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 |
-
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
-
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
-
Disorders of affect
-
Congruence, apathy, blunted or flattened
-
Avolition – loss of motivation, “drained”
-
Flat affect: separation from external
world
-
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
§
Substance that decrease DA levels decrease
symptoms of Schizophrenia.
§
Reserpine affects vesicles–reduces
Schizophrenia
§
Substance that block access to DA receptors
effective in Schizo
§
high correlation between blocking & effective
treatment.
§
agonist of DA (apomorphine) or that increase
DA formation (L-Dopa), or increase release (amphtamine),
or block DA (cocaine) worsen schizophrenia
§
May best explain Type I –
§
Type II does not seem to be related to
abnormal DA chemistry in the brain
Serotonin hypothesis:
§
Serotonin modulates and help to control excess
dopamine.
§
Some believes excess serotonin contributes to
schizophrenia
Structural Abnormalities-neuroanatomic
§
Many Type II patients have structural
abnormalities in brain:
§
Enlarged ventricles (site in brain where
cerebro-spinal fluid (CSF) is produced)
§
Found that people with schizophrenia has less
brain tissue and CSF
§
PET studies suggest diminished glucose
metabolism and oxygen in frontal cortical
areas of the brain
§
Research shows decreased brain volume and
abnormal brain function in the frontal and
temporal areas of the brain of persons with
schizophrenia
§
May be related to prenatal brain development
or brain damage
§
Also linked to abnormal blood flow within
brain, smaller temporal and frontal lobes, and
less gray matter
3.
Viral Infection:
§
May result from prenatal exposure to certain
viruses (don’t know which for sure) that come
out of dormancy in teens, adulthood
§
Mothers of schizophrenic patients report more
instances of flu during winter
§
Increased levels of antibodies to certain
viruses found in blood of schizophrenic
patients
§
Not specific to Type I or Type II
4.
Psychological Theories
§
Stress-increased
number of stressful life events probably
triggering effect on onset of schizophrenia in
predisposed individual
§
Increased Expressed Emotions(EE) (hostility,
critical comments, emotional over involvement
of “significant others”
§
Family Theories:
“ schizophrenogenic mothers”, lack of “real
parents”, dependency on mother, anxious
mother, parental marital discord are examples
§
Information Processing Hypothesis:
disturbances in attention, inability to
maintain a set, and inability to assimilate
and integrate percepts are common finding in
schizophrenia
§
There is possibility of breakdown in the inter
al representation of mental events
§
Psychoanalytical theories-
According to Freud, there is regression to the
pre-oral (and oral) stage of psychosexual
development with the use of defense mechanisms
of denial, reaction formation, and projection
5.
Socio-cultural:
§
Social influences (like poverty, abuse, family
problems) affect an individual’s mental
functioning
§
Not much evidence to support it as a cause,
but it definitely affects the course of the
disease
§
May have a diathesis-stress explanation:
Biological predisposition and
psychological/sociocultural stresses
Course of Schizophrenia:
Usually 3 phases:
-
Prodromal
– no obvious symptoms, but everyday
functioning is beginning to deteriorate
-
Active
– Full-blown schizophrenia, with active
symptoms
-
Residual
– Symptoms subside, prodromal-like state.
Symptoms can return – back into active phase
Classification
-
Acute schizophrenia
-
Chronic schizophrenia
Classification ICD 10
-
Paranoid schizophrenia
-
Disorganized or Hebephrenic schizophrenia
-
Catatonic schizophrenia
-
Residual and latent schizophrenia
-
Undifferentiated schizophrenia
-
Simple schizophrenia
-
Post-schizophrenic depression
-
Others
Criteria as per ICD 10
-
A minimum of very clear symptom and usually
2 or more less clear cut belonging to SFRSS
for a period of 1 month or more or
-
2 of the following symptoms (persistent
hallucinations in any modality, breaks or
interpolations in the train of thought,
catatonic behaviour, negative symptoms)
-
if duration less than one month, then
diagnosis of acute schizophrenia like
psychotic disorder
Classification (DSM IV)
The following disorders are included:
-
Schizophrenia
-
Paranoid,
-
Disorganized
-
Catatonic
-
Undifferentiated
-
Residual
Criteria as per DSM IV
A.
Two or more of the following, each present for
a significant portion of time during a 1 month
period
1.
delusions (positive sx), e.g., grandeur,
persecution
2.
hallucinations (positive sx)
3.
disorganized speech
4.
grossly disorganized or catatonic behavior
5.
negative symptoms, i.e., affective flattening,
6.
alogia (inability to speak), or avolition
(inability to act).
B.
Social/occupational dysfunction: for a
significant portion of the time, one or more
areas of functioning (work, interpersonal
relationships, or self-care) are markedly
below prior levels.
C.
Duration: Continuous signs persist for at
least 6 months, with at least 1 month meeting
criteria for A. Can include “prodromal
period”.
D.
Schizoaffective disorder, mood disorder,
substance abuse, medical problem ruled out.
Types
nType
I: Mainly has positive symptoms
Tend to have better prognosis
Respond better to treatment
Linked to biochemical abnormalities in brain
nType
II: Mainly negative symptoms
Tend to have worse prognosis
Respond poorly to treatment
Tend to have poor premorbid functioning
Linked to abnormal brain structures
Sub Types of Schizophrenia:
These can be either Type I or II depending on
what symptoms manifest
1.
Paranoid Schizophrenia:
Hallucinations-persecutory content, grandiose
content
Delusions-persecution, reference, grandiosity,
control, infidelity, well-systemized
Disturbances of affect, volition, speech, and
motor behaviour
Tends to be organized in thought, speech, just
bizarre
Usually Type I
John Nash (“A Beautiful Mind”) had this type
2.
Catatonic Schizophrenia:
Psychomotor disturbance is prime symptom
Usually Type II
3.
Disorganized Schizophrenia:
Flat/Inappropriate Affect
Disorganized Thoughts/Speech
Confused, Incoherent
Prognosis usually poor
4.
Undifferentiated Schizophrenia:
Not easily classified into other types;
Mix of symptoms
5.
Residual Schizophrenia:
Maps onto residual phase of disorder
Symptoms decrease in intensity & number
Some trace remains
Can be residual while on medication
6.
Post Schizophrenia Depression
Differential diagnosis
Organic Psychosis
-
Complex partial seizures
-
Drug induced psychosis (amphitamine )
-
Metabolic disturbance
-
Cerebral neoplasm
Possibility of Mood Disorder
-
Mania
-
Depression
-
Mixed episodes
Other non-organic psychosis-ATPD
Management of Schizophrenia:
Old:
§
Psychoanalysis
§
Shock Treatment (Insulin, ECT)
§
Lobotomy
§
Institutionalization
New:
§
Antipsychotic drugs, also known as
neuroleptic drugs
§
ECT
§
Psychosocial Treatment- Psychotherapy to help
increase functioning and compliance in taking
medications
§
Psychosurgery-limbic lobotomy
1.
Antipsychotic Medications.
Typical Antipsychotics