics stress the tenuous adaptive capacity of the schizophrenic
person.
3.
Pseudomutual and Pseudohostile Families:
As described by Lyman Wynne, some
families suppress emotional expression by consistently using pseudomutual or
pseudohostile verbal communication. In such families, a unique verbal
communication develops, and when a child leaves home and must relate to other
persons, problems may arise. The child's verbal communication may be
incomprehensible to outsiders.
4.Expressed
Emotion.
Parents or other caregivers may behave with
overt criticism, hostility, and overinvolvement toward a person with
schizophrenia. Many studies have indicated that in families with high levels of
expressed emotion, the relapse rate for schizophrenia is high. The assessment
of expressed emotion involves analyzing both what is said and the manner in
which it is said.
CLINICAL FEATURES:
POSITIVE OR HARD
SYMPTOMS
v Ambivalence:
Holding seemingly contradictory beliefs or feelings about the same
person, event, or situation
v Associative
looseness: Fragmented or poorly related thoughts and ideas
v Delusions:
Fixed false beliefs that have no basis in reality
v Echopraxia:
Imitation of the movements and gestures of another person whom the
client is observing
v Flight
of ideas: Continuous flow of verbalization in which the person jumps rapidly
from one topic to another
v Hallucinations:
False sensory perceptions or perceptual experiences that do not
exist in reality
v Ideas
of reference: False impressions that external events have special meaning for
the person
v Perseveration:
Persistent adherence to a single idea or topic; verbal repetition
of a sentence, word, or phrase; resisting attempts to change the topic.
NEGATIVE OR SOFT
SYMPTOMS:
v
Alogia: Tendency
to speak very little or to convey little substance of meaning (poverty of
content)
v
Anhedonia: Feeling
no joy or pleasure from life or any activities or relationships
v
Apathy: Feelings
of indifference toward people, activities, and events
v
Blunted affect: Restricted
range of emotional feeling, tone, or mood
v
Catatonia: Psychologically
induced immobility occasionally marked by periods of agitation or excitement;
the client seems motionless, as if in a trance
v
Flat affect: Absence
of any facial expression that would indicate emotions or mood
v
Lack of volition: Absence
of will, ambition, or drive to take action or accomplish tasks
v
Diminution or
loss of normal functions
v
Anergia (lack of energy)
v
Emotional
withdrawal
v
Poor
eye contact (avoidant)
v
Avolition (passive,
apathetic, social withdrawal)
v
Difficulty
in abstract thinking
v
Alogia (lack of
spontaneity and flow of conversation)
v
Dysfunctional
relationship with others
Bleuler’s
Four As
Bleuler identified specific
fundamental (or primary) symptoms of schizophrenia to develop his theory about
the internal mental schisms of patients. These symptoms included associational
disturbances of thought, especially looseness, affective disturbances, autism,
and ambivalence, summarized as the four As:
1. ‘ Affect’: Inappropriate or
flattened affect-emotions in-congruent to circumstances/situation.
2. ‘Autism’:
social withdrawal- preferring to live in a
fantasy world rather than interact with social world appropriately.
3. ‘Ambivalence’ : holding of conflicting attitudes and
emotions towards others and self;lack of
motivation and depersonalization.
4. ‘Associations’ : loosening of thought associations
leading to word salad/flight of ideas/
thought disorder.
Bleuler also identified accessory (secondary)
symptoms, which included those symptoms that Kraepelin saw as major indicators
of dementia precox: hallucinations and delusions.
Premorbid
Signs and Symptoms
In theoretical formulations of
the course of schizophrenia, premorbid signs and symptoms appear before the
prodromal phase of the illness. The differentiation implies that premorbid
signs and symptoms exist before the disease process evidences itself and that
the prodromal signs and symptoms are parts of the evolving disorder. In the
typical, but not invariable, premorbid history of schizophrenia,
v Patients had schizoid or schizotypal personalities
characterized as quiet, passive, and introverted; as children, they had few
friends.
v Preschizophrenic adolescents may have no close friends and
no dates and may avoid team sports. They may enjoy watching movies and
television, listening to music, or playing computer games to the exclusion of
social activities.
v Some adolescent patients may show a sudden onset of
obsessive-compulsive behavior as part of the prodromal picture.The validity of
the prodromal signs and symptoms, almost invariably recognized after the
diagnosis of schizophrenia has been made, is uncertain; once schizophrenia is
diagnosed, the retrospective remembrance of early signs and symptoms is
affected.
v Nevertheless, although the first hospitalization is often
believed to mark the beginning of the disorder, signs and symptoms have often
been present for months or even years.
v The signs may have started with complaints about somatic
symptoms, such as headache, back and muscle pain, weakness, and digestive
problems. The initial diagnosis may be malingering, chronic fatigue syndrome,
or somatization disorder. Family and friends may eventually notice that the
person has changed and is no longer functioning well in occupational, social,
and personal activities. During this stage, a patient may begin to develop an
interest in abstract ideas, philosophy, and the occult or religious questions.
PROBLEMS IN
COGNITIVE FUNCTIONING
Memory
Ø Difficulty retrieving and using stored memory
Ø Impaired short-term/long-term memory
Attention
Ø Difficulty maintaining attention
Ø Poor concentration
Ø Distractibility
Ø Inability to use selective attention
Form and
Organization of Speech (Formal Thought Disorder)
Ø Loose associations
Ø Tangentiality
Ø Incoherence/word salad/neologism
Ø Illogicality
Ø Circumstantiality
Ø Pressured/distractible speech
Ø Poverty of speech
Decision Making
Ø Failure to abstract
Ø Indecisiveness
Ø Lack of insight (anosognosia)
Ø Impaired concept formation
Ø Impaired judgment
Ø Illogical or concrete thinking
Ø Lack of planning and problem-solving skills
Ø Difficulty initiating tasks
Thought Content
Ø Delusions
•
Paranoid
•
Grandiose
•
Religious
•
Somatic
•
Nihilistic
Ø Thought broadcasting
Ø Thought insertion
Ø Thought control
Psychomotor
Behavior:
ANERGIA: Anergia is a
deficiency of energy. The individual with schizophrenia may lack sufficient
energy to carry out activities of daily living or to interact with others.
WAXY FLEXIBILITY:Waxy flexibility
describes a condition in which the client with schizophrenia allows body parts
to be placed in bizarre or uncomfortable positions.
Once placed in position, the arm,
leg, or head remains in that position for long periods, regardless of how
uncomfortable it is for the client. For example, the nurse may position the client’s
arm in an outward position to take a blood pressure measurement. When the cuff
is removed, the client may maintain the arm in the position it was placed to
take the reading.
POSTURIN:. This symptom is
manifested by the voluntary assumption of inappropriate or bizarre postures.
PACING AND
ROCKING. Pacing
back and forth and body rocking (a slow, rhythmic, backward-and-forward swaying
of the trunk from the hips, usually while sitting) are common psychomotor
behaviors of the client with schizophrenia.
Associated
Features:
ANHEDONIA:
Anhedonia is
the inability to experience pleasure. This is a particularly distressing
symptom that compels some clients to attempt suicide.
REGRESSION :Regression is
the retreat to an earlier level of development. Regression, a primary defense mechanism
of schizophrenia, is a dysfunctional attempt to reduce anxiety. It provides the
basis for many of the behaviors associated with schizophrenia.
Content of
Thought
DELUSIONS: Delusions are
false personal beliefs that are inconsistent with the person’s intelligence or cultural
background. The individual continues to have the belief in spite of obvious
proof that it is false or irrational. Delusions are subdivided according to their
content. Some of the more common ones are listed here.
●
Delusion
of Persecution:
The individual feels threatened and believes that others intend harm or persecution
toward him or her in some way
(e.g., “The FBI has ‘bugged’ my room and
intends to kill me.” “I can’t take a shower in this bathroom; the nurses have
put a camera in there so that they can watch everything I do”).
●
Delusion
of Grandeur:
The individual has an exaggerated feeling of importance, power, knowledge, or
identity (e.g., “I am Jesus Christ”).
●
Delusion
of Reference:
All events within the environment are referred by the psychotic person to himself
or herself (e.g., “Someone is trying to get a message to me through the
articles in this magazine [or newspaper or TV program]; I must break the code
so that I can receive the message”). Ideas of reference are less rigid
than delusions of reference. An example of an idea of reference is irrationally
thinking that one is being talked about or laughed at by other people.
●
Delusion
of Control or Influence: The individual believes certain objects or persons
have control over his or her behavior (e.g., “The dentist put a filling in my
tooth; I now receive transmissions through the filling that control what I
think and do”).
●
Somatic
Delusion:
The individual has a false idea about the functioning of his or her body (e.g.,
“I’m 70 years old and I will be the oldest person ever to give birth. The
doctor says I’m not pregnant, but I know I am”).
●
Nihilistic
Delusion:
The individual has a false idea that the self, a part of the self, others, or
the world is nonexistent (e.g., “The world no longer exists.” “I have no
heart.”).
