SCHIZOPHRENIA: NURSING MANAGEMENT

“Arguably the worst disease affecting mankind”-(Nature 1988)

Introduction

When we think of madness, we think of schizophrenia. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movements, and behaviour. It cannot be defined as a single illness, rather schizophrenia is a syndrome or disease process with many different varieties and symptoms.

History

Schizophrenia was recorded in Indian history nearly 3,300 years ago by Charaka.

Early figures in the History of Psychiatry

§         1809 John Haslam (1764-1844) Superintendent of a British hospital. In Observations on Madness and Melancholy, he outlined a description of the symptoms of schizophrenia.

§         1802/1809 Philippe Pinel (1745-1826) A French physician who described cases of schizophrenia.

§         1852 Benedid Morel (1805-1873) Physician at a French institution who used the term demence precoce (in Latin,dementia praecox). meaning early or premature (precoce) loss of mind (demence) to describe schizophrenia.

§         1898/1899 Emil Kraepelin (1856-1926) A German psychiatrist who unified the distinct categories of schizophrenia (hebephrenic, catatonic and paranoid) under the name dementia precox. The scientific study of the disorder began with the description by Kraepelin

§         1908 Eugen Bleuler (1857-1939) A Swiss psychiatrist who introduced the term “schizophrenia” meaning splitting of the mind. It does not mean multiple personalities. Referred to the  associative splitting of the basic functions of   personality.

Prevalence of Schizophrenia

§         A recent meta-analysis of 13 epidemiological studies in India, comprising 33,572 individuals, concluded that the prevalence of mental illness is estimated as  58.2 per 1,000 population where schizophrenia—2.7/1,000

§         1% of world population

§         all ethnic groups in all parts of world

§         rare in tropics

§         10-100 times more reported in U.S. & Europe than 3rd world

o        Found more often in low socioeconomic classes (SES) & African Americans

§         first diagnosed at 15-30 years of age, 60 -70% doesn't disappear

Myths of “Madness”

§         People with schizophrenia have “split personalities.”

§         People with schizophrenia are intellectually disabled?

§         People with schizophrenia are dangerous?

§         People with schizophrenia are addicted to their drugs?

Schizophrenia is

§         NOT caused by bad parenting or an unhappy childhood.

§         NOT due to a weakness in character.

§         NOT a hopeless situation.

Society & Schizophrenia

–         Concern for ultimate fate of these individuals in society

–         Stigma associated with any mental disorder, especially Schizophrenia.

–         Many fail to continue medication

–         Estimated: 50% of U.S. homeless population suffers from inadequately controlled schizophrenia.

Onset and Course

§         Onset may be abrupt or insidious

§         Regardless of the onset and type schizophrenia, consequences for most clients and families are substantial and enduring

§         Those who develop the illness earlier show worst outcomes than those who develop later

§         Years immediately after the onset two clinical patterns emerge-ongoing course with varying severity or episodic patterns with near complete recovery

§         Long term course-intensity diminishes with age and may regain some social and occupational functioning

Psychopathology

Bleuler classification of symptoms (Bleuler 1911)

Fundamental symptoms	accessory symptoms
include 4 As- disturbances of associations, changes in emotional (affective) reactions, autism (withdrawal from reality), and ambivalence	Hallucinations, delusions, catatonia and abnormal behaviours

Schneider (1887-1967)

Schneider’s first rank symptoms of schizophrenia

Thought echo- hearing thoughts spoken aloud

Third person auditory hallucinations

Hallucinations in the form of a commentary

Somatic hallucinations

Thought withdrawal or insertion

Thought broadcasting

Delusional perception

Feelings or actions experienced a made or influenced by external agents-soamatic passivity

1. Disorders of thought and verbal behaviour-usually identified from speech and writing

Delusions-false beliefs, unshakable, not affected by rational argument or evidence, firmly held on inadequate grounds that may accompany psychotic disorders

§         Primary, secondary and shared delusions

§         Grandeur – Great/Special Person

§         Reference – Special/Personal Meanings

§         Control – Controlled by Others

§         Bizarre-- unusual

Steam of thought-perseveration,  loosening of associations, derailment, word salad, neologisms

2. Disorders of perception
   • Hallucinations-perception in the absence of stimuli to the sense organs in a similar quality to a true percept.

§         Auditory-Second person, third person

may hear voices, respond & act on voices

§         Visual- false sensory experiences such as seeing something without any external visual stimulus

§         Olfactory

§         Somatic-tactile and deep

§         Pseudohallucinations

• Illusions- misperceptions of external stimuli
2. Disorders of affect
   • Congruence, apathy, blunted or flattened
   • Avolition – loss of motivation, “drained”
   • Flat affect: separation from external world
3. Disorders of motor behavior-Psychomotor:

Psychomotor agitation or retardation

• Agitation = purposeless or disorganized movement
• Retardation = slowed or lack of movement
• In extreme form = catatonia
• Catatonic stupor – stopped responding to environmental stimulus

§         Waxy flexibility – posed like a wax statue

• Rigidity – don’t move
• Posturing – assume bizarre postures for long periods of time

Positive & Negative Symptoms

• Primary difference - Positive outgoing & socially interactive,
• Symptoms may reflect 2 different stages of disorder
• Long term sufferers show atrophy of cerebral cortexes

Positive:

§         Excessive or additional to normal thoughts, emotions, or behaviors

§         Disorganized thoughts and speech

§         Excessive affect (emotion)

§         Active and socially functioning

Negative:

§         Flat affect: separation from external world

§         lack of behavior (diminished motor movements)

§         completely separated from interactions with others

§         Deficits or reductions in normal thoughts, emotions, and/or behaviors

§         Poverty of speech – reduced speech or content

§         Avolition – loss of motivation, “drained”

§         Social Withdrawal – distanced from others

Etiology: Theories About Schizophrenia

Whether schizophrenia is an organic disease with underlying physical brain pathology is studied for long.

Old:

1.      Cold, uncaring, domineering mothers use their children to fill their own needs and ignore those of child

2.      “Schizophrenogenic Mother”

3.      Discredited

4.      Behavioral: Operant Conditioning (also not much evidence)

Newer:

Biological

Biological theories of schizophrenia focus on genetic factors, neuroanatomic, neurochemical factors and immunovirology.

1.      Genetic contribution:

§         Genetic studies have concentrated on immediate families-parents, siblings, offsprings

§         Twin Studies – Identical twins have a 50% risk of schizophrenia (even though their genes are 100% equal) than Fraternal twins or other sibs with 15% risk

§         Adoption studies

§         May be polygenic

2.     Neurochemical and Neuroanatomic factors

Alterations in neurotransmitter systems of the brains of people with schizophrenia. Currently the most prominent neurochemical theories involve dopamine and serotonin.

Dopamine (“DA”) Hypothesis:

All can also lead to psychotic behaviors

§         too much DA linked to schizophrenic symptoms

§         Neurons using DA fire too often

§         Transmit too many messages, confusing the brain

§         Produces symptoms of disorder

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