Schizophrenia

Background
Schizophrenia is the most common and disabling of the psychotic disorders.
Schizophrenia occurs twice as often in people who are unmarried and divorced people as in those who are married or widowed.
People with schizophrenia are more likely to be members of lower socioeconomic groups

Continum of neurobiological responses
Etiology of Schizophrenia
A. Predisposition factors
The genetic or hereditary

Biochemical and Neurostructural Theory
This therory suggested the dopamine hypothesis:
An excessive amount of the neurotramsmitter dopamine allows nerve impulses to bombard the mesolimbic pathway, the part of the brain normally involved in arousal and motivation. It causes the development of hallucinations and delusions, symptoms of schizophrenia .
Organic or Psychophysiologic Theory
These theories stated a functional deficit occurring in the brain caused by stressors such as viral infection, toxins, trauma, or abnormal substances and also a metabolic disorder
Environmental or Cultural Theory
This theory state that the person who develops schizophrenia has a faulty reaction to the environment, being unable to respond selectively to numerous social stimuli, come from low socioeconomic areas or single-parent homes.
Perinatal Theory
This suggested that risk of schizophrenia exists if:
The developing fetus or newborn is deprived of oxygen during pregnancy or if the mother suffers from malnutrition or starvation during the first trimester of pregnancy.
Any impaired events during fetal life at critical points in brain development, generally the 34th or 35th week of gestation.
The incidence of trauma and injury during the second trimester and birth
Psychological or Experiential Theory
Individuals with schizophrenia experience environmental stress when family members and acquaintances respond negatively to the individual’s emotional needs.
It causes poor mother–child relationships, deeply disturbed family interpersonal relationships, impaired sexual identity and body image, rigid concept of reality, and repeated exposure to double-bind situations
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 as a result of a severe vitamin deficiency.
Clinical Symptoms and Diagnostic Characteristics
Eugene Bleuler introduced the term schizophrenia and cited symptoms referred to as Bleuler’s 4 A’s:
Affective disturbance refers to the person’s inability to show appropriate emotional responses.
Autistic thinking is a thought process in which the individual is unable to relate to others or to the environment.
Ambivalence refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person, thing, or situation.
Looseness of Association is the inability to think logically. Ideas expressed have little, if any, connection and shift from one subject to another.

Clinical Symptoms :POSITIVE SYMPTOMS
Excess or distortion of normal functions
Delusions (persecutory or grandiose)
Conceptual disorganization
Hallucinations (visual, auditory, or other sensory mode)
Excitement or agitation
Hostility or aggressive behavior
Suspiciousness, ideas of reference
Pressurized speech
Bizarre dress or behavior
Possible suicidal tendencies

NEGATIVE SYMPTOMS
Diminution or loss of normal functions
Anergia (lack of energy)
Anhedonia (loss of pleasure or interest)
Emotional withdrawal
Poor eye contact (avoidant)
Blunted affect or affective flattening
Avolition (passive, apathetic, social withdrawal)
Difficulty in abstract thinking
Alogia (lack of spontaneity and flow of conversation)
Dysfunctional relationship with others

DISORGANIZED SYMPTOMS
Cognitive defects/confusion
Incoherent speech
Disorganized speech
Repetitive rhythmic gestures (such as walking in circles or pacing)
Attention deficits

Type I schizophrenia
The onset of positive symptoms is generally acute.
Type I symptoms generally respond to typical neuroleptic medication.
Theorists believe that an increased number of dopamine receptors in the brain, normal brain structure, and the absence of intellectual deficits contribute to a better prognosis than for those identified with type II schizophrenia.
Type II schizophrenia
It is characterized by a slow onset of negative symptoms caused by viral infections and abnormalities in cholecystokinin.
Intellectual decay occurs.
Enlarged ventricles are present.
Response to typical neuroleptic medication is minimal. However, negative symptoms generally respond to atypical antipsychotic medication

Diagnostic Characteristics
Evidence of two or more of the following:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
Above symptoms present for a major portion of the time during a 1-month period
Cont…
Significant impairment in work or interpersonal relations, or self-care below the level of previous function
Demonstration of problems continuously for at least a 6-month interval
Symptoms unrelated to schizoaffective disorder and mood disorder with psychotic symptoms and not the result of a substance-related disorder or medical condition

Classification of Subtypes of Schizophrenia
Other types of psychotic

It is the diagnosis used to describe the presence of prominent hallucinations or delusions determined as due to the direct physiologic effects of a specific medical condition.
For example:
Olfactory hallucinations may be experienced in the presence of temporal lobe epilepsy.
A right parietal brain lesion may cause an individual to develop delusions.
Assessment
Coping mechanism
Behaviours in a schizophrenic client
Nursing diagnosis
Disturbed thought processes,
Disturbed sensory perception,
Low self esteem
Social isolation
Risk for violence : self-directed or other directed
Impaired social interaction
Impaired verbal communication,
Ineffective individual coping
Self care deficit
Risk for Suicide,
How to manage : DELUSION
Types of Delusions
Delusion of reference or persecution
Delusion of alien control
Nihilistic delusion
Paranoid delusion
Delusion of grandeur
Somatic delusion
Strategies for working with patients with delusion
Establishing a trusting, interpersonal relationship
Place the delusion in atime frame and identify triggers
Assess the intensity, frequency, and duration of the delusion
Identify the emotional component of the delusion
Observe for evidence of concrete thinking

Cont……
Observe speech for symptoms of thought disorder
Observe for the ability to accurately use cause and effect reasoning
Distinguis between the description of the experience and the facts of the situation.
Carefully question the fact as they are presented and their meaning
Discuss consequences of delusion when the person is ready
Promote distraction as way to stop focusing on the delusion

Types of Hallucinations
Auditory hallucination
Visual hallucination
Olfactory hallucination.
Gustatory (taste) hallucination
Tactile hallucination
Level of intensity of hallucination
Stage 1 : Comforting
Moderate level of anxiety
Hallucination is generally pleasant
Stage 2 : Condemning
Severe level of anxiety
Hallusination generally become repulsive
Stage 3 : Controlling
Severe level of anxiety
Sensory experiences become omnipotent
Stage 4 : Conquering
Panic level of anxiety
Generally becomes elaborate and interwoven with delusion
Strategies for working with patients with halucination
Establising a trusting, interpersonal relationship
Assess for symptoms of hallucination including duration, intensity and frequency.
Focus on the symptom and ask the patient to describe what is happening
Monitor for command hallucinations that may precipitate aggressive or violent behavior.
Identify whether drugs or alcohol have been used
If asked, point out simply that you are not experiencing the same stimuli

Cont….
Suggest and reinforce the use of interpersonal relationship as symptom management technique
Help the patient describe and compare current and past hallucination
Help the patient identify needs that may be reflected in the content of the hallucination.
Determine the impact of the patient’s symptoms on activities of daily living.
Administer prescribed medication as ordered.

References
Townsend, M (2005), Essentials of psychiatric mental health nursing, 3rd ed, FA Davis Philadhelphia, pp 271-293
Stuart, GW & Laraia, MT(2005), Principles and practice of psychiatric nursing, 8th ed, Mosby, Philadelphia, pp 386-421

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