RELIGIOSITY:
Religiosity is
an excessive demonstration of or obsession with religious ideas and behavior. Because
individuals vary greatly in their religious beliefs and level of spiritual
commitment, religiosity is often difficult to assess. The individual with
schizophrenia may use religious ideas in an attempt to provide rational meaning
and structure to his or her behavior.
Religious preoccupation in this
vein may therefore be considered a manifestation of the illness. However, clients
who derive comfort from their religious beliefs should not be discouraged from
employing this means of support.
An example of religiosity is the individual who
believes the voice he or she hears is God and incessantly searches the Bible
for interpretation.
PARANOIA: Individuals with
paranoia have extreme suspiciousness of others and of their actions or
perceived intentions (e.g., “I won’t eat this food. I know it has been
poisoned.”).
MAGICAL
THINKING.With
magical thinking, the person believes that his or her thoughts or have
control over specific situations or people (e.g., the behaviors mother who
believed if she scolded her son in any way he would be taken away from her).
Magical thinking is common in children (e.g., “Step on a crack and you break
your mother’s back.” “An apple a day keeps the doctor away”).
Form of Thought
ASSOCIATIVE
LOOSENESS: Thinking
is characterized by speech in which ideas shift from one unrelated subject to
another. With associative looseness, the individual is unaware that the
topics are unconnected. When the condition is severe, speech may be incoherent.
(For example, “We wanted to take the bus, but the airport took all the traffic.
Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven.
We have it all in our pockets.”)
NEOLOGISMS:The psychotic
person invents new words, or neologisms, that are meaningless to others
but have symbolic meaning to the psychotic person (e.g., “She wanted to give me
a ride in her new uniphorum”).
CONCRETE
THINKING:Concreteness,
or literal interpretations of the environment, represents a regression to an
earlier level of cognitive development Abstract thinking is very difficult. For
example, the client with schizophrenia would have great difficulty describing
the abstract meaning of sayings such as “I’m climbing the walls,” or “It’s
raining cats and dogs.”
CLANG
ASSOCIATIONS. Choice
of words is governed by sounds. Clang associations often take the form
of rhyming. For instance “It is very cold. I am cold and bold. The gold has
been sold.”
WORD SALAD:A word salad is
a group of words that are put together randomly, without any logical connection
(e.g., “Most forward action grows life double plays circle uniform”).
CIRCUMSTANTIALITY.:With circumstantiality,
the individual is delayed in reaching the point of a communication because of
unnecessary and tedious details. The point or goal is usually met but only with
numerous interruptions by the interviewer to keep the person on track of the
topic being discussed.
TANGENTIALITY:Tangentiality
differs
from circumstantiality in that the person never really gets to the point of the
communication. Unrelated topics are introduced, and the original discussion is
lost.
MUTISM. This is an
individual’s inability or refusal to speak.
PERSEVERATION:The individual
who exhibits perseveration persistently repeats the same word or idea
in response to different questions.
Affect Affect describes the behavior associated
with an individual’s feeling state or emotional tone.
INAPPROPRIATE
AFFECT: Affect
is inappropriate when the individual’s emotional tone is incongruent with the
circumstances (e.g., a young woman who laughs when told of the death of her
mother).
BLAND OR FLAT
AFFECT: Affect
is described as bland when the emotional tone is very weak. The individual with
flat affect appears to be void of emotional tone (or overt expression of
feelings).
APATHY: The client with
schizophrenia often demonstrates an indifference to or disinterest in the
environment. The bland or flat affect is a manifestation of the emotional
apathy.
Sense of Self
Sense of self describes the
uniqueness and individuality a person feels. Because of extremely weak ego
boundaries, the individual with schizophrenia lacks this feeling of uniqueness
and experiences a great deal of confusion regarding his or her identity.
ECHOLALIA:The client with
schizophrenia may repeat words that he or she hears, which is called echolalia.
This is an attempt to identify with the person speaking. (For instance,
the nurse says, “John, it’s time for lunch.” The client may respond,
“It’s time for lunch, it’s time for lunch” or sometimes, “Lunch, lunch,
lunch, lunch”).
ECHOPRAXIA.:The
client who exhibits echopraxia may purposelessly imitate movements made
by others.
IDENTIFICATION
AND IMITATION: Identification,
which occurs on an unconscious level, and imitation, which occurs on a
conscious level, are ego defense mechanisms used by individuals with
schizophrenia and reflect their confusion regarding self-identity. Because
Perception
HALLUCINATIONS. Hallucinations,
or false sensory perceptions not associated with real external stimuli, may
involve any of the five senses. Types of hallucinations include the following:
●
Auditory:
Auditory
hallucinations are false perceptions of sound. Most commonly they are of
voices, but the individual may report clicks, rushing noises, music, and other
noises. Command hallucinations may place the individual or others in a
potentially dangerous situation. “Voices” that issue commands for violence to
self or others may or may not be needed by the psychotic person. Auditory
hallucinations are the most common type in psychiatric disorders.
●
Visual:
These
are false visual perceptions. They may consist of formed images, such as of
people, or of unformed images, such as flashes of light.
●
Tactile:
Tactile
hallucinations are false perceptions of the sense of touch, often of something
on or under the skin. One specific tactile hallucination is formication, the
sensation that something is crawling on or under the skin.
●
Gustatory:
This
type is a false perception of taste. Most commonly, gustatory hallucinations
are described as unpleasant tastes.
●
Olfactory:
Olfactory
hallucinations are false perceptions of the sense of smell.
ILLUSIONS:
Illusions are
misperceptions or misinterpretations of real external stimuli. they have
difficulty knowing where their ego boundaries end and another person’s begins,
their behavior often takes on the form of that which they see in the other
person.
DEPERSONALIZATION: The unstable
self-identity of an individual with schizophrenia may lead to feelings of
unreality (e.g., feeling that one’s extremities have changed in size; or a
sense of seeing oneself from a distance).
Volition
Volition has to do with
impairment in the ability to initiate goal-directed activity. In the individual
with schizophrenia, this may take the form of inadequate interest, motivation,
or ability to choose a logical course of action in a given situation.
EMOTIONAL
AMBIVALENCE: Ambivalence
in the client with schizophrenia refers to the coexistence of opposite emotions
toward the same object, person, or situation. These opposing emotions may
interfere with the person’s ability to make even a very simple decision (e.g.,
whether to have coffee or tea with lunch). Underlying the ambivalence in the
individual with schizophrenia is the difficulty he or she has in fulfilling a satisfying
human relationship. This difficulty is based on the need-fear dilemma—the
simultaneous need for and fear of intimacy.
Impaired
Interpersonal Functioning and Relationship to the External World
Some clients with acute
schizophrenia cling to others and intrude on the personal space of others,
exhibiting behaviors that are not socially and culturally acceptable.
Impairment in social functioning may also be reflected in social isolation,
emotional detachment, and lack of regard for social convention.
AUTISM. Autism describes the
condition created by the person with schizophrenia who focuses inward on a
fantasy world while distorting or excluding the external environment.
DETERIORATED
APPEARANCE: Personal
grooming and self-care activities may become minimal. The client with
schizophrenia may appear disheveled and untidy and may need to be reminded of
the need for personal hygiene.
Impulsiveness,
Violence, Suicide, and Homicide
Patients with schizophrenia may be
agitated and have little impulse control when ill. They may also have decreased
social sensitivity and appear to be impulsive when, for example, they grab
another patient's cigarettes, change television channels abruptly, or throw
food on the floor. Some apparently impulsive behavior, including suicide and
homicide attempts, may be in response to hallucinations commanding the patient
to act.
Sensorium
and Cognition
Orientation
Patients with schizophrenia are
usually oriented to person, time, and place. The lack of such orientation
should prompt clinicians to investigate the possibility of a medical or
neurological brain disorder. Some patients with schizophrenia may give
incorrect or bizarre answers to questions about orientation, for example, I am
Christ; this is heaven; and it is AD 35.
A schizophrenic patient asserted
that he was in a prison elaborately disguised to look like a hospital with a
staff of jailers disguised as doctors and nurses who were all engaged in a
charade to elicit incriminating facts about the patient and his family. He made
a severe suicidal attempt because he believed that only upon his death would
the jailers spare the lives of his loved ones.
Memory
Memory, as tested in the mental
status examination, is usually intact, but there can be minor cognitive
deficiencies. It may not be possible, however, to get the patient to attend
closely enough to the memory tests for the ability to be assessed adequately.
Cognitive
Impairment
An important development in the
understanding of the psychopathology of schizophrenia is an appreciation of the
importance of cognitive impairment in the disorder. In outpatients, cognitive
impairment is a better predictor of level of function than is the severity of
psychotic symptoms. Patients with schizophrenia typically exhibit subtle
cognitive dysfunction in the domains of attention, executive function, working
memory, and episodic memory. Although a substantial percentage of patients have
normal intelligence quotients, it is possible that every person who has
schizophrenia has cognitive dysfunction compared to what he or she would be
able to do without the disorder. Although these impairments cannot function as
diagnostic tools, they are strongly related to the functional outcome of the
illness and, for that reason, have clinical value as prognostic variables, as
well as for treatment planning.
