Etiology and Pathophysiology

The exact cause of schizophrenia is unknown; however, current research favors the theory that there is a neurobiologic basis with a genetic component. As with most chronic conditions, an unfavorable social environment contributes to a poor prognosis. Schizophrenia usually develops in late adolescence or the early 20s.

Signs and Symptoms

Delusions can be either grandiose or persecutory. An individual who believes he is a king is having delusions of grandeur. Individuals with delusions of persecution believe that they are being persecuted by agencies, by other people, or by supernatural beings. An illusion is a misinterpretation of something that really exists. For example, an electrical cord appears to be a snake, or a pencil is misinterpreted to be a knife blade. When ideas of reference occur, the individual believes that events or situations are occurring because of—or specifically for—him. A common idea of reference is to believe that people on the television are sending special telepathic messages. Positive symptoms are much more responsive to medication therapy compared to the negative symptoms; however, some patients will tell you that “the voices are always there, but if I take my medications the voices are less intrusive.”

Negative symptoms are abilities or personal characteristics that are absent or lost to the patient. For example, think of elements of personality that make people motivated, socially outgoing, happy, and active in daily life, and then take away those elements. The results are negative symptoms: apathy, social isolation, psychomotor retardation, flat affect (obvious absence of emotional expression), poverty of thoughts (alogia), lack of motivation (avolition), and inability to experience pleasure or joy (anhedonia). These symptoms are notoriously more difficult to treat because the symptoms, in and of themselves, inhibit the individual from seeking help. Negative symptoms are also linked to acquisition of important social skills and prognosis (Roberson, 2009). For example, if your teenage patient withdraws because of feelings of persecution, he will miss the important socialization tasks that occur during adolescence, such as exploring identity and preparing to live independently away from his parents.

In addition, these patients also have cognitive impairments that manifest as difficulty with memory, judgment, problem solving, and decision making. Concurrent mental health problems such as anxiety and depression can also occur. Overall there is an impact on the individual’s quality of life, and some will have great difficulty functioning in society.

Diagnosis

Tardive dyskinesia is a primary concern because symptoms are irreversible once they have developed. Symptoms include tongue protrusion, lip smacking, sucking, chewing, blinking, lateral jaw movements, grimacing, shoulder shrugging, pelvic thrusting, wrist and ankle flexion or rotation, foot tapping and toe movements, and rapid, purposeless, and irregular movements. Movements are often described as writhing and wormlike. Monitor for signs of tardive dyskinesia, particularly in patients who have been taking a conventional antipsychotic medication for longer than 6 to 12 months.

Other adverse effects associated with the use of antipsychotic medications include blurred vision; bone marrow suppression; cardiac dysrhythmias; endocrine changes such as elevation of blood sugar, weight gain, and breast enlargement; and hepatotoxicity (liver injury and jaundice). Neuroleptic malignant syndrome is a rare reaction; however, it is life threatening, and frequently the patient will be transferred to the intensive care unit. Symptoms include high fever, increased pulse, muscle rigidity, stupor, incontinence, elevated white blood cell count, hyperkalemia, and renal failure.

Negative symptoms are treated with a therapeutic environment, including a therapeutic relationship with the nurse, and education regarding basic living skills. Historically, individuals with schizophrenia were shunned and stigmatized because of unusual and bizarre behavior. Evidence-based practice indicates that with early intervention these individuals can cope with symptoms and maintain independent and productive lives outside of an institution. Community mental health teams decrease likelihood of relapse (Malone et al., 2009). Programs such as the Program for Assertive Community Treatment (PACT), Assertive Community Treatment (ACT), and Functional Adaptation Skills Training (FAST) include elements of patient and family support, education about disease management, and skills training (American Psychiatric Association, 2004; National Institute of Mental Health, 2007). If left untreated, individuals with schizophrenia are particularly vulnerable to poverty, homelessness, drug abuse, and suicide.

Evidence suggests that cognitive-behavioral therapy (CBT) should be used in conjunction with medication in the treatment of schizophrenia (American Psychiatric Association, 2004). In CBT, the therapist helps the patient to identify stressors, to make plans, and to modify behaviors. For example, the patient is assisted to recognize that hallucinations increase during the late evening hours. The plan might include listening to music and going to bed earlier. If the voices continue or get louder the patient knows to say, “Stop!”