Judgment
and Insight:
Classically, patients with
schizophrenia are described as having poor insight into the nature and the
severity of their disorder. The so-called lack of insight is associated with
poor compliance with treatment. When examining schizophrenia patients,
clinicians should carefully define various aspects of insight, such as
awareness of symptoms, trouble getting along with people, and the reasons for
these problems. Such information can be clinically useful in tailoring a
treatment strategy and theoretically useful in postulating what areas of the
brain contribute to the observed lack of insight (e.g., the parietal lobes)
THE FIVE DIMENSIONAL PROFILE :
Some studies
subcategories symptoms of schizophrenia into five dimensions, viz
a) Positive
symptoms(hallucinations and delusions)
b) Negative
symptoms(alogia, anhedonia, avolition, affective flattening and attention
impairment)
c) Cognitive
symptoms(formal thought disorder, impaired attention, impaired information
processing and other specific impairments)
d) Aggressive
or hostile symptoms(verbal and physical assault,self injury)
e) Effective
symptoms (depression and anxiety)
Dimensions of schizophrenia
Psychoticism
(delusions,hallucinations etc)
Disorganization
( Thought disorder, bizarre
behavior, inappropriate affect)
DIAGNOSIS:
v HISTORY COLLECTION
v MSE
v PHYSICAL EXAMINATION
|
Diagnostic Criteria for
Schizophrenia
|
||||
|
CLINICAL TYPES:
1.
Paranoid
schizophrenia
2.
Hebephrenic
schizophrenia
3.
Catatonic
schizophrenia
4.
Undifferentiated
schizophrenia
5.
Post-schizophrenic
depression
6.
Residual
schizophrenia
7.
Simple
schizophrenia
8.
Other
schizophrenia
9.
Schizophrenia,
unspecified
1. Paranoid
schizophrenia:
The paranoid type of schizophrenia
is characterized by preoccupation with one or more delusions or frequent
auditory hallucinations. Classically, the paranoid type of schizophrenia is
characterized mainly by the presence of delusions of persecution or grandeur .
Patients with paranoid schizophrenia usually have their first episode of
illness at an older age than do patients with catatonic or disorganized
schizophrenia. Patients in whom schizophrenia occurs in the late 20s or 30s
have usually established a social life that may help them through their
illness, and the ego resources of paranoid patients tend to be greater than
those of patients with catatonic and disorganized schizophrenia. Patients with
the paranoid type of schizophrenia show less regression of their mental
faculties, emotional responses, and behavior than do patients with other types
of schizophrenia.
Patients with paranoid schizophrenia
are typically tense, suspicious, guarded, reserved, and sometimes hostile or
aggressive, but they can occasionally conduct themselves adequately in social
situations. Their intelligence in areas not invaded by their psychosis tends to
remain intact.
This is the commonest type of
schizophrenia in most parts of the world. The clinical picture is dominated by
relatively stable, often paranoid, delusions, usually accompanied by hallucinations,
particularly of the auditory variety, and perceptual disturbances. Disturbances
of affect, volition, and speech, and catatonic symptoms, are not prominent.
Examples of the most common
paranoid symptoms are:
(a) Delusions of persecution,
reference, exalted birth, special mission, bodily change, or jealousy;
(b) Hallucinatory voices that
threaten the patient or give commands, or auditory hallucinations without
verbal form, such as whistling, humming, or laughing;
(c)hallucinations of smell or
taste, or of sexual or other bodily sensations; visual hallucinations may occur
but are rarely predominant.
Thought disorder may be obvious
in acute states, but if so it does not prevent the typical delusions or
hallucinations from being described clearly.
Affect is usually less blunted than in other
varieties of schizophrenia, but a minor degree of incongruity is common, as are
mood disturbances such as irritability, sudden anger, fearfulness, and
suspicion.
"Negative" symptoms such as blunting
of affect and impaired volition are often present but do not dominate the
clinical picture.
The course of paranoid
schizophrenia may be episodic, with partial or complete remissions, or chronic.
In chronic cases, the florid symptoms persist over years and it is difficult to
distinguish discrete episodes. The onset tends to be later than in the
hebephrenic and catatonic forms.
Diagnostic criteria:
- The general criteria for schizophrenia must be met.
- Delusions or hallucinations must be prominent (such as
delusions of persecution, reference, exalted birth, special mission,
bodily change, or jealousy; threatening or commanding voices,
hallucinations of smell or taste, sexual or other bodily sensations).
Flattening
or incongruity of affect, catatonic symptoms, or incoherent speech must not
dominate the clinical picture, although they may be present to a mild degree.
2.
Hebephrenic schizophrenia
The disorganized (formerly
called hebephrenic) type of schizophrenia is characterized by a marked
regression to primitive, disinhibited, and unorganized behavior and by the
absence of symptoms that meet the criteria for the catatonic type. The onset of
this subtype is generally early, occurring before age 25. Disorganized patients
are usually active but in an aimless, non constructive manner. Their thought
disorder is pronounced, and their contact with reality is poor. Their personal
appearance is disheveled, and their social behavior and their emotional
responses are inappropriate. They often burst into laughter without any
apparent reason. Incongruous grinning and grimacing are common in these
patients, whose behavior is best described as silly or fatuous.
A form of schizophrenia in which
affective changes are prominent, delusions and hallucinations fleeting and
fragmentary, behavior irresponsible and unpredictable, and mannerisms common.
The mood is shallow and inappropriate and often accompanied by giggling or
self-satisfied, self-absorbed smiling, or by a lofty manner, grimaces,
mannerisms, pranks, hypochondriacal complaints, and reiterated phrases. Thought
is disorganized and speech rambling and incoherent. There is a tendency to
remain solitary, and behavior seems empty of purpose and feeling
This form of schizophrenia
usually starts between the ages of 15 and 25 years and tends to have a poor
prognosis because of the rapid development of "negative" symptoms,
particularly flattening of affect and loss of volition.
In addition, disturbances of
affect and volition, and thought disorder are usually prominent.
Hallucinations and delusions may
be present but are not usually prominent. Drive and determination are lost and goals
abandoned, so that the patient's behavior becomes characteristically aimless
and empty of purpose. A superficial and mannerist preoccupation with religion,
philosophy, and other abstract themes may add to the listener's difficulty in following
the train of thought.
Diagnostic criteria:
- The general criteria for schizophrenia must be met.
- Either of the following must be present:
- definite and sustained flattening or shallowness of
affect;
- Definite and sustained incongruity or
inappropriateness of affect.
- Either of the following must be present:
- behavior that is aimless and disjointed rather than
goal-directed;
- Definite thought disorder, manifesting as speech that
is disjointed, rambling, or incoherent.
D.
Hallucinations or delusions must not
dominate the clinical picture, although they may be present to a mild degree.
3.
Catatonic schizophrenia:
The catatonic
type of schizophrenia, which was common several decades ago, has become rare in
Europe and North America. The classic feature of the catatonic type is a marked
disturbance in motor function; this disturbance may involve stupor, negativism,
rigidity, excitement, or posturing . Sometimes, the patient shows rapid
alteration between extremes of excitement and stupor. Associated features
include Stereotypies, mannerisms, and waxy flexibility. Mutism is particularly
common. During catatonic excitement, patients need careful supervision to
prevent them from hurting themselves or others. Medical care may be needed
because of malnutrition, exhaustion, hyperpyrexia, or self-inflicted injury.
Prominent psychomotor disturbances
are essential and dominant features and 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. For reasons that are poorly
understood, catatonic schizophrenia is now rarely seen in industrial countries,
though it remains common elsewhere. These catatonic phenomena may be combined
with a dream-like (oneiroid) state with vivid scenic hallucinations
CLINICAL FEATURES
a)
Stupor
(marked decrease in reactivity to the environment and in spontaneous movements
and
activity) or mutism;
b)
Excitement
(apparently purposeless motor activity, not influenced by external stimuli);
c)
Posturing
(voluntary assumption and maintenance of inappropriate or bizarre postures)
d)
Negativism
(an apparently motiveless resistance to all instructions or attempts to be moved,
or movement in the opposite direction);
e)
Rigidity
(maintenance of a rigid posture against efforts to be moved);
f)
Waxy
flexibility (maintenance of limbs and body in externally imposed positions);
g)
Other
symptoms such as command automatism (automatic compliance with instructions),
and perseveration of words and phrases.
In uncommunicative patients with
behavioural manifestations of catatonic disorder, the diagnosis of
schizophrenia may have to be provisional until adequate evidence of the
presence of other symptoms is obtained. It is also vital to appreciate that
catatonic symptoms are not diagnostic of schizophrenia. A catatonic symptom or
symptoms may also be provoked by brain disease, metabolic disturbances, or
alcohol and drugs, and may also occur in mood disorders.
Diagnostic criteria:
- The general criteria for schizophrenia must eventually
be met, although this may not be possible initially if the patient is
uncommunicative.
- For a period of at least 2 weeks one or more of the
following catatonic behaviors must be prominent:
- stupor (marked decrease in reactivity to the
environment and reduction of spontaneous movements and activity) or
mutism;
- excitement (apparently purposeless motor activity, not
influenced by external stimuli);
- posturing (voluntary assumption and maintenance of
inappropriate or bizarre postures);
- negativism (an apparently motiveless resistance to all
instructions or attempts to be moved, or movement in the opposite
direction);
- rigidity (maintenance of a rigid posture against
efforts to be moved);
- waxy flexibility (maintenance of limbs and body in
externally imposed positions);
7. Command automatism
(automatic compliance with instruction).
4.
Undifferentiated schizophrenia:
Undifferentiated schizophrenia
usually is characterized by atypical symptoms do not meet the criteria for the
subtypes of paranoid, catatonic, or disorganized schizophrenia.
The client may exhibit both positive and negative symptoms. Behavior,
delusions, hallucinations, and incoherence may occur. Prognosis is favorable
if the onset of symptoms is acute or sudden.
Diagnostic criteria:
- The general criteria for schizophrenia must be met.
Either of the following must apply:
- insufficient symptoms to meet the criteria for any of
the subtypes
2. So many symptoms that the criteria
for more than one of the subtypes listed above are met.
5.
Post-schizophrenic depression:
Following an acute schizophrenia episode,
some patients become depressed. The symptoms of post psychotic depressive
disorder of schizophrenia can closely resemble the symptoms of the residual
phase of schizophrenia and the adverse effects of commonly used antipsychotic
medications. The diagnosis should not be made if they are substance induced or
part of a mood disorder due to a general medical condition. ICD-10 describes a
category called post schizophrenia depression arising in the aftermath of a
schizophrenic illness. These depressive states occur in up to 25 percent of
patients with schizophrenia and are associated with an increased risk of
suicide
A depressive episode, which may be
prolonged, arising in the aftermath of a schizophrenic illness. Some
schizophrenic symptoms must still be present but no longer dominate the clinical
picture. These persisting schizophrenic symptoms may be "positive" or
"negative", though the latter are more common. It is uncertain, and
immaterial to the diagnosis, to what extent the depressive symptoms have merely
been uncovered by the resolution of earlier psychotic symptoms (rather than
being a new development) or are an intrinsic part of schizophrenia rather than
a psychological reaction to it. They are rarely sufficiently severe or extensive
to meet criteria for a severe depressive episode (F32.2 and F32.3), and it is
often difficult to decide which of the patient's symptoms are due to depression
and which to neuroleptic medication or to the impaired volition and affective
flattening of schizophrenia itself. This depressive disorder is associated with
an increased risk of suicide.
Diagnostic criteria:
- The general criteria for schizophrenia must have been
met within the past 12 months but are not met at the present time.
- One of the conditions in Criterion G1(2) a, b, c, or d
for general schizophrenia must still be present.
C .The depressive symptoms must be
sufficiently prolonged, severe, and extensive to meet criteria for at least a mild depressive
episode.
6.
Residual schizophrenia
A chronic stage in the
development of a schizophrenic disorder in which there has been a clear
progression from an early stage (comprising one or more episodes with psychotic
symptoms meeting the general criteria for schizophrenia described above) to a
later stage characterized by long-term, though not necessarily irreversible,
"negative" symptoms.
This diagnostic category is used when
the individual has a history of at least one previous episode of schizophrenia with
prominent psychotic symptoms. Residual schizophrenia occurs in an individual
who has a chronic form of the disease and is the stage that follows an acute
episode
(Prominent delusions,
hallucinations, incoherence, bizarre behavior, and violence). In the residual
stage, there is continuing evidence of the illness, although there are no
prominent psychotic symptoms. Residual symptoms may include social isolation,
eccentric behavior, impairment in personal hygiene and grooming, blunted or
inappropriate, poverty of or overly elaborate speech, illogical thinking, or
apathy.
Diagnostic criteria:
- The general criteria for schizophrenia must have been
met at some time in the past but are not met at the present time.
- At least four of the following negative symptoms have
been present throughout the previous 12 months:
- psychomotor slowing or underactivity;
- definite blunting of affect;
- passivity and lack of initiative;
- poverty of either the quantity or the content of
speech;
- poor nonverbal communication by facial expression, eye
contact, voice modulation, or posture;
6.
Poor social performance or
self-care.
7.Simple
schizophrenia
An uncommon 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.
Delusions and hallucinations are not evident, and the disorder is less
obviously psychotic than the hebephrenic, paranoid, and catatonic subtypes of
schizophrenia. The characteristic "negative" features of residual
schizophrenia (e.g. blunting of affect, loss of volition) develop without being
preceded by any overt psychotic symptoms. With increasing social
impoverishment, vagrancy may ensue and the individual may then become self-absorbed,
idle, and aimless.
Diagnostic criteria:
- There is slow but progressive development, over a
period of at least 1 year, of all three of the following:
- a significant and consistent change in the overall
quality of some aspects of personal behavior, manifest as loss of drive
and interests, aimlessness, idleness, a self-absorbed attitude, and
social withdrawal;
- gradual appearance and deepening of negative symptoms
such as marked apathy, paucity of speech, under activity, blunting of
affect, passivity and lack of initiative, and poor nonverbal
communication (by facial expression, eye contact, voice modulation, and
posture);
- marked decline in social, scholastic, or occupational
performance.
- At no time are there any of the symptoms referred to in
criterion G1 for general schizophrenia, nor are there hallucinations or
well-formed delusions of any kind; i.e., the individual must never have
met the criteria for any other type of schizophrenia or for any other
psychotic disorder.
C.
There is
no evidence of dementia or any other organic mental disorder
OTHER SUB TYPES
The sub typing of schizophrenia has had a long history; other sub typing
schemes appear in the literature, especially literature from countries other
than the United States.
Acute
Delusional Psychosis
This French diagnostic concept
differs from a diagnosis of schizophrenia primarily on the basis of symptom
duration of less than 3 months. The diagnosis is similar to the DSM-IV-TR
diagnosis of schizophreniform disorder. French clinicians report that about 40
percent of patients with a diagnosis acute delusional psychosis of progress in
their illness and are eventually classified as having schizophrenia.
Latent
The concept of latent schizophrenia
was developed during a time when theorists conceived of the disorder in broad
diagnostic terms. Currently, patients must be very mentally ill to warrant a
diagnosis of schizophrenia, but with a broad diagnostic concept of
schizophrenia, the condition of patients who would not currently be thought of
as severely ill could have received a diagnosis of schizophrenia. Latent
schizophrenia, for example, was often the diagnosis used for what are now
called borderline, schizoid, and schizotypal personality disorders. These
patients may
occasionally show peculiar behaviors or thought disorders but do not
consistently manifest psychotic symptoms. In the past, the syndrome was also
termed borderline schizophrenia.
Oneiroid
The oneiroid state refers to a
dream-like state in which patients may be deeply perplexed and not fully
oriented in time and place. The term oneiroid schizophrenic has been used for
patients who are engaged in their hallucinatory experiences to the exclusion of
involvement in the real world. When an oneiroid state is present, clinicians
should be particularly careful to examine patients for medical or neurological
causes of the symptoms.
EXAMPLE
After a 20-year-old female college
student had recovered from her schizophrenic breakdown, she wrote the following
description of her experiences during the oneiroid phase:
This is how I remember it. The road
has changed. It is twisted and it used to be straight. Nothing is constant “all
is in motion. The trees are moving. They do not remain at rest. How is it my
mother does not bump into the trees that are moving? I follow my mother. I am
afraid, but I follow. I have to share my strange thoughts with someone. We are
sitting on a bench. The bench seems low. It, too, has moved. The bench is low,
I say, Yes, says my mother. This isn't how it used to be. How come there are no
people around? There are usually lots of people and it is Sunday and there are
no people. This is strange. All these strange questions irritate my mother who
then says she must be going soon. While I continue thinking I'm in a kind of
nowhere
Paraphrenia
The term paraphrenia is sometimes
used as a synonym for paranoid schizophrenia, or for either a progressively
deteriorating course of illness or the presence of a well-systemized delusional
system. The multiple meanings of the term render it ineffectual in
communicating information.
Pseudoneurotic
Schizophrenia
Occasionally, patients
who initially have such symptoms as anxiety, phobias, obsessions, and
compulsions later reveal symptoms of thought disorder and psychosis. These
patients are characterized by symptoms of pananxiety, panphobia, panambivalence,
and sometimes chaotic sexuality. Unlike persons with anxiety disorders,
pseudoneurotic patients have free-floating anxiety that rarely subsides. In
clinical descriptions, the patients seldom become overtly and severely
psychotic. This condition is currently diagnosed in DSM-IV-TR as borderline
personality disorder.
Deficit
Schizophrenia:
In the 1980s, criteria were
promulgated for a subtype of schizophrenia characterized by enduring,
idiopathic negative symptoms. These patients were said to exhibit the deficit
syndrome. This group of patients is now said to have deficit schizophrenia (see
the criteria for that putative disease diagnosis in Table 13-8). Patients with
schizophrenia with positive symptoms are said to have nondeficit schizophrenia.
The symptoms used to define deficit schizophrenia are strongly interrelated,
although various combinations of the six negative symptoms in the criteria can
be found.
Deficit patients have a more
severe course of illness than nondeficit patients, with a higher prevalence of
abnormal involuntary movements before administration of antipsychotic drugs and
poorer social function before the onset of psychotic symptoms. The onset of the
first psychotic episode is more often insidious, and these patients show less
long-term recovery of function than do nondeficit patients. Deficit patients
are also less likely to marry than are other patients with schizophrenia.
However, despite their poorer level of function and greater social isolation,
both of which should increase a patient's stress and, therefore, the risk of
serious depression, deficit patients appear to have a decreased risk of major
depression and probably have a decreased risk of suicide as well.
The risk factors of
deficit patients differ from those of non deficit patients; deficit
schizophrenia is associated with an excess of summer births, whereas non deficit
patients have an excess of winter births. Deficit schizophrenia may also be
associated with a greater familial risk of schizophrenia and of mild,
deficit-like features in the non psychotic relatives of deficit pro bands.
Within a family with multiply affected siblings, the deficit-non deficit
categorization tends to be uniform. The deficit group also has a higher
prevalence of men.
MANAGEMENT:
Organic
Treatment
Psychopharmacology
Antipsychotic medications are
also called neuroleptics or major tranquilizers. They are effective in
the treatment of acute and chronic manifestations of schizophrenia
and in maintenance therapy to prevent exacerbation of schizophrenic
symptoms. Without drug treatment, an estimated 72 percent of individuals
who have experienced a psychotic episode relapse within a year. This
relapse rate can be reduced to about 23 percent with continuous
medication administration
Typical
Antipsychotic Agents (fi rst generation; conventional)
1.
Chlorpromazine
(Thorazine) 40–400 MG
2.
Fluphenazine
(Prolixin) 2.5–10 MG
3.
Haloperidol
(Haldol) (IM decanoate) 1–100MG
4.
Loxapine
(Loxitane) 20–250 MG
5.
Molindone
(Moban) 15–225 MG
6.
Perphenazine
(Trilafon) 12–64 MG
7.
Pimozide
(Orap) 1–10 MG
8.
Prochlorperazine
(Compazine) 15–150MG
9.
Thioridazine 150–800MG
10.
Thiothixene
(Navane) 6–30 MG
11. Trifl uoperazine
(Stelazine) 4-40 MG
Atypical
Antipsychotics (second generation; novel)
1.
Aripiprazole
(Abilify) 10–30MG
2.
Asenapine
(Saphris) 10–20MG
3.
Clozapine
(Clozaril) 300–900MG
4.
Iloperidone
(Fanapt) 12–24 MG
5.
Olanzapine
(Zyprexa) 5–20 MG
6.
Paliperidone
(Invega) 6–12 MG
7.
Quetiapine
(Seroquel) 300–400 MG
8.
Risperidone
(Risperdal) 4–8 MG
9.
Ziprasidone (Geodon) 40–160 MG
Treatment of acute episode:
Acute episodes or relapses are usually
predominated by positive symptoms. Aim of treatment is to ameliorate these and
avoid the risk of harm due to them both to the patient and others. Any of the
high potency conventional antipsychotics or new generation antipsychotics
(except clozapine, which is not the first-line of treatment because of the
possible potential high risk) are commenced in an adequate dose. If there is no
response within 3-8 weeks, another drug is substituted for the initial drug. If
there is a partial response at the end of 2-3 weeks, the same drug is continued
for another 2-9 weeks. Low potency antipsychotics (e.g. chlorpromazine) may
also be used which are more sedating but have the risk of orthostatic
hypotension and lowered seizure threshold especially at higher doses.
Maintenance
treatment:
A good majority
of schizophrenic patients require long-term maintenance treatment in spite of
which some patients relapse. Although doses are individualized, doses between
50-150 mg chlorpromazine or its equivalents suffice for maintenance treatment.
The dosage sufficient to control symptoms and prevent their exacerbation is the
effective dosage. Because of the risks of often
irreversible adverse symptoms dosage should be small I individually tailored.
Atypical antipsychotics are equally useful or are superior to conventional
drugs because of their relatively low toxic profile. Non-compliance to
medication is a serious problem often causing preventable relapses. Personality
factors, adverse effects of drugs, lack of insight, financial problems and many
others are contributing factors for noncompliance. Use of parenteral depot
preparations and liquid forms and constant supervision will minimize
non-compliance in addition to strategies to minimize drug side-effect.
Treatment
resistance:
Ten
to twenty per cent of patients are poor responders to antipsychotic medication.
; Treatment resistance was once defined as failure to respond to neuroleptics
from three different biochemical classes. With the advent of atypical
antipsychotics, failure with at least one new generation antipsychotic and with
clozapine is an added option. Four to six weeks' trial at therapeutic doses
(400-600 mg chlorpromazine or its equivalents) is needed. Clozapine has
proved its efficacy over other drugs, both conventional and others in treating
resistant cases. Atypical antipsychotics are preferred in the presence of
negative symptoms.
Other Biological Therapies:
Electroconvulsive therapy:
In a small percentage of
schizophrenia patients ECT is of value. ECT and medicines given together will
bring about a quicker remission, but in the long run ECT has no advantage over
drugs. ECT is helpful in catatonic stupor and in catatonic schizophrenia in
general. "Positive" symptoms usually respond well to ECT. In chronic
schizophrenia ECT is of little value unless there are acute exacerbations of
illness in a chronic patient. ECT is also indicated when there are affective
symptoms in a schizophrenic patient.
ECT has been studied in both
acute and chronic schizophrenia. Studies in recent-onset patients indicate that
ECT is about as effective as antipsychotic medications and more effective than
psychotherapy. Other studies suggest that supplementing antipsychotic
medications with ECT is more effective than antipsychotic medications alone.
Antipsychotic medications should be administered during and after ECT
treatment.
Psychosurgery:
Although psychosurgery is no longer
considered an appropriate treatment, it is practiced on a limited experimental
basis for severe, intractable cases.
Psychological
Treatments:
Individual
Psychotherapy:
Reality-oriented individual
therapy is the most suitable approach to individual psychotherapy for schizophrenia.The
primary focus in all cases must reflect efforts to decrease anxiety and
increase trust.
Establishing a relationship is
often particularly difficult because the individual with schizophrenia is
desperately lonely yet defends against closeness and trust. He or she is likely
to respond to attempts at closeness with suspiciousness, anxiety, aggression,
or regression.
Successful intervention may be
achieved with honesty, simple directness, and a manner that respects the
client’s privacy and human dignity. Exaggerated warmth and professions of
friendship are likely to be met
with confusion and suspicion. Once a therapeutic interpersonal relationship has
been established, reality orientation is maintained through exploration of the
client’s behavior within relationships. Education is provided to help the
client identify sources of real or perceived danger and ways of reacting
appropriately. Methods for improving interpersonal communication, emotional
expression, and frustration tolerance are attempted. Individual psychotherapy
for clients with schizophrenia is seen as a long-term endeavor that requires patience
on the part of the health-care provider, as well as the ability to accept that
a great deal of change may not occur. Some cases report treatment durations of many
years before clients regain some degree of independent functioning.
Group Therapy:
Group therapy with individuals
with schizophrenia has been shown to be effective, particularly with
outpatients and when combined with drug treatment. Group therapy in inpatient
settings is less productive. Inpatient treatment usually occurs when
symptomatology and social disorganization are at their most intense. At this
time, the least amount of stimuli possible is most beneficial for the client.
Because group therapy can be intensive and highly stimulating, it may be
counterproductive early in treatment.
Group therapy for schizophrenia
has been most useful over the long-term course of the illness. The social interaction,
sense of cohesiveness, identification, and reality testing achieved within the
group setting have proven to be highly therapeutic processes for these clients.
Groups that offer a supportive environment appear to be more helpful to clients
with schizophrenia than those that follow a more confrontational approach.
Behavior Therapy:
Behavior modification has a
history of qualified success in reducing the frequency of bizarre, disturbing, and
deviant behaviors and increasing appropriate behaviors. Features that have led
to the most positive results include:
●
Clearly
defining goals and how they will be measured
●
Attaching
positive, negative, and aversive reinforcements to adaptive and maladaptive
behavior
●
Using
simple, concrete instructions and prompts to elicit the desired behavior
Behavior therapy can be a powerful
treatment tool for helping clients change undesirable behaviors. In the
treatment setting, the health-care provider can use praise and other positive
reinforcements to help the client with schizophrenia reduce the frequency of
maladaptive or deviant behaviors. A limitation of this type of therapy is the
inability of some individuals with schizophrenia to generalize what they have learned
from the treatment setting to the community setting.
Social Skills
Training:
Social skills training has become
one of the most widely used psychosocial interventions in the treatment of schizophrenia.
Mueser, Bond, and Drake (2002) state: The basic premise of social skills
training is that complex interpersonal skills involve the smooth integration of
a combination of simpler behaviors, including nonverbal behaviors (e.g.,
facial expression, eye contact); paralinguistic features (e.g., voice
loudness and affect); verbal content (i.e., the appropriateness of what
is said); and interactive balance (e.g., response latency, amount of
time talking). These specific skills can be systematically taught, and, through
the process of shaping (i.e., rewarding successive approximations toward
the target behavior), complex behavioral repertoires can be acquired. Social dysfunction
is a hallmark of schizophrenia. Indeed, impairment in social functioning is
included as one of the defining diagnostic criteria for schizophrenia in the DSM-IV-TR
(APA, 2000). Considerable attention is now being given to enhancement of
social skills in these clients. The educational procedure in social skills
training focuses on role-play. A series of brief scenarios are selected. These
should be typical of situations clients experience in their daily lives and be
graduated in terms of level of difficulty. The health-care provider may serve
as a role model for some behaviors.
For example, “See how I sort of
nod my head up and down and look at your face while you talk.” This
demonstration is followed by the client’s role-playing. Immediate feedback is
provided regarding the client’s presentation. Only by countless repetitions
does the response gradually become smooth and effortless. Progress is geared
toward the client’s needs and limitations. The focus is on small units of
behavior, and the training proceeds very gradually. Highly threatening issues
are avoided, and emphasis is placed on functional skills that are relevant to
activities of daily living.
Dialectical
Behavior Therapy:
This form of therapy, which combines
cognitive and behavioral theories in both individual and group settings, has
proved useful in borderline states and may have benefit in schizophrenia.
Emphasis is placed on improving interpersonal skills in the presence of an
active and empathic therapist.
Vocational
Therapy:
A variety of methods and settings
are used to help patients regain old skills or develop new ones. These include
sheltered workshops, job clubs, and part-time or transitional employment
programs. Enabling patients to become gainfully employed is both a means
toward, and a sign of, recovery. Many schizophrenia patients are capable of
performing high-quality work despite their illness. Others may exhibit
exceptional skill or even brilliance in a limited field as a result of some
idiosyncratic aspect of their disorder.
Cognitive
Behavioral Therapy:
Cognitive behavioral therapy has
been used in schizophrenia patients to improve cognitive distortions, reduce
distractibility, and correct errors in judgment. There are reports of
ameliorating delusions and hallucinations in some patients using this method.
Patients who might benefit generally have some insight into their illness
Social Treatment:
Milieu Therapy:
Some clinicians believe that
milieu therapy can be an appropriate treatment for the client with schizophrenia.
Research suggests that psychotropic medication is more effective at all levels
of care when used along with milieu therapy and that milieu therapy is more
successful if used in conjunction with these medications. Individuals with
schizophrenia who are treated with milieu therapy alone require longer hospital
stays than do those treated with drugs and psychosocial therapy. Other economic
considerations, such as the need for a high staff-to-client ratio, in addition
to the longer admission, limit the use of milieu therapy in the treatment of
schizophrenia. The milieu environment can be successfully employed in
outpatient settings, however, such as day and partial hospitalization programs.
Family Therapy
Some health-care providers treat
schizophrenia as an illness not of the client alone, but of the entire family. Even
when families appear to cope well, there is a notable impact on the mental
health status of relatives when a family member has the illness. Safier (1997)
states: When a family member has a serious mental illness, the family must deal
with a major upheaval in their lives, a terrible event that causes great pain
and grief for the loss of a once-promising child or relationship. The
importance of the expanded role of family in the aftercare of relatives with
schizophrenia has been recognized, thereby stimulating interest in family
intervention programs designed to support the family system, prevent or delay
relapse, and help to maintain the client in the community.
These psychoeducational programs treat the
family as a resource rather than a stressor, with the focus on concrete problem
solving and specifi c helping behaviors for coping with stress. These programs
recognize the biological basis for schizophrenia and the impact that stress has
on the client’s ability to function. By providing the family with information about
the illness and suggestions for effective coping, psychoeducational programs
reduce the likelihood of the client’s relapse and the possible emergence of
mental illness in previously nonaffected relatives. Mueser and colleagues
(2002) state that although models of family intervention with schizophrenia
differ in their characteristics and methods, effective treatment programs share
a number of common features:
●
All
programs are long term (usually 9 months to 2 years or more).
●
They
all provide client and family with information about the illness and its
management.
●
They
focus on improving adherence to prescribed medications.
●
They
strive to decrease stress in the family and improve family functioning.
Asen (2002) suggests the
following interventions with families of individuals with schizophrenia:
v
Forming
a close alliance with the caregivers
v
Lowering
the emotional intrafamily climate by reducing stress and burden on relatives
v
Increasing
the capacity of relatives to anticipate and solve problems
v
Reducing
the expressions of anger and guilt by family members
v
Maintaining
reasonable expectations for how the ill family member should perform
v
Encouraging
relatives to set appropriate limits while maintaining some degree of separateness
v
Promoting
desirable changes in the relatives’ behaviors and belief systems
Family therapy typically consists of a
brief program of family education about schizophrenia and a more extended
program of family contact designed to reduce overt manifestations of conflict
and to improve patterns of family communication and problem solving. The
response to this type of therapy has been very dramatic. Studies have clearly revealed
that a more positive outcome in the treatment of the client with schizophrenia
can be achieved by including the family system in the program of care.
Assertive
Community Treatment (ACT):
Assertive Community Treatment
(ACT) is a program of case management that takes a team approach in providing
comprehensive, community-based psychiatric treatment, rehabilitation, and
support to persons with serious and persistent mental illness such as
schizophrenia. Aggressive programs of treatment are individually tailored for
each client and include the teaching of basic living skills, helping clients
work with community agencies, and assisting clients in developinga social
support network (Ho et al, 2003).There is emphasis on vocational expectations,
and supported work settings (i.e., sheltered workshops) are an important part
of the treatment program. Other services include substance abuse treatment,
psycho educational programs, family support and education, mobile crisis
intervention, and attention to health-care needs.
Responsibilities are
shared by multiple team members, including psychiatrists, nurses, social
workers, vocational rehabilitation therapists, and substance abuse counselors.
Services are provided in the person’s home, within the neighborhood, in local
restaurants, parks, stores, or wherever assistance by the client is required.
These services are available to the client 24 hours a day, 365 days a year. The
National Alliance for the Mentally Ill (NAMI, 2009) lists the primary goals of
ACT as follows:
v
To
meet basic needs and enhance quality of life
v
To
improve functioning in adult social and employment roles
v
To enhance an individual’s ability to
live independently in his or her own community
v
To lessen the family’s burden of
providing care
v
To
lessen or eliminate the debilitating symptoms of mental illness
v
To minimize or prevent recurrent acute
episodes of the illness
Psychosocial
Treatments for Schizophrenia
Antipsychotic drugs
have proven to be crucial in relieving the psychotic symptoms of schizophrenia — hallucinations, delusions, and
incoherence — but are not consistent in relieving the behavioral symptoms of
the disorder.
Even when patients with schizophrenia are
relatively free of psychotic symptoms, many still have extraordinary difficulty
with communication, motivation, self-care, and establishing and maintaining
relationships with others. Moreover, because patients with schizophrenia
frequently become ill during the critical career-forming years of life (ages 18
to 35), they are less likely to complete the training required for skilled
work. As a result, many with schizophrenia not only suffer thinking and
emotional difficulties, but lack social and work skills and experience as well.
It is
with these psychological, social and occupational problems that psychosocial
treatments may help most. While psychosocial approaches have limited value for
acutely psychotic patients (those who are out of touch with reality or have
prominent hallucinations or delusions), they may be useful for patients with
less severe symptoms or for patients whose psychotic symptoms are under
control. Numerous forms of psychosocial therapy are available for people with schizophrenia , and most focus
on improving the patient’s social functioning — whether in the hospital or
community, at home or on the job. Some of these approaches are described here.
Unfortunately, the availability of different forms of treatment varies greatly
from place to place.
COURSE
AND PROGNOSIS:
The course of schizophrenia is
generally a chronic one though it differs considerably showing| individual
variations. Long before a fully fledged clinical picture sets in,
"character anomalies" may appear as subtle indications of an oncoming
illness in later life. These are in the form of delay in development of
specific skills, and other deficit symptoms as well as tendency for
social aloofness and maladjustment. Often a prodromal stage with an insidious
onset and where the above features become more prominent precede the active
phase of illness. The clinical features become florid in the active phase and
the patient is brought to the hospital invariably at this stage. After
the violation of the active phase with proper treatment, a residual phase may
follow which resembles the prodromal phase of the illness.
The residual symptoms may
persist and may not totally disappear in a good proportion of patients. But many long-term studies have conclusively shown
that the course of illness is not uniform and
the outcome is not bleak as was once believed. A few recover totally and
asymptomatic for several years. Some
continue to relapse with stable or worsening deficits. A good number
of patients are able to meet their basic needs and many among them show good
social functioning. The course of schizophrenia takes
one of the six following pattern
1. Total remission
2. Incomplete remission
3. Episodic remittance
4. Episodic with stable deficit
5. Episodic with progressive deficit
6. Continuous
5.
episodic with progressive deficit 6.Continuous
R
R
R=residual
symptoms
|
Features Weighting Toward Good to
Poor Prognosis in Schizophrenia
|
||||||||||||||||||||
|
Teaching Client
and Family:
Ø Coping
with schizophrenia is a major adjustment for boththe clients and their
families. Understanding the illness, the need for continuing medication and
follow-up, and the uncertainty of the prognosis or recovery are key issues.
Ø Clients
and families need help to cope with the emotional upheaval that schizophrenia
causes. See Client/Family Education for Schizophrenia for education points.
Ø Teaching
the client and family members to prevent or manage relapse is an essential part
of a comprehensive.
Ø Identifying
and managing one’s own health needs are primary concerns for everyone, but this
is a particular challenge for clients with schizophrenia because their health
needs can be complex and their ability to manage them may be impaired.
Ø The
nurse helps the client to manage his or help an of care. This includes providing
facts about schizophrenia, identifying the early signs of relapse, and teaching
health practices to promote physical and psychological well-being.
Ø Early
identification of these relapse signs has been found to reduce the frequency of
relapse; when relapse cannot be prevented, early identification provides the
foundation for interventions to manage the relapse. For example, if the nurse
finds that the client is fatigued or lacks adequate sleep or proper nutrition,
interventions to promote rest and nutrition may prevent a relapse or minimize
its intensity and duration.
Ø The nurse can
use the list of relapse risk factors in several ways. He or she can include
these risk factors in discharge teaching before the client leaves the inpatient
setting so that the client and family know what to watch for and when to seek
assistance.
Ø The nurse also
can use the list when assessing the client in an outpatient or clinic setting
or when working with clients in a community support program.
Ø The nurse also
can provide teaching to ancillary personnel who may work with the client so
they know when to contact a mental health professional.
Ø Taking
medications as prescribed, keeping regular follow-up appointments, and avoiding
alcohol and other drugs have been associated with fewer and shorter hospital
stays.
Ø In addition,
clients who can identify and avoid stressful situations are less likely to
suffer frequent relapses. Using a list of relapse risk factors is one way to
assess the client’s progression the community.
• How to manage
illness and symptoms
• Recognizing early
signs of relapse
• Developing a plan
to address relapse signs
• Importance of
maintaining prescribed medication regimen and regular follow-up
• Avoiding alcohol
and other drugs
• Self-care and
proper nutrition
• Teaching social
skills through education, role modeling, and practice
• Seeking assistance
to avoid or manage stressful situations
• Counseling and
educating family/significant others about the biologic causes and clinical
course of schizophrenia and the need for ongoing support
• Importance of
maintaining contact with community and participating in supportive
organizations and care illness and health needs as independently as possible.
This can be accomplished only through education and ongoing support.
EARLY SIGNS OF
RELAPSE
• Impaired
cause-and-effect reasoning
• Impaired
information processing
• Poor nutrition
• Lack of sleep
• Lack of exercise
• Fatigue
• Poor social skills,
social isolation, loneliness
• Interpersonal
difficulties
• Lack of control,
irritability
• Mood swings
• Ineffective
medication management
• Low self-concept
• Looks and acts
different
• Hopeless feelings
• Loss of motivation
• Anxiety and worry
• Disinhibition
• Increased
negativity
• Neglecting
appearance
• Forgetfulness
NURSING
MANAGEMENT:
Diagnosis/Outcome
Identification
Possible nursing diagnoses for
clients with psychotic disorders include:
●
Disturbed
sensory perception: Auditory/visual related to panic anxiety, extreme
loneliness and withdrawal into the self, evidenced by inappropriate responses, disordered
thought sequencing, rapid mood swings, poor concentration, disorientation
●
Disturbed
thought processes related to inability to trust, panic anxiety, possible
hereditary or
biochemical factors, evidenced by
delusional thinking; inability to concentrate; impaired volition; inability to problem
solve, abstract, or conceptualize; extreme suspiciousness of others.
●
Social
isolation related to inability to trust, panic anxiety, weak ego development,
delusional thinking, regression, evidenced by withdrawal, sad and dull affect, need-fear
dilemma, preoccupation with own thoughts, expression of feelings of rejection
or of aloneness imposed by others.
●
Risk
for violence: Self-directed or other-directed related to extreme
suspiciousness, panic anxiety, catatonic excitement, rage reactions, command
hallucinations, evidenced by overt and aggressive acts, goal-directed
destruction of objects in the environment, self-destructive behavior, or active
aggressive suicidal acts.
●
Impaired
verbal communication related to panic anxiety, regression, withdrawal, and
disordered, unrealistic thinking evidenced by loose association of ideas,
neologisms, word salad, clang associations, echolalia, verbalizations that
reflect concrete thinking, and poor eye contact.
●
Self-care
deficit related to withdrawal, regression, panic anxiety, perceptual or
cognitive impairment, inability to trust, evidenced by difficulty carrying out tasks
associated with hygiene, dressing, grooming, eating, and toileting.
●
Disabled
family coping: Related to difficulty coping with client’s illness evidenced by
neglectful care of the client in regard to basic human needs or illness treatment,
extreme denial or prolonged over concern regarding client’s illness
●
Ineffective
health maintenance related to disordered thinking or delusions, evidenced by
reported or observed inability to take responsibility for meeting basic health
practices in any or all functional pattern areas
●
Impaired
home-maintenance management related to regression, withdrawal, lack of knowledge
or resources, or impaired physical or cognitive functioning evidenced by
unsafe, unclean, disorderly home environment
The following criteria may be
used for measurement of outcomes in the care of the client with schizophrenia.
The client:
Ø Demonstrates an
ability to relate satisfactorily with others.
Ø Recognizes
distortions of reality.
Ø Has not harmed
self or others.
Ø Perceives self
realistically.
Ø Demonstrates the
ability to perceive the environment correctly.
Ø Maintains
anxiety at a manageable level.
Ø Relinquishes the
need for delusions and hallucinations.
Ø Demonstrates the
ability to trust others.
Ø Uses appropriate
verbal communication in interactions with others.
Ø Performs
self-care activities independently
.
Planning/Implementation
●
Self-care deficit related to withdrawal,
regression, panic anxiety, perceptual or cognitive impairment, inability to
trust, evidenced by difficulty carrying out tasks associated with hygiene,
dressing, grooming, eating, and toileting.
Goals/Objectives
Short-Term Goal
Client will verbalize a desire to
perform ADLs by end of 1 week.
Long-Term Goal
Client will be able to perform
ADLs in an independent manner and demonstrate a willingness to do so by time of
discharge from treatment.
Interventions
with Selected Rationales
1. Encourage client to perform
normal ADLs to his or her level of ability. Successful performance of
independent activities enhances self-esteem.
2. Encourage independence, but
intervene when client is unable to perform. Client comfort and safety are
nursing priorities.
3. Offer recognition and positive
reinforcement for independent accomplishments. (Example: “Mrs. J., I see you
have put on a clean dress and combed your hair.”) Positive reinforcement
enhances self-esteem and encourages repetition of desirable
behaviors.
4. Show client, on concrete
level, how to perform activities with which he or she is having difficulty.
(Example: If client is not eating, place spoon in his or her hand, scoop some
food into it, and say, “Now, eat a bite of mashed potatoes (or other food).”
Because concrete
thinking prevails, explanations must be provided at the client’s concrete level
of comprehension.
5. Keep strict records of food and fluid
intake. This information is necessary to acquire an accurate nutritional
assessment.
6. Offer nutritious snacks and
fluids between meals. Client may be unable to tolerate large amounts of
food at mealtimes and may therefore require additional nourishment at other
times during the day to receive adequate nutrition.
7.If client is not eating because
of suspiciousness and fears of being poisoned, provide canned foods and allow
client to open them; or, if possible, suggest that food be served family-style so
that client may see everyone eating from the same servings.
7.
8. If client is soiling self,
establish routine schedule for toileting needs. Assist client to bathroom on
hourly or bi-hourly schedule, as need is determined, until he or she is able to
fulfill this need without assistance.
2.
Disturbed sensory perception: Auditory/visual related to panic anxiety, extreme
loneliness and withdrawal into the self, evidenced by inappropriate responses,
disordered thought sequencing, rapid mood swings, poor concentration,
disorientation
Goals/Objectives
Short-Term Goal
Client will discuss content of
hallucinations with nurse or therapist
within 1 week.
Long-Term Goal
Client will be able to define and
test reality, eliminating the occurrence of hallucinations. (This goal may not
be realistic for the individual with chronic illness who has experienced
auditory hallucinations for many years.) A more realistic goal may be: Client
will verbalize understanding that the voices are a result of his or her illness
and demonstrate ways to interrupt the hallucination
Interventions
with Rationales
1. Observe client for signs of
hallucinations (listening pose, laughing or talking to self, stopping in
mid-sentence). Early intervention may prevent aggressive
responses to command hallucinations.
2. Avoid touching the client
before warning him or her that you are about to do so. Client may
perceive touch as threatening and respond in an aggressive or
defensive manner.
3. An attitude of acceptance will
encourage the client to share the content of the hallucination with you. This
is important in order to prevent possible injury to the client or
others from command hallucinations.
4. Do not reinforce the
hallucination. Use “the voices” instead of words like “they” that imply
validation. Let client know that you do not share the perception. Say, “Even
though I realize that the voices are real to you, I do not hear any voices
speaking.” The nurse must be honest with the client so that
he or she may realize that the hallucinations are not real.
5. Try to connect the times of
the hallucinations to times of increased anxiety. Help the client to understand
this connection. If client can learn to interrupt escalating anxiety,
hallucinations may be prevented.
6. Try to distract the client
away from the hallucination. Involvement in interpersonal activities and
explanation of the actual situation will help bring the client back to reality.
7. For some clients, auditory
hallucinations persist after the acute psychotic episode has subsided.
Listening to the radio or watching television helps distract some clients from
attention to the voices. Others have benefited from an intervention called voice
dismissal. With this technique, the client is taught to say loudly, “Go
away!” or “Leave me alone!” thereby exerting some conscious control over the
behavior.
3. Disturbed thought processes related to inability to trust, panic
anxiety, possible hereditary or biochemical factors, evidenced by delusional
thinking; inability to concentrate; impaired volition; inability to problem
solve, abstract, or conceptualize; extreme suspiciousness of others
Goals/Objectives
Short-Term Goal
By the end of 2 weeks, client
will recognize and verbalize that false
ideas occur at times of increased
anxiety.
Long-Term Goal
Depending on chronicity of
disease process, choose the most realistic long-term goal for the client:
‘
Interventions
with Rationales
1. Convey your acceptance of
client’s need for the false belief, while letting him or her know that you do
not share the belief. It is important to communicate to the
client that you do not accept the delusion as reality.
2. Do not argue or deny the
belief. Use reasonable doubt as a therapeutic technique: “I find that
hard to believe.” Arguing with the client or denying the belief
serves no useful purpose, because delusional ideas are not
eliminated by this approach, and the development of a trusting
relationship may be impeded.
3. Help client try to connect the
false beliefs to times of increased anxiety. Discuss techniques that could be
used to control anxiety (e.g., deep breathing exercises, other relaxation
exercises, thought stopping techniques). If the client can learn to
interrupt escalating anxiety, delusional thinking may be
prevented.
4. Reinforce and focus on
reality. Discourage long ruminations about the irrational thinking. Talk about
real events and real people. Discussions that focus on the false ideas
are purposeless and useless, and may even aggravate the
psychosis.
5. Assist and support client in
his or her attempt to verbalize feelings of anxiety, fear, or insecurity. Verbalization
of feelings in a nonthreatening environment may help client come
to terms with long unresolved issues.
4..Social isolation related to inability to trust, panic anxiety, weak ego
development, delusional thinking, regression, evidenced by withdrawal, sad and
dull affect, need-fear dilemma, preoccupation with own thoughts, expression of
feelings of rejection or of aloneness imposed by others.
Goals/Objectives
Short-Term Goal
Client will willingly attend therapy
activities accompanied by trusted staff member within 1 week.
Long-Term Goal
Client will voluntarily spend
time with other clients and staff members in group activities.
Interventions
with Rationales
1. Convey an accepting attitude
by making brief, frequent contacts. An accepting attitude increases
feelings of self-worth and facilitates trust.
2. Show unconditional positive
regard. This conveys your belief in the client as a worthwhile human
being.
3. Be with the client to offer
support during group activities that may be frightening or difficult for him or
her. The presence of a trusted individual provides
emotional security for the client.
4. Be honest and keep all
promises. Honesty and dependability promote a trusting relationship.
5. Orient client to time, person,
and place, as necessary.
6. Be cautious with touch. Allow
client extra space and an avenue for exit if he or she becomes too anxious. A
suspicious client may perceive touch as a threatening gesture.
7. Administer tranquilizing medications
as ordered by physician. Monitor for effectiveness and for adverse side
effects. Antipsychotic medications help to reduce psychotic
symptoms in some individuals, thereby facilitating interactions
with others.
8. Discuss with client the signs
of increasing anxiety and techniques to interrupt the response (e.g.,
relaxation exercises, thought stopping). Maladaptive behaviors such as
withdrawal and suspiciousness are manifested during times of
increased anxiety.
9. Give recognition and positive reinforcement
for client’s voluntary interactions with others. Positive reinforcement
enhances selfesteem and encourages repetition of acceptable
behaviors
4.Risk for
violence: Self-directed or other-directed related to extreme suspiciousness,
panic anxiety, catatonic excitement, rage reactions, command hallucinations,
evidenced by overt and aggressive acts, goal-directed destruction of objects in
the environment, self-destructive behavior, or active aggressive suicidal acts
Goals/Objectives
Short-Term Goals
1. Within [a specified time],
client will recognize signs of increasing anxiety and agitation and report to
staff for assistance with intervention.
2. Client will not harm self or
others.
Long-Term Goal
Client will not harm self or
others.
Interventions
with Selected Rationales
1. Maintain low level of stimuli
in client’s environment (low lighting, few people, simple decor, low noise
level). Anxiety level rises in a stimulating environment. A
suspicious, agitated client may perceive individuals as
threatening.
2. Observe client’s behavior
frequently (every 15 minutes). Do this while carrying out routine activities so
as to avoid creating suspiciousness in the individual. Close
observation is necessary so that intervention can occur if required
to ensure client (and others’) safety.
3. Remove all dangerous objects
from client’s environment so that in his or her agitated, confused state
client may not use them to harm self or others.
4. Try to redirect the violent
behavior with physical outlets for the client’s anxiety (e.g., punching bag). Physical
exercise is a safe and effective way of relieving pent-up
tension.
5. Staff should maintain and
convey a calm attitude toward client. Anxiety is contagious and can be
transmitted from staff to client.
6. Have sufficient staff
available to indicate a show of strength to client if it becomes necessary. This
shows the client evidence of control over the situation and
provides some physical security for staff.
7. Administer tranquilizing
medications as ordered by physician. Monitor medication for its effectiveness
and for any adverse side effects. The avenue of the “least restrictive
alternative” must be selected when planning interventions for a
psychiatric client.
8. If client is not calmed by “talking
down” or by medication, use of mechanical restraints may be necessary. Be sure
to have sufficient staff available to assist. Follow protocol established by
the institution. The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) requires that the physician reissue a new order for restraints every 4
hours for adults and every 1 2 hours for children and adolescents.
9. Observe the client in
restraints every 15 minutes (or according to institutional policy). Ensure that
circulation to extremities is not compromised (check temperature, color,
pulses). Assist client with needs related to nutrition, hydration, and
elimination. Position client so that comfort is facilitated and aspiration can
be prevented. Client safety is a nursing priority.
10. As agitation decreases,
assess client’s readiness for restraint removal or reduction. Remove one
restraint at a time while assessing client’s response. This minimizes
risk of injury to client
and staff.
5.
Impaired
verbal communication related to panic anxiety, regression, withdrawal, and
disordered, unrealistic thinking evidenced by loose association of ideas,
neologisms, word salad, clang associations, echolalia, verbalizations that
reflect concrete thinking, and poor eye contact.
Goals/Objectives
Short-Term Goal
Client will demonstrate ability
to remain on one topic, using appropriate, intermittent eye contact for 5
minutes with nurse or therapist.
Long-Term Goal
By time of discharge from
treatment, client will demonstrate ability to carry on a verbal communication
in a socially acceptable manner with staff and peers.
Interventions
with Selected Rationales
1. Use the techniques of consensual
validation and seeking clarification to decode communication
patterns. (Examples: “Is it that you mean . . . ?”or “I don’t understand
what you mean by that.Would you please explain it to me?”) These
techniques reveal to the client how he or she is being perceived
by others, and the responsibility for not understanding is accepted by
the nurse.
2. Maintain consistency of staff
assignment over time, to facilitate trust and the ability to understand
client’s actions and communication.
3. In a nonthreatening manner,
explain to client how his or her behavior and verbalizations are viewed by and
may alienate others.
4. If client is unable or
unwilling to speak (mutism), use of the technique of verbalizing the implied
is therapeutic. (Example: “That must have been very difficult for you when
. . .”) This may help to convey empathy, develop trust, and
eventually encourage client to discuss painful issues.
5. Anticipate and fulfill
client’s needs until satisfactory communication patterns return. Client
comfort and safety are nursing priorities.
CONCLUSION:
Schizophrenia is a chronic
illness requiring long-term management strategies and coping skills. It is a
disease of the brain, a clinical syndrome that involves a person’s thoughts, perceptions,
emotions, movements, and behaviors. The effects of schizophrenia on the client
may be profound, involving all aspects of the client’s life: social
interactions, emotional health, and ability to work and function in the
community. Schizophrenia is conceptualized in terms of positive signs such as
delusions, hallucinations, and disordered thought processes as well as negative
signs such as social isolation, apathy, anhedonia, and lack of motivation and
volition. The clinical picture, prognosis, and outcomes for clients with
schizophrenia vary widely. Therefore, it is important that each client is
carefully and individually assessed, with appropriate needs and interventions determined. Careful
assessment of each client as an individual is essential to planning an
effective plan of care. Families
of clients with schizophrenia may experience fear, embarrassment, and guilt in
response to their family member’s illness. Families must be educated about the
disorder, the course of the disorder, and how it can be controlled. Failure to
comply with treatment and the medication regimen and the use of alcohol and
other drugs are associated with poorer outcomes in the treatment of schizophrenia.